For debate in the Standing Committee — see Rule 15 of the Rules of Procedure
22 October 2003
Teenagers in distress: a social and health-based approach to youth malaise
Committee on Social, Health and Family Affairs
Rapporteur : Mr Ouzký, Czech Republic, European Democratic Group
Young people in Europe are increasingly engaging in behaviour likely to put their health and lives at risk. Such behaviour includes smoking, excessive alcohol consumption, illegal drug use, eating disorders and unprotected sexual activity. Suicide rates represent in many European countries the second most frequent cause of death among teenagers.
The transition from childhood to responsible adulthood is a time when young people need strong support to manage this transition successfully and to develop their capacities for “life management”. The Parliamentary Assembly therefore recommends to devise and set up information and awareness campaigns on various risk behaviours; health education programmes on general health, mental health and sexual health; suicide prevention, drug prevention and violence prevention campaigns; to establish facilities, such as drop-in centres or advice booths also outside school environments; strengthen emergency intervention and relapse prevention; and to introduce higher taxation on alcohol and tobacco.
I. Draft recommendation
1. The Parliamentary Assembly is concerned that young people in Europe are increasingly engaging in behaviour likely to put their health and lives at risk. Such behaviour includes smoking, excessive alcohol consumption, illegal drug use, eating disorders and unprotected sexual activity. Other dangerous activities include self-strangulation, “train-surfing” and crossing of motorways, undertaken in the search for intense and sensational feelings. Most young people are well aware of the danger such behaviour poses for their health and lives.
2. Also worrying is the rise in suicide rates among young people, which in many European countries represents the second most frequent cause of death among teenagers, after road accidents.
3. Young people have individual reasons and motivations for engaging in such behaviour. Nevertheless, the increase in risk activity indicates a growing distress common to young people in general.
4. In view of the rapidly changing social and economic environment, young people face an insecure and unpredictable future. In particular, high youth unemployment makes it difficult for them to integrate through the labour market. Alternative experience such as voluntary or community work should be encouraged.
5. Weakening social institutions and networks are one characteristic of the transformation of the social order. Former vehicles for social integration such as the family, the church, schools and trade unions have tended to lose their traditional influence. As the path into adulthood is no longer predictable, young people have to find their own way. The Assembly considers that the supportive role of the family, in particular, should be strengthened as the primary influence in fostering the successful integration of young people and that the member states should promote policies appropriate to this objective.
6. Young people in the Council of Europe member states have to face specific changes and challenges in their societies. They have weaker support networks and often lack adequate access to health care and information. These problems need to be addressed.
7. A major problem for young people in Central and Eastern Europe is the explosive increase of sexually transmittable infections, including in particular HIV/Aids. Low levels of awareness, deteriorating health care systems, poverty and high unemployment rates are conditions that foster the rapid spread of the epidemic. Other signs pointing to the distress of young people in this region are rising suicide rates and increasing alcohol consumption.
8. The transition from childhood to responsible adulthood is a time when young people need strong support to manage this transition successfully and to develop their capacities for “life management”. In the last decades this transition process has become longer and more complex. In order to manage the transition successfully, young people must be exposed to an extensive range of life experiences including formal education and training, opportunities for wide social contact and recreation and travel, including abroad, opportunities for achievement and for developing their talents, and access to advice and counselling in a friendly and supportive environment.
9. In order to strengthen the ability of young people to cope with the uncertainty and unpredictability of their future, programmes to foster resiliency should be made an integral part of general youth policies.
