Improving the Health, Safety, and Well-Being of Young Adults: Workshop Summary (2013)

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Background Paper: Pathways to Young Adulthood and Preventive Interventions Targeting Young Adults

Sabrina Oesterle, Ph.D.
University of Washington

Introduction

What Is Young Adulthood?

Health, Safety, and Well-Being Vulnerabilities and Risks During Young Adulthood

Diverse Pathways to Adulthood

Evidence-Based Interventions Targeting Young Adults

Summary and Conclusions

References

This paper was commissioned by the Institute of Medicine (IOM) and the National Research Council (NRC) to provide background for the May 7-8, 2013, Workshop on “Improving the Health, Safety, and Well-Being of Young Adults,” hosted by the IOM/NRC Board on Children, Youth, and Families. The author is responsible for the content of this paper, which does not necessarily reflect the views of the IOM or the NRC.

The author wishes to acknowledge the contributions of Tara Mainero, Marina Epstein, and Tanya Williams, who provided extensive bibliographic, research, and editorial assistance in the preparation of the paper.

INTRODUCTION

The transition to adulthood is an important period in life that links development in childhood and adolescence with development in adulthood (McLeod and Almazan, 2003; Settersten, 2007). In the United States, the young adult period begins for most with high school graduation around age 18 and can last into the late 20s and early 30s. The way in which young adults move from ages 18 to 30 has potentially important implications for health, well-being, and quality of life in later adulthood (Arnett, 2000; George, 1993; Hogan and Astone, 1986; Macmillan and Eliason, 2003; Shanahan, 2000). Most often, times of transition between two stages of life encourage continuity and reinforce developmental and behavioral patterns already established earlier in life (Elder and Caspi, 1988). However, transition periods also can function as turning points, providing opportunities for change from negative to more positive life pathways, but also the reverse, interrupting and disrupting healthy trajectories (Elder, 1985, 1998; Feinstein and Bynner, 2004; Maughan and Rutter, 1998; Nagin et al., 2003; Rutter, 1996; Schulenberg and Maggs, 2002; Schulenberg et al., 2003; Wheaton, 1990). Young adulthood deserves special attention because it is a period of risk as well as opportunity. Although much evidence suggests that preventive interventions early in life are crucial for later health and well-being, less is known about the possibly unique opportunities to intervene during the transition to adulthood. The goals of this paper are to summarize the character of the transition to young adulthood for contemporary young adults; survey what tested and effective preventive interventions are available that specifically target young adults; and identify areas of need for future attention and research.

WHAT IS YOUNG ADULTHOOD?

Moving into adulthood is characterized by the adoption of new roles and statuses. Completing school, moving into full-time employment, leaving the parental home to establish one’s own residence, forming romantic relationships, getting married, and becoming a parent are key normative developmental tasks in young adulthood that are expected to be completed during this life period (Booth et al., 1999; Cohen et al., 2003; George, 1993; Macmillan and Eliason, 2003; Modell, 1989; Neugarten et al., 1965; Roisman et al., 2004; Shanahan, 2000). A sense of independence, autonomy, and responsibility are often associated with these role transitions and can be markers of young adulthood in and of themselves (Arnett, 1998, 2000). However, studies of young people’s own perceptions of when adolescence ends and young adulthood begins have indicated that role transitions,

particularly into parenting, continue to be important markers of young adulthood (Johnson et al., 2007; Shanahan et al., 2005).

Since the middle of the 20th century, the transition to adulthood has become much more diverse, individualized, and destandardized in Western societies (Arnett, 2000; Buchmann, 1989; Elzinga and Liefbroer, 2007; Settersten, 2007; Shanahan, 2000). Age norms have weakened and no longer clearly prescribe the timing and sequencing of transitions into adult roles. Although some young adults still follow a pathway into young adulthood that is characterized by sequencing high school completion with work or college attendance in the early 20s, and family formation during the mid- to late 20s, this previously normative sequence is less common for contemporary young adults. Some young adults do not attend college, but move into both work and family roles simultaneously or in more rapid succession during their early 20s. Some become parents as teenagers. Others take on adult roles more slowly, living with parents into their late 20s or returning to the parental home and limiting involvement in adult roles beyond work (Cherlin et al., 1997; De Marco and Berzin, 2008; Hill and Holzer, 2007; Seiffge-Krenke, 2013). Also, more young people than ever delay marriage and parenthood into their 30s or forgo these roles entirely (Blackstone and Stewart, 2012; Hagestad and Call, 2007; Umberson et al., 2010; Waren and Pals, 2013).

