NeuroRehabilitation An IntenfilCiplinary Journal
ELSEVIER
NeuroRehabilitation 9 (1997) 167-176
Violence: A preventable cause of head injury in children Robert D. Segea,b,*, Sue E. Schnepsb,c, Vincent G. Licenziatob,c, Marilyn Lash b,c a Department
of Pediatrics, Pediatric and Adolescent Health Research Center, The Floating Hospital for Children at New England Medical Center, Boston, MA, USA bTufts University School of Medicine, Medford, MA, USA CDepartment of Physical Medicine and Rehabilitation, Research and Training Center in Rehabilitation and Childhood Trauma, New England Medical Center, Boston, MA, USA
Abstract Violence is one of the most important and preventable causes of head injury in children. This review discusses the epidemiology of youth violence from previously published reports and from new information obtained from the National Pediatric Trauma Registry. Violence prevention is considered in two categories: primary prevention aimed at the general population, and secondary prevention strategies focused on injured children and adolescents. Rehabilitation professionals have substantial roles to play in both primary and secondary prevention of youth violence. © 1997 Elsevier Science Ireland Ltd. Keywords: Violence-related injuries; Prevention; Epidemiology
1. Introduction
Violence is one of the most important and preventable causes of severe childhood neurologi-
* Corresponding author. NEMC Box 351, 750 Washington Street Boston, MA 02111, USA. TeL: + 1 617 6365241; fax: + 1 6176367719; e-mail: [email protected]
cal injury. For this reason, it is important for the rehabilitation specialist to understand the opportunities for violence prevention in the professional setting. This article will first review the role of violence in the etiology of neurological injuries in children, and then discuss current thinking concerning the prevention of youth violence, with a special emphasis on the roles of rehabilitation and related health professionals.
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2. Epidemiology of youth violence in the United States Some of the children and young adults seen for rehabilitation seIVices have received their neurological injuries through interpersonal violence either child abuse or adolescent peer violence. In fact, children are one of the more vulnerable segments of the population, and violence is one of the leading causes of illness, disability and death in the United States for adolescents and young adults [1,2]. American males, 15-24 years of age, have an annual mortality rate of 21.9 deaths per 100000 population, by far the highest in the industrialized world [3]. The Centers for Disease Control and Prevention estimate that by the year 2003, more Americans will die from firearms injury than from motor vehicle crashes [4]. This is particularly disturbing for the African-American community, where death rates are four-fold higher than for the general population [5]. When one examines injuries other than homicide, the vulnerability of children and adolescents becomes particularly evident. In a recent national phone sUIVey of children aged between 10 and 16, 25% reported that they had been victims of violence within the past year [6]. Most of these children (86%) had been victimized by someone known to them and more than one in five had been assaulted by a family member. 3. Information from the National Pediatric Trauma Registry The National Pediatric Trauma Registry (NPTR), part of the Research and Training Center in Rehabilitation and Childhood Trauma at the New England Medical Center in Boston, Massachusetts, is a voluntary, multi-institutional database, established in 1985 to collect information on the causes, circumstances, treatment and consequences of injuries to children and adolescents from birth through 19 years [7]. Data is collected at New England Medical Center in Boston from more than 70 hospitals and trauma centers around the United States, Puerto Rico
and Toronto on children and adolescents who are admitted to participating institutions for acute injury. We analyzed NPTR data concerning children injured by assault or child abuse resulting in a head injury with or without other injuries. Assault is defined as an injury inflicted purposely by another person with the intent to injure or kill, by any means. Child abuse is child battering or other maltreatment. Altogether, 1760 children were admitted to participating hospitals and trauma centers between September 1988 and January 1996 (7 years and 5 months) with head injuries (skull fracture, concussion and/or brain injury diagnoses) that were caused by assault (49%) or child abuse (51 %). Diagnoses analyzed were indicated by ICD-9 N codes: 800.00-801.99, 803.00-803.99 and 850.0-854.19 [8]. The 1760 head injury cases represent 36% of all children recorded in the NPTR who were injured by assault or child abuse, and 3.3% of all children recorded in the NPTR during this time period. Males were intentionally injured approximately twice as often as females (68% to 32%). These injuries most often affected infants « 1year-old, 21 %), toddlers (l-4-year-olds, 32%) and teenagers (l5-19-year-olds, 26%). Less than a quarter of these injuries affected school aged children (5-14-year-olds). The majority of these injuries were the result of beatings (54%), although firearms injuries accounted for 11 % of injuries seen - more than those caused by either blunt objects (6%) or stabbing (2%). Over half of the injuries (55%) occurred in a home environment, while only 4% of these violence-related injuries occurred in a school environment. One-third of the children (33%) had one or more identified pre-existing conditions: 9% had a chronic illness such as asthma or diabetes; 6% had an acute illness; 4% had cognitive, behavioral or psychological problems; 2% had physical limitations such as cerebral palsy or blindness; and 22% had some other condition such as prior child abuse or prematurity. Over 17% of the children with intentional head injuries (302) died at the trauma center or en route. A functional assessment, done by a clini-
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cian prior to discharge, revealed that of the 1458 survivors, 10% had impairments in vision, 5% in hearing, 9% in speech, 13% in cognition and 12% in behavior. Nearly half of these impairments were expected to last more than 2 years. The children were discharged to a variety of settings after leaving the trauma center: 64% went home, 26% went to foster or custodial care, 8% went to inpatient rehabilitation or another medical setting and 2% went to other locations. Of children assessed to have one to three functional impairments when leaving the hospital, 15% were discharged to inpatient rehabilitation; 38% of those with four to nine inipairments were discharged to inpatient rehabilitation. For the children discharged to settings other than inpatient rehabilitation or another medical setting, the following outpatient rehabilitation services were recommended: physical therapy (8%), occupational therapy (7%) and speech therapy (4%). Fewer than 4% of the children were referred for psychological services or special education [9]. However, recent results suggest that psychiatric consequences following violence-related injuries to children are extremely common and may involve large numbers of people [10]. Children with violence-related injuries are at a particularly high risk for post-traumatic stress disorder (PTSD), a psychiatric syndrome consisting of a reaction to an event outside the range of normal human experience and characterized by symptoms of re-experiencing the trauma, numbing of responsiveness or avoidance of thoughts related to the trauma, and symptoms of dysphoria and arousal [11]. For example, young adults who had ever experienced physical assault had a 22.6% prevalence of PTSD in one large study conducted in Detroit, nearly twice the rate seen in other types of sudden injuries or serious accidents [12]. This same study noted that men were somewhat more likely than women to develop PTSD. 4. Prevention
Those of us who care for the victims of violence have an opportunity to help prevent future injuries. Prevention takes two forms: primary pre-
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vention, aimed at the general population, and secondary prevention, designed to reduce the risk of future injury to already injured patients. Once someone has been injured by violence, the risk of future violence-related injury is dramatically increased [13].
