Assessing Violence Risk in Adolescents in the Pediatric Emergency Department: Systematic Review and Clinical Guidance

Behavioral Health Flag Use by Race and Ethnicity in a Pediatric Emergency Department

Importance

Behavioral health flags are intended to serve as safety alerts for staff by identifying patients at risk of aggression but may also be prone to racial bias, leading to inequities in care.

Objective

To investigate racial and ethnic differences in the use of an aggression risk evaluation tool and being labeled as high aggression risk in the electronic health record among youths presenting to a pediatric emergency department.

Design, Setting, and Participants

This cross-sectional study of electronic health record data was conducted at a single-center pediatric emergency department. Visits from patients aged 21 years or younger presenting with mental health-related concerns between January 2020 and December 2022 were included.

Exposure

Patient race and ethnicity (Hispanic, non-Hispanic Black [hereafter, Black], non-Hispanic White [hereafter, White], or other, which includes individuals who identify as American Indian or Alaska Native, Asian, multiple races, or any other race).

Main Outcomes and Measures

The primary outcomes were (1) the use of an aggression risk evaluation tool by a psychiatric social worker, (2) being labeled with a high aggression risk behavioral health flag, or (3) being labeled with a high aggression risk behavioral health flag with a history of violent behavior documented with no other aggression risk behaviors documented. Separate logistic regression models were used to examine association of race and ethnicity with each outcome.

Results

There were 5121 visits for mental health concerns. The majority of patients were female (3198 patients [62.5%]) and publicly insured (3161 patients [61.8%), with a mean (SD) age of 13.8 (2.7) years. With regard to race and ethnicity, 3061 patients (59.8%) were Black, 893 patients (17.4%) were Hispanic, 778 (15.2%) were White, and 389 (7.6%) belonged to other racial and ethnic groups. Most visits (4119 visits [80.4%]) had an aggression risk evaluation tool completed, and 627 (15.2%) were labeled with a high aggression risk behavioral health flag. There were no racial and ethnic differences in use of the aggression risk evaluation tool. Compared with White youths, Black youths were more likely to be labeled as high aggression risk (60 White youths [9.8%] vs 486 Black youths [19.8%]; adjusted odds ratio, 1.71; 95% CI 1.24-2.35). Among patients who had a history of violent behavior and no other aggression risk behaviors documented on the evaluation tool, Black patients had higher odds of being labeled as high aggression risk compared with White patients (72 Black patients [32.4%] vs 3 White patients [10.7%]; odds ratio, 4.00; 95% CI, 1.16-13.69).

Conclusions and Relevance

In this cross-sectional study, Black youths were more likely to be labeled with a high aggression risk behavioral health flag despite similar responses to an aggression risk evaluation tool. Processes to ensure equitable care delivery are critically needed.

Anger and associated risk and protective factors among rural American adolescents: Implications for violence prevention

Background

Adolescent violence in the United States is a prevalent public health problem and is understudied in rural settings. Anger is a significant risk factor for adolescent violence. To better craft adolescent violence interventions, it is important to examine anger and identify its most significant associated factors.

Aims

This study examined (1) self-reported anger changes over time for rural American adolescents; and (2) structural, community, interpersonal, and individual level factors that may contribute to anger.

Methods

We analyzed self-reported survey data from West Virginian middle schoolers (N = 2861) with anger as the outcome. Data was collected twice yearly from October 2020 through April 2023. Independent variables included perceptions of inequality, individual socioeconomic status (SES), neighborhood characteristics, family structure, support from adults at home and school, and harsh parenting.

Analysis

Generalized estimating equation Poisson regression models for main effects and gender interaction were used. Parameter estimates were exponentiated and interpreted as Rate Ratios (RR). Self-reported gender was an effect modifier.

Results

Significant main effects included perceived inequality (RR = 0.98, 95 % CI = 0.97-0.99), SES (RR = 0.99, 95 % CI = 0.98-0.99), supportive adults at school (RR = 0.99, 95 % CI = 0.98-0.99), primary caregiver support (RR = 0.99, 95 % CI = 0.98-0.99), and harsh parenting (RR = 1.10, 95 % CI = 1.05-1.05). Significant gender interaction terms included perceived harsh parenting (RR = 0.98, 95 % CI = 0.97-0.99) and supportive adults at school (RR = 1.01, 95 % CI = 1.00-1.02) for 'other' genders (i.e., participants identifying as neither boy nor girl) compared to boys.

Conclusions

Findings underline the importance of examining rural adolescent anger development and associated risk factors for designing prevention approaches to curb downstream violent behavior.

