CONTEXT:

Risky behaviors are the main threats to adolescents’ health; consequently, evidence-based guidelines recommend annual comprehensive risk behavior screening.

OBJECTIVE:

To review studies of adolescent risk behavior screening and interventions in urgent care, emergency department (ED), and hospital settings.

DATA SOURCES:

Our data sources included PubMed (1965–2019) and Embase (1947–2019).

STUDY SELECTION:

Studies were included on the basis of population (adolescents aged 10–25 years), topic (risk behavior screening or intervention), and setting (urgent care, ED, or hospital). Studies were excluded if they involved younger children or adults or only included previously identified high-risk adolescents.

DATA EXTRACTION:

Data extracted were risk behavior screening rates, screening and intervention tools, and attitudes toward screening and intervention.

RESULTS:

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]). In 6 studies, authors examined comprehensive risk behavior screening, demonstrating low rates at baseline (∼10%) but significant increases with clinician reminder implementation. Adolescents and clinicians were highly accepting of risk behavior screening in all settings and preferred electronic screening over a face-to-face interview. Reported barriers were time constraints and limited resources.

LIMITATIONS:

Only 1 included study was a randomized controlled trial, and there was large heterogeneity of included studies, potentially limiting generalizability.

CONCLUSIONS:

Rates of adolescent risk behavior screening are low in urgent care, ED, and hospital settings. Our findings outline promising tools for improving screening and intervention, highlighting the critical need for continued development and testing of interventions in these settings to improve adolescent care.

Risky behaviors present a great threat to adolescent health and safety and are associated with morbidity into adulthood.1,2  Unintended pregnancy, sexually transmitted infections (STIs), substance use, suicide, and injury are the primary causes of morbidity and mortality in those aged 10 to 24 years.3  Risky behaviors are prevalent among US high school students, with 35% reporting alcohol use, 23% reporting marijuana use, and 47% reporting sexual activity (but only 59% reporting using a condom during their last sexual encounter).1  Consequently, the American Academy of Pediatrics recommends comprehensive risk behavior screening at annual preventive care visits during adolescence,4  with the goal of identifying risk behaviors and providing risk behavior–related interventions (eg, STI testing).5 

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.

Previous studies indicate low rates of risk behavior screening and interventions in ED and hospital settings. Inconsistent or incomplete adolescent risk behavior screening in these settings may result in missed opportunities to intervene, mitigate risk, and improve health outcomes. In this scoping review, we aim to comprehensively describe the extent and nature of the current body of research on risk behavior screening and risk behavior interventions for adolescents in urgent care, ED, and hospital settings. 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. Our findings can help guide efforts in these settings to advance screening and interventions for risk behaviors, thereby improving health outcomes for adolescents.

We conducted a scoping review given expected heterogeneity of the body of literature on this topic. Scoping reviews map out broad themes and identify knowledge gaps when the published works of focus use a wide variety of study designs.15  We used the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews guidelines to inform our search and synthesis of the literature.16 

We conducted a literature search in June 2019. Data sources included PubMed (1965–2019) and Embase (1947–2019). In the Supplemental Information, we outline the details of our search strategy. We pooled results from both queries together and removed duplicates. Inclusion criteria were study population age (adolescents aged 10–25 years), topic (risk behavior screening or risk behavior interventions), and setting (urgent care, ED, or hospital). 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. We also excluded any studies with interventions taking place outside the urgent care, ED, or hospital because we aimed to identify interventions that could be completed during acute care encounters. In this study, the terms “hospitalized” or “hospital setting” refer to patients admitted to pediatric units under either inpatient or observation status. We only included studies published in English.

Two independent reviewers screened, extracted, and summarized the studies (N.P. and A.D.). 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. Next, the 2 reviewers independently completed a full-text screen. We calculated Cohen’s κ to assess interrater reliability. The 2 reviewers made joint final decisions on inclusion of studies with conflicting initial determinations.

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. We described and summarized major findings, organized by the following risk behavior categories: comprehensive, sexual activity, mood and suicidal ideation (SI), substance use, and abuse and violence. Within each category, we grouped studies by subcategory: screening rates, screening and intervention tools, and attitudes toward screening and intervention. We did not combine and quantitatively analyze study results because of heterogeneity in study design.

This study was determined exempt by the Institutional Review Board at the University of California, San Francisco.

Our initial search yielded 1336 studies in PubMed and 656 studies in Embase. After duplicates were removed, 1867 unique studies were identified. After a title and abstract screen, 75 studies remained. In the full-text screen, both reviewers included 43 studies and excluded 25 studies; 7 studies were in conflict. Cohen’s κ was calculated and determined to be 0.8, correlating with a 90.7% agreement. One study that met inclusion criteria was found post hoc and included in the final review for a total of 46 studies (Fig 1). Included studies were published between 2004 and 2019, and the majority (n = 38) of the studies took place in the ED setting, whereas 7 took place in the hospital setting, and only 1 took place in the urgent care setting. Study design and risk of bias are presented in Table 1. 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.

FIGURE 1

Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines flowchart of study selection.

FIGURE 1

Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines flowchart of study selection.

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TABLE 1

Risk of Bias

StudyStudy TypeUse of a Comparator or ControlRandom AssignmentBlind Outcome AssessmentReported Response and/or Attrition RateValidated MeasureOverall Risk of Bias
Wilson et al19  Cross-sectional − − − Moderate 
Van Amstel et al21  Cross-sectional − − Moderate 
Horowitz et al44  Cross-sectional − − Moderate 
Hopper et al47  Cross-sectional − Low 
Patel et al50  Cross-sectional − − − Moderate 
Ahmad et al34  Cross-sectional − − − Moderate 
Miller et al29  Cross-sectional − − − Moderate 
Spirito et al58  Cross-sectional − − Moderate 
Fairlie et al57  Cross-sectional − − − Moderate 
Linakis et al56  Cross-sectional − − Moderate 
Erickson et al62  Cross-sectional − − Moderate 
Bernstein et al20  Implementation − − − Moderate 
Horowitz et al46  Mixed methods − − − Moderate 
Fein et al49  Mixed methods − − − Moderate 
Shamash et al36  Mixed methods − − − − High 
Miller et al42  Mixed methods − − − Moderate 
Ambrose and Prager48  Narrative review − − − − − High 
Burke et al59  Narrative review − − − − − High 
Jackson et al63  Narrative review − − − − − High 
Cronholm et al54  Qualitative − − − Moderate 
Ballard et al52  Qualitative − − − Moderate 
Ballard et al53  Qualitative − − − Moderate 
Goyal et al35  Qualitative − − − Moderate 
Miller et al41  Qualitative − − − − High 
Miller et al39  Qualitative − − Moderate 
Falcón et al61  Qualitative − − − Moderate 
Goyal et al28  RCT − Low 
Yeo et al13  Retrospective cohort − − − Moderate 
Riese et al24  Retrospective cohort − − − Moderate 
McFadden et al25  Retrospective cohort − − − Moderate 
Stowers and Teelin26  Retrospective cohort − − − Moderate 
Nager et al22  Retrospective cohort − − − − High 
Beckmann and Melzer-Lange27  Retrospective cohort − − − − High 
Guss et al38  Survey − − − − High 
Masonbrink et al40  Survey − − − − High 
Ranney et al23  Survey − − − Moderate 
Hengehold et al43  Survey − − Moderate 
King et al45  Survey − − Moderate 
O’Mara et al51  Survey − − − − High 
Solomon et al30  Survey − − Moderate 
Mollen et al37  Survey − − − − High 
Miller et al32  Survey − − Moderate 
Fine and Mollen31  Survey − − − Moderate 
Chernick et al33  Survey − − − Moderate 
Jun et al60  Survey − − − Moderate 
Newton et al55  Systematic review − − − Moderate 
StudyStudy TypeUse of a Comparator or ControlRandom AssignmentBlind Outcome AssessmentReported Response and/or Attrition RateValidated MeasureOverall Risk of Bias
Wilson et al19  Cross-sectional − − − Moderate 
Van Amstel et al21  Cross-sectional − − Moderate 
Horowitz et al44  Cross-sectional − − Moderate 
Hopper et al47  Cross-sectional − Low 
Patel et al50  Cross-sectional − − − Moderate 
Ahmad et al34  Cross-sectional − − − Moderate 
Miller et al29  Cross-sectional − − − Moderate 
Spirito et al58  Cross-sectional − − Moderate 
Fairlie et al57  Cross-sectional − − − Moderate 
Linakis et al56  Cross-sectional − − Moderate 
Erickson et al62  Cross-sectional − − Moderate 
Bernstein et al20  Implementation − − − Moderate 
Horowitz et al46  Mixed methods − − − Moderate 
Fein et al49  Mixed methods − − − Moderate 
Shamash et al36  Mixed methods − − − − High 
Miller et al42  Mixed methods − − − Moderate 
Ambrose and Prager48  Narrative review − − − − − High 
Burke et al59  Narrative review − − − − − High 
Jackson et al63  Narrative review − − − − − High 
Cronholm et al54  Qualitative − − − Moderate 
Ballard et al52  Qualitative − − − Moderate 
Ballard et al53  Qualitative − − − Moderate 
Goyal et al35  Qualitative − − − Moderate 
Miller et al41  Qualitative − − − − High 
Miller et al39  Qualitative − − Moderate 
Falcón et al61  Qualitative − − − Moderate 
Goyal et al28  RCT − Low 
Yeo et al13  Retrospective cohort − − − Moderate 
Riese et al24  Retrospective cohort − − − Moderate 
McFadden et al25  Retrospective cohort − − − Moderate 
Stowers and Teelin26  Retrospective cohort − − − Moderate 
Nager et al22  Retrospective cohort − − − − High 
Beckmann and Melzer-Lange27  Retrospective cohort − − − − High 
Guss et al38  Survey − − − − High 
Masonbrink et al40  Survey − − − − High 
Ranney et al23  Survey − − − Moderate 
Hengehold et al43  Survey − − Moderate 
King et al45  Survey − − Moderate 
O’Mara et al51  Survey − − − − High 
Solomon et al30  Survey − − Moderate 
Mollen et al37  Survey − − − − High 
Miller et al32  Survey − − Moderate 
Fine and Mollen31  Survey − − − Moderate 
Chernick et al33  Survey − − − Moderate 
Jun et al60  Survey − − − Moderate 
Newton et al55  Systematic review − − − Moderate 

Overall risk of bias was as follows: low, 1 variable not present; moderate, 2–3 variables not present; and high, 4–5 variables not present. RCT, randomized controlled trial; −, not present; +, present.

