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Publications | Strategic Plan | Chapter 1

Understanding Adolecent Health

Issues and Approaches

This is Chapter 1 of California's adolescent health strategic plan. To view the full plan, click here.

The health and well-being of California teens has a major impact on the overall social and economic health of our state. Today’s teens are tomorrow’s workforce, parents, and leaders, and their future is shaped by the opportunities we create for them today. Most parents make significant personal investments in their children’s future. Yet as a society, we are not making the investments necessary to ensure the health and well-being of all of our youth.

During adolescence (10 to 19 years of age) young people confront new issues that affect their physical and mental health. Similarly, young adults (20 to 24) continue to experience many of the same challenges to their health and well-being. The health issues of teens and young adults are easy to overlook because they are not, for the most part, acute illnesses or chronic diseases. Instead, they are largely behavioral and social issues. Addressing these issues requires change at multiple levels—from service delivery, to funding priorities, to community resources and environments, and, more fundamentally, to the behavior and attitudes of California’s adults.

Why is adolescent health a critical issue in California?

Adolescent health problems result in great personal, social, and monetary costs. Adolescents are particularly prone to risk-taking and experimentation as they learn to manage new capabilities and greater freedom. These behaviors are often a normal part of establishing independence, but they can also lead to negative and potentially serious health consequences. Every year in California, approximately:

500 teens are killed in motor vehicle crashes.
170 teens commit suicide.
28,000 hospitalizations occur for mental health disorders among youth ages 10 to 19.
3,200 young people ages 13 to 20 are hospitalized due to assault.
59,000 teens become parents.
8.7 billion dollars are spent treating adults for tobacco-related illnesses caused by a habit that began in adolescence.

California’s adolescent population is growing, especially in communities where needs are greatest

Figure 1.1

It is estimated that between 1995 and 2005, the number of youth ages 10 to 19 in California will grow from 4.4 to 6.0 million—a 34% increase. By contrast, this age group will grow by only 13% nationally. California’s adolescent population, already among the most ethnically diverse in the nation, will become even more diverse. While the number of white youth will grow by 16%, the number of African American youth will grow by 22%, Asian youth by 45%, and Latino youth by 61% (Figure 1.1). The Native American youth population will grow by only 2%. Because the sheer number of adolescents in the state is increasing, and because this increase is greater among groups that often have poorer health outcomes and less access to health care, we can anticipate growing demands on the service system.

Adolescence offers an opportunity for prevention. Many of the health and social problems we pay for as a society can be averted during adolescence.

Sixteen percent of California AIDS cases occur among young adults, ages 20 to 29. Given the average 10 to 12 year latency period between HIV infection and the onset of symptoms, it is likely that many of these individuals were infected as teens.
The teenage years are a critical time for the initiation of tobacco use. Ninety percent of current adult smokers started smoking during adolescence, and new evidence suggests that teens become addicted to nicotine more quickly than adults.^{^1,2}
Poor diet and physical inactivity are second only to tobacco as preventable causes of death among adults.³ These lifestyle habits are often formed in adolescence.
More than half of all school-age children have untreated tooth decay, which is easily and inexpensively preventable.

We can make a difference

Figure 1.2

Risk behaviors such as substance use, early and unprotected sex, and drinking and driving, are not an inevitable part of adolescence. In fact, the leading causes of death among adolescents are preventable (Figure 1.2). The success of public initiatives in several areas illustrates the type of results we can expect to achieve with further public investment in effective prevention and intervention strategies. The success of public initiatives in several areas illustrates the type of results we can expect to achieve with further public investment in effective prevention and intervention strategies.

Motor vehicle safety is improving: motor vehicle deaths are lower than the national average and use of seat belts is higher.
Teen birth rates fell by 28% from 1991 to 1998 and are now only slightly higher than national rates.
Juvenile homicide arrests declined from 696 in 1991 to 308 in 1998.
There has been a steady decline in the percentage of dropouts from California’s public high schools across all ethnic groups.

How should we approach adolescent health?

The World Health Organization’s definition of health has become a standard in the field of public health. Health is defined as more than just the “absence of disease,” but rather a state of “complete physical, mental, and social well-being.” This broad definition has particular relevance to adolescent health. Adolescent health encompasses not only the prevention and treatment of disease and disability, but also behavioral and social issues. Issues of safety, social relationships, self-esteem, education and skill development all figure into healthy adolescent development. Thus, to make progress in improving adolescent health, a combination of perspectives and approaches is needed.

Promoting resiliency and creating supportive environments

Traditionally, adolescent health has been defined as the absence of problems (e.g., pregnancy, violent behavior, drug use).⁴ Early efforts focused on eliminating these problems, often through approaches that were too narrow or failed to address the root causes of these issues. Too often we blamed teens for these behaviors, without fully acknowledging that adolescent behavior mirrors that of adults and is shaped by their social and cultural environments, including families, communities, schools, media, popular culture, and public opinion.

