Address correspondence to Nora Pfaff, MD, Department of Pediatrics, University of California, San Francisco Benioff Childrens Hospital, 550 16th St, 5th Floor, San Francisco, CA 94143. Studies were included on the basis of population (adolescents aged 1025 years), topic (risk behavior screening or intervention), and setting (urgent care, ED, or hospital). l+PxF.wYh|:7#jvUF\A_Xr9Gs#C:Ynu,-,-AFk[,b5+"*,gbJW*;A[PA[r}Xq~jy!.N(7kF f Comprehensive Adolescent Risk Behavior Screening Studies. We report on evaluation of the network after 10 years of operation by reviewing program context, input, processes, and products to measure its progress in performing educational research that advances . High risk for SI was identified in 93.4% of yes respondents and in 84.5% of the no response group. Even patients with a current primary care provider and those who were not sexually active were interested in inpatient interventions. MI-based brief intervention to assess sexual behaviors and provide personalized treatment (STI testing, contraception) and referral for follow-up care. A majority of patients in the ED did not prefer EPT, and clinicians should address concerns if they do plan to prescribe EPT. For cannabis use screening, the authors recommend using the DISC Cannabis Symptoms (1 question): In the past year, how often have you used cannabis: 0 to 1 time, 2 times? For alcohol use screening, the authors recommend using the DSM-IV 2-item scale: In the past year, have you sometimes been under the influence of alcohol in situations where you could have caused an accident or gotten hurt? Have there often been times when you had a lot more to drink than you intended to have?, Reviews epidemiology, screening, and MI and brief interventions for substance use. We review studies in which rates of risk behavior screening, specific risk behavior screening and intervention tools, and attitudes toward screening and intervention were reported. Adolescents reported interest in receiving education about sexual health topics, such as STIs, contraception, and HIV, in the ED. The CSSRS has been validated in multiple settings (including the ED and inpatient setting in patients with mental health problems). When implementing an alcohol use screening and/or intervention program for adolescents in the ED, it is important to minimize workflow disruption caused by the program and provide adequate education to achieve staff participation. of Items and Format Age-group and Any Languages / Reading Level if Specified Administration and Scoring Time Training a Source Initial Psychosocial Assessment (Algorithm Step 2): Previsit or Intra -visit Data Collection and Screening Surveillance The STI testing frequency (intervention) was higher in the intervention group (52.3% vs 42%; OR 2.0 [95% CI 1.13.8]) and in asymptomatic patients (28.6% vs 8.2%; OR 4.7 [95% CI 1.415.5]). A model of 4 candidate questions (ASQ) was found to have a sensitivity of 96.9%, a specificity of 87.6%, and an NPV of 99.7%. Abstract. Data extracted were risk behavior screening rates, screening and intervention tools, and attitudes toward screening and intervention. The ED is an opportunity to screen adolescents for SI, and there are numerous (although some not validated in a hospital setting) tools that can be used for screening despite no consistent recommendations for universal screening. The authors noted that although 94% of patients in the study were documented as sexually active, only 48% of charts documented condom use, only 38% of charts documented STI history, and only 19% of charts documented the number of partners. We conducted a literature search in June 2019. The Social Needs Screening tool screens for five core health-related social needs, which include housing, food, transportation, utilities, and personal safety, using validated screening questions,. Four screening questions identified 99% of patients who had experienced IPV. Prevalence of IPV was 36.6% in screened patients. Of those who participated, 89.2% reported willingness to receive STI testing if it was recommended (regardless of reason for ED visit). A significant proportion of adolescents who screened positive for elevated suicide risk in the ED were presenting for nonpsychiatric reasons. There are limited studies on ARA screening and intervention in the ED setting; however, successful brief interventions from the outpatient setting could be feasibly implemented in the ED. Paper questionnaire to assess sexual activity, pregnancy or desire for pregnancy, interest in receiving sexual health interventions in the ED, and use of health care, Thirteen percent of surveyed adolescents (. Female adolescents and parents were generally more supportive of mental health screening (other than suicide risk) than their male counterparts. One of the best qualities of the HEEADSSS approach is that it