Multiple Risk Behaviors among Adolescents and

Implications for PreventionPeggy McManus

Past Studies

• Past studies:– Typically focus on a specific behavior and its

co-occurring risks– Often focus on interrelatedness of substance

abuse behaviors and also link with sexual risk, aggressive behaviors, and depression symptoms

Past Studies Older national studies found about 1/3 of high

school students engaged in 2+ risk behaviors Other national studies examine clustering of risk

by gender and severity Clear evidence of multiple risk behavior

syndromes among adolescents

Our Multiple Risk Behavior Study• Study based on 2007 Youth Risk Behavior Survey • Sample: 14,041 students from public and private high

schools in grades 9-12• Self-administered questions – 87 questions covering a

variety of risks• Performed an original analysis of 12 significant health

risks– Prevalence of individual risk factors by gender, race/ethnicity,

and grade level– Prevalence of multiple risk behaviors and patterns of co-

occurring behaviors

Methodology

• Criteria for selecting 12 risks:– Reported action, behavior, or feeling (excluded

measurable medical risks –obesity, and victimization – sexual assault)

– Potential for significant health problem– Combined measures reflecting common problem

(problem alcohol behavior, suicidal thoughts or plans, and abnormal weight loss problem)

12 Significant Risks

1. Intercourse before age 13

2. Last intercourse unprotected

3. Persistent sadness

4. Suicidal thoughts or plans (= seriously considering suicide and making a plan to attempt suicide)

5. Abnormal weight loss behavior (= going without eating for 24 hours or more; taking pills, powder or liquids to lose weight; and vomiting or taking laxatives)

6. No exercise in past week

12 Significant Risks

7. Current frequent smoker (smoked in 20 of last 30 days)

8. Problem alcohol behavior (= binge drinking and driving

while drinking)

9. Used marijuana in the past month

10. Ever used other drug(s)

11. Two or more fights in the past year

12. Carried a weapon

Prevalence of Individual Risks

• Table 1 handout• Certain risk behaviors are particularly prevalent among

high school students:– Almost 30% report feeling persistently sad, and same

proportion report problem alcohol behavior– About 20%

• Involved in 2 or more fights• Used marijuana in past month• Ever used drugs other than marijuana

Gender Differences in Risk

• Males higher for 7 of 12 risks: problem alcohol behavior, weapon carrying, fighting, marijuana use, suicidal thoughts/plans, frequent smoking, & intercourse before 13

• Females higher for 4 risks: persistent sadness, abnormal weight loss behavior, no exercise, & unprotected sex

Racial & Ethnic Risk Differences • Hispanic students higher than Whites for 7 risks,

especially problem alcohol behavior and persistent sadness

• Black students higher than Whites for 6 risks, especially persistent sadness and fighting

• Whites higher than Hispanics for 1 risk – frequent smoking

• Whites higher than Blacks for 4 risks, especially problem alcohol behavior

Grade Level Risk Differences

• 6 of 12 risk behaviors increase from 9th to 12th grade, with most change in unprotected sex (11% - 27%) and frequent smoking (5% - 12%).

• 4 of 12 risk behaviors higher in 9th grade: fighting, weapon carrying, intercourse before age 13, and suicidal thoughts/plans

• Grade level differences likely influenced by drop-out rates among older students

Prevalence of Multiple Risk Behaviors in the High School Population

Prevalence of Multiple Risk Behaviors in the High School Population

Prevalence of Multiple Risk Behaviors in the High School Population

Prevalence of Multiple Risk Behaviors in the High School Population

Multiple Risk Differences by Gender, Race/Ethnicity, & Grade

• Males were significantly more likely to engage in 2, 4, and also 5 or more risks.

• Blacks & Hispanics both more likely than Whites to engage in 2 or more risks

• Blacks significantly less likely than Whites and Hispanics to be engaged in 5 or more risks

• Consistent pattern of significant increases from freshman to senior year

Prevalence of Multiple Risk Among Students Engaging in Particular Risk• See Table 1 handout• Students engaging in 2 low-prevalence risk behaviors:

intercourse before age 13 & frequent smoking are highly likely to engage in 7 other health risk behaviors

• Intercourse before 13 (8%): 40% or more fighting, weapons, sadness, unprotected sex, alcohol, marijuana, other drugs

