Society for Adolescent Medicine
Position Statements and Resolutions

Access to Health Care for Adolescents (March 1992)
Position papers summary

• Universal access to a basic level of health care for all adolescents
• Individual communities must decide how and where to provide confidential, appropriate care for their adolescents
• Providers must address the concerns of their adolescent patients and must help guide their development as independent agents with regard to their health
• Far-reaching societal commitments are needed to provide quality care for all adolescents, to improve the health of youth, and to promote well-being into adulthood
• Proposals for health-care reform should be examined for their effect on adolescents using seven developed and adopted criteria: availability, visibility, quality, confidentiality, affordability, flexibility, and coordination.

• Availability
  age-appropriate services and trained health care providers must be present in all communities
  location of services and hours of operation should consider the demography and activities of the target population

• Visibility
  health services must be recognizable, convenient, and should not require extensive or complex planning by parents or adolescents-need for services on a spontaneous basis
  outreach, including education about how to use the system and about the need for preventive care is an important component of adolescent health services

• Quality
  a basis level of service must be provided to all youth, and adolescents should be satisfied with care they receive
  health professional must be able to deal confidently with a broad range of adolescent health concerns and should demonstrate a basic level of competence

• Confidentiality
  adolescents should be encouraged to involve their families in health decisions whenever possible; however, when such involvement is not in the best interest of the adolescent or when parental involvement may prevent the adolescent from seeking care, confidentiality must be assured

• Affordability
  employment-based proposal for health insurance reform must cover adolescents either as employees or as dependents
  public and private insurance programs must provide adolescents with preventive services designed to promote healthy behaviors and decrease morbidity and mortality
  provider reimbursement must reflect the additional time and intensity needed to provide appropriate care to adolescents

• Flexibility
  services, providers, and delivery sites must consider the cultural, ethnic, and social diversity among adolescents
  providers must be able to assess an individual adolescent's developmental readiness and to assist youth in making the transition between pediatric and adult care

• Coordination
  service providers must coordinate the comprehensive services that influence the health behaviors of adolescents
  when services are categorical, mechanisms must exist to help adolescents pay for and obtain necessary care from multiple sites and providers
  providers must understand and facilitate entry to specialized services for those adolescents who require them

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Firearms and Adolescents (August 1998)
Position papers summary

• Legislative and regulatory strategies to reduce availability of the primary source of firearms (e.g., handguns) injuries among adolescents, including restricting the purchase and possession of handguns by private citizens.
• Regulations to reduce the severity of injuries from firearms by reductions in the destructive power of ammunition.
• Adolescent health care providers to incorporate regular violence-prevention counseling into their health care activities.
• The involvement of adolescent health care providers in public education campaigns about the dangers of guns and the need for gun control.
• Participation by providers in the development of strong and active coalitions that bring together community members with diverse perspectives and expertise to promote the development and implementation of multidimensional, scientifically based strategies, interventions, and legislation to reduce firearm violence.
• To identify, treat, and make appropriate referrals for youth at high-risk for firearm injury, including those with depression, physical fighting, history of weapon-carrying, substance use, or exposure to family violence.
• Research on firearm violence, including the scope of the problem on firearm injuries among youth, risk and protective factors for involvement in firearm violence and the effectiveness of intervention strategies to reduce firearm morbidity and mortality.

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Adolescent Inpatient Units (April 1996)
Position papers summary

• Advocates the continuation and establishment of adolescent medicine inpatient units in both pediatric and general hospitals as an optimal approach to the delivery of developmentally-appropriate health care to hospitalized adolescents.
• Units should be geared to meeting the psychosocial needs of adolescents and the training needs of health professional students.
• In those hospitals in which there are too few admissions of adolescents to warrant a separate adolescent unit, a multidisciplinary team of health care professionals with expertise in adolescent health should set guidelines and policies for, as well as provide consultative services to hospitalized adolescents; whenever possible, teenagers admitted to such hospitals should be placed with other teens, rather than with older adults or infants or young children.

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Adolescent Medicine (February 1995)
Position papers summary

• Adolescent Medicine applies to the health care, professional training, health research, and advocacy related to persons age 10 to 26 years.
• Applies to the provision of both primary and specialty care.

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Clinical Preventive Services for Adolescents (September 1997)
Position papers summary

• Educational efforts should be developed to enhance public and professional recognition of the merit and value of adolescent preventive care.
• Practice guidelines are endorsed as a means to standardize the content of adolescent preventive services, improve quality, and promote consistent deliver; they are designed as tools for health care professionals and are not meant to replace individual decision-making or practice styles.
• Preventive services visits are recommended annually for adolescents to promote frequent, repetitive guidance, screening, and counseling about risk behaviors and healthy lifestyles.
• Primary care clinicians and other health care providers should receive appropriate training and preparation to provide comprehensive adolescent preventive services confidently and effectively.
• Adequate system financing and provider reimbursement are essential for the broad delivery of comprehensive adolescent preventive services.
• The health outcomes and cost-effectiveness of adolescent preventive services and their individual components should be studied.
• Adolescent preventive services should be widely available and easily accessible.
• Comprehensive preventive services for adolescents should be delivered in a manner that meets the needs of adolescents and their families; quality should be monitored to facilitate their timely and appropriate delivery and to ensure that they meet accepted standards.
• Innovative approaches should be designed and tested to expand the capacity to deliver comprehensive, cost-effective preventive services.