Youth Violence Does not Discriminate: Inclusive Violence Prevention Support Services Focused on Counseling and Peer Support are Essential for Youth and Young Adults

BACKGROUND

Violence disproportionately affects individuals of low socioeconomic status, and rates of injury amongst youth and young adults (YYAs) are rising. Little is known about how the social needs of this high-risk subgroup compared to the overall violently injured population.

METHODS

This is a retrospective review of an intake assessment of violently injured victims admitted to a level I trauma center (Jan 2022-Aug 2023). Data collected include race, age, mechanism of injury, and protective and predisposing factors for violent injury. We compared the risk factors of YYAs (=≤ 24 years) to those of adults (>24) and evaluated rates and types of violence prevention services requested by age group.

RESULTS

Of 350 individuals surveyed, 94 (27%) were <= 24 years and 256 (73%) were >24 years. Younger patients were less likely to be male (77% vs 86%, P = .03) and experienced more firearm injury (76% vs 51%, P < .001). They reported less alcohol use (20% vs 38%, P < .001), similar rates of mental illness (25% vs 26%, P = .62), less housing instability (5% vs 22%, P < .001), and similar access to government benefits (20% vs 29%, P = .2) compared to the older cohort. Services were requested by 41% of the study population (N = 142); the younger cohort was 2.9 times more likely to request non-financial services (P = .042).

DISCUSSION

Violently injured youth and young adults (YYAs) experience disproportionately high rates of gun violence. Efforts should be made to prioritize legal, peer support, and mental health services over financial services for this population.

Risk assessment for aggressive behaviour in schizophrenia

BACKGROUND

Aggressive or violent behaviour is often associated with people with schizophrenia in common perceptions of the disease. Risk assessment methods have been used to identify and evaluate the behaviour of those individuals who are at the greatest risk of perpetrating aggression or violence or characterise the likelihood to commit acts. Although many different interventions have been developed to decrease aggressive or violent incidences in inpatient care, staff working in inpatient settings seek easy-to-use methods to decrease patient aggressive events. However, many of these are time-consuming, and they require intensive training for staff and patient monitoring. It has also been recognised in clinical practice that if staff monitor patients' behaviour in a structured manner, the monitoring itself may result in a reduction of aggressive/violent behaviour and incidents in psychiatric settings.

OBJECTIVES

To assess the effects of structured aggression or violence risk assessment methods for people with schizophrenia or schizophrenia-like illnesses.

SEARCH METHODS

We searched the Cochrane Schizophrenia Group's Study-Based Register of Trials, which is based on CENTRAL, MEDLINE, Embase, CINAHL, PsycINFO, PubMed, ISRCTN registry, ClinicalTrials.gov, and WHO ICTRP, on 10 February 2021. We also inspected references of all identified studies.

SELECTION CRITERIA

We included all randomised controlled trials (RCTs) comparing structured risk assessment methods added to standard professional care with standard professional care for the evaluation of aggressive or violent behaviour among people with schizophrenia.

DATA COLLECTION AND ANALYSIS

At least two review authors independently inspected citations, selected studies, extracted data, and appraised study quality. For binary outcomes, we calculated a standard estimation of the risk ratio (RR) and its 95% confidence interval (CI). For continuous outcomes, we calculated the mean difference (MD) and its 95% CI. We assessed risk of bias in the included studies and created a summary of findings table using the GRADE approach.

MAIN RESULTS

We included four studies in the review. The total number of participants was not identifiable, as some studies provided number of participants included, and some only patient days. The studies compared a package of structured assessment methods with a control group that included routine nursing care and drug therapy or unstructured psychiatric observations/treatment based on clinical judgement. In two studies, information about treatment in control care was not available. One study reported results for our primary outcome, clinically important change in aggressive/violent behaviour, measured by the rate of severe aggression events. There was likely a positive effect favouring structured risk assessment over standard professional care (RR 0.59, 95% CI 0.41 to 0.85; 1 RCT; 1852 participants; corrected for cluster design: RR 0.59, 95% CI 0.37 to 0.93; moderate-certainty evidence). One trial reported data for the use of coercive measures (seclusion room). Compared to standard professional care, structured risk assessment may have little or no effect on use of seclusion room as days (corrected for cluster design: RR 0.92, 95% CI 0.27 to 3.07; N = 20; low-certainty evidence) or use of seclusion room as secluded participants (RR 1.83, 95% CI 0.39 to 8.7; 1 RCT; N = 20; low-certainty evidence). However, seclusion room may be used less frequently in the standard professional care group compared to the structured risk assessment group (incidence) (corrected for cluster design: RR 1.63, 95% CI 0.49 to 5.47; 1 RCT; N = 20; substantial heterogeneity, Chi2 = 0.0; df = 0.0; P = 0.0; I2 = 100%; low-certainty evidence). There was no evidence of a clear effect on adverse events of escape (RR 0.2, 95% CI 0.01 to 4.11; 1 RCT; n = 200; very low-certainty evidence); fall down (RR 0.33, 95% CI 0.04 to 3.15; 1 RCT; n = 200; very low-certainty evidence); or choking (RR 0.2, 95% CI 0.01 to 4.11; 1 RCT; n = 200; very low-certainty evidence) when comparing structured risk assessment to standard professional care. There were no useable data for patient-related outcomes such as global state, acceptance of treatment, satisfaction with treatment, quality of life, service use, or costs.

