Children and AdolescentsCounseling

Abuse of alcohol and other drugs is a major health problem for older children and adolescents. Accidental injuries are the leading cause of death for adolescents, and approximately 40% of such injuries are related to alcohol use. Alcohol use has also been implicated in a significant percentage of adolescent homicides and suicides -- the second and third leading causes of death in this age group. Cocaine use leads to increased cardiovascular morbidity and mortality in adolescents and young adults and indirectly contributes to the number of violent deaths of young people that are related to illegal drug activities. Use of illegal drugs is also related to poor school performance, social withdrawal, and family dysfunction.

Drug abuse affects children in all cultural and socioeconomic groups, not only minorities, the poor, and the undereducated. A 1990 survey of high school seniors found that the percentage of white youths reporting use of alcohol, marijuana, and cocaine in the month prior to the survey was higher than that of African-American youths (alcohol: 62.2% versus 32.9%; marijuana: 15.6% versus 5.2%; cocaine: 1.8% versus 0.5%). In this same study, alcohol and marijuana use were found to be directly related to parental educational levels. Higher parental educational levels were associated with greater drug use by the child. In general, the prevalence of alcohol and other drug abuse among females is lower than that among males.

See chapter 53 for information on counseling adults about abuse of alcohol and other drugs. See chapters 24 and 60 for information on counseling about tobacco use and smoking cessation.

American Academy of Family Physicians --

Recommends counseling about accidental injury prevention with regard to impaired driving.

American Academy of Pediatrics --

Clinicians should condemn the nontherapeutic use of all psychoactive drugs, including alcohol and nicotine, by children and adolescents. All providers of adolescent health care should discuss the hazards of alcohol and other drug use with their patients as a routine part of risk behavior assessment. Providers should reinforce abstinent behaviors and assess current use with a nonjudgmental approach. Special attention should be paid to the discussion of this issue when risk factors for problem drinking, such as family history of alcoholism, are present. Preventive child health care visits provide an opportunity to inquire about a family history of alcoholism and parental attitudes about alcohol use.

American Medical Association --

Clinicians should counsel all adolescents on the dangers of substance use and strategies to refrain from use. This approach should be complemented by counseling parents to monitor adolescents' social behaviors. Clinicians should screen adolescents for use of alcohol and other drugs. Previsit questionnaires may be used to determine risk for substance abuse, with direct questioning about actual use during a clinical interview. Once use is identified, a positive response to any of the following questions should alert the health care provider to possible abuse and prompt a referral: Does the adolescent ever use drugs when alone?Does the adolescent ever use alcohol when alone?Does the adolescent ever get drunk or high at social events or have friends who do?Does the adolescent ever consume alcohol on school grounds?Does the adolescent ever miss school because of drinking or hangovers?When truant, does the adolescent ever go drinking or get high on drugs?

All adolescent males who participate in high school athletic programs should be asked about their knowledge and use of anabolic steroids. Particular attention should be given to those who participate in sports that require weight and strength, such as football, track and field, and weight-lifting.

Bright Futures --

Child and adolescent health supervision visits should include interview questions, developmental surveillance questions, and anticipatory guidance that address alcohol and other drug abuse, as well as tobacco use.

Canadian Task Force on the Periodic Health Examination --

Routine active case-finding of problem drinking among patients in medical practices is highly recommended on the basis of the high prevalence of this problem, its association with adverse consequences before the stage of dependency is reached, and its amenability to a counseling intervention by clinicians. Active case-finding should be performed through structured interviews and questionnaires. Clinicians should be sensitive to the possibility of alcohol-related stressors in offspring of alcoholic or alcohol-abusing parents and in some high-risk groups, particularly children hospitalized for injury. Primary health care providers are in an excellent position to prevent children's injuries by identifying, evaluating, and assisting families in recovery from the effects of family alcoholism.

US Preventive Services Task Force --

Screening to detect problem drinking is recommended for all adult and adolescent patients. Screening should involve a careful history of alcohol use and /or the use of standardized screening questionnaires. Routine measurement of biochemical markers is not recommended in asymptomatic persons. Pregnant women should be advised to limit or cease drinking during pregnancy. Although there is insufficient evidence to prove or disprove harms from light drinking in pregnancy, recommendations that women abstain from alcohol during pregnancy may be made on other grounds. All persons who use alcohol should be counseled about the dangers of operating a motor vehicle or performing other potentially dangerous activities after drinking alcohol.

There is insufficient evidence to recommend for or against routine screening for drug abuse with standardized questionnaires or biologic assays. Including questions about drug use and drug-related problems when taking a history from all adolescents and adult patients may be recommended on other grounds, including the prevalence of drug use and the serious consequences of drug abuse and dependence. All pregnant women should be advised of the potential adverse effects of drug use on the development of the fetus. Clinicians should be alert to the signs and symptoms of drug abuse in patients and refer drug-abusing patients to specialized treatment facilities where available.

Anabolic Steroids and Athletes. American College of Sports Medicine, PO Box 1440, Indianapolis, IN 46206-1440; (317)637-9200. Internet address: http://www.acsm.org/sportsmed

Alcohol: What to Do If It's a Problem for You. American Academy of Family Physicians, 8880 Ward Parkway, Kansas City, MO 64114-2797; (800)944-0000. Internet address: http://www.aafp.org

Alcohol: Your Child and Drugs; Cocaine: Your Child and Drugs; Marijuana: Your Child and Drugs; Teens Who Drink and Drive: Reducing the Death Toll; Inhalent Abuse: Your Child and Drugs. American Academy of Pediatrics, PO Box 927, Elk Grove Village, IL 60009-0927; (800)433-9016. Internet address: http://www.aap.org

Let's Talk Facts about Substance Abuse. American Psychiatric Association, 1400 K Street, NW, Washington, DC 20005; (800)368-5777. Internet address: http://www.psych.org

National Clearinghouse for Alcohol and Drug Information. Information about numerous publications available in both English and Spanish. (800)729-6686.

The Adolescent Drinking Index. Manual and 25 test booklets (cost $55). Available from Psychological Assessment Resources, Inc, PO Box 998, Odessa, FL 33556; (800)331-TEST.

Bright Futures: Guidelines for Health Supervision of Infants, Children and Adolescents; Bright Futures Pocket Guide; Bright Futures Anticipatory Guidance Cards. Available from the National Center for Education in Maternal and Child Health, 2000 15th Street North, Suite 701, Arlington, VA 22201-2617; (703)524-7802. Internet address: http://www.brightfutures.org

Table 18.1. Sample Questions Concerning Drugs for School-aged Children

Table 18.2. Sample Questions Concerning Drug Use for Adolescents

Dental and oral health problems are common in children. Caries and periodontal diseases are the most frequent, but other significant problems include malocclusion, trauma, congenital anomalies, and oral malignancies. Widespread use of fluoride and other preventive dental health practices have led to a significant decrease in the incidence of dental caries. Nonetheless, two thirds of 12- to 17-year-old children have decayed or filled permanent teeth, and among teens aged 13 to 17 years, 73% have some gingival bleeding. In most cases, these problems are preventable, and the dental and oral health status of adults is largely determined by the quality of preventive and treatment services received during childhood.

See chapter 54 for information on dental and oral health counseling for adults. See chapters 24 and 60 for information on counseling on tobacco and smoking cessation.

All major dental and medical authorities

Dental and oral health counseling for children and parents should be provided routinely by primary care clinicians.

American Academy of Pediatrics --

Referral for the first dental visit should occur at 3 years of age, with frequency of subsequent visits determined by the dentist. Earlier referrals may be appropriate for some children.

American Academy of Pediatric Dentistry, American Society of Dentistry for Children, American Dental Association, and Bright Futures --

A child's first dental visit should occur at 6 months of age or when the first tooth erupts, whichever comes later, but no later than 1 year of age. Frequency of subsequent visits should be determined by the dentist.

US Preventive Services Task Force --

All patients should be encouraged to visit a dental-care provider on a regular basis, with the optimal frequency determined by the patient's dental-care provider.