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.

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. Two of the studies took place in the hospital setting and 4 in the ED setting.

TABLE 2

Comprehensive Adolescent Risk Behavior Screening Studies

StudySettingStudy DesignPopulationInterventionResults
Wilson et al19  Hospital Cross-sectional Adolescents 10–18 y old HEADSS assessment–based interview conducted by resident physicians Thirty percent of adolescents (n = 114) screened positive and required risk behavior–related care, which included follow-up referrals and patient education. 
Yeo et al13  Hospital Retrospective cohort Adolescents 13–18 y old HEADSS-based psychosocial screening by admitting physician The majority (62% of patients [n = 100]) had no documentation of psychosocial screening, 29% had inadequate screening (1–4 HEADSS domains), 7% had complete screening, and 3% had thorough screening (5–6 HEADSS domains). Seventy-five percent had documented risk behavior–related care. 
Van Amstel et al21  ED Cross-sectional Adolescents 13–18 y old 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% (n = 153) (P = .003). 
Ranney et al23  ED Survey Adolescents 13–17 y old 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 (n = 234) were interested in receiving risk behavior–related care, even when screen results were negative. Approximately 50% reported a preference for technology-based care. 
Bernstein et al20  ED Implementation Adolescents 14–21 y old Youth and Young Adult Health and Safety Needs Survey completed by HPAs Thirty-seven percent of adolescents (n = 2149) screened positive for substance use, and most of this group received a brief intervention (81%) and/or referral for substance abuse treatment (70%). An additional 496 patients received referrals for health risks not related to substance. 
Nager et al22  ED Retrospective cohort Adolescents >12 y old The ED-DRS, a nonvalidated screening tool to assess for health risk behaviors, was administered by physician trainees. Of patients, 47.5% (n = 992) screened positive for risk behaviors, and 14% of these patients received a social worker referral. 
StudySettingStudy DesignPopulationInterventionResults
Wilson et al19  Hospital Cross-sectional Adolescents 10–18 y old HEADSS assessment–based interview conducted by resident physicians Thirty percent of adolescents (n = 114) screened positive and required risk behavior–related care, which included follow-up referrals and patient education. 
Yeo et al13  Hospital Retrospective cohort Adolescents 13–18 y old HEADSS-based psychosocial screening by admitting physician The majority (62% of patients [n = 100]) had no documentation of psychosocial screening, 29% had inadequate screening (1–4 HEADSS domains), 7% had complete screening, and 3% had thorough screening (5–6 HEADSS domains). Seventy-five percent had documented risk behavior–related care. 
Van Amstel et al21  ED Cross-sectional Adolescents 13–18 y old 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% (n = 153) (P = .003). 
Ranney et al23  ED Survey Adolescents 13–17 y old 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 (n = 234) were interested in receiving risk behavior–related care, even when screen results were negative. Approximately 50% reported a preference for technology-based care. 
Bernstein et al20  ED Implementation Adolescents 14–21 y old Youth and Young Adult Health and Safety Needs Survey completed by HPAs Thirty-seven percent of adolescents (n = 2149) screened positive for substance use, and most of this group received a brief intervention (81%) and/or referral for substance abuse treatment (70%). An additional 496 patients received referrals for health risks not related to substance. 
Nager et al22  ED Retrospective cohort Adolescents >12 y old The ED-DRS, a nonvalidated screening tool to assess for health risk behaviors, was administered by physician trainees. Of patients, 47.5% (n = 992) screened positive for risk behaviors, and 14% of these patients received a social worker referral. 

ED-DRS, Emergency Department Distress Response Screener.

Screening Rates

Yeo et al13  found that ∼10% of admitted patients at a tertiary children’s 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). 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). In 75% of cases in which risk behaviors were identified, interventions were provided. Similarly, in a hospital study of surgical adolescent patients by Wilson et al,19  the authors found that only 16% of patients were offered screening, and of these, 30% required interventions.

Screening Tools and Interventions

Three ED studies described interventions to increase comprehensive risk behavior screening. 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. However, lack of initial physician buy-in and administrative hurdles, such as funding for HPAs, training, and competition with other medical professionals (ie, social workers), made it difficult to transition this intervention into sustainable clinical practice.20  In 2 studies, researchers evaluated physician reminders to screen, including a home, education, activities, drugs, sexual activity, suicide and/or mood (HEADSS) stamp on paper medical charts and a distress response survey in the electronic health record (EHR). The HEADSS stamp resulted in a significant increase in postintervention screening rates (from <1% to 9%; P = .003).21  The EHR distress response survey by Nager et al22  was found to be feasible to integrate into the busy ED physician workflow, but the study offered limited insight into effects on screening or utility of the tool (assessed by using only yes or no questions).

Adolescent, Parent, and Clinician Attitudes

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.

There were no studies on parent or clinician attitudes toward comprehensive risk behavior screening.

Nineteen studies on sexual activity screening and/or intervention were included in our review: 5 in the hospital setting (Table 3) and 14 in the ED (Table 4).

TABLE 3

Adolescent Risk Behavior Screening and Interventions in the Hospital Setting

StudyStudy TypePopulationRisk Behavior DomainInterventionResults
Wilson et al19  Cross-sectional Adolescents 10–18 y old All domains HEADSS assessment–based interview conducted by resident physicians Thirty percent of adolescents (n = 114) screened positive and required risk behavior–related care, which included follow-up referrals and patient education. 
Yeo et al13  Retrospective cohort Adolescents 13–18 y old All domains HEADSS-based psychosocial screening by admitting physician The majority (62% of patients [n = 100]) had no documentation of psychosocial screening, 29% had inadequate screening (1–4 HEADSS domains), 7% had complete screening, and 3% had thorough screening (5–6 HEADSS domains). Seventy-five percent had documented risk behavior–related care. 
Guss et al38  Survey Adolescents 13–18 y old Sexual activity (patient attitudes) Patient-administered 22- to 27-item survey on attitudes toward inpatient reproductive health screening and interventions 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). Even patients with a current primary care provider and those who were not sexually active were interested in inpatient interventions. 
Masonbrink et al40  Survey Hospitalists Sexual activity (clinician attitudes) Survey of hospitalists to assess beliefs and practices surrounding sexual and reproductive health screening and interventions More than half (56%) of hospitalists reported regularly taking sexual history but rarely provided condoms or a referral for IUD placement. Barriers identified included time, concern about follow-up, and lack of knowledge. 
Riese et al24  Retrospective cohort Adolescents 14–18 y old Sexual activity Audit of sexual activity and risk-level status documentation 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. Details on risk level were frequently left out. 
McFadden et al25  Retrospective cohort Adolescents 13+ y old Sexual activity 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. Of those, 47% endorsed sexual activity. A patient was more likely to have documentation if the note was written by an intern (P < .01), if the patient was female (P < .01), or if the patients was hospitalized for an ingestion (P < .01). Interventions: Twelve percent were tested for STIs (27% positive rate). Nineteen percent of patients due for HPV immunization received it. Contraception was provided in 2 encounters (2% of female adolescents). 
Stowers and Teelin26  Retrospective cohort Adolescents 11–18 y old Sexual activity domain Sexual and menstrual history documentation Less than half of admitted patients had documented menstrual (32.8%) or sexual history (45.9%). 
StudyStudy TypePopulationRisk Behavior DomainInterventionResults
Wilson et al19  Cross-sectional Adolescents 10–18 y old All domains HEADSS assessment–based interview conducted by resident physicians Thirty percent of adolescents (n = 114) screened positive and required risk behavior–related care, which included follow-up referrals and patient education. 
Yeo et al13  Retrospective cohort Adolescents 13–18 y old All domains HEADSS-based psychosocial screening by admitting physician The majority (62% of patients [n = 100]) had no documentation of psychosocial screening, 29% had inadequate screening (1–4 HEADSS domains), 7% had complete screening, and 3% had thorough screening (5–6 HEADSS domains). Seventy-five percent had documented risk behavior–related care. 
Guss et al38  Survey Adolescents 13–18 y old Sexual activity (patient attitudes) Patient-administered 22- to 27-item survey on attitudes toward inpatient reproductive health screening and interventions 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). Even patients with a current primary care provider and those who were not sexually active were interested in inpatient interventions. 
Masonbrink et al40  Survey Hospitalists Sexual activity (clinician attitudes) Survey of hospitalists to assess beliefs and practices surrounding sexual and reproductive health screening and interventions More than half (56%) of hospitalists reported regularly taking sexual history but rarely provided condoms or a referral for IUD placement. Barriers identified included time, concern about follow-up, and lack of knowledge. 
Riese et al24  Retrospective cohort Adolescents 14–18 y old Sexual activity Audit of sexual activity and risk-level status documentation 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. Details on risk level were frequently left out. 
McFadden et al25  Retrospective cohort Adolescents 13+ y old Sexual activity 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. Of those, 47% endorsed sexual activity. A patient was more likely to have documentation if the note was written by an intern (P < .01), if the patient was female (P < .01), or if the patients was hospitalized for an ingestion (P < .01). Interventions: Twelve percent were tested for STIs (27% positive rate). Nineteen percent of patients due for HPV immunization received it. Contraception was provided in 2 encounters (2% of female adolescents). 
Stowers and Teelin26  Retrospective cohort Adolescents 11–18 y old Sexual activity domain Sexual and menstrual history documentation Less than half of admitted patients had documented menstrual (32.8%) or sexual history (45.9%). 

