INVESTING IN
THE HEALTH
AND WELL-BEING
OF YOUNG ADULTS
Committee on Improving the Health, Safety, and
Well-Being of Young Adults
Board on Children, Youth, and Families
Richard J. Bonnie, Clare Stroud, and Heather Breiner, Editors
INSTITUTE OF MEDICINE AND
NATIONAL RESEARCH COUNCIL
OF THE NATIONAL ACADEMIES
THE NATIONAL ACADEMIES PRESS
Washington, D.C.
THE NATIONAL ACADEMIES PRESS 500 Fifth Street, NW Washington, DC 20001
NOTICE: The project that is the subject of this report was approved by the Governing Board of the National Research Council, whose members are drawn from the councils of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine. The members of the committee responsible for the report were chosen for their special competences and with regard for appropriate balance.
This study was supported by contracts and grants between the National Academy of Sciences and the Health Resources and Services Administration (HHSH25034014T), the Office of the Assistant Secretary for Planning and Evaluation (HHSP23337004), the Robert Wood Johnson Foundation, the Annie E. Casey Foundation, and the Department of Defense (HHSP23337009). Any opinions, findings, conclusions, or recommendations expressed in this publication are those of the author(s) and do not necessarily reflect the views of the organizations or agencies that provided support for the project.
International Standard Book Number-13: 978-0-309-30995-0
International Standard Book Number-10: 0-309-30995-6
Library of Congress Control Number: 2014959552
Additional copies of this report are available for sale from the National Academies Press, 500 Fifth Street, NW, Keck 360, Washington, DC 20001; (800) 624-6242 or (202) 334-3313; http://www.nap.edu.
For more information about the Institute of Medicine, visit the IOM home page at: www.iom.edu.
Copyright 2014 by the National Academy of Sciences. All rights reserved.
Printed in the United States of America
The serpent has been a symbol of long life, healing, and knowledge among almost all cultures and religions since the beginning of recorded history. The serpent adopted as a logotype by the Institute of Medicine is a relief carving from ancient Greece, now held by the Staatliche Museen in Berlin.
Suggested citation: IOM (Institute of Medicine) and NRC (National Research Council). 2014. Investing in the health and well-being of young adults. Washington, DC: The National Academies Press.
THE NATIONAL ACADEMIES
Advisers to the Nation on Science, Engineering, and Medicine
The National Academy of Sciences is a private, nonprofit, self-perpetuating society of distinguished scholars engaged in scientific and engineering research, dedicated to the furtherance of science and technology and to their use for the general welfare. Upon the authority of the charter granted to it by the Congress in 1863, the Academy has a mandate that requires it to advise the federal government on scientific and technical matters. Dr. Ralph J. Cicerone is president of the National Academy of Sciences.
The National Academy of Engineering was established in 1964, under the charter of the National Academy of Sciences, as a parallel organization of outstanding engineers. It is autonomous in its administration and in the selection of its members, sharing with the National Academy of Sciences the responsibility for advising the federal government. The National Academy of Engineering also sponsors engineering programs aimed at meeting national needs, encourages education and research, and recognizes the superior achievements of engineers. Dr. C. D. Mote, Jr., is president of the National Academy of Engineering.
The Institute of Medicine was established in 1970 by the National Academy of Sciences to secure the services of eminent members of appropriate professions in the examination of policy matters pertaining to the health of the public. The Institute acts under the responsibility given to the National Academy of Sciences by its congressional charter to be an adviser to the federal government and, upon its own initiative, to identify issues of medical care, research, and education. Dr. Victor J. Dzau is president of the Institute of Medicine.
The National Research Council was organized by the National Academy of Sciences in 1916 to associate the broad community of science and technology with the Academy’s purposes of furthering knowledge and advising the federal government. Functioning in accordance with general policies determined by the Academy, the Council has become the principal operating agency of both the National Academy of Sciences and the National Academy of Engineering in providing services to the government, the public, and the scientific and engineering communities. The Council is administered jointly by both Academies and the Institute of Medicine. Dr. Ralph J. Cicerone and Dr. C. D. Mote, Jr., are chair and vice chair, respectively, of the National Research Council.
