research findings of child and adolescent development

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• Published: 02 June 2022

A methodological perspective on learning in the developing brain

• Anna C. K. van Duijvenvoorde   ORCID: orcid.org/0000-0001-9213-8522 1 , 2 ,
• Lucy B. Whitmore   ORCID: orcid.org/0000-0002-5672-5081 3 ,
• Bianca Westhoff   ORCID: orcid.org/0000-0003-2481-5661 1 , 2 &
• Kathryn L. Mills   ORCID: orcid.org/0000-0002-6463-186X 3 , 4  

npj Science of Learning volume  7 , Article number:  12 ( 2022 ) Cite this article

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• Cognitive neuroscience
• Human behaviour

The brain undergoes profound development across childhood and adolescence, including continuous changes in brain morphology, connectivity, and functioning that are, in part, dependent on one’s experiences. These neurobiological changes are accompanied by significant changes in children’s and adolescents’ cognitive learning. By drawing from studies in the domains of reading, reinforcement learning, and learning difficulties, we present a brief overview of methodological approaches and research designs that bridge brain- and behavioral research on learning. We argue that ultimately these methods and designs may help to unravel questions such as why learning interventions work, what learning computations change across development, and how learning difficulties are distinct between individuals.

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Introduction.

Childhood and adolescence are considered natural times of learning and adjustment. In the first decades of life, changes in physical appearance, as well as cognitive and social-emotional development, are readily apparent 1 , 2 , 3 , 4 . What is, however, less readily observed are the profound changes in the structure, function, and connectivity of the brain. These changes underlie the development of skills and cognitive processes, for which input from the environment (i.e., experience) is required to fully develop.

Learning, defined as the gain of knowledge or skills through experience, can take on many different forms and can be studied at multiple levels. For instance, cognitive domains of learning—such as learning to read, or the ability to learn through feedback—can be studied together with measures of brain development to eventually inform our understanding of how children and adolescents learn in environments such as school and society. In this review, we discuss three methodological approaches with clear potential for advancing the study of learning in relation to the developing brain.

We will start this review with a concise overview of how the brain is changing over time in structure and function, and the role of plasticity in learning. We will first highlight the opportunities afforded by longitudinal intervention designs, which can inform approaches to understand learning processes during periods of substantial brain development. We then discuss a computational modeling approach that examines how people adjust to their environment based on the processing of positive and negative outcomes. In computational models, learning processes can be broken down into several steps—cognitive computations—that may help to formalize the process of learning and can be linked to underlying brain development. Finally, we highlight the importance of recognizing that developmental patterns differ across individuals when examining learning. As development is not the same for everyone, subgroups of individuals may share learning strategies or even struggles in learning. We will discuss methodological approaches that allow us to study individual differences in learning, and the degree to which these differences in learning are reflected in the developing brain.

Taken together, we present a developmental cognitive neuroscience perspective on child and adolescent learning by summarizing different methodological approaches and their potential combination with brain imaging techniques, such as magnetic resonance imaging (MRI).

Structural and functional brain development

Methods such as MRI have greatly advanced the study of the development of the human brain. The first years of life are characterized by a vast increase in cortical grey matter 5 , which is composed of neural and glial cell bodies, dendritic processes and synapses, as well as blood vessels. This initial overgrowth is followed by a reduction in cortical grey matter volume between roughly ages 8–25 years 6 , 7 . While the resolution of MRI does not allow for us to identify specific cellular changes occurring, the observed reduction in cortical grey matter during childhood and adolescence is thought to, in part, reflect synaptic pruning , in which the brain is cutting back and reorganizing synaptic connections potentially on the basis of how frequently they are used 6 , 7 . This reduction in cortical grey matter is a normative developmental pattern that can vary across individuals and also varies across regions of the cortex 8 , 9 . Another structural brain measure, white matter volume, is composed of the myelinated axons connecting distal regions of the brain and increases until mid-adolescence or early adulthood before it begins to stabilize 6 . This increase in white matter volume reflects, in part, the strengthening of synaptic connections between brain regions 1 , 10 . In short, these changes in the brain result in a more efficient and specialized brain system, with stronger connections between brain regions.

These developmental changes in brain structure are paralleled by changes in brain function and behavior in the affective, cognitive, and social domains 1 , 11 , 12 . Brain function is typically studied in task-based paradigms, examining individuals’ brain responses to a specific event, such as receiving negative feedback or a rewarding outcome. In addition to task-based paradigms, the intrinsic functional connectivity of the brain has been studied during scans called ‘resting-state’. In these scans, participants’ spontaneous brain activation is examined while they are lying in the scanner (but without falling asleep). Resting-state fMRI analyses are designed to probe functional brain connectivity . Functional brain connectivity refers to the correlation of activation signals between different brain regions or networks and is thought to signal to what extent these regions/networks are functionally related. Developmental studies have observed changes in functional connectivity strength, and changes in network interactions 13 . For instance, functional connectivity strength between subcortical and cortical brain regions increased with age 12 , and are tied to changes in reward-sensitivity and learning. Resting-state studies have shown that the brain becomes increasingly ‘modular’ (i.e., functionally segregated) across childhood and adolescence 14 , 15 . An increase in modularity is also seen in structural brain development 16 , and both these functional and structural network-level changes are shown to support the development of, for instance, executive functioning 14 , 16 . Resting-state and task-based studies can thus both provide unique insights into the development of a specific cognitive function or experimental manipulation, as well as the broad network-organization of the brain.

Although not the main focus of this article, when discussing the developing brain and learning, the importance of plasticity (i.e., the brain’s ability to change and adapt as a result of experience) is evident 17 . A typical distinction is made between brain plasticity that is experience-independent , in which brain changes unfolds, relatively independent of experience; brain plasticity that is experience-expectant , in which neural sensitivity is attuned to particular environmental stimuli during specific developmental windows (i.e., sensitive periods); and brain plasticity that is experience-dependent , which reflects experiences and environmental inputs that can vary between individuals and supports learning throughout life 18 . Neuroplasticity, particularly in sensitive periods, is related to molecular processes that can inhibit or stimulate brain plasticity through neurotrophic factors such as brain-derived neurotrophic factor (BDNF) that may result in changes in synaptic and neural pruning 19 .

An example of experience-expectant learning in the brain comes from the development of basic sensory processing regions. Seminal research on visual processing has demonstrated that the development of the visual cortex is dependent on relevant stimulation from the environment. Specifically, depriving visual input to one eye resulted in ocular dominance in the visual cortex of the eye that received input, and an absence of developing binocular vision 20 . Moreover, this work highlighted that the impact of experience on visual cortex development depended on the environmental input in a specific developmental window, referred to as a sensitive period . Sensitive periods are periods of heightened neuroplasticity to specific environmental input. They have been historically studied for the development of the visual neural system, yet are thought to occur across multiple cognitive and social-emotional domains such as language and face processing 17 , 21 . Experience-dependent learning, on the other hand, can be thought of as learning due to practice, exposure, or experience. This type of learning therefore depends on individual’s experiences and can occur at all points of ontogeny. Experience-dependent learning may contribute to brain development by gradually modulating brain connectivity, activation, or structure. The developmental cognitive neuroscience work we will discuss here focuses on experience-dependent learning in the brain across childhood and adolescence.

Learning shapes the developing brain: language

Although brain development may affect the efficiency with which we can learn about the world, or acquire a new skill, learning can also have an impact on brain structure and function at a level that can be measured through MRI, through observed changes in cortical thickness and changes in functional activation during task or at rest. Given that learning in cognitive domains often occurs at the same time as substantial development in both brain structure and function, it is a challenge to differentiate whether the observed changes in the brain reflect experience-independent maturational processes, or experience-dependent learning. In order to specify the areas of the brain that support learning in cognitive domains, we must be able to disentangle if an observed effect is related to the experience and not just reflective of maturational change that might occur in absence of the experience of learning a specific skill.

By taking an example of one skill that has to be explicitly taught in order to be learned, reading, we can begin to unpack these processes. The left arcuate fasciculus and inferior longitudinal fasciculus are white matter tracts that are considered crucial for skilled reading 22 , 23 . The left arcuate fasciculus connects anterior and posterior brain regions (i.e., frontal, parietal, and temporal lobes). The inferior longitudinal fasciculus connects the occipital lobe, important for vision, with the temporal lobe, which is—among others—important for semantics. In general, these two white matter tracts continue to mature during the same time as children develop reading skills across childhood and into adolescence. Longitudinal MRI studies have demonstrated substantial increases in fractional anisotropy (FA) in these two tracts from early childhood and into early adolescence 24 , 25 . This increase in FA is thought to reflect increased integrity of the white matter fibers. This may increase the potential for communication, and thus signaling between the brain regions connected by these tracts. Increases in FA within these tracts have been associated with improvements in reading skill in children 26 , and the rate to which the arcuate fasciculus and inferior longitudinal fasciculus increases in FA across childhood varies by the reading skill of the child 23 . However, in a given MRI study, how can we tell if it is the experience-independent maturational process or the experience of learning that underlies a change in brain measurement between two time points?

Longitudinal intervention designs are one possible method to disentangle maturational and experience-dependent processes in the brain. Although these designs might incur higher costs and burden on participants, repeatedly measuring the same individual over time brings unique opportunities to study ‘true’ development and the influence of experience. Further, the concurrent acquisition of behavioral and neuroimaging measures in these designs allows us to disentangle if change in a brain measure is coupled or uncoupled with change in the behavioral measure of interest. A recent study examined white matter integrity four times in children across the course of an intensive 8-week reading intervention and compared these children to a group of children who did not complete the reading intervention 27 . Participants of the intervention group were recruited based on parent reports of reading difficulties and/or a clinical diagnosis of dyslexia, and the control group was matched for age but not reading level 27 . By taking this longitudinal intervention approach, this study could compare the magnitude of experience-dependent learning (in this case, through a reading intervention) on white matter integrity to the magnitude of developmental change. This study identified the left arcuate fasciculus and inferior longitudinal fasciculus as being responsive to the experience-dependent learning in the cognitive domain of reading, as the observed change in integrity of these white matter paths was coupled to improved reading skill level in the children who received the intervention 27 . In contrast, this study also identified white matter paths that predicted a child’s reading skill level, but did not change in white matter integrity throughout the intervention, such as posterior callosal white-matter connections 27 . This finding suggests that some parts of the brain are already related to readiness to learn certain skills even during a developmental period marked by changes in brain structure.

When looking at evidence of learning on brain measures from another cognitive learning domain—second language acquisition—the age period when one learns a second language can result in differential effects on observed brain measures. For example, cortical thickness measures did not differ between monolinguals and bilingual individuals who acquired two languages simultaneously in early life 28 . However, bilingual individuals who acquired their second language later in childhood show differences in cortical thickness of the inferior frontal gyrus (thicker cortex in the left IFG, thinner cortex in the right IFG), and the magnitude of observed differences correlated with the age of second language acquisition 28 . Thus, multilingual individuals showed no difference in overall cortical thickness as long as they acquired their languages simultaneously, and only individuals who acquired another language later in life showed a difference in cortical thickness. Given that cortical thickness seems sensitive to experiences, such as later language learning, we must consider what differences in overall measures of cortical thickness could actually represent. Perhaps these group-level differences in cortical thickness changes are more likely to reflect the experience-dependent process of learning, which would be more in line with later second language acquisition, than learning that is expected to occur largely early in life. However, to answer this question, one would need longitudinal designs to compare the magnitude of change in cortical thickness observed in individuals who acquired a second language to magnitude of change observed in individuals of the same age who did not.

Using a computational modeling approach in the study of learning

One way in which we learn is by processing and integrating the good and bad outcomes we experience. For instance, through positive and negative feedback, we may learn to play a new videogame, learn to play the guitar, or learn the correct spelling of a difficult word. A computational approach can help us to understand these behavioral changes and formalize the process of outcome-based learning in the developing brain.

Computational learning models have been used to investigate questions such as how children, adolescents, and adults learn from positive and negative outcomes and integrate information into subsequent decision-making. An important element of learning in computational reinforcement learning models focuses on the difference between an expected outcome and a received outcome 29 , 30 . This difference, a so-called prediction error , forms the basis of a specific learning signal that indicates how much one should update expectations of the world, and thereby one’s subsequent actions. These prediction error computations have been linked to brain activation, as this learning signal was found to correlate with dopamine release 31 , 32 that would instigate neural activation. In the context of understanding learning, reinforcement learning models thus provide a computational link (e.g., a prediction-error signal) between brain-level processes and the observed behavior.

Research examining reinforcement learning in children, adolescents, and adults in combination with the developing brain, has shown that learning signals such as prediction errors are found in brain regions, including the striatum, medial prefrontal cortex, and hippocampus. These brain regions are linked to the processing of reward, value, and memory 33 . A number of studies have investigated differences in prediction-error learning in children, adolescents, and adults to understand sensitivities in learning across development. Some findings highlight that adolescents are particularly sensitive to positive prediction errors (feedback that is better than expected), resulting in higher neural activation in adolescents compared to children and adults in the striatum 34 . Moreover, adolescents outperformed adults in their learning performance, and the strength of functional connectivity between the striatum and hippocampus after positive (compared to negative) outcomes related to subsequent memory performance for positive events. These findings indicate that the striatum, and its closely connected regions (see also 35 ), may contribute to heightened reward-learning in some ages, and a bias towards learning from positive outcomes 36 . Note that other studies suggest that the valence-dependency in children’s and adolescent’s learning is context-specific. For instance, it has been observed that adolescents may be more prone to learn from unexpected negative outcomes than adults in other contexts, such as when reward-structures change quickly 37 , 38 .

Computational models may have several advantages for the study of learning 4 , 39 , 40 . A general advantage is that computational models allow to simulate behavior. Generating behavioral data with specific learning parameter settings, allows for better predictions of (expected) behavioral patterns and helps hypothesis testing as well as theory formation. A specific advantage of computational models for brain-behavioral studies is that they allow us to compute latent variables, i.e., variables (such as prediction errors) that cannot be directly observed in behavioral data, but that theory assumes is happening in the brain. These latent variables can be directly linked to brain activation and compared across groups or ages.

Taken together, combining a computational approach with measures of brain functioning allows us to examine learning at different levels of explanation. For instance, on a latent variable level, we can study whether different age groups weigh positive and negative outcomes differently or use different goal-directed strategies in learning 41 , 42 , 43 . On the other hand, developmental change may also occur at the brain (i.e., implementation) level. For instance, learning from experience can involve different brain regions or networks at different ages. Including these levels of explanation in the study of learning can help us to identify mechanisms of learning that may not be apparent, or cannot be disentangled, from observed behavior only.

Examining heterogeneity in the neurocognition of learning

Another challenge in learning research is to characterize individual differences in learning. Most of the studies on learning, or domains of learning, have focused on comparing brain and behavioral differences between ages or condition. This approach is useful for detecting mean-level differences. However, there may be striking heterogeneity in brain development and learning within groups. How could we target those in the study of learning?

An approach that behavioral studies have taken is to use clustering techniques that detect subgroups in the data. For instance, a recent study used such a data-driven approach and has grouped children based on behavioral measures across a range of learning domains, including reading, phonological processing, and executive functioning 44 . This study showed that within a group of 442 struggling learners, three distinct subgroups were found using this range of behavioral indicators. The first group showed symptoms of elevated inattention and hyperactivity/impulsivity. The second group was characterized by learning problems, and the third by aggressive behavior and disturbed peer relations. Moreover, these groups were distinguished by their structural connectivity of the lateral prefrontal cortex, cingulate cortex, and the striatum. In particular, aggression and peer problems loaded on the integration between the prefrontal cortex and the striatum. These findings support the idea that data-driven profiling can distinguish common learning problems in children and provide insight into the neurobiological mechanisms underlying these problems.

Another study from the same group used a clustering technique on white-matter microstructure in a sample of 313 children and adolescents 45 . This analysis showed that the group with higher white matter integrity in the cingulum had profoundly different cognitive abilities. Applying the cingulate-based grouping to independent groups of typically-developing children and struggling learners showed that children with lower cingulum FA showed lower performance across a variety of cognitive performance measures (e.g., fluid intelligence, working memory, and vocabulary) 45 . The value in this approach may particularly relate to children and adolescents with learning difficulties or psychopathologies that show complex behavioral phenotypes that may be better qualified with brain-based than behavioral subtyping.

A recent study compared sub-grouping profiles generated on behavioral measures (e.g., literacy, numeracy, working memory) and structural brain measures (i.e., regional cortical thickness, gyrification, and sulci depth) 46 . This approach was used on a sample of 479 children and adolescents consisting partly of struggling learners. The results based on behavioral measures indicated six cognitive profiles ranging from high- to poor performers on executive function tasks. A similar profile mapping based on structural brain measures indicated that neural and cognitive mappings for individuals were not one-to-one. That is, the same neural profile could be associated with different cognitive impairments in different children 46 . In a subsequent analysis, the authors observed that an individual’s whole-brain network (i.e., the connectome) of white-matter tracts was more strongly related to the cognitive profiles of struggling learners. Particularly, the hub-like structure of individuals’ brain network related to children’s cognitive abilities. Hubs are well-connected nodes in a network and are therefore assumed play an important role in the communication across a network.

Together, these results aid our understanding how the relationship between brain and cognition may be moderated by the organizational properties of developing brain networks. Consequently, it challenges the idea that a neurodevelopmental disorder (such as learning difficulty) is only linked to one specific neuro-anatomical substrate, and instead suggests that learning difficulties are likely to depend on the interactions and organizational properties between different brain systems 47 . These findings also add to the discussion on the transdiagnostic nature of cognitive developmental problems, in which developmental difficulties in learning reflect complex patterns of associations that are not easily matched to singular diagnostic categories.

Note that these reviewed studies identified subgroups using brain and behavioral measures. Although this approach allows to quantify heterogeneity in learning, brain-behavioral relationships can also be studied at the individual level. For instance, finding robust individual-differences markers may help to identify children at risk for developing learning problems. Moreover, questions of heterogeneity in samples have often been tested on cross-sectional datasets with wide age-ranges thereby missing a longitudinal developmental perspective. Finally, these reviewed studies focus on brain structure and not on brain function. Functional brain measures may provide a new mapping for learning profiles, which remains to be explored 47 .

Where do we go from here?

By drawing from research methods and designs in the domains of reading, reinforcement learning, and learning difficulties, we have presented a brief overview of methodological approaches and key findings in developmental cognitive neuroscience research on learning. We started with the central question of how maturational processes can be distinguished from experience-dependent learning. Longitudinal intervention designs are one possible method to examine learning potential and to disentangle maturational and learning-related processes in the brain. Then, we discussed the use of computational modeling for understanding and disentangling the processes that underlie age-related changes in learning from positive and negative outcomes. Computational modeling approaches are rising in developmental studies, and such studies can move this field forward by quantifying the changes in learning processes over age, and their relation to changes in the developing brain. Finally, we discussed handling individual differences using clustering techniques to find data-driven subgroups that may share a commonality in behavioral learning difficulty, or neural patterns of connectivity and/or brain structure. These findings highlight that not all learning brains are the same, and that methods for detecting individual differences are applicable using brain- and behavioral measurements.

Developmental cognitive neuroscience studies have the potential to advance our understanding of learning by combining innovative research methods with longitudinal datasets capturing development from micro (genes, brain) to macro (behavior, environment) levels 48 . That is, (more) rich longitudinal studies are needed to understand learning and learning challenges within individuals, and to address outstanding questions on how interactions between individual characteristics, experience, and environmental influences shape learning across development 26 , 48 , 49 , 50 , 51 . In the methods discussed in this review, the longitudinal element is sometimes central (such as in intervention studies), whereas in other methodological approaches they have yet to be integrated (such as computational modeling approaches). Longitudinal brain research may also help towards better characterization of normative developmental trajectories, and the consequences for functional and structural brain development (see for instance an overview of normative structural development papers 52 ). Eventually, these insights may help in understanding how for instance psychopathology may be explained as a deviation from normative development 53 . Given that longitudinal studies within the field of developmental cognitive neuroscience are time-consuming, valuable, and dependent on long-lasting research funding, the large longitudinal datasets that are becoming increasingly accessible (e.g., 54 , 55 , 56 , 57 ) will be important for advancing the field and examine the neurodevelopmental changes of learning.

In this review, we focused predominantly on individual learning. However, learning obviously does not happen in a vacuum, and humans learn the vast majority of their knowledge from other humans or are influenced by the social context of learning. Learning in a social context is hugely complex and encompasses interactions between learning and the regulatory demands of a social context (e.g., distraction by others), motivational processes (e.g., the desire to interact and engage with others), and our experience with others (e.g., learned trustworthiness of others). As such, an individual’s social context can impact the rate of learning, as well as what is learned in a given situation depending on the developmental period. For instance, reinforcement learning models have been used to study how we update our expectations about others across development and how this is distinct from non-social learning (e.g., 58 , 59 , 60 , 61 , 62 , 63 ). Although the social context of learning warrants a review article of itself, we do want to highlight that the methods displayed in the current review are also valuable to apply to research that studies learning in a social context.

Taken together, the study of behavioral learning can benefit from both structural and functional MRI research. We discussed methodological approaches that aim to unravel why learning interventions work, what learning computations change across development, and how learning difficulties are distinct between subgroups of individuals. These corresponding findings indicate that these approaches have the potential to have a lasting impact on promoting children’s and adolescents’ positive development.

Reporting summary

Further information on research design is available in the Nature Research Reporting Summary linked to this article.

Data availability

No datasets were generated or analyzed during the current study.

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Acknowledgements

K.L.M. was supported by the Research Council of Norway, grant number 288083. A.C.K.D. and B.W. were supported by an Open Research Area (ORA) grant, grant number 464-15-176, financed by the Netherlands Organization for Scientific Research (NWO). A.C.K.D. was supported by the Gratama Foundation and the Leiden University Fund. We thank Marieke G.N. Bos and Kiki Zanolie for carefully reviewing the manuscript.

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van Duijvenvoorde, A.C.K., Whitmore, L.B., Westhoff, B. et al. A methodological perspective on learning in the developing brain. npj Sci. Learn. 7 , 12 (2022). https://doi.org/10.1038/s41539-022-00127-w

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Child and Adolescent Development

• First Online: 28 January 2017

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• Rosalyn H. Shute 3 &
• John D. Hogan 4  

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For school psychologists, understanding how children and adolescents develop and learn forms a backdrop to their everyday work, but the many new ‘facts’ shown by empirical studies can be difficult to absorb; nor do they make sense unless brought together within theoretical frameworks that help to guide practice. In this chapter, we explore the idea that child and adolescent development is a moveable feast, across both time and place. This is aimed at providing a helpful perspective for considering the many texts and papers that do focus on ‘facts’. We outline how our understanding of children’s development has evolved as various schools of thought have emerged. While many of the traditional theories continue to provide useful educational, remedial and therapeutic frameworks, there is also a need to take a more critical approach that supports multiple interpretations of human activity and development. With this in mind, we re-visit the idea of norms and milestones, consider the importance of context, reflect on some implications of psychology’s current biological zeitgeist and note a growing movement promoting the idea that we should be listening more seriously to children’s own voices.

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School-Age Development

Children’s Developmental Needs During the Transition to Kindergarten: What Can Research on Social-Emotional, Motivational, Cognitive, and Self-Regulatory Development Tell Us?

Transition to School from the Perspective of the Girls’ and Boys’ Parents

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Adolescent Development and the Biology of Puberty: Summary of a Workshop on New Research (1999)

Chapter: new research on adolescent development and the biology of puberty, adolescent development and the biology of puberty.

Adolescence is one of the most fascinating and complex transitions in the life span. Its breathtaking pace of growth and change is second only to that of infancy. Biological processes drive many aspects of this growth and development, with the onset of puberty marking the passage from childhood to adolescence. Puberty is a transitional period between childhood and adulthood, during which a growth spurt occurs, secondary sexual characteristics appear, fertility is achieved, and profound psychological changes take place.

Although the sequence of pubertal changes is relatively predictable, their timing is extremely variable. The normal range of onset is ages 8 to 14 in females and ages 9 to 15 in males, with girls generally experiencing physiological growth characteristic of the onset of puberty two years before boys. Pubertal maturation is controlled largely by complex interactions among the brain, the pituitary gland, and the gonads, which in turn interact with environment (i.e., the social, cultural, and ambient environment). A relatively new area of research related to puberty is that of brain development. Evidence now suggests that brain growth continues into adolescence, including the proliferation of the support cells, which nourish the neurons, and myelination, which permits faster neural processing. These changes in the brain are likely to stimulate cognitive growth and development, including the capacity for abstract reasoning.

Although the biology of physical growth and maturation during pu-

berty is generally understood, available data on the biochemical and physiological mediators of human behavior are extremely primitive, and their clinical applicability remains obscure. Despite the limitations of available data, a substantial body of evidence suggests that variations in the age of onset of puberty may have developmental and behavioral consequences during adolescence. Mounting evidence also suggests that gonadal hormones, gonadotropins, and adrenal hormones influence and are affected by social interactions among groups of experimental animals, and they may also play an important role in regulating human social behavior. Interesting and potentially informative parallels exist between the maturational process in human beings and in other animals, especially those having well-documented social structures.

Research conducted with both humans and nonhuman primates suggests that adolescence is a time for carrying out crucial developmental tasks: becoming physically and sexually mature; acquiring skills needed to carry out adult roles; gaining increased autonomy from parents; and realigning social ties with members of both the same and the opposite gender. Studies of such commonalities underscore the critical importance of this part of the life course in establishing social skills. For many social species, such skills are further developed through peer-oriented interactions that are distinct from both earlier child-adult patterns and later adult pairings.

Adolescence is a time of tremendous growth and potential, but it is also a time of considerable risk. Most people would argue that being an adolescent today is a different experience from what it was even a few decades ago. Both the perceptions of this change and the change itself attest to the powerful influence of social contexts on adolescent development. Many of the 34 million adolescents in the United States are confronting pressures to use alcohol, cigarettes, or other drugs and to initiate sexual relationships at earlier ages, putting themselves at high risk for intentional and unintentional injuries, unintended pregnancies, and infection from sexually transmitted diseases (STDs), including the human immunodeficiency virus (HIV). Many experience a wide range of painful and debilitating mental health problems.

One of the important insights to emerge from scientific inquiry into adolescence in the past decade is the profound influence of settings on adolescents' behavior and development. Until recently, research conducted to understand adolescent behavior, particularly risk-related behaviors, focused on the individual characteristics of teenagers and their families. In 1993, the National Research Council conducted a study that took a critical

look at how families, communities, and other institutions are serving the needs of youth in the United States. This study concluded that adolescents depend not only on their families, but also on the neighborhoods in which they live, the schools that they attend, the health care system, and the workplace from which they learn a wide range of important skills. If sufficiently enriched, all of these settings and social institutions in concert can help teenagers successfully make the transition from childhood to adulthood.

Family income is perhaps the single most important factor in determining the settings in which adolescents spend their lives. Housing, neighborhoods, schools, and the social opportunities that are linked to them are largely controlled by income; a family's income and employment status decide its access to health care services and strongly influence the quality of those services (National Research Council, 1993). Opportunities for advanced education and training and entry into the workforce are also closely linked to family income. Moreover, income is a powerful influence in shaping what is arguably the most important setting, the family. At this point in time, the evidence is clear—persistent poverty exacts a significant price on adolescents' health, development, educational attainment, and socioeconomic potential, even though the causal relationships are not well understood in all cases.

Not only is current research attempting to more fully characterize the physiological mechanisms responsible for initiating and regulating neuroendocrine maturation and somatic growth, but it is also attempting to characterize these environmental and contextual factors that may interact with biological ones to enhance or impede maturation. This research is attempting to address questions that could help to inform the development of policies and the delivery of services for youth. Such questions include: What is the pubertal experience like for teenagers today, and how does it differ from that in the past, both in the United States and in other cultures? How do pubertal experiences, in some circumstances and for some subgroups, trigger maladaptive responses? What role do pubertal processes play in cognitive change? How does puberty, in conjunction with other events that occur during early adolescence, influence the emergence of developmental psychopathology?

CHANGES IN THE STUDY OF ADOLESCENT DEVELOPMENT

Over the last two decades, the research base in the field of adolescent development has undergone a growth spurt. Knowledge has expanded sig-

nificantly. New studies have allowed more complex views of the multiple dimensions of adolescence, fresh insights into the process and timing of puberty, and new perspectives on the behaviors associated with the second decade of life. At the same time, the field's underlying theoretical assumptions have changed and matured.

Researchers of human development have consistently observed that the second decade of life is a time of dramatic change: a period of rapid physical growth, endocrine (hormone) changes, cognitive development and increasing analytic capability; emotional growth, a time of self-exploration and increasing independence, and active participation in a more complex social universe. For much of this century, scientists and scholars studying adolescence tended to assume that the changes associated with adolescence were almost entirely dictated by biological influences. It has been viewed as a time of storm and stress, best contained or passed through as quickly as possible. Adolescence , a 1904 book by G. Stanley Hall, typified this standpoint. It was Hall who popularized the notion that adolescence is inevitably a time of psychological and emotional turmoil (Hall, 1904). Half a century later, psychoanalytic writers including Anna Freud accepted and augmented Hall's emphasis on turmoil (Petersen, 1988). Even today, "raging hormones" continue to be a popular explanation for the lability, aggression, and sexual activity associated with adolescence (Litt, 1995). Intense conflict between adolescents and their parents is often considered an unavoidable consequence of adolescence (Petersen, 1988). However, this assumption is not supported by scientific evidence. The assumption that turmoil and conflict are inevitable consequences of the teenage years may even have prevented some adolescents from receiving the support and services they needed.

Research is now creating a more realistic view of adolescence. Adolescence continues to be seen as a period of time encompassing difficult developmental challenges, but there is wider recognition that biology is only one factor that affects young people's development, adjustment, and behavior. In fact, there is mounting evidence that parents, members of the community, service providers, and social institutions can both promote healthy development among adolescents and intervene effectively when problems arise.

The study of adolescence is now 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 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. This research has contributed the following to our understanding of adolescence:

The adolescent years need not be troubled years. There is now greater recognition that young people can move through the adolescent years without experiencing great trauma or getting into serious trouble; most young people do. Although adolescence can certainly be a challenging span of years, individuals negotiate it with varying degrees of difficulty, just as they do other periods of life. Moreover, when problems do arise during adolescence they should not be considered as "normal"—i.e., that the adolescent will grow out of it—nor should they be ignored (Petersen, 1988).

Only a segment of the adolescent population is at high risk for experiencing serious problems. Over the past 50 years, studies conducted in North America and Europe have documented that only about a quarter of the adolescent population is at high risk for, or more vulnerable to, a wide range of psychosocial problems (Carnegie Corporation of New York, 1995). These adolescents are not believed to be at increased risk because of biological or hormonal changes associated with puberty, but rather from a complex interaction among biological, environmental, and social factors. Indeed, as discussed by Anne Petersen, there is mounting evidence that most biological changes interact with a wide range of contextual, psychological, social, and environmental factors that affect behavior (Buchanan et al., 1992; Susman, 1997, see also Brooks-Gunn et al., 1994). Researchers are also concluding that behaviors associated with adolescence, including some high risk behaviors, are influenced by the social milieu (Brooks-Gunn and Reiter, 1990). Studies show that, in contrast to children and adults, the most common causes of mortality among adolescents are associated with social, environmental, and behavioral factors rather than genetic, congenital, or biological diseases. Indeed, many of today's adolescents are using alcohol and other drugs, engaging in unprotected sexual intercourse, and are both victims and perpetrators of violence, which puts them at increased risk for a wide range of developmental and health-related problems, including morbidity and mortality. It is important to note that the leading

causes of morbidity and mortality among adolescents are entirely preventable. Although relatively small, a significant number of adolescents also experience morbidity and mortality associated with genetic and congenital disorders (such as cystic fibrosis, muscular dystrophy, cerebral palsy), cancer, and infectious diseases that affect their development, behavior, and well-being.

Adolescent behavior is influenced by complex interactions between the biological and social contexts. 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 and social environments, and the interaction between these environments and adolescent behavior (Graber et al., 1997).

Current understanding of adolescent development remains limited. Although the study of adolescence is becoming more sophisticated in nature, researchers also recognize that the current knowledge base on adolescent development and behavior is quite limited. The research conducted to date has predominately been descriptive in nature, relied on cross-sectional data, and been unidimensional in focus. Indeed, few research studies have successfully considered the multiple factors that collectively influence adolescent development. As discussed by Iris Litt, there is now a growing appreciation 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.

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 re-

finement 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 (called 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).

An Increasing Number of Disciplines are Beginning to Conduct Research on Adolescent Development. Understanding adolescent development requires answers to a number of difficult questions: how do adolescents develop physically, how do their relationships with parents and friends change, how are young people as a group viewed and treated by society, how does adolescence in our society differ from adolescence in other cultures, and how has adolescence and adolescent development changed over the past few decades. A complete understanding of adolescence, and the potential to answer these questions depends on an integrated approach, and involvement of a wide range of disciplines, including but not limited to endocrinology, psychology, sociology, psychiatry, genetics, anthropology, neuroscience, history, and economics. While each discipline offers its own view point regarding adolescence and adolescent development, the field will not be able to successfully answer these questions without integrating the contributions of different disciplines into a coherent and comprehensive viewpoint. Fortunately, studies of puberty are increasingly drawing on and therefore benefiting from the knowledge base of these diverse fields.

KEY FINDINGS OF RECENT STUDIES

The workshop included a series of panel discussions that focused on adolescence as experienced by both human and nonhuman primates, including neuroendocrine physiology at puberty, the interplay between pubertal development and behavior, and implications for research, policy, and practice. Here we briefly summarize key findings from some of the studies that were discussed at the workshop (also see Crockett and Petersen, 1993; Grumbach and Styne, 1998; Pusey, 1990; Suomi, 1997;1991). As previously noted, this summary is not intended to provide a comprehensive review of the new research in this field; rather, it highlights important new findings that emerged during the workshop presentations and discussions.

In the United States, the Onset of Puberty Occurs Earlier than was Previously Recognized. Over the last 150 years, girls' sexual maturation, as measured by the age of menarche, is occurring at younger ages in all developed countries by at least two to three years. In the mid-nineteenth century, the average age at which girls reached menarche was approximately 15. The trend toward earlier menarche is now being documented in developing countries as well. Improved diets and more effective public health measures are the reasons often cited for this trend (Garn, 1992).

Research conducted during the 1990s greatly enhanced researchers' understanding of the age of puberty among girls. For example, although the onset of menarche is still considered to be a significant indicator of the tempo of maturation, researchers now view menarche as a late event in the pubertal process. At the workshop, Frank Biro presented data from the Growth and Health Study funded by the National Heart, Lung, and Blood Institute. This longitudinal study enrolled a cohort of over 2,000 girls, ages 9 to 10 years in 1987–1988; approximately half of the sample was white and half was black; the sample was recruited from clinics at three clinical centers located in Richmond, California, Cincinnati, Ohio, and metropolitan Washington, D.C. According to the study design, girls' maturation stage and body mass index were assessed annually; data for other variables, such as household income, nutrition, physical activity, cardiovascular risk factors, self-esteem and self-perception, and other psychosocial measures, were collected biennially (Brown et al., 1998). Almost half of the participants had begun puberty before the onset of the study. According to Biro, indicators of pubertal growth have been observed as early as age 7. These findings suggest that as children experience puberty and other develop-

mental changes at earlier ages, there may be the need to consider how to design and deliver age-appropriate interventions during the middle childhood and preteen years, to help them avoid harmful or risky behaviors and develop a health-promoting lifestyle.

There is Significant Variation Among Individuals in the Timing of Puberty. There is variation in both the onset and the tempo of puberty. Research shows that the timing of puberty can affect other aspects of development, especially for girls. Jeanne Brooks-Gunn discussed the findings from a recent study, which recruited a community sample of nearly 2,000 high school students from urban and rural areas of western Oregon. The study found that early-maturing girls and late-maturing boys showed more evidence of adjustment problems than other adolescents (Graber et al., 1997).

Multiple Factors Affect the Age of Puberty. Research now suggests that the timing of puberty can be affected by a wide range of factors, including genetic and biological influences, stress and stressful life events, socioeconomic status, environmental toxins, nutrition and diet, exercise, amount of fat and body weight, and the presence of a chronic illness. Research also shows that the family, the peer group, the neighborhood, the school, the workplace, and the broader society have all been shown to influence adolescent developmental outcomes, although it is less clear if these factors influence pubertal development. With respect to school settings, research suggests that the transition from small elementary schools to larger, more anonymous middle schools can be a stressful event in the lives of children (National Research Council, 1993). Some of the stressful influences or events factors mentioned above have been correlated with pubertal timing, but a causal relationship cannot be assumed.

Stress does not Trigger Puberty, But it does Modulate the Timing of Puberty. In her remarks at the workshop, Elizabeth Susman took note of research correlating stress and the timing of puberty. 1 A review of this literature shows that researchers observe different effects of stress at differ-

ent stages of puberty (Susman et al., 1989). For example, stress appears to delay maturation for young adolescents but to precipitate puberty for older adolescents. According to Susman, it makes sense that stress would delay maturation because stress hormones tend to suppress reproductive hormones (Susman, 1997; Graber and Warren, 1992). She added that her research has not yet resolved the question of directionality: Do environmental stressors affect the reproductive hormones, or does the rate of maturation affect the level of circulating stress hormones? Other participants at the meeting noted that social factors influence this process as well. For example, family conflict appears to be associated with earlier menarche in girls (Graber et al., 1995).

There is some Evidence that, on Average, Girls experience more distress during adolescence than boys. Some researchers have speculated that, for girls, the transition during puberty brings about greater vulnerability to other environmental stressors (Ge et al., 1995). In particular, a growing literature suggests that the early onset of puberty can have an adverse effect on girls' development (Caspi et al., 1993; Ge et al., 1996). It can affect their physical development (they tend to be shorter and heavier), their behavior (they have higher rates of conduct disorders); and emotional development (they tend to have lower self-esteem and higher rates of depression, eating disorders, and suicide). The youngest, most mature children are those at greatest risk for delinquency.

