David A. Levine

School start times for adolescents

The American Academy of Pediatrics recognizes insufficient sleep in adolescents as an important public health issue that significantly affects the health and safety, as well as the academic success, of our nation’s middle and high school students. Although a number of factors, including biological changes in sleep associated with puberty, lifestyle choices, and academic demands, negatively affect middle and high school students’ ability to obtain sufficient sleep, the evidence strongly implicates earlier school start times (ie, before 8:30 am) as a key modifiable contributor to insufficient sleep, as well as circadian rhythm disruption, in this population. Furthermore, a substantial body of research has now demonstrated that delaying school start times is an effective countermeasure to chronic sleep loss and has a wide range of potential benefits to students with regard to physical and mental health, safety, and academic achievement. The American Academy of Pediatrics strongly supports the efforts of school districts to optimize sleep in students and urges high schools and middle schools to aim for start times that allow students the opportunity to achieve optimal levels of sleep (8.5–9.5 hours) and to improve physical (eg, reduced obesity risk) and mental (eg, lower rates of depression) health, safety (eg, drowsy driving crashes), academic performance, and quality of life.

Office-Based Care for Lesbian, Gay, Bisexual, Transgender, and Questioning Youth

The American Academy of Pediatrics issued its last statement on homosexuality and adolescents in 2004.This technical report reflects the rapidly expanding medical and psychosocial literature about sexual minority youth. Pediatricians should be aware that some youth in their care may have concerns or questions about their sexual orientation or that of siblings, friends, parents, relatives, or others and should provide factual, current, nonjudgmental information in a confidential manner. Although most lesbian, gay, bisexual, transgender, and questioning (LGBTQ) youth are quite resilient and emerge from adolescence as healthy adults, the effects of homophobia and heterosexism can contribute to increased mental health issues for sexual minority youth. LGBTQ and MSM/WSW (men having sex with men and women having sex with women) adolescents, in comparison with heterosexual adolescents, have higher rates of depression and suicidal ideation, higher rates of substance abuse, and more risky sexual behaviors. Obtaining a comprehensive, confidential, developmentally appropriate adolescent psychosocial history allows for the discovery of strengths and assets as well as risks. Pediatricians should have offices that are teen-friendly and welcoming to sexual minority youth. This includes having supportive, engaging office staff members who ensure that there are no barriers to care. For transgender youth, pediatricians should provide the opportunity to acknowledge and affirm their feelings of gender dysphoria and desires to transition to the opposite gender. Referral of transgender youth to a qualified mental health professional is critical to assist with the dysphoria, to educate them, and to assess their readiness for transition. With appropriate assistance and care, sexual minority youth should live healthy, productive lives while transitioning through adolescence and young adulthood.

Health Care for Youth in the Juvenile Justice System

Youth in the juvenile correctional system are a high-risk population who, in many cases, have unmet physical, developmental, and mental health needs. Multiple studies have found that some of these health issues occur at higher rates than in the general adolescent population. Although some youth in the juvenile justice system have interfaced with health care providers in their community on a regular basis, others have had inconsistent or nonexistent care. The health needs of these youth are commonly identified when they are admitted to a juvenile custodial facility. Pediatricians and other health care providers play an important role in the care of these youth, and continuity between the community and the correctional facility is crucial. This policy statement provides an overview of the health needs of youth in the juvenile correctional system, including existing resources and standards for care, financing of health care within correctional facilities, and evidence-based interventions. Recommendations are provided for the provision of health care services to youth in the juvenile correctional system as well as specific areas for advocacy efforts.

Care of Adolescent Parents and Their Children

Teen pregnancy and parenting remain an important public health issue in the United States and the world, and many children live with their adolescent parents alone or as part of an extended family. A significant proportion of teen parents reside with their family of origin, significantly affecting the multigenerational family structure. Repeated births to teen parents are also common. This clinical report updates a previous policy statement on care of the adolescent parent and their children and addresses medical and psychosocial risks specific to this population. Challenges unique to teen parents and their children are reviewed, along with suggestions for the pediatrician on models for intervention and care.

Integration strategies for using virtual patients in clinical clerkships.

Purpose To explore students’ perceptions of virtual patient use in the clinical clerkship and develop a framework to evaluate effects of different integration strategies on students’ satisfaction and perceptions of learning effectiveness with this innovation. Method A prospective, multiinstitutional study was conducted at six schools’ pediatric clerkships to assess the impact of integrating Web-based virtual patient cases on students’ perceptions of their learning during 2004–2005 and 2005–2006. Integration strategies were designed to meet the needs of each school, and integration was scored for components of virtual patient use and elimination of other teaching methodologies. A student survey was developed, validated, and administered at the end of the clerkship to 611 students. Data were analyzed using confirmatory factor analysis and structural equation modeling. Results A total of 545 students (89%) completed the survey. Overall student satisfaction with the virtual patients was high; students reported that they were more effective than traditional methods. The structural model demonstrated that elimination of other teaching methodologies was directly associated with perceived effectiveness of the integration strategies. A higher use score had a significant negative effect on perceived integration, but a positive effect on perceived knowledge and skills gain. Students’ positive perceptions of integration directly affected their satisfaction and perception of the effectiveness of their learning. Conclusions Integration strategies balancing the use of virtual patients with elimination of some other requirements were significantly associated with students’ satisfaction and their perceptions of improved knowledge and skills.

