PAGE 1
Adolescent Health, Vol. II: Background and the Effectiveness of Selected Prevention and Treatment Services October 1991 OTA-H-466 NTIS order #PB92-157577 GPO stock #052-003-01235-9
PAGE 2
Recommended Citation: U.S. Congress, Office of Technology Assessment, Adolescent Health-Volume II: Background and the Effectiveness of Selected Prevention and Treatment Services, OTA-H-466 (Washington, DC: U.S. Government Printing Office, November 1991). 101 \.llC b) Ihc ~ I \ (J(l\L>llllllLhll[ l~ ot t ILC Sup(.[ IIIILI1(ICIII (11 I)(Kulll(l)l\, Nlclll \lo J) Ssol. M J.lllllgloll. [)( 3)402 -)328 ISBN 0-16 -035981-3
PAGE 3
Foreword Adolescence, the poet suggested, is the one age [that] defeats the metaphor. In many respects, such as legal and financial dependence, adolescents are still children; in other respects, such as physical development, they approach and then reach adult status. In part because they experience profound biological, emotional, intellectual and social changes, adolescents as a group-and some adolescents more than others-are uniquely vulnerable to the impact of many of the Nations social policies. For numerous reasons, policymakers and the public have long struggled with the establishment of appropriate health-related policies and programs for adolescents. OTAs report responds to the request of numerous Members of Congress to review the physical, emotional, and behavioral health status of contemporary American adolescents, including adolescents in groups who might be more likely to be in special need of health-related interventions: adolescents living in poverty, adolescents from racial and ethnic minority groups, Native American adolescents, and adolescents in rural areas. In addition, OTA was asked to: 1) identify risk and protective factors for adolescent health problems and integrate national data in order to understand the clustering of specific adolescent problems, 2) evaluate options in the organization of health services and technologies available to adolescents (including accessibility and financing), 3) assess options in the conduct of national health surveys to improve collection of adolescent health statistics, and 4) identify gaps in research on the health and behavior of adolescents. Senator Daniel K. Inouye, Chairman of the Senate Select Committee on Indian Affairs, and Senator Nancy Landon Kassebaum, Ranking Minority Member of the Subcommittee on Education, Arts, and Humanities of the Senate Committee on Labor and Human Resources, were the lead requesters of OTAs adolescent health study. Requesters included chairmen or Ranking Minority Members of the Senate Appropriations Committee, the Senate Commerce, Science, and Transportation Committee, the Senate Finance Committee, the Senate Labor and Human Resources Committee, the Senate Small Business Committee, the Senate Veterans Affairs Committee, and the House Interior and Insular Affairs Committee; and the Chairman and six senatorial members of the congressional Technology Assessment Board. A letter of support was received from the House Select Committee on Children, Youth, and Families. This OTA assessment is being published in three volumes: Volume I, Summary and Policy Options; Volume II, Background and the Effectiveness of Selected Prevention and Treatment Services; and Volume III, Crosscutting Issues in the Delivery of Health and Related Services. Volume I was published in April 1991, and Volume III was published in June 1991. Two related reports have already been issued as part of this study (see appendix A in Volume I). OTA was greatly assisted by an advisory panel, chaired by Felton Earls, Professor of Behavioral Sciences at the Harvard University School of Public Health. Michael I. Cohen, Chairman of the Department of Pediatrics at the Albert Einstein College of Medicine in New York, served as vice chairman. In addition, many individuals from academia, the Federal Government, the private sector, and the public provided information and reviewed drafts of the assessment. OTA would like to especially thank Carnegie Corporation of New York, and its operating program, the Carnegie Council on Adolescent Development, for their generous and diverse assistance throughout the course of this assessment. Finally, the members of our Youth Advisory Panel-a group of 21 individuals ages 10 through 19, who met often with OTA staff, with OTAs advisory panel, and with workshop participants-were essential to the study. These young people provided the adolescent perspective on health concerns of importance to young people, and made valuable suggestions for improving health services and health policy. The final responsibility for the content of the assessment rests with OTA. &f a&&L9-A JOHN H, GIBBONS Director ,.. ///
PAGE 4
Adolescent Health Advisory Panel Felton Earls, M. D., Chair Professor, Department of Behavioral Sciences Harvard School of Public Health, Boston, MA Michael I. Cohen, M. D., Vice Chair Chairman, Department of Pediatrics Albert Einstein College of Medicine, Montefiore Medical Center Claire Brindis, Dr. P.H. Center for Reproductive Health Policy Research Institute for Health Policy Studies UCSF School of Medicine San Francisco, CA Ann W. Burgess, R.N., D.N.Sc. van Amerignen Professor of Psychiatric Mental Health Nursing University of Pennsylvania School of Nursing Philadelphia, PA Delores L. Delaney President State of Virginia Parent and Teacher Association Virginia Beach, VA Abigail English, J.D. Staff Attorney Adolescent Health Care Project National Center for Youth Law San Francisco, CA Jewelle Taylor Gibbs, Ph.D. Associate Professor School of Social Welfare University of California Berkeley, CA Michael Graf, Ph.D. Director, Mental Health Tanana Chief Conference, Inc. Fairbanks, AK David E. Hayes-Bautista, Ph.D. Professor, School of Medicine Director, Chicano Studies Research Center University of California, Los Angeles Los Angeles, CA Karen Hein, M.D. Associate Professor Division of Adolescent Medicine Department of Pediatrics Albert Einstein College of Medicine Montefiore Medical Center Bronx, NOTE: iv Bronx, NY Charles E. Irwin, Jr., M.D. Director Division of Adolescent Medicine Department of Pediatrics School of Medicine University of California San Francisco, CA Robert Johnson, M.D. Associate Professor Division of Adolescent Medicine Department of Pediatrics New Jersey Medical School Newark NJ Alan Kazdin, Ph.D. Professor Department of Psychology Yale University New Haven, CT Teresa LaFromboise, Ph.D. Assistant Professor Counseling Psychology and Counselor Education The School of Education University of Wisconsin Madison, WI Mary Nell Lehnhard Vice President Office of Government Relations Blue Cross & Blue Shield Association Washington, DC Barbara D. Matula, M.P.A. Director Division of Medical Assistance Department of Human Resources State of North Carolina Raleigh, NC Robert B. Millman, M.D. Director, Adolescent Development Program Director, Alcohol & Substance Abuse Service Cornell University Medical CollegeNew York Hospital New York, NY Leticia Paez, M.P.A. Associate Director Area Health Education Center School of Medicine Texas Technical University El Paso, TX Cheryl Perry, Ph.D. Associate Professor Division of Epidemiology School of Public Health University of Minnesota Minneapolis, MN Anne C. Petersen, Ph.D. Dean, College of Health & Development Human Pennsylvania State University University Park, PA Lee Etta Powell, Ph.D. Superintendent Cincinnati Public Schools Cincinnati, OH Roxanne Spillett Director, Program Services Boys and Girls Clubs of America New York, NY Edward Tetelman, J.D. Assistant Commissioner Intergovernmental Affairs New Jersey Department of Human Services Trenton, NJ Myron Thompson Trustee Bernice Pauahi Bishop Estate Honolulu, HI NY OTA appreciates and is grateful for the valuable assistance and thoughtful critiques provided by the advisory panel members. The panel does not, however, necessarily approve, disapprove, or endorse this report. OTA assumes full responsibility for the report and the accuracy of its contents.
PAGE 5
Adolescent Health Roger C. Herdman, Assistant Director, OTA Health and Life Sciences Division Clyde J. Behney, Health Program Manager Project Staff Denise Dougherty, Senior Associate/Project Director Jill Eden, Senior Analyst Kerry B. Kemp, Senior Analyst/Division Kelly Metcalf, Research Analyst l Kirsten Rowe, Analyst 2 Gloria Ruby, Senior Analyst Pamela Simerly, Analyst Editor Andrea Solarz, Carnegie Detailee 3 Urvi Thanawala, Research Assistant 4 Paul Robertson, Research Assistant 5 Other Staff James Havel, Carnegie Contractor 6 Charlotte Clarke, Carnegie Contractor Elizabeth Anglarill, Work Study Student 8 Helima Croft, Summer Intern 9 Jennifer Hart, Summer Intern 10 Alex Ching. Summer Intern ll Rachel Wolfe, Research Assistant Heather Francese, Research Assistant Administrative Staff Virginia Cwalina, Office Administrator Carolyn Martin, Word Processor Specialist 12 Eileen Murphy, P,C. Specialist Marian Grochowski, Word Processor Specialist IUntil July 1990 2From octo~r 1988 to Mach 19~ 3From Decem& 1988 to Au~st 1990 4From June 1990 sFrom September 1990 6From April to September 1990 7From May to Augllst 1990 sFr~m November 198910 May 1990 %om May 1990 to August 1990 loFrom June 1988 to August 1988 I IFrom June 1991 to Au~st 1991 2 Until June 1991
PAGE 6
Contractors LaRue Allen, Ph. D., University of Maryland and Christina Mitchell, Ph. D., New York University* Trina Anglin, M.D:, Ph.D., Cleveland Metropolitan Genera! Hospital* Lois Bergeisen, Gaithersburg, MD Barbara Burns, Ph. D., Duke University, Carl A. Taube, Ph.D. (deceased 9/28/89), Johns Hopkins University, and John E. Taube, University of Maryland* Paul Casamassimo, D. D. S., M. S., Childrens Hospital, Columbus, OH Johanna Dwyer, D.Sc., R. D., New England Medical Center Hospital, and Carol N. Meredith, University of California at Davis James Emshoff, Ph.D. and Ronnie Margolin, Georgia State University* Mathea Falco, J. D., New York, NY Ronald A. Feldman, Ph.D., Columbia University Michelle Fine, Ph.D., University of Pennsylvania James Garbarino, Ph.D., Erikson Institute Josephine Gittler, J. D., Mary Quigley-Rick, J.D., and Michael J. Saks, Ph. D., University of Iowa Robert Guntow, Hyattsville, MD Thomas Hoffman, Washington, DC Angela Holder, LL.M., Yale University* Jonathan Klein, M.D., M. P.H., Milton Kotelchuck, Ph. D., and Gordon H. DeFriese, Ph.D., University of North Carolina at Chapel Hill* Barry Krisberg, Ph. D., National Council on Crime and Delinquency* Richard Kronick, San Diego, CA* Spero Manson, Ph. D., University of Colorado Margaret McManus, M. H. S., Harriette Fox, M.S.W., Paul Newacheck, D.P.H., Lori Wicks, and Rebecca Kelly, McManus Health Policy, Inc. Gary B. Melton, Ph.D. and Lois B. Oberlander, M.A., University of Nebraska-Lincoln Scott Menard, Ph.D., University of Colorado Larry Miike, M. D., J. D., University of Hawaii* Edward P. Mulvey, Ph. D., Michael A. Arthur, M.A., and N. Dickson Reppucci, Ph. D., University of Pittsburgh D. Wayne Osgood, Ph. D., and Janet K. Wilson, University of Nebraska-Lincoln* Carol Runyan, M. P. H., Ph. D., Elizabeth A. Gerken, M. S. P. H., and Laura S. Sadowski, M. D., M. P. H., University of North Carolina Stanley Sue, Ph. D., University of California, Los Angeles, and Nolan Zane, University of California at Santa Barbara* Dalmas A. Taylor, Ph. D., Wayne State University, and Phyllis A. Katz, Ph. D., Institute for Research on Social Problems* H. Rutherford Turnbull, Esq., J. D., LL.M. and Lisa Dorrill, M. A., University of Kansas Robert Valdez, Ph. D., University of California, Los Angeles* Margaret West, M. S.W., Ph.D. and Sally N. Stuart, M. S.W., University of Washington* l Supported by Carnegie Co~oration of New York and the Carnegie Council on Adolescent Development, vi
PAGE 7
Volume II BACKGROUND AND THE EFFECTIVENESS OF SELECTED PREVENTION AND TREATMENT
PAGE 8
Contents Page Chapter 1. Introduction . . . . . . . . . . . . . . . . 3 Part I: Background on Adolescent Health Chapter 2. What Is Adolescent Health? . . . . . . . . . . . . 13 Chapter 3. Parents and Families Influence on Adolescent Health . . . . . . 35 Chapter 4. Schools and Discretionary Time . . . . . . . . . . . 59 Part II: Prevention and Services Related to Selected Adolescent Health Concerns Prevention and Services Related to Physical Health Problems Chapter 5. Accidental Injuries: Prevention and Services . . . . . . . . 117 Chapter 6. Chronic Physical Illnesses: Prevention and Services . . . . . . 149 Chapter 7. Nutrition and Fitness Problems: Prevention and Services . . . . . 193 Chapter 8. Dental and Oral Health Problems: Prevention and Services . . . . . 231 Prevention and Services Related to Sexually Transmitted Diseases and Pregnancy Chapter 9. AIDS and Other Sexually Transmitted Diseases: Prevention and Services . 257 Chapter 10. Pregnancy and Parenting: Prevention and Services . . . . . . 323 Prevention and Services Related to Mental Health Problems Chapter 11. Mental Health Problems: Prevention and Services . . . . . . 433 Chapter 12. Alcohol, Tobacco, and Drug Abuse: Prevention and Services . . . . 499 Prevention and Services Related to Delinquency and Homelessness Chapter 13. Delinquency: Prevention and Services . . . . . . . . . 583 Chapter 14. Hopelessness: Prevention and Services . . . . . . . . . 663 Appendix A. Glossary of Abbreviations and Terms . . . . . . . . . 695 Index . . . . . . . . . . . . . . . . . . . . 729 VII!
PAGE 9
Chapter 1 INTRODUCTION
PAGE 10
Contents Page Chapter 1 References . . . . . . . . . . . . . . . . . 6 Boxes Box Page l-A. Full Table of Contents for OTAs Adolescent Health Report . . . . . . . 4 l-B, Summary of Major Policy Options Related to Adolescent Health . . . . . . 5 l-C. Requesters of OTAs Adolescent Health Report . . . . . . . . . . 7
PAGE 11
Chapter 1 INTRODUCTION This is Volume II of OTAs assessment, Adolescent Health. This volume, Background and the Effectiveness of Selected Prevention and Treatment Services, provides background information on important aspects of adolescents lives and detail on the effectiveness of selected prevention and treatment interventions. Volume I is entitled Summary and Policy Options (2). Volume III is entitled Crosscutting Issues in the Delivery of Health and Related Services (3). As shown in box l-A, which lists the table of contents for all three volumes of the assessment, : 1 Part I: Background Volume II has two major parts. on Adolescent Health and Part II: Prevention and Services Related to Selected Adolescent Health Concerns. Part I: Background on Adolescent Health provides a framework for viewing the lives and social environments of contemporary adolescents. Chapter 2, What Is Adolescent Health? provides a brief overview of aspects of adolescent development that may affect adolescents health, the delivery of health services, and public policy with respect to adolescents. This chapter notes that researchers have found that popular conceptions of adolescents as a group whose behavior is overwhelmingly determin ed by raging hormones and of adolescence as a period when to be abnormal is normal are misguided. These misconceptions are not benign: they may have deleterious effects on attitudes towards individual adolescents and on interactions with individual adolescents and on policy and program development, with neglect of adolescents being a predominant response. Adolescence is a period of profound biological, emotional, intellectual, and social transformation, and substantial societal support may be needed by adolescents and their families in order to promote healthy development. Chapter 2 also discusses conceptualizations of health, providing background for the broad conceptualization used by OTA in its assessment. Chapter 3, Parents and Families Influence on Adolescent Health, addresses a most important aspect of adolescents lives and social environments, their families. Research suggests that being the parent of an adolescent requires an approach different from that required for being the parent of a younger child. But relative to the amount of guidance and support provided to parents of infants and young children, little guidance and support are provided to parents as their children mature into adolescence. promising models of parent-adolescent interaction are available, however, and these are reviewed in chapter 3. More research is needed on these models and on models of appropriate governmental and private support to make parents more appropriately available to their adolescent children. 2 Chapter 4, Schools and Discretionary Time, turns to two other important aspects of adolescents lives. These two facets of the social environment become increasingly important as adolescents spend more time physically away from their families and testing a range of skills, beliefs, and behaviors. Although little systematic empirical research has been supported, the studies that have been conducted suggest that academic and health outcomes of adolescent students are influenced by school environments; studies of school environments and the policy implications of the studies are reviewed in chapter 4. Also discussed is the time that adolescents spend away from school in discretionary activities such as being with their friends, solitary leisure activities, doing volunteer work, and engaging in hobbies. Although information is again scarce, the chapter focuses on the apparent paucity of activities for adolescents that are satisfying to adolescents, conducive to healthy development, and acceptable to the adult community. Part II: Prevention and Services Related to Selected Adolescent Health Concerns includes chapters 5-14, each of which ex amines a specific health problem of concern to policymakers, the public, parents, and, to varying degrees, to adolesIVo[ume I+jummry andpo[icy Options was pub;ished in April 1991 (2), and Volume III
PAGE 12
II-4 Adolescent HealthVolume II: Background and the Effectiveness of Selected Prevention and Treatment Services Box l-AFull Table of Contents for OTAS Adolescent Health Report VOLUME I: SUMMARY AND POLICY OPTIONS Appendixes A. Method of the Study B. Acknowledgments C. Issues Related to the Lack of Information About Adolescent Health and Health and Related Services D. Glossary of Abbreviations and Terms VOLUME II: BACKGROUND AND THE EFFECTIVENESS OF SELECTED PREVENTION AND TREATMENT SERVICES 1. Introduction Part I: Background on Adolescent Health 2. What Is Adolescent Health? 3. Parents and Families Influence on Adolescent Health 4. Schools and Discretionary Time Part II: Prevention and Services Related to Selected Adolescent Health Concerns Prevention and Services Related to Physical Health Problems 5. Accidental Injuries: Prevention and Services 6. Chronic Physical Illnesses: Prevention and Services 7. Nutrition and Fitness Problems: Prevention and Services 8. Dental and Oral Health problems: Prevention and Services Prevention and Services Related to Sexually Transmitted Diseases and Pregnancy 9. AIDS and Other Sexually Transmitted Diseases: Prevention and Services 10. Pregnancy and Parenting: Prevention and Services Prevention and Services Related to Mental Health Problems 11. Mental Health Problems: Prevention and Services 12. Alcohol, Tobacco, and Drug Abuse: Prevention and Services Prevention and Services Related to Delinquency and Hopelessness 13. Delinquency: Prevention and Services 14. Hopelessness: Prevention and Services Appendix A. Glossary of Abbreviations and Terms VOLUME III: CROSSCUTTING ISSUES IN THE DELIVERY OF HEALTH AND RELATED SERVICES 15. Major Issues Pertaining to the Delivery of Primary and Comprehensive Health Services to Adolescents 16. Financial Access to Health Services 17. Consent and Confidentiality in Adolescent Health Care Decisionmaking 18. Issues in the Delivery of Services to Selected Groups of Adolescents 19. The Role of Federal Agencies in Adolescent Health Appendixes A. Glossary of Abbreviations and Terms B. Burden of Health Problems Among U.S. Adolescents C. HCFAs Method for Estimating National Medicaid Enrollment and Expenditures for Adolescents cents themselves: accidental injuries (ch. 5); chronic and drug abuse (ch. 12); delinquency (ch. 13); and physical illnesses (ch. 6); nutrition and fitness hopelessness (ch. 14). As discussed in each chapter, problems (ch. 7); dental and oral health problems the problems reviewed do not constitute the entire (ch. 8); AIDS and other sexually transmitted disset of possible adolescent health problems; rather, eases (ch. 9); pregnancy and parenting (ch. 10); the intent of the chapters is to provide detail on mental health problems (ch. 11); alcohol, tobacco, selected problems illustrative of important policy
PAGE 13
Chapter IIntroduction l II-5 Box l-BSummary of Major Policy Options Related to Adolescent Health In Volume I of this Report, OTA suggests a range of options that could be implemented in an effort to help improve adolescent health, broadly defined (2). Three major options that OTA believes Congress may want to consider are as follows: 1. improving U.S. adolescents access to appropriate health services, 2. restructuring and invigorating Federal efforts to improve adolescent health, and 3. improving adolescents environments. Strategies to improve U.S. adolescents access to appropriate health services include: support the development of centers that provide, in schools and/or communities, comprehensive and accessible services designed specifically for adolescents-e. g., by providing seed money, continuation funding, or removing existing financial barriers; increase financial access-e. g., by expanding Medicaid to immediately include all poor adolescents, by increasing access to private insurance, and by increasing outreach for Medicaid; l increase legal access to health services-e. g., by supporting the development of a model State statute, or requiring or conditioning States receipt of Federal moneys for specific programs on substantive changes in consent and confidentiality regulations; increase support for training for the providers of health and related services; and empower adolescents to gain access to health and related service --e.g., through education and encouraging adolescent participation in the design of services. Strategies to restructure and invigorate Federal efforts to improve adolescent health include: create a new locus for a strong Federal role in addressing adolescent health issues; strengthen traditional U.S. executive branch activities in: 1) program development for promising or neglected areas of intervention, 2) research, and 3) data collection. Strategies to improve the social environment for adolescents include: increase support to families of adolescents-e. g., through tangible supports such as child allowances or more flexible working hours, and through providing information on appropriate, health-promoting parenting for adolescents; support additional limitations on adolescents access to firearms; l support the expansion of appropriate recreational opportunities for adolescents; and l monitor the effects on adolescents of the implementation of the National and Community Service Act of 1990. In addition to these major options and strategies, which cut across the areas examin ed by OTA, a number of topic-specific policy options are listed in Volume I of the Report. OTA notes that, apart from whatever specific strategies the Federal Government may adopt to improve adolescents health, there is a need for a basic change in approach to adolescent health issues in this country, so that adolescents are approached more sympathetically and supportively, and not merely as individuals potentially riddled with problems and behaving badly. issues. This detail provides support for the major chapter. It is important to note that OTA generally policy options discussed in Volume I of this found data limitations to be considerable. 3 Using assessment (see box l-B). available sources of data, the background section of Each of the 10 chapters in Part II follows a similar each chapter also provides information on the format. A background section in each chapter prevalence of the problem among adolescents. discusses limitations of existing sources of data on These sections typically provide support for OTAs the adolescent health problem that is the focus of the conclusion that individuals may encounter signifi3 See app. C, Issues Related to the Lack of Information About Adolescent Health and Health and Related Services, in Vol. I, for a synthesis of limitations in available data.
PAGE 14
II-6 l Adolescent HealthVolume II: Background and the Effectiveness of Selected Prevention and Treatment Services cant health problems during the course of adolescence. 4 Also presented in the background section of each chapter is available information about differences in prevalence by selected sociodemographic characteristics (e.g., age, gender, race, ethnicity, social class, and residence) and nondemographic risk factors (e.g., family factors, community and peer influences, biological factors, adolescents beliefs and attitudes). These sections provide support for the importance of targeting interventions to adolescents based on demographic characteristics and other risk factors but also for the conclusion that many adolescent health problems (e.g., alcohol use, suicide) cut across a wide variety of ages, races, ethnicities, and social classes. s The primary focus of OTAs analyses in the 10 chapters in Part II of this volume was to determine the effectiveness of prevention and treatment interventions for adolescent health problems. Thus, each chapter in Part II has sections on the prevention and treatment of the health problem that is the focus of the chapter. Information is presented on the appropriateness of prevention and treatment interventions and problems adolescents may encounter in gaining access to services. Particular attention is paid to the effectiveness of interventions, in terms of improved health outcomes for adolescents. Evaluations of preventive interventions for adolescents suggest that many of the interventions are not based on available knowledge about risk factors, and that too many interventions rely on attempts to change individual behavior, when research-albeit limited 6 -ha s shown that primary preventive interventions based on automatic protection and other environmental change (e.g., legislation and regulation) are more effective than those that rely solely on education and persuasion. Too little attention has been paid to secondary prevention through early intervention: adolescents face many barriers to gaining access to needed health services. 7 Each of the 10 chapters in Part II also includes a section on Federal policies and programs that are most relevant to the health problem discussed in the chapter. Federal agencies attention to adolescent health problems has varied over time and by topic, with much attention now being paid to illicit drug use and preventing sexual activity. OTAs analysis identifies a number of problems with the Federal approach to adolescent health topics. A major problem is the very limited attention being paid by Federal agencies to providing adolescents with needed health and related services. Another problem is that the sheer number of congressional committees and U.S. executive branch agencies and programs contributes to fragmentation in data collection, research, and service delivery related to adolescents. 8 Finally, it should be noted that each chapter in this volume ends with conclusions and policy implications. Specific legislative options pertinent to each of the issues discussed in this volume (and in Volume III of this assessment) can be found in Volume I-Summary and Policy Options (2). Appendix A of this volume is a glossary of terms and abbreviations. The way OTA went about conducting the assessmentincluding lists of workshop participants and members of OTAs Youth Advisory Panel for the assessmentis described in appendix A of Volume I. The many individuals who assisted OTA in the development of the three volumes of this Report are listed in appendix B of Volume I. The congressional requesters of the assessment are listed in box 1-C below. Chapter 1 References 1. Osgood, D.W., and Wilson, J.K., Covariation of Adolescent Health Problems, paper prepared under contract to Carnegie Council on Adolescent Development and Carnegie Corporation of New York for the Office of Ech.nology Assessment.j U.S. Congress, Washing4For a review of the r~~ch on c~variation in adolescent herdth problems, see Osgood and Wilson (l). Covariation is the tendency of health problems to occur in the same individual at about the same time. Most of the evidence on covariation of adolescent problems is based on cross-sectional studies, so it is still unclear for many problems whelher one problem leads to another or the problems occur together, due to a single cause or set of causes. Another limitation of the evidence on covariation is that most of the evidence is limited to covariation in adolescent behaviors and does not consider emotional or physical problems. Nonetheless, there is evidence for statistically signiilcant covariation among several adolescent health behaviors (l). 5A @buIM s~ ary of prevalence data and capsule statements of adolescents most at risk (usually in terms of demographic characteristics) for the problems discussed in this volume can be found in app. B, Burden of Health Problems Among U.S. Adolescents, in Vol. III of this Report (3). 6The fact that the research on environmental change is limited is in part related to the fact that much of the literature on risk factors limits itself to studies of individual or, at most+ family factors. It is also difficult to evaluate the impact of global environmental changes on adolescents specfkally. 7Barriers t. he~th sewic~ are discussed in each chapter and in Vols. I and III of thk assessment (2,3). s~ Ovewiew of Feder~ programs relevant to adolescent health ~ & fo~d ~ ch. 19, The Role of Federal Agencies in Adolescent Heal@ in Vol. III of this Report (3). Major policy options related to the Federal role in adolescent health are presented in Vol. I (2).
PAGE 15
Chapter lintroduction l II-7 Box l-CRequesters of OTAs Adolescent Health Report (with current committee chair or ranking minority assignments) Senator Daniel K. Inouye, chairman of the Senate Select Committee on Indian Affairs; Senator Nancy Landon Kassebaum, Ranking Minority Member of the Subcommittee on Education, Arts, and Humanities of the Senate Committee on Labor and Human Resources; Senator Bob Dole, Minority Leader of the Senate; Senator Robert C. Byrd, Chairman of the Senate Committee on Appropriations; Representative William H. Gray, III, Majority Whip of the House of Representatives; Senator James M. Jeffords, Ranking Minority Member of the Subcommittee on Labor of the Senate Committee on Labor and Human Resources; Senator Orrin G. Hatch, Ranking Minority Member of the Senate Committee on Labor and Human Resources; Senator Edward M. Kennedy, chairman of the Senate Committee on Labor and Human Resources; Senator Quentin W. Burdick, Chairman of the Senate Committee on Environment and Public Works; Senator Mark O. Hatfield, Ranking Minority Member of the Senate Committee on Appropriations; Senator Alan K. Simpson, Assistant Minority Leader of the Senate; Senator Alan Cranston, Chairman of the Senate Committee on Veterans Affairs; Senator Ted Stevens, Ranking Minority Member of the Senate Committee on Rules and Administration; Senator Bob Packwood, Ranking Minority Member of the Senate Committee on Finance; Senator Charles Grassley, Member of the Technology Assessment Board; Senator Barbara Mikulski, Chairman of the Subcommittee on Veterans Affairs, Housing and Urban Development, and Independent Agencies of the Senate Committee on Appropriations; Senator Ernest Hollings, Chairman of the Senate Committee on Commerce, Science, and Transportation; Senator Arlen Specter, Ranking Minority Member of the Subcommittee on Veterans Affairs; Representative Henry A. Waxman, Chairman of the Subcommittee on Health and the Environment of the House Committee on Energy and Commerce; Senator Daniel K. Akaka; Representative Morris K. Udall, Chairman of the House Committee on Interior and Insular Affairs; Senator Frank H. Murkowski, Vice chairman of the Senate Select Committee on Intelligence; Senator Christopher J. Dodd, Chairman of the Subcommittee on Children, Family, Drugs, and Alcohol of the Senate Committee on Labor and Human Resources; Senator Claiborne Pen, chairman of the Senate Committee on Foreign Relations; Senator Dale Bumpers, Chairman of the Senate Committee on Small Business; Senator Lloyd Bentsen, Chairman of the Senate Committee on Finance; Senator Daniel P. Moynihan, Chairman of the Subcommittee on Social Security and Family Policy of the Senate Committee on Finance; Senator John D. Rockefeller, IV, Chairman of the Subcommittee on Medicare and Long Term Care of the Senate Committee on Finance; Representative Don Young, Ranking Minority Member of the House Committee on Interior and Insular Affairs. A letter of support was received from the House Select Committee on Children, Youth, and Families. ton, DC, 1990 (Springfield, VA: National Technical Information 3. U.S. Congress, OffIce of Ikchnology Assessment, Adolescent Service, NTIS NO.-PB 91-154 377/AS). Health: V;lume 111-Crosscutting Issues in the Delivery of Health 2. U.S. Congress, Office of Technology Assessmen~ Adolescent Health: Volume L-Summary and Policy Options, OTA-H-468 and Related Services, OTA-H-467 (Washington DC: U.S. Govem(WashingtoL DC: U.S. Government Printing Office, April 1991). ment Printing Office, June 1991).
PAGE 16
Part 1: BACKGROUND ON ADOLESCENT HEALTH
PAGE 17
Chapter 2 WHAT IS ADOLESCENT HEALTH?
PAGE 18
Contents Page Introduction . . . . . . . . . . . . . . . . . . . What Is Adolescence? . . . . . . . . . . . . . . . . ., Historical Perspectives on Adolescence . . . . . . . . . . . . Basic Physiological Changes in Adolescence . . . . . . . . . . . Overt Physical Changes in Adolescence . . . . . . . . . . . Hormonal Changes in Adolescence.. . . . . . . . . . . . . Cognitive Changes During Adolescence. . . . . . . . . . . . . A Perspective on Adolescent Risk-Taking . . . . . . . . . . . summary . . . . . . . . . . . . . . . . . . . Defining Adolescent Health . . . . . . . . . . . . . . . Current Conceptualizations of Health . . . . . . . . . . . . Measures of Health . . . . . . . . . ,.,.... . . . . . Measures of the Health of Individuals . . . . . . . . . . . . Measures of the Social Environment . . . . . . . . . . . . Factors Affecting Conceptualizations of Adolescent Health ..........,.. . . . . summary . . . . . . . . . . . . . . . . . . . Conclusions and Policy Implications . . . . . . . . . . . . . Chapter 2 References . . . . . . . . . . . . . . . . 13 13 13 17 17 18 20 23 24 24 24 26 26 26 26 27 27 29 Boxes Box Page 2-A. Examples of Differences in the Legal Status of U.S. Adolescents by Category of Activity 16 2-B. In Search of Self: Identity Development in Adolescence . . . . . . . . 20 2-C. Toward Improving Adolescent Health: Key Concepts Developed by Adolescent Health Scholars at the1986 National Invitational Conference on the Health Futures of Adolescents . . . . . . . . . . . . . . . . . 28 Figures Figure Page 2-1. Sequence and Timing of Four Key Pubertal Events During Adolescence: Adolescent Females . . . . . . . . . . . . . . . . 2-2. Sequence and Timing of Four Key Pubertal Events During Adolescence: Adolescent Males . . . . . . . . . . . . . . . . 2-3. Growth Spurts During Adolescence . . . . . . . . . . . . 18 18 19
PAGE 19
Chapter 2 WHAT IS ADOLESCENT HEALTH? Introduction Although analyses by OTA and others certainly suggest a need for attention to the health of U.S. adolescents, it is important to note that what is meant by adolescent health is still not all that clear (37,56). Considerations of the meaning of adolescence and the way the health of adolescents is conceptualized are important, because such conceptions have significant consequences for: l judgments about how healthy adolescents are; judgments about which adolescent health problems are most important; judgments about what health-related policies are justified; and decisions about the development of measures of health and health services utilization that are in turn used to help judge the need for changes in services and policies. Conceptualizations of health are important in considering the health of any segment of the population, but because of the unusual social status of adolescents (55), unique issues are raised. This chapter provides a brief overview of some of the basic changes that occur during adolescence and their implications for adolescent health policy. It then discusses issues in defining health and adolescent health in particular. As discussed below, the focus of the chapter, and of this Report, is on adolescents ages 10 through 18 years. What Is Adolescence? For some adults, the period of adolescence is one they would rather forget (they learned the truth at 17 ). For others, it is a period they continue to recall with happy memories (the Glory Days ). Probably most adults view adolescence, like other periods of development, as a period of both positive and negative experiences and emotions. But there is something about the intensity of adolescence that marks it as subjectively different from other periods. At the same time, no two adolescent experiences are alike, and capturing the adolescent experience (18) in research, and on paper, is a difficult task. This section on adolescent development reviews evidence for the notion that adolescence is a social construct, one that is changing even as we examine it (55). It then describes the basic biological and cognitive foundations of change during adolescence. The section relies heavily on chapters by Modell and Goodman (55), Keating (43), and Brooks-Gunn and Reiter (11) in the recent volume, At the Threshold: The Developing Adolescent (24), which should be consulted for more comprehensive analyses, and on a summary of these chapters and others by Zaslow (89). Historical Perspectives on Adolescence As Zaslow notes, our understanding of adolescence is enhanced by placing it in a historical context (89). Basic physical changes do mark the transition from childhood to maturity (see below), but the long period that we now refer to as adolescence has largely been constructed in response to economic and social changes in the last 2 centuries (55), According to Modell and Goodman, in terms of the current social status of adolescents, The most critical component in this evolution was the spread of schooling. (55). 1 According to Modell and Goodman, the contemporary idea of adolescence in Western Europe and the U.S. emerged from particular economic and social circumstances associated with industrialization (55,89). Just prior to the industrial revolution, there was a special status for young people that IModell and Goo&na,n provide an interesting comparison of changes in the status of adolescents and the retative iInpOrtanCe of schooling V labor in Great Britain and the United States (55). This portion of Modell and Goodmans analysis suggests that it is not only economic forces, but the predominant ideology of a nation, that determines a nations sociat structure (55). A comprehensive analysis of the forces that determine a nations social structure is beyond the scope of this Report. As s ummarized by Modell and Goodmq the British tended to be more concerned with inculcating and maintaining internalized codes of behavior appropriate to ones station in life, while the Americans were interested in conveying to its citizens the sense of a capacity to master whatever situation might arise (55). Thus, when American school authorities urged children to stay in school, they reflected the ideological structures that held that extended schooling meant opportunity (55). In contrast, the British system made decisions early on about educational and thus employment opportunities for young people. For example, until 1921, Britons as young as ages 12 and 13 could attend school for only balfa day and leave school by age 14 (55). The American experience was also marked by a great influx of unskilled immigrants at around the turn of the century, with fewer requirements for the labor of children (55). -II-13
PAGE 20
//-14 l Adolescent Health-Volume //: Background and the Effectiveness of Selected Prevention and Treatment Services gave modest recognition to [youth] as [a period] of preparation for adulthood (55). But in this period, youth roles were almost continuous with adult roles (55). 2 In the agrarian societies that predominated, the family was the primary economic and social unit and thus the dominant force in an individuals life. 3 Occupational choices were limited and fairly well-defined. With the coming of the industrial revolution and the urbanization of industrialized nations, the progression from childhood to adulthood became more difficult: It was no longer entirely clear what steps one had to take to become an adult. The shrinking of opportunities for farming led families to encourage sons to seek other professions requiring formal training. The tradition of apprenticeship declined. Adolescents became economically dependent on the family. Adult roles were no longer inherited and prescribed, but now involved choice and initiative (89). Whereas before young people were integral to the economic survival of their families and thus to society, they came increasingly to be seen as marginal (55). For a while, young peopleespecially those in citieswere viewed as brash and troublesome. This perception shifted to a view of young people as vulnerable and in need of help, and various extrafamilial institutions came into being to help socialize individuals into the new corporate and bureaucratic world (55,72). Chief among these extrafamilial institutions was the public high school, which was becoming an upward route into the American middle class (55). 4 Other institutions (e.g., Boy Scouts, settlement houses 5 ) also became part of the child development movement. 6 As summarized by Modell and Goodman: With the industrialization and urbanization of the nineteenth century, the orderly progression of young people toward adulthood became so widely problematic that concerned middle-class adults elaborated a specialized vocabulary and set up special institutions for adolescents (55). According to Modell and Goodman, no single individual did more to popularize and solidify adolescence as a critical developmental phase than G. Stanley Hall, the psychologist and author of the 1904 volume Adolescence: Its Psychology, and Its Relations to Anthropology, Sex, Crime, Religion, and Education (28,55). According to Modell and Goodman, Halls volume contributed to the cooperation in America between academic psychology, the rapidly spreading public school bureaucracy, and the lesser groupings of professionals outside the schools committed to the task of aiding child development (55). Hall and his followers conception of adolescence was as a period in which a person is virtually reborn; it was a phase of upheaval and trauma, storm and stress, corresponding to mankinds evolutionary progress from savagery to civilization (55). 7 8 These conceptions of adolescence also became a powerful justification for the institutional specialization and even segregation of youth, so they might %e term youth was used, but it was not age-specific, and it overlapped considerably with use of the term childhood (55). Youth referred to an extended stage defined by the economic status and role of the individual who was not fully dependent on his or her parents for economic suppon who contributed to the fmcial stability of the family, but who was nonetheless not in a position to assume an independent adult role and set up his or her own household (55). Individuals as young as age 12 or as old as age 24 could be referred to as youths, but the term children encompassed individuals ages 18 or 21 and younger (55). sModell and Goodman note the tradition of fostering out that seems contrary to the dorninan ce of the family of origin (55). Children who were fostered out worked in other households while they were aged 12 to 15. This tradition provided further txaining in economic roles, [and] a transitional period toward independence but within a family setting (89). AEven~y, tie (to~ ~gh school exyfience ~c~e] ro~tic~ed as ~ episode of irrepla~able soc~ md perso~ discovery. The h@ school popularized a new image of youth. .as a creative and progressive life stage (74). The reality of the contemporary high school experience varies considerably, of course. Evidence for the impact of middle and high school environments on adolescent health is reviewed in ch. 4, Schools and Discretionary Time, in this volume. sse~ement hous~ were institutions providing various community Se~lCeS, cXptX~y to hge city pop~tions. 6At abut me Sme time, here Wm concern abut he fate of c~&en on a Mtioti level. ne es~bhstient of a Childrens Bureau h the U.S. executive branch is described in ch. 19, The Role of Federal Agencies in Adolescent Heal@ in Vol. III. 7T0 H~ ~d M5 followem, e~h s~ge of life corresponded to the developmental process of the human race m a whole (55). 8AS discuss~ el=whem ~ ~S Re~rt, ~s formerly pop~~ notion ~ ~n diSCr~i@d (2A). such notions led to the view that poor health, in particular, poor mental healt.& odd behavior, and sub@tive distress, were to be expected during adolescence.
PAGE 21
Chapter 2What Is Adolescent Health? l /1-15 more productively act out phase-specific turmoil understood as characteristic of their age (55). It is usually more difficult to characterize contemporary times than to reflect on historical changes. 9 As noted above, there are many adolescent experiences, in the past (55) and in modern times (12a). It seems fair to say that many of the changes in conceptualizations and social structure of adolescence that occurred following the industrial revolution (e.g., 28) persist today. As summarized by Modell and Goodman: At the beginning of the twentieth century, most youth were in the work force, not in school. 10 Good behavior was positively sanctioned not by promises of future utility and reward but by immediate payment and preferment. Bad behavior was sanctioned negatively not by physical or social humiliation but by the threat of dismissal, At the same time, marriage was typically far in the future, l1 and a youths commitment was solidly to the family of origin. There were many points of tension in the turn-ofcentury transition pattern. .The modal adolescent increasingly found herself or himself at school, and his or her perceived needs and deficiencies changed accordingly. School, unlike the work force, is an age-segregated institution which, by its nature, focuses on socializing young people for adult roles. .In th[e school] setting, adolescence has evolved as a transitional period of preparation for adulthood (55). In late-20th century United States, there is some ambiguity about social expectations during adolescence (box 2-A), although there continues to be considerable age-segregation of youth. Staying in school until high school graduation (typically age 1 8 12 ) or, increasingly, beyond (i.e., college or graduate school) is the preferred norm 13 (87). There is increasing concern that adherence to this norm results in the neglect of the millions of young people who do not go on to college-the so-called forgotten half 14 (87), as well as to a prolonged sense of rolelessness among young people who remain in school (60a). The young people who do not go on to college and who obtain jobs 15 may be better able than young people still in school to perceive themselves as adults in some respects (i.e., they are more financially independent), but the reality is that the initial earning power and the long-term prospects for advancement of these young people have declined considerably in comparison with the earning power and prospects for advancement of young gAs Modell and Goodrnan, note, however, social-historical accounts are r~e!y definitive; thus, a chapter like theirs is necessarily interpretive (55). IOIn 1900, u.S. males typically left school at age 16 and entered the work force at age 15.5; British males left school at age 13 and entered the work force at age 14 (55). ] I The typical age of marriage for U.S. females in 1900 was 22.5 years; in 1960, it was about 20 years; and in 1980, about 24 years (55). lzwithout attempting to come to a definitive definition of adolescence, OTA decided to focus thk Report on 10tiough 18-yem-olds. Many individuals have begun puberty by age IO, and health issues of young adolescents have been relatively neglected. While the Iegat age of majority is 18 in most States (and thus many 18-year-olds are legally adults), many adolescents are still in high school at age 18 and thus are more or less dependent. High school completion continues to define the end of adolescence in many ways; age 18 is used as a surrogate marker for high school completion. As discussed in the W.T. Grant Commission report, the fact of high school graduation or legally becoming an adult creates a whole new set of contingencies and opportunities for addressing health issues (87). OTA felt that attempting to address these issues as well as those affecting younger adolescents would compromise its overatl effort; however, this does not mean that the post-high-school period is not potentially fraught with health-related difficulties and does not deserve attention (58,87). The Report tries to k as specific as possible in referring to adolescents of different developmental stages. However, much of the research refers to adolescents of unspecified ages. When ages are indicated, the adolescents involved in the research are more likely to be older than younger adolescents. As a generat matter, 10to 14-year-olds are considered early adolescents, 15-to 17-year-olds are considered middle adolescents, and 18-to 21-year-olds are considered late adolescents (e.g., 18). But, as discussed below, age is not an ironclad indicator of developmental status. 131n 1988, 80 percent of U.S. 25t. 29-yem-olds, and approximately 70 Pacent of those 25 and older, had&n graduated from high school and had some college (76). Many individuals finish high school and go on to college, but do not complete 4 years of college. In 1988, 60 percent of U.S. 25to 29-year-olds had completed at least 12 years of high school, but had less than 4 years of college; 20 percent had completed 4 or more years of college (76). 14~e ~~culation tit c *M ~ ~e forgotten is bm~ on he 20 ~lllon 16to zq-y~-olds in the us. population Who have not graduated from high school or gone on to college and who are unlikely to go to college (87). Note that this calculation is somewhat different from calculations of the numbers who have been graduated from high school or gone to college by age 25 or older (76). 15[n June 1991, ~emplopentrates for Youg us. workers ages 20 to 24 were 9,9 per~nt for whites and 22.7 percent for blacks (83). In June 1991, unemployment rates for adolescents ages 16 to 19 were 17.5 percent on average (19.9 percent for white mates), and 33.7 percent for btacks (37.4 percent for black males) (83). Unemployment rates are calculated onty for those who are looking for employment; they do not include adolescents attending school or keeping house, or adolescents who are discouraged workers, defined as persons who did not look for work because they believed that no jobs were available in the area or that no jobs were available for which they could qualify (83).
PAGE 22
II-16 Adolescent Health-Volume II: Background and the Effectiveness of Selected Prevention and Treatment Services Box 2-AExamples of Differences in the Legal Status of U.S. Adolescents by Category of Activity Although the age of majority is 18 in all States but three (Alaska Nebraska, and Wyoming, where it is 19), adolescents can legally assume adult-like rights and responsibilities at different ages. Depending on the privilege or obligation in question, and, sometimes, the State in which they live, adolescents: l are able to work part time at 14, full time at age 16 1 (84); are able to leave school at 14, 16, 17, or 18, depending on the State 2 (76); l can be licensed to drive at age 14 3 or 16 (2a); are able to buy cigarettes at age 17 (80); l are able to sign contracts at age 18 4 ; are able to consent to health care at age 18 or 19, except in five States 5 (27,75a); are able to vote at age 18 (Public Law 91-285); must enlist for draft at 18 (males) (Public Law 96-107); and are able to buy alcohol at age 21 (78). Illlese are the basic minimums fornonagricukural industries set by the Fair Labor Standards AX of 1938 (Chapter 676 of the U.S. Code) (84). Different standards for agricultural industries, famUy fand hazdous occupations, as well as rostrictiona on hours W are Summarkd in the Us. General Accounting 0.tllce report on chUd labor violations (84). ZAS of 1%$, Omy one State (Mississippi) pcmnitted imiividuala to leave school at age 14 (76). Thilty-two S* CO-W *1 attendance at age 16 (76). 3M ~ _tiOIIS in the States tbat aUoW driving at age 14, but the restrictions vary (2a). In some of the States tM dow M* at age 14, the driver merely must have completed an approved driver education course (e.g., in Idaho) or must have a guardians or parents consent to get the drivers Iicemse (e.g., Nevada). Ln other States, 14-year-old licensed drivers must be awmpmed byanolderliccnsedd river (e.g., aged 18 in Wyoming aged 21 in ~). 4h ~ sh& (a N_ and Wyoming), the age of majority is 19. See ch. 17, Cement ~d C~ tiality in Adolescent Health ~ Decisionmaking, in VOL III. 5Five States (AabamIL _-q South Camand Oregon) have enacted statuta that specifically authorize minors who have reached a designated ageran gingfiom 14 to 16-to consent to health care. Inthe body oflawgoverningthe auocationofauthority for health care decisionmahlg concerning adolescents is large and compUcated and there are many exceptions to tbe commm law rule that parental consent is generaUy required for the medical or surgical care of a child who has not ~ the age of majority. See ch. 17, Consent and Confidentiality inMolewxnt Health Care Decisionmaking, in Vol. III (75a), and Oittleret al., MolescatHealthC sre Decision-I$fak@ the Law and Public Policy (27). people who go on to college (87). 16 The impact of than the current average of about 121/2 years (29,70). rolelessness on adolescent health is less wellAs discussed below, maturation of the reproductive documented, but anecdotal evidence suggests that it glands (e.g., the ovaries and testes) begins at about may be considerable. ages 9 to 10, before overt signs of reproductive In addition to the lengthening of adolescence, maturity such as menstruation (68). Thus, individubiological changes in the past 2 centuries, induced als are becoming reproductively mature at earlier by the control of infection and better nutrition, have ages. Although she is in the minority with respect to caused adolescence to begin earlier, at least in the the upper age bound for adolescence, 17 Baumrind biological sense (29,52). According to McAnarney, suggests with good reason that contemporary adorecent decreases in the average age of menarche lescence can be said to span ages 10 through 25, with have occurred at approximately 3 months per decade biological markers indicating the youngeragebound(52). Thus, at the turn of the century, the average age ary and social changes (end of postsecondary of menarche in the United States would have been education, marriage) indicating the upper boundary about 14 years of age, approximately 2 years older (6). 16~cord@ t. fie W*T. &~t co~~~ions ~~ysi~ of dab from U.S. Cems Bureau C=nt Population Surveys, between 1973 ~d 1986, ~d mean annual earnings of 20-to 24-year-old civilian males not enrolled in school declined 42 percent for those without a high school diplo~ 28 percent for high school graduates, 16 percent for those with some college, and 6 percent for coUege graduates (87). Another comparison of census data on avexage earnings of slightly older groupings of males (males ages 25 to 34 and 35 to 44) from 1979 and 1986 found results that were similar, though not as striking (61). 170~a ~m~es on ~olescence include ~e~ 10 to 20 (2); ages 10 to 18 (39); ages 10 to 18 ad 10 to 19 (3,58); ~d ages 12 to 17 (46).
PAGE 23
Chapter 2What Is Adolescent Health? II-17 Photo credit: Ca[pitol Hill Arts Workshop, Washington, DC Adolescence is a period of profound biological, emotional, intellectual, and social transformation. In the contemporary United States, the core developmental tasks 18 of adolescence can be said to be the following (18): l l l l l becoming emotionally and behaviorally interdependent, rather than dependent; dealing with emerging sexuality; acquiring interpersonal skills and preparing for mate selection; acquiring education and other experiences needed for adult work roles; and resolving issues of identity and values. Societal expectations may make appropriate completion of the developmental tasks difficult by at the same time: 1) expecting all adolescents to take one developmental pathway; 2) sending ambivalent messages about the completion of adolescence and the beginning of adulthood; and 3) lending relatively little support for coping with developmental changes. A return to a more structured, family-dominated, agrarian life in the United States, and thus a more well-defined adolescence, is unlikely; in any event, it would be foolhardy to romanticize pre-20th century life for young people (55). But in considering public policy related to adolescents, it is important to recognize that, as a consequence of economic and social changes, the years of preparation for adulthood in contemporary times may be fuller, tenser, and more overwhelming for the young people moving through them (55); they may also span a longer portion of an individuals life. As noted by Modell and Goodman in the conclusion to their chapter, these observations may be somewhat troubling to readers, but the notion that adolescence is a social construct should not deflect our attention. Rather, the malleability of adolescence points to the deep importance of understanding its attributes within a concrete context;. [y]oung people. need more guidance from caring and watchful adults (55). 19 Succeeding parts of this section provide a brief review of basic physiological and cognitive foundations of change that occur during adolescence. The recent book At the Threshold: The Developing Adolescent provides a more comprehensive review of the knowledge base on adolescent development (24). Understanding these changes is basic to understanding the experiences of contemporary adolescents. Basic Physiological Changes in Adolescence Physical development, in particular the spectacular development of the reproductive system (69) permeates every aspect of development during adolescence, especially early adolescence (1 1,24,69). The progression of physical development during adolescence has been well-described (see 11,69), but the physiological mechanisms responsible for initiating and regulating maturation and bodily growth, and the environmental factors that may interact with biological ones to enhance or impede maturation are still not fully understood (11,68). Overt Physical Changes in Adolescence Figures 2-1 and 2-2 present several of the critical overt physical aspects of the developmental course of adolescence in relation to each other: the height spurt, the beginning of menstruation (menarche), breast development, and pubic hair development in adolescent females (figure 2-1); and the height spurt, penile and testicle development, and pubic hair development in males (figure 2-2). In females, the height spurt takes place between 9.5 and 14.5 years on average; menarche between 10.5 and 15.5 years on average; breast development in five stages 18Deve/opmenta/ fa& we ~~11~, levels of achievement, ad social adjus~ent considered impoflat at cefiain ages for the successful adjustment Of the individual, and for the individual to progress to the next stage of development (e.g., adulthood). l~e idea tit it is ~w~t t. unders~d tie ~~ent s~~ context for yo~g p~ple wfi ~so reflect~ in the w.T. ~mt cOllMIIiSSiOII IEpOfi On youth ages 16 to 24 who do not go on to college: The world around us hais changed, but our institutions have not responded with the flexibility required to help lay a new foundation under young families and their children (87).
PAGE 24
II-18 l Adolescent HealthVolume II: Background and the Effectiveness of Selected Prevention and Treatment Services Figure 2-l-Sequence and Timing of Four Key Pubertal Events During Adolescence: Adolescent Females a 8 9 10 11 12 13 14 15 16 I I I 1 I 1 I 1 Height spurt A 9 91/~ .14 I/* Menarche n 10-16V2 Bud 8-13 Pubic hair 2 ~354 8-14 8 9 10 11 12 13 14 15 16 Age (years) %Jote that the figure indicates averages, ranges, and the normative sequence forfour specific events. The horizontal lines and rating numbers marked pubic hair stand for its advent and development. The rating numbers for pubic hair indicate stages of pubertal development (69). The appearance of the breast bud is as a rufe the first sign of puberty in the female, though the appearance of public hair may sometimes precede it. Stages of breast development are incorporated within the solid line to the right of the word breast. The range of times for appearance of the breast bud, the beginning of pubic hair, menatie, and peak voliaty in height are shown directly under those events (69). SOURCE: J.M. Tanner, Growth dAdo/escence, 2d ed. (Oxford, England: Blackwell Scientific Publications, 1962). Reprinted with permission. between ages 8 and 18; and pubic hair development in several stages between ages 11 and 14 (figure 2-l). In males, the acceleration of penis growth begins on average at about age 12.5, but sometimes as early as 10.5 and sometimes as late as 14.5 (70). According to Tanner, the sequence of events, though not exactly the same for each boy, is much less variable than the age at which the events occur. The spurt in height and other body dimensions begins on average about a year after the first testicular enlargement [ages 10 to 13.5] and reaches its maximum. after about a further year. (figure 2-2) (70). At various points, dramatic changes occur in other body systems (e.g., weight, facial structure and expression, brain structure) (see figure 2-3). The fact that these changes are not simultaFigure 2-2-Sequence and Timing of Four Key Pubertal Events During Adolescence: Adolescent Males n 10 11 12 13 14 15 16 17 18 I I I I 1 n Apex strength spurt / \i Height spurt 6 h 101/2 .1 fj 13-17 1/2 Penis 11-14 Y2 1 31/ 2 .17 Testis 10-13 v2 14 1/ 2 .18 Pubic 2 hair =3=4 5E 10-15 14-18 I I I I 1 I 1 1 10 11 12 13 14 15 16 17 18 Age (years) 3 aNote that the figure indicates averages and ranges for four smcific events. as well as the &erage sequence o~ four pubefial events, as follows: The solid areas marked penis and testis represent a general picture of the period of accelerated growth of these organs, and the horizontal lines and rating numbers marked pubic hair stand for its advent and development, with the rating numbers for pubic hair indicating stages of pubertal development (69). Figures for the range of ages at which the spurts for height and for penis and testis growth begin and end are inserted underneath the first and last points of the curves or bars. The acceleration of penis growth, for example, begins on average at about age 13, but sometimes it occurs as earfy as 11, and sometimes as late as 141/2. The completion of penis development usually occurs about age 15, but sometimes at 131/2 and sometimes at 17. At ages 13 and 14, there is an enormous variability among any group of boys, who range practically all the way from wmplete maturity to absolute preadolescence. The sequence of events, though not exactty the same for every adolescent male, is much less variable than the time at which the events ocxwr (69). SOURCE: J.M. Tanner, Growth at Addescencq 2d ed. (Oxford, England: Blackwell Scientific Publications, 1962). Reprinted with permission. neous is important to understanding what individuals face during adolescence. Hormonal Changes in Adolescence 20 In addition to confronting overt and discontinuous changes in themselves and others, with attendant concerns about being normal, adolescents must begin to deal with sexual arousal and other internal changes (11). Prior to and during adolescence, the following normative physiological and hormonal changes occur, as summ arized by Susman and her colleagues: 20~ormne~ Me ~h~mi~ ~u~~c=, fo~ed ~ one org~ or pm of the My and carried in the blood to another organ or part of the body, thilt ~ alter the functional activity (and sometimes the structure) of another organ or organs.
PAGE 25
Chapter 2What Is Adolescent Health? l II-19 Figure 2-3-Growth Spurts During Adolescence r L r L Height 1 # 1 Bi-iliac /~, $ \ \ / 1 J+& \ ,., /~ t \ / ) \ \ ~/( $ Hand length \ ,\ ) #\ \ \ /! L ------1 \ Head Circ. ,-0 ~, \ / \ !1 \ A \ \ \ \ \ /1 \ 1 -\ !-\ / \ \/ \ l J \ -. \ \ \ ~\ \ Weight \ L 1 I 1 1 I 8 9 10 11 12 13 14 15 16 17 18 Age, years SOURCE: Figure 5 on p. 13 in J.M. Tanner, Growth atAdo/escer?ce, 2d ed. (Oxford, England: Blackwell Scientific Publications, 1962) based on L. Reynolds and G. Schoen, Growth Patterns of Identieal Triplets From 8 to 18 Years, American Journal of Physical Anthropo/ogy5:l 65-200, 1947. Copyright O 1947 by John Wiley & Sons. Reprinted by permission of Mley-1-iss, a Division of John Wiley & Sons. Adrenarche, maturation of the adrenal glands, 21 begins at ages 6 to 8. Following adrenarche, there is a gradual rise in adrenal androgens 22 that continues up to the age of 18 to 20, when levels reach a plateau. Adrenarche is followed in rather rapid succession by gonadarche [maturation of the reproductive organs], which is accompanied by a rise in gonadotropins and gonadal steroids that continue to rise up to age 15 or 16, when adult levels are reached (68). The physiological changes during adolescence are profound and discontinuous with earlier periods of development (68). According to Tanner, Puberty is the time of the greatest sex differentiation since the early intrauterine months (70). Thus, it is not surprising that a popular conception about adolescents is that they are controlled by raging hormones. Many commonly observed adolescent attitude problems such as talking back to teachers and parents, sullenness, moodiness, and irritability, as well as major emotional and behavioral disturbances, have been attributed to the hormonal changes that occur prior to and during adolescence (68). According to Susman and her colleagues, the natural rise in hormone levels at puberty provides for an experiment in nature. adolescence is an ideal developmental period in which to trace the patterns of change in both hormones and behavior within a short period (68). Unfortunately, research in this area has begun relatively recently (circa 1978), and the effects of the rise in many hormones on the behavior of adolescents generally are unknown (68). While there is some evidence that hormonal changes in adolescence influence some behaviors (see 68), there is also considerable evidence for the primary influence of prior expectations and social environment on adolescents behavioral responses to pubertal processes (24). As Susman and her colleagues note, the connection between normal attitude problems and hormone changes is of major concern to those individuals who are entrusted with the socialization of youth (68). She and her colleagues suggest that additional resources and effort be put into studying the hormonal and other aspects of emotional development in normal adolescents. Important research questions include: What are the mechanisms whereby pubertal hormone changes affect brain development and behavior during adolescence? To what extent is adolescence continuous or discontinuous with other periods of development? What is the causal role of hormonal variations in adolescent mood fluctuations? As noted elsewhere in this Report, very few 21~e ~dremf ~fd~~ Me ~nd~rine ~lands sit~ted ~~ he ~~ey tit pr~cc steroids we Sex hormones (e.g., estrogen, testosterone, eS@lldiOl), hormones related to metabolic functions, and adrenaline. ~AndrOgens (or ~drogenic hormones) are male sex hormones such as testosterone, which is responsible for inducing and maintaining secondary male sex characteristics. ~Gon~o(ropins me hormones tit act upon tie gomds (e.g., follicle-s~ulating hormone, which stimulates the grOWh Of fOfiC1eS COn@g OVa [eggs] and activates sperm-forming cells).
PAGE 26
11-20. Adolescent HealthVolume II: Background and the Effectiveness of Selected Prevention and Treatment Services Box 2-BIn Search of Self: Identity Development in Adolescence The development of an integrated, positive, yet realistic identity has long been considered a hallmark of healthy emotional and social development; optimally, much of this development takes place during the adolescent years (23). Harters recent review of the process of identity development during adolescence in At the Threshold: The Developing Adolescent (32) helps to encapsulate the subjective m caning for adolescents of some of the basic processes described in other chapters in that volume (1 1,43,55). An adolescents emerging ability to think abstractly makes it possible to imagine ideal selves, which can be compared to perceived actual selves. Yet the same cognitive changes that can facilitate the journey of self-development during adolescence make its navigation difficult. Like inconsistencies between the real world and the ideal world (24,43), substantial inconsistencies between ones actual and ideal selves can be a cause of extreme subjective distress (35), as is evident from the following synthesis of a self-portrait at mid-adolescence: What am I like as a person? Complicated! Im sensitive, friendly, outgoing, popular, and tolerant, though I can also be shy, self-conscious, and even obnoxious. Obnoxious! Id like to be friendly and tolerant all of the time. Thats the kind of person I want to be, and Im disappointed when Im not. Sometimes I feel phony, especially around boys. Say I think some guy might be interested in asking me out. I try to act different, like Madonna. Ill be flirtatious and fun-loving. And then everybody, I mean everybody else is looking at me like they think Im totally weird! Then I get self-conscious and embarrassed and become radically introverted, and I dont know who I really am! Am I just trying to impress them or what? But I dont really care what they think anyway. I dont want to cam, that is. I just want to know what my close friends think. I can be my true self with my close fiends. I cant be my real self with my parents. At least at school people treat you more like youre an adult. That gets confusing, though. I mean, which am I, a kid or an adult?. (32). As summarized by Harter: This personal narrative exemplifies numerous prototypic features of self-description during middle adolescence. We witness an introspective self-portrait that is couched in the language of traits of the self-obnoxious, tolerant, introverted, popular, cheerful, depressed-many of which appear to be contradictory. We glean that the display of different selves in different social contexts is cause for concern, as the adolescent struggles to reconcile these different selves as well as determine which is the real me. Experimenting with ones persona. .is typically an emotional experience for the adolescent preoccupied with the challenge of self-definition. (32). Federal resources are dedicated to studying normal adolescent development. 24 Cognitive Changes During Adolescence The evidence suggests that the early adolescent period is a key juncture in the development of human cognitive capabilities, in that, across the age range of 11 to 14, what was previously a minority of successful reasoners becomes a majority (43,89). 25 Thus, in contrast to younger children, adolescents: show an increased ability to generate and hold in mind more than one complex mental representation; l show an appreciation of the relativity and uncertainty of knowledge; l tend to think in terms of abstract rather than only concrete representations; show afar greater use of strategies for obtaining knowledge, such as active planning and evaluation of alternatives; and l are self-aware in their thinking, being able to reflect on their own thought processes and evaluate the credibility of knowledge sources (43,89). Although these changes clearly give adolescents an advantage over younger children in daily decisionmaking, the process of going through these changes may be difficult for some adolescents and Msw ch. 19, me F~er~ Role in ~Ol~Cent Heal@ in Vol. III, which notes that under 7 percent of the budget of the National I.IMitute fOr Child Health and Human Development (Nationat Institutes of Heal@ Public Health Semice, U.S. Department of Health and Human Services) is devoted to adolescent issues. Much of this is problem-oriented rather than focused on normal development. 2s~s is ~omistent wi~ tie evidence (sptise ~ou@ it my be) on adoles~nts remoning during health care decisions (see ch. 17, Consent ad Confldentirdity in Adolescent Health Care Decisio ~g! ~ VO1. ~). ~so see -, Harmoni, and Power (49) whose review found that ~m
PAGE 27
Chapter 2What Is Adolescent Health? l II-21 Harter notes further that these processes do not occur within an introspective vacuum (32). Peers, parents, and teachers are important sources of expectations, evaluations, values, directives, feedback and social comparison (32). Others have noted that adolescent experiences can vary considerably in different gender groups (26) and racial groups (66a,71). An important contribution of work on the process of identity development by Harter and others is the finding that the dramatic changes in the conceptions of self that occur during adolescence do not occur overnight; important changes occur throughout the adolescent period (13,32). The most subjectively distressing shift appears to occur around ages 14 or 15, when individuals not only detect inconsistencies across what they perceive as their various selves (e.g., their behavior in relation to parents, friends, romantic partners), but are also extremely troubled and conflicted over these contradictions, much more so than are the youngest (around ages 11 to 12) or oldest (around ages 17 to 18) groups (13,31,32). For example, the youngest adolescents, who are apparently unconcerned about potential contradiction, make remarks such as Well, you are nice to your friends and then mean to people who dont treat you nicely; theres no problem (31,32). By about age 17 or 18, many adolescents have reached an accommodation with their different selves and can make such statements as: Sometimes its fun to be rowdy, but at other times you just want to be in a quiet mood; you really need to do both with really good friends (31 ,32). Harter refers to these shifts as normative because they typically happen in a normal adolescent; however, certain deficiencies in an adolescents social and psychological environment may interfere with their occurrence. In addition, although these shifts are normal, some of them are accompanied by significant subjective distress while they occur. As Harter points out, it is a myth that these normal changes necessarily produce happy outcomes in the short run (e.g., 21). Further, adolescents may act out these possible selves (22,62), and this role experimentation can usher in another potential source of tension among multiple selves (32). To summarize, the elements of self and identity development during normal adolescence include differentiation of the self into multiple domains (e.g., scholastic competence, athletic competence, physical appearance, social acceptance), the construction of actual and ideal selves, and the integration of multiple self-concepts into a unified self-theory (32). It is no wonder that adolescents often evidence a preoccupation with the self (17,32,40,41). SOURCE: Office of Technology Assessment, 1991, based on S, Harter, Adolescent Self and Identity Development, At the Threshold: The Developing Adolescent, S.S. Feldman and G.R. Elliott (eds.) (Cambridge, MA: Harvard University Press, 1990). the adults in their lives. For example, while Keatcognitive changes to the process of thinking about ings review concludes that, in general, the 11to themselves. 14-year-old range is the period during which a minority of generally successful reasoners becomes The origins of these new or more developed a majority, he also finds some evidence that there is abilities and strategies are an important research a period in early adolescence that Keating terms question with practical implications for educating rampant relativism. That is, when early adolesadolescents and for their abilities to make decisions cents first begin correctly to give a cant tell affecting their health. For example, whether and how response to logical syllogisms, they also give such physiological and cognitive changes may be related an answer when, indeed, there is a valid conclusion is still a matter in dispute (19,43,68). 26 According to and one that younger children can infer (43). Keating Keating, the available evidence indicates that changes suggests that this may be a necessary cost of in cognitive ability occur gradually with age and becoming a critical reasoner. Additional research is over time, rather than showing a sudden onset or needed on this apparent propensity to question irreversible stepwise increments (43,89). But, as everything, which is a familiar one to parents of Keating notes, at the beginning of the 1980s, early adolescents. Box 2-B suggests some of the research on adolescent thinking could easily have necessary difficulties adolescents face as they apply been organized around a few central questions, but GFor example, Susman and her colleagues note thiit gonadal steroids are thought to affect brain development during adolescence, and changes in cognitive abilities arc hypothesimd to be related to changes in gonadal steroids, although the findings reviewed by Susman and her colleagues in 1987 were not consistent across studies (68). According to Kcating, while theories of brain maturation associated with pubertal development continue to arise, the cvidcncc has not been found sufficient to support some of the changes in educational policy that have been suggested (43).
PAGE 28
II-22 l Adolescent Health-Volume II: Background and the Effectiveness of Selected Prevention and Treatment Services since then, accumulating evidence from a variety of perspectives has strikingly expanded the questions that must be considered and [has] made consensus a more distant goal (43). One major change in conceptualizations of adolescent thinking has been the lack of independent support for Piagetian stage theories of cognitive development. Piaget theorized that the changes in thought processes in adolescence reflected internal structural changes in the ability to think logically regardless of content. Although Piaget, his colleagues, and others found evidence of sequential changes in childrens abilities to make logical inferences, the identification of structural changes in logic as the source of the age-related changes has proved problematic (43). 27 There are other potential limitations on the cognitive abilities of younger children that researchers have not been able to rule out as accounting for changes in individuals cognitive abilities, such as memory capacity or efficiency, content knowledge differences, and task familiarity (43). There is a practical implication of the lack of evidence for cognitive developmental stages as such. One common use of the Piagetian model was to view age-related shifts as placing limits on the ability of adolescents to think logically or critically (43). 28 On the contrary, much of the research has shown that supportive contexts and early attention to the development of reasoning are precisely what is required to increase the likelihood of its emergence (43). For example, Vygotsky has found that many differences in cognitive performance may be related to identifiable features of the cognitive environment (86,44). Nonetheless, Keating concludes that the current research provides encouraging evidence that higher order thinking among adolescents is attainable (43). The caution, he says, is that desirable cognitive outcomes are neither easily nor automatically attainable. Positive outcomes have largely been achieved in controlled situations in which ample time is given to solve problems. In the real world, adolescents and adults spontaneous thinking is rarely as systematic, reflective, or intentional as in controlled situations (14). 29 At a practical level, then, it would be foolhardy to assume that cognitive interventions for adolescents could rely on highly active and reflective engagement with demanding material. Yet attempts to encourage such higherlevel engagement, if carried out systematically, do offer considerable promise. The implications of research on adolescent thinking for the delivery of health care services and health-related education to adolescents seem clear. Adolescents cannot be expected to automatically have the cognitive wherewithal to understand disease processes and the increasingly complicated delivery of health services. As is true with adults, a certain amount of ability to draw inferences and make reasonable decisions will depend on adolescents experience and the accumulation of knowledge. The context in which the knowledge is delivered also appears to be important (86). But rather than assumin g that adolescents are incapable of making health care decisions, 30 the working assumption might be that adolescents have the capacity and can be taught to do so in a participatory fashion (43). Certainly, it would be preferable for parents to be the teachers of this information, but often parents and children experience discomfort in discussions of sensitive topics or are themselves not knowledgeable (1 1). 31 Thus, schools and a broad range of health service providers could broaden their roles as educators. Such an expansion of roles zT~e tenets of Piagets theory have been well-described (43). AS s ummarized by Keating, Piaget focused on the development and organization of logicomathematical operations through four major stages or periods: the sensorimotor functioning of infancy; the preoperational, largely egocentric thmkmg of early childhood; the concrete operationat logic of middle and later childhood; and the formal operational logic that characterizes adolescence and adulthood (43). Further, the cognitive operations within any given stage are organized in a structure; thus, stage changes imply shifts in underlying structure brought about through the constructive interaction of the individual with the physical and social world. .This progression is presumed to be universal and invariable (43). 2ESfim1y, EpStein~S ~eo~es abut possible Whole brain growth spurts inspired a move in education to delay C~eW@ cow~work ~til late in adolescence (19,43). 29f30~ Kea@ (43) ~d Ko510wski ~d og~ (45) fmd tit adolescen~ me more simi~ to, ~ &fferent from, ad~~ in drawing causal hlfereIICeS. Level of education appears to make a difference as well, with non-college-educated adults scoring between sixthand ninth-graders (47). %%e legal presumption that minors are incompetent to make health care decisions is discussed inch. 17, Consent and Confidentiality in Adolescent Health Care Decisionmakm g, in Vol. III (75a). 31Also see ch. 3, 14 Pmnts ~d F~lies ~uence on Adoles~nt H~l@ in ~ vol~e.
PAGE 29
Chapter 2What Is Adolescent Health? l II-23 Photo credit: Benjamin Smith Available evidence suggests that higher-order thinking among adolescents is attainable, but it is neither easily nor automatically achieved. Attempts to encourage higher level cognitive engagement require intensive, systematic efforts that involve real-world content. would, however, have training 32 and cost implications. A Perspective on Adolescent Risk-Taking An area important to the delivery of health services (particularly health education) that is related to research on cognitive development is the area of adolescent risktaking .33 As noted in a recent review of adolescent risk-taking by Furby and Beyth-Marom, Although there is little empirical research on adolescent decisionmaking and risk taking, there is no paucity of beliefs about how to characterize adolescent behavior in these areas (26b). In their review of the empirical literature relevant to these beliefs, 34 Furby and Beyth-Marom conclude: there is as yet little evidence that adolescents are more likely than adults to engage in behavior that seems risky to them. That is, there is little evidence that they seek out or are willing to accept greater risks. However, neither is there clear evidence that they do not seek or accept greater risks. The 1ack of empirical evidence on this issue reflects, in large part, the dearth of information on how adolescents (and adults) perceive the options they do consider [and] the likelihood of [the options] possible consequences. .This lack of information on option and consequence perception and evaluation is not surprising, given the methodological difficulties involved in measuring these variables. However, without better evidence, it is hard to justify the [perception] that teenagers are particularly prone to seek out or accept risks. (26b). Knowledge about adolescent risk-taking and decisionmaking is important in considerations of adolescent health policy. For example, Furby and Beyth-Marom raise the possibility that, instead of being poor decisionmakers, many adolescents may be making rational decisions, given the existing conditions and contingencies (26b). 35 If adolescents are engaging in faulty decisionmaking, it seems reasonable to focus on improving their capacity to make better health-related choices, for example, szFor ex~ple, Keating notes two findings with implications for an intensity of effort: 1) that modest intementions kve litfle impaCt (in improving formal logic); and 2) that the greatest difficulties arise when individuals are asked to reason in tasks for which there is no real content. Those who become involved in improving adolescents cognitive development would also have to be aware of other purported aspects of adolescent thinkm g that may affect adolescents abilities to make rational health-related decisions: adolescents appear to have great difficulty in attempting to achieve an integrated understanding of their persoml and social experiences (32,42,64) and adolescents may have a specific form of egocentrism in which they assume themselves to be the focus of most other peoples perspectives much of the time (17). (Keating notes that the latter model is intuitively appeating but has little empirical support (43).) s~F~by and Bey~-M~om provide definitions of risk and risky behavior: The te~ risk. refers to a chance of loss, that chance being greater than 0 percent but less than 100 percent. Thus, the definition of risky behavior .is action (or inaction) that entails a chance of loss (26b). They note that risk taking may or may not be deliberate. That is, one mayor may not be conscious that a given behavior entails a non-zero probability of loss (26b). Furby and Beyth-Maroms perspective on risk taking is based on a decision-making perspective: Decision theorists define decision making as the process of making choices among competing courses of action. The normative models of decision theory prescribe the processes that people should follow in order to have the best chance of maximizing their well-being, given their beliefs and values (26b). (Furby and Beyth-Marom also provide a review of other perspectives on risk taking (e.g., risk taking as sensation-seeking).) %l~e following, according t. Furby and Bey&Mmom, Me some common m~s abut adolescent decisionm~ng and risk-taking: 1) adolescents are not capable of competent decisionmaking; 2) adolescents take more risks than do adults, and their risk taking endangers their well-being; 3) adolescents do not consider sufficiently those possible consequences (of various options) that might occur in the distant future; 4) adolescents think that they are invulnerable; 5) adolescents let emotions rule their choices; 6) adolescents rely heavily on peer information and attitudes when making decisions about risky behavior (26 b), JSFor exmple, if ~1 known alternative outcomes ~e t~en ~to ~cco~t, it ma y seem most ration~ to an adolescent female to beaI a child. h abused adolescent may seek refuge in the use of alcohol or illicit drugs. Reviews of risk factors and preventive interventions related to selected adolescent health concerns can be found throughout this volume and in Vol. I of this Report (75).
PAGE 30
II-24 l Adolescent HealthVolume II: Background and the Effectiveness of Selected Prevention and Treatment Services with tr aining in decisionmaking. 36 If, on the other hand, adolescents are, from their own perspectives, making rational choices, the emphasis should be on encouraging changes in the social structure that would make health-generating choices more likely among adolescents (26b). 37 A potential implication of realistically evaluating the literature on adolescent decisionmaking and risk-taking relates to adults attitudes towards adolescents and towards particular activities. As have adolescents themselves (74a), Furby and BeythMarom note inconsistencies in societal attitudes around sexuality, drug use, and risk taking in general, suggesting that adults may have concerns other than adolescents health: 38 Exactly what these other concerns are is an open question, .Perhaps it is somewhat threatening to adults to see their children acquiring this new (and more equal) status. Or, perhaps these are simply behaviors about which adults are quite ambivalent themselves, being uncertain whether to condemn or condone them even in adults (26b). A considerable amount of additional research and thnking needs to be done with respect to conceptualizations of adolescent decisionmaking and risktaking. 39 Summary Adolescence is a period of profound biological, emotional, intellectual, and social transformation, which appears to be lengthening as a result of national economic demands. One difficulty in gaining the attention of policymakers for some adolescent health concerns is that adolescence is often viewed solely as a transitional period between childhood and adulthood (93). But this transitional period can take as long as one-seventh of the typical life span. One can argue-without coming to the conclusion that to be normal in adolescence is in itself abnormal (26a) (and, perhaps, therefore, that striking aberrations in behavior, should be ignored (88))-that contemporary adolescents deserve sympathetic societal attention, including attention to their perspectives on health, during their second decade of life. Defining Adolescent Health As noted in the introduction to this chapter, definitions of health have for: l judgments about the particular group; l judgments about what important implications health status of any health-related services and policies are justified; and decisions about the development of indicators of health status that are in turn used to help judge the need for services and policies. For adolescents, these implications translate to: How healthy are adolescents? What kinds of interventions, if any, should be developed to improve their health? How shall the health of adolescents and the effectiveness of interventions-be monitored? 40 Hence, an understanding of contemporary conceptualizations of health, and of their implications for the allocation of health-related resources, is important. Current Conceptualizations of Health As is adolescence, the concept of health is socially defined and subject to change. To some extent, adolescents have been affected by recent reconceptualizations of health and attributions of responsibility for health status. ~As discussed below, this approach is part of the approach to health improvement that emphasizes individual mspomibility. sv~s ~omapond~ t. tie he.~ protection approach t. Prmmtion, des~bed blow ~d & FMby ~d Beyth-Marom (26b). 38 For example, the considerable controversy over whether to make contraceptives easily available to teenagers suggests that there may be something other than the risk of pregnancy that bothers adults about adolescents being sexually active. Likewise, the much greater concern expressed about the risks some adolescents take by smoking marijuana than about the risks many more adults take by drinking alcohol. suggests that there may be something other than the possibility of negative behavioral or health effects that bothers adults about adolescents smoking marijuana (26b). JgSuggest~ directions for future research can be found in Furby ~d Beyth-Mamm (Zbb). %ese questions are addressed throughout this Report,
PAGE 31
Chapter 2What Is Adolescent Health? l II-25 A complete history of evolving conceptions of health is beyond the scope of this Report. 41 In the past century, as measures such as improved sanitation, and later, immunizations against bacterial and some infectious diseases have helped to improve life expectancy, 42 there has come to be more of an emphasis on nonphysical aspects of health and on the notion that much disease and disorder is avoidable (5a,53a,77,82a). For example, in 1948 the World Health Organization (WHO) defined health as complete physical, mental, and social well-being, not merely the absence of disease or infirmity (33). While the WHO definition has not been completely adopted, the accepted definition of health is, according to some observers, evolving toward including well-being as well as the absence of disease (8). The idea that, especially for younger people, natural causes of death, disease, and disability had been largely replaced by mortality and morbidity related to behavior is an idea that has taken hold in the last 15 or so years (e.g., 56,60,82). However, most health data systems, health care systems, and insurance reimbursement arrangements in the United States continue to emphasize care for physical illness. 43 The idea that much premature death, disability, and disease is largely avoidable (and even associated with behavior) should not lead exclusively to the notion that preventable avoidable death and disability are the sole responsibility of the individual. For example, a 1979 U.S. Surgeon Generals report placed approximately equal emphasis on societal measures to protect the health of the U.S. population (health protection), on health promotion, and on prevention of specific diseases and disorders (77). 44 By at least 1984, however, many in the field of public health had come to recognize that much of the responsibility in health promotion and prevention had fallen to individual, rather than collective, action (5a,73) and one of the main objectives of a WHO conference in the mid-1980s was to shift the focus from individualistic explanations of variations in health to an awareness of the public policies which were necessary to promote and protect health (5a emphasis added). Thus it was at the 1984 conference that the idea of the healthy city (later to become the healthy community) took root as a WHO strategy for promoting health for all by the year 2000 (5a). The notion that the health of adolescents is grounded in the health of their communities is that may be gaining momentum (e.g., 78a). also one For example, a recent publication by the Office of Substance Abuse Prevention in the U.S. Department of Health and Human Services sought to provide balance to the public health model of agent, host, and 41A~ht~~ ~ecenfly de~e~ted four ~~~ ~public fieafth ~m tie 18* ~td tie 1970s tit may & useful iKI providing some historicld clXltt?xt: 1) the period of sanitary reform (1840-1900), which responded to the miserable living conditions for the urban poor arising from the rapid urbanization that accompanied the industrial revolution (see above); 2) the period of personal prevention opportunities (e.g., child and family health clinics; birth control services; the provision of free milk and meals in schools) (1880-1930) that arose with advances in bacteriology and the development of immunization 3) the therapeutic era (1930-1974) that arose with the advent of insuliq antimicrobial, and a later explosion of other therapeutic possibilities, which in m according to Ashton, coincided with the apparent disappearance of the major infectious diseases on the one hand, and the increasing involvement of goverrunents in the provision of health and social semices on the other; and 4) the new public health movement (1975-present), which can be traced to increases in longevity, recognition that a great deal of premature death and disability was avoidable, and growing awareness of the limitations of therapy (5a,53a). dz~e life ex~~cy of ~ average ~e~cm (all races, both genders) bo~ iII 1988 WaS 74.9 y~s; ~ c0mpti50Q tie We exPec~cY of ~ av~ge American born in the period 1900 was approximately 47.3 years (82a). (The figure for 1900 is approximate because it included only the U.S. death registration area of 10 States and the District of Columbia (82a).) In both 1988 and 1900, the life expectancy of nonwhite Americans was lower than that of whites, although the gap narrowed between 1900 and 1988. For example, in 1988, the life expectancy for black Americans was 69.2 years; in 1900, the life expectancy for Americans of all other races than white was 33.0 years (82a). Figures specifically for black Americans are not available for the year 1900. qsFor examples, SIX ch. 15, Major Issues Pertaining to the Delivery of primary and Comprehensive Health Services to Adolescents, and ch. 16, Financial Access to Health Services, in Vol. III. 44Hea/rh protection compfis~ s~ate~es for h~~ p~rnotion ~d dis~se prevention that are related tO envho~~~ or rewatov meas~~ it confer protection on large population groups. As most broadly defined, health promotion is a philosophy of health or a set of activities that takes as its aim the promotion of health, not just the prevention of disease; WHO has defiied health promotion as the process of enabling people to increase control over and improve their health (5a). Sometimes, however, health promotion is more narrowly defined as the set of prevention efforts aimed at changing individual behavior. Prevention is used most often to refer to primary prevention which is a category of health and related interventions that aim to eliminate a disease or disordered state before it can occur.
PAGE 32
II-26 Adolescent HealthVolume II: Background and the Effectiveness of Selected Prevention and Treatment Services environment by targeting the environment (78a). However, relatively few of the Healthy People 2000 national objectives related to adolescents (or to other age groups) were objectives requiring environmental or regulatory measures to improve health (82b). 45 Measures of Health Measures of the Health of Individuals In no sense have widely published measures of health status in the United States approached broader and more positive definitions of health (8). 46 In the United States, the health status of the population is still measured primarily in terms of mortality or is inferred from the extent to which individuals seek care from physicians (e.g., 82a). 47 48 There is increasing publication of behavioral risk factors as indicators of the health of the U.S. population (79). Measures that are limited to the absence of physical health problems can be used to infer that U.S. adolescents as a group are healthy and, therefore, that they may not require health care services and other health-related resources (37,88). As noted above, a potential problem with an exclusive emphasis on individual behaviors, however, is that social and environmental factors that play a role in eliciting individual behaviors may be overlooked (8,73). Measures of the Social Environment The literature on health does not typically include objective measures of social and physical environments and the ways in which those factors affect adolescent health. 49 For example, precious little research has been done on how adolescents perceive their environments and the effects those perceptions have on their health (for examples of exceptions, see 20,85). 50 The evidence that is available suggests that adolescents believe that there is considerable social ambivalence when it comes to adolescent behavior such as sexuality, alcohol, tobacco, and drug use, and other risk-taking behaviors (e.g., dangerous driving practices) (74a), 51 that many adults do not really care about them (85), that health care providers do not discuss the issues of concern to them (36,48,66), 52 and that many adults seem only to see the negative when it comes to adolescents (34). Adult observers have also noted that public attitudes toward adolescents are, if not negative, then largely unsympathetic (7,65). Factors Affecting Conceptualizations of Adolescent Health Apart from considerations of adolescence as a period of life, additional issues relating to the definition of adolescent health include: who defines health and health problems, the social context of the definition of health problems, difficulties in operaqSFor~~~ysis of tie Healthy people 2000 obj~tives pertahing to adolescents, see the discussion of Major option 3 in VO1. I, S ummary and policy Options, of this Report. ~For a sP~esis and critique of widely published measures of adolescent health, see app. C, Issues Related to the Lack of Information About Adolescent Health and Health and Related Services, in Vol. I. dT~e presence of a ment~ he~ti problem is also considered an aspect of health (56), although Federal overviews of the hdti Shhls of tie PoP~tion rarely include information on mental health status measures (e.g., 82a). Further, many adolescent meutal disorders are defined in behavioral terms (5). ~~ditio~ issues concerning tie tio~tion available about adolescent health status, even using widely accepted indicators ZN measures, are discussed in app. C, Issues Related to the Lack of Information About Adolescent Health and Health and Related Services, in Vol. I. qsAJzen notes tit me=uement of social ~d contextual factors in he~~ ~d h~ behavior is underdeveloped (l). Although the health of communities as well as that of individuals is becoming anadditionalfocus in changing conceptualizations of health (8), measures of a communitys health appear at this point to be limited to aggregations of the health status of the communitys individual members (8). For example, a recent consensus set of indicatom for assessing community health status published by the Centers for Disease Control in the U.S. Department of Health and Human Services, includes only one measure of the physical environment (proportion of persons living in counties exceeding U.S. Environmental Protection Agency standards for airqwdity during the previous year) and one measure of the socioeconomic environment (childhood poverty, as measured by the proportion of children less than 15 years of age living in families at or below the poverty level) among 18 suggested indicators (81). Nine of the indicators are mortality rates, 4 are reported incidence rates for physical illnesses (i.e., acquired immunodeficiency syndrome, measles, tuberculosis, and primary and secondary syphilis), and 3 are indicators of risk factors (i.e., incidence of low birth weight, births to adolescents, and lack of prenatal care) (81). Also see app. A, Method of the Study, in Vol. I (75). S] For e-pie, OTA~s you~ A&isow Pmel pointed Out tit w~e hey me fo~y ks~cted to abstain from sex, drinking, ~d (hgs, they We bombarded daily with contradictory messages from the adult-controlled media. sZFor discussion of time s~dies, ~d ~yses of tie competence of he~fi c~e providers in @eating adolescenfi, see ch. 6, (hollic Physical Illnesses: Prevention and Services, in this volume, and ch. 15, MajorIssues Pe rtaining to the Delivery of Primary and Comprehensive Health Services to Adolescents, in Vol. III.
PAGE 33
Chapter 2What Is Adolescent Health? l /1-27 tionalizing well-being, and the potential consequences of broadening the definition of adolescent health. The way that adolescent health and health problems are defined and measured greatly influences adolescents lives, but as a generally (legally) powerless group, adolescents have very little say in the way health and health problems are defined and measured. As noted above, adolescents have been found to see discrepancies between issues of concern to them and issues likely to be discussed by health care providers and others who have the potential to affect adolescent health and make referrals to health care services. Clearly, if there is disagreement on what adolescent health and health problems are, there is likely to be disagreement on appropriate approaches to promoting health and to addressing problems. Another factor in defining adolescent health problems is some things that are regarded as adolescent health problems are problems only in the context of the contemporary social environment (55). Possibly, for example, droppinq out of high school (or not going on to college) might not be so terrible for some adolescents if jobs at living wages or other alternatives were available (87) or if academic paths were more flexible. The social environment is the product of longstanding cultural and philosophical roots in this country that are not about to be changed in a wholesale manner (9,55), but in considering what an adolescent health problem is, it is important to recognize the social environments impact on the way adolescent health problems are defined. A related social dilemma concerns operationalizing the concept of complete. well-being or optimal functional status (33,37). Although broadly acceptable definitions of complete well-being could be socially constructed, they would be difficult to devise because to a large extent complete well-being is inherently a subjective notion. Findings such as those by Malus and colleagues suggest, for example, that, in contrast to health care providers, adolescents perceived sexual intercourse, alcohol and drug use, as common occurrences, but not serious health problems (48). Maluss findings suggest a gulf between adult and adolescent perceptions of adolescent well-being. Broadening the definition of health can have implications for the organization of health services and, as a consequence, cost implications. Summary Clearly, the issue of defining health as a general matter across the life-span-and all the implications of that definition for intervention and resource allocation-is not yet settled. Scholars in the field of adolescent health, realizing the limitations of more traditional definitions of health and health-related interventions for that group, seem considerably more inclined to subscribe to broad definitions such as WHOS. For example, Irwin argues that a reconceptualization of adolescent health as optimal functional status may provide a better understanding of the broader issues affecting adolescents health (37,53). Issues surrounding the definition and measurement of adolescent health may receive greater attention as the findings of OTAs Report, and others related to adolescent health (e.g., 3,4,12,15,54,57, 58,59,60), are considered by local and national policymakers, parents, researchers, and adolescents themselves. Many of these issues are relevant to populations other than adolescents, but a broader definition of health is especially important for adolescents because adolescence is both a critical transitional period (24,29) and a period that comprises perhaps one-seventh of the life span, and because narrower definitions of health can lead to the neglect of important health issues during adolescence (88). Conclusions and Policy Implications The discussion of adolescent development in the frost part of this chapter, as well as discussions of specific health and related topics later in this volume, suggest that, in attempts to define health for adolescents, is important to consider a broad range of issues and to include measures of adolescents sense of well-being, their social environments, as well as the more familiar individual measures of physical illness, mortality, and behavioral risk factors. However, OTA found during its assessment that existing quantitative assessments of adolescent health, and even attempts to further develop definitions of adolescent health have not caught up with the conclusion that adolescent health needs to be thought of broadly (37,56). Throughout this Report, OTA attempts to take a broad view of adolescent health. Health is viewed in this Report in the most traditional terms of the presence or absence of physical disease and
PAGE 34
II-28 l Adolescent Health-Volume II: Background and the Effectiveness of Selected Prevention and Treatment Services Box 2-C--Toward Improving Adolescent Health: Key Concepts Developed by Adolescent Health Scholars at the 1986 National Invitational Conference on the Health Futures of Adolescents 1. Provide a prolonged supportive environment for adolescents Healthy adolescent development is fostered by providing a prolonged supportive environment during early adolescence, with graded steps toward autonomy. 2. Devise a precise conceptualization of risk-taking behavior. Positive as well as negative developmental and healthy outcomes are associated with certain exploratory behaviors. A more precise conceptualization of risk taking is needed to study and distinguish between constructive exploration and potentially destructive behaviors occurring during adolescence. 3. Increase the focus on positive aspects of adolescence. The major biological and psychosocial changes occurring during adolescence are not necessarily associated with negative outcomes and instability. Adolescence is not necessarily turbulent. Understanding positive growth, the acquisition of new skills and health-promoting behaviors, and the changing nature of interpersonal relationships deserves increased attention. 4. Mutually engage with adolescents in a positive way. Healthy development is encouraged by a process of mutual, positive engagement between the adolescent and various adults and peers. This process should occur through family and other significant adults and take place in schools, health institutions, and the community. 5. Study adolescence in multiple contexts. Healthy development must be studied and viewed in relation to the various contexts within which it occurs. Demographic, socioeconomic, psychological, biological, sociological, and historical factors can modify the characterization of normal development. SOURCE: C. I.rw@ Editors Notes, MoZescent Sociaf Behuvior and Heufth (San Fran&co: Josscy-Bass, Inc., 1987). disability; the implications of that view for adolescent development (e.g., 13) are important to interventions and the allocation of resources are discussed. As has become well-accepted in the adolescent development and health research communities, the health of adolescents is also viewed in this Report in behavioral terms-such as engagement in behaviors variously characterized as risky, health-compromising, healthenhancing, or problem behaviors. The Report also attempts to measure health in positive terms (e.g., social competence) and health and well-being from the perspective of adolescents themselves (e.g., perceived quality of life). The influence of the social context on health-related behaviors is also discussed (e.g., families, schools, discretionary time). In many cases, however, OTAs attempt at a broad analysis of adolescent health was hampered by a lack of data. The future of monitoring adolescent health needs to take a well-rounded approach to measuring health and the factors that affect it, rather than continuing its emphasis on mortality and behavior. In addition, the differences that occur during the long (10 or more years) period of integrate into an agenda for monitoring adolescent health and well-being. In addition, it is important to continue the renaissance in research on normal adolescent development noted recently by the Carnegie Council on Adolescent Development (24,25,89). The Carnegie volume suggests many opportunities for such research and emphasizes three priority areas of crosscutting importance (24,25). 53 In order to make adolescence a better period of life, it may also be important to attempt to market adolescents differently to the American public and to health care providers. As discussed above, many earlier hypotheses that seemed to describe universal processes in adolescent development have now been tested and found wanting (24). In the process of testing grand theories, the field of adolescent development has found that the popular conceptions of adolescents as a group whose behavior is overwhelmingly determin ed by raging hormones and of adolescence as inevitably a period of storm and stress are overstated. But on the other hand, the rapid ss~cording to Fel@ and Elliott, the three crosscutting areas of primary impOrtitnCC Me: imore about nonwhite youth; examining the contexts of adolescent development and considering adolescence as part of the life course (24,25). Suggestions for future research can also be found in various reports from the 1986 National Invitational Conference on Health Futures of Adolescents (e.g., 37,39) and in a reeent review by Susman and her colleagues (68).
PAGE 35
Chapter 2What Is Adolescent Health? l //-29 physical change that occurs during adolescence, and the increasing ability of adolescents to think reflectively, can make adolescence a difficult period for some individuals, their parents, teachers, other adults, and their peers. Little help is provided to adolescents, and their parents and teachers, as they try to cope with these changes. Societal expectations for adolescents are inconsistent and may simultaneously restrict adolescents unnecessarily and demand from them an unrealistic level of maturity. It is important to consider the basic physiological and cognitive changes that occur during adolescence in the design of health and related services, health education, and adolescent environments generally. It is important to continuously acknowledge that adolescence is largely a social construct, and one that is continuously changing, even as we study it (55). As a starting place, the key concepts developed by participants in the 1986 National Invitational Conference on the Health Futures of Adolescents deserve additional application arid testing (box 2-C). Chapter 2 References 1. 2. 2a. 3. 4. 5. 5a. 6. 7. 8. 9. 10. 11. Ajzen, I., Attitudes, Traits, and Actions: Dispositional Prediction of Behavior in Personality and Social Psychology, Ad}ances in Experimental Social Psychology, Vol. 21, Social Psychological Perspectives of the Self: Perspectives and Programs, L. Berkowitz (cd.) (San Diego, CA: Academic Press, 1988). American Academy of Pediatrics, Guidelines for Health Supervision 11 (Elk Grove Village, IL: American Academy of Pediatrics, 1988). American Automobile Associatio& Digest of Motor Laws, 57th ed. (Heathrow, FL: American Automobile Association, Traftlc Safety and Engineering Department, 1991). American Medical AssoeiatioL Americas Adolescents: How Healthy Are They? (Chicago, IL: American Medical Association 1990). American Medical Association Healthier Youth by the Year 2000 Project, Healthy Youth 2000 (Washington, DC: 1990). American Psychiatric Association Diagnostic and Statistical Manual of Mental Disorders, 3rd cd., revised (Washington, DC: 1987). Ashton, J., The Healthy Cities Project: A Challenge for Health Educatiom Health Education Quarterly 18:39-48, 1991. Baumrind, D., A Developmental Perspective on Adolescent Risk 7hking in Contemporary America, Adolescent Social Behavior and Health (Sari Francisco, CA: Jossey-Bass, Inc., 1987). Bearinger, L. H., and McAnarney, E.R., Integrated Community Health Delivery Programs for Youth: Study Group Report, Journal of Adolescent Health Care 9:36 S-40S, 1989. Breslow, L., A Health Promotion Primer for the 1990s, Health Aflairs 9(2):6-21, 1990. Brindis, C. D., and Lee, P. R., Public Policy Issues Affecting the Health Care Delivery System of Adolescents, Journal of Adolescent Health Care 11:387-397, 1990. Brooks-Gunn, J., Petersen, A. C,, and Eichom, D., The Study of Maturatioml Timing Effects in Adolescence, Journal of Youth and Adolescence, Special Issue, 14(3):4, 1985. Brooks-Gum, J., and Reiter, E. O., The Role of Pubertal Processes, At the Threshold: The Developing Adolescent, S.S. 12, 12a. 13. 14. 15, 15a. 16. 17. 18. 19. 20. 21. 22. 23. 24. 25. 26. 26a. 26b. 27. 28. 29. 30. 31. Feldman and G.R. Elliott (eds.) (Cambridge, MA: Harvard University Press, 1990). Carnegie Corporation of New York Carnegie Council on Adolescent Development Task Force on Education of Young Adolescents, Zhrning Points: Preparing Amencan Youth for the 21SC Century (Washington DC: June 1989). Carnegie Corporation of New York, Adolescence: Path to a Productive Life or a Dimini shed Future?-The Carnegie Council on Adolescent Development: Work in Progress, Carnegie Quarterly 25(1,2):1-3, 1990. Darno~ W., and H~ D, Se&Understanding in Childhood and Adolescence (New York, NY: Cambridge University Press, 1988). diSessa, A.A., Knowledge in Pieces, Constructivism in the Computer Age, G. Forman and P. Pufall (eds.) (HiHsdale, NJ: Erlbaum, 1988). Dryfoos, J., Adolescents at Risk (New Yorlq NY: Oxford University Press, 1990). Duhl, L.J., The Healthy City: Its Function and Its Future, Health Promotion 1:55-60, 1986. Duhl, L.J., Comprehensive City Interventions, Bulletin of the New York Academy of Medicine 66:547-557, 1990. Elkind, D., Egocentrism in Adolescence, Child Development 38:1025-1034, 1967. Elliott, G.R,, and Feldnuq S. S., Capturing the Adolescent Experience, At the Threshold: The Developing Adolescent, S,S. Feldman and G.R. Elliott (eds.) (Cambridge, MA: Harvard University Press, 1990). Epste@ H.T, Phrenoblysis: Special Brain and Mind Growth Periods, Developmental Psychobiology 7:207-216, 1974. Erickson, J.B., Indiana Youth Poll: Youths Views of High School Life (Indianapolis, IN: Indiana Youth Institute, 1991). Eriksoq E. H., Childhood and Society (New York: Norto~ 1950). Eriksou E., Identity and the Life Cycle, Psychological Issues 1:18-164, 1959. EriksoQ E., Identity, Youth, and Crisis (New York NY: Nortou 1968). Feldrmq S. S., and Elliott, G.R. (eds.), At the Threshold: The Developing Adolescent (Cambridge, MA: Harvard University Press, 1990). Feldu S. S., and EIJiott, G.R., Progress and Promise, S.S. Feldman and G.R. Elliott (eds.), At the Threshold: The Developing Adolescent (Cambridge, MA: Harvard University Press, 1990). Fine, M., Sexuality, Schooling, and Adolescent Females: The Missing Discourse of Desire, Harvard Educatzona[ Review 58:29-84, 1988. Freud, A,, Adolescence, Psychoanalytic Study of the Child, Vol. 13 (New Yorlq NY: International Universities Press, 1958). Furby, L., and Beyth-Mmo~ R., Risk Taking in Adolescence: A Decision-Making Perspective, working paper prepared for the Carnegie Council on Adolescent Development Carnegie Corporation of New York Washingto% DC, June 1990. Gittler, J. D., Quigley-Ric~ M., and Saks, M.J., Adolescent Health Care Decision-Making: The Law and Public Policy, paper prepared under contract to Carnegie Council on Adolescent Development and Carnegie Corporation of New York, for the Office of ~chnology Assessment, U.S. Congress, Washington DC, and published as a working paper by the Carnegie Council on Adolescent Development Washingto% DC, 1990. Hall, G. S., Adolescence: Its Psychology, and Its Relations to Anthropology, Sex, Crime, Religion, and Education (New York NY: Appletom 1904). Hamburg, D. A., Preparing for Lfe: The Critical Transition of Adolescence (New York, NY: Carnegie Corporation of New York 1986). Hamburg, D., Carnegie Corporation of New Yorh Early Adolescence: A Critical Time for Interventions in Education and Health+ New YorL NY, 1989. Harter, S., Cognitive-Developmental Processes in the Integration of Concepts About Emotion and the Self, Social Cognition
PAGE 36
11-30. Adolescent Health-Volume II: Background and the Effectiveness of Selected Prevention and Treatment Services 32. 33, 34. 35. 36. 37. 38. 39. 40. 41. 42. 43. 44. 45. 46. 47. 48. 49. 50. 51. 52. 53. 53a. 4:119-151, 1986. Harter, s., Adolescent Self and Identity Development At the Threshold: The Developing Adolescent, S.S. Feldman and G.R. Elliott (eds,) (Cambridge, MA: Harvard University Press, 1990). Health Promotion, Ottawa Charter for Health l%omotio~ HeaZth Promotion l(4): iii-v, 1987. Hevesi, D., Youtha Criticize Media on Coverage of Children, New York Times, p. B2, Nov. 19, 1990. Higgins, E.T., SeM-Discrepancy: A Theory Relating Self and A.ffecc Psychological Review 94:319-340, 1987. Hodgso~ C., Fel_ W., Corber, S., et al., Adolescent Health Needs: Perspectives of Health Professionals, Canadian Journal of Public HeaZfh 76: 167-170, 1985. IrwiIL C.E., Jr., Editors Notes, Molescent Social Behavior and Health, C.E. Irwin, Jr. (cd.) (San Francisco, CA: Jossey-Bass, Inc., 1987). ~ C.E., Jr., ~d Millste@ S. G., Biopsychosocial Correlates of Risk-Taking Behaviors During Adolescence, Journal of Adolescent Health Care 7:82S-96S, 1986. In+@ C.E,, Jr., and Wu~ E., Psychosocial Context of Adolescent Development: Study Group Ret)ort, Journal of Adolescent Health Care 9:1 1S-19S, 1988. Josselsoq R., Ego Development in Adolescence, Handbook of Molescent Psychology, J. Adelson (cd.) (New Yorlq NY: Wiley, 1980). Josselsou R., Greenberger, E., and McConochie, D., Phenomenological Aspeets of Psychosocial Maturity in Adolescents. Part 2: Girls, Journal of Youth and Aa%lescence 6:145-167, 1977. Kegan, R., The Evolving Se/f (Cambridge, MA: Harvard University Press, 1982). Keating, D.P., Adolescent Thinking, At the Threshold: The Developing Adolescent, S.S. Feldman and G.R. Elliott (eds.) (Cambridge, MA: I%u-vard University Pros, 1990). Keating, D.P., and MacI.aq D.J., Reconstmctions in Cognitive Development: A Post-Structuralist Agen@ Lye Span Development and Behavior, Vol. 8, P.B. Baltes, D.L. Weatherman, and R.M. bmer (eds.) (Hills&de, NJ: Erlbaum, 1988). Koslowski, B., and Okagaki, L., Non-Humean Indices of Causation in Problem-Solving Situations: Causal Mectiw Analogous Effects, and the Status of Alternative Rival Accounts, Child Development 57:110008, 1986. Kovar, M.G. Special Assistant for Data Policy and Analysis, U.S. Department of Health and Human Services, Public Health Service, Centers for Disease Control, National Center for Health Statistics, Office of Vital and Health Statistics Systems, personal communication 1990. Kuhq D., Amsel, E., and OImugti M., The Development of Scientific Thinhng Skills (San Diego, CA: Academic Press, 1988). Malus, M., LaChance, P.A., Lamy, L., et al., priorities in Adolescent Health Care: The I&magers Viewpoin4 Journal of Family Practice 25:159-162, 1987. MMUL L., HUDIOIQ R., and Power, C.N., Adolescent Decision Making: The Development of Competence, Journal of Adolescence 12:265-78, 1989. IWdms, H., and Nurius, P., Possible Selves, American Psychologist 41:954-969, 1986. Mason, J. O., A Prevention Policy Framework for the Nation, Health Affairs 9(2):22-29. McAnamey, E., Adolescent Pregnancy: Consequences and Prevention unpublished manuscript, University of Rochester Medicat Center, Rochester, NY, no date. McCormic~ M.C., and Brooks-Gunq J., The Health of Children and Adolescents, Handbook of Medical Sociology, 4th ed, H.E. Freeman and S. Levine (eds.) (Englewood Cliffs, N,J.: Prentice Hall, 1989). Mechanic, D., Curing, Caring, and Economics: Dilemmas of Progress, Perspectives in Biology and Medicine 25:722-735, 1982. 54. 55. 56. 57. 58. 59. 60. 60a. 61, 62, 63, 64. 65. 66. 66a. 67. 68. 69. 70. 71. 72. 73. Millsteti S., Petersen, A.C., and Nightingale, E.O. (e&), Molescent Health Promotion, in preparation for the Carnegie Council on Adolescent Developmen~ Carnegie Corporation of New York Washington DC, 1990. Modell, J., and Goodrnq M., Historical Perspectives, At the Threshold: The Developing Adolescent, S.S. Feldman and G.R. Elliott (eds.) (Cambridge, MA: I-Iamard University Press, 1990). National Academy of Sciences, Institute of Medicine, Adolescent Behavior and Health: A Conference Summa National Academy Press, 1978). v was~gom DC: National Association of Childrens Hospitals and Related Institutions, Inc., Profile of Child Health in the United States (Alexandria, VA: 1989). National Center for Education in Maternal and Child HealtiL The Health ofAmericas Youth (Washington DC: Georgetown University, September 1990), National Commis sion on Childreq Open@ Doors for Americas Chikiren, Interim Report (Washington, DC: Mar. 31, 1990). National Commission on the Role of the School and the Community in Improving Adolescent Health, Code Blue: Uniting for Healthier Youth (Alexandriiz VA: Nationat Association of State Boards of Educatioq 1990). Nightingale, E. O., and Wolverto~ L., Adolescent Rolelessn~s in Modem Society, working paper prepared for the Carnegie Council on Adolescent Development, Carnegie Corporation of New Yorlq Washington DC, September 1988, RauclL J., Downsizing the Dre~ National Journal 21 :20382043, Aug. 12, 1989. Rosenberg, M., Self-Concept From Middle Childhood Through Adolescence, Psychological Perspective on the Self, J. Suls and A.G. Greenwald (eds.) (Hillsdale, NJ: Erlbaum, 1986). Science, Sullivan Overrules NIH on Sex SWey, 253:502, August 1991. Sehnaq RL., Beadslee, W., Schultz, L.H., et al., Assessing Adolescent Interpersonal Negotiation Strategies: Toward the Integration of Structural and Functional Models, Developmental Psychology 22:450-459, 1986. Sheleff, L. S., Generations Apart: Adult Hostility to Youth (Nw York, NY: McGraw-Hill, 1981). Sobal, J., Klein, H., Gr_ D., et al., Health Concerns of High School Students and lkachers Beliefs About Student Herdth Concerns, Pediatrics 81(2):218-223, 1988. Spencer, M.B., and Dombusch, S. M., Challenges in Studying Minority You@ At the Threshold: The Developing Molescent, S.S. Feldman and G.R. Elliott (eds.) (Cambridge, MA: I-Iaward University Press, 1990). Steinberg, L., Autonomy, Conflicg and Harmony in the Family Relationship, At the Threshold: The Developing Molescent, S.S. Feldman and G.R. Elliott (eds.) (Cambridge, MA: Harvard University Press, 1990). SusrnmL E.J., Nottelrn~ E.D., Inoff-Germain, G., et al., Hormonal Influences on Aspects of Psychological Development During Adolescence, Journal of Adolescent Health Care 8:492504, 1987. Ihnner, J.M., Growth at Molescence, 2nd ed (Oxford, England: Blackwetl Public&ions, 1962). lhnner, J. M., Fetus Into Man: Physical Growth From Conception to Maturity (Cambridge, MA: Harvard University Press, 1978), Taylor, D. and Katq P., Health and Related Services Available to Black Adolescents, contract paper prepared for the Oflice of lkchnology Assessment, U.S. Congress, Washington DC, April 1990, Reter, R., The Travails of 19th-Century Urban Youth as a Precondition to the Invention of Modem Adolescence, Adolescence 23(89): 15-18, 1988. IkslL S. N., Hialien Arguments: Political Ideology and Disease Prevention Policy (New Brunswick NJ: Rutgers University Press, 1988).