Early-maturing boys also appear to have higher rates of delinquency (Graber et al., 1997; Rutter and Smith, 1995). Generally speaking, however, boys who mature early fare better than late bloomers. Because they are taller and more muscular than their age-mates, they may be more confident, more popular, and more successful both in the classroom and on the playing field. In contrast, late-maturing boys have a poorer self-image, poorer school performance, and lower educational aspirations and expectations (Dorn et al., 1988; Litt, 1995).

Girls from Ethnic Minority Groups may be Reaching Puberty Earlier than White Girls. Data presented at the workshop show that for black girls, the average age of menarche is 12.1 years, compared with 12.9 years for white girls (see Brown et al., 1998). Black girls also begin pubertal development earlier than their white peers do—by 15 months. Interestingly, even though they reach menarche earlier, tempo of the pubertal development is slower. Researchers have also found that self-esteem does not fol-

low the same developmental pattern in black and white girls. It appears that black girls' higher self-esteem may be rooted in cultural differences in attitudes toward physical appearance and obesity (Brown et al., 1998). In general, however, the factors that protect some girls and place others at risk are not well understood. It is important to note that these findings are preliminary in nature, and more research is need to further validate them, as well as determine if these differences apply to girls from other ethnic, and racial groups, such as Hispanics, American Indians, Asians, and Pacific Islanders.

Puberty may be a Better Predictor of Aggression and Problem Behaviors than Age. There is growing evidence to suggest that puberty rather than chronological age may signal the onset of delinquency and problem behaviors among some teenagers (Keenan and Shaw, 1997; Rutter et al., 1998). For example, early maturers—both mate and female—are more likely than other adolescents to report delinquency. Early-maturing females also appear to be at increased risk for victimization, especially sexual assault, and this may partially explain their greater likelihood of problem behaviors (Flannery et al., 1993; Raine et al., 1997). These findings suggest the need for interventions that are targeted to early-maturing adolescents who may be at increased risk for a wide range of behavior problems and associated poor developmental outcomes.

Physical Maturation Appears to have Little Correlation with Cognitive Development. Many developmental psychologists, most notably Jean Piaget, have documented an expanded capacity for abstract reasoning during adolescence. Today's adolescents are often capable of complex reasoning and moral judgment; their capacities frequently astonish parents and teachers. Indeed, IQ tests show an overall gain in cognitive capacities since the 1940s, when military personnel were tested in large numbers and achieved a median score of about 100. However, there appears to be little relationship between physical and cognitive maturation.

Researchers have tested the hypothesis that growth across the developmental spectrum—physical, cognitive, social, and emotional—proceeds on a similar timetable, and they have found little evidence to support this hypothesis. However, the research in this area is relatively weak, in part due to a lack of reliable, valid, easily administered instruments for assessing cognitive development (Litt, 1995). When cognitive development and capacities are not in sync with physical and sexual maturation, young people

are more vulnerable; this also creates special challenges for designing and delivering age appropriate clinical interventions and services. Adults will often assume that adolescents who look older have a better grasp of the consequences of their actions.

Brain Development Appears to Continue During Adolescence. One of most remarkable findings in neurobiology over the last decade is the extent of change that can occur in the brain, even in the adult brain, as a function of the physical, social, and intellectual environment.

Starting in infancy and continuing into later childhood, there is a period of exuberant synapse growth followed by a period of synaptic ''pruning" which is largely completed by puberty. Although, neuroscientists have documented the time line of this synaptic waxing and waning, they are less sure about what it means for changes in childrens' and adolescents' cognitive development, behavior, intelligence, and capacity to learn. Generally, they point to correlations between changes in synaptic density or numbers and observed changes in behavior based on developmental and cognitive psychology. In coming decades, research tools such as positron emission tomography (PET) scans and functional magnetic resonance imaging (MRI) scans should greatly expand researchers' knowledge about adolescent brain development. In particular, functional imaging, if repeated over time, carries the potential for providing a better understanding of the functional connections between brain development and psychological performance (including cognitive development). New insights into brain development may also shed light on some psychopathologies and learning disabilities that affect preteens and adolescents, such as attention deficit/ hyperactivity disorder (ADHD), depressive disorders, and schizophrenia.

Researchers are Also Providing New Insights into the Relationship Between Gender, Hormones, Brain Development, and Behavior. In terms of the onset of puberty, boys generally follow girls by two years. For example, boys typically reach their maximum height velocity two years later than girls. In the realm of neuroscience, there is new evidence of divergent patterns of male and female brain development; these patterns have been observed between the ages of 5 and 7. Case in point: during this period, the amygdala (a part of the limbic system concerned with the expression and regulation of emotion and motivation) increases robustly in males, but not in females; the hippocampus (a part of the limbic system that plays an important role in organizing memories) increases robustly in females, but

not in males. The basal ganglia are larger in females; this appears to be significant, since boys are more likely to have disorders, such as ADHD, that are associated with smaller basal ganglia. Girls may have extra protection against this type of disorder. Although there are clear differences in the path of brain development for girls and boys, it is not yet possible to look at a brain scan and determine whether the subject is male or female.

Pregnancy During Adolescence may Alter the Physiological Development of Girls. During pregnancy, young women at different points in pubertal development show comparable hormone profiles. Pregnancy in very young women may compromise their skeletal growth, preventing them from reaching maximum bone mass. Frank Biro noted that his research team, which followed several hundred adolescent pregnancies, found that, after giving birth, adolescent mothers were on average significantly heavier (by approximately 10 pounds) and fatter (having thicker skin folds) than their counterparts who had not given birth.

RESEARCH CHALLENGES

The final session of the workshop focused on a broad view of the field of puberty and adolescent development, considering the implications of recent advances for the future of research, as well as its effects on current policies and practices. Summarizing the comments made by workshop participants, we outline below a number of challenges that researchers now face in moving this area of inquiry to its next stage of development. Gaps within the current knowledge base of adolescent development that require further research as identified by the presenters are also summarized.

Adolescence Should be Recognized as a Credible Area of Scientific Inquiry. Numerous workshop participants emphasized the need to build the capacity of the field of adolescent research with new funding for longitudinal research and incentives for providing professional training and conducting interdisciplinary research.

The many studies showing that adolescence is not necessarily a time of storm and stress (Elkind, 1992; Hamburg, 1992) represent a significant shift in perspective. However, there has been relatively little research on the affective and attitudinal characteristics often associated with the adolescent period—elation, thrill seeking, excitement, moodiness, shifts in energy, irritability, restlessness. Only recently have studies linked negative emotional

or affective states to the hormonal changes of puberty, particularly in normal children (Buchanan et al., 1992).

Advancing the field's understanding of adolescence requires a focus on research and on the policies that are ideally informed by this research. Existing theoretical models should be expanded to take advantage of advances in the biomedical sciences. As workshop participant Elizabeth Susman observed, "Further integration of physiological processes into models of adolescent development will enable scientists to construct more holistic, integrative models than currently are available" (Susman, 1997).

Research is Needed to Explore the Relationship Among Various Aspects of Pubertal Growth by Creating and Applying more Complex Modeling Procedures. Until quite recently, models of adolescent development tended to be unidirectional, allowing researchers to track either behavior or hormones. Some progress was then made in developing bidirectional analyses, showing the interaction between behavior and hormones. Only recently have investigators looked seriously at physical and social factors that may influence adolescent development. Consequently, existing models do not afford the opportunity to take more than a snapshot of adolescence or, at best, to conduct longitudinal studies that follow the trajectory of one or another variable. Advances in the understanding of adolescence therefore hinge on the development of more complex, multidimensional theoretical and statistical models—i.e., a "global weather map" of puberty. An interdisciplinary effort is needed to develop such models.

Research is Needed to Further Study the Age of Onset of Menarche and Differences Among Girls of Different Racial and Ethnic Groups. According to some researchers, "maturational timing appears to be the same across ethnic groups, provided nutrition is adequate" (Brooks-Gunn and Reiter, 1990). As they acknowledge, however, this assertion is controversial within the field, and many questions remain.

In light of research that suggests that black girls reach menarche earlier than white girls, which factors contribute to the early onset of puberty for black girls? Can we assume that the reasons for differences in the timing of menarche are the same today as they were in the 1960s? If, as discussed earlier, black girls begin puberty approximately 15 months before their white counterparts, but they arrive at menarche only 8 months earlier, what accounts for their slower tempo of pubertal development? What is the relationship between body weight and age of puberty for black and white

girls? Do girls who are heavier have a slower tempo of pubertal development? How important are different cultural attitudes toward body image? What insights might cross-cultural studies provide?

Although much of the current research focuses on the different course of puberty among black and white girls, clearly there is a need for additional research to characterize differences in the timing of puberty and menarche (and outcomes associated with these differences) in an increasingly racially and ethnically diverse adolescent population in the United States. This research must go beyond black-white comparisons to other racial and ethnic groups, such as Hispanics, American Indians, and Asians and Pacific Islanders. Moreover, given the heterogeneity that exists within these groups, within-group comparisons are also needed—e.g., comparisons of African Americans, Nigerians, and Caribbean blacks within black populations; Cubans, Puerto Ricans, Central Americans, and Mexicans within Hispanic populations; and Chinese, Japanese, and Vietnamese within Asian populations. How do genetic and cultural factors affect the timing of pubertal development and the timing of menarche? An anthropologist taking part in the workshop noted that, among the Lumi people of New Guinea, the average age of menarche is significantly later than it is in the United States and other developed countries.

Research is Needed to Investigate the Relationship Between Adrenarche and Puberty. Puberty is now considered to be one event along a continuum of development. It is preceded by adrenarche (the reinitiating of adrenal androgen secretion), which begins about two years before what has traditionally been considered the onset of puberty. Heredity appears to play a major role in determining the onset of adrenarche as well as puberty. Adrenarche is still poorly understood; its function is not entirely clear. Researchers initially thought that adrenarche causes a prepubertal growth spurt between the ages of 5 and 7, but it is difficult to attribute this "blip" to adrenarche, since adrenal androgen secretion continues while growth drops back to its former rate. Are there cross-cultural and cross-national differences with respect to the onset of adrenarche? If so, why?

Research is Needed to Explore Further the Relationship Between Sex Steroids and Behavior. It is commonly thought that pubertal change affects moods and behavior, but the evidence is mixed (Richards and Larson, 1993). Despite decades of speculation, the effects of sex steroids, in particular on moods and behavior, during adolescence remain unclear. What

is the relationship between the adrenal and gonadal systems (or HPA and HPG systems) and their influence on mood and behavior? Many researchers are looking at these relationships, but more research is needed. Reliable and valid measures that will permit examinations with greater specificity are needed to determine how the pubertal rise in hormone concentrations affects cognition, as well as its effect on problem behaviors, such as aggression.

Research is Needed to Study Vulnerability and Resiliency Across the Spectrum of Child and Adolescent Development. Why are some preteens and adolescents more or less vulnerable or resilient given comparable life events and contexts in which they are growing and developing? Are biological systems more or less sensitive to life events and contexts at certain points in time? If so, do genetic influences predispose some youth to be more or less vulnerable, or conversely, more or less resilient? For example, if an adolescent girl develops an eating disorder, does her life trajectory in general, and the biological impact of the disease in particular, depend on the point in her development when it occurs?

Research is Needed to Study the Factors that Promote or Impede Cognitive Development in Adolescence. The field would benefit from a more complex model of adolescent cognitive development. Why does cognitive development proceed on a different timetable than physical and sexual maturation? Researchers focusing on puberty have not detected the effects of steroids on cognitive functioning, but, in menopause, estrogen therapy demonstrably affects cognitive functioning. What accounts for this discrepancy? How is the architecture of the brain related to adolescent cognitive development? Will functional MRI studies enhance knowledge in this area? Moreover, we need to better understand the decision-making processes of adolescents and the factors that motivate them to engage in high risk versus health promoting behaviors.

Research is Needed to Expand the Field's Understanding of the Effects of Stress—both Negative and Positive Forms of Stress—on Adolescent Development. Researchers have just recently begun to establish a connection between stress and the timing of pubertal maturation. New research is needed to identify adverse environmental conditions (such as those associated with poverty) that may affect the long-term suppression or stimula-

tion of endocrine processes that, in turn, may affect normal growth and psychological development (Susman, 1997).

Research is Needed to Further Clarify Developmental Differences According to Gender. Why do girls reach puberty before boys? What are the implications with respect to health promotion and the prevention of risky behaviors? What are the implications of gender differences in brain development?

Research is Needed to Address Key Issues in Adolescent Development in Light of Advances in Genetics. Adolescence is a time when a whole set of genetic influences become more important while another set of genetic factors, which were apparent in early life, become less important. For example, there is clear evidence for a genetic predisposition to schizophrenia, and the onset of schizophrenia typically occurs during the later adolescent years. What interaction between the host and environment signals the onset of schizophrenia during adolescence? Can we with greater specificity account for how and when these as well as other genetic "signals" are turned on or off during childhood as well as adolescence? How are new genetic mechanisms brought into play? What are the factors, both genetic and nongenetic, that can influence the expression of specific genes during adolescence? Increasing knowledge about the interaction of multiple genes, the environment, and behavior will someday help to inform the development of new strategies to promote the healthy development of both children and adolescents.

In summary, as discussed at the workshop, there are a number of challenges for conducting research in this area, as well as clear opportunities for advancing the knowledge base regarding adolescent development, health, behavior, and well-being. The next generation of research studies needs to be interdisciplinary in nature; to integrate cross-sectional and longitudinal research methods with more sophisticated modeling techniques to examine the interrelationship among genetic, biological, social, and environmental influences and their unique and shared contribution to adolescent development; and to be couched within a broader developmental framework.

POLICY CHALLENGES

In discussing the state of research on puberty and adolescent development, workshop participants turned to issues related to policy and practice.

Summarizing their remarks, we outline below some opportunities to inform policy and practice through scientific research.

The Gap Among Research, Policy, and Practice Needs to be Narrowed. As in many other fields of science, in the field of adolescent development more knowledge is available than is put to use. Although there is much more still to learn, the knowledge base is already sufficient to allow reconsideration of many policies now. The communication of research findings to policy makers, service providers, educators, parents, and young people may help them develop more effective strategies for addressing the opportunities and challenges of adolescence, including helping adolescents to learn how to form close, durable human relationships; feel a sense of worth as a person; express constructive curiosity and exploratory behavior; know how to use the support systems available to them; succeed at school; and acquire the technical and analytic capabilities to participate in a world-class economy (Carnegie Corporation of New York, 1995). In particular, parents, educators, health providers, and human service providers need to have a greater awareness that puberty begins earlier than most people imagine (especially for girls), that early-maturing girls may be at higher risk for depression and problem behaviors, that many factors affect the timing and course of pubertal development, and that physical or sexual maturation is most likely on a different schedule than cognitive development. Finally, individuals or groups that make decisions about important legal and social questions need access to such information so they can make the kinds of decisions that protect the health and well-being of youth. For example, research findings should be used to undergird policies and regulations regarding when it is appropriate for adolescents to be treated as adults—by courts, health agencies, sex education programs, and schools.

Research Needs to be Applied to Promote Positive Developmental Outcomes. Studies of the timing of puberty suggest that preventive efforts need to start earlier—particularly interventions designed to prevent problem behaviors, such as violence. Research findings can help policy makers determine when particular interventions are most likely to be effective, and for whom. One workshop participant pointed out that, too often, conduct disorders are not identified until a child reaches adolescence. As the knowledge base expands, it may become more possible to recognize, in advance of puberty, which children are at risk for such disorders and to provide anticipatory guidance. Research can also point to subpopulations (such as chil-

dren born to adolescent mothers) that may be more likely to encounter problems in adolescence (Hardy et al., 1997; Graber and Brooks-Gunn, 1999). A key challenge is to track and anticipate different patterns of maturation before they actually occur and to encourage parents, teachers, health care providers, and other key players to provide primary prevention intervention.

The Focus Needs to Shift to One That Embraces Both Prevention and Health Promotion. A shift in emphasis is needed from simply preventing problems to actively promoting a wide range of healthful behaviors. Policy makers and practitioners need the kind of information that will help them promote healthy development, including information about what is happening at various stages of adolescence; how hormonal changes interact with contextual factors and how they affect sexual arousal; and the risk factors affecting early, middle, and late maturers. For example, preventing unwanted pregnancy and infection with STDs is an urgent concern for all those who raise adolescents or who work with them. Some ethnic or cultural groups look favorably on early marriage and childbirth and, within these groups, young mothers and their children tend to fare well. However, across the United States, most teenage pregnancies are unplanned and unwanted. Fortunately, the nation has made some progress in reducing rates of unintended pregnancies among teenagers in recent years (Institute of Medicine, 1995). After reaching 117 pregnancies per 1000 females ages 15–19 in 1990, the pregnancy rate has fallen a total of 17 percent between 1990 and 1996 to 97 births per 1000 females ages 15–19; these pregnancy data include births, abortions, and miscarriages (Henshaw, 1998). Despite these improvements, these rates remain high thus warranting further attention. Research shows that other nations are doing much better at ensuring the health and well-being of adolescents and helping them avert unwanted pregnancies. Young people in other countries have similar patterns of sexual activity; however, they have access to better information and supports, including sex education and contraception.

Resources Need to be Invested in an Effort to Promote Sound Decision Making Among Adolescents. Adolescents are capable of impressive intellectual feats, but research shows that studies of cognitive capacity in artificial settings (such as laboratories and classrooms) may overestimate what adolescents are able to do in real life, in which stress and time pressure are often intense (Petersen and Leffert, in press). Moreover, a wide range of

factors, such as social coercion and the use of alcohol and other drugs may influence and compromise adolescents' ability to accurately process information to make well-informed choices. For this reason, it is often useful to distinguish between the kind of "cold cognition" described by cognitive scientists—formal operations, the capacity for abstract thought—and "hot cognition"—the capacity to reason and make multiple decisions under conditions of high anxiety and stress. Too little is known about hot cognition. It is clear, however, that adolescents need more help in coping with the kinds of situations in which competent decision making is essential.

Cross-cultural studies raise key questions. What insights can be drawn from studies of other countries, in which youth are engaging in fewer high risk behaviors? Are adolescents in the United States engaging in risky behaviors because they have had too few opportunities to learn how to avoid them and make good decisions? Is there a need for more and better models of responsible adult decision making, both in their communities and in the media? Many other cultures expect youth to take on adult roles earlier, and they lay the groundwork for adult decision making. What kind of policies or programs will strengthen adolescents' capacity for sound decision making? What are the mechanisms underlying changes in cognitive capacities, leading toward adult intellectual functioning? What kinds of experiences and tools can be provided to adolescents that will help them learn to make good decisions? What kinds of settings and experiences will further their moral development?

Cultural Diversity must be Taken into Account when Studying Adolescence and Planning Interventions. In efforts to understand adolescence and promote good outcomes for young people and their families, the importance of cultural context cannot be overstated. The same conditions or circumstances may pose different risks and challenges for different groups. For example, different cultures have different attitudes toward sexual precocity and sexual behavior, including early pregnancy and childrearing. Early puberty poses fewer problems for girls in cultures whose adult women tend to support early maturation; for example, there is limited research suggesting that black girls cope better with early maturation than their white peers. Clearly this research needs to be further replicated, conducted with both girls and boys, and conducted with a diverse group of teens—i.e., with teenagers from a variety of racial and ethnic groups.

These findings have important implications for professionals who work

with adolescents and their parents. Not every early-maturing girl is at high risk. Moreover, research shows that adolescents growing up in different contexts may have different views of their own development. White girls may be more likely than black or Hispanic girls to value a thin body type; they are more likely to restrict their diets and to smoke, affecting their pubertal development. Studies also indicate that young people from different ethnic or cultural groups tend to have different estimations of their own physical and sexual maturity, regardless of the objective evidence.

Adolescents should be Included in Efforts Intended to Improve Outcomes for Them and Their Families. Given access to good schools, access to preventive information, needed services, and strong social supports, young people can control their own behavior through effective cognitive, self-regulatory, and self-management techniques. They can learn to respond to stressful life events and the unpredictable nature of day-to-day life as experienced by most adolescents and adults. They can also serve as positive role models within their schools and communities and encourage their peers to engage in health promoting behaviors.

In summary, as discussed at the workshop, there are a number of opportunities to inform policy through research. Specifically, participants discussed the need to construct policies and design programs that focus on both prevention and health promotion; that seek to promote positive developmental outcomes (not just the absence of problems); that engage adolescents as young adults (rather than talking down to them as if they were children). Moreover, in light of the growing diversity in the adolescent population, policies must ensure that health care and social services are delivered in a culturally relevant and sensitive manner.

IMPROVING PUBLIC UNDERSTANDING

In the course of the workshop discussions, participants identified a number of important findings from research that should be communicated to increase the public's understanding of the reality of adolescence. Summarizing the comments of workshop participants, we lay out below some of the most important messages that can be communicated to parents, teachers, health care providers, and others who live and work with adolescents.

Sexually Transmitted Diseases and other Health Problems Pose a Major Threat to Adolescents. It is clear, from nearly three decades of research, that adolescents are at high risk for infection with STDs, including HIV; rates of infection with STDs are higher among adolescents and young adults than any other age group, and incidence rates of HIV infection remain alarmingly high among teenagers (Institute of Medicine, 1995). All adolescents require the knowledge and skills needed to protect themselves from STDs, HIV, and unintended pregnancy. There remains the need to deliver effective prevention and health promotion interventions to all adolescents, to ensure that they have long, productive, and healthy lives. The public can play a very important role to ensure the health, safety, security, and wellbeing of adolescents. For example, health providers and educators can and should provide adolescents with the knowledge and skills they require to protect themselves from a wide range of public health problems, including STDs, HIV, alcohol and other drug abuse, and violence. Parents can also play an important role by encouraging and facilitating meaningful discussions with their teenagers in an effort to provide them with needed information and skills, as well as to provide them with the opportunity to explore their own values and beliefs. Finally, the media can play a very important role by reinforcing prevention and health promotion messages.

Children Need Health Monitoring and Care During the Elementary and Middle School Years. Puberty begins earlier than most parents and many health professionals realize. And yet, many 5- to 11-year-olds are rarely seen in doctors' offices or health centers unless they have an acute health care need or a serious medical problem. Once the well-baby visits of infancy and toddlerhood are over and a full round of immunizations has been completed, most parents seldom take their children to the doctor. As a result, parents lack the kind of information and guidance they need to help them fully understand and appreciate the developmental changes experienced by the prepubescent child. Some problems that could be addressed in middle childhood (including growth problems and behavioral issues) may go unrecognized or untreated until a later age. Clearly, health care providers, health care institutions, community-based organizations, and other social service agencies can play a very important role by educating parents that their children in the middle childhood, preadolescent, and adolescent years require access to health care and preventive services. Health care delivery systems also need to consider revising their standards of care

and recommendations about needed health care services during the middle childhood and preadolescent years.

Middle childhood is also a good time to address or prevent obesity and eating disorders, such as anorexia and bulimia. Most obese adolescents do not become obese adults, but about 15 percent (well over the chance level) do become obese (Garn, 1992). This statistic merits attention in view of the long-term risks associated with obesity in adolescence, including cardiovascular disease and Type II diabetes. Parents, health professionals, and teachers can introduce or reinforce the importance of regular exercise and a good diet. Neither is sufficient alone for staying healthy throughout the life span; they must be considered together. Again, health care providers, social agencies, educators, and community-based programs can and should be playing an active role to ensure that adolescents know what constitutes a healthful diet and are encouraged to eat well-balanced meals and exercise regularly. They are also often in a unique position to identify children and adolescents who are at high risk for developing an eating disorder before they develop such problems and to ensure that children and adolescents who do have an eating disorder know how to get help.

Storm and Stress are not Inevitable in Adolescence. The developmental milestones of adolescence have often been viewed in terms of pathology, yet decades of research would suggest otherwise. It is important to communicate clearly that adolescence does not inevitably bring on years of storm and stress for young people or their families. A classic epidemiological study of the mental health status of adolescents conducted in Great Britain by Michael Rutter and his colleagues found that half reported sadness or ''misery" on questionnaires, but less than 15 percent of boys or girls were found to be depressed—that is, to have impaired functioning or true mood disturbance—based on in-depth interviews (Rutter et al., 1976).

When Psychological Difficulties Do Occur in Adolescence, They are not Necessarily Outgrown Later. At the same time, there has been a growing recognition from the past decade of research that psychological difficulties during adolescence need and deserve attention from parents and professionals. When adults overlook these problems, assuming that they are an inevitable part of adolescence and will be outgrown, they may be placing young people at risk; there is evidence that difficulties experienced in adolescence often continue into adulthood (Petersen, 1988). Will and com-

mitment on the part of society are needed to screen for and respond to mental health problems experienced by adolescents to ensure that they do not become chronic and debilitating problems in adulthood.

Biology is not Destiny. Although it gives definition to various aspects of development, biology alone does not determine outcomes (positive or negative) for young people. The modern perspective is that behavioral factors also modulate biological systems. It is widely recognized that many factors—including some that parents can influence—affect the course of adolescent development. Genetic differences among individuals and groups are usually influenced by social and cultural contexts. For example, differences in the timing of puberty for black and white girls may relate only partially to genetic factors; nutrition, socioeconomic conditions, and other factors have been shown to influence pubertal development.

Families Matter. Humans are a social species. The regulation of children's biological systems, and their resilience when confronted with day-to-day stress, depend heavily on their interactions with important adults. This is true for adolescents as well as for younger children. Parents need to stay actively involved as their children move through the second decade. And although adolescents need and deserve privacy in some areas of their lives, stable, supportive relationships with parents and other family members are essential to their development, health, and well-being.

Civic Engagement should be Encouraged Among Adolescents. During the past two decades, there has been a growing literature that suggests that as much as 40 percent of young adolescents' time is unstructured, unsupervised, and consequently unproductive; much of this time occurs during the after-school hours when adolescents are frequently alone, watching television. Quite often, there are few after-school activities that provide young people with the opportunity to explore the community, put lessons learned in school and home to practical use, meet peers and adults other than classmates and teachers, and begin to transition to young adulthood (Carnegie Corporation of New York, 1995). Moreover, there are few links between schools and the workforce. Research shows that many factors influence adolescent development. Social institutions, such as schools, the health care delivery system, faith institutions, and community organizations, play an important role in supporting the healthy and productive development

of adolescents. In this regard, adults appear to be missing important opportunities to influence young people's lives. In particular, research suggests, community context influences the developmental processes that can promote positive developmental outcomes among adolescents and discourage them from engaging in problem behaviors, such as substance abuse, precocious sexual activity, and delinquency (National Research Council, 1993, 1996; Petersen et al., 1991).

Other than infancy, no stage in human development results in such rapid or dramatic change than adolescence. During adolescence, a child matures into an adult physically. Within a matter of four to five years, the average child grows nearly a foot taller, assuming adult size, shape, and reproductive status. How can such enormous changes take place during such a compressed period? How does the body initiate, regulate, and time these changes? How do these changes affect behavior, and vice versa? Today, we are in a better position to answer these questions than ever before. Breakthroughs in science and technology have sparked an explosion of new knowledge about the developmental changes that occur during adolescence. Advances in neuroendocrinology and brain imaging are beginning to produce important insights into pubertal growth and adolescent development.

While focusing on the biological mechanisms that underlie adolescent development, workshop participants repeatedly sounded this theme: social ecology is crucial. Physical development is influenced by a broad spectrum of environmental, social, and cultural factors, and both experience and heredity affect the timing of puberty. The evidence for this dual influence is growing rapidly.

The study of adolescence in general, and puberty in particular, is challenging as a result of their complexity. A multitude of factors interact, affecting the timing and trajectory of development in the second decade of life. Which factors interact under which circumstances? Which factors are driving forces in adolescent development, and which have more marginal roles? What is the relationship between the timing of puberty and the progression of hormonal changes? These are some of the issues that will require further investigation as the field of adolescent development itself comes of age.

Adolescence is one of the most fascinating and complex transitions in the human life span. Its breathtaking pace of growth and change is second only to that of infancy. Over the last two decades, the research base in the field of adolescence has had its own growth spurt. New studies have provided fresh insights while theoretical assumptions have changed and matured. This summary of an important 1998 workshop reviews key findings and addresses the most pressing research challenges.

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Developing adolescents: A reference for professionals

Despite the negative portrayals that sometimes seem so prevalent—and the negative attitudes about adolescents that they support—the picture of adolescents today is largely a very positive one. Most adolescents in fact succeed in school, are attached to their families and their communities, and emerge from their teen years without experiencing serious problems such as substance abuse or involvement with violence. With all of the attention given to negative images of adolescents, however, the positive aspects of adolescents can be overlooked. Professionals can play an important role in shifting perceptions of adolescents to the positive. The truth is that adolescents, despite occasional or numerous protests, need adults and want them to be part of their lives, recognizing that they can nurture, teach, guide, and protect them on the journey to adulthood. Directing the courage and creativity of normal adolescents into healthy pursuits is part of what successfully counseling, teaching, or mentoring an adolescent is all about.

Much has been written, both in the lay press and the scientific literature, about adolescents’ mental health problems—such as depression, suicide, and drug abuse—and about the serious problems that some adolescents experience. The purpose of Developing Adolescents , however, is not to describe these problems or the therapeutic strategies to address them, but to address them in the context of adolescent development, with a focus on preventing these problems and enhancing positive outcomes even under adverse circumstances. Efforts are made to move to a new way of understanding and working with adolescents in the context of larger systems (Lerner & Galambos, 1998); although working with adolescents and families is critical, systemic change is sometimes needed to safeguard adolescent health. Also at the heart of Developing Adolescents is the theme that today’s adolescent needs one thing that adults seem to have the least surplus of—time. It takes time to listen and relate to an adolescent. In a report by the U.S. Council of Economic Advisers, teens rated “not having enough time together” with their parents as one of their top problems. This report also indicates that adolescents whose parents are more involved in their lives (as measured by the frequency of eating meals together regularly, a simple measure of parental involvement) have significantly lower rates of “problem behaviors” such as smoking, alcohol or marijuana use, lying to parents, fighting, initiation of sexual activity, and suicidal thoughts and attempts (U.S. Council of Economic Advisors, 2000).

A crosscutting theme, regardless of one’s professional role, is the need to communicate effectively with youth. Adolescents will not simply “open up” to adults on demand. Effective communication requires that an emotional bond form, however briefly, between the professional and the adolescent. Professionals must find a way to relate comfortably to adolescents, and be flexible enough to accommodate the wide range of adolescents they are likely to encounter. And, professionals must recognize that developing effective communication with the adolescents with whom they work requires effort on their part. It may take a number of sessions of nonjudgmental listening to establish the trust needed for a particular adolescent to share with an adult what he or she is thinking and feeling. It may take even longer before an adolescent feels comfortable asking an adult for help with an important decision. Discussing options for using birth control with a physician or telling a school psychologist or social worker that one is feeling depressed or sad generally requires both time and trust.

Professionals may find that the strategies they use to provide information and offer services to adults just don’t work as well with adolescents. Young people need adults who will listen to them—understand and appreciate their perspective—and then coach or motivate them to use information or services offered in the interest of their own health (Hamburg, 1997). Simply presenting information on the negative consequences of high-risk behaviors is not enough. Having an understanding of normal adolescent development can help professionals be effective communicators with young people.

Recognizing Diversity

It is critical that professionals educate themselves about the different cultural and ethnic groups with whom they work in order to provide competent services and to relate effectively one-on-one with adolescents. The population of adolescents in the United States is becoming increasingly racially and ethnically diverse, with 37% of adolescents ages 10 to 19 today being Hispanic or members of non-White racial groups (see table on page 5). This population diversity is projected to increase in the decades ahead.

A growing number of households in the United States include individuals who were born in other countries. Immigrants enter the United States for diverse reasons; some may be escaping a war-torn country, just as others are in the country to pursue an advanced education. They vary in their English proficiency and educational levels and in their cultural practices and beliefs. The number of foreign-born in the United States grew 44% between 1990 and the 2000. People born in other countries now constitute 10% of the U.S. population, the highest rate since the 1930 census (U.S. Census Bureau, 2002).5 Half of those from other countries are from Latin American countries—overall, about 15% of adolescents ages 10 to 19 are of Hispanic or Latino origin (U.S. Census Bureau, 2001a).

Unfortunately, many of the studies of adolescents reported in the scientific literature have looked only at White middle-class adolescents (Lerner & Galambos, 1998; Ohye and Daniel, 1999). Thus, research on most areas of normal adolescent development for minority youth is still lacking; so caution should be used in generalizing the more global findings reported here to all adolescents.

Organization of Developing Adolescents: A Reference for Professionals  

The physical changes that herald adolescence—the development of breasts and first menstrual periods for girls, the deepened voices and broadened shoulders for boys—are the most visible and striking markers of this stage. However, these physical changes represent just a fraction of the developmental processes that adolescents experience. Their developing brains bring new cognitive skills that enhance their ability to reason and to think abstractly. They develop emotionally, establishing a new sense of who they are and who they want to become. Their social development involves relating in new ways both to peers and adults. And, they begin to experiment with new behaviors as they transition from childhood to adulthood. In Developing Adolescents , we thus discuss adolescent development with reference to physical, cognitive, emotional, social, and behavioral development. Each section presents basic information about what is known about that aspect of adolescent development and suggests roles professionals can play to help support adolescents.

Of course, no adolescent can truly be understood in separate parts—an adolescent is a “package deal.” Change in one area of development typically leads to, or occurs in conjunction with, changes in other areas. Furthermore, no adolescent can be fully understood outside the context of his or her family, neighborhood, school, workplace, or community or without considering such factors as gender, race, sexual orientation, disability or chronic illness, and religious beliefs. Thus, these issues are also touched on throughout.

Developing Adolescents: A Reference for Professionals is not intended to solve all of the mysteries of relating to adolescents, but it will provide scientifically sound, up-to-date information on what is known about today’s youth. Hopefully, this will make it just a bit easier and more comfortable for professionals to relate to adolescents in the context of their particular professions.

Adolescent physical development

Entering puberty heralds the physical changes of adolescence: a growth spurt and sexual maturation. Professionals who work with adolescents need to know what is normative and what represents early or late physical development in order to help prepare the adolescent for the myriad changes that take place during this time of life. Even in schools where sex education is taught, many girls and boys still feel unprepared for the changes of puberty, suggesting that these important topics are not being dealt with in ways that are most useful to adolescents (Coleman & Hendry, 1999).

Puberty and sexual development

Although it sometimes seems that adolescents’ bodies change overnight, the process of sexual maturation actually occurs over a period of several years. The sequence of physical changes is largely predictable, but there is great variability in the age of onset of puberty and the pace at which changes occur (Kipke, 1999). There are numerous factors that affect the onset and progression of puberty, including genetic and biological influences, stressful life events, socioeconomic status, nutrition and diet, amount of body fat, and the presence of a chronic illness. The growth spurt, which involves rapid skeletal growth, usually begins at about ages 10 to 12 in girls and 12 to 14 in boys and is complete at around age 17 to 19 in girls and 20 in boys (Hofmann & Greydanus, 1997). For most adolescents, sexual maturation involves achieving fertility and the physical changes that support fertility. For girls, these changes involve breast budding, which may begin around age 10 or earlier, and menstruation, which typically begins at age 12 or 13.9 For boys, the onset of puberty involves enlargement of the testes at around age 11 or 12 and first ejaculation, which typically occurs between the ages of 12 and 14. The development of secondary sexual characteristics, such as body hair and (for boys) voice changes, occurs later in puberty.

Many adults may still believe that the magic age of 13 is the time to talk about puberty, but for many boys and girls, this is years too late. A recent study of 17,000 healthy girls ages 3 through 12 visiting pediatricians’ offices found that 6.7% of White girls and 27.2% of African American girls were showing some signs of puberty by age 7 (i.e., breast and/or pubic hair development) (Herman-Giddens et al., 1997; Kaplowitz and Oberfield, 1999). The findings of this study suggest that onset of puberty may be occurring about 1 year earlier in White girls and 2 years earlier in African American girls than had previously been thought. However, studies have not yet been completed on nonclinical samples to confirm that this is the case for girls in general. Relatively little research has examined differences in the course of puberty among different ethnic groups; this is clearly an area that deserves additional attention (Lerner & Galambos, 1998). Professionals who work with children and their families can alert parents to the need to prepare their children early for the changes of adolescence. Professionals can also offer helpful advice to parents and other adults about how to discuss puberty with younger adolescents.

Research findings suggest that adolescent girls who are unprepared for the physical and emotional changes of puberty may have the most difficulty with menstruation (Koff & Rierdan, 1995; Stubbs, Rierdan, & Koff, 1989). When 157 ninth grade girls were asked to suggest how younger girls should be prepared for menstruation, they recommended that mothers provide emotional support and assurance, emphasize the pragmatics of menstrual hygiene, and provide information about how it will actually feel, emphasizing positively their own first experiences with menstruation (Koff & Rierdan, 1995). The girls also recommended that fathers not comment on their daughters’ physical changes, and that mothers not discuss these changes with fathers in front of the adolescent, even when they become evident.

Although research on boys’ first experiences of sexual maturation is limited, some evidence suggests that boys, too, are more comfortable with the physical changes of adolescence when adults prepare them. For example, young adolescent boys who were not prepared for these changes have reported feeling “somewhat perplexed” upon experiencing their first ejaculations of semen during dreaming or masturbation (Stein & Reiser, 1994). The implication of these findings is that adolescents should be prepared for the upcoming changes early, at about 9 or 10 years of age, so they will not be caught off guard when the changes occur.

Early or late sexual development 

It is important for adults to be especially alert for signs of early and late physically maturing adolescents—particularly early maturing girls and late maturing boys—because these adolescents appear to be at increased risk for a number of problems, including depression (Graber, Lewinsohn, Seeley, & Brooks-Gunn, 1997; Perry, 2000). For example, early maturing girls have been found to be at higher risk for depression, substance abuse, disruptive behaviors, and eating disorders (Ge, Conger, & Elder, 2001; Graber et al., 1997; Striegel-Moore & Cachelin, 1999). Likewise, there is growing evidence that boys whose physical development is out of synch with their peers are at increased risk for problems. Early maturing boys have been found to be more likely to be involved in high-risk behaviors such as sexual activity, smoking, or delinquency (Flannery et al., 1993; Harrell, Bangdiwala, Deng, Webb, & Bradley, 1998). Although early physical maturation does not appear to pose as many problems for boys as it does for girls, late maturation seems to place boys at greater risk for depression, conflict with parents, and school problems (Graber et al., 1997). Because of their smaller stature, late maturing boys may also be at higher risk for being bullied (Pollack & Shuster, 2000).

