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Some Indicators of Health-Related Behavior Among Adolesce-nts in the United States MARY GRACE KOVAR' THS BEHAVIOR OF CHILDREK AND ADOLESCENTS ha5 been a matter of concern~ since antiquity,. Each genera- tion of adults seems to feeli that the oncoming genera- tion is rejecting the values of society and endangering Ihe su!vivali of its institutions, . Dwing the past few years there has been a st'eadyy stream of comments on the behavior of adolescents. There have been, stories and articles about the rising tide of violence, arrests, pregnancy, and drug use inn both the popular and professional press leading one to believe that the majority, if not all'of the adolescents in the United States, are engaging in behavior harmful to themselves or other people. As a result, there is pressure to "do something" to change the situation. The knowledge thati other generations have worried about youth~ should not be interpreted to mean that there is no reason for concern at present. Nor should the high level of comment during the past few yearss be interpreted to mean that something is radically wrong with American youth and something must be done at once. There is a need for perspective. Before deciding what if anything should be done, it is advisable to have baseline data, preferably for several points in tiune, to determine trends for a defined popu• lation. Fortunately, a number of agencies of the Federal Government collect or fund the collection of a great deal, of data on various aspects of the behavior of adolescents in the United States. The data are scattered in numerous government publications and journal' articles dealing with substan- tive issues rather than with the population of inteiest, and they are not always tabulated and presented for the same age groups. Nevertheless, they exist and it is possible to make a reasonable assessment of some aspects of adolescent behavior. It is possible to begin to establish baselines. Baseline data are essential for rational decision making about programs designed to change any current situation. First, there is the decision as to whether a program is needed. In the final' analysis, that decision depends on the goals of society. It is possible that society will find even the rare occurrence of some events intolerable and the common occurrence of other events tolerable. It is nevertheless advisable to know how frequently each occurs. Second, there is the evaluation of a program's eRec- Ms. Kovar is a rtatistician wich the Division of Anaiysit, . tiveness. It is not unusual for the proponents of a Narional Center for Health; Statistics, Public Health Seryice. program to claim success because the level of the item O The paper is adapted from her presentation at the Conference creased after th f inter t was "aece tabl ~ l d p y e es ow or e on ~ldo7escent Behauior and'Htalth; sponsored by the Institute o of Medicine, National Academy of Sciences, in Washington, program was instituted when, had they but looked, ~ i D.C., on June 26-27, 1978, the level was just as low or had been declining before CA Trarrheet rzquests to Mr. Mary Grace Kovar, Nationai ~e program was started and had also decreased where N Center for Health Statutics, 2-27 Center Blde., 3700 East- N West Highway, Hyattavillc, Md. 20782. thert was no program. Nor is it unusual for the' (Z Norcl.-ApeU tM, Yot: ft, No. ! 10B

~ opponents of a program to clair~''ailure because the level of the item of interest was ~nacceptably high" or increased after the program was institute& when, had they but looked, the level was higher or had been increasing before the program began and increased at a more rapid rate where there was no program. The purpose of this paper is to present such baseline data for selected indicators of hcalth,related behavior among adolescents. The indicators were chosen from among many possible ones according to three criteria. First, they illuminate issues that are currently the subject of legislative and other public debate. Second, they illustrate aspects of behavior with a high prob- ability of adverse health consequences. The role of behavior is the focus of many of the current strategies for health promotion~ and disease prevention (1). Third, they are based on national data that were tabulated or could be tabulated for the age group 12-17 years. The ages 12-17 years are used to define adolescence for both conceptual and practical reasons. Conceptually, an adolescent can be defined as an individual who is biologically mature but has not yet attained full adult status (2). The beginning of adolescence is usually related to the onset of puberty. The end of adolescence is more' difficult to specify, but it is related to the assumption of adult roles, responsibilities, and preroga- tives. Few people attain sexual maturity before age 12, and few are not sexually mature by age 18. In the United States today adult roles, responsibilities, and prerogatives come at different ages for differenU people, but no one has the legal right to vote before age 18, which iF al.,o the usual age for having completed public school. Ages 12-17' are the junior an& senior high school years for those who start first grade at age 6 and are promoted each year. Practically, a considerable body of national data about the health of youths ages 12-17 years is already in the public domain. In 1966-70 a probability sample of almost 7,000 youths ages 12-17 were examined and interviewed in the third cycle of the Health Examin3- . tion Survey conducted by the Nationali Center for Health Statistics. Detailed data from that survey have been published, and the data tape can be purchased (3). The adolescent health survey in Harlern focused on the same age group, thus making comparable data available for a defined subnational population, (4). The Population at Risk One reason that adolescents have attracted a great deal of attention in the past few years is that there have been so many of them. From 1954 through 1964 more than 4 million babies were born in the United 110 Pub11o Health peporl. States each year. ~e number of babies born in 1961 was greater than . number im any year before or since then. Those childtcn'of the baby boom have resulted in unprecedented numbers of adolescents in the early 1970s, but by the late 1970s their numbers were already starting to decrease (table 1). From 1972 through 1976 there were about; 25 million youths ages 12-17 in the United States. By 1978 the number had declined to about 24 million: Population projections are for fewer than 23 million in 1980, fewer than 22 million in 1982, and a continuing decrease in numbers through the 1980s (5,6). Thus, if there is no' increase in the rate of any specified event or activity (such as the birth rate for ado- lescents or the percentage of adolescents smoking or drinking) or even if the rate remains constant, the num- ber of adolescents involved will decrease from the current level. If there is am increase in the rate, the number of adolescents involved can increase, remain constant, or decrease, depending upon whether the rate increases more rapidly, at the same pace, or more slowly than the rate at which the populatiom of adolescents is decreas- ing. Substance Use The majority of adolescents today have tried one or more substances by the time they finish high school, and the proportion of adolescents using marijuana, tbbacco, or alcohol is higher than it was at the beginning of the decade. Two national surveys funded by the National Insti- tute on Drug Abuse provide data on recent trends and current levels of drug use among adolescents. The methodology and the populations included differ; thus the data are not strictly comparable. One is based on questionnaires filled out by seniors in a sample of high Table 1. Number of adolescents (in thousands) ages 12-17 years, United States, 1970-84 Year 1970 ................ 1972 ................ 1974 ................ 1976 ................ 1978 ................ 19B0 ................ 1982 ................ 1984 ................ Total 12-15 years 16-r7 years 24,254 16,482 7,772 24,873 16,B0B 8,065 25,223 16,80B 8,415 I 24,968 16,573 8,395 24,114 15,689 8,425 22,737 14,5M 8,157 ~ 21,724 14,175 7,549 t'J 21,267 14,211 7,056 WD, i -~ SOUHCE: References 5 and 6.

