Original Article
Levels of Teen Dating Violence and Substance Use in an Urban Emergency Department Michael J. Mason, PhD,* Leah Campbell, PhD,* Nikola Zaharakis, MS,* Robin Foster, MD,† Susan Richards, MSN, RN, CPEN† ABSTRACT: Objective: Teen dating violence (TDV) is associated with multiple sequelae including substance use. The objective of this study was to determine the prevalence and association between levels of dating violence and substance use among urban adolescents presenting at a pediatric emergency department (ED). Methods: As part of standard practice, 282 adolescents were screened for relationship status, producing 135 dating violence screens. Scales from the Revised Conflict Tactics Scale and the Youth Risk Behavior Survey were used to capture variables of interest. Logistic regression was performed to test the influence of levels of dating violence on substance use, while controlling for gender, race, age, sexual orientation, and psychiatric symptoms. Results: Over one-quarter of those teens (27.3%) within a current relationship reported experiencing any dating violence, 26.1% experienced psychological violence, and 11.9% experienced physical violence. Teens experiencing psychological violence were at twice the risk for any substance use (alcohol, marijuana, and tobacco use) and specifically for alcohol and marijuana, whereas no increased risk was found for teens experiencing physical violence. Conclusions: This study contributes to the understanding of TDV within the context of high-risk, urban adolescents presenting at a pediatric ED. Identifying levels of TDV and understanding the association with substance use can provide an important foundation for prevention and early intervention for urban youth. (J Dev Behav Pediatr 35:576–581, 2014) Index terms: teen dating violence, adolescent substance use, pediatric emergency department.
A
dolescent substance use continues to be a public health concern. Results from an ongoing national survey of adolescent drug use indicated that 50% of students had used an illicit drug by the time they left high school.1 At present, daily marijuana use is at a 12-year of high school, and 68% of students report drinking alcohol by the end of high school.1 Research has demonstrated that the influence of adolescent substance use persists and is linked with substance use disorders as well as negative mental health outcomes in adulthood.2 The literature suggests that adolescents diagnosed with a psychiatric illness are also at increased risk for substance use disorders.3 Specific to our study, substance use during adolescence has been linked with teen dating violence (TDV).4,5 The goal of this study was to determine the prevalence and association between levels of dating violence and substance use among urban adolescents presenting at a pediatric emergency department (ED).
From the *Division of Child and Adolescent Psychiatry, Commonwealth Institute for Child & Family Studies; †Division of Pediatric Emergency Services, Virginia Commonwealth University, Richmond, VA. Received May 2014; accepted July 2014. Disclosure: The authors declare no conflict of interest. Address for reprints: Michael J. Mason, PhD, Commonwealth Institute for Child and Family Studies; Department of Psychiatry, Virginia Commonwealth University, 515 N 10th St, PO Box 980489, Richmond, VA 23298-0489; e-mail: [email protected]. Copyright Ó 2014 Lippincott Williams & Wilkins
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Teen Dating Violence Dating violence among adolescents is a significant and persistent public health problem. Prevalence estimates may vary, but data from national studies suggest that between 30%6 and 50%7 of adolescents have experienced some form of dating violence. TDV has been defined in a variety of ways within the literature, but generally includes 3 distinct forms: psychological/ emotional, physical, and sexual dating violence.8 Psychological dating violence is often operationalized as threats of violence, coercive tactics, and trauma.8 Examples include name calling, disrespect,6 humiliating a victim, or controlling a victim’s behavior.8 Research suggests that psychological dating violence is the most prevalent type, with estimates indicating that between 20% and 50%7,9 of adolescents are victims. Physical violence is defined as the use of force with the intent to harm someone, such as pushing or shoving and throwing things at a victim.6,8 Prevalence rates suggest that 10% to 20% of adolescents experience physical dating violence.8,9 Sexual dating violence comprises nonconsensual or forced touching or sexual intercourse and is reported least frequently, with estimates between 2% and 15% of adolescents experiencing this type of dating violence.8 Experiencing dating violence can interrupt critical developmental processes such as individuation, intimate attachment, and peer relations and can have long-term negative effects.10 Relative to nonabused teens, adolescents Journal of Developmental & Behavioral Pediatrics
who are victims of dating violence are more likely to smoke cigarettes, binge drink, and use marijuana and other drugs.5,11 Physical and sexual dating violence have been linked with mental health symptoms, poor educational outcomes,12 and high-risk sexual behavior (early age of sexual debut ,15; lack of condom use, increased number of partners).13 Psychological dating violence is also linked with high-risk sexual behavior, alcohol, and drug use.13 TDV has long-term consequences with longitudinal research establishing that 5 years after victimization, teens report increased alcohol, marijuana, and tobacco use.4 Furthermore, evidence from one national study suggests that outcomes may operate cumulatively across forms of dating violence.6 Adolescents in this sample who reported being victims of both nonphysical and physical TDV reported higher levels of depression and substance use than those who experienced only nonphysical violence. Foshee et al,14 studying a large rural adolescent population, found that psychological abuse increased risk for alcohol use for boys and girls. Unfortunately, much of the extant literature examining links between TDV and risk behavior has not focused on urban youth, and thus, very little is known about consequences of differing violence severity with this at-risk group. Previous research has most often included samples comprised primarily of females,7,11 white youth,7 those living in suburban and rural areas,14 and youth enrolled in school.5,6 More research on dating violence, severity levels, and outcomes is needed with urban youth to better inform interventions with this important subgroup. Given the negative sequelae associated with dating violence, targeting adolescents at high-risk for victimization is important. The extant literature has begun to illuminate characteristics of adolescents at highest risk for dating violence victimization. Research suggests that dating violence may occur more frequently among members of racial, ethnic, and sexual minority groups. For example, research reveals that African-American and Hispanic adolescents report the highest rates of dating violence compared with other racial and ethnic groups.13,15 Lesbian, gay, and bisexual youth also may be at increased risk, as they also report higher rates of dating violence than heterosexual teens.16 Regarding gender differences, the current literature suggests that rates of psychological and physical dating violence are similar across males and females.8
Substance Use and Dating Violence Screenings in the Emergency Department As adolescents are less likely to seek professional mental health and substance use services addressing these issues within a nonspecialty health care setting holds much promise.17 Importantly, for many adolescents that do not have a primary care provider or the resources to access regular health care services, the ED serves as their primary source of medical care. Children from racial minority populations, in particular, may be most likely to present to an ED with undetected mental health concerns, as these groups often have less access Vol. 35, No. 9, November/December 2014
to mental health services.18 EDs have a unique opportunity to address these issues through efficient screening, and brief interventions and studies indicate that adolescents have positive attitudes toward ED mental health and substance use screening.19 Substantial evidence has shown a positive association between TDV and substance use, which can be interpreted as sharing of greater risk-taking behaviors (use of substances and involvement with violent peers) for some teens and for others, a sharing of greater vulnerability (less self-control and communication).6 Based on this review, we tested the relationship between severity levels of dating violence (psychological and physical) and increased risk of substance use (tobacco, alcohol, and marijuana). We hypothesized that TDV would be positively and linearly associated with substance use, such that teens experiencing physical TDV would be at greater risk of substance use relative to teens experiencing psychological dating violence.
