Portal de Periódicos da CAPES

Health Futures of Youth II: pathways to adolescent health, executive summary and overview

2002; Elsevier BV; Volume: 31; Issue: 6 Linguagem: Inglês

10.1016/s1054-139x(02)00513-x

1879-1972

Charles E. Irwin, Paula M. Duncan,

School Health and Nursing Education

Health Futures of Youth II: Pathways to Adolescent Health, a national invitational conference, was convened on September 14–16, 1998, in Annapolis, Maryland. The Office of Adolescent Health (OAH) in the Maternal and Child Health Bureau (MCHB) of the Health Resources and Services Administration, U.S. Department of Health and Human Services (DHHS) sponsored the conference. Collaborating with OAH in the development of the conference was a non-Federal planning committee co-chaired by Drs. Charles E. Irwin, Jr. and Paula M. Duncan. The structure of the meeting was similar to the Health Futures of Youth conference sponsored by MCHB in 1986 at Daytona Beach, Florida. The recommendations developed at the 1986 meeting played a major role in shaping public health policy for youth during the past decade [1Journal of Adolescent Health. Health Futures of Youth. J Adolesc Health 1988;9(Suppl 6):1S–69SGoogle Scholar]. The 124 participants at Health Futures of Youth II Conference included many of the Nation's leading experts on Adolescent Health from fields as diverse as communications, economics, education, law, medicine, nursing, nutrition, psychology, health policy, public policy, social work and sociology. Participants were charged with reviewing the most current research regarding major Adolescent Health issues and then developing recommendations designed to advance knowledge about, and improve, the health status and well-being of our adolescents. Recommendations on priorities for future research, training, and demonstration projects developed at the meeting, were intended to constitute an Adolescent Health agenda for the next decade. Work at the conference emphasized asset building and successes in Adolescent Health, but participants were also urged to find ways to improve the well-being of all adolescents — such as youth with special needs — and to include multiple perspectives in their deliberations. Participants met in six working groups to discuss broad topical areas and formulate sets of recommendations with rationales. Background papers were prepared to help focus the discussion of the work group participants. The four plenary presentations (and their corresponding papers as published in this volume) were included to highlight important cross-cutting issues relevant to all of the work groups. On the final day of the conference, the work groups reported their recommendations in a general session and received responses from representatives of the public and philanthropic sectors. The final reports of the six working groups as reported in this volume reflect the integrated responses generated at this last session. The members of the Planning Committee are listed on the title page, and the Appendix lists all the participants in attendance at the conference. Two plenary papers [2Irwin CE Jr, Burg SJ, Uhler Cart C. America's adolescents: Where have we been, where are we going? J Adolesc Health 2002;31(Suppl):91–121Google Scholar, 3Lerner RM, Castellino DR. Contemporary developmental theory and adolescence: Developmental systems and applied developmental science. J Adolesc Health 2002;31(Suppl):122–35Google Scholar] focused on the individual level, with overviews of the conceptual models for studying adolescent development and a summary of demographic and health-status data on adolescents in the United States. The second two plenary papers [3Lerner RM, Castellino DR. Contemporary developmental theory and adolescence: Developmental systems and applied developmental science. J Adolesc Health 2002;31(Suppl):122–35Google Scholar, 4Burt M. Reasons to invest in adolescents. J Adolesc Health 2002;31(Suppl):136–52Google Scholar] addressed influences on adolescent health and possible ways to enhance healthy adolescent development. Presentations focused on reasons to invest in adolescents and the effect of the media on adolescent health behaviors. Dr. Charles Irwin's paper, "America's Adolescents: Where Have We Been, Where Are We Going?" presents a comprehensive overview of the current national data and trends over the past two decades on demography, risk behaviors, and health status of youth [2Irwin CE Jr, Burg SJ, Uhler Cart C. America's adolescents: Where have we been, where are we going? J Adolesc Health 2002;31(Suppl):91–121Google Scholar]. Dr. Irwin noted that at the 1986 Health Futures of Youth conference, statistics on mortality were the only relevant national data available on adolescents [1Journal of Adolescent Health. Health Futures of Youth. J Adolesc Health 1988;9(Suppl 6):1S–69SGoogle Scholar]. Today, national data sets provide unprecedented opportunities to understand patterns of mortality, utilization of health services by insurance status, health risk behaviors, and the environmental context of adolescents. However, the use of available data is still limited by problems such as varying cohort age ranges, homogenized data about race and ethnicity, race and ethnicity used as proxies for socioeconomic status, and issues related to the duration and frequency of tracking trends over time. Nevertheless, national data sets can provide valuable insights into the