1
Setting the Stage

SUMMARY

  • Adolescents aged 10–19 made up 14 percent (42 million) of the total population of the United States in 2006.

  • The racial and ethnic makeup of the U.S. adolescent population is becoming more diverse. The correlations among minority racial and ethnic status, poverty, and lack of access to quality health services for adolescents are strong. Without specific attention to disparities in access to quality health services among adolescent members of minority racial and ethnic groups and actions to reduce them, such disparities may increase.

Adolescence1 is a critical period of transition between childhood and adulthood. It is a period when significant physical, psychological, and behavioral changes occur and when young people develop many of the habits, behavioral patterns, and relationships they will carry into their adult lives. This chapter demonstrates how the healthy development of adolescents matters. While most adolescents in the United States appear to be healthy, many engage in risky behavior and develop unhealthful habits that can jeopardize their immediate health and safety and contribute to

1

As will be elucidated later in this chapter, adolescence is defined in this report as ages 10–19.



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1 Setting the Stage Summary • Adolescents aged 10–19 made up 14 percent (42 million) of the total population of the United States in 2006. • The racial and ethnic makeup of the U.S. adolescent population is becoming more diverse. The correlations among minority racial and ethnic status, poverty, and lack of access to quality health services for adolescents are strong. Without specific attention to disparities in access to quality health services among adolescent members of minority racial and ethnic groups and actions to re- duce them, such disparities may increase. A dolescence1 is a critical period of transition between childhood and adulthood. It is a period when significant physical, psychological, and behavioral changes occur and when young people develop many of the habits, behavioral patterns, and relationships they will carry into their adult lives. This chapter demonstrates how the healthy development of adolescents matters. While most adolescents in the United States appear to be healthy, many engage in risky behavior and develop unhealthful hab- its that can jeopardize their immediate health and safety and contribute to 1 As will be elucidated later in this chapter, adolescence is defined in this report as ages 10–19. 7

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 ADOLESCENT HEALTH SERVICES poor health in future years. Others experience physical and mental illnesses, including chronic conditions, during adolescence and into adulthood. At the same time, adolescence is a critical period for developing positive be- havioral patterns, healthful habits, and independent decision-making skills that create a strong foundation for healthy lifestyles and behavior over the full life span. Therefore, receiving quality health promotion and disease prevention services, supportive counseling, and chronic care treatment and management, as well as engaging in positive activities and personal skill building, plays a crucial role in nurturing healthy adolescents, as well as in reducing their risk for many adult diseases and injuries. Indeed, according to a joint report by the World Health Organization, United Nations Popula- tion Fund, and United Nations Children’s Fund (1995, p. 3), “One of the most important commitments a country can make for future economic, social, and political progress and stability is to address the health and de- velopment needs of its adolescents.” It is of concern, therefore, that adolescents have one of the lowest rates of primary care use of any age group in the United States (Hing, Cherry, and Woodwell, 2006) and one of the highest rates of being under- or un- insured (Agency for Healthcare Research and Quality, 2006; U.S. Census Bureau, 2006b). Moreover, some aspects of adolescent health—such as the escalating rate of adolescent obesity and related illnesses—have become increasingly problematic over time (Institute of Medicine, 2005). In addi- tion, certain groups within the adolescent population characterized by se- lected circumstances—for instance, those who are in the foster care system; homeless; lesbian, gay, bisexual, or transgender (LGBT)2; or in the juvenile justice system—may be especially prone to participate in risky behavior and lack community, family, or economic support. Consequently they may face special challenges that put them at particular risk for poor health outcomes (D’Augelli, Hershberger, and Pilkington, 1998; Saewyc et al., 1999, 2006; Tonkin, 1994). Being part of a racial or ethnic minority group, being poor, or being in a family that has recently immigrated to the United States may also contribute to decreased access to quality and appropriate health ser- vices (Weinick and Krauss, 2000; Wise, 2004). There is some disagreement as to whether health status is dependent more on health services or on other factors, such as genetics, income, or behavior (Association of Maternal and Child Health Programs and the National Network of State Adolescent Health Coordinators, 2005; Fuchs, 1974, 1991; Garfinkel, Hochschild, and McLanahan, 1996). Nonetheless, 2 The group referred to as “lesbian, gay, bisexual, and transgender” sometimes also encom- passes the term “questioning” and is commonly referred to by the acronym LGBT (or GLBT) or LGBTQ (or GLBTQ). For the purposes of this report, the identifier “lesbian, gay, bisexual, and transgender” or LGBT is used.

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 SETTING THE STAGE it is clear that a number of potential impediments to quality health services for adolescents exist, including a lack of financial support, insurance, physi- cians and other health professionals who are trained in adolescent health, and transportation; cultural and language barriers; discomfort with or lack of understanding of who provides adolescent health services; and concern about the confidentiality of health services (Hock-Long et al., 2003; Kodjo, Auinger, and Ryan, 2002; Perloff, 1992; Sanci, Kang, and Ferguson, 2005; St. Peter, Newacheck, and Halfon, 1992). Another barrier to quality adolescent health care is the fact that ado- lescents do not fit easily into current models of health care. There are two prevailing models of health care: one focused on children and the other on adults. In a pediatric approach to medicine, the parent is the responsible agent, and the focus is on nurturing the patient in a family context. In an adult-centered approach, the patient is the responsible agent; the provider offers information with which the patient makes decisions; and the focus is on the individual, not the family. The treatment of adolescents does not fit well into either model, and their needs change as they progress through adolescence. While some practitioners focus on caring for adolescents, their numbers are few. A third model—family medicine, in which the family, including children, adolescents, and adults, is cared for by a family physi- cian or nurse practitioner—may offer another alternative, but the number of family medicine practices is limited. Over the past decade, numerous published studies have addressed par- ticular aspects of adolescent health (Ozer et al., 2003; Park et al., 2005, 2006). Much of that research, however, is focused on specific health do- mains, injuries or illnesses, special interests, or problem behavior—such as mental health, teen pregnancy, sexually transmitted infections, substance abuse, tobacco use, violence, diet and exercise, or oral health. Often ne- glected is a more comprehensive strategy for adolescent health services that integrates behavioral, psychological, physical, and social aspects of health. Moreover, much of the research available to help understand differ- ent types of services, organizational models, service settings, and provider skills that influence the health, safety, and well-being of today’s adolescents is scattered among different disciplines and literatures, including pediatrics, reproductive health, social work, mental health, and education (The Cen- ter for Development and Population Activities, 2003; Chung et al., 2006; Committee on Adolescence, 2008; Kopelman, 2004; Lear, 2002; National Association of Social Workers, 2002; Rand et al., 2007). Experimentation with different models for providing health services to adolescents has occurred at the local, state, and national levels, and the health, safety, and well-being of adolescents are receiving attention from diverse public and private agencies. Fundamentally, however, the research being conducted is not always comprehensive, the health service approaches

