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Suggested Citation:"2 Normative Adolescent Development." National Academies of Sciences, Engineering, and Medicine. 2019. Promoting Positive Adolescent Health Behaviors and Outcomes: Thriving in the 21st Century. Washington, DC: The National Academies Press. doi: 10.17226/25552.
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Suggested Citation:"2 Normative Adolescent Development." National Academies of Sciences, Engineering, and Medicine. 2019. Promoting Positive Adolescent Health Behaviors and Outcomes: Thriving in the 21st Century. Washington, DC: The National Academies Press. doi: 10.17226/25552.
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Suggested Citation:"2 Normative Adolescent Development." National Academies of Sciences, Engineering, and Medicine. 2019. Promoting Positive Adolescent Health Behaviors and Outcomes: Thriving in the 21st Century. Washington, DC: The National Academies Press. doi: 10.17226/25552.
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Suggested Citation:"2 Normative Adolescent Development." National Academies of Sciences, Engineering, and Medicine. 2019. Promoting Positive Adolescent Health Behaviors and Outcomes: Thriving in the 21st Century. Washington, DC: The National Academies Press. doi: 10.17226/25552.
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Suggested Citation:"2 Normative Adolescent Development." National Academies of Sciences, Engineering, and Medicine. 2019. Promoting Positive Adolescent Health Behaviors and Outcomes: Thriving in the 21st Century. Washington, DC: The National Academies Press. doi: 10.17226/25552.
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Suggested Citation:"2 Normative Adolescent Development." National Academies of Sciences, Engineering, and Medicine. 2019. Promoting Positive Adolescent Health Behaviors and Outcomes: Thriving in the 21st Century. Washington, DC: The National Academies Press. doi: 10.17226/25552.
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Suggested Citation:"2 Normative Adolescent Development." National Academies of Sciences, Engineering, and Medicine. 2019. Promoting Positive Adolescent Health Behaviors and Outcomes: Thriving in the 21st Century. Washington, DC: The National Academies Press. doi: 10.17226/25552.
×
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Suggested Citation:"2 Normative Adolescent Development." National Academies of Sciences, Engineering, and Medicine. 2019. Promoting Positive Adolescent Health Behaviors and Outcomes: Thriving in the 21st Century. Washington, DC: The National Academies Press. doi: 10.17226/25552.
×
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Suggested Citation:"2 Normative Adolescent Development." National Academies of Sciences, Engineering, and Medicine. 2019. Promoting Positive Adolescent Health Behaviors and Outcomes: Thriving in the 21st Century. Washington, DC: The National Academies Press. doi: 10.17226/25552.
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Suggested Citation:"2 Normative Adolescent Development." National Academies of Sciences, Engineering, and Medicine. 2019. Promoting Positive Adolescent Health Behaviors and Outcomes: Thriving in the 21st Century. Washington, DC: The National Academies Press. doi: 10.17226/25552.
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Suggested Citation:"2 Normative Adolescent Development." National Academies of Sciences, Engineering, and Medicine. 2019. Promoting Positive Adolescent Health Behaviors and Outcomes: Thriving in the 21st Century. Washington, DC: The National Academies Press. doi: 10.17226/25552.
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Suggested Citation:"2 Normative Adolescent Development." National Academies of Sciences, Engineering, and Medicine. 2019. Promoting Positive Adolescent Health Behaviors and Outcomes: Thriving in the 21st Century. Washington, DC: The National Academies Press. doi: 10.17226/25552.
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Suggested Citation:"2 Normative Adolescent Development." National Academies of Sciences, Engineering, and Medicine. 2019. Promoting Positive Adolescent Health Behaviors and Outcomes: Thriving in the 21st Century. Washington, DC: The National Academies Press. doi: 10.17226/25552.
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Suggested Citation:"2 Normative Adolescent Development." National Academies of Sciences, Engineering, and Medicine. 2019. Promoting Positive Adolescent Health Behaviors and Outcomes: Thriving in the 21st Century. Washington, DC: The National Academies Press. doi: 10.17226/25552.
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Suggested Citation:"2 Normative Adolescent Development." National Academies of Sciences, Engineering, and Medicine. 2019. Promoting Positive Adolescent Health Behaviors and Outcomes: Thriving in the 21st Century. Washington, DC: The National Academies Press. doi: 10.17226/25552.
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Suggested Citation:"2 Normative Adolescent Development." National Academies of Sciences, Engineering, and Medicine. 2019. Promoting Positive Adolescent Health Behaviors and Outcomes: Thriving in the 21st Century. Washington, DC: The National Academies Press. doi: 10.17226/25552.
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Suggested Citation:"2 Normative Adolescent Development." National Academies of Sciences, Engineering, and Medicine. 2019. Promoting Positive Adolescent Health Behaviors and Outcomes: Thriving in the 21st Century. Washington, DC: The National Academies Press. doi: 10.17226/25552.
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Suggested Citation:"2 Normative Adolescent Development." National Academies of Sciences, Engineering, and Medicine. 2019. Promoting Positive Adolescent Health Behaviors and Outcomes: Thriving in the 21st Century. Washington, DC: The National Academies Press. doi: 10.17226/25552.
×
Page 36
Suggested Citation:"2 Normative Adolescent Development." National Academies of Sciences, Engineering, and Medicine. 2019. Promoting Positive Adolescent Health Behaviors and Outcomes: Thriving in the 21st Century. Washington, DC: The National Academies Press. doi: 10.17226/25552.
×
Page 37
Suggested Citation:"2 Normative Adolescent Development." National Academies of Sciences, Engineering, and Medicine. 2019. Promoting Positive Adolescent Health Behaviors and Outcomes: Thriving in the 21st Century. Washington, DC: The National Academies Press. doi: 10.17226/25552.
×
Page 38
Suggested Citation:"2 Normative Adolescent Development." National Academies of Sciences, Engineering, and Medicine. 2019. Promoting Positive Adolescent Health Behaviors and Outcomes: Thriving in the 21st Century. Washington, DC: The National Academies Press. doi: 10.17226/25552.
×
Page 39
Suggested Citation:"2 Normative Adolescent Development." National Academies of Sciences, Engineering, and Medicine. 2019. Promoting Positive Adolescent Health Behaviors and Outcomes: Thriving in the 21st Century. Washington, DC: The National Academies Press. doi: 10.17226/25552.
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Below is the uncorrected machine-read text of this chapter, intended to provide our own search engines and external engines with highly rich, chapter-representative searchable text of each book. Because it is UNCORRECTED material, please consider the following text as a useful but insufficient proxy for the authoritative book pages.