social and environmental context of youth. Highlights of data and trends reported by Irwin and his colleagues indicate positive trends as well as areas of concern. Irwin notes that after two decades of unprecedented investment in both policy and program initiatives and improved data collection, there are some major improvements in the health status of all adolescents. In spite of the major improvements, however, African-American, Hispanic, Native American and impoverished youth are still being left behind in a number of areas. There do remain continuing challenges in the field which include societal ambivalence about adolescents; a lack of willingness in health initiatives to prioritize adolescents; and a weak connection between data, research, policy, and program. Irwin emphasizes the need to consider how data can be used to drive research, and how resultant policy developed from research and demonstration projects can be used to drive the development and sustenance of programs. Dr. Richard Learner's paper, "Contemporary Development Theory of Adolescence: Developmental Systems and Applied Development Science" emphasized the need to look at adolescence in the context of the entire lifespan and also from an assets based approach [3Lerner RM, Castellino DR. Contemporary developmental theory and adolescence: Developmental systems and applied developmental science. J Adolesc Health 2002;31(Suppl):122–35Google Scholar]. In his paper in this supplement, he emphasizes the critical importance of these assumptions and how they have important implications for research and application. For example, the interrelationship between levels of the developmental system calls for the design of policies and programs based on an integrative approach that is attentive to the complexity of adolescent-context relations at all levels of organization, ranging from micro (e.g., individual) to macro (e.g., community, society). Researchers can use policies and programs conducted in real-world settings as tools to explore whether certain variations in adolescent-context relations promote the desired developmental trajectories. Evaluation of the outcomes of these contextual changes may elucidate theoretical issues pertaining to plasticity in human development and the extent to which policy and program interventions can alter and enhance the course of human development in adolescence and throughout the lifespan. Such research based on the developmental systems perspective is an example of a new field of research known as applied developmental science (ADS). ADS is the systematic synthesis of research and applications to describe, explain, and promote optimal developmental outcomes in individuals and families as they develop throughout the life cycle. ADS provides a framework for the advancement of understanding about adolescent development and explores ways to enhance the development of individuals whose quality of life is being challenged by normative developmental problems and risks associated with the current historical moment. Dr. Martha Burt's presentation and paper in this volume entitled "Reasons to Invest in Adolescents" presents convincing arguments for prioritizing investments in adolescents and describes types of preventive and developmental programs that have produced positive outcomes for this age group [4Burt M. Reasons to invest in adolescents. J Adolesc Health 2002;31(Suppl):136–52Google Scholar]. Because adolescents suffer from few life-threatening conditions, they are often ignored by public health investments. Burt's thesis maintains that adolescence is a time period with great plasticity when the formation of harmful health habits can have long-term effects that will eventually exact a heavy toll on society, but where positive health habits may have the opposite effect, and will lead to the health of the country. Dr. Burt suggests that a focus on the quality of life for adolescents and the rest of the community rather than merely on morbidity and mortality might be a more effective strategy for convincing policymakers of the need for investment in adolescents. Policymakers need to understand the value of investing in the future health and productivity of adolescents and the need for holistic rather than problem-focused programming for youth. Efforts to help adolescents become contributing members of society rather than "resource absorbers" have the potential to foster economic productivity. Holistic programs for youth need positive developmental opportunities that are appropriate to adolescents' age and experience, families and environments, and the overall context in which their behavior occurs. Policymakers also need to know what strategies work for adolescents. One useful model provides a conceptual framework for designing programs for youth by explicating the connections between risk antecedents, protective factors, system markers, problem behaviors, and outcomes. Such a model can help policymakers decide where investments in supplying protective factors could be made most effectively to produce specific targeted outcomes. One way of describing the importance of investing in Adolescent Health in a comprehensive way is to consider the consequences of not making investments. There are compelling examples of the economic cost of risky behaviors in adolescents that may help overcome the resistance of policymakers to investing in interventions targeting