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Approximately 1 in 9 teenagers and young adults aged 16-24 in the United States is currently disconnected from school and employment. These disconnected young people (ie, opportunity youth) are not only at high risk for long-term emotional, behavioral, and health problems, but they also represent a loss of human capital, with high social and economic costs. In this article, we offer a public health perspective on opportunity youth by describing their distribution in the population and consequences of their disconnection; proposing a conceptual model of the issue based on epidemiological principles, life course development concepts, and ecological theory; and recommending multisector strategies for preventing disconnection of young people and reengaging opportunity youth. A public health approach to the problem of opportunity youth would involve developing and investing in youth monitoring data systems that can be coordinated across multiple sectors, consolidating both the delivery and funding of services for opportunity youth, developing policies and programs that encourage engagement of young people, and fostering systematic approaches to the testing and scaling up of preventive and reengagement interventions.
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Special Article
Opportunity Youth: Insights and
Opportunities for a Public Health
Approach to Reengage Disconnected
Teenagers and Young Adults
Tamar Mendelson, PhD
, Kristin Mmari, DrPH
, Robert W. Blum, MD
Richard F. Catalano, PhD
, and Claire D. Brindis, DrPH
Approximately 1 in 9 teenagers and young adults aged 16-24 in the United States is currently disconnected from school and
employment. These disconnected young people (ie, opportunity youth) are not only at high risk for long-term emotional,
behavioral, and health problems, but they also represent a loss of human capital, with high social and economic costs. In this
article, we offer a public health perspective on opportunity youth by describing their distribution in the population and conse-
quences of their disconnection; proposing a conceptual model of the issue based on epidemiological principles, life course
development concepts, and ecological theory; and recommending multisector strategies for preventing disconnection of young
people and reengaging opportunity youth. A public health approach to the problem of opportunity youth would involve
developing and investing in youth monitoring data systems that can be coordinated across multiple sectors, consolidating both the
delivery and funding of services for opportunity youth, developing policies and programs that encourage engagement of young
people, and fostering systematic approaches to the testing and scaling up of preventive and reengagement interventions.
conceptual model, disconnection, prevention, reengagement, youth disconnection
Emerging adulthood—the period between the late teens and
early 20s—is a profoundly important developmental stage.
During this time, most young people obtain the education
and training that will provide the foundation for their occu-
pational trajectories during the rest of adulthood.
young people, however, do not obtain adequate levels of
these important experiences to support future financial
independence and productive careers. In 2016, nearly
12%of teenagers and young adults aged 16-24 in the United
States were both out of school and out of work.
young people are commonly referred to as disconnected
youth or opportunity youth. The latter term is preferred by
some because it conveys the notion that engaging this group
in the educational system and the labor force has potential
benefits. Relative to their connected contemporaries,
opportunity youth have a disproportionate share of prob-
lems as they age, including chronic unemployment, pov-
erty, mental health disorders, criminal behaviors,
incarceration, poor health, and early mortality.
alarming disparities between opportunity youth and their
more connected peers represent a public health problem
with serious social, economic, and health implications.
In this article, we view youth disconnection from a public
health perspective, dividing our discussion into 3 sections.
First, we describe the distribution and consequences of youth
disconnection in the United States. Second, we provide a
conceptual model of youth connection and disconnection,
which is grounded in ecological theory, life course develop-
ment concepts, and epidemiological principles. Third, we
offer recommendations for multisector strategies aimed at
reducing and preventing youth disconnection.
Department of Mental Health, Johns Hopkins Bloomberg School of Public
Health, Baltimore, MD, USA
Department of Population, Family, and Reproductive Health, Johns
Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
School of Social Work, University of Washington, Seattle, WA, USA
Adolescent and Young Adult Health National Research Center, University
of California, San Francisco, School of Medicine, San Francisco, CA, USA
Corresponding Author:
Kristin Mmari, DrPH, Johns Hopkins Bloomberg School of Public Health,
Department of Population, Family, and Reproductive Health, 615 N Wolfe
St, Room E4620, Baltimore, MD 21205, USA.
Public Health Re ports
2018, Vol. 133(Supplement 1) 54S-64S
ª2018, Association of Schools and
Programs of Public Health
All rights reserved.
Article reuse guidelines:
DOI: 10.1177/0033354918799344
Youth Disconnection: Distribution in
the Population and Individual and Social
Disconnected youth compose a sizable portion of the US
population of teenagers and young adults aged 16-24. Mea-
sure of America, a project of the Social Science Research
Council, uses data from the American Community Survey
(ACS) to develop detailed reports on disconnected youth.
Measure of America reported that the proportion of US teen-
agers and young adults aged 16-24 who were neither
employed nor in school 3 months before each survey
declined from 14.7%in 2010 to 11.7%in 2016. Although
this decline represents a 20%decrease in the percentage of
disconnected youth from 2010 to 2016, an estimated 4.6
million young people were still disconnected in 2016, the
most recent year for which data were available.
The 2016 Measure of America data suggested that the
probability of disconnection among young people was
affected by income, race/ethnicity, and residential environ-
ment. Disconnected youth were nearly twice as likely as
connected youth to live in poverty and to receive Medicaid.
In communities where the poverty rate was below 6%, about
1 in 14 young people were disconnected; however, in com-
munities where the poverty rate was above 21%, 1 in 5 young
people were disconnected. Racial/ethnic disparities were
striking; youth disconnection occurred in 6.6%of Asian
American, 9.7%of white, 13.7%of Latino, 17.2%of black,
and 25.8%of American Indian/Alaska Native young peo-
The fact that these disparities persisted even when con-
trolling for income suggests that structural racism and
discrimination may also contribute to youth disconnection.
Residential environment disparities were also noted; youth
disconnection was found among 11.3%of young people in
suburban areas, 12.9%in urban areas, and 19.3%in rural
areas. Whereas the national average for youth disconnection
was 11.7%,24%of young people in the rural South were
disconnected. Other factors reportedly related to youth dis-
connection have included poor grades, mental health and
substance use disorders, parental unemployment, exposure
to trauma, and association with socially deviant peers.
Youth disconnection has consequences, both for each
affected young person and for society. In a longitudinal study
published in 2002, young people who were not in school or
employed for at least 6 months while aged 16-18 were 3 times
more likely than their connected peers to develop depression
and other mental health disorders and 5 times more likely to
have a criminal record, yet one-sixth as likely to obtain a high
school or college degree.
In 2012, each disconnected young
person was estimated to cost taxpayers $13890 per year and
approximately $250000 during a lifetime, taking into account
criminal justice expenses, welfare and social service payments,
taxpayer-funded health care costs, and lost tax revenue.