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Code of Research Ethics
Position papers summary

Creation of the research question and design

• SAM member scientific investigators should maintain basic competence in research methods and seek competent methodologic and analytic support when it is indicated. The principle of beneficence demands that the contribution of research subjects be honored and optimized so that the objective of improving health and welfare is achieved.
• Research efforts involving human subjects should be scientifically sound and feasible while all attendant risk to subjects be made proportional to their particular circumstances.
• Research projects with little statistical probability of achieving study objectives should be avoided. Investigators are duty bound to ensure that the research experiences contributed by study subjects in good faith be evaluated and reported as understood by the subjects in the consent process.
• SAM members should consider the effect of study results on identifiable communities in which studies are conducted. Communities should be understood as sponsors and consumers of research. SAM members should make efforts to elicit and respond to community concerns during the development of research projects.
• Investigators conducting sponsored research must maintain independence. This extends to study design, conduct, interpretation, and reporting of study results. Investigators must always be aware of their moral obligation to hold the public interest above the interest of sponsors if a conflict arises.
• Investigators should undertake animal experimentation only to advance knowledge, when known alternatives are scientifically inadequate, and when scientifically valid conclusions will be possible. Study design must ensure respect and due concern for animal health and welfare.

Formal review process

• SAM members should strive for honest appraisal of their own limitations, seeking peer review of research initiatives, making efforts to learn from critical evaluation, and assuming good faith on the part of colleagues. No member should discriminate against or harass colleagues who have offered criticism nor should a member retaliate against a colleague who raises concerns about a member's misconduct.
• Investigators must obtain objective ethical review of proposed projects before contact with human subjects. These reviews are generally conducted by institutional review boards (IRBs). Researchers should adhere to requirements imposed by IRBs.
• Investigators must be alert to conflicts of interest, prudently engage in relationships that might precipitate such conflicts, and disclose such conflicts to the affected parties. Investigators are required to disclose all relevant financial, personal, or professional relationships that might lead to a conflict of interest, for themselves and their family members, to their institutions, in their writings and public speeches, and to the sponsors of their research funding.

• SAM members must honor the role of parents or guardians in the lives of adolescents and carefully balance the developing maturity of the adolescent with the benefits of adult engagement in the research process8. Adult involvement becomes increasingly important if adverse consequences are possible from research with higher levels of inherent risk.
• SAM members, in their work with adolescent research subjects, should respect the adolescent's evolving intellect, judgment, and experience. The adolescent's capacity for independent decision-making should be respected in a careful balance of the individual adolescent's experience and personal circumstances with the inherent research risks. The adolescent's right to autonomy must be honored in the research process with clear, patient, and complete explanations of the research and implications which can be readily understood by the adolescent⁸.

Management of study data

• The investigative team is obligated to honor the consent agreement related to the confidentiality of subject information. Consent agreements should explicitly note the circumstances in which there are limits on confidentiality in the professional-client relationship (e.g. child abuse reporting requirements). SAM investigators should ensure that there is a written confidentiality policy understood and adhered to by the full team which addresses both verbally shared and recorded information collected on subjects. The principal investigator is responsible for the integrity of the system.
• In general, information maintained in study databases should not include personal identifiers. In special circumstances, viz. database linkage requiring personal identifiers, investigators assume greater responsibility for providing additional protections for the confidentiality of the information. Under no circumstance may databases which include direct or potential personal identifiers be made available to investigators external to the original IRB-reviewed investigator team and project unless specific subject consent for that practice has been expressly obtained.
• Research records should be maintained for a minimum period of five years after publication for reference purposes if questions arise. The integrity of the scientific process rests on the capacity to challenge and question and the existence of the primary data source makes the process possible. Investigators must keep in mind that the end of the process is not publication but the advancement of knowledge.
  Authorship
• Primary or submitting authors assume responsibility for the contents of the manuscript and the accuracy of all primary data, for determining all legitimate coauthors, and specifying the order in which the authors' names appear⁴
• Legitimate coauthors are those who make significant scientific contributions to the work and who share responsibility for the results. An author is first of all a writer and the criterion of merit is the advancement of knowledge9. Authors must substantially contribute to each of three activities: (1) conception and design, or analysis and interpretation; (2) drafting the article or revising it critically for important intellectual content; and (3) approval of the final version to be published10 .
• Granting honorary authorship is an unacceptable practice. Individuals with contributions not meriting coauthorship should be acknowledged; such contributions include clerical assistance, arranging for research subjects, and computer programming.
  The scientific contributions of students must be acknowledged.
  Scholars are obligated to acknowledge the use of the intellectual property of others.
• Teachers and mentors are not to appropriate the work of students as their own.