4.1. Primary prevention: violence is preventable Child abuse most often results when parents are socially isolated, suffer from major life stresses, and have poor child management skills [14]. Protecting children from abuse involves teaching parents effective parenting skills as alternatives to corporal punishment. This review will largely discuss the prevention of youth violence, however, risk factors for youth violence and child abuse often overlap [15]. Most childhood and adolescent peer violence is the result of situations arising among people who know each other [16-18]. From the perspectives of law enforcement, public health and the schools, it is apparent that some young people have adopted habits of thought which pre-dispose them to violent injury [19]. The two main goals of primary prevention of youth violence are to develop in the mind of the young person: (1) methods of conflict resolution; and (2) outlets for anger which are productive, yet not violent. Experimental evidence of these pro-violence habits of thought come from experiments conducted by the developmental psychologists Slaby and Guerra in the mid-1980s [20]. They studied three groups of adolescents: (1) those incarcerated in the youth detention center for violent crimes; (2) those identified by school authorities as violence-prone; and (3) a group identified by school personnel as non-violent. Each child was presented with a standard scenario and asked to respond. The more violent youths were more likely to indicate that the behavior described in the scenario was aggressive, compared to the less violent youths who described several possible explanations for the scenario. When asked to solve the problem, these violent youths had a limited number of possible reactions compared to less violent youths. The more violent youths said that one needed to fight or lose face and run.
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Similar results were obtained with a large scale sample of 10th graders in New York Public Schools [21]. Compared to the general population, those teens who had had a serious fight in the past 30 days were more likely to list menacing or violent ways of resolving potential fights such as threatening to use a weapon, and less likely to apologize or walk away from a situation of potential conflict. Some of these violent habits of thought are developed at a young age. Heusmann et al. [22] performed a landmark study of 8-year-old children attending public schools in upstate New York who were then followed for 22 years (up to age 30). The authors found that the peers of 8-year-old students were able to identify the most physically aggressive children, and that these peer-nominated aggressors were far more likely to have been convicted of violent crime by age 30 than were their less aggressive peers. This study, and others like it, suggests that at least some of the foundations for violence occur prior to school entry. Patterson et al. [23] synthesized much of the existing data in developing the model shown in
Fig. 1. Poor parenting of young children prior to school entry leads to children who are rejected by their normal peers and who do poorly at their academic assignments. These children later find each other, and form peer groups in which violent and risk-taking behaviors are socially valued. With this theoretical background in mind, several clinicians have developed approaches to primary prevention of violence which are suitable in a healthcare practice. These approaches vary with the age and stage of the child's development, and have been summarized previously [24,25]. Table 1 summarizes an approach taken by healthcare professionals to provide developmentally appropriate advice to families. These topics, meant to be included in routine healthcare maintenance visits, explain to parents the natural course of childhood cognitive and emotional maturation, and incorporate thought concepts to reduce the risk of violence into these topics. Because of the importance of pre-school development, there is particular emphasis on teaching effective, non-violent parenting techniques to parents of young children. Experience with using this approach has been
Middle Childhood
Early Childhood
Late Childhood and Adolescence
Fig. 1. Developmental progression of anti-social behavior (from Paterson et aI., Copyright 1989 by the American Psychological Association, reprinted with permission).
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Table 1 Primary violence prevention strategies by age of child Age
Strategies
Birth-18 months
• Instruct new parents (mothers and fathers) about practical parenting skills such as anticipating and finding solutions to sleep problems and knowing how to let an infant explore in a safe environment. • Discuss with parents that the safest home for a child is one without a gun. If there is a gun in the home, it is best to have it unloaded and locked (with the ammunition stored separately).
18 months-4 years
• With a child's increasing independence, parents will need to learn how to provide guidance on 'good' and 'bad' behaviors. • Informing parents about the developmental aspects of a child's fears will help them understand the 'why's' behind certain behaviors. • Teaching parents that positive reinforcement of a child's good behavior is an effective parenting technique. • When discussing discipline, encourage parents to use a technique like time-out as opposed to corporal punishment. • Review the behavioral techniques that parents can use when dealing with a tantrum.
4-12 years
• Discuss with parents why television viewing should be supervised, and, in particular, why violent shows should be limited. • Encourage parents not to buy realistic toy guns, and advocate for the use of non-violent toys. • When a conflict with a friend (or 'bully') occurs, parents need to talk about non-violent solutions with their child. • Inform parents that the ways in which they resolve conflicts with each other will be copied by their children.