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20 ADOLESCENT HEALTH SERVICES are not always the same, and the services or systems are not always inte- grated. Gaps in the service delivery system for today’s adolescents are com- mon, particularly for those who are most vulnerable to risky behavior and poor health or who face major barriers in gaining access to primary and preventive services. STUDY CHARGE, APPROACH, AND SCOPE Study Charge Concerned about these issues, the National Academies’ Board on Chil- dren, Youth, and Families formed the Committee on Adolescent Health Care Services and Models of Care for Treatment, Prevention, and Healthy Development, with funding from The Atlantic Philanthropies. The National Research Council (NRC) and the Institute of Medicine (IOM) appointed the 19-member committee in May 2006 to study adolescent health services in the United States and develop policy and research recommendations that would highlight critical health needs, promising service models, and components of care that could strengthen and improve health services for adolescents and contribute to healthy adolescent development. Committee members brought to this task expertise in the areas of adolescent health; general pediatrics; health care services; adolescent development; school- based health services; health care finance; mental health; alcohol, tobacco, and drug abuse treatment; sexual health; oral health; nursing; public policy; statistics/epidemiology; preventive medicine; program evaluation; injury research; law; and immigrant/minority adolescents (see Appendix C for bi- ographies of the committee members). The committee was asked to explore the following issues: • Features of quality adolescent health services. What does the evi- dence base suggest constitutes high-quality health care and health promotion services for adolescent populations? What do parents, community leaders, and adolescents themselves perceive to be es- sential features of such services? • Approaches to the provision of adolescent health services. What are the strengths and limitations of different service models in addressing adolescent health care needs? What lessons have been learned in efforts to promote linkages and integration among ado- lescent health care, health promotion, and adolescent development services? What service approaches show significant promise in offering primary care as well as prevention, treatment, and health promotion services for adolescents with special health care needs and for selected adolescent populations?

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2 SETTING THE STAGE • Organizational settings and strategies. What organizational set- tings, finance strategies, and communication technologies promote engagement with, access to, and use of health services by adoles- cents? Are there important differences in the use and outcomes of different service models among selected adolescent populations on the basis of such characteristics as social class, urbanicity, ethnicity, gender, sexual orientation, age, special health care needs, and risk status? • Adolescent health system supports. What policies, mechanisms, and contexts promote high-quality health services for adolescents? What innovative strategies have been developed to address such concerns as decision making, privacy, confidentiality, consent, and parental notification in adolescent health care settings? What strat- egies help adolescents engage with and navigate the health care system, especially those at significant risk for health disorders in such areas as sexual and reproductive health, substance use, mental health, violence, and diet? What barriers impede the optimal provi- sion of adolescent health services? • Adolescent health care providers. What kinds of training programs for health care providers are necessary to improve the quality of health care for adolescent populations? Study Approach A variety of sources informed the committee’s work. Five formal com- mittee meetings and two public workshops were held during the course of the study. A community forum on adolescent health care revealed the views of both those who consume and those who provide adolescent health services so the committee could learn about adolescent and provider per- spectives, as well as organizational and contextual factors that diminish or enhance the delivery and quality of adolescent health services. A research workshop on adolescent health care services and systems highlighted the views of those who are familiar with current research on the organization and delivery of adolescent health services, as well as identified research needs and gaps in the literature base. The National Academies published a summary report of these two meetings in 2007. The committee also reviewed literature from a range of disciplines and sources. Data and research on adolescents, their families, and health prac- titioners who treat adolescents were analyzed. The committee considered research on various health services, the features of settings that serve ado- lescents, and the utilization of health services by adolescents. Public policies related to adolescent health, health services, health care provider training,

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22 ADOLESCENT HEALTH SERVICES and financing were studied. Private-sector health funding mechanisms were reviewed. Additionally, the committee visited several institutions and organiza- tions focused on providing adolescent health services. The sites visited were chosen because they represent different institutional structures and service delivery locations, types, and models. The limited evaluation of these services and the lack of a standard against which to study them make it impossible to designate any of them as exemplary models of adolescent health care. However, these visits provided examples of health services be- ing delivered specifically to adolescents, and they helped the committee gain insight into various services, settings, financing arrangements, partnerships, approaches to coordination of care, and care models used in the United States to meet the health service needs of adolescents. A description of each site and what was learned from these visits is presented in Chapter 4. The sites visited were Denver Health, Denver, Colorado; Broadway Youth Center, Chicago, Illinois; Jetson Center for Youth, Baton Rouge, Louisiana; Arkansas Children’s Hospital, Little Rock; and Mt. Sinai Ado- lescent Health Center, New York City, New York. Each visit encompassed a tour of the program site or sites; meetings with leaders of the sponsoring institution to discuss institutional objectives and program operations, as well as reflections on successes, challenges, lessons learned, and research related to their efforts; and meetings with the institution’s various health practitioners to discuss the nature of the adolescents who receive services in their setting, the primary health issues being addressed, obstacles to service delivery, and clinical and program management issues. Meetings involved clinical leadership; key program staff (managers, relevant senior staff, and others identified by the site); clinical/agency partners; and health care pro- viders working with adolescents in the setting, such as physicians, nurses, counselors, and office assistants. The committee also made various efforts to understand the perspectives of adolescents on their health and their experiences with health services. During the site visits, the committee met with groups of adolescents to dis- cuss their perceptions of adolescent health issues and health service needs in their community and to gather first-hand accounts of experiences illustrat- ing how health programs have successfully reached out to this population. The adolescents were also encouraged to suggest ways in which adolescent health services in general could better serve their needs and those of their peers. As well, questions were posed in an online Harris Interactive poll of a nationally representative sample (in terms of geographic location, age, race/ethnicity, and socioeconomic status) of adolescents aged 10–18. (The results of this poll are described later in this chapter, and the list of ques- tions included in the poll is provided in Appendix B.)

