Implications for Research and Linking Research to Policy and Practice
Although research and new policies and programmatic initiatives have documented the many problems that adolescents face in an increasingly complex and diversified society, a clear federal policy mandate is lacking that sets forth funding and policy priorities, and that could provide guidance for how to approach the needs of diverse adolescent populations (Brindis et al., 1998). The complexity of those needs, and the ambivalence expressed by society concerning the role of adolescents, have made it difficult to establish a focused agenda for youth-related issues. Progress in the coming decade requires that the field take a step back, map out the areas in which additional research is needed, identify opportunities for research to inform policy and practice, and proceed in a thoughtful and coordinated manner to address these needs.
In this chapter we outline a number of issues that will become increasingly important and that the Forum on Adolescence expects to explore. These include the implications of a changing adolescent population; new research methodologies and approaches needed to further advance understanding of adolescent health and development; strategies to strengthen and support relationships between teenagers and their parents; the continued development of indicators of adolescent well-being; approaches to integrating frameworks for preventing risk behaviors and promoting positive developmental outcomes among youth; the delivery of developmentally appropriate health care services to youth; and ensuring adolescents' safe and productive use of new technologies.
INCREASING NUMBERS AND GROWING DIVERSITY
As discussed earlier in this report, the size and composition of the adolescent population is expected to change dramatically during the coming decades—i.e., there will be more adolescents than ever before. Moreover, white teenagers will no longer be the majority group, and Hispanic teenagers will outnumber black teenagers. Now is the time to ask if current systems and policies are prepared to respond to these changes. Are private and public institutions and systems (e.g., education, employment, housing, transportation, and health) prepared to respond to these trends? How will institutions and systems need to be redesigned to respond appropriately? How can a national youth policy agenda be developed to ensure the health and well-being of this segment of the population?
With this increase in diversity, coupled with worldwide patterns of increased mobility and migration, cooperative relations among different racial and ethnic groups are essential to the nation's future. Yet there is growing evidence to suggest that white youth and youth from ethnic minority groups hold deeply divergent views on how to relate to each other. The harmful results of this racial divide among youth are becoming more apparent as demonstrated by an alarming increase of adolescent hate crimes, organized hate groups, and overt expressions of racial intolerance.
Research is needed to characterize how youth derive a sense of belonging and personal meaning from their ethnic and other affiliations, as well as on how youth understand, interpret, and experience such constructs as race, ethnicity, racism, and all other forms of discrimination. While there is growing evidence that strategies can be crafted to create positive intergroup relations, there is little agreement regarding what intervention strategies are essential to promote peaceful, respectful relations or to prevent conflict and violence among youth stemming from ethnic identity. Certainly, ethnicity is not the only defining characteristic of teenagers. They also differ from one another according to their physical, cognitive, and learning abilities; body shape and size; religious and political beliefs and values; sexual orientation; and interests and expressions of creativity. Future efforts are needed to encourage and support enduring changes in the ways that teenagers relate and interact with their peers who are different from themselves. As a society, the goal should be to help young people promote peaceful, respectful relations among all youth.
HEALTHY ADOLESCENT DEVELOPMENT
The study of adolescence is becoming an increasingly sophisticated science. Thanks to powerful new research tools and other scientific and technological advances, today's theories of adolescent development are more likely to be supported by scientific evidence than in the past. Indeed, there has been sufficient research to allow a reassessment of the nature of adolescent development. At the same time, there is greater recognition that neither puberty nor adolescence can be understood without considering the social, psychological, and cultural contexts in which young people grow and develop, including the familial and societal values, social and economic conditions, and institutions that they experience. In the past, researchers tended to conduct research designed to examine the impact of hormones on adolescent behavior. While this work continues, there is now an appreciation for the complex reciprocal relationship and interaction between biological, psychological, and social environments and the interaction between these environments and adolescent behavior.
The field of adolescence is also increasingly benefiting from the fact that researchers from diverse fields, including the biological, behavioral, and social sciences, have developed new techniques to study adolescent development. Use of more rigorous research methods has improved the reliability and validity of the measurement techniques used, and consequently the ability to document the multifaceted dimensions of growth and maturation during adolescence.
