PEDIATRICS Vol. 122 No. 5 November 2008, pp. e1113-e1118 (doi:10.1542/peds.2008-1479)
ARTICLE |
Health Risk Behaviors in Adolescents With Chronic Conditions
a Research Group on Adolescent Health, Institute of Social and Preventive Medicine, University of Lausanne, Lausanne, Switzerland
b Centre for Adolescent Health, Royal Children's Hospital, Victoria, Australia
c Department of Paediatrics, University of Melbourne, Victoria, Australia
d Murdoch Children's Research Institute, Victoria, Australia
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ABSTRACT |
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 TOP ABSTRACT METHODSRESULTSDISCUSSIONCONCLUSIONSREFERENCES |
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OBJECTIVE. The objective of this study was to compare the frequency of risk behaviors and to measure the extent of co-occurrence of these behaviors in chronically ill and healthy adolescents.
METHODS. Data were drawn from the 2002 Swiss Multicenter Adolescent Survey on Health database, a nationally representative survey of 7548 adolescents in postmandatory school aged 16 to 20 years. There were 760 subjects who reported a chronic illness and/or a disability. The comparison group consisted of 6493 subjects who answered negatively to both questions. We defined 8 risk behaviors: daily smoking, alcohol misuse, current cannabis use, current use of any other illegal drug, early sexual debut, eating disorder, violent acts, and antisocial acts. We analyzed each behavior and the sum of behaviors, controlling for age, gender, academic track, parents' education level, depression, and health status. Results are given as adjusted odds ratios using the comparison group as the reference category.
RESULTS. Youth with a chronic condition were more likely to smoke daily, to be current cannabis users, and to have performed violent or antisocial acts. Youth with a chronic condition were also more likely to report 3 or 
4 risk behaviors.
CONCLUSIONS. These results indicate that having a chronic condition carries additional risks for engaging in health risk behaviors and emphasize the importance of health risk screening and preventive counseling for young people in general and among those suffering from chronic conditions in particular.
Key Words: adolescence • chronic disease • risk-taking behavior
Abbreviations: SES—socioeconomic status • aOR—adjusted odds ratio • CI—confidence interval
The concept of health risk behavior has been used to describe behaviors with potentially negative effects on health, such as substance use, early onset of sexual activity or unsafe sexual practices, risky driving, violent or suicidal behaviors, antisocial behaviors, and disordered eating, among others.1 There is evidence that health risk behaviors tend to cluster together, with similar risk factors for many different risk behaviors.2–7 Often exploratory,8 risk behaviors can be considered a normal aspect of adolescent development.9
Approximately 1 in 10 adolescents suffers from a chronic illness or disability that limits his or her daily activities.10–12 A growing body of research indicates that adolescents with chronic conditions are as likely or even more likely to engage in risky behaviors13 such as using legal or illegal substances,10,11 being sexually active10,11,14 and having unsafe sexual practices,10,11,15 and having disordered eating behaviors16 when compared with their healthy counterparts.
Almost by definition, risk behaviors are of concern for healthy young people. However, additional concerns for young people with chronic conditions reflect the increased potential for adverse health outcomes in this group because of complex interactions of these behaviors with their underlying condition.13 In this regard, it has been argued that health risk behaviors in young people with chronic conditions are concerning even if their prevalence were lower than those of healthy peers.16
Notwithstanding such concerns, there have been remarkably few studies of health risk behaviors in adolescents with chronic conditions. With few exceptions,10,11,14 most studies have been based on small clinical samples17 that were limited to only 1 or, at most, 2 conditions17–22 and that did not include a control group.19,20,23 There has been even less research on the co-occurrence of risk behaviors in this population, with most studies addressing single risk behaviors.15–17
Risk behaviors increase with age,2,3,6 and their prevalence differs according to gender,2,7 although boys seem to have a higher number of concurrent risk behaviors.3 Academic track can also play a role, with adolescents in vocational schools being more likely to engage in risk behaviors than those in more academically focused schools.24,25 Socioeconomic status (SES) has also been linked to risk behaviors, although with differing conclusions. Some studies have indicated that family income has no relation with adolescents' sexual behavior,26 others have reported that low family SES is indirectly associated with substance use problems,27 and yet others have described high-SES teenagers as being more likely to use substances.28 Anxiety and depressive disorders are associated with risk behaviors.23,29–31 Although some studies have indicated that risk behaviors predict an increased likelihood of depression,28 others have reported that depression predicts later risk behaviors.29 It is also worth noting that while chronic conditions are associated with increased emotional distress and depression23,32,33; very few studies have controlled for this confounder,21,23 with contradictory results. Self-reported health status is also associated with emotional well-being34 and may influence participation in risk behaviors by chronically ill adolescents. However, the few studies that have controlled for health status have failed to show any association with smoking or other risk behaviors.23
Given the methodologic limitations of many previous studies, the objective of our study was to compare the frequency of risk behaviors between chronically ill and healthy adolescents in a representative population of Swiss adolescents. We were also interested in measuring the extent of co-occurrence of health risk behaviors in chronically ill adolescents, hypothesizing that if similar or even greater rates of risk behaviors are reported, then young people with chronic conditions will also report at least similar rates of co-occurring behaviors.