H&P, history and physical; IUD, intrauterine device.

TABLE 4

ED and Urgent Care Adolescent Risk Behavior Screening and Interventions

StudyStudy TypeRisk Behavior DomainInterventionResultsConclusions
Bernstein et al20  Implementation All domains Youth and Young Adult Health and Safety Needs Survey completed by HPAs Thirty-seven percent of adolescents (n = 2149) screened positive for substance use, and most of this group received a brief intervention (81%) and/or referral for substance abuse treatment (70%). An additional 496 patients received referrals for health risks not related to substance use. HPAs can be a valuable resource for providing screening and preventive interventions beyond the scope of an ED physician. Buy-in from physicians was difficult in the implementation phase. 
Nager et al22  Retrospective cohort All domains The ED-DRS, a nonvalidated screening tool to assess for health risk behaviors, was administered by physician trainees Of patients, 47.5% (n = 992) screened positive for risk behaviors, and 14% of these patients received a social worker referral. Those who screened positive were more likely to have a chronic medical condition. 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. 
Van Amstel et al21  Cross-sectional All domains 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% (n = 153) (P = .003). Most physicians who participated in the study (n = 10) reported they would support use of the HEADSS stamp if it was proven effective. Use of a visual reminder, such as a HEADSS stamp, on patient charts may increase rates of adolescent psychosocial screening in the ED. 
Ranney et al23  Survey All domains 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 (n = 234) were interested in receiving risk behavior–related care, even when screen results were negative. Approximately 50% reported a preference for technology-based care. Adolescents reported high rates of risky behaviors and interest in receiving interventions for these behaviors. Further study of technology-based behavioral interventions is warranted.  
Hengehold et al43  Survey Mood and SI ASQ on a validated self-screening tablet tool High risk for SI was identified in 93.4% of “yes” respondents and in 84.5% of the “no response” group. Youth who select “no response” are at elevated risk of SI and may warrant further screening and/or evaluation.  
Horowitz et al46  Mixed methods Mood and SI (patient attitudes) RSQ and SIQ Nonpsychiatric ED patients who were screened had a 5.7% prevalence of SI (clinically significant), and screening positively did not significantly increase the mean length of stay in the ED. SI screening of all patients in the ED is feasible and acceptable to adolescent patients.  
Horowitz et al44  Cross-sectional Mood and SI Survey of 17 candidate suicide screening questions 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%. The ASQ is a brief tool to assess suicide risk in pediatric patients in the ED and has a high sensitivity, specificity, and NPV.  
Hopper et al47  Cross-sectional Mood and SI The RSQ, a verbal 4-question suicide screening instrument Twenty-two percent of patients screened positive on the RSQ. However, none of the patients screened positive for SI on the SIQ (comparison standard). The questions that accounted for the false-positives on the RSQ were the following: “Has something very stressful happened to you in the past few weeks?” and “Have you ever tried to hurt yourself in the past?” 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).  
King et al45  Survey Mood and SI Written surveys: RADS-2, SIQ-JR, AUDIT-3, POSIT, BHS, and BIS-11; positive suicide risk screen result defined as follows: (1) positive SIQ-JR result or recent suicide attempt or (2) positive AUDIT-3 and RADS-2 results Sixteen percent (n = 295) screened positive for elevated suicide risk. Of those, 19% presented for nonpsychiatric complaints. Ninety-eight percent of adolescents with elevated suicide risk had a positive SIQ-JR result and/or a recent suicide attempt. Only 1 patient met elevated suicide risk criteria via positive RADS-2 and AUDIT-3 results (concurrent depression and alcohol use) and did not have a positive SIQ-JR result or a recent suicide attempt. Concurrent validity of the screening protocol was supported by significantly higher POSIT scores for adolescents who screened positive for alcohol use and/or depression and high BHS scores for those who screened positive for SI and/or a recent suicide attempt. A significant proportion of adolescents who screened positive for elevated suicide risk in the ED were presenting for nonpsychiatric reasons. Almost all patients deemed to have elevated suicide risk endorsed SI (SIQ-JR) and/or had a recent suicide attempt. 
Ambrose and Prager48  Narrative review Mood and SI Investigates different SI screening tools used in ED 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 ASQ, RSQ, CSSRS, and HEADS-ED have been all been validated in the ED setting. The CSSRS has been validated in multiple settings (including the ED and inpatient setting in patients with mental health problems). More research and development into risk screening algorithms and interventions is needed, specifically prospective controlled trials.  
Cronholm et al54  Qualitative Mood and SI (clinician attitudes) Semistructured interviews of clinicians to assess perceptions of depression in the adolescent population and thoughts about screening for depression in the ED All clinicians (n = 41) endorsed that depression is prevalent among adolescents and can have significant negative health effects. Identified barriers to screening include lack of rapport with patient, insufficient time, high patient acuity, lack of training, maintaining privacy, and appropriate response to positive screening results. ED clinicians acknowledged the importance of depression screening. However, many barriers to screening in the ED setting were reported. Most clinicians agreed that computerized depression screening could be a suitable approach to address many of the identified barriers to screening.  
Fein et al49  Mixed methods Mood and SI 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. Six-five percent agreed to screening (n = 857). Use of the BHS-ED increased identification of mental health problems to 4.2% of patients from 2.5% in the preimplementation period (OR 1.70; 95% CI 1.38–2.10). Patients were also more likely to be evaluated by a psychiatrist or social worker during the implementation phase (2.5% vs 1.7%; OR 1.47 [95% CI 1.13–1.90]). A computerized psychosocial screening tool, such as the BHS-ED, may be a feasible intervention to increase detection of mental health problems in adolescent patients in the ED.  
O’Mara et al51  Survey Mood and SI (patient attitudes) Questionnaire used to assess beliefs regarding screening and intervention for suicide risk and other mental health problems in the ED Eighty-six percent of adolescents (n = 294) and 92% of parents (n = 300) rated suicide screening in the ED as important. Speaking with a clinician in the ED was rated as the most helpful response to positive screening results by adolescents (82%) and parents (93%), followed by receiving information regarding further care (79% of adolescents, 93% of parents). Adolescents were most concerned about privacy (47%), and parents were most concerned about the adolescent being in too much pain and/or distress for screening (34%). Most adolescents and parents rated screening for suicide risk and other mental health problems in the ED as important. Female adolescents and parents were generally more supportive of mental health screening (other than suicide risk) than their male counterparts. Immediate intervention in the ED and receiving information for follow-up care were rated as the most helpful responses to a positive screening result.  
Ballard et al53  Qualitative Mood and SI (patient attitudes) Interview, primary question of interest: “Do you think ER nurses should ask kids about suicide/thoughts about hurting themselves…why or why not?” Ninety percent of adolescents (n = 165) reported they believe ED nurses should ask about suicide. The most common supportive themes were suicide identification, suicide prevention, connection between nurse and patient, linkage to appropriate resources, and feelings of isolation. The most common nonsupportive themes were feeling that suicide screening is irrelevant for nonpsychiatric visits, feeling that screening should be conditional, and concern about screening leading to increased SI and/or suicide attempts. Most adolescents support suicide risk screening in the ED. Adolescents expressed that screening could lead to identification, prevention, and treatment of suicidal thoughts and/or behavior as well as provide an opportunity to connect with the nurse for those who lack other sources of support.  
Ballard et al52  Qualitative Mood and SI (patient attitudes) Interview, primary question of interest (asked after standardized suicide screening): “Do you think ER nurses should ask kids about suicide/thoughts about hurting themselves…why or why not?” Ninety-six percent of adolescents (n = 156) supported suicide screening by nurses in the ED. Only 31% of patients with nonpsychiatric complaints and 44% of those with psychiatric complaints had previously been asked about suicide. Supportive themes included identification and prevention of suicide risk, a desire to be understood, connection to further resources, and lack of others to confide in. Almost all adolescents agreed that nurses should screen for suicide risk in the ED. Adolescents expressed that screening could lead to identification, prevention, and treatment of suicidal behavior.  
Patel et al50  Cross-sectional Mood and SI SI screening via 2-question paper survey Eighty-two percent of patients who screened positively were referred to outpatient mental health, and 10% were admitted to a psychiatric facility. Screening in the urgent care setting helped identify adolescents at risk for SI, most of whom did not have mental health–related chief complaints, and this led to interventions in the form of referrals or urgent admission.  
Shamash et al36  Mixed methods Sexual activity (patient attitudes) Survey eliciting sexual history, preferences for partner STI notification, and partner EPT Two-thirds of patients surveyed did not prefer EPT and cited reasons such as importance of determining partner STI status, partner safety, partner accountability, and importance of clinical interaction. A majority of patients in the ED did not prefer EPT, and clinicians should address concerns if they do plan to prescribe EPT.  
Ahmad et al34  Cross-sectional Sexual activity (patient attitudes) Sexual activity self-disclosure tool (ACASI) Of those who participated, 89.2% reported willingness to receive STI testing if it was recommended (regardless of reason for ED visit). Of those who ended up needing it, 92% had answered yes before knowing. A computerized self-disclosure tool is a feasible way to collect sensitive adolescent data, and adolescents prefer self-disclosure methods and were willing to disclose sexual activity behaviors and receive STI testing, regardless of the chief complaint.  
Solomon et al30  Survey Sexual activity (patient attitudes) Web-based questionnaire on pregnancy risk 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. There is a high unintended pregnancy risk in adolescents using the ED. Teenagers report wanting to receive pregnancy and STI preventive care in the ED, regardless of the reason to visit.  
Goyal et al28  Randomized controlled trial Sexual activity Computerized health survey and guided decision-making tool for physicians in intervention arm The STI testing frequency (intervention) was higher in the intervention group (52.3% vs 42%; OR 2.0 [95% CI 1.1–3.8]) and in asymptomatic patients (28.6% vs 8.2%; OR 4.7 [95% CI 1.4–15.5]). Providing decision support to physicians on the basis of survey results led to an increase in intervention (STI testing).  
Goyal et al35  Qualitative Sexual activity (patient attitudes) 20-item sexual health survey Of respondents, 76.5% preferred an electronic survey to face-to-face interviews. There was no difference in the median length of ED stay between those who completed the survey and those who did not. A sexual health screening electronic tool was acceptable to patients and feasible in terms of workflow in the ED.  
Miller et al42  Mixed methods Sexual activity (patient and clinician attitudes) Computerized survey to assess acceptability and usefulness of a sexual health CDS system ED clinicians (n = 57) rated the CDS system as very or somewhat useful on average. Clinicians reported time constraints, privacy concerns, and technological issues as potential barriers to CDS system use. Ninety-five percent of adolescents (n = 57) reported that the CDS system questionnaire was very or somewhat easy to use and understand. Both adolescents (69%) and clinicians (65%) preferred computerized sexual health screening. A sexual health CDS system for adolescents in the ED received high acceptability and usability ratings from ED clinicians and adolescents. Further research is needed to assess the effectiveness of the CDS system in improving adolescent sexual health care.  
Mollen et al37  Survey Sexual activity (patient attitudes) Survey of female adolescent patients using ACA software Female adolescents showed preference for in-person counseling, from a person of authority (doctor, nurse) rather than from a peer counselor. Adolescents prefer in-person counseling and target education (related to their chief complaint).  
Miller et al41  Qualitative Sexual activity (Clinician attitudes) Semistructured focus groups covering thoughts and experience with EC; written survey to assess EC knowledge Clinicians (n = 85) had low scores on the survey to assess EC knowledge. In focus groups, most physicians and NPs supported EC availability to adolescents but did not believe the ED was the best place for EC prescription and did not support routine screening for EC candidacy. Nurses were more likely to express that EC should only be available to teenagers in select scenarios, such as after sexual assault. EC knowledge was poor among clinicians surveyed. ED physicians and NPs were more likely than nurses to support providing adolescents with EC, but most did not agree with routine screening for EC need in the ED.  
Miller et al29  Cross-sectional Sexual activity MI-based brief intervention to assess sexual behaviors and provide personalized treatment (STI testing, contraception) and referral for follow-up care Sixty-five percent of participants (n = 20) accepted at least 1 health care service in the ED, including CT and/or GC testing, provision of condoms, HIV testing, and EC, and 60% accepted referral to an adolescent clinic. The average length of the intervention was ∼15 min. Eighty percent of participants reported being very satisfied with the intervention. Seventy-eight percent of participants reported the interventionist maintained high fidelity to MI principles. An MI-based intervention in the ED may be feasible and effective at promoting adolescent sexual health. Further study is warranted.  
Beckmann et al27  Retrospective cohort Sexual activity Documentation of sexual history A total of 862 charts of adolescents discharged from the ED with an STI diagnosis were reviewed. 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%). No documentation of sex of partners, partner’s STI risk, partner’s drug use, anal sex practice, or use of contraception other than condoms was found in charts reviewed. Sexual history documentation was incomplete in charts of adolescents discharged from the ED with STI diagnosis.  
Miller et al32  Survey Sexual activity (patient attitudes) Computerized survey to assess sexual history and interest in interventions in the ED Of adolescents surveyed (n = 168), approximately two-thirds were interested in same-day initiation of some form of hormonal contraception, including LARC. Factors associated with interest in starting contraception included lack of recent well visit (previous 12 mo) and concerns regarding barriers to acquiring contraception, such as cost, privacy, and where to obtain. Most female adolescents with sexual experience reported interest in same-day initiation of hormonal contraception in the ED. The ED visit may provide an opportunity to meet the contraceptive needs of adolescents, particularly for those who do not receive regular well care.  
