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U.S. Teens in Our World

Understanding the Health of U.S. Youth in Comparison to Youth in Other Countries

Table of Contents | Executive Summary | Introduction | Chapter 1 | Chapter 2 | Chapter 3 | Chapter 4 | Chapter 5 | Chapter 6 | What Was Left Out | Summary


In this chapter:
Overall Health and Well-Being | Feeling Healthy | Quality of Life | Symptoms | Medication Use | What We Didn't Know | References


Adolescence is characterized by rapid physical growth, significant physical and psychological changes, and changing dynamics in family and peer relationships. The large, rapid changes associated with adolescence may have major effects on the health of individuals, and conversely, variations in health may significantly affect the transitions of adolescence. Optimal health and well-being of adolescents in their daily lives is basic to their successful development into healthy adults in addition to their functional capacity in performing normal daily activities.

The teenage years are traditionally viewed as a time of very good health with low levels of illness and chronic disease, except for the effects of traumatic injuries.1 Health-related behaviors, such as smoking, may not have immediate health effects for adolescents, although they have implications for chronic diseases later in life and they may affect adolescents' future choices. In contrast, how a student feels on a daily basis, both physically and psychologically, may significantly affect the transitions of adolescence. Thus, measures of factors that influence the success and difficulties of this transition should include indicators of both physical and psychological health. Perceptions of health, self-confidence and satisfaction with life reflect the level of biological and psychosocial stress and anxiety that young people experience.

The ages included in the HBSC study (11, 13, and 15 years) incorporate the significant changes associated with puberty, with expected differences by gender.2,3,4 By age 15, most of the students described in the following charts have entered puberty, with many already attaining established characteristics that will predict their health as adults. The following charts compare the overall health and well-being of U.S. students to those in other countries at age 15. Reference is made to any differences among counties found in younger age groups and changes between age groups associated with developmental status that have been published in the larger international report.2 International comparisons of variations in health measures during transitions through adolescence offer rich opportunities to confirm the biological and developmental characteristics that adolescents around the world have in common, while examining the effects of cultural influences in each country.

Adolescents have a greater awareness of their physical status and well-being than do younger children. One way to measure adolescents' health and well-being is their own self-report on health status. The concept of measuring both adolescent and adult health using standardized self-report is well established.5,6,7,8 In the U.S. adolescents have reported on their own health status in school-based surveys such as the YRBS9 and AddHealth studies.10

Adolescents in the HBSC were asked to describe their general health status and quality of life in a manner comparable to questions in the YRBS and AddHealth. Questions also asked about specific biological and psychological symptoms, including headache, stomachache, backache, and tiredness. Though not always reflective of serious illness, these symptoms may directly measure functional status or indicate the adolescent's sense of physical well-being. In addition, assessments of how students feel about life in general and whether they feel low or lonely are included because of their effect on general health and because they may reflect levels of mental health or psychosocial well-being. Medication use for specific symptoms may indicate the severity of physical symptoms or the availability and inclination to use medication. Measuring medication use improves our understanding of adolescents' use of health care and their response to their symptoms.

Some symptoms describe depressive feelings, such as feeling low. Students were not given an example of 'feeling low' although it has consistently measured negative affects in earlier international studies from the HBSC.2 Together with the U.S. AddHealth study,11 the HBSC provides insight into the day-to-day mental health of students, including assessment of negative feelings. Related questions are asked in the YRBS, which found that 28 percent of U.S. high school students felt so sad or hopeless every day for at least two weeks in the previous year that they stopped doing some usual activities.9 The HBSC adds to surveillance information by broadly assessing adolescent health and well-being in a broader context beyond the traditional indicators of physical health and disabilities.12


Boys tend to report somewhat better health than girls in all countries, with 8 percent of U.S. boys reporting not feeling healthy compared to 13 percent of the girls. U.S. students rank among the highest countries in reports of not feeling healthy, ranking seventh highest for boys and 10th for girls. Other countries with such high levels are primarily Eastern European and the Russian Federation. Finland, Sweden, Switzerland and Austria report the lowest levels of students who do not feel healthy. The proportion of students who do not feel healthy tends to increase slightly between ages 11 and 15 for both genders in almost all countries, including in the U.S.2

Graph: "How Healthy Do You Think You Are?"[d]


U.S. students rank among the highest for those who are not feeling happy (seventh for boys and 11th for girls), along with students from Israel, Eastern Europe, and the Russian Federation. Girls are slightly less happy than boys (25 percent and 19 percent respectively), consistent with gender differences among all countries. Boys and girls report slight increases in the proportion who feel unhappy as they age from 11 to 15 years in the U.S. and in many other countries (data not shown).2 However, the age trend is not consistent for boys in every country - but is consistent for girls.

In all countries, girls are more likely than boys to often feel lonely. In almost half of the countries, fewer than 10 percent of boys often feel lonely compared to 15 percent in the U.S. About one of five U.S. girls often feels lonely, significantly more than girls in Denmark, Norway, England, Switzerland, Sweden, and Germany, but in comparable proportions to most other countries.

