Adolescence is the transition from being a dependent child to an independent adult. Extending from the onset of puberty until the completion of brain development (roughly between the ages of 10 and 26), it is a time of great vulnerability and opportunity. The health-related behaviors and conditions of most noncommunicable diseases—tobacco and alcohol use, diet and exercise habits, and increased weight—often begin in adolescence. In addition, sexually transmitted diseases; human immunodeficiency virus (HIV); and other health issues, for example, those related to early maternity or to exposure to violence, also have serious impacts on the health and development of adolescents, their future adult selves, and future generations. With over 1 billion adolescents worldwide, the importance of this stage of life cannot be overstated. Homelessness, recent immigration, minority status, or Lesbian, Gay, Bisexual or Transgender (LGBT) identification further increase the vulnerabilities of this already vulnerable developmental life stage. This chapter focuses on how health-care providers can identify potential problems, support the maturation process and the development of a positive self-image, and address behaviors that may put youth at risk for poor health outcomes.

In the last two decades, neurobiological research, aided by magnetic resonance imaging, has demonstrated the profound brain growth that occurs during adolescence.¹ The cells of the brain respond to hormonal changes (estrogen, progesterone, testosterone), and are likely influenced by environmental factors such as nutrition, education, infection, and parenting. The limbic structures of the brain, associated with socioemotional development, are among the first to experience changes accompanying the onset of puberty, although full maturation does not occur until later in adolescence.¹ The neural connections of the prefrontal cortex, responsible for cognitive development and impulse control, develop more slowly.¹ It is this “asynchronous” development of the brain that may lead to emotional liability, risk taking, and behavioral control issues.

The overall task for the adolescent is to become an autonomous functioning “other” adult, individuated from his or her family. Adolescent psychosocial development generally is described in three stages: early adolescence (10–13 years), middle adolescence (14–17 years), and late adolescence (17–21 years). More recently, late adolescence has been combined with or followed by a fourth stage, young adulthood (18 or 21–26), which is an increasingly studied and referenced developmental stage. Developmental tasks of adolescence include acceptance of sexuality (which does not necessitate being sexually active), developing future life plans, beginning to develop life philosophies, and transitioning to adult roles and responsibilities in young adulthood.

The principal task confronting the family with adolescents is to strike a changing balance between freedom and personal responsibility as adolescents mature and individuate. Although most adolescents are able to navigate these developmental tasks successfully and without lasting social and emotional consequences, for those who do not, the adverse effects can persist well into adulthood (Table 21-1).

The leading causes of adolescent mortality globally are road injuries, HIV/AIDS, and self-harm. Mortality is higher in boys than in girls and higher in older adolescents than in younger adolescents. These deaths are closely related to adolescent risk taking. Risk-taking behaviors are defined as those potentially harmful to the initiator or others that exceed normal behavior for that developmental phase.

The Youth Risk Behavior Surveillance (YRBS) System monitors six categories of priority health-risk behaviors among youth and young adults in the United States (http://www.cdc.gov/HealthyYouth/yrbs/index.htm).² Although high-risk behaviors among high school students have decreased since 1991, the 2013 YRBS report indicates that adolescents continue to engage in behaviors that place them at risk for the leading causes of morbidity and mortality. Seventy-two percent of all deaths in 2011 among persons aged 10–24 in the United States continue to be related to behaviors that contribute to unintentional injuries and violence: motor vehicle accidents (26%), other unintentional injuries (17%), homicide (16%), and suicide (13%).³

For example, in the United States, vehicular accidents remain the leading cause of mortality and morbidity among young people. The 2013 YRBS data indicate that teens engaged in high-risk behaviors that are associated with motor vehicle accidents: 41% of adolescents texted or e-mailed while driving, while 35% had consumed alcohol in the past month (10% drank prior to or while driving and 21% rode with a driver who had been drinking) and 23% had used marijuana in the past month.

