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These behaviors contribute to the spread of infections and risk of unintended adolescent pregnancy 7 , 8 , both significant public health concerns 9 , Identification of targets for interventions that will most effectively reduce potential societal costs requires knowledge about risk factors that are causally associated with these sexual risk behaviors 11 , Childhood behavior problems have been identified as a risk factor for engaging in sexual intercourse in early adolescence 5 , 13 , 14 and having more sexual partners during adolescence 5.
Adolescents with a history of behavior problems, such as attention deficit hyperactivity disorder ADHD , oppositional defiant disorder ODD , or conduct disorder CD , may exhibit a more pronounced vulnerability for sexual risk behavior due to impaired risk assessment and judgment, higher impulsivity, or increased sensitivity to the immediate rewards of engaging in risk behavior rather than its long-term consequences 15 , These adolescents may also be more susceptible to negative peer influences encouraging unsafe sexual activity While engaging in sexual risk behavior could directly result from impairment due to behavior problems, this observed association could also be confounded by factors predisposing an individual to experience behavior problems and also engage in sexual risk behavior.
However, these variables may not be always be measured—or measured well—especially in large, longitudinal samples needed to establish potential causal associations.
Regardless, researchers must be able to rule out these unmeasured confounds in order to identify risk factors causally associated with sexual risk behavior. Most research on adolescent sexual health is based on traditional one-participant-per-family designs, which cannot control for many of these possible confounds.
Quasi-experimental approaches 20 that rely on natural experiments, such as comparing twins who differ in exposure to a risk factor 21 , 22 , provide more control for unmeasured familial confounds.