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2 SETTING THE STAGE Challenges and Limitations The committee was challenged by the limited data and existing sci- entific literature in a number of key areas. There are no comprehensive national indicators of the health status of adolescents that place particular emphasis on behavioral and developmental health. Specifically, information is lacking by selected population characteristics (e.g., income, racial and ethnic status, geographic location) and other circumstances (e.g., LGBT, in the foster care system) that would provide longitudinal trends and enable comparison of the health behaviors of selected adolescent populations as they grow. Health services for adolescents are delivered in myriad settings and through varied institutional structures, and data on and evaluation of services are limited, thus making comprehensive assessment of the quality of service delivery, as well as comparison of different settings and services, a further challenge. Information on issues related to the adolescent health workforce, such as competency requirements for health professionals who work with adolescents, is also difficult to obtain. Finally, while there may be costs associated with the recommendations presented in this report, the committee did not address these economic implications. Such an analysis was beyond the scope of the study charge and the committee’s expertise. A future topic for research, therefore, is whether implementing the com- mittee’s recommendations would require additional resources or could be financed through reallocation of current investments. Study Scope The committee was charged broadly with an examination of adolescent health and health services. However, the charge did not specify what ages fall within the period of adolescence and what “health” should encompass. Therefore, one of the committee’s early tasks was to reach consensus on how to define these terms in reviewing the literature. Defining Adolescence The period of adolescence is influenced by social, cultural, economic, and physical elements, and the boundaries of this life phase are not precise. As a period in the life span, adolescence is a fairly new concept, recognized first at the beginning of the twentieth century. Psychologist G. Stanley Hall wrote a two-volume book in 1904 in which he described the nature of teens and argued that their specific developmental period required particular types of supports. The concept of adolescence became increasingly popular throughout the twentieth century as society changed its perspective on children. The view of children shifted from their being simply members of

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2 ADOLESCENT HEALTH SERVICES a family during agrarian times (Hernandez, 1993) to their being economic assets working in factories during the period of industrialization (zelizer, 1985). As the rate of industrialization decreased, the need for workers also decreased, and society began to become aware of the awful conditions to which child factory workers were subjected. As a result, numerous laws were passed at the end of the nineteenth century to protect children. Public education through mass schooling originated early in the twentieth cen- tury. These profound changes led to society’s view of adolescents as valued members of society with future intellectual and economic contributions to make, a view that has continued into the twenty-first century (Brown, 2001; Larson, Wilson, and Mortimer, 2003). Research on behavior and develop- ment during the adolescent period also emerged in the twentieth century, further highlighting the unique aspects of adolescence and the importance of health services and systems that would support the healthy development of adolescents into adulthood. Adolescence is characterized by profound changes at many levels— physical, social, emotional, and behavioral; it is also a time of transition between childhood and adulthood. Dramatic biological changes are asso- ciated with pubertal development: the body grows physically; adult facial appearance develops; and production of the hormones estrogen, proges- terone, and testosterone begins. These biological changes generally result in burgeoning sexual interest and may lead to health issues, such as the development of acne and weight loss or gain. For a variety of reasons, the period that delineates adolescence has expanded over time, starting earlier because of early pubertal development and lasting longer because of such factors as changes in employment and education and later ages at both marriage and childbearing (Arnett, 2006). Adolescence is also characterized by identity formation, with individu- als starting to make independent choices and experiment with new behavior and experiences. During this time, adolescents often select their peer group and decide for themselves how to spend time out of school. Peer group acceptance becomes increasingly important, and adolescents may focus on conforming to their peers and be susceptible to peer influence. For some adolescents, these decisions can result in rebellious, independent, thrill- seeking, and sometimes risky attitudes and behaviors (National Research Council and Institute of Medicine, 1999). For many adolescents, risk taking and experimentation are simply an important stage in their development, and when not taken to an extreme, do not result in problems. And of course some young people experience adolescence as a tranquil transition into adulthood. For others, however, these attitudes and behaviors can have negative impacts on health and development. Adolescents also often begin to make independent purchases that may affect their health. Among these purchases, food and beverages— particularly high-calorie and low-nutrient candy, carbonated soft drinks,

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25 SETTING THE STAGE and salty snacks—consistently dominate (Institute of Medicine, 2006). Once they reach age 18, adolescents also may be purchasing health care independently, with additional potential impacts on health. Research conducted in the last decade suggests that the brain is not completely developed until late in adolescence, and until that time, the connections between neurons affecting emotional, physical, and mental abilities are incomplete. Some adolescent behavior, such as inconsistency in controlling emotions, impulses, and judgments, may be attributable to this incomplete brain development, and much of that behavior is associated with unhealthful and risky adolescent activities (Dahl, 2003; Giedd et al., 1999; National Institute of Mental Health, 2001). The committee recognized that among health care providers, research- ers, and policy makers, different age brackets often demarcate the period of adolescence, ranging from as young as 10 to as old as 25. In most cases, those at the upper end of this age range are identified separately as “young adults” or “emerging adults.” Even within the U.S. government, several definitions are in use. Examples include the following: • U.S. Department of Health and Human Services (2007) (Healthy People 2010) – Adolescents (ages 10–19) – Young adults (ages 20–24) • ubstance Abuse and Mental Health Services Administration (2007) S (National Survey on Drug Use and Health) – Youths (ages 12–17) – Young adults (ages 18–25) • enters for Disease Control and Prevention (2006) (STD Surveillance) C – Adolescents (ages 10–19) – Young adults (ages 20–24) • U.S. Department of Justice (2006) (Criminal Victimization) – Age clustering: ages 12–15, 16–19, 20–24 • outh Risk Behavior Survey (Centers for Disease Control and Pre- Y vention, 2007) – Young people (grades 9–12) • Society for Adolescent Medicine (1995) (position statement) – Adolescent medicine (ages 10–25) • ational Longitudinal Study of Adolescent Health (Carolina Popu- N lation Center, 2007) – Adolescents (grades 7–12) • ffice of Technology Assessment (OTA) (U.S. Congress and Office O of Technology Assessment, 1991) – Adolescents (ages 10–18) – Young adults (ages 18–26)

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2 ADOLESCENT HEALTH SERVICES • ational Initiative to Improve Adolescent Health (NIIAH 2010, or N the National Initiative) (National Adolescent Health Information Center, 2004) – Youth (ages 10–14) The committee reviewed these and other delineations of the period of adolescence, as well as literature on child and adolescent behavior and development, and examined health service needs, health service options, health financing issues, and issues regarding legal autonomy for those aged 10–24. This broad age range encompasses the most critical years of ado- lescent development, as well as the sometimes complex transitions from childhood to adolescence and from adolescence to adulthood. Ultimately, given the marked differences in health issues, developmental needs, health service needs, health financing issues, and legal status between adolescents and young adults, the committee found it difficult to address adequately the health service needs of such a broad age group. The committee also found that most evidence was limited regarding the health status, health services, and health service needs of those at the upper end of this age range. The committee therefore focused this report on adolescents aged 10–19. This age range allows the discussion to include the lower bound of puberty, as well as the age at which most adolescents embark on adult paths, such as college, employment, military service, or marriage. This target population is referred to throughout the report primarily by the term “adolescents,” but that term is sometimes used interchangeably with others, including “youths,” “young people,” and “teens” or “teenagers.” Where appropri- ate and possible, the committee broke the available data down into two subsets: early adolescence (ages 10–14) and adolescence (ages 15–19). In addition, some issues salient for those aged 18–19 do not apply to those aged 10–17 since the former are legally defined as adults; where relevant, this distinction is made. Having decided to focus this study on those aged 10–19, however, the committee faced a significant challenge arising from the variation in age ranges used to define adolescence among the various professional organi- zations, authorities (federal, state, and local), researchers, and advocacy groups that take an interest in, enact public policy for, and collect data and conduct research on adolescents. This variation made it impossible for the committee to rely exclusively on data and research on those aged 10–19. Throughout this report, therefore, the committee uses the best available evi- dence for adolescents aged 10–19, but notes that there are inconsistencies in the data and cases in which parallel data were not available. At times, more- over, the report refers to late adolescence or early adulthood (ages 20–24). For example, the health service needs of this older age group are included

