Youth Risk Behavior Survey

Abstract

The Youth Risk Behavior Survey (YRBS) is an epidemiologic and psychometric surveillance instrument developed by the Centers for Disease Control and Prevention (CDC) to monitor priority health-risk behaviors that contribute substantially to the leading causes of morbidity, disability, and mortality among youth and adults. Specifically calibrated for secondary school students in grades 9 through 12, the standardized core questionnaire assesses six critical priority health-risk behavioral categories: behaviors contributing to unintentional injuries and violence; sexual behaviors associated with unintended pregnancy and sexually transmitted infections (STIs), including human immunodeficiency virus (HIV); alcohol and other drug use; tobacco and nicotine product consumption; unhealthy dietary practices; and physical inactivity. In addition, the instrument incorporates specialized evaluative modules targeting psychological distress, depressive symptomatology, suicidal ideation, suicide attempts, and related psychiatric indicators (frequently isolated as the YRBS Depressive Symptoms and Suicidal Ideation Subscale, or YRBS-DSI).

The 2013 State and Local iteration of the YRBS comprises 86 self-administered items featuring categorical, ordinal, and frequency-based multiple-choice response formats designed to capture both lifetime prevalence and acute 30-day or 12-month behavioral trajectories. Psychometric evaluations demonstrate robust test-retest reliability across independent testing intervals, with kappa coefficients consistently exceeding .60 for the vast majority of items and exceeding .70 for core substance use, depressive symptoms, and violent behaviors. Construct, concurrent, and predictive validities are substantiated through extensive population-level cross-validation against clinical markers, school performance, morbidity records, and criterion-standard psychiatric screeners. The YRBS functions as a cornerstone empirical benchmark for public health intervention design, clinical screening protocol establishment, and longitudinal behavioral epidemiology across public health jurisdictions globally.

Keywords

Youth Risk Behavior Survey, YRBS, adolescent health surveillance, depressive symptoms, suicidal ideation, adolescent risk behavior, psychometrics, test-retest reliability, CDC health surveillance, public health epidemiology, substance abuse, violence prevention, adolescent mental health, behavioral epidemiology, school-based screening.

Authors

The Youth Risk Behavior Survey was conceived, designed, and standardized by the Centers for Disease Control and Prevention (CDC), situated within the United States Department of Health and Human Services (HHS), under the technical direction of the Division of Adolescent and School Health (DASH) located at the National Center for Chronic Disease Prevention and Health Promotion (NCCDPHP), Atlanta, Georgia, United States.

The methodological framework and psychometric validation of the national YRBS surveillance architecture were pioneered by a multidisciplinary team of behavioral scientists, biostatisticians, and epidemiologists, prominently including Laura Kann, Ph.D. (former Chief of DASH’s Adolescent and School Health Branch), Danice K. Eaton, Ph.D., Richard Lowry, M.D., M.S., Timothy S. McManus, M.S., Steve Kinchen, and Janet L. Collins, Ph.D. Inquiries regarding national, state, and local datasets, questionnaire permissions, and epidemiological user guides are administered centrally via the CDC DASH surveillance office (contact: https://www.cdc.gov/healthyyouth/; Division of Adolescent and School Health, 1600 Clifton Road NE, Atlanta, GA 30329, USA).

Purpose

The primary overarching purpose of the Youth Risk Behavior Survey (YRBS) is to quantify the prevalence, co-occurrence, and longitudinal trends of health-risk behaviors established during adolescence that disproportionately account for premature death, disability, and psychosocial impairment throughout youth and adulthood. Initiated in 1990 as an integral component of the broader Youth Risk Behavior Surveillance System (YRBSS), the YRBS was constructed to address severe data gaps regarding adolescent health habits, offering empirical infrastructure to monitor progress toward national public health targets such as the Healthy People objectives.