Fine et al31  Survey Sexual activity (patient attitudes) Survey to assess sexual history, sexual health knowledge, and desire for sexual health education Fifty-six percent of adolescents (n = 77) reported previous sexual activity. Fourteen percent of those with previous sexual activity reported having unprotected sex in the past 5 d and thus could be candidates for EC. Approximately one-half of adolescents were interested in learning more about STIs in the ED, and approximately one-third were interested in learning more about HIV and birth control options. A significant percentage of sexually active adolescents surveyed were potential candidates for EC. Adolescents reported interest in receiving education about sexual health topics, such as STIs, contraception, and HIV, in the ED.  
Chernick et al33  Survey Sexual activity (patient attitudes) 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 (n = 459) reported current pregnancy. Among nonpregnant patients, approximately one-third reported using no contraception during the time of the last intercourse. The calculated PRI was 19.5 (19.5 pregnancies expected per 100 adolescents in 1 y) for the nonpregnant group. Of note, a higher PRI was associated with recent ED use and lack of a regular doctor. Approximately one-half of adolescents were supportive of sexual health screening in the ED, and one-fourth of adolescents were interested in starting oral contraceptive pills in the ED. Risk for pregnancy was high among adolescent patients in the ED, particularly for those with recent ED use and without a primary care provider. A significant proportion of adolescents were interested in starting contraception in the ED. 
Miller et al39  Qualitative Sexual activity (patient and clinician attitudes) Survey to assess acceptability of sexual health discussion, STI testing, and pregnancy testing in the ED; verbal explanation of answers also obtained from participants Overall, 91% of adolescents (n = 127) and parents (n = 90) were accepting of sexual health discussion, 81% of adolescents and 76% of parents were accepting of STD testing, and 83% of adolescents and 77% of parents were accepting of pregnancy testing. Comparatively, ∼60%–70% of clinicians (n = 190) were accepting of sexual health discussion and pregnancy testing, and ∼50% were accepting of STD testing. Among reasons for nonacceptance in HCPs, the dominant theme was a chief complaint not related to sexual health. Parents and adolescents were highly accepting of sexual health discussion, STD testing, and pregnancy testing in the acute care setting. Clinicians were comparatively less accepting, particularly if the visit was not related to sexual health.  
Jun et al60  Survey Substance use (clinician attitudes) Survey regarding SBIRT screening The majority of ED physicians felt that the ED was an appropriate venue for screening and intervention on alcohol use disorders. Fewer than half of respondents used a validated tool when screening for alcohol use. Twenty-five percent never conducted SBIRT (limited time and resources are barriers). Only 1.2% used SBIRT consistently. ED physicians used SBIRT in limited and nonstandardized ways.  
Spirito et al58  Cross-sectional Substance use Self-administered tablet questionnaire: NIAAA 2-question screen (the 2 questions differed between high school–aged and middle school–aged adolescents) Moderate to good test-retest reliability was found between questionnaire takers. The NIAAA 2-question screen is a valid and brief way to screen for alcohol use in pediatric EDs.  
Newton et al55  Systematic review Substance use Review of instruments used to assess alcohol and other drug use in pediatric patients in the ED (published in 2011; included studies published in 2000–2009) Six studies met inclusion criteria, and 11 instruments were evaluated (AUDIT, CAGE, CRAFFT, DISC Cannabis Symptoms, DSM-IV 2-item scale, FAST, RAFFT, RAPS4-QF, RBQ, RUFT-Cut, TWEAK). The DSM-IV 2-item scale was reported to have a sensitivity of 88%, a specificity of 90%, and an LR+ of 8.8. The DISC Cannabis Symptoms was reported to have a sensitivity of 96%, a specificity of 86%, and an LR+ of 6.83. 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?”32  
Burke et al59  Narrative review Substance use Reviews epidemiology, screening, and MI and brief interventions for substance use CRAFFT is a valid substance use screening tool for the adolescent population. If a patient screens positive, MI can be used to assess readiness to change and develop patient-driven brief interventions. It is important to conduct adolescent substance use screening in the ED. MI and brief intervention are effective methods to address high-risk behaviors. The FRAMES acronym tool can be used to outline brief interventions. 
Fairlie et al57  Cross-sectional Substance use AUDIT-10 Approximately 4% of younger adolescents (aged 13–15; n = 500) and 19% of older adolescents (aged 16–17; n = 359) screened positive on the AUDIT-10. The 3-item AUDIT-C and 5-item AUDIT-PC did not identify ∼25% and 60% of those who screened positive on the AUDIT-10, respectively. The AUDIT-10 may be a less useful tool in the younger adolescent population (13–15) compared with the older adolescent population (16–17) given the low rate of positive screen results in the younger group. The shorter versions of AUDIT (AUDIT-C and AUDIT-PC) failed to identify a significant proportion of adolescents with a positive AUDIT-10 result. Therefore, lower positive result screen cutoff scores may be necessary when using the AUDIT-C or AUDIT-PC in the adolescent population.  
Falcón et al61  Qualitative Substance use (clinician attitudes) Focus groups to assess clinician-perceived barriers to alcohol use screening and/or brief intervention for adolescents in the ED Among ED medical staff interviewed (n = 24), common perceived barriers to screening and intervention for adolescent alcohol use were time constraints, inadequate staffing, and concerns about parents’ reaction to screening. Most physicians felt screening and/or brief intervention would only be feasible if the patient presented for intoxication. Many physicians felt screening protocols were more appropriate in the primary care setting. 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.  
Linakis et al56  Cross-sectional Substance use Newton Screen: 3 questions on substance use based on DSM5 aimed at adolescents (self-administered tablet tool with follow-up phone calls) Alcohol use disorder: sensitivity = 78.3%, specificity = 93%; cannabis use disorder: sensitivity = 93.1%, specificity = 93.5% The Newton Screen may be a good brief screening tool for assessing alcohol and cannabis use. The Newton Screen had better sensitivity for cannabis use and good specificity for both. 
Erickson et al62  Cross-sectional Violence 8-item abbreviated CTS Prevalence of IPV was 36.6% in screened patients. Four screening questions identified 99% of patients who had experienced IPV. Four screening questions can capture patients at risk for IPV: “Have you felt unsafe in past relationships?” “Is there a partner from a previous relationship that is making you feel unsafe now?” “Have you been physically hit, kicked, shoved, slapped, pushed, scratched, bitten, or otherwise hurt by your boyfriend or dating partner when they were angry?” “Have you ever been hurt by a dating partner to the point where it left a mark or bruise?”  
Jackson et al63  Narrative review Violence Narrative review to explore ARA identification and intervention in the ED Youth presenting to the ED are at elevated risk of ARA (with reported prevalence of up to 55%). Computer-based interventions for adolescents who screen positive for ARA, as well as universal education in the form of wallet-sized cards, are promising and could be successful in the ED setting. 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.  
StudyStudy TypeRisk Behavior DomainInterventionResultsConclusions
Bernstein et al20  Implementation All domains Youth and Young Adult Health and Safety Needs Survey completed by HPAs Thirty-seven percent of adolescents (n = 2149) screened positive for substance use, and most of this group received a brief intervention (81%) and/or referral for substance abuse treatment (70%). An additional 496 patients received referrals for health risks not related to substance use. HPAs can be a valuable resource for providing screening and preventive interventions beyond the scope of an ED physician. Buy-in from physicians was difficult in the implementation phase. 
Nager et al22  Retrospective cohort All domains The ED-DRS, a nonvalidated screening tool to assess for health risk behaviors, was administered by physician trainees Of patients, 47.5% (n = 992) screened positive for risk behaviors, and 14% of these patients received a social worker referral. Those who screened positive were more likely to have a chronic medical condition. 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. 
Van Amstel et al21  Cross-sectional All domains 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% (n = 153) (P = .003). Most physicians who participated in the study (n = 10) reported they would support use of the HEADSS stamp if it was proven effective. Use of a visual reminder, such as a HEADSS stamp, on patient charts may increase rates of adolescent psychosocial screening in the ED. 
Ranney et al23  Survey All domains 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 (n = 234) were interested in receiving risk behavior–related care, even when screen results were negative. Approximately 50% reported a preference for technology-based care. Adolescents reported high rates of risky behaviors and interest in receiving interventions for these behaviors. Further study of technology-based behavioral interventions is warranted.  
Hengehold et al43  Survey Mood and SI ASQ on a validated self-screening tablet tool High risk for SI was identified in 93.4% of “yes” respondents and in 84.5% of the “no response” group. Youth who select “no response” are at elevated risk of SI and may warrant further screening and/or evaluation.  
Horowitz et al46  Mixed methods Mood and SI (patient attitudes) RSQ and SIQ Nonpsychiatric ED patients who were screened had a 5.7% prevalence of SI (clinically significant), and screening positively did not significantly increase the mean length of stay in the ED. SI screening of all patients in the ED is feasible and acceptable to adolescent patients.  
Horowitz et al44  Cross-sectional Mood and SI Survey of 17 candidate suicide screening questions 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%. The ASQ is a brief tool to assess suicide risk in pediatric patients in the ED and has a high sensitivity, specificity, and NPV.  
Hopper et al47  Cross-sectional Mood and SI The RSQ, a verbal 4-question suicide screening instrument Twenty-two percent of patients screened positive on the RSQ. However, none of the patients screened positive for SI on the SIQ (comparison standard). The questions that accounted for the false-positives on the RSQ were the following: “Has something very stressful happened to you in the past few weeks?” and “Have you ever tried to hurt yourself in the past?” 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).  
King et al45  Survey Mood and SI Written surveys: RADS-2, SIQ-JR, AUDIT-3, POSIT, BHS, and BIS-11; positive suicide risk screen result defined as follows: (1) positive SIQ-JR result or recent suicide attempt or (2) positive AUDIT-3 and RADS-2 results Sixteen percent (n = 295) screened positive for elevated suicide risk. Of those, 19% presented for nonpsychiatric complaints. Ninety-eight percent of adolescents with elevated suicide risk had a positive SIQ-JR result and/or a recent suicide attempt. Only 1 patient met elevated suicide risk criteria via positive RADS-2 and AUDIT-3 results (concurrent depression and alcohol use) and did not have a positive SIQ-JR result or a recent suicide attempt. Concurrent validity of the screening protocol was supported by significantly higher POSIT scores for adolescents who screened positive for alcohol use and/or depression and high BHS scores for those who screened positive for SI and/or a recent suicide attempt. A significant proportion of adolescents who screened positive for elevated suicide risk in the ED were presenting for nonpsychiatric reasons. Almost all patients deemed to have elevated suicide risk endorsed SI (SIQ-JR) and/or had a recent suicide attempt. 
Ambrose and Prager48  Narrative review Mood and SI Investigates different SI screening tools used in ED 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 ASQ, RSQ, CSSRS, and HEADS-ED have been all been validated in the ED setting. The CSSRS has been validated in multiple settings (including the ED and inpatient setting in patients with mental health problems). More research and development into risk screening algorithms and interventions is needed, specifically prospective controlled trials.  
Cronholm et al54  Qualitative Mood and SI (clinician attitudes) Semistructured interviews of clinicians to assess perceptions of depression in the adolescent population and thoughts about screening for depression in the ED All clinicians (n = 41) endorsed that depression is prevalent among adolescents and can have significant negative health effects. Identified barriers to screening include lack of rapport with patient, insufficient time, high patient acuity, lack of training, maintaining privacy, and appropriate response to positive screening results. ED clinicians acknowledged the importance of depression screening. However, many barriers to screening in the ED setting were reported. Most clinicians agreed that computerized depression screening could be a suitable approach to address many of the identified barriers to screening.  
Fein et al49  Mixed methods Mood and SI 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. Six-five percent agreed to screening (n = 857). Use of the BHS-ED increased identification of mental health problems to 4.2% of patients from 2.5% in the preimplementation period (OR 1.70; 95% CI 1.38–2.10). Patients were also more likely to be evaluated by a psychiatrist or social worker during the implementation phase (2.5% vs 1.7%; OR 1.47 [95% CI 1.13–1.90]). A computerized psychosocial screening tool, such as the BHS-ED, may be a feasible intervention to increase detection of mental health problems in adolescent patients in the ED.  
O’Mara et al51  Survey Mood and SI (patient attitudes) Questionnaire used to assess beliefs regarding screening and intervention for suicide risk and other mental health problems in the ED Eighty-six percent of adolescents (n = 294) and 92% of parents (n = 300) rated suicide screening in the ED as important. Speaking with a clinician in the ED was rated as the most helpful response to positive screening results by adolescents (82%) and parents (93%), followed by receiving information regarding further care (79% of adolescents, 93% of parents). Adolescents were most concerned about privacy (47%), and parents were most concerned about the adolescent being in too much pain and/or distress for screening (34%). Most adolescents and parents rated screening for suicide risk and other mental health problems in the ED as important. Female adolescents and parents were generally more supportive of mental health screening (other than suicide risk) than their male counterparts. Immediate intervention in the ED and receiving information for follow-up care were rated as the most helpful responses to a positive screening result.  
