Robert E. Morris
Ralph J. DiClemente
Changes in society over the last 25 to 30 years have significantly influenced the adolescent years. The educational experience has been prolonged and the job market constricted. Adaptations to intrinsic psychological developmental triggers are now made in an environment of increasing drug use, sexual activity, and media stimulation and weakened family structure. Attempts by adolescents to cope with these pressures often result in social behaviors that are associated with inherent and inconstant degrees of risk to health. The consequences of these health risks may be immediate or long range.
In the United States the following have been estimated:
The major causes of death and disability among the approximately 40 million American youth aged 10 to 19 years, who comprise 14% of the U.S. population, have essentially social and behavioral issues at their root—and parenthetically, the majority are preventable!
Risk and Resilience
The concept of risk has been well established as a characteristic that detrimentally exposes young people to threats to their health and well-being. Related to the concept of risk is the construct of resilience, which has received a great deal of attention through research for many decades. One of the difficulties that persists in understanding this construct is the lack of a unified theoretical framework (Luthar et al., 2000).
A review of the literature on resilience among adolescents suggests that there are two primary operational definitions of this construct (Olsson et al., 2003). First, resilience can be viewed as various psychosocial outcomes characterized by functional behavior patterns among adolescents exposed to risk. Included among such outcomes are mental health functioning, functional capacity, and social competence (Blum, 1998). Absent from this list of psychosocial outcomes defining the construct of resilience is emotional well-being. Rather than conceptualizing emotional well-being as an outcome of the resilient individual facing adverse life events, researchers have suggested that the resilient individual may indeed experience emotional distress; however, what differentiates him/her from the nonresilient individual is his/her ability to function effectively even in the presence of difficult emotions (Luthar, 1991). In other words, emotional difficulty compounds the risk to which an individual is exposed and to which he/she must adapt. Those who are resilient will display good mental health, high functional capacity, and high social competence in adverse circumstances, including those charged with negative emotional stress. In fact, Garmezy (1991) defines resilience as “the capacity to recover and maintain adaptive behavior after insult.” This operational definition may be useful in understanding adaptation to adverse events; however, it does not provide much information regarding the mechanism or process by which the impact of a stressful event is modified in such a way as to allow for successful adaptation.
The second way to conceptualize resilience is by investigating the protective mechanisms that contribute to successful adaptation to a stressful event (Olsson et al., 2003). In this view, resilience involves a healthy set of behaviors and coping mechanisms that are integrated into decision making and elicited in response to a threatening situation. The youth responds flexibly and makes positive choices despite impoverished life experiences. Factors associated with resilience as identified in this view include individual-level factors such as intelligence (Eccles, 1997), communication skills (Werner, 1995), sociability (Allen, 1998), as well as personal attributes such as self-esteem (Blum, 1998), and tolerance for negative affect (Smith, 1999). Additionally, family-level factors are also major contributors to the development of resilience. These include parental warmth, encouragement, and assistance (Smith, 1999; Eccles, 1997), authoritative parenting, that is, acceptance, encouraging psychological autonomy, and behavioral control in a firm but loving manner (Steinberg et al., 1989), as well as cohesion within the family (Maggs et al., 1997). Finally, social-level factors include socioeconomic status (Allen, 1998; Maggs et al., 1997), school experiences (Werner, 1995; Rutter, 1987), and supportive communities (Smith, 1999; Werner, 1995).
It is important to note that when considering resilience as a process of interplaying risk and protective factors, the relationship between resilience and adaptability is a multifactorial process. Just as multiple risk factors may
have a synergistic effect on one's ability to adapt, protective factors associated with resilience may exert their influence in a similar manner, leading to successful adaptation and coping with a stressful environment.