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METHODS |
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TOPABSTRACTMETHODSRESULTSDISCUSSIONCONCLUSIONSREFERENCES |
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Data were drawn from the 2002 Swiss Multicenter Adolescent Survey on Health database, a nationally representative survey including 7548 adolescents (3890 girls) in postmandatory schooling aged 16 to 20 years from the 3 language areas of Switzerland. In Switzerland, school attendance is mandatory up to the age of 16 years. Afterward,
30% of adolescents enter high school (these students are usually the most academically gifted and commonly enter university after school), whereas 60% commence vocational school (these are apprentices who usually have 1 or 2 days of classes per week and spend the rest of the week working in a company related to their field of study). Another 10% do not continue (or delay) their education. All public educational institutions in Switzerland were included in a 2-stage sampling process by using a random cluster sample of classes that was drawn without replacement, the classes being considered as primary sampling units. Of 600 selected classes, 586 (97.7%) agreed to participate. Four percent of the questionnaires were discarded because of incomplete data. Approved by the ethics committee of the University of Lausanne School of Medicine, an anonymous self-administered questionnaire was completed in the classrooms. A description of the questionnaire and sampling method has been published elsewhere.35
Two groups were created by using a noncategorical approach as described by Stein and Jessop36 that aims to identify young people living with a wide range of different chronic conditions (rather than a checklist of specific conditions) on the basis that adolescents with different chronic health conditions face common life experiences based on generic rather than disease-specific dimensions of their conditions.36,37 The chronic-condition group included 760 subjects (380 girls) who reported having a chronic illness (defined as a disease lasting >6 months and requiring continuous medical care) and/or disability (defined as a condition that limits body functioning). Those who answered negatively to both questions (n = 6493 [3365 girls]) were considered the comparison group. Responses from the 295 subjects (150 girls) who did not answer these questions were not included in these analyses. In summary, our analyses were based on 7253 subjects (96% of the total sample). We defined 8 risk behaviors: daily smoking (smoking at least 1 cigarette per day); alcohol misuse (at least 1 episode of drunkenness in the previous 30 days); current cannabis use (having used cannabis in the previous 30 days); use of any other illegal drug (such as cocaine, synthetic drugs, inhalants, medication to get high, LSD, GHB, heroin, nonprescribed tranquilizers, or methadone) in the previous 30 days; early sexual debut (first sexual intercourse before 15 years of age); having an eating disorder (eating a large amount without feeling able to stop and/or self-induced vomiting); engaging in violent acts (any of the following in the previous 12 months: attacking an adult, stealing with violence, carrying a weapon, using a weapon at a fight); and engaging in antisocial acts (any of the following in the previous 12 months: vandalism, burglary, setting fire to something). We created an equally weighted summative index of these risk behaviors (categorized as none [reference category], 1, 2, 3, or 4) that was then compared between groups to assess co-occurrence of risk behaviors. Initially, we calculated the prevalence of each behavior and the summative index of behaviors. Subsequently, we used logistic regression to analyze each behavior and the summative index of behaviors while controlling for age, gender, academic track, and parents' education level. SES has been associated with both higher prevalence of chronic conditions38,39 and risk behaviors.26–28 Because family income was not assessed, we used parents' education as a proxy measure of SES. We combined the father's and mother's education level to create the variable parents' education with 3 categories: both parents with low education (defined as mandatory schooling or less); at least 1 parent with low education; and no parent with low education (reference category). Finally, we repeated the analyses while controlling for depression and health status (as a proxy for disease severity because it has been shown to be associated with clinical indicators40,41). The Depressive Tendencies Scale includes 8 items that assess feelings of sadness, hopelessness, and unhappiness. This scale has been shown to be a valid and reliable instrument.42,43 For our study, Cronbach's 
was .89. A single question assessed health status. The 5 possible responses (excellent, very good, good, mediocre, and poor) were dichotomized into good (which included the categories from good to excellent) and poor (which included mediocre and poor).