COMMITTEE ON IMPROVING THE HEALTH, SAFETY,
AND WELL-BEING OF YOUNG ADULTS
RICHARD BONNIE (Chair), Harrison Foundation Professor of Medicine and Law, University of Virginia School of Law
CLAIRE D. BRINDIS, Director, Philip R. Lee Institute for Health Policy Studies, University of California, San Francisco
GLADYS CARRIÓN, Commissioner, New York City Administration for Children’s Services
MARK E. COURTNEY, Professor, School of Social Service Administration, University of Chicago, Illinois
ROBERT CROSNOE, The Elsie and Stanley E. (Skinny) Adams, Sr., Centennial Professor in Liberal Arts, Department of Sociology, The University of Texas, Austin
MARYANN DAVIS, Research Associate Professor, Systems and Psychosocial Advances Research Center, Department of Psychiatry, University of Massachusetts Medical School, Worcester
KATHLEEN MULLAN HARRIS, James E. Haar Distinguished Professor of Sociology, University of North Carolina at Chapel Hill
HARRY J. HOLZER, Professor, McCourt School of Public Policy, Georgetown University
CHARLES E. IRWIN, JR., Distinguished Professor of Pediatrics, UCSF Benioff Children’s Hospital, University of California, San Francisco
BEATRIZ LUNA, Director, Laboratory of Neurocognitive Development, University of Pittsburgh, Pennsylvania
VELMA McBRIDE MURRY, Professor of Human Development and Lois Autrey Betts Chair, Department of Human and Organizational Development, Peabody College, Vanderbilt University, Nashville
ZIZI PAPACHARISSI, Professor and Head, Department of Communication, University of Illinois, Chicago
JOHN SCHULENBERG, Professor of Psychology and Research Professor, Institute for Social Research and Center for Human Growth and Development, University of Michigan, Ann Arbor
MARTIN SEPÚLVEDA, IBM Fellow & Vice President, IBM Research
KASISOMAYAJULA VISWANATH, Professor of Health Communications, Harvard School of Public Health
LESLIE R. WALKER, Professor and Chief, Adolescent Medicine Division, Seattle Children’s Hospital and the University of Washington, Seattle
YOUNG ADULT ADVISORY GROUP
MARCUS BROWN, Chief Executive Officer, Adolesco Services
HERNAN CARVENTE, Research Assistant, Vera Institute of Justice
JENNIFER COLLINS, Student, University of Maryland
AMY DOHERTY, Board President, National Youth Leadership Network
SEMIRA ABDULMALIK KASSAHUN, Former Youth Advisor, Colorado Department of Public Health and Environment
JACKIE MALASKY, Public Health Professional, Baltimore, Maryland
PAUL RASTRELLI, Community Health Action Team Member, Kaiser Permanente
ANDREA VESSEL, Student, American University
Consultants
RONA BRIERE, Consultant Editor
VICTORIA FAUST, Doctoral Student, School of Ecology, University of Wisconsin–Madison
CONSTANCE FLANAGAN, Professor, School of Ecology, University of Wisconsin–Madison
RACHEL FAULKENBERRY McCLOUD, Doctoral Student, Harvard School of Public Health
LAUREN MIMS, Doctoral Student, University of Virginia
EVELYN STRAUSS, Consultant Writer
LAUREN TOBIAS, Principal, Maven Messaging and Communications
JOANNA WILLIAMS, Assistant Professor, University of Virginia
Project Staff
CLARE STROUD, Study Director
HEATHER BREINER, Associate Program Officer
DOUGLAS KANOVSKY, Senior Program Assistant
AMANDA PASCAVIS, Senior Program Assistant (July-August 2014)
FAYE HILLMAN, Financial Associate
PAMELLA ATAYI, Administrative Assistant
KIMBER BOGARD, Director, Board on Children, Youth, and Families
Reviewers
This report has been reviewed in draft form by individuals chosen for their diverse perspectives and technical expertise, in accordance with procedures approved by the National Research Council’s Report Review Committee. The purpose of this independent review is to provide candid and critical comments that will assist the institution in making its published report as sound as possible and to ensure that the report meets institutional standards for objectivity, evidence, and responsiveness to the study charge. The review comments and draft manuscript remain confidential to protect the integrity of the deliberative process. We wish to thank the following individuals for their review of this report:
ANNE-MARIE BRAGA, Colorado Department of Public Health and Environment
ELLEN WRIGHT CLAYTON, Vanderbilt University
DONNA FUTTERMAN, Albert Einstein College of Medicine
ADRIANA GALVÁN, University of California, Los Angeles
RENÉE R. JENKINS, Howard University College of Medicine
MEREDITH KLEYKAMP, University of Maryland
ROBERT I. LERMAN, American University and Urban Institute
ELIZABETH LOWER-BASCH, Center for Law and Social Policy
