Adolescents in the intervention group were more likely to receive STI testing compared with those in the control arm (52.3% vs 42%; odds ratio [OR] 2.0 [95% confidence interval (CI) 1.13.8]). 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. Adolescent use of the emergency department instead of the primary care provider: who, why, and how urgent? Given that guidelines recommend universal risk screening of all adolescents, we excluded studies that were focused only on high-risk adolescents, such as patients admitted to adolescent medicine, trauma, or psychiatry services or patients admitted for toxic ingestions, suicide, or eating disorders. 321 0 obj <>stream Buy-in from physicians was difficult in the implementation phase. To access log in and visit endstream endobj 322 0 obj <>stream The ED-DRS, a nonvalidated screening tool to assess for health risk behaviors, was administered by physician trainees. This IMPACT project analyzes which factors are associated with HEADSS assessment completion and aims . This demonstrates that we do not viewyouth only in the risk context. ED physicians used SBIRT in limited and nonstandardized ways. Depression scales include the Patient Health Questionnaire 9 Modified for Adolescents (PHQ9M) and the Columbia Depression Scale can be administered universally to adolescents or used in a targeted population. Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines flowchart of study selection. Prevalence of suicidality in asymptomatic adolescents in the paediatric emergency department and utility of a screening tool, Suicide evaluation in the pediatric emergency setting, Feasibility and effects of a Web-based adolescent psychiatric assessment administered by clinical staff in the pediatric emergency department, Universal adolescent suicide screening in a pediatric urgent care center, Adolescent and parent attitudes toward screening for suicide risk and mental health problems in the pediatric emergency department, Patients opinions about suicide screening in a pediatric emergency department, Asking youth questions about suicide risk in the pediatric emergency department: results from a qualitative analysis of patient opinions, Adolescent depression: views of health care providers in a pediatric emergency department, Instruments to detect alcohol and other drug misuse in the emergency department: a systematic review, Pediatric Emergency Care Applied Research Network, Reliability and validity of the Newton Screen for alcohol and cannabis misuse in a pediatric emergency department sample, Utility of the AUDIT for screening adolescents for problematic alcohol use in the emergency department, Reliability and validity of a two-question Alcohol screen in the pediatric emergency department, Adolescent substance use: brief interventions by emergency care providers, Screening, brief intervention, and referral to treatment for adolescent alcohol use in Canadian pediatric emergency departments: a national survey of pediatric emergency physicians, Perceived barriers to implementing screening and brief intervention for alcohol consumption by adolescents in hospital emergency department in Spain, Risk factors for dating violence among adolescent females presenting to the pediatric emergency department, Adolescent relationship abuse: how to identify and assist at-risk youth in the emergency department, American Academy of Pediatrics. 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. Female adolescents and parents were generally more supportive of mental health screening (other than suicide risk) than their male counterparts. The DSM-IV 2-item scale was reported to have a sensitivity of 88%, a specificity of 90%, and an LR+ of 8.8. Computerized survey to assess sexual history and interest in interventions in the ED. l+PxF.wYh|:7#jvUF\A_Xr9Gs#C:Ynu,-,-AFk[,b5+"*,gbJW*;A[PA[r}Xq~jy!.N(7kF f In 6 studies, authors examined comprehensive risk behavior screening, demonstrating low rates at baseline (10%) but significant increases with clinician reminder implementation. The Sexual Health Screen reported on by Goyal et al35 presents a feasible and valid way to screen for sexual and reproductive health. The ASQ is a brief tool to assess suicide risk in pediatric patients in the ED and has a high sensitivity, specificity, and NPV. Already purchased? 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. Many adolescents felt the ED should universally provide education on sexual and reproductive health practices and provide contraceptive services, especially for patients who may not have access to a primary provider.25,3032 Chernick et al33 found that one-fourth of the adolescent patients in their study were interested in receiving contraception in the ED. Documentation of reproductive health and inpatient delivery of reproductive health services (STI testing and/or treatment, HPV vaccination, and contraceptive provision), Documentation: Fifty-five percent of patients had sexual history documentation. 13-20% of children in the U.S. experience a mental health disorder each year. Data extracted from the full texts included the full citation, study type, risk of bias, risk behavior domain, intervention or screening tool, results of the study, and conclusions. Adolescent Risk Behavior Screening and Interventions in the Hospital Setting. Pediatrics April 2021; 147 (4): e2020020610. This fast movement can cause the brain to bounce around or twist in the skull, creating . In an ED survey study by Ranney et al,23 for all risk behavior categories assessed, 73% to 94% of adolescent patients (n = 234) were interested in interventions, even when screen results were negative. 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. 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 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. The value of such interaction was echoed in another study in which patients preferred in-person counseling.37 However, in a cross-sectional hospital study, Guss et al38 found that patients who were interested in more information preferred learning about contraceptive options from a brochure rather than from a clinician. Guidance for authors when choosing between a systematic or scoping review approach, PRISMA Extension for Scoping Reviews (PRISMA-ScR): checklist and explanation, Rayyan-a web and mobile app for systematic reviews, Families experiences with pediatric family-centered rounds: a systematic review, Opportunistic adolescent health screening of surgical inpatients, Reaching adolescents for prevention: the role of pediatric emergency department health promotion advocates, Raising our HEADSS: adolescent psychosocial documentation in the emergency department, Mental health screening among adolescents and young adults in the