1. Multiple Risk Behaviors
among Adolescents and
Implications for Prevention
Peggy McManus

2. 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

3. 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

4. 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

5. 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)

6. 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

7. 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

8. 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

9. 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

10. 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

11. 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

12. Prevalence of Multiple Risk Behaviors
in the High School Population

13. Prevalence of Multiple Risk Behaviors
in the High School Population

14. Prevalence of Multiple Risk Behaviors
in the High School Population

15. Prevalence of Multiple Risk Behaviors
in the High School Population

16. 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

17. 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

18. 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

19. 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

20. • 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

21. 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

22. More Summary
– Recognize risk differentials by gender, race, and
ethnicity
– Recognize common co-occurring behaviors
– Recognize individual behaviors that are predictive of
other risks

23. 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

24. 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

25. 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

26. 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

27. 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

28. 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

29. 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”

30. 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.