Identify Behavior Risk Level

A sense of an escalated person's overall risk is formulated by integrating information from observations of a person’s current behaviors with information about known patient, caregiver, and environmental risk and protective factors that may influence the likelihood of escalation or increased safety concerns. Patients who have multiple risk factors, particularly in the absence of protective factors, may benefit from enhanced precautions to include a greater level of support and responsiveness. When observing the escalated person's behaviors, consider whether these behaviors represent low, medium, or high risk, as defined below.

Low Risk

Distress behaviors are present but are subtle and at a low level of intensity. These behaviors can sometimes be recognized as a change from previous “baseline” behavior (e.g., a child who was sitting calmly and then starts to get restless or begins to whine or voice discomfort). There is no imminent danger to self or others.

Medium Risk

Distress behaviors are increasing in intensity and there is greater concern for risk of harm to self or others. There is a high level of concern that behaviors could escalate to need for urgent intervention and support to maintain safety. Signs of distress are more clear-cut and include visible agitation, increased emotional intensity, and some “lower-level” escalated behavior acts (e.g., moving towards door, arguing).

High Risk

Distress behaviors are of high intensity and uncontrolled. Behavior is an immediate risk for harm to self and/or others.

Agitation/Aggression Risk Levels

Low	Medium	High
Whining Crying Pacing Wringing of hands Foot tapping Abrupt gestures Fidgeting Picking Rocking Running around Withdrawal Complaining Not responding or complying	Arguing Hostile Defensive Blaming statements Clenching fists Swearing Raising or swinging hands Verbal escalation with increased volume Verbal or physical expletives Threatening	Verbal or physical gestures/threats meant to intimidate “I’m going to kill you.” Acting in unsafe and dangerous ways Punching Pushing Threatening with objects Self-Injurious behavior such as head banging Kicking Biting self or others

Elopement Risk Levels

Low	Medium	High
Saying “I don’t want to be here.” “I want to go home.” Restless Scoping/surveying the environment	Visible agitation Freezing, refusal, withdrawing Verbal protest Increased volume, crying Moving toward doors or exits Avoidance of care	Visible agitation with actual attempts to leave such as running away

Immediate Threat

Actively Suicidal/Self Harm Behavior

Note that the below risk formulation is based on assessing risk for immediate suicidal risk occurring at the time of clinical visit.

For additional guidance on evaluating suicidal risk and behavior refer to suicide pathway.

Actively Suicidal/Homicidal Risk Levels

Low Needs an additional intensive care plan but is not a safety risk in the moment.	Medium Increasing risk of harm in the moment, may require an immediate plan for transition to higher level of care (e.g., person should not return home without more intensive evaluation and plan for immediate intervention).	High Immediate and current threat of harm to self in the moment and requires immediate intervention (e.g., call to 911).
Wishing to be not alive anymore Wishing to not be born Expressed unhappiness with life Nonspecific active suicidal thoughts Sullen and/or depressed mood Expressed feelings of worthlessness Reckless or risk-taking behaviors Increased alcohol and or drug use Significant decline in person’s mental state	Expresses non-specific active suicidal “I want to die/kill…” Active suicidal ideation with any method (no plan) without intent to act “I would use a knife but I’m not planning to do it.” Active suicidal ideation with some intent to act without specific plan “I am going to hurt myself but not sure how yet.” Active suicidal ideation with specific plan and intent “I’m going to take an overdose of my medication.” Dramatic changes in mood; or significant worsening in person’s presentation Homicidal ideation and/or threat to others Thoughts, intent/method, and plan to act on harming self	Presents with injurious behaviors Trying to stab self with pencil Has weapon or other weaponized implement, and threatening to harm self or others Physically aggressive or makes high intensity verbal threats “I’m going to kill myself.”

Threat to Harm Others

Low	Medium	High
Expresses non-specific threat to harm others. “I hate them…” Expressed anger/hatred towards others. Paranoia, persecutory thoughts.	Active intent to harm others with specific plan. Identified person(s) not present in the current location. “I’m going to wait for my enemy after school.”	Active intent to harm others with specific plan. Identified person(s) present or immediate accessible. Presents with injurious behaviors. Trying to harm others. Has a weapon or other weaponized implement, and threatening to harm identified person. Physically aggressive or makes high intensity verbal threats. “I’m going to kill you.”