PAGE 37
Chapter 2What /s Adolescent Health? l II-31 74. Uedai R., Advenues to Adulthood: The Origins of the High School and Social Mobility in an Amen can Suburb (New York, NY: Cambridge University Press, 1987). 74a. U.S. Congress, OffIce of Twhnology Assessment, Adolescent Health Youth Advisory Panel, meetings in Washington DC, 1989-90. 75. U.S. Congress, Office of Technology Assessment, Adolescent Healt&-Volume I: Summary and Policy Implications, OTA-H468 (Washington, DC: U.S. Government Printing Office, April 1991), 75a. U.S. Congress, Office of Technology Assessment, Adolescent HealtLVolume III: Crosscutting Issues in the Delivery of Health and Related Services OTA-H467 (Washington. DC: U.S. Govemmcnt Printing Office, June 1991). 76. U.S. Department of Education, Office of Educational Research and Improvement, National Center for Education Statistics, Digesf of Educa(ion Statistics, 25th cd., NCES 89-643 (Washington, DC: U.S. Department of EducatioL 1989). 77. U.S. Department of Health, Education, and Welfare, Public Health Service, Office of the Assistant Secretary for Health and Surgeon General, Healthy People: The Surgeon Generals Report on Health Promotion and Disease Prevention (Washington, DC: U.S. Government Printing Office, 1979). 78. U.S. Department of Health and Human Services, Public Health Service, Alcohol, Drug Abuse, and Mental Health Administration, National Institute on Alcohol and Alcohol Abuse, bgal Minimum Age for Sate/Purchase, Possession and Consumption of Beverage Alcohol, unpublished list, Rockville, MD, 1990. 78a. U.S. Department of Health and Human Services, Alcohol, Drug Abuse, and Mental Health Administration, Office for Substance Abuse Prevention, Youth and Drugs: Societys Mixed Messages OSAP Prevention Monograph-6, DHHS Publication No. (ADM) 901689 (Rockville, MD: U.S. Department of Health and Human Services, Alcoho!, Drug Abuse, and Mental Health Administration, Office for Substance Abuse Prevention, 1990). 79. U.S. Department of Health and Human Services, Public Health Service, Centers for Disease Control, Commonty Asked Questions About Youth Risk Behavior Survey s, Atlanta, GA, no date. 80. U.S. Department of Health and Human Services, Public Health Service, Centers for Disease Control, Progress in Chronic Disease Prevention: State Laws Restricting Minors Access to Tobacco, Morbidity and Mortality Weekly Report, 39:349-353, June 1, 1990. 81. U.S. Department of Health and Human Services, Public Health Service, Centers for Disease Control, Consensus Set of Health Status Indicators for the General Assessment of Community Health Statu*United States, iUorbidi~ and Mortality Weekly Report 40:449-45 1, 1991. 82. U.S. Department of Health and Human Services, Public Health Service, Centers for Disease Control, National Center for Health Statistics, Trends and Current Status in Childhood Mortality: United States, 190085, Vital and Health Statistics, Series 3, No. 26, DHHS Pub. No. (PHS)89-1410 (Washington DC: U.S. Government Printing Oft7ee, 1989). 82a. U.S. Department of Health and Human Services, PubLic Health Service, Centers for Disease Control, Natioml Center for Health Statistics, Health, United Stares, 1990 DHHS Pub. No. (PHS)911232 (Washington DC: U.S. Government Printing Office, 1991). 82b. U.S. Department of Health and Human Services, Public Health Service, Healthy People 2000: National Health Promotion and Disease Prevention Objectityes, conference edition (Washington, DC: September 1990). 83. U.S. Department of Labor, Bureau of Labor Statistics, Employment and Earnings (Washington, DC: U.S. Department of Labor, July 1991). 84. U.S. General Accounting OffIce, Child Labor: Increases in Detected Child Labor Violations Throughout the United States, GAO/HRD-90-l 16 (Washington DC: U.S. General Accounting Office, April 1990). 85. University of Minnesota and Minnesota Department of HealtlL School Survey Results: The Minnesota Adolescent Health Survey Adolescent Health Database Project 19861987, Minneapolis, MN, no date. 86. Vygotsky, L. S., Mind in Society (Cambridge, MA: Hanard University Press, 1978). 87. William T. Grant Foundation Commission on Work Family, and Citizenship, The Forgotten Half: Pathways to Success for Amencas Youth and Young Families (Washington DC: November 1988). 88. World Health Organization Announcement: The Health of You(h, Technical Discussions, May 1989 (Gencv% Switzerland: October 1988). 89. Zadow, M.J., A Summary of Key Findings and Research Opportunities From At the Threshold: The Developing Adolescent, Carnegie Council on Adolescent Development Carnegie Corporation of New York, Washington DC, 1990.
PAGE 38
Chapter 3 PARENTS AND FAMILIES INFLUENCE ON ADOLESCENT HEALTH
PAGE 39
Contents Page Introduction . . . . . . . . . . . . . . . . . . . 35 The Changing Nature of the American Family . . . . . . . . . . . 35 Positive Parental Influences on Adolescent Health. . . . . . . . . . . 37 Parents Who Serve as Positive Behavioral Role Models and Transmitters of Values and Information ...,.,. . . . . . . . . . . . . . . . 37 Parents Who Provide Emotional/Psychological Support and Encouragement . . . . 38 Parents Who Connect Adolescents to Needed Services . . . . . . . . . 38 Parents Who Promote Adolescents Autonomy and Independence . . . . . . 39 Negative Parental Influences on Adolescent Health . . . . . . . . . ,. 41 Parents Who Serve as Negative Behavioral Role Models and Transmitters of Values and Information . . . . . . . . . . . . . . . . . 41 Substance-Abusing Parents . . . . . . . . . . . . . . 41 Violent Parents . . . . . . . . . . . . . . . . . 41 Parents Who Are Unable To Resolve Conflicts . . . . . . . . . . 42 Parents Who Do Not Have Accurate Information . . . . . . . . . 42 Parents Who Maltreat Adolescents . . . . . . . . . . . . . 42 Incidence and Prevalence of Adolescent Maltreatment . . . . . . . . 43 Gender Differences in Adolescent Maltreatment . . . . . . . . . 45 Perpetrators of Adolescent Maltreatment . . . . . . . . . . . 46 Genesis of Adolescent Maltreatment: When Does It Begin? . . . . . . . 48 Effects of Adolescent Maltreatment . . . . . . . . . . . . 48 Who Investigates Adolescent Maltreatment Cases? . . . . . . . . . 49 Adolescents in the Child Welfare System . . . . . . . . . . . 49 Conclusions and Policy Implications . . . . . . . . . . . . . 51 Chapter 3 References . . . . . . . . . . . . . . . . 52 Box Box Page 3-A. Limitations of Research on Adolescent Maltreatment . . . . . . . . 45 Tables Table Page 3-1. Studies of Adolescent Maltreatment . . . . . . . . . . . . 44 3-2. Case of Maltreatment per 1,000 Children/Adolescents, 1979 and 1986 . . . . . 46 3-3. Incidence of Maltreatment Among Children/Adolescents in Two Poor inner-City Areas of Chicago . . . . ., . . ..0...... . . . . . . . . . 48
PAGE 40
Chapter 3 PARENTS AND FAMILIES INFLUENCE ON ADOLESCENT HEALTH Introduction The family has long been considered the bedrock of American society. Pictured as a place of refuge from the trials and tribulations of everyday life, the family has been praised from podium and pulpit. Poets remind us that the family is where, when you go there, they have to take you in. It is a safe harbor, a supportive environment for personal growth and expression. And, indeed, for most people, the family is a place of succor and nourishment-if not always, then at least most of the time. But there is a darker side to some families that belies these virtues. Life in such families can be terrifying, as violence replaces tranquility, hatred preempts love, hope becomes despair, and a corrosion of character directs the development of family members. These are the families in which nightmares are real and children and adolescents are transformed into victims of oppression. Adolescent growth and development are deeply affected by the family environment in manifold and enduring waysfor good or for ill. This chapter explores the positive and negative influences of families on the health and maturation of adolescents. Since parents are central authority figures in most families (even during their childrens adolescence, when peers influence increases), the discussion that follows emphasizes the role of parents vis-a-vis adolescent family members. The interactions of siblings, grandparents, and other significant individuals in a variety of family structures are clearly important for adolescent health, but the body of research on their significance to adolescent health is sparse, This chapter provides a brief overview of the changing nature of the American family, and discusses positive, then negative, influences of parents on adolescents, including maltreatment of adolescents. The chapter is intended to provide an overview of the importance of parents in the lives of adolescents. For some specific adolescent health problems, there has been considerable research on the negative impact of specific features of parentadolescent relationships; this research is discussed in more detail in the relevant chapters in this volume. l It is important to keep in mind, however, that some widely held views that parents are not an important positive influence in the lives of their children during adolescence are now seen as inappropriate inferences drawn from a small body of influential writings earlier in this century. The relationship between parents and their children during adolescence is complicated and clearly differs from that between parents and their younger children. This chapter concludes that more research is needed to investigate the positive and negative features of the parent-child relationship during adolescence, and more guidance is needed for parents during this important period. The Changing Nature of the American Family The traditional American nuclear family is often depicted in popular culture as a father, a mother, and several children. Grandparents are depicted either as living with the family or residing somewhere nearby. The father works and the mother cares for the children and home. Today the picture of the traditional family is evolving rapidly into a pluralistic collage of alternative structures (79). Economic and social forces have brought about significant demographic changes that are reflected in family life throughout the Nation. Divorce, for example, has made the one-parent family commonplace, and remarriage has introduced a stepparent into many homes. Over one-third of the marriages performed in 1988 were second marriages (47,93). With about half of all marriages now ending in divorce and about 23 percent of children born today born outside of marriage, 15.5 million children under age 18 including 6.7 million 10to 17-yearolds (92a)live with one parent. In the vast majority of cases (90 percent), children in single parent ls ece s pml ~] y Ch, IO, 1Pregm~cy~d Parenting: Prevention and Services, ch. 12, Alcohol, Tobacco, and Drug Abuse: Prevention and Semices, and ch. 13, Delinquency: Prevention and Services, in this volume. -II-35-
PAGE 41
II-36 Adolescent Health-Volume II: Background and the Effectiveness of Selected Prevention and Treatment Services households live with their mother (47,92a). 2 3 According to the U.S. Department of Commerce, Bureau of the Census, in 1990, only 28 percent of households consisted of married couples living with their own children 4 underage 18; in 1970,64 percent of households consisted of married couples living with their own children under age 18 (92a). 5 Data from the Bureau of the Censuss Current Population Survey indicate that 6,789,000 U.S. children under 18 (approximately 11 percent of the resident population) lived in stepfamilies in 1985 (92d). In 1986, Garbarino and his colleagues estimated that about 11 percent of all adolescents lived in stepfamilies (67). New social values and fiscal imperatives (e.g., self-actualization, professional opportunities, desire for a higher standard of living) have enabled or compelled many women to work outside the home. Two-thirds of adolescents (17.5 million of those ages 10 to 17) live in households where both parents (or a single parent) work full time (92c). Group housing or similar extended family configurations are sometimes encountered. And all of these and other forms of nontraditional family structures are now part of the domestic landscape of America (3). In addition, changes in employment are now routine, and families may move from one geographic area to another several times during the course of a decade, removing a child or adolescent from close contact with grandparents and altering the stability of peer relationships. Changes in longevity, later/delayed childbearing, and improvements in health care and nutrition have increased the number of older parents of adolescent children. The automobile and easy access to mass transit in urban areas have also provided adolescents a broader degree of mobility, and with it certain independence from parental influence. Although the specific influences of television and other electronic media on adolescents are not known with certainty, it is widely believed that adolescents are exposed to a more diverse set of messages through the media than they would be through their parents alone (92). For parents with responsibility for their minor children, these changes can be confusing. Families modeled along traditional lines may feel embattled as they witness the changes occurring around them. Furthermore, many of the new family models have no established or tested guidelines for raising children. Instead, they place parents in the position of having to improvise without the benefit of the historical experience of others to assist them. Neither research nor custom yields much counsel outside of the traditional nuclear setting. In fact, society tends to question (and sometimes condemn) nontraditional families, so that support is virtually nonexistent. At the same time, those in nontraditional families sometimes criticize traditional family arrangements, further adding to the confusion surrounding families in contemporary society. Science, too, has added to the problem. New discoveries offering genetic linkages to a variety of health problems raise unanswered ethical questions about parental responsibilities for preventing hereditary conditions. There is increasing evidence, for example, that genetic factors play a role in schizophrenia, major affective disorders, and alcoholism (16,37,38,39,81,106). Genetic factors may also play z~cor~g to the U S Department of Commerce, Bureau of the Census, the increase in the number of family households maintied by women done has accounted for a considerable amount of the change in family compositio~ especially during the 1970s (92b). About 17 percent of family households were maintained by women alone in 1990, compared with 15 percent in 1980, and 11 percent in 1970 (92 b). However, it is important to note that families maintained by women do not necessarily include any dependent children. For example, these families could include a woman sharing her home with an elderly parent or any other adult relative. In about 61 percent of these families in 1990, one or more of the womans children underage 18 was present (92b). s~e prow~on off~ti ~~ depndent children ti~ti by mothers alone is much higher for blacks (56 percent in 1990) ~ for whites (18.8 percent in 1990) (92b). About 30 percent of Hispanic family groups with children under age 18 were maintained by mothers alone (92b). d~wn children in a family me sons and daughters, including stepchildren and adopted childreni of ti householder (92b). sIt my ~ somew~t ~~t t. note tit tie a~lute n~~ of U.S. hou~holds incr~ed &tween 1970 ~d 1990, from 63 million to 93 tdhO~ largely because of large increases in nonfamily households (e.g., men or women living alone) (92b). Even so, there was a greater absolute number of family households consisting of married couples living with their own children under age 18 in 1970 (40.3 millio% or 50 percent of family households) than in 1990 (26.3 households, or 27 percent of family households) (92b). (The U.S. Department of Commerce, Bureau of the Census defines afanuly as a group of two persons or more, one of whom is the householder, related by birtlq marriage, or adoption and residing together (92b). A househoki consists of alt the persons who occupy a housing unit (a house, an apartment or other group of rooms, or a single room occupied or intended for occupancy as separate living quarters, that is, when the occupants do not live and eat with any other persons in the structure and there is direct access from the outside or through a common hall) (92 b). A faZy k.wehofd is a household maintained by a family; in addition, any unrelated persons who may be residing there are included in the count of household members (92b).) bsee ch. 7, Nutrition and Fitness I%oblms, and ch. 13, Delinquency: Preventions and Service, in this volume for further discussion.
PAGE 42
Chapter 3Parents and Families influence on Adolescent Health l 11-37 a role in some cases of obesity and violent delinquent behavior. 6 As if these points of departure from past experience were not enough, parents of adolescents also must face an additional transition in their parenting roles. Adolescents bring challenges that may demand revision of parenting skills; as a result, parents may confront personal uncertainty about appropriate responses to adolescence. Furthermore, some parents may be experiencing significant life changes themselves. And, indeed, studies have found that the parents of adolescents feel less adequate and more anxious about their roles than do parents of younger children (2,48,101). Positive Parental Influences on Adolescent Health Many nontechnical books on parenting laud the role of parents in shaping the character of their children, 7 but the predominance of this theme in the popular press is not paralleled in research literature on adolescent health. Instead, most research concentrates on adolescent behaviors, attitudes, and problems and systemic or institutional approaches to problem solving. As Irwin observes, much of the existing research on adolescent health has serious limitations: Past research has been guided by the storm and stress perspective of adolescence and has focused on what goes wrong, went wrong, or is going wrong during adolescence. Less is known about what contributes to positive growth and health-enhancing behaviors (51). To be sure, demonstrations and projects that marshal schools and community agencies in efforts to promote improved adolescent health abound and some of these include family components. But the concept of the family as a front line of defense against adolescent health problems has not permeated the research or services consciousness to any significant extent. As pointed out elsewhere in this OTA Report, for example, there are few carefully evaluated primary prevention efforts that target families for the prevention of human immunodeficiency virus (HIV) infection in adolescents and virtually none that target families to prevent sexually transmitted diseases in adolescents. 8 Furthermore, in those research studies where the family is considered at length, it is usually considered in one of two contexts-either the familys economic or caregiving burden for adolescent health problems or the familys role in causing or exacerbating adolescent health problems (73a). 9 10 A balanced approach would seem to demand some recognition of the positive parental influence, in the majority of families, on the health and well-being of adolescents. Yet there is a clear need for additional research in this arena-for all family structures, but particularly for separated, minority, and nontraditional families (6,42,43,45,85). In 1987, Campbell noted that fewer than 5 percent of the articles in the literature on families and health were empirical studies (96). If, in fact, parents serve as role models for their children, then the behaviors of parents and the strength of adolescent behavior modeled after parents would seem appropriate areas of investigation. Unfortunately, the old adage Like father, like son has not been evaluated extensively from a serious scientific perspective. The opportunities for significant research on the positive influence of parents and families on adolescent health are manifold. Examples are cited below. Parents Who Serve as Positive Behavioral Role Models and Transmitters of Values and Information To what extent are the values and behaviors of parents regarding health practices, personal hygiene, and safety transmitted to adolescents? Do parent models influence adolescent attitudes and behavior to any significant extent? Under what conditions are parental values and behaviors imitated by adoles7vev few nonc~c~ wks m written to guide the parents of adolescents, however. s~~ Petit is made ti ch. 9, AIDS and Other Sexually Transmitted Diseases: Prevention and Services, in this volume. Whis observation+ of course, is not intended to denigrate the importance of a famiIys fmcial contribution to adolescent health, nor is it intended to diminish the significance of caregiving within the family setting. lqn ~on~~t, Sals review of preventive pro~tended to ~pport parents of adolescen~ fo~d tit most proadtiss~ the parental rOle in enforcing rules and limits and in communicating with their childre~ no programs addressed the basic resource provision function of parents, and very few addressed the role of parents as advocates for their children (i.e., by attempting to help parents become more knowledgeable about the availability and use of community resources) (83a). Very few of the programs had been evaluated for their effectiveness (83a).
PAGE 43
//-38 Adolescent Health-Volume II: Background and the Effectiveness of Selected Prevention and Treatment Services cents? How do a parents positive healthand safety-related values and behaviors relate to adolescent health outcomes? If a parent always uses a seat belt, is an adolescent driver any more likely to do so? If parents have strong objections to alcohol, marijuana, or other psychoactive substance use, will the adolescent be less likely to engage in the use or abuse of such a substance? To what extent do family attitudes about sexuality affect risk of pregnancy, sexually transmitted diseases, and HIV-infection? Do sound family exercise and nutrition practices reduce adolescent problems of obesity or dietary deficiencies? ll Are parental dental practices correlated with the presence or absence of caries in their adolescent children? Several studies have found that adolescents agree with their parents on most basic values (7,21,53,56, 72). It has been established that parents are viewed by most adolescents as credible sources of information (17,46,74,88,105). To what extent is this credibility merited? Do parents generally transmit accurate and current information on health, mental health, and safety issues to adolescent family members, or is their information incomplete, outdated, or incorrect? There is some evidence to suggest that parents exert a great influence on particular health behaviors of adolescents (particularly daughters) within a family (4). When one examines risk factors for adolescent pregnancy, for example, there emerges a strong relationship between the mothers experiences and those of their daughters (70). Girls in female-headed households are more likely to have intercourse at earlier ages, as are those who have large numbers of siblings (49,109). Although the evidence is not strong, some studies suggest that open communications between parents and adolescents about sexual issues result in less sexual activity, better use of contraceptives, and parental support in seeking family planning services (27,50, 59). And Rosen has shown that parents play a major role in the decision to terminate an unintended pregnancy-particularly among young adolescents (81). 12 What is not known is how generalizable the limited existing data on the parental influences are to subjects that have not received the close scrutiny given to the parental role in adolescent pregnancy, nutrition and fitness, or substance use and abuse. Do parental influences shape the type and quantity of foods consumed by adolescents? Are cautious parents more or less likely to raise adolescents who escape accidental injury or avoid risk taking behaviors? Are childhood handwashing and teethbrushing drills effective in shaping the personal hygiene habits of adolescents? Parents Who Provide Emotional/Psychological Support and Encouragement Adolescence is a time of rapid changes. 13 Relations with peersand particularly with members of the opposite sexraise new and perplexing questions. Can the experiences of parents provide a useful reservoir for adolescents seeking counsel on issues surrounding dating behavior, friendships, and appropriate interactions in society? If so, under what conditions? How is such counsel best conveyed? Similarly, for those physical and emotional changes which may seem inexplicable, can parents help guide their adolescent to greater understanding and knowledge, a sense of perspective, and self-acceptance-thereby reducing unnecessary anxiety? To what extent can a parents views about an adolescents disability-r sexuality, or need for increased autonomy, or any of a number of other issues enhance or impede sound psychological development in the adolescent? Parents Who Connect Adolescents to Needed Services To what extent do parents serve as early screeners of health care needs for adolescents, either making their own discretionary diagnoses and referrals or providing direct health care services themselves? How important are parental home remedies for adolescent health care? Are these parental interventions appropriate and beneficial? What role do parents play in connecting an adolescent to dental, 1 Ich. 7, $ *Nurnti~n ad Fitness ~oblems: ~vention and Services, in this volume, notes that exercise levels are similar among members of the same family and that children in obese families expend less energy than those in lean families, suggesting that family lifestyle can be a strong factor influencing healthy behavior in adolescents. However, findings such as these must be tempered by the recent finding that obesity may have a genetic component. lzfie limited research on the eff@s of parental pressure on hdth care decisio~ g by adolescents is discussed in ch. 17, Consent and Contldentiality in Adolescerit Health Care Decisionmaking, in Vol. III, A 1988 study by Scherer and Reppucci examin ed the effects of parental pressure on hypothetical health decisions by adolescents ages 14 and 15 and found that these adolescents yielded greatly to parental pressure (82). Iss& Ch. 2, {~t I.s Adolescent He~ti? in this volume fOr discussion of these ChangeS.
PAGE 44
Chapter 3-Parents and Families Influence on Adolescent Health l II-39 health, and mental health services? 14 How important are the financial, transportation, and scheduling roles of parents in the connection of adolescents with needed services? What are the role and significance of family caregivers in the system of adolescent health care? How can parents become more effective in promoting the health maintenance of their adolescent family members? These are just a few areas where families maybe making a major, and largely unrecognized, contribution to the overall health of their adolescent members (73a). Future research should help illuminate how the personal family sector interacts with the public and private systems of health care, since many health problems may be first noticed in the home setting and decisions to seek professional intervention are initiated through the threshold of family concern. Parents Who Promote Adolescents Autonomy and Independence As they mature, adolescents typically demand a more nearly equal and active role in family discussions and decisionmaking (87). Thus, it is perhaps not surprising that families which allow latitude for adolescent participation in family decisions have fewer problems during adolescence than more rigid and authoritarian families. According to Laurence Steinberg, a family that combines democracy with warmth and demandingness is likely to foster an adolescents mental health: Generally speaking, adolescents thrive develop mentally when their family environment is characterized by warm relationships in which individuals are permitted to express their opinions and assert their individuality and in which parents expect mature behavior and set and enforce reasonable rules and standards. This constellation of warmth, democracy, and demandingness has been labelled authoritative. According to several comprehensive reviews of the literature on parenting practices and their outcomes, adolescents who grow up in authoritative homes score higher on indices of psychological development and mental health, virtually however defined (86). Thus, basic questions on parent-child relationships during adolescence include: How can parents best facilitate movement toward adolescent autonomy Photo credit: Office of Technology Assessment Views on the nature of adolescent and family development have undergone radical transformation. Rather than becoming detached and independent of their parents, adolescents need to learn to assume increasing responsibility y and decision making within the context of their close relationships, not away from them. A burgeoning body of research suggests that parents can help their adolescent children become socially and cognitively competent by adopting a style of interacting that is simultaneously stimulating, demanding, loving, supportive, and committed to the adolescent. and interdependence? What external controls should be relaxed and when should relaxation occur? Most parents continue to exercise some restrictive authority throughout adolescence. Where behavioral restrictions are imposed for health or safety reasons, to what extent are these effective? What kinds of restrictions are appropriate and under what circumstances? How can parents more effectively transfer external controls to internalized self-controls in adolescents? As S ummarized recently by Ooms and Owen for the Family Impact Seminar: Views on the nature of adolescent and family development have undergone radical transformation. Earlier research and writing about adolescence described the central [developmental] task of adolescence as becoming detached and independent of, in effect emancipated from, parents. Recent research has led to a reconceptualization of the developmental tasks of the adolescent stage of the family life cycle. 14we d. know hat ~o~t ~hildh~~d ~an~ers, for example, are detected a[ early s@ges, as parents are ]ike]y (O seek m~ic~ care soon after ob~ing a health problem (100).
PAGE 45
11-40. Adolescent HealthVolume II: Background and the Effectiveness of Selected Prevention and Treatment Services Adolescents need to learn to assume increasing responsibility and decision making but within the context of their close relationships, not away from them. They must renegotiate their relationship with their parents so that they can assume greater autonomy, but they also need to remain connected with their parents in a new relationship of mutuality and friendship rather than dominance and control. Parents need to gradually let go, but stay interested in their children, and provide them with continued advice and support. .(73a). Baumrin d describes two parent types that have positive outcomes for adolescents: authoritative and democratic parents (3,6). She states: Authoritative parents, by definition, are not punitive or authoritarian. They may, however, embrace traditional values. Authoritative parents, in comparison to lenient parents, are more demanding and, in comparison to authoritarian-restrictive parents, are more responsive. Authoritative parents are demanding in that they guide their childrens activities firmly and consistently and require them to contribute to family functioning by helping with household tasks. They willingly confront their children in order to obtain conformity, state their values clearly, and expect their children to respect their norms. Authoritative parents are responsive affectively in the sense of being loving, supportive, and committed: they are responsive cognitively in the sense of providing a stimulating and challenging environment. Authoritative parents characteristically maintain an appropriate ratio of childrens autonomy to parental control at all ages. However, an appropriate ratio is weighted in the direction of control with young children and in the direction of autonomy in adolescence. Authoritative parents of adolescents focus on issues rather than personalities and roles, [and] they encourage their adolescents to voice their dissent and actively seek to share power as their children mature (3). Democratic parents are highly responsive, moderately demanding, and not restrictive. They are less conventional, directive, and assertive in their control than authoritative parents, but like authoritative parents are supportive, caring, personally agentic, and manifest no problem behavior or family disorganization (6). The extent to which American families follow these models is not known. Research has shown, however, that adolescents in authoritative and democratic families on the average are better adjusted in terms of mental health, self-image, social integration, and ability to make independent decisions (self-directed) than their peers from authoritarian homes (i.e., homes in which parents exert rigid controls) or permissive homes (i.e., homes in which parents are either uninvolved or are lax in controlling behavior of their children) (3,5,6,15,20,44,45,63, 78,86). In the Family Socialization and Developmental Competence Project, Baumrind evaluated the consequences for children of four parental styles in terms of the childrens social and cognitive competence: l authoritative, l authoritarian, l permissive, and l rejecting-neglecting (or indifferent) (6). Preadolescent children from authoritative/democratic families, Baumrin d found, had developed the greatest social and cognitive competence (6). Preadolescent girls from permissive families were less self-assertive than preadolescent girls from authoritative families, and boys and girls from permissive families were less cognitively competent than those from authoritative families. Preadolescent children from rejecting-neglecting families, were the least socially competent of all. Baumrind found that the effects of family structure among preadolescents varied with the socioeconomic and demographic characteristics of the family. An authoritarian family upbringing, for example, was more harmful, as measured in terms of a variety of social competency scales, to middle-class boys than to girls; more harmful to preschool white girls than to black girls, and more harmful to white boys than Hispanic boys (6). 1s When children in the Family Socialization and Developmental Competence Project were adolescents, Baumrin d measured the consequences of different parental styles again (using a different categorization), and the findings were similar to those for preadolescents (6). Adolescent children from democratic/authoritative homes were the most socially competent, and adolescents from permissive and rejecting-neglecting families continued to have the most interpersonal problems. Researchers other than Baumrind have identified yet another type of family that frequently produces 15~e ~mblem fxed by mmy poor adolescen~ and adolescents in speci13c racial and ethnic minoriw wups we ~scussed ~ ch. 18, Issues in tie Delivery of Semlces to Selected Groups of Adolescent& in Vol. III.
PAGE 46
Chapter 3-Parents andFamiliesinfluence on Adolescent Health l II-41 psychological dysfunction and involvement in various problem behaviors in adolescentsthe indifferent family (63). An indifferent family is one in which the parents are uninvolved, making few, if any, demands on their adolescent family member. In this model, decisionmaking is laissez-faire and there is a low level of warmth and affection among family members. Negative Parental Influences on Adolescent Health Whereas positive family influences on adolescent health have received only scant attention from researchers, negative parental influences are more widely documented. Dysfunctional families, l6 for example, have been shown to be associated with poor diabetic control in adolescents (96). Furthermore, there is some evidence to suggest that stresses within families can trigger streptococcal infections or increase the severity of respiratory illnesses (12,66). And, while the schizophrenogenic mother concept has been largely discredited as a causal factor in major mental illnesses and replaced by genetic/biological or other theories of etiology, there is evidence that environmental factors (including family interactions, support, and stress) contribute to both the course and treatment of such illnesses (96). High levels of family conflict and lack of intimacy have been correlated with heroin abuse in adolescents (40). Some other adverse ways in which families can affect the health and well-being of their adolescent members are described below. Parents Who Serve as Negative Behavioral Role Models and Transmitters of Values and Information Just as parents can presumably contribute in a positive way toward adolescent development through their behaviors and values, so too can they provide negative role models. Furthermore, wellintentioned but uninformed parents may, through ignorance, provide adolescents with information that is incorrect. Substance-Abusing Parents Alcoholism and illicit drug use by an adolescents parents or siblings have been shown to significantly increase an adolescents vulnerability to becoming an alcohol or drug abuser (18,38,84,91).17 Some research suggests that sons of alcoholic fathers may have up to nine times greater probability of becoming alcoholics than sons of nonalcoholic fathers (11,16). Whether these increased risks are due to an inherited genetic vulnerability, adolescent identification and mimicking of parental or sibling substance use, easy accessibility to substances, or lack of family prohibitions and punishments has not been established. According to Kandel, however, parents who use alcohol can become role models for an adolescents use of alcohol, while families characterized by lack of closeness, lack of maternal involvement in the activities of children, lack of or inconsistent parental discipline, and low parental educational aspirations for the children tend to experience greater adolescent illicit drug use (55). Kandel identifies three parental factors that help to predict initiation into drug use during adolescence: parental drug-using behaviors, parental attitudes about drugs, and parent-child interactions. Violent Parents The risk of a childs being physically abused increases proportionately to the degree and severity of assault between that childs parents (89). This relationship appears to carry over into the childs adolescence, although the greater physical power of abused adolescents may lead to reciprocal assault (and even parricide) in some instances (13,76). In fact, adolescents who kill their parents (and wives who kill their husbands) often do so in retaliation for abuse, usually as the culmination of a long period of mutual assault (31). In 1980, one research group found that 18 percent of the children and adolescents they studied engaged in physical attacks on their parents (90). Since the research team interviewed mothers in half of the families and fathers in the other half, the team estimated that as many as one out of every three 16Dy@nctioM/fam/ie~ me f~~e~ ~~~h lack ~~h~ion ad mu~ support wi~ a fr~ework of ~ection tit respects individual differences ad the need for personal expression of autonomy. Such families may either stifle individuality or use inappropriate means of expressing such individuality (conflict and confrontation). ITFor a gena~ discussion of substance use and abuse by adolescents, s= ch. 12, Alcohol, Tobacco, and Drug Abuse: Prevention and Services, in this volume.
PAGE 47
//-42 Adolescent Health-Volume II: Background and the Effectiveness of Selected Prevention and Treatment Services children in their sample hit their parents at least once during the year in which the interviews occurred. They attributed this violence to retaliation for physical abuse and mimicking of parental behavior which was itself violent. Within families where parents were categorized as nonabusive, the rate of assault by a child upon a parent was only 1 in 400. Parents Who Are Unable To Resolve Conflicts Observational research shows that abusive families are behaviorally differentiated from nonabusive families mainly in their handling of the 5 to 10 percent of parent-child interactions that are negative (80). Nonabusive families are able to conclude (or at least termin ate) these negative interactions quickly. Abusive families are ineffective and become enmeshed in escalating conflict. Parents Who Do Not Have Accurate Information Parents, in assuming a conscious teaching role or as unintentional conveyors of knowledge and attitudes, may not always possess accurate or current information. Thus, parents may sometimes inadvertently transmit erroneous facts or myths and superstitions, causing potential problems for the adolescent who acts on the basis of the information. The low rates for which adolescent girls seek care for dysmenorrhea, 18 for example, may be due in part to their mothers beliefs that nothing can be done about menstrual cramps (61). In addition, although parents are often seen as credible sources of information, they do not often discuss sensitive topics like sexuality, homosexuality, or prostitution with their adolescent family members (46,88,99). Sixty percent of U.S. parents receiving the brochure Understanding AIDS from the Centers for Disease Control in the U.S. Department of Health and Human Services (DHHS) did not discuss it with their 10to 17-year-olds according to a 1988 National Health Interview Survey (97,98). Parents Who Maltreat Adolescents As noted earlier, some parents abuse or neglect their adolescent children, either emotionally or physically .19 Emotional abuse and neglect are difficult to define (31,34). Emotional abuse can involve the deliberate or unintentional assault on the emotional well-being of a dependent. Emotional neglect is the withholding of warmth, affection, and psychological support necessary to maintain sound mental health. Mild emotional abuse or neglect is difficult to differentiate from normal and occasional ribbing or expressions of disapproval. But in extreme cases, parents can destroy an adolescents self-esteem or ability to cope by belittling the person and making repetitive attacks on personality traits or ego needs. Some, emotional abuse results from wellmeaning ignorance, as when a parent taunts an adolescent about acne, ascribing the condition to a failure to attend to personal hygiene. Sometimes, however, emotional abuse is pathologic in origin and may reflect a parents need to maintain dominance and control in the face of increasing resistance by an adolescent. Like emotional abuse, emotional neglect can be innocent and unknowing. The parents of an adolescent with a disability, for example, may deny the adolescents growing sexuality or limit his or her socialization with able-bodied peers out of protective instincts and ignorance, but the adolescent must pay the price in stunted sexual development, a more confining self-image, and restricted opportunities for emotional expression (64). Whether resulting from benign motives or not, emotional abuse and neglect can have long-lasting adverse consequences for an adolescent. 20 In her studies of parenting styles, Baumrind has demonstrated that adolescents from families characterized by a lack of warmth and affection-families whose members are disengaged from any emotional involvement with one another--consistently rank 18~y~menorr~ea is p~~ me~mticm and may & caused by my of sev~ factors. See ch. 6, Chronic Physical Illnesses: Prevention and Services, in this volume, for information on the rate at which adolescents seek care for dysmenorrhea. 19Ma/~earment ficl~des ~A abuse ~d negl~t. Abuse, w~ch refers to tie active assa~t upon a dependent victim (as diSti.l@shd fmm ViOlenCe against an individual over whom the perpetrator has no dependency relationship), may be physical, sexual, or psychological. ~eglecf, which refers to acts of omission that include failure to meet basic needs (as def~ed by prevailing community standards), may be either physical neglect (i.e., grievous failure to provide physical necessities such as food or clothing) or psychological neglect (i.e., failure to provide appropriate supervision or basic emotional responsiveness and stimulation necessary for development). ~At 1emt one au~ofi~ ~~ev= tit ~otio~ neglect gene~ly ~ more S~OUS consequences than emotional abuse for personality development (30).
PAGE 48
Chapter 3Parents and Families Influence on Adolescent Health l 11-43 lowest on social competency scales and highest on substance use and other problem behaviors (6). Physical abuse and neglect are less elusive than their emotional/psychological counterparts and have been studied in greater depth. Wauchope and Straus have analyzed parental self-reports of minor violence (i.e., corporal punishment such as spanking, pushing, or slapping generally accepted as nonabusive in American communities) and found that prevalence varies with the age of recipient (104). Minor violence by parents against children increases from a prevalence of 20 percent in the first year of life, to a high of 90 percent at age 3, and then declines to approximately 15 percent by age 17, The prevalence of severe violence 21 exhibits a similar pattern, moving from 5 percent during the first year to a high of 16 percent at age 6, and then declining to 6.5 percent by age 17. When hitting or trying to hit was removed from the data, however, age differences disappeared, yielding a uniform 2 to 4 percent prevalence of physical abuse throughout childhood and adolescence. There is some evidence that physical maltreatment is related to an adolescents behaviors considered unacceptable to the abuser (e.g., disobeying or arguing), Libby and Bybee report that in more than 90 percent of the cases they studied, specific abusive incidents were preceded by negative adolescent behavior (60). One cannot tell from the existing data, however, precisely what is cause and what is effect. The precipitating behavior may itself be the result of earlier maltreatment. As defined by the U.S. Department of Health and Human Services National Center on Child Abuse and Neglect, sexual abuse of a child can take three forms: actual penile penetration; molestation with genital contact; and other unspecified acts not known to have involved actual genital contact (e.g., fondling of breasts or buttocks, exposure), or inadequate or inappropriate supervision of a childs voluntary sexual activities. Incidence and Prevalence of Adolescent Maltreatment Table 3-1 outlines the small body of research on adolescent victims of maltreatment. As noted in box 3-A, studies of adolescent maltreatment have several limitations related to the availability of data. Furthermore, such studies use different definitions of maltreatment. Table 3-1 includes both surveys and small-scale studies. The surveys are as follows: l l l The two studies of the national incidence and severity of child abuse and neglect conducted by the National Center on Child Abuse and Neglect in DHHS----one in 1979-80 (published in 1981) (94) and the other in 1986 (published in 1988) (95); the annual tabulation (through 1986) of reported cases of maltreatment compiled by the American Humane Association (l), and two national probability samples assessed for domestic violence conducted by Straus and colleagues in 1975 and 1985 (89). small-scale studies include clinical and questionnaire studies of identified or suspected cases of adolescent maltreatment (34). The National Center on Child Abuse and Neglects study of the national incidence and severity of child abuse and neglect conducted in the late1970s defined maltreatment as demonstrable harm due to maltreatment (94). Using a sample of 26 U.S. counties, this study estimated that there were approximately 650,000 cases of maltreatment (including educational neglect 22 ) of children and adolescents in the United States. The national incidence study by the National Center on Child Abuse and Neglect conducted in 1985 defined maltreatment as instances where a childs health or safety is seriously endangered. This study estimated that there were 1,025,900 cases of maltreatment of children and adolescents in the United States (95). The 1979-80 national incidence study by the National Center on Child Abuse and Neglect found that 47 percent of the known cases of all forms of child maltreatment were against adolescents, who made up just 38 percent of the population under age 18 (94), A 1985 American Humane Association survey, on the other hand, found that adolescents were victims in 24 percent of all reported cases of child maltreatment (1). The discrepancy between the Zlsevere violence includes kicking, biting, hitting with ones fist, beathg, bg or scalding, and threatening to or using a weapon. 22EduC.ationa/ neg~e~f refers to tie failure to provide appropriate edu~tion (e.g.$ through failure to enroll a dependent in school or permitting/encouraging truancy).
PAGE 49
//-44 Adolescent Health-Volume II: Background and the Effectiveness of Selected Prevention and Treatment Services Table 3-l-Studies of Adolescent Maltreatment Study a Sample Age Types of rnaltreatrnent Measures surveys U.S. DHHS, Office of Human Development Services, National Center on Child Abuse and Neglect, Survey of 1979, 1980 26 counties-all maltreatment cases known to professionals surveyed 0-17 0-17 0-17 3-17 0-17 0-17 12-18 12-18 15-20 10-16 12-17 12-17 12-17 12-17 10-19 Alltypes, including educational neglect Case records U.S. DHHS, Office of Human Development Services, National Center on Child Abuse and Neglect, Survey of 1986, 1988 29 counties-all maltreatment cases known to professionals surveyed All types, including educational negiect Case records American Humane Association, Survey of 1985,1987 40 States case reports of maltreatment 2,143 famiiies All types Demographic and case records Straus, Geiles, and Steinmetz, 1980 Gelies and Straus, 1987 Physical abuse and normal violence (corporal punishment) Physical abuse All types (31% neglect, 42% sexual abuse, 19% physicai abuse) Conflict Tactics Scale (parents seif reports) Conflict Tactics Scaie Protective services b case reports 3,229 famiiies 1,874 reported cases (NY State) Powers and Eckenrode, 1988 Small-scale studies Farber et ai., 1984 199 runaways 47 abused protective services cases 77 youth (diverse sampie) Physical abuse Conflict Tactics Scale Physical abuse a) Conflict Tactics Scale b) Structured Ciinicai Assessments Checklist c) Demographic background Farber and Joseph, 1985 McCormack, Janus, and Burgess, 1986 89 maie runaways 55 femaie runaways Sexuai abuse interview on dealing with sexual abuse, delinquency, and demographic background Garbarino, Sebes, and Schellenbach, 1984 27 females 35 maies All forms of maltreatment a) Adolescent Abuse Inventory b) Child Behavior Checklist c) FACES-(famiiy cohesion and flexibility) d) Demographics e) Adolescent Famiiy inventory of Life Events and Changes Ciinicai assessment Berdie and Waxier, 1984 Libby and Bybee, 1979 163 families 25 reported cases Ali forms of maltreatment Sexuai abuse excluded Case history based Protective Service 70 reported cases 33 cases to protective services 2 neighborhoods, inner Physical abuse Physical abuse Clinical assessment case records Lourie, 1977 Pelcovitz et al., 1984 Clinical assessment Garbarino and Kosteiny, 1989 Physical abuse, negiect, sexual abuse citv Chicago aFull Citations are listed at the end of this chapter. b~rot~~ve ~em-m~ are an ~pat of s~al ~er~as designed t. prevent n%l=t, abuse, and exploitation of children by rewhing out with social services to stabilize family life (e.g., by strengthening parental capacity and ability to provide good child care). The provision of protective services follows aeomplaint or referral, frequently from a source outside the family, although it may be initiated by an adolescent him or herself. SOURCE: Office of Technology Assessment, 1991. national incidence study by the National Center for that the former study included data from not only Child Abuse and Neglect and the American Humane childrens protective services 23 but from other agenAssociation survey may be accounted for by the fact cies as well. ~Chil&~~~ ~rOf~C~V~ ~~WiC~~ ~~ Saices provided by a State or loc~ c~d we~~e agency to chil&en md adoleswnts Whc) have been identified as being abused or neglected. They may include assessment family support services, removal horn the home and placement in foster care, or similar interventions and assistance by a caseworker.
PAGE 50
Chapter 3-Parents and Families influence on Adolescent Health l II-45 Box 3-ALimitations of Research on Adolescent Maltreatment Available studies of adolescent maltreatment, which includes abuse and neglect, have several limitations. Perhaps the most important is that they rely on data from official reports and self-reports. Both these data sources have serious limitations and are likely to underrepresent the extent of adolescent maltreatment. Parents who maltreat their children are unlikely to give self-reports that accurately reflect the true incidence and prevalence of maltreatment because abuse and neglect are c riminal offenses. Official reports may significantly undercount the incidence of abuse and neglect because public agencies are unlikely to learn about instances of abuse and neglect that do not result in major physical injury. Furthermore, adolescent victims of maltreatment tend to be served by agencies other than childrens protective services and hospitals, which makes adolescents less likely to be identified and included in the hospital and childrens protective services samples. Finally, local jurisdictions may have varying degrees of competence in and fidelity to reporting abuse and neglect cases or have administrative practices that confound the data. Yet another problem with available studies of maltreatment is that researchers have used various definitions of maltreatment, with some including and others excluding spanking, verbal abuse, and emotional abuse. The variation in definitions has made it difficult to compare data across studies and has led to contentious challenges to survey findings. Compounding the problem, communities (and laws) vary in their tolerance and acceptance of physical expressions of parental discipline; some actions deemed abuse in one area of the country maybe considered appropriate--even commendable--in another. An additional problem is that the bulk of family studies involving maltreated adolescents have been conducted on samples of white, middle-class, two-parent families. Family influences within minority populations have not been as intensively examined. As a result, ethnic, cultural, economic, and nontraditional family differences from these samples await further research. A limitation of available studies of adolescent maltreatment for the purpose of this OTA Report is that most of these studies cite data on age groups other than the 10-to 18-year-old age group. Thus, the figures quoted from these studies typically reflect a smaller number than the actual incidence of abuse and neglect among the population focused on in this study. SOURCE: Offke of Rdmology Assessment, 1991. Table 3-2 shows the overall rate of maltreatment enced physical abuse, 35 percent were neglected, cases known to professionals (childrens protective services and other agencies) from the 1975 national incidence study by the National Center for Child Abuse and Neglect. Also shown are rates of maltreatment cases from the 1985 survey. In both surveys, known maltreatment rates were higher among older children than among younger ones. The 1986 national incidence study by the National Center for Child Abuse and Neglect found that psychological abuse was more common among adolescents ages 12 and over than among children ages O to 11 (32 percent of reported adolescent cases v. 25 percent of cases reported among children) (95). Conversely, it found that physical abuse was more common among children ages O to 11 than among adolescents (52 percent of reported childrens cases and 42 percent of adolescent cases). In a smaller clinical study, Berdie and Wexler reported that 68 percent of their sample of abused adolescents suffered emotional maltreatment, 54 percent experiand 24 percent had been sexually abused (9). Gender Differences in Adolescent Maltreatment Some gender differences are evident in the data on adolescent maltreatment. Females appear to be more likely to be abused as they pass through adolescence than in childhood, while risk for males peaks early and generally declines through adolescence. The study of the national incidence and severity of child abuse and neglect conducted by the National Center on Child Abuse and Neglect in 1975 identified two female adolescent maltreatment victims for every one male (73). Small studies tend to confirm the finding that female adolescents are at greater risk for maltreatment than males, with the reported figures for females in their samples of maltreatment adolescents ranging from 55 percent (34) to 77 percent (62). Powers and Eckenrodes analysis of New York State data found that among 12to 17-year-olds, females accounted for 65 percent of the physical
PAGE 51
II-46 Adolescent HealthVolume II: Background and the Effectiveness of Selected Prevention and Treatment Services Table 3-2-Cases of Maltreatment per 1,000 Children/ Adolescents, 1979 and 1986 a National Center on Child National Center on Child Abuse and Neglect, Abuse and Neglect, Age Survey, 1979 Survey, 1986 0-2 . . 6 6 3-5 . . 6 10 6-8 . . 11 15 9-11 . . 11 15 12-14 . 12 23 15-17 . 14 28 aDefinitions for maltreatment were different in the two surveys. h the survey ecmducted in 1979 -80the definition of maltreatment was demonstrable harm due to maltreatment. In 1986 the definition of maltreatment included instances where a childs health or safety is seriously endangered. SOURCE: J. Garbarino, Adolescent Viitims of Maltreatment, contract paper prepared for the Office of Technology Assessment, U.S. Congress, Washington, DC, April 1990. abuse cases reported, 88 percent of the sexual abuse cases, and 54 percent of the neglect cases. A 1984 study by Pelcovitz and others, however, found that only 45 percent of the abused and neglected adolescent population studied were females (75). 24 Perpetrators of Adolescent Maltreatment Families at high risk for maltreatment of adolescents can be characterized in terms of family structure or family dynamics. These factors may not be independent, but there has been little research on family dynamics (e.g., authoritative v. other styles) in nontraditional families. Family Structure--Considerable research demonstrated that families at high risk for maltreatment in adolescence often contain stepparents. A variety of analyses point to the stepparent-adolescent relationship as a very risky one (19,54) and studies of maltreatment discussed below tend to confirm this. Libby and Bybee reported that 28 percent of the families in their study of adolescent maltreatment were stepfamilies, even though only 11 percent of all adolescents live in stepfamilies (60). Berdie and colleagues reported similar findings; 25 percent of their families were stepfamilies (8). Olson and Holmes analyzed the data from the National Center on Child Abuse and Neglects 1979-80 study of the national incidence and severity of child abuse and neglect and concluded that 40 percent of the adolescent maltreatment cases occurred in families with a stepparent (73). Garbarino and his associates found that, among a sample of 10to 16-year-old adolescents (from families containing two adults not always married) whom professionals identified as having problems, families at high risk for adolescent maltreatment were more likely to have a stepparent (35). Farber and Joseph reported that only 30 percent of their maltreated adolescents were living with both biological parents (25). Obviously, these findings do not imply that the majority of stepfamilies are abusive or that intact birth families are nonabusive, but they do suggest the stepfamily as a possible risk factor in adolescent maltreatment. Family Dynamics--Families characterized as being high risk for adolescent maltreatment reveal a general pattern of difficulty in relating as an interpersonal system (6). Such families are at high risk on the dimensions of adaptability, cohesion, support, discipline, and interparental conflict. Pelcovitz and colleagues conducted a clinical analysis of 22 families in which adolescents were physically abused, classifying them either as families in which the onset of abuse was during childhood (8 families) or as families in which the onset of abuse was during adolescence (14 families) (75). The eight families with adolescents who were first physically abused in childhood (involving 14 adolescents) manifested intergenerational abuse, spousal abuse, and developmentally inappropriate demands (75)all elements of what has been termed the world of abnormal rearing (41). Pelcovitz and colleagues classified the 14 families with adolescents where physical abuse first occurred during adolescence (involving 19 adolescents) in one of two categories on the basis of multiple, independent clinical assessments authoritarian families (7 families) and overindulgent families (7 families). The authoritarian families (as distinguished from the authoritative families discussed earlier) were characterized by paternalistic, harsh, rigid, domineering styles of childrearing (75). They were also characterized by denial by the parents of their feelings toward each other and about the family Z4However, thi5 s~dy o~y involved 33 a&les~nts from 22 f~es, titi ages ranging from 13 to 18. In 80 percent of the cases where girk were the victims of maltreafmen4 the abuse was attributed to dating or sexual exploration% while in all cases of maltreatment of boys, the abuse was associated with truancy or delinquent behavior. The investigators used the definition of abuse found in the New York State Family Court Act of 1976, which includes physicaf injury, risk of death or disfiguremen~ impairment of physical or emotional he.al~ and impairment of a bodily organ. The record does not indicate if any of the maltreatment cases involved sexual abuse--the exclusion of which could be a source of sample bias.
PAGE 52
Chapter 3-Parents and Families Influence on Adolescent Health l II-47 system. Incidents of abuse typically arose from a challenge by the adolescent (acting out or testing behavior) that was met with overwhelming force. The high priority placed upon control provided the foundation for high levels of force. In contrast, the overindulgent families were characterized by parental efforts to compensate for the emotional deprivation that they had experienced in their own childhood (12 of the 14 parents had lost one or both of their parents during childhood) (75). These families made few demands upon their children, set few limits, and desired a high level of emotional gratification from their children. But when the children reached adolescence and sought to form primary attachments outside the home or began to act impulsively in important social settings, the overindulgent parents also reacted with excessive force. Garbarino and his colleagues have contrasted the family system of families judged to be abusive with that of families judged to be nonabusive (34). These researchers used FACES, a measure of family adaptability and cohesion, to assess overall family interactions. Abusive families were more likely to be scored as chaotic or enmeshed. Nonabusive families tended to fall into the more normal flexible and connected ranges. 25 On a measure of interparental conflict, adolescents in the abusive families tended to rate their parents as evidencing more conflict. It is important to note, however, that the average difference masks the fact that some abusive families evidenced extremely high conflict while, consistent with the finding that abusive families were more likely to be enmeshed, others evidenced extremely low conflict. In a 2-year followup, it appeared that some abusive families dealt with conflict by expelling the adolescent, while others simply suppressed all manifestations of conflict through a conspiracy of silence. Poverty and Adolescent Maltreatment Families at high-risk for destructive parentadolescent relations are less heavily concentrated among families living in poverty than families at high risk for child maltreatment (34). The National Center on Child Abuse and Neglects study of the national incidence and severity of child abuse and neglect conducted in the mid1970s suggests that the big social class differences that characterize child maltreatment cases are attenuated in the case of adolescent maltreatment (94), Families in which adolescents were abused were half as likely to be poor (i.e., e arning less than $7,000 per year in 1979 dollars) as families in which children were abused, Presumably, some of the observed attenuation of social class differences in adolescent maltreatment is attributable to the fact that parents of adolescent tend to be older, and thus earning higher wages (on average) than the parents of young children. The attenuation may also be due to the greater difficulties that some families have in dealing with adolescence than with early childhood. Blum and Runyan reported, for example, that 42 percent of all confirmed cases of maltreatment in Minnesota involved adolescent victims (10). Minnesota is a State with relatively little of the extreme poverty that tends to be associated with maltreatment (particularly neglect) in early childhood, and has been a leader in promoting professional awareness of adolescent maltreatment. In contrast to the Minnesota study, Garbarino and Kostelny report an intensive study of maltreatment rates in inner city Chicago neighborhoods where poverty is a major problem and there is little leadership in dealing with adolescent maltreatment (32). This study revealed a different picture, but still supported previous findings of a relatively poor predictive association between poverty and adolescent maltreatment, at least relative to child maltreatment (see table 3-3). Garbarino and Gilliam also reported findings consistent with the National Center on Child Abuse and Neglects study of the national incidence and severity of child abuse and neglect (31). In their work, they found that families with adolescent-onset cases of maltreatment were about half as likely to be poor as families with the child onset (and child maltreatment) cases. Despite the finding that family income alone is not a powerful predictor of risk for adolescent maltreatment, some research does suggest that a feeling of deprivation and strained resources, often associated with larger family size, may play a role (102). In addition, other measures of social status not based on income yield contradictory results. Farber and Joseph report that their families were predomi~A Chuoric fhly is a ftiy chacterizti by lack of s~cture. An enmeshed family is a family in which individuals are excessively dependent upon each other. Aj7exible family is one that is able to combine structure with responsiveness to situational conditions. A connected family is one that is able to have close relationships without finding them stifling.
PAGE 53
II-48 Adolescent Health-Volume II: Background and the Effectiveness of Selected Prevention and Treatment Services Table 3-3-incidence of Maltreatment Among Children/Adolescents in Two Poor Inner-City Areas of Chicago Cases per 100 children/adolescents Physical abuse Neglect Sexual abuse Age Area l a Area Il b Area l a Area Il b Area l a Area Il b 0-4 . . . . 5.1 3.8 40.0 32.8 1.6 1.7 5-9 . . . . 5.2 4.6 22.3 22.5 0.7 1.8 10-14 . . . 2.4 1.8 10.8 13.5 0.5 1.9 15-19 . . . 1.5 1.8 3.9 4.6 1.0 0.1 afiea I ~verty rate -51 percent. b~ea II poverty rate -40 percent. SOURCE: J. Garbarino and K. Kostelny, Patterns and Trendsin Reported Cases of Maltreatment and Infant Mortality in Chicago Community Areas, Erikson Institute, Chicago, IL, 1989. nantly lower class, while Pelcovitz and his colleagues report that 59 percent of their families were classified in the top two socioeconomic groups on a five-point measurement known as the Hollingshead Index (25,75). Only 12 percent of Libby and Bybees families were categorized among the lowest socioeconomic groups, while Garbarinos research team found differences on the Hollingshead Index of socioeconomic status among abusive and nonabusive families (35,60). Berdie and colleagues reported that about 51 percent of the families in her study of maltreated adolescents earned less than $15,000 at a time when approximately 20 percent of all families did so (8). Genesis of Adolescent Maltreatment: When Does It Begin? Two theories dominate current thinking about the origins of adolescent maltreatment. The first holds that parents establish patterns of child abuse and simply continue such behavior through their childs adolescence. The second avers that much adolescent maltreatment occurs independently of earlier childhood abuse and may reflect the inability of a previously functional family to adapt to the new challenges of adolescence (28). The existing body of research on this question suggests that both theories account for a portion of the adolescent maltreatment population, but that there is a distinctly adolescent genesis to a significant number of cases-ranging from a high estimate of 90 percent to a low of 24 percent (8,9,25,31,60,62,75). Sexual abuse may represent a special case, since studies suggest that sexual abuse begins in childhood, before the onset of adolescence. KendallTackett and Simon interviewed 365 adults who were victims of childhood sexual abuse and found that the average age of onset was reported to be 7.5 years, with less than 10 percent having an onset after 12 years of age (57). In over half of the cases, the sexual abuse did not continue past the age of 12. This study offers an intriguing opportunity for further research to identify factors related to the ages of the victim and perpetrator which may be associated with both the onset and the cessation of sexual abuse within families. Effects of Adolescent Maltreatment Adolescents who are maltreated seldom die from the maltreatment. The fatality rate declines with agefrom 0.09 per 1000to 2-year-old children to less than 0.01 per 1,000 adolescents. As Garbarino notes, however, some adolescent deaths may be indirectly attributable to maltreatment: A full accounting of the adolescent fatalities attributable to maltreatment could reasonably include numerous suicides and other self-destructive behavior appropriately linked dynamically and developmentally to the experience of maltreatment. For example, a runaway who leaves home to escape abuse and then falls prey to AIDS, or is murdered, or becomes suicidal on the streets is, in a very real sense, an adolescent maltreatment fatality (29). Berdie and her colleagues report that 49 percent of their adolescent maltreatment victims exhibited significant clinical indicators of depression (8). Between 45 and 70 percent of the adolescents showed problems such as nervous habits, isolation, poor social skills with peers, lethargy, low self-esteem, low frustration tolerance, temper outbursts, and stubbornness.
PAGE 54
Chapter 3Parents andFamiliesinfluence on Adolescent Health l II-49 Running away from home is directly correlated with maltreatrnent. 26 Approximately 73 percent of adolescent female runaways and 38 percent of the male runaways in one recent study reported that they ran away to avoid further sexual abuse (65). Who Investigates Adolescent Maltreatment Cases? The study of the national incidence and severity of child abuse and neglect conducted by the National Center on Child Abuse and Neglect concluded that the childs age may be a major determinant of whether or not a recognized maltreatment problem is reported to CPS [childrens protective services] for investigation and treatment (95). The bulk of adolescent maltreatment cases are reported to and handled by agencies other than childrens protective services. Thus, intervention models designed from study findings that rely on data from childrens protective services and hospital samples may not be generalizable across the full range of adolescent maltreatment cases. One reason that adolescent maltreatment is so often investigated by agencies other than childrens protective services is that it is often viewed as a consequence of acting-out behavior by the adolescent or dysfunction within the family; and agencies such as community mental health centers or family services may be called upon to provide assistance. Adolescents in the Child Welfare System For children and adolescents who-for reasons of parental abuse and neglect, findings of delinquency, or other causesare unable to live in an acceptable home environment with their parents, an elaborate child welfare system has been developed throughout the Nation. 27 This system includes the foster care system, a network of public and private institutions and agencies intended to provide substitute out-ofhome care for dependent youth. Primarily regulated by the States, the child welfare system is backed up by juvenile and family courts. While child welfare programs have their historic roots in orphanages and institutions, today the emphasis is largely upon community-based care, provided by surrogate families under professional supervision by public entities (23). 28 Two-thirds of all children in foster care are placed in families; the remainder are sent to institutions, including detention centers, mental hospitals, and special schools often because no suitable family homes can be found (108). Foster care is designed as temporary placement until a child or adolescent can be returned to his or her family or pending completion of necessary treatment and rehabilitation. Unfortunately, the reality has fallen short of the promise of foster care. The criteria for removal of children from their homes tend to be vague and subjective, and studies have confirmed significant differences in the handling of cases by caseworkers and judges (58,68). Nonwhites and Hispanics are placed out-of-home more frequently than other children (108). But worst of all, the system has tended to lose children and adolescents, in the sense that temporary out-of-home placements have resulted in permanent failures to reintegrate clients back into their homes. 29 In 1984, the average foster care stay was about 17 months (108). Tragically, children who remain in care longer than 18 months are seldom ever returned to their parents (58,68). The 1990 Family Impact Seminar notes that a recent study of 500 adolescents/young adults who received care from the Casey Family Program indicates that the more placements they had, the more difficulties they encountered later in life (23). Between 20 and 30 percent of those evaluated had serious difficulties. In addition, a significant number of children in foster care were exposed to physical and sexual abuse from foster parents (24). A 1988 zbFor a discussion of the health and other needs of homeless and runaway adolescents, see ch. 14, Hopelessness: Prevention and Services, in this volume. zTchi/d ~e/fare ~enlc.e~ ~clude adoptlo~ Ctid prot~tio~ foster we ad centers, independent hving programs, drop-ill centers, sexual abuse ~d prevention programs, victim assistance programs, adolescent pregnancy programs, and shelters for runaway children and adolescents. Frequently, programs are operated by private nonprofit entities under grants or contracts with governmental agencies. 2$~ 1982, 76 Pement of ~hil&en in foster cme were in f~ly or group homes, ad o~y lb percent Were in institutions. tiOUp hOIIleS We the faStfXSt growing form of care, yet they accounted for only 7 percent of out-of-home placements in 1982mostly for adolescents. z~ere ~e Clmly imtmces when ~ adolescents welfme r~uires continued out-of-home placement. But even tiough the ret~ of some adolescents to the home environment may not always be desirable, the adolescents who are considered lost in the child welfare system do not return for other reasons (e.g., because family reintegration efforts are nonexistent, superficially conducted, or easily abandoned in poorly monitored programs).
PAGE 55
11-50. Adolescent HealthVolume II: Background and the Effectiveness of Selected Prevention and Treatment Services study by the William T. Grant Foundations Commission on Work, Family, and Citizenship found that older adolescents average four different placements and at least one runaway episode while in foster care (108). There has in general been increasing recognition that the child welfare and foster care systems are not functioning well. In a recent article in the journal Child Welfare, Woolf noted that: A review of foster care history reflects a perpetual march down a road of good intentions with the failure to check the quality of the road, and, indeed, whether the interim goals to be accomplished along the way coincide with those of the final destination. .The time has come to integrate good intentions and optimism with wisdom in the development of child welfare strategies for foster care. Cooperation, teamwork, and self-discipline between professionals and organizations is imperative to the development, implementation, and monitoring of a systematic treatment approach to foster care services (108a). A 1989 National Health Policy Forum workshop referred to the child welfare system as a crisis intervention system in crisis (58a). In their issue brief for the National Health Policy Forum workshop, Koppelman and Jones noted the emerging health and social problems that burden a child welfare system; in turn, the child welfare system is fraught with case overloads and personnel shortages (58a). Personnel shortages include a shortage of foster parents (58a). Although they are indicative of the problems faced by the child welfare system, it is important to note that recent commentaries have not focused specifically on adolescents in the child welfare and foster care systems. Recognition of the problems associated with foster care has led to increasing emphasis on preserving families and reuniting children with their natural parents. Between 1977 and 1983, the number of out-of-home placements for children of all ages declined from 502,000 to 272,000 (108). Apparently aiding this trend was passage of the 1980 Federal Adoption Assistance and Child Welfare Act (Public Law 96-272). 30 In addition to requring child welfare agencies to make reasonable efforts to maintain a child or adolescent in the home prior to placing him or her in foster care, this act funded family preservation demonstration programs and research. Nonetheless, between 1984 and 1985, 31 States reported an increase in foster care placements (108). In 1985, there were 270,000 children in foster care, and about 45 percent of these (121,000 children) were between the ages of 13 and 18. 31 In an effort to reduce out-of-home placements, State and local governments have experimented with innovative family preservation programs in which adolescents are viewed as an integral part of their family system. 32 These programs seek to assess and treat families as units (23). The family is seen as a part of the community in a broad ecological context. Services provided to families are generally oriented to specific and limited goals, which are jointly defined by the family and a program worker, in accordance with the expressed needs of the family. Such services may include parent education and skills training, referral to other services, family therapy, and individual psychological support and counseling. Family preservation programs attempt to draw on the strengths of families, with a caseworker acting as a catalyst and enabler. Among the widely replicated models of family preservation programs are the following: the Homebuilders model, a crisis intervention model, which provides intensive services to families over 4 to 8 weeks, based on the assumption that the placement crisis presents a window of opportunity, when parents are most likely to be able to learn and change; the FAMILIES model, a home-based services model, which is adapted to rural areas and widely used in Iowa, where it had its beginnings; and the Oregon Intensive Family Preservation Services model, which unlike the other two places primary emphasis on family therapy rather than on the provision of concrete services (23). 301n ~ 1989 ~epofl, fie U.S. Gener~ ~o~fig OffIce made the poirlt that k the absence of Mtiond evdwtions or comprehensive information systems, they could not determine whether or to what extent the Public Law 96-272 reforms were responsible for reducing the number of unnecessary out-of-home placements. slIn the pr~edirlg year, about Igo,ooo children entered foster care ad an M @ number left It (108). 32~e Fmlly Impact Sefim ~s identifi~ pm~ams ~ c~ofia, Colorado, COMWtiCU~ Delaww, Florid% Illinois, IOW~ Kentucky, Wtid, Michigan, Mimesot~ Missouri, New Jersey, New Mexico, New York North Dakot% Oregop Pemsylvania, Temessee, Ikxas, and Washington (23).
PAGE 56
Chapter 3Parents and Families Influence on Adolescent Health II-51 According to a review for the Family Impact Seminar, 33 the Oregon Intensive Family Preservation Services model emphasizing family therapy has the highest success rate (87.3 percent, measured at termination of service) in terms of preventing out-of-home placement of children and adolescents, but the other two models have nearly as good success rates (81.4 percent for the crisis intervention model and 79.6 percent for the home-based services model) (23). 34 Implicit in family preservation strategies is the assumption that it is better for a child or adolescent to remain with his or her family than to be taken out of the home and placed in foster care. It is important to note, however, that there may well be circumstances when preservation of the family is not in the best interests of the child or adolescent, For some, like the runaway and homeless adolescents studied by Shane, there isnt always a home to which they can return (83). 35 For others, the home environment is irretrievably hostile and destructive. Thus, reduction in out-of-home placements should not be the sole criterion for program success or public policy. Future evaluations of family preservation services should develop broader measurements of effectiveness and clearer definitions of outcome expectations. Finally, Woolf notes that the family preservation policy mandated by Public Law 96-272 has meant that only the severest cases are remanded to foster care (108a). The implication has been that foster care has had to become more treatment-oriented, although, according to Woolf, it is not nearly treatmentor family-oriented enough (108a). A true treatmentand family-orientation would place foster care in a continuum of services for children and families, in which the entry of a family into the foster care system should be accompanied by a diagnostic component to assess specified areas such as family system dysfunction, placement requirements for the child, and recommendations for treatment of family members (108a). Such an initial assessment would be the frost component in determin ing the treatment services needed to assist the family in becoming a healthier, functioning system (108a). Additional research on attitudes and skills needed by parents of adolescents (e.g., 5,6,86) may help to keep adolescents in their homes or improve the foster care system for adolescents. Conclusions and Policy Implications Adolescents do not grow up in a vacuum. Both their health and their development are influenced by myriad social and environmental interactions from the immediate (e.g., daily contact with peers, parents, and teachers or physical contact with poison ivy) to the global (e.g., changes in the ozone layer). The familys significance in this constellation of influences, if not preeminent, is at least majorfor it touches the lives of most adolescents on a daily and deeply personal basis. Because parents usually have continuing proximity and can exercise some degree of power over the actions of adolescent family members, they are centrally important to any configuration of social factors shaping adolescent health. From time to time, peers and community may loom larger or smaller among an adolescents external influences, but the family and parents will remain as constant elements despite fluctuations in their relative importance. Given their ongoing role, if parents and families are to be a positive influence, they need to have accurate and useful information about adolescent development. Using parenting strategies with adolescents that were successful with children may generate conflict that could be avoided through alternative approaches to resolving differences. Research (as documented through this Report) has suggested that the enhancement of parenting skills can improve the quality of life within families and reduce conflict, but studies of the effectiveness of JJ~e F~y ~pact Semti is an activity of the American Association for Marriage and Family Therapy Research arid Education Foudatiow Family Impact Seminar meetings provide information to public policy staff (23). w~e F~ly Impact sem~ notes tit these Comparison are hampered by methodological concerns but suggests that the Oregon Intemive F~lY Preservation Semices model emphasizing therapy seems best adapted to families with udofescen~s at risk of placement. At an average cost of $1,000 per family, the Intensive Family Presemation Services model also appears to be the lmt expensive (the average cost of Homebuilders is $2,600 per family and that of FAMILIES is $2,000). The reader is cautioned, however, that these cost figures, in the absence of experimental designs, do not provide a reliable basis for estimating cost savings over placement services. 35 While rumway adolescents usually leave their homes voluntarily and without parental permission, sometimes parents or guardians encourage them to leave, abandon them, or force them out of their residence. The parents or guardians of these pushout or throwaway adolescents may resist family presemation services and deny an adolescent reintegration into the family. For a general discussion of homeless and runaway adolescents, see ch. 14, Hopelessness: Prevention and Services, in this volume.
PAGE 57
II-52 Adolescent Health-Volume II: Background and the Effectiveness of Selected Prevention and Treatment Services parenting programs on improving parent-adolescent relations and reducing specific problems of adolescence remain inconclusive (83a). 36 Still, the evidence suggests that authoritative parenting skills should be encouraged and information and training about this family model more widely disseminated. A variety of public and private supports could help to relieve families in distress. Respite care to relieve family caregivers, family and parental leave, comprehensive (or at least catastrophic) insurance coverage, and increased access to family therapy and parenting education programs all merit serious consideration for development or expansion. Policy aimed at reducing adolescent maltreatment should be a high priority. First, however, more analysis is needed concerning the definition and causes of adolescent maltreatment. Much of the research, policy, and programs on the causes, prevention, and treatment of maltreatment has not been specific as to the age of the child victim or has focused on younger children. Additional research on a range of other issues and aspects related to families and adolescent health would be useful. Research on the effect of parenting styles on adolescent health and development in nontraditional families (e.g., stepfamilies and singleparent families) and ethnic and racial minority families, for example, is sparse (42,43,45,85). It would be useful if additional research emphasis were given to examining effective, well-functioning families and their impact on adolescent health rather than maintaining g the traditional focus of research on family dysfunction and pathology. Knowledge of family influences that work to enhance adolescent health and development is as important as an examination of negative family influences. To assist researchers, improvements in the collection and reporting of data about intrafamilial maltreatment and family caregiving are desirable. Perhaps most importantly, though, parents need to be viewed with respect and treated with dignity in their interactions with public and private agencies. The institutions of society-religious, social, and political institutions and the mediashould recognize the diversity of Americas families and the familys potentially significant role in improving the health of our Nations children and adolescents. Rather than adhering to the outdated notion that parents are solely the obstacles to treatment for children and adolescents, many more professional health/mental health care providers should try to regard parents and other family members as partnerstogether with the practitioner and the patientin the prevention, treatment, and rehabilitation of adolescent health problems (73a). While some families surely bear culpability for the health problems of their members, a blame the family or blame the parents approach to understanding the problems of adolescent health obfuscates more than it illuminates. Through strengthening the many positive contributions of families and parents to adolescent health, a more balanced and constructive perspective can be maintained. Chapter 3 References 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. American Humane AssociatioxL Annual Report of the National Study of ChildAbuse andNeglectReporting (Denver, CO: 1987). Ballenski, C., and Cook A., Mothers Perceptions of Their Competence in Managing Selected Parenting Tasks, Family Relations 31:489-494, 1982. Ba umrind, D., A Developmental Perspective on Adolescent Risk Taking in Contemporary Ameriw Adolescent Social Behavior and Health, New Directions for Child Development, C.E. h-win+ Jr. (cd.) (San Francisco, CA: Jossey-Bass, 1987). Baumrin d, D., The Influence of Parenting Style on Adolescent Competence and Problem Behavior, paper presented at the Science Weekend of the American Psychological Association Convention New Orleans, LA, Aug. 12-13, 1989. d, D., The Influence of Parenting Style on Adolescent Baumrin Competence and Substance Use, Journal of Early Adolescence, 11(1):56-95, 1991. Baumrin d, D., Parenting Styles and Adolescent Development, The Encyclopedia on Adolescence, J. Brooks-Gu R. Lesner, and A.C. Petersen (eds.) (New York NY: Garland, 1991). Bengston, V.L., The Generation Gap: A Review and ~logy of Social-Psychological Perspectives, Youth and Society 2:732, 1970. Berdie, J., Berdie, M., Wexler, S., et al., An Empirical Study of Famlies Involved in Adolescent Maltreatment (San Francisco, CA: URSA Institute, 1983). Berdie, J., and Wexler, S., Prelim&ry Research on Selected Adolescent Maltreatment Issues: An Analysis of Supplemental Data From the Four Adolescent Maltreatment Projects, Adolescent Maltreatment: Issues and Program Models, National Center on Child Abuse and Neglect A&mm strationfor Childreq You@ and Families, Office of Human Development Services, U.S. Department of Health and Human Services (Washington DC: U.S. Government Printing Oftlce, 1984). Blum, R., and RunyarL C., Adolescent Abuse: The Dimensions of the problem Journal of Adolescent Health Care 1:121-126, 1980. BohmarL N., Sigvardssou S., and Cloninger, R., Maternal Inheritance of Alcohol Abuse: Cross-Fostering Analysis of Adopted Wome~ Archives of General Psychiatry 38:965-969, 1981. ~For furthel discussio~ see ch. 9, AIDS and Other Sexually Transmitted Diseases: Prevention and Services, ch. 10, pregnancy and Parent@: Prevention and Services, and ch. 13, Delinquency: Prevention and Services, in this volume.
PAGE 58
Chapter 3Parents and Families Influence on Adolescent Health II-53 12. 13. 14. 15. 16. 17. 18. 19. 20. 21. 22. 23. 24. 25. 26. 27. 28. 29. 30. 31. 32, 33. 34. 35. Boyce, W.T., Jense% E.W., Cassel, J. C., et al., Influence of Life Events and Family Routines on Childhood Respiratory Illness, Pediatrics 60:609-615, 1977. Browne, A., When Battered Women Kill (New York NY: Free Press, 1987). Butler, J., Budetti, P., McManus, M., et al., Health Care Expenditures for Children With Chronic Illnesses, Issues in the Cure of Children With Chronic Illness, N. Hobbs and J. M. Perrin (eds.) (San Francisco, CA: Jossey-Bass, 1985). Clark, R., Family Life and School Achievement: Why Poor Black Children Succeed or Fail (Chicago, IL: University of Chicago Press, 1983). Cloninger, C.R., Bohrnan, M., and Sigvardssou S., Inheritance of Alcohol Abuse: Cross-Fostering Analysis of Adopted Meu Archives of General Psychiat~ 38:861-868, 1981. Coles, R., and Stokes, G., S= and the American Teenager (New York NY: Harper & Row, 1985). CottorL N. S., The Familial Incidence of Alcoholism, Journal of Studies on Alcohol 44):89-1 16, 1979. Daly, M., and WilsoU M., Child Maltreatment in Sociobiological Perspective, New Directions for Child Development 11 :93112, 1981. Dombuscb S. M., Ritter, P.L., hideP.H., et al., The Relation of Parenting Style to Adolescent Performance, Child Development 58:1244-1257, 1987. DouvaIL E., and Adelso~ J., The Adolescent Experience (New York NY: Wiley, 1966). Eisen, M., Zellm G. L., Leibowitz, A., et al., Factors Discriminating Pregnancy Resolution Decisions of Unmarried Adolescents, Genetic Psychology Monographs 108:69-95, 1983. Family Impact Seminar, Keeping Troubled Families Together: Promising Programs and Statewide Reform, panel discussion by E. Cole, K. Nelsom B. Purcell, F. Farrow, and T. Ooms, Seminar on Family-Centered Social Policy: The Emerging Agenda, American Association for Marriage and Family Therapy, Washington, DC, June 8, 1990. Fanshel, D., Finch+ S.J., and Grundy, J.F., Foster Children in Lfe Course Perspective (New York, NY: Columbia University Press, 1990). Farber, E., and Josep& J., The Maltreated Adolescent: Patterns of Physical Abuse, Child Abuse and Neglect 9:201-206, 1986. Farber, E., McCoard, W.D., Kinasc C., et al., Violence in the Families of Adolescent Runaway s, Child Abuse and Neglect 8:295-300, 1984. Fox, G.L., The Familys Role in Adolescent Sexual Behavior, Teenage Pregnancy in a Family Context, T. Ooms (cd.) (Philadelphia% PA: fkmple University Press, 1981). Garbarino, J., Meeting the Needs of Mistreated Youths, Social Work 25:122-126, 1980. Garbarino, J., Adolescent Victims of MaltreatrnenL contract paper prepared for the OffIce of Ikchnology Assessment, U.S. Congress, WashingtorL DC, April 1990. Garbarino, J., President, The Erikson Institute, personal communication% Aug. 10, 1990. Garbarino, J., and Gilliam, G., Understanding Abusive Families @xir@ou MA: Lexington Books, 1980). Garbarino, J., and Kostelny, K., Patterns and Trends in Reported Cases of Maltreatment and Infant Mortality in Chicago Community Areas, Erikson Institute, Chicago, IL, 1989. Garbarino, J., and Plantz, M., Abuse and Delinquency, Troubled Youth, Troubled Families, J. Garbarino, C. Schellenbach, J. Sebes, et al. (eds.) (New York, NY: Aldine Publishing Co., 1986). Garbarino, J., Schellenbach, C., Sebes, J., et al. (eds.), Troubled Youth, Troubled Families (New York+ NY: Aldine Publishing Co., 1986). Garbarino, J., Sebes, J. and Schellenbach, C., Families at Risk for Destructive Parent-Child Relations in Adolescence, Child 36. 37. 38. 39. 40. 41. 42. 43. 44. 45. 46. 47. 48. 49. 50. 51. 52. 53. 54. 55. Development 55:174-183, 1984. Genes, R.J., and Straus, M.A., Is Violence lbward Children Increasing? A Comparison of 1975 and 1985 National Survey Rates, Journal of Interpersonal Violence 2(2):212-222, 1987. Gersho% E.S., Hamovit, J., Guroff, J., et al., A Family Study of Schizoaffective, Bipolar I, Bipolar II, Unipolar and Normal Controls, Archives of General Psychiatry 39:1157-1167, 1982. Goodwiq D.W., Alcoholism and Genetics: The Sins of the Fathers, Archives of General Psychiatry 42:171-174, 1985. Gottesmiq 1.1., and Shields, J., A Critical Review of Recent Adoptio% Twin and Family Studies of Schizophrenia: Behavioral Genetics Perspective, Schizophrenia Bulletin 2:360400, 1976. Graevew D.B., and Schaef, R.D., Family Life and Levels of Involvement in an Adolescent Heroin Epidemic, International Journal of the Addictions 13:747-771, 1978. Heifer, R., and Kempe, C.H., Child Abuse and Neglect: The Famly and the Community (Cambridge, MA: Ballinger, 1976). HetheringtoL E. M., and C axrutr% K. A., Families in Transition: The Processes of Dissolution and ReconstitutiorL Review of Child Development Research, Vol. 7: The Family, R.D. Parke (cd.) (Chicago, IL: University of Chicago press, 1984). HetheringtoL E. M., Cox, M., and Cox, R., Imng-Tmn Effects of Divorce and Remarriage on the Adjustment of Children, Journal of the American Academy of Child Psychiatry 24(5):518530, 1985. Hill, J.P., The Early Adolescent and the Family, The Seventy-Ninth Yearbook of the National Society for the Study of Education, M. Johnson (cd.) (Chicago, IL: University of Chicago Press, 1980). Hill, J.P., Research on Adolescents and Their Families: Past and Prospect, Adolescent Social Behavior and Health, New Directionsfor Child Development, C.E. Irw@ Jr. (cd.) (San Francisco, CA: Jossey-Bass, 1987). llingso~ R. W., Strunin, L. and Berl@ B., Acquired Immunodeficiency Syndrome Transmission: Changes in Knowledge and Behaviors Among lkenagers, Massachusetts Statewide Surveys, 1986 to 1988, Pediamcs 85(1):24-29, 1990. Hodgkdnso% H.L., The Same Client: The Demographics of Education and Service Delivety Systems (Washington, DC: Center for Demographic Policy, Institute for Educational LeaderShip, hlC., 1989). HoffmarL L.W., and Manis, J.D., Influences of Children on Marital and Parental Satisfactions and Dissatisfactions, Child Influences on Marital and Famly Interaction: A Life-Span Perspective, R.M. Lerner and G.B. Spanier (eds.) (New York NY: Academic Press, 1978). Hogm D.P., and Kitagaw% E. M., Family Factors in the Fertility of Black Adolescents, paper presented at tie AMU~ Meeting of the Population Association of Americ% Pittsbur~ PA, 1983. Inazu, J.K., and F OX G.L., Maternal Influence on the Sexual Behavior of Rmage Daughters, Journal of Family Issues 1:81-102, 1980. Irw@ C. E., Jr. (ML), Adolescent Social Behavior and Health, New Directions for Child Development (San Francisco, CA: Jossey-Bass, 1987). Jacobs, P., and McDermott, S., Family Caregiver Costs of Chronically Ilt and Handicapped Children: Method and Literature Review, Public Health Reports 104(2): 158-163, 1989. Jennings, M., and Niemi, R., Continuity and Change in Political Orientations: A Imngitudinal Study of Two Generations, American Political Science Review 69:13161375, 1975. Kalter, N., children of Divorce in an Outpatient Psychiatric Population American Journal of Orthopsychiatry 47:4051, 1977. Kandel, D.B., Developmental Stages in Adolescent Drug Involvement+ Theories on Drug Abuse, D.J. Lettieri, M. Sayers, and H.W. Pearson (eds.), National Institute on Drug Abuse,
PAGE 59
II-54 Adolescent Health-Volume II: Background and the Effectiveness of Selected Prevention and Treatment Services 56. 57. 58. 58a. 59. 60, 61. 62. 63. 64. 65. 66. 67. 68. 69. 70. 71. 72. 73. 73a. 74. Alcohol, Drug Abuse and Mental Health AdmmM t13tiO~ Public Health Service, U.S. Department of Health and Human Services, Research Monogmph 30, DHHS Pub. No. 80-967 (Wshin@om DC: U.S. Government Printing Oftlce, 1980). Kande~ D.B., and Lesser, G. S., Youth in Two Worlds: United Stares and Denmark (San Francisco, CA: Jossey-Bass, 1972). Kendall-TackeW K., and Simom A., Molestation and the Onset of Puberty: Data From 365 Adults Molested as Childreq Child Abuse and Neglect 12:73-83, 1988. Knitzer, J., and Alleq M., Children Without Homes (Washington DC: Childrens Defense Fun4 1978). Koppelrnaq J. and Jones, J. M,, Child Welfare Services: A Crisis Intervention System in Crisis, Issue Brief No. 528 (WashingtoIL DC: George Washington University, National Health Policy Forum, Sept. 21, 1989). Ktsanes, V., Assessment of Contraception by Tkemgers, fti report prepared for the National Institute of Child Health and Human Developme@ National Institutes of Health, Public Health Service, U.S. Department of Health and Human Services, Bethes@ MD, 1977. Libby, P., and Bybee, R., The Physical Abuse of Adolescents, Journal of Social Issues 35:101-126, 1979. Litl I., The Health of Adolescent Women in the 1980s, Western Journal of Medicine 149:696-699, 1988. Lourie, I., The Phenomenon of the Abused Adolescent: A clinical Study, VictimoZogy 2:268-276, 1977. Maccoby, E., and Martin, J., Socialization in the Context of the Family: Parent-Child Interactio~ Handbook of Child Psychology: Socialization, Personality, and Social Development, vol. 4, E.M. Hetherington (cd.) (New York NY: Wiley, 1983). McAnarney, E, R., Social Maturation: A Challenge for Handicapped and Chronically Ill Adolescents, Journal of Adolescent Hea/rh Care 6:9@100, 1985. McCormac~ A., Janus, M., and Burgess, A., Runaway Youths and Sexual Victimization: Gender Differences in an Adolescent Runaway Population Chiki Abuse and Neglect 10:387-3%, 1986. Meyer, R. J., and Haggerty, R.J., Streptococcal Infections in Families: Factors Altering Individual Susceptibility, Pediamcs 29:539-549, 1962. Mikesell, J. and Garbarino, J., Adolescents in Stepfarnilies, Troubled Youth, Troubled Fanulies, J. Garbarino, C. Schellenbach, J. Sebes, et al. (eds.) (New York, NY: Aldine Publishing Co., 1986). National Commission on Children in Need of Parents, Who Knows? Who Cares? Forgot fen Children in Fosfer Care (Washington DC: 1979). Newachec~ P., and McManus, M., Financing Health Care for Disabled Childreu Pediamcs 81(3):385-394, 1988. Newcomer, S., and Udry, J.R., Adolescent Sexual Behavior and Popularity, Adolescence 18:515-522, 1983. Norbeclq J. S., and Tilde% V.P., Life Stress, Social Supports, and Emotional Disequilibrium in Complications of Pregnancy: A Prospective, Multivariate Study, Journal of Health and Social Behavior 24:30-46, 1983. Offer, D., The Psychological World of the Teenager (New York NY: Basic Books, 1969). Olse% L., and Holmes, W., Youth at Risk: Adolescents and Maltreatment (Boston, MA: Center for Applied Social Research 1983). Ooms, T. and Oweu T., Parents Role in Tkenage Health Problems: Allies or Adversaries, background briefing report and meeting highlights of a seminar in a series of monthly seminars titled Famly Centered Social Policy: The Emerging Agenda conducted by the Family Impact Seminar, American Association for Marriage and Family Therapy, Resewch and Education Foundation Washington, DC, 1990. Overby, K.J., Bernard, L. and LitL I.F., Knowledge and Concerns About Acquired Immunodeficiency Syndromes and 75, 76, 77, 78. 79. 80. 81. 82. 83. 83a. 84. 85. 86. 87. 88. 89. 90. 91. 92. 92a. Their Relationship to Behavior Among Adolescents With Hemo phi~ Pediamcs 82(2):204210, 1989. Pelcovitz, D., Kaplaq S., Samit, C., et al., Adolescent Abuse: Family Structure and Implications for Treatmen~ Journal of Child Psychiatry 23:85-90, 1984. Post S., Adolescent Parricide in Abusive Families, C/u&f We~are 61:445455, 1982. Powers, J., and Eckenrode, J., The Maltreatment of Adolescents, Child Abuse and Neglecf 12:189-199, 1988. Powers, S.1., Hauser, S.T., Schwartz, J.M., et al., Adolescent Ego Development and Family Interaction: A StructuralDevelopmental Perspective, Adolescent Development in the Famly, H.D. Grotevant and C. R. Cooper (eds.) (San Francisco, CA: Jossey-Bass, 1983). Quinones, N., The Implications of Demographic Trends for the Future of Public Educatio& Demographic Changes in the United Stares: The Economc and Social Consequences Into the 21st Century, hearings before the Subcommittee on Economic Resources, Competitiveness, and Security Economics of the Joint Economic Committee, U.S. Congress, July 25,29, and 31, 1986 (W-OXL DC: U.S. Government Prindng OffIce, 1989). ReiA J., Sociat Interfactional Patterns in Families of Abused and Nonabused childre~ Social andBiological Origins of Altruism andAggression, C. Waxier and M. Radke-Yarrow (eds.) (Cambridge, MA: Cambridge Press, 1986). Roseu R.H., Adolescent Pregnancy Decisionmaking: Are Parents Important? Adolescence 15:4345, 1980. Scherer, D.G., and Reppucci, N.D., Adolescents Capacities RI Provide Voluntary Informed Consent, Law arui Human Behavior 12(2): 123-141, 1988. Shane, P., Changing Patterns Among Homeless and Runaway Youth, American Journal of Orthopsychiatry 59(2):208-214, 1989. Small, S.A., Preventive programs That Support Families With Adolescents, working paper prepared for the Carnegie Council on Adolescent Development, Carnegie Corpomtion of New York Washingto~ DC, January 1990. Srna@ R.G., and Fejer, D., Drug Use Among Adolescents and Their Parents: Closing the Generation Gap in Mood Modiilcatiou Journal of Abnormal Psychology 79:153-160, 1972. Springer, C., and Wallersteti J. S., Young Adolescents Reponses to Their Parents Divorces, New Directions for Child Development, 19: Chil&en and Divorce, L.A. Kurdek (etI.) (San Francisco, CA: Jossey-Bass, 1983). Steinberg, L., Autonomy, Conflict and Harmony in the Parent-Adolescent Relationship, At the Threshold: The Developing Adolescent, S.S. Feldman and G.R. Elliott (eds.) (Cambridge, MA: Harvard University Press, 1990). Steinberg, L., and Hill, J., Family Interaction Patterns During Early Adolescence, Adolescent Behavior and Society: A Book of Readings, R. Muuss (cd.) (New York NY: Random House, 1980). Stiffrnq A.R., and Earls, F., Behavioral Risks for Human Immunodeficiency Virus Infection in Adolescent Medical Patients, Pediatrics 85(3):303-310, 1990. Straus, M., and Genes, R., Societal Change and Change in Family Violence From 1975-1985 as Revealed in Two National Surveys, Journal of Mamage and the Famly 48:465-479, 1986. Straus, M., Genes, R., and Steinmetz, S., Behind Closed Doors (New Yorlq NY: Doubleday, 1980). Theme, C.R., and DeBlassie, K.K., Adolescent Substance Abuse, Adolescence 20(78):335-347, 1985. U.S. Congress, Office of lkchnology Assessment Adolescent Health Projec$ Youth Advisory Panel, meeting on Sept. 11, 1989 U.S. Department of Commerce, Bureau of the Census, Marital Status and Living Arrangements: March 1989, Current Population Reports, Series P-20, No. 445 (Wash@tom DC: U.S. Government Printing Office, June 1990).
PAGE 60
Chapter 3Parents and Families Influence on Adolescent Health //-55 92b. 92c. 92d. 93. 94. 95. 96. 97. 98. 99. U.S. Department of Commerce, Bureau of the Census, Household and Famly Charactenstics. March 1990 and 1989, Current Population Reports, Series P-20, No. 447 (Washington, DC: U.S. Government Printing Office, December 1990), U.S. Department of Commerce, Bureau of the Census, unpublished data on the resident population ages 10 through 17 as of July 1, 1989, 1990. U.S. Department of Commerce, Bureau of the Census, Studies in Marriage and the Family, Current Population Reports, Scnes P-23, No, 162 {Washington, DC: U.S. Government Printing Office, June 1989). U.S. Department of Education, Office of Educational Research and Improvement, Yourh Indicators, 1988: Trends in the Well-Being of American Youth (Washington, DC: August 1988). U.S. Department of Health and Human Semices, Office of Human Development Services, Administration for Children, Youth, and Families, Childrens Bureau, National Center on Child Abuse and Neglect, Recognition and Reporting of Child Maltreatment Findings From the Study of National Incidence and Severity of Child Abuse and Neglect (Washington, DC: 1980). U.S. Department of Health and Human Services, Office of Human Development Services, Administration for Childrem Youth, and Families, Childrens Bureau, National Center on Child Abuse and Neglect, Study Findings: Study of National [ncidence and Preyalence of Child Abuse and Neglect: 1988 (Washington, DC: 1988). U.S. Department of Health and Human Services, Public Health Service, Alcohol, Drug Abuse, and Mental Hczdth Administration, National Institute of Mental Health, Familys Impact on Health: A Critical Review and Annotated Bibliography, prepared by T.L. Campbell, DHHS Pub, No. ADM 87-1461 (Rockville, MD: 1987). U.S. Department of Health and Human Services, Public Health Service, Centers for Disease Control, National Center for Health Statistics, AIDS Knowledge and Attitudes for May-June, 1988, D.A. Dawson, No. 160, DHHS Pub. No. PHS 88-1250 (Hyattsville, MD: September 1988). U.S. Department of Health and Human Services, Public Health Service, Centers for Disease Control, National Center for Health Statistics, AIDS Knowledge and Attitudes for July, 1988, D.A. Dawson, No. 161, DHHS Pub. No. PHS 89-1250 (Hyattsville, MD: October 1988). U.S. Department of Health and Human Services, Public Health Service, Centers for Disc&se Control, National Center for Health 100. lOOa. 101. 102. 103. 104. 105. 106. 107. 108. 108a. 109. Statistics, AIDS Knowledge and Attitudes for January-March 1989, D.A. Dawson, No. 176, DHHS Pub. No. PI-IS 89-1250 (Hyattsville, MD: August 1989). U.S. Department of Health and Human Semices, Public Health Service, National Institutes of Healti Nation.aJ Cancer Institute, Z987 Annual Cancer Statistics Review, DHHS Pub. No. NIH 88-2789 (Bethesda, MD: February 1988). U.S. General Accounting, Foster Care: Incomplete Implementation of the Reforms and Unknown Effectiveness GAO/PEMD-8917 (Washington DC: U.S. General Accounting Office, August 1989). Veroff, J., and Felt S., Mamage and Work in Amenca (New York NY: Van Nostrand Reinhold, 1970). Vondra, J., Socioeconomic Stress and Family Functioning in Adolescence, Troubled Youth, Troubled Families, J. Garbarino, C. Schellenbach, J. Sebes, et al. (eds.) (New York, NY: Aldine Publishing Co., 1986). Wald, M. S., Carlsmit4 J. M., and Leiderman, P. H., Protecting Abu,sedand Neglected Children (Stanford, CA: Stanford University Press, 1988). Wauchope, B., and Straus, M., Age, Class, and Gender Differences in Physical Punishment and Physical Abuse of American Children, paper presented to the Third National Conference on Family Violence Resea.rc~ University of New Hampshire, DurharrL NH, 1987. Weis~ C. S., Nathansou C.A., Ensminger, M., et al., AIDS Knowledge, Perceived Risk and Prevention Among Adolescent Clients of a Family Planning Clinic, Family Planning Perspectives 21(5):213-216, 1989. Weissman, M. M., Gershon, E. S., Kidd, K.K., et al., Psychiatric Disorders in the Relatives of Probands With Affective Disorders, Archives of General Psychiatry 41: 13-21, 1984. West, M., and StuarL S., The Child Welfare System for Adolescents, contract paper prepared for the Office of lkchnology Assessment, U.S. Congress, Washington DC, January 1990. William T. Grant Foundation, Commission on Work Family, and Citizenship, The Forgotten Half: Pathways to Success for Americas Youth and Young Famlies (Washington, DC: November 1988). Woolf, G.D., An Outlook for Foster Care in the United States, Child We~are 69:75-81, 1990. Zeu M., Kantner, J., and Ford, K., Sex and Pregnancy in Adolescence (Beverly Hills, CA: Sage publications, 1981).
PAGE 61
Chapter 4 SCHOOLS AND DISCRETIONARY TIME Contents Page Introduction . . . . . . . . . . . . . . . . . . . 59 School Influences on Adolescent Health . . . . . . . . . . . . 60 overview of the U.S. Educational System for Adolescents . . . . . . . . 60 Relationships Between Adolescent Health and School Adaptation . . . . . . 62 Overview of the Effects of Specific Factors on School Environments and on Adolescent Health . . . . . . . . . . . . . . . . 66 Evidence for the Effects of Specific Academic Policies on Adolescent Health . . . 67 Evidence for the Effects of School Size on Adolescent Health . . . . . . 69 Evidence for the Effects of School Decisionmaking and Other Processes on Adolescent Health . . . . . . . . . . . . . . . 70 Evidence for the Effects of School Transitions on Adolescent Health . . . . . 71 Evidence for the Effects of Class Size on Adolescent Health . . . . . . . 72 Evidence for the Effects of School Environments on Teachers Attitudes and Behaviors . 73 Evidence for the Effects of Teacher Behaviors on Adolescent Health . . . . . 76 Evidence for the Effects of School Policies Regarding Cultural Diversity on Adolescent Health . . . . . . . . . . . . . . . 76 Evidence for the Effects of Parental Involvement in Schools on Adolescent Health . . 77 Summary: School Influences on Adolescent Health . . . . . . . . . 78 Major Federal Policies and Programs Related to Education . . . . . . . . 78 U.S. Department of Education . . . . . . . . . . . . . 78 U.S. Department of Labor . . . . . . . . . . . . . . 87 Adolescents Discretionary Time . . . . . . . . . . . . . . 88
PAGE 62
How Do U.S. Adolescents Spend Their Time? . . . . . . . . . . 89 Alternatives for the Constructive Use of Adolescents Discretionary Time . . . . 91 Basic Requirements of Alternatives for the Constructive Use of Adolescents Discretionary Time . . . ..0,.... . . . . . . . . . . 91 Youth-Serving Organizations . . . . . . . . . . . . . . 92 Community Service Programs . . . . . . . . . . . . . 93 School-Based Programs . . . . . . . . . . . . . . . 94 Municipal Recreation Centers . . . . . . . . . . . . . 94 Churches and Synagogues . . . . . . . . . . . . . . 95 Other Alternatives . . . . . . . . . . . . . ,. 96 Major Issues in the Elaboration of Health-Enhancing Alternatives for the Use of . ,. Adolescents Discretionary Time . . . . . . . . . . . . . 96 Counterproductive Theories of Adolescent Development . . . . . . . . 96 Categorical Funding Sources . . . . . . . . . . . . . . 97 Public Support v. Private Support . . . . . . . . . . . . . 97 Common Infrastructure v. Adolescents as a Special Case . . . . . . . 98 Adolescent Development, Recreation, or Employment? . . . . . . . . 98 Extent of Adult Involvement and Supervision . . . . . . . . . . 98 Differing Needs for Differing Adolescent Populations . . . . . . . . 99 National Youth Service . . . . . . . . . . . . . . . 100 Revitalization and Reinstitution of Social Service Agency Programs . . . . . 100 Recent Federal Initiative: National and Community Service Act of 1990 . . . . 101 Conclusions and Policy Implications ....., . . . . . . . . . . . 103 Chapter preferences . . . . . . . . . . . . . . . . 104 Box Box Page 4-A. Innovative Approaches to Improving American Schools ........, . . . . . 79 Figures Figure Page 4-1. Typical Patterns of Progression From Elementary School Through High School, . . 61 4-2. High School Dropout Rates in the United States, 1989 . . . . . . . . 62 4-3. Possible Relationships Among School Environments, School Adaptation, and Adolescent Health . . . . . . . . . . . . . . . . 63 4-4. U.S. Department of Education . . . . . . . . . . . . . 84 Tables Table Page 4-1. Evidence for the Relationship Between School Adaptation and Adolescent Health . . 64 4-2. National Data on the Relationship of Students Race/Ethnicity and Socioeconomic Status to School Adaptation . . . . . . . . . . . . . . 65 4-3. Evidence for the Relationship of Various School Environments to Teachers Attitudes and Behaviors . . . . . . . . . . . . . . . . . 74 4-4. Evidence for the Relationship of Parental Involvement in Schools to the School Environment and Adolescent Health . . . . . . . . . . . . 77 4-5. Where Adolescents Spend Their Time . . . . . . . . . . . . 89 4-6. What Adolescents Spend Their Time Doing . . . . . . . . . . 90
PAGE 63
Chapter 4 SCHOOLS AND DISCRETIONARY TIME Introduction Every day, some 26 million U.S. adolescents ages 10 through 18 go to school. How do school environments affect adolescents health-that is, their physical, social, and behavioral development and well-being? The role of schools in adolescent health is the subject of increasing debate (e.g., 27,147,210). School personnel often think that adolescents bring their health problems to the schools and regard efforts to address specific problems and generally improve adolescent health as the responsibilities of adolescents themselves, their parents, the health care system, and perhaps other institutions in the community (107b). The view that adolescents bring a considerable number of health problems with them to the school building each day is certainly supported by clinical evidence, but there is also evidence that schools play a role in exacerbating or ameliorating adolescents health problems, broadly defined. 1 As discussed elsewhere in this Report, some schools offer health education, fitness activities, and lunch or other meals to students, and some schools provide health care services through school nurses or school-linked health centers (SLHC S ). 2 Some school buildings, are located in unsafe neighborhoods and have deteriorating facilities with asbestos, lead paint, radon, or other problems with potential implications for the health of their adolescent students, but these risks will not be addressed in this chapter. The question addressed in the first half of this chapter is how school academic and social environments affect U.S. adolescents health. As discussed further below, particular aspects of school academic and social environments have been correlated with indicators of school adaptation (e.g., school grades, attendance, educational attainment, being retained in grade, and school dropout 3 ), and some of these indicators have been correlated with adolescent health outcomes (e.g., self esteem, substance use, adolescent pregnancy and childbearing, and delinquency). Some major Federal policies and programs related to the education of adolescents are also discussed. U.S. adolescents attending school spend some of their time every day away from school. It is virtually certain that the physical, social, and behavioral development of adolescents is shaped, at least in part, by the experiences that occur during their discretionary time (i.e., time that is not spent at school or in essential maintenance activities such as eating or sleeping). The second half of this chapter is devoted to an ex amination of adolescents discrePhoto credit: Bruce Clark/Education Week Each day, some 26 million U.S. adolescents go to school, but the role of school environments in promoting adolescent health, whether discretely or through academic achievement, only recently seems to have emerged as a concern. IAs noted iII Vol. I of thk R~ort ad in Ch. 2, What Is Adolescent Health? in this volume, a broad deftition of health-including physical, social, and mental aspects and emphasizing a sense of well-being in addition to the absence of problemsfits the period of adolescence better than a narrow definition emphasizing the absence of physical health problems. In considering adolescent healm one should take into account traditional measures of physical healh newer behavioral measures, and a broad range of indicators of optimal functional status (including emotional and social status, pereeived quality of life). A fully realized view of adolescent health should also be sensitive to the developmental changes that occur during adolescence. Nm_ition and fitness activities in schools are discussed in ch. 7, Nutrition and Fitness problems: Prevention and Services, in this volume. Information abut SLHCS is presented in ch. 15, Major Issues Pertaining to the Delivery of Primary and Comprehensive Health Services to Adolescents, in Vol. HI. qAl~ough 1 *sch@l &oPut is aw~ard te~ology, ~s is such a common term ~ tie field tit OTA is Wing it. Sch~l drOpOUt Cm be rlletlNIRd in various ways. In the U.S. Department of Educations report Dropout Rates in the United Sfates. 1988, distinctions are made among event dropout rafes (the proportion of students who drop out in a single year), status dropout rufes (the proportion of the popdation that has dropped out at a given point in time), and cohort dropout rates (the proportion of a group of students that drop out over time) (202b). -II-59-
PAGE 64
11-60. Adolescent Health-Volume II: Background and the Effectiveness of Selected Prevention and Treatment Services tionary time. It discusses available research on how adolescents spend their time and describes issues related to the development of health-enhancing alternatives, including the National and Community Service Act of 1990 (Public Law 101-610). The chapter ends with conclusions and policy implications. School Influences on Adolescent Health 4 Evidence that allows inferences about causal relationships between school environments and adolescent health outcomes such as substance abuse, pregnancy, delinquency, or victimization to be made with confidence is limited. The reason is that schools are seldom considered as factors in discussions of ways to improve adolescent health, and most of the research that has been done in this area shows correlational relationships rather than causal relationships. Another problem is that school and nonschool factors (e.g., individual factors, family factors, neighborhood factors) interact with each other in complex ways that have yet to be fully understood. When considering how school environments affect the health, behavior, and well-being of 10to 18-year-old students, it is important to keep these caveats in mind. The bulk of the discussion below details available evidence for the effects of different aspects of school environments academic policies, school size, school decisionmaking and other processes, timing of school transitions, and classroom size, teachers attitudes and behavior, school policies regarding cultural diversity, and parental involvement in schools-on adolescent health. First, however, overview of the U.S. educational system, with descriptions of Federal, State, and local funding responsibilities, and student enrollment statistics, is presented as background in the first section below. Major Federal programs related to education are discussed briefly after the discussion of evidence on the effects of school environments on adolescent health. Overview of the U.S. Educational System for Adolescents Figure 4-1 provides an overview of the structure of elementary and secondary education in the United States. Students usually spend 6 to 8 years in the elementary grades and then go on to a 4to 6-year program in high school. They normally complete the entire program through grade 12 by age 17 or 18 (204). Ten-year-olds typically enter grade 5, ll-yearolds grade 6, 12-year-olds grade 7, 13-year-olds grade 8, 14-year-olds grade 9, 15-year-olds grade 10, 16year-olds grade 11, and 17-year-olds grade 12. In 1987, adolescents ages 10 to 18 totalled an estimated 26.4 million students (13.2 million in elementary school and 13.2 million in secondary school) (204). 5 From 1971 to 1984, enrollment in U.S. elementary and secondary schools steadily declined, but a new wave of secondary school students is expected in the years ahead (204). U.S. schools are affected by funding, policies, and regulations at various levels of government, but public education is primarily a State and local responsibility. States establish State educational policies and determine how State monies are allocated. Generally, the States delegate operational responsibility for schools to local school boards. Some 15,000 local school boards set most policy for over 100,000 individual elementary and secondary schools in the United States (202). The Federal Government supports elementary and secondary education through financial aid programs that include the Chapter 1 program discussed later in this chapter. In fiscal year 1989, the appropriation for Chapter 1 was $4.6 billion (202a). Federal spending for education is a small percentage of overall spending for elementary and secondary education. At its highest point in 1979-80, Federal spending accounted for 9.8 percent of total expenditures. In 1985-86, the Federal Government contributed only 6.7 percent of total revenues, with the States picking up nearly half of the expenses (49.4 d~.s ~tlO~ &aW~ ~~bs~ti~y ~m a paper prep~~ under Contrwt to oTA by Michelle Fine entitled Middle ~d !hXOn@ School Environments as They Affect Adolescent Well-Being (72a). 5AS noted in ch. 18, lssues in the Delivery of Services to selected Groups Of Adolescent% in Vol. III, adolescents ages 10 through 18 numbered about 31 million in 1987. About 22.01 million (71 percent) are white, non-Hispanic adolescents; about 4.65 million (15 percent) black non-Hispanic adolescents; about 3.1 million (10 percent) are Hispanic adolescents; and 1.24 million (4 percent) are other (including Asian) adolescents. The percentage of U.S. adolescents who are not white, non-Hispanic is growing, and this trend can be expected to continue into the foreseeable future. Racial and ethnic minority adolescents disproportionately live in poor or near-poor families.
PAGE 65
. . . Chapter 4Schools and Discretionary Time .11-61 Figure 4-lTypical Patterns of Progression From Elementary School Through High School a High school diploma 17 12 11 10 9 8 I Senior high schools (grades 10-12) 4-year high schools (grades 9-12) 16 Combined junior-senior high schools (grades 9-12) 15 14 13 7 12 I schools (grades 4-8) 11 LA (grades 1-6) u (grades 1-6) I 10 4 9 (grades K-3) I 3 8 Elementary (or primary) schools 2 7 I 6 ii -. 0 3 5 5 I K Nursery schools PK 4 3 Age L I Grade %hart reflects typical patterns of progression rather than all possible variations. SOURCE: U.S. Department of Education, Office of Educational Research and Improvement, National Center for Educaticn Statistics, Digest of Education Statistics, 1989 (Washington, DC: U.S. Government Printing Office, 1989). percent) and local sources picking up the rest (43.9 percent) (72a). Schools have grown increasingly dependent on local tax bases and other resources (94).6 school is a serious problem in this country. Each year, more than 425,000 students in grades 10 through 12 drop out of school; others leave before reaching high school (202b). As of October 1989, the status dropout rate among 16to 24-year-olds i.e., the percentage of 16to 24-year-olds reporting themselves to be dropouts-was 12.6 percent (204a). This means that about 4 million 16to 24-year-olds in October 1989 were without a high school diploma or certificate and were not attending school. 7 Dropout rates for blacks, Hispanics, and Native AmeriThe proportion of U.S. students who graduate from high school has increased dramatically in the last century. In 1989, the graduation rate (defined as the percentage of 9th graders in 1985 who have been graduated in 1989) was calculated to be 71.2 percent (204b). Despite the improvements, dropping out of s~g~ c~lengti brought in several States (e.g., New Jersey, Ikxas, Montan% and Kentucky) have rwendy res~t~ in court decisio~soW school financing systems because of disparities between spending in poor and wealthy school districts (107a). Similar chaUenges can be expected in the future. 7Some high schml &opou~ ~vent~y em a ~gh sc,hool degree, ei~er by returning to school or by passing the tats of general educational development (GED).
