Journal of Adolescent Health
Volume 41, Issue 3 , Pages 221-223, September 2007

Advocating the Inclusion of Adolescent Work Experience as Part of Routine Preventive Care

University of North Carolina Injury Prevention Research Center, Schools of Public Health and Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina

Article Outline

 

See Related Article p. 248

A century ago child labor was the norm, with very young children involved in farming, factories, and mines [1]. Until the 1938 passage of the Fair Labor Standards Act (FLSA), most teenagers were working, often living on their own, unprotected by safety regulations. The FLSA remains the primary federal protection for workers less than 18 years old by limiting allowable hours and tasks, complemented by state laws that may be more stringent [2]. These laws regulate the work of youth aged 14–18 years, with different restrictions for 14–15-year-olds and 16–17-year-olds. Today, in rural areas, children are working early, helping on family farms where there are no regulations [3]. Most teens, however, work in paid jobs covered by the FLSA. Unfortunately, enforcement of child labor laws is a significant problem [4], [5], [6].

In this issue of the Journal, McCall et al [7] add to a growing literature from the health and social sciences on the benefits and risks of youth work. Their 8-year series in Oregon included 87 amputations, 838 fractures or dislocations, 385 burns, and 158 cases of multiple trauma; and their report demonstrates that the first year of work is the most dangerous, regardless of age [7]. The authors note a rate of claims to worker’s compensation of 134 per 10,000 workers with associated costs exceeding $3,000 per claim. Extrapolating to the U.S. population of teenagers (assuming the same rate of working and injuries as in Oregon), the data suggest 100,000 injuries per year for adolescents, with annual compensation costs totaling $314 million. The National Institute of Occupational Safety and Health reports 133 deaths (2002) and 45,443 activity-limiting injuries (2001) among workers less than 20 years of age in the U.S. [8]. Other authors suggest that the injury rates for working teens are even higher, arguing that current surveillance systems miss many cases [9], [10].

Despite the numbers of adolescent work injuries, including serious events resulting in amputations or fatalities, it is notable that employment has received virtually no mention in any of the practice guidelines for adolescent health care [11]. Gadomski et al, in writing about the GAPS guidelines, states that “…screening for and preventing risk behaviors is one of the basic functions of adolescent primary care” [12]. Granted, there are multiple issues to discuss in the limited time available in clinical visits. However, most U.S. adolescents are employed, and those 14–17-years-olds spend an average of 16 hours per week on the job during the school year [6]. In the summer and after the age of 18 years, work hours increase substantially. As such, work is a significant part of adolescent culture and includes exposure to many dangerous circumstances such as toxins [13], dangerous equipment [4], [5], and workplace violence [14].

The table provides summary information about the recommendations for adolescent care from several advisory committees [11]. Admittedly, the risks of workplace injury are exceeded by the risks for adolescent injuries in other settings, most notably traffic crashes and suicide. However, as McCall et al [7] indicate, workplace hazards are not trivial; work has implications that go beyond health outcomes, including relationships between work and school performance, fatigue, and exposure to conditions that may influence normal development in either positive or negative ways [4], [9].

Table. Incidence of adolescent health topics and recommendations for counseling in routine health care examination
Health issue or risk behavior% of Teens engaging in behavior or at risk
Employment[4], [5], [6]
75–80% of teens work during high school

60% of teens work in retail and service sectors

Not included in any professional recommendations
Most hazardous work is in agriculture, construction, retail

82% of teens working in retail work after 7 PM on school nights

47% of teens working in groceries and food service reported doing at least one illegal task

84% of teens working in construction (NC) had done at least one prohibited task

Recommended by: AAFP, AAP, AMA, BF, and USPSTF11
Obesityi
13.1% were overweight

9.6% had no vigorous or moderate physical activity in prior week

Contraceptioni
46% had had intercourse

7.5% had had forced intercourse

4.3% had had more than four partners

66% of sexually active adolescents had used condoms in prior 30 days

Tobacco usei
54% had ever tried cigarettes

20% had smoked in last 30 days

13% smoked daily

Alcohol usei
In last 30 days:

