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ImprovingAdolescentHealth

An Analysis and Synthesis of Health Policy Recommendations

Claire D. Brindis, Dr. P.H.Charles E. Irwin, Jr., M.D.Elizabeth M. Ozer, Ph.D. Margaret Handley, M.P.H.David K. Knopf, L.C.S.W., M.P.H.Susan G. Millstein, Ph.D.

National Adolescent Health Information CenterDivision of Adolescent Medicine, Department of Pediatrics and Institute for Health Policy StudiesSchool of MedicineUniversity of California, San Francisco

Report Summary

U.S. Department of Health & Human ServicesPublic Health Service

Health Resources & Services AdministrationMaternal & Child Health BureauOffice of Adolescent Health

ImprovingAdolescentHealth

An Analysis and Synthesis of Health Policy Recommendations

Claire D. Brindis, Dr. P.H.Charles E. Irwin, Jr., M.D.Elizabeth M. Ozer, Ph.D. Margaret Handley, M.P.H.David K. Knopf, L.C.S.W., M.P.H.Susan G. Millstein, Ph.D.

National Adolescent Health Information CenterDivision of Adolescent Medicine, Department of Pediatricsand Institute for Health Policy StudiesSchool of MedicineUniversity of California, San Francisco

Report Summary

Cite asBrindis, C. D., Irwin, C.E., Jr., Ozer, E. M., Handley, M., Knopf, D. K., Millstein, S. G. (1997).Improving Adolescent Health: An Analysis and Synthesis of Health Policy Recommendations.San Francisco, CA: University of California, San Francisco. National Adolescent Health Information Center.

To order a copy of the full report, please write to the National Adolescent HealthInformation Center, 1388 Sutter St. Suite 605A, San Francisco, California, 94109. Please remit a check payable to “UC Regents” for $25.00 to cover copying and mailing costs of the final report.

National Adolescent Health Information Center

The National Adolescent Health Information Center of the University of California, San Francisco was established in October, 1993. The Center is based within the Division of Adolescent Medicine, Department of Pediatrics and the Institute for Health Policy Studies. The Center's goal is to promote linkages among key sectors of the health care system that affect the health of adolescents.

The activities of the Center include: 1) increasing the availability of information related to the health of adolescents through a coordinated strategy that links collection, analysisand dissemination of Maternal and Child Health-related and other national activities; 2) improving the capacity of State Title V agencies to plan, deliver and improve accessand coordination of comprehensive primary care for adolescents; 3) conducting shortterm and long term studies to synthesize research findings, identify health trends, compare policy approaches and analyze current and proposed legislation affecting adolescents; and 4) developing strategies to increase the public's awareness of thehealth needs for special populations.

The National Adolescent Health Information Center is supported primarily by a grantfrom the Maternal and Child Health Bureau, MCJ06A80, Health Resources and ServicesAdministration, Public Health Service, U.S. Department of Health and Human Services.

Published byNational Adolescent Health Information CenterDivision of Adolescent Medicine, Department of Pediatricsand Institute for Health Policy StudiesSchool of MedicineUniversity of California, San Francisco1388 Sutter Street, Suite 605A,San Francisco, CA 94109Telephone: (415) 502-4856Facsimile: (415) 502-4858E-Mail: [email protected]

A C K N O W L E D G M E N T S

We greatly appreciate the generous support of the Maternal and Child HealthBureau (MCHB) which made the development of this document possible. In particular,we thank the following individuals for their assistance with the completion of this document: Audrey Nora, M.D., M.P.H., Director of the Maternal and Child Health Bureau;David Heppel, M.D., M.P.H., Director of the Division of Maternal, Infant, Child andAdolescent Health; Juanita Evans, M.S.W., L.C.S.W., Chief of the Office of AdolescentHealth; Woodie Kessel, M.D., M.P.H., Director of the Division of Education, Science, andAnalysis, and Trina Anglin, M.D. Ph.D., Medical Officer of the Office of Adolescent Health.

We also greatly appreciate the assistance of the members of the National Advisory Board of the National Adolescent Health Information Center for their review of an earlier draft of this monograph. Members of the National Adolescent HealthInformation Center Advisory Board include: Robert Blum, M.D., Ph.D., University ofMinnesota; Arthur Elster, M.D., American Medical Association; Abigail English, J.D.,National Center for Youth Law; James Farrow, M.D., University of Washington; Missy Fleming, Ph.D., American Medical Association; Jacqueline Gentry, Ph.D., American Psychological Association; Kathleen Grasso, J.D., American Bar Association;Holly Grayson, M.A., Johns Hopkins University; Karen Hendricks, J.D., American Academyof Pediatrics; Catherine Hess, M.S.W., Association of Maternal and Child HealthPrograms; Lorraine Klerman, Dr. P.H., University of Alabama at Birmingham; Rochelle Mayer, Ed.D., National Center for Education in Maternal and Child Health; Rose Mays, R.N., Ph.D., Indiana University; Barbara Ritchen, B.S.N., M.A., National Center for Leadership Enhancement in Adolescent Programs and the ColoradoDepartment of Public Health and Environment; Sheryl Ryan, M.D., University of Rochester; Michelle Solloway, Ph.D., Center for Health Policy Research at George WashingtonUniversity; Norma Taylor, Ph.D., National Association of Social Workers; and Linda Wildey, R.N., M.S.N., University of Cincinnati.

We are also grateful to Mr. James Kilbane, University of California, San Francisco for his contribution to the manuscript preparation and to Ms. Bobbie Wunsch, Mr. Steve Snider and Ms. Courtney Cart for their editorial assistance.

T A B L E O F C O N T E N T S

Prologue .............................................1

Report Overview ......................................3

Policy Goal One:Improve Access to Health Care for Adolescents........8Recommendation 1: Assure the Delivery of High Quality Services Recommendation 2: Provide Access to Comprehensive Health ServicesRecommendation 3: Improve Financial Access to Comprehensive Health ServicesRecommendation 4: Assure the Legal Right to Health Care and ConfidentialityRecommendation 5: Provide Adolescent-Focused and Adolescent-Acceptable Health Services

Policy Goal Two:Improve Adolescent Environments .....................12Recommendation 1: Strengthen, Support and Preserve FamiliesRecommendation 2: Improve the Social and Economic Conditions of FamiliesRecommendation 3: Improve Community Environments and ResourcesRecommendation 4: Encourage Understanding and Prevent DiscriminationRecommendation 5: Reduce Exposure to Unhealthy Conditions and Behaviors Including Violence

Policy Goal Three:Increase the Role of Schools in Improving Adolescent Health .........................15Recommendation 1: Promote Educational Policies that Encourage Success for All StudentsRecommendation 2: Link Schools with Families and with CommunitiesRecommendation 3: Develop Comprehensive Educational Policies that Include HealthRecommendation 4: Establish School-Based Health Clinics and School-Linked Health Centers

Policy Goal Four:Promote Positive Adolescent Health ..................17Recommendation 1: Create Adolescent-Positive Societal Norms and Commitment to Health IssuesRecommendation 2: Create Opportunities for Adolescents to Engage in Healthy BehaviorsRecommendation 3: Promote Adolescent Health

Policy Goal Five:Improve Adolescent Transition to Adulthood. . . . . . . . . . . . .2 0Recommendation 1: Enhance Life OptionsRecommendation 2: Create Community Involvement and Service OpportunitiesRecommendation 3: Create Employment OpportunitiesRecommendation 4: Facilitate Independent Living

Policy Goal Six:Improve Collaborative Relationships .................22Recommendation 1: Improve Government-Level CollaborationRecommendation 2: Improve Public-Private CollaborationRecommendation 3: Improve Community-Level CollaborationRecommendation 4: Improve Inter- and Intra-Professional Level Collaboration

Cross-Cutting Themes and Next Steps .................24

References ..........................................29

P R O L O G U E

Over the past decade, the health status of adolescents and young adultshas been the subject of growing concernamong policy makers, researchers, cliniciansand advocates interested in youth issuesand adolescent health. Poor health outcomes caused by health-damagingbehaviors, compounded by inadequateuse of available health resources, haveled to a number of national efforts tostudy the special health, social, economic,and legal needs of adolescents. Anunprecedented range and number ofbooks examining the health and well-being of America’s youth, as well as ahost of federal, state, and foundationreports, have proffered a multitude of recommendations aimed at rectifying abroad spectrum of problems.