For example, the development of radioimmunoassay methodology in the late 1960s, and the considerable refinement of that process over the decades, have made it possible to study the hormones that control reproductive maturation. The development of neuroimaging technology in the 1970s created exciting new opportunities for studying brain development; these techniques include more sensitive, easy-to-use hormone assay technology and new brain-imaging technologies, allowing insight into brain development and function.
Moreover, longitudinal studies are increasingly being designed to characterize the interaction among genetic, biological, familial, environmental, social, and behavioral factors (both risk and protective in nature) among children and adolescents. For example, a valuable new source of data that has the potential to significantly advance the knowledge base of physiological and behavioral development among adolescents is the National Longitudinal Study of Adolescent Health (Add Health). From the collection of
longitudinal data, it will be possible to examine how the timing and tempo of puberty influences social and cognitive development among teenagers. This dataset will also permit analyses to examine how family-, school-, and individual-level risk and protective factors are associated with adolescent health and morbidity (e.g., emotional health, violence, substance use, sexuality).
Despite advances in the science and knowledge base, it remains the case that current understanding of adolescent development is rather limited. The research conducted to date has been predominately descriptive in nature, has relied on cross-sectional data and adolescent self-report and has been unidimensional in focus. Indeed, few research studies have successfully considered the multiple factors that collectively influence adolescent development. There is now a growing appreciation, however, that new research is needed, including research that employs longitudinal designs; characterizes developmental changes associated with the onset of puberty well before the age of 8; and seeks to characterize growth and development across the life span—i.e., from infancy to adolescence, young adulthood adulthood, and the senior years.
Studying these developmental stages in isolation from one another provides only a partial and incomplete picture. In addition, while the current literature is rich with respect to research that characterizes adolescents' involvement in risk and risk-related behaviors, research on risk factors is only correlational or bidirectional in nature, which tells only half the story. It examines the extent to which, in any given sample of adolescents and at any given time, teens exposed to a risk factor are doing worse in some respect compared with children who are not exposed to that same risk factor. It says nothing about the base rates of either the risk factors or the outcomes. Base rates could be rising or falling, while the correlations between risk factors and outcomes could be quite undisturbed. This means, for example, that although it may not matter greatly whether there are increasing or decreasing numbers of adolescents in poverty; it is also true that those in poverty are still at risk.
Finally, previous research has been limited when it has assumed that adolescents, as a segment of the population, are a homogenous group. We now know that while all adolescents experience the biological, cognitive, and social transitions of this period, not all adolescents experience these changes in the same way. For example, puberty makes some adolescents feel adult-like, attractive, and confident; it makes others feel awkward, unattractive, and self-conscious. Being able to think in abstract and hypo-
thetical terms offers some teenagers the opportunity to imagine the wide range of possibilities that exist for their future; it prompts others to feel uncertainty and despair. While the fundamental changes associated with adolescence are universal, there is wide variation in the ways in which adolescents experience these changes, and this variation is largely accounted for by the child's interpretation of these changes, as well as the environment in which these changes occur. As described by Bronfenbrenner (1979), the psychological impact of the biological, cognitive, and social changes of adolescence is shaped by the environment in which these changes take place. These considerations need to be further explored by research.
RELATIONSHIPS BETWEEN TEENAGERS AND PARENTS
Adolescence is not just a time of major developmental changes in children; it is also a time of significant transformations and realignment in family relations. Raising adolescents can certainly be stressful and difficult for parents who are likely to feel less adequate and more anxious and stressed than when their children were younger. Raising a teenager can also be rewarding, and families as well as other supportive adults clearly matter with respect to the healthy development of adolescents.
As discussed by Small (1990), there have been a number of recent changes in American society and in the nature of adolescence that have also contributed to the challenge of raising adolescents today:
The length of time during which adolescents rely on their parents for financial, emotional, and material support is increasing, with more and more young adults in their early 20s living at home or financially dependent on their parents, resulting in a protracted period of responsibility for parents and a greater uncertainty regarding how to raise adolescents.
Parents have become confused about how best to prepare adolescents for future adult roles as a result of rapid sociocultural change and the multiple and often competing sources of information and values that are increasingly complex in a diverse society.
Parents are often worried as a result of the greater number of potentially dangerous activities, substances, and influences to which contemporary adolescents are exposed.