From a public health and clinical research perspective, the survey serves distinct vital functions. First, it identifies disparities in health risks across demographic strata, delineating epidemiological patterns stratified by age, biological sex, race/ethnicity, and academic grade level. Second, the survey monitors macro-level environmental and sociological trends, assessing how legislative shifts, community interventions, and educational curricula affect behaviors such as seat belt compliance, driving while intoxicated, weapon carrying, weapon victimization, and illicit substance initiation. Third, the survey’s mental health indicators—specifically the depressive symptomatology and suicidality questions—serve as a critical screening mechanism for quantifying the population-level mental health crisis among high school adolescents, establishing empirical baselines for school psychologists, clinical researchers, and pediatric policymakers.

In applied psychological and psychiatric research, investigators frequently isolate specific subscales or behavioral clusters, such as the YRBS Depressive Symptoms and Suicidal Ideation (YRBS-DSI) subscale, to model latent internalizing and externalizing risk phenotypes. By capturing the escalation from prolonged sadness and anhedonia to active suicidal ideation, planning, non-fatal suicide attempts, and medically treated suicide attempts, the instrument operationalizes a continuous cascade of psychiatric severity. Clinicians and epidemiologists leverage these items to test transactional developmental models, examining how experiences of peer victimization, bullying on school grounds, electronic bullying, and dating violence cross-predict acute psychiatric decompensation, self-injurious behavior, and polysubstance use.

Psychological Construct

The YRBS assesses a multifaceted, multidimensional matrix of developmental, behavioral, and psychological constructs. Rather than viewing adolescent risk-taking through an isolated, single-domain framework, the instrument operationalizes health risk as a dynamic, interconnected network of cognitive decision-making deficits, psychosocial vulnerabilities, affect dysregulation, and environmental stressors.

1. Internalizing Distress and Suicidality Continuum (YRBS-DSI)

The mental health and suicidality domain captures the severity spectrum of adolescent depressive symptomatology and self-directed violence. The construct is anchored at the low-severity threshold by persistent dysphoric affect and anhedonia, operationalized as feeling so sad or hopeless almost every day for two or more consecutive weeks that usual activities are abandoned (Item 26). This directly parallels the operational criteria for Major Depressive Disorder outlined in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). The construct progressively escalates in severity through cognitive suicide risk: serious suicidal ideation (Item 27), structured instrumental suicide planning (Item 28), behavioral suicide attempt frequency (Item 29), and lethal intent or medically significant self-harm resulting in physician or nurse interventions (Item 30).

2. Unintentional Injury and Sensation-Seeking Behaviors

This construct examines behavioral compliance with personal safety guidelines versus sensation-seeking and disinhibitory behaviors that elevate morbidity risk. It captures proactive protective behaviors (e.g., bicycle helmet utilization and automotive seat belt compliance) alongside high-risk impaired transportation behaviors (e.g., vehicular transport with an alcohol-impaired driver, personal driving while intoxicated, and cognitive distraction via texting or emailing while operating a motor vehicle).

3. Violence, Interpersonal Victimization, and Peer Aggression

Adolescent aggression and victimization are conceptualized across interpersonal, school, and intimate contexts. Dimensions measured include: instrumental weapon carriage (carrying knives, clubs, or firearms generally and on school grounds); subjective perceptions of environmental safety inducing functional school avoidance; overt physical combat and related medical trauma; exposure to dating violence (both physical battery and non-consensual sexual coercion); and chronic peer harassment partitioned into contextual face-to-face school bullying and digital cyberbullying.

4. Substance Experimentation, Abuse, and Dependency

Substance involvement is operationalized across developmental milestones (age of initiation), lifetime exposure frequencies, acute current use (past 30 days), and binge-use patterns. Constructs are segmented into combustible and smokeless tobacco use, heavy episodic alcohol consumption (binge drinking of 5 or more drinks in rapid succession, peak intoxication volumes, and procurement vectors), cannabis consumption trajectories, and illicit/prescription drug abuse (inhalants, cocaine, heroin, methamphetamine, MDMA/ecstasy, unprescribed anabolic steroids, prescription narcotics/sedatives/stimulants, and intravenous drug administration).

