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Screening Out Danger :

March 30, 2021

These patients are in our EDs and in our hospital beds, yet the vast majority of these issues remain unrecognized. Why?

- 63% of adolescent human trafficking victims report an emergency department (ED) visit while they were being trafficked.1

- 37% of adolescent females presenting to the ED report a history of intimate partner violence. 2

- 6% of adolescents presenting to the ED with non-psychiatric complaints report suicidal ideation.3

These patients are in our EDs and in our hospital beds, yet the vast majority of these issues remain unrecognized. Why?

Hospitals and EDs are typically “problem-focused” settings with full attention paid to the presenting complaint. In this month’s Pediatrics,Pfaff et al make a strong case that adolescents seen in these settings, particularly in the ED, are at high risk for undiagnosed conditions or unrecognized problems (10.1542/peds.2020-020610). When things get busy, a problem-oriented tunnel vision often becomes the norm and higher throughput becomes the priority. Clinicians do not have time for a full HEADSS* assessment or detailed case finding, yet the consequences for missing these behavior-related issues can be dire and interventions are limited.

Dr. Pfaff and her co-authors emphasize the role of effective and time-efficient screening tools in identifying these patients. They looked specifically at screening rates, tools, and interventions, as well as patient, parent, and clinician attitudes toward the process. Clinicians can be reassured that adolescents and caregivers are generally receptive to these screenings and interventions. Adolescents appear to prefer electronic self-disclosure tools, which are also more time- and resource-efficient as compared to more traditional screening methods. The authors highlight a variety of these tools currently in use in other settings that could be adapted and validated for future hospital-based use. 

Given the growing awareness of behavioral and mental health issues in adolescence, and the strain this is putting on the health care system, it is surprising that more work has not already been done on this issue. Pfaff et al shine a bright light on this deficit and will hopefully create some momentum toward innovative, compassionate, efficient, and effective solutions to identify these adolescents at high risk for significant harm.

*HEADSS screenings include assessments of: home, education/employment, activities/peer relationships, drugs/alcohol/tobacco, sexuality/gender, suicide/safety and spirituality


  1. Tiller J, Reynolds S. Human Trafficking in the Emergency Department: Improving Our Response to a Vulnerable Population. West J Emerg Med. 2020;21(3):549-554. doi:10.5811/westjem.2020.1.41690
  2. Erickson MJ, Gittelman MA, Dowd D. Risk factors for dating violence among adolescent females presenting to the pediatric emergency department. J Trauma. Oct 2010;69(4 Suppl):S227-32. doi:10.1097/TA.0b013e3181f1ec5a
  3. Horowitz L, Ballard E, Teach SJ, et al. Feasibility of screening patients with nonpsychiatric complaints for suicide risk in a pediatric emergency department: a good time to talk? Pediatr Emerg Care. Nov 2010;26(11):787-92. doi:10.1097/PEC.0b013e3181fa8568
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