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BackgroundConcerns have been raised about the utility of self-report assessments in predicting future suicide attempts. Clinicians in pediatric emergency departments (EDs) often are required to assess suicidal risk. The Death Implicit Association Test (IAT) is an alternative to self-report assessment of suicidal risk that may have utility in ED settings.MethodsA total of 1679 adolescents recruited from 13 pediatric emergency rooms in the Pediatric Emergency Care Applied Research Network were assessed using a self-report survey of risk and protective factors for a suicide attempt, and the IAT, and then followed up 3 months later to determine if an attempt had occurred. The accuracy of prediction was compared between self-reports and the IAT using the area under the curve (AUC) with respect to receiver operator characteristics.ResultsA few self-report variables, namely, current and past suicide ideation, past suicidal behavior, total negative life events, and school or social connectedness, predicted an attempt at 3 months with an AUC of 0.87 [95% confidence interval (CI), 0.84-0.90] in the entire sample, and AUC = 0.91, (95% CI 0.85-0.95) for those who presented without reported suicidal ideation. The IAT did not add significantly to the predictive power of selected self-report variables. The IAT alone was modestly predictive of 3-month attempts in the overall sample ((AUC = 0.59, 95% CI 0.52-0.65) and was a better predictor in patients who were non-suicidal at baseline (AUC = 0.67, 95% CI 0.55-0.79).ConclusionsIn pediatric EDs, a small set of self-reported items predicted suicide attempts within 3 months more accurately than did the IAT.

Purpose: To assess implementation outcomes and potential efficacy of a user-informed, theory-based digital health intervention developed to improve adolescent and young adult (AYA) male sexual health., Methods: We conducted a pilot randomized controlled trial of sexually active male emergency department (ED) patients aged 14-21 years. Participants were randomized to the intervention (Dr. Eric, Emergency Room Interventions to improve Care) or usual care. Dr. Eric consists of an ED-based sexual health app followed by 3 months of interactive text messages. We assessed the feasibility, adoption, and fidelity among users. Condom use, defined as the number of sexual encounters with condoms divided by the total number of sexual encounters over the past 4 weeks, was the primary efficacy outcome., Results: We enrolled 119 patients; mean age was 17.9 years, 87% were Hispanic, and half used condoms at last intercourse. Dr. Eric demonstrated feasibility, with high rates of consent (86.2%) and follow-up (81.5%). Intervention participants found Dr. Eric acceptable, liking (86.2%) and recommending (87.9%) the program. 98% of intervention participants interacted with all five app modules; one-quarter opted out of text messaging. At 6-week follow-up, the intervention group more often used a condom compared to the control group [OR 3.57, 95% confidence interval (1.93, 6.60)], p < .001]; however, this significant difference did not sustain at 13 weeks., Discussion: Dr. Eric was feasible to deliver and acceptable to male AYA patients. To our knowledge, Dr. Eric is the first intervention to demonstrate evidence of short-term efficacy for improving condom use among male AYA in the ED., (Copyright © 2024 Society for Adolescent Health and Medicine. Published by Elsevier Inc. All rights reserved.)

Background: Adolescents and young adults frequently present to the emergency department (ED) for medical care and continue to have many unmet sexual health needs. Digital interventions show promise to improve adolescent and young adult sexual health; yet, few interventions focus on male ED patients, despite their infrequent use of contraceptives and rising rates of sexually transmitted infections., Objective: This paper describes the design and development of Dr. Eric (Emergency Room Interventions to Improve Care), a digital app focused on promoting condom use among sexually active adolescent and young adult male ED patients., Methods: This study followed 4 phases of app development, which were based on user-centered design and the software development lifecycle. In phase 1, define, we explored our target population and target health problem (infrequent condom use among male ED patients) by collecting key stakeholder input and conducting in-depth interviews with male patients and urban ED medical providers. In phase 2, discover, we partnered with a digital product agency to explore user experience and digital strategy. In phase 3, design, we refined Dr. Eric's content, a 5-part sexual health educational module and a 10-week SMS text messaging program that focuses on condom use and partner communication about effective contraceptives. We conducted semistructured interviews with male adolescent and young adults to gather feedback on the app and perform usability testing, editing the app after each interview. We also interviewed informatics experts to assess the usability of a high-fidelity prototype. Interviews were recorded and analyzed via descriptive thematic analysis; informatic expert feedback was categorized by Nielsen's heuristic principles. In phase 4, develop, we created the technical architecture and built a responsive web app. These findings were gathered leading to the final version of the digital Dr. Eric program., Results: Using data and key stakeholder input from phases 1 and 2, we iteratively created the Dr. Eric prototype for implementation in the ED setting. Interviews with 8 adolescent and young adult male ED patients suggested that users preferred (1) straightforward information, (2) a clear vision of the purpose of Dr. Eric, (3) open-ended opportunities to explore family planning goals, (4) detailed birth control method information, and (5) games presenting novel information with rewards. Five usability experts provided heuristic feedback aiming to improve the ease of use of the app. These findings led to the final version of Dr. Eric., Conclusions: Following these mobile health development phases, we created a digital sexual health mobile health intervention incorporating the principles of user experience and interface design. Dr. Eric needs further evaluation to assess its efficacy in increasing condom use among adolescent and young adult male ED patients. Researchers can use this framework to form future digital health ED-based digital interventions., (©Lauren S. Chernick, Mona Bugaighis, Victoria Daylor, Daniel Hochster, Evan Rosen, Rebecca Schnall, Melissa S Stockwell, David L. Bell. Originally published in JMIR Formative Research (https://formative.jmir.org), 04.10.2024.)

Objectives: More than 19 million adolescents seek care in the emergency department (ED) annually. We aimed to describe the knowledge, attitudes, and behaviors related to confidential adolescent care among pediatric ED physicians., Methods: We conducted a cross-sectional questionnaire of US physician members of the Pediatric Emergency Medicine Collaborative Research Committee survey listserv. The 24-item questionnaire assessed familiarity with adolescent confidentiality laws, attitudes toward providing confidential care, frequency of discussing behavioral health topics confidentially, and factors influencing the decision to provide confidential care. We dichotomized Likert responses and used χ 2 to compare subgroups., Results: Of 476 eligible physicians, 151 (32%) participated. Most (91. 4%) had completed pediatric emergency medicine fellowship. More participants reported familiarity with all sexual health-related laws compared with all mental health-related laws (64% vs 49%, P < 0.001). The median age at which participants thought it was important to begin routinely providing confidential care was 12 years; 9% thought confidential interviews should not be routinely conducted until older adolescence or at all. Their decision to provide confidential care was influenced by the following: chief complaint (97%), time (43%), language (24%), presence of family (23%) or friends (14%), and space (22%)., Conclusions: Respondents reported moderate familiarity with adolescent confidentiality laws. Although they viewed confidential care as something they were comfortable providing, the likelihood of doing so varied. Barriers to confidential care were influenced by their assessment of adolescents' behavioral health risk, which may contribute to health inequity. Future efforts are needed to develop strategies that augment confidential ED care for adolescents., Competing Interests: Disclosure: The authors declare no conflict of interest., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Suicide is a major public health crisis among youth. Several prominent theories, including the Interpersonal Theory of Suicide (IPTS), aim to characterize the factors leading from suicide ideation to action. These theories are largely based on findings in adults and require testing and elaboration in adolescents., Methods: Data were examined from high-risk 13-18-year-old adolescents (N = 167) participating in a multi-wave, longitudinal study; 63% of the sample exhibited current suicidal thoughts or recent behaviors (n = 105). The study included a 6-month follow-up period with clinical interviews and self-report measures at each of the four assessments as well as weekly smartphone-based assessments of suicidal thoughts and behaviors. Regression and structural equation models were used to probe hypotheses related to the core tenets of the IPTS., Results: Feelings of perceived burdensomeness were associated with more severe self-reported suicidal ideation (b = 0.58, t(158) = 7.64, p < .001). Similarly, burdensomeness was associated with more frequent ideation based on weekly smartphone ratings (b = 0.11, t(1460) = 3.41, p < .001). Contrary to IPTS hypotheses, neither feelings of thwarted belongingness, nor interactions between burdensomeness and thwarted belongingness were significantly associated with ideation (ps > .05). Only elevated depression severity was associated with greater odds of suicide events (i.e., suicide attempts, psychiatric hospitalizations, and/or emergency department visits for suicide concerns) during the follow-up period (OR = 1.83, t(158) = 2.44, p = .01). No effect of acquired capability was found., Conclusions: Perceptions of burdensomeness to others reflect a critical risk factor for suicidal ideation among high-risk adolescents. Null findings with other IPTS constructs may suggest a need to adopt more developmentally sensitive models or measures of interpersonal and acquired capability risk factors for youth. Refining methods and theoretical models of suicide risk may help improve the identification of high-risk cases and inform clinical intervention., (© 2023 Association for Child and Adolescent Mental Health.)