MICHELLE R. MUNSON, New York University
ALICE SHOBE, Building Changes
PATRICK H. TOLAN, University of Virginia
PATIENCE WHITE, Got Transition
JOY JOHNSON WILSON, National Conference of State Legislatures
JONATHAN F. ZAFF, America’s Promise Alliance
Although the reviewers listed above provided many constructive comments and suggestions, they were not asked to endorse the report’s conclusions or recommendations, nor did they see the final draft of the report before its release. The review of this report was overseen by ANTONIA M. VILLARRUEL, University of Michigan School of Nursing, and SARA ROSENBAUM, The George Washington University School of Public Health and Health Services. Appointed by the National Research Council and the Institute of Medicine, they were responsible for making certain that an independent examination of this report was carried out in accordance with institutional procedures and that all review comments were carefully considered. Responsibility for the final content of this report rests entirely with the authoring committee and the institution.
Prologue1
Marcus Brown is working toward a business management degree at Davenport University in Grand Rapids, Michigan. He spent 5 years in the foster care system before being adopted into a family of 23 children.
Lack of contact with one’s biological family raises significant questions that many people never encounter, Marcus said. “I have had experiences where I had to go to the hospital. They say, ‘Tell me about your family.’ I go, ‘Your guess is as good as mine.’” Boys who grow up without a father can lack other basic information, too, and Marcus relied on social media to learn some basic life skills. “I did not know how to tie a tie, so I had to YouTube that,” he said. “My other parent is the Internet.”
Marcus offered ideas about ways to smooth and improve the transition from the foster care system into independent life. As adulthood looms and people are about to age out, “It is like, ‘oh yeah, we want to talk to you about housing now.’ I say, ‘Should we not have talked about that a year ago so I could start saving for the deposit?’”
Hernan Carvente will soon graduate from the City University of New York with a bachelor’s degree in criminal justice. He is a research assistant at the Vera Institute of Justice, where he works on projects related to juvenile justice and family engagement. Many of Hernan’s insights and sug-
__________________
1 The vignettes presented here are from eight young adults who served as a young adult advisory group to the committee that prepared this report. They provided written permission to include their stories, quotes, and names. Their stories are not intended to be representative of all young adult experiences and views. A description of the group and its work is in Chapter 1.
gestions are based on his experiences with various government institutions and programs. Beginning at age 15, he served 4 years at a secure juvenile detention facility. “My family was broken, so the gang became my family,” he said. “The only system that could hold onto me was the criminal justice system, unfortunately.”
Hernan highlighted the importance of problem-solving skills. “In public schools, I never experienced any structured lesson on how to deal with conflicts,” he said. “With my troubled background, I had no ways to deal with issues impacting me at home, which led to issues with peers at school.” He sees family-centered initiatives as a priority. Rather than telling parents that “you did no good,” so “we are going to take care of your child,” Hernan suggested that government programs “give the responsibility back to the people who brought that child into the world by offering them the appropriate resources.” He also emphasized the value of communication among agencies. “When a young person goes into the foster care system and ends up in the criminal justice system, it is hell to get the data that was in the foster care system,” said Hernan. Yet that information is essential to “understand what the young person went through” and provide the services he or she needs. “The systems fall apart when we don’t have that collaboration.”
Jennifer Collins entered foster care for the first time at age 7. As a teen, she struggled with mental health issues. Now pursuing a bachelor’s degree in family science at the University of Maryland at College Park, she credits numerous “tireless advocates”—her social worker, foster mother, and adoptive mother—with helping her get the help she needed to persevere and succeed.