10. The Assembly therefore recommends that the Committee of Ministers invite the member states to:
i. i. pay greater attention to all forms of risk behaviour among young people and provide for appropriate prevention and support measures in their national and regional youth policies;
ii. ii. co-ordinate their child, youth and family policies with a view to preventing risk behaviour through the establishment of strong and reliable social networks;
iii. promote policies designed to strengthen the family in its traditional role of fostering the successful social integration of young people;
iv. devise and set up
a. information and awareness campaigns for young people on the dangers to which they are exposed through tobacco, alcohol and drug consumption or abnormal dietary habits;
b. health education programmes, based on better training for teaching and medical staff, to promote general health, mental health and sexual health;
c. programmes to prevent suicide;
d. violence prevention and awareness campaigns for young people;
e. prevention facilities, such as drop-in centres or advice booths, in particular outside the school environment, so that counsellors may hear teenagers’ pleas for help and defuse crises;
f. provisions for emergency intervention, particularly within the hospital sector;
g. programmes designed to improve relapse prevention;
h. measures to reduce the social cost of alcohol and tobacco consumption, including higher taxation on these products, and to bar minors from obtaining them;
i. strengthened drug prevention programmes for minors;
v. seek the support of the mass media in pursuing the above objectives.
11. The Assembly also recommends that the Committee of Ministers:
i. instruct the relevant bodies of the Council of Europe dealing with health matters to consider young people as an especially vulnerable group;
ii. promote closer co-ordination between the youth, social cohesion, education and family law sectors in the Council of Europe in order to ensure the coherence of policies on children, youth and the family;
iii. establish guidelines for dealing with risk behaviour of young people, including methods for improving their resiliency;
iv. launch programmes to establish institutionalised support directed specifically at young people in Council of Europe member countries in the areas of health care, information and prevention;
v. further research the causes of, and recent trends in, risk behaviour among young people.
II. Explanatory memorandum by Mr Ouzký
I. Definition of youth
1. Youth is regarded as the time of transition between childhood and adulthood. It is a time when young people need strong support to manage this transition successfully and to develop capacities for “life management”. In the last decades this transition process has become longer and more complex. Young people gain biological and intellectual maturity long before they are regarded as socially and financially independent and adult. Longer lasting education and growing difficulties in entering the labour market leave them economically dependent on parents or the state. The age of marriage and family founding has also increased. It takes longer for young people to establish independent households and families of their own.1
2. As the transition period is getting longer, it is not appropriate anymore to talk only about teenagers or adolescents, who are people aged 13 to 19. The United Nations uses the term “young people” to cover the 15-24 year age group2, and UN statistics relate to this group. However, it may be more helpful to make a distinction between adolescents in the 13-18 age group, which is when they need the greatest support for the transition to young adulthood, a term covering the 18-24 age group.
II. Demographic data
3. In the European Union countries the age group of 15-24 year olds represents about 12% of the entire population. The figure ranges from 10,8% in Germany up to 17,6% in Ireland.3
4. In the countries of Central and Eastern Europe and Central Asia the average is 16%. Central Asia has the highest proportion of 15-24 year olds at 19% and the Baltic States the lowest at 14%. In total numbers the region has around 65 million people aged 15-24 years.4
III. Explanations for risk behaviour
Social change and consequences for young people in Western European countries
5. Risk behaviour is often regarded as normal in young people. Testing one’s own capacities and experimenting with limits are seen as necessary factors in the process of establishing one’s own identity, which is the major development task during the adolescent years.5 However, new forms of increasingly risky behaviour, being a threat to the life and the health of young people, give cause for concern. Changes in society are regarded as possible explanations for these attitudes.