Compared with research on families with young children, there has been much less attention to the home and family environments of adoles-
cents. Yet it is clear, as this report discusses, that adolescents develop best when they live and develop in a supportive home and family environment. Despite the fact that adolescents are moving out beyond the family and striving for greater autonomy, parents remain an important influence in the lives of their adolescent children. In a paper published by Resnick and colleagues, early analyses from the National Longitudinal Study of Adolescent Health found that teenagers who have strong emotional attachments to their parents and teachers are much less likely to use drugs and alcohol, attempt suicide, engage in violence, or become sexually active at an early age (Resnick et al., 1997). The authors concluded that feeling loved, understood, and paid attention to by parents helps teenagers avoid high-risk activities, regardless of whether they come from a one-or a two-parent household. At school, positive relationships with teachers were found to be more important in protecting teenagers than any other factor, including classroom size or the amount of training a teacher has.
What are the practical implications of research on parenting adolescents, and how can research, policy, and practice be linked? Very little is known about how to educate and support parents of adolescents most effectively and enhance their childrearing abilities. There is an enormous gap between what is known about the effects of parenting on adolescents as it naturally occurs and what can be done to enhance it when parents struggle. This gap is especially striking in light of the recent growth in the development and availability of parenting programs, videos, articles, and books aimed at supporting and guiding parents of adolescents. Research on best practices and the effectiveness of education, training, and support programs and materials is almost nonexistent. Understanding of the types of knowledge, skills, and supports that parents of adolescents need and desire, as well as the strategies and change techniques that are likely to be most helpful and effective, is also very limited. Research is therefore needed to further strengthen relationships between teenagers and their parents and to provide support to parents of adolescents.
NEW TRENDS IN ADOLESCENT BEHAVIOR
The past few years have seen a number of encouraging changes and even reversals in trends in some of the leading causes of mortality and morbidity among adolescents. While these trends are not consistent across all causes of death, problems, or risk behaviors, these data are promising and they do suggest that some combination of events—whether it is new ways
in which social services are addressing the needs of adolescents, new approaches to the design and delivery of prevention and health promotion interventions, or new policies—has had a positive impact on the health, safety, and security of teenagers in the United States. The following pages highlight a few of these trends, including recent rates of adolescent mortality, adolescent pregnancy, school dropout, and use of tobacco, alcohol, and other illicit drugs.
As discussed in this report, adolescents have much higher mortality rates compared with younger children. In 1980, the death rate among adolescents was 98 per 100,000. This rate then decreased to 89 in 1991, and further declined to 84 in 1995 (see Figure 6-1). Injury, which includes homicide, suicide, and unintentional injuries, continues to account for 4 out of 5 or 78 percent of deaths among adolescents. While accidents continue to account for more than twice as many teen deaths as any other source, including homicide, examination of recent trends in causes of death among teenagers reveals some changes. Between 1985 and 1996, the number of teen deaths due to accidents fell from 8,202 in 1985 to 6,756 in 1996, while the number of teen homicides increased from 1,602 to 2,924 during the same period. However, between 1994 and 1996, the number of
teen homicides fell by 18 percent, which may signal a change in long-term trends. The annual number of teen suicides also decreased, albeit slightly, from 1,849 to 1,817, between 1985 to 1996.
As previously discussed, teenage childbearing is problematic because it often diminishes the opportunities of both the child and the young mother. Births to females under age 18 are particularly troublesome because most of these mothers are unmarried, and the vast majority have not completed high school. Nationally, the birth rate to teenagers has been decreasing over the past several years. In 1991, the birth rate among 15- to 17-year-olds was 39 per 1,000 females, and between 1991 to 1997, this rate decreased to 33. This rate increased slightly, however, in 1997, to 34 per 1,000 females (see Figure 6-2). The birth rate among 18- to 19-year-olds also declined between 1991 and 1996, and blacks, Hispanics, and whites have all experienced the decline.
As previously discussed, graduating from high school is critical for obtaining postsecondary education or getting a good job. Indeed, teens who
drop out of high school face enormous odds of achieving financial success in life. Nationwide, there was very little change in this measure between 1985 and 1996. In 1985, 11 percent of teens ages 16 to 19 were high school dropouts, compared with 10 percent in 1996. There was, however, a slight decline in the percentage of 16- to 19-year-olds not attending school and not working, from 11 percent in 1985 to 9 percent in 1996.
