Young, Restless & At Risk

Biological, social and behavioral factors converge in the health problems facing today's youth. Knowing more about them will help adolescent medicine specialists design interventions that work.

Humans experience more rapid change physically and psychologically during adolescence than at any other point in life. Recognizing this evolution of the body, mind and spirit is critical for physicians and other health care providers in order to care for this unique population. Adolescent medicine specialists in the Department of Pediatrics at Indiana University School of Medicine are working to improve the care given to adolescents by understanding more about their attitudes and behavior patterns, especially those who choose risky behaviors.

Research sets IUSM's Division of Adolescent Medicine apart from other academic centers. The division is considered a leader in studying the sexual behavior patterns and incidence of sexually transmitted disease (STD) among adolescents. The division is unique because of its research of both behavioral and biologic factors in predicting STD. Last fall, the National Institutes of Health awarded a five-year, $7 million grant to IUSM to establish the Mid-America Adolescent Sexually Transmitted Disease Cooperative Research Center, the only one of its kind.

Sexual activity is undoubtedly one of the riskiest behaviors for adolescents because of the seriousness of the potential consequences: STD or pregnancy. Donald Orr, MD, professor of pediatrics and director of Adolescent Medicine and the Mid-America Research Center, and Dennis Fortenberry, MD, associate professor of pediatrics, are leading researchers of sexual disease transmission in adolescents. They and colleagues study the behavior patterns of sexually active and inactive youth, what sustains the behaviors and what factors make them risky.

"Adolescents are at highest risk of any age group for STD," says Dr. Orr. "That is a result of a combination of factors including biological, social and behavioral issues, and the fact that teens are becoming sexually active at an earlier age." The national average age for first sexual encounter is sixteen. Among adolescents with an STD in Marion County, Indiana, which includes Indianapolis, the average age for first sexual encounter is thirteen years for males and fourteen years for females.

In 1997 the Institute of Medicine identified STDs as a hidden epidemic. Of fourteen million reported STD cases in the United States in 1995, three million were adolescents. Health care costs that year for STD treatment totaled approximately $8 billion. In the U.S., sixty-five percent of all reported STD cases occur in individuals between the ages of fifteen and twenty-four. According to Dr. Orr, some geographic areas have a much higher incidence of STD, which might explain why nearly forty percent of adolescents diagnosed with an STD become re-infected within six to twelve months after receiving initial treatment. "It takes a certain concentration of infection to maintain an epidemic," he explains.

"The more we know about adolescent sexual relationships the better we will be able to design more effective interventions," says Dr. Fortenberry. Dr. Orr adds, "We know that blanket interventions don't work. Our goal is to tailor STD intervention programs to fit different subpopulations of kids."

Collecting accurate data about adolescent sexual behavior is the challenge. Drs. Orr and Fortenberry use a variety of data collection tools, but the most effective is a sex and behavior diary. Dr. Fortenberry created the pocket-size calendar to help research subjects record sexual activity accurately and privately. Adolescents are instructed to use abbreviations and symbols to record the name of their partner(s), number of encounters, use of condoms, and use of alcohol or drugs.

Condom use among adolescents is about the same as young adults and increasing. In 1984, twenty percent of adolescents used condoms; in 1995 a reported fifty-five percent did so. Drs. Fortenberry and Orr's research has shown condom use to be selective, meaning adolescents who use condoms don't use them properly, or all the time, or with all partners. Condom use also appears to depend on the emotional relationship between partners.

Girls report they are less likely to insist their partner use a condom if he is a long-time partner or the father of their child. Yet girls report more frequent use of condoms with new partners. Often it is established partners, however, who appear to infect and re-infect the girls with an STD. Another problem is that in populations where STD prevalence is high, condom use is less likely to make a difference in preventing disease transmission because partners have a greater chance of being infected.

There appears to be little connection between condom use and drug and alcohol use. Those who usually use condoms do so regardless of the involvement of drugs or alcohol prior to or during the sexual encounter. There is evidence, however, that adolescents who use alcohol and drugs are likely to become sexually active at an early age and have a greater STD risk because of multiple partners and choice of risky partners.

"There is great complexity in adolescent sexual relationships," says Dr. Fortenberry. "As with adults, there are many social and emotional factors that influence sexual decisions. Many of our subjects report having serious or long-term relationships before becoming sexually active with their partner. So for adolescents who choose to become sexually active, we have to teach them to become sexually responsible as well."