schools (7), the other on qucstionnaires filled out for interviewers in a sample of households (8). Because drug use is associated with droppfing out of school and conventional family life, both surveys underestimate the actual level of drug use by failing to obtnin~ infor- mation from adolescents who are not in school or living in households. Unless there has been a change in the propensity to drop out, however, the underestimation will be consistent over time and the time trends will not be affected. The time trends will be affected, however, if there is an increase in the willingness to report illegal be- havior. Such a change in reporting has been guarded against insofar as possible by maintaining strict con- fidentiality dn both surveys, but whether such safe- guards adequately protect cannot be measuredL How- ever, both surveys reveal similar changes in the use of both legal andi illicit substances, and the changes in~ cigarette smoking are consistent with those reported by the National Clearinghouse on Smoking. More than 90 percent of the high school class of 1977 had tried alcohol at least once, and' 76 percent had tried cigarettes (7). Trying psychoactive drugs was not uncommon. Twenty-three percent of the class of 1977 had tried stimulants, 18 percent tranquilizers, and 17 percent had tried sedatives that were not ordered by a phys: cian. About 62 percent of the class of 1977 had tried one or more illicit drugs. The proportion of seniors who have tried an illicit drug has been increasing, because of the appreciable rise in marijuana use. While 47 percent of the class of' 1975 had tried marijuana, 56 percent of the class of 1977 had done so-a significant increase in 2 years. There was no change in the pro- portion using other illicit drugs-about 36 percent had tried hallucinogens, inhalants, opiates, or cocaine. Having tried a substance does not indicate abuse, nor does it measure current use. The proportion who had used a substance within 30 days was much lower. Among members of the class of 1977, the proportions were still substantial, however; 71 percent had used ~/ alcohol, 38 percent cigarettes, and 35 percent mari- juana; and about 9 percent had used stimulants with- out a physician's orders within 30 days of the survey.. One possible measure of abuse (because heavier levels of use are more likely to have detrimental effects) is daily or near daily use of a substance during the past 3&days. About 29 percent of the seniors smoked cigar- ettes daily, 6 percent reported daily use of alcohol, and 9 percent reported daily use of marijuana. Levels of usage reported on the population-base& survcy (8) are somewhat lower than the levels reported by the seniors, but the relative ranking of substances and the change over time are similar. This survey also provides the opportunity of examining how the usee of substances changes from~ early to late adolescence. In 1977 about one-half of all adolescents ages 12-17 had tried alcohol or cigarettes and a quarter had trie& marijuana (8). Less than 10 percent had tried one of the other substances (table 2). About 31 percent had used alcohol, 22 percent cigarettes, and 16 percent had used marijuana within 30 days of the survey. Less than 2 percent of the adolescents reported using any other substance within 3&days. In 1977 current use of alcohol, cigarettes, and mari- juana was higher among older adolescents, males, white adolescents, and those living in large metropolitan areas than among their counterparts. Current use of alcohol increases sharply with increas. ing age, but there is no indication that levels of usage at any given age have increased over the 5 years 1972- 77. The proportion of adolescents who are users, es- pecially the younger ones and those in large metropoli- tan areas, may actually have declined somewhat from 1974 to 1977 (table 3). ~ Current use of cigarettes shows a similar pattern. The 16 and 17-year-olds were much more likely than the 12 and 13-year-olds to have smoked in the past month, but adolescents of any age were less likely to be smokers ,r in 1977 than in 1974 (table 3). In contrast, use of marijuana has continued' to in- crease, especially among, older adolescents. In 1971, 1974, and 1977, 10, 20, and 29 percent respectively, of the 16-17-year-olds ha& smoked marijuana within the month before the survey (table 4). The increases have been especially noteworthy among white youths and those living in large metropolitan areas. If the trends noted in 1977 continue, it will not be long before more adolescents are using marijuana than nicotine, but daily use of nicotine appears likely to remain higher than daily use of marijuana if high school seniors are an indicator. According to secondary school students in a National 0 j t 'I i i 9 b i f Ed d t tu nst ucat on survey ( ), eer, w ne, an e o W marijuana are widely available in the schools (the ~ question~ was not asked about tobacco). Almost half ~ of the students (47 percent) said that marijuana was N easy to get at school, with 56 percent of the senior high Q school students in contrast with 29 percent of the junior high school students reporting marijuana easy to obtain. Yarch-Aprli'1iTY, Vot. 