Adults, including parents, may not be aware of the risks of early maturation for girls and be unprepared to help these adolescents deal with the emotional and social demands that may be placed on them (Graber et al., 1997). For example, older boys—and even adult men—may be attracted to early maturing girls at a time when the girls do not yet have the social maturity to handle these advances, placing them at risk for unwanted pregnancies and sexually transmitted diseases (Flannery, Rowe, & Gulley, 1993).

Professionals can talk openly with early maturing youth and their parents about the likelihood that they will confront peer pressure to engage in activities that they are not yet emotionally ready to handle, such as dating and sexual activity. For most teens, telling them to “just say no” does not help them to deal with sexually stressful interpersonal situations in which they are anxious to be liked. Instead, professionals can help the adolescent identify and practice strategies in advance for dealing with or avoiding these situations.

Parents may need guidance to understand that adolescent autonomy should be linked to the teen’s chronological age and social and emotional development, and not to the level of physical development, whether early, on time, or late. For example, 13-year-olds should be given earlier curfews and be more closely supervised than older teens, even if they physically appear to be much older. Likewise, an adolescent whose physical maturity is behind his or her peers may still be ready for increased independence.

Physical appearance and body image 

Regardless of the timing of the physical changes that take place during adolescence, this is a period in which physical appearance commonly assumes paramount importance. Both girls and boys are known to spend hours concerned about their appearance, particularly in order to “fit in” with the norms of the group with whom they most identify. At the same time, they wish to have their own unique style, and they may spend hours in the bathroom or in front of the mirror trying to achieve this goal.

Adults should take adolescents seriously when they express concerns about aspects of their appearance, such as acne, eyeglasses, weight, or facial features. If an adolescent is concerned, for example, that he is overweight, it is important to spend the time to listen, rather than dismissing the comment with the reassurance that “you look fine.” Perhaps a peer made a comment about his appearance at a time when he had been wondering about the same thing. Adults need to understand the meaning and context of the adolescent’s concern and to keep the lines of communication open. Otherwise, the adolescent may have a difficult time keeping the problem (and potential solutions) in perspective or be less likely to express concerns in the future.

Physical activity and weight 

Approximately 14% of adolescents aged 12 to 19 years are overweight—nearly 3 times as many as in 1980 (USDHHS, 2001). Overweight adolescents are at greater risk for type II diabetes, high blood lipids, and hypertension and have a 70% chance of becoming overweight or obese adults. In addition, they may suffer from social discrimination, particularly from their peers, which can contribute to feelings of depression or low self-esteem. Diseases directly related to lack of exercise, such as obesity and diabetes, have been reported to be more prevalent among ethnic minority teens (Ross, 2000). For example, type II diabetes is particularly prevalent among Native American and Alaska Native adolescents, and obesity is more frequent among African American teenage girls than among White teenage girls (Ross, 2000).

Several factors contribute to the increased prevalence of overweight among teens. One factor is that levels of physical activity tend to decline as adolescents get older. For example, a 1999 national survey found that over a third of 9th through 12th graders do not participate regularly in vigorous physical activity (USDHHS, 2000). Furthermore, enrollment in physical education drops from 79% in 9th grade to 37% in 12th grade; in fact some of the decline in activity is due to fewer opportunities to participate in physical education classes and to reduced activity time in physical education classes. Lastly, many teens do not have nutritionally sound diets: Three-quarters of adolescents eat fewer than the recommended servings of fruits and vegetables per day (MMWR, 2000).

Participation in sports, which has important direct health benefits, is one socially sanctioned arena in which adolescents’ physical energies can be positively channeled. Other activities in which physical energy can be channeled include dance, theatre, carpentry, cheerleading, hiking, skiing, skateboarding, and part-time jobs that involve physical demands. These activities provide adolescents with opportunities for getting exercise, making friends, gaining competence and confidence, learning about teamwork, taking risks, and building character and self-discipline (Boyd & Yin, 1996).

Despite the considerable rewards of sports and other extracurricular activities, many adolescents do not participate in them. Barriers to participation in organized sports activities include costs, lack of transportation, competing time commitments, competitive pressures in the sport, and lack of parental permission to participate (Hultsman, 1992). Other barriers can include lack of access to safe facilities, such as recreation centers or parks, particularly in inner city or rural areas. Some youth may also have other important obligations, such as working or caring for younger siblings, that prevent their participation. Youth with disabilities or special health needs may especially experience difficulty identifying recreational opportunities that accommodate their particular needs (Hergenroeder, 2002). Professionals should examine each of these impediments to determine how to overcome them to reduce barriers to participation.

Professionals can help adolescents and their parents understand the importance of physical activity and good nutrition for maintaining health and suggest healthy options. In doing so, it is important to keep in mind the family’s resources, such as the family’s ability to pay for organized athletic activities, and its cultural background, which may, for example, influence its diet.

Disordered eating

Puberty, by its very nature, is associated with weight gain, and many adolescents experience dissatisfaction with their changing bodies. In a culture that glorifies being thin, some adolescents—mostly girls—become overly preoccupied with their physical appearance and, in an effort to achieve or maintain a thin body, begin to diet obsessively. A minority of these adolescents eventually develops an eating disorder such as anorexia nervosa or bulimia (Archibald, Graber, & Brooks-Gunn, 1999; Striegel-Moore & Cachelin, 1999). The consequences of eating disorders are potentially very serious, resulting in death in the most extreme cases.

Between 0.5% and 1% of all females ages 12 to 18 in the United States are anorexic, and 1% to 3% are bulimic, with perhaps 20% engaging in less extreme but still unhealthy dieting behaviors (Dounchis, Hayden, Wilfley, 2001). Although boys can also have these eating disorders, the large majority are female (over 90%). Symptoms of eating disorders usually first become evident early in adolescence. Factors that appear to place girls at increased risk for anorexia or bulimia include low self-esteem, poor coping skills, childhood physical or sexual abuse, early sexual maturation, and perfectionism. Daughters of women with eating disorders are at particular risk for developing an eating disorder themselves (Striegel-Moore & Cachelin, 1999).

Information is limited about the prevalence of eating disorders among different ethnic groups, although there is some evidence to suggest that patterns of disordered eating differ. For example, dieting appears to occur most frequently in Hispanic females and least frequently in Black females, and binge eating may be more frequent in Black females (Dounchis et al., 2001). Although anorexia and bulimia appear to occur much more frequently in White girls as compared to ethnic minority girls, there is also evidence that the prevalence of eating disorders is more common than has been reported among ethnic minorities. Thus, it is important that professionals not assume that only White girls are at risk. Although much more research is needed (particularly with regard to ethnic minority adolescents), some strategies hypothesized to protect adolescents in general from developing an eating disorder or an obsession with weight include:

• Promoting the acceptance of a broad range of appearances
• Protecting adolescents from abusive experiences
• Promoting positive self-image and body image
• Educating adolescents and their families about the detrimental consequences of a negative focus on weight
• Promoting a positive focus on sources of self-esteem other than physical appearance, such as academic, artistic, or athletic accomplishments (Striegel-Moore & Cachelin, 1999).

Adolescent cognitive development

The changes in how adolescents think, reason, and understand can be even more dramatic than their obvious physical changes. From the concrete, black-and-white thinkers they appear to be one day, rather suddenly it seems, adolescents become able to think abstractly and in shades of gray. They are now able to analyze situations logically in terms of cause and effect and to entertain hypothetical situations and use symbols, such as in metaphors, imaginatively (Piaget, 1950). This higher-level thinking allows them to think about the future, evaluate alternatives, and set personal goals (Keating, 1990). Although there are marked individual differences in cognitive development among youth, these new capacities allow adolescents to engage in the kind of introspection and mature decision making that was previously beyond their cognitive capacity. Cognitive competence includes such things as the ability to reason effectively, problem solve, think abstractly and reflect, and plan for the future.

Although few significant differences have been identified in the cognitive development of adolescent boys and girls, it appears that adolescent boys and girls do differ in their confidence in certain cognitive abilities and skills. Adolescent girls tend to feel more confident about their reading and social skills than boys, and adolescent boys tend to feel more confident about their athletic and math skills (Eccles, Barber, Jozefowicz et al., 1999). This is true even though their abilities in these areas, as a group, are roughly the same (there are, of course, many individual differences within these groups). Conforming to gender stereotypes, rather than differences in ability per se, appears to be what accounts for these difference in confidence levels (Eccles et al., 1999). Adults can help to dispel these myths, which can lead adolescents to limit their choices or opportunities. For example, an adolescent girl might be encouraged to take advanced math or technology courses, and an adolescent boy to consider relationship-based volunteer opportunities such as mentoring—options that they might not otherwise consider.

Despite their rapidly developing capacity for higher-level thinking, most adolescents still need guidance from adults to develop their potential for rational decision making. Stereotypes to the contrary, adolescents prefer to confer with their parents or other trusted adults in making important decisions about such things as attending college, finding a job, or handling finances (Eccles, Midgley, Wigfield et al., 1993). Adults can use this openness as an opportunity to model effective decision making or to guide adolescents as they grapple with difficult decisions.

As adolescents develop their cognitive skills, however, some of their behaviors may be confusing to the adults who interact with them. These characteristics are normal, though, and should not be taken personally. In a later section on emotional development, practical strategies for communicating with adolescents will be discussed; these strategies will be helpful for fostering adolescents’ budding cognitive competencies.

Just as adults sometimes make poor decisions, so do adolescents. This can especially be a problem when poor decisions lead adolescents to engage in risky behaviors, such as use of alcohol or violence. Immature adolescents are especially likely to choose less responsible options. This level of maturity of judgment has been found to be more important than age in predicting whether an adolescent will make more responsible decisions (Fischoff, Crowell, & Kipke, 1999). It is important to understand that level of maturity of judgment may actually drop during the mid-teen years before increasing again into young adulthood.

There are a number of ways that adults can help adolescents to make better decisions. One is to help them expand their range of options so they can consider multiple choices (Fischoff et al., 1999). Because adolescents who make snap decisions are more likely to be involved in risky behaviors, adults can help adolescents to carefully weigh their options and consider consequences. Because adolescents can be more influenced by what they believe their peers are doing, thus increasing the social pressure they feel to engage in these activities, it can be helpful to provide them with more accurate objective information if it is available. Adults can help adolescents to understand how emotions—both positive and negative—can affect their thinking and behavior. Finally, it is important to understand that adolescents may fear potential negative social consequences of their choices more than they do possible health risks. For example, a teen may fear being ostracized from a social group or being made fun of if he or she refuses to drink alcohol at a party more than the potential negative consequences of consuming alcohol. Thus, it is important for adults to consider and understand the context in which adolescents make decisions about risk behaviors.

Even adolescents who are very skilled or talented in some areas may have weaknesses in others. For example, an adolescent who has trouble with learning mathematical concepts may excel on the basketball court or at learning a foreign language. Harvard University psychologist Howard Gardner has developed a theory of multiple intelligences, or ways of approaching problems and analyzing information that expands the traditional view of ability (Gardner, 1993). According to Gardner, these different pathways for learning—which everyone possesses and has developed to varying degrees—include verbal/linguistic, logical-mathematical, spatial, musical, bodily kinesthetic, intrapersonal, naturalist, and possibly existential intelligence (i.e., the capacity to tackle fundamental questions about human existence). Traditional approaches to learning have focused primarily on logical—mathematical and verbal/linguistic intelligence. Gardner suggests that the other forms of intelligence are just as important and that teaching and learning will be most successful when multiple intelligences are engaged. Consequently, adults can help adolescents develop their multiple intelligences and not just focus on problems or deficits.

Another theory of intelligence that focuses on multiple strengths has been proposed by Yale University psychologist Robert Sternberg, who posits that creativity and practical abilities (i.e., common sense), and not just the analytical abilities and memory skills measured by traditional intelligence tests, are important components of intelligence (Sternberg, 1996). In order to be successfully intelligent, it is not necessary to be equally high in each of these spheres. Rather, one must find ways to exploit effectively whatever pattern of abilities one has. For example, Sternberg found in one of his studies that when high school students taking a psychology course were placed in sections of the course that better matched their particular pattern of analytical, creative, and practical abilities, they outperformed students who were more poorly matched (Sternberg, Ferrari, Clinkenbeard, & Grigorenko, 1996). In other words, giving young people the opportunity to learn in ways that emphasize different types of abilities increases their chances of success.

Adults can foster the development of adolescents’ sense of competence. Although parents often feel that they have little influence during the teen years, research has found that feelings of competence in both adolescent boys and girls are directly linked to feeling emotionally close and accepted by parents (Ohannessian, Lerner, Lerner, & Eye, 1998). Professionals can educate parents about their role in fostering these competencies and in engendering feelings of competence in their children. Parents need to know just how influential they are in their adolescent’s life. Professionals can directly reinforce adolescents’ growing competencies by simply noticing and commenting on them during routine contacts. Even passing comments can mean a great deal to a young person, especially one who may be getting little in the way of positive feedback.

Moral development 

Moral development refers to the development of a sense of values and ethical behavior. Adolescents’ cognitive development, in part, lays the groundwork for moral reasoning, honesty, and prosocial behaviors such as helping, volunteerism, or caring for others (Eisenberg, Carlo, Murphy, & Van Court, 1995). Adults can help facilitate moral development in adolescents by modeling altruistic and caring behavior toward others and by helping youth take the perspective of others in conversations. For example, an adult might ask the adolescent, “How would you feel if you were _____?” Educators and other adults can ensure that issues involving fairness and morality are identified and discussed sensitively and in a positive atmosphere where adolescents are encouraged to express themselves, ask questions, clarify their values, and evaluate their reasoning (Eisenberg, Carlo, Murphy, & Van Court, 1995; Santilli & Hudson, 1992). This atmosphere should reinforce the concept that racism, sexism, homophobia, ageism, and biases against persons with disabilities are inherently destructive to both the individual and society.

Volunteering in the community is an important positive avenue for youth that can help promote their moral development. In addition to helping foster a sense of purpose and meaning and enhancing moral development, volunteering is associated with a number of positive long-term outcomes. For example, one national study of girls from 25 schools found that those who volunteered in their communities were significantly less likely to become pregnant or to fail academically than girls who did not volunteer (Allen, Philliber, Herrling, & Kuperminc, 1997). Professionals can help adolescents understand the value of volunteering and direct them toward valuable volunteer experiences.

Learning disabilities

Learning disabilities refer to disorders that affect the ability to interpret what one sees and hears or to link information from different parts of the brain (Neuwirth, 1993). Individuals with learning disabilities may have problems with reading, spoken language, writing, memorizing, arithmetic, or reasoning. Without careful assessment, some adolescents with learning disabilities may be seen as having behavior problems, and the cognitive problems underlying their behavioral problems may be overlooked and left untreated. Hormonal changes of adolescence and the increased demands of school can exacerbate learning disabilities that adolescents were able to manage or mask when they were younger. Once they reach middle and high school, adolescents with learning disabilities are at increased risk of school failure if their problems are not understood and addressed. In addition, problems with processing verbal information or poor reasoning skills can make it difficult for some adolescents with learning disabilities to form positive relationships with their peers.

Adolescents with learning disabilities reportedly experience severe emotional distress at rates 2 to 3 times higher than other adolescents, with girls being more likely to experience these problems than boys (Svetaz, Ireland, & Blum, 2000). Furthermore, youth with learning disabilities are significantly more likely than adolescents in the general population to report having attempted suicide in the past year or to have been involved in violence. They are at especially high risk for these negative outcomes if they are experiencing emotional distress. For adolescents with learning disabilities, feeling connected to family and school and having a religious identity are all factors found to be associated with lower risk for negative outcomes such as emotional distress, suicide attempts, and involvement in violence. Thus, families, schools, and other institutions have important roles to play in protecting these youth from negative outcomes (Svetaz et al., 2000). Because of the higher risk that adolescents with learning disabilities have for serious problems, professionals should monitor adolescents’ social and emotional functioning, paying particular attention to signs of anxiety and depression. Conversely, youth experiencing anxiety or depression who have not been identified as having a learning disability or emotional disorder should also be evaluated to rule out the presence of these problems.

Yes... it’s normal for adolescents to...

• Argue for the sake of arguing. Adolescents often go off on tangents, seeming to argue side issues for no apparent reason; this can be highly frustrating to many adults (Walker & Taylor, 1991). Keep in mind that, for adolescents, exercising their new reasoning capabilities can be exhilarating, and they need the opportunity to experiment with these new skills.
• Jump to conclusions. Adolescents, even with their newfound capacities for logical thinking, sometimes jump to startling conclusions (Jaffe, 1998). However, an adolescent may be taking a risk in staking out a position verbally, and what may seem brash may actually be bravado to cover his or her anxiety. Instead of correcting their reasoning, give adolescents the floor and simply listen. You build trust by being a good listener. Allow an adolescent to save face by not correcting or arguing with faulty logic at every turn. Try to find what is realistically positive in what is being said and reinforce that; you may someday find yourself enjoying the intellectual stimulation of the debates.
• Be self-centered (Jaffe, 1998). Adolescents can be very “me-centered.” It takes time to learn to take others’ perspectives into account; in fact, this is a skill that can be learned.
• Constantly find fault in the adult’s position (Bjorklund & Green, 1992). Adolescents’ newfound ability to think critically encourages them to look for discrepancies, contradictions, or exceptions in what adults (in particular) say. Sometimes they will be most openly questioning or critical of adults with whom they feel especially safe. This can be quite a change to adjust to, particularly if you take it personally or the youth idealized you in the past.
• Be overly dramatic (Jaffe, 1998). Everything seems to be a “big deal” to teens. For some adolescents, being overly dramatic or exaggerating their opinions and behaviors simply comes with the territory. Dramatic talk is usually best seen as a style of oration rather than an indicator of possible extreme action, unless an adolescent’s history indicates otherwise.

Adolescent emotional development

Emotional development during adolescence involves establishing a realistic and coherent sense of identity in the context of relating to others and learning to cope with stress and manage emotions (Santrock, 2001), processes that are life-long issues for most people. Identity refers to more than just how adolescents see themselves right now; it also includes what has been termed the “possible self”—what individuals might become and who they would like to become (Markus & Nurius, 1986). Establishing a sense of identity has traditionally been thought of as the central task of adolescence (Erikson, 1968), although it is now commonly accepted that identity formation neither begins nor ends during adolescence. Adolescence is the first time, however, when individuals have the cognitive capacity to consciously sort through who they are and what makes them unique.

Developing a sense of identity

Identity includes two concepts. First is self-concept: the set of beliefs one has about oneself. This includes beliefs about one’s attributes (e.g., tall, intelligent), roles and goals (e.g., occupation one wants to have when grown), and interests, values, and beliefs (e.g., religious, political). Second is self-esteem, which involves evaluating how one feels about one’s self-concept. “Global” self-esteem refers to how much we like or approve of our perceived selves as a whole. “Specific” self-esteem refers to how much we feel about certain parts of ourselves (e.g., as an athlete or student, how one looks, etc.). Self-esteem develops uniquely for each adolescent, and there are many different trajectories of self-esteem possible over the course of adolescence (Zimmerman, Copeland, Shope, & Dielman, 1997). Thus, self-esteem, whether high or low, may remain relatively stable during adolescence or may steadily improve or worsen.

Many of the factors already described in Developing Adolescents influence identity development and self-esteem during adolescence. For example, adolescents’ developing cognitive skills enable them to make abstract generalizations about the self (Keating, 1990). The physical changes they are experiencing can strongly influence, either positively or negatively, global self-esteem. This is particularly true in early adolescence when physical appearance tops the list of factors that determine global self-esteem, especially for girls (Harter, 1990a). Comments by others, particularly parents and peers, reflect appraisals of the individual that some adolescents may incorporate as part of their identity and feelings about themselves (Robinson, 1995).

The process by which an adolescent begins to achieve a realistic sense of identity also involves experimenting with different ways of appearing, sounding, and behaving. Each adolescent approaches these tasks in his or her own unique way. So, just as one adolescent will explore more in one domain (e.g., music), another will explore more in another (e.g., adopting a certain style or appearance). Professionals whose role involves advising parents or adolescents can assure them that most experimentation is a positive sign that adolescents feel secure enough to explore the unknown. Adolescents who fail to experiment in any realm are sometimes seen to be more stable but may, in fact, be experiencing more difficulty than youth who seem to flit from one interest to another. Adolescence is a time when experimenting with alternatives is developmentally appropriate, except when it seriously threatens the youth’s health or life. Although it may seem a simple strategy, professionals can help adolescents begin to define their identity through the simple process of taking time to ask questions and listen without judgment to the answers. It is amazing how many youth are hungry to discuss these issues with a trusted adult, and how few are offered the opportunity. Discussing these issues can also help adolescents to develop their new abstract reasoning skills and moral reasoning abilities.

Raising self-esteem

Low self-esteem develops if there is a gap between one’s self-concept and what one believes one “should” be like (Harter, 1990b). How can a professional know whether an adolescent has low self-esteem? The following characteristics have been identified by different researchers as being associated with low self-esteem in adolescents (Jaffe, 1998):

• Feeling depressed
• Lacking energy
• Disliking one’s appearance and rejecting compliments
• Feeling insecure or inadequate most of the time
• Having unrealistic expectations of oneself
• Having serious doubts about the future
• Being excessively shy and rarely expressing one’s own point of view
• Conforming to what others want and assuming a submissive stance in most situations

Because consistently low self-esteem has been found to be associated with negative outcomes, such as depression, eating disorders, delinquency, and other adjustment problems (Harter & Marold, 1992, Striegel-Moore & Cachelin, 1999), it is important that professionals identify youth who exhibit these characteristics and help them get the extra help they need.

How can a professional help an adolescent raise his or her self-esteem? The most important task is to identify the specific areas that are important to the adolescent. Trying to improve global self-esteem is difficult, but helping adolescents to improve their self-concepts in specific valued areas is both doable and contributes to global self-esteem in the long run (Harter, 1990b). For example, a professional may find that an adolescent with low self-esteem is interested in learning to play the guitar. Encouraging the adolescent to explore that specific interest and helping to find resources that might lead to guitar lessons may lead to important gains in self-esteem.

Professionals can help to enhance adolescents’ self-esteem by helping them face a problem instead of avoiding it. This can involve such activities as teaching the youth interpersonal or problem-solving skills, role-playing a difficult conversation, or providing information and resources. Or, it may simply entail providing ongoing encouragement and support in facing feared situations, such as taking an exam, breaking up with a boyfriend, or telling a parent that one has decided to stop participating in a sport. The professional must use his or her skills and knowledge to determine whether the youth is in over his or her head and needs more than coaching and support to handle a particular situation. For example, if a youth is expressing thoughts of suicide, this is clearly a situation where professional psychological help is needed.

Emotional intelligence

Identity development as well as moral development occurs in the context of relating to others (Jordan, 1994). All adolescents must begin to master the emotional skills necessary to manage stress and be sensitive and effective in relating to other people. These skills have been called “emotional intelligence” (Goleman, 1994). Emotional intelligence involves self-awareness, but above all, relationship skills—the ability to get along well with other people and to make friends. Professionals who can help adolescents develop emotional intelligence provide them with resources that will help them succeed as adults in both their personal and professional lives. However, one does not have to look to the future for the benefits; youth without relationship skills are at greater risk than their peers who have these skills for a number of problems, including dropping out of school (Olweus, 1996).

What follows is a brief description of the most important skills for adolescents to begin to master as part of their emotional development.

• Recognizing and managing emotions. In order to label their feelings accurately, adolescents must learn to pay conscious attention to them. Without this self-awareness, they may simply say that they feel “good” or “bad,” “okay”or “uptight.” When adolescents are able to specify that they feel “anxious” about an upcoming test or “sad” about being rejected by a possible love interest, then they have identified the source of their feelings, which can lead to discovering options to resolve their problem. For example, they can set aside time to study or ask for help in preparing for the test, or they can talk over their feelings about being rejected by a love interest with a friend or think about a new person in whom to become interested. The important point is that being aware of and being able to label their feelings helps adolescents identify options and to do something constructive about them. Without this awareness, if the feelings become uncomfortable enough and the source is undefined, they may seek to numb their emotions with alcohol or other drugs, to overeat, or to withdraw and become depressed. Adolescents who feel angry may take out their anger on others, hurting them or themselves instead of dealing with their anger in constructive ways, if they are not aware of its source (Goleman, 1994).
• Developing empathy. Recognizing their own emotions lays the groundwork but does not ensure that youth will recognize that others have feelings and that they need to take these feelings into account. Some youth have particular difficulty “reading” the emotions of others accurately, for example, mistaking neutral comments for hostility. Empathy can be taught in various contexts, such as helping students to empathize with different groups of immigrants and understand emotionally the negative consequences of prejudice (Aronson, 2000).
• Learning to resolve conflict constructively. Given the unique and differing needs and desires that people have, conflict is inevitable. Tools for managing conflict can be modeled informally by professionals or, as in some schools, actively taught to adolescents. Conflict resolution programs teach students to define their objectives in conflicts, their feelings, and the reasons for what they want and feel, and then ask them to take the perspective of others involved when coming up with options that might resolve conflicts (Johnson & Johnson, 1991). Although many of these skills are taught within programs targeting adolescents, they can also be taught informally with good results.
• Developing a cooperative spirit. It is hardly surprising that schools mirror the competitive attitudes present in our larger society. Yet, in the contemporary work world, the importance of teams and the ability to work cooperatively with others is increasingly emphasized. Even some Nintendo and video games require cooperation among the players (Santrock, 2001). The “jigsaw classroom” is a teaching technique pioneered to facilitate the development of cooperation skills (Aronson & Patnoe, 1997). It requires students to rely upon one another to learn a subject, using strategies that reduce competition and that elevate the standing of students who are sometimes ignored or ridiculed. The name derives from the fact that each student becomes part of a small expert group that is an informational puzzle piece that must be assembled with others in order to fully understand a subject. This approach has been successful not only in helping adolescents learn how to work cooperatively toward a group goal, but also in improving their academic performance.

Professionals can bring an awareness of the importance of these skills to their work with youth and can develop strategies for helping youth to build these skills in their everyday contacts with them.

Group differences in emotional development

Emotional development occurs uniquely for each adolescent, with different patterns emerging for different groups of adolescents. Boys and girls can differ in the challenges they face in their emotional development. For adolescents from minority cultures in the United States, feeling positive about their ethnic identity, sometimes in the wake of negative stereotypes about their culture, is an important challenge for healthy emotional development. Youth whose sexual orientation is gay, lesbian, or bisexual and youth who have a physical disability or are chronically ill, experience additional challenges in building a positive self-esteem in a culture where the predominant media image of an adolescent is a White, heterosexual, thin, and able-bodied middle-class teen. Adolescents need adults who can model positive self-esteem, teach them to be proud of their identity, and help them cope positively with any prejudice they encounter in their lives.

Gender differences

Longitudinal research has shown that feelings of self-esteem tend to decrease somewhat as girls become adolescents, with different patterns emerging for different ethnic groups (Brown et al., 1998). Particularly in early adolescence, some studies have shown that boys tend to have higher global self-esteem than girls (e.g., Bolognini, Plancherel, Bettschart, & Halfon, 1996; Chubb, Fertman, & Ross, 1997).

Because of differences in how boys and girls are socialized in our society, male and female adolescents may also differ in their specific needs for help from professionals in promoting identity formation. For example, some adolescent girls may need help learning to become more assertive or in expressing anger. Adolescent boys, on the other hand, may need to be encouraged to have cooperative rather than competitive relationships with other males and helped to understand that it’s okay to feel and express emotions other than anger (Pollack & Shuster, 2000).

Ethnic diversity

Developing a sense of ethnic identity is an important task for many adolescents, and numerous studies have found that having a strong ethnic identity contributes to high self-esteem among ethnic minority adolescents (e.g., Carlson, Uppal, & Prosser, 2000). Ethnic identity includes the shared values, traditions and practices of a cultural group. Identifying with the holidays, music, rituals, clothing, history and heroic figures associated with one’s culture helps build a sense of belonging and positive identity. For many of these youth, adolescence may be the first time that they consciously confront and reflect upon their ethnicity (Spencer & Dornbusch, 1990). This awareness can involve both positive and negative experiences.

Adolescents with a strong ethnic identity tend to have higher self-esteem than do those who do not identify as strongly with their ethnic group. Professionals can advise parents of this fact, encouraging them to discuss and practice aspects of their own ethnic identity (e.g., history, culture, traditions) at home to help their child develop a strong ethnic identity (Phinney, Cantu, & Kurtz, 1997; Thornton, Chatters, Taylor, & Allen, 1990).

Quite naturally, the values that parents consider to be most important to impart to youth vary among ethnic cultures. For example, Asian American parents consider valuing the needs and desires of the group over those of the individual and the avoidance of shame to be important values to convey to youth (Yeh & Huang, 1996). African American families tend to value spirituality, family, and respect. Values stressed by Latino parents include cooperation, respect for elders and others in authority, and the importance of relations with the extended family (Vasquez & de las Fuentes, 1999). Parents from many Native American Indian cultures highly value harmony with nature and ties with family (Attneave, 1982). And, parents from the mainstream White culture may stress independence and individualism.

Great diversity exists within each of these ethnic groups. Well-meaning individuals can still fail to recognize that within the Latino community, for example, there are wide cultural differences among those who come from Mexico, Cuba, El Salvador, or Puerto Rico. Black adolescents may have cultural roots in such varied parts of the world as Africa, the West Indies, Europe, or Latin American countries. Asian Americans from Vietnam, China, and Japan also differ significantly in their cultural heritage.

Similarly, it can be important to consider whether an adolescent is from a family that has recently immigrated to the United States or from a family whose roots have been in America for many generations. Different levels of acculturation, that is, the adoption of behaviors and beliefs of the dominant culture, are important to consider in working with adolescents and their families. For example, parents who are not proficient in English may rely on their children to interpret important information for them.

For many in the United States, becoming aware of racism and gaining an understanding of the manifestations of social injustice is an inevitable and important part of building a sense of ethnic identity. Professionals who work with ethnic minority youth can help them to make sense of the discrimination they may face and to build the confidence and skills necessary to overcome these obstacles (Boyd-Franklin & Franklin, 2000; Oyserman, Gant, & Ager, 1995).17 Professionals can also help White youth to understand and be aware of racism and discrimination and their impact on people of color.

Gay, lesbian, and bisexual youth

Lesbian, gay, and bisexual (LGB) youth constitute another minority group for whom identity concerns may be particularly salient during adolescence. In addition to the typical identity tasks of any adolescent, these youths may also be negotiating the development task of incorporating a sexual identity in a society that discriminates against homosexuals and a youth culture that is largely homophobic. Ethnic minority youth, who must also deal with the stress of racial discrimination, face the additional challenge of developing an identity that reflects both their racial or ethnic status and their sexual identity. The development of a gay, lesbian, or bisexual identity often begins with an awareness of being “different,” of feeling attracted to members of one’s own sex, and of not sharing peers’ attraction to the opposite sex. An adolescent may find this awareness frightening and try to deny feelings of attraction to the same sex and to intensify feelings toward the opposite sex. A supportive environment can help adolescents negotiate this process and realize their sexual orientation (Fontaine & Hammond, 1996; Ryan & Futterman, 1998; Savin-Williams, 1998). As with heterosexual youth, sexual exploration proceeds with variability, depending on the individual. Most youth will disclose their sexual orientation to trusted friends first, but may prefer that their status remain a secret because of the stigma associated with differing sexual orientation. When family members are told, mothers tend to be told before fathers (Savin-Williams, 1998).

It is important to understand that there are numerous reasons that some adolescents (particularly males) will engage in same-sex sexual behavior—they may self-identify as gay, lesbian, or bisexual; they may be questioning their sexual identity; or they may simply be experimenting. Professionals ho are privy to disclosures from youth about such experiences should not necessarily assume that those youth are in the process of discovering or developing a gay, lesbian, or bisexual identity—they may or may not be. At the same time, professionals should be aware that being gay, lesbian or bisexual could present unique challenges for teens.

Lesbian, gay, and bisexual youth are at higher risk than their heterosexual peers for a number of health-related concerns. These include, for example, substance use, earlier onset of heterosexual intercourse, unintended pregnancy, HIV infection (especially males), and other sexually transmitted diseases (Blake, Ledsky, Lehman, & Goodenow, 2001; Faulkner & Cranston, 1998; Saewyc, Bearinger, Blum, & Resnick, 1999; Saewyc, Skay, Bearinger, & Blum, 1998). Lesbian, gay, and bisexual youth have also been reported to be at greater risk for experiencing verbal and physical violence directed toward them in a variety of settings (Faulkner & Cranston, 1998; Russell, Franz, and Driscoll, 2001). In addition to the danger associated with violence from others, there is some evidence that homosexual or bisexual boys are at higher risk for suicide attempts than heterosexual youth (Remafedi, French, Story, Resnick, & Blum, 1998). This risk of suicide is not related to sexual orientation per se, but to the intolerable stress created by the stigma, sexual prejudice, and the pressure to conceal one’s identity and feelings without adequate interpersonal support (Rotheram-Borus, Rosario, Van Rossem, Reid, & Gillis, 1995).

A challenge for professionals is not just to endeavor to reduce risks for these youth, but to promote resilience so youth can deal effectively with the challenges that may come their way. Youth who are connected to their family, school, and community are more likely to have the resources necessary to help them cope with the stresses and challenges they face. Professionals who work with adolescents who are in the process of discovering and accepting their lesbian, gay, or bisexual identity can do the following:

• Provide accurate information about sexual orientation to dispel stereotypes about gay, lesbian, or isexual sexuality
• Avoid communicating disapproval of gay, lesbian, or bisexual sexuality
• Help the adolescent identify sexual prejudice and reject its messages
• Refrain from pressuring the adolescent to reach a decision about his or her sexual orientation
• Provide developmentally appropriate information about sexual behaviors, including both same-sex and pposite sex behaviors, that can lead to HIV infection, STDs and unintended pregnancy in a manner that is inclusive of a lesbian, gay, or bisexual sexual orientation
• Be aware of the heightened risk of suicide for some youth and make appropriate referrals for psychotherapeutic help for distressed youth
• Acknowledge and address any biases they may have about gay, lesbian, or bisexual youth

Tips for talking with adolescents

Engage adolescents with nonthreatening questions. Choosing only one or two questions at a given time, ask adolescents questions that help them to define their identities. For example, whom do you admire? What is it about that person that makes them admirable? What do you like to do in your free time? What do you consider to be your strengths? What are your hopes for the future? What have you done in your life that you feel proud of (even if just a little)?

• Listen nonjudgmentally (and listen more than you speak). This enables the adolescent to realize that you value his or her opinions, and thus to trust you more (Forgatch & Patterson, 1989).
• Ask open-ended questions. Ask questions that require more than a yes or no response; this helps the adolescent think through ideas and options (Hill & O’Brien, 1999).
• Avoid “why” questions. “Why?” questions tend to put people on the defensive (Plutchik, 2000). Try to rephrase your questions to get at what the adolescent was thinking rather than the reason for something the adolescent has said or done. For example, instead of asking, “Why did you say that?” ay instead: “You seemed to be really trying to get across a point when you did that. Can you tell me more about what you meant?”
• Match the adolescent’s emotional state, unless it is hostile. If the adolescent seems enthusiastic or sad, let your responses reflect his or her mood. Reflecting someone’s mood helps the individual feel understood (Forgatch & Patterson, 1989).
• Casually model rational decision-making strategies. Discuss how you once arrived at a decision. xplain, for example, how you (or someone you know well) defined the problem, generated options, anticipated positive and negative consequences, made the decision, and evaluated the outcome. Keep in mind that the adolescent has a relatively short attention span, so be brief. Choose a topic that is relevant to adolescents (e.g., deciding how to deal with an interpersonal conflict, identifying strategies for earning money for college) (Keating, 1990).
• Discuss ethical and moral problems that are in the news. Encourage the adolescent to think through the issues out loud. Without challenging his or her point of view, wonder aloud about how others might differ in their perspective on the issue and what might influence these differences (Santilli & Hudson, 1992).

Adolescent social development

The social development of adolescents is best considered in the contexts in which it occurs; that is, relating to peers, family, school, work, and community. It is important to keep in mind when interpreting the findings of research on the social development of adolescents that most of the research to date is based on samples of White, middle-class adolescents. Research done with more diverse groups of adolescents has revealed differences among youth of different ethnic backgrounds, so generalizations to specific ethnic groups should be made with care when the research is based solely on samples of White adolescents.

Peer relationships

One of the most obvious changes in adolescence is that the hub around which the adolescent’s world revolves shifts from the family to the peer group. It is important to note that this decreased frequency of contact with family does not mean that family closeness has assumed less importance for the adolescent (O’Koon, 1997). In fact, family closeness and attachment has recently been confirmed as the most important factor associated with not smoking, less use of alcohol and other drugs, later initiation of sexual intercourse, and fewer suicide attempts among adolescents (Resnick, Bearman, & Blum et al., 1997).

In order to establish greater independence from their parents, adolescents must orient themselves toward their peers to a greater extent than they did in earlier stages of development. Those professionals whose role is to advise parents can help reassure them that increased peer contact among adolescents does not mean that parents are less important to them, but that the new focus on peers is an important and healthy new stage in their child’s development. Professionals can also educate parents about the importance of positive peer relationships during adolescence.

Peer groups serve a number of important functions throughout adolescence, providing a temporary reference point for a developing sense of identity. Through identification with peers, adolescents begin to develop moral judgment and values (Bishop & Inderbitzen, 1995) and to define how they differ from their parents (Micucci, 1998). At the same time, however, it is important to note that teens also strive, often covertly, for ways to identify with their parents. Another important function of peer groups is to provide adolescents with a source of information about the world outside of the family and about themselves (Santrock, 2001). Peer groups also serve as powerful reinforcers during adolescence as sources of popularity, status, prestige, and acceptance.