Youth between the ages of 13 and 24 account for over 20% of new HIV diagnoses in the United States but are the least likely age group to be HIV tested in healthcare settings including the emergency department. This is in part due to the fact that almost 50% of youth decline testing when offered. We elucidated youth patients' perspectives on barriers to and facilitators of routine HIV testing of youth in an urban emergency department setting. Thirty-seven patients aged 13-24 years were recruited from the pediatric and adult emergency departments at a high-volume hospital in New York City from August 2019 to March 2020. Semi-structured in-depth interviews were conducted with all participants. Interviews were audio-recorded and transcribed verbatim, and transcripts were coded using an inductive thematic analysis approach. Youths' main reasons for declining HIV testing when offered included low risk perception, privacy concerns, HIV-related stigma, and low levels of HIV-related knowledge. Participants' responses suggested that HIV educational materials provided when testing is offered may be insufficient. Participants recommended providing additional HIV education and better incorporating HIV testing into the emergency department routine to increase testing among youth. Efforts are needed to help youth recognize their own HIV risk and increase their HIV-related knowledge. This may be accomplished by providing youth with additional educational materials on HIV, possibly via tablet-based interventions or other methods that may enhance privacy, combined with discussions with healthcare providers. Such efforts may help increase HIV testing acceptance among youth seen in the emergency department.

HIV testing rates among US youth aged 13-24 years are sub-optimal, with high rates of missed testing opportunities in emergency departments (EDs). We assessed barriers to routine HIV testing of youth in urban ED settings from the perspective of healthcare providers. Ten physicians and nurses were recruited from the pediatric and adult EDs at a high-volume hospital in New York City, USA to complete in-depth interviews to provide their perspectives on barriers to routine HIV testing of youth ages 13 to 24 in EDs. Interviews were conducted using a semi-structured interview guide with questions and probes. All interviews were conducted via Zoom due to the COVID-19 pandemic and were audio-recorded and transcribed verbatim. Transcripts were coded independently by two researchers using an inductive thematic analysis approach. Participants often offered HIV testing to youth in the ED based on their perceptions of patients' HIV risk, with pediatric providers sometimes discouraging adolescents they perceived to be at low HIV risk from testing. Participants cited other priorities, logistics of blood-based testing, and discomfort discussing HIV as other reasons for not offering HIV testing to all youth in the ED. Efforts are needed to encourage providers to offer HIV testing to all youth regardless of perceived risk, as the ED often serves as youths' only point of contact with the healthcare system. Emphasis on this and the importance of early detection, along with institutional change, clear guidance, and support for the testing process may help increase youth testing and avoid missed HIV diagnosis opportunities.

Background: Health care providers (HCPs) in the emergency department (ED) frequently must decide whether to conduct or forego confidential conversations with adolescent patients about sensitive topics, such as those related to mental health, substance use, and sexual and reproductive health. The objective of this multicenter qualitative analysis was to identify factors that influence the conduct of confidential conversations with adolescent patients in the ED., Methods: In this qualitative study, we conducted semistructured interviews of ED HCPs from five academic, pediatric EDs in distinct geographic regions. We purposively sampled HCPs across gender, professional title, and professional experience. We used the Theoretical Domains Framework (TDF) to develop an interview guide to assess individual and system-level factors affecting HCP behavior regarding the conduct of confidential conversations with adolescents. Enrollment continued until we reached saturation. Interviews were recorded, transcribed, and coded by three investigators based on thematic analysis. We used the coded transcripts to collaboratively generate belief statements, which are first-person statements that reflect shared perspectives., Results: We conducted 38 interviews (18 physicians, 11 registered nurses, five nurse practitioners, and four physician assistants). We generated 17 belief statements across nine TDF domains. Predominant influences on having confidential conversations included self-efficacy in speaking with adolescents alone, wanting to address sexual health complaints, maintaining patient flow, experiencing parental resistance and limited space, and having inadequate resources to address patient concerns and personal preconceptions about patients. Perspectives divided between wanting to provide focused medical care related only to their chief complaint versus self-identifying as a holistic medical HCP., Conclusions: The factors influencing the conduct of confidential conversations included multiple TDF domains, elucidating how numerous intersecting factors influence whether ED HCPs address sensitive adolescent health needs. These data suggest methods to enhance and facilitate confidential conversations when deemed appropriate in the care of adolescents in the ED., (© 2022 Society for Academic Emergency Medicine.)

Importance: Screening adolescents in emergency departments (EDs) for suicidal risk is a recommended strategy for suicide prevention. Comparing screening measures on predictive validity could guide ED clinicians in choosing a screening tool., Objective: To compare the Ask Suicide-Screening Questions (ASQ) instrument with the Computerized Adaptive Screen for Suicidal Youth (CASSY) instrument for the prediction of suicidal behavior among adolescents seen in EDs, across demographic and clinical strata., Design, Setting, and Participants: The Emergency Department Study for Teens at Risk for Suicide is a prospective, random-series, multicenter cohort study that recruited adolescents, oversampled for those with psychiatric symptoms, who presented to the ED from July 24, 2017, through October 29, 2018, with a 3-month follow-up to assess the occurrence of suicidal behavior. The study included 14 pediatric ED members of the Pediatric Emergency Care Applied Research Network and 1 Indian Health Service ED. Statistical analysis was performed from May 2021 through January 2023., Main Outcomes and Measures: This study used a prediction model to assess outcomes. The primary outcome was suicide attempt (SA), and the secondary outcome was suicide-related visits to the ED or hospital within 3 months of baseline; both were assessed by an interviewer blinded to baseline information. The ASQ is a 4-item questionnaire that surveys suicidal ideation and lifetime SAs. A positive response or nonresponse on any item indicates suicidal risk. The CASSY is a computerized adaptive screening tool that always includes 3 ASQ items and a mean of 8 additional items. The CASSY's continuous outcome is the predicted probability of an SA., Results: Of 6513 adolescents available, 4050 were enrolled, 3965 completed baseline assessments, and 2740 (1705 girls [62.2%]; mean [SD] age at enrollment, 15.0 [1.7] years; 469 Black participants [17.1%], 678 Hispanic participants [24.7%], and 1618 White participants [59.1%]) completed both screenings and follow-ups. The ASQ and the CASSY showed a similar sensitivity (0.951 [95% CI, 0.918-0.984] vs 0.945 [95% CI, 0.910-0.980]), specificity (0.588 [95% CI, 0.569-0.607] vs 0.643 [95% CI, 0.625-0.662]), positive predictive value (0.127 [95% CI, 0.109-0.146] vs 0.144 [95% CI, 0.123-0.165]), and negative predictive value (both 0.995 [95% CI, 0.991-0.998], respectively). Area under the receiver operating characteristic curve findings were similar among patients with physical symptoms (ASQ, 0.88 [95% CI, 0.81-0.95] vs CASSY, 0.94 [95% CI, 0.91-0.96]). Among patients with psychiatric symptoms, the CASSY performed better than the ASQ (0.72 [95% CI, 0.68-0.77] vs 0.57 [95% CI, 0.55-0.59], respectively)., Conclusions and Relevance: This study suggests that both the ASQ and the CASSY are appropriate for universal screening of patients in pediatric EDs. For the small subset of patients with psychiatric symptoms, the CASSY shows greater predictive validity.