Jennifer spoke about the difficulties she faced while trying to navigate the Medicaid system, particularly when she was dealing with serious emotional challenges. “The most frustrating thing is just getting on the phone with someone,” she said. “It usually took a drastic event, like me attempting to off myself, to access care. The only way you could get into the mental health system, as I recall, was the police had to take you there after you tried to take your own life.” Jennifer raised other issues that are commonly misunderstood, such as abuse. “I don’t think a lot of people realize that abuse may start at any point—and many people discount abuse of older kids,” she said. “I was stuck in a situation for three years until I could get someone to listen. If I had been younger, someone would have done something sooner.”
Jennifer pointed out that low Medicaid reimbursement rates lead to high turnover in the system and a lack of experienced professionals—a problem that has particularly grave ramifications in the area of mental health. When a person starts working with a new psychologist, “you are
not starting where you dropped off before,” she said. “You are starting all the way back at square one.”
Amy Doherty graduated from Mount Holyoke College in South Hadley, Massachusetts, and conducts research in a vision rehabilitation lab. She was born legally blind and currently serves as board president for the National Youth Leadership Network, a group that works to break down isolation and build community among young people with disabilities.
Amy discussed the many challenges young adults face as they grow toward independence. “One of the things that I noticed in transitioning from high school to college was that you lose a lot of your support system,” she said. The people who previously had played that role are no longer “right there with you.” She talked about the importance of helping young adults access health care, which has been difficult for her, even with private insurance, and she also pointed out that young people typically do not learn financial management skills. That crucial topic “is missing from education,” she said, “but it could be incorporated in lots of ways.”
Semira AbdulMalik Kassahun came to the United States at age 3. Her English fluency grew, and she soon was translating for her parents at doctor appointments and teacher conferences to “make everything go smoothly . . . which is a typical scenario for U.S. immigrant families.” Semira is the first person in her family to graduate college and is now pursuing a master’s degree in public health, focusing on maternal and child health, at The George Washington University in Washington, DC.
“Growing up, you sometimes have to take charge,” she said. “My parents always supported me by saying, ‘Keep going,’ but due to language and education barriers I needed to take the initiative of finding guidance and role models who I could ask about college and higher education.” She now feels “proud and happy” to serve a similar role for young people in her community. In addition, she is reaching out to individuals beyond her cultural circle to raise awareness about issues that matter to her, such as religion. “I’m a Muslim and I follow Islam,” she said. “There’s a lot of work I’ve tried to do to fight misconceptions about Islam.” Semira stressed the value of connections with older people to whom young adults can direct personal and professional questions. “Relationships are like fuel,” she said, “helping young people move forward in their lives.”
Jackie Malasky majored in public health and anthropology at New York University. She then earned a master’s degree in education at The George Washington University, where she concentrated on maternal and child health. Jackie did her master’s thesis on how men and women use the Inter-
net differently to access sexual health resources online. She currently works as an HIV program evaluator.
Technology—especially social media—is changing how young adults mature and establish themselves in the world. “We are developing our self-identity by using two-way media,” she said, but often “people post without really thinking about what it means or what it says about them.” Jackie is especially interested in using entertainment to educate young adults. She also would like to see that they are trained to recognize and assist with mental health problems in their communities. “Our friends may be depressed,” she said, but “we are not psychologists. How can I have the tools I need to really provide resources?”
Paul Rastrelli has always been interested in health, perhaps because both of his parents work in that field. In high school, he was already making significant contributions to his community’s welfare. For instance, he spearheaded an antibullying campaign. Paul was a member of Kaiser’s Community Health Action Team (CHAT), which is creating classroom resources that help students learn about comprehensive health. He commuted 2.5 hours to attend CHAT meetings, “but it was totally worth it,” he said. He is now studying mechanical engineering at the University of Colorado Boulder.
Through his work with CHAT and other enterprises, Rastrelli encountered—and was captivated by—the concept of human-centered design. “When you are designing a product or an experience, you design around the eventual end user and really get their input,” he said. He talked about the importance of following one’s enthusiasm—and how social status can interfere with that endeavor. “Regardless of who you are, you contribute the most to the world when you feel you are doing something you are passionate about,” he said.