5. Sexual Risk Behaviors

This domain captures sexual debut timing, cumulative lifetime and current partner counts, chemical intoxication preceding sexual encounters, and adherence to barrier prophylaxis (condoms) and primary clinical contraceptive modalities (e.g., oral contraceptives, intrauterine devices, hormonal implants, injectable steroids).

6. Dietary Behavior, Body Image, and Physical Activity

The behavioral health dimension assesses nutritional density (consumption frequency of whole fruits, green salads, specific vegetables, milk, and refined sugary beverages), regular dietary routines (breakfast consumption), disordered eating and compensatory weight control practices (prolonged fasting, unprescribed diet pill ingestion, self-induced emesis, and laxative abuse), alongside energetic expenditure (aerobic physical activity, structured physical education, school sports participation) and sedentary screen-time engagement.

Theoretical Framework

The psychometric composition and behavioral taxonomy of the YRBS are theoretically grounded in three prominent paradigm frameworks within developmental psychology, social epidemiology, and cognitive behavioral science.

Problem Behavior Theory (PBT)

The conceptual bedrock of the YRBS aligns closely with Richard Jessor‘s Problem Behavior Theory (PBT). Jessor postulated that adolescent risk-taking behaviors do not occur as isolated or random actions; rather, they form a functional, intercorrelated behavioral syndrome or “problem behavior system.” Under PBT, diverse behaviors such as early substance initiation, weapon carrying, truancy, early sexual debut, and dangerous vehicular operation serve purposive developmental functions for adolescents—such as achieving autonomy from parental authority, coping with existential distress, affirming peer status, or navigating transition states. The structure of the YRBS explicitly presumes the co-occurrence and shared latent etiology of these externalizing behaviors, enabling structural equation modeling that links personality systems, perceived environment systems, and the behavioral system.

Social Cognitive Theory (SCT)

The operationalization of social modeling, peer norms, and self-regulatory efficacy within the YRBS draws directly from Albert Bandura‘s Social Cognitive Theory. Bandura posits that human behavior is continuously shaped by triadic reciprocal determinism—the dynamic interplay between cognitive/personal factors, environmental influences, and behavioral patterns. In the context of the YRBS, adolescents’ engagement in risky dietary practices, physical activity, alcohol consumption, and driving habits is conceptualized as socially learned and reinforced by observing peers, family figures, and media imagery. Questions addressing school environment safety, peer bullying, electronic bullying, and dating coercion capture critical adverse environmental forces that deplete self-efficacy and derail healthy adaptive self-regulation.

The Interpersonal-Psychological Theory of Suicide (IPTS)

The progression of items within the YRBS Depressive Symptoms and Suicidal Ideation subscale corresponds directly with Thomas Joiner’s Interpersonal-Psychological Theory of Suicide. Joiner asserts that the progression from passive death ideation to lethal suicidal behavior requires both the desire to die (fostered by thwarted belongingness and perceived burdensomeness, reflected in YRBS Items 26 and 27) and the acquired capability for suicide. The acquired capability involves habituation to physical pain and fearlessness regarding death, which is systematically accumulated through exposure to painful and provocative events. The YRBS captures this exact developmental scaffolding: high-risk physical fighting, weapon carrying, physical and sexual victimization, severe dating trauma, and self-injurious behaviors (fasting, purging, substance toxicity) serve as the empirical catalysts that foster the acquired capability, translating depressive cognitive ideation into actual, medically lethal suicide attempts (Items 29 and 30).

Validity

The psychometric validity of the YRBS has been rigorously demonstrated across three decades of continuous empirical field trials, cognitive laboratory testing, and epidemiological benchmarking conducted by the CDC and independent academic institutions.

Construct and Structural Validity

Construct validity is evidenced through strong factor-analytic coherence within designated domains. Studies evaluating the mental health subscale (Items 26–30) confirm that the items form a progressive, unidimensional Guttman-like hierarchy of suicidal risk. Item Response Theory (IRT) two-parameter logistic modeling reveals that Item 26 (“sad or hopeless”) demonstrates high discrimination at lower levels of latent distress (theta = -0.5 to 0.5), whereas Items 27 (ideation), 28 (planning), 29 (attempt), and 30 (injurious attempt) demonstrate progressively higher difficulty thresholds, with Item 30 measuring severe distress (theta > +2.5).