12-18 years
On-going, developmentally appropriate, discussions with youth about a variety of issues will need to take place. The following discussions can be lead by either parents or a professional: • drug and alcohol use; • insight into fighting behaviors and alternatives; • effects of witnessing violence; and • dangers of carrying weapons. Note: when taking a psychosocial history, it is essential that the above issues be reviewed with the child.
gratifying. Parents can recall the advice given, and, in some cases, will immediately adopt some of the techniques described. A recently published study [26] demonstrated that the use of printed materials improved parent recall of advice concerning television use and the use of alternatives to corporal punishment. Those families who received a written description of Time-Out from their healthcare provider were far more likely to use non-violent disciplinary techniques than were control parents who did not receive printed information. In contrast, families responded differently to advice concerning the ownership of guns vs. ad-
vice on the proper storage of firearms in homes with children. David Webster at The Johns Hopkins Medical Center found that families were unlikely to heed advice not to own handguns, but were somewhat more likely to be receptive about advice concerning firearm storage [27]. 4.2. Secondary prevention: interventions tor injured youth
Children who have been injured through known or suspected child abuse warrant thorough investigation. Healthcare professionals are legally required to report all such injuries to state child-
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protection authorities [28]. These agencies will dispatch social workers to the home and conduct investigations to determine if abuse has occurred. While some children need to be removed from the home, many states also have the resources to assist families, and try to preserve existing families through increased social supports. Children and adolescents who have been injured through peer violence appear to be at higher risk for subsequent violent injuries [29]. In part, this may be due to the fact that the injured youth is seeking revenge. Other youngsters who are at a high risk for violence or violent victimization may be identified through their primary care providers or teachers [30]. In general, intervention for youth at high risk involves the following steps: Identification - either through history or by presentation with a violence-related injury. 2. Helping the youngster and/or the family identify this as a problem needing a solution. 3. Counseling and/or referral. 1.
Once the child or adolescent realizes that peer violence is both dangerous and avoidable, the main point of the counseling is to help the child develop ways to avoid violence by using non-violent methods of conflict resolution. Programs intended to teach these techniques to patients hospitalized due to violence have been modestly successful [31]. One of these programs utilized a six-step approach to help young people develop alternative, non-violent responses. This six-step intervention is reproduced in Table 2. The steps lead the youngster from a review of the incident which led to the injury through to an understanding of violence and the patient's own reactions towards development of non-violent strategies. This is an integrated model using referrals to other community agencies where necessary.
4.3. Specific issues fOT rehabilitation specialists Given this broad view of peer violence and its causes, what are the special issues facing pediatric rehabilitation specialists? In general, there are three different sorts of situations in which
children may have issues concerning interpersonal violence which need attention. First, while there is very little literature on the topic, it appears that children with special needs may be the victims of bullying or teasing at school by their able-bodied peers. This may adversely affect the child's social and emotional well-being, as well as interfere with the child's school performance. While this is a complex and challenging problem, parents can be referred to support groups in their community or nationally for the benefit of other parents' and children's experiences. Most peer aggression at school occurs during times and in places where adult supervision is weakest: going to and from school, in the lunchroom and bathroom, and at recess. Some children may be reluctant to tell their parents of this problem, but tell-tale signs, in addition to unexplained cuts and bruises, may include 'lost' lunch money and damaged or lost school books. If parents suspect their child is being taunted, attacked, or abused, they should discuss the situation both with the classroom teacher (who knows the child best) and with the school principal, who is responsible for the whole school, including areas outside the classroom, where peer violence is most likely to occur [32]. A second situation to be addressed is the case of the child or youth whose injuries result from violence. Not only will many of these children have severe physical limitations and difficulties [33,34], but the psychological sequelae may also be disabling. Children who witness violence may have severe mental health consequences [35]. Children who are themselves victims of violence have pointed to an increased incidence of certain conditions, including post-traumatic stress disorder [12,36,371. Counseling and treatment for the psychological and psychiatric sequelae of violence are often necessary to restore a child's ability to function. A recent volume edited by Apfel and Simon [38] contains a thoughtful and practical guide to these issues in childhood [39]. The third situation encountered by rehabilitation specialists involves the sequelae of traumatic brain injury (TBI). Some of the common behavioral sequelae for TBI - increased impulsivity
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Table 2 Boston violence prevention program six-step intervention Step 1- Review and assess the incident.
• The youth has an opportunity to talk through the incident step-by-step, to make sense of what has happened to him or her, and to understand his or her role in what transpired, • The counselor works with the patient to frame the events and allows for the development of strategies by which the youth can remain safe in the future.
Step 2 - Review the patient's conflict-resolution strategies and introduce non-violent alternatives.
The counselor seeks to: • review the incident and explore the patient's role; • review the patient's history of previous conflicts to identify patterns of behavior, allowing the patient to see his or her particular style and the kinds of roles he or she takes in conflict situations; • return to the most recent incident and explore ways it could have been resolved non-violently without loss of respect, by examining specific conflict-resolution strategies that might have been used.
Step 3 - Provide information on the prevalence of violence and homicide. Determine patient's risk status.
• The patient is presented with epidemiologic information on homicide and violence among inner-city youth 15-24 years old. • A list of risk factors strongly associated with teen homicide victims is presented, and the patient is asked to assess how often he or she find themselves in the presence of these risk factors. • The index incident is revisited to determine which risk factors were present.
Step 4 - Explore with the patient his or her coping skills and current support system.
• The counselor explores sources of social support and encourages youths to seek out this support on discharge as needed. • The patient is asked about how his or her family is coping with the incident and about past coping strategies. • As needed, the counselor suggests contacts for the patient or his or her family as sources of support within their communities. • The counselor discusses PTSD and urges the patient to pursue counseling services if symptoms develop.
Step 5 - Develop a plan to stay safe.
• A plan is developed that permits the patient to remain safe once he or she is discharged from the hospital and returns home. • This step is designed to give the patient confidence in his or her own ability to take charge of his or her life (in non-violent ways) and overcome feelings of helplessness common among victims.
Step 6 - Refer the patient to services for follow-up activities.
As appropriate, referrals are made for the patient and family and both are encouraged to pursue them. Referral sites include outpatient violence-prevention counseling, victim witness programs, violence-prevention programs, and outpatient child psychiatry.
See Vos et al. (1996) Reprinted with permission.