1. Begin oral health education and care at an infant's first visit, and continue education and care throughout childhood and adolescence.

2. Assess an infant's need for fluoride supplementation. Only 62% of Americans live in areas with fluoridated community water supplies. If a child lives in an area without an optimally fluoridated community water supply, the water supply should be tested and other sources of fluoride identified before recommending supplementation. Information about fluoride content of community water supplies can be obtained from the local water department.

See Table 19.1 for the recommended dosages for fluoride supplementation. Fluoride supplementation may begin as early as 6 months of age and continue until approximately 16 years of age, if necessary. Fluoride supplements are available as drops (for infants and young children) and as chewable tablets. Prescribe the recommended dose once daily. When chewable tablets are used, encourage children to chew and swish the resultant fluid in the mouth for 30 seconds before swallowing.

3. Instruct parents to wipe their infant's gums and teeth after each feeding, using a moist washcloth or gauze pad. As multiple teeth appear, parents should begin brushing the infant's teeth daily with a small toothbrush and a very small (pea-sized) amount of fluoride-containing toothpaste. Swallowing large amounts of toothpaste by infants and children may lead later to enamel discoloration of permanent teeth because of fluorosis. To avoid gum tissue injury, use a brush with soft end-rounded or polished bristles, and replace it when bristles are bent or worn. Although children should actively participate in their dental care, they should continue to receive assistance from parents or other care givers until they are 7 or 8 years old.

4. Parents can sooth irritability caused by teething by allowing the infant to chew on a cold teething ring, by gently massaging the infant's gums with a finger, or by administering acetaminophen. Advise parents that fever is not a symptom of teething; if fever is present, parents should contact their child's primary care provider.

5. Address strategies to prevent tooth decay from breast- or bottle-feeding. Infants should not be permitted to nurse throughout the night or fall asleep with a bottle containing anything other than water. If a bottle is required to quiet or comfort the infant before sleep, instruct parents to use only water. Also, a child should not be allowed to keep a bottle during the day for extended periods for ad libitum drinking with anything other than water. Parents should encourage infants to begin using a cup instead of a bottle at 1 year of age.

6. Advise parents to talk with their dentist or dental hygienist about when their child should begin using dental floss.

7. Thumb-sucking or use of a pacifier generally does not cause permanent dental problems for children younger than 4 years of age. Children who thumb-suck beyond age 5 years, however, may develop alignment problems of their permanent teeth. These children may need to be referred to a dentist for assessment.

8. Counsel parents about the impact of dietary habits on oral health: Avoid foods that are high in simple sugars or starches or those that are particularly sticky. If snacks are eaten, select them carefully; encourage consumption of raw fruits and vegetables, nuts, and low-sugar drinks. Limit ingestion of sweets to once or twice a day, preferably with a meal.

9. If a child has a permanent tooth knocked out that is intact and whole, rinse it gently without removing any attached tissue, and immediately reinsert it into the socket. If this is not possible, place it in cool water or milk. The child should see a dentist as soon as possible for emergency treatment. Replacement of the tooth within the first hour is critical for long-term retention. Primary teeth should not be reinserted.

10. Advise parents that children between the ages of 5 and 13 years should be evaluated by their dentist regarding the need for dental sealants on newly erupted permanent molars. First molars usually erupt at about 6 years of age and second molars at about 12 years of age. The sealant is most effective if applied soon after eruption, before the decay process has had time to begin.

11. Give children and adolescents special counseling about dental and oral health problems, such as dental injuries and tobacco-related illnesses, for which they are at increased risk. Advise those involved in contact sports to use appropriate mouth protectors and helmets. Advise adolescents of the cosmetic (yellowed teeth, bad breath) and health (lung cancer, heart disease, leukoplakia, and oral and pharyngeal cancers) problems caused by tobacco use. Smokeless tobacco (snuff and chewing tobacco) is a particular problem among adolescents, and its use should be seriously discouraged (chapter 24).

12. When examining the oral cavity, remain alert for signs of oral diseases, such as caries and inflamed or cyanotic gingiva, mucosal changes such as white patches or wrinkling characteristic of spit tobacco, malalignment or crowding of teeth, and mismatching upper and lower dental arches.

13. Transient bacteremia is common during dental procedures, including cleaning. Give antibiotic prophylaxis to children before a dental cleaning or procedure if they have underlying great vessel or heart disease (Tables 54.2 and 54.3).

A Guide to Children's Dental Health; Baby Bottle Tooth Decay: How to Prevent It. American Academy of Pediatrics, PO Box 927, Elk Grove Village, IL 60009-0927; (800)433-9016. Internet address: http://www.aap.org

Dental Emergency Procedures; Seal Out Decay; Your Child's Teeth; Smokeless Tobacco: Think Before You Chew; Diet and Dental Health; Smoking Can Really Do a Number on Your Health; Oral Health Guidelines for Special Patients. American Dental Association, Department of Salable Materials, 211 E Chicago Ave, Chicago, IL 60611; (800)947-4746.

For a Lifetime of Smiles.... American Dental Hygienists' Association, 444 N Michigan Ave, Suite 3400, Chicago, IL 60611; (312)440-8900. Internet address: http://www.adha.org

Baby's Bright Smile. American Society of Dentistry for Children, 875 N Michigan Ave, Suite 4040, Chicago, IL 60611; (312)943-1244.

A Healthy Mouth for Your Baby; Prevent Baby Bottle Tooth Decay; Rx for Sound Teeth (Spanish and English); Seal Out Dental Decay (English and Spanish); Kids-Snack Smart for Healthy Teeth, Fever Blisters and Canker Sores, Sealants and Fluorides (bookmark). National Institute of Dental Research, Building 31 Room 2C35, 31 Center Dr MSC 2290, Bethesda, MD 20890-2290; (301)496-4261. Internet address: http://www.nidr.nih.gov

Bright Futures: Guidelines for Health Supervision of Infants, Children and Adolescents; Bright Futures Pocket Guide; Bright Futures in Practice: Oral Health; Bright Futures in Practice: Oral Health Quick Reference Cards. National Center for Education in Maternal and Child Health, 2000 15th Street North, Suite 701, Arlington VA 22201-2617; (703)524-7802. Internet address: http://www.brightfutures.org

Detection and Prevention of Periodontal Disease: A Guide for Health Care Providers. National Institute of Dental Research, Building 31 Room 2C35, 31 Center Dr MSC 2290, Bethesda, MD 20890-2290; (301)496-4261. Internet address: http://www.nidr.nih.gov

Getting the Picture on Dental X Rays. FDA Office of Consumer Affairs. HFE 88 Room 1675, 5600 Fishers Lane, Rockville, MD 20857. (800)532-4440.

Table 19.1. Daily Fluoride Dosage (mg) According to Age and Water Supply Content

Proper nutrition during childhood is essential for normal growth and development. Inadequate intake of nutrients is reflected in slow growth rates, inadequate mineralization of bones, and low body reserves of micronutrients. The nutrients most commonly deficient in children's diets are iron and calcium. Excessive caloric intake is a greater problem for children in United States than is inadequate caloric intake. Many children are substantially overweight, physically inactive, and have high dietary intakes of total fat and saturated fat. These factors may lead to obesity and poor nutritional habits as adults, resulting in an increased risk of heart disease, type 2 diabetes, high blood pressure, certain types of cancer, and other chronic diseases. Primary care clinicians face the challenge of helping children develop dietary habits that promote growth and development and reduce the risk of chronic diseases later in life.

Most major authorities, including the American Academy of Family Physicians, American Academy of Pediatrics, American Dietetic Association, American Medical Association, Bright Futures, and US Preventive Services Task Force (USPSTF) --

Primary care providers should counsel children and adolescents and their parents about proper nutrition. The USPSTF has reported that there is insufficient evidence that nutritional counseling by physicians has an advantage over dietitian counseling or community interventions in changing the dietary habits of patients.

American Academy of Family Physicians --

Counseling should be provided to promote breast-feeding through at least 6 months of age.

American Academy of Pediatrics, American Medical Association, Bright Futures, Canadian Task Force on the Periodic Health Examination, and US Preventive Services Task Force --

Parents should be counseled about the benefits and techniques of breast-feeding for infants.