The heterogeneity of this population complicates efforts
to understand the unique experiences of or help opportunity
youth. The population encompasses a broad range of young
people, including those in the juvenile justice and foster care
systems, teenage mothers, and homeless young people.
these subgroups are often excluded from or underrepresented
in population surveys, including the ACS and Current
Population Survey.
Adding to the challenge, youth discon-
nection is usually assessed as if it were binary (ie, discon-
nected or not), when it may actually be better conceptualized
and measured along a continuum. Furthermore, although
some young people (described as chronically disconnected
youth) are consistently out of work and school, others
(described as underattached youth) are only intermittently
disconnected, having either not progressed satisfactorily
through the educational system or not secured consistent,
stable employment. Evidence suggests that various sub-
groups may require different intervention approaches.
Another challenge is that the prevailing structural defini-
tion of disconnection (ie, out of school and work) may not
capture the extent to which many young people lack mean-
ingful connections, including positive relationships with
peers, adults, and family. Those enrolled in school (techni-
cally connected) may be homeless or abused and may have
family disruptions or inadequate peer relationships. Thus,
understanding disconnection within not only a structural
context but also social and emotional contexts is crucial to
providing adequate support to opportunity youth.
Conceptual Model of Youth Connection
and Disconnection
To clarify the theoretical underpinnings of youth
disconnection, we propose a conceptual model that draws
from epidemiological principles,
life course development
and ecological theory (Figure). The model is
informed by the Positive Youth Development Framework,
which views youth development as embedded within family,
school, community, society, culture, and history, and which
promotes strategies that provide opportunities that build on
young people’s strengths.
This framework assumes plas-
ticity (ie, the capacity for adaptive change), which is espe-
cially relevant during adolescence, a time of dramatic brain
development and emotional growth, both of which provide
opportunities for transformation. The framework also empha-
sizes that positive change can take place within multiple social
contexts (ie, family, peer groups, school, community) and can
be promoted by various people in those contexts.
The conceptual model is built around young people aged
16-24 and their developmental stages. The model depicts a
continuum from connection, to underattachment, to discon-
nection (Figure). The model includes protective factors for
connection and risk factors for disconnection, all of which
potentially affect youth development at multiple ecological
levels, including individual, family, school/friends, commu-
nity, and society/policy. At each developmental stage and
ecological level, risk and protective factors can increase or
decrease disconnection. For example, at the societal level,
structural racism, sexism, and income inequality may limit
Mendelson et al 55S
options for housing, education, and employment and, thus,
increase the likelihood of disconnection.
Conversely, access
to supportive adults and services can reduce the likelihood of
The model additionally incorporates various
interventions, which can also influence youth development.
These interventions may range from promotion of connection,
to prevention of disconnection, to reengagement of those who
are disconnected.
The model indicates that promotion and
prevention strategies—key components of a public health
approach that are detailed later—as well as reengagement stra-
tegies can be envisioned that target various youth populations,
which, depending on the intervention goals, may include all
young people regardless of risk (universal interventions);
young people with risk factors for disconnection, such as place-
ment in child welfare (selective interventions); and young peo-
ple exhibiting early signs of disconnection, such as missing
numerous school days (indicated interventions).
Strategies for Preventing or Reducing
Youth Disconnection: Applying a Public
Health Approach
In this next section, we describe promising prevention and
reengagement strategies, and we make recommendations for
how these strategies might be improved or expanded by
using public health tools. Public health tools—including
identifying populations at highest risk for health issues, mon-
itoring protective and risk factors, and implementing
population-based prevention and intervention strategies—
can be used in an intentional and systematic way to reduce
the number of opportunity youth.
So far, the predominant response to youth disconnection
has been the use of reengagement strategies. These strategies
aim to reconnect young people with education or to provide
young people with apprenticeships, other job training, or
employment (Table 1). National reengagement programs,
such as YouthBuild, Job Corps, and Year Up, have demon-
strated measurable (albeit small) benefits for high school gra-
duation rates and wages.
Other large-scale initiatives have
broadened the scope and impact of this work. One of these
initiatives is the Aspen Institute’s Opportunity Youth Incen-
tive Fund, an initiative established in 2012 that provides sup-
port to 21 US sites and has 3 goals: (1) reconnecting
opportunity youth to education and employment; (2) catalyz-
ing the adoption of approaches in education and career attain-
ment that lead to family-sustaining careers; and (3) promoting
local, state, and national policies that increase the replication
and scaling up of these approaches.
Another reengagement
Figure. Conceptual model of youth connection and disconnection. Disconnected youth are teenagers and young adults aged 16-24 who are
neither in school nor employed.
The model is built around developmental stages (continuum: connection to underattachment to discon-
nection) of young people aged 16-24. Protective factors for connection and risk factors for disconnection may affect development at multiple
ecological levels: individual, family, school/friends, community, and society/policy. Promotion of connection, prevention of disconnection, and
reengagement of disconnected youth with school, employment, or key social supports can be used to target young people universally (all young
people), selectively (young people with risk factors), or as indicated (young people showing early signs of disconnection).
56S Public Health Reports 133(Supplement 1)
project is the 100 000 Opportunities Initiative, which was
launched in 2015 and is the largest employer-led, opportunity
youth–focused coalition in the United States. In this initiative,
the coalition committed to training and hiring 100000 oppor-
tunity youth by 2018. More recently, after surpassing this
original goal 2 years ahead of schedule, it established a new
goal to hire 1 million opportunity youth by 2021.
Historically, strategies to prevent youth disconnection
have not received the same level of priority as reengagement
strategies. Yet prevention is at least as important as reen-
gagement; it can reduce the need for costly interventions
later in life, and it can reduce suffering and enhance well-
being among young people.
Preventive approaches for
youth disconnection include strengthening connections
within the key contexts in young people’s lives (school, fam-
ily, and community) and promoting academic and career
engagement among young people (Table 2). For example,
a large body of evidence supports the role that universal
preschool education can play in both readiness to learn and
good academic performance, demonstrating a positive long-
term effect on student engagement in school.
The Good
Behavior Game, an example of a classroom-centered
Table 1. Examples of school-, family-, community-, and employer-based programs for the reengagement of disconnected youth
Program Name Target Audience Program Description Outcomes
School-based programs
PACE Center
for Girls
Girls aged 11-18 who exhibit multiple
health, safety, and delinquency risk
factors such as poor academic
performance, truancy, risky sexual
behavior, and substance use
PACE operates in 19 nonresidential,
year-round centers across Florida.
Girls attend PACE during school
hours and receive academic and
social services (eg, life skills training,
care planning). Parental engagement,
transition, and follow-up services
are key to PACE. When girls leave
PACE, they are expected to return
to schools to complete their
secondary education.
