mental aspects mean that one must consider not only what domains of health are measured but also how and when to measure health. The timing of measurement is important relative to critical and sensitive periods of development and relative to critical transitions and turning points in children’s lives.

Other Methodological Challenges

The committee noted a number of other methodological challenges to current health efforts. First, manifestations of health may vary from setting to setting (for example, in school and at home), so what is noted by an observer in one setting may not be seen in a different setting. As a result, information discrepancies are common when multiple informants are used and procedures must be employed that connect the information and observations provided by different informants.

Second, young children and even older youth tend to not be accurate reporters of their own experiences and behaviors, in part by virtue of cognitive immaturity in younger children and because of concerns about the consequences of candid disclosure in older youth.

Third, privacy concerns are also important, because some health-related phenomena may be associated with embarrassment, stigma, or even legal consequences (e.g., substance use, unprotected sex, suicidal ideation, aggression or violence, victimization).

Fourth, many health-related phenomena, whether positive or negative, are experienced by many youngsters at one time or another over the course of their development, so it may be unclear when they become important in terms of current or future health. For example, many youth experience suicidal ideation, many are intermittently depressed or anxious, and many experiment with drugs or unprotected sex, but not all of those who do have serious health issues. To distinguish what is normal from what is unhealthy or of concern, measurement experts often attempt to qualify the presence or absence of a given condition by adjectives related to severity, frequency, or duration, for example, extreme sadness, frequent drug use, ability-limiting illness. However, most qualifying terms such as “extreme” or “frequent” are also subjective and could be interpreted differently by informants of different cultural backgrounds. Even if one attempts to demarcate normal from abnormal with more specific modifiers (e.g., sadness lasting all day, most days, for two weeks or more), knowledge about what constitutes normal and abnormal is lacking and may vary by age of the child.

Meaningful measurements of health across regions and populations often require reliance on multiple informants, reconciliation of discrepant information across informants, combining different measures across informants and settings, demonstration that the measurements are not simply normal variations (e.g., extreme in terms of frequency, duration, or severity or in short- and long-term prognosis) of impairment in functioning or compromise in future health. As a



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