American College of Obstetricians and Gynecologists, US Preventive Services Task Force, and Canadian Task Force on the Periodic Health Examination --

Women of childbearing age who are capable of becoming pregnant should consume 0.4 mg of folic acid per day.

The Gift of Love; Feeding Kids Right Isn't Always Easy: Tips for Preventing Food Hassles; Growing Up Healthy: Fat, Cholesterol and More; Right from the Start: ABC's of Good Nutrition for YoungChildren; What's to Eat? Healthy Foods for Hungry Children. American Academy of Pediatrics, PO Box 927, Elk Grove Village, IL 60009-0927; (800)433-9016. Internet address: http://www.aap.org

Nutrition and Sports Performance: A Guide for High School Athletes. American College of Sports Medicine, PO Box 1440, Indianapolis, IN 46202-1440; (317)634-7817.

Nutrition and Your Health: Dietary Guidelines for Americans; The Food Guide Pyramid. These booklets are available through the Cooperative Extension System, or contact the Superintendent of Documents, US Government Printing Office, Washington, DC 20402; (202)783-3238.

The Food Guide Pyramid: Beyond the Basic 4. Food Marketing Institute, 800 Connecticut Ave NW, Washington, DC 20006.

Bright Futures: Guidelines for Health Supervision of Infants, Children and Adolescents; Bright Futures Pocket Guide; Bright Futures Anticipatory Guidance Cards. Available from the National Center for Education in Maternal and Child Health, 2000 15th Street North, Suite 701, Arlington, VA 22201-2617; (703)524-7802. Internet address: http://www.brightfutures.org

Most Americans, including American children and adolescents, are not physically active. Although the health consequences of physical inactivity usually become apparent in adulthood, the early changes that lead to their development may begin in childhood and adolescence. Physical activity, even moderate levels, confers significant health benefits including: building and maintaining healthy bones, muscles, and joints; controlling weight; reducing body fat; and preventing or delaying the development of hypertension and diabetes. Further, physical activity patterns developed in childhood and adolescence are believed to influence adult activity patterns.

According to the 1996 Report of the Surgeon General on Physical Activity and Health, only about half of young persons in the United States aged 12 to 21 years regularly participate in vigorous physical activity. The level of participation in all types of physical activity declines strikingly as age or grade in school increases. Physical education requirements in schools vary widely in terms of days per week and total physical education requirements. During the first half of the 1990s, total enrollment of high school students in physical education remained unchanged, although daily attendance in physical education classes decreased from 42% to 25%. A corollary of escalating physical inactivity among children and adolescents is the increase of obesity among this age group. A 55-year follow-up study by Must, Jacques, Dallai, Bajema, and Dietz (Selected References) that controlled for adult weight found that being overweight in adolescence was a more powerful predictor of premature mortality than was being overweight as an adult.

See chapter 57 for information about physical activity counseling for adults. See chapters 20 and 56 for information on nutrition counseling for children and adolescents and adults, respectively.

American Academy of Family Physicians and US Preventive Services Task Force --

Counseling to promote regular physical exercise is recommended for all children and adults.

American Academy of Pediatrics --

Clinicians should assess the frequency, type, and duration of physical activities during any health supervision visit for a child 3 years of age or older. They should teach the importance of regular moderate-to-vigorous physical activity as a way to prevent illness in adult life. Parents should be encouraged to serve as role models by participating in regular physical activity, ideally with their child or as a family. Clinicians should also serve as role models by participating in regular physical activity themselves, work with schools to promote daily physical education, encourage measurements of physical fitness in physical education classes, and develop the ability to perform or refer children for body composition analysis, such as skinfold measurement.

American College of Sports Medicine --

The health-care professions need to become more actively involved in promoting physical fitness for children and youth. Health-care professionals can make a major impact by promoting and supporting physical fitness programs for children and youth.

American Medical Association --

Adolescents should receive annual counseling about the benefits of exercise and should be encouraged to engage in safe exercise on a regular basis.

Bright Futures --

Parents, children, and teenagers should be counseled regarding physical activity using open-ended trigger questions, developmental surveillance questions, and anticipatory guidance.

National Institutes of Health Consensus Panel on Physical Activity and Cardiovascular Health --

All Americans should engage in regular physical activity at a level appropriate to their capacity, needs, and interest. Children and adults should set a goal of accumulating at least 30 minutes of moderate-intensity physical activity on most, and preferably, all days of the week.

US Preventive Services Task Force --

Clinicians should encourage regular physical activity, encouraging a variety of self-directed, moderate-level physical activities that can be incorporated in an individual's daily routine. The effectiveness of physician counseling to change patients' physical activity behaviors is not proven.

Better Health and Fitness Through Physical Activity; Sports and Your Child. American Academy of Pediatrics, PO Box 927, Elk Grove Village, IL 60009-0927; (800)433-9016. Internet address: http://www.aap.org

Get Fit: A Handbook for Youth Ages 6-17; Kids in Action: Fitness for Children Ages 2-17; Presidential Sports Awards: 4-Month Qualifications for Anyone Ages 6 and Up; The Physician's Rx: Exercise. The President's Council on Physical Fitness and Sports, 701 Pennsylvania Ave, SW, Suite 250, Washington, DC 20004; (202)272-3421.

Anabolic Steroids and Athletes; Nutrition and Sports Performance: A Guide for High School Athletes; Weight Loss and Wrestlers; Youth Fitness. American College of Sports Medicine, Public Information Department, PO Box 1440, Indianapolis, IN 46206-1440; (317)637-9200. Internet address: http://www.acsm.org/sportsmed

Bright Futures: Guidelines for Health Supervision of Infants, Children and Adolescents; Bright Futures Pocket Guide; Bright Futures Anticipatory Guidance Cards. Available from the National Center for Education in Maternal and Child Health, 2000 15th Street North, Suite 701, Arlington VA, 22201-2617; (703)524-7802. Internet address: http://www.brightfutures.org

Physician-based Assessment and Counseling for Exercise. Project PACE, San Diego State University, San Diego, CA 92182-0567; (619)594-5949.

Sports Medicine: Health Care for Young Athletes, 2nd ed; Pre-Participation Physical Evaluation, 2nd ed; A Self Appraisal Checklist for Health Supervision in Scholastic Athletic Programs. American Academy of Pediatrics. PO Box 927, Elk Grove Village, IL 60009-0927; (800)433-9016. Internet address: http://www.aap.org

Table 21.1. Sports Guidelines for Children with Certain Medical Conditions

Injuries are the number one cause of death for children in the United States. Each year childhood injuries result in 20,000 deaths, 600,000 hospitalizations, and 16 million visits to emergency rooms, with an associated cost of approximately $165 billion.

Almost half of the injury-related deaths of children involve motor vehicles. Other causes of unintentional childhood injuries are drowning, burns and scalds, choking, firearms, falls, poisoning, and sports.

The vast majority of unintentional childhood injuries are preventable. Children at a higher risk of injury include males, children with previous serious injuries, children in families with low income, and children in families with young mothers. Among adolescents, alcohol and drug use are significant risk factors.

For additional information on safety, refer to chapter 26, which deals with counseling children and adolescents on violent behavior and firearms, and to chapter 55 for information about counseling adults about injury prevention.

All major authorities, including American Academy of Pediatrics (AAP), Bright Futures, Canadian Task Force on the Periodic Health Examination, and US Preventive Services Task Force --

Age-specific safety counseling should be provided as a part of routine well-child care. American Academy of Family Physicians specifies counseling for accidental injury prevention, including (as appropriate) child safety seats, lap and shoulder belt use, bicycle safety, motorcycle helmet use, poison control center numbers, and driving while intoxicated. AAP specifies unintentional injury counseling as appropriate for traffic safety, burn prevention, fall prevention, poisoning prevention, drowning, water safety, sports safety, and firearm safety.

American Academy of Pediatrics and Bright Futures --

Healthy, sleeping infants should be positioned on the back, instead of prone, to decrease the risk of sudden infant death syndrome (SIDS).