All analyses were performed with Stata 9.2 (Stata Corp, College Station, TX), which allows computing coefficient estimates and variances taking into account the sampling weights, clustering, and stratification procedure. Classes were used as clusters, and stratification was based on language area, type of school, and year of study. Results are given as prevalence and adjusted odds ratios (aORs) with 95% confidence intervals (CIs) using the comparison group as the reference category.
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RESULTS |
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TOPABSTRACTMETHODSRESULTSDISCUSSIONCONCLUSIONSREFERENCES |
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A description of both groups is summarized in Table 1. Adolescents with chronic conditions were slightly older than their otherwise healthy peers (comparison group), more likely to be depressed, and more likely to rate their health as poor. There were no differences in relation to gender, academic track, or parents' education level.
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Youth with a chronic condition reported higher rates of all risk behaviors than youth in the comparison group, as summarized in Table 2. After controlling for age, gender, academic track, and parents' education level, all differences except alcohol misuse remained significant.
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When additionally controlling for depression and health status, youth with a chronic condition remained significantly more likely to smoke daily (aOR: 1.18 [95% CI: 1.01–1.38]), to be current cannabis users (aOR: 1.21 [95% CI: 1.03–1.41]), and to have performed violent (aOR: 1.29 [95% CI: 1.06–1.56]) or antisocial (aOR: 1.35 [95% CI: 1.14–1.59]) acts.
Adolescents with a chronic condition had higher rates of 3 (15.4% vs 13.5%) and 4 (21.8% vs 15.2%) risk behaviors. After controlling for age, gender, academic track, and parents' education level, youth with a chronic condition remained more likely to report 3 (aOR: 1.54 [95% CI: 1.21–1.98]) and 4 risk behaviors (aOR: 2.00 [95% CI: 1.59–2.52]) than adolescents in the comparison group. After controlling for all potential confounding variables, youth with a chronic condition were significantly more likely to report 3 (aOR: 1.37 [95% CI: 1.07–1.76]) or 4 (aOR: 1.60 [95% CI: 1.26–2.03]) risk behaviors (Table 3).
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DISCUSSION |
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TOPABSTRACTMETHODSRESULTSDISCUSSIONCONCLUSIONSREFERENCES |
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These results confirm that Swiss adolescents with chronic conditions report higher rates of risk behaviors than their otherwise healthy peers. These young people are also significantly more likely to report
3 risk behaviors. It is interesting to note that our results reveal that one fifth of young people with chronic conditions have performed violent acts and one third have performed antisocial acts in the previous year, rates that are significantly higher than those in healthy adolescents. Apart from the study by Britto et al,18 which showed higher rates of weapon carrying and being in a fight in a clinical sample of chronically ill youth with cystic fibrosis and sickle cell disease, this is the first time that violent behaviors have been investigated in young people with chronic conditions. One possible explanation for this finding might be that young people with chronic conditions have more problems gaining access to prosocial groups and, thus, socialize with more risk-taking peers who may accept them more easily. The cross-sectional nature of our research did not allow us to explore an alternative explanation, namely, that these violent behaviors could have been the cause of their chronic condition.
Why might adolescents with chronic conditions be more likely to engage in health risk behaviors than healthy young people? Given the influence of peer behaviors on the onset of risk behaviors,44 it has been argued that young people with chronic conditions may feel a greater need to be accepted by their healthy peers, with participation in risk behaviors apparently serving to demonstrate their "normality."45 Young people with chronic conditions are more likely to experience higher rates of emotional distress,44 which is a recognized risk factor for a range of risk behaviors.46,47 However, our results show that even after controlling for depression, adolescents with chronic conditions remain significantly more likely to smoke daily, to be current cannabis users, and to have performed violent or antisocial acts. An additional explanation may be that some young people whose chronic conditions might be expected to shorten their life span may feel more reckless than others, choosing to live life "to the fullest" or "on the fast track," which might include engaging in a range of health risk behaviors.