Although field research and new policy and programmatic initiatives have documented the many problems adolescentsface in our increasingly complex and diversified society, we continue to lack aclear federal policy mandate that setsforth funding and policy priorities, andthat could provide guidance for how we approach the needs of our diverseadolescent populations. The complexity of those needs, and the ambiva l e n c eexpressed by our society concerning therole of adolescents, have made it difficult to establish a focused agenda for youth-related issues. Other societal demandscompeting for attention add another layerof difficulty to achieving a coherent agendafor action.

The policy analysis embodied inImproving Adolescent Health: An Analysis and Synthesis of Health PolicyR e c o m m e n d a t i o n s was compiled by theNational Adolescent Health InformationCenter to highlight areas where a common agenda can be developed, and to help clarify the steps that will becritical to improving the health of America’s

adolescents. This document is intended toprovide a framework for considering themany valuable policy recommendationsthat have been made in 36 major studies,reports, and books produced during thepast decade. Promising future directionsfor developing policy action, establishingpriorities, and mobilizing the private andpublic sectors are suggested as well. Amajor premise of this report is that, bybringing together the collective wisdom represented by the policy r e c o m m e n d a t i o n ssynthesized here, needless du p l i c ation ofeffort can be spared from going overalready well-trodden ground. Instead, theserecommendations, which represent a significant level of professional concur-rence, can be tested to see if they producea significant improvement in the health status of adolescents. In short, it is time to use these recommendations for thedevelopment and evaluation of the next generation of programmatic and policy efforts.

Improving Adolescent Health presentsan overview of six priority policy goalsthat emerged from a synthesis of the recommendations that were culled fromthe 36 source documents that werereviewed for this report. These priorityareas range from improving access to care, to improving collaborative relation-ships among our health, education, social services and justice sectors.Underlying all six of these major policygoals is an important fundamental postulate: if adolescents are to find ameaningful role in society, then societymust accept the responsibility for helpingthem to do so. Support for issues relatedto adolescent health must come not justfrom our health and education sectors,but from throughout society.

This policy review has been compiledat a time when our conception of adoles-cence has begun to shift. We havemoved from defining adolescence as a

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period of turbulence and stress to viewingthe adolescent years as a time whenopportunities to develop positive lifetimebehaviors and skills can be maximized.In this sense, we are indeed at a cross-roads: societal factors are increasinglyseen as playing a larger role in influencingadolescent development and behavior, aresult of which has been that greater policya t t e n tion is now being placed on adultinvolvement in, and responsibility for, ado-lescent well-being. A renewed national commitment to the needs of our youth has been reflected in recent calls for therecruitment of mentors and volunteers to develop meaningful and sustained relationships with children and youth.Efforts are being promoted that aim toprovide young people with safe places to learn and grow, help them to develop marketable skills through effective education,and create opportunities for youth to giveback to their communities. Further effortsto lower the high prevalence of teenagechildbearing, to prevent or reduce the use of tobacco, alcohol, and other sub-stances, and to prevent neighborhood andcommunity violence are also being mounted.

At the same time, major welfare and health care reforms are well underway, changing many traditional healthand social programs. State and local governments are taking on new roles andresponsibilities as the federal governmentsteps back from its long-standing leader-ship role in social programs that seek toaddress a variety of pressing societalproblems. This shift away from federalguidance and support is happening at atime when dramatic increases in thenumber and diversity of adolescents livingin this country add a significant extraurgency to the challenge of meetingincreasingly complex needs. The increasingpace of this devolution of responsibilitiesfrom the federal government to our statesand counties is a source of concern to

many experts, who fear that this trend willresult in a dilution of leadership and anunequal fragmentation of standards.Many adolescent health advocates areconcerned that without some form of centralized guidance, inequities in eligibilityr e q u i r e ments, benefits, resources, and service availability will be the inevitableresult of a loss of standardization.Standards and service availability are likely to vary widely, not just from state tostate, but within states, and even withincounties. To avoid extreme variance, somekind of balance or partnership must bestruck between a centralized role forestablishing nationwide standards, andthe responsiveness to local needs that can be achieved through shared federal,state and local community leadership and responsibility.

To advance a truly effective, proactiveyouth agenda, it is imperative to carefullyconsider a course of action that will produce the most favorable and possibleresults. In the absence of a national policy for children and youth, a multifacetedbut comprehensive and coordinatedapproach that ties together efforts at thecommunity, local, state, and national levels will be needed to resolve the complex issues that face both the adoles-cent population and our entire society.Our policy agenda must ally the health,education, job training, business, justice,and social service sectors to serve theneeds of adolescents, families and communities. Public policies must support these integrated, coordinated approaches, and professionals and advocates concerned with youth issuesneed to play a crucial role to ensure thatwe achieve this goal. This policy synthesisprovides a framework to move forwardthe process of improving the health and well-being of America’s adolescentpopulation.

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Agrowing concern regarding thehealth status of adolescents andyoung adults has led to a number

of national efforts to study the specialhealth, social, economic and legal needs ofa d o l escents. As a result, multiple federal,state and foundation reports and bookshave been written, promoting over 1,000recommendations and strategies aimed atimproving the health and well-being ofAmerica’s youth. Table 1 lists the names,sources, and the year of publication forthese documents.

In spite of these groundbreakingefforts, it appears that relatively little follow-through has occurred in responseto the recommendations, and no clearpolicy mandate has been developed thatestablishes priorities to guide change.Furthermore, the complexity of the social,economic, legal and health problems facing youth, the ambivalence concerningtheir role in society, and other competingsocietal demands have made it evenmore difficult to make significant inroadsin establishing a shared agenda aimed at improving the health and well-being of youth.

This analysis identifies consensusareas where policy recommendationshave been made. It also delineates critical barriers to implementation, identifies areas that have been omitted o r have only emerged more recently and highlights strategies that may aid in developing programs that reflect policy priorities. Six primary policy goals emerge as part of this policy framework:

➊ improving access to health care foradolescents;

➋ improving adolescent environments;

➌ increasing the role of schools inimproving adolescent health;

➍ promoting positive adolescent health;

➎ improving adolescent transition toadulthood; and

➏ improving collaborative relationships.

Clear goals and priorities, in the formof a national comprehensive AdolescentHealth Policy, need to be established.While this will help mobilize both thepublic and private sector to improve adolescent health, a number of barriersexist in creating such a consensus.

First, as a society, we appear to beambivalent about adolescents and therole that government should play in theirlives. There is a strong preference for families to take the lead in guiding thedevelopment of the next generation ofadults; however, parents are often notequipped with the knowledge and skillsthey need to raise their adolescents, northe support systems that would help themthrough this developmental transition.

