Adolescent Interpersonal Violence Implications for Health Care Professionals Naomi Nichele Duke, MD, MPHa,*, Iris Wagman Borowsky, MD, PhDb KEYWORDS Adolescent violence Bullying involvement Adolescent dating/relationship violence Adolescent health screening Adolescent health counseling KEY POINTS Violence involvement represents a significant burden affecting the health and positive development of youth. As in other forms of adolescent violence and violence-related behaviors, bullying involvement and dating/relationship violence have immediate and long-term health consequences. Health care providers in the primary office setting have a pivotal role in the prevention, identification, and management of adolescent violence involvement. Screening and counseling of all youth and parents on violence involvement is recommended. Resources are available to support primary care providers in assessment and intervention on behalf of youth.
INTRODUCTION
The problem of adolescent violence is particularly troubling because each act is preventable. Each year, the number of lives lost and youth potential destroyed by disability related to violence serves as a reminder that adolescent violence prevention is a responsibility for all individuals involved in the care of youth. In the primary care setting, health providers have a pivotal role to play in the detection of adolescent violence involvement and in mitigating health consequences related to youth violence. This review provides a summary of the burden of adolescent violence and violencerelated behavior, risk, and protective factors for violence outcomes, the importance
Disclosures: None. a Division of General Pediatrics and Adolescent Health, Department of Pediatrics, University of Minnesota, 3rd Floor, #385, 717 Delaware Street Southeast, Minneapolis, MN 55414, USA; b Division of General Pediatrics and Adolescent Health, Department of Pediatrics, University of Minnesota, 3rd Floor, #389, 717 Delaware Street Southeast, Minneapolis, MN 55414, USA * Corresponding author. E-mail address: [email protected] Prim Care Clin Office Pract 41 (2014) 671–689 http://dx.doi.org/10.1016/j.pop.2014.05.013 primarycare.theclinics.com 0095-4543/14/$ – see front matter Ó 2014 Elsevier Inc. All rights reserved.
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of screening for violence involvement in the primary care setting, and examples of online resources to support providers in advocating, assessing, and intervening on behalf of youth. The article draws attention to bullying and dating/relationship violence, not as new forms of violence-related behavior, but as behaviors with health outcomes that have received increased attention more recently. ADOLESCENT VIOLENCE INVOLVEMENT: SCOPE OF THE PROBLEM
Despite increased awareness of the negative consequences of youth violence involvement over the past decade, violence-associated acts (including self-directed violence) remain among the leading causes of death for youth ages 10 to 24 years. In the United States in 2010, suicide and homicide were the third and fourth leading causes of death for youth ages 10 to 14 years, and the second and third leading causes of death for young people ages 20 to 24 years, respectively.1 For youth ages 15 to 19 years, the order of cause was reversed, with homicide being the second leading cause of death and suicide a very close third.1 In the United States, almost 5000 young people ages 10 to 24 years lost their lives due to homicide in 2010, an average of 13 individuals each day.2 Overwhelmingly, the cause of these deaths involved the use of a firearm (71.3% among youth ages 10–14; 84.8% among youth ages 15–19; 82% among young people ages 20–24).1 These numbers do not tell the whole story, as we know that homicide is experienced in greater numbers among some groups of youth. Among African American youth ages 10 to 24 years, homicide is the leading cause of death; in this same age range, for Hispanic youth it is the second leading cause of death; and for American Indian and Alaska Native youth it is the third leading cause of death.2 Among youth taking the 2011 Youth Risk Behavior Survey (YRBS; youth grades 9– 12), just more than 1 in 13 reported an attempt on their life at least once during the previous year (1 in 10 females; 1 in 17 males).3,4 In this same survey, more than 1 in 7 youth reported seriously considering suicide during the 12 months before survey administration (almost 1 in 5 female and 1 in 8 male youth).3,4 For youth ages 10 to 24 years, firearms are the method used in 30% to 47% of suicides (male youth 37.8%–50.8%; female youth 13.8%–27.4%).1 Nonfatal injuries related to violence represent a significant source of poor health among adolescents. In 