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and irritability, poor social judgment, lowered behavioral control, misinterpretation of social cues and emotional lability - would increase the risk of verbal and physical altercations with peers and strangers [19,40]. Thus, brain-injured children, regardless of the etiology of the original injury, are at increased risk of committing violence. 4.4. Prevention advocacy
Just as there are specific treatment considerations for the rehabilitation of children affected by violence, there is an opportunity for public health intervention on a larger scale. Our experiences with violence and its aftermath can provide important data for public policy makers. There are several important roles that the healthcare system can play regarding public policies aimed at violence reduction; these roles range from information-gathering and reporting to advocacy within families, schools and communities. 4.4.1. Information-gathering and reporting Injured youth seek treatment at emergency, acute care and rehabilitation facilities for injuries which result from violence. Through collecting statistics about these admissions, we can characterize the neighborhoods and activities at highest risk and identify other local risk factors. This information is critically important in designing public policy to reduce violence. For example, the role of handgun possession and use in increasing the youth homicide rate has been well documented [41]. Recently, these public health data have been cited in regulations designed to deny access to handguns to minors, and for adults with criminal, mental health, or spousal abuse histories. 4.4.2. Advocacy in the community In local communities, health professionals may be called on to help criminal justice authorities, school system officials or neighborhood groups cope with the problem of youth violence. Knowledge of current theories of prevention and local statistics concerning youth involvement in violence-related injuries provides a basis for making sound recommendations in the area of vio-
lence prevention in all of its manifestations. Medical and public health officials have taken a leadership role in advocating for effective violenceprevention measures on community, state and national levels [42].
5. Summary Since violence is an important cause of morbidity in the pediatric and adolescent population, it is crucial that rehabilitation specialists understand its causes and consequences. The data presented here from the National Pediatric Trauma Registry demonstrate that a significant fraction of children and youth injured through violence receive rehabilitation services. In addition, patients with pre-existing disabilities or with brain injuries may be at increased risk of violence. Since rehabilitation professionals treat some of the most severely injured children, they have a unique role to play in primary and secondary violence prevention. While some of these roles can be filled directly through patient contacts, long-term reduction in violence also requires policy advocacy. Acknowledgements We would like to thank Dr. Carla DiScala of the National Pediatric Trauma Registry for generously allowing us access to NPTR data for this publication. Preparation of this manuscript was funded in part by a grant from The Robert Wood Johnson Foundation Generalist Physician Faculty Scholars Program, and the National Institute on Disability and Rehabilitation Research, US Department of Education (award H133B0044). Note: Parent 'tip cards', designed for primary prevention use in a healthcare setting, are available from the authors. Currently available topics include: Myths and Facts about Violence, TimeOut, Television Violence, and The Use of Positive Reinforcement for Toddlers. New cards on related topics are under development. References [1] CDC. Firearm-related years of potential life lost before United States, 1980-91. MMWR age 65 years 1994;43:609-611.
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[2) Alpert E, Cohen S, Sege R: Family violence: an overview. Acad Med (supplement) 1997;72:S3-S6. [3) Fingerhut LA, Ingram DD, Feldman JJ. Firearm homicide among black teenage males in metropolitan counties. J Am Med Assoc 1992;267:3054-3058. [4) CDC. Deaths resulting from firearm- and motorvehicle-related injuries - United States, 1968-1991. MMWR 1994;43:37-42. [5) Fingerhut LA, Kleinman Jc. International and interstate comparisons of homicide among young males. J Am Med Assoc 1990;263:3292-3294. [6) Finkelhor D, Dzubia-Leatherman J. Children as victims of violence: a national survey. Pediatrics 1994; 94:4l3-420. [7) Tepas JJ, Ramemofsky ML, Barlow B et al. National pediatric trauma registry. J Pediatr Surg 1989; 24:156-158. [8) International Classification of Diseases. Clinical Modification, vol. 1, 9th Revision. Geneva, Switzerland: World Health Organization, 1989. [9) DiScala C, Osberg JS, Savage R. Children hospitalized with traumatic brain injury: transition to post-acute care. J Head Trauma RehabiI1997;12(2):1-1O. [10) Martinez P, Richters J. The NIMH community violence project: I I. Children's distress symptoms associated with violence exposure. Psychiatry 1993;56:22-34. [11) American Psychiatric Association. Diagnostic and statistical manual of mental disorders, 3rd ed. - revised, 1987. [12) Breslau N, Davis Gc. Traumatic events and post-traumatic stress disorder in an urban population of young adults. Arch Gen Psychiatry 1991;48:216-232. [l3) Tellez MG, Mackersie RC, Morabito D, Shagoury C, Heye C. Risks, costs, and the expected complication of re-injury. Am J Surg 1995;170(6):660·-663. [14) Jorgensen EC. Child abuse. New York: Continuum Publishing, 1990. [15) Straus MA. Discipline and deviance: physical punishment of children and violence and other crime in adulthood. Soc Probl 1991 ;38:l33-154. [16) Spivak H, Prothrow-Stith D, Hausman AJ. Dying is no accident: adolescents, violence, and intentional injury. Pediatr Clin North Am 1988;35:1339-1347. [17) The Violence Prevention Task Force of the Eastern Association for the Surgery of Trauma. Violence in America: a public health crisis - the role of firearms. J Trauma: Injury, Infect Crit Care 1995;38:163-168. [18) Sege R, Stigol LC, Perry C, Goldstein R, Spivak H. Intentional injury surveillance in a primary care pediatric setting. Arch Pediatr Adolesc Med 1996; 150:277-283. [19) Eron LD, Gentry JB, Schlegel P. Reason to hope: a psychosocial perspective on violence and youth. Washington DC: American Psychological Association, 1994. [20) Slaby RG, Guerra NG. Cognitive mediators of aggression in adolescent offenders: 1. Assessment. Dev Psychol 1988;24:580-588.
