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

2007; Elsevier BV; Volume: 41; Issue: 3 Linguagem: Inglês

10.1016/j.jadohealth.2007.06.009

1879-1972

Carol W. Runyan,

Traffic and Road Safety

See Related Article p. 248 See Related Article p. 248 A century ago child labor was the norm, with very young children involved in farming, factories, and mines [[1]Levine M.J. Children for Hire: The Perils of Child Labor in the United States. Praeger, Westport, CT2003Google Scholar]. 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]Fair Labor Standards Act, U.S. Department of Labor: http://www.dol.gov/esa/regs/compliance/whd/whdfs43.htm, accessed June 7.Google Scholar]. 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]Zierold K.M. Garman S. Anderson H. Summer work and injury among middle school students, aged 10–14 years.Occup Environ Med. 2004; 61: 518-522Crossref PubMed Scopus (28) Google Scholar]. Most teens, however, work in paid jobs covered by the FLSA. Unfortunately, enforcement of child labor laws is a significant problem [4Committee on the Health and Safety Implications of Child Labor—National Research Council and Institute of MedicineProtecting Youth at Work: Health, Safety, and Development of Working Children and Adolescents in the United States. National Academy Press, Washington, DC1998Google Scholar, 5Runyan C.W. Dal Santo J. Schulman M. et al.Work hazards and workplace safety violations experienced by adolescent construction workers.Arch Pediatr Adolesc Med. 2006; 160: 721-727Crossref PubMed Scopus (16) Google Scholar, 6Runyan C.W. Schulman M. Dal Santo J. et al.Safety of U.S Adolescents Working in the retail and service sectors.Pediatrics. 2007; 119: 526-534Crossref PubMed Scopus (57) Google Scholar]. In this issue of the Journal, McCall et al [[7]McCall B.P. Horowitz I.B. Carr B.S. Adolescent occupational injuries and workplace risks: An analysis of Oregon workers’ compensation data 1990–1997.J Adolesc Health. 2007; 41: 248-255Abstract Full Text Full Text PDF PubMed Scopus (30) Google Scholar] 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]McCall B.P. Horowitz I.B. Carr B.S. Adolescent occupational injuries and workplace risks: An analysis of Oregon workers’ compensation data 1990–1997.J Adolesc Health. 2007; 41: 248-255Abstract Full Text Full Text PDF PubMed Scopus (30) Google Scholar]. 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]Centers for Disease Control and PreventionNational Institute of Occupational Safety and HealthNIOSH Publication No. 2004–146. 2004Google Scholar]. Other authors suggest that the injury rates for working teens are even higher, arguing that current surveillance systems miss many cases [9Runyan C.W. Schulman M. Ta M. Adolescent employment: Relationships to injury and violence.in: Liller K. Injury Prevention for Children and Adolescents: Integration of Research, Practice and Advocacy. American Public Health Association, Washington, DC2005Google Scholar, 10Layne L.A. Castillo D.N. Stout N. Cutlip P. Adolescent occupational injuries requiring hospital emergency department treatment: A nationally representative sample.Am J Public Health. 1994; 84: 657-660Crossref PubMed Scopus (82) Google Scholar]. 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]Elster A.B. Comparison of recommendations for clinical preventive services developed by national organizations.Arch Pediatr Adolesc Med. 1998; 152: 193-198Crossref PubMed Scopus (50) Google Scholar]. 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]Gadomski A. Bennett S. Young M. Wissow L.S. Guidelines for Adolescent Preventive Services: The GAPS in practice.Arch Pediatr Adolesc Med. 2003; 157: 426-432Crossref PubMed Scopus (30) Google Scholar]. 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]Runyan C.W. Schulman M. Dal Santo J. et al.Safety of U.S Adolescents Working in the retail and service sectors.Pediatrics. 2007; 119: 526-534Crossref PubMed Scopus (57) Google Scholar]. 