METHODS As part of standard practice, 282 adolescent patients of 12 to 17 years presenting at a large, urban, university emergency department (ED) were prescreened by ED staff to determine whether they were currently in a relationship. The dedicated pediatric ED serves over 20,000 patients annually, is staffed continuously by nurses, physicians, and social workers, and is the only Level I pediatric trauma center within the state. The research team trained the head nurse in the screening protocol. The head nurse then trained her nursing staff to screen adolescents and to ask the parent/guardian to leave the room for completion of the screen to increase privacy and data accuracy. The implementation of the screening protocol was challenging as introducing a new research procedure within a busy, urban ED is often not given priority. This proved to be the case with the head nurse needing to repeatedly remind staff of the importance of collecting screens on all teens. Patients were screened after they were determined by ED staff to be medically stable enough to complete the screener. Prescreening for relationship status yielded 135 completed screeners that were used in the analyses. As described below in the measure section, we used a valid and reliable measure to capture our data. This study used data collected between March 2013 and April 2014. The study complied with all Institutional Review Board regulations within the authors’ institution. In the end of the current study, approximately 15% of adolescent patients were screened. The final sample was compared with those teens who were not screened on demographic characteristics and presenting problems, and no significant difference was found based on t tests (p . .05).
Screening Measure Due to time restrictions on the busy ED staff, only a very brief (1 page) screening instrument was used to ensure completion, reduce error, and limit training. © 2014 Lippincott Williams & Wilkins
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Demographic data, 7 items regarding TDV, and 3 items covering basic substance use endorsement and frequency made up the entire screening measure. This increased the external validity of the implementation of this screening project as most busy EDs would be able to implement a 1-page screening instrument versus an intensive psychosocial assessment. Demographics Demographic data were collected in the form of gender, age, race/ethnicity, and sexual orientation. For analytic and interpretative clarity, we coded variables dichotomously. Gender was coded 0 5 male, 1 5 female; race was coded not-black 5 0, black 5 1 (due to 80% of African-American samples); age was coded as younger (12–15 years) 5 0, older (16–17 years) 5 1; and sexual orientation was coded as straight 5 0, not-straight 5 1. PreScreen We classified adolescents who were in a relationship with the prescreening item, “Are you dating/seeing anyone now or have been in the past year?” Responses were yes or no. Dating Violence The Revised Conflict Tactics Scale20 was used to measure dating violence victimization severity levels into 3 mutually exclusive types: none, minor (psychologicalyelling, destroying belongings, insisting on sex), and severe (physical-shoving, punching/kicking, sprain/bruise, forced sex). We refer to minor as psychological and severe as physical. Three items formed the psychological violence scale coded as 0 5 no and 1 5 yes, and 4 items formed the physical violence scale coded as 0 5 no and 2 5 yes. Each set of items were summed to create a subscale score; all 7 items were summed to produce a total violence score. Higher scores represent the presence of more violence. An alpha reliability coefficient of .84 for the entire scale, .78 for the psychological subscale, and .75 for the physical violence subscale with the current study provides acceptable internal consistency. Substance Use In the Youth Risk Behavior Survey,21 past 30-day tobacco, alcohol, and marijuana use items were used to measure presence of substance use, coded (0 5 no and 1 5 yes). Tobacco use was defined as use of “cigarettes, cigarillos, little cigars, black and mild, and others.” An alpha reliability coefficient of .82 with the current study provides acceptable internal consistency. These 3 substances were measured as the investigative team’s current research informed the data collection method as to which substances are most frequently used (with these 3 substances representing over 98% of all substance use in this population). Psychiatric Symptoms Emergency department staff documented teens’ presenting problems on all screeners. We identified screens that represented psychiatric symptomology, such as “depression, anxiety, attention-deficit disorder, obsessive compulsive disorder, bipolar, suicide, overdose, self578 Levels of TDV
injury, and being high.” Responses were coded as not symptomatic 5 0 and symptomatic 5 1.
Analytical Approach Descriptive statistics were used to examine participant demographics, substance use, dating violence, and psychiatric symptomatology. Pearson’s product-moment correlation analysis was conducted between past-month substance use and levels of violence to determine directionality and strength of the relationships among these variables. Logistic regression was employed to test the influence of levels of dating violence on substance use, while controlling for gender, race, age, sexual orientation, and psychiatric symptoms. Outcome variables were tobacco, alcohol, marijuana, and any substance use; predictor variables were psychological, physical, and total violence; and covariates were gender, race, age, sexual orientation, and psychiatric symptoms. To control for multicollinearity, separate logistic regressions were run for each violence level (psychological, physical, and total), for each substance type (tobacco, alcohol, and marijuana), and for any substance use (combined alcohol, marijuana, and tobacco). IBM SPSS statistical software version 21 was used for all analyses.