Prepublication copy, uncorrected proofs 2 Normative Adolescent Development Living my best life would include being physically, mentally, and emotionally “fit” and striving every day to reach a sense of stability. Male, age 171 Adolescence is a dynamic period of growth and change. As described in the recent National Academies report The Promise of Adolescence: Realizing Opportunity for All Youth, adolescence is “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” (NASEM, 2019, p. 1). This chapter begins by presenting the major conclusions of The Promise of Adolescence. It then reviews research in the five domains of optimal health—physical health, emotional health, social health, spiritual health, and intellectual health—as they relate to adolescent development. While not an exhaustive review of adolescent development, this chapter highlights the influences that are most relevant to each domain of optimal health. CONCLUSIONS OF THE PROMISE OF ADOLESCENCE: REALIZING OPPORTUNITY FOR ALL YOUTH (2019) Adolescence forms the critical bridge between childhood and adulthood, making it an ideal window of opportunity to promote positive development. As noted in Chapter 1, although adolescence is often considered a “dark and stormy” time, exploration and risk taking are in fact necessary parts of growing up. They allow adolescents to form their identities; become more autonomous; and develop new cognitive, social, and emotional skills required for success in adulthood. During adolescence, moreover, connections within and between brain regions strengthen and become more efficient, while unused connections are pruned away. These changes in the brain thus provide opportunities for positive, life-shaping development and resilience in the face of past adversity. Conversely, this plasticity also makes youth more vulnerable to adverse experiences. In that sense, adolescence represents a unique and important opportunity to support youth and promote the behaviors and skills that are critical to growth and development. Yet despite the opportunity provided by the brain’s plasticity during adolescence, for too many youth, the promise of adolescence is not being realized. Adolescents’ access to opportunities and 1 Response to MyVoice survey question: “Describe what it would look like to live your best life.” See the discussion of the MyVoice methodology in Appendix B for more detail. 2-1

Prepublication copy, uncorrected proofs supports vary by age, race and ethnicity, socioeconomic status, rurality/urbanity, sexual orientation and gender identity, and disability status. Longstanding disparities have created an opportunity gap that leaves many adolescents in stressful, dangerous, disadvantaged, and isolated situations that can have lifelong effects. Youth from disadvantaged circumstances therefore need more than equal access to resources; rather, to ensure access to comparable opportunities, these youth need more resources relative to their peers from more advantaged backgrounds. Determining what resources might be necessary requires understanding how best to support adolescents as they begin to navigate the challenges and opportunities of this period of development, enabling them not only to survive but to thrive during this period. ADOLESCENT DEVELOPMENT ACCORDING TO THE FIVE DOMAINS OF THE OPTIMAL HEALTH FRAMEWORK As discussed in Chapter 1, the committee found only one definition of “optimal health” in our literature search. This definition, first presented by O’Donnell in 1986 and later updated in an editorial statement for the American Journal of Health Promotion, describes optimal health as “a dynamic balance of physical, emotional, social, spiritual, and intellectual health” (O’Donnell, 2009, p. vi). The five dimensions are further defined as follows (O’Donnell, 2017, p. 76):  physical health: the condition of the body;  emotional health: the ability to cope with or avoid stress and other emotional challenges;  social health: the ability to form and maintain nurturing and productive relationships with family, friends, classmates, neighbors, and others;  spiritual health: having a sense of purpose, love, hope, peace, and charity; and  intellectual health: the necessary skills for academic achievements, career achievements, hobbies, and cultural pursuits An important strength of this definition is the understanding that health is not unidimensional, but comprises various dimensions of well-being that are constantly changing and interrelated. As stated by O’Donnell (2017, p. 76) in his later work, “It is not realistic to expect to reach that magic point of perfect balance and stay there. It is more realistic to seek opportunities for growth and think in terms of a process of striving for balance under changing circumstances.” Importantly, this statement allows for change in the relative importance of each dimension given the time, place, and situation. In each of the five dimensions of optimal health then, a person’s health is constantly changing based on a variety of biological, social, and environmental factors. Though individual goals and motivations drive certain health behaviors, O’Donnell (2017) asserts that perhaps the greatest predictors of health behaviors are the physical and social environments in which people live. Hence, these avenues may provide the greatest opportunity for health promotion. O’Donnell (2017) describes a number of reasons why the social environment is so influential. First, individual goals are influenced by socializing agents and places. Second, socialization governs the norms and pressures that people face. Third, socialization occurs primarily outside conscious thought, which often leads to a lack of awareness about how socialization influences values, priorities, and goals. Thus, the social environment is critically important because of its powerful influence on people’s daily goals, choices, and behaviors. 2-2