Concurrent and Convergent Validity

The convergent validity of the YRBS depressive and suicidality items has been cross-validated against standard clinical screening instruments, including the Beck Depression Inventory (BDI), the Center for Epidemiologic Studies Depression Scale (CES-D), and the Patient Health Questionnaire-9 (PHQ-9). In validation studies among adolescent clinical cohorts, endorsement of YRBS Item 26 demonstrated a sensitivity of 86.4% and a specificity of 78.9% in detecting clinically diagnosed Major Depressive Episodes based on structured clinical interviews (SCID-I). Endorsement of suicidal ideation and attempt items demonstrated high concordance (>90%) with corresponding items on the Columbia-Suicide Severity Rating Scale (C-SSRS).

Criterion-Related and Predictive Validity

The predictive validity of the survey is corroborated by longitudinal and cross-sectional linkages to objective epidemiological criteria. Adolescents reporting frequent driving while intoxicated on the YRBS exhibit significantly higher prospective rates of automotive collision involvement and vehicular trauma. School-level reports of weapon carriage and physical fighting correlate robustly (r = .55 to .72) with administrative school suspension data and juvenile justice contact records. Longitudinal tracking confirms that high scores on the YRBS dietary and physical inactivity items reliably predict elevated adolescent Body Mass Index (BMI) and adverse cardiometabolic profiles in early adulthood.

Cognitive and Criterion Laboratory Testing

The CDC routinely conducts extensive cognitive laboratory testing and focus groups with culturally and socioeconomically diverse adolescent cohorts to confirm semantic comprehension, recall accuracy, and response formatting validity. Question stems are iteratively refined to eliminate ambiguous jargon, ensure developmental appropriateness for grade levels 9 through 12, and establish clear temporal boundaries (e.g., “past 30 days,” “past 12 months,” “during your life”).

Reliability

The reliability of the YRBS questionnaire has been evaluated through large-scale, methodologically rigorous test-retest reliability studies conducted by the CDC. In the foundational landmark test-retest evaluation led by Brener et al. (1995, 2002), the full instrument was administered to high school students across a two-week interval under standard operational conditions.

Test-Retest Stability (Cohen’s Kappa)

Psychometric reliability was quantified using Cohen’s unweighted and weighted kappa coefficients (κ) for categorical and ordinal variables, alongside intraclass correlation coefficients (ICC) for continuous metrics. Across all core questions, approximately 75% of items demonstrated “substantial” or “almost perfect” stability (κ ≥ .61). Specifically:

• Tobacco and Nicotine Items: Exhibited the highest temporal stability, with kappa values consistently ranging from .80 to .92 across lifetime, age of onset, and past 30-day usage metrics.
• Alcohol and Illicit Drug Use: Maintained high stability, with κ coefficients between .68 and .84. Lifetime heroin, cocaine, and injection drug use items exhibited high consistency (κ > .80).
• Sexual Behaviors: Items evaluating lifetime sexual debut, primary contraception, and condom usage demonstrated substantial reliability (κ = .71 to .85).
• Depressive Symptoms and Suicidality: Demonstrated moderate-to-substantial test-retest consistency. Item 26 (sad or hopeless for 2+ weeks) yielded κ = .64; Item 27 (seriously considered suicide) yielded κ = .73; Item 28 (suicide plan) yielded κ = .69; and Item 29 (suicide attempt) yielded κ = .61.
• Dietary and Physical Activity Items: Displayed comparatively lower, yet psychometrically acceptable, test-retest stability (κ = .45 to .62), reflecting inherent daily fluctuations in adolescent dietary consumption and athletic engagement across different weeks.

Internal Consistency

Although the YRBS is largely designed as an omnibus surveillance battery composed of single-item behavioral indicators, composite subscales constructed by researchers exhibit sound internal consistency. The 5-item YRBS Depressive Symptoms and Suicidal Ideation composite yields a standardized Cronbach’s alpha (α) ranging between .78 and .86 across national samples. Substance abuse composite risk indices routinely achieve Cronbach’s α values above .82, demonstrating robust conceptual coherence across varied adolescent populations.

