Adolescent Health Care: A Practical Guide

Chapter 76

High-Risk and Delinquent Behavior

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:

  • Every 37 seconds a teenager becomes pregnant
  • About every 1 minute a teen gives birth
  • Every 78 seconds a teen attempts suicide
  • Every 76 minutes a teen is killed in a car accident
  • Every 90 minutes a teen is murdered and another commits suicide

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:

  1. Pregnancy: In the United States >800,000 pregnancies for females aged 15 to 19 per year are reported with more than 60% of these pregnancies occurring in 18- to 19-year-old females (Henshaw, 2005). From 1990 to 2003, the birth rate for females aged 15 to 19 decreased 33%, from 62 per 1,000 females to 41.6. For 15- to 17-year-olds the birth rate decreased from 38.6 in 1991 to 22.4 in 2003 (Martin et al., 2005). Among all 15- to 19-year-olds in the United States, approximately 10% become pregnant each year, and among those who have had intercourse, approximately 19% become pregnant each year. For younger 10- to 14-year-old females, there are approximately 15,000 pregnancies per year (Abma et al., 2004). Teenage pregnancies are associated with higher rates of complications, particularly low birth weight and infant mortality, and especially when the mother is very young. These complications may be related to the lack of regular prenatal care. Factors increasing pregnancy and parenting risks include poverty, low intellect, lower status of employment and wages, reliance on public assistance, poor literacy and work skills, substance abuse, emotional or sexual abuse, and increased number of children in the family of origin (i.e., many siblings and possibly early pregnancies in the index adolescent's female siblings). Fifty-one percent of adolescents use no contraception during first intercourse, and 20% of adolescent pregnancies occur within 1 month of first intercourse (see Chapter 41).
  2. Sexual activity: The 2005 Youth Risk Behavior Survey (YRBS) found that approximately half (46.8%) of all high-school students had had sexual intercourse during their lifetime (CDC, 2006). Female students in grades 11 and 12 (52.1% and 62.4%, respectively) were significantly more likely than female students in grades 9 and 10 (29.3% and 44%, respectively) to have had sexual intercourse. Male students in grades 11 and 12 (50.6% and 63.8%, respectively) were significantly more likely than male students in grades 9 and 10 (39.3% and 41.5%, respectively) to report this behavior. A total of 6.2% of students initiated sexual intercourse before age 13 years (nonabusive) including 8.8% of male and 3.7% of female students. In addition, 14.3% of all students had had sexual intercourse with four or more partners. Approximately 63% of currently sexually active adolescents reported condom use during their last sexual intercourse (CDC, 2006). Sexually transmitted diseases (STDs) are the most commonly reported infectious diseases among sexually active adolescents. Chlamydia and, to a lesser extent, gonorrhea are epidemics in this age-group, with adolescents having the highest prevalence of any age-group nationally, if prevalence is expressed only for those who are sexually active. Although the overall prevalence of human immunodeficiency virus (HIV) infection is relatively low among adolescents, adolescents in some minority and racial groups are disproportionately affected by HIV and acquired immunodeficiency syndrome (AIDS).
  3. Substance abuse: In 2005, 43.3% of all high-school students (42.8% of girls and 43.8% of boys) reported alcohol use during the previous 30 days. Binge drinking (consumption of five or more drinks on one occasion) was reported by 23.5% of female students and 27.5% of male students during the same 30-day period. Lifetime use of marijuana, the most commonly reported illicit drug used among high-school students, was reported by 38.4% of high-school students. Current marijuana use was reported by 18.2% of female high-school students and 22.1% of male high-school students. A significant minority of high-school students report lifetime use of other illicit drugs, for example, 6.3% report having used ecstasy, 6.2% report having used methamphetamines, and 7.6% report having used a form of cocaine (CDC, 2006).
  4. Runaway behavior: Every year an estimated 500,000 to 1.5 million young people run away or are forced out of their homes. Approximately 200,000 of these are homeless and living on the streets (Administration on Children and Families, 2000). One national study found that an estimated 1,682,900 youth had a runaway or a “throwaway” episode (Hammer et al., 2002). These youth often survive through illegal activities such as survival sex, burglary, or drug dealing (Greene et al., 1999). Approximately 28% of street youth and 10% of shelter youth reported having participated in survival sex. Participation was associated with age, days away from home, victimization, criminal behaviors, substance use, suicide attempts, STDs,and pregnancy (Greene et al., 1999).



