The Adolescents and Young People of Europe have the right to good health Policy statement on preservation of good health among adolescent and young people.

Contents

Introductory statement

1. Introduction
2. Summary - main recommendations
3. Important factors influencing the health of adolescents and young people and recommendations about how to cope with them
• a. Depression
• b. Violence
• c. Exclusion and isolation
• d. Abuse of alcohol
• e. Drugs of abuse
• f. Accidents
• g. Puberty, unwanted pregnancies and sexually transmitted diseases
• h. Tobacco
• i. Eating disorders
• j. Nutritional habits
• k. Physical activity/inactivity
• l. Health services
4. References

Note
For the purposes of this document the term "adolescents and young people" refers to those aged 10 to 24 years.

Introductory Statement

The general practitioners of Europe believe that:

1. The maintenance of good health among adolescents and young people is of crucial importance with regard to their future health as adults.
2. Special attention should be paid to the health of adolescents and young people by health care services and the rest of society.
3. A fully comprehensive range of easily accessible services should be provided for all adolescents and young people.

Introduction

The years of adolescence young adulthood are often thought of as the years of life with the best mental and physical health and the lowest need for health services. It may seem a paradox for UEMO to pay special attention to this group of people, generally considered to be one of, or even the most, healthy part of the population.

Although this is true for most of the younger generation, a substantial proportion experiences a wide range of health problems and worries. Adolescents and young people are particularly vulnerable to the effects of the erosion of family structure and protection within contemporary society. They are subject to powerful peer pressure and the influence of a wide variety of role models especially in sport. They may be exposed to societal violence and even to state-sponsored violence.

Loneliness, depression, suicidal or self-harming behaviour, eating disorders, victimisation through violence or accidents, sexually related diseases, unwanted pregnancies, and alcohol and drug abuse are examples of health problems which are particularly prevalent in the adolescent period of life.

During these crucial years, young people develop from the dependent and irresponsible life of a child, to the independence and responsibilities of adult life. This is not always an easy task, and the way the young girl or boy copes with it is of great importance to their adult mental and physical health. Several studies find that there is a high degree of stability of health problems and "problem creating" behaviour from adolescent to adult life. It is well documented that those who score high on health problems as teenagers, are more likely to do so also as adults, while those who score low, continue to do so in adult life.

This same preservation of habits seems also to be true for other lifestyle risk factors including unhealthy nutrition, physical inactivity, obesity and smoking. There is good scientific evidence to support the view that habits laid down in adolescence tend to follow us for the rest of our lives and create the foundation of our future health.

This makes these vulnerable and crucial years a very important arena where appropriate preventive and supportive activities are likely to be of great importance to future health.

Unfortunately, the health services, and other arenas for health promoting activities such as schools, do not always function as well as they should in these respects.

Sadly, we have less knowledge about health problems and their prevention in the young generation, than we do when adults are concerned.

Although the results of inadequate prevention of health risks sooner or later will be a task for the health services, other arenas are equally, or even more important, sites for preventive activities. Preventive efforts need to be shared by skilled workers from many different professions, by politicians and by others. This should be borne in mind, even if this statement especially reflects the view of doctors in general practice.

The primary focus of this paper will be on the age group of 10-24 years, but we recognise that this is not a rigidly or clearly demarcated phase of life.

For practical purposes we will not make rigorous distinctions between primary, secondary and tertiary preventions.

The following is not intended to be a complete overview of health risks to adolescents, but a brief focus on important areas of special concern, and some proposals about how to prevent negative effects on health of adolescents and young people.

Knowledge on its own is not enough to change behaviour when dealing with adolescents. Therefore information alone is probably of limited value, although still widely used as the main preventive activity. It is necessary to do something about the social influences on adolescents and young people, support their ability to meet and handle social pressure, and to some degree change their opinions on what is normal behaviour. (If they believe that it is actually normal to be drunk every weekend, they are more likely to adopt such behaviour.)

