An estimated 200,000 workers between 14 and 17 years of age experience job-related injuries annually, and some 64,000 of these workers require treatment in emergency departments.¹ When adjusted for differences in the number of hours worked, the nonfatal injury rate for adolescent workers exceeds that for adults.² In addition, approximately 70 adolescents younger than 18 years die in work-related incidents each year.¹

Work is a common feature of adolescent life in the United States, with more than 5 million children and teenagers legally employed. In addition, several million adolescents work in violation of wage, hour and safety regulations.³ Limited youth employment data are available at the national or state levels, but the Bureau of Labor Statistics conservatively estimates that 35 percent of 16- and 17-year-olds were employed in 1995.¹ High school surveys suggest that about 80 percent of students are employed at some time during their high school years,⁴ and that nearly 18 percent of them work at least 20 hours per week during the school year.⁵

Teenagers enter the workplace in after-school and summer jobs or in school-based work experience programs. Most work in the retail trades, notably in restaurants and grocery stores.⁴ Students in vocational schools enter simulated workplace environments, such as auto-body repair shops and construction sites.

Benefits and Risks of Work

Employment provides the potential for many benefits to teenagers, including opportunities to earn money for themselves and their families; gain valuable time management, interpersonal and occupation-specific skills; develop discipline and responsibility; and enhance self-confidence and self-esteem.

Work also poses potential threats to the physical, emotional, economic and academic health of teenagers. Like their adult co-workers, teenagers face exposure to a variety of health and safety hazards that can lead to injury and illness (Table 1).

Occupational injuries can cause working teenagers to lose time from school, recreational and social activities, and work itself. Musculoskeletal injuries, particularly back injuries, may cause permanent impairment, and traumatic injuries can have serious physical and emotional sequelae. Little is known about the long-term effects of exposure to toxic chemicals and their possible contribution to the development of cancer, reproductive disorders or chronic diseases in adulthood.

Injury and illness are not the only risks to teenage workers. Working students juggle class time, homework and family, social, religious and civic activities with the demands of their jobs. A recent study of high school students found that working 20 hours or more a week during the school year is associated with higher levels of emotional distress, more substance abuse and earlier onset of sexual activity than are experienced by students working less than 20 hours a week or not at all.⁵

The developmental characteristics of adolescents, combined with workplace risk factors, may increase their vulnerability to injury and illness. Working teenagers may be physically unable to correctly use tools and equipment designed for the average adult male or may lack the strength to perform a job safely. Even physically mature adolescents may lack the emotional maturity or judgment necessary to perform a particular work assignment without injury.⁶ The failure of many employers to provide young workers with safety training,⁷ combined with adolescents' desire to meet the expectations of supervisors, their unwillingness to ask for assistance and their characteristic risk-taking behaviors, may increase their risk of injury.⁶

Regulatory Issues

The federal Occupational Safety and Health Act and equivalent state statutes guarantee workers of all ages the right to a safe and healthy workplace by regulating specific hazards and requiring employers to provide information and training to avoid workplace dangers.

The primary federal law governing the employment of workers younger than 18 years is the Fair Labor Standards Act (FLSA). The FLSA child labor provisions are designed to protect minors by restricting the types of jobs they may hold, for safety reasons (Table 2), and the number of hours they may work, for educational reasons (Table 3). Despite the potentially serious hazards of farm work, the FLSA provides less stringent protection for teenagers working in the agricultural setting than for those in nonfarm employment, and permits the children of farmers to perform any job at any age on their family farm.

Individual states also have child labor laws. Where the provisions of state laws conflict with those of the FLSA, the stricter standard applies.

The Role of the Family Physician

Work-related injuries and illnesses are largely preventable. Family physicians can help their adolescent patients avoid these occupational hazards through appropriate office-based interventions.

OFFICE-BASED INTERVENTIONS

Many states require minors to obtain employment certificates, also known as “working papers” or “work permits,” from school authorities before seeking or starting a job, in an effort to ensure that employment does not compromise the young workers' health, safety or academic performance. In states where a physician must certify fitness for duty before a work permit is issued, the office visit is the ideal time to discuss work-related issues. However, because many employers hire teenagers without work permits and because some states do not require them, nearly any encounter with an adolescent patient (e.g., school, sports, camp and driver's license physicals, family planning visits) should be taken as an opportunity to inquire about work and promote a healthy attitude toward job safety and health.

The physician may wish to offer input into the job choices made by adolescent patients, especially those with special health needs. For example, teenagers with asthma or cystic fibrosis should be counseled to avoid work environments with tobacco smoke. The employment-related provisions of the Americans with Disabilities Act may help adolescents with disabilities obtain the accommodations necessary to participate in the workforce.

Recognizing that many demands compete for the limited time available in a patient encounter, the following framework is suggested. Physicians are encouraged to selectively pursue the most relevant of the following areas with working adolescent patients (Table 4).

INQUIRE ABOUT THE SPECIFICS OF THE JOB

The physician should determine the teenage patient's job tasks, responsibilities and exposures (Table 1) and consider these when formulating differential diagnoses and addressing medical management.

At least 38 percent of adolescent work-related deaths are associated with illegal work activities.² The physician who learns that the patient's job duties or hours violate wage or hour rules should be alerted to the additional possibility of health and safety violations. At a minimum, the physician should advise the patient that the work is illegal and may be dangerous, understanding that the young worker may nevertheless need the job and that other options may be scarce. With the teenager's consent, the physician should include parents or legal guardians in this discussion.

Even legally permitted work may pose potential hazards, and the physician should counsel the young worker accordingly. Table 5 presents some information resources for the physician and the patient.

ASK ABOUT WORK HOURS

The FLSA only regulates the hours of work for 14- and 15-year-olds, although state laws and regulations may cover older teenagers. The physician can play an important role in protecting the adolescent from the hazards of excessive work hours by asking about time available for homework and other activities. When necessary, the physician should encourage the patient to modify work time and priorities.

Teenagers and others who work during the early morning or late evening, especially in retail trade or service establishments such as gasoline stations, are at increased risk for assault and should be encouraged to ask their employers to adjust their hours. Working alone in these situations increases the risk and, at a minimum, teenagers should be encouraged to refuse to work alone during these hours.

DISCUSS PROTECTIVE MEASURES

Protective gear such as gloves, hard hats, safety shoes, goggles or respiratory protection may be necessary for some jobs; this necessity usually signals exposure to hazardous substances. This type of exposure is prohibited for teenagers, except in supervised educational environments such as vocational-technical programs. Even then, these exposures remain a health and safety hazard. Drawing on some of the same strategies used when advising teenagers to wear bicycle helmets, physicians should encourage adolescent workers to ask for and use safety equipment on the job.

REVIEW LEGAL RIGHTS AND RESPONSIBILITIES

Table 6 summarizes some of the most essential occupational health and safety rights relevant to teenagers and provides information resources. Frequently overlooked is the right of teenagers who suffer a work-related injury or illness to receive workers' compensation benefits for medical and rehabilitation expenses and, in some cases, lost wages. Eligibility and benefits vary from state to state. Teenage workers and their parents or guardians should be advised of this right and of the strict time limits for providing the employer with notice of the injury and filing a claim.