Project Overview +

The urban emergency department (ED) represents an underutilized venue for delivering violence interventions among adolescents. In the United States, there are over 100 million ED visits each year, of which at least 3 million are the result of violence.

A recent study (the SafERteens Study) demonstrated the efficacy of an ED-based BI for violence on changing attitudes, self-efficacy, and reducing violent behaviors, peer victimization, and violence related consequences. From a public health standpoint, however, in order to reduce violence on a broader scale studies are needed to determine the effectiveness of the SafERteens behavioral intervention (BI) when delivered by clinical staff in real world ED settings.

This study is designed to translate this efficacious BI for violence into a practical prevention program incorporated into ED clinical practice; with ED staff conducting the screening and BI. Specifically, we will determine the reach, effectiveness, adoption, implementation, and maintenance of the SafERteens BI in two diverse and novel ED settings: Childrenís Hospital of Philadelphia (CHOP) and Grady Memorial Hospital in Atlanta (GMH).

Aims +

Aim 1: To refine and package intervention and training materials essential to translating an efficacious ED-based behavioral intervention (BI) for violence (SafERteens) for delivery by ED staff.

Aim 2: To conduct a translation study of an ED based BI for violence among adolescents (ages 14-18) at two diverse urban ED settings (CHOP and GMH) using the RE-AIM framework.

Participants +

A total of 650 patients ages 14-18 who seek care at the Children's Hospital of Philadelphia and Grady Memorial Hospital in Atlanta; and who screen positive for past year violence.

Intervention +

The SafERteens behavioral intervention (BI) uses an adaptive motivational interviewing (MI) approach as applied to violence based on the CDC Best Practices for Youth Violence Prevention. It is designed to be culturally relevant for urban youth, who at the original site as well as the proposed sites are primarily African-American. 

Prior to testing within the ED environment, the BI will be created using tailored and standardized messages by provision of computer screens that will be delivered by ED social workers. In addition, a text messaging computerized system will be developed. Training materials for ED health care providers will be developed, including a training video using web stream and DVD formats and live video chat with standardized patients for skill assessment and supervision.

The SafERteens BI will be facilitated by a tablet computer which will present tailored screens to efficiently prompt individualized content for the therapists and to standardize BI content for delivery during in the hectic ED setting. It consists of three phases: Explore, Guide, and Choose.

During Explore, the therapists build rapport and collaboratively decide what behaviors to address during the session. Key strategies include agenda setting, open-ended questions, and reflections. Tailored computerized prompts include: goals, personalized feedback on related risk behaviors (violence, weapon carriage, substance use, peer-group affiliation, triggers) and strengths.

During Guide, the therapist elicits change talk by asking the client to consider life with and without change and by building discrepancy between their actions and their goals. Key strategies used during this phase include: 0-10 rulers, benefits of staying away from fighting and other risk behaviors (substance use, weapon carriage).

During the Choose phase, if the teen chooses to make a change, the therapist helps the teen identify a goal, choose an action plan, and anticipate barriers. Key skills in this phase include action reflections, menu building, and goal setting. Tailored computerized prompts include: tailored situations to identify tools for avoiding violence (e.g., anger management, conflict resolution, retaliation, dating violence, substance use/ violence connection and refusal skills), and referrals to community resources to increase promotive factors (e.g., psychosocial services, mentors including important adults, leisure activities, employment/education).

Social workers will elicit from the adolescents key next steps that they will take in the next month to reduce the risk of violence and injury (e.g., goals/reasons to avoid fighting, tools for avoiding fighting and substance use, and resources).

During the month post-ED visit, adolescents receiving the BI will automatically receive twice weekly tailored text messages regarding the key intervention elements that the adolescent identified. These messages will be pre-programmed and automatically sent; thus, no ED staff involvement will be needed. The content of the text will be tailored based on what the adolescent chose during the BI and include 1 text regarding goals/strengths each week (e.g., U can B the 1st in UR Fam to graduate hi skool; U R talented and can avoid fighting).

In addition, each week youth will chose to receive 1 text per week from these areas: reasons to avoid fighting (e.g., Itís not that serious, U can avoid being injured; U B the one to end it); tools (e.g., Talk to a wise adult; Exercise to chill out when mad; Work it out without fighting); and, resources (e.g., Find better things to do, Ask advice from UR counselor). Consistent with an MI framework, the messages will be tailored to the adolescent and adolescents will determine when (day/time) they would like the texts delivered. For example, it may be that they will prefer to receive these text messages in the early evening because violence injuries are more likely to occur during evening/night time hours. Given recent increases in cell phone use, it is expected that the majority of teens (85%) will be able to receive these texts.

SafER Teens

09/01/2012 - 08/31/2017


Centers for Disease Control and Prevention

Principal Investigators:

Maureen A. Walton, MPH, PhD
Rebecca M. Cunningham, MD