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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2019. The Promise of Adolescence: Realizing Opportunity for All Youth. Washington, DC: The National Academies Press. doi: 10.17226/25388.
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PREPUBLICATION COPY, UNCORRECTED PROOFS     THE PROMISE OF ADOLESCENCE: REALIZING OPPORTUNITY FOR ALL YOUTH Committee on the Neurobiological and Socio-behavioral Science of Adolescent Development and Its Applications Richard J. Bonnie and Emily P. Backes, editors Board on Children, Youth, and Families Division of Behavioral and Social Sciences and Education Health and Medicine Division   A Consensus Study Report of    

PREPUBLICATION COPY, UNCORRECTED PROOFS     THE NATIONAL ACADEMIES PRESS 500 Fifth Street, NW Washington, DC 20001 This activity was supported by contracts between the National Academy of Sciences and the Bezos Family Foundation (unnumbered), the National Public Education Support Fund (unnumbered), the Robert Wood Johnson Foundation (#75005), and the Seattle Foundation (unnumbered). Any opinions, findings, conclusions, or recommendations expressed in this publication do not necessarily reflect the views of any organization or agency that provided support for the project. International Standard Book Number-13: 978-0-309-XXXXX-X International Standard Book Number-10: 0-309-XXXXX-X Digital Object Identifier: https://doi.org/10.17226/25388 Additional copies of this publication are available for sale from the National Academies Press, 500 Fifth Street, NW, Keck 360, Washington, DC 20001; (800) 624-6242 or (202) 334-3313; http://www.nap.edu. Copyright 2019 by the National Academy of Sciences. All rights reserved. Printed in the United States of America Suggested citation: National Academies of Sciences, Engineering, and Medicine. 2019. The Promise of Adolescence: Realizing Opportunity for All Youth. Washington, DC: The National Academies Press. doi: https://doi.org/10.17226/25388.    

PREPUBLICATION COPY, UNCORRECTED PROOFS     The National Academy of Sciences was established in 1863 by an Act of Congress, signed by President Lincoln, as a private, nongovernmental institution to advise the nation on issues related to science and technology. Members are elected by their peers for outstanding contributions to research. Dr. Marcia McNutt is president. The National Academy of Engineering was established in 1964 under the charter of the National Academy of Sciences to bring the practices of engineering to advising the nation. Members are elected by their peers for extraordinary contributions to engineering. Dr. C. D. Mote, Jr., is president. The National Academy of Medicine (formerly the Institute of Medicine) was established in 1970 under the charter of the National Academy of Sciences to advise the nation on medical and health issues. Members are elected by their peers for distinguished contributions to medicine and health. Dr. Victor J. Dzau is president. The three Academies work together as the National Academies of Sciences, Engineering, and Medicine to provide independent, objective analysis and advice to the nation and conduct other activities to solve complex problems and inform public policy decisions. The National Academies also encourage education and research, recognize outstanding contributions to knowledge, and increase public understanding in matters of science, engineering, and medicine. Learn more about the National Academies of Sciences, Engineering, and Medicine at www.nationalacademies.org.    

PREPUBLICATION COPY, UNCORRECTED PROOFS     Consensus Study Reports published by the National Academies of Sciences, Engineering, and Medicine document the evidence-based consensus on the study’s statement of task by an authoring committee of experts. Reports typically include findings, conclusions, and recommendations based on information gathered by the committee and the committee’s deliberations. Each report has been subjected to a rigorous and independent peer-review process and it represents the position of the National Academies on the statement of task. Proceedings published by the National Academies of Sciences, Engineering, and Medicine chronicle the presentations and discussions at a workshop, symposium, or other event convened by the National Academies. The statements and opinions contained in proceedings are those of the participants and are not endorsed by other participants, the planning committee, or the National Academies. For information about other products and activities of the National Academies, please visit www.nationalacademies.org/about/whatwedo.    