6. At present young people face new challenges and problems that former generations did not experience. There is a transformation of the social order taking place which is characterised by a fragmentation of the normative framework, weakening social institutions such as the family, the church, schools and trade unions and the disappearance of collective rites. Former vehicles for social integration are vanishing and the path to adulthood is no longer paved in advance. Therefore young people are forced to show initiative to find their own way. These highly individualised life struggles put young people under pressure. This sense of uncertainty about one’s place in a less socially cohesive world and about a future marked by greater flexibility and a lesser degree of common purpose, characterised as social dislocation, may be a more important explanation of psychosocial disorders in young people (crime, alcohol and drug abuse, depression, anorexia, bulimia, etc.) than social disadvantage.6
7. Nevertheless, the uncertainty due to rapidly changing economic and social conditions, especially a lack of jobs and high youth unemployment, produces additional stress.7 Youth unemployment rates are significantly higher than general unemployment rates everywhere in Europe, but they are especially high in southern Europe, in the Central and Eastern European (CEE) countries and, most of all in the war-struck zones of Southeast Europe and the Commonwealth of Independent States (CIS) countries. Moreover young people are over-represented in marginal and precarious employment.8
8. There is a widespread view that low self-esteem is a risk factor for a broad range of psychological and behavioural problems. However, research by Nicholas Emler for the J. Rowntree Foundation has shown among other things that relatively low self-esteem is not a risk factor for delinquency, violence towards others (including child and partner abuse), drug use, alcohol abuse, educational under-attainment or racism, but that relatively low self-esteem is a risk factor for suicide, suicide attempts and depression, for teenage pregnancy, and for victimisation by others. In each case, however, this risk factor is one of several and probably interacts with others. There are indications that childhood self-esteem is associated with adolescent eating disorders and with economic outcomes - earnings, continuity of employment - in early adulthood, but the causal mechanisms involved remain unclear.9
9. Risk behaviour of young people is explained to a certain extent by all these factors. Nevertheless, the majority of young people are able to cope well with these difficulties and insecurities and do not react with behaviour that puts their life or their health at risk.
Social change and consequences for young people in transition countries
10. Young people in Eastern Europe are facing major transformation processes in society. The time after communism brought new opportunities and new choices, but also new risks. Not only the opening of the frontiers, which increased drug and sex traffic, but also the social changes accompanying the transition such as poverty, inequality, weakening social cohesion, tensions around ethnicity, family and gender roles and discrimination had a negative impact on the health and development of young people. The consequences became manifest in poor nutrition, substance abuse, early and unprotected sexual activity, infections, depression and anxiety, suicide, and injury due to accidents and violence.10
11. It appears that young people in the region now face problems and risks similar to their western peers, although they often have much weaker support networks. The new risks are largely unknown by parents, educators and other authorities in society. The channels that brought young people into regular contact with health services, such as school and workplace check-ups, have been cut back. This means that young people have inadequate access to health care and information during this period of their lives when they are most likely to take risks.
12. Research has shown that 20 % of school age children suffer mental problems sufficient to distract them from learning. Much greater attention should be paid to this neglected area and examples of good practice studied and discussed, such as the Child and Adolescent Mental Health Services (CAMS) in the United Kingdom. The J. Rowntree Foundation will hold a conference on young people and mental health in July 2003.
Individual factors associated with risk behaviour
13. To find a definition for risk behaviour is difficult, as there exists a wide variety of such activity. The common and binding element of all these types of behaviour is the fact that the young people expose their lives and bodies to risk, well aware of the possible negative outcome. According to David Le Breton, a sociologist at the University of Strasbourg, every person has his or her own individual motivation for this behaviour. He states that in most cases the intention is not to die, but to gain an intense experience. Being confronted with the uncertainty and uncontrollability of the outside world, this gives a feeling of sovereignty. Considering that these young people take the initiative and try to show autonomy, their behaviour can be seen more positively, as a way to find their own identity. But it can also mean a cry for help or for attention. 11
14. Very often young people showing risk behaviour live in big agglomerations, go to overcrowded schools and live in problematic family situations. Young people from highly cohesive families, low family conflict and high social support from the family very seldom act in a risky way (except for occasional or low alcohol consumption). Further associated factors seem to be dissatisfaction with different aspects of school/academic experience and the availability of too much leisure time.12 In fact two categories of abusers may be distinguished: those without employment skills who see nothing but a bleak future and so indulge in alcohol or drug abuse in a structured or programmed way, and those, usually in full time education who binge at week-ends in response to the pressure they are under to perform well.13
15. Quite different are the reasons for undertaking extreme kinds of leisure and sports activities. Here people are too much integrated, they are suffering from a too structured life and their behaviour is a way of escaping the routine. 14
16. An important factor influencing risk behaviour seems to be the social and cultural context young people are in. Risk and risk-taking have to be regarded as a negotiated process, which is a product of social interactions. Risk and choice are mediated and negotiated through social relationships. The influence of the peer-group and of other important persons of reference should be taken into consideration.15
IV. Forms of risk behaviour
Smoking, alcohol and use of illegal drugs
17. Regular alcohol use among adolescents (11-15 year olds) in West European countries shows a clear downward trend. However, the increasing frequency of drunkenness is a cause for concern. On individual occasions ever larger amounts of alcohol are consumed with the intention of getting drunk. This behaviour is known as binge drinking.16
18. In Eastern Europe the figures for regular alcohol consumers are increasing. Alcohol use and abuse are well established in all countries of the transition region: young people start drinking at younger ages and the intensity of drinking is rising.17
19. A strong association between alcohol use and smoking tobacco reveals the clustering of different risk behaviours.18
20. The use of illegal substances is concentrated among young adults and particularly males in urban areas, although it seems to be spreading to some extent to smaller towns and rural areas. Research in Britain suggests that recreational drug use has become “normalised”, i.e. a mainstream, rather than marginal, activity among British youth.19 Cannabis use increased markedly during the 1990s in most EU countries, particularly among young people. Also, cocaine (powder and crack) use may have increased in recent years, although this trend is reported to be less clear.20 The same may be said of heroin.
