Public health consequences

Youth violence represents a major public health problem in the United States, exacting enormous social and economic costs. The public health consequences of youth violence are vast, stemming from youth being both victims and perpetrators of violence. These consequences are discussed in detail below.

Social toll

emergency_r.jpgHomicide is the number-one cause of death in African-Americans ages 15 to 24 years, and the second leading cause of death in this age group overall. Adolescents aged 15 to 19 are twice as likely to be injured by violence as the overall U.S. population (CDC, 2010).

In 2006, more than 5,700 youths ages 10 to 24 were murdered in the U.S.--an average of 15.6 youth homicides per day. Non-fatal violent injuries led 752,000 youths to seek medical care in 2008, with nearly 10% of these requiring hospitalization (CDC, 2010).

In Minneapolis, 80 youths between the ages of 15 and 24 died as a result of homicide from 2003 to 2006. Homicide was the leading cause of death in all Minneapolis residents in this age group (MDH, 2010).

Economic consequences

In addition to the non-fatal injuries and deaths discussed above, youth violence exacts a considerable economic toll. A hospitalized victim of non-fatal assault incurs an average of $24,553 in medical expenses and $57,029 in lost productivity.

The total annual cost of violence-related injuries in 15 to 24 year-olds is approximately $13 billion--$1.4 billion in medical costs and $11.6 billion in lost productivity. (Corso, et al., 2007). A non-fatal, paralyzing gunshot injury will cost an average of $2-5 million over the course of a victim's lifetime for health care, long-term care expenses, and lost productivity (Blueprint for Action, 2008).

Other significant effects attributable to violence, perhaps more difficult to measure, include the impact on a community's future productivity, property values, and psychological health.

Youth as perpetrator

Marasalvatrucha13arrest.pngYouths are not only victims of violence, but also perpetrators of violent crime. In 1999, there were 104,000 youths arrested for violent crimes (U.S. Department of Health and Human Services, 2001). An adolescent victim of violence has increased odds of becoming a perpetrator of crime, including felony assault, and thus, having involvement with the criminal justice system (Menard, 2002).

It costs $9,360 per month to detain a youth at the Hennepin County Detention Center, which houses an average of 98 juveniles per day. This amounts to an annual cost of $11 million per year to Hennepin County taxpayers (Blueprint for Action, 2008).

Operational definition

An operational definition of youth violence is necessary to accurately and consistently report incidence rates, compare rates across different jurisdictions, follow temporal trends, and monitor impact of prevention and intervention efforts.

The Centers for Disease Control and Prevention defines interpersonal violence as "the intentional use of physical force or power, threatened or actual, against another person or against a group or community that results in or has a high likelihood of resulting in injury, death, psychological harm, maldevelopment, or deprivation" (CDC, 2010).

Most available research and interventions in the field of youth violence include individuals between the ages of 10 and 24, though it is acknowledged that youth violence patterns may begin in early childhood.

Risk and protective factors

Thumbnail image for Thumbnail image for Thumbnail image for Thumbnail image for DSC_5918.jpgAn individual's likelihood of becoming involved with violence, either as a victim or a perpetrator, is largely dependent upon a dynamic interplay of both risk and protective factors. The "paradigm of resilience" maintains that it is not only the destabilizing forces, but also the nurturing, buffering factors that ultimately determine a youth's vulnerability to involvement with violence (Borowsky, 2008). A large body of research has elucidated risk and protective for youth violence (CDC, 2010; National Youth Violence Prevention Resource Center, 2010; Borowsky, 2008) at the individual, family and community levels.

At the individual level, the strongest predictor of youth violence is a history of previous violent behavior. Even lower-grade violence, such as bullying and physical fighting, can predict more serious subsequent violent involvement, such as weapons use and homicide (Borowsky, 2008). Other individual risk factors include hyperactivity, attention problems, restlessness, risk taking, aggression during childhood, antisocial behavior, poor school performance, school absenteeism, and drug and alcohol use. Protective factors include a sense of purpose and belief in a positive future; a dedication to learning; a sense of control over one's environment; resourcefulness; flexibility; empathy for others; conflict resolution skills; and ability to act independently, solve problems and think.

Family risk factors include lack of parental interaction, inadequate youth supervision, child abuse or neglect, exposure to high levels of family conflict, exposure to violence in the home, parental substance abuse, severe or inconsistent family disciplinary practices, and failure to set clear expectations. Family protective factors derive from a sense of family caring and connectedness, including closeness to a parent, good communication between parents and children, positive and consistent discipline, and parental monitoring and supervision.

At the community level, risk factors for youth violence include weapon and drug availability, lack of access to quality schools and recreational options, and general community disorganization (e.g., high neighborhood violence and crime rates, gang activity, substandard housing, unemployment, poverty). A powerful community protective factor is the availability of youth-oriented programs that foster supportive, caring relationships between youths and adults in the community.

