How One Hospital Is Addressing Youth Violence

Robert Glatter, MD; Joel A. Fein, MD, MPH


August 07, 2017

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Robert Glatter, MD: Welcome. I'm Dr Robert Glatter, assistant professor and attending physician in the Department of Emergency Medicine at Lenox Hill Hospital in Northwell Health.

Hundreds of thousands of injured youth are treated annually in the emergency department across the United States as a result of violent acts. Violence can have long-term consequences, with physical and emotional effects that may linger for years after the actual violence occurs.[1]

The Violence Prevention Initiative at Children's Hospital of Philadelphia (CHOP) is an evidence-based effort to protect youth from violence. In 2015, there were 280 people murdered in Philadelphia, according to data from the Philadelphia Police Department.[2] Of these victims, 47% were youths aged 24 and under. In 2015 alone, CHOP treated nearly 500 assault-injured youth in the CHOP emergency department and trauma unit.[3] CHOP's program is one of more than 30 member programs in the National Network of Hospital-based Violence Intervention Programs.

Joining us to discuss this initiative is Dr Joel Fein, an attending physician in emergency medicine and codirector of the Violence Prevention Initiative at CHOP. Welcome, Dr Fein.

Joel A. Fein, MD, MPH: Thank you.

Dr Glatter: I want to start off with talking about how violence is truly a public health problem, and not so much an issue of the criminal justice system. I want to get your thoughts on that as we begin our discussion.

Dr Fein: We have always framed violence in our world as a public health problem. What we've realized is that it may be even better framed as a health problem. Because it is something that we know, as you mentioned, affects physical health—but even the emotional effects affect long-term health. We know that the impact of stress on health is significant, and violence is one of the major stressors in kids' lives.

Dr Glatter: Let's jump in and start discussing some of the initiatives that you've developed in your program, and the framework behind these.

Dr Fein: The Violence Prevention Initiative is actually a compendium of programs at CHOP. We look at the problem of violence, like other health issues and public health issues, as something that requires multiple touch points and multiple tiers of intervention.

At the very earliest stages of childhood, you can imagine that violence in the home is one aspect of stress and impairment that kids can experience, even from infancy. We developed a screening program through our partnerships in the community, with such places as Lutheran Settlement House and others, to screen for domestic violence in our emergency department. That is one early touch point.

Then in school, as kids get out into the real world, they experience bullying and school violence. We also have a whole school program for bullying prevention, as well as some very highly technical approaches to bullying prevention in the schools.

Finally, in adolescence, we know that schoolyard fights and/or community fights can get incredibly violent and possibly fatal. We also have, for the most intensive high-risk kids, the Violence Intervention Program that you've mentioned. That is one of the national models for violence prevention in kids who are already assault-injured.

They are already at high risk; they've already experienced it, and then we have to wrap around them and provide them with the most support that they can get together with their families to prevent that next injury. We know there is up to a 40% chance of another assault or injury occurring.[1]

Dr Glatter: I think the data are staggering when you look at the chance for recidivism and patients who are treated initially in your department, and then that potential for them to have another injury or even be the victim of a homicide within the next 5 years.[4,5,6] Some of the data are pretty compelling.

Dr Fein: They are. I think one of the things that we have to think about is the fact that the risk for violent injury is higher. Also, the risk for psychological and emotional injury can lead to a fairly dysfunctional life if the child is not surrounded and supported by people who care, with caring adults in their home, their school, and their community. However, there's a potential for amelioration of that; I don't want to think that it's fatalistic and that we are a lost cause here.

Dr Glatter: Could you go through some of the screens that you use in your emergency department that have formed part of your published research?[7]

Dr Fein: As we mentioned, adolescence is a fairly high-risk time for experiencing violence, but we also know that there are many other mental health and behavioral issues that can occur during that time period. We—myself and someone who is now at Drexel [University]—developed a Behavioral Health Screen for the emergency department through our partnership with a company called mdlogix (Medical Decisions Logic, Inc.).

Every adolescent 14 years of age and above is eligible to receive a computerized screen that is set up by a nurse. All the nurse has to do is click a button, let the kid finish the screening, and then click another button, and the results are sent to the doctor or nurse practitioner who's caring for that patient. We ask about depression, suicidality, posttraumatic stress, exposure to violence, and substance use.

We also have—because we are a children's hospital emergency department, as many do—social workers and other support systems that can help if we need it. This is meant for every adolescent, not just for the ones coming in with complaints of mental health issues or behavioral issues. Because we know that especially for the internalizing disorders, such as suicide and depression, we wouldn't be finding these unless we were asking.

Dr Glatter: There's an additional screen, I believe: the fight screen that assesses the risk for retaliation. How does that work into your assessment?

Dr Fein: We ask the adolescent during that computerized screening tool whether or not they're there because of an injury that someone else caused, specifically a fight. If they confirm this is the case, then we go on, and the screening tool drops down into a menu of questions around what their intentions are; whether they feel safe; and whether the police were called, because that's a protective factor if somebody involved the police. If so, they're less likely to take retaliation into their own hands.

We developed these five or six questions so that we can reduce the risk for reinjury once they leave the emergency department. That "treat and street" mentality really has to be discarded, because these are the kids who are at highest risk, especially within the next 4 weeks, and we've shown that to be the case.[1]

Dr Glatter: What are the main reasons that children carry guns?