proceeds naturally from expected and less threatening questions to more personal and intrusive questions. RCT, randomized controlled trial; , not present; +, present. ED clinicians acknowledged the importance of depression screening. Research on clinical preventive services for adolescents and young adults: where are we and where do we need to go? In a 2011 systematic review of substance use screening tools in the ED, the authors concluded that for alcohol screening of adolescent patients, the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) 2-item scale was best, with a sensitivity of 88% and a specificity of 90% (likelihood ratio of 8.8).55 For marijuana screening, they recommended using the Diagnostic Interview Schedule for Children (DISC) Cannabis Symptoms, which is reported to have a sensitivity of 96% and a specificity of 86% (likelihood ratio of 6.83) and is composed of 1 question. Computerized survey to assess sexual history and interest in interventions in the ED. A 2-question SI screen was piloted by Patel et al50 in an urgent care setting to identify adolescents at risk for SI. Copyright 2023 American Academy of Pediatrics. In the United States, young adults are the age group least likely to receive preventive care services, despite improvements in access to care through the Affordable Care Act. Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents, HEADSS, a psychosocial risk assessment instrument: implications for designing effective intervention programs for runaway youth, Effectiveness of SBIRT for alcohol use disorders in the emergency department: a systematic review, The role of motivational interviewing in children and adolescents in pediatric care. Download ACE Care Plan - Work version ACE Care Plan - School version American Academy of Pediatrics Offers Guidance for Caring and Treatment of Long-Term Cancer Survivors Childhood Cancer Survivors: What to Expect After Treatment News Releases Policy Collections Advocacy The State of Children in 2020 Healthy Children Secure Families Strong Communities The American Academy of Pediatrics on Monday recommended that all children over the age of 2 wear masks when returning to school this year, regardless of vaccination status. This demonstrates that we do not viewyouth only in the risk context. Documentation of sexual history in hospitalized adolescents on the general pediatrics service, Addressing reproductive health in hospitalized adolescents-a missed opportunity, Documentation of sexual and menstrual histories for adolescent patients in the inpatient setting, Sexual-history taking in the pediatric emergency department, A computerized sexual health survey improves testing for sexually transmitted infection in a pediatric emergency department, Brief behavioral intervention to improve adolescent sexual health: a feasibility study in the emergency department, Examining the role of the pediatric emergency department in reducing unintended adolescent pregnancy, A pilot study to assess candidacy for emergency contraception and interest in sexual health education in a pediatric emergency department population, Factors associated with interest in same-day contraception initiation among females in the pediatric emergency department, Identifying adolescent females at high risk of pregnancy in a pediatric emergency department, Characteristics of youth agreeing to electronic sexually transmitted infection risk assessment in the emergency department, Development of a sexual health screening tool for adolescent emergency department patients, Preferences for expedited partner therapy among adolescents in an urban pediatric emergency department: a mixed-methods study [published online ahead of print March 14, 2019], Developing emergency department-based education about emergency contraception: adolescent preferences, Using the hospital as a venue for reproductive health interventions: a survey of hospitalized adolescents, Acceptability of sexual health discussion and testing in the pediatric acute care setting, Adolescent reproductive health care: views and practices of pediatric hospitalists, Pediatric emergency health care providers knowledge, attitudes, and experiences regarding emergency contraception, Development of a novel computerized clinical decision support system to improve adolescent sexual health care provision, Utility of the no response option in detecting youth suicide risk in the pediatric emergency department, Ask Suicide-Screening Questions (ASQ): a brief instrument for the pediatric emergency department, Adolescent suicide risk screening in the emergency department. Fein et al49 describe successful implementation of a more broad behavioral health screen: the BHS-ED, which is used to assess for mood and behavioral health issues as well as associated risks, such as substance use. Use of a visual reminder, such as a HEADSS