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Report Overview

4

Second, the major biological and psychological changes occurring throughadolescence often test adults’ limits andcomfort, resulting in a negative societalresponse. Third, many of the health, social and educational supports requirelong-term investment, rather than briefepisodic responses. Fourth, there is significant controversy surrounding healthcompromising behaviors initiated duringadolescence, especially early sexualbehavior and tobacco, alcohol and druguse, preventing consensus on some of themajor health issues facing adolescents.

In some areas of adolescent healthpolicy, recent efforts, such as campaignsaimed at reducing drinking and driving,and the use of condoms, have hadpromising results. This success is due inpart to widespread consensus throughoutsociety about the acceptability of theseapproaches to improving health outcomes,sound fiscal backing for these efforts anda uniform policy approach which havecreated new norms. However, actions toaddress most adolescent health issueshave not met with similar conditions. Thelack of clear consensus in some of thecomplex areas has continued to limit previous and current efforts to implementrecommended policy changes. It is impor-tant to note that while consensus is vitalin establishing policy directions, the abilityto translate these policies into fundingdecisions, systemic changes and protocolsis also essential for creating actual change.

With this in mind, the reviewed recommendations seldom provide clearguidance to make change. Few providecommunities with direction for selectingthe strategies most suited to their needs.Many groups need technical assistanceand consultation to move forward. Further,the recommendations rarely propose howto build the level of community consensus

necessary to advocate for change, norassist with developing adequate under-standing of the steps needed for planningand implementation. Providing concretemodels and potential strategies for operationalization, financing, and long-term sustainability may help assure thatfuture efforts in defining recommendationswill have a greater likelihood of successful implementation.

Finally, many important changes haveoccurred in the environment since mostof the recommendations were made.These include managed care, system-widecollaborations, realization that evaluationshave not consistently tracked outcomes,demographic shifts which are affectinga vailable resources, the movement ofg o v ernment decision-making from thefederal to the state and local levels, andthe rapid expansion of technology thatincreases the importance of training andother educational opportunities for adoles-cents. These issues need to be addressedwith a national Adolescent Health Policy.The following is a synopsis of the six policy goals highlighted in the policy synthesis, with their rationale and a summary of their major recommendations.

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Table 1

National Policy Reports on theHealth of Adolescents

1987

1987

1988

1988

1988

1988

1989

1989

1990

1990

1990

1991

Health Futures of Youth:Conference Proceedings, specialissue of Journal of AdolescentHealth Care

Risking the Future, AdolescentSexuality, Pregnancy andChildbearing

Alcohol Use and Abuse: A Pediatric Concern

America 2000: An EducationStrategy

The Forgotten Half: Pathways toSuccess for America’s Youth andYoung Families

School-Based Health Clinics

Confidentiality in AdolescentHealth Care

Turning Points: Preparing AmericanYouth for the 21st Century

Code Blue: Uniting for HealthierYouth

Contraception and Adolescents

Latino Youths at the Crossroads

Adolescents at Risk: Medical andSocial Perspectives

Maternal & Child Health Bureau,Society for Adolescent Medicine,University of Minnesota (confer-ence sponsors)

National Research Council, Panelon Adolescent Child Bearing andPregnancy

American Academy of Pediatrics,Committee on Adolescence

U.S. Department of Education

William T. Grant Foundation,Commission on Work, Family and Citizenship

Society for Adolescent Medicine

American Academy of Pediatrics

Carnegie Corporation of New York,Carnegie Council on AdolescentDevelopment

National Commission on the Roleof the School and Community inImproving Adolescent Health,National Association of StateBoards of Education, AmericanMedical Association


Children’s Defense Fund

Cornell University Medical CollegeConference on Health Policy

YEAR POLICY REPORT ORGANIZATION

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Healthy Children 2000: NationalHealth Promotion and DiseasePrevention Objectives Related toMothers, Infants, Children,Adolescents and Youth

Report to the Congress and theNation on Adolescent Health,Volumes I-III

Reproductive Health Care forAdolescents

Access to Health Care forAdolescents

Beyond Rhetoric: A New AmericanAgenda for Children and Families

Corporal Punishment in Schools

Firearms and Adolescents

Health and Health Needs ofHomeless and Runaway Youth,

A Matter of Time: Risk andOpportunities in the Non-School Hours

National Action Plan forComprehensive School Health Education

Confidential Health Services forAdolescents

Health Promotion for OlderChildren and Adolescents

Healthy People 2000: NationalHealth Promotion and DiseasePrevention Objectives, ProgressReview on Adolescents/Young Adults

U.S. Department of Health andHuman Services

U.S. Congress, Office of TechnologyAssessment



National Commission on Children





American Cancer Society (in collaboration with 40 nationalo r g a n i z a t i o n s )

American Medical Association,Council on Scientific Affairs

National Institute on NursingResearch, Priority Expert Panel onHealth Promotion

U.S. Department of Health andHuman Services

Table 1 (cont’d)

National Pol icy Reports on theHealth of Adol escents

1991

1991

1991

1992

1992

1992

1992

1992

1992

1992

1993

1993

1993


7

1993

1993

1993

1993

1994

1994

1994

1994

1995

1995

1996

National Research Council, Panelon High-Risk Youth

Association of Maternal and ChildHealth Programs

American Medical Association





Carnegie Corporation of New York,Carnegie Task Force on Meetingthe Needs of Young Children

Institute of Medicine, Division ofHealth Promotion and DiseasePrevention, Committee onUnintended Pregnancy


American Medical Association,Department of Adolescent Health

Losing Generations: Adolescents inHigh-Risk Settings

Position Paper on AdolescentHealth

State-of-the-Art ConferenceAdolescent Health Promotion:Proceedings

Transition from Child-Centered toAdult Health Care Systems forAdolescents with ChronicConditions

HIV Infection and AIDS inAdolescents

Principles to Link By: IntegratingEducation, Health and HumanServices for Children, Youth andFamilies. Proceedings from anAAP Consensus BuildingConference on Integrated Services

Report of the AAP Task Force onMinority Children’s Access toPediatric Care

Starting Points: Meeting the Needsof Young Children

The Best Intentions: UnintendedPregnancy and the Well-Being ofChildren and Families

Great Transitions: PreparingAdolescents for a New Century

Healthy Youth 2000: A Mid-Decade Review, from HealthyPeople 2000-National HealthObjectives

Table 1 (cont’d)

Nationa l Policy Reports on theHealth of Ad olescents


Improving access to health care wasthe single most identified policy objective throughout the more than

1,000 recommendations and strategiesreviewed for this report. While adolescentsare at increased risk for many health-related conditions, they face considerablebarriers to accessing health care at alllevels of the health care system. Limitedaccess has been most frequently associatedw ith financial barriers, as well as with the organization of the delivery system,types of services currently available, legalrestrictions, and adolescents’ own percep-tions of restricted health care access.

Recommendations highlight system-wide approaches and specifically tailoredstrategies, including outreach strategies to link vulnerable adolescent populationswith developmentally appropriate andcomprehensive care that encompasses a user-friendly, nonjudgmental and confidential philosophy. The task ofincreasing service availability, throughsuch efforts as expanding service locations,and of integrating outreach services, ischallenging at a time when the healthcare system is undergoing major reforms.