Although these behaviors are considered a normative aspect of adolescent development, risk behaviors among chronically ill adolescents can carry additional burdens that have been described as "a double whammy."48 Certain risk behaviors are associated with adverse interactions with medications,17,38 such as alcohol interacting with methotrexate in adolescents with juvenile rheumatoid arthritis.17 Other risk behaviors are associated with increased disease complications. For example, smoking is associated with more microvascular disease in people with diabetes49 and poorer disease control in people with asthma.23 Less specifically, various risk behaviors are associated with poor treatment adherence and illness control.19,20,47,50
Adolescents with chronic conditions are expected to have more contact with health care providers than healthy youth. Although this should provide greater opportunity for preventive and anticipatory counseling and health risk screening, adolescents with chronic conditions infrequently receive preventive counseling13,51–53 regardless of whether their main source of health care is a primary care doctor or a specialist.51 These youth are also uncommonly screened by doctors for substance use and sexuality issues.54 One explanation is that, because of their chronic condition, they are less likely to be seen alone with their doctor, which provides less opportunity for confidential consultations, which are known to be associated with greater likelihood of discussing sensitive health risk behaviors and greater honesty around these discussions.44 For example, Nash et al17 found that nearly 3 of every 4 adolescents with rheumatoid arthritis were never seen alone by their rheumatologist. Yet, young people with chronic illness have been shown to welcome the opportunity to see doctors alone and desire greater discussion around health risk behaviors than they actually receive.53
Common barriers to health risk screening in primary care include lack of time and insufficient training.55 Although these same barriers have also been described in specialist medical settings,52 they have been less systematically studied in tertiary services. The importance of appropriate training in adolescent health is well recognized in primary care.56 These data suggest that young people with chronic conditions warrant greater emphasis on health risk screening and preventive counseling regardless of whether their care is provided by a primary care doctor or specialist.
The strength of our study is that it was based on a nationally representative sample that controlled for both depression and health status. Some limitations need to be addressed. First, the study was cross-sectional, and causality could not be assessed. Thus, for some young people, it may be that their involvement in violent or antisocial behavior has led to the development or occurrence of a chronic condition, rather than the reverse. Longitudinal studies would help assess the direction of the relationship between having a chronic condition and adopting risk behaviors in adolescence. Qualitative studies would also be valuable for exploring the meaning of health risk behaviors in young people with chronic conditions. Second, because young people who were too unwell to attend school or who attend special schools were not surveyed, these data are biased to those with milder health conditions. These data do not include adolescents who had dropped out of school, who are more likely to engage in multiple risk behaviors.2,3 Nevertheless, the prevalence of young people with chronic conditions in our sample (10%) is very consistent with other population studies.10,11 Finally, these data do not indicate the type, nature, or severity of the condition, and we do not know whether they were managed solely in primary care or had additional involvement from specialist services. We controlled for perceived health status to minimize any associated bias.
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CONCLUSIONS |
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TOPABSTRACTMETHODSRESULTSDISCUSSIONCONCLUSIONSREFERENCES |
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These data suggest that health care providers would do well to appreciate that the presence of a chronic condition does not protect young people from participating in risk behaviors. Instead, it seems that having a chronic condition in adolescence carries additional risks for engaging in health risk behaviors. These data emphasize the importance of health risk screening and preventive counseling in young people in general and remind us that young people with chronic conditions are first and foremost young people, who face additional challenges in adolescence when living with chronic conditions.12 As with other adolescents, they need time alone with their health care providers so that these issues, among others, can be discussed.
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ACKNOWLEDGMENTS |
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The 2002 Swiss Multicenter Adolescent Survey on Health was conducted with the financial support of Swiss Federal Office of Public Health contracts 00.001721 to 2.24.02.-81 and the participating cantons.
The survey was run within a multicenter multidisciplinary group from the Institute of Social and Preventive Medicine in Lausanne (Véronique Addor, Chantal Diserens, André Jeannin, Guy van Melle, Pierre-André Michaud, Françoise Narring, Joan-Carles Suris), the Institute for Psychology, Psychology of Development and Developmental Disorders, University of Bern (Françoise Alsaker, Andrea Bütikofer, Annemarie Tschumper), and the Sezione Sanitaria, Dipartimento Della Sanità e Della Socialità, Canton Ticino (Laura Inderwildi Bonivento).
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FOOTNOTES |
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Accepted Jul 31, 2008.
