During the past decade there have been two simultaneous movements affecting the approach to delivery of health care to the adolescent population. There is a general assumption that teenagers engage in a series of health-damaging behaviors and feel invulnerable to the consequences of these behaviors as compared with adults. Second, there is an emerging consensus that all risk taking behaviors occurring during the second decade of life can be seen as driven by similar mechanisms. Underlying these two assumptions is the evident perception by youth of their invulnerability. The media has stated repeatedly that the top three killers of young people are essentially psychological and that teenagers are dying of their own reckless behavior. Included under the generic construct of risk taking are behaviors that result in death due to homicide, suicide, and accidents, which together account for more than 85% of the mortality during adolescence.13 These assumptions create a sense of disillusionment for the pediatri - cian who feels powerless regarding prevention or intervention during adolescence. A review of mortality and morbidity data, the prevalence of health-damaging behaviors including the age of onset and gender differences, and the nature of biopsychosocial change during adolescence can provide the pediatrician with a better understanding of the meaning of risk taking. This understanding provides the basis for a meaningful health encounter with the pediatric patient prior to and during adolescence.
This article reviews the concept of risk taking behavior, the prevalence of the health damaging behaviors of adolescence and adulthood, the interrelationships of certain behaviors, and the role of biopsychosocial development in their onset and maintenance. It also proposes ways for pediatricians to develop effective prevention and intervention programs.
DEFINITION OF RISK TAKING
The definition of an impulsive act implies that it is actuated by sudden involuntary influences. In our use of the term "risk taking," we must remember that risk taking is a normal transitional behavior during adolescence. During the teenage years, young people begin to understand cause and effect relationships. Differences need to be clarified between behaviors that are developmentally adaptive and enhancing and those pathological actions in which such gains are minimal.4 Some experimentation is essential and may contribute to optimal competence in adolescence and adulthood. 5 However, crack addiction or the acquisition of a sexually transmitted disease clearly have little to recommend them and actually serve to foreclose rather than explore options.
In order for a behavior to be considered as risk taking, it must have two essential components: a volitional quality to and an uncertain outcome from the behavior. By definition, risk taking behavior must have either a potentially noninjurious outcome or one that may result in harm. The behavior is neither arbitrary nor fortuitous.6 Two behaviors that further elucidate this definition are sexual activity and recreational vehicle use. Under most conditions young people can make choices regarding participation in sexual activity although the outcome is uncertain. One can achieve pleasure from this activity, but one can also end up with an unintended pregnancy or a sexually transmitted disease. One can experience a sense of mastery from using a skateboard on a steep hill; however, one can also incur a major traumatic injury, especially when using drugs or alcohol.
The definition of risk taking used in this article is that young people with limited or no experience engage in potentially destructive behaviors with or without understanding the immediate or long term consequences of their actions.2 This definition deliberately excludes behaviors associated with homicide, suicide, or psychiatric disorders including eating disorders. The excluded behaviors have significant attendant psychopathological processes or major environmental forces beyond the control of the young person (eg, homicide).
Three prime examples of risk taking behavior are sexual activity, substance use, and recreational vehicle use. These three behaviors account for more than 50% of the medical morbidity during adolescence. In addition, they are generally considered normative adult behaviors. 7
PREVALENCE OF HEALTH DAMAGING BEHAVIORS
Substance use continues to be a major problem of adolescence. In spite of the general decline in substance use since the late 1970s, the most habituating substances - alcohol and tobacco - continue to be used during adolescence with reported rates of 65% and 30%, respectively. Marijuana use has dropped from a high of 60% in 1979 to a low of 51% in 1986. Cocaine use has increased slightly from 15% in 1979 to 17% in 1986.8,9
Alcohol is the most commonly used substance with a mean self-reported age of onset of 12.6 years. The most recent survey reported that 91% of high school seniors and 56% of 12- to 17-year-olds had a past history of having consumed alcohol.8,9 Thirty-seven percent of the high school seniors reported consuming more than five drinks at one time in the last two weeks.8
Tobacco, either in the form of cigarettes or smokeless (chewing), remains the second most commonly used substance. In 1986, 19% of seniors reported daily use of cigarettes with a lifetime prevalence use of 68% and 45.3% for high school seniors and 12- to 17-yearolds respectively.8,9 The mean self- reported age of onset is 12.0 years for cigarette use. Currently, cigarette use is more common in females than males; however, the use of smokeless tobacco is more common in males.10 Recent reports indicate that up to 36% of male high school and college students and up to 11% of 8- to 9-year-olds use chewing tobacco regularly.11
Unintentional injuries are the primary cause of premature mortality and account for the largest number of hospital days in adolescents.12·13 Motor vehicle related injuries are responsible for 80% of the deaths in the 15- to 24-year-old category. Motor vehicle accidents occur most frequently on weekends immediately before and after midnight when other factors including alcohol, recklessness, high speed, and decreased reaction time secondary to fatigue can be implicated.14
We have found that 29. 5% of middle school and 37-5% of high school youth reported engaging in physically risky behaviors, including the use of recreational vehicles such as skateboards and bicycles.14 Lewis and Lewis15 have documented that young people (especially males) dare each other to engage in physically risky activities as early as grade 5.