PREPUBLICATION COPY, UNCORRECTED PROOFS     COMMITTEE ON THE NEUROBIOLOGICAL AND SOCIO-BEHAVIORAL SCIENCE OF ADOLESCENT DEVELOPMENT AND ITS APPLICATIONS RICHARD J. BONNIE, (Chair), Institute of Law, Psychiatry and Public Policy, Schools of Law, Medicine and the Frank Batten School of Leadership and Public Policy, University of Virginia ANNA AIZER, Department of Economics, Brown University MARGARITA ALEGRÍA, Departments of Medicine and Psychiatry, Harvard Medical School & Disparities Research Unit, Department of Medicine, Massachusetts General Hospital, Boston CLAIRE D. BRINDIS, Philip R. Lee Institute for Health Policy Studies & The Adolescent and Young Adult Health National Resource Center, University of California, San Francisco ELIZABETH CAUFFMAN, Department of Psychological Science, University of California, Irvine MESMIN DESTIN, Department of Psychology, School of Education and Social Policy & Institute for Policy Research, Northwestern University ANGELA DIAZ, Department of Pediatrics and Deparment of Environmental Medicine and Public Health & Mount Sinai Adolescent Health Center, Icahn School of Medicine at Mount Sinai NANCY E. HILL, Graduate School of Education, Harvard University MICHELLE JACKSON, Department of Sociology, Stanford University ARLENE F. LEE, Maryland Governor’s Office for Children (formerly) LESLIE LEVE, Department of Counseling Psychology and Human Services, College of Education & Prevention Science Institute, University of Oregon JENS LUDWIG, Harris School of Public Policy, University of Chicago SUSAN VIVIAN MANGOLD, Juvenile Law Center BRUCE S. MCEWEN, Harold and Margaret Milliken Hatch Laboratory of Neuroendocrinology, The Rockefeller University STEPHEN T. RUSSELL, Department of Human Development and Family Sciences, University of Texas, Austin JOANNA LEE WILLIAMS, Curry School of Education and Human Development, University of Virginia EMILY P. BACKES, Study Director ELIZABETH TOWNSEND, Associate Program Officer DARA SHEFSKA, Research Associate MARY GHITELMAN, Senior Program Assistant TAMMY CHANG, James C. Puffer, M.D./American Board of Family Medicine Fellow STEPHANIE OH, Christine Mirzayan Science and Technology Policy Graduate Fellow (January through May 2018) v   

PREPUBLICATION COPY, UNCORRECTED PROOFS     BOARD ON CHILDREN, YOUTH, AND FAMILIES ANGELA DIAZ, (Chair), Department of Pediatrics and Deparment of Environmental Medicine and Public Health, Mount Sinai Adolescent Health Center, Icahn School of Medicine at Mount Sinai HAROLYN BELCHER, Kennedy Krieger Institute and Johns Hopkins University School of Medicine W. THOMAS BOYCE, University of British Columbia DAVID V. B. BRITT, Sesame Workshop (retired CEO) RICHARD F. CATALANO, School of Social Work, University of Washington DIMITRI CHRISTAKIS, Seattle Children’s Research Institute, University of Washington JEFFREY W. HUTCHINSON, Uniformed Services University of the Health Sciences JACQUELINE JONES, Foundation for Child Development STEPHANIE J. MONROE, The Wrenwood Group, LLC JAMES M. PERRIN, Harvard Medical School and MassGeneral Hospital for Children NISHA SACHDEV, Bainum Family Foundation DONALD F. SCHWARZ, Robert Wood Johnson Foundation MARTÍN J. SEPÚLVEDA, IBM Corporation (Retired) MARTIN H. TEICHER, Developmental Biopsychiatry Research Program at McLean Hospital and Harvard Medical School JONATHAN TODRES, Georgia State University College of Law  NATACHA BLAIN, Director PAMELLA ATAYI, Program Coordinator vi   

