ADOLESCENTS: Risk Taking Behaviors

Objectives:
1. Describe the different risk behaviors and related factors
2. Discuss national epidemiology on adolescent mortality and morbidity
3. Analyze the impact or various risk behaviors on the adolescents
DEVELOPMENT

Nature vs Nurture
Genetics vs Environment
Genetics and Environment
Class Stage Theories
-Psychosexual
-Psychosocial
-Cognitive

Classic Stage Theories

Theory
Freud
Erikson

Piaget
Kohlber
g

Infancy (01yr)
Oral
Basic Trust

Sensorimo
tor

Toddlerhood (23yr)
Anal
Autonomy vs
shame and
doubt
Sensorimotor
Preconventiona
l: avoid
punishment/ob
tain rewards
(stages 1 and
2)

Preschool
(3-6)
Oedipal
Initiative vs
guilt

School Age
(6-12yr)
Latency
Industry vs
inferiority

Preoperatio
nal
Convention
al:
conformity
(stage 3)

Concrete
operation
Conventio
nal: Law
and order
(stage 4)

Adolescence
(12-20yr)
Adolescence
Identity vs
Identity
confusion
Formal
operations
Postconventio
nal: Moral
Principles

Findings from the 2008 NDHS

Of 2749 female adolescents aged 15-19

3.5% had used any modern method (pill, male condom, IUD, injectables,
mucus/billings/ovulation, Basal Body Temperature lactational amenorrhea
method (LAM) emergency contraception)
4.1% had ever used any traditional method (withdrawal, rhythm folk)
1.6% were currently using a modern method (pill, male condom, IUD,
injectables)
1.5% were currently using a traditional method (withdrawal, rhythm)

Of 283 currently married female adolescents aged 15-19

26.3% had ever used an modern method (pill, male condom, IUD injectables,
mucus/billings/ovulation, BBT, LAM, emergency contraception)
29.9% had ever used any traditional method, withdrawal, rhythm, folk)
14.3% were currently using a modern method (pill, male condom, IUD,
injectables)
11.6% were currently using a traditional method (withdrawal, rhythm)

VIOLENCE
The intentional use of physical force or power, threatened or actual, against
oneself, another person or against a group or community that either results in or
has a high likelihood of resulting in injury, death, psychologic harm,
maldevelopment or deprivation

Poverty
Substance abuse
Mental health disorders
Poor family functioning

Electronic Aggression

Centers for Disease Control and Prevention (CDC)

Type of harassment or bullying (teasing, telling lies, making fun of someone,
making rude or mean comments, spreading rumors, or making threatening or
aggressive comments)
Occurs Through e-mail, chatrooms, instant messaging, blogs, text messaging
or videos or photos posted on a website or sent via cell phone.

WHO: 3 Larger types of violence

Interpesonal violence is subdivided into violence largely between family

members or partners and includes child abuse
Community violence occurs between individuals who are unrelated
Collective violence incorporates violence by people who are members of an
identified group against another group of individuals with social, political or
economic motivation

2 Types of antisocial youths

Adolescent-limited offenders:
-no childhood aberrant behaviors
-more likely to commit status offenses such as vandalism, running away, and
other behaviors symbolic of their struggle for autonomy from parents
Life course-persistent offenders

-exhibit aberrant behavior in childhood such as problems with temperament,

behavioral development and cognition
As adolescent they participate in more victim-oriented crimes

3rd theoretical Model

Violent behaviors across the spectrum occurring within and outside the family
and is referred to as the cycle of violence
Precursors such as child abuse and neglect, as child witnessing violence,
adolescent sexual and physical abuse, and adolescent exposure to violence
and violent assaults predispose youth to outcomes of violent crime,
delinquency, violent assaults, suicide or premature death

Risk Factors for Youth Violence

Poverty
Association with delinquent peers
Poor school performance
Low education status
Disconnection from adult role models or mentors
Prior history of violence or victimization
Poor family functioning
Childhood abuse
Substance Abuse
Certain Mental Health Disorders

