Racial-ethnic disparities in adolescent sexual behaviours: the cross-sectional Youth Risk Behavior Survey, 2009–19.

BACKGROUND: There are notable disparities by race/ethnicity in the sexual health of US adolescents and young adults. Our objective was to examine change over time in racial-ethnic disparities in sexual behaviours among US high school students. METHODS: Data were analysed from six biennial cycles of the national Youth Risk Behavior Survey (2009-19), conducted among cross-sectional, nationally representative samples of 9th-12th grade students. Data were collected via self-administered questionnaires. Multivariable logistic regression models tested for linear trends by race/ethnicity (White, Black, Hispanic) and differences in these trends in: ever had sex, current sexual activity, having four or more lifetime sexual partners, and condomless sex. Prevalence ratios and risk differences by race/ethnicity for each cycle were used to calculate average percent change in the estimates to determine if health disparities changed over time. RESULTS: During 2009-19, prevalence estimates for ever had sex, current sexual activity, and having four or more lifetime sexual partners decreased overall and across all racial-ethnic groups. For condomless sex, prevalence estimates increased over time overall (38.9-45.7%) and for Black (37.6-51.8%) and White (36.7-44.2%) students, but not Hispanic (45.1-43.8%) students. Significant differences in trends by race/ethnicity were observed for all variables. Data suggest that racial-ethnic health disparities for sexual behaviours decreased over time, except for condomless sex. CONCLUSIONS: Although racial-ethnic gaps in sexual behaviours may be shrinking for many behaviours, work is still needed to achieve health equity in risks associated with HIV/AIDS, sexually transmitted infections, and pregnancy.

Association of Children's Mode of School Instruction with Child and Parent Experiences and Well-Being During the COVID-19 Pandemic - COVID Experiences Survey, United States, October 8-November 13, 2020.

In March 2020, efforts to slow transmission of SARS-CoV-2, the virus that causes COVID-19, resulted in widespread closures of school buildings, shifts to virtual educational models, modifications to school-based services, and disruptions in the educational experiences of school-aged children. Changes in modes of instruction have presented psychosocial stressors to children and parents that can increase risks to mental health and well-being and might exacerbate educational and health disparities (1,2). CDC examined differences in child and parent experiences and indicators of well-being according to children's mode of school instruction (i.e., in-person only [in-person], virtual-only [virtual], or combined virtual and in-person [combined]) using data from the COVID Experiences nationwide survey. During October 8-November 13, 2020, parents or legal guardians (parents) of children aged 5-12 years were surveyed using the NORC at the University of Chicago AmeriSpeak panel,* a probability-based panel designed to be representative of the U.S. household population. Among 1,290 respondents with a child enrolled in public or private school, 45.7% reported that their child received virtual instruction, 30.9% in-person instruction, and 23.4% combined instruction. For 11 of 17 stress and well-being indicators concerning child mental health and physical activity and parental emotional distress, findings were worse for parents of children receiving virtual or combined instruction than were those for parents of children receiving in-person instruction. Children not receiving in-person instruction and their parents might experience increased risk for negative mental, emotional, or physical health outcomes and might need additional support to mitigate pandemic effects. Community-wide actions to reduce COVID-19 incidence and support mitigation strategies in schools are critically important to support students' return to in-person learning.

Timing of Community Mitigation and Changes in Reported COVID-19 and Community Mobility - Four U.S. Metropolitan Areas, February 26-April 1, 2020.

Community mitigation activities (also referred to as nonpharmaceutical interventions) are actions that persons and communities can take to slow the spread of infectious diseases. Mitigation strategies include personal protective measures (e.g., handwashing, cough etiquette, and face coverings) that persons can use at home or while in community settings; social distancing (e.g., maintaining physical distance between persons in community settings and staying at home); and environmental surface cleaning at home and in community settings, such as schools or workplaces. Actions such as social distancing are especially critical when medical countermeasures such as vaccines or therapeutics are not available. Although voluntary adoption of social distancing by the public and community organizations is possible, public policy can enhance implementation. The CDC Community Mitigation Framework (1) recommends a phased approach to implementation at the community level, as evidence of community spread of disease increases or begins to decrease and according to severity. This report presents initial data from the metropolitan areas of San Francisco, California; Seattle, Washington; New Orleans, Louisiana; and New York City, New York* to describe the relationship between timing of public policy measures, community mobility (a proxy measure for social distancing), and temporal trends in reported coronavirus disease 2019 (COVID-19) cases. Community mobility in all four locations declined from February 26, 2020 to April 1, 2020, decreasing with each policy issued and as case counts increased. This report suggests that public policy measures are an important tool to support social distancing and provides some very early indications that these measures might help slow the spread of COVID-19.