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27 SETTING THE STAGE in the discussion of insurance coverage in Chapter 5 since the available evi- dence tends to distinguish between issues related to those aged 10–18 and those aged 19–24. Since the committee’s definition includes those aged 19, data on insurance eligibility and coverage for the full older age range are included to demonstrate the major transitions and striking shortcomings in access to health services that occur as adolescents grow older. The committee’s decision to focus on ages 10–19 was difficult and problematic. The lack of attention to the health and health service needs of older adolescents or emerging adults is a major concern that lies beyond the scope of this report, but one that the committee believes deserves careful attention in its own right in future studies. Selected Adolescent Subpopulations The range of subpopulations of adolescents in the United States results in broad variation among adolescents and their health status. The health and development and health service needs of adolescents vary by gender, race and ethnicity, social and economic environment, information and skills, and access to health services, as well as other factors. When pos- sible, the committee considered a variety of population variables and their relationship to adolescent health status and health services. In addition, the committee considered the specific issues and needs of adolescents in various circumstances, such as those who are in the foster care system, are homeless, are in families that have recently immigrated to the United States, identify themselves as LGBT, or are in the juvenile justice system. Data on the number of adolescents who fall into these subpopulations are sparse, and in many cases there is overlap among groups. Where possible, however, the committee attempted to quantify the numbers of adolescents in these specific groups. Finally, it is important to note that, while there is recognition in the literature and among experts that certain groups of adolescents have dif- fering needs, risks, and resources related to health, there is no agreement on the specific subpopulations within the adolescent population (Knopf et al., 2007). As will be discussed further in subsequent chapters, this lack of agreement creates challenges in addressing the unique health and health service needs of selected subpopulations and tailoring service delivery ac- cordingly. As well, much of the evidence on health status and health objec- tives for specific adolescent subpopulations is based on limited data and likely represents an underestimation of the challenges involved (Knopf et al., 2007).

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 SETTING THE STAGE healthy eating/obesity, injuries/orthopedics, sexual behavior and reproduc- tive health, and safety/domestic issues (McDonagh et al., 2006). Some health care providers (physicians, nurses, nurse practitioners) lack confidence that they have the training needed to provide the best health services to adolescents. Fewer than half of providers who care for adolescents on a regular basis have received formal training in doing so (Burack, 2000). Communication between health care providers and adolescents is also important. In one study, 43 percent of physicians reported that they did not believe adolescents would tell the truth about their sexual activity. This was the case even though the physicians indicated that they had discussed sexual health needs, sex education, and/or birth control and condoms with nearly 75 percent of their patients (Igra and Millstein, 1994). Many health care providers fail to realize that the health concerns of adolescents can vary greatly by gender and are much more diverse than might be expected, with social and psychological concerns being just as important as traditional medical concerns. Without rigorous and diligent inquiry on the part of providers regarding social and emotional as well as physical issues, adolescents may not reveal important information that relates to their total well-being (Kowpak, 1991). Pharmacists have an important role in assessing, initiating, monitor- ing, and modifying medications, one that often leads to interactions with patients and creates opportunities to assist in providing adolescent health services. In a survey of close to 1,000 pharmacists, however, a substantial portion reported inadequate training in issues related to adolescent health (Conard et al., 2003). Many of the pharmacists expressed interest in gain- ing a better understanding of these issues, which could improve their inter- actions with adolescent patients. Given the important role of pharmacists as an integral part of a health care team, Conard and colleagues (2003) suggest that the role of pharmacists in adolescent health receive increased attention during pharmacy training and in postgraduate forums. Policy Environment Whether adolescents receive quality health services, preventive health services, and supportive counseling is affected by the policy environment in which the need for and cost of these services are debated. There is dis- agreement among policy makers on whether there should be universal ac- cess to health services in the United States. There is also no agreement on the appropriate role of government-supported health services versus those that should be financed by private health insurance. The result has been a haphazard system for providing these services for adolescents, as well as other children and adults. With much of the ultimate determination of the

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2 ADOLESCENT HEALTH SERVICES quality and extent of care being left to the states, and with federal and state funding for health services frequently being limited, many adolescents fall through the cracks of the health system. This situation is exacerbated by the fact that there is no national policy consensus in the United States on how to deal with adolescents except with regard to education. The operation of Medicaid and SCHIP provides an example of this problem. These programs provide health coverage that, in theory, should be adequate for children and adolescents. In reality, however, both pro- grams have flaws that result in many adolescents being covered not at all or inadequately as states adjust eligibility, the extent of service provision, and the requirements for copayments that adolescents and their families may not be able to afford. The federal government has focused on private health care and insurance that covers care for more vulnerable populations not currently served by Medicaid or SCHIP, and has therefore encouraged changes to the tax code to make private insurance affordable and state ac- tion to monitor the adequacy of coverage. As a result, a variety of proposals for the reform of state health insurance have surfaced that are currently being considered to increase health insurance coverage for children and adolescents. Privacy and Confidentiality Beyond attitudes and perceptions about adolescent health and health services, legal considerations of confidentiality and informed consent are central to any discussion of the interests and rights of adolescents with re- spect to their health. These matters are ethically and legally complex, and a great deal is at stake in these discussions. Although the ethical and legal complexities involved have the potential to divide health care providers, parents, policy makers, and advocates for children4 and for families,5 there is also significant potential for defining common ground. Some parents may believe that their authority and their ability to shape their children’s lives and values (Wisconsin v. Yoder [1972], 406 U.S. 205, 234)—moral, religious, and spiritual—are threatened by the notion that adolescents themselves have independent interests and rights. Most parents, however, are concerned primarily with promoting their adolescent chil- dren’s health, safety, and well-being. In that context, it can be challenging for parents to understand when and why it is appropriate for adolescents to be able to consent to their own health services and receive those services on a confidential basis, and how those interests may differ from their own. Many adolescents perceive that they are engaged in a process of self- 4 See http://www.plannedparenthood.org/. 5 See http:///www.afa.net/prolife/articles.asp.