Being accepted by peers has important implications for adjustment both during adolescence and into adulthood. One study found, for example, that fifth graders who were able to make at least one good friend were found to have higher feelings of self-worth at age 30 when compared to those who had been friendless (Bagwell, Newcomb, & Bukowski, 1998). Positive peer relations during adolescence have been linked to positive psychosocial adjustment. For example, those who are accepted by their peers and have mutual friendships have been found to have better self-images during adolescence and to perform better in school (Hansen, Giacoletti, & Nangle, 1995; Savin-Williams & Berndt, 1990). On the other hand, social isolation among peer-rejected teens has been linked to a variety of negative behaviors, such as delinquency (Kupersmidt & Coie, 1990). In addition, adults who had interpersonal problems during adolescence appear to be at much greater risk for psychosocial difficulties during adulthood (Hansen et al., 1995).

The nature of adolescents’ involvement with peer groups changes over the course of adolescence. Younger adolescents typically have at least one primary peer group with whom they identify whose members are usually similar in many respects, including sex (Savin-Williams & Berndt, 1990). During this time, involvement with the peer group tends to be most intense, and conformity and concerns about acceptance are at their peak. Preoccupation with how their peers see them can become all consuming to adolescents. The intense desire to belong to a particular group can influence young adolescents to go along with activities in which they would otherwise not engage (Mucucci, 1998; Santrock, 2001). Adolescents need adults who can help them withstand peer pressure and find alternative “cool enough” groups that will accept them if the group with which the adolescent seeks to belong is undesirable (or even dangerous). The need to belong to groups at this age is too strong to simply ignore.

During middle adolescence (ages 14–16 years), peer groups tend to be more gender mixed. Less conformity and more tolerance of individual differences in appearance, beliefs, and feelings are typical. By late adolescence, peer groups have often been replaced by more intimate dyadic relationships, such as one-on-one friendships and romances, that have grown in importance as the adolescent has matured (Micucci, 1998). For some adolescents from ethnic minority groups, higher emphasis may be placed on peer groups throughout adolescence, particularly when they are in the minority in a school or community, as the group may provide a much needed sense of belonging within the majority culture (Spencer & Dornbusch, 1990).

Adolescents vary in the number of friends that they have and in how they spend time with their friends. Introverted youth tend to have fewer but closer friendships, and boys and girls differ with regard to the kinds of activities they engage in most frequently with their friends. In general, boys tend to engage in more action-oriented pursuits, and girls spend more time talking together (Smith, 1997). Individuals of both sexes, however, appear to value the same qualities in a friend: loyalty, frankness, and trustworthiness (Claes, 1992). Some studies have also shown that adolescent girls value intimacy, the feeling that one can freely share one’s private thoughts and feelings, as a primary quality in friendship (Bakken & Romig, 1992; Claes, 1992; Clark & Ayers, 1993). Boys also speak of the high importance of intimacy in friendship (Pollack & Shuster, 2000). One review of studies showed that White adolescent girls tend to reveal their innermost thoughts and feelings to friends more so than do boys, and that they receive more social support from friends. However, this gender difference does not appear to hold for African American adolescents (Brown, Way, & Duff, 1999).

To have a friend presupposes that one has the social skills to make and keep that friend. For most adolescents, the rudiments of those skills are in place, and peer groups and friendships allow them to further hone those skills. For a small subset of adolescents, however, this is not the case. These adolescents may be rejected by their peers, and this rejection can have serious negative effects, such as delinquency, drug abuse, dropping out of school, and aggression (Asher & Coie, 1990). For adolescents who lack social skills, adults who informally coach them in the appropriate skill areas can be lifesavers. Discussions about how to initiate conversations with peers, give genuine compliments, be a good listener, share private information appropriately, and keep confidences can go a long way toward enhancing social skills.

Professionals who come in contact with youth with more significant deficits in social skills should take the time to find ongoing professional help for these adolescents. Youth who lack social skills who also develop aggressive behaviors are likely to need professional help to eliminate their aggressive and disruptive behavior (Coie & Dodge, 1998). However, youths who lack social skills but who do not exhibit behavior problems need help as much as the youths who are acting out in antisocial ways, such as by getting into fights or having problems in school. They may not be making as much “noise” in the community as these youth, but they are still at risk for long-term difficulties if their problems do not receive attention during adolescence.

Dating and sexual behavior

Dating typically begins in middle adolescence, usually between the ages of 14 and 16 years. Even very young adolescents are now “cyberdating” over the internet, chatting about mutual interests without having to risk face-to-face or even telephone encounters (Santrock, 2001). Early romantic relationships tend to be of short duration, usually just a few months, with most of the dating occurring in a group context, at least for White adolescents. As the amount of time invested in a particular relationship increases, the expectation that sexual involvement will occur tends to increase for many adolescents. The latest data from the National Longitudinal Study on Adolescent Health indicate that nearly half of White and Hispanic adolescents and 65% of Black adolescents have had intercourse by 12th grade. For reasons not yet understood, Black adolescents tend to begin having intercourse at younger ages than other ethnic groups, with 37% reporting having had intercourse by eighth grade (Resnick et al., 1997).

Reliable data on sexual experiences other than vaginal intercourse, such as oral sex or anal sex, are not currently available for adolescents. There is some anecdotal evidence, however, that adolescents sometimes engage in these “outercourse” activities as an alternative to vaginal intercourse as a way to protect against pregnancy or maintain virginity (Remez, 2000). Certain sexual behaviors (e.g., anal sex) can put young people at especially higher risk for sexually transmitted diseases. It is important that sexually active adolescents who engage in these behaviors understand the heightened risk for contracting sexually transmitted diseases, including HIV, herpes simplex, human papillomavirus, gonorrhea, syphilis, and chlamydia. Because adolescents may have different ideas about what constitutes “having sex,” professionals must take care that both they and the adolescent understand exactly what behaviors they are talking about when discussing issues of sexuality. For example, although both will view vaginal sexual intercourse as having sex, they may differ in their perceptions about whether such activities as oral sex, mutual masturbation, or even kissing constitute “having sex.”

Negotiating sexuality in relationships can be challenging for adolescents. For some, there are significant costs in terms of unwanted pregnancies and sexually transmitted diseases. Professionals can help adolescents by being open and willing to discuss frankly the interpersonal and health aspects of teens’ developing sexuality. Many sexually active adolescents, even if unwilling to stop being sexually active, may be open to guidance about making decisions about their sexual partners and about changing sexual behaviors that increase risk for pregnancy and sexually transmitted diseases (e.g., multiple sexual partners, failure to use contraceptives and barriers that protect against sexually transmitted diseases) (Rosenthal, Burklow, & Lewis et al., 1997).

Issues related to adolescent sexuality can come up for professionals who work with adolescents in many different settings. Nurses and physicians, as well as various other professionals, must be well informed about state and local laws governing the provision of contraceptive information and services to minors, as well as any relevant guidelines that may be present in the professionals’ particular work settings. Evidence suggests that at least some adolescents are open to discussing sexuality with adults. In a study of 148 adolescent girls who had not yet had intercourse, 33% stated that they would discuss sexuality with a health care professional. In addition to information about contraception and prevention of sexually transmitted diseases, these girls mentioned the following topics as appropriate: “decisions about having sex,” “whether ready for sex,” “alternatives to sex,” “how to refuse sex,” and “help you talk to parents.” The predominant concern about talking to a health care professional was confidentiality, but these adolescents also feared being lectured to or were concerned that the professional would use “big, confusing words” (Ford, Millstein, Eyre, & Irwin, 1996).

In addition to sensitivity about issues of sexuality in relationships, it is important that professionals be aware of the grief and sense of loss associated with the ending of romantic relationships during adolescence. Adolescents need emotional support to work through their grief, and feelings of sadness and distress should be taken seriously and validated. Although clearly not the sole cause of suicide, loss of a boyfriend or girlfriend has been reported to trigger suicide attempts for adolescents with a prior history of difficulty or loss (Santrock, 2001).

Professionals should also be alert for signs of emotional or physical (including sexual) abuse in adolescent relationships, including same-sex relationships. If an adolescent is in a relationship that exhibits patterns of uncontrolled anger, jealousy, or possessiveness or if there is shoving, slapping, forced sex, or other physical violence—even once—it’s time to find help. APA has published a helpful pamphlet, Love Doesn’t Have to Hurt Teens (PDF, 640KB), to help adolescents understand abuse and take action if they are in an abusive situation.

Family relationships

Families today can take many forms—single parent, shared custody, adoptive, blended, foster, traditional dual parent, to name a few. Regardless of family form, a strong sense of bonding, closeness, and attachment to family have been found to be associated with better emotional development, better school performance, and engagement in fewer high-risk activities, such as drug use (Resnick et al., 1997; Klein, 1997; Perry, 2000).

For more than half of families in the United States, divorce is a fact of life. Whether divorce will have negative effects on adolescents appears to depend on a number of factors, not simply the fact of the divorce itself. Although it is true that adolescents from divorced families exhibit more adjustment problems than do adolescents from intact families (Conger & Chao, 1996), evidence suggests that most adolescents are able to cope well with their parents’ divorce (Emery, 1999). The factors that appear to have the greatest impact on coping include whether parents can harmoniously parent after the divorce (Hetherington, 2000) and whether the economic problems that often occur after a divorce and lead to other stresses, such as having to move, can be kept to a minimum (Emery, 1999).

Parents often ask professionals how they should modify their parenting practices as their children become older. It appears that parents who are warm and involved, provide firm guidelines and limits, have appropriate developmental expectations, and encourage the adolescent to develop his or her own beliefs tend to be most effective. These parents tend to use reasoning and persuasion, explain rules, discuss issues, and listen respectfully. Adolescents who come from homes with this style of parenting tend to achieve more in school, report less depression and anxiety, score higher in measures of self-reliance and self-esteem, and be less likely to engage in delinquent behaviors and drug abuse (Carlson et al., 2000; Dornbusch, Ritter, Liderman, & Fraleigh, 1987; Sessa & Steinberg, 1991; Steinberg, 2001). It should be noted, however, that the level of parental supervision and monitoring necessary to promote healthy adolescent development can differ depending on the characteristics of the adolescent’s peer and neighborhood environments. For example, setting stricter limits may in fact be desirable for adolescents who live in communities where there is a low level of adult monitoring, a high level of danger, and higher levels of problem behavior among peers, such as in some inner-city, high crime neighborhoods (Roth & Brooks-Gunn, 2000).

During adolescence, parent–adolescent conflict tends to increase, particularly between adolescent girls and their mothers. This conflict appears to be a necessary part of gaining independence from parents while learning new ways of staying connected to them (Steinberg, 2001). Daughters, in particular, appear to strive for new ways of relating to their mothers (Debold, Weseen, & Brookins, 1999). In their search for new ways of relating, daughters may be awkward and seem rejecting. Understandably, mothers may withdraw, and a cycle of mutual distancing can begin that is sometimes difficult to disrupt. If parents can be reassured that the awkwardness their teen is displaying is not rejection and can be encouraged to stay involved, a new way of relating may eventually evolve that is satisfying for all.

Parent–teen conflict tends to peak with younger adolescents (Lauren, Coy, & Collins, 1998). Two kinds of conflict typically occur: spontaneous conflict over day-to-day matters, such as what clothes the adolescent is allowed to purchase or wear and whether homework has been completed, and conflict over important issues, such as academic performance. Interestingly, the spontaneous conflict that occurs on a day-to-day basis seems to be more distressing to parents than to the adolescents (Steinberg, 2001). This is important for parents to keep in mind. Parents often give greater meaning to conflict-laden interactions, construing them to be rejections of their values or as indicators of their failures as parents. Adolescents, on the other hand, may see the interaction as far less significant—just another way of showing Mom or Dad that they are individuals or just as a way to blow off steam. Professionals can help parents understand that minor conflict or bickering is normal and that these exchanges do not mean that they are not skilled or effective parents (Steinberg, 2001).

For most adolescents, school is a prominent part of their life. It is here that they relate to and develop relationships with their peers and where they have the opportunity to develop key cognitive skills. For some youth, it is also a source of safety and stability. Some of the same qualities that characterize families of adolescents who do well—a strong sense of attachment, bonding, and belonging, and a feeling of being cared about—also characterize adolescents’ positive relationships with their teachers and their schools. One additional factor, adolescent perception of teacher fairness, has also been found to be associated with positive adolescent development. These factors, more than the size of the school, the type of school (e.g., public, private), or teacher–pupil ratio, have been found to be strongly associated with whether adolescents are successful or are involved with drugs or delinquency or drop out of school (Resnick et al., 1997; Klein, 1997). Because schools are such a critical setting for adolescents, it can be important even for professionals who work in other settings to connect with the school psychologist, counselor, or social worker of an at-risk adolescent to help create a supportive system of care.

During adolescence, young people typically move from elementary school to middle or junior high school and then to senior high school. Each of these transitions can present challenges both to academic performance and psychological well-being (Seidman, Aber, & French, in press). Declines in academic performance are common following the move to middle or junior high school, a transition that can be quite disruptive for some adolescents. For some, this signals the beginning of a process of disengaging from school. Declines in self-esteem are also common. Although most will “bounce back” later, for some this decline will continue, increasing their risk for lower grades and even failure in high school. Although the transition to senior high school is not as dramatic, some students will continue to disengage at this stage. Professionals should be alert to the difficulty that adolescents can have with school transitions and be ready to provide additional support and guidance during these periods.

More than ever before, having a high school diploma is required for economic success in this country. Fortunately, the trend over the past 20 years has been for adolescents, including those from most ethnic minority groups, to complete high school. Furthermore, the gap in scholastic achievement between ethnic minority and majority groups has narrowed considerably in the past two decades. Despite these gains, however, significant disparities continue among ethnic groups. Although 92% of non-Hispanic White and 84% of Black non-Hispanic 18- to 24-year-olds in 2000 had completed high school with either a diploma or equivalency certificate, only 64% of Hispanics in this age group had completed high school (Kaufman, Alt, & Chapman, 2001). It is also important to keep in mind that adolescents have variable access to quality education. In particular, school systems in poor areas, where students are more likely to be ethnic or racial minorities, are typically less well-funded, may have teachers who are less qualified, and have fewer resources than schools in more affluent areas.

Having a college degree has become increasingly important for economic success. Distressingly, some groups are being left behind, particularly African American adolescents and adolescents who come from families with lower incomes (U.S. Council of Economic Advisors, 2000). Professionals can help to make these teens aware of the financial and other assistance available to them to obtain a college degree and provide them with access to resources to overcome the economic and social barriers that can make it more difficult for them to succeed academically. They also need adults in their lives who believe in their potential as college-bound students, particularly if they come from homes where they will be the first to attend college. Without at least one adult reaching out to them early in their junior high school career, these young people may not see college as being within their range of possibilities. College is, however, only one option for youth after high school. Vocational training is another important choice to consider. Increased emphasis is now being placed on linking students to community job training while they are in high school and in preparing them for vocational training beyond high school. According to the American Vocational Association, 9,400 postsecondary institutions currently offer technical programs that provide training ranging from the culinary arts to computer technology. Students who are not drawn to college should be directed to explore these options. If not, they are likely to drift into easily accessible jobs that initially seem to offer high pay given the youth’s limited experience. Although the ease with which these jobs are obtained can make them very attractive, in the long run, they are unlikely to provide the resources necessary to allow a young adult to live independently, much less to support a family (Jaffe, 1998). The large number of students and the small number of guidance counselors in many schools virtually guarantee that many students will fall through the cracks in terms of career planning. Therefore, regardless of one’s professional role, it is helpful to inquire about and encourage adolescents to pursue postsecondary education and career training.

Many adolescents hold part-time jobs during high school. These jobs can help youth learn many important lessons, such as how the business world works, how to get and keep a job, how to manage time and money, and how to set goals and take pride in one’s accomplishments (Committee on the Health and Safety Implications of Child Labor, 1998; Perry, 2000). What appears to be clear from the most extensive research conducted to date, however, is that the number of hours an adolescent works is critical for determining whether these positive benefits are offset by negative ones. Adolescents who work 20 or more hours per week during the school year are at higher risk for a variety of negative outcomes, including work-related injuries, lower educational attainment, substance abuse, and insufficient sleep (Committee on the Health and Safety Implications of Child Labor, 1998). Findings from the National Longitudinal Study on Adolescent Health suggest that these young people are more emotionally distressed, have poorer grades, are more likely to smoke cigarettes, and are more likely to become involved in other high-risk behaviors, such as alcohol and drug use (Resnick et al., 1997). Adults who work with youth should caution them that, whenever possible, they should keep their work hours to fewer than 20 hours a week during the school year, recognizing that for some youth working is an economic necessity.

For youth who are not going on to college, the transition to work after high school can be difficult. Young people can feel they are drifting and feel a lack of connection to either school or the world of work. Mentoring and school-to-work programs can be helpful for some of these youth, particularly when planned as a prevention rather than crisis-intervention strategy (Besharov, 1999).

The characteristics of the community in which an adolescent lives can have a profound impact on the adolescent’s development. Community includes such factors as the socioeconomic characteristics of one’s neighborhood, the types of resources available, the service systems within the community (including schools), religious organizations, the media, and the people who live in the community. Some communities are rich in resources that provide support and opportunity for adolescents. Unfortunately, many communities, particularly in inner cities or poor rural areas, do not.

The influence of neighborhood characteristics

Neighborhood socioeconomic status (SES) and stability (i.e., the degree to which people of all SES classes tend to remain in the neighborhood over a period of time) can significantly affect adolescent development. For example, living in a high SES neighborhood is positively associated with academic achievement and negatively associated with dropping out of school, especially for adolescent males. On the other hand, adolescents who reside in low SES neighborhoods—particularly younger adolescents—are more likely to be involved in delinquent and criminal behavior and to experience behavioral problems, such as acting out or aggression and substance use. If youth have the opportunity to move out of poor neighborhoods, however, their prospects improve. For minority youth, those who move from public housing to more affluent neighborhoods have been found to be more likely to stay in school and to go to college than their peers who remain in public housing. And, adolescent boys involved in the criminal justice system who move to higher SES neighborhoods are less likely to be arrested again for violent crimes than their peers who remain in the same low-SES environments. The links between low SES and adolescent delinquent and problem behavior may be due in part to the lack of community institutions in poorer neighborhoods to monitor the activities of youth (e.g., recreation, employment) (Leventhal & Brooks-Gunn, 2000).

Neighborhood stability is another important factor. For example, neighborhood instability has been linked to higher rates of substance abuse in young adolescents (Leventhal & Brooks-Gunn, 2000). On the other hand, the presence of professional and managerial workers in a neighborhood, as well as lower unemployment rates, are associated with more positive outcomes for adolescents. As the number of professional and managerial workers in a neighborhood decreases and the unemployment rate increases, rates of adolescent sexual activity and childbearing increase. Lack of institutional resources (e.g., education, child care, medical, and employment opportunities) and lack of support for positive parenting relationships and practices are also implicated in these outcomes, although further research is needed to clarify their influence (Leventhal & Brooks-Gunn, 2000).

Grassroots efforts are important to strengthen support networks for parents and children in unstable and low SES neighborhoods. However, without other changes, they are unlikely to make much difference. Employment opportunities for youth, affordable and accessible health care, community policing, rehabilitation of housing, and other resources that provide stability and safety are also needed (Greene & Smith, 1995; Leventhal and Brooks-Gunn, 2000).

Many professionals choose to become involved in their communities as members of boards of directors of community organizations or on school boards and other public policymaking agencies. In this way, they are in a position to help decide which programs are developed and funded in their community. These professionals need to know which programs have been evaluated and found to be effective for promoting healthy adolescent development. The characteristics of the most successful programs, for example, tend to engage youth as early in adolescence as possible, involve at least one adult who is personally attached to each adolescent in a meaningful way, involve parents and peers, be located in schools, and address the varied needs of youth (Lerner & Galambos, 1998).

To succeed, community intervention efforts must consider the values of the cultural groups in that neighborhood (Greene & Smith, 1995). Because lower SES neighborhoods in many regions of the country are predominately populated by ethnic minority groups, it is particularly important that efforts to help youth in these neighborhoods keep the cultural context in mind. For example, the “I Have a Future” program, which takes a community-based approach to (among other things) improve knowledge and attitudes related to personal health and to reduce risk of behaviors that endanger health (e.g., substance abuse, unprotected sex), is purposefully structured around values of African American culture (Greene & Smith, 1995).

Faith institutions

Adolescents from many ethnic groups, including European Americans, are positively influenced by spiritual and cultural values. Adolescents, hungry for meaning, benefit from positive role models, explicit discussions of moral values, and a community in which there are activities structured around prosocial values, including religious values. That religious issues are important to many adolescents is illustrated by a recent study of youth aged 11 to 25, in which more than 85% said that they believed in God, and more than 90% that religion was at least somewhat important in their lives (Holder et al., 2000). Religious values are prominent among many ethnic minority cultures. African American groups have been particularly articulate about the strengths that they derive from religion and from faith communities (Franklin & Franklin, 2000). For many American youth, their church serves both as a spiritual resource and a source of social support (Santrock, 2001). Religiosity is associated with less involvement in alcohol and marijuana use. Specifically, the National Longitudinal Study on Adolescent Health found that youth whose families place importance on church attendance and prayer are less likely to become involved with these substances than those whose families do not place importance on church attendance and prayer (Resnick et al., 1997). Adolescents who attach greater importance to religion also reported less involvement in sexual activity (Holder et al., 2000).

The media—including music, television, and most recently, the internet—are an important part of the adolescent’s “community.” Adolescents spend an estimated 6 to 8 hours per day exposed to some form of media (Roberts, 2000), and youth are increasingly attending to more than one form of media at a time (e.g., conversing on a cell phone with one friend while “instant messaging” several others on the computer). Although media will continue to be a growing influence on the development of adolescents, the ultimate effects will depend upon the extent to which positive possibilities can be harnessed and negative influences minimized. On the one hand, for example, television and movies can be negative influences because of their portrayals of violence and unhealthy sexuality and their lack of positive role models (e.g., for adolescents of color; Berry, 2000). On the other hand, they can also be venues for education, providing young people with valuable information about such issues as how to handle sexual situations (e.g., information about how to say “no” or about the importance of contraception), substance abuse, nutrition, violence prevention, and mental health concerns (e.g., Kaiser Family Foundation, 2002).

The internet is now a ubiquitous presence in the lives of adolescents. Although all youth do not have equal access to computers, either at home or at school, the vast majority of youth today do have access to computers and to the internet. A recent survey found that 95% of 15- to 17-year-olds have been online, with most in this age group (83%) having access to the internet from home. Nearly a third (29%) have access to the internet from a computer in their bedroom, where parents are much less able to monitor its use (Rideout, 2001). Much of adolescents’ online activity consists of talking with people via e-mail, instant messaging, and chat rooms (Girl Scout Research Institute, 2002; Rideout, 2001). Typically, this activity is simply a form of interacting with peers. However, it is also important to be aware of the potential risks of going online. For example, youth who enter chat rooms can be targets of sexual harassment or worse, and pornography is easily accessible on the World Wide Web, even by accident (Girl Scout Research Institute, 2002; Rideout, 2001).

In a recent study of internet use among girls ages 13 to 18, most reported that they receive very little advice from adults in their lives about the internet, with most of the advice they do receive consisting of general precautions about online safety issues (Girl Scout Research Institute, 2002). On the other hand, respondents indicated that they wished that adults would provide them with help to avoid emotionally charged situations, such as sexual harassment or online porn, and to process them when they occur. Although almost a third reported that they had been sexually harassed while online (e.g., asked to have cyber sex or about their bra size) and had found the experience disturbing, most were hesitant to tell their parents about the experience. Professionals and other adults can help youth to understand the potential risks of being online in a nonjudgmental way and help them to identify and implement specific strategies for dealing with unwelcome or scary situations.

Finally, professionals can also act as advocates for adolescents, first learning about media influences on youth (for example, see the August 2000 Supplemental issue of the Journal of Adolescent Health on youth and media) and then providing input to and supporting policies that protect youth from harmful media influences (Hogan, 2000). In this way, they both help to change unhealthy conditions and serve as important role models for youth, showing that it is important to act on one’s beliefs, not simply to talk about them.

Adolescent behavioral development

All of the ways adolescents develop—cognitively, physically, socially, emotionally—prepare them to experiment with new behaviors as they transition from childhood to adulthood. This experimentation in turn helps them to fine-tune their development in these other realms. Risk taking in adolescence is an important way that adolescents shape their identities, try out their new decision-making skills, and develop realistic assessments of themselves, other people, and the world (Ponton, 1997). Such exploratory behaviors are natural in adolescence (Hamburg, 1997), and teens need room to experiment and to experience the results of their own decision making in many different situations (Dryfoos, 1998). However, young people sometimes overestimate their capacities to handle new situations, and these behaviors can pose real threats to their health. To win the approval of peers or to avoid peer rejection, adolescents will sometimes take risks even they themselves judge to be “too risky” (Jaffe, 1998).

Adults have legitimate reasons to be concerned about adolescents’ risk-taking behaviors. In the United States in 1999, 72% of all deaths among youth and young adults aged 10 to 24 years resulted from only four causes, all linked to behavior: motor-vehicle crashes (31%), homicide (18%), suicide (12%), and other unintentional injuries (11%) (Kann et al., 2000). And, in 2000, nearly one-half million teenaged girls gave birth (Moore et al., 2001). Many adolescents today have much more free unsupervised time on their hands compared with previous generations, particularly in the afternoon, and parents worry that their teenagers will get into trouble during these hours. For many youth of course, these hours are spent in constructive pursuits, such as hobbies, extracurricular activities associated with school, and studying. For others, however, this unsupervised time becomes an opportunity to experiment with sexual behavior, crime and delinquency, or substance abuse (Sickmund, Snyder, & Poe-Yamagata, 1997; U.S. Department of Education & U.S. Department of Justice, 1998). This time at the end of the day is also when an adolescent is at highest risk of being a victim of a violent crime, such as robbery or assault (Snyder & Sickmund, 1999). Although it is important to focus on the positive aspects of youth, awareness of the health-endangering behaviors of adolescents is also of vital concern to those who wish to help prevent and modify those behaviors.

Reasons for adolescent risk taking

Several theories have been proposed as to why adolescents engage in risky behaviors (e.g., Arnett & Balle-Hjensen, 1993; Gibbons & Gerrard, 1995; Jessor, 1991). One theory stresses the need for excitement, fun, and novel, intense sensations that override the potential dangers involved in a particular activity (Arnett & Balle-Jensen, 1993). Another theory stresses that many of these risk behaviors occur in a group context and involve peer acceptance and status in the group (Jessor, 1991). A third theory emphasizes that adolescent risk taking is a form of modeling and romanticizing adult behavior (Gibbons & Gerrard, 1995). In other words, adolescents engage in some behaviors, such as cigarette smoking and sex, to identify with their parents and other adults. In considering these theories, it should be kept in mind that teenagers are not all alike and that they may have different reasons for engaging in the same risk behavior (Jaffe, 1998).

Adolescents may also have multiple reasons for engaging in a particular risk behavior. For example, given the use of sexuality to market just about every product imaginable, it is no wonder that adolescents are so curious and tempted to experiment. At the same time, research shows that many youths experience significant peer pressure to engage in sexual behavior. In a national survey of 12–18 year olds, 61% of the girls and 23% of the boys said that they thought that pressure from a partner was “often” a reason that teenagers have sex, and 43% of boys and 38% of girls said they thought that fear of being teased by others about being a virgin was often a reason (Kaiser Family Foundation, 1996).

Overall, many experts conclude that risk taking in adolescence is “normal” (Dryfoos, 1998; Hamburg, 1997; Roth & Brooks-Gunn, 2000) and that the key is to provide guidance in decision making and encourage the adolescent to channel the positive developmental aspects of this energy into less dangerous and more constructive “risky” pursuits. Adults also need to consider where current programs and policies may be going wrong. For example, despite the fact that American adolescents are no more sexually active than adolescents from other cultures, our teen pregnancy rates are still much higher than those of most other industrialized nations (Santrock, 2001), even though they have declined over the past decade (Kann et al., 2000). These differences may be due to a number of factors, including differential access to birth control and abortion, differences in sex education, and cultural differences in attitudes toward sexual behavior, especially among young people.

How can adults provide guidance, and what other outlets are there for healthy risk taking for adolescents? First, adults must become comfortable talking with adolescents about decision making in these somewhat sensitive areas—sex, drugs and alcohol, and other safety concerns. The goal is to help the adolescent weigh the dangers and benefits of a particular situation, consider his or her own strengths and weaknesses that may affect decision making, and then make the best decisions possible (Ponton, 1997). This requires being knowledgeable both about the risks of a particular behavior and about that adolescent and being able to listen and respond to the adolescent without being dogmatic. The mere fact that an adolescent is having a conversation with an adult about these topics is a positive sign. Keep in mind that there are many positive aspects of adolescent risk taking and that most adolescents will take some risks. With time, most youths gradually learn to assess risks realistically and modify their behavior accordingly.

Second, adults must be tuned into positive pathways that youth might take—volunteering at a local youth center, taking up a sport, becoming involved in the school play, learning to play a musical instrument, and so forth. Keep in mind that risk taking does not have to be dramatic. Simply stretching beyond one’s former capacities constitutes taking a risk and can satisfy many adolescents’ needs for risk taking if they are encouraged to do so (a youth who is talented in art may need to be encouraged to try a new medium; a shy youth who has a facility for languages may need prompting to use his skills in the community). Finding out what talents or interests a youth might have and then challenging that youth to channel his or her energies to take risks in positive ways takes time. But it is incredibly rewarding to see a potential problem behavior become an asset for the youth and the community.

When risk-taking behavior becomes problem behavior

For some youths, risk-taking behavior may signal a problem that can threaten their well being in both the short and long term. It is very important that professionals understand the difference between normal experimentation and signs of troubled or high-risk youth so they can make appropriate referrals to mental health professionals when warranted. What are some signs that youth have crossed the line between normal experimentation and problem behavior? Concern is warranted when high-risk behaviors begin early, such as at ages 8 or 9, are ongoing rather than occasional, and usually occur in a social context of peers who engage in the same activities. In this case, consideration should be given to referring the adolescent and his or her family to a mental health professional. In addition, it may be a sign that an adolescent is in serious trouble and needs professional help if he or she is engaged in multiple risk behaviors (Lerner & Galambos, 1998). Indeed, research has found that serious problems tend to cluster in the same adolescents (Hamburg, 1997). Youths who are at greater risk for serious negative outcomes tend to engage in multiple problem behaviors, such as drug use and unprotected sexual intercourse, at an early age and usually have several antecedent risk factors in common, such as poor school performance and low self-esteem (Jessor, 1991; Lerner & Galambos, 1998).

The major problem areas of most concern for high-risk adolescents are alcohol and drug abuse; pregnancy and sexually transmitted diseases; school failure and dropping out; and crime, delinquency, and violence. Information about what is known regarding the risk factors for each of these problems is briefly summarized in the following sections. Because protective factors, on the whole, tend to be the same for all of the problem behaviors, these will be discussed as a group after the problem behaviors.

Alcohol and drug abuse

It is difficult to draw the line between teens who are simply experimenting with alcohol and drugs and teens who have developed an alcohol or drug problem. Often, only a trained substance abuse professional can make this judgment. Teens who begin using drugs early, who rely on alcohol and drugs to alleviate feelings of anxiety or depression (“self-medicate”), especially when such use is shared by their friends, may be at higher risk than other teens for developing a substance abuse problem (Simons, Whitbeck, Conger, & Melby, 1991).

Parental substance abuse, including alcohol abuse, is a risk factor for the development of substance abuse problems for adolescents (Obot & Wagner, 2001), as are certain parenting and family management characteristics. These include lack of monitoring or supervision of youth, unclear expectations of youth behavior, and no (or only rare) rewarding of positive behavior (Barnes, Farrell, & Banerjee, 1995; Peterson, Hawkins, Abbott, & Catalano, 1994). Exposure to peer use of substances and susceptibility to peer pressure can also increase risk of substance abuse, although there is some evidence that this may be less of a factor for African American youth (Barnes, Farrell, & Banerjee, 1994).

Pregnancy and sexually transmitted diseases

Despite the recent decline in teen pregnancy rates in the United States, pregnancy and birth rates for youth in this country continue to be among the highest of all developed countries, largely because of differences in contraceptive use (Boonstra, 2002; Moore et al., 2001). Pregnancy results when sexually active adolescents fail to use or effectively use contraceptives. Despite dramatic increases over the past two decades in the reported use of contraceptives (especially condoms) by teens at first intercourse, contraceptive use at most recent sexual intercourse has declined (Terry & Manlove, 2000). While an estimated 24% of teen girls ages 15 to 19 report that they did not use contraceptives the first time they had intercourse, 31% report that they did not use contraceptives the last time they had intercourse. These figures are higher for Hispanic females, only 47% of whom report that they used contraceptives at their last intercourse. Thus a substantial number of sexually active teen girls remain at risk for unintended pregnancy.

Factors associated with delaying first intercourse include being in a two-parent family, having a higher socioeconomic status, greater feelings of religiosity, belief that parents or other adults care and have high expectations of adolescents, and better high school performance (Lammers, Ireland, Resnick, & Blum, 2000). Other factors are associated with increased risk of teen pregnancy. Teens who live in low-income, socially disorganized communities in which family planning services are not readily available are at higher risk (Lerner & Galambos, 1998). Several studies have also found that girls are more likely to use contraception when they believe that their parents support this behavior (Balassone, 1991; Lerner & Galambos, 1998). Finally, having sexual partners unwilling to use contraception increases risk, highlighting the need to discuss contraception in the context of communication within relationships.

Roughly 4 million teens contract a sexually transmitted disease (STD) each year (Lee, 2000), with older Hispanic and African American adolescents tending to have higher rates of HIV/AIDS compared to other groups of teens (Ross, 2000). Although adolescents have become their feelings or intuition about whether a person is “safe.” If an adolescent likes and trusts a person and has known that person for a period of time, the adolescent may have a false sense of security about his or her risk for sexually transmitted diseases, thus feeling that there is no need to use condoms to protect against STDs (Jaffe, 1998; Thompson, Anderson, Freedman, & Swan, 1996).

School failure and dropping out

Dropping out of school can be one of the most detrimental actions youths can take, with potentially disastrous effects on their economic futures. Each year, about 15% of students drop out of school, with higher rates among low-income students, particularly those in large cities. Although the dropout rate for African Americans has decreased in recent years, that for Hispanics has remained quite high—approximately 36% of those ages 18 to 24 have failed to graduate from high school or receive an equivalency certificate.

Some studies have found that members of different ethnic groups cite different reasons for dropping out of school. In one national study, White teenagers who dropped out spoke mainly of feelings of estrangement and alienation from school, not getting along with teachers, and failing academically. Black and Hispanic teenagers, on the other hand, cited the need to provide income for their families and to help with younger children, with Black teenagers also citing getting suspended or expelled as reasons for dropping out (Jordan, Lara, & McPartland, 1996).

Delinquency, crime, and violence

Qualitatively different patterns of delinquency and antisocial behavior (e.g., shoplifting, using drugs, or otherwise breaking the rules of society) have been noted (Moffitt, 1993). For the majority of adolescents who act out, their behavior reflects a gap between their biological and social maturity. Young people commit these acts impulsively and, if handled in a way that discourages them from this type of behavior and puts them back on the right track, most cease all forms of this type of behavior by adulthood (Moffitt, 1993).

This is not to say that the youths who commit these acts are not at risk for further trouble. For example, youths whose one-time antics put them in contact with more seriously offending youths may be influenced by these youths, who reinforce their antisocial behaviors (Dishion, McCord, & Paulin, 1999). But single acts, particularly those that occur in adolescence without any antecedents in childhood, are of less serious concern than multiple acts or acts that follow aggressive behaviors in childhood.

Another much more serious pattern, which is referred to as “life course persistent antisocial behavior,” extends beyond adolescence. Typically, this pattern of behavior expresses itself in childhood through cruelty toward animals and vulnerable children and through antisocial acts at younger ages and more serious acts at older ages (e.g., shoplifting and truancy at ages 8 or 10, selling drugs and stealing cars at 13 or 14, robbery at 16 or 17) (Moffitt, 1993).

Many factors, including violence in the media, the availability of handguns, exposure to violence in the home and in the community, and the economically and socially impoverished communities in which many youths and their families live can contribute to antisocial or violent behavior among youth. Living in poverty is a particularly powerful risk factor for increasing the chances that a youth will engage in high-risk problem behaviors (Lerner & Galambos, 1998; Perry, 2000).

Protective factors and resilience

Just as there are a number of factors that can place adolescents at higher risk, there are also factors that can help protect young people from developing problems, even under such adverse circumstances as poverty. The term “resilience” is used to refer to having good outcomes despite serious threats to healthy development (Masten, 2001). Resilience can be facilitated not just by reducing the level of risk, but also by promoting competence and strengthening assets (Maton, Schellenbach, Leadbeater, and Solarz, in press). Although it is not necessary for all of these factors to be in place in order for an adolescent to be resilient in the face of adversities, greater resilience tends to be associated with having more of these kinds of protective factors present.

Many psychologists caution against viewing resilience from an individual framework. Instead, resilience should be seen as a function of developmental experiences that are grounded in a community context (Debold et al., 1999; Perry, 2000). Whether a community is able to offer the relationships, resources, and commitment needed to provide the kinds of supports and developmental experiences that produce resilient youth depends on many factors, but primary is whether the needs of youth are given priority.

Adolescent risk-taking behaviors

Cigarette smoking.

