CHAPTER 5
HEALTHY ADOLESCENTS AND YOUNG ADULTS

Goal:  To improve the health and health
    habits of adolescents and young
    adults, and, by 1990, to reduce
   deaths among people ages 15 to
    24 by at least 20 percent, to
   fewer than 93 per 100,000.

  Obviously enough,  adolescence is a period of
complex changes-- in physical growth and maturation
and in transition from childhood dependency to adult
autonomy.

  In health,  it is--relatively--a good period as
measured by the usual morbidity and mortality
indicators.  Although the death rate for the 40
million young Americans in the 15 to 24 year age
group is 2.5 times  the rate for children, it is
substantially below that for other age groups.

  Yet,  while health for this age group, as for
others,  is considerably better than 75 years  ago
(Figure 5-A),  there is one startling difference:
for adolescents and young adults, recent progress
has not been sustained, as it has been for other age
groups.

  Americans aged 15 to 24 now have a higher death
rate than 20 years ago.

  In 1960,  the adolescent/young adult mortality
rate was 106 deaths per 100,000.  By 1970, the rate
was up to 128.  By 1976, it had dropped to 113--but
1977 statistics show an increase again to 117. This
represents  nearly 48,000 deaths in 1977 alone.
Americans aged 15 to 24 have a higher death rate
than their counterparts in other countries such as
Sweden, England and Wales, and Japan (Figure 5-B).

5-l


FIGURE 5A

DEATH RATES FOR AGES 1524 YEARS: UNITED STATES,

SELECTED YEARS lBBB-1977

1900    1910     1920     1930     1940     1950    1960     1970     1980

5-2


         FIGURE 58
DEATH RATES FOR AGES 1524 YEARS:
   SELECTED COUNTRIES, 1975

United
states

Sweden

England
and
W.3kS

NOTE  me most recent year Of data lo. Chlk <s ,971

Sources: UnIted States, Natlonal Center for Health Statlstlcs, Dlvlsion of Vital Stat!stics:
     other countries, United Nations.

5-3


  What are the principal threats to health? Vio-
lent death and injury, alcohol and drug abuse,
unwanted pregnancies,  sexually transmissible dis-
eases   are  among the more common health-related
problems for this age group.

  Young men are at particular risk, their death
rate being almost three times that of young women.
And,  although chronic  diseases are not among the
major causes of death at this period of life (Figure
5-C), the lifestyles and behavior patterns which are
shaped during these years may determine later sus-
ceptibility to chronic diseases.

  Accidents, homicides,  and suicides account for
about three-fourths of all deaths in this age group.
Responsibility has been attributed to behavior pat-
terns characterized by judgmental errors, aggres-
siveness,  and,  in some cases,  ambivalence about
wanting to live or die.  Certainly, greater risk-
taking occurs in this period of life.

  The variability of these traumatic deaths by sex
and race is striking.  All types are three to four
times more frequent for males.  While motor vehicle
accident deaths are more likely to occur among white
youths, young blacks of either sex are at least five
times as likely to be murdered; homicide is the
leading cause of death for young blacks, ranking
slightly ahead of total accidents.

  Certainly, injury control must be a clear health
promotion priority for young people but the task
will  not be easy.   Injury rates are linked to
factors--lifestyle and socioeconomic--not usually
addressed by  health programs.   Nevertheless, a
strong effort must be made since this is a major
public health problem.

  An equally difficult task will be to reduce mis-
use of alcohol and drugs.   But it is essential to
strengthen the effort--for the misuse contributes
greatly not only to injuries, homicides and suicides
but also to other problems of young people which
have been growing rapidly.

5-4


             FIGURE 5-C
MAJOR CAUSES OF DEATH FOR AGES 16-24 YEARS:
        UNITED STATES, 1976

50 -







40 -






30-






20 -







10 -






O-

0 White

All other

Motor
vehicle
accidents

All other
accidents

Cancer

Heart
disease

Source Based on data from the Nattonal Center for Health Statlstuzs. D~ws~on of Vital Statinlcs

5-5


Subgoal:  Reducing Fatal Motor Vehicle Accidents

  In 1977 motor vehicle accidents were the leading
cause of mortality in the 15 to 24 year age group,
accounting for 37 percent of all deaths.

  Although a complex interaction--of driver, ve-
hicle and roadway--determines the risk of accidents,
nevertheless a teenage or young adult driver who is
involved in a traffic accident is twice as likely to
die as a driver 25 years old or older.

  Alcohol consumption is clearly implicated in
many of the fatalities.  About half of fatally in-
jured drivers have been found to have blood alcohol
concentrations of more than 100 mg/dl (100 milli-
grams of alcohol per deciliter of blood).   In most
states,  this is considered presumptive evidence of
intoxication.  Blood alcohol levels even lower than
100 mg/dl increase the likelihood of an accident--
especially for teenagers, the elderly,  and others
particularly sensitive to alcohol.  Young people
also place themselves at greater risk by driving
while under the influence of marijuana or other
drugs.