Results of a randomized controlled
trial are expected in 2018 that will
include examining the impact of the
program on high school completion,
school suspensions, absenteeism,
arrests, and employment stability.
Interim report findings were
included in Treskon et al.
Adolescents aged 10-12 who are (1)
behind in credits for grade level, (2)
in the top 25th percentile for
absences, (3) have a grade point
average lower than 2.3 OR have a
prior dropout OR have been
referred by school personnel
Evidence-based program intended to
increase school performance,
decrease drug involvement, and
decrease emotional distress via a
75-lesson curriculum, social and
school bonding activities, and a
school crisis response plan.
A qualitative study in an urban high
school setting showed that the
program directly increased personal
control, prolonged exposure to the
program, and increased protective
Employer-based programs
National Guard
Young men and women aged 16-18
who have difficulty completing
traditional high school
Using a military model, a voluntary 17-
month dropout recovery program
helps at-risk young people earn their
high school diploma or GED, enroll
in college or trade school, start a
career, or join the military.
Compared with controls, program
participants were more likely to
obtain their GED, to have earned
college credits (72% vs 56%), to be
employed and earning about 20%
more income, and to report living
on their own. Unfavorable trends
increased the risk of not using birth
control and having tried illegal drugs
other than marijuana.
Diverse young people and young adults
aged 18-24 from disadvantaged
The initiative provides young people
with an opportunity to engage in an
environmental service project,
workplace readiness training,
assistance in transition to college,
and professional certifications,
including OSHA.
Results showed that 48% of
participants indicated that they
enrolled in a school, and 52%
indicated that they successfully
obtained employment. Substantial
differences emerged in community
engagement, teamwork, leadership,
self-responsibility, communication,
and grit.
Abbreviations: GED, general educational development; OSHA, Occupational Safety and Health Administration.
Disconnected (or opportunity) youth are teenagers and young adults aged 16-24 who are neither in school nor employed.
Note: Additional evidence-based and promising prevention and reengagement programs can be found at the following websites:
Mendelson et al 57S
Table 2. Examples of school-, family-, community-, and employer-based programs for the prevention of youth disconnection
Program Name Target Audience Program Description Outcomes
School-based programs
Good Behavior Game Early elementary grades Classroom-centered universal
prevention program delivered by
teachers in classrooms.
Shown to have short- and long-term
positive effects on problem
behaviors, conduct disorder,
educational outcomes, substance
use, and violence.
Life Skills Training Students in kindergarten through
12th grade, students in transition,
and parents
Substance abuse prevention
program that builds knowledge
about the dangers of drug use and
promotes healthy alternatives
through personal self-
management skills, general social
skills, and drug and violence
resistance skills.
Reduced tobacco, alcohol, and illicit
drug use and reduced verbal and
physical aggression and
delinquency for intervention
participants relative to controls.
Produced $50 benefit for every $1
invested in terms of reduced
corrections costs, welfare and
social services burden, drug
and mental health treatment,
and increased employment and
tax revenue.
Family-centered programs
Strengthening Families High-risk families with children in
preschool through age 17
14-session evidence-based program
that provides parent, child, and
family with life skills training.
Parents and children participate in
groups together and separately.
Various randomized controlled trials
evaluating the program reported
positive results in reducing
substance use and delinquency by
improving family
Triple P: Positive
Parenting Program
Parents of children up to age 17,
specialized programs for parents
of children with disabilities, family
issues (separation/divorce),
minority populations
Parenting program designed to
address behavioral and emotional
problems in children and teens.
Based on social learning, cognitive
behavioral theory, and
developmental theory.
Shown to reduce rates of child
abuse, reduce foster care
placements, and decrease
hospitalizations from child abuse
Reduced problems in children and
improved parental well-being and
parenting skills.
Community-based programs
Communities That
Care (CTC)
Young people in grades 5 through
12 in participating communities
CTC is a coalition-based prevention
approach in which researchers
consult with community
stakeholders to identify relevant
risk and protective factors and
implement evidence-based
school, family, and community
preventive interventions to
promote positive youth
Multiple large-scale impact
evaluations have found that CTC
reduces short- and long-term
substance use and delinquent
CTC was also found to increase
youth-reported protective
and to be a cost-
beneficial intervention with a
return of $5.30 per $1 invested
under conservative
Partnerships to
Enhance Resilience)
Young people through 12th grade PROSPER is a community-university
partnership that delivers
evidence-based school-, family-,
and community-based preventive
interventions with the primary
goal of preventing substance
Lower substance misuse was seen in
intervention youth (relative
reduction rates up to
approximately 31%)
as well as
reduced conduct problems
through 6.5 years after baseline.
Long-term effects, beyond high
school, were observed on
reducing substance misuse.
Disconnected (or opportunity) youth are teenagers and young adults aged 16-24 who are neither in school nor employed.
Note: Additional evidence-based and promising prevention and reengagement programs can be found at the following websites:
58S Public Health Reports 133(Supplement 1)
universal prevention program, was found to reduce conduct
problems, emotional disorders, school suspensions, and spe-
cial education service use, as well as to increase high school
standardized test scores and the odds of high school gradua-
tion and college attendance; and, during early childhood, to
reduce antisocial behaviors, substance use, and violent and
criminal behavior.
Both Communities That Care and
Promoting School-Community-University Partnerships
to Enhance Resilience (PROSPER) are examples of
community-based strategies to prevent youth disconnection,
each of which has demonstrated positive effects that extend
into young adulthood.
In these approaches, researchers
provide structured guidelines and support to communities
and help them convene a coalition of agencies, schools, and
community leaders to conduct school-based assessments,
prioritize protective and risk factors, and implement
evidence-based school, family, and community prevention
programs matched to their identified priorities.
To be maximally effective, however, strategies to prevent
disconnection need to be delivered at multiple ecological
levels (ie, family, peers, school, community), during various
developmental stages (infancy through early adulthood), and
across various sectors (eg, education, health). Effective
evidence-based prevention strategies certainly exist,
many have not measured their effect on youth disconnection,
and most have not been scaled up sufficiently to affect a
broad population. In addition, only a few prevention strate-
gies, such as that reported by Stormshak et al,
have been
integrated with reengagement strategies.
To expand on the work already begun and address a prob-
lem as complex as youth disconnection, multisectoral
approaches are needed. Public health strategies should be
well suited to this effort because they can be formulated to
target diverse sectors, to work at multiple ecological levels,
and to engage a wide range of stakeholders and disciplines
Strategies most likely to succeed will be
those that (1) use coordinated data systems, (2) consolidate
service delivery and blend funding, (3) involve young people
in the design and implementation of interventions, and
(4) undertake systematic approaches to the testing and scal-
ing up of prevention and reengagement interventions.