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[21) CDC. Physical fighting among high school students United States, 1990. Morbidity Mortality Weekly Report 1992;41:91-94. [22) Huesmann LR, Eron LD, Lefkowit MM, Walder LO. Stability of aggression over time and generations. Dev Psychol 1984;20:1120-1134. [23) Patterson GR, DeBaryshe D, Ramsey E. A developmental perspective on antisocial behavior. Am Psychol 1989;44:33l. [24) Sege RD. Adolescent violence. Curr Opin Pediatr 1992;4:575-581. [25) Stringham PG. Strategies for preventing children from becoming victims of violence. Curr Probl Pediatr 1995;25(5):155-162. [26) Sege RD, Perry C, Stigol L et al. Short-term effectiveness of anticipatory guidance to reduce early childhood risks for subsequent violence. Arch Pediatr Adolesc Med 1997;151:392-397. [27) Webster D, Wilson M. Gun violence among youth and the pediatrician's role in primary prevention. Pediatrics 1994;94:617-622. [28) Council on Scientific Affairs. AMA diagnostic and treatment guidelines. Concerning child abuse and neglect. J Am Med A~soc 1985;254:796-800. [29) Perron C, Kharasch S, Wilson K, Robateau R, Griffith J, Sege R. Recurrence rate among pediatric patients with violence related injuries. Paper presented at the Ambulatory Pediatrics Association, Washington, DC, 1997. [30) Stringham P, Weitzman M. Violence counseling in the routine health care of adolescents. J Adolesc Health 1988;9:389-393. [31) DeVos E, Stone DA, Goetz MA, Dahlberg LL. Evaluation of a hospital based youth violence intervention program. Am J Prev Med 1996;12 Suppl 2:101-108. [32) Olweus D. Bullying at school. Oxford UK: Blackwell Publishers, 1993. [33) Collins V. Violence and psychological trauma. Pediatr Direct 1994;5:14-15. [34) Singer MI, Anglin TM, Song LY, Lunghofer L. Adolescents' exposure to violence and associated symptoms of psychological trauma. J Am Med Assoc 1995; 273(6):477-482. [35) Groves BM, Zuckerman B. Silent victims: children who witness violence. J Am Med Assoc 1993;269:262-264. [36) Pynoos RS, Frederick C, Nader K et al. Life threat and posttraumatic stress in school-age children. Arch Gen Psychiatry 1987;44:1057-1063. [37) Arroyo W, Eth S. Post-traumatic stress disorder and other stress reactions. In: Apfel RJ, Simon B, editors. Minefields in their hearts. New Haven, CT: Yale University Press, 1996. [38) Apfel RJ, Simon B, editors. Minefields in their hearts. New Haven, CT: Yale University Press, 1996. [39) Garbarino J, Kostelny K. What do we need to know to understand children in war and community violence. In: Apfel RJ, Simon B, editors. Minefields in their hearts. New Haven, CT: Yale University Press, 1996.
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[40) Blosser J, De Pompei. Pediatric traumatic brain injury: proactive intervention. San Diego, California: Singular Publishing Company, 1994. [41) Kellermann AL, Rivara FP, Rushforth NB et al. Gun ownership as a risk factor for homicide in the home. New Engl J Med 1993;329:1084-1091. [42] Prothrow-Stith D, Spivak H, Sege R. Interpersonal vio-
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ELSEVIER
NeuroRehabilitation 9 (1997) 167-176
Violence: A preventable cause of head injury in children Robert D. Segea,b,*, Sue E. Schnepsb,c, Vincent G. Licenziatob,c, Marilyn Lash b,c a Department
of Pediatrics, Pediatric and Adolescent Health Research Center, The Floating Hospital for Children at New England Medical Center, Boston, MA, USA bTufts University School of Medicine, Medford, MA, USA CDepartment of Physical Medicine and Rehabilitation, Research and Training Center in Rehabilitation and Childhood Trauma, New England Medical Center, Boston, MA, USA
Abstract Violence is one of the most important and preventable causes of head injury in children. This review discusses the epidemiology of youth violence from previously published reports and from new information obtained from the National Pediatric Trauma Registry. Violence prevention is considered in two categories: primary prevention aimed at the general population, and secondary prevention strategies focused on injured children and adolescents. Rehabilitation professionals have substantial roles to play in both primary and secondary prevention of youth violence. © 1997 Elsevier Science Ireland Ltd. Keywords: Violence-related injuries; Prevention; Epidemiology
1. Introduction
Violence is one of the most important and preventable causes of severe childhood neurologi-
* Corresponding author. NEMC Box 351, 750 Washington Street Boston, MA 02111, USA. TeL: + 1 617 6365241; fax: + 1 6176367719; e-mail: [email protected]
cal injury. For this reason, it is important for the rehabilitation specialist to understand the opportunities for violence prevention in the professional setting. This article will first review the role of violence in the etiology of neurological injuries in children, and then discuss current thinking concerning the prevention of youth violence, with a special emphasis on the roles of rehabilitation and related health professionals.