PREPUBLICATION COPY, UNCORRECTED PROOFS     Title: Only Skin Deep Artist: Angela Casarez (Fort Worth, TX) Artist age: 19 Artist statement: This collage of different facial features and anatomy illustrates the many dimensions of global health disparities that include race, ethnicity, socioeconomic status, and geography. It is critically important for both policy makers and health care providers to identify the many facets of disparities so that solutions address health security for a variety of different circumstances and lifestyles. Efforts to eliminate disparities and increase equity must be part of a broader effort to transform health care and improve the quality and breadth of care delivered to individual patients—no matter what piece of this collage they may identify with. The strongest and most evident point this piece illustrates is simply that we are all human. Yet ironically, although beneath our skin and our socioeconomic positions, we all share the same anatomy, modern medicine is not practiced with such certainty and consistency. With that, I and my piece put forth that a world in which everyone has an equal chance to be healthy, safe, and happy, is one in which health care is as undeniable as the fact that any and every human possesses a zygomaticus major to smile. This artwork was submitted as a part of the National Academy of Medicine’s Young Leaders Visualize Health Equity nationwide call for art. This call for art encouraged young people between the ages of 5 and 26 to use art to explore how the social determinants of health play a role in shaping their lives and their communities, and what it might look and feel like to one day live in a world where everyone has the same chance to be healthy, safe, and happy. More information on this project can be found at nam.edu/youngleaders. vii   

PREPUBLICATION COPY, UNCORRECTED PROOFS       viii   

PREPUBLICATION COPY, UNCORRECTED PROOFS     PREFACE Our nation’s youth hold the key to our future well-being. Investing generously in them will create a “more perfect union.” That is the central message of this consensus report on the “promise of adolescence” sponsored by Funders for Adolescent Science Translation, a consortium of foundations that came together with the aim of using science to produce more equitable and positive life outcomes for youth. This report takes its place in a sequence of National Academies of Sciences, Engineering, and Medicine reports exploring the science of child and adolescent development that began with From Neurons to Neighborhoods, the pathbreaking Institute of Medicine study on the science of early childhood development published in 2000. The science of adolescent development explores the neurobiological and socio-behavioral processes that underlie the unique and fascinating process of maturation. The 21st century has featured extraordinary advances in knowledge about the unique developmental processes—and challenges—of adolescence as well as the important role of this developmental period in shaping the trajectory of the life course. Our committee’s assignment was to synthesize these exciting advances in the science of adolescent development and draw out their implications for the social systems charged with helping all adolescents flourish. This committee’s study is a companion to a parallel study funded by the Robert Wood Johnson Foundation exploring the neurobiological and socio-behavioral sciences’ findings concerning childhood development from the prenatal period through early childhood: Together, these two reports consolidate the extraordinary advances in the science of human development in order to inform child and youth-serving institutions and policy makers. In this respect, they also complement a 2014 HRSA-funded study focused on improving the safety and well-being of young adults. Studying adolescents provides a rich opportunity for exploring the developing mind. For one thing, the fascinating process of evolving self-awareness—indeed, a preoccupation with self—is heightened during adolescence and our individual memories of that experience tend to be especially vivid. In addition, our sense of identity—of who we are and who we want to be— is taking shape during adolescence. We all tend to remember these experiences many years later. As the report explains, the adolescent brain undergoes a remarkable transformation between puberty and the mid-20s that underpins amazing advances in learning and creativity. The plasticity of the adolescent brain also provides the potential for resilient responses to childhood trauma and distress. Personal experience teaches us, of course, that the excitement and emotional preoccupations of adolescence can yield both opportunity and risk. As a society, we bear a collective obligation to unleash the creativity of the adolescent brain while cushioning adolescents from experiences that could endanger their future well-being. Another central theme of this report, signified by its subtitle, is that our nation must ensure that the “promise of adolescence” is realized for all adolescents. As the report shows, millions of adolescents are being left behind because they have lacked equal opportunity to succeed. Disparities in developmental outcomes for disadvantaged youth are attributable to lack of adequate resources and supports in their families and in the neighborhoods where they live, as well as the effects of bias and discrimination. The committee has concluded that we have the knowledge needed to reduce these disparities and close the opportunity gap. The committee has also expressed its collective view that these remedial measures should be taken because it is ix   