emergency department. An additional 28% had partial or incomplete screening, with less sensitive issues, such as home life, education, and employment, documented significantly more often than sexual activity, depression, or drug use (P = .013). The ED-DRS, a nonvalidated screening tool to assess for health risk behaviors, was administered by physician trainees. We excluded studies that involved outpatient follow-up of patients to evaluate interventions that could be completed in the ED or hospital setting, but this may have limited our review of more longitudinal effects. Tools to aid. Fifty-seven percent of female adolescents answered that adolescents should be offered contraception in the inpatient setting (no significant difference in response between self-reported sexually active and nonactive patients). Yeo et al13 found that 10% of admitted patients at a tertiary childrens hospital had a comprehensive risk behavior assessment documented (defined as 5 of 7 domains: home, education, activities, tobacco use, drug and/or alcohol use, sexual activity, suicide and/or depression). 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. 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. Initial evaluation involves eliminating concern for cervical spine injury and more serious traumatic brain injury before diagnosis is established. Adolescents prefer in-person counseling and target education (related to their chief complaint). The goal of the training is to provide an overview of the evidence-based recommendations outlined in the CDC Pediatric mTBI Guideline and to equip healthcare . Further research is needed to assess the effectiveness of the CDS system in improving adolescent sexual health care. 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). Investigates different SI screening tools used in ED. For an initial psychosocial assessment consider administering a general screening tool such as the Pediatric Symptom Checklist-17 or the Strengths and Difficulties questionnaire, Secondary screening tools are designed to focus on a specific set of symptoms. Using methods from a study by Rea et al,18 we analyzed risk of bias for each of the included studies and found that only 2of 46 studies had a low risk of bias, 33 of 46 had moderate risk of bias, and 11 of 46 had a high risk of bias. These funders played no role in the study design, analysis, or preparation of this article. 10.1542/peds.2020-020610. Forty-six percent of patients were due for the human papillomavirus (HPV) vaccine, and 19% of these received it during admission.25. To review studies of adolescent risk behavior screening and interventions in urgent care, emergency department (ED), and hospital settings. Within each category, we grouped studies by subcategory: screening rates, screening and intervention tools, and attitudes toward screening and intervention. A significant proportion of adolescents who screened positive for elevated suicide risk in the ED were presenting for nonpsychiatric reasons. Twenty-five percent never conducted SBIRT (limited time and resources are barriers). Dr Ozer is supported by grants from the Health Resources and Services Administration of the US Department of Health and Human Services and the Maternal and Child Health Bureau under cooperative agreement UA6MC27378 and Maternal and Child Health Bureau Leadership Education in Adolescent Health Training grant T71MC00003. 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. The RSQ could not be validated in an asymptomatic population of adolescents and was noted to have a high false-positive rate in this low-risk population (recommended doing more general HEADSS screening). There is a high unintended pregnancy risk in adolescents using the ED. Survey eliciting sexual history, preferences for partner STI notification, and partner EPT. This type of screening can identify children with significant developmental and behavioral challenges early, when they may benefit most from intervention, as . Sexual history documentation was incomplete in charts of adolescents discharged from the ED with STI diagnosis. 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. 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.) For intimate partner violence and adolescent relationship abuse, Jackson et al63 outline successful outpatient interventions (eg, universal wallet-sized educational cards and targeted computerized interventions) that could be feasible in the ED setting but would require further investigation. Questionnaire used to assess beliefs regarding screening and intervention for suicide risk and other mental health problems in the ED. 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. Clinicians were comparatively less accepting, particularly if the visit was not related to sexual health. No charts contained documentation on other important risk-stratifying details, such as contraception use other than condoms, the sex of partners, partners risk of STIs, anal sex practice, or partners drug use.27 None of these studies reported on whether privacy was ensured in sexual history taking, although they did mention the need for confidentiality as a possible barrier to higher rates of screening.2326, McFadden et al25 described sexual health services provided in the hospital setting and reported that STI testing was conducted in 12% of patients, that pregnancy testing was done in 60% of female patients, and that contraception was provided for 2% of patients. EC knowledge was poor among clinicians surveyed. Teenagers report wanting to receive pregnancy and STI preventive care in the ED, regardless of the reason to visit. E-mail: Search for other works by this author on: Achieving quality health services for adolescents, Centers for Disease Control and Prevention, Opportunistic adolescent health assessment in the child protection unit, Does screening for and intervening with multiple health compromising behaviours and mental health disorders amongst young people attending primary care improve health outcomes? Of those who ended up needing it, 92% had answered yes before knowing. 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. 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%. 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. 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. Immediate intervention in the ED and receiving information for follow-up care were rated as the most helpful responses to a positive screening result. For more educational content visitwww.pedialink.org. Patients and clinicians are generally receptive to screening in these settings, with barriers including adolescents privacy concerns, clinicians time constraints, and clinicians comfort and knowledge with risk behavior screening and risk behavior interventions. FUNDING: Dr Kaiser is supported by grants from the Agency for Healthcare Research and Quality (K08HS024592 and R03HS027041). A significant percentage of sexually active adolescents surveyed were potential candidates for EC. 