Public Health Challenges in Adolescence. Mortality

Mortality. The health challenges in adolescence have not always been recognized by public health professionals, partly because adolescence is a period of relatively low mortality compared with other age groups. However, substantial numbers die from unintentional injuries, homicide, sui­cide, and other causes. In many countries (especially high-income countries), unintentional injuries (the most important cause of which is traffic accidents) are the leading cause of death in adolescents, with rates of close to 50 per 100 000 in some places. In low- and middle- income countries, the current rates tend to be lower than in developed countries. However, with the increase in the number of motor vehicles, rates are rising precipitously in recent years (Blum and Nelson-Mmari, 2004).

Homicide is the second major contributor to mortality among ado­lescents. However, rates of death from homicide are underestimated in many developing countries, as large numbers of adolescents are killed in conflict situations in which accurate mortality data are not available. Suicide is the third leading cause of adolescent deaths worldwide, although there is wide international variation in the ado­lescent suicide rate.

Whereas the suicide rate has risen in most countries over the past few decades, especially for males, there has been a decline in some countries such as Australia and the United States in recent years (Commission on Adolescent Suicide Prevention, 2005). This decline has been attributed to factors such as reduced access to firearms, increased access to antidepressant med­ication, and improved economic circumstances.

Risk Behavior. Mortality data do not provide an accurate impression of the health challenges of adolescence because they do not reflect behavior that places one at risk for adverse con­sequences later in life.

Unsafe sexual behavior can cause unwanted pregnancy, abortions, and sexually transmitted infections such as HIV infection. The proportion of adolescents who are sexually active has been increasing in recent years, and less than half of those who are sexually active use condoms (World Bank, 2006). Unsafe sexual behavior is more likely to occur among economically deprived adolescents, who are not well placed to negotiate for safer sex practices and are more likely to experience transactional sex or sexual coercion.

Sexual coercion in turn has a number of adverse consequences such as behavioral and psychologi­cal problems, relationship problems, suicidal ideation, alcohol and other substance abuse, sexual dysfunction, and unsafe sexual behavior.

Tobacco use is a preventable cause of mortality that is particularly important for adolescents in that the majority of people who smoke cigarettes commenced doing so before the age of 18 years. Rates vary enormously between countries, from 3% of males aged 13 to 15 years in Sri Lanka to 46% in Lebanon (World Bank, 2006).

Rates are declining in high-income countries, but they are increasing in low- and middle-income countries, where ages of commencing smoking are dropping. While boys generally report higher rates of tobacco use, the rates among girls are starting to increase in low- and middle- income countries. Alcohol is the most widely consumed drug in the world, but of course only a small proportion of alcohol users experience any harm from the habit. Among young people aged 15 to 19 years, about 60% report ever having consumed alcohol, but only 10% to 30% (depend­ing on the country) engage in binge drinking (World Bank, 2006).

There is some evidence that young people in low- and middle-income countries are starting to drink at earlier ages. This is a source of concern, because early onset of alcohol use is associated with a greater likelihood of the development of alcohol dependence and alcohol- related injury (World Bank, 2006). Finally, there are a few young people who experiment with illegal drugs, and an even smaller number who go on to develop long-term problems with such substances.

Mental Health. It has been estimated that about 1 in 5 adolescents suffers from one or more psychiatric disorders (Patel et al., 2007). This has enormous public health significance for the following reasons: (1) They are accompanied by a signifi­cant amount of burden and impairment; (2) there are long-term economic consequences of mental disorder in terms of the inability to function occupationally, health­care costs, and criminal involvement that can occur with a subset of people with mental health problems; (3) psychi­atric disorders are frequently associated with some of the risk behaviors that have been mentioned earlier, such as unsafe sexual behavior and substance use; (4) stigma can accompany both adolescents suffering from a mental health problems and their families; and (5) there is a high degree of persistence of psychiatric disorders from adolescence into adulthood.

This is best illustrated by the results of the National Comorbidity Replication Study in the United States (Kessler etal, 2005). It was reported that 75% of all adults with a psychiatric disorder had an age of onset of 24 years or less; 50% had an age of onset of 14 years or less; and 25% had an age of onset of 7 years or less. For anxiety disorders, the corresponding ages were 21, 11, and 6 years or less.

Health Challenges of Adolescence in Context. It is clear from the preceding discussion that adolescence is associated with substantial public health challenges. However, this conclusion should be tempered by two important caveats.

First, adolescence is not necessarily a period of tur­moil, suffering, and conflict. Indeed, the majority of adolescents do not engage in significant risk behavior, nor do they suffer from significant mental health problems (Rutter et al, 1976). However, it is important to identify those that do engage in high rates of risk behavior or suffer from mental health problems so that they can receive the appropriate intervention.

If one has the mis­taken belief that adolescence is necessarily a period of turbulence and instability, there is the potential danger that adolescents who would benefit from pharmacological and/or psychosocial interventions are denied such inter­vention on the grounds that their distress is attributable simply to their developmental stage. In short, one should not attribute an adolescent’s risk behavior or mental health problems (such as depression) to the fact that they are adolescents. Adolescence is a developmental stage and not a diagnosis.

Second, it is not necessarily the case that adolescents have higher mortality rates, engage in more risk behavior, or suffer from a greater degree of psychopathology than adults. Indeed, for many challenges the prevalence of problems is greater or at least similar in older age groups (Graham, 2004). However, the public health challenges of adolescence have increased salience because many of the problems mentioned have their onset in adolescence.

The rates of suicide, for example, are not higher in adolescence than in subsequent years, but there is rapid increase in the incidence of suicide through the adolescent years. Many risk behaviors, for example, unsafe sexual behavior and substance use, have their onset in adolescence, and preventing or postponing their onset in adolescence clearly has long-term benefits. For example, if a person does not commence smoking in adolescence, they are unlikely to commence at a later stage.

Similar considera­tions apply to psychiatric disorders. Although we do not yet have evidence that the early treatment of disorders that commence in adolescence will alter the course of the disorder, it is reasonable to suppose that this might be the case. It is also reasonable to suppose that the early identification and treatment of psychiatric disorders will prevent the development of associated psychopathology.