Epidemiology

In 2006, homicide in the USA was the second leading cause of death for 10-24 yr olds totaling 5,958 deaths, which were largely males (87%) killed by a handgun (84%) in a gang-related incident (Table 107-1). The WHO reports that other than the USA, where the youth and young adult homicide rate was 11 per 100,000, most countries with homicide rates above 10 per 100,000 are developing nations or countries with rapid socioeconomic changes. However, while rates of violent deaths among adolescents are higher in the USA compared to other developed countries, rates are increasing; in Israel, France, and Norway, firearms are the second leading mechanism of death in 15-24 yr olds. Although the prevalence of behaviors that contribute to violence has decreased from 1991 to 2007, fighting and weapon carrying remain prevalent among U.S. youth (Table 107-2). In 2007, 668,000 youths were treated in U.S. emergency departments for violence-related injuries such as stab wounds, gunshot wounds, broken bones, and lacerations. The rate of homicide by handgun is considerably higher than homicide by other weapon type, suggesting that access to firearms may play a major role in youth injuries and deaths (Fig. 107-1). A cross-sectional, nationally representative survey of ~21,000 youth at ages 11.5, 13.5, and 15.5 yr in 5 countries (Ireland, Israel, Portugal, Sweden, and the USA) revealed that the rates of fighting, weapon carrying, and fighting injury were similar among the countries while bullying frequency varied widely, from 15% in Sweden to 43% in Israel (Table 107-3).

Figure 107-1 Number of victims of homicides by weapon type, 1976-2005.

(From U.S. Department of Justice, Office of Justice Programs, Bureau of Justice Statistics: Homicide trends in the U.S. www.ojp.usdoj.gov/bjs/homicide/teens.htm. Accessed June 2009.)

Violence at schools in the USA and elsewhere remains a significant problem with 12.4% of students reported being in a fight on school property in the preceding 30 days. The 2007 Youth Risk Behavior Surveillance System reported 18% youths overall carried a weapon such as a gun, knife, or club in the last 30 days; 6% carried the weapon to school; and 8% reported being threatened or injured with a type of weapon on school property. Males are more likely than females to carry a gun or weapon and therefore may need increased monitoring at home and at school. Physical fighting remains prevalent at schools; 12.4% of students report having been in a physical fight on school property in the preceding 12 mo. These violence-related behaviors at school affect the students’ perception of safety. Five percent of students did not go to school on 1 or more days in the preceding 30 days because they felt it unsafe at school. Dating violence (having been hit, slapped, or physically hurt intentionally by a boyfriend or girlfriend) is reported by 9.9% of students, with highest prevalence rates seen in African-American students (14.2%) and older students (10.6%, 11th graders; 12.1%, 12th graders). School-based prevention programs initiated at the elementary school level have been found to decrease violent behaviors in students. Increased surveillance of students is warranted both on and around school property to improve student safety.

Advancements of technology are being used by youths as a vehicle to inflict aggression of a different nature. The Centers for Disease Control and Prevention (CDC) defines electronic aggression as any type of harassment or bullying (teasing, telling lies, making fun of someone, making rude or mean comments, spreading rumors, or making threatening or aggressive comments) that occurs through e-mail, chat rooms, instant messaging, blogs, test messaging or videos or photos posted on a website or sent via cell phone (Chapter 36.1). In 2005, 9% of youth surveyed reported being a victim of online harassment via instant messaging (67%), e-mail (24%), and text messages (15%). Of the youth surveyed, 7-14% reported being both a victim and a perpetrator, suggesting that there is a related behavioral link between the 2 roles.

Parents can provide the primary prevention with filters on the home computer, increased monitoring of their teen’s use of electronic interactions, and setting limits on texting and instant messaging. Many schools have established cyber-bullying policies and are increasingly involved with teaching youth about guidelines for appropriate online interactions, and monitoring for cyber-bullying problems. About 12 states have enacted legislation that allows schools to take action in response to electronic aggression or cyber-bullying against a student, whether it takes place on or off school grounds.

Etiology

The WHO places youth violence in a model within the context of 3 larger types of violence: self-inflicted, interpersonal, and collective. Interpersonal violence is subdivided into violence largely between family members or partners and includes child abuse. Community violence occurs between individuals who are unrelated. Collective violence incorporates violence by people who are members of an identified group against another group of individuals with social, political, or economic motivation. The types of violence in this model have behavioral links, in that child abuse victims are more likely to experience violent and aggressive interpersonal behavior as adolescents and adults. Overlapping risk factors exist for the types of violence, such as firearm availability, alcohol use, and socioeconomic inequalities. The benefit to identifying common risk factors for the types of violence lies in the potential for intervening with prevention efforts and gaining positive outcomes for more than one type of violent behavior. The model further acknowledges 4 categories that explore the potential nature of violence as involving physical, sexual, or psychologic force, or deprivation.

There may be 2 types of antisocial youths: one that is life course persistent and one that is life course limited. Adolescent-limited offenders have no childhood aberrant behaviors and are more likely to commit status offenses such as vandalism, running away, and other behaviors symbolic of their struggle for autonomy from parents. Life course–persistent offenders exhibit aberrant behavior in childhood, such as problems with temperament, behavioral development, and cognition; as adolescents they participate in more victim-oriented crimes. The public health model emphasizes the environment and other external influences. A 3rd theoretical model examines violent behaviors across the spectrum occurring within and outside the family and is referred to as the cycle of violence. This hypothesis proposes that precursors such as child abuse and neglect, a child witnessing violence, adolescent sexual and physical abuse, and adolescent exposure to violence and violent assaults predispose youths to outcomes of violent behavior, violent crime, delinquency, violent assaults, suicide, or premature death. An additional common paradigm for high-risk violence behavior poses a balance of risk and protective factors at the individual, family, and community levels. None of these theories successfully explains interpersonal or self-inflicted violent behavior. Although the media influence violence through a modeling effect on aggressive behavior, many questions still remain about the causes of violent behavior.

