Journal of Adolescent Health
Volume 50, Issue 3 , Pages 213-214, March 2012

The Assault-Injured Youth: What We Know, How We Use It

Philadelphia Collaborative Violence Prevention Center, Division of Emergency Medicine, Department of Pediatrics, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania

Article Outline

 

See Related Article p. 215

In 2009, more than 80,000 early adolescents aged 10–14 years were treated in U.S. emergency departments (ED) for injuries due to violence by others; 78,000 of these children were discharged home from the ED [1]. The ED is often the only point of contact after an assault injury, and up to 20% of these youth will be involved in another assault as a result of the altercation that brought them to the ED [2]. Just as one would not send out a patient with chest pain who has a 20% chance of reocclusion, ED clinicians are key to preventing the next, possibly tragic, ED visit. The first and most critical aspect of this task is to ensure that neither the patient nor anyone else involved in the incident is in immediate danger. Past publications have presented an ED risk assessment tool that asks directly about retaliation intent, safety concerns, and intent to involve police or other authorities [3]. In a recent issue of this journal, Wiebe et al have shown a positive association between answers to direct questions about retaliation intent and actual self-reported fighting behavior [2]. In this issue, Copeland-Linder et al add to the menu of potential assessment questions by associating retaliatory attitudes with future self-reported fights and aggression [4]. The predictive nature of the study is unique, and the fact that the questions were asked in relation to an actual violent event offers ED clinicians hope that we can discern which assault-injured patients require limited immediate resources, such as social work consultation, on-site brief interventions, or facilitated referrals. Specific practical techniques to help address safety concerns in this setting are available to emergency practitioners, but we still need validated predictive instruments, such as the ones presented in this issue, to be confident about our approach [5]. To begin this conversation, we can ask our patient something like, “Is this (fight, argument) over? What happens next?”

After a “danger assessment” is performed, the next priority for ED management of assault-inured youth is to consider the need for and interest in interventions that improve coping and reduce future injury. Although prevention services may not seem to fit into a narrow definition of the role of the emergency care system, EDs are increasingly incorporating these efforts into their standard of care. Behavior-related health care encounters may represent unique “teachable moments” that can be used for brief interventions [6]. ED-based interventions for smoking and alcohol abuse have been shown to be successful and cost-effective, but the window of opportunity may decrease over time, suggesting that prompt attention may be key to engagement into effective behavioral interventions [7], [8], [9], [10], [11], [12]. Barriers to prevention efforts in the acute care setting include lack of clinicians' time, lack of access to appropriate referral resources, and lack of proper training in violence prevention [13], [14]. Technological solutions using computer-based self-administered surveys offer assistance in addressing these issues in the ED, but they cannot completely replace one-on-one counseling and support [9], [11].

Because interpersonal violence also involves environmental and situational factors, individual-level interventions may be insufficient to prevent further injury for a specific patient. In response to this, distinct hospital-based violence prevention programs such as the parent study for the Copeland-Linder article have developed during the past two decades. These programs identify, assess, and support assault-injured patients after discharge from the hospital [15]. A number of these programs have either joined with local nonprofit organizations or developed their own programs to provide case management services. The National Network of Hospital-based Violence Intervention Programs (NNHVIP—http://nnhvip.org) is a coalition of almost 20 such programs in the United States, with the mission of strengthening existing hospital-based violence intervention programs and helping to develop similar programs in communities across the country; the network has developed a “best practices guide” that outlines the steps required to start and maintain this kind of program within a hospital system [16].

Some hospital-based programs have incorporated a “trauma-informed” approach to their young clients. This approach, starting with the ED visit and extending through postdischarge interventions and dealings with social service and justice systems, can positively influence outcomes for assault-injured youth [17]. Psychological trauma, in the form of experiences that overwhelm an individual's ability to cope, can impact cognitive function and social development and can lead to risk behaviors that are ill-explained by rational decision-making. Community and institutional stressors such as poverty and racism, and individual-level stressors such as poor nutrition, family dysfunction, and family violence, influence how an adolescent copes with a threatening situation. This, combined with the fact that the adolescent brain is still “under construction” and the response to stress may be driven more by the limbic system than by the cortex, needs to be considered when discussing how we counsel an assault-injured youth on how to avoid retaliation or risky situations [18]. Acute stress reactions to the violent event that brought the youth to the hospital can be additive to these conditions and complicate this picture [19], [20].

In the ED, patients' trauma histories impact the content and tenor of their presenting complaints, their reactions to treatment interventions, and their adherence to discharge recommendations. Trauma-informed emergency providers have learned to recognize acute stress and begin to elicit the trauma history by asking “What happened to you?” rather than “What's wrong with you?” or “What did you do?” They avoid retraumatization by allowing the patient some control over the depth and direction of the conversation about the event itself [21]. Trauma-informed service providers elicit how the patient may have experienced or/and witnessed family and community violence and other adverse childhood experiences, and learn what the youth does to cope with these experiences. Trauma-informed systems transcend the stress and frustrations of delivering services to wounded individuals and instead understand how to avoid the triggers and retraumatization of clients and the secondary trauma of their service providers [21].

It is clear that many, but not all, the youth who present for medical care after an assault injury are at risk for similar injury in the future, whether it is because of the dangerous environment that they are forced to negotiate, their attitudes toward fighting and aggression, or their desires to maintain their “status” in the hierarchy of the street. Copeland-Linder's study allows us to measure retaliatory attitudes in the ED as a predictor of future violent injury. This, incorporated into a broader assessment of their life experiences and emotional sensitivities, can go a long way in guiding our care of assault-injured youth.

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References 

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PII: S1054-139X(11)00712-9

doi:10.1016/j.jadohealth.2011.12.023

Journal of Adolescent Health
Volume 50, Issue 3 , Pages 213-214, March 2012

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