21. Polydrug use is prevalent particularly among young people in dance club settings, but is an increasingly generalised phenomenon. Polydrug use is defined very broadly as the use of an illegal drug plus another legal or illegal drug at the same time. Alcohol, cannabis and ecstasy in particular are common combinations at parties. Fortunately, there is a relatively small number of deaths by overdose. However, there is growing concern about the health risks and potential long-term damage from this recreational form of drug use.21
22. Factors seen as associated with substance abuse are availability, advertising and legal restriction as well as the social position and social group of the young people involved. Research has shown that young people have a very clear idea of the risk of damaging their health. They are well informed about the consequences, but they are not able to resist the social pressure from their friends.22 Policy responses should include raising the financial and social cost of such behaviour and placing more emphasis on health education.
23. Anorexia nervosa and bulimia nervosa are the two major forms of eating disorders and they occur most often in adolescent girls and young women. Young men account for only five to ten percent of reported cases. For both disorders an increase has been noted in the last two decades. While unhealthy dietary habits seem to be a genuine problem in rich Western countries, leading also to a rapid rise in the incidence of obesity, little is known so far about the situation in Eastern Europe.
24. Anorexia nervosa is “a disorder characterized by deliberate weight loss, induced and/or sustained by the patient. This is done by avoidance of fattening foods and is very often accompanied by the use of appetite suppressants or by excessive exercise.”23 The people affected report feeling fat even when they are very thin and they are terrified of gaining weight or becoming fat. About one percent of young women are said to have anorexia.
25. Bulimia nervosa is “a syndrome characterized by repeated bouts of overeating and an excessive preoccupation with the control of body weight, leading the patient to adopt extreme measures so as to mitigate the “fattening” effects of ingested food. The patient attempts to counteract the “fattening” effects of food by one or more of the following: self-induced vomiting; purgative abuse, alternating periods of starvation; use of drugs such as appetite suppressants, thyroid preparations or diuretics.”24 The persons binge eat frequently and during this time feel out of control and are unable to stop eating. Afterwards they feel guilty and ashamed. It is estimated that two to four percent of young people are suffering from this disorder. But as bulimic persons are secretive, it is difficult to say exactly how many people are affected.
26. Most physical consequences of the eating disorder can be improved with nutritional rehabilitation, but some may be irreversible. Potentially irreversible effects can be growth retardation, pubertal delay or arrest and prevented acquisition of peak bone mass, which increases the risk of osteoporosis in adulthood.25 Furthermore, eating disorders have negative effects on the emotional well being of young people and on the accomplishment of their developmental tasks.
27. The reasons for developing eating disorders are complex. Biological, psychological, family and other social factors play an important role. The mass media are another significant influence as they promote an unrealistic beauty ideal that very few women can live up to. Thinness is presented in connection with success and popularity and is therefore a desirable goal for young people. Anorectic or bulimic persons are very often highly insecure, although they might act as if they have everything under control. Their forceful controlling of their body weight and ritualised eating habits give them a certain feeling of autonomy and power.26 All these eating disorders and unhealthy eating habits call for strengthened education programmes focusing on healthy eating.