Address correspondence to Joan-Carles Suris, MD, MPH, PhD, Institute of Social and Preventive Medicine, Research Group on Adolescent Health, Bugnon, 17, 1005 Lausanne, Switzerland. E-mail: joan-carles.suris{at}chuv.ch
The authors have indicated they have no financial relationships relevant to this article to disclose.
| What's Known on This Subject Research indicates that adolescents with chronic conditions are as likely or even more likely to engage in risky behaviors such as using substances, having unsafe sexual practices, and having disordered eating behaviors when compared with their healthy counterparts.
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| What This Study Adds Our results indicate that youth with chronic conditions are significantly more likely to engage in several risk behaviors at the same time than are their healthy counterparts.
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REFERENCES |
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TOPABSTRACTMETHODSRESULTSDISCUSSIONCONCLUSIONSREFERENCES |
|---|
1. Igra V, Irwin CE. Theories of adolescent risk-taking behavior. In: DiClemente RJ, Hansen WB, Ponton LE, eds. Handbook of Adolescent Health Risk Behavior. New York, NY: Plenum; 1996:35–51
2. Duberstein Lindberg L, Boggess S, Williams S. Multiple Threats: The Co-occurrence of Teen Health Risk Behaviors. Washington, DC: Urban Institute; 2000. Available at: www.urban.org/UploadedPDF/multiplethreats.pdf. Accessed August 18, 2008
3. Brener ND, Collins JL. Co-occurrence of health-risk behaviors among adolescents in the United States. J Adolesc Health. 1998;22 (3):209 –213[CrossRef][Web of Science][Medline]
4. DuRant RH, Smith JA, Kreiter SR, Krowchuk DP. The relationship between early age of onset of initial substance use and engaging in multiple health risk behaviors among young adolescents.
Arch Pediatr Adolesc Med. 1999;153
(3):286
–291
5. Valois RF, Oeltmann JE, Waller J, Hussey JR. Relationship between number of sexual intercourse partners and selected health risk behaviors among public high school adolescents. J Adolesc Health. 1999;25 (5):328 –335[CrossRef][Web of Science][Medline]
6. Viner RM, Haines MM, Head JA, et al. Variations in associations of health risk behaviors among ethnic minority early adolescents. J Adolesc Health. 2006;38 (1):55[Medline]
7. Rhee D, Yun SC, Khang YH. Co-occurrence of problem behaviors in South Korean adolescents: findings from Korea Youth Panel Survey. J Adolesc Health. 2007;40 (2):195 –197[CrossRef][Web of Science][Medline]
8. Michaud PA, Blum RW, Ferron C. "Bet you I will!" Risk or experimental behavior during adolescence?
Arch Pediatr Adolesc Med. 1998;152
(3):224
–226
9. Steinberg L, Morris AS. Adolescent development. Annu Rev Psychol. 2001;52 :83 –110[CrossRef][Web of Science][Medline]
10. Suris JC, Parera N. Sex, drugs and chronic illness: health behaviours among chronically ill youth.
Eur J Public Health. 2005;15
(5):484
–488
11. Miauton L, Narring F, Michaud PA. Chronic illness, life style and emotional health in adolescence: results of a cross-sectional survey on the health of 15–20-year-olds in Switzerland. Eur J Pediatr. 2003;162 (10):682 –689[CrossRef][Web of Science][Medline]
12. Suris JC, Michaud PA, Viner R. The adolescent with a chronic condition. Part I: developmental issues.
Arch Dis Child. 2004;89
(10):938
–942
13. Sawyer SM, Drew S, Yeo MS, Britto MT. Adolescents with a chronic condition: challenges living, challenges treating. Lancet. 2007;369 (9571):1481 –1489[CrossRef][Web of Science][Medline]
14. Surís JC, Resnick MD, Cassuto N, Blum RW. Sexual behavior of adolescents with chronic disease and disability. J Adolesc Health. 1996;19 (2):124 –131[CrossRef][Web of Science][Medline]
15. Choquet M, Du Pasquier FL, Manfredi R. Sexual behavior among adolescents reporting chronic conditions: a French national survey. J Adolesc Health. 1997;20 (1):62 –67[CrossRef][Web of Science][Medline]
16. Neumark-Sztainer D, Patterson J, Mellin A, et al. Weight control practices and disordered eating behaviors among adolescent females and males with type 1 diabetes: associations with sociodemographics, weight concerns, familial factors, and metabolic outcomes.