• 70% of high school students have tried cigarette smoking, 25% before the age of 13
• About one-quarter of high school students smoke at least one cigarette per day, with male students smoking more than female students
• Smoking has been on the rise for girls; in 1991, one in eight girls in eighth grade reported smoking (13%), but by 1996 more than one in five reported smoking (21%) (Lee, 2000)

Alcohol use

• 81% of high school students have tried alcohol; 32% had their first drink before the age of 13
• Half of all high school students report having had more than one alcoholic beverage in the past 30 days, and approximately 30% report having had more than five alcoholic beverages at one time during this period. Girls ages 12–18 are now as likely as boys to drink alcohol (Lee, 2000)
• Male students are more likely than female students to report heavy episodic drinking, as are those in the upper grades (11 and 12) compared to those in the lower grades (9 and 10)
• 13% of students drove a vehicle more than once after drinking during the past month, with males significantly more likely to do so than females. A third (33%) report having ridden more than once during the past month with a driver who had been drinking alcohol

Other drug use

• 47% of high school students have tried marijuana, with males more likely than females to report such use; 11% tried marijuana beforethe age of 13
• 9% of high school students have used some formof cocaine, and 4% have used cocaine more thanone time in the past 30 days
• 14% of students have used inhalants to get high; 4% more than once in the past 30 days
• 9% of high school students have used methamphetamines, and approximately 4% have used steroids

Weapon carrying, fighting, and sexual violence

• 17% of students have carried a weapon (e.g., a gun, knife, or club) to school on one or more days during the past month, with boys significantly more likely than girls to carry weapons
• Approximately 36% of high school students have been in a physical fight one or more times during the 12 months, with male students (44%) more likely than female students (27%) to have been in a fight
• During the past 12 months, approximately 9% of students were hit or slapped on purpose by their boyfriend or girlfriend
• Approximately 9% of students had ever been forced to have sexual intercourse when they did not want to
• Homicide rates for Black youth ages 10 to 14 are 3 to 4 times greater than those for White youth (Ross, 2000)

Sexual intercourse

• Half of all high school students have had sexual intercourse, with 8% having had intercourse before the age of 13, and 36% having had sexual intercourse during the past 3 months
• 19% of male high school students report having had more than four sexual partners, as do 13% of female students
• Approximately 25% of sexually active students used alcohol or drugs at last sexual intercourse
• Among currently sexually active high school students, 58% used a condom during last sexual intercourse, with males more likely to report using a condom than females. Among sexually active female students, 20% report using birth control pills
• Approximately 6% of students report that they have been pregnant or responsible for getting someone pregnant
• Between 1991 and 2000, the pregnancy rate for girls ages 15–19 years declined from 56.8 per 1,000 teens to 48.7 (Moore et al., 2001)

Failure to use motorcycle or bicycle helmets

• Of the 24% of students who report having ridden a motorcycle in the past year, 38% rarely or never wore a helmet. Of the 71% of students who rode a bicycle in the past year, 85% rarely or never wore a helmet

Factors associated with resilience and positive outcomes

• Stable, positive relationship with at least one caring adult Numerous studies have found that the presence of an adult—a parent or someone other than a parent—with a strong positive, emotional attachment to the child is associated with resilience (Garbarino, 1999). This might be a teacher or coach, an extended family member, or a mentor, such as those found in the Big Brothers/Big Sisters Program (Roth & Brooks-Gunn, 2000).
• Religious and spiritual anchors A sense of meaning is one of the major pathways through which violent youth find their way to a constructive future, with religious and spiritual institutions and practices being important vehicles for developing a sense of meaning for these youth (Garbarino, 1999).
• High, realistic academic expectations and adequate support Schools that provide students with a sense of shared cooperative responsibility and belonging, convey high expectations for participation, and provide high levels of individual support for students tend to enhance resilience (Siedman et al., in press).
• Positive family environment A warm, nurturing parenting style, with both clear limit setting and respect for the growing autonomy of adolescents, appears to be associated with resilience in adolescents (Jessor, 1991; Lerner & Galambos, 1998). Strong, positive mother-adolescent relations have also been found to be associated with resilience among youth when fathers are absent from the home (Mason, Cauce, Gonzales, & Hiraga, 1994).
• Emotional intelligence and ability to cope with stress Although intelligence per se has been reported to be associated with resilience (Fergusson & Lynskey, 1996), the factors that may be more important, because they are more amenable to change and are also involved in resilience, are emotional intelligence and the ability to cope with stress (Garbarino, 1999).

We end Developing Adolescents: A Reference for  Professionals  with a discussion of resilience because we believe that all youth can be resilient if they have adults to nurture and support them as they navigate the sometimes-risky passage from adolescence to adulthood. Each professional who works with adolescents can make a positive difference in their lives. All youths can be given the message that they are worthwhile, that there are people who care about them, and that there are resources available to meet their needs.

Adolescents are creative, energetic, and challenging. We hope that this publication has made their normal developmental course more understandable and that this understanding will help professionals in their day-to-day work with them.

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Applied Research in Child and Adolescent Development

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Developed for an NIH training institute, this volume is organized around the most frequently asked questions by researchers starting their careers in applied research in child and adolescent development. With contributions from the leading scholars in the field, actual research experiences highlight the challenges one faces in conducting such research. The techniques and theoretical frameworks most suitable for guiding the applied research process are reviewed along with related ethical and cultural considerations. Each chapter features the authors’ introduction to their own careers in applied research. Also included are practical tips, case studies, and sidebars featuring frequently asked questions.

This practical resource provides tips on how to:

• Modify the most frequently used methodological techniques while maintaining the integrity of the data
• Manage the unpredictable nature of real world research
• Frame community relevant research questions in an academically acceptable way
• Secure funding to conduct applied research
• Disseminate the research results so as to have the greatest impact on policy and practice.

The book opens with the most frequently asked questions, tips on getting started in an applied research career, and an overview of and theoretical framework for generating applied developmental research ideas. Section 2 focuses on research designs including the most frequently used methodological and measurement techniques and tips on how to modify them to applied settings. Ethical challenges and cultural issues in working with special populations are also addressed. Section 3 focuses on conducting applied research in school, community, and clinical settings with an emphasis on the challenges encountered when conducting actual research as opposed to the more controlled settings taught in a classroom. Guidelines for protecting the populations involved in the study and strategies for recruiting and retaining participants are also addressed. The book concludes with strategies for disseminating research findings so as to have the greatest impact on policy and practice, for publishing research, and for securing funding.

Intended as a practical guide, this book is ideal for those just starting their careers in applied research, for students preparing their dissertations, and for the faculty who prepare these students. The book’s accessible approach also appeals to researchers in the behavioral, social, and health sciences, education, and those in government and industry.

TABLE OF CONTENTS

Chapter 1 | 4  pages, introduction, part | 2  pages, section i: getting started with applied research on child and adolescent development, chapter 2 | 30  pages, getting started: answering your frequently asked questions about applied research on child and adolescent development, chapter 3 | 22  pages, applied developmental science: definitions and dimensions, chapter 4 | 20  pages, letting your questions guide the way: framing applied questions in child and adolescent development research, section ii: challenges and issues conducting applied research on child and adolescent development, chapter 5 | 20  pages, designing applied studies for special populations: establishing and maintaining trust in research relationships, chapter 6 | 30  pages, challenges and issues in designing applied research, chapter 7 | 22  pages, ethical issues and challenges in applied research in child and adolescent development, section iii: conducting research in applied settings, chapter 8 | 20  pages, conducting translational research on child development in community settings: what you need to know and why it is worth the effort, chapter 9 | 24  pages, applied research in school settings: common challenges and practical suggestions, chapter 10 | 24  pages, conducting applied research in child and adolescent settings: why to do it and how, section iv: how to make the most of your applied research, chapter 11 | 22  pages, getting funded in applied child and adolescent development research: the art and science of applying for grants, chapter 12 | 20  pages, communicating and disseminating your applied research findings to the public, chapter 13 | 36  pages, “i am pleased to accept your manuscript”: publishing your research on child and adolescent development, chapter 14 | 6  pages, conclusion and future directions.

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The Swedish Twin study of CHild and Adolescent Development: the TCHAD-study

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• 1 Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Sweden. [email protected]
• PMID: 17539366
• DOI: 10.1375/twin.10.1.67

The Swedish Twin study of CHild and Adolescent Development (TCHAD) is a longitudinal study of how genes and environments contribute to development of health and behavioral problems from childhood to adulthood. The study includes 1480 twin pairs followed since 1994, when the twins were 8 to 9 years old. The last data collection was in 2005 when the twins were 19 to 20 years old. Both parents and twins have provided data. In this article we describe the sample, data collections, and measures used. In addition, we provide some key findings from the study, focusing on antisocial behavior, criminality, and psychopathic personality.

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Adolescent Brain and Cognitive Developments

Adolescence is a time of significant physical, social, and emotional developments, accompanied by changes in cognitive and language skills. Underlying these are significant developments in brain structures and functions including changes in cortical and subcortical gray matter and white matter tracts. Among the brain regions that develop during adolescence are areas that are commonly damaged as a result of a traumatic brain injury (TBI). This paper summarizes major brain changes during adolescence and evidence linking maturation of these cognitive and language functions to brain development, placing consideration of both areas of development in the context of rehabilitation for adolescents with TBI.

Adolescence spans the developmental period from preadolescence, beginning from about age 9 years, through the end of late adolescence in the early 20s ( Table 1 ). It is a time of significant physical, social, and emotional changes, accompanied by changes in cognitive and language skills. Intervention for adolescents with traumatic brain injury (TBI) must take into account not only important changes at this stage but also the interaction of development and injury effects on brain functions and structures.

Stages of adolescence

From “Adolescence Terminable and Interminable: When Does Adolescence End?” J. J. Arnett and S. Taber, 1994, Journal of Youth and Adolescence, 23 (5), pp. 517–537. Copyright 1994 by Springer. Reprinted with permission; Adolescence (5th ed.), by L. Steinberg, 1999, Boston: McGraw-Hill College. Copyright 1999 by McGraw-Hill College. Reprinted with permission; “Should My Shirt Be Tucked In or Left Out? The Communication Context of Adolescence,” L. S. Turkstra, 2000, Aphasiology, 14(4), pp. 349–346. Copyright 2000 by University of Pittsburgh. Reprinted with permission.

In this paper, we review recent research on brain development in adolescence and its relation to cognitive and language developments. The effects of injury are discussed, and the combination of developmental events and injury effects are considered in light of current rehabilitation practices.

ADOLESCENT BRAIN DEVELOPMENT

Recent structural and functional imaging studies have characterized brain development from childhood to early adulthood. The results are summarized in several research reviews (e.g., Durston et al., 2001 ; Paus et al., 1999 , 2001 ). The consensus of the reviewers is that although overall brain volume is relatively constant or increases slightly through the teen years, total volume measures mask significant regional changes in gray and white matter distribution (see Table 2 for definitions of neuroanatomical terms).

Review of neuroanatomical terms

From Neuroscience for the Study of Communicative Disorders (3rd ed.), by S. C. Bhatnagar, 2008, Baltimore. Lippincott Williams & Wilkins. Copyright 2008, 2000, 1997 by Lippincott Williams & Wilkins, a Wolters Kluwer business. Adapted with permission.

White matter volume increases linearly with age until adulthood, with a net increase of about 12% from age 4 to 22 years and a greater increase in males than in females ( Giedd et al., 1999 ). Specific white matter volume changes have been described in the internal capsule and arcuate fasciculus bilaterally ( Paus et al., 1999 ), as well as the corpus callosum ( Durston et al., 2001 ), and the frontal, parietal, and occipital lobes ( Sowell, Trauner, Gamst, & Jernigan, 2002 ).

Paus et al. (1999) postulated that increases in white matter volume reflect an increase in either the diameter or myelination of axons and underlie improvements in fine motor performance, processing of auditory information, and transfer of sensory information between anterior and posterior language areas. In addition, white matter tract size has been correlated with body height ( Eyre, Miller, & Ramesh, 1991 ), which is increasing rapidly during this stage, so, in part, white matter tract changes might be a by-product of overall body growth. Although numerous studies address functional connectivity via white matter tracts in adults, relatively little is known about how changes in connections between brain regions relate to developments in specific cognitive functions ( Paus et al., 2001 ), especially during adolescence.

In contrast to white matter, cortical gray matter increases steadily in volume until adolescence in most regions studied, followed by a decline that continues across the lifespan ( Giedd et al., 1999 ). This trajectory varies by lobe of the brain, with parietal lobe gray matter reaching a peak volume at about age 10 years in girls and 12 years in boys, frontal lobe volume peaking at about age 11 years in girls and 12 years in boys, and a late peak in temporal lobe volume at about age 16 years in adolescent boys and girls ( Giedd et al., 1999 ). The exception is occipital lobe gray matter, which continues to increase in volume throughout adolescence and the early adult years, without evidence of a plateau or decline.

Changes in cortical gray matter are thought to reflect a second wave of overproduction of synapses in the preadolescent years, followed by pruning that may be related to environmental input ( Giedd et al., 1999 ). Thatcher (1997) found that these cycles of synaptic overproduction and pruning were associated with an increase in the synchrony of neuronal firing patterns (i.e., increased coherence of brain electrical activity). Thatcher identified three cycles of increasing electroencephalographic coherence in postnatal development, the last of which occurs during early adolescence.

Total subcortical gray matter volume declines through adolescence, with significant decreases in the volume of the thalamus, caudate nucleus, nucleus accumbens, and basomedial diencephalon ( Sowell et al., 2002 ). Subcortical gray matter volume continues to decline at least into the third and fourth decades of life ( Sowell, Thompson, Holmes, Jernigan, & Toga, 1999 ).

Mesial temporal structures such as the hippocampus and amygdala have been found to increase in volume with age in some studies ( Durston et al., 2001 ) and decrease in others ( Sowell et al., 2002 ). The difference in findings may be attributable to limitations of anatomical research ( Durston et al., 2001 ), as the influence of total volume measures mask significant regional changes in gray and white matter distribution.

Although findings of changes in brain morphology through imaging research have increased the awareness of adolescence as a developmental period, it should be noted that there are limitations in imaging research as in all research. These issues include reliability and validity of anatomical and functional measures, bias in participant selection (e.g., exclusion of particular socioeconomic groups), and sample size. In addition, macroscopic measures such as magnetic resonance imaging (MRI) do not reveal the cellular morphology that may be responsible for gross anatomical differences ( Durston et al., 2001 ). These limitations should be considered when contemplating the application of the research described in the following text to individual adolescents.

Variability in adolescent brain development

As at other stages of development, variability occurs among adolescents in the timing and extent of brain changes. Although the mechanisms of this individual variability are unknown, there are several possible candidates. For example, brain growth is correlated with body growth in humans ( Peters et al., 1998 ) and body growth is highly variable among adolescents, particularly in early adolescence ( Steinberg, 1999 ). This is evident when one considers the range of sizes and shapes among middle-school students. It has been suggested that the diameter of fibers in the corticospinal tract increases as a function of height ( Eyre et al., 1991 ), and this may be true of cortical white matter as well.

Electroencephalographic studies of children and adolescents show age-related increases and sex differences in structural and functional differentiation of the cerebral cortex, particularly in the left hemisphere ( Anokhin, Lutzenberger, Nikolaev, & Birbaumer, 2000 ). Thus, neurophysiological changes are likely to play a role in individual differences. Individual variation in regional neurochemistry and resultant effects on brain structure and function might also contribute to functional heterogeneity, particularly during puberty ( Grumbach, 2002 ; McEwen, 2001 ; Muneoka, Shirayama, Minabe, & Takigawa, 2002 ), although, as Cameron (2001) noted, this is a relatively new area of inquiry.

A final possible contributor to within-subject variability is environmental input. This may be particularly true for the prefrontal cortex (PFC). Because of its prolonged developmental trajectory, it is thought that the PFC has the greatest plasticity of any brain structure ( Casey, Giedd, & Thomas, 2000 ). Thus, it may be the most vulnerable to both environmental stimulation and the effects of toxins, hormones, and other internal and external factors ( Casey et al., 2000 ). Perhaps, as a result of these influences, it has been hypothesized that some individuals never attain the distribution of PFC gray and white matter characteristic of most adults ( Rabinowicz, 1986 ).

COGNITIVE AND COMMUNICATION DEVELOPMENTS DURING ADOLESCENCE

Adolescence is a time of significant development in cognition and communication. An overall increase occurs in speed of processing, with a steep trajectory from ages 5 to 11 years followed by a slower rate of improvement from 11 to 18 years ( Kail & Ferrer, 2007 ). Changes also appear in specific aspects of cognition, primarily in functions that depend on the speed of processing and executive functions (EFs). Development in 3 areas of particular relevance to adolescents is discussed next: executive functions, social cognition, and language.

Executive function development

Executive functions have been defined as “supervisory functions” that control other modular cognitive functions ( Levin & Hanten, 2005 ). They include self-control, abstraction, and temporal estimation and sequencing ( Lezak, 1982 ). The coordination of these three core processes under the guidance of goal-directed behavior provides the ability to create a plan and follow that plan through to completion, making corrections as needed and modifying future behavior based on the results. Executive functions are the basis for metacognitive skills such as the ability to self-monitor performance on complex and demanding tasks (e.g., in social interactions), which undergo significant changes during later childhood and adolescence ( Hanten, 2004 ; Steinberg, 2004 ). Executive functions also underlie functions such as attentional control and processing, which continue to develop throughout adolescence ( Crone et al., 2006 ).

Some evidence suggests that executive function-related functions, such as cognitive flexibility and goal setting, remain relatively stable following rapid preadolescent growth ( Anderson, Anderson, Northam, Jacobs & Catroppa, 2001 ; De Luca et al., 2003 ). What changes significantly is the functional integration of these components. For example, performance on tests such as the Tower of London, which measure complex problem solving, shows improvements into later adolescence ( Asato, Sweeney, & Luna, 2006 ; De Luca et al., 2003 ). Overall, adolescence may be characterized as a stage at which qualitative differences in executive functions combine with increased speed and capacity for dealing with multiple, competing concepts and stimuli. The net result is an increase in the ability to achieve complex, integrated thought and action.

Social cognition development

The predominance of social concerns is a defining characteristic of preadolescence and adolescence. Although parents continue to exert an indirect influence at this stage ( Brown, Mounts, Lamborn, & Steinberg, 1993 ), the main focus is on peer social relationships ( Blakemore, 2008 ). By age 10 or 11 years, preadolescents are acutely aware of themselves and others in their social world, and this awareness is associated with a variety of positive social outcomes ( Bosacki, 2003 ).

Many of the skills required to execute social behaviors successfully are included under the umbrella term of social cognition , which refers to a set of cognitive processes that are thought to be specific to social functioning ( Schulkin, 2000 ). Although the specific cognitive functions that are included in social cognition continue to be debated ( Beer & Ochsner, 2006 ), most authors agree that they include, at minimum, the ability to recognize emotions using affective cues, as well as theory of mind (ToM). Theory of mind is defined as the ability to make inferences about the mental states of others and use these inferences to interpret others’ behaviors ( Premack & Woodruff, 1978 ). The development of ToM is thought to be complete in preadolescence, signaled by the comprehension of faux pas ( Bosacki, 2000 ). A full understanding of faux pas requires the recognition that one’s words were inappropriate, given the knowledge and feelings of others, and that this necessitates some form of conversational repair ( Baron-Cohen et al., 1999 ; Bosacki, 2000 ). Emotion recognition continues to develop into later adolescence ( Tonks, Williams, Frampton, Yates, & Slater, 2007 ), and this might improve social cognition performance as well. Social performance as a whole continues to improve into adulthood, but it is unclear if this reflects changes in social cognition per se or the continued development of cognitive functions that are not specific to social behavior, such as declarative knowledge, metacognition, speed of processing, and working memory. Our understanding of ToM development after early childhood—including when development ends, what aspects change, and how it should be measured—is still in a primitive stage, with much remaining to be learned.

Language development

The preadolescent and adolescent years are characterized by major development in language form, content, and use ( Nippold, 1998 , 2000 ). It is during these years that speakers master sophisticated syntactic functions such as appositive constructions, postmodification of noun phrases, perfect and passive tenses, and modals ( Scott, 1988 ). Sentence length and clause subordination also increase ( Scott, 1988 ), and skills emerge in genres such as persuasive writing ( Nippold, 2000 ). With regard to language form, adolescents are developing a “literate lexicon” ( Nippold, 1988 ), which includes the vocabulary they will need in academic and employment settings. While some of these developments appear to reflect declarative knowledge gains (e.g., in vocabulary and knowledge about language), others, such as the use of complex embedded clause structures, the ability to resolve ambiguous sentences, and the comprehension of proverbs in written text, have been linked to improvements in working memory and abstract reasoning ( Felser, Marinis, & Clahsen, 2003 ; Moran, Nippold, & Gillon, 2006 ). Evidence suggests that improvements in language processes such as metaphor comprehension and inference reflect gains in working memory ( Moran et al., 2005 ), but they also likely reflect improvements in executive functions such as abstraction and cognitive flexibility.

With regard to language use, adolescents are developing the skills required to communicate in the increasingly diverse social, vocational, and educational contexts in which they are expected to interact. They are learning to regulate their own verbal behavior, negotiate, and use language to achieve complex goals ( Turkstra, McDonald, & Kaufmann, 1996 ). Taken together, these skills typically are considered “higher level language functions,” and increasingly they are viewed as reflecting developments in cognitive abilities that are not specific to language, but also to executive functions and social cognition ( Blakemore, 2008 ; Blakemore & Choudhury, 2006 ). These cognitive abilities, in turn, appear to depend on environmental mediation over time to mature fully ( Klahr, McClelland, & Siegler, 2001 ).

Relation of brain changes to cognitive changes

Maturation of cognitive, emotional, and behavioral processes has been linked to the observed gray and white matter developments described earlier in this paper ( Barnea-Goraly et al., 2005 ; Paus et al., 1999 ; Shaw et al., 2006 ; Sowell, Delis, Stiles, & Jernigan, 2001 ; Sowell et al., 1999 ). Spear (2000) increased axon size and myelination improve signal transduction between neurons and improve the networking capability and cross talk among areas of the brain. It is this improved organization of white matter tracts that is believed to underlie the behavioral developments observed in adolescence ( Barnea-Goraly et al., 2005 ), including improvements in functions such as response inhibition, emotional regulation, planning, and organization ( Sowell et al., 1999 ). A few studies have also revealed correlations between specific anatomical changes and improvements in cognitive functions. The most consistent finding is that executive functions are closely linked to the development of the PFC. For example, functional imaging has shown increased activation of dorsolateral PFC with increasing age in children, associated with improvements in working memory task performance ( Crone et al., 2006 ). Activation in this same region has been shown to increase with age on tasks that require response inhibition and switching rules, with continued development into early adolescence ( Crone, Zanolie, van Leijenhorst, Westenberg, & Rombouts, 2008 ). Although these studies suggest that executive functions can be localized to specific subparts of the PFC, several researchers have theorized that the integrity of the entire brain is necessary for efficient executive functions ( Anderson, 1998 ; Spanos et al., 2007 ), particularly given the presence of executive function impairments in a wide variety of clinical groups. This has been supported by imaging data from adults with TBI, in whom executive function impairments were more correlated with overall white matter loss than with the presence of focal frontal lesions ( Kennedy et al., 2009 ).

Other cognitive functions have been studied using structural and functional imaging techniques. Structural studies in children have provided evidence that changes in cortical thickness are correlated with improvements in visuospatial memory ( Sowell et al., 2001 ) and general intelligence ( Shaw et al., 2006 ). It also has been shown that changes in myelination (measured as white matter volume) are the main predictors of increased processing speed with age ( Mabbott, Noseworthy, Bouffet, Laughlin, & Rockel, 2006 ).

Improvements in social cognition have been linked to changes in what Brothers (1990) referred to as the “social brain,”which includes frontal, medial temporal, and parietal lobe regions in a densely connected network. Kolb, Wilson, and Taylor (1992) observed that improvements in emotion recognition, which occur at about age 10 years and then again at age 14 years, are associated with periods of brain growth spurts identified by Thatcher (1997) . Baron-Cohen, Wheelwright, Hill, Raste, and Plumb (2001) observed similar phases of improvement in the ability to read emotion from eyes.

Although research linking specific behaviors to brain regions and networks is in the early stages, the findings to date support the notion that structural changes provide the architecture for specific changes in cognitive abilities. As is discussed later, current research has also shown how disruption to this architecture can lead to disruption of normal development in adolescent cognition and behavior.

INJURY EFFECTS ON THE BRAIN

Effects of preadolescent tbi on brain structure and function.

On the basis of the “Kennard principle” ( Kennard, 1940 ), it was widely accepted until fairly recently that an early brain injury would result in better outcome than a similar acquired lesion in an adult. This idea was challenged earlier by Hebb (as reviewed by Kolb et al., 2000 ) and has been further challenged with recent findings regarding the trajectory of brain development and factors that influence plasticity (reviewed by Kolb et al., 2000 ). Specifically, the idea has been reconsidered that all aspects of language and cognition are affected uniformly by an early lesion ( Tranel & Eslinger, 2000 ). Growing evidence indicates that early damage, especially to prefrontal areas, can have drastic consequences for the continued development of brain structures and functions ( Jacobs, Harvey, & Anderson, 2007 ), including effects on the development of personality, moral reasoning, social cognition, and executive functions ( Hanten, Bartha, & Levin, 2000 ; Tranel & Eslinger, 2000 ). In a few extreme cases (e.g., Anderson, Bechara, Damasio, Tranel, & Damasio, 1999 ), adolescents with early focal lesions have presented with a profile of behavior described as “acquired sociopathy,” in which moral reasoning had failed to develop. Although the potential effects of TBI on moral reasoning and personality in adults are well documented (see discussion that follows), the link between these functions and frontal lobe injury in a developing system is only beginning to be understood, and the effects of subtler lesions are not well known.

The use of structural and functional imaging techniques in the pediatric population, including adolescents, has provided a framework to investigate the impact of TBI on brain–behavior relationships during this critical period. Structural imaging techniques, including computerized tomography (CT) and MRI, have been used for some time in both the acute diagnosis of TBI ( Munson, Schroth, & Ernst, 2006 ) and attempts to predict longterm outcomes ( Bigler, 1999 ). More recently, functional imaging techniques, such as functional magnetic resonance imaging (fMRI), have emerged as a promising tool for identifying recovery mechanisms that are specific to pediatric TBI ( Munson et al., 2006 ), investigating issues of plasticity, and measuring the impact of behavioral interventions on brain function ( Strangman et al., 2005 ). In theory, the use of imaging technology will also support the exploration of the relationship between brain development and age of injury, although to date this relationship has received relatively little research attention.

Structural imaging studies

The use of structural imaging in TBI, outside of the realm of clinical diagnosis and medical management, has provided a good foundation of information regarding patterns of brain injury (including focal vs. diffuse damage) and injury mechanisms, and their relation to outcome. For example, Wilde et al. (2005) conducted an MRI volumetric study to evaluate brain volume differences between the whole brain and prefrontal, temporal, and posterior regions of the brain of children after moderate to severe TBI. Compared with a control group that was matched for age, the TBI group had significantly reduced whole-brain volume as well as reduced prefrontal and temporal region tissue volumes, accompanied by an increase in cerebrospinal fluid volume. More detailed analysis of each of these regions revealed differences in both gray and white matter volumes in the superior medial and ventromedial PFC (also found by Berryhill et al., 1995 ), white matter differences in the lateral PFC, and gray matter, white matter, and cerebrospinal fluid differences in the temporal regions. In this study, the location of the lesion was an important variable in that gray matter loss in the frontal areas was primarily attributed to focal injury, whereas the white matter loss in frontal and temporal regions was related to both diffuse axonal injury and focal lesions. The degree of PFC atrophy, related to either focal or diffuse injury, was related inversely to functional recovery. While recognizing that further research was needed to relate these findings to specific behaviors, the authors speculated that the specific cognitive and behavioral difficulties that follow frontotemporal lesions might result in a decreased adaptive ability, reflecting impairments in executive functions. In light of the differences between gray versus white matter volume changes, the authors noted the need for further consideration of the effects of TBI on the developmental time course of myelination in the frontal and temporal lobes. This highlights the potential impact of TBI in preadolescence on the developing brain and supports the idea that mechanism of injury and site of lesion are important factors in predicting outcome.

In addition to the structural images that are obtained by CT or MRI scans, diffusion tensor imaging (DTI) is a technique that allows an in vivo view of brain connections. Specifically, DTI is an imaging technique that assesses the microstructure of cerebral white matter on the basis of the movement of water molecules and has been used to characterize damage to white matter in a wide variety of clinical disorders, including pediatric TBI ( Hanten et al., 2008 ; Kraus et al., 2007 ; Wilde et al., 2006 ). Researchers have used DTI as a tool not only to describe the integrity of white matter but also to explore the relationship between white matter integrity and behavioral performance. A study conducted by Wilde et al. (2006) focused specifically on the corpus callosum. The results reflected those found in the adult TBI literature, that is, children and adolescents with TBI showed decreased integrity of the corpus callosum compared with typical peers as indicated by a decrease in fractional anisotropy (i.e., anisotropic diffusion of water molecules along white matter tracts). This finding was independent of the presence of any overt structural lesion. This measure of the integrity of the corpus callosum correlated significantly with functional outcome as measured by the Glasgow Outcome Scale ( Jennett et al., 1981 ) and with the performance on a measure of reaction time with interference. Similarly, Kraus et al. (2007) found that DTI changes correlated significantly with the performance on measures of executive function, memory, and attention, even in children and teens with mild TBI.

In a different study using DTI, Wilde et al. (2006) examined white matter integrity and postconcussive symptoms in adolescents with mild TBI. This study demonstrated that DTI techniques are better suited to examine clinically meaningful cognitive, somatic, and emotional changes than traditional imaging measures (i.e., CT and MRI). Measures of fractional anisotropy and radial diffusivity (i.e., diffusion of water perpendicular to white matter tracts) along the corpus callosum were found to correlate significantly with postconcussive and emotional distress levels. These findings indicate that compromise to white matter tracts along the corpus callosum can be associated with mild TBI in adolescents.

In a study that specifically focused on young adolescents (mean age = 13.87 years) at 3 months postinjury, Hanten et al. (2008) found a strong relationship between white matter integrity in the cingulate gyrus bilaterally, dorsolateral PFC bilaterally (although left more than right), and left temporal lobe to performance on the interpersonal negotiation strategies (INS) task, which measures social problem solving. The scores on INS were related to the presence of focal frontal lesions in younger participants but not in older adolescents. These findings speak to both the specific vulnerability of the late-developing frontal lobes and the importance of white matter integrity to cognitive processing, a point that was mentioned previously in this paper when discussing the development of executive functions.

Together, these structural studies provide a foundation for understanding the most likely areas of damage in TBI and how these areas are affected specifically by the injury. Additional well-documented neuropathological changes after TBI include (1) damage to and associated atrophy of the frontal and temporal lobes; (2) diffuse axonal injury and related exvacuo dilation of the ventricles (dilation that is a result of brain tissue loss); (3) decreased volume of the corpus callosum; and (4) generalized cerebral atrophy in the chronic phase, even in the absence of structural findings at the time of the injury ( Barkley, Morales, Hayman, & Diaz-Marchan, 2007 ; and see review in Bigler, 1999 ). Such structural changes have been observed in both pediatric and adult populations, with adolescents included in both types of studies. Additional structural differences, specifically after moderate to severe TBI, include (1) reduced growth of the corpus callosum 3 years postinjury ( Levin et al., 2000 ); and (2) decreased hippocampal volume, specifically following pediatric TBI ( Di Stefano et al., 2000 ). In addition, Tasker et al. (2006) found that when pediatric TBI was complicated by increased intracranial pressure, there was a disproportionate hippocampal growth reduction 5 years postinjury, which was most notable on the ipsilateral side to the site of impact. These results indicate that there are widespread, yet consistent, areas of structural damage following TBI, providing a foundation from which to consider links between lesion location and performance on tasks that are specific to adolescents.

Functional imaging studies

Although structural imaging does provide vital information, there are instances in which a person with behavioral deficits after TBI does not present with identifiable structural lesions on either a CT scan or an MRI scan. A “normal” structural scan during the acute phase of injury does not rule out subsequent structural or functional damage ( Munson et al., 2006 ). In these instances, functional imaging begins where structural imaging leaves off. Functional imaging , as indicated by the term, refers to a group of techniques that provide information about brain function, typically by measuring blood flow, brain electrical activity, or brain chemistry. For the study of adolescents, functional imaging has the added benefit of providing insight beyond what might be possible when pairing structural imaging with performance on behavioral measures, by providing a more complete window into the function of a developing system.

The use of functional imaging techniques has become increasingly common in research on typical populations and has begun to be used to study issues related to plasticity and relearning in clinical populations. In contrast to structural imaging techniques, which have a long history of use in clinical settings, functional imaging currently is used most frequently as a research tool ( Ricker & Arenth, 2007 ). The functional imaging technique that appears most frequently in the pediatric TBI literature is fMRI, which is reported to be a powerful tool for investigating biological models of recovery and rehabilitation ( Matthews, Johansen-Berg, & Reddy, 2004 ). Although functional imaging research in general has grown, few studies have been published on use of this technology in the TBI population, and even fewer studies have used functional imaging to focus on pediatric injury or to consider adolescents as a distinct population. Of the pediatric studies that have been conducted, most have focused primarily on working memory, language, and social cognition.

A case study of working memory in pediatric TBI recovery used a combination of fMRI and behavioral measures to examine recovery of function following brain injury ( Williams, Rivera, & Reiss, 2005 ). In this study, a 9-yearold boy with severe TBI was tested at 30 days and 15 months postinjury on measures of intelligence and behavior and then completed a working memory task during functional imaging. At 30 days postinjury, the fMRI results revealed a significant decrease in areas of brain activation between an easier version of the working memory task versus a more difficult version; however, at the second follow-up visit, the patterns of activation resembled those of typical individuals. These improved patterns of performance were accompanied by improved behavioral performance, demonstrating the possible uses of functional imaging for understanding recovery processes for preadolescents including plasticity. It is important to note, however, that this was a single case study, the results of which are not easily generalizable.

Two functional imaging studies have focused on language skills after pediatric TBI ( Chiu Wong et al., 2006 ; Karunanayaka et al., 2007 ). Karunanayaka et al. (2007) used fMRI to study patterns of brain activity during a verb generation task and found differences in activation patterns in the perisylvian language zones between young children with TBI ( n = 8; mean age = 7.9 years) and their peers who were matched for age and sex but who had sustained only orthopedic injuries ( n = 9; mean age = 7.1 years). In the TBI group, there was a significant association between fMRI results and behavioral measures, such as verbal fluency and Glasgow Coma Scale scores. This association was present even in the absence of focal lesions because more than half of the participants had no evidence of lesions on structural imaging ( Karunanayaka, et al., 2007 ). The second study, conducted by Chiu Wong et al. (2006) , used single photon emission computed tomography to study eight pediatric TBI patients 3 years postinjury with scans obtained during a complex discourse task. The results of this study revealed positive correlations between discourse abstraction abilities and amount of right frontal perfusion (blood flow). In addition, increased perfusion to the left frontal regions was associated with decreased discourse abstraction abilities, indicating that a pattern of supportive plasticity-induced change would involve preferential recovery of right frontal perfusion versus maladaptive plasticity-induced change that appeared to be associated with increased left frontal perfusion.

Together, these functional imaging studies provide a foundation to consider issues of plasticity and associations among behavioral performance, patterns of brain activation, and injury severity. Although this is a new area of inquiry and not yet directly applicable to clinical intervention for individual clients, a group picture is beginning to emerge regarding injury in the developing nervous system. Studies that include older children have focused thus far on preadolescents, but the results provide a starting point to understand the potential delayed effects that TBI can have on brain development during adolescence. The limitations of these studies, however, must be addressed before applying specific results to individual patients. To date, no studies have been large enough to explore the combined effects of development and brain injury to show how development, injury severity, and outcome are related to patterns of brain function and recovery of function. Furthermore, no studies have considered adolescents as a unique group.

Because the application of these techniques is so new, there are additional limitations that must be addressed, including issues such as within-age variability and possible interactions of age with sex ( Blakemore, 2008 ; Chiu Wong et al., 2006 ; DeBellis et al., 2001 ). Other issues relate to the limited inclusion of individuals from groups such as children in poverty, who are at risk for negative environmental influences on development. There also are limitations that are common in the TBI literature in general, such as the exclusion of individuals with developmental learning disabilities, who are overrepresented in the TBI population and may have a complex interaction of developmentally atypical function and acquired impairments ( Donders & Strom, 1997 ). Growing evidence shows differences in brain structures and functions between children with learning disabilities and their typically developing peers ( Holland et al., 2007 ); however, to the authors’ knowledge, only one study ( Donders & Strom, 1997 ) described outcome in children with a combined diagnosis of TBI and learning disability, and this study included only 10 children.

IMPLICATIONS FOR THE ASSESSMENT OF COGNITIVE--COMMUNICATION SKILLS

As discussed, changes in social, emotional, and cognitive functions during adolescence reflect the interaction of neural maturation and environmental factors. Traumatic brain injury clearly has the potential to cause deviations in the expected neurodevelopmental trajectory; this, combined with typical adolescent heterogeneity, variation in the general population in the types of skills that are developing in adolescence (e.g., executive functions), and variability among adolescents in the timing, location, and magnitude of brain damage, pose significant challenges for assessment ( Blosser & DePompei, 1994 ; Ciccia & Turkstra, 2002 ; Snow & Douglas, 2000 ; Turkstra, 1999 ). In short, it can be exceptionally challenging to distinguish “different”from “disordered” when it comes to adolescents. Although brain development in adolescence is a relatively new area of inquiry, the literature reviewed here suggests three factors to consider when assessing adolescents with TBI: (1) the nature of brain and cognitive developments during adolescence (i.e., what to test), (2) the identification of age-appropriate contexts in which to assess performance (i.e., how to test); and (3) the timing of assessment relative to ongoing brain and cognitive developments (i.e., when to test).

What cognitive--communication functions should be assessed?

Most of the aspects of language, executive functions, and social cognition that can be measured reliably with existing standardized tests are those that mature at around the onset of puberty. These include functions such as basic spoken language forms, emotion recognition, and self-regulation in structured environments. As the review of cognitive developments earlier in this paper indicates, adolescence is characterized by further development of skills in integrating and applying basic cognitive, language, and social functions in progressively more complex contexts, and these are much more difficult to measure than are changes in language skills such as vocabulary.

The assessment of adolescent communication ability must address complex skills such as higher level written language skills, which improve, in part, as a function of developments in working memory and complex social cognition ( Kamhi et al., 2007 ; Proctor, Wilson, Sanchez, & Wesley, 2000 ; Singer, 2007 ), as well as self-regulation, self-monitoring, and motivation ( Singer, Kamhi, Masterson, & Apel, 2007 ). For this reason, tasks such as homework assignments, peer conversations, and daily scheduling are likely to be more revealing of challenges in students with TBI than scores on standardized language tests. Given the wide variability in what is considered successful, or typical, performance on these tasks, it is critical to have comparison data from peers, which should be possible when authentic curriculum-based contexts are used for assessment and classroom data are available.

