The emergency department approach to violently injured patient care: a regional survey.

OBJECTIVE: Since the early 1990s public health workers have challenged healthcare practitioners to take an active role in violence prevention with patients aged 10-24 years. Emergency department (ED) clinicians are uniquely positioned to identify, assess, and refer youth involved in violent events. The objective of this study was to describe ED directors' estimate of the number of violently injured youth seen, the presence of established protocols or guidelines for handling youth violence, and the type of training programs offered to ED physicians regarding this issue. METHODS: The authors conducted a survey of EDs (n = 64) in the Philadelphia metropolitan region to determine the standard of ED care for violently injured youths. Half of the EDs were in urban areas and half in suburban. RESULTS: A total of 41 out of 64 (64.1%) ED directors completed and returned the written questionnaire. In addition to treating the specific injuries sustained, ED responses to youth violence primarily involved talking with patients about the events surrounding the injury. The estimated number of violently injured youth seen per month varied considerably. Twenty four directors (58.5%) estimated that their institution treated fewer than 10 per month; 10 (24.4%) reported 11-30, and seven (17.1%) mostly large urban hospitals, saw more than 30 per month. Although most hospitals reported that the staff counsels patients about safety concerns, only 17% offered their staff formal training programs on youth violence. CONCLUSIONS: To address the prevention of youth violence, EDs need specific training programs for ED staff, as well as systematic risk assessment and referral resources for structured intervention and follow up.     

School-based violence prevention programs: systematic review of secondary prevention trials

OBJECTIVE: To quantify the effectiveness of school-based violence prevention programs for children identified as at risk for aggressive behavior. DESIGN: Systematic review and meta-analysis of randomized controlled trials. Electronic databases and bibliographies were systematically searched and authors and organizations were contacted to identify randomized controlled trials. Standardized, weighted mean effect sizes were assessed by meta-analysis. SETTING: Elementary, middle, and high schools. PARTICIPANTS: Children at risk for aggressive behavior. MAIN OUTCOME MEASURES: Violent injuries, observed or reported aggressive or violent behaviors, and school or agency responses to aggressive behaviors. RESULTS: Of the 44 trials identified, none reported data on violent injuries. For the 28 trials that assessed aggressive behaviors, the pooled difference between study groups was -0.36 (95% confidence interval, -0.54 to -0.19) in favor of a reduction in aggression with intervention. For the 9 trials that reported data on school or agency responses to aggression, the pooled difference was -0.59 (95% confidence interval, -1.18 to 0.01). Subgroup analyses suggested greater effectiveness in older students and when administered to mixed-sex groups rather than to boys alone. CONCLUSIONS: School-based violence prevention programs may produce reductions in aggressive and violent behaviors in children who already exhibit such behavior. These results, however, need to be confirmed in large, high-quality trials.     

Childhood speech disorders: reported prevalence, comorbidity and socioeconomic profile

OBJECTIVE: To describe the reported prevalence, comorbidity and socioeconomic status (SES) of children with speech disorders. METHODOLOGY: Data from the 1995 Australian Health Survey were used. Information relating to the health of 12 388 children aged 0-14 years was collected via face-to-face interviews with a responsible adult. Speech disorders were recorded if children had reported difficulty talking, producing speech sounds, or who stuttered. RESULTS: The prevalence of childhood speech disorders (CSD) was 1.7% (n = 209). Of this group, 25.8% (n = 54) had a developmental delay or intellectual impairment; when these were excluded, the prevalence of CSD was reduced to 1.3% (n = 155). Among males, the peak prevalence occurred at age 5 (6.5%), for females the highest rates were for 3-4-year-olds (1.8%). Children with a speech disorder had a greater number of additional health problems. No relationship was found between SES and CSD. CONCLUSIONS: Children with speech disorders often have complex health and developmental needs. Developing effective prevention programs with a view to improving the long-term health and social outcomes of these children will require a mix of individual (clinical) and population-based (public-health) strategies.     