Encourage parents to learn basic life-saving skills, including cardiopulmonary resuscitation (CPR).

Counsel parents to teach their children to dial 911 or other local emergency numbers.

Encourage parents to teach their children self-esteem and how to handle peer pressure that might result in risk-taking behavior that may interfere with making good safety decisions.

Encourage parents to be good role models for safe behavior. In particular, counsel parents to avoid drinking alcohol before or while driving, to always wear a seat belt and bicycle helmet, and to drive within the posted speed limit.

Be attentive to issues involving limited parental and community access to resources for child safety. Be aware of programs in your practice community offering affordable, reliable equipment, devices, and assistance for parents of limited means, and have referrals to these sources available at the time of counseling.

Advise parents to keep objects that can cause suffocation (such as plastic bags) and choking (such as coins, small toy parts, and certain foods, including whole grapes, gum, peanuts, popcorn kernels and pieces of raw carrots, and hot dogs) away from small children.

Inform parents that children can drown in small depths of water such asmay be contained in buckets, toilets, bathtubs, and wading pools. Empty and store buckets after use. Never leave infants in the bathtub without supervision.

• Do not allow children to swim alone.
• Advise parents to protect their children from drowning by installing fences around swimming pools/spas; fences should be at least 4 ft (1.2 m) high with completely self-closing gates.

Advise parents to keep unused electrical outlets covered with plastic guards or to install breaker outlets. Ground fault interrupter circuits (GFIC) should be used in bathrooms and other areas where water is likely to touch bare skin.

• Safety gates: Advise parents to use safety gates (preferably not the accordion type) across stairways (both top and bottom), to install window guards above the first floor, and to move furniture away from upper-story windows so children cannot use the furniture to climb onto the window sill.
• Baby Walkers: Baby walkers are associated with more injuries each year than any other baby product. If they are used, strict supervision must be maintained to avoid falls down stairwells.

• Water heaters: Counsel parents to protect their children from scald burns by reducing the temperature setting of their water heater to 49° C (120° F), if possible, or install anti-scald devices on bathroom and kitchen faucets.
• Smoke detectors : Counsel parents about the importance of using smoke alarms to prevent residential fire injuries. Emphasize proper installation, semiannual battery changes, and monthly checks to make sure they work. Discuss the use of a family fire drill and escape plan.

Advise parents about the dangers of keeping a firearm in the home. If a gun is kept in the home, counsel parents to keep it unloaded and locked up separately from the ammunition.

• Car seats: Use of child safety seats is required by law in all 50 states. Counsel parents to install child safety seats in the rear seat of the car, preferably in the middle, and to use them every time children ride. Safety seats should be used until children weigh at least 40 lbs (18 kg). Safety seats should face backward until children weigh at least 20 lbs (9 kg) or reach 1 year of age. Failure to properly secure either the child in the seat or the seat in the car is common; therefore, urge parents to take particular care when securing both.
• Booster seats/Seat belts: Advise parents to have their children sit in the rear seat of cars and to use safety belts every time they ride. Until children grow tall enough so that the lap belt stays low on their hips and the shoulder belt crosses their shoulders or until children's ears come above the top of the vehicle seat back, they should use properly secured booster seats. Remind parents that children should not ride in the cargo areas of pickup trucks, vans, or station wagons.
• Air bags: Infants riding in rear-facing safety seats should never be placed in the front seat of a vehicle equipped with a passenger-side air bag. Children should ride in a car's rear seat. If a vehicle does not have a rear seat, children riding in the front seat should be positioned as far back as possible from an air bag.
• Impaired driving: Advise children and adolescents to avoid riding in a vehicle driven by anyone who has been or is drinking. Counsel adolescents not to drink and drive.

Remind parents to keep medicines and other dangerous substances locked up and in child-resistant containers, to have the local poison control center telephone number posted in a prominent place near the telephone, and to keep a 1-oz bottle of syrup of ipecac at home and to replace it when it reaches its expiration date. Advise parents not to administer syrup of ipecac without first consulting with a poison control center or health care professional.

Encourage parents to teach and demonstrate pedestrian safety to their children. Remind them that children younger than aged 9 to 12 years need supervision when crossing streets, depending on the density and speed of traffic.

• A safety helmet approved by the American National Standards Institute (ANSI), Snell Memorial Foundation, or the American Society for Testing Materials (ASTM) should be worn by all persons every time they ride or are a passenger on a bicycle. Helmets should also be worn while using roller skates, in-line skates, and skateboards.
• Wrist guards, elbow pads, and knee pads should be worn by all children of all ages using roller skates, in-line skates, and skateboards.
• Personal flotation devices should be worn by every child engaged in any boating activity.

Advise parents that positioning sleeping infants on their backs, rather than prone, may decrease the risk of SIDS.

Auto Safety Hot Line. National Highway Traffic Safety Administration: (800)424-9393.

Child Safety: How to Keep Your Home Safe for Your Baby. American Academy of Family Physicians, 8880 Ward Parkway, Kansas City, MO 64114-2797; (800)944-0000. Internet address: http://www.aafp.org

Fun in the Sun: Keep Your Baby Safe; 1995 Family Shopping Guide To Car Seats: Guidelines for Parents. American Academy of Pediatrics, PO Box 927, Elk Grove Village, IL 60009-0927; (800)433-9016. Internet address: http://www.aap.org

Reduce The Risk of Sudden Infant Death Syndrome (SIDS). Brochures available in English and Spanish. Back to Sleep, PO Box 29111, Washington, DC 20040; (800)505-2742.

Safe Kids Gear Up Guide; How to Protect Your Child From Injury. These and other injury-prevention magazines, brochures, posters, videos, and other materials are available from the National SAFE KIDS Campaign, 1301 Pennsylvania Ave NW, Suite 1000, Washington, DC 20004; (202)662-0600.

US Consumer Product Safety Commission, Publication Requests, Washington, DC 20207. Brochures about preventing injuries from toys, household goods, and other common items. Available in English and Spanish; (800)638-2772.

Bright Futures: Guidelines for Health Supervision of Infants, Children and Adolescents; Bright Futures Pocket Guide. Available from the National Center for Education in Maternal and Child Health, 2000 15th Street North, Suite 701, Arlington, VA 22201-2617; (703)524-7802. Internet address: http://www.brightfutures.org

Centers for Disease Control and Prevention: National Center for Injury Prevention and Control; Internet address: http://www.cdc.gov/ncipc

The Injury Prevention Program (TIPP). American Academy of Pediatrics, PO Box 927, Elk Grove Village, IL 60009-0927; (800)433-9016. Internet address: http://www.aap.org

A Guide to Safety Counseling in Office Practice; Physician's Resource Guide for Bicycle Safety Education; Injury Prevention for Children and Youth. American Academy of Pediatrics, PO Box 927, Elk Grove Village, IL 60009-0927; (800)433-9016. Internet address: http://www.aap.org

National Highway Traffic Safety Administration, Office of Occupant Protection, NTS-13, 400 7th St SW, Washington, DC 20590; (202)366-2727.

US Consumer Product Safety Commission, Washington, DC 20207. Recorded messages, in both English and Spanish, (800)638-2772.

Injury Control News. Association for the Advancement of Injury Control, 888 17th St NW, Suite 1000, Washington, DC 20006; (202)296-6161.

Sexually transmitted diseases (STDs), including infection with human immunodeficiency virus (HIV), represent a major health problem for adolescents. Approximately 3 million American teenagers acquire an STD annually. According to national surveys of male and female high school students taken in 1990, 1991, 1993, and 1995, the proportion of students who reported being sexually experienced (having ever had sexual intercourse) has remained stable, ranging from 53.0% to 54.2%. In contrast, the percentage of those who reported condom use at last sexual intercourse increased significantly, from 46.2% in 1991 to 54.4% in 1995. Despite the increase in condom use, many adolescents continue to be at risk for STDs, including HIV infection, because they engage in unprotected sexual intercourse.