Prepublication copy, uncorrected proofs Although O’Donnell did not intend his definition of optimal health to serve as a model for adolescent health, the concept of seeking opportunities for growth under changing circumstances has relevance for this developmental period. While adolescence is a period of growing autonomy and independence, the adolescent experience is also highly dependent on the individual, family, community, and societal context (see Box 2-1). BOX 2-1 Youth Voices: Tell us about something or someone that helps you live your best life. In a recent MyVoice survey, adolescents were asked about something or someone that helps them live their best life (see Appendix B for more detail on the MyVoice methodology). The top 10 answers from the 913 responses received are shown in the figure below. Overall, youth most commonly cited support from family, friends, and romantic partners and extracurricular activities or hobbies. SOURCE: Generated by the committee from data in the MyVoice (2019) report. Of course, this definition is not without its limitations. First, not all of the five dimensions of optimal health are easy to measure. For example, anthropometric data or medical and psychiatric diagnoses can be used to measure various aspects of physical and emotional health, and school grades, educational attainment, and cognitive ability can serve as measures of intellectual health. In contrast, levels of social and spiritual health are much more difficult to measure. Second, while the interactions among these dimensions make O’Donnell’s definition attractive, they can make the dimensions difficult to tease apart. For instance, programs and interventions aimed at promoting adolescent health and well-being often focus on more than one 2-3

Prepublication copy, uncorrected proofs dimension, as in the example of social-emotional learning. As a result, assigning such programs and interventions to one particular category can be virtually impossible. These measurement challenges are well illustrated in the review of programs in Chapter 4, where the committee was unable to identify groups of programs that fit exclusively into the social and spiritual health domains; instead, quite a few programs in the category of “multiple optimal health domains” include aspects of social and spiritual health. Third, though adolescents typically reach a number of milestones in each of O’Donnell’s five areas of optimal health, and while certain developmental progressions tend to occur during this period, adolescent development is also a highly individual process. This individuality creates some limitations in defining what constitutes normative development during this period. Defining stages and behaviors as “normative” can suggest that non-normative behaviors are negative; in the context of this report, therefore, the term “normative” is meant to align with typical developmental trajectories and milestones shared by youth of diverse backgrounds. Finally, and in line with the aforementioned limitations, this report is, to our knowledge, the first to provide such a detailed examination of the literature on adolescent development and behavior using an optimal health lens. However, this review was constrained by the lack of definitions of “optimal health” in the peer-reviewed literature, and our use of O’Donnell’s definition should not be interpreted as an endorsement of its application to adolescent health programming. Each of the following sections is dedicated to one of the five optimal health dimensions. Each section first provides a description of important adolescent developmental milestones and trajectories for that particular dimension, followed by a discussion of the major social and environmental influences that affect those milestones and trajectories, including but not limited to parents, peers, schools, and media. Physical Health Developmental Milestones and Trajectories In adolescence, puberty drives the primary physical changes that occur. These physiological developments, which include changes in a person’s height, weight, body composition, sex characteristics, and circulatory and respiratory systems, are caused primarily by hormonal activity. Hormones prime the body to behave in a certain way once puberty begins and trigger certain behavioral and physical changes, and hormone production gradually increases until an adolescent reaches sexual maturation. Although puberty typically follows a series of predictable physical changes, the onset and timing of these developments vary from person to person and have changed over time (Parent et al., 2016). Genetic, environmental, and health factors, including biological determinants, life stressors, socioeconomic status, nutrition and diet, amount of body fat, and presence of chronic illness, can all affect the onset and progression of puberty (Aylwin et al., 2019). Understanding the role of puberty is particularly important because pubertal hormones and the context in which they occur drive many of the motivations for novelty seeking that occur during adolescence. Social and Environmental Influences on the Development of Physical Health Bodily changes during puberty can have important effects on how adolescents perceive themselves and are perceived by others (NASEM, 2019). The physical changes that occur during puberty have been found to have as great an effect on an adolescent’s self-image as the way he or she is treated and responded to by others (Graber, Nichols, and Brooks-Gunn, 2010). 2-4

Prepublication copy, uncorrected proofs Because adolescents experience puberty at different times and rates, their physical development can be a source of pride or shame. Parents and peers play a large role in shaping the attitudes of adolescents about their bodies and physical activity. Parents in particular can model healthy eating and physical activity and communicate positive messages about their child’s appearance from an early age (Hart et al., 2015). Schools have the potential to equalize access to opportunities for all students, as they provide an important environment for encouraging behaviors related to physical health, such as engaging in physical activity and eating a nutritious diet (Hills, Dengel, and Lubans, 2015). Schools can also provide a basic level of primary care services through school-based health centers (SBHCs). Indeed, research on SBHCs has demonstrated their effectiveness in delivering health promotion messages and services to young people, particularly those who may not have access to these services outside of school. SBHCs therefore represent an important venue for delivering health programming (Brown and Bolen, 2018; NASEM, 2019; Parasuraman and Shi, 2014). However, many schools struggle to implement high-quality programs that can drive positive physical health outcomes because of a lack of resources and institutional support. Ultimately, many different genetic, social, and environmental factors affect physical development. The coordination of services and supports, as well as increased equitable access to resources, can help promote optimal physical health outcomes for adolescents. Emotional Health Developmental Milestones and Trajectories Emotional health refers to the ability to cope with or avoid stress and other emotional challenges. In the past, adolescents have been characterized by their rapidly fluctuating emotions. Although researchers once attributed these emotions to the “storm and stress” expected in adolescence, these emotions generally reflect the interplay between the individual’s social environments and the neurobiological and psychological changes that mark this period of development (Lerner and Steinberg, 2009). In this report, the committee takes a strengths-based approach, viewing adolescence as an opportunity and indeed a critical time to help youth acquire positive skills related to emotional regulation. These skills interact with neurobiological and psychological changes to form the basis for the development of emotional health. Neurobiological Changes during Adolescence Second only to infancy, the greatest neurobiological developments—many of which are associated with emotional regulation and decision making—occur during adolescence. Studies have found that the brain is extremely malleable during adolescence, with connections forming and reforming in response to a variety of experiences and stressors (Ismail, Fatemi, and Johnston, 2017; Selemon, 2013). This plasticity means that adolescent brains are highly adaptable to environmental demands. The onset of puberty spurs changes in the limbic system, causing greater sensitivity to rewards, threats, novelty, and peers; in contrast, the cortical regions, which are related to cognitive control and self-regulation, take longer to develop (NASEM, 2019). Theories of adolescent cognitive neuroscience suggest that this asynchronous development of these reward and control systems is responsible for adolescents’ biased decision making and sensation seeking (Casey, 2015; Steinberg, 2014). 2-5