Objective: Adolescent females in the United States continue to have unmet sexual and reproductive healthcare needs. Research shows that interventions incorporating peer support can augment perceived self-efficacy and reinforce healthy behaviors. Yet, few user-centered digital sexual health interventions incorporate peer support, and aim to change perceptions of peer norms and model social skills. The objective of this study was to design and demonstrate the receptivity of adolescent females to illustrated digital social media stories that promote healthy sexual behaviors and peer social support., Methods: We conducted a three-phase study approved by our Institutional Review Board. In Phase 1, we presented sexually active adolescent female emergency department patients aged 14-19 with eight sexual health scenarios via a survey study. Participants wrote three text messages addressed to the protagonist of each scenario which motivated and encouraged her to consider the use of contraceptives. Messages were scored based on the construct of peer support (emotional, tangible, informational, and belonging). In Phase 2, we worked with a professional artist and screenwriter to design digital sexual health comics using the gathered messages. In Phase 3, we gathered feedback on the comics from adolescent female emergency department patients., Results: Females ( n   =  22) provided 352 messages. Using top rated messages, we designed five digital visualizations in a running story called Mari tells it like it is . Each story incorporated 5-12 peer-authored quotes. We inserted the final images into Instagram®. Additional females ( n   =  39) found the images "relatable," "super-realistic," and "educational.", Conclusion: Collecting peer-authored texts from our local adolescent community led to the creation of well-received sexual health visualizations. This novel method of design incorporated adolescent voices to promote peer support and healthy behaviors., Competing Interests: Declaration of conflicting interests: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article., (© The Author(s) 2022.)

Despite federal guidelines, many adolescents and emerging adults are not offered HIV testing by their healthcare providers. As such, many-including those who may be at high-risk for contracting HIV given their sexual and/or substance use risk-are not routinely tested. The current study examines sexual risk and substance use among emergency department patients aged 13-24 years (n = 147), who completed an automated screening as part of a tablet-based intervention designed to increase HIV testing. Twenty seven percent (n = 39) of participants chose to test for HIV after completing the tablet-based intervention. Among this sample, sexual risk was a significant independent predictor of HIV testing (χ 2  = 16.50, p < 0.001). Problem substance use (e.g. trying but failing to quit) also predicted testing (χ 2  = 7.43, p < 0.01). When considering these behaviors together, analyses indicated that the effect of problem substance use (ß = 0.648, p = 0.154) on testing is explained by sexual risk behavior (ß = 1.425, p < 0.01). The study's findings underscore the value of using routine automated risk screenings to collect sensitive data from emergency department patients, followed by computer-based HIV test offers for adolescent youth. Our research indicates tablet-based interventions can facilitate more accurate reporting of sexual behavior and substance use, and can also potentially increase HIV test uptake among those at risk., (© 2021. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Objective: Male adolescents frequently present to the emergency department (ED) and many participate in behaviors increasing their risk of sexually transmitted infections and unintended pregnancies. Although the ED visit may represent an intervention opportunity, how best to design and deliver a sexual health intervention matching the preferences of adolescent male users is unclear. Our objective was to explore receptivity to and preferences for sexual health interventions among adolescent male ED patients., Methods: In this qualitative study, we asked sexually active male ED patients aged 14 to 21 years about their attitudes toward ED-based sexual health interventions and preferences for intervention modalities. Participants interacted with an early prototype of a digital intervention to gather specific feedback. Enrollment continued until saturation of key themes. Interviews were recorded, transcribed, and coded based on thematic analysis using NVivo., Results: Participants (n = 42) were predominantly 18 to 21 years (63%) and Hispanic (79%). Although most (71%) had sex in the prior 3 months, 45% did not use a condom at last intercourse and 17% had impregnated a partner. Participants viewed the ED visit as unused time without distracting influences, suitable for educational sexual health interventions. They considered ED-based digital interventions a reliable and confidential source of information. Engaging interventions allowed user control and provided novel and relatable content., Conclusions: Adolescent male ED patients are receptive to ED-based digital sexual health interventions. These identified preferences should be considered when designing future user-informed sexual health interventions for the ED setting., Competing Interests: Disclosure: The authors declare no conflict of interest., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Intravenous ketorolac is commonly used for treating migraine headaches in children. However, the prerequisite placement of an intravenous line can be technically challenging, time-consuming, and associated with pain and distress. Intranasal ketorolac may be an effective alternative that is needle-free and easier to administer. We aimed to determine whether intranasal ketorolac is non-inferior to intravenous ketorolac for reducing pain in children with migraine headaches., Methods: We conducted a randomized double-blind non-inferiority clinical trial. Children aged 8-17 years with migraine headaches, moderate to severe pain, and requiring parenteral analgesics received intranasal ketorolac (1 mg/kg) or intravenous ketorolac (0.5 mg/kg). Primary outcome was reduction in pain at 60 min after administration measured using the Faces Pain Scale-Revised (scored 0-10). Non-inferiority margin was 2/10. Secondary outcomes included time to onset of clinically meaningful decrease in pain; ancillary emergency department outcomes (e.g. receipt of rescue medications, headache relief, headache freedom, percentage improvement); 24-h follow-up outcomes; functional disability; and adverse events., Results: Fifty-nine children were enrolled. We analyzed 27 children who received intranasal ketorolac and 29 who received intravenous ketorolac. The difference in mean pain reduction at 60 min between groups was 0.2 (95% CI -0.9, 1.3), with the upper limit of the 95% CI being less than the non-inferiority margin. There were no statistical differences between groups for secondary outcomes., Conclusions: Intranasal ketorolac was non-inferior to intravenous ketorolac for reducing migraine headache pain in the emergency department., (© 2021 Society for Academic Emergency Medicine.)

Background: Adolescent females presenting to emergency departments (EDs) inconsistently use contraceptives. We aimed to assess implementation outcomes and potential efficacy of a user-informed, theory-based digital health intervention developed to improve sexual and reproductive health for adolescent females in the ED., Methods: We conducted a pilot-randomized controlled trial of sexually active female ED patients age 14-19 years. Participants were randomized to the intervention Dr. Erica (Emergency Room Interventions to improve the Care of Adolescents) or usual care. Dr. Erica consists of an ED-based digital intervention along with 3 months of personalized and interactive multimedia messaging. We assessed the feasibility, adoption, and fidelity of Dr. Erica among adolescent female users. Initiation of highly effective contraception was the primary efficacy outcome., Results: We enrolled 146 patients; mean (±SD) age was 17.7 (±1.27) years and 87% were Hispanic. Dr. Erica demonstrated feasibility, with high rates of consent (84.4%) and follow-up (82.9%). Intervention participants found Dr. Erica acceptable, liking (98.0%, on Likert scale) and recommending (83.7%) the program. A total of 87.5% adopted the program, responding to at least one text; a total of 289 weblinks were clicked. Dr. Erica demonstrated fidelity; few participants opted out (6.9%) and failed to receive texts (1.4%). Contraception was initiated by 24.6% (14/57) in the intervention and 21.9% (14/64) in the control arms (absolute risk difference [ARD] = 2.7%, 95% confidence interval [CI] = -12.4% to 17.8%). Participants receiving Dr. Erica were more likely to choose a method to start in the future (65.9% [27/41]) than controls (30.0% [15/50]); ARD = 35.9%, 95% CI = 16.6% to 55.1%)., Conclusions: A personalized, interactive digital intervention was feasible to implement, acceptable to female ED patients and demonstrated high fidelity and adoption. This ED-based intervention shows potential to improve contraception decision making., (© 2021 by the Society for Academic Emergency Medicine.)

