NUBE 2024

The increasing volume of children and adolescents presenting to emergency departments (ED) with mental health complaints presents a national crisis. A decade-long longitudinal study revealed that such presentations are trending upward, with an annual rise of 6-10% [1]. This trend will continue to have cumulative effects that challenge our current systems of care. In an effort to inform disposition in situations where aggression and violence are relevant, it is important that emergency medicine providers be informed regarding how to effectively assess the risk for violence in youth.  Youth demonstrating aggressive behavior can present a unique challenge to the ED setting, particularly if they are awaiting inpatient psychiatric treatment and/or possess psychosocial challenges that yield disposition planning difficulties. These situations are not unique to pediatric EDs or academic centers that may have integrated pediatric providers. Community hospitals that may have limited mental health resources might benefit from the implementation of evidence-based violence risk screening that can be applied by a variety of clinical staff to inform risk, treatment disposition, and safety planning.

While the ED presents a uniquely restrictive environment for all persons, some children are more likely to manage related distress through externalized behaviors when compared to adults [1]. Intervention by ED staff who have not received de-escalation training specific to children and youth may subsequently escalate young patients further, thus contributing to the risk of injury for both patients and staff.

There are several widely known youth-specific violence risk assessment tools, such as SAVRY [2], which has moderate validity for those aged 12-18 years old and is well known to the juvenile justice system. Similar well-validated violence risk assessment tools have useful applications, but can be time intensive and difficult to translate to the ED setting as they require specialized training programs. ED providers often have limited time to assess patients who present with psychosocially complex complaints.  Therefore, there is a practical necessity to validate a violence risk assessment tool that balances reliability and brevity.

The Fordham Risk Screening (FRST) has a growing body of data to support its utility in the ED [4] and civil inpatient settings [3]. Recently, the FRST has been integrated as a standard portion of the assessment of patients who present in behavioral or mental health crisis at Maine Medical Center’s (MMC) ED. All patients seen by MMC's Emergency Psychiatry team have been asked FRST screening questions and a subset of these patients are youth who present to the ED seeking crisis evaluation. Therefore, we aim to retrospectively evaluate the utility of the FRST as a clinical tool for evaluating and assessing the risk of violence in children and adolescents. Increasing objectivity of violence risk assessment will allow more thoughtful approaches to patient management in ED settings, and ideally reduce the length of stay and the necessity for pharmacologic interventions, while informing future risk of violence as predicted by an objective screening tool. This work will also inform whether it is possible to streamline risk assessment to a single tool for all ages.

Learning Objectives:

Consider the need and potential clinical utility of violence risk assessment in children and youth specific to emergency departments.

Appreciate the uniqueness of caring for youth in the Emergency Department setting, particularly when there are violence risk factors.

Understand factors that contribute to pediatric violence risk when compared to adults.