Self harm and suicide
28. In comparison with other age groups the suicide rate of young people is very low. Nevertheless suicide is the second most frequent cause of death among young people and international comparative studies have demonstrated a rise in suicide rates in 15-24 year olds.
29. Young males are 4 to 7 times more likely to commit suicide than their female counterparts and use more violent methods. But young women more often attempt suicide.
30. Although the majority of young people who commit suicide have been diagnosed as suffering from a psychiatric disorder (depression or alcohol and/or substance abuse) it is not regarded as an illness. It is to be seen as the end-result of several interacting factors (neurobiological, psychological, cultural, social) that have an impact on the person.
31. The causes of suicide are complex. Associations have been made between suicidal behaviour and the depressive effects of physical or sexual abuse, youth unemployment, imprisonment, drug and alcohol misuse, bullying and school exclusion and, more generally, social inequality. Suicidal children seem to have a distorted assessment of reality (reality testing), are impulsive and have problems in emotional and social problem solving. Still it remains unclear why in similar circumstances some young people decide to take their own life, while others do not. 27
32. East European countries faced a substantial increase in suicides in the early years of transition. Over 4500 teenagers aged 15-19 committed suicide in the region in 1999, more than half of them in Russia. The Baltic States, Belarus and Slovenia are other countries with high suicide rates.28
33. Cause for concern are the numerous suicide chat rooms developing on the web. There are reports about persons having planned their joint suicide via email. One person killed himself (with sleeping pills) while chatting. None of his chat partners reacted although he informed them about what was going on. The existing chat rooms are widely used, but apart from this little is known about the real influence they are having on young people and about the consequences of the growing number of suicide chat rooms.
Sexually transmittable infections and HIV/Aids in Eastern Europe
34. The number of HIV infections in Eastern Europe increased nine-fold in just three years, growing from less than 30’000 HIV infections in 1995 to an estimated 270000 infections by December 1998.29
35. Young people seem to be the population group most concerned. In the Commonwealth of Independent States (CIS), almost 80% of new infections were among people under 29 between 1997 and 2000. In Estonia, 90% of newly registered infections involve people under 30.30
36. Poverty and high unemployment rates have made many young people turn to alternative sources of economic and emotional sustenance. Many escape into alcoholism or drug use; others work on the street and engage in commercial sexual activity. Prostitution and the trafficking of young girls and women to Western European countries are on the increase. In combination with a deteriorating health care system the conditions are ripe for an explosive spread of HIV/Aids in the region.31
37. Low awareness and unsafe behaviour among injecting drug users, like sharing of injecting equipment, are seen as the main reasons for the rapid spread of the epidemic. Most infections occur among injecting drug users. But a rapid spread of sexually transmitted diseases such as syphilis and gonorrhoea are signs of increasing unsafe sexual activity. This paves the way for an HIV/Aids crisis in a region that was one of the least affected parts of the world in 1989. UNICEF considers the HIV epidemic to be the biggest threat to young people’s health in Eastern Europe.32
38. The surveys undertaken by UNICEF have shown that the level of awareness about the prevention of HIV transmission is low among teenagers across much of the region. Furthermore they state inequalities in awareness according to gender, education and household wealth. Women with a low level of education or who live in poor conditions are especially disadvantaged.
39. Different organisations are making appeals for immediate and urgent action to prevent this crisis. They call for more accurate and relevant information on issues related to reproductive health and rights and promotion of access to safe and high-quality reproductive health services, targeted on specific socio-cultural settings.33
Other risk activities
40. In France some cases of deaths caused by an activity called ”jeu du foulard” (“the scarf game”) have recently received a lot of media attention. Young people strangulated themselves with the intention of causing temporary hallucination. Besides bearing the risk of dying when the pressure is loosened too late, this activity can cause serious and irreparable cardiac and neurological damage.