Most common Disorders Associated with Aggressive behavior

Menatal retardation
Learning Disabilities
Moderately severe language disorders
Mental disorders such as attention-deficit/hyperactivity and mood
disturbances

Conduct disorder and oppositional defiant disorder are specific psychiatric

diagnoses whose definitions are associated with violent behavior

Occur co-morbidity with other disorders such as attentiondeficit/hyperactivity disorder and increase an adolescents vulnerability for
juvenile delinquency, substance use or abuse, sexual promiscuity, adult
criminal behavior, incarceration, and antisocial personality disorder

Other co-occurring risk factors for youth violence:

Use of anabolic steroids

Gang Tattoos
Belief in ones premature death
Preteen alcohol use
Placement in a juvenile detention center

FISTS Mnemonic to assess an adolescents risk of violence

F: Fighting (How many fights were you in last year? What was the last?
I: Injuries (Have you ever been injured? Have you ever injured someone else?)
S: Sex (Has your partner hit you? Have you hit your partner? Have you ever been
forced to have sex?)
T: Threats (Has someone with a weapon threatened you? What happened? Has
anything changed to make you feel safer?)
S: Self- defense (What do you do if someone tries to pick a fight? Have you carried
a weapon in self-defense?)

Multiple Treatment Modalities

Cognitive-behavioral Therapy involving the individual and family to specific

family interventions (parent management training, multisystemic treatment)
Pharmacotherapy
Treatment of existing co-morbid conditions such as attentiondeficit/hyperactivity disorder depression and substance abuse

Prevention

Individual approaches concentrate on changing attitudes and behaviors to

avoid aggressive and violent behavior as well as teaching coping strategies
and nonviolent conflict resolution for all children as well as youths who have
already displayed some violent tendencies.

Relationship approaches focus more on victims, families, ad peer

relationships, especially those with the potential to trigger aggressive or
violent responses
-improving skills in coping or problem solving in recent perceived crises,
interpersonal conflicts and close relationships
-Family-based programs provide training for parents in areas of effective
communication, child development, and solving problems in nonviolent
methods

SUBSTANCE ABUSE

Individuals who initiate drug use at an early age are at a greater risk for
becoming addicted that those who try drugs in early adulthood
Drug use in younger, less experienced adolescents can act as a substitute for
developing age-appropriate coping strategies and enhance vulnerability to
poor decision-making

SCREENING

Privacy and confidentiality

Interview the parents
See early warning signs: go unnoticed or disregarded b the teen
-change in mood, appetite or sleep pattern, decreased interest in school or
school performance, loss of weight

-secretive behavior about social plans; or valuables such as money or jewelry

missing from the home
CRAFFT MNEMONIC TOOL

Have you ever ridden in a Car driven by someone (including yourself) who
was high or had been using alcohol or drugs?

Do you ever use alcohol or drugs to Relax, feel better about yourself or fit
in?
Do you ever use alcohol or drugs while you are by yourself ( Alone)?
Do you ever Forget things you did while using alcohol or drugs?
Do your Family or Friends ever tell you that you should cut down on your
drinking or drug use?
Have you ever gotten into Trouble while you were using alcohol or drugs?

Adopted from Anglin TM: Evaluation by interview and questionnaire In Schydlower

M. editor Substance abuse: a guide for health professsionalss ed 2, Elk Grove
Village, IL 2002 , American Academy of Pediatrics

Table 108-9 DSM IV-TR Diagnostic Criteria for Substance Abuse and Substance
Dependence
SUBSTANCE ABUSE. A maladaptive pattern

Recurrent substance use resulting in a failure to full major role obligations at

work, school or home (e.g, substance-related absences or suspensions from
school, being fired from a job
Recurrent substance use in circumstances that are physically hazardous (e.g.
driving an automobile, skiing, swimming, rock climbing, riding a bicycle,
scooter or skateboard or operating machinery while impaired by a
substances effects)
Recurrent substance-related legal problems (e.g. arrest for driving under the
influence, disorderly conduct, or vandalism while impaired a substances
effects)
Continued substance use despite persistent or recurrent social or
interpersonal problems caused or exacerbated by the effects of the
substance (e.g. physical fights or unpleasant argument, damaging furniture
or punching holes in the wall, sexual behavior that is later regretted.