Weakening age norms and less prescribed and more individualized pathways to young adulthood increase the freedom for exploration, experimentation, and self-expression and create a period of “emerging adulthood” (Arnett, 2000), which may ease the transition into adult life. However, less structure and direction can also create more serious stresses and restricted opportunities to develop important skills and resources. This may limit opportunities for positive social development and negatively affect later health, well-being, and functioning in adulthood (Jackson, 2004; Mouw, 2005; Schulenberg et al., 2005).

HEALTH, SAFETY, AND WELL-BEING VULNERABILITIES AND RISKS DURING YOUNG ADULTHOOD

The transition to adult roles occurs in the context of fewer social controls than are in place in adolescence, including laws that make certain behaviors legal. For example, in the United States, purchasing and consuming alcohol becomes legal at age 21, and tobacco becomes legal at 18. Also, several behavioral and mental disorders (e.g., substance abuse and dependence and certain anxiety and mood disorders) begin to emerge during this time period and may be increasing in prevalence for more recent cohorts (Kessler et al., 2005). Some of the new freedoms during young adulthood encourage exploration and experimentation and have been found to be

associated with increased substance use and health-risking behaviors, including sexual behaviors that contribute to sexually transmitted infections (STIs) and HIV/AIDS (CDC, 2010; Cooper, 2002; Hall et al., 2008). Other transitions, especially taking on family roles, such as marriage and raising children, increase adult responsibilities and conventionality and have been found to be associated with decreased substance use, criminal activities, and fewer risky behaviors (Arnett, 2000; Bachman et al., 1997; Oesterle et al., 2011; White et al., 2006). Because there is variability in the timing of transitions into adult roles, some young adults will be more vulnerable to the health, safety, and well-being risks than others and at different times in their life course. This variability is important to consider when planning preventive services targeting young adults.

Several recent reports describe the unique health, safety, and well-being risks during the young adult years (Jiang et al., 2011; Lau et al., 2013; Mulye et al., 2009; Neinstein, 2013; NRC, 2009; Park et al., 2006; Office of Disease Prevention and Health Promotion, HHS, 2010). Some of the most notable risks are

• Substance use, abuse, and dependence peak during young adulthood.
• Unintentional injuries, particularly motor vehicle accidents, are the leading cause of death for young adults. Homicide (mostly related to firearms) and suicide are the second and third leading causes of death in this age group.
• Several mental health problems begin to emerge at this age.
• Young adults have the highest rates of STIs, including HIV.
• Young adults are the most uninsured age group in the United States.
• Rates of overweight and obesity have greatly increased in this age group (as they have for other segments of the population).
• Young adults receive few preventive services (including vaccinations and counseling for substance abuse, mental health, reproductive health, and physical activity and nutrition).
• Young adults have the highest rates of behavioral problems, but the lowest perception of risk and least access to preventive care and treatment.
• Although children and adolescents have consistent professional medical guidelines, young adults do not.
• Many disparities are present in health, safety, and well-being by gender, race/ethnicity, and socioeconomic status at this age.

Some commentators have argued that we need to pay more attention to young adults because they tend to fare worse than adolescents (Furstenberg,

2006; Irwin, 2010). Several subpopulations of young adults have especially few institutional supports during the transition to adulthood and may be at even greater risk for worse health, safety, and well-being outcomes than young adults in general (Foster and Gifford, 2005; Osgood et al., 2005a). Some of the most vulnerable subgroups of young adults include

• Youth transitioning out of foster care (Courtney and Heuring, 2005);
• Juvenile justice-involved youth (Chung et al., 2005; Uggen and Wakefield, 2005);
• Homeless youth (Hagan and McCarthy, 2005);
• Young adults with physical disabilities/chronic illnesses (Blum, 2005; White and Gallay, 2005);
• Youth involved in the mental health system (Gralinski-Bakker et al., 2005);
• Youth in special education (Levine and Wagner, 2005);
• Rural young adults (Carr and Kefalas, 2009; Snyder et al., 2009);
• Sexual minority youth (Needham, 2012); and
• Immigrant youth, particularly those who are undocumented (Gonzales, 2011; Rumbaut and Komaie, 2010).