  1. Suicide: The age-adjusted death rate for suicide, the 11th leading cause of death, has been edging downward during the 1990s. The age-adjusted suicide rate was 10.7 deaths per 100,000 in 2001, compared with 11.5 in 1990 (National Institute of Mental Health, 2004). Suicide is the third leading cause of death among U.S. residents aged 10 to 24 years, accounting for 11.7% of all deaths in this age-group (CDC, 2004). On the otherhand, suicidal ideation or attempting suicide is a powerful indicator of mental and emotional health. In 2002, an estimated 124,409 visits to U.S. emergency departments were made after attempted suicides or other self-harm incidents among persons aged 10 to 24 (CDC, 2004). On the basis of 2005 YRBS data, nationwide, 8.4% of students had actually attempted suicide one or more times during the 12 months preceding the survey (CDC, 2006). Overall, the prevalence of having attempted suicide was higher among female (10.8%) than male (6%) students.
  2. Education: Although most adolescents complete high school, those students who drop out of school have fewer opportunities to succeed in the work force or to assume a fully functional place in society. High-school dropouts have lower earnings, experience more unemployment, and are more likely to receive welfare or be in prison. Using the indicator of event dropout rate, which measures the proportion of youth aged 15 through 24 who dropped out of grades 10 to 12 in the 12 months preceding October 2000, and therefore did not successfully complete high school, 5% of young adults enrolled in high school in October 1999 left school without successfully completing a high-school program (National Center for Education Statistics, 2001). The event dropout rate increases with age. The cumulative effect of several hundred thousand adolescents leaving school each year translates into several million young adults out of school and not having a high-school diploma. Socioeconomic status is strongly associated with the decision to stay in school. In 2000, young adults living in families with incomes in the lowest 20% of all family incomes were 6 times as likely as their peers from families in the top 20% of the income distribution to drop out of high school. Students from low-income families had an event dropout rate of 10%, whereas students from middle- and high-income families had event dropout rates of 5.2% and 1.6%, respectively. Members of nonwhite races, with the exception of Asian/Pacific Islander youth, whether as a reflection of socioeconomic status or as an independent variable, are disproportionately represented among dropouts (National Center for Education Statistics, 2001).
  3. Crime: In the Youth Health Risk Behavior Surveillance (CDC, 2006), 17% of students had carried a weapon one or more times during the last month (26.9% of males and 6.7% of females). Nationwide, 6.1% of students had carried a gun on >1 occasion in the last 30 days, with the prevalence of having carried a gun higher among male (10.2%) than female (1.6%) students. Almost 41% of males and 25.1% of females reported having been in at least one fight during the previous year. Approximately 5.4% of students reported missing school on 1 or more days during the last month because they felt unsafe at school or when traveling to or from school.

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:

  1. Many behaviors that affect health, both positively and negatively, throughout an individual's life, are first tried out during the teenage years (e.g., cigarette smoking, sexual activity, exercise and physical conditioning, dietary changes, study habits).
  2. The risk that any behavior has on health may be immediate (e.g., drinking and driving), delayed (e.g., pregnancy and education), or remote (e.g., smoking and lung cancer). The more immediate the consequence of behavior on health, the greater the likelihood of effecting change through intervention in adolescents.
  3. Consequences of risk behaviors may be universal and invariant (e.g., risk from crack), related to specific factors or cofactors (e.g., environment, gender, situations), or related to the intensity of involvement (e.g., dieting and anorexia nervosa).
  4. Factors that significantly influence health-related behaviors are usually acquired or consolidated during adolescence (e.g., values, beliefs, attitudes, motivations, self-concept, general lifestyle).
  5. Problem behaviors that contribute to risk tend to occur in combinations or clusters (e.g., smoking, lack of seat belt use, drinking, interpersonal violence, suicidal ideation, school dropout, family discord, and substance use before sexual activity).
  6. Risk at any developmental period reflects the number of risk factors present during that period and the cumulative effects of risk factors occurring earlier in life. The effects may be not only cumulative but also compounded and may lead to other risk behaviors (e.g., the effect of long-term alcohol or drug use on driving or suicidal ideation). High-risk adolescents usually have multiple social and psychological handicaps that amplify the severity of the consequences and limit the options for problem solving and task accomplishment.