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]Woolf A. Alpert H.R. Garg A. Lesko S. Adolescent occupational toxic exposures—a national study.Arch Pediatr Adolesc Med. 2001; 115: 794-810Google Scholar], dangerous equipment [4Committee on the Health and Safety Implications of Child Labor—National Research Council and Institute of MedicineProtecting Youth at Work: Health, Safety, and Development of Working Children and Adolescents in the United States. National Academy Press, Washington, DC1998Google Scholar, 5Runyan C.W. Dal Santo J. Schulman M. et al.Work hazards and workplace safety violations experienced by adolescent construction workers.Arch Pediatr Adolesc Med. 2006; 160: 721-727Crossref PubMed Scopus (16) Google Scholar], and workplace violence [[14]Runyan C.W. Schulman M. Hoffman C. Understanding and preventing violence against adolescent workers: What is known and what is missing?.Occup Envir Med. 2003; 3: 711-720Crossref Scopus (8) Google Scholar]. The table provides summary information about the recommendations for adolescent care from several advisory committees [[11]Elster A.B. Comparison of recommendations for clinical preventive services developed by national organizations.Arch Pediatr Adolesc Med. 1998; 152: 193-198Crossref PubMed Scopus (50) Google Scholar]. 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]McCall B.P. Horowitz I.B. Carr B.S. Adolescent occupational injuries and workplace risks: An analysis of Oregon workers’ compensation data 1990–1997.J Adolesc Health. 2007; 41: 248-255Abstract Full Text Full Text PDF PubMed Scopus (30) Google Scholar] 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 [4Committee on the Health and Safety Implications of Child Labor—National Research Council and Institute of MedicineProtecting Youth at Work: Health, Safety, and Development of Working Children and Adolescents in the United States. National Academy Press, Washington, DC1998Google Scholar, 9Runyan C.W. Schulman M. Ta M. Adolescent employment: Relationships to injury and violence.in: Liller K. Injury Prevention for Children and Adolescents: Integration of Research, Practice and Advocacy. American Public Health Association, Washington, DC2005Google Scholar].TableIncidence of adolescent health topics and recommendations for counseling in routine health care examinationHealth issue or risk behavior% of Teens engaging in behavior or at riskEmployment4Committee on the Health and Safety Implications of Child Labor—National Research Council and Institute of MedicineProtecting Youth at Work: Health, Safety, and Development of Working Children and Adolescents in the United States. National Academy Press, Washington, DC1998Google Scholar, 5Runyan C.W. Dal Santo J. Schulman M. et al.Work hazards and workplace safety violations experienced by adolescent construction workers.Arch Pediatr Adolesc Med. 2006; 160: 721-727Crossref PubMed Scopus (16) Google Scholar, 6Runyan C.W. Schulman M. Dal Santo J. et al.Safety of U.S Adolescents Working in the retail and service sectors.Pediatrics. 2007; 119: 526-534Crossref PubMed Scopus (57) Google Scholar75–80% of teens work during high school60% of teens work in retail and service sectorsNot included in any professional recommendationsMost hazardous work is in agriculture, construction, retail82% of teens working in retail work after 7 PM on school nights47% of teens working in groceries and food service reported doing at least one illegal task84% of teens working in construction (NC) had done at least one prohibited taskRecommended by: AAFP, AAP, AMA, BF, and USPSTF11ObesityiEaton DK, Kann L, Kinchen S, et al. Youth Risk Behavior Surveillance—United States, 2005. J Sch Health 2006;76:353–72.13.1% were overweight9.6% had no vigorous or moderate physical activity in prior weekContraceptioniEaton DK, Kann L, Kinchen S, et al. Youth Risk Behavior Surveillance—United States, 2005. J Sch Health 2006;76:353–72.46% had had intercourse7.5% had had forced intercourse4.3% had had more than four partners66% of sexually active adolescents had used condoms in prior 30 daysTobacco useiEaton DK, Kann L, Kinchen S, et al. Youth Risk Behavior Surveillance—United States, 2005. J Sch Health 2006;76:353–72.54% had ever tried cigarettes20% had smoked in last 30 days13% smoked dailyAlcohol useiEaton DK, Kann L, Kinchen S, et al. Youth Risk Behavior Surveillance—United States, 2005. J Sch Health 2006;76:353–72.In last 30 days: 43.3% had consumed alcohol 25.5% had consumed more than five drinks at a time 10% had driven while drinkingSubstance useiEaton DK, Kann L, Kinchen S, et al. Youth Risk Behavior Surveillance—United States, 2005. J Sch Health 2006;76:353–72.In the last 30 days: 20.2% had used marijuana 3.4% had used cocaineDepression and suicideiEaton DK, Kann L, Kinchen S, et al. Youth Risk Behavior Surveillance—United States, 2005. J Sch Health 2006;76:353–72.28.5% had felt sad or hopeless in prior 