Tobacco, Alcohol, and Illicit Drug Use
Alcohol and illicit drug use has both short-and long-term implications with respect to the health and development of adolescents. Long-term trends indicate that heavy drinking, defined as drinking five or more alcoholic beverages in a row in the last two weeks, peaked in 1981 with 41 percent of high school seniors reporting this behavior. The percentage of seniors reporting heavy drinking then declined significantly, to a low of 18 percent in 1993. Unfortunately, since 1993, the prevalence of this behavior has risen to 31 percent. In 1997, almost 1 in 3 12th graders, 1 in 4 10th graders, and more than 1 in 10 8th graders reported heavy drinking (Federal Interagency Forum on Child and Family Statistics, 1997).
According to data reported by the Monitoring the Future study, marijuana, cocaine, and heroin use bottomed out in the early 1990s but has since risen among children at all grade levels (see Figure 6-3) (Backman et al., 1998). However, data for 1997 and 1998 suggest that this trend toward increased illicit drug use is leveling off and may be in the process of reversing. For example, annual use of any illicit drug by high school seniors peaked at 54.2 percent in 1979, declined to a low of 27.1 percent in 1992, then climbed steadily to 42.4 percent in 1997. Annual marijuana use among high school seniors crested in 1979 at 50.8 percent, then declined to 21.9 percent in 1992, before rising steadily to 38.5 percent in 1997. Annual cocaine use more than doubled among high school seniors, from 5.6 percent in 1975 to 13.1 percent in 1985, then decreased to 4.9 percent in 1996. Seniors' use of any illicit drug, marijuana, and cocaine has, however, been stable since 1996.
Unfortunately, these same encouraging trends are not apparent for tobacco use by adolescents. The percentage of 8th, 10th, and 12th graders who reported that they smoked cigarettes daily increased between 1992 and 1997 (Backman et al., 1998). In 1997, 25 percent of 12th graders reported smoking daily during the previous 30 days, as did 18 percent of 10th graders and 9 percent of 8th graders. Prior to 1992,
smoking had been decreasing among 12th graders since 1980, when 21 percent of 12th graders reported that they smoked daily (Federal Interagency Forum on Child and Family Statistics, 1997).
Because the federal and state governments are organized to identify needs and to address and solve problems, it tends to collect data on problems, such as morbidity, mortality, poverty, and crime. So trends in drug use, violence, and sexual activity are often mentioned, but we rarely hear about the commitment of youth to recycling or to work they do around the house or outside, close parent-child relations, or the time that youth spend volunteering (Moore, 1998). To provide a more balanced perspective, data are needed to assess not only the problems experienced by youth and poor developmental outcomes, but also positive indicators of safety, security, and well-being. This will require the development of new measures and the collection of new data at the federal, state, and local levels. Possible constructs include community involvement, recycling, volunteering, religious practice and activities, exercise and sports, activities in school clubs, civic engagement, reading and participation in cultural affairs, family activities, and work done in the home. The lives of
children are complex and multifaceted. Indicators should reflect the complexities of adolescents' lives. For example, long-term poverty is more problematic than short-term spells of poverty, and cumulative risks undermine child development more than a single risk. And average values do not reflect the diversity experienced by children and adolescents from varied backgrounds.
Until very recently, research and services have been largely problem focused, funded by categorical ''problem identified" funding streams, and driven by policies that rarely view problems as interrelated. Federal statistics on children and adolescents are similarly highly fragmented and administered by different agencies, each with its own interests and each with distinctive histories and constituencies. This suggests the need for improvements in data collection and reporting systems in order to ascertain the connections between resources and outcomes and also to identify the family and community processes that translate resources into outcomes.
During the past five years, a great deal of scientific and policy-related activity has taken place around the development and use of child and youth indicators (Hauser et al., 1997). In addition, there have been several important attempts to broaden existing conceptual frameworks in order to support more multidisciplinary approaches to the study of child and youth well-being (Brooks-Gunn et al., 1995; Family and Child Well-Being Research Network, 1999). For example, some researchers are now attempting to develop indicators that could provide informative measures of youth's perceptions of their own safety and security and their willingness to invest time and resources in preparing for long-term goals as opposed to short-term advantages. Others are using measures of youth potential and connectedness to examine positive aspects of youth development (such as indicators of personal and family responsibility, civic engagement, and community service) that are often overlooked in datasets focused narrowly on the presence or absence of problem behaviors. At the community level, some scholars are experimenting with measures designed to judge the capacity of a neighborhood or other social setting to support the values of its residents, including youth, in achieving positive social, economic, and personal benefits (see Hauser et al., 1997).