Background: Alcohol and cannabis use frequently co-occur, which can result in problems from social and academic impairment to dependence (i.e., alcohol use disorder [AUD] and/or cannabis use disorder [CUD]). The Emergency Department (ED) is an excellent site to identify adolescents with alcohol misuse, conduct a brief intervention, and refer to treatment; however, given time constraints, alcohol use may be the only substance assessed due to its common role in unintentional injury. The current study, a secondary data analysis, assessed the relationship between adolescent alcohol and cannabis use by examining the National Institute of Alcohol Abuse and Alcoholism (NIAAA) two question screen's (2QS) ability to predict future CUD at one, two, and three years post-ED visit. Methods: At baseline, data was collected via tablet self-report surveys from medically and behaviorally stable adolescents 12-17 years old ( n  = 1,689) treated in 16 pediatric EDs for non-life-threatening injury, illness, or mental health condition. Follow-up surveys were completed via telephone or web-based survey. Logistic regression compared CUD diagnosis odds at one, two, or three-year follow-up between levels constituting a single-level change in baseline risk categorization on the NIAAA 2QS (nondrinker versus low-risk, low- versus moderate-risk, moderate- versus high-risk). Receiver operating characteristic curve methods examined the predictive ability of the baseline NIAAA 2QS cut points for CUD at one, two, or three-year follow-up. Results: Adolescents with low alcohol risk had significantly higher rates of CUD versus nondrinkers (OR range: 1.94-2.76, p < .0001). For low and moderate alcohol risk, there was no difference in CUD rates (OR range: 1.00-1.08). CUD rates were higher in adolescents with high alcohol risk versus moderate risk (OR range: 2.39-4.81, p < .05). Conclusions: Even low levels of baseline alcohol use are associated with risk for a later CUD. The NIAAA 2QS is an appropriate assessment measure to gauge risk for future cannabis use.

Objectives: The aim of this study was to understand the prevalence of alcohol and other substance use among teenagers in generalized samples., Methods: This study compared the alcohol and other substance use of adolescents enrolled in a screening study across 16 Pediatric Emergency Care Applied Research Network emergency departments (EDs) (ASSESS) with those sampled in 2 nationally representative surveys, the Youth Risk Behavior Surveillance System (YRBSS) and the National Survey of Drug Use and Health (NSDUH). The analysis includes 3362 ASSESS participants and 11,142 YRBSS and 12,086 NSDUH respondents., Results: The ASSESS patients had a similar profile to the NSDUH sample, with small differences in marijuana and cocaine use and age at first tobacco smoking and smoking within the last 30 days and higher use of snuff or chewing tobacco. The YRBSS participants had higher rates of using marijuana, snuff/chewing tobacco, methamphetamine, and hallucinogens and higher smoking rates compared with ASSESS and NSDUH., Conclusions: Adolescents visiting Pediatric Emergency Care Applied Research Network EDs have substantial rates of substance use, similar to other nationally representative studies on this topic, although not as high as a school-based survey. Future ED studies should continue to investigate adolescent substance use, including exploring optimal methods of survey administration., Competing Interests: Disclosure: The authors declare no conflict of interest., (Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.)

Because adolescents and emerging adults are frequently not offered HIV testing, and often decline tests when offered, we developed and tested a tablet-based intervention to increase HIV test rates among emergency department (ED) patients aged 13-24 years. Pediatric and adult ED patients in a high volume New York City hospital (N = 295) were randomized to receive a face-to-face HIV test offer, or to complete a tablet-based intervention that contained an HIV test offer delivered via computer. Test rates in both conditions were then compared to historic test rates in the same ED during the previous six months. Among participants aged 19 years and younger who were offered HIV testing and declined before enrollment in the study, participants in the tablet-based condition were 1.7 times more likely to test for HIV compared to participants in the face-to-face condition. Participants aged 19 years and younger were three times as likely to test for HIV compared to patients the same age who were treated in the previous six months (26.39%, n = 71 study participants vs. 10.29%, n = 189 prior patients, OR = 3.13, [Formula: see text] 2 = 54.76, p < 0.001). Protocols designed to offer HIV testing to all eligible patients can significantly increase adolescent test rates compared to standard practice. Because tablets are equally effective compared to face-to-face offers, and in some cases more so, EDs may consider tablet-based interventions that require fewer staff resources and may integrate more easily into high-volume workflows., Competing Interests: As mentioned above, Dr. Aronson is a co-founder and part-owner of Digital Health Empowerment. Digital Health Empowerment is the grant recipient and the developer of intervention software and the intervention video., (Copyright © 2021, Aronson et al.)

Importance: The rate of suicide among adolescents is rising in the US, yet many adolescents at risk are unidentified and receive no mental health services., Objective: To develop and independently validate a novel computerized adaptive screen for suicidal youth (CASSY) for use as a universal screen for suicide risk in medical emergency departments (EDs)., Design, Setting, and Participants: Study 1 of this prognostic study prospectively enrolled adolescent patients at 13 geographically diverse US EDs in the Pediatric Emergency Care Applied Research Network. They completed a baseline suicide risk survey and participated in 3-month telephone follow-ups. Using 3 fixed Ask Suicide-Screening Questions items as anchors and additional items that varied in number and content across individuals, we derived algorithms for the CASSY. In study 2, data were collected from patients at 14 Pediatric Emergency Care Applied Research Network EDs and 1 Indian Health Service hospital. Algorithms were independently validated in a prospective cohort of adolescent patients who also participated in 3-month telephone follow-ups. Adolescents aged 12 to 17 years were consecutively approached during randomly assigned shifts., Exposures: Presentation at an ED., Main Outcome and Measure: A suicide attempt between ED visit and 3-month follow-up, measured via patient and/or parent report., Results: The study 1 CASSY derivation sample included 2075 adolescents (1307 female adolescents [63.0%]; mean [SD] age, 15.1 [1.61] years) with 3-month follow-ups (72.9% retention [2075 adolescents]). The study 2 validation sample included 2754 adolescents (1711 female adolescents [62.1%]; mean [SD] age, 15.0 [1.65] years), with 3-month follow-ups (69.5% retention [2754 adolescents]). The CASSY algorithms had excellent predictive accuracy for suicide attempt (area under the curve, 0.89 [95% CI, 0.85-0.91]) in study 1. The mean number of adaptively administered items was 11 (range, 5-21). At a specificity of 80%, the CASSY had a sensitivity of 83%. It also demonstrated excellent accuracy in the study 2 validation sample (area under the curve, 0.87 [95% CI, 0.85-0.89]). In this study, the CASSY had a sensitivity of 82.4% for prediction of a suicide attempt at the 80% specificity cutoff established in study 1., Conclusions and Relevance: In this study, the adaptive and personalized CASSY demonstrated excellent suicide attempt risk recognition, which has the potential to facilitate linkage to services.