stamp, on patient charts may increase rates of adolescent psychosocial screening in the ED. By continuing to use our website, you are agreeing to, https://www.cdc.gov/healthyyouth/data/yrbs/index.htm, www.aap.org/en-us/advocacy-and-policy/aap-health-initiatives/adolescent-sexual-health/Pages/Assessing-the-Adolescent-Patient.aspx, www.pediatrics.org/cgi/content/full/123/4/e565, www.pediatrics.org/cgi/content/full/122/5/e1113, https://doi.org/10.1097/PEC.0000000000001746, www.pediatrics.org/cgi/content/full/128/1/e180, HEADSS assessmentbased interview conducted by resident physicians, HEADSS-based psychosocial screening by admitting physician, HEADSS stamp placed on patient charts to serve as a visual reminder for ED clinicians to complete psychosocial screening, The HEADSS assessment rate increased from <1% to 9% (, Tablet-based survey to assess risk behaviors, technology use, and desired format for risk behavior interventions, For each category of risk behavior assessed, 73%94% of adolescents (, Youth and Young Adult Health and Safety Needs Survey completed by HPAs. Survey to assess sexual history, sexual health knowledge, and desire for sexual health education. Health risk behaviors in adolescents with chronic conditions, Health risk screening in adolescents: room for improvement in a tertiary inpatient setting, Hospital readmission of adolescents and young adults with complex chronic disease, Systematic review or scoping review? More prospective controlled studies are needed to evaluate such interventions in ED and hospital settings. After a title and abstract screen, 75 studies remained. Self-disclosure screening tools have been shown to increase privacy and disclosure of sensitive information by adolescent patients when compared with face-to-face screening by a clinician.68 The use of technology and creation of electronic self-disclosure screens may further provide means to maintain comfort and patient privacy while streamlining workflow and maximizing efficiency for clinicians, particularly when a reminder to screen is integrated.21,22 Special consideration should be given to the interplay between documentation of sensitive information in the EHR and the privacy and confidentiality crucial in screening for adolescent risk behaviors.69 One strategy to mitigate possible breaches of confidentiality with EHR documentation is to mark risk behavior screening notes as sensitive or confidential, thus preventing parents or guardians from access to the note (an option that is available on most EHR software). Geopolitical boundaries do not circumscribe health issues and nowhere is this more obvious than in Los Angeles. Pediatrics. The elements of sexual history most frequently documented were sexual activity (94%), condom use (48%), history of STIs (38%), number of sexual partners (19%), and age at first intercourse (7%). Copyright American Academy of Pediatrics. This study was determined exempt by the Institutional Review Board at the University of California, San Francisco. MI avoids confrontation, and the authors note that both of these evidence-based tools work with a patients readiness to change and build awareness of the problem, resulting in increased self-efficacy for the adolescent.59. Documentation of sexual activity screening of adolescents was low in both ED and hospital settings. Completely updated and revised for new diagnostic criteria, this toolkit provides practical guidance and fillable forms to help you turn your practice into a medical home for children with ADHD. In 75% of cases in which risk behaviors were identified, interventions were provided. Six of 46 studies that were included in our review were focused on comprehensive risk behavior screening and/or interventions (across all risk behavior domains), as summarized in Table 2. These funders played no role in the study design, analysis, or preparation of this article. Youth presenting to the ED are at elevated risk of ARA (with reported prevalence of up to 55%). Please note, Internet Explorer is no longer up-to-date and can cause problems in how this website functionsThis site functions best using the latest versions of any of the following browsers: Edge, Firefox, Chrome, Opera, or Safari. Twelve studies on mood and SI screening and intervention were included in our review; 11 took place in the ED setting, and 1 took place in the urgent care setting (Table 4). More recently, researchers evaluated a self-administered 3-item screening tool based on the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, the Newton Screen, concluding that it was a brief and effective tool for screening both alcohol (sensitivity of 78.3% and specificity of 93%) and cannabis use (sensitivity of 93.1% and specificity of 93.5%).56, In a study on the use of the Alcohol Use Disorder Identification Test (AUDIT) tool, researchers observed