One challenge involves understandingthe service utilization patterns of adoles-cents and determining the effectiveness ofproposed integrated strategies. As manyadolescent health problems are related to underlying social, psychological andeconomic factors, questions are raisedabout the types of health-related servicesmost needed and how the health caresystem can better coordinate its serviceswith other large systems involved in thelives of adolescents. Involvement from

major institutions, such as the family, thereligious community, the private sector, andthe judicial system must be increased tocomplement what is provided within thehealth and educational institutions thatserve adolescents. Coordination and continuity of care are particularly importantf or special populations of adolescentswhose health care needs often encompassnot only physical health, but mentalhealth and substance abuse treatment.

Many of the recommendations high-light the need to provide care that is inter-disciplinary, collaborative, compre-hensive and community-based. Enablingadolescents to legally access care andensuring its confidentiality is also seen ascritical. While the documented lack ofaccess to care has generated considerablep olicy attention, far less emphasis hasbeen placed on examining the content of services that adolescents r e c e i v e .Additionally, adolescents need to be morefully engaged in planning and shapingthe types of services available to assurethat services are responsive to their needs.

Recommendation 1.

Assure the delivery of high quality services

Improve training in adolescent health.

Training of health providers is recommendedfor specific health issues, such as consentand confidentiality, coercive sex, sexuallytransmitted diseases (STDs) diagnoses andtreatments, sexual orientation, culturalbeliefs, immunizations, provision of fostercare, health promotion and education,

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P O L I C Y G O A L O N E

I m p rove Access to Health Care for Adolescents

counseling techniques, and managementof victims of violence. Recruitment, training and incentives for racially andethnically diverse professionals workingwith adolescents were all discussed asmethods to increase access.

Improve the workforce distribution forproviding adolescent-related services.

Recommendations include changingreimbursement procedures to expand thepool of health providers and recruitingadditional providers; bringing providers togeographically underserved areas throughthe National Health Service Corps; anddeveloping standard practice guidelinesand quality assurance measures for basicadolescent health care through periodicityschedules and a manual of care thataddresses the health needs of migrantadolescents and their families.

Enhance coordination and supportfor adolescent health services.

Recommendations are generally system-wide at local, state and federal levels.These include establishment of schooland neighborhood health centers;increased technical assistance from thefederal Maternal and Child Health Bureauand state level Title V Maternal and ChildHealth programs; new ways to linkMedicaid-eligible youth with primary care providers; expansion of funding;“decategorization” of overlapping govern-ment-funded programs; and establishmentof Integrated School Health ServicesCouncils to oversee the provision of multidisciplinary services.

Recommendation 2.

Provide access to comprehensive health services

Ensure appropriate services arereadily available.

Adolescents need comprehensive, developmentally-appropriate services.Adolescents with specific health issuesmay benefit from comprehensive servicestailored to their needs. Examples includeadolescents who are pregnant and parenting; considered “at-risk”; members of ethnic, racial, sexual orientation minorityg r o u p s; homeless; poor; incarcerated; rural;or adolescents having special needs.There is general consensus that accessremain or become available to qualityreproductive services, including pregnancytesting, contraceptive care, prenatal care,and abortion services. These servicesshould also be provided without financialor legal restrictions.

Implement strategies to overcome adolescents’ barriers to access.

Adolescents face a variety of perceivedbarriers to care. One major strategy forovercoming adolescents’ concerns regardinga c c essing care is through intensive out-reach efforts. Establishing targeted outreachfor adolescent health services includes: 1) prioritizing the provision of outreachservices; 2) integrating outreach strategieswith overall program objectives; 3) fundingoutreach services; and 4) developing follow-up strategies to assure continuity of services and compliance with requiredmedical regimens. The most frequentlynamed groups needing special attentionwere homeless, runaway and pregnantadolescents. Latino, Asian, AmericanIndian, incarcerated, and HIV-positive adolescents were also mentioned asrequiring special outreach focus.

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Recommendation 3.

Improve financial access to comprehensive health services

Improve existing health coverage.

Recommendations include improvingexisting health insurance coverage foradolescents, expanding Medicaid eligibilityand improving the types of services covered. Some improvements couldinclude enrolling larger numbers of adolescents in health insurance plans,facilitating reimbursement for health andpsychosocial services, and providing reimbursement for case management,school-based health services, and treat-ment of behavioral problems. The passage of the State Child HealthInsurance Program (part of the 1997Budget Reconciliation Act) provides animportant opportunity for adolescents to gain the health coverage they have often been denied in the past.

Expand coverage for adolescents beyondexisting parameters.

Recommendations include universalhealth coverage plans, child-specific benefits plans, and coverage for clinicalpreventive services for adolescents, including psychosocial and counselingservices, mental health and substanceabuse treatment, dental services, nutrition services and reproductive health care. Use of co-payments as a way to discourageuse and control costs was seen as anadditional barrier to access care.

Recommendation 4.

Assure the legal right to health careand confidentiality

Improve legal access to health services for adolescents.

Recommendations call for new legislationmandating an expansion of Medicaid eligibility for adolescents, requiringemployers’ coverage of dependents’ health and prenatal care, and adopting a Child’s Bill of Rights that would protectadolescents. Providers should also receiveconsistent information about laws affectingadolescents’ access to health care.

Assure legal protection of confidential care.

Two primary routes to assure this accessare recommended. First, legislativeapproaches are recommended for assuringconfidentiality of care to adolescents seek-ing sensitive services, including policiesabout parental consent and notification,and mechanisms that would allow ado-lescents to establish independent accessto confidential care. Secondly, expansionof the roles of health care providers atmultiple levels, including at the individualpatient care, practice, policy and medicalassociation levels, are also recommended.

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Recommendation 5.

Provide adolescent-focused and adolescent-acceptable health services

Provide services that focus on adolescents’ needs.

Making health care delivery more personaland engaging for adolescents and providing them with services that meettheir needs are widely supported goals.The recommendations center on designatingr e s p o n s i b i l i t y for adolescent health at thelocal, state, provider and family levels, toassure that adolescent-focused servicesare appropriate and flexible, and that theyserve the best interests of adolescentsand their families, rather than suitingadministrative convenience.

Involve adolescents directly in the planning and delivery of health ser-vices.

Recommendations provide a variety ofmethods to involve adolescents in thedesign and delivery of services, rangingfrom mandated participation, use of focusgroups, and providing health professionalsw i th opportunities to collaborate with adolescents.

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The role of environments in affectingadolescent health has emerged asone of the most frequently discussed

policy areas. Environment refers to the formal and informal settings and institutionsw here adolescents spend most of theirtime or which significantly impact on their lives; key examples include the family, school, religious organizations,neighborhoods, and community settings.Economic trends and discrimination arealso important environmental influences.These contextual factors are increasinglyassociated with positive and negativeeffects on adolescents’ environments and their resultant behavior.

Despite recognition that settings affectbehavior, most policy efforts have focusedon improving adolescent health and well-being through changing individualbehavior without emphasizing the socialcontext of their lives. There is broad consensus among different policy groupsthat two strategies are needed: one thattargets the settings of family, school, andneighborhood, and another that emphasizesc o m p rehensive approaches to assure broadenvironmental changes.

Families, and the environments theycreate for adolescents, are seen as a criticalforce in shaping the experiences of adoles-c e n ts. At the same time, as a result ofeconomic and social developments, theAmerican family has undergone majortransitions which often result in symptomsof inadequate parenting. Many recom-mendations are geared to providing economic and social support to parents toenable them to enhance their abilities toparent their adolescents. Others recognize

that the lack of support for families hasoften resulted in social institutions becomingsurrogate families. Additional mentoringand afterschool programs will be neededto help adolescents. Many of these strategiescan further reinforce the efforts of families.