While young adulthood is a time of risk for all young adults, these subgroups of young adults are especially vulnerable and need special support to ensure that they will manage the transition to adulthood well. Discussing the literature on these vulnerable groups in depth is beyond the scope of this background paper. However, Osgood et al. (2005a, 2010), and Foster and Gifford (2005) provide excellent treatments of the issues associated with the transition to adulthood for many of these vulnerable populations.

DIVERSE PATHWAYS TO ADULTHOOD

To understand pathways to young adulthood and their consequences for health, safety, and well-being, it is important to consider transitions to adult roles simultaneously across different salient domains, such as work, education, and family, because they are interdependent within and across time (Elder, 1998, p. 941). For example, participation in postsecondary education is associated with delaying the transition to a parenting role; (Mortimer et al., 2004; Oesterle et al., 2010; Rindfuss et al., 1987); conversely, individuals who have children very young are less likely to enter postsecondary education (Haggstrom et al., 1986; Oesterle et al., 2010; Upchurch, 1993).

Although the pathways to adulthood have become more diverse, several distinct pathways characterize the transition to adulthood for the ma-

jority of today’s young adults. These pathways are differentiated primarily by the timing of family formation (marriage and parenthood) and participation in postsecondary education (Macmillan and Copher, 2005; Oesterle et al., 2010; Osgood et al., 2005b; Sandefur et al., 2005). Three primary pathways are common for women and men, with some notable gender differences (Amato et al., 2008; Hawkins et al., 2008; Macmillan and Eliason, 2003; Oesterle et al., 2010; Sandefur et al., 2005):

1. College attendance during the 20s with postponed family formation (including marriage, but especially child rearing) until at least the late 20s.
2. Family formation by age 30 (both marriage and children) with fulltime (more likely for men) or part-time (more likely for women) employment, sometimes preceded by college attendance.
3. Unmarried working mothers (most have children by age 21) and unmarried working men (most do not have children) with very limited postsecondary education and varied attachments to the workforce.

Because nationally representative longitudinal data on transitions into multiple young adult roles are rare, studies of pathways to adulthood often have to rely on regional and community studies, which make it difficult to provide exact estimates of the prevalence of each pathway among young adults nationally. However, proportions found in pathway studies appear comparable to national rates of individual transitions (Rumbaut and Komaie, 2007); many results from studies of pathways to adulthood are comparable to each other (Amato et al., 2008; Macmillan and Eliason, 2003; Oesterle et al., 2010; Osgood et al., 2005b; Sandefur et al., 2005). Roughly speaking, about 40-45 percent of young adult men and women attend college and postpone family formation (pathway 1); about one-third of young adult men and women become married parents in their 20s (pathway 2); and about 25-30 percent are unmarried working mothers and working men (pathway 3).

Studies of multidimensional pathways to young adulthood illustrate how comparing young adults in one domain and at only one point in time could be misleading (Macmillan and Copher, 2005). For example, in Oesterle and colleagues’ study (2010), young men who were on a pathway of “married fathers” and those men who remained “unmarried with limited postsecondary education” had about the same probability of living with children at age 21 (about 30 percent) and both were unlikely to be married at that age. However, by age 30 these pathways looked very different. The majority of the “married fathers” had married (76 percent) or were divorced (24 percent) by age 30, 71 percent lived with children, and 87 percent worked full-time. In contrast, only 13 percent of the “unmarried

men” had married by age 30; 34 percent lived with children; and only 57 percent worked full-time.