A fundamental shift in orientation is beginning to take place. Rather than focusing solely on reducing risk factors for morbidity and mortality, new approaches look at strengthening resiliency. Resiliency is the ability of youth to overcome obstacles, to meet the new social demands of adolescence, and to build the competencies necessary for success as adults. Resilient adolescents have benefited from supportive relationships and opportunities enabling them to move successfully into adulthood. In many cases, resilient adolescents are successful even when the odds are stacked against them as a result of risk factors in their environments.

A growing body of research on the clustering of risk-taking behaviors and adolescent health problems suggests that several factors contribute to adolescent resiliency.⁵ Adolescents are less likely to engage in risk behaviors if they:

have a sense of physical, emotional, and economic security;
have connections with adults and peers—in particular, a strong relationship with a caring adult;
are able to make a contribution to the community and have input into decision-making;
believe that others have high expectations of them; and
have opportunities for participation in challenging and engaging activities that build skills and competencies.

Shifting the focus to building resiliency and healthy development points to the need to ensure access to services and opportunities to enable all youth to thrive. It turns our attention to creating supportive environments rather than looking to correct deficiencies in teens themselves.

Although many existing programs do seek to build supports for youth, a broader shift is needed. For example, we collect statewide data on the percentage of youth who smoke, or use illicit drugs, but we know very little about the percentage of youth who have a caring adult in their lives. The focus on creating supportive environments must be strengthened in order to move beyond narrow, categorical approaches and to make substantial progress in addressing the root causes of adolescent health issues.

Targeting approaches and recognizing special needs

Although many adolescent health outcomes will be improved by enhancing supports and services for all teens, targeted approaches can be useful for making progress on specific health outcomes. Chapter 3 presents data and strategies in seven targeted action areas:

Injury Prevention
Mental Health and Suicide
Nutrition and Physical Activity
Alcohol, Tobacco, and Other Drugs
Teen Pregnancy and Sexually Transmitted Infections
Oral Health
Environmental and Occupational Health

To build resiliency among all teens, it is also important to consider the challenges brought about by special circumstances or characteristics of youth such as chronic illness and disability, foster care, homelessness, immigration status, incarceration, race/ethnicity, and sexual orientation.

Chronic Illness and Disability. Youth with chronic illnesses, both physical and mental, often require more frequent and complex medical services than other youth. They face special social, psychological, and educational challenges during the adolescent years and in transition to adulthood. Data from the 1994 National Health Interview Survey indicate that approximately 8% of children ages 6 to 18 experience some degree of limitation in their activities due to chronic conditions, and 0.2% experience severe limitations.⁶

Foster Care. Adolescents who lack a permanent and stable home encounter formidable challenges to their physical and mental well-being. The number of California youth in foster care has almost doubled from approximately 59,000 in 1988 to 103,024 in 1999.^7,8 The growth in the foster care caseload is related to the increase of youth living in poverty, the increase of youth in single-parent households, and the number of parents abusing drugs and alcohol.⁹ Youth in the foster care system are more likely to be poor and suffer from problems affecting their health and overall development than youth who live with their families.¹⁰ Approximately half of all foster youth suffer from chronic conditions, and 60% to 80% are estimated to have moderate to severe mental health disorders.⁹ Studies have shown that many older adolescents who exit out-of-home care have significant problems caring for themselves, and, in many cases, continue to be dependent on public programs.¹¹ One of the barriers to providing appropriate services for foster youth is that caregivers often lack access to their medical histories or other service records.¹²

Homelessness. In California, an estimated 20,000 to 25,000 youth are homeless and living on the streets with no supervision or family support.¹³ Many are separated from homeless families; others have left their homes often due to abuse or neglect; and still others are former foster children who have “aged out” of the system. More than 60% of the youth residing in shelters and transitional living facilities have been physically or sexually abused by their parents, and 20% have experienced violence from other family members.¹⁴ Although these youth are often eligible for public programs, they are unlikely to access them without tailored outreach and service approaches.

Immigration. Since 1990, the number of youth in immigrant families in the United States has expanded about seven times faster than the number with U.S.-born parents.¹⁵ One of every five children under the age of 18—14 million altogether—is an immigrant or has an immigrant parent. Available evidence suggests that, on many measures of health and well-being, they fare as well or better than U.S.-born children with U.S.-born parents.¹⁵ However, immigrant youth are more likely to have difficulty accessing health services. The care they receive is often episodic and frequently occurs in emergency rooms, limiting the provision of continuous, preventive and comprehensive care.¹⁶ Undocumented immigrants fear that accessing services will alert immigration authorities or cause them to be labeled a “public charge,” thereby jeopardizing their chances of obtaining residency or citizenship. All immigrants or refugees, regardless of residency status, may experience barriers related to language and culture that make it difficult or uncomfortable to seek medical care. In California, the size and diversity of the refugee/immigrant population make issues of language and cultural sensitivity extremely important.

Incarceration

Table 1.1

Among the 50 states and the District of Columbia, California has the third highest rate of juveniles in custody (549 per 100,000 compared to the national rate of 368).⁸ In June 1998, more than 14,000 youth were under the jurisdiction of the California Youth Authority, over 8,000 of whom were incarcerated, with the remainder on parole.¹⁷ This population is disproportionately minority, particularly African Amer-ican (Table 1.1). These racial/ethnic differences are related to crime rates, social factors and the way cases are processed in the legal system.

