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Appreciating the Universality of Risk:

Rating Children with HRST

By Karen Green McGowan, RN, CDDN
& Erin R. Mathews, BS, DC


We often get this question with regard to the applicability of the HRST: How young is too young? The answer is simple; there is no age limit. The HRST rating criteria applies from womb to tomb. In this brief article we will quickly cover how this works.The HRST does not recognize or acknowledge the concept of normal vs. abnormal. It simply does not apply here. What matters to a SCREENING instrument is the presence or absence of certain factors, not their source. That territory is covered by any necessary assessment and will be addressed when the team consults the HRST Service and Training Considerations. For the purposes of rating we only ask ourselves whether or not a particular situation exists and then subsequently determine risk.

Children, by the very nature of having not yet acquired full physical or cognitive skill development, are at higher risk. Typically developing children will eventually “age out” of the severity of these risks due to skill acquisition. Nevertheless, until that happens the risks are very much present and real. For children who, due to a condition or intellectual and developmental disability, do not eventually acquire these skills, the risks often do not diminish and may never go away. Instead these risks may remain indefinitely and at times even increase. Unlike children who age-out of certain risks and thereby lower their HRST score over time, children for whom the risk factors remain due to developmental issues will likely retain HRST scores accordingly.

Let’s look at several items on the HRST that apply to infants and children, regardless of if or where they fall on the developmental spectrum. Keep in mind that in either situation described above, when the risks are present regardless of the reason, cause, or age the risks must not only be identified but also addressed as effectively as possible.

A. Eating – All infants begin life on an altered-textured diet, both for safety and nutritional reasons. This lasts the majority of the first year of life, after which they should progress to regularly textured items. The HRST scoring for this item would reflect the risks that are involved as a result of eating altered-textured food. If the child were entirely fed via feeding tube or other external source, this would increase the score. These risks remain very real for adults who also need assistance eating, altered-textured diets, or are fed by tube.

“Children, by the very nature of having not yet acquired full physical or cognitive skill development, are at higher risk.”

B. Ambulation – No child under the age of around twelve years old should score a 0 on this item, which indicates no risk is identified. Most infants do not walk until they are around one year of age. Infants under eight months of age usually require outside support to sit. Children up to a fairly advanced age require supervision with walking for safety reasons, like avoidance of cross-traffic. Ambulation scores for even typically developing children will be triggered depending upon their specific needs. Children, or any adult, who cannot be placed in an upright sitting position regardless of adaptation are assigned the maximum score for this item.

C. Transfer – A slightly tougher item than ambulation, but again, it will rarely rate a score of 0 (noting no identified risk) until well after the first year of life is completed. Early in life children can usually be moved about with the physical assistance of a single caregiver. For safety reasons they require assistance and supervision with things like stairs, uneven surfaces and getting in and out of the bath or shower for several years. Infants and children should always trigger a score in this item until they develop both the physical ability and judgment needed to manage all transfer situations independently. For those individual who do not develop these skills the risks and scores remain.

D. Behaviors – Many children will score in the behavioral section, not because they are bad or poorly parented, but because they lack the formal communication skills and frustration tolerance of adults. Hitting, biting, kicking, cutting hair, and painting walls, etc., happens often and it qualifies for scoring. If physical restraint use applies, and it often does, it should be included, as should any medications used. Again, for some these behaviors may not disappear but remain along with the associated risks.

E. Gastrointestinal issues – Although spitting up after meals is not uncommon in infants under one year of age it still presents certain risks. These risks, such as aspiration, choking, or esophageal damage are very real for the individual regardless of age.

F. Skin Integrity – Continuous incontinence is an issue that is associated with skin vulnerability. This will earn any child a higher score until they are potty-
trained, no longer requiring skin monitoring. If other issues related to skin apply,they should be considered as well. These risk do not go away with age as long as the condition causing incontinence remains.

G. Safety – according to the CDC the single most common cause of preventable death in individuals younger than 45 years of age is accidental injury. Depending upon age bracket, injuries related to falls are either the number one or two cause of emergency room visits across the age spectrum. While we do not advocate rating every trivial scratch or bump, if an injury requires first aid or medical attention it should be captured here, as should falls or near-falls. These serve as indicators of other, often hidden, issues.

In order to thrive and reach their full potential, children require protection and support for many years after birth. Just because these needs are part of the typical developmental process does not mean they do not pose risks and cannot be captured on a screening instrument like the HRST. We strongly encourage our users to think in terms of what is needed, not what is “normal” for the person.

The tool should be applied to children exactly as it is to adults, with the exception of frequency of review. This is due to the rate of expected, normal developmental changes. If the child is under two years of age, the tool should be reviewed quarterly. From ages two to five, the frequency should be semi-annually. From six and above, the normal annual schedule may be observed.