Coordinated Data Systems
Multiple youth monitoring data systems collect data on edu-
cation, health care, juvenile justice, child welfare, and foster
care. However, because most of these data systems currently
lack interoperability, it is nearly impossible to track oppor-
tunity youth who move in and out of these sectors. Also,
these data systems often fail to gather data elements in con-
sistent ways. The current situation presents an opportunity
for creating policies that incentivize standardized data col-
lection and data sharing. Ultimately, coordinated collection
and integration of data across multiple systems is crucial for
effectively preventing and reducing youth disconnection.
Another challenge is that in many data systems, certain
opportunity youth subgroups (eg, homeless and unstably
housed young people, lesbian/gay/bisexual/transgender/
queer and questioning [LGBTQ] young people) are invisible.
LGBTQ young people are known to be disproportionately
discriminated against and harassed in schools and the work-
but they are often concealed within the broader
category of opportunity youth because many data systems do
not capture data on sexual orientation or gender identity.
Data system consistency, consolidation, and sharing across
various educational, health, and social services should be a
priority. Through new public policies, integrated data sys-
tems could be established that would identify disconnected
youth communities or subgroups to prioritize for prevention
and reengagement efforts.
A related obstacle is the lack of longitudinal data pertain-
ing to opportunity youth. Information about the pathways
that young people may follow into and out of disconnection
is valuable. For example, longitudinal data have shown that
the quality of parental caregiving from age 6 to 42 months is
a predictor of high school dropout rates.
Evidence also
indicates that children exhibiting problem behaviors in first
grade or having to repeat first grade had higher high school
dropout rates than children without these issues.
longitudinal datasets, such as the National Longitudinal Sur-
vey of Youth, the Educational Longitudinal Survey of Youth,
and the National Longitudinal Study of Adolescent Health,
can be useful in broadening the understanding of differences
among chronically disconnected, underattached, and institu-
tionalized young people.
Nevertheless, an increase in the
collection and monitoring of youth disconnection risk indi-
cators over time could help ensure that at-risk young people
are identified early and provided with additional supports to
prevent disconnection as they age.
The San Diego Youth Opportunity Pathway Initiative is
an example of how detailed and integrated data can be used
to prioritize prevention and reengagement programs.
Beginning in 2013, this collaborative merged data from the
US Census tract with data from the US Department of Health
and Human Services and the San Diego Association of
Governments to create “heat” maps, which display areas
with high concentrations of young people who have various
risk factors for disconnection, including unemployment, teen
births, probation, foster care, and school dropout. Along with
data on levels of existing programming, the maps have been
used by collaborative partners to identify priority neighbor-
hoods and potential entry points for prevention and reen-
gagement efforts. Another example is the Opportunity
Index, created by Opportunity Nation, a cross-sector national
coalition working to expand economic mobility and close the
opportunity gap in the United States. This group has inte-
grated information from various data sources to provide an
annual opportunity score for states and counties throughout
the United States.
The opportunity score is based on 20
economic, health, and civic indicators that measure expan-
sion or restriction of access to opportunity for upward
Mendelson et al 59S
mobility, and it can be used to identify the communities that
are most in need of prevention and reengagement efforts. We
recommend that similar types of monitoring systems, which
would collect, merge, and integrate data, preferably across
the life course and at a population level, be implemented
broadly by the communities.
Most data sets either do not include key risk factors (eg,
family trauma) and protective factors (eg, positive relation-
ships with a caring adult) for youth disconnection or do not
monitor these risk and protective factors longitudinally. One
exception is the Communities That Care Youth Survey,
which is administered to young people in grades 6, 8, 10,
and 12 on a population-wide basis and provides data on more
than 20 risk and protective factors.
Another exception is
Search Institute’s Developmental Assets Profile,
which has
been used in schools and communities since 2005. This sur-
vey measures young people’s internal strengths, external
supports, and growth in these key areas over time. An impor-
tant step toward preventing youth disconnection would be
the development of policies that require schools to perform
longitudinal population-level surveys, starting in early ele-
mentary school and extending through high school or
beyond. These surveys should measure disconnection levels,
risk and protective factors, and their consequences. Data
captured by such surveys could help inform interventions
that are tailored to and responsive to the needs of various
subgroups of opportunity youth.
Another strategy that would help deepen our understand-
ing of the experiences and needs of opportunity youth would
be to integrate data obtained using qualitative and mixed
methods with quantitative data. Interviewing young people
who are either at risk for disconnection or are already dis-
connected would enhance the ability of researchers and pol-
icy makers to view issues from the perspective of young
people. A more frequent use of qualitative methods would
allow comparisons of the experiences of various discon-
nected youth subgroups, including those in rural areas and
urban areas, and those in culturally disadvantaged groups
(eg, immigrant youth) and marginalized groups (eg,
LGBTQ). Qualitative reviews of school policies would be
a way to identify policies that may be contributing to youth
disconnection, either inadvertently or by design. One exam-
ple is the use of “one strike and you’re out” (zero tolerance)
school expulsion policies.
These and other school policies
have been criticized for increasing dropout and incarceration
rates, as well as other problems.
Information obtained
from regular policy analyses would offer the opportunity to
modify such policies that may be placing more students at
risk for disconnection.
Strategies and policies that promote the capture and use of
appropriately detailed, coordinated, and integrated longitu-
dinal data are needed to help various systems and sectors
better align with each other to address youth disconnection.
However, substantial challenges to implementation of
these strategies and policies exist. These challenges
include costs, privacy concerns, technological issues, and
obtaining stakeholder buy-in. Progress in this area will
require collaborative efforts, including making infrastruc-
ture- and data-sharing arrangements, to move the field
Service Delivery and Funding
Disconnected youth have historically relied on a handful of
public and nonprofit agencies or stand-alone programs in
their communities for the prevention and reengagement ser-
vices they need. These agencies and programs have typically
been supported by a fragmented array of funding sources.
Because of ineffective interagency coordination, information
sharing, and longitudinal follow-up, disconnected youth
have received inadequate attention to their needs, and data
on both the short- and long-term effects of programmatic
efforts have been lacking. Consolidation of prevention and
reengagement services to disconnected youth would help
address some of these deficiencies, and public policy could
be used to help drive and shape this consolidation.
For policies directed at service consolidation to be effec-
tive, however, policy makers need to consider the potential
costs and benefits of the outcomes they are seeking, applying
a return-on-investment approach to any funding commit-
ments that are being considered.