youth. For example, in the United States, $260 billion is lost in earnings and forgone taxes for each-year's cohort of high-school dropouts, and $20 billion is spent annually in payments for income maintenance, health care, and nutrition to support families begun by teenagers. Burt maintains that because decision makers value these potential costs differently, such justifications for investments in adolescents must take into account the personal and societal outcomes that are most valued by the people who are being asked to invest. Dr. Jane Brown's presentation and paper entitled "The Mass Media and American Adolescents' Health" identifies how the media are contributing to risky adolescent health behaviors and provides ways to use the media as an ally in creating healthier futures for youth [5Brown JD, Witherspoon EM. The mass media and American adolescents' health. J Adolesc Health 2002;31(Suppl):153–70Google Scholar]. She described a teenager's media diet pyramid, which conceptualizes adolescents' use of the mass media according to scales of passive to interactive use and to levels of involvement in the common culture or realms of individual self-expression. A bi-directional model developed by Steele and Brown to depict adolescents' media practice assumes that teens are active users of the media and bring with them a set of experiences and motivations that will affect what media they choose as well as how it will be incorporated into their lives. Brown reviewed research that focused almost exclusively on television. This research provides evidence indicating that the media affect adolescents' health in a negative manner. Examples include desensitization to violence, aggressive behavior as a means to solve conflicts, premarital sex as acceptable, depiction of the use of contraceptives as rare, food advertisements that encourage adolescents to eat "unhealthy foods", female beauty as synonymous with being thin, alcohol advertisements that encourage positive attitudes about drinking and the sophisticated marketing strategy of cigarette advertisements to young adults. Given that adolescents will continue to be major consumers of the media, Brown identifies some promising approaches for investigators and the public to consider as we attempt to build liaisons with the media. Several of these strategies have been utilized over the past few years to minimize the media's potential negative effect on adolescents' health. More research is needed on the effects of the media (including music, magazines, and especially the Internet) on Adolescent Health, particularly sexual behavior and body consciousness. Public Health Campaigns need to be using the paid media to counter prevailing no-consequence messages to teens. These approaches will be costly but may be some of the most effective in promoting healthy behaviors. Media advocacy may help create a more positive environment for our youth through a reframing of youth and their health issues. The entertainment industry may present us with an opportunity to embed socially responsible health messages within entertainment programming. Role models in the popular media may be helpful in presenting responsible healthy behavior. Finally, there is a need to educate our youth through media literacy. Youth and their families need to learn how to critically analyze the media and assist health professionals to develop positive media messages about youth. The full details of the recommendations developed in each working group can be found in the six papers summarizing the deliberations of each working group within this volume [6Susman EJ, Reiter EO, Ford C, Dorn LD. Work Group I: Developing models of healthy adolescent physical development. J Adolesc Health 2002;31(Suppl):171–74Google Scholar, 7Halpern-Felsher BL, Millstein SG, Irwin CE Jr. Work group II: Healthy adolescent psychosocial development. J Adolesc Health 2002;31(Suppl):201–07Google Scholar, 8Farrow JH, Saewyc E. Work group III: Identifying effective strategies and interventions for improving adolescent health at the individ-ual level. J Adolesc Health 2002;31(Suppl):226–29Google Scholar, 9Steinberg L, Duncan P. Work group IV: Increasing the capacity of parents, families, and adults living with adolescents to improve adolescent health outcomes. J Adolesc Health 2002;31(Suppl):261–63Google Scholar, 10Blum RW, Ellen J. Work group V: Increasing the capacity of schools, neighborhoods, and communities to improve adolescent health outcomes. J Adolesc Health 2002;31(Suppl):288–92Google Scholar, 11English A, Wilcox B. Work group VI: Exploring the influence of law and public policy on adolescent health. J Adolesc Health 2002;31(Suppl):293–95Google Scholar]. The overarching message that developed from the meeting was the need for a major paradigm shift. Instead of adolescents being viewed as the problem, and adolescence as a distinct life stage with little relevance to the remainder of the life cycle, adolescence needs to be viewed as a positive period of the life cycle with unique opportunities for developing assets and promoting healthy development. A healthy adolescence is essential for a healthy and productive adulthood. The following summaries of each working group represent a synthesis of the recommendations developed at the conference. Work Group I [6Susman EJ, Reiter EO, Ford C, Dorn LD. Work Group I: Developing models of healthy adolescent physical development. J Adolesc Health 2002;31(Suppl):171–74Google Scholar] addressed the physiologic and behavioral changes that occur during adolescence and how they may affect health throughout the lifespan. Specific recommendations focus on four priority research areas including a further understanding of: (a) the neurophysiology of puberty using the "new technologies"; (b) the complex roles of the hormonal changes of puberty and its relationship to a number of physical and mental health disorders with their onset during adolescence; (c) the complex area of sleep and its affect on adolescents; and (d) nutrition research. The specific recommendations for each of these four areas are further identified below. 