43.3% had consumed alcohol

25.5% had consumed more than five drinks at a time

10% had driven while drinking

Substance usei
In the last 30 days:

20.2% had used marijuana

3.4% had used cocaine

Depression and suicidei
28.5% had felt sad or hopeless in prior 30 days

16.9% had seriously considered suicide in prior year and 8.4% attempted

Eating disordersi4.5% had vomited or took laxatives to reduce weight in prior 30 days
Abuseii3.9% of parents reported harsh physical punishment of 13–17-year-olds
Drivingi
10.2% of teens never or rarely used a seat belt while riding

28.5% had ridden in past 30 days with a driver who had been drinking

Sportsiii
During high school:

54% were active in organized sports

Injury rate: 2/1,000 athlete exposures (games or practices)

Weapon carryingi
In prior 30 days:

5.4% had carried a gun

6.5% had carried a weapon on school property

iEaton DK, Kann L, Kinchen S, et al. Youth Risk Behavior Surveillance—United States, 2005. J Sch Health 2006;76:353–72.

iiTheodore AD, Chang JJ, Runyan DK, et al. Epidemiologic features of the physical and sexual maltreatment of children in the Carolinas. Pediatrics 2005;115:331–7.

iiiKnowles SB, Marshall SW, Bowling JM, et al. A prospective study of injury incidence among North Carolina high school athletes. Am J Epidemiol 2006;164.

Adult medicine experts point to the importance of understanding the work environment in considering the context for patients’ health problems [15], [16], [17], [18]. These sources stress the importance of an occupational history in making a good differential diagnosis of new problems [15], [17], [18] and in routine preventive care [16].

The value of querying adolescent patients about health risks and risk behaviors as a means of initiating discussion of their concerns is commonly understood [11], making the adolescent visit a potentially good venue in which to discuss employment. Some of the topics, based on the growing literature about work-related risks that might be covered under the rubric of a simple mnemonic, “WORKS,” to include the following types of issues: 1) Work hours (e.g., total hours, late hours on school nights); 2) Organization of work (e.g., working with others vs. alone, especially after dark; presence of qualified adult supervision); 3) Risks related to working (e.g., types of equipment used, toxic exposures, potential for assault, involvement in alcohol or substance use); 4) Kinds of training for performing job safely; and 5) Safety precautions (e.g., use of protective measures such as protective clothing and safety devices).

Finally, although it is important to understand teen work as one issue to be addressed as part of one-on-one health care, it is also important for adolescent medicine leaders to engage with the policy process so as to improve the safety of teen work environments. Clinicians must remember that the burden of change for workplace safety for adolescents, as for adults, lies with employers and with the regulatory system and not with individual workers. Helping teens and parents to understand potential work hazards as well as worker rights to a safe workplace is an important function, but health care providers also should join with public health professionals in advocating for safer work. It is critical that support be provided for occupational safety and health research, quality surveillance systems, and regulatory oversight of existing safety policies. Physicians play important roles in both advocacy and anticipatory guidance for many safety issues—for example, traffic safety, poison prevention, burn prevention, child abuse prevention, and safe storage of firearms. The time has come to do the same for worker safety.

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Acknowledgments 

Dr. Runyan’s time was partially supported by a grant from the National Center for Injury Prevention and Control to the University of North Carolina Injury Prevention Research Center. The author thanks Craig Zwerling, M.D., P.h.D., and Desmond Runyan, M.D., Dr.P.H., for conceptualizing the paper.

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References 

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  2. Fair Labor Standards Act, U.S. Department of Labor: http://www.dol.gov/esa/regs/compliance/whd/whdfs43.htm, accessed June 7.
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PII: S1054-139X(07)00274-1

doi:10.1016/j.jadohealth.2007.06.009

Refers to article:

  • Adolescent Occupational Injuries and Workplace Risks: An Analysis of Oregon Workers’ Compensation Data 1990–1997 , 13 April 2007

    Brian P. McCall, Irwin B. Horwitz, Bethanie S. Carr
    Journal of Adolescent Health September 2007 (Vol. 41, Issue 3, Pages 248-255)

Journal of Adolescent Health
Volume 41, Issue 3 , Pages 221-223, September 2007

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