Ballard et al53  Qualitative Mood and SI (patient attitudes) Interview, primary question of interest: “Do you think ER nurses should ask kids about suicide/thoughts about hurting themselves…why or why not?” Ninety percent of adolescents (n = 165) reported they believe ED nurses should ask about suicide. The most common supportive themes were suicide identification, suicide prevention, connection between nurse and patient, linkage to appropriate resources, and feelings of isolation. The most common nonsupportive themes were feeling that suicide screening is irrelevant for nonpsychiatric visits, feeling that screening should be conditional, and concern about screening leading to increased SI and/or suicide attempts. Most adolescents support suicide risk screening in the ED. Adolescents expressed that screening could lead to identification, prevention, and treatment of suicidal thoughts and/or behavior as well as provide an opportunity to connect with the nurse for those who lack other sources of support.  
Ballard et al52  Qualitative Mood and SI (patient attitudes) Interview, primary question of interest (asked after standardized suicide screening): “Do you think ER nurses should ask kids about suicide/thoughts about hurting themselves…why or why not?” Ninety-six percent of adolescents (n = 156) supported suicide screening by nurses in the ED. Only 31% of patients with nonpsychiatric complaints and 44% of those with psychiatric complaints had previously been asked about suicide. Supportive themes included identification and prevention of suicide risk, a desire to be understood, connection to further resources, and lack of others to confide in. Almost all adolescents agreed that nurses should screen for suicide risk in the ED. Adolescents expressed that screening could lead to identification, prevention, and treatment of suicidal behavior.  
Patel et al50  Cross-sectional Mood and SI SI screening via 2-question paper survey Eighty-two percent of patients who screened positively were referred to outpatient mental health, and 10% were admitted to a psychiatric facility. Screening in the urgent care setting helped identify adolescents at risk for SI, most of whom did not have mental health–related chief complaints, and this led to interventions in the form of referrals or urgent admission.  
Shamash et al36  Mixed methods Sexual activity (patient attitudes) Survey eliciting sexual history, preferences for partner STI notification, and partner EPT Two-thirds of patients surveyed did not prefer EPT and cited reasons such as importance of determining partner STI status, partner safety, partner accountability, and importance of clinical interaction. A majority of patients in the ED did not prefer EPT, and clinicians should address concerns if they do plan to prescribe EPT.  
Ahmad et al34  Cross-sectional Sexual activity (patient attitudes) Sexual activity self-disclosure tool (ACASI) Of those who participated, 89.2% reported willingness to receive STI testing if it was recommended (regardless of reason for ED visit). Of those who ended up needing it, 92% had answered yes before knowing. A computerized self-disclosure tool is a feasible way to collect sensitive adolescent data, and adolescents prefer self-disclosure methods and were willing to disclose sexual activity behaviors and receive STI testing, regardless of the chief complaint.  
Solomon et al30  Survey Sexual activity (patient attitudes) Web-based questionnaire on pregnancy risk 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. There is a high unintended pregnancy risk in adolescents using the ED. Teenagers report wanting to receive pregnancy and STI preventive care in the ED, regardless of the reason to visit.  
Goyal et al28  Randomized controlled trial Sexual activity Computerized health survey and guided decision-making tool for physicians in intervention arm The STI testing frequency (intervention) was higher in the intervention group (52.3% vs 42%; OR 2.0 [95% CI 1.1–3.8]) and in asymptomatic patients (28.6% vs 8.2%; OR 4.7 [95% CI 1.4–15.5]). Providing decision support to physicians on the basis of survey results led to an increase in intervention (STI testing).  
Goyal et al35  Qualitative Sexual activity (patient attitudes) 20-item sexual health survey Of respondents, 76.5% preferred an electronic survey to face-to-face interviews. There was no difference in the median length of ED stay between those who completed the survey and those who did not. A sexual health screening electronic tool was acceptable to patients and feasible in terms of workflow in the ED.  
Miller et al42  Mixed methods Sexual activity (patient and clinician attitudes) Computerized survey to assess acceptability and usefulness of a sexual health CDS system ED clinicians (n = 57) rated the CDS system as very or somewhat useful on average. Clinicians reported time constraints, privacy concerns, and technological issues as potential barriers to CDS system use. Ninety-five percent of adolescents (n = 57) reported that the CDS system questionnaire was very or somewhat easy to use and understand. Both adolescents (69%) and clinicians (65%) preferred computerized sexual health screening. A sexual health CDS system for adolescents in the ED received high acceptability and usability ratings from ED clinicians and adolescents. Further research is needed to assess the effectiveness of the CDS system in improving adolescent sexual health care.  
Mollen et al37  Survey Sexual activity (patient attitudes) Survey of female adolescent patients using ACA software Female adolescents showed preference for in-person counseling, from a person of authority (doctor, nurse) rather than from a peer counselor. Adolescents prefer in-person counseling and target education (related to their chief complaint).  
Miller et al41  Qualitative Sexual activity (Clinician attitudes) Semistructured focus groups covering thoughts and experience with EC; written survey to assess EC knowledge Clinicians (n = 85) had low scores on the survey to assess EC knowledge. In focus groups, most physicians and NPs supported EC availability to adolescents but did not believe the ED was the best place for EC prescription and did not support routine screening for EC candidacy. Nurses were more likely to express that EC should only be available to teenagers in select scenarios, such as after sexual assault. EC knowledge was poor among clinicians surveyed. ED physicians and NPs were more likely than nurses to support providing adolescents with EC, but most did not agree with routine screening for EC need in the ED.  
Miller et al29  Cross-sectional Sexual activity MI-based brief intervention to assess sexual behaviors and provide personalized treatment (STI testing, contraception) and referral for follow-up care Sixty-five percent of participants (n = 20) accepted at least 1 health care service in the ED, including CT and/or GC testing, provision of condoms, HIV testing, and EC, and 60% accepted referral to an adolescent clinic. The average length of the intervention was ∼15 min. Eighty percent of participants reported being very satisfied with the intervention. Seventy-eight percent of participants reported the interventionist maintained high fidelity to MI principles. An MI-based intervention in the ED may be feasible and effective at promoting adolescent sexual health. Further study is warranted.  
Beckmann et al27  Retrospective cohort Sexual activity Documentation of sexual history A total of 862 charts of adolescents discharged from the ED with an STI diagnosis were reviewed. 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%). No documentation of sex of partners, partner’s STI risk, partner’s drug use, anal sex practice, or use of contraception other than condoms was found in charts reviewed. Sexual history documentation was incomplete in charts of adolescents discharged from the ED with STI diagnosis.  
Miller et al32  Survey Sexual activity (patient attitudes) Computerized survey to assess sexual history and interest in interventions in the ED Of adolescents surveyed (n = 168), approximately two-thirds were interested in same-day initiation of some form of hormonal contraception, including LARC. Factors associated with interest in starting contraception included lack of recent well visit (previous 12 mo) and concerns regarding barriers to acquiring contraception, such as cost, privacy, and where to obtain. Most female adolescents with sexual experience reported interest in same-day initiation of hormonal contraception in the ED. The ED visit may provide an opportunity to meet the contraceptive needs of adolescents, particularly for those who do not receive regular well care.  
Fine et al31  Survey Sexual activity (patient attitudes) Survey to assess sexual history, sexual health knowledge, and desire for sexual health education Fifty-six percent of adolescents (n = 77) reported previous sexual activity. Fourteen percent of those with previous sexual activity reported having unprotected sex in the past 5 d and thus could be candidates for EC. Approximately one-half of adolescents were interested in learning more about STIs in the ED, and approximately one-third were interested in learning more about HIV and birth control options. A significant percentage of sexually active adolescents surveyed were potential candidates for EC. Adolescents reported interest in receiving education about sexual health topics, such as STIs, contraception, and HIV, in the ED.  
Chernick et al33  Survey Sexual activity (patient attitudes) 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 (n = 459) reported current pregnancy. Among nonpregnant patients, approximately one-third reported using no contraception during the time of the last intercourse. The calculated PRI was 19.5 (19.5 pregnancies expected per 100 adolescents in 1 y) for the nonpregnant group. Of note, a higher PRI was associated with recent ED use and lack of a regular doctor. Approximately one-half of adolescents were supportive of sexual health screening in the ED, and one-fourth of adolescents were interested in starting oral contraceptive pills in the ED. Risk for pregnancy was high among adolescent patients in the ED, particularly for those with recent ED use and without a primary care provider. A significant proportion of adolescents were interested in starting contraception in the ED. 
Miller et al39  Qualitative Sexual activity (patient and clinician attitudes) Survey to assess acceptability of sexual health discussion, STI testing, and pregnancy testing in the ED; verbal explanation of answers also obtained from participants Overall, 91% of adolescents (n = 127) and parents (n = 90) were accepting of sexual health discussion, 81% of adolescents and 76% of parents were accepting of STD testing, and 83% of adolescents and 77% of parents were accepting of pregnancy testing. Comparatively, ∼60%–70% of clinicians (n = 190) were accepting of sexual health discussion and pregnancy testing, and ∼50% were accepting of STD testing. Among reasons for nonacceptance in HCPs, the dominant theme was a chief complaint not related to sexual health. Parents and adolescents were highly accepting of sexual health discussion, STD testing, and pregnancy testing in the acute care setting. Clinicians were comparatively less accepting, particularly if the visit was not related to sexual health.  
Jun et al60  Survey Substance use (clinician attitudes) Survey regarding SBIRT screening The majority of ED physicians felt that the ED was an appropriate venue for screening and intervention on alcohol use disorders. Fewer than half of respondents used a validated tool when screening for alcohol use. Twenty-five percent never conducted SBIRT (limited time and resources are barriers). Only 1.2% used SBIRT consistently. ED physicians used SBIRT in limited and nonstandardized ways.  
Spirito et al58  Cross-sectional Substance use Self-administered tablet questionnaire: NIAAA 2-question screen (the 2 questions differed between high school–aged and middle school–aged adolescents) Moderate to good test-retest reliability was found between questionnaire takers. The NIAAA 2-question screen is a valid and brief way to screen for alcohol use in pediatric EDs.  
Newton et al55  Systematic review Substance use Review of instruments used to assess alcohol and other drug use in pediatric patients in the ED (published in 2011; included studies published in 2000–2009) Six studies met inclusion criteria, and 11 instruments were evaluated (AUDIT, CAGE, CRAFFT, DISC Cannabis Symptoms, DSM-IV 2-item scale, FAST, RAFFT, RAPS4-QF, RBQ, RUFT-Cut, TWEAK). The DSM-IV 2-item scale was reported to have a sensitivity of 88%, a specificity of 90%, and an LR+ of 8.8. The DISC Cannabis Symptoms was reported to have a sensitivity of 96%, a specificity of 86%, and an LR+ of 6.83. 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?”32  
Burke et al59  Narrative review Substance use Reviews epidemiology, screening, and MI and brief interventions for substance use CRAFFT is a valid substance use screening tool for the adolescent population. If a patient screens positive, MI can be used to assess readiness to change and develop patient-driven brief interventions. It is important to conduct adolescent substance use screening in the ED. MI and brief intervention are effective methods to address high-risk behaviors. The FRAMES acronym tool can be used to outline brief interventions. 
Fairlie et al57  Cross-sectional Substance use AUDIT-10 Approximately 4% of younger adolescents (aged 13–15; n = 500) and 19% of older adolescents (aged 16–17; n = 359) screened positive on the AUDIT-10. The 3-item AUDIT-C and 5-item AUDIT-PC did not identify ∼25% and 60% of those who screened positive on the AUDIT-10, respectively. The AUDIT-10 may be a less useful tool in the younger adolescent population (13–15) compared with the older adolescent population (16–17) given the low rate of positive screen results in the younger group. The shorter versions of AUDIT (AUDIT-C and AUDIT-PC) failed to identify a significant proportion of adolescents with a positive AUDIT-10 result. Therefore, lower positive result screen cutoff scores may be necessary when using the AUDIT-C or AUDIT-PC in the adolescent population.  
Falcón et al61  Qualitative Substance use (clinician attitudes) Focus groups to assess clinician-perceived barriers to alcohol use screening and/or brief intervention for adolescents in the ED Among ED medical staff interviewed (n = 24), common perceived barriers to screening and intervention for adolescent alcohol use were time constraints, inadequate staffing, and concerns about parents’ reaction to screening. Most physicians felt screening and/or brief intervention would only be feasible if the patient presented for intoxication. Many physicians felt screening protocols were more appropriate in the primary care setting. 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.  
Linakis et al56  Cross-sectional Substance use Newton Screen: 3 questions on substance use based on DSM5 aimed at adolescents (self-administered tablet tool with follow-up phone calls) Alcohol use disorder: sensitivity = 78.3%, specificity = 93%; cannabis use disorder: sensitivity = 93.1%, specificity = 93.5% The Newton Screen may be a good brief screening tool for assessing alcohol and cannabis use. The Newton Screen had better sensitivity for cannabis use and good specificity for both. 
Erickson et al62  Cross-sectional Violence 8-item abbreviated CTS Prevalence of IPV was 36.6% in screened patients. Four screening questions identified 99% of patients who had experienced IPV. Four screening questions can capture patients at risk for IPV: “Have you felt unsafe in past relationships?” “Is there a partner from a previous relationship that is making you feel unsafe now?” “Have you been physically hit, kicked, shoved, slapped, pushed, scratched, bitten, or otherwise hurt by your boyfriend or dating partner when they were angry?” “Have you ever been hurt by a dating partner to the point where it left a mark or bruise?”  
Jackson et al63  Narrative review Violence Narrative review to explore ARA identification and intervention in the ED Youth presenting to the ED are at elevated risk of ARA (with reported prevalence of up to 55%). Computer-based interventions for adolescents who screen positive for ARA, as well as universal education in the form of wallet-sized cards, are promising and could be successful in the ED setting. 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.  