Purpose: Female adolescents seeking emergency department (ED) care are at high risk of unintended pregnancy, primarily because of contraceptive nonuse; yet, few ED patients follow up for reproductive care when referred. The objective of this cohort study was to determine the feasibility, acceptability, adoption, fidelity, and potential efficacy of a personalized and interactive ED-based pregnancy prevention mobile health intervention (Emergency Room Interventions to improve the Care of Adolescents [Dr. Erica])., Methods: We conducted a prospective cohort study with sexually active female ED patients aged 14-19 years who were not using highly effective contraceptives. Dr. Erica consists of a 10-week, automated, two-way texting intervention based on an evidence-based sexual health curriculum, the Social Cognitive Theory, and motivational interviewing techniques. At 12 weeks, we conducted follow-up via online survey and phone call to measure feasibility, acceptability, adoption, fidelity, and preliminary efficacy data (contraception initiation)., Results: We screened 209 female ED patients to enroll 42. The average age was 17.5 years (standard deviation ± 1.4); the majority were Hispanic (n = 37, 88%) and had a primary provider (n = 40, 95%). One participant opted out (1/42, 2%), and a total of 35 participants (83%) completed follow-up. Although interactivity diminished with time, 83% of participants (35/42) replied to one or more text. Ninety-four percent of participants (29/31) liked the messages, and 83% (25/30) would recommend the program. Hormonal contraceptives were initiated by 46% of participants (16/35)., Conclusions: Dr. Erica was feasible and acceptable among female adolescent ED patients and demonstrated high fidelity and adoption. The intervention also showed potential to increase highly effective contraceptive use among high-risk females., (Copyright © 2020 Society for Adolescent Health and Medicine. Published by Elsevier Inc. All rights reserved.)

Competing Interests: POTENTIAL CONFLICT OF INTEREST: The author has indicated she has no potential conflicts of interest to disclose.

Objectives: Expedited partner therapy (EPT) refers to treating sexual partners of patients with sexually transmitted infections by providing prescriptions or medications to give to their partners. Expedited partner therapy is not routinely prescribed in the emergency department (ED). Our objective was to explore adolescent preferences for EPT use in the ED., Methods: We conducted a mixed-methods study using surveys and semistructured interviews in one urban ED. Sexually active patients aged 15 to 19 years completed an anonymous survey eliciting (1) sexual history and risky sexual behaviors, (2) preferences for partner notification when hypothetically testing positive for an STI, and (3) preferences for EPT. A subsample of survey respondents participated in the interviews, which were conducted until no new perspectives emerged. Investigators analyzed interviews using thematic analysis., Results: A total of 247 participants completed surveys; the majority were female (183/247, 74%), Hispanic (209/243, 86%), and did not use a condom at last intercourse (129/243, 53%). Two thirds of participants (152/236, 64%) did not prefer EPT for partner notification. Preference for EPT was not associated with sex, age, ethnicity, condom use, a steady sexual partner, or STI history. Qualitative data from both surveys and interviews revealed the following reasons for not preferring EPT: concern for partner safety, importance of determining partner STI status, perceived benefit of clinical interaction, and partner accountability. Reasons for preferring EPT included increased treatment accessibility and convenience., Conclusions: The majority of adolescent patients in a pediatric ED did not prefer EPT. Emergency department practitioners should address common concerns regarding EPT to increase EPT adherence if prescribed., Competing Interests: Disclosure: The authors declare no conflict of interest., (Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Differences in risk and protective factors (e.g., victimization, abuse, social support) have been used to explain elevated rates of suicidal ideation and suicide attempts in sexual minority youth (SMY) relative to heterosexual peers. However, little is known regarding how risk and protective factors may explain suicide risk differences among subgroups of SMY. The aims of this study were to 1) examine differences in prevalence and severity for suicide risk and protective factors among SMY, and 2) explore whether risk and protective factors are differentially associated with suicidal ideation and suicide attempts for SMY subgroups., Methods: Participants were 6,423 adolescents (ages 12-17) recruited from 14 Emergency Departments across the United States who completed an assessment of suicide risk and protective factors. SMY were 20% of the sample (n = 1,275) and categorized as bisexual (8%), gay/lesbian (2%), mostly straight (5%), or other sexual minority (5%)., Results: Bisexual youth had elevated rates of suicidal ideation and attempts, more risk factors (e.g., bullying victimization, depression), and fewer protective factors (e.g., parent-family connectedness, positive affect) relative to mostly straight and other sexual minority youth. Bisexual and gay/lesbian youth only differed in parent-family connectedness (lower among bisexual youth). Depression and parent-family connectedness had weaker associations with suicidal ideation for bisexual youth., Limitations: Emergency departments were not nationally representative. Study design was cross-sectional, preventing causal inferences., Conclusions: Interventions seeking to mitigate risk factors and promote protective factors are greatly needed for SMY and may benefit from tailoring to address unique stressors for sexual minority subgroups., (Copyright © 2020. Published by Elsevier B.V.)

Objective: Adolescents at risk for suicide are highly heterogeneous in terms of psychiatric and social risk factors, yet there has been little systematic research on risk profiles, which would facilitate recognition and the matching of patients to services. Our primary study aims were to identify latent class profiles of adolescents with elevated suicide risk, and to examine the association of these profiles with mental health service use (MHSU)., Method: Participants were 1,609 adolescents from the Emergency Department Screen for Teens at Risk for Suicide (ED-STARS) cohort. Participants completed baseline surveys assessing demographics, MHSU, and suicide risk. Telephone follow-up interviews were conducted at 3 months to assess suicide attempts. Participants met pre-established baseline criteria for suicide risk., Results: Using latent class analysis, we derived 5 profiles of elevated suicide risk with differing patterns of eight risk factors: history of multiple suicide attempts, past-month suicidal ideation, depression, alcohol and drug misuse, impulsive-aggression, and sexual and physical abuse. In comparison to adolescents who did not meet baseline criteria for suicide risk, each profile was associated with increased risk of a suicide attempt within 3 months. The MHSU was lowest for adolescents fitting profiles with previous (but no recent) suicidal thoughts and behavior, and for adolescents from racial and ethnic minority groups., Conclusion: Adolescents at elevated risk for suicide present to emergency departments with differing profiles of suicide risk. MHSU varies across these profiles and by race/ethnicity, indicating that targeted risk recognition and treatment linkage efforts may be necessary to reach some adolescents at risk., (Copyright © 2019 American Academy of Child and Adolescent Psychiatry. Published by Elsevier Inc. All rights reserved.)

Objectives: In the United States, rates of teenage pregnancy and sexually transmitted infections (STIs) remain exceptionally high, and racial and ethnic disparities persist. Emergency departments (EDs) care for over 19 million adolescents each year, the majority being minority and low socioeconomic status. Single-center studies demonstrate infrequent use of contraceptives among adolescent ED patients and an association between risky sex and behaviors such as alcohol and drug use; however, no multicenter ED data exist. The objectives of this study were to 1) determine the prevalence of sex without contraceptives in a large multicenter adolescent ED study and 2) assess patient demographic and risky behaviors associated with sex without contraceptives., Methods: Participants aged 14 to 17 years (n = 3,247) in 16 pediatric EDs across the United States completed an electronic survey. Questions focused on validated measures of risky sex; use of alcohol, tobacco, marijuana, and other drugs; and depression and violence. In this secondary analysis, we constructed univariable and multivariable models to identify demographic and behavioral factors associated with sex without contraceptives (our primary outcome), separately for adolescent males and females., Results: In the prior year, 17.4% (236/1,356) of males and 15.8% (299/1,891) of females had sex without contraceptives. In the multivariable model, sex without contraceptives for both genders was more likely among teens who were black, with conduct problems and participated in casual sex, binge drinking, or cannabis use. Sex without contraceptives was also more likely among Hispanic and cigarette-smoking males, as well as depressed females., Conclusions: Adolescent ED patients across the United States are participating in risky sexual behaviors that increase their likelihood of pregnancy and STI acquisition. These adolescents report a number of problem behaviors, including substance use, which are strongly correlated with unprotected sex. The ED visit may be an opportunity to identify at-risk adolescent patients, address risky behaviors, and intervene to improve adolescent health., (© 2019 by the Society for Academic Emergency Medicine.)