There is also recognition that a number of institutions will need to worktogether to improve the life environmentsof adolescents, and that there is a need to greatly reduce environmental hazards,such as access to firearms, alcohol andtobacco, and unsafe driving conditions,which contribute to the mortality and morbidity patterns evident in adolescents.

Recommendation 1.

Strengthen, support and preserve families

Adopt a broad-based commitment to fam-ilies with adolescents.

Recommendations reflect the need tostrengthen societal commitments to familiesand, in turn, families’ commitments toadolescents. Many of the family environ-ments are in trouble themselves, due toeconomic changes. Many recommenda-tions aim at supporting families so thatthey can be more involved with their children, from early infancy throughoutadolescence.

Establish policies to strengthen and support families.

There is consensus that parents’ timecommitment to adolescents must increaseand that family supports must be widelyavailable, so that families can spend more

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P O L I C Y G O A L T W O

Improve Adolescent Environments

time together, receive intensive servicesand benefit from broad-based efforts toaddress their multiple needs. Workplacepolicy changes in flexibility, such as family leave, are essential so that timecommitment does not compete withfinancial commitment. Family supportthrough family preservation, family therapy,mental health counseling services andcase management is deemed critical.

Recommendation 2.

Improve the social and economic conditions of families

Develop income support policies for families.

Family income is considered to be themost pervasive and important aspect indetermining the environment of the adolescent and in defining opportunities,as well as limitations. The revision ofincome support programs and tax reformsis consistently recommended, including theEarned Income Tax and Child Care Credits.Non-custodial parent support, especially inteenage families, is another key area, asprevious welfare policies appear to havediscouraged establishing paternity.

Increase opportunities for self-sufficiency.

Recommendations focus on low incomefamilies and the need to financially support employment options that promote the successful transition from welfare programs. Employer incentives for estab-lishing additional community employmentopportunities are seen as a potentiallyuseful strategy. Developing fatherhoodprograms that combine training withother non-cash contributions, such aschild care, were encouraged as legitimateways of meeting parental obligations.

Recommendation 3.

Improve community environments and resources

Strengthen the role of community institutions in the lives of adolescents.

Recommendations center on increasingthe availability of community sites to provide adolescent activities and onstrategies to increase community-basedplanning, collaboration and responsibilityfor adolescents.

Expand the re s o u rces and capacity of communities to conduct planning,implementation and evaluation activities.

Recommendations include making needsassessments an ongoing part of assessmentprocesses, tailoring needs assessments toindividual communities, focusing on community strengths, and establishingspecific objectives to be addressed bythese assessments and evaluations.

Recommendation 4.

Encourage understanding and prevent discrimination

Implement specific anti-discriminationmeasures and practices.

Few of the national recommendationsaim to eliminate or ameliorate the effectof discrimination on adolescents. However,a number of strategies are proposed,including addressing the inequities inschool funding, the enforcement of stateand federal legislation guaranteeing civilrights, increasing the use of role modelsfor disabled adolescents, using hiringincentives, supporting independent livingprograms, and supporting community pro-grams that can decrease gender stereotypes.

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Educate and train health professionalsand others to be responsive to the needsof diverse adolescents.

The importance of training for both healthproviders and others working with adoles-cents, including cultural competency training,is consistently recommended by severalgroups. Awareness of the social, cultural andethnic diversity of adolescents is critical forthe delivery of quality health care and otherservices. Experiential learning as part offormal education and training efforts tailored to the needs of local populationsare also necessary. Training in order toincrease sensitivity to adolescents, especially those representing special populations, should be integrated into the curricula of students in the health sciences and other professional schools.

Recommendation 5.

Reduce exposure to unhealthy conditions and behaviors including violence

Develop interventions that target environmental conditions and hazards.

Limiting access to firearms, reducingaccess to the means of suicide and homicide, and developing community-based violence prevention programs are strategies that reflect the greatest consensus. Other strategies addressreducing parental drug use, increasinglevels of adult supervision to reduce therisk of drug use among adolescents,improving the physical appearance of thecommunity, appointing youth to local taskforces and crime prevention programs,and incorporating law-related curricula inschools.

Develop and enforce restrictions toimprove environmental conditions and reduce hazards.

Restricting gun ownership and access toalcohol and tobacco, as well as assuringthat adolescents adopt social norms thatprevent driving while under the influenceof alcohol, are key recommendations.

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These recommendations reflect a con-sensus that a broad-based expansionof school and health services may

provide a critical link between adolescentsand needed services. There is a strongconsensus that a successful educationalexperience is an important strategy forimproving adolescent health and well-being, and that educational institutionshave a vital role to play in this endeavor.

Recommendation 1.

Promote educational policies thatencourage success for all students

Implement policies and practices thatsupport adolescents’ achievements.

Changing staffing patterns so that educatorshave additional time to develop closerrelationships with students, to work withtroubled youth, to form teacher-studentteams, and to work as supervisors isrecommended to address a structuralblock to deeper teacher involvement with students.

Other recommendations include developingmiddle school transition programs, creatingsmaller "school within school” programs,hiring guidance counselors sensitive to cultural and social issues, and strengtheningwork study options. In addition, educatorsare encouraged to develop and use curriculathat teach diverse, useful skills that enablestudents to be successful both duringschool and after graduation (including constructive communication training, par-enting education, critical thinking skills).

Recommendations call for a re-evaluationof school practices that create barriers tolearning and making changes to assureresource equity across school districts.School practices such as tracking, corporalpunishment, retention policies, use of lessqualified teachers in areas with studentswith higher needs, and implementingschool choice need to be reviewed.

Implement policies that focus on stafftraining and development.

Recommendations fall into two categories.The first addresses training teachers to beeffective, sensitive and responsive whenworking with diverse youth, and providingtraining in the specific areas of healthpromotion, adolescent sexuality, workingwith families, and cultural sensitivity. Thesecond addresses the need to increasethe health-focused training of professionalsby increasing the role of state adolescenthealth coordinators, health educators andschool nurses.

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P O L I C Y G O A L T H R E E

Increase the Role of Schools in ImprovingAdolescent Health

Recommendation 2.

Link schools with families and with communities

Strongly encourage parental and familyinvolvement in the schools.

The importance of building on the over-lapping roles of parents and schools isemphasized in these recommendations.Strategies include engaging parentsthrough creating mutual school andparental responsibilities, giving parents a meaningful role in school governanceand curriculum development and supportingl e arning in the home. They also stress the importance of providing services toparents and the community, such as literacy programs, volunteer opportunitiesand sponsored community events. Providingspecial services for teen parents is alsohighlighted.

Encourage community involvement with schools.

Several recommendations focus on linkingschools with community organizations,including social service agencies, privateand public sector providers, religious organizations, local government, interestedindividuals and the business community.Other recommendations focus on link-ages between the schools and the youththemselves, providing mentoring andcommunity service opportunities.

Recommendation 3.

Develop comprehensive educationalpolicies that include health

Implement policies that link health and educational goals.

Prioritizing health issues within educationalplanning, primarily through efforts sponsoredby state and local school boards, r e g i o n a lplanners and individual educators, is themost important strategy proposed forimplementing this recommendation. Many recommendations concern thedevelopment of comprehensive, health-based curricula, that include such topicsas nutrition, physical activity and fitness,driver education, oral health, alcohol anddrug use prevention, health promotion,injury prevention, STD/HIV prevention,avoidance of risky behaviors, and non-violent conflict resolution.