Gender Differences in Pathways to Adulthood

Overall, these three pathways to adulthood are about equally prevalent among men and women. Increasing gender equality in some transitional roles, including educational and professional roles, has created similarities in the pathways men and women take into adulthood (Fussell and Furstenberg, 2005; Johnson et al., 2001; Oesterle et al., 2010; Spain and Bianchi, 1996). In the domains of marriage and parenting, however, men’s and women’s life courses still differ (Moen, 2001; Oesterle et al., 2010; Williams and Umberson, 2004). For example, women marry and have children younger than men. Women are also more likely than men to raise children outside the context of marriage, and are much more likely to live with and have primary responsibility for raising their children (Cohen et al., 2003; Coltrane, 2000; Hochschild and Machung, 1989; Oesterle et al., 2010; Seltzer, 2000; Woodward et al., 2006). This appears to be the case particularly among those young adults on pathways with limited postsecondary education (Oesterle et al., 2010; Sandefur et al., 2005), suggesting that parenting is less tied to marriage for women than for men among noncollege young adults. The relatively large proportion of young adult women who raise children outside of marriage (while most young adult men who live with children are married) suggests that unmarried young adult mothers may need greater supports to successfully manage the transition to adulthood. More than men at this age, young unmarried mothers may need to take on multiple adult roles simultaneously to support their children, combining school, work, and parenting responsibilities. If no familial or partner support is available, this may create considerable stress for the young adult mothers, and may also put their children at risk for growing up in poverty (Bianchi and Milkie, 2010; Brandon and Bumpass, 2001; Falci et al., 2010). For men, the pathway of the “unmarried working men” is probably of greatest concern as they have the lowest probability of being employed full-time, but are also not attending college. They may have the fewest resources and supports to make a successful transition into young adult roles, exacerbated by the fact that men’s economic position, especially for men with little education, is continuing to decline.

Race Differences in Pathways to Adulthood

Pathways to adulthood vary considerably by race. One of the major differences is that African American young adults (in particular, women) tend to be on a track of early parenting more so than whites and Asian

Americans, and they are less likely to marry or they tend to marry later (Macmillan and Copher, 2005; Mollenkopf et al., 2005; Schoen et al., 2009). Hispanic and Native Americans are also more likely than whites and Asian Americans to become parents early, that is, in late adolescence; however, African American early parents (and, in particular, mothers) are much less likely to have children in the context of marriage compared to Hispanic and Native American and other young adults (Macmillan and Copher, 2005; Sandefur et al., 2005). Oesterle et al. (2010) found that, in their community study of a cohort born in 1975 and beginning their transition to adulthood in 1993 when they were age 18, “African American women were 2.5 times more likely than white women to be on the ‘Unmarried Early Mothers’ pathway than on the ‘Postsecondary-Educated Without Children’” pathway (p. 1449). Race was not associated with men’s pathways to adulthood in this study after controlling for other sociode-mographic factors and adolescent experiences such as parental education, family income, school performance, family disruptions such as parental divorce or death, and having been born to a teenage mother.

These findings are supported by results of Sandefur et al.’s study (2005) of two national cohorts (High School and Beyond cohort born in 1964 and National Educational Longitudinal Study cohort born in 1974). They found significant racial differences not only with respect to family aspects of pathways to adulthood, but also in terms of involvement in postsecondary education. African American, Hispanic, and Native American young adults tend to be the least likely to follow a pathway to young adulthood that involves college attendance compared to white and Asian American young adults. It is important to remember that, like in the Oesterle et al. (2010) study, these associations were found independent of other factors such as parental education and family structure. Furthermore, pathways to adulthood of nonwhite young adults also tend to involve less participation in the labor force (Fussell and Furstenberg, 2005). These racial patterns in family formation, education, and work participation during the transition to adulthood suggest that nonwhite young adults face a considerably greater risk of not making a successful transition to adulthood. Young African American women seem to have the greatest need for support during young adulthood because they face a particularly vulnerable situation with a high likelihood of raising children outside of marriage combined with lower employment and less participation in postsecondary education (Macmillan and Copher, 2005).

Childhood and Adolescent Predictors of Pathways to Adulthood

The timing of transitions into adult roles is greatly influenced by a person’s social location, experiences of early adversity, and adolescent experi-

ences and behaviors. Sociodemographic characteristics, “including gender and race/ethnicity (as discussed above), socioeconomic status and family structure in childhood, and adolescent experiences such as academic performance and involvement in substance use and crime” significantly influence the acquisition of adult roles (Oesterle et al., 2010, p. 1438).