Reporting procedures

While all 50 states have mandatory reporting laws for child abuse and neglect that qualified them for funding through the Child Abuse Prevention and Treatment Act, this federal law requires that the harm be brought about by a parent or caretaker responsible for the child's welfare. Acts of violence toward youth that are perpetrated by other youth, or by adults who are not caretakers, do not fall under this mandatory reporting law.

However, at least 40 states, including Minnesota (Statute 626.52), require health care workers to report any injury to a patient that appears to have been caused by a deadly weapon, such as a firearm or knife (Hyman, 1997; Minnesota Office of the Revisor of Statutes, 2007).

Prevention strategies

makelovenowar.jpgEvidence-based research has demonstrated that the most successful youth violence prevention programs have utilized strategies that enhance protective factors and build resilience, such as social skills training, support of positive youth development, mentoring, parent and family training, and home visitation. Interventions that have been shown to be ineffective and possible even harmful include boot camps, gun buy-back programs, and the use of scare tactics (Cunningham, et al., 2009).

Ample opportunities for prevention and control of youth violence exist at the federal, state, and community levels. Federal funding for community-level youth violence initiatives can help identify effective prevention and intervention strategies that might be more widely implemented. Increased funding for law enforcement at federal, state and community levels could help remove violent offenders from the streets and strengthen a potential deterrent to violent crime. Funding at all three levels for community-based organizations that work with troubled youth would build a stronger infrastructure to help mitigate the risk factors and strengthen protective factors that contribute to a community's incidence of youth violence.

Haddon's Ten Strategies

In 1973, William Haddon developed a list of 10 basic strategies for preventing injuries, a system that has gained widespread acceptance in the field of injury prevention and control. The 10 strategies are detailed below, as they apply to the subject of youth violence.

1. Prevent the creation of the hazard in the first place.
Assure that all children are raised in supportive, nurturing families with ample parental involvement, and assure economically vibrant communities with high-quality schools and recreational activities, no gang activity, no access to weapons, drugs or alcohol.
2. Reduce the amount of the hazard brought into being.
Reduce risk factors at the individual (e.g., hyperactivity, school absenteeism, drug use), family (e.g., poor parental supervision, family conflict) and community level (e.g. poverty, gang presence, weapon availability), and increase protective factors in a community's youth population.
3. Prevent the release of the hazard that already exists.
Take youths with multiple risk factors for violence and somehow institutionalize them, keeping them from society at large.
4. Modify the rate or spatial distribution of release of the hazard from its source.
Same as #2.
5. Separate, in time or space, the hazard and that which is being protected.
Keep all youth with elevated risk for violence separated from one another and from other youth.
6. Separate the hazard and that which is to be protected by interposition of a material barrier.
Institutionalize or incarcerate violent youth offenders.Thumbnail image for 6250_22A.jpg
7. Modify basic relevant qualities of the hazard.
Provide anger management and conflict-resolution training to at-risk youth. Reduce access to drugs and firearms.
8. Make what is to be protected more resistant to damage from the hazard.
Teach conflict resolution skills to potential victims; encourage them to
involve authorities--parents, community leaders, teachers, police--early in impending conflict.
9. Begin to counter the damage already done by the environmental hazard.
Provide quality and timely medical and mental health care.
10. Stabilize, repair, and rehabilitate the object of the damage.
Provide quality medical and mental health care, assure safe environment upon hospital discharge, refer for community-based services (e.g., mentoring, life skills training, job and education assistance)

The best strategies to employ depend upon their practicality and effectiveness. In the case of youth violence, I believe that the best strategies to employ would be #2, 4, 7, 8, 9, and 10. As discussed in "Prevention Strategies" above, considerable research supports the notion that the most effective youth violence prevention and intervention programs are those that reduce risk factors and strengthen protective factors in youth. This requires an approach that recognizes risk and protective factors at multiple levels--individual, family and community. These programs should target both victims and perpetrators of youth violence, as they are frequently one and the same, and often share known risk and protective factors.

Haddon's Matrix

Haddon's Matrix is a commonly used paradigm in public health that identifies potential intervention strategies for preventing injury. It explores characteristics related to the individual host, the vector/agent causing injury, and the environment at three stages: before the injury, at the time of the injury, and after the injury. This process helps identify potential interventions for preventing injury.