For example, funding
could be made dependent on programs providing certain
returns, such as demonstrations of interagency collaboration,
service-system integration, and engagement of young people
in service and system development. Policy makers could also
consider promoting the blending of funding within jurisdic-
tions. An example of this blending of funding is Performance
Partnership Pilots (P3) for Disconnected Youth,
which was
reauthorized by Congress in 2015. P3 provides jurisdictions
with the opportunity to test innovative, cost-effective, and
outcome-focused strategies for improving results for discon-
nected youth. It allows jurisdictions to blend their existing
federal discretionary funds across multiple eligible pro-
grams, thus removing barriers to disconnected youth service
delivery across communities. Another example is a new col-
lective effort by national nonprofit organizations and
employers to consolidate $6.5 billion of federal funding, with
the goal of reengaging more than 1 million opportunity youth
in education and employment annually for the next 5 years.
Jurisdictions that use blended funding approaches should be
required to provide rigorous impact evaluations of their pro-
grams. The results of these evaluations would then shape
subsequent policy and programmatic efforts.
Another challenge with current service delivery and pro-
gramming for young people is that they are often focused
only on one developmental period (or age group) without
considering the life course implications of disconnection.
Although numerous evidence-based programs exist at vari-
ous grade levels (eg, the Good Behavior Game intervention),
rarely are these programs integrated with programming at the
next grade level. One exception is the Raising Healthy Chil-
dren program, which delivers teacher, parent, and child
60S Public Health Reports 133(Supplement 1)
interventions across primary and secondary school.
nally tested in primary schools and found to have broad and
lasting effects,
the primary school intervention was
extended into middle school in a separate trial.
people in the intervention group demonstrated increased
school and family connectedness
; reduced problems with
mental health, risky sexual behavior, sexually transmitted
infections, and substance use; and other positive outcomes,
including increases in high school graduation rates, number
of years of college attendance, and measures of socioeco-
nomic status.
Disconnected Youth Involvement
Disconnected youth should be asked to provide input on
research, strategy development, and intervention delivery
efforts. The participation of disconnected youth who are
most marginalized (ie, those who are chronically discon-
nected) should be sought. Young people can provide
important perspectives on intervention feasibility and accept-
ability, which may improve program efficacy. Their involve-
ment also has the potential to provide opportunity youth with
leadership and employment opportunities and positive con-
nections with adults. One strategy involves the use of previ-
ously disconnected youth as mentors or coaches to young
people at risk for leaving school and being disconnected.
An example of this strategy is in Baltimore City, Maryland,
where the Thread Program ( pro-
vides a network of supports for high school students at high-
est risk for leaving school early or for gang engagement.
Keys to success in involving disconnected youth include
using specific outreach strategies, providing ongoing training
with useful real-world applications, engaging in retention
efforts, ensuring meaningful representation, and acknowled-
ging input. Trust can be developed by prioritizing the con-
cerns of young people over those of service providers. To
date, the most successful efforts to involve disconnected
youth have provided young people with human and financial
resources and training on how to make meaningful contribu-
That said, more research is needed to ascertain the
most effective ways to engage disconnected youth in
research, strategy, and intervention efforts.
Systematic Intervention Testing and Scaling Up
The United States currently lacks a national public health
policy agenda for, or systematic approach to, the develop-
ment, testing, scaling up, and funding of interventions aimed
at disconnected and at-risk youth. Public policy makers
could help improve each of these processes by developing
policies that provide incentives for programs that use
evidence-based practices and for programs that require sys-
tematic documentation of implementation and outcomes in a
manner that would enable knowledge sharing. Also,
researchers and public health practitioners could work
together to systematically identify, test, and refine the core
components of intervention programs for disconnected
The results of this work could then be used to
inform future efforts to implement and scale up effective
As part of this effort, realistic measures of success should
be identified. These measures should be developed based on
the understanding of pathways into and out of youth discon-
nection. Development of these outcome indicators would
allow for the consistent monitoring of intervention and ini-
tiative outcomes and of the progress of target populations.
Both intermediate outcome indicators (eg, active engage-
ment with adults, tutors, or other support people) and
longer-term outcome indicators (eg, school graduation,
post–high school training, education enrollment) need to be
specified, refined, and tracked over time.
Public Health Implications
The societal and economic costs of failing to address the
needs of disconnected youth in the United States are high,
both for this generation of young people and for their chil-
dren. These costs include the loss of human resources to
compete in a global economy, increased demands for public
assistance, mass incarceration, drug abuse and opioid epi-
demics, and massive health service delivery costs.
moral case for preventing and reducing youth disconnection
is equally compelling. Most disconnected youth grow up in
impoverished households and are the victims of failed
schools, failed neighborhoods, and failed child welfare sys-
tems. Their poor emotional, behavioral, and health outcomes
are therefore not surprising.
Now, more than ever, we must
use the tools of public health—coordinated data systems,
consolidated services and funding, population engagement,
and systematic evaluation and scaling up—to expand the
work already begun for this population.
Authors’ Note
Drs Mendelson and Mmari, listed in alphabetical order, contributed
equally to this article.
Declaration of Conflicting Interests
The authors declared no potential conflicts of interest with respect
to the research, authorship, and/or publication of this article.
The authors disclosed receipt of the following financial support for
the research, authorship, and/or publication of this article: This
article was produced with the support of the Bloomberg American
Health Initiative, which is funded by a grant from the Bloomberg
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... In the United States, more than 4.6 million adolescents and young adults aged 16-24 are not employed or enrolled in some form of education or training, hereafter referred to as NEET (Mendelson, Mmari, Blum, Catalano, & Brindis, 2018). In 2016, the NEET population represented approximately 11.7% of individuals 16 to 24 in the U.S. (Mendelson et al., 2018). ...
... In the United States, more than 4.6 million adolescents and young adults aged 16-24 are not employed or enrolled in some form of education or training, hereafter referred to as NEET (Mendelson, Mmari, Blum, Catalano, & Brindis, 2018). In 2016, the NEET population represented approximately 11.7% of individuals 16 to 24 in the U.S. (Mendelson et al., 2018). Significant increases in the estimates of the NEET population have been observed due to the ongoing COVID-19 pandemic, with a recent estimate placing the number of adolescents or young adults not working or in education/training between 20% and 28% in the summer of 2020, surpassing corresponding estimates for the same period in previous years (Fry & Barroso, 2020). ...