Prepublication copy, uncorrected proofs Psychological Development during Adolescence In adolescence, youth must learn to identify, understand, and express emotions in healthy ways, also referred to as emotional regulation. A primary component of emotional regulation is the ability to handle emotions internally rather than externally. This includes recognizing how emotions impact thoughts and behaviors, learning to delay or reduce impulsive reactions to intense emotions, making decisions about situations based on how one might react emotionally, and engaging in cognitive reframing to change one’s perspective of a particular situation (DeSteno, Gross, and Kubzansky, 2013). Self-esteem (value judgments about oneself) is another critical aspect of psychological development and identity formation. Self-esteem is often at its lowest point in early adolescence, tending to improve in middle to late adolescence as teenagers become more emotionally mature. Differences between how one views oneself and how one believes one “should” be can lead to low self-esteem. Persistently low self-esteem is related to negative outcomes, including depression, delinquency, and other adjustment problems, in multiple optimal health domains (Allwood et al., 2012). Adolescents are also at particularly high risk for developing many health conditions, including major depression, eating disorders, substance use disorders, and anxiety disorders (Herpertz-Dahlmann, Bühren, and Remschmidt, 2013; Merikangas et al., 2010). Beyond genetics, risk factors for these mental health conditions include exposure to, perceptions of, and reactions to stressors; elevated emotional and physiological reactivity; and developmental variation in the utilization of emotional regulation strategies (Carthy et al., 2010; Green et al., 2010; McLaughlin et al., 2012; McLaughlin et al., 2011). Social and Environmental Influences on the Development of Emotional Health Pubertal hormones released during adolescence make youth particularly sensitive to stress (NASEM, 2019). These biological processes, combined with the heightened interpersonal stressors that occur during adolescence, are associated with disruptions in adolescents’ ability to regulate their emotions effectively (McLaughlin, Garrad, and Somerville, 2015). Fortunately, an adolescent’s social and environmental contexts can help mitigate the effects of stress. Adolescents who feel secure and protected in their immediate environments—home, community, and school—tend to handle stress more effectively than youth who feel unsupported, unsafe, or unprotected. Chronically stressful environments put youth at higher risk for depression, anxiety, alcohol or other drug use, teen pregnancy, and violence (NASEM, 2019). To handle stress and difficult situations effectively, adolescents must develop resilience—the capacity to recover quickly from difficulties. Resilience is developed through interactions within families, schools, neighborhoods, and the larger community (Zimmerman et al., 2013), which allow adolescents to practice dealing with stressful situations in safe and supportive environments. However, just as social support can help mitigate stress, adolescents who lack social support may be unable to develop confidence and effective stress management techniques (Compas, 2009). Although disengagement from parents is common during adolescence, research has shown that parental relationships continue to influence important emotional outcomes (Branje, Laursen, and Collins, 2012). Research also has shown that family environments that support adolescents’ expressions of autonomy are associated with a greater sense of agency and confidence in their own abilities, positive self-concept, and a sense of self-worth (McElhaney and Allen, 2012; Noller and Atkin, 2014). In cases where parents do not play central roles in adolescents’ lives, natural mentors can serve as attachment figures and mitigate the risk for adverse outcomes (Dang et al., 2014; Thompson, Greeson, and Brunsink, 2016). 2-6

Prepublication copy, uncorrected proofs As illustrated earlier in Box 2-1, peers play a particularly important role in emotional development during adolescence. By middle to late adolescence, youth report relying more on either best friends or romantic partners than on parents for emotional support (Farley and Kim- Spoon, 2014). Although these interpersonal relationships can increase stressors and negative emotions, they can also, when of high quality, protect against the negative effects of such stressors and emotions (Farley and Kim-Spoon, 2014; Thompson and Leadbeater, 2013). Schools also have the capacity to promote adolescent resilience by providing students with a sense of mutual responsibility and belonging (Epstein, 2011). Likewise, schools can help identify adolescents in need and provide services that can help. As with physical health, this role of schools is especially important for adolescents who may not have regular access to health care outside of school. In addition to such informal services as positive social interactions and emotional skill building, schools can provide formal services, such as counseling, that can improve both adolescents’ social-emotional well-being and their academic performance (Brown and Bolen, 2018; Walker et al., 2010) (see Box 2-2). BOX 2-2 Youth Voices: Specifically, what could your school do to help you live your best life? (now or in the past) In a recent MyVoice survey, adolescents were asked about what their schools could do to help them live their best life (see Appendix B for more detail on the MyVoice methodology). The top 10 answers from the 886 respondents are shown in the figure below. Youth most commonly cited more school breaks, access to their passions, more real-world classes, improved social and mental health support, reduced costs, career and academic guidance, and a supportive school environment. SOURCE: Generated by the committee from data in the MyVoice (2019) report. 2-7