PAGE 66
II-62 Adolescent Health-Volume II: Background and the Effectiveness of Selected Prevention and Treatment Services cans are higher than aggregate rates for the U.S. population (202b) (see figure 4-2). Relationships Between Adolescent Health and School Adaptation In the course of this assessment, OTA found that school environments, academic achievement and failure, and adolescent health are typically viewed as discrete entities. If relationships between academic achievement and failure and adolescent health are considered, it is the impact of health problems on academic achievement that is discussed, not the reverse (e.g., 108a). The role of school environments in promoting or impeding academic achievement has been controversial (32a,103a,178). The role of school environments in promoting adolescent health, whether discretely or through academic achievement, appears to be a recent concern and one not yet fully recognized by many professional educators (27,107b,147). This section reviews research that suggests that, just as adolescent health problems can affect school adaptation, 8 some indicators of school achievement have been found to affect adolescents health, well-being, and ultimately, their long-term economic productivity. After briefly addressing measures of school adaptation, the next section reviews evidence for the impact of aspects of school social environments and policies on school adaptation and on adolescent achievement and health. It is important to note that OTA knows of no single study that has tracked in a systematic way the impacts of school environments on school adaptation and health, and the feedback loops that must occur among these elements (see figure 4-3). It is difficult, of course, to disentangle the effects of the academic achievement and health of students attending a school from other aspects of the school environment. 9 Thus, tentative inferences must be drawn about many of the relationships among school processes and adolescent outcomes. Students adaptation to school can be measured using a variety of indicators. Short-term indicators of school adaptation include school attendance, school grades, participation in extracurricular activiFigure 4-2High School Dropout Rates in the United States, 1989 a b Percentage of dropouts among individuals ages 16 to 24 36 -- ---.-- 33% 24; I 154% 126% 12 4% 12 0 911 Total U S Central White cities 13.8% Black Hispanic c aDropoutrates shown inthisfigure are status dropout rates (the proportion of individuals of a speeified age who are not enrolled in school and have not finished high school at any given point in time) among individuals ages 16 to 24 as of October 1989. %hedata on whiehthisfigure is based are Current Population Survey data from the U.S. Department of Commerce, Bureau of the Census. cHispanics may be of any race. SOURCE: Office of Technology Assessment, 1991, based on U.S. Department of Education, Office of Educational Researeh and improvement, National Centerfor Education Statistics, Dropout Ratesin the United States, NCES 90-659 (Washington, DC: September 1 990). ties, and being retained in grade. Short-term indicators of school adaptation are sometimes predictive of school dropout. One highly predictive short-term indicator is retention in grade (70,1 12). After social class controlled for ability, being retained in grade (and therefore being overage for that grade) is the best predictor of school dropout (68a). As shown in table 4-1, studies have found that dropping out of school and other indicators of poor school adaptation are associated with adolescent health outcomes that include substance abuse, delinquency, and adolescent pregnancy and childbearing 10 (l,14,62,84a,85,137,210). Furthermore, the lack of a high school diploma seriously jeopardizes adolescents future economic and social well-being (216). The consequences are particularly adverse for poor and minority students (14,81a,198). Having a BFor ~ ~ysis of adolescent school loss (i.e., absences) occurring as a result of illness, see ch. 6, Chronic Physical Illnesses: Prevention and Services, in this volume. Wor example, a school in which many students are routinely absent, or hang around school but skip classes, or are violent in school, can have a deleterious impact on teachers and administrators (e.g., they may come to feel powerless and depressed), who in turn have an impact on the more well-behaved students. Environments such as these are commonly observed but have rarely been systematically researched (72a). l~e relationship ~~~n school dropout and adolescent pregnancy and school dropout is complex. For further discussion see ch. 10, Adolescent Pregnancy and Parenting: Prevention and Services, in this volume.
PAGE 67
Chapter 4Schools and Discretionary Time II-63 Figure 4-3Possible Relationships School Adaptation, and 1 Individual academic factors _~ l Abilit y I l Effort School environment s and policies l l l l l l Tracking M;;;m;; competency Standardized tests School transitions Parental involvement MuIticultural cu rr icu Ium Among School Environments, Adolescent Health Individual academi c o u tco mes l Achievement v. failure A l Promotion v. retention in grade 1 l Graduation v. dropout I / t D high school SOURCE: Office of Technology Assessment, 1991. diploma, even with a poor achievement record, significantly improves labor market participation (216), although poor achievement may have other negative consequences (84a,137). High school dropouts are more likely to be unemployed or underemployed than high school graduates and are half as likely to hold white collar jobs as high school graduates are (216). Because they are less likely to be employed or to have jobs with good career prospects, high school dropouts are more likely to be poor and to experience the health and other disadvantages associated with poverty (e.g., substandard living conditions, poor nutrition, diminished access to health care services). Their children are also likely to experience disadvantage. 11 For society as well as dropouts, dropping out of school has high costs. The societal costs include not only lost productivity and increased social welfare costs but more intangible costs associated with poverty and lack of education among certain segments of society. Adolescent health outcomes Delinquency l Pregnancy l Self-esteem According to some observers, high dropout rates and high rates of retention in grade are one indication of the failure of schools to meet their students educational or social growth needs (81a). This failure seems particularly apparent in schools serving largely poor, racial, and ethnic minority adolescents, and adolescents in central cities. Unfortunately, dropout rates are typically reported by population groupings based on race, and not by school or community. Reporting measures of school adaptation in this way makes it difficult to disentangle school environment effects on dropout and retention in grade from the influence of other factors (e.g., family economic need). National data suggest that socioeconomic status and race/ethnicity are related to students school adaptation, as measured in terms of retention in grade and school dropout (see table 4-2). An analysis of data from the High School and Beyond Survey using a composite family socioeconomic status index (including family income, parental education, and other factors) found 1 l~e heal~ and o~er effec~ of growing up poor are complex and not fully understood. SW Ch. 18, Issues in the Delivery of Services to Selected Groups of Adolescents, in Vol. III.
PAGE 68
Table 4-l-Evidence for the Relationship Between School Adaptation and Adolescent Health Study a Indicator of school adaptation Adolescent health Berlin and Sum, 1988 (High School and Beyond survey data) W.T. Grant Foundation, 1988 (national survey data) Young, 1983 Hispanic Policy Development Project, 1989 (review of the literature) Fagan and Pabon, 1988 Garbarino and Asp, 198 Gottfredson, 1988 McPartland, Colderon, and Braddock, 1987 Academy for Educational Development, 1989 Pallas, Natriello, and McDill, 1987 Dropout School dropout. Dropout rates. Dropout status. Dropout and low-achieving graduates. Lack of high school diploma and poor academic achievement. Male dropouts. Other Indicators More years of school. Poor school grades, limited educational attainment, special education placement, being retained in grade, poor attendance. Poor school grades. Lower than average academic performance, school dropout. Participation in extracurricular activities. Associated with adolescent pregnancy and parenting ; high rates of subsequent poverty and unemployment; skill deficits. Situation getting worse for blacks-in 1973, 14 percent of black male dropouts reported no earnings, as compared with 43 percent in 1984. Associated with higher rates of adolescent pregnancy. b High school dropouts are far more likely to be underemployed or unemployed than high school graduates; employed dropouts are half as likely to hold white collar jobs as are high school graduates. Decreased likelihood of enrolling in postsecondary education; increased levels of welfare receipt; higher unemployment rates. Associated with early Childbearing. b Weak social attitudes, more drug problems, and more delinquency among dropouts than among high school graduates. b Male dropouts are far more likely to be involved in criminal behavior than their in-school Peers. c Positively associated with enhanced quality of child care offered to ones own children and with political competence; negatively associated with criminal activity. Associated with juvenile delinquency. c Associated with school property violence. Associated with adolescent pregnancy. b Correlates, particularly for academically marginal students, with academic progress, heightened self-expectations, reduced frequency of delinquency, and increased persistence in schools. aFutl ~tat~m are listed at the end of this chapter. %he relationship between school dropout and adolescent pregnancy is discussed inch. 10, Pregnancy and Parenting: Prevention and Services, in this volume. CFor a d~ssion of adol~nt delinquen~, See ~. 13, lDelinque~y: prevent~n and servkss, h th.~ VOIUnle. SOURCE: Office of Technology Assessment, 1991.
PAGE 69
Table 4-2-National Data on the Relationship of Students Race/Ethnicity and Socioeconomic Status to School Adaptation Study a Adolescent health outcomes Aspira, 1983 (cohort study) Tobier, 1984 (survey of adults) National Assessment of Educational Progress, 1990 (large data set on the reading ability of students) U.S. Department of Education, 1987 (national survey data collected from schools) Neckerman and Wilson, 1987 (U.S. Bureau of the Census data collected retrospectively as self-reports from adults) Rumberger, 1987 (U.S. Department of Education national survey data from 1984) Barrow and Kolstad, 1987 (High School and Beyond survey data) Berla, Henderson, and Kerewsky, 1989 (review of the literature) New York City dropout rates exceed 68 percent for blacks and 80 percent for Hispanics. In 1985,32 percent of New York Citys white adults had fewer than 4 years of high school, as compared with 39 percent of blacks and 57 percent of Latinos. Students in general are better readers in the 1980s than they were in the 1970s, although no discernible changes occurred between 1984 and 1988; blacks and Hispanics made improvements during the period of 1971 to 1988-nearly all 13and 17-year-olds can read basic material; however, the mean reading profile of black and Hispanic 17-year-olds remains only slightly better than white 13-year-olds. In 1986, among 18to 19-year-olds, 13 percent of white males, 11 percent of white females, 15 percent of black males, 15 percent of black females, 29 percent of Hispanic males, and 24 percent of Hispanic females were classified as dropouts. National dropout rate is 27 percent; central city dropout rate is 42 percent; dropout rate in poverty areas in central cities is 54 percent. In poor neighborhoods-+ defined as over 50 percent living below the poverty line-dropout rates vary: in Anaheim, California, for instance, the dropout rate is 75 percent; in poor neighborhoods in Madison, Wisconsin, the dropout rate is 20 percent; in poor neighborhoods in New York City, the dropout rate is 58.5 percent. In 1972, national dropout rate was 22.8 percent; in 1984, dropout rate was 29.1 percent; New York State dropout rate was 25.3 percent in 1972 and 37.8 percent in 1984; New York State estimates that 62 percent of Hispanics drop out, and 53 percent of blacks drop out. The dropout rate among students from the lowest socioeconomic quartile is about 22 percent; the dropout rate among students from the highest socioeconomic quartile is about 7 percent. The relationships between socioeconomic variables and dropout rates often differ substantially between the sexes and among white, black, and Hispanic students. By age 15,25 percent of all students have been held back once or more. By age 11,44 percent of black males, 26 percent of black females, 38 percent of Latino males, and 32 percent of Latino females have repeated one grade. at%ll citations are listed at the end of this chapter. SOURCE: Office of Technology Assessment, 1991.
PAGE 70
II-66 Adolescent HealthVolume II: Background and the Effectiveness of Selected Prevention and Treatment Services that the dropout rate among students from the lowest socioeconomic quartile was about 22 percent, whereas the dropout rate among students from the highest socioeconomic quartile was about 7 percent (l0a). Blacks and especially Hispanics have considerably higher rates of retention in grade and school dropout rates than white non-Hispanic adolescents, especially in urban areas (7,175,198,203). As shown in table 4-2, Berla and colleagues report that by age 11, 44 percent of black males, 26 percent of black females, 38 percent of Latino males, and 32 percent of Latino females have repeated at least one grade (12). As noted above, 13,8 percent of black 16to 24-year-olds, 33 percent of Hispanic 16-to 24-yearolds on average, and 15.4 percent of 16to 24-yearolds living in central cities report not having a high school education (the so-called status dropout rate) (figure 4-2). It is notable that dropout rates in central cities are higher than in the United States as a whole, and dropout rates in cities with a high proportion of minorities are about one and a half times greater than the overall dropout rates (148). Overview of the Effects of Specific Factors on School Environments and on Adolescent Health The next several sections of this chapter examine evidence regarding the effects of the following factors on adolescent health: l l l l l l l l specific academic policies (e.g., use of minimum competency tests, use of other standardized tests, tracking of students by achievement levels), school size, school decisionmaking policies and orientation to punishment, arrangements for school transitions, class size, teacher behaviors, school policies regarding cultural diversity, and parental involvement in schools. As discussed below, school academic policies that emphasize raising achievement levels through means such as standardized testing and school policies that implicitly or explicitly track students by achievement level may have some positive effects on high-achieving students but generally have been found to have detrimental effects on academically marginal, low-income or minority adolescents. Especially for low-income or minority students, school environments that emphasize these practices are likely to affect adolescent health by dimini shing self-esteem, increasing psychological symptoms, and segregating adolescent friendships (89,188). These policies have been found to be associated with low levels of academic achievement and increased rates of retention in grade and school dropout among academically marginal low-income and minority students (84,89,1 10,1 17). School size has often been found to be related to student attendance levels, levels of participation in extracurricular activities, and reported sense of responsibility (74,168). Large school size--e. g., more than 1,000 students-has been associated with adverse adolescent health outcomes, even when location (e.g., urban, rural) and social class or minority composition of the school is controlled for. These include increased rates of a range of behaviors including vandalism, drug selling, theft, and violence (74,137,203) and elevated rates of school expulsions, disciplinary transfers, and school suspensions, which are indicators of delinquency (127,133). Some studies have found larger schools to have higher rates of retention in grade and dropout (127,168). In contrast, some studies have found that school size has no effect on academic achievement (178), a measure of school adaptation that is related to health outcomes (table 4-2). Some school decisionmaking and other processes have been associated with high dropout rates and delinquent behaviors (84, 137,158,178). Adolescents in schools where students, teachers, and parents collaborate in school decisionmaking and other processes tend to have higher rates of attendance, fewer behavioral problems, and higher levels of academic achievement (84,137,178). Some studies have found that students in schools with a punitive orientation are more likely to be violent and express feelings of alienation (178). The timing and nature of transitions to different levels of schooling also have been found to influence adolescent health. In general, school transitions that occur in the 7th and 10th grades seem to cause the most difficulties (18,22, 169). Such transitions seem to have the most detrimental effects on females and may also negatively affect low-income students (1 1,18). During school transitions, some adolescents show diminished levels of self-esteem, school participation, and academic achievement (18,22,169). These effects are influenced by the number of
PAGE 71
Chapter 4Schools and Discretionary Time II-67 teachers adolescents are exposed to and the size of their classes (22,15 1). As discussed further below, the evidence on the effect of class size on student achievement is somewhat ambiguous. It does appear, however, that small classes are beneficial to academically marginal students. Teachers are likely to be influential in mediating the effects of school environments on adolescent health and well-being. Of course, school environments are likely to have a large influence on teachers attitudes and behaviors. For example, a schools orientation towards punishment, its decisionmaking strategies, the schools physical conditions, and work demands have been found to affect teachers (9,40,144). When teacher practices are substantially controlled by administrative decisions, teachers are more likely to have low levels of morale and job satisfaction, and high rates of absenteeism (9,40). In schools that emphasize shared decisionmaking, teachers have better attitudes about their students, higher levels of morale and satisfaction, and are more likely to successfully implement and maintain new practices (24,40,45 ,72,122, 194). Teachers that use cooperative teaching strategies (e.g., team teaching) foster adolescent health through their effects on achievement, cross-racial friendships, and lower levels of delinquency (75,141 ,178). Working conditions and administrative policies that affect teachers behaviors (e.g., absenteeism) and teachers attitudes (e. g., morale, attitudes toward students) and evidence for the effects of teacher behaviors on adolescent health are discussed below. School policies that ignore racial and ethnic differences in their social arrangements and curriculum may have adverse consequences for students social development and academic achievement (72). It could be argued that minorities are forced to choose between their own culture and their academic and professional development when schools sensitivities, and resultant curricula and activities, do not reflect the cultural diversity of their members. In schools that lack a multicultural perspective, minority students are likely to develop negative attitudes about their ethnicity or oppositional cultural forms (e.g., consider being smart to be acting white) (43,102,157a). Schools with bilingual programs have been found to enhance minority students levels of academic achievement (43). Finally, it appears that adolescent students levels of achievement are enhanced by parental expectations of achievement and parental presence in schools (25,35,70,73,195).1 2 Evidence for the Effects of Specific Academic Policies on Adolescent Health Among the school reforms of the 1980s were efforts to raise academic standards by increasing course requirements for graduation and by using standardized testing or minimum competency tests (MCTs), Another approach that some schools have used is separating students by achievement levels also known as academic tracking. Using Standardized Testing and Other Practices To Raise Academic Standards-Since 1980, 45 States and the District of Columbia have changed requirements for e arning high school diplomas, primarily by increasing the course units required to graduate (166). The length of the school day has been changed (or changes have been recommended) in 13 States and the District of Columbia, And in 12 States, the teaching career ladders have been changed. Increases in requirements have been found to place additional responsibilities on teachers and lengthen the school day without additional support. Available evidence suggests that such policies have had some adverse consequences, especially for academically at-risk students. Increased course requirements diminish time for participation in extracurricular activities, participation which particularly for marginal, poor and minority students, enhance academic progress and reduce delinquency. Pallas and colleagues found that an increase in course requirements was associated with increased alienation among marginal students who seem to be most attached to courses outside the core curriculum (164). Unfortunately, Pallas and colleagues noted, teachers in the schools where increased course requirements were required were seldom given the support they needed to reach academically marginal students. Raising standards was therefore an empty gesture, tending to push low-achieving students out of school. 12For f~er discussion of parents influence on adolescents hdth, see ch. 3, Parents and Families Lnfluence on Adolescent Health, in this volume.
PAGE 72
II-68 Adolescent Health-Volume II: Background and the Effectiveness of Selected Prevention and Treatment Services Table 4-4 also suggests that the use of standardized testing and MCTs have adverse consequences for marginal students. One study found that standardized testing is practiced in larger schools where there are more marginal students and tends to result in curricula that conform to the test (138). Several studies have found that, although standardized testing has small positive effects on high-achieving students, students in schools where such testing is used are more likely to be retained in grade (84,138,185). Educators generally agree that promoting adolescents who are not ready to be promoted will not be beneficial to their health unless they receive additional support to learn the skills they lack (71), but many educators have voiced concerns that standardized testing has the capacity to further marginalize disadvantaged students (209,213). Similar, yet more pronounced, are the effects of the recent national shift toward the widespread use of MCTs. In 1989, 24 States used MCTs for remediation, 12 for promotion, and 24 for graduation (91). According to Haney and Madaus, the recent national shift toward the use of MCTs has had profound and devasting consequences for students academic performance (91). The use of MCTs has been linked to increased rates of retention in grade and school dropout in school districts that use MCTs (91). Some evidence suggests that dropout rates may be disproportionately high for at-risk (e.g., black and bilingual) adolescents (91,110). MCTs may also have adverse psychological consequences (e.g., apprehension, diminished self-esteem) for some students. To sum up, school academic policies that emphasize raising achievement levels by increasing courses, using standardized testing, or using MCTs can adversely affect academically marginal students through increasing rates of retention in grade and increasing rates of school dropout. Tracking Students by Achievement LevelsPolicies used to track students by achievement level range from the use of selective criteria for entry into schools which parents can choose for their child, district-wide stratification of public high schools, heterogeneous course offerings, school intake policies, teacher-selected ability groupings, and differential access to school guidance counselors. Such policies may be developed and implemented by local school districts, by individual schools, by teachers within schools, or by guidance counselors. School districts that stratify their public schools and use selective criteria for entry into choice schools foster differential ability groupings across schools. Administrators who build in specialized courses, and who admit a homogeneous intellectual mix of students to schools are tracking within a school, whereas teachers who create student ability groupings are tracking within their classes. Finally, guidance counselors who devote more of their resources to counseling academically tracked students about educational and vocational options reinforce the existing system of tracking. Schools that use student selection criteria typically receive a disproportionate share of district resources (21 1). Furthermore, national data suggest that schools that have a higher concentration of at-risk poor and minority students receive fewer resources for staffing and materials, and such schools have been found to rely more heavily on remedial and rote memory activities (143). Tracking practices that skim the best students off the top and place them in selective schools may not only have adverse consequences for marginalized schools but may also minimize overall achievement records of entire school districts. In a longitudinal analysis of adolescents attending nonselective schools in London, Rutter and colleagues found that the intellectual heterogeneity of students was strongly associated with positive educational outcomes for the entire school (178). Rutter and colleagues concluded that schools need a substantial nucleus of averageto above-average-intellectual-ability students in order to achieve schoolwide. Other researchers, examining schools with good academic records, have found that most such schools restrict or reject tracking, reinforcing Rutters conclusions that heterogeneous ability groupings enhance school achievement outcomes (79). Furthermore, schools where school composition is skewed towards marginal students have been found to have disproportionately high rates of dropout and low rates of achievement (21 1). Tracking that occurs when teachers place students into ability groupings is sometimes rather arbitrary; criteria unrelated to the ability of students have been demonstrated to have effects on the placement of students into ability groupings. According to Hallinan, for example, teachers often create a set number of equally sized groups that assume that student ability is equally distributed in their class-
PAGE 73
Chapter 4Schools and Discretionary Time II-69 room (89). Students who are older when entering an elementary school are more likely to be placed in the highest ability groups, an observation suggesting that advantages resulting from age and previous experience play a role in determining ability groupings (89). Adolescents who are placed in low-ability groups have been found to fall behind academically, and students chosen for high-ability groups have been found to achieve more than their peers of equal ability who are not in high-ability groups (89). Placement in ability groupings also seems to exert an effect on adolescent friendships: students placed in ability groups are less likely to have crossracial and crossachievement friendships than students not placed in ability groups (89,188). Minority students may also come away from tracking with more negative attitudes towards their own ethnic group. For example, Iadicola ex amined the effects of tracking across schools and found that Hispanics, especially females, who attended schools with higher rates of testing and higher numbers of ability groupings were more likely to express negative attitudes toward their ethnicity (102). Ingrained social patterns of racial stratification seem to be reinforced by institutionalized tracking practices which only reinforce white students preferences to bond with similar others. Some studies have found that minority, poor, rural, and vocationally tracked students report that counselors do not play a significant role in their future goals, whereas academically tracked students report that they do (1 18,1 19). This situation may sometimes result from academically tracked students greater initiative in contacting guidance counselors, but it may sometimes result from counselors seeking a greater role in counseling academically tracked students. Evidence suggests that in some situations, guidance counseling is more directed to high-achieving students (1 18,119). To sum up, tracking students by achievement level is inequitable because academically tracked students receive better instruction, easier access to counseling, heightened teacher expectations, better peer evaluations and more interesting curricular content than students in lower achievement groups (155). Since there is evidence that ability groups are sometimes based on arbitrary criteria (e.g., a students entry into selective choice school may reflect the parents ability to negotiate or may be determin ed in part by a students age) and because the students in groups receive different school resources, it can be argued that ability groupings create differences in students academic achievement levels rather than minimize them. Students marginalized by the tracking process achieve less and drop out more than students in matched schools that do not use tracking (155). Available evidence suggests that a heterogeneous mix of intellectual ability is associated with high rates of overall school achievement. Thus, it can be argued that minimizing the intellectual mix of schools (i.e., tracking across schools) or offering specialized courses to high achieving students and remedial courses for low-achieving students (i.e., tracking within schools) may not responsibly serve the majority of adolescents. Policies that place students into homogeneous groupings may have detrimental effects on the majority of adolescents academic achievement levels. Nonetheless, some observers have concluded that tracking persists because of fears about the effects of untracked schools on the best students (37). Evidence for the Effects of School Size on Adolescent Health In considering the differences between the effects of large and small schools on adolescent health, it is important to realize that size of school is confounded with variables that include location (i.e., rural v. urban), financing, and school-related processes. Large schools are typically in urban, often more socially disorganized, settings than small schools with a high density of low-income students. These schools often receive less money or receive money with restrictions on how it can be utilized (25). Large schools are also often associated with more administrative staff, more centralized decisionmaking processes, and fewer opportunities for teachers and students to participate in school policymaking (40,168). Furthermore, large schools have been found to have more rigid and compartmentalized roles, more complexity in their communication patterns, larger class sizes, more institutionalized tracking, and punitive and controlling disciplinary orientations (25,27,75,85,163,203). Finally, the students attending large schools may be different from students attending small schools. For example, more students attending large schools (i.e., minority, lower income, and poorer students) may confront problems with health, housing, language, welfare, and academic difficulties (24).
PAGE 74
11-70. Adolescent Health-Volume II: Background and the Effectiveness of Selected Prevention and Treatment Services ..+Photo credit: April Saul/Education Week Many large urban schools serving socioeconomically disadvantaged students lack the combination of features that promotes adolescents health and well-being, A longitudinal study in England by Rutter and colleagues found no relationship between school size and students academic achievement (178), but numerous other investigators have found correlations between large school and adverse academic and health outcomes, especially for marginal, poor, and minority students (27,74,75,1 18,130,162). Large school size has been correlated with high levels of alienation among students and teachers (24,25), with high delinquency rates, high suspension rates, low attendance rates, and high dropout (27, 133,137,168). Small schools have been found to have lower levels of vandalism, less anomie, and lower levels of victimization (74). Although small schools seem to be beneficial for all students, they appear to be most beneficial for academically marginal low-income and minority students (27,75, 130, 162). School size seems to affect social cohesion, participation in school activities, sense of responsibility, and interactions with faculty (168). Small schools offer greater social cohesion and intimacy and Garbarino found marginal students to be four times more active in small schools than in large ones (74). Large schools tend to have more diverse curricula and more tracking, and such schools may tend to marginalize adolescents with relatively poor academic achievement records (see discussion above). To sum up, small schools seem to be associated with better academic and health outcomes for adolescents than large schools. Furthermore, school size appears to differentially matter most to academically marginal low-income and minority students. Larger schools are associated with negative academic outcomes (i.e., increased rates of retention in grade and school dropout), as well as delinquency (i.e., higher rates of drug selling, theft, vandalism), behavioral problems (i.e., higher rates of expulsions, suspensions, and disciplinary transfers), and lower rates of participation in extracurricular activities and fewer interactions with faculty. It may be that the health outcomes of adolescents attending schools of different sizes are particularly influenced by the impact that size of school has on shaping school-related processes. Possibly school size is only important because it shapes a wide array of school processes. If that is the case, simply changing the size of the school without attending to all of the associated factors (e.g., less funding, increased bureaucracy) would, in all likelihood, be futile. In the next section, the effects of schoolrelated processes that have sometimes been associated with school size are ex amined for their impact on adolescent health. Evidence for the Effects of School Decisionmaking and Other Processes on Adolescent Health There is limited evidence regarding the relationship between school processes and adolescent health outcomes. Rutter and his colleagues were among the first investigators to systematically examine the relationship between processes that occur within schools and student outcome variables (178). They devised a composite school process measure which reflected the degree of emphasis on academic achievement, the extent to which courses were planned and taught by teams of teachers, the availability of incentives and rewards for student
PAGE 75
Chapter 4Schools and Discretionary Time l II-71 performance, and the degree of encouragement that adolescents were given to participate and take responsibility for themselves and for others. In a longitudinal study in England, Rutter and colleagues found that such processes improved adolescents academic achievement and school attendance rates and minimized behavioral problems and delinquency. Some investigators have examined the relationship between the decisionmaking process used by school administrators and school staff and adolescent health. 13 McPartland and colleagues found that schools where students participate in decisionmaking have lower rates of vandalism, and students report enhanced communication (137). Gottfredson and colleagues found that the schools where students, teachers, administrators, and parents have access to the decisionmaking process tend to have reduced rates of delinquency (84). Furthermore, schools that have poor teacher-administration cooperation and where teachers report lack of administrative soundness tend to have higher dropout and delinquency rates and more discipline problems (84). Some investigators have found a relationship between a schools orientation towards punishment and adolescent health. They have found that schools that frequently use punishment and that focus on control tend to have high rates of school victimization and increased rates of disciplinary problems and that students who attend those schools often report feeling alienated (84,178). Optow has argued on theoretical grounds that schools that underreact to school-based violence (e.g., ignore) or overreact to school-based violence (e.g., inflict excessive punishment) make it difficult for adolescents to develop trusting relationships with adults from whom they can learn to control their aggressive impulses (158). To sum up, available evidence suggests that some school processes-+. g., relying on team teaching efforts, encouraging students to participate in deci sionmaking and relying more on rewards and positive incentives for student performance than on punishment--improve students academic achievement, school attendance rates, and are associated with reduced rates of delinquency, dropout, school victimization, and reported alienation among Stu dents. Evidence for the Effects of on Adolescent Health School transitions are mentary school to either School Transitions changes from an elejunior high or middle school and changes from junior or middle school to high school. Figure 4-1 illustrates the common ways that school transitions have been organized in the United States, The most common school configuration is kindergarten through 6th grade (elementary school), 7th through 9th grade (junior high school), and 10th through 12th grade (high school) (204). Another common configuration is kindergarten through 8th grade, followed by 9th through 12th grade. Yet another common configuration is kindergarten through 4th grade, 5th through 8th grade (middle school), and 9th through 12th grade. Whether looking at evidence of retention in grade, suspensions, schoolwide victimizations, or academic achievement, several studies suggest that seventh grade is often a difficult year, especially when it corresponds to the frost year out of elementary school. In a 1988 analysis of Philadelphias grade reorganization, Pugh compared seventh and eighth graders in junior high schools (schools configured grades 7 through 9) with seventh and eighth graders in middle schools (schools configured grades 5 through 8 or grades 6 through 8) (169). The seventh and eighth graders in junior high schoolsi.e., students who underwent school transitions in the seventh grade-had substantially more suspensions (35 v. 23 percent) and retentions in grade (15 v, 8 percent), had lower rates of attendance, and on achievement tests adjusted for socioeconomic status scored 12.9 points lower than the seventh and eighth graders in middle schools did. The Pugh analysis is consistent with other analyses (72a). Blyth and colleagues conducted a 5-year longitudinal study of 594 white adolescents from the 6th through 10th grades (1974-79) in 18 schools in Milwaukee (18). Some of the students attended schools configured kindergarten through grade 6, grades 7 through 9, and grades 10 through 12 and others attended schools configured kindergarten through grade 8 and grades 9 through 12 (18). Blyth and colleagues interviewed the students in grades 6, 7, 9, and 10. They looked at the students global self-esteem, grades, achievement tests, and particiIWhe effects of school d~isiowtig policies on teachers attitudes and behaviors are examined in a separate seCtiOn of tis chapter ~low.
PAGE 76
II-72 l Adolescent HealthVolume II: Background and the Effectiveness of Selected Prevention and Treatment Services pation in extracurricular activities. Blyth and colleagues found that seventh grade female students in schools where transitions occurred in the seventh grade were more likely than female students in schools configured kindergarten through grade 8 to have drops in grade point average, self-esteem, and rates of participation in extracurricular activities. Seventh grade male students in schools where transitions occurred in the seventh grade similarly had lower grade averages than seventh grade male students in schools configured kindergarten through grade 8. Male self-esteem was not affected by school transitions. Adolescent males rates of participation in extracurricular activity decreased in the seventh grade when they changed schools, but their rates of participation ultimately returned to the base level; the rates for females never returned to their base level. Becker found that students from the lowest income groups scored higher on achievement tests in elementary schools than adolescents from the same background in middle schools, suggesting that low-income groups fare better with elementary school structures than with middle school structures (11). In an attempt to understand why school transitions cause difficulties for adolescents, some investigators have examin ed how different school arrangements mediate the effects of school transitions on adolescent health. Braddock and other investigators have found that schools where adolescents change classrooms for different content areas are associated with the majority of problems at transition (11,18,22). Braddock and colleagues found that seventh grade students appear to be most academically productive in schools where they interact with two or three different teachers rather than with six or seven (22). Reviewing the evidence and building on developmental theories of adolescents, Eccles and Midgley found that structures and practices in middle or junior high schools are not suited to the developmental needs of early adolescents (57a). They argue that size differences, tracking practices, competitive motivational strategies, controlling teacher behaviors, using a lecture format and the absence of opportunities for students to practice autonomous behaviors all conflict with adolescent development. These investigators also found that transition effects (e.g., student attitudes about school) are mediated by changes in the school and classroom environment such that negative attitudes were associated with schools that were not developmentally appropriate. To sum up, available research on school transitions is limited, but some evidence suggests that school transitions are associated with increased rates of suspension, retention in grade, and decreased levels of achievement, attendance, self-esteem, and participation in extracurricular activities. Female students seem to be particularly adversely affected by transitions that occur in the seventh grade. The research that has been conducted to date suggests that there may be better and worse developmental moments for shifting from one school to another; the experience of transition may in and of itself be traumatizing; and some school transitions may conflict with adolescents developmental needs (72a). In addition, some research has shown that adverse effects can be ameliorated by specific changes in school environments such as prolonged contact with a single teacher rather than multiple classes and teachers (27). Evidence for the Effects of Class Size on Adolescent Health The evidence on the relationship between class size and adolescent health is somewhat difficult to interpret. In 1986, Robinson and Wittebols compiled a comprehensive review of the literature on class size and achievement for the Educational Research Service (174). Their review of 22 studies published from 1950 to 1985 found that 50 percent of kindergarten through grade 3 studies, 38 percent of the grade 4 through grade 8 studies, and 18 percent of the grade 9 through 12 studies indicate that small classes have a positive effect on student achievement. Robinson and Wittebols concluded that available research fails to show that small classes have a positive effect on high school students achievement levels generally. According to Fine, a class size of 15 to 20 seems to be substantially more productive when dealing with low-achieving students than a class size of 35 (72a). In high schools in which students are educationally disadvantaged, classes of 35 reinforce what Goodlad and others have written about-passive downtime will constitute upwards of 85 percent of most secondary classroom instructional practices (83). McNeil argues that such teaching is a structurally created characteristic of large schools and oversized classes (82).
PAGE 77
Chapter 4Schools and Discretionary Time l II-73 To sum up, it appears that class size may have differential impacts on students in different grade levels. At the high school level, class size may have more impact on academically marginal students than on average students. Improved classroom size may be a necessary but not sufficient condition for improved academic achievement of academically marginal students (72a). Evidence for the Effects of School Environments on Teachers Attitudes and Behaviors Studies examin ing the relationship between school environments and teachers attitudes and behaviors are summarized in table 4-3. These studies relate contextual factors (e.g., working conditions, location, size) and teacher involvement in decisionmaking practices with teachers attitudes and behaviors. Corcoran and colleagues, analyzing national school and teacher survey data, report that many U.S. educators-specially urban secondary school teachers-experience poor working conditions (40). According to Corcoran and colleagues, poor working conditions reported by educators include substandard facilities, a lack of space, inadequate classroom materials, large classes, a lack of influence in decisions, and concerns about safety. These conditions are associated with high absenteeism, low effectiveness, low morale, and low job satisfaction. Moos found that teachers on whom work demands are high tend to rely more on rote teaching methods (143). Various school reforms have been investigated by researchers as sources of influence on teacher behaviors (see table 4-3). One wave of reforms has emphasized standards and monitoring teacher behaviors in public schools. Bachrach and colleagues have characterized schools that operate under these reforms as schools organized around controlling teachers activities, centralized decisionmaking, and rendering the curriculum teacherproof (9). A more recent series of reforms, often called restructuring, has emphasized bringing teachers into policy and decisionmaking processes. National survey data indicate that teachers in urban and other schools where incentives and school policies are determined largely by school administrators report being more suspicious, feeling more contempt, having higher rates of absenteeism, expePhoto credit: Sharon Knarvik Teachers morale, sense of commitment, and other attitudes and behaviors that can be expected to improve the school environment for adolescents are enhanced by school reforms emphasizing collaborative and inoperative relations within schools. riencing lowered morale and feelings of powerlessness, and being distrustful of administrators (9). The majority of these teachers also experienced problems with inadequate instructional time, receiving minimal feedback from administrators, and the extensive use of standardized tests (9,40). Furthermore, teachers in schools where decisionmaking is centralized express a desire to be given a greater voice in decisionmaking and to have more communication with administrators (9). School reforms emphasizing collaborative and cooperative relations within schools have been found to increase teacher satisfaction, successful implementation and maintenance of new practices, morale, sense of ownership and commitment, while they tended to decrease rates of absenteeism (9,24, 40,194). Furthermore, educators who reported having a substantial say in shaping policy also report more positive views of adolescents and more optimism that they can make a difference in the adolescents academic accomplishments (72a). To sum up, there is clear evidence that teachers are negatively affected by poor working conditions and administrative policies that centralize decisionmaking and use narrow authority structures. Teachers attitudes and behaviors that can be expected to improve the school environment for adolescents are enhanced by a collective and cooperative school environment.
PAGE 78
Table 4-3-Evidence for the Relationship of Various School Environments to Teachers Attitudes and Behaviors Study a School environment Adolescent health Poor working environment Corcoran, White, and Walker, 1988 Urban schools where teachers expressed concerns (national school and teacher survey about substandard physical renditions, lack of data) space, resources, safety, and classroom size. Schools in which teachers are required to use standardized testing. M OOS 1985 Schools where very high work demands are placed on teachers. Bachrach, Bauer, and Shedd, 1986 (national survey of teachers) Pallas, Natriello, and McDill, 1989 Bryk, Lee, and Smith, 1990 Bachrach, Bauer, and Shedd, 1986 Fine, 1984 Bryk and Driscoll, 1988 Centralized decisionmaking with little Input from teachers Schools in which policies and incentives are made by administrators. Schools are currently organized around controlling teachers activities, centralized decision making and rendering curriculum teacher-proof. Majority of teachers experience problems with instructional time, problems receiving feedback from administrators. School social climate perceived as positive. Positive school climate. Increased administrative control and narrowing of authority of teachers. Centralized decisionmaking in schools. Schools in which teachers classroom policies are controlled. Teachers perception of influence in shaping policy. Collaborative environment with teachers involved in decisionmaking Schools that have collaborative relationships between teachers and administrators and schools that focus on cooperative processes. Poor working renditions related to absenteeism, low effectiveness, low morale, and low job satisfaction for teacher--especially for urban secondary school teachers. Teachers report that standardized tests are a threat to their professionalism. Teachers in such schools tend to rely more on rote learning teaching methods. Teachers who report having minimal input to decisions concerning their working conditions and incentives had higher rates of absenteeism and lower morale. Teachers are alienated, tired, and feel powerless. Teachers perceptions of mean ability of students in their classroom were positively related to perceived school social climate (regardless of the actual ability levels of their students). Positive school climate is positively related to the extent to which there seems to be a shared sense of purpose among teachers-goal consensus. Teachers expressed that they did not feel apart of the school community and that people did not listen to their ideas (alienation). Teachers report being more suspicious, feeling more contempt, having deteriorated morale, and being distrustful of administrators; teachers indicate that they should be given a greater voice in decisionmaking; teachers reported dissatisfaction with communications with administrators. Teachers have higher rates of absenteeism and lower reported morale. Educators who saw themselves as powerless tend to view adolescents they work with as beyond help; educators who report having substantial say in shaping policy also report more positive views of adolescence and more optimism about making a difference. Teachers report increased satisfaction; decreased rates of absenteeism.
PAGE 79
Table 4-3-Evidence for the Relationship of Various School Environments to Teachers Attitudes and Behaviors-Continued Study a School environment Adolescent health Stevenson, 1987 Collective and cooperative school climate. Teachers report enhanced sense of ownership, more successful implementation of new practices. Lifton, 1988; Dade County Public School, Schools restructured to give teachers more input Preliminary evidence that teacher morale, commitment, willingness to 1988 (preliminary evidence from into decision making. continue teaching are enhanced. teacher surveys in restructured school district) Corcoran, White, and Walker, 1988 Small schools, with high levels of teacher influence Teachers in such schools expressed more positive attitudes towards (national school and teacher survey and with staff cohesion. students. data) aFUll citations are listed at the end of this chapter. SOURCE: Office of Technology Assessment, 1991. l
PAGE 80
II-76 Adolescent Health-Volume II Background and the Effectiveness of Selected Prevention and Treatment Services Evidence for the Effects of Teacher Behaviors on Adolescent Health Limited evidence suggests that the behaviors of teachers and students are interconnected. Educators using team teaching (where teachers share responsibility for a group of students either within or across schools) affect adolescent health in a positive way. Furthermore, teachers in schools with centralized decisionmaking, where there is little coordination between the efforts of teachers and school administrations, are more likely to use authority and coercion as part of their instructional style, which also affects adolescent health. Studies have found that adolescents who have teachers that use team teaching have increased levels of academic achievement and are more likely to develop interracial friendships (24,124,141). Team teaching approaches also have been associated with decreases in student dropout, delinquency, and suspension (75,178). Further, the use of coercive techniques by teachers has been associated with lowered self-esteem among students and increased frequency of classroom disruption (137). Students who report that they are treated disrespectfully by their teachers report higher rates of feelings of alienation and school victimization (85). Furthermore, in schools where coordination between teachers and principals is poor, adolescents are more likely to have high discipline and criminal problems (133). Evidence for the Effects of School Policies Regarding Cultural Diversity on Adolescent Health It has been argued that social education in which students come to learn about and respect critically and creatively their own ethnic and racial heritage is important so that adolescents can generate strategies for managing difference as difference, not as deficits (73). It also has been argued that schools as they are currently organized do not educate students about ethnic diversity and students are, therefore, more likely to form stereotypes and have their racial and other biases reinforced (69,73). There is currently considerable debateand limited evidenceabout how to celebrate, rather than disparage, cultural diversity (58a). Research that has examined the effects of schools on racial and ethnic minority adolescents health outcomes 14 suggests that there are insidious school processes that differentially affect minorities. For example, when schools ignore ethnic differences in their social arrangements and in their curriculum, there are consequences for minority adolescents related to academic achievement and the degree of attachment to their own ethnic group. Iadicola compared schools that differed with respect to the degree of Hispanic cultural influence on the curricula and the percentages of non-Hispanic white and Hispanic students. Iadicola found that Hispanic students in schools with a high degree of nonHispanic white cultural influence were more likely to express lower levels of attachment to their own group (102). It could be argued that schools in low-income communities that do not embrace cultural differences are structured so that Hispanic students are forced to make a choice between self and family and between personal development and community involvement (102). Obgu has argued that racial stratification and classroom materials that reflect the perspective of whites with little or no acknowledgement of minorities results in black adolescents behaving in ways that undermine their academic success (157a). Some studies suggests that multicultural education and school-based collaborations with minorities in the community can improve minority adolescents academic achievement (43,102). In interviews with students and educators, Fine found that students in integrated schools valued differences between diverse groups as strengths, not defects (70). In contrast, students in a fully segregated school learned stereotypes and had their racial biases reinforced (70). However, there is still considerable confusion among teachers and others about defining and implementing multicultural education (58a). According to one informed observer, the support that multicultural education needs will come only from comprehensive policymaking and from teachers who see differences among students as reasons for celebration rather than for handwringing (58a). ld~e delivq of he~th ~d relatti services to racial and ethnic minority adolescents is discus~ in Ch. lg. Issues in the Delivery of Services to Selected Groups of Adolescents, in Vol. III.
PAGE 81
Chapter 4Schools and Discretionary Time II-77 Table 4+ Evidence for the Relationship of Parental Involvement in Schools to the School Environment and Adolescent Health Study a Form of parental involvement School environment Adolescent health Svec, 1986 (experimental study) Bryk, Lee, and Smith, 1990 (review) Fine, 1989; Fine and Phillips, 1990 (interviews with educators and with Iow-income parents of middle-school students) Comer, 1988 (intervention among 3rd, 4th, and 5th graders in schools in low-income districts in New Haven, Connecticut, and Maryland) In experimental study, randomly assigned high school drop outs went to school with or without parents to negotiate reentry to school. Parents expect achievement and place importance on educational attainment. Parents volunteer in schools. Parent involved in professional councils at school sites. Decentralization (community amtrol) in New York City. Parents presence at schools. As part of a comprehensive school intervention program, parents work closely with school administrators, teachers, a mental health specialist, and a nonprofessional support person to meet the emotional, social, psychological, and academic needs of their children. Some parents work as classroom assistants, tutors, or aides; some join the schools governing body. Principals are more sensitive to community interests, schools have more legitimacy in the community, culturally relevant curriculum is developed. Especially with Iow-income students, parents presence serves as a reminder to teachers that they need to be concerned about the impact of school on their students. Relations between parents and school staff improve. School administrators, staff, and parents collaboration results in increased organizational effectiveness. More schools refused the dropouts who did not have their parents with them. Parental expectations are highly and consistently related to academic outcomes. Parental volunteering is associated with positive outcomes, especially for elementary school students. Intervention had no significant influences on student academic achievement. Intervention had ambiguous impact on student achievement. Students whose parents question school policies are more likely to receive fair treatment. Preliminary evidence suggests intervention improved reading, language, and math scores. Behavior problems declined. aFull citations are listed at the end of this chapter. SOURCE: Office of Technology Assessment, 1991. Evidence for the Effects of Parental Involvement in Schools on Adolescent Health Research on parental involvement has been limited until recently to national surveys that focus on traditional forms of involvement by parents. Investigators have examin ed the effects of parental expectations, parental volunteering, and parental presence in schools and have generally found-especially when research findings are related to local school districts-that parental involvement is beneficial to adolescents (see table 4-4). Probably the most thoroughly documented effect that parents have on adolescent health is related to their expectations that their children will achieve. A review by Bryk and colleagues noted that studies consistently find that parents who expect their children to achieve and who place importance on educational att ainment affect their levels of academic achievement (25). Although not as well documented, evidence suggests that adolescents are also positively affected by the presence of their parents at schoolwhether at school to volunteer, to serve as advocates for their children, or simply to be present (25,70,73,195). The importance of parental
PAGE 82
II-78 Adolescent Health-Volume II: Background and the Effectiveness of Selected Prevention and Treatment Services involvement is recognized in Comers comprehensive school interventions, first implemented in New Haven, Connecticut, elementary schools, and now being implemented in more than 50 schools around the country, including 2 middle schools and a high school (35) (see box 4-A). In a recent review, Bryk and colleagues noted that parental involvement on professional councils at school sites in Salt Lake City had no significant influence on student academic achievement (25). These investigators also described a study of community control in New York City. This evaluation found that parental choice had an ambiguous effect on student achievement (25). Summary: School Influences on Adolescent Health Although it is limited, of variable methodological quality, and difficult to conduct, available research strongly suggests the importance of school environments on academic achievement and on adolescents health. Studies in the last 20 years provide contrast to earlier studies that led many to believe that schools make little difference (32a, 103a). These earlier studies have been criticized because they focused mainly on a limited measure of attainment and examin ed a very narrow range of school variables (175a). According to Rutters studies in England, and a host of studies in the United States reviewed in this chapter, social variables account for much of the variation between schools, and hence some of the variation in adolescent health (175a). Generally, school policies found to have adverse effects on the minority, low-income, academically marginal students include MCTs without the addition of academic supports, academic tracking, large school size, punitive orientation, little support during transitions between levels of schooling, and lack of cultural diversity and appreciation of racial and ethnic differences. School policies generally found to have positive effects on adolescent health include participatory decisionmaking, parental involvement in schools, and a combination of other process variables (178). Effects of the school environment on adolescent health are often mediated through teachers attitudes and behaviors and through adolescents academic achievement, most prominently retention in grade and school dropout. The most compelling evidence suggests that improving schools to benefit adolescents requires a combination of approaches. This combination can be summarized as a school that is a small, comfortable, safe, intellectually engaging, and emotionally intimate community (72a). Transitions are minimized, and when they must occur, they are managed with a view toward meeting the developmentally appropriate needs of adolescents. Teachers are encouraged to initiate and develop new programs that are sensitive to the diversity of their students. The curriculum responds to individuality as well as to differences, while developing a common knowledge base among students in a particular school. Teacher, parent, and student participation in decisionmaking is encouraged. Unfortunately, this combination of features characterizes few schools, particularly those public schools serving socioeconomically and educationally disadvantaged students, many of whom are racial and ethnic minorities. Box 4-A reviews selected promising interventions that attempt, at least in part, to address the shortcomings of many contemporary American schools. Major Federal Policies and Programs Related to Education As discussed elsewhere in this Report, Federal programs related to education are primarily the responsibility of the U.S. Department of Education. ls The U.S. Department of Labor also has some responsibilities in this area. U.S. Department of Education In 1989, the U.S. Department of Education had a budget of approximately $22 billion and was responsible for 187 programs sp anning six different offices (see figure 4-4). The U.S. Department of Education does not administer educational programs targeted specifically to adolescents but includes adolescents as part of the school-aged population. It is impossible to determine total expenditures on adolescents, because U.S. Department of Education funds are distributed to State and local educational agencies that determin e their own priorities. The U.S. Department of Educations priorities include increasing educational services to econom15s= ch. 19, me Role of F~eral Agencies in Adolescent Heal@ k VO1. HI.
PAGE 83
Chapter 4Schools and Discretionary Time II-79 Box 4-AInnovative Approaches to Improving American Schools l In recent years, promising interventions in schools have been tested and found to demonstrate beneficial effects on adolescent health through their effects on adolescents levels of academic achievement, school persistence, attitudes toward school, self-esteem, and confidence. These interventions, discussed further below, are generally of two major types: l interventions that are focused on improving individual learning and preventing selected heal t associated with school failure (e.g., adolescent pregnancy and parenting); and interventions that are focused on changing school and/or community environments. Interventions focused on individual learning and preventing selected health problems associated with school failure include peer tutoring interventions; cooperative learning interventions; summer learning interventions; and interventions that provide incentives and supports to students to graduate and go on to college. Interventions focused on improving school environments include the School Development Program developed by Yale child psychiatrist James Comer and also include some school-linked health centers (SLHCs). Examples of these two major types of interventions that have undergone some evaluation and seem to show some promise are discussed below. Also discussed below is the comprehensive school/community health model, which is drawing considerable attention from researchers and policymakers who are concerned about the health of U.S. adolescents (27,107b,108b,147), Promising Interventions Focused on Improving Individual Learning and Preventing Selected Health Problems Associated With School Failure As noted above, interventions that focus on improving the skills of low-achieving students through means that do not involve academic tracking include peer tutoring interventions, cooperative learning interventions, summer learning interventions, and, most recently, interventions that provide incentives and supports to students to graduate and goon to college. Several interventions that offer a more intensive focus on individual students than can typically be found in the large public schools that are attended by many minority, poor, and academically at-risk adolescents are discussed below. All of the interventions discussed below have undergone at least some preliminary evaluation in terms of outcomes for adolescents and appear to hold some promise for enhancing adolescents adaptation to school. Peer tutoring interventions-Peer tutoring means using older or same age students to work individually with students to teach a particular content area. Peer tutoring strategies emerged from concerns about how educators can deal creatively with 35 students or more, engage students in appreciating rather than depreciating peer differences, and promote active participatory learning among students. Generally, peer tutoring appears to be an effective approach for adolescents. Some studies have found peer tutoring to be less costly than computer-assisted instruction, to enhance levels of academic achievement beyond those found in conventional classes, and to be beneficial for tutors and tutees (31,97,121). Cooperative learning interventions-Teachers using cooperative learning strategies create groups where each student has exclusive knowledge of a topic and where the students need to work together as a group to create a final product. This strategy often stimulates interdependency among students. Cooperative learning appears to satisfy many educational ends simultaneously (104,206). Cooperative learning enables heterogeneous groups of students to work across ability levels, thus reducing the need to track students. It encourages students to participate actively as teachers and as learners with their peers. It facilitates empathy across and within racial, ethnic, and ability groups, and it shifts the questions of absolute authority away from teachers. In elementary schools, cooperative learning strategies tend to enhance students academic achievement, teaching instruction, and students sense of empathy (6,152). Investigators have sought to document the effects of cooperative learning on achievement in secondary schools. One analysis of 27 selected studies involving 37 comparisons of cooperative v. control learning strategies concluded that over two-thirds of the studies favored cooperation (207). Math and language arts seem to be the curricular areas most amenable to positive effects of cooperative learning. Summer learning interventions--Particularly for socioeconomically disadvantaged students, summers are typically a time of enormous educational regress. Heyns argues that schools that provide educational interventions IEvi&~ce on preschool interventions W nOt be Men uP in this c~Pter. Continued on next page
PAGE 84
11-80. Adolescent Health-Volume II: Background and the Effectiveness of Selected Prevention and Treatment Services Box 4-AInnovative Approaches to Improving American Schools l -Continued during the summer to low-income and academically disadvantaged students can and do reduce disparities in the academic skills associated with the background characteristics of children and adolescents (99). The Summer Training and Education Program (STEP) is an intervention designed to help reduce dropout levels among poor and educationally deficient youth by focusing on two factors that are closely associated with dropping out of school: poor academic performance and adolescent parenthood (184a). STEP targets low-income 14and 15-year-olds who are performing below grade level in either reading or math and offers them two consecutive summers of remediation, life skills instruction and work experience, and various support services (e.g., counselor advocates and group meetings) during the intervening school year. The goal of STEP is to reduce participants summer learnin g losses, increase their reading and math skills, increase their graduation rates, and decrease their pregnancy and parenting rates. A national evaluation of STEP managed by the Philadelphia nonprofit corporation Public/Private Ventures is comparing STEP participants outcomes to outcomes for a control group of students in the federally funded Summer Youth Employment and Training Program (who received remedial education and a summer job but no other support services) (184a). Preliminary results from the evaluation indicate that STEP minimized participants academic losses over the summer. 2 Furthermore, STEP increased participants reading and math scores and increased their knowledge of contraception (184a). Preliminary findings regarding STEPs impact on dropout rates among participants are consistent with the hypothesis that STEP reduces dropout behavior but are based on small numbers and are not statistically significant. Firm conclusions about STEPs long-term effects on participants will have to await the completion of the research in 1993. Interventions to provide incentives and support for adolescents to graduate and go on to collegeEugene Langs celebrated I Have a Dream (IHAD) Project is perhaps the best known of these types of interventions. The IHAD project began when Lang promised to pay college tuition fees for a class of sixth-graders then preparing to graduate from his elementary school alma mater (99a). Lang realized quite quickly, however, that while a tuition guarantee was essential, if IHAD students were to graduate, they would need considerable additional social and academic support. The basic features of all IHAD projects have come to include a sponsor, 3 a tuition guarantee, a project coordinator, 4 and additional support services [for students (e.g., tutoring, cultural enrichment)] (99a). IHAD student participants are known as Dreamers (99a). The publicity surrounding Langs project helped it become the formal prototype for many similar programs--140 by summer 1990, at a total cost in private funds of $50 million, according to a 1991 report by Public/Private Ventures (99a). Evaluating the effectiveness of IHAD projects is difficult, however, both because IHAD sponsors have been reluctant to allow formal research (99a,207a) and because individual IHAD and similar projects (207a) vary considerably within the basic framework Public/Private Ventures obtained permission from the Greater Washington IHAD Foundation to evaluate its IHAD Projects, most of which were begun in the 1988-89 school year. 5 It is too early to tell whether the Greater Washington area projects will be effective in achieving their ultimate objective of high school graduation and 2S= Ch. 10, ~qwm arid Pmaing: Prevention and services, in this volume for further discussion of the national evaluation of STEP, 3sponsors ~ b indiviws WhO guarautee the college tuition and provide financial support for other aspects Of ~ prO@tS. Conk@ between sponsors and IXwunms are tiequent, but according to Public/Private Ventures evaluation they am valued by both groups (99a). Personal conwt seemed to be centml to the meaning sponsors derived tim KIWl support, as opposed to more anonymous forma of charity (99a). Comments by Dreamers suggested that some Dreamers develop commi tmcnt to IHADs [achievement] goals as a way to reciprocate sponsors geamrosity (99a). 4-* @ ~b~~v~ v~~s, h) II?httiotip with tie P@=t ~ is a Dreamers crucial link to the IHAD program: Project c oorbatm qresent a continuous stable source of support for these youth. Unlike teac~ project monlinators provide a havea in the midst of a school environment that can be indifferent or competitive.. .Pmject coordinate advocate for Dmamera within a school and leverage t@Wkmal maourcc& such as tutoring, tX@S or concrete assistance during emcxgmcies. Tky ean and do drive youth to SISWO1, thus improving att~ and bring in parents for teacher consultations, thus kmasing !mmntal involvement (9%). M@q ~ form strong emo?iond mdmEnts to project coordinators. However, contacts with project Coordmatom are voluntary d vary among Studaltls and project CodmWrs. Project Coordinator are not formally -iated with the Studlmts ScMols. 5= ~Wva& v~ evaluation is Iknded by a private foundation (99a). Tkious supportem back the 8 classes now overseen by the Greater w aabmgbn IHAD Fmmtadon. An initial sponsor formed the cheater wUllh@On IIMD Foundation and convcaed a class in 1987. sponsors as of s1990 irwluded individual benefactors (three *); pairs of bu8ir&ss executives (three classes); a group of professional athletes and abusincas executive (one claas); and two churches (one class) (99a).
PAGE 85
Chapter 4Schools and Discretionary Time II-81 college entry (99a). 6 However, Public/Private Ventures preliminary 1-year review of three of the Washington areas IHAD projects, based on interviews with 14 of the Dreamers and project coordinators, found that IHAD was a promising intervention (99a). In its l-year review, Public/Private Ventures found that: l the IHAD intervention had targeted and reached very disadvantaged youth; the timing of the IHAD intervention (at the end of fifth or sixth grade-the beg inning of junior high or middle school entry) was developmentally propitious; l the IHAD model seemed to have a positive effect on Dreamers attitudes towards education, and the IHAD intervention provides adult relationships (i.e., sponsors, project coordinators, mentors 7 ) that are meaningful to youth (99a). On the other hand, Public/Private Ventures expressed concern that support services, especially tutoring, are necessary program components, but are provided unevenly (99a). It also noted that enrichment activities (e.g., a summer program for Dreamers) and incentive awards are inconsistently delivered within each school and among schools. Project coordinators were found to be overburdened and in need of help in gaining access to social services for their students (99a). Public/Private Ventures found that the inconsistency of the services is probably inevitable within the present Foundation structure and that the quality of Foundation-wide activities, such as the summer school, is worrisome (99a). The evaluators recommended additional oversight by the Greater Washington IHAD Foundations board of directors to improve these aspects of the program. IHAD raises an interesting public policy dilemma (99a). According to Public/Private Ventures, the benefits of IHAD may derive from IHADs private sponsorship: IHADs unique contribution may be exclusive to the private sector: an association with a wealthy and even famous benefactor. This benefit can have immense repercussions for a youth from a poverty background: a sudden change of luck, intermittent reminders of a special status, and a long-term commitment by a distant and powerful advocate. Publicly funded interventions can probably never deliver this sense of a special connection, or elicit the high expectations that youth-and some school officials-attribute to sponsors (99a). Nonetheless, it may be that many of the elements of IHAD--the project coordinator who provides a haven for adolescents in a competitive and often hostile school environment, tutoring, the link to intensive social and academic support services, guaranteed college tuition--an be reproducd in school and community settings using public funds. Promising Interventions Focused Largely on Changing School and Community Environments While some interventions focus on improving the school adaptation of selected individuals, other interventions focus largely on changing school and sometimes community environments, although they may build in individually focused attention (e.g., 35). The primary purpose of interventions focused on changing these environments is to make schools (and, sometimes, communities) more health-promoting environments for adolescents. One of the most frequently cited of these approaches to improving school environments is Comers School Development Program (35). In addition, proponents of SLHCs often view SLHCs as a means of integrating a health perspective into a school, as well as a way to deliver health and other nonacademic services to individual adolescents (141a). 8 These approaches come under the general rubric of comprehensive school health (107b,108a), establishing the school as a health-promoting environment (27), or school/community linkages to promote adolescent health (147). Comers School Development Program A longitudinal study of an intervention developed by Yale University child psychiatrist James Comer provides strong evidence that creating a collaborative dynamic between educators and parents, as opposed to the traditional social service bureaucratic relationship, markedly advances both 6A news ~icIe rep~~ mixed results for the initial Eugene Lang class in New York City (152b). 7Mentors Wme provided by 11-IAD at only one of the schools. IKI thiS school, apprOXbt@ 30 emPloYf$es of the spo~ors comP~Y adopted two Dreamers each: They phone the Dreamers, wrote them letters and attended company-sponsored trips and dinners with them. .Addit.iorud contacts could be initiated if either the mentor or the youth desired [and they often were] (99a). Public/Private Ventures evaluation notes that mentors were sometimes frustrated by the differences in values between the mentors and the Dreamers, and that one mentor recommended @aining for mentom and matching youth with mentors from similar backgrounds (99a). Interventions using mentors to prevent specific adolescent health problems are discussed in other chapters in this volume; there are no evaluations of such interventions available. s~e role of sLHcs in health services delivery are discussed further in VO1. I of this Repo~ SWWM r-y and Policy Options, and inch. 15, Major Issues in the Delivery of Primary and Comprehensive Health Services to Adolescents, in Vol. III. Continued on next page
PAGE 86
II-82 Adolescent Health-Volume II: Background and the Effectiveness of Selected Prevention and Treatment Services Box 4-AInnovative Approaches to Improving American Schools l -Continued organizational responsiveness to students personal needs and students academic work (35). Unlike some current educational reforms which focus on instruction and curriculum, the Comer intervention is based on the understanding that many kinds of development, in social, psychological, emotional, moral, linguistic, and cognitive areas, are critical to future academic learning (35). The Comer intervention, also known as the School Development program, seeks to overcome what Comer terms a basic problem underlying the schools dismal academic and disciplinary record: the sociocultural misalignment between home and school (35). For many black and Hispanic children whose parents have had a traumatic social history, Comer suggests, education must do more than teach the basics (127a). It must also address students emotional, social, and psychological needs (127a). The School Development Program has three goals: 1) to induce parents to participate in the schools life; 2) to force school administrators, teachers, and other staff to share authority in managing the school; and 3) to bring guidance counselors, mental health professionals, and teachers into a team that meets regularly to combat behavior problems (127a). A school governance and management team, consisting of parents and teachers, the principal, a mental health specialist, develops a comprehensive school plan covering academics, social activities (e.g., potluck suppers to teach children social skills and enable parents to meet teachers), and special programs. A mental health team assigns a member to work with a child who is having difficulty and tries to identify whether some school process is contributing to the behavior. Parents are also encouraged to become classroom assistants, tutors, or aides. The Comer process has already been adopted by more than 100 schools in nine districts in eight States (127a). In the schools where Comers programs are being implemented, the evaluation data for at-risk students are very encouraging. In the two New Haven elementary schools where the program was implemented, behavioral problems in the schools declined and math and reading scores climbed. Similar results were achieved, from 1985 to 1987, in 10 predominantly black schools involved in the Comer program in Prince Georges County, Maryland (35). A more rigorous evaluation of the Comer intervention in Prince Georges County is being developed. School-linked health centers 9 As discussed further elsewhere in this Report, SLHCs vary in the services they offer. Comprehensive SLHCs (and comprehensive community-based centers for adolescents) are centers that aspire to provide health services that address the range of problems that many adolescents face: care for acute physical illness, general medical examinations in preparation for involvement in athletics, mental health counseling, laboratory tests, reproductive health care, counseling for family members, prescriptions, advocacy, and coordination of care. The more comprehensive of the centers may also offer adolescents additional services, such as educational services, vocational services, legal assistance, recreational opportunities, child care services and parenting education for adolescent parents. The defining feature of a comprehensive Service center for adolescents is the extent to which the center attempts to be responsive to the specific needs of adolescents by, for example, offering free care or using sliding-fee schedules for payment, evening and weekend hours of operation, confidentiality of services, and staff members who are knowledgeable about and committed to adolescents. OTA has concluded that SLHCs are the most promising recent innovation to improve U.S. adolescents access to health and related services. Although there is as yet little systematic evidence that SLHCs for adolescents improve health outcomes, there is clear evidence that such centers can improve adolescents access to the health and related services that adolescents are most likely to need. In the opinion of many observers, however, SLHCs are not just a site for delivering health services to adolescents. SLHCs can be a means of integrating a health perspective into a school and making schools more health-promoting environments. They can provide health services to faculty, provide linkages with health professionals and services outside the school building, serve as a source of referral and consultation for teachers and students, and make health-promoting suggestions to school administrators. Perhaps as a consequence of this perspective on SLHCs, some evaluations of SLHCs have focused on whether the presence of an SLHC improves the health of the entire student body in a school, not just the users of clinic services (e.g., 107c). However, it is as yet difficult to make judgments about the ability of SLHCs to improve school environments and so influence the health of entire student bodies: there have been few evaluations and those that have been conducted are 9See Vol. I of thiS Report, SWWM ry and PolicY Options, the Report Brief, and ch. 15, Major Issues in the Delivery of Rimary and Comprehensive Health Services to Adolescents, in Vol. III.
PAGE 87
Chapter 4Schools and Discretionary Time II-83 methodologically weak hence, findings concerning impact are mixed. 10 Most important, however, evaluations have not formally evaluated whether SLHCs have become fully integrated into schools. The comprehensive school/community health model-An increasing recognition that there are inherent limitations to what individuals, the traditional health care system, schools, and social services can do on their own to promote and improve adolescent health has led observers to recommend more comprehensive and integrated approaches. Evaluations of SLHCs (see above) by Kirby and others have pointed to the need for additional integration of SLHCs into schools and communities (e.g., 2a,107c). In their review of the provision of mental health services in SLHCs, for example, Adelman and Taylor suggested that SLHC-based mental health services take a more preventive orientation, in part by becoming better integrated into the daily life of a school (2a). Kirby and his colleagues suggested that SLHCs develop communitywide programs involving parents, youth-serving agencies, religious and other community leaders, and the media (107c). One approach to integrating school and community programs offered by Kirby makes the community the center of the effort: programs are subject to community control and programs are overseen by a child health council (107b). Because schools are the one institution regularly attended by most young people ages 5 to 16, however, Kirby suggests that schools represent the public institution with the greatest opportunity for playing an important role in improving the health of most youth (107b). According to Kirby, a comprehensive school/community health program at the school level: l includes health instruction, school health services, other school activities, and a reinforcing school environment; l integrates special programs for parents and includes adult mentors; and has linkages with health and youth-serving agencies, churches, businesses, and local media (107b). Thus, schools are the central locus of efforts to promote and improve adolescent health, but they are not expected to act alone (see also 27,147). As pointed out by Kirby and others (107b,147), the implementation of comprehensive school/community health programs has been impeded by the failure to resolve some important issues. Key issues include resistance by schools to adopting additional responsibilities and a lack of formal evidence that integrated school/community programs are more effective than more segmented efforts (107b). Recently, however, a sense of urgency about adolescent health and achievement has stimulated many learned observers, including those in the education community, to come out in support of a greater role for schools in improving adolescent health (e.g., 27,147). The analysis in this chapter (and throughout this Report) strongly suggests that a key to improving adolescent health would be to encourage the view of schools as environments that can either promote or impede adolescent health, rather than merely as settings in which to place additional responsibilities, such as the delivery of additional programs, without providing additional supports. 1OSW ch. 15, ~jor Issues in the Delivery of Primary and Comprehensive Health Services to Adolescents, in VO1. ill. SOURCE: Office of Technology Assessment, 1991. ically and educationally disadvantaged children. For The Office of the Assistant Secretary for Elethe past two decades, the primary Federal vehicle for helping schools meet the educational needs of educationally disadvantaged children (i.e., children perfo rming below their appropriate grade level, children of migrant workers, children with physical disabilities, and neglected or delinquent children under State care) has been grant programs authorized by Chapter 1 and administered by the Office of the Assistant Secretary for Elementary and Secondary Education. mentary and Secondary Education has one of the largest appropriations in the U.S. Department of Education, approximately $6.6 billion in fiscal year 1989. Although the proportion of funding allocated to adolescents cannot be precisely determined, major programs that provide adolescent-related efforts include the following: Chapter 1 grants to provide financial assistance to State and local educational agencies to meet
PAGE 88
E Figure 4-4--U.S. Chief of Staff ~1 I Executiv e w Secretary of 1 Secretary I I Educatio n ~ I I Executive Assistant I Private Education + ~ Counsel I Deputy Under ~ i Secretary fo r I Planning, Budget, and Evaluation I 1 [ Assistant Secretary I I Assistant Secretary for Elementary I for Postand Secondary ~ Secondary Education Education I +- 1 I L Inspector General .-~ ( ( I Deputy Unde r I Secretary fo r Management l I ) I 1 Assistant Secretary I for Educational I i Research and I Improvement I I I I ~-- Deputy Under Secretary for Intergovernmental and Interagency Affairs i I Assistant Secretar y E ~ =Fjijjq ~1 w! K Education Languages Affairs 1 SOURCE: U.S. Department of Education, organizational chart, Washington, DC, Sept. 15, 1989. l
PAGE 89
Chapter 4Schools and Discretionary Time II-85 l l l l the special educational needs 16 of disadvantaged children and adolescents; 17 education of homeless children and youth, as authorized by the Stewart B. McKinney Homeless Assistance Act; Indian education programs, as authorized by the Indian Education Act of 1988; training for elementary and secondary school teachers in math and science, as authorized by the Dwight D. Eisenhower Mathematics and Science Education, Hawkins-Stafford Amendments of 1988; and drug abuse education and prevention coordination in States and communities, as authorized by the Drug-Free Schools and Communities Act of 1986. Chapter 1, Title I of the Elementary and Secondary Education Act, provides Federal assistance for State and local programs of education for disadvantaged U.S. pupils at all levels, from prekindergarten through secondary school (202a). The fiscal year 1989 appropriation for Chapter 1 was $4.6 billion, making this program the largest program of aid to elementary and secondary education in the United States. Chapter 1 was initially authorized as Title I of the Elementary and Secondary Education Act in 1965 (202a). In 1988, Congress reauthorized the Chapter 1 program, again as part of the Elementary and Secondary Education Act, in the Augustus F. Hawkins-Robert T. Stafford Elementary and Secondary School Improvement Amendments of 1988 (Public Law 100-297) (202a). The 1988 law, better known as the Hawkins-Stafford Act, made a number of changes in State and local educational agency programs of Chapter 1. 18 Among other things, the Hawkins-Stafford Act provided for the following: l incentives to enhance accountability and improve performancethe Hawkins-Stafford Act contained several provisions aimed at evaluating the performance of individual pupils, schools, and local educational agencies served l by Chapter 1 and at providing Federal assistance to improve this performance. The law specifies that if an individual pupil participates in Chapter 1 for a year without academic improvement, the local educational agency must consider changing the services provided to that pupil. If the aggregate performan ce of pupils in a school fails to improve over 1 year, the local educational agency must develop a program improvement plan. It is important to note that the law allows State and local educational agencies a great deal of flexibility in setting the standards to which they are to be held accountable. programs to increase parental involvement in the education of Chapter 1 participantsThe law requires local educational agencies to implement procedures of sufficient size, scope, and quality to give reasonable promise of substantial progress toward achieving the goals of informing parents about the Chapter 1 program, training parents to help instruct their children, and consulting with parents. The agencies are required, among other things, to develop written policies for parental involvement in plannin g and implementing Chapter 1 programs, to convene an annual meeting of parents, and to provide program information and an opportunity for regular meetings for parents if the parents so desire. The law gives general guidance and lists numerous examples to illustrate the types of authorized parental involvement activity that would allow local educational agencies to meet their responsibilities--e.g., parent training programs, the hiring of parent liaisons, the trainin g of school staff to work with parents, the use of parents as tutors or classroom aides, and parental advisory councils-but it leaves local educational agencies with about the same level of flexibility in the area of encouraging parental involvement as they had before. Thus, it remains to be seen 16F~er~ ~uppo~ for ~ ~Pi~ edu~tj~n 1 ~rogm under fiblic ~w 94142, tie Education of tie Handicapped Act, as amended, is not discussed in thiS chapter. Sm ch. 19, The RoIe of FederaI Agencies in Adolescent Health in Vol. III, and ch. 11, Mental Health Problems: Prevention ~d Services, in this volume. 17N0 age bre~do~ we av~lable for c~ent fiding of ~pter 1. However, in he 1987-88 school year, 21 percent (1,037,127) Of the pOpllhtiOn served were students in grades 7 through 12 in both public and private schools, with funding for these adolescents totaling $3.8 billion. lg~~ ~ucatio~ ~gencypmgms of @ptm 1 ~present abut 90 percent of Chapter 1 tiding (202a). Chpter 1 Iocal edu~tiotd agency gr~ts are calculated by the Federal Government on a county basis. State education agencies receive the aggregate funds for counties in their States, then allocate the county amounts to individual local educational agencies.
PAGE 90
II-86 l Adolescent Health-Volume II: Background and the Effectiveness of Selected Prevention and Treatment Services what impact the new provisions will have on the actual level of parental involvement. 19 programs for secondary school pupils and school dropoutsThe Hawkins-Stafford Act devoted substantial attention to establishing programs specifically for compensatory education of secondary school students. Although local educational agencies have always been authorized to use Chapter 1 funds for secondary school students, Chapter 1 services have historically been focused on pupils in kindergarten through sixth grade. In 1985-86, for example, about 88 percent of all Chapter 1 basic grant participants were enrolled in kindergarten through grade 6, while only 5 percent were in grades 10 through 12. Two different titles of the Elementary and Secondary School Education Act, as amended by the Hawkins-Stafford Act, provide authorizations for programs of school dropout prevention and secondary school basic skills improvement: Title VI and Title I, Chapter 1, part C. Title VI contains l-year demonstration grant authorizations under the School Dropout Demonstration Assistance Act of 1988 and the Secondary Schools Basic Skills Demonstration Assistance Act of 1988. The former act authorizes demonstration grants to local educational agencies for dropout prevention and reentry activities both within schools and in cooperation with community organizations and businesses. 20 Dropout prevention and reentry activities may include services to address poor academic achievement, work-study programs, services intended to improve student motivation and the school learnin g environment, remedial services to youth at risk of dropping out, occupational training, educational programs offering jobs or college admission to students who complete them, summ er employment, etc. The fiscal year 1989 authorization for this program to address school dropout programs was $50 million; the appropriation was $21.7 million (202a) .21 22 The Secondary Schools Basic Skills Demonstration Assistance Act authorizes a program of national demonstration grants to local educational agencies for activities to help educationally disadvantaged secondary school students attain grade level proficiency in basic skills and learn more advanced skills. The grants may be used to initiate or expand compensatory education programs for secondary school students or dropouts, transition-to-work activities in cooperation with the private sector or communitybased organization, and use of secondary students as tutors of other educationally disadvantaged pupils. The fiscal year 1989 authorization for this program was $200 million; however, no funds were appropriated for the program. In fiscal year 1990, the frost year of funding, just under $5 million was appropriated for the program (202b). According to the U.S. Department of Education, basic skills programs can continue to be carried out through Chapter 1 basic and concentration grants and the School Dropout Demonstration Assistance Act. Title I, Chapter 1, part C established a longer term formula grant program of State grants to secondary schools for basic skills improvement plus dropout prevention and reentry. In general, funds will be allocated to States in proportion to the Chapter 1 basic grants their schools receive .23 l~e Haw~.Stafford Act authorized on a demonstration basis, in the Even Start progrrun, support for projects that provide basic education for both educationally disadvantaged children ages 1 through 7 and their parents who reside in was of relatively high poverty concentration. This program is intended to provide geneml basic education to parents and to increase their involvement in helping to instruct their children (202a). It may have the potential to benefit adolescent parents. mAt lat fine other U.S. Department of Education programs and three U.S. Department of Labor programs may help schools that have dropout programs. For information about these programs, which range from large grant programs (e.g., Chapter 1 and the Job Training Partnership Act programs) to small programs explicitly focused on helping students complete school, see the March 1990 Congressional Research Service issue brief entitled High School Dropouts: Current Federal Programs (202b). That publication notes that little is known about the extent to which the available programs actually help students complete school (202b). It also notes that because the fragmentation of programs maybe confusing to orga.nhtions working with dropouts, greater coordination may be desirable. OTAs discussion of the general problem of fragmentation in Federal programs for adolescents is presented in ch. 19, The Role of Federal Agencies in Adolescent Health, in Vol. Ill of this Report. zlTi~e w ~so rquimd tie Secmof ~ucation to es@blish a s~~d deffition of the term school dropout. Such a deffition W & S publishd in the Federal Register on May 10, 1988, p. 16667 (202a). ~As of M~h 1990, fisc~ yea 1988 ~d 1989 appropriatio~ for~e School Dropout Demo~~tion Assistance Aclhad provided 2 JW.WS Of aSSiSlilIl~ to 89 projects in 31 States and the District of Columbia (202 b). Evaluations were not yet available. ~AU of these c~ges Me discussed at 1ength ~ a J~u~ 1989 Congressio@ Re~mch Service report entitled Education for Disadvantaged Children: Major Themes in the 1988 Reauthorization of Chapter 1 (202a).
PAGE 91
Chapter 4Schools and Discretionary Time II-87 U.S. Department of Labor Within the U.S. Department of Labor, the Employment and Training Administration is the agency most directly supporting activities affecting adolescents. In program year 1989, funding for youth was estimated to account for 58 percent ($2.2 billion) of the budget. Employment and Training Administration projects for youth typically focus on adolescents and young adults ages 16 and over. The Employment and Training Administration supports employment and training programs for economically disadvantaged youth under the 1982 Job Training Partnership Act. Three programs authorized under Titles II-A, II-B, and IV of the Job Partnership Training Act support the provision of services to high school dropouts and potential dropouts ages 14 or 16 to 21 (202b), Title II-A provides training grants for disadvantaged adults and youth to States, which pass on 78 percent of the funds to local service delivery areas for training of people who are economically disadvantaged or face other barriers to employment (e.g., lack of a high school diploma) (202b). Local service delivery areas must spend 40 percent of the funds for youth ages 16 to 21. States must use a portion of their education set-aside (8 percent of the total grant) for literacy training, dropout prevention, and school-towork transition programs. The fiscal year 1990 appropriation for Title H-A was $1.7 billion. Title II-B provides S ummer Youth Employment and Training grants for low-income youth to States, which pass on funds to service delivery areas for summer on-the-job training, work experience, and supportive services for disadvantaged youth ages 16 to 21 (202 b). At local option, 14and 15-year-olds may also be served. Local service delivery areas plans must include assessments of participants reading and math skills and describe available remedial education activities. The fiscal year 1990 appropriation was $699 million. Title IV authorizes various federally administered programs affecting adolescents, such as Job Corps and programs designed for Native Americans and migrant workers (202 b). Job Corps, a joint venture between the U.S. Department of Labor, private corporations, and nonprofit organizations, provides employment and training in primarily residential centers for severely disadvantaged adolescents and young adults ages 16 to 21. The U.S. Department of Labor provides funding for the centers, which totaled $741.8 million in program year 1989, and corporations and nonprofit organizations organize and manage the centers under a contractual agreement. In program year 1989, there were 100,000 participants in Job Corps. After completing the program, 66.9 percent of the participants were placed in jobs and 16.7 percent went on for further education. Title IV also establishes funding for research, which is administered by the Division of Research and Demonstrations in the Office of Strategic Planning and Policy Development. One of the primary goals is to address the problem of unemployed youth or those at risk of becoming unemployed. Specific programs include grants to integrate Federal, State, and local services; to investigate patterns of youth achievement; to link school and employment with apprenticeships; to evaluate demonstrations providing alternative education to at-risk youth; and to analyze interagency demonstrations. In one recent year, there were 35 such research projects underway, and the average cost per project was approximately $275,000. Under the Employment and Training Administrations Office of Work-Based Learning, the Bureau of Apprenticeship and Training administers various apprenticeship programs authorized by the National Apprenticeship Act of 1937. Federal staff from the Bureau of Apprenticeship and Training, as well as State personnel in some States, assist in providing technical assistance to the apprenticeship programs, which are sponsored by industry. The average age of most apprentices is about 29, and about 17 percent of apprentices are between the ages of 16 and 22. There is one type of apprenticeship program designed specifically for adolescents. The School-toApprenticeship Program, which makes up less than 1 percent of all apprenticeship programs, provides adolescents with the opportunity to attain valuable job skills in an apprenticeship when they are high school seniors (101).
PAGE 92
II-88 Adolescent Health-Volume //: Background and the Effectiveness of Selected Prevention and Treatment Services Adolescents Discretionary Time 24 Neither researchers, policymakers, nor even parents know a great deal about how U.S. adolescents use their time when they are not in school or engaged in basic maintenance activities (e.g., eating, sleeping). A number of questions remain to be answered. For instance, how many hours per week do adolescents typically spend in discretionary activities? Where do they engage in such activities? With whom, if anyone, are such activities shared? Furthermore, does the use of adolescents discretionary time vary by age, race, gender or other cultural, ethnic, or demographic factors? Despite the paucity of systematic data on the topic, it is virtually certain that the physical, social, and behavioral development of U.S. adolescents is shaped, at least in part, by experiences that occur during their discretionary time. Hence, it is likely that the constructive and creative use of discretionary time will enhance adolescents prospects for healthy development. Toward this end, future policies regarding adolescent development must be well informed by knowledge about the past, present, and potential uses of discretionary time. Given the large amounts of time that adolescents devote to highly structured activities (such as schooling and homework) and essential maintenance activities (such as eating, sleeping, and personal hygiene), their discretionary time probably constitutes the most abundant and flexible resource that exists for the provision of health-enhancing programs. Studies have shown that recreational and leisure activities, as well as work activities, can provide adolescents with opportunities for experiences of mastery and competency (103); creativity and self-expression (50); self-improvement and self-definition (125); self-fulfillment and personal meaning (50); enhancement of character and personality (103); testing oneself in competition (106); development of interpersonal and social skills (103); and, the development of autonomy (50). Leisure and work activities also can contribute to social experimentation and recognition (125); improved physical health (17); an increased sense of freedom (50); identification with positive role models and mentors (66); companionship and improved relationships with others (50); and, of course, entertainment and relaxation (132). Research has shown that leisure and work activities which involve the attainment of specific goals (59) and meaningful goal-directed activity (65,129) are positively related to important developmental variables such as self-esteem, positive affect, and life satisfaction. For a number of reasons, U.S. adolescents today probably spend much less time with their parents and families than in previous years. The reasons include the breakdown of two-parent families due to separation and divorce (29,77); the deterioration of extended family relationships as a result of high rates of geographic mobility and urban migration (76); the rapid entry of mothers into the work force (216) and the concurrent emergence of numerous latchkey children who are unattended after school (192); high incidence of parental substance abuse and mental illness, and parents attendant inability to exert positive socializing effects upon their children (68); decreased family size and, therefore, fewer siblings who are available to socialize youngsters (16,29); and, fiscal exigencies which constrain the availability of funds for afterschool programs (128). According to some observers, U.S. adolescents have become increasingly separated from adults, have fewer adult responsibilities, and communicate less frequently with adults. Indeed, one study indicates that relatively few adolescents ask their parents for advice about such basic concerns as jobs, college, school problems, sibling problems, health or diet, drinking, sex, trouble with other adolescents, and drugs (154). To the extent that adolescents spend less time with their parents, their development is likely to be shaped less frequently and less influentially by parents and more often by peers or others with whom adolescents come into contact during their free time or by parental surrogates and role models who appear on television or elsewhere. Some observers suggest that the relative isolation of adolescents from adults has helped to bring about adolescent rolelessness" (153). Others contend that adolescents insulation from the real business of life produces apathy, self-hatred, boredom, loneliness, meaninglessness, and acute feelings of frustration (46). a~s ~tion draws substantially from a paper entitled How Can Society Contribute to M@d Use of Adolescents Spare Time, prepared under contract to OTA by Ronald Feldman (66a).
PAGE 93
Chapter 4Schools and Discretionary Time l II-89 Given the central role of discretionary time in adolescent growth and development, it is unfortunate that relevant research concerning this topic is very limited. Such research is essential to better comprehend how adolescents use their discretionary time and how we can devise appropriate policies and programs to promote health-enhancing uses of discretionary time. How Do U.S. Adolescents Spend Their Time? Results from the Monitoring the Future/High School Seniors Survey, which surveyed a nationally representative sample of about 17,000 U.S. high school seniors, indicate that U.S. adolescents consider discretionary and leisure activities to be of great importance (8). Seventy percent of the high school seniors who were interviewed in 1986 stated that it was either extremely important or quite important to have plenty of time for recreation and hobbies. This was the highest 25 percentage reported in the surveys 10-year history. In considering the attributes of preferred jobs, 78 percent of the 1986 high school seniors regarded more than 2 weeks of vacation as pretty important or very important, while 83 percent deemed it pretty important or very important that their job afford a lot of time for other things in life. Both figures were higher than at any other time in the surveys history. A review by Easterlin and Crimmins further substantiates that a significant shift has emerged in the leisure aspirations of American adolescents during the decade from 1976 to 1986 (55). Among 14 life goals studied, the goal with the greatest increase in importance to adolescents in the decade from 1976 to 1986 was having lots of money. The 1986 adolescent respondents considered it much more important than their counterparts a decade earlier to own such items as a vacation house, at least two cars, and a recreational vehicle. Although in both 1976 and 1986 these goals were exceeded in importance by other goals, including a good marriage and family life, the foregoing goals rose most in importance and were integrally related to high valuations of leisure time. Perhaps the most systematic study of American adolescents use of time was a study by CzikszentTable 4-5-Where Adolescents Spend Their Time a Home (41%) Bedroom . . . . . . Living room . . . . . Kitchen . . . . . . Yard or garage . . . . . Dining room . . . . . Basement . . . . . . Bathroom . . . . . . School (32%) Classroom. . . . . . Miscellaneous locations . . . Cafeteria . . . . . . Halls . . . . . . . Gym . . . . . . . Student center . . . . . Library . . . . . . School grounds . . . . . Public (27%) Friends home . . . . . At work . . . . . . Automobile . . . . . . Other public areas . . . . Store or cafe . . . . . Street . . . . . . Park . . . . . . . Walking . . . . . . Indoor recreational facility . . Church . . . . . . Bus or train . . . . . ~he data shown in this table were derived from a study of 75 adolescents who for a l-week period carried an electronic pager and were buzzed frequently during thedayand asked torecordtheiraetivities (see text). The data here are based upon 2,734 weighted self-reports. Each percentage point is equivalent to approximately 1 hour per week spent in the given location or activity. 12.9% 8.9 8.1 4.1 3.3 2.2 1.6 19.8 2.3 2.2 2.0 1.9 1.3 1.2 0.8 5.4 5.3 3.8 3.0 2.8 2.0 1.7 1.5 0.8 0.8 0.4 SOURCE: Adapted from M. Csikszentmihalyi and R. Larson, 5eing Adolescent: Conflict and Growth in the Tmnage YWS (New York, NY: Basic Books, 1984). mihalyi and Larson published in 1984 (44). These investigators utilized an innovative research procedure in which 75 adolescents were asked to carry an electronic pager and a pad of self-report forms for 1 week. At a random moment within every 2-hour period, a signal was sent to the pager and the adolescent was instructed to complete a self-report form about his or her activity at that time. Despite sampling limitations, this study did provide an overview of 75 adolescents daily experience. As shown in table 4-5, the investigators found that the sampled adolescents spent 41 percent of their time at home, 32 percent at school, and 27 percent in locations such as fiends homes, work or parks (44). Much (nearly 40 percent) of the time these adolescents spent at school was spent in places other than 2S~~~ it ~ ~o@t tit pla~ing ~ ~gh ~~e on le~ rime M~r ~nrernpor~ ~O]e~en~ me ltiernow ~ hey were iIl ptis~ it iS illlpollilllt to compare adolescents attitudes towards leisure time to those of adults. A sumey recently reported in the Washington Post found that many private sector executives considered vacations crucial to their psychological and physical well-being (215a). 2$}7-!).1(; !)] --i (Jl, :{
PAGE 94
11-90. Adolescent Health-Volume II Background and the Effectiveness of Selected Prevention and Treatment Services the classroom (e.g., miscellaneous locations, cafeteria, halls, gym). Time spent in these locations frequently afforded opportunities for unstructured social interaction with peers. As shown in table 4-6, the sampled adolescents spent 40 percent of their time in discretionary activities such as socializing, watching television, reading, and engaging in sports or games (44). They spent approximately 31 percent of their time in daily maintenance activities such as chores, errands, eating, traveling from one place to another, sleeping, and personal care (e.g., grooming, dressing and bathing). Finally, they spent 29 percent of their time in activities that the investigators characterized as productive, primarily studying, classwork, or jobs and related activities. Even though the sampled adolescents devoted more time to self-selected discretionary activities than to maintenance or productive activities, it is probable that the researchers estimates of the subjects discretionary time are low. The reason is that data were not collected during such prime leisure periods as Sundays, weekdays after 11 p.m., and the summer. If one considers the sampled adolescents leisure time (see table 4-6), one finds that the greatest proportion of this was spent in socializing; the adolescents spent one-sixth of their waking hours socializing. In addition, the sampled adolescents reported engaging in conversation while studying, watching television, and eating. In total, therefore, the sampled adolescents probably spent about onethird of their day conversing with others. Hence, conversation was by far the single most prevalent activity in the sampled adolescents lives. The next largest amount of leisure time, after that spent socializing, was spent in watching television. The sampled adolescents spent much smaller proportions of their leisure time in essentially solitary activities such as reading, thinking, and listening to music or in activities that typically involve friends and peers such as sports and games or arts and hobbies. Altogether, more than one-half of the adolescents discretionary time was spent in social interaction with others and in activities that adults often consider to be of secondary importance. In terms of sheer amount of time, peers were by far the greatest presence in the sampled adolescents lives. In the late 1970s, Farley conducted a related study with 129 Canadian adolescents who ranged between 10 and 17 years of age (60). Information regarding Table 4-6-What Adolescents Spend Their Time Doing e Leisure activities (40%) Socializing. . . . . . Watching television . . . . Miscellaneous . . . . . Reading (nonschool) . . . Sports and games . . . . Thinking . . . . . . Arts and hobbies . . . . Listening to music . . . . Maintenance activities (31%) Chores and errands . . . . Eating . . . . . . . Transportation . . . . . Rest and napping . . . . Personal care . . . . . Productive activities (29%) Studying . . . . . . Classwork . . . . . . Jobs and other activities . . . 16.0?! 7.2 4.6 3.5 3.4 2.4 1.5 1.4 14.3 5.6 4.9 3.2 3.2 12.7 12.0 4.3 ~hedata in this table were derived from a study of 75 adolescents who for a 1-week period carried an electronic pager and were buzzed frequently during the day and asked to record their activities (see text). SOURCE: Adapted from M. Csikszentmihalyi and R. Larson, Being Adolescent: Conflict and Growth in the T-nqge Y-s (New York, NY: Basic Books, 1984). the daily activities of 129 adolescents was collected by recall of a sequential record of every activity that lasted at least 15 minutes. Aside from weekday school attendance, passive leisure was the activity grouping that clearly emerged as the most widespread on both weekdays and Sundays. Nearly 90 percent of the adolescents devoted some time each day to passive leisure activities. On the average, the adolescents in this study spent 2 to 3 hours per day passively. Nearly three-quarters of this time was accounted for by television watching. Low levels of participation were recorded for such activities as working away from home, cultural or educational activities, and organizational activities. Only 18 percent of the respondents participated in adolescent organizations, and an even lower percentage (12 percent) took part in church activities. Nevertheless, 100 percent of the subjects who participated in adolescent organizations or church activities regarded these organizations as important or very important. Related research further supports the observation that a great deal of American adolescents time is spent watching television. Some studies indicate that more than 70 percent of U.S. adolescents watch television daily (105) and that adolescents spend up to 25 hours per week watching television (145,191). Hispanic adolescents may watch television for as many as 30 hours per week (87). Home-based video
PAGE 95
Chapter 4Schools and Discretionary Time II-91 games and televised music videos are of increasing interest to American adolescents (42,135). While some critics regard these leisure time activities as an addiction (189), the effects of such activities depend upon a wide range of variables such as the extent of peer and parental involvement and the substantive content of the videos. Rigorous research concerning the effects of these activities is virtually nonexistent. Schneller conducted a 1988 study of adolescents discretionary activity based on diaries logged every half hour from the close of school until bedtime (179). This study found a negative correlation between television viewing and activities such as participation in social or cultural events, adolescent movement activities, excursions, and outdoor games. Selnow and Reynolds 1984 study of 184 sixth, seventh, and eighth graders similarly found a negative correlation between television viewing and membership in school, church, and musical groups (182). The authors concluded that extensive television viewing entails opportunity costs that preclude other forms of valuable activity. Adolescents who view greater amounts of television are less likely to take advantage of the social learning opportunities that can be provided by group membership. The optimum amount of solitary activity is likely to vary in accord with the unique needs of each adolescent. For more mature adolescents, increased time alone generally is associated with better adjustment. Although some adolescents do not regard the experience of being alone as particularly pleasant, those who spend at least a moderate amount of time alone-that is, about 30 percent of their waking hours-appear to be better adjusted than others (108). Hence, being alone for reasonable periods of time may serve a constructive developmental function for adolescents (42,1 15). In comparison with younger children, adolescents tend more often to be alone or with peers during the after-school hours (192). Some studies have shown that adolescents spend up to 10 hours per week at video arcades (149) and shopping malls (4). 26 As children are increasingly left to fend for themselves, parents fear about their childrens safety (62). Among other things, they express concern about after-school injuries, excessive television viewing, being kidnapped, and sexual abuse (98). Concurrently, they worry that their adolescent children may not be utilizing their discretionary time in a way which contributes to more effective social, emotional, and behavioral development. Alternatives for the Constructive Use of Adolescents Discretionary Time As discussed elsewhere in this Report, 27 since at least the early 1900s, a number of extrafamilial youth-serving agencies and, to some extent, other entities (e.g., schools, municipal recreation centers) have developed to enhance adolescents access to health-enhancing alternatives for occupying their discretionary time. Just as there has been little systematic research on how, where, why, and with whom adolescents spend their discretionary time, there has been little systematic research into the nature, quality, and effectiveness of existing alternatives for the constructive use of adolescents discretionary time. Nonetheless, as discussed below, many of these entities have attempted to base their programs on research on adolescent development and the prevention of problem behavior. Views on the basic requirements of programs to promote healthy adolescent development are discussed below, as are several typical programs and, when available, evaluations of their effectiveness. Perhaps because adolescents discretionary time has not been a central focus of research or policy development, several issues about the nature of these alternatives have yet to be resolved. These issues are raised in the next section of this chapter. Basic Requirements of Alternatives for the Constructive Use of Adolescents Discretionary Time According to Kerewsky and Lefstein, a number of factors are of particular importance in the design of effective and developmentally appropriate programs for adolescents (107). 28 Such factors include selfexploration and definition, meaningful participation, positive interaction with peers and adults, ~Subst~ce abuse problems among U.S. adolescents are discussed in ch. 12, Alcohol, Tobacco, and Drug Abuse: Prevention and Services, in this volume. ZTS= ch. 2, What Is Adolescent Health? in t.his vOIUme. Z8CWent ~der~~dings of the developrnen~ ne~s of adol~cents me discussed ti ch. 2, What Is Adolescent Health? in this volume.
PAGE 96
II-92 Adolescent Health-Volume II: Background and the Effectiveness of Selected Prevention and Treatment Services physical activity, competence and achievement, and structure and clear limits. Kerewsky and Lefstein suggest that effective programs for adolescents ought to be characterized by the following nonnegotiable criteria: they must have a clearly defined mission; be responsible to the local community; be safe and clean; and be caring, enjoyable and supervised. Moreover, they must meet at least once weekly in the after-school hours, be locally based, and be available during vacations. Several other criteria are regarded by Kerewsky and Lefstein as negotiable that is, desirable under ideal circumstances but hardly expected in all instances (107). Specifically, programs should be accessible both physically and financially; include parent participation and provide in-service training for staff; and have a means of assessing the results. And, to the extent possible, programs should not overlap with local organizations and should proceed upon the basis of interagency collaboration. A variety of adolescent programs meet many, if not all, of these criteria. Lefstein and Lipsitz assert that appropriate and effective program alternatives for adolescents must take place in environments that offer realistic expectations for adolescents, caring relationships with adults, and diverse opportunities for constructive and enjoyable activities with peers (120). Costello suggests that adolescents must acquire four important capacities that are essential for well-functioning adults: 1) physical vitality, 2) the ability to sustain caring relationships, 3) resourcefulness, and 4) social connectedness (41). Toward these ends, adolescent development programs should enable adolescents to engage in physical and mental activities which are adequate to accomplishing the tasks of everyday life. They should promote adolescents sense of self-worth and the well-being of others in the family and the community. They should promote adolescents ability to seek and sift information, apply practical knowledge, and improve ones cognitive and social skills. And, they ought to strengthen adolescents sense of affiliation with a social community, which validates the adolescents personal identity, provides support and services, and requires contributions in turn. The available literature suggests the efficacy of basing program design efforts on a developmental perspective regarding adolescents (66a). Adolescents mature at varying rates. Both developmental and progr ammatic needs may differ considerably in accord with such factors as the participants gender, race, socioeconomic status, and ethnicity (107). Moreover, the quantity, quality, and operational features of programs for adolescents can be expected to vary in accord with the nature of the respective communities in which they are located. The accessibility and utility of adolescent development programs necessarily are shaped by such factors as the communitys financial resources, geographic location, and demographic composition. The available literature reveals many ways for American adolescents to spend their discretionary time. These may be either formally organized, informally organized, or unorganized (66a). Several types of programs are discussed further below. Youth-Serving Organizations Many youth-serving programs are sponsored by national organizations that are funded primarily by the independent sector. One tabulation indicates that more than 300 national youth organizations operate with chapters of varying size throughout the United States (61). Two of the largest national organizations are the Boy Scouts and the 4-H Clubs, each with a membership of over four million youth in 1986. The membership in these and seven other major youth organizations (Girl Scouts of America, Boys and Girls Clubs, Young Mens and Young Womens Christian Association, Camp Fire, and Salvation Army) totaled 17 million in 1980, representing over one-third of all elementary and high-school age youths (1 13). Long established agencies dominate the adolescent service field. In 1983, for example, the Boy Scouts of America had a 1983 membership equal to 15.9 percent of all American males 7 through 16 years of age (19). Between 1972 and 1983, however, the number of Scouts and Explorers in the organization declined by 22 percent, from 2,405,220 youth to 1,867,982 (19). From 1984 through 1988, by contrast, some youth organizations experienced increases in membership--e.g., the Boys Clubs 29 (+2 percent), Girl Scouts (+8 percent), Boy Scouts (+16 % order to more accurately reflect its membership, the Boys Clubs of America recently changes its name to the Boys and Girls Clubs of America.
PAGE 97
Chapter 4Schools and Discretionary Time l II-93 percent), Girls Clubs 30 (+25 percent), and Camp Fire (+48 percent). Concurrently, however, there was a decline in the youth membership of the YMCA and YWCA (60). In recent years, the Boy Scouts, Girl Scouts, the Salvation Army, and related organizations have progressed substantially beyond their original missions. They have established a variety of new programs including after-school programs for latchkey children, problem-solving programs for minority youths, and programs that help parents to promote ethical decisionmaking on the part of their children. Some organizations have devised highly targeted programs for special populations such as runaways and neglected or abused adolescents. Within the private sector, the Boys and Girls Clubs of America is the major nationwide organization with a primary focus on direct service for disadvantaged youths. In 1983, the Boys Clubs served about 1.2 million youth (20). Of these, 61 percent ranged in age from 11 to 18 years, 75 percent were from families with annual incomes under $12,000,30 percent from families that receive public assistance, 51 percent from minority families, and 46 percent from single-parent households (20). Data from 1988 indicate that the membership of the Boys and Girls Clubs of America has remained stable with 1.285 million members at 1,100 facilities across the Nation (21). However, the proportion of 11to-l 8-yearold members declined from 61 percent in 1983 to 53 percent in 1988. Boys and Girls Clubs programs focus on abroad range of concerns including citizenship and leadership development, health and fitness, adolescent employment, delinquency prevention, and the promotion of talent in sports and the arts. The Boys and Girls Clubs have developed curricula for youth programs in a number of areas, including health promotion, delinquency prevention, adolescent employment, citizen and leadership development, alcohol abuse prevention, and education for family life. The Girls Clubs of America (now Girls Inc.) experienced an increase in membership from 200,000 in 1984 to 250,000 in 1988 (81). It also experienced in increase during the same period in the proportion of black, Hispanic, and Asian members (from 44 percent to 50 percent). However, only 29 percent of Girls Club members range in age from 12 to 18 years (81). Among the Girls Clubs innovative programs are AIDS education, a pregnancy prevention programs, Friendly Persuasion (a program for substance abuse prevention), and Operation SMART (science, math, and relevant technology). As Wynn and colleagues have noted, adolescents can participate in a wide range of programs offered by independent sector organizations. There are career groups such as Junior Achievement; characterbuilding organizations such as the Boy Scouts; political groups like Young Democrats and Young Republicans; veterans organizations such as the Sons of the Veterans of Foreign Wars; hobby groups such as Junior Philatelists of America; and, ethnic groups like the Ukranian Youth Organization and Indian Youth of America (205). In the absence of adequate surveys, however, few systematic data are available regarding the total number of adolescents who participate in privately supported youth organizations. It is especially difficult to ascertain the membership of such private organizations as high school fraternities, sororities, and local social clubs. A number of studies have reported beneficial effects as a result of program participation in national youth-serving organizations. In 1987, Ladewig and Thomas found, for instance, that former 4-H members attained higher levels of education than nonparticipants and, as adults, were more likely to be involved in civic activities and political organizations (114). Likewise, a large-scale survey of high school seniors by Hanks found that adolescents participation in voluntary organizations was related to subsequent voting behavior and involvement in political campaigns (92). Community Service Programs Approximately 4,000 adolescent community service programs are in existence in the United States (18 1). The programs include more than 50 full-time youth service corps, 550 campus-based service programs, 3,000 school-based service programs, at least 50 service corps and programs that are organized by local communities, and Federal service programs overseen by ACTION. Cities are particularly active sponsors of youth service programs. Thus, for instance, the City ~(j~ls clubs of America is now known as Ghk hlc.
PAGE 98
II-94 Adolescent Health-Volume II: Background and the Effectiveness of Selected Prevention and Treatment Services Volunteer Corps of New York City (CVC), with an annual $8 million budget, has pioneered volunteer efforts in human service delivery. It has established a program for high school adolescents who work full-time in the s ummer and part-time during the school year. In 1988, CVC instituted a small program for students already in college, offering summer stipends and bonuses for one and two semesters of part-time Corps work. About 600 CVC volunteers work on projects in city parks, building rehabilitation, centers for retarded adults, nursing homes, and schools. Every 3 months, the participants change projects so that they can have a variety of environmental and human service work experiences during a l-year period. CVC also offers completion incentives: $2500 for those who complete 1 year of service, or $5000 toward college for those who choose to resume their studies (210). Adolescents who participate in community service programs can obtain a variety of benefits. A survey of a random sample of participants in projects sponsored by young volunteers overseen by the Federal program ACTION found that the young participants intended to continue volunteer service both in school and as adults and, also, that they would encourage others to volunteer (2). Moreover, adolescent participants have reported gains in understanding community service, ability to work with others, development of career objectives, willingness to learn, and reduced need for supervision. Calabrese and Schumers study of ninth grade participants in a 20-week school community service program showed reduced levels of alienation, isolation, and discipline problems (26). Likewise, in a study of 11to-17-year-old volunteers in community improvement projects, Hamilton and Fenzel found that participants developed positive attitudes toward social responsibility for needy people and a commitment toward continued volunteer work (90). Participants also developed vocational and interpersonal skills and gained greater knowledge of themselves and others. School-Based Programs Schools typically are accessible and often-used sites for adolescent development and adolescent service activities. Peer counseling and peer tutoring programs are among the most successful and visible programs that have been offered in schools. Such programs often are reported to yield a wide range of benefits both for the tutees and the tutors (48,80, 111,1 16). Reported benefits include gains in tests of ego and moral development (32). Adolescents in such programs have been employed as counselors (49), trainers (126), therapists for the remediation of behavior disorders (33), and peer mediators. In one New York City school, administrators reported that a peer mediation program cut the suspension rate in half (52). Many school-based programs address adolescent problems primarily on a reactive basis, but some school systems also have initiated a wide range of community service programs that are essentially proactive and preventive in nature. Following extensive deliberations, the Carnegie Council on Adolescent Development recommended that adolescent community service be part of the core program in middle school education (27). The Carnegie Council on Adolescent Development observed that students can volunteer to work in such diverse settings as senior citizen centers, nursing homes, soup kitchens, child care centers, parks, and environmental centers. Assistance for such programs can be provided by institutions of higher education. The Early Adolescent Helper Program of the City University of New York, for example, has involved hundreds of students from 17 New York City middle and junior high schools in educational enrichment and adolescent service activities (27). Significant benefits for adolescents have been identified by many studies of school-based programs. Thus, Conrad and Hedins study of 4,000 students in experiential educational programs reported that the students showed improvements in self-esteem, moral reasoning, personal and social development, attitudes toward adults, and involvement in the community (36). Similarly, Hanks and Ecklands study of 1,627 high school sophomores found that participation in school-based extracurricular activities is associated with later educational attainment and with participation in adult voluntary organizations (93). Related studies have shown participation in extracurricular activities to be associated with higher educational goals (190), subsequent educational attainment (159), occupational att ainment and income (160), and participation in voluntary organizations and the political process (161). The studies do not allow any firm conclusions about causality.
PAGE 99
Chapter 4Schools and Discretionary Time II-95 Photo credit: Ron Larson/Youth Service America Some studies suggest that participation in extracurricular activities can keep adolescents in school and enhance their academic progress. Municipal Recreation Centers Numerous adolescent development programs have been established at municipal recreation centers throughout the Nation. As noted by Lefstein and Lipstiz, for example, the Arlington County (Virginia) Recreation Division operates neighborhood centers that offer planned activities and drop-in programs for adolescents (120). A Junior Jamboree program is conducted on alternate Saturdays which offers arts and crafts, sports, cooking, field trips, and health information for 12to 15-year-olds (120). Similarly, the Concord (California) Recreation and Human Services Division has created a Department of Leisure Services which operates a city-wide recreation program at elementary schools, intermediate schools, high schools, and local community centers (120). The Department of Leisure Services has established a variety of adolescent Services Target Programs for low-income neighborhoods where parents cannot afford to pay for special out-of-school activities for their children. Besides offering an extensive array of games, sports, and special interest classes, the program seeks to help the participants to build social skills and to experience a world other than their own impoverished neighborhoods by means of parties, excursions out of the neighborhood, and other events. After 1 year of progr amming that included recreation, counseling, and employment, juvenile crime decreased in three target neighborhoods by 31 percent, 63 percent, and 69 percent, respectively (120). A unique collaborative program with the private sector has been established by the East Oakland (California) Youth Development Center (120). The center sponsors a comprehensive program that offers job skills development, basic skills tutoring, counseling, and recreation. Over 1,000 adolescents ranging in age from 10 to 21 years are registered as members (120). While the City of Oakland invested $350,000 in community development funds toward initiation of the program, the Youth Development Center was launched largely by means of an aggressive fundraising campaign conducted by the Community Affairs Department of the Clorox Company. The Clorox Company contributed $247,000 toward construction of the center, pledged $50,000 annually for program operation, and initiated an endowment campaign aimed at matching the companys own gift of $1.5 million. Since the Center opened, 25 foundations and more than 70 corporations have contributed finds for its operation (120). Churches and Synagogues There is a great need for ample and diverse family-based activities that are attractive to adolescents. Churches and synagogues are among the foremost institutions that can offer such activities on a regular basis. Some of the most extensive family-oriented programs have been devised by the Church of Jesus Christ of Latter Day Saints (Mormons) (197). The Mormon church promotes wholesome recreation as a part of its religious creed by setting aside 1 weekday evening as a Family Activity Night (197). Families are free to choose the activity that they desire but are encouraged to engage in varied and challenging activities that appeal to all age groups. The church makes available a comprehensive Family Resource Manual which identifies family enrichment activities (e.g., first aid, food storage, and home repairs) as well as physical, cultural, social and intellectual activities. Each church parish has a small activities committee tha t helps families to develop their own activities. Information about exemplary programs is disseminated to other such committees on a yearly basis. Churches and synagogues also have sponsored a wide range of community service programs (120) and family camps for parents and their children.
PAGE 100
II-96 l Adolescent Health-Volume II: Background and the Effectiveness of Selected Prevention and Treatment Services Some of these have introduced programming g that teaches or reinforces selected family and societal values (96), while others have concentrated on sports, skills development, or cultural and educational learning such as was introduced by the Chautauqua movement (58). Other Alternatives Various innovative alternatives for the constructive use of adolescents discretionary time have been developed by a wide range of agencies at the national, regional, and local levels. One innovative alternative is a family recreation program, known as Together Is Better, that has been introduced nationally by the Canadian Parks and Recreation Association (95). This program emphasizes a high degree of interaction among family members. Examples include family picnics, group hikes, and family games. Information kits about activities such as kite-making, backyard camping, hiking, and tracing family trees are distributed nationally. A major marketing campaign gives the overall program a central focus and creates high visibility. The U.S. Air Forces Community Action Program sponsored a Youth Services Camping Program for boys in the State of Michigan, that brought together 590 14to 17-year-old low achievers, predelinquents, expelled or suspended students, and wards of the court (201). The Youth Services Camping Program emphasized vocational opportunities, health care, recreation, fellowship and leadership. The behaviors and self-concepts of all categories of the boys participating improved substantially (201). A suburban community center achieved similar results by integrating small numbers of antisocial adolescents into activity groups with prosocial adolescents (67). Innovative adolescent development progr amming can occur at community centers and neighborhood agencies sponsored by religious organizations, fraternal associations and other groups. Revitalized efforts at these sites and others can capitalize upon major adolescent development resources that have been underutilized in recent decades. Public libraries are important, but often overlooked, sites for adolescent development programs. Some libraries offer creative opportunities for adolescents to provide support across generations including service as storytellers for young children and as computer tutors for children and adults (172). They also offer programs for consolidating academic and reading skills, le arning practical life skills such as budget plannin g and hunting safety, and exploring social or emotional issues that are relevant to adolescence (215). Finally, paid jobs constitute an important resource for the constructive use of adolescents discretionary time (3). As are other alternatives, paid jobs are likely to be most beneficial when they engage adolescents in meaningful tasks, bring them into regular contact with adults and responsible peers, and provide fair and adequate remuneration for the services that are provided (183). Special care must be taken to ensure that adolescents do not devote excessive amounts of time to paid jobs and thereby forgo opportunities to keep up with their schoolwork or to take part in other growth-enhancing activities with their peers and family (193). Major Issues in the Elaboration of HealthEnhancing Alternatives for the Use of Adolescents Discretionary Time A number of major issues must be addressed if significant improvements are to be made in the quantity, quality, and diversity of health-enhancing alternatives for Americas adolescents. These pertain both to key barriers that impede the development of innovative programs and to a variety of unanswered questions that must be resolved, at least in part, if significant advances are to be made. Counterproductive Theories of Adolescent Development Adolescent services, and the misperceptions upon which they often are based, have evolved largely from theories of adolescent deviance (199). These formulations view adolescents, particularly those from low-income households, as essentially deviant or potentially deviant. From this standpoint, adults must guide adolescents along a fairly narrow path toward adulthood and they must correct and constrain those who stray. Given the prevalence of this perspective, programs are most likely to be funded when they can claim the capacity to combat a particular deviancy such as drug use, vandalism, or delinquency. Proactive and preventive programs are less likely to attract the financial support that they deserve.
