Future Directions 481parental knowledge. Efforts to facilitate care prompted a
movement to expand health services available in schools.
Prior to 1980, school health typically consisted of, at best, a
nurse in a •health roomŽ and a school psychologist who
provided psychoeducational assessment in multiple schools,
with an extremely limited role for each professional; more ex-
tensive services were generally provided only for special edu-
cation services (see Weist, 1997). Given increased recognition
of the •new morbidityŽ and the need for preventive services
and intervention, the obvious advantages of providing ser-
vices in the school fueled an expansion of school-based pro-
grams in the 1980s and 1990s.
In addition to geographic ease of access, school-based ser-
vices offer many advantages both to the individual patient
and the student population in general. For example, a
teenager can discreetly request treatment for a cold, feared
pregnancy, or suicidal thoughts in the same general setting.
Also, the overall school environment can be improved
through special prevention programs and other collaborative
efforts between health and educational staff. The obvious ad-
vantages of this approach led to amazing growth, with 607
school-based health centers being established by 1994; these
are located in 41 states and the District of Columbia, with the
majority located in high schools (46%) or middle schools
(16%) (see Weist, 1997).
Mental health services have been increasingly incorpo-
rated as a needed component of comprehensive care. For ex-
ample, there were mental health programs in three Baltimore
schools in 1987 and in 60 schools by 1995; 80% of the
Baltimore students referred for services had had no prior
mental health services despite signi“cant presenting prob-
lems (see Weist, 1997). School-based health programs are
thus a very important aspect of national efforts to improve
teenagers• health, although they confront a variety of ongoing
challenges ranging from funding problems to integration
with community services and are still very far from being
able to meet the national need (Weist, 1997).
School-based healthhas come to refer to health services
placed in elementary, middle, and high schools. Another
component of school-based health, however, has been in ex-
istence for 50 years or more: college health services. Virtu-
ally every college and university in the United States provide
health services on campus for their students, and these
services frequently include mental health. College health
providers are also adolescent health providers and are well-
represented among the membership of the Society for Ado-
lescent Medicine (SAM). The line of demarcation between
adolescents and young adults is so unclear that SAM has
adopted the formal position that •adolescent medicineŽ cov-
ers the ages of 10 to 25 (SAM, 1995).
FUTURE DIRECTIONSEmpirical investigation of adolescent health has expanded
and changed considerably over the past two decades. For ex-
ample, Cromer and Stager (2000) analyzed articles published
in the Journal of Adolescent Health Care1980 to 1998,
reporting an increase in annual numbers of articles (69 to
169), decreased proportion of medical topics (61% to 38%),
and increased proportion of psychosocial issues (23% to
50%). This change re”ects increased awareness of •the new
morbidityŽ and recognition of the relevance of psychosocial
considerations to health risks, health promotion, and inter-
vention. Also evident was the increasing participation of
nonphysicians from nonpediatric disciplines such as psychol-
ogy, public health, and nutrition. These changes were accom-
panied by a shift in research design from retrospective
reviews to cross-sectional and longitudinal studies, although
the percentage of experimental designs has remained low
(never more than 5%).
This increased scholarly activity has prompted numerous
national reports summarizing current knowledge and identi-
fying future directions for research. Members of the
National Adolescent Health Information Center (Millstein
et al., 2000) have summarized recommendations from 53
national documents published between 1986 and 1997. They
identi“ed four major content areas as targets for future
research: adolescent development, social and environmental
contexts, health-related behaviors, and physical and mental
disorders. In each area, priorities focused on speci“c appli-
cations to health. For example, additional research on
adolescent cognition is needed to address teenagers• health
beliefs and attitudes and decision making regarding health
behaviors.
In addition to content areas, Millstein et al. (2000) identi“ed
four cross-cutting themes that should be prioritized in future
research: applying a developmental perspective to investiga-
tion of adolescent health, focusing on health rather than treat-
ment of illness, recognizing the diversity of the adolescent
population, and investigating multiple models of in”uence.
For example, studies of causal in”uences should consider the
interrelationships among biological, psychological, and social
aspects of development; their effects on behavior and health;
and the multiple sources of social and environmental in”u-
ences on adolescent development and health.
Millstein et al. (2000) note that implementing these re-
search priorities will necessitate the requisite human resources
and adequate funding. They recommend establishing a task
force on training needs to identify gaps in training and propose
training initiatives. Since children and adolescents currently
receive less than 3% of national research funds, Millstein et al.