480 Adolescent Health
perceived social support by parents and partner, and expecta-
tions regarding coping well with abortion (see Phillips,
1997a). These data suggest that abortion may be an even
more signi“cant event for teenagers than for older women.
The advent of RU-486, approved by the Food and Drug Ad-
ministration, could reduce the dif“culty and negative impact
of abortion (see Phillips, 1997a).
Live births are of concern due to a variety of physical and
psychosocial risks for the infant and mother (Neinstein,
Rabinovitz, et al., 1996; Phillips, 1997a). One of these is the
risk of teenage parenthood, which is highly likely given that
adoption has become an unpopular choice for White
teenagers (3% elect adoption) and has historically been un-
common among African American teenagers (less than 1%
elect adoption); teenage parents (especially mothers) are
likely to complete less education, be socioeconomically
disadvantaged, be unmarried in adulthood, and have more
children (see Neinstein, Rabinovitz, et al., 1996).
As with STD prevention, pregnancy prevention efforts
that have emphasized abstinence or brief education have
generally had limited success (R. Brown, 2000; Harlap,
Kost, & Forest, 1991; Metzler et al., 2000). Some programs
have had some success in postponing sexual activity among
young teenagers. For example, the Postponing Sexual In-
volvement (PSI) program was developed for eighth graders
in 16 middle schools in Atlanta and reported some effect on
delaying sexual activity past the eighth grade, although not
changing the behavior of girls who were already sexually
active (Friedman, 1998). A randomized-control evaluation
of a program for seventh and eighth graders in Washington,
D.C. used elements of the PSI intervention and found no
change in attitude toward abstinence and no effects for
males except greater knowledge of birth control method ef-
“cacy, compared with a control group; girls did more often
report virginity and birth-control use at last intercourse
(for nonvirgins; Aarons et al., 2000). In general, however,
abstinence-focused and brief educational programs have had
little impact on reducing pregnancy rates (U.S. Congress,
OTA, 1991).
Because STDs and pregnancy are the result of similar
risky behaviors, formal interventions that have had some
success and recommendations for clinical intervention with
individuals share many of the same features: targeting spe-
ci“c behaviors, skills training, attitude change, and tailoring
intervention to the individual teenager•s future goals (R.
Brown, 2000; Cates & Berman, 1999; Metzler et al., 2000;
Phillips, 1997a). Effective and consistent use of protection
may be at least as much a function of access to methods and
a sympathetic staff as it is due to gains in knowledge
(Zabin, Hirsch, & Smith, 1986). The good news is that the
adolescent birth rate has declined, with a 12% drop from
1991 to 1996; this was especially pronounced for African
American teenagers (a 21% decrease) while Hispanic
teenagers• rates have not decreased and their birth rate is
now the highest of any ethnic group in the United States
(R. Brown, 2000).SPECIAL SERVICES FOR ADOLESCENTSLegal ConsultationWhile the legal aspects of health care are relevant for all
age groups, they are particularly important for adolescents,
given their unique •in-betweenŽ status. Care providers must
become familiar with general constitutional principles,
federal statutes, and the statutes of their own states. The
most relevant issues relate to consent, con“dentiality, and
payment.
Adolescent providers confront a host of dif“cult circum-
stances in which these issues are commingled. For example,
it is common for parents to request a drug screen for their
teenager without his or her knowledge, and the parents are
paying the bill. Who controls the medical record varies from
state to state, with some denying disclosure to parents if the
minor objects and some permitting noncontingent access by
the parents. Patient-physician privilege can prevent physi-
cian disclosure in court in most but not all states (and may
not extend to nonphysicians), but medical records can be
subpoenaed. Most states permit minors to consent to treat-
ment for contraception and pregnancy, communicable dis-
eases, substance abuse, and emotional problems without
parental noti“cation, but provisions for abortion are highly
variable and controversial; in some cases, the teenager
may request a •judicial bypassŽby the court to avoid parental
noti“cation.
Successfully navigating the challenges posed by most
teenagers• legal status requires, at a minimum, that education
of adolescent health providers include the legal requirements
and guidelines that apply to diagnosis, treatment, counseling,
record keeping, and court testimony. The availability of good
legal counsel for providers is also a necessity. Finally, many
providers “nd that patient advocacy is facilitated by learning
about inexpensive legal resources that can be accessed by
their adolescent patients.School-Based Health ServicesOne obstacle to good adolescent health care is the need to learn
about and access services in hospitals and clinics, with atten-
dant problems with transportation, payment, and potential