1.Recommendations for research in neuroendocrine physiology address the need for studies on the following areas:•The regulation of the onset of puberty and the neurobiological mechanisms that synchronize the activity of hypothalamic GnRH neurons.•The structural and molecular plasticity of the hypothalamic pulse generator.•The complex modulators of the pubertal endocrine process (e.g., diet, stress, and obesity).•Brain maturation in children and adolescents as they progress through puberty using neuroimaging and electrophysiologic techniques.2.Recommendations for research on growth and puberty call for:•The temporal characterization of the physical onset of puberty and its tempo of progression.•New longitudinal studies on the role in the maturational process of estrogen, leptin, adrenal androgens, and IGF I and II and their family of binding proteins.•Studies on the continuum of intrauterine growth retardation, premature adrenarche, obesity, functional ovarian hyperandrogenism, and a later adult syndrome of heightened cardiovascular risk.3.Recommendations for sleep research include the need for:•Studies on the influence of neuroendocrinologic pubertal changes on sleep and the consequences of inadequate sleep on adolescents.•The development of guidelines using existing data to educate the public and health professionals about the importance of sleep during adolescence.4.Recommendations for research on nutrition include studies to increase our understanding of:•Adolescent obesity and type II diabetes.•Risk factors for osteoporosis and possible prevention strategies in adolescence.•Issues related to nutrition, exercise, obesity, and dieting behavior. Work Group II [7Halpern-Felsher BL, Millstein SG, Irwin CE Jr. Work group II: Healthy adolescent psychosocial development. J Adolesc Health 2002;31(Suppl):201–07Google Scholar] examined adolescent psychosocial development, including cognitive, social, emotional, and affective development issues. A developmental systems perspective was used in developing the recommendations. The identified recommendations focus on five priority areas related to healthy adolescent psychosocial development. Action steps were suggested for each recommendation. A few examples of these action steps are provided in the following summary. 1.Adopt a developmental systems perspective in research, policy, program development, and practice.This recommendation is intended to promote a more integrative and dynamic systems perspective on adolescent development, encompassing biological, psychological, and social development in relation to the multiple, diverse, and changing contexts and cultures in which development is embedded and from which developmental pathways emerge. Examples of action steps include developing and disseminating change-sensitive methods and measures and encouraging more research on diversity of settings and people.2.Encourage adults to take greater responsibility for adolescents and their development.The goal of this recommendation is to educate and challenge all adults to foster the positive development of adolescents in their actions, in their institutions, in their policies, and in their programs. Examples of action steps include developing protocols on adolescent development that can be disseminated directly to people who work with adolescents and encouraging school policies and curriculum activities that promote cooperation and a sense of community.3.Encourage adolescents to be engaged as active participants.This recommendation is intended to foster greater opportunities for adolescents to be active, constructive agents in their own development and to encourage their engagement in all policies and programs that focus on adolescent well-being and healthy development. Examples of action steps include developing more peer programs and integrating adolescent input into all intervention, prevention, and training programs, as well as all research efforts related to adolescents.4.Pay more attention to the critical transitions in the lives of adolescents.The goal of this recommendation is to facilitate successful transitions in the lives of adolescents and understand ways that these transitions are promoted in diverse cultural, educational, religious, and social settings. Examples of action steps include fostering more successful adolescent transitions to work, especially for adolescents who are not going to college directly after high school, and developing alternative ways of measuring successful outcomes other than college attendance and completion.5.Help adolescents overcome challenges to healthy psychosocial development.This recommendation is intended to promote the use knowledge about psychosocial development to prevent and ameliorate problems that confront adolescents in today's society. Examples of action steps include implementing programs for pre-adolescents and identifying ways to keep adolescents in school. Work Group III [8Farrow JH, Saewyc E. Work group III: Identifying effective strategies and interventions for improving adolescent health at the individ-ual level. J Adolesc Health 2002;31(Suppl):226–29Google Scholar] focused on strategies to improve interventions at the individual level, with the goal of enabling adolescents to advocate for themselves and reach their full potential. To achieve this goal, the work group organized its recommendations around four areas: (a) research; (b) practices and services; (c) the translation and dissemination of research and best practices; and (d) policy. 