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Q• r Beer and wine were, according fae students, less available at school. Thirty-seven percent of the students said that beer or wine wcre easy to get; 45 percent of the senior and 21 percent of the junior high school students reported that alcohol was av.ailable. The National, Institute of Education report empha- sizes that these are students' perceptions rather than objective data. Nevertheless, it is clear that students perceive the substances as available and that schools in all kinds of areas~ *ties, suburbs, and rural areas- are af~ected `. It is not lack of information, per se, which leads adolescents to use these substances. For example, almost, 90 percent of the adolt scents believe that the intorma- tion about smoking is true and that cigarette smoking can harm the health of teenagers. Even among smokers, more than three-quarters believe that smoking can harm the health of teenagers (10). Table 2. Lifetime prevalence and recency of use of specified substances by adolescents ages 12-17 years, United States, 1977, in percentages i Ever used- Past year, Not Substanca Total, Past not past Pes6 Never used month month year Legal substances: Alcohol ... .......................... .......•........ 52.6 31.2 16.3 5.0 46.5 Cigarettes ................................................ Illicit drugs: Marijuana or hashish or botFi .............................. 47.3 28.2 22.3 16.1 ... 5.7 6.4 48.6 71.8 Inhatants ................................................ Hallucinogens ............................................ Cocaine ................................................. Heroin ................................................... Other opiates ..................•......................... 9.0 4.6 4.0 1.1 '6.1 0.7 1.6 0:8 0:0 0.6 1.5 6.9 1.5 1.5 1.8 1.4, 0.6 0.7 2.8 2.3 91.0 95.4 96.0 98.9 192.8 Prescription drugs, nonmedicall use: Stimulants ................................................ Sedatives ................................................ Tranquilizers ................................................. 5.2 3.1 3.8 1.3 0.8 0.7 2.4 1.1 1.2 1.1 2.2 0:6 94.8 96.9 96.2 , = Inctudes methadone. SOURCE: Reference 8. Table 3. Current drinking and smoking among adolescents ages 12-17 years, United States, 1972-77, in percentages Current, drinkers i Current smokenr = Selected characterlsUcs 1972 1974 1976 1977 • 1971 1972 1974 1976 1977 Total: youths 12-17 years .•.•... 24 34 32.4 31.2 15 17 25 23.4 22.3 Age (years): 12-13 ............................ 16 19 19 13 5 4 13 11 10 14-15 ............................ 21 32 31 ' 28 17 16 25 20 22 16-17 ............................. 35 51 47 52 23 32 38 39 35 V Sex: Mate ............................. 27 39 36 37 16 17 27 - 21 23 Female ........................... 21 29 29 25 14 17 24 26 22 Color: White ............................... 24 37 34 33 ... ... 25 22 23 Oth r 19 21 23 23 26 28 18 e ............................ Region: ... ... 1 Northeast ......................... 28 44 42 35 18 16 27 22 24 0 South Central ..................... 28 33 38 35 14 19 27 24 26 W , i South ............................ 15 21 21 24 9 17 22 25 20 ~ West ............................ ~ 28 46 32 36 22 16 27 21 19 • • Population density: • CA .- ' t Large metropolitan .................. 24 44 38 36 16 16 27 25 . 25 N Other metropolitan ................. . 28 27 33 30 15 19 22 • 22 23 N Nonmetropolitan ................... 20 28 26 27 14 16 27 24 19 ~ ~ s Derined as pasT7 days in 1972, past month In Ieter years. SOURCE: Reference fl. 43 s Defined as present time in 1971 and 1972, past month in later years. ~ ~ 112 Public Health Reporta ~ ~ ~

k. : k. How then do they rationalize their behavior? Almost ;.' two-thirds of the smokers believe that it's okay to smoke , if •you quit before it becomes a habit, and one-third believe that teenagers who smoke regularly can quit any time they like. While it is encouraging that adolescents bclieve that . . smoking can be harmful, it does appear to be futile to continue saying, "It is harmful. Don't do it." Theyy know that. One can speculate whether the publicity about people quitting has helped adolescents rationalize by encouraging the belief that quitting is easy. Encouraging a sense of personal responsibility for one's well-being might help adolescents make intelligent decisions about substance use, but that in no way re- duces parental responsibility. Studies have shown re- peatedly that adolescents are more likely to smoke or drink when, parents do. Illicit drug use is more likely in families where various substances (not necessarily illicit ones)i are used by their mothers or older siblings. And, it might be more difficult to obtain tranquilizers, stimulants, and sedatives if they were not available in the home. The association between use of tobacco and pre- mature disability or death in later life has now been Table 4. Use of marijuana or hashish„or both; In past month among Pdolescents ages '2-17 years, according to selected characteristics, United States, 1971-77, In percentages Use In past month Selected chsracleristlca 1971 1 1972 1 1974 1976 1977 Total't youths ages •12-17 years ... 6 7 11.6 12.4 16.1 Age (years): 12-13 .............. 2 1 2 2 4 14-15 .............. 7 6 12 13 15 16-17 .............. 10 16 20 22 29 Sex: Mate ............... 7 9 12 14 19 Fema le ............. 5 6 11 10 13 Color: white .. ............. .. 8 12 12 17 Other .............. .. 2 9 10 12 Region: Noriheast ........... 9 7 14 14 21 North Central ....... 