The evidence is very clear. Young adults from socioeconomically advantaged families (higher family income and more highly educated parents) are more likely to invest in postsecondary education, and because the two role transitions are closely tied to each other, they are also more likely to postpone family formation during the young adult years (Amato et al., 2008; Guldi et al., 2007; Oesterle et al., 2010; Osgood et al., 2005b; Sandefur et al., 2005). Other characteristics of the family of origin, such as family structure (two-parent vs. single-parent household), family disruptions (e.g., parental divorce or death), and having been born to a teenage mother are also associated with less educational participation during the transition to adulthood, early family formation, and having children outside of marriage (Barber, 2001; Oesterle et al., 2010; Ross et al., 2009; Sandefur et al., 2005; Wolfinger, 2003).

Although strongly associated with parental education, young adults’ own academic performance in adolescence appears to independently increase the likelihood that they will go to college and delay family formation (Amato et al., 2008; Oesterle et al., 2010; Sandefur et al., 2005). Youth with less academic talent and motivation in adolescence are less likely to attend college and move into family roles earlier.

Drug use and delinquency in adolescence have been linked with precocious transitions to adult roles, including early and risky sexual behavior, teenage parenthood, and leaving high school early, as well as problems with the assumption of adult roles and less socioeconomic success, such as unemployment, single parenthood, lower educational attainment, and welfare receipt (Brook et al., 1999; Krohn et al., 1997; Newcomb and Bentler, 1988). Oesterle et al.’s (2010) pathway study found that more frequent substance use in adolescence and having been arrested in adolescence were significantly associated with a lower probability of being on a pathway to adulthood characterized by investment in postsecondary education and postponed family formation when these factors were considered by themselves. However, because youth from more disadvantaged families are more likely to engage in these behaviors, adolescent substance use and arrest did not uniquely predict different pathways to adulthood once family resources and family structural factors were considered at the same time.

Family background seems to be an important selection factor that is a source of important resources and the socialization and modeling processes that shape different life trajectories. For that reason, it makes sense to target the mediating processes through which family background influences path-

ways to adulthood with childhood and adolescent interventions. Early prevention is clearly important because it has the potential to redirect young people into healthier and more successful life paths. Much less is known about the potential of interventions during young adulthood.

Health, Safety, and Well-Being Consequences of Pathways to Adulthood

Different pathways to adulthood have the potential to be an expression of agency that matches the individual’s needs, desires, values, and strengths to their situation, providing a good person–environment fit (Roberts and Robins, 2004; Schulenberg et al., 2003). It would be difficult to assume that certain pathways necessarily lead to better or worse health and well-being. However, research has shown that those who move into adulthood quickly and early, especially with respect to early parenthood, seem to fare worse in adulthood than those who are college bound and delay family formation (Amato and Kane, 2011). The risk of precocious transitions is that they are often accompanied by a lack of appropriate skills, resources, and social support (Harnish et al., 2000; Jackson, 2004; Newcomb, 1996; Pearlin, 1989; Pearlin and Lieberman, 1979; Pearlin et al., 2005). Off-time transitions, which are those that depart from normative age sequences and violate age norms, can have negative consequences because of social sanctions such as stigma and lack of support (Elder and Rockwell, 1976; Hogan, 1978; Jackson, 2004; Marini, 1984; Mortimer et al., 2004; Neugarten et al., 1965; Newcomb, 1996; Settersten, 1998).

Earlier ages at which transitions are made have been found to increase the likelihood of drug use, criminal behavior, unemployment, divorce, limited physical activity, anxiety, and decreased socioeconomic status (Bell and Lee, 2006; Newcomb, 1996). In particular, earlier timing of financial autonomy, independent living, and involvement in intimate relationships was later associated with poorer adult health and functioning (Newcomb, 1996). Delaying first parenthood can be more positive for a parent’s health the longer it is delayed, up to about age 34, after which the health benefits begin to decline (Mirowsky, 2005).

Stalled or slow transitions to adulthood (e.g., living with parents for an extended period of time or returning to live with parents) also may be detrimental to later functioning and well-being. Bell and Lee (2006) found that completing full-time education at an older age was related to more stress. The “slow starters” in Osgood et al.’s (2005b) study, who had made no or only few transitions to adult roles by age 24, had the highest involvement in criminal behaviors at age 24 and did “not seem to be engaged in positive exploration or on a forward-looking path of any kind” (Osgood et al., 2005b, p. 31). Similarly, Schulenberg et al. (2005) found that having made fewer transitions by age 24 in education, work, family formation, and

living situations was related to lower well-being at that age as measured by self-esteem, self-efficacy, and social support.