Summary - main recommendations

Recommendations with specific relevance within the field of medical general practice:

1. UEMO should challenge the medical organisations of Europe to pay special attention to the work of preventive activities to preserve good health among adolescents and young people. This can be done through their courses, conferences, policy statements etc.
2. General practitioners need to increase their focus and competence on primary, secondary and tertiary preventive activities to preserve good health among adolescents and young people.
3. General practitioner services should be easily accessible and freely available to adolescents and young people.
4. Adolescents and young people should have the same rights to confidentiality as adults and general practitioners should inform adolescents of their right to confidential health care.
5. All general practitioners, and other health care professionals, must be offered, as part of their regular CME, the opportunity for further education within the fields of preventive activities, communication, diagnosis and treatment for adolescents and young people.
6. Specialist expertise and advice should be easily available to general practitioners.
7. Contraception should be easily accessible and freely available to adolescents and young people.

Recommendations with relevance to society in general for which general practitioners and their national organisations should campaign and advocate:

1. Preventive activities and health promoting work for adolescents and young people need to be developed and strengthened, exploiting newer communication media such as SMS texting.
2. Adolescents and young people should be actively involved  in the planning of preventive activities.
3. All preventive activities should be evaluated and quality controlled to ensure the efforts are effective.
4. The capacity of specialized psychiatric health services for adolescents and young people needs to be increased to provide fully comprehensive services across the age range.
5. Both schools and primary care teams should actively identify adolescents and young people at risk of damaging social exclusion, and services should be provided to enable and support the their reintegration.
6. Adolescents and young people should be provided with access to a range of stimulating and challenging leisure activities.
7. The health services ability to diagnose and treat young patients with alcohol or drug problems, or those at risk of having such problems, needs to be improved.
8. The minimum age for drinking alcohol should be made clear.
9. Formal education should include information about the risks of experimenting with drugs of abuse and about the responsible use of alcohol, including the risks related to the excessive use of alcohol.
10. Formal education should include information about the risks related to the use of tobacco, and all schools, as both public places and places of work, should be declared non-smoking areas.
11. The prevention of traffic accidents should have a high priority.
12. Prices of healthy food and drinks should be reduced, and prices of unhealthy food, drinks and tobacco increased through taxes.
13. Adolescents and young people should be encouraged to increase their levels of physical activity. Physical activity should be an integral part of the school day and facilities should be made available in the community out of school hours and for young people who have left school. There should be a choice of a wide range of alternative activities offering variable degrees of competition.

Important factors influencing the health of adolescents and young people and recommendations about how to cope with them

Depression

Depression in children and adolescents is associated with social dysfunction, academic under achievement, and suicidal behaviour. It is generally under-recognised. Prevalence is estimated at 2-10% in primary school children, rising to 5-20% in adolescents. Children and adolescents with depressive disorders lack interest in activities they previously enjoyed, criticise themselves, and are pessimistic or hopeless about the future. They may feel sad or irritable. Problems at school arise from indecision and difficulties with concentration. Depressed children tend to lack energy and have problems sleeping.

Depression may progress to suicidal thinking and even suicide attempts. Some authors believe that suicide is as frequent a cause of death as accidents. Depression in children and adolescents usually arises from a combination of genetic vulnerability, suboptimal early developmental experiences, and exposure to stresses. Depressive syndromes sometimes occur following physical illness such as viral infection and may overlap with fatigue syndromes.

The average duration of a depressive episode in young people is about nine months, with a 70% probability of relapse within five years. Evidence shows continuity between childhood depression and depression experienced in adulthood, with the phenomenology becoming more "adult-like" as the child progresses through adolescence.

The majority of depressed children and adolescents have been in contact with a family doctor at the time of depression, but often their problem has not been adequately diagnosed. Investigations have shown that general practitioners, who are educated by specific training programs to diagnose and treat depressed adolescents, do so successfully, when compared to treatment that demands more extensive resources.