RESULTS Descriptive demographic statistics reveal the final sample average age to be 15.5 (SD 5 1.3) 66% female, with 79.7% identifying as African-American, 18.0% white, and 2.3% as other. Sexual orientation was reported as 83.3% straight/heterosexual, 11.1% bisexual, 4.0% gay/ lesbian, and 1.6% transexual. The emergency department staff identified 10.4% of the samples with psychiatric symptoms as the primary presenting concern. Regarding past 30-day use of substances, 16.4% reported use of marijuana, 11.2% alcohol, 20.1% tobacco, and 26.1% reported using any of these 3 substances in the last 30 days. Over one-quarter, 27.3%, of those teens within a current relationship reported experiencing any dating violence, 26.1% experienced psychological violence, and 11.9% experienced physical violence. Table 1 shows correlations among levels of dating violence and past 30-day substance use. Psychological violence was significantly correlated with alcohol, marijuana, and any substance use. No significant correlations were found between physical violence and any substances. Total violence (combined psychological and physical) was significantly correlated with marijuana and any substance use (combined alcohol, marijuana, and tobacco). Table 2 provides results for our 3 logistic regression models, including odds ratios and confidence intervals (95%). Each of the outcome variables (tobacco, alcohol, marijuana, and any substance use) were regressed on 3 predictor variables (psychological, physical, and total violence) and 5 covariates (gender, race, age, sexual orientation, and psychiatric symptoms). Beginning with the tobacco use, being male, older, identifying as Journal of Developmental & Behavioral Pediatrics
Table 1. Correlations Among Levels of Dating Violence and Past 30-Day Substance Use Minor Violence
Severe Violence
Total Violence
Tobacco use
.127
.101
.150
Marijuana use
.267**
.094
.211*
Alcohol use
.217*
.024
.133
Total substance use
.244**
.092
.200*
model accounted for 25% of the variance (Nagelkerke R2 5 0.250). In all, only psychological violence predicted alcohol, marijuana, and total substance use, whereas physical and total violence did not predict any substance use.
DISCUSSION
*p , .05; **p , .01.
non-straight (gay/lesbian, bisexual, or transgender), and having psychiatric symptoms predicted tobacco use. We found that no level of dating violence predicted tobacco use. The model accounted for 27% of the variance (Nagelkerke R2 5 0.267). For alcohol, psychological violence put teens at 2-fold risk for alcohol use, whereas no other variables put adolescents at risk for alcohol use. The model accounted for 19% of the variance (Nagelkerke R2 5 0.188). Regarding marijuana, identifying as nonstraight predicted marijuana use and experiencing psychological violence put teens at a 2-fold increase risk for marijuana relative to teens not reporting psychological violence. The model accounted for 26% of the variance (Nagelkerke R2 5 0.258). Examining all substances together, being older and having psychiatric symptoms, increased risk of any substance use while experiencing psychological violence also put teens at a 2-fold increase risk for any substance use relative to teens not reporting psychological violence. The
Limited research has examined the variation of severity of urban teen dating violence (TDV) and the association with specific substances. This study contributes to the understanding of TDV within the context of high-risk, urban adolescents presenting at a pediatric emergency department (ED). Our findings show that urban teens who experience psychological violence are at twice the risk for marijuana and alcohol use compared with those who experience physical violence. Our findings add to the literature that supports screening urban adolescents for TDV and substance use within nonspecialty health care settings such as EDs.22 The finding that only psychological violence increased risk for substance use contradicts our hypothesis that increased severity would be associated with increased risk of substance use. One potential explanation is that teens experiencing psychological violence are in the early stages of a violent relationship, where the psychological victimization is a new, disturbing experience. The teen may then turn to substances at a higher level than those teens who have experienced physical violence to cope with this new emotional disturbance within their intimate relationship. This reasoning is
Table 2. Odds Ratios and Confidence Intervals (95%) From Logistic Regression Results of Levels of Dating Violence and Past 30-Day Substance Use (n 5 135)
Gender
Tobacco
Alcohol
Marijuana
0.24* (0.06–0.88)
0.48 (0.12–1.82)
0.70 (0.24–2.03)
Total Substances 0.55 (0.22–1.34)
Race
1.39 (0.28–6.87)
4.00 (0.40–39.3)
1.54 (0.37–6.42)
2.46 (0.69–8.78)
Age
4.89* (1.07–22.3)
1.00 (0.26–3.82)
1.78 (0.61–5.22)
3.02* (1.19–7.67)
7.80** (1.73–34.9)
3.12 (0.53–18.3)
3.82* (1.07–13.6)
2.51 (0.75–8.38)
Psychiatric symptoms
Sexual orientation
5.19 (0.80–33.6)
2.54 (0.47–13.5)
3.60 (0.76–16.9)
5.37* (1.28–22.5)
Psychological violence
1.10 (0.45–2.67)
2.36* (1.05–5.26)
2.14* (1.10–4.17)
2.45** (1.25–4.81)
Gender
0.51 (0.19–1.35)
0.38 (0.12–1.18)
0.66 (0.23–1.88)
0.55 (0.23–1.30)
Race
2.06 (0.53–7.98)
1.18 (0.28–4.93)
1.35 (0.35–5.12)
2.13 (0.64–7.13)
Age
3.21* (1.10–9.37)
1.66 (0.51–5.36)
1.94 (0.66–5.70)
2.95* (1.17–7.42)
Sexual orientation
4.41* (1.28–15.0)
2.20 (0.47–10.1)
3.95* (1.14–13.6)
2.52 (0.77–8.19)
Psychiatric symptoms
4.64* (1.06–20.2)
2.62 (0.53–12.8)
3.22 (0.72–14.2)
4.61* (1.13–18.7)
Physical violence
1.12 (0.74–1.69)
0.89 (0.52–1.51)
1.05 (0.68–1.63)
1.15 (0.79–1.67)
Gender
0.52 (0.19–1.41)
0.41 (0.13–1.27)
0.70 (0.24–2.01)
0.56 (0.23–1.36)
Race
2.16 (0.54–8.58)
1.27 (0.28–5.62)
1.43 (0.36–5.69)
2.22 (0.64–7.66)
Age
3.04* (1.05–8.82)
1.40 (0.44–4.49)
1.73 (0.59–5.07)
2.79* (1.11–7.00)
Sexual orientation
4.21* (1.22–14.5)
1.83 (0.38–8.64)
3.65* (1.04–12.8)
2.37 (0.71–7.91)
Psychiatric symptoms
4.71* (1.06–20.8)
2.40 (0.47–12.2)
3.21 (0.70–14.7)
4.85* (1.17–20.1)
1.19 (0.88–1.62)
1.10 (0.80–1.52)
1.22 (0.90–1.65)
1.34 (0.99–1.79)
Total violence *p , .05; **p , .01.