Behavior-oriented approaches to reducing youth gun violence

Advocacy groups on both sides of the guns issue frequently point to changing personal behavior--of both parents and children--as a key element in reducing gun violence among youth. Efforts to bring about these changes range from community-based campaigns, to laws and programs that encourage parents to store their guns safely, to educational initiatives that focus on keeping young children away from guns and encouraging youth to resolve disputes without violence. Unfortunately, these behavior-oriented programs have not shown great success in reducing youth gun violence. This article reviews the research surrounding behavioral approaches to gun violence prevention and highlights obstacles that hamper the effectiveness of these programs. Supportive communities can play a key role in protecting youth from violence in general, but the few community-based violence prevention programs that focus on youth have not been shown to decrease youth access to or use of guns. By and large, behavioral programs and legal interventions aimed at parents have not been proven to reduce youth gun violence. This may be due in part to parental misperceptions about children's risk of injury and ability to protect themselves. Children and youth are particularly difficult targets for behavioral change programs. Cognitive immaturity among younger children and perceptions of invulnerability among adolescents may be part of the reason. Most programs that seek to persuade youth to stay away from guns have not been proven effective. The author concludes that, although behavioral programs could be improved, overall they hold only limited promise for reducing youth gun violence.     

Correlates of violent behavior among adolescents presenting to an urban emergency department

OBJECTIVE: To examine rates and correlates of self-reported perpetrated violence among teens presenting to an urban emergency department. STUDY DESIGN: Cross-sectional study of a consecutive sample of youth (12-17 years) presenting to an urban emergency department. The youth were surveyed about demographics, community violence exposure, parental monitoring, substance use, weapon carriage, group fighting, and aggression (past 12 months). Bivariate and multivariate analyses were performed to identify correlates of the severity of the violence (none, moderate, or severe) perpetrated in the past year. RESULTS: A total of 115 youth were surveyed (males, 47%; response rate, 85%). The sample group was 51% African American. A total of 77% of the youth reported that they perpetrated violence in the past year, with 37% reporting severe violence (use of a weapon, group fighting, causing an injury requiring medical care). All patients who self-reported perpetrating severe violence in the past year were discharged home from the emergency department. The diagnosis made in the emergency department (illness versus injury) was not associated with the violence perpetrated in the past year. Sex was not a significant predictor of severe perpetrated violence. CONCLUSIONS: Youth presenting to urban emergency departments report high rates of perpetrating violence in the past year that, on the basis of other studies, is likely to continue. These results suggest that future emergency department-based violence prevention efforts should consider universal screening of adolescents.     

Evidence based physical activity for school-age youth

OBJECTIVES: To review the effects of physical activity on health and behavior outcomes and develop evidence-based recommendations for physical activity in youth. STUDY DESIGN: A systematic literature review identified 850 articles; additional papers were identified by the expert panelists. Articles in the identified outcome areas were reviewed, evaluated and summarized by an expert panelist. The strength of the evidence, conclusions, key issues, and gaps in the evidence were abstracted in a standardized format and presented and discussed by panelists and organizational representatives. RESULTS: Most intervention studies used supervised programs of moderate to vigorous physical activity of 30 to 45 minutes duration 3 to 5 days per week. The panel believed that a greater amount of physical activity would be necessary to achieve similar beneficial effects on health and behavioral outcomes in ordinary daily circumstances (typically intermittent and unsupervised activity). CONCLUSION: School-age youth should participate daily in 60 minutes or more of moderate to vigorous physical activity that is developmentally appropriate, enjoyable, and involves a variety of activities.     