Prepublication copy, uncorrected proofs Finally, social media have implications for adolescents’ emotional health. Teenagers can use social media to express their emotions and opinions online, to seek social support, or to compare themselves with others. Research has found that adolescents who experience a greater number of positive reactions to their social media profile also experience higher self-esteem and satisfaction with their life (Ahn, 2011). On the other hand, misinterpreted communications, social rejection, and cyberbullying can have a range of negative emotional effects (Chou and Edge, 2012). Social Health Developmental Milestones and Trajectories Social health refers to the ability to form and maintain nurturing and productive relationships with others. As noted previously, adolescence is a period marked by increased autonomy. During normative adolescent development, most adolescents establish a level of independence and self-sufficiency that is marked by individuating from their family and beginning the important process of transferring dependencies from parental to peer relationships (McElhaney and Allen, 2012). An adolescent’s social network can include friends, acquaintances, romantic partners, teams, and virtual communities. This social network continues to grow as adolescents seek out new experiences and engage in their community (Farley and Kim-Spoon, 2014). Early adolescence tends to be marked by the most intense involvement in peer groups, with conformity and concerns about acceptance at their peak (Cowie, 2019). Although early adolescents experiment with romantic relationships, these experiences tend to be brief. Typically, early adolescents choose partners who align with the expectations of their social networks, reflecting their preoccupation with peers’ perceptions of them (Cowie, 2019). In middle adolescence, peer groups tend to become more gender-mixed. Adolescents begin to exhibit less conformity and greater acceptance of individual differences in this period, which is marked by a dramatic shift in multiple aspects of relationships, including number of relationships, length of relationships, and choices of partners (Bowker and Ramsay, 2018; Little and Welsh, 2018). They also begin what is more traditionally thought of as dating. By late adolescence, one-on-one friendships and romantic relationships are often prioritized above relations with peer groups. Accordingly, the manifestation of romantic relationships between older adolescents reflects a greater interdependence between the partners than is the case in the romantic relationships of young adolescents (Bowker and Ramsay, 2018; Little and Welsh, 2018). Social and Environmental Influences on the Development of Social Health Compared with other age groups, adolescents are particularly influenced by the social norms of many groups, including family, friends, peers, virtual communities, and the broader society (McDonald, Fielding, and Louis, 2013). The family is the first and primary social group to which most people belong, and parents represent important role models for the development of prosocial behavior (Hurd, Wittrup, and Zimmerman, 2018). As adolescents continue to develop more agency, this socialization process moves from being unidirectional (i.e., parent to child) to a more bidirectional, mutually beneficial process, characterized by discussion and negotiation of attitudes, beliefs, and practices (Smetana, Robinson, and Rote, 2015). 2-8

Prepublication copy, uncorrected proofs As discussed earlier, peer norms become particularly influential during adolescence. Positive peer modeling and awareness of peer norms have been found to be protective against violence, substance misuse, and unhealthy sexual risk (Viner et al., 2012). In contrast, social isolation, peer rejection, and bullying are associated with numerous unhealthy risk behaviors and adverse health outcomes such as increased delinquency, depression, numbers of suicide attempts, and low self-esteem (Smokowski and Evans, 2019). Schools also play a prominent role in the development of social health. In school, youth learn to relate with peers and form relationships with adult role models. For adolescents, a strong sense of attachment, bonding, and belonging; a feeling of being cared about; and a perception of teacher fairness are key factors in developing positive relationships with their teachers and their schools. Adolescents also tend to feel more motivated and engaged in school when they have strong, supportive relationships with their peers and teachers (Bakadorova and Raufelder, 2017; Wang and Eccles, 2013). Perhaps the greatest social environmental influence on today’s adolescents is social media. Social media add another layer to adolescent identity development, as adolescents must shape their virtual identities by determining what information to disclose online and where to disclose it (Boz, Uhls, and Greenfield, 2016). Social media platforms have also changed the ways in which they relate to one another, increased the amount of time youth stay connected to one another, and redefined the meaning of friendship. Research has found that youth use such technologies as social media platforms to mediate their relationships with friends, romantic partners, and broader groups of peers (Nesi, Choukas-Bradley, and Prinstein, 2018) (see Box 2-3). BOX 2-3 Generation Z and the Role of Media Adolescents identified as “Generation Z” (Gen Z; those born in the mid-1990s to mid- 2000s; Dimock, 2019) are the first truly “digital generation” that grew up surrounded by communication technologies and are accustomed to being both consumers and creators of media (Madden, 2017). This current cohort of adolescents therefore has unique experiences that affect their current and future health behaviors and outcomes. Gen Z adolescents were children during the global rise of the web, the Internet, smart phones, laptops, freely available networks, and digital media. Because they were raised with these technologies, they were able to internalize the newly connected world instead of having to adopt and adapt to it as did older generations (Seemiller and Grace, 2018). Today, use of social media is nearly ubiquitous among U.S. adolescents. Recent reports indicate that 95 percent of 13- to 17-year-olds in the United States have a smartphone, and 71 percent use at least one social media platform (Anderson and Jiang, 2018; Barry et al., 2017). The bulk of research on the role of social media in adolescent health to date has focused on displays of risky content and the potential influence of this online content on adolescent behavior offline. Only very recently has there been a shift towards seeking a better understanding of how social media may promote wellness, healthy behaviors, or optimal health (Wong, Merchant, and Moreno, 2014). Further work is needed in this area, including studies that fully harness the social aspects of social media by studying interactions among peers, the distribution of content through a social network, or content posted on different platforms. There are also opportunities to engage youth in this process so as to understand their perceptions and interpretations, and to involve them in generating solutions (Liang, Commins, and Duffy, 2010; Moreno et al., 2018). Such studies would provide a better understanding of how health-related content is distributed and shared through social networks, 2-9