Sexual Intercourse Among High School Students - 29 States and United States Overall, 2005-2015.

Early initiation of sexual activity is associated with having more sexual partners, not using condoms, sexually transmitted infection (STI), and pregnancy during adolescence (1,2). The majority of adolescents initiate sexual activity during high school, and the proportion of high school students who have ever had sexual intercourse increases by grade; black students are more likely to have ever had sexual intercourse than are white students (3). The proportion of high school students overall who had ever had sexual intercourse did not change significantly during 1995-2005 (53.1% to 46.8%) (Division of Adolescent and School Health, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, CDC, unpublished data). To assess whether changes have occurred in recent years in the proportion of high school students who have ever had sexual intercourse, CDC examined trends overall and by grade, race/ethnicity, and sex among U.S. high school students, using data from the 2005-2015 national Youth Risk Behavior Surveys (YRBSs) and data from 29 states* that conduct the YRBS and have weighted data. Nationwide, the proportion of high school students who had ever had sexual intercourse decreased significantly overall and among 9th and 10th grade students, non-Hispanic black (black) students in all grades, and Hispanic students in three grades. A similar pattern by grade was observed in nearly half the states (14), where the prevalence of ever having had sexual intercourse decreased only in 9th grade or only in 9th and 10th grades; nearly all other states saw decreases in some or all grades. The overall decrease in the prevalence of ever having had sexual intercourse during 2005-2015 is a positive change in sexual risk among adolescents (i.e., behaviors that place them at risk for human immunodeficiency virus, STI, or pregnancy) in the United States, an overall decrease that did not occur during the preceding 10 years. Further, decreases by grade and race/ethnicity represent positive changes among groups of students who have been determined in previous studies to be at higher risk for negative outcomes associated with early sexual initiation, such as greater numbers of partners, condom non-use, teen pregnancy, and STI (1-3). More work is needed to understand the reasons for these decreases and to ensure that they continue.

Health-Related Behaviors and Academic Achievement Among High School Students - United States, 2015.

Studies have shown links between educational outcomes such as letter grades, test scores, or other measures of academic achievement, and health-related behaviors (1-4). However, as reported in a 2013 systematic review, many of these studies have used samples that are not nationally representative, and quite a few studies are now at least 2 decades old (1). To update the relevant data, CDC analyzed results from the 2015 national Youth Risk Behavior Survey (YRBS), a biennial, cross-sectional, school-based survey measuring health-related behaviors among U.S. students in grades 9-12. Analyses assessed relationships between academic achievement (i.e., self-reported letter grades in school) and 30 health-related behaviors (categorized as dietary behaviors, physical activity, sedentary behaviors, substance use, sexual risk behaviors, violence-related behaviors, and suicide-related behaviors) that contribute to leading causes of morbidity and mortality among adolescents in the United States (5). Logistic regression models controlling for sex, race/ethnicity, and grade in school found that students who earned mostly A's, mostly B's, or mostly C's had statistically significantly higher prevalence estimates for most protective health-related behaviors and significantly lower prevalence estimates for most health-related risk behaviors than did students with mostly D's/F's. These findings highlight the link between health-related behaviors and education outcomes, suggesting that education and public health professionals can find their respective education and health improvement goals to be mutually beneficial. Education and public health professionals might benefit from collaborating to achieve both improved education and health outcomes for youths.

Differences in Chronic Disease Behavioral Indicators by Sexual Orientation and Sex.