UEMO recommends that:

• Children, adolescents and young people should have easy access to their family doctor, and the waiting time should be kept to a minimum.
• General practitioners should be offered the necessary education for effectively diagnosing and treating depressed children and adolescents.
• There should be clear referral pathways between schools and primary care and between primary care and child psychology and psychiatry services.
• The capacity of specialized psychiatric health services for children, adolescents and young people should be increased to provide fully comprehensive services across the age range.
• Specialist expertise and advice should be easily available to general practitioners.
• Mental health services for children, adolescents and young people should be provided in accessible and non-stigmatising settings.
• Dedicated telephone help-lines for young people with mental health problems should be provided

Violence

Youth violence includes a range of aggressive acts from bullying, intimidation and physical fighting to more serious forms of assault and homicide. In all countries, young males are both the principal perpetrators and victims of homicide. The tendency to use violence is strongly related to depression and different kinds of mental discomfort.

Involvement in youth violence is predicted by early onset of delinquent behaviour often resulting in exclusion from school. Antisocial behaviour has a very strong tendency to continue from childhood to adolescence and approximately half of all children aged 8-10 who show antisocial behaviour will continue to have this problem at 14. Similarly, troublesome behaviour at 8-10 years strongly predicts truancy, bullying, and aggression at 12-14. The relationship between violence and involvement in sport needs further elucidation. Longitudinal studies have confirmed that the likelihood of conduct disorder in young children continuing into adolescence is much greater if the conduct disorder is associated with hyperactivity (ADHD).

Adolescents may be either victims or perpetrators of domestic violence or may be caught up in violence between adults in the household.

UEMO recommends that:

• Children who are failing at school should be identified early and offered intensive support.
• Young people should be provided with access to a range of stimulating and challenging leisure activities.
• Access to weapons including knives and guns needs to be strictly controlled.
• Children and adolescents need education that includes understanding of the rights and dignity of others.
• Specific anti-bullying initiatives and facilities for conflict resolution should be available in all schools.
• The exposure of children and adolescents to violence on television, film and other recreational media should be minimised.

Exclusion and isolation

Social exclusion and isolation is both the result and the driver of many other adolescent health problems. Children whose parents have significant mental health problems or who are dependent on drugs or alcohol are at serious risk of developing behaviour problems, which are compounded and exacerbated by social isolation.

UEMO recommends that:

• Both schools and primary care teams should actively identify adolescents and young people at risk of damaging social exclusion.
• Services should be provided to enable and support the reintegration of adolescents who have become socially excluded.
• Leisure activities including sport, music, drama and art should be made available to adolescents and young people at risk of social isolation in settings that incorporate social and emotional support.
• Policies should be developed to tackle the systematic underperforming of boys within schools
• Adolescents should have access to the skills of social workers and psychologists within schools
• School pupils themselves should be involved in tackling the problems posed by social exclusion and isolation.

Abuse of alcohol

The way alcohol is used varies widely within Europe. Drunkenness is more common in the northern countries. Those who start drinking early tend to have higher alcohol consumption both as teenagers and in adult life. There has been a great increase in alcohol consumption among adolescents during recent years. 50-60% of 15 years old report having been drunk at least once during the previous 12 months. Being drunk increases the risk of accidents and behaviour that can lead to a wide variety of health damage, sexually transmitted diseases, unwanted pregnancies etc.

UEMO recommends that:

• The minimum age for drinking alcohol should be made clear.
• Appropriate education about the responsible use of alcohol should be included within formal education and should cover the implications of alcohol use for driving, crime and violence and the particular vulnerability of girls when they are drunk.
• Effective campaigns focusing on "being drunk is not cool" should be set up, using the positive participation of trendsetters.
• Alcohol should not be sold to persons under the age of 18 years.
• Attention should be paid to the proliferation of the sweetened, flavoured spirits popular among young adolescents.
• Shops, restaurants etc should need a licence to sell alcohol, and the license should be withdrawn if the age limit is not respected or if alcohol is sold to drunken people.
• The health services ability to diagnose and treat patients with alcohol problems needs to be upgraded.
• Specialized health services for the treatment of people with alcohol problems need to be developed. 