PAGE 101
Chapter 4Schools and Discretionary Time II-97 Correspondingly, agencies that serve adolescents sometimes tend to overreact to incidents of adolescent deviance that are depicted by the mass media. This can lead them to emphasize programs that are essentially reactive rather than proactive. It also reinforces the stereotype of adolescents as deviants on the part of the public, policymakers, and the adolescent service community. The result is a highly fragmented service delivery system, increased barriers to the elaboration of holistic service delivery programs, and heightened activity by entrepreneurial agencies that may design their programs more to reflect the availability of public funds than the serious needs of the community. Categorical Funding Sources The specialized funding that has been promoted by single-purpose advocacy groups, legislative committee systems, and narrowly targeted adolescent service bureaucracies make the delivery of comprehensive adolescent services all but impossible. The ability of both public and private agencies to plan coherent adolescent services is often undermined by the rigidity of Federal, State, and local categorical funding requirements and by the tendency to formulate narrowly targeted contracts in response to specific problems that come to the publics awareness (135). Legislative committee systems used to formulate public policies and programs often tend to conceptualize adolescents categorically as drugusers, runaways, adolescents in need of job training, or in terms of similarly constraining definitions that overlook the fact that a single adolescent may have multiple needs. 31 In the real world, the same adolescent is often a dropout, a drug abuser, a mother or a father, in need of mental health care, and unemployable in the local labor market-a fact that politicians, grantmakers, service providers, and even families sometimes fail to recognize (51,199). Categorical conceptualizations have led to the haphazard growth of specialized direct service agencies and provided little opportunity or incentive for programs to cooperate, coordinate, or engage in systematic long-term planning of comprehensive adolescent programs. Another problem is that public and private funds for adolescent programs tend to be awarded on a short-term basis. But, when funds are doled out for only 1, 2, or 3 years at a time, it is virtually impossible to plan coherent long-term programs and to develop initiatives that seek to sustain or expand hard-won gains. It also is difficult to retain talented staff who may have more secure jobs waiting elsewhere. Inordinate staff attention must be directed constantly toward the acquisition of financial resources. A patchwork quilt aggregation of poorly interrelated and inadequately integrated programs may emerge from a myriad of funding sources. Moreover, counterproductive competition can occur on the part of agencies who might otherwise benefit from a collaborative and collegial relationship. Time spent in school and time spent in discretionary (nonschool, nonmaintenance) activities constitute large segments of an adolescents life. Outside the family and home, 32 school buildings and personnel, and peers and adults in community settings (including the media) constitute important and influential environments for adolescents. This chapter reviewed shortcomings in many of these settings and ways in which these environments can be improved. Public Support v. Private Support A fundamental issue in the provision of adolescent development programs pertains to the optimum mix between public support and private support. Private auspices may be highly effective for the creation and sustenance of such programs. Yet there are communities that do not have the resources whether in funds or in leadership--to support the development of an infrastructure which is sufficient to create and maintain an array of programs. Key questions regarding this issue have been articulated by Wynn and colleagues (215). If the provision of community supports for adolescent development programs ought to be through voluntary efforts, where can resources be found to sustain them at an adequate level? Should a quasi-public corporation or organization be created to assist in stimulating and sustaining community support? Or, should government play a more active role in the provision of community supports? Might we actually need to create a social care and community 31~e problem ~fmultiple ~omitt= juri~dlction~ ~ con~ess ad tie fi~en~tionof Fede~ progr~s for adolescents is discussed in ch. 19, Role of Federal Agencies in Adolescent Heal@ in Vol. III. Jzpments ad fmi1i6~ ~uences on adolescent healti are reviewed in ch. 3, Parents and Families Influence on Adolescent He~th, ~d elsewhem in this volume.
PAGE 102
II-98 Adolescent Health-Volume II: Background and the Effectiveness of Selected Prevention and Treatment Services support system like our educational system or health care system to foster the development of adolescent programs? How can government effectively support the informal, voluntary, and associational nature of many existing and potential forms of community support? And, would government bring with it rigid formulas or bureaucratic approaches that are antithetical to the existence of community supports? An overview of Federal expenditures for children and adolescents indicates that only a scant portion of governmental resources is devoted to nonschool developmental programs. 33 In 1980, for instance, the greatest percentages of Federal outlays for children and adolescents were for income maintenance programs (35.5 percent), nutrition (19.4 percent), education (16.5 percent), health (8.4 percent), employment (6.4 percent), housing (5.3 percent), and community development (5.2 percent). A relatively small percentage was allocated for child care (2.4 percent), juvenile justice (0.6 percent), or recreation (0.3 percent). Moreover, U.S. Government expenditures for recreation declined steadily, from 0.5 percent of the domestic Federal budget in 1964 to only 0.3 percent in 1980 (34). In Britain, by contrast, youth work receives approximately 1.5 percent of the national budget (215). The scant attention directed toward recreation and leisure programs for U.S. adolescents is reflected at the State level as well as the Federal level. Of 56 States, territories, and the District of Columbia participating in the 1982 White House Conference on Children and Youth, only 6 treated recreation and leisure as a major concern in their statewide conferences (205). New York City sponsors a Youth Bureau that is responsible for plannin g, implementing, and monitoring development and delinquency prevention programs for adolescents. The Youth Bureau contracts with community-based organizations to provide services for youth. The community-based programs with which the Youth Bureau contracts typically provide recreational, educational, counseling, cultural enrichment, and vocational services. There were 582 such contract agencies in fiscal year 1989 with a budget of $30.7 million (134). Altogether, the agencys budget averages less than $16 per adolescent in New York City. Common Infrastructure v. Adolescents as a Special Case A strong case can be made for the provision of special finding and program initiatives designed expressly for adolescents. Indeed, a sound investment in adolescent development programs can be expected to yield highly beneficial long-term outcomes for society as a whole. Adolescents who are properly challenged, motivated, and trained are likely to develop into mature and responsible parents, breadwinners, and citizens. Nevertheless, alternative strategies for funding and program development also can be considered. It has been suggested, for instance, that programs can be devised which are based upon the common needs of varying at-risk populations. By this formulation, the provision of community supports can be thought of not as categorical responses to a separate and independent adolescent population but as ways in which communities can assist a broad range of individuals with common interests and needs (215). Thus, efforts to convey information about health and educational resources, provide transportation services for isolated or dependent individuals, or implement mutual assistance programs can be organized across age groups rather than by means of a single age category. Systematic study of the relative advantages and disadvantages of these approaches and others would be useful. Adolescent Development, Recreation, or Employment? In an era of limited resources, it is essential to ascertain what proportions of available funds can be allocated optimally to initiatives that aim, respectively, at adolescent development, recreation, employment, or other goals. The guidelines for this task will be determined largely by the particular subpopulations of adolescents under consideration. Thus, adolescents from economically impoverished families or neighborhoods may benefit relatively more than other adolescents from programs that offer job skills training or employment opportunities. Nevertheless, the goals of adolescent development, recreation, and employment need not be mutually exclusive. Many types of programs can progress toward all three objectives albeit in varying respects and at differing rates. 33M Ovewiew of F~e~ expenditures on adolescents is preSentd in cb. 19, The Role of Federal Agencies in Adolescent Heal@ in Vol. III.
PAGE 103
Chapter 4Schools and Discretionary Time //-99 Extent of Adult Involvement and Supervision Adult involvement may be necessary in the design or supervision of especially complex or demanding programs and for programs that are geared primarily toward younger adolescents. To the extent possible, though, adolescents themselves should be actively engaged in the design and operation of their own programs. In some cases when adults are involved, professional training may be desirable. Such training may be particularly important for the design and implementation of programs that require extensive expertise in administration or for programs that serve large numbers of seriously disturbed adolescents. Graduate training in adolescent work and the related helping professions has proven beneficial in programs for such high-risk populations as antisocial adolescents (67) and adolescents whose parents are mentally ill (68). Clearly, however, adult volunteers can contribute safely and cost-effectively to the vast majority of programs that aim to promote health-enhancing activities on the part of adolescents. A more concerted effort to involve adult volunteers may be needed. Because some of the adolescents and institutions volunteers may be dealing with may present serious obstacles, it will be important to provide appropriate support and referral networks to adult volunteers. Differing Needs for Differing Adolescent Populations Fairly little is known about the differing developmental needs of particular groups of adolescents. Patterns may or may not be similar in varying subcultures. Increased peer-group orientation and a growing interest in group activities during early and middle adolescence has been observed concurrently, for instance, in England (187), Australia (78), and the United States (67). Yet, a crosscultural study of school dropouts has shown that Australian and American adolescents who quit secondary school use their leisure time in different ways (15). Australian school leavers typically spend their extra time in sports and recreation. By contrast, American dropouts report more visiting, loafing, and problem behaviors. The investigators posit that these differences reflect the differential structuring of available activities for adolescents in the two societies rather than national differences in leisure preferences. They suggest further that some of the deleterious consequences that are presumed to follow from dropping out in America reflect the daily social experiences of dropouts in this country more than the act of quitting school. Cultural and subcultural variations often are evident in the use of discretionary time by adolescents. Hispanic adolescents, for instance, devote more time than white non-Hispanic adolescents to television viewing (87). White adolescents are more likely to have paid jobs than black adolescents (66a). Yet these variations also may reflect such factors as the decreased availability of two-parent families for certain categories of adolescents, more dual-career couples, reduced employment opportunities, and dimini shed community availability of leisure alternatives such as public libraries, after-school programs, and for-profit or nonprofit youth service agencies. A study of Chicago neighborhoods has shown, for instance, that in areas where the median family income is below $25,000, the average number of children per each available public library is twice the number of children in areas with higher family income (196). More than twice as much money was spent per child on libraries in the more affluent neighborhoods. Adolescent programs can profitably bring together adolescents from differing social, cultural and behavioral backgrounds. The most dramatic examples in this regard pertain to programs that integrate adolescents with behavioral problems into groups of normal peers in classroom or recreational settings (23,39,47,88,170,217). Peer-based therapy programs for adolescents typically have been regarded as failures when interventions were attempted solely in groups comprised of antisocial peers and at institutions denoted primarily as correctional or mental health settings (13,109,131,214). The latter tend to be unnecessarily stigmatizing. In contrast, experimental evidence suggests that antisocial adolescents are more likely to achieve behavioral gains when they are treated among prosocial peers and when the interventions are offered in nonstigmatizing environments such as community centers (67). Adolescents needs may also be different at different times of the day. OTA observes that more programs and facilities are available during the day, but not at night or on weekends when adolescents may have little to do. Some communities have setup Friday night dances, midnight basketball sessions, and the like, but these seem to be the exception rather than the rule. Often, administrative convenience
PAGE 104
II-100 Adolescent Health-Volume II: Background and the Effectiveness of Selected Prevention and Treatment Services rather than adolescent need seems to be the determining factor in program development. National Youth Service Since the days of the post-Depression Civilian Conservation Corps (CCC), there has been debate in this country concerning the desirability of a national youth service. The factors that are regarded as important to the success of the CCC ought perhaps to be considered as criteria for the evaluation of future proposals concerning a national youth service (57). First, the CCC was operated with a clear sense of purpose, namely, conservation work and economic support, as opposed to purely adolescent development objectives. Second, the CCC emphasized productivity. Third, many CCC projects were highly visible to surrounding communities and to the country at large. Fourth, local communities had a voice in projects undertaken by the CCC. And, fifth, each CCC camp made distinct contributions to the local economy. New models of national youth service have been endorsed by groups such as The Commission on Work, Family and Citizenship of The William T. Grant Foundation (210), advocacy organizations such as the Coalition for National Service (56), and the public in general, who favor voluntary service by a ratio of better than seven to one (56). Because of the size, visibility and vast impact of any form of national youth service, public acceptance of such an initiative will depend upon the answers to a variety of questions. These are likely to be based not only on economic considerations but on philosophical and political ones as well. To cite but a few: Should a national service program be mandatory or voluntary? Should it be in lieu of military service or in addition to it? Should it be during high school or afterwards? Should it offer economic incentives to the participants or not? What is the preferred length of service? Will participants necessarily replace employed adult workers? What should be the respective roles of federal and local authorities? And, what are the relative economic costs and benefits? Few of these questions can be answered definitively. Yet, several key considerations are worth noting. With regard to financial costs and benefits, for example, a study of the California Conservation Corps by Public/Private Ventures estimates $1.34 in benefits for each dollar spent in the program (210). A second study suggests that the proportionate benefit is even higher, to wit, $1.60 in public benefit for each dollar spent by the Corps (210). The Job Corps has been similarly evaluated. Analyses have shown that the Job Corps increases earnings, enables its graduates to be employed longer, and helps many to goon to full-time study (210). From 1934 through 1939,90,000 acres of land in the Capitol Forest in Washington State was reforested by the CCC at an approximate cost $270,000 (101). In 1981, the acreage was harvested, and the timber value was placed conservatively at $7,000 per acre, or $630,000,000. Examples such as this dramatize not only the fact that significant financial benefits can accrue from large-scale youth service programs but also that planners and politicians must calculate their relative benefits on along-term basis. They must act upon the same principles of delayed gratification that are regarded as so essential to the development of healthy adolescents. Revitalization and Reinstitution of Social Service Agency Programs In the past several decades, much of the Nations organizational infrastructure for adolescent development programs has deteriorated. Traditional social service agencies such as neighborhood houses and community centers have increasingly relocated to affluent suburban areas; they have employed nonprofessional and volunteer personnel more readily than professionals; and they reduced the quantity and quality of their programs for adolescents (200). Nevertheless, neighborhood houses, community centers, and other social service agencies can constitute excellent settings for leisure and community service programs for adolescents of all ages. Many observers believe they may be more productive sites for helping high-risk adolescents than conventional types of treatment organizations (68). The developmental gains that are achieved by adolescents in such settings can be readily generalized to their natural environments and can be achieved on the basis of expenditures that may be as much as 80 percent lower than for comparable intervention programs in mental health or juvenile justice settings (67). A significant revitalization of social service agencies would require a major infusion of Federal, State, and local support. Among other things, funds will be necessary to train professionals and volunteers and perhaps construct or renovate facilities in
PAGE 105
Chapter 4Schools and Discretionary Time l II-101 Photo credit: Youth Service America Revitalized social service agencies could work to develop volunteer opportunities that strengthen intergenerational connections among adolescents and adults from different social and economic backgrounds. high-need areas. Revitalized social service agencies could explore new ways to involve adolescents in instrumental tasks as well as in purely recreational activities. They could sponsor nonprofit or for-profit adolescent-operated enterprises and can provide seed money, technical assistance and supervision. They can work with schools to develop leisure counseling centers and can develop volunteer opportunities that strengthen intergenerational connections among adolescents and adults from different social and economic backgrounds. They also could establish funded positions for adolescents to serve as apprentice-level adolescent workers. Recent Federal Initiative: National and Community Service Act of 1990 In 1990, Congress passed a law designed to enhance opportunities for national and community service for all U.S. citizens, particularly the disadvantaged. This law, the National and Community Service Act of 1990 (Public Law 101-610), authorizes Federal financial assistance for a number of voluntary service programs, including programs for in-school and out-of-school adolescents. In presenting the rationale for the legislation, the senatorial authors of the legislation argued in part that (S. 1430, 101st (1) (2) (3) (4) (5) (6) Congress, 2d session): service to the community and the Nation is a responsibility of all citizens of the United States, regardless of the economic level or age of such citizens; citizens of the United States who become engaged in service at a young age will better understand the responsibilities of citizenship and continue to serve the community into adulthood; serving others builds self-esteem and teaches teamwork, decisionmaking, and problemSolving; the 70,000,000 youth of the United States who are between the ages of 5 and 25 offer a powerful and largely untapped resource for community service; conservation corps and human service corps provide important benefits to participants and to the community; the Volunteers in Service to America Program is one of the most cost effective means of fighting poverty in the United States. Many of the activities and program requirements authorized by the National and Community Service Act of 1990 (Public Law 101-610) are particularly relevant to adolescents. Title I of the National and Community Service Act of 1990 establishes a National and Community Service State Grant Program. Several subtitles of Title I are relevant to adolescents: --Subtitle B. School-Aged Service (Seine America; The Community Service, Schools and Service Learning Act of 1990). 34 This subtitle provides Serve America grants to States or local applicants for service-learnin g programs ~
PAGE 106
11-102. Adolescent HealthVolume II: Background and the Effectiveness of Selected Prevention and Treatment Services for students, 35 community service programs, and adult volunteer programs. For the latter two programs, dropouts and other out-of-school youth (individuals under age 27 who have not completed college or the equivalent and who are not in school) are target participants and recipients. Serve America grants will be administered by the Commission on National and Community Service established under Subtitle G (202b). -Subtitle C. American Conservation and Youth Corps (American Conservation and Youth Service Corps Act of 1990)-This authorizes grants to States, Indian tribes, local agencies, to the Secretary of Agriculture, to the Secretary of the Interior, or to the Director of ACTION for the creation or expansion of full-time or summer youth service programs focusing on conservation and human services. Full-time youth service programs are intended for 16to 25-yearolds, and the summ er youth service programs are intended for 15to 21-year-olds. The law requires that participants educational levels be assessed and that participants be provided with appropriate education and training. Priority for services must be given to participants without high school diplomas, and the program must enable such participants to earn a diploma or its equivalent. Arrangements may be made with schools to upgrade literacy skills, obtain high school diplomas or the equivalent, obtain college degrees, or improve work skills. Youth corps grants will be administered by the Commission on National and Community Service (202b). -Subtitle D. National and Community Service (National and Community Service Act )-This authorizes grants to States and Indian tribes for the creation of fulland part-time national and community service programs to address unmet educational, human, environmental, and public safety needs, especially those needs relating to poverty. The programs will include fulland part-time volunteers age 17 and older. National and Community Service grants will be administered by the Commission on National and Community Service (202b). -Subtitle E. Innovative and Demonstration Programs and Projects-One part of this provides for grants to States and Indian tribes for the creation of innovative volunteer service programs. Section 165 authorizes a rural youth service demonstration project. Projects may include volunteer service involving the elderly and assisted-living services performed by students, school dropouts, and out-of-school youth. -Subtitle G. National Commission on National and Community Service-This establishes the National Commission on National and Community Service to administer Title I programs. The Commission is to be composed of 21 members to be appointed by the President. The Secretary of Education, Secretary of Health and Human Services, Secretary of Labor, Secretary of Interior, Secretary of Agriculture, and the Director of ACTION shall serve as ex-officio members of the Commission. Not later than January 1, 1993, the President shall prepare and submit to Congress a report containing recommendations for the improvement of the administration and coordination of volunteer, national, and community service programs administered by ACTION, the Commission on National Service, and other Federal entities. Congress authorized $56 million for Title I in fiscal year 1991, $95.5 million in fiscal year 1992, and $105 million for fiscal year 1993. In each of these years, not less than 30 percent is to be allocated for subtitle B, not less than 30 percent for subtitle C, and not less than 30 percent for subtitle D. In each year, Congress authorized $2 million for the National Commission on National and Community Service. Title II of the National and Community Service Act of 1990 modifies a number of existing programs. The following subtitles are relevant to adolescents: -Subtitle B. Youthbuild Projects (amends the Domestic Volunteer Service Act of 1973 (42 USC 4951 et seq)--This provides for the Director of ACTION, in consultation with the Secretary of Labor, to provide Federal grants for Youthbuild projects. Such projects, which involve constructing and rehabilitating housing ss~e law defines service 1 earning as a method under which students learn and develop through active participation in organized service experiences that meet actual community needs and that are coordinated in collaboration with the school and community; that is integrated into the students academic curriculum; that provides students with opportunities to use newly acquired skills and knowledge in real life situations in their own communities; and that enhances what is taught in school by extending student learnin g beyond the classroom into the community and helps to foster the development of a sense of caring for others (Title I, Subtitle A, Sec. 101. Defdtions).
PAGE 107
Chapter 4Schools and Discretionary Time II-103 and community facilities (e.g., youth recreation centers, senior citizen centers, community health centers) for low-income people, are intended to provide economically disadvantaged young people with opportunities for service to their communities and opportunities to obtain education and employment skills. At least 75 percent of the participants must be individuals who are ages 16 to 24, economically disadvantaged, and high school dropouts whose reading and math skills are at or below the eighth grade level. Projects must provide basic skills instruction and remedial education, bilingual education for participants with limited English proficiency, and secondary education leading to a high school diploma or its equivalent. -Subtitle C. Amendments to Student Literacy Corps (amends the Higher Education Act of 1965 (20 USC 1018)--This amends the act to give priority in providing tutoring services to educationally disadvantaged students receiving services under Chapter 1 of Title I of the Elementary and Secondary Education Act of 1965 and to, illiterate parents of educationally or economically disadvantaged elementary school students, with special emphasis on single-parent households. For Title II, Congress authorized $5 million for fiscal year 1991, $7.5 for fiscal year 1992, and $10 million for fiscal year 1993. While the total amounts authorized for programs with a considerable emphasis on adolescents are not very large, the National and Community Service Act of 1990 does begin to address many of the concerns about adolescent rolelessness and preparation for the future expressed by numerous observers (160,330). It is too early to judge the effectiveness of the legislation in improving the lives of adolescents, but Congress could encourage the newly established Commission on National and Community Service (also established by Public Law 101-610), to evaluate systematically the impact on adolescents in the Commissions report to Congress. Conclusions and Policy Implications Time spent in school and time spent in discretionary (nonschool, nonmaintenance) activities constitute large segments of an adolescents life. Outside the family and home, 36 important and influential environments for adolescents include school buildings and personnel, and peers and adults in community settings (including the media). This chapter has reviewed several shortcomings in many school and other environments and suggested ways in which these environments can be improved. Although little systematic empirical research has been supported, the studies that have been conducted suggest that academic and health outcomes of adolescent students are influenced by school environments. Overall, school environments that facilitate adolescent well-being take the shape of small (fewer than 1,000 students in the school, and 15 to 20 per class), comfortable, safe, intellectually engaging, and emotionally intimate communities. Transitions are minimized, and when they must occur, they are managed with a view toward meeting the developmentally appropriate needs of adolescents. Teachers are encouraged to initiate and develop new programs that are sensitive to the diversity of their students. The curriculum responds to individuality as well as to differences, while developing a common knowledge base among students in a particular school. Teacher, parent, and student participation in decisionmaking is encouraged. Unfortunately, this combination of features characterizes few schools, particularly those public schools serving socioeconomically and educationally disadvantaged students, many of whom are racial and ethnic minorities. Instead, the larger, often impersonal, schools that these students attend have been found to be associated with higher rates of retention in grade, suspensions from school, discipline and crime problems, lowered social cohesion, more negative student attitudes, and greater student passivity (including lower participation in school activities, and less interaction with faculty). Specific practices such as tracking and teaching to the test for minimum competency testing have been associated with lowered levels of academic achievement, retention in grade, and school dropout, especially for low income racial and ethnic minority 36pacnts ~d f~liea$ ~uenceS on adolescent he~~ me reviewed inch. 3, Paren@ and F~hes ~uen~ on Adolescent Health, and elsewhere in this volume.
PAGE 108
//-104 Adolescent HealthVolume II: Background and the Effectiveness of Selected Prevention and Treatment Services students. Although school practices and policies are rarely investigated for their direct links to adolescent health and well-being, studies have shown that lower grades are associated with violence toward school property, other delinquency, and pregnancy. Students who are retained in grade school are more likely to drop out of school before graduation. In turn, school dropout is associated with high rates of subsequent poverty and unemployment, underemployment, diminished earnings, and adolescent pregnancy and parenting. Adolescents, particularly females, can be particularly harmed by the transition from elementary to middle or junior high school grades, if such transitions are not handled well in the middle school setting. The environment of the typical junior or middle school adolescent has been found to clash with early adolescents needs for autonomy, their budding cognitive abilities to think at an abstract level, their heightened needs for intimacy, and their heightened self-consciousness. Teachers attitudes and parental involvement are critical links in the relationships between school policies and environments and health outcomes for adolescents. Teachers attitudes toward students tend to be more positive in schools that are smaller, use decentralized governance and participatory decisionmaking, and rely less on standardized testing. Parental involvement in schools has been shown to be related to increasing the responsivity and efficiency of schools and to fair treatment of students, but the evidence on academic achievement is mixed. Some interventions have yielded increased tolerance across racial groups and improvements in the self-esteem or academic achievement of racial and ethnic minorities; these interventions include exposure to persons of differing cultural backgrounds, learning in mixed-ability groupings, a multicultural curriculum, bilingual education, and school-based collaborations with minority communities. Much of adolescents time is spent away from school. The scarce data that are available suggest that sufficient opportunities do not exist for adolescents to spend their discretionary time in ways that are attractive and satisfying, conducive to healthy development, and acceptable to the adult community. The problem has been found to be worse in poor than in middle-class communities. The Federal share in funding for schools (6.3 percent of public school revenues in 1988) rose until 1980, when it began to fall again. Financial and progr ammatic support for recreation and youth service activities from Federal, State, and local governments, and the private for-profit sector, has been meager and fragmented. Federal support for 4-H clubs and, more recently, the National and Community Service Act of 1990 (Public Law 101-610) is an exception. Chapter 4 References 1. 2. 2a. 3. 4. 6. 7. 8. 9. 10. IOa. 11. 12. 13. 14, 15. 16, Academy for Educational Developmenfi A Stitch in Time (New Yorlq NY: 1989). ACTION, Young Volunteers in ACTION Evaluation: Final Report (Washington DC: 1986). Adelman, H., and Taylor, L., Mental Health Facets of the School-Based Health Center Movement: Need and Opportunity for Research and Development, in press, IJM Angeles, CA, December 1990. Anderson, B.E., and Sawhill, I.V. (eds.), Youth Employment and Public Policy (J@lewood Cliffs, NJ: Prentice-Hall, 1980). Anthony, K.H., The Shopping Mall: A Xbenage Hangout Adolescence 20(78):308-318, 1985. AronsorA E., The Jigsaw Classroom (Beverly Hills, CA: Sage Publications, 1978), ASP~ of New York Inc., Racial and Ethnic High School Dropout Rates in New York City: A Summary Report @lew York NY: 1983). BacJ.G., Johnsto~ L.D., and OMalley, P.M., Monitoring the Future: Questionnaire Responses From the Nations High School Semors (Arm Arbor, MI: Institute for Social ResearciL University of MichigU 1987). Bachrach, S., Bauer, S., and Shedd, J., The Work Environment and School Refo~ Tuchers College Records 88(2):241-256, 1986. Barnett, S., Benefit-Cost Analysis of the Perry Pre-School program and its Policy Implications, Educational Analysis and Policy Analysis 7(4):333-342, 1985, BZUTOW, S.M., and Kolsta& A., WhO DrOpS out of High School: Findings From High School and Beyond contract report prepared for the Center for Education Statistics, Offke of Educational Research and Improvement, U.S. Department of l?ducatio~ Washington DC, May 1987. Becker, HJ., Aakiressing the Neeak of Diflerent Groups of Early Molescents: E#ects of W-ying School and Classroom Organizational Practices on Students From Diflerent Backgrounds and Abilities (Baltimore, MD: Center for Research on Elermmtary and Middle Schools, Johns Hopkins University, June 1987). Berl% N., Henderson, A.T., and Kerewsky, W., The Middle School Years: A Parents Handbook (Columbia, MD: National Committee for Citizens in Educatio~ 1989). Berlemq W.C., Seaberg, J.R., and Stem T.W,, The Delinquency Prevention Experiment of the Seattle Atlantic Street Center: A Final Evaluation Soaa/ Service Review 42:323-347, 1972. Berl@ G., and Sum, A., Ibward a More Perfect UnioXL paper prepared for the Ford Foundation, New York NY, 1988. Biddle, BJ., BanJG BJ., Anderson, D. S., et al., The Structure of Idleness: In-School and Dropout Adolescent Activities in the United States and Australiq Sociology of E&cation 54:10& 119, 1981. Blake, J., Is Zero Preferred? American Attitudes lbward Childlessness in the 1970s, Journal of Marriage and the Family
PAGE 109
Chapter 4Schools and Discretionary lime l //-105 17. 18. 19. 20. 21. 22. 23. 24. 25. 26. 27. 28. 29. 30. 31. 32. 32a. 33. 34. 35 36. 37. 4:245-265, 1979. Bloland, P.A., hiSure as a Campus Resource for Fostering Student Development, Journal of Counseling and Development 65:291-294, 1987. Blyth, D.A., Simmons, R. G., and Carlton-Ford, S., The Adjustments of Early Adolescents to School Transitions, Journal of Early Adolescence 3(1-2) -105-120, 1983. Boy Scouts of Americ~ Local Council Index: A Three-Year Comparison, 1981-1984 (Irving, TX: 1984). Boys Clubs of America, Annual Report, 1983 (New York NY: 1984). Boys Clubs of Americ& Profde Sheet, New Yorlq NY, June 3, 1988. Braddock, J., Wu, S., and McPartland, J., School Organization in the MiaWe Grades: National Variations and Effects (Baltimore, MD: Center for Research on Elementary and Middle Schools, Johns Hopkins University, 1988). Bradfield, R.H., Brown, J., Kapl~ P.P., et al., The Special Child in the Regular Classroom, Exceptional Children 39:384390, 1973. Bryk, A. S., and Driscoll, M.E., The High School as Community: Contextual Influences and Consequences for Students and Teachers (Madison, WI: National Center for Effective Secondary Schools, University of Wisconsiq 1988). Bryk, A. S., Lee, V., and SmittL J., High School Organization and its Effects on Wchers and Students: An Interpretive s ummaxy of the Researck Choice and Control in American Education, Vol. I, W.H. Klune and J.F. Witte (eds.) (Imndou England: Fahner Press, 1990). Calabrese, R. L., and Schumer, H., The Effects of Service Activities on Adolescent Alienation Adolescence 21:675-687, 1986. Carnegie Corporation of New York Carnegie Council on Adolescent Development Task Force on Education of Young Adolescents, Thrning Points: Preparing American Youth for the Zlst Century (WashingtorL DC: June 1989). Carnoy, M., and McDonnell, J., School District Restructuring in Santa Fe, New Mexico, unpublished manuscrip~ Stanford University, Palo Alto, CA, 1989. Cherlm A., Mamage, Divorce, Remarriage: Changing Patterns in the Postwar United States (Cambridge, MA: Harvard University Press, 198 1). Chubb, J.E., and Moe, T. M., Give Choice a Chance, Florida Policy Review 5:17-24, 1989. Coen, P., Kuhkj L., and Kul~ C., Educational Outcomes of fbtoring: A Meta-Analysis of Findings, American Educational Research Journal 19(2):237-248, 1982. Cogne~ P. V., and SpMthall, N.A., Students as Tkachers: Role Taking as a Means of Promoting Psychological Develop ment During Adolescence, 141ue Development as the Aim of Education, N.A. Sprinthall and R.L. Mosher (eds.) (Schenectady, NY: Character Research Press, 1978). Colema J. S., et al., Equality of Educational Opportunity (Washington DC: U.S. Gove rnment Printing OffIce, 1966). Colletti, G., and Harris, S. L., Behavior Moditlcation in the Home: Siblings as Behavior Moditlers, Parents as Observers, Journal of Abnormal Child Psychology 5:21-31, 1977. Columbia University, Conservation of Human Resources Projec4 The Youth Budget: Expenditures, Equity and Eflciency. Final Policy Report, (Washington DC: U.S. Department of Educatio% Office of Educational Research and Improvement, October 1982). Comer, J., Educating Poor Minority Childre% Scientific American 259(5):4248, 1988. Conrad, D., and Hedi% D., National Assessment of Experiential Education: A Final Report (St. PauI, MN: Center for Youth Development and Researcb University of Minneso@ 1981). Congressional Quarterlys Editorial Research Reports, Why Schools Still Have Tracking, Editorial Research Reports 38. 39. 40. 41. 42. 43. 44. 45, 46. 47. 47a. 48. 49. 50. 51. 52. 53. 54. 55. 56. 57. 57a. 1(48):746. COOQ T.D., and Walberg, H.J., The High Schoo/ as Community. Contextual Influence for Students and Teachers (MadisoG WI: National Center on Effective Secondary Schools, University of Wiscons@ 1985). Cooke, T.P., Apollonij T., and Cooke, S.A., Normal Preschool Children as Behavioral Models for Retarded Peers, Exceptional Children 43:531-532, 1977. Corcom T.B., Walker, L., and White, J., Working in Urban Schools (WashingtorL DC: Institute for Educational Leadership, 1988). Costello, I., CriteriaforEvaluating and Planning Public Policies for childreq unpublished manuscript, University of Chicago, Chapin Hall Center for Childreq Chicago, IL, 1980. Crespi, P., Sorting Out the Video Game Controversy, Parkr and Recreation 17(5):28-31, 1983. Cummins, J., Empowering Minority Students: A Framework for Intervention Harvard Educational Review 56(1):18-36, 1986. Czikszentmihalyi, M., and Larsom R., Being Adolescent: Conflict and Growth in the Teenage Years (New York NY: Basic Books, 1984). Dade County Public Schools, Ofilce of Educational Accountability, Interim Evaluation Report School Based Management: Shared Decision-Making project 1987-88, Project Wide Findings, Dade County, FL, October 1988. Danzig, R., and Szanto% P., National Service: What Would It Mean? (Lexington, MA: D.C. Heath& Co., 1987). Deno, E.N., Instructional Alternatives for Exceptional Children (Arlingto~ VA: Council for Exceptional childre~ 1973). Deut.sch, M., Educating Beyond Hate, paper prepared for a seminar titled The Anatomy of Hate, Bosto% m Mar. 19, 1989. DineerL J.P., Clark H.B., and Risley, T.R., Peer lhtoring Among Elementary Students: Educational Benefits to the fbtor, Journal of Applied Behavior Analysis 10:231-238, 1977. Dorosti D., DAndrea, V., and Jacks, R., A Peer Counselor Training Program: Rationale, Curriculum, and EvaluatiorL Boys Town Center for the Study of Youth Development Stanford University, Stanford, CA, April 1976. Dowd, E.T., Leisure Counseling With Adults Across the Life Span, Leisure Counseling: Concepts and Application, E.T. Dowd (cd.) (Springfield, IL: Charles C. Thomas, 1984). Dryfoos, J., Adolescents at Risk: Prevalence and Prevention (New York: Oxford University Press, 1990). Dune% G., For the Conflicts of You@ Help From a Peer, New York Times, p. Al, Feb. 9, 1987. Earle, J., Roacb V., and Fraser, K., Female Dropouts: A New Perspective (Alexa.ndri% VA: National Association of State Boards of Educatio~ 1987). Earle, J., Roac4 V., and Kysilko, D., Whats Pronusing: New Approaches to Dropout Prevention for Girls (Alexandria, VA: National Association of State Boards of Educatiom 1987). Easterl@ R.A., and Crimmins, E. M., Recent Social Trends: Changes in Personal Aspirations of American Youti Sociology and Social Research 72(4):217-223, 1988. Eberly, D.J., National Service and the High School, National Association of Secondary School Principals Bulletin 73:53-60, 1989. EberIy, D.J., and Sherradeq M., United States: Several Noteworthy Programs, The Moral Equivalent of War? A Study of Non-Military Service in Nine Nations, D. Eberly and M. Sherraden (eds.) (Westport, CT: Greenwood Press, 1990). Eccles, J., and Midgley, C., Stage-Environment Fit: Develop mentally Appropriate Classrooms for Young Adolescents, Research on Motivation in Education, Volume 3, Goals and Cognition, C. Ames and R. Ames (eds.) (San Diego, CA: Academic Press, 1989).
PAGE 110
II-106 Adolescent HealthVolume II: Background and the Effectiveness of Selected Prevention and Treatment Services 58. 58a. 59. 60. 61, 62. 63. 64. 65. 66. 66a. 67. 68. 69. 70, 71. 72. 72a. 73. 73a. 74. 75. 76. 77. 78. EdgintoL C.R., and Cannon, E.C., Jr., Family Wcation College: A Unique Family bisure Learning Experience, Leisure Today 58:14-16, 1984. Education Writers Association (WashingtoXL DC), High Strides, Vol. 3, No. 4, Jane 1991. Emmons, R.A., and Diener, E. A Goal-Affect Analysis of Everyday Situational Choices, Journal of Research in Personality 20:309-326, 1986. Ericksmq J.B., Nonformal Education in Organizations for American Yout& Children Toaizy 15:17-25, 1986. Ericksou J.B., Directory of American Youth Organizations, 3rd ed. (Minneapolis, MN: Free Spirit Publishing Co., 1989). Fag% J., and Pabou E., Contributions of Delinquency and Substance Abuse to School Dropout New York City Giminal Justice Agency, New Yorlq NY, 1988, Farel, A.M., After-School Activities Questionnaire: A Preliminmy Study of Parents Preferences and Needs, unpublished manuscript, University of North Carolina Center for Early Adolescence, Carrboro, NC, 1983. Farley, J., Activities and Pastimes of Children and Youth: Age, Sex, and Parental Effects, Journal of Comparative Fawly Studies 10(3):385410, 1979. Feather, N. T., and Bond, M.J., Time Structure and Purposeful Activity Among Employed and Unemployed University Graduates, Journal of Occupational Psychology 56:241-254, 1983. FelR. A., Group Work With Antisocial Youths, Individual Change Through Small Groups, 2nd cd., M. Sundel and P.M. Glasser (eds.) (New York NY: Free Press, 1985). Feldman, R. A., How CarI Society Contribute to Meaningful Use of Adolescents Spare Time? contract paper prepared for the Offlce of lkchnology Assessment, U.S. Congress, Washington, DC, January 1990. Fel@ R.A., Caplinger, T.E., and Wodarski, J. S., The St. Louis Conundrum: The Effective Treatment of Antisocial Youths (Englewood Cliffs, NJ: Prentice-Hall, 1983). FeMrna.q R.A., Stiffq A.R., and Jung, K.G., Children at Risk: In the Web of Parental Mental Illness (New Brunswick, NJ: Rutgers University Press, 1987). Fine, M., Silencing in the Public Schools, L.unguage Arts 64(2):157-174, 1987. Fine, M., Silencing and Nurturing Voice in an Improbable Context: Urban Adolescents in Public Schools, Schooling and the Politics of CuZture, H. Giroux and P. McLaren (eds.) (Albany, NY: SUNY Albany PK.SS, 1989). Fine, M., Professor, Graduate School of Educatio~ University of Pennsylvania, Philadelphi& PA, personal communicatioxL 1990. Fine, M., Framing Dropouts: Notes on the Politics of an Urban High School (Albany, NY: SUNY Press, 1990). Fine, M., Middle and Secondary School Environments as They Affect Adolescent Well-Being, contract paper prepared for the Office of lkchnology Assessment, U.S. Congress, WashingtorL DC, May 1990. Fine, M., and Phillips, L., Reflections on Activist Research: Mistakes and Possibilities (Boston, MA: American Psychological Association, 1990), Foley, E., and Crull, P., Educating the At-Risk Adolescent: More Lessons From Alternative High Schools (New Yorlq NY: Public Education Association 1984). Garbarino, J., Some Thoughts on School Size and its Effects on Adolescent Development, Journal of Youth and Adolescence 9(1):19-31, 1980. Garbarino, J., and Asp, C. E., Successjid Schools and Competent Students (LexingtorL MA: Lexington Books, 1981). Garbarino, J., Children and Families in the Social Environment (New York NY: Aldine Publishing, 1982). Garflnkel, I., and McLanahan, S. S., Single Mothers and Their Children (Washington, DC: Urban Institute Press, 1986). GartoIL A.F., and Pratt, C., Participation and Interest in Leisure Activities by Adolescent SchoolchiMreq Journal of Adoles79. 80. 80a. 81a. 82. 83. 84. 84a. 85. 86. 87. 88. 89. 89a. 89b. 90. 91. 92. 93. 94. 95, 96. 97. cence 10:341-351, 1987. George, P., A Response to Yoder: But We Do Need Good Middle Level Schools, Eakational Leadership 40(2) :5@51, 1982. Gerber, M., and KauffmarL J.M., Peer Ibtoring in kademic Settings, The Utilization of Classroom Peers as Behavioral Change Agents, P.S. Strain (cd.) (New Yorlq NY: Plenum Press, 1981). Gibbs, J. T., BrunswiclG A.F., Conner, M.E., et al., Young, BZack, and Male in America: An Endangered Species (Dover, MA Auburn House Publishing Co., 1988). Girls Clubs of Americ%Annual Report (New Yoxk, NY: 1988). Glass, G. V., and Smit.tL M.L., Meta-Analysis of Research on the Relationship of Class Size and Achievement (Boulder, CO: Laboratory of Educational ResearclL University of Colorado, September 1978), GoodlaL J.I., SirotnilG K. A., OveB.C., An Overview of A Study of Schooling, Phi Delta Kappan 61:174-178, 1979. Gottfredsoq G.D., You Get What You Measure, You Get What You Dont: Higher Standirrds, Higher Test Scores, More Retention in Grade (report #29) (Baltimore, MD: Center for Research on Elementary and Middle Schools, Johns Hopkins University, 1988). Gottfredsoq G.D., American Educatio6mencan Delinquency (Baltimore, MD: Centez for Research on Elementary and Middle Schools, Johns Hopkins University, May 1988). GottfiedsorL G.D., Kanvei4 N.L., and Gottfredson, D.C., Reducing Disorderly Behavior in Miaiile Schools (report #37) (Baltimore, MD: Center for Research on Elementary and Middle Schools, Johns Hopkins University, 1989). Graham, P. A., Achievement for At-Risk Students, School Success for Students at Risk, Council of Chief State School Officers (eds.) (Orlando, FL: Harcourt Brace JovanovicL 1987). Greenberg, B. S., and Heeter, C., Mass Media Orientations Among Hispanic YoutlL Hispanic Journal of Behavioral Sciences 5(3):305-323, 1983. Guralnic~ MJ., The Wlue of Integrating Handicapped and Nonhandicapped Preschool Childrerq American Journal of Orthopsychiatry 46:236-245, 1976. HalhnmL M.T. (cd.), The Social Orgamzation of Schools (New York NY: Plenum Press, 1987). Hall@ M.E, Ability Groupings and Sex Differences in Mathematics Achievement, The Social Organization of Schools, M.T. Hallinan (cd.) (lIew York NY: Plenum Press, 1987). HaWnaXL M.E, and Williams, R.A., Interracial Friendship Choices in Secondary Schools, American Sociological Review 54(1):67-78, 1989. Hamilton, S.F., and Fenzel, L.M., The Impact of Volunteer Experience on Adolescent Social Development: Evidmce of Program Effects, Journal of Adolescent Research 3(1):65-80, 1988. Haney, W., and Madaus, G., Searching for Alternatives to Standard Iksts: Whats and Whithers, Phi Delta Kappan 70(9):683-687, 1989, Hanks, M., Youth Voluntary Associations and Political Socialization Social Forces 1:2 11-223, 1981. Hanks, M., and Eckland, B., Adult voluntary Associations and Adolescent Socialization, Sociological Quarterly 19:481-490, 1978. Hardey, R., New Jersey Curbs Spending on All Schools, New York Times p. 25, June 23, 1990. Harper, J.A., and Searle, M. S., Together Is Better: A Nation Rediscovers the Family, Leisure Today 58:14-16, 1984. Hart, K., Values Progr amming in Family EducatioG Leisure Today 58:8-10, 1984. He@ D., Students as Ikachers: A Tbol for Improving School Climate and Productivity, paper presented at the Carnegie
PAGE 111
Chapter 4-Schools and Discretionary lime .11-107 98. 99. 99a. 100. 101. 102. 103. Forum on Education and the Economy, Carnegie Foundation New York NY, 1986. Hedti D., Summary of the Familys View of After-School Time (Minneapolis, MN: Center for Youth Development and ResearcL University of Minneso@ July 1986). Heyns, B., S urmner Programs and Compensatory Education: The Future of an Idea, working paper for the OffIce of Educational Research and Improvement, U.S. Department of Educatiou presented at a conference on the Effects of Alternative Designs in Compensatory Educatio~ Washingto% DC, 1986. Higgins, C., Furano, K., lbsco, C., et al., I Have A Dream in Washington, DC: Initial Report (Philadelphia, PA: Public/ Private Ventures, Winter 1991). Hispanic Policy Development Program, Washington, DC, and New York NY, The Research Bulletin 1(3):3, Fall 1989. Human Environment Center, Background information on YACC Activities in Washington and Oregon (Washington DC: 1986). Iadicola, P., Schooling and Symbolic Violence: The Effect of Power Differences and Curriculum Factors on Hispanic Students Atthudes Toward Their Own Ethnicity, Hispanic Journal of Behavioral Sciences 5(1):21-43, 1983. Iso-Ahola, S.E., The Social Psychology of Leisure and Recreation (Dubuque, IA: Brow 1980). 103a. Jencks, C., Smi@ M., Acldand, H., et al., Inequality: A 104. 105. 106. 107. 107a. 107b. 107C. 108. 108a. 108b. 109. 110. 111. Reassessment of the Effect of Family and Schooling in America (New York, NY: Basic Books, 1972). Johnson+ D.W., Johnsou R. T., Roger, P., et al., Oral Interaction in Cooperative Learning Groups: Speaking, Listening, and the Nature of Statements Made by Higk Medium-, and bwAchieving Students, Journal of Psychology 119(4):303-321, 1985. Keith, J.A., Hoopfer., L., Nelson, C., et al., Michigan Early Adolescent Survey: Final Report (East Lansing, MI: Michigan State University Cooperative Extension Service, 1986). Kelly, J. R., Leisure (Englewood Cliffs, NJ: Prentice-Hall, 1982). Kerewsky, W., and Lefste@ L. M., Young Adolescents and Their Community: A Shared Responsibility, 3.00 to 6:00 PM: Programs for Young Adolescents, L.M. hfstein and J. Lipsitz (eds.) (Carrboro, NC: Center for Early Adolescence, 1982). Kerr, P. Good News for Ftorio, New York Times, p. B-4, June 6, 1990. Kirby, D., Comprehensive School Health and the Larger Community: Issues and a Possible Scenario, Journal of School Health 60: 170-177, 1990. Kirby, D., Waszak+ C. S., and Ziegler, J., An Assessment of Sti School-Based Clinics: Services, Impact, and Potential (Washington, DC: Center for Population Options, October 1989). Kleiber, D.A., and Richards, W.H., Leisure and Recreation in Adolescence: Limitations and Potential, Constraints in Leisure, M.G. Wade (cd.) (Springfield, IL: Charles C. Thomas, 1985). Klerrnan, L. V., School Absence---A Health Perspective, Pediatric Clinics of North America 35(6): 1253-1269, 1988. Kolbe, L., Director, Division of School and Adolescent Healtk Centers for Disease Control, Public Health Service, U.S. Department of Health and Human Services, School Health Services and Health Promotion: A Critical Examination of Their Evaluation Current Status, and Potentiat for Linkage, address to the Thsk Force on Education of Young Adolescents, Consultation on Health Services and Health Promotion in Middle Gmde Schools, Carnegie Council on Adolescent Development, Carnegie Corporation of New York Washington, DC, June 7-8, 1988. Koshel, J., Deinstituhonalization: Dependent and Neglected Children (Washington, DC: Urban Institute, 1973). Kreitzer, A., Madaus, G., and Haney, W., Drop Outs From Schools: Issues, Dile mmas, and Solutions, Competency, Testing and Drop Outs, L. Weis, E. Farrar, and H. Petrie (tis.) (NCW Yot~ NY: SUNY Press, 1989). Kuhn, D., and Pressman, H., Working Together: Multi-Purpose Programs for Troubled Youth (Washingto% DC: Benchmarks, 112. 113. 114. 115. 116. 117. 118. 119. 120. 121. 122. 124. 125. 126. 127. 127a. 128. 129. 130. 131. 132. 133. 134. hC., 1980). Labaree, D.F., Setting the Standard: The Characteristics and Consequences ofAlternative Student Promotional Policies (Philadelphia% PA: Citizens Committee on Public Education in Philadelpl@ 1983). La Belle, T., An Introduction to the Nonformal Education of Children and Youth+ Comparative Education Review 25:313329, 1981. Ladevvig, H., and Thomas, J.K., Assessing the Impact of 4-H on Former Members (LubbocL TX: Ikxas A & M University and the Cooperative Extension 1987). Larsoq R., and Czikszentmihalyi, M., Experimental Correlates of Time Alone in Adolescence, Journal ofPersonality 46(4):672693, 1978. Lavigueur, H., The Use of Siblings as an Adjunct to the Behavioral Treatment of Children in the Home With Parents as Therapists, Behavior Therapy 7:602-613, 1976. Lee, V., and Brylq A., Curriculum Tracking as Mediating the Social Distribution of High School Achievement, Sociology of Education 61:78-94, 1988. he, V., and BryL A., A Multilevel Model of the Social Distribution of High School Achievement Sociology of Education 62:172-192, 1989. he, V., and Ekstrom R., Student Access to Guidance Counseling in High School, Amen-can Educational Research Journal 24(2):287-310, 1987. Lefste@ L. M., and Lipsitz, J. (eds.), 3.00 to 6:00 PM: Programs for Young Adolescents (Carrboro, NC: Center for Early Adolescence, 1982). Lev@ H. M., Financing the Education of At-Risk Students, Educational Evaluation and Policy Analysis 11(1):47-60, 1989. Lift@ E., School-Based Management-Shared Decision Making: A Keystone in Dade Countys Professionalization Effort, Florida Journal of Teacher Education 5:7G76, 1988. Lipsitz, J., Succes@U Schools for Young Adolescents (New Brunswick NJ: Transaction Books, 1985). Loesch+ L.C., and Wheeler, P.T., Principles of Leisure Counseling (Minneapolis, MN: Educational Media Corp., 1982). Maloney, D. M., Timbers, G.D., and Maloney, K. B., BIABH Project: Regional Adaptation of the lkaching-FamiIy Model Group Home for Adolescents, Child We~are 56:787-7%, 1977. Manhattan Borough Presidents Thsk Force on Education and Decentralization, People Change Schools (New York NY: 1989). Marriotg M., A New Road to Learning: llmching the Whole Child, New York Times, p. A-1, June 13, 1990. Marx, F., Ajier-School Programs for bw-income Young Adolescents: Overview and Program Projiles, Working Paper No. 194 (Wellesley, MA: Wellesley College Center for Research on Wome% 1989). Matop K.I., Meanin gful Involvement in Instrumental Activity and Well-Being: Studies of Older Adolescents and At-Risk Urban lkenagers, American Journal of Community Psychology 18(2):297-320, 1990. Mayer, V. J., cited in Big Kids lkach Little Kids: What We tiow About Cross Age IMoring, Harvard Education titter 3(2):1-3. McCord, J., A Thirty-Year Follow-Up of Treatment Effects, American Psychologist 33:284-289, 1978. McDaniel, C., Work and Leisure in the Career Spaq Designing Careers, N.C. Gysbers (cd.) (San Francisco, CA: Jossey-Bass, 1984). McDermott, J., Crime in the School and in the Community: Offenders, Victims, and Fearful Youths, Crime and Ddinquency 29(2):270282, 1983. McGow~ B. G., and Walsk E. M., Services to Children, Setnng Municipal Priorities, 1990, C. Brecker and R. Horton (eds.) (New York NY: NTV Press, in press).
PAGE 112
II-108 Adolescent HealthVolume II: Background and the Effectiveness of Selected Prevention and Treatment Services 135. 136. 137. 138. 139. 140, 141. 141a. 142. 143. 144. 145. 146. 147. 148. 149. 150. 151. 152. 152a. McGowaIL B. G., KahIL A.J., and Kamermaq S.B., Social Services for Chil&en, Youth, and Families: The New York City Study (New York NY: Cross National Studies program, School of Social Work Columbia University, June 1990). McNeil, L., Contradictions of Control: School Structures and School Knowledge (New York NY: Routlege and Kegan Paul, 1986). McPartland, J., Calderom R., and Bmddock, J., School Structures and Climate: Practices in Elementary, MiaWe, and Seconalrry School (Baltimore, MD: Johns Hopkins University, 1987). Medina, N., and Nei~ D. M., Fallout From the Testing Explosvon: How 100 Million Standardized Exams Undermine Equity and Excellence in Americas Public Schools (Cambridge, MA: Fair R@ October 1988). Meier, D., Good Schools Are Still Possible: But kachers Must Be Freed From System Mandates, Dissent 34:543-8, Fall 1987. Meier, D., Success in East Harlem: How One Group of lkachers Built a School That Works, American Educator 11(3):34-39, 1987. Metz, M.H., Field Study on the Effects of the School as a Workplace on Teachers EngagemenHhase One. Final Report (Madison+ WI: National Center for Effective Secondary Schools, University of Wiscons@ 1988). Millstein, s., The Potential for School-Linked Centers To Promote Adolescent Health and Development paper presented to the Carnegie Council on Adolescent Developmen~ Washington DC, August 1988. Milwaukee Public Schools, Study Commission on the Quality of Education in the Metropolitan Milwaukee Public Schools, Better Public Schools (Milwaukee, WI: 1985). Moore, D., and Davenport, S., The New Improved Sorting Machine (Chicago, IL: Designs for Change, December 1988). Moos, R.H., Person-Envircmment Congruence in Work, Schools, and He.dth Care Settings, Journal of Vocational Behavior 31:231-247, 1985. Murdock, G., and Phelps, G., Mass Media and the Seconaluy School (lmndoq England: Routledge and Kegan Paul, 1976). National Assessment of Educational Progress, The Reading Report Card, 1971-88 (Princeto~ NJ: Educational Wsting Service, 1990). National Co rnrnission on the Role of the School and the Community in Improving Adolescent Health and National Association of State Boards of Education and American Medical Association, Code Blue: Uniting for Healthier Youth (Alexand& VA: 1990). Neckerman, K. M., and Wilson, W.J., origins of Pbverty in the United States and Present-Day Consequences for the Schools, paper prepared for the Sumrn es Institute of the Council of Chief State School Ofllcers, Whitefi@ ~, Aug. 2-7, 1987. Nelson, TM., and Carlsom D.R., Determining Factors in Choice of Ascade Games and Their Consequences Upon Young Male Players, Journal ofAppliedSocial Psychology 15(2): 124139, 1985, Newachec~ P.W., Improving Access to Health Services for Adolescents From Economically Disadvantaged Families, Pediatrzcs 84:1056-1063, 1989. Newberg, N.A., Bridging the Gap: An Organiza tional Inquiry into an Urban School System Reflective 7hrn: Case Studies of Rejection in and on Practice, S. Schon (cd.) (New York NY: lkachers College Press, 1991). Ne~ F. M., and Thompsom J.A,, Eflects of Cooperative Learning on Achievement in Secondary Schools: A Summary of Research (MadisorL WI: National Center on Effective Secondary Schools, University of Wisconsiq 1987). New York City Board of Educatiom Ofllce of Educational Assessment, Evaluation Upalzte on the Effectiveness of the Promotional Policy Program (New York NY: 1986). 152b, 153 < 154. 155, 156. 157. 157a. 158, 159. 160. 161. 162. 163, 164. 165. 166. 167. 168. 169. 170. 171. 172. 173. 174. 175. 175a. Nieves, E., The offer Money for College, but Some Have Passed it Up, New York Times, Sec. B, p. 1, July 12, 1991. Nightingale, E. O., and WolvertoU L., AaWescent RoZeZessness in Modern Society (WashingtorL DC: Carnegie Council on Adolescent Development September 1988). NormaIL J., and Harris, M.W., The Private Life of the American Teenager (New York, NY: Rawsoq Wade Publishers, 1981). Oakes, J., Keeping Track: How Schools Structure Inequality (New Havem CT: Yale Univemity Press, 1985). Offer, D., and Offer, J.B., From Teenage to Young Manhood: A Psychological Study (New Yoti NY: Basic Books, 1975). Offer, D., and Offer, J.B., Three Developmental Routes Through Normal Male Adolescence, Adolescent Psychiatry 4:121-141, 1976. Ogbu J., Cultural Discontinuities and Schooling, Anthropology and Education Quarterly 13(4):29307, 1982, Opotow, s,, Adolescent Peer Conflicts: Implications for Students and for Schools, Education and Urban Society 23(4):416-441, 1991. Otto, L.B., Extracurricular Activities in the Educational Attainment Process, Rural Sociology 40: 162-176, 1975. Otto, L.B., Social Integration and the Status-A ttalnment Process, American Journal of Sociology 81:1360-1383, 1976. Otto, L.B., and Feathennaq D.L., Social Structural and psychological Antecedents of Self-Estrangement and Powerlessness, American Sociological Review 40:701-719, 1975. Oxley, D., Smaller Is Better, American Educator 13(1):28, 1989. Pallas, A.M., Natriello, G., and McDill, E.L., The High Costs of High Standards, Urban Education 22(l): 103-114, 1987. Pallas, A. M., Natriello, G., and McDill, E.L., The Changing Nature of the Disadvantaged Population: Current Dimensions and Future Trends (Baltimore, MD: Center for Research on Elementary and Middle Schools, Johns Hopkins University, March 1989). Panelas, T., Adolescents and Video Games: Consumption of Leisure and the Social Construction of the Peer Group, Youth and Society 15(1):51-65, 1983. Pipho, C., States Move Reform Closer to Reality, Phi DeZta Kappan 68(4) :K1-K8, December 1986. Pipho, C., Dropout Statistics-The Unreliable Indicator, Education Week 15:30, June 1988. PittmaQ R., and Haughwout, P., Influence of High School Size on Dropout Rate, Education, Evaluation, and Policy Analysis 9(4):337-343, 1987. pll~ w., A Study of School Grade Organiza tion: Policy Lrnplicationa for Middle Schools, paper prepared for the OffIce of Research and Evaluation, School District of philadelphi~ Philadelphia, 1988. Pumphrey, M.W., GoO&naq M., and Flax, N. Integrating Individuals With Impaired Adaptive Behavior in a Group Work Agency, Social Work Practice, E. Berlatsky (cd.) (New York NY: Columbia University Press, 1969). Raywid, M.A., Alternative Routes to Excellence, National Forum: Phi Kappa Phi Journal 67(3):25-28, 1987. Razzano, B.W., Creating the Library Habi4 Librag Journal 110:1 11-114, 1985. llichardso~ J.L., Dwyer, K., McGuig~ K., et al., Substance Use Among Eighth-Grade Studenta Who Ihke Care of Themselves After School, Pediatrzcs 84(3):556-556, 1989. Robinsor+ G.E., and Wittebols, J., Class Size Research:A Related Cluster Analysis for Decision Making (Arlington, VA: Educational Research Semices, 1986). Rurnberger, R.W., High School Dropouts: A Review of Issues and Evidence, Review of Educational Research 57(2):101-121, 1987. Rutter, M., School Influences on Childrens Behavior and Development: The 1979 Kenneth Blackfan Lecture, Pediatrics 65:208-220, 1980.
PAGE 113
Chapter 4-Schools and Discretionary lime .11-109 176. 177. 178. 179. 181. 182. 183. 184. 184a. 185. 186. 187. 188. 189. 190. 191. 192. 193. 194. 195. 1%. 197. 198. 199. Rutter, M., Changing Youth in a Changing Society (Cambridge, MA: Harvard University Press, 1980). Rutter, M., and Giller, H., Juvenile Delinquency: Trends and Perspectives (New York NY: Guilford Press, 1984). Rutter, M., Maugham B., Mortimore, P., et al., Fifieen Thousand Hours: Secondary Schools and Their Effects on Children (Cambridge, MA: Harvard University Press, 1979). Schneller, R., Video Watching and its Societal Functions for Small-Town Adolescents in Israel, Youth and Society 19(4):441459, 1988. Schwartz, J. L., Tripling the Youth Service Network: Thoughts About Expansion Strategies (Washington, DC: Youth Service America, June 1989). Selnow, G. W., and Reynolds, H., Some Opportunity Costs of IkJevision Viewing, Journal of Broadcasting 28(3):315-322, 1984. Shore, M. F., Youth Employment: Curse or Blessing? Children Today 13:6-8, 1984. Simmons, R. G., and Blyth+ D.A., Moving Info Adolescence: The Impact of Pubertal Change and School Context (New YorL NY: Aldine de Gruyter, 1987). Sipes, C. L., Grossma J.B., and Milliner, J. A., Summer Training and Education Program (STEP): Report on the 1987 Expenence (Philadelphia, PA: Public/Private Ventures, S ummer 1988). Slavin, R. E., Cooperative Leamin g: Where Behavioral and Humanistic Approaches to Classroom Motivation Mee4 The Elementa~ School Journal 81(1):261-269, 1987. Slavti R. E., and MaddeY N. A., Effective Classroom Programs for Students at Risk (Baltimore, MD: Center for Research on Elementary and Middle Schools, The Johns Hopkins University, 1987), Smi@ D. M., Some Patterns of Reported Leisure Behavior of Young People, A bngitudinal Study, Youth and Society 18(3):255-279, 1987, SorensoL A. B., The Organizational Differentiation of Students in Schools as an Opportunity Structure, The Social Organization of Schools, M.T. Hallinan (cd.) (New York NY: Plenum Press, 1987). Soper, W. B., and Miller, M.J., Junk-Time Junkies: An Emerging Addiction Among Students, The School Counselor 3 1( 1):40 43, 1983. Spady, W. G., Status, Achievement and Motivation in the American High School, School Review 79:379-403, 1971. Starr, J., American Youth in the 1980s, Youth and Society 17(4):323-345, 1986. Steinberg, L. D., Latchkey Children and Susceptibility to Peer Pressure: h Ecological Analysis, Developmental Pgchology 22(4):433-439, 1986. Steinberg, L. D., Greenberger, E., Garduque, L., et al., Effects of Working on Adolescent Development Developmental Psychology 18:385-395, 1982. Stevensom R.B., Autonomy and Support: The Duat Needs of Urban High Schools Urban Education 22(3):366-386, 1987. Svec, H., School Discrimin ation and the High School Dropout: A Case for Adolescent Advocacy, Adolescence 21(82):449452, 1986. Wsta, M., and Lawlor, E., The State of the Child: 1985 (Chicago, IL: Chapin Hall Center for Children, 1985). Thorstenson, C. T., The Mormon Commitment to Family Recreation Leisure Today 58:20-21, 1984. Tobier, E., The Changing Face of Poverty: Trends in New York Citys Population in Poverty, 1960-1990 (New York NY: Community Service Society, 1984). Treanor, W., Barriers to Developing Comprehensive and Effective Youth Semices, Youth and Americas Future, Commission on Work, Famity and Citizenship, WiUiam T. Grant Foundation (Washington DC: William T. Grant Foundation September 1988). 200. 201. 202, 202a. 202b. 202C. 202d. 203. 204. 204a. 204b. 205. 206. 207. 207a. 208. 208a. 209. 210. 211. 212. Trotander, J.A., Professionalism and Social Change: From the Settlement House Movement to Neighborhood Centers, 1886 to the Present (New Yorlq NY: Columbia University Ress, 1987). Unkovic, C. M., Brow W.R., and Miersw% C. G., Counterattack on Juvenile Delinquency: A Conf@rational Approach, Adolescence 13(51):401-410, 1978. Usdam M.D., Restructuring American Educational Systems and Programs to Accommodate a New Health Agenda for Youth, Journal of School Health 60139-140, 1990. U.S. Congress, Library of Congress, Congressional Research Service, Education for the Disadvantaged Children: Major Themes in the 1988 Reauthorization of Chapter l, prepared by W.C. Riddle, Washington DC, January 1989. U.S. Congress, Library of Congress, Congressional Research Service, High School Dropouts: Current Federal Programs, prepared by B. Lyke, Washington DC, March 1990. U.S. Department of Education, Schools That Work, Educating Disadvantaged Children (Washington DC: U.S. Government Printing Ofllce, 1987). U.S. Department of Educatio% Office of Educational Research and Lmprovaent, Class Size and Public Policy (Washington DC: U.S. Government Printing Offke, 1988). U.S. Department of Educatio% Office of Educational Research and Improvement National Center for Education Statistics, Digest of Educational Statistics, 1988 (Washington DC: U.S. Government Printing OffIce, 1988). U.S. Department of Educatio% OffIce of Educational Research and Improvement National Center for Education Statistics, Digest of Education Statistics, 1989 (Washington DC: U.S. Government Printing Office, 1989). U.S. Department of Educatiow Oftlce of Educational Research and IrnprovemenC National Center for Education Statistics, Dropout Rates in the United States, NCES 90-659 (Wa.shingtoU DC: September 1990). U.S. Departxnent of Educatio% Office of Plannin g, Budge4 and Evaluations, State Education Performan ce Ch@ Washington, DC, May 1990. U.S. Department of Health and Human Services, Office of Human Development Services, National Report: 1982 State Conferences on Children and Youth (Alexandria, VA: U.S. Government Printing Office, July 1983). U.S. Department of Health and Human Services, Alcohol, Drug Abuse, and Mental Health A&rums tration, National Institute on Drug Abuse, Division of Prevention and Treatment Develop ment, Adolescent Peer Pressure: Theo~, Correlates, and Program Implications for Drug Abuse Prevention (Washington DC: 1981). U.S. Department of Labor, Bureau of Labor Statistics, Employment in Perspective: Working Women, Report 663 (Washingto4 DC: U.S. Government Printing Off@ 1981). U.S. General Accounting Oftlce, Promsing Practice: Private Programs Guaranteeing Student Aid for Higher Education GAO/PEMD-9016,B-238753 (Washingto% DC: 1990). Walberg, H., District Size and Student Larnm g, Education and Urban Society 21(2): 154-163, 1989. Walberg, H.J., and Rasher, S., Public School Effectiveness and Equatity: New Evidence and its Implications, Phi Delta Kappan 56(1):3-9, 1974, Wiggins, G., A True I&t: lbward More Authentic and Equitable Assessment lhi Delta Kappan 56(1):3-9, 1974. Wiltiam T. Grant Foundation, Commission on Worlq Family and Citizenship, The Forgotten Ha~ Pathways to Success for Americas Youth and Young Families (Washington DC: November 1988). Wilsow R., Proprietary Schools Growing Share of Pen Grant Money Means Less for College Students, CampUS OffiCialS Warm Chroniclefor Higher Education 33(45): 1, 18, 1987. Winkleby, M.A., Fortmann, S. P., and Barrett, D.C., Social Class Disparities in Risk Factors for Disease: Eight-y-
PAGE 114
11-110. Adolescent Health-Volume II: Background and the Effectiveness of Selected Prevention and Treatment Services Prevalence Patterns by Level of Educatioq Preventive Mealcine 19: 1-12, 1990. 213. wolf, DR., Portfolio Assessment: Sampling Studemt Work Educational Leadership 46:35-39, April 1989. 214. Wright, W.E., and Dixom M.C., Community prevention and Treatment of Juvenile Delinquency: A Review of Evaluation studies, Journal of Research in Crime and Delinquency 14:35-67, 1977, 215. WymL J., RichmarL H., Rubensteim A., et al, Communities and Molescents: An Exploration of Reciprocal Supports (Nw Yo% ~: Wihm T. &tnt Foundation Commisa ion on WO* Family, and Ci tlZXI&ip, hflly 1988). 215a. Yenckel, J.T., Executives, Working at Play, Washington Post, p. El, Sept. 1, 1991. 216. Young, A.M., Youtb Labor Force Marked mrning Point in 1982, Monthly Labor Review 106(8):29-34, 1983. 217. Ziegler, S., and Harnbleto@ D., Integration of Your TMR children Into a Regular Elementary Sd.K@ Exceptional Children 42:459-461, 1976.
PAGE 115
Part II: PREVENTION AND SERVICES RELATED TO SELECTED ADOLESCENT HEALTH CONCERNS
PAGE 116
PREVENTION AND SERVICES RELATED TO PHYSICAL HEALTH PROBLEMS
PAGE 117
Chapter 5 ACCIDENTAL INJURIES: PREVENTION AND SERVICES Contents Page Introduction . . . . . . . . . . . . . . . . . . 117 Background on Accidental Injuries Among Adolescents . . . . . . . . 117 Sources of Data on Accidental Injuries . . . . . . . . . . . . 117 Trends in the Incidence and Prevalence of Accidental Injuries Among Adolescents . . 118 Injury Deaths and Death Rates . . . . . . . . . . . . . 118 Health Survey Data on Injuries . . . . . . . . . . . . . 118 Injury-Related Health Services Utilization . . . . . . . . . . 119 Specific Types of Injuries Among Adolescents . . . . . . . . . . 120 Motor-Vehicle-Related Injuries . . . . . . . . . . . . . 121 Drowning . . . . . . . . . . . . . . . . . . 123 Accidental Firearm Injuries . . . . . . . . . . . . . . 124 Sports and Recreational Injuries . . . . . . . . . . . . . 124 Factors Associated With Accidental Injuries Among Adolescents . . . . . . 126 Demographic Characteristics . . . . . . . . . . . . . 126 Risk-Taking Behavior . . . . . . . . . . . . . . . 129 Stressful Life Events . . . . . . . . . . . . . . . 131 Consequences of Accidental Injuries Among Adolescents . . . . . . . . 131 Prevention of Accidental Injuries Among Adolescents . . . . . . . . . 132 Educational and Incentive Approaches . . . . . . . . . . . . 132 Driver Education . . . . . . . . . . . . . . . . 133 Incentives . . . . . . . . . . . . . . . . . . 133 Combining Education and Incentives . . . . . . . . . . . . 133 legislation . . . . . . . . . . . . . . . . . . 134 Special Driver Licensing Restrictions for Adolescents . . . . . . . . ...............134 Requirements for School Bus Safety Belts . . . . . . . . . . 135 Automatic Protection . . . . . . . . . . . . . . . . 135
PAGE 118
Treatment of Accidental Injuries Among Adolescents . . . . . . . . . 136 Major Federal Policies and Programs Pertaining to Accidental Injuries Among Adolescents . 138 U.S. Department of Health and Human Services . . . . . . . . . . 138 Centers for Disease Control . . . . . . . . . . . . . . 138 Health Resources and Services Administration . . . . . . . . . 138 National Institute for Child Health and Human Development . . . . . . 139 U.S. Department of Transportations National Highway Traffic Safety Administration . 139 U.S. Consumer Product Safety Commission . . . . . . . . . . . 139 Conclusions and Policy Implications . . . . . . . . . . . . . 139 Chapter 5 References . . . . . . . . . . . . . . . . 141 Figures Figure Page 5-1. Death Rates Among U.S. Adolescents Ages 10 to 14 and Ages 15 to 19, by All Causes and External Causes of Death, 1987 . . . . . . . . . . . . . 118 5-2. Death Rates for the Five Leading Causes of Death Among U.S. Adolescents Ages 10 to 14 and Ages 15 to 19, 1970-87 . . . . . . . . . . 119 5-3. Accidental Injury Deaths by Cause Among U.S. Adolescents Ages 10 to 19, 1984-86 . 121 5-4. Drowning Deaths Among U.S. Adolescents Ages 10 to 14 and Ages 15 to 19, by Race and Gender, 1968-87 . . . . . . . . . . . . . 123 5-5. Motor Vehicle Accident Deaths Among U.S. Adolescents Ages 10 to 14 and Ages 15 to 19, by Race and Gender, 1968-87.. . . . . . . . . . . . . . 128 Tables Table Page 5-1. Average Annual Accidental Injury Deaths and Death Rates Among U.S. Adolescents Ages 10 to 14 and Ages 15 to 19, 1984-86 . . . . . . . . . . 120 5-2. Top 14 Consumer Products Related to Accidents Leading to Hospital Emergency Room Visits Among U.S. Adolescents Ages 10 to 18, 1988 . . . . . . . . 122 5-3. Male-to-Female Ratios of Injury Deaths Among U.S. Adolescents Ages 10 to 14 and Ages 15 to 19, by Selected Causes, 1984-86 . . . . . . . . . . 127
PAGE 119
Chapter 5 ACCIDENTAL INJURIES: PREVENTION AND SERVICES 1 Introduction Broadly speaking, injuries to adolescents are of two general types, accidental (or unintentional) injuries 2 and nonaccidental injuries such as those inflicted in suicide attempts or assaults. 3 Accidental injuries are responsible for more deaths to American adolescents than any other problem, causing more than half of all deaths to persons ages 10 to 19 4 (see figure 5-l). In 1987, 55 percent of all deaths to persons ages 10 to 19 were due to accidental injuries (93). That year, 10,658 U.S. adolescents ages 10 to 19 died from accidental injuries (93). Many more adolescents experienced accidental injuries that caused visits to physicians offices or hospital emergency rooms, temporary or permanent disability, restricted-activity and school-loss days, and other problems. This chapter reviews information on the problem of accidental injuries for U.S. adolescents, the factors associated with accidental injuries among adolescents, consequences of accidental injuries, and the effectiveness of different strategies to prevent accidental injury. The chapter also describes major Federal Government policies and programs pertaining to accidental injuries. Background on Accidental Injuries Among Adolescents Sources of Data on Accidental Injuries No single source of information provides comprehensive data on the cause, nature, and severity of injuries among the U.S. population (58). Particularly lacking are detailed data on injuries that do not result in death. 56 National data on injuries currently have to be gathered from the National Center for Health Statistics in the U.S. Department of Health and Human Services (DHHS), the National Highway Traffic Safety Administration (NHTSA) in the U.S. Department of Transportation, and other sources. These sources offer data that include: l mortality data based on death certificates, national, population based, health survey data, l~is chapter is based, in part, on a background paper on unintentional injuries prepared for OTA (66). OIA, however, ties MI responsibtiity for the use of information in this chapter, and for the use of the phrase accidental injuries rather than unintentional injuries. To make this Report more accessible to the lay reader and for other reasons, OTA has chosen to use the term accidental injury in this Report. The term preferred by those in the injury prevention community, however, is unintentional injury (e.g., 66).-Those who prefer the term unintentional ti~ believe that the term accidental injury implies that injuries cannot be prevented, whereas the term unintentional injury implies that while an individual may not have consciously intended to hurt him or herself, some action taken or not taken may have prevented the injury. Perhaps to overstate this perspective somewhat all injuries are avoidable. The position that true accidents do not wcur (i.e., by chance, entirely without cause) correctly brings attention to injuries as a public health problem to which additional preventive interventions can and should be applied, but it seems to be unprovable. Use of the term unintentional also may have the unfortunate effect of placing the onus of causation (and responsibility for precautions) exclusively on the person who is injured, atthough in fact unintentional injuries may be caused unintentionally, by persons, organizations, or systems other than the victim. s~omtlon on adolescent suicide is presented in ch. 11, Mental Health Problems: Prevention and S-ices, in this volume. Information in homicide among U.S. adolescents is presented inch. 13, Delinquency: Prevention and Services, in this volume, and inch. 18, Issues in the Delivery of Services to Selected Groups of Adolescents, in Vol. III. 4~e fwu~ of ~s OTA Report is on adoles~nts ages 10 ~ough 18. There is no single agr~d-upon deftition of ~olewents, however, ad much of the data reported in this chapter is for individuals ages 10 through 19, because data obtained from the National Center for Health Statistics on causes of death for adolescents are reported using age breaks of 10 to 14 and 15 to 19. Differences in Federat agencies deftitions of adolescence are discussed inch. 19, The Role of Federal Agencies in Adolescent HealtlL in Vol. III. fThere are relatively more data available on injuries related to motor vehicle crashes because of the efforts of the National Highway Tra.tlic Safety Administration (NHTSA) and the Insurance Institute for Highway Safety, both of which have a mandate to study automobile injuries (47). me Nationat Center for Heatth Statistics is currently working on merging and expanding its health care surveys (87a). Designed to include a patient followup component and tinkage with the household interview survey, the new National Health Care Survey witl generate data that will permit analysis of patient outcomes, the relationship between uses of health services and health characteristics, and the use of health care at the local level (87b). As discussed further in app. C, Issues Related to the Lack of Information About Adolescent Health and Health and Related Services, in Vol. I of this Report (76a), oversarnpling of adolescents and their use of health services is also required to improve the Nations knowledge base about adolescent health. -11-117-
PAGE 120
II-118 Adolescent HealthVolume II: Background and the Effectiveness of Selected Prevention and Treatment Services l health care services utilization data (e.g., hospital discharge abstracts, hospital emergency room reports, and surveys of office-based physicians), and l traffic accident data (78). 7 In addition to national sources of data on injuries, there are a number of smaller, local or regional studies that provide data on injuries. The generalizability of data from these smaller studies is limited. In the aggregate, however, these studies do provide some useful information about accidental injuries among adolescents. Trends in the Incidence and Prevalence of Accidental Injuries Among Adolescents Injury Deaths and Death Rates Over time, the prominence of accidental and other injuries as a cause of death for young people has increased, in part because of the significant decrease in the numbers of deaths associated with infectious disease (78,88). Injury death rates for adolescents ages 10 to 14 decreased from 23.6 deaths per 100,000 in 1950 to 16.3 per 100,000 in 1987, but the rates for adolescents ages 15 to 19 actually increased over the same period, from 55.6 deaths per 100,000 to 67.3 per 100,000 (65,93). Accidental injury death rates for adolescents declined between 1970 and the mid-1980s. But between 1986 and 1987, they leveled off for 10to 14-year-olds and increased for 15to 19-year-olds (see figure 5-2). In 1987, approximately half of all deaths-and more than two-thirds (70 percent) of injury deathsamong U.S. adolescents ages 10 to 19 were due to accidental injuries (see figure 5-1 and table 5-l). The percentage of injury deaths that are accidental changes during adolescence. In 1987, for example, 79 percent of injury deaths among adolescents ages 10 to 14 were accidental, but 69 percent of the injury deaths for adolescents ages 15 to 19 were accidental. Figure 5-l-Death Rates Among U.S. Adolescents Ages 10 to 14 and Ages 15 to 19, by All Causes and External Causes of Death, 1987 Deaths/100,000 100 1 I I 84.6 80 60 4 0 2 0 0 1 All causes b All injuries Ez 46.2 Accidents Ages 10 Ages 15 Ages 10 to 14 to 19 to 19 10.3 1.5 Suicide Homicide Cause of death aAlthough this OTA Report focuses on adolescents ages 10 to 18, the *ta here are for $year age groups and therefore fndude 19-year-olds. b~All causes~~ ind~es inju~es and diW=es. Th e rates at ~~h muses of death other than injuries oceursintheadolescent population are relatively small-e. g., malignant neopfasms, the next highest cause of death after injuries, occurs in 10to 19-year+ids at a rate of 3.7 per 100,000 adolescents ages 10 to 19. CAII injufies includes acd&n@ suicide, homidde, and other ki@ieS. SOURCE: Office of Technology Assessment, 1991, based on U.S. Department of Health and Human Services, Public Health service, Centers for Disease Control, National Center for Health Statistics, unpublished 1987 mortality rates, Hyattsville, MD, 1990, Health Survey Data on Injuries Data on injuries available from the National Health Interview Survey 8 (NHIS) conducted by the National Center for Health Statistics in DHHS indicate that each year about 30 percent of U.S. children and adolescents ages 5 to 17 experience an injury (92), NHIS does not provide separate breakdowns for accidental and intentional injuries. Data from the 1988 NHIS indicate that injuries accounted for 18 percent of restricted-activity days 9 reported for adolescents ages 10 to 18 in 1988 (93). Adolescent males had more injury-related restrictedactivity per 100 adolescents than adolescent females. 10 7Sever~ Fede~ souces of &h on physical health of U.S. adolescents are described ti box 6-B ~ ch. 6 Chronic Physical Illnesses: Prevention and Services, in this volume. 8~e N~o~ H~~ ~temiew s~ey cofl~@ data on c~~en ~d adoksc~ts up to age 17 from thek parerl@ USUatly theh 1110~. 9As d~j~ by tie N~tjO~ H~~ ~t~i~ s~ey co~uct~ by D~s, a res~icted-activi~ &y is my by on which ii person CUt her usual activities for more than one-half day because of an illness or an injury. Restricted-activity days are unduplicated counts of bed-disability days, work-loss days, and school-loss days, and other days on which a person cuts down on his or her usual activity (92). 1OS= ~ble 6-5 in ch. 6, chronic Physical Illnesses: Prevention and SeWices, in this volume for data on restricted-activity days associated with injuries.
PAGE 121
Chapter 5Accidental Injuries: Prevention and Services II-119 Figure 5-2Death Rates for the Five Leading Causes of Death Among U.S. Adolescents Ages 10 to 14 and Ages 15 to 19, 1970-87 Adolescents ages Deaths/100.000 population 70 60 50 I I 4 0 30 20k10 I Oi 1970 10 to 14 .Accidents and adverse effects & Mallgnant neoplasms f. Major cardiovascular problems Y SuIclde Homicide and legal i n te rve nt ion ., k -* 4-=+ ii ---%:xb-.. 1975 1980 1985 1987 Adolescents ages 15 to 19 Deaths/100,000 population 7 0 40 30 1 -+4 20 s2 -~ .. +: I Accidents and adverse effects Malignant neoplasms Major cardiovascular problems Suicide Homicide and legal intervention .7 0 ------.~ ~ .. .- J 1970 1975 1980 1985 1987 SOURCE: Office of Technology Assessment, 1981, based on U.S. Department of Health and Human Services, Public Health Service, Centers for CXsease Control, National Center for Health Statistics, Vifa/ Statistics of the Urrited States 1970, Vo/. //-tWorta/ify (Washington, DC: U.S. Government Printing Office, 1974); U.S. Department of Health and Human Services, Public Health Service, Centers for Disease Control, National Center for Health Statistics, Vii%/ Statistics of the United States 1975, Vol. /Morfa/ify (Washington, DC: U.S. Government Printing Office, 1979); U.S. Department of Health and Human Services, Public Health Service, Centers for Disease Control, National Centerfor Health Statistics, Viti/StatMcs of the United States 1980, Vo/. //-hforta/ity, Pub. No. (PHS) 85-1101 (Washington, DC: U.S. Government Printing Office, 1985); U.S. Department of Health and Human Services, Public Health Servics, Centers for Disease Control, National Center for Health Statistics, Vita/Statistics oftfre United States 1985, Vo/. //-hforta/ity, Pub. No. (PHS) 88-1102 (Washington, DC: U.S. Government Printing Office, 1987); and U.S Department of Health and Human Services, Public Health Service, Centers for Disease Control, National Center for Health Statistics, unpublished 1987 mortality data, Hyattsville, MD, 1990. School-loss days are a subset of restricted-activity Injury-Related Health Services Utilization days (92). 11 NHIS data indicate that injuries were According to data from the 1985 National Amburesponsible for 8.5 percent of school-loss days latory Medical Care Survey conducted by the associated with acute conditions among adolescents National Center for Health Statistics in DHHS, some ages 10 to 17 in 1988 (93). 12 Again, adolescent 8,177,000 visits to private office-based physicians males had higher rates of school-loss days associoffices by adolescents ages 10 to 18 in 1985 were for ated with injuries than adolescent females. a diagnosis of injury or poisoning, accounting for 1 IA~ defined b y tie Nati~~ He~~ ~tcwlew Smey conducted by DHHS, a schoo/./oss day is my &y on w~ch a ctil(j did not attend school fOr at least half of his or her normal school day because of a specific illness or injury (92). School-loss days are determined only for children 5 to 17 years of age, beginning in 1982. IZSW table 6.6 in ch. 6, ~onic Physical Illness: Prevention ~d services, in this volume for data on school-loss days associated with injuries.
PAGE 122
11-120. Adolescent HealthVolume II: Background and the Effectiveness of Selected Prevention and Treatment Services Table 5-l-Average Annual Accidental Injury Deaths and Death Rates Among U.S. Adolescents Ages 10 to 14 and Ages 15 to 19, 1984-86 Ages 10 to 14 Ages 15 to 19 Rate Rate Deaths (per 100,000) Deaths (per 100,000) Vehicle-related: Motor vehicle occupant . . . . . 458 2.69 3,770 20.18 Drivers . . . . . . . . 56 0.33 2,094 11.21 Passengers . . . . . . . 402 2.36 1,676 8.97 Motorcycles . . . . . . . . 87 0.51 639 3.42 Pedestrians . . . . . . . . 294 1.72 515 2.76 Bicycles . . . . . . . . . 219 1.28 142 0.76 Other &vehicle unspecified . . . . 203 1.19 1,526 8.17 Other: Drowning . . . . . . . . 280 1.64 566 3.03 Firearms . . . . . . . . 169 0.99 248 1.33 Fires/burns . . . . . . . . 174 1.02 238 1.27 Falls . . . . . . . . . . 39 0.23 143 0.77 Other accidental . . . . . . . 324 1.90 752 4.02 Total accidental . . . . . . . 2,248 13.18 8,537 45.69 SOURCES: U.S. Department of Commerce, Bureau of the Census, Current Popu/atiorr Reports, Series P-25, No. I&W, Estimates of the Population of the United States by Age, Sex, and Race: 1980 to 1986 (Washington, DC: U.S. Government Printing Office, 1987); U.S. Department of Health and Human Serviees, Public Health Serviee, National Center for Health Statistics, Vita/ Statistics of the United States, Vo/urne //, 1984-1986 Morta/ity, Parf A (Washington, DC: U.S. Government Printing Office). 16.3 percent of adolescents visits to physicians offices (89). 13 Presumably, many adolescents with injuries are treated at home, in clinics, by athletic trainers, or in emergency rooms. Data from hospital emergency rooms on visits associated with a range of consumer products are discussed below (79,80, 81). 14 The National Hospital Discharge Survey, also conducted by the National Center for Health Statistics within DHHS, reports that in 1987 injuries and poisonings together were the most frequent reasons for adolescents hospitalizations (91). 15 In 1988, injuries and poisonings accounted for approximately 31 percent of hospitalizations of adolescent males ages 10 to 14 and 42 percent of hospitalizations of males ages 15 to 18 (91). The percentage of hospitalizations due to injuries for adolescent females that year was lower; injuries accounted for approximately 26 percent of hospitalizations of 10to 14-year-old females and 9 percent of hospitalizations of 15to 18-year-old females. It is not possible to distinguish accidental from nonaccidental injuries in hospital discharge data (91). 16 Specific Types of Injuries Among Adolescents Information on the causes of fatal injuries to adolescents is available from the Vital Statistics System of the National Center for Health Statistics in DHHS. As shown in figure 5-3, about threefourths of accidental injury deaths among U.S. adolescents ages 10 to 19 in 1984 to 1986 resulted from vehicle-related accidents (99,100,101). Deaths from vehicle-related accidents include deaths among drivers and passengers in cars, all-terrain vehicles (ATVs), and bicycles. Drowning is also a significant cause of accidental death among adolescents, ac13sw @bIe 6.3 inch. 6, ChrOniC Physical Illnesses: Prevention and Services, in this volume for data on office visits to physicians associated with injury and poisoning. The National Ambulatory Medical Care Survey does not provide a breakdown of visits by type of injury (i.e., accidental or intentional), Furthermore, the number of visits for injwy is undoubtedly higher than the number of individual patients, making a count of individual adolescents difficult. lds~ ~tion below endued Speci.flc Causes of Injury Among AdOleS03M% 15s= ~ble 6-2 in ch. (j, ChmniC Physical Illnesses: Prevention and Services, for data on hospital discharges associated with injuries among adolescents. 16More ~mplete ~omtion on me diWoses involv~ in adolmmnts visi~ to physici~s OffiCXX and hospitalizations Cm bC fo~d in ch. 6, Chronic Physical Illnesses: Prevention and Services, in this volume.
PAGE 123
Chapter 5Accidental Injuries: Prevention and Services .11-121 Figure 5-3-Accidental Injury Deaths by Cause Among U.S. Adolescents Ages 10 to 19, 1984-86 Veh licles a 7,85 =..,. Other 1,076 r \ > Falls 182 Fires/burr Firearms 7 Drowning Z# IS 412 417 846 aThis ~tegory includes deaths among drivers, passengers, and pedestr i ans; and includes ears, trucks, all-terrain vehicles, motorcycles, bicycles, and other and unspecified motor vehicles. Differences by type of vehiele and age are reported in table 5-1. SOURCE: Office of Technology Assessment, 1991, based on U.S. Department of Health and Human Services, Public Health Service, National Center for Health Statistics, Vtia/Statistics of the United SfatesVo/. //, Morta/ity (Washington, DC: U.S. Government Printing Office, various years). counting for nearly 8 percent of accidental injury deaths (see figure 5-3). Other important causes of accidental injury deaths among adolescents are firearm accidents, fires/burns, and falls. Comprehensive national data on nonfatal accidental injuries are not available. Neither NHIS nor the National Hospital Discharge Survey nor the National Ambulatory Medical Care Survey obtains information on the causes of such injuries. One source of cause-specific data on health services utilization related to injuries is the U.S. Consumer Product Safety Commissions National Electronic Injury Surveillance System, conducted in U.S. emergency rooms (80). This survey is limited, however, in that it excludes motor vehicles and firearms from its purview. Data from a review by the U.S. Consumer Product Safety Commission of the top 20 leading consumer products associated with accidental injuries resulting in emergency room treatment for adolescents ages 10 to 18 in 1988 reveals that the vast majority of such injuries are associated with recreational activities (see table 5-2) (80). Among the leading categories of products are those involved in basketball, football, baseball, skateboarding, wrestling, roller skating, or bicycling. Injuries are reported both for organized and informal activities (80). Photo credit: Education Week Sports, including organized sports, are a leading cause of nonfatal injuries among adolescents. According to data from the U.S. Consumer Product Safety Commissions surveillance system, football accounted for nearly 236,000 visits to hospital emergency rooms in 1988. Local studies provide additional information about the causes of nonfatal injury to adolescents. In a statewide study in Massachusetts, 17 sports injuries accounted for the greatest number of injuries in adolescents ages 13 to 19 that resulted in medical treatment (32). This study estimated that 1 in 14 adolescents ages 13 to 19 required hospital treatment for sports injury and 20 percent of these injuries were from football (32). The authors suggest that because of the methodological limitations of their study, these figures should be considered minimal injury rates. A more detailed discussion of motor-vehiclerelated injuries, drowning, firearm-related injuries, and injuries associated with sports and recreational activities (e.g., football, bicycling) is presented below. Motor-Vehicle-Related Injuries National data indicate that vehicle-related injuries are the leading cause of accidental injury deaths among U.S. adolescents ages 10 to 19. Fatal motor vehicle injuries account for the largest proportion of 17~S S~dy ~ollect~ ~~ on fa~ ad no~a@ ~tentio~ injfies to a s~ple of over 5,()()() children ~d adoltiwnts ages O to 19 h Massachusetts over a l-year period as part of the Massachusetts Statewide Childhood Injury Prevention Program Surveillance System (32). Adolescents ages 13 to 19 made up about half of the sample. ?!)? -!ld(; !) 1 .-I (J1, :\
PAGE 124
//-122 Adolescent Health-Volume II: Background and the Effectiveness of Selected Prevention and Treatment Services Table 5-2Top 14 Consumer Products a Related to Accidents Leading to Hospital Emergency Room Visits Among U.S. Adolescents Ages 10 to 18, 1988 Number of emergency Consumer product room visits Basketball.. . . . . . . . . . 244,166 Organized . . . . . . . . . 81,176 Informal . . . . . . . . . 26,850 Not specified . . . . . . . . 136,140 Football . . . . . . . . . . 235,853 Organized . . . . . . . . . 110,253 Informal . . . . . . . . . 28,174 Not specified . . . . . . . . 97,426 Bicycles or accessories . . . . . . 182,031 Baseball . . . . . . . . . . 109,920 Organized . . . . . . . . . 47,463 Other . . . . . . . . . . 62,457 Stairs or steps . . . . . . . . . 102,297 Knives, not elsewhere classified . . . . 57,774 Soccer . . . . . . . . . . 54,820 Organized . . . . . . . . . 27,025 Other.. . . . . . . . . . . 27,795 Skateboards . . . . . . . . . 50,095 Floors or flooring materials . . . . . . 46,846 Nails, screws, carpet tacks, or thumbtacks . . 43,600 Doors, not specified . . . . . . . 41,738 Ceiling and walls . . . . . . . . 37,301 Roller skating (activity, apparel or equipment) .,.... 31,729 Wrestling (activity, apparel, or equipment) . . 30,990 aThe U.S. Consumer Proctucts safety Commission keeps track of injuries associated with activities that involve the use of consumer products, although every injury is not directly caused bythe product. Theydo not collect dataon accidents involving motor vehicles orfirearms. SOURCE: U.S. Consumer Product Safety Commission, unpublished 1988 data from the National Electronic Injury Surveillance System, 1989. fatal vehicle-related injuries among U.S. adolescents, especially 15to 19-year-olds (table 5-1). 18 Drivers ages 16 to 19 represent only 6 percent of licensed drivers but account for 13 percent of all fatal motor vehicle crashes (110). Adolescent drivers are at greatest risk of becoming involved in a motor vehicle crash when they drive at night. Although adolescent drivers do only 20 percent of their driving at night, they suffer more than half their crash fatalities during nighttime hours (42,123). In 1988, half of all fatal crashes involving drivers ages 15 to 17 took place between the hours of 4 p.m. and midnight (1 10). 19 The nighttime fatality rates for adolescent males exceed those for females by more than two to one (122,123). Most motor vehicle Photo credit: Bethesda Chevy Chase Rescue Squad Drowning is the second leading cause of accidental injury deaths for adolescents; black adolescent males are particularly at risk. crashes involving adolescents take place on the weekend. In 1988, adolescent drivers ages 15 to 17 were most frequently involved in fatal crashes on Fridays or Saturdays; 40 percent of fatal crashes took place on one of these days. Another 16 percent took place on Sunday (110). Alcohol consumption is a risk factor for automobile crashes for persons of all ages, but it appears that adolescents may be at even greater risk than adults of becoming involved in a motor vehicle crash if they drive after cons uming alcohol (42). The National Highway Traffic Safety Administration (NHTSA) in the U.S. Department of Transportation reports that about half of the motor vehicle crash fatalities among adolescents ages 15 to 19 are related to alcohol, and about a quarter of fatally injured drivers ages 15 to 19 are intoxicated at the time of their accident (116). Interestingly, however, drivers ages 16 to 19 are less likely than older drivers (e.g., those ages 20 to 24) to have consumed alcohol prior to involvement in a crash. Furthermore, in alcoholrelated crashes, the average blood alcohol content is lower for the fatally injured adolescent driver than for the fatally injured adult driver (42,1 10). This suggests that it takes less alcohol for the adolescent driver to be at risk for a serious or fatal motor vehicle crash (42,104,1 17,1 18). 20 18B@-le ~d ATv.~lat~ injfies are dismssed in the St?CtiOII below On SpOltS md ra~tio~ injuries. lg~o~er 18 Pmcent of faM crashes took place between the hours of noon and 4 p.m. (1 10). ~sk factors, prevention and treatment for alcohol and other drug abuse are discussed in ch. 12, Alcohol, Tobacco, and Drug Abuse: Prevention and Services, in this volume.
PAGE 125
c o .Z 3 0. 0 n Chapter 5Accidental injuries: Prevention and Services .11-123 100 80 60 F Figure 5-4-Drowning Deaths Among U.S. Adolescents Ages 10 to 14 and Ages 15 to 19, by Race and Gender, 1968-87 10-14 years 40 20 [ --., 1--\ 10 \4 \ 8 6 .\ 4 2 1 0.8 I 0.6 0.4 0.2 I -----\ /-~., / \ \ / ,.n, ., \ \ ,\ \, \ / v ,/ \ \ / \ ., \ %,// .. ~~\ /. \ 0.1 ~ 1 1 1 I 1 I 1968 1970 1975 1980 1985 1987 100 80 60 40 20 10 8 6 4 2 1 0.8 0.6 0.4 0.2 0.1 15-19 years ---/{ \ ---/ \ / / s, / // \ \ ,~. \ / \ / \ / A. _/\\ 1 \ \ /\ & / >~, ,/ \ z-~.~ \y. / .~ -L 1 1 1 1 1 1 1968 1970 1975 1980 1985 1987 Year Year White male Black male . White female -------Black female SOURCES: 1968-85 data: U.S. Department of Health and Human Services, Public Health Service, National Center for Health Statistics, Trends and Current Status in Childhood Mortality: United States, 1900-85, Vita/and Hea/fh Statistics, Series 3, No. 26, DHHS Pub. No. (PHS) 89-1410 (Washington, DC: U.S. Government Printing Office, 1989). 1987 data: U.S. Department of Health and Human Services, Public Health Service, National Center for Health Statistics, unpublished mortality data, Washington, DC, 1990. Passengers of adolescent drivers are also at increased risk of being involved in a motor vehicle crash. The majority of adolescents killed as passengers are in vehicles driven by other adolescents (124). In addition, adolescents have been found to be disproportionately involved in the vehicle-related deaths of other nonadolescent drivers, passengers, and pedestrians (122,124). Drowning National data indicate that drowning is the second leading cause of accidental injury death among U.S. adolescents ages 10 to 19 (88,90). A review of national drowning rates indicates that the risk of drowning increases substantially during adolescence, before peaking during the earlyto midtwenties (84). Similar patterns have been reported in local studies in North Carolina (54) and in Maryland (25). Death rates from drownin g are higher for adolescent males than for adolescent females. Furthermore, according to data from the National Center for Health Statistics in DHHS, black adolescents (particularly males) are at greater risk of drowning than their white counterparts (see figure 5-4). The site of adolescent drowning is usually a lake, river, stream, pond, or canal rather than an ocean or swimming pool (54,126). This finding may reflect greater exposure time near these bodies of water or
PAGE 126
11-124. Adolescent HealthVolume II: Background and the Effectiveness of Selected Prevention and Treatment Services lower levels of supervision. Interestingly, however, the 10 to 19 age group accounted for half of all drownings in public or motel pools in a North Carolina study (54). Alcohol is involved in close to 40 percent of adolescent drownings (39,53,54,126). Alcohol may impair judgment of the adolescent in a dangerous situation. It also may decrease the likelihood of struggling to get out of the water, thus increasing the chances of drownin g (71). Accidental Firearm Injuries Accidental firearm injuries follow drownings as a cause of accidental injury death among adolescents ages 10 to 19 (see table 5-1 and figure 5-3). It is encouraging to note that death rates for accidental firearm-related injuries among adolescents ages 15 to 19 have recently been decreasing. 21 Accidental firearm-related death rates for adolescents ages 15 to 19 peaked in 1972 at a rate of 2.5 deaths per 100,000 population but declined to a low of 1,2 deaths per 100,000 in 1987 (29). Accidental firearm deaths occur primarily among adolescent males. Accidental firearm-related death rates for adolescent males exceed rates for adolescent females by almost 8 to 1. Males ages 15 to 19 have the highest accidental firearm death rate (1.33 deaths per 100,000) of all other age groups. Adolescent males ages 10 to 14 have the third highest accidental firearm death rate (0.99 deaths per 100,000) (99,100,101). Racial differences among adolescent males vary somewhat by age. For males ages 10 to 14, the accidental firearm death rate is nearly twice as high for whites as for blacks (1.93 deaths per 100,000 v. 0.97 deaths per 100,000). Among 15to 19-year-old males, rates are slightly higher among blacks than whites (2.56 deaths per 100,000 v. 2.31 deaths per 100,000) (29,99,100,101). National data on nonfatal accidental firearm injuries among U.S. adolescents are unavailable (5). 22 A Massachusetts study found that accidental firearm injuries were a less common type of accidental injury among adolescents ages 13 to 19 presenting to hospital emergency rooms, with a rank order of 15 among all injuries (32). Little is known about risk factors associated with accidental firearm injuries among U.S. adolescents, but adolescents exposure to firearms appears to be quite high. Over 40 percent of the 8th and 10th graders surveyed in the National Adolescent Student Health Survey in 1987 reported that they had used a gun during the past year; of these, over 40 percent had used a gun more than 10 times (6). In general, the source of these firearms is unknown. However, the National School Safety Center reports that the overwhelming majority of weapons that have been confiscated in schools were obtained legitimately (e.g., from parents) (50a). About half the American households reported having a gun in 1989 (76). Information on when and where accidental firearmrelated deaths occur among U.S. adolescents is quite limited. In 1984, more than 30 percent of the fatalities of adolescents ages 10 to 14 that occurred in the home resulted from firearm injuries; this was a significantly higher percentage than for children in younger age groups (85). A study of a limited sample of 88 accidental firearm deaths among children through age 14 in California indicated that most of these deaths occurred while children were playing with a gun (127). In rural areas, accidental firearm injuries may be associated with hunting. A study of accidental firearm fatalities in North Carolina indicated that 28 percent of accidental firearms deaths to adolescents ages 15 to 19 occurred while hunting (45). Another study of hunting-related accidental firearm injuries revealed that younger victims (ages 8 to 19) of hunting injuries were more likely than older hunters to engage in unsafe hunting practices, including carrying the gun incorrectly (21). Sports and Recreational lnjuries 23 As noted above, sports and recreational activities appear to be a leading source of nonfatal adolescent injury. The U.S. Consumer Product Safety Commission has reported that, in fiscal year 1987, sports and recreational activities and equipment were responsible for nearly $2 billion in costs of hospital emergency room treatment for injuries to persons 21u~omtely, however, ~ole~cent d~~ ~t= for ho~cide and s~cide involving tie use of fwearms have continued to increase. See ch. 11, Mental Health Problems: Prevention and Treatment (suicides), and ch. 13, Delinquency: Prevention and Treatment (homicides), in this volume. Because firearms are not under the jurisdiction of the U.S. Consumer Product Safety Cornmissioq data on fuearm-related injuries are not included in the Commissions National Electronic Injury Surveillance System (78). ~For a ~ena~ discussion of adolescent fitness, s~ ch. 7) Nutrition and Fitness Problems: Prevention and Services, in this volume.
PAGE 127
Chapter 5Accidental injuries: Prevention and Services .11-125 ages 5 to 24, more than any other class of consumer products 24 (79). Data from limited samples suggest that injury rates vary considerably by type of sport or recreational activity. A l-year study of 1,283 student athletes in grades 9 through 12 found that 22 percent sustained injuries during the year (43). Students playing football were most likely to experience an injury (61 percent of those participating), followed by females participating in gymnastics (46 percent), males participating in gymnastics (40 percent), wrestling (40 percent), and males basketball (37 percent), Males, who made up 58 percent of the sample of student athletes, experienced nearly threequarters of the injuries. A study of sports injuries treated at the University of Rochester Section of Sports Medicine over a 7-year period found that these injuries peaked during ages 16 to 19; this age group was responsible for 45 percent of the cases seen (24). Overall, football was responsible for the greatest number of injuries. Knee injuries were most common for all sports. Although the relationship between physical fitness and risk of injury has not been well studied, a limited study of 124 young men and 186 young women undergoing basic military training indicated that higher physical fitness may reduce the risk of certain types of less serious sports injuries. The authors conclude, however, that fitness probably has no effect on reducing severe or catastrophic injury (22). Football-Related Injuries--Football is one of the most hazardous interscholastic athletic activities, accounting for 28 injuries per 100 participants per year in national samples (46,74). 25 In 1988, football-related injuries were responsible for nearly 236,000 visits to emergency rooms by adolescents ages 10 to 19 26 (see table 5-2) (80). About a third of high school football players experience an injury that keeps them out of practice or a game (20). Between 1973 and 1980, 260 high school and college players died from football-related injuries. Improvements in helmet design reduced the frequency of head trauma during the late 1960s and early 1970s but resulted in greater use of the head for blocking. As a result, in the early 1970s there was an increased incidence of neck injuries, including injuries resulting in quadriplegic. In 1976, the National College Athletic Association and the National Federation of State High School Athletic Associations ruled to prohibit spearing (using the head to strike an opponent while tackling), which poses particular risks for cranial and spinal cord injuries. Subsequently, the incidence of permanent quadriplegic resulting from football injuries declined from an average of 35 cases per year in 1971 to fewer than 10 per year as of 1986 (46,74). A study examining the injury experience of 5,128 males ages 8 to 15 participating in 208 youth football teams found that 5 percent of the males sustained injuries during the football season (33). Of these, 61.4 percent were classified as moderate injuries, and 38.9 percent were classified as major injuries. Males on the oldest and heaviest teams in this age group (Junior Bantam teams) had the highest rates of injury (9.6 percent of males), and males on the smallest and youngest teams (Junior Pee Wee teams) had the lowest rate of injury (1.9 percent of males). About a third of the males experienced a fracture, the most common type of injury; another quarter sustained sprains. Most injuries (88.3 percent) resulted from contact with another player; 41 percent of injuries occurred during tackling. Over two-thirds of the injuries occurred during games or scrimmages as opposed to practices, and more injuries occurred at away games than home games. A higher prevalence of injury during practice as opposed to games has been reported by other researchers. For example, a study of 1,283 high school athletes, 179 of whom played football, indicated that about two-thirds of the football-related injuries occurred during practice. However, given the much greater amount of exposure experienced in practice rather than game episodes, it was calculated that game situations were actually more likely to produce an injury per unit of exposure (43). It has been suggested that the elimination of kickoffs and punt returns could reduce the footballrelated injury rate because of the high incidence of Z4~e U.S. Comuer ~~uct s~e~ co~~~ion k~~~ @ack of ~juries ~sociated wi~ ~tivities tit involve tie use of consumer produ c the injuries may not be caused directly by the consumer product. 2S~gher ratfi ~ve ~n rewfled ~ ~~die~ u~@ more limited s~p]es, For ex~p]e, G] percent of s~denw playing football were reported tO hive sustained an injury in one study (43). u~~ fiWe ~cludes orgmiz~ ~ well as ifioml football; organized football accounted for 110,253 visits to emergencY rooms.
PAGE 128
11-126. Adolescent HealthVolume II: Background and the Effectiveness of Selected Prevention and Treatment Services major injuries sustained during these plays (33). In addition, improvements could be made in the teaching methods for blocking and tackling to reduce the numbers of injuries caused by direct impact by helmets; this was a cause of 18 percent of football-related injuries in a study of injuries experienced by males ages 8 to 15 participating in youth football (33). Bicycle-Related Injuries-Adolescents ages 10 to 17 accounted for 30 percent of all fatal bicycle accidents in the United States in 1988 (1 10). The majority of fatal bicycle accidents in 1988 (91 percent) occurred on roadways rather than at intersections or other locations (1 10). Among adolescents, the older the bicycle rider, the more likely it is that an injury will be the result of a collision with a motor vehicle; as many as 90 percent of all bicycling fatalities involve motor vehicles, and they are largely the result of head injuries sustained in the accident (41). For bicycle-related injuries requiring hospital admission, the injury is five times more likely to be the result of collision with a motor vehicle than the result of some other type of event (e.g., collision with another bicycle or falling off of a bike) (31). Figures indicating alcohol involvement among adolescent bicyclists, specifically, do not exist. Alcohol testing is not done uniformly in the case of bicycle accidents, and little information exists about exposure to alcohol among noninjured bicyclists. All-Terrain-Vehicle (ATV)-Related Injuries-ATVs have become a source of considerable controversy since their introduction in the United States in the 1980s. Originally designed as tractors for use in the flat, wet rice paddies of the Orient, these 3or 4-wheel vehicles have been adopted for off-road recreational use in rough terrain (66). Instability of ATVs, some of which are capable of speeds as high as 70 miles per hour, is a major problem (66). In 1985, there were 238 documented deaths attributed to ATVs among persons of all ages (2,51). In 1988, ATVs were associated with 27,000 visits to emergency rooms by adolescents ages 10 to 18 (80). Injuries from ATVs are primarily a consequence of hitting an obstacle or tipping over. Among all age groups, head injuries are responsible for 70 percent of the deaths involving ATVs and are the major cause of hospitalization (19,70). Helmets are used by less than 20 percent of the victims, despite clear evidence of their potential to reduce the incidence and severity of head injury (27,63,73,120). Adolescents ages 12 to 15 account for 27 percent of accidents involving 3-wheel ATVs and 42 percent of those involving 4-wheel ATVs; adolescents and young adults ages 16 to 24 account for 35 percent of accidents involving 3-wheel ATVs and 19 percent of those involving 4-wheel ATVs (1,51). Males are involved in close to 80 percent of the cases, most likely a function of their greater exposure time relative to females. As of March 1988, the U.S. Consumer Product Safety Commission had instituted a ban on the sale of 3-wheel ATVs and ruled that the sale of 4-wheel vehicles to minors be more closely controlled 27 (75). Nonetheless, because many previously purchased 3-wheel ATVs are still being used, nearly half of the emergency room visits by adolescents ages 10 to 18 in 1988 that were associated with ATVs occurred with 3-wheel ATVs (80). Factors Associated With Accidental Injuries Among Adolescents Factors associated with accidental injuries can be categorized as demographic factors, risk-taking behaviors, and stressful life events. Demographic Characteristics Demographic characteristics of adolescents that appear to be associated with differing rates of accidental injuries among adolescents include age, gender, and race/ethnicity. While these characteristics are not amenable to change and thus cannot be the targets of intervention or prevention efforts, this information is useful to identify groups at highest risk. Age~Children at different developmental stages experience different types of injuries (59). Thus, adolescents can be expected to have different patterns of experience with injury than younger children or adults, and older adolescents experience different patterns of injury than younger adolescents. For example, adolescents experience much higher rates of motor vehicle occupant injuries, bicycle injuries, and sports injuries than younger ZIU.SA. v. Polaris Industries, LP. 87-3525 GAG (108).