How and where should cognitive--communication skills be evaluated?

The limitations of most standardized tests for the assessment of cognitive, language, and social skills in adolescents apply equally to the assessment context, that is, skills related to the integration and application of information must be assessed in contexts in which they will be used. This includes activities and contexts of daily living, including social contexts and real-world academic situations. This will help identify deficits that clinical testing may mask owing to the artificial structure of many clinical tests and the absence of competing stimuli ( Lezak, 1982 ; Sohlberg & Mateer, 2001 ). By observing students in classroom contexts, clinicians can gain appreciation of the scope of the impact of the injury. It is the convergence of multiple processes, including working memory and response inhibition, as well as judgment of performance and flexibility of applying newly acquired information, that are important for successful communication functioning in everyday life. In other words, the ability to balance the demands of an adolescent life successfully and the ability to meet these demands in facilitative environments with adequate structure are two separate skill sets. This is particularly true for adolescents with TBI because of the high prevalence of executive function impairments in this group and the high risk for failure to advance in age-typical executive function development postinjury. If a new injury has impaired the ability to use previously learned information in novel contexts, then performance on tests of preinjury knowledge in structured contexts is likely to cause teachers and others to overestimate the adolescent’s capacity for succeeding in everyday life.

When should cognitive--communication skills be evaluated?

The evidence supporting a reciprocal relationship between brain and behavioral developments during the teen years suggests that ongoing reevaluation is warranted when a child or adolescent sustains a TBI, even if he or she has been discharged from services after meeting goals at one point in development. Increasing environmental demands and expectations for cognitive functioning necessitate ongoing reevaluation of the adolescent’s ability to communicate and interact successfully. The environment can influence not only expectations but also actual skill development, as evidenced by the finding that “higher”cognitive skills—including social cognition, executive functions, and metacognitive skills— depend on environmental input over time to mature fully ( Klahr et al., 2001 ).

The protracted developmental time course for the frontal lobes and the high sensitivity of developing neural structures to environmental influences necessitate a shift to a life-span approach to intervention. There is growing recognition that the effects of TBI are revealed at later points in development and that the injury may derail neural development in progress so that negative effects are not fully apparent for months or years afterward ( Kolb, Gibb, & Gorny, 2000 ). Early injury may change not only the capacity for brain development but also the brain’s ability to respond to environmental input, which, in turn, may limit future developments. Thus, an adolescent who cannot control his or her attention on a task might fail to develop complex divided attention skills as well as miss learning the information on which he or she is meant to focus. Our approach must take into consideration not only disorder-specific effects but also the complex relationship of neurodevelopmental changes and continuously changing environmental demands. Thus, in planning assessment and treatment, clinicians working with adolescents with TBI must consider existing functions that are affected by the injury as well as functions that are dependent on the development of injured regions in the future.

The research presented here also indicates that adolescence, as a period of natural change, provides a particularly important window of opportunity for intervention. As noted earlier in this paper, preadolescence is characterized by a new wave of synaptogenesis and subsequent pruning. Clinicians may be able to capitalize on this plasticity to focus on the development of complex cognitive skills. At a minimum, the research to date suggests that there are potential risks to not treating children who have sustained TBI during their adolescence.

Barriers to providing services in a life-span framework include current service delivery and reimbursement models, which do not readily allow for this type of approach. However, as research begins to expand in the area of adolescent brain development and clinical disorders, it is possible that the evidence would contribute to a paradigm shift in service delivery models and policy changes to support them. The adolescent brain is a work in progress, and the opportunities for intervention at this stage are likely to outweigh the challenges.

FUTURE DIRECTIONS FOR CLINICALLY BASED RESEARCH

It is a very exciting time in the area of clinical intervention for adolescents. The connection of imaging and behavioral research has allowed questions to be asked and answered that previously could not have been addressed ( Munson et al., 2006 ). While the current research evidence suggests only preliminary recommendations for clinical intervention with individual clients, the results provide an exciting base upon which to ask future clinical questions. Longitudinal studies are needed that combine imaging and behavioral measures over time to increase understanding of the complex interactions among brain development, brain injury, and outcome. A critical need also exists for studies that link brain recovery mechanisms to behavioral outcomes and specific interventions, as currently is being done in studies of adults with neurological disorders ( Raymer et al., 2008 ). The results of this research will arm clinicians with powerful information that truly encompasses the complexities of treating adolescents with TBI.

CONCLUSIONS

The physical developments of adolescence are accompanied by dynamic changes in multiple cognitive, language, and social domains. These include improvements in executive functions, working memory, efficiency of information processing, social cognition, and emotion recognition. When a TBI occurs during the preadolescent and adolescent years, or even earlier, it may affect not only skills that are emerging at that time but also skills that are expected to develop in the future. The impact of injury during adolescence is exacerbated by the type of damage that is most common in TBI, including diffuse axonal injury and reduction in cortical volume and associated brain functions, particularly in the frontal lobes—the very regions that are developing during this stage.

Given the dynamic and protracted nature of both behavioral and brain changes that occur during adolescence, the interconnections of these two aspects of development, and the role that environment plays in development and rehabilitation, one can begin to understand how an injury that interrupts this intricate process can have effects at the time of injury and also many years later. Clinical intervention for adolescents with TBI requires an understanding of the typical trajectory of adolescent brain and cognitive developments and the ability to use this information to inform the “when,” “what,” and “how”of clinical assessment and intervention. In the future, the results of research combining imaging techniques with behavioral approaches have the power to change how clinical services are provided to adolescents with TBI.

Acknowledgments

This work was supported in part by an American Speech-Language-Hearing Foundation New Century Scholar’s grant to Dr. Ciccia and the Wisconsin Alumni Research Foundation and the Walker Foundation at the University of Wisconsin-Madison to Dr. Turkstra.

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• Open access
• Published: 12 September 2024

“I’m trying to take the lead from my child”: experiences Parenting Young Nonbinary Children

• Noah Sweder 1 ,
• Lucinda Garcia 2 &
• Fernando Salinas-Quiroz   ORCID: orcid.org/0000-0002-1257-6379 1  

Child and Adolescent Psychiatry and Mental Health volume  18 , Article number:  117 ( 2024 ) Cite this article

Metrics details

While research has emphasized the importance of parental support for LGBTQIA + youth wellbeing, there remains limited understanding of parental experiences with nonbinary children, particularly those prepubescent. This study aimed to explore how parents of nonbinary children ages 5–8 learn to support their child’s identity, examining initial reactions, emotional processes, supportive behaviors, societal responses, and associated challenges and rewards.

A qualitative study was conducted using Reflexive Thematic Analysis (RTA) within a framework of ontological relativism and epistemological constructivism. Nine parents of nonbinary children aged 5–8 from the Northeastern United States participated in semi-structured interviews lasting 60–80 min. Questions explored various aspects of parenting nonbinary children, including the child’s gender identity, parental feelings, experiences sharing the child’s identity, and challenges and rewards of raising a gender-diverse child. The research team, comprising individuals who identify as trans, genderqueer, and nonbinary, employed collaborative coding and thematic development.

Four main themes were constructed: (1) Parents hear and support their child’s nonbinary identity , this theme highlights immediate acceptance and efforts parents make to affirm their child’s gender; (2) Parents learn about ways cisnormative society harms their child , here, parents recognize the societal pressures and barriers their children face; (3) Parents take significant and proactive steps to affirm their child , this theme documents the actions parents take to support their child in environments that invalidate their identity; and (4) Gender is just one aspect of who my child is , this theme reflects on parental insights of gender as just one part of their child’s overall personhood.

Conclusions

This study provides insights into the experiences of parents supporting young nonbinary children, emphasizing the importance of affirming expressed identity, the parent-child relationship, and proactive support in navigating cisnormative societal structures. Findings highlight the transformative experience of parenting nonbinary children, with parents often challenging their own preconceptions of gender and coming to more nuanced understandings. These results can inform supportive interventions and policies for nonbinary children and their families, and we hope to contribute to a growing body of research that shifts narratives towards joy, resilience, and community in trans and nonbinary experiences.

Over the past three decades, cultural discourse around ‘intensive parenting’ [ 1 ] has emphasized the need to dedicate significant time, energy, and resources to raising children in a way that prioritizes their ability to communicate needs and self-advocate [ 2 ]. While current literature highlights the importance of parental support for the wellbeing of LGBTQIA + youth [ 3 , 4 , 5 ], there is still very little research focused on the experiences of parents of trans and nonbinary (TNB) children [ 6 ].

In this context, Hidalgo et al. [ 7 ] propose a gender-affirmative model of supportive parenting that views genderqueernes not as a disorder but as a culturally influenced variation shaped by biology, development and socialization. This model acknowledges that gender is fluid rather than binary and suggests that the struggles children experience with identity often stem from societal prejudices like transphobia and the institution of cisnormativity, an element of the social, political and economic system in our society designed to force individuals into a gender and sex binary, while punishing behavior and expression that deviates from it. Legal and medical professionals are primary enforcers of cisnormativity. Despite being society’s supposed experts on gender and sex, as a field they fail to acknowledge the self-determination of gender and conceptualize sex as a spectrum [ 8 ]. This begins with the assessment of genitals at birth and the 'corresponding' gender assignment [ 9 , 10 ].

Amidst the ongoing discourse on gender fluidity, we are witnessing a significant amount of anti-transgender violence. Trans people–especially TNB children– are increasingly becoming the targets of political campaigns, fearmongering, and public debates that challenge their right to exist. In 2023, the number of anti-trans legislation in the U.S. surged dramatically, from 174 (26 passed) to 604 (87 passed), more than tripling the record set the year before. By July 2024, 635 bills had been introduced into state legislatures, with 123 active and 47 passed [ 11 ]. These laws aim to exclude TNB children from accessing healthcare, updating legal documents to reflect their gender, using appropriate bathroom facilities, and participating in school activities such as sports and clubs [ 12 ].

Given these vicious attacks on children, the role of the family in supporting their TNB child has become increasingly critical. Research consistently demonstrates that family dynamics significantly impact the psychological health of LGBTQIA + youth, with supportive environments providing a buffer against stigma, and promoting overall wellness [ 3 , 4 , 5 ]. Recent longitudinal studies underscore that while TNB youth face increased risks for adverse mental health outcomes, their wellbeing improves significantly within supportive family contexts [ 13 ]. Central to this support is the acceptance and understanding of nonbinary identities and expressions, including the adoption of gender-neutral language by family members, which enhances the child’s perception of acceptance from their parents [ 14 , 15 , 16 ].

The sharing of pronouns is becoming increasingly popular in the U.S. and beyond, including Western countries like the UK and Canada, as well as parts of Asia, especially among younger generations and progressive circles [ 17 , 18 , 19 , 20 , 21 ]. A 2020 Pew Research Center survey found that over half of Americans are aware of pronouns that are not ‘she/her’ and ‘he/him’, with younger people being more likely to use them. This trend reflects a growing global awareness of gender existing beyond the binary, as well as the importance of validating these identities through inclusive language. As awareness and popularity of gender diversity grows, it has become popular to share pronouns in introductions and email signatures [ 22 ], and transphobic people have been attempting to politicize pronouns in an effort to villainize TNB people. The adoption of gender-neutral pronouns, like the singular ‘they’, which gained recognition when Merriam-Webster named it the word of the year in 2019, underscores an ongoing challenge to binary norms.

In this paper, we define ‘nonbinary’ as an umbrella term encompassing individuals who self-identify as a gender outside the gender binary, and/or does not identify as always and completely being just a man or a woman, recognizing gender as existing along a spectrum. Various expressions of nonbinary identities are present, such as identifying as both a boy and a girl, experiencing gender as fluid or fluctuating, feeling a partial connection to one gender without fully aligning with it (known as demigender), embracing multiple gender identities, adhering to two-spirit traditions rooted in Indigenous cultures, adopting gender concepts from ‘unrelated domains’ (known as xenogender), or ‘lack of’ a gender [ 23 ]. While terms like ‘trans’ and ‘nonbinary’ originate from Western contexts, they strive to encompass a diverse and evolving spectrum of gender identities. It is important to note that while many nonbinary individuals may identify as trans, not all do.

For nonbinary people, recognition and affirmation is deeply intertwined with language use. Employing gender-affirming language—such as neutral labels, pronouns, and grammatical structures—in environments like schools, workplaces, healthcare facilities, and the home, is crucial for encouraging “self-definition,” as well as “visibility and understanding” of nonbinary identities [ 24 ]. In Budge and colleagues [ 14 ]’ five-year study of families with a TNB member, pronouns were best understood by the end of the research period. Their findings suggest that conducting regular family check-ins on gender identity, pronouns, and gender expression can significantly enhance family members’ understanding of the individual’s needs. Matsuno and colleagues [ 25 ] found that support can be further conceptualized as advocating for the child’s rights across various settings, expressing love verbally and nonverbally, and actively seeking community and professional resources for the growth of both the parent and the child.

Some studies have documented that initial parental reactions to their child’s TNB identity such as shock, fear, and worry, often hinder their acceptance and support [ 26 , 27 ]. These emotional barriers, compounded by cisnormativity and transphobia in society, may lead to reluctance in acknowledging or understanding TNB identities [ 28 ]. Moreover, entrenched beliefs in binary and immutable gender norms further complicate parental efforts to support nonbinary children. In fact, Matsuno and colleagues [ 4 ]’ study found that among parents of TNB youth, half of those who were unsupportive had nonbinary children, indicating potentially greater challenges in support within this demographic.

McGuire and colleagues [ 29 ] theorized that the presence of a TNB individual in a family leads to other members of the family challenging existing theories about essentialist and social constructionist notions of gender and sexuality. Given that gender is “messy, plural and in constant evolution” [ 30 ], these authors argue that describing it requires “dynamic approaches […] that can account for within-person variability over time” ( [ 29 ] p.63). This perspective underscores the evolving nature of gender identities within families and highlights the need for flexible mental frameworks that are welcoming to the diverse expressions of nonbinary individuals.

Addressing emotional barriers, transphobia, and cisnormativity necessitates parents being equipped with the knowledge and skills to navigate the social exclusion of nonbinary identities effectively [ 27 , 28 ]. Facilitators of supportive parental behaviors include building social support networks, and accessing informational resources [ 4 ]. Connecting with others, whether online or in person, is crucial for parents of TNB youth, highlighting the importance of making support groups accessible [ 31 ]. Exposure to positive portrayals of gender diversity also plays a crucial role in fostering affirming parental attitudes and behaviors [ 32 , 33 ]. Schools often lack knowledge about gender diversity and inclusive practices suitable for all children, regardless of their gender identity. Therefore, in these environments, parents have to ‘make room’ for their children by informing school staff about their child’s chosen names, pronouns, individual needs, and sometimes even providing basic education on gender identity and diversity [ 34 ].

The trans family systems framework, proposed by Robinson and Stone [ 35 ], challenges traditional family dynamics by integrating trans identities as an analytical category [ 36 ]. This category questions the sex/gender distinction, challenges biological determinism, exposes the production of normativity, and disrupts cisnormative gender practices. The trans family systems approach explores how either investments in or divestments from cisnormativity shape both family interactions and individual experiences. The concept of cisgender divestments [ 35 ] describes how family members resist cisnormative gender norms to support their gender-diverse children. Actions such as providing a variety of toys, clothes, and activities (i.e., ‘gender buffet’ [ 37 ]), and validating TNB identities (i.e., ‘giving gender’ [ 38 ]), can be seen as forms of cisgender divestment.

Parents are not only socializing their children, rather, parents are also re-socializing themselves. This means that many caregivers are rethinking their own relationship to gender as they engage in ‘gender-expansive childhood socialization’ [ 39 ]. Initially, children are often required to ‘prove’ their identity. Subsequently, these same parents of TNB children often find themselves explaining their children’s gender to others [ 40 ]. Many caregivers transition from confusion and uncertainty to ‘pride’ and ‘empowerment,’ becoming advocates for TNB people beyond their children [ 29 ]. Learning to affirm one’s TNB child not only enhances family cohesion, but also contributes to a broader divestment from cisnormativity.

The evolution of parental responses to nonbinary identities reflects a broader societal shift from pathologizing to affirming non-normative identities. According to de Bres [ 41 ]’ critical review of research on parents of gender-diverse children, early studies from the 1990s and 2000s predominantly took a pathologizing stance toward gender diversity in children, often validating parents’ negative reactions. During the 2010s, research began to shift towards a more affirming perspective, although it still frequently equated the experiences of a ‘parental transition’ to a process of grief [ 42 ], continuing a level of pathologization. Hidalgo and Chen [ 43 ] assert that parents experience both external stressors (e.g., school discrimination, rejection by family and friends, and verbal abuse) and internal stressors (e.g., negative messages about gender diversity and ‘fitting in’ difficulties) while supporting their nonbinary child’s identity. Parents worry about their child’s well-being in a society that often invalidates gender diversity. Supportive parents might also face stigma and a reduction in social safety, such as losing connections with family, friends, and religious communities. Additionally, they must address their own cisnormative beliefs and navigate barriers in educational and healthcare settings. These challenges can impact their ability to support their nonbinary child [ 25 ].

Since the late 2010s, there have been numerous documented stories of parents highlighting their support for TNB children by shielding them from societal stigma, embracing a gender-affirming approach, and normalizing gender diversity in their home and broader community [ 41 ]. Recent studies have shown how parents are reframing the narrative of grief, instead focusing on the rewards of parenting a TNB child, which include ‘greater critical awareness’ [ 44 ], ‘expanded knowledge’ [ 45 ], and ‘personal growth as a parent’ [ 46 ]. Abreu et al. [ 47 ] describe this shift as “using radical hope to create meaning and purpose for their child’s existence and envisioning positive future possibilities for them” (p.7). Exploring positive experiences in parenting TNB children can counterbalance the traditional focus on challenges, reflecting many parents’ narratives of joy and transformation.

In summary, the literature underscores the critical role of family support in shaping the wellbeing of nonbinary youth, highlighting the transformative power of parental acceptance and understanding. However, existing research predominantly focuses on trans boys and girls, primarily adolescents, and their families. Little attention has been paid to families with young children who identify beyond the gender binary. Our study aims to “contribute something to a rich tapestry of understanding” Footnote 1 by exploring, in a general sense, the experiences of parents of nonbinary children, guided by our research question, ‘How do parents of nonbinary children learn to support their child?’ Specifically, we seek to understand initial reactions to their children sharing their gender, and changes over time, as well as emotional processes, supportive behaviors, societal responses, and the challenges and rewards for parents in this context. By exploring these dynamics, we aim to contribute insights that can inform supportive interventions and policies tailored to meet the needs of young nonbinary children and their families.

Methodology 

Our study Footnote 2 , Footnote 3  was initially conceived by [AUTHOR 3– MASKED] and further developed with [AUTHOR 1– MASKED] during a summer scholars’ program that supports juniors and seniors in conducting ten-week research projects with faculty mentors. [AUTHOR 3– MASKED], a Brown trans, genderqueer, and nonbinary Mexican immigrant who holds a doctoral degree from the largest university in Latin America, also serves as an Assistant Professor at a private ‘little ivy’ university in the U.S. [AUTHOR 1– MASKED] is a white, trans, genderqueer, and nonbinary undergraduate student at the same institution Footnote 4 .

The research question for this study was addressed within a paradigmatic framework of ontological relativism and epistemological constructivism. This fully qualitative approach (i.e., ‘Big Q’), combined with Reflexive Thematic Analysis (RTA), fosters a nuanced and reflective research practice. Unlike more structured and positivistic methods, ontological relativism views reality as diverse and shaped by human actions and interactions [ 48 ]. Interpretations of reality differ across cultures and contexts, acknowledging that reality is not fixed. This study is based on the idea that people construct meaning from their experiences (constructionism) and express this through their individual perspectives (relativism). Epistemological constructivism posits that knowledge is dynamic and evolves as individuals reflect on their beliefs and experiences, contributing to collective understanding. This qualitative analysis values the symbolic power of language in data collection, recognizing its role in meaning-making [ 48 ].

Recruitment

Parents were eligible to participate in our study if their child identified beyond the gender binary (see page 1), was aged between 3 and 8 years, and lived in the Northeastern U.S. (Connecticut, Maine, Massachusetts, New Hampshire, New Jersey, New York, Pennsylvania, Rhode Island, and Vermont) to make transportation expenses feasible. Prepaid train rides, parking fees, and/or bus fare were provided.

Between July and August 2022, we created a database and contacted organizations supporting LGBTQIA + individuals/families. In October 2022, specialists from the National Institutes of Health Clinical and Translational Science Program (NIH CTSI) launched a one-month Facebook targeted advertising campaign (UL1TR002544) and posted an advertisement on Craigslist from October 2022 to March 2023. Eleven parents completed a Qualtrics questionnaire, and nine met the inclusion criteria (see Table  1 ), proceeding to the scheduling of an in-person visit. Families received a $50 USD gift card as compensation. Despite efforts to sample a diverse population, seven participating parents were white, one was Asian-white, and one was Asian. Additionally, all were married, lived in the Greater Boston Area, and earned between the categories of $50,000 to $74,999 USD, and $150,000 USD and above, with a mode of $150,000 USD and above. For reference, the median household income in Boston was $81,744 in 2021 Footnote 5 . Although we desired to interview parents of children ages 3–5, we only recruited those with children ages 5–8.

Methods: interviews

The semi-structured interview consisted of 10 predetermined questions, with consent documented from all participants. The interviews typically lasted 70 minutes on average, ranging from 60 to 80 minutes. Questions were designed to explore various aspects of parenting children who identify beyond the gender binary, including describing the child’s gender (e.g., ‘How would you describe your child’s gender?’), changes in gender identity over time (e.g., ‘Has their gender changed over time?’), parental feelings towards the child’s gender identity (e.g., ‘How do you feel about them being [preferred term for child’s gender]?’), experiences sharing the child’s gender identity with others (e.g., “How have people in your child’s life reacted to them being [preferred term]?’), as well as the challenges and rewards of raising a gender-diverse child (e.g., ‘What has been the most rewarding part of raising a [preferred term] child?’). The study adhered to ethical standards set by institutional and national research committees, following the principles of the 1964 Helsinki declaration and its subsequent amendments or comparable ethical standards.

Reflexivity

[AUTHOR 2 - MASKED], a white graduate student who identifies as trans, genderqueer, and nonbinary, transcribed the interviews. In summer 2023, [AUTHOR 3– MASKED], along with [MASKED], conducted a 5-day workshop on Reflexive Thematic Analysis (RTA). Although exclusively mentioning our skin color, gender identities and educational attainment may resemble a ‘brief confessional’ - see the first paragraph of the Method-ology section and [ 49 ] -, on the workshop’s first day, each author spent a 4-hour period crafting their own reflexivity statement, dedicating the initial hour and a half to writing and the remaining time to sharing. These statements proved invaluable throughout the analysis.

Under AUTHOR 3’s guidance, who regularly practices this exercise each semester, the other authors were prompted to reflect on their intersecting identities, social privileges, and marginalities. They were asked to consider how these positions influence their perspectives in the research, and how it may affect how they are perceived by others. Additionally, they reflected on how their backgrounds, life experiences, and beliefs shape their worldview. Next, the authors examined their relationship with knowledge, scholarship, and research practice, considering their research training, experiences, and understanding of ‘good quality’ research, as well as institutional pressures including the capitalist demand to ‘publish or perish.’ They also explored their methodological preferences and how these choices impact the research process and outcomes. Finally, AUTHOR 3 encouraged them to revisit reflexivity regarding their identities and experiences in relation to the project and nonbinary children. They considered how their positions intersect with this topic and examined any assumptions about individuals inside and outside the gender binary. These statements, while lengthy, fostered a sense of closeness and safety among the group. Ideally, they would be included here, but due to the constraints of academic publishing and the emphasis on brevity, interested readers can contact the corresponding author for access.

In summary, the three of us identify as trans, genderqueer, and nonbinary individuals, and share the following beliefs: (a) reality and truth are constructed, contingent, and multiple; (b) gender is experienced in a unique way by everyone; (c) nonbinary individuals know who they are [ 50 ]; and (d) we prioritize compassion and curiosity over comprehension [ 51 ].

Reflexive Thematic Analysis (RTA)

Thematic Analysis is a method for identifying, analyzing, and interpreting patterns across qualitative data. Reflexive Thematic Analysis (RTA) differentiates itself by valuing “.a subjective, situated, aware and questioning researcher, a reflexive researcher.” ( [ 48 ], loc. 1246). We followed the six-phase RTA process: familiarizing ourselves with the interviews, engaging in collaborative coding , developing , reviewing , refining themes, and finally, producing this analytic report.

While familiarizing ourselves with the data is an ongoing process with no single approach, coding is structured and systematic. We carefully read each interview at least twice, identifying and labeling segments relevant to our research question (‘How do parents of nonbinary children learn to support their child?’). Not all segments were coded, as codes are “.ultimately guided by your research question and purpose.” ( [ 48 ], loc. 2953).

Collaborative coding enhanced our understanding, interpretation, and reflexivity, rather than achieving consensus on codes. The three authors worked together, discussing and reflecting on their ideas and assumptions. Our aim was to “.gain richer or more nuanced insights collaboratively, not t o reach agreement on every code.” ( [ 48 ], loc. 3028). This structured exploration ensured a thorough analysis for theme development and attempted to safeguard against accusations of cherry-picking .

We used an inductive approach with predominantly semantic codes. Pure induction is impossible as “.we bring various perspectives, theoretical and otherwise, to our meaning-making,” and as a result “our engagement with data is never purely inductive” ( [ 48 ], loc. 3027). Semantic codes capture expressed meanings, often mirroring participants’ language, unlike latent coding, which prioritizes underlying meanings that are not explicitly stated.

Thematization (development, revision, and refinement)

Developing initial themes from our codes involved several processes. We explored areas of similar meaning within the data, clustering potentially connected codes into candidate themes, and examining these patterns of meaning. Each cluster was considered independently, in relation to the research question, and within the broader analysis. We recognized that data “do[es] not speak for [itself];” as researchers, we interpret and tell the story of our data [ 48 ].

Phase four provided a crucial check on initial theme development through re-engagement with coded data extracts and the entire dataset. This iterative process ensured that our analysis effectively addressed our research question with a compelling narrative, remaining grounded in the data. We ensured each theme captured a distinct core point and offered rich diversity and nuance, verifying that themes were coherent, distinct, and comprehensive.

We constructed four themes that emerged from the accounts of participating parents. The first theme, Parents hear and support their child’s nonbinary identity , details how children share their nonbinary identity with their parents and documents parents’ initial reactions and meaning-making processes. The second theme, Parents learn about ways cisnormative society harms their child , captures how parents learn about the struggles their child faces living in a cisnormative society as a nonbinary person. The third theme, Parents take significant and proactive steps to affirm their child , documents participants taking action to support their child in environments that do not validate their gender identity. The fourth and final theme, Gender is just one aspect of who my child is , discusses insights and conclusions drawn by parents about their child, as well as gender identity. These themes are discussed in detail below.

Theme 1: Parents hear and support their child’s nonbinary identity.

Among all parents, a universally reported experience was receiving a clear and straightforward declaration from their children about their nonbinary identity. Some examples of these explicit statements include: “They always say, I’m not a girl or a boy” (Dahlia), “[They] tell me that [they are] both a boy and a girl” (Helena), and “They describe themself as ‘they/them’” (Iris). All parents were told by their child the way they had been referred to and understood thus far was not correct (i.e., as exclusively a girl or a boy).

All but one parent’s reaction to their child informing them of their gender identity was immediate support for their desired changes (e.g., pronouns and name): “‘Can you call me they/them?’ ‘Okay, great’” (Iris); “Awesome! Whatever you want, we will follow you and affirm you” (Fiona); “We just said ‘okay,’ and we did it” (Grace). The overwhelming support from these parents reflects other child-led approaches, placing affirmation of the child’s lived experience at the center of their parenting style, and validating their emotions and desires even without necessarily understanding them [ 2 ].

Some parents initially found it challenging to adjust to using their child’s new pronouns or name, but they all made their best effort. Bianca candidly shared that her husband struggled a lot with they/them pronouns, “not for lack of love or trying, [he] just didn’t have [.] much practice”. The time and effort all parents had to spend to retrain their brain to meet the expressed needs of their child follows the previously mentioned movement towards ‘intensive parenting’ [ 1 ].

Despite the dominant paradigm of a gender binary in Western society, no parents reported skepticism of the validity of their child’s nonbinary identities. In fact, the majority of the parents were active in divesting from cisnormativity [ 35 ], with six parents explicitly making an effort to raise their children in ways that were not constrained by traditional gender norms. Adrienne explained that she was “quite strongly opposed to having a very gendered upbringing,” and Grace shared a similar sentiment, emphasizing that she wanted her children to “play with whatever [toys] they want,” and that she would buy “whatever clothing” for them. The actions described by these parents exemplify forms of cisgender divestment [ 35 ] and a movement away from strict ideas of what a child assigned male at birth (AMAB) or assigned female at birth (AFAB) should look like or how they should act.

Despite the traditional paradigm of a gender binary in society, no parents reported skepticism of the validity of nonbinary identities. In contrast, the majority of the parents valued divesting from cisnormativity [ 35 ], with six parents explicitly making an effort to raise their children in ways that were not constrained by traditional gender norms. Adrienne explained that she was “quite strongly opposed to having a very gendered upbringing,” and Grace shared a similar sentiment, emphasizing that she wanted her children to “play with whatever [toys] they want,” and that she would buy “whatever clothing” for them. The actions described by these parents exemplify forms of cisgender divestment [ 35 ] and a movement away from strict ideas of what a child assigned male at birth (AMAB) or assigned female at birth (AFAB) should look like or how they should act.

Additionally, four parents spoke with their child about gender being more than just boy or girl before their child named themselves nonbinary. Adrienne had “a book about gender identity,” and Fiona had “books that have nonbinary characters and just talk about gender identity and expression.” Bianca “read some books where there was they [pronouns] as an option” and “talked about what that meant ‘’ with her child. Grace could not “point to a moment when [they] started talking about gender and pronouns because it’s [always] been incorporated.” Alternatively, a few parents made no mention of proactively sharing gender-diverse stories, with Christine describing their early conversations around gender as “talking about boys and girls […] talking within the binary, because […] that’s sort of the usual thing.”

Overall, the majority of these parents demonstrated active efforts to divest from expectations of cisnormativity, even before learning their child was nonbinary, with some even deconstructing the gender binary through supportive environments that benefit TNB youth [ 35 , 37 , 38 ]. However, not sharing previous efforts to divest from cisnormativity is also a common experience among both the parents in our study, and parents of TNB children in other studies [ 29 , 40 ]. There is no evidence supporting the absurd notion that home environments can ‘turn children trans’ [ 52 ], and the briefly popular theory of ‘rapid onset gender dysphoria’ has been debunked [ 53 ]. Conversely, supportive home environments help TNB children freely explore and come to understand themselves ( [ 23 , 52 , 53 ], and actually fosters a ‘stronger attachment’ between parent and child [ 42 ].

While all parents supported their child’s gender identity, some still grappled with doubts and concerns along the way. Iris and Grace questioned whether their child understood what they were saying or was simply using they/them pronouns “because [a peer] said it” (Grace). Grace “didn’t know” whether the desired name/pronoun changes “would stick,” a sentiment echoed by Adrienne’s husband. Additionally, there were concerns about whether the child was “transitioning too young.” Christine expressed caution, not wanting to “act too quickly,” or “be seen to be pushing something on the child,” while Emiko mentioned concerns about their child being perceived as “too young” possibly reflecting societal worries. This experience is not uncommon among parents of TNB children [ 29 ]. These parents faced a challenging situation; there is no script for raising nonbinary individuals -as we will discuss further-, and currently, there is a widespread fear-mongering targeting parents of TNB children [ 53 ]. Despite these doubts and uncertainties, all but one parent in the study immediately affirmed their child. Many parents expressed worries about their child’s future as a nonbinary person in society, but they understood this as a concern to bear with their spouse, not one with which to burden their child.

Two factors which may have helped parents overcome their doubts, or at least put them aside, are their observations of cisgender nonconformity in their children before the children shared their nonbinary identity, and the insistence of the children themselves.

Bianca, Fiona, Emiko, and Iris’s children who were AMAB all enjoyed wearing dresses, an example of physical presentation not stereotypically associated with their assigned gender. Other parents noted verbal expressions: Adrienne’s child would “call themself a boy or a girl […] depending on what [they] felt more like,” while Christine recalled her child, AFAB, stating plainly that they “don’t always feel like a girl.” Therefore, when these children expressed a desire to use different names or pronouns, it did not necessitate a complete overhaul of how the parents understood them. Reflecting on her reactions to her child sharing their nonbinary identity, Grace shared that she “[was not] really surprised,” Adrienne stated that “[she] had often suspected [her child’s] idea of gender was not [rigid],” and Emiko adding that she felt her child “has never cared about [society’s] gender boundaries.”

Multiple parents mentioned that seeing their child “feel strongly” (Bianca) about their gender identity, “even in the face of lots of situations where it would have been easier [to not identify as nonbinary]” (Dahlia), helped affirm their support. Christine noted that her child’s insistence made it “increasingly clear” to her that their gender identity was both “very important to them” and “that it was real,” and Emiko added “[they] have a sense of agency.”

Although the parents may not fully comprehend their child’s identity, they showed respect for their child as a self-advocate and are committed to centering their child’s expressed needs [ 1 , 2 ]. This can be seen as a way of prioritizing compassion and curiosity over comprehension [ 51 ].

Theme 2: Parents learn about ways cisnormative society harms their child.

With that said, aside from a parent who also identifies as nonbinary, the parents lacked prior understanding of the specific needs of a nonbinary child. We are all familiar with parenting scripts tailored for raising cisgender children, reinforced by abundant resources and support networks, both formal and informal. However, the same cannot be said for parents of nonbinary children. Christine shared her experience of researching how to “best support” her child, finding that there “[is not] a lot out there.” The unique nuances and challenges faced by nonbinary children have not been sufficiently discussed or documented to establish rudimentary frameworks or ‘best practices’ [ 2 ]. As a result, these parents found themselves having to find other ways to learn about their child’s needs, largely through conversations with them as well as observing their child’s reaction to experiences, for example, Fiona described herself as a “sponge” absorbing so much new information. Despite their affirmation of the child’s gender identity and use of validating language, it became evident to the parents that their support needed to extend beyond the home.

One common experience for parents was observing their child feeling pressure to “[not] rock the boat” by “bucking” (Fiona) societal norms of gender presentation. Fiona’s AMAB child enjoyed wearing dresses and having their nails painted at home, but intentionally wanted both off before going to school. Helena’s AMAB child was generally open about their feminine expression, “I am a girl, or I feel like a girl,” they would say, yet emphasize, “but it’s secret and I only want you and daddy [to know].” Emiko described an interaction where her AMAB child said, “Most people think that I’m a boy, so if I wear a dress, they’re confused.” The parent followed up, asking “Is that what’s stopping you from wearing a dress?” to which the child responded, “A little bit.” Grace reported her child hesitating about sharing their pronouns with their transphobic grandmother, saying “I don’t want my relationship with grandma to suffer because I’m nonbinary.” This really struck Grace, “the kid is eight years old saying that to me.” All the parents with these experiences shared some understanding gained about their child. Helena reflected that her child “has some awareness […] that being nonbinary is different.” Fiona understood that her child “was self-conscious […] about what people would think,” and Emiko, similarly, saw that her child was feeling pressure from a “societal ‘you should do this.’” It became very clear to the parents that their children were keenly aware of cisnormativity and felt pressure to conform.

Parents also observed barriers to inclusion that exist in what are mundane, day-to-day moments for cisgender people. Some reported their children getting frustrated when confronted with the categorizations, including bathrooms, sections in stores, and birthday party goodie bags. Parents also witnessed their children’s worry and frustration in the context of various forms of potential and realized micro- and macro-aggressions, including experiences of minority stress [ 54 ]. For instance, not wearing button up shirts in public “because they were worried that they would be called he” (Bianca), deciding it was “not worth it” to attend to an otherwise ideal camp that was separated into ‘boys’ and ‘girls’ (Emiko), feeling like they “have to” wear a pin that says ‘They/Them’ to avoid being misgendered at school (Grace), and frequently correcting people in public (Adrienne, Bianca, Grace), among many other experiences. Bianca best summarizes what all parents come to understand: their children are made “very upset” about the fact that “the world is not set up to include them.”

When these children leave their homes, they confront a world that overwhelmingly does not validate their identity. Through conversations and observed experiences, parents came to understand distress, anger, and shame their children feel at being constantly invalidated, and gained insights into what kinds of support and affirmation their children need.

Theme 3: Parents take significant and proactive steps to affirm their child.

As expanded on in the second theme ( Parents learn about ways cisnormative society harms their child) , parents came to recognize the importance of their child’s gender being affirmed and that society is not currently set up to do that. These parents observe their child often having to either self-advocate or endure micro- and macro-aggressions. Following the pattern of intensive parenting, these parents felt a strong desire to advocate for and protect their children, “to make things a little smoother for [their] life” (Iris). It is understood that parental support has a strong influence on the mental health and wellbeing of TNB people [ 14 , 15 ], highlighting the importance of this approach by parents.

One area of identity affirmation parents recognized as lacking for their children was in models of nonbinary identities. The parents express an understanding that their child rarely, if at all, sees people who share that aspect of their identity. Bianca wanted her child to get more “exposure” to people who “exist outside of this rigid gender binary,” and as Christine points out, “they see plenty of cisgender people. I’m not worried about them not having cisgender role models.” As a result, parents take steps to correct this. Christine took a book that did not explicitly address nonbinary experiences and “spent six hours whiting out and writing new words over every part of it.” Adrienne started going out of her way to attend a queer rock-climbing club in an effort to “cultivate a [queer] community” for her child, and introduced them to a nonbinary person she met there. Iris and Dahlia also made explicit efforts to provide their children with gender-diverse representation.

Same-gender models are understood to be important in one’s development and understanding of gender [ 55 , 56 ]. While children imitate individuals with traits they identify with, and not just people of their gender [ 55 ], much research has reaffirmed the importance of same-gender models. Although these studies have generally focused on girls and young women, research from nonbinary author Koonce [ 57 ] states from their professional experience “.it is in the mirroring of others that [non-binary identities] truly take form” (location 3,021). Kuper and colleagues [ 56 ] add that exposure to models with diverse gender presentations is crucial in supporting ongoing gender exploration.