Associations between sexually transmitted disease diagnosis and subsequent sexual risk and sexually transmitted disease incidence among adolescents.

Background Empiric evidence is lacking in regard to the subsequent sexually transmitted disease (STD)-associated risk behaviors of adolescents diagnosed and treated for an STD. Goal The goal of this study was to prospectively identify associations between STD diagnosis and subsequent sexual risk and STD incidence among a sample of U.S. adolescents. Study Design A cohort of 455 adolescents (age 15–21 years) was followed for 3 months. Adolescents were recruited from primary care clinics and through outreach activities. Results A total of 10.8% were initially diagnosed with at least one STD. After adjusting for observed covariates, these adolescents (compared with those testing negative) were 2.8 times (P = 0.0001) more likely to be abstinent from sex and 2.2 times more likely to report always using condoms (P = 0.04). However, during the ensuing 3 months, they were approximately 2.4 times more likely to report having sex with multiple partners (P = 0.01), 8.9 times more likely to test positive for trichomonas (P = 0.009), and 3.0 times more likely to test positive for chlamydia (P = 0.04). Conclusions Compared with those testing negative, adolescents diagnosed with an STD may subsequently adopt safer sex behaviors, including abstinence. However, perhaps in part as a result of having sex with multiple partners, they might fail to practice safer sex behaviors stringently enough to avoid subsequent STD acquisition.

Condom Use by Adolescents

Rates of sexual activity, pregnancies, and births among adolescents have continued to decline during the past decade to historic lows. Despite these positive trends, many adolescents remain at risk for unintended pregnancy and sexually transmitted infections (STIs). This policy statement has been developed to assist the pediatrician in understanding and supporting the use of condoms by their patients to prevent unintended pregnancies and STIs and address barriers to their use. When used consistently and correctly, male latex condoms reduce the risk of pregnancy and many STIs, including HIV. Since the last policy statement published 12 years ago, there is an increased evidence base supporting the protection provided by condoms against STIs. Rates of acquisition of STIs/HIV among adolescents remain unacceptably high. Interventions that increase availability or accessibility to condoms are most efficacious when combined with additional individual, small-group, or community-level activities that include messages about safer sex. Continued research is needed to inform public health interventions for adolescents that increase the consistent and correct use of condoms and promote dual protection of condoms for STI prevention with other effective methods of contraception.

Standards for health information technology to ensure adolescent privacy

Privacy and security of health information is a basic expectation of patients. Despite the existence of federal and state laws safeguarding the privacy of health information, health information systems currently lack the capability to allow for protection of this information for minors. This policy statement reviews the challenges to privacy for adolescents posed by commercial health information technology systems and recommends basic principles for ideal electronic health record systems. This policy statement has been endorsed by the Society for Adolescent Health and Medicine.

The impact of marijuana policies on youth

This policy statement is an update of the American Academy of Pediatrics policy statement “Legalization of Marijuana: Potential Impact on Youth,” published in 2004. Pediatricians have special expertise in the care of children and adolescents and may be called on to advise legislators about the potential impact of changes in the legal status of marijuana on adolescents. Parents also may look to pediatricians for advice as they consider whether to support state-level initiatives that propose to legalize the use of marijuana for medical and nonmedical purposes or to decriminalize the possession of small amounts of marijuana. This policy statement provides the position of the American Academy of Pediatrics on the issue of marijuana legalization. The accompanying technical report reviews what is currently known about the relationships of marijuana use with health and the developing brain and the legal status of marijuana and adolescents’ use of marijuana to better understand how change in legal status might influence the degree of marijuana use by adolescents in the future.

Screening for Nonviral Sexually Transmitted Infections in Adolescents and Young Adults

Prevalence rates of many sexually transmitted infections (STIs) are highest among adolescents. If nonviral STIs are detected early, they can be treated, transmission to others can be eliminated, and sequelae can be averted. The US Preventive Services Task Force and the Centers for Disease Control and Prevention have published chlamydia, gonorrhea, and syphilis screening guidelines that recommend screening those at risk on the basis of epidemiologic and clinical outcomes data. This policy statement specifically focuses on these curable, nonviral STIs and reviews the evidence for nonviral STI screening in adolescents, communicates the value of screening, and outlines recommendations for routine nonviral STI screening of adolescents.