Objective: The objective was to identify key questions for emergency medicine (EM)-based adolescent sexual and reproductive health and to develop an evidence-based research agenda., Methods: We recruited national content experts to serve as advisory group members and used a modified Delphi technique to develop consensus around actionable research questions related to EM-based adolescent reproductive and sexual health care. Author subgroups conducted literature reviews and developed the initial list of research questions, which were iteratively refined with advisory members. External stakeholders then independently rated each item for its importance in expanding the evidence base (1 = not important to 5 = very important) via electronic survey., Results: Our final list of 24 research questions included items that intersected all sexual and reproductive health topics as well as questions specific to human immunodeficiency virus/sexually transmitted infections (HIV/STIs), pregnancy prevention, confidentiality/consent, public health, and barriers and facilitators to care. External stakeholders rated items related to HIV/STI, cost-effectiveness, brief intervention for sexual risk reduction, and implementation and dissemination as most important., Conclusions: We identified critical questions to inform EM-based adolescent sexual and reproductive health research. Because evidence-based care has potential to improve health outcomes while reducing costs associated with HIV/STI and unintended pregnancy, funders and researchers should consider increasing attention to these key questions., (© 2019 by the Society for Academic Emergency Medicine.)

Purpose: Personalized and interactive text messaging interventions may increase participant engagement; yet, how to design messages that retain adolescent attention and positively affect sexual health behaviors remains unclear. The purpose of this study was to identify the characteristics of sexual health text messages perceived as engaging by sexually active adolescent females., Methods: We conducted semistructured, open-ended interviews with sexually active females aged 14-19 in one urban emergency department. Participants received automated sexual health information sent via an interactive, two-way texting format. The 343 messages viewed by participants were based on key stakeholder input, relevant theoretical models, and existing evidence-based guidelines. Interviews elicited feedback. Enrollment continued until saturation of themes. Interviews were recorded, transcribed, and coded based on thematic analysis using NVivo 10., Results: Participants (n = 31) were predominantly Hispanic (28; 90%), insured (29; 94%), and recently sexually active (24; 77%). Themes were as follows: (1) Tone: messages should be direct, factual, entertaining, and respect adolescent autonomy; messages should not be intrusive, presumptive, or preachy. (2) Emotion evoked: participants preferred messages that provoked thought, validated feelings, and empowered. Messages from a reliable source felt comforting, making participants feel cared for and special. (3) Interactivity: participants favored messages that offered choices, such as a mini-conversation. (4) Personalization: messages should look similar to adolescent digital preferences but be individually tailored with relatable characters., Conclusions: This study informs the tone, structure, and style of sexual health text messages directed toward adolescent females in the emergency department. Future work should consider these characteristics when designing digital interventions to engage adolescent females., (Copyright © 2019 Society for Adolescent Health and Medicine. Published by Elsevier Inc. All rights reserved.)

Objective: The aim of this study was to determine the psychometric properties of the National Institute on Alcohol Abuse and Alcoholism (NIAAA) 2-question alcohol screen within 16 Pediatric Emergency Care Applied Research Network pediatric emergency departments. This article describes the study methodology, sample characteristics, and baseline outcomes of the NIAAA 2-question screen., Methods: Participants included 12- to 17-year-olds treated in one of the participating pediatric emergency departments across the United States. After enrollment, a criterion assessment battery including the NIAAA 2-question screen and other measures of alcohol, drug use, and risk behavior was self-administered by participants on a tablet computer. Two subsamples were derived from the sample. The first subsample was readministered the NIAAA 2-question screen 1 week after their initial visit to assess test-retest reliability. The second subsample is being reassessed at 12 and 24 months to examine predictive validity of the NIAAA 2-question screen., Results: There were 4834 participants enrolled into the study who completed baseline assessments. Participants were equally distributed across sex and age. Forty-six percent of the participants identified as white, and 26% identified as black. Approximately one quarter identified as Hispanic. Using the NIAAA 2-question screen algorithm, approximately 8% were classified as low risk, 12% were classified as moderate risk, and 4% were classified as highest risk. Alcohol use was less likely to be reported by black participants, non-Hispanic participants, and those younger than 16 years., Discussion: This study successfully recruited a large, demographically diverse sample to establish rates of the NIAAA screen risk categories across age, sex, ethnicity, and race within pediatric emergency departments.

Background: The incidence of adolescent suicide is rising in the United States, yet we have limited information regarding short-term prediction of suicide attempts. Our aim was to identify predictors of suicide attempts within 3-months of an emergency department (ED) visit., Methods: Adolescents, ages 12-17, seeking health care at 13 pediatric EDs (Pediatric Emergency Care Applied Research Network) and one Indian Health Service Hospital in the United States were consecutively recruited. Among 10,664 approached patients, 6,448 (60%) were enrolled and completed a suicide risk survey. A subset of participants (n = 2,897) was assigned to a 3-month telephone follow-up, and 2,104 participants completed this follow-up (73% retention). Our primary outcome was a suicide attempt between the ED visit and 3-month follow-up., Results: One hundred four adolescents (4.9%) made a suicide attempt between enrollment and 3-month follow-up. A large number of baseline predictors of suicide attempt were identified in bivariate analyses. The final multivariable model for the full sample included the presence of suicidal ideation during the past week, lifetime severity of suicidal ideation, lifetime history of suicidal behavior, and school connectedness. For the subgroup of adolescents who did not report recent suicidal ideation at baseline, the final model included only lifetime severity of suicidal ideation and social connectedness. Among males, the final model included only lifetime severity of suicidal ideation and past week suicidal ideation. For females, the final model included past week suicidal ideation, lifetime severity of suicidal ideation, number of past-year nonsuicidal self-injury (NSSI) incidents, and social connectedness., Conclusions: Results indicate that the key risk factors for adolescent suicide attempts differ for subgroups of adolescents defined by sex and whether or not they report recent suicidal thoughts. Results also point to the importance of school and social connectedness as protective factors against suicide attempts., (© 2019 Association for Child and Adolescent Mental Health.)

Background: The pediatric emergency department (PED) provides care for adolescents at high risk of unintended pregnancy, but little is known regarding the efficacy of PED-based pregnancy prevention interventions. The objectives of this PED-based pilot intervention study were to 1) assess the rate of contraception initiation after contraceptive counseling and appointment facilitation in the PED during the study period, 2) identify barriers to successful contraception initiation, and 3) determine adolescent acceptability of the intervention., Methods: This pilot intervention study included females 14 to 19 years of age at risk for unintended pregnancy. Participants received standardized contraceptive counseling and were offered an appointment with gynecology. Participants were followed via electronic medical record and phone to assess contraception initiation and barriers. Chi-square tests were used to examine the association between contraception initiation and participant characteristics., Results: A total of 144 patients were eligible, and 100 were enrolled. In the PED, 68% (68/100) expressed interest in initiating hormonal contraception, with 70% (48/68) of interested participants indicating that long-acting reversible contraception (LARC) was their preferred method. Twenty-five percent (25/100) of participants initiated contraception during the study period, with 19 participants starting LARC. Thirty-nine percent (22/57) of participants who accepted a gynecology appointment attended that appointment. Barriers to follow-up include transportation and inconvenient follow-up times. Participants were accepting of the intervention with 93% agreeing that the PED is an appropriate place for contraceptive counseling., Conclusions: PED contraceptive counseling is acceptable among adolescents and led to successful contraception initiation in 25% of participants. The main barrier to contraception initiation was participant follow-up with the gynecology appointment., (© 2018 by the Society for Academic Emergency Medicine.)