2012, assault-related injuries (physical assault by striking) topped the list for causes of nonfatal violence-related injuries among those 10 to 24 years old in the United States.5 In this same year, more than 500,000 young people ages 10 to 24 years were treated in emergency departments for assault-related injuries.5 The use of firearms resulted in nonfatal injuries requiring emergency department care for more than 26,000 10-year-olds to 24-year-olds in 2012.5 For youth taking the 2011 YRBS, one-third reported being in a physical fight one or more times in the previous year3; approximately 4% reported being in a physical fight with injuries requiring medical attention from a doctor or nurse at least once during the same time period.2 Just less than 10% of 2011 YRBS respondents reported being assaulted (eg, hit, slapped, or physically hurt on purpose) by a boyfriend or girlfriend in the previous year.3 Earlier data from the 2005 National Survey of Adolescents estimates the overall prevalence of dating violence to be 1.6% (sexual assault 0.9%, physical assault 0.8%, alcohol-drug facilitated rape 0.1%).6 Using 2005 Census data, this figure is equivalent to 400,000 US adolescents.6 Many behaviors contribute to youth violence. Among youth respondents for the 2011 YRBS, just more than 16% reported carrying a weapon (eg, gun, knife, or club) on at least 1 day during the previous month; 5% reported carrying a gun during the same time period.3 Bully victimization occurred during the previous year for 1 in 5
Adolescent Interpersonal Violence
to 1 in 6 respondents taking the 2011 YRBS (eg, 20.1% on school property; 16.2% electronically, including through e-mail, chat room, instant messaging, Web site, or texting).3 In each type of bully victimization, the prevalence was higher among female than male youth (on school property 22.0% vs 18.2%; electronic 22.1% vs 10.8%).2 Using data from a nationally representative group of 6th to 10th graders participating in the Health Behaviors in School-Aged Children Survey (2005–2006), Wang and colleagues7 found the prevalence for bullying, being bullied, or both in the previous 2 months to vary according to type: 20.8% physical, 53.6% verbal, 51.4% relational (rumors to hurt reputation, relationships), and 13.6% cyber. The use of alcohol and other drugs presents another context in which violence may occur as a direct result of youth impairment in judgment and decisional capacity. For example, binge drinking (consuming 5 or more drinks in a row within a couple of hours) at least once in the previous month was reported by more than 1 in 5 2011 YRBS respondents (21.9%).3 For some youth, the school environment presents a context for vulnerability to violence involvement. In 2011, 5.9% of YRBS respondents reported skipping school at least once during the previous month because of concerns about safety at school or on the way to school.3 Among students taking the same survey, 12.0% reported being in a physical fight on school property in the previous year and 7.4% reported being threatened or injured with a weapon at least once in the school setting during the previous year.2 The Bureau of Justice estimates that 1,246,000 students ages 12 to 18 years experienced nonfatal victimizations at school in 2011, with 597,500 events related to simple assault (assault without a weapon, resulting in no, minor, or undetermined injury requiring
INTRODUCTION
The problem of adolescent violence is particularly troubling because each act is preventable. Each year, the number of lives lost and youth potential destroyed by disability related to violence serves as a reminder that adolescent violence prevention is a responsibility for all individuals involved in the care of youth. In the primary care setting, health providers have a pivotal role to play in the detection of adolescent violence involvement and in mitigating health consequences related to youth violence. This review provides a summary of the burden of adolescent violence and violencerelated behavior, risk, and protective factors for violence outcomes, the importance
Disclosures: None. a Division of General Pediatrics and Adolescent Health, Department of Pediatrics, University of Minnesota, 3rd Floor, #385, 717 Delaware Street Southeast, Minneapolis, MN 55414, USA; b Division of General Pediatrics and Adolescent Health, Department of Pediatrics, University of Minnesota, 3rd Floor, #389, 717 Delaware Street Southeast, Minneapolis, MN 55414, USA * Corresponding author. E-mail address: [email protected] Prim Care Clin Office Pract 41 (2014) 671–689 http://dx.doi.org/10.1016/j.pop.2014.05.013 primarycare.theclinics.com 0095-4543/14/$ – see front matter Ó 2014 Elsevier Inc. All rights reserved.