Responsibility takes on a whole new meaning for adolescents who become parents. Marilyn Graham, MD, clinical assistant professor of obstetrics and gynecology, directs six adolescent parent/child clinics offered by Wishard Hospital, part of the Marion County Health and Hospital Corporation. She and adolescent medicine physicians from the IUSM Department of Pediatrics collaborate with nursing and social work staff from Wishard Hospital to provide prenatal and postnatal care to adolescent girls.

Both parent and child are followed from the time of pregnancy diagnosis through at least the first two years of the child's life. Adolescents are counseled and educated about the realities of parenthood. Care also is provided for the baby's father and any other sex partners if an STD is diagnosed. (Adolescent males receive all other medical care in the adolescent primary care clinic, a collaborative effort between IU and Wishard, or in the adolescent consulting clinic at Riley Hospital for Children.)

"It's so important that we get pregnant girls and their partners into coordinated programs so they receive proper medical care, counseling and education," stresses Dr. Graham. "Often girls are in denial or unaware of their pregnancy until much later in the term, which is why we work closely with social service agencies and schools to identify them. We also want the girls and their partners to learn how to take responsibility for their past and future sexual activity so they can avoid future pregnancies and STD."

Indiana's teen birth rate in 1995 for girls ages fifteen to nineteen was fifty-eight per 1,000. Marion County's rate of eighty-eight per 1,000 is higher than any state's in the country. More than thirty percent of pregnant girls in Marion County who are nineteen years or younger deliver at Wishard Hospital.

The current national consensus is that teen pregnancy rates are coming down, perhaps due to more or better intervention programs promoting abstinence, safe sex or birth control. Even so, rates in certain geographic locations continue to increase, according to Dr. Graham.

Adolescent pregnancy remains a major problem in the U.S. "Poverty, conflicting messages about sexuality, and lack of education and contraceptive services result in one in ten teens becoming pregnant each year," she says.

Pediatricians, family physicians and adolescent medicine specialists share the responsibility of helping adolescents make healthy lifestyle choices. Many behaviors and habits formed during adolescence carry over into adulthood. Helping youth shape positive attitudes and habits related to fitness, nutrition and sexuality is important to prepare them to take responsibility for their health.

Appropriate and consistent intervention is the key, says Margaret Blythe, MD '72, professor of pediatrics. She treats young patients at Riley Hospital and in the adolescent primary care clinics offered with Wishard. She and her colleagues train residents to screen patients for risk behaviors and to give educational messages about drug/alcohol use, depression/suicide, exercise, injuries, nutrition, sexuality, STDs, and breast and testicular self-exams.

"One of the difficulties in identifying health and behavior problems in adolescents is the lack of time with them in the clinic," says Dr. Blythe. "Until recently, national guidelines stated that adolescents should see their doctor only every three years. Now, a once-a-year preventive health care visit is considered standard, which is important because sick visits are usually not the time to counsel patients."

Negotiation skills can be helpful when dealing with adolescents. Dr. Blythe has found that suggestions and contracts work much better than ultimatums. For example, physicians can usually help teens adjust their eating habits, especially if they relate appropriate eating to improved stamina and maximum strength. Similarly, a patient smoking marijuana every day may agree to restrict smoking to the weekends, but not necessarily quit. Dr. Blythe finds that sometimes her patients will take the behavior modification to the next level. The patient who smokes marijuana realizes how much better she feels when she doesn't smoke and decides to quit smoking marijuana altogether.

"Adolescence is a time of 'trying on different hats,' both risky and health promoting," she says. "We just don't want them to leave one of the risky hats on too long."

Blanket interventions don't work.
Tailoring intervention programs to subpopulations might work.
But collecting data is a challenge.

Eating habits in teens reflect social norms: too many fat grams, too many "empty" calories through carbohydrates in soft drinks, and not enough calcium. As a result of poor nutrition and obesity, adolescents are being diagnosed more frequently with type II diabetes, and many have "eating issues" which lead them to restrict foods that are needed to sustain daily activity.

0.48% of girls 15-19 years old are diagnosed with anorexia nervosa each year in the U.S.

About 1-5% of adolescent girls have met criteria for bulimia.

10-50% report participating in occasional self-induced vomiting or binge-eating.

Up to 50-60% of junior and senior high school girls consider themselves overweight.

Many young women have eating issues which don't fit all criteria for a specific disorder.