5 7 11 15 19 South .............. 2 4 6 7 7 West ............... 11 14 19 17 22 Population density: Large metropolitan .,. 9 ,. 14 18 22 Other metropolitan ... 7 .. 11 10 16 Nonmetropolitan ..... 3 .. 10 9 10 s1gAarffuana onty. SOURCE: Reterenca S. documented by so many studies that it would take a separate paper merely to list them. The literature on alcohol use and health consequences is also extensive. Less is knowmabout the association between marijuana use and health, at least partly because extensive mari- juana use in the' United States is a relatively recent phenomenon. The Institute of Medicine staff paper (1) mentioned previously, contains bibliographies of studies on all three. Of immediate concern, however, is whether use of the latter two is associated with other risk-taking be- havior im adolescence such as having sexual intercourse without using contraception, reckless or inattentive driving„ swimming or boating alone or in bad weather, or other risky kinds of behavior without safeguards. Associations have been documented in special studies and the existence of some relationships can be inferred from national data, but as far as the author knows, there are no national data available that document associations among substance use and the various formss of risk-taking behavior among adolescents in the United States today. Sexual Activity and its Consequences Data from, two national surveys funded by the National Institute of Child Health and Human Development provide data on~ the proportion of adolescent girls who have had sexual intercourse. There are no national data for boys. Increasing proportions of unmarried adolescent girls have had intercourse, and they have had their first experience at a younger age. In 1971, 27 percent, and in 1976, 41 percent of the unmarried 17-year-old women reported that they had had sexual intercourse at least once-an increase of 54 percent in just 5 years (11). They were also more likely to have had more than one partner. Moreover the percentage of 15-year-o16 girls who had had sexual intercourse at least once increased from 14 percent in 1971 to 18 percent in 1976. While the pro- portion of 15-year-old girls who have ever had sexual intercourse is still much lower for whites than for blacks (14 compared to 38 percent), the proportional increase over the 5 years has been much greater for white than for black girls. 03"j ~5z . ! 22 Like substance use, having tried intercourse does not necessarily mean continuation. Of the unmarried 15-17- year-old girls who had had intercourse, 20 percent had done so only once. However, another 20 percent had had intercourse 3 times or more in the previous 4 ilareArAprIl 1279, Vol. 94, No. 2 113

. ~ weeks; 445 percent of these young (inen, .had ha& more than one partner. If all other factors had ramained the same, the substantial, increase in the prevalence of, sexual experi- ence would have been expected to result in an increase in adolescent fertility. Inste-ad, birth rates for the 15-17- year-old girls, which had, been rising, have been declin- ing steadily since 1972 (table 5). In that year there were almost 237,000 births to 15-17-year-old girls; the birth rate was 39.2 per 1,000. In 1976, with 21:5,000 births, the rate was 34.6 per 1,000. The birth rate is still high among black adolescents. In 1976, there were 81.5 live births per 1,000' blaclc women ages 15-17. However, that rate representa a Table 5. Birth rates and distribution of births to women under 20 years, according to age and race of mother, United States, 1966-76 Llve births per 7400 women Cumulative percenrof all births Race and year 20 percem decreas{ am 1970, when there were 101.4 live births. Babies are also born to girls who are not yet 15 themselves-almost 12,000 in 1976. They represent a very' small proportion of aU births, only 0:4 percent, but these young mothers are barely out of childhood themselves. They are not physiologically ready for pregnancy and the physical risk to the infant is enor- mously increased, to say nothing of the mother's psy- cholbgical, economic, or educational unpreparedness for parenthood. Concurrently, abortion rates have been increasing. The number of legal abortions reported to the Center for Disease Control increased each year from 1972 through 1976, and about one-third of the abortions 10-11 15-17 18-19 Under 16 Under 78 Undbr 20 years years years years years years Total, 1966 .......................... ....................... 0.8 35.7 120.3 0,2 5,4 17.5 1967 .............................................. 0.9 35.3 116.7 0.2 5.6 17.2 1968 .............................................. 1.0 35.1 ' 113.5 0.3 5:8 17.2 1969 .............................................. 1.0 35.7 112.4 0.3 5.9 17.1 1970 .............................................. 1.2 38.8 114.7 0.3 6.3 17.6 1971 .............................................. 1.1 38.3 105.6 0,3 6.7 18.0 1972 ............................................... 1.2 39.2 97.3 0.4 7.6 19.3 1973 ..........................................:...... 1.3 38.9 91.8 0:4 8.0 19.7 1974 .............................................. 1.2 37.7 89.3 0.4 7.8 19.2 1375 .............................................. 1.3 36.6 85.7 0.4 7.6 18.9 1916 ............................................... 1.2 34.6 81.3 0.4 7.2 18.0 1966 White ............................................... 