Responsibility to disseminate study results

• Researchers must truthfully report study data. Lying, misrepresenting, falsifying, or selectively reporting only favorable data are all reprehensible practices.
• After the original investigator has completed analysis and all prior rights to publication are satisfied, and unless specifically prohibited by provisions of the subject consent process or the proprietary nature of the data, investigators should open access to research databases to competent and qualified researchers. The original IRB-reviewed investigator must ensure that no personally identifying data exist in shared databases including the capacity to link database information with other sources to identify subjects. It is expected that the requesting investigator will bear the expense of the project. This practice of data-sharing furthers the advancement of knowledge by expanding the scope of the original study question through ancillary analyses and optimizes the societal benefit to be derived from the contributions of study subjects.
• If datasets are particularly complicated or the conditions under which the data were collected may affect the interpretation of results, it is appropriate for the original investigator to suggest a collaborative relationship in order to fully share all aspects of the research design, data collection procedures, and unique features of the database for the purpose of ensuring accuracy. This collaborative relationship does not imply automatic authorship on resulting publications; the criteria for authorship must be met.
• SAM members should decline participation in peer review if it poses a conflict of interest for them. Conflicts of interest should not be narrowly defined by institutional or financial relationship but should extend to any situation in which a reviewer knows s/he cannot deliver a fair and objective review. No reviewer should use the review process to further his/her own research by unnecessarily delaying the publication timetable or appropriating the work of others entrusted for review.
• SAM members should consider the effect of study results on the communities in which studies are conducted. SAM members should make efforts to insure that study results are provided to guide and support relevant community programmatic initiatives. SAM members should be committed to the improvement of the communities in which adolescents live. Communities which have provided support, volunteer time, or accepted intrusion into their privacy should be provided with a thorough review of research findings.

• All SAM members, whether they are involved in a formal institutional training program or not, should consider mentorship and the training of junior investigators a professional responsibility. All members are obligated to act as exemplary role models adhering to the highest standards of conduct.
• SAM members who function within training and educational programs should ensure that values and ethical principles governing research are understood by trainees and students. This process should be formal and systematic not haphazard or assumed.
• Effective and beneficent mentoring is premised on respect for the junior partner. It elicits initiative and independent thinking while providing guidance and supervision. Mentors must assiduously avoid acting in their self-interest at the expense of their junior partners.
• SAM members must hold each other accountable in the conduct of research. Preserving the integrity of the research process and thereby maintaining and enhancing the good will of our larger society demands vigilance and engagement from us all. SAM members must be willing to advise and confront and, failing resolution, report concerns to appropriate authorities for private investigation.
• SAM members should approach this duty respectfully and confidentially and never exploit the situation for character assassination or personal gain.

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Confidential Care for Adolescents in the Health Care Setting (December 1997)
Position papers summary

• Health providers should inform adolescent patients and their parents, if available, about the requirements of confidentiality, including a full explanation of what confidential care entails and the conditions under which confidentiality might be beached.
• Health providers must remain flexible when delivering confidential care to adolescents. Blind adherence to absolute confidentiality, or absence of confidentiality (in deference to parental wishes), is neither desirable nor required by ethics or law.
• Health providers should develop a disclosure plan for those adolescents who are deemed not to have capacity to give informed consent or for whom disclosure of information to responsible adults becomes necessary which involves adolescent wishes about the manner in which information is shared.
• Confidentiality considerations regarding record keeping are necessary. Health providers must consider the manner in which written and electronic medical records might be available to parties in ways that verbal communication are not, and in ways that would be objectionable to adolescent patients.
• Expanded efforts are needed to increase the education of health professionals regarding the laws and regulations in their jurisdiction relating to confidentiality and informed consent for adolescents. In addition, specific training is needed to increase providers' skills in effectively and appropriately incorporating confidentiality into clinical practice.
• Further research is necessary to evaluate the process of maintaining confidentiality. These investigations should include studies of the attitudes of adolescents related to confidentiality, specific influences of gender and race/ethnicity, provider and parental attitudes about confidentiality, and the approaches necessary to allow professional practices to optionally meet ethical and legal requirements.

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Corporal Punishment (May 1992)
Position papers summary

• Corporal punishment in schools in ineffective, dangerous, and an unacceptable method of discipline.
• Recommends banning and urges that nonviolent methods of classroom control be utilized in school systems.

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Driver Education (December 1997)
Position papers summary

• Legislation allowing for early licensure of adolescents who have completed a driver education course be eliminated until such time as those courses demonstrate a reduction motor vehicle collisions, fatalities, and injuries among the young.
• Provisional or graduated licensing plans require evaluation before implementation.
• Research and evaluation be conducted on the components of driver education, its delivery, benefits, and effects on motor vehicle collisions.

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Eating Disorders in Adolescents (June 1995)
Position papers summary

Diagnosis
The diagnosis of an eating disorder should be considered in an adolescent patient who engages in potentially unhealthy weight-control practices and/or demonstrates obsessive thinking about food, weight, shape or exercise, and not only in one who meets established diagnostic criteria.

A diagnosis of an eating disorder should be considered if the teenager fails to attain or maintain a health weight, height, body composition or stage of sexual maturation for gender and age.

Medical Complications
The threshold for intervention in adolescents should be lower than in adults.

Medical monitoring should continue until the adolescent has demonstrated a return to both medical and psychological health .

Nutritional Disturbances
Evaluation and management of nutritional disturbances in eating disordered adolescents should take into account the specific nutritional requirements of patients in the context of pubertal development and activity level.

Psychosocial Disturbances
All adolescents with an eating disorder should be evaluated for co-morbid psychiatric illness .

Mental health intervention should address not only psychopathology characteristic of eating disorders, but also the accomplishment of the developmental tasks of adolescence and the specific psychosocial issues central to this age group.