Recommendation 4.

Establish school-based health clinics(SBCs) and school-linked health centers (SLHCs)

Develop a rationale for the delivery ofhealth services in school sites.

Many of these recommendations weremade when SBCs and SLHCs were undergoing a rapid phase of growth, andaddressed the start-up phase of what arenow over 800 school-based clinics andseveral hundred school-linked services.The underlying theme of linking schoolsto outside agencies in a community-based planning process is highlighted as a successful strategy that facilitatesaccess to needed services.

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Recommendations promoting positivesocial norms focus on increasingopportunities for youth that help

to assure the development of healthybehaviors and life-long skills, and develop-ing programs directed at both preventionand health promotion. Important societalattitudinal shifts are needed to encourageadolescents to choose healthy lifestyles.Additional efforts are also required thatemphasize positive aspects of adoles-cence, and the necessity of assuring a skills-based approach to assure theadoption of positive health behaviors.

Increasingly, adolescent behavior, bothpositive and negative, is seen as beingshaped by external influences, such asschool transitions and family stability.Thus, a shift is needed from a narrowfocus on individual behavior to one inwhich both the individual and his or herenvironment are seen as playing an interactive role in the development of lifelong skills and in the adoption ofhealth promoting behaviors.

The view of adolescence has shiftedfrom a period dominated by turbulence to one in which opportunities to developlifelong behaviors and skills can be maxi-mized. As a result of this shift, positiveaspects of adolescent health and behaviorhave gained greater attention in programdevelopment and policy efforts, althoughchanging behaviors which are perceivedto be negative or risky continue to receivemuch focus. Since contextual factors areseen as playing a large role in influencingadolescent development and behavior, theneed for increased adult involvement insupporting adolescents and increased

adult responsibility for adolescent well-being has gained greater policy attention.Helping adolescents find a meaningfulrole is redefined as a societal responsibility.Therefore, it is important to create supportfor adolescent health issues beyond thetraditional health and educational sectorsinto the broader society.

Recognition that risk-taking is a normative part of adolescent developmenthas increased the need to develop strategieswhich encourage exploratory behaviorsand the development of additional lifeskills and goals through constructive outlets and opportunities. Adolescenceoffers a unique opportunity to develop or enhance resiliency and independentthinking skills. It is essential to provideadolescents with opportunities and themotivation to select positive behaviorsand the skills necessary to incorporatethese behaviors into their lifestyle.

Recommendation 1.

Create adolescent-positive societal normsand commitment to health issues

Mobilize all sectors of society in support-ing adolescent health promotion.

Consensus exists regarding both the need to develop a strong advocacy baseon behalf of adolescents and the notionthat adolescents are misperceived interms of their ability to choose health-enhancing lifestyles and to access health-related services. While the roles of healthprofessionals, educators and the privates e c t o r, (including the business community),are seen as vital, media, the entertainment

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P O L I C Y G O A L F O U R

Promote Positive Adolescent Health

industry, public officials, the religious com-munity, other community members andadolescents themselves also have roles toplay. Enhancing support for adolescentsis reflected in three arenas: 1) giving thempriority in policy and programmatic efforts;2) raising public consciousness aboutadolescent issues, including correction ofmisconceptions; and 3) advocating tochange business practices in areas thatcan negatively influence adolescents,such as the entertainment industry andmarketing practices.

Create a supportive environment for promoting adolescent health.

Changing business practices that are perceived as harmful to adolescents isstrongly recommended. These recommen-dations include regulating both programcontent and amount of advertising in television, preventing distribution of harmfulmaterials by the record industry, reducingthe amount of advertising by tobacco,alcohol and other harmful substances,and increasing the portrayals of responsiblesexuality and contraception. Highlightingthe potential of health education and prevention programs to prevent or ameliorate adolescent health problems is necessary. Disseminating information topolicy makers on the cost-effectiveness ofsuch programs is seen as a proactive stepto encourage the additional funding ofsuch programs.

Recommendation 2.

Create opportunities for adolescents toengage in healthy behaviors

Maximize opportunities for adolescents to engage in healthy behaviors.

Providing adolescents with positive behavioral choices and access to education and skill training to meet developmental needs are two means ofpromoting positive behaviors. These needto be reinforced throughout every majorsector intersecting with adolescents,including education, media, families, andthe broader society. Providing accurateand accessible information to help adolescents make appropriate and healthpromoting decisions, especially related tosexual behavior, mental health problems,or substance abuse is also seen as important. Adolescents also need to beactive partners in helping to determinethe content of their health care.

Education and skill training for adolescents focus on 1) developing b r o a d -based life skills, including assertiveness andd e c i s ion-making training; 2) developingskills to resist peer pressure or abusive situations; 3) self-esteem training; and 4) special life skills education, counseling,and employment training. Those most inneed of life skills training are perceived tobe out-of-school youth, adolescents whoare sexually active or considering earlysexual activity, and adolescents at risk forsexual exploitation.

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Recommendation 3.

Promote adolescent health

Enhance the visibility to adolescenthealth issues and positive aspects of adolescents.

Adolescence is an important period inwhich health promoting behaviors can beadopted which will positively affect adulthealth. Recognition of this opportunityfocused many recommendations on earlyintervention for mental health problems,sexuality, HIV/AIDS prevention, and violence prevention. Involving the mediato reinforce these messages is seen bymany as an important adjunct, althoughno group specifies how such messageswould be marketed or funded.

Make commitments to adolescents and adolescent health issues.

Critical aspects in planning and conductingh e a l th promotion and disease preventionprograms rely on multiple level interven-tions that use a variety of strategies, such as changes in social policy, mediamessages and marketing campaigns.Adolescents must be treated as individualsand as part of the broader context of theirfamilies and other institutional settings.Health promotion and prevention servicesneed to include the following components:affordability, convenience, and culturalcompetence. Adolescents also need skillsto incorporate health promoting changesin their lives, as well as in their environ-ments. People who interact with adoles-cents should be enlisted to support them.Adolescents should have increased contact and involvement with people of all ages.

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Adolescents need to learn about the expectations that society holdsfor adults and have opportunities

to practice taking adult roles. These experiences, in turn, are thought to becrucial in encouraging their positive transitions from adolescence to adulthood.Currently, adolescents have few opportunitiesto interact in meaningful ways with adultsor with societal institutions in a non-punitive context. Adolescents also need to form meaningful connections to theinstitutions with which they will interactas adults.

The lack of these experiences contributes to an increasingly disengagedadolescent population. There is consensusfor the need to expand adolescents’opportunities to engage in meaningfulways in the adult world and to exploretheir community roles and workingoptions. These opportunities should flow naturally within the settings theyencounter daily.

Increasing understanding of thebroader economic forces which contributeto high unemployment rates among ado-lescents and young adults will require anexpansion of efforts to link adolescentsboth in and out-of-school to communityemployment opportunities. In addition toemployment skills, many adolescentsrequire other skills that will enable themto live and prosper independently as theytransition to adulthood.

Recommendation 1.

Enhance life options

Provide adolescents with meaningfulpathways to educational opportunities.

A social contract, with the promise of realrewards for positive behaviors, must existfor adolescents. If employment and otheropportunities are made more readily available, adolescents also need to commit themselves to hard work and perseverance in both their intellectualpursuits and personal goals. Establishingsocial relationships with adults, learningcooperative skills, and gaining respect fordiversity are also beneficial to adolescents’future interactions as adults. There is consensus that adolescents, particularlyethnic and minority youth, need to beencouraged to pursue academic goals.