... Significant increases in the estimates of the NEET population have been observed due to the ongoing COVID-19 pandemic, with a recent estimate placing the number of adolescents or young adults not working or in education/training between 20% and 28% in the summer of 2020, surpassing corresponding estimates for the same period in previous years (Fry & Barroso, 2020). The disconnection from both the educational system and the workforce may significantly increase the propensity for risky health behaviors, which are found already at higher rates among adolescents and young adults, ultimately impacting future health (Cubbin, Santelli, Brindis, & ;Hair, Park, Ling, & Moore, 2009;Mendelson et al., 2018). Despite the size of this population, limited research in the U.S. has explored potential differences in health status between NEETs and the non-NEET population. ...
Full-text available
Adolescents and young adults not employed or in education/training (NEET) could be at higher risk of adverse health outcomes. Approximately 4.6 million Americans aged between 16 and 24 fall in this group. However, differences in health between NEET and non-NEET population remain unaddressed. This study examines the association of NEET status and poor/fair self-reported health status (SRH), among adolescents and young adults in the United States. Data for this study come from the 2016–2018 National Survey on Drug Use and Health (NSDUH). Our analytical sample consisted of 53,690 respondents. We used logistic regression models to investigate the association between NEET and health status in the United States, while controlling for potential covariates. Approximately 14% of our analytical sample was classified as NEET. NEET reported worse health status than their counterparts who remained in school and/or had a job (11.30% vs. 5.62%). The NEET population was older, had a higher proportion of non-Hispanic Blacks, engaged in more smoking but in less alcohol drinking than non-NEET. In our initial model, NEET were more likely report poor/fair SRH than their non-NEET counterparts (OR = 2.14; p < 0.001). This difference remains strong when demographic and socioeconomic characteristics are accounted for in our empirical models (OR = 1.93, p < 0.001). In our fully specified model, which accounts for health behaviors, NEET continue to have higher odds of reporting poor/fair SRH (OR = 1.77, p < 0.001). Our analyses suggest that NEET populations report worse health than non-NEETs. The health of this population may improve if interventions to reinsert them into either education or employment are effectively deployed.
... When schools function as carceral spaces, punishment is prioritized over learning and youth are displaced from classrooms into the streets and the juvenile justice system. Youth who are displaced from schools and become justice-involved 1 experience higher rates of unemployment, higher levels of income inequality, and increased issues with mental and physical health over their lifetimes (Mendelson et al., 2018). ...
Full-text available
With little recourse for social and political injustices due to state and federal laws and institutional governance structures that negate youth autonomy as citizens, they are particularly vulnerable to a lack of legislative will for gun violence reform. This chapter focuses on the development of the out-of-school-time project of the National Youth Art Movement Against Gun Violence that launched an art and Augmented Reality interactive tour in the city of Chicago in the fall of 2017. The project provided youth between the ages of 13 and 27 years old with the ability to use their intrinsic talent in the visual arts to develop and lead a public intervention for gun violence enabled with the affordances of mixed reality technologies utilizing public spaces. The result was a nuanced portrayal of the impact of gun violence from their perspective, and a public learning experience that inverted typical power dynamics by placing youth as the teachers and leaders of adults and the traumas of the marginalized into the mainstream.
... Youth delinquency is a serious public health concern associated with significant societal consequences (Corso, Mercy, Simon, Finkelstein, & Miller, 2007;Mendelson, Mmari, Blum, Catalano, & Brindis, 2018;Welsh et al., 2008). In 2018, juvenile courts handled 23.5 cases for every 1000 juveniles aged 10 or older in the United States (Hockenberry & Puzzanchera, 2020). ...
Full-text available
Background Universal school-based prevention programs for alcohol, tobacco, and other drug use are typically designed for all students within a particular school setting. However, it is unclear whether such broad-based programs are effective for youth at risk for substance use and violence in juvenile justice settings. Method The present study tested the feasibility, appropriateness, and efficacy of a preventive intervention to reduce risk factors for substance use and delinquency among youth in juvenile justice diversionary settings by promoting positive youth development and building personal strengths and prosocial relationships. Participants in the study ( N = 288) were predominantly male (69%) and in the 9th grade (14 years old) or higher (91%), received the preventive intervention, and completed confidential questionnaires at the pre-test and post-test. Results The majority of youth who participated in the intervention rated the program topics (77.9%) and activities (72%) as appropriate for their age, would recommend it to their peers (73.6%), and would use the skills learned in the future (85.4%). Comparison of post-test adjusted means revealed that the prevention program had a significant positive impact on key knowledge, attitudes, and skills including goal-setting, stress-management, and communication skills. Conclusions The findings indicate that an evidence-based prevention approach adapted for youth diversionary settings can be effectively implemented and well-received by participating youth, and can produce positive changes in psychosocial skills and protective factors known to prevent multiple risk behaviors among youth. Future efforts to implement substance use prevention in community juvenile justice settings may benefit from highlighting a positive youth development, skills-based approach.
... Research on dating violence perpetration among young women has generally focused on school-based samples (Cohen et al. 2018;King et al. 2017;Spencer et al. 2017) and has rarely included youth who are disconnected from school or work. Youth who are not in school or working are at high risk for long-term emotional, behavioral, and health problems; they are also twice as likely to live in poverty (Mendelson et al. 2018). The current study analyzed data gathered from a sample of young urban Black women who were not in school or working to address gaps in our understanding of dating violence perpetration in this population. ...
Full-text available
Parental support is a well-documented protective factor against dating violence perpetration. However, no studies have investigated this relationship among disconnected, young urban Black women, despite higher reported instances of perpetration among this group. We hypothesized that higher levels of parental support would be associated with lower levels of dating violence perpetration. Participants were 374 disconnected, young urban Black women (ages 16–23) recruited from two employment training programs in Baltimore, Maryland. We used multivariate logistic regression analyses to assess the association between youth reported maternal and paternal support and physical dating violence perpetration. Over 20% of the sample reported past-year physical dating violence perpetration. Experience with recent dating violence victimization was the most robust correlate of physical dating violence perpetration (aOR = 6.44, p = 0.000). Contrary to prediction, maternal support was associated with a 37% increase in the odds of physical dating violence perpetration among participants (aOR = 1.37, p = 0.027). Findings highlight the need for additional research on the complex relationship between maternal support and physical dating violence perpetration among disconnected, young urban Black women.
... At the school-level, fostering a sense of belonging and attachment keeps students more academically engaged and reduces rates of high school drop-out [44]. Given that youth who have dropped out of school and are unemployed are more likely to engage in health-damaging behavior, including smoking, drinking, and drug use [45,46], communities that keep youth connected to school may also report better overall population health and wellbeing. ...