For most adolescents with an eating disorder, family therapy should be considered as in important part of treatment.

Treatment Guidelines
Require evaluation and treatment focused on biological, psychological and social features of these complex, chronic health conditions.

Assessment and ongoing management should be interdisciplinary and are best accomplished by a team consisting of medical, nursing, nutritional and mental health disciplines.

Treatment should be provided by health care providers who have expertise in managing adolescent patients with eating disorders and are knowledgeable about normal adolescent physical and psychological development.

Hospitalization is necessary in the presence of malnutrition, physiologic evidence of medical or psychiatric decompensation ,or failure of outpatient treatment.

Ongoing treatment should be delivered with appropriate frequency, intensity, and duration.

Barriers to Care
Adolescents with eating disorders should not be denied access to care because of absent or inadequate health care coverage.

Coverage should provide reimbursement for outpatient and inpatient interdisciplinary treatment that is dictated by the severity of the clinical situation and takes into account the developmental needs of the patient.

Managed care agencies should work with adolescent health care providers in defining appropriate strategies for the management of adolescent with eating disorders.

Research
Carefully evaluate those aspects of eating disorders particularly relevant to the adolescent age group, including outcome studies of early intervention and randomized treatment trials when appropriate.

Call on private and public agencies to provide necessary funding to allow for advancement of knowledge in the prevention, etiology, and management of eating disorders in adolescents.

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Guidelines for Adolescent Health Research (November 1995)
Position papers summary

Endorses research conference proceedings as a reasonable interpretation of federal guidelines when conducting research with adolescents.

Guidelines

• For health research with adolescent minors that does not pose greater than minimal risk, the requirement of parental permission may be waived, provided that the institutional review board (IRB) has found that the following conditions for the protection of human subjects are met: 1) the investigator have ensured the privacy and confidentiality of the study participants; 2) the informed consent of each adolescent participate is obtained; 3) investigators encourage each adolescent to seek the support of a parent or another adult prior to participation in the research; and 4) the investigators have established procedures to allow adolescents to seek assistance on a confidential basis after completing surveys containing questions that may raise issues for which adolescents may desire further information or assistance.
• For research involving potentially beneficial procedures or interventions that entail greater than minimal risk but hold out the prospect of direct benefit to the individual subject, investigators must undertake a thoughtful and honest attempt to encourage minor adolescents to involve their parent(s) in the consent process. If, after these attempts, seeking parental permission is found not to be reasonable, or if the minor declines parental involvement, a minor may provide consent provided that the IRB has found that the following conditions for the protection of human subjects are met: 1) the investigators have ensured the privacy and confidentiality of the study participants; 2) the informed consent of each adolescent participant is obtained; 3) in the absence of parental involvement, the adolescent will be assisted by clinical staff other than the investigator to identify an adult who understands the adolescent's situation, is committed to the adolescent's well-being, and is willing to provide necessary emotional support. This adult will not be required to assume a formal, legal role in relation to the adolescent; and 4) an appropriate trained professional (e.g., psychologist, masters level social worker or nurse, physician), not directly involved in the research, has confirmed the capacity of the adolescent as a mature minor to give informed consent by finding evidence of: a) cognitive ability to comprehend the objectives and requirements of the research and other important considerations (e.g., the voluntary nature of participation, the potential of risks and benefits) as would be required for a competent adult; b) reasonable judgment as evidenced by the ability to address problems, to foresee the long-term consequences of action or inaction, and to evaluate the validity of information; and c) personal responsibility to be able to comply with the requirements of the research protocol, especially those designed to ensure individual safety.
• For research involving greater than minimal risk and no prospect of direct benefit to the individual subject but likely to yield generalizable knowledge about the participant's disorder or condition, participation in this type of research, in general, should require both adolescent assent and parent/guardian permission. Research that presents more than a minor increase in risk over minimal risk and no prospect of direct benefit can be conducted with minor adolescents but only under extraordinary circumstances.
• For all research not otherwise approvable that presents an opportunity to understand, prevent, or alleviate a serious problem affecting the health or welfare of minor adolescents, federal regulations require an extraordinary process involving the Secretary of Health and Human Services after consultation with a panel of experts in pertinent disciplines. Such extraordinary cases when they involve adolescent minors should be handled on a case-by-case basis and should incorporate the general principles of these guidelines.
• Research conducted in health care settings (e.g., clinics, physician offices, hospitals) includes research of varying degrees of risk and benefit. In these settings consent for health care may be obtained directly from the minor adolescent under various states laws. In situations where minor adolescents are permitted to give their own consent for clinical care, adolescent informed consent may often serve to provide adequate protection for research purposes, subject to the guidance regarding waiver of parental consent as described above. In these circumstances, the consent procedure for research should insure that the adolescent understands the separate purposes and procedures involved in the research.

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Health and Health Needs of Homeless and Runaway Youth (December 1992)
Position papers summary

Data Collection and Research
Support worldwide scientific conferences on health care and health needs of runaway and homeless youth.

Encourage systematic collection of data on the physical health, mental health, and other needs of homeless and runaway youth.

Support rigorous research on the causes of runaway behaviors.

Encourage membership to further define the scope of the problems facing this population, delineating service needs, professional training needs, and creating a research agenda.