Andrea Vessel grew up in a middle-class household with both of her parents. She often was racially isolated—the only black person in predominantly white communities—and felt pressured to “represent my culture,” she said. As she advanced through school and noticed that fewer people “looked like me,” she wanted “to prove myself.” Because of her involvement in 4-H and Girl Scouts, she said, “I never thought, ‘I couldn’t do this’ or ‘people around me may not be doing this and I can’t do it either.’ I saw myself as being able to achieve.” Now studying justice and law at American University in Washington, DC, she also serves as a youth trustee on the National 4-H Council Board of Trustees.
Andrea spoke about mistrust among young adults that can interfere with public health campaigns. “For example,” she said, “when people say
Preface
Young adulthood (spanning the ages of approximately 18-26) is a significant and pivotal time of life. During this time, young women and men typically complete their education, start working, develop relationships, and pursue other endeavors that help set them on the path to a healthy and productive adult life. Older adults, myself included, who have the opportunity to work on a daily basis with successive generations of young adults, often marvel at the energy, talent, creativity, and hopefulness they bring to their classrooms and workplaces and to their relationships with each other and their elders. Almost every new insight I have had in recent memory emerged from my interactions with the young adults I see every day. It is therefore all the more troubling that many young adults in our country are having difficulty accomplishing these transitions, particularly in the aftermath of the Great Recession and in the face of escalating costs of higher education. The dizzying pace of change in modern life also has confounded the traditional pathways to marriage, parenting, and other hallmarks of independent adulthood. Any conversation with today’s young adults is likely to evoke observations about the stresses and uncertainties they confront.
The needs of young adults, and the challenges they face, do not receive a great deal of systematic attention in policy and research. Accordingly, the Health Resources and Services Administration asked the Institute of Medicine (IOM) to convene a committee to examine, analyze, and synthesize information and knowledge on the health, safety, and well-being of young adults. The IOM appointed a planning committee to design, organize, and conduct a workshop to review the current state of knowledge in this area.
The workshop was held on May 7-8, 2013, and a summary of the presentations was published in September 2013.1 The Committee on Improving the Health, Safety, and Well-Being of Young Adults was then formed to conduct a consensus study and develop a set of recommendations for policies, programs, practices, systems development, service delivery, and research to address the needs of young adults and guide policy makers and other stakeholders in meeting those needs. (See Chapter 1 for the committee’s full statement of task.) This report is the product of that study.
The central aim of this report is to draw attention to young adulthood as a distinct and important period in the life course of young people who are growing up in modern society. From a developmental standpoint, young adults are different, biologically and psychologically, from both adolescents and older adults in ways that affect their decision making, health, and behavior. From a social point of view, many of today’s young adults confront major challenges in making a successful transition to adult roles in a rapidly changing and stressful world. Policy makers and service providers need to understand these differences in designing and implementing policies and programs to help young people accomplish these transitions successfully.
It is also important for public and private agencies monitoring the health, safety, and well-being of young adults to collect, classify, and maintain data in a way that permits researchers to analyze the status, behavior, and well-being of young adults, as well as their correlates and causes and the outcomes of interventions designed to improve them. Many of the report’s recommendations focus on advancing understanding of young adulthood and the effects of policies and programs focused on this critical period of life. While the committee’s recommendations include specific substantive changes in current policies and programs where the evidence is sufficiently compelling to warrant action, we were generally content to sketch our policy prescriptions with broad strokes, pointing the way for others to conduct more specialized investigations.
I would like to express my sincere appreciation to each member of the committee and the talented IOM staff for their extraordinary commitment to this important project. The health, safety, and well-being of young adults are of immense interest to us all as parents, colleagues, scientists, and members of the body politic. I am particularly grateful to our young adult advisory group for their uniquely insightful contributions to the committee’s work.
