A Brief Tool to Predict Agitation in Pediatric Emergency Psychiatric Patients

OBJECTIVES To validate the 5-item Brief Rating of Aggression in Children and Adolescents–Short (BRACHA-S) completed by emergency department (ED) nurses at triage for predicting agitation requiring intervention (ARI) among pediatric ED psychiatric or mental and behavioral health (MBH) encounters. METHODS We conducted a prospective observational prognostic validation study (October 2024-November 2025) at 2 pediatric EDs. Eligible encounters included children aged 5 to 18 years presenting with MBH concerns. After ED arrival, nurses completed the 5 BRACHA-S items assessing aggression-related history and current agitation (total score, 0–5). ARI was defined as pharmacologic treatment of agitation/aggression and/or physical or mechanical restraint use. Discrimination was assessed with area under the receiver operating characteristic curve (AUROC). Performance characteristics were estimated for a 3-tier model (scores 0–2, 3, and 4–5). RESULTS Among 472 encounters, 55 (11.7%) had ARI. BRACHA-S scores were associated with ARI (AUROC, 0.72; 95% CI, 0.64–0.79). ARI incidence increased with score: 0, 3.3% (2/60); 1, 6.3% (6/96); 2, 6.4% (7/110); 3, 12.4% (17/137); 4, 31.8% (14/44); and 5, 36.0% (9/25). Scores 0 to 1 had a negative predictive value of 96.7% but a specificity of 13.9%. Scores 4 to 5 had a specificity of at least 89% and a positive predictive value of greater than 33%. Compared with scores 0 to 2, relative risk of ARI was 2.2 (95% CI, 1.1–4.3) for score 3 and 5.9 (95% CI, 3.3–10.7) for scores 4 to 5. CONCLUSIONS In pediatric ED MBH encounters, the nurse-completed triage BRACHA-S demonstrated moderate discrimination and identified clinically meaningful risk gradients for ARI that may support early safety planning.