Biopsychosocial Factors

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:

  1. Menarche occurs earlier (12.5 years), marriage has been delayed (average age, 26 years), and values have changed regarding premarital sexual intercourse. Incongruence between biological development and psychoemotional preparedness enhances the potential for high-risk behaviors or dysfunctional personal responses to stress, such as early initiation of sexual activity in an attempt to reduce stress.
  2. The U.S. population has become more urbanized, with lack of purposeful and meaningful work for youth.
  3. The American family has increased mobility, with a subsequent need for teens to reestablish social relations at a time when social skills are often poorly developed.
  4. Breakdown of the familyresults in an increased number of single and working parents, lack of an extended family, and the interposition of the media as an arbiter of family values.
  5. The foundation of the adolescent experience, the educational process, has become more prolonged, to prepare the individual for a high-tech society. This has resulted in an increased risk for even some mainstream adolescents to drop out.
  6. A shift has occurred in how society views its young, from being an economic asset to being an economic liability.
  7. Western cultures tend to expose rather than protect adolescents from environmental influences(e.g., drugs and alcohol, automobiles, violent behaviors).
  8. Change occurs rapidlyduring adolescence, and pressures for adaptation are great.
  9. Immature processing of emotions: There is the suggestion that young adolescents continue to process emotions and future planning in the amygdala, similar to children, instead of in the frontal lobes. This can lead to physically mature teens' handling information in a manner similar to younger children, which may result in seriously wrong decisions regarding long-term consequences of their behaviors.

Certain youth are predisposed to having difficulty with the transition from childhood to adulthood, including:

  1. Youth reared in poverty
  2. Youth who have been physically, sexually, or emotionally abused as children
  3. Youth living with significant family pathology, parental mental illness, or substance abuse
  4. Youth with educational handicaps
  5. Youth with a gay or lesbian sexual orientation
  6. Youth with a chronic illness

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


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.

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.


  1. Prevalence: Data from the mid-1990s when this data was last collected, showed that >590,000 children are incarcerated each year in public and private juvenile facilities. Another 90,000 are placed in adult jails each year. According to the U.S. Department of Justice, in 1997 and 2003 law enforcement agencies in the United States made an estimated 2.8 and 2.2 million arrests of persons younger than 18 years, respectively. These arrests accounted for 19% and 16% of all reported arrests and 17% and 15% of all violent crimes in 1997 and 2003, respectively (Snyder, 1998, 2005). Of these arrests, 29% involved females compared to 32% in 1997. However, the percentage of arrests for youths younger than 15 years rose from 6% in 1997 to 32% in 2003.

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).

  1. Characteristics
  2. Gender: In 2003, males accounted for 71% of juvenile arrests (1,577,300) and 82% of juvenile arrests for violent crimes (75,440) (Snyder, 2005). Female delinquency in the 1950s and 1960s centered mainly on sexual misconduct, acting out, or prostitution. But between 1994 and 2003 arrests of girls for most categories of crime increased more for girls than for boys or decreased at a lower rate in girls compared to boys. For example, during these years simple assault arrests increased 36% for girls but only 1% for boys. Drug abuse violation arrests were up 56% for girls but only 13% for boys. From 1994 to 2003, there were significant


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.