Supports research to identify the etiologic factors in runaway behavior

Support research designed for early recognition and prevention of runaway behavior at family, school, and street levels.

Prevention
Support programs of health education for street youth including the development and dissemination of educational materials.

Support programs of education and training related to homosexuality for professionals working with children, youth, and families.

Support for training within service delivery agencies.

Support interdisciplinary graduate level training which includes the development of curricula and the development of a stipend fellowships in adolescent medicine.

Services
Encourage creative multidisciplinary service strategies.

Support continuity of care, including case management and follow-up services.

Support collaborative efforts to track street youth.

Support provision of specialized services for street youth with chronic illnesses.

Support outreach education about the network of services, including available legal services.

Support outreach programs to all youth, including outreach workers, mobile units and the media.

Support long-term transitional housing and appropriate services that include supervision, training for independent living skills, in-depth medical screening, evaluation and treatment, and psychological evaluation and treatment.

Support specialized health services for pregnant and parenting street youth including family planning counseling and comprehensive primary health care.

Target preventive services to youth in juvenile justice settings.

Substance abuse assessment, referral, and treatment should be incorporated into outreach, shelter, and primary health-care services.

The health care of street youth should be given a priority by the National Health Services Corps with assignment of corps professionals to locations where there are large numbers of street youth and a provider scarcity.

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Hepatitis B Immunization (May 1995)
Position papers summary

• Recommend universal hepatitis B immunization for all adolescents.

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HIV Infection and AIDS in Adolescents (July 1994)
Position papers summary

Epidemiology
Increase serosurveillance studies to determine the level of infection and the antecedent risk factors for HIV infection.

Augment basic epidemiological data with information concerning the presentation and course of HIV infection in adolescents.

Develop a consensus on adequate definition of "adolescence," "youth," or other appropriate descriptive construct and standardize this across all reporting lines.

Develop a calculated national projection of HIV infection among adolescents using data from selected cities, as well as suburban and rural areas throughout the United States.

Clinical Profile and Medical Care
Guarantee access to diagnostic testing necessary to determine the presence and progress of conditions and infections common in all adolescents as well as those likely to occur in HIV infected youth including, but not limited to a)an age-appropriate history and physical examination including a careful history of living situation, lifestyle, sexual orientation, actual sexual behaviors and practices, and substance use (this should occur in a nonjudgmental and supportive manner and be conducted by a knowledgeable, sensitive, health care provider trained in both adolescent health care and HIV issues); b)serologic tests and cultures for sexually transmitted diseases, opportunistic infections, and related malignancies; c)markers of immune system competence (CD4 lymphocyte subset evaluation) and indicators of treatment success or failure; and d)proper staging of HIV disease based on Centers for Disease Control and Prevention criteria.

Assure the availability of ready access to therapeutic modalities to treat conditions common in all adolescents as well as those particularly prevalent in HIV infected youth including: a)psychological support services including individual, family, and group counseling and therapy; b)social support services including assistance with obtaining entitlements, securing food, housing, continuing education and/or employment opportunities and problems related to potential or experiences of discrimination due to HIV status; c)access to medical treatments including zidovudine (AZT), ddI, ddC, and other approved antiviral agents; prophylaxis for opportunistic infections (such as Pneumocystis carinii, Mycobacterium avium intracellulare, Toxoplasma gondii, etc.); conditions whose treatment and course are altered by the presence of concomitant HIV infection (i.e., TB, syphilis); and immunizations for common preventable infections including Hepatitis B; d)access to clinical trials, preferably in a setting geared to youth. This program should make available a wide array of protocols covering a range of HIV-related health problems including primary infection, opportunistic infection, and perinatal transmission; e)provision or referral for related services such as drug treatment, prenatal care, housing; f)provision of appropriate, informed and nonjudgmental options, including counseling to pregnant adolescents and appropriate protocols to ensure the referral of infants born to infected mothers.

Create regional care networks organized under the auspices of the Society for Adolescent Medicine in cooperation with existing centers (HRSA funded programs and others) that will ensure that all adolescents will have access to appropriate HIV specific services.

HIV counseling and Testing
Develop counseling and testing services specifically oriented to the developmental and psychosocial needs of adolescents. These should be widely available, efficient, and inexpensive and should adhere to the following guidelines and principles: a) there should be no mandatory HIV testing of individual adolescents or population groups as a prerequisite for admission to programs, services, or placements; b) there should be no involuntary routine HIV testing of adolescents; c) an adolescent should not be tested for HIV without consent; informed consent should be obtained from the adolescent if the adolescent is capable of consenting or, if the adolescent is not capable of giving consent, consent should be obtained from some other person with appropriate legal authority or from a court.

Foster the recognition of specific indications for testing an adolescent and use these indications as an active guide as to whom to offer testing. Testing should be offered to: a) anyone who voluntarily requests testing; b)anyone who has signs or symptoms consistent with HIV infection without an alternative etiologic diagnosis; c) anyone who currently engages in or previously has engaged in high-risk behavior; d) anyone who has a history of sexually transmitted disease; e) anyone who is pregnant and either is known to be at increased risk for HIV infection based on reported personal behavior or is unknown risk; f) anyone who has history of sexual abuse; or g) anyone who received multiple transfusions or clotting factor infusions between 1978 and 1985.