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consistent with adult interpersonal violence studies that report victims perceive psychological abuse as more emotionally harmful than physical abuse.23 Another explanation could be the insufficient power in our study to demonstrate physical violence’s association with substance use, as only 17 cases were classified as physical violence. Unfortunately, our findings and those in the extant literature cannot specify a temporal pattern among varying levels of severity of TDV and substance use behaviors.6 Further clarification of the interactions and temporal sequencing between these behaviors is needed through longitudinal designs. At minimum, this finding highlights the importance of focusing on psychological abuse in screening and intervention programs. Adolescents who identified as sexual minority and those classified as having psychiatric symptoms emerged as being at elevated risk for substance use compared with their peers. Consistent with previous literature,24 adolescents in this study who identified with a sexual minority orientation were at higher risk of using tobacco and marijuana. Minority stress theory, a framework often used to conceptualize sexual minority health, posits that sexual minorities experience chronic stress from the social environment because of the conflict between dominant societal values and minority group values.25 This stress may lead sexual minority youth both to use substances to cope with their negative emotions related to the stress and to seek the support of peers from whom they feel accepted, possibly other sexual minority youth. Similarly, adolescents in this study experiencing psychiatric symptoms also were at increased risk of substance use. A large body of research has demonstrated the high comorbidity of psychiatric and substance use disorders.26 These findings can be interpreted through the selfmedication hypothesis, where teens could be using substances in an attempt to regulate emotions related to ostracization based on psychiatric symptoms. Understanding the mechanisms underlying these relationships is important for future research, especially among teens experiencing dating violence, as victimization is one of the strongest risk factors for substance use among sexual minority youth27 and among those with a psychiatric disorder.28 There are several limitations that need to be considered when interpreting these findings. First, the crosssectional and convenience sample design limits the causal interpretations from these data. We cannot infer timing between TDV and subsequent substance use, thus these events may have occurred in reverse order or simultaneously. Second, the data were collected with a brief screening instrument, designed for ease and speed in a busy, urban ED. Much more detail on TDV could have been captured with more extensive measures, as well as more substance use and psychological covariate measures. Our confidence intervals were fairly wide for some variables, suggesting the need for caution in interpreting the stability of these results. Our lack of 580 Levels of TDV
detecting an association between physical dating violence and substance use could be a function of our limited screening measure (only screening for 3 substances) and/or lack of sufficient power to detect differences among this smaller subgroup. This pilot study was launched as part of a real-world screening initiative within the ED. Nurses completed the screens when they could, when patients were stable enough, and likely, when they remembered. Not having a highly controlled, funded research staff to conduct assessments limits the scientific rigor of these preliminary data. Nevertheless, it is the real-world nature of the design and data collection efforts that may provide guidance to other urban ED settings and staff. Although our findings cannot establish causation, these data suggest even psychological violence has negative outcomes and should be screened for and attended to. These data support screening for TDV in an urban pediatric ED, as an encounter with supportive health care providers at a vulnerable time can provide an opportunity for necessary reflection and increased help seeking behaviors. Importantly, the dating violence screening measure used (Revised Conflict Tactics Scalepsychological and physical subscales) is widely regarded as the gold standard, providing confidence in these data and our interpretations. Identifying levels of TDV and understanding the association with substance use within the context of an ED, can provide an important foundation for prevention and early intervention for urban youth. More evidenced-based randomized control trials are needed within urban pediatric EDs, where most patients will not receive high-quality substance use interventions.29 REFERENCES 1. Johnston LD, O’Malley PM, Miech RA, et al. Monitoring the Future National Results on Drug Use: 1975–2013: Overview, Key Findings on Adolescent Drug Use. Ann Arbor, MI: Institute for Social Research, The University of Michigan; 2014. 2. McCambridge J, McAlaney J, Rowe R. Adult consequences of late adolescent alcohol consumption: a systematic review of cohort studies. PLoS Med. 2011;8:1–13. 3. Swendsen J, Conway KP, Degenhardt L, et al. Mental disorders as risk factors for substance use, abuse and dependence: results from the 10-year follow-up of the national comorbidity survey. Addiction. 2010;105:1117–1128. 4. Exner-Cortens D, Eckenrode J, Rothman E. Longitudinal associations between teen dating violence victimization and adverse health outcomes. Pediatrics. 2013;131:71–78. 5. Temple JR, Freeman DH Jr. Dating violence and substance use among ethnically diverse adolescents. J Interpers Violence. 2011; 26:701–718. 6. Haynie DL, Farhat T, Brooks-Russell A, et al. Dating violence perpetration and victimization among US adolescents: prevalence, patterns, and associations with health complaints and substance use. J Adolesc Health. 2013;53:194–201. 7. Zweig JM, Dank M, Yahner J, et al. The rate of cyber dating abuse among teens and how it relates to other forms of teen dating violence. J Youth Adolesc. 2013;42:1063–1077. 8. Leen E, Sorbring E, Mawer M, et al. Prevalence, dynamic risk factors and the efficacy of primary interventions for adolescent dating
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19. O’Mara RM, Hill RM, Cunningham RM, et al. Adolescent and parent attitudes toward screening for suicide risk and mental health problems in the pediatric emergency department. Pediatr Emerg Care. 2012;28:626–633. 20. Straus MA, Douglas EM. A short form of the revised conflict tactics scales, and typologies for severity and mutuality. Violence Vict. 2004;19:507–520. 21. Centers for Disease Control and Prevention. 2013 Youth Risk Behavior Survey. Available at www.cdc.gov/yrbss. Accessed April 10, 2013. 22. Pepler D. The development of dating violence: what doesn’t develop, what does develop, how does it develop, and what can we do about it? Prev Sci. 2012;13:402–409. 23. Follingstad DR, Rutledge LL, Berg BJ, et al. The role of emotional abuse in physically abusing relationships. J Fam Violence. 1990;5: 107–120. 24. Corliss HL, Rosario M, Wypij D, et al. Sexual orientation and drug use in a longitudinal cohort study of U.S. adolescents. Addict Behav. 2010;35:517–521. 25. Meyer IH. Prejudice, social stress, and mental health in lesbian, gay and bisexual populations: conceptual issues and research evidence. Psycholl Bull. 2003;129:674–697. 26. Conway KP, Compton WM, Stinson FS, et al. Lifetime comorbidity of DSM-IV mood and anxiety disorders and specific drug use disorders: results from the National Epidemiologic Survey on Alcohol and Related Conditions. J Clin Psychiatry. 2006;67:247–257. 27. Goldbach JT, Tanner-Smith EE, Bagwell M, et al. Minority stress and substance use in sexual minority adolescents: a meta-analysis. Prev Sci. 2013;15:1–14. 28. Ford JD, Elhai JD, Connor DF, et al. Poly-victimization and risk of posttraumatic, depressive, and substance use disorders and involvement in delinquency in a national sample of adolescents. J Adolesc Health. 2010;46:545–552. 29. D’Onofrio G, Degutis L. Screening, brief intervention in the emergency department. Alcohol Res Health. 2005;28:63–72.