These scientific efforts have been quite successful in pushing the field forward by taking advantage of existing data sources. However, these efforts have uncovered substantial holes in existing models, in available measures of key constructs, and in the contents of longitudinal and
cross-sectional surveys. Thus, future research is needed to operationally define indicators of well-being and of safety and security as necessary for assessing and monitoring well-being among youth, including their perceptions of health and well-being. New measurement tools and methodologies that can be used to collect these data are also likely to be needed. Once developed, further work will be needed to integrate these new indicators into the evaluations of interventions intended to promote positive developmental outcomes among youth, and into data systems intended to monitor national, state, and local-level trends in the health and well-being of adolescents.
PROGRAMS FOR INTERVENTION AND YOUTH DEVELOPMENT
In seeking to explain variations in adolescent development, researchers have focused traditionally on personal characteristics, family relationships, and friendships. Such lines of inquiry suggest that these factors interact across multiple dimensions to influence youth outcomes. Different theories have emerged over the past decade that provide frameworks to guide research and youth service programs, especially in meeting the needs of disadvantaged youth (National Research Council, 1993). Some of these efforts emphasize the role of the individual in terms of biological and psychological interactions that shape youth identity and decision-making processes during adolescence. Others focus on family or peer interactions and the ways in which adolescents negotiate greater autonomy while still needing support during their teenage years.
As discussed in this report, researchers have increasingly focused on the social settings in which youth develop. This has prompted new research inquiry designed to explore how individual, family, and peer relationships and outcomes are influenced by factors such as physical environment, economic opportunity structures, and ethnic and social networks, especially in urban areas characterized by concentrated poverty (see Duncan and Brooks-Gunn, 1997). Scholars are also investigating relationships between types and density of social interactions, youth perceptions of positive and negative influences within their social and physical environments, and ways in which these relationships and perceptions are associated with the emergence of problem behaviors within communities (such as crime, gangs, substance abuse, child maltreatment, and unintended teen pregnancy).
Longitudinal studies and other research now suggest that complex social support interactions occur (or not) as a result of a mix of physical and social factors in community settings that affect youth's perception of their own strengths and deficits, family life, and choice of friends and role models (Carnegie Council on Adolescent Development, 1995).
This research on settings suggests that certain implicit social norms, behaviors, resources, and networks in affluent or higher resource settings that are often taken for granted (such as good schools; recreational and sports programs; safe homes and social centers; private health care; attitudes toward the value of work, education, community service, and parenting; and beliefs about future career and employment opportunities) constitute positive assets that have profound impact on the ways in which youth prepare themselves for their adult lives. Conversely, the absence of these assets creates significant gaps in the social support and opportunity structure for youth as they experience important transitions in becoming adults.
In addition, the presence of individuals and groups who represent sources of danger, insecurity, and deviant role models can diminish youth's motivation in preparing for productive and meaningful relationships and create cynicism about their opportunities to achieve participatory membership in society. Conversely, the presence of individuals who serve as positive role models may give youth a sense of optimism and the belief in future opportunities, as well as discourage them from engaging in risk behaviors. These attitudes and beliefs—whether they are pessimistic or optimistic—influence the types of choices and behaviors that young people acquire during their developmental years.
The influence of settings is also likely to be mediated by the child's mind, i.e., by the child's interpretation and perception of his or her experiences within these settings. For this reason, changing the institutions—neighborhoods and schools—without attending to the adolescent's construction and interpretation of those changes will not have the intended effects on most children.
Scholars from multiple disciplines are presently engaged in developing theory and indicators that relate to the relations between social settings and youth development. Experimental program initiatives are under way to improve teenager's engagement and involvement with their communities and use of available resources and supports. Unfortunately, researchers often lack the opportunity to interact and work with those who are responsible for designing and implementing youth development programs. Re-
search evaluations of program interventions and their outcomes, in particular, reflect the absence of a shared vision about the overall mission of youth development initiatives and the capacity of a program to achieve ambitious, long-term goals.