When indicated, conduct HIV testing based on clinical criteria or an appropriate request of an adolescent, in settings where pretest and post-test counseling that is sensitive, age-appropriate, and culturally appropriate is available. Confidential testing is preferred because it more readily allows the immediate provision of medical and support services to be offered to the adolescent. However, anonymous HIV testing services should also be available for the adolescent who prefers to be tested in this manner. This modality of testing is often preferred by older or emancipated adolescents. If anonymous testing is provided, efforts need to be made prior to offering these services to a particular adolescent to ascertain if he/she will be responsible in returning for results and if an appropriate support mechanism is in place to help them cope with a positive test result. Whether the testing is confidential or anonymous, special preparations should be made, including training of staff, to ensure that services are appropriate to the adolescent age group. In each case in which HIV testing is offered to an adolescent: a) the offer to test an adolescent should be made only after individualized counseling which develops a personalized client-risk assessment including evaluation of the adolescent's sexual, behavioral, medical, and psychological history and weighing of the possible risks and benefits of testing; b) the counseling should result in a personalized plan for the adolescent client to reduce the risk of HIV infection/transmission; c) the counseling should include an explanation to the adolescent of the circumstances under which the test results will be disclosed and to whom; and d) the identification and participation of a supportive adult should be encouraged and if an adolescent is unable to identify such an adult, the program or health care professional providing the testing should assist the adolescent in identifying someone.

Strictly maintain the confidentiality of an adolescent's HIV test results and other HIV-related information.

Share HIV-related information about an adolescent among health care professionals and other services providers only with appropriate authorization. The following guidelines should be adopted: a) test results should only be released with the explicit agreement, preferably in writing, of the adolescent if the adolescent has consented to the test; or b) in those extraordinary instances when an adolescent has not consented to the test, authorization to release the test results should be obtained from someone with proper legal authority to do so as directed by order of the court.

Those with access to HIV test results should treat these results and other HIV-related information with sensitivity in order to minimize the risk of discrimination that often occurs against adolescents with HIV infection or those perceived to be at high risk for infection.

Provide extensive counseling and support to adolescents who have tested positive for HIV to enable them to inform their sexual or needle-sharing partners that they are HIV infected. Specifically: a) an offer should be made to assist them in the notification process; and b) ongoing counseling should be provided to adolescents who are initially reluctant or unwilling to inform their partners to help them to understand the importance of doing so.

Provide access to HIV testing and follow-up care to adolescents in juvenile detention or correctional facilities, foster care, or the mental health system. Specifically: a) they should be able to receive careful assessments, pre-test and post-test counseling, and confidential HIV testing if appropriate; b) they should be tested only with their voluntary informed consent; and c) the privacy of these young people should be protected to the maximum extent possible, although legal requirements applicable to youth in these systems may sometimes place limitations on the confidentiality of information, or on who makes decisions concerning disclosure.

Ensure that facilities and health care professionals offering HIV testing to adolescents provide linkage to treatment, take steps to ensure that adolescents who are tested for HIV have access to necessary health care, and implement HIV testing of adolescents on a wide-spread basis only after the appropriate linkages are in place. Specifically, linkages must be established enabling adolescents who are tested for HIV to obtain: a) primary health care; b) specialized diagnostic and treatment services related to HIV infection, including early intervention services; and c) ongoing mental health services to assist in dealing with the diagnosis.

Special Populations
Address the needs of special populations of adolescents at federal, state, and local government levels. Comprehensive health care services should be available to these youth, and targeted prevention projects should be available to help reduce their risk of infection. Programs should be gender and culturally sensitive.

Remove potential barriers to health care for all adolescents, particularly those from groups deemed "special populations." Adolescents should be appropriately included in all entitlement programs, and health care reform must pay special attention to adolescents.

Prevention
Prioritize adolescent prevention interventions so that intensive HIV prevention programs are aimed at youth at greatest risk of HIV infection: young men who have sex with men, injection drug users, young men or women whose sex partners include injection drug users, young men or women with other sexually transmitted diseases, homeless and/or runaway youth, youth in detention, youth in detoxification programs.

Focus these programs on repeated contacts, aggressive follow-up, and teaching practical life skills. The use of peer educators and counselors is encouraged.

Link prevention programs to immediately available counseling and testing programs, as well as to care and treatment services.

Design prevention programs for HIV infected youth as well as HIV negative youth. These programs should focus on prevention of transmission to others and prevention of reinfection of HIV infected individuals.

Encourage and support prevention research that attempts to define the best ways to reach adolescents, influence constructive behavior, and help maintain positive changes in behavior

Introduce specific and explicit mass prevention messages and skills, optimally targeting youth ages 9-13 years. School based AIDS education should begin in kindergarten.

Consider adolescents as future candidates for therapeutic prevention interventions, including vaccines. These interventions are dependent on the provision of adequate and appropriate informed consent.

Research
Make available appropriate funding to continue to ensure that scientific observations are the basis of service-oriented projects and interventions. Key areas of research have been identified by both the Society for Adolescent Medicine and the Adolescent Advisory Group of the Health Services Research Administration and include the following: a) documentation of the natural history of HIV infection in adolescents; b) determination of successful secondary prevention efforts with HIV infected youth; c) effects of HIV testing on attitudes and behaviors.