1.Recommendations for research address the need for:•All future research on early intervention to encourage the use of models that are contextually and culturally appropriate.•Longitudinal studies to determine the developmental interplay of what occurs prior to adolescence and the relationship between risk and protective factors.•Further development of adolescent preventive services research, including an emphasis on economic analysis.•Analyses of evidence-based, cost-effective practices to develop evaluation tools that accurately reflect observed changes.•Prioritization of data collection and analyses that include underrepresented minority groups.2.Recommendations for practice and services include:•Ensuring access for all adolescents to a full range of culturally competent and developmentally appropriate health services, including prevention and early intervention services.•Using interdisciplinary practice and management models to inform prevention and early intervention services.•Ensuring that practice models demonstrate the effectiveness of process and outcome indicators.•Promoting and nurturing mentor-rich environments in all adolescent services.3.Recommendations for translation and dissemination of research and best practices call for:•Developing effective social marketing strategies for disseminating basic and applied research findings to inform adolescents, their families, and the general public as well as various professional and administrative audiences.•Promoting and supporting the development of interdisciplinary and culturally appropriate training models for adolescent services providers, including health professionals.•Developing, promoting, and supporting training models for researchers and providers that are based on principles of positive youth development, prevention, and early intervention.4.Recommendations in the area of policy include:•Building policy on evidence-based principles and best practices of youth development, prevention, and early intervention. To achieve this goal, research findings need to be translated into theory, principles, and best practices that define priorities for funding to support the needs of youth at greatest risk. Work Group IV [9Steinberg L, Duncan P. Work group IV: Increasing the capacity of parents, families, and adults living with adolescents to improve adolescent health outcomes. J Adolesc Health 2002;31(Suppl):261–63Google Scholar] focused on recommendations concerning the development of strategies for building the capacity of parents, families, and other caregivers to promote Adolescent Health and for disseminating information to educate parents about adolescence. The recommendations originating from this group included those that were directed to the Office of Adolescent Health within the Maternal and Child Health Bureau, public and private agencies, and general recommendations that cut across all facets of society. 1.Recommendations for the Office of Adolescent Health (OAH) include:•Providing national leadership for the dissemination of information about the importance of parents, families, and other caregivers in Adolescent Health and development.•Promoting research on the utility and cost-effectiveness of capacity-building strategies for parents and other caregivers to enhance Adolescent Health.•Identifying and developing strategies for disseminating research results to the public with a special emphasis on families with adolescents.•Including adolescents and their caregivers in the development of strategies to design, deliver, and disseminate programs and information to increase the capacities of families to foster healthy adolescent development.•Urging federal agencies, such as the Agency for Healthcare Research and Quality (AHRQ) to consider conducting a projected cost-benefit analysis for implementing the recommendations from Health Futures of Youth II.•Encouraging OAH to assume the leadership in making recommendations to DHHS on the role that the OAH and other DHHS agencies should play in fulfilling the Health Futures of Youth II recommendations.2.Recommendations for public and private agencies address the need to:•Encourage and support research to improve the dissemination through the media of information on parenting adolescents.•Encourage and support programmatic efforts to strengthen the relationship between experts on adolescence and parenting and people who work within the media.•Support research on parental characteristics and family circumstances that affect the capacity of parents and other caregivers to promote Adolescent Health and well-being.3.Other recommendations call for:•Reflecting the diversity of the American adolescent population in all policies, programs, practices, and research designed to enhance parents' capacity to promote Adolescent Health.