PAGE 129
Chapter 5Accidental injuries: Prevention and Services II-127 children, but young children are more likely to experience pedestrian accidents (32,59). In addition, dramatic increases in the rates of accidental injury deaths occur during adolescence and early adulthood. For example, although the rate of death due to accidents in a recent year was 15.7 deaths per 100,000 population for adolescents ages 12 to 14, it was 55.8 deaths per 100,000 for those ages 15 to 17, and 93.3 deaths per 100,000 for those ages 18 to 19 (40). An evaluation of Massachusetts data also revealed differences between injury patterns for younger adolescents ages 13 to 15 and older adolescents ages 16 to 19 (9). 28 The older adolescents experienced higher rates of injury and more severe injuries than the younger ones; the older adolescents rates of admission to hospitals due to injuries were 1.26 times higher than the younger adolescents rates, and their death rates due to injuries were 1.50 times higher, Although the younger adolescents experienced more bicyclerelated injuries, older adolescents experienced more injuries of other types, including motor vehicle occupant injuries, motorcycle injuries, burns, and deaths due to overexertion. Because 19-year-olds are likely to disproportionately contribute to the totals of injuries or deaths due to some types of accidents (e.g., motor vehicle crashes or accidents involving alcohol), figures presented in this chapter that include 19-year-olds may actually be higher than if 19-year-olds were excluded. GenderAdolescent males are at considerably higher risk of death from injury than adolescent females. Although there is some variation by cause of injury, total rates of injury death for males ages 10 to 19 exceed those for females by as much as 9 to 1 (see table 5-3). The magnitude of this difference is greater for older adolescents ages 15 to 19 than for those ages 10 to 14 (65). For example, the male-tofemale ratio of deaths due to motor vehicle occupant injury for the years 1984 to 1986 was 1.3:1 for ages 10 to 14, compared with 2.1:1 for those ages 15 to 19; similarly, the male-to-female ratio for drowning deaths increases from 4.4: 1 forages 10 to 14, to 9.9:1 for ages 15 to 19. It is impossible, because appropriate data are not systematically collected, to determine the extent to Table 5-3-Male-to-Female Ratios of Injury Deaths Among U.S. Adolescents Ages 10 to 14 and Ages 15 to 19, by Selected Causes, 1984-86 Age group Cause 10 to 14 15 to 19 Motor vehicle occupant . . . . 1.3:1 2.1 :1 Motorcycles . . . . . . . 4.4:1 8.2:1 Pedestrians . . . . . . . 1.7:1 2.4:1 Fires and burns . . . . . . 1.5:1 2.7:1 Falls . . . . . . . . . 4.8:1 5.9:1 Drowning . . . . . . . 4.4:1 9.9:1 Firearms-accidental . . . . . 8.9:1 8.9:1 Suicide . . . . . . . . 3.2:1 4.4:1 Firearms.. . . . . . . . 3.6:1 5.8:1 Homicide . . . . . . . . 1.5:1 3.2:1 Firearms.. . . . . . . . 2.6:1 5.0:1 SOURCE: U.S. Department of Health and Human Services, Public Health Serviee, National Center for Health Statistics, Vhd ~atisfks of the United States, Vo/urne /1-Morta/ity, %rf A (Washington, DC: U.S. Government Printing Office, various years). which differences between adolescent males and females in accidental injury rates are a function of differing exposure to situations where injuries may occur, or to differing susceptibility based on some other factor. There is some evidence that males tend to engage more in behaviors that put them at higher risk of injury. For example, the 1987 National Adolescent Student Health Survey of 8th and 10th graders found that 71 percent of males v. 48 percent of females rode a motorcycle or minibike during the past year; 32 percent of males v. 20 percent of females swam alone; 71 percent of males v. 46 percent of females drove or rode a go-cart, snowmobile, or ATV; and 64 percent of males v. 19 percent of females used a gun during the past year (6). These data suggest that adolescent males, and the high risk activities that males engage in, should be prime targets of preventive interventions. Race and EthnicityRace and ethnicity are sometimes, but not always, differentially associated with accidental injury deaths among U.S. adolescents. 29 For example, the 1986 rate of accidental injury death for black adolescents ages 10 to 14 was 14.7 deaths per 100,000, as compared with 13.0 deaths per 100,000 for white adolescents ages 10 to 14 (40). The 1986 rate of accidental injury death for black adolescents ages 15 to 19 was 27.9 deaths per 100,000, as compared with 52.6 deaths per 100,000 for whites (40). These overall rates consist largely of ~Dam rewtid by Bass and colleagues (9) were collected from Sept. 1, 1979 through Aug. 31, 1982. %e extent to which racial and ethnic differences reflect factors associated with socioeconomic status is not known. See ch. 18, Issues in the Delivery of Sewices to Selectcxi Groups of Adolescents, in Vol. III for discussion.
PAGE 130
11-128. Adolescent HealthVolume II: Background and the Effectiveness of Selected Prevention and Treatment Services Figure 5-5-Motor Vehicle Accident Deaths Among U.S. Adolescents Ages 10 to 14 and Ages 15 to 19, by Race and Gender, 1968-87 100 F 10-14 years 80 60 \ -> /-\ \ -~. ~ \ / . .. ./ \ / ./ --/ / .-,, . / / =., . Z ,./ \ ---,~ 1968 1970 1975 1980 1985 1987 Year 100 80 60 40 20 10 8 6 4 2 15-19 years \ \ \ /-- --\ -; \~ \ / \ _b ,/, > .= ---,~\ / \ \ \ \ ,/ \ \ \/ \ \ \ ,-~ \ -. / \ ~. ,-~ .~-, \ -.. --. ../ J I I I 1 I J 1968 1970 1975 1980 1985 1987 Year White male Black male White female ---------Black female SOURCES: 1966-85data: U.S. Department of Health and Human Services, Public Health Service, National Center for Health Statistics, Trends and Current Status in Childhood Mortality: United States, 1900-85, 14ta/and HeaMr Statistics, Series 3, No. 26, DHHS Pub. No. (PHS) 89-1410 (Washington, DC: U.S. Government Printing Office, 1989). 1987 data: U.S. Department of Health and Human Services, Public Health Service, National Center for Health Statistics, unpublished mortality data, Washington, DC, 1990. motor vehicle accident-related deaths. As noted above, black adolescents are somewhat more likely than white adolescents to die as a result of drowning. As shown in figure 5-5, motor vehicle accident deaths declined somewhat for black male and female adolescents between 1968 and 1987, although recently, death rates have leveled off. Native American adolescents ages 10 to 19 are at particularly high risk for injury, experiencing death from accidental injury at over twice the rate of blacks or whites. In 1986, Native American adolescents ages 10 to 14 experienced injury deaths at a rate of 33.2 per 100,000; Native Americans ages 15 to 19 experienced injury deaths at a rate of 108.4 per 100,000 (12). There are several explanations for the higher rates of injury among Native Americans (77). Because a high proportion of Native Americans live in rural areas, they are less likely to be discovered quickly if they crash, and, once injured, they may not have speedy access to trauma centers for treating emergencies. Also, because alcohol cannot be legally purchased on reservations, many Native Americans travel some distance in order to drink, thus increasing the number of miles that they drive under the influence of alcohol if they drive home after consuming alcohol. There are few data on injuries among other racial and ethnic groups of adolescents. According to The Injury Fact Book, when all ages are considered together, Asians have the lowest rates of injury (8a). A recent analysis of childhood injury deaths found that Asians ages O to 14 had an overall injury death
PAGE 131
Chapter 5Accidental injuries: Prevention and Services 1/-129 rate equivalent to that of white children ages O to 1430 (117a). However, Asian children ages 0 to 14 were found to have higher death rates than average for pedestrian traffic deaths, drownings, and deaths resulting from falls (117a). Other Demographic Factors--In the aggregate, both social class and rural v. urban locale have been shown to be associated with many types of injuries, but many of the specific relationships between these factors and injury among adolescents have not been well-investigated. Adolescents in rural areas have been found to be at higher risk of accidental injuries, in part because of work with farm equipment (43a). People who live in poverty, whether in rural or urban environments, are at greater risk for drowning, residential fires, and motor-vehicle-related deaths (8a). As noted elsewhere in this Report, existing data on the health status of poor adolescents and research on the health effects of poverty have severe limitations. 31 Risk-Taking Behavior Some adolescents engage in behaviors that potentially increase their risk of accidental injury. These include unsafe driving or bicycling practices (e.g., driving after consumin g alcohol, not wearing safety belts, not wearing a helmet), participating in football or other contact sports, and not following water safety rules (e.g., swimmin g alone) .32 Three types of risk-taking behaviors known to increase the risk of accidental death or injury are discussed below: alcohol or drug use, failure to use safety belts, and failure to use bicycle or motorcycle helmets. Alcohol or Drug Abuse-Alcohol use is a major risk factor for all types of injury .33 Alcohol affects the injury process in at least three ways. First, it impairs judgment, increasing the chances that the user wilI become involved in a potentially injuryproducing situation (e.g., driving too fast, diving into shallow water); second, alcohol impairs the ability of the user to perform tasks necessary to avoid injury (e.g., negotiating a slippery curve while driving, Sw imming to shore); and third, alcohol exacerbates the severity of injuries by inhibiting the ability of the body to withstand trauma (1 19). In 1988, 3,158 adolescents ages 15 to 19 died in alcohol-related motor vehicle crashes (1 13). Data from the U.S. Department of Transportations Fatal Accident Reporting System indicate that there have been significant decreases in driver alcohol involvement in fatal motor vehicle crashes since the early 1980s (116). In 1988, 12.1 percent of drivers under age 18 involved in fatal motor vehicle crashes had a blood alcohol content of 0.10 percent or greater, compared with 18.6 percent of drivers of that age in 1982 (1 10). Another 9.5 percent of the fatally injured drivers under age 18 in 1988 (and 11.4 percent in 1982) had a blood alcohol content between 0.01 and 0.09, suggesting that alcohol use below the usual legal limit is also associated with fatal accidents. Alcohol is also frequently involved in fatal pedestrian and bicycle accidents; in 1988, 23.6 percent of victims of fatal pedestrian or bicycle accidents had a blood alcohol content of 0.10 percent or greater (1 10). A review of blood alcohol levels measured in 41 adolescents ages 16 to 18 admitted to a trauma center following motor vehicle, bicycle, or pedestrian accidents in North Carolina revealed that 29 percent had measurable (although not legally prohibited) levels of blood alcohol (55). 35 Males were much more likely to test positive for alcohol than females; 32 percent of males had measurable levels of blood alcohol, compared with only 18 percent of females. 30N0 further age breakdowns were provided. SIS= ch. 18, Issues in tie Delive~ of Health and Related Services to Selected Groups of Adolescents, in VO1. ~. 32~ 1987, for e-pie, over ~ ~rd of 8~ and 1~ graders pficipating ~ tie Natio~ Smdent Heal~ Swey reported that they SWam alone dutig the previous year, 26.4 percent that they swam in a restricted or unsupewised area and 28.4 percent that they dove into water of unknown depth (6). 33 For a general discussion of the use of alcohol and other drugs by adolescents, Sm Ch. 12, Alcohol, Tobacco, and Drug Abuse: Prevention and Services, in this volume. 34~sA wi~ fie us Dep~en[ of Tr~portation defines a motor ve~cle crash as king relat~ to alcohol if the driver or nOnOCCUpaIlt (e.g, pedestrian) has a blood alcohol concentration of 0.10 percent or greater. Persons with a blood alcohol content of 0.10 percent or greater are considered to be intoxicated (1 16). qs~e s~dy also includ~ 34 individuals ages 19 and 20. Blood alcohol content @AC) determina tions were made for only 50 of the total 86 patients admitted to the hospital during the survey period. Unfortunately, the authors do not indicate the ages of the patients for whom BAC readings were not obtained; rather they report the numbers of patients of each age with positive BAC relative to the total number of patients of each age who were admitted to the hospital.
PAGE 132
11-130. Adolescent Health-Volume II: Background and the Effectiveness of Selected Prevention and Treatment Services Less information is available on the possible link between alcohol consumption and other types of accidental injuries (47). Also, other drugs, such as marijuana or cocaine, may elevate risk of injury, though no systematic epidemiologic studies have been conducted to identify the role these other drugs may play in accidental injuries. Failure To Use Safety Belts-There is substantial evidence that the use of safety belts in cars reduces the chances of experiencing serious injury in the event of a crash. For example, although about the same proportion of restrained and unrestrained passenger car occupants involved in fatal crashes in 1988 sustained nonfatal injuries (42 percent of restrained occupants v. 40 percent of unrestrained occupants), nearly twice as many unrestrained occupants as restrained occupants were killed as a result of injuries (49 v. 26 percent) (112). 36 Surveys of U.S. adolescents indicate that most adolescents do not wear safety belts (35). In the 1987 National Adolescent Student Health Survey of 8th and 10th graders, only 41.2 percent reported that they had worn a safety belt the last time they were in a car (6). U.S. adolescents do report, however, that protection in a crash is one of the most important factors in their deciding to wear a safety belt; 81.2 percent of adolescents surveyed in the National Adolescent Student Health Survey reported that this was a very important factor; in comparison, only 12.1 percent said that friends use was a very important factor, and over half reported that friends use was not important at all (6). Riccio-Howe found that safety belt use by family and friends was an important factor in adolescents safety belt use (57a). Laws were also found to be an important factor. RiccioHowe found that adolescents reported higher safety belt use when a law mandating such use was in effect than when it was repealed, and that adolescents who had learned to drive during the period the law was in effect continued to report higher safety belt use (57a). The law was more predictive of adolescents safety belt use than were the adolescents health beliefs and perceived locus of contro1 37 (57a). Failure To Use Bicycle or Motorcycle HelmetsEvidence suggests that very few adolescents wear bicycle helmets and that adolescents are less likely than bicycle riders in older age groups to wear helmets (120). Only 3.7 percent of over 200 bicyclists ages 11 to 19 interviewed in one study were found to be wearing helmets; this compared with 16.2 percent of those age 30 or older (120). In the 1987 National Adolescent Student Health Survey of 8th and 10th graders, fewer than 10 percent said that they ever wore a bicycle helmet, and less than 1 percent reported that they always wore a helmet (6). A review of bicycle-riding-related accidents to children ages 1 to 18 (80 percent of whom were between ages 5 and 14) found that less than 1 percent (ages not specified) had been wearing protective equipment at the time of their injury (68). Peer influence appears to play a role in whether U.S. adolescents wear bicycle helmets. Over 60 percent of the 8th and 10th graders surveyed in the National Adolescent Student Health Survey reported that they thought that their friends would think that wearing a bicycle helmet was a silly thing to do (6). Anecdotal evidence suggests that some young adolescents distinguish between casual neighborhood riding of bicycles and longer bicycle trips and are more likely to wear helmets during the latter activity. Use of helmets among adolescents riding minibikes or motorcycles is also low. As of April 1990, only 23 States required use of motorcycle helmets for riders of all ages (44). Another 23 States required use under a specified age, usually 18 (although in some States the maximum age is as low as 15 years old). Data on crashes in States where only minors are required to wear motorcycle helmets indicate that fewer than 40 percent of fatally injured minors were wearing helmets, even though the law required them to do so (1 14). Enforcement of helmet wearing among minors is difficult, as it can be difficult to distinguish them from older riders. Nearly 60 percent of 8th and 10th graders participating in the 1987 National Adolescent Student Health Survey reported that they sometimes rode a motorcycle or ~~ese data are for all ages combined. 37A ~r.son~~ ~r=lv~ IW~ of ~on~ol is ~ o r her gene~ sense tithe or she ei~er con~ls or is contioll~ by events (63a). Riccio-Howe USd a locus of control scale speeifkally related to the occurrence of accidents (57a). 38 Smd~ts were not ~k~ &wfly whe~er, or how frquently, ~q rode a motorcycle ortib~, Rather, thq were tlskd how fr~UeIldy ~ey WOIE a helmet when they did ride a motorcycle or minibike. Thus, it is not possible to determin e frequency of riding from the survey responses.
PAGE 133
Chapter 5Accidental injuries: Prevention and Services II-131 minibike; however, only a third of those reported that they always wore a helmet when riding (6). 38 Stressful Life Events In a study that compared ill and injured hospitalized adolescents on a variety of measures including demographics, impulse control, emotional tone, and alcohol and other drug use, Slap and her colleagues found that the occurrence of stressful life events was, along with gender and previous hospitalization for an injury, a reliable characteristic distinguishing the injured from the ill adolescents (68a). The stressful life events most associated with hospitalization for an injury included suspension from school, failing a grade level, difficulty getting a summer job, breaking up with a boyfriend or girlfriend, and the death of a grandparent (68a). However, Slap and her colleagues note that their study sample was small and otherwise somewhat limited methodologically and that a prospective study to confirm the results is needed (68a). It is also important to note that 28 percent of the injured patients in the Slap et al. sample had been victims of assault; thus, the studys findings may be applicable to violent as well as accidental injuries. Nonetheless, Slap and her colleagues results suggested that stresses that may be minimized by adults are important risk factors for injury during the adolescent years (68a). In an article directed at school nurses, Lee and colleagues also noted that high school is a stressful time for adolescents, and that there is a potential relationship between high levels of stress and accidental injury (41a). Consequences of Accidental Injuries Among Adolescents In general, the total dollar costs associated with injuries, both accidental and intentional, in the United States are enormous. An estimated $158 billion in aggregate lifetime direct and indirect costs 39 is imposed annually by injuries in this country (58). 40 About a quarter of those costs (around $39.4 billion) can be attributed to injuries incurred by persons ages 15 to 24 (58). It is important to note, however, that costs have not been estimated separately for 10to 18-year-olds. Thus, it is difficult to infer the actual proportion of costs attributable to accidental injuries among 10to 18-year-olds. For the 15to 24-year-old age group, motor-vehiclerelated injuries are responsible for the greatest lifetime costs, followed by falls, firearms, burns and frees, drownings and near drownings, and poisonings (58). Overall, males, who experience greater mortality and morbidity due to accidental injuries, also account for more mortality and morbidity costs. According to a study based on data gathered in the 1980 National Medical Care Utilization and Expenditure Survey, injuries and poisonings are responsible for the third greatest proportion of direct medical costs to persons under age 17, 41 accounting for $1.9 billion in 1980 dollars 42 (36). Anecdotal evidence from case studies indicates that injuries have a tremendous impact on injured adolescents, their families, and society (58). Along with lost productivity, school absenteeism, and health care expenses, injuries can have long-term or permanent effects including disfigurement and loss of ability to perform social roles. 43 However, data on injury-related disabilities are surprisingly sparse. No national data are available to ex amine injury-related disability in a systematic manner. Little information is available on the long-term consequences of injuries, particularly those that are less severe (47). As a result, it is very difficult to document the impact of injury survival beyond the acute phases of treatment for injuries. Data on the health consequences of accidents for adolescents in terms of restricted-activity days, as mentioned earlier, are available through NHIS (93). In 1988, injuries (accidental and intentional 3QDirect cosrs we ~OWItS ptid for personal hedti c= (and) for home mocliflcationj vocational rehabilitation and overhead and administrative costs for automobile and health insurance for those tijured (58). Indirect costs can be divided into morbidity and mortality costs; morbidity costs include the value of goods and services not produced because of injury-related illness and disability, while mortality costs constitute the value of lifetime earnings lost by all who die prematurely as a result of injury. Wstirnates are based on the lifetime costs for the 57 million persons injured in 1985 (58). 41~clud= children underage 10. 42However, inj~= ~d poiso~g5 ~co~ted for a lower proportion Of direct rnedi~ cm cOStS for ~jury for tie ~der IT age grOUp b it did f O 17to #-year-oIds. 43sW ch. (j, C~onic physical Illnesses: Prevention and SerVICeS, in this volume for additional discussion of disabilities among adolescents.
PAGE 134
11-132 Adolescent HealthVolume II: Background and the Effectiveness of Selected Prevention and Treatment Services combined) were responsible for 18 percent of restricted-activity days and 8.5 percent of school1 0SS days for acute conditions (93). 44 Injuries were responsible for 133.5 restricted-activity days and 38.9 bed-disability days per 100 males, and 104.9 restricted-activity days and 26.1 bed-disability days for females (92). Injuries accounted for 32.3 school1 0SS days for every 100 students ages 10 to 17. For adolescents ages 15 to 17, injuries accounted for 55 school-loss days per 100 students. Prevention of Accidental Injuries Among Adolescents Accidental injury prevention efforts can focus either on reducing or eliminating the occurrence of accidents or on minimizing the effects of accidents i.e., reducing the severity of the injuries that might result from the accident. Three basic approaches have been used for the prevention of accidental injuries: 1) persuasion or education, 2) legislation and regulation, and 3 ) automatic protection (47,58). The provision of direct incentives or other tangible support, sometimes combined with education, is another prevention strategy (18,26). Although results of evaluation efforts are not definitive, there appears to be some consensus that, in general, automatic protection is the most effective strategy for injury protection, followed by laws and regulation, and that education and persuasion is the least effective strategy for injury prevention (9,47, 58,128). The use of direct incentives, sometimes combined with education, has not been evaluated as an overall strategy, but results of some programs suggest that it too is promising (18,26). As with other adolescent health problems, it is likely that no single approach to prevention is sufficient (see also 12a). Rivara has estimated that 29 percent of deaths from trauma to U.S. children ages 1 to 14 could be prevented if only 12 currently available prevention strategies were implemented (60). Some of these strategies (e.g., use of infant restraint seats) are not applicable to adolescents ages 10 to 18. Nonetheless, Rivaras approach could be used to develop estimates of the numbers of preventable adolescent injury deaths. Injury prevention approaches targeted to individuals (education and incentives), regulation and legislation, and automatic protection are discussed below, along with specific examples of injury prevention efforts. Educational and Incentive Approaches Educational strategies are some of the mos t widely used approaches to preventing injury; they tend to be relatively inexpensive and have a high level of community acceptance (78). The success of educational efforts, however, has been mixed, and there appears to be some consensus in the injury field that, as mentioned above, education an d persuasion alone has been the least effective means of accident prevention (9,47,58,128). OTA agrees with this finding. There are a number of reasons why educational efforts may be unsuccessful. First, the change in behavior advocated by the educational effort maybe too complex (e.g., executing safe turns on a 3-wheel ATV may be quite difficult for a 13-year-old) Second, complete compliance may be required for the behavior to be effective (e.g., safety belts must be worn every time the adolescent rides in a car). Third, the required behavior may be unpleasant (e.g. adolescents may feel that wearing a bicycle helmet is hot and uncomfortable or socially unacceptable). And last, there may be other external barriers to compliance (e.g., bicycle helmets may be unaffordable or unavailable; there maybe cultural, literacy, or language barriers to receiving or responding to the educational message). Thus, some interventions have offered positive incentives to adolescents to help increase health-enhancing behaviors such as the use of safety belts and bicycle helmets. Some education may help adolescents avoid accidents. Educational efforts can be directed at many different audiences including adolesents parents, teachers, manufacturers, and policymakers. For example, educational efforts can be directed toward convincing adolescents to use safety belts, parents can be taught how to discuss safety belt use with their children, manufacturers can be educated about public views regarding safety belt design, and policymakers can be educated about the effectiveness of a law requiring safety belt use. ~R~trict~.activi~ days ~ c~c~tti for 10 to 18-year-olds. School-loss &tys are calculated for 10to 17-yw-olds (w)
PAGE 135
Chapter 5Accidental injuries: Prevention and Services II-133 Examples of education and incentive efforts targeted at changing the behavior of adolescents are discussed below. Driver Education The lack of evaluation information on injuryprevention interventions has resulted in the implementation of programs that are ineffective, or that even have adverse effects. A good example of this is high school driver education programs (47,128) Driver education had long been endorsed as an intervention to reduce adolescent morbidity and mortality due to motor vehicle crashes, Subsequent research, however, has not supported the use of driver education as it is currently delivered as a strategy to reduce motor vehicle crashes (47,78). A driver education study, involving rando m assignment of students to an extensive driver education course, a shortened version of the course, or no course at all, found that although students in the shortened class experienced slightly fewer crashes than those who had not taken a class, no reduction in crashes was found for those who completed the longer version of the class (69). Other researc h indicates that driver education programs may actually result in higher rates of accidents amon g adolescent drivers, in part because they make it possible for adolescent drivers to obtain a license at a younger age, when they may be more likely to be in motor vehicle crashes (47,78). This occurs i n States where taking driver education is a prerequisite for license at an earlier age (e.g., at age 16 instead of 17) (78). Another explanation of the low impact of high school driver education courses is that such courses provide novice drivers with inadequate behind-the-wheel experience (72,105). In response, some States have developed resource materials to assist parents in providing behind-the-wheel practice (72). An additional response, of course, would be for schools themselves to increase the amount of behind-the-wheel experience provided to students learning to drive. Incentives Safety restraints in automobiles have gained increasing acceptance over the past decade as a means of preventing or limiting the severity of injuries associated with motor vehicle crashes. 45 However, because adolescents have lower rates of use of safety belts than other age groups, special approaches to encourage adolescents to use safety belts seem to be necessary (6,47,109). One such program, which used cash incentives to increase voluntary safety belt use, was implemented in Chapel Hill, North Carolina (18). Students cars, identified by bumper stickers, were stopped randomly by study personnel as they entered the school parking lot and, if the occupants were wearing their safety belts, they were rewarded with $5 in cash. For students not driving to school, family cars were identified by bumper stickers. When the occupants were observed anywhere in the community to be wearing safety belts, the adolescent was rewarded with $5 the next day in school. The program involved soliciting donations from parents and private businesses, paired with extensive publicity at the high school (18). The program succeeded in increasing observed use of safety belts among adolescent males from just under 20 percent to close to 39 percent, and among adolescent females from 21 percent to 44 percent. The long-term effects of this program have not been assessed, so it is unknown whether increases in safety belt use by adolescents were maintained over time. Combining Education and Incentives The use of bicycle helmets has the potential to reduce head injury among cyclists. Helmets are relatively ineffective in most crashes that result in fatalities but have considerable potential for reducing the severity of injury in nonfatal crashes. Several studies have indicated that hardshell bicycle helmets are associated with as much as a tenfold reduction in the incidence of significant injuries to cyclists (27,64,120). Despite its demonstrated effectiveness in reducing the severity of injury, helmet use among adolescent bicyclists is low (6,73,120). In Seattle, a communitywide education campaign was implemented in an effort to increase the use of bicycle helmets (26). The campaign included efforts to increase parental awareness of the need for helmets, to promote the use of helmets by children, and to reduce financial barriers to the purchase of helmets. To increase parental awareness of the need for helmets, the campaign included the use of a variety of media to promote the use of bicycle helmets, such as public service announcements on television and radio, press conferences, informa4sAfibags ~e dis~ssed in tie sm[ion on Automatic ROteCtiOn ~low.
PAGE 136
//-134 l Adolescent HealthVolume II: Background and the Effectiveness Of Selected prevention and Treatment Services tional pamphlets distributed through physicians and health departments, and presentations to community groups. Efforts to promote use of helmets included the implementation of a bicycle safety program in public elementary schools, distribution of stickers promoting helmets to school and youth groups and at bicycling events, and the provision of incentives, such as baseball tickets, to children who wore helmets at bicycling events. Finally, in order to reduce financial barriers to the purchase of bicycle helmets, more than 100,000 discount coupons that lowered the cost of helmets to about $25 were distributed through physicians offices, schools, youth groups, and community events; 1,300 helmets were sold at cost through the Parent-Teacher Association; and 1,300 helmets were donated to youth groups serving low-income children. The effectiveness of the campaign was evaluated by comparing observed use of bicycle helmets before the campaign with observed use at various intervals after the start of the campaign. Observations were made at a variety of sites, including schools, bike trails, parks or playgrounds, and streets. To control for intervening events not related to the helmet campaign, observations of helmet use were also made in a demographically similar city (Portland, Oregon), where no organized effort to increase helmet use occurred during the study period. A total of 9,871 observations were made in the two cities of children estimated to be ages 5 to 15. Results of the evaluation indicated significantly greater increases in the use of bicycle helmets in Seattle as compared with Portland (26). Use of helmets in Seattle increased from 4.6 to 14.0 percent 16 months after the campaign commenced, compared with an increase from 1.0 to 3.6 percent in Portland. % Both before and after the campaign, use was associated with race (whites were most likely to wear helmets), bicycle type (riders of geared bikes were more likely to use helmets), and site type (riders on bicycle paths were more likely to use helmets). In addition, children riding with companions (either other children or adults) who wore helmets were much more likely to wear helmets themselves, suggesting that peer and parental pressure may have an effect on use of helmets. Like other multifaceted prevention efforts described throughout this Report, it is difficult to disaggregate the effects of different elements of the Seattle prevention program. An evaluation that could disaggregate the effects of education from helmet distribution and other incentives, as well as assess the effectiveness of both strategies used together, would be useful, particularly if compared with a multifaceted intervention such as Seattles. Legislation Another strategy for preventing or controlling accidental injuries is through legislation. Legislative measures are usually directed at changing either the environment or mandating specific behaviors. Examples include the motorcycle helmet and safety belt laws currently in effect in most States, or through local ordinances. In the first such effort in the country, for example, bicycle helmets were recently made mandatory for all bicycle riders in Howard County, Maryland, riding on county paths and streets (13,14). After pressure, however, the Howard County Council subsequently voted to amend the law to exempt riders over age 15 (14). Laws and regulations can also be limited in their effectiveness and may be least effective for those who are at highest risk. For example, although 35 States plus the District of Columbia now have safety belt-use laws 47 (44,112), adolescents still have lower use of safety belts than adults or younger children (47,112). In 19 cities surveyed by the U.S. Department of Transportations NHTSA, safety belt use by passengers ages 5 to 12 averaged 37 percent, with a range from 24 to 60 percent, while usage fo r passengers ages 13 to 19 averaged only 24 percent (112). As noted previously, in States where only minors are required to wear motorcycle helmets, many adolescents do not wear them. Special Driver Licensing Restrictions for Adolescents Nighttime driving curfews for adolescents, and changes in the minimum driving age have been shown to be effective in reducing adolescent vehicle crashes. States with nighttime curfews for 16-yearti~e~e fiwe~ ~ae ~ju~t~ for a ~e~ of co~omfig v~~les, ~clu~g ~ce, type of bicycle, where bicyclist wu observed riding, ~ld with whom (if anyone) bicyclist rode. The unadjusted rates for Seattle were 5.5 percent use of helmets before the campaign, and 15.7 percent use after the campai~ unadjusted rates for Portland were 1.0 and 2.9 percent during the same period (26). 47A11 States ~ve laws rw~g fiat yo~ger c~dren be restra~ed by a c~d safety seat or (for older children) safety belt, but most of these 1aWS affect only children under the age of 6 (1 12).
PAGE 137
Chapter 5Accidental injuries: Prevention and Services .11-135 old drivers have reduced the fatalities in this age group by as much as 69 percent (122). Since half of fatal crashes involving 16to 19-year-olds occur between 9 p.m. and 6 a.m., this measure has considerable potential for reducing injury. It has also been suggested that the age for obt aining a driver license be raised so that adolescents would be more mature before taking on the complex task of driving. This approach is a response to data demonstrating a disproportionate involvement of young drivers in severe and fatal crashes. However, the approach does not account for the fact that it takes time and practice to become a proficient driver, even at older ages. Another strategy that has been proposed is to develop a graduated driver licensing system whereby adolescents could actually start driving as early as age 14 under close parental supervision (11 1). The privileges of driving at night, and without parents present, would be phased in over the course of several years. This would allow a period of time for adolescents to gradually master the task of driving. Because this approach has yet to be tested, no conclusions can be drawn about the potential effectiveness of the approach in reducing adolescent involvement in motor vehicle crashes. Requirements for School Bus Safety Belts A number of school districts have moved to require safety belts in school buses, although the ratio of effectiveness to costs has been of concern 48 (1 1), As part of a cost-benefit analysis of safety belts in Texas school buses, estimates of the numbers of preventable school bus injuries and fatalities were calculated. It was calculated that 13 percent of serious injuries 49 to children ages 5 to 14 were preventable with the use of safety belts, as were 52 percent of injuries to adolescents ages 15 to 18. 50 Based on their analyses, the authors concluded that installation of safety belts in Texas was not costbeneficial because the anticipated savings in direct medical care and legal costs and indirect costs (e.g., foregone earnings) did not offset the significant costs involved in retrofitting old buses and equipping new buses with safety belts. A more recent and comprehensive study on school bus safety was conducted by the Transportation Research Board of the National Research Council (48). The analysis examined the effectiveness of safety belts in buses in preventing injury, assuming that only one-half of all students would actually wear the safety belts. It was estimated that, if all large school buses in the United States were equipped with safety belts, up to 1 life, 48 incapacitating injuries, 238 nonincapacitating injuries, and 665 injuries could be saved each year for a total annual cost of $43 million to equip the buses and maintain the safety belts. Based on these findings, the Committee concluded that a Federal standard mandating safety belts was unwarranted. Data from the U.S. Department of Transportations NHTSA show that far more children are injured or killed in the process of boarding or leaving school buses than in school buses themselves. The Transportation Research Board recommended that, rather than equipping large school buses with safety belts, the safety of children riding school buses could be more effectively improved through driver training, pupil education, school bus monitors, safer school bus routing, improved mirrors, and improved signaling devices. Automatic Protection In contrast to voluntary efforts that rely on education to promote compliance, automatic protection measures typically are directed at changing consumer products or the environment. These efforts are frequently intended to provide protection by making changes that do not require individual action. Efforts may be voluntary, or required as the result of legislation or regulation. For example, Federal regulations now require a wide array of safety features on cars designed to reduce risks of injury. These include shatterproof windshields, energyabsorbing steering columns, and automatic safety belts or airbags. Environmental improvements, such as better street design, improved lighting, and installation of energy-absorbing materials at roadside sites where crashes are likely to occur, are also #s~, m.tw Schml buS~ we ~Wenfly ~u~~ t. ~ve safe~ ~1~ due to heir simi]ari~ to Cm md he lack of ohm protective features are found in the larger buses (44). bgsenous injune$ wmedefim~ as those receiving a score of 3 or grat~ on tie ~ um Abbreviated Injury Scale (lMAIS), a commonly used trauma severity scale (11). A MAIS score of 3 would reflect injuries such as major nerve laceration multiple rib fracture; abdominal organ contusion; or hand, foot, or arm crush or amputation. A MAIS score of 6 would indicate that the injwy was potentially fatal. ~~er~l, however, chll&en ages 5 to 14 received 84 ~rcent of au injuries, and 83 permnt C)f SeriOUS hJUrieS.
PAGE 138
11-136. Adolescent HealthVolume II: Background and the Effectiveness of Selected Prevention and Treatment Services Photo credit: Bethesda-Chevy Chase Rescue Squad In general, automatic safety features such as airbags have been found to be more effective than education-based preventive measures in preventing injuries. Airbags are not yet required standard equipment in cars sold in the United States and are unlikely to be found in the older cars that adolescents apparently tend to use. examples of efforts to provide automatic protection (2a,78). In automobiles, passive restraint devices such as airbags or automatic safety belts are becoming increasingly available as a result of Federal regulation. These devices are each limited in ways different from standard shoulder-lap safety belts. Airbags, as they are currently constructed, are most effective in frontal collisions, which make up about 35 percent of all fatal car crashes (106). However, airbags are designed to supplement the use of safety belts. In order to enhance protection in frontal crashes, and to provide protection in other types of crashes, manually operated safety belts must be worn in conjunction with airbags. While the effectiveness of automatic safety belts is believed to be slightly less than traditional lap and shoulder belts, the use of automatic safety belts could have a substantial impact on injury reduction because, like airbags, they do not rely upon active compliance. In addition, the effectiveness of some automatic safety belts can be enhanced by the simultaneous use of a manually operated lap belt. Federal Motor Vehicle Rule 208 required that all new cars sold in the United States after September 1989 must have an automatic crash protection system as standard equipment (28,1 13). However, this system could be either airbags or automatic safety belts. Some observers have noted that more expensive model cars have been the first to use airbags (121). (Honda, for example, will not make airbags standard until late 1993, and even then a few low-priced, stripped cars may not have standard airbags (121)). Anecdotal evidence suggests that adolescent drivers tend to use older, less expensive cars. Treatment of Accidental Injuries Among Adolescents Health service needs for acute and short-term treatment of accidental injuries differ by the type and severity of the injury sustained and, to a lesser degree, the developmental characteristics of the injured person. Adolescents may present some special concerns for treatment. For example, medical personnel may have difficulty dealing with adolescents (22). 51 In addition, adolescents may have a need for additional types of services beyond the immediate medical treatment of the injury. National data are not available, but there is some evidence reported in smaller studies that the treatment needs of adolescents differ from those of younger children. A study of persons under age 18 residing in upper Manhattan who sustained severe injuries that resulted in hospitalization, for example, found differences in the need for nonmedical services identified at the time of treatment. Adolescents ages 10 to 16 were more likely than younger children to have a need for psychological services, 52 and less likely to need child welfare services, according to information recorded on hospital charts (52). There is also evidence that the pattern of injury differs by age. Data from emergency departments in Massachusetts indicated that adolescents ages 16 to 19 sustain more severe injuries than adolescents ages 13 to 15 (9). Adolescents ages 16 to 19 had 51AIS0 see ch. 15, ~jor ~~es Pe_ to the Delive~ of Primary and Comprehensive Services to Adolescents, in Vol. III for a diSCU55i0n Of issues in the delivery of health services to adolescents. szAdolescents were more Mely to have received gun shot wounds or to be referred for ingestions Of tOXiC substances.
PAGE 139
Chapter 5Accidental injuries: Prevention and Services .11-137 more injuries requiring treatment in emergency rooms and higher rates of hospital admission. Data from 88 Los Angeles County emergency departments indicate that 28 percent of all trauma cases involved children and adolescents ages 1 to 19; adolescents ages 13 to 19 had twice the number of injuries requiring emergency services as children under the age of 13 (67). In addition, head injuries and abdominal injuries were found to be more common among children and adolescents ages 1 to 19 than among adults. The immediate treatment goal for all victims of moderate to severe injury is timely and appropriate prehospital and hospital care, regardless of age. Guidelines specific to the treatment of adolescents sustaining an injury do not exist; neither the American College of Emergency Medicine nor the American College of Surgery has a special protocol for adolescents who sustain injury. Because extremes of age are a factor in the initial management of a severely injured person, however, guidelines for the very young (under 8 years of age) and the elderly have been developed (4). The issue of pediatric trauma care has received increased attention over the past decade (37,38). The American Pediatric Surgical Association and the American College of Surgeons, for example, have endorsed standards of care for critically injured pediatric patients (3,57). These standards of care recognize that children may have different treatment needs from adults. Children tend to sustain different types of injuries (e.g., head injuries), some types of injuries need to be managed differently (e.g., growth plate fractures must be properly managed to prevent limb shortening or deformity), children have smaller nutritional reserves and have different metabolic requirements, and there is a need for providing psychological support. There are no special guidelines for adolescent patients, however. Following a 1987 conference on unintentional injury among adolescents, the American Medical Associations (AMA) Council on Scientific Affairs reviewed issues surrounding the use of emergency room services by adolescents (15). The review was prompted by the concern that the unique health needs of adolescents might be neglected when it comes to procedures and training of personnel involved with emergency services. Unfortunately, the AMA review was limited by a lack of current Photo credit: Bethesda-Chevy Chase Rescue Squad After a committee of the American Medical Associations Council of Scientific Affairs found that there was an insufficient body of scientific knowledge relating to the specific needs of adolescents in emergency rooms to warrant a full report, the committee planned to monitor the issue. data on adolescent use of emergency room services. Their analysis of clinical and developmental issues suggested that adolescents in emergency rooms had several requirements that might not be recognized by emergency room personnel: the need for confidential services; the need for physicians to identify hidden agendas (e.g., suicidal ideation in an 18-yearold male who has had a motorcycle accident); and the need for followup services. These needs were believed to apply to adolescents in all clinical settings, not just in emergency facilities, and the report suggested that as more family practice, pediatric, and internal medicine programs include training in adolescent medicine, the care of adolescents in emergency rooms should improve (15). It is not clear why specialists in emergency care were not included in this group. The most important conclusion seemed to be that the body of scientific knowledge relating to the specific needs of adolescents in emergency rooms is not large enough currently to support a full [Council of Scientific Affairs] report. The Committee pledged to monitor the issue.
PAGE 140
11-138. Adolescent HealthVolume II: Background and the Effectiveness of Selected Prevention and Treatment Services Major Federal Policies and Programs Pertaining to Accidental Injuries Among Adolescents Wide-ranging injury prevention and control activities, related to both accidental and intentional injury, are conducted by the Federal Government. These activities involve a number of different agencies, each focusing on different aspects of the injury problem. The involvement of many agencies and activities has meant that attention has been given to many injury-related issues, but the overall Federal response has been fragmented (16). 53 Some efforts have been made by DHHS and other agencies to coordinate Federal injury prevention and control efforts. Within the Centers for Disease Controls (CDC) Center for Environmental Health and Injury Epidemiology and Control, a Division of Injury Epidemiology and Control has been established to carry out a program of injury prevention research in conjunction with the U.S. Department of Transportations NHTSA, with half of the funding to be directed to prevention and control of motor-vehiclerelated injury (16,30,108). In fiscal year 1989, a Federal advisory committee for Injury Prevention and Control was established through the Bureau of Maternal and Child Health and CDC within DHHS, and NHTSA within the U.S. Department of Transportation (50). The charge of the Advisory Committee is to report on the state of injury prevention and set priorities for injury-related research; the first meeting of the advisory committee took place in September 1989 (50,87). Various injury prevention and control activities of the Federal Government that include a focus on adolescents are described below. U.S. Department of Health and Human Services Centers for Disease Control The Division of Injury Epidemiology and Control (DIEC) in CDC was created in 1986 through funding from NHTSA in an effort to better coordinate Federal efforts in the area of injury control. Prior to this, no central agency had Federal responsibility for reducing the incidence of injuries (47). Funding for injury research activities at CDC has increased substantially over the past several years, although it is still quite low in comparison with the funding appropriated for heart disease or cancer. Appropriations for fiscal year 1989 were over $23 million, more than twice the budget for 1988 (103). Some programs that are funded through DIEC specifically target accidental and intentional injury among adolescents (e.g., motor-vehicle-related injuries, adolescent suicide or homicide); however, most do not. Although there is no budget line item specific to adolescents at DIEC, an estimated 15 percent of their funding, $3.3 million, is directed at adolescent issues (87). The priorities of DIEC are to support intramural and extramural injury research and to support State and local injury prevention and control programs (87). Funded activities include the development of injury surveillance systems; collection and analysis of data; professional education and training; and research in acute care, biomechanics, epidemiology, and prevention (87,103). In addition, several multidisciplinary, injury prevention academic research centers are funded; these centers provide injuryrelated research, trainin g, and technical assistance (87). Health Resources and Services Administration The Bureau of Maternal and Child Health in the Health Resources and Services Administration of DHHS has provided grants for injury prevention projects through the special projects of regional and national significance (SPRANS) program authorized under Title V of the Social Security Act. In fiscal year 1988, 23 SPRANS projects dealt with injury prevention among adolescents. 54 Children and adolescents are targeted through these programs. Projects have been funded to implement injury prevention programs in States, provide injury prevention services to Native American adolescents, and reduce drinkin g and driving among adolescents (49,94). Also funded through the Bureau of Maternal and Child Health are 12 demonstration projects designed to improve emergency medical services for children, including adolescents, although adolescents are not specifically targeted (95). ss~e gene~ problem of fragmen~tion in the Federal approach to adolescent health is discussed at length iLI ch. 19, The Role of Federal Agencies in Adolescent Healt& in Vol. III. ~For tier diseussio~ see ch. 19, The Role of Federal Agencies in Adolescent HedtlL in Vol. III.
PAGE 141
Chapter 5Accidental Injuries: Prevention and Services II-139 National Institute for Child Health and Human Development The National Institute of Child Health and Human Development (NICHD) within the National Institutes of Health identifies the prevention of childhood injury as one of its priorities. In 1987, NICHD developed a plan for the development of research on the prevention of childhood injury (102). Initially funded projects focus on the prevention of injury among younger children rather than adolescents. U.S. Department of Transportations National Highway Traffic Safety Administration NHTSA was established within the U.S. Department of Transportation in 1970 by the Highway Safety Act of 1970 (108). The mandate of NHTSA is to reduce deaths, injuries, and economic costs resulting from motor vehicle crashes. NHTSAs activities and research include efforts to stimulate activities to improve occupant protection, improve traffic law enforcement, improve the quality of emergency medical services, and establish and maintain a computerized traffic recordkeeping system (109). Adolescents and young adults ages 15 to 24 are a major focus of the efforts of NHTSA to increase safety belt use and to reduce drunk and drugged driving-related traffic fatalities (109). NHTSA annually awards four to five research and demonstration grants targeted at 15to 24-year-olds. Most of the past research conducted through NHTSA has focused on programs to educate young people about the risks of drinking and driving, and about safety belt usage. Although most efforts of NHTSA are not agespecific, some efforts are directed at adolescents and young adults under the age of21. In fiscal year 1988, NHTSA focused over $1 million on research and program activities designed to address highway safety problems of individuals ages 15 to 24 (109). The majority of programs have targeted high-school age adolescents. These include media campaigns addressing the issue of drunk driving, the development of high school assembly programs, and training programs for teachers to enhance their abilities to discuss alcohol and drug abuse issues with their students. In January 1990, NHTSA issued a report on a Young Adult Highway Safety Plan, which focuses on the involvement of 15to 24-year-olds in motor vehicle crashes (1 15). Areas of emphasis in the plan include adjudication, supervision, enforcement, legislation, licensing, school-based and extracurricular programs, and communityand workbased programs. NHSTA also funds activities aimed at younger children which affect adolescents in the 10to 14-year-old age group. These activities include Pedestrian Safety Programs that teach children ages 9 to 12 to deal with a complex traffic environment (44,56). In 1990, a Bicycle Education Program directed at children in grades 5 and 6 was in the pl anning stages; and a new instructional kit providing information on occupant protection to junior and middle school students, The Car Club, was under development (44). NHTSA also administers the Fatal Accident Reporting System, which gathers data on fatal vehicle accidents, and the National Accident Sampling System, which reports on fatal and nonfatal traffic crashes based on a sample of cases. U.S. Consumer Product Safety Commission The U.S. Consumer Product Safety Commission, in operation since 1973, is responsible for overseeing a wide range of consumer products to ensure that they are not hazardous to consumers (79). The commission uses several strategies for correcting consumer hazards, including issuing and enforcing mandatory standards, working with industry to develop voluntary standards, banning products, recalling products, conducting research on potential hazards of products, encouraging the development of new or improved voluntary standards, and conducting consumer information programs. For example, the commission was responsible for banning the sale of 3-wheel ATVs, and the request that industry develop a voluntary standard for 4-wheel ATV safety. The commission also oversees the National Electronic Injury Surveillance System, which maintains information on emergency room visits for injuries that are related to consumer products (excluding motor vehicle, firearms, and several other classes of consumer products that are not under the jurisdiction of the commission). Conclusions and Policy Implications Accidental injuries are responsible for more deaths among U.S. adolescents than any other problem. In 1987, 10,658 U.S. adolescents ages 10
PAGE 142
11-140. Adolescent HealthVolume II: Background and the Effectiveness of Selected Prevention and Treatment Services to 19 died as a result of accidental injury. Nearly two-thirds of these deaths resulted from motor vehicle crashes. U.S. adolescents are particularly susceptible to being involved in a motor vehicle crash when driving at night, or when driving after consuming alcohol. Accidental injury deaths, however, represent just the tip of the iceberg of problems resulting from accidental injuries (58). Such injuries also cause temporary or permanent disabilities, 55 utilization of health care, school loss, and other problems. Sports and recreational activities, such as basketball and football, are a leading cause of nonfatal injuries among adolescents. Three basic approaches have been used for the prevention of accidental injuries. These are persuasion or education, legislation and regulation, and automatic protection. Positive incentives to encourage the use of protective equipment have also been tried and evaluated. Although results are not definitive, there appears to be some consensus that automatic protection (e.g., airbags in cars) is the most effective strategy for injury prevention, followed by laws and regulation, and that education and persuasion is the least effective strategy for injury prevention. In a few evaluations, however, programs that provide incentives to use protective devices (e.g., safety belts, bicycle helmets) have shown promise. Over the past few years, there has been a significant increase in the amount of attention paid to injury research (62). Nonetheless, few reliable data exist on the causes of accidental injuries among adolescents, or on the effectiveness of interventions to prevent accidental injuries or limit their severity. Studies have primarily been descriptive in nature; rigorous effectiveness evaluations of prevention programs are particularly needed, as well as studies that seek to identify causal relationships so interventions may be developed (62). There is little information on the long-term economic and other costs of injury (58). Neither the long-term monetary costs of injuries nor the sometimes devastating effects on families of seriously injured adolescents (e.g., financial and emotional stress) have been extensively assessed. 56 The lack of comprehensive national data on accidental injuries among adolescents ages 10 to 18 makes it difficult to reach conclusions about which groups of adolescents are most at risk, and about the environmental characteristics that increase risk for accidental injury (17). This lack of data inhibits the development of a national strategy to address the problem of accidental injury. At the same time, it is critical that local jurisdictions have adequate injury surveillance systems so they can effectively identify problem areas, develop community responses that address their unique injury problems, and evaluate the effectiveness of their efforts (86). 57 Evidence about the cause of injury is essential for determin ing appropriate interventions. While diagnostic information helps to distinguish skull fractures from concussions or lacerations from contusions, it does not identify factors pertinent to the prevention of the injury. Data about injury causation are essential to differentiate, for example, whether the skull fracture resulted from a fall, a motorcycle crash, or from playing football. Each of these causal factors implies the need for different preventive strategies (e.g., installation of a secure railing on a bridge, passage of motorcycle helmet laws, or changes in the design of football helmets). Inclusion in medical records of information on the causes of injuries would greatly enhance the utility of injuryrelated diagnostic information. Data on the full spectrum of injuries, including those that do not result in hospitalization or death, are necessary to monitor the injury problem adequately, and to define appropriate countermeasures. Focusing only on injuries with the most severe outcomes results in a biased view of the injury problem. For example, although motor vehicle crashes are clearly the most important cause of severe injuries and death among adolescents, sports and recreational injuries actually account for many more injuries and are experienced by many more adolescents. A review of mortality data alone would not reveal the important role that sports and recreational activities play in adolescent injuries. 55s= Ch. 6, @onic physic~ Illnesses: Prevention and SerViCeS, in this volume for a discussion of the effects of chronic physical illnesses and disabilities on adolescents. fisome of tie effec~ of Molewent ~s~ility on families are discussed in ch. 6, Chronic Physical Illnesses: Prevention and Services, in thiS vOIUme. STFor Cxmple, a @@ n~~r of ~des~~ injuries along a particular stretch of road might indicate a need for better lightkg, the need for a pedestrian walkway, or a need for w arning signs, depending on the circumstances.
PAGE 143
Chapter 5Accidental injuries: Prevention and Services .11-141 Another type of information that is lacking is the measurement of exposure. This is a difficult task that typically requires collection of data outside the health care delivery system. For example, in drawing appropriate conclusions about the risk of motor vehicle crashes involving adolescent drivers, it is important to document both the numbers of adolescent drivers and the extent to which they drive. This kind of exposure information serves as the denominator in calculating rates. It allows comparisons that take into account whether adolescents contribute disproportionately to motor vehicle crashes, or become involved in crashes at rates (per mile driven or time spent driving) that are no different from their parents or other adults. Some estimates of miles driven by adolescents can be obtained by transportation or insurance authorities; however, this kind of exposure information is not available for other types of injuries. Thus, for example, information on how many miles adolescents log on bicycles or ATVs or on how many adolescents know how to swim or swim well is not available. Few good evaluation studies have been conducted on the effectiveness of specific injury prevention programs or intervention approaches. Although there appear to be many good ideas among injury prevention efforts, few have been well evaluated (50). It is critical that adolescent attitudes and beliefs about injury problems and various modes of injury prevention be considered when developing injury prevention interventions (65). Although there is some evidence that adolescents with injuries may require some specialized treatment (e.g., psychological services, education on injury prevention) after injury, there is little information available on these needs, or on whether there is a need to train medical personnel in the special care of adolescents with injuries. Information is also lacking on long-term outcomes of accidental injury and the costs associated with injury. This requires a recordkeeping system with the ability to track injury victims over time and through various systems of health care, rehabilitation, and education services. Funding for injury prevention research is scarce and has not been sufficient to permit well-designed intervention trials or solid evaluation studies. The new initiatives within CDC to fund research and intervention programs are directed, in part, at meeting this need. In proportion to the magnitude of the problem and funding of programs for other health problems, however, funding for these injury prevention programs is minimal. For example, despite the significant costs of injuries, both monetary and personal, overall finding for injury prevention and control is significantly less than that for cancer and cardiovascular diseases (58). There is a critical need for a focus by Federal and local governments on the problem of accidental injury, including support for prevention research and programming g, and for data systems to provide the information necessary to develop informed policies. Chapter 5 References 1. 2. 3. 4. 5. 6. 7. 8, 8a. 9. 10. 11. 12. 12a. 13. 14. 15. 16. American Academy of Pediatrics, ATV Fact Sheets, Elk Grove Village, IL, 1989. American Academy of Pediatrics, Committee on Accident and Poison Prevention Skateboard Injuries, Pediamcs 83(6):1070 1071, 1989. American College of Surgeons, Planning Pediatric Trauma Care, Hospital and Prehospital Resources for Optimal Care of the Injured Patient (Chicago, IL: February 1987). American Heart Association% Texrbook of Advanced Cardiac Life Support, 2nd. ed. (TXdlas, TX: 1987). American Medical AssociatiorL Council on Scientiilc Affairs, Firearm Injuries and Deaths: A Critical Public Health Issue, Public Health Reports 104(2):1 11-120, 1989. American School Health Association, Association for the Advancement of Health Educatioq Society for Public Health Educatio% Inc., The National Adolescent Student Health Survey: A Report on the Health of Americas Youth (Oakland, CA: Third Party Publishing Co., 1989). Armstrong, K., Director, Healthy People Programs, Western Consortium for Public Heal@ Berkeley, CA, personal communication to the OffIce of Tkd.nology Assessment, U.S. Congress, Washingto% DC, June 18, 1990. Baker, S.P., and LL G., The Risk of Drowning: Males in Masyland Rivers (letter to the editor), Journal of the American MedicalAssociation 265(3):356, 1991. Baker, S. P., ONeill, B., and Karpf, R., The Injury Fact Book (Lexingtoq MA: Lexington Books, 1984). Bass, J., Gallagher, S., and Mehta, K., InJuries to Adolescents and Young Adults, Pediatric Clinics ofNorthAmenca 32(1):3 139, 1985. Bass, J., Mehta, K., and Eppes, B., What School Chiktren Need to barn About Injury Prevention Public Health Reports 104(4):385-388, 1989. Begley, C., and Biddle, A., Cost-Benefit Analysis of Safety Belts in lkxas School Buses, Public Health Reports 103(5):479485, 1988. Bergeisen, L., physical Health of Indian Adolescents, paper prepared for the Office of lkchriology Assessment+ U.S. Congress, November 1989. BergmasL A.B., and R&U7i, F. P., Swedens Experience in Reducing Childhood Injuries, fediatncs 88(1):69-74, 1991. Beyers, D., Howard Mandates Helmets, Washington Post, p. Al, hhy 8, 1990. Beyers, D., Howard Council To Vote on Limiting Helmet Law, Washington Post, p. Dl, July 30, 1990. Bohigi~ G. M., Emergency Room Services for Adolescents, background report of the Council on Scientitlc Affairs, American Medical Association% Evanstow IL, 1989. Brow S., Federal Funding, Public Health Reports lCT2(6):659662, 1987.
PAGE 144
II-142 Adolescent HealthVolume II: Background and the Effectiveness of Selected Prevention and Treatment Services 17. 18. 19. 20. 21. 22. 23. 24. 25. 26. 27. 28. 29. 30. 31. 32. 33. 34. 35. 36. 37. 38. Butler, J.A., and Mitrovick K.A., The Select Panel for the Promotion of Child Health: Injury Recommendations in Retrospec~ Journal of Social Issues 43(2):119-133, 1987. Campbell, B.J., Hunter, W.W., Stew@ J.R., et al., lncreaszrtg Safety Belt Use Through an Incentive Program (Chapel N NC: Highway Safety Research Center, 1982). CogbilL IIH., Landercasper, J., Strut~ P.J., et al., lhe New Thrmwheeled Motorcycle--A New Mechanism of serious Injury, Wisconstn MedicaIJournal 85:18-20, 1986. Colb~ D., Serious Injuries Up in High School Football, Washington Post, Health SectioQ p. 7, Feb. 21, 1989. Cole, T.B., and Patet@ M.J., Hunting Firearm Injuries, North carolm American Journal of Public Health 78:1585-1586, 1988. Cowart, v., Adolescent Patients Pose Particular Problems; Physical Fitness May Help Prevent Injuries, Jourrud of the American MedicalAssociation 259(23):3380-3381, 1988. Cowart, V., Policy Recommendations Expected From Meeting on Unintentional Injuries in Adolescents, Journal of the American h4e&cal Association 259(23):3381, 1988. DeHaveq K., and Lintner, D., Athletic Injuries: Comparison by Age, Spo% and Gender, American Journal of Sports Me&cine 14(3) :218-2M, 1986. Dietz, P., and Baker, S., Drowning: Epidemiology and Prevention American Journal of Public Health 64(4):303-312, 1974. DiGuiseppi, C., Rivara, F., Koepsell, T., et al., Bicycle Helmet Use by Children: Evaluation of a Community-Wide Helmet Campaign Journal of the American Medical Assooation 262(16):2256-2261, 1989. DorsclL M. M,, Woodward, A.J., and Somers, R.L., Effects of Helmet Use in Reducing Head Injury in Bicycle Accidents, presented at the 28th Annual Meeting of the American Association for Automotive Medicine, Denver, CO, Oct. 8-10, 1984. Fai~ B., Economis4 Office of Plans and Policy, National Highway Traftlc Safety Admuu stratiom Department of Transportation WashingtorL DC, personal communications, Sept. 24, 1990. Fingerhut, L.A., and Kle_ J.C., Firearm Mortality AIIIOtlg Children and Youth, Advance Data From Vital and Health Statistics of the National Center for Health Statistics, No. 178, National Center for Health Statistics, Centers for Disease Control, Public Health Service, U.S. Department of Health and Human Services (Hyattsville, MD: Nov. 3, 1989). Finklea, J.F., Injury prevention Research and Demonstration Grants: An Overview of the Process, Public Health Reports 102(6):648-651, 1987. Friede, A. M., C. V., Gallagher, S. S., et al., The Epidemiology of I@@ to Bicycle Riders, Pediatric Clinics of North America 32(l): 141-151, 1985. Gallagher, S., FinisOn, K., Guyer, B., et al., The Incidence of Injuries Among 87,000 Massachusetts Children and Adolescents: Results of the 1980-81 Statewide childhood Injury Prevention Program Surveillance Systeu American Journal of Public Health 74(12):13401347, 1984. Goldberg, B., Rosenthal, P., Robertson, L., et al., Injuries in Youth Football, Pediamcs 81(2):255-261, 1988. Guyer, B., Talbot A., and Pless, I.B., Pedestrian Injuries to Children and Youth, Pedia~c Clinics of North America 32(1):163-174, 1985. HalperixL S., Bass, J., Meht% K., et al., Unintentional Injuries Among Adolescents and Young Adults: A Review and Analysis, Journal of Adolescent Health Care 4(4):275-281, 1983. Harlan, L., Harla.q W., and Parsons, P.E., Ihe Economic Impact of Injuries: A Major Source of Medical Costs, American Journal of Public Health 80:453459, 1990. Harris, B., Pediatric Care in Hospitals, Emergency Care Quarterly 3(1):65-72, 1987. Harris, B., and Latchaw, L., The Best Is Yet lb Come, Emergency Care Quarterly 3(1):73-75, 1987. 39. 40. 41. 41a. 42. 42a. 43, 43a. 44. 45, 46, 47. 48. 49. 50. 5oa. 51. 52. 53. 54. Howhmd, J., and Hingso~ R, Alcohol as a Risk Factor for DrOWIliD@: A Review of the Literature (19501985), Acci&nt Analysis and Prevention 20(1):19-71, 1988. Kovar, M.G., U.S. Department of Health and Human seMces, Public Health Seavice, National Center for Health Statistics, unpublished mortality daa WashingtorL DC, 1989. Kraus, J.F., Fife, D., and Conroy, C., Incidencq Severity and Outcomes of Brain Injuries Involving Bicycles, American Journal of Public Health 77:76-78, 1987. Ixe, EJ., Jacobsoq J.M., and bvanas, V., Stressful Life Events and Accidents at Schools, Pediam.c Nursing 15:140-142, 1989. Lewis, C., Preventing Ttilc Casualties Among Youtlx What Is Our Knowledge Base? Alcohol, Drugs and Driving 4(l): 1-7, 1988. Marq DJ., lklciL MJ., Killeq J.D., et al., Correlate of Seat Belt Use by Adolescents: Implications for Health Promotiom Preventive Medicine 15:614-23, 1986. McLa@ L.G., and Reynolds, S., Sports Injuries in a High Schoo4 Pediutn.cs 84(3) :44W50, 1989. Meltou G.B., and Oberlander, LB,, Health of Rural Adolescents, contract paper prepared for the Office of Ikchnology Assessment, U.S. Congress, Wa.shingkq DC, September 1989. Miller, J.R., Deputy Adrmm.s trator, National Highway Traffic Safety kkninistratioq U.S. Department of Tranaportatioq written comments to the Oftice of lk&nOlogy Assessment U.S. Congress, WashingtorL DC, June 21, 1990. Morrow, P.L., and Hudsq P., Accidental Fireamn Fatalities in North Carol@ American Journal of Public Health 76:11201123, 1986. Mueller, F.O., and Schindler, R.D., Annual Survey of Football Injury Research 1931 -1986, monograph prepared for the American Football Coaches AssociatiorL and the National Federation of State High School Association Orlando, FL, Kansas City, MO, 1987. National Academy of Sciences, National Researc h Counm Institute of Medicine, Co remission on Life Sciences, Committee on Trauma Researc IL Injury in America (WashingtorL DC: National Academy Press, 1985). National Academy of Sciences, National Research Council, Transportation Research Board, Improving School Bus S~ety (W-01% DC: National Academy of Sciences, 1989). National Center for Education in Maternal and Child Heal@ Georgetown University, Adolescent Health: SPRANS Ab stracts FY 1989, Washington DC, 1989. National Committee for Injury Prevention and Control and Education Development Center, Injury Prevention: Meeting the Challenge, report to the Bureau of Maternal and Child Health and Resources Development, Centers for Disease Control, U.S. Department of Health and Human Services, and the National Highway Traffic Safety Administration, U.S. Department of Transportation (New Yorlq NY: Oxford University Press, 1989). National School Safety Center, Safety Is Priority, Say Urban School Chiefs, School Safety (Encino, CA: Pepperdine University, Spring 1988). Newmaq R., Analysis of All Terrain Vehicles, Related Injuries, and Deaths (Washingto% DC: U.S. Consumer Product Safety Commission, September 1987). OConnor, P., Davidsoq L., DurkiQ M., et al., Prevention Strategies: An Approach to Changing the Outcomes of Severe Injuries to childrem paper presented at the Second Biennial Conference on Community Research and Actioq East Lansing, MI, June 23, 1989. Orlowski, J.P., Adolescent Drownings: Swimming, Boating, Diving, rind Scuba Accidents, Pediatric sAnnals 17(2): 125-132, 1988, Patet@ M., and Biddinger, P., Characteristics of Drowning Deaths in North Carol@ Public Health Reports 103(4):406 411, 1988.
PAGE 145
Chapter 5Accidental injuries: Prevention and Services .11-143 55. 56. 57. 57a. 58. 59. 60. 61. 62. 63. 63a. 64. 65. 66. 67. 68. 68a. 69. 70. 71. 72. 73. Pipl@ N., Walker, L., and Thomason, M., Alcohol and Vehicular Injuries in Adolescents, Journal ofAdo/escent Health Care 19:119-121, 1989. Preusser, D., and Lund, A., And Keep on Looking: A Film to Reduce Pedestrian Crashes Among 9-to 12-Year-Olds, Journal of Safety Research 19:177-185, 1988. Ramenofsky, M., and Morse, T., Standards of Care for the CnticallyInjurd Pediatric Patient Journal ofTraurna 22(11):92 1933, 1982. Riccio-Howe, L.A., Health Wlues, Locus of Control and Cues to Action as Predictors of Adolescent Safety Belt Use, Journal of Adolescent Health Care 12:256-262, 1991. Rice, D., MacKenzie, E., et al., Cos~ of]njury in the United States: A Report to Congress 1989 (San Francisco, CA: Institute for Health and Aging, Injury Prevention Center, University of California, Johns Hopkins University, 1989). RivarL F.P., Epidemiology of Childhood Injuries, Preventing Childhood Injuries, A.B. Bergman (cd.) (Columbus, OH: Ross Laboratories, 1982). RivarA F. P., Traumatic Deaths of Children in the United States: Currently Available Prevention Strategies, Pediatncs75(3):45& 462, 1985. RivarA F.P., and Barber, M., Demographic Analysis of childhood Pedestrian Injuries, Pediatrics 76(3):375-381, 1985. RiVW~ F. P., and WOM, M.E., Injury Research: Where Should We Go From Here? Pediatrics 84(1):180-181, 1989. Rodgers, G. B., The Effect of Helmets in Reducing A1l-lkrrain Vehicle Injuries and Deaths, Accident Analysis and Prevention 22(1):47-58, 1990. Rotter, J., Some Problems and Misconceptions Related to the Constructs of Internal Versus External Control of Reinfomement, Journal of Consulting and Clinical Psychology 43:56-67, 1975. Runy~ C. W., Earp, J. A., and Reese R.P., Injury Experiences, Bicycle Helmets and Beliefs About Mandated Helmet Use in a National Sample of Competitive Cyclists, unpublished manuscript, Chapel Hill, NC, 1990. Runyan, C.W., and Gerke& E., Epidemiology and Prevention of Adolescent Injury: A Review and Research Agenda, Journal of the Amencan Medical Association 262(16):2273-2279, 1989. RunyW C.W., Gerkem E., and Sadowski, L. S., Unintentional Injury Among Adolescents, paper prepared for the Office of Tuhnology Assessment, U.S. Congress, Washington, DC, January 1990. Seidel, J. S., HombeiL M., Yoshiyu K., et al., Emergency Medical Services and the Pediatric Patient: Are the Needs Being h4et? Pediatrics 73:769-772, 1984. Selbst, S., Alexander, D., and Ruddy, R., Bicycle-Related Injuries, American Journal of Diseases of Children 141:140 144, 1987. Slap, G.B., Chaudhuri, S., and Vorters, D. F., Risk Factors for Injury During Adolescence, Journal of Adolescent Health Care 12:263-268, 1991. Smiti M.F., Follow-Up Evaluation: Safe Perforrnan ce Curriculum Driver Education Project, written comments to J.R. Miller, National Highway Traffic Safety Admuu stratiom U.S. Department of Transportation Washington DC, August 1987. Smi@ S. M., and Middaugh, J.P., Injuries Associated With Three-Wheeled, All lkrrain Vehicles, Alaska, 1983 and 1984, Journal of the American Medical Association 255:2454-2458, 1986. Spyker, D.A., Submersion Injury: Epidemiology, Prevention, and Management, Pediarnc Clinics of North America 32:1 13125, 1985. Sweedler, B. M., Strategies To Reduce Youth Drinking and Driving, Alcohol Healrh and Research Mbrld 14(1):76-80, 1990. Thompsom R. S., Rivara, F. P., and Thompsou D. C., A CaseControl Study of the Effectiveness of Bicycle Safety Helmets, 74. 75. 76. 76a. 77. 78. 79. 80. 81, 82. 83. 84. 85. 86. 87. 87a. 87b. New England Journal of Medicine 320(21):1361-1367, 1989. Tbrg, J. S., Vegso, J.J., and Sennet$ B., The National Football Head and Neck Injury Registry: 14-Year Report on Cervical Quadriplegic (1971 -1984), Clinics in Sports Medicine 6:61-73, 1987. U.S. Congress, House of Representatives, Committee on Government Operations, Subcommittee of Commerce, ConSum tTS, and Monetary Affairs, Consumer Product Safety Commissions Oversight of Consent Decree Regarding Hazzzrds of All-Terrain Vehicles (ATVs), hearing, Feb. 28, 1990, serial No. 101-2 (Washington DC: U.S. Government Printing Office, 1990). U.S. Congress, Library of Congress, Congressional Research Service, Guns and Gun Control: National Public Opinion Polls, prepared by R. SII@ Nov. 26, 1990. U.S. Congress, OffIce of kchnology Assessment, Adolescent Health-Volume I: Summa ry and Policy Options, OTA-H-468 (-Washington DC: Us. Gov emment Printing Office, April 1991). U.S. Congress, OffIce of Twhnology Assessment, Indian Health Care, OTA-H-291 (Washingto% DC: U.S. Government Printing OffIce, April 1986). U.S. Congress, Oftlce of lkchnology Assessment, Healthy Children: Investing in the Future, OTA-H-345 (WashingtorL DC: U.S. Government Printing Offlce, February 1988). Us. Consum er Product Safety Cornmissio~ 1987 Annual Report @%ShiIlgtO~ DC: 1988). U.S. Consumer Product Safety Cornmissio% unpublished 1988 data from the National Electronic Injury Surveillance Systerm Washington DC, 1989. U.S. Consumer Product Safety Commission Division of Hazard and Injury Data Systems, The National Electronic Injury Surveillance System: A Description of its Role in the U.S. Consumer Product Safety Commission Washington DC, Apxti 1989. U.S. Department of Commerce, Bureau of the Census, Estimates of the Population of the United States by Age, Sex, and Race: 1980 to 1986, Current Populations Reports, Series P-25, No. 1000 (WashingtorL DC: U.S. Government Printing Office, 1987). U.S. Department of Health and Human Services, OffIce of the Secretary, Task Force on Black and Minority Heal@ Report of the Secretarys Twk Force on Black and Minority Health, Volume V Hormcide, Suicide, and Unintentional Injunes (Washington DC: U.S. Government Printing Office, January 1986). U.S. Department of Health and Human Services, Public Health Service, Centers for Disease Control, Drowning in the United States, 1978 -1984, Morbidity and Mortality Weekly Report, prepared by J.A. Gulaid and R.W. Sattiq 37(SS-1):26-32, February 1988. U.S. Department of Health and Human Services, Public Health Service, Centers for Disease Control, Deaths Due to Injury in the Home Among Persons Under 15 Years Of Age, 19701984, Morbidity and Mortality Weekly Report, prepared by D.A. Pollock, D.L. McGee, and J.G. Rodriguez, 37( SS-1):13-20, February 1988. U.S. Department of Health and Human Services, Public Health Service, Centers for Disease Control, Introduction: Moving From the 1990 Injury Control Objectives to State and Local Surveillance Systems, Morbidity and Mortality Weekly Report, prepared by M.L. Rosenberg, P.L. Graitcer, and R.J. Waxweiler, 37(SS-1):1-4, February 1988. U.S. Departrmmt of Health and Human Services, Public Health Service, Centers for Disease Control, response to 1989 Office of Technology Assessment questio tie regarding adolescent health initiatives, WashingtorL DC, 1989. U.S. Department of Health and Human Services, Public Health Semice, Centers for Disease Control, National Center for Health Statistics, Health, United States, ]989 (Washington DC: U.S. Government Printing Office, 1990). U.S. Department of Health and Human Services, Public Health Service, Centers for Disease Control, National Center for Health
PAGE 146
II-144 Adolescent HealthVolume II: Background and the Effectiveness of Selected Prevention and Treatment Services 88. 89. 90. 91. 92. 93. 94. 95. %. 97. 98. 99. 100. 101. 102. Statistics, National Center for Health Statistics: Organization and Activities, DHHS Pub. No. (PHS) 88-1200 (Hyattsville, MD: 1988). U.S. Department of Health and Human Services, Public Health Service, Centers for Disease Control, National Center for Health Statistics, Trends and Current Status in Childhood Mortality: United States, 1900-85, Vital and Health Statistics, Series 3, No. 26, DHHS Pub. No. (PI-N) 89-1410 @kdliI@OQ DC: U.S. Government Printing Office, 1989). U.S. Department of Health and Human Services, Public Health Service, Centers for Disease Control, National Center for Health Statistics, unpublished 1985 data from the National Ambulatory Medical Care Survey, Hyattsville, MD, 1989. U.S. Departznent of Health and Human Semices, Public Health Semice, Centers for Disease Control, National Center for Health Statistics, unpublished 1987 mortality daa Washington+ DC, 1990. U.S. Department of Health and HumruI Services, Public Health Service, Centers for Disease Control, National Center for Health Statistics, unpublished 1987 data from the National Hospital Discharge Survey, Washington DC, 1989. U.S. Department of Health and Human Services, Public Health Service, Centers for Disease Control, National Center for Health Statistics, Vital and Health Statistics: Current Estimates From the National Health Interview Survey, 1988, DHHS Pub. No. (PHS) 89-1501 ~aShi@OW DC: U.S. GOV ernment Printing Office, 1990). U.S. Department of Health and Human Services, Public Health Service, Centers for Disease Control, National Center for Health Statistics, unpublished 1988 data from the National Health Interview Survey, Hyattsville, MD, 1990. U.S. Department of Health and Human Services, Public Health Sewice, Heatth Resources and Services Adrmms tratiom Bureau of Health Care Delivery and Assistance, Offlce of Maternal and Child HealtlL Abstracts of Active Projects, FY 1986 (ROckville, MD: 1986). U.S. Department of Health and Human Services, Public Health Service, Health Resources and Services Mrmru stratioq Bureau of Maternal and Child Health and Resources Development, Emergency Medical Sexvices for Children Program, Emergency Medical Services for Children-The Federal Initiative, Rockville, MD, no date. U.S. Department of Health, Education, and Welfare, Public Health Service, National Center for Health Statistics, Vital Statistics of the United States, 1970, Vol. II-Mortality (Washington DC: U.S. Government Printing Office, 1975). U.S. Department of Herdth, Education, and Welfare, Public Health Service, National Center for Health Statistics, Vital Statistics of the United States, 1975, Vol. II-Mortality (Washington DC: U.S. Government Printing Offlce, 1980). U.S. Department of Health and Human Services, Public Health Service, National Center for Health Statistics, Vital Statistics of the United States, 1980, Vol. 11-ortality (Washington DC: U.S. Government Printing Office, 1985). U.S. Department of Health and HumarI Services, Public Health Service, National Center for Health Statistics, Vital Statistics of the United States, 1984, Vol. 11-Mortaiity (Washington DC: U.S. Government Printing OffIce, 1989). U.S. Department of Health and Human Services, Public Health Service, National Center for Health Statistics, Vital Statistics of the United States, 1985, Vol. II-Mortality (Washington DC: U.S. Government Printing OffIce, 1988). U.S. Department of Health and Human Services, Public Health Service, National Center for Health Statistics, Vital Statistics of the United States, 1986, Vol. II-Mortality (Washingto~ DC: U.S. Government Printing Office, 1989). U.S. Department of Health and Human Services, Public Health Semice, National Institutes of Hezdti National Institute of Child Health and HumaII Developmen~ response to OffIce of lkchnol103. 104, 105. 106. 107. 108. 109. 110. 111. 112. 113. 114. 115. 116. 117. 1 17a. 118. 119. 120. ogy Assessment questionnaire regarding adolescent health initiatives, Washington, DC, 1989. U.S. Department of Health and Human Services, Public Health Service, Oflice of Disease Prevention and Health Promotiom Prevention Report, Washingto~ DC, December 1988. U.S. Department of Transportatio~ National Highway Traffic Safety Adminiatmtiom Alcohol in Fatal Accidents for Jhrioua Driver Age Groups, research notes, J.C. Fel~ Washington DC, 1982. U.S. Department of Transportation National Highway Traffic Safety Administration Prowsional Driver Licensing System for Young Novice Drivers, DOT HS 806-891 (Washingto~ DC: 1985). U.S. Department of Transportatio~ National Highway Traflic Safety Administration Fatal Accident Repomng System (Washingto~ DC: 1987). U.S. Department of Transportation National Highway Traffic Safety Adminis tratioq Tr@ic Safety : A Report on the Activities Under the National Trajjic and Motor Vehicle Safety Act of 1966, as Amended and the Motor Vehicle Information and Cost Savings Act, as Amended January 1, 1987-December 31, 1987 (waShingtO~ DC: 1988). U.S. Department of TransportatiorL National Highway Traffic Safety Adrninistratiou Status Report on Priority Programs, DOT HS 807-265 ~WhiIlgtOq DC: April 1988). U.S. Department of Transportation% National Highway Traffic Safety AdministratiorL response to 1989 Office of Ikdmology Assessment questio nnaire regarding adolescent health initiatives, Washingto~ DC, 1989. U.S. Department of Transportatio~ National Highway Traffic Safety Administration Fatal Accident Repom-ng System 1988: A Review of Information on Fatal Trafic Crashes in the United States in 1988 (WashingtorL DC: 1989). U.S. Department of Transportatio~ National Highway Traffic Safety Administration Provisional Licensing Programs for Young Drivers, DOT HS 807-375, prepared by P.F. Wailer (W-O% DC: February 1989). U.S. Department of TransportatiorL National Highway Traffic Safety A&rums tratiorL Restraint System Usage in Trafic Population 1988, Annual Report, DOT HS 807-447 (lW@@gtoq DC: June 1989). U.S. Department of Transportation National Highway Traffic Safety Administration Consumer Information Washington DC, November 1989. U.S. Department of Transportation National Highway Traffic Safety A&mm stratiou Facts About Motorcycle Crashes and Safety Helmet Use, NTS-23/4 (WAhgtorij DC: 1990). U.S. Department of Transportatio~ National Highway Traffic Safety Mrmru stration+ Young Mult Highway Safety Plan (Washington DC: January 1990). U.S. Department of TransportatiorL National Highway Traffic Safety Adrninistratioq Nationrd Center for Statistics and Analysis, Drunk Dnving Facts (Washington DC: July 1989). Wagenaar, A. C., Alcohol, Young Drivers, and Traj6c Accidents wow MA: Wington Books, 1983). Wailer, A.E., Baker, S.P., and Szocka, A., Childhood Injury Deaths: National Analysis and Geographic Vuiations, American Journal of Public Health 79(3):310315, 1989. Wailer, P.F., Runyan+ C. W,, and Perry, P.E., Assessing the Impact of Increasing the Drinkm gAge on Motor Vehicle Injuries: An Injury Control Case Study, Centers for Disease Control, Public Health Service, U.S. Department of Health and Human Semices, Atlan@ GA, 1986. Wailer, P.F., Stewart, J.R., I-Iansq A.R., et al., The Potentiating Effects of Alcohol on Driver Injury, Journal of the American Medical Association 256:1461-1466, 1986. WassermarL R., Walk, J., Monty, M., et al., Bicyclists, Hehnets and Head Injuries: A Rider-Based Study of Helmet Use
PAGE 147
Chapter 5Accidental injuries: Prevention and Services II-145 121. 122. 123. 124. andEffectiveness, AmericanJournal ofPublicHealth 78(9):1220 125. 1221, 1988. White, J.B., Honda Follows IEad of U.S. On Air Bags, Wall Streef Journal, p. Bl, Sept. 25, 1990. 126. Williams, A.F., Fatal Motor Vehicle Crashes Involving llxmagers, Pediamcian 12:3740, 1985. Williams, A.F., Nighttime Driving and Fatal Crash Involve127. ment of T&magers, Accidents Analysis and Prevention 17:1-5, 1985. Williams, A.F., and Karpf, R. S., Deaths of Ikenagers as 128. Passengers in Motor Vehicles, Accidents Analysis and Prevention 15:49-54, 1983. Williams, A.F., Wells, J.K., and Lund, A.K., Voluntary Belt Use Among High School Students, Accidents Analysis and Prevention 15:161-165, 1983. Wintemute, G.J., Kraus, J.F., lkreg S.P., et al., Drowning in Childhood and Adolescence: A Population Based Study, American Journal of Public Health 77:830-832, 1987. Wintemute, G.J., lkre~ S.P., Kraus, J.F., et al., When Children Shoot Childre% Journal of the American Medical Association 257:3107-3109, 1987. Withers, B., and Baker, S., Epidemiology and Prevention of Injuries, Emergency iUedicine Climcs ofNorthAmerica 2(4):701715, 1984.
PAGE 148
Chapter 6 CHRONIC PHYSICAL ILLNESSES: PREVENTION AND SERVICES Contents Page Introduction . . . . . . . . . . . . . . . . . . 149 Background on Physical Health Problems of Adolescents . . . . . . . . 150 Physical Causes of Death . . . . . . . . . . . . . . . 150 Reasons for Hospitalizations . . . . . . . . . . . . . . 151 Reasons for Visits to Office-Based Physicians . . . . . . . . . . 154 Findings From National Population-Based Surveys . . . . . . . . . 156 National Health Interview Survey (NHIS) . . . . . . . . . . . 156 National Health Examination Survey (NHES) . . . . . . . . . . 159 Physical Health Problems From the Perspective of Adolescents . . . . . . 161 Physical Health Problems From the Perspective of Parents . . . . . . . 162 Background on chronic Physical Illnesses and Disabilities of Adolescents . . . . 163 Trends in the Incidence and Prevalence of Chronic Physical Illnesses and Disabilities Among Adolescents . . . . . . . . . . . . . . . 163 Consequences of Serious Chronic Conditions for Adolescents . . . . . . . 164 Activity Limitations . . . . . . . . . . . . . . . 165 Psychosocial Consequences . . . . . . . . . . . . . . 167 Prevention of Chronic Physical Illnesses and Disabilities Among Adolescents . . . . 168 Services and Interventions for Adolescents With Chronic Physical Illnesses and Disabilities 169 Use of Health Services by Adolescents With Chronic Conditions . . . . . . 169 Costs of Treatment for Adolescents With Chronic Conditions . . . . . . . 169 Interventions To Treat Psychosocial Problems of Adolescents With Chronic Conditions . 171 State and Local Services for Adolescents With Chronic Conditions . . . . . 173 Examples of Chronic Physical Illnesses Among Adolescents . . . . . . . 174 Cancer Among Adolescents . . . . . . . . . . . . . . 174 Trends in the Incidence and Prevalence of Cancer Among Adolescents . . . . 174 Consequences of Cancer Among Adolescents . . . . . . . . . . 175 Prevention of cancer Among Adolescents . . . . . . . . . . 176
PAGE 149
Services and Interventions for the Treatment of Adolescent Cancer . . . . . 177 Major Federal Policies and Programs Pertaining to Cancer Among Adolescents . . 179 Acne Among Adolescents . . . . . . . . . . . . . . . 179 Dysmenorrhea Among Adolescent Females . . . . . . . . . . . 181 Major Federal Policies and Programs Pertaining to Adolescents With Chronic Conditions . 183 Education for All Handicapped Children Act . . . . . . . . . . 183 Developmental Disabilities Assistance and Bill of Rights Act . . . . . . . 183 Other Federal Efforts . . . . . . . . . . . . . . . . 183 Conclusions and Policy Implications . . . . . . . . . . . . . 184 Chapter 6 References . . . . . . . . . . . . . . . . 186 Boxes Box Page 6-A. Examples of Definitions of Chronic Illness and Disability . . . . . . . 150 6-B. Federal Sources of Data on the Physical Health of U.S. Adolescents . . . . . 152 6-C. Trends in the Prevalence of Chronic Physical Conditions Among U.S. Adolescents . 164 Figures Figure Page 6-1. Parents Ratings of Child and Adolescent Health Compared to Physicians Findings on Examination, U.S. Children Ages 6 to 17, 1963-65 and 1966-70 . . . . . 162 6-2. Incidence of Cancer Among U.S. Adolescents Ages 10 to 19, 1975 -87 . . . . 175 6-3. Cancer Mortality for U.S. Adolescents Ages 10 to 19, 1973-87 . . . . . . 175 Tables Table Page 6-1. Rates of Different First-Listed Diagnoses for U.S. Adolescents Ages 10 to 18 Discharged From Short-Stay Non-Federal Hospitals, 1987 . . . . . . . . . 154 6-2. Number of Different First-Listed Diagnoses for U.S. Adolescents Ages 10 to 18 Discharged From Short-Stay Non-Federal Hospitals, 1987 . . . . . . . 155 6-3. Visits to Office-Based Physicians by U.S. Adolescents Ages 10 to 18: Number and Distribution by Diagnosis, 1985 . . . . . . . . . . . . . 155 6-4. Visits to Office-Based Physicians by U.S. Adolescents Ages 10 to 18: Number and Distribution by the 15 Most Common Principal Diagnoses, 1985 . . . . . 156 6-5. Number of Restricted-Activity Days Associated With Acute Conditions per 100 U.S. Adolescents for Noninstitutionalized Adolescents Ages 10 to 18, by Sex, Age, and Type of Condition, 1988 . . . . . . . . . . . . . 157 6-6. Number of School-Loss Days Associated With Acute Conditions per 100 U.S. Adolescents for Noninstitutionalized Adolescents Ages 10 to 17, by Sex, Race, Family Income, and Type of Condition, 1988 . . . . . . . . . . . . . 158 6-7. Prevalence Rate for 20 Leading Chronic Conditions Among Noninstitutionalized U.S. Adolescents Ages 10 to 18, 1988 . . . . . . . . . . . 159 6-8. Distribution of U.S. Adolescents Ages 10 to 18 by Degree of Activity Limitation Due to a Chronic Physical or Menta1 Condition and Socioeconomic Characteristics, 1988 . . 160 6-9. Estimated Prevalence of Chronic Conditions in U.S. Children Ages O to 20, 1980 . 165 6-10. Number of Restricted-Activity Days Due to Acute/Chronic Conditions Among Noninstitutionalized U.S. Adolescents Ages 10 to 18, by Type of Restricted-Activity Day and Sociodemographic Characteristics, 1988 . . . . . . . . . . 166
PAGE 150
Chapter 6 CHRONIC PHYSICAL ILLNESSES: PREVENTION AND SERVICES Introduction Despite the common perception that U.S. adolescents are among the healthiest of Americans, evidence from a variety of sources discussed below indicates that many adolescents experience acute or chronic conditions that adversely affect their lives (see definitions in box 6-A). Acute conditions experienced by adolescents include injuries (e.g., sprains, lacerations, and fractures) l and illnesses ranging from colds and influenza to appendicitis. Chronic conditions include a wide spectrum of physical and mental health problems (e.g., hay fever, acne, cancer, diabetes, cardiovascular disease, epilepsy, orthopedic impairments due to injury, hearing impairments, visual impairments, emotional problems, and mental retardation). Nevertheless, in the 1988 National Health Interview Survey (NHIS ) conducted by the U.S. Department of Health and Human Services (DHHS), 97.1 percent of 10t o 18-year-olds were reported to be in good to excellent health (105). NHIS data generally reflect parents perceptions of adolescents health status, 2 but other evidence suggests that, for the most part, adolescents also regard themselves as healthy. 3 This chapter raises some important issues related to the prevention and treatment of chronic physical health problems among U.S. adolescents. 4 First, it provides background on physical health problems of adolescents using a variety of data. Next it provides an overview of chronic physical illnesses an d disabilities among adolescents and discusses the prevention and treatment of such problems. The chapter includes an in-depth discussion of cancer and of two physical health problems whose importance to adolescents is sometimes overlooked by parents, health care providers, and policymakers: acne and dysmenorrhea (painful menstruation). Finally, the chapter reviews major Federal programs pert aining to chronic physical illness and disability. It is important to emphasize that this chapter is not designed to be a comprehensive assessment of all chronic physical health problems affecting adolescents. Rather, this chapter is intended to stimulate further discussion of issues such as how to assess the physical health status of adolescents; how to prevent and treat adolescents chronic physical health problems; and what role the Federal Government can play in addressing the needs of adolescents with physical health problems. Other chapters in this volume cover a variety of specific adolescent physical health topics. s Chronic physical illnesses that affect adolescents and merit policy analysis but are not covered in depth in this chapter include asthma, diabetes, hypertension, chronic renal disease, seizures, and visual and hearing impairments (14,22,78) It is also important to note that this chapter does not cover generic issues related to the delivery of health care services to adolescents. The delivery of primary and comprehensive care to adolescents, adolescents health insurance status and financial l~njurie~ me or hu~s ~mted t. the body by an external force (16a). Information on injuries among U.S. adolescents is pre~nted fi ch. 5! Accidental Injuries: Prevention and Services, in this volume. WS has a number of limitations. As a household survey of a sample of the civilian noninstitutionalized population, it does not include individuals who are homeless or in institutions such as nursing homes or hospitaIs. For individuals under age 17, information is collected from a proxy, usually a parent or guardian. Older adolescents, 17and 18-year-olds, may respond for themselves (105). 3A Smey of M~e50ta youth found, for exmple, that 91.4 percent of males and 85.9 percent of fdes believed that the~ he~~ status was good to excellent (88). dFollowing current mainstream usage, although not without occasional difficulty and ambiguity, this chapter defines physical health problem as problems of or related to the body, and having material existence and defines mental health problems as problems pe rtaining to the mind. Information on mental health problems in adolescents is presented in ch. 11, Mental Health Problems: Prevention and Services, in this volume. Some mental health problems have a physical basis, so the distinction between physical and mental health problems is somewhat arbitrary. sFor exaple, tie prev~ence, Con.squences, prevention, and short-term treatment of accidental injties ~ covered in this ol~e h Ch. 5! Accidental Injuries: Prevention and Services nutrition and fitness problems, in ch. 7, Nutrition and Fitness Problems: Prevention and Services; dental problems, inch. 8, Dental and Oral Health Problems: Prevention and Services AIDS and other sexually transmitted diseases, inch. 9, AIDS and Other Sexually Transmitted Diseases: Prevention and Services. -II-149-
PAGE 151
11-150. Adolescent HealthVolume II: Background and the Effectiveness of Selected Prevention and Treatment Services Box 6-AExamples of Definitions of Chronic Illness and Disability The literature on chronic illness and disability-for adolescents and for individuals of all ages--con tains a wide array of definitions. Although some of the differences cannot be resolved in this chapter, several definitions are provided below as a guide to OTAs approach to assessing the prevalence and consequences of chronic illness and disability among adolescents. For the purpose of the National Health Interview Survey (NHIS) conducted by the National Center for Health Statistics in the U.S. Department of Health and Human Services (DHHS), a health condition is a departure from a state of physical or mental well-being (104). A condition maybe either an illness, an injury, or an impairment (see below). A condition is considered acute if it has lasted 3 months and is of sufficient consequence to have involved either a physician visit or at least 1 day of restricted activity; a condition is considered chronic if it has lasted 3 months or more or is a type of condition that normally lasts for at least 3 months (e.g., asthma, diabetes, heart conditions) (105). NHIS defines a disability as any temporary or long-term reduction of a persons activity as a result of an acute or chronic condition (104). Disabilities are sometimes caused by illnesses (e.g., spina bifida, cerebral palsy, severe asthma) and sometimes caused by injuries or impairments. In NHIS, an impairment is a chronic or permanent defect, usually static in nature, that results from disease, injury, or congenital malformation (107a). NHIS measures disability in several ways. One way is in terms of the number of disability days, or days that a persons activity has been reduced. NHIS identifies several types of disability days. Restricted-activity days (the most inclusive and least descriptive measure) are any days on which a person restricts his or her usual activities for more than half the day because of illness or injury. NHIS measures four types of restricted-activity days: bed-disability days, work-loss days, school-loss days, and cutdown days. School-loss days area type of ed only for children ages 5 through 17; basically these days are any days on which restricted-activity day determin a child did not attend school for at least half the day because of illness or injury. NHIS also measures disability in terms of limitation of activity due to chronic conditions (107a). A limitation of activity refers to a long-term reduction in a persons capacity to perform the average kind or amount of activities associated with his or her age group. Individuals identified as having a chronic condition by NHIS are classified into categories that reflect the extent to which their activities are limited because of the conditions as follows: 1) unable to carry on the major activity for their age group (for children 5 to 17, major activity refers to school attendance; for individuals age 18 and over, it usually refers to a job, housework, or school attendance); access to health services, consent and confidentiality offices and for hospitalizations; data from household issues affecting adolescents, and issues specific to the delivery of services to selected groups of adolescents (e.g., black, Hispanic, Asian-American, American Indian and Alaska Native, Native Hawaiian, rural, and poor adolescents) are topics addressed in Volume III of this Report. Background on Physical Health Problems of Adolescents There is no single comprehensive source of information about the physical health status of U.S. adolescents. Hence, a variety of sources must be used to identify the most important physical health problems facing adolescents. As noted in box 6-B, data available from the National Center for Health Statistics in DHHS include vital statistics data that provide information on causes of death for adolescents; data on reasons for visits to physicians interview surveys-hat gather information on health problems, including those that result in limitations in activity; and data from epidemiologic surveys that include clinical examinations. Physical health concerns of particular importance to adolescents maybe identified through surveys of young people that ask directly about their most pressing health concerns. Data from all of these sources are presented below to identify important health problems for U.S. adolescents. Physical Causes of Death As noted in box 6-B, national mortality data are compiled from State death certificates by the National Center for Health Statistics in DHHS on an ongoing basis. National mortality statistics include information on the cause of death and demographic
PAGE 152
. Chapter 6-Chronic Physical Illnesses: Prevention and Services l II-151 2) able to perform the basic activity but limited in the amount or kind of major activity performed; 3) not limited in major activity but limited in the kind or amount of other activities; and 4) not limited in activity. OTA has sometimes broadly defined a chronic condition as a problem or disease that is lingering and lasting, as opposed to acute. In its 1982 report Technology and Handicapped People, OTA defined disability as a functional limitation, noting that a person with a disability has a limited ability or an inability to perform one or more basic [daily] life functions (e.g., walking) at a level considered typical (92). Disabilities are often caused by impairments (92). According to OTA, an impairment is a physiological, anatomical, or mental loss or abnormality caused by accident, disease, or congenital condition (92). Visual impairments, for example, may limit the ability to see. A handicap, according to OTA, has to be defined within its environmental and personal contexts (92). Individuals are handicapped by their disability if it prevents them from performing one or more life functions at a typical level (92). Handicaps are caused not by the disabilities themselves, but by the interaction between an individuals disability and the social environments in which the individual is functioning or expected to function (92). Thus, an adolescent with poor vision has an impairment which reduces her ability to see (a disability). However, if corrective lenses can adequately correct her vision or if she can communicate effectively through the use of oral interpreters and braille, the visual impairment may not prevent the adolescent from performing in school, at home, or socially (i.e., it may not become a handicap). In this chapter, chronic ilnesses are defined as diseases that persist over a long period of time. According to a current medical dictionary, a disease is any deviation from or interruption of the normal structure or function of any part, organ, or system, or combination thereof, of the body that is manifested by a characteristic set of symptoms and signs and whose etiology, pathology, and prognosis may be known or unknown (16a). 1 Disabilities refer to limitations, usually long-term, in an individuals ability to perform basic activities of daily living. Mainstream distinctions between physical and mental conditions are adhered to in this Report, so that physical is generally defined as being of or related to the body, and having material existence, whereas mental is defined as pertaining to the mind. Some mental health problems have at least some biological component so the distinction between physical and mental health problems is rather arbitrary. 2 IDis~s are SOmetimeS distinguished horn injuries, which have been defii as harms or hurts i.tlfliCted to the body by ~ ext~ force (16a). Information on injuries among U.S. adolescents is presented inch. 5, Accidental Injuries: Prevention and Services, in this volume, 2~o-tionon sel=t~ men~ ~~problems tit ~ectu,s. adolescents is presen~ inch. 11, WM H~thProt)lems: prevention and Services, in this volume. characteristics of the decedent. Recent mortality hospitals in the United States (see box 6-B). statistics indicate that the most frequent natural cause of death among U.S. adolescents ages 10 to 19 6 is cancer. 7 Reasons for Hospitalizations The National Hospital Discharge Survey (NHDS), a survey sponsored by the National Center for Health Statistics, provides information on hospital discharges from a sample of short-stay non-Federal According to the 1987 NHDS, injury and poisoning are the problems that most frequently lead to hospitalization for U.S. males and females ages 10 to 18. Childbirth is the most frequent reason for hospitalization for U.S. females ages 15 to 18. 8 The types of physical illnesses that most frequently lead to hospitalization for U.S. males and females ages 10 to 18 are diseases of the respiratory system and diseases of the digestive system (see table 6-l). 6T0 the extent possible, this OTA Report focuses on adolescents ages 10 through 18. It also attempts, whenever possible, to present evidence for smatler age groupings of adolescents (e.g., 10 to 14and 15to 18-year-olds). Sometimes, however, data were not readily available for these age groupings, and OTA used other age breaks. As a prominent example, the National Center for Health Statistics typically makes mortality data available at 5-year age breaks; thus, this section reports on information for 10to 14-year-olds and 15to 19-year+ Ms. lNatural ~au~e~ of d~~ refer t. ~us~ such as illness, disease, or chronic conditions as opposed to external causes of death such m acciden~ injuries, homicide, or suicide. As shown intigure 5-1 inch. 5, Accidental Injuries: Prevention and Services, more adolescents die from external causes than from natural causes. These other problems are covered in other chapters of the Report. Age differences in causes of death in the U.S. population are covered in Vol. I of this Repoti. gsee ch. 10, ~e~cy and Parenting: Prevention and SerVICeS, in this volume for a discussion of the physical and other consequences of childbearing among U.S. adolescents.
PAGE 153
//-152 Adolescent HealthVolume II: Background and the Effectiveness of Selected Prevention and Treatment Services Box 6-BFederal Sources of Data on the Physical Health of U.S. Adolescents National Center for Health Statistics The National Center for Health Statistics (NCHS) of the U.S. Department of Health and Human Services (DHHS) is the primary Federal source of data on the physical health of U.S. adolescents. Through the National Vital Statistics System, NCHS collects and publishes data on births, deaths, marriages, and divorces in the United States (104). In addition, NCHS collects and publishes data from ongoing and special surveys such as the National Hospital Discharge Survey, the National Ambulatory Medical Care Survey, the National Health Interview Survey, the National Health Examination Survey, the National Health and Nutrition Examination Survey, and the National Survey of Family Growth. Some of these surveys are described below. National Hospital Discharge Survey (NHDS) NHDS is a continuing nationwide sample survey that gathers information each year on patients (excluding newborn infants) discharged from a sample of non-Federal short-stay and specialty hospitals located in the 50 States and the District of Columbia (108). The information collected includes data on personal information about the patient (e.g., birth date, race, sex, marital status), administrative information (e.g., dates of admission and discharge), and medical information (e.g., diagnosis and medical procedures performed). To be included in the sample, hospitals must have a minimum of six beds for patient use and average patient stays of less than 30 days. Limitations-Relatively few adolescents are hospitalized each year. Because NHDS does not oversimple for adolescents, the number of adolescents sampled in the survey is small. Consequently, NHDS does not provide reliable information on the incidence of hospitalization among adolescents for any but the most frequent reasons for hospitalization and does not allow for finer breakdowns such as by race, gender, or socioeconomic status. In addition, data are not reported using appropriate age breaks for adolescents. National Ambulatory Medical Care Survey (NAMCS) NAMCS is a continuing national probability sample survey of ambulatory medical encounters. It collects data on physician-patient encounters in the offices of a sample of non-federally employed physicians classified as office-based, patient care physicians. Sample physicians are asked to complete a patient record information form for a systematic random sample of office visits oc curring during a randomly assigned l-week reporting period. Approximately 3,500 physicians provided data in 1985 (the last year for which data are available), submitting 71,594 patient record forms for patients of all ages. These data are used to develop estimates of the use of office-based visits by the U.S. population. Data are collected on patient characteristics (e.g., birth date, sex, race, ethnicity) and medical information (e.g., diagnostic services performed, diagnosis, reason for visit, medication provided or prescribed, and disposition of visit). Additional data are collected on the expected source of payment, referral status of the patient, and characteristics of the provider (e.g., specialty). Limitations-NAMCS does not collect data on visits to hospital-based physicians. In addition, because there is no stratification of the sample on race or ethnicity and the sample sizes are quite small for racial and ethnic minorities, NAMCS does not present reliable information on office visits made by minority adolescents. The survey also includes information only on those individuals who seek care. Thus, adolescents who do not seek care for medical problems, or who use alternative sources of care, are not included in the survey. These adolescents may disproportionately include poor adolescents or those of nonwhite racial or ethnic backgrounds. National Health Interview Survey (NHIS) NHIS is a continuing nationwide survey of households (105,106), Data are collected from a probability sample of the civilian noninstitutionalized population residing in the United States on personal and demographic characteristics, restricted-activity days due to acute and chronic conditions, injuries, activity limitations due to chronic health conditions, and use of medical services. In 1988,47,485 households, representing 122,310 persons, were sampled; 94.9 percent of these households were surveyed. The 1988 NHIS included a special focus 1~ and limitations of Fedexai data O?.I U.S. adokacents accidental injuries nutrition and fitness problems; dental and oral W@ cases of ArDs d sex* transmitted diseases pregnancy; mental health problems; alcohol, tobacco, and drug abuse problems; delinquq, and hopelessness are discussed in the relevant chaptem of this volume. Also see ch. 18, hues in the Dclivcxy of Health and Related %xvices to Sekxted @UpS of Adol cscents, in Vol. III of this Report and app. C, Issues Related to the Luck of Information About Molesccnt Health and Health and Related Semices, in Vol. I of this Report.
PAGE 154
Chapter 6---Chronic Physical Illnesses: Prevention and Services .11-153 on the health status of children and adolescents. Since 1985, the survey has oversampled black persons in order to increase the precision of estimates for this population. Data have been collected continuously since 1957. Limitations-The NHIS sample does not include homeless persons, persons residing in institutions, or members of the armed services. Proxy interviews are generally used for all persons underage 17. Because the adults interviewed may be unaware of, or be reluctant to report, certain health problems or use of health services of adolescents, this information may not reflect the true health status of and utilization of services by adolescents in the household. The NHIS adolescent sample is too small to provide adequate measures of low prevalence physical conditions. Data are generally not reported using age groupings appropriate to describe adolescents. National Health Examination Survey (NHES) and the National Health and Nutrition Examination Survey (NHANES) National clinical epidemiological information on the health status of todays U.S. adolescents is not available. There are no recent national population surveys that provide clinical data about the health status of adolescents. One of the most comprehensive sources of national clinical epidemiological data on adolescents was NHES (94). The third cycle of this survey, which was conducted from 1966 to 1970, gathered information through interviews and physical examinations on the health status of a representative national sample of 6,768 adolescents ages 12 to 17. However, because this information is now over 20 years old, it is difficult to generalize to todays adolescents. There are likely to be many similarities in the health status of adolescents today and those of 20 years ago, but there may be significant differences as well. NHANES was initiated as a successor to NHES in 1971 but has not yet collected comparable information on the health of U.S. adolescents. To measure the health status and characteristics of a sample of the civilian noninstitutionalized population of the United States, ages 1 to 74, NHANES uses interviews and, for a subsample, clinical examinations. NHANES I took place from 1971 to 1974, with a subsample of persons ages 25 to 74 selected for in-depth examinations. NHANES II began in 1976 and ended in 1980; this study oversampled persons 6 months to 5 years of age and those ages 60 to 74 (96,104). NHANES III is underway and has child health as a special focus (99). However, the adolescent sample in NHANES III will be small in comparison to the 1966-1970 NHES sample, and although blacks and Mexican Americans are being oversampled generally, the numbers of such adolescents included in NHANES III will be small. A total of 3,200 adolescents ages 12 to 19 will be included in the survey, including 1,120 black adolescents, 1,120 Mexican-American adolescents, and 980 white and other adolescents (17). Data collection for NHANES III is not expected to be completed until 1994. Thus, at this time, there is no good source of national clinical epidemiological information on the health status of todays adolescents. Other Federal Agencies Although NCHS is the primary source of national data on the physical health of U.S. adolescents, other DHHS agencies also collect and publish such data (104). The National Cancer Institute within the National Institutes of Health, for example, collects data from 11 population-based registries on people diagnosed with cancer through its Surveillance, Epidemiology, and End Results Program. That program is described below. Surveillance, Epidemiology, and End Results (SEER) Program of Data Collection on Cancer The SEER program provides information about the incidence of and the mortality due to malignant neoplasms in the United States (all ages included). Incidence data are based on information collected from a sample of 12 sites in the United States, plus one in Puerto Rico, representing approximately 13 percent of the total U.S. population. Participants in the program provide data annually to the SEER program. Mortality data are derived from mortality tapes obtained from NCHS, and include data on cancer mortality for the entire United States. The program began in 1972. Limitations-SEER data are only limited if information is required on very specific cancers for smaller populations. In addition, although certain ethnic groups are oversampled (e.g., Japanese, Filipinos), small sample sizes make data on these groups somewhat unreliable. Because relatively few U.S. adolescents are hossions about the specific diseases for which adoles pitalized each year for physical illnesses and thus cents are hospitalized. Nonetheless, a more detailed few are represented in the NHDS sample, sample review of the leading causes of hospitalization for sizes for number of hospitalizations for most spe10to 18-year-olds indicates that asthma, chronic cific illnesses are too small to draw reliable concludiseases of the tonsils and adenoids, and acute !!17 (1 11; t)] (, Q1, ,{
PAGE 155
11-154 Adolescent HealthVolume II: Background and the Effectiveness of Selected Prevention and Treatment Services Table 6-lRates of Different First-Listed Diagnoses a for U.S. Adolescents Ages 10 to 18 Discharged From Short-Stay Non-Federal Hospitals, 1987 Number of first-listed diagnoses/1 ,000 inpatients Males Females Diagnosis by ICD-9-CM category b 10 to 14 15 to 18 10 to 14 15 to 18 Injury and poisoning . . . . . . . 24.8 33.1 16.3 8.2 Diseases of the digestive system . . . . 13.9 11.7 12.1 5.8 Diseases of the respiratory system . . . . 13.4 10.7 19.5 6.1 Mental disorders . . . . . . . . 6.9 14.3 8.8 7.1 Diseases of the nervous system and sense organs 5.9 l l Diseases of the musculoskeletal system and connective tissue . . . . . . . 5.2 5.8 2.8 Diseases of the genitourinary system . . . 5,2 4.3 7.5 Endocrine, nutritional and metabolic diseases, and immunity disorders . . . . . . . 4.7 3.4 1.9 Infectious and parasitic diseases . . . . . 4.0 l 1.8 Complications of pregnancy, childbirth . . . l 12.1 Supplementary classification.. . . . . . * 5.0 39.7 ain the National Hospital Discharge Survey, a ~irst-listed diagnosis is the diagnosis listed first on the face sheet of a patients medical record. b[CD-9-CM refers t. th e International Classification of Disea~e~, 9th Revision, Clinical M~ification, ~hi~h is u~~ to code morbidity data. cEntries mark~ with an asterisk (*) did not meet the requisite standard of reliability. dFemales with deliveries are inducted under Supplementary classifications. SOURCE: U.S. Department of Health and Human Services, Public Health Service, Centers for Disease Control, National Center for Health Statistics, unpublished 1987datafrom the National HosDital Discharae Survev. Hyattsville, MD, 1989. appendicitis are among the physical illnesses most frequently leading to the hospitalization of U.S. adolescents (see table 6-2). Reasons for Visits to Office-Based Physicians As noted in box 6-B, the National Ambulatory Medical Care Survey (NAMCS) gathers information periodically on visits made by patients to a sample of non-Federal physicians in office-based practice (106). Inferences from NAMCS data are limited because the number of physicians sampled in the survey is small; furthermore, adolescents are one of the groups least likely to visit physicians. 9 The most recent available NAMCS data are from 1985. According to these data, diseases of the respiratory system are the most frequent diagnosis for visits by adolescents to office-based physicians (17.0 percent of visits), followed by injury and poisoning (16.3 percent of visits), followed by diseases of the skin and subcutaneous tissue (9.9 percent of visits) (see table 6-3). If one groups NAMCS data by more specific conditions, acne emerges as the most frequent diagnosis for an office visit for a physical problem (4.8 percent of visits) (see table 6-4). 10 Acne is particularly prevalent among older adolescents, who received a diagnosis of diseases of the sebaceous glands (e.g., acne) for 7.4 percent of visits; acne was the 12th most common diagnosis for younger adolescents (1.9 percent of visits) .11 %or a discussion of barriers to adolescents use of physician services, see ch. 15, Major Issues Pe rtaining to the Delivery of Primary and Comprehensive Health Services to Adolescents, in Vol. III. l~e ne~ for a general medic~ examimtion is actually the most frequent specific principal diagnosis (5.8 percent of visits). The need for a gene~ exam does not, however, reflect any specific health problem and is more likely to be part of general preventive health care. 11A prel~~ ~ysis b y OTA suuest~ some interesting discontinuities in the NAMCS data using year-by-year age breti, but ~ause of tie lower reliability and interpretability of information based on fewer numbers of adolescents, it was not possible to look at information using these fme breakdowns. Age breaks of 10 to 14 years and 15 to 18 years were used based on the recommendations of the National Center for Health Statistics (60), and analysis of the patterns of visits to office-based physicians using the NAMCS data. Analysis of visit rates for adolescents of different ages indicated that the rate of visits for adolescent females increases at about age 15, most likely reflecting the increase in pregnancy-related visits. Pregnancies generally involve more than one visit per pregnant female during the course of a year (including postnatal visits). Thus, 10to 14-year-old females have fairly similar visit patterns, as do 15to 18-year-olds. No clear pattern emerged for males. The age break between 10to 14-, and 15to 18-year-olds. the~ is driven by the utilization of physicians by females, which is in turn driven by pregnancy-related visits.