However, few of these studies account for selection effects and it is unclear whether the reported differences in outcomes are due to choosing different pathways to adulthood or due to preexisting differences in health and well-being during adolescence (often tied to family background) that are also associated with different life paths. Several studies suggest that it is, for the most part, not the chosen transition path per se that determines later health and well-being, but earlier preexisting differences in health and well-being. For example, Amato and Kane (2011) found that college-bound women who delayed family formation rated their health higher, were less depressed, and had higher self-esteem in their mid-20s than women on other pathways; single mothers ranked the lowest on all of these measures. However, the same was true already 7 years earlier in adolescence before they even began their transition to adulthood.

For other outcomes, such as substance use, the results are more mixed, suggesting that in some instances more proximal experiences during the transition to adulthood may be important. In the Amato and Kane (2011) study, women who attended college and postponed family formation experienced a significantly greater increase in heavy drinking than women on other pathways, controlling for their drinking behavior in adolescence. This is consistent with findings from other studies that showed that family roles, and in particular normatively timed (not teenage) parenthood, decreased involvement in substance use, especially for women (Bailey et al., 2008; Oesterle et al., 2011; Staff et al., 2010).

Oesterle et al. (2011) found differences by pathways to adulthood in alcohol, tobacco, and marijuana misuse. Adolescent substance use was associated with, but did not fully explain, pathway differences in tobacco and marijuana misuse. Daily smoking and nicotine dependence were the most prevalent among “unmarried early mothers” and “unmarried men with little educational involvement” during young adulthood. These men were also the most likely to use marijuana. Different mechanisms associated with adult role changes (e.g., assortative mating) may be at work for tobacco and marijuana misuse as compared to alcohol misuse (Merline et al., 2008).

In sum, what these studies suggest is that experiences in childhood and adolescence appear to select and socialize young people into pathways that are predictive of later health and well-being and that more proximal experiences associated with transition pathways are not directly responsible for differences in some health and well-being outcomes in young adulthood. This phenomenon may be a form of “anticipatory socialization” (Yamaguchi and Kandel, 1985), in which those who initiate drug use early, for example, are more likely to abuse substances or become dependent later

in life (Guo et al., 2000; Hingson et al., 2006) and are also more likely to make precocious transitions into adult roles (including teenage parenting).

More research is needed to clarify which health and well-being outcomes are consequences of pathways to adulthood and which outcomes are best explained by selection effects due to earlier experiences and behavioral patterns established in childhood and adolescence. If family background and early socialization are indeed the most important factors in determining later health and well-being (regardless of pathways to adulthood), efforts to prevent problems in young adulthood should include a focus on early prevention. However, transition periods also can function as turning points, providing opportunities for change and intervention. If mastering new developmental tasks can provide experiences of competence and create a better match between person and context, earlier difficulties or negative experiences and behaviors may have less of a continued influence (Schulenberg and Maggs, 2002; Schulenberg et al., 2003, 2004).

EVIDENCE-BASED INTERVENTIONS TARGETING YOUNG ADULTS

Most of the health risks faced by young adults (unintentional injuries, violence, drug use, risky sexual behaviors and associated STIs, mental health problems, and overweight and obesity) are among the leading preventable causes of disease and death in the United States and have large costs to society (Catalano et al., in press; HHS, 2001; McCollister et al., 2010; Mokdad et al., 2004; Woolf, 2006). The good news is that much progress has been made in understanding the risk and protective factors associated with these health-risking behaviors, and a growing number of tested and effective programs and policies for preventing these behaviors have been identified. Furthermore, choosing appropriate evidence-based preventive programs is easier than ever since the creation of several inventories that compile tested and effective programs and policies and the quality of evidence for their efficacy. This information is accessible online and free of charge. However, despite the availability of these inventories, widespread dissemination and high-quality implementation of these effective programs and policies in communities have not been achieved (Ennett et al., 2003; Gottfredson and Gottfredson, 2002; Hallfors and Godette, 2002; Ringwalt et al., 2002, 2011; Wandersman and Florin, 2003). Prevention systems designed to facilitate a science-based approach to decision making around prevention and to choosing and implementing appropriate tested-effective programs may be necessary to achieve community-wide public health impacts. Prevention systems such as Communities That Care (CTC) (Hawkins et al., 2008) and Promoting School–University Partnerships to Enhance

Resilience (PROSPER) (Spoth et al., 2011) have been tested in randomized trials with promising results.