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2. Epidemiology of youth violence in the United States Some of the children and young adults seen for rehabilitation seIVices have received their neurological injuries through interpersonal violence either child abuse or adolescent peer violence. In fact, children are one of the more vulnerable segments of the population, and violence is one of the leading causes of illness, disability and death in the United States for adolescents and young adults [1,2]. American males, 15-24 years of age, have an annual mortality rate of 21.9 deaths per 100000 population, by far the highest in the industrialized world [3]. The Centers for Disease Control and Prevention estimate that by the year 2003, more Americans will die from firearms injury than from motor vehicle crashes [4]. This is particularly disturbing for the African-American community, where death rates are four-fold higher than for the general population [5]. When one examines injuries other than homicide, the vulnerability of children and adolescents becomes particularly evident. In a recent national phone sUIVey of children aged between 10 and 16, 25% reported that they had been victims of violence within the past year [6]. Most of these children (86%) had been victimized by someone known to them and more than one in five had been assaulted by a family member. 3. Information from the National Pediatric Trauma Registry The National Pediatric Trauma Registry (NPTR), part of the Research and Training Center in Rehabilitation and Childhood Trauma at the New England Medical Center in Boston, Massachusetts, is a voluntary, multi-institutional database, established in 1985 to collect information on the causes, circumstances, treatment and consequences of injuries to children and adolescents from birth through 19 years [7]. Data is collected at New England Medical Center in Boston from more than 70 hospitals and trauma centers around the United States, Puerto Rico
and Toronto on children and adolescents who are admitted to participating institutions for acute injury. We analyzed NPTR data concerning children injured by assault or child abuse resulting in a head injury with or without other injuries. Assault is defined as an injury inflicted purposely by another person with the intent to injure or kill, by any means. Child abuse is child battering or other maltreatment. Altogether, 1760 children were admitted to participating hospitals and trauma centers between September 1988 and January 1996 (7 years and 5 months) with head injuries (skull fracture, concussion and/or brain injury diagnoses) that were caused by assault (49%) or child abuse (51 %). Diagnoses analyzed were indicated by ICD-9 N codes: 800.00-801.99, 803.00-803.99 and 850.0-854.19 [8]. The 1760 head injury cases represent 36% of all children recorded in the NPTR who were injured by assault or child abuse, and 3.3% of all children recorded in the NPTR during this time period. Males were intentionally injured approximately twice as often as females (68% to 32%). These injuries most often affected infants « 1year-old, 21 %), toddlers (l-4-year-olds, 32%) and teenagers (l5-19-year-olds, 26%). Less than a quarter of these injuries affected school aged children (5-14-year-olds). The majority of these injuries were the result of beatings (54%), although firearms injuries accounted for 11 % of injuries seen - more than those caused by either blunt objects (6%) or stabbing (2%). Over half of the injuries (55%) occurred in a home environment, while only 4% of these violence-related injuries occurred in a school environment. One-third of the children (33%) had one or more identified pre-existing conditions: 9% had a chronic illness such as asthma or diabetes; 6% had an acute illness; 4% had cognitive, behavioral or psychological problems; 2% had physical limitations such as cerebral palsy or blindness; and 22% had some other condition such as prior child abuse or prematurity. Over 17% of the children with intentional head injuries (302) died at the trauma center or en route. A functional assessment, done by a clini-
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cian prior to discharge, revealed that of the 1458 survivors, 10% had impairments in vision, 5% in hearing, 9% in speech, 13% in cognition and 12% in behavior. Nearly half of these impairments were expected to last more than 2 years. The children were discharged to a variety of settings after leaving the trauma center: 64% went home, 26% went to foster or custodial care, 8% went to inpatient rehabilitation or another medical setting and 2% went to other locations. Of children assessed to have one to three functional impairments when leaving the hospital, 15% were discharged to inpatient rehabilitation; 38% of those with four to nine inipairments were discharged to inpatient rehabilitation. For the children discharged to settings other than inpatient rehabilitation or another medical setting, the following outpatient rehabilitation services were recommended: physical therapy (8%), occupational therapy (7%) and speech therapy (4%). Fewer than 4% of the children were referred for psychological services or special education [9]. However, recent results suggest that psychiatric consequences following violence-related injuries to children are extremely common and may involve large numbers of people [10]. Children with violence-related injuries are at a particularly high risk for post-traumatic stress disorder (PTSD), a psychiatric syndrome consisting of a reaction to an event outside the range of normal human experience and characterized by symptoms of re-experiencing the trauma, numbing of responsiveness or avoidance of thoughts related to the trauma, and symptoms of dysphoria and arousal [11]. For example, young adults who had ever experienced physical assault had a 22.6% prevalence of PTSD in one large study conducted in Detroit, nearly twice the rate seen in other types of sudden injuries or serious accidents [12]. This same study noted that men were somewhat more likely than women to develop PTSD. 4. Prevention
Those of us who care for the victims of violence have an opportunity to help prevent future injuries. Prevention takes two forms: primary pre-
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vention, aimed at the general population, and secondary prevention, designed to reduce the risk of future injury to already injured patients. Once someone has been injured by violence, the risk of future violence-related injury is dramatically increased [13].
4.1. Primary prevention: violence is preventable Child abuse most often results when parents are socially isolated, suffer from major life stresses, and have poor child management skills [14]. Protecting children from abuse involves teaching parents effective parenting skills as alternatives to corporal punishment. This review will largely discuss the prevention of youth violence, however, risk factors for youth violence and child abuse often overlap [15]. Most childhood and adolescent peer violence is the result of situations arising among people who know each other [16-18]. From the perspectives of law enforcement, public health and the schools, it is apparent that some young people have adopted habits of thought which pre-dispose them to violent injury [19]. The two main goals of primary prevention of youth violence are to develop in the mind of the young person: (1) methods of conflict resolution; and (2) outlets for anger which are productive, yet not violent. Experimental evidence of these pro-violence habits of thought come from experiments conducted by the developmental psychologists Slaby and Guerra in the mid-1980s [20]. They studied three groups of adolescents: (1) those incarcerated in the youth detention center for violent crimes; (2) those identified by school authorities as violence-prone; and (3) a group identified by school personnel as non-violent. Each child was presented with a standard scenario and asked to respond. The more violent youths were more likely to indicate that the behavior described in the scenario was aggressive, compared to the less violent youths who described several possible explanations for the scenario. When asked to solve the problem, these violent youths had a limited number of possible reactions compared to less violent youths. The more violent youths said that one needed to fight or lose face and run.