0.3 26.6 108.2 0.1 4.1 15.6 1967 .............................................. 0.3 25.7 104.0 0.1 4.1 15.0 1968 .................. . ......................... 0.4 25.6 100.5 0.1 4.3 14.8 1969 .............................................. 0.4 26.4 99.2 0.1 4.4 14.6 1970 .............................................. 0.5 29.2' 101.5 0.1 4.8 15.1 1971 .............................................. 0.5 28.6 92.4 0.1 5.1 15.4 1972 .............................................. 0.5 29.4 84.5 0.2 5.9 16.5 1973 ............................................ 0.6 29.5 79.6 0.2 6.2 16.8 1974 ............. .............................. 0:6 29.0 77.7 0.2 6.1 16.5 1975 .............................................. 0.6 28.3 74.4 0.2 6.0 16.3 1976 .............................................. 0.6 26.7 70.7 0.2 5.6 15.5 1966 Black .............................................. 4.2 97.9 2191 1.0 12.6 27.8 1967 .............................................. 4.4 99.5 213.4 1.1 13:6 29:5 1968 .............................................. 4.7 98:2 206.1 1.2 14.3 30.9 1969 ........................:....................... 4.8 96.9 202.5 1.2 14.3 U 31.0 1970............................................... . 5.2' 101.4 204.9 1.3 14.7 CJ 31.3 1971 ............................................... 5.1 99.7 193.8 1.3 15.3 ~ 31.7 1972 .............................................. 5.1. 99.9 181.7 1.4 16.9 ~ 33.8 1973 .............................................. 5.4 96.8 169.5 1.5 17.4 01 34.4 1974 .............................................. 5.0 . 91.0 162.0 1.4 16.8 ~ 33.9 1975 ..................... .._....................... . 5.1 86.6 156.0 1.4 16.1 N 32.9 1976 . ................................ .................. 4.7 81.5 146.0 1.3 15,2 w 31.2 s Includes all other races not shown separately. SOURCE: Nationsl' Center for Health Stetistics„ Division of Vital Sta- tistics. Data are based on the national vital registration system. 114 Publlc Health Reports

each year have been for women under the age of 20. As the number of live births has decreased and the number of abortions has increased, the legal abortion ratio has increased even more rapidly. More adolescents under age 15 obtained legat abortions than had live births in 1976; about two-thirds as many adolescents ages 15-17 obtained abortions as had liveborn children (12). Between 1971 and 1976, the surveys showed a dra- matic increase in contraceptive use, in use of the most effective measures, and in more regular use of con- traception by adolescent girls. Nevertheless, in 1976 only about one-third (35.8 percent) of the adolescent girls who ha& had intercourse used contraception the first time (13). The decline in birth rates in the face of increases in sexual activity appears to be due to an increase im the proportion of adolescent girls using, contraception, thus keeping the pregnancy rate from rising, and to an increase in the proportion of preg- nancies ending in abortiom followed by contraceptive use after the young woman recognizes that she can become pregnant. Among the teenagers who had had one premarital - pregnancy and had not married, less than one-fourth had intended to become pregnant, yet only one-fifth of those who had not intended the pregnancy reported that they had been using contraception regularly to prevent it. The majority knew that pregnancy was possible, yet they and their partners did not consistently use contraceptiom Pregnancy and childbirth among adolescents is a special concern because it affects the adolescent girl herself, sometimes the father, and it affects the offspring. The birth, of a child to an adolescent can be hazardous for both mother and ch?ld. The young mother is not completely out of childhood herself, has probably not had an,opportunity to complete high school, and seldom is prepared to care for herself or her child. For most young mothers, their lifetime options are reduced (14, 15). It is hazardous for the newborn child. The chance of su1viving infancy is lower for infants born to adoles- cent mothers than to mothers of any other age, and the chances of physical defects are higher. In 1976, when about 7 percent of all liveborn chil- dren were low-birth weight babies, the proportion was . 15 percent if the mother was under age 15, and 11 percent if she was 15-17 years old. The increased risk of low birth weight may be the single most important medical aspect of adolescent pregnancy. Studies (16, 17) have shown that the child weighing 2,500 grams or less at birth is 17-19 times as likely as the child weighing more to die in the first year of life. Low birth weight is also associated, with handicapping conditions, especially neurologicalt ones (18). Risks of deafness and blindness are also higher (19, 20). The social'and economic consequences of early child- bearing in the United States have been documented repeatedly. The age of a young woman at the birth of her first child has an important impact on the young woman's educational attainment, especially if the mother is still in high school at the time of the birth. The chance of her completing high schoot is small. Teenage mothers have also been found to have higher subsequent fertility. Through its direct effect on~ educational attainment and on~ family size, age atfirst birth is indirectly related to family income and to poverty. Consequently, women who bear their