Clinical Manifestations

There are several identified risk factors for youth violence, including poverty, association with delinquent peers, poor school performance/low education status, disconnection from adult role models or mentors, prior history of violence or victimization, poor family functioning, childhood abuse, substance abuse, and certain mental health disorders. The most common disorders associated with aggressive behavior in adolescents are mental retardation, learning disabilities, moderately severe language disorders, and mental disorders such as attention-deficit/hyperactivity and mood disturbances. Of note, the link between severe mental illness and violent behaviors is most strongly linked for those with co-occurring alcohol or substance abuse or dependence.

Inability to master prosocial skills such as the establishment and maintenance of positive family and peer relations and poor resolution of conflict may put adolescents with these disorders at higher risk of physical violence and other risky behaviors. Conduct disorder and oppositional defiant disorder are specific psychiatric diagnoses whose definitions are associated with violent behavior (Table 107-4). They occur co-morbidly with other disorders such as attention-deficit/hyperactivity disorder and increase an adolescent’s vulnerability for juvenile delinquency, substance use or abuse, sexual promiscuity, adult criminal behavior, incarceration, and antisocial personality disorder. Other co-occurring risk factors for youth violence include use of anabolic steroids, gang tattoos, belief in one’s premature death, preteen alcohol use, and placement in a juvenile detention center.

Table 107-4 OPPOSITIONAL DEFIANT DISORDER, CONDUCT DISORDER, AND JUVENILE DELINQUENCY

From Greydanus DE, Pratt HD, Patel DR, et al: The rebellious adolescent, Pediatr Clin North Am 44:1460, 1997.

Diagnosis

The assessment of an adolescent at risk, or with a history of violent behavior or victimization should be a part of the health maintenance visit of all adolescents. The answers to questions about recent history of involvement in a physical fight, carrying a weapon, or firearms in the household, as well as concerns that the adolescent may have about his or her personal safety may suggest a problem requiring a more in-depth evaluation. The FISTS mnemonic provides guidance for structuring the assessment (Table 107-5). The additional factors of physical or sexual abuse, serious problems at school, poor school performance and attendance, multiple incidents of trauma, substance use, and symptoms associated with mental disorders are indications for evaluation by a mental health professional. In a situation of acute trauma, assault victims are not always forthcoming about the circumstances of their injuries for fear of retaliation or police involvement. Stabilization of the injury or the gathering of forensic evidence in sexual assault is the treatment priority; however, once this is achieved, addressing a more comprehensive set of issues surrounding the assault is appropriate.

Treatment

In the instance of acute injury secondary to violent assault, the treatment plan should follow standards established by the American Academy of Pediatrics model protocol, which includes, but is not limited to, the stabilization of the injury, evaluation and treatment of the injury, evaluation of the assault circumstance, psychologic evaluation and support, social service evaluation of the circumstance surrounding the assault, and a treatment plan on discharge that is designed to protect the adolescent from subsequent injury episodes and minimize the development of psychologic disability. Victims as well as witnesses of violence are at risk for post-traumatic stress disorder, and future aggressive and/or violent behavior.

Multiple treatment modalities are used simultaneously in managing adolescents with persistent violent and aggressive behavior and range from cognitive-behavioral therapy involving the individual and family to specific family interventions (parent management training, multisystemic treatment) and pharmacotherapy. Treatment of existing co-morbid conditions such as attention-deficit/hyperactivity disorder, depression, and substance abuse appears to reduce aggressive behavior.

Prevention

The WHO report recognizes a multifactorial approach to prevention: individual approaches, relationship approaches, community approaches, and societal approaches (Table 107-6). Individual approaches concentrate on changing attitudes and behaviors to avoid aggressive and violent behavior as well as teaching coping strategies and nonviolent conflict resolution for all children as well as youths who have already displayed some violent tendencies. Relationship approaches focus more on victims, families, and peer relationships, especially those with the potential to trigger aggressive or violent responses. Solutions include improving skills in coping or problem solving in recent perceived crises, interpersonal conflicts, and close relationships. Family-based programs provide training for parents in areas of effective communication, child development, and solving problems in nonviolent methods. Community-based approaches raise public awareness in an effort to stimulate action by community members to reduce violence and protect vulnerable community members. Universal school-based violence prevention programs have been found to be effective in reducing violent and aggressive behaviors. Interventions beginning as early as preschool have been found to have positive outcomes years later. Societal approaches include broader advocacy and legislative actions, as well as changing the cultural norm toward violent behaviors. A specific prevention strategy can incorporate several approaches, such as the handgun/firearm prevention recommendations that include gun-lock safety, public education, and legislative advocacy. Other efforts are directed toward establishing a national database to track and define the problem of youth violence. The National Violent Death Reporting System (NVDRS) collects and analyzes violent death data from 17 states and aims to improve surveillance of current trends, to share information state to state, to build partnerships among state and community organizations, and to develop and implement prevention and intervention programs. Ultimately the NVDRS will be expanded to include all 50 states. The CDC characterizes specific successful programs and summarizes program content on its website (www.cdc.gov).