Injury Prevention
FiGHTS: A preliminary screening tool for adolescent firearms-carrying☆

https://doi.org/10.1016/S0196-0644(03)00722-4Get rights and content

Abstract

Study objective

Adolescent firearms-carrying is a risk factor for serious injury and death. Clinical screening tools for firearms-carrying have not yet been developed. We present the development of a preliminary screening test for adolescent firearms-carrying based on the growing body of knowledge of firearms-related risk factors.

Methods

A convenience sample of 15,000 high school students from the 1999 National Youth Risk Behavior Survey was analyzed for the purpose of model building. Known risk factors for firearms-carrying were candidates for 2 models predicting recent firearms-carrying. The “brief FiGHTS score” screening tool excluded terms related to sexual behavior, significant substance abuse, or criminal behavior (Fi=fighting, G=gender, H=hurt while fighting, T=threatened, S=smoker). An “extended FiGHTS score,” which included 13 items, was developed for more precise estimates.

Results

The brief FiGHTS score had a sensitivity of 82%, a specificity of 71%, and an area under the receiver operating characteristic (ROC) curve of 0.84. The extended FiGHTS score had an area under the ROC curve of 0.90. Both models performed well in a validation data set of 55,000 students.

Conclusion

The brief and extended FiGHTS scores have high sensitivity and specificity for predicting firearms-carrying and may be appropriate for clinical testing.

Introduction

Homicides and suicides resulted in approximately 55,000 deaths per year in the 1990s, with 70% attributable to firearms.1 Recognizing these intentional injuries as a leading cause of death in adolescents, a number of national medical organizations have made policy statements favoring screening for gun carrying, referring patients to violence treatment, and increasing firearms research.2, 3, 4, 5 Primary care screening will miss adolescents, including a majority of male adolescents, who do not present for well-patient visits, demonstrating the importance of the emergency department (ED) in determining at-risk status for firearms.6 Screening for other behaviors such as domestic violence, seat belt use, and drug and alcohol abuse is effective and results in improved patient outcomes; therefore, the ED is a likely place for effective firearms interventions as well.7, 8, 9

Capsule Summary

What is already known on this topic

Firearms-carrying by adolescents is a major risk factor for injury and death, but physicians rarely screen for this behavior.

What question this study addressed

Responses to the 1999 National Youth Risk Behavior Survey were analyzed to develop a screening tool to identify youth at high risk for current or recent firearms-carrying.

What this study adds to our knowledge

Four simple screening questions and male sex may be used to generate a FiGHTS score (Fi=fighting, G=gender, H=hurt while fighting, T=threatened, S=smoker) that appears to be fairly sensitive and specific for identifying youth who carry firearms.

How this might change clinical practice

If the FiGHTS score is prospectively validated, it will be a useful addition to the growing list of screening questions that can be used to identify patients whose behavior or circumstances places them at increased risk of serious injury, disease, or death.

Direct questioning of a patient about high-risk behavior as an initial screening test is reasonable but often insufficient. In the case of illegal activity, substance abuse, or sexual behaviors, studies have shown the sensitivity of direct questioning to be far inferior to that of formalized screening tests.10 Additionally, direct questioning is not helpful in primary prevention strategies in which patients are at risk for an adverse behavior but have not yet engaged in it. Finally, direct questioning often fails to adequately risk-stratify patients for determining severity of disease and response to therapy compared with formalized screening tools.

For these reasons, it is essential to develop a screening tool to augment direct questioning for firearms-carrying. A partial list of known risk factors on which to build such a tool includes male sex,11, 12, 13, 14 smoking,15 alcohol use,12, 15, 16, 17 drug use,11, 18 multiple sex partners,16 poor academic performance,15, 16 being older than classmates,19 television viewing,20 criminal behavior,14 feeling threatened,21 fear,17, 21, 22, 23 and poor parental relations.12, 24 Although associations between these risk factors and firearms are widely accepted, neither an overall assessment of firearms-carrying risk nor a screening tool is currently available.

Implicit in the screening paradigm is that the disease being screened for has an effective intervention. Because 50% of firearms deaths are suicides, screening for firearms could play a valuable role in expediting appropriate referrals in the depressed and substance-abusing patients who, before their deaths, frequently interact with health professionals.25 Psychiatric history alone is insufficient to select at-risk adolescents for screening, however, because many adolescent firearm suicides appear to be impulsive.26 Additionally, there is evidence that many locally implemented programs decrease interpersonal violence.27 For the violence researcher, the benefit of screening and adequate risk stratification might help clarify the most effective violence intervention strategies and the populations to which they apply. We propose a brief bedside clinical test, supported by an extended regression model, to developing a clinically useful screening test for firearms-carrying.

Section snippets

Materials and methods

The National Youth Risk Behavior Survey is a cross-sectional surveillance survey administered by the Centers for Disease Control and Prevention every 2 years and has been described in detail elsewhere.6 Data from the 1999 survey were used for the following analysis. The sample was drawn from 52 communities selected from across the United States according to the degree of urbanization and racial factors to ensure a representative cross-section of the country. From within the 52 communities, 187

Results

Each of the 15 characteristics, including race, sex, metropolitan status, and 12 other risk factors, was significantly associated with firearms-carrying in the crude analysis (Table 1). Excluding intravenous drug use, all risk factors were found in at least 5% of subjects. More than 98% of students offered a response to the questions of interest, with the exception of recent sexual activity and alcohol use (6% and 4% missing, respectively). In a fully adjusted model, smoking, being injured

Discussion

The National Youth Risk Behavior Survey, a large, nationally representative survey of adolescents with high response rate and frequent administration, was used to develop a screening tool for adolescent firearms-carrying. This tool, the FiGHTS score, is robust over time and generalizable to suburban, rural, and urban communities across the United States. The FiGHTS score performs well at risk-stratifying adolescents, low scores in particular providing the clinician with confidence in

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    ☆

    Author contributions: DNH conceived the study, performed all of the analyses, and drafted the manuscript. RS served as mentor for the project, including project design and interpretation of results, and contributed substantially to revisions of the manuscript. DNH takes responsibility for the paper as a whole.

    Presented at the American Public Health Association annual meeting, October 23, 2001, Atlanta, GA.

    Supported in part by the Agency for Healthcare Research and Quality, Postdoctoral Fellowship in Health Services Research Training grant T32HS00060 and R49/CCR115279-03 from the Centers for Disease Control and Prevention and the Harvard Center for Youth Violence Prevention.

    Reprints not available from the authors.

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    Copyright © 2003 American College of Emergency Physicians. Published by Mosby, Inc. All rights reserved.