The consequences of sexually transmitted diseases can be very serious for teenagers. Female adolescents are more susceptible to certain STDs than older adult women because of the histology of their cervix. Gonorrhea and chlamydial infection lead to pelvic inflammatory disease and potential sterility. Although the primary phase of syphilis is relatively asymptomatic, the later stages of this disease may cause great damage to multiple organ systems. Human papilloma virus (HPV) infection, which may be the most prevalent sexually transmitted disease in adolescents, can lead to cervical cancer. Transmission of HIV may be facilitated by the presence of other STDs. During pregnancy, STDs, if left untreated, can lead to serious consequences for the fetus or newborn child, including congenital infection and malformations, prematurity, low birth weight, and increased mortality.

Adolescents at high risk for HIV infection and other STDs include those who: (1) have unprotected intercourse; (2) are homosexual or bisexual males; (3) have been sexually abused by or have had sexual contact with individuals with documented STDs/HIV infection or injection drug use; (4) have a past history of STDs; (5) trade sex for money or drugs; and/or (6) use drugs, particularly if injected, or alcohol.

Refer to chapter 40 for information on screening for STDs and HIV infection. See chapter 59 for information on counseling adults about STDs and HIV infection. See chapters 25 and 61 for related information on counseling adolescents and adults to prevent unintended pregnancy. See chapters 14 and 48 for information about hepatitis B in children and adults, respectively.

American Academy of Family Physicians --

Adolescents should be counseled about the risks for sexually transmitted diseases and how toprevent them.

American Academy of Pediatrics --

As a routine part of health supervision, adolescents should be asked about sexual behavior and provided with counseling about responsible sexual behavior, including contraception and prevention of STDs and HIV. Clinicians should encourage abstaining from intercourse as the surest way to prevent STDs, including HIV infection, and pregnancy in adolescents. Adolescents who have been sexually active previously should be counseled regarding the benefits of postponing future sexual relationships. Clinicians should actively support and encourage the use of reliable contraception and condoms by adolescents who are sexually active or contemplating sexual activity. The responsibility of male as well as female adolescents in preventing unintended pregnancies and STDs should be emphasized. Clinicians need to be actively involved in community programs directed toward this goal.

American College of Obstetricians and Gynecologists --

Adolescents should be routinely counseled about sexual practices and sexually transmitted diseases, including partner selection and use of barrier protection.

American Medical Association --

All adolescents should be asked annually about involvement in sexual behaviors that may result in unintended pregnancy and STDs, including HIV infection. This should include their use of and motivation to use condoms. All sexually active adolescents should be screened for gonorrhea and chlamydia; high-risk adolescents should be screened for syphilis; and HIV testing should be offered to high-risk adolescents.

American Nurses Association --

Education about the risks of HIV infection, basic sex information, including the option of abstinence, and the essential features of safer sex practices should be a major priority within community health practice, with a special emphasis in school health settings and school-based clinics.

Canadian Task Force on the Periodic Health Examination --

Adolescents should be counseled on sexual activity, and sexually active adolescents should be advised about the correct use of condoms.

US Preventive Services Task Force (USPSTF) --

All adolescent and adult patients should be advised about risk factors for sexually transmitted diseases and HIV infection and counseled appropriately about effective measures to reduce risk of infection. This recommendation is based on the proven efficacy of risk reduction, although the effectiveness of clinician counseling in the primary care setting is uncertain. Counseling should be tailored to the individual risk factors, needs, and abilities of each patient. Assessment of risk should be based on a careful sexual and drug use history and consideration of the local epidemiology of STDs and HIV infection. Patients at risk of STDs and HIV infection should receive information on their risk and be advised about measures to reduce their risk. Effective measures include abstaining from sex, maintaining a mutually faithful monogamous sexual relationship with a partner known to be uninfected, regular use of latex condoms, and avoiding sexual contact with high-risk individuals (eg, injection drug users, commercial sex workers, and persons with numerous sex partners). Women at risk of STDs should be advised of options to reduce their risk in situations when their male partner does not use a condom, including the female condom. Warnings should be provided that using alcohol and drugs can increase high-risk sexual behavior. Persons who inject drugs should be referred to available drug treatment facilities, warned against sharing drug equipment and, when possible, referred to sources for uncontaminated injection equipment and condoms. All patients at risk for STDs should be offered testing in accordance with USPSTF recommendations for screening for syphilis, gonorrhea, chlamydia, genital herpes, hepatitis B, and HIV infection (chapter 40).

Being a Teenager: You and Your Sexuality; Sexually Transmitted Diseases. American College of Obstetricians and Gynecologists, 409 12th St, SW, Washington, DC 20024-2188; (800)762-2264; Internet address: http://www.acog.com

Sex Education: A Bibliography of Educational Materials for Children, Adolescents, and Their Families. American Academy of Pediatrics, PO Box 927, Elk Grove Village, IL 60009-0927; (800)433-9016; Internet address: http://www.aap.org

The Correct Use of Condoms: A Message to Teens. American Academy of Pediatrics, PO Box 927, Elk Grove Village, IL 60009-0927, (800)433-9016; Internet address: http://www.aap.org

Know the Facts about HIV and AIDS. American Academy of Pediatrics, PO Box 927, Elk Grove Village, IL 60009-0927; (800)433-9016; Internet address: http://www.aap.org

Teenagers and HIV (#329 536); Children, Parents, and HIV (#329 540). American Red Cross. Contact your local chapter.

On the Teen Scene: Preventing STDs. Contact the FDA Office of Consumer Affairs. HFE 88 Room 1675, 5600 Fishers Lane, Rockville, MD 20857. (800)532-4440.

Jimmy and the Eggs Virus. To order this parent-information booklet and other materials on pediatric AIDS, contact the National Pediatric HIV Resource Center, 15 S Ninth St, Newark, NJ 07107; (201)268-8251.

Surgeon General's Report to the American Public on HIV Infection and AIDS; Condoms and Sexually Transmitted Diseases...Especially AIDS. CDC National AIDS Information Hot Line: (800)342-AIDS (English); (800)344-SIDA (Spanish); (800)AIDS-TTY (hearing impaired). All phone calls are confidential.

HIV in America: A Profile of the Challenges Facing Americans Living With HIV. National Association of People Living with AIDS, 1413 K St, NW, Washington, DC 20005; (202)898-0435.

National STD Hot Line: (800)227-8922 or (809)765-1010 (Spanish; call collect).

Hemophilia and AIDS Network for the Dissemination of Information, 110 Green St, New York, NY 10012. For information on hemophilia and HIV, call: (800)424-2634.

HIV and AIDS in Children: Questions and Answers. National Pediatric HIV Resource Center, 15 S Ninth Street, Newark, NJ 07107; (201)268-8251. Internet address: http://www.wdcnet.com/peds.aids

National AIDS Information Clearinghouse, PO Box 6003, Rockville, MD 20850. To order brochures on STDs, HIV, AIDS, and AIDS-related diseases or a Fact Sheet packet, call: (800)458-5231 (English and Spanish).

Pediatric Human Immunodeficiency Virus (HIV) Infection. American Academy of Pediatrics, PO Box 927, Elk Grove Village, IL 60007-0927, (800)433-9016; Internet address: http://www.aap.org

Adolescent Sexuality: Guidelines to Professional Involvement. American Academy of Pediatrics, PO Box 927, Elk Grove Village, IL 60009-0927, (800)433-9016; Internet address: http://www.aap.org

Table 23.1. Guidelines for Proper Condom Use

Tobacco use continues to be the single largest cause of preventable illness and death in the United States. Cigarette use is related to heart disease, lung and esophageal cancer, and chronic lung disease. Smokeless tobacco use is associated with numerous cancers, including cancers of the gum, mouth, larynx, pharynx, and esophagus.

The decision to start smoking is often made during the teenage years. Approximately 22% of high school students now report smoking cigarettes daily. However, cigarette smoking is becoming increasingly common among younger children. Surveys indicate that 10% to 25% of children try cigarettes before or during sixth grade. Similarly, use of smokeless or chewing tobacco is increasing among children and adolescents. An estimated 11.4% of high school students use smokeless tobacco. The majority of smokeless tobacco users begin by 13 years of age, and some begin as early as 4 or 5 years of age. Nicotine addiction is rapidly established; therefore, initiation of tobacco use by youth perpetuates tobacco-related chronic health problems in our country. In 1993, smoking-related illnesses cost the nation $50 billion in direct health care costs.