Public and private agencies are now increasingly experimenting with a wide array of youth development interventions that are designed to foster social support for youth by two approaches: (1) strengthening the ability of youth to interact successfully with community resources and networks, and (2) improving the capacity of community programs and services to engage youth in their efforts. Such efforts include mentorship programs (such as Big Brothers/Big Sisters); school-based community service efforts (such as volunteer programs); school-to-work transition programs (such as YouthBuild); teen pregnancy, substance abuse, or violence prevention programs; and others (see Dryfoos, 1998). Significantly, rather than focus on the deficits of today's youth (such as delinquency, drug use, teenage pregnancy, and violence), many of these programs focus on the resilience of youth and reconfiguring assets within the community in an effort to promote positive youth developmental outcomes (Blum, 1998).
Although some approaches appear to be promising because of their ability to sustain broad youth-adult relationships, no single approach is yet strong enough to provide general guidance for the field. As a result, program sponsors, service providers, and researchers are examining the reasoning behind different interventions and the outcome measures associated with their use. Program participants are also keenly interested in knowing how the impacts of broader types of youth development initiatives compare with other, more narrowly focused problem prevention interventions such as teen pregnancy, substance abuse, and violence prevention efforts.
Community-based youth programs can provide enriching and rewarding experiences for young adolescents, and many do: their young members socialize with their peers and adults and learn to set and achieve goals, compete fairly, win gracefully, recover from defeat, and resolve disputes peaceably. These programs also provide children and adolescents with the opportunity to acquire life skills—i.e., the ability to communicate effectively, make decisions, solve problems, make plans, and set goals for education and careers.
Considerable work is needed to inform the design, implementation, and evaluation of programs targeted to youth. Clearly, no single program approach will be appropriate for all adolescents: one size does not fit all. The challenge therefore becomes one of designing a range of intervention
strategies that are comprehensive and interdisciplinary in nature, that are developmentally appropriate and culturally relevant, and that take advantage of the many settings or environments in which children and adolescents grow and develop—e.g., the home, schools, communities, social services, the media, and the business or corporate sector. Other questions will also need to be addressed. For example, what are programs really trying to accomplish and how can they be designed to accomplish these goals? Conceptually, how are such constructs as safety, security, and well-being defined, and can programs be designed to accomplish this? What are appropriate outcomes and what are the strengths and limitations of existing data sources and data collection instruments? How do we move beyond evaluating programs by measuring the presence or absence of problem behaviors, to measuring the presence or absence of positive developmental outcomes and well-being? How can evaluations look at both short-term or interim effects and long-term outcomes? What is known about the youth who access after-school and community services and those who do not? What are the implications if those who are most vulnerable or in greatest need do not choose to take advantage of these services? Are certainly types of programs more or less effective with specific segments of the population?
Finally, the field needs to consider what are appropriate expectations for these programs in term of individual-level outcomes. For example, it is clearly unrealistic to think that a single three-month community-based after-school program will have such a profound impact that it will overcome competing deficits or problems, such as dysfunctional home; overcrowded schools with few resources and poorly trained teachers; and impoverished and disorganized communities with few social services.
DEVELOPMENTALLY APPROPRIATE HEALTH CARE SERVICES
During the past decade, the health status of adolescents and young adults has been the subject of growing concern among policy makers, researchers, clinicians, and advocates interested in youth issues and adolescent health. Poor health outcomes caused by health-damaging behaviors, compounded by inadequate use of available health resources, have led to a number of national efforts to study the special health, social, economic, and legal needs of adolescents. An unprecedented number of books examining the health and well-being of youth, as well as a host of federal, state, and foundation reports, has offered an overwhelming array of recommen-
dations for addressing the spectrum of problems experienced by adolescents (Brindis et al., 1998).