ACA, adaptive conjoint analysis; ACASI, audio-enhanced computer-assisted self-interview; ARA, adolescent relationship abuse; AUDIT-C, Alcohol Use Disorders Identification Test—Consumption; AUDIT-PC, Alcohol Use Disorders Identification Test-(Piccinelli) Consumption; AUDIT-3, 3-Item Alcohol Use Disorder Identification Test; AUDIT-10, 10-Item Alcohol Use Disorder Identification Test; BHS, Beck Hopelessness Scale; BIS-11, Barratt Impulsivity Scale; CAGE, Cut down, Annoyed, Guilty, Eye-opener; CDS, clinical decision support; CRAFFT, Car, Relax, Alone, Forget, Friends, Trouble; CSSRS, Columbia Suicide Severity Rating Scale; CT, Chlamydia trachomatis; CTS, Conflict Tactics Survey; DSM5, Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition; EC, emergency contraception; ED-DRS, Emergency Department Distress Response Screener; EPT, expedited partner therapy; ER, emergency department; FAST, Fast Alcohol Screening Test; GC, Neisseria gonorrhoeae; HCP, health care provider; HEADS-ED, Home, Education, Activities and peers, Drugs and alcohol, Suicidality, Emotions and behaviors, Discharge resources; IPV, intimate partner violence; LARC, long-acting reversible contraception; LR+, positive likelihood ratio; NIAAA, National Institute of Alcohol Abuse and Alcoholism; NP, nurse practitioner; NPV, negative predictive value; POSIT, Problem Oriented Screening Instrument for Teenagers; PRI, pregnancy risk index; PTSD, posttraumatic stress disorder; RADS-2, Reynolds Adolescent Depression Screening, Second Edition; RAFFT, Relax, Alone, Friends, Family, Trouble; RAPS4-QF, Remorse, Amnesia/blackouts, Perform, Starter/eye-opener, Quantity, Frequency; RBQ, Reckless Behavior Questionnaire; RUFT-Cut, Riding with a drinking driver, Unable to stop, Family/Friends, Trouble, Cut down; SIQ, Suicidal Ideation Questionnaire; SIQ-JR, Suicidal Ideation Questionnaire Junior; STD, sexually transmitted disease; TWEAK, Tolerance, Worried, Eye-opener, Amnesia, Kut-down .