Entry risk into the juvenile justice system: African American,American Indian,Asian American,European American,and Hispanic children and adolescents

Background: Findings on disproportionate minority contact remain mixed. Few empirical studies have examined to what extent entry risk into juvenile justice varies across ethnic/racial groups, and to what extent childhood aggressive behaviors foretell later deviance and entry risk. In the current study, we sought to address these shortcomings by implementing a survival analysis on a representative sample of youth followed from age 8 to 18. Methods: The sample included N = 2,754 lower to lower‐middle SES youth from five different ethnic/racial groups (African American, American Indian, Asian American, European American, and Hispanic youth), part of a large‐scale violence prevention effort. Aggressive behaviors were rated by teachers during elementary school, entry risk into juvenile justice was measured by official data, while SES was based on census data. Results: Developmental entry risk into the juvenile justice system peaked at age 14 and subsequently declined. No differences were found across the four racial groups; however, Hispanic youth were at elevated risk (by 73%). Only childhood physical aggressive behavior increased entry risk (by 87%); this was above and beyond a ‘simple’ maturational liability we found and net any effects by sex, race/ethnicity, and SES. Conclusions: Some evidence suggested disproportionate minority contact, but only for Hispanic youth. Entry risk was invariant by race, but differed for males versus females and for youth from relatively higher socioeconomic status (SES) strata compared to youth from lower ones. Intervention efforts should target physically aggressive children during the elementary school years; however, some of the evidence also suggests that there exists a ‘maturational liability’ developmentally over time, between the ages of 8 and 18, independent of any of the focal predictors tested.     

Children and adolescents with sexual behavior problems

Youth with substantial sexual behavior problems (n = 166) were compared with youth from the same sample with few sexual behavior problems (n = 413) and with no sexual behavior problems (n = 943). It was hypothesized that youth with significant sexual behavior problems would be characterized by higher rates of sexual and physical abuse and higher rates of internalizing problems relative to youth without sexual behavior problems and that all youth would evidence a positive treatment response to multisystemic therapy. Relative to youth with no sexual behavior problems, youth with significant sexual behavior problems were more likely to have been sexually or physically abused and had higher rates of internalizing and externalizing behavior problems. These youth were also more likely to include girls, were younger, and had more social problems than youth with no sexual behavior problems. Youth in all groups responded with clinically relevant and statistically significant reductions in problem behaviors at posttreatment.     

The role of the pediatrician in preventing suicidal behavior

Suicidality is a serious cause of morbidity and mortality among young people. Important risk factors for suicidal behavior are mental illness, alcohol and other substance use disorders, previous suicide attempt, impulsive and/or aggressive behavior, history of abuse, and access to lethal means. Emotional well-being and connectedness to family and school act to buffer or protect young people from involvement in self-directed violence. Pediatricians can play a major role in suicide prevention by identifying emotional and behavioral problems and intervening appropriately, promoting positive parenting skills and family cohesion, and providing injury prevention education to reduce access to lethal means. As part of a comprehensive strategy to prevent youth suicidal behavior, child health professionals are uniquely positioned to promote resiliency among youth and families as well as identify and provide appropriate treatment and service coordination for risk factors before injuries occur. Adequate training is critical to ensure that pediatricians are prepared to provide effective assessment, prevention and intervention for suicidal behavior.     

Male partner pregnancy-promoting behaviors and adolescent partner violence: findings from a qualitative study with adolescent females.

OBJECTIVE: To examine the context of pregnancy and sexual health among adolescent females with a history of intimate partner violence (IPV). This paper reports on a subset of females who described abusive male partners' explicit pregnancy-promoting behaviors (ie, messages and behaviors that led females to believe their partner was actively trying to impregnate them). METHODS: Semistructured interviews were conducted with 53 sexually active adolescent females, with known history of IPV, about violence, sexual experiences, and related behaviors. Interviews were analyzed using a content analysis approach; 14 interviews in which females reported that partners were actively trying to impregnate them were further analyzed for pregnancy and contraceptive use. RESULTS: Participants (N = 53) were aged 15 to 20 years, with notable minority representation, 21% African American (n = 11) and 38% Latina (n = 20). Over half (n = 31, 58%) had experienced pregnancy. A key finding was that approximately one quarter of participants (26%, n = 14) reported that their abusive male partners were actively trying to get them pregnant. Females' stories revealed that abusive male partners desiring pregnancy manipulated condom use, sabotaged birth control use, and made explicit statements about wanting her to become pregnant. CONCLUSIONS: Pregnancy-promoting behaviors of male abusive partners may be one potential mechanism underlying associations between adolescent IPV and pregnancy. These findings suggest that exploring pregnancy intentions and behaviors of partners of sexually active adolescents may help to identify youth experiencing IPV. The frequency of birth control sabotage and explicit attempts to cause pregnancy in adolescent IPV needs to be examined at the population level.     