Epidemiology of Risk-Taking Behavior
In 2003, approximately 17,651 adolescents aged 10 to 19 died (Centers for Disease Control and Prevention, 2006). Approximately 75% of deaths occurred from injuries (intentional and unintentional) and 25% from natural causes. The proportion of all deaths from injuries increased with age, from approximately 47% among 10-year-old to 81% among those 18 years of age. In 2002, motor vehicle- and traffic-related accidents caused 25% of all deaths and 50% of injury-related deaths in 10- to 14-year-olds, 42% of all deaths and 78% of injury-related deaths in 15- to 19-year-olds, and 31% and 75% in 20- to 24-year-olds, respectively. Motor vehicle accidents increase with age, with the greatest increase being between 15 and 16 years of age (see Chapter 5). Many of these events are related to drug or alcohol use. The mortality figures do not reflect the magnitude of morbidity and subsequent disability associated with these leading causes of injury.
It is estimated that 20% of U.S. teenagers have great difficulty making the transition from childhood to adulthood and that this difficulty is often reflected in their risk-taking behaviors. The frequency of these morbidities correlates with the teen's biobehavioral risk profile. The latter is directly dependent on the frequency and number of risky behaviors that the teenager uses to resolve psychological and social developmental needs. Frequent subsequent problems include the following:
Factors Involved in Risk-Taking Behavior
Childhood and adolescence are continuous and contiguous events in the life cycle. The manner in which the developmental challenges of adolescence are expressed is dependent on, if not largely determined by, personality traits and other characteristics established in childhood. The physical, psychological, and social maturational forces of development combine to determine behavior at any moment. During adolescence these behaviors may be perceived by those close to the teenagers as a problem because they may constitute a health risk. Viewed developmentally, however, these behaviors serve a purpose (i.e., that of a developmental task accomplishment). Often the adolescent does not perceive risk-taking behavior as a problem but, rather, as a solution. This paradox helps explain the behavior and also the difficulty of managing youth who engage in high-risk behaviors. What health professionals see as a problem, youth often see as a solution. People, in general, do not give up their solutions easily.
General characteristics of risk-taking behaviors in adolescents include the following:
Many factors have been suggested as contributing to problem behaviors among youth in the United States. Although biological maturational forces have remained
relatively constant, the timing of puberty and the social environment in which it occurs have dramatically changed over the last decade. This has put increased pressure on the individual for adaptation to these new norms that define adolescence. These factors include the following:
Certain youth are predisposed to having difficulty with the transition from childhood to adulthood, including:
It is important to realize that most of these young people mature successfully through adolescence without apparent long-term problems. The health professional may be on the lookout for problems and offer help when appropriate but should not automatically label these teens as being at high risk.
In summary, high-risk and out-of-control behaviors require prompt evaluation and attention. Associated are a wide spectrum of behaviors, including runaway behavior, truancy, theft, vandalism, substance abuse, sexual promiscuity, and suicide. Loss of parental control must be assessed along with what has been tried to regain control. The health professional must evaluate what are the greatest influences on the teen's present behavior and how those influences are related to developmental needs. Underlying issues often involve autonomy, low self-esteem, frustration, or depression.
Incarcerated Youth and Juvenile Delinquency
A juvenile delinquent is a person younger than 17 or 18 years (depending on the state) who commits any criminal offense as defined by state or local laws. Delinquents are subject to the regulations of the juvenile or family court, with a goal of rehabilitation rather than punishment. For serious offenses including murder, rape, and assault with a deadly weapon, many states have moved jurisdiction from juvenile court to adult criminal court with the possibility of sentencing juveniles to adult prisons where there is little rehabilitation.
A status offender is a juvenile younger than 17 or 18 years who commits an offense that would not be illegal for an adult. Examples include disobedience to parents or guardians leading to loss of disciplinary control, truancy, runaway behavior, and curfew violation. Status offenders are often referred to as persons, children, juveniles, or minors in need of supervision (PINS, CHINS, JINS, or MINS, respectively). In some states, juvenile delinquents and status offenders are grouped together. Increasingly, states and local agencies separate the two groups, nonetheless an effective system to deal with status offenders is lacking in most states. Many of these young people are referred to mental health or social service agencies by the court.