ERRATUM Adverse Events in Children: Predictors of Adult Physical and Mental Conditions: Erratum The article did not include the affiliations of the authors. Their affiliations are: Cornelius Van Niel, MD, Department of Pediatrics, University of Washington School of Medicine, Sea Mar Community Health Centers, Seattle, WA. Lee M. Pachter, DO, Drexel University College of Medicine, St. Christopher’s Hospital for Children, Philadelphia, PA. Roy Wade Jr, MD, PhD, MPH, The Perelman School of Medicine at the University of Pennsylvania, The Children’s Hospital of Philadelphia, Philadelphia, PA. Vincent J. Felitti, MD, University of California San Diego, San Diego, CA, and Kaiser Permanente, San Diego, CA. Martin T. Stein, MD, Division of Child Development and Community Health, University of California San Diego, San Diego, CA. REFERENCE: 1. Van Niel C, Pachter LM, Wade R Jr, et al. Adverse Events in Children: Predictors of Adult Physical and Mental Conditions. J Dev Behav Pediatr. 2014;35:549–551.
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Levels of Teen Dating Violence and Substance Use in an Urban Emergency Department Michael J. Mason, PhD,* Leah Campbell, PhD,* Nikola Zaharakis, MS,* Robin Foster, MD,† Susan Richards, MSN, RN, CPEN† ABSTRACT: Objective: Teen dating violence (TDV) is associated with multiple sequelae including substance use. The objective of this study was to determine the prevalence and association between levels of dating violence and substance use among urban adolescents presenting at a pediatric emergency department (ED). Methods: As part of standard practice, 282 adolescents were screened for relationship status, producing 135 dating violence screens. Scales from the Revised Conflict Tactics Scale and the Youth Risk Behavior Survey were used to capture variables of interest. Logistic regression was performed to test the influence of levels of dating violence on substance use, while controlling for gender, race, age, sexual orientation, and psychiatric symptoms. Results: Over one-quarter of those teens (27.3%) within a current relationship reported experiencing any dating violence, 26.1% experienced psychological violence, and 11.9% experienced physical violence. Teens experiencing psychological violence were at twice the risk for any substance use (alcohol, marijuana, and tobacco use) and specifically for alcohol and marijuana, whereas no increased risk was found for teens experiencing physical violence. Conclusions: This study contributes to the understanding of TDV within the context of high-risk, urban adolescents presenting at a pediatric ED. Identifying levels of TDV and understanding the association with substance use can provide an important foundation for prevention and early intervention for urban youth. (J Dev Behav Pediatr 35:576–581, 2014) Index terms: teen dating violence, adolescent substance use, pediatric emergency department.
A
dolescent substance use continues to be a public health concern. Results from an ongoing national survey of adolescent drug use indicated that 50% of students had used an illicit drug by the time they left high school.1 At present, daily marijuana use is at a 12-year of high school, and 68% of students report drinking alcohol by the end of high school.1 Research has demonstrated that the influence of adolescent substance use persists and is linked with substance use disorders as well as negative mental health outcomes in adulthood.2 The literature suggests that adolescents diagnosed with a psychiatric illness are also at increased risk for substance use disorders.3 Specific to our study, substance use during adolescence has been linked with teen dating violence (TDV).4,5 The goal of this study was to determine the prevalence and association between levels of dating violence and substance use among urban adolescents presenting at a pediatric emergency department (ED).
From the *Division of Child and Adolescent Psychiatry, Commonwealth Institute for Child & Family Studies; †Division of Pediatric Emergency Services, Virginia Commonwealth University, Richmond, VA. Received May 2014; accepted July 2014. Disclosure: The authors declare no conflict of interest. Address for reprints: Michael J. Mason, PhD, Commonwealth Institute for Child and Family Studies; Department of Psychiatry, Virginia Commonwealth University, 515 N 10th St, PO Box 980489, Richmond, VA 23298-0489; e-mail: [email protected]. Copyright Ó 2014 Lippincott Williams & Wilkins
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Teen Dating Violence Dating violence among adolescents is a significant and persistent public health problem. Prevalence estimates may vary, but data from national studies suggest that between 30%6 and 50%7 of adolescents have experienced some form of dating violence. TDV has been defined in a variety of ways within the literature, but generally includes 3 distinct forms: psychological/ emotional, physical, and sexual dating violence.8 Psychological dating violence is often operationalized as threats of violence, coercive tactics, and trauma.8 Examples include name calling, disrespect,6 humiliating a victim, or controlling a victim’s behavior.8 Research suggests that psychological dating violence is the most prevalent type, with estimates indicating that between 20% and 50%7,9 of adolescents are victims. Physical violence is defined as the use of force with the intent to harm someone, such as pushing or shoving and throwing things at a victim.6,8 Prevalence rates suggest that 10% to 20% of adolescents experience physical dating violence.8,9 Sexual dating violence comprises nonconsensual or forced touching or sexual intercourse and is reported least frequently, with estimates between 2% and 15% of adolescents experiencing this type of dating violence.8 Experiencing dating violence can interrupt critical developmental processes such as individuation, intimate attachment, and peer relations and can have long-term negative effects.10 Relative to nonabused teens, adolescents Journal of Developmental & Behavioral Pediatrics
who are victims of dating violence are more likely to smoke cigarettes, binge drink, and use marijuana and other drugs.5,11 Physical and sexual dating violence have been linked with mental health symptoms, poor educational outcomes,12 and high-risk sexual behavior (early age of sexual debut ,15; lack of condom use, increased number of partners).13 Psychological dating violence is also linked with high-risk sexual behavior, alcohol, and drug use.13 TDV has long-term consequences with longitudinal research establishing that 5 years after victimization, teens report increased alcohol, marijuana, and tobacco use.4 Furthermore, evidence from one national study suggests that outcomes may operate cumulatively across forms of dating violence.6 Adolescents in this sample who reported being victims of both nonphysical and physical TDV reported higher levels of depression and substance use than those who experienced only nonphysical violence. Foshee et al,14 studying a large rural adolescent population, found that psychological abuse increased risk for alcohol use for boys and girls. Unfortunately, much of the extant literature examining links between TDV and risk behavior has not focused on urban youth, and thus, very little is known about consequences of differing violence severity with this at-risk group. Previous research has most often included samples comprised primarily of females,7,11 white youth,7 those living in suburban and rural areas,14 and youth enrolled in school.5,6 More research on dating violence, severity levels, and outcomes is needed with urban youth to better inform interventions with this important subgroup. Given the negative sequelae associated with dating violence, targeting adolescents at high-risk for victimization is important. The extant literature has begun to illuminate characteristics of adolescents at highest risk for dating violence victimization. Research suggests that dating violence may occur more frequently among members of racial, ethnic, and sexual minority groups. For example, research reveals that African-American and Hispanic adolescents report the highest rates of dating violence compared with other racial and ethnic groups.13,15 Lesbian, gay, and bisexual youth also may be at increased risk, as they also report higher rates of dating violence than heterosexual teens.16 Regarding gender differences, the current literature suggests that rates of psychological and physical dating violence are similar across males and females.8
Substance Use and Dating Violence Screenings in the Emergency Department As adolescents are less likely to seek professional mental health and substance use services addressing these issues within a nonspecialty health care setting holds much promise.17 Importantly, for many adolescents that do not have a primary care provider or the resources to access regular health care services, the ED serves as their primary source of medical care. Children from racial minority populations, in particular, may be most likely to present to an ED with undetected mental health concerns, as these groups often have less access Vol. 35, No. 9, November/December 2014
to mental health services.18 EDs have a unique opportunity to address these issues through efficient screening, and brief interventions and studies indicate that adolescents have positive attitudes toward ED mental health and substance use screening.19 Substantial evidence has shown a positive association between TDV and substance use, which can be interpreted as sharing of greater risk-taking behaviors (use of substances and involvement with violent peers) for some teens and for others, a sharing of greater vulnerability (less self-control and communication).6 Based on this review, we tested the relationship between severity levels of dating violence (psychological and physical) and increased risk of substance use (tobacco, alcohol, and marijuana). We hypothesized that TDV would be positively and linearly associated with substance use, such that teens experiencing physical TDV would be at greater risk of substance use relative to teens experiencing psychological dating violence.