Recommendation 2.

Create community involvement and service opportunities

Actively engage adolescents in theireveryday settings.

There is widespread concern that adoles-cents are increasingly disengaged fromthe community institutions that s u r r o u n dthem and that this disengagement is harmful to healthy development. Schools,which provide the most accessible institu-tional bridge, should promote communityparticipation by identifying appropriateopportunities for adolescents to engage in community service. Because few communities have the resources to

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P O L I C Y G O A L F I V E

Improve Adolescent Transition to Adulthood

provide sufficient programs, expandingthe network of community service programs will require both governmentand private sector support. Adolescentsneed support in developing successfulcommunity programs and establishing ayouth agenda. Mentoring programs werespecifically identified as a means of assuring that every adolescent has atleast one genuinely supportive adult intheir lives.

Recommendation 3.

Create employment opportunities

Establish meaningful employment opportunities for adolescents while they are still in school.

Important shifts in the labor market andthe national economy have reduced theavailability of jobs for semi- or unskilledworkers, and have also resulted in anincreased number of part-time positionsthat often do not provide adequateincome or insurance benefits. Increasedunderstanding of the broader economicforces which contribute to high unemploy-ment rates among adolescents and youngadults has led to a recommended expan-sion of efforts to link adolescents both inand out-of-school to community employ-ment opportunities where they can gaintransferable employment skills. Schoolsare the institution most often targeted fortransition programs, although community-based programs for out-of-school youthare also described.

There is clear consensus that a varietyof school-to-work programs need to beimplemented in schools and in communityw o r k p laces. Such programs should becomprised of educational and vocationaltraining, as well as apprenticeships, with most available programs based on

successful vocational training models.These programs should be incorporatedinto the academic curriculum. Addressingcareer and employment issues early inadolescents’ academic studies helps toassure that youth are given ample opportunity to imagine themselves in avariety of potential employment positions,before they have narrowed their choices.Many of these efforts require partnershipsbetween government at all levels andbusiness and community alliances.

Recommendation 4.

Facilitate independent living

Support adolescents in their efforts toestablish independent living skills.

An increasing number of parents areunable to care for adolescents because of their own economic hardship, drug andalcohol dependence and other factors.“Independent living” in this context refersprimarily to establishing settings outsidethe family or the foster care system whichmay be transitional. For example, the foster care system needs to provide alternatives to the existing array of services. Providing opportunities for independent living requires both systemschanges and programs targeted at individual behavior. Services also need tobe improved for adolescent parents,enabling adolescent and young adultfathers to gain employment so that theycan contribute to their children’s and/orfamily’s economic support, as well as providing more general support for adolescent parents, including parentingeducation and counseling, housing, andchild care.

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The themes of coordination and

collaboration across different levels of government, communities, and the

private sector are interwoven throughoutmany recommendations. The recommen-dations acknowledge that there are anumber of ways to operationalize suchconcepts. First, efforts that focus onimproving the functioning of the currentsystem are needed. Examples includemore effective information sharing andservice coordination. Second, new systemsneed to be designed that facilitate theestablishment of collaborative policiesacross several sectors concerned withadolescent health.

Recommendation 1.

Improve government-level collaboration

A s s u re an active role of the federal g o v e rnment in establishing collaborative models.

Increasing the federal government’s rolein improving adolescent health is a common theme. Since many of the recommendations were made, an Office of Adolescent Health was establishedwithin the Maternal and Child HealthBureau of the Health Resources andServices Administration in 1995. Inter-agency efforts were also recommended.Collaboration among federal, state andlocal governments was also stressed,reflecting the need for higher levels ofgovernment to support local initiativesand to increase consistency across policies and programs.

Assure an active partnership between thestate and federal government.

All state-level recommendations focus ondeveloping coordinating mechanisms toprovide oversight, monitor progress andmake recommendations for adolescent-related services, programs and policies.The importance of state government andcommunity level partnerships for decision-making and priority setting is alsostressed.

Recommendation 2.

Improve public-private collaboration

Establish formal links between government and private sector.

A number of recommendations identifythe important role of private fundingsources in initiating more collaborativeand flexible programs, which strengthenand stabilize the funding base for youth development organizations. Theimportance of building local or nationally-level partnerships and networks of privatesector organizations is also stressed.

Recommendation 3.

Improve community-level collaboration

Expand inter-agency efforts aimed atincreasing improved service coordination.

These recommendations reflect the general consensus that a participatoryapproach is essential for collaborationamong all community members. The three primary goals are to develop local

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P O L I C Y G O A L S I X

Improve Collaborative Relationships

advisory groups or community councils, to facilitate the development of collaborativee f f orts by various institutions in the community, and to develop community or neighborhood initiatives directed atspecific problems affecting youth.

Recommendation 4.

Improve inter- and intra-professionallevel collaboration

Expand staff training to assure improvedservice collaboration.

Trained professionals, including healthcare providers, educators, business leaders, government employees, and other stakeholders, need to have the flexibility within their work schedules topursue collaborative relationships. Theyalso need further assurance that their collaborative efforts will have a directimpact on service delivery.

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Drawing together the main pointsand areas of consensus across the recommendations helps to

determine what additional steps are necessary to improve the health of ado-lescents. We need to consider how ourcountry’s political will expedites orimpedes our planning efforts, determineways that available resources can bemaximized, and establish an approach for priority setting that can improve thehealth of adolescents. In previous efforts,few proposals outlined specific stepsneeded to implement the proposed recommendations. While each communityrepresents a unique entity, the stepsrequired for planning and implementationcan be used across a wide variety of sites.

Relatively little guidance is provided tohelp communities assess which strategiesbest fit their own community environment,resources, and commitment to the issue.Implementation is also hindered by lack of access to information on modelprograms, and lack of systemic trainingand technical assistance. Six cross-cuttingthemes emerge that draw together thesemain points; they are described below.

Cross-Cutting Theme 1.

A systemic approach to prioritizing the health and well-being of adoles-cents is needed on a national level.

A clear set of goals and prioritiesneeds to be established to help mobilizeboth the public and private sectors toimprove adolescent health. A number ofbarriers exist to creating consensus. First,our society is ambivalent about adoles-cents and the roles government should

play in their lives. There is a strong preference for families to take the lead in guiding the next generation of adults;however, parents are often not equippedwith the knowledge and skills needed toraise adolescents.

Second, the major biological and psychological changes occurring through-out adolescence often test adults’ limitsand comfort, resulting in negative societalresponse. Yet, these developmentalchanges are predictable, sequential, and normative.

Third, many of the health, social andeducational supports require long-terminvestment, rather than brief episodic and categorical responses. Thus, policymakers’ funding timelines and desire forsimple solutions often interfere with thetypes of necessary strategies. Combinedwith the lack of knowledge regarding successful models of interventions that either prevent or ameliorate adolescenthealth problems, such lack of commit-ment to long-term investment contributesto a sense that little can be done.


System coordination to reduce fragmentation and maximize existingresources at the local, state and federal levels is necessary.

The degree of fragmentation faced by adolescents, their families and the network of service providers is highlightedin many reports. Creating effective linkagesis often suggested as a means to reducethis problem, with increasing system coordination through inter-agency collaboration as the most viable

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Cross-Cutting Themes and Next Steps

approach. Few substantive strategies aredescribed for overcoming existing barriers.Since most of these recommendations were made, collabora-tions have emerged, including thosebringing together schools and health care providers. However, little informationexists to document their effectiveness.