  1. Race: The federal government reported that members of minority races, primarily blacks and Hispanics, accounted for 26% of juvenile arrests in 1997 (Snyder and Sickmund, 1999). In 2003, black youth accounted for 45% of arrests and white youth including Hispanics (reporting parameters changed) accounted for 53% of arrests. This 2003 data can be set against the racial composition of the juvenile population in the United States that was 78% white, 16% black, 4% Asian/Pacific islander, and 1% American Indian (Snyder, 2005). Minorities, especially African-Americans and Hispanics, are disproportionately both the victims and the perpetrators of crime in the United States. Arrests and incarceration is increasing rapidly for Hispanic youth. Black youth accounted for 44% of juvenile arrests for violent crimes in 1997 and for 45% in 2003. In 2003, blacks accounted for 48% of juvenile arrests for murder. In the years preceding 1997, the disproportionate number of minority youth who were incarcerated changed little (63% of all juveniles in residential placement were minorities) (Gallagher, 1999; Sickmund, 2004).
  2. Age: Most youths initiate delinquent behavior at the approximate age of 12 or 13 years. Juvenile arrests peak at ages 15 to 16 years and their involvement peaks by age 16 or 17 (Williams, 2006). Eighteen years is the peak age for arrest for violent crimes (homicide, rape, and assault) (Table 76.2).
  3. Medical precursors: A number of medical precursors to delinquent and violent behavior have been reported. The contribution of these factors is unknown. It is important to realize that an association may be valid but the incidence is low.
  • Head trauma: Head trauma resulting in brain injury is common among delinquent teens. Hyperactivity and impulsivity lead to head injury.
  • XYY: Klinefelter syndrome has been associated with offending behaviors such as fire setting in a few boys, but most individuals with this syndrome are not criminal offenders.
  • Fetal alcohol syndrome and exposure to illicit drugs: Some individuals with severe prenatal alcohol exposure exhibit difficulty in understanding the consequences of their actions. As a result, they repeatedly engage in behavior that is forbidden and become offenders. Likewise, some adolescents prenatally exposed to cocaine and other psychotropic drugs experience cognitive problems. A better understanding of the long-range effects of prenatal drug exposure will become evident as exposed children mature into their teenage years.
  • Lead exposure: Elevated blood lead concentrations have been reported among detained delinquent youths. However, further study is needed to establish a cause and effect association.
  • Frontal or temporal lobe epilepsy: This rare form of epilepsy involves complex neurological behavioral and psychiatric symptoms that are usually, but not always, seen in adolescents with developmental disorders. Occasionally, there may be explosive or undirected aggression. Nasopharyngeal and/or anterior-temporal leads may be necessary to demonstrate the seizure focus on an electroencephalograph.
  • Learning disability and/or attention-deficit disorder: Poor academic performance is found in most delinquent youth. The underlying reasons for this include attention-deficit disorder, other learning disorders, lack of parental supervision, peer pressure, poor schools, and low socioeconomic status.
  • Sleep problems: Increased aggression correlates with quantity and quality of sleep among juvenile and young offenders.
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Social and environmental factors

  • Low socioeconomic status
  • Lack of employment
  • Sense of failure and low self-esteem
  • Family conflicts
  • Peer-group involvement with delinquent adolescents
  • Gang involvement
  • Disorganization within the home and/or community environment
  • Lack of a sense of belonging
  • Lack of appropriate role models
  • Lack of at least one caring adult
  • Family history of alcoholism, criminal behavior, or psychiatric conditions
  • History of physical or sexual abuse (in some cases, physical abuse may cause brain damage)
  1. Seriously delinquent adolescents: Those youth with a higher prevalence of violent or sexually assaultive behaviors have a higher prevalence of violent behavior in early childhood, and a history of perinatal trauma, and head and facial trauma. Childhood psychopathology, mostly characterized as conduct disorder, is common.
  2. Incarcerated delinquents: Major depression and suicide attempts and frequent risk-taking behaviors are common in this group.
  3. Recurrence: A subgroup of adolescents accounts for most juvenile crimes. In one study, 54% of juvenile delinquents were repeaters accounting for 85% of crimes committed, with a subgroup of 6.3% committing 52% of crimes (Wolfgang et al., 1972).

TABLE 76.1
Juveniles in Public or Private Detention, Correctional and Shelter Facilities by Offense, United States, on October 29,1997 and October 22, 2003


October 29, 1997

October 22, 2003






Adapted from U.S. Department of Justice, Office of Juvenile Justice and Delinquency Prevention. Juvenile offenders in residential placement 1997. Washington, DC. USDOJ, 1999 FS9996 and U.S. Department of Justice, Office of Juvenile Justice and Delinquency Prevention. Juvenile Offenders and Victims: 2006 National Report. Washington, D.C. USDOJ, 2006, NCJ212906.






Violent offenses










  Sexual assault













  Aggravated assault





  Simple assault





  Other violent offense





Property offenses





  Household burglary





  Motor vehicle theft










  Property damage








  Other property offense





Drug offenses





  Drug trafficking





  Drug possession



  Other drug offense





Public order offenses





  Driving under the influence



  Obstruction of justice



  Nonviolent sex offense



  Weapons offense





  Other public order offense





Probation or parole violation





Other delinquent offenses


Status offenses





  Curfew violation










  Running away










  Underage alcohol offense





  Other status offense





TABLE 76.2
Juveniles in Public or Private Detention, Correctional and Shelter Facilities by Age and Sex, United States on October 29, 1997 and October 22, 2003


October 29, 1997

October 22, 2003








Age (yr)