There was considerable growth in juvenile crime arrests beginning in the late 1980s that peaked in 1994 and dropped every year through 2003 (Snyder, 2005). The violent crime index showed that offenders decreased 48% between 1994 and 2003. Juvenile arrests for murder in 1993 dropped from 3,790 to 1,130 in 2003, a 70% decrease. But, the arrest rate for simple assault increased 102% for males and 269% for females between 1980 and 2003. Arrests for drug abuse increased 19% from 1994 to 2003 with the rate for females increasing much more, to 56% compared to an increase for males at 13% (Snyder, 2005). Table 76.1 compares the types of offenses for
which juveniles were held in correctional facilities on an index day in 1997 and 2003.
Statistics show that juveniles are more likely to commit crimes in groups and are more likely to be arrested compared to adults. Overall, however, approximately 5% to 10% of the adolescent population accounts for more than 50% of all juvenile crimes and most serious and violent juveniles crimes (Williams, 2006).
As of 2000, there were 73 death row inmates who committed their crime before the age of 18, and 17 had been executed from 1985 through 2000. One of the offenders was 16 at the time of the crime and the remainder were 17 (Sickmund, 2004).
decreases in arrests of girls for larceny/theft (19% but boy's arrests were down 43%), motor vehicle thefts (reduced 44% for girls and 54% for boys), vandalism (down 11% in girls and 36% in boys), and weapons offenses (down 22% in girls versus 42% for boys) (Snyder, 2005). Table 76.2 compares the gender and ages of juveniles held on an index day in 1997 and 2003.
Social and environmental factors
Effective Rehabilitation For Delinquent and Violent Youth
Until recently, few interventions to reduce delinquent behavior were rigorously evaluated to determine if they reduced recidivism. Current successful rehabilitation programs address the criminogenic factors of offenders. The major risk factors that correlate with recidivism risk in order of importance are:
Further information about assessment of risk and case management can be accessed at www.Assessments.com.
The list of most important criminogenic factors varies somewhat from author to author. However, the principle concepts is that attributes related to criminal behavior are targeted by the rehabilitation program and factors such as self esteem that are not related to ongoing delinquent behavior are not stressed.
Effective and cost-efficient programs identify those youth at high risk to re-offend. The programs present their interventions in a responsive manner that meets the learning styles and culture of the youth. Each program must follow ethical guidelines and adhere to program integrity i.e. programs must closely replicate those programs proven to be effective. Some interventions that have been shown to be effective are: Aggression Replacement Training, Multisystemic Treatment, Functional Family Therapy, and Multidimensional Treatment Foster Care. On the other hand, boot camps and scared straight type programs are not effective in reducing recidivism while intensive juvenile probation has a mixed record of success. Considerably more research is needed to develop more effective interventions that address delinquent behavior. In addition researchers must develop collaborative working relationships with legislators who often control the types of rehabilitation available in government funded facilities.
A comprehensive review of mental health and medical issues of institutionalized youth is beyond the scope of this book. The health care provider should know that approximately 1 million adolescents live away from home, and one half of them are in institutions for juvenile offenders. The June 2006 issue of Journal of Adolescent Health and the April 2006 issue of Child and Adolescent Psychiatric Clinics of North America are devoted to health issues of youth in juvenile detention centers.
Between 40% and 80% of these youth have medical problems that may include the following:
Delinquent youth rarely malinger. Many obscure symptoms that result in a confusing clinical picture are either caused by an unusual presentation of a common disease or the presence of an uncommon disease.
Providing medical services to detained youth can be very rewarding. Most institutionalized children have long histories of neglect and abuse. They respond well to kindness and understanding from their care providers. Therefore, medical personnel should remember that they are caregivers and youth advocates rather than correctional staff.
Morris et al. (1995) reviewed the health risk behaviors of youth in juvenile correctional facilities and found that risky behaviors began early and reached a plateau at 15 or 16 years of age. Male and female youths reported comparable rates of drinking, binge drinking, and illicit drug use. By 12 years of age, 62% of those in the study reported a history of sexual intercourse, and 89% were sexually active by age 14. The mean age at onset of sexual intercourse was 12 years. Fighting was common, with 25% reporting fight-related injuries in the last year. Almost one half of the group was in a gang. Suicide had been contemplated by 22%. STDs were common, and fewer than half of the group had used a condom at last intercourse.