Effective use of resources throughblending of existing funding mechanisms, joint collaborative efforts to help maximize existing funding, and the development of additional, sustainable funding to meet major gaps in the field of adolescent health is recommended.

Few recommendations focus on theissues of program sustainability and fiscalaccountability. While the number of adolescents is increasing and their healthand social needs continue to grow, it isparticularly difficult to meet service gaps.The harnessing of multiple fundingstreams to pay for health services hasoften contributed to the fragmentation ofservice provision and the creation of acomplicated maze for adolescents to navi-gate. In response, recommendations callfor integration of services and blending of different funding streams to reduceadministrative costs. Again, evaluation of such recommendations is lacking, andthus its impact cannot be assumed.


A greater programmatic focus on primary prevention and early intervention, which is substantiated and shaped by rigorous research, is needed.

Many recommendations concern adolescents whose problems reflect complex behavioral, social and economicconditions. While much importance isascribed to treatment (as opposed to preventive services), few recommendationsaddress how to pay for both types of services, assure continuity of care, andensure that greater numbers of adoles-cents in need of services will have accessto the array of needed care. Again, evaluation is lacking, especially of theeffects of primary prevention efforts.Current evaluations of clinical preventiveservices will likely help to illuminate thecontributions of the provision of preventives e r v i ces to adolescents. This informationwill be critical in determining which services should be included as part ofbenefit packages. As the health care system shifts to managed care and theconcern regarding health care expendituresincreases, advocates for a comprehensivearray of services will need additionalresearch findings to support the inclusionof preventive services.

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Increase the role of families and othermeaningful adults who play a criticalrole in the lives of young people, andwho should be supported in their efforts to help adolescents successfullymake the transition through andbeyond adolescence.

One of the most critical themes woven throughout the recommendationsconcerns the importance of families inanchoring the lives of adolescents and in creating the initial environment inwhich they receive emotional, social, and economic support. The proposed recommendations recognize that manyfamilies face a number of economic,social and environmental stresses thatplace them in jeopardy of being able tofulfill their expected roles to adequatelyparent their children.

Workplace changes are proposed,including providing parents with increasedflexibility in their work day so that theymay be more readily available to theirchildren after school and during schoolvacations. Many of these recommendedchanges are inconsistent with the dramaticchanges in the roles of American womenas workers, or traditional expectationsrelated to the roles of fathers. There areneither mechanisms nor policy optionsdescribed for helping to change societalstandards for appropriate parenting. Thisis in part due to the traditional approachto the family wherein government involve-ment or intervention would be consideredstepping over the boundaries of the priva-cy and responsibilities of the family. Thishas resulted in most recommendationsfocusing on treating the symptoms ofinadequate parenting through intensivesupport programs, rather than prevention.


A systemic approach to build a nationalpolicy on adolescents is needed.

A review of the 1,000 recommenda-tions and strategies confirms that a comprehensive Adolescent Health Policyhas not been implicitly articulated. Sucha framework may not even be feasible toestablish on a national level, where a formal, comprehensive public policy forhealth does not exist. It appears thatthere is too little consensus or commit-ment to build such a policy; the countryhas too little experience developing comprehensive policy for any number ofimportant areas. Generally, policies aredeveloped in response to a problem, andif the problem is perceived as seriousenough, funding is devoted to it. Far fewer efforts are directed at primaryprevention.

Many of the funding efforts to datehave treated the health problems of adolescents in a fragmented manner, withlimited recognition of all the interwovencauses and effects. Few previous effortshave addressed income distribution andaccess to resources, poor educationalexperiences, and limited job and other life opportunities. Often, previous preventionefforts focused merely on providing information and education, sometimesresulting in adolescents receiving fragmentedand disconnected messages from differentstakeholders in their lives.

As adolescent health has been reconceptualized over the past decade,making it broader in scope, the necessityof including physical and mental healthhas been recognized, as well as the socialand cultural context of young people’slives. As a result, society’s approach toimproving adolescent health will require

26

the involvement of multiple sectors andnot merely health professionals. At thesame time, there has been a shift fromapproaching adolescent health from asingle dimension to a recognition thatcomplex problems often require multiplestrategies that are tailored to specific subgroups of adolescents who may needdifferent levels of intervention. Such interventions will require an expansionand enhancement of efforts that incorporatek n o w l e dge, access, skill development andmotivation of adolescents.

New Trends

The recommendations reviewed needto be considered in light of significantchanges in the social, political and economicenvironments that have developed sincemost of the recommendations were proposed. Important trends include thefollowing areas, which are likely to have a significant effect on the implementationof any of the proposed recommendations.

■ Managed care will continue to growthroughout the country, affecting thesources of health care available foradolescents. Health care providersworking in the context of managedcare organizations may likely havemore constraints placed on their time,thus, they will be less able to pursuethe types of collaborative relationshipsand partnerships that are increasinglybeing recognized as being needed.Managed care organizations have thepotential opportunity, however, of playing a leadership role in this arenaas the potential cost-effectiveness ofinvesting in adolescent healthbecomes increasingly apparent.

■ Communities will need to developmechanisms for individually designedservices that are simultaneously comprehensive, intense, and of tailoredlength. In order to meet the health,social, and educational needs of individual adolescents and their families, a variety of “wrap-around” services are needed. For example, casemanagement, tutoring, and mentoringprograms reflect services that are ableto fill in existing gaps. Developing comprehensive interventions for adolescents often requires multiplecomponents. However, categoricalfunding streams, with their own uniqueeligibility requirements, have often prevented communities from develop-ing the types of interventions that areclearly needed. Flexible and accountablefinancing mechanisms that support suchtailored interventions for adolescents andtheir families need to be established.

■ An increasing shift in political and fiscal decision-making from the federalto the state, county and local levels isoccurring. For example, such shifts areunderway in the areas of welfarereform and child health insurance. As a result, there will be concernsabout inconsistencies and lack of standards across the country, as wellas the effects on local resources, whichwill be drawn upon in greater proportion.A stronger focus on establishing l o c a lcontrol and increasing communityinvolvement will likely emerge.

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■ Strong demographic shifts will affectavailable resources. An importantdemographic change will be the significant increase in the number of adolescents living in this country,particularly adolescents representingdiverse ethnic and racial groups.However, adolescents will continue torepresent a smaller percentage of theoverall population with the increasedlife expectancy and aging of the “baby boomers”.

■ Significant technological changes willmake training and other educationalopportunities for all adolescents evenmore important. Without increasingaccess to technology for all sectors ofthe adolescent population, there will be an increasing socio-economicschism between groups of adolescentsresulting from the technological advan-tages available only for certain groups.

New efforts will need to consider theincreasingly complex social problemsaffecting youth, while simultaneouslyresponding to a growing cynical sensethat relatively little can be done about theissues facing adolescents. Ensuring thehealthy growth and development of adolescents requires the commitment ofthe full range of institutions that interactwith and have a profound effect on youth.The strengths of adolescents, families, andcommunities, as well as their shortcomings,must be acknowledged. We must find wa y sto build on strengths to develop viable, oftengrassroots, solutions to perceived p r o b l e m s .Our policy agenda must ally the health,education, job training, business andsocial service sectors with adolescents,families and communities. Our publicpolicies must support these integrated,coordinated approaches.

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