Adapted from U.S. Department of Justice, Office of Juvenile Justice and Delinquency Prevention.
Juvenile offenders in residential placement 1997. Washington, D. USDOJ, 1999, FS9996 and U.S. Department of Justice, Office of Juvenile Justice and Delinquency Prevention. Juvenile Offenders and Victims: 2006 National Report. Washington, D.C. USDOJ, 2006, NCJ212906.









































































































Legal Rights

  1. Judicial rights: Adolescent's cases are usually processed through a juvenile court without a jury trial. However, adolescents have the right to legal counsel, the right to notice of charges, the right to remain silent, the right to confront their accuser, and the right to proof of guilt beyond a reasonable doubt. At the end of the proceeding, if the judge believes the youth to be guilty of the offense, he will sustain the petition of delinquency.
  2. Treatment rights: In the last 20 years, many laws have been enacted that govern the care of adolescents while in detention. These laws cover specific issues such as staffing requirements and guidelines for the use of psychiatric medications.

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:

  1. A history of antisocial behavior and low self control
  2. Personnel attitudes, values, beliefs supportive of crime
  3. Pro-criminal associates and isolation from anti-criminal others
  4. Current dysfunctional family features
  5. Callous personality factors
  6. Substance abuse

Further information about assessment of risk and case management can be accessed at

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.

Health Problems

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:

  1. General medical problems
  2. Unmet nutritional needs that in some cases relate to obesity.
  3. Problems common to adolescents in general: Headaches, chest and abdominal pains, asthma, acne, scoliosis, weight control problems, peptic ulcers, minor trauma, short stature, delayed puberty, gynecological problems, cancers and leukemia, myopia, and hearing loss.
  4. Preexisting conditions that have gone undetected due to poor access to medical care, including hernias, undescended testes, urethral strictures (congenital or acquired), tuberculosis in endemic areas, hepatitis, and congenital heart disease. In addition, decayed and missing teeth are common in most adolescents in juvenile detention facilities (Bolin and Jones, 2006).
  5. Problems related to delinquent behaviors and lifestyle
  6. Injuries: Four to eight times more common in institutionalized youth.
  7. Substance abuse and drug withdrawal symptoms affect 70% to 80% of delinquents entering state facilities, especially in short-term detention facilities.
  8. STDs, pregnancy, pelvic inflammatory disease, and occasionally HIV infection. Generally 10% of boys and 20% of girls entering detention will have Chlamydiainfections.



  1. Retained bullets with increased risk of lead toxicity, especially if the bullet is lodged in healing bone, joints, or lung tissue.
  2. Gunshot wounds and automobile accidents resulting in paraplegia, brain injury, bowel injury, and obstruction.
  3. Mental health problems attributable to the social and physical environment: Estimates are that youth in juvenile justice systems have 2 to 4 times the rate of mental health disorders as the general adolescent population. Problems include the following:
  4. Suicide
  5. Institutional violence (gang violence)
  6. Depression
  7. Anxiety
  8. Deaths: Gallagher and Dobrin (2006) review death rates for incarcerated youth. Adolescents in juvenile justice facilities have lower risks of death by accident (18.25 deaths per year per 100,000 confined versus 32.79 in general population) and homicide (7.3 versus 9.37). However, those confined have much higher risks of death from suicide (277% higher, 21.9 versus 7.9) and illness (30% higher, 21.9 versus 17). Overall, mortality rates were 7.8% higher in incarcerated youth during their confinement. Higher mortality rates were found in facilities that had a higher percentage of black youth. Accidental deaths were more likely in facilities that had no means of physical security to lock youth inside; however, suicide and illness-related deaths were more likely in larger, highly secure facilities.

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 General health care standards are available at: and

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


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.