Parents come to understand that the act of negotiating one’s way through transphobic and cisnormative systems is a “heavy lift” (Bianca). They do not want their child to have to be “constantly” (Bianca) educating and correcting people, especially “[not] by themselves” (Christine). Parents would rather take on the “forefronting” (Dahlia) and “emotional labor” (Christine) themselves. The overwhelming sentiment from parents is that “[their child] should not be expected to do” (Grace) the work of making space for themselves.

Despite the diverse realities of the children and experiences of the parents, a pattern emerged: parents respected their child’s ability to know and communicate their desires and leveraged their abilities and resources as adults to support them. A common example involved pronouns in public. According to Garcia [ 58 ], ‘gender math’ refers to the complex calculations parents must make when attempting to prioritize their child’s well-being while simultaneously accounting for restrictive systems of cisnormativity. For decisions regarding sharing their child’s gender identity, Bianca and her child devised a collaborative scale-ranking system to gauge the significance of individuals. “Is this an important person that we need to [understand your gender]? Is this person not worth it? Can this person potentially be toxic?” In similar fashion, Emiko and her child “came up with a system” to organize how much they care about the person in question, and gave us the example, “Do we care about the gas station attendant? Not really.” Powell and colleagues [ 42 ] similarly found that sharing the child’s gender with extended family was “often led by the child” (p.4). Additionally, a parent in their study shared that when they had made the decision without their child’s consent it “caused a big problem” (p.4). This kind of collaborative approach empowers the child to make decisions while also providing the assurance of a supportive caregiver during challenging circumstances.

In situations where the child was subject to explicit invalidation and/or transphobia, parents very readily took strong action. Adrienne shared that her child’s grandma refused to correctly gender the child. In response, she “nearly asked her to leave,” and was currently undergoing a “grandma rehabilitation plan.” Adrienne made sure it was clear to both the grandparent and the child that transphobic behavior was “[not] welcome under this roof.” Christine and Grace shared instances of invalidating behavior by their child’s classmates relating to gender which prompted them both to contact their child’s teachers, demanding that they “do better” (Christine) to make their child feel safe and included in the classroom. Ehrensaft [ 59 ] advocates for parental involvement in actively dismantling social pathologies that adversely affect trans youth such as gender policing and harassment. She recommends methods such as direct intervention within broader institutional spheres, encompassing schools, social institutions, and policy-making bodies.

While strategies were initially discussed between the parent and child, many parents became exceptionally proactive in their support. The parents’ efforts extended beyond casual conversations. While correction after an instance of misgendering or other aggression is crucial, the parents recognized the importance of minimizing these experiences before they occur. Bianca decided to coach her child’s soccer team “because [they] wanted to make sure [the team] was a safe space [for their child]” and that all the children “could hear role modeling of using ‘they’ [pronouns].” Emiko reached out to her child’s teachers and sports coaches, urging them to adopt inclusive language and suggesting alternatives to gendered terms: “You could use, ‘alright players,’ or ‘alright team.’” Fiona found a “How to They/Them book” immensely helpful, sent it to everyone in her family and is “making [them] read it.” Christine and her husband expended “a lot of emotional labor” to get their family on the “right page.” She shares that advocating for her child has been “a huge time investment on [her] part,” but that she is “fighting the good fight,” echoing a sentiment shared by all parents.

Theme 4: Gender is just one aspect of who my child is.

In society, there’s a prevalent notion that undergoing a gender ‘transition’ entails a departure from one’s ‘pre-transition’ self. This misconception is especially pronounced in expectations regarding clothing and presentation, where there is a common belief that AMAB individuals who are TNB must present as feminine, and vice versa. However, this presumption extends beyond outward appearance to encompass behavior and preferences as well. It originates from the entrenched concept of gender binary, whereby deviation from assigned gender norms is often perceived as a desire to conform to the norms of the ‘opposite gender.’ Through the parents’ demonstrated willingness to let their child’s expressed emotions and demonstrated actions alter their preconceived notions and internalized frameworks, the parents came to understand that very little about their child’s ‘being’ changed after sharing their nonbinary identity [ 2 , 42 ]. These experiences helped the parents expand their understanding of what gender is, but also what gender is not: a determining characteristic of a person’s identity.

In Grace’s experience, her child’s nonbinary identification “did not change anything about [their] clothes or identity or books or anything.” In comparing her child pre- and post-nonbinary identification, Adrienne explains “they wear the same things they’ve always worn. The main [difference] is they tell people that they’re nonbinary.” Instead of basing presentation off of gender, Bianca observed her child dressing “for practical reasons,” namely the weather and season, and Helena shared her child’s understanding of clothes being as plain as “[these shoes] are on my feet and I’m wearing them.” Fiona shared that at first when learning that her AMAB child was nonbinary, her brain struggled holding it as they felt that her child “seem[ed] like such a boy.” Fiona had to open her mind to what nonbinary could mean through meeting people of diverse gender identities and presentations, and reading books, and arrived at the conclusion that “if there are 7 billion people, [there are] 7 billion [gender] identities.”

A big takeaway explicitly communicated by six parents, is that gender is just a part of how they understand their child as a person. Powell and colleagues [ 42 ] had the same finding with parents of TNB children between the ages of 10 and 18. Parents acknowledge that while the identification with naming a nonbinary identity (nonbinary, boy-girl, etc.) holds personal, practical, and political significance, and while it can be and is a very important identity to many people, it does not provide a singular definition of their child. Iris identifies her child’s nonbinary identity as just “another characteristic, [but] not what defines [their child].” Dahlia adds that “[gender] is a piece of information, but it’s not the most interesting or important thing about who they are.” Christine understands the nonbinary identity to be a component of their child’s identity in addition to “loving Lego and loving dresses, and jumping off stuff, and hitting stuff with other stuff. It’s just part of their kernel, you know?” Expressions like the highlighted quote are not meant to invalidate or diminish the nonbinary experience. Instead, they seek to understand gender as an integral aspect of the child’s being, one that significantly influences their interactions within society. Nevertheless, this acknowledgment does not necessitate a complete overhaul of their core identity. In reflecting, Iris shares, “I try to think of them as a person that I’m finding out about and not a set of expectations,” and that she tries to “not to make [gender] a big deal […] a guiding thing that I have taken from [my child].” Adrienne adds, “It’s the same child that I’ve always known, just using different pronouns,” and Bianca is glad that her child feels that “[they] can be anything [they] want. But [does not] have to be not something.” These parents came to recognize that their child’s nonbinary gender was simply an extension of who the child already was. Bianca found this experience “really joyous,” and for Helena, seeing their child being themself was “indescribably heartwarming.” Dahlia feels that it is “such a gift,” and “rewarding to know that they know” they can be their true self, and Fiona echoes that she feels “happy… that they’ve discovered that this can be their identity.”

General discussion

We examined how parents of nonbinary children learn to support their child through the lenses of ontological relativism and epistemological constructivism. We interpreted these parents’ experiences, taking on the role of ‘subjective storytellers’ [ 48 ]. Despite space limitations, our aim was to offer a comprehensive exploration and contribute nuanced insights to the limited, yet growing, understanding of parental support for gender affirmation among TNB youth [ 6 , 13 , 14 , 25 , 31 , 47 , 52 ]. Our aim was not merely to ‘fill a gap’ but to enrich the broader understanding that we and others are collectively developing [ 48 ]. Our strength lay in adhering to a ‘Big Q’ approach that challenges the structured and positivist paths towards absolutisms.

As a result, RTA was the perfect methodology for our study. We were interested in “…process and meaning, over cause and effect; a critical and questioning approach to life and knowledge; the ability to reflect on the dominant assumptions embedded in [our] cultural context—being a cultural commentator as well as a cultural member; the ability to read and listen to data actively and analytically […] a desire for understanding that is about nuance, complexity, and even contradiction, rather than finding a nice tidy explanation…” ( [ 48 ], loc. 1334). We made active efforts to reflect on dominant assumptions and divest from cisnormativity in our daily lives [ 35 ]. Moreover, we, the authors–cultural commentators– are still learning what it means to be trans, genderqueer, and nonbinary–cultural members– in a society that has traditionally only had space for men and women. We are collectively working on this tapestry of understanding.

While all parents supported their child’s gender identity, some struggled with doubts and concerns, highlighting the nuances and even contradictions in their experiences. Parents faced a complex situation with no clear guidance on raising nonbinary children, amidst widespread fear-mongering targeting parents of TNB children [ 47 , 53 ]. Although we focus on parents and avoid pathologizing and stigmatizing rhetoric, it is a matter of fact that TNB children are facing intense violence and legislative attacks, with more anti-trans laws introduced in the past nine years than in the previous 240, aiming to restrict their healthcare, legal recognition, participation in school activities, and more [ 9 , 12 , 60 ]. In the face of this anti-trans violence and exclusionary legislation, recent scholarship emphasizes that trans communities extend beyond struggle and hardship, embracing resilience and thriving through radical hope [ 47 , 61 , 62 , 63 ].

de Bres [ 41 ]’s recommendations fit well within this call to shift the narrative towards joy. This is why we aimed to ask similar questions and create a realistic but uplifting account that acknowledges struggles but celebrates the joys of parenting a nonbinary child. As de Bres [ 41 ] reminds us, the questions researchers ask shape the responses they receive. Common questions like ‘When did you first notice your child was gender-diverse?’ often prompts a ‘coming-out’ narrative. Shifting to asking questions such as ‘What has been the most rewarding part of raising a [preferred term] child?’ can prompt reflection through a more joy- and strengths-based lens.

One of our primary insights was the discovery that parents approached parenting a nonbinary child within minimal preconceptions. This finding was surprising, considering prevalent societal narratives, often steeped in fearmongering as previously discussed. While we recognize that not all initial parental reactions may have been disclosed during interviews, those that were shared demonstrated a nuanced understanding of nonbinary identities. Parents deconstructed much of society’s cisnormativity and debunked transphobic misconceptions. Particularly notable was their collective sentiment that their child’s nonbinary identity is ‘just’ simply another integral aspect, as natural as their love for activities like soccer or building with Legos, and as natural as their other children identifying as girls or boys.

Furthermore, we were impressed by their comprehension of the fluidity inherent in their children’s nonbinary identities, embracing expressions that may encompass elements considered traditionally masculine or feminine. This included recognizing that their child’s desire to wear a dress and paint their nails on one day and wear pants and a t-shirt another is not merely an ‘exploration’ but a genuine expression of their gender.

We were heartened by the rapid evolution in societal acceptance of genderqueer identities in recent years. As early as 2020, during our collective virtual interactions due to the COVID-19 pandemic, we began to regularly encounter individuals displaying pronouns next to their names -a small but significant shift. Four years later we observe a growing recognition and understanding of ‘they/them’ pronouns, alongside remarkable parental support for young children in the Northeast who identify as nonbinary. Beyond just gender, this progress inspires hope for a world that embraces ambiguity and rejects rigid absolutes, celebrating the diverse spectrum of human experience rather than confining individuals to either one thing or another.

Throughout our exploration of parental experiences, we were struck by their responsiveness to their children’s desires and needs. While following a child’s lead is not a new concept, these parents had minimal pre-existing knowledge of TNB experiences. Their support required a leap into uncharted territory, yet with open minds and attentive listening, they made decisions that appeared highly supportive and affirming of their child’s gender identity to us. Witnessing this support brought us profound joy and optimism amidst pervasive fear mongering rhetoric and transphobic narratives.

Research consistently highlights improved outcomes for TNB individuals when their families support their gender identities. While the relationship between familial support and wellbeing is nuanced, it remains clear that supportive parenting plays a pivotal role. Even within a transphobic and cisnormative society that often lacks understanding of pronoun usage and genderqueer identities, and remains fixated on binary norms, these parents demonstrate that by valuing their nonbinary children’s communications of needs, they can profoundly make them feel seen, loved, and supported.

In conclusion, our pioneering study focuses uniquely on the experiences of parents of nonbinary children, applying rigorous ‘Big Q’ principles and emphasizing narratives of joy. Utilizing RTA, we hope to contribute valuable insights to understanding and supporting young nonbinary children and their families. Christine’s words resonate deeply: “Sometimes I just say to my husband, ‘We’re doing it, this child’s heart is intact. This child’s heart is strong, and intact. And, no matter what, we’re doing it right if their heart is intact’.” This sentiment underscores our commitment to providing shared experiences and celebrating the resilience of TNB communities throughout our research. Our work adds to the growing body of research aimed at promoting understanding and support for nonbinary individuals.

We hope our findings contribute to the shift away from adult-centric perspectives and towards respecting children’s ability to be cognizant of their own needs, as well as understand themselves in the context of broader society. As our study shows, children will be who they are, and will express themselves, despite any barriers. Banning learning or restricting ideas does not control children; it only harms them. Violence against children should never be normalized. Families and youth deserve legal autonomy, and everyone should be educated about the diversity that exists in this world. We are optimistic that these experiences will inspire advocates and lawmakers to recognize children as experts in their own lives, as the parents in our study did.

Our research highlights how parents can deconstruct binary conceptions of gender in favor of more open-minded perspectives, positively impacting both family dynamics and children’s well-being. We are hopeful that these narratives will encourage adults who work with children -therapists, social workers, teachers, coaches, pediatricians, and others- to re-examine their own understanding of gender. To parents who may be struggling or worried about their nonbinary child: we hope our work offers guidance and hope. The gender binary can be unlearned, and new pronouns can be practiced. You can learn from your child and from the growing resources available. Your child knows themself. You will continue to learn about them and their identity, just as they do, and just as every person does.

Data availability

The authors confirm that the data supporting the findings of this study are available within the article. Due to the sensitive nature of the research and limitations of participant consent, the supporting data is not available for sharing beyond what is presented in the article.

In qualitative research “… you are not seeking to show that you have found an empty cell in the spread-sheet of ultimate truth about the topic, which your study will fill in. We think it’s useful to get beyond the filling the gap idea, and conceptualize our qualitative analyses as contributing something to a rich tapestry of understanding that we and others are collectively working on, in different places, spaces and times” (Braun & Clarke, 2022, loc.5192).

The term ‘method’ risks becoming “...a practically orientated descriptive summary, rather than a more theoretically-oriented and reflexive discussion of what, why and how one did the research” (Braun & Clarke, 2022, loc.5232).

“How Do Children Identifying Beyond the Gender Binary and Their Parents Understand Gender?” (IRB ID: CR-01-STUDY00002649).

We emphasize the significance of dynamic and reflective positionality in research, advocating to move beyond static researcher-centered perspectives towards amplifying marginalized communities (Salinas-Quiroz et al., 2024). We also recognize challenges posed by word limits and traditional research guidelines yet stress the continual integration of reflexivity to enrich qualitative inquiry.

Although we collected demographic data, it will not be fa central part of our analysis. The research on demographic factors related to TNB identities is limited, and our sample size is too small to draw significant conclusions about ‘potential correlations.’ Moreover, it’s important to consider broader historical contexts. While there is a common belief that white, wealthy individuals with higher education levels are more socially progressive, focusing solely on these factors overlooks how legal, medical, and academic institutions have systematically reinforced racial, gender and class hierarchies. Emphasizing these demographics risks overshadowing the richness of individual experiences, which is the true strengths of qualitative research.

Abbreviations

lesbian, gay, bisexual, transgender, queer or questioning, intersex, and sexual. The + represent other identities that are noy included in the acronym

Transgender and nonbinary

Reflexive Thematic Analysis

Transgender and Gender Diverse

Assigned Male At Birth

Assigned Female At Birth

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Acknowledgements

We are most thankful to Jocelyn Demos Utrera for helping us with the conceptualization, data curation, investigation and methodology.

This research was supported by [MASKED], and [AUTHOR 3– MASKED]’s start-up research funds (Faculty Research Funds), [MASKED].

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NS: Conceptualization (lead); Writing– original draft (equal); Formal analysis (equal); Writing– review and editing (equal).LG: Data Curation (lead); Writing - review and editing (equal); Formal analysis (equal); Conceptualization (supporting); Writing– original draft (supporting); Methodology (supporting).FS-Q: Investigation (lead); Supervision (lead); Methodology (lead); Funding Acquisition (lead); Project Administration (lead); Formal analysis (equal); Writing– review and editing (equal); Conceptualization (supporting); Writing– original draft (equal).

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Sweder, N., Garcia, L. & Salinas-Quiroz, F. “I’m trying to take the lead from my child”: experiences Parenting Young Nonbinary Children. Child Adolesc Psychiatry Ment Health 18 , 117 (2024). https://doi.org/10.1186/s13034-024-00807-y

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Open Access

Peer-reviewed

Research Article

Financing for equity for women’s, children’s and adolescents’ health in low- and middle-income countries: A scoping review

Roles Conceptualization, Data curation, Formal analysis, Methodology, Supervision, Writing – review & editing

Affiliations Faculty of Health Sciences, Department of Health Management and Policy, American University of Beirut, Beirut, Lebanon, Knowledge to Policy (K2P) Center, American University of Beirut, Beirut, Lebanon

Roles Writing – review & editing

Affiliation Partnership for Maternal Newborn and Child Health, World Health Organisation, Geneva, Switzerland

Roles Conceptualization, Funding acquisition, Writing – review & editing

Affiliations Faculty of Health Sciences, Department of Health Management and Policy, American University of Beirut, Beirut, Lebanon, Knowledge to Policy (K2P) Center, American University of Beirut, Beirut, Lebanon, Department of Health Research Methods, Evidence and Impact (HEI), McMaster University, Hamilton, Ontario, Canada

Roles Data curation, Formal analysis, Visualization, Writing – review & editing

Roles Data curation, Formal analysis, Writing – original draft

Roles Data curation, Formal analysis

Roles Data curation

Roles Conceptualization

Affiliation Knowledge to Policy (K2P) Center, American University of Beirut, Beirut, Lebanon

Affiliation Department of Internal Medicine, Ain Wazein Medical Village, Ain Wazein, Lebanon

Affiliation Saab Medical Library, American University of Beirut, Beirut, Lebanon

Roles Conceptualization, Writing – review & editing

* E-mail: [email protected]

• Lama Bou-Karroum, 
• Domenico G. Iaia, 
• Fadi El-Jardali, 
• Clara Abou Samra, 
• Sabine Salameh, 
• Zeina Sleem, 
• Reem Masri, 
• Aya Harb, 
• Nour Hemadi, 

• Published: September 12, 2024
• https://doi.org/10.1371/journal.pgph.0003573
• Reader Comments

Over the past few decades, the world has witnessed considerable progress in women’s, children’s and adolescents’ health (WCAH) and the Sustainable Development Goals (SDGs). Yet deep inequities remain between and within countries. This scoping review aims to map financing interventions and measures to improve equity in WCAH in low- and middle-income countries (LMICs). This scoping review was conducted following Joanna Briggs Institute (JBI) guidance for conducting such reviews as well as the PRISMA Extension for Scoping Reviews (PRISMA-ScR) for reporting scoping reviews. We searched Medline, PubMed, EMBASE and the World Health Organization’s (WHO) Global Index Medicus, and relevant websites. The selection process was conducted in duplicate and independently. Out of 26 355 citations identified from electronic databases, relevant website searches and stakeholders’ consultations, 413 studies were included in the final review. Conditional cash transfers (CCTs) (22.3%), health insurance (21.4%), user fee exemptions (18.1%) and vouchers (16.9%) were the most reported financial interventions and measures. The majority were targeted at women (57%) and children (21%) with others targeting adolescents (2.7%) and newborns (0.7%). The findings highlighted that CCTs, voucher programs and various insurance schemes can improve the utilization of maternal and child health services for the poor and the disadvantaged, and improve mortality and morbidity rates. However, multiple implementation challenges impact the effectiveness of these programmes. Some studies suggested that financial interventions alone would not be sufficient to achieve equity in health coverage among those of a lower income and those residing in remote regions. This review provides evidence on financing interventions to address the health needs of the most vulnerable communities. It can be used to inform the design of equitable health financing policies and health system reform efforts that are essential to moving towards universal health coverage (UHC). By also unveiling the knowledge gaps, it can be used to inform future research on financing interventions and measures to improve equity when addressing WCAH in LMICs.

Citation: Bou-Karroum L, Iaia DG, El-Jardali F, Abou Samra C, Salameh S, Sleem Z, et al. (2024) Financing for equity for women’s, children’s and adolescents’ health in low- and middle-income countries: A scoping review. PLOS Glob Public Health 4(9): e0003573. https://doi.org/10.1371/journal.pgph.0003573

Editor: Ashish Singh, Indian Institute of Technology Bombay, INDIA

Received: December 15, 2023; Accepted: July 15, 2024; Published: September 12, 2024

Copyright: © 2024 Bou-Karroum et al. This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Data Availability: All data underpinning the results of the scoping review are found within the paper and in the Supporting Information files.

Funding: This work is funded by the Partnership for Maternal, Newborn and Child Health (PMNCH) at the World Health Organization (WHO). The Partnership for Maternal, Newborn and Child Health (PMNCH) has contributed to the development of this work, as part of its 2021–2025 strategy and related workplans. PMNCH is the world’s largest alliance for women’s, children’s and adolescents’ health and well-being, with over 1400 partner organizations working together through 10 constituency groups. Its work is funded by a range of government and philanthropic donors, which had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

Competing interests: The authors have declared that no competing interests exist.

Over the past few decades, and prior to the onset of the COVID-19 pandemic, the world witnessed considerable progress in WCAH and well-being and the SDGs. The number of maternal deaths worldwide decreased to 223 000 in 2020 from 342 000 in 2000 [ 1 ], and the mortality rate for children under-five years decreased by almost 50% between 2000 and 2021 [ 2 ]. Yet deep inequities remain between and within countries. For instance, although the global maternal mortality ratio is estimated to have fallen by 34% between 2000 and 2020, 94% of all maternal deaths occur in LMICs with the risk of stillbirth being 23 times higher in the most severely affected countries [ 3 ].

Inequities are also pronounced within countries where progress is not reaching every woman, adolescent and child, especially those in population groups facing multiple deprivations. These groups are often found in settings that are remote, rural, urban, conflict-affected or mobile. They are bearing the disproportionate burden of death and are being left furthest behind. For instance, two-thirds of zero-dose children (those who have not received a single dose of the DTP-containing vaccine, which protects against diphtheria, tetanus and polio) live below the poverty line and suffer nearly 50% of global deaths from vaccine-preventable diseases. Similarly, maternal mortality increase on average by 11% in conflict zones and by 28% in the worst hit conflicted affected areas [ 4 ]. Similarly, while significant reductions have been achieved in under-five mortality rates, progress on newborn mortality and stillbirths has fallen behind. It is estimated that 47% of under-five deaths occur during the neonatal period [ 5 ]. Factors such as age, gender, ethnicity, sexual orientation, migration status, socio-economic status and geographic location contribute to the important inequities across the continuum of sexual, reproductive, maternal, neonatal, child and adolescent health (SRMNCAH).

The COVID-19 pandemic has exacerbated these existing inequities and compounded the difficulties that women, children and adolescents face in accessing health and social services, negatively impacting SRMNCAH outcomes. For instance, recent estimates provided by the United Nations Population Fund indicate that across 115 LMICs, the pandemic disrupted contraceptive use for approximately 12 million women, causing nearly 1.4 million unintended pregnancies in 2020 [ 6 ]. Findings from a Lancet systematic review also indicate that maternal deaths and stillbirths increased during the pandemic, as did ruptured ectopic pregnancies and maternal depression. There seemed to be a considerable disparity between high-resource and low-resource settings [ 7 ]. In 2020, the number of children who missed out on receiving even a single vaccine shot increased by 3 million, from 10.6 million in 2019 to 13.7 million in 2020, in Gavi-supported countries. Zero-dose children and the communities they live in often face multiple deprivations and can be regarded as a marker of inequity [ 8 ]. For example, in Nepal, hospital deliveries decreased, most markedly among disadvantaged groups, including women in castes perceived as lower in status [ 9 ].

Furthermore, the socioeconomic consequences of the COVID-19 pandemic and the related restrictions that were imposed indicate that approximately 131 million more people were pushed into poverty in 2020, many of them women, children and adolescents from marginalized communities [ 10 ]; a finding which suggests that COVID-19 has reversed progress for the first time since 1999 [ 11 ]. Nevertheless, the prospect of recovery from the COVID-19 pandemic is emerging with the count of zero-dose children almost at pre-pandemic levels [ 12 ].

Certain populations are being more affected than others by the socioeconomic consequences of COVID-19. These include: women, children, and adolescents; those who are marginalized and excluded; who depend on the informal sector for income; who live in areas prone to fragility; who have insufficient access to social and health services; who lack social protection; who are denied access to health services due to discrimination; who have low levels of political influence; who have low incomes and limited opportunities to cope and adapt; and who have limited or no access to technologies [ 13 ].

Conflict, climate change, COVID-19 and the cost-of-living crisis, known as the four Cs, present many challenges to the health and welfare of women, children and adolescents [ 14 ]. In 2022, more than 100 million people were forcibly displaced from their homes due to armed conflict and violence with women and children bearing the greater share of this burden [ 15 ]. In addition to the direct maternal and newborn fatalities attributed to the conflicts, there are greater indirect consequences such as the collapse of the health systems, the diminished access to health services and the disruption to food supplies [ 15 , 16 ]. Exacerbating these challenges are the effects of climate change which causes floods, droughts and crop failure that endanger the livelihoods of the poorest and most vulnerable populations [ 17 ]. This global polycrisis has drastically increased the cost of living worldwide; global inflation rose from 4.7% in 2021 to 8.8% in 2022. This has jeopardized lower income households’ access to maternal and newborn health services [ 14 ]. The impact and extent of this multifaceted crisis varies among countries, presenting distinct yet interconnected and complex challenges that exacerbate pre-existing inequalities, particularly in LMICs with vulnerable health systems [ 14 ].

In light of these emerging findings, there is an urgent need to stimulate, coordinate and deliver financing strategies that are equity-enhancing and that target the most vulnerable communities. Such efforts should be supported by evidence-based strategies and interventions to improve equity in WCAH and well-being, especially among vulnerable populations living in specific situations, such as humanitarian and fragile contexts. The objective of this scoping review is to explore the depth and breadth of existing literature on financing interventions and measures to improve equity in WCAH in LMICs and to map out and summarize the evidence to support decision-making and advocacy across different stakeholders, including governments, civil society organizations (CSOs) and donors

Review questions

• What are the financing interventions and measures employed by different stakeholders, including governments, CSOs and donors, to improve equity in WCAH in LMICs?
• What is the available evidence on the effectiveness and implementation of financing interventions and measures to enhance equity for WCAH in LMICs?

Definitions

A scoping review is typically used to present “a broad overview of the evidence pertaining to a topic, irrespective of study quality, to examine areas that are emerging, to clarify key concepts and to identify gaps”. The updated JBI guidance for conducting scoping reviews was used [ 18 ] alongside the PRISMA Extension for Scoping Reviews (PRISMA-ScR) [ 19 ].

Financing for equity reflects on the need to “adapt, extend and scale up innovative and equity enhancing financing strategies that consider the differentiated reaches and impacts on vulnerable groups and populations, including women, children and adolescents in humanitarian and fragile settings” [ 20 ]).

Equity in health can be defined as “the absence of disparities in health (and in its key social determinants) that are systematically associated with social advantage/disadvantage” [ 21 ]. This report used the guidance framework PROGRESS-Plus, which identifies components affecting health and healthcare equity including place of residence, race or ethnicity, occupation, gender, religion, education, social capital, socioeconomic status (SES), plus age, disability and sexual orientation.

Protocol and registration

The protocol was not registered as PROSPERO does not accept scoping review protocols. The protocol is available upon request from the corresponding author.

Eligibility criteria

Population of interest: The population of interest consisted of women, newborns or neonates, children and adolescents. The explicit use of terms to define each population were used as they had been categorized into different age groups across the different articles.

Intervention of interest: The report looked at financing interventions and measures employed by different stakeholders including government, international donors and CSOs that aim to improve equity in WCAH. It considered demand and supply-side financial interventions including user fee exemption policies, national health insurance plans, subsidization policies, health equity funds, pro-equity policies, performance-based financing (PBF), financial protection schemes for vulnerable women, children and adolescents and incentive programmes such as CCTs, unconditional cash transfers (UCTs) and voucher schemes. The search excluded financial interventions targeting the general population without addressing any equity component such as SES, place of residence, disability etc. It also excluded studies that assessed financial interventions as part of a multi-component intervention and did not separate the results.

Outcome of interest: Only studies that assessed health outcomes were included, for instance those looking at morbidity and mortality and health systems outcomes such as access to healthcare, healthcare utilization and quality of care.

Setting of interest: The search focused on LMICs including humanitarian and fragile settings (HFS) as per the World Bank Country and Lending Groups’ classification by income issued in July 2022 [ 22 ] ( S1 Appendix ).

Study design: The study included primary studies, narrative reviews, systematic reviews and technical reports. The eligibility criteria was restricted to articles and reports published since the year 2000.

Literature search

The following electronic databases were searched: Medline, PubMed, Emboss, the WHO’s Global Index Medicus. The websites of key actors in this space for technical reports were included, including Gavi, The Vaccine Alliance, the World Bank, the Global Financing Facility and UNHCR, The UN Refugee Agency. The search was conducted for studies published between January 2000 and June 2023. S2 Appendix provides the search strategies of the databases searched.

Both index terms and free text words for the three following concepts were used: health financing, women, children and adolescents, equity and setting (i.e. LMIC). The search strategy was co-developed and run by an information specialist who validated the information sources—for example, electronic databases and websites—the search and medical subject headings (Mesh) terms, the search techniques—for example, boolean operators and search filters—and the documentation of search strategies and results. The search was not limited to specific languages. Additionally, purposive outreach was conducted for a few key actors, such as WHO, Gavi, the Global Fund to Fight AIDS, Tuberculosis and Malaria and the World Bank, to identify additional documents.

Selection process

Title and abstract screening: Teams of two reviewers used the above eligibility criteria to screen titles and abstracts of identified citations in duplicate and independently for potential eligibility. The full text for citations judged as potentially eligible by at least one of the two reviewers were retrieved.

Full-text screening: Teams of two reviewers used the above eligibility criteria to screen the full texts in duplicate and independently for eligibility. The teams of two reviewers resolved any disagreement by discussion or with the help of a third reviewer. Standardized and pilot-tested screening forms were used.

To ensure the validity of the selection process, calibration exercises were conducted. This involved a random subset of 100 articles for reviewers to independently screen against the eligibility criteria. Reviewers then met to discuss the point of disagreement and revise the eligibility criteria and instructions to ensure clarity, minimize disagreements and avoid confusion.

Data extraction

One reviewer extracted data using standardized and pilot-tested forms and a senior reviewer validated these. The data extraction form was pilot tested to ensure the clarity and validity of the data extraction process.

The following information was extracted from each paper:

• Last name of first author or name of institutions for reports
• Year of publication
• Study characteristics:
• Type of publication
• Type of study design or report
• Language of publication
• Authors’ information:
• Country of affiliation of the contact author
• Country of affiliation of first author
• Source (Journal name or institution name)
• Country (ies) subject of the paper
• Income level classification according to the World Bank list of economies issued in July 2022 ( S1 Appendix )
• HFS classification ( S3 Appendix )
• Financing intervention or measure
• Type of intervention or measure
• Target population (women, newborns, children or adolescents)
• Equity component (PROGRESS Plus factor)
• Outcomes assessed and key findings including effects/implementation of interventions and SRMNCAH/well-being/equity outcomes
• Statements on funding and conflict of interest of authors

Risk of bias assessment

No risk of bias assessment was conducted, consistent with the JBI guidance manual.

Data analysis

A descriptive analysis of the general characteristics of the included papers, including study designs and settings, was conducted. A thematic analysis of the included studies was also done. These were categorized according to the intervention and outcomes assessed. Findings were further stratified according to variables such as country income group (LMIC level), HFS classification, population of interest and equity factor such as SES, migration etc.

Fig 1 summarizes the selection process. Out of 26 355 citations identified from electronic databases, relevant website searches and stakeholders consultations, 413 studies were included in the final scoping review [ 23 – 435 ]. 678 full texts were excluded for the following reasons: not an intervention of interest (n = 260); did not address equity (n = 152); not a population of interest (n = 134); not a design of interest (n = 61); not an outcome of interest (n = 18); not a setting of interest (n = 16); duplicate (n = 14); full text not retrievable (n = 13); no separate data for the effects of the financing policy (n = 9); or not a time frame of interest (n = 1).

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Characteristics of included studies

The figures below present the characteristics of the included studies. As shown in Fig 2 , most of the studies employed observational study designs (n = 254; 61.5%), followed by quasi-experimental (n = 52; 12.5%) and experimental designs (n = 38; 9.3%). 22 systematic reviews on the topic were identified (5.3%). Most the studies were conducted in lower-middle income countries (n = 209; 50.6%) and low-income countries (n = 82; 19.7%) with fewer studies conducted in upper-middle income countries (n = 70; 13%) ( Fig 3 ). Most of the studies were conducted in India (n = 40; 10.6%) or Burkina Faso (n = 35; 8.7%) ( Fig 4 ). The first authors of included studies were mostly affiliated with institutions from high-income countries (n = 228; 55.2%) mainly the United States (n = 76; 33.2%), the United Kingdom (n = 56; 24.5%) and Canada (n = 27; 11.8%) while only 4.1% of studies had first authors affiliated with institutions from low-income countries ( Fig 5 ).

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As shown in Fig 6 , CCTs (n = 92; 22.3%), health insurance (n = 89; 21.4%), user fee exemptions (n = 75; 18.1%) and vouchers (n = 70; 16.9%) were the most reported financial interventions and measures. Some studies assessed several financial interventions whether implemented separately or as multi-component financial interventions (n = 28; 6.7%). Financial interventions or measures mainly targeted women (n = 236; 57.1%), children (n = 87; 21%) or both women and children (n = 62; 15%) with fewer targeting adolescents (n = 10; 2.7%) and newborns (n = 3; 0.7%) ( Fig 7 ). As shown in Fig 8 , the majority of the studies were evaluation studies (n = 354; n = 85.7%) with 59 studies addressing implementation considerations (14.2%). The outcome mostly assessed was the healthcare utilization (n = 245; 59.3%) followed by health expenditures (n = 61; 14.6%), mortality rates (n = 52; 12.6%) and morbidity (n = 44; 10.8%).

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Equity components

Fig 9 presents the equity components addressed in the included studies. Most of the studies assessed the impact of financial interventions on addressing inequities related to SES (n = 171; 41.4%) followed by place of residence (n = 82; 19.8%) and age (n = 17; 4.2%). Many studies addressed several equity components (n = 132, 31.9%) including SES and place of residence (n = 70; 53%), SES and ethnicity (n = 8; 6.1%), SES and age (n = 7; 5.3%), SES, place of residence and education (n = 7; 5.3%), SES and occupation (n = 2; 1.6%), gender, disability and ethnicity (n = 1; 0.8%). None of the included studies addressed sexual orientation, religion or social capital.

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Funding and conflicts of interest characteristics of the included studies

As shown in Fig 10 , most of the studies reported study funding (n = 261; 63.1%). Of the studies reported as funded, the funding sources were mainly governments (n = 96; 36.6%), academia (n = 31; 12.8%), private not-for-profit (n = 33; 12.4%) and international organizations (n = 30; 11.1%). Some studies reported being funded by multiple sources (n = 59; 22.6%). Almost a third of the papers (30.1%) did not report on conflict of interest of study authors ( Fig 11 ).

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The findings below are presented by financial interventions and corresponding outcomes. S1 to S11 Tables present the characteristics of the individual studies.

CCTs (n = 92)

CCTs have been introduced in many LMICs as a provision of monetary transfers to households on the condition that they comply with a set of requirements [ 46 ]. 92 studies evaluated the effectiveness of CCT programs on healthcare utilization, morbidity, mortality, child development, healthcare expenditure, quality of care and other outcomes including health knowledge, responsive caregiving, teenage pregnancy and nutrition as well as implementation considerations [ 23 – 109 , 407 – 411 ]. The majority of the studies assessed CCT programs in Latin America (n = 41), mainly Brazil (n = 17), and India (n = 24) assessing the Janani Suraksha Yojana (JSY) program.

Healthcare utilization (n = 48): 48 studies assessed the effect of CCT programs on healthcare utilization [ 23 – 27 , 29 , 30 , 32 , 33 , 35 – 37 , 39 – 43 , 45 – 50 , 59 , 62 , 63 , 71 , 78 , 81 – 87 , 89 , 90 , 94 – 97 , 100 , 101 , 105 , 107 – 109 , 408 ]. 40 studies found that CCT interventions can increase the utilization of maternal and child health services for the poor and the disadvantaged, including antenatal care visits [ 24 – 26 , 29 , 30 , 35 , 39 , 41 – 43 , 45 , 47 , 50 , 63 , 96 , 105 , 108 ], post-partum care [ 63 , 105 ], institutional delivery [ 23 – 26 , 29 , 33 , 36 , 37 , 47 , 78 , 82 , 84 – 87 , 89 , 94 ], caesarean sections [ 37 , 95 ], skilled birth attendance [ 26 , 45 , 94 , 96 ], contraceptive use among young women [ 90 ], child health check-ups [ 40 – 42 , 46 , 49 , 59 , 81 ] and immunization coverage [ 26 , 27 , 32 , 71 , 100 , 101 ]. One study reported that the CCT program encouraged adolescents to attend the clinic for assessments or HIV testing [ 109 ]. Although CCT was shown to increase access to institutional delivery, three studies revealed a disproportionate lower concentration of institutional deliveries in low-income populations in comparison to high-income populations [ 33 , 36 , 48 ]. One study revealed that CCT decreased rates of caesarean section deliveries, which is explained by a shift from the private sector [ 94 ]. Two studies suggested that CCT programs addressing both the supply and demand side of health services may increase the coverage of maternal and child health services [ 62 , 408 ]. Five studies found negative results on the impact of CCTs on immunization coverage [ 41 , 46 , 63 , 83 , 87 ]. One study reports the poor effect of CCTs on immunization coverage to be because of weak monitoring of conditionality [ 83 ]. One systematic review found mixed results on immunization coverage that might be due to the initial high rates of immunization [ 46 ] while another systematic review found insufficient evidence on the impact of CCTs on child health service utilization in sub-Saharan Africa [ 107 ].