Case-control confusion.

OBJECTIVE: Critical analysis of journal articles by using principles of evidence-based medicine is important for clinicians applying research results in their practice and is a valuable component of pediatric residency training. Appraisal of an article's methodological rigor is often tailored to a particular type of study design, so that misclassification of study design can confuse the appraisal. The goal of this study was to determine how often pediatric research articles that are self-declared as case-control studies conform to a standard definition for this study design. METHODS: A Medline search identified articles published in two pediatric journals from January 1996 through August 2004 with the phrase "case-control study" in the title or abstract. Articles that were self-declared as case-control studies were analyzed to determine whether they satisfied a standard definition of a case-control study. RESULTS: Of the 91 purported case-control studies, only 68 (75%) met the standard definition for at least the most important analysis. The remaining 23 articles could be classified as cross-sectional studies (N = 16) or prospective cohort studies (N = 7). CONCLUSIONS: Ambiguity in the definition of a case-control study can cause confusion in the critical appraisal of published clinical research.     

Internet prevention messages: targeting the right online behaviors

BACKGROUND: Internet safety programs urge youth to avoid sharing personal information and talking with "strangers" online. OBJECTIVE: To examine whether sharing personal information and talking with strangers online or other behaviors are associated with the greatest odds for online interpersonal victimization. DESIGN: The Second Youth Internet Safety Survey was a cross-sectional random digit-dial telephone survey. SETTING: United States. PARTICIPANTS: A total of 1500 youth aged 10 to 17 years who had used the Internet at least once a month for the previous 6 months. MAIN EXPOSURE: Online behavior, including disclosure of personal information, aggressive behavior, talking with people met online, sexual behavior, and downloading images using file-sharing programs. OUTCOME MEASURE: Online interpersonal victimization (ie, unwanted sexual solicitation or harassment). RESULTS: Aggressive behavior in the form of making rude or nasty comments (adjusted odds ratio [AOR], 2.3; P<.001) or frequently embarrassing others (AOR, 4.6; P = .003), meeting people in multiple ways (AOR, 3.4; P<.001), and talking about sex online with unknown people (AOR, 2.0; P = .02) were significantly related to online interpersonal victimization after adjusting for the total number of different types of online behaviors youth engaged in. Engaging in 4 types of online behaviors seemed to represent a tipping point of increased risk for online interpersonal victimization (OR, 11.3; P<.001). CONCLUSIONS: Talking with people known only online ("strangers") under some conditions is related to online interpersonal victimization, but sharing personal information is not. Engaging in a pattern of different kinds of online risky behaviors is more influential in explaining victimization than many specific behaviors alone. Pediatricians should help parents assess their child's online behaviors globally in addition to focusing on specific types of behaviors.     

Policing guns and youth violence

To combat the epidemic of youth gun violence in the 1980s and 1990s, law enforcement agencies across the United States adopted a variety of innovative strategies. This article presents case studies of eight cities' efforts to police gun crime. Some cities emphasized police-citizen partnerships to address youth violence, whereas others focused on aggressive enforcement against youth suspected of even minor criminal activity. Still others attempted to change youth behavior through "soft" strategies built on alternatives to arrest. Finally, some cities used a combination of approaches. Key findings discussed in this article include: Law enforcement agencies that emphasized police-citizen cooperation benefited from a more positive image and sense of legitimacy in the community, which may have enhanced their efforts to fight crime. Aggressive law enforcement strategies may have contributed to a decline in youth gun violence, but they also may have cost police legitimacy in minority communities where residents felt that the tactics were unfair or racially motivated. Approaches that emphasize nonarrest alternatives and problem-solving strategies offer an intriguing but unproven vision for addressing youth gun violence. None of the initiatives presented in the case studies has been shown conclusively to reduce youth gun crime over the long term. The author suggests that policing alone cannot contain youth gun violence, but by carefully balancing enforcement with community collaboration, police departments can help shift social norms that contribute to youth gun violence.     