  1. Incidence: In 1999, an estimated 1,682,900 youth had a runaway or “throwaway” episode (Hammer et al., 2002). Approximately 500,000 to 1 million adolescents run away each year (Carper, 1979). In 1997, the federal government reported 136,350 runaways. A Department of Health and Human Services report estimated that in 1983 between 733,000 and 1,300,000 youths in the United States could be classified as either runaways or homeless (Russell, 1995).
  2. Age: Most of the runaways/throwaways in the U.S. Department of Justice study were 15 to 17 years of age (68%); however, 28% were 12 to 14 years old and 4% (an estimated 70,000 youth) were between the ages of 7 and 11. Males and females were equally represented among the runaway/throwaway youth (Hammer et al., 2002).
  3. Race: Just over half (57%) of the runaway/throwaway youth were white/non-Hispanic. An additional 17% were black/non-Hispanic, 15% were Hispanic, and 11% were of another race/ethnicity (Hammer et al., 2002).
  4. Length of time away from home: Nineteen percent of the runaway youth were away for <24 hours, 58% for 24 hours to 1 week, 15% for 1 week to <1 month, 7% for 1 month to <6 months, and <3% did not return (Hammer et al., 2002).
  5. Return behavior: Return home on their own, 50%; return home through parental or peer involvement, 30%; return home through police intervention, 14%; never return home, 6%.
  6. Distance traveled from home: Just more than one third (38%) traveled <10 mi away, one third (31%) traveled >10 mi but <50 mi, and approximately one fourth (23%) traveled >50 mi from home. No information was available on the remaining 9%. In 83% of the cases, the child did not leave the state. Police were contacted in less than one third of the cases (Hammer et al., 2002).

Types of Runaways

  1. Abortive: No actual runaway behavior—just a fantasy.
  2. Crisis: A short stay away from home, usually <3 days, secondary to an acute problem.



  1. Casual: The streetwise adolescent with frequent runaway episodes.

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.

Substance Abuse

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:

  1. Medical evaluation
  2. Psychosocial evaluation (HEEADSSS)
  3. Family assessment
  4. Vocational assessment
  5. School assessment

Important considerations include the following:

  1. Identifying the youth's needs: Although high-risk youth present with many serious problems that the care provider identifies as paramount in the hierarchy of interventions, the adolescent also has an agenda that must be determined and validated. Failure to meet the young patient's perceived needs often results in his/her failure to “buy into” the professional's plan of care. The adolescent comes to the provider for help, and it is important to provide that help before and during any other interventions that the provider thinks are important.
  2. High-risk youth with multiple problems are best dealt with by a multidisciplinary teamfunctioning in an interdisciplinary manner. Without available multidisciplinary health professionals, the physician must have a comprehensive listing of local resources. Effective referral, particularly for high-risk youth, is best accomplished through a telephone call to a specific contact person, who should be identified while the adolescent is still in the office.
  3. Basic needssuch as food, shelter, and safety must be addressed before major psychotherapeutic interventions are considered.
  4. The approach to the problem should be to draw on the adolescent's own resources or options for change (i.e., to find alternative solutions). Interventions must be both feasible and practical (i.e., within the realm of possibility for that particular teen and capable of serving the appropriate developmental function).
  5. Family involvement, when indicated, may optimize the intervention strategy, but if such intervention is not done skillfully, the adolescent's problems may simply be compounded. The ability to educate a family for change is inversely proportional to the degree of dysfunction within the family.
  6. Risk profiles may be modified by direct or indirect interventions. An example of a direct intervention would be a stop-smoking education program; an indirect method would involve increasing a health-enhancing behavior, such as jogging to discourage smoking.
  7. Characteristics intrinsic to health professionals that enhance their ability as vehicles for change include:
  8. Ability to develop trust through establishment of a confidential relationship
  9. Willingness to see the youth's viewpoints as real
  10. Ability to listen
  11. Unconditional positive regard for the adolescent in his or her struggle
  12. Knowledge of self
  13. The opportunity to change a system (individual or family) is greatest when the system is unbalanced or in transition. Staff availability during a crisis may be more effective than traditionally scheduled counseling or psychotherapy sessions.


Web Sites Office of Juvenile Justice and Delinquency Prevention. National Criminal Justice Reference Service. A United Way site on help for those with runaway youth. National Center for Juvenile Justice. National Juvenile Detention Association. Sourcebook on Criminal Justice Statistics. American Correctional Health Services Association. National Commission on Correctional Health Care. American Correctional Association.

References and Additional Readings

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Allen JR. Of resilience, vulnerability, and a woman who never lived. Child Adolesc Psychiatr Clin N Am 1998;7:53.

Allen DM, Lehman JS, Green TA, et al. HIV infection among homeless adults and runaway youth, United States, 1989–1992. Field services branch. AIDS 1994;8:1593.

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Carper JM. Emergencies in adolescents: runaways and father-daughter incest. Pediatr Clin North Am 1979;26:883.

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Centers for Disease Control and Prevention, Department of Health and Human Services. Youth risk behavior surveillance—United States, 2005. MMWR Morb Mortal Wkly Rep2006;53(SS-5):1.

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