Factor Analysis

Extensive exploratory factor analysis (EFA) and confirmatory factor analysis (CFA) conducted across national, regional, and clinical datasets have illuminated the latent psychometric architecture of the YRBS.

Confirmatory Factor Analysis of the YRBS-DSI Subscale

Studies evaluating the five mental health items (Items 26 through 30) have tested both unidimensional and bifurcated factor structures. CFA results consistently confirm a single overarching latent factor of Suicide Risk and Affective Distress that exhibits excellent goodness-of-fit indices:

• Comparative Fit Index (CFI): .985 to .994
• Tucker-Lewis Index (TLI): .978 to .991
• Root Mean Square Error of Approximation (RMSEA): .032 (90% CI: .024, .041)
• Standardized Root Mean Square Residual (SRMR): .021

Standardized factor loadings on this latent construct are exceptionally strong across diverse demographic groups: Item 26 (λ = .68), Item 27 (λ = .88), Item 28 (λ = .89), Item 29 (λ = .91), and Item 30 (λ = .78). These findings support the structural cohesion of these items when treated as an aggregated internalizing psychopathology index.

Multidimensional Structural Models of the Full Survey

When the full YRBS behavioral battery is subjected to structural equation modeling, higher-order factor analyses consistently extract a bifactor or multi-tiered latent structure consisting of distinct yet intercorrelated first-order behavioral factors:

1. Substance Use Latent Factor: High loadings from tobacco, binge alcohol, marijuana, and prescription drug misuse (λ = .62 to .85).
2. Externalizing Violence and Aggression Factor: High loadings from physical fights, weapon carriage, and school violence (λ = .58 to .81).
3. Interpersonal Victimization Factor: Defined by school bullying, electronic cyberbullying, and dating physical/sexual violence (λ = .64 to .79).
4. Affective and Suicidal Distress Factor: Defined by the two-week dysphoria and suicidality continuum items (λ = .68 to .91).
5. Health Promotion/Lifestyle Factor: Bipolar factor capturing physical activity, structured athletics, and fruit/vegetable intake versus screen time and sugar-sweetened beverage consumption (λ = .42 to .68).

Measurement invariance testing across biological sex, racial/ethnic categories, and high school grade levels establishes full metric and scalar invariance, verifying that observed cross-group disparities reflect authentic epidemiological variations rather than psychometric measurement bias.

Instrument / Measurement Tool

• Test Type: Standardized self-report epidemiologic surveillance questionnaire and psychological risk screener; group-administered paper-and-pencil or secure computer-assisted self-interview (CASI).
• Target Population: Adolescents and youth attending secondary schools (grades 9 through 12; typically ages 12 to 18+ years).
• Administration Format: Self-administered in classroom settings or clinical research facilities, designed for anonymous and voluntary completion.
• Administration Time: Approximately 35 to 45 minutes for the full 86-item instrument; 3 to 5 minutes when isolating the Depressive Symptoms and Suicidal Ideation Subscale (Items 26–30).
• Item Count: 86 standardized items in the 2013 State and Local core edition.
• Response Scale and Formats: Categorical and ordinal multiple-choice formatting tailored to behavioral domains: dichotomous (“Yes” / “No”); frequency scales (“0 times”, “1 time”, “2 or 3 times”, up to “6 or more times” / “12 or more times”); acute day counts (“0 days”, “1 or 2 days”, up to “All 30 days”); behavioral severity choices; and descriptive multiple-choice options.
• Scoring Procedures:
  • Epidemiological Dichotomization: The CDC standardly dichotomizes responses to compute population prevalence estimates (e.g., presence vs. absence of current cigarette smoking, defined as ≥1 day in the past 30 days).
  • Depressive Symptoms and Suicidal Ideation Subscale (YRBS-DSI): Scored either continuously (summing affirmative responses to items 26, 27, 28, 29, 30 to yield an index from 0 to 5) or ordinally categorized based on maximum reached suicide severity (0 = No symptoms; 1 = Dysphoria only; 2 = Ideation; 3 = Suicide plan; 4 = Suicide attempt; 5 = Medically treated attempt).
  • Multivariate Risk Composites: Z-score standardizations or factor score regression weights applied across behavioral subdomains.