Diabetes Care. 2002;25
(8):1289
–1296
17. Nash AA, Britto MT, Lovell DJ, Passo MH, Rosenthal SL. Substance use among adolescents with juvenile rheumatoid arthritis. Arthritis Care Res. 1998;11 (5):391 –396[Web of Science][Medline]
18. Britto MT, Garrett JM, Dugliss MA, et al. Risky behavior in teens with cystic fibrosis or sickle cell disease: a multicenter study.
Pediatrics. 1998;101
(2):250
–256
19. Kyngäs H. Compliance of adolescents with diabetes. J Pediatr Nurs. 2000;15 (4):260 –267[CrossRef][Medline]
20. Kyngäs H. Compliance with health regimens of adolescents with epilepsy. Seizure. 2000;9 (8):598 –604[CrossRef][Web of Science][Medline]
21. Tercyak KP. Brief report: social risk factors predict cigarette smoking progression among adolescents with asthma.
J Pediatr Psychol. 2006;31
(3):246
–251
22. Precht DH, Keiding L, Madsen M. Smoking patterns among adolescents with asthma attending upper secondary schools: a community-based study. Pediatrics. 2003;111 (5 pt 1). Available at: www.pediatrics.org/cgi/content/full/111/5/e562
23. Bush T, Richardson L, Katon W, et al. Anxiety and depressive disorders are associated with smoking in adolescents with asthma. J Adolesc Health. 2007;40 (5):425 –432[CrossRef][Web of Science][Medline]
24. Kohn L, Dramaix M, Favresse D, Kittel F, Piette D. Trends in cannabis use and its determinants among teenagers in the French-speaking community of Belgium. Rev Epidemiol Sante Publique. 2005;53 (1):3 –13[Web of Science][Medline]
25. Rodondi PY, Narring F, Michaud PA. Drinking behaviour among teenagers in Switzerland and correlation with lifestyles. Eur J Pediatr. 2000;159 (8):602 –607[CrossRef][Web of Science][Medline]
26. Santelli JS, Lowry R, Brener ND, Robin L. The association of sexual behaviors with socioeconomic status, family structure, and race/ethnicity among US adolescents.
Am J Public Health. 2000;90
(10):1582
–1588
27. Fothergill KE, Ensminger ME. Childhood and adolescent antecedents of drug and alcohol problems: a longitudinal study. Drug Alcohol Depend. 2006;82 (1):61 –76[CrossRef][Web of Science][Medline]
28. Hanson MD, Chen E. Socioeconomic status and substance use behaviors in adolescents: the role of family resources versus family social status.
J Health Psychol. 2007;12
(1):32
–35
29. Hallfors DD, Waller MW, Ford CA, Halpern CT, Brodish PH, Iritani B. Adolescent depression and suicide risk: association with sex and drug behavior. Am J Prev Med. 2004;27 (3):224 –231[Web of Science][Medline]
30. Waller MW, Hallfors DD, Halpern CT, Iritani BJ, Ford CA, Guo G. Gender differences in associations between depressive symptoms and patterns of substance use and risky sexual behavior among a nationally representative sample of U.S. adolescents. Arch Womens Ment Health. 2006;9 (3):139 –150[CrossRef][Medline]
31. Haarasilta LM, Marttunen MJ, Kaprio JA, Aro HM. Correlates of depression in a representative nationwide sample of adolescents (15–19 years) and young adults (20–24 years).
Eur J Public Health. 2004;14
(3):280
–285
32. Surís JC, Parera N, Puig C. Chronic illness and emotional distress in adolescence. J Adolesc Health. 1996;19 (2):153 –156[CrossRef][Web of Science][Medline]
33. Haarasilta L, Marttunen M, Kaprio J, Aro H. Major depressive episode and physical health in adolescents and young adults: results from a population-based interview survey.
Eur J Public Health. 2005;15
(5):489
–493
34. Huurre TM, Aro HM. Long-term psychosocial effects of persistent chronic illness: a follow-up study of Finnish adolescents aged 16 to 32 years. Eur Child Adolesc Psychiatry. 2002;11 (2):85 –91[CrossRef][Web of Science][Medline]
35. Jeannin A, Narring F, Tschumper A, et al. Self-reported health needs and use of primary health care services by adolescents enrolled in post-mandatory schools or vocational training programmes in Switzerland. Swiss Med Wkly. 2005;135 (1–2):11 –18[Medline]
36. Stein RE, Jessop DJ. A noncategorical approach to chronic childhood illness. Public Health Rep. 1982;97 (4):354 –362[Web of Science][Medline]
37. Perrin EC, Newacheck P, Pless IB, et al. Issues involved in the definition and classification of chronic health conditions.