In three countries, Portugal, Israel, and Greece, 40 percent or more of girls often feel lonely. No significant differences occur across the three age groups in the U.S. (data not shown).2

Differences by age for girls are not consistent across other countries. Large increases between ages 11 and 15 in the proportion of girls who report feeling lonely occur in Portugal, Greece, Latvia, and Greenland, for example.2

Graph: "How Do You Feel About Your Life At Present?"[d]   Graph: "Do You Ever Feel Lonely?"[d]


U.S. students, both boys and girls, rank first or second among all countries in reporting of backache, stomachache, and headache at least weekly, significantly higher than the vast majority of other countries. In all countries, girls report more biological symptoms than boys. More than 40 percent of U.S. females report backaches or stomachaches at least weekly; 57 percent report headaches. Among U.S. boys, about one-third reported headaches or backaches occurring at least weekly; 28 percent reported stomachaches. U.S. ranking does not differ for ages 11 and 13 years.1 Headache and backache are somewhat less common in the youngest years in other countries according to data shown in the international report.2

International contrasts show stomachache is reported by <25 percent of girls in 19 other countries; 10 percent in the lowest ranked country. Less than 20 percent of boys elsewhere report stomachache in all but three countries. Similarly low proportions are shown for backache in 20 other countries. Headache is reported by about one-third of girls in six countries with lowest proportions, <20 percent of boys. Less than half of girls report these frequent headaches in the majority of countries. As with headaches, at least 10 percent more girls than boys report weekly stomachaches in all countries.

Graph: "In The Past Six Months, How Often Have You Had A Backache?"[d]


Graph: "In The Past Six Months, How Often Have You Had A Headache?"[d]

  Graph: "In The Past Six Months, How Often Have You Had A Stomachache?"[d]

The U.S. ranks among the top four for both boys and girls in feeling low, behind Greece, Israel, and Hungary, and ranked first for students at age 11.2 Feeling low is higher for girls than boys for all ages, and increases with age in the U.S. About half of 15-year-old U.S. girls (49%) feel low at least once a week and almost one-third of boys (34 percent). This is consistent for girls in all countries, but not for boys.2

U.S. boys rank first in reporting of difficulty sleeping at least once a week (41 percent); 46 percent of U.S. girls reported weekly difficulty, ranking second after France. Both U.S. boys and girls had rates similar to Canada, Wales, and Israel.

Graph: "In The Past Six Months, How Often Have You Felt Low?"[d]   Graph: "In The Past Six Months, How Often Have You Had Sleep Difficulties?"[d]

U.S. students rank third among countries for feeling tired in the morning four or more times a week, led only by Norway and Finland. (Rankings among countries are generally consistent at ages 11 and 13 years also.)2 About 40 percent of U.S. students report feeling tired compared to <15 percent in the lowest ranked countries. In contrast to other symptoms, boys feel morning tiredness slightly more often than girls in all three age groups in most countries.2

Graph: "How Often Do You Feel Tired When You Go To School In The Morning?"[d]


Medication use tends to reinforce the pattern of reported symptoms for headache, stomachache and difficulty sleeping. U.S. students rank first in taking medication for headache (and first or second at ages 11 and 13 years).2 They rank eighth in taking medication for stomachache (fourth at age 11 years; and 7th at 13 years).2 U.S. boys ranked fourth and girls ranked third in taking medication for sleep difficulties with similar rankings at younger ages. However, U.S. students are no more likely to take medications for nervousness than students in the majority of other countries nor were they more likely to report being nervous (data not shown).2

Graph: "During The Past Month, Have You Taken Medication For Sleep Difficulties?"[d]

What Didn't We Know?

Students in the U.S. rank highest or among the top four countries in prevalence of stomachache, backache, headache, difficulty sleeping, feeling tired, and feeling low. Report of medication use for headache, stomachache, and difficulty sleeping is equally high, supporting high estimates of student reports for these symptoms. U.S. students are no more likely to feel lonely, but they are more likely to report feeling low at least once a week. Girls report higher levels of all these symptoms than boys, except for feeling tired.

The relatively high prevalence of headache, stomachache, and backache symptoms in the U.S. are consistent with the comparatively low ranking in the U.S. for feeling healthy. The concurrent high reports of medication use for these symptoms raises a number of questions about both the reasons for higher reporting of the symptoms and whether U.S. youth are more likely to medicate for such symptoms. Gender differences in the U.S. are consistent with HBSC reports from earlier surveys.13 Compared to boys, adolescent girls across the countries are more likely to report feeling less healthy or happy, to feel more lonely or low, and to have more biological symptoms.

Household health surveys in the U.S. show that parents and guardians report their children's general health status to be good, very good or excellent for 98 percent of both boys and girls at ages 12-17 years; 81-82 percent are reported by their parents to be in "very good" or "excellent" health.14 How parental reports compare to adolescent self-reports is unknown but would be a useful study, particularly taking family relationships and communication levels into consideration. Parental perceptions and adolescent perceptions with additional self-knowledge may differ through the transitions to independence.