first child' as adolescents have a greater risk of poverty and welfare dependency. Nearly half of government ex- penditures through the Aid to Families with Dependent Children (AFDC) program~ went to households con- taining women who bore their first child while a teen- ager (personal communication from Kristin A. Moore of the Urban Institute, Washington, D.C., ;May 1978). More than~ three-fifths of women in the households receiving AFDC' had their first child while a teenager. Thus, the economic and social consequences of adoles- cent childbearing are great, both for the individuals concerned and for society. Sexually transmitted diseases are also adverse con- sequences of sexual activity, and they cannot be pre- vented by reliance on the pill or an IUD. Gonorrhea is the most common of the sexually transmitted diseases and by the mid-1970s had become epidemic; the case rate for 15-19-year-olds in 1975 was 12.9 per 1,000, 3 times that of 2& years earlier. Since' then the rate seems to have stabilized (21). - Sexually transmitted diseases are rare among adoles- cents younger than 15 and more common among the 16- and 17-year-olds. The author's estimate (based on Center for Disease Control data corrected for under- reporting) is that in 1976, 3 of every 1,000i younger adolescents and 20 out of every 1,000 older ones ac- quired gonorrhea. Other sexually transmitte& diseases were less cominon (personal communication from Oscar G. Jones, statistician, Research Statistics Section, Ven- ereal Disease Control Division, Center for Disease Con- trol, May 1978). .03745224 In contrast with adult men and women, in adoles- cence gonorrhea is more common among girls than among boys. This pattern may reflect higher levels of MareA-Aprtl 1979, YVol. 04, No.: 1111

1N .• I t r' sezuafactivity among adolescent ~ than boys; girls may have intercourse with boys and men older than they are. The health consequences for infected girls can be great. Gonorrhea is a more complex disease in females than in males, much more difficult to diagnose, and more likely to result in residual, morbidity: It has been estimated that' pelvic inflammatory disease occurss in 17 percent of all women, who have gonorrhea (22)1 and that damage to the fallopian tubes from a single' episode of adequately treated pelvic - inflammatory disease results in sterility in from, 15 to 40 percent of the cases. Illness, Use of Medical Services, Death According to data especially tabulated for this paper from data tapes of the National Center for Health Statistics (3), illness rates, use of medical services, and death rates are all low for adolescents. The acute respi' ratory illnesses and infections of childhood are past, and the chronic conditions of adulthood are in the future. : Adolescents had, on the average, 2.4 acute conditions per year, 10:3 days during which activity was restricted, and 4.5 days im bed because of ill health, and they missed 4.8 days from school. Less than 5 percent were reported to be limited in activity because of health (4.7 percent) or were in poor or fair healtl* (4.5 percent), Table 6. Ysslts by adolescents ages 12-17 years to office- based physicians, according to principal: diagnosis, age, and sex, United States, 1975-76 12-15 16-17 Sex and diagnosis Total years years ( Physician rls/ts per person per year Both sexes ....... 1.6 1.5 1.9 Males .......... 1.5 1.5 1.5 Females ........ 1.7 1.5 2.2 Percent distrlbution by principal diagnosis Males Total ............. . 100.0 100.0 Illness ......... 60.6 61 L9 Injury .......... 16.8 16.3 Examination and observation ... 21.5 20.7 Females Total ............. 100.0 100:0 I llness ......... 69.1 71.2 Injury .......... 8.2 9.0: Examination and observation ... 21.1 18.5 Prenatal ...... ~ 6.3 3.0 100.0 58.3 17.7 23.0 100.0 . 66.5 7.2 Adolescents mad~ the average, 1.6 visits to offce- based physicians pe~,zar in 1975-76. (table 6). The majority of the visits were because of illness. However, 17 percent of the visits of adolescent boys ages 12-17 were because of injuries (in contrast' with 11 percent for elementary school boys ages 6-11)I. Adolescent girls were much less likely (8'percent of the visits) to visit a physi- cian because of an injury. However, 6 percent of the visits of adolescent girls ages 12-17 and 11 percent of the visits of those ages 16-17 were for prenatal care. Thus injuries and pregnancy, both results of behavior, account for a small but significant portion of the medical care adolescents receive from private physicians. Adolescents were unlikely to be hospitalized. In 1975- 76 there were 361 days of hospitalization for every 1,000 adolescents ages 12-17 (table 7). About 23 percent of the days adolescents spent in hospitals were due to injuries, and 13 percent were due to pregnancy and deliveries. Thirty-five percent of the days adolescent boys spent in the hospital were because of injuries. Thirteen percent of the time adolescent girls spent in the hospital was because of injuries; 18 percent was because of childbirth. Among, younger boys ages 12-15; there were 89 days of hospitalization per 1,00& per year for injuries, and among older boys ages 16-17, there were 164 days per year. Among younger girls ages 12-15, there were 35 days of hospitalization per 1,000 Table 7. Hospital days for adolescents ages 12-17 years, according to principal diagnosis, age„and sex, United States, 1975-76 12-15 1d-17 Sex and diagnosis Total yaars years Hospital days per 1,1100 persons per y.at Both sexes ....... 