differences in sensitivity based on the age group of adolescents, noting lower utility in younger adolescents.57 The National Institute of Alcohol Abuse and Alcoholism 2-question screen, a self-administered tool via tablet that features 2 different questions for middle schoolaged versus high schoolaged adolescents, was found to be a valid and brief way to screen for alcohol use in the ED.58, For positive screen results, MI and brief intervention tools, such as the FRAMES acronym (feedback, responsibility, advice, menu, empathy, self-efficacy) have been found to be effective in addressing high-risk behaviors, particularly in adolescent patients. Therefore, lower positive result screen cutoff scores may be necessary when using the AUDIT-C or AUDIT-PC in the adolescent population. Self-administered BHS-ED: computerized survey to assess substance use, PTSD, exposure to violence, SI, and depression, During the implementation period, BHS-ED was offered to 33% of patients by clinical staff. With the heterogeneity of studies included, we could only summarize findings but could not perform a meta-analysis. . Adolescents have suboptimal rates of preventive visits, so emergency department (ED) and hospital visits represent an important avenue for achieving recommended comprehensive risk behavior screening annually. In the United States, young adults are the age group least likely to receive preventive care services, despite improvements in access to care through the Affordable Care Act.1,6 Studies indicate that a majority (62%70%) of adolescents do not have annual preventive care visits, and of those who do, only 40% report spending time alone with a clinician during the visit to address risk behaviors.7,8 Screening for risk behaviors confidentially is crucial to disclosure of engagement in risky behavior and also increases future likelihood of patients seeking preventive care and treatment.9 An estimated 1.5 million adolescents in the United States use EDs as their main source of health care,10 and these adolescents are more likely to come from vulnerable and at-risk populations.11 Additionally, risky behaviors and mental health disorders are prevalent among teenagers with chronic illnesses, a group that accounts for a significant proportion of hospitalized adolescents.1214 These findings underscore the need to perform risk behavior screening and interventions, such as STI testing and treatment, motivational interviewing (MI), and contraception provision, in ED and hospital settings. 10.1542/peds.2020-020610. However, none of the patients screened positive for SI on the SIQ (comparison standard). Cohens was calculated and determined to be 0.8, correlating with a 90.7% agreement. Confidentiality, consent, and caring for the adolescent patient, Digital health technology to enhance adolescent and young adult clinical preventive services: affordances and challenges, Copyright 2021 by the American Academy of Pediatrics, This site uses cookies. All students are required to complete an observed HEADSS assessment over the course of their clerkship. H&P, history and physical; IUD, intrauterine device. Learn Steps to Improve the Care of Your Pediatric Patients with mTBI. 2003; 122(6):1387-1394; and American Academy of Pediatrics Section of Pediatric Dentistry. An MI-based intervention in the ED may be feasible and effective at promoting adolescent sexual health. Computerized health survey and guided decision-making tool for physicians in intervention arm. Falcn et al61 found that, during implementation of a standardized screening program, it was important to minimize workflow disruption and provide adequate education to achieve participant buy-in. and A.D.). The American Academy of Pediatrics (AAP) recommends screening all children for ASD at the 18 and 24-month well-child visits in addition to regular developmental surveillance and screening. In fact, in a study by Miller et al,39 parents were more accepting of sexual activity screening and STI testing than surveyed clinicians. The Generalized Anxiety Disorder (GAD-7) and the Screen for Child Anxiety Related Disorders (SCARED) helps the practitioner assess for an anxiety disorder. No documentation of sex of partners, partners STI risk, partners drug use, anal sex practice, or use of contraception other than condoms was found in charts reviewed. If your child is alert and responds to you, the head injury is mild and usually no tests or X-rays are needed. The NIAAA 2-question screen is a valid and brief way to screen for alcohol use in pediatric EDs. For example, Shamash et al36 found that the majority of adolescents did not support provision of expedited partner therapy and partner notification if an STI was identified, citing reasons such as the importance of interaction between the partner and his or her own clinician. 