CONTEXT: Lesbian, gay, and bisexual (LGB) populations experience significant health inequities in preventive behaviors and chronic disease compared with non-LGB populations. OBJECTIVES: To examine differences in physical activity and diet by sexual orientation and sex subgroups and to assess the influences of home and neighborhood environments on these relationships. DESIGN: A population-based survey conducted in 2013-2014. SETTING: A stratified, simple, random sample of households in 20 sites in the United States. PARTICIPANTS: A total of 21 322 adult LGB and straight-identified men and women. OUTCOME MEASURES: Any leisure-time physical activity in the past month; physical activity 150 min/wk or more; daily frequency of consumption of vegetables, fruit, water, and sugar-sweetened beverages; and the number of meals prepared away from home in the past 7 days. RESULTS: Physical activity and diet varied by sexual orientation and sex; differences persisted after adjusting for sociodemographic factors and household and community environments. Bisexual men reported a higher odds of engaging in frequent physical activity than straight men (odds ratio [OR] = 3.10; 95% confidence interval [CI], 1.57-6.14), as did bisexual women compared with straight women (OR = 1.84; 95% CI, 1.20-2.80). LGB subgroups reported residing in more favorable walking and cycling environments. In contrast, gay men and lesbian and bisexual women reported a less favorable community eating environment (availability, affordability, and quality of fruit and vegetables) and a lower frequency of having fruit or vegetables in the home. Lesbian women reported lower daily vegetable consumption (1.79 vs 2.00 mean times per day; difference = -0.21; 95% CI, -0.03 to -0.38), and gay men reported consumption of more meals prepared away from home (3.17 vs 2.63; difference = 0.53; 95% CI, 0.11-0.95) than straight women and men, respectively. Gay men and lesbian and bisexual women reported a higher odds of sugar-sweetened beverage consumption than straight men and women. CONCLUSIONS: Findings highlight opportunities for targeted approaches to promote physical activity and mitigate differences in diet to reduce health inequities.

Associations Between Verbal and Physical Abuse in the Home and Mental Health Indicators Among Heterosexual and Lesbian, Gay, Bisexual, and Questioning High School Students in the US-Adolescent Behaviors and Experiences Survey, 2021.

PURPOSE: A number of factors may contribute to disparities in mental health and suicidality for lesbian, gay, bisexual, and questioning (LGBQ) students, including parental abuse. METHODS: The Centers for Disease Control and Prevention's (CDC) Adolescent Behaviors and Experiences Survey included a nationally representative sample of US high school students during the COVID-19 pandemic. The current analyses examined experiences of verbal and physical abuse in the home with mental health and suicidality among LGBQ students compared to heterosexual students. RESULTS: The relationship between abuse and mental health and suicidality was significant for all students; however, LGBQ students experienced substantially more abuse and had significantly poorer mental health and greater suicidality than heterosexual students. DISCUSSION: Experiencing verbal or physical abuse in the home is strongly associated with poor mental health and suicidality among youth, regardless of sexual identity; however, among LGBQ students who experienced abuse, the prevalence of poor mental health and suicidality reached crisis levels.

Measuring Population-Level Adolescent Mental Health Using a Single-Item Indicator of Experiences of Sadness and Hopelessness: Cross-Sectional Study.

BACKGROUND: Population-level monitoring of adolescent mental health is a critical public health activity used to help define local, state, and federal priorities. The Youth Risk Behavior Surveillance System includes a single-item measure of experiences of sadness or hopelessness as an indicator of risk to mental health. In 2021, 42% of high school students reported having felt sad or hopeless for 2 weeks or more during the past 12 months. The high prevalence of US high school students with this experience has been highlighted in recent studies and media reports. OBJECTIVE: This study seeks to examine associations between this single-item measure of experiences of sadness or hopelessness with other indicators of poor mental health including frequent mental distress and depressive symptoms. METHODS: We analyzed survey data from a national sample of 737 adolescents aged 15-19 years as a part of the Teen and Parent Surveys of Health. Participants were recruited from AmeriSpeak, a probability-based panel designed to be representative of the US household population. Feeling sad or hopeless was operationalized as a "yes" response to the item, "During the past 12 months, did you ever feel so sad or hopeless almost every day for 2 weeks or more in a row that you stopped doing some usual activities?" Unadjusted and adjusted prevalence ratios (aPRs) were calculated to examine associations between the single-item measure of having felt sad or hopeless almost every day for 2 weeks with moderate to severe depressive symptoms, frequent mental distress, and functional limitation due to poor mental health. Adjusted models controlled for age, race and ethnicity, sex assigned at birth, and sexual identity. RESULTS: Overall, 17.3% (unweighted: 138/735) of adolescents reported that they felt sad or hopeless for 2 weeks or more during the past 12 months, 30.2% (unweighted: 204/716) reported moderate to severe depressive symptoms, 18.4% (unweighted: 126/732) reported frequent mental distress, and 15.4% (unweighted: 107/735) reported functional limitation due to poor mental health. After adjusting for demographics, adolescents who reported that they felt sad or hopeless for 2 weeks or more were 3.3 times as likely to report moderate to severe depressive symptoms (aPR 3.28, 95% CI 2.39-4.50), 4.8 times as likely to indicate frequent mental distress (aPR 4.75, 95% CI 2.92-7.74), and 7.8 times as likely to indicate mental health usually or always interfered with their ability to do things (aPR 7.78, 95% CI 4.88-12.41). CONCLUSIONS: Associations between having felt sad or hopeless for 2 weeks or more and moderate to severe depressive symptoms, frequent mental distress, and functional limitation due to poor mental health suggest the single-item indicator may represent relevant symptoms associated with poor mental health and be associated with unmet health needs. Findings suggest the single-item indicator provides a population-level snapshot of adolescent experiences of poor mental health.