360i8 282.0 513.8 Males .......... 330.1 278.9 426.7 Females ........ 392.0 385.2 601.0 Percent distribution by princ/pahdiapnosJs Males Tot al ............. 100.0 100.0 100.0 Illness ......... 64.5 67.6 60.6 Injury .......... 34.7 31.9 38.2 Examinatiom and observation ... 0.8 0.6 1.2 ! F ema es Total ............. 100.0 100.0 ~ 100.0 Illness ......... 86.7 84.1 4 89.1 Delivery ...... 18.4 9.2 • ept 27.0 • 24.5 Injury .......... • 12.5 14.9 ~ 10.3 10.5 Examination and - observation ... 0.8 1.0 ~ 0.6 SOURCE: Nationall Center for Health Stetistics, National' Ambutatory Medical Care Survey. Date are based on reporting by a sample of physl- clans In office-based practice. 11t public Health Reports SOURCE: National Center for Health Statistics, Hospltall Discharge Survey. Data are based: on reporting by a sample of hospitala. , ,~,,. J1__ ~ -M~~~ ~ ~. ~ ~ ~- . <' --, - P.._, ~ ~ ~y~ 3 . ~ ~~ ~ ' ..,. ai_ ...rc'r~-^t~':YS^...... _-

per year for deliveries, and among older girls ages 16-17, there were 162 days per year. Death rates are also low in adolescence. In 1976 there were 6 deaths per 10,000 youths ages 12-17 (table 8). There is no question that the majority of deaths of adolescents are related to behavior. If one uses the simplest dichotomy, deaths caused by accidents and violence versus those caused by diseases and conditions, 70 percent of the deaths of youths ages 12-17 were from accidents or violence in 1976 (table 8). These deaths were certainly related to behavior. Because some of those attributed to diseases and conditions may also have been behavior related, 70 percent is probably a conservative estimate. More adolescents died as a result of motor vehicle accidents than any other cause. Thirty-six percent of all adolescents ages 12-17 who died in 1976 died as a result of a motor vehicle accident. In cont'rast, 6 percent of the deaths were due to drowning, 5 percent were recorded as suicides, and 6.5 percent as homicides. Table S. Death rates among adolescents ages 12-17 years for all causes, accidents and violence, and diseases and eonditions and percent of, deaths due to selected specified causes, by age, United States, 1976 12-J5f6-17 Causa of deefh Total years years Deaths per 10,000 persons All causes .. ... ... ... 6.0 4.4 9.1 Accidents and violence. . 4.2 2.7 7.0 Diseases and conditions. 1.8 1.6 2.1 Piroent of deaths due to apect7ted cause Al! causes . . . . . . . . . 100.0 100.0 100.0 Accidents and violence.. 69.9 62.5 76.8 Accidents .......... 56.5 52.5 60.4 Motor vehicles .... 36.0 28.3 43.2 Fire and flames ... 1.6 2.2 1.0 Drowning ......... 6.3 7.5 5.3 Suicide ............ 5.4 4.0 6.7 Homicide ........... 6.5 4.5 8.3 Diseases and condltions. 30.1 37.5 23.2 Neoplasms . . . . . . . . 8.9 11.2 6.8 Malignant neoplasms 8.4 10:5 6.5 LeukemTa ....... 3.2 4.3 2.1 Congenital anomalies. 2.5 3.4 1.6 Heart . . ....... ... .1.3 - . 1.7 0.8 Nervous system ..... 3.3 4.1 2.6 Respiratory system .. 2.9 3.8 2.1 Pneumonia ....... 1.8 2.3 1.3 Circulatory system ... 4.5 5.4 3.7 Infective and parasitlc. 1.4 1.9 0.9 NOTE: Deaths an coded according to the Eighth Revision of the Intematlonat Classlncation of Diseases Adapted for Use In the United States. SOURCE: National Gnler for Health StatlstlCs, Dtvlslon of Vital Sta- tistics. Data are based on the natlond~ vital nplstration system. These three together account for only half as many deaths as motor vehicles. Only one condition, malignant neoplasms, was a major cause of death, accounting for a quarter as many deaths as motor vehicle accidents. The chance of dying during adolescence is related to both age and sex with the differences between age- sex groups due primarily to differences in the death rates from accidents and violence. As can be seen in the chart, which shows death rates by single years of age for males and females, iates increase with age throughout adolescence, and the rates are consistently higher for males than for females. The differentials exist when only diseases and conditions are considered and the external causes are excluded. However, the differences are much greater when only the deaths due to accidents and violence are considered and the so- called natural causes are excluded. The greatest increase with age is in the death rate from accidents and vio- lence for adolescent males. Motor vehicle accidents are the single most important cause of death in adolescence. Death rates due to motor vehicle accidents are so much higher for young white males that they account for a large part of the differ- entials by age and sex and for the lack of any difference by race. Death rates for children and young adults 1-24 years, by age, sex, and cause of death+ United States, 1976 1 3 5 7 9 11 13 15 17 19 21 23 25 Age in years aOURCE; Divtslon of Vital Statlsttu,,Natlonal l;enur for Health Statlstics March-Aprtt tl79, Vol. 94, No. 2 117