Risk-taking behaviors for suicide and sexually transmitted diseases are also common in adolescents. Alcohol and substance use along with access to a weapon are significantly associated with both homicide and suicide. In 2013, 30% of teens reported feeling sad or hopeless at a level consistent with clinical depression. Seventeen percent seriously considered suicide, with 14% making a plan and 8% actually attempting suicide in the past 12 months.³ In the same year, 18% of high school students had carried a weapon in the past month, with 6% reporting carrying a gun. Among sexually active high school students in the United States, the 2013 YRBS survey found that 15% of adolescents had had intercourse with four or more partners and 59% had used condoms during their previous intercourse. World Health Organization (WHO) data indicate that globally, at least half of 15-year-olds who are sexually active report using condoms the last time that they had sex.³

Although any adolescent may engage in behaviors that can compromise their health, certain individual, family, and community characteristics can result in greater vulnerability in adolescence. Contextual factors such as the physical environment, the social environment, and the availability and access to health and social services have been proposed as a framework for assessing urban adolescent vulnerability worldwide.⁴

Physical environments associated with a higher prevalence of adolescent pregnancy and sexually transmitted infections include communities or neighborhoods with high levels disorganization, physical disorder (run-down buildings, broken windows, trash, and graffiti) and poverty. In addition, exposure to adults who have lower levels of education, lower income, and higher unemployment is more likely in these neighborhoods.⁵ Lack of recreational facilities, youth-oriented organizations, and positive alternatives for activities during out-of-school time are correlated with poorer reproductive and sexual health outcomes for girls and young women and involvement in alcohol and drug use and violence for boys and young men.⁶

Social environments include the home and family as well as the broader social environments of school and community.⁷ Unstable households where there is a lack of parental engagement and monitoring, limited parental presence in the home (whether due to the need to work long hours or multiple jobs to support the family, incarceration, parental drug or alcohol use, or other issues that limit parental presence and engagement), poor communication patterns, and domestic violence or abuse are associated with increased risk behaviors and poorer health outcomes in youth. Family rejection and lack of familial and social support for youth who are gay, lesbian, bisexual, or transgender (sexual minority youth) are associated with higher sexual risk, mental health, and substance use problems.⁸ Lack of academic goals and low levels of school engagement are associated with earlier sexual debut, early childbearing, and substance involvement.⁹ Family norms and expectations, perceived peer norms, and community norms all influence adolescent decision making when it comes to risky behaviors.

Problems in school are problems in themselves, jeopardizing an adolescent’s future employment possibilities, for example. School phobias, truancy, academic failure, fights, poor concentration, learning disabilities, and school dropout or suspension may be indications of other underlying troubles. Early identification and intervention of school problems may prevent progression to other adolescent risk behaviors.¹⁰

ACCESS TO CARE AND CONFIDENTIALITY

As a whole, adolescents are among the most underserved populations worldwide. Routine checkups for adolescents are rare in both developed and developing countries alike.^11,12 While some youth may be reached in traditional health clinic settings, nearly half of those surveyed by the WHO global consultation indicated a preference for school-based health centers. Any facility-based care may not reach the most vulnerable adolescents, including homeless, runaway, and immigrant/migrant youth.¹³

Lack of confidentiality, real and perceived, can be a major barrier to care.¹⁴ Even with symptoms, a significant number of adolescents forego health care because of concerns over confidentiality. Studies indicate that if mandatory reporting for reproductive health services were instituted, 60% of adolescents would delay or discontinue seeking reproductive health-care services. Low-income and uninsured adolescents are even less likely to get confidential care.¹⁵

Key tasks for health-care providers working with adolescents lie in navigating the legal and political landscapes in which privacy and confidential care are not protected. Accessible, convenient care across a spectrum of settings from school-based health centers and community clinics to urgent care and emergency rooms may be venues for adolescents seeking care. Regardless of the setting, it is incumbent on those working with adolescents to address the social and behavioral factors that contribute most significantly to their health status.¹⁶

Although laws vary, federal and most state regulations in the United States carry exceptions to the requirement for parental consent prior to providing care to an adolescent for reproductive health, mental health, substance abuse, and emergency situations. Adolescents may consent for their own care if they are pregnant, parenting (in some, but not all, states), married, or emancipated minors.¹⁴

SPECIFIC SUBPOPULATIONS OF AT-RISK YOUTH

Specific subpopulations of youth are at risk for experiencing greater challenges and are more vulnerable to poorer outcomes as they move through adolescence and into adulthood. Particularly vulnerable youth populations include immigrant, poor rural and urban, educationally disadvantaged, homeless, runaway, and sexual, racial, and ethnic minority youth.