For the purposes of the current paper, we reviewed eight inventories (shown in Table D-1) to identify tested and effective programs that are specifically designed or adapted to target young adults (ages 18-30). We did not include any programs or policies that target youth only up to age 18 or those that are aimed at adults in general. A more comprehensive review would be required to identify programs that were designed for adults in general, but have been tested and shown to be effective also for young adults (Hadley et al., 2010).

A few additional inventories of tested and effective programs exist, but were not included in Table D-1 because they draw on several of the reviewed databases in the table and, therefore, do not provide any additional information (e.g., Child Trends’ LINKS database [www.childtrends.org/Links] and FindYouthInfo.gov’s Program Directory [www.findyouthinfo.gov/program-directory]). Other inventories were not included here because they do not list programs targeting young adults (e.g., the Institute of Education Sciences’ What Works Clearinghouse, or WWC [ies.ed.gov/ncee/wwc], the National Secondary Transition Technical Assistance Center’s Evidence-Based Practices [www.nsttac.org/content/evidence-based-practices], and the Promising Practices Network’s Programs That Work [www.promisingpractices.net/programs.asp]).

The inventories listed in Table D-1 include hundreds of tested-effective programs and policies. However, only a few of the programs and policies specifically target young adults (Hadley et al., 2010). Our review identified 26 programs across five major topic areas (see Table D-2). Although a more comprehensive review may identify a few more programs and policies, the results from this initial review suggest that young adult interventions are an underdeveloped area and warrant further attention.

Each inventory uses somewhat different criteria for evaluating and categorizing the level of available evidence for the efficacy of a program. The last column in Table D-1 includes the efficacy categorization used by each inventory, starting with the highest category indicating the strongest evidence. Table D-2 identifies the level of evidence given for each program by an inventory. A description and comparison of the different rating systems is beyond the scope of this paper. Details on how each inventory rated the quality of available evidence can be found on each inventory’s webpage (see Table D-1).

As Table D-2 shows, more than half of the identified programs targeting young adults (14 out of 26 programs total) are aimed at reducing alcohol and other substance use and related problems, such as drinking and driving and related injuries. Furthermore, most of these programs are designed for college students. Although a focus on college students is ad-

TABLE D-1 Reviewed Inventories of Tested, Effective Interventions and Programs

vised because binge drinking and heavy or excessive drinking is a problem on college campuses (Neinstein, 2013), a lack of programs targeting non-college-bound young adults is concerning. Among 18- to 22-year-olds in 2011, college students have only slightly higher rates of past-month binge drinking than non-enrolled young adults (39 percent versus 35 percent, respectively), whereas cigarette smoking is more prevalent among young adults not attending college (Neinstein, 2013). In fact, with the exception of alcohol and marijuana use, rates of past-year use of most illicit drugs are higher among young adults not in college compared to college students (Neinstein, 2013, Table 5.3A). Not only do young adults not attending college have about a similar or a higher risk of substance use than college students, they also represent are larger proportion of the U.S. young adult population. As studies of pathways to adulthood indicate, half to two-thirds of young adults are taking a pathway to adulthood that does not involve college attendance or only to a limited extent. Most recent data from the U.S. Census indicate that only 42 percent of all 18- to 24-year-olds were enrolled in college in 2011 (U.S. Bureau of the Census, 2011). Twenty-five years ago, a report by the W.T. Grant Foundation (1988) already tried to bring attention to the vulnerability of non-college-bound young adults by calling them the “forgotten half.” Apparently young adults who do not go to college are still the “forgotten half.” A focus on substance use prevention programs seems advisable for all young adults.

