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Frontiers of Public Health: Adolescent Health

Chris Hartlove

The Kids are Alright


They are their own tribe—42 million in the U.S. alone—with their own social, behavioral and linguistic codes.

Still developing in brain and body, they are physically and mentally different from us and, yet, they are us—or at least younger, risk-taking, energetic, less-experienced versions of us. Adolescents, defined as 10- to 19-year-olds by the WHO, undergo a tumult of physical, sexual and emotional changes as they negotiate their way from childhood to independence. How they make that journey while preserving their health is the main focus of Center for Adolescent Health director Freya Sonenstein, PhD, and the subject of a new book, The Teen Years Explained, published by the Center. During a March talk with Johns Hopkins Public Health editor Brian W. Simpson, the Population, Family and Reproductive Health professor discussed the latest research, the challenges of preventing teen pregnancy and tips for parents whose children are entering a “messy” but wondrous stage of life..

What do we know today about adolescent health that we didn’t know 20 years ago?
One of the big discoveries has been about brain development. During adolescence there’s a massive pruning of the synapses [neural connections] of the brain, and this process doesn’t really stop until around age 24. And the last part of the brain to develop is the prefrontal cortex, which helps us in cognitive thought and making good decisions in our behavior. So that partially explains why teenagers are sort of known worldwide for their risk-taking behavior.

How can one best guide teens?
In terms of preventing teen pregnancy, the simplest solutions try to change when they begin to have sex and to get them to use contraception when they do have sex. Clearly, if you think about kids being embedded in their social environment, you need to build a community that sends very clear messages to kids about the importance of waiting to have children until they’re ready. And teaching them the ways to do that. And motivating them to do that by providing hope for what their adult lives will be like if they wait.

Is that a confusing message for adolescents? Wait to have sex, but if you do have sex, then use contraception.
Over the last 20 years, we’ve done a lot of program evaluation and we actually have a whole series of programs that have been demonstrated to effectively reduce kids’ sexual behavior and increase their contraceptive behavior. And most of those programs are built on the dual messages. So kids apparently are able to deal with that complicated a message.

How successful are those programs?
Well, they’re modestly successful. They increase the age at first intercourse modestly, by on average a few months. In terms of contraceptive use, it’s the same kind of thing. So the effects are small, but they do mean that there are fewer pregnancies and when condoms are used, fewer sexually transmitted infections.

The effects are small. Do you think that we’ll ever make dramatic advances?
I think we can get a lot closer to a more ideal situation in terms of preparing kids. In many communities, youth are not getting full and complete information about how to prevent pregnancies. So in terms of basic knowledge we can do better. And in many communities, clinical services and emergency contraception are not readily available. If all that were to improve, we’d see some reduction in the rates. It wouldn’t make it go away, but … .

What about other high-risk behaviors like drinking, drug use and reckless driving?
There’s been a fair amount of research about problem behavior syndrome; basically kids who engage in a single high-risk behavior like drinking or drug use are also very likely to be engaging in other high-risk behaviors. There are interventions that look more universally at high-risk behaviors and work with kids to reduce substance abuse, violence and delinquency, for example, as well as sexual risk taking. The thing about sexual behavior is it’s something that’s expected in adults whereas the others are behaviors that are not encouraged [in adults]. When you try to keep people from smoking, you try to keep them from smoking forever. Whereas with teenagers and sex, you’re just trying to get them to wait and to be safe when they do have sex.

What are the key differences faced by young people in developing countries?
The recognition of adolescence as a period of life that we should think about differently is relatively new in our own society. Certainly, in many developing countries, there is less luxury for teens to have a long transition period. Early marriage is common in many countries. However, some cultures do a much better job symbolically than we do. Some  have rites of passage that set up expectations about the transition to adulthood more clearly.

Are adolescents more receptive to certain public health messages?
Preaching what one should do (laughs) is apparently not the way to get a teenager’s attention. The way messages are delivered is as important as their content.

What do you mean?
Well, in the book, we are trying to encourage adults to listen to the kids and to provide space to the teens to think through for themselves the consequences of behavior. Instead of telling a kid not to smoke, it might be more useful to encourage the kid to think about what they were doing and weigh the pros and cons for themselves. [That way] they go through this process and potentially [learn] to make good decisions about their health. In good situations where kids come to you for advice, then (laughs) by all means provide advice. But usually they’re not seeking it!

Adults stereotype teenagers as surly, self-involved risk-takers who have to be endured. 
Well, all of those things are kind of true and they are driven by the developmental processes that they are going through, but the problem is the adults’ perspective—that they should just endure it, instead of understanding it, engaging it, and providing support so that kids can exercise their independence and learn how to do that well. I think the major message [for adults] is not to be so frightened. There are things you can do to understand what’s going on in terms of their development. A lot can be accomplished if you approach it with a positive point of view.

This is a nice segue into the book that the Center is publishing. Why did you publish it?
We wanted to get some very basic, rigorously acquired information about adolescent development to parents and to people who work with young people so that they understand better the very complex and massive changes going on when kids when enter these years. As [a colleague] pointed out, over the years, parents have turned to Dr. Spock and then to other guides to know about stages of child development. But we’ve never had anything that laid it out for parents in terms of adolescents.

What is the book’s most important message?
It’s that there’s a lot of change going on in adolescence—cognitively, emotionally, and in terms of sexual, moral and spiritual development. And they don’t all occur in sync. It’s messy but it’s very normal.

American Youth: Good News/Bad News

  • 94 percent of adolescents feel safe coming and going to school.
  • 89 percent of high school students regularly wear a seatbelt.
  • 90 percent of high school students have been taught about HIV and AIDS prevention.
  • 750,000 15–19-year-olds become pregnant each year.
  • 230,000 alcohol-related ER visits are made by 14–20-year-olds annually.
  • 13,000 10–19-year-olds die each year from injuries.
Horizontal Rule

The Teen Years ExplainedAdolescents: By the Book

The Teen Years Explained: A Guide to Healthy Adolescent Development by Clea McNeely, DrPH, and Jayne Blanchard (Johns Hopkins University Press, 2010); $24.95
Download the book for free.

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Average: 4/5 stars (12 votes)
  • S Fawbush

    Antananarivo, Madagascar 06/11/2010 09:07:25 AM

    Thank you to the authors for their work in preparing this book. While not an expert myself I would like to contribute the following thoughts.

    I took a course called "Raising up Animators for Junior Youth Groups." An important part of this course goes into what is an adolescent and their potential. As adults and in society in general, we underestimate the potential of youth to make big decisions about their life and what they want to do.

    We can do much to help youth understand their potential and to encourage them to find their purpose in life and to set bold goals early on (starting at 11 youth have the capacity to think about their life and to make decisions is the assertion in the course).

    The course suggests that a service ethic is the most appropriate goal to which teens can be encouraged to aspire as this resonates, appeals to and develops the teens innate helpful nature. The service ethic is also a context which can guide their future life, studies and eventual work choices. i.e. youth can make the choice that their purpose in life is to help make the world a better place.

    However such ideals and action don't come naturally in today's society as it is opposed to the increasingly ubiquitous worldview that as human beings we are "utility maximizing" consumers and seek our happiness from material sources. A service ethic has to be nurtured, and materialistic tendencies have to be put into perspective for young minds.

    The point is that the teenage years don't have to be that messy, with the right atmosphere and training they can be beautiful instead.

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