PAGE 156
Chapter 6-Chronic Physical Illnesses: Prevention and Services .11-155 Table 6-2Number of Different First-Listed Diagnoses for U.S. Adolescents Ages 10 to 18 Discharged From Short-Stay Non-Federal Hospitals, 1987 Estimated number of discharges b NHDS diagnostic Males Females Diagnosis code 10 to 14 15 to 18 10 to 14 15 to 18 Other fractures . . . . . . . . . . . . 167 18,969 27,184 * Appendicitis . . . . . . . . . . . . . 91 16,843 16,727 Asthma . . . . . . . . . . . . . . 80 13,845 l * Other mental disorders . . . . . . . . . . 39 21,174 13,485 24,190 Other injury . . . . . . . . . . . . . 177 15,307 l 11,000 Lacerations/wounds. . . . . . . . . . . 174 14,847 l Other psychoses . . . . . . . . . . . . 33 11,570 l 10,747 Chronic disease of tonsils and adenoids . . . . . . 75 * 20,681 16,387 Females with deliveries . . . . . . . . . . 184 309,689 Other implications of pregnancy, childbirth, and the puerperium. 137 47,459 Other inflammatory diseases of the female pelvic organs . . 120 20,532 Other disorders of the genital tract . . . . . . . 125 19,720 Other pregnancy with abortive outcome . . . . . . 128 16,500 Poisoning by drugs, medicinal agents, and biological substances.. 178 * 15,443 Other neurosis and personality disorders . . . . . . 35 * 11,569 aEqimate~with fewerthan 60=mpled@ seshavebeen omhtedfrom thistaNe.Many ofthespe~ficd iagnosticc ategories formales andfemalesages 10 to 14and15to 18hadfewerthan 60sampledcases.Thus, many ofthediagnostic categories Iistedherecansistofaggregations ofother: ratherthanmore specific categories. bEntfies marked with an asterisk (*) did not meet the requisite standard of reliability. SOURCES: Discharges: U.S. Department of Health and Human Services, Public Health Service, Centers for Disease Control, National Center for Health Statistics, unpublished 1987 data from the National Hospital Discharge Survey, Hyattsville, MD, 1989. NHDS diagnostic codes: U.S. Department of Health and Human Services, Public Health Service, National Center for Health Statistics, NHDS Diagnostic Recodes for ICD-9-CM, Hyattsville, MD, June 1987. Table 6-3Visits to Office-Based Physicians by U.S. Adolescents Ages 10 to 18: Number and Distribution by Diagnosis, 1985 Number of visits in Percent Diagnosis by ICD-9-CM Category a ICD-9-CM Code a thousands distribution All diagnoses . . . . . . . . . . . . . . 50,218 100.0 Diseases of the respiratory system . . . . . 460-519 8,535 17.0 Injury and poisoning . . . . . . ... ........800-999 8,177 16.3 Diseases of the skin and subcutaneous tissue ...........680-709 4,957 9.9 Diseases of the nervous system and sense organs ......320-389 4,833 9.6 Infections and parasitic diseases . . . . .. .......001-139 3,593 7.2 Diseases of the musculoskeletal system and connective tissue . . . . . . . . . . . 71 O-739 2,280 4.5 Diseases of the genitourinary system ... ..............580-629 1,969 3.9 Diseases of the digestive system . . . . . . 520-579 1,607 3.2 Mental disorders . . . . . . . . . ...290-31 9 1,226 2.4 Endocrine, nutritional and metabolic diseases, and immunity disorders. . . . . . . . . 240-279 587 1.2 Neoplasms . . . . . . . . . . . 140-239 470 0.9 Diseases of the circulatory system. . . . . . 390-459 454 0.9 Supplementary classification . . . . . . . VO1-V82 8,467 16.9 Symptoms, signs, and ill-defined conditions . . . 780-799 1,424 2.8 Unknown diagnoses . . . . . . . . . . . . 965 1.9 All other diagnoses . . . . . . . . . . . . . 673 1.3 alCD-g-CM refers t. the International Classifimtion of Diseases, 9th Revision, clinical Modification, which is used to code morbidity data. b~is includes blank diagnosis, noncodable diagnosis, and illegible diagnosis. ~his includes diseases of the blood and blood-forming organs (280-289); complications of pregnancy, childbirth, and the puerperium (630-676); congenital anomalies (740-759); and certain conditions originating in the perinatal period (760-779). SOURCE: U.S. Department of Health and Human Services, Public Health Service, Centers for Disease Control, National Center for Health Statistics, unpublished 1985 data from the National Ambulatory Medical Care Survey, Hyattsville, MD, 1989.
PAGE 157
11-156. Adolescent HealthVolume II: Background and the Effectiveness of Selected Prevention and Treatment Services Table 6-4-Visits to Office-Based Physicians by U.S. Adolescents Ages 10 to 18: Number and Distribution by the 15 Most Common Principal Diagnoses, 1985 Number of Percent of Most common principal diagnosis visits in all adolescent Rank by ICD-9-CM Category a thousands visits 1 General medical examination . . . . . . . . . . 2,914 5.8 2 Diseases of sebaceous glands b . . . . . . . . . 2,394 4.8 3 Acute pharyngitis.. . . . . . . . . . . . . 1,822 3.6 4 Acute upper respiratory infections of multiple or unspecified sites . 1,627 3.2 5 Normal pregnancy . . . . . . . . . . . . . 1,548 3.1 6 Earache or ear infection . . . . . . . . . . . 1,368 2.7 7 Suppurative and unspecified otitis media . . . . . . . 1,236 2.5 8 Disorders of refraction and accommodation . . . . . . . 1,197 2.4 9 Other diseases due to viruses and chlamydiae . . . . . . 1,139 2.3 10 Certain adverse effects not elsewhere cfassified c . . . . . 1,086 2.2 11 Contact dermatitis and other eczema . . . . . . . . 1,063 2.1 12 Health supervision of infant or child . . . . . . . . . 1,000 2.0 13 Acute tonsillitis . . . . . . . . . . . . . 799 1.6 14 Asthma . . . . . . . . . . . . . . . 704 1.4 15 Open wound of other and unspecified site . . . . . . . 659 1.4 alCD.9.CM refers t. th e International cla~~ifi=tion of Di~ea~e~, 9th Re~~ion, Clin&l Modif~ation, which is us~ to code morbidity data. bchiefly ~ne other than varioliformis. cpflmarily allergy, unspecified. SOURCES: U.S. Department of Health and Human Services, Public Health Service, Centers for Disease Control, National Center for Health Statistics, unpublished 1985data from the National Ambulatory Medical Care Survey, Hyattsville, MD, 1989. Findings From National Population-Based Surveys Judgments about the importance of particular health problems derived from health care utilization data are limited in that they do not reflect the health concerns of individuals who do not use the health care system. 12 Such concerns are more likely to be reflected in population-based surveys. As noted in box 6-B, the National Center for Health Statistics has used two types of population-based surveys. The National Health Interview Survey (NHIS) collects data from a sample of the civilian noninstitutionalized U.S. population through personal household interviews (108). The National Health and Nutrition Examination Survey (NHANES)--formerly the National Health Examination Survey (NHES)collects health-related data by means of direct physical examin ations, clinical and laboratory tests, and related measurement procedures (108). The latter two surveys have been conducted more rarely than NHIS, and no adequate sample of adolescents was included in NHANES I or II. (NHANES) III is collecting some adolescent-specific data, but the results are not expected until 1994.) National Health Interview Survey (NHIS) NHIS collects information on both acute conditions and chronic conditions. A physical or mental condition is considered acute for purposes of NHIS if: 1) it was first noticed 3 months before the reference date of the interview; and 2) it is not one of the conditions considered chronic regardless of the time of onset. To be counted in NHIS data, an acute condition must also have been of sufficient consequence to have been associated with at least 1 restricted-activity day or at least one visit to a doctor. A physical or mental condition is considered chronic for purposes of the NHIS if: 1) the respondent indicates it was first noticed more than 3 months before the reference date of the interview and it exists at the time of the interview, or 2) it is a type of condition that ordinarily has a duration of more than 3 months. Examples of physical conditions that are considered chronic regardless of their time of onset are diabetes, heart conditions, emphysema, and arthritis. Acute Conditions-The impact of acute conditions on adolescent health is measured in terms of restricted-activity days (overall and due to specific problems) and school-loss days (overall and due to
PAGE 158
Chapter 6-Chronic Physical Illnesses: Prevention and Services II-157 Table 6-5-Number of Restricted-Activity Days a Associated With Acute Conditions b per 100 U.S. Adolescents for Noninstitutionalized Adolescents Ages 10 to 18, by Sex, Age, and Type of Condition, 1988 Both Number of restricted-activity days/100 adolescents in age group c sexes, ages Males Females Type of acute condition 10 to 18 10 to 18 10 to 14 15 to 18 10 to 18 10 to 14 15 to 18 All acute conditions . . . . . . . . . Infective and parasitic diseases . . . . . . . Common childhood diseases . . . . . . Intestinal virus, unspecified . . . . . . . Viral infections, unspecified . . . . . . . Other . . . . . . . . . . . . Respiratory conditione d . . . . . . . . Common cold . . . . . . . . . . Other acute upper respiratory infections . . . . Influenza . . . . . . . . . . . Digestive system conditions . . . . . . . Injuries f . . . . . . . . . . . . Fractures and dislocations . . . . . . . Sprains and strains . . . . . . . . . Other current injuries.. . . . . . . . . Selected other acute conditions g . . . . . . Delivery and other conditions of pregnancy and peurperium . . . . . . . . . . 659.6 121.7 25.7 28.0 57.5 307.0 72.5 35.4 175.0 23.3 119.5 40.8 29.4 19.2 74.8 606.7 117.9 l l 55.6 287.2 71.3 35.6 152.2 l 133.5 51.7 l l 39.4 629.2 580.6 104.3 714.4 125.6 59.4 327.6 73.7 35.3 198.7 l 104.9 l l l 111.5 664.7 770.7 129.6 156.0 91.1 l l l l l l l l 325.7 242.3 57.4 319.6 336.7 64.8 l 83.2 81.6 169.0 132.5 179.5 220.6 l l 118.7 94.9 178.4 92.7 l l l l l l l l l l l 174.9 24.7 50.3 107.4 aForthepurpo~G~ ~fthe Nati~nal Health lnterviewSurvey (N~S), ~es~~~.a~i~~~ayisany dayonwh~haperson restricts tdsortterusual acthities fOr morethanhalfaday because ofanillnessoran injury (i.e., aschool-loss, work-loss, orcutdownday orabeddisability day). Restricted-activity days are measures used for both acute and chronic conditions. This table shows only the restricted-activity days associated with acute conditions. bAmndition isconsider~ ,,ac~e~~ for the Pu~ses of N~S if it has lasted under 3 months, is not a @ndition ~nstiered chronic regardless Of time Of OnSet, and is of sufficient consequences to have been associated with either at least one doctor visit or at least 1 day of restricted activity. cEntries marked with an asterisk (*) did not meet the requisite standard Of rdiablity. dcategories not shown ~use of low reliability of estimates i~l~e acute bronchitis, pneumonia, and othet respiratory conditions. ~his includes dental conditions; indigestion, nausea, and vomiting; and other digestive conditions. No specific category had enough sampled cases to be considered reliable. fcatwories not shown ~Quse of Iow reliability of estimates i~lude open wounds and lacerations ad contusions and superfi~al injuries. 9Categories not shown because of low reliability of estimates include eye conditions, acute ear infections, other ear conditions, acute urinary cxmditions, disorders of menstruation, other disoders of the female genital tract, skin conditions, acute musculoskeletal conditions, headache (excluding migraine), and unspecified fever. SOURCE: U.S. Department of Health and Human Services, Public Health Serviee, Centers for Disease Control, National Center for Health Statistics, unpublished 1988 data from the National Health Interview Survey, Hyattsville, MD, 1990. specific problems). As noted in box 6-A, a restrictedactivity day is any day on which a person restricts his or her usual activities for more than one-half day because of an illness or injury (106). 13 A school-loss day, a type of restricted-activity day calculated for 5-to 17-year-olds, is any day on which a child did not attend school for half a day because of illness or days associated with acute conditions (see table 6-6). Other acute conditions that cause relatively high numbers of restricted-activity and school-loss days among U.S. adolescents are infective and parasitic diseases and injuries. Although the reported average rate of restrictedactivity days due to acute conditions for younger (10to 14-year-old) adolescents is similar to that for older (15to 18-year-old) adolescents, there are some interesting age differences by condition and general differences by sex and race. As shown in table 6-5, younger adolescents are more likely to have restricted-activity days due to acute physical illness (respiratory conditions, infective and parasitic diseases), and older adolescents are more likely injury. The 1988 NHIS found the acute conditions causing the highest numbers of restricted-activity days among noninstitutionalized adolescents ages 10 to 18 were acute respiratory conditions (particularly influenza), followed by infective and parasitic diseases (see table 6-5). Acute respiratory conditions are also responsible for over half of the school-loss 136 *~eSr~cfe~-dc~vig &YS f me ~duplimted ~oun~ of tie fouowing: 1) bed-~sability days, d~g which a yrson spent more thm hdf a bed because of illness or injury: 2) work-loss days, during which a currently employed person 18 years of age and over missed more than half a day from a job or business; 3) school-loss days, during which a student 5 to 17 years of age missed more than half a &y from the school in which he or she was currently emolled; and 4) cut-down days, during which a pemon cuts down for more than half a day on the things he or she usualIy does. Note that a day of restricted activity due to an acute condition is not the same as a limitation in activity caused by a chronic condition (105).
PAGE 159
11-158. Adolescent HealthVolume II: Background and the Effectiveness of Selected Prevention and Treatment Services Table 6-6Number of School-Loss Days a Associated With Acute Conditions b per 100 U.S. Adolescents for Noninstitutionalized Adolescents Ages 10 to 17, by Sex, Race, Family Income, and Types of Condition, 1988 Number of school-loss days/100 adolescents ages 10 to 17C Sex Race Family income All ages Less than $10,000-$20,000$35,000 Type of acute condition 10 to 17 Male Female White Black $10,000 $19,999 $34,999 or more All acute conditions . . . . Infective and parasitic diseases d . Common childhood diseases . . Viral infections, unspecified . . Other . . . . . . . Respiratory Conditions e . . . . Common cold . . . . . Other acute upper respiratory infections . . . . . . Influenza . . . . . . Digestive system Conditions f . . Injuries g . . . . . . . Selected other acute conditions . All other acute conditions. . . . 379.6 79.9 22.0 17.3 33.0 210.0 48.4 23.7 122.3 15.4 32.3 34.3 362.8 82.6 l 36.7 199.8 47.8 110.0 42.4 22.2 397.1 76.9 * 220.7 49.1 l 135.3 * 46.9 399.9 84.8 20.5 39.3 226.2 48.9 26.7 132.2 35.5 29.8 302.8 * l 137.8 * * * 483.1 l * 235.1 * 151.5 l * 403.2 * * 196.2 l 119.0 * 419.3 84.3 l 236.5 61.7 133.3 * l 349.1 83.8 * 42.8 200.2 l 123.1 l * aFor th e purposes of the National Health Interview Survey (NHIS), a schoo/-/oss day is a day on which a student 5 to 17 years of age missed more than half a day from the school in which he or she was currentty enrolled. A school-loss day is one type of restricted-activity day. bA ~.ndition is ~nsider~ ilW~e for the Pu~ses of NHS if it has lasted under 3 months, is not a andition mnsidered chronic regardless Of time of onset, and is of sufficient consequences to have been associated with either at least one doctor visit or at least 1 day of restricted activity. cEntfles marked with an asterisk (*) did not meet the requisite standard of relia~lity. ~ategories not shown because of insufficient reliability include: intestinal virus, unspecified. ecategorie.s not shown ~=use of insuff~ient reliability in~ude: acute bmn~itis, pneumonia, other respiratory conditions. fcategones not shown -use of insuff~ient reliability include: &ntal conditions; indigestion, nausea, and vomiting; and other digestive conditions. 9Categories not shown because of insufficient reliability include : fractures and dislocations; sprains and strains; open wounds and lacerations; contusions and superficial injuries; other current injuries. hsu~ategories are not shown because of insufficient reliability. SOURCE: U.S. Department of Health and Human Services, Public Health Service, Centers for Disease Control, National Center for Health Statistics, unpublished 1988 data from the National Health Interview Survey, Hyattsville, MD, 1990. to have restricted-activity days due to injuries and pregnancy-related causes. Female adolescents in general (but particularly older female adolescents) are more likely than males to have days of restricted activity due to acute conditions; perhaps not surprisingly, this phenomenon is largely due to pregnanct. 14 Black adolescents are less likely (506.6 days per 10010to 18-year-olds per year) than white adolescents (704.4 days per 10010to 18-year-olds per year) to have restricted-activity days reported for acute conditions. 1s School-loss days and restricted-activity days generally show similar age, sex, and race patterns, except that 10to 14-year-old females have fewer school-loss days than their male counterparts (107). As shown in table 6-6, adolescents in families with annual incomes less than $10,000 have higher rates of school-loss days (483.1 days per 100 adolescents per year) than adolescents in families with annual incomes of $35,000 or more (349.1 days per 100 adolescents per year). Differences in school-loss days by family income level are more marked for adolescents ages 10 to 14 than for those ages 15 to 17, although they follow the same general pattern. l6 Chronic Conditions--The 1988 NHIS found the most frequently reported chronic physical conditions for noninstitutionalized U.S. adolescents ages 10 to 18 were hay fever or allergic rhinitis without asthma, chronic sinusitis, acne, asthma, deformity or orthopedic impairment, chronic bronchitis, chronic disease of the tonsils or adenoids, dermatitis, and Ids= ch. 10, pre~cy and Parenting: Prevention and S_iCeS, in this volume for a discussion of adolescent pregnancy. ls~teres~gly, the nm~r of restricted-activity &ys per 1~ ~mo~ per y~ bcr~s with age for black adolescents ~d decreases for white adolescents. Because of small sample sizes, it is not possible to be speci.tlc about mce differences for specific conditions. 16~e average nm~r of school.loss &ys ~r 10010to l~ye~+l~ per yea reported by families with ~ud incomes less thaII $10,000 W~ 491.9 days; by families with annual incomes from $10,000 to $19,999 was 379.8 days; by families with annual incomes from $20,000 to $34,999 was 402.0 days; and by families with incomes of $35,000 or more was 340.7 days. See ch. 18, Issues in the Delivery of Services to Selected Groups of Adolescents, in Vol. III for a discussion of the health problems of adolescents in poor and near-poor families.
PAGE 160
Chapter 6---Chronic Physical illnesses: Prevention and Services II-159 Table 6-7Prevalence Rate for 20 Leading Chronic Physical Conditions a Among Noninstitutionalized U.S. Adolescents Ages 10 to 18,1988 Number of chronic conditions/ 1,000 Persons b Ages 10 to 18 10 to 14 15 to 18 Hay fever or allergic rhinitis without asthma . . . 91.2 92.4 89.8 Chronic sinusitis . . . . 89.6 82.9 97.4 Acne . . . . . . 61.7 34.6 92.9 Asthma . . . . . . 58.1 62.1 53.5 Deformity or orthopedic impairment. . . . . 54.2 39.3 71.3 Back . . . . . . 26.6 16,6 38.1 Lower extremities . . . 26.5 23,0 30.5 Chronic bronchitis . . . 38.8 33.8 44.5 Chronic disease of tonsils or adenoids . . . . . 31.1 29.6 32.9 Dermatitis . . . . . 31.1 32.3 29.8 Migraine headaches . . . 28.6 27,4 29.9 Heart disease . . . . 22.4 20.4 16.1 Heart murmurs . . . 16.7 19.8 13.1 Hearing impairment.. . . 20.7 19.7 22.0 Visual impairment . . . 18.9 16.5 21.6 Trouble with ingrown nails . 17.6 10.1 26.4 Color blindness . . . . 12.3 10.4 14.6 Trouble with dry, itching skin . 10.1 12.8 Speech impairment . . . 9.0 11.3 Diseases of female genital organs . . . . . 7.1 13.0 Anemias . . . . . 6.2 * Arthritis. . . . . . 4.7 * High blood pressure . . . 4.5 * aA physkal or mental co~ition is considered chronic for purposes of the National Health Interview Survey if it has lasted more than 3 months or is a type ofcxmdition that ordinarily lasts more than 3 months (e.g., diabetes, heart conditions, emphysema, or arthritis). bEntnes mark~ with an asterisk (*) did not meet the requisite standard of reliability. SOURCE: U.S. Department of Health and Human Services, Public Healt h Service, Centers for Disease Control, National Center for Health Statistics, unpublished 1988 data from the National Health Interview Survey, Hyattsville, MD, 1990. migraine headaches (see table 6-7). Other physical chronic conditions with a rather high reported prevalence among adolescents were heart disease, hearing impairments, and visual impairments (see table 6-7). Each person identified by NHIS as having a chronic physical or mental condition is classified according to the extent to which his or her activities are reported as limited. 17 As shown in table 6-8, the 1988 NHIS found that 93.2 percent of U.S. adolescents were reported to have no activity limitation due to a chronic physical or mental condition; 6.8 percent were reported to have some activity limitation. The 6.8 percent with activity limitation due to a chronic condition included 0.6 percent of U.S. adolescents who were unable to perform a major activity (e.g., attending school); 4.3 percent who were limited in the amount or kind of major activity; and 1.9 percent who were limited but not in major activity (see table 6-8). Among adolescents with chronic conditions, there was very little difference in reported degree of activity limitation by age, sex, race, or place of residence. However, there were some differences by income, with a larger proportion of adolescents (94.9 percent) in higher income families than in the lower income families (e.g., 90.2 percent in families with annual incomes under $10,000) free of an activity limitation (107). Newacheck conducted an in-depth analysis of 1984 NHIS data by type of serious chronic disorder (62). This analysis revealed that 75 percent of U.S. adolescents ages 10 to 18 with a reported limitation of activity due to a chronic disorder or disorders had a disorder in one of the five following categories: l l l l l mental disorders (including mental retardation, psychoses, and substance dependence syndromes), 32 percent; respiratory conditions (e.g., asthma), 21 percent; diseases of the musculoskeletal system or connective tissue (e.g., arthritis or acquired limb deformities), 15 percent; diseases of the nervous system (e.g., multiple sclerosis, cerebral palsy, or epilepsy), 6 percent; and diseases of the ear and mastoid process (e.g., hearing impairments), 4 percent. National Health Examination Survey (NHES) A compelling source of information on the health status of any group is a population-based survey that includes clinical examinations by health care providers. Unfortunately, the last such survey to include sufficient numbers of adolescents for meaningful analysis was the NHES completed in 1970 by the U.S. Department of Health, Education, and Welfare (now the U.S. Department of Education and DHHS) I_/Note tit l~l~tiom of ~ctlvl~ a~s~iated ~i~ ~~onic con~tiom differ from restricted-activity &ys discussed above. NHIS meWW2d restricted-activity days for both acute and cbronic conditions, but limitations of activity only for chronic conditions.
PAGE 161
II-160 Adolescent HealthVolume II: Background and the Effectiveness of Selected Prevention and Treatment Services Table 6-8--Distribution of Noninstitutionalized U.S. Adolescents Ages 10 to 18 by Degree of Activity Limitation Due to a Chronic Physical or Mental Condition and Socioeconomic Characteristics, 1988 Percent Percent Percent limited Percent Percent Percent with unable in amount limited, with no with limitation to carry or kind but not activity activity in major on major of major in major Characteristic Total a limitation Iimitation a activity b c activity c activity c activity b c All 10to 18-year-olds . . . . Age: 10to 14-year-ods . . . . . 15to 18-year-olds . . . . . Sex and age: Male All ages (10 to 18) . . . . 10to 14-year-olds . . . . 15to 18-year-olds . . . . Female All ages (10 to 18) . . . . 10to 14-year-olds . . . . 15to 18-year-olds . . . . Race and age: White All ages (10 to 18) . . . . 10to 14-year-olds . . . . 15to 18-year-olds . . . . Black All ages (10 to 18) . . . . 10to 14-year-oids . . . . 15to 18-year-olds . . . . Family Income and age: Under $10,000 All ages (10 to 18) . . . . 10to 14-year-olds . . . . 15to 18-year-olds . . . . $10,000 to $19,999 All ages (10 to 18) . . . . 10to 14-year-olds . . . . 15to 15-year-olds . . . . $20,000 to $34,999 All ages (10 to 18) . . . . 10to 14-year-olds . . . . 15to 18-year-olds . . . . $35,000 or more All ages (10 to 18) . . . . 10to 14-year-olds . . . . 15to 18-year-olds . . . . Geographic region: Northeast . . . . . . . Midwest . . . . . . . South . . . . . . . . West . . . . . . . . Place of residence: Metropolitan statistical area . . . Central city . . . . . . Not central city . . . . . . Not metropolitan statistical area . . 100.00 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 93.2 93.2 93.3 92.7 92.3 93.0 93.8 94.1 93.5 93.0 92.9 93.2 93.2 93.3 93.2 90.2 88.8 91.5 91.1 91.5 90.5 92.9 93.5 92.0 94.9 94.4 95.5 94.1 92.6 93.0 93.5 93.5 93.7 93.3 92.5 6.8 6.5 6.7 7.3 7.7 6.9 6.2 5.9 6.5 7.0 7.1 6.8 6.8 6.7 6.8 9.8 11.2 8.5 8.9 8.5 9.5 7.1 6.5 8.0 5.1 5.6 4.5 5.9 7.3 7.0 6.5 6.5 6.3 6.7 7.5 4.8 5.3 4.4 5.4 6.1 4.6 4.3 4.4 4.1 4.9 5.4 4.4 5.1 5.3 7.8 9.5 6.6 6.6 6.5 5.0 4.8 5.2 3.5 4.1 2.7 4.3 5.5 5.0 4.2 4.7 4.7 4.7 5.3 0.6 0.9 l * l l 0.6 l * l * * * * * * l * 0.6 * 4.3 4.9 3.5 4.9 5.8 3.9 3.6 4.0 3.2 4.4 5.1 3.6 4.4 4.3 l 6.9 9.2 6.0 6.2 5.7 4.3 4.4 4.1 3.1 4.0 3.9 5.0 4.4 3.6 4.1 4.0 4.2 4.8 1.9 1.6 2.3 1.9 1.6 2.3 1.9 1.5 2.3 2.0 1.7 2.4 l .* .* * .* * 2.1 l l 1.6 * l 1.8 2.0 2.2 1.8 1.6 2.0 2.2 aNote that th e numbers i n horizontal rows do not ati Up to 100 percmt. The reason is that the last four columns show breakdowns of the overall Percentage with activity limitations shown In the third column. In addition, numbers in some rows may not add up because of rounding. b~~mx~~(or usual ~ti~ty) refers to the Primipal actitity of a person or of a person of his or her age-sex group (e.g., Mool attendan-, wo~n9 at a job). cEntries ma~~ ~th an asterisk (*) did not meet the requisite standard Of re[ia~lity. SOURCE: U.S. Department of Health and Human Services, Public Health Service, Centers for Disease Control, National Center for Health Statistics, unpublished 1988 data from the National Health Interview Survey, Hyattsville, MD, 1990.
PAGE 162
Chapter 6-Chronic Physical Illnesses: Prevention and Services //-161 (94,95). 18 Because they are so old, estimates of adolescents physical health problems based on NHES may not pertain to the health status of contemporary adolescents. Still, the data from NHES suggest that the physical health of American adolescents may not be as positive as is often assumed. Most troubling is the NHES finding that more than one adolescent out of jive (about 22 percent) had some illness, deformity, or handicap affecting normal growth, development, or function cardiovascular, neurological, musculoskeletal, or other (94). NHES found that the proportion of adolescents ages 12 to 17 with physical health problems was greater than the proportion of younger children (ages 6 to 1119) with physical health problems. NHES also recorded information by race, region, and family income. This survey found no differences in physical health status by race. Adolescents living in the South had more health problems than adolescents from other regions, and adolescents of lower income had more health problems than adolescents from families with higher incomes (94). Physical Health Problems From the Perspective of Adolescents Adolescents themselves are rarely asked to identify the physical (or other) health problems that they believe are most important. Even in adolescent health surveys, adolescents are infrequently asked to rate the importance of various health issues. The National Adolescent Student Health Survey conducted by a consortium of groups funded partially by the Federal Government in 1987, for example, questioned more than 11,000 8th and 10th graders nationwide but failed to ask respondents to identify the most important physical health issues for adolescents (4). Adolescents were asked to identify physical health issues in the Minnesota Adolescent Health Survey of over 36,000 Minnesotan students in grades 7 through 12, but reports of the Minnesota survey results emphasized nonphysical concerns (88). 20 Thus, data are very limited on the specific physical health concerns identified as most important by adolescents. Some evidence suggests, however, that adolescents do not always agree with adults on what adolescents most important health needs are. A Canadian study that asked a random sample of 1,000 adolescents ages 12 through 20 and 100 schoolbased public health nurses and school psychologists or counselors to rate the seriousness and prevalence of a variety of health problems among adolescents found differences in the perceptions of adolescents and the professionals (32). The health providers identified menstrual problems, acne, and headaches as common, but not serious, problems; pregnancy, venereal diseases (i.e., sexually transmitted diseases), and chronic health problems as serious but not common; and nervousness or emotional, schoolrelated, and birth control problems as serious and common problems. Adolescents concurred with the health providers that menstrual problems and acne were common complaints, but few of the adolescents identified birth control problems, venereal diseases, or chronic health problems as significant. The professionals cited substance abuse (alcohol and drugs) and sexual problems as the most serious, but relatively uncommon, psychosocial problems. Adolescents reported fairly high rates of alcohol use (49.0 percent), drug use (15.1 percent), and sexual intercourse (22. 1 percent) but did not perceive these to be problems. Another study conducted in Canada asked adolescents ages 13 to 18 what issues they would like to discuss or have covered when they visit primary care physicians and how often the issues were actually discussed during a visit (50). This study was somewhat flawed in that it asked adolescents both questions simultaneously; the results would have been more valid if the responses had been independent. Nonetheless, the results of this Canadian study are consistent with the results of previous studies that pediatricians e xamined 12to 17-year-olds using a standardized physical examination for problems with eyes, ears, nose, and throat; goiteq musculoskeletal and limited neurological evaluatio% cardiovascular examination; grading of facial acne; assessment of sexual maturation through a genital examination and an appraisal of nutrition. The examination did not include an evaluation of mental health problems, except for an assessment of mental retardation by appearance. 190TA ~Cluded lo ~d 1 l-ye~-olds in me adolescent age ~oup, but ~S ag~egated many of its findings by hvO age ~OUpS: 6tO 1 I-year-olds and 12to 17-year-olds. Fewer 6to 11 -year-olds than 12to 17-year-olds were found to have signifkxmt abnormal findings on ex arnination by the physician (one in eight 6to 1 l-year-olds v. one in five 12to 17-year-olds). Much of the difference between the rate of problems for children and adolescents was attributed to the conditions associated with the onset of puberty or other aspects of maturation (94). ~physlc~ heal~ ~oncem were not, however, listed as a possible response in he Minnesoti survey item concerning lhiIlgS students WOITy d)ollt.
PAGE 163
11-162. Adolescent HealthVolume II: Background and the Effectiveness of Selected Prevention and Treatment Services found diverging interests of health care providers and adolescents (see 50, for a review) and suggest that, at least from the adolescents perspective, adolescents real concerns are not being attended to by health care providers. In almost all cases, the adolescents who were questioned in this study reported that discussion of issues of interest to them took place considerably less frequently than the adolescents desired (50). 21 For example, while over 80 percent of responding adolescents were interested in discussing physical fitness, nutrition, and growth, discussion of these topics reportedly took place in only 40 to 50 percent of visits. From 60 to 70 percent of adolescents were interested in discussing sexually transmitted diseases, contraception, acne, fear of cancer, and obesity, but these topics were reported to be discussed only 12 to 30 percent of the time. Almost 60 percent of adolescents were interested in discussing feelings of depression and lack of confidence, but such discussion took place only 16 and 11 percent of the time, respectively. Interestingly, the only topic with a close match between adolescents desire for discussion and how often it actually took place was the topic of menses (of interest to adolescents 55 percent of the time and discussed 49 percent of the time); no specific details of the content of discussions about menses were provided. 22 Dysmenorrhea (painful menstruation) has been identified through surveys of small samples of adolescent girls as a leading cause of pain and absence from school due to physical problems (44,120). Physical Health Problems From the Perspective of Parents As discussed above, some surveys (e.g., NHIS and part of NHES) use adolescents parents as a source of information about the health of their adolescent children. It is important to note that parents may not be a valid source of information on the health of their adolescent children. No current data are available on this issue, but the 1963-65 and 1966-70 NHES, conducted by the U.S. Department of Health, Education, and Welfare, was able to compare parents ratings of their childrens 25 20 15 10 5 0 Figure 6-l-Parents Ratings of Child and Adolescent Health Compared to Physicians Findings on Examination, U.S. Children Ages 6 to 17, 1963-65 and 1966-70a Percent Significantly abnormal findings on examination /\l ,.~ by physicians / ~~ --/1 -. / ,// Health a worry -----/ ~t / to parents -----. \ k 1 ~ -\ --\ /1 \ / \ / \ \ / / .,{ \ \/ ,. .,/ .Health rated fair or poor / / ~ by parents \ I /\ / \/ \/ I I I I I 6 8 10 12 14 16 Child/adolescents age in years %hildren ages 6 to 11 were examined from 1963 to 1965 and adolescents 12 to 17 were examined from 1966 to 1970. SOURCE: U.S. Department of Health, Education, and Welfare, Examination and Health History Findings Among Children and Youths, 6-17 Years: United States, Vita/ and Health Statistks: Data From the Nationa/ Health Survey, Series 11, No. 129, DHEW Pub. No. (HRA) 74-1611 (Roekville, MD: November 1973). (including adolescents) health with findings from physicians physical examin ations 23 of the adolescents (94). As shown in figure 6-1, parents worries about their childrens health dropped considerably at about age 13, but there was a large increase in significantly abnormal findings on examination beginning at age 11 through age 17 (the last year of age included in the survey). Parents of 12to 17-year-olds tended to rate their childrens health significantly better than did parents of children ages zl~e ~encm he~~ ~me ~y~tems compet~~ to treat the he~th needs of adolescents is discussed more fully in ch. 15, Major Issues Pe*g to the Delivery of Primary and Comprehensive Health Services to Adolescents, in Vol. III. 22For e~ple, the discussion could have consisted merely of a question about whether menses had begun. ~As noted above, the physical e xamination was generally limited to the identification of primarily physicxd abnommlities, although apparent mental retardation would have been noted.
PAGE 164
Chapter 6-Chronic Physical illnesses: Prevention and Services .11-163 6 to 11,24 both when giving a categorical statement of their childs health status and when indicating whether or not aspects of their childs health were a concern or worry. 25 In contrast, surve y pediatricians, who actually examined the children and adolescents, rated substantially more adolescents than children as having some significant abnormality. The National Center for Health Statistics could not come to definitive conclusions about the reasons for the reduction in parents concern but suggested that the reduction probably reflected a change in attitude or concern. The National Center for Health Statistics was not able to tell if this change occurred because of increased maturity of the child, because more of the abnormal conditions were under care, or because of some other factor. Unfortunately, children and adolescents themselves were not asked to report on their overall health status or specific health concerns in a survey comparable with that given to parents. Background on Chronic Physical Illnesses and Disabilities of Adolescents Trends in the incidence and prevalence of chronic illness and disability among adolescents are reviewed below. Also discussed are consequences common to many chronic illnesses, with a focus on psychosocial consequences. Two other chronic physical health problems of importance to adolescents themselvesacne and dysmenorrhea-are also reviewed in this section. Trends in the Incidence and Prevalence of Chronic Physical Illnesses and Disabilities Among Adolescents A small but significant number of U.S. adolescents are believed to experience very serious chronic physical conditions such as severe asthma, juvenileonset diabetes, congenital heart disease, leukemia, cystic fibrosis, and chronic kidney diseases (70). Unfortunately, however, it is difficult to determine the incidence and prevalence of such illnesses among adolescents. Most studies of chronic illness among children do not report information separately for adolescents. Furthermore, many serious chronic illnesses are not of sufficient prevalence in adolescents to reliably measure in national epidemiological and health services utilization surveys that sample only a small number of adolescents (e.g., NHIS, NAMCS, NHDS, and NHANES). Estimates of the prevalence of serious chronic disorders among all children under age 20 range from 10 to 20 percent (27,72,80) (see box 6-C). In 1984, using published prevalence estimates for 21 types of chronic conditions, Gortmaker and Sappenfield estimated the prevalence of chronic conditions in U.S. children under the age of 20 (see table 6-9). In aggregate (assuming that each child had no more than one of the specified problems), Gortmaker and Sappenfield estimated that 13.3 percent of U.S. children ages O to 20 had a chronic physical or mental condition. If one excludes some chronic mental disorders (i.e., mental retardation, Downs syndrome, and autism), 26 the figure for the remaining chronic conditions drops to 10.6 percent of U.S. children ages O to 20. If one assumes that 90 percent of children experiencing these 18 chronic conditions survive to age 20 (as Gortmaker and Sappenfield estimate) and thus experience a chronic condition during adolescence, the prevalence of these 18 remaining chronic conditions among adolescents would be 9.5 percent. Not all of these 18 conditions result in major activity limitations. If one excludes the chronic physical conditions that do not result in a major activity limitation (i.e., mild asthma, nonsevere congenital heart disease, mild and moderate hearing impairments, and mild visual impairments), one could estimate that 4 to 5 percent of U.S. adolescents have chronic physical conditions that make them either unable to carry on a major activity (e.g., attending school) or limited in the amount or kind of major activity. It is important to note that this prevalence estimate by OTA does not include chronic mental disorders. 240TA ~efer~ t. 10. and 1 l-ye~+]d~ ~ adolescents, but the National Center for Health Statistics ~ports on NHES referred to 6tO 1 l-year-olds m children and 12to 17-year-olds as youths or, less frequently, adolescents. When compwisons by age were made in the narrative, the National Center for Health Statistics typically aggregated data for these two age groups. However, detailed tables also provided results by each year of age from 6 through 17 (94). ~Differences ~Neen reports of abnormalities in the medical history (taken from parents) and findings on examina tion were also reported. Large differences were found for hearing trouble, walking trouble, arm or leg limitations, with more findings on examination than reports of abnormality. (Tt is important to note, however, that reports of any abnormality in the medical history were compared with specific abnormalities on examination (94).) ZbAs noted at tie &ginning of this chapter, some chronic mental disorders have a physical basis.
PAGE 165
II-164 Adolescent Health-Volume II: Background and the Effectiveness of Selected Prevention and Treatment Services Box 6-CTrends in the Prevalence of Chronic Physical Conditions Among U.S. Adolescents During the 1960s, an estimated 4 percent of U.S. childrens visits to primary care practices were for chronic health problems (27). By 1980, some 13 percent of visits to pediatric practices by children under the age of 15 and 18 percent of their visits to all physicians were for chronic problems, both routine and flareup. The increase in proportion of primary care visits by children for chronic conditions reflects a decrease in the incidence of acute illnesses (e.g., infectious diseases 1 ) and in the proportion of children with chronic conditions who survive through adolescence (27). Over the last several decades, technological and medical advances have greatly increased the survivability into adolescence of children with certain chronic illnesses. For example, chances of survival to age 21 for children with cystic fibrosis increased from an estimated 5 percent between 1945 and 1959 to an estimated 70 percent during the 1970s (25). Less dramatic, but significant, improvements in the survivability of children with acute lymphocytic leukemia, sickle-cell anemia, congenital heart disease, and chronic kidney diseases have also been noted (25). According to data from the National Health Interview Survey (NHIS), the prevalence of chronic conditions that limit activity more than doubled between 1960 and 1981 among U.S. children under 17 years of age (63). There is some disagreement about whether these prevalence changes are real or due to changes in questionnaire design, parent and physician perceptions, and other factors (63). Thus, the degree to which the prevalence of chronic conditions has actually increased among children is somewhat unclear (64). Gortmaker suggests that dramatic increases in the absolute numbers of children and adolescents with chronic illnesses should not be expected during the coming decades for several reasons (25,26). First, there is little room for improvement in levels of survivability, given current rates of greater than 90 percent survival to age 20. Second, even if higher levels of survivability are achieved, smaller birth cohorts since the post World War II baby boom have resulted in lower absolute numbers of children with chronic illnesses, thus tending to offset any increases. The only substantial evidence for increases in the incidence of chronic physical conditions in children is the evidence of an increasing number of infants infected with human immunodeficiency virus (HIV). 2 I%ere is also increasing concern about the disabling long-term effects of crack cocaine use during pregnancy on children. lu~ ~ ~iden~ of some infectious diseases, tk intidof -y WmiWd ti= ~ ~ For further discussio~ tted Diseases: I%evention and S see ch. 9, AIDS and Other Sexually TransmI ervices, in this volume. %urrent problems associated with HIV infection among adolescents am discussed inch. 9. As noted earlier, data from the 1988 NHIS suggest are institutionalized are probably more likely to have that 6.8 percent of noninstitutionalized U.S. adolescents ages 10 to 18 are limited in a major or other activity by a chronic physical or mental condition: 4.8 percent are limited in or are unable to perform a major activity (e.g., attending school), and 1.9 percent are limited in an activity other than major activity as the result of a chronic condition (see table 6-8). Although OTAs estimate (based on Gortmaker and Sappenfields work) that between 4 and 5 percent of U.S. adolescents have a chronic physical condition that limits major activity is similar to the NHIS estimate (4.8 percent), it is important to emphasize that the NHIS estimate includes mental disorders, while the OTA estimate does not. If mental disorders were included in the OTA estimate, it would be higher. Another difference between the OTA and NHIS estimates is that the OTA estimate (based on Gortmaker and Sappenfields work) includes at least some institutionalized populations, while the NHIS estimate does not. Individuals who seriously disabling chronic conditions than individuals who are not institutionalized. Differences in estimates of the prevalence among adolescents of chronic conditions that significantly limit their ability to perform a major activity of daily living) are difficult to resolve. As Gortmaker and Sappenfield noted in their review, Widely varying estimates concerning the population prevalence of chronic childhood disorders exist, depending upon the definitions used, the methods of study, and the population under investigation (27). Consequences of Serious Chronic Conditions for Adolescents There are significant differences in the physical (and thus the emotional and social) consequences of specific types of chronic physical conditions. Still, the experiences of adolescents with various types of
PAGE 166
. Chapter 6-Chronic Physical illnesses: Prevention and Services .11-165 Table 6-9-Estimated Prevalence of Serious Chronic Conditions in U.S. Children Ages O to 20, 1980 Prevalence Range of prevalence Disorder a estimates/1,000 estimates/l ,000 Arthritis . . . . . . . . . . . . . 2.2 1.0-3.0 Asthma . . . . . . . . . . . . . 38.0 20.0-53.0 Moderate to severe... . . . . . . . . . 10.0 8.0-15.0 Autism . . . . . . . . . . . . . 0.44 0.40-0.48 Central nervous system injury Traumatic brain injury.. . . . . . . . . 0.05 Paralysis . . . . . . . . . . . . 2.1 2.0-2.3 Cerebral palsy . . . . . . . . . . . 2.5 1.4-5.1 Chronic renal failure . . . . . . . . . . 0.080 Terminal . . . . . . . . . . . . 0.010 Nonterminal . . . . . . . . . . . 0.070 Cleft lip/palate . . . . . . . . . . . 1.5 1.3-2.0 Congenital heart disease . . . . . . . . . 7.0 2.0-7.0 Severe congenital heart disease . . . . . . 0.50 Cystic fibrosis . . . . . . . . . . . 0.20 Diabetes mellitus . . . . . . . . . . . 1.8 1.2-2.0 Downs syndrome . . . . . . . . . . 1.1 Hearing impairment . . . . . . . . . . 16.0 Deaf . . . . . . . . . . . . . 0.1 0.06-1.5 Hemophilia . . . . . . . . . . . . 1.5 Leukemia Acute lymphocytic leukemia . . . . . . . 0.11 Mental retardation . . . . . . . . . . 25.0 20.0-30.0 Muscular dystrophy . . . . . . . . . . 0.06 Neural tube defect . . . . . . . . . . 0.45 Spinabifida . . . . . . . . . . . 0.40 Encephalocele . . . . . . . . . . . 0.05 Phenylketonuria . . . . . . . . . . . 0.10 Sickle-cell disease* . . . . . . . . . . 0.46 Sickle-cell anemia . . . . . . . . . . 0.28 Seizure disorder . . . . . . . . . . . 3.5 2.6-4.6 Visual impairment. . . . . . . . . . . 30.0 20.0-35.0 Impaired visual acuity . . . . . . . . . 20.0 Blind . . . . . . . . . . . . . 0.6 0.5-1.0 aEntrieS ma~edWitha naStefiSk(*)deSignatO estimatesthatweremade using specificprevalence atbirthandsurtival data, as well as incidence and duration data, which are described in detail in the original study. SOURCE: S.L. Gortmaker andW, Sappenfield, ChronicChildhood Disorders: Prevalence and Impact Pediatric Clinics of fVorth America31(l ):3-18, 1984, reprintedby permission. serious chronic conditions show at least some similarities (72). As discussed below, adolescents with such conditions may experience consequences ranging from lost school days to limitations in major activity. They also may experience psychosocial consequences. The families of adolescents with such conditions (and society) may have to bear substantial financial costs (see the section of this chapter on services and interventions for the treatment of chronic physical illness). Activity Limitations As noted earlier, the 1988 NHIS found that 6.8 percent of noninstitutionalized U.S. adolescents ages 10 to 18 have limitations of activity due to chronic physical or mental conditions (see table 6-8). About 0.6 percent of noninstitutionalized U.S. adolescents (or about 1 in every 200) are unable to carry on their major activity (i.e., attending school or working) because of a chronic condition; an additional 4.3 percent are limited in the amount or kind of major activity; and an additional 1.9 percent are limited in an activity other than major activity. The 1988 NHIS also found that noninstitutionalized U.S. adolescents experienced an average of 8.7 restricted-activity days due to acute and chronic conditions per person (see table 6-10). Newachecks analysis of 1984 NHIS data found that adolescents with a reported limitation of activity due to chronic illness experienced more restricted-activity and bed-disability days than other adolescents (62). In the Newacheck study, adolescents reporting some limitation of activity due to a chronic condition
PAGE 167
II-166 Adolescent HealthVolume II: Background and the Effectiveness of Selected Prevention and Treatment Services Table 6-10-Number of Restricted-Activity Days Due to Acute/Chronic Conditions Among Noninstitutionalized U.S. Adolescents Ages 10 to 18, by Type of Restricted-Activity Day and Sociodemographic Characteristics, 1988 a Number of days per person in year Number of days in thousands All BedWorkor Ail BedWorkor restricteddisability school-loss restricteddisability school-loss Characteristic activity days a days b days c activity days a days b days c Ail persons ages 10 to 18 . . . . . Age 10 to 14 years . . . . . . . . 15 to 18 years . . . . . . . . Sex and age Male All ages (10 to 18) . . . . . . 10 to 14 years . . . . . . . 15 to 18 years . . . . . . . Females All ages (10 to 18) . . . . . . 10 to 14 years . . . . . . . 15 to 18 years . . . . . . . Race and age White All ages (10 to 18) . . . . . . 10 to 14 years . . . . . . . 15 to 18 years . . . . . . . Black All ages (10 to 18) . . . . . . 10 to 14 years . . . . . . . 15 to 18 years . . . . . . . Family income and age Less than $l0,000 All ages (lOto 18) . . . . . . IO to 14 years . . . . . . . 15 to 18 years........ . . . . . $10,000-$19,999 All ages (lO to 18) . . . . . . 10 to 14 years. . . . . . . . 15 to 18 years . . . . . . . $20,000-$34,999 All ages (lOto 18) . . . . . . 10 to 14 years . . . . . . . 15 to 18 years ...,..... . . . . . $35,000 or more All ages (lO to 18) . . . . . . 10 to 14 years . . . . . . . 15 to 18 years. . . . . . . . Geographic region Northeast . . . . . . . . . Mideast . . . . . . . . . . South . . . . . . . . . . West . . . . . . . . . . Place of residence Metropolitan statistical area. . . . . . Central city . . . . . . . . . Not central city . . . . . . . . Not metropolitan statistical area . . . . 8.7 8.2 9.3 8.0 8.3 7.6 9.5 8.1 11.0 9.3 9.9 9.8 6.6 5.8 7.6 11.8 11.4 12.3 9.1 8.1 10.4 8.4 8.6 8.2 8.0 7.5 8.6 6.7 9.1 7.8 11.4 8.7 8.0 9.1 8.7 4.1 3.9 4.4 3.4 3.5 3.1 4,9 4.2 5.6 4.4 4.2 4.6 3.3 2.7 3.9 5.8 5.7 5.8 4.2 3.8 4.7 4.0 3.9 4.2 3.9 3.8 4.0 3.2 4.1 3.7 5.5 4.1 3.9 4.2 4.0 4.7 4.5 5.0 4,5 4.6 4.3 5.0 4.4 5.7 4.9 4.8 5.0 4.0 3.6 4.5 6.7 6.9 6.5 5.0 4.5 5.7 4.8 4.5 5.3 4.1 4.2 4.1 4.1 4.9 3.9 6.3 4.7 4.4 4.9 4.8 269,439 135,717 133,722 125,674 70,051 55,624 143,764 65,666 78,098 233,185 119,105 114,080 31,844 15,036 16,808 43,548 20,591 22,957 44,637 21,364 23,273 62,974 36,231 26,743 84,720 42,540 42,180 37,896 72,918 84,267 74,358 204,409 72,344 132,065 65,030 127,082 64,077 63,005 52,952 30,121 22,831 74,130 33,956 40,174 109,763 56,355 53,408 15,654 7,061 8,592 21,182 10,348 10,835 20,443 9,951 10,491 29,999 16,308 13,681 41,411 21,805 19,603 18,141 32,805 40,180 35,935 96,945 35,332 61,613 30,136 137,604 75,286 62,520 66,710 39,469 27,241 71,096 35,816 35,280 116,810 64,751 52,059 17,657 9,340 8,317 20,890 12,471 8,419 23,170 11,978 11,192 34,933 19,103 15,831 42,116 23,891 18,539 21,891 37,156 39,935 38,825 104,397 36,799 67,597 33,409 aForthe pljrposesoftheNational Health [nterview Survey(NHIS), aresttid~adiwlydayis any dayonwhichaperson restricts hisorher usualactivfties for morethanonehalfdaybecauseofan ilinessoran injury. Restricted-activity daysareunduplicated countsofbeddisability days,work-lossdays, school-ioss days, andcutdowndays. bAb~~j~~flj~~ayisdefined by NHSasany dayon~hicha per~nstaysin~formorethan ha~theda$ight hours (ornormaiwaking hours) because ofanillness orqninjury. cAs&oo/-/o~~&Yis~fin~ by NHiSasany ~yonwhi.ch achflddid notattend school forat least ha~ofhis or hernormal school day because OfaSp~ifiC Illnessorlnjury.school-lossdays aredetermlned onlyforchildren 5t017yearsofage.A work-/ossdayisdefined byNHiSas anydayonwhichan Individual did not work at his or her job or business for at least half of his or her normal workday because of a specific illness or injury. The number of work-loss days is determined only for currently employed persons. SOURCE: U.S. Department of Health and Human Services, Public Health Service, Centers for Disease Control, National Center for Health Statistics, unpublished 1988 data from the National Health Interview Survey, Hyattsville, MD, 1990.
PAGE 168
Chapter 6---Chronic Physical Illnesses: Prevention and Services .11-167 experienced an average of 27 restricted-activity days per year, while other adolescents experienced 7.7 restricted-activity days per year. Adolescents reporting some limitation of activity due to a chronic condition also experienced significantly more beddisability days than other adolescents: 12.2 bed-days v. 3.7 bed-days (62). Newacheck found that male adolescents in the 1984 NHIS were more likely to be reported as having a limitation of activity due to a chronic condition than females (7.2 percent of males v. 5.2 percent of females). Younger adolescents were more likely to be reported as having a limitation of activity due to a chronic condition than older adolescents (6.6 percent of 10-to 14-year-olds v. 5.7 percent of 15to 18-year-olds). Newacheck also found that poor adolescents were 46 percent more likely to be reported as having limitations of activity due to a chronic condition than adolescents living in families with incomes above the poverty line (62). Not surprisingly, several studies have found that children with chronic conditions miss more school days than healthy children (44). One study found that among children ages 6 to 17, those with chronic mental or physical conditions (e.g., mental retardation, cerebral palsy, or asthma) missed 8.7 days of school, while other children missed 5.8 days of school (1 17). Another study revealed that students with allergies in nursery school through 12th grade (15 percent of whom were in grades 8 through 12) experienced significantly more absences than nonallergic children (data on magnitude of differences were not presented) (53). Also, one study reported that asthmatic children ages 4 to 16 (one-third of whom were age 12 or older) had an absence rate approximately 24 percent higher than other children (19). Psychosocial Consequences McAnarney suggests that social experiences for adolescents with physical disabilities may differ from those of other adolescents in three ways: 1) their exclusion from school activities because of their high levels of school absence, 2) their inability to keep up with their peers physically and their exclusion from some activities because they feel different or ill, and 3) their lack of opportunity for normal peer interactions, both in and out of school (52). Only a few studies have examined the associations between chronic illness or disability and psychosocial outcomes for adolescents. Most of these studies suffer from various methodological limitations, including small sample sizes and lack of appropriate control groups (9). In addition, most studies are cross-sectional rather than longitudinal, making it difficult to draw conclusions about causality or about the process of adjustment through the course of an illness or disability. Despite these methodological limitations, existing studies do provide some useful information on young people with disabilities. In the aggregate, adolescents with physical disabilities appear to be more like than unlike their able-bodied peers with respect to their social maturation (52), but the evidence is not consistent. For example, studies of large cohorts comparing adolescents with and without physical disabilities have generally found that these groups do not differ significantly in their levels of self-esteem. Other studies using samples of adolescents with the same types of disability have frequently found that disabled adolescents have lower levels of self-esteem than nondisabled adolescents (52). Still other research, such as a study of survivors of childhood cancer, have found that adolescents with chronic illness actually score higher on measures of selfconcept than do normative samples (21). A recent study found higher levels of emotional and behavioral problems among adolescents ages 12 to 17 with serious chronic physical conditions than among adolescents without such problems (28). Adolescents with serious chronic physical conditions in this study were particularly likely to be reported by their parents to be depressed and socially withdrawn. Although flawed in some ways, 27 this study is impressive in that it was able to disaggregate the effects of socioeconomic status from the effects of having a chronic physical disorder, demonstrating that both have independent effects. An interview survey comparing matched samples of adolescents with diabetes (n = 31, mean age = 14.7 years) or cystic fibrosis (n = 31, mean age = 14.5 years) with healthy adolescents (n = 31, mean 27A ~oSS1ble flaw not Pofited out ~ the s~dy is tit the msessrnent of problems relied entirely on a child be~vior ch~~t fdled out by p~nts; children and adolescents themselv~ were not surveyed.
PAGE 169
//-168 Adolescent HealthVolume II: Background and the Effectiveness of Selected Prevention and Treatment Services age = 14.5 years) found no statistically significant differences among the three groups on how often they used various strategies to cope with their social and emotional problems, their perceived degree of social support, their feelings of social competency, their perception of control over their life, or feelings of depression (9). However, results indicated that the adolescents with chronic illness were more concerned about their parents reaction to their health than healthy adolescents were; believed that their parents experienced more stress because of their illness; and were more concerned about their future health (9). The survey found some differences between the adolescents with diabetes and those with cystic fibrosis; adolescents with cystic fibrosis rated their health worse than did adolescents with diabetes or healthy adolescents. In a study examinin g depressive symptoms over time in a sample of 17 adolescents ages 13 to 19 with cancer, the mean level of depressive symptoms for adolescent cancer patients did not differ from a general population sample of adolescents (41). As in the general population of adolescents, depressive symptoms for the adolescents with cancer were associated with psychosocial events, such as arguing with parents, breaking up with a girlfriend or boyfriend, or being dissatisfied with ones appearance. Similarly, another study found that depression was uncommon among adolescent survivors of childhood cancer (21). (Other consequences associated with cancer during adolescence are discussed in the following section.) Normal tasks of adolescence may be particularly difficult for adolescents with serious chronic physical conditions (52). Many of the concerns of adolescents with disabilities are the same concerns experienced by all adolescents, but the concerns may be exacerbated by a disability (52). Adolescents with some disabilities may experience more difficulty in achieving separation and independence from their parents than other adolescents, for example, if they rely heavily on their families for financial and personal assistance. And, although adolescents with disabilities have the same concerns about their sexuality as other adolescents, adolescents with some disabilities may have limited chances to develop their sexuality as a result of constraints that include the lack of knowledge about or denial of their sexuality by their parents and the adolescents themselves (52). Lack of socialization with ablebodied peers, either because of limited contact or because of negative attitudes among peers towards developing romantic attachments with someone with a disability, also limits opportunities for some adolescents with disabilities to explore their sexuality. Independence for people with disabilities requires access to the same opportunities afforded to people without disabilities and sufficient capacity to take advantage of those opportunities (87). Thus, independence may require access to a full range of residential alternatives, accessible transportation, and participation in the political process and may also require family support and assistance; personalcare assistance in the activities of daily living; social support from friends, neighbors, and communities; and the application of technology, such as computers. Some adolescents with disabilities need training to improve their capacities to make life choices, such as through life planning, instruction in problem solving, participation in the development of their individualized education program, 28 and participation in self-advocacy groups (87). The ability of disabled adolescents to achieve independence depends on the severity of their condition, the ability of their family to cope financially and psychologically with that condition, and their personal motivation to become independent (52). Prevention of Chronic Physical Illnesses and Disabilities Among Adolescents Many of the chronic physical illnesses and disabilities that U.S. adolescents experience (except those due to injuries) are not really preventable during adolescence. Some of the illnesses (e.g., cystic fibrosis, heart disease, spina bifida, sickle-cell disease) are congenital conditions that cannot be prevented during adolescence. Other chronic illnesses may develop during adolescence, but for many of them (e.g., cancer, arthritis, diabetes, renal failure), not enough is known to establish protocols for prevention for adolescents. Until effective means 2S~ individ~~ ~du~atio~ profor each ~di~ppd c~d is rqfied under the Education for ~ Handicapped Chikken Ad (fiblic Law 94-142), which was passed in 1975 (92). The program must include a statement of the childs present levels of educational performance; annual goals, including short-term instructional objectives; and other things specified in the regulations implementing Public Law 94-142.
PAGE 170
Chapter 6--Chronic Physical Illnesses: Prevention and Services II-169 of primary prevention 29 are developed, the emphasis for many chronic illnesses that adolescents experience must be on early intervention 30 and other forms of treatment. Clearly, however, efforts can be made to prevent adolescents disabilities from becoming handicaps (see OTA definition of handicap in box 6-A). It is important to note that health-compromising behaviors initiated in adolescence may lead to the development of chronic illness among adults. For example, smoking may lead to the development of lung cancer, engaging in unprotected sexual activity may lead to the development of acquired immune deficiency syndrome (AIDS) and other sexually transmitted diseases, and eating high fat diets may lead to an increased risk of heart disease. Attention to the prevention of these and other healthcompromising behaviors during adolescence may be warranted. 31 Services and Interventions for Adolescents With Chronic Physical Illnesses and Disabilities Use of Health Services by Adolescents With Chronic Conditions Adolescents with chronic conditions have more contact with the health care system than do other adolescents. According to 1984 NHIS data, adolescents with a chronic condition (mental disorders included) have more physician contacts annually than other adolescents (8.8 physician contacts v. 2.7 physician contacts) (62). They are also more likely to experience a hospitalization (O. 181 hospitalizations per year v. 0.038 hospitalizations per year). Furthermore, when adolescents with a chronic condition are hospitalized, they spend nearly twice as long in the hospital as adolescents without such conditions (9.1 v. 4.8 days on average) (62). A survey of 456 children ages 3 to 18 (no further age distribution was provided) with chronic physical conditions (i.e., cystic fibrosis, cerebral palsy, myelodysplasia, or multiple physical handicaps) found that these children were far more likely than a randomly selected comparison group of children from the same region to be hospitalized during the year (34 percent were hospitalized v. 6 percent of controls) and to have more lengthy periods of hospitalization (11.0 days v. 3.7 days for controls) (81). A relatively small subset of children in the study accounted for the majority of health care use; 75 percent of all outpatient use was accounted for by 25 percent of the sample, and all hospital care was accounted for by 33 percent of the sample. Similar results were reported from an analysis of 1980 data from the National Medical Care Utilization and Expenditure Survey (NMCUES) by Newacheck and McManus (65). Children and adolescents with activity limitations due to chronic conditions (mental disorders included) were twice as likely to be hospitalized, made twice the number of visits to physicians, and saw nonphysician health care professionals (e.g., physical therapists, social workers) five times more frequently than children and adolescents without activity limitations due to chronic conditions. Costs of Treatment for Adolescents With Chronic Conditions Little is known about the total costs of medical services for chronically ill children in the United States (66). There is no single source of information on the full range of costs of care for people with chronic conditions, including adolescents. Total expenditures include personal expenses; expenditures reimbursed by insurance companies; services provided by private organizations; and costs of various 2~e ~ditioml t=onomy of prevention &s@uishes among primary, secondary, and tertiary prevention (see, e.g., 93a). fn~ry Preven~~n fa to activities designed to avoid disease or other conditions that adversely affect health. Immuniza tions are one example of primary prevention but regulatory activities to protect health (health protection) are also forms of primary prevention. Seconalzry prevention includes efforts to identify existing conditions that could cause illness and disability before the appearance of clinical symptoms, or to minimize the progression of disease. Screening for the existence of disease is one form of seconday prevention. Terriary prevention refers to efforts to control irreversible chronic conditions in order to avoid disability or death. Some have suggested that this typology does not adequately distinguish among preventive services (see 93a). Another way to characterim preventive services is by the target of an intervention (e.g., the environment, the individual) and the intended beneficiary (usually individuals). 3oAs de~cn~d a~ve, ~eco~o ~d te~i~~ prevention (but especi~y ~e~tiary prevention) ~ ficlude ~ea~ent. k this Repofi lhe term early intervention is also used for treatment services delivered before a problem becomes serious and/or chronic. 31~event10n of smoking is covered in this volume inch. 12 Tobacco, Alcohol, and Drug Abuse: Prevention and Semices; prevention of AIDS is discussed inch. 9, AIDS and Other Sexually Transmitted Diseases: Prevention and Services; and nutrition and fimess problems among adolescents are covered in ch. 7, Nutrition and Fitness Problems: Prevention and Semices.
PAGE 171
11-170. Adolescent HealthVolume II: Background and the Effectiveness of Selected Prevention and Treatment Services Federal programs, such as Medicaid, that provide coverage for health care of people with disabilities. One study that defined disability as having a reported long-term limitation in usual activities (e.g., school) estimated that U.S. children and adolescents with disabilities accounted for a relatively small proportion-$ 3.9 billion in 1986 dollars (10.9 percent)--out of a total of $35.7 billion in charges for health services provided to persons under the age of 21 (65). 32 3334 In this study, the four leading reported causes of disability for individuals under age 21 were mental and nervous system disorders (prevalence of 7.3 cases per 1,000), followed by respiratory diseases (6.0 cases per 1,000), musculoskeletal and connective tissue diseases (4.3 cases per 1,000), and eye and ear diseases and disorders (3.7 cases per 1,000). 35 Other evidence suggests that children and adolescents with chronic physical conditions have significantly higher health care costs than other children. For example, one report estimated that a sample of chronically ill and disabled children ages 3 to 18 with cystic fibrosis, cerebral palsy, myelodysplasia, or multiple physical impairments averaged 10 times the yearly expenditures for health care of a general population comparison group of children (81). Half of this difference was accounted for by the greater amount of hospitalization experienced by the children with chronic physical illness and disability. The costs of care for children and adolescents with chronic conditions are not evenly distributed across this population. In a ranking of children and adolescents under age 21 who were reported to have activity limitations due to chronic conditions in the 1980 NMCUES according to their total health charges, the 10 percent who experienced the greatest health care expenses accounted for 65 percent of all charges accumulated by the children and adolescents with activity limitations (65). Those who experienced the highest total health care costs were most likely to be between ages 16 and 20. An estimated 14 percent of adolescents with chronic conditions do not have health insuranceabout the same percentage as for adolescents without chronic conditions (62,93). 36 Because adolescents with chronic conditions often have high health care expenses, it is critical that they have health insurance. In addition to needing basic coverage provided by most health insurance policies, many adolescents with chronic conditions need more extensive coverage, such as for mental health services, prescription drug coverage, and long-term care benefits. 37 Even those who do have adequate health insurance coverage may incur significant related expenses that are not covered (e.g., travel to health care centers) (61). Thus, families shoulder a significant burden of costs of care for chronically ill children of all ages (7,37), although the extent of the family role is often not considered by policymakers (37). Moreover, excessive burdens to the family may be a factor in a familys decision to institutionalize a chronically ill child rather than attempt to care for the child at home. Few studies have assessed the actual economic impact of caregiver costs on families with a seriously chronically ill or disabled child. Available studies use different methods and categories of costs and focus on children of different ages with different types of disabilities (sometimes including mental illness and mental retardation). Consequently, it is difficult to generalize the results to all children with chronic physical illness or disability, particularly adolescents, or to assess the overall economic burden to these families. Nonetheless, it is clear that substantial family costs are associated with the care of chronically ill or disabled children (37). Analyses of the health care costs borne by families of chronically ill or disabled children in 32Da~ were collected ~~ pa of the 1980 ~c~s. Fi~es were adjust~ up to 1986 leve~ using the m~~ care component of the Consumer ~Ce Index (65). 3S~e ~op~ation considered ~~s s~dy is a subset of thepop~ation with chronic conditions, which includes peopkwhohw c~onic conditions but who do not suffer activity limitations. ~k 1980, individu~s under 21 constituted 34 percent of the U.S. resident population (93b). 35~ese fow categories accomted for ju5t over M of repofled disabilities ~ the s~ey. Note that individu~s with disability as a resdt of mental and nervous system disorders, which include mental retardation and neurotic and personality disorders, are included in these analyses. It is not possible, however, to determine from the data presented (65) what the impact of these disorders is relative to other causes of disability. sG~eW ~yses included adolescents with chronic mental, as well as physical, disorders. 37sW ch. 16, Financial Access to Health StT%lUs, in Vol. III for fiuther information on adolescents health insurance status and health insurance benefits.
PAGE 172
Chapter 6-Chronic Physical Illnesses: Prevention and Services .11-171 general (or by society) have been scarce (65). Newacheck and McManus analysis, based on data from the 1980 NMCUES, suggested that only a small fraction of families incur catastrophic costs, but that analysis was limited by NMCUES small sample size (65). Of the 6,245 persons younger than age 21 in the sample, only 249 were reported to be limited in their activities. According to Newacheck and McManus, the small sample implies that few children with low prevalence, very serious and costly, chronic conditions will be represented in the sample, In addition, the NMCUES sample excludes the institutional population, and thus excludes a large segment of the most severely ill children and adolescents. Also, the NMCUES data were collected in 1980 and 1981, when children were often hospitalized rather than cared for at home and when health care costs were lower. Finally, NMCUES interviewers were instructed to indicate to survey respondents that limitation of activity refers to a limitation caused by long-term illness or disability only when a respondent asked for clarification; in some cases, therefore, a limitation reported in the NMCUES may have been caused by an acute, rather than a chronic, condition. Although Newacheck and McManus suggest that the number of such cases should be small (and that other features of the NMCUES questions could compensate for the ambiguity about chronicity), the small overall number with reported limitations in activity still invites cause for concern, Thus, a particular finding from Newacheck and McManus analysis should be viewed very cautiouslynamely, the finding that families of all children with limitations in activity averaged $135 in 1980 dollars per child in out-ofpocket expenses for health care and that families of the 10 percent of children consuming the greatest amount of care averaged $300, while families with children without activity limitations averaged $76. A study by Butler et al. examining sources of payment for physician visits by disabled children 38 (about a third of the 1,726 children in the study were ages 11 to 13) found that in families without health insurance, parents paid all of the costs of the visit 70.6 percent of the time (8). In families with private health insurance, parents paid all costs 30.7 percent of the time and partial costs 44.3 percent of the time; in families with public health insurance, parents paid all costs 4.6 percent and partial costs 2.8 percent of the time. Whether children with disabilities had seen a physician in the past year was significantly associated with whether the children were covered by insurance, even after controlling for survey site, race and ethnicity, socioeconomic status, age, and type of disability. Disabled children with health insurance were 1.8 times more likely to have seen a physician than those without insurance. Jacobs and McDermotts review of three studies of family caregiver costs for chronically ill and disabled children concluded that: 1) estimated incremental money costs (i.e., apart from the costs of therapy) to families of children (ages unspecified) with cancer ranged from $1,121 to $4,012, and 2) estimated annual time costs (e.g., family members giving up time from work and other activities) ranged from $1,514 to $4,697, for a total range of estimated incremental money costs from $3,000 to $9,000 annually (37). Two studies that met minimal methodological criteria and covered other serious chronic diseases were also subject to review. One of the studies, on cystic fibrosis, found an annual incremental money cost of $334, but the reviewers were unable to estimate the incremental time or money costs to families of a child with spina bifida (37). In conclusion, current estimates of the financial costs to families of chronic illness and disability among adolescents are highly variable, and more research on this topic is warranted. /interventions To Treat Psychosocial Problems of Adolescents With Chronic Conditions In a 1990 review of the association of chronic physical health problems and behavioral or emotional problems, Gortmaker and colleagues concluded that, despite general acceptance of the idea that children with chronic conditions are at higher risk for developing behavioral problems, the literature contains few accounts of systematic, welldocumented attempts to prevent or ameliorate these functional problems (28). 38~~ study ~l=~fl~d ~~l&~n ~ dl~abl~d on the b~ls of emo]lment in speci~ education c~ses. me prim~ disabling condition of about a third of the children in the sample was a neuromuscular, orthopedic, or sensory impairment or a chronic disease, The remainder of the disabled sample included children with problems such as 1 earning disabilities, attentional deficits, mental retardation% speech impairments, or emotional or behavioral dysfunctions (8).
PAGE 173
II-172 Adolescent HealthVolume II: Background and the Effectiveness of Selected Prevention and Treatment Services Photo credit: Katherine Criss, New York, NY Independence for adolescents with disabilities may require access to the same opportunities in life afforded to people without disabilities. The Gortmaker review found only five accounts of systematic, well-documented attempts to prevent or ameliorate chronically ill childrens psychosocial problems (28). All but one of the studies found beneficial effects, but only two of the programs included or focused on adolescents (28). Tw o studies with small samples documented the effectiveness of educational programs geared to increase health knowledge and self-care and to improve the functioning of children with asthma (18,46). A randomized controlled trial of a university hospitalbased home care program for children with a broad range of long-term health needs demonstrated beneficial effects on the pyschologic functioning of the children (82). Pless and Satterwhite found that a lay family counselor intervention also improved psychosocial functioning of children with chronic physical health problems (73). On the other hand, a randomized controlled trial of a social work intervention conducted by Nolan et al. at Montreal Childrens Hospital indicated no effects from a 6-month intervention intended to improve psychosocial functioning for children with chronic physical conditions (68). The two programs that included or focused on adolescents were the lay family counselor intervention (73) and the social work intervention in Montreal (68). Both of the programs focused on providing assistance to families as a whole (primarily parents), although it was the aim of the programs to improve the psychosocial status of the adolescents. Differences between these two programs may be helpful in evaluating why one failed and the other did not. The program reported by Nolan et al. was a short-term (6-month) intervention in which social workers had minimal (an average of three times) personal contact with some member of the family (68). Half the families did not find the intervention helpful. Although the program reported by Pless and Satterwhite used lay volunteers rather than professionals, these lay volunteers were able to spend much more time with the families (an average of 4.6 hours per month with each of eight families) over the course of a year (73). Pless and Satterwhite found that childrens psychological improvement increased with the amount of time spent by the lay counselor (73). In addition, the lay volunteers were chosen on the basis of their personal characteristics and proven success in childrearing, which Pless and Satterwhite asserted might not be possible to do with professional staff (73). One of the main issues for adolescents with serious chronic physical illnesses or disabilities is the development of greater independence (49), and a number of programs have developed to enhance the capacities of adolescents with serious chronic physical illnesses or disabilities to be independent. Some programs employ interdisciplinary teams to assess and provide services to adolescents with chronic illness or disability. One such program is the Comprehensive Adolescent Medicine program at the Montefiore Medical Center in New York City. The program, originally funded by the Robert Wood Johnson Foundation in 1979, provides chronically ill young people ages 10 to 20 with comprehensive, interdisciplinary care designed to help them develop into independent adults. The program serves between 450 and 500 young people each year (77). Another program, the Youth in Transition Project at the University of Washington in Seattle, is a demonstration project funded by DHHS Bureau of Maternal and Child Health. This program is designed to facilitate transitions from high school and home to employment and independent living for individuals ages 17 to 21 with developmental disabilities, cognitive impairments, or chronic physical illness (10). Each participant in the project receives an extensive evaluation from an interdisciplinary team including a physician, nutritionist, psychologist, and a social worker. A transition plan is then developed that might include, depending on the needs of the adolescent, vocational planning life skills training, sexuality education, and nutrition education and a diet plan. Followup is then provided to determine how clients are progressing in their
PAGE 174
Chapter 6--Chronic Physical Illnesses: Prevention and Services l II-173 transition and whether assistance is needed in implementing the transition plan. Preliminary evaluations of the demonstration project based on the first 27 clients indicate that families found the assessment process useful. Other types of programs focus on experiential learning for adolescents with chronic illness or disability to increase their sense of personal efficacy. Adventure, Inc. is a program that provided an Outward Bound experience, consisting of a 9-day wilderness and a 5-day urban experience, for chronically ill, physically disabled, and able-bodied adolescents (42). After participating in the program, both able-bodied adolescents and adolescents with disabilities or chronic illnesses, showed improved body image, declines in family conflict, and increases in individual recreational activities relative to family recreational involvement. Although the study is limited by a small sample size (n= 37, 23 of whom were chronically ill or disabled), the study does indicate the potential of an Outward Bound type of program for developing independence for adolescents with chronic illness or disability. Another program, the Adolescent Employment Readiness Center at Childrens Hospital National Medical Center in Washington, DC, has provided vocational services, including vocational aptitude and aptitude testing and job placement, to over 100 young people ages 12 to 19 with chronic health problems such as juvenile rheumatoid arthritis, spina bifida, muscular dystrophy, kidney failure, diabetes, epilepsy, and cystic fibrosis (12). The program, which was funded by a grant from the DHHS Bureau of Maternal and Child Health, is designed to improve prevocational readiness and enhance independence. Through the program, adolescents are placed in volunteer or paid jobs ranging from clerical jobs to lifeguarding. An evaluation of this program is under way, but no outcome data are available yet (118). State and Local Services for Adolescents With Chronic Conditions Assistance may be available for adolescents with physical or mental disabilities from a variety of State agencies depending on the State (36). These agencies include State departments of education, which provide special education services; offices of State coordinators of vocational education for handicapped students, which coordinate vocational education services; and State mental health departments. Other sources include State mental retardation agencies, programs that have received funding from the DHHS Bureau of Maternal and Child Health for direct medical and related services to children with special health care needs, and State developmental disabilities agencies. State protection and advocacy systems provide services to persons with developmental disabilities, and State vocational rehabilitation agencies provide services needed to prepare persons with disabilities for work. Finally, a number of universities have universityaffiliated programs, which provide services and programs for children and adolescents with disabilities and their families. There is considerable variability across States in how these various services are provided, and in where the various functions are housed organizationally. According to Blum, there are major problems in the care of adolescents with chronic illness and disabilities (5). These include the lack of coordinated care among subspecialist services; provider ignorance of the various health, education, and social services in the community; a lack of attention on the part of health care providers and policymakers to providing for adolescents transition to the adult health care system; and failure to address the sexual and reproductive needs of adolescents with chronic illnesses and disabilities. Some observers have noted that services to children with chronic illness are frequently disease specific (72). That is, often specialized services emerge to address the needs of persons with only certain types of disorders. Voluntary and advocacy organizations, which represent only one or a few disorders, rarely coordinate their advocacy efforts .39 The result is that policies are made or programs are developed that address specific concerns of advocates for specific problems, rather than the generic needs of people with varying types of disabilities. In addition, the needs of children with illnesses without effective advocates may not be addressed in the policy domain. 3~crc ~~ ~~~bl~ ~xC~ptiom t. M5 la&of ~oord~atlq for exmp]e, the lkchnology-Related Assistance for htividtis Witi Disabilities Act of 1988 (Public Law 100-407), which was actively backed by a broad coalition of org animations and individuals in the disability community. However, the coordinated effort was to encourage the passage of legislation not to actually provide services.
PAGE 175
II-174 Adolescent HealthVolume II: Background and the Effectiveness of Selected Prevention and Treatment Services Examples of Chronic Physical Illnesses Among Adolescents OTA has used the available information on the prevalence and importance of chronic physical health problems to identify for further discussion in this chapter one serious problem--cancer--and two problems with less dire consequencesacne and dysmenorrhea. Each of these illnesses illustrates certain important issues about services to treat physical illness in adolescents. Cancer was chosen because it is the most frequent cause of natural death (i.e., death caused by illness, disease, or chronic conditions as opposed to death caused by external causes such as accidental injuries, suicide, or homicide) among U.S. adolescents. Adolescents with serious chronic illness such as cancer and their families merit public attention for these major reasons: l l l significant public funds are consumed by these children, particularly for health care; the needs of children with chronic illness are not likely to be met by the existing health care system; and, thanks to the advances in technology and health care over the past several decades, significantly greater numbers of children with chronic illness are now surviving into adolescence and adulthood (72). Cancer is a low prevalence disease that has very serious shortand long-term consequences for adolescent victims and their families. Acne is a leading cause of adolescents visits to office-based physicians, and it is identified by adolescents as an important concern. Usually thought of by adults as a minor problem, common acne (acne vulgaris) is experienced by the vast majority of U.S. adolescents. Dysmenorrhea (painful menstruation) is a problem for many young women, and it contributes significantly to school-loss days among adolescent females (39,44,120). Although identified by adolescents as an important concern, dysmenorrhea may not be adequately addressed by health care providers. Cancer Among Adolescents Cancer is the leading cause of natural death among U.S. adolescents. For U.S. adolescents ages 10 to 14, malignant neoplasms (cancer) are the second leading cause of death, following accidental injuries; for U.S. adolescents ages 15 to 19, malignant neoplasms are the fourth leading cause of death, following accidental injuries, suicide, and homicide (103). While the number of adolescents dying from cancer is small, and cancer treatment represents only a small portion of health care services delivered to adolescents, a number of issues specific to cancer are important to address. Adolescents with cancer, and their families, suffer devastating personal effects as a result of treatment, and the costs to families of cancer treatment are high. Cancer and cancer treatment put adolescents at risk for a number of short-and long-term physical problems, and death. Trends in the Incidence and Prevalence of Cancer Among Adolescents U.S. adolescents generally have lower cancer rates than Americans in other age groups. However, adolescents ages 10 to 19 experience the highest rate of bone cancer except for those ages 60 and above. And, they experience more acute lymphoblastic leukemia, the most common form of leukemia experienced by adolescents, than all Americans except those ages 9 or younger, or 80 and above (1 10). In general, the incidence of cancer among U.S. adolescents has remained relatively stable since the early 1970s (see figure 6-2), with the exception of acute lymphoblastic leukemia, which has increased in incidence (110). Substantial advances in treatment of childhood cancers have led to declining death rates in recent years (see figure 6-3). Between 1960 and 1984, 5-year survival rates among children of all ages increased from 20 to 48 percent for bone cancer, from 52 to 91 percent for Hodgkins disease, from 33 to 82 percent for Wilms tumor, from 35 to 55 percent for brain and nervous system cancers, and from 18 to 60 percent for non-Hodgkins lymphoma (110). Dramatic increases in survival have also been realized for leukemia among young people. While as recently as 40 years ago nearly all children diagnosed with leukemia died of the disease (83), about half of the white males and females ages O to 14 diagnosed with leukemia in 1979 survived 5 to 6
PAGE 176
Chapter 6-Chronic Physical Illnesses: Prevention and Services //-175 Figure 6-2incidence of Cancer Among U.S. Adolescents Ages 10 to 19, 1973-87 Annual incidence rate (new cases per 100,000 population) 18 r- ~ I () L.. -~-J 777 T 1973 1975 1977 1979 1981 1983 1985 1987 SOURCE: Office of Technology Assessment, 1991, based on U.S. Department of Health and Human Services, Public Health Service, National Institutes of Health, National Cancer Institute, unpub Iished Surveillance, Epidemiology, and End Results Program data, Bethesda, MD, 1989, years (11O).W Nevertheless, leukemias, followed by brain and central nervous system cancers, are the most common cause of cancer deaths among U.S. adolescents. Consequences of Cancer Among Adolescents Increases in survival among cancer patients mean that more individuals contracting cancer during early childhood will survive into adolescence and that persons with cancer during their adolescence have a high probability of surviving into adulthood. There are a number of significant shortand long-term consequences of cancer for adolescents. Short-Term Consequences for Adolescen--Shortterm consequences of cancer include the side effects of treatments, interruptions in major academic and socializing activities, and the psychological distress that may arise from these more overt consequences. The side effects of cancer treatments such as radiation and chemotherapy can be devastating for adolescents. In a study involving interviews with 40 survivors of childhood and adolescent Hodgkins disease (70 percent of whom were ages 12 to 19 at the time of diagnosis), half of the respondents reported that the worst thing about having Hodgkins disease was experiencing the side effects of treatment (115). A study by Wasserman et al. of survivors of childhood/adolescent Hodgkins disease found that females, in particular, were likely to identify side effects of treatment (especially loss of hair) as the most traumatic part of their illness (1 15). 6 5 4 3 2 1 0 Figure 6-3-Cancer Mortality for U.S. Adolescents Ages 10 to 19, 1973-87 Mortality rates (deaths per 100,000 population) p. ~ 1 1 i 1973 1975 1977 1979 1981 1983 1985 1987 SOURCE: Office of Technology Assessment, 1991, based on U.S. Department of Health and Human Services, Public Health Servioe, National Institutes of Health, National Cancer Institute, unpub Iished Surveillance, Epidemiology, and End Results Program data, Bethesda, MD, 1989. Immediate side effects of treatment include nausea and vomiting and pain associated with the administration of the chemotherapy agents. Ulceration of the mouth or gastrointestinal tract are also common side effects, appearing several days after a dose of chemotherapy (57). Radiation and chemotherapy frequently lead to loss of hair (alopecia), necessitating the use of a wig or appearing bald in public (33). These side effects of treatment can be particularly difficult for adolescents because of their heightened concern about their appearance and relationship to their peers. Individuals receiving treatment for cancer also are particularly susceptible to secondary infections (83). Even after they receive treatment, some individuals experience anxiety about their condition. In a 1988 study, a quarter of the 41 survivors of childhood cancer interviewed were extremely preoccupied with their physical condition (21). Young people with cancer may find it difficult to keep up with school. The need for frequent treatments, often at a distance from home, may result in high levels of school absence. Many school systems provide good in-home tutoring services, but the quality of services is not consistent across schools (69). Individuals interviewed in Wasserman et al.s retrospective study of the effects of childhood and adolescent cancer missed an average of 6 months of school while they were undergoing treatment (1 15). Some may drop out of school after extended absences (1 15). Even when young people return to %ata presented are for white children only; data for black chiklren are unreliable because of small sample sizes.
PAGE 177
II-176 Adolescent Health-Volume II: Background and the Effectiveness of Selected Prevention and Treatment Services school, they may find that they are ostracized by their peers. Forty percent of those interviewed in the study by Wasserman et al. remembered being teased about their appearance or being treated as outcasts (115). Long-Term Consequences for Adolescents--Longterm side effects of cancer can also be quite serious and include secondary cancers, sterility, and growth retardation (13,57,83,1 15). Chemotherapy and radiation can also result in gonadal damage, resulting in smaller testes for males (76). The long-term effects of gonadal damage resulting from chemotherapy and irradiation may not become evident until adulthood (e.g., sexual dysfunction, increased risk of heart disease) (76). Females treated for leukemia with chemotherapy and radiation have been found to experience significantly earlier breast development, to have a lower mean age of menarche than average, and to go through puberty in a shorter period of time than average. This early puberty and limited potential for growth can have a number of psychological effects on adolescents. Secondary cancers are also possible sequelae of cancer treatment (57). Adolescent cancer can also have long-term social or emotional effects. For example, evidence indicates that survivors of childhood cancer often confront employment dis crimination and discrimination in obtaining life and health insurance policies (11 1). For people who do not belong to group health insurance policies (e.g., through an employer), health insurance may be very expensive or even unobtainable (115). Discrimin ation may occur in other areas as well; Wasserman et al. found that 5 of their 23 male subjects reported being denied entry into the armed forces because of their cancer history (115). Available evidence suggests that most adolescent survivors of childhood cancer do not experience higher levels of depression or lower levels of self-esteem than other adolescents (29). Survivors with severe long-term medical effects (e.g., physical disfigurement, loss of a limb, gonadal failure, or second malignant neoplasm) tend to experience greater levels of depression and to have a lower self-concept than survivors with no long-term cosmetic or organ dysfunction (29). Many survivors of childhood cancer actually identify positive effects of their experience with cancer. One study reported that 61 percent of the adolescent survivors of childhood cancer interviewed identified positive effects, such as increasing their self-confidence, enabling them to be more empathetic, increasing their appreciation of life, and making them more mature (21). Likewise, Wasserman et al. found that 95 percent of adult survivors of child or adolescent Hodgkins disease identified positive consequences (115). Prevention of Cancer Among Adolescents Most cancers that occur during adolescence could not have been prevented given the current state of knowledge. Except for the relationship between prenatal radiation of a pregnant mother and childhood leukemia (6,79), little is known regarding the cause of leukemia. The risk of secondary leukemia increases with certain types of cancer chemotherapy (110). Discussions about preventing cancer in adolescents generally focus on the prevention of future cancers that are linked to engaging in healthcompromising behaviors (e.g., 51). These behaviors, which may be initiated or established during adolescence, include smoking, drinking alcohol, using certain contraceptives, eating habits, and t arming.dl Results of the 1987 National Adolescent Student Health Survey of more than 11,000 8th and 10th graders found that these adolescents had a number of eating practices that may increase their risk of cancer later in life. These include high consumption of fatty foods (59 percent reported eating fried foods one to three times weekly and 39 percent did so more than three times weekly), and a lack of knowledge about some risk factors for cancer (e.g., few were aware of the role of dietary fiber in the prevention of colon cancer) (74). Other behaviors common among U.S. adolescents, such as t arming, may increase the risk of developing cancer later in life. A survey including 126 adolescents, conducted by the American Academy of Dermatology, found for example, that 67 percent of adolescent females and 33 percent of adolescent males reported intentionally working on a tan and that they did not take precautions from the dl~olmants~ smo~ and alcohol use is dkCUSSed in Ch. 12> Alcohol, Tobacco, and Drug Abuse: Prevention and Services, their nutrition and eating habits are discussed in ch. 7, Nutrition and Fitness Problems: Prevention and Services, and their contraceptive use is discussed in ch. 10, Pregnancy: Prevention and Services, all in this volume.
PAGE 178
Chapter 6-Chronic Physical Illnesses: Prevention and Services .11-177 sun (23). Although similar percentages of adults reported working on a tan, fewer (23 percent) took no precautions to protect themselves from the sun. Seventy-five percent of adolescents (compared to 66 percent of adults) believed tans make people look healthy. Overexposure to the sun, however, can have dangerous outcomes. In a study of melanoma in women, those who reported having five or more blistering sunburns between the ages of 15 and 20 were more than twice as likely to have developed malignant melanoma by ages 38 to 65 (the age group surveyed) as were those who had experienced no such burns (1 16). This exposure during the adolescent years was found to be a much more important determinant of melanoma incidence than exposure after the age of 30. Preventive efforts should focus on the behaviors of children and adolescents to reduce their intensive sun exposure. There is evidence that many U.S. adolescents do not have accurate knowledge about the etiology, warning signs, prevention, and treatment of cancer. A survey of 870 inner-city junior and senior high school students (mean age = 14) found a significant lack of understanding about cancer (75). Although most (approximately 90 percent) recognized the association between cigarette smoking and cancer, fewer than half recognized the role of nutrition. Of the seven warnin g signs of cancer recognized by the American Cancer Society (ACS), only the sign of a lump or bump in the breast or elsewhere was identified as a warning sign of cancer by more than half the students. The study found differences between white and black adolescents in their understanding of cancer. Only 9 percent of the black students and 3 percent of the white students knew that blacks are more likely than whites to get cancer and to die from cancer. In addition, fewer black than white students believed that they could get cancer. Perhaps most critically, the black adolescents were significantly less likely than whites to see the value of early treatment for cancer or to believe that cancer can be cured. Thus, there appears to be a need, particularly for some adolescents who may be at highest risk for developing cancer in the future, to increase knowledge about risk factors, warning signs, and the importance of early detection and treatment. In 1985, the ACS appointed a National Public Education Subcommittee on Youth Education that developed a Plan for ACS Youth Education Program (15). ACS initiated a campaign to increase awareness of childhood and adolescent cancer (83) that includes a book by humorist Erma Bombeck (40) and a Peanuts television special (16). ACS also sponsors a variety of public education programs, including programs targeted at elementary, intermediary, and secondary school students. The programs include educational strategies designed to promote good health habits among young people, help them make health-enhancing lifestyle decisions, and help them understand the relationships between health behaviors and cancer risk reduction (2). Services and Interventions for the Treatment of Adolescent Cancer Cancers in adolescents are most frequently discovered by primary care physicians (33). Most childhood cancers are detected at early stages, as parents are likely to seek medical care soon after observing a health problem (1 10). Current methods of treating cancer generally have to be offered in tertiary care facilities that provide sophisticated multidisciplinary care to cancer patients (55). Although much treatment must take place in these cancer centers, however, the primary care physician in the community can still play an important role. He or she can act as a link between the family and the cancer center, administer certain drug treatments (particularly during the maintenance phase), and monitor the adolescent with cancer during followup. Because cancer centers are often some distance away from the adolescent home, families frequently incur extensive nonmedical costs when the adolescent is at the treatment center, such as travel and lodging costs and lost wages because of time away from work. It is believed that the use of community-based care, in coordination with treatment at a tertiary center, has the potential to greatly reduce these economic costs to the family (55). Despite the difficulties inherent in undergoing treatment for cancer, some evidence indicates that adolescents are generally cooperative partners in treatment, although little research exists in this area. One study covering adolescents compliance with treatment, however, found older adolescents to be less compliant than younger adolescents, suggesting that the transfer of greater responsibility for treatment from parent to adolescent may be associated with greater noncompliance in adolescents struggling to gain autonomy (85). Similarly, in a study
PAGE 179
11-178. Adolescent HealthVolume II: Background and the Effectiveness of Selected Prevention and Treatment Services with 27 adolescents in remission from cancer (ages 12 to 18), adolescents were rated by nurses as being moderately cooperative with treatment, though older adolescents were rated as being less cooperative than younger adolescents (38). Compliance with orally administered chemotherapy agents may be increased if adolescents and parents agree on who is responsible for administering the medications, although older adolescents may still tend to be less compliant than younger adolescents even when they agree with their parents on medication instructions (85). (85). There is evidence that while younger children with cancer may be more comfortable with not fully understanding the seriousness of their disease, adolescents appreciate being kept informed throughout their diagnosis and treatment and have a good understanding of their treatment (115). Efforts to improve the quality of life of adolescents with cancer by reducing the negative effects (e.g., loss of hair, nausea, risk of secondary cancers) of treatments are greatly needed. Strategies include developing mechanisms for best identifying leukemia patients at highest risk of relapse so patients at most risk may be targeted for more extensive treatments and patients at least risk will not have to endure longer courses of therapy (13). Interventions for the Treatment of Adolescent Cancer--Substantial support for basic and clinical cancer research and patient activities comes from private sources such as ACS. ACS has an affiliation agreement with the Candlelighters Childhood Cancer Foundation that links over 250 parent self-help groups for families of children and adolescents with cancer (56). These groups can provide families a diverse range of support including funds for wigs or prostheses, educational information, peer counseling, and a forum for discussion of common concerns. Supportive services provided by ACS include the provision of home-care items, transportation services, and patient and family education. Of the 1986-87 ACS budget of $306.23 million, 28 percent went to research, 19 percent to public education, 13 percent to patient services, and 10 percent to professional education (2). Barriers to Treatment for Adolescents With CancerA significant barrier to care for adolescents with cancer is the current state of available treatment. Although significant advances have been made in the development of treatments that increase survivability, the treatments themselves may reduce the quality of life to the extent that adolescents and their parents may question their value. Adolescent medicine specialists, and health care providers who feel competent to work with adolescents, are relatively few in number. 42 Adolescents, however, have a number of special concerns related to their treatment for cancer that need to be addressed. For example, they must adjust to the impact of the illness and treatment on their relationships with their peers, their sexuality, and their developing independence. In addition, adolescents understanding of the disease and its implications will be more sophisticated than those of young children because they are more advanced developmentally and more capable of abstract reasoning. Costs of Cancer Treatment for AdolescentsEven for adolescents with health care coverage, the costs of cancer treatment can be staggering. For adolescents in geographically isolated areas, which are likely to be farther from pediatric cancer centers, these problems can be even more burdensome (3,69). Some families may even lose their homes. A witness at a hearing of ACS reported that his 13-year-old daughter was hospitalized 63 times in one year because of an abdominal tumor; the family was eventually evicted for falling behind in their rent because of medical bills (3). Pendergrass et al. followed for 2 years the total hospital costs for 24 children (no ages specified) diagnosed with leukemia at a Seattle hospital in 1979 (69). They estimated that the first-year therapy costs for children with acute lymphoblastic leukemia averaged $12,334, with a range from $2,000 to $40,825. For the 10 children who completed 2 years of therapy, costs averaged $21,114 for 2 years, with a range from $2,958 to $52,343. Many of these costs were probably covered by insurance. However, these estimates included only treatment costs within the site where participants were identified; they did not include other physician fees or out-of-pocket expenses for the families. Thus, they are conservative estimates of the actual costs of care for these children. 42For tier discussion see Ck 15, Major Issues Pertain@ to the Delivery of Primary and Comprehensive Health Services to Adolescents, in vol. III.
PAGE 180
Chapter 6-Chronic Physical Illnesses: Prevention and Services .11-179 Data for the study by Pendergrass et al. were collected in 1979 when bone marrow transplants for leukemia were extremely rare. Bone marrow transplants have been a major factor in improving leukemia survival rates. However, for a child with leukemia who requires a bone marrow transplant and does not have access to a compatible donor, the limited information available suggests that costs can go well beyond what insurance will cover. In interviews with four transplant centers for a 1990 staff paper, OTA found that the costs of locating an unrelated donor ranged from $13,810 to $20,475 (1 13). Information is scarce on the costs of the procedure itself; one transplant center puts the range at $150,000 to $250,000 (67). In 1989, researchers ex amined the so-called incremental costs to families of caring for children with cancer (no ages were specified) (37). Cost categories in the study included direct home costs, travel costs, durable equipment and other capital costs, and time costs (i.e., family members giving up time from work and other activities) but did not include costs of therapy. In analyzing the three studies that provided data on such incremental costs, the researchers found that estimated annual money costs ranged from $1,121 to $4,012 across the studies; estimated annual time costs ranged from $1,514 to $4,697. Overall, total incremental costs (including time costs) represented about 28 percent of family incomes. Major Federal Policies and Programs Pertaining to Cancer Among Adolescents The National Cancer Institute (NCI) within DHHS provides the major Federal support for research on cancer. Currently funded basic research includes study of the basic biology of normal and malignant hematopoietic cells to learn more about the origin and progression of leukemia, studies of drug metabolism in leukemia patients to learn more about disease and treatment-related changes in these patients, and studies to predict which patients might benefit most from additional therapy (1 11). NCI is also currently funding a followup study of childhood leukemia survivors through early adulthood to learn more about the effects (especially endocrinologic effects) of the disease and its treatment. Other epidemiologic studies are examining the environmental and genetic risk factors for developing leukemia (both acute lymphocytic leukemia and nonlymphocytic leukemia). Other studies focus on different childhood cancers. One study is assessing the risk of developing leukemia and other cancers after intensive chemotherapy and radiation therapy for Hodgkins disease. Another is examining exposure to N-nitroso compounds as a risk factor for developing brain tumors during childhood and adolescence, Other studies are ex amining the effects of various treatment therapies on different cancers (111) 0 NCI also provides support for programs and research studies that focus on the physical and psychological health of cancer patients (1 11). These include teen support groups to aid adolescent patients, pain management and stress-reduction programs for young cancer patients, and programs that focus on reducing the psychological side effects of cancer treatments, including a study identifying and monitoring the effects of cancer and treatment on the neuropsychologic development of children with leukemia. Another focus of support for NCI is on interventions that minimize the social and academic difficulties of long-term childhood cancer survivors. One currently funded study is focusing on increasing school attendance of children with newly diagnosed cancer. It is anticipated that the provision of ongoing scholastic and peer involvement will help to counteract the anxiety and depression experienced by severely ill patients. Another main focus of NCI funding is on prevention. This includes support for antismoking efforts and nutrition studies. Acne Among Adolescents Acne vulgaris, or common acne, is a disorder of the sebaceous (or oil) glands, sebaceous ducts, and hair follicles that results in skin eruptions. The vast majority of American adolescents experience acne. An estimated 90 percent of adolescent males and 80 percent of adolescent females are affected with acne to some degree (33). Some adolescents experience only a few occasional pimples; others are plagued by persistent pustular acne that lasts for years, leaving disfiguring scars. Each case of acne follows its own individual course. Because acne is so prevalent among adolescents and is not life-threatening, many health care providers, policymakers, and others may minimize its importance to young people. According to data collected during the 1985 NAMCS sponsored by the National Center for Health Statistics, the majority of U.S. adolescents who visited a dermatologist (60.1 percent) in 1985
PAGE 181
//-180 Adolescent HealthVolume II: Background and the Effectiveness of Selected Prevention and Treatment Services did so because of acne (101). The percentage of older adolescents who went to a dermatologist because of acne was higher than the percentage of adolescents ages 10 to 12 who visited a dermatologist because of acne. 43 About two-thirds (66.4 percent) of visits to dermatologists by adolescents ages 16 to 18 were for acne (101). Only 1.2 percent of visits by 16to 18-year-olds to general practice or family physicians were for acne, however for older adolescent males, acne was the most frequent reason for visiting a physician. Limitations in available data make comparisons by race impossible for specific conditions. Myths about acne abound. These include beliefs that acne is caused by the consumption of certain foods (such as chocolate), by sexual activity or thoughts, or by poor hygiene. Actually, several factors are involved in the development of acne. Rising levels of certain hormones during adolescence increase the activity of oil glands. Heredity also plays a role; adolescents are more likely to develop acne if they inherit oily skin that is sensitive to the effects of hormones. Plugged oil glands are also a factor; oil glands can become plugged when cells lining the oil glands or pores shed and stick together. Finally, skin bacteria are a factor; plugged pores can become infected when bacteria are present, leading to the development of pustules or cysts (1,33). An estimated $120 million is spent each year on acne treatment, including $100 million on over-thecounter acne medications (114). What portion of this is spent by or on the behalf of adolescents is unknown, but it is likely to be considerable given the high prevalence of acne among adolescents. There is no cure for acne. The goal of treatment is generally to control the condition and prevent or limit scarring (33). A variety of treatments are available (30,33,84). A topical 5to 10-percent benzoyl peroxide solution is a commonly used drying and peeling agent. It is available over-thecounter as a lotion, or by prescription as a gel. Another topical product used for more severe acne is tretinoin, which is available only by prescription. Antibiotics are also frequently part of the treatment regimen for severe acne. Oral antibiotics (e.g., tetracycline or erythromycin) or topical antibiotics (e.g., erythromycin or clindamycin) may be used. Isotretinoin (13-cis-retinoic acid) is a relatively new treatment for severe cystic acne. Each of these treatments has negative side effects (33,84). Benzoyl peroxide and tretinoin produce drying and peeling. About 2 to 3 percent of people may be allergic to benzoyl peroxide. Tretinoin can also be very irritating to the skin, sometimes resulting in exacerbation of acne during the initial stages of treatment. Sun exposure increases skin irritation for adolescents using tretinoin, necessitating either avoidance to sun exposure or use of a sunscreen. Oral antibiotics can irritate the stomach and, in young women, increase the chances of developing vaginal yeast infections. Topical antibiotics may cause a yellowish discoloration of the skin. Isotretinoin, which should be used for only the most severe cases of acne, can produce birth defects if used during pregnancy and should not be used for anyone who is pregnant or who is likely to become pregnant. Other side effects of isotretinoin include cracking and scaling of the lips (90 percent of users), severe drying of the skin (80 percent of users), and conjunctivitis (inflamm ation of the mucous membrane that lines the inner surface of the eyelids and the forepart of the eye) and difficulty with contact lens use (40 percent of users) (86). The course of treatment for acne can be difficult for adolescents for other reasons. Weeks of treatment are frequently required before improvement is visible. In addition, some adolescents have difficulty effectively complying with complicated treatments that may involve washing their face several times a day, applying one solution to their skin in the morning and another at night, and taking oral antibiotics. Oral antibiotics are most effective when taken on an empty stomach, necessitating that adolescents remember to take their medication either an hour before or 2 hours after meals. Following such a regimen may be especially difficult for adolescents who snack throughout the day. Cosmetics, frequently used by girls to cover their blemishes, may actually exacerbate their acne. Thus, adolescents may become frustrated and give up on treatments that take weeks to show any effects, have undesirable side effects, do not actually cure their acne, and are complicated and time-consuming to administer (20). 43~~ ~um~r of lo t. 12.y~.olds visiting dermatologists was too sm~l to retie a reliable numencd estimate.
PAGE 182
Chapter 6-Chronic Physical Messes: Prevention and Services II-181 Photo a e w ., wcan tidemy of Dermatology There is no cure for acne, an almost universal problem among adolescents. An estimated $124 million is spent each year on acne treatment. Health care providers should help adolescents understand that treatments designed to control the condition and prevent scarring maybe slow to work, cause side effects, or even temporarily worsen an adolescents appearance. Health care providers may fail to recognize the difficulties that adolescents experience in adhering to treatment regimens. It is important that they emphasize the slow course and complicated nature of treatment, ensure that adolescents realize there is no cure, and advise adolescents of potential side effects, including the possibility of a temporary worsening in appearance (20), Dysmenorrhea Among Adolescent Females Primary dysmenorrhea (menstrual pain in the absence of anatomic pathology such as endometriosis 44 ) usually has its onset in the first year or 2 following menarche, but its incidence increases through the adolescent period (1 1). Over half of those experiencing dysmenonhea may experience moderate to severe menstrual cramps. The 1966-70 NHES conducted by the U.S. Department of Health, Education, and Welfare included taking menstrual history of adolescent females ages 12 to 17 (94). Almost 60 percent of the adolescents in this study reported some degree of menstrual pain, and 14 percent reported frequent school absenteeism due to dysmenorrhea (43). 45 Although there are no current national populationbased studies of the prevalence and effects of dysmenorrhea for adolescent females, 46 studies with small samples indicate that dysmenorrhea remains a leading contributor to school absenteeism for adolescent females. For example, one-fourth of the 88 high school females surveyed by Wilson and Keye reported that they had missed classes because of dysmenorrhea (120). A study involving middleschool students with excessive absences in Boston found that almost half of these students cited health problems as a reason for the absence; menstrual pain was one of the most frequently cited problems (44). Forty-five percent of 14to 18-year-old adolescent females in two Midwestern communities reported some school or work absenteeism due to menstrual pain (39), and 59.7 percent of otherwise healthy females in an independent New England high school reported dysmenorrhea (1 19). Even though the prevalence of dysmenorrhea appears to be high, less than 2 percent of visits to office-based physicians by adolescent females ages 15 to 18 are for abdominal pain, cramps, or spasms (which could possibly include menstrual cramps); fewer than 1 percent are for menstrual symptoms other and unspecified" (101). Although the numbers are too low to be reliable because trouble with menstruation was reported for few adolescent females, 1988 NHIS data indicate that only 5.9 percent of females ages 5 to 18 (virtually all of whom must be age 10 or over) experiencing trouble with menstruation sought medical care. In comparison, 77.9 percent of women ages 18 to 44 with disorders of menstruation reported seeking medical care (101) Dysmenhorrea due to endometriosis or other anatomic pathology is termed seconub?y dysmenorrhea. According to Litt, endometriosis (a condition in which tissue resembling the uterine mucous membrane occurs aberrantly in various locations in the pelvic cavity) has been underdiagnosed in adolescent females (47), another reason for paying serious attention to menstrual pain. ds~e pWenE of 2.5 ~r~nt of females ages 12 through 17 rewfled genitoconditions (no more specifics given) as having been the adolescents most serious illness (94). ti~s, for emple, provides awr memwe of mem~ problems experienced by adolescent females because my of ~eProxY r~pondents (e.g.! mothers) may be unaware that the adolescent is experiencing problems. It seems likely that primarily the most severe difficulties, those resulting in medical interventio~ will be reported. It is also difficult to use NAMCS data to assess the prevalence of dysmenorrhea because it only captures information on females who seek medical intervention for their menstrual cramps.
PAGE 183
11-182. Adolescent HealthVolume II: Background and the Effectiveness of Selected Prevention and Treatment Services Photo credit: Education Week Menstrual pain (dysmenorrhea) is a frequently cited reason for missing school. Adolescent females may need to be informed that dysmenorrhea is physically, not psychologically, caused and that it is easily treatable. Only recently has the medical profession recognized a physiological basis for menstrual pain: elevated concentration of menstrual prostaglandins that cause painful uterine contractions. As late as the 1980s, menstrual cramps were believed to be a psychosomatic complaint caused by poor attitudes of women about their femininity (11). Psychotherapy was seen as an appropriate response to the problem. Now that a physiological basis is known, however, treatment for dysmenorrhea can usually be straightforward. Nonsteroidal anti-inflammatory drugs (e.g., salicylates such as aspirin, propionic acids such as ibuprofen and naproxen sodium) inhibit the production of prostaglandins and have been effective in reducing uterine contractions (11). Ibuprofen, previously available only by prescription, is now available over-the-counter. 47 The low rates at which adolescent females seek care for dysmenorrhea may be due to beliefs by them, their mothers, or both that nothing can be done (39,48). Negative attitudes and erroneous beliefs may also be supported through misinformation received from peers and others. Because the medical community has only recently come to understand the physiological basis for dysmenorrhea (47), it is likely that some providers are not adequately informed about the importance of providing relief to young women suffering from menstrual cramps. Some of them, for example, may believe that exercise is an appropriate treatment, although recent evidence suggests that exercise is more directly associated with relieving stress which may reduce the intensity of dysmenorrhea (54). Even when providers are informed about the issues, they may not ask appropriate questions during health care 47~u~, it my ~ tit newer s~dies (COnduCt~ titer ibuprofen w~ ~de mom ~(,tely av~~le) wo~d indicate fewer problems with meDShWd p@l (39). This would only apply if more adolescents were aware tbat menstrual pain can be prevented or ameliorated.