The teenage years provide an important window of opportunity to provide youth with guidance and support to avoid behaviors that involve risk and to encourage a healthful lifestyle, including but not limited to exercise, a healthful diet, and healthful sleep patterns. Health care providers can play an important role in this respect. Unfortunately, there are a number of barriers that prevent adolescents from accessing and utilizing primary health, preventive, and specialty services. Barriers to adolescents receiving care include lack of experience in negotiating complex medical systems; reticence in seeking care for potentially embarrassing needs, such as reproductive or mental health concerns; concern about confidentiality and parental consent laws; fragmented care; and distance from medical facilities. However, access to health services, especially for ambulatory care, depends in large part on the ability to pay for services, and adolescents and young adults are less likely to have health insurance than other age groups (Newacheck et al., 1990). Moreover, adolescents who lack health insurance have been found to be in poorer health than those who do have adequate insurance. Clearly efforts are needed to address these barriers and to increase teenagers' access to and use of needed health care and preventive services.
Teenagers with a chronic illness or disability are a segment of the adolescent population that warrants special attention. These youth are defined as having a chronic condition that results in limitations in daily activities that require ongoing services to maintain or enhance daily life function. It is estimated that nearly 2 million adolescents (6 percent) ages 10 to 18 have a chronic condition that limits their daily activities. Within this 6 percent of the adolescent population, the major physical disabilities include chronic respiratory conditions (21 percent) and diseases of the musculoskeletal system (15 percent). Youth with disabilities make greater use of health and hospital services than the rest of the adolescent population.
In many respects, there has been insufficient attention to the needs of children and adolescents with chronic debilitating conditions and with disabilities, and there are a number of very important policy-related questions that can and should be informed by research and analysis of available data. For example, there is considerable debate among policy makers, health care providers, and families with a disabled child about current definitions of disability and criteria or tools for determining disability. Other questions relate to the provision of care, such as what are the patterns of providing
care for children with disabilities? What are the effective ways of providing care? How accessible are they? How are existing health insurance and managed care plans covering these services? How are other forms of coverage, such as Medicaid and the new State Children's Health Insurance Program, covering these children? What care is provided by families at reasonable levels of cost and burden? What are appropriate standards for the duration of benefits, such as the factors that can predict the long-term prognosis of children and adolescents with disabilities? What are effective ways to advance such children toward economic independence? What are appropriate incentives to encourage children to develop to their full potential? All of these questions must be addressed in order to help these young people grow and develop to their full potential.
THE MEDIA AND ADVANCES IN TECHNOLOGY
Adolescents today have greater access to more kinds of media and technology than ever before. In the midst of a world-wide communications explosion, with relatively recent advances in computer and telecommunications technology, adolescents are spending considerable amounts of time online. Indeed, recent advances in media and computer technology, including satellite transmission, remote control, the video cassette recorder, computers, and the Internet, have exponentially expanded the number and kinds of media, and have given teens more control over when and where they use them. Advances in various forms of media and computer technology, including the Internet, has changed the ways in which children and adolescents access information in both their home and their classrooms. Many teenagers now actively communicate through electronic mail with their peers around the world. They share ideas, interests, opinions, and beliefs regarding a wide range of issues and current events. There is also evidence that teenagers are becoming more interested in civic engagement through the Internet, but defined on their terms. However, it is clear that all children and adolescents do not have equal access to these technologies, and it is not clear what the long-term implications will be of these inequities.
Children and adolescents are likely to benefit greatly from the wealth of information and educational materials available on the Internet, as well as valuable skills that are likely to ensure their competitiveness in the workforce. There is also growing concern about children and adolescents' access to information and material that are developmentally inappropriate
and even potentially harmful. As a result, there has been a growing interest on behalf of the public and policy makers to identify the range of tools and strategies that can be used to ensure children's safe and appropriate use of the Internet.
The Internet and future technologies will no doubt continue to play an important role in the lives of teenagers worldwide. Research is therefore needed to characterize how children and adolescents use the Internet and what are their experiences with it; what technological and nontechnological tools might be used by parents, educators, librarians, local communities, and state and federal policy makers to ensure children's safe and appropriate use of the Internet; ensure that the Internet is used to its full potential—i.e., to enhance learning opportunities and promote the healthy development of children and adolescents. Finally, research is needed to explore how the various forms of the media and social marketing strategies can be used to encourage or reinforce health-promoting behaviors among adolescents.
ROLE OF THE FORUM
The forum undertook this report to inform its future work. From the body of research considered for this synthesis, we were impressed by how much is now known about adolescent development, as well as overwhelmed by how much is still unknown about how to ensure the safety, security, and well-being of adolescents. The task for us—and all those in research, policy, and practice—is to extract from this report the most fruitful avenues for the next steps.