PREPUBLICATION COPY, UNCORRECTED PROOFS     unjust (and contrary to the nation’s collective self-interest), to allow these disparities to continue. We did so because this value judgment is implicit in our charge. On behalf of the National Academies and its Board on Children, Youth and Families, I want to thank the member foundations of Funders for Adolescent Science Translation for sponsoring this important study. I am deeply grateful to Emily Backes and the Academies staff for their extraordinary skill and diligence, and most of all, to my fellow members of the committee. It has been a pleasure to work with such talented colleagues on this interesting and important project. I look forward to working with them, as well as our sponsors, to disseminate the committee’s findings and implement its recommendations for developmentally informed youth-serving systems. I want to close with a personal observation. The Virginia Bar Association, to which I belong, devoted the plenary session of its annual meeting in 2019 to a panel discussion lamenting the incivility of discourse in our fractious society. As we discussed what our organization can and should do about it, I observed that our current state of polarization has emerged and deepened over several decades and that remedial efforts should focus on our young people, beginning in adolescence when they are learning how people differ from one another and as they are discovering (and shaping) their own identities. Our obligation as parents and teachers is to help them develop the desire, and the skill, to listen to each other and to respect differences in their beliefs and values. We need to invest in our youngsters to repair our weakened (and imperfect) union. Richard J. Bonnie, Committee Chair Committee on the Neurobiolgoical and Socio- behavioral Science of Adolescent Development and Its Applications x   

PREPUBLICATION COPY, UNCORRECTED PROOFS     ACKNOWLEDGMENTS This report would not have been possible without the contributions of many people. First, we thank the sponsors of this study: the Funders for Adolescent Science Translation, including the Annie E. Casey Foundation, the Bezos Family Foundation, the Chan Zuckerberg Initiative, the Ford Foundation, the Conrad N. Hilton Foundation, the Raikes Foundation, the Robert Wood Johnson Foundation, and the National Public Education Support Fund. Special thanks go to the members of the study committee, who dedicated extensive time, thought, and energy to the project. Thanks are also due to James C. Puffer, M.D./American Board of Family Medicine Fellow Tammy Chang (University of Michigan Medical School, Department of Family Medicine), who contributed her time and expertise throughout the report process, as well as Natalie Slopen (University of Maryland, Department of Epidemiology and Biostatistics), who served as a liaison between our study committee and the Committee on Applying Neurobiological and Socio-behavioral Sciences from Prenatal through Early Childhood Development: A Health Equity Approach. We also extend our gratitude to Nat Kendall-Taylor, Marisa Gerstein Pineau, and Daniel Busso from the Frameworks Institute for their insights on communicating about adolescence. In addition to its own research and deliberations, the committee received input from several outside sources, whose willingness to share their perspectives and experiences was essential to the committee’s work. We thank Linda Burton (Duke University), Tammy Fields (Palm Beach County Youth Services Department), Andrew J. Fuligni (University of California, Los Angeles), Seema Gajwani (Office of the Attorney General for the District of Columbia), Roberto G. Gonzales (Harvard School of Education), Phil Hammack (University of California, Santa Cruz), Cheri Hoffman (U.S. Department of Health and Human Services), Diane Hughes (New York University), Allyson Mackey (University of Pennsylvania), Gloria Mark (University of California, Irvine), Steve Michael (Iowa Collaboration for Youth Development), Jacqueline Nesi (Brown University), Candice Odgers (Duke University), Uma Rao (University of California, Irvine), Russell Romeo (Barnard College), Robert Sainz (Economic and Workforce Development Department, City of Los Angeles), Kaveri Subrahmanyam (California State, Los Angeles), and Roderick J. Watts (University of New York).The committee also gathered information through two commissioned analyses. We thank Monica Kirkpatrick Johnson (Washington State University) for “Contemporary Adolescents: Understanding the Demographic, Social, and Economic Changes Shaping Adolescent Life” and the University of Michigan MyVoice team for “Contemporary Adolescents: Understanding the Lived Experiences of Today’s Youth.” The committee was also able to elicit input from adolescents throughout the report process. We extend our gratitude to the thoughtful young people who graciously gave their time to inform our work: Zachary Caplan, Darius Craig, Tanya Gumbs, Shyara Hill, Marcus Jarvis, Carolin Larkin, Nyla Mpofu, Jocelyn Nolasco, and Ayanna Tucker. We were truly awed by their ability to speak their truth and their impassioned commitment to bettering society. Their insights were incredibly valuable. This Consensus Study Report was reviewed in draft form by individuals chosen for their diverse perspectives and technical expertise. The purpose of this independent review is to provide candid and critical comments that will assist the National Academies of Sciences, Engineering, and Medicine in making each published report as sound as possible and to ensure that it meets the institutional standards for quality, objectivity, evidence, and responsiveness to xi   