Youth of Color: Racism as a Source of Vulnerability

Youth of color, particularly African-American and Latino adolescents, face additional vulnerabilities owing to structural inequities and institutionalized racism. They are likely to be over-criminalized, over-policed, and consequently over-represented in incarceration systems.¹⁷ Experiences of racism and discrimination result in lowered self-esteem, increased rates of depression, and poorer educational outcomes.^18,19 Institutionalized racism occurs even in clinical settings, as African-American and Latino youth are disproportionally diagnosed with Conduct Disorder.²⁰ Fifty plus years after the Civil Rights act, African-American youth are still likely to live in segregated neighborhoods and are more likely to attend segregated public schools now than they were 40 years ago.^21,22

Immigrant Youth

Immigrant youth are vulnerable to discrimination, and if they struggle with English proficiency they may be educationally and vocationally vulnerable as well. Immigrant youth are often faced with conflicting pressures of acculturation versus maintenance of a sense of ethnic and cultural heritage. Data are conflicting in the directionality of risk and acculturation. Immigrant youth and children of immigrants are most vulnerable when they or their parents lack legal residency. In most states, they lack access to jobs, financial aid for school, and may face difficulties obtaining health-care coverage. They are at risk for multiple vulnerabilities including neglect, foster system placement, or homelessness if their parents are deported.

Youth in the Foster Care System

There are approximately 500,000 children in the foster care system in the United States, with adolescents making up approximately 45% of the foster care population. About half of these children and youth are in nonrelative foster home, 28% are fostered by relatives (kinship care), and 15% live in institutions and group homes.²³ Children and youth in foster care have higher rates of physical, developmental, dental, and behavioral health problems than any other group of American youth. The heightened vulnerability of youth in foster care is attributable to the familial, social, and environmental contexts that resulted in their removal from their home (abuse, neglect, and family dysfunction) and their experiences once in a system that often provides suboptimal environments in terms of safety, stability, consistency, and support-essential assets for developing adolescents.

The instability, impermanence, and fragmentation of home, community, school, and health care for youth in foster care creates an environment that mediates against healthy adolescent growth and development.^24,25 A meta-analysis of research evaluating the impact of intervention programs for foster-care families on the health and mental health outcomes of foster youth showed that effective programs had some common characteristics, including (1) a focus on enhancing individual strengths and reducing specific risk behaviors, (2) a developmentally sensitive and appropriate approach, and (3) a base in the mediating effect of parenting on the impact of adversity on outcomes. The only adolescent-focused intervention found to be effective was a multicomponent program placing foster youth in an individual home where foster caregivers were intensively trained, supervised, and supported to provide mentoring, supervision, and consistent limit setting.²⁵ The issues of permanence, monitoring and support for both youth and foster caregivers, and continued support for foster youth into young adulthood have emerged as key policy concerns.

The role of health-care providers in reducing the vulnerability of foster youth includes (1) provision of a medical home for youth in foster care, (2) collaboration with child welfare workers to ensure adequate, ongoing health and mental health care, (3) a working knowledge of state programs to provide health coverage to youth and young adults in and aging out of the foster-care system, (4) an understanding of the health needs of and resources for foster youth, and (5) engagement in transition planning for the ongoing care of youth as they age out of the foster-care system.²⁶ (See Healthy Foster Care America Web site: http://www.aap.org/fostercare for tools and resources.)

Incarcerated Youth

While the rate of juvenile detention has declined over the past 15 years, over 54,000 young people were detained in residential facilities in 2013,²⁷ and up to an additional 10,000 adolescents are housed in adult jails and prisons on any given night.²⁸ Young men and youth of color, particularly African-American adolescents and young adults (AYA), are over-represented in the juvenile justice system. African-American, Latino, and Native-American youth are more likely to be detained, to spend more time in detention, to be adjudicated to out-of-home placement, and to be committed to an adult facility than are White youth.²⁹

The impact of juvenile incarceration is profound. Recidivism rates are high, and up to one-third of incarcerated youth will return to jail or prison in young adulthood. Rates of reoffending vary by the nature of the crime, with individuals who were charged with property offences the least likely to reoffend and those with violent and drug offences the most likely.³⁰ Incarceration compounds the vulnerability of these already vulnerable youth, resulting in a significant impact on income for up to 10 years post-release, which, in turn, affects their mental well-being, physical health, social attachments, and life expectancy.³¹ Preventing youth incarceration or recidivism is important for public and individual health (see Chapter 27).