• Frequent smoking (8%): 40% or more unprotected sex, sadness, fighting, weapons; 60% or more with alcohol, marijuana, and other drugs

More Multiple Risk Patterns• Students using at least one type of substance highly

likely to use others– Problem alcohol behavior (29%) – about 40% other

drugs, about 50% marijuana– Using another drug (20%) – more than 55% problem

alcohol behavior, more than 45% marijuana– Using marijuana (20%) – 70% alcohol, almost 50%

other drugs– Also high proportion reporting sadness & fighting

More Multiple Risk Patterns

• Abnormal weight loss (16%): 55% sadness, about 40% suicidal plans/thoughts, about 40% alcohol, about 40% other drugs

• Suicidal thoughts or plans (18%): more than 2/3 sadness, more than 40% alcohol, more than 40% other drugs

• Fighting (20%): 40% sadness, more than 40% weapon carrying, and 45% alcohol

• Only risk behavior not carrying a high likelihood (> 40%) of other risks was lack of exercise (17%), although sadness was common (36%).

• More than half of teens who reported any of 4 risk factors – early intercourse, frequent smoking, marijuana use, and use of other drugs – found to report 5 or more health risk behaviors

More Multiple Risk Patterns

Summary• Our results confirm that risk behaviors do not occur in

isolation and suggest that clinical and community prevention interventions:– Identify and reduce multiple, not single health risk

behaviors– Begin interventions early in adolescence, before 9th

grade– Recognize changes in risk as teens get older

More Summary

– Recognize risk differentials by gender, race, and ethnicity

– Recognize common co-occurring behaviors– Recognize individual behaviors that are predictive of

other risks

Implications for Clinical Preventive Care: Adolescents

• Need to strengthen the content and quality of preventive care for adolescents– Targeted outreach – Scheduling of teens for longer preventive care appointments– More engagement of adolescents in decisionmaking and

feedback– Careful explanation and assurance of confidentiality and consent– Use of strength-based vs. problem-based approaches – More effective assessment of health risks and screening for

emerging chronic conditions

More Implications for Clinical Preventive Care: Adolescents

• Greater use of brief behavioral health counseling• Organized processes for systematic identification, follow-up, and

care management of teens with moderate to high risk• Expanded health education opportunities for teens during and after

visit (online resources, websites, group sessions) • Organized linkages with school and community-based prevention

and youth development supports • Use of team-based care with nurse educators, health educators, or

behavioral/mental health counselors• Incorporating risk assessments and preventive counseling into

every primary care encounter with a teen

More Implications for Clinical Preventive Care: Parents

• Many parents not familiar with practice of teens having private time with doctors (40% of teens = no private time)

• Parents desire more time with health care providers to receive guidance on discussing sensitive issues, spotting warning signs, and counseling related to specific problems

• Literature shows importance of positive parenting during adolescence and need to promote:– Parental monitoring, frequent communication, greater

connection, and meals together

Implications for Community Prevention

• Need to move away from single issues and categorical program approaches

• Need to establish and strengthen linkages between clinical, school, and community prevention/youth development supports

• Providing youth development support/opportunities at or near clinical sites is key

More Implications for Community Prevention

• Literature on community-based prevention to address multiple risks:– Start early (often in middle school)– Use a combination of approaches– Emphasize strengths and need to value youth– Involve teens (eg, peer health educators, youth advisory

councils)– Incorporate parenting support– Involve a mix of community agencies

More Implications for Community Prevention

• Increase availability of adult support for teens• Build sustained relationships with caring adults• Increase adult supervision of adolescent activities with

appropriate discipline• Strengthen school connections for teens, esp. those with

learning difficulties• Develop teen skills – Self esteem, problem solving,

resisting peer pressure, relationship building, setting life goals

Effective Community-Based Prevention Programs

• SAMHSA’s National Registry of Evidence-based Programs and Practices

• CDC’s Registry of Programs Effective in Reducing Youth Risk Behaviors

• Center for the Study of Prevention of Violence – “Blueprints Promising Programs

• Child Trends “What Works”

Conclusion• Need for improved health promotion and disease

prevention strategies at clinical and community levels to address the complex and dynamic risk factors of adolescents

• Our organization, The National Alliance to Advance Adolescent Health, is working to form partnerships with federal and state agencies, national organizations, and adolescent health centers to promote holistic clinical and community innovations for improved adolescent health outcomes.