PREPUBLICATION COPY, UNCORRECTED PROOFS     the study charge. The review comments and draft manuscript remain confidential to protect the integrity of the deliberative process. We thank the following individuals for their review of this report: Sarah M. Bagley, CATALYST Clinic, Boston University School of Medicine/Boston Medical Center; Robert Wm. Blum, Department of Population, Family and Reproductive Health, Urban Health Institute, Johns Hopkins University; Catherine Bradshaw, Curry School of Education and Human Development, University of Virginia; Jeanne Brooks-Gunn, Teachers College and College of Physicians and Surgeons, Columbia University; Cleopatra Cabuz, Technology and Partnerships (retired), Honeywell Safety and Productivity Solutions; Ron E. Dahl, Institute of Human Development, University of California, Berkeley; Amy Dworksy, Chapin Hall, The University of Chicago; Adriana Galván, Department of Psychology Brain Research Institute, University of California, Los Angeles; Jonathan Guryan, Institute for Policy Research, Northwestern University; Cheri Hoffman, Division of Children and Youth Policy, Office of the Assistant Secretary for Planning and Evaluation, U.S. Department of Health & Human Services; Velma McBride Murry, Department of Human and Organizational Development, Vanderbilt University; Anne C. Peterson, Ford School, University of Michigan; Alex R. Piquero, School of Economic, Political and Policy Sciences, The University of Texas at Dallas; Ricki Price-Baugh, Director of Academic Achievement, Council of the Great City Schools. Although the reviewers listed above provided many constructive comments and suggestions, they were not asked to endorse the conclusions or recommendations of this report nor did they see the final draft before its release. The review of this report was overseen by Rosemary Chalk, independent consultant, Bethesda, MD, and Antonia M. Villarruel, School of Nursing, University of Pennsylvania. They were responsible for making certain that an independent examination of this report was carried out in accordance with the standards of the National Academies and that all review comments were carefully considered. Responsibility for the final content rests entirely with the authoring committee and the National Academies. The committee also wishes to extend its gratitude to the staff of the National Academies of Sciences, Engineering, and Medicine, in particular to Liz Townsend and Dara Shefska, who contributed research and writing assistance to the committee’s work and played an important role in editing portions of the report. Mary Ghitelman provided key administrative and logistical support and made sure that committee meetings and report production ran efficiently and smoothly. Thanks are also due to fellows Stephanie Oh, who provided valuable research assistance in the report’s early stages, and Katrina Ferrara, who made important contributions during the editing process. Throughout the project, Natacha Blain, director of the Board on Children, Youth, and Families, provided helpful oversight. The committee is also grateful to Anthony Bryant and Pamella Atayi for their financial and administrative assistance on the project. From the Division of Behavioral and Social Sciences and Education Office of Reports and Communication, we thank Kirsten Sampson-Snyder, Yvonne Wise, and Douglas Sprunger, who shepherded the report through the review and production process and assisted with its communication and dissemination. We also thank Marc DeFrancis for his skillful editing. We are grateful to our colleagues and collaborators in the Health and Medicine Division and the National Academy of Medicine’s Culture of Health program. In particular, we would like to extend our thanks to HMD’s Rose Marie Martinez, Amy Geller, Yami Negussie, and Sophie Yang for their wonderful collegiality and thoughtful input throughout the endeavor. Thanks are also due to National Academy of Medicine staff Charlee Alexander, Ivory Clarke, Kyra Cappelucci, and the entire Culture of Health program team. xii   