Exposure to environmental tobacco smoke is a potential health hazard for infants and children. An estimated 31.2% of children aged 10 years and younger are exposed to tobacco smoke daily in their homes. Passive smoking can exacerbate the symptoms of asthma and allergies and decrease pulmonary function. The rates of lower respiratory tract infection and middle ear effusions are higher in children who are exposed to environmental tobacco smoke. Each year, an estimated 300,000 children suffer from lower respiratory tract infections attributable to environmental tobacco smoke.

Parental smoking is a risk factor for the initiation of smoking by youth. Children from families in which one or both parents smoke are twice as likely to smoke as are those whose parents do not smoke. See chapter 60 for information about smoking cessation.

All major authorities, including American Academy of Family Physicians, American Academy of Pediatrics, American Medical Association, Bright Futures, Canadian Task Force on the Periodic Health Examination, National Cancer Institute, Smoking Cessation Guideline Panel convened by the Agency for Health Care Policy and Research and the Centers for Disease Control and Prevention and the US Preventive Services Task Force --

Primary care clinicians should counsel both parents and children about the importance of abstaining from initiating tobacco use and of stopping tobacco use after initiation.

American Academy of Family Physicians --

Children, adolescents, and young adults should be counseled on the risks of tobacco use. Parents who smoke while children are in the house should be counseled regarding the harmful effects of smoking on children's health. All tobacco users should be provided with tobacco cessation counseling on a regular basis. Clinicians should discuss nicotine replacement therapy as an adjunct for smoking cessation with patients desiring to quit smoking.

American Academy of Pediatrics and Bright Futures --

Inquiry into tobacco use and smoke exposure should be a routine part of pediatric health supervision visits. Clinicians should inform parents of the dangers of environmental tobacco smoke and the implications and complications of exposing their children to tobacco smoke. Information about available smoking cessation assistance should be offered. Discussion and anticipatory guidance about smoking and tobacco use should begin well before the patient enters junior high school, with particular emphasis on the importance of resisting the influence of advertising and the peer group. Clinicians should obtain a history of environmental tobacco smoke exposure when encountering a child with a respiratoryillness.

American Medical Association --

Adolescents should receive annual screening and health guidance to promote avoidance of tobacco use. A cessation plan should be provided for adolescents who use tobaccoproducts.

Canadian Task Force on the Periodic Health Examination --

There is good evidence to support counseling for smoking cessation in the periodic health examination for individuals who smoke. There is fair evidence to support counseling to prevent smoking initiation for adolescents. Counseling by physicians has not been evaluated but given the burden of disease, the benefits of preventing addiction, the effectiveness of other smoking-related counseling, and the support of expert opinion, all children and adolescents should be counseled on avoiding tobacco use.

National Cancer Institute --

Clinicians treating children should follow five principles that start with the letter A in counseling about smoking prevention/cessation:

US Preventive Services Task Force --

Tobacco cessation counseling is recommended on a regular basis to all patients who use tobacco. Parents of children living at home should be counseled on the potential harmful effects of smoking on child health. Anti-tobacco messages should be included in health promotion counseling of children and adolescents based on the proven efficacy of risk reduction from avoiding tobacco use, although the evidence for the effectiveness of clinical counseling to prevent the initiation of tobacco use is less clear. Clinicians should support school-based programs to prevent initiation of tobacco use.

Chew or Snuff Is Real Bad Stuff; Why Do You Smoke? National Cancer Institute. Superintendent of Documents, Consumer Information Center 3C, PO Box 100, Pueblo, CO 81002.

Stop Smoking Kit; Smoking: Steps To Help You Break the Habit. American Academy of Family Physicians, 8880 Ward Parkway, Kansas City, MO 64114-2797; (800)944-0000; Internet address: http://www.aafp.org

Through with Chew. American Academy of Otolaryngology, 1 Prince St, Alexandria, VA 22314; (703)836-4444.

Smoking: Guidelines for Teens; Tobacco Abuse -- A Message to Parents and Teens; Straight Talk About Smokeless Tobacco; Smoking: Straight Talk for Teens; Environmental Tobacco Smoke: A Danger for Children. American Academy of Pediatrics, PO Box 927, Elk Grove Village, IL 60009-0927; (800)433-9016; Internet address: http://www.aap.org

Smoking and Reproductive Health; Smoking in Women. American College of Obstetricians and Gynecologists, 40912th St SW, Washington, DC 20024; (800)762-2264; Internet address: http://www.acog.com

Smokeless Tobacco: Think Before You Chew; Smoking Can Really Do A Number on Your Health. American Dental Association, Department of Salable Materials, 211 E Chicago Ave, Chicago, IL 60611; (800)947-4746.

You Can Quit Smoking: Smoking Cessation Consumer Guide, Clinical Practice Guideline Number 18. Publication number 96-0695. Agency for Health Care Policy and Research, Publications Clearinghouse, PO Box 8547, Silver Spring Md 20907; (800)358-9295, Also available through InstantFAX at (301)594-2800 (push 1 and start, wait for directions);Internet address: http://www.ahcpr.gov

Bright Futures: Guidelines for Health Supervision of Infants, Children and Adolescents; Bright Futures Pocket Guide; Bright Futures Anticipatory Guidance Cards. Available from the National Center for Education in Maternal and Child Health, 2000 15th Street North, Suite 701, Arlington VA, 22201-2617; (703)524-7802. Internet address: http://www.brightfutures.org

Centers for Disease Control and Prevention Information and Prevention Source Page: http://www.cdc.gov/tobacco

Clinical Interventions To Prevent Tobacco Use by Children and Adolescents. National Cancer Institute; (800)4-CANCER; Internet address: http://cancernet.nci.nih.gov

Doctors Helping Smokers. For information about this office-based tobacco cessation program and video, contact: Doctors Helping Smokers at Blue Plus, PO Box 64179, R 3-11, St Paul, MN 55164; (800)382-2000, ext 1975.

How To Help Your Patients Stop Smoking: A National Cancer Institute Manual for Physicians; How To Help Your Patients Stop Using Tobacco: A National Cancer Institute Manual for the Oral Health Team. Office of Cancer Communications, National Cancer Institute, Bldg 31, Rm 10A16, Bethesda, MD 20892; (800)4-CANCER; Internet address: http://cancernet.nci.nih.gov

Helping Smokers Quit: A Guide for Primary Care Clinicians, Clinical Practice Guideline No. 18, AHCPR Publication No. 96-0693. Agency for Health Care Policy and Research, Publications Clearinghouse, PO Box 8547, Silver Spring, MD 20907; (800)358-9295. Also available through InstantFAX at (301)594-2800 (push 1 and start, wait for directions).Internet address: http://www.ahcpr.gov

Nurses: Help Your Patients Stop Smoking. National Heart, Lung, and Blood Institute Smoking Education Program, PO Box 30105, Bethesda, MD 20824-0105; (301)251-1222; Available in both English and Spanish. Internet address:gopher://fido.nhlbi.nih.gov:70/11/nhlbi/health/lung/other/prof/nrsmk

On the Teen Scene: Young People Talk with FDA Commissioner About Smoking. FDA Office of Consumer Affairs, HFE 88 Room 1675, 5600 Fishers Ln, Rockville, MD 20857; (800)532-4440.

The rate of pregnancies among teenagers in the United States currently exceeds that of any other country in the western world. During the year 1990, one in 10 female adolescents in the United States aged 15 to 19 years became pregnant. Of teenage pregnancies, approximately 95% are unintended, and 40% are terminated by elective abortion. Among nonwhite teenagers, the rates of unintended pregnancies are nearly twice those of white teenagers. Young women with the least familial, educational, and financial resources are the most likely to become pregnant. As a result, teenage pregnancies are more likely than adult pregnancies to result in adverse health outcomes for both mother and baby, largely because of prenatal care delays, poor nutrition, and other lifestyle factors.