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Similar results were obtained with a large scale sample of 10th graders in New York Public Schools [21]. Compared to the general population, those teens who had had a serious fight in the past 30 days were more likely to list menacing or violent ways of resolving potential fights such as threatening to use a weapon, and less likely to apologize or walk away from a situation of potential conflict. Some of these violent habits of thought are developed at a young age. Heusmann et al. [22] performed a landmark study of 8-year-old children attending public schools in upstate New York who were then followed for 22 years (up to age 30). The authors found that the peers of 8-year-old students were able to identify the most physically aggressive children, and that these peer-nominated aggressors were far more likely to have been convicted of violent crime by age 30 than were their less aggressive peers. This study, and others like it, suggests that at least some of the foundations for violence occur prior to school entry. Patterson et al. [23] synthesized much of the existing data in developing the model shown in
Fig. 1. Poor parenting of young children prior to school entry leads to children who are rejected by their normal peers and who do poorly at their academic assignments. These children later find each other, and form peer groups in which violent and risk-taking behaviors are socially valued. With this theoretical background in mind, several clinicians have developed approaches to primary prevention of violence which are suitable in a healthcare practice. These approaches vary with the age and stage of the child's development, and have been summarized previously [24,25]. Table 1 summarizes an approach taken by healthcare professionals to provide developmentally appropriate advice to families. These topics, meant to be included in routine healthcare maintenance visits, explain to parents the natural course of childhood cognitive and emotional maturation, and incorporate thought concepts to reduce the risk of violence into these topics. Because of the importance of pre-school development, there is particular emphasis on teaching effective, non-violent parenting techniques to parents of young children. Experience with using this approach has been
Middle Childhood
Early Childhood
Late Childhood and Adolescence
Fig. 1. Developmental progression of anti-social behavior (from Paterson et aI., Copyright 1989 by the American Psychological Association, reprinted with permission).
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Table 1 Primary violence prevention strategies by age of child Age
Strategies
Birth-18 months
• Instruct new parents (mothers and fathers) about practical parenting skills such as anticipating and finding solutions to sleep problems and knowing how to let an infant explore in a safe environment. • Discuss with parents that the safest home for a child is one without a gun. If there is a gun in the home, it is best to have it unloaded and locked (with the ammunition stored separately).
18 months-4 years
• With a child's increasing independence, parents will need to learn how to provide guidance on 'good' and 'bad' behaviors. • Informing parents about the developmental aspects of a child's fears will help them understand the 'why's' behind certain behaviors. • Teaching parents that positive reinforcement of a child's good behavior is an effective parenting technique. • When discussing discipline, encourage parents to use a technique like time-out as opposed to corporal punishment. • Review the behavioral techniques that parents can use when dealing with a tantrum.
4-12 years
• Discuss with parents why television viewing should be supervised, and, in particular, why violent shows should be limited. • Encourage parents not to buy realistic toy guns, and advocate for the use of non-violent toys. • When a conflict with a friend (or 'bully') occurs, parents need to talk about non-violent solutions with their child. • Inform parents that the ways in which they resolve conflicts with each other will be copied by their children.
12-18 years
On-going, developmentally appropriate, discussions with youth about a variety of issues will need to take place. The following discussions can be lead by either parents or a professional: • drug and alcohol use; • insight into fighting behaviors and alternatives; • effects of witnessing violence; and • dangers of carrying weapons. Note: when taking a psychosocial history, it is essential that the above issues be reviewed with the child.
gratifying. Parents can recall the advice given, and, in some cases, will immediately adopt some of the techniques described. A recently published study [26] demonstrated that the use of printed materials improved parent recall of advice concerning television use and the use of alternatives to corporal punishment. Those families who received a written description of Time-Out from their healthcare provider were far more likely to use non-violent disciplinary techniques than were control parents who did not receive printed information. In contrast, families responded differently to advice concerning the ownership of guns vs. ad-
vice on the proper storage of firearms in homes with children. David Webster at The Johns Hopkins Medical Center found that families were unlikely to heed advice not to own handguns, but were somewhat more likely to be receptive about advice concerning firearm storage [27]. 4.2. Secondary prevention: interventions tor injured youth
Children who have been injured through known or suspected child abuse warrant thorough investigation. Healthcare professionals are legally required to report all such injuries to state child-
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protection authorities [28]. These agencies will dispatch social workers to the home and conduct investigations to determine if abuse has occurred. While some children need to be removed from the home, many states also have the resources to assist families, and try to preserve existing families through increased social supports. Children and adolescents who have been injured through peer violence appear to be at higher risk for subsequent violent injuries [29]. In part, this may be due to the fact that the injured youth is seeking revenge. Other youngsters who are at a high risk for violence or violent victimization may be identified through their primary care providers or teachers [30]. In general, intervention for youth at high risk involves the following steps: Identification - either through history or by presentation with a violence-related injury. 2. Helping the youngster and/or the family identify this as a problem needing a solution. 3. Counseling and/or referral. 1.
Once the child or adolescent realizes that peer violence is both dangerous and avoidable, the main point of the counseling is to help the child develop ways to avoid violence by using non-violent methods of conflict resolution. Programs intended to teach these techniques to patients hospitalized due to violence have been modestly successful [31]. One of these programs utilized a six-step approach to help young people develop alternative, non-violent responses. This six-step intervention is reproduced in Table 2. The steps lead the youngster from a review of the incident which led to the injury through to an understanding of violence and the patient's own reactions towards development of non-violent strategies. This is an integrated model using referrals to other community agencies where necessary.