PREPUBLICATION COPY, UNCORRECTED PROOFS     Finally, the committee wishes to thank our chair, Richard Bonnie, for his time, intellectual leadership, and devotion to this study. It was an honor to work with Richard, and this report is truly better for his commitment. Emily P. Backes, Study Director Committee on the Neurobiolgoical and Socio- behavioral Science of Adolescent Development and Its Applications xiii   

PREPUBLICATION COPY, UNCORRECTED PROOFS

PREPUBLICATION COPY, UNCORRECTED PROOFS CONTENTS Summary 1 Part I: Adolescence as a Period of Opportunity 1 Introduction 11 Study Charge and Approach, 12 History of Adolescence, 17 Contemporary Adolescents, 19 The Promise of Adolescence, 23 The Political Challenge, 24 Study Methods, 25 Organization of the Report, 25 2 Adolescent Development 27 Puberty, 27 Neurobiological Development, 34 Psychosocial Development in Adolescence, 44 Conclusion, 56 3 How Environment “Gets Under the Skin”: The Continuous Interplay between Biology and Environment 58 Understanding Epigenetics, 59 Reciprocal Interactions between Brain, Body, and Environment, 63 Ameliorating Early Life Adversities in Adolescence, 69 Conclusion, 71 4 Inequity and Adolescence 73 Disparities in Adolescent Outcomes, 74 Sources of Disparities: Inequality of Opportunity, 89 Achieving Equity for Adolescents, 106 Conclusion, 112 5 Introduction to Part II: Using Developmental Knowledge to Assure Opportunity for all Youth 113 Growing System Complexity, 113 Parents and Caregivers, 115 Faith-based Institutions, 117 Envisioning Developmentally Informed Youth-serving Systems, 119 xv 

PREPUBLICATION COPY, UNCORRECTED PROOFS 6 Education 121 Societal Changes, 123 Improved Understanding of Adolescence, 126 Creating the Education Sector of the Future, 130 Recommendations, 150 7 Health System 159 The Vision: Seamless Access to Adolescent-friendly Health Services, 159 Sexual and Reproductive Health Care, 165 Behavioral Health Care, 168 Confidentiality and Parental Consent Requirements, 178 Adolescent Health Care Workforce, 180 Meeting Adolescents Where They Are: Services in Nonclinical Settings, 182 Recommendations, 185 8 Child Welfare System 196 Child Maltreatment and the Adolescent Brain, 197 Introduction to the Child Welfare System, 199 Aligning the Child Welfare System with the Needs of Adolescents, 203 Developmental Research on Adolescents in the Child Welfare System: Challenges and Promising Solutions, 209 Flourishing for Child Welfare-Involved Adolescents, 217 Recommendations, 218 9 Justice System 225 Developmentally Informed Juvenile Justice: Progress Report, 227 Reducing Racial Disparities, 235 Opportunities for Continued Juvenile Justice Reforms, 240 A Developmentally Informed Criminal Justice System, 253 Opportunities for Cross-System Collaboration, 258 Recommendations, 261 10 The Scientific Opportunity 266 Data Limitations, 267 Recommendations for Future Research, 268 Investments in Research on Adolescence, 272 Conclusion, 273 References 274 xvi 

PREPUBLICATION COPY, UNCORRECTED PROOFS APPENDIXES A. Assessing the Evidence 395 B. Youth Engagement 397 C. Biosketches of Committee Members and Staff 404 xvii 

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Adolescence—beginning with the onset of puberty and ending in the mid-20s—is a critical period of development during which key areas of the brain mature and develop. These changes in brain structure, function, and connectivity mark adolescence as a period of opportunity to discover new vistas, to form relationships with peers and adults, and to explore one’s developing identity. It is also a period of resilience that can ameliorate childhood setbacks and set the stage for a thriving trajectory over the life course.

Because adolescents comprise nearly one-fourth of the entire U.S. population, the nation needs policies and practices that will better leverage these developmental opportunities to harness the promise of adolescence—rather than focusing myopically on containing its risks. This report examines the neurobiological and socio-behavioral science of adolescent development and outlines how this knowledge can be applied, both to promote adolescent well-being, resilience, and development, and to rectify structural barriers and inequalities in opportunity, enabling all adolescents to flourish.

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