Recent data reveal a decrease in teenage sexual activity in the United States, with a concurrent increase in the rate of teenage contraceptive use. Previous surveys had demonstrated an increasing trend in teenage sexual activity since the 1970s. In 1995, 50% of females and 55% of males aged 15 to 19 years reported ever having sexual intercourse. These figures represent a decline from prior years (down from 55% of females in 1990 and 60% of males in 1988).

Approximately two-thirds of teenagers report using contraception (almost exclusively condoms) during their first sexual intercourse, and 78% report contraception usage during their most recent sexual intercourse. Younger adolescents are the least likely to use a contraceptive method when compared with either older teenagers or young adults.

See chapter 61 for information on counseling to prevent unintended pregnancy in adults. See chapters 23 and 59 for related information on counseling to prevent sexually transmitted diseases (STDs) and human immunodeficiency virus (HIV) infection among adolescents and adults, respectively. See chapters 14 and 48 for related information on hepatitis B in children and adults.

All major authorities, including American Academy of Pediatrics (AAP), American College of Obstetricians and Gynecologists (ACOG), American Medical Association (AMA), Canadian Task Force on the Periodic Health Examination, and US Preventive Services Task Force (USPSTF) --

Primary care providers should routinely counsel adolescents in the prevention of unintended pregnancies. AAP recommends that all pediatricians who choose to see teenagers should be able to provide counseling about sexual behavior, education on contraceptive methods and prevention of STDs, and assistance with access to contraception, preferably in the office or, if necessary, by referral. ACOG recommends that special attention be given to ensure that sexually active adolescents have access to suitable methods of contraception. AMA recommends that all adolescents should be asked annually about involvement in sexual behaviors that may result in unintended pregnancy and STDs, including HIV infection. USPSTF recommends that counseling be based on information from a careful history that includes direct questions about sexual history, current and past use of contraception, level of concern about pregnancy, and past history of unintended pregnancies. The USPSTF also recommends that clinicians inform adolescent patients that abstinence is the most effective way to prevent unintended pregnancy and sexually transmitted diseases; the effectiveness of abstinence counseling has not yet been established. Clinicians should involve young pubertal patients (and their parents, when appropriate) in early, open discussion of sexual development and effective methods to prevent unintended pregnancy and sexually transmitted diseases.

1. Ask all adolescents about their sexual experiences and use of contraceptives. Attempt to maintain a nonjudgmental, empathetic manner. This discussion can begin with questions about the patient's peer group before moving on to more explicit questions about the patient's own sexual behavior. State your willingness to answer any questions and to provide contraceptive advice and prescriptions. Provide adolescents with explicit information about the consequences of pregnancy and STDs and about effective methods to prevent them.

2. Counsel adolescents individually, assuring the patient that you will maintain confidentiality to the maximum extent possible. State laws vary regarding the minimum age at which an adolescent may consent to treatment, receive prescription contraceptives, or both. Become familiar with the laws in your state regarding these issues. Inform adolescents about their legal rights to confidentiality regarding pregnancy prevention and STD testing and treatment.

3. Counsel parents about the role of emerging sexuality in teenagers' lives, desire for privacy, and the options for contraception. Fostering effective communication between adolescents and their families regarding responsible sexual behavior is very important.

4. Support the decision of adolescents who choose to be sexually abstinent.

5. All patients should be encouraged and supported in their efforts to resist unwelcome or coercive sexual relationships.

6. Assist sexually active adolescents in choosing an effective, appropriate primary method of contraception. The choice should take into consideration the patients' personal preferences and motivation, religious beliefs, cultural norms, and relationship with their partner(s).

See Table 61.1 for the pregnancy ("failure") rates of women during the first year of contraceptive use. The two most popular contraceptive methods among adolescents are oral contraceptives and condoms. Oral contraceptives can confer the benefits of less painful menstrual periods and regular, predictable cycles. Implants or injectable contraceptives may also be appropriate choices for teens. In general, diaphragms, cervical caps, withdrawal, and periodic abstinence are technically more difficult methods for teenagers to use effectively. Intrauterine devices (IUDs) are not recommended for adolescents because of the increased risk of pelvic inflammatory disease, which may lead to sterility. Permanent sterilization procedures are not appropriate for adolescents and are prohibited for individuals under age 21 years when Federal funds are involved. In situations of unprotected intercourse, suggesting use of emergency oral contraceptives (morning-after pills) may be appropriate if treatment can be initiated within 72 hours after sexual contact. See chapter 61 for a discussion on emergency contraception.

7. Encourage all sexually active adolescents to use condoms as a means of preventing STDs and HIV infection, even if they are using another form of contraception. Stress that latex condoms used consistently and correctly are an effective method for both pregnancy protection and disease prevention. Many teenagers, particularly those at younger ages, are hesitant to purchase condoms. Educating teenagers about their rights to purchase condoms and about access to other sources of condoms can be helpful. Some authorities recommend making condoms available to teenagers during office visits.

8. Encourage adolescents of both sexes to talk frankly with their partners about STDs, HIV, and hepatitis B infection, and the use of contraceptives. Encourage adolescents to be assertive with their partners about using contraception and protective measures against STDs. Also stress that saying "no," is every person's right each and every time.

9. Provide male adolescents with as much counseling as that provided to females about contraception and STD prevention. Instruct young adolescent males about responsible sexual behavior at an early age, particularly regarding the importance of condom use.

10. Provide adolescents with close follow-up after they begin using contraceptives. Adolescents often discontinue contraceptive use unnecessarily because of concerns about side effects and misconceptions about proper technique. Many such concerns and misconceptions can be easily dealt with in follow-up counseling. Table 25.1 provides sample responses to some common concerns of adolescents about oral contraceptives.

Being a Teenager: You and Your Sexuality; Teaching Your Children About Sexuality, Growing Up. American College of Obstetricians and Gynecologists, 409 12th St SW, Washington, DC 20024; (800)762-2264. Internet address: http://www.acog.com

Birth Control: Choosing the Method That's Right for You. American Academy of Family Physicians, 8880 Ward Pkwy, Kansas City, MO 64114-2797; (800)944-0000. Internet address: http://www.aafp.org

Emergency Contraception Website. The Office of Population Research at Princeton University. Internet address: http://opr.princeton.edu/ec/index.html

Emergency Contraception Hotline. The Office of Population Research at Princeton University. (800)584-9911.

How to Talk With Your Child About Sexuality, Decisions About Sex; How to Talk to Your Teenagers About the Facts of Life. Planned Parenthood, 810 Seventh Ave, New York, NY 10019; (212)541-7800.

Making the Right Choice: Facts Young People Need to Know About Avoiding Pregnancy; Talking to Your Teen About Sex; The Correct Use of Condoms: A Message to Teens. American Academy of Pediatrics, 141 Northwest Point Blvd, PO Box 927, Elk Grove Village, IL 60009-0927; (800)433-9016. Internet address: http://www.aap.org

The Adolescent and Young Adult Fact Book; Evaluating Your Adolescent Pregnancy Program: How to Get Started; Teenage Pregnancy Prevention Strategies; What About the Boys? Children's Defense Fund, 25 E St NW, Washington, DC 20001; (202)628-8787.

Table 25.1. Addressing Adolescents' Common Concerns About Oral Contraceptives

Violence is a major health and social problem affecting children and adolescents in the United States. Homicide is the second leading cause of death among all 15- to 24-year-olds. For African-American males and females aged 15 to 24 years and Hispanic males aged 15 to 24 years, homicide is the leading cause of death. Firearms are involved in more than two thirds of homicides involving children and adolescents. A high percentage (41%) of school-aged boys report having easy access to a gun; handguns are in one of every four homes in the United States. According to Kellerman (1986), for every report of a gun being used in self-defense within the home, 40 shooting deaths of family members or acquaintances, by suicide, nonjustifiable homicide, and accidents, are reported.