More than 50% of all youth entering detention facilities have health-related problems; nearly half have a previously undiagnosed learning disability; and 90% have dental problems.^{20, 21} Incarcerated youth are also at significantly greater risk for health problems and health compromising behaviors, including sexually transmitted and infectious diseases, pregnancy, substance abuse, psychotic behavior, depression, suicide attempts, physical/sexual abuse, and trauma.^{20, 21}

Race/Ethnicity

Information about disparities in health status among racial/ethnic groups can be used to target interventions and to tailor strategies to the needs of individual communities. However, it is important to recognize that racial/ethnic disparities often are caused by underlying socioeconomic differences.

Nationally, Native American youth have the worst health and social status indicators of any racial/ethnic group. Motor vehicle death and suicide rates among Native Americans are three times those of the general population, and substance abuse rates are higher than in any other ethnic group.^22,23
African Americans experience the highest homicide and incarceration rates, along with the highest rates of poverty and foster care placement.⁷
Latino youth experience high rates of poverty, homicide, incarceration, and teen birth, as well as low rates of health insurance coverage.^15,22
White teens generally have better outcomes and more favorable socioeconomic indicators, yet suicide rates, rates of tobacco use—particularly smokeless tobacco—and substance abuse rates are higher than among other racial/ethnic groups.
Although Asian/Pacific Islander Americans generally have favorable health indicators, there are exceptions. For example, Asian 15 year olds are more than 13 times less likely to have received dental sealants than their white counterparts. In addition, aggregate data obscure significantly worse outcomes among some Asian groups. For example, in California, Vietnamese are four times as likely as Japanese to live below the poverty line.²⁴

Sexual Orientation. Gay, lesbian, bisexual, and transgender youth who self-identify during high school are at greater risk for a variety of health risk and problem behaviors, including suicide, victimization, sexual risk-taking, and multiple substance use.^25,26,27They are less likely to seek health care due, in part, to fear that medical providers will respond negatively to them or reveal their sexual orientation to their family.²⁸

Focusing on Outcomes

At the federal, state, and local levels, a new emphasis is being placed on assessing the outcomes of programs and policies. This focus represents a departure from previous monitoring approaches that counted the number and types of services delivered and assumed that improvements in health status would follow. By contrast, tracking outcomes allows us to gauge progress in addressing important health issues, and to identify policies and programs that work.

Table 1.2

Tracking adolescent health outcomes requires the collection of data on specific indicators. At the federal level, the Centers for Disease Control and Prevention’s (CDC) Healthy People 2010 objectives are a set of indicators designed to assess progress in public health in a wide range of areas. These objectives contain a subset of 21 critical indicators for adolescent health. In addition, the state collects data on Maternal and Child Health (MCH) Performance Measures to report progress to the federal Maternal and Child Health Bureau. Drawing largely on these two indicator sets, as well as on efforts to develop new indicators, we identified 27 indicators of adolescent health that can be used to assess the impact of program and policy changes in California (Table 1.2).

Resiliency and supportive environments. The identification of indicators of resiliency and the collection of population-based data are in their early stages. California is at the forefront of this effort with the California Healthy Kids Survey which includes a module on resiliency. Although not entirely representative of the state population, data currently available from over 26,000 students across the state provide a first look at indicators of supports and opportunities for adolescents in the home, school, and community environments.

Healthy choices. Indicators of health behavior provide important information about whether teens are making healthy choices. Many of these choices can have long-term effects on health and the need for health services. Major areas of concern for adolescents include: motor vehicle safety, including drinking and driving; early or unprotected sexual intercourse; use of tobacco, alcohol, and other drugs; poor nutrition and lack of physical activity; and involvement in activities that increase exposure to violence.

Health services. Adolescents’ use of health services is an important indicator of the extent to which service systems are meeting their needs. Currently, there is a lack of adolescent-specific data on key indicators, including health insurance coverage and use of preventive medical and dental services.

Reduced morbidity. Indicators of morbidity provide important information for the prevention of illness and injury and the management of chronic conditions. Preventable medical problems among teens include sexually transmitted infections, hepatitis, dental diseases, obesity and other cardiovascular risk factors such as high blood pressure and high cholesterol. A variety of chronic conditions, such as asthma and diabetes, can be life-threatening if not managed appropriately.

California’s Challenge

The tremendous social, economic, and demographic changes that lie ahead place our state at an important crossroads. The challenge is to ensure that all of California’s teens have the supports they need for healthy development and a smooth transition to adulthood. Meeting this challenge will require significant improvements in infrastructure, service systems, and community-level supports. Continuing past policies and categorical approaches that far too often ignore the multidimensional needs and assets of youth is unlikely to produce significant changes. However, if we combine forces, and begin to seriously address the social, cultural and economic factors that shape adolescent health, there is tremendous potential to improve the health of our teens and our society.

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