METHODS As part of standard practice, 282 adolescent patients of 12 to 17 years presenting at a large, urban, university emergency department (ED) were prescreened by ED staff to determine whether they were currently in a relationship. The dedicated pediatric ED serves over 20,000 patients annually, is staffed continuously by nurses, physicians, and social workers, and is the only Level I pediatric trauma center within the state. The research team trained the head nurse in the screening protocol. The head nurse then trained her nursing staff to screen adolescents and to ask the parent/guardian to leave the room for completion of the screen to increase privacy and data accuracy. The implementation of the screening protocol was challenging as introducing a new research procedure within a busy, urban ED is often not given priority. This proved to be the case with the head nurse needing to repeatedly remind staff of the importance of collecting screens on all teens. Patients were screened after they were determined by ED staff to be medically stable enough to complete the screener. Prescreening for relationship status yielded 135 completed screeners that were used in the analyses. As described below in the measure section, we used a valid and reliable measure to capture our data. This study used data collected between March 2013 and April 2014. The study complied with all Institutional Review Board regulations within the authors’ institution. In the end of the current study, approximately 15% of adolescent patients were screened. The final sample was compared with those teens who were not screened on demographic characteristics and presenting problems, and no significant difference was found based on t tests (p . .05).
Screening Measure Due to time restrictions on the busy ED staff, only a very brief (1 page) screening instrument was used to ensure completion, reduce error, and limit training. © 2014 Lippincott Williams & Wilkins
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Demographic data, 7 items regarding TDV, and 3 items covering basic substance use endorsement and frequency made up the entire screening measure. This increased the external validity of the implementation of this screening project as most busy EDs would be able to implement a 1-page screening instrument versus an intensive psychosocial assessment. Demographics Demographic data were collected in the form of gender, age, race/ethnicity, and sexual orientation. For analytic and interpretative clarity, we coded variables dichotomously. Gender was coded 0 5 male, 1 5 female; race was coded not-black 5 0, black 5 1 (due to 80% of African-American samples); age was coded as younger (12–15 years) 5 0, older (16–17 years) 5 1; and sexual orientation was coded as straight 5 0, not-straight 5 1. PreScreen We classified adolescents who were in a relationship with the prescreening item, “Are you dating/seeing anyone now or have been in the past year?” Responses were yes or no. Dating Violence The Revised Conflict Tactics Scale20 was used to measure dating violence victimization severity levels into 3 mutually exclusive types: none, minor (psychologicalyelling, destroying belongings, insisting on sex), and severe (physical-shoving, punching/kicking, sprain/bruise, forced sex). We refer to minor as psychological and severe as physical. Three items formed the psychological violence scale coded as 0 5 no and 1 5 yes, and 4 items formed the physical violence scale coded as 0 5 no and 2 5 yes. Each set of items were summed to create a subscale score; all 7 items were summed to produce a total violence score. Higher scores represent the presence of more violence. An alpha reliability coefficient of .84 for the entire scale, .78 for the psychological subscale, and .75 for the physical violence subscale with the current study provides acceptable internal consistency. Substance Use In the Youth Risk Behavior Survey,21 past 30-day tobacco, alcohol, and marijuana use items were used to measure presence of substance use, coded (0 5 no and 1 5 yes). Tobacco use was defined as use of “cigarettes, cigarillos, little cigars, black and mild, and others.” An alpha reliability coefficient of .82 with the current study provides acceptable internal consistency. These 3 substances were measured as the investigative team’s current research informed the data collection method as to which substances are most frequently used (with these 3 substances representing over 98% of all substance use in this population). Psychiatric Symptoms Emergency department staff documented teens’ presenting problems on all screeners. We identified screens that represented psychiatric symptomology, such as “depression, anxiety, attention-deficit disorder, obsessive compulsive disorder, bipolar, suicide, overdose, self578 Levels of TDV
injury, and being high.” Responses were coded as not symptomatic 5 0 and symptomatic 5 1.
Analytical Approach Descriptive statistics were used to examine participant demographics, substance use, dating violence, and psychiatric symptomatology. Pearson’s product-moment correlation analysis was conducted between past-month substance use and levels of violence to determine directionality and strength of the relationships among these variables. Logistic regression was employed to test the influence of levels of dating violence on substance use, while controlling for gender, race, age, sexual orientation, and psychiatric symptoms. Outcome variables were tobacco, alcohol, marijuana, and any substance use; predictor variables were psychological, physical, and total violence; and covariates were gender, race, age, sexual orientation, and psychiatric symptoms. To control for multicollinearity, separate logistic regressions were run for each violence level (psychological, physical, and total), for each substance type (tobacco, alcohol, and marijuana), and for any substance use (combined alcohol, marijuana, and tobacco). IBM SPSS statistical software version 21 was used for all analyses.