1 HEADSS is an acronym for the topics that the physician wants to be sure to cover: home, education (ie, school), activities/employment, drugs, suicidality, and sex. Further study of technology-based behavioral interventions is warranted. Adolescents and clinicians were highly accepting of risk behavior screening in all settings and preferred electronic screening over a face-to-face interview. Adolescent use of the emergency department instead of the primary care provider: who, why, and how urgent? *0zx4-BZ8Nv4K,M(WqhQD:4P H!=sb&ua),/(4fn7L b^'Y):(&q$aM83a hdQT Nj'8PHla8K^8nLBs7ltJ2umZi96^p&)PZ?]3^$Zc`O;|462 L-{:ZA:JmGv?Hw(ibKWyK2>{)K_P/)g?\(E~&=wAez8nsM7bvE^#FUTd1"$73;ST\ao=7S[ddf(K$7v |(|w .AFX h222W0Pw/+Q0,H/-K-0 = We report on a number of successful domain-specific screening tools validated in ED and hospital settings. As physicians, we need to ask about the context of a teen's life, and the HEADSS assessment is a good guide. Investigates different SI screening tools used in ED. In several studies, researchers found that computerized self-disclosure tools were preferred by adolescent patients, regardless of the presenting chief complaint.34,35 Regarding counseling and interventions, adolescent patients generally valued clinician-patient interactions. Pediatrics April 2021; 147 (4): e2020020610. Two of the studies took place in the hospital setting and 4 in the ED setting. Parents and adolescents were highly accepting of sexual health discussion, STD testing, and pregnancy testing in the acute care setting. Sexual history documentation was incomplete in charts of adolescents discharged from the ED with STI diagnosis. The American Academy of Pediatrics recognizes global health as an important component of general pediatrics residency training. We pooled results from both queries together and removed duplicates. The American Academy of Pediatrics (AAP) is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians. Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines flowchart of study selection. Less than half of admitted patients had documented menstrual (32.8%) or sexual history (45.9%). Mental health is an essential component of overall health. POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose. Most adolescents support suicide risk screening in the ED. There were no studies on parent or clinician attitudes toward comprehensive risk behavior screening. Similarly, in 2 qualitative studies by Ballard et al,52,53 90% to 96% of interviewed adolescents responded positively to SI screening in the ED. Providing decision support to physicians on the basis of survey results led to an increase in intervention (STI testing). Review of instruments used to assess alcohol and other drug use in pediatric patients in the ED (published in 2011; included studies published in 20002009). The majority of respondents reported they would be more likely to increase delivery of sexual health services if provided with further education.40 Clinicians expressed concerns about the acute nature of illness and injury in the ED and the sensitive nature of sexual activity screening. To access log in and visit These findings were more pronounced in adolescents without symptoms of STI (28.6% vs 8.2%; OR 4.7 [95% CI 1.415.5]).28 In a study by Miller et al29 done in the ED setting, MI was found to be a feasible, timely, and effective technique in promoting sexual health in adolescents. Fein et al49 found that with the BHS-ED, mental health problem identification increased from 2.5% to 4.2% (OR 1.70; 95% CI 1.382.10), with higher rates of social work or psychiatry evaluation in the ED (2.5% vs 1.7%; OR 1.47 [95% CI 1.131.90]). Depression increased, and the American Academy of Pediatrics declared a national emergency in children's mental health." (And to think we called you racist for pleading for open schools.) Download Emergency Department ACE form Physician/Clinician office ACE form Acute Concussion Evaluation (ACE) Care Plans ACE (Acute Concussion Evaluation) c are plans help guide a patient's recovery. Inconsistent or incomplete adolescent risk behavior screening in these settings may result in missed opportunities to intervene, mitigate risk, and improve health outcomes. There were no studies on patient or parent attitudes toward substance use screening or interventions. Overall risk of bias was as follows: low, 1 variable not present; moderate, 23 variables not present; and high, 45 variables not present. Survey to assess acceptability of sexual health discussion, STI testing, and pregnancy testing in the ED; verbal explanation of answers also obtained from participants. The 2 reviewers made joint final decisions on inclusion of studies with conflicting initial determinations. A screening tool is a standardized set of questions used to identify issues in a child that require further investigation. Eighty-two percent of patients who screened