672
Duke & Borowsky
of screening for violence involvement in the primary care setting, and examples of online resources to support providers in advocating, assessing, and intervening on behalf of youth. The article draws attention to bullying and dating/relationship violence, not as new forms of violence-related behavior, but as behaviors with health outcomes that have received increased attention more recently. ADOLESCENT VIOLENCE INVOLVEMENT: SCOPE OF THE PROBLEM
Despite increased awareness of the negative consequences of youth violence involvement over the past decade, violence-associated acts (including self-directed violence) remain among the leading causes of death for youth ages 10 to 24 years. In the United States in 2010, suicide and homicide were the third and fourth leading causes of death for youth ages 10 to 14 years, and the second and third leading causes of death for young people ages 20 to 24 years, respectively.1 For youth ages 15 to 19 years, the order of cause was reversed, with homicide being the second leading cause of death and suicide a very close third.1 In the United States, almost 5000 young people ages 10 to 24 years lost their lives due to homicide in 2010, an average of 13 individuals each day.2 Overwhelmingly, the cause of these deaths involved the use of a firearm (71.3% among youth ages 10–14; 84.8% among youth ages 15–19; 82% among young people ages 20–24).1 These numbers do not tell the whole story, as we know that homicide is experienced in greater numbers among some groups of youth. Among African American youth ages 10 to 24 years, homicide is the leading cause of death; in this same age range, for Hispanic youth it is the second leading cause of death; and for American Indian and Alaska Native youth it is the third leading cause of death.2 Among youth taking the 2011 Youth Risk Behavior Survey (YRBS; youth grades 9– 12), just more than 1 in 13 reported an attempt on their life at least once during the previous year (1 in 10 females; 1 in 17 males).3,4 In this same survey, more than 1 in 7 youth reported seriously considering suicide during the 12 months before survey administration (almost 1 in 5 female and 1 in 8 male youth).3,4 For youth ages 10 to 24 years, firearms are the method used in 30% to 47% of suicides (male youth 37.8%–50.8%; female youth 13.8%–27.4%).1 Nonfatal injuries related to violence represent a significant source of poor health among adolescents. In 2012, assault-related injuries (physical assault by striking) topped the list for causes of nonfatal violence-related injuries among those 10 to 24 years old in the United States.5 In this same year, more than 500,000 young people ages 10 to 24 years were treated in emergency departments for assault-related injuries.5 The use of firearms resulted in nonfatal injuries requiring emergency department care for more than 26,000 10-year-olds to 24-year-olds in 2012.5 For youth taking the 2011 YRBS, one-third reported being in a physical fight one or more times in the previous year3; approximately 4% reported being in a physical fight with injuries requiring medical attention from a doctor or nurse at least once during the same time period.2 Just less than 10% of 2011 YRBS respondents reported being assaulted (eg, hit, slapped, or physically hurt on purpose) by a boyfriend or girlfriend in the previous year.3 Earlier data from the 2005 National Survey of Adolescents estimates the overall prevalence of dating violence to be 1.6% (sexual assault 0.9%, physical assault 0.8%, alcohol-drug facilitated rape 0.1%).6 Using 2005 Census data, this figure is equivalent to 400,000 US adolescents.6 Many behaviors contribute to youth violence. Among youth respondents for the 2011 YRBS, just more than 16% reported carrying a weapon (eg, gun, knife, or club) on at least 1 day during the previous month; 5% reported carrying a gun during the same time period.3 Bully victimization occurred during the previous year for 1 in 5
Adolescent Interpersonal Violence
to 1 in 6 respondents taking the 2011 YRBS (eg, 20.1% on school property; 16.2% electronically, including through e-mail, chat room, instant messaging, Web site, or texting).3 In each type of bully victimization, the prevalence was higher among female than male youth (on school property 22.0% vs 18.2%; electronic 22.1% vs 10.8%).2 Using data from a nationally representative group of 6th to 10th graders participating in the Health Behaviors in School-Aged Children Survey (2005–2006), Wang and colleagues7 found the prevalence for bullying, being bullied, or both in the previous 2 months to vary according to type: 20.8% physical, 53.6% verbal, 51.4% relational (rumors to hurt reputation, relationships), and 13.6% cyber. The use of alcohol and other drugs presents another context in which violence may occur as a direct result of youth impairment in judgment and decisional capacity. For example, binge drinking (consuming 5 or more drinks in a row within a couple of hours) at least once in the previous month was reported by more than 1 in 5 2011 YRBS respondents (21.9%).3 For some youth, the school environment presents a context for vulnerability to violence involvement. In 2011, 5.9% of YRBS respondents reported skipping school at least once during the previous month because of concerns about safety at school or on the way to school.3 Among students taking the same survey, 12.0% reported being in a physical fight on school property in the previous year and 7.4% reported being threatened or injured with a weapon at least once in the school setting during the previous year.2 The Bureau of Justice estimates that 1,246,000 students ages 12 to 18 years experienced nonfatal victimizations at school in 2011, with 597,500 events related to simple assault (assault without a weapon, resulting in no, minor, or undetermined injury requiring