Study Objective: Nearly 20 million adolescents receive emergency department (ED) care each year, many of whom have untreated reproductive health issues. ED visits represent an opportunity to provide appropriate care, however, ED physician reproductive health care practices and capabilities in the United States have not been described. We sought to characterize pediatric ED director's individual practice and ED system resources for providing adolescent reproductive health care., Design, Setting, Participants, and Interventions: We invited pediatric ED division and/or medical directors nationally to participate in an anonymous, online survey., Main Outcome Measures: Outcomes included ED directors' personal practice regarding providing adolescent patients reproductive health care, and their ED's resources and standard practice regarding screening adolescents for sexually transmitted infections (STIs) and other reproductive health concerns., Results: One hundred thirty-five of 442 (30.5%) ED directors responded. Respondents were 73% (90/124) male, with a median of 18 (interquartile range, 13-23) years of experience and 63% (84/134) working in urban EDs. Seventy-one percent (90/130) preferred face-to-face interviews for obtaining a sexual history, but only 59% (77/130) of participants "always ask parents to leave the room for sensitive questions." Eighty-four percent (106/127) were receptive to pregnancy prevention interventions being initiated in the ED, with 75% (80/106) of those willing to provide an intervention. Only 16% (21/128) indicated their ED has a universal STI screening program, and only 18% (23/126) "always" successfully notify patients of a positive STI test., Conclusion: ED directors are comfortable providing adolescent reproductive health care, and many individual- and ED-level opportunities exist to provide improved reproductive health care for adolescents in the ED., (Copyright © 2018 North American Society for Pediatric and Adolescent Gynecology. Published by Elsevier Inc. All rights reserved.)

Background: The National Institute on Alcohol Abuse and Alcoholism (NIAAA) 2-question screen is a valid adolescent alcohol screening tool. No studies have examined if this tool predicts future alcohol problems. We conducted a study at 16 pediatric emergency departments to determine the tool's predictive validity for alcohol misuse and alcohol use disorders (AUDs)., Methods: Participants ( N = 4834) completed a baseline assessment battery. A subsample of participants completed the battery at 1, 2, and 3 years follow up., Results: Of the 2209 participants assigned to follow-up, 1611 (73%) completed a 1-year follow-up, 1591 (72%) completed a 2-year follow-up, and 1377 (62%) completed a 3-year follow-up. The differences in AUDs between baseline NIAAA screen nondrinkers and lower-risk drinkers were statistically significant at 1 year ( P = .0002), 2 years ( P <.0001), and 3 years ( P = .0005), as were the differences between moderate- and highest-risk drinkers at 1 and 2 years ( P < .0001 and P = .0088, respectively) but not at 3 years ( P = .0758). The best combined score for sensitivity (86.2% at 1 year, 75.6% at 2 years, and 60.0% at 3 years) and specificity (78.1% at 1 year, 79.2% at 2 years, and 80.0% at 3 years) was achieved by using "lower risk" and higher as a cutoff for the prediction of a Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition diagnosis., Conclusions: The NIAAA 2-question screen can accurately characterize adolescent risk for future AUDs. Future studies are needed to determine optimaluse of the screen., Competing Interests: POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose., (Copyright © 2019 by the American Academy of Pediatrics.)

Background: The pediatric emergency department (PED) represents an opportune time for alcohol and drug screening. The National Institute of Alcohol Abuse and Alcoholism (NIAAA) recommends a two-question alcohol screen for adolescents as a predictor of alcohol and drug misuse., Objective: A multi-site PED study was conducted to determine the association between the NIAAA two-question alcohol screen and adolescent cannabis use disorders (CUD), cigarette smoking, and lifetime use of other drugs., Methods: Participants included 12-17-year olds (n = 4834) treated in one of 16 participating PEDs. An assessment battery, including the NIAAA two-question screen and other measures of alcohol, tobacco and drug use, was self-administered on a tablet computer., Results: A diagnosis of CUD, lifetime tobacco use or lifetime drug use was predicted by any self-reported alcohol use in the past year, which indicates a classification of moderate risk for middle school ages and low risk for high school ages on the NIAAA two-question screen. Drinking was most strongly predictive of a CUD, somewhat weaker for lifetime tobacco use, and weakest for lifetime drug use. This same pattern held for high school and middle school students and was stronger for high school students over middle school students for all three categories. This association was also found across gender, ethnicity and race. The association was strongest for CUD for high school students, sensitivity 81.7% (95% CI, 77.0, 86.5) and specificity 70.4% (95% CI, 68.6, 72.1). Conclusions/Importance: A single question about past year alcohol use can provide valuable information about other substance use, particularly marijuana.

Early fatherhood is common in the United States (U.S.). The emergency department (ED) plays a disproportionate role in serving patients with unmet reproductive and sexual health needs. With 8 million adolescent males visiting U.S. EDs annually, the ED is a potential site to implement interventions to minimize early fatherhood and unintended teenage pregnancy. Little is known about how adolescent male ED patients perceive and behave in sexual relationships and how they influence contraceptive decision making. The objective of this study was to identify the barriers and enablers affecting contraceptive and condom use among adolescent male ED patients. Semistructured interviews were conducted with males aged 14-19 in one urban ED. Enrollment continued until saturation of key themes. Interviews were recorded, transcribed, and coded based on thematic analysis using NVivo 10. The Social Ecological Model was used to organize and understand themes. Participants ( n = 24) were predominantly 18-19 years (63%) and Hispanic (92%). Most (71%) had sex ≤3 months prior but infrequently used a condom at last intercourse (42%). The primary barrier influencing contraceptive use was lack of knowledge of effective contraceptives. Other barriers consisted of perceived gender roles, poor partner communication, and little relationship with a primary provider. Enablers included intention not to get a partner pregnant, school-based sexual health education, normalcy to use condoms, and a trustworthy confidante. The identified barriers and enablers influencing adolescent males' perspectives toward contraceptives should be addressed if designing future ED-based pregnancy prevention interventions targeting teen males.

Purpose: To evaluate the feasibility and acceptability of a text messaging intervention to increase contraception among adolescent emergency department patients., Methods: A pilot randomized controlled trial of sexually active females aged 14-19 receiving 3 months of theory-based, unidirectional educational and motivational texts providing reproductive health information versus standardized discharge instructions. Blinded assessors measured contraception initiation via telephone follow-up and health record review at 3 months., Results: We randomized 100 eligible participants (predominantly aged 18-19, Hispanic, and with a primary provider); 88.0% had follow-up. In the intervention arm, 3/50 (6.0%) participants opted out, and 1,172/1,654 (70.9%) texts were successfully delivered; over 90% of message failures were from one mobile carrier. Most (36/41; 87.7%) in the intervention group liked and wanted future reproductive health messages. Contraception was initiated in 6/50 (12.0%) in the intervention arm and in 11/49 (22.4%) in the control arm., Conclusions: A pregnancy prevention texting intervention was feasible and acceptable among adolescent females in the emergency department setting., (Copyright © 2017 The Society for Adolescent Health and Medicine. Published by Elsevier Inc. All rights reserved.)