RESULTS Descriptive demographic statistics reveal the final sample average age to be 15.5 (SD 5 1.3) 66% female, with 79.7% identifying as African-American, 18.0% white, and 2.3% as other. Sexual orientation was reported as 83.3% straight/heterosexual, 11.1% bisexual, 4.0% gay/ lesbian, and 1.6% transexual. The emergency department staff identified 10.4% of the samples with psychiatric symptoms as the primary presenting concern. Regarding past 30-day use of substances, 16.4% reported use of marijuana, 11.2% alcohol, 20.1% tobacco, and 26.1% reported using any of these 3 substances in the last 30 days. Over one-quarter, 27.3%, of those teens within a current relationship reported experiencing any dating violence, 26.1% experienced psychological violence, and 11.9% experienced physical violence. Table 1 shows correlations among levels of dating violence and past 30-day substance use. Psychological violence was significantly correlated with alcohol, marijuana, and any substance use. No significant correlations were found between physical violence and any substances. Total violence (combined psychological and physical) was significantly correlated with marijuana and any substance use (combined alcohol, marijuana, and tobacco). Table 2 provides results for our 3 logistic regression models, including odds ratios and confidence intervals (95%). Each of the outcome variables (tobacco, alcohol, marijuana, and any substance use) were regressed on 3 predictor variables (psychological, physical, and total violence) and 5 covariates (gender, race, age, sexual orientation, and psychiatric symptoms). Beginning with the tobacco use, being male, older, identifying as Journal of Developmental & Behavioral Pediatrics
Table 1. Correlations Among Levels of Dating Violence and Past 30-Day Substance Use Minor Violence
Severe Violence
Total Violence
Tobacco use
.127
.101
.150
Marijuana use
.267**
.094
.211*
Alcohol use
.217*
.024
.133
Total substance use
.244**
.092
.200*
model accounted for 25% of the variance (Nagelkerke R2 5 0.250). In all, only psychological violence predicted alcohol, marijuana, and total substance use, whereas physical and total violence did not predict any substance use.
DISCUSSION
*p , .05; **p , .01.
non-straight (gay/lesbian, bisexual, or transgender), and having psychiatric symptoms predicted tobacco use. We found that no level of dating violence predicted tobacco use. The model accounted for 27% of the variance (Nagelkerke R2 5 0.267). For alcohol, psychological violence put teens at 2-fold risk for alcohol use, whereas no other variables put adolescents at risk for alcohol use. The model accounted for 19% of the variance (Nagelkerke R2 5 0.188). Regarding marijuana, identifying as nonstraight predicted marijuana use and experiencing psychological violence put teens at a 2-fold increase risk for marijuana relative to teens not reporting psychological violence. The model accounted for 26% of the variance (Nagelkerke R2 5 0.258). Examining all substances together, being older and having psychiatric symptoms, increased risk of any substance use while experiencing psychological violence also put teens at a 2-fold increase risk for any substance use relative to teens not reporting psychological violence. The
Limited research has examined the variation of severity of urban teen dating violence (TDV) and the association with specific substances. This study contributes to the understanding of TDV within the context of high-risk, urban adolescents presenting at a pediatric emergency department (ED). Our findings show that urban teens who experience psychological violence are at twice the risk for marijuana and alcohol use compared with those who experience physical violence. Our findings add to the literature that supports screening urban adolescents for TDV and substance use within nonspecialty health care settings such as EDs.22 The finding that only psychological violence increased risk for substance use contradicts our hypothesis that increased severity would be associated with increased risk of substance use. One potential explanation is that teens experiencing psychological violence are in the early stages of a violent relationship, where the psychological victimization is a new, disturbing experience. The teen may then turn to substances at a higher level than those teens who have experienced physical violence to cope with this new emotional disturbance within their intimate relationship. This reasoning is
Table 2. Odds Ratios and Confidence Intervals (95%) From Logistic Regression Results of Levels of Dating Violence and Past 30-Day Substance Use (n 5 135)
Gender
Tobacco
Alcohol
Marijuana
0.24* (0.06–0.88)
0.48 (0.12–1.82)
0.70 (0.24–2.03)
Total Substances 0.55 (0.22–1.34)
Race
1.39 (0.28–6.87)
4.00 (0.40–39.3)
1.54 (0.37–6.42)
2.46 (0.69–8.78)
Age
4.89* (1.07–22.3)
1.00 (0.26–3.82)
1.78 (0.61–5.22)
3.02* (1.19–7.67)
7.80** (1.73–34.9)
3.12 (0.53–18.3)
3.82* (1.07–13.6)
2.51 (0.75–8.38)
Psychiatric symptoms
Sexual orientation
5.19 (0.80–33.6)
2.54 (0.47–13.5)
3.60 (0.76–16.9)
5.37* (1.28–22.5)
Psychological violence
1.10 (0.45–2.67)
2.36* (1.05–5.26)
2.14* (1.10–4.17)
2.45** (1.25–4.81)
Gender
0.51 (0.19–1.35)
0.38 (0.12–1.18)
0.66 (0.23–1.88)
0.55 (0.23–1.30)
Race
2.06 (0.53–7.98)
1.18 (0.28–4.93)
1.35 (0.35–5.12)
2.13 (0.64–7.13)
Age
3.21* (1.10–9.37)
1.66 (0.51–5.36)
1.94 (0.66–5.70)
2.95* (1.17–7.42)
Sexual orientation
4.41* (1.28–15.0)
2.20 (0.47–10.1)
3.95* (1.14–13.6)
2.52 (0.77–8.19)
Psychiatric symptoms
4.64* (1.06–20.2)
2.62 (0.53–12.8)
3.22 (0.72–14.2)
4.61* (1.13–18.7)
Physical violence
1.12 (0.74–1.69)
0.89 (0.52–1.51)
1.05 (0.68–1.63)
1.15 (0.79–1.67)
Gender
0.52 (0.19–1.41)
0.41 (0.13–1.27)
0.70 (0.24–2.01)
0.56 (0.23–1.36)
Race
2.16 (0.54–8.58)
1.27 (0.28–5.62)
1.43 (0.36–5.69)
2.22 (0.64–7.66)
Age
3.04* (1.05–8.82)
1.40 (0.44–4.49)
1.73 (0.59–5.07)
2.79* (1.11–7.00)
Sexual orientation
4.21* (1.22–14.5)
1.83 (0.38–8.64)
3.65* (1.04–12.8)
2.37 (0.71–7.91)
Psychiatric symptoms
4.71* (1.06–20.8)
2.40 (0.47–12.2)
3.21 (0.70–14.7)
4.85* (1.17–20.1)
1.19 (0.88–1.62)
1.10 (0.80–1.52)
1.22 (0.90–1.65)
1.34 (0.99–1.79)
Total violence *p , .05; **p , .01.