In light of these data, incarcerated youth must undergo health and psychiatric screening during intake procedures, and short-term health and mental health care must be available. Guidelines for health care in juvenile detention institutions are available through state boards of correction, from the National Commission on Correctional Health Care (NCCHC) and from the American Correctional Association (ACA).
Clinical health care guidelines for adolescents are available at www.ncchc.org/resources/clinicalguides.html. General health care standards are available at: www.ncchc.org/resources/standards.html and www.aca.org/standards/.
There are many problems facing juvenile correctional facilities, including overcrowding, poorly trained staff, decaying facilities, inadequate medical and psychiatric care, and poor educational resources. These problems tend to persist because of a lack of public scrutiny and disenfranchisement of poor minority youth. For these reasons, a number of states and local jurisdictions are sued each year in order to force improved conditions of confinement.
Runaway behavior is defined as an unauthorized absence from home overnight. A throwaway episode is defined as a time that a child is asked or told to leave the home by a parent or household adult and, or a time when a child who is away from home is prevented from returning and when no alternative care is offered or provided.
Types of Runaways
Reasons for Running Away
Many reasons exist for runaway behavior, including lack of communication with parents, school failure, overly strict or overly permissive parents, discovery of sexual identity discordant with parental values, experimentation, escape from a hopeless situation, being thrown out of the house, revenge, imitation of peers, and the simultaneous crises of adolescence, parental middle-age crisis, and elderly grandparents. Depression is another reason for runaway behavior, 4% of the youth in the Department of Justice study reported previously attempting suicide (Hammer et al., 2002). In this study, 21% of runaway and throwaway youth had been physically or sexually abused at home in the year before leaving home and were afraid of abuse upon return (Hammer et al., 2002).
For those adolescents who become homeless, the situation is aggravated by decreased access to food, shelter, medical services, and social supports. Homeless youth lack a mainstream social network, and create their own social networks within their runaway environment.
An estimated 71% have the potential for being endangered during their runaway/throwaway episode because of substance dependency, use of hard drugs, sexual or physical abuse, presence in a place where criminal activity was occurring, or extremely young age (Hammer et al., 2002). Homeless, runaway, and throwaway youth are at significantly greater risk for health problems including HIV and other STDs, substance abuse, depression and suicide attempts, prostitution, and trauma (Clatts et al., 2005; Greenblatt and Robertson, 1993;Greene et al., 1999; Green et al., 1995; Whitbeck, 2004). Allen et al. (1994) reported HIV prevalence rates of 0% to 7.3% (median, 2.3%) among homeless youth. Rotheram-Borus (1993) reported a suicide attempt in 37% of runaway youth, with 44% of them having made an attempt within the previous month. Girls were significantly more likely than boys to have attempted suicide and to be depressed. Runaways with a history of attempted suicide were significantly more likely to be currently suicidal and depressed.
This topic is discussed in Chapter 79.
This topic is discussed in Chapters 68,69,70,71,72,73,74.
For the primary care provider, the contact point with adolescents with high-risk behavior is the presentation of a medical problem. Rather than merely treating the medical problem, the physician needs to gather more background information to elicit the context in which the medical complaint has evolved. A brief psychosocial or lifestyle interview should be conducted. One method is the HEEADSSS Adolescent Risk Profile discussed in Chapter 3. The HEEADSSS evaluation assesses risk and provides an opportunity to discuss with the adolescent the practices or behaviors that may influence health. The assessment should include the following:
Important considerations include the following:
http://ojjdp.ncjrs.org/. Office of Juvenile Justice and Delinquency Prevention.
http://ncjrs.gov/App/Topics/Topic.aspx?TopicID=122. National Criminal Justice Reference Service.
http://www.childinc.com/runaway.htm. A United Way site on help for those with runaway youth.
http://www.ncjj.org/. National Center for Juvenile Justice.
http://www.njda.com/. National Juvenile Detention Association.
www.ojp.usdoj.gov/bjs/guide.htm. Sourcebook on Criminal Justice Statistics.
http://www.achsa.org/. American Correctional Health Services Association.
http://www.ncchc.org/. National Commission on Correctional Health Care.
http://www.aca.org. American Correctional Association.
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