Four identified young adult programs are aimed at risky sexual behav-

TABLE D-2 Evidence-Based Programs Targeting Young Adults

ior and related consequences, such as unintended pregnancies and sexually transmitted infections, including HIV (see Table D-2). However, most of these programs target only specific or indicated populations such as African American women or young adults diagnosed with HIV. Given the general increase in sexual activity during this age, which often co-occurs with substance use—increasing the risk for unprotected sex, STIs, and sexual violence (Patrick et al., 2012)—there seems to be a need for broader preventive programming aimed at the general population of young adults.

We identified a few evidence-based programs aimed at other outcomes in the areas of suicide prevention, mental health, educational and vocational skills, and crime or antisocial behavior. What is striking, however, is that few young adult programs are focused specifically on building the life skills required to transition into and successfully navigate new adult roles, such as relationship skills, financial management, and parenting skills. That being said, many tested and effective parenting programs exist, but were not flagged in our search of the inventories because they are not specifically aimed at young adult parents. However, because most first-time parents are young adults, parenting programs (especially for preschool-aged children) should be applicable to young adults, despite not having been tested specifically in this population.

Table D-3 lists some of the tested and effective parenting programs for parents with preschool-aged children. Most of the reviewed inventories recommend four parenting programs based on the strength of the evidence:

• Nurse–Family Partnership
• Triple P–Positive Parenting Program
• Incredible Years
• Parent–Child Interaction Therapy

Details for each of these programs can be found on the websites of the inventories listed in Table D-1. In addition, there are several tested and effective parenting programs for parents of older children and adolescents. They were not listed here because they seemed less clearly relevant to young adult parents.

SUMMARY AND CONCLUSIONS

This paper focused on the most common pathways to young adulthood, which are differentiated primarily by the timing of family formation and participation in postsecondary education. Pathways defined by very early parenting and those characterized by not attending college seem to carry the most risk for poor health and well-being. Pathways are associated with race, gender, and socioeconomic factors in the family of origin. Women, and

TABLE D-3 Evidence-Based Parenting Programs for Parents of Preschool-Aged Children

especially African American women, are more likely to be on a trajectory of early parenthood, often outside the context of marriage, more so than men and other racial groups. Young adults from disadvantaged families (in terms of parental income, education, and family disruptions such as divorce that can lead to single-parent households) are less likely to choose or be able to follow a pathway to adulthood that involves college attendance. Some of the most vulnerable subgroups of young adults—such as youth transitioning out of foster care, youth leaving the juvenile justice system, or young adults with physical disabilities or mental health problems—may require special support to manage the transition to adulthood successfully because they have few institutional supports.

Much of the variation in health and well-being outcomes during young adulthood may be less a function of particular transition pathways than family resources, family background, and experiences during childhood and adolescence that put youth on specific trajectories. However, more research is needed on a greater range of important outcomes related to health, safety, and well-being of young adults; importantly, this research needs to take into account important selection factors that may be associated with both transition pathways and the outcome of interest to better understand the proximal and distal developmental factors at play.

The fact that early experiences during childhood and adolescence seem to play such an important role in determining pathways to adulthood underscores the importance of early preventive interventions. However, transition times also allow for change and discontinuity. But much less is understood about processes of discontinuity and turning points and the potential to intervene during young adulthood to achieve better outcomes. The survey of available tested-effective programs presented in this paper suggests that only a limited number of current programs, often narrowly focused on college students, specifically target young adults. Good young adult programs may already exist, but may not have accumulated enough evidence to be listed as promising or evidence based. Prioritizing the testing of such interventions in well-designed studies (e.g., randomized trials) is highly recommended. Many of the existing evidence-based programs for adults in general may be suitable for young adults as well, but would need to be evaluated (and possibly adapted) specifically for that population. Furthermore, with the exception of parenting programs, there seems to be a lack of preventive interventions that focus on building the life skills required to make a successful transition to adulthood (e.g., relationship skills, financial skills, workplace-related skills). Program development and evaluation may need to be matched more closely to indicators of young adult problems, especially for the most vulnerable subpopulations of young adults, to provide more tested-effective solutions. For example, no programs addressing overweight and obesity and healthy living were identified.

Finally, existing programs that work need more widespread dissemination and high-quality implementation to achieve community-wide public health impacts.

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