1 I I I ' . Conclusion ( Although according to the conventional indicators the health of adolescents is good'y many do engage in activi- ties that increase the probability of either immediately adverse health consequences or of latcr disease or dis- ability. Among all adolescents ages 12-17, it is estimated that 53 percent have tried alcohol, 47 percent have tried tobacco, and 28 percent have tried marijuana. Twenty- eight percent of the girls have had intercourse at least once. As'far as can be ascertained, the proportion using or having used alcohol and tobacco increased until the mid-1970s and has since leveled off. The proportion using marijuana and the proportion of girls who have had intercourse has continued to increase. There are later health and social consequences from some of these activities. There can also be immediate consequences of risk-taking behavior. Intercourse, es- pecially without use of contraception, can result in 'ttnwanted 'pregnancy. The increasid use of contracep- tion among adolescent girls has apparently kept the pregnancy rate from rising, and the birth rate among adolescent girls ages 15-17 has been decreasing since 1972. Other kinds of behavior can result in injuries re- quiring medical care or in death. On any, given day, about 35 percent of the adolescent boys and 13 percent of the girls who are in the hospital are there because of injuries. About 70 percent of all deaths of adolescentss are due to accidents or violt?nce; 36 percent are due to motor vehicle accidents. Homicide, drowning, and suicide each account for 5 to 6 percent of the deaths of adolescents. Only malignant neoplasms among all the diseases account for more deaths of adolescents. (8 percent) than these 3 causes. It is increasingly recognized that social, environ- mental, and behavioral factors are critical in promoting good health and preventing ill health. The behavioral factors are especially important for adolescents, since it is at this age that youths acquire the independencee to make their own decisions about behavior and: be- cause most are in good health~ If good health~ can be maintained into adulthood, the return: to the individual and society can be great. - References 1. Institute of Medicine: Perspectives on health promotion and disease prevention in the United States. National Academy of Sciences, Washington, D.C., May 1978. 2. Health needs of adolescents. WHO Tech Rep Ser No.,609, Geneva, 1977. 3. National Center for Health Statistics: Standardized micro-data tape transcripts. DHEW Publication No. (PHS) 78-1213. Hyattsville, Md., June 1978. • tlfa Publlc Health Reports 4. Brunswick, A~ and Josephson, E.: Adolescent health in Harlem. A ., Public Health, October 1972. Supple- ment. S. U;S: Burcau of the Census: Projections of the population of the United States: 1977 to 2050. Current Population Reports, Series P-25, No. 704, July 1977. 6. U:S, Bureau of the Census: Estimates of the population of the Unite& States by age, sex, and race: 1970 to 1977. Current Population Reports, Series P-25, No. 721, April 1978. 7. Johnston, L. D., Bachman, J. G., and O'Malley, P. M.: Drug use among American high school students: 1975- 1977: DHEW Publicatiom No. (ADM)~ 78-619: National Institute on Drug Abuse, Rockville, Md., 1977: 8. Abelson, H. I., Fishburne, P. M., and Cisin, I.: National survey on drug abuse: 1977. Main findings. Vol. 1. DHEW Publication No. (ADM) 78-618. National Insti- tute on Drug Abuse, Rockville, Md., 1977. 9. National Institute of Education: Violent schools-safe schools: the safe school study report to the Congress. Vol. 1. U~Sa Government Printing Office, Washington, D.C., January 1978, pp. 72-73. 10. National Institutes of Health: Teenage smoking: national patterns of cigarette smoking, ages 12 through 18, in 1972 and 1974. DHEW Publication No. (NIH) 76-931. Bethesda, Md., 1976. 11. Zelnick, M., an& Kantner, J. F.: Sexual and contracep- tive experience of young unmarried women in the United -States, 1971 and 1976, Fam Plann Perspect 9: 55-71, March/April 1977. 12. Center for Disease Control: Abortion surveillance 1976. DHEW Publication No: (CDC) 7&-8205. Atlanta, Ga., August 1978: 13. Zelnick, M., and Kantner, J. F.: Contraceptive patterns and premarital pregnancy among women aged 15-19 in 1976. Fam Plann Perspect 10: 135-142, May/June 1978. 14. Bumpass, L. L., Rindfuss, R. R., and Janosik, R. B.: Age and marital status at first birth and pace of subsequent fertility. Demography 15: 75-86, February 1978. 15. Hofferth, S. L, and Moore, K. A.: Age at first birth and later economic well being. Presented at a meeting of the Population Association of America,. Atlanta, Ga., Apr. 13-15, 1978. 16. Chase, H.: Trends in 'prematurity': United States, 1950- 1967. Am J Public Health 60: 1967-1984 (1970). 17. Nationa] Center for Health Statistirs: Infant mortality rates: socio-economic factors. Vital and Health Statistics Series 22,,No. 14 (1972). _ 18. Pasamanick, B., and Lilienfeld, A.: Association of mater- nal and fetal factors with the development of mental deficiency. I. Abnormalities in, the prenatal and perinatal periods. JAMA 159: 155-160 (1i955). 19. Vernon, M.: Prematurity, and deafness: the magnitude and nature of the problem among deaf childten. Excep- tional Children 33: 289-298 (1967). 037Q522'7 20. Goldberg, I. D., Goldstein, H., Quade, D., and Rogot, E.: Association of perinatal factors with blindness in ehildren. Public Health Rep 82: 519-531, June 1967. 21. Center for Disease Control': VD Statistical Letter. Issue' No. 126. Limited edition, Atlanta, Ga., May 1977. 22. Rendtorff, R. C., and Curran, J. W.: Memphis gonorrheaa complication study-a progress report. J Am Venereal Dis Assoc 1: 40-47, September 1974. a ©