Prepublication copy, uncorrected proofs and potentially help identify ways of linking social media and offline approaches to implement successful interventions (McCreanor et al., 2013). See the paper by Moreno (2019) commissioned for this study for further detail adolescent health and media. Although there are correlations between sociodemographics and particular social media communities, overall social media use is consistent across levels household income and parents’ educational attainment. Overall, 88 percent of teens report having access to a desktop or laptop computer at home, ranging from 75 percent among those from households with an annual income of $30,000 or less to 96 percent among those from households with an annual income of $75,000 or more. Moreover, as mentioned in Box 2-3, 95 percent of all teens report having access to a smartphone, a figure that has increased by 22 percent since 2014–2015. Interestingly, there is even less variation in smartphone relative to computer access by income, ranging from 93 percent of teens from households with an annual income of $30,000 or less to 97 percent among teens from households with an annual income of $75,000 or more (Anderson and Jiang, 2018). As noted earlier, adolescents are particularly vulnerable to the effects of social media, both positive and negative (Walrave et al., 2016). For example, social media can expose adolescents to unhealthy risk behaviors and portray these behaviors as normative, which may increase the likelihood of their engaging in those behaviors. In addition, social media can magnify existing peer influences on behavior. For instance, adolescents may post photos of themselves drinking alcohol that others interpret as desirable. Furthermore, for teens who are already engaging in unhealthy risk behaviors, social media may provide a way to find and interact with others who share these interests or further normalize these behaviors within a given community (Ahn, 2011). In contrast, given their ubiquity and influence on behavior, social media may also represent an important opportunity for future health promotion efforts. Spiritual Health Developmental Milestones and Trajectories O’Donnell defines spiritual health as having a sense of purpose, love, hope, peace, and charity. In this report and consistent with this definition, spirituality refers not only one’s religious beliefs but also to the morals, values, character development, and goal setting that contribute to a person’s identity. Spirituality and religiosity are perhaps the most well-recognized influences on spiritual health. The way in which adolescents choose to engage in spiritual or religious practices varies widely. Among those youth who identify with a particular religious group, some maintain a minor, often cultural affiliation with a religious institution, while others regularly engage with religious practices at home and in religious institutions (Barry, Nelson, and Abo-Zena, 2018). In line with the broader definition of spiritual health adopted in this report, adolescence is also characterized by identity formation, a process during which they explore their environments to better understand how they see themselves fitting into the world. While some youth develop identities that align with those of their families, others may explore other identities and values in seeking to develop a personal identity (Hall, 2018a). An important part of an adolescent’s identity development is the formation of a value system, which strongly influences behaviors, plans for the future, interests, and interpersonal 2-10

Prepublication copy, uncorrected proofs relationships. (Levesque, 2018). While value systems were traditionally shaped by religious or institutional values, cultural and technological changes have given today’s youth opportunities to learn and explore more diverse ideas and opinions in establishing who they are and what they believe (Berzonsky, 2018). As they establish these values, adolescents also begin to seek out information that informs their attitudes and beliefs about civic and global issues. At the same time, they often become involved in their community through volunteering, participating in school clubs or community organizations, and voting. This time spent learning and engaging in civic issues helps them focus on their emerging role in society (Allen, Bogard, and Yanisch, 2018). Social and Environmental Influences on Spiritual Development Identity and spiritual development are grounded in interpersonal relationships. How a person expresses his or her identity is strongly based in particular contexts. Religion and spirituality can help adolescents discover a higher sense of purpose, which is associated with greater psychological well-being, a more unified identity, a greater sense of meaning, and fewer health-compromising behaviors (Burrow and Hill, 2011; Sumner, Burrow, and Hill, 2018). Other research has found that a sense of purpose beyond oneself is related to academic performance and persistence among high school students (Yeager et al., 2014). In addition, studies show that more religious/spiritual adolescents report less depression, anxiety, and other psychiatric concerns compared with their less religious/spiritual peers (Yonker, Schnabelrauch, and DeHaan, 2012). Families play an important role in the development of spiritual identity, as early engagement in religion and spirituality is often mediated by parents and other close adults (Kim and Esquivel, 2011). Beyond engaging with family in religious or spiritual activities, adolescents may also become more interested in their cultural heritage and question the meaning of their family culture as they begin to form their own cultural identity. In developing this cultural identity, adolescents often express themselves by educating others, participating in cultural activities and social groups, or incorporating cultural pride into their self-presentation. (Barry, Nelson, and Abo-Zena, 2018). In addition to religious organizations, other community venues can serve as important sources for youth’s identity and spiritual development. For instance, having a pride center allows lesbian, gay, bisexual, transgender, and queer/questioning (LGBTQ) teens from different neighborhoods or schools to gather in a communal space, share their experiences, and support each other (Higa et al., 2014) (see Box 2-4 for more information about LGBTQ youth). In addition, community centers can hold events specifically oriented toward youth that can facilitate social support around shared interests or aspects of identity. BOX 2-4 LGBTQ Youth Adolescence is an important developmental period for all youth. For LGBTQ youth, however, adolescence poses several unique challenges as well as opportunities to provide skills and resources for healthy development, particularly with regards to sexual health. The number of young people in the United States identifying as LGBTQ has grown in recent years. Data from the 2017 Youth Risk Behavior Survey (YRBS) show that at least 8 percent of youth identify as bisexual and 2.4 percent as gay or lesbian (Kann et al., 2018). Data suggest that the number of transgender or gender-nonconforming youth is also growing, with 1.8-3 percent of youth identifying as transgender (Kann et al., 2018; Rider et al., 2018). 2-11