For adolescent males, the risk of dying as a result of homicide is more than twice that of adolescent females, and their risk of victimization from other violent crimes is three times greater. However, adolescent females should not be overlooked as victims of violence, in particular dating violence, sexual assault, and rape. Urban adolescents, both males and females, of low socioeconomic status and low educational achievement are at greatest risk of being affected by violence. Other risk factors include a history of juvenile detention or incarceration, alcohol or other drug use, access to firearms, homelessness, mental illness, social isolation, and violence in the home. The risk factors for victims and perpetrators of violence are similar.

For information about depression and suicide, see chapter 5 (for children and adolescents) and chapter 33 (for adults). For information about alcohol and other drug abuse, see chapter 18 (for children and adolescents) and chapter 53 (for adults). For information about safety and injury prevention, see chapter 22 (for children and adolescents) and chapter 55 (for adults).

American Academy of Pediatrics and Bright Futures --

Children, adolescents, and their parents should be questioned about impulsiveness, antisocial behavior, and methods of dealing with anger. The clinician should be concerned about adolescents who display aggressive or acting-out behaviors, such as lying, stealing, temper outbursts, vandalism, excessive fighting, and destructiveness. Health-care providers should encourage families who own firearms to create a gun-safe home environment, with particular emphasis placed on high-risk homes -- those with alcohol or drug-prone or drug-addicted individuals and those with adolescent boys. This should include asking about the presence of guns in the home; counseling patients, parents, and relatives (particularly male relatives) on the dangers of having a gun, especially a handgun, in the home; advising the removal or a reduction in the number of guns in the household; providing office literature on the risks of guns; and emphasizing gun safety rules when patients visit friends' homes. Asking about the presence of a gun in the home and, if one is present, counseling on its removal or secured storage may be the most effective action the primary care clinician can take.

American Medical Association --

Parents or other adult care-givers of adolescents should be given health guidance during their children's early, middle, and late adolescence (more often if necessary) to avoid having weapons in the home and, if weapons are kept in the home, to make them inaccessible to adolescents. Adolescents should be counseled to avoid the use of weapons. Weapons should be removed from homes of adolescents with suicidal intent.

US Preventive Services Task Force --

There is currently insufficient evidence to recommend for or against clinician counseling to prevent morbidity and mortality from youth violence. Adolescent patients should be screened for problem drinking. Clinicians may wish to inform patients (and the parents of child and adolescent patients) of the risk to household members associated with the presence of firearms in the home. Clinicians should also be alert for symptoms and signs of drug abuse and dependence, the various presentations of family violence, and suicidal ideation in persons with established risk factors. In settings where the prevalence of violence is high, clinicians should ask adolescents and young adults about previous violent behavior or victimization, current alcohol and drug use, and the availability of handguns and other firearms. Clinicians should inform those identified as being at high risk for violence about the risks of violent injury associated with easy access to firearms and with intoxication with alcohol or other drugs.

1. Make preventing violence-related injuries a priority. Assess every child and family for the potential for injury from violence. Factors to consider include:

Is there a history of violent injury to the child or other family members?

Is there a history of alcohol or other drug abuse by the child or other family members?

Are guns or other weapons kept in the home?

Are violence-related injuries prevalent in the community?

2. Advise all parents about the dangers of keeping a gun in the home. This advice may be better accepted if it is given as part of general counseling on safety-related issues. The following model intervention has been suggested by the American Academy of Pediatrics and the Center To Prevent Handgun Violence (1994):

You are doing all you can to make sure your children are not hurt by using a car seat, buckling up safety belts in the car, locking away poisonous chemicals, and putting safety latches on kitchen cabinets. Along with these safety measures, I urge you to take another. Easy-to-reach, loaded guns at home are risky. The safest thing for your family is not to have a gun at home. If you keep a gun at home, be sure to empty it out and lock it up at all times. Lock and store the bullets in a separate location.

From: American Academy of Pediatrics, Center To Prevent Handgun Violence. STOP: Steps to Prevent Firearm Injury. Washington, DC: Center To Prevent Handgun Violence; 1996, 2nd edition. Reproduced by permission of the publisher; copyright 1996.

3. Urge parents who keep a gun in the home to follow basic rules of safety:

Never keep a loaded gun in the house or car.

Keep guns and ammunition locked in separate places.

Always treat a gun as if it were loaded and ready to fire.

Never allow children access to guns.

Have a gunsmith check antique and souvenir guns to be sure they are not loaded. Fix these guns so they cannot be fired.

From: American Academy of Pediatrics, Committee on Injury Control for Children and Youth. Firearms. In: Injury Control for Children and Youth. Elk Grove Village, Ill: American Academy of Pediatrics; 1987. Reproduced by permission of the American Academy of Pediatrics; copyright 1987.

4. Advise parents to inquire about the availability of guns in places their children spend time, such as at friends' houses, schools, and recreation facilities. Suggest to parents that limiting their children's access to these places may be wise until guns are no longer available. Encourage parents to take an active role in limiting the availability of guns in their children's environment.

5. Asking first about violence in an adolescent's environment (at school, at friends' houses) before asking specifically about their personal experiences may be less threatening.

6. When treating patients who have injuries that may have been caused by violence, ask specific questions about the cause of the injury. If the injury was caused by violence, attempt to determine if the conflict has been settled or has the potential to lead to further violence. The following sample questions have been suggested for use in this situation*:

Have you settled it?

Is there anyone who can settle this -- someone who can talk for you and explain your side?

Do you know where to go if this is not settled?

Are you safe?

7. Despite the desirability of maintaining confidentiality, consulting parents, police, and other authorities may be necessary to protect the safety of children and adolescents involved in potentially violent situations.

8. Ask patients about ways in which they deal with anger*.

Emphasize that anger is a normal emotion.

Encourage young people to consider alternative ways of dealing with anger.

Offer positive ways to deal with anger and arguments, the leading precipitators of homicide.

*From: Violence Prevention Project. Identification and Prevention of Youth Violence: A Protocol for Health Care Providers. Boston, Mass: Violence Prevention Project, Department of Health & Hospitals; 1992. Reproduced by permission of the publisher; copyright 1992.

9. Provide facts about violence with a variety of media in the office or clinic, such as posters, videotapes, and brochures.

10. Encourage participation in activities aimed at ensuring safe communities.

Raising Children to Resist Violence: What You Can Do; Child Sexual Abuse: What It Is and How to Avert It. American Academy of Pediatrics, 141 Northwest Point Blvd, PO Box 927, Elk Grove Village, IL 60009-0927; (800)433-9016; Internet address: http://www.aap.org

The Abused Woman. American College of Obstetricians and Gynecologists, 409 12th St SW, Washington, DC 20024-2188; (202)638-5577; Internet address: http://www.acog.com

What Can You Do About Family Violence? (#NC110992) American Medical Association, 515 N State St, Chicago, IL 60610; (800)621-8335; Internet address: http://www.ama-assn.org

STOP: Steps to Prevent Firearm Injury. American Academy of Pediatrics and the Center To Prevent Handgun Violence. To order, contact the Center To Prevent Handgun Violence, 1225 I St NW, Suite 1100, Washington, DC 20005; (202)289-7319.

Bright Futures: Guidelines for Health Supervision of Infants, Children and Adolescents; Bright Futures Pocket Guide; Bright Futures Anticipatory Guidance. Available from the National Center for Education in Maternal and Child Health, 2000 15th Street North, Suite 701, Arlington VA, 22201-2617; (703)524-7802. Internet address: http://www.brightfutures.org

Identification and Prevention of Youth Violence: A Protocol for Health Care Providers; Assessment and Treatment of Hospitalized Adolescent Victims of Interpersonal Violence. These materials, audiotapes, slides, a script on the process of interviewing youth on violence-related issues, and office posters on violence prevention are available from the Adolescent Wellness Program (formerly the Violence Prevention Project), Department of Health & Hospitals, 1010 Massachusetts Ave, 2nd Floor, Boston, MA 02118; (617)534-5196.

Diagnostic and Treatment Guidelines on Domestic Violence. American Medical Association, Department of Mental Health, 515 N State St, Chicago, IL 60610; (312)464-5066. Internet address: http://www.ama-assn.org