PAGE 184
Chapter 6--Chronic Physical illnesses: Prevention and Services II-183 visits to probe about suffering from this problem and to make appropriate interventions (39). Major Federal Policies and Programs Pertaining to Adolescents With Chronic Conditions Federal efforts to address the needs of U.S. adolescents with chronic conditions include a Federal law requiring that education be provided to all handicapped children and a Federal law authorizing the provision of financial assistance to States and private nonprofit organizations that offer services to persons with developmental disabilities. These efforts are managed by various Federal agencies within the U.S. Department of Education and DHHS. Education for All Handicapped Children Act Educational opportunities for U.S. adolescents with disabilities have been greatly enhanced by the Education for All Handicapped Children Act (Public Law 94-142), which was passed in 1975 an d amended several times since then (e.g., Public Law 99-457 in 1986, Public Law 101-476 in 1990). This act is designed to guarantee free and appropriate public education for all children ages 3 to 21 with disabilities, including mental retardation; hearing, speech, vision, or orthopedic impairments; serious emotional impairments ; autism; traumatic brain injury; multiple disabilities; specific learning disabilities and other health impairments (35; Public Law 101-476). Some Federal funds are provided to support these efforts, but State and local-educational agencies bear most of the burden. The Education for all Handicapped Children Act also authorized a transition-from-school program for children and adolescents with disabilities. Amendments to the act in 1986 (Public Law 99-457 ) clarified that funded activities may serve students throughout their school years as well as those who have left secondary school, and it expanded the purposes of this provision to include improving vocational and life skills. The act also authorized funding for physical education and therapeutic recreation programs designed to increase community participation among adolescents with disabilities (89). Developmental Disabilities Assistance and Bill of Rights Act Services to persons with developmental disabilities are authorized through the Developmental Disabilities Assistance and Bill of Rights Act, which in 1970 amended the Mental Retardation Facilities and Community Mental Health Centers Construction Act of 1963 (Public Law 88-164) (91). The act authorizes Federal financial assistance to States and public and nonprofit agencies for programs that help people with developmental disabilities to achieve their full potential through increased independence, productivity, and integration into the community. Funded programs also provide assistance to the families of people with developmental disabilities. Under the act, the definition of developmental disabilities is based on functional limitations rather than specific disorders. These limitations must be manifest before age 22; be attributable to a mental or physical impairment; be likely to continue indefinitely; and result in substantial limitations in three or more major life activities, such as self-care, learning, receptive and expressive language, and mobility. Each State is required to have a State planning council that receives funds under the act. State pl anning councils serve as advocates for people with developmental disabilities and develop a State plan that identifies unmet service needs and services to be provided. The act also requires States to have in place a protection and advocacy system to provide information and referral services and to investigate reports of abuse and neglect of people with developmental disabilities. University-affiliated programs provide interdisciplinary training for people preparing to work with persons with developmental disabilities, conduct applied research, provide technical assistance to agencies working with people with developmental disabilities, and provide services for people with developmental disabilities. Other Federal Efforts A new disabilities prevention program has been established within DHHS at the Centers for Disease Control (34). Efforts will focus on the areas of developmental disabilities, injuries to the head and spinal cord, and secondary complications among people with physical disabilities. There are some tax code provisions designed to alleviate the financial burden on the families of people with disabilities (90). The costs of sending a
PAGE 185
//-184 Adolescent HealthVolume II: Background and the Effectiveness of Selected Prevention and Treatment Services dependent with mental or physical disabilities to a special school may be deducted if the main reason for using the school is that the school provides facilities for alleviating the handicap. The dependentcare tax credit can be claimed for expenses incurred in the care of a physically or mentally disabled dependent necessary for the primary care provider to be gainfully employed. This includes expenses for household services, day-care centers, and other noninstitutional care. In addition, the U.S. Surgeon General has sponsored several campaigns and conferences on children and adolescents with special health care needs (formerly known as crippled children (see 24, 49,100). The 1989 Surgeon Generals Conference focused specifically on issues for individuals with special health care needs making the transition between childhood and adulthood (49). A main focus of DHHSs Bureau of Maternal and Child Health is the dissemination of funds for programs assisting adolescents with disabilities. 48 Conclusions and Policy Implications Available data suggest that there may be more U.S. adolescents with physical health problems than is generally assumed. The most recent intensive health examin ation survey of a number of adolescents was the National Health Examin ation Survey (NHES) completed in 1970. This survey found that about 22 percent of U.S. adolescents had some illness, deformity, or physical handicap affecting normal growth, development, or function (94,95). Although not all of these were serious and chronic conditions, they were judged to interfere with healthy adolescent development in some way. As discussed in this chapter, OTA estimates (using Gortmaker and Sappenfields work) that roughly 5 percent of today U.S. adolescents experience chronic physical conditions that make them physically unable to carry on major activity (e.g., attending school) or limit the amount or kind of major activity they can perform. Little can be done during adolescence to prevent many of the serious chronic physical illnesses of adolescence. 49 In the absence of effective preventive interventions, attention to treatment and to issues affecting the quality of life of affected adolescents is particularly important. Although adolescents with chronic illnesses and disabilities experience many of the same problems as their nondisabled peers, such adolescents face a number of additional problems. These range from concerns that are specific to certain chronic illnesses (e.g., the devastating effects of chemotherapy and radiation associated with cancer treatment) to concerns that are associated with a variety of chronic illnesses (e.g., problems related to having to be absent from school, difficulties in socializing with peers, and substantial economic costs for families and for society). Adolescents with some chronic illnesses or disabilities may have limited options for employment and marriage, may be unable to (or choose not to) have children, and may experience dis crimination in obtaining life and health insurance. Another problem is that even for families with adequate health insurance, many of the often substantial costs associated with care of adolescents with chronic conditions are not covered. As discussed elsewhere in this Report, there is generally a scarcity of personnel trained to provide services to adolescents and services for adolescents tend to be fragmented. 50 The problems of fragmentation are compounded for adolescents with a serious chronic condition, who are typically in need of a broad range of often specialized services. Additional personnel trained to identify the needs of adolescents with chronic illnesses and disabilities, and to provide them with services, are needed. Some chronic physical health problems of U.S. adolescents are so common that they may be accepted by parents, health care providers, and policymakers as normal and not worthy of mention or intervention. Adolescents, on the other hand, may find them extremely troubling. Acne and dysmenorrhea are examples. The vast majority of U.S. adolescents experience common acne which, 48 For f~r di~cu~~ion of tie role of tie B~eau of Matem~ and Child H~& ~ adolescent heal~ Sm ch. 19, The Role of Federal Agencies in Adolescent Health, in Vol. Ill. @As noted ~her, ~my physic~ h~~ problems due [o inj~es are preventable. For f@er discussio& S= ch. 5, Accidental hlJUrieS: prevention and Services, in this volume. 50sm ch. 15, Major Issues pert aining to the Delivery of Primary and Comprehensive Health Services to Adolescents, and ch. 19, The Role of Federal Agencies in Adolescent Heal@ in Vol. III.
PAGE 186
Chapter 6--Chronic Physical Illnesses: Prevention and Services l II-185 although not physically disabling, negatively affects the day-to-day lives of many adolescents. Evidence from a variety of sources suggests that at least half of adolescent females report dysmenorrhea (painful menstruation) and about 1 in 7 miss school because of this pain. Dysmenorrhea is a problem that, in most cases, could be alleviated through the use of certain over-the-counter drugs. It appears that adolescents are not routinely made aware of current information about the causes of these and other disorders of importance to them, or of the fact that treatment is available. There is no single comprehensive source of information about the physical health status of U.S. adolescents. Rather, a variety of sources must be used to identify the most important physical health problems facing adolescents. National surveys sponsored by the National Center for Health Statistics in DHHS that provide information on the health of adolescents include NHIS, NHDS, and NAMCS, but these data sources have a variety of limitations. Most do not include large enough samples of adolescents to provide reliable data on low-prevalence chronic conditions. Furthermore, NHDS and NAMCS measure utilization of services (e.g., the number of adolescents with hospital stays or visits to physicians offices) rather than need. Thus, adolescents who do not seek care for services, or who use alternative services, are not included in the surveys. These data may disproportionately exclude racial and ethnic minority adolescents and poor adolescents who may not have access to services. 51 National surveys do provide some information on differences in health status or health care utilization among adolescents of different ethnic or racial groups, between males and females, and among adolescents of varying socioeconomic status, but much of this information is not reliable for policymaking purposes because of limitations in these data sources (e.g., small sample sizes of minority adolescents). There are virtually no populationbased data on the health status of minority adolescents and their utilization of health services. Even when minority groups are oversampled in some national surveys, the number of minority adolescents remains small. Similar problems exist for describing the health of adolescents living in poverty. Although some useful data are collected on socioeconomic status and health, 52 sufficient data are rarely collected to allow for analyses to determine the nature of relationships between socioeconomic status and health. Additional information is particularly needed on the health status of these groups of adolescents and their utilization of services. As described elsewhere in this Report, programs related to adolescents with chronic illness and disability can be found in a wide range of Federal agencies and departments. 53 These include the U.S. Department of Education and, within DHHS, the Centers for Disease Control; the National Cancer Institute; the National Heart, Lung, and Blood Institute; the National Institute of Allergy and Infectious Diseases; the National Institute of Arthritis and Musculoskeletal and Skin Diseases; the National Institute of Neurological Disorders and Stroke; and the Office of Human Development Services. There is, however, no central place in the Federal Government that coordinates programs for children and adolescents with chronic illness or disability. In summary, policy changes to improve the physical health of U.S. adolescents might include: l improved data collection, l additional support for coordinated services and services to improve the quality of life for adolescents with serious chronic physical conditions, and health education on issues of importance to adolescents. NHANES III currently in the field will oversample children, but includes relatively few adolescents and will not include institutionalized adolescents. NAMCS, NHDS, and NHIS (which are conducted more regularly than the infrequent NHANES) could oversimple so that more adolescents of a greater racial, ethnic, and economic diversity are included. Population-based interview surveys would be improved if they asked adolescents about their own health problems rather than relying on parents as 51sw Ch, lg, Issues h he Delivery of Services to Selected Groups of Adolcsccnts, in VO1. In. 5zsome data, for ~xmplc, ~e Collec[ed as pm of tie Natio~ Health Intewicw Survey. However, tis su~eY is 1imited cause adO1escents themselves arc not asked about their health problcms. s~sm Ch, 19, 1~c ROIC of Federal Agencies in Adolescent Health, In VOI. III. ~~+7 (1 111 -. i QI
PAGE 187
II-186 Adolescent Health-Volume II: Background and the Effectiveness of Selected Prevention and Treatment Services reporters of this information and if they included problems of importance to adolescents. Adolescents who have serious chronic physical conditions are in need of a broad range of often specialized services. Additional personnel trained to identify the needs of adolescents with chronic illnesses and disabilities, and to provide them with services, are also needed. Many adolescents with chronic physical illnesses may be in need of supportive or mental health services, for example. Although recent Federal efforts have addressed the needs of children and adolescents with special health care needs, there is no central place in the Federal Government that coordinates programs for adolescents with chronic illness or disability. More active support for the development and evaluation of programs, as well as for efforts to coordinate available programs, is needed. Finally, health education for adolescents could be improved if it addressed health issues of importance to adolescents and provided information on how to get access to medicine and services. Chapter 6 References 1, 2, 3. 4< 5. 6< 7, 8. 9. 10, American Academy of Pediatrics, Section on Adolescent Heal@ Acne: Treatment and Control Information, Adolescent Health Upalzte 2(1):2-3, 1989. American Cancer Society, Cancer Facts and Figures, 1988 (New York, NY: American Cancer Society, 1988). American Cancer Society, Cancer and the Poor: A Report to the Nation (AtlanQ GA: American Cancer Society, 1989). American School Health Association Association for the Advancement of Health Educatio~ Society for Public Health Educatiom Inc., The National Adolescent Student Health Survey: A Report on the Health of Americas Youth (Oakland, CA: Third Party Publishing Co., 1989). BlurIL R., Contemporary Threats to Adolescent Health in the United States, Journal of the American Medical Association 257(24):3390-3395, 1987. Boice, J.D., Carcinogenesis-A Synopsis of Human Experience With External Exposure in Medicine, Health Physician 55:62 1630, 1988. Butler, J., Budetti, P., McManus, M., et al., Health Care Expenditures for Children With Chronic Illnesses, Issues in the Care of Children With Chronic Illness, N. Hobbs and J.M. Pernn (eds.) (San Francisco, CA: Jossey-Bass, 1985). Butler, J.A., Singer, J. D., Palfrey, J. S., et al., Health Insurance Coverage and Physician Use Among Children With Disabilities: Findings From Probability Samples in Five Metropolitan Areas, Pediatrics 79:89-98, 1987. Cappelli, M., McGrattL P.J., Heick C.E., et al., Chronic Disease and its Lrnpact, Journal of Adolescent Health Care 10:283-288, 1989. Carlin, E., The Youth in Transition Project, University of Washingto& Assessment of Adolescents With Special Needs: A Guide for Transition Planning (Seattte, WA: Division of Adolescent Medicine, Child Development and Mentat Retardation Center, University of Washington, 1987). 11. 12. 13. 14, 15, 16. 16a. 17. 18. 19. 20. 21. 22. 23. 24. 25. 26. 27. 28. 29. 30. 31. 32. Cholst, I.N., and Carlon, A.T, Oral Contraceptives and Dysmenorrhea, Journal of Adolescent Health Care 8:121-128, 1987. Cire, B., They Try, No Matter What! A Program for lkens With Chronic Illnesses and Disabilities Improves Their Job Skills, In&pendent Living 4(2):89-93, 1989. Civiq C.I., Reducing the Cost of the Cure in Childhood kdmrnkL New England Journal of Medicine 321:185-187, 1989. Cohen, Ml., ChaimmL Department of Pediatrics, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, NY, personal communication% June 1990. Corcow R., and Portnoy, B., Risk Reduction Through Comprehensive Cancer Education: The American Cancer Society Plan for Youth Educatiou Journal ofSchoolHealth 59(5): 199-204,1989. Dakatis, P., Charles Schulz: Why Charlie Brown, Why? Cancer News 43(3):9, 1989. Dorlands Illustrated Medical Dictionary (Philadelphia, PA: W.B. Saunders Co., 1988). Ezzati, T., Mathematical Stadsticiaq Division of Health Examination Statistics, National Center for Health Statistics, Centers for Disease Control, Public Health Service, U.S. Department of Health and Human Services, memorandum to the Office of Ikchnology Assessmen~ Washington DC, Oct. 1, 1990. Fireman, P., Friday, G.A., Gir~ C., et al., Timching SelfManagement Skills to Asthmatic Children and Their Parents in an Ambulatory Care Setting, Pediatrics 68:341-348, 1981. Freudenberg, N., Feldmm C.H., Clark N. M., et al., The Impact of Bronchial Asthma on School Attendance and Pdormance, Journal of School Health 9:522-526, 1980. FriI. M., and Liw LF., Adolescents Compliance With Therapeutic Regimens: Psychological and Social Aspects and Intervention Journal oftilescent Health Care 8:52-67, 1987. Fritz, G., and Williams, J., Issues of Adolescent Development for Survivors of Childhood Cancer, Journal of the American Academy of Child and Adolescent Psychiatry 27(6):712-715, 1988. GergeL P.J., and Weiss, K.B., Changing Patterns of Asthma Hospitalization Among Children: 1979 to 1987, Journal of the American Medical Association 264(13):1688-1692, 1990, Gihnore, G.D., Sunscreens: A Review of the Skin Cancer Protection Value and Educational Opportunities, Journal of School Health 59:210-213, 1989. Gittler, J., Community-Based Service Systems for Children With Special Health Care Needs and Their Families: U.S. Surgeon Generals Conference, Campaign (Iowa City, IA: National Maternal and Child Health Resource Center, University of Iowz 1988). Gortmaker, S.L., Demography of Chronic Childhood Disease, Issues in the Care of Children With Chronic Illness, N. Hobbs and J.M. Perrin (eds.) (San Francisco, CA: Jossey-Bass, 1985). Gortmaker, S.L., Senior Lecturer and Acting Chairrnq Department of Behavioral Sciences, Harvard School of Public HealtlL Cambridge, MA, personal communication June 20, 1990. Gortmaker, S.L., and Sappentleld, W., Chronic Childhood Disorders: Prevalence and Impact+ Pediamc Clinics Uf North Amenca 31(1):3-18, 1984. Gortmaker, S.L., Walker, D. K., Weit+ M., et al., Chronic Conditions, Socioeconomic Risks, and Behavioral Problems in Children and Adolescents, Pediamcs 85:267-276, 1990. Greenberg, H. S., Kazak, A. E., and Meadows, A. T., Psychologic Functioning in 8to 16 Year-Old Cancer Survivors and Their Parents, Journal of Pediamcs, 114:488-493, 1989. Greydanus, D., Acne Vulgaris: Pathway to the Adolescent, Adolescent Health Upahte 2(1):1-2,5 1989. Hobbs, N., Perr@ J. M., and Ireys, H. T., Chronically Ill Children and Their Fanfies (San Francisco, CA: Jossey-Bass, 1985). Hodgso% C., FeId+ W., Corber, S., et al., Adolescent Health Needs: Perspectives of Health Professionals, Canadian Journal of Public Heaith 76: 167-170, 1985.
PAGE 188
Chapter 6-Chronic Physical Illnesses: Prevention and Services //-187 33. Hofman, A., and Greydanus, D., Adolescent Medicine (Norwalk, CT: Appleton & Lange, 1989). 34. Houk V. N., and Thacker, S.B., The Centers for Disease Control 35. 36. 37. 38. 39. 40. 41. 42. 43. 44. 45. 46. 47. 48. 49. 50. 51. 52. 53. Program To Prevent Primary and Secondary Disabilities in the United States, Public Health Reports 104(3):226-231, 1989. Interstate Research Associates, Disabilities Which Qualify children for Special Education Services Under Public Law 94-142, Fact Sheet, available from the National Information Center for Children and Youth With Handicaps, Washington, DC, September 1988. Interstate Research Associates, General Information About Public Agencies, Fact Sheet, available from the National Information Center for Children and Youth With Handicaps, Washington DC, September 1988. Jacobs, P., and McDermott, S., Family Caregiver Costs of Chronically 111 and Handicapped Children: Method and Literature Review, Public Health Reports 104(2):158-163, 1989. Jamisom R., Lewis, S., and Burisk T, Cooperation With Treatment in Adolescent Cancer Patients, Yourna/ of Ado/escenf Hea/th Care 7:162-167, 1986. JohnsorL J., Level of Knowledge Among Adolescent Girls Regarding Effective Treatment for Dysmenorrh~, Journal 0$ Adolescent Health Care 9:398-402, 1988. Jordan+ J., Errna Bombeck: Touting the Triumphs, Cancer News 43(3):5-6, 1989. Kaplm S., Busner, J., Weinhold, C., et al., Depressive Symp toms in Children and Adolescents With Cancer: A Imngitudinal Study, Journal of the American Academy of Child and Adolescent Psychiatry 26(5):782-787, 1987. Kessell, M., ResnicL M., and Blum, R., Adventure, Etc.A Heatth-Promotion Program for Chronically Itt and Disabled Youti Journal of Adolescent Health Care 6:433-438, 1985. Klein, J. R., and Litt, I.F., Epidemiology of Adolescent Dysmenorrhea, Pediamcs 68:661-664, 1981. Kle~ L. V., School Absenc&A Health Perspective, Pediamc Clinics of North America 35(6):1253-1269, 1988. Kronic~ R., Adolescent Health Insurance Status: Analyses of Trends in Coverage and Preliminary Estimates of the Effects of an Employer Mana%te and Medicaid Expansio@ackground Paper prepared under contract to Carnegie Councit on Adolescent Development and Carnegie Corporation of New York, for the Office of Technology Assessment, U.S. Congress, OTA-BP-H-56 (Washington DC: U.S. Government Printing Office, July 1989). Laski B., and Matthew, D., Childhood Asthma: A Controlled Trial of Family Psychotherapy, Archives of rhe Diseases of Chifdhood 54:1 16-119, 1979. Litt, I., Menstrual Problems During Adolescence, Pediamcs in Review 4(7):203-212, 1983. Litt, I., The Health of Adolescent Women in the 1980s, Western Journal of Medicine 149:696-699, 1988. Magrab, P. R., and Millar, H. E. C., Surgeon Generals Conference: Growing Up and Getting Medical Care: Youth With Special Health Care Needs: A Summary of Conference Proceedings (Washington DC: National Center for Networking Community Based Services, Georgetown University Child Development Center, March 1989). Malus, M., LaChance, P.A., Lamy, L., et al., Priorities in Adolescent Health Care: The Teenagers Viewpoin6 Journal of Family Practice 25:159-162, 1987. hfNklO, L., and I.&vy, S., m ~d Seconda.fy Prevention of Cancer in Children and Adolescents: Current Status and Issues, Pediatric Clinics of North America 33(4):975-993, 1986. McAnarney, E. R., Social Maturation: A Challenge for Handicapped and Chronically 111 Adolescents, Journal of Adolescent Health Care 6(2):9(L101, 1985. McLaughlin, J., Nail, M., Isaacs, B., et al., The Relationship of Allergies and Allergy Treatment to School Perfo rmance and Student Behavior, Anna/s of Affergy 51:506510, 1983. 54. 55. 56. 57. 58. 59. 60. 61. 62. 63. 64. 65, 66. 67. 68, 69, 70. 71 72, 73. 74. 75, Metheny, W. P., and Smith, R. P., The Relationship Among Exercise, Stress, and Primary Dysmenorrhea, JournaZ of Behavioral Medicine 12:569-586, 1989. Miller, L.P., and Miller, D., The Pediatricians Role in Caring for the Child With Cancer, Pediatric Clinics of North America 31(1):119-131, 1984. Monaco, G.P., Parent Self-Help Groups for Families of Children With Cancer, Ca-A Cancer Journal for Clinicians 38(3):169175, 1988. Mulne, A., and Koepke, J., Adverse Effects of Cancer Therapy in Childrem Pediatncs in Review 6(9):259-268, 1985. National Academy of Sciences, National Research Council, Committee on the Status of Black Americans, Commision on Behavioral and Social Sciences and EdueatiorL A Common Destiny: Blacks and American Society, G.D. Jaynes and R.M. Williams (eds.) (Washington, DC: National Academy Press, 1989). Neinste@ L. S., Adolescent Health Care (Baltimore, MD: Urban & Schwarzenberg, 1984). Nelso@ C., Ambulatory Care Survey, National Center for Health Statistics, Centers for Disease Control, Public Health Semice, U.S. Department of Health and Human Services, Hyattsville, MD, personal communication Apr. 14, 1989. Nelsou R.P., Political and Financial Issues That Affect the Chronically Ill Adolescent, Chronic Illness and Disabilities in Chifdhood and Adolescence, R.W. Blum (cd.) (Orlando, FL: Grune & Strattou 1984). Newacheclq P., Adolescents With Special Health Needs: Prevalence, Severity, and Access to Health Services, Pediatrics 84(5):872-881, 1989. Newacheclq P., Budetti, P.P., and Halfon, N., Trends in Activity-Limiting Chronic Conditions Among Children, Amencan Journal of Public Health 76:178-184, 1986. NewachecL P., Budetti, P.P., and McManus, P., Trends in Childhood Disability, American Journal of Public Health 74:232-236, 1984, Newacheclq P., and McManus, M., Financing Health Care for Disabled Childreq Pediamcs 81(3):385-394, 1988. NewachecQ P., and McMimus, M., Health Care Expenditure Patterns for Adolescents, Journal of Adolescent Health Care 1 1:133-140, 1990. Nida, A., Bone Marrow Transplant Coordinator, Bone Marrow Transplant Center, Georgetown University Hospital, Washington DC, pemonal communication Sept. 19, 1990. NOIW T., Zvagulis, 1., and Pless, B., Controlled Trial of Social Work in Childhood Chronic Illness, Lancet 2(8556):41 1-415, 1987. Pendergrass, T., Chard, R., and Hartmu J., Leukemia, Issues in the Care of Children With Chronic Illness, N. Hobbs and J.M. Perrin (eds.) (San Francisco, CA: Jossey-Bass, 1985). Perr@ J. M., IntroductiorL Issues in the Care of Children With Chronic Illness, N. Hobbs and J.M. Perrin (eds.) (San Francisco, CA: Jossey-Bass, 1985). Pe@ J. M., Homer, C.J., Berwic~ D. M., et al., Wriations in Rates of Hospitalization of Children in Three Urban Communities, New England Journal of Medicine 320(18):1 183-1187, 1989. Pless, I.B., and Per@ J. M., Issues Common to a Mriety of Illnesses, Issues in the Care of Children With Chronic Illness, N. Hobbs and J.M. Perrin (eds.) (San Francisco, CA: Jossey-Bass, 1985). Pless, I.B,, and Satterwhite, B., Chronic Illness in Childhood: Selectiou Activities, and Evaluation of Non-Professional Family Counselors, Clinical Pediamcs 11:403-410, 1972. Portnoy, B., and Christenson G. M., Cancer Knowledge and Related Practices: Results From the National Adolescent Student Health Survey, Journal of School Health 59(5):218-224, 1989. Price, J., Desmond, S., Wallace, M., et al., Differences in Black and White Adolescents Perceptions About Cancer, Journal of
PAGE 189
//-188 Adolescent HealthVolume II: Background and the Effectiveness of Selected Prevention and Treatment Services 76. 77. 78. 79. 80. 80a. 81. 82. 83. 84. 85. 86. 87. 88. 89. 90. 91. 92. 93. 93a. 93b. 94. School Health 58(2):6670, 1988. Quigley, C., Cowell, C., Jimenez, M., et al., Normal or Early Development of Puberty Despite Gonadal Damage in Children Treated for Acute Lymphoblastic Leukemia, New England Journal of Medicine 321(3):143-151, 1989. Robert Wood Johnson Foundation Adolescents, Making Connections: A Summary of Robert Wood Johnson Foundation Programs (Princeton, NJ: Fall 1989). Schechter, N. L., AltrnmL A., and Weisu S. (eds.), Report of the Consensus Conference on the Management of Pain in Childhood Cancer, Pediatncs 86(5) :Suppl., November 1990. Shu, X. O,, Gao, Y.T, BrintoL L.A., et al., A Population-Based Case-Control Study of Childhood Leukemia in Shanghai, Cancer 62:635-644, 1988. Siegel, D.M., Adolescents and Chronic Illness, Journal of the American Medical Association 257(24):3396-3399, 1987. Solomom G.F., The Emerging Field of Psychoneuroimmunology, Advances 2(1):6-19, 1985. Smyth-Staruchj K., Breslau, N., Weitzmm M., et al., Use of Health Services by chronically Ill and Disabled Children, Medical Care 22(4):310-328, 1984. Ste@ R, E.K., and Jessop, D.L., Does Pediatric Home Care Make a Difference for Chitdren With Chronic Illness: Findings From the Pediatric Ambulatory Care Treatment Study, Pediatrics 73:845853, 1984. Stone, A., Childhood Cancer Today: Helping Us Help Children, Cancer News 43(3):2, 1989. Strauss, J., Update on Acne, Primary Care 14(1):167-176, 1987. Tebbi, C., Richards, M., Cummings, M., et al., The Role of Parent-Adolescent Concordance in Compliance With Cancer Chemotherapy, Adolescence 23(91):599-61 1, 1988. Trcadwell, P., Isotretinoin: The Pros and Cons of Accutane, Adolescent Health UpAte 2(1):6, 1989. Tbrnball, A. P., and llu-nball, R. T., Developing Independence, Journal of Adolescent Health Care 6: 108-119, 1985. University of Minnesota Adolescent Health Program, The State of Adolescent Health in Minnesota (Minneapolis, MN: University of Minnesota, February 1989). U.S. Congress, Library of Congress, Congressional Research Service, S ummary of the Education of the Handicapped Act Amendments of 1986, P.L. 99457, prepared by C.J. Fraas, Washington DC, October 1986. U.S. Congress, Library of Congress, Congressional Research Service, Tax Code Provisions of Interest to the Disabled and Handicapped, prepared by L.A. Talley, Washington DC, August 1987. U.S. Congress, Library of Congress, Congressional Research Service, Developmental Disabilities Programs: Statutory Authority and Program Operations, prepared by M. SmitlL WashiIlgtO@ DC, January 1988. U.S. Congress, Office of lkchnology Assessment, Technology and Handicapped Peep/e, OTA-H-179 (Washingto% DC: U.S. Government Printing Office, May 1982). U.S. Congress, OffIce of Technology Assessmen6 Healthy Children: Investing in the Future, OTA-H-345 (Washingto& DC: U.S. Government Printing OffIce, Februmy 1988). U.S. Congress, Office of lkchnology Assessmen4 The Use of Preventive Services by the Elderly (Washington, DC: Office of Technology Assessment, U.S. Congress, January 1989). U.S. Department of Commerce, Bureau of the Census, U.S. Population Estimates, by Age, Sex, Race, and Hispanic Origin: 1989, Current Population Reports, Population Estimates and Projections, Series P-25, No. 1057 (Washington, DC: U.S. Government Printing Office, 1990). U.S. Department of Hcal@ Education, and Welfare, Examination and Health History Findings Among Children and Youths, 6-17 Years: United States, Vital and Health Statistics: Data 95. 96. 97. 98. 99. 100. 101, 102. 103. 104. 105. 106. 107. 107a. 108, From the National Health Survey, Series 11, No. 129, DHEW Pub. No. @IRA) 74-1611 (Rockville, MD: November 1973). U.S. Department of HealtlL Educatiom and Welfare, SelfReported Health Behavior and Attitudes of Youths, 12-17 Yars: United States, Vital and Health Statistics: Data From the National Hea/th Survey, Series 11, No. 147, DHEW Pub. No. (HRA) 75-1629 (Rockville, MD: April 1975), U.S. Department of Health and Human Services, Health Information Policy Co~,nci~ Health Data Inventory: Fiscal Years 198319&, January 1984. U.S. Department of Health and Human Services, Office of the Swretary, Secretarys Task Force on Black and Minority HedtlL Report of the Secretarys Task Force on Black and Minority Health: Volume 111, Cancer (Washington DC: U.S. Government Printing OffIce, 1986). U.S. Department of Health and Human Services, Public Health Service, Centers for Disease Control, Results From the National Adolescent Student Health Survey, Morbidity and Mortality Weekfy Report 38(9):147-150, Mar. 10, 1989. U.S. Department of Health and Human Services, Public Health Service, Centers for Disease Control, National Center for Health Statistics, Final Clearance Package for the Third National Health and Nutrition Ex amination Swey, Hyattsville, MD, no date. U.S. Department of Health and Human Services, Public Health Service, Centers for Disease Control, National Center for Health Statistics, National Hospital Discharge Survey Diagnostic Recodes for ICD-9-CM, Hyattsville, MD, June 1989. U.S. Department of Health and Human Services, Public Health Service, Centers for Disease Control, National Center for Health Statistics, unpublished 1985 data from the National Ambulatory Medical Care Survey, Hyattsville, MD, 1989. U.S. Department of Health and Human Services, Public Health Service, Centers for Disease Control, Nationat Center for Health Statistics, unpublished 1987 data from the National Hospital Discharge Survey, Hyattsville, MD, 1989. U.S. Department of Health and Human Services, Public Health Service, Centers for Disease Control, National Center for Health Statistics, unpublished 1986 mortality da@ Hyattsville, MD, 1989. U.S. Department of Health and Human Services, Public Health Service, Centers for Disease Control, National Center for Health Statistics, Health, United States, 1988, DHHS Pub. No. (PHS) 89-1232 (Washington DC: U.S. Government Printing Office, March 1989). U.S. Department of Health and Human Services, Public Health Service, Centers for Disease Control, National Center for Health Statistics, Current Estimates From the National Health Interview Suwey, 1988, Viral and Health Statistics, P.F. Adams and A.M. Hardy (eds.), DHHS Pub. No. (PHS) 89-1501 (Hyattsville, MD: October 1989). U.S. Department of Health and Human Services, Public Health Service, Centers for Disease Control, National Center for Health Statistics, Health, United States, 1989, DHHS Pub. No. (PHS) 9@1232 (Washington DC: U.S. Government Printing Office, 1990). U.S. Department of Health and Human Services, Public Health Service, Centers for Disease Control, National Center for Health Statistics, unpublished 1988 data from the National Health Intemiew Survey, Hyattsville, MD, 1990. U.S. Department of Health and Human Services, Public Health Service, National Center for Health Statistics, Disability and Health: characteristics of Persons by Limitation of Activity and Assessed Health Status, United States, 1984-88, Advance Data From Vital and Health Statistics, No. 197, DHHS Pub. No. (PHS) 91-1250, May 21, 1991. U.S. Department of Health and Human Services, Public Health Service, National Center for Health Statistics, Hospital Care Statistics BrancL Summary: National Hospital Discharge
PAGE 190
Chapter 6--Chronic Physical illnesses: Prevention and Services l II-189 survey, Ad\ance Duta From Vital and Health Statistics, No. 159 (Rev.) DHHS Pub. No. (PHS) 88-1250, 1988. 109. U.S. Department of Health and Human Services, Public Health Service, Health Resources and Services Administration, Bureau of Hcxdth Cam Delivery ,and Assistance, Division of Maternal and Child Health, Surgeon Generals Report: Children With Special Health Care Needs, Campaign DHHS Pub. No. HRS/D/MC 87-2 (Rockvillc, MD: 1987). 110. U.S. Department of Health and Human Services, Public Health Service, National Institutes of Health, National Cancer Institute, 1987 Annual Cancer Sf[ztistics Review, DHHS Pub. No. (PJIH) 88-2789 (Bethcsdz MD: February 1988). 111. U.S. Department of Health and Human Services, Public Health Service, National Institutes of Health, National Cancer Institute, unpublished Surveillance, Epidemiology, and End Resul[s (SEER) program data, Bethesda, MD, 1989. 112. U.S. Department of Health and Human Services, Public Health ScrvIcc, National Institutes of Health, National Cancer Insti[ute, response to 1989 Office of Technology Assessment questionnaire regarding adolescent health initiatives, 1989. 113, Wadhw~ S., and Gelband, H., Unrelated Bone Marroti) Transplan~s in the United Stutes. Pofic> Issues From a Patient Perspecfl\e-$tajf faper (Washington, DC: Office of Technology Assessment, U.S. Congress, March 1990). 114. Wagner, K., and Wagner, R,, Impact of Acne on Sexuality, Medical Aspects of Human Sexuality 19(6):252-255, 1985. 115. Wasserman, A., Thompson, E,, Wilimas, et al., The Psychological Status of Survivors of Childhood/Adolescent Hodgkins Disease, American JourrtulqfDiseases qfChildren 141:626-631, 1987. 116. Weinstoc~ M. S., Colditz, G. A., Willett, W. C,, et al., Nonfamilial Cutaneous Melanoma Incidence in Women Associated With Sun Exposure Before 20 Years of Age, Pediatrics 84(2): 199204, 1989, 117. Wcitzman, M,, Klermw L. V., Alperl, J.J., et al., Factors Associated With Excessive School Absence, Pediatrician 13:74 80, 1986. 118. White, P., Director, Adolescent Employment Readiness Center, Childrens Hospital National Medical Center, Washington DC, personal communication, Sept. 25, 1990. 119. WilsoU C., Emans, S. J., Mansfield, J,, et al,, The Relationships of Calculated Body Fat, Sports Participation, Age, and Place of Residence on Menstrual Patterns in Healthy Adolescent Girls at an Independent New England High School, JournaZ of AdoZescenf Health Care 5:248-53, 1984. 120, Wilson, C., and Keye, W. R., A Survey of Adolescent Dysmenorrhea and Premenstrual Symptom Frequency, Journal of Ado/escenf Health Care 10:317-322, 1989.
PAGE 191
Chapter 7 NUTRITION AND FITNESS PROBLEMS: PREVENTION AND SERVICES Contents Page Introduction . . . . . ., . . . ., . . . . . . . . 193 Background on Adolescent Nutrition and Fitness . . . . . . . . . . 193 Adolescents Nutritional and Physical Fitness Needs.... . . . . . . . . 193 Definitional Issues . . . . . . . . . . . . . . . . 193 Nutritional Needs . . . . . . . . . . . . . . . . 193 Physical Fitness and Activity Needs . . . . . . . . . . . . 202 Adolescents Nutrition and Fitness Problems . . . . . . . . . . 202 Nutritional Deficiencies . . . . . . . . . . . . . . . 202 Inadequate Dietary Fiber . . . . . . . . . . . . . . 203 Excessive Consumption of Fat, Cholesterol, Sodium, and Low-Nutrient Density Foods... 205 Low Levels of Physical Activity . . . . . . . . Obesity or overweight . . . . . . . . . . Conclusions . . . . . . . . .. .. $ . . . Consequences of Adolescent Nutrition and Fitness Problems . . Immediate Consequences of Nutritional and Fitness Problems During Risk of Chronic Diseases Later in Life..... . . . Conclusions . . . . . . . . . . Adolescents With Particular Nutritional and Fitness Problems Pregnant Adolescents . . . . . . . . Adolescent Athletes . . . . . . . . Adolescents With Eating Disorders.. . . . . . . . . . . . . . ., . . . . Adolescents With Chronic Conditions and Physical Disabilities . Adolescents With Mental Retardation or Developmental Disabilities Emotionally Ill Adolescents . . . . . . . . . Conclusions . . . . . . . . . . . . Prevention and Treatment of Nutrition and Fitness Problems . . . Adolescents Nutritional Choices . . . . . . . . Influencing Adolescents Nutritional Choices . . . . . . . . . . 206 . . . . 208 . . . . 208 . . . . 209 Adolescence . 209 . . . . 210 . . . . 211 . . . . 211 . . . . 211 . . . . 212 . . . . 213 . . . . 214 . . . . 215 . . . . 215 . . . . 215 . . . . 215 . . . . 215 . . . . 216
PAGE 192
Health Education . . . . . . . . . . . . . . . . 216 Food Labels . . . . . . . . . . . . . . . . . 217 Menus in Schools and Institutions . . . . . . . . . . . . 217 Conclusions . . . . . . . . . . . . . .; . . . 217 Influencing Adolescents Physical Activity Levels . . . . . . . . . 217 Physical Education in Schools . . . . . . . . . . . . . 217 Community Facilities for Physical Activities . . . . . . . . . . 217 Conclusions . . . . . . . . . . . . . . . . . 217 Interventions To Prevent or Reduce Adolescent Obesity . . . . . . . . 218 Major Federal Programs Related to Nutrition and Fitness . . . . . . 219 U.S. Department of Agriculture . . . . . . . . . . . . . . . 219 U.S. Department of Health and Human Services . . . . . . . . . . 219 Centers for Disease Control . . . . . . . . . . . . . . 220 National Institutes of Health . . . . . . . . . . . . 220 Conclusions and Policy Implications . . . . . . . . . . . . . 221 . Chapter preferences . . . . . . . . . . . . . . . . 222 Boxes Box Page 7-A. Federal Data Collection Efforts Related to Adolescent Nutrition . . . . . . 194 7-B. Biological Functions of Dietary Substances . . . . . . . . . . 196 7-C. Broad Nutritional Guidelines That Provide Guidance Beyond Recommended Daily Allowances . . . . . . . . . . . . . . . . . 201 7-D. Healthy People 2000 Objectives Pertaining to Adolescents Physical Activity and Nutrition . . . . . . . . . . . . . . . . . 204 Figures Figure Page 7-1. Percentage of U.S. Students in lst Through 12th Grade Receiving Daily Physical Education, 1984-86 . . . . . . . . . . . . . . . . . . 206 7-2. Prevalence of Anemia Among U.S. Women During the Third Trimester of Pregnancy, by Race and Age, 1987 . . . . . . . . . . . . . . . 212 7-3. Prevalence of Anemia Among U.S. Women During the Third Trimester of Pregnancy, by Race and Trimester of Enrollment in Public Health and Nutrition Programs, 1987 . 212 Tables Table Page 7-l. Weight and Height of U.S. Males and Females Ages 10 to 18 . . . . . . 198 7-2. NAS Recommended Dietary Allowances for Protein, Vitamins, and Minerals for U.S. Males and Females Ages ll to 24, 1989 . . .,,.... . . . . . . 199 7-3.NAS Estimated Ranges of Safe and Adequate Daily Dietary Intakes of Additional Viatmins and Minerals for Adolescents Ages 11 and Over . . . . . . . . . 199 7-4. NAS Recommended Daily Energy Intakes for Males and Females Ages ll to 24 of Median Weights and Heights, 1989... . . . . . . . . . . . 200 7-5. Average Daily Nutrient Intake as a Percentage of the 1980 RDAs Among U.S. Adolescents Ages 9 to 18,1977-78 . . . . . . . . . . . . . . . 203 7-6. Nutritional Values of Seven Sample Fast-Food Meals . . . . . . . . 207 7-7. Examples of Chronic Diseases and Conditions With Nutrition and Fitness Implications Among U.S. ChildrenAgesOto 20, 1980 . . . . . . . . 214 7-8. Participation in the National School Breakfast and School Lunch Programs, 1983-84 School Year . . . . . . . . . . . . . . . . . 220
PAGE 193
Chapter 7 NUTRITION AND FITNESS PROBLEMS: PREVENTION AND SERVICES 1 Introduction Adolescence is a period of biological and social change, and because of the changes that they undergo (e.g., in their size, body composition, body functions, physical abilities, and life styles) and other individual factors, adolescents as a group and as individuals have special nutritional and, possibly, fitness needs. Nutrition and physical activity during adolescence can influence the process of physical growth and development. Evidence concerning the impact of adolescent dietary patterns on the occurrence of chronic diseases in adulthood is very limited, but there is some evidence to suggest that dietary patterns are important factors in the occurrence of some major chronic diseases (e.g., atherosclerotic cardiovascular diseases and hypertension, certain forms of cancer, obesity, non-insulindependent diabetes, and dental caries) and that dietary modifications can reduce the risk of some of these diseases (152). The changing nutritional needs and physical abilities of adolescents as a group are addressed in this chapter, as are the nutritional and other needs of certain subgroups of adolescents (e.g., adolescents with diabetes, adolescents with physical disabilities). Also described in this chapter are selected Federal programs related to the nutritional health and physical fitness status of U.S. adolescents. The chapter ends with conclusions and implications for public policy. Background on Adolescent Nutrition and Fitness Adolescents Nutritional and Physical Fitness Needs Definitional Issues Good nutrition is a somewhat elusive concept not easily defined or determined. It is generally agreed, however, that good nutrition embraces the principles of sufficiency, variety, balance, and moderation (59a). Especially in large population groups, research tools cannot capture or interpret all the interrelated aspects of food intakes and nutritional outcomes; most studies instead focus on substitute measures (e.g., specific nutrient consumption or dietary attitudes). Physical fitness is defined in various ways. In the not too distant past, a person with obvious motor (or athletic abilities)--defined in terms of muscle strength, agility, speed, and powerwas considered physically fit. Recently, however, the concept of physical fitness has been undergoing a major change. According to a 1987 American Academy of Pediatrics statement, physical fitness is now considered to include five components: 1) muscle strength, 2) muscle endurance, 3) flexibility, 4) body composition (i.e., ratio of lean body mass to fat), and 5) cardiorespiratory endurance (4). Many available studies focus on proxy measures of fitness, such as performance on standardized tests of fitness. Several major Federal sources of data on nutritional status, food and nutrient consumption, and other information related to adolescent nutrition are identified in box 7-A. Nutritional Needs The human body requires for health the intake of water, amino acids from protein, vit amins, minerals, fatty acids, and sources of calories (protein, carbohydrate, and fat) (226) (see box 7-B). A physiologic diet provides intakes of each essential nutrient between the two thresholds of minimal requirement and maximal tolerance (186). The minimal requirement is defined as the smallest quantity of an essential nutrient that maintains normal mass, chemical composition, morphology, and physiologic functions of the body and prevents any clinical or biochemical sign of the correspond1~1~ ~~pter is not ~ ~x~u~tive ~o~pendium of ~1 ~d~le~cent ~u~tion ~d fi~ess issues. ~tead, is p~ose is to f~us on Wht appear tO be the major problems associated with nutrition and fitness affecting many American adolescents. me focus of this OTA Repo~ for reasons noted in Vol. I, Summa-y ad PoZicy Implications, is on 10through 18-year-olds. Some of the data presented in this chapter are for other age groupings, because data for 10 through 18-year-olds are not readily available. -II-193--
PAGE 194
II-194 Adolescent HealthVolume II: Background and the Effectiveness of Selected Prevention and Treatment Services Box 7-AFederal Data Collection Efforts Related to Adolescent Nutrition Several federally sponsored national surveys l gather information on health and nutritional status measurement.s, 2 food and nutrient consumption measurements, food composition measurements, dietary knowledge and attitude assessments, food supply determinations, sociodemographic and economic measurements, and other relevant data. A number of the surveys sponsored by the U.S. Department of Health and Human Services and the U.S. Department of Agriculture are discussed below. Several of the surveys are components of the National Nutritional Monitoring System, a Federal assessment system that allows continuous nutrition monitoring through complementing, periodic surveys. U.S. Department of Health and Human Services (DHHS): 3 l National Health and Nutrition Examination Survey (NHANES): NHANES is one component of the National Nutrition Monitoring System. This survey, conducted by the National Center for Health Statistics (NCHS) in DHHS, obtains health-related data by means of direct physical examination, clinical and laboratory tests, and related measurement procedures (232). A major goal of NHANES I (1971-74) was to measure and monitor indicators of the nutritional status of the America people through dietary intake data, biochemical tests, physical measurements, and clinical assessments for evidence of nutritional deficiency. The target population was the civilian, noninstitutionalized U.S. population ages 1 through 74. NHANES II (1976-80) had a nutrition component that was nearly identical to the NHANES I. Neither NHANES I nor NHANES II had an adequate adolescent sample. NHANES III is now in progress. It is collecting some adolescent-specific data, but results are not expected until 1994. Hispanic HANES (1982-84): NCHS conducted this survey on about 76 percent of the Hispanic adult population (187). l National Health lnterview Survey (NHIS): This survey, conducted by NCHS, uses personal household interviews to collect data on personal and demographic characteristics, utilization of health resources, and a variety of health topics from a sample of the civilian, noninstitutionalized U.S. population. It will include a special supplement on adolescent health in 1991, 1995, and 2000. Total Diet Study: This study, by the Food and Drug Administration, gathers information on intakes of pesticides, toxic substances, radionuclides and industrial chemicals, as well as or intakes of iodine, iron, sodium, potassium, copper, magnesium, and zinc, for males and females ages 6 to 11 months, 2 years, 14 to 16 years, 25 to 30 years, and 60 to 65 years. Youth Risk Behavior Surveillance System (YRBSS) (to be implemented in 1991, 1995, and 2000): This system, recently developed by the Centers for Disease Control in DHHS, will monitor the prevalence of IFor a M@ of F~e~ nutrition monito@ and weihnce activities, see NwrTfion Monitoring in the United Srates: The Directory of Federal Numtion A40rutoring Activities (243). 2~ ~en~, & v~idi~ ~d ~li~iliy of ~~ts of dietary and of nutritional Shlhls USCSSmnts VW (~~ds -y ~ we~-t~~ but are limited (58)). Also, errors of inteqmtation of dietary intake data are common (18). 3F~er dew on tie JX-lHS system are provided in a report on the National NutritioMI Motito@ syst~ (256). ing deficiency state (186). In children and adolesNutritional needs during adolescence correlate cents, the minimal requirement also must meet an additional criterion: it must maintain an optimal rate of growth (186). The maximal tolerance for an essential nutrient is an important consideration for individuals taking dietary supplements, which may be harmful at certain levels. Factors that influence the minimal requirement and maximal threshold for a nutrient include rate of growth, age, exercise, chemical composition of the diet, presence of certain diseases or physical conditions (e.g., diabetes, pregnancy), and intake of prescription drugs (186). closely with biological maturity (140). Adolescents should consume diets providing more total nutrients than younger children (131,203), because adolescents typically have a larger body and different body composition (e.g., a different ratio of lean body mass to fat). Adolescents experience gains in height and weight that alter their nutritional needs (see table 7-l). Females typically experience a pubertal height spurt between ages 10 and 13, and males experience a height spurt between ages 12 and 15 (200). This growth requires nutrients as structural materials. Changes in physiologic function that occur during
PAGE 195
.- .. Chapter 7Nutrition and Fitness Problems: Prevention and Services l II-195 priority risk behaviors among samples of school-aged adolescents by collecting data from a periodic school-based survey combined with special supplemental data from NHIS on youth risk behavior. U.S. Department of Agriculture (USDA): l Nationwide Food Consumption Survey (NFCS): This survey is one component of the National Nutrition Monitoring System. Conducted by USDAs Human Nutrition Information Service every 10 years, NFCS collects information on the general and low-income U.S. population ages O to 75 years and older (213a). The most recent survey, conducted in 1987-88, included the collection of information on foods used by households and eaten by individuals. l Continuing Survey of Food Intakes by Individuals (GSFII): This survey, like NFCS, is part of the National Nutritional Monitoring System. It is conducted by USDAs Human Nutrition Information Service. Initiated in 1985, it is designed to measure levels and changes in the food and nutrient content and nutritional adequacy of U.S. diets on a continuing basis (213a). In 1985 and 1986, the CSFII included all-income and low-income samples of women 19 to 50 years of age and their children 1 to 5 years of age. In 1985, the survey also included men 19 to 50 years of age. The CSFII was not conducted in 1987 and 1988. The 1989, 1990, and 1991 samples included men, women, and children of all ages. All CSFII samples are drawn from households in the 48 coterminus States and include a basic survey (households with incomes at any level) and a low-income survey (households with incomes at or below 130 percent of the Federal poverty level). The kinds and amounts of food ingested at home and away from home by individual household members are reported for 3 consecutive days using a l-day recall in an in-person interview and a 2-day diary. Diet and Health Know/edge Survey (DHKS): This survey, begun in 1989 as a followup to CSFII, targets food managers in households participating in CSFII. Its purpose is to link an individuals knowledge and attitudes about diet and health to his or her actual dietary behavior. National Evaluation of School Nutrition Programs: This survey, conducted only occasionally, provides information on U.S. adolescents eating patterns and use of school nutrition programs. Federally sponsored national surveys have several positive features: l the surveys provide population-based parameters of current nutritional status, the surveys identify some groups at risk and their nutritional problems; and the surveys contribute useful population-based information for national planning purposes. On the other hand, federally sponsored national surveys have a number of limitations including the following: Neither NHANES nor NFCS provides data on energy expenditures and fitness status. Subgroup sample sizes are not large enough to permit analyses and cross-tabulations using several variables (e.g., income, race, and sex); that is, adolescents with combinations of problems are not sufficiently targeted. Because of high nonresponse rates among very low-income, non-English-speaking people and because adolescents living in institutional settings are not included in the surveys, some problems may be underestimated. Nutritional status data are collected only periodically. adolescence also alter adolescents nutritional reof factors that include differences in body composiquirements. U.S. females, for example, typically begin menstruating at age 12 1 /2. Females who start menstruating have an increased requirement for iron due to menstrual losses (200,211). Changes in lifestyle, especially in physical activity, may also affect adolescents nutrient needs (142). Male or female adolescents who regularly participate in vigorous physical activity, for example, increase their energy needs. Nutritional needs for male and female adolescents of the same age are typically quite different because tion and function (90). But even adolescents of the same sex and age may have different nutritional needs. Adolescents mature at different rates, sometimes as a consequence of genetic endowment and sometimes as a result of environmental factors (e.g., chronic undernutrition slows height and weight growth and slightly delays puberty). Furthermore, as discussed later, some adolescents have diseases or special conditions (e.g., diabetes, thyroid conditions, or pregnancy) that alter their nutritional needs by changing the absorption, metabolism, or excretion of particular nutrients (212).
PAGE 196
II-196 l Adolescent HealthVolume II: Background and the Effectiveness of Selected Prevention and Treatment Services Box 7-BBiological Functions of Dietary Substances ProteinDietary protein provides a mixture of amino acids to replace the bodys continuous degradation of these substances and is also a metabolic fuel for energy. Sufficient protein intake is important for body growth, hair growth, blood and organ mass, muscle development, and proper balance of hormones and body fluids. Vitamins Vitamin AA group of compounds essential for vision, growth, cellular differentiation and proliferation, reproduction, and integrity of the immune system. Vitamin DEssential for proper formation of the skeleton and for mineral equilibrium. Vitamin EInhibits the oxidation of essential cell constituents and prevents the formation of toxic oxidation products. Primary deficiency of vitamin E is not found in otherwise healthy humans because of the wide distribution of the vitamin in foods, but secondary deficiency (which may result from intestinal malabsorption) is associated with reproductive failure, muscular dystrophy, and neurological abnormalities. Vitamin KEssential for the formation of proteins involved in the regulation of blood clotting, and for the biosynthesis of some other proteins found in the plasma, bone, and kidney. Vitamin CRequired for the formation and synthesis of collagen (an abundant protein of connective tissue). Deficiency may affect immune responses, wound healing, iron absorption, and allergic reactions. Often vitamin C deficiency results in scurvy, a serious disease in which the weakening of collagenous structures leads to capillary hemorrhaging. Thiamin (B-1)-Involved in the breakdown of carbohydrates. Deficiency can lead to beriberi, a disease affecting the cardiovascular and nervous systems and characterized by symptoms including mental confusion, muscle weakness, enlarged heart, and congestive heart failure. Riboflavin (B-2)-Participates in a variety of oxidation-reduction reactions and essential to the structure of some enzymes. Among the symptoms of deficiency are sore throat, excess blood and fluid in the mucous membranes, and angular stomatitis. Niacin-Also involved in oxidation-reduction reactions. Deficiency is associated with skin rashes, swelling and reddening of the tongue, dermatosis, diarrhea, and dementia. Vitamin B-6--Important in the metabolism of amino acids. Deficiency leads to dermatitis and depression in adults and seizure in infants. Folate-Designates a compound that plays an important role in amino acid metabolism and nucleic acid synthesis. Deficiency leads to impaired cell division and alterations of protein synthesis. Vitamin B-12Essential to metabolism. Deficiency can cause pallor, weight loss, diarrhea, optic neuritis, and mental changes. An important dietary standard used in the United specific nutrients, based on nutritional studies and States is the recommended dietary allowances (RDAs), expert judgment. 3 They are neither minimal requireestablished by the Food and Nutrition Board of the ments nor necessarily optional levels of intake. National Academy of Sciences (NAS) (153). The Rather, they are the levels of intake of essential 1989 RDAs for protein, vitamin s, and minerals for nutrients that, on the basis of scientific knowledge, U.S. males and females ages 11 to 14, ages 15 to 18, are judged by the Food and Nutrition Board to be and ages 19 to 24 are specified in table 7-2. RDAs adequate to meet the known nutrient needs of are recommendations for daily dietary intakes of practically all healthy people (153). 4 sl~ ~n~CiPl~, ~A~ ~~ b~~ on Vfiou ~& of evidence: 1) swdies of subjects maintained on diets containing 10W or deficient levels of a nu~ent, followed by correction of the deficit with measured amounts of the nutrient; 2) nutrient balance studies that measure nutrient status in relation to intake; 3) biochemical measurements of tissue saturation or adequacy of molecukw function in relation to nutrient intake; 4) nutrient intakes of fully breastfed infants and of apparently healthy people from their food supply; 5) epidemiological obsemations of nutrient status in populations in relation to intake; and 6) in some cases, extrapolation of data from animal experiments. In practice, there are only limited data on which estimates of nutrient requirements Call be based (153). 4~& apply t. he~~y ~emom o~y and do not cover SpeciaJ nutritio~ needs ~Sing from metabolic disorders, chronic diseases, Or Other ltlediCid conditions or drug therapies (153).
PAGE 197
Chapter 7Nutrition and Fitness Problems: Prevention and Services l II-197 Minerals CalciumEssentia.l for bone mineral formation. Bone undergoes constant resorption and formation throughout life. In childhood and adolescence, dietary calcium helps to build strong bones; in adults, when bone resorption exceeds formation, it slows the rate of bone loss. PhosphorusAn essential component of all cell protoplasm, aiding in biochemical synthesis and energy transfer. Phosphorus is a constituent of nervous tissue and bone. Magnesium-Modulates numerous biochemical and physiological processes. Deficiency may cause growth failure, behavioral disturbances, weakness, tremor, seizures or cardiac arrhythmias. IronA constituent of blood and a number of enzymes. Anemia and reduced resistance to infection are among the symptoms of deficiency. Zinc-A constituent of enzymes involved in most major metabolic pathways, Zinc intake affects appetite, growth, skin, and the immune system. IodineEssential part of the thyroid hormones. Deficiency can cause swelling of the thyroid gland (goiter), and excessive intake can cause depression of thyroid activity. Lipids FatsFats are an important energy source and help to facilitate the intestinal absorption of vitamins A, E, and D. Saturated and monounsaturated fats, however, are not essential to the diet because they can be synthesized by the body. Polyunsaturated fats are essential components of the diet, functioning as precursors to important structural lipids such as those found in cell membranes. CholesterolCholesterol is an important component of all cell membranes and a precursor to steroid hormones and bile acids in the liver, but is not essential to the diet because it can be synthesized by the body. salt---serves as the primary regulator of extracellular body fluid volume, It is also important in regulating acid-base balance and the membrane potential of cells, and is involved in active transport across cell membranes. CaloriesA calorie is a unit of quantity of heat, used to express the energy value of food. Energy requirements vary according to body size and composition, and level of physical activity. The level of energy intake from food balances energy expenditures and allows for necessary or desirable levels of physical activity. In children and pregnant or lactating women energy is also needed for the deposition of tissues or secretion of milk. If calorie intake is consistently above or below an individuals requirement, changes in body weight and composition will result. SOURCES: Office of Technology Assessment 1991, based on the following sources: National Academy of Sciences, National Research Council, Recommended Dietary Allowances, IOth ed. (Washington DC: Natiomd Academy Press, 1989); E. Braunwald, K.J. Isselbacher, R.G. Petersdorf, et al. (eds.), Harrisons Pnnciples oflnrernul Medicine, 1 lth ed. (New York NY: McGraw-Hill Book Co., 1988). In practice, there are only limited data on which height and weight (153). Recommended energy estimates of nutrient requirements can be based intakes for U.S. males and females ages 11 to 24 of (153). Traditionally, RDAs have been established for essential nutrients only when there are sufficient data to make reliable recommendations. For several nutrients for which there is insufficient information on which to base an RDA, the NAS Food and Nutrition Board publishes estimated safe and adequate ranges of daily intakes, as shown in table 7-3. In addition to listing RDAs for protein, vitamins, and minerals, the NAS publication Recommended Dietary Allowances lists recommended daily energy intake levels (caloric intake) for persons of median median heights and weights, by age and sex, are shown in table 7-4. The principal dietary sources of energy are carbohydrates, fat, and protein (153). Energy needs vary from person to person. An individuals energy requirements depend on how much energy the individual expends at rest, in physical activity, and as a result of the bodys adaptive response to heat (153). These, in turn, are affected by variables that include age, 5 sex, body size and composition, genetic factors, energy intake, physiologic state (e.g., growth, pregnancy, lactation), coexisting pathological conditions, and ambi5Rest1ng enern expendltue is ~]o@y correlated ~ifi le~ body mass, ~d MS V~CS by age, Activi~ pattern,s dSO VMY by age.
PAGE 198
11-198 l Adolescent HealthVolume II: Background and the Effectiveness of Selected Prevention and Treatment Services Table 7-lWeight and Height of U.S. Males and Females Ages 10 to 18 a Males, by percentile Weight, in kg (lb) Height, in cm (in) Age 5th 50th 95th 5th 50th 95th 10 11 12 13 14 15 16 17 18 24,33 26.80 29,85 33.64 38,22 43.11 47.74 51.50 53.97 31.44 (69.2) 35.30 (77.7) 39.78 (87.5) 44.95 (98.9) 50.77 (111.7) 56.71 (124.8) 62.10 (136.6) 66.31 (145.9) 68.88 (151.5) 45.27 51.47 58.09 65.02 72.13 79.12 85.62 91.31 95.76 127.7 132.6 137.6 142.9 148.8 155.2 161.1 164.9 165.7 137.5 143.3 149.7 156.5 163.1 169.0 173.5 176.2 176.8 (54.1) (56.4) (58.9) (61.6) (64.2) (66.5) (68.3) (69.4) (69.6) 148.1 154.9 162.3 169.8 176.7 181.9 185.4 187.3 187.6 Females, by percentile Weight, in kg (lb) Height, in cm (in) Age 5th 50th 95th 5th 50th 95th 10 24.36 32.55 (71.6) 47.1 7 127.5 138.3 (54.4) 149.5 11 27.24 36.95 (81.3) 54.0 0 133.5 144.8 (57.0) 156. 2 12 30.52 41.53 (91.4) 60.8 1 139.8 151.5 (59.6) 162. 7 13 34.14 46.10 (101 .4) 67.30 145.2 157.1 (61.9) 168.1 14 37.76 50.28 (1 10.6) 73.08 148.7 160.4 (63.1) 171. 3 15 40.99 53.68 (1 18.1) 77.78 150.5 161.8 (63.7) 172. 8 16 43.41 55.89 (123.0) 80.99 151.6 162.4 (63.9) 173. 3 17 44.74 56.69 (124.7) 82.46 152.7 163.1 (64.2) 173.5 18 45.26 56.62 (124.6) 82.47 153.6 163.7 (64.4) 173. 6 a~edata in this table Werecollected from nationality respective samples of individuals in three studies conducted by the National Center for Health Statistics of DHHS between 1962 and 1974. It is not intended that the figures in this table necessarily be considered standards of normal growth and development. SOURCE: Adapted from P.V.V. Hamiil, T.A. Drizd, C.L. Johnson, et al., Physical Growth: National Center for Health Statistics, American Journaiof Clinid Nutnlion 32:607-609, 1979, cited in National Academy of Sciences, National Research Council, Dietand Hedfh;/n@cations for Reducing Chronic Disease Risk (Washington, DC: National Academy Press, 1989). Reprinted by permission.
PAGE 199
Chapter 7Nutrition and Fitness Problems: Prevention and Services l II-199 Table 7-2NAS Recommended Dietary Allowances (RDAs) for Protein, Vitamins, and Minerals for U.S. Males and Females Ages 11 to 24, 1989 a RDAs for males (by age) RDAs for females (by age) Nutrient and unit of measurement 11-14 15-18 19-24b 11-14 15-18 19-24 b Protein, gm c . . . . . 45 Vitamins Vitamin A, micrograms RE d . . 1,000 Vitamin D, micrograms . . . 10 Vitamin E, mg . . . . . 10 Vitamin K, micrograms . . . 45 Vitamin C, mg . . . . . 50 Thiamin, mg . . . . . 1.3 Riboflavin, mg . . . . . 1.5 Niacin, mg NE e . . . . . 17 Vitamin B-6, mg . . . . . 1.7 Folate, micrograms . . . . 150 Vitamin B-12, micrograms . . 2.0 Minerals Calcium, mg . . . . . 1,200 Phosphorus, mg . . . . 1,200 Magnesium, mg . . . . . 270 Iron,m g . . . . . . 12 Zinc, mg... . . . . . 15 Iodine, micrograms . . . . 150 Selenium, micrograms . . . 40 59 1,000 10 10 65 60 1.5 1.8 20 2.0 200 2.0 1,200 1,200 400 12 15 150 50 58 46 1,000 10 10 70 60 1.5 1.7 19 2.0 200 2.0 800 10 8 45 50 1.1 1.3 15 1.4 150 2.0 1,200 1,200 1,200 1 ,200 350 280 10 15 15 12 150 150 70 45 44 800 10 8 55 60 1.1 1.3 15 1.5 180 2.0 1,200 1,200 300 15 12 150 50 46 800 10 8 60 60 1,1 1.3 15 1.6 180 2.0 1,200 1,200 280 15 12 150 55 aN~ritional requirements Vaw among itiividuals as a consequence of numerous genetic and environmental circumstances: RDAs are intended to provide for the needs of most healthy individuals living in the United States under normal environmental stresses (186). bTh e focus of this OTA Report is o n I@ through 18_year+lds. RDAs for 1 ~ to 2&year+lds are pmvid~ in this table for the purpose of comparison. cHealth~ ~ult~ require nin e ~s~ential amino acids in varying amounts each day. Dietary protein provides a rYliXtUre Of amino acids for endogenous protein synthesis and is also a metabolic fuel for energy (1 86). dRE retinol ~uivalents, One RE is equal to 1 microgram of retinol or 6 m~rograms C)f beta
PAGE 200
11-200. Adolescent HealthVolume II: Background and the Effectiveness of Selected Prevention and Treatment Services Table 7-4NAS Recommended Energy Intakes for Males and Females Ages 11 to 24 of Median Weights and Heights, 1989a Males Females Energy intakes Energy intakes Median Median Calories Total Median Median Calories Total weight height per kg calories weight height per kg calories Age b (kg) (cm) of body weight per day (kg) (cm) of body weight per day c Age 11-14 . . 45 157 55 2,500 46 157 47 2,200 Age 15-18 . . 66 176 45 3,000 55 163 40 2,200 Age 19-24 . . 72 177 40 2,900 58 164 38 2,200 aEnergy requirements of indivtiuals are affected by several variables, including level of physical activity, age, sex, body size and composition, genetic factors, physiologic state (e.g., growth, pregnancy, lactation), coexisting pathological conditions, and ambient temperature. Recommended energy allowances, in cxmtrast to RDAs for other nutrients (see table 7-2), are intended to meet the average needs of individuals. %he focus of this OTA Report is on 10through 18-year-olds. Recommended energy intakes for 19to 24-yea r-olds are provided in this table for the purpose of comparison. cFor prWnant females and for females who are breastfeeding, the recommended energy intakes are higher (300 calories more Per day for Pre9nant females in the second and third trimesters of pregnancy and 500 calories more per day for lactating females in the first year). SOURCE: Adapted from National Academy of scienees, National Research Council, Recommended Dietary A//owances, 10th ed. (Washington, DC: National Academy Press, 1989), p. 33. Reprinted by permission. females because of differences in the age of puberty, evolving activity patterns, and body composition. On average, energy needs for adolescent males are higher than for females. Pregnant and lactating females have higher food energy needs than other females, as shown in table 7-4. Data on the role of diet as a causal or contributing factor in chronic diseases have led some groups to issue dietary recommendations derived through approaches other than those used in developing RDAs for specific nutrients (153). Broad nutritional guidelines that provide guidance beyond that provided by RDAs were issued in the NAS report Diet and Health.. Implications for Reducing Chronic Disease Risk (152), in The U.S. Surgeon Generals Report on Nutrition and Health (242), and in Nutrition and Your Health: Dietary Guidelines for Americans published by the US. Department of Agriculture (USDA) and the U.S. Department of Health and Human Services (DHHS) (227). Those guidelines are summ arized in box 7-C. Among other things, these guidelines suggest restricting intakes of fat, saturated fat, cholesterol, sodium, sugar, and alcohol. Populations with high fat diets have more heart disease, certain types of cancer, and obesity (226). A diet low in saturated fatty acids and cholesterol can help maintain a desirable level of blood cholesterol, possibly reducing the risk for heart disease (226). Eating a diet with less salt (which contains sodium) may help some people reduce their risk of developing hypertension (high blood pressure). Sugars supply calories but are limited in essential nutrients and may increase the risk of tooth decay. Drinking alcohol is linked with a variety of chronic and other health problems (e.g., liver disease, accidental injuries). 6 The guidelines in box 7-C also suggest that diets include plenty of vegetables, fruits, and grain products. Vegetable and fruits are good sources of vitamins A and C, folic acid, fiber and minerals (226). Breads and cereals provide B vitamin s, iron, protein, and dietary fiber. Over the last decade, several organizations have recommended increasing the intake of complex carbohydrates or dietary fiber (153). The consumption of a fiber-rich diet promotes normal elimination and may have other beneficial effects (e.g., reducing blood cholesterol levels, preventing colon cancer and diabetes) (153). Finally, it should be noted that USDA and DHHS Dietary Guidelines for Americans recommends maintaining a healthy weight (227). Being too fat or too lean (a less common problem in the United States) increases the risk of various health problems. Available knowledge also suggests that whether ones weight is healthy depends on how much of ones body weight is fat, where in the body the fat is located, and whether one has weight-related medical problems or a family history of such problems (226). 6~oleKent~$ den~ he~~ s~~s is discuss~ in ch. 8, c *Dent~ and Oral Health Problems: l%ventiOII and Services, ti ~s volume; use of alcohol is discussed in ch. 12, Alcohol, Tobacco, and Drug Abuse: Prevention and Services, in this volume.
PAGE 201
Chapter 7Nutrition and Fitness Problems: Prevention and Services II-201 Box 7-CBroad Nutritional Guidelines That Provide Guidance Beyond Recommended Daily Allowances (RDAs) National Academy of Sciences Diet and Health Report (1989): This report made recommendations for quantities of nutrients and numbers of suggested servings from some food groups, specifically: l Limit intake of fat to less than 30 percent of total calories. Limit intake of saturated fatty acids to less than 10 percent of total calories. Limit cholesterol intake to under 300 mg daily. Limit salt intake to under 6 grams daily. Maintain protein at moderate levels, not more than twice recommended daily allowance (R-DA). l For those who drink alcoholic beverages, limit intake to less than 1 oz of pure alcohol per day. 1 l Maintain optimal intake of fluoride. l Avoid the use of dietary supplements in levels greater than RDA. l Have 5+ servings of vegetable and fruit combinations, especially green and yellow vegetables and citrus fruits. l Have 6+ daily servings of a combination of breads, cereals, legumes, and other starches and complex carbohydrates. U.S. Surgeon Generals Report on Nutrition and Health (1988): This report endorsed USDAs Dietary Guidelines for Americans (those that were current at the time) and also recommended the following: l that fluoridated community water systems, or other appropriate sources of fluoride be used to prevent tooth decay; 2 l that those who are particularly vulnerable to dental caries should limit their consumption and frequency of foods high in sugar; 2 l that adolescent females should increase consumption of foods high in calcium, including low-fat dairy products; and l that adolescents and women of childbearing age, especially those in low-income families, be encouraged to consume foods that are good sources of iron. USDA and DHHS Dietary Guidelines for Americans (October 1990): Eat a variety of foods. l Maintain healthy weight. l Choose a diet low in fat, saturated fat, and cholesterol. l Choose a diet with plenty of vegetables, fruits, and grain products. l Use sugars in moderation. l Use salt and sodium in moderation. l If you drink alcoholic beverages, do so in moderation. 1 The published guidelines provide more information on each guideline, including details on what the guideline means, how it is important to health, and some tips on using the guideline. l~e co~~ption of alcohol by U.S. adolescents is discussed inch. 12, Alcohol, Tbbacco, and Drug Abuse: Prevention and Services, in this volume. *S= Ch. 8, Den~ and Ord He~ti Problems: PTevCIItiOII and Services in this volume for a discussion of the importance of fluoride to adolescents dental health and other topics related to adolescents dental health. SOURCES: National Academy of Sciences, National Research Council, Diet and Health: Implications for Reducing Chronic Disease (Washington DC: National Academy Press, 1989); U.S. Department of Health and Human Services, Public Health Service, Ofl%e of the Surgeon General, Surgeon Generals Report on NutrMon and Health (Washingto% DC: U.S. Government Printing Offke, 1988); and U.S. Department of Agriculture and U.S. Department of Health and Human Services, Nutrition and Your Health: Dietary Guidelinesfor Americans, Home and Garden Bullet@ No. 232 (Hyattsville, MD: 1990).
PAGE 202
11-202. Adolescent HealthVolume II: Background and the Effectiveness of Selected Prevention and Treatment Services Researchers are developing more precise ways to measure healthy weight. 7 Physical Fitness and Activity Needs Numerous recent studies have suggested that physical fitness and/or physical activity 8 have, or potentially have, positive impacts on health and longevity (22,22a,33,33a,106a,171,174b,241). It is important to note, however, that these studies have had methodological flaws and have almost been conducted with adult samples. During adolescence, physical activity is thought to influence growth and development of skeletal bone, muscle, and fat (142). There appears to be a reciprocal relationship between physical activity and obesity or overweight (see below). Adolescents Nutrition and Fitness Problems A lack of data on contemporary adolescents and a paucity of systematic research on the impact of varying levels of nutrients and physical activity and fitness on health (including adolescent health) (254a) make conclusions about the nutrition and fitness problems of U.S. adolescents difficult to draw. Some survey data suggest that if one uses available nutritional and fitness guidelines as a standard, many U.S. adolescents have inadequate diets and engage in low levels of physical activity. Not coincidentally, a substantial minority are also overweight or obese. These problems may occur more often in some groups of adolescents, especially low-income adolescents or those in particular racial or ethnic groups. 9 Recent national data regarding the incidence or prevalence of these problems among U.S. adolescents are not available (see box 7-A), and national information about specific groups of adolescents (e.g., racial or ethnic minority adolescents, low-income adolescents) is practically nonexistent. Nutritional Deficiencies Essential nutrients are proteins, minerals, carbohydrates, fat, and vitamin s that are necessary for growth, normal functioning, and maintaining life; they must be supplied by food, because they cannot be synthesized by the body (box 7-B). Table 7-5 shows U.S. adolescents intake of food energy, protein, vitamins, and minerals in 1977-78 as a percentage of the 1980 RDAs. 10 USDAs 1977-78 Nationwide Food Consumption Survey found that most U.S. adolescents got more than enough protein (see table 7-5). More recent data also confirm that intakes of protein by U.S. adolescents typically meet or exceed the RDA (1 11). USDAs 1977-78 Nationwide Food Consumption Survey also found that, on average, U.S. adolescents intakes of vit amins A, B 12, and C, thiamin, riboflavin, and niacin, were sufficient or more than sufficient. On the other hand, USDAs 1977-78 Nationwide Food Consumption Survey (224) found that U.S. adolescents energy intakes (calories consumed) in the late 1970s were, on average, lower than the RDA levels. The data in table 7-5 suggest that the nutrients U.S. adolescents are most likely to be getting insufficient quantities of include vitamin B-6, iron and calcium. Females ages 9 to 18 tended to consume less iron and calcium than males, but males, too, consumed less than the 1980 RDA. The RDA for iron in 1989 was lower than in 1980, but recent data support the finding that iron is one of the nutrients most likely to be deficient in U.S. adoles70veWeighf is somct~= d~m~ ~ Wy mass index (BMl)-i.e., weight in kilograms divided by height k meters squmd-greater ~ or ~u~ to the 85tlI percentile of a similar population group. Obesiry, a more serious problem is defined in various ways. One deftition is BMI greater than or equal to the 95th percentile of a similar population group. Another deftition is weight at least 20 percent over normal weight. Measuring triceps skinfolds is another way of measuring obesity. 8physic~fi~ne~s is ~ a~~~ufe tit Shodd tX &s@@hed from physical ucfivify, which is a br?hUviOr. Physical activiv has been fo~d to be ~ important det erminant of physical fitness. To some exten4 therefore, physical fitness can be considered to be an objective murker for habitual physical activity (and vice versa), but physical fitness and physical activity are not the same thing (22a). Whe health problems of low-income adolescents and racial and ethnic minority adolescents are discussed further in ch. 18, Issues in the Delivery of Services to Selected Groups of Adolescents, in Vol. III. Also discussed in that chapter is the general paucity of data and research on low-income and racial and ethnic minority adolescents. l~e fist e~tion of tie NAS publi~tion Reco~endedDiefa~A//owances was pub~shed iII 1943. since t.hc~ nine revised editions have appeared, the most recent in 1989. The 1980 RDAs are similar to the 1989 RDAs, but there are some differences. In 1980, for example, the RDA for iron was 18 mg per day as opposed to 15 mg per day in 1989 (150). For a discussion of other differences, see the 1989 NAS publication Recommended Dietary Allowances (153).
PAGE 203
Chapter 7Nutrition and Fitness Problems: Prevention and Services l //-203 Table 7-5Average Daily Nutrient Intake as a Percentage of the 1980 RDAs Among U.S. Adolescents Ages 9 to 18, 1977-78 a b Male Female Vegetarian Nonvegetarian Vegetarian Nonvegetarian Nutrient (N= 20) (N= 3,462) (N= 31) (N= 3,600) Food energy c . . . . 98% 86% 91% 82% Protein . . . . . . 203 193 170 160 Vitamins Vitamin A . . . . . 182 123 121 112 Thiamin . . . . . 166 121 143 134 Riboflavin . . . . . 171 149 118 111 Niacin d . . . . . 150 122 118 111 Vitamin B6 . . . . 123 94 81 72 Vitamin B12 . . . . 191 205 142 148 Vitamin C . . . . . 225 173 172 150 Minerals Calcium . . . . . 107 97 87 74 Iron . . . . . . 121 91 90 76 Magnesium . . . . 97 80 115 103 Phosphorus . . . . 151 133 129 115 ane 19s0 RDASI150J aresirnilartothe 1989 RDAs (153) in many respects, but there are some differences. For example, the 1980 RDAforironwas 18mg., while the 1989 RDAforironwas 15mg. See text fordiscussion. bhe percentages in this table are basedon data from the U.S. Department of Agricultures 1977-1978 Nationwide Food Consumption Survey (224). cRecommend~ energy intake levels are ievels to meet average needs, unlike RDAs for other nutrients, which are believed to meet the needs of the vast majority of healthy individuals. dRDA is for preform~ niacin rather than niacin equivalents. SOURCE: Adapted from National Academy of Sciences, National Research Council, Diet and Health: Implicdions for Reducing Chronic Disease Risk (Washington, DC: National Academy Press, 1989). Reprinted by permission. cents diets, especially among females (122,142). Females iron needs are particularly high. In addition, exercise may increase the need for iron (128), and iron deficiency during physical training is more common in females than males (see section on female adolescent athletes below). In 1989, the NAS Food and Nutrition Boards Subcommi ttee on the Tenth Edition of the RDAs urged that special attention be paid to calcium intakes throughout childhood to age 25 to reduce the risk of osteoporosis later in life (153). However, another NAS committee, the Committee on Diet and Health, found that the evidence was not sufficient for drawing conclusions about the influence of dietary patterns on osteoporosis (152). As opposed to the effects of exercise on iron stores, exercise increases the retention of calcium in the body (23,98), as measured by the mineral content in bones; peak bone mineral density has been found to be enhanced by large calcium intakes and large energy expenditures (102). According to data from other studies, levels of vitamin C, folic acid, thiamin, and riboflavin are low in some adolescents (47,123,191,228,23 1,234). Levels of manganese and copper are unknown because food composition data are incomplete (152,168). Physical activity may deplete zinc stores, but the evidence is unclear (52). For most U.S. adolescents, vitamin and mineral deficits are subclinical and do not require professional intervention (59a). In the few cases where deficiency is commonly observed (e.g., iron deficiency in females), treatment with supplements may be necessary. Inadequate Dietary Fiber ll Data on intakes of dietary fiber by U.S. adolescents are incomplete, but some observers have suggested that intakes are probably lower than recommended (2,5). On the other hand, Healthy People 2000 noted that one expert panel (of the Life Sciences Research Office of the Federation of American Societies for Experimental Biology) indicated that levels of dietary fiber appropriate for adults may not be appropriate for children (no ages specified, and so Healthy People 2000 did not make
PAGE 204
//-204 Adolescent HealthVolume II: Background and the Electiveness of Selected Prevention and Treatment Services Box 7-DHealthy People 2000 Objectives Pertaining to Adolescents Physical Activity and Nutrition Healthy People 2000 is the Nations most prominent statement on health promotion and disease prevention objectives for the U.S. population (241). This report, published by the U.S. Department of Health and Human Services, contained a number of objectives for the year 2000 pertaining to adolescents nutrition and physical activity and fitness. The report also provided baseline data when they were available (see below). In addition to the health status, risk reduction, services, and protection objectives listed below, Healthy People 2000 enumerated objectives for personnel needs, surveillance and data systems, and research (241). These latter objectives were not specific to adolescents, but meeting them would be important to meeting the health status objectives for adolescents. Nutrition Objectives for the Year 2000 Health Status and Risk Reduction Objectives Reduce dietary fat intake to an average of 30 percent of calories or less and average saturated fat intake to less than 10 percent of calories among people ages 2 and older (no baseline data cited for adolescents or children). Increase calcium intake so at least 50 percent of youth ages 12 through 24 and 50 percent of pregnant and lactating women consume three or more servings daily of foods rich in calcium (no baseline data cited for adolescents). Decrease salt and sodium intake so at least 65 percent of home meal preparers prepare foods without adding salt, at least 80 percent of people avoid using salt at the table (baseline: 54 percent of women aged 19 through 50 who served as the main meal preparer did not use salt in food preparation; no baseline data cited for adolescents use of salt). Services and Protection Objectives: l l l l l Increase to at least 5,000 brand names l the availability of processed food products that are reduced in fat and saturated fat (baseline: 2,500 items reduced in fat in 1986). Increase to at least 90 percent the proportion of restaurants and institutional food service operations that offer identifiable low-fat, low-calorie food choices, consistent with the Dietary Guidelines for Americans (baseline: about 70 percent of fast food and family restaurant chains with 350 or more units had at least one low-fat, low-calorie item on their menu in 1989). Increase to at least 90 percent the proportion of school lunch and breakfast services and child care food services with menus that are consistent with the nutrition principles in the Dietary Guidelines for Americans (baseline data available in 1993). Increase to at least 75 percent the proportion of the Nations schools that provide nutrition education from preschool through 12th grade, preferably as part of quality school health education (baseline data available in 1991). Increase to at least 75 percent the proportion of primary care providers who provide nutrition assessment and counseling and/or referral to qualified nutritionists or dietitians (baseline: physicians provided diet counseling for an estimated 40 to 50 percent of patients in 1988). 2 Physical Activity and Fitness Objectives for the Year 2000 Health Status and Risk Reduction Objectives: l l l Increase to at least 75 percent the proportion of children and adolescents aged 6 through 17 who engage in vigorous physical activity that promotes the development and maintenance of cardiorespiratory fitness 3 or more days per week for 20 or more minutes per occasion (baseline: 66 percent for youth aged 10 through 17 in 19843). Reduce to no more than 15 percent the proportion of people aged 6 and older who engage in no leisure-time physical activity (no baseline data available for adolescents or children). Increase to at least 40 percent the proportion of people aged 6 and older who regularly perform physical activities that enhance and maintain-muscular strength, muscular endurance, and flexibility (no baseline data available for any age group). 1 A bitem is d~m~ ~ ~ ~~c~ fivor ~d/or si~ of a specfic b~d @ is &piMy the consumer tit of purchase (241). 2~s Obj=tive ~ ~ ~line &@ ci~ me not spwific to a&kscmW. For a discussion of X care providers behaviors with adolescents, see ch. 15, Major Issues in the Delivery of RirnaIY and Comprehensive Services to Adolescents, in Vol. III. s~e SOWW ci~d for this value was the National Children and Youth Fimess Study I.
PAGE 205
..... _- Chapter 7Nutrition and Fitness Problems: Prevention and Services II-205 Services and Protection Objectives: l Increase to at least 50 percent the proportion of children and adolescents in 1st through 12th grade who participate in daily school physical education (baseline: 36 percent in 1984-86). Increase to at least 50 percent the proportion of school physical education class time that students spend being physically active, preferably engaged in lifetime physical activities (baseline: students spent an estimated 27 percent of class time being physically active in 1983). l Increase to at least 50 percent the proportion of primary care providers who routinely assess and counsel their patients regarding the frequency, duration, type, and intensity of each patients physical activity practices (baseline: physicians provided exercise counseling for about 30 percent of sedentary patients in 1988). l Increase community availability and accessibility of physical activity and fitness facilities. 4 Combination Nutrition and Physical Activity and Fitness Objectives for the Year 2000 Health Status and Risk Reduction Objectives: Reduce overweight to a prevalence of no more than 15 percent among adolescents ages 12 through 19 (baseline: 15 percent for adolescents ages 12 through 19 in 1976-80). 5 Increase to at least 50 percent the proportion of overweight people aged 12 and older who have adopted sound dietary practices combined with regular physical activity to attain an appropriate body weight (no baseline provided for adolescents), 4~e~e ~omendatiom were not adolesunt-spcflc. s~e ~um used for adolescents wem the gender-specific 85th percentile values of the 1976-80 National Health and Nutrition Examination Sumey (NHANES II) corrected for sample variation (241). SOURCE: U.S. Department of Health and Human Services, Public Health Service, Office of the Assistant Secretary for Health, Heahhy PeopZe 2000: Narionul Health Promotion and Disease Prevention Objectives, DHHS Pub. No. (PHS)91-50213 (Washingto% DC: U.S. Government Printing OffIce, 1991). recommendations on dietary fiber for children or r ~ 4 z ~,, ~ ~ adolescents (box 7-D) (241 ). Excessive Consumption of Fat, Cholesterol, Sodium, and Low-Nutrient Density Foods The diets of most U.S. adolescents in national surveys fail to meet the recommendations of the NAS report Diet and Health (see box 7-C) because they are excessive in total fat, saturated fat, cholesr ?/ terol, and sodium (46,64,1 11,153,159,189). It is not surprising to find that adolescents diets are high in fat and cholesterol. NAS reports that food patterns have changed significantly in the United States (152). Between 1909 and 1985 the percentage of calories available in the food supply from fats increased from 32 to 43 percent (152). NAS recommended that children over 2 years old should consume no more than 30 percent of calories in fat. Recent studies have found that school meals are often very high in fat (37,70,164). Fast-food meals or snacks consumed by adolescents are often high in total and saturated fat, cholesterol, sodium, and sugar (135). Table 7-6 shows the nutritional values of seven sample fast-food meals. Approximately 25 percent of total calories consumed by U.S. adolescents, almost regardless of Photo credit: Benjamin Smith Current data on the food consumption patterns and nutritional status of U.S. adolescents, especially subgroups of adolescents such as racial and ethnic minorities and low-income adolescents, are limited. The most recent comprehensive information about what U.S. adolescents eat is from 1977-78. These data suggest that adolescents diets contain sufficient amounts of most essential vitamins and minerals and more than enough protein, but not enough total calories, vitamin B6, iron, and calcium. But more recent information suggests that adolescents diets may be too high in fat, cholesterol, and sodium.
PAGE 206
11-206. Adolescent HealthVolume II: Background and the Effectiveness of Selected Prevention and Treatment Services income, sex, or race (142), come from high calorie foods that are relatively low in protein, vitamin S, and minerals (low nutrient density foods). Snacking, or foods consumed outside of traditional meals, provides 20 to 35 percent of adolescents total energy intakes (46,145,224), but several studies show that the nutrient density is usually lower for snacks than for meals (57). Because recent data are not available, and data from the late 1970s suggest that adolescents generally consume sufficient proteins, vitamin s, and minerals (with the exception of vitamin B6, calcium, and iron) (see table 7-5), it is not clear how much of a nutritional problem beyond fat intake-snacking represents. Low Levels of Physical Activity Like their nutritional needs, the physical abilities of adolescents differ from those of younger children. The changes that occur with puberty involve not only increased linear growth and mass but also physiological changes that improve physical and athletic ability. The onset of puberty is associated with an increase in aerobic and anaerobic power (97) and tolerance of exercise in the heat (13) and in the cold (202). As noted above, there is considerable concern about levels of physical activity among U.S. adolescents on average (91a,174a,241). Detailed, accurate studies have not been carried out to show trends in activity patterns or the effects of age on activity during adolescence, but low levels of physical activity throughout adolescence have been discerned from recent surveys and semiquantitative measures of fitness (173,182). Enrollment and participation in daily physical education classes decrease somewhat in late adolescence. Figure 7-1, based on results from the National Children and Youth Fitness Studies, 12 shows the percentage of U.S. students in 1st through 12th grades enrolled in daily physical education classes in 1984-86 (182,183, 241). Only about 20 percent of the time is spent in moderate or vigorous activity during a class (15). Results from the National Children and Youth Fitness Studies indicate that 59percent of 5th to 12th graders reported engaging in appropriate physical Figure 7-lPercentage of U.S. Students in 1st Through 12th Grade Receiving Daily Physical Education, 1984-86 30 20 10 0 Iz 12345 6 78 9 10 11 12 Grade in school SOURCE: U.S. Department of Health and Human Serviees, Public Health Service, Office of the Assistant Secretary for Health, Hea/thy People 2000: National Health I?omotion and Disease Prevention @jectfves, DHHS Pub. No. (PHS)91-50213 (Washington, DC: U.S. Government Printing Office, 1991), based on the National Children and Youth Fitness Study I (students in 5th through 12th grade) and the National Children and Youth Fitness Study II (students in Ist through 4th grade). activity year round (182). 13 Of the time these adolescents spent in physical activity outside of school physical education classes (84 percent of their average weekly minutes of participation in physical activities), nearly 47 percent of students reported engaging in appropriate activities that could be carried over into adulthood (182). Results from the National Children and Youth Fitness Studies also indicate that U.S. children and adolescents physical fitness is related to their mothers physical activity and inversely to the amount of time children watch television (182). Studies of adults show that adult women of lower socioeconomic status engage in less fitness-related activity than women of higher socioeconomic status (68), and that exercise levels are similar among members of the same family (63). Taken together, these observations suggest that low-income adolescents may be less likely to be engaging in fitnessrelated activities. Lower participation by lower socioeconomic status individuals may be more a matter of opportunity than inclination; thus, schools could play an important role in providing occasions lz~e Natio~ c~~en and Youti Fi@ws S~dies (NCYFS) were surveys of 5th to 12th grade students (NCYFS I) md 1 st through4tb fpde smdmts (NCYFS II) (182,183,241). 13APProPr~afe physical ucfivi~ was defm~ in this swey as physical activity involving large muscle grOUpS at ~ intemity r~a 60 Per~nt or greater of an individuals cardiovascular capacity engaged in at least three times per week for at least 20 minutes.
PAGE 207
Chapter 7Nutrition and Fitness Problems: Prevention and Services II-207 u) o m In 1+ 0 N 3 N 0 In mo o 7T--r r-f FOm l-m m% Omo f= 00 0 ml-e 0 0 m cmaolNYF CO*O -T ?-* 75+-I. -CQo p.. Oomm *TT= . ,. . ,. ,. ,. . . ..ai .N ..fn .L .Lm :5 :~ . . . . . . . . . . . . . . E :Cm .s2 .L1 . . . . . . . . . . . . . . . . . . . . := :0 . . :? : .:% m :% .al c :0 .a .? :g . . . . . . . . . . . . . . . . :gJ : : .: :$ : .s? :U : .W K :0 : a :y G3 uo = ~ m~o =? = . . . . . . . . . rN m m
PAGE 208
//-208 Adolescent HealthVolume II: Background and the Effectiveness of Selected Prevention and Treatment Services for exercise by lower socioeconomic status adolescents. A recent study of the effects of television on children and adolescents shows that adolescents spend many hours outside of school watching televisionan average of 23 hours per week from 1976 to 1980 (86). Watching television may affect the amount of time adolescents spend engaging in physical activities. 14 Obesity or Overweight Depending on the measurement used, the prevalence of overweight and obesity in U.S. adolescents ranges from 15 to 22 percent (86,241). 15 Obesity may have genetic origins (26,3 1,208), but it is also associated with diet and physical activity. The family environment and the community are important in explaining obesity in children and adolescents (166). Family involvement in active lifestyles and moderation in eating patterns is usually critical in preventing and avoiding obesity. Children in obese families expend less energy than those in lean families, possibly because they copy sedentary family lifestyles (10). Obese adolescents have lower than usual levels of physical activity (21), and even when obese adolescents are physically active, they are less so than their leaner peers (30). Obesity in adolescents may be associated with other factors, such as socioeconomic status, rate of biological maturity, or race. Fatness and sedentary habits are more common in adults of lower socioeconomic status (78). Early maturing females tend to be fatter and are more likely to become obese as adults (79). Black female adolescents appear to be overweight more often than white female adolescents (116,1 17,233). However, this information may be confounded in part when considering that black body composition during adolescence differs from whites; black individuals have a higher bone and muscle mass so that overweight may not always mean overfatness at levels of moderate overweight. The risk of early obesity in Mexican American adolescents, especially for the central or trunkal type of obesity (highly associated with heart disease and diabetes mellitus), is extremely high (117,236). 16 Obesity is prevalent in some American Indian tribes (20a,152), but data on obesity in American Indian adolescents are very limited (20a). Conclusions that many adolescents are overweight and that fatness may be increasing among adolescents (53,54,55,87)17may seem inconsistent with findings that U.S. adolescents energy intakes are, on average, lower than recommended. It may be that U.S. adolescents are more sedentary than is assumed by NAS when formulating its recommended energy allowances. Conclusions Current national data on the food consumption patterns of U.S. adolescents are limited. Available evidence suggests that many U.S. adolescents do not follow the general dietary guidelines set forth in publications such as the NAS report Diet and Health: Implications for Reducing Chronic Disease Risk (152) or in USDA and DHHS Nutrition and Your Health: Dietary Guidelines for Americans (227) (see box 7-B). Specifically, it appears that U.S. adolescents tend to consume excessive amounts of fat, saturated fat, cholesterol, sodium, and foods with low nutrient density. Recent studies have found school meals to be very high in fat, Available evidence from the late 1970s suggests that while U.S. adolescents diets generally provide enough protein, they tend to be deficient in some specific nutrients (e.g., iron, calcium, and vitamin B6) ( 152). This same source suggests, however, that, on average, U.S. adolescents consume more than sufficient amounts of other vitamin s, minerals, and 14s& Ch. 4, c(Schools and Discretionary Time, in this volume for a discussion of what adolescents do during their time away from school. 1SA5 noted e~lier, o~sity and ovewei@t can be defined in different ways, Obesi~ can be defined as BMI greater than or equrd to tie 95dI Perantde of a similar population group (usually by age); or it can be defined as 20 percent or more over normal weight, Overweight can be defined as BMI greater than or equal to the 85th percentile of a similar population group. Measuring triceps skinfolds is another method of measuring obesity. A matter of contentio% the method used to measure the ratio of body fat does affect prevalence and incidence rates of obesity in a population (86,91,132,241). Because of the rate of physiological change and consequent effect on fat distribution patterns during childhood and adolescence, some measures may not accurately reflect body fat in adolescents. Also, some studies refer to obese and superobese rather than overweight and obese adolescents (86). 16~e5e data ~ve not ken conect~ for sociWconomic status levels; however, cefi~ ~OUpS of Hispanics experience relatively high levels poverty. For further discussion, see ch. 18, Issues in the Delivery of Semices to Selected Groups of Adolescents, in Vol. III. ]yHowever, ~o~a s~dy which us~ tie sae dam set m many of ~ese studies but different methods for measuring the aKIIOUIIt of body fat did IIOt show any secular increases in BMI in adolescents (91). Inconsistent conclusions maybe due to the different indices of obesity employed, and differences in age distributions and sample designs. However, no study suggests that the prevalence of obesity is decreasing among adolescents (142).
PAGE 209
Chapter 7Nutrition and Fitness Problems: Prevention and Services lI-209 protein. Data on average nutrition in contemporary U.S. adolescents will become available in the mid1990s, but smaller regional studies are needed to determin e nutritional deficiencies in some groups of adolescents. Physical activity levels of most adolescents decline throughout adolescence. The best opportunity for physical activity for some adolescents, particularly low socioeconomic status adolescents, may be during school hours. But physical education classes during school currently provide little opportunity for actual physical activity. Available evidence suggests that from 15 to 22 percent of U.S. adolescents are overweight or obese (86,241). Diets high in fats and low levels of physical activity are factors, in conjunction with the family environment and, possibly, genetic factors. Low-income adolescents and adolescents in some racial or ethnic groups are more likely to be overweight or obese than others. Consequences of Adolescent Nutrition and Fitness Problems Malnutrition, low levels of physical activity, obesity, and other nutrition and fitness problems experienced by U.S. adolescents have immediate consequences (e.g., failure to grow, decreased resistance to disease, lack of energy, obesity) and may also have long-term consequences. This section reviews evidence for both the immediate and longterm consequences of nutrition and fitness problems during adolescence. Immediate Consequences of Nutritional and Fitness Problems During Adolescence Immediate Consequences of Nutritional Problems--The biological functions of selected dietary substances in humans were reviewed in box 7-B earlier in this chapter. Insufficient caloric intake can lead to death by starvation and insufficient intake of vitamin s and minerals can lead to diseases such as scurvy or pellagra. Fortunately, starvation and diseases caused by vitamin and mineral deficiencies are rare in this country (226). Adolescents whose caloric intakes are too high may experience weight gain, leading to overweight or obesity. Those whose caloric intakes are low may experience weakness, weight loss, physical inactivity, and less than optimal growth (186).18 Excessive leanness is associated with health problems and premature death. Meal skipping is associated with lower intakes of several nutrients on a daily basis. Recent data suggest that 5 percent of U.S. adolescents, especially females, are chronic meal skippers (142). This finding may be cause for concern because low calorie diets (e.g., under 1,800 calories) may make it difficult to meet intake standards for some essential nutrients, such as iron and calcium, without supplementation. 19 As noted in box 7-B, iron deficiency may result in anemia, causing decreased physical ability, impaired body temperature regulation, lowered resistance to infection, and alterations in behavior and intellectual performance (49). Calcium intake and absorption are necessary for adequate bone growth during adolescence (152). Zinc deficiency has not been found to impair the capacity for aerobic exercise in animals (128), but strength may be affected (1 14). Immediate Consequences of Low Levels of Physical ActivityDuring adolescence, physical activity can influence growth and development of skeletal bone, muscle, and fat (142). Health values of childhood physical activity include relationships to obesity (see below) and to physical fitness and functional capacity (196). In adults, participation in high-intensity aerobic exercise has been shown to improve self-concept (130) and this may also be true for adolescents. Immediate Consequences of obesity-----obesity has immediate and delayed effects on social development and health (100,142). Poor body image and a decreased sense of personal worth are common among obese adolescents, especially if obesity dates from childhood (34,59,175). Obesity further encourages the tendency towards physical inactivity (10,142) and is associated with an increased risk of hypertension and high blood cholesterol (see below) (20,54, 71,85,180,246). 18~olawnt~ ~i~ he ~at~g dl~o~de~~ ~orexla newo5a ad bulimia (dlscuss~ below) expedience weight ]OSS and other p threats to their health. l% 1989, tie NAS Food ~d Nu~ti~n Bo~d reco~ende(j hat individ~]s eat diets composd of a variety of foods rather hIl rely On supplementation or fortification (153).
PAGE 210
11-210. Adolescent HealthVolume II: Background and the Effectiveness of Selected Prevention and Treatment Services Risk of Chronic Diseases Later in Life Some nutritional and fitness behaviors during adolescence, though not immediately threatening to the adolescent population, may be associated with chronic diseases later in life. In a recent comprehensive review of the effects of diet on health, an NAS committee drew the following conclusion: A comprehensive review of the epidemiologic, clinical, and laboratory evidence indicates that diet influences the risk of several major chronic diseases. The evidence is very strong for atherosclerotic cardiovascular diseases and hypertension and is highly suggestive for certain forms of cancer (especially cancers of the esophagus, stomach, large bowel, breast, lung, and prostate). Furthermore, certain dietary patterns predispose to dental caries and chronic liver disease, and a positive energy balance produces obesity and increases the risk of non-insulin-dependent diabetes mellitus. However, the evidence is not sufficient for drawing conclusions about the influence of dietary patterns on osteoporosis and chronic renal disease (152). The NAS committee also cautioned as follows, however: Most chronic diseases in which nutritional factors play a role also have genetic and other environmental determinants, but not all the environmental risk factors have been clearly characterized and susceptible genotypes usually have not been identified. Furthermore, the mechanisms of genetic and environmental interactions involved in disease are not fully understood. It is evident that dietary patterns are important factors in the etiology of several major chronic diseases and that dietary modifications can reduce such risks. Nevertheless, for most diseases, it is not yet possible to provide quantitative estimates of the overall risks and benefits (152). It is important to note that the NAS committee did not specifically review the effects of adolescents dietary patterns on health during adulthood. There is in general very little information on such effects. While more research on the impact of adolescent dietary patterns on adolescents immediate and future health is clearly needed, the available research on diet and chronic disease suggests that adolescents might be well advised to follow prudent dietary recommendations and should receive continuing education about links between diet and health as such information becomes available. Risk of ObesityThough most obese adolescents do not become obese adults, it is difficult to predict (except for the most obese) who will persist in their obesity (242). It appears, however, that the risk of continued adult obesity rises the longer an adolescent remains obese (85). Continued obesity is especially likely to be associated with increased risks of later hypertension, high serum cholesterol and coronary artery disease, adult-onset diabetes mellitus, gall bladder disease, an increase in certain forms of cancer, and other medical problems (85,133, 237). Risk of Coronary Artery Disease-Coronary artery disease in adults is highly associated with high cholesterol levelsparticularly high low-densitylipoprotein (LDL) levels and low high-densitylipoprotein (HDL) levelsphysical inactivity, and high blood pressure (139,206,251). The Pathobiological Determin ants of Atherosclerosis in Youth (PDAY) and the Bogalusa Heart studies have recently shown that high LDL and low HDL levels in adolescence are associated with artery-narrowing plaque (139) and that high cholesterol levels may follow an adolescent into adulthood (251). Recently, an expert panel on blood cholesterol levels in children and adolescents at the National Cholesterol Education Program of the National Institutes of Health suggested selective cholesterol screening of some children and adolescents (i.e., those who have a family history of premature cardiovascular disease or at least one parent with high blood cholesterol) (237). But in one study, the predictive value of the occurrence of high cholesterol in adolescence for high cholesterol in adulthood is questioned; of children with cholesterol concentrations exceeding the 75th percentile, 75 percent of the females as adults and 56 percent of males as adults did not qualify for intervention using the National Cholesterol Education Program criteria (118). There is no evidence that fitness during adolescence has a direct effect on adult health, but establishing lifetime activities (e.g., walking, running, and cycling) during adolescence may encourage continued adult participation in physical activity (196). Increased physical activity in adults has been associated with an overall decreased risk of coronary heart disease (22,146,162,163,171,197). Risk of Diabetes--Diabetes is the most common of the serious metabolic diseases (69). Type I
PAGE 211
Chapter 7Nutrition and Fitness Problems: Prevention and Services II-211 (insulin-dependent) diabetes usually begins in adolescence. Type 11 (non-insulin-dependent) diabetes usually begins in middle life or beyond. The development of Type I diabetes occurs when an environmental event (e.g., a viral infection) triggers an autoimmune reaction in a genetically susceptible individual (69). The development of Type II diabetes is less well understood (69). The disease runs in families, however, and the typical patient is overweight. As noted above, an NAS committee concluded that a positive energy balance (i.e., too many calories) produces obesity and thus increases the risk of Type II diabetes (152). Risk of CancerExcess dietary fat and low intakes of plant foods and vitamin C are the dietary factors most strongly linked to increased risk of some cancers 20 (152). Generally, increased weight relative to height is associated with increased risk of cancer (195 ). Caloric expenditure or some other factor associated with physical activity in recreation or employment may be associated with decreased risk of some cancers (73,76,82,245). Risk of Osteoporosis--Begin too thin is linked with osteoporosis in women and thinness is associated with poor nutrient (e.g., calcium) intakes (226). However, the relationship of dietary calcium to osteoporosis is uncertain (152,226). It does appear, however, that higher intakes of calcium and iron by women, especially during adolescence and early adulthood can increase bone mass and delay the onset of fractures later in life. The level of bone mass achieved at skeletal maturity (generally in the mid-twenties) is a major factor modifying the risk for fractures (152). Conclusions The consequences of adolescents nutrition and fitness problems may directly affect individuals during adolescence or later in life. Some adolescents experience immediate effects, such as poor bone growth due to calcium deficiency, lack of energy due to iron-deficiency anemia, impaired resistance to infection, or obesity due to a combination of genetics, diet, and sedentary behavior. Little research has been directed toward the effects of adolescent dietary and physical activity patterns on adult chronic disease, but some evidence suggests that the ultimate consequences of a longterm pattern of poor nutrition and low levels of physical activity may be life-threatening. As a consequence, the recent consensus document, Hea1thy People 2000, made the recommendations shown in box 7-D. Adolescents With Particular Nutritional and Fitness Problems Some adolescents have special nutritional and fitness problems. As discussed below, adolescents who are pregnant or lactating need increased energy intakes and other nutrients. Adolescent athletes also have special nutritional needs and subsequent problems. Other adolescents with special needs include adolescents with eating disorders such as anorexia and bulimia and adolescents with serious chronic physical or mental conditions and disabilities who may have either difficulty making proper nutritional choices, decreased mobility, or decreased access to facilities that provide exercise assistance. Pregnant Adolescents 21 The diets of pregnant younger adolescents are often deficient in energy, calcium, and iron. Special problems with nutritional implications include gestational diabetes, pregnancy-induced hypertension, inadequate prepregnancy weight, inadequate weight gain during pregnancy, and iron-deficiency anemia (24). Anemia during pregnancy is associated with premature delivery, low birth weight, and fetal death (80,148). The Centers for Disease Controls (CDC) 1987 Pregnancy Nutrition Surveillance System gathered hematologic data (which define anemia) on 63,709 low-income pregnant women from ages 15 to 39 (230). CDC found that the prevalence of anemia during the third trimester of pregnancy was higher in pregnant adolescents (ages 15 to 19) than in other age groups, and for all age groups, black women had a higher prevalence than white women (see figure 7-2). 2oAvailablc evidence from epidemiologic ad animal research suggests that a high fat intake is associated with increased risk of cancers of the CO1OU prostate, and breast ( 152). Vitamin C may protect against stomach cancer (1 52). NAS found the evidence for protective effects of dietary fiber inconsistent (152). zlFor f~er discussio~ see ch. 10, Pregnancy and Parenting: Prevention and Services, in this volme.
PAGE 212
//-212 Adolescent Health-Volume II: Background and the Effectiveness of Selected Prevention and Treatment Services Figure 7-2Prevalence of Anemia Among U.S. Women During the Third Trimester of Pregnancy, by Race and Age, 1987 a Percentage 50 T--- 1 40 30 I 2 0 1 0 o 15-19 20-24 25-29 30-34 35-39 Age (years) White ~ Blac k aData are lg87 data from the Centers for Disease controls pregnancy Nutrition Surveillance System. SOURCE: U.S. Department of Health and Human Services, Public Health Service, Centers for Disease Control, Anemia During Pregnancy in bw-lnmme V&men, United States, 1987, Morbidity and Mortality Weekly Repori 39(5):73-76, Feb. 9, 1990. According to the CDC study, there is some evidence that participation in public nutrition programs (e.g., the Special Supplemental Food Program for Women, Infants, and Children (WIC) 22 ) may improve iron nutrition status and reduce the prevalence of anemia in all age groups of low-income pregnant women (see figure 7-3). The WIC program focuses on low-income pregnant and lactating women and on children under age 5. Only 3 percent of those participating in WIC are pregnant, breastfeeding, or postpartum females under age 18. 23 Adolescent Athletes Participating in activities that require a certain weight or body type may in some cases lead adolescents to engage in unhealthful behaviors, For example, activities that require thinness for either aesthetic or performance purposes (e.g., wrestling, gymnastics, dance) may cause adolescents to become undernourished, bulimic, anorexic, or amenorrheic (females), and affect testosterone levels (males) (136). Activities that require greater body mass may lead adolescents to use steroids or become susceptible to fraudulent health food claims (29,66). Figure 7-3-Prevalence of Anemia Among U.S. Women During the Third Trimester of Pregnancy, by Race and Trimester of Enrollment in Public Health and Nutrition Programs, 1987 a 40 i m .5 First Second Third Trimester of enrollment ~ White ~ Blac k aData are 1987 data from the Centers for Disease Controls pregnancy Nutrition Surveillance System. SOURCE: U.S. Department of Health and Human Services, Public Health Service, Centers for Disease Control, Anemia During Pregnancy in Low-Income VWmen, United States, 1987, Morbidly arrd Morta/ify Week/y Report 39(5):73-76, Feb. 9, 1990, It is not clear to what extent coaches or physical education teachers currently work with adolescents so that they avoid unhealthful practices and obtain adequate levels of essential energy and nutrients. Female Athletes-Female athletes may become amenorrheic, which can be detrimental to bone health; consequently these females can experience a higher prevalence of scoliosis (249) and stress fractures (17,121). They are also inclined toward vegetarianism (201), resulting in weight loss, and excessively low-fat fiber-rich diets which increase fecal loss of estrogens and reduce circulating estrogens (84,94). The quality of their diet itself could help induce amenorrhea by altering reproductive hormone levels. Female athletes, more than males, are also likely to be iron deficient (158,178). Male Athletes--Surveys of adolescents attending high school show an increasing consumption of illegal anabolic steroids 24 to increase muscle mass and strength for athletic competition (29). The use of anabolic steroids in adult strength-trained athletes affects blood lipid profiles; there is a 55-percent decline in HDL-cholesterol and a 25-percent in22s= the ~ection &]ow on F~er~ ~rogms pefl~fig IO adolescent nutrition and fi~ess for a discussion of other Federal nutrition programs. AISO see ch. 10, Pregnancy and Parenting: Prevention and Semices, in this volume for discussion of Federal programs available to pregnant adolescents. ~See ch. 19, The Role of Federal Agencies in Adolescent Healti in Vol. III for more discussion of Federal agencies emphasis on adolescents. ~~e ~ti-Drug Abuse Act of 1988 (Public Law 100-690) made unapproved use of anabohc steroids illegal.