Richard Bonnie, Chair
Committee on Improving the Health, Safety, and Well-Being of Young Adults
__________________
1 The full text of the summary is available online via www.iom.edu/youngadults.
Acknowledgments
The committee would like to express its sincere gratitude to everyone who assisted in the development of this report. This work would not have been possible with the support of our sponsors—the Health Resources and Services Administration and the Office of the Assistant Secretary for Planning and Evaluation in the U.S. Department of Health and Human Services, the Robert Wood Johnson Foundation, the Annie E. Casey Foundation, and the U.S. Department of Defense. We thank them for generously providing information and responding to our questions.
Shortly after the study was initiated, a young adult advisory group was formed to give the committee opportunities for ongoing dialogue with young adults during the research phase of the study and the preparation of this report. We are grateful to the following individuals for their thoughtful comments throughout the study process: Marcus Brown, Hernan Carvente, Jennifer Collins, Amy Doherty, Semira AbdulMalik Kassahun, Jackie Malasky, Paul Rastrelli, and Andrea Vessel. Their efforts proved invaluable to the committee.
The committee would also like to acknowledge several consultants who contributed to this study: Constance Flanagan and Victoria Faust (University of Wisconsin–Madison) for their synthesis of research on civic engagement among young adults and service programs in which many young adults participate; Rachel Faulkenberry McCloud, a doctoral candidate in the Department of Social and Behavioral Sciences at the Harvard School of Public Health, for her assistance with the committee’s review of the literature on public health interventions; Joanna Williams and Lauren Mims (University of Virginia) for their assistance in reviewing the literature
on diversity; Sandra Graham at the University of California, Los Angeles, Graduate School of Education and Information Studies for her technical review; Evelyn Strauss for her assistance with writing and her advice on incorporating young adult voices throughout the report; and Lauren Tobias of Maven Messaging for her advice on presenting the evidence in a compelling manner. The committee is also grateful to Rona Briere and Alisa Decatur of Briere Associates, Inc., for their assistance in editing the report.
Many individuals volunteered significant time and effort to address and educate the committee during our information-gathering meetings (see Appendix A for the names of these speakers). In addition, Rebecca Gudeman of the National Center for Youth Law provided valuable information about confidentiality issues in young adult health. These contributions informed our deliberations and enhanced the quality of this report.
The committee also expresses its deep appreciation for the opportunity to work with the talented and dedicated members of the staff of the Institute of Medicine and the National Research Council on this important project. We are grateful for the ongoing contributions of Kimber Bogard, director of the Board on Children, Youth, and Families. The assistance of associate program officer Heather Breiner and senior program assistant Douglas Kanovsky were indispensable. Finally, special praise is due to study director Clare Stroud, whose impeccable planning, superb judgment, and faithful support made serving on (and especially chairing) this committee a genuine pleasure.
Romantic Relationships and Union Formation
Intergenerational Relationships
Conclusions and Recommendation
Employment Outcomes of Young Adults
Educational Patterns and Outcomes of Young Adults
Health and Social Causes and Consequences
Education and Employment Policy for Young Adults
Conclusions and Recommendations
5 CIVIC ENGAGEMENT AND NATIONAL SERVICE
Overview of Civic Engagement and National Service
National Service Programs for Young Adults
Conclusions and Recommendations
Overview of Public Health Perspectives and Activities
Priority Public Health Issues for Young Adults
Public Health Interventions for Young Adults
Social Media and the Health of Young Adults
Protective Public Policies for Young Adults
Improving and Coordinating Public Health Programs
Conclusions and Recommendations
Current Use of Health Care by Young Adults
Preventive Care for Young Adults
Behavioral Health Interventions for Young Adults
Conclusions and Recommendations
8 GOVERNMENT INVESTMENTS IN MARGINALIZED YOUNG ADULTS
Young Adults Aging Out of Foster Care
Young Adults in the Justice System
Characteristics Common to Marginalized Young Adults and the Programs That Serve Them
The Evidence Base for Assisting Marginalized Young Adults
Conclusions and Recommendations
Overall Conclusions About Policies and Programs That Serve Young Adults
Organization of Domain-Specific Recommendations by Responsible Entities
B DIVERSITY AND THE EFFECTS OF BIAS AND DISCRIMINATION ON YOUNG ADULTS’ HEALTH AND WELL-BEING
