Violence and Youth
Peter Stringham
I. Description of the problem. Parents are anxiously searching for sensible advice to keep their children safe in what they perceive as an increasingly violent world. Pediatric practitioners can suggest behaviors that will increase nonviolent problem-solving skills in their patients.
A. Epidemiology.
The murder rate of men of ages 15 to 24 years in the United States is 15,000 (compared to 180,000 in England and 1200,000 in Japan). Murder is the second leading cause of death (after auto accidents) in this age group. The lifetime risk for being murdered in the United States is 1 in 450 for white females, 1 in 164 for African American females, 1 in 117 for white males and 1 in 28 for African American males.
The rate of assaults outnumber fatalities by a ratio of more than 100. Adolescents’ victimization rates are almost twice the rates for adults 25 to 34 years old (741,000 vs. 381,000 per year).
For adolescents in dating relationships, rates are between 32% and 50% for females using violence and between 20% and 32% for males. Three percent of female college students admit to injuring their boyfriends; 7% of males admit to injuring their girlfriends.
Guns are unsafely designed, so that anyone who borrows or steals a gun can easily fire a lethal cartridge. User specific guns (guns that cannot fire unless the owner gives permission), while feasible, are not part of the 50 million handguns now in circulation in the United States.
B. Etiology/contributing factors.
1. Environmental. A host of environmental factors have been shown to contribute to violent behaviors in children and adults: a cold, inconsistent child-rearing style; the experience of child abuse; excessive corporal punishment; witnessing violence in the home and community; viewing media violence; coping with socioeconomic disadvantage; and the use of alcohol and other drugs. Equally important, the presence of a gun can turn a violent impulse into a lethal event.
Environmental factors can also protect from violence. School success, having an adult from outside the family interested in the success of the child, having a feeling of connection to something bigger than they are that is positive—such as nature, humanity or the divine are all protective.
2. Developmental. Constant exposure to environmental violence in an infant and young child can create a disconnected, hypervigilant style of relating to adults and peers. Witnessing violence in the home, neighborhood, and television teaches children that the “best” way to solve conflict is through violence. Some parents actively teach their children to use violence to resolve conflicts. Violent individuals tend to believe that violence is the preferred way to handle most conflict. They tend to experience the world as harsh and interpret ambiguous situations as laden with hostility. They view people as either victims or bullies and have few nonviolent strategies for resolving potentially violent conflicts. Many have an impulsive style of acting when assessing the situation or the consequences of their actions.
Nonviolent teenagers experience the world as a neutral or positive place. They believe themselves to be of high value and think even potentially violent opponents are of high value. In a potentially violent conflict, they are not impulsive; they ask questions of their opponents, state their own positions, and offer to work out compromises. Their response to conflict is respectful, deliberate, and not impulsive. They feel connected to realms that are larger than they are that are positive—such as nature, humanity or the divine.
II. Making the Diagnosis.
A. History: Key clinical questions. The goal of the history is to assess the risk that the child is or will become violent. As in other aspects of clinical care, the best way to determine the risk for violence is to ask directly about violence in the home, disciplinary techniques,
violent encounters in the community, and personal behaviors and attitudes. Clinical judgment must be exercised in pursuing these lines of questions; there is no need to ask all the questions at each visit or for every patient.
1. For parents.
a. Spousal abuse.
(1) “How do you and the baby’s father get along? How often do you have yelling or screaming fights? How about pushing or shoving fights?” If answers are negative, no other questions are necessary. At subsequent visits, the clinician can inquire about how the couple is getting along.
(2) “Any injuries? What was it about? Tell me about your worst fight. Tell me about your last fight. Are you afraid? Are you safe now? Do you know what to do if you are not safe? Is there a gun in the house?”
b. Gun in the house.
“Is there a gun in any place where your child spends time? What kind? What is it for? Is it loaded? Is it locked up?”
c. Discipline.
“How do you correct the child if he or she slaps or bites? For an older child, how do you correct your child if he or she misbehaves?”
d. Attitudes toward violence.
“If a child tries to pick on your child, what do you think your child should do?”
e. Street fighting.
“How many fights has your child had in the last year? What were they about? What did you do about it?”
2. For older children and teenagers: The FIGHTS pneumonic.
F—Fights
“How many pushing or shoving fights have you had in the last year? What were they about? How do you usually get out of a fight?” Assess their nonviolent coping skills.
I—Injuries
“Was anyone injured in any of these fights?”
G—Guns
“Is there a gun in your home? Possibly did you ever carry a weapon for self-protection?”
H—Home
“Has anyone hit you at home in the last year?”
T—Threats
“Have you ever been threatened with a weapon?”
S—Sexual violence
“Have you ever had a pushing or shoving fight with a boy or with a girl?”
“Have you ever been forced to have sex against your will?” (As part of the sexual history.)
B. Assessing the risk for violence. In all areas, consider patients and their families on a continuum. They are at small risk, moderate risk, or severe risk for spousal abuse or street violence.
III. Management.
A. Primary goals.
1. To teach beliefs and skills that enhance the child’s ability to respond to stress and perceived threats in a nonaggressive way.
2. To help parents and patients incorporate nonviolent behavior as an integral part of their self-image.
3. To decrease the environmental factors that increase violence.
B. Initial treatment strategies.
1. Intimate partner violence. Pediatric clinicians need basic screening skills for intimate partner violence because medical professionals may be the only adults outside the family who have any contact with a coerced or battered parent.
The ideal clinical practice has set up a 24-hour referral service, where a trained mental health clinician can do an in-depth assessment and/or intervention after a medical clinician screens for and discovers intimate partner violence. Large medical practices can set up in a house on call schedule. A time-limited task force with professionals from mental health, pediatrics, internal medicine, OB/GYN (obstetrics/gynecology), urgent care, security, support services, and human resources can plan and implement a sensible screening and referral network. Human resources is essential so that all employees get basic intimate partner violence training; people with any patient contact get more training. Clinicians get more training, and the mental health staff that will do the deeper assessments, interventions and referrals can get intensive training. Smaller practices need to make a relationship with a mental health group or urgent care center who can help with subacute and acute assessments.
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