30 days16.9% had seriously considered suicide in prior year and 8.4% attemptedEating disordersiEaton DK, Kann L, Kinchen S, et al. Youth Risk Behavior Surveillance—United States, 2005. J Sch Health 2006;76:353–72.4.5% had vomited or took laxatives to reduce weight in prior 30 daysAbuseiiTheodore AD, Chang JJ, Runyan DK, et al. Epidemiologic features of the physical and sexual maltreatment of children in the Carolinas. Pediatrics 2005;115:331–7.3.9% of parents reported harsh physical punishment of 13–17-year-oldsDrivingiEaton DK, Kann L, Kinchen S, et al. Youth Risk Behavior Surveillance—United States, 2005. J Sch Health 2006;76:353–72.10.2% of teens never or rarely used a seat belt while riding28.5% had ridden in past 30 days with a driver who had been drinkingSportsiiiKnowles SB, Marshall SW, Bowling JM, et al. A prospective study of injury incidence among North Carolina high school athletes. Am J Epidemiol 2006;164.During high school: 54% were active in organized sportsInjury rate: 2/1,000 athlete exposures (games or practices)Weapon carryingiEaton DK, Kann L, Kinchen S, et al. Youth Risk Behavior Surveillance—United States, 2005. J Sch Health 2006;76:353–72.In prior 30 days: 5.4% had carried a gun 6.5% had carried a weapon on school propertyi Eaton DK, Kann L, Kinchen S, et al. Youth Risk Behavior Surveillance—United States, 2005. J Sch Health 2006;76:353–72.ii Theodore 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.iii Knowles SB, Marshall SW, Bowling JM, et al. A prospective study of injury incidence among North Carolina high school athletes. Am J Epidemiol 2006;164. Open table in a new tab Adult medicine experts point to the importance of understanding the work environment in considering the context for patients’ health problems [15Landrigan P.L. Principles of occupational and environmental medicine.in: Arend W.P. Armitage J.O. Drazen J.M. Goldman: Cecil Textbook of Medicine. 22nd ed. W. B. Saunders, Philadelphia, PA2004Google Scholar, 16Levy B.S. Wegman D.H. Halperin W.E. et al.Recognizing occupational and environmental disease and injury.in: Levy B.S. Wegman D.H. Baron S.L. Sokas R.K. Occupational and Environmental Health. Lippincott Williams & Wilkins, Philadelphia, PA2005Google Scholar, 17Goldman R.H. Peters J.M. The occupational and environmental health history.JAMA. 1981; 246: 2831-2836Crossref PubMed Scopus (54) Google Scholar, 18Occupational and Environmental Health Committee of the American Lung Association of San Diego and Imperial CountiesTaking the occupational history.Ann Intern Med. 1983; 99: 641-651Crossref PubMed Scopus (28) Google Scholar]. These sources stress the importance of an occupational history in making a good differential diagnosis of new problems [15Landrigan P.L. Principles of occupational and environmental medicine.in: Arend W.P. Armitage J.O. Drazen J.M. Goldman: Cecil Textbook of Medicine. 22nd ed. W. B. Saunders, Philadelphia, PA2004Google Scholar, 17Goldman R.H. Peters J.M. The occupational and environmental health history.JAMA. 1981; 246: 2831-2836Crossref PubMed Scopus (54) Google Scholar, 18Occupational and Environmental Health Committee of the American Lung Association of San Diego and Imperial CountiesTaking the occupational history.Ann Intern Med. 1983; 99: 641-651Crossref PubMed Scopus (28) Google Scholar] and in routine preventive care [[16]Levy B.S. Wegman D.H. Halperin W.E. et al.Recognizing occupational and environmental disease and injury.in: Levy B.S. Wegman D.H. Baron S.L. Sokas R.K. Occupational and Environmental Health. Lippincott Williams & Wilkins, Philadelphia, PA2005Google Scholar]. 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]Elster A.B. Comparison of recommendations for clinical preventive services developed by national organizations.Arch Pediatr Adolesc Med. 1998; 152: 193-198Crossref PubMed Scopus (50) Google Scholar], 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. 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. Adolescent Occupational Injuries and Workplace Risks: An Analysis of Oregon Workers’ Compensation Data 1990–1997Journal of Adolescent HealthVol. 41Issue 3PreviewInjuries to adolescents from occupational activities has been recognized as a significant public health concern. The objective of this study was to quantify adolescent injury rates, analyze risk factors, and measure the severity of injuries sustained using Oregon workers’ compensation data. Full-Text PDF