AUTHORS' CONCLUSIONS

Based on the available evidence, it is not possible to conclude that structured aggression or violence risk assessment methods are effective for people with schizophrenia or schizophrenia-like illnesses. Future work should combine the use of interventions and structured risk assessment methods to prevent aggressive incidents in psychiatric inpatient settings.

Appraising risk factors of aggression in children and adolescents at psychiatric inpatient units

This study examined predictors of aggression and assessed whether different subgroups of children and young people (CYP) display varying risks of aggressive incidents during hospitalization. Data from 10,090 children admitted to the psychiatric inpatient units of Cincinnati Children's Hospital between April 2010 and June 2021 were analysed. Multivariable logistic regression models were used to determine significant predictors associated with aggression, followed by average marginal effects and cluster analyses to rank and establish clusters by the order of predictor importance. About 32.5% reported positive history of an aggressive incident. The mean BRACHA score was doubled compared to those without a prior history. The primary analysis showed that both younger and male CYPs had higher odds of aggressive incidents. We also found that CYP with an African descent, not being able to live with both biological parents, those who reported positive history of psychiatric hospitalisation, and prior externalising behaviours had higher odds of aggressive incidents. These findings have important clinical and public health implications, as they provide valuable knowledge for healthcare professionals to improve prevention strategies for aggression amongst this vulnerable population.

Machine Learning-Based Aggression Detection in Children with ADHD Using Sensor-Based Physical Activity Monitoring

Aggression in children is highly prevalent and can have devastating consequences, yet there is currently no objective method to track its frequency in daily life. This study aims to investigate the use of wearable-sensor-derived physical activity data and machine learning to objectively identify physical-aggressive incidents in children. Participants (n = 39) aged 7 to 16 years, with and without ADHD, wore a waist-worn activity monitor (ActiGraph, GT3X+) for up to one week, three times over 12 months, while demographic, anthropometric, and clinical data were collected. Machine learning techniques, specifically random forest, were used to analyze patterns that identify physical-aggressive incident with 1-min time resolution. A total of 119 aggression episodes, lasting 7.3 ± 13.1 min for a total of 872 1-min epochs including 132 physical aggression epochs, were collected. The model achieved high precision (80.2%), accuracy (82.0%), recall (85.0%), F1 score (82.4%), and area under the curve (89.3%) to distinguish physical aggression epochs. The sensor-derived feature of vector magnitude (faster triaxial acceleration) was the second contributing feature in the model, and significantly distinguished aggression and non-aggression epochs. If validated in larger samples, this model could provide a practical and efficient solution for remotely detecting and managing aggressive incidents in children.

Delays in commitment and treatment court proceedings worsen psychiatric and other medical conditions

OBJECTIVE

Adversarial hearings in hospital commitment and de novo treatment proceedings, or court hearings, delay psychiatric treatment in many jurisdictions. In Massachusetts, the "treatment over objection" process requires a court petition. For state hospital patients, the delay to treatment is an initial 34 day waiting period in addition to continuances of court hearings that extend treatment delays. This study examined the frequency of adverse medical events due to delayed court hearings within a forensic state hospital in the US.

METHODS

The study reviewed all (n = 355) treatment petitions filed by a Massachusetts forensic hospital from 2015 and 2016. The incidence and nature of adverse events (e.g. patient/staff assaults, milieu disruptions) and acute medical symptoms (e.g. catatonia, acute psychosis), before and after the Court granted a petition for treatment, were analyzed by two raters. Adverse events included patient and staff assaults, acute psychiatric symptoms, and milieu problems.

RESULTS

82.6 % of treatment petitions led to involuntary treatment, 16.6 % were withdrawn by the medical petition filer, and only 0.8 % petitions were denied by the judge. Adversarial hearings occasioned an average delay of 41 days from treatment petition filing to receipt of standing treatment in addition to statute required delays. Once treatment was court-approved, all types of adverse events were significantly reduced.

CONCLUSIONS

Results established that the court treatment hearing scheme exacerbates health and safety risks to patients with serious mental illness. Increasing physician and court personnel awareness of these risks is likely key to enhancing a patient-focused, rights-oriented approach to these matters. This and other recommendations is proposed for jurisdictions that deal with this problem around the world.