  The attitudes of young people about risk are
significant.  While excessive speed was a factor in
35 to 40 percent of all vehicular fatalities in
1977, it was an influence in almost half of those
involving teenagers 15 to 19.  Although lap and
shoulder belts can help to prevent serious injuries
and fatalities, 80 percent of Americans, including
teenagers and young adults, do not use them.

  Motorcycle  accidents killed more than 4,000
Americans in 1977--30 percent of them under 20 years
of age.  Motorcyclists,  because they have so little
protection,  have a seven times greater chance of
fatal injury for each mile driven than do automobile
drivers.   And,  more frequently than   automobile
accidents,  motorcycle   accidents    cause   severe,
permanent head injuries leading to paralysis.

5-6


  Although  some decline in  vehicular  accidents
resulted from institution of the 55 miles an hour
speed limit,  more can be done.  Greater production
and use of active and passive passenger restraints,
safer cars, and increased use of helmets by motorcy-
clists,  as well as continued enforcement of speed
limits, would lead to further reductions, and these
actions are discussed in Chapter 9.

Subgoal:  Reducing Alcohol and Drug Misuse

  Alcohol and drug abuse are behaviors with major
implications in many areas.  Not only do they in-
crease risk of accidents, suicides, and homicides,
they also contribute to family disruption and poor
school and job performance; and they have a poten-
tial for leading to long-term chronic disease.

  Use of alcohol and drugs has been increasing
among young people.  About 80 percent of 12 to 17
year olds report having had a drink, more than half
drink at least once a month, nearly three percent
drink daily.  Since 1966, the number of high school
students intoxicated at least once a month has more
than doubled, from 10 to over 20 percent. Nearly 80
percent of male high school seniors drink at least
once a month and more than six percent drink daily.

  Although young people may drink less regularly
than older people,  they tend to consume larger
quantities and are more likely to become intoxicated
on  drinking  occasions.   No wonder,  then,   that
alcohol-related accidents are the leading cause of
death in the 15 to 24 age group and 60 percent of
all alcohol-related highway traffic fatalities are
among young people.

  Drug abuse was  virtually unknown among young
people in 1950.  Prior to 1962, lifetime experience
with any illicit drug was limited to less than two
percent of the population, including young people.

  By 1977,  60 percent of 18 to 25 year olds had
tried marijuana; about 20 percent had tried stronger

5-7


substances such as cocaine and hallucinogens; and
about 30 percent had illegally used drugs available
only on medical prescription.  Even among 12 to 17
year olds, nearly 30 percent had tried marijuana.

  Beyond  increasing drug experimentation among
young people, the frequency of use is increasing.
Less than one percent of high school students report
daily use of drugs other than alcohol, tobacco or
marijuana-- but over 20 percent regularly smoke ciga-
rettes and about 10 percent smoke marijuana every
day.    And   stimulants --amphetamines--are   another
category of drugs which young people report taking
most frequently.

The physical and psychological effects are high-
ly variable.  They differ from person to person as
well as from drug to drug.  It is, therefore diffi-
cult to determine precisely how harmful experimenta-
tion is in terms of the drug use to which it leads.

  By any measure, however, drug problems are seri-
ous, have increased greatly--and if the full poten-
tial of our adolescents and young adults is to be
realized,  additional steps  (Chapter 10) must be
taken to reduce the harmful effects from both alco-
hol and drugs.

Other Important Problems

Among other prominent threats to the physical
and mental health of young people are problems of
adolescent pregnancy,  sexually transmissible dis-
eases, mental illness,  suicide and homicide.   To a
great extent, they represent failures to help young
people acquire the skills and information needed to
solve problems and make sound decisions during years
of rapid change.

Teenage Pregnancy

Childbearing during adolescence is a high risk
experience for mother and child alike.

Yet one-fourth of American teenage girls have
had at least one pregnancy by age 19.  Every year

5-8


about one million adolescents under the age of 19
become pregnant,  including perhaps 300,000 under
15--which represents an annual rate of 10 percent of
all teenage girls.   Two-thirds of them are unmar-
ried.  At least three of every 10 elect to terminate
their pregnancies.  Birth rates for teenagers aged
16 to 19 are declining but they are increasing for
girls under 16.

  These young mothers have greater risk of bearing
low birth weight infants--with consequent develop-
mental problems and risk of infant death associated
with low birth weight, as noted in Chapter 3.  And
often they face significant social problems:   dis-
ruption of schooling,  high rates of repeat preg-
nancy, and public dependency.

