Risk Factors Resulting in Poor Health Outcomes For Adolescents Poverty Lack of resources Socioeconomic differences Lack of access to health care delivery systems Lack of health insurance coverage Preventive health services and substance abuse treatment limitations Disparities in the coverage of mental health services Confidentiality laws that require parental consent Lack of centralized guidance

The problems of youth often have been viewed in isolation, without the full acknowledgment that adolescent health is largely a function of the health of families, communities, and the larger environment. There is increasing recognition of the need to assess adolescents within the context of the family, and to assess the family within the context of the community. Traditional biomedical models of assessment and intervention have proved inadequate in connecting the social, cultural, and structural components of health outcomes. These concepts, however, are intrinsically linked to the social work perspective in understanding and assessing risk and protective health factors, and effecting positive health outcomes.

• Low neighborhood attachment and community disorganization, poor family management practices, and social and economic deprivation are related to poor health outcomes (Ewalt, Freeman, and Poole, 1998).
• Poverty is the single most important factor correlated with health status, and the number of juveniles in poverty has grown 13 percent, almost double the poverty rate for those 18 and over (20 percent compared with 11 percent) (Office of Juvenile Justice and Delinquency Prevention, 1999).
• Lack of resources seriously impedes an individual's ability to access needed health services. Youths from single-family homes and ethnic minority youths are more likely to be poor. Socioeconomic differences, to a large extent, undergird racial and ethnic health disparities in our youths and society overall.

Consideration of racial, ethnic, and cultural diversity is crucial—the adolescent population is more ethnically diverse than any other segment of the population, and all ethnic minority groups are anticipated to grow. These demographic shifts make requisite the need for culturally competent, appropriate, and specific health care services and providers. Social work philosophy expands this limited notion of diversity beyond race and ethnicity to include gender, socioeconomic, religion or spiritual belief, age, disability, and sexual orientation, recognizing that all are important and influence health outcomes.

• More than 50 percent of youths entering the juvenile justice system have health-related problems and previously undiagnosed learning disabilities. They also experience heightened risk of physical/sexual abuse, suicide attempts, depression, and other health-compromising behaviors (Clayton, Brindis, Hamor, Raiden-Wright, & Fong, 2000).
• Gay and lesbian youths who self-identify during high school are at greater risk of suicide, victimization, and multiple substance use. Fear of negative responses and compromised confidentiality from medical providers regarding their sexual orientation impacts the fact that they are less likely to seek needed medical services (Clayton et al., 2000).
• Teenagers that make up 30 percent of the foster care population are also more likely to suffer from health problems. Nearly half of youths in the foster care system have chronic health conditions, and 60 percent to 80 percent have severe mental health disorders (Clayton et al., 2000). Young people who "age out" of foster care are often unable to acquire needed health and mental health services. A 1998 study indicated that nearly 44 percent of these young people had difficulty securing health services, and only 21 percent were able to continue with mental health services they were receiving prior to transitioning from foster care (Child Welfare League of America, 1998).
• Teenagers who are pregnant and parenting, migrant or newly immigrated, or have limited English speaking skills also may have more difficulty in gaining access to health services.

• Adolescents have low rates of health care usage, an occurrence largely attributable to the lack of health insurance coverage. Approximately 17 percent of adolescents have no health care coverage (Mackay, Fingerhut, & Duran, 2000). This is a key factor for youths, particularly those not able to qualify for Medicaid—a key concern in immigrant communities.
• Historically, there has been a lack of providers for this population — this has been a factor for adolescents covered by Medicaid, as reimbursement rates are often significantly lower than private insurance. The implications for reimbursement under managed care are often low capitation rates.
• Many policies do not cover or have limits on some preventive health services and substance abuse treatment. It is estimated that adolescents 11 to 21 years of age incur direct annual medical costs of approximately $33.5 billion or $859 per adolescent to treat selected preventable health problems (Adolescent Health and Managed Care Project, 2000). Prevention is clearly cost-effective.
• There are also disparities in the coverage of mental health services. Social workers understand that good mental health is a part of overall health and well-being, and health services must integrate both.

• Most states have confidentiality laws that may require parental consent for various treatments. This makes service delivery challenging in certain arenas, including reproductive health and substance abuse, or for youths not connected to stable family systems.
• Current federal proposals may further erode or ultimately eradicate adolescent protections for patient confidentiality. Major welfare and health care reforms are also current national foci and may very well change traditional health and social programs in a negative way.
• Shifts in traditional federal roles in the governance, allocation, and administration of social programs to states may alter, dilute, or fragment services to our youths—the lack of centralized guidance may produce variations and inequities in eligibility requirements, benefits, resources, and service availability.

• Whether in individual practice settings or in collaborative/interdisciplinary efforts, take opportunities to ensure that dialogue and interventions on adolescent health integrate contextual factors.
• Identify structured programs that promote academic and social development and help to foster strong and healthy relationships for teenagers. This could be in the form of mentoring programs, sports activities, and the like.
• Work on macro issues such as poverty, disparities in health care and education, discrimination, and other social justice issues. Given that these are issues often articulated as insurmountable, changes in these areas will have the greatest effect on adolescent health and the health of all people.

Shelia Clark, MSW
Senior Staff Associate
Adolescent Health
sclark@naswdc.org