Conduct a national survey of sexual behavior, attitudes, and knowledge in teenagers.

Plan and implement a prospective study of intensive prevention intervention that employs both biologic as well as self-report psychosocial endpoints.

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Immunization of Adolescents (August 1998)
Position papers summary

National coverage goals for 13 year olds or 8th graders should include:

State school entry requirements for 6th or 7th graders should include all recommended vaccines by the year 2002.

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Improving the Nutritional Health of Adolescents
(In press)
Position papers summary

• Insure all adolescents have access to adequately nourishing food.
• Development and maintenance of accessible, specializing health care services to assist adolescents to eat adequately, but not excessively, and to meet their nutritional needs, whether normal or modified by chronic diseases and metabolic disturbances, competitive athletics, pregnancy or other life events.
• Implementation of nutritional education, health promotion and disease prevention programs for all adolescents, especially those at increased risk for inadequate or excessive nutritional intake.
• Dedication of resources for research to determine the long- and short-term consequences of nutritional intake during adolescence, as well as the potential to improve biological conditions by altering the intake of nutritients and to positively influence food choices at this stage of life.
• Strengthen basic and advanced training opportunities in adolescent nutrition for nutritionists and adolescent health professionals, and for students preparing for these professions.

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Media Advertising of Contraceptives (October 1987)
Position papers summary

• Retired

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Meeting the Health Care Needs of Adolescent in Managed Care (April 1998)
Position papers summary

• Adolescents enrolled in managed care arrangements should have access to comprehensive coordinated care on a continuous basis. In order to achieve this it will be necessary to maximize insurance coverage, establish a comprehensive benefit package, coordinate services, offer anticipatory guidance, and provide support services to facilitate access.
• Managed care arrangements should be structured so that adolescents enrolled in managed care have access to age-appropriate adolescent-focused services and providers. In order to achieve this it will be necessary to protect the adolescents' special access concerns, recognize the needs of special populations of adolescents, assure access to adolescent-focused providers, require adolescent-specific proficiency among providers, implement adolescent specific practice guidelines, and assure fairness in prior authorization and utilization review.
• Financing mechanisms should be adequate to support services for adolescents enrolled in managed care arrangements. In order to achieve this it will be necessary for policymakers , public and private purchasers of health care, and managed care arrangements to provide for adequate capitation rates, protect the financial viability of safety net providers, and avoid inappropriate financial incentives.
• Quality goals and indicators that are adolescent-specific should be developed and implemented for monitoring managed care arrangements. In order to achieve this it will be necessary to implement adolescent-specific quality assurance, collect and report adolescent-specific data, develop adolescent-specific indicators, track utilization, measure satisfaction, and conduct further research.

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Minimum Age for Purchase of Alcoholic Beverages (June 1984)
Position papers summary

• Endorses a uniform age of 21 years to purchase alcohol in the United States, all provinces of Canada, and District of Columbia.

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Reproductive Health (December 1991)
Position papers summary

Adolescent Sexuality

• Supports and encourages the development of responsibility toward sexuality on the part of adolescents.
• Supports and encourages an awareness and acceptance by adults that sexuality is a part of adolescent development.
• Affirms the need for families to be involved in their children's sexuality education.
• Support innovative efforts to delay the age of onset of coitus in adolescents, but to affirm the importance of self-exploration and intimacy.
• The Society for Adolescent Medicine recommends an increasing the awareness of the problem of sexual abuse and to provide services to adolescents who have been sexually victimized.
• Improve the reproductive health care of adolescents with disabilities and chronic illnesses.
• Support health care and to enhance life options to meet the needs of heterosexual, gay, and lesbian youth.

Sex Education

• All states should mandate the teaching of health and sex education from kindergarten through 12th grade as part of the overall curriculum in schools.
• Content of education should include discussion of sexuality, reproduction, fertility, decision making, delaying first intercourse, abstinence, methods of contraception, abortion, parenting, and sexually transmitted disease with emphasis on HIV and AIDS, teaching risk assessment and risk reduction with the use of explicit language and illustrations applicable to the student population.
• Schools and communities have available reproductive health services including condoms.
• School personnel responsible for teaching health and sex education should have proper training in biological, psychological, and moral aspects of human sexuality and undertake a nonjudgmental approach.
• Parents should be integrally involved in the development and implementation of the sex education curriculum planned for their children.
• Sex education should not be limited to schools, but targeted to youth in high-risk situations not attending schools.
• Relevant messages about responsible sexuality and contraception should be encouraged in magazines, newspapers, movies, and television. In addition , the impact of the media on adolescent behavior needs further assessment.

Contraception

• Contraceptive education, counseling, and services should be made available to all male and female adolescents desiring such care on the adolescents' own consent without legal or financial barriers.
• Parental consent should be encouraged but not required through either consent or notification.
• Low or no cost contraceptive services should be available to male and female adolescents in communities and schools, and counseling and screening for sexually transmitted diseases and prevention strategies should be a part of contraceptive health care where follow-up care and compliance are stressed.
• Endorse contraceptive advertising on television and other media targeted to adolescents.
• Long-term surveillance of teenagers initiating oral contraceptive use is essential to assess safety. Funding of research and development for new safe, effective contraception should be a high priority for the United States.