Early identification and linkage into evidence-based family interventions such as Functional Family Therapy (see http://www.childtrends.org/?programs=functional-family-therapy) and Multisystemic Therapy (see http://www.childtrends.org/?programs=multisystemic-therapy) and/or individual interventions such as Insiders Juvenile Crime Prevention (see http://www.childtrends.org/?programs=the-insiders-juvenile-crime-prevention-program), a “Scared Straight”-style program, exposing youth to the realities of life in prison and Multidimensional Treatment Foster Care (see http://www.childtrends.org/?programs=multidimensional-treatment-foster-care-mtfc) have been shown to have an impact on recidivism and the reincarceration of juvenile offenders in young adulthood.

Gang-Involved Youth

Gang violence accounted for 20% of homicides in the United States from 2002 to 2008.³² History of incarcerated relatives, acquaintances, and neighborhood exposure to drugs and crime may represent risk factors for gang involvement.³³ Participation in gang activity and living in gang “war zones” put youth at exceptionally high risk for violent injury and death. In addition to death and injury, gang involvement puts youth at high risk of criminal acts, incarceration, substance abuse, and early sexual debut. Gang involvement is further associated with economic hardship and family problems in adulthood. Youth with high coping skills and more parental monitoring have been shown to have lower rates of gang involvement.

The ability and willingness of AYA to leave a gang depends on the length of time of their involvement and the strength of the gang in their area.³⁴ Successful interventions mitigate the economic and social pushes and pulls of the gang lifestyle. Such interventions include motivational interviewing, referrals to employment assistance, vocational training, remedial/alternative education assistance, counseling, substance abuse services, and mentoring. Evidence-based gang and violence programs such as Gang Resistance Education and Training (G.R.E.A.T.) are available through national partner organizations such as Boys and Girls Clubs of America.³⁵ Because past or present gang affiliation is often readily identifiable through tattoos on the face, neck, forearms, hands, and other easily viewed parts of the body, tattoo-removal services have emerged in recent years as an important intervention to help youth escape gang involvement.³⁶

Youth with Chronic Conditions and Disabilities

Obesity

The prevalence of obesity in US children and adolescents in 2010 was 16.9%, with the prevalence of overweight at 31.8%, both of which were unchanged from 2007 to 2009 levels.³⁷ There are significant differences in obesity prevalence by race/ethnicity with increased obesity in Hispanic and non-Hispanic black children and adolescents compared with non-Hispanic white children and adolescents. The lifelong risk factors for overweight and obese children and adolescents are well known and include cardiovascular risks, increased health-care costs, and premature death. Extremely obese children and adolescents are also likely to be obese during adulthood; obese adults are at increased risk for stroke and many chronic diseases, including coronary heart disease, hypertension, type 2 diabetes, and certain types of cancer.³⁸

Reports from the Centers for Disease Control and Prevention (CDC)’s National Center for Health Statistics (NCHS) indicate that socioeconomic status is relevant to obesity in adolescents.³⁹ Although most obese children and adolescents are not low income (below 130% of the poverty level), low-income children and adolescents are more likely to be obese than their higher-income counterparts. Children and adolescents in households where the head of the household had a college degree are also less likely to be obese compared with those living in households where the household head has less education, but the relationship is not consistent across race and ethnicity groups.

Adolescents who experience food insecurity, that is, lack of resources to obtain adequate nutritional intake, often maintain a substantial portion of their dietary intake on “junk” (high caloric) foods that can lead to obesity, for example, excessive soda beverages, foods high in carbohydrates, fried foods, and snacks, with minimal intake of recommended portions of protein, fruits, and vegetables. Clinicians working with adolescents need to obtain dietary histories on all patients as well as body mass index measurements.⁴⁰ Questions about usual sources of food and identifying food insecurity can be included in the modified HEEADSSS screen (see “Core Competency”). When food insecurity and/or obesity are identified, clinicians should attempt to engage the adolescent in teen-friendly weight management programs as well as programs that can provide adequate resources to address food insecurity and weight management.^41,42 Community-based programs such as Boys and Girls Clubs are excellent resources to address these issues and engage the teens in creative nutritional education programs.