Prepublication copy, uncorrected proofs Despite increases in the acceptance of LGBTQ persons and the growing number of people who identify as LGBTQ, LGBTQ youth still face substantial health challenges. LGBTQ adolescents continue to be more likely to report victimization, both at school and in their homes, compared with adolescents who are heterosexual and cisgender (those whose gender identity aligns with their sex assigned at birth; Austin, Herrick, and Proescholdbell, 2016; McKay, Lindquist, and Misra, 2017; Russell et al., 2014; Toomey and Russell, 2016). High rates of harassment and victimization contribute to the consistent findings of research that, compared with their heterosexual peers, LGBTQ youth are more likely to report depression, alcohol and tobacco use, and sexually transmitted infections and adolescent pregnancy (Goldbach et al., 2014; Hall, 2018b; Saewyc, 2014; Tornello, Riskind, and Patterson, 2014). Increasingly, researchers have demonstrated that there are pathways that promote resilience and healthy development among LGBTQ youth. For example, facilitating healthy parent-child relationships and parents’ acceptance of their LGBTQ children provides a powerful protective factor for LGBTQ youth, being associated with greater self-esteem, social support, lower rates of substance abuse, and improved mental health (Ryan et al., 2010). Schools are also an important venue for promoting resilience among LGBTQ adolescents. LGBTQ students in schools with gay-straight alliances and other policies that prohibit LGBTQ-based bullying report higher levels of classmate and teacher support and less bullying (Day et al., 2019). In addition, policies that allow transgender students to use the bathroom of their choice in schools have been linked to lower levels of sexual assault of transgender students, and LGBTQ-inclusive sexual education is associated with lower rates of bullying, depression, substance use, and sexual risk taking behaviors among not only LGBTQ students, but also their heterosexual peers. (Anderson and Jiang, 2018; Baams, Dubas, and van Aken, 2017; Day et al., 2019; Kull et al., 2016; Murchison et al., 2019; Proulx et al., 2019). See the paper by Everett (2019) commissioned for this study for further detail on LGBTQ youth. Intellectual Health Developmental Milestones and Trajectories The final domain of optimal health is intellectual, which encompasses the skills that lead to academic achievements, career achievements, hobbies, and cultural pursuits. During adolescence and into adulthood, the regions of the brain that regulate executive functioning and oversee critical abilities for decision making gradually develop (Giedd, 2015; Johnson, Blum, and Giedd, 2009). In addition, improved abstract thinking allows youth to process information, use evidence to draw conclusions, and engage in strategic problem solving and deductive reasoning (Kuhn, 2009). Social and Environmental Influences on the Development of Intellectual Health While the school environment itself has perhaps the greatest overall influence on intellectual health, parents, peers, and others also have important impacts in this domain. Research shows that parenting styles contribute to intellectual health outcomes. Compared with other parenting styles, authoritative parenting, characterized by frequent involvement and supervision, is associated with greater academic achievement (Pinquart, 2016). In particular, research shows that parents’ engagement and involvement in their children’s 2-12

Prepublication copy, uncorrected proofs schools are associated with better academic outcomes (LaRocque, Kleiman, and Darling, 2011). In addition, adolescent perceptions of closeness and trust with their parents predict better academic competence, engagement, and achievement (Murray, 2009). The adolescent’s peer group can also influence academic achievement and identity. Research shows that high-quality peer relationships are associated with academic engagement and achievement, reflecting a desire to be like high-achieving friends or a shared social identity that affects student behaviors (Juvonen, Espinoza, and Knifsend, 2012; Martin and Dowson, 2009). Dropping out of high school is strongly associated with poor intellectual health, as it can lead to numerous adverse outcomes, including low wages, unemployment, incarceration, and poverty (Wilson et al., 2011). Dropout rates vary by state, ethnic background, and socioeconomic status (Cataldi and KewalRamani, 2009). The National Center for Education Statistics (2019a) reports that Asian/Pacific Islander students had the highest public school graduation rates in 2016–2017 at 91 percent, followed by white students at 89 percent, and significantly lower rates among Hispanic/Latino (80%), black (78%), and American Indian/Alaska Native (72%) students. Generally, males are more likely than females to drop out of high school (National Center for Education Statistics, 2019b). However, teenage pregnancy and parenthood significantly increase the risk of dropout for adolescent girls, with only 50 percent of teenage mothers in the United States earning a high school diploma by age 22 (Perper, Peterson, and Manlove, 2010). The single greatest predictor of gaps in academic achievement by race and income is the segregation of schools by family income (NASEM, 2019). Schools in neighborhoods with lower socioeconomic status, where students are more likely to be people of color, typically are less well funded, have less-qualified teachers, and have fewer resources relative to schools in wealthier areas. All of these factors can affect academic outcomes for students. As income inequality continues to rise, so does income segregation among schools, which denies youth from low-income families equal opportunities for success. For this reason, The Promise of Adolescence (2019) report emphasizes that children from adverse circumstances need more rather than equal resources if society is truly going to reduce disparities in educational outcomes. Regarding social media, many studies indicate that educators can take advantage of these technology platforms to engage effectively with students, such as by having them complete online courses, tests, or assignments; watch instructional videos; conduct research; and participate virtually in classroom activities; as well as by fostering communication between students and teachers (Ahn, 2011; Greenhow, Sonnevend, and Agur, 2016). Such technology platforms can also help to engage more effectively with students with disabilities (see Box 2-5 for more information about adolescents with disabilities). BOX 2-5 Adolescents with Disabilities Recent decades have seen efforts to distinguish between the constructs of disability and health (Krahn et al., 2009). When these concepts are understood as separate, it follows logically that people with disabilities can be either sick or healthy; thus, one can have a disability and also experience good or excellent health (U.S. Department of Health and Human Services, 2005). Important in this view is the recognition that many of the health problems experienced by people with disabilities are preventable (Krahn et al., 2009). Accordingly, addressing the health needs of individuals with disabilities is an important responsibility of public health, comparable to addressing health disparities experienced by other marginalized groups (Iezzoni, 2011; Krahn et al., 2009). 2-13