41. A report ordered by the French Minister of Education revealed that this is especially a boys' activity and that it occurs mostly among teenagers at very young age (11-13). It seems that they are not aware of the possible negative consequences and that they rely on (sometimes false) information given by their friends. 34
42. It is difficult to estimate how many young people engage in this activity and also how many cases end in death. In France it is not obligatory to declare the circumstances and the causes of a natural / non-violent death, therefore no statistical data are available. Different associations of victims’ parents speak of 30 to 70 deaths per year. However, doubts on the correctness of these numbers are expressed in the report to the French Minister of Education. On the basis of the information given on the websites of victims’ parents, the report estimates that there were around ten deaths by strangulation in this manner in the last ten years. The report draws the conclusion that at least the quantitative dimensions of this kind of risk behaviour are not grounds for major concern.
43. Besides the “jeu du foulard” other dangerous risk activities as for example “train surfing” or the crossing of highways are undertaken by young people.35 There are also games involving physical violence. Still very little is known about this type of risk behaviour concerning only a very small minority of young people. There is a lack of Europe-wide, comparative surveys.
44. The risk behaviour characteristic of many young people may take many forms and has complex and varied causes. The transition from childhood to responsible adulthood is a time when young people need strong support, in particular from the family acting in its traditional role, to manage this transition successfully and to develop capacities for “life management”. In recent times this transition process has become longer and more complex. In order to manage the transition successfully, young people must be exposed to an extensive range of life experiences including formal education and training, opportunities for wide social contact and recreation and travel, including abroad, opportunities for achievement and for developing their talents, and access to advice and counselling in a friendly and supportive environment. In this context, greater emphasis should be laid on the traditional role of the family. Member States should promote policies designed to strengthen the family in its supportive role.
45. The Council of Europe and the member States should do everything to ensure that sufficient attention is paid to this vulnerable age group and should take appropriate supportive and preventive measures as set out in the draft recommendation that accompanies this report.
Reference to committee: Doc. 8572, Ref. No. 2457 of 4 November 1999
Draft recommendation adopted on 30 September 2003
Members of the committee: Mrs Belohorská (Présidente), MM Christodoulides (1st Vice-Chairman), Surján (2nd Vice-Chairman), Mrs McCafferty (3rd Vice-Chair), Mrs Ahlqvist, MM Alís Font, Arnau, Mrs Bargholtz, Mr Berzinš, Mrs Biga-Friganović, Mrs Bolognesi, MM Brînzan, Brunhart, Buzatu, Çavuşoğlu, Colombier, Cox, Dees, Donabauer, Drljević, Evin, Flynn, Mrs Gamzatova, MM Geveaux, Giertych, Glesener, Gonzi, Gregory, Gülçiçek, Gündüz, Gusenbauer (alternate : Mrs Schicker), MM Hegyi, Herrera (alternate : Mrs Torrado), MM Hladiy, Hřie, Mrs Hurskainen, MM Jacquat, Klympush, Baroness Knight (alternate : Mr Vis), MM Kocharyan, Lomakin-Rumiantsev, Mrs Lotz, Mrs Lučić (alternate : Mr Dimić), MM Makhachev, Małachowski, Markowski, Marty, Maštálka (alternate : Mr Cabrnoch), Mrs Milićević, Mrs Milotinova, MM Mladenov, Monfils (alternate : Mr Timmermans), Ouzký, Padilla (alternate : Mrs Fernández-Capel), Mr Pavlidis, Mrs Pétursdóttir, MM Podobnik, Popa, Poty, Poulsen, Provera (alternate : Mr Piscitello), Pysarenko, Rauber, Riester, Rigoni, Rizzi, Mrs Roseira, Mrs Saks, Seyidov, Mrs Shakhtakhtinskaya (alternate : Mr Aliyev), MM Slutsky, Sysas, Mrs Tevdoradze, Mrs Topalli, Mr Vathias, Mrs Vermot-Mangold, MM Viera, Volpinari, Mrs Wegener, MM Van Winsen, Zernovski, ZZ…
NB: The names of those members present at the meeting are printed in italics.
Secretariat of the Committee: Mr Mezei, Ms Meunier, Ms Karanjac, Mr Chahbazian
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