Drugs of abuse

Drugs of abuse can seriously damage health and often lead to mental disturbances. There are substantial differences concerning the willingness of adolescents and young people from different European countries to experiment with drugs.

The percentage of young people in the age group of 15-16 years who in 1999 reported having at some time experimented with cannabis, varies within the range of 10-35% in different European countries. The percentage that reports having experimented with stronger drugs varies from 3 to 12%. With the exception of some countries, there has not been a huge increase since 1995.

In subgroups of adolescents and young people involved in "problem behaviour", the percentage is higher.

UEMO recommends that:

• Formal education should include information about the risks of experimenting with drugs of abuse, the relationship between the use of drugs and driving accidents and the prevalence of crime to finance the purchase of drugs.
• Adolescents and young people at risk of abusing drugs should be identified early and offered help to avoid addiction. Schools identifying drug misuse should provide an initial response that is rehabilitative and should only resort to punitive measures such as exclusion when other responses have been exhausted.
• Parents, teachers, nurses, GPs and others dealing with adolescents and young people should be better educated to spot early signs and symptoms of drug addiction.
• GPs should be offered possibilities to learn more about the treatment of young drug addicts and young people at risk as a part of their CME.
• Specialised health services for the treatment of drug addiction need to be developed.
• Adolescents and young people convicted of drugs related crimes should be offered intensive support and rehabilitation.
• Campaigns focusing on "narcotics are out" should be set up, involving the participation of "trendsetters".

Accidents

According to a report from UNICEF (Innocenti Research Centre in Florence) traffic and other accidents are the most important causes of death for children between 1 and 15 years in the industrialized world. More than 20,000 children and adolescents die from different accidents each year in the western world. The chance of a child, born in the industrialised world today, dying from an accident before 15 years of age is estimated to be approximately 1 to 750. 41 % of these deaths are caused by traffic accidents, 15 % by drowning, 14% by violence and 7% by fires.

A substantial proportion of the traffic accidents involving adolescents and young people happen late at night during weekends. A young car driver is more likely to be involved in traffic accidents during the first 6 months after obtaining a drivers license than later.

UEMO recommends that:

• First aid, safety and basic driver education should be incorporated within formal education.
• Prevention of traffic accidents should have a high priority.
• Driving schools and parents should cooperate to improve the quality of driving education
• The legislative framework should enable an increase in the number of hours of supervised driving for new drivers.
• Cheap public transport should be available at late hours over weekends in all parts of each country
• There should be frequent police checks for driving at excessive speed or while drunk late at night during weekends.
• Trauma teams with high competence should be available in hospitals in all regions of each country.
• All pupils should have the opportunity to learn how to swim.
• The provision and maintenance of domestic smoke alarms should be promoted and encouraged.

Puberty, unwanted pregnancies and sexually transmitted diseases

Although general knowledge about these subjects among adolescents and young people is higher than before, several investigations show that many still lack basic information on puberty, sexually transmitted diseases and the prevention of unwanted pregnancies.

At the age of 14 only 4% of girls and 2% of boys have had their sexual debut, these figures rise to 24% and 15% respectively at the age of 16, and, at the age of 18, 62% of girls and 47% of boys have had their sexual debut. Good knowledge about sexuality and the prevention of unwanted pregnancies, and positive self-esteem, is shown to postpone the age of sexual debut and reduce the number of teenage pregnancies.

The most important predictors of early intercourse are reported to be poor social resources and the early development of problem behaviour, including early alcohol intoxication.

UEMO recommends that:

• Every school should have access to health advice on a regular basis. Health professionals should cooperate with teachers to give the pupils necessary information about puberty, sexually related diseases and the prevention of unwanted pregnancies, including the problems caused by the misuse of alcohol. They should also inform pupils about the services available to them from their general practitioner.
• General practitioner services and contraception should be easily accessible and freely available to adolescents and young people.
• Adolescents and young people should be informed and made aware that consultation with a general practitioner is confidential
• All investigations and treatment of sexually transmitted diseases should be free (paid by the Government).
• The advice to all adolescents and young people should be: set your own limits and use safe prevention against both sexually transmitted diseases and unwanted pregnancy.