Pediatrics. 1993;91
(4):787
–793
38. Gortmaker SL, Walker DK, Weitzman M, Sobol AM. Chronic conditions, socioeconomic risks, and behavioral problems in children and adolescents.
Pediatrics. 1990;85
(3):267
–276
39. Newacheck PW, Halfon N. Prevalence and impact of disabling chronic conditions in childhood.
Am J Public Health. 1998;88
(4):610
–617
40. Frey M. Behavioral correlates of health and illness in youths with chronic illness. Appl Nurs Res. 1996;9 (4):167 –176[CrossRef][Web of Science][Medline]
41. Gee L, Abbott J, Conway SP, Etherington C, Webb AK. Quality of life in cystic fibrosis: the impact of gender, general health perceptions and disease severity. J Cyst Fibros. 2003;2 (4):206 –213[Medline]
42. Alsaker FD. Pubertal timing, overweight, and psychological adjustment. J Early Adolesc. 1992;12 (4):396 –419[CrossRef]
43. Holsen I, Kraft P, Vittersø J. Stability and depressed mood in adolescence: results from a 6-year longitudinal panel study. J Youth Adolesc. 2000;29 (1):61 –78[CrossRef][Web of Science]
44. Patton GC, Carlin JB, Coffey C, Wolfe R, Hibbert M, Bowes G. Depression, anxiety, and smoking initiation: a prospective study over 3 years.
Am J Public Health. 1998;88
(10):1518
–1522
45. Valencia LS, Cromer BA. Sexual activity and other high-risk behaviors in adolescents with chronic illness: a review. J Pediatr Adolesc Gynecol. 2000;13 (2):53 –64[CrossRef][Medline]
46. Yeo M, Sawyer SM. Strategies to promote better outcomes in young people with chronic illnesses. Ann Acad Med Singapore. 2003;32 (1):36 –42[Web of Science][Medline]
47. Geist R, Grdisa V, Otley A. Psychosocial issues in the child with chronic conditions. Best Pract Res Clin Gastroenterol. 2003;17 (2):141 –152[CrossRef][Medline]
48. Sawyer S, Drew S, Duncan R. Adolescents with chronic disease: the double whammy. Aust Fam Physician. 2007;36 (8):622 –627[Web of Science][Medline]
49. Chaturvedi N, Stephenson JM, Fuller JH. The relationship between smoking and microvascular complications in the EURODIAB IDDM Complications Study. Diabetes Care. 1995;18 (6):785 –792[Abstract]
50. Bender BG. Risk taking, depression, adherence, and symptom control in adolescents and young adults with asthma.
Am J Respir Crit Care Med. 2006;173
(9):953
–957
51. Britto MT, Garrett JM, Dugliss MA, Johnson CA, Majure JM, Leigh MW. Preventive services received by adolescents with cystic fibrosis and sickle cell disease.
Arch Pediatr Adolesc Med. 1999;153
(1):27
–32
52. Sawyer SM, Tully MA, Colin AA. Reproductive and sexual health in males with cystic fibrosis: a case for health professional education and training. J Adolesc Health. 2001;28 (1):36 –40[CrossRef][Web of Science][Medline]
53. Zack J, Jacobs CP, Keenan PM, et al. Perspectives of patients with cystic fibrosis on preventive counseling and transition to adult care. Pediatr Pulmonol. 2003;36 (5):376 –383[CrossRef][Web of Science][Medline]
54. Britto MT, Rosenthal SL, Taylor J, Passo MH. Improving rheumatologists' screening for alcohol use and sexual activity.
Arch Pediatr Adolesc Med. 2000;154
(5):478
–483
55. Sanci LA, Coffey CM, Veit FC, et al. Evaluation of the effectiveness of an educational intervention for general practitioners in adolescent health care: randomised controlled trial.
BMJ 2000 Jan 22;320
(7229):224
–230
56. Viner R. The scope of adolescent medicine. J R Coll Physicians Lond. 2000;34 (1):12 –15[Web of Science][Medline]
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