positively were referred to outpatient mental health, and 10% were admitted to a psychiatric facility. Sexual activity (patient and clinician attitudes), Computerized survey to assess acceptability and usefulness of a sexual health CDS system. FUNDING: Dr Kaiser is supported by grants from the Agency for Healthcare Research and Quality (K08HS024592 and R03HS027041). Barriers identified included time, concern about follow-up, and lack of knowledge. Twenty-five percent never conducted SBIRT (limited time and resources are barriers). Pediatricians are an important first resource for parents and caregivers who are worried about their child's emotional and behavioral health or who want to promote healthy mental development. Below we report results by risk behavior domain, with studies organized into subcategories of screening rates, screening tools and interventions, and adolescent, parent, and clinician attitudes toward screening and intervention. Most adolescents who screened positive did not have mental healthrelated chief complaints, and positive screening results led to interventions in the form of referrals (82% of positive screen results) or urgent admission to an inpatient psychiatric facility (10% of positive screen results). The DISC Cannabis Symptoms was reported to have a sensitivity of 96%, a specificity of 86%, and an LR+ of 6.83. Preventive oral health intervention for pediatricians. Pain assessment is an integral component of the dental history and comprehensive evaluation. MI and brief intervention are effective methods to address high-risk behaviors. endstream endobj 323 0 obj <>stream We first screened titles and abstracts using Rayyan software (Qatar Computing Research Institute, Doha, Qatar),17 and we resolved conflicts regarding the title and abstract screen through discussion. Details on risk level were frequently left out. Fewer than half of respondents used a validated tool when screening for alcohol use. One study that met inclusion criteria was found post hoc and included in the final review for a total of 46 studies (Fig 1). Bernstein et al20 used nonphysician providers, or health promotion advocates (HPAs), to perform risk behavior screening and were successful in standardizing comprehensive screening and intervention for adolescents in a busy ED setting by having a dedicated role for the task. The ED-DRS is a short but effective tool in screening for mental health risks and can create an environment in the ED for quick, feasible screening and intervention. The Newton Screen may be a good brief screening tool for assessing alcohol and cannabis use. Your child's doctor will want to know when and how the injury happened and how your child is feeling. Three ED studies described interventions to increase comprehensive risk behavior screening. Forty-six studies were included; most (38 of 46) took place in the ED, and a single risk behavior domain was examined (sexual health [19 of 46], mood and suicidal ideation [12 of 46], substance use [7 of 46], and violence [2 of 46]). This type of screening can identify children with significant developmental and behavioral challenges early, when they may benefit most from intervention, as . Significant strides have been made in reducing rates of cigarette smoking among adolescents in the United States. HEADS-ED is an easy-to-use screening tool that physicians, nurses, intake workers, and other mental health caregivers can use during a patient visit to identify mental health and addictions needs from early infancy to transitional aged youth. A sexual health screening electronic tool was acceptable to patients and feasible in terms of workflow in the ED. The American Academy of Pediatrics recommends that clinicians screen adolescents for substance use and, if applicable, provide a brief intervention, establish follow-up, and consider referral. In a qualitative study, researchers assessed ED physician use of screening, brief intervention, and referral to treatment (SBIRT) and found that <50% of respondents used a validated tool when screening for alcohol use.60 Common perceived barriers were time constraints, inadequate staffing, lack of knowledge of screens, and concerns about parents reactions to screening. The Sexual Health Screen reported on by Goyal et al35 presents a feasible and valid way to screen for sexual and reproductive health. We're 67,000 pediatricians committed to the optimal physical, mental, and social health and well-being for all infants, children, adolescents, and young adults. Adolescents prefer in-person counseling and target education (related to their chief complaint). For a preterm baby, it is important to use the baby's adjusted age when tracking development until 2 years of age so that his growth and progress take into account that he was born early.

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