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 SETTING THE STAGE definition and individuation that requires—to a greater or lesser degree— the creation of a private persona with desires and behavior that, even if not forbidden by parents, are separate from parental scrutiny and supervision. For a few young people, adolescence can lead to a significant disjunction of interests that may even threaten the integrity of the family. In some families, the impetus for this disjunction comes from the adolescent, while in others the parents are motivated by their own problems or their children’s behav- ior to initiate a break. Even so, the majority of adolescents obtain health services with the knowledge and support of their parents and benefit from that involvement. Health professionals, both by inclination and by training, focus on the needs of their patients. For this reason, providers of health services to adolescents often view themselves as allies of the adolescent who is seeking to define a separate existence and decision-making structure. At the same time, adolescent health experts in clinical settings, research institutions, and professional organizations have repeatedly recognized the important role of parents in fostering the health of adolescents. It is critical that these challenging issues be addressed within a cur- rent social and policy context in which there is little overt support for the adolescent experimentation and risk taking that may give rise to the need for confidentiality protection in adolescent health services. Even so, a large body of evidence, drawn from research conducted over the past several decades, serves not only to document the range and extent of behavior that affects adolescents’ health, but also to provide a rationale and strong justification for protecting confidentiality in their health services. BEHAVIORAL AND CONTEXTUAL CHARACTERISTICS Creating successful interactions between adolescents and health service settings and systems requires a multifaceted approach. The committee was guided by two frameworks in its data collection, review of the evidence, and attention to various dimensions of adolescent health status and health services. The first focuses on behavioral and contextual characteristics that influence how adolescents interact with the health system. The second, which is described in Chapter 3, focuses on the objectives of adolescent health services. Neither framework alone is sufficient to explain significant variations in adolescent health outcomes; rather, they complement each other and, in tandem, provide a more complete picture of the features of the health system that should be improved in order to provide adolescents high-quality care and thus help to improve their health status. The committee recognized that certain sets of behavioral and con- textual characteristics shape the ways in which adolescents approach and interact with health care services, providers, and settings. When these

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 ADOLESCENT HEALTH SERVICES characteristics are addressed in the design of health services for adolescents, these services can offer high-quality care that is particularly attuned to the needs of this age group. These characteristics helped frame the chapters of this report and, where relevant and supported by the evidence, are reflected in the committee recommendations. • Development matters. Adolescence is a period of significant and dramatic change spanning the physical, biological, social, and psy- chological transitions from childhood to young adulthood. This dynamic state influences both the health of young people and the health services they require (Chapter 1). • Timing matters. Adolescence is a critical time for health promotion. Many health problems and much of the risky behavior that under- lies later health problems begin during adolescence. Prevention, early intervention, and timely treatment improve health status for adolescents and prepare them for healthy adulthood; such services also decrease the incidence of many chronic diseases in adulthood (Chapter 2). • Context matters. Social context and such factors as income, ge- ography, and cultural norms and values can profoundly affect the health of adolescents and the health services they receive (Chapters 2 and 3). • Need matters. Some segments of the adolescent population, defined by both biology and behavior, have health needs that require par- ticular attention in health systems (Chapter 2). • Participation matters. Effective health services for young people in- vite adolescents and their families to engage with clinicians (Chap- ter 4). • Family matters. At the same time that adolescents are growing in their autonomy, families continue to affect adolescents’ health and overall well-being and to influence what health services they use. Young people without adequate family support are particularly vulnerable to risky behavior and poor health and therefore often require additional support in health service settings (Chapter 4). • Community matters. Good health services for adolescents include population-focused as well as individual and family services since the environment in which adolescents live, as well as the supports they receive in the community, are important (Chapter 4). • Skill matters. Young people are best served by providers who un- derstand the key developmental features, health issues, and overall social environment of adolescents (Chapter 5). • Money matters. The availability, nature, and content of health ser- vices for adolescents are affected by such financial factors as public

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5 SETTING THE STAGE and private health care insurance, the amount of funding invested in special programs for adolescents, and the support available for adequate training programs for providers of adolescent health ser- vices (Chapter 6). • Policy matters. Policies, both public and private, can have a pro- found effect on adolescent health services. Carefully crafted policies are a foundation for strong systems of care that meet a wide variety of individual and community needs (Chapter 6). ORGANIZATION OF THE REPORT This report reviews the literature on adolescent health and health service delivery; presents the committee’s findings; and offers recommenda- tions directed to both public and private entities, for investing in, strength- ening, and improving the system of health services for adolescents. Chapter 2 reviews the health status of adolescents, while Chapter 3 describes the health services, settings, and providers currently available for adolescents. Chapter 4 identifies strategies for improving current health services to achieve a system that would reflect the needs and concerns of the adoles- cent population more accurately. Chapter 5 describes the training require- ments and needs of health care providers who serve adolescents. Chapter 6 describes adolescent health insurance coverage and associated challenges in accessing health services. Finally, Chapter 7 highlights the committee’s task, summarizes the committee’s overall conclusions related to this task, and presents the committee’s recommendations. In addition, for reference throughout the report, a list of acronyms is provided in Appendix A. The questions on the online Harris Interactive Omnibus Survey used for this study are listed in Appendix B, and Appendix C contains biographical sketches of the committee members. REFERENCES Agency for Healthcare Research and Quality. (2006). Medical Expenditure Panel Survey: Table . Health insurance coverage of the civilian noninstitutionalized population: Per- cent by type of coverage and selected population characteristics, United States, first half of 200. Available: http://www.meps.ahrq.gov/mepsweb/data_stats/quick_tables_results. jsp?component=1&subcomponent=0&year=2006&tableSeries=4&searchText=&search Method=1&Action=Search [December 6, 2007]. Agency for Healthcare Research and Quality and Health Resources and Services Administra- tion (2000). Access to Quality Health Services. Healthy People 200, Volume I (second edition). Objectives for Improving Health (Part A: Focus Areas 1-14), 1–47. Avail- able: http://www.healthypeople.gov/Document/pdf/Volume1/01Access.pdf [January 22, 2008].