In the HBSC, feeling low is considered to be a negative or depressive symptom. Since students were not given an example of what 'feeling low' meant, it is possible that reports of 'feeling low' may be measuring either biological and/or psychological feelings. However, findings for U.S. students about feeling low at least once a week are consistent with relatively high reports of feeling sad among high school students in the 2001 YRBS.9 The YRBS also found that girls are more likely to report feeling sad than boys. A report from the U.S. Surgeon General finds that approximately 20 percent of children and adolescents experience a diagnosable mental disorder annually.15 An AddHealth study that followed students for one year found changes in depressive symptoms during that year, with female gender the only sociodemographic variable consistently associated with higher prevalence of depressive symptoms at baseline and one year later. Factors significantly associated with persistent moderate/severe depressive symptoms were school suspension, fair/poor general health, somatic symptoms, suicidal ideation, receiving psychological counseling, and difficulty in obtaining needed medical care.16

U.S. research on feeling tired shows that adolescents are biologically challenged by early school start times and shortened sleep schedules, resulting in impaired daytime functioning.17 Data showing high U.S. ranking for difficulties sleeping, including medication treatment, indicate that other factors may be affecting tiredness as well. Reports of relatively low quality of life (such as not feeling happy and feeling lonely) also raise questions about the relationship between these problems with physical health symptoms. Feelings of health and well-being may be correlated with factors described in the following chapters on fitness, family and peer relations, and school.


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  1. MacKay AP, Fingerhut LA, Duran CR. Adolescent Health Chartbook. Health United States, 2000. Hyattsville, MD: National Center for Health Statistics, 2000.
  2. Currie C, Hurrelman K, Settertobulte W, Smith R, Todd J. Health and Health Behaviour Among Young People. WHO Policy Series: Health Policy for Children and Adolescents Issue 1.
  3. Behrman RE. Kliegman RM, Jenson JB. Nelson Textbook of Pediatrics. 16th ed. Philadelphia PA: W.B. Saunders Co., 2000;pages 52-57.
  4. Friedman SB, Fisher M, Schonberg SK, Alderman EM. Comprehensive Adolescent Health Care. St. Louis, MO: Mosby Press, 1998;pages 23-33.
  5. Starfield B, Riley AW, Green BF, Ensminger ME, Ryan SA, Kelleher K, Kim-Harris S, Johnston D, Vogel K. The adolescent child health and illness profile. A population-based measure of health. Medical Care 1995;33(5):553-66.
  6. Riley AW, Forrest CB, Starfield B, Green B, Kang M, Ensiminger M. Reliability and validity of the adolescent health profile-types. Medical Care 1998;36(8):1237-48.
  7. U.S. Department of Health and Human Services. Major Data Sources for Healthy People 2010. In: Tracking Healthy People 2010. Washington, DC: U.S. Government Printing Office, 2000;pages C1-C48.
  8. Raphael D, Rukholm E, Brown I, Hill-Bailey P, Donato E. The Quality of Life Profile— Adolescent Version: Background, description, and initial validation. Journal of Adolescent Health 1996;19(5):366-75.
  9. Grunbaum JA, Kann L, Kinchen SA, et al. Youth Risk Behavior Surveillance - United States, 2001. MMWR 2002;51(SS4):1-28.
  10. National Longitudinal Study of Adolescent Health: In school questionnaire. Chapel Hill, North Carolina: Carolina Population Center, University of North Carolina at Chapel Hill, September 1998.
  11. Rushton JL, Forcier M, Schectman RM. Epidemiology of depressive symptoms in the National Longitudinal Study of Adolescent Health. J Am Academy of Child and Adolescent Psychiatry 2002;41:199-205.
  12. Federal Interagency Forum on Child and Family Statistics. America's Children: Key national indicators of well-being, Federal Interagency Forum on Child and Family Statistics. Washington, D.C.: U.S. Government Printing Office, 1998.
  13. Kolip P, Schmidt B. Gender and health in adolescence. WHO Policy Series "Health policy for children and adolescents", Issue 2. Copenhagen, Denmark: WHO Regional Office for Europe, 1999;pages 14-19.
  14. Bloom B, Tonthat L. Summary Health Statistics for U.S. Children: National Health Interview Survey, 1997. Data from the National Health Interview Survey. Centers for Disease Control and Prevention, National Center for Health Statistics, Vital and Health Statistics, Series 10, No. 203. Hyattsville, MD: DHHS Pub. No. (PHS) 2002-1531, 2002.
  15. U.S. Department of Health and Human Services. Mental Health: A Report of the Surgeon General-Executive Summary. Rockville, MD: U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, Center for Mental Health Services, National Institutes of Health, National Institute of Mental Health, 1999.
  16. Rushton JL, Forcier M, Schectman RM. Epidemiology of depressive symptoms in the National Longitudinal Study of Adolescent Health. J Am Academy of Child and Adolescent Psychiatry 2002; 41:199-205.
  17. Wolfson AR, Carskadonm MA. Sleep schedules and daytime functioning in adolescents. Child Development 1998; 69:875-887.

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Table of Contents | Executive Summary | Introduction | Chapter 1 | Chapter 2 | Chapter 3 | Chapter 4 | Chapter 5 | Chapter 6 | What Was Left Out | Summary

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