From American Psychiatric Association: Diagnostic and statistical manual of

mental disorders fourth edition

Table 108-10 DOMAINS OF RISK AND PROTECTIVE FACTORS FOR SUBSTANCE

ABUSE PREVENTION
RISK FACTORS
Early aggressive behavior
Lack of parental
supervision
Substance Abuse
Drug availability

DOMAIN
Individual
Family

PROTECTIVE FACTORS
Self-control
Parental Monitoring

Peer
School

Academic competence
Anti-drug use policies

Poverty

Community

Strong neighborhood
attachment

Alcohol
Tobacco
Marijuana
Inhalants
Hallucinogens
Cocaine
Amphetamine
Opiates
Anabolic Steroids

Other Issues

Health: Breast and Menstrual Concerns/Chronic Fatigue Syndrome

Adolescent/ Teenage Pregnancy
Adolescent Rap
STI

HEADSS: A Psychosocial Interview for Adolescents

Home
Education/employment, peer group
Activities
Drugs

Sexuality
Suicide/Depression
Safety

Background

Major cause of M and M in adolescents:

-Unintentional injuries, including motor vehicle accidents
-Drug or alcohol use
-Unwanted pregnancy
-Sexually transmitted disease (STD)
-Eating Disorders
-Mood Disorders
-Not easily amenable to the intervention of physiologically-oriented health
care provider
-May not even show up on the standard interview that health care providers
are taught to perform

Develpmentally-appropriate psychosocial history

Dr. Cohen (LA) refined a system for organizing the psychosocial history that
was developed in 1972 by Dr. Harvey Berman (Seattle)
Facilitate communication and to create a sympathetic, confidential, respectful
environment where youth may be able to attain adequate health care

Preparing for the Interview

The note a health care provider strikes at the outset of the assessment interview
may affect the entire outcome. Parents, family members, or other adults should not
be present during the HEADSS assessment unless the adolescent specifically gives
permission, or asks for it.
Confidentiality

It is not reasonable to expect an adolescent to discuss sensitive and personal

information unless confidentiality can be assured. All adolescents and families,
including caregivers (most commonly a parent or both parents), should be told
about confidentiality at the beginning of the interview. Each health care provider
must determine the nature of his/her own confidentiality statement.
Belief Systems
As a health care provider, your own set of beliefs, based on your knowledge,
experience, and level of tolerance in dealing with particular situations, will set the
standard in providing developmentally-appropriate health care to youth and their
families. Health care providers interfacing with youth may be confronted with
difficult situations where this particular belief system may be tested, if not
challenged. Particular examples relate to health risk-taking behaviors; 80% of
adolescents in North America are deemed to be physically and psychologically
healthy, and the rate of chronic illness is quoted in the literature as up to 10%.
When a health care provider is confronted with a particularly challenging situation
that causes him/her to be in a dilemma, i.e. a youth is seeking options counselling
due to unwanted pregnancy, it is suggested that the health care provider consult
with a colleague or refer the youth for developmentally-appropriate care.
Assumptions
Based on particular individual belief systems, these are some assumptions that
many of us may have about youth:
youth live in a home with two parents
all youth go to school and get along with peers and teachers
all youth are heterosexual
It is of significant importance not to assume, but rather to ask non-judgemental
questions in a respectful, caring fashion.
Starting The Interview
1. Introduction: Set the stage by introducing yourself to the youth and parents.
Suggestion: If the parents are present before the interview, always introduce
yourself to the adolescent first. In fact, ask the adolescent to introduce you to the
other people in the room. This gives the adolescent a clear message that you are
interested in him/her.
2. Understanding of Confidentiality: Ask either the parents or the youth to explain
their understanding of confidentiality or confidential health care.
3. Confidentiality Statement: After the youth and family have given you their views
(from step 2), acknowledge their responses and add your views accordingly
(confidentiality statement), based on the particular situation.