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 ADOLESCENT HEALTH SERVICES Albert, B., Brown, S., and Flanigan, C. (Eds.). (2003).  and Younger: The Sexual Behavior of Young Adolescents (Summary). Washington, DC: National Campaign to Prevent Teen Pregnancy. Alderman, E. M., Rieder, J., and Cohen, M. I. (2003). A history of pediatric specialties: The history of adolescent medicine. Pediatric Research, 5, 137–147. Arnett, J. J. (2006). Emerging adulthood: Understanding the new way of coming of age. In J. J. Arnett and J. L. Tanner (Eds.), Emerging Adults in America: Coming of Age in the 2st Century (pp. 3–18). Washington, DC: American Psychological Association. Association of Maternal and Child Health Programs and the National Network of State Ado- lescent Health Coordinators. (2005). A Conceptual Framework for Adolescent Health. Washington, DC: Association of Maternal and Child Health Programs. Battjes, R., Gordon, M., O’Grady, K., Kinlock, T., and Carswell, M. (2003). Factors that predict adolescent motivation for substance abuse treatment. Journal of Substance Abuse Treatment, 2, 221–232. Breda, C., and Heflinger, C. (2004). Predicting incentives to change among adolescents with substance abuse disorder. American Journal of Drug and Alcohol Abuse, 20, 251–267. Brown, N. A. (2001). Promoting Adolescent Livelihoods. A discussion paper prepared for the Commonwealth Youth Programme and UNICEF. Available: www.unicef.org/adolescence/ files/promoting_ado_livelihoods.pdf [July 29, 2008]. Burack, R. (2000). Young teenagers’ attitude towards general practitioners and their provision of sexual health care. British Journal of General Practice, 50, 550–554. Carolina Population Center. (2007). Add Health: The National Longitudinal Study of Adoles- cent Health 2007. Available: http://www.cpc.unc.edu/addhealth [November 27, 2007]. The Center for Development and Population Activities. (2003). Adolescent Sexual and Repro- ductive Health: A Training Manual for Program Managers. Washington, DC: The Center for Development and Population Activities. Centers for Disease Control and Prevention. (2006). Sexually Transmitted Disease Surveil- lance, 2005. Atlanta, GA: Division of Sexually Transmitted Disease Prevention. Centers for Disease Control and Prevention. (2007). Youth Online: Comprehensive Re- sults Youth Risk Behavior Survey. Available: http://www.cdc.gov/healthyyouth/physical activity/ [August 8, 2007]. Cheeseman Day, J., Janus, A., and Davis, J. (2005). Computer and Internet use in the United States: 2003. Current Population Reports, P2-20, October. Chung, P. J., Lee, T. C., Morrison, J. L., and Schuster, M. A. (2006). Preventive care for children in the United States: Quality and barriers. Annual Review of Public Health, 27, 10.1–10.25. Committee on Adolescence. (2008). Achieving quality health services for adolescents. Pedi- atrics, 2, 1263–1270. Conard, L. A., Fortenberry, J. D., Blythe, M. J., and Orr, D. P. (2003). Pharmacists’ attitudes toward and practices with adolescents. Archives of Pediatric and Adolescent Medicine, 57, 361–365. Dahl, R. E. (2003). Adolescent Brain Development. Key note address. Available: http://www. nyas.org/ebriefreps/main.asp?intSubsectionID=318 [April 1, 2008]. D’Augelli, A. R., Hershberger, S. L., and Pilkington, N. W. (1998). Lesbian, gay, and bisexual youth and their families: Disclosure of sexual orientation and its consequences. American Journal of Orthopsychiatry, , 361–371. DeNavas-Walt, C., Proctor, B. D., and Hill Lee, C. (2006). Income, Poverty, and Health Insurance Coverage in the United States, 2005. Washington, DC: U.S. Department of Commerce, U.S. Census Bureau.

OCR for page 17
7 SETTING THE STAGE Deptula, D., Henry, D. B., Shoeny, M. E., and Slavick, M. S. (2006). Adolescent sexual be- havior and attitudes: A costs and benefits approach. Journal of Adolescent Health, , 35–43. Fields, J. (2003). Children’s living arrangements and characteristics: March 2002. Current Population Reports, P20-57, June. Fuchs, V. (1974). Who Shall Live? Health, Economics, and Social Choice-Expanded Edition. Singapore: World Scientific. Fuchs, V. (1991). National health insurance revisited. Health Affairs, 0, 10–17. Gamm, L., Hutchison, L., and Bellamy, G. (2002). Rural healthy people 2010: Identifying rural health priorities and models for practice. Journal of Rural Health, , 9–14. Garfinkel, I., Hochschild, J., and McLanahan, S. (Eds.). (1996). Social Policies for Children. Washington, DC: The Brookings Institution. Garland, A. F., and Besinger, B. A. (1996). Adolescents’ perceptions of outpatient mental health services. Journal of Child and Family Studies, 5, 355–375. Giedd, J., Blumenthal, J., Jeffries, N., Castellanos, F., Liu, H., zijdenbos, A., Paus, T., Evans, A., and Rapoport, J. (1999). Brain development during childhood and adolescence: A longitudinal MRI study. Nature Neuroscience, 2, 861–863. Gohel, M., Diamond, J., and Chambers, C. (1997). Attitudes toward sexual responsibility and parenting: An exploratory study of young urban males. Family Planning Perspectives, 2, 280–283. Grunbaum, J. A., Kann, L., Kinchen, S., Ross, J., Hawkins, J., Lowry, R., Harris, W. A., McManus, T., Chyen, D., and Collins, J. (2004). Youth risk behavior surveillance— United States, 2003. Morbidity and Mortality Weekly Report, 5, 1–96. Hernandez, D. (1993). America’s Children: Resources from Family, Government, and the Economy. New York: Russell Sage Foundation. Hing, E., Cherry, D. K., and Woodwell, D. A. (2006). National Ambulatory Medical Care Survey: 2004 summary. Advance Data from Vital and Health Statistics, 7, 1–36. Hock-Long, L., Herceg-Baron, R., Cassidy, A. M., and Whittaker, P. G. (2003). Access to ado- lescent reproductive health services: Financial and structural barriers to care. Perspectives on Sexual and Reproductive Health, 5, 144–147. Horner, R. D., Kolasa, K. M., Irons, T. G., and Wilson, K. (1994). Racial differences in ru- ral adults’ attitudes toward issues of adolescent sexuality. American Journal of Public Health, , 456–459. Hutchinson, M., Jemmott III, J., Sweet Jemmott, L., Braverman, P., and Fong, G. (2003). The role of mother–daughter sexual risk communication in reducing sexual risk behavior among urban adolescent females: A prospective study. Journal of Adolescent Health, , 98–107. Igra, V., and Millstein, S. G. (1994). Physician Attitudes towards STD/HIV-Related Preventive Services to Teens. The Woodlands, TX: American Pediatric Society. Institute of Medicine. (2001). Crossing the Quality Chasm. A New Health System for the 2st Century. Washington, DC: National Academy Press. Institute of Medicine. (2005). Preventing Childhood Obesity: Health in the Balance. Wash- ington, DC: The National Academies Press. Institute of Medicine. (2006). Food Marketing to Children and Youth: Threat or Opportunity? Washington, DC: The National Academies Press. Jacobson, L. D., Mellanby, A. R., Donovan, C., Taylor, B., and Tripp, J. H. (2000). Teenag- ers’ views on general practice consultations and other medical advice. Family Practice, 7, 156–158. Kirby, D. (2007). Emerging Answers 2007. Research Findings on Programs to Reduce Teen Pregnancy and Sexually Transmitted Diseases. Washington, DC: National Campaign to Prevent Teen and Unplanned Pregnancy.