Emerging strategies in the prevention of domestic violence

Responses to domestic violence have focused, to date, primarily on intervention after the problem has already been identified and harm has occurred. There are, however, new domestic violence prevention strategies emerging, and prevention approaches from the public health field can serve as models for further development of these strategies. This article describes two such models. The first involves public health campaigns that identify and address the underlying causes of a problem. Although identifying the underlying causes of domestic violence is difficult--experts do not agree on causation, and several different theories exist--these theories share some common beliefs that can serve as a foundation for prevention strategies. The second public health model can be used to identify opportunities for domestic violence prevention along a continuum of possible harm: (1) primary prevention to reduce the incidence of the problem before it occurs; (2) secondary prevention to decrease the prevalence after early signs of the problem; and (3) tertiary prevention to intervene once the problem is already clearly evident and causing harm. Examples of primary prevention include school-based programs that teach students about domestic violence and alternative conflict-resolution skills, and public education campaigns to increase awareness of the harms of domestic violence and of services available to victims. Secondary prevention programs could include home visiting for high-risk families and community-based programs on dating violence for adolescents referred through child protective services (CPS). Tertiary prevention includes the many targeted intervention programs already in place (and described in other articles in this journal issue). Early evaluations of existing prevention programs show promise, but results are still preliminary and programs remain small, locally based, and scattered throughout the United States and Canada. What is needed is a broadly based, comprehensive prevention strategy that is supported by sound research and evaluation, receives adequate public backing, and is based on a policy of zero tolerance for domestic violence.     

Violence prevention: reaching adolescents with the message

OBJECTIVE: To identify an effective medium for communicating with adolescents in a large-scale, cost-effective violence prevention program. METHODS: A set of youth violence prevention programs was established at The Stamford Hospital, a level II trauma center. The traveling version of the program was presented to middle school students in four parts: 1) a rap music video created by our violence prevention staff, 2) a facilitated discussion about dealing with anger, 3) a video of a trauma resuscitation in our emergency department, and 4) a commercial video of a teenage boy paralyzed after a gunshot wound. A written questionnaire with a five-point rating scale (1 to 5) was used to survey the audience 1 month after the program. The survey assessed the respondents' recall of each part of the program and the perceptions of the value of each part in identifying the problem of violence and reducing violent behavior. RESULTS: Of 99 respondents, the highest ratings for retention, problem identification, and impact were given to the commercial video (combined average category ranking of 11.394) and the rap music video (11.182). The trauma resuscitation video and the discussion of anger were ranked as being less effective (10.253 and 9.383, respectively). The audience seemed to comprehend the main point of the program and ranked the program, as a whole, higher than any of the parts when measured by success at problem identification and impact. CONCLUSION: Effective communication with adolescents is possible through many avenues. Children of the video age respond well to visual material. A violence prevention program should incorporate effective multimedia presentations. A variety of methods in combination proves to be most effective.     

Exposure to violence and victimization, depression, substance use, and the use of violence by young adolescents

OBJECTIVE: To examine the relationships among exposure to violence; tobacco, alcohol, and other substance use; depression; church attendance; and the use of violence among very young adolescents. METHODS: An 86-item confidential questionnaire was administered to 722 sixth grade students (mean age = 11.9+/-0.8 years) attending 4 middle schools serving neighborhoods in and around public housing. RESULTS: Boys had a higher mean violence scale score than girls (P < or =.0001), and students living in public housing had higher violence scale scores than other students (P< or =.0001). Self-reported use of violence was significantly associated with exposure to violence (r =.45); age (r =.28); frequency of church attendance (r = -.14); depression (r =.28); the probability of being alive at age 25 (r = -.09); the frequency of use of cigarettes (r =.39), alcohol (r =.37), and multiple substances (r =.38); and interest in a gang (r =.37). When all of these variables were analyzed with multiple linear regression, multiple substance use, exposure to violence, interest in a gang, male gender, cigarette smoking, and depression level accounted for 49.7% of the variation in the use of violence scale. CONCLUSION: Recent multiple substance use and lifetime exposure to violence and victimization were the strongest correlates with the frequency that these youth reported using violence and carrying weapons.     

