472 Adolescent Health
Interaction between Developmental Issues and
Health Care
Rising Importance of Peers and Increased Risk Taking
As children enter the developmental stage of adolescence,
they become more responsive to peer attitudes and norms and
also become increasingly independent, spending more time
in circumstances without close parental supervision (some-
times without any adult supervision) and acquiring increased
personal mobility. They also become larger and more power-
ful physically, more cognitively sophisticated, and often have
more discretionary income. These factors, combined with
biological changes, provide teenagers with increased motiva-
tion and ability to engage in behaviors that may have adverse
consequences for their health.
A relatively small subset of adolescents are at very high
risk for signi“cant problems. For example, some psychiatric
problems meet diagnostic criteria for the “rst time during
adolescence; dif“culties in childhood may be exacerbated by
puberty and/or increasing age and social demands. This prob-
lematic subgroup consists of teenagers who constitute a sig-
ni“cant danger to themselves (e.g., long-term street youth) or
others (e.g., those arrested for major crimes before the age of
15). Most teenagers, however, are distributed along a contin-
uum of risk that ranges from higher to lower; it would be dif-
“cult to “nd adolescents who have not engaged in any risky
behavior throughout adolescence.
Some risks are so common that they virtually de“ne ado-
lescence. For example, it is expected that all teenagers will
begin to drive, typically doing so independently by the age of
- Yet motor vehicle deaths are the leading cause of death
among adolescents, and both deaths and crashes are four
times more likely to occur with drivers between 16 and
19 years of age, compared with drivers 25 to 69 years old
(Patel, Greydanus, & Rowlett, 2000). Similarly, sexual activ-
ity is the norm, with at least 50% of 15-year-olds having
begun sexual activity (R. Brown, 2000) and about 82% of
18- to 20-year-olds having had sexual intercourse (Neinstein
& MacKenzie, 1996). Substance use is also very prevalent,
with 26% of high school seniors reporting current use of ille-
gal drugs (excluding alcohol and tobacco) and 48% reporting
previous or current use, 25% reporting daily cigarette
smoking, and 32% reporting problem drinking (consuming
“ve or more drinks in a row at least once in the past two
weeks). Note that these statistics do not include teenagers
who have dropped out of school (Comerci & Schwebel,
2000). The drop-out rate is about 25% nationally but 50% to
80% in some inner cities (Scales, 1988). Finally, 49% of ado-
lescent boys and 28% of adolescent girls reported having
been in at least one physical “ght in the past year (Neinstein
& Mackenzie, 1996). In summary, from a normative perspec-
tive, adolescence per se is a risky business.
Increasing evidence suggests that multiple types of risk-
taking behavior are associated (Irwin, 1990). Alcohol and
other substance use is a factor in violence, motor vehicle
accidents, and risky sex. Some behaviors appear to occur in
clusters, such as sensation seeking in sports and self-reported
criminality (Patel & Luckstead, 2000). Most teenagers age
12 to 17 do not engage in multiple forms of risk taking, but
there is a dramatic increase with age. Approximately one-
third of 14- to 17-year-olds does so versus one-half of 18- to
20-year-olds, with males and out-of-school teens being sub-
stantially more likely to display multiple high-risk behaviors
(Brener & Collins, 1998). The line of demarcation is not
always clear, with a continuum of risk often existing even for
the same behavior. For example, some high school students
(23% of males and 15% of females) and college students
(12% of males and 7% of females) report rarely or never
using seat belts (see Patel et al., 2000), but only 34% of
teenagers report consistentuse of seat belts (see Neinstein,
1996c).Morbidity and MortalityOf the 10 leading causes of death among American adoles-
cents and youth (age 12 to 24), four are behavioral in origin:
unintentional injury/accidents, homicide, HIV, and suicide.
The leading cause of death in this age group is unintentional
injury, primarily from motor vehicle crashes. Accidents, sui-
cide, and homicide cause more than 80% of deaths of 15- to
24-year olds. Death rates and causes vary as a function of
gender and race. Overall, adolescent males have twice the
death rate of adolescent females. African American youth
(age 15 to 24) are twice as likely to die as White youth and
are more than three times more likely to die than Asian Amer-
ican youth. Further, African American youth are most likely
to die as a result of homicide and legal intervention, whereas
accidents are the primary cause of death for all other major
racial groups. The homicide rate for African American males
(15 to 24) is nine times that for White males, and the Hispanic
rate is 3.5 times that for White males (for all statistics, see
Neinstein 1996c).
Even if unintentional injury does not result in death, it is a
major source of morbidity (e.g., injury is the leading cause
of loss of productive years of life). Adolescents have the high-
est injury rate of all age groups, with the highest rates for older
adolescents, males, Whites, and Midwestern residents (Fraser,
1995). Automobile crashes are the leading cause of both
fatal and nonfatal unintentional injuries, but signi“cant mor-
tality and morbidity also result from motorcycles, bicycles,