4.3. Specific issues fOT rehabilitation specialists Given this broad view of peer violence and its causes, what are the special issues facing pediatric rehabilitation specialists? In general, there are three different sorts of situations in which
children may have issues concerning interpersonal violence which need attention. First, while there is very little literature on the topic, it appears that children with special needs may be the victims of bullying or teasing at school by their able-bodied peers. This may adversely affect the child's social and emotional well-being, as well as interfere with the child's school performance. While this is a complex and challenging problem, parents can be referred to support groups in their community or nationally for the benefit of other parents' and children's experiences. Most peer aggression at school occurs during times and in places where adult supervision is weakest: going to and from school, in the lunchroom and bathroom, and at recess. Some children may be reluctant to tell their parents of this problem, but tell-tale signs, in addition to unexplained cuts and bruises, may include 'lost' lunch money and damaged or lost school books. If parents suspect their child is being taunted, attacked, or abused, they should discuss the situation both with the classroom teacher (who knows the child best) and with the school principal, who is responsible for the whole school, including areas outside the classroom, where peer violence is most likely to occur [32]. A second situation to be addressed is the case of the child or youth whose injuries result from violence. Not only will many of these children have severe physical limitations and difficulties [33,34], but the psychological sequelae may also be disabling. Children who witness violence may have severe mental health consequences [35]. Children who are themselves victims of violence have pointed to an increased incidence of certain conditions, including post-traumatic stress disorder [12,36,371. Counseling and treatment for the psychological and psychiatric sequelae of violence are often necessary to restore a child's ability to function. A recent volume edited by Apfel and Simon [38] contains a thoughtful and practical guide to these issues in childhood [39]. The third situation encountered by rehabilitation specialists involves the sequelae of traumatic brain injury (TBI). Some of the common behavioral sequelae for TBI - increased impulsivity
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Table 2 Boston violence prevention program six-step intervention Step 1- Review and assess the incident.
• The youth has an opportunity to talk through the incident step-by-step, to make sense of what has happened to him or her, and to understand his or her role in what transpired, • The counselor works with the patient to frame the events and allows for the development of strategies by which the youth can remain safe in the future.
Step 2 - Review the patient's conflict-resolution strategies and introduce non-violent alternatives.
The counselor seeks to: • review the incident and explore the patient's role; • review the patient's history of previous conflicts to identify patterns of behavior, allowing the patient to see his or her particular style and the kinds of roles he or she takes in conflict situations; • return to the most recent incident and explore ways it could have been resolved non-violently without loss of respect, by examining specific conflict-resolution strategies that might have been used.
Step 3 - Provide information on the prevalence of violence and homicide. Determine patient's risk status.
• The patient is presented with epidemiologic information on homicide and violence among inner-city youth 15-24 years old. • A list of risk factors strongly associated with teen homicide victims is presented, and the patient is asked to assess how often he or she find themselves in the presence of these risk factors. • The index incident is revisited to determine which risk factors were present.
Step 4 - Explore with the patient his or her coping skills and current support system.
• The counselor explores sources of social support and encourages youths to seek out this support on discharge as needed. • The patient is asked about how his or her family is coping with the incident and about past coping strategies. • As needed, the counselor suggests contacts for the patient or his or her family as sources of support within their communities. • The counselor discusses PTSD and urges the patient to pursue counseling services if symptoms develop.
Step 5 - Develop a plan to stay safe.
• A plan is developed that permits the patient to remain safe once he or she is discharged from the hospital and returns home. • This step is designed to give the patient confidence in his or her own ability to take charge of his or her life (in non-violent ways) and overcome feelings of helplessness common among victims.
Step 6 - Refer the patient to services for follow-up activities.
As appropriate, referrals are made for the patient and family and both are encouraged to pursue them. Referral sites include outpatient violence-prevention counseling, victim witness programs, violence-prevention programs, and outpatient child psychiatry.
See Vos et al. (1996) Reprinted with permission.
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and irritability, poor social judgment, lowered behavioral control, misinterpretation of social cues and emotional lability - would increase the risk of verbal and physical altercations with peers and strangers [19,40]. Thus, brain-injured children, regardless of the etiology of the original injury, are at increased risk of committing violence. 4.4. Prevention advocacy
Just as there are specific treatment considerations for the rehabilitation of children affected by violence, there is an opportunity for public health intervention on a larger scale. Our experiences with violence and its aftermath can provide important data for public policy makers. There are several important roles that the healthcare system can play regarding public policies aimed at violence reduction; these roles range from information-gathering and reporting to advocacy within families, schools and communities. 4.4.1. Information-gathering and reporting Injured youth seek treatment at emergency, acute care and rehabilitation facilities for injuries which result from violence. Through collecting statistics about these admissions, we can characterize the neighborhoods and activities at highest risk and identify other local risk factors. This information is critically important in designing public policy to reduce violence. For example, the role of handgun possession and use in increasing the youth homicide rate has been well documented [41]. Recently, these public health data have been cited in regulations designed to deny access to handguns to minors, and for adults with criminal, mental health, or spousal abuse histories. 4.4.2. Advocacy in the community In local communities, health professionals may be called on to help criminal justice authorities, school system officials or neighborhood groups cope with the problem of youth violence. Knowledge of current theories of prevention and local statistics concerning youth involvement in violence-related injuries provides a basis for making sound recommendations in the area of vio-
lence prevention in all of its manifestations. Medical and public health officials have taken a leadership role in advocating for effective violenceprevention measures on community, state and national levels [42].
5. Summary Since violence is an important cause of morbidity in the pediatric and adolescent population, it is crucial that rehabilitation specialists understand its causes and consequences. The data presented here from the National Pediatric Trauma Registry demonstrate that a significant fraction of children and youth injured through violence receive rehabilitation services. In addition, patients with pre-existing disabilities or with brain injuries may be at increased risk of violence. Since rehabilitation professionals treat some of the most severely injured children, they have a unique role to play in primary and secondary violence prevention. While some of these roles can be filled directly through patient contacts, long-term reduction in violence also requires policy advocacy. Acknowledgements We would like to thank Dr. Carla DiScala of the National Pediatric Trauma Registry for generously allowing us access to NPTR data for this publication. Preparation of this manuscript was funded in part by a grant from The Robert Wood Johnson Foundation Generalist Physician Faculty Scholars Program, and the National Institute on Disability and Rehabilitation Research, US Department of Education (award H133B0044). Note: Parent 'tip cards', designed for primary prevention use in a healthcare setting, are available from the authors. Currently available topics include: Myths and Facts about Violence, TimeOut, Television Violence, and The Use of Positive Reinforcement for Toddlers. New cards on related topics are under development. References [1] CDC. Firearm-related years of potential life lost before United States, 1980-91. MMWR age 65 years 1994;43:609-611.
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