There are few public health and dietary education reports that address disparate health needs of specific populations. One study reported that the diets of Hispanic children, regardless of the level of acculturation and food insecurity, were less nutritious than the national average for children in the United States, and do not contain adequate quantities of healthful foods such as fruits and vegetables, suggesting a need for qualitative research into the underlying communication and acculturation processes and how these affect diet and nutrition.⁴³ Another study on food insecurity found that interventions to improve food-insecure adolescents’ eating behaviors may benefit from supporting mothers’ use of health-promoting parenting practices.⁴⁴

Adolescents with disabilities

Youth with developmental and/or intellectual disabilities encounter challenges that may increase their vulnerabilities and impair their access to health care during adolescence. The Americans with Disabilities Act requires health-care professionals to ensure access to health care (Developmental Disabilities Assistance and Bill of Rights Act of 2000 http://www.acl.gov/Programs/AIDD/DDA_BOR_ACT_2000/Index.aspx). These adolescents and their families or caregivers have special needs that require, among other skills, particular knowledge and skills for examination room etiquette, effective communication, knowledge of resources, and skills with working in interdisciplinary teams (see Chapter 42).⁴⁵

Adolescents with disabilities also need access to sexuality education and medical care that addresses their sexual health needs. As with all adolescents, these teens need to be able to have confidential and private discussions with providers that address their gender and sexual identity, sexuality, prevention of sexually transmitted infections, and pregnancy. The Office of Developmental Primary Care (http://odpc.ucsf.edu.) offers many resources for the care of adolescents with disabilities. Of particular concern for parents and caregivers of youth with disabilities is their increased risk of vulnerability to physical and sexual violence, neglect, and emotional abuse. Vulnerability to abuse is increased for those youth whose disability leads to heightened dependency on others, particularly those with intellectual disability, and for those with communication difficulties. With mild developmental impairments, victimization can be related to the need to “fit in” and be like their peers. Although families frequently express concerns about the risks of stranger abuse, family and caregivers more frequently perpetrate abuse. Although findings related to the prevalence and risk of abuse varies between studies, a recent meta-analysis of international data shows a consistent finding of a higher prevalence and risk for abuse among youth with disabilities than for their peers without disabilities.⁴⁶

Chronic conditions

Management of chronic conditions, for example, asthma and diabetes, can be especially challenging for vulnerable youth with minimal resources and/or family supports. Throughout earlier childhood, parents and caregivers regularly make treatment decisions. During the transitions through adolescence, youth need to become more involved in taking control of their chronic illness management. However, there have been few studies that look at how these decisions are made during the childhood years.⁴⁷

Development of one’s sexual identity is a normative and expected process that occurs during adolescence and young adulthood. The abilities to engage in romantic relationships and experience intimacy are positive aspects of sexual identity. However, there are risks associated with sexual behaviors, including sexually transmitted infection and unintended pregnancy. These risks are often intensified during adolescence and young adulthood when sexual activity is often initiated without an accurate understanding of reproduction, contraception, or the transmission of infection.⁴⁸

In the United States, early sexual debut (sexual activity prior to the age of 14) is uncommon. Fewer than 8% of adolescents have had sex by their 14th birthday. However, the percentage of adolescents who have had sex increases after the age of 15, and by 12th grade 49% of youth have been sexually active in the past 3 months.³ By the age of 20, 74% of adolescents, both male and female, have initiated sexual activity.⁴⁹

The percentage of young adolescents, ages 13–15 years, who have had sex varies greatly by specific country, from approximately 70% (males in Samoa and females in Greenland) to less than 1% (both males and females in Indonesia).² However, the overall rate of sexual activity among adolescents is similar in most high-income countries, and not dissimilar to those living in low- and middle-income countries (LMICs): by the age of 18, 60% of females in the United States and sub-Saharan Africa have had sex.^49,50 In LMICs, sexual activity usually occurs within the context of marriage, with early sexual debut associated with early marriage. Globally, 34% of girls are married before the age of 18 years, and 11% are married before the age of 15.⁵¹ In many LMICs, however, the decreasing age of puberty and the increasing age of marriage are resulting in an increase in premarital sexual activity among adolescents.⁵²