The most recent survey of sexual activity for 1983 indicates that 77.9% of males and 62.9% of females had experienced intercourse by 19 years of age. Various racial and ethnic groups report different numbers with higher rates for blacks (92.2% of males and 77.0% of females by age 19 years) and Hispanice (78. 5% of males and 58.0% of females by age 19 years).16 Cumulative estimates from these samples indicate that adolescents are initiating coitus at an earlier age. Information regarding sexual activity in adolescents younger than 15 years is difficult to obtain other than in clinical samples. Some recent reports of adolescents in this age cohort report rates of 12% to 32%. M The incidence of sexually transmitted diseases (the highest of any age cohort considering the incidence of sexual activity) and unintended pregnancy parallels the rate of sexual activity.16,17
Interrelationships of Behaviors
Risk taking behaviors tend to be associated in predictable ways depending on age, gender, and racial or ethnic group.
Substance use has long been implicated in injuries. Alcohol has been associated with motor vehicle, nonmotor vehicle, and other accidents. In 1981, 45% of all alcohol-related single vehicle accidents were experienced by youths 15 to 24 years old.2·12 A San Francisco study documented the contribution of alcohol to non-motor recreational vehicles. Similar numbers of deaths occurred in motorized and nonmotorized vehicles.18 Marijuana has also been associated with traumatic injuries secondary to vehicle use.
Increasingly, the use of substances is associated with initiation of early sexual activity. Several researchers have now documented the association of substance use with early sexual activity including the predictive nature of substance use and increased risk behaviors for the onset of sexual activity in white females.14,19 The disinhibiting effects of substances may explain this relationship.
Substances are also associated in predictable patterns, which may help the physician to identify young people at risk. Kandel and others have shown the importance of tobacco and alcohol as the drugs of initial use and their connection to other substance use.20 The trajectory of substance use begins with alcohol and tobacco, which precede marijuana use; alcohol, tobacco, and marijuana precede other illicit drugs and the use of prescribed psychoactive drugs. Cigarettes are often a more important gateway drug for adolescent females than for males.20
Figure 1. Relationships of the biological, psychological, and environmental changes that occur in the second decade of life. (Adapted from Irwin CE, Millstein SG: Biopsychosocial correlates of risk taking behaviors during adolescence. J Adolesc Health Care 1986; 7:93 and Irwin CE, Ryan S: Problem behavior of adolescents. Pediatrics in Review 1989; 10:235-246.)
BIOPSYCHOSOCIAL DEVELOPMENT DURING ADOLESCENCE
Adolescence does not take place in a vacuum; rather, it is highly dependent on the environment. Figure 1 highlights the important relationships of the biological, psychological, and environmental changes that occur during the second decade of life.2 These changes encourage the young person to begin to explore various facets of change. Certain developmental forces may encourage the young person to take chances. During pubescence, the rising levels of testosterone (especially in males) appear to have a direct effect on the onset of heterosocial behavior, including coitus.21 With the onset of formal operations in middle and late adolescence, the young person will begin to explore cause and effect relationships previously beyond his or her understanding. Environmental changes in the school system along with frequent and developmentally maladaptive changes in setting and structure may place additional burdens on the teenager.
Since many risk taking behaviors are statistically normal, it is critical to understand them in the context of normal adolescence. The developmental tasks of adolescence include mastery, autonomy, identity, experimentation and logical verification, and affiliation (see Table 1). The achievement of these tasks through emancipation from the family, moving toward adult decision making without having acquired the requisite cognitive capacities, and extending new activities into extra-familial areas are all strong forces encouraging the emergence of risk taking.
Asynchronous biological and psychosocial development may encourage onset of risk behavior. Females who mature earlier than normal have been shown to have an earlier onset of sexual activity, increased needs for independence, and lower self-esteem.2,22 The effects of asynchrony in males is less well documented; however, there is some evidence that boys with earlier than normal development experience earlier sexual activity.2
Biopsychosocial Developmental Needs Associated with Risk Taking
Risk Factors for Onset of Risk Taking Behaviors*
Several models of risk taking behavior integrate the developmental principles of adolescence with the risk factors for health damaging behaviors.2,6 Jessor and Jessor have advocated a deviance model that integrates factors in the environment and in the personality that lead to a tendency to engage in such behaviors. Irwin and Millstein have advocated a theoretical model that integrates not only psychosocial factors but also the timing of biological maturation as an intervening variable critical to the onset of the behavior.2 Figure 2 highlights factors contributing to the onset of risk taking behaviors during the second decade.2,14 Figure 2 also identifies critical endogenous and exogenous factors that create a vulnerable situation for the adolescent. The precipitating factors are so-called "trigger" factors that influence the onset of the behavior.