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 American Academy of Pediatrics recognizes global health as an important component of general pediatrics residency training. Parents were overall supportive of sexual activity screening and care provision in the ED and hospital setting. The FRAMES acronym tool can be used to outline brief interventions. In the intervention arm, the results of the screen provided decision support for ED physicians. Research on clinical preventive services for adolescents and young adults: where are we and where do we need to go? To help identify such patients, a cross-sectional study done to validate the RSQ in patients presenting to the ED revealed a clinically significant prevalence (5.7%) of SI in patients with nonpsychiatric chief complaints.46 However, another validation study revealed that in a low-risk, nonsymptomatic patient population, the RSQ had high false-positive rates. You can find the latest versions of these browsers at https://browsehappy.com. Specifically, 5 of 10 patients who met criteria for inpatient psychiatric facility admission did not have an initial mental healthrelated chief complaint.50, In a cross-sectional survey, OMara et al51 found that after a positive screen result, the majority of adolescent patients and their parents valued the chance for immediate intervention and resources in the ED. Two of the studies took place in the hospital setting and 4 in the ED setting. A majority of participants (85%) felt the ED should provide information on contraception, and 65% believed the ED should provide safe sex and pregnancy prevention services at all ED visits. 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. Adolescents and clinicians were highly accepting of risk behavior screening in all settings and preferred electronic screening over a face-to-face interview. The authors reported screening rates of 55% to 62%.24,25 For patients who had documented sexual or reproductive history, screening for more specific risk behaviors (such as condom use, birth control use, and number of sexual partners) was often omitted.24, Similarly, in the ED, a retrospective study by Beckmann and Melzer-Lange27 reported that even in charts of patients diagnosed with an STI, documentation of sexual activity was incomplete and inconsistent. The 2 reviewers made joint final decisions on inclusion of studies with conflicting initial determinations. 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. To overcome these collective barriers, future researchers should investigate (1) feasible, efficient risk behavior screening tools with guidance for clinicians on providing risk behavior interventions and (2) tools that increase privacy and comfort for patients (likely through the use of electronic formats). *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 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. The majority of ED physicians felt that the ED was an appropriate venue for screening and intervention on alcohol use disorders. We developed the rapid screening tool home, education, activities/peers, drugs/alcohol, suicidality, emotions/behavior, discharge resources (HEADS-ED), which is a modification of "HEADS," a mnemonic widely used to obtain a psychosocial . All rights reserved. After a title and abstract screen, 75 studies remained. Self-administered tablet questionnaire: NIAAA 2-question screen (the 2 questions differed between high schoolaged and middle schoolaged adolescents). CRAFFT is a valid substance use screening tool for the adolescent population. Positive themes included detection of youth who may be at risk and have a lack of social support as well as possible prevention of suicide attempts. Although poverty increases the risk for mental health conditions, studies show that the greatest increase in prevalence occurred among children living in households earning greater than 400% above the federal poverty line. hmO0Qb1 BV`T!JkX&TI*u_~9M(*06*tgP.5VKd Survey to assess sexual history, sexual health knowledge, and desire for sexual health education. Copyright 2023 American Academy of Pediatrics. We calculated Cohens to assess interrater reliability. Only 62% of charts had sexual history documented in the admission H&P, and among those patients who did have documentation, 50.5% were found to be sexually active. Copyright American Academy of Pediatrics. The American Academy of Pediatrics (AAP) and other organizations recommend using this assessment in order to address risk behaviors. Survey of female adolescent patients using ACA software. Of those, 47% endorsed sexual activity. MI-based brief intervention to assess sexual behaviors and provide personalized treatment (STI testing, contraception) and referral for follow-up care. Previous studies indicate low rates of risk behavior screening and interventions in ED and hospital settings. Additionally, most studies of screens or interventions have thus far been limited to a single study done in 1 center, thus limiting generalizability. We conducted a literature search in June 2019. Providing decision support to physicians on the basis of survey results led to an increase in intervention (STI testing). The AAP, which said. The ED visit may provide an opportunity to meet the contraceptive needs of adolescents, particularly for those who do not receive regular well care. 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. 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. Interview, primary question of interest (asked after standardized suicide screening): Do you think ER nurses should ask kids about suicide/thoughts about hurting themselveswhy or why not?. 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. Most clinicians agreed that computerized depression screening could be a suitable approach to address many of the identified barriers to screening. Studies were excluded if they involved younger children or adults or only included previously identified high-risk adolescents. Semistructured focus groups covering thoughts and experience with EC; written survey to assess EC knowledge. The American Academy of Pediatrics (AAP) is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians. Rates of adolescent risk behavior screening are low in urgent care, ED, and hospital settings. Adolescents preference for technology-based emergency department behavioral interventions: does it depend on risky behaviors? 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.

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