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Background Stark inequalities in health and wellbeing exist across US counties. Schools are a key feature of counties and residents often make decisions about where to live based on the quality of the local schools. How counties invest in their local schools may reflect one way that health and wellbeing become embedded in geographic places. Methods We constructed four indicators of county-level education context using administrative data from all US public schools and linked these to population health data from the RWJF County Health Rankings and Roadmaps Program. Using state-fixed effects spatial error models, we examined if county-level education context relates to county rankings on two indices of population health and wellbeing – quality of life and health behaviors – after adjusting for county-level demographic, economic, and social contexts. Results Total county revenue from local sources and the percentage of a county's high school students enrolled in advanced placement coursework were associated with better county rankings on quality of life and health behavior. We also found a curvilinear relationship between county-level per-pupil spending and county rankings on our population health and wellbeing outcomes. In fully adjusted models, the education context indicators were attenuated; all three remained significantly associated with county rankings on health behavior, but only revenue from local sources was significantly associated with county rankings on quality of life. Conclusion Providing a quality education context may yield health and wellbeing dividends at the county-level given the public education system's far-reaching influence on social and economic wellbeing.
Opportunity youth (OY; i.e., youth ages 16–24 who are neither working nor in school) are a population who is difficult to engage and retain in educational programs, particularly in community college career and technical education (CTE) programs. OY are an important population to community colleges, as CTE programs culminating in industry-recognized credentials and employment constitute an important on-ramp to the workforce for young adults. The Manufacturing Training Program is a vocational training program offered at a local community college in Phoenix, Arizona that was informed by input from youth and service providers to support OY in obtaining the necessary technical skills/credential for entry-level employment in manufacturing. Researchers conducted a qualitative study using in-depth interviews with 32 program stakeholders and beneficiaries (i.e., 14 staff and 18 youth). Data were coded and analyzed using content analysis to identify major themes for each stakeholder and beneficiary group interviewed as well as working hypotheses to guide future CTE program development. Findings suggest that there are both challenges and successes related to recruiting, retaining and employing OY. Recruitment challenges include lack of information about and disinterest in manufacturing, whereas successes include leveraging family members in recruiting youth. Retention challenges include meeting OYs’ basic needs, whereas successes include providing quality case management. Employment challenges include limited employer participation whereas successes include developing an effective process to connect employers with trained youth. Findings and lessons learned on recruitment, retention, and employment challenges and successes offer direction for community colleges to develop and strengthen CTE programs for OY.
Transition-aged foster youth with disabilities are arguably one of the most vulnerable sub-groups in state child welfare systems. However, little research has examined the ways in which services may be coordinated in and across child welfare systems and with adult service systems. To fill this gap, this study reports the findings from an online survey of U.S. independent living coordinators regarding coordination of services for foster youth with disabilities. In all, 43 surveys were completed, for an 84% response rate. Survey responses were uploaded into SPSS and descriptive analyses were completed. The majority of respondents (87%) reported their state child welfare system screened for disabilities. More than half (63%) reported their state’s data system tracks disabilities. Although a majority of respondents (79%) indicated a child welfare representative is required to attend Individualized Education Program (IEP) meetings, criteria vary regarding who is eligible to fill that role. A majority of respondents reported that their agency collaborates with other public agencies serving adults with disabilities (92%). The most frequently mentioned agencies that respondents reported coordinating transition planning with were mental health, vocational rehabilitation, and other community programs. Study findings are discussed in the context of federal independent living policy, which requires child welfare agencies to collaborate with and rely on other public institutions.
Bystander intervention programs are viewed as innovative community-level responses to sexual and dating violence among adolescents and young adults (Banyard, 2014; McMahon & Farmer, 2009; Moynihan et al., 2015; Storer et al., 2017). At the school and community level, factors such as social cohesion, collective efficacy, and exposure to community violence have been found to influence use of bystander behaviors (Edwards et al., 2014; Lucero et al., 2019; McMahon, 2015; Rothman et al., 2019). Despite the explosion of literature examining the efficacy of bystander interventions, most study populations are on college and high school campuses. There has been limited exploration of the feasibility of such programs among disadvantaged youth in resource-poor communities not affiliated with formal school or work settings (i.e., low opportunity youth). The purpose of this exploratory study is to investigate these emerging adults’ willingness to use bystander behaviors in response to witnessing dating and community violence. Data were collected from six focus groups at three youth-serving agencies in New Orleans. Participants were aged 17–22 (n = 39) and both male- and female-identified; the majority identified as African American. All participants were involved with community-based organizations with missions to positively engage socially disconnected emerging adults. Our exploratory thematic content analysis involved multiple rounds of inductive coding. Once we applied codes to the data, we employed matrices to construct key social processes both within and across the focus groups. Across the focus groups, participants described community environments that exposed them to racial injustice and to community, police-perpetrated, and intimate partner violence. Participants reported an overarching reluctance to utilize bystander behaviors. Although the participants did not condone these acts of violence, they perceived intervention to be dangerous due to retaliatory violence and/or they equated bystander behaviors to “snitching.” Participants were more willing to intervene in instances of extreme violence and when the incident involved a friend or family member. This study illustrates the intricate ways community violence and complex trauma influence emerging adults’ willingness to intervene in instances of community and dating violence. These findings challenge the idea that existing bystander intervention models can account for the multitude of community-level barriers faced by low opportunity emerging adults with trauma backgrounds when deciding to use bystander intervention behaviors.
Opportunity Youth represents over four million young people who are not in school and are unemployed. In Maryland, Baltimore City has the highest rate of youth disconnection. In spite of this, there are limited culturally relevant program models specific to the experiences of urban, African American youth. None focus on the unique needs of young women who are disconnected from school and work. In partnership with two local youth organizations, a 6-week program was co-developed and implemented to address the social and emotional needs of female opportunity youth in Baltimore. The program promoted self-efficacy, fostered a supportive network of trusted adults and increased awareness of resources. Lessons learned included the importance of program flexibility, the value of youth voice in program development, and the need to reframe how success is measured. This case study highlights a novel approach to bolstering the development of female opportunity youth.
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This meta-analysis reviewed 82 school-based, universal social and emotional learning (SEL) interventions involving 97,406 kindergarten to high school students (Mage = 11.09 years; mean percent low socioeconomic status = 41.1; mean percent students of color = 45.9). Thirty-eight interventions took place outside the United States. Follow-up outcomes (collected 6 months to 18 years postintervention) demonstrate SEL's enhancement of positive youth development. Participants fared significantly better than controls in social-emotional skills, attitudes, and indicators of well-being. Benefits were similar regardless of students’ race, socioeconomic background, or school location. Postintervention social-emotional skill development was the strongest predictor of well-being at follow-up. Infrequently assessed but notable outcomes (e.g., graduation and safe sexual behaviors) illustrate SEL's improvement of critical aspects of students’ developmental trajectories.