OCR for page 17
 ADOLESCENT HEALTH SERVICES Knopf, K. D., Jane Park, M., Brindis, C. D., Mulye, T. P., and Irwin, C. E., Jr. (2007). What gets measured gets done: Assessing data availability for adolescent populations. Maternal and Child Health Journal, , 335–345. Kodjo, C., Auinger, P., and Ryan, S. (2002). Barriers to adolescents accessing mental health services. Journal of Adolescent Health, 0, 101–102. Kopelman, J. (2004). The provider system for children’s mental health: Workforce capacity and effective treatment. National Health Policy Forum Issue Brief, 0. Kowpak, M. (1991). Adolescent health concerns: A comparison of adolescent and health care provider perceptions. Journal of the American Academy of Nurse Practitioners, , 122–128. Larson, R. W. (2001). How U.S. children and adolescents spend time: What it does (and doesn’t) tell us about their development. Current Directions in Psychological Science, 0, 160–164. Larson, R. W., and Verma, S. (1999). How children and adolescents spend time across cultural settings of the world: Work, play, and developmental opportunities. Psychological Bul- letin, 25, 701–736. Larson, R. W., Wilson, S., and Mortimer, J. T. (2003). Conclusions: Adolescents’ preparation for the future. Journal of Research on Adolescence, 2, 159–166. Lear, J. G. (2002). Schools and adolescent health: Strengthening services and improving out- comes. Journal of Adolescent Health, , 310–320. Lee, B. R., Munson, M. R., Ware, N. C., Ollie, M. T., Scott, L. D., and McMillen, J. C. (2006). Experiences of and attitudes toward mental health services among older youths in foster care. Psychiatric Services, 57, 487–492. Magura, S., and Moses, B. S. (1984). Clients as evaluators in child protective services. Child Welfare, , 99–112. Maternal and Child Health Bureau. (2005a). The Health and Well-Being of Children: A Portrait of States and the Nation, 2005. Rockville, MD: U.S. Department of Health and Human Services, Health Resources and Services Administration. Maternal and Child Health Bureau. (2005b). The Health and Well-Being of Children in Rural Areas: A Portrait of the Nation, 2005. Rockville, MD: U.S. Department of Health and Human Services, Health Resources and Services Administration. McDonagh, J., Minnaar, G., Kelly, K., O’Connor, D., and Shaw, K. (2006). Unmet education and training needs in adolescent health of health professionals in a UK children’s hospital. Acta Paediatrica, 5, 715–719. Mensinger, J. L., Diamond, G. S., Kaminer, Y., and Wintersteen, M. B. (2006). Adolescent and therapist perception of barriers to outpatient substance abuse treatment. American Journal of Addiction, 5, 16–25. Miller, M., and Whitaker, D. (2000). Parent–adolescent discussions about sex and condoms. Journal of Adolescent Research, 5, 251–273. National Adolescent Health Information Center. (2004). Improving the Health of Adolescents & Young Adults: A Guide for States and Communities. Atlanta, GA: Centers for Disease Control and Prevention. National Association of Social Workers. (2002). Dismantling stereotypes about adolescents: The power of positive images. Adolescent Health NASW Practice Update, 2(5). National Institute of Mental Health (2001). Teenage Brain: A Work in Progress. Available: www.nimh.nih.gov/publicat/teenbrain.cfm [April 1, 2008]. National Research Council and Institute of Medicine. (1999). Risks and Opportunities: Synthesis of Studies on Adolescence. M. D. Kipke (Ed.). Washington, DC: National Academy Press.

OCR for page 17
 SETTING THE STAGE National Research Council and Institute of Medicine. (2002). Community Programs to Pro- mote Youth Development. J. Eccles and J. Appleton Gootman (Eds.). Washington, DC: The National Academies Press. National Research Council and Institute of Medicine. (2004a). Children’s Health, the Nation’s Wealth: Assessing and Improving Child Health. Washington, DC: The National Acad- emies Press. National Research Council and Institute of Medicine. (2004b). Reducing Underage Drinking: A Collective Responsibility. R. J. Bonnie and M. E. O’Connell (Eds.). Washington, DC: The National Academies Press. National Research Council, Institute of Medicine, and Transportation Research Board. (2007). Preventing Teen Motor Crashes: Contributions from the Behavioral and Social Sciences, A Workshop Report. Washington, DC: The National Academies Press. National Runaway Switchboard. (2006). NRS Call Statistics. Available: http://www.1800 runaway.org/news_events/call_stats.html [July 30, 2007]. Ozer, E. M., Park, M. J., Paul, T., Brindis, C. D., and Irwin, C. E., Jr. (2003). America’s Adolescents: Are They Healthy? San Francisco: University of California and National Adolescent Health Information Center. Park, M. J., Paul, T., Irwin, C. E., Jr., and Brindis, C. D. (2005). A Health Profile of Adolescent and Young Adult Males. San Francisco: University of California. Park, M. J., Mulye, T. P., Adams, S. H., Brindis, C. D., and Irwin, C. E., Jr. (2006). The health status of young adults in the United States. Journal of Adolescent Health, , 305–317. Perloff, J. (1992). Health care resources for children and pregnant women. The Future of Children, 2, 78–94. Phillip Morris USA. (2006). Teenage Attitudes and Behavior Survey. Available: http://www. philipmorrisusa.com/en/ysp/tabs/results/charts/topic_5/chart_5_6.asp?navId=c1&sub=s5 [July 31, 2007]. Pleck, J., and O’Donnell, L. (2001). Gender attitudes and health risk behaviors in urban African American and Latino early adolescents. Maternal and Child Health Journal, 5, 265–272. Prescott, H. M. (1998). A Doctor of Their Own. A History of Adolescent Medicine. Cam- bridge, MA: Harvard University Press. Rand, C. M., Shone, L. P., Albertin, C., Auinger, P., Klein, J. D., and Szilagyi, P. G. (2007). National health care visit patterns of adolescents. Implications for delivery of new ado- lescent vaccines. Archives of Pediatrics and Adolescent Medicine, , 252–259. Reading, R. (1997). Poverty and the health of children and adolescents. Archives of Disease in Childhood, 7, 463–467. Rideout, V. J., Vandewater, E. A., and Wartella, E. A. (2003). Zero to Six: Electronic Media in the Lives of Infants, Toddlers, and Preschoolers. Menlo Park, CA: Henry J. Kaiser Family Foundation. Roberts, D., Foher, U., Rideout, V., and Brodie, M. (1999). Kids and the Media @ the New Millennium. Menlo Park, CA: Henry J. Kaiser Family Foundation. Saewyc, E., Bearinger, L., Blum, R., and Resnick, M. (1999). Sexual intercourse, abuse, and pregnancy among adolescent women: Does sexual orientation make a difference? Family Planning Perspectives, , 127–131. Saewyc, E., Bearinger, L., McMahon, G., and Evans, T. (2006). A national needs assessment of nurses providing health care to adolescents. Journal of Professional Nursing, 22, 304–313. Sanci, L. A., Kang, M. S. L., and Ferguson, B. J. (2005). Improving adolescents’ access to primary health care. The Medical Journal of Australia, , 416–417.