Tobacco

Smoking tobacco causes some 4 million premature deaths each year, and is the single factor with the most negative effect on health.

Regular smokers often started at the age of 13-15 years, therefore this is an important age for preventive activities. Although the incidence varies among the different European countries, in many countries approximately 10-20% of 15-years old pupils in school smoke on a regular basis, and 25-30% smoke occasionally.

There has been a decrease in the number of regular smokers among adolescent and young people over the last 30 years, but the decrease seems to have flattened out in many countries lately. There are particular concerns about the rising numbers of young women who smoke.

UEMO recommends that:

• All advertising of tobacco should be prohibited
• All tobacco subsidies should be phased out
• There should be high taxation of tobacco products
• There should be effective health warnings on all tobacco products
• Tobacco should be excluded from national price indices
• Elimination of non-smokers' exposure to environmental tobacco smoke by ensuring smoke free public places
• All schools should be declared "non-smoking areas".
• There should be an age limit of 18 years for buying tobacco
• Shops should need a license to sell tobacco, and the license should be withdrawn if the age limit is not respected.
• Effective campaigns aimed at adolescents and young people with the message that "smoking is out" should be set up, using the participation of different trendsetters etc. Schools should be actively engaged in this.
• Preventive health care should acknowledge and address the use of tobacco as a vehicle for the taking of marijuana.
• Targeted smoking cessations treatments should be readily accessible and freely available to adolescents and young people.

Eating disorders

Reports of anorexia nervosa and bulimia nervosa are more common in industrialized nations where food is plentiful and where thinness for women is correlated with attractiveness. For example, the prevalence of anorexia nervosa in Greek girls living in Germany was double the rate for those girls living in Greece and Turkey where they remained less exposed to Western values equating thinness with beauty. Eating disorders are much more common in adolescent girls than in boys and are associated with depression and with a history of excessive dieting. The prevalence of eating disorders in adolescent girls is about 4%.

Recognition of individuals at risk and early intervention can prevent the development of full-blown eating disorders. Severe eating disorders are potentially life threatening.

UEMO recommends that:

• General practitioners have a high index of suspicion to promote the early diagnosis of eating disorders in adolescents and young people.
• General practitioners should be supported by ready access to specialist expertise in the care of adolescents and young people with eating disorders, including access to family therapy.
• General practitioners should be offered the necessary education to effectively diagnose and treat adolescents and young people with eating disorders.
• Plans should be set up to prevent the problem from increasing in society. Schools are especially important arenas for such preventive activities.

Nutritional habits

Adolescents and young people have nutritional habits that are similar to adults. Generally they eat too much fat, salt, sugar and too little fibre, vitamins, minerals, fruit and vegetables. However they tend to eat more sugar than adults , mostly through sweet drinks and confectionery. Many families do not have regular meals where the whole family eat together, and many adolescents and young people eat at irregular times and often drop one of the meals during the day.

Bad nutritional habits predispose to several diseases and bad health.

Social changes mean that most mothers are no longer at home which means that children and adolescents have many fewer opportunites to learn how too cook within the home environment.

UEMO recommends that:

• Prices of healthy food should be reduced, and prices of unhealthy food and sweet drinks increased through taxes.
• All schools should offer their pupils free fruit, vegetables and juice or water daily, and sufficient time to have lunch in suitable surroundings.
• Schools are important arenas for teaching good nutritional habits and schools should provide cooking education.
• All adolescents and their parents should know the importance of eating breakfast every day, and school breakfast clubs should be provided where needed

Physical activity/inactivity

Inactivity and excessive weight are closely linked together. 30-40% of the population in Europe are overweight, 10-15% severely. The increase in body weight is so large that WHO describes the growing inactivity as a global epidemic with significant importance for public health. Physical inactivity and obesity predispose to several diseases, and inactivity among adolescents and young people correlates well with several self-reported physical and mental health problems.