Family Economics and Mental Health Among High-School Students During COVID-19.

INTRODUCTION: The COVID-19 pandemic has had unprecedented socioeconomic and health impacts in the U.S. This study examined racial/ethnic and school poverty status differences in the relationship between parent job loss, experiences with hunger, and indicators of mental health problems among public high-school students nationwide during the COVID-19 pandemic. METHODS: The study analyzed data from the Adolescent Behaviors and Experiences Survey, conducted in January-June 2021. The Adolescent Behaviors and Experiences Survey was a 1-time, cross-sectional, online survey that used a stratified, 3-stage cluster sample to obtain a nationally representative sample of high-school students in the U.S. This study was limited to public-school students (n=7,379). RESULTS: Among public high-school students nationwide, 36.9% experienced poor mental health during the pandemic, and during the past year, 43.9% experienced persistent feelings of sadness or hopelessness, 19.8% seriously considered attempting suicide, and 9.1% attempted suicide. Parent job loss and having gone hungry were associated with indicators of mental health problems overall and across racial/ethnic groups and school poverty status levels. CONCLUSIONS: Students who experience parent job loss and hunger are likely to also experience poor mental health and may be at higher risk for suicide.

School Connectedness and Risk Behaviors and Experiences Among High School Students - Youth Risk Behavior Survey, United States, 2021.

School connectedness, defined as students' belief that adults and peers in their school care about their learning as well as about them as persons, has been linked to positive educational, behavioral, and health outcomes in adolescence and into adulthood. Data from the 2021 nationally representative Youth Risk Behavior Survey, conducted during the COVID-19 pandemic, were used to estimate prevalence of students' perception of school connectedness and examine associations between school connectedness and seven risk behaviors and experiences: poor mental health, marijuana use, prescription opioid misuse, sexual intercourse, unprotected sex, experiencing forced sex, and missing school because of feeling unsafe. Prevalence estimates were generated and pairwise t-tests were used to detect differences among student subpopulations by sex, grade, race and ethnicity, and sexual identity; Wald chi-square tests were used to detect differences in risk behaviors by level of connectedness within a subpopulation. Logistic regression models were used to estimate prevalence ratios comparing the prevalence of risk behaviors and experiences of students with high connectedness with students with low connectedness, stratified by demographics. During 2021, 61.5% of U.S. high school students reported feeling connected to others at school. In addition, school connectedness was associated with lower prevalence of every risk behavior and experience examined in this study, although certain associations differed by race and ethnicity and sexual identity (e.g., school connectedness was associated with better mental health outcomes for youths with heterosexual, bisexual, and questioning or other sexual identities, but not for youths who identified as lesbian or gay). These findings can guide public health interventions that promote youth well-being by creating school environments where all youths have a sense of belonging and feel they are cared for and supported.

Parental Monitoring and Risk Behaviors and Experiences Among High School Students - Youth Risk Behavior Survey, United States, 2021.