Mortality (n = 20): 20 studies reported on the effect of CCT programmes on maternal and child mortality [ 23 , 24 , 26 – 30 , 32 – 34 , 73 , 85 , 87 , 88 , 91 , 94 , 99 , 103 , 409 ]. 13 studies and one systematic review revealed a positive impact of CCTs in reducing infant, child and maternal mortality rates for the poor and the disadvantaged [ 27 – 30 , 32 , 34 , 73 , 85 , 87 , 88 , 91 , 99 , 103 , 409 , 410 ]. Five studies reported a reduction in child mortality whereby the intervention led to a decrease in overall mortality from poverty-related causes, which included malnutrition and diarrhoea [ 24 , 27 , 34 , 73 , 91 ]. One study suggested an improvement in child mortality when CCTs are combined with improvements to adequate access to water, sanitation and solid waste collection [ 34 ]. Another study highlighted that although CCT programmes reduce maternal mortality, inequalities persisted whereby fewer death were observed in the richest divisions compared to the poorest division [ 33 ]. One study showed a positive impact on determinants of maternal mortality but suggested a small effect on maternal mortality due to implementation issues [ 25 ]. Three studies did not find any impact of CCTs on maternal or child mortality [ 23 , 26 , 94 ].

Morbidity (n = 16): 16 studies reported on the effects of CCT programmes on morbidity [ 32 , 46 , 55 , 56 , 64 , 66 , 79 – 82 , 85 , 91 , 98 , 102 , 107 , 411 ]. 10 studies found that CCT interventions can improve child health for vulnerable groups by reducing malnutrition and wasting [ 79 , 91 , 411 ], hospital admissions [ 27 , 91 ], illness and anemia rates [ 46 , 64 , 79 , 85 ], diarrhea and acute respiratory infections [ 32 ], psychosocial health [ 81 ] and incidences of dental caries [ 80 ]. One systematic review found insufficient evidence on the impact of CCTs on child health status in sub-Saharan Africa [ 107 ]. One study suggested that CCTs reduced HIV risks among young women [ 56 ]. Two studies reported a positive impact of CCTs on women’s health including a lower prevalence of being underweight or overweight [ 79 ] and lower current hypertension rates [ 55 ] while one study reported an increase in body mass index (BMI) and obesity risks among women [ 66 ]. Another study found no evidence that the CCTs led to a reduction in preventable delivery complications [ 82 ]. Two studies found no impact on mental health among youth [ 98 , 102 ], mainly among females, suggesting that conditions should not stereotype females [ 98 ].

Child development (n = 14): 14 studies addressed the effect of CCTs on child development [ 30 , 38 , 43 , 46 , 52 , 57 , 58 , 60 , 64 , 67 , 75 , 76 , 103 , 104 ]. 10 studies found that CCT interventions can improve child health by reducing the incidence of low birth weight [ 30 , 57 , 103 , 104 ], and improving height-for-age Z scores, length and stunting among children [ 38 , 43 , 46 , 58 , 64 , 75 , 76 ]. Four studies showed that CCTs did not significantly impact weight-for-age Z scores [ 43 ], height-for-age Z scores [ 67 ], BMI-for-age Z scores and stunting [ 52 ] and weight gain [ 60 ].

Other health outcomes (n = 9): Nine studies reported on the effect of CCTs on health knowledge and behavior [ 25 , 88 ], responsive care giving [ 43 ], teenage pregnancy [ 61 , 65 ], adult fertility [ 72 ] and nutrition [ 40 , 74 , 93 ]. One study showed an increase in demand for maternal and child health services within facilities among beneficiaries [ 88 ] while another study found no improvement in health knowledge among mothers [ 25 ]. Three studies reported on the effectiveness of CCT programmes on nutrition [ 40 , 74 , 93 ]. All studies suggested a positive impact of CCTs on nutrition determinants including an increase in dietary diversity and food consumption [ 40 , 93 ], especially in rural areas [ 40 ], and an increase in food per capita household consumption [ 74 ]. One study found that CCTs resulted in a positive change in key parenting practices, including children’s intake of protein-rich foods and care-seeking behavior [ 43 ] and a decrease in teen pregnancy and fertility [ 61 , 65 ] with no effect on adult fertility [ 72 ].

Health expenditures (n = 3): Three studies from India found that although CCTs can enhance financial access to maternal and child health services, it did not adequately protect beneficiaries from out-of-pocket expenditures [ 84 , 97 , 106 ].

Quality of care (n = 2): Two studies reported on the effect of CCTs on the quality of care and beneficiaries’ satisfaction [ 82 , 103 ]. CCT programmes significantly improved the quality of delivery care and satisfaction with care in one study [ 82 ]. One systematic review reported on two studies from Mexico suggesting that CCTs improved the quality of care but the measure of care was based on women’s recall [ 103 ].

Implementation considerations (n = 15): 15 studies reported on implementation considerations for CCT programmes [ 31 , 36 , 44 , 51 , 53 , 54 , 68 – 70 , 77 , 88 , 92 , 98 , 105 , 407 ]. Challenges to the implementation of CCT programmes included the complicated eligibility criteria, irregular cash transfers, insufficient entitlements, unclear payment procedures, the quality of care in public health facilities, insufficient healthcare personnel, infrastructure, medicine and equipment, increased workload and low literacy levels among beneficiaries [ 36 , 44 , 54 , 68 , 70 , 77 , 88 , 407 ]. The lack of awareness among beneficiaries about the CCT programme and the included services may have also hindered service uptake [ 36 ]. In India, the bribes imposed by providers incurred additional out-of-pocket expenditures for CCT beneficiaries [ 53 ]. The misuse and mismanagement of cash were also reported as a challenge [ 44 , 54 , 70 ]. In one study, beneficiaries proposed that CCT programmes may be unsustainable and expressed concern that young women may misuse or mismanage the transfers [ 54 ]. Another study reported that mothers’ in-laws forced their daughters-in-law to stay in their villages, not allowing them to go to the mother’s area at the time of delivery for the sake of securing the cash incentive, which is given only upon the condition of the women delivering in the local institution where she is registered [ 70 ]. To increase the effectiveness and acceptance of CCT programmes, studies suggested the need for adequate human resources, staff training systems, improving the access and quality of care, community engagement in the design and implementation of the programme, improvement in targeting, increasing awareness of the programme and removing any stereotype in conditions and extensive monitoring [ 31 , 36 , 51 , 69 , 77 , 92 , 98 , 105 ].

Health insurance (n = 89)

89 studies tackling various health insurance schemes including national health insurance, social health insurance and employment-based health insurance were included. These studies evaluated the effectiveness of these various health insurance schemes on healthcare utilization, healthcare expenditure, mortality, morbidity, quality of care and other outcomes including insurance coverage and nutrition as well as implementation considerations [ 327 – 404 , 406 , 412 – 421 ].

Healthcare utilization (n = 46): 37 studies reported that various health insurance schemes increased skilled birth attendants, facility-based deliveries, caesarean section deliveries, antenatal care utilization, children health consultations and vaccination coverage, utilization of health services among women with disabilities and use of family planning services [ 328 , 334 , 336 , 337 , 339 , 341 , 345 , 346 , 349 – 352 , 354 , 358 , 359 , 365 , 367 , 368 , 370 , 374 , 376 , 377 , 379 , 383 – 387 , 390 , 391 , 394 – 397 , 399 , 401 , 404 , 406 , 414 , 420 ]. 11 of these studies indicated that these favorable effects were mostly prominent among poor households [ 334 , 337 , 367 , 370 , 377 , 394 , 396 , 397 ], those residing in rural areas [ 346 ], individuals with disability [ 345 ] and indigenous women [ 390 ]. This suggests that insurance schemes led to more equitable access to health services among the impoverished and vulnerable populations. While three studies reported that although there has been a notable increase in the utilization of maternal health services due to the insurance schemes, this increase was not as significant among the extremely poor [ 349 , 415 ] and those residing in rural areas [ 376 ]. Five studies showed that insurance schemes had no effect on the use of family planning services [ 329 , 363 ], access to HIV testing during antenatal care visits [ 332 ], utilization of outpatient services in children [ 343 ] and facility-based deliveries [ 403 ].

Health expenditures (n = 21): 10 studies reported that enrollment in an insurance scheme reduced households’ out-of-pocket expenditures for maternal care [ 340 , 352 ], facility-based deliveries [ 337 ], inpatient care [ 330 , 348 ], child care [ 334 , 365 ], neonates critical care [ 375 ] and breast cancer treatment [ 382 , 401 ]. Five studies indicated that insurance schemes can protect poor households and migrant women from the financial burden of out-of-pocket health expenses [ 369 , 380 , 392 , 420 ], and can provide adequate health coverage for children with mental disorders [ 347 ]. Four studies showed that these schemes had no significant effect on reducing out-of-pocket payments sustained by poor households for maternal and child care [ 336 , 345 , 362 , 421 ]. As for the remaining two studies, they reported that the enrollment in insurance schemes caused women extra financial hardship due to their lack of awareness about their rights within the programme and mistrust in the scheme that drove them to private health providers [ 389 ] and that women from lower socioeconomic disadvantage had higher out-of-pocket health expenses than those from higher socioeconomic disadvantage [ 402 ].

Mortality rate (n = 15): 12 studies reported that national health insurance schemes reduced maternal, neonatal and infant mortality rates [ 327 , 341 , 351 , 358 , 371 , 375 , 378 , 379 , 382 , 385 , 393 , 394 ]. Three studies reported that insurance schemes had no significant positive effect on neonatal mortality rates [ 403 ], didn’t reduce inequality in maternal mortalities within the regions [ 388 ] and that one year all-cause mortality rates were notably higher in women enrolled in rural insurance schemes than those enrolled in an urban insurance scheme [ 381 ].

Morbidity (n = 10): All 10 studies reported a positive effect of the different types of health insurance schemes on treatment adherence in children with cancer [ 333 , 394 ], overall health status of women and children [ 355 , 356 , 398 , 400 ], preventing malnutrition and stunting in children [ 344 , 366 , 379 ] and reducing the incidence of influenza and diarrhea in children [ 375 ].

Other outcomes (n = 9): Five studies highlighted inequities in health coverage under several insurance schemes with women who are poorer, less educated, unemployed or residing in remote areas being less likely to be insured [ 335 , 353 , 357 , 412 , 413 ]. One study showed that a health insurance scheme implemented in Peru had increased health coverage among marginalized women and contributed to more equity in healthcare access [ 364 ]. Another study reported that enrollment in a public health insurance scheme in China didn’t improve the nutritional status of rural poor children [ 372 ]. A study conducted in Colombia showed that women living in low socioeconomic residential areas and who were affiliated to a subsidized health insurance scheme (versus contributive) experienced a reduced probability of cervical cancer survival compared to women living in high socioeconomic areas [ 419 ]. One study found higher cancer survival rates for insured versus uninsured children in Kenya [ 417 ].

Implementation considerations (n = 8): Eight studies reported on different barriers that hindered either women’s enrollment in insurance schemes or their access to healthcare despite their enrollment. The barriers included: the need to move to another city to get the treatment; the authorizations of the paying entities; the medication costs [ 331 ], the distance to facilities [ 418 ]; having unreliable sources of income [ 342 ]; having invalid insurance cards [ 353 ]; having a low educational level [ 360 ]; encountering high premiums [ 416 ] and the extra costs of care [ 336 ]. One study addressed facilitators to the enrollment of children from lower socioeconomic status in insurance schemes. These included: eliminating the remaining small yearly renewal fee’ organizing outreach initiatives to offer registration assistance to female guardians of children; and establishing additional administrative offices for the programme in remote areas [ 361 ]. Another study addressed the facilitators of enrollment of poor women residing in rural areas. These were educating the public on the importance of enrolling in a health insurance programme and offering initial free subscriptions to individuals with the lowest economic wealth status [ 391 ].

User fee exemption (n = 75)

User fee exemptions have been implemented in many LMICs to alleviate the substantial out-of-pocket payments and the resulting financial burden incurred by low-income households [ 113 ]. 69 studies evaluated the effectiveness of user fee exemption policies on healthcare utilization, healthcare expenditure, mortality, morbidity, quality of care and other outcomes including health-seeking behavior and teen pregnancy as well as implementation considerations [ 107 – 175 , 419 – 424 ].

Healthcare utilization (n = 43): 27 studies reported positive effects of these programmes on the use of facility-based delivery services [ 113 , 121 , 126 , 139 , 141 , 147 , 150 , 156 , 160 , 163 , 168 , 173 , 426 ], malaria prevention and treatment services for pregnant women and children [ 119 , 145 , 155 , 161 ], maternal and child consultations [ 122 , 132 , 133 , 136 , 142 , 158 , 164 , 177 ] and family planning and contraception services [ 167 , 170 ], leading to more equitable access among the poor and vulnerable populations. 16 studies indicated that user fee exemption programmes had minimal to no effect on increasing the utilization of maternal and sexual and reproductive health services among poor women or those living in rural areas [ 110 – 112 , 115 , 120 , 123 , 124 , 127 – 129 , 134 , 137 , 138 , 140 , 157 , 178 ].

Health expenditures (n = 17) : Nine studies reported a positive effect of user fee exemption programmes on reducing out-of-pocket health expenditures and medical expenses among poor households [ 130 , 131 , 143 , 152 , 157 , 171 , 172 , 177 , 426 ]. While eight studies showed limited to no effect of these programmes on eliminating out-of-pocket health expenditures among impoverished households, this could be attributed to additional expenses not covered by the scheme such as transportation, medical supplies, medications and unofficial provider fees [ 116 , 150 , 154 , 159 , 165 , 175 , 176 , 425 ].

Mortality (n = 7): Four studies reported that despite the implementation of user fee exemption programmes there was no noticeable reduction in maternal, neonatal or under-five child mortality rates [ 119 , 126 , 139 , 168 ]. Three other studies reported that these programmes reduced maternal, neonatal and under-five child mortality rates due to the uptake of institutional deliveries and child health services [ 113 , 121 , 145 ].

Morbidity (n = 4): Three studies reported a positive effect of user fee exemption programmes on reducing wasting and stunting in children [ 162 ], on prompt treatment of sick newborns [ 166 ] and on improved screening for sexually transmitted infections (stir) in young women [ 175 ]. One study indicated that these programmes did not reduce illness in children [ 115 ].

Quality of care (n = 4): Three studies reported that user fee exemption programs had a positive effect on the quality of delivery and maternal care services [ 135 , 172 ] and on the quality of medical prescriptions with physicians reducing their use of antibiotics in for children by 62% [ 177 ]. One study indicated that the quality of maternal care provided under these programmes was perceived as poor by managers and health providers due to the increase in workload, delayed reimbursement of funds and stock-out of essential drugs and medical supplies [ 117 ].

Other outcomes (n = 2): Two studies reported that user fee exemption programs led to a decrease in teen pregnancies [ 169 ] and had a positive effect on health-seeking behaviors in children [ 149 ].

Implementation considerations (n = 15): Nine studies reported on several barriers to the implementation and uptake of user fee exemption policies. These included: a lack of infrastructure and human resources; sociocultural factors; limited awareness of the policy; out-of-pocket payments on drugs; transportation and lab tests; reduced quality of the services; and increased administrative workload [ 114 , 118 , 125 , 148 , 154 , 174 , 422 , 424 , 427 ]. Six studies reported on facilitators for the implementation of these policies. They included: residing near the facility; knowledge and awareness of the policy; residing in urban areas; having a good drug supply system in place; and having higher levels of education [ 144 , 146 , 151 , 153 , 156 , 423 ].

Vouchers (n = 70)

This financial intervention involves distributing vouchers of a predetermined value to patients, which they can redeem to receive services from providers who are then repaid by the insurance or government payor that issued the voucher. 70 studies that evaluated the effectiveness of voucher schemes on healthcare utilization, quality of care, health expenditures, mortality, morbidity, health knowledge and child development as well as implementation considerations were included in the scoping review [ 176 – 243 , 425 , 426 ].

Healthcare utilization (n = 56): All 56 studies reported on the positive effect of voucher schemes on the use of sexual and reproductive health services [ 179 , 180 , 183 , 189 , 196 , 197 , 204 , 205 , 210 , 213 , 218 , 225 , 231 ], contraceptive and family planning services [ 181 , 182 , 187 , 192 , 200 , 201 , 208 , 211 , 212 , 222 , 228 , 241 , 244 , 246 , 428 ], facility-based deliveries [ 186 , 190 , 193 , 199 , 209 , 214 , 223 , 224 , 227 , 229 , 232 , 233 , 238 , 242 , 245 ], skilled birth attended deliveries [ 191 , 230 ], antenatal care services [ 185 , 198 , 215 , 219 , 226 , 239 ], child immunization services [ 194 , 429 ] and the use of insecticide-treated nets for pregnant women and children [ 188 , 216 , 236 ]. Across the majority of these studies, the effect of the voucher scheme was notably pronounced among the poorest populations, fostering more equity in healthcare utilization with the exception of one study where a voucher program aiming at providing insecticide-treated nets for pregnant women reported coverage of only 18% among the poorest compared to 37% among the richest [ 188 ].

Quality of care ( n = 10): Seven studies showed that voucher schemes helped to improve the comfort of the patients, thus increasing their satisfaction and improving the interpersonal skills of the healthcare workforce [ 193 , 203 , 210 , 221 , 231 , 240 , 246 ]. However, one study showed that vouchers increased the workload for public health facilities [ 224 ]. Two studies showed that the current evidence is inconclusive on the effect of voucher programs on the quality of care [ 180 , 181 ].

Health expenditures (n = 6): Four studies agreed that voucher schemes helped reduce the out-of-pocket expenditure on healthcare services endured by women and decreased the financial barrier to access to maternal and sexual health services. [ 185 , 195 , 200 , 229 ]. One study highlighted that an SMS money transfer system can successfully reimburse healthcare providers located in remote and rural areas [ 182 ]. One study showed that the effect of vouchers on low-income households’ health spending is more substantial when coupled with health equity funds [ 206 ].

Mortality (n = 3): Two studies reported that vouchers helped to reduce maternal and newborn mortality rates [ 197 ] as well as malaria-related under-five mortality rates in the context of an insecticide-treated net voucher [ 220 ]. However, one study showed that a voucher scheme implemented in Bangladesh did not improve stillbirths, neonatal or infant mortality rates [ 245 ].

Health knowledge (n = 3): Two studies concluded that voucher schemes enhanced the knowledge and awareness of voucher receivers on contraceptives and STIs [ 183 , 201 ]. One study, however, showed that a voucher scheme had no effect on enhancing adolescent girls’ knowledge about STIs [ 211 ].

Morbidity (n = 1): One systematic review reported that the impact of vouchers on the overall health status of women was inconclusive since improvements in health outcomes require more time to manifest and may not be apparent within the designated evaluation time [ 189 ].

Child development (n = 1): One study conducted within a refugee camp in Bangladesh showed that the substitution of food rations with electronic food vouchers was linked to enhanced linear growth among children aged between six years and 23 months [ 217 ].

Implementation considerations (n = 8): Eight studies explored facilitators to the implementation of voucher programmes. Facilitators included: designing a context-specific programme [ 213 , 235 ]; sensitizing the community [ 233 ]; and integrating vouchers within other programmes [ 207 ]. Four other studies identified barriers, including the complex eligibility procedures used in determining beneficiaries that might at times mean missing out the poorest beneficiaries, to the implementation of voucher schemes [ 234 ]. Other barriers included: a lack of knowledge among the target population about the services provided by the voucher program [ 237 ]; the significant amount of time required to achieve awareness and uptake of the program [ 184 ]; and the high cost of starting a mobile e-voucher program that requires software systems and staff training [ 243 ].

Studies assessing several interventions (n = 28)

28 studies addressed several financing interventions whether implemented separately or as part of a multi-component intervention. 19 studies, mainly literature reviews, assessed the use of different financing interventions including vouchers, user fee exemptions, cash transfers, the introduction of user fees, community healthcare plans, social protection schemes and insurance schemes that were either implemented in different countries or the same country but at different time periods or in different regions of the country [ 254 – 272 ]. The outcomes assessed were healthcare utilization [ 254 – 264 , 266 , 269 , 271 ], quality of care [ 254 , 258 , 259 , 264 , 268 , 269 ], healthcare expenditure [ 261 , 265 , 271 ], child development [ 267 ] and insurance coverage [ 256 ] as well as implementation considerations [ 255 , 257 , 268 – 270 , 272 ].

Five studies compared the effectiveness of CCT versus UCT interventions in Zimbabwe and other LMICs [ 247 – 249 , 431 ]. Four studies assessed the combination of different financing interventions to address health inequities [ 250 – 253 ]. A study conducted in Kenya found that the combination of a voucher and a CCT programme led to an increase in facility-based deliveries with 48% of the women using these schemes and subsequently delivering in a hospital or a clinic [ 250 ]. Another study assessing the use of a UCT programme paired with health insurance found that this combination increased the access of vulnerable households to healthcare services by reducing cost barriers [ 251 ]. The study evaluating the use of PBF in addition to user fee exemption found that despite the increase in facility-based deliveries due to these interventions, caesarean section rates remained alarmingly low (3%) and below the WHO recommendation [ 252 ].

Finally, according to a study assessing the combination of public insurance, a pay-for-performance scheme and a CCT program in Argentina, there was a significant decrease in the prevalence of stunting and underweight among children enrolled in these schemes [ 253 ]. However, stunting and obesity remained more common among rural populations [ 253 ]. One study assessing the effect of the a PBF program and a user fee removal policy on out-of-pocket expenditure found that user fee exemption can reduce out-of-pocket costs while there was no substantial effect of PBF [ 430 ].

Cost-sharing (n = 20)

Cost-sharing has been used by the public health sector in several LMICs to partially redeem the expenses associated with providing healthcare services [ 273 ]. 20 studies that evaluated the effectiveness of cost-sharing and subsidies on healthcare utilization, health expenditures, morbidity, quality of care, and mortality, as well as implementation considerations were included in this scoping review [ 273 – 291 , 432 ].

Healthcare utilization (n = 11): 11 studies reported a positive impact of cost-sharing and subsidies on healthcare utilization with an increase in institutional deliveries [ 275 – 278 , 281 ], use of child health services [ 283 ], skilled birth attendance rates [ 280 , 288 ], households’ use of different health services [ 273 , 284 ] and consumption of fortified packaged complementary food (FPCF) in children [ 282 ].

Health expenditures ( n = 5): Four studies reported that cost-sharing schemes led to a reduction in poor households’ facility-based delivery and reproductive health medical expenses [ 281 , 285 , 291 ] as well as a reduction in the societal cost of micronutrient deficiencies in children [ 282 ]. One study reported that despite the implementation of a cost-sharing scheme in Kenya, spending on family planning and reproductive health remained disproportionately borne by households with an increase in out-of-pocket expenses from 10% in 2005–06 to 14% in 2009–10 [ 274 ].

Morbidity (n = 2): Two studies reported a positive effect of cost-sharing policies on morbidity in women and children by reducing incidence and prevalence of reproductive tract infections and reducing the number of disability-adjusted life years due to iodine deficiency, vitamin A deficiency and iron-deficiency anemia in children aged six to 23 months [ 279 , 282 ].

Quality of care (n = 2): Two studies reported a positive effect of subsidy policies on the quality of care provided to women delivering in hospitals [ 281 , 291 ].

Mortality ( n = 2): One study found significant reductions in national under-five mortality following a targeted subsidization of case management of under-five malaria [ 432 ] while another study conducted in Burkina Faso reported a non-significant decrease in deaths per live births [ 275 ].

Implementation considerations (n = 5): Five studies reported on implementation considerations for the cost-sharing policies [ 286 – 290 ]. A subsidy program implemented in Peru to improve the follow-up of cervical cytology was highly accepted by lower-income women [ 290 ]. The interaction between health workers and women is an important factor in determining their use of facility-based deliveries in light of a subsidy policy [ 286 ]. Moreover, three studies addressed implementation gaps which included health workers taking advantage of the subsidy policy to overestimate the cost of deliveries and incur financial gains [ 288 ], inadequate enforcement and organizational capacity [ 289 ] and limited understanding of the power dynamics between individuals representing the health system and communities [ 287 ].

Community-based health insurance (CBHI) (n = 15)

CBHI is a form of health insurance that revolves around mutual assistance, solidarity and collective risk pooling. It offers flat rates to workers in the informal sector and rural communities [ 302 ]. 15 studies that evaluated the effectiveness of CBHI on healthcare utilization, health expenditures, morbidity, and mortality and implementation considerations were included in this scoping review [ 292 – 304 , 434 , 435 ].

Healthcare utilization (n = 9): Seven studies found a positive impact of CBHI on increasing the utilization of health services mainly when it came to institutional deliveries, antenatal and postnatal care, vaccinations among the poorest, and increasing the likelihood of mothers seeking healthcare services for child illnesses [ 292 – 294 , 297 , 300 , 302 , 303 ]. One systematic review found that the CBHI had a negative impact on the use of family planning and reproductive health services [ 296 ] and one study found no significant effects of CBHI on the utilization of maternal and child healthcare services [ 435 ].

Health expenditures ( n = 5): Four studies reported that CBHI had a positive effect on reducing out-of-pocket expenditures at the point of service [ 293 ], providing substantial financial protection to households [ 300 , 304 ] and decreasing annual health expenditure [ 294 ]. One study reported that the high cost of transportation added to the cost of inpatient care was enough to prevent insured women with a low-income from being hospitalized [ 298 ].

Morbidity (n = 3): Two studies reported that household participation in a CBHI scheme was associated with a lower likelihood of stunting in offspring [ 299 , 302 ]. Another study reported that in terms of the distribution of stunting, children in the lowest socioeconomic welfare index had a higher prevalence of stunting and that there was no statistically significant association between CBHI participation and stunting [ 295 ].

Mortality ( n = 2): One study conducted in Burkina Faso reported no significant difference in overall mortality rates between households enrolled and not enrolled in the CBHI scheme [ 292 ] while another study reported that the intervention was associated with lowering of the risk of mortality in children enrolled in health insurance when compared to those not enrolled [ 294 ].

Implementation considerations (n = 2): One study conducted in Cameroon reported that income was a barrier to women’s enrollment in health insurance schemes, which emphasizes the need for collaboration between health insurance programmes and governments in providing a financial safety net that will lessen the toll of illness on the underprivileged [ 301 ]. Another study suggested the need to increase women’s understanding of the CBHI system to develop their trust and enable recognition of its benefits [ 434 ].

PBF (n = 10)

PBF is a supply-side intervention that offers incentives to healthcare providers upon the achievement of a set of objectives [ 312 ]. 10 studies that evaluated the effectiveness of PBF on healthcare utilization, quality of care, morbidity, resource availability and implementation considerations were included in this scoping review [ 305 – 313 , 433 ].

Healthcare utilization (n = 6): Six studies found no significant impact of PBF on increasing the utilization of maternal and child health services for institutional deliveries, antenatal and postnatal care and vaccinations among the poorest [ 305 , 306 , 309 – 311 , 433 ]. One study found that the effect of PBF is greater when supplemented by maternal vouchers that eliminate user fees [ 310 ]. Another study found that combining PBF with equity interventions, such as systematic targeting and subsidizing health services, did not improve the utilization of maternal health services. The study suggested that financial incentives for providers might not be enough to improve equity as other non-financial barriers to access, including distance to catchment primary health facility, literacy, parity and religion, should be considered [ 311 ].

Quality of care (n = 4): Four studies reported contradictory results in regards to the effect of PBF on the quality of care. Two studies found positive effects of PBF on improving the quality of care, specifically in improving the quality of treatment received by children from lower-income backgrounds [ 306 ] and on the motivation of health providers in delivering care to lower-income women. One study conducted in Malawi showed that PBF had neither a positive nor a negative effect on the quality of the antenatal care services provided by healthcare providers [ 313 ]. Another study on PBF covering under-five curative care, child vaccination and growth monitoring visits in Burkina Faso showed no impact on the quality of care [ 305 , 306 , 312 ].

Morbidity (n = 2): Two studies conducted in Burundi [ 308 ] and Rwanda [ 306 ] reported no significant effectiveness of PBF in reducing morbidity such as fever, diarrhea and malnutrition in children [ 306 , 308 ].

Resource availability (n = 1): One study conducted in Cameroon showed that PBF is associated with a significant reduction in stock-outs of family planning medicines but not in stock-outs of antenatal care drugs, vaccines, integrated management of childhood illness drugs and labour and delivery drugs [ 307 ].

Implementation considerations (n = 1): One study reported that the effectiveness of any PBF scheme addressing inequity specific to maternal health depends on the different stakeholders’ sharing a common understanding of what poor and vulnerable means as well as on the prompt payment of incentives to healthcare facilities and providers [ 312 ].

UCTs (n = 7)

UCT programmes provide low-income and vulnerable populations with additional income without imposing any requirements on the recipients [ 320 ]. Seven studies that evaluated the effectiveness of UCTs on morbidity, healthcare utilization, health expenditures, nutritional status and child development were included in this scoping review [ 314 – 320 ].

Morbidity (n = 4): Two studies found a favorable effect of UCTs on the likelihood of having experienced any disease in children [ 320 ] and on the anthropometric measures in children [ 319 ]. Another two studies found no effects of UCT programmes on the prevalence of malnutrition, incidence of wasting or stunting in children [ 316 , 318 ].

Health expenditures (n = 2): One study conducted in Burkina Faso reported that the availability of UCTs supported families in spending more on healthcare to support children’s health [ 317 ]. One systematic review found that UCTs may help improve healthcare expenditures in LMICs [ 320 ].

Healthcare utilization (n = 2): One study noticed better access to maternal health services, specifically skilled attendance at birth, as a result of UCTs [ 315 ] while another study reported that UCTs had no effect on the utilization of health services among children and adults [ 320 ].

Nutrition (n = 2): Two studies mentioned that UCTs improved the quality of children’s diets and increased the food availability in the house [ 317 ] as well as households’ access to food [ 320 ].

Child development (n = 1): One study reported that a UCT programme had a preventive effect on children’s growth in Togo [ 314 ].

Introduction of user fees (n = 5)

Across many sub-Saharan African countries user fees are paid directly at the point-of-care as the introduction of fees generates revenue for health systems and may decrease the demand for unnecessary care [ 321 , 323 ]. Five studies that evaluated the effect of the introduction of user fees on healthcare utilization were included in this study [ 321 – 325 ].

Healthcare utilization (n = 5): Three studies reported that this policy decreased the utilization of inpatient care by women and children in the rural areas of Zambia [ 321 ], decreased the use of health services and presentation for care by women in Mali [ 323 ] and decreased the number of skilled birth deliveries and antenatal care in Malawi [ 325 ]. One study reported an increase in the use of cervical screening despite the introduction of a fee-for-service policy [ 322 ]. Another study reported that the increase in prices did not have any disproportionate effect on the use of family planning and reproductive health services among lower-income women [ 324 ].

Micro-credit (n = 2)

Microcredit extends loans to the impoverished without requiring collateral thereby including those who would o’t have been able to access credit otherwise [ 405 ]. One study reported that microcredit positively affected child mortality [ 405 ]. Another study highlighted that microcredit can complement health insurance in enhancing child health by increasing households’ affordability for out-of-pocket health expenditures, protecting them from the financial risks associated with health insurance plans and improving rural households’ access to insurance plans [ 326 ].

Equity considerations

The scoping review’s findings highlight that CCT and voucher programmes can improve the utilization of maternal and child health services as well as the health outcomes for the poor and the disadvantaged. However, multiple implementation challenges impact the effectiveness of these programmes such as the complex eligibility procedures, unsustainability and misuse of transfers. Other barriers included irregular cash transfers, unclear payment mechanisms, and cultural barriers [ 24 ]. An increased workload and the insufficient healthcare personnel and infrastructure can also limit the effectiveness of CCT and voucher programmes in providing access to high-quality care to vulnerable groups. The various insurance schemes were found to have positive effect on healthcare utilization, healthcare expenditures, mortality rates and morbidity especially among the vulnerable populations including the poor, those residing in rural areas and other vulnerable populations. Few studies suggested that inequities in health coverage persisted under these programmes and schemes among the lower-income, less educated and those residing in remote regions, implying that demand-side interventions alone are insufficient in achieving equity. This also could be attributed to the persistence of other financial barriers and a lack of awareness about the programmes.

Findings showed that combining demand-side interventions with supply-side interventions can have better effect on maternal and child health outcomes [ 33 , 408 ]. Although user fee exemption of healthcare was found to have a positive impact on increasing utilization for the lower-income, leading to more equity, its effect is limited due to other financial and non-financial barriers. PBF was also found to have a limited impact on increasing utilization of maternal and child health services among the poorest, suggesting that financial incentives for providers might not be enough to improve equity due to non-financial barriers to access at the demand side. Not enough evidence was identified to draw conclusions on the other financial interventions such as UCTs, the introduction of user fees and microcredit. Also, evidence on the effect of financial interventions on improving equity for those living with a disablity, those less educated and LGBTIQ+ community was insufficient to draw any conclusions.

Principal findings and research gaps

This scoping review mapped the literature on financing interventions and measures aiming to improve equity for WCAH. This review can inform the agendas of funders and researchers working in the field of WCAH of potential knowledge gaps. The review highlighted the lack of studies assessing financial interventions targeting adolescents and newborns; the majority of the studies focused on women and children.

The review’s findings show that most of the included studies assessed CCTs, health insurance, vouchers and user fee exemptions while fewer studies addressed supply-side interventions such as PBF. The findings highlight that even when financial barriers are removed, inequities can persist due to other non-financial barriers to access including distance to catchment primary health facility, literacy, parity and religion. Financial interventions and measures are not enough unless coupled with other non-financial interventions that address barriers such as knowledge and geographical barriers. The findings suggest a strong synergy between the effects of supply-side and demand-side incentives. The engagement of concerned stakeholders is crucial for the successful implementation of financial interventions and design of financial interventions should be context-specific. Maintaining the sustainability of the effect and the quality of care while implementing financial interventions is crucial to achieving a positive impact on the target population. Successful implementations require adequate health system inputs, such as a capable, motivated and sufficient health workforce, and provision of reimbursements, supplies and equipment. The findings can inform the design of equitable health financing policies and health system reform efforts essential in moving toward UHC [ 436 ].

This review highlighted the scarcity of studies addressing the effect of financial interventions on addressing inequities related to education, age, disability and sexual orientation. The included studies mainly focused on financing mechanisms aiming to improve socioeconomics and place of residence disparities. This finding reflects a gap in evidence of financing mechanisms targeted at people living with a disability and LGBTIQ+ communities. Other reviews also focused on equity of health financing based on SES and place of residence but with a lesser focus on other equity components [ 437 , 438 ].

Most of the studies were conducted by authors affiliated with institutions based in high-income countries. This can be interpreted as a result of limited research capacity in low-income countries to conduct health policy and systems research. This finding corroborates other studies and reviews, highlighting the imbalance of research capacity between high-income and low-income countries [ 439 – 441 ]. This scoping review found that studies are mostly funded by governments, academic institutions, private not-for-profits and international organizations.

Strengths and limitations

To our knowledge, this scoping review is the first to map financing interventions and measures to improve equity in WCAH in LMICs. One strength of the review is that it followed JBI guidance for conducting scoping reviews [ 18 ] and the PRISMA-ScR for reporting scoping reviews [ 19 ]. One limitation is that the review aimed to include studies addressing at least one PROGRESS-plus equity component without due attention to the general pattern of inequity in low-income and LMICs where 91.9% of the global population living in extreme poverty, namely with less than US$ 2.15 per day, resides [ 442 ]. Another limitation is the fact that we did not search non-English databases although we did include non-English articles.

Implications on policy and research

The latest data on progress towards the SDGs shows that vulnerable populations are not doing well with WCAH outcome improvements. The COVID-19 pandemic and climate change, which impact the most vulnerable the hardest, including those living in conflict settings, pose challenges. These intersectional issues amplify the exclusion and marginalization of the most vulnerable. Dedicated policy efforts are required to redress the imbalance. This review provides evidence on different financing interventions that may be used to address the needs of the most vulnerable communities and improve equity. The review can be used to inform future research on financing interventions and measures to improve equity when addressing WCAH in LMICs by revealing current knowledge gaps.

Supporting information

S1 appendix. list of lmics as per the world bank country and lending groups classification by income (july 2022)..

https://doi.org/10.1371/journal.pgph.0003573.s001

S2 Appendix. Search strategy.

https://doi.org/10.1371/journal.pgph.0003573.s002

S3 Appendix. Composite humanitarian and fragile settings classification.

https://doi.org/10.1371/journal.pgph.0003573.s003

S1 Table. Conditional Cash Transfer (CCT).

https://doi.org/10.1371/journal.pgph.0003573.s004

S2 Table. Health insurance.

https://doi.org/10.1371/journal.pgph.0003573.s005

S3 Table. User fee exemptions.

https://doi.org/10.1371/journal.pgph.0003573.s006

S4 Table. Vouchers.

https://doi.org/10.1371/journal.pgph.0003573.s007

S5 Table. Several interventions.

https://doi.org/10.1371/journal.pgph.0003573.s008

S6 Table. Cost-sharing and subsidies.

https://doi.org/10.1371/journal.pgph.0003573.s009

S7 Table. Community-Based Health Insurance (CBHI).

https://doi.org/10.1371/journal.pgph.0003573.s010

S8 Table. Performance-based financing (PBF).

https://doi.org/10.1371/journal.pgph.0003573.s011

S9 Table. Unconditional Cash Transfer (UCT).

https://doi.org/10.1371/journal.pgph.0003573.s012

S10 Table. Introduction of user fees.

https://doi.org/10.1371/journal.pgph.0003573.s013

S11 Table. Microcredit.

https://doi.org/10.1371/journal.pgph.0003573.s014

Acknowledgments

The Partnership for Maternal, Newborn and Child Health (PMNCH) gratefully acknowledges the contributions of the many individuals and organizations who contributed to this report. PMNCH is the world’s largest alliance for women’s, children’s and adolescents’ health and well-being, with over 1400 partner organizations working together through 10 constituency groups. Its work is funded by a range of government and philanthropic donors. More information can be found on https://pmnch.who.int/ .

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