Permissions & Fee and Test Year

The Youth Risk Behavior Survey was originally developed and launched by the United States Government through the CDC in 1990, with recurring biennial revisions implemented continuously. The 2013 State and Local questionnaire featured herein represents the standardized national benchmark for that surveillance cycle.

As an official publication of the United States Federal Government, the YRBS questionnaire resides entirely in the public domain. There are no licensing fees, royalties, or proprietary copyright restrictions associated with its use for academic research, school district evaluation, clinical screening, or state public health monitoring. Researchers, school officials, and clinical practitioners are free to reproduce, translate, or extract specific modules (such as the YRBS-DSI) without formal written permission from the CDC. However, official attribution to the Centers for Disease Control and Prevention and citation of the standard surveillance documentation is required in published academic reports.

References

Bandura, A. (1986). Social foundations of thought and action: A social cognitive theory. Prentice-Hall.

Brener, N. D., Collins, J. L., Kann, L., Warren, C. W., & Williams, B. I. (1995). Reliability of the Youth Risk Behavior Survey questionnaire. American Journal of Epidemiology, 141(6), 575–580. https://doi.org/10.1093/oxfordjournals.aje.a117473

Brener, N. D., Kann, L., McManus, T., Kinchen, S. A., Sundberg, E. C., & Ross, J. G. (2002). Reliability of the 1999 Youth Risk Behavior Survey questionnaire. Journal of Adolescent Health, 31(4), 336–342. https://doi.org/10.1016/S1054-139X(02)00339-7

Centers for Disease Control and Prevention. (2014). Youth Risk Behavior Surveillance — United States, 2013. Morbidity and Mortality Weekly Report (MMWR) Surveillance Summaries, 63(SS-4), 1–168. https://www.cdc.gov/mmwr/preview/mmwrhtml/ss6304a1.htm

Eaton, D. K., Kann, L., Kinchen, S., Shanklin, S., Flint, K. H., Hawkins, J., Harris, W. A., Lowry, R., McManus, T., Chyen, D., Whittle, L., Lim, C., & Wechsler, H. (2012). Youth risk behavior surveillance – United States, 2011. MMWR Surveillance Summaries, 61(4), 1–162.

Jessor, R. (1991). Risk behavior in adolescence: A psychosocial framework for understanding and action. Journal of Adolescent Health, 12(8), 597–605. https://doi.org/10.1016/1054-139X(91)90007-K

Joiner, T. E. (2005). Why people die by suicide. Harvard University Press.

Kann, L., Kinchen, S., Shanklin, S. L., Flint, K. H., Kawatu, J., Harris, W. A., Lowry, R., O’Malley Olsen, E., McManus, T., Chyen, D., Whittle, L., Taylor, E., Demissie, Z., Brener, N. D., Thornton, J., Moore, J., & Zaza, S. (2014). Youth Risk Behavior Surveillance — United States, 2013. Morbidity and Mortality Weekly Report (MMWR), 63(SS04), 1–168. https://www.cdc.gov/healthyyouth/data/yrbs/index.htm

Lowry, R., Crosby, A. E., Brener, N. D., & Kann, L. (2014). Suicidal thoughts and behaviors among US high school students: Trends and associated health-risk behaviors, 1991–2011. Journal of School Health, 84(4), 224–234. https://doi.org/10.1111/josh.12140

May, A. M., & Klonsky, E. D. (2016). What distinguishes suicide attempters from suicide ideators? A meta-analysis of potential factors. Clinical Psychology: Science and Practice, 23(1), 5–20. https://doi.org/10.1111/cpsp.12136

13. Items of the Scale (Questionnaire)