Screening Rates

Documentation of sexual activity screening of adolescents was low in both ED and hospital settings. In retrospective cohort studies by Riese et al,24  McFadden et al,25  and Stowers and Teelin,26  sexual activity screening rates in the hospital setting are described. 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 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. 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 

Screening Tools and Interventions

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. Forty-six percent of patients were due for the human papillomavirus (HPV) vaccine, and 19% of these received it during admission.25 

In the ED, researchers of a single-blind randomized controlled trial tested a computerized self-administered screening tool to identify adolescent patients who were at risk for STIs. In the intervention arm, the results of the screen provided decision support for ED physicians. 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) 1.1–3.8]). These findings were more pronounced in adolescents without symptoms of STI (28.6% vs 8.2%; OR 4.7 [95% CI 1.4–15.5]).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.

Adolescent, Parent, and Clinician Attitudes

In several of the included studies in the sexual activity domain, researchers looked at attitudes of adolescent patients, parents, and clinicians toward adolescents being screened in acute care settings. 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. 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. 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. 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.

Parents were overall supportive of sexual activity screening and care provision in the ED and hospital setting. In fact, in a study by Miller et al,39  parents were more accepting of sexual activity screening and STI testing than surveyed clinicians.

In the hospital setting, the top 3 barriers to sexual activity screening among clinicians included concerns about follow-up (63%), lack of knowledge regarding contraception (59%), and time constraints (53%). 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. In several ED studies, authors cited concerns from clinicians that the ED was not the appropriate setting to address sexual activity, particularly if it was not related to the patient’s presenting problem.39,41  Clinicians in the ED setting had a preference for computerized screening tools as well.42 

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).