Objectives: To determine pregnancy risk and receptiveness to emergency department (ED)-based pregnancy prevention interventions among adolescents accessing care in the ED., Study Design: Cross-sectional electronic survey of adolescent females in a pediatric ED used to calculate the Pregnancy Risk Index, a validated measure estimating the annual risk of becoming pregnant based on recent sexual activity, contraceptive method(s), method-specific contraceptive failure rates, and interest in receipt of ED-based contraceptive services., Results: Of 229 participants, 219 were not pregnant, and 129 reported sexual experience. Overall, 72.4% (n = 166) endorsed negative pregnancy intentions. The overall Pregnancy Risk Index for the 219 nonpregnant participants was 9.6 (95% CI 6.8-12.4), and was 17.5 (95% CI 12.8-22.2) for the 129 sexually experienced participants. A Pregnancy Risk Index greater than the national average of 5 was associated with older age (aOR 3.0; 95% CI 1.5-5.85), nonprivate insurance (aOR 7.1; 95% CI 1.6-32.1), prior pregnancy (aOR 2.7; 95% CI 1.2-6.0), and chief complaint potentially related to a reproductive health concern (aOR 2.6; 95% CI 1.4-5.1). In this cohort, 85.1% (n = 194) believed that the ED should provide information about pregnancy prevention, the majority of whom (64.9%; n = 148) believed that pregnancy prevention services should be offered at all ED visits., Conclusion: This study demonstrates a high unintended pregnancy risk among adolescents accessing care in the ED. Adolescents report interest in receiving pregnancy prevention information and services in the ED, regardless of reason for visit. Strategies to incorporate successfully the provision of reproductive health services into ED care should be explored., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Objective: Adolescents are the largest users of mobile technology; yet, there are little data regarding their receptivity to the use of mobile health technology (mHealth) from the emergency department (ED). The objective of this study was to determine adolescents' preferences for receiving ED discharge and follow-up information via mHealth and factors associated with those preferences., Methods: We administered an anonymous self-reporting survey to patients aged 14 to 19 years discharged from an urban pediatric ED. We conducted exploratory bivariate analyses to evaluate differences in communication preferences based on patient characteristics. We used multivariable logistic regression to determine whether preference for health information via mHealth is associated with frequent information technology (IT) use, adjusting for age, sex, ethnicity, and insurance status., Results: Four hundred thirty-nine adolescents completed the survey. Most were female (n = 279, 64%), 14 to 17 years old (n = 247, 57%), Hispanic (n = 359, 86%), and insured (n = 388, 88%). Adolescents used IT often, texting more than 30 times a day (58%) and emailing more than once a day (61%). Most (n = 335, 78%) were interested in electronic communication from the ED. Teens expressed particular interest in using email for discharge instructions (n = 196, 47%), physician referrals (n = 197, 48%), and test results (n = 201, 48%) and using texting for medication (n = 155, 38%) and appointment reminders (n = 170, 41%). Individuals tended to prefer communication with IT modes that they typically used, although only email was independently associated with preference for this mode (adjusted odds ratio, 2.8; 95% confidence interval, 1.5-5.3)., Conclusions: Adolescent patients are interested in receiving health information from the ED, mainly via email and texting. Future ED interventions should evaluate the effectiveness of these modalities to communicate with patients after discharge.

Background: Over 15 million adolescents use the emergency department (ED) each year in the United States. Adolescent females who use the ED for medical care have been found to be at high risk for unintended pregnancy. Given that adolescents represent the largest users of text messaging and are receptive to receiving text messages related to their sexual health, the ED visit represents an opportunity for intervention., Objective: The aim of this qualitative study was to explore interest in and preferences for the content, frequency, and timing of an ED-based text message intervention to prevent pregnancy for adolescent females., Methods: We conducted semistructured, open-ended interviews in one urban ED in the United States with adolescent females aged 14-19 years. Eligible subjects were adolescents who were sexually active in the past 3 months, presented to the ED for a reproductive health complaint, owned a mobile phone, and did not use effective contraception. Using an interview guide, enrollment continued until saturation of key themes. The investigators designed sample text messages using the Health Beliefs Model and participants viewed these on a mobile phone. The team recorded, transcribed, and coded interviews based on thematic analysis using the qualitative analysis software NVivo and Excel., Results: Participants (n=14) were predominantly Hispanic (13/14; 93%), insured (13/14; 93%), ED users in the past year (12/14; 86%), and frequent text users (10/14; 71% had sent or received >30 texts per day). All were interested in receiving text messages from the ED about pregnancy prevention, favoring messages that were "brief," "professional," and "nonaccusatory." Respondents favored texts with links to websites, repeated information regarding places to receive "confidential" care, and focused information on contraception options and misconceptions. Preferences for text message frequency varied from daily to monthly, with random hours of delivery to maintain "surprise." No participant feared that text messages would violate her privacy., Conclusions: Adolescent female patients at high pregnancy risk are interested in ED-based pregnancy prevention provided by texting. Understanding preferences for the content, frequency, and timing of messages can guide in designing future interventions in the ED., Competing Interests: Conflicts of Interest: None declared.

Background: Female adolescents at high pregnancy risk frequently visit the emergency department (ED) and lack primary providers. It is unclear if current methods of ED referral are successful. The objective of this pilot study was to assess the potential effect and feasibility of a standardized, enhanced method of referral of sexually active females from an ED for family planning (FP)., Methods: We conducted an ED-based intervention study using an enhanced referral process, which included a wallet card advertising a walk-in, adolescent-friendly FP clinic and a standardized ED physician monologue. ED physicians were instructed to disseminate the enhanced process to sexually active females ages 12-19 years (intervention group). Patients receiving the intervention were prospectively enrolled. The control group consisted of patients who, on retrospective review, came to the ED during the enrollment period and were eligible but were not enrolled. We used the electronic medical record (EMR) to identify and randomly select missed eligible patients (control group) and accumulated one control for each case. The primary outcome was FP follow-up within 2 months, measured by EMR review., Results: The intervention (n=101) and control groups (n=101) were similar in age, prior ED visits (54% versus 56%), and previous FP visits (28% versus 28%). The absolute difference in follow-up to a FP clinic between the enhanced referral group (7%; 7/101) compared with the nonenhanced referral group (5%; 5/101) was only 2% (95% confidence interval -5% to 9%). Feasibility of the intervention was modest, with a best-case scenario of 59/160 (37%) of eligible patients captured., Conclusions: An enhanced referral initiative relying on physician participation did not substantially increase follow-up rates to a FP clinic and showed modest feasibility. More research is required to identify effective means of ED-based referral for preventive reproductive care.

Objective: Over 15 million adolescents, many at high risk for pregnancy, use emergency departments (EDs) in the United States annually, but little is known regarding reasons for failure to use contraceptives in this population. The purpose of this study was to identify the barriers to and enablers of contraceptive use among adolescent females using the ED and determine their interest in an ED-based pregnancy prevention intervention., Study Design: We conducted semistructured, open-ended interviews with females in an urban ED. Eligible females were 14-19 years old, sexually active, presenting for reproductive health complaints and at risk for pregnancy, defined as nonuse of effective (per the World Health Organization) contraception. Interviews were recorded, transcribed and coded based on thematic analysis. Enrollment continued until no new themes emerged. A modified Health Belief Model guided the organization of the data., Results: Participants (n=14) were predominantly Hispanic (93%), insured (93%) and in a sexual relationship (86%). The primary barrier to contraceptive use was perceived health risk, including effects on menstruation, weight and future fertility. Other barriers consisted of mistrust in contraceptives, ambivalent pregnancy intentions, uncertainty about the future, partner's desire for pregnancy and limited access to contraceptives. Enablers of past contraceptive use included the presence of a school-based health clinic and clear plans for the future. All participants were receptive to ED-based pregnancy prevention interventions., Conclusions: The identified barriers and enablers influencing hormonal contraceptive use can be used to inform the design of future ED-based adolescent pregnancy prevention interventions., Implications: Adolescents who visit the emergency department (ED) identify contraceptive side effects, mistrust in contraceptives, limited access, pregnancy ambivalence and partner pregnancy desires as barriers to hormonal contraception use. They expressed interest in an ED-based intervention to prevent adolescent pregnancy; such an intervention could target these themes to maximize effectiveness., (Copyright © 2015 Elsevier Inc. All rights reserved.)