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The Communities That Care (CTC) prevention system has shown effects on reducing incidence and prevalence of problem behaviors among a panel of youth followed from 5th through 12th grade. The present report examines whether similar intervention effects could be observed using a repeated cross-sectional design in the same study. Data were from a community-randomized trial of 24 US towns. Cross-sectional samples of sixth, eighth, and tenth graders were surveyed at four waves. Two-stage ANCOVA analyses estimated differences between CTC and control communities in community-level prevalence of problem behaviors for each grade, adjusting for baseline prevalence. No statistically significant reductions in prevalence of problem behaviors were observed at any grade in CTC compared to control communities. Secondary analyses examined intervention effects within a "pseudo cohort" where cross-sectional data were used from sixth graders at baseline and tenth graders 4 years later. When examining effects within the pseudo cohort, CTC compared to control communities showed a significantly slower increase from sixth to tenth grade in lifetime smokeless tobacco use but not for other outcomes. Exploratory analyses showed significantly slower increases in lifetime problem behaviors within the pseudo cohort for CTC communities with high, but not low, prevention program saturation compared to control communities. Although CTC demonstrated effects in a longitudinal panel from the same community-randomized trial, we did not find similar effects on problem behaviors using a repeated cross-sectional design. These differences may be due to a reduced ability to detect effects because of potential cohort effects, accretion of those who were not exposed, and attrition of those who were exposed to CTC programming in the repeated cross-sectional sample.
We assessed the immediate effects of two universal, first‐grade preventive interventions on the proximal targets of poor achievement, concentration problems, aggression, and shy behaviors, known early risk behaviors for later substance use/abuse, affective disorder, and conduct disorder. The classroom‐centered (CC) intervention was designed to reduce these early risk behaviors by enhancing teachers' behavior management and instructional skills, whereas the family‐school partnership (FSP) intervention was aimed at improving parent‐teacher communication and parental teaching and child behavior management strategies. Over the course of first and second grades, the CC intervention yielded the greatest degree of impact on its proximal targets, whereas the FSP's impact was somewhat less. The effects were influenced by gender and by preintervention levels of risk. Analyses of implementation measures demonstrated that greater fidelity to the intervention protocols was associated with greater impact on behavior ratings and on achievement scores, thus providing some evidence of specificity in the effect of the interventions.
Despite undeniable progress since the civil rights era, the gulf that separates black and white Americans remains vast. This chapter reviews the reasons for this stubborn race gap, focusing in particular on data showing the extent, causes, and impact of housing segregation and health inequity. It proposes concrete recommendations for the new administration to shrink the racial divide, urging strong political leadership, improved housing market mobility, innovative focus on the social determinants of health, and tools to reduce unintentional biases in health care.
Mental health and substance use disorders among children, youth, and young adults are major threats to the health and well-being of younger populations which often carryover into adulthood. The costs of treatment for mental health and addictive disorders, which create an enormous burden on the affected individuals, their families, and society, have stimulated increasing interest in prevention practices that can impede the onset or reduce the severity of the disorders. Prevention practices have emerged in a variety of settings, including programs for selected at-risk populations (such as children and youth in the child welfare system), school-based interventions, interventions in primary care settings, and community services designed to address a broad array of mental health needs and populations. Preventing Mental, Emotional, and Behavioral Disorders Among Young People updates a 1994 Institute of Medicine book, Reducing Risks for Mental Disorders, focusing special attention on the research base and program experience with younger populations that have emerged since that time. Researchers, such as those involved in prevention science, mental health, education, substance abuse, juvenile justice, health, child and youth development, as well as policy makers involved in state and local mental health, substance abuse, welfare, education, and justice will depend on this updated information on the status of research and suggested directions for the field of mental health and prevention of disorders. © 2009 by the National Academy of Sciences. All rights reserved.
This paper reviews specific conceptual frameworks and focuses on the evidence from evaluations of program applications delivered prior to age 21 that have the common aim of encouraging Positive Youth Development.
Unprecedented global forces are shaping the health and wellbeing of the largest generation of 10 to 24 year olds in human history. Population mobility, global communications, economic development, and the sustainability of ecosystems are setting the future course for this generation and, in turn, humankind. At the same time, we have come to new understandings of adolescence as a critical phase in life for achieving human potential. Adolescence is characterised by dynamic brain development in which the interaction with the social environment shapes the capabilities an individual takes forward into adult life.3 During adolescence, an individual acquires the physical, cognitive, emotional, social, and economic resources that are the foundation for later life health and wellbeing. These same resources define trajectories into the next generation. Investments in adolescent health and wellbeing bring benefits today, for decades to come, and for the next generation. Better childhood health and nutrition, extensions to education, delays in family formation, and new technologies offer the possibility of this being the healthiest generation of adolescents ever. But these are also the ages when new and different health problems related to the onset of sexual activity, emotional control, and behaviour typically emerge. Global trends include those promoting unhealthy lifestyles and commodities, the crisis of youth unemployment, less family stability, environmental degradation, armed conflict, and mass migration, all of which pose major threats to adolescent health and wellbeing. Adolescents and young adults have until recently been overlooked in global health and social policy, one reason why they have had fewer health gains with economic development than other age groups. The UN Secretary-General's Global Strategy for Women's, Children's and Adolescents' Health initiated, in September, 2015, presents an outstanding opportunity for investment in adolescent health and wellbeing. However, because of limits to resources and technical capacities at both the national and the global level, effective response has many challenges. The question of where to make the most effective investments is now pressing for the international development community. This Commission outlines the opportunities and challenges for investment at both country and global levels (panel 1).
Unlabelled: This study tested sustained effects of the Communities That Care (CTC) prevention system on health-risking behaviors 9 years after baseline in a community-randomized trial involving 24 towns in seven states. Earlier analyses found sustained effects on abstinence from drug use and delinquency through Grade 12 in a panel of fifth graders. At age 19, 91 % (n = 3986) of the living panel completed the survey. Data were analyzed using generalized linear mixed models. The prevalence of lifetime and current substance use and delinquency were the primary outcomes. Secondary outcomes included substance use disorders, major depression, suicidality, educational attainment, and sexual risk behaviors. CTC had a significant overall effect across lifetime measures of the primary outcomes for males, but not for females or the full sample, although lifetime abstinence from delinquency in the full sample was significantly higher in CTC communities (ARR = 1.16). Males in CTC communities also continued to show greater lifetime abstinence from cigarette smoking (ARR = 1.22). CTC did not have a sustained effect on current substance use and delinquency nor did it improve the secondary outcomes at age 19 for either gender. Communities using CTC may need to extend their prevention planning to include the high school years to sustain effects on drug use and delinquency beyond high school for both genders. Trial registration: identifier: NCT01088542.