Home

Examples of Questions
Who lives at home with you? Where do you live? How long? Do you have your
own room?
How many brothers and sisters do you have and what are their ages? Are your
brothers and sisters healthy?
Are there any new people living in your home?
Are your parents healthy? What do your parents do for a living?
What are the rules like at home? How do you get along with your parents, your
siblings? What kinds of things do you and your family argue about the most? What
happens in the house when there is a disagreement?
Is there anything you would like to change about your family?
Asking about parental abuse or substance use (also see Drugs section) may be
difficult. Using a scenario may facilitate this line of questioning, i.e. Working with
youth I have learned from some kids that their relationship with their parents is a
difficult one; by this I mean they argue and fight. Some youth have told me that
they wish their parents did not drink so much or use drugs. Is this a situation in your
household? Has anything like it happened to you?

Education & Employment

Examples of Questions
Which school do you go to? What grade are you in? Any recent changes in
schools?
What do you like best and least about school? Favourite subjects? Worst
subjects?
What were your most recent grades? Are these the same or different from the
past? Have you ever failed or repeated any years?
How many hours of homework do you do daily?
How much school did you miss last/this year? Do you skip classes? Have you
ever been suspended?
What do you want to do when you finish school? Any future plans/goals?
Do you work know? How much? Have you worked in the past?
How do you get along with teachers, employers?

Drugs
Opening Lines: (Less/More) Developmentally-Appropriate

Examples of Questions
When you go out with your friends or to party, do most of the people that you
hang out with drink or smoke? Do you? How much and how often?
Do any of your family members drink, smoke or use other drugs? If so, how do you
feel about this - is it a problem for you?
Have you or your friends ever tried any other drugs? Specifically, what? Have
you ever used a needle?
Do you regularly use other drugs? How much and how often?
Do you or your friends drive when you have been drinking?
Have you ever been in a car accident or in trouble with the law, and were any of
these related to drinking or drugs? How do you pay for your cigarettes, alcohol or
drugs?

Wrapping Up The Interview

Suggestions For Ending Interviews With Teenagers:
Ask them to sum up their life in one word or to give the overall weather report
for their life (sunny with a few clouds, very sunny with highs all the time, cloudy
with rain likely, etc.).
Ask them to tell what they see when they look in the mirror each day.
Specifically, look for teenagers who tell you that they are bored. Boredom in
adolescents may indicate that the youth is depressed.

 Ask them to tell you whom they can trust and confide in if there are problems in
their lives, and why they trust that person. This is especially important if you have
not already identified a trusted adult in the family. We always tell the adolescent
that he/she now has another adult -the health care provider who can be trusted
to help with problems and to answer questions. Let them know you are interested
in them as a whole person and that you are someone who wants to help them lead
a fuller, healthier life.
Give them an opportunity to express any concerns you have not covered, and ask
for feedback about the interview. If they later remember anything they have
forgotten to tell you, remind them that they are welcome to call at any time or to
come back in to talk about it.
For teenagers who demonstrate significant risk factors, relate your concerns. Ask
if they are willing to change their lives or are interested in learning more about ways
to deal with their problems. This leads to a discussion of potential follow-up and
therapeutic interventions. Many adolescents do not recognize dangerous life-style
patterns because they see their activities not as problems but as solutions. Your
challenge lies in helping the adolescent to see health risk-taking behaviours as
problems and helping to develop better strategies for dealing with them.
If the adolescents life is going well, say so. In most cases, you can identify
strengths and potential or real weaknesses, and discuss both in order to offer a
balanced view.
Ask if there is any information you can provide on any of the topics you have
discussed, especially health promotion in the areas of sexuality and substance use.
Try to provide whatever educational materials young people are interested in.