Violence-related medical visits open the door for early intervention

Between cases of family maltreatment, peer assault, sex crimes, and community violence, kids and teens experience high rates of assault and violence, prompting visits to health professionals, emergency departments (EDs), pediatricians, family physicians, and social health services, David Finkelhor, PhD; Heather Turner, PhD; and Deirdre LaSelva, MA, of the University of New Hampshire, explained in JAMA Network Open. And, they added, if these visits are properly managed, they can be used to facilitate interventions with children at high risk for additional violence exposures that can potentially reduce the physical and mental toll of not only the current exposure, but also future exposures. The researchers used nationally representative data to characterize the size and characteristics of kids and teens seeing medical professionals after experiencing different forms of violence.

Surveying Children & Their Caregivers About Violence Exposure

For their survey study, Dr. Finkelhor and colleagues used data from two waves of the National Survey of Children Exposed to Violence (2011 and 2014) for children and teens aged 2-17. Interviews were conducted over the phone with the child’s caregiver if the children were 9 or younger; participants aged 10-17 were interviewed directly. The study authors evaluated violence exposures with the 53-item Juvenile Victimization Questionnaire, “which had follow-up questions that asked about injury and going ‘to the hospital, a doctor’s office, or some kind of health clinic because of what happened,’” they explained. They also asked questions about lifetime and past-year childhood adversities and current trauma symptoms using the Trauma Symptom Checklist and the Trauma Symptom Checklist for Young Children. The combined two-survey sample consisted of 8,503 children (54.0% aged 2-9; 46.0% aged 10- 17; 51.2% male), among whom 5,187 reported a lifetime violence exposure (45.6% aged 2-9; 54.4% aged 10-17; 53.6% male).

1.4 Million With Violence-Related Medical Visits

Among the whole sample, 3.4% had a violencerelated medical visit at some point in their lives, the study authors found. The rate for these medical visits in the past year was 1.9%, which equated to a point estimate of approximately 1.4 million kids and teens with violence-related medical visits in the United States during a 12-month period. Of those with medical visits, 33.3% were aged 2-9.

The authors noted that 71% of visits were for peer violence and 23% were for sexual assaults, while parental child maltreatment comprised 1% of the total. Sexual assaults by adults were the type of exposure most likely to result in a medical visit (20%), and police knowledge of the exposure and teacher awareness were both associated with increased likelihood of a medical visit. Notably, while most of those with medical visits reported injuries, 14% did not. “This group was too small for separate analysis, and no details were gathered about what prompted the visits among the non-injured,” they wrote. “They could have involved matters like forensic documentation, assessment for possible injuries that were not confirmed, and seeking medical consultation about mental health and psychosocial issues.”

Dr. Finkelhor and colleagues also found that kids and teens with medical visits in the past year had higher levels of general vulnerability: “In the medical visit group, 28% had high levels of trauma symptoms, 87% had high adverse childhood experience scores, and 41% had unusually high levels of different kinds of violence exposures (poly victimization),” they wrote. “The risk ratio for these vulnerabilities in the medical visit group (in comparison with the other children in the sample) was 1.71 for trauma symptoms, 2.55 for high adverse childhood experiences, and 3.9 for poly-victimization.”

This finding of 1.4 million children and youth visiting medical professionals during 1 year for help related to a violence exposure “is larger than estimates based on hospital ER visits, and likely reflects in part the reality that non-ER health settings receive considerable usage from violence-exposed children and youth,” wrote the study authors. “These non-ER settings may include urgent care facilities, private practices, and the offices of school health personnel. Whereas hospital ER studies generally focus on adolescents exposed to violence, perhaps assuming them to be the high-risk group, the present study revealed considerable use by children aged 2-9. It is important that studies of medical response to crime, violence, and abuse recognize the full developmental spectrum of exposures.”

Laudable Goals

In an invited commentary accompanying the study, Howard Dubowitz, MD, MS, of the University of Maryland School of Medicine, acknowledged that the potential roles for healthcare professionals outlined in the study are “laudable goals;” however, he argued that there are “important questions as to whether medical professionals and systems are adequately equipped to play this expanded role… Beginning with medical education and training, relatively little attention is typically devoted to topics such as bullying, sexual assault, or assessing family relationships. Increased and creative efforts are needed to help medical professionals be competent and comfortable addressing such issues.”

He added that there are practice constraints— particularly time pressures and limited resources— and financial barriers that may impede progress in this area, though he noted that developments such as increased interest in integrated behavioral health, embedded care management, and the trend toward fee-for-value reimbursement may be helpful in this area.

Important Considerations

The study authors argued that the considerable amount of violence-related medical visits in this age group opens the door for possible early interventions, adding that typical assessments should include evaluations of signs of “emotion dysregulation and symptoms that may be putting the youth at risk, problems in the parent-child relationship that are preventing adequate supervision, or ineffective or abusive behavioral management.” And, they added, practitioners should be prepared to provide information about access to prevention education skills training, and health facilities should staff adequately trained behavioral health and social work professionals to facilitate evaluations and referrals.

Dr. Finkelhor and colleagues acknowledged that the medical care visits reported in their study represent a small portion of kids exposed to violence; however, they noted that “they include many of the most serious exposures and most vulnerable children—sexual assaults, kidnappings, gang assaults, and aggravated assaults. They also disproportionately include children with high levels of previous violence exposure, children with many childhood adversities, and children manifesting mental health symptoms.” They concluded that kids and teens who have medical visits for violence-related causes are a high-risk group. “Almost half have had multiple different kinds of other violence exposures,” they wrote. “More than half had an extreme history of [adverse childhood experiences] more generally. Almost a third had clinical levels of trauma symptoms. This means they are a population in need of more than simple treatment or documentation of injury.”

Study limitations include relying on caregiver reports for children younger than 10, which may have led to underreporting, particularly in cases of parental child maltreatment; the omission of children younger than 2; the potential for memory distortion of violence-related events occurring in the past; and limited information on details of the medical visits or the seriousness of the injuries.