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consistent with adult interpersonal violence studies that report victims perceive psychological abuse as more emotionally harmful than physical abuse.23 Another explanation could be the insufficient power in our study to demonstrate physical violence’s association with substance use, as only 17 cases were classified as physical violence. Unfortunately, our findings and those in the extant literature cannot specify a temporal pattern among varying levels of severity of TDV and substance use behaviors.6 Further clarification of the interactions and temporal sequencing between these behaviors is needed through longitudinal designs. At minimum, this finding highlights the importance of focusing on psychological abuse in screening and intervention programs. Adolescents who identified as sexual minority and those classified as having psychiatric symptoms emerged as being at elevated risk for substance use compared with their peers. Consistent with previous literature,24 adolescents in this study who identified with a sexual minority orientation were at higher risk of using tobacco and marijuana. Minority stress theory, a framework often used to conceptualize sexual minority health, posits that sexual minorities experience chronic stress from the social environment because of the conflict between dominant societal values and minority group values.25 This stress may lead sexual minority youth both to use substances to cope with their negative emotions related to the stress and to seek the support of peers from whom they feel accepted, possibly other sexual minority youth. Similarly, adolescents in this study experiencing psychiatric symptoms also were at increased risk of substance use. A large body of research has demonstrated the high comorbidity of psychiatric and substance use disorders.26 These findings can be interpreted through the selfmedication hypothesis, where teens could be using substances in an attempt to regulate emotions related to ostracization based on psychiatric symptoms. Understanding the mechanisms underlying these relationships is important for future research, especially among teens experiencing dating violence, as victimization is one of the strongest risk factors for substance use among sexual minority youth27 and among those with a psychiatric disorder.28 There are several limitations that need to be considered when interpreting these findings. First, the crosssectional and convenience sample design limits the causal interpretations from these data. We cannot infer timing between TDV and subsequent substance use, thus these events may have occurred in reverse order or simultaneously. Second, the data were collected with a brief screening instrument, designed for ease and speed in a busy, urban ED. Much more detail on TDV could have been captured with more extensive measures, as well as more substance use and psychological covariate measures. Our confidence intervals were fairly wide for some variables, suggesting the need for caution in interpreting the stability of these results. Our lack of 580 Levels of TDV
detecting an association between physical dating violence and substance use could be a function of our limited screening measure (only screening for 3 substances) and/or lack of sufficient power to detect differences among this smaller subgroup. This pilot study was launched as part of a real-world screening initiative within the ED. Nurses completed the screens when they could, when patients were stable enough, and likely, when they remembered. Not having a highly controlled, funded research staff to conduct assessments limits the scientific rigor of these preliminary data. Nevertheless, it is the real-world nature of the design and data collection efforts that may provide guidance to other urban ED settings and staff. Although our findings cannot establish causation, these data suggest even psychological violence has negative outcomes and should be screened for and attended to. These data support screening for TDV in an urban pediatric ED, as an encounter with supportive health care providers at a vulnerable time can provide an opportunity for necessary reflection and increased help seeking behaviors. Importantly, the dating violence screening measure used (Revised Conflict Tactics Scalepsychological and physical subscales) is widely regarded as the gold standard, providing confidence in these data and our interpretations. Identifying levels of TDV and understanding the association with substance use within the context of an ED, can provide an important foundation for prevention and early intervention for urban youth. More evidenced-based randomized control trials are needed within urban pediatric EDs, where most patients will not receive high-quality substance use interventions.29 REFERENCES 1. Johnston LD, O’Malley PM, Miech RA, et al. Monitoring the Future National Results on Drug Use: 1975–2013: Overview, Key Findings on Adolescent Drug Use. Ann Arbor, MI: Institute for Social Research, The University of Michigan; 2014. 2. McCambridge J, McAlaney J, Rowe R. Adult consequences of late adolescent alcohol consumption: a systematic review of cohort studies. PLoS Med. 2011;8:1–13. 3. Swendsen J, Conway KP, Degenhardt L, et al. Mental disorders as risk factors for substance use, abuse and dependence: results from the 10-year follow-up of the national comorbidity survey. Addiction. 2010;105:1117–1128. 4. Exner-Cortens D, Eckenrode J, Rothman E. Longitudinal associations between teen dating violence victimization and adverse health outcomes. Pediatrics. 2013;131:71–78. 5. Temple JR, Freeman DH Jr. Dating violence and substance use among ethnically diverse adolescents. J Interpers Violence. 2011; 26:701–718. 6. Haynie DL, Farhat T, Brooks-Russell A, et al. Dating violence perpetration and victimization among US adolescents: prevalence, patterns, and associations with health complaints and substance use. J Adolesc Health. 2013;53:194–201. 7. Zweig JM, Dank M, Yahner J, et al. The rate of cyber dating abuse among teens and how it relates to other forms of teen dating violence. J Youth Adolesc. 2013;42:1063–1077. 8. Leen E, Sorbring E, Mawer M, et al. Prevalence, dynamic risk factors and the efficacy of primary interventions for adolescent dating
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ERRATUM Adverse Events in Children: Predictors of Adult Physical and Mental Conditions: Erratum The article did not include the affiliations of the authors. Their affiliations are: Cornelius Van Niel, MD, Department of Pediatrics, University of Washington School of Medicine, Sea Mar Community Health Centers, Seattle, WA. Lee M. Pachter, DO, Drexel University College of Medicine, St. Christopher’s Hospital for Children, Philadelphia, PA. Roy Wade Jr, MD, PhD, MPH, The Perelman School of Medicine at the University of Pennsylvania, The Children’s Hospital of Philadelphia, Philadelphia, PA. Vincent J. Felitti, MD, University of California San Diego, San Diego, CA, and Kaiser Permanente, San Diego, CA. Martin T. Stein, MD, Division of Child Development and Community Health, University of California San Diego, San Diego, CA. REFERENCE: 1. Van Niel C, Pachter LM, Wade R Jr, et al. Adverse Events in Children: Predictors of Adult Physical and Mental Conditions. J Dev Behav Pediatr. 2014;35:549–551.
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