PREVENTION OF RISK TAKING BEHAVIORS
Because pediatricians generally know the young person and the family, they may be uniquely able to identify a young person at risk. Some of the factors listed in Figure 2 occur prior to, and some occur during, adolescence. Table 3 highlights these factors in greater detail. Within the biopsychosocial category asynchrony of biological and psychosocial development, attitudes and beliefs in the young person who lacks awareness of the consequences of behavior, as well as male gender, are associated with an increased tendency to initiate risk taking behavior. Factors in the social environment that promote risk taking include belonging to a peer group in which such behavior is normative, permissive or authoritarian parenting style, multiple school transitions, chronic family conflict, parental or familial use of substances, and readily available substances with lack of supervision. In the behavioral category, lack of skills to resist peer pressure, sensation seeking drives, and personality factors associated with depression,23 anxiety, and poor self esteem lead to a predisposition to risk taking. Recently Bijur et al identified behavioral predictors of injury in children between ages 5 and 10. Boys who were highly aggressive at age 5 tended to sustain more injuries during the next 5 years.24 There is good reason to expect that this association will remain through adolescence.
General Recommendations for Clinical Visit
Since there is no laboratory test to identify the young person at risk, the physician must depend on the information disclosed by the parents and the adolescent. An open therapeutic relationship established before adolescence may enable the pediatrician to identify at risk families. Certain parental risk factors such as substance use (eg, smoking cigarettes and alcohol use) or lack of safe procedures (eg, not wearing a seat belt or bicycle helmet) can be discussed long before the child enters adolescence. During late childhood, the pediatrician must establish a relationship with the child and family that demonstrates that the physician is the child's doctor. This can best be done through a transition interview in which the issues of adolescence are explained and the privacy of the doctor-patient relationship is discussed with the parents and patient. During this interview, anticipatory guidance with the family begins by defining graduated independence and the rights and responsibilities that go with these new privileges.4
Figure 2. Factors contributing to the onset of risk taking behaviors during the second decade of life. (From Irwin CE. Millstein SG: Biopsychosocial correlates of risk-taking behavior during adolescence: Can the physician intervene. J Adolesc Health Care 1986. 7:82S-96S.)
Developing an intervention strategy for a patient implies that the young person is already engaging in a risk behavior and that the physician needs to develop an appropriate treatment plan. When the patient presents with a specific complaint relative to a specific risky behavior, the task is less complicated than with the routine health visit. These situations may include the patient with a traumatic injury secondary to a recreational vehicle accident, a sexually transmitted disease, or a chronic tracheobronchitis secondary to cigarette or marijuana use. Each of these results from a specific behavior or cluster of behaviors. Therefore, the physician can openly discuss the antecedent behavior. However, a more usual situation is a well care visit during which the clinician must elicit information about highly sensitive, often illegal activities from a patient who is often resistant to the inquiry. It helps to assure the adolescent about the confidential nature of the session, approaching the interview from the generally recognized involvement in risk taking behaviors common to young people, then proceeding to the specific behavior of the individual. In addition, I specifically inquire about intensity and frequency of involvement of all risky behaviors. Beyond the specific reported behavior, I query about other associated behaviors. By confining the evaluation to the obvious risk behavior and ignoring highly related and more dangerous behaviors, a chance for timely intervention may be lost. For example, during the office visit of an adolescent female who is using substances, the physician should inquire about her knowledge of sexually related issues because she may be on a risk behavior trajectory with coitus likely to occur in the near future.
Table 3 highlights important general recommendations to consider during the office visit. It is naive for pediatricians to think that they can prevent all risk taking behaviors during adolescence since many of these are normal adult behaviors. The challenge to the pediatrician is to understand the developmental needs of the teenager and encourage age appropriate and developmentally enhancing risk taking. Given the normal developmental needs of adolescence and the prevalence of risk taking behaviors, as well as the multiple antecedent factors, all adolescents must be considered at risk. This article has detailed two approaches: (1) All families need basic counseling regarding the nature and consequences of risk taking during adolescence. Families need to know the importance of their own behaviors and the positive role of encouraging initiative during childhood and adolescence through health promoting activities rather than health damaging activities. (2) All adolescents need a setting in which disclosure of risk taking behaviors can be made and appropriate information can be provided.
