Adolescent Development and Health 475care and treatment of addictions and eating disorders, with
appointment-keeping, and with prevention efforts focused
on smoking, drug and alcohol use, exercise, nutrition, and
sexually transmitted disease. A comprehensive review of
noncompliance and adherence is beyond the scope of this
chapter.
Much of the research on noncompliance has focused on
patient characteristics such as gender, age, socioeconomic
status, family characteristics, knowledge, skills, attitudes,
health beliefs, and health status. However, the demands of the
treatment regimen, the structure of health care, and the nature
of the patient-provider relationship are also key factors in
promoting compliance (see Manne, 1998; Phillips, 1997b;
Ruggiero & Javorsky, 1999). While not yet demonstrated em-
pirically, it would be reasonable to expect interaction effects
among these variables, with speci“c aspects of the regimen,
delivery system, and patient-provider relationship exerting
greater in”uence on compliance among teenagers than for
patients in other age groups.
Vulnerability to Abuse
Maltreatment of children and adolescents includes physical,
emotional, and sexual abuse and neglect. Overall rates of
maltreatment are lower in adolescence than in childhood;
Burgdoff (1980) reports estimates that adolescents represent
23% to 47% of all reported cases. However, differences be-
tween age groups vary as a function of the type of abuse and
appear related to adolescents• increasing independence
and physical power, increasing contact with persons beyond
their immediate families, and sexual development. Com-
pared with children, adolescents are less likely to experience
physical abuse and more likely to experience emotional
abuse (Burgdoff, 1980), although the picture is complicated
by the unreliability of estimates regarding how much abuse
has been ongoing versus that with onset in adolescence. In
general, adolescents are more likely than children to be
abused by acquaintances and strangers rather than by family
members (Christoffel, 1990; Crittenden & Craig, 1990).
Gender differences are dif“cult to summarize because overall
maltreatment rates for females increase in adolescence, with
twice as many females maltreated than males, while male
teenagers are more likely than female teenagers to be the
victims of physical abuse and homicide.
For those adolescents who are maltreated by their fami-
lies, family risk factors appear to be different from those seen
for maltreated children. While socioeconomic status is nega-
tively correlated with maltreatment risk during childhood,
there is little relationship in adolescence: The families of
adolescents have higher incomes and parents have more
education, compared with maltreated children (National
Center of Child Abuse and Neglect, 1988). However, families
of maltreated adolescents are more likely to include steppar-
ents, even after controlling for the effect of older families,
and it has been noted that stepparent-adolescent interaction is
especially problematic when the adolescent demonstrates any
developmental pathology (Burgess & Garbarino, 1983).
The psychosocial sequelae of maltreatment in adolescence
are similar to those of childhood maltreatment, although it
has been suggested that the processes involved may be dif-
ferent (Garbarino, Schellenbach, & Sebes, 1986). Compared
with community controls, abused teenagers displayed signif-
icantly higher rates of diagnosed psychopathology even after
controlling for parental psychopathology, family structure,
and gender; this included major depression, dysthymia, con-
duct disorder, drug use and abuse, and cigarette use (Kaplan,
1994). A separate study using the Child Behavior Checklist
and Youth Self-Report Form reported signi“cantly more
behavior problems (especially externalizing problems)
among maltreated teenagers than among teenagers who were
not maltreated (Garbarino et al., 1986).
The clearest instance of increased vulnerability for adoles-
cents is seen with sexual abuse, particularly rape (the follow-
ing discussion refers to forcible rape without consent, not
statutory rape). Adolescents are twice as likely as adults to be
victims of rape (Finkelhor & Dziuba-Leatherman, 1994),
with half of all rape victims in the United States being under
the age of 18; the peak age for victimization is 16 to 19
(Neinstein, Juliani, Shapiro, & Warf, 1996). These statistics
presumably re”ect the fact that teenagers are both physically
attractive and more vulnerable to deception and coercion
than adults. Compared with rape victims over the age of 20,
adolescent victims have been assaulted more often by an ac-
quaintance or relative (77% versus 56%) and have delayed
medical evaluation (Peipert & Domalgalski, 1994). While
96% of victims of reported rapes are female, it is important to
note that male teenagers also are victims of rape and that
male rape may be even more underreported than female rape
(Finkelhor & Dziuba-Leatherman, 1994). The rapist also
tends to be young, with the peak age being 16 to 20 and 66%
of all rapists being between the ages of 16 and 24 (Neinstein,
Juliani, et al., 1996).
A rare study of 122 adolescent rape victims (Mann, 1981)
judged the impact of the rape to be severe more often for par-
ents (80%) than for the teenagers themselves (37%). Rather
disturbingly, 80% of the teenagers reported having problems
with their parents after the rape, and only 20% described their
parents as supportive and understanding. More parents (67%)
expressed anger at the assailant than did the teenagers (45%),
and 41% of parents expressed anger at the victim. While