Screening Rates

No studies were found.

Screening Tools and Interventions

In our review, we found several reports on various SI screening tools in acute care settings, including the Ask Suicide-Screening Questionnaire (ASQ), the Risk of Suicide Questionnaire (RSQ), and the Behavioral Health Screening–Emergency Department (BHS-ED); these studies indicate the potential promise of these tools and also reveal significant SI risk in adolescents presenting for nonpsychiatric issues. The ASQ has been widely referenced in literature as a brief and feasible tool to assess suicide risk in pediatric patients in the ED.43  The ASQ 4-question screen has a sensitivity of 96.9%, a specificity of 87.6%, and a negative predictive value of 99.7%.44  In their review, King et al45  found that universal screening for mood and SI in the ED setting can identify a clinically significant number of patients who have active SI but are presenting for unrelated medical reasons. 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. The authors concluded that a more general psychosocial risk screen, such as the HEADSS, should be implemented instead.47  Ambrose and Prager48  described potential screening tools for SI (eg, ASQ and RSQ) and concluded that these tools need further prospective study and validation in a general population of adolescents without mental health complaints.

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. 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 1.38–2.10), with higher rates of social work or psychiatry evaluation in the ED (2.5% vs 1.7%; OR 1.47 [95% CI 1.13–1.90]).

A 2-question SI screen was piloted by Patel et al50  in an urgent care setting to identify adolescents at risk for SI. Most adolescents who screened positive did not have mental health–related 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). Specifically, 5 of 10 patients who met criteria for inpatient psychiatric facility admission did not have an initial mental health–related chief complaint.50 

Adolescent, Parent, and Clinician Attitudes

In a cross-sectional survey, O’Mara 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. 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. 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. The biggest concerns from adolescent patients included worries about privacy issues.51 

Parental reservations regarding screening were focused on the patient being in too much pain or distress for screening.46  Other identified hesitations were fear of a lack of focus on nonpsychiatric chief complaints and possible iatrogenic harm secondary to screening.53 

Clinicians felt that a computerized depression screen would overcome many of the identified barriers (lack of rapport, time constraints, high patient acuity, lack of training or comfort, privacy concerns, and uncertainty with next steps), but they endorsed a need for support to facilitate connecting patients with mental health resources and interventions.54 

Seven studies on substance use screening and intervention were included in our review; all took place in the ED setting (Table 4).

Screening Rates

No studies were found.

Screening Tools and Interventions

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. 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 school–aged versus high school–aged 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. MI avoids confrontation, and the authors note that both of these evidence-based tools work with a patient’s readiness to change and build awareness of the problem, resulting in increased self-efficacy for the adolescent.59 

Adolescent, Parent, and Clinician Attitudes

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. Falcón 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.

There were no studies on patient or parent attitudes toward substance use screening or interventions.

Two studies on abuse and violence screening and intervention were included in our review; both took place in the ED setting (Table 4).

Screening Rates

No studies were found.

Screening Tools and Interventions

In their study, Erickson et al62  described screening and intervention regarding abuse or violence, specifically focusing on evaluating risk of intimate partner violence with an 8-item screening tool (the Conflict Tactics Survey). They found that the risk of intimate partner violence in female adolescents who presented to the ED was high (37%) and that 4 screening questions had 99% sensitivity.62 

In a narrative review by Jackson et al63  on adolescent relationship abuse screening and interventions in the ED, the authors described successful outpatient interventions that could be easily adapted for the ED setting. They described targeted computer modules as interventions for adolescents who screen positive or, alternatively, use of a universal education intervention, such as a wallet-sized informational card.

Adolescent, Parent, and Clinician Attitudes

No studies were found.

The studies in our review reveal ubiquitously low rates of risk behavior screening in the ED and hospital setting across all risk behavior domains. Our study also highlights the general dearth of studies on the topic (only 7 studies in the hospital setting, only 2 studies with low risk of bias based on our analysis). We outline potential tools and approaches for improving adherence to guideline-recommended comprehensive screening and adolescent health outcomes.

Although comprehensive risk behavior screens (eg, the American Academy of Pediatrics Bright Futures64  and HEADSS3,65 ) remain the gold standard, they have not been validated in the ED or hospital setting. We report on a number of successful domain-specific screening tools validated in ED and hospital settings. The Sexual Health Screen reported on by Goyal et al35  presents a feasible and valid way to screen for sexual and reproductive health. For mood and SI screening, validated tools include the ASQ and RSQ.48,53  For substance use screening, potential tools include the Newton Screen, the National Institute of Alcohol Abuse and Alcoholism 2-question screen, and SBIRT.56,58,66  For intimate partner violence screening, Erickson et al62  validated the 8-item Conflict Tactics Survey. These brief validated tools within single risk behavior domains could potentially be combined into a single comprehensive screen (with consideration that these screening tools may have been validated for specific populations and plans to assess feasibility and time burdens).

When patients screen positive for risky behaviors, it is imperative to have strategies and resources in place to address these behaviors. MI has been demonstrated to be feasible, effective, and a preferred method to change risky behavior across all risk behavior domains in ED and hospital settings.29,59,67  Specifically, the FRAMES acronym provides a promising framework for MI for adolescent substance use but can be applied to any high-risk behavior change.59  However, some adolescents may instead prefer paper materials or brochures over face-to-face counseling, so this presents an alternative option.38  As demonstrated in the McFadden et al25  study, other interventions to consider implementing in the ED and hospital settings include STI testing and treatment, contraceptive provision, HPV vaccination, and referral to subspecialty resources (both inpatient and outpatient). 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.

We found that although clinicians and patients are receptive to risk behavior screening and interventions in these settings, they also report several barriers.54  Clinicians are concerned that parents may object to screening; however, parents favor screening and intervention as long as their child is not in too much pain or distress.46  Clinicians additionally identify obstacles such as time constraints, lack of education or knowledge on the topic, and concerns about adolescent patients’ reactions.40,60,61  Additionally, adolescent patients report concerns around privacy and confidentiality of disclosed information.51 

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). Promising methods to increase screening rates include self-disclosure electronic screening tools coupled with reminders for clinicians (paper or within the EHR). 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). Another option is creating labeling functions within the EHR for children aged 13 to 18 so clinicians can label whether each problem, medication, or diagnostic test result can be accessed by the patient, parents, or both.69  In a recently published scoping review, Wong et al70  further explore possible systemic solutions in designing digital health technology that captures and delivers preventive services to adolescents while maximizing safety and privacy.

A limitation of this scoping review is heterogeneity in the design and quality of the included studies, with only 1 randomized controlled trial in our area of focus. Additionally, most studies of screens or interventions have thus far been limited to a single study done in 1 center, thus limiting generalizability. With the heterogeneity of studies included, we could only summarize findings but could not perform a meta-analysis. Also, most studies had limited durations of follow-up, so we cannot comment on long-term effects. 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.

ED and hospital encounters present a missed opportunity for increasing risk behavior screening and care provision for adolescent patients; current rates of screening and intervention are low. 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. Promising solutions include self-disclosure via electronic screening tools, educational sessions for clinicians, and clinician reminders to complete screening. More prospective controlled studies are needed to evaluate such interventions in ED and hospital settings.

We acknowledge Evans Whitaker, MD, MLIS, for his assistance with the literature search.

Dr Pfaff conceptualized and designed the study, conducted the literature search, screened literature for inclusion, extracted data from included studies, and drafted and edited the manuscript; Dr DaSilva helped in study design, conducted the literature search, screened literature for inclusion, extracted data, and helped with drafting the original manuscript; Dr Ozer helped in study design, editing and revising the manuscript, and critically appraising the manuscript content; Dr Kaiser supervised the conceptualization and design of the study, supervised the data extraction from the included literature, and helped in revising and editing the manuscript; and all authors approved the final manuscript as submitted and agree to be accountable for all aspects of the work.

FUNDING: Dr Kaiser is supported by grants from the Agency for Healthcare Research and Quality (K08HS024592 and R03HS027041). 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. These funders played no role in the study design, analysis, or preparation of this article.

     
  • ASQ

    Ask Suicide-Screening Questionnaire

  •  
  • AUDIT

    Alcohol Use Disorder Identification Test

  •  
  • BHS-ED

    Behavioral Health Screening–Emergency Department

  •  
  • CI

    confidence interval

  •  
  • DISC

    Diagnostic Interview Schedule for Children

  •  
  • DSM-IV

    Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition

  •  
  • ED

    emergency department

  •  
  • EHR

    electronic health record

  •  
  • FRAMES

    feedback, responsibility, advice, menu, empathy, self-efficacy

  •  
  • HEADSS

    home, education, activities, drugs, sexual activity, suicide and/or mood

  •  
  • HPA

    health promotion advocate

  •  
  • HPV

    human papillomavirus

  •  
  • MI

    motivational interviewing

  •  
  • OR

    odds ratio

  •  
  • RSQ

    Risk of Suicide Questionnaire

  •  
  • SBIRT

    screening, brief intervention, and referral to treatment

  •  
  • SI

    suicidal ideation

  •  
  • STI

    sexually transmitted infection

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Competing Interests

POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.

FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.

Supplementary data