Parents have an important role in the promotion of healthy adolescent behaviors that can influence positive developmental trajectories and health outcomes. Parental monitoring is a central component of the parent-child relationship with the potential to reduce adolescent risk behaviors. Data from CDC's 2021 nationally representative Youth Risk Behavior Survey were used to describe the prevalence of parental monitoring reported by U.S. high school students and examine associations between parental monitoring and adolescent behaviors and experiences. Behaviors and experiences included sexual behaviors, substance use, violence, and indicators of poor mental health. This report marks the first national assessment of parental monitoring among U.S. high school students. Point prevalence estimates and corresponding 95% CIs were generated in the bivariate analyses between parental monitoring and the outcomes, stratified by demographic characteristics (sex, race and ethnicity, sexual identity, and grade). Multivariable logistic regression analyses were conducted to estimate the main effects of parental monitoring (categorized as high = always or most of the time and low = never, rarely, or sometimes) for each outcome, controlling for all demographics. Overall, 86.4% of students reported that their parents or other adults in their family know where they are going or with whom they will be all or most of the time. Reports of high parental monitoring were protective for all risk behaviors and experiences, with models controlling for sex, race and ethnicity, sexual identity, and grade. Results highlight the need for public health professionals who develop public health interventions and programs to conduct further research on the relation between parental monitoring and student health outcomes.

Local Education Agency Impact on School Environments to Reduce Health Risk Behaviors and Experiences Among High School Students.

PURPOSE: The purpose of the study is to assess associations between exposure to a multilevel, socio-ecological health program administered by local education agencies and changes in health behaviors among high school students. METHODS: This analysis used a multilevel difference-in-differences approach to compare student health experiences and outcomes between schools selected by local education agencies nationwide to implement the program (exposed schools) and schools that were not (unexposed schools). We measured repeated cross-sectional outcomes using the 2015 and 2017 Youth Risk Behaviors Surveys. The final analytic sample comprised 638 schools in total (N = 64,838 students), with 237 exposed schools (n = 30,336 students) and 401 unexposed schools (n = 34,502 students). RESULTS: Students in exposed schools demonstrated significant reduction in odds compared with those in unexposed schools in ever having sex (adjusted odds ratio [aOR] = .88, 95% confidence interval [CI]: .81-.96), having four or more lifetime sexual partners (aOR = .84, 95% CI: .72-.97), being currently sexually active (aOR = .78, 95% CI: .78-.96), and using effective hormonal birth control (aOR = .7, 95% CI: .56-.88). Exposure to the program was associated with significant reduction in odds of not going to school because of safety concerns (aOR = .87, 95% CI: .78-.97), having experienced forced sex (aOR = .76, 95% CI: .68-.86), ever used marijuana (aOR = .89, 95% CI: .81-.98), and currently using marijuana (aOR = .77, 95% CI: .64-.93). CONCLUSIONS: Exposure to the program was associated with significant decreases in sexual risk behaviors, experience of violence, and substance use.

Adolescent Mental Health, Connectedness, and Mode of School Instruction During COVID-19.

BACKGROUND: Because COVID-19 was declared a pandemic in March 2020, nearly 93% of U.S. students engaged in some distance learning. These school disruptions may negatively influence adolescent mental health. Protective factors, like feeling connected to family or school may demonstrate a buffering effect, potentially moderating negative mental health outcomes. The purpose of the study is to test our hypothesis that mode of school instruction influences mental health and determine if school and family connectedness attenuates these relationships. METHODS: The COVID Experiences Survey was administered online or via telephone from October to November 2020 in adolescents ages 13-19 using National Opinion Research Center's AmeriSpeak Panel, a probability-based panel recruited using random address-based sampling with mail and telephone nonresponse follow-up. The final sample included 567 adolescents in grades 7-12 who received virtual, in-person, or combined instruction. Unadjusted and adjusted associations among four mental health outcomes and instruction mode were measured, and associations with school and family connectedness were explored for protective effects. RESULTS: Students attending school virtually reported poorer mental health than students attending in-person. Adolescents receiving virtual instruction reported more mentally unhealthy days, more persistent symptoms of depression, and a greater likelihood of seriously considering attempting suicide than students in other modes of instruction. After demographic adjustments school and family connectedness each mitigated the association between virtual versus in-person instruction for all four mental health indicators. CONCLUSION: As hypothesized, mode of school instruction was associated with mental health outcomes, with adolescents receiving in-person instruction reporting the lowest prevalence of negative mental health indicators. School and family connectedness may play a critical role in buffering negative mental health outcomes.