OCR for page 17
50 ADOLESCENT HEALTH SERVICES Shapiro, A. (2006). Quality Health Care for Homeless Youth: Examining Barriers to Care. Presentation at a National Community Forum on Adolescent Health Care, November, Washington, DC. Shapiro, J. P., Welker, C. J., and Jacobson, B. J. (1997). The Youth Client Satisfaction Ques- tionnaire: Development, construct validation, and factor structure. Journal of Clinical Child Psychology, 2, 87–98. Society for Adolescent Medicine. (1995). A position statement of the Society for Adolescent Medicine. Journal of Adolescent Health, , 413. Available: https://www.adolescenthealth. org.PositionStatement_Adolescent_Medicine.pdf [November 27, 2007]. Society for Adolescent Medicine. (2004). New Survey Reveals Surprising Insights into Pa- rental Attitudes Toward Teenage Sexual Behavior: Parents Share Top Concerns about Their High Schoolers. Available: http://www.eurekalert.org/pub_releases/2004-08/cw- nsr081004.php [September 22, 2008]. St. Peter, R. F., Newacheck, P. W., and Halfon, N. (1992). Access to care for poor children. Journal of the American Medical Association, 267, 2760–2764. Stevens, D., Seid, M., Mistry, R., and Halfon, N. (2006). Disparities in primary care for vulnerable children: The influence of multiple risk factors. Health Services Research, , 507–531. Substance Abuse and Mental Health Services Administration. (2006). Treatment Episode Data Set (TEDS). Highlights—200. National Admissions to Substance Abuse Treatment Services, DASIS Series: S-31, DHHS Publication No. (SMA) 06-4140. Rockville, MD: Office of Applied Studies. Substance Abuse and Mental Health Services Administration. (2007). Results from the 200 National Survey on Drug Use and Health: National Findings. FMA 07-4923. Rockville, MD: Office of Applied Studies, U.S. Department of Health and Human Services. Tonkin, R. (1994). Adolescent Health Survey: Street Youth in Vancouver. Vancouver, Canada: McCreary Centre Society. U.S. Census Bureau. (n.d.). Intercensal Estimates of the United States Resident Population by Age and Sex: 0. Available: http://www.census.gov/popest/archives/EST90INTERCENSAL/ US-EST90INT-07/US-EST90INT-07-1990.csv [November 6, 2007]. U.S. Census Bureau. (1992). 0 Census of Population: General Population Characteristics, United States (CP-1-1). Available: http://www.census.gov/prod/cen1990/cp1/cp-1-1.pdf [August 13, 2007]. U.S. Census Bureau. (2000). American FactFinder. Available: http://factfinder.census.gov/ servlet/DatasetTableListServlet?_ds_name=DEC_2000_SF1_U&_type=table&_program= DEC&_lang=en&_ts=191842413501 [May 25, 2007]. U.S. Census Bureau. (2003). American FactFinder, Census 0 Summary Tape File  [tabu- lated data]. Washington, DC: Author. U.S. Census Bureau. (2004). National Estimates. Quarterly Population Estimates, 0 to 0. Available: http://www.census.gov/popest/archives/1980s/80s_nat_detail.html [No- vember 6, 2007]. U.S. Census Bureau. (2005). Foreign-Born Population of the United States Current Population Survey—March 200, Table .a. Available: http://www.census.gov/population/www/ socdemo/foreign/ppl-176.html [May 22, 2008]. U.S. Census Bureau. (2006a). America’s Families and Living Arrangements: 200. Avail- able: http://www.census.gov/population/www/socdemo/hh-fam/cps2006.html [May 25, 2007]. U.S. Census Bureau. (2006b). National Population Estimates for the 2000s. Estimates by Age, Sex, Race, and Hispanic Origin: January , 200. Available: http://www.census. gov/popest/national/asrh/2005_nat_res.html [November 6, 2007].

OCR for page 17
5 SETTING THE STAGE U.S. Census Bureau. (2007). U.S. Interim Projections by Age, Sex, Race, and Hispanic Origin. Available: http://www.census.gov/ipc/www/usinterimproj/ [November 6, 2007]. U.S. Congress and Office of Technology Assessment. (1991). Adolescent Health. OTA-H-466, 467, and 468. Washington, DC: U.S. Government Printing Office. U.S. Department of Health and Human Services. (2007). 2 Critical Health Objectives for Adolescents and Young Adults. Available: http://www.cdc.gov/HealthyYouth/adolescent health/NationalInitiative/pdf/21objectives.pdf [October 17, 2007]. U.S. Department of Justice. (2006). Criminal Victimization in the United States, 2005: Statisti- cal Tables. Bureau of Justice Statistics. Available: http://www.ojp.usdoj.gov/bjs/pub/pdf/ cvus05.pdf [October 2, 2007]. Weinick, R., and Krauss, N. (2000). Racial/ethnic differences in children’s access to care. American Journal of Public Health, 0, 1771–1774. Wise, P. (2004). The transformation of child health in the United States. Health Affairs, 2(5), 9–25. World Health Organization. (1948). Constitution of the World Health Organization. Geneva: World Health Organization. World Health Organization, United Nations Population Fund, and United Nations Children’s Fund. (1995). Action for Adolescent Health: Towards a Common Agenda: Recommenda- tions from a Joint Study Group. Available: http://www.who.int/child_adolescent_health/ documents/frh_adh_97_9/en/index.html [May 28, 2008]. zelizer, V. (1985). Pricing the Priceless Child: The Changing Social Value of Children. New York: Basic Books. zeni, M. B., Sappenfield, W., Thompson, D., and Hailin Chen, H. (2007). Factors associated with not having a personal health care provider for children in Florida. Pediatrics, , (Supplement 1), S61–S67. zill, N., Nord, C. W., and Loomis, L. S. (1995). Adolescent Time Use, Risky Behavior, and Outcomes: An Analysis of National Data. Rockville, MD: Westat. zimet, G. (2005). Improving adolescent health: Focus on HPV vaccine acceptance. Journal of Adolescent Health, 7, S17–S23.