Dr Fein: I've been able to participate in research. One of my colleagues, Dr Ruth Abaya, and I have looked at qualitative research asking kids when they answer that question on the screen. If they reply yes, they have access to a gun or they have a gun in the home, we then ask them why they would carry it. Almost all of them actually say that it's for safety reasons—that they needed to have it or they needed to get it, [and] they would only get it to protect themselves.

Dr Glatter: How can you break this cycle, knowing that they want it for protection?

Dr Fein: In my own practice, if I learn that the child has a gun and that they got it for protective reasons or they would access one for that reason, I talk to the child a little bit. We play out the questions¾"What happened?" and the "What ifs?" I give them an example, and this is again from my colleague, who teaches this all the time.

We say, "Well, if you're carrying a gun and somebody knows you're carrying a gun, what do they have to do?" If they don't think you're carrying a gun, they can actually overcome you without lethal force. If they know you're carrying, they have to kill you. There's no choice for that assailant. In effect, what we do know is that we play it out in their mind and let them march through the steps of what would happen "if, if, if"—not everybody gets to do that.

Not every adolescent responds to this approach, but it's at least an attempt on our part as clinicians to take the 1 or 2 extra minutes to really walk a kid through what the consequences are of carrying versus not carrying.

Dr Glatter: Do you see your program as mostly an urban-based program, or does it have applicability out in the community or even rural settings?

Dr Fein: I think for the work that we're doing specifically around bullying and suicide prevention, absolutely, there is a universal application. No one in a community would say that there's no bullying occurring if they are looking in the right place. We know that suicide is actually very high per capita in rural areas. Suicidal screening and that kind of intervention is really applicable almost everywhere.

Dr Glatter: Clearly, school performance is one aspect that's affected when you have a child who's been injured in such a violent way. Are there specific measures you use that continue to integrate the child back into school?

Dr Fein: The violence prevention specialists in our Violence Prevention Initiative program and many others around the country work with schools, counselors, principals, and teachers to help the child reintegrate back into the classroom.

This is important for students who have special needs, for example—when they have concussions or special needs because they're just so traumatized. Even going to school, by getting out in the street, walking to school, and getting back to their daily activities, is a huge stressor for that child. We do actually work directly with schools as well as families. Importantly, one of our goals is to work with the family to show them how you navigate a system such as this, because we're not there forever.

When something else happens or this violence continues, we really have to think about building the capacity within that family to make sure that they can handle it when we're not there.

Dr Glatter: Do you continue the interface with social workers or counselors within the school system for years to come?

Dr Fein: We have spent much more than 6-9 months with families, especially if we're involved with school systems or court systems and justice systems. In general, we try and keep our involvement to between 3 and 9 months, mainly because, as we mentioned, there are 500 kids a year coming into our emergency department.

Dr Glatter: Talking about cost, if a university or academic program or community hospital wants to develop a violence intervention program, what are the costs involved? Are we talking in the millions of dollars range?

Dr Fein: The cost of these programs, specifically for the violence intervention programs, depends on the length of treatment time and the number of kids whom you're seeing. At the very least, a full-time violence prevention specialist plus a coordinator would require probably in the hundreds of thousands a year—maybe $100,000-$200,000 a year in salaries and support.

If you're adding people—we're lucky enough to have three violence prevention specialists—then you can imagine you are adding salaries to that. It's mostly people time I'm talking about, and the training that these folks have is really worthwhile. It's a very trauma-informed social work-type approach.

Dr Glatter: Do you find that victims of violence in general develop posttraumatic stress or disorder (PTSD) or anxiety on a large scale, or do you find that that's rare?

Dr Fein: Actually, PTSD is pretty common. The question is what they had before they came in, but in fact, we do note that their posttraumatic stress symptoms are pretty high as we're seeing them, because we do a scale called the PTSS. We actually are currently trying to fund a short PTSD prevention therapy for our violently injured kids and are looking at whether we can reduce the PTSS or posttraumatic stress symptoms in those kids over time.

Dr Glatter: For children who are unable to actually see a provider, is there any thought to using text-based messaging as a way to intervene and get them involved when they are at risk and are thinking about committing crimes?

Dr Fein: I think that the text-based messaging has to be paired with a support system, and there are people who are using that for suicide prevention. I think the jury is still out as to what capacity that can afford an institution that really doesn't have the people to do the counseling. Yes, it's a possibility. I don't think we have enough evidence about it yet to say that it's an absolutely successful program.

For violence prevention, it's a little more complicated, and what we find is that the kids who come in assault-injured—their problem list can be very long. It could encompass the school, the criminal justice system, and the family—all of those things—and it's really hard to handle that selectively in a text-based messaging program. I'm not saying that it can't be done; it hasn't quite been shown yet.

Dr Glatter: Would you like to add any other information to our discussion?

Dr Fein: Yes. I think the other aspect of it is that we shouldn't as emergency physicians be scared of asking these questions. If you think about it, when we send someone home and we're missing their most significant diagnosis, and we're missing the most significant problem, all of us in the medical world would say, boy, we've really lost something there.

In fact, the role of the emergency physician is to find out what's going to hurt this patient when they leave my emergency department. Even though it's hard, there are ways we have of building that kind of push button that emergency doctors want. This is the way the computers are going to ask the question. I'm going to see the answer, and then I'm going to push another button to get some help.

It really is that kind of identification, assessment, and referral that we're all used to. It's just a matter of building that system and having a few people spend the time to build that system around us.

Dr Glatter: I want to thank you so much for your time and bringing us some information about this important program that you're doing at CHOP.


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