Sexual coercion and exploitation are common in adolescents. In the United States, about 7% of adolescents, 11% of girls, and 4% of boys report sexual exploitation.³ Sexual coercion is more likely among younger adolescents, with 50% of US girls who had sex by the age of 11 and 23% of those who had sex by the age of 12 reporting that their first sexual experience was not consensual.⁴⁹ Perpetrators of sexual coercion include partners (dating violence), family members (incest), and strangers. Sexual coercion is common in other countries as well. In Malawi, 14% of females aged 15–19 reported their first sexual encounter was forced.⁵³ A study of Chinese high school students found that 41% of females and 30% of males had experienced sexual coercion.⁵⁴

SEXUALLY TRANSMITTED INFECTIONS

Sexually transmitted infections (STIs) challenge public health systems in the United States and worldwide, cause significant morbidity and economic burden, and disproportionately affect AYA. The estimated annual incidence of STIs in the United States is nearly 20 million, with 50% occurring in youth ages 15–24, although they comprise only 25% of the sexually active population.⁵⁵ The most prevalent STI is human papilloma virus (HPV), followed by chlamydia and trichomoniasis.⁵⁵ While condoms remain the most commonly used method of contraception among US AYA and provide the most effective protection against STIs, 41% of sexually active adolescents reported not using a condom at last intercourse in 2013.³

HUMAN IMMUNODEFICIENCY VIRUS

Of particular concern is infection with the HIV. HIV is now the second leading cause of mortality among the world’s adolescents.² Ninety percent of these deaths occur in sub-Saharan Africa, where one out of every six adolescent deaths is due to HIV.² Among AYA ages 15–24, the global HIV prevalence is 0.4% (about half that of total global prevalence) or more than 2 million AYA living with HIV.² Countries in sub-Saharan Africa have been particularly devastated by the HIV epidemic, and again, youth are disproportionately affected. For example, the HIV prevalence rate among AYA is 11% in Lesotho and Swaziland, and 9% in South Africa.⁵¹ In much of the world, women are equally, and in some countries more, affected than men. Globally, girls and women aged 15–24 have twice the HIV infection rates as their male counterparts.⁵⁶

In 2010, 26% of new HIV infections in the United States occurred in youth ages 13–24, although they represented only 17% of the population.⁵⁷ At particular risk are AYA males who have sex with other males and minority youth.⁵⁷ An estimated 39,000 youth are living with HIV in the United States as of 2010. About 28,000 of those infected are AYA boys/men who acquired the infection from sex with other men; 13% were infected perinatally. Approximately 11,000 AYA girls are HIV infected, 56% as a result of heterosexual contact, and the remainder perinatally infected.⁵⁷

PREGNANCY AND CONTRACEPTION

Pregnancy in adolescents, both married and single, is common throughout the world, particularly in LMICs. An estimated 16 million girls aged 15–19 give birth each year, accounting for 11% of all births. Approximately 95% of these births occur in the poorest countries.⁵⁸ Most adolescent pregnancies occur within the context of marriage, with nearly 100% of pregnant adolescents married in Asia and Northern Africa, yet only 70% of pregnant adolescents are married in sub-Saharan Africa.⁵⁹

In the United States, teen pregnancies have been declining, but still remain higher than the rates found in other developed countries. In addition, significant disparities in teen pregnancy rates exist among poor and minority AYA. Black, Hispanic/Latino, American-Indian/Alaska Native and socioeconomically disadvantaged youth, particularly those in foster care and with histories of exposure to the juvenile delinquent system, experience the highest rates of teen pregnancy and childbirth.

Adolescent pregnancies can have a number of deleterious effects on both the mother and her child. Very young mothers are at high risk of perinatal complications, from preterm birth to preeclampsia. In low-resource countries, where a lack of health-care facilities and providers and a high prevalence of anemia and malaria infection confer additional risks for adverse perinatal outcomes, studies document an increased risk of perinatal complications including an increased risk of preterm labor, preterm delivery, and neonatal deaths among pregnant adolescents.^60,61 According to research conducted by the WHO’s Making Pregnancy Safer program, pregnant young adolescents (younger than 16 years) have a four times higher risk of maternal death than older women, and a 50% higher death rate among their infants.⁶²

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