Mental Health, Suicidality, and Connectedness Among High School Students During the COVID-19 Pandemic - Adolescent Behaviors and Experiences Survey, United States, January-June 2021.

Disruptions and consequences related to the COVID-19 pandemic, including school closures, social isolation, family economic hardship, family loss or illness, and reduced access to health care, raise concerns about their effects on the mental health and well-being of youths. This report uses data from the 2021 Adolescent Behaviors and Experiences Survey, an online survey of a probability-based, nationally representative sample of U.S. public- and private-school students in grades 9-12 (N = 7,705), to assess U.S. high school students' mental health and suicidality during the COVID-19 pandemic. The study also examines whether mental health and suicidality are associated with feeling close to persons at school and being virtually connected to others during the pandemic. Overall, 37.1% of students experienced poor mental health during the pandemic, and 31.1% experienced poor mental health during the preceding 30 days. In addition, during the 12 months before the survey, 44.2% experienced persistent feelings of sadness or hopelessness, 19.9% had seriously considered attempting suicide, and 9.0% had attempted suicide. Compared with those who did not feel close to persons at school, students who felt close to persons at school had a significantly lower prevalence of poor mental health during the pandemic (28.4% versus 45.2%) and during the past 30 days (23.5% versus 37.8%), persistent feelings of sadness or hopelessness (35.4% versus 52.9%), having seriously considered attempting suicide (14.0% versus 25.6%), and having attempted suicide (5.8% versus 11.9%). The same pattern was observed among students who were virtually connected to others during the pandemic (i.e., with family, friends, or other groups by using a computer, telephone, or other device) versus those who were not. Comprehensive strategies that improve feelings of connectedness with others in the family, in the community, and at school might foster improved mental health among youths during and after the COVID-19 pandemic.

Dosage in Implementation of an Effective School-Based Health Program Impacts Youth Health Risk Behaviors and Experiences.

PURPOSE: This study is part of a larger evaluation of a multilevel, multistrategy federal program to reduce high school students' risk for HIV/sexually transmitted infection and unintended pregnancy. Local education agencies supported schools in implementing three strategies: delivering exemplary sexual health education, increasing student access to quality sexual health services, and enhancing safe and supportive school environments (SSE). We examined how levels of school implementation of these strategies moderated program effects on targeted student outcomes. METHODS: The Youth Risk Behavior Survey was implemented in participating local education agencies in 2015 and 2017 to assess student behaviors and experiences, whereas the School Health Profiles surveys assessed school policies and practices in 2014 and 2016. We used these surveys to measure student-level outcomes and school-level program delivery, respectively, which were analyzed using multilevel modeling in a difference-in-differences framework. RESULTS: Levels of SSE implementation significantly moderated program effects on multiple student outcomes, including ever having sex, having four or more lifetime sexual partners, being sexually active, using hormonal birth control, dual use of a condom and hormonal birth control, ever being forced to have sex, missing school because of safety concerns, and lifetime and current marijuana use. However, we found few moderating effects of exemplary sexual health education and sexual health services dosage. DISCUSSION: We found a significant relationship between incremental increases in implementation of activities to increase the safety and supportiveness of school environments and enhanced program effects in improving multiple student health outcomes. These findings suggest that school implementation of SSE activities contributed to intended program effects.

Let's stay together: relationship dissolution and sexually transmitted diseases among parenting and non-parenting adolescents.

Relationships influence sexual risk and maternal-child health. Few studies have assessed relationship dissolution and its association with sexually transmitted diseases (STD) among adolescent parents. Our study aimed to describe relationship dissolution among 295 parenting and non-parenting adolescents over an 18-month period and how it related to STD incidence. Results showed that nonparenting adolescents in a relationship with someone other than their baby's father were more likely to have a relationship dissolution over an 18-month period compared to those in a relationship with the baby's father (OR = 1.69, P < .05). Parenting adolescents who ended their relationship with their baby's father were 3 times more likely to get an STD over the course of the study compared to parenting adolescents who remained with their baby's father (39% vs. 13%). Comparatively, nonparenting adolescents who ended their relationship were only 1.4 times more likely to get an STD compared to non-parenting adolescents who remained with their partner (44% vs. 32%). Our results suggest that prevention programs that incorporate male partners and components that strengthen relationship skills may reduce HIV/STD risk and help adolescents adapt during times of transition such as parenthood.