PAGE 213
Chapter 7Nutrition and Fitness Problems: Prevention and Services l II-213 Photo credit: Katherine Criss Participating in activities that require a certain weight or body type may in some cases lead adolescents to engage in unhealthful behaviors such as having diets that are too low in essential nutrients. crease in total cholesterol, indicating a possible higher risk for cardiovascular disease (95,250) These drugs also impair the metabolism of glucose (41,83) and favor net accretion of body protein, especially as muscle mass (66). Immediate effects such as acne, baldness, reduced libido, breast growth, impaired sexual function (257), and affective and psychotic symptoms (170) may present more persuasive arguments against their use by adolescent males as opposed to the more long-term effects such as cardiovascular disease. Adolescents have much higher rates of sports injuries than younger children (75, 179). 25 Older adolescents (ages 16 to 19) experience more sports injuries requiring treatment than do other age groups (50). Overall, according to one survey of adolescents, males experience the most (almost 75 percent) sports-related injuries (129). Females, however, experience more injuries related to specifc activities and sports than males participating in the same activity or sport at a similar rate (9,169). According to Bar-Or, adolescent athletes and their coaches should be warned of the risk for low bone mineral stores (irrespective of calcium intake), fractures, and hypothermia or hyperthermia while exercising in cold or hot temperatures (16). The American Academy of Pediatrics Committee on Sports Medicine and Committee on School Health recommends that all coaches should be certified (4). Only 16 percent of high schools nationwide have a certified athletic trainer or comparable professional on staff (42). Adolescents With Eating Disorders Two serious eating disorders that afflict U.S. adolescents are anorexia nervosa and bulimia. Anorexia nervosa is a mental disorder characterized by an intense fear of becoming obese and a refusal to eat, leading to a significant weight loss (at least 25 percent of body weight) (6). Bulimia is a mental disorder characterized by a compulsion to binge and then purge the body by self-induced vomiting or use of laxatives (6). Adolescents with bulimia, most of whom are females, may experience weight fluctuations of more than 10 pounds. Anorexia nervosa and bulimia present serious threats to adolescents physical health, including dehydration, hormonal imbalance, and depletion of important minerals (1 1,25,77,92,99,106,112), Without treatment, including psychological counseling, medical treatment, and dietetic advice, some adolescents with anorexia may die. Bulimia can have serious consequences for adolescents later physical development. One recent survey suggests that the prevalence of anorexia among U.S. females ages 15 to 19 is 0.5 percent (126). The prevalence of bulimia in the U.S. population is estimated to be 2 percent (143). Adolescents with anorexia nervosa or bulimia need psychological counseling and medical treatment. Adults who teach, coach, or train adolescents should recognize signs of the eating disorders in their charges and refer those at risk for treatment. Student health services in schools should similarly be able to assist students with these problems. See ch. 5, Accidental Injuries: Prevention and Services, in this volume.
PAGE 214
II-214 Adolescent HealthVolume II: Background and the Effectiveness of Selected Prevention and Treatment Services Table 7-7Examples of Chronic Diseases and Conditions With Nutrition and Fitness Implications Among U.S. Children Ages O to 20, 1980 Prevalence per 1,000 children ages Disorder O to 20 years Nutrition and fitness implications Arthritis. . . . . . Asthma . . . . . . Central nervous system injury Cerebral palsy . . . . Chronic renal failure . . . Cleft lip or palate . . . Congenital heart disease . . Cystic fibrosis . . . . Diabetes mellitus . . . Downs syndrome . . . Leukemia . . . . . Mental retardation . . . Muscular dystrophy . . . Spina bifida . . . . . Phenylketonuria . . . . Blindness . . . . . 2.20 38.00 2.15 2.50 0.08 1.50 7.00 0.20 1.80 1.10 0.11 25.00 0.06 0.40 0.10 0.60 Feeding difficulties, obesity, diet-drug interactions, mobility inhibited, possibly altered growth Mobility may be inhibited Feeding and mobility difficulties Feeding and mobility difficulties Therapeutic diets required, wasting and delayed growth common Feeding difficulties if not repaired Therapeutic diets may be required if severe, mobility affected, diet-drug interactions, growth retardation Therapeutic diets needed, diet-drug interactions, growth retardation Therapeutic diets needed, diet-drug interactions, possible growth retardation, exercise must be planned Feeding difficulties if severe, obesity, growth retardation Anorexia at some stages, diet-drug interactions, growth retardation Feeding difficulties if severe, obesity, emaciation, growth retardation Special forms and routes of feeding required, diet-drug interactions, feeding and mobility difficulties, growth retardation Therapeutic diets required, obesity, mobility problems Therapeutic diets required, growth retardation Feeding difficulties, obesity, mobility problems SOURCE: Adapted from S.L. Gortmaker and W. Sappenfield, ChronicChildhood Disorders: Prevalence and Impact, Pediatric Clinics of North Amedca 31 :3-18, 1984. Reprinted by permission. Adolescents With Chronic Conditions and Physical Disabilities Serious chronic conditions and disabilities often have nutritional or fitness consequences for adolescents (see table 7-7). 26 Chronic conditions and disabilities that are indirectly associated with hypoactivity (abnormally low levels of activity) include massive obesity, asthma, diabetes, blindness, Downs syndrome, and mental retardation of other types (14,194,199,209). Adolescents with disabilities that preclude walking tend to be fatter and less active than normal adolescents. Low physical activity may explain the lower aerobic ability and greater fatness found in blind adolescents (194). Although near normal aerobic fitness can be achieved, most blind adolescents lack sighted guides and adequate facilities to allow independent exercise (194). There are limited opportunities for adolescents with physical and developmental disabilities to engage in fitnessrelated activities, although there is considerable evidence that such activity would benefit such adolescents (160). Nutrition counseling and interventions can help minimize or eliminate preventable causes of poor growth. Unfortunately, schools and school food services often lack technical skills or money to implement special health, food, and educational services often needed by disabled adolescents (93). The role of nutrition could be stressed in the care of disabled and chronically ill adolescents by, for example, including a nutritionist on the health care team or emphasizing nutrition in physical training programs. 26s~ ch. 6, Chronic Physical Illnesses: Prevention and Services, in this volume for a discussion of the difficulties faced by many adolescents with serious chronic conditions and disabilities.
PAGE 215
Chapter 7Nutrition and Fitness Problems: Prevention and Services .11-215 4 Photo credit: Jill Slater Typically, physical fitness opportunities for children and adolescents with physical disabilities are limited. These early adolescents at the Kentucky School for the Deaf belong to a soccer team. PhenylketonuriaPhenylketonuria is a genetic disorder of amino acid metabolism that is characterized by the inability to metabolize the amino acid phenylalanine (156,219). Although no abnormalities are apparent at birth, blood levels of phenylalanine rise rapidly after protein feedings are begun, and if diagnosis and dietary treatment is not begun within 30 days of birth, severe mental retardation will result (181). Phenylalanine-restricted diets are known to enhance normal intellectual development in children with phenylketonuria. Studies suggest that continuation of such therapeutic diets throughout adolescence could maintain a childs intellectual achievement (38,124). Juvenile-Onset DiabetesAs noted earlier, there are two major types of diabetes. Type I (insulindependent) diabetes typically has its onset in childhood or adolescence. Age 14 is the peak age for incidence of disease (69). Insulin is required for treatment of all type I patients (69). In addition, adolescents with type I diabetes must follow a specified dietary regimen. Therapeutic diets, in conjunction with exercise and drug therapy, control some of the complications of type I diabetes (such as insulin shock, diabetic ketoacidosis, coma, and hypoglycemic reactions) (74). In adolescents, as well as adults, dietary cooperation is sometimes enhanced if the patient is occasionally allowed a special treat (e.g., a dessert ordinarily forbidden) with the understanding that resumption of the diet will begin the next day (69). Studies suggest that overweight diabetic adolescents could improve their carbohydrate metabolism by exercising regularly (144,176). Adolescents With Mental Retardation or Developmental Disabilities Mental retardation may be associated with secondary malnutrition, due to difficulties in feeding, or to inadequate care (12). Thus, the nutritional status of mentally retarded adolescents, living both in and outside of institutions, is of concern. According to teachers and parents, participation of mentally retarded adolescents in physical fitness programs has good psychological effects (199). Emotionally Ill Adolescents Some emotional disorders, or their treatments, have nutritional implications (e.g., some antidepressant drugs can affect the appetite). Nutritional guidance could be integrated into settings for mental health services provision. In adults, participation in high-intensity aerobic exercise has been shown to improve self-concept (130) and reduce depression (213). The possibility that aerobic exercise could be a beneficial addition to programs for troubled adolescents should be explored. Conclusions Certain populations of adolescents have special nutritional and fitness needs which may require attention by the adolescents themselves, their families, and the professionals around them. Heightened awareness of the importance of nutrition and fitness to the overall health of these adolescents (e.g., through nutrition education or physical education for the adolescents, or training programs for family and professionals) and providing opportunities to achieve nutrition and fitness goals (e.g., food programs or access to physical activity facilities) could help alleviate or prevent some problems experienced by these adolescents. Prevention and Treatment of Nutrition and Fitness Problems Adolescents Nutritional Choices The National Adolescent Student Health Survey in 1987 found that 37 percent of 8th and 10th graders ate breakfast every day (the survey period was the previous week ), 51 percent ate lunch every day,
PAGE 216
11-216 Adolescent HealthVolume II: Background and the Effectiveness of Selected Prevention and Treatment Services and 68 percent ate dinner every day (7). In contrast, 16 percent never ate breakfast during the past week, 6 percent never ate lunch, and 1 percent never ate dinner. Females ate fewer meals in a week than males, and 10th grade females ate fewer meals than 8th grade females. The survey found that most (89 percent) of the surveyed 8th and 10th grade students who reported eating breakfast ate their breakfast at home, though some (7 percent) ate at school (7). Those who ate lunch, however, typically obtained it at school (72 percent v. 19 percent bringing lunch from home). Fewer 10th graders than 8th graders brought lunch from home (13 percent v. 19 percent) though more ate lunch someplace other than at school (13 percent v. 4 percent). The National Adolescent Student Health Survey also showed that most 8th and 10th grade students snack (only 12 percent ate no snacks the day before), and further, that most (61 percent) of the snacks consumed were junk food (chips, soda, candy, ice cream, or cake) rather than nutritious snacks (fruits, vegetables, nuts, juice, milk, yogurt, or cheese) (7). Male and female snacking behaviors were about the same. As adolescents grow older, competing demands on their interests and energy and potent social forces (including peer pressures, busy schedules, and sports concerns) rise in importance (1 19,125,136,198,204, 253), while the importance that adolescents attach to nutrition may decline (125). In one study, 45 percent of junior high school students felt that nutrition is very important, as compared with 36 percent of senior high school students (125). Interestingly, nutrition decreased in importance at the same time that perceived control over nutritional choices increased. Fifty-six percent of junior high school students reported that they themselves have the most influence over what they eat, as compared with 74 percent of senior high school students (125). Adolescents sometimes emphasize factors other than health or nutrition in making food choices (44). For example, weight was of great concern among adolescents surveyed in 1989, especially females; nearly half of all 11th and 12th grade students surveyed had been on a diet at least once, and the vast majority who had dieted did so for cosmetic rather than health reasons (125). Societal stresses on the cosmetic aspects of fitness are extreme and lead some adolescents to attempt to control weight and appear fit by restrictive (and potentially harmful) dieting (34) rather than by a combination of diet and physical activity. Increasingly, female adolescents are concerned about their weight at younger ages (113). Influencing Adolescents Nutritional Choices Health Education In 1985, only 12 States had mandated nutrition as a core content area in school health education (241). But, of the 80 percent of 8th and 10th graders surveyed in 1987 who had at least one health education class, 74 percent had received nutritional instruction in that class (7); this finding suggests that there is substantial dissemination of at least some nutrition information. In addition, community-based programs can reach targeted adolescent populations (e.g., pregnant adolescents not in school). USDAs Food and Nutrition Service has prepared nutrition advice and information, which is available for groups with special nutritional needs (222). Food and nutrition-related services in rural areas could be expanded and links with already existing services could be explored (e.g., the Cooperative Extension Service of USDA has offices in almost every county which is supported by a State office) (222). State health departments provide nutrition education materials, nutrition counseling, and nutrition consultation to targeted populations and to programs developed for them. But increasing knowledge about proper nutrition alone does not necessarily improve eating habits. Although 67 percent of 11th and 12th grade students reported that saturated fat and cholesterol should not be eaten in excess, this knowledge had only a slight influence on consumption of foods high in these constituents (125). The manner in which the information is presented may influence its impact. For example, adolescents regard nutrition education curricula that neglect food preferences and other motivational factors as boring and irrelevant (33). Other school-based health promotion activities have been effective, however. For example, one schoolbased approach resulted in the short-term reduction of cardiovascular disease risk factors in 10th graders by modifying diet and exercise (1 10). Marketing science experts recognize that adolescents have special wants, and they tailor appeals to the youth market to meet them (81). Appropriate motivation and modifications in the social environment help to persuade adolescents and adults to give
PAGE 217
Chapter 7Nutrition and Fitness Problems: Prevention and Services II-217 more priority to healthful food choices when they decide what to eat (253). Food Labels Data from the National Adolescent Student Health Survey in 1987 suggest that adolescents in the 8th and 10th grades are able to apply basic skills in solving nutrition-related consumer problems but lack certain specialized consumer information which would permit them to make wise food choices (7). Further, only 27 percent had previously received any education or instruction during school in interpreting food labels. The current national debate on the content of food labels (108,149) highlights the importance of information in making informed nutritional choices. In addition to recommending Federal regulations regarding nutrition labeling, a recent Institute of Medicine report calls for regulations that would require fast-food restaurants to provide nutrition information to consumers (149). Menus in Schools and Institutions Many schools incorporate the principles of USDA and DHHS Dietary Guidelines for Americans (227) in their meal planning (241). Nevertheless, it has been reported that school meals are high in fat (37,70,164). Modifying school menus appears to command some public support (216). One study successfully altered the diets of students by modifying the menu and the way foods were prepared (the polyunsaturated-to-saturated fat ratio of the diet of students who were served fat-modified diets increased significantly) (61). Low-income adolescents in participating schools can receive breakfast and lunch at school free or at a reduced price (see section below on Federal programs). USDA prepares recipes for schools to use in planning their meals. Evaluations of these meal programs have shown that they have a positive overall effect on the nutritional intake of the participants (216), although as noted above, they may be high in fat. Conclusions Nutrition education, either as a component of school health education curricula or more targeted outreach programs, is available from a number of sources and most adolescents appear to receive some nutrition education, at least while they are in school. There is little information about the effect of nutrition education on adolescent dietary behaviors, though some studies show that there are effective interventions. Providing nutritional foods in meals provided by schools may provide as much benefit to adolescents as nutrition education does. Influencing Adolescents Physical Activity Levels Physical Education in Schools As noted above, students attend physical education classes in decreasing numbers throughout adolescence. Further, these classes do not provide much opportunity for physical activity (20 percent of class time) (13). The emphasis in physical education classes is on competitive sports rather than on activities and skills that can be more easily carried over to later years (e.g., swimming, tennis, and cycling) (13,196). Although there is little adolescent specific information on the effects of not participating in so-called lifetime physical activity during adolescence, there is a general consensus that adolescents could benefit from additional physical activity (e.g., 3,241). Community Facilities for Physical Activities Several observers have suggested that every adolescent should have access to public facilities and community programs that encourage safe, beneficial, enjoyable physical activity (177,184). Many adults believe that greater availability of exercise facilities would help them become more involved in regular exercise (241). To OTAs knowledge, adolescents have not been asked about their recreational needs or preferences. A 1986 survey of municipal and county park and recreation departments found that the average number of citizens per managed acre was well within the standards set by the National Recreation and Park Association (138). But the numbers of trails (for hiking, jogging, bicycling, or cross-country skiing), pools, tennis courts, and basketball courts per citizen are below those suggested by the National Recreation and Park Association (138), and the DHHS publication Healthy People 2000 recommends that communities establish additional opportunities for engaging in physical activity (box 7-D) (241). Conclusions Opportunities for adolescents to participate safely in physical activity are hampered by the current construction of school physical education classes, the lack of certified physical education teachers and
PAGE 218
II-218 Adolescent HealthVolume II: Background and the Effectiveness of Selected Prevention and Treatment Services Photo credits: Education Week (top photo); Benjamin Smith (bottom photo) Some observers concerned about adolescent health have noted that opportunities for physical activity during adolescence tend to emphasize competitive sports (top) rather than activities and skills that can be more easily carried over to later years (bottom). coaches, and the lack of community facilities for physical activity. Interventions To Prevent or Reduce Adolescent Obesity The effectiveness of specific treatment interventions to help obese adolescents appears to be dependent on a multiple approach that includes diet, exercise, behavioral techniques, and the support of families, communities, or peers (93a,97a,247). Further, some interventions to prevent obesity take an environmentally based approach meant to narrow the range of adolescents food choices (61,97a). Powerful predictors of success in fitness and obesity control include afterschool activities of adolescents at home and in the community (165). When parents and children participate in obesity control programs together and incorporate all program elements (e.g., behavior modification practices), they can be fairly effective (28). An example of a family-based program is Shapedown, which involves behavior modification, physical activity, modest reduction in food intake, and attention to the families and adolescents views of themselves (141a). Clinical treatment of obesity has been found to be effective when it includes the traditional emphasis on increased physical activity with modest decreases in energy inputs combined with behavioral techniques (62), including self-monitoring diet and exercise, control of stimuli that precede eating, and reward of desirable behaviors. One review of various treatment schemes for pediatric obesity suggests that the most effective school-based programs include exercise, nutrition, and behavior modification (248). Five elements are important for school-based programs: physical education programs, classroom education, the school lunchroom, the school health office, and liaison with home and community programs. Obese adolescents need help in setting realistic targets for fatness and weight loss (57,59,97a). Support programs using younger and older peers, with frequent reinforcement of progress from teachers, physical education instructors, school nurses, and others are also important (207).
PAGE 219
Chapter 7Nutrition and Fitness Problems: Prevention and Services II-219 Major Federal Programs Related to Nutrition and Fitness U.S. Department of Agriculture USDA is the Federal agency with major responsibility for Federal nutritional programs, including the collection of data on topics listed in box 7-A and the provision of food services for low-income people. USDAs Human Nutrition Information Service conducts and interprets applied research in food and nutrition. Its responsibilities include monitoring food and nutrient content of American diets, assessing dietary status and trends in food consumption, understanding food choice influences, maintaining the national nutrient data bank on the nutrient content of foods, and developing information and techniques for making informed food choices. USDAs Food and Nutrition Service administers the Federal Food Stamp Program and Child Nutrition Programs (including National School Lunch and Breakfast Programs, the S ummer Food Service Program, the Special Supplemental Food Program for Women, Infants, and Children 27 and the Child Care Food Program). The Food Stamp Program is a program that provides low-income individuals and families with children with noncash transfers which can be used only for food. Eligibility is based on family income. The amount of the benefit for each family is calculated based on a number of family-dependent factors (e.g., work and child care expenses) and on the cost of the Thrifty Food Plan (based on an inexpensive, but nutritionally sound diet). For those participating, the program has been associated with significant improvements in dietary intake (217). But, according to USDAs 1977-78 Nationwide Food Consumption Survey, 28 only 12 percent of low-income households spending at the full food stamp allotment obtained 100 percent of their recommended dietary allowances, and only a third obtained at least 80 percent (217). Adolescents ages 15 to 17 make up 34 percent of the participants in the Food Stamp Program, but all eligible adolescents may not benefit. In 1979, less than 60 percent of all poor households participated in the Food Stamp Program (216). Other food programs directly affecting adolescents are the School Breakfast and School Lunch programs, which provide meals for low-income school children free or at a reduced price depending on family income. The programs have been shown to increase the amount of food consumed by participants, as a supplement for family meals rather than as a substitute (216). A 1981 USDA study found that students from families qualifying for free or reduced-price meals were dependent on the National School Lunch Program for between 34 and 49 percent of their daily nutrient intake (217). Forty-three percent of individuals in the National School Lunch Program and 24 percent in the School Breakfast Program are adolescents ages 13 to 18, (see table 7-8). In 1983,92 percent of all elementary and secondary schools participated in the National School Lunch Program (214), but the School Breakfast Program was available in only about a third of all schools (215). Schools that participate in the School Breakfast Program are generally located in low-income areas (215). U.S. Department of Health and Human Services Within DHHS, nutrition research and monitoring are principally conducted by two Public Health Service agencies: the Centers for Disease Control and the National Institutes of Health (see below). These make up the Departments major effort related to the nutrition of adolescents. Other nutritionrelated services are provided to adolescents by the Bureau of Maternal and Child Health in the Health Resources and Services Administration of DHHS, 29 by the Indian Health Service, and by the Office of Human Development Services. The Office of the Assistant Secretary for Health compiles DHHS Health Objectives for the Year 2000 (found in the recent DHHS publication, Healthy People 2000), which include nutritionand physical activityrelated policy objectives (box 7-D). 27~e Swlal Supplement Food ~ou~ for Women, Infants, and Children (WIC) was mentioned in an eulier smtion about Pre~t ~ole~n~. 28Da~ from the 1987.88 Nationwide Food Comumption Survey were not available as of mid-1991. 2~e Bweau of ~tem~ ~d ~]d H~lth provides nu~tioml support princip~ly in the form of bl~k grants to States for the prOviSiOn Of nU~tiOnld semices. Also, funds for training public health nutritionists and research and program development projects are disseminated through the sp=ial programs of regional and mtioml significance (SPRANS) program.
PAGE 220
//-220 Adolescent HealthVolume II: Background and the Effectiveness of Selected Prevention and Treatment Services Table 7-8-Participation in the National School Breakfast and National School Lunch Programs, 1983-84 School Year Number of students participating Number of students in the program at participating on an Average daily least once per week Participation average day (ADP) participation (thousands) rate (thousands) (ADP) rate School Breakfast Program a All students . . . . . . Meal price status Free . . . . . . . Reduced . . . . . . Full . . . . . . . . Grade level 1-3 . . . . . . . . 4-6 . . . . . . . . 7-9 . . . . . . . . 10-12 . . . . . . . School Lunch Program All students . . . . . . Meal price status Free . . . . . . . Reduced . . . . . . Full . . . . . . . . Grade Ievel 1-3 . . . . . . . . 4-6 . . . . . . . . 7-9 . . . . . . . . 10-12 . . . . . . . 3,609 2,564 222 823 1,316 1,337 614 342 30,078 9,763 1,816 18,497 8,327 8,535 7,373 5,841 24.2?! 53.9 20,6 9.0 31.3 31.5 17.4 11.6 77.570 96.2 91.4 69.4 87.9 85.0 76.0 61.0 2,733 2,107 157 469 1,049 1,027 425 232 25,550 9,319 1,658 14*574 6,916 7,644 6,230 4,761 18.3% 44.3 14.6 5.1 25.0 24.2 12.0 7.8 65.9%0 91.8 83.4 54.7 73.0 76.1 64.2 49.7 aAStudent iSapartiCipant inthe%hwlBre~~tprOgram (School Lunch Program)ifhe orsheselects oneormore breakfasts (h.mches)dur ingaweek.The partk@ationrafeisthenumberofparticipantsdivided bythetotalnumberofstudentsin schoolsthatoffertheprogram.The numberofstudentsparticipating on an average day (ADP) is calculated as one-fifth the reported number of meals served in a week. The ADP rate is the ADP divided by the total number of students in schools that offer the program. SOURCE: U.S. Department of Agriculture, Food and Nutrition Service, Office of Analysis and Evaluation, Characteristics of the National School Lunoh and School Breakfast Program Participants, Washington, DC, January 1988. Centers for Disease Control CDC works to promote sound nutritional habits through comprehensive school health programs. CDCs efforts include: 1) building consensus regarding priority nutrition intervention issues for the purpose of developing national guidelines; 2) collaborating with USDA to ensure that these guidelines incorporate the perspective of the Nutrition Education and Trainin g Program and National School Lunch and Breakfast Programs; and 3) reviewing State policies relevant to nutrition intervention in schools and to school breakfast and lunch programs. In addition, as noted earlier, CDC is developing the Youth Risk Behavior Surveillance System (YRBSS) to monitor trends in the prevalence of priority risk behaviors among youth at the national and State levels (see box 7-A). CDC also supported the 1987 National Adolescent Student Health Survey (7). The National Center for Health Statistics in CDC conducts the National Health and Nutrition Examination Survey (NHANES) and the National Health Interview Survey (NHIS) (see box 7-A), which collect nutrition and health data on adolescents. National Institutes of Health National Heart, Lung, and Blood Institute (NHLBI)--In April 1991, NHLBI issued the Panel Draft Report of the National Cholesterol Education Program, which called for all Americans over 2 years of age to adopt a low saturated fat, low cholesterol diet. Also, NHLBI is conducting a multicenter monitoring project to compare risk factors, such as hyperlipidemia and blood pressure, in black and white adolescent females. National Cancer Institute (NCI)--NCI is supporting, through a collaboration between NCI and the American Cancer Society, a school-based nutrition education project to improve adolescent health. A curriculum for intermediate and secondary school students is being pilot tested in four regions. A companion manual for food service providers is also being tested as an aid in making school lunch
PAGE 221
Chapter 7Nutrition and Fitness Problems: Prevention and Services II-221 programs consistent with USDA and DHHS Dietary Guidelines for Americans (227). Conclusions and Policy Implications Conclusions about U.S. adolescents nutritional and fitness status are difficult to draw for several reasons. Current national data on U.S. adolescents nutrition and fitness are not available. Research on nutrition and on fitness is hampered by inconsistent outcome measures and other methodological problems (225). Extrapolating from available information, OTA concludes that the most prevalent nutritional problems among todays adolescents are overweight or obesity, iron deficiency anemia, and eating disorders. Obesity is often associated with low levels of physical activity and poor self esteem. Obese adolescents may be at increased risk of heart disease, hypertension, diabetes (particularly if obesity is continued during adulthood) and certain cancers. For female adolescents, especially female athletes and females who are pregnant, iron deficiency anemia is a particular problem, because it decreases physical ability, resistance to infection, and intellectual performance. During pregnancy, anemia can also affect the health status of the fetus (low birthweight, premature delivery, and fetal death). Calcium, another mineral often deficient in adolescent diets, is important for achieving peak bone growth. Female adolescents with anorexia nervosa or bulimia are at great risk of experiencing health problems and even death. Some evidence suggests that the diets of American adolescents are high in fat and sodium. High-fat diets can contribute to obesity in the short term, and, if such diets persist, to the occurrence of some cancers (e.g., colon and breast), coronary heart disease, and non-insulin-dependent diabetes later in life (152). Some adolescents with physical disabilities or chronic diseases (e.g., diabetes) require special attention to meet their nutritional and physical activity needs. Some diseases and medications can affect the absorption of nutrients, and sometimes, therapeutic diets can help control diseases (e.g., diabetes). The availability of special health, food, and education services in schools and school food services for these adolescents is often limited. U.S. adolescents ability to make good nutritional choices and decisions about physical activity for themselves may be influenced by the information Photo credit: Benjamin Smith, Washington, DC Very often, adolescents have little control over the food available to them. Congress could support efforts to provide better nutritional choices to adolescents. provided to adolescents (or lack of it) about the foods they eat and the effects of physical activity. Nutritional information about school menus and fast food meals may not be routinely available to adolescents (although some fast food restaurants make or plan to make nutritional information more accessible at point of purchase). Many health education classes include nutrition education as a component, but it is not clear that these classes alone significantly influence the eating habits of adolescents. Some evidence suggests that education curricula that take adolescents preferences into account may be better received than curricula that do not. Most adolescents get breakfast and lunch from home or school, so food choices (at least for these two meals) may be dependent on whoever buys the groceries or plans the menus. There have been several calls to improve the nutritional content of school (37) and fast food (27a) meals. Access to fitness-promoting activities is apparently a problem for adolescents. Enrollment in physical education classes declines somewhat during the adolescent years; in any event, school-based physical education classes appear to provide little opportunity for actual physical activity. For adolescents in general, there is little information about the specific benefits of physical activity; for example, there is no research to suggest that physical activity during adolescence leads to continued activity as an adult. It is clear, however, that increased physical activity could help overweight
PAGE 222
//-222 Adolescent HealthVolume II: Background and the Effectiveness of Selected Prevention and Treatment Services adolescents reduce their weight and thereby reduce the immediate psychological consequences of obesity and the potential risk of future chronic diseases. Specific policy options regarding adolescents nutrition, physical activity, and physical fitness are listed in Volume I. Chapter 7 References 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15, 16. 17. 18. Agre, J. C., Findley, T.W., McNally, C., et al., Physical Activity Capacity in Children With Myelomeningocele, Archives of Physical Medicine and Rehabilitation 68(6):372-7, June 1987. American Academy of Pediatrics, Committee on Nutritioq Prudent Lifestyles for Children: Dietary Fat and Cholesterol, Pediatrics 78:521-525, 1986. American Academy of Pediatrics, Committee on Sports Medicine and Committee on School Heal@ Physical Fitness and the Schools, Pediamcs 80(3):449450, 1987. AmericanAcademy of Pediatrics, Committee on Sports Medicine and Committee on School Heal@ Organized Athletics for Preadolescent Children, Pediatrics 84(3):583-584, 1989. American Heart Association Dieta~ Guidelines jor Healthy American Adults (Dallas, TX: American Heart Association 1986). American Psychiatric Associatio~ Diagnostic and Statistical Manual of Mental Disorders, 3rd cd., revised (DSM-111-R) (wSShiIlgtOq DC: 1987). American School Health Association, Association for the Advancement of Health Educatioq Society for Public Health Educatioq Inc. The National Adolescent Student Health Survey: A Report on the Health of Americas Youth (Oakland, CA: Third Party Publishing Co., 1989). Anderse~ E., Mahoney, L., Lauer, R., and Clarke, W., Progeny of Hypertensive Have Altered Hemodynamic Mechanisms During Mental Challenge, Circulation Part Ii 72(4):259, 1985. Anderson, J. L., Womens Sports and Fitness Programs at the U.S. Mititary Academies, Physician Sports Medicine 7:72-82, 1979. Avons, P., and James, W.P., Energy Expenditure of Young Men From Obese and Nonobese Families, Human Nutrition: Clinical Nutrition 1OC:259-27O, 1986. Bachrach, L.K., Guide, D., Katnnaq D., et al., Decreased Bone Density in Adolescent Girls With Anorexia Nervosa, Pediatrics 83(6) :440-447, 1990. Baer, M, T., Nutrition Services for Children With Handicaps, Children and Youth: A Comprehensive Commentary and Clinical Approach, H.M. Wallace, R.F. Biehl, and A.C. Ogelsby (eds.) (New York NY: Humau Services Press, 1987). Bar-Or, O., Climate and the Exercising Child: A Review, International Journal of Sports Medicine 1:53-65, 1980. Bw-Or, O., Pathophysiological Factors Which Limit the Exercise Capacity of the Sick Child, Medicine and Science in Sports and Exercise 18:276-282, 1986, Bar-Or, O., A Comrnentmy to Chiluren and Fitness: A Public Health Perspective, Research Quarterly for Exercise and Sport, 53:304-347, 1987. Bar-Or, O., Tbe Prepubescent Fernale, Women and Exercise: Physiology and Sports Medicine, M.M. Shangold and G. Mirkin (eds.) (Philadelphia% PA: Davis, 1988). Barrow, G.W., and Saha, S., Menstrual Irregularity and Stress Fractures in Collegiate Fernale Distance Runners, American Journal of Sports Medicine 16:209-215, 1988. Beaton, G. H., Criteria of an Adequate Die4 Modern Nutrition in Healfh and Disease, 7th cd., M.E. Shils and V.R. Young (eds.) (Philadelphia, PA: Lea and Febiger, 1988). 19. 20. 20a. 21. 22. 22a. 23. 24. 25. 26. 27. 27a. 28. 29. 30. 31. 32. 33. 33a, 34. 35. 36. Becque, M. D., Katc~ V.L., Rocchini, A.L., et al., Coronary Risk Incidence of Obese Adolescents: Reduction by Exercise Plus Diet Intemmtio~ Pediatrics 81:605-612, 1988. Berenson, G. S., Cardiovascular Risk Factors in Children: The Early Natural History ofAtherosclerosis andEssential Hypertension (New York NY: Oxford University Press, 1980). Bergeise~ L., Physical Health of Indian Adolescents, contract paper prepared for Oflice of Ikdmology Assessmen~ U.S. Congress, Washington DC, November 1989, Berkowitz, R.I., Agras, J.A., Komer, A.F., et al., Physical Activity and Adiposity: A Longitudinal Study from Birth to Childhood, Journal of Pediatrics 106:734-738, 1985. Berl@ J.A., and Colditz, G.A., A Meta-A.nalysis of physi~ Activity in the Prevention of Coronary Heart Disease, American Journal of Epidenuology 132(4):612-628, 1990. Blair, S.N., Kohl, H.W., Paffenbarger, R. S., et al., Physical Fimess and All-Cause Mortality: A Prospective Study of Healthy Men and Womeq Journal of the American Medical Association 262:2395-2401, 1989. BIOCIL J.E., Genan~ H.K., and Black D., Greater Vertebral Bone Mineral Mass in Exercising Young Meq Western Journal of Medicine 145:39-42, 1986. Boatright-Wilsoq J., Womtm and Poverty: A Demographic Overview, Women, Health, and Poverty: Women and Health 12(3 and 4):2140, 1987. Boskind-White, M., and White, W., Buhrnarexia: A Historical Sociocuhral Perspective Handbook of the Eating Disorders, K. BrownelJ and J. Foreyt (eds.) (New York NY: Basic Books, 1986). Bouchard, C., Tremblay, A., Despres, J., et al., The Response to Imng-T&rn Overfeeding in Identical Twins, New EngZand Journal of Medicine 322(21):1477-1482, 1990. Bougneres, P., Artavia-Loria, E., Henry, S., et al., Lncreased Basal Glucose Production and Utilization in Chikiren With Recent Obesity Versus Adults With Long-Tkrrn Obesity, Diabetes 38:477-483, 1989. Breo, D.L., Phil Sokolof Fights the Fatting of Ameri~ Journal of the American Medical Association 264:3071-3073. Brovvnell, K.D., Kehnan, J.H., and Stunkard, A.I., Treatment of Obese Children With and Without Their Mothers: Changes in Weight and Blood Pressure, Pediatncs 71:5 15-523, 1983. Buckley, W.E., Yesalis, C.E., Friedl, K.E., et al., Estimated Prevalence of Anabolic Steroid Use Among Male High School Seniors, JournaIoftheAmerican Me&calAssociation 260:34413445, 1988. Bulleq B., Reed, R.B., and Mayer, J., Physical Activity of Obese and Nonobese Adolescent Females as Appraised by Motion Picture Sampling, American Journal of Clinical Numtion 14:21 1-218, 1970. Bums, T. L., Obesity Gene, The Brown University Child Behavior and Development Letter, p.7, January 1990. Burr, M., Sweetnaq P., and Barasi, M., Dietaxy Fibr, Blood Pressure, and Plasma Cholesterol, Numtion Reviews 5:465472, 1985. Byrd-Bredbenner, C., OConnell, H., ShannoQ B., et al., A Nutrition Curriculum for Health Education: Its Effect on Students Knowledge, Attitude, and Behavior, Journal of School Health 54(10):385-388, 1984. Care~ L. D., Effects of Exercise on the Human Immune System, Bioscience 41 :410-415. @XZ, R.C., and Offer, D., Weight and Dieting Concerns in Adolescents, Fashion or Symptom? Pediatrics 86(3):384390, 1990. Casperseu C., Powell, K.E., Christenson, G. M., et al., Physical Activity, Exercise, and Physical Fimess: Definitions for HealthRelated Researc4 Public Health Reports 100:126-131, 1985. Center on Budget and Policy Priorities, Holes in the Safety Nets: Poverty Programs and Policies in the States: National Overview (Washington DC: 1988).
PAGE 223
Chapter 7Nutrition and Fitness Problems: Prevention and Services II-223 37. 38. 39. 40. 41. 42. 43. 44. 45. 46. 47. 48. 49, 50. 50a. 51. 52. 53. 54. 55. 56. 57 Citizem Committee on School Nutrition, White Paper on SchooZ-Lunch Nutrition (Wmhington, DC: Center for Science in the Public Interest, 1990). Clarke, W., Gates, R., Hogan, S., et al., Neuropsychological Studies on Adolescents With Phenylketonuria Returned to Phenylalanine-Restricted Diets, American JournaZ of Mental Retardation 92(3):244-262, 1987. Clarke, W., Schrott, H., Bums, T., et al., Aggregation of Blood pressure in the Families of Children With Labile High Systolic Blood pressure, American Journal of Epidemiology 123:67-80, 1986. Coates, T., Jeffery, R., and Slinkard, L., Heart Healthy Eating and Exercise: Introducing and Maintaining Changes in Health Behaviors, American Journal of Public Health 71: 15-23, 1981. Cohen, J. C., and Hickman, R., Insulin Resistance and Diminished Glucose Tolerance in Powerlifters Ingesting Anabolic Steroids, Journal of Clinical Endocrinology and Metabolism 64:960-963, 1987. Colbum+ D., Serious Injuries Up in High School Football, Washington Pos~, Health Section, p. 7, Feb. 21, 1989. Colten, H. R., Cystic Fibrosis, Harrisons Principles of Internal hledicine, 1 lth cd., E. Braunwald, K.J. lsselbacher, R.G. Petersdorf, et al. (eds. ) (New York, NY: McGraw Hill, 1987). Contento, I. R., Michel& J. L., and Goldberg, C. J., Food Choice Among Adolescents: Population Segmentation by Motivations, Journal of Nutrition Education 20:289-298, 1988. Crayton, E.F., Auburn University, Extention Foods and Nutr i tion, presentation at Nutrition Symposium held by U.S. Department of Health and Human Services, Public Health Service on Nutrition and Minority Populations, Washington, DC, Mar. 14, 1990. Crcsant% J. L., Burke, G. L., Downey, A. M., et al., Prevention of Atherosclerosis in Childhood, Pediatric Chnics of Norrh America, 33:835-58, 1986. Cromcr, B., Thomas, S. D., Padill% L. D., et al., Riboflavin Status in Urban Adolescents, Journal of Adolescent Health Care 10:382-385, 1989. Dahlquist, G. G., Blom, LG., Persson, L., et al., Dietary Factors and the Risk of Developing Insulin Dependent Diabetes in Childhood, British Medical Journal 300:1302-1306, 1990. Dallman, P. R., Biochemical Basis for the Manifestation of Iron De ficiency, Annual Revieul of Nutrition 6:13-40, 1986. DeHaven, K., and Lintner, D., < Athletic Injuries: Comparison by Age, Sport, and Gender, American Journal of Sports Medicine 14(3):218-224, 1986. DeLapa, R. M., Mayer, J. A., Candelaria, J., et al., Food Purhcase Patterns in a Latino Community: Project Sals& Journal of Nutrition Education 22: 133-136, 1990. Dennison, B. A., Kikuchi, D. A., Srinivasan, S. R., et al., Serum Total Cholesterol Screening for the Detection of Elevated Lmw-Density Lipoprotein in Children and Adolescents: The Bogalusa Heart Study, Pediatrics 85(4):472479, 1990. Deuster, PA., Day, B. A., Singh, A., et al., Zinc Status of Highly Trained Women Runners and Untrained Women, American Journal of Clinical Nutrition 49:1295-1301, 1989. Dietz, W. H., Childhood Obesity: Susceptibility, Cause, and Management, Journal of Pediatrics 103:676-686, 1983. Dietz, W. H., Prevention of Childhood Obesity, Pediaoic Clinics of North America 33:823-834, 1986. Dietz, W. H., and Gortrnaker, S. L., Factors Within the Physical Environment Associated With Childhood Obesity, American Journal of Clinical Numition 39(4):619-624, 1984. Dietz, W. H., Gortrnaker, S. L., Sobol, A. M., et al., Trends in the Prevalence of Childhood and Adolescent Obesity in the United States, Pediatric Research 19: 198A-1203A, 1985. Dwycr, J. T., Diets for Children and Adolescents That Meet the Dietary Goals, American Journal of Diseases of Children 134: 1073-1080, 1980. 58. 59. 59a. 60. 61. 62. 63. 64. 65. 66. 67. 68. 69. 70. 71. 72. 73. 74. 75. 76. 77. Dwyer, J. T., Assessment of Dietary Intake, Modern Nutrition in Health and Disease, 7th cd., M.E. Shds and V.R. Young (eds.) (Philadelphia, PA: Lea and Febiger, 1988). Dwyer, J. T., and Mayer, J., Psychosexual Aspects of Weight Control and Dieting Behavior in Adolescents, Medical Aspec(s of Human Sexua/i~ 7:82-1 14, 1973. Dwyer, J. T., and Meredith, C., Great Expectations: Adolescent Nutrition and Fitness, contract paper prepared for the Office of Technology Assessment, U.S. Congress, Washington DC, 1989. Dyckncr, T., and Wester, P., The Effect of Magnesium on Blood Pressure, British Medical Journal 286: 1947-1949, 1983. Ellisom R. C., Goldberg, R. J., Witschi, J. C., et al., Use of Fat-Modified Food Products To Change Dietary Fat Intake of Young people, American Journal of Public Health 80(11): 13741376, 1990. Epste@ L. H., Wing, R. R., Penner, B. C., et al., Effect of Diet and Controlled Exercise on Weight Loss in Obese Children, Journul of Pediatrics 107:358-361, 1985. Evcrson, S. K., and Freedson, P. S., Familial Aggregation and Physical Activity, Medicine and Science in Sports and E.rercise 21:S94, 1989. Ferris, R. P., Cresanta, J. L., Frank+ G. C., et al., Dietary Studies of Children From a Biracial Population: Intakes of Fat and Fatty Acids in 10and 13-Year-Olds, American Journal of Clinical Nutrition 39: 114-28, 1986. Fixlcr, D., and Group on Physician Behaviors To Reduce Smoking, Epidemiology of Childhood Hypertension, Atherosclerosis: Its Pediatric Aspects, W.B. Strong (cd.) (New York NY: Grune and Stratton+ 1978). Forbes, G.B., The Effect of Anabolic Steroids on Lean Body Mass: The Dose Response curve, Metabolism 34:57 1-573, 1985. Ford, C., McGandy, R., and Stare, F., An Institutional Approach to the Dietary Regulation of Blood Cholesterol in Adolescent Males, Preventive Medicine 1:426-445, 1972. Ford, E., Heati G., Merrit, R., et ai., Physical Activity and Socioeconomic Status, Medicine and Science in Sports and Exercise 21:S94, 1989. Foster, D. W., Diabetes Mellitus, Harrisons Principles of Internal Medicine, 1 lth cd., E. Braunwald, K.J. Isselbacher, R.G. Petcrsdorf, et al. (eds.) (New York, NY: McGraw Hill, 1987). Franlq G., Wden+ A., Martin, J., School Health Promotion: Child Nutrition Programs, Journal of School HeaZth 57:45 1460, 1987. Freedman, D. S., Burke, G.L., Harsh% D.W., et al., Relationship of Changes in Obesity to Serum Lipid and Lipoprotein Changes in Childhood and Adolescence, Journal of the American Medical Association 254:515-520, 1985. Friedman, G., and Goldberg, S., An Evaluation of the Safety of a Lmw Saturated Fat, Imw Cholesterol Diet Beginning in Infancy, Pediatncs 58:655-667, 1976. Frisch, R. E., WysU G., Albright, N. L., et al., Lower Lifetime Occurrence of Breast Cancer and Cancers of the Reproductive System Among Former College Athletes, Anterican Journal of Clinical Nutrition 45(suppl. 1):328-335, 1987. Gabbay, K., Treatment of Diabetes Mellitus, Pediatric Numtion: Theory and Practice, R. Grand, J. Sutpheq and W. Dietz (eds.) (Boston, MA Butterworths, 1987). Gallagher, S., Finison, K., Guycr, B., et al., The Lncidence of Injuries Among 87,000 Massachusetts Children and Adolescents: Results of the 1980-81 Statewide Childhood hjury prevention program Surveillance System, Amencan Journal of public Heafth 74(12):1340-1347, 1984. Garabrant, D. H., Peters, J. M., Mac~ T. M., et al., Job Activity and Colon Cancer Risk American Journal of Epidemiology 119: 1005-1014, 1984. Garfinkel, P., Moldofsky, H., and Gamer, D., The Heterogeneity of Anorexia Nervosa, Archives of General Psychiatry 37: 1030-1040, 1980.
PAGE 224
//-224 Adolescent HealthVolume II: Background and the Effectiveness of Selected Prevention and Treatment Services 78. 79. 80. 81. 82. 83. 84. 85. 86. 87. 88. 89. 90. 91. 91a. 92. 93. 93a. 94. 95. %. 97. 97a. Garn, S. M., and Clarlq D.C., Trends in Fatness and the Origins of Obesity, Pediatrics 47:433-456, 1976. Garn, S. M., hVelle, M., Rosenberg, K., et al., Maturational Timing As a Factor in Female Fatness and Obesity, American Journal of Clinical Nutrition 43:879-883, 1986. Garn, S. M., Ridell% S.A., Petzold, A. S., et al., Maternal Hematologic Levels and Pregnancy Outcomes, Semnars in Pennatology 5:155-162, 1981. Gene Reilly Group, The Child (New York, NY: 1977). Gerhardssou M., Norell, S.E., Kiviranta, H., et al., Sedentary Jobs and Colon Cancer, Amencan Journal of Epidemiology 123:775-780, 1986. Godsland, I.F., Shennaq N. M., and Wynq V., Insulin Action and Dynamics Modelled in Patients Taking the Anabolic Steroid Methandienone @anabol), Clinical Science 71 :665-673, 1986. Goldm B.R., Adlercreutz, H., Gorback S.L., et al., Estrogen Excretion Patterns and Plasma Levels in Vegetarian and Omnivorous Women, New EnglandJournal of Medicine 307(25): 15421547, 1982. Gortmaker, S. L., Dietz, W.H., and Cheung, L. W.Y., Inactivity, Dieg and the Fattening of America, Journal of the American Dietetic Association 90:1247-1255, 1990. Gortmaker, S.L., Die@, W.H., Sobol, A.N., et al., Increasing Pediatric Obesity in the United States, American Journal of Diseases of Children 141:535-540, 1987. Gortrnaker, S. L., and Sappenfield, W., Chronic Childhood Disorders: Prevalence and hnpac~ Pediattic Clinics of North America 31:3-18, 1984. ~lths, M., Payne, P.R., Stunkard, AJ., et al., Metabolic Rate and Physical Development in Children at Risk of Obesity, L.ancet 336:76-78, 1990. Gyarfas, I., Blood Pressure in Childhood and Adolescence: Results From an International Collaborative Study on Juvenile Hypertension Acta Paediamca Scandinavia 318(Suppl):l 1222, 1985. Hamill, P. V., Drizd, T.A., and JohnsoG C.L., Physical Growth: National Center for Health Statistics Percentiles, American Journal of Clinical Nutrition 32:607-629, 1979. Harlan, W. M., Landis, J. R., Flegal, K.M., et al., SecularTrends in Body Mass in the United States, 19601980, American Journal of Epidemiology 128:1065-1074, 1988. Henig, R. M., Fitness Dilemma: Getting Kids Off the Couc& Getting Moms Off Kids Backs, Washington Post, Health Section, Apr. 3, 1990. Herzog, D., Bulimia in the Adolescent, American Journal of Diseases of Children 136:985-989, 1982. Hobbs, N., Perr@ J., and Ireys, H., Chronically 111 Chi/dren and Their Fanulies, Issues in the Care of Children With Chronic Illness, N. Hobbs and J. Perrin (eds.) (San Francisco, CA: Jossey Bass, 1985). Hoerr, S. L. M., Nelso@ R.A., and Essex-Sorlie, D., Treatment and Follow-Up of Obesity in Adolescent Girls, Journal of Adolescent Health Care 9:28-37, 1988. Howie, BJ., and Schultz, T.D., Dietary and Hormonal Interrelationships Among Vegetarian Seventh-Day Adventists and Nonvegetarian Me& Amencan Journal of Clinical Numtion 42:127-134, 1985. Hurley, B.F., Seals, D.R., Hagberg, J. M., et al., High-Density Lipoprotein cholesterol in Bodybuilders v. Powerlifters: Negative Effects of Androgen Use, Journal of the American Medical Association 252:507-513, 1984. Iacono, J., Dougherty, R., and Puska, P., Reduction of Blood Pressure Associated With Dietary Polyunsaturated Fat, Hypertension 4(Suppl. 3):3442, 1982. Inbar, O., and Bar-Or, O., Anaerobic Characteristics in Male Children and Adolescents, Medicine and Science in Sports and Exercise 18:264-269, 1986. Jackson, M.Y,, Proulx, J.M., and PelicW S., Obesity Prevention American Journal of Clinical Numtion 53: 1625 S-1630S, 98. 99. 100. 101. 102. 103. 104. 105. 106. 106a. 107. 108. 109. 110. 111. 112. 113. 114. 115, 116. 1991. Jacobson, P.C., Beaver, W., Grubb, S.A., et al., Bone Density in Women: College Athletes and Older Athletic Women, Journal of Orthopedic Research 2:328-332, 1984. JohnsorL C., Anorexia Nervosa and BuX Promoting Adolescent Health: A Dialog on Research and Practice, T. Coates, A. Peterseq and C. Peny (eds.) (New York, NY: Academy Press, 1982). Johnstoq F.E., Health Implications of Childhood Obesity, Annals of Internal Medicine 103:1068-1072, 1985. Joint National Committee on Detectioq Evaluation and Treatment of High Blood pressure, The 1988 Report of the Joint National Committee on Detectioq Evaluation and Treatment of High Blood Pressure, Annals of Internal Medicine 148: 10231038, 1988. Kanders, B., Dempster, D. W., and Lindsay, R. Interaction of Calcium Nutrition and physical Activity on Bone Mass in Young WomeWJournal of Bone andMineral Research 3:145-9, 1988. Kantor, M., Cullinane, E.M., Sady, S.P., et al., Exercise Acutely Increases High Density Lipoprotein Cholesterol and Lipoprotein Lipase Activity in Trained and Untrained Meq Metabolism 36:188-192, 1987. Kate@ V., Becque, M.D., Marks, C., et al., Oxygen Uptake and Energy Output During Walking of Obese Male and Female Adolescents, American Journal of Clinical Nutrition 47:26-32, 1988. Katc& V., Becque, M.D., Marks, C., et al., Basal Metabolism of Obese Adolescents: Inconsistent Diet and Exercise Effects, American Journal Cliru-cal Numtion 48:565-569, 1988. Kaye, W., Gwirtsrnaq H., Obarzanelq E., et al,, Caloric Intake Necessary for Weight Maintenance in Anorexia Nemosa: Nonbulimics Require Greater Caloric Intake Than Bulimics, Amencan Journal of Clinical Numtion 44:435443, 1986. Keiler, E.B., Mannin g, W. G., Newhouse, J.P., et al., The External Costs of a Sedentary Life-S tyle, American Journal of Public Health 79:975-980, 1989. Kemper, H. C., Snel, J., Verschuur, R., et al., Tracking of Health and Risk Indicators of Cardiovascular Diseases From lkenager to Adult: Amsterdam Growth and Health Study, Preventive Medicine 19:642-655, 1990. Kessler, D.A., The Federal Regulation of Food Labelling: Promoting Foods lb Prevent Disease, New England Journal of Medicine 321(11):717-725, 1989. Khaw, K., and Thorn, S., Randomized Double-Blind CrossOver Trial of Potassium on Blood Pressure on Normal Subjects, Lancer 2: 1127-1229, 1982. Killeq J., Telch, M., Robinsoq T., et al., Cardiovascular Disease Risk Reduction for Rmth Graders: A Multiple FactorSchool-Based Approack Journal of the American Medical Assoaation 260:1728-1733, 1988. z S.Y., Gergen, PJ., Malloy, M., et al., Dietary Patterns of U.S. Children: Implications for Disease Prevention Preventive Medicine 19:432-442, 1990. Kirkley, B., Bulimia: clinical Characteristics, Development, and Etiology, Journal of the American Dietetic Association 86;468-475, 1986. Koff, E., and Rierdan, J., Perceptions of Weight and Attitudes lbward Eating in Early Adolescent Girls, Journal ofAdoZescenr HeaZth 12(4):307-312, 1991. Krotkiewski, M., GudmundssorL M., Backstrom, P., et al. Zinc and Muscle Strength and Endurance, Acta Physiologic Scandinavia 116:309-31 1, 1982. Krowlewsu A., Cmessq M., Warram, J., et al., Predisposition to Hypertension and Susceptibility to Renal Disease in Insulin Dependent Diabetes Mellitus, New England Journal of Medicine 318: 140-145, 1988. K umanyilq S.K., Obesity in Black Womq Epidemiological Review 9:31-50, 1987.
PAGE 225
Chapter 7Nutrition and Fitness Problems: Prevention and Services II-225 117. 118. 119. 120. 121, 122. 123. 124. 125. 126. 127. 128. 129. 130. 131. 132. 133. 134. 135. 136. 137. 138. Kumanyika, S. K., and Helitzer, D.L., NutritioL Report of the Secretarys Task Force on Black and Minority Health: Volume II: Cross Cutting Issues in Minority Health (Washington, DC: U.S. Department of Heattb and Human Services, 1985). Lauer, R. M., and Clarke, W. R., Use of Cholesterol Measurements in Childhood for the Prediction of Adult Hypercholestcrolemia: The Muscatine Study, Journal of the American Medical Association 264(23):3034-3038, 1990. Izwis, M., BrurL J., Tahnage, H., et al., Teenagers and Food Choices: The Impact of Nutrition Education, JournaZ of Nutrition Education 20:336-340, 1988. Lipscomb, P. A., Bulimia: Diagnosis and Management in the Primary Care Setting, Journal of Famdy Practice 24: 187-194, 1987. Lloyd, T., Triantafyllou, S.J., Baker, E. G., et al., Women AtMetes With Menstrual Irregularity Have Incrm.sed Musculoskeletal Injuries, Medicine and Science in Sports andExercise 18:374-379, 1986. Imoker, A. C., Sempos, C. T., Johnsom C.L., et al., Comparison of Dietary Intakes and Iron Status of Vitamin Mineral Supplement Users and Nonusers Aged 1-19 Years, American Journal of Clinical Nutrition 46:655-672, 1987. Lqez, R., Schwartz, J. V., Coope~ J. M., Riboflavin Deficiency in an Adolescent Population in New York City, Amencan Journal of Clinical Nutrition 33:1283-1286, 1980. Imu, H., Guttler, F., Lykkelund, C., et al., Decreased Vigitance and Neurotrammitter Synthesis After Discontinuation of Dietary Treatment for Phenylketonuria in Adolescents, European Journal of Pediatrics 144(1): 17-20, 1985. Louis Harris Associates, The Kelloggs Child Nutrition Suney (New Yorh NY: 1989). Lucas, A. R., Update and Review of Anorexia Nervosa, Contemporary Numtion 14(9): 1-2, 1989. Lyle, R., Melby, C., Hyner, G., et al., Blood Pressure and Metabolic Effects of Calcium Supplementation in Norrnotensive White and Black Males, Journal of the American Medical Association 257: 1772-1776, 1987. MacDonald, R., and Keen, C. L., Iroq Zinc, and Magnesium Nutrition and Athletic Performance, Sports Me(iicine 5: 171184, 1988. Maclaiq L. G., and Reynolds, S., Sports Injuries in a High School, Pediatrics 84(3):446-450, 1989. MacMahon, J.R., and Gross, R. T., Physical and Psychological EffecL$ of Aerobic Exercise in Delinquent Adolescent Males, America nJournal of Diseases of Children 142: 1361-1366, 1988. Mahani L. K., Nutrition in Adolescent Pregnancy, Nutrition in Adolescence, L.K. Mahan and J.M. Rees (eds.) (St. Louis, MO: Times Mirror/Mosby College Publishing, 1985). Malim, R. M., Bouchard, C., and Beune@ G., Human Growth: Selected Aspects of Current Research on Well-Nourished Childreni Annual Reviews in Anthropology 1717:187-238, 1988. kfan.som J. E., Colditz, GA., Stampfer, M.J., et al., A Prospective Study of Obesity and Risk of Coronary Heart Disease in WomeL New England Journal of Medicine 322(13):882-889, 1990. Marks, A., and Fisher, M., Health Assessment and Screening During Adolescence, Pediatrics 80(l) : Supplement, July 1987. Ma.wachusetts Medical Society, Committee on Nutrition, Sounding Board: Fast Food Fare: Consumer Guidelines, New England Journal of Medicine 321(11):7S2-756, 1989. McBean, L. D., Adolescent Nutrition: Issues and Challenges, Dairy Council Digest 58: 19-24, 1987. McCarron, D., Morns, C., Henry, H., et al., Blood Pressure and Nutrient Intake in the United States, Science 224: 1392-1398, 1984. McDonatd, B. L., and Cordell, H. K., Local Opportunities for Americans: Final Report of the Municipal and County Park and Recreation Study (Alexandria, VA: National Recreation and Park Association, 1983). 139. 140. 141. 141a. 142. 143. 144. 145. 146. 147. 148. 149. 150. 151. 152. 153. 154. 155. 156, 157. 158. 159. 160. 161. McGill, H., The Pathogenesis of Atherosclerosis, Clinical Chemistry 34: B33-B39, 1988. McKigney, J.I., and Munro, H. N., Nutrient Requirements of Adolescents (Cambridge, MA: MIT Press, 1976). Melby, C., Dun, P., Hyner, G., et al., Correlates of Blood Pressure in Elementary Schoolchildren% Journal of School Health 57:375-378, 1987. Mellin, L., Shapedown: Weight Management Program for Adolescents (San Francisco, CA: Balboa Publishing, 1983). Meredith, C. N., and Dwyer, J. T., Nutrition and Exemise: Effects on Adolescent HealtlL Annual Reviews in Public Health 12:309-333, 1991. Mitchell, J.E., Bulimia Nerves% Contemporary Numtion 14(10):1-2, 1989. Mikines, K.J., Sonne, B., Farrell. P.A., et at., Effect of Physical Exercise on Sensitivity and Responsiveness to Lnsuhn in Humans, American Journal of Physiology 254: E248-E259, 1988. Morgan+ K., Zabilq M.E., and Leveille, G.L., Food Behavior of Children, Research Report No. 374, Home and Family Lwing (East Lansing, MI: Agricultural Experiment Statioq Michigan State University, 1978). Morns, J.N., Everitt, M. G., Pollard, R., et al., Vigorous Exercise in Leisure-Time: Protection Against Coronary Heart Disease, Luncet 2: 1207-1210, 1980. Morrisou J., Larseu R., GlatfeIter, L., et al., *Interrelationships Between Nutrient Intake and Plasma Lipids and Lipoproteins in School Children Aged 6 to 19: The Princeton School District Study, Pediatrics 65:727-734, 1980. Murphy, J.F., ORiordu J., Newcombe, R. G., et al., Relation of Hemoglobin hvels in First and Second Trimesters to Outcome of Pregnancy, Lxrncet 1992-995, 1986. Nationat Academy of Sciences, Lnstitute of Medicine, Nutrition Labeling: Issues and Directions for the 1990s (Washington DC: National Academy Press, 1990). National Academy of Sciences, National Research Council, Recommended Dietary Allowances, 9th rev. ed. (Washington DC: National Academy Press, 1980). National Academy of Sciences, Nationat Research Council, Diet, Nutrition, and Cancer (Washingto% DC: National Academy Press, 1983). National Academy of Sciences, National Research CounciI, Diet and Health: Implicafions for Reducing Chronic Disease Risk (Vhshingtom DC: Nationat Academy Press, 1989). National Academy of Sciences, Natioml Research Council, Recommended Dietary Allowances, IOth rev. ext. (Washington+ DC: National Academy Press, 1989). National Academy of Sciences, National Research Council, Improving Americas Diet and Health: From Recommendations to Achon (Washington DC: National Academy Press, 1991). National Dairy Council, Diet and Nutrition Related Concerns of Blacks and Other Ethnic Minorities, Dairy Council Digest 59(6):31-35, 1988. Naylor, E. W., Screening for PKU Cofactor Variants, Disease: Screening and Management, T.P. Carter and A.M. Willey (eds.) (New Yorlq NY: Atan R. Liss, 1986). Newrnq T.B., Browner, W. S., Hullcy, S.B., The Case Against Childhood Cholesterol Screening, Journal of the American Medical Association 264(23):3039-3043, 1990. Nickersom H.J., Holubets, M. C., Weiler, B.R., et al., Causes of Iron Deficiency in Adolescent Athletes, Journal of Pediatrics 114:657-663, 1989. Nicldas, T.A., Farris, R.P., Major, C., et al., Dietary Intakes, American Journal of Clinical Nutrition 39:1 14-128, 1984. OConnell, D. G., Barnhart, R. C., and Parks, L., Strength Training in Disabled Children: Improvements in Strength and Wheelchak propulsion, Medicine and Science in Sports and Exercise 21:S95, 1989. Olefsky, J. M., *Obesity, Harrisons Principles of Internal Medicine, 1 lth cd., E. Braunwald, K.J. Isselbacher, R.G.
PAGE 226
II-226 Adolescent HealthVolume //: Background and the Effectiveness of Selected Prevention and Treatment Services 162. 163. 164. 165. 166. 167. 168. 169. 170. 171. 172. 173. 174. 174a. 174b, 175. 176. 177. 178. 179. 180. Petersdorf, et al. (eds.) (New York NY: McGraw Hill, 1987). Paffenbarger, R. S., and Hale, W. E., Work Activity and Coronary Heart Mortality, New England Journal of Medicine 292:545-550, 1975. Paffenberger, R. S., Hyde, R. T., Wing, A.L., et al., Physical Activity, Ail-Cause Mortality, andhmgevityof College Alumni, New England Journal of Medicine 314:605-613, 1986. Parcel, G., Simons-Morton, B., OHara, N., et al., School Promotion of Healthful Diet and Exercise Behavior An Integration of Org anizatiooal Change and Social I&arning Theoxy Interventions, Journal School Health 57:150-156, 1987. Pate, R.R., Dowd% M. and Ross J. G., Associations Between Physical Activity and Physical Fimess in American Children, American Journal of Children 144(10):1123-1129, 1990. Pate, R.R., and Ross, J. G., Factors Associated With Health Related Fitness, Journal of Physical Education, Recreation, and Dance 48:93-98, 1987. Pathological Determinants of Atherosclerosis in Youth (PDAY) Research Group, Relationship of Atherosclerosis in Young Men to Serum Lipoprotein Cholesterol Concentrations and Smoking,Journalof [he American Medical Association 264(23):301 83024, 1990. PemingtoL J., Mineral Content of Foods and Total Diets: The Selected Minerals In Foods, Survey 1982 -84, Journal of the Amencan Dietetic Association 86:876-891, 1986. Petosa, S., Women in the Military Academies: U.S. Air Force Academy, Physician Sports Medicine 17: 133-142, 1989. Pope, H. G., and Katz, D. L., Affective and Psychotic Symptoms Associated With Anabolic Steroid Use, American Journal of Psychiatry 145:487-490, 1988. Powell, K.E., Thompson, P. D., Caspersen, C.J., et al., Physical Activity and the Incidence of Coronary Heart Disease, Annual Review of Public Health 8:253-287, 1987. Powers, M. A., Handbook of Diabetes Numtional Management (Rockvitle, MD: Aspen Publishers, 1987). Presidents Council on Physical Fimess and Sports, Youth Physical Fitness in 1985 (Ann Arbor, MI: Institute for Social Research, University of Michigan, 1986). R&a, P., Wrtianieu E., Pallonem U., et al., The North Karelia Youth Project: Evaluation of Two Years of Intervention on Health Behavior and Cardiovascular Disease Risk Factors Among 13to 15-Year-Old Childrq Preventive Medicine 11:550-570, 1982. Reiff, G. G., DixorL W. R., Jacoby, D., et al., The Presidents Council on Physical Fitness and Sports: 1985 National School Population Fitness Survey (Washingto~ DC: U.S. Department of Health and Human Services, Office of the Assistant Secretary for Heal@ 1986). Reynolds, K. D., Killen, J. D., Bryson, S.W., et al., Psychosocial Predictors of Physical Activity in Adolescents, Preventive Medicine 19:541-551, 1990. Richards, M. H., Casper, R.C., and Larsou R., Weight and Eating Concerns Among Preand Young Adolescent Boys and Girls, Journal of Adolescent Health Care 11:203-209, 1990. Richter, E. A., Mikines, K.J., Galbo, H., et al., Effect of Exercise on Insulin Action in Human Skeletal Muscle, Journal of Applied Physiology 66:876-885, 1989. Riopel, D., Boer@ R., Coates, T., et al., Coronary Risk Factor Modit3cation in Children: Exercise, Circulation 74:1 189A1191A, 1986. Risser, W.L., Lee, E.J., Poindexter, H. B., et al,, Iron Deficiency in Female Athletes: Its Prevalence and Impact on Performance, Medicine and Science in Sports and Exercise 20:1 16-121, 1988. llivar~ F. P., Epidemiology of Childhood Injuries, Preventing Childhood Injuries, A.B. Bergman (cd.) (Columbus, OH: Ross Laboratories, 1982). Rocchini, A. P., HatcL V., Anderson, J., et al., B1ood Pressure in Obese Adolescents: Effect of Weight LQSS, Pediarncs 82:16-22, 1988. 181, 182, 183, 184< 185, 186. 187. 188. 189. 190. 191. 192. 193. 194. 195. 196. 197. 198. 199. Rosenberg, L.E., Inherited Disorders of Amino Acid Metabolism Hamsons Principles of Internal Medicine, llth cd., E. Braunwald, KJ. Isselbacher, R.G. Petersdorf, et al. (eds.) (New York NY: McGraw HiLl, 1987). ROSS, J.G., and GilberL G. G., The National Youth and Fitness Study; A Summary of Findings, Journal of Physical Education 1:45-50, 1985. Ross, J.G., and Pate, R.R., The National Children and Youth Fimess Study II: A Summary of Findings, Journal of Physical Education, Recreation, and Dance 58(10):51-56, 1987. Rowland, M., and Roberts, J., Blood pressure LeveLs and Hypertension in Persons Ages 6-74 Years: United States, 1976-80, Advance Data From Vital and Health Statistics of the National Center for Health Statistics, No. 84, DHHS Pub. No. (PHS)82-1250, Hyattsville, MD, 1982. Rowland, T., Physical Fimess in Children: Implications for the Prevention of Coronary Artery Disease, Current Problems in Pediatrics, L. Gluck (cd.) (Chicago, IL: Year Book Medieat Publishers, 1987). Rudrnaq D., Nutritional Requirements, Harrison s Principles of Internal Medicine, 1 lth cd., E. Braunwald, K.J. Isselbacher, R.G. Petersdorf, et al. (eds.) (FJew York NY: McGraw Hitl, 1987). Ryan, A. S., Roche, A.F., and Martin ez, G.A., ArI Evaluation of the Associations between Socioeconomic Status and the Growth of Mexican American Children: Data From the Hispanic Heatth tion Survey, 1982 -1984, American and Nutrition Examina Journal of Clinical Nutrition 51(suppl. 5):944S-952S, 1990. Sady, S. P., Thompsoq P.D., Cullinane, E. M., et aL, Prolonged Exercise Augments Plasma Triglyceride Clearance, Journal of the American Medical Association 256;2552-2555, 1986. Salz, K. M., Ramir, I., Ems~ N., et al,, Selected Nutrient Intakes of Free-Living White Children Ages 6-19 Yeas: The Lipid Research Clinics Program Prevalence Study, Pediatric Research 17: 124-130, 1983. Sangi, H., and Muetler, W.H., Which Measure of Body Fat Distribution Is Best for Epidemiologic Research Among Adolescents, American Journal of Epidewology 133(9):870-883, 1991. SauberlicL H.E., Judd, J. H., Nichoalds, G.E., et al., Application of the Erythroeyte Glutathione Reductase Assay in Evaluating Riboflavin Nutritional Status in a High School Student Population American Journal of Clinical Numtion 25:756-762, 1972. Schmid, T.L., Jeffery, R.W., Forster, J.L., et al., Public Support for Policy Initiatives Regulating High-Fat Food Use in Minnesota: A Multicommunity Survey, Preventive Medicine 18:791805, 1989, Seals, D.R., Hagberg, J.M., Alle% W.K., et aL, Glucose Tolerance in Young and Older Athletes and Sedentaq Men, Journal of Applied Physiology 56:1521-1525, 1984. Shephard, R.J., Ward, G.R., and he, M., Physical Ability of Deaf and Blind Childreu Children and Exercise 12:355-362, 1986. Siiteri, P.K., Adipose Tissue as a Source of Hormones, American Journal of Clinical Nutrition 45:277-282, 1987. Simons-Mortoq B. G., Parcel, G. S., OH.M% N. M., et al., Health-Related Physical Fitness in Childhood: Status and Recommendations, Annual Reviews of Public Health 9:403425, 1988. Siscovick, E. S., Weiss, N. S., Fletcher, R.H., et al., Habitual Vigorous Exercise and Primary Cardiac Arrest: Effect of Other Risk Factors on the Relationship, Journal of Chronic Disability 37:625-631, 1984. Skinner, J.D., Salvetti, N.N., Ezell, J. M., et aL, Appalachian Adolescents Eating Patterns and Nutrient Intakes, Journal of the American Dietetic Association 85:1093-1099, 1985. Skrobak-Kaczynski, J., and WAC, T., Physical Fimess and Trainability of Young Male Patients With Down Syndrome, Children and Exercise 9:300-316, 1980.
PAGE 227
Chapter 7Nutrition and Fitness Problems: Prevention and Services (l-227 200. Slap, G., Normal Physiological and Psychosocial Growth in the Adolescent, Journal of Adolescent Health Care 7:13 S-23S, 1986. 201. Slav@ J., Lutter, J., and Cushmaq S., Amenorrhea in Vegetarian Athletes, Lancer 1: 1474-1475, 1984. 202. SloaQ R. E., and Keatinge, W.R., Cooling Rates of Young People S wirnming in Cold Water, Journal of Applied Physiology 35:371-375, 1973. 203. Story, M., and Alto~ I., Nutrition Issues and Adolescent ?regnancy, Contemporary Numtion 12:7-12, 1987. 204. Story, M., and Resnick, R., Adolescents Views on Food and Nutrition, Journal of Nutrition Education 18:188-192, 1986. 205. Strazulo, P., Ferro-Luzzi, A,, Siani, A., et al., Changing the Mediterranean Diet: Effects on Blood Pressure, Journal of Hypertension 4:407-12, 1986. 206. Strong, J., Coronary Atherosclerosis in Soldiers: A Clue to the Natural History of Atherosclerosis in the Young, Journal of the American Medical Association 256:2863-2866, 1986. 207. Stunkard, A. J., Obesity (Philadelphia PA: Saunders, 1980). 208. Stunkard, A.J., Harris, J. R., Pedersen, N, L., et al., The Body-Mass Index of Twins Who Have Been Reared Apart, New England Journal of Medicine 322(21): 1483-1487, 1990. 209. Sundberg, S., Maximal Oxygen Uptake in Relation to Age in Blind and Normal Boys and Girls, Acta Pediatric Scandinavia 71:603-608, 1982. 210. Tamborlane, W., and Sherwin, R,, Diabetes Control and Complications: New Strategies and Insights, Journal of Pediatrics 102:805-813, 1985, 211. Tanner, J. W., Fetus Into Man: Physical Growth From Conception to Maturity (Cambridge, MA: Harvard University Press, 1978). 212. Tanner, J, W., Catchup Growth in Man, British Medical Journal 37:233-238, 1981, 213. Taylor, C. B., Sallis, J. F., and Needle, R., The Relationship Between Physical Activity and Exercise and Mental Health, Public Health Reports 100:195-202, 1985. 213a. Tippett, K., Human Nutrition Information Service, U.S. Department of Agriculture, personal communication, Sept. 16, 1991. 214. U.S. Congress, General Accounting Office, Participation in the National School Lunch Program, Washington, DC, March 1984. 215. U.S. Presidents Task Force on Food Assistance, Report of the President~ Task Force on Food Assistance (Washington, DC: 1984). 216. U.S. Congress, House of Representatives, Committee on Ways and Means, Children in Po\erty, prepared by the Congressional Research Service, Library of Congress and the Congressional Budget Office (Washington, DC: U.S. Government Printing Office, May 1985). 217. U.S. Congress, House of Representatives, Select Committee on Hunger, A Re\iew of Selected Studies on World Hunger, Pub. No. 51-5590 (Washington, DC: U.S. Government Printing Office, 1985). 218, U.S. Congress, Office of Technology Assessment, Indian Health Care, OTA-H-290 (Washington, DC: U.S. Government Printing office, 1986). 219. U.S. Congress, Office of Technology Assessment, Healthy Children: Investing in the Future, OTA-H-355 (Washington, DC: U.S. Government Printing Office, February 1988). 220, U.S. Congress, Office of Technology Assessment, Policy Issues in the Prevention and Treatment of Osteoporosis (Washington, DC: U.S. Government Printing Office, forthcoming). 221. U.S. Congress, Senate, Committee on Agriculture, Nutrition and Forestry, Child Nutrition Programs: Description, History, Issues, und Options, Committee Print S. Prt. 98-15 (Washington, DC: U.S. Government Printing Office, 1983). 222. U.S Department of A@culturc, response to 1989 Office of Technology Assessment questionnaire rcgardrng adolescent hcal[h Initiatives, Washington, DC, 1989. 223. U.S. Department of Agriculture, Food and Nutrition Service, Office of Analysis and Evaluation Characteristics of the National School Lunch and School Breakfast Program Participants, Washington DC, January 1988. 224. U.S. Department of Agriculture, Human Nutrition Information Service, Nationwide Food Consumption Survey. Nutrient Intakes: Individuals in 48 States, Year 1977-78, Report No. I-2 (Hyattsville, MD: 1984). 225. U.S. Department of Agriculture, Human Nutrition Information Service, USDA Methodological Research for Lasge-Scale Dietary Intake Surveys, 1975 -88, Home Economics Research Report, No. 49, Washingto% DC, December 1989. 226. U.S. Department of Agriculture, Human Nutrition Information Service, Dietary Guidelines Advisory Committee, Report of the Dietary Guidelines Advisory Committee on the Dietary Guidelinesfor Americans, 1990 (Hyattsville, MD: 1990). 227, U.S. Department of Agriculture and U.S. Department of Health and Human Semices, Nutrition and Your Health: Dietary Guidelinesfor Americans, Home and Garden Bulleti No. 132 (Hyattwille, MD: 1990). 228. U.S. Department of Health, Education, and Welfare, Public Health Service, Centers for Disease Control, National Center for Health Statistics, Body Weight, Stature, and Sitting Height: White and Negro Youths 12-17 Years, United States, Vital and Health Statistics Series 11, No. 126, DHEW Pub. No. (HRA)74-1605 (Rockville, MD: 1973). 229. U.S. Department of Health and Human Services, Public Health Service, Centers for Disease Control, Prevalence of Overweight Hispanics, United States, 1982 -1984, Journal of the American Medical Association 263(5):631-632, 1990. 230. U.S. Department of Health and Human Services, Public Health Service, Centers for Disease Control, Anemia During Pregnancy in Low-Income Womem-4_Jnited States, 1987, Morbidity and Mortality Weekly Report 39(5):73-76, Feb. 9, 1990. 231. U.S. Department of Health and Human Services, Public Health Service, Centers for Disease Control, NationaJ Center for Health Statistics, Dietary Intake Source Data: U.S. 1976-1980, Vital and Health Statistics Series 11, No. 231, DHHS Pub. No. (PHS)831681 (Washington DC: 1983). 232. U.S. Department of Health and Human Services, Public Health Service, Centers for Disease Control, Natioml Center for Health Statistics, Health, United States, 1989 (Washingto& DC: U.S. Government Printing Office, 1990). 233. U.S. Department of Health and Human Services, Public Health Service, Hcatth Resources and Services Administration Healrh Status of the Disadvantaged, DHHS Pub. No. (HRSA)HRS-PDV-86-2 (Washingto~ DC: 1986). 234. U.S. Department of Health and Human Services, Public Health Service, Hadth Resources and Services Administration, Bureau of Maternal and Child Health and Resources Development, Office of Maternal and Child Health, Nutritional Issues in Adolescent Health: Information Bulletin, Youth 2000 prepared by J.M. Rees (Rockville, MD: 1988). 235. U.S. Department of Health and Human Services, Public Health Semice, National Institutes of Health, Diet, Nutrition, and Cancer Prevention: The Good News, NIH Pub. No. 87-2878 (Washington DC: U.S. Government Printing Oftlce, 1986). 236. U.S. Department of Heatth and Human Services, Public Health Service, National Institutes of Heal@ Natioml Diabetes Data Group, Diabetes in America: Diabetes Data Compiled 1984, NIH Pub. No. 85-1468 (Bethesda, MD: 1985). 237. U.S. Department of Health and Human Services, Public Health Service, National Institutes of Health, Natioml Heart, Lung, and Blood Institute, Consensus Development Panel, Imwering Blood Cholesterol To Prevent Heart Diseases, Journal of the American Medical Association 253:20802086, 1985. 238. U.S. Department of Health and Human Services, Public Health Service, Nationat Institutes of Healti National Heart, Lung, and Blood Institute, Joint National Committee on Detection, Evalua-
PAGE 228
II-228 Adolescent HealthVolume II: Background and the Effectiveness of Selected Prevention and Treatment Services 239. 240. 241. 242. 243. 244. 245. 246. 247. tie% and Treatment of High Blood Pressure, Subcommittee on Nonpharrnacologic Therapy, Nonphannacologic Approaches to the Control of High Blood Pressure (Bethesd4 MD: 1986). U.S. Department of Health and Human Services, Public Health Service, National Institutes of Healti National Hearg Lung, and Blood Institute, National Cholesterol Education Prograrq Highlights of the Report of the Expert Panel on Blood Cholesterol Levels in Children and Adolescents, draft report, Bethesd~ MD, Apr. 7, 1991. U.S. Department of Health and Human Services, Public Health Service, National Institutes of Healtlu National HeLung, and Blood Institute, Task Force on Blood Pressure Control in ChildrerL Report of the Task Force on Blood Pressure Control in Children (Bethesda, MD: 1987). U.S. Department of Health and Human Services, Public Health Service, Office of the Assistant Secretary for Heal@ Healthy People 2000: National Health Promotion and Disease Prevention Objectives, DHHS Pub. No. (PHS)91-50213 (Washington DC: U.S. Government Printing Oftlce, 1991). U.S. Department of Health and Human Services, Public Health Service, Office of the Surgeon General, The U.S. Surgeon Generals Report on Nutntion and Health (Washington DC: U.S. Government Printing Office, 1988). U.S. Department of Health and Human Services and U.S. Department of Agriculture, Interagency Committee on Nutrition Monitoring, Nutrition Monitonng in the United States. The Directory of Federal Nutrition Monitoring Activities, DHHS Pub. No. (PHS) 89-1255-1 (Washington DC: U.S. Government Printing Office, 1989). Wrthnieu E., Puska, P., Pietinine~ P., et al., Effects of Dietary Fat Modiilcations on Serum Lipids and Blood Pressure in Children+ Acta Paediamca Scandinavia 75:396-401, 1986. Veni& J. E., Graham, S., Zielezny, M., et al., Occupational Exercise and Risk of Cancer, American Journal of Clinical Nutrition 45(suppl. 1):318-327, 1987. Voors, A.W., Foster, T.A., Frerichs, R. R., et al., Studies of Blood pressure in ChildreG Ages 5-14, in a Total Biracial Community: The Bogalusa Heart Study, Circulation 54:319327, 1976. Wadden, T. A., Stunkard, A.J., Rick L., et al., Obesity in Black Adolescent Girls: A Controlled Clinical Trial of Treatment by Die4 Behavior Modification and Parental SuppOrt, Pediatrics 85(3):345-352, 1990. 248. 249. 250. 251. 252. 253. 254. 254a. 255. 256. 257. 258. Ward, D. S., and Bar-Or, O., Role of the Physician and Physical Education %cher in the Treatment of Obesity at School, Pediatrician 13:44-51, 1986. Warreu M.P., Brooks-Gunn, J., Hamiltou L. H., et al., Scoliosis and Fractures in Young Ballet Dancers, New Eng{and Journa/ of Medicine 314: 1348-1353, 1986. Webb, O.L., Laskarzewski, P. M., and Gluec~ C.J., Severe Depression of High-Density Lipoprotein Cholesterol Uvels in Weight-Lifters and Bodybuilders by SelfAdministered Exogenous I&tosterone and Anabolic-Androgenic Steroids, Metabolism 33:971-975, 1984. Webber, L. S., Srinivasan, S. R., and Berensoq G. S., Tracking of Serum Lipids and Lipoproteins Over 12 Years Into Young Adulthood: The Bogalusa Heart Study, Circulation 79:11 -481, 1988. Webber, L, S., Voors, A., SrinivasQ S.R., et al., Occurrence in Children of Multiple Risk Factors for Coronary Artery Disease: The Bogalusa Heart Study, Pediatric Medicine 8:407-418, 1979. White, A. A., and Skinner, J.D., Can Goal Setting as a Component of Nutrition Education Effect Behavior Change Among Adolescents? Journal of Nutrition Education 20:327334, 1988. Wiley, J.J., and McIntyre, W. M., Fracture Patterns in Childre% Current Concepts in Bone Fragility 159-165, 1986. WilleW W., Challenges for Public Health Nutrition in the 1990s, American Journal ofPublic Health 80: 1295-1298,1990. WilliamS, G.H., and Braunwald, E., Hypertensive wbmk Disease, Hamsons Principles of Internal Medicine, 1 lth cd., E. Braunwald, K.J. Isselbacher, R.G. Petersdorf, et al. (eds.) (New York NY: McGraw Hill, 1987). Wotecki, C. E., and Fanelli-Kuczsnarski, M., The National Nutrition Monitoring System, unpublished rnanuwrip~ Washington, DC, 1989. Wright, J.E., and Stone, M.H., National Strength ~d CfJnditioning Associations Statement on Anabolic Drug Use, Journal of the National Strength and Condinoning Association 7:45-59, 1985. Young, E.A., SirnS, O.L., Bingham, C., et al., Fast Foods 1986: Nutrient analysis, Dietetic Currents 13:25-36, 1986.
PAGE 229
Chapter 8 DENTAL AND ORAL HEALTH PREVENTION AN PROBLEMS: D SERVICES Contents Page Introduction . . . . . . . . . . . . . . . . . . 231 Background on Adolescents Dental and Oral Health . . . . . . . . . 231 Biological Factors That Affect Adolescents Dental and Oral Health . . . . . 231 Trends in the Incidence and Prevalence of Adolescents Dental and Oral Health Problems 232 Dental Caries . . . . . . . . . . . . . . . . . 232 Periodontal Disease . . . . . . . . . . . . . . . 235 Malocclusion . . . . . . . . . . . . . . . . . 235 Factors Associated With Adolescents Dental and Oral Health Problems . . . . 236 Adolescents in Racial and Ethnic Minority Groups . . . . . . . . . 236 Adolescents With Disabilities . . . . . . . . . . . . . 239 Adolescents in Juvenile Justice Facilities . . . . . . . . . . . 240 Adolescents With Certain Behaviors or Conditions . . . . . . . . . 240 Prevention of Adolescents Dental and Oral Health Problems . . . . . . . 240 Preventive Interventions for Major Dental Health Problems . . . . . . . 241 Prevention of Dental Caries . . . . . . . . . . . . . . 241 Prevention of Periodontal Disease . . . . . . . . . . . . 244 Prevention of Malocclusion . . . . . . . . . . . . . . 244 Dental Health Education and Behaviors . . . . . . . . . . . . 244 Dental Health Education . . . . . . . . . . . . . . 244 Adolescents Knowledge of and Attitudes Toward Dental Health . . . . . 244 Interventions and Services for the Treatment of Adolescents Dental and Oral Health Problems 245 Interventions for the Treatment of Adolescents Dental Health Problems . . . . 245 The Dental Service Delivery System . . . . . . . . . . . . 245 Federal Programs Pertaining to Adolescents Dental and Oral Health . . . . . . 245 Public Health Service. . . . . . . . . . . . . . . . 246 Health Care Financing Administration . . . . . . . . . . . . 247 Conclusions and Policy Implications . . . . . . . . . . . . . 247 Chapter preferences . . . . . . . . . . . . . . . . 249
PAGE 230
Boxes Box Page 8-A. Overview of Three Dental Problems: Dental Caries, Periodontal Disease, and Malocclusion . . . . . . . . . . . . . . . . . 233 8-B. Federal Sources of Data on Adolescents Dental and Oral Health . . . . . 241 Figures Figure Page 8-1. Caries-Free Adolescents and Mean DMFS Scores Among U.S. School Children Ages 10 to 17, 1979-80 and 1986-87 . . . . . . . . . . . . 235 8-2. Percentage Decrease From 1980 to 1987 in Caries Prevalence Among U.S. School Children Ages 5 to 17 . . . . . . . . . . . . . . . . . 236 8-3. Distribution of Components of Age-Specific Mean DMFT Scores for White and Nonwhite U.S. School Children Ages 10 to17,1979-80 and 1986-87 . . . . . . . 237 8-4. Periodontal Health Status of U.S. Schoolchildren Ages 14 to17, by Gender and Race, 1986-87 . . . . . . . . . . . . . . . . ., 238 8-5. Gingival Treatment Needs of White and Nonwhite U.S. Adolescents Ages 10 to17, . . 1979-80 . . . . . . . . . . . . . . . . . . 242 8-6. Percentage of U.S. Adolescents Ages 12 to 17 With a Dental Visit in the Past Year, by Family Income, 1986 . . . . . . . . . . . . . . . 246 8-7. Dental and Oral Health Expenditures by the U.S. Department of Health and Human Services, Fiscal Year 1988 . . . . . . . . . . . . . . . . 247 Tables Table Page 8-1. Selected Dental Treatment Needs of White and Nonwhite U.S. Adolescents Ages 10 and 17,1979-80 . . . . . . . . . . . . . . 238 8-2. Malocclusion Among U.S. Adolescents Ages 12 to 17, by Race and Gender, 1970 . . 239 8-3. Distribution of Malocclusion Among U.S. Adolescents Ages 12 to17, by Race and Gender, 1970 . . . . . . . . . . . . . . 240 8-4. Oral Hygiene Among U.S. Adolescents Ages 12 to 17 as Measured by the Simplified Oral Hygiene Index (OHI-S) . . . . . . . . . . . . . . 242 8-5. Behaviors and Conditions With Potential Effects on Adolescents Dental and Oral Health . . . . . . . . . . . . . . . . . 243 8-6. Characteristics of U.S. Adolescents Ages 12 to 17 Who Do and Do Not Have Private Dental Insurance, 1986 . . . . . . . . . . . . . 246
PAGE 231
Chapter 8 DENTAL AND ORAL HEALTH PROBLEMS: PREVENTION AND SERVICES Introduction For the last three decades, dentistry has emphasized population-wide public oral health measures to prevent dental caries (e.g., fluoridation of water supplies) and the treatment of dental caries l i n younger children, assuming that early interventions would achieve the best shortand long-term effects (4). This emphasis has clearly proved successful. In the last 20 years, the prevalence of dental caries in all age groups, including adolescents ages 10 through 18, has declined dramatically (97). As a consequence of the success of preventive measures in reducing dental caries and of dentistrys focus on the treatment of dental caries in younger children, however, many aspects of the dental and oral health of adolescents have been neglected (l). Traditionally, many dental professionals have tended to regard adolescence as a quiescent period with few dental needs, a continuation of childhood in which earlier dental intervention carried the patient to adulthood in good oral health (20). In fact, however, adolescence is a unique time, in terms of dental considerations, during which: l l l l dental caries rates increase from childhood (18); the first signs of periodontal disease 2 occur (20); up to a third of facial growth occurs (during a relatively short growth spurt) (34); and most orthodontic therapy occurs. Furthermore, the transition from childhood to consenting adulthood and responsibility for care, along with issues such as differences in dental disease patterns and care-seeking behaviors of specific groups of adolescents, and unmet dental treatment needs, make adolescence a pivotal period with respect to dental and oral health. This chapter covers several topics pertaining to the oral health of U.S. adolescents, beginning with physiologic and anatomic changes that affect adolescents teeth and related structures and the prevalence of major dental problems in 10to 18-yearolds. 4 It also identifies a number of factors that are associated with adolescent dental health problems. Prevention of dental and oral health problems is addressed, along with the dental service delivery system. Finally, the Federal Governments role in oral health is discussed, and conclusions and policy implications are presented. Background on Adolescents Dental and Oral Health Biological Factors That Affect Adolescents Dental and Oral Health Puberty is the initiation of adolescence, and several of the physical developmental changes that characterize puberty are mirrored in a persons oral cavity (mouth). From the standpoint of oral health, three types of changes during adolescence are particularly important: the transition from primary to permanent teeth, skeletal growth, and hormonal change, The first few years of adolescence are a dynamic time in terms of dentition (teeth). Between the ages of 10 and 12, a persons entire set of primary teeth has been replaced with permanent successors, second or 12-year-old molars have erupted, and only the third molars remain to develop and erupt (27). By ages 12 or 13, an individuals permanent teeth are usually stable. Skeletal growth during adolescence has implications for orthodontic treatment. The face grows l~en(a/ ~aneS cm ~ dcflned ~~ ~c ]oc~lzcd, ~rogresslvc decay of a too~, starting on ~C sUrfacC and, if un~catcd, extending tO the inner tOOt chamber and resulting in infection. zrcrlodontu/ di~ea~e is an y disease of tie tissue surrounding the teeth. The two most prevalent periodontal diswcs are gi~gi~ifi~ (i~ammation confined to tbc gums) and periodontitis (infl amrnation of both the gum and the other supporting structures of the teeth). ~Orth(jd(jnticL~ 1s the area of dentistry concemcd with the bite and how teeth mesh toge~cr. dFor tie PUWOSC of ~is Rcw~, OTA has focused on adolescents ages 10 through 18. Data pertaining to dentil healfi are not readily available or this age group. For that rcascm, some of the data cited in this chapter do not conform precisely to this agc grouping. -11-231
PAGE 232
//-232 l Adolescent HealthVolume II: Background and the Effectiveness of Selected Prevention and Treatment Services significantly during adolescence, completing almost all of the vertical growth that affects tooth position, facial contour, and space available for teeth (66). Orthodontic treatment must take skeletal growth into account during this period. 5 Hormonal changes seem to affect the susceptibility of adolescents to gingival problems (74) (e.g., because hormones interact with local irritating factors such as plaque and calculus). Like other aspects of adolescents dental health, however, the relationship between hormonal changes and gingival problems is poorly understood. Trends in the Incidence and Prevalence of Adolescents Dental and Oral Health Problems The major dental diseases and conditions affecting adolescents (indeed, all age groups) are dental caries, periodontal disease, and malocclusion. These three problems and various indexes used to measure the extent of these problems are discussed in box 8-A. Over the last three decades, adolescents have experienced some dramatic changes in dental disease patterns the most impressive of which is the drop in prevalence of dental caries during the last 20 years. 7 Malocclusion has also undergone a transition in recent decades, from a condition caused to a significant degree by premature tooth loss due to dental caries and subsequent crowding of teeth to a condition that is largely inherited (la). Dental Caries For most U.S. adolescents, the situation with respect to dental caries seems to have changed significantly for the better in recent years. Data collected among U.S. school children by the National Institute of Dental Research (NIDR) in the U.S. Department of Health and Human Services (DHHS) suggest that the prevalence of dental caries as measured by the DMFS index 8 has been diminishing among 10to 17-year-olds (see figure 8-l). Also, they suggest that the percentage of caries-free adolescents has been increasing (see figure 8-l). Although the prevalence of dental caries still remains higher among adolescents than among younger children, data from the NIDR surveys shown in figure 8-2 indicate that 10to 17-year-old school children in this country experienced a 20to 40-percent decline in the prevalence of dental caries from 1980 to 1987 (97). The data from the NIDR surveys of U.S. school children conducted in 1979-80 and 1986-87 suggest that dental caries of permanent teeth is slowly, but consistently, decreasing in the U.S. adolescent population as a whole. Despite the overall improvements, however, it is important to note that dental caries remains a significant dental problem for certain groups of adolescents. 9 Figure 8-3 shows data from the NIDR surveys that compare white and nonwhite adolescents with respect to the distribution of components of agespecific mean DMFT scores. 1011 In both surveys, the D component of the DMFT index (decayed teeth) accounted for a higher percentage of age-specific mean DMFT among nonwhite adolescents than among white adolescents. This means that nonwhite adolescents had a higher percentage of untreated caries than white adolescents. The M component of the DMFT index (missing teeth) accounted for a larger and far more rapidly increasing percentage of mean DMFT among nonwhite adolescents ages 10 Sunfotimtely, n. Precise predictor of faci~ growth exists, and while such growth can be tracked and extremes identiled, the development of useti tools to help plot an adolescents fd orthodontic status remains elusive (19). bpluque is a soft &pOSit of bacteria and otier materials on the surface of a tooth. Calculus is a hard deposit of calcium phosphate and mbonate witi organic matter on the surfaces of the teeth. Trhe main data so~ces OTAUSed to describe trends in the prevalence of dental caries in adolescents are national surveys Of school ctildren @orm~ by or for the Federal Government-e.g., National Institute of Dental Research: National Caries Program, The Prevalence of Dental Caries in United States School Children, 1979-80 and Oral Health of U.S. Children: The National Survey of Dental Caries in U.S. School Children, 1986-87 (94,97). These data sources have limitations described in box 8-B. One of the primaty limitations is that natioml survey data do not adequately portray the caries experience of particular subgroups of adolescents with unique circumstances or risks, such as poor or disabled adolescents or adolescents who do not attend school. 8~e D~FCJ index ~d the D~f7T ind~ are Used to measure the prev~cncc of den~ caries and are described ill bOX 8-A gsee the following section on Factors Associated With Adolescents Dental and Oral Health Problems. lone D~ index is described in bOX 8-A. 1 l~ese smey &ta differentiate o~y ~~~n white and nonw~te pop~atio~. see box 8-B for Werdiscussion of the knitations of Ftdtial SOUrCeS of data on dental and oral health.
PAGE 233
Chapter 8--Dental and Oral Health Problems: Prevention and Services l II-233 Box 8-A-Overview of Three Dental Problems: Dental Caries, Periodontal Disease, and Malocclusion Three major dental diseases and conditions affect adolescents: dental caries, periodontal disease, and malocclusion. These problems, and indexes commonly used to measure the prevalence or other aspects of these problems, are described below. Dental Caries-Dental caries is the localized, progressive decay of a tooth, beginning on the tooths outer enamel surface and, if left untreated, extending to the inner tooth chamber. Dental caries is a condition to which individuals of all age groups and races are susceptible, but the rate of dental caries is highest among adolescents (l). Far more is known today about dental caries than even a decade ago. Basically, dental caries is an infectious condition that requires a combination of a susceptible host, cariogenic bacteria, and a diet high in carbohydrates; over an extended period of time (usually at least several months), the acid produced by bacterial metabolism leads to the decalcification of the tooth. One especially virulent form of caries that affects a small portion of adolescents is rampant caries. Rampant caries involves extensive breakdown of enamel and dentin, and pulpal pathosis. It devastates the dentition and creates pain. This rapidly progressing condition can occur in individuals with or without a significant history of dental caries. Not all patients who experience high caries activity experience rampant caries, but the destruction of rampant caries puts those patients with the condition in the high caries activity group. The DMFT and DMFS Indexes: Two indexes are commonly used to measure the prevalence of dental caries. One of these, the DMFT index, measures the average number per person in a specified population of Decayed permanent teeth in need of a filling or extraction, Missing permanent teeth that have been removed as a result of caries, and Filled permanent teeth. The other index, the DMFS index, measures the average number per person in a specified population of Decayed permanent tooth surfaces, Missing permanent teeth, and Filled (or restored) Surfaces of permanent Teeth. The DMFS index is a somewhat more sensitive measure of the prevalence of dental caries, because it identifies caries on several sites of each tooth. The technique of examination for the both the DMFS and the DMFT index is described in a variety of references (79,97). Sometimes, the separate components of the DMFT or DMFS index are used as a measure of service utilization (e.g., the F component is an indication of dental treatment of decayed teeth, and the M component may suggest what type of dental care has or has not been received (i.e., a high M component suggests that teeth were extracted as a result of untreated decay). Treatment: The treatment for dental caries varies, depending on the conditions severity. Although dental caries in its mildest form affects only the tooths enamel and causes lesions that may not require treatment, dental caries that progresses beyond the tooths enamel to the inner tooth may cause lesions that necessitate a filling or dental restoration, pulpal l therapy, or even removal of the tooth. The focus in this chapter is on carious lesions requiring treatment. Periodontal Disease--Periodontal disease includes several diseases of the tissue surrounding and supporting the teeth (76). The two most prevalent periodontal diseases are gingivitis and periodontitis. Gingivitis, by far the most common, is inflammation of the gingiva (gum) only; and is by itself relatively innocuous. Periodontitis is infl ammation of both the gums and other supporting structures of the teeth (e.g., the outer bone of the tooth socket, the outer layer of the root of the tooth, and the soft tissues that attach these structures to one another). Unlike gingivitis, periodontitis is associated with the destruction or loss of the supporting structures of the teeth. Periodontitis does not develop in the absence of gingivitis, but gingivitis does not always lead to periodontitis. Bacterial infection is an essential factor in both gingivitis and periodontitis (76). Periodontal disease is more common and more severe among adults than among adolescents. Periodontal problems are generally fewer and less severe than dental caries problems among adolescents, rarely leading to tooth loss during this age period. Nevertheless, adolescents are affected by a variety of acute and chronic periodontal problems, ranging from mild gingivitis to frank periodontal disease. One chronic periodontal condition peculiar to adolescence is localized juvenile periodontitis, which causes the loss of alveolar bone supporting permanent teeth and the weakening of the dentition. Thought to be caused by the organism Haemophilus (Actinobacillus) actinomycetemcomitans, or a combination of organisms, iodized juvenile periodontitis is insidious and is not necessarily present with inflammation as is gingival disease. It occurs in a small percentage of adolescents, IDen~ pulp is tic soft sensitive tissue that falls the Cilamti Of tie tooti. Continued on next page
PAGE 234
//-234 l Adolescent HealthVolume II: Background and the Effectiveness of Selected Prevention and Treatment Services Box 8-A--Overview of Three Dental Problems: Dental Caries, Periodontal Disease, and Malocclusion Continued usually early on. The superficial gingival tissue of a person with localized juvenile periodontitis can appear normal, so the condition is often missed or diagnosed late in its course. The Simplified Oral Hygiene Index (OHI-S): The OHI-S is a measure of oral cleanliness and plaque control, with a low score denoting good oral hygiene. Good oral hygiene can improve periodontal health (76). Periodontal Health Measures: The periodontal health of 14-to 17-year-old school children in 1986-87 was assessed using two measures-gingival bleeding upon probing and periodontal attachment loss (11,12,97). Bleeding gums are generally the result of mild gingivitis. Periodontal attachment loss is a measurement of periodontal destruction--the loss or destruction of the supporting structures results in the formation of pathologic spaces or pockets around the teeth. These pockets are measured in millimeters using a periodontal probe (97). Treatment: Uncomplicated gingivitis is usually easy to treat with nonsurgical methods such as plaque removal (76). Daily plaque removal is considered optimally conducive to gingival health. The treatment of more serious periodontal disease may involve periodontal surgery or nonsurgical methods such as the Keyes technique (76). MalocclusionMalocclusion is the malpositioning of maxillary (upper jaw bone) and mandibular (lower jaw bone) teeth, a condition that can have both esthetic, functional, and emotional implications (l). There is no clear relationship between malocclusion and either periodontal disease, dysfunction of the temporomandibular joint, or other oral problems. Malocclusion is largely due to genetic factors, although individuals who experience premature primary tooth loss due to dental caries may later experience orthodontic problems as a result. In its minor and even moderate manifestations, malocclusion seldom creates pain and is rarely disfiguring. In its more severe form, malocclusion causes functional problems in chewing, may predispose one to periodontal conditions (due to the inability to clean between teeth), and can create significant emotional problems (due to diminished self-confidence and self-esteem) (l). Treatment: Many malocclusions of a minor variety can be prevented, intercepted, or corrected by the supervision of a dentist and provision of space maintenance appliances or minor orthodontic treatment. The correction of more major malocclusions typically requires major orthodontic treatment. Orthodontic Treatment Priority Index (TPI): Determining the prevalence and severity of malocclusion is a complicated procedure and is, ultimately, subjective. Survey data reflect the judgment of orthodontists who have examined patients and a variety of records, including radiographs and models of teeth. From this information, a score, or orthodontic TPI, is determined The orthodontic TPI score is a score ranging from O (normal occlusion) to 10 (very severe occlusion, with treatment mandatory). A TPI score of 4 to 6 is considered a definite malocclusion, but treatment is elective. SOURCES: OffIce of Ikchnology Assessment 1991, based on the following souxces: American Academy of Pediatric Dentistry, Guidelines for Dental Health of the Adolescent, Chicago, IL, May 1986; M. Bha$ Periodontal Attachment IJXS in 14to 17-Year-Old U.S. School Chil&ew Program and Abstracts, American Association for Public Health De@istry, November 1989; M. Bhat and J. Bruneile, Gingival Status of 14to 17-Year-Old U.S. School ChildreIL Journal of Dental Research 68:955, June 1989; U.S. Congress, OfiIce of lkchnology Assessment, Periodontal Disease: Assessing the Effectiveness and Costs of the Keyes Technique+-Wealth Technology Case Study #5, OTA-BP-Ii-9 (W@iI@W DC: U.S. Government Printing Office, May 1981); U.S. Department of Healt4 IMucatioQ and Welfare, Public Health Service, National Center for Health Statistics, Decayed, Missing and FiZledTeethAmong Chif&en, DHEWPub. No. (HSM)72-1003 (Washington DC: U.S. Government Printing Office, August 1972); and U.S. Department of Health and Human Services, Public Health Service, National Institutes of Heal@ National Institute of Dental Research Oral Health of U.S. Children: The National Survey of Dental Caries in U.S. School Children, 1986-87, NIH Pub. No. 89-2247 (Wtshingtom DC: U.S. Government Printing OffIce, September 1989). to 17 than among their white counterparts. This adolescents are filled than decayed teeth of nonwhite means that nonwhite adolescents lost more teeth to adolescents. caries than white adolescents. Finally, the F compotable 8-1 shows differences in selected dental nent of the DMFT index (filled teeth) represents a treatment needs due to caries for white and nonwhite greater percentage of the DMFT index for white 10and 17-year-olds in 1979-80. In every category, adolescents ages 10 to 17 than for nonwhite adolesthe needs of nonwhite adolescents exceeded those of cents. This means that more decayed teeth of white white adolescents. The racial disparity in treatment
PAGE 235
Chapter 8Dental and Oral Health Problems: Prevention and Services II-235 Percent caries-free 60 50 40 30 20 10 0 Figure 8-lCaries-Free Individuals and Mean DMFS Scores Among U.S. School Children Ages 10 to 17, 1979-80 and 1986-87 a b 10 11 12 13 14 15 16 17 Age -1979-8 0 Mean DMFS score 12{ 10 8 6 4 2 0 1 10 11 12 13 14 15 16 17 Age ~ 1986-87 aThe data shown in this figure are from two national school-based surveys conducted by the National Institute of Dental Research in 1979-80 and 19 W-87. ~he DMFS index measu~es t he mean number per person of Decayed pe;manent toot h s_urfaces, Missing permanent teeth, and Filled Surfaces of permanent teeth. SOURCE: Office of Technology Assessment, 1991, based on the following: 1979-80 data: U.S. Department of Health and Human Services, Public Health Service, National Institutes of Health, National Institute of Dental Research, National Caries Program, The Prevalence of L?enta/ Caries in United States Schoo/Chi/dren, 1979-80, NIH Pub. No. 82-2245 (Washington, DC: U.S. Government Printing Office, 1982). 1986-87 data: U.S. Department of Health and Human Services, Public Health Service, National Institutes of Health, National Institute of Dental Research, Ora/ l-/ea/th of U.S. Children: The Alational SwveyofDenta/ Caries in U.S. School Children, 1986-87, NIH Pub. No. 8%2247 (Washington, DC: U, S. Government Printing Office, September 1989). needs was more pronounced among 17-year-olds than among 10-year-olds. While major school-based studies show an overall decrease in caries prevalence, other smaller studies point to a changing pattern and distribution of dental caries. Though uncommon, rampant caries 12 affects a small portion of adolescents, devastating the dentition and creating pain, Perhaps as many as one-fifth of school children get as much as half of the dental caries in the population (35). Studies of naval recruits, many of whom are older adolescents, show similar findings-5 percent of those individuals account for 38 percent of new caries (44). Although the caries-active group is small, it represents a group which seems resistant to most preventive measures that benefit the population in general. Periodontal Disease National representative data from NIDRs schoolbased surveys paint a generally positive picture of periodontal health for most American adolescents ages 14 to 17 (12,95). Although many school children do experience some gingival inflammation (signified by bleeding gums upon probing), very few have more serious problems (e.g., periodontal attachment loss of more than 2 mm). Older studies also suggest that many school children need moderate gingival treatment and improved oral hygiene (62,63, 95). According to the NIDR 1986-87 school-based survey, nonwhite adolescents ages 14 to 17 tended to have slightly worse periodontal health than white adolescents (see figure 8-4). The percentage of nonwhite adolescents with periodontal attachment loss greatly exceeded the percentage of white adolescents with periodontal attachment loss. Localized juvenile periodontitis (see box 8-A) affects an estimated 0.1 to 2.3 percent of U.S. adolescents (69). If untreated, the condition can cause significant periodontal destruction, including bone and tooth loss. MaloccIusion 13 A review of available data on malocclusion found that the condition tends to worsen in adolescence (57). Crowding increases, some orthodontic probIIRamPan[ ~arie$ iS ~ ~apld]y ~rowcsslng fom of dental CMCS which by definition inVOIVeS extensive bre*down of enamel and dentin, d Pulpd pathosis, and can occur in patients with or without a sigmflctant caries history. I ~BC)x 8-A ~lscusscs ~a]occluslon, ~ong ~1~1 its trca~cnt ~d measuremcn[. ~cvcn[ive services are discussed in a later SeCtlOn.
PAGE 236
II-236 Adolescent HealthVolume II: Background and the Effectiveness of Selected Prevention and Treatment Services Figure 8-2Percentage Decrease From 1980 to 1987 in Caries Prevalence Among U.S. School Children Ages 5 to 17 a Percent decrease 50 r 7 40 30 20 10 n I 5 6 7 8 9 10 11 12 13 14 15 16 17 Age All aTh e data shown in this figure are from two national school-based surveys cmnducted by the National Institute of Dental Research in 1979-80 and 1986-87. SOURCE: Office of Technology Assessment, 1991, based on the following: 1979-80data: U.S. Department of Health and Human Services, Public Health Service, National Institutes of Health, National Institute of Dental Research, Natiorra/ Caries Program, The Prevalence of Dental Caries in United States School Children, 1979-80, NIH Pub. No. 82-2245 (Washington, DC: U.S. Government Printing Office, 1982). 1986-87 data: U.S. Department of Health and Human services, Public Health Serviee, National Institutes of Health, National Institute of Dental Researeh, Qa/ HeaJth of U.S. ChiMen: The National Survey of Denta/ Caries in U.S. Schoo/ ChMren, 1986-87, NIH Pub. No. 89-2247 (Washington, DC: U.S. Government Printing Office, September 1989). lems worsen, and others become apparent later in adolescence. Estimates of malocclusion in the adolescent population available from the National Center on Health Statistics in DHHS are based on national data from 1970 (81). Table 8-2 shows data from 1970 on the average orthodontic Treatment Priority Index score for U.S. adolescents ages 12 to 17 by sex and race. 14 White male adolescents had the highest Treatment Priority Index score (5.2), and black male adolescents had the lowest (4.6). These scores fall into a range in which there is a definite malocclusion but treatment is elective. Table 8-3 shows a breakdown of the orthodontic Treatment Priority Index scores for all U.S. adolescents ages 12 to 17 in 1970. About 13 to 16 percent (about 3.6 million adolescents in 1970 15 ) had severe to very severe malocclusion. Factors Associated With Adolescents Dental and Oral Health Problems Federal sources of data on the dental health problems of adolescents include national surveys by NIDR, as well as other national surveys conducted by various agencies in DHHS (see box 8-B). These national surveys, as a whole, have yielded limited information about subgroups of the population. Available data on racial differences in dental disease patterns, for example, differentiate only between whites and nonwhites. The national surveys are not designed to explain why racial differences in dental disease patterns may occur by, for example, also collecting information on family income level or insurance status. Race, family income, and insurance status, along with education, age, sex, and perceived need, have been shown to be correlated with the use of dental services (31,82), and consequently associated with dental disease patterns. Also, past history of dental disease, oral hygiene behaviors, and diet may affect dental disease patterns. Adolescents in certain racial and ethnic minority groups, disabled adolescents, and adolescents in institutions seem to experience greater dental disease than other adolescents. But the data on these groups of adolescents are very limited, reflecting the national datas descriptiveness, and are shallow in terms of explaining differences in disease patterns and use of dental services. Despite the limitations of the data and the possibility of misinterpretation, it is important to understand that, for whatever the reasons, some adolescen