Please click on the link below to see how Haddon's Matrix can be applied to the problem of youth violence.

haddons matrix.pdf

Hospital-based prevention

Rationale
There is a growing recognition that emergency departments (ED's), especially those in large urban hospitals, can provide an effective setting for violence risk factor detection and intervention (Ketterlinus, 2008). In addition to the treatment of physical injuries in the intentionally injured youth, the ED offers a potential opportunity to explore psychosocial needs and to provide early intervention, with the aim of preventing future violence in the form of reinjury or retaliation. The significant life disruption and physical suffering brought about by a violent injury provide a unique teachable moment during which a youth may feel vulnerable and more receptive to a message of change (Cunningham, et al., 2005).

Thumbnail image for 532px-Thai_Hospital.jpg

Youth violence has been shown to be a chronic, recurrent disease, with victims being at increased risk for repeat injury and retaliation. After their physical injuries have been treated, youth violence victims are oftentimes discharged from the hospital to the same high-risk environments in which they were victimized. Reported hospital readmission rates of violently injured youth have ranged from 6-44% (Snider & Lee, 2009). In one study (Sims, et al., 1989), urban violence victims admitted to a hospital trauma service had a 20% rate of becoming victims of homicide within 5 years. Youth victims of assault not only are likely to be revictimized, but are also significantly more likely to become perpetrators of future violence (Rivara, et al., 2005).


History
Beginning in the early- to mid-1990's, a number of hospital- and ED-based youth violence intervention programs began to take root in U.S. urban settings. Such programs have now been implemented in at least 8 major cities. While these programs vary in their structure as well as the nature, intensity and duration of provided services, they share in common the basic approach of providing psychosocial evaluation to youth violence victims while in the hospital, assessing safety and retaliation risks, and referral to appropriate community-based resources. Such community resources include individual and family counseling, support groups, life skills training (e.g., anger management, conflict resolution), mentoring programs, academic support, chemical dependency programs, mental health treatment, employment training and legal support (Worden & McLean, 2008).

Results
One of the earliest hospital-based programs is the Caught in the Crossfire Program in Oakland, California, implemented in 2004, and now considered a model violence prevention program. Becker, et al. (2004) demonstrated that six months after their injury, the youth enrolled in the intervention arm were 70% less likely to be arrested for any offense and 60% less likely to have any criminal involvement than the control group. However, the authors found no statistically significant differences for rates of re-injury or death. My major critique of this study is that it did not perform random assignment of hospitalized youth, but instead compared youth from two different time periods, allowing for potential confounding of the results. In addition, the subjects were only followed for six months, leaving in question the longer-term outcomes of the intervention.

Twelve months after enrollment in a Chicago hospital's youth violence intervention program, the treatment group self-reported a significantly lower incidence of repeat violence (8.1%), compared with the control group (20.3%) (Zun, et al., 2006). There were, however, no significant differences in rates of return to the ED, arrest, or incarceration. While this study did randomize its patients, the nature of the intervention precluded blinding of the assignment process.

Marcelle and Melzer-Lange (2001) reported that, of more than 200 patients aged 10-18 who had been enrolled in Project Ujima, a Milwaukee ED-based violence intervention program, only 3 (1%) returned to the ED as a result of violent injury one year after enrollment. However, the authors did not follow non-enrolled youth, precluding comparison with a control group.

In a randomized control trial in a Baltimore pediatric ED, Cheng, et al. (2008) found that those youth enrolled in a violence intervention program had no significant difference in rate of repeat injury or community service utilization after enrollment in a violence intervention program, compared to controls. However, the study was limited by large loss to follow-up, and by the fact that the intervention often did not begin until weeks after the injury, potentially missing a short-lived teachable moment opportunity immediately after injury.

Cooper, et al. (2006) found that those youth enrolled in a Baltimore hospital violence intervention program had a significantly lower rate of hospital recidivism for repeat violent injury (5%) than the control group (36%). Youths from the treatment group also had a higher rate of employment (82% vs. 20%), were one-fourth as likely to be convicted of a violent crime, and had significantly shorter times of incarceration. The authors also made a strong case for cost effectiveness of the intervention. They estimated the aggregate cost of hospitalization to be $138,000 for the 56 youth in the treatment group versus $736,000 for the 44 youth in the treatment group. They further predicted that the total cost of incarceration would be $450,000 for the treatment group versus $1,700,00 for the control group. A strength of this study is its randomization process. However, as in the Zun (2006) study discussed above, the nature of the intervention prevents blinding of the study.

A limitation, common to all studies cited above is large loss to follow up of enrolled patients. Many of these youth have transient and shifting social situations that make extended follow up challenging. In addition, these studies tend to have relatively low numbers of subjects and limited follow up periods, highlighting the need for ongoing research. As the study of hospital-based interventions evolves, it will also be informative to elucidate the specific intervention features of individual hospital programs that prove to be the most effective in preventing re-injury and future criminal involvement.