Dating violence, sexual assault, and suicide attempts among urban teenagers

OBJECTIVE: To evaluate the relationship between dating violence, sexual assault, and suicide attempts among urban adolescents. DESIGN: Secondary analysis of the 2005 New York City Youth Risk Behavior Survey. SETTING: Eighty-seven New York City public high schools. PARTICIPANTS: Representative population-based sample of 8080 students, 14 years and older. MAIN EXPOSURES: Dating violence in the past year and lifetime history of sexual assault. OUTCOME MEASURE: One or more suicide attempts in the past year. RESULTS: Respondents were 50.0% female and primarily black (36.0%) or Hispanic (40.1%). In the past year, 11.7% of females and 7.2% of males reported 1 or more suicide attempts. Lifetime history of sexual assault was reported by 9.6% of females and 5.4% of males. Dating violence in the past year was reported by 10.6% of females and 9.5% of males. In multivariate models, controlling for persistent sadness, sexual orientation, and significant risk behaviors, recent dating violence (odds ratio, 1.61; 95% confidence interval, 1.05-2.47) was associated with suicide attempts in adolescent girls, while lifetime history of sexual assault (odds ratio, 3.86; 95% confidence interval, 2.11-7.06) was associated with suicide attempts in adolescent boys. CONCLUSIONS: In this population of urban youth, recent dating violence among females and lifetime history of sexual assault among males were significantly associated with suicide attempts. Clinicians and educators should be trained to routinely screen adolescents for violence victimization and should have a low threshold for referring these at-risk teenagers for mental health services.     

How do high-risk youth use the Internet? Characteristics and implications for prevention

Using data from the Second Youth Internet Safety Survey, a nationally representative telephone survey of 1,500 youth Internet users (ages 10 to 17), this study explores differences in Internet use characteristics between high risk youth and other Internet users. Those youth who engaged in aggressive behavior online and those who used the Internet on a cell phone were about twice as likely to be classified as high risk (having experienced high parent conflict or child maltreatment) as compared to other Internet users. Those youth who talked with known friends online were significantly less likely to be included in the high risk group. Controlling for demographic and Internet use characteristics, youth who received an aggressive sexual solicitation were almost 2.5 times as likely to report experiencing physical abuse, sexual abuse or high parent conflict. Implications for prevention are discussed, including avenues for reaching high risk populations of youth.     

Violence risk and protective factors among youth held back in school.

OBJECTIVE: To identify risk and protective factors for violence perpetration among youth with a history of grade retention. DESIGN: Longitudinal analysis of in-home interviews of 13,781 adolescents in grades 7 through 12 conducted in 1995 and 1996. METHODS AND MEASURES: Serious interpersonal violence perpetration at time 2 by time 1 independent variables including measures of community and school context, family context, and individual characteristics. RESULTS: The 20% of girls and 28% of boys who had repeated 1 or more grades were more likely than those who had not to be in the top quintile of violence perpetration at time 2 (P <.001). For both girls and boys with a history of grade repetition, predictive risk factors with an odds ratio of 3 or greater (P <.001) included time 1 violence perpetration, violence victimization, weapon carrying, school problems, and alcohol and marijuana use. Although a high grade point average was a significant protective factor against violence perpetration for both girls (odds ratio, 0.36; P <.05) and boys (odds ratio, 0.23; P <.001), performance on a validated measure of verbal knowledge was not associated with violence perpetration over the study period. School connectedness, parent-family connectedness, and emotional well-being were also significant universal protectors against violence perpetration. CONCLUSIONS: Youth who are held back in school are at heightened risk for violence perpetration. Violence-related behaviors and substance use considerably increase the likelihood of this outcome. The findings suggest that schools can participate in violence prevention by providing youth with a positive community and academic experience.