•Training all professionals who work with adolescents or their parents and caregivers to assess and strengthen parents' and caregivers' capacity to foster healthy adolescent development.•Educating employers and other purchasers of health care about the importance of providing programs for parental capacity building.•Enlisting the support of partnerships and collaborations of community institutions in efforts to inform and assist parents of adolescents.•Providing information about adolescent development to parents of adolescents in special circumstances. Work Group V [10Blum RW, Ellen J. Work group V: Increasing the capacity of schools, neighborhoods, and communities to improve adolescent health outcomes. J Adolesc Health 2002;31(Suppl):288–92Google Scholar] addressed how communities can build their capacity to foster healthy adolescent development through programs that provide services to youth. Recommendations were focused on four central capacities that need to be strengthened: (a) the capacity to enhance what we know (research and evaluation); (b) the capacity to develop and implement effective interventions (training); (c) the capacity to ensure sustainability of successful interventions (policy and advocacy); and (d) the capacity to conduct other activities that support the interventions (infrastructure). 1.Recommendations for research and evaluation call for:•Developing a new theoretical model of positive youth development.•Testing the validity of the model through the analysis of extant databases and retrospective analyses of promising practices, programs, collaborations, and partnerships.•Conducting prospective studies that compare the validity or effectiveness and costs of various strategies based on the positive youth development model and the deficit model.•Conducting randomized controlled studies to determine the efficacy of programs, when appropriate.•Developing reliable and valid process and outcome indicators that can be used to plan programs, establish efficacy (accountability), and demonstrate effectiveness.2.Recommendations for training address the need to:•Provide technical training and support to local adolescent development planning councils.•Disseminate and market information about successful and effective community programs to local adolescent development planning councils.•Disseminate and market information about how communities can take effective programs to scale.•Disseminate and market tools for monitoring and evaluating community-based, youth-focused interventions.3.Recommendations for policy and advocacy call for:•Developing a unified policy statement with regard to development, implementation, evaluation, and monitoring of the multitude of effective programs.•Developing a unified advocacy strategy for ensuring investment in youth.4.Recommendations for infrastructure focus on:•Creating and supporting a national adolescent development planning council consisting of a full range of national stakeholders.•Creating local adolescent development planning councils consisting of a full range of local stakeholders.•Creating regional training and technical support centers.•Identifying and recruiting leaders to sustain the effective programs, evaluation, and advocacy. Work Group VI [11English A, Wilcox B. Work group VI: Exploring the influence of law and public policy on adolescent health. J Adolesc Health 2002;31(Suppl):293–95Google Scholar] examined the effects of law and public policy on Adolescent Health in the United States and sought to identify ways to influence the development of laws and policies for the benefit of youth. In addition to supporting recommendations made in the four background papers prepared for the conference, Work Group VI identified two overarching recommendations: (a) Reframe the public discourse regarding adolescence to create a more balanced image of youth, and (b) Protect and expand adolescents' access to a wide range of health services. Under each of these recommendations, three priority strategies were identified. 1.Reframe public discourse regarding adolescence to create a more balanced image of youth.•Develop and implement a communications strategy to educate and inform the public, policymakers, parents, and youth about the strengths, assets, and contributions of youth.•Develop national, state, and local sources of asset-oriented data on adolescent development, health, and well-being. These data sources should help assess youth strengths, assets, and contributions.•Develop constituencies and coalitions at the Federal, state, and local levels to prioritize, advocate for, and monitor policies addressing salient adolescent issues and problems.2.Protect and expand adolescents' access to a wide range of health care services.•Protect and monitor the implementation of existing funding streams for Adolescent Health care (e.g., Medicaid, State Children's Health Insurance Programs) at the state and Federal levels.•Ensure confidential access for minors to sensitive services such as reproductive health, substance abuse, and mental health services.•Develop and advocate for the funding and delivery of a comprehensive range of mental and behavioral health services for adolescents, including preventive, assessment, and treatment services.