  A substantial proportion of school districts
still encourage expectant teenage mothers to drop
out of school;  many do not provide for continuing
education; more than 25 percent of the young mothers
become pregnant again within just a year after their
first delivery.

  A major underlying problem that urgently needs
addressing for this age group is the inadequate
knowledge of,  and access to,  information on sexual
behavior and family planning services.  In 1976, an
estimated 40 percent of unmarried teenage girls,
aged 15 to 19 (two-thirds by age 19), had engaged in
sexual intercourse and 25 percent of them never used
any form of contraception.

  Birth control methods currently prevent an esti-
mated 750,000 unwanted pregnancies annually.  If all
sexually active young people who did not want to
become pregnant were to use some effective form of
contraception regularly,  it is estimated that pre-
marital pregnancies would drop by more than 300,000
a year.

  There is growing evidence, too, that for the
pregnant  teenager   and   her  baby,  comprehensive
programs,  which include emphasis on the mother's
continued  schooling,   are  associated  with fewer

5-9


repeat pregnancies.  Many programs have been devel-
oped which demonstrate the value of education for
parenthood  and family planning--and of improved
family support for teenage parents.

  An example of what a medical center-based pro-
gram for teen mothers and their infants can accom-
plish is provided by a program at the Johns Hopkins
Medical Institutions in Baltimore.

  There, staff members provide young mothers with
comprehensive medical and psychological  services,
conduct  classes from the first prenatal   visit
through labor, delivery,  and for three years after
delivery, and,  perhaps most important, form close
supportive relationships with the young women.

  Recent results indicate that 85 percent of
mothers enrolled at the center have returned to
school and only five percent became pregnant again
within a year after delivery.  Of all Baltimore teen
mothers,  only 10 percent return to school and 47
percent become pregnant again within a year.   Teen
mothers in the program also have had fewer obste-
trical complications and fewer premature deliveries,
and have given birth to larger and healthier babies
than Baltimore's teen mothers in general.

Sexually Transmissible Diseases

  Sexually   transmissible   diseases  increasingly
threaten the health and well-being of millions of
adolescents and young adults.

  Although there has been some recent improvement,
overall, in the incidence of gonorrhea and syphilis,
both diseases continue to increase among adolescents.

  Moreover,   other  sexually  transmissible  dis-
eases-- such as herpes virus and nonspecific urethri-
tis--have recently become recognized as major public
health problems.  Along with gonorrhea and syphilis,
they account for an estimated eight to 12 million
cases of sexually transmitted diseases a year.

5-10


  And the greatest risk of acquiring them occurs
among young people age 15 to 24 who account for
about 75 percent of all cases.

  Because infection is often unrecognized for lack
of apparent symptoms, many young people also suffer
serious permanent complications.  Each year, an es-
timated 75,000 women of childbearing age become
sterile as a result of pelvic inflammatory disease
caused by a sexually transmitted infection.  Actions
to control  sexually  transmissible  diseases   are
discussed in Chapter 8.

Mental Health

  That adolescents today are coming of age in a
predominantly urban,  technological society, charac-
terized in part by shifting values and traditions,
may account in no small part for alcohol and drug
abuse problems and others.

  Since individual development does not take place
in a vacuum but is strongly influenced by sociocul-
tural factors,  society's expectations play a large
part in the way young people experience this period
of their lives.   But the turbulence of the last
decade has made it difficult for young people to de-
velop any clear sense of what these expectations are.

  Some observers point to teenage pregnancy, de-
linquency and crime, suicides, and child abuse as
well as drug and alcohol abuse as both evidence and
products of that uncertainty.   Others contend that
these problems  are simply more visible today and
involve only a minority of adolescents.

  In any event,  the transition from childhood to
adulthood may take some toll on an adolescent's emo-
tional stability.  And problems such as 20 percent
unemployment among teenagers (40 percent for minor-
ity youth) create additional stress for young people
trying to develop their identity and their place in
life.

5-11


  While the full degree of impact of broad social
issues and overall social and national stability on
personal development is not clear, there is general
agreement that the family has the most direct influ-
ence on  the expectations of young people.   Yet
family structures have been undergoing significant
changes in recent years.

  Added complexity is faced by the teenage parent,
often single, trying to fulfill the personal growth
needs of an adolescent while simultaneously having
to meet the needs of a dependent, rapidly developing
baby.  Because of the demands of these responsibili-
ties,  support through special programs for teenage
parents,  including some form of day care and other
community and mental health services, is very much
needed.

  The diverse problems of teenagers and young
adults require  a broad range of mental  health
services and the combined efforts of the family,
school, workplace,  and community.  The pressures of
parents and peers, as well as of the media, are all
factors which contribute to these problems--and
which can be employed to help solve them.