Adolescent Childbearing and Childrearing

• Pregnancy detection and subsequent prenatal care, counseling, educational, and postnatal services (including child care) should be available and accessible to adolescents who choose to continue their pregnancies, without legal or financial barriers.
• Services should be available to the adolescent's partner and family, if she desires, and should include counseling on adoption and/or parenting.
• Services should be available on a confidential basis.
• Special needs of needs of the school-age mother, especially those < 16 years, should be recognized and intervention designed to lessen the potential for low birth weight babies.
• Counseling and screening for sexually transmitted infections should be included to prevent serious maternal and fetal sequelae.
• Interventions must be long-term and include educational and social services, health care including contraception, and vocational counseling.
• Programs should also be aimed at the needs of the infants' fathers to help them maintain meaningful contact with their infants, to augment their academic and employment skills, and to enhance their ability to be financially supportive of their children.
• Promotes the evaluation of all intervention programs to determine if elements of some programs can be replicated in other areas and determine what components are cost effective.

Abortion

• Adolescents (whether indigent or well-to-do) must have access to counseling about all options and access to elective termination of pregnancy as a legal, safe, available alternative to continuing a pregnancy.
• Adolescents should have access to abortion without legal or financial barriers and without interference from anti-abortion demonstration.
• 
  The decision to terminate a pregnancy should rest with the pregnant adolescent in concert with the advice and counsel of her physician.
• Although involvement of significant others should be strongly encouraged, particularly for minors, mandatory parental consent and/or notification should not be required.
• When determination of maturity is necessary, that determination is best made by a knowledgeable health professional.
• Encourage further research on the safety and effectiveness of new methods of abortion such as RU-486.

Sexually Transmitted Diseases

• Adolescents should have access to education, counseling, and health care services for the prevention, screening, diagnosis, and treatment of sexually transmitted diseases.
• Minors should have access to these services on their own consent.
• Education and testing for sexually transmitted diseases should be integrated into the delivery of all adolescent health care services, including those providing contraceptive and prenatal care.
• Practitioners need to be educated about the signs and symptoms of pelvic inflammatory disease and early diagnosis and treatment instituted in adolescent females.
• Condoms and foams should be widely available, and teenagers should be instructed in their use and how to integrate them into their sexual relationships.
• Risk reduction messages should be targeted to all adolescents, both those in and out of school, in a variety of settings.
• HIV-testing programs must include a continuum of counseling not limited to one session of pre- and post-test counseling and must have linked medical and psychosocial services.
• Access to HIV/AIDS services must be expanded and new protocols for AIDS clinical trials need to include age-appropriate assessments.

Training of Health Care Providers

Education about the special needs of adolescent patients, including those with chronic illness and disabilities, and the technical skills to care for problems of reproductive health and sexually transmitted diseases should be included in the curriculum of residency programs in pediatrics, internal medicine, family practice, and obstetrics and gynecology.

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School-based Health Clinics (December 2001)
Position papers summary

• School-based health centers are a valuable asset in health promotion and prevention programming for teens.
• School-based health centers provide essential access to mental health and substance use services for teens.
• School-based health centers are valuable sites for learning about interventions that best support adolescents' healthy behaviors.
• School-based health centers are well situated to minimize financial and non-financial barriers of access to care for adolescents.
• School-based health centers are well-situated to play a central role addressing the treatment of sexually transmitted infections in teens. School-based health centers recognize the need to negotiate some of the specific issues of reproductive health care on an individual school and community basis.
• School-based health centers are a valuable training site for health professionals and can model interdisciplinary and multisystem collaboration.
• School-based health centers provide a unique opportunity for research on adolescent health issues including the evaluation of outcomes related to health promotion and disease prevention as well as specific programmatic interventions.

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Sports Participation for Adolescents with Handicaps (Resolution) (November 1987)
Position papers summary

• Endorse and encourage the participation of adolescents with handicaps in all aspects of sports with appropriate guidance to minimize any health risk imposed by the handicap.

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Transition from Child-Centered to Adult Health-Care Systems for Adolescents with Chronic Conditions (November 1993)
Position papers summary

These statements reflect recommendations made by the Society for Adolescent Medicine

• Increase federal funding of model transition programs designed to meet adolescent developmental needs.
• Target existing federal research funding by prioritizing requests for proposals (RFPs) for transition-related , adolescent-focused projects.
• Sustain federal funding for the development and comprehensive evaluation of several different models of transition across a spectrum of chronic conditions.
• Collaborate with other professional medical organizations and industries with respect to transition issues.
• Include transition issues in the professional training of medical students, residents in pediatrics, internal medicine, family medicine and rehabilitation medicine, nurses and nurse practitioners, and other health-care providers stressing a shared responsibility in the treatment of adolescents and young adults.

Prepared by:
Vaughn I. Rickert, Psy.D., FSAM
Director of Publications
March 25, 1999

© 2000 Society for Adolescent Medicine
Published by Elsevier Science Inc.

These policy statements are protected by copyright. Individual copies may be downloaded and printed for the reader's personal research and study. For any other reproduction of the material in any format please contact the Publisher, Elsevier Science, either by FAX +44 1865 853333 or by e-mail on permissions@elsevier.co.uk

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