The amount of physical activity drops steadily through the adolescent period of life. In the age group 11-15 years only 14% are physically active less than once a week, but in the age group 16-24 years this percentage has risen to 32%, and at 50 the percentage is more than 50%.

UEMO recommends that:

• Adolescents and young people should be encouraged to increase their levels of physical activity. Physical activity should be an integral part of the school day. There should be a choice of a wide range of alternative activities offering variable degrees of competition.
• Governments should stimulate widespread distribution of facilities for physical activities aimed at all ages, but particularly adolescents.
• Adolescents and young people should be involved in the planning of leisure activities in their local communities.
• Adolescents, young people and their parents should be informed of the need to achieve a balance between active and passive leisure activities.
• Government and schools should promote walking to school campaigns.
• Protected cycle routes should be provided in all urban areas.

Health services

Many reports indicate that today's health services are not organised in an optimal way to meet the needs of adolescents and young people.

Health workers often lack skills of communication and understanding.

UEMO recommends that:

• Preventive activities and health promoting work for adolescents and young people need to be developed and strengthened.
• Adolescents and young people should be involved in the planning of preventive activities.
• All preventive activities should be evaluated and quality controlled to ensure the efforts are effective.
• It should be possible for adolescents and young people to access quality controlled health information through their own communication channels (internet, SMS)
• Health services in schools should be developed and be a primary arena for preventive activities for children and adolescents.
• Schools should be informed, and inform the pupils about what help health services in general, and general practitioner services in particular, can offer.
• General practitioner services should be easily accessible and freely available to adolescents and young people.
• General practitioners should be able to offer adolescents an appointment with very short waiting time and consider having some opening hours after school.
• General practitioners should inform adolescents and young people of their right to confidential health care.
• All general practitioners, and other health care professionals, should have the possibility, as part of their regular CME, to be further educated within the fields of preventive activities, communication, diagnosis and treatment of adolescents and young people.
•  Regional competence centres for "adolescent medicine" should be developed around the three specialities of general practice, paediatrics and psychiatry.
• The capacity of specialized psychiatric health services for adolescents and young people needs to be increased to provide fully comprehensive services across the age range.
• All hospitals should have facilities to meet the needs of adolescents when hospitalised.

References

1. British Medical Association 2003, "Adolescent health" www.bma.org.uk/ap.nsf/Content/AdolescentHealth/$file/Adhealth.pdf
2. The Norwegian Medical Association 2002; "A status report on adolescent health"
3. L. A. Sanci & al., Centre for Adolescent Health, University of Melbourne, Australia; Evaluation of the effectiveness of an educational intervention for general practitioners in adolescent health care: randomised controlled trial.
4. Yuong R, Sweet H, West P. "The West of Scotland 11 to 16 study". Glasgow: Medical Research Council, University of Glasgow 2000
5. Haugland S. "School related  stress, physical activity and health complains." University of Bergen, Norway 2001.
6. Samdal O. "The school environment as a risk or resource for students health related behaviours and subjective well-being". University of Bergen 1998, Norway.
7. http://www.emcdda.eu.int./    http://www.emcdda.org
8. www.adolescenthealth.org
9. http://monitoringthefuture.org/pubs/espad_pr.pdf
10. http://www.sirus.no
11. http://www.elisad.uni-bremen.de/
12. Paulus D. & al. "Teenagers and their family practitioner: matching between their reasons for encounter". Family Practice Vol. 21, No. 2 Oxford University Press 2004
13. Pedersen W. & al., "Intercourse Debut Age: Poor resources, problem behaviour or romantic appeal? A population based longitudinal study". University of Oslo, Norway.
14. Haavet OR & al. "Illness and exposure to negative life experiences in adolescence: two sides of the same coin" A study of 15-year-olds in Oslo, Norway. Acta Pædiatr. 2004; 93: 405-411 Stockholm.
15. http://www.adolescentmedicine.com/office_location.htm
16. UEMO discussion paper 2003, "The Role of General Practitioners in Tobacco Prevention".

Acknowledgement:
The working group would like to thank Dr Ole R. Haavet for his valuable help and support.