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December 2019 (Volume 97)
Quarterly Article
Joshua M. Sharfstein
December 2024
Dec 19, 2024
Back to The Milbank Quarterly
In May 2019, the National Academies of Sciences, Engineering, and Medicine published a consensus study on adolescent development. The study reviews the latest research on the neurobiology and epigenetics of individuals ages 10 to 25, with a special focus on the complex interaction between the brain and the environment. Its key findings are that adolescents have special capacity to adapt to their environments, develop a unique sense of identity, tolerate risks to explore possibilities, and embrace self‐direction.
Titled The Promise of Adolescence: Realizing Opportunity for All Youth, the study is also a call to action for population health.1 “Because adolescents comprise nearly one‐fourth of the entire US population,” the study finds, “the nation needs policies and practices that will better leverage these developmental opportunities to harness the promise of adolescence—rather than focusing myopically on containing the risks.”
Unfortunately, the myopic focus on containing the risks of adolescence is a national pastime. Teen pregnancy, drug use, violence, and school failure are all social taboos, and youth who experience these challenges are routinely blamed for their conditions. A common conceptual approach is to view the adolescent brain as not fully formed and, thus, at high risk for making poor choices. A common refrain is to ask what went wrong at home or school that led these youth to such irredeemable places. A young person out of school and work is seen as a ”ship that has sailed”—a lost cause.
The National Academies study, by contrast, invites looking at adolescence from a broader perspective. Rather than seeing an adolescent’s condition as the result of a series of bad decisions, the study points out that “striking differences in outcomes” are related to “striking differences in opportunity.”
Millions of children who live in poverty, encounter racism and discrimination in their daily lives, and suffer physical and emotional abuse tend to experience worse physical and mental health than their peers. Those who live in neighborhoods with poor housing quality, high exposure to violence, inadequate schools, and few jobs are much more likely to suffer adversity.
The study describes classic challenges of population health: to see a problem beyond one person at a time, and to recognize that the potential solution is more than a matter of exhortation or education to do better. The study finds that even youth in dire circumstances have the ability—with such supports as mentorship, apprenticeship, and friendship—to turn around the trajectories of their lives. If the core of the problem lies in an adolescent’s environment, the solution is to change that environment by creating opportunities for all.
Efforts to support a healthy adolescence can draw from recent progress on early childhood. Thanks to decades of research and advocacy, adverse birth outcomes are widely recognized to be deeply related to social disadvantage. Few would blame a baby born at 32 weeks for her predicament, and many recognize that a city experiencing a high infant mortality rate can do better. Virtually every health department in the United States has a maternal and child health bureau focused on providing supports for pregnant women and infants at risk. Community hospitals commonly host special programs for young parents and their children. Funding agencies and philanthropies support a robust research agenda to seek improved birth outcomes, and increasingly, these studies are assessing interventions to improve key social determinants of health.
Hardly any of this infrastructure now exists for adolescents. In its place are large systems, from child welfare to juvenile justice, which rarely invest in prevention and which barely acknowledge the fact that adolescents have tremendous capacity to blossom in supportive environments.
The National Academies study calls for a radical rethinking of these approaches. Its recommendations include ending the immense disparities in resources for education, investing in health services for adolescents, supporting programs to build resilience in youth in the child welfare system, providing counselors and caregivers to those in the juvenile justice system, and conducting research on ways to improve the trajectory of adolescents as a group.
In short, the study makes the case for a population health approach to adolescence. Such an approach can start with core measures and a data infrastructure. Beyond statistics on adverse outcomes, such as high school drop‐out and unemployment rates, jurisdictions should track signs of resilience, such as school attendance, job opportunities, access to healthy food, and the availability of other key resources.
An instructive example may come from the City of Baltimore. In September 2019, Dr. Jerome Adams, the US Surgeon General, came to the Johns Hopkins Bloomberg School of Public Health to galvanize a conversation about the economic, educational, and social potential of young people. He heard a presentation with new data by Measure of America of the Social Science Research Council indicating that 11,000 youth ages 16 to 24 in Baltimore are out of school and out of work, representing nearly 16% of those in this age range.2 The findings included the potential economic advantage associated with helping these youth connect to opportunities, which can be measured in tens of millions of dollars in tax revenues over time. Dr. Adams also participated in discussions with school officials, employers, health care leaders, academic experts, and—perhaps most importantly, youth themselves—regarding what might be done to realize this potential.
Youth at the event described the feeling of not having opportunities to work as “stressful,” “depressing,” “tiring,” and “dangerous.”3 They explained that dropping out of the workforce could be the result of “embarrassment and fatigue from constant rejection” and the inability to wait weeks for a paycheck “when having immediate needs.”4 They said to business leaders: “Don’t be afraid to take that risk. One opportunity may change a young person’s entire life.”5 Participants developed ideas that included focused support for youth in the workplace, special efforts to reach out to those who have become disillusioned by their inability to find work, and rapid assistance for young people experiencing housing instability.
When the nation embraces the importance of a healthy adolescence, these conversations will drive change. Policies on school suspension, expulsion, and start times will adapt to support educational success. Child welfare and juvenile justice systems will shift from addressing poor outcomes to identifying youth who are starting to struggle and supporting their engagement with peers, family, and schools. Researchers will report the results of novel approaches to capitalize on adolescence as—in the words of the National Academies study—a “window of opportunity.”
This concept should reframe the national perspective on youth and inform population health efforts at every level. As should the study’s conclusion: “The nation should ensure that all adolescents have genuine opportunity to flourish, not only as an expression of a collective sense of justice but as an investment in the nation’s future.”1
References
Published in 2019 DOI: 10.1111/1468-0009.12425
Joshua M. Sharfstein is associate dean for public health practice and training at the Johns Hopkins Bloomberg School of Public Health. He served as secretary of the Maryland Department of Health and Mental Hygiene from 2011 to 2014, as principal deputy commissioner of the US Food and Drug Administration from 2009 to 2011, and as the commissioner of health in Baltimore, Maryland, from December 2005 to March 2009. From July 2001 to December 2005, Sharfstein served on the minority staff of the Committee on Government Reform of the US House of Representatives, working for Congressman Henry A. Waxman. He serves on the Board on Population Health and Public Health Practice of the Institute of Medicine and the editorial board of JAMA. He is a 1991 graduate of Harvard College, a 1996 graduate of Harvard Medical School, a 1999 graduate of the combined residency program in pediatrics at Boston Medical Center and Boston Children’s Hospital, and a 2001 graduate of the fellowship program in general pediatrics at the Boston University School of Medicine.