  The growth of community mental health services
in recent decades has made resources more available
in local areas and adolescents are gradually begin-
ning to use them.  But mental health programs
tailored to adolescents are not abundantly avail-
able.  The recent report of the President's Com-
mission on Mental Health recommends expansion of
these programs.

Suicide

  Suicide is the third leading cause of death
among teenagers and young adults, some 5,600 of whom
took their own lives in 1977. Of total suicides, 20
percent are committed by people under age 25.

  Among adults, three times as many men as women
commit suicide and adolescent males are more likely
to take their own lives than adolescent females.

5-12


  The most frequent weapons include firearms,
drugs,  and motor vehicle exhaust gases.   Firearms
are used four times as often as poisoning (the
second most frequent method), and firearm suicides
have been increasing at a much faster rate than
suicides by other means.

  Unfortunately the  suicide  rate  among young
people has not plateaued, but is increasing. In
1950, the rate was only about 20 percent of what it
reached in 1977.  In 1976, more than one of every 10
teenagers and young adults who died committed sui-
cide.  Many more suicides were attempted but not
reported as  such or not  identified as suicidal
efforts.

  It is estimated that some five million Americans
have made one or more unsuccessful attempts at sui-
cide and that 10 percent of this group will ulti-
mately succeed.   Some estimates indicate that the
actual suicide rate is three times the reported rate.

  An increased suicide rate is not unique to this
country.  Many other industrialized nations are ex-
periencing  increases,  particularly   among   young
people.  Indeed,  in 1974 several countries exceeded
the United States suicide rate of about 12 deaths
per 100,000.  Japan had 18,  Sweden 20, and Germany
21.

  Most suicidal persons give verbal or behavioral
warnings first,  and 80 percent of those who take
their own lives have made previous attempts. While
predicting suicide with certainty is  impossible,
those at highest risk include people who are severe-
ly depressed and those at odds with themselves and
the people close to them. Mental health workers are
becoming more skillful in early detection and man-
agement of suicidal tendencies.  A prime need is for
hotlines --and prompt referral to sources of profes-
sional help when problems are noted (see Chapter 10).

Homicide

  Murder accounts for over 10 percent of all
deaths among adolescents and young adults--just

5-13


under seven percent for whites but almost 30 percent
for blacks in this age group.

  In 1977, when an estimated 21,000 Americans were
victims of homicide,  about 25 percent were aged 15
to 24, placing that group at greater risk than the
rest of the population.  The deaths of these young
people represent a very large and tragic waste in
terms of the many years of productive life lost with
each death.

  The American homicide rate is very much greater
than for most other industrialized nations.   Our
rate of 10.2 homicides per 100,000 people in 1974
compares with a rate of only 0.9 for France, 1.0 for
Great Britain, 1.1 for Sweden, and 1.3 for Japan.

  In about 20 percent of murders in this country,
victim and offender are relatives or have a close
relationship; in 40 percent, they are acquaintances;
and in the remaining 40 percent, there is no known
relationship.  An estimated 60 to 80 percent of
homicides occur as the result of personal disagree-
ments and conflict, while robbery, sexual assault
and other circumstances account for the rest.

  As with other fatal injuries, homicide is more
common among the poor, more frequent on weekends and
at night,  and often associated with alcohol abuse.
In about 90 percent of murders, both offender and
victim are of the same race.  Men are three to four
times more likely to be victims--and five times as
likely to be offenders--as women.

  Many factors  undoubtedly are  involved in our
high homicide rate.  Economic deprivation, family
breakup, the glamorizing of violence in the media,
and the availability of handguns all are important.
Firearms,  the most frequently used homicide weapon
in the United States, were involved in 63 percent of
the murders occurring in 1977, with handguns used in
half, and cutting or stabbing weapons employed in 18
percent.

  Easy access to firearms appears to be the one
factor with a striking relationship to murder. From

5-14


1960 to 1974, handgun sales quadrupled to more than
six million a year.  During that same period, the
homicide rate increased from 4.7 per 100,000 to 10.2
for the overall population--and from 5.9 to 14.2 for
young people aged 15 to 24.

**********

  Broad  physical,  psychological,  social,   and
family changes all have a powerful impact on young
people.

  Young people are compelled to adjust not only to
rapid individual changes, but simultaneously to meet
the expectations of both family and community.  The
strains which result can have considerable bearing
on the problems of adolescents and young adults.

  Stress is to be expected in life. But for some
adolescents and young adults, it can become over-
whelming.

  At critical junctures, they urgently need as-
sistance in finding ways to cope and make important
decisions   and   constructive   adjustments.    Such
assistance (described in Chapter 10) can contribute
greatly to improving  both their health and the
quality and value of their lives.

5-15