Summary

Thumbnail image for Thumbnail image for Thumbnail image for Thumbnail image for P7230975.jpgYouth violence represents a public health problem of great magnitude in the United States, resulting in enormous social and economic consequences.

Youth are both victims and perpetrators of violence, and the risk and protective factors that influence susceptibility to violence apply in both cases. Youth violence is a chronic, recurrent condition that can lead to a cycle of violence and retaliation.

Prevention efforts should be directed toward both reducing risk factors and enhancing protective factors. Though experience to date is limited, hospitals appear to provide a unique and effective setting for intervention in the aftermath of incidents leading to youth injury.

References

Becker M, Hall S, Ursic C, Jain S & Calhoun D. (2004). Caught in the Crossfire: the
effects of a peer-based intervention program for violently injured youth. Journal of Adolescent Health, 34(3), 177-183.

Blueprint for Action. (2008). Preventing youth violence in Minneapolis. Accessed
online March 2010 at http://www.ci.minneapolis.mn.us/dhfs/blueprint.pdf

Borowsky I, Widome R, & Resnick M. (2008). Young people and violence.
International Encyclopedia of Public Health, First Edition. 6, 675-684.

Centers for Disease Control and Prevention. (2010). Youth violence prevention
scientific information. Accessed online March 2010 at http://www.cdc.gov/NCIPC/dvp/YVP/YVP-def.htm

Centers for Disease Control and Prevention, National Center for Injury
Prevention and Control (2010). Web-based Injury Statistics Query and Reporting
Systems (WISQARS). Accessed online March 2010 at http://www.cdc.gov/injury/wisqars/

Cheng T, Wright J, Markakis D, et al. (2008). Randomized trial of a case management
program for assault-injured youth: impact on service utilization and risk for reinjury. Pediatric Emergency Care, 24, 130-136.

Cooper C, Eslinger D, & Stolley P. (2006). Hospital-based violence intervention
programs work. Journal of Trauma, 61, 534-540.

Corso P, Mercy J, Simon T, Finkelstein E, & Miller T. (2007). Medical costs and
productivity losses due to interpersonal and self-directed violence in the United States. American Journal of Preventive Medicine, 32(6), 474-482.

Cunningham R, Vaidya R, Walton M, & Maio R. (2005). Training emergency medicine
nurses and physicians in youth violence prevention. American Journal of Preventive Medicine, 29(5S2), 220-225.

Cunningham R, Knox L, Fein J, et al. (2009). Before and after the trauma bay: the
prevention of violent injury among youth. Annals of Emergency Medicine, 53(4), 490-500.

Hyman, A. (1997). Mandatory reporting of domestic violence by health care providers:
a policy paper. The Family Violence Prevention Fund. Accessed April 2010 at: http://www.endabuse.org/userfiles/file/HealthCare/mandatory_policypaper.pdf

Marcelle D & Melzer-Lange M. (2001). Project Ujima: working together to make things
right. Wisconsin Medical Journal, 100,22-25.

Menard S. (2002). Short- and long-term consequences of adolescent victimization.
Washington DC: US Department of Justice, Office of Juvenile Justice and Delinquency Prevention.

Minnesota Department of Health. (2010). Minnesota injury data access system.
Accessed online March 2010 at http://www.health.state.mn.us/injury/midas/ub92/index.cfm

Minnesota Office of the Revisor of Statutes. (2007). 6262.52 Minnesota statutes, 2007.
Accessed April 2010 at: https://www.revisor.mn.gov/bin/getpub.php?pubtype=STAT_CHAP_SEC&year=current§ion=626.52

National Youth Violence Prevention Resource Center. (2010). Risk and protective
factors for youth violence fact sheet. National Youth Violence Prevention Resource Center Website. Accessed March 2010 at http://safeyouth.org/scripts/facts/risk.asp#eco

Rivara F, Shepherd J, Farrington D, Richmond P, & Cannon P. (1995). Victim as
offender in youth violence. Annals of Emergency Medicine, 26(5), 609-614.

Sims D, Bivins B, Obeid F, et al. (1989). Urban trauma: a chronic recurrent disease.
Journal of Trauma, 29:7, 940-946.

Snider C & Lee J. (2009). Youth violence secondary prevention initiatives in emergency departments: a systemic review. Canadian Journal of Emergency Medicine, 11(2), 161-168.

U.S. Department of Health and Human Services. (2001). Youth violence: a report of the Surgeon General. Rockville, MD, U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Injury Prevention and Control.

Worden R & McLean S. (2008). Hospital-based violence prevention programs: a
synopsis. The John F. Finn Institute for Public Safety, Inc. pp. 1-4.

Zun S, Downey L & Rosen J. (2006). The effect of an ED-based violence prevention
program. American Journal of Emergency Medicine, 24,8-13.

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