Prepublication copy, uncorrected proofs Approximately 15 percent of children aged 3–17 have a disability (Boyle et al., 2011). The most common causes of disabilities present during the adolescent years are emotional and behavioral disorders, learning disabilities, mild intellectual disability, speech and language impairments, and autism (Gage, Lierheimer, and Goran, 2012). Lower-incidence disabilities in this age range include blindness/low vision, deafness/hard-of-hearing, and physical disabilities (Boyle et al., 2011; Halfon et al., 2012). Attention to optimal health and improving outcomes of youth with disabilities is greatly needed. Numerous studies have shown that youth with disabilities are more likely to engage in unhealthy risk behaviors and experience adverse outcomes compared with their peers without disabilities. More specifically, youth with disabilities have been shown to be more likely to use alcohol and tobacco and to have unprotected sex and sex with multiple partners. Women with disabilities have also been shown to be less likely to use contraceptive methods, which contributes to higher proportions of unintended pregnancy among those with versus those without disabilities (Bernert, Ding, and Hoban, 2012; Blum, Kelly, and Ireland, 2001; Jones and Lollar, 2008; Mitra et al., 2015; Mosher et al., 2018; Wu et al., 2017). The dimensions of optimal health are applicable to youth with disabilities in much the same way that they are to youth without disabilities, with some minor variations. Medical self- care is a more central issue for youth with some types of disabilities than it is for those without disabilities, and the focus on medical management of their disability may result in less attention to other aspects of optimal health (Lindsay, 2014). Youth with disabilities may also need greater support in coping with stress and emotional challenges, which may be related to aspects of their disabilities and/or to the social stigma and marginalization they disproportionally experience (Anaby et al., 2013; Kramer et al., 2012; Lindsay, 2014; Tonkin et al., 2014). For similar reasons, attaining and maintaining social health may be more challenging for youth with disabilities. Relationships with family, friends, teachers, and others can therefore serve as crucial buffers against the more negative social interactions that youth with disabilities may encounter (Kramer et al., 2012; Lindsay, 2014; Whitehill, Brockman, and Moreno, 2013). See the paper by Horner-Johnson and Sauvé (2019) commissioned for this study for further detail on youth with disabilities. As with other aspects of optimal health, however, these technologies can have adverse effects on intellectual health. For example, multitasking on social media may come at the expense of academic work and put youth at higher risk of exposure to inaccurate information. Much attention has been given to the spread of misinformation online, and a 2018 study reported in Science found that such misinformation spreads faster than the truth (Vosoughi, Roy, and Aral, 2018). Adolescents are particularly vulnerable in this regard, since their developing cognitive skills may make it more difficult for them to judge information. Promoting digital literacy for adolescents can therefore provide them with the necessary tools to avoid and interpret misinformation. CONCLUSIONS This chapter has defined and applied O’Donnell’s optimal health framework to the context of normative adolescent development and highlighted how that development is 2-14

Prepublication copy, uncorrected proofs influenced by the physical and social environments. Based on the evidence presented in this chapter, the committee drew the following conclusions. CONCLUSION 2-1: Adolescents face variations in access to opportunities and supports that often relate to age, race and ethnicity, socioeconomic status, rurality/urbanity, sexual orientation, sex and gender, and disability. CONCLUSION 2-2: The physical and social environments, including parents and family, peers, schools, neighborhoods, and media, have a major influence on adolescent development and well-being. CONCLUSION 2-3: Adolescents from disadvantaged backgrounds need more resources relative to their peers from more advantaged backgrounds to ensure their access to comparable opportunities. The next chapter addresses normative adolescent risk taking and describes the current landscape of adolescent alcohol use, tobacco use, and sexual behavior, as well as their related health outcomes. 2-15

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Adolescence is a critical growth period in which youth develop essential skills that prepare them for adulthood. Prevention and intervention programs are designed to meet the needs of adolescents who require additional support and promote healthy behaviors and outcomes. To ensure the success of these efforts, it is essential that they include reliably identifiable techniques, strategies, or practices that have been proven effective.

Promoting Positive Adolescent Health Behaviors and Outcomes: Thriving in the 21st Century identifies key program factors that can improve health outcomes related to adolescent behavior and provides evidence-based recommendations toward effective implementation of federal programming initiatives. This study explores normative adolescent development, the current landscape of adolescent risk behavior, core components of effective programs focused on optimal health, and recommendations for research, programs, and policies.

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