We have demonstrated that adolescents are well aware of the health damaging consequences of risk behaviors early in adolescence and yet choose to engage in them. Often teenagers are misinformed regarding the consequences of the behaviors and the probability of negative outcomes and do not have the skills to resist the engagement process. Furthermore, the developmental drives to imitiate adult-like behaviors are strong. Adolescence represents a pivotal time for health related learning and socialization.6 The clinician is in a unique position to give authoritative information regarding risk taking behaviors and to help the adolescent develop ways to change such behaviors or to prevent their most negative outcomes.25-27
1. National Center for Health Statistics: Heakh United States 1987. Department of Health and Human Services publication No. (PHS) 88-1232. Public Health Service. March 1988.
2. Irwin CE Jr. Millstein SG: Biopsychosocial correlates of risk taking behavior during adolescence: Can the physician intervene. ; Adolesc Health Care 1986; 7:82S-96S.
3. Blum R: Contemporary threats to adolescent health in the United States. JAM A 1987; 257:3390-3395.
4. Irwin CE Jr: Adolescent Social Behavior and Heakh. New Directions for Chid Development. San Francisco, Jossey-Bass, 1988.
5. Baumrind D: A developmental perspective on adolescent risk taking in contemporary America, in Irwin CE Jr (ed): Adolescent Social Behavior and Health. New Directions for Chad Development San Francisco. Jossey-Bass. 1987, pp 93-126.
6. Jessor R: Adolescent development and behavioral heakh, in Mararazzo JR, "weiss SM, Herd JA (eds): Behavioral Health: A Handbook of Health Enhancement and Disease Prevention. New York, John Wiley & Som. 1984, pp 69-90.
7. Petersen AC: Adolescent development, in Roseruweig MR, Porter LW (eds): Ann Rev Psychol 1988; 39:583-608.
8. Johnston LD, O'Malley PM, Bachman J: National trends in drug use and related factors among American high school students and young adults 1975-86. Department of Health and Human Services publication No. (ADM) 87-15350. National Institute on Drug Abuse, 1987.
9. National Household Survey on Drug Abuse. NIDA Capsules. US Department of Health and Human Services. 1985.
10. Centers for Disease Control: Psychosocial predictors of smoking among adolescents. MMWR 1987; 45:IS-45S.
11. Connolly CN. Winn DM, Hecht SS, et al: The reemergence of smokeless tobacco. N Engl J Med 1986; 16:1020-1027.
12. Bass JL, Gallagher SS, Mehta KA: Injuries to adolescents and young adults. Pedum CIm North Am 1985; 32:31-39.
13. Irwin CE Jr: Why adolescent medicine? J Adolesc Health Care 1986; 7:IS-12S.
14. Irwin CE Jr. Ryan S: Problem behavior of adolescents, red Review 1989; 10:235-246.
15. Lewis CL, "Lewis MA: Peer pressure and risk-taking behaviors in children. Am J Public Health 1984; 74:580-584
16. Hofferth SL, Hayes CD: Risking tier Future. Adolescent Sexuality. Pregnancy, and CkHdbearing. Washington, DC, National Academy Press. 1987. vol 2.
17. Shafer MA, Irwin CE: Sexually transmitted diseases in adolescents, in Green M, Haggerty RJ (eds): Ambtdatory ftdiorrics. Philadelphia. WB Saunders, 1985, pp 214-223.
18. Friedman I: Alcohol and youth unnatural deaths. Marries 1985; 76:191-193.
19. Zabin LS: The association between smoking and sexual behavior among teens in the United States contraceptive clinics. Am) Public Heakh 1984; 74:261-263.
20. Kandel CB, Logan JA: Patterns of drug use from adolescence to young adulthood: I. Periods of risk for initiation, continued use and discontinuation. Am I Public Heakh 1984; 74:660-666.
21. Udry JR. Talbert LM: Sex hormone effects on personality at puberty. JPcrsSoc Psychol 1988; 51:291-295.
22. Petersen AC: The nature of biological-psychosocial interactions: The sample case ai early adolescence, in Lerner RM. Foch TT (eds): Biciogcal-Psychosocial Interactions m Early Adolescence. Hillsdale. NJ. L Eribaum Associates, 1987. pp 35-57.
23. Tonkin RS: Adolescent nsk-taking behavior. ; Adolesc HeaWi Care 1987: 8:213-220.
24. Bijur R, Golding J, Haslum M: Behavioral predictors of injury in school-age children. Am J Dis Child 1988: 142:1307-1312.
25. Greydanus D (ed): Risk-taking behaviors in adolescence. JAMA 1987; 258:2110.
26. Committee on Adolescence. American Academy of Pediatrics: Alcohol use and abuse: A pediatric concern. ttdiatrics 1987; 79:450-453.
27. Committee on Adolescence, American Academy of Pediatrics: Sexually transmitted diseases. Pedriatirics 1987; 79:454-456.
Biopsychosocial Developmental Needs Associated with Risk Taking
Risk Factors for Onset of Risk Taking Behaviors*
General Recommendations for Clinical Visit