Youth Violence Preventation and the Role of the Physician

Youth Violence Preventation and the Role of the Physician

Case Study

Case: Thomas
Age: 16 years old
Grade: 11th grade
Problem: Firearms and Violent Environment

This morning, Thomas, who is 16 years old, was caught carrying a gun onto his high school campus. The campus police were called and Thomas explained to them that he brought the gun from home and is carrying it for "protection." There has been an increase in violence in the community surrounding the school and Thomas looks nervous when describing his recent encounters with some gang members at the school. Until now, Thomas has been doing fairly well in school. He is making Bs and Cs in his classes and talks about enrolling at the local community college after he graduates to study computers. He is popular with his peers, but several of his teachers are concerned about his friendships with several youths whom they believe to be active in a local gang.

Thomas has a close relationship with his mom and younger brother. Thomas' father no longer lives with them. When he did, he was distant and occasionally was physically abusive to Thomas' mother. There have been several shooting incidents and robberies in Thomas' neighborhood in the past year, and because of this Thomas' mother keeps a loaded gun in the home for self-defense. She keeps the gun hidden under her sweaters in her closet and believes that, "Thomas will never find it there." To be certain, she has instructed Thomas never to touch a gun if he ever finds one.

Because Thomas has no previous criminal record and no gang affiliation, he spends minimal time in custody and is released to his mother. The school suspends him for a period of time. During his suspension, Thomas and his mother will begin a life skills training program at the local Boys Club. They will also see a trained counselor for family therapy, who will use a multi-systemic therapy approach. At the end of the suspension period, Thomas will complete the school year at the Alternative Learning Center adjacent to the school.

Discussion Questions:

• What factors place Thomas at risk for becoming involved in serious violence?
• What elements in Thomas' life can help protect him against involvement in serious violence?
• What can you do to help Thomas and his family?

* Excerpted from Knox, L. Connecting the Dots to Prevent Youth Violence: A Training and Outreach Guide for Physicians and Other Health Professionals. Chicago, IL: American Medical Association; 2002.

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1. What factors place Thomas at risk for becoming involved in serious violence?
   
   The presence of a firearm in the home and failure to store it properly. A major risk factor for Thomas and for his younger brother is the presence of a firearm in their home. Guns in the home are much more likely to be used in a suicide attempt or to intimidate family members than in self-defense against an intruder.1, 2
   
   To increase the risk further, Thomas' mother does not use safe storage procedures. Instead of storing the ammunition and firearm in separate locked containers, having the only set of keys that she keeps inaccessible to others, or using a safety device such as a trigger lock to secure her gun, Thomas' mother keeps the gun loaded, unlocked, and believes her children will not touch it if they find it.
   
   Young people often do not adhere to parental prohibitions to not touch a gun. In fact, these prohibitions may make a young person even more likely to handle a gun because of the attraction of the "forbidden." A recent study of young people's behavior around guns found that 76% handled a hidden gun they "discovered" despite prior instructions from their parents not to touch guns.3 It is interesting and disturbing to note that most young people caught with guns report they got the gun from their home or from friends.4
   
   Exposure to violence in the home. There is a close relationship between violence in the home and youth violence, what one might describe as a "cycle of violence." From an early age, Thomas has watched the adults in his life use violence to "solve" their problems. Research suggests that violence is learned, learned early, and often learned in the home.5 Children who witness violence in their homes may come to believe that it is acceptable and even necessary to use violence to solve problems with others.6 In addition, Thomas' early exposure to violence and traumatic stress may have affected his brain chemistry, making him more susceptible to depression and problems with impulse control.7
   
   Living in a distressed community. Thomas lives in a community that is distressed, a place where violence is common and gangs are evident. Young people who live in communities like Thomas' and who are involved with street gangs, whether voluntarily or involuntarily, are at greater risk both for becoming the victim of violence and for becoming a perpetrator.8
   
   Peer group. During adolescence, young people are influenced by the behavior of their peers. In fact, many researchers believe that at this stage, young people are more influenced by their peers than by the adults in the their lives.7 Young people whose friends are involved in gangs or other high-risk activities, are more likely to engage in these high-risk activities themselves.9 Several of Thomas' friends are involved in gangs, which engage in high-risk behaviors that are frequently violent. His association with these individuals increases the risk that Thomas will become involved in the high-risk behaviors, including violence.
   
   The influence of peers is also an important factor to consider when Thomas returns to school. Being placed in an alternative learning center may actually increase Thomas' exposure to peers who engage in high-risk behaviors and could increase his risk for involvement in serious violence. The pros and cons of such a placement, especially given the fact that this appears to be Thomas' first offense, should be carefully evaluated.
   
   The role of younger siblings. It is important to note that many of the factors that place Thomas at risk increase risk for his younger brother as well. When addressing Thomas, it is also important to consider risk reduction for the younger brother.
   
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2. What elements in Thomas' life may help protect him against involvement in serious violence?
   
   While there are many risk factors for violence in Thomas' life, there are a number of important protective factors as well
   
   Positive experiences in school and future orientation. Thomas has dreams and plans for the future (a future orientation) and a commitment to education, both of which have been proven to protect young people against involvement in violence and other high-risk behaviors.4 This is a personal resource that Thomas, you, and others in Thomas' life can build on to reduce the chance he will become involved in serious violence.
   
   Strong relationship with an adult figure. Thomas has a close and positive relationship with his mother. Young people who have a strong relationship with a parent or another responsible adult are significantly less likely to engage in high-risk behavior, including violence, than those who do not.8 While it is unclear from the case description just how responsible Thomas' mother actually is, her presence at the school and obvious concern for Thomas are good signs. Thomas' mother and his strong connection with her are resources you can build on to reduce the likelihood of his involvement in serious violence.
   
   Access to effective violence prevention services. Finally, Thomas and his problems have come to the attention of his school and the local authorities. As a result, both he and his family have been referred to mental health and supportive services in the community. The recent Surgeon General's report on youth violence lists a number of interventions that have been proven to be effective in preventing violent behavior among youth. Life Skills Training programs and Multisystemic Therapy are included on the list of programs that are effective in preventing youth violence.9 It is important to note that other popular types of interventions, including boot camp, residential treatment, and peer counseling, have not been found to be effective in reducing risk. It will be important to learn more about intervention methods used in the alternative learning center to ensure that they are consistent with "model" and "promising" programs described in the Surgeon General's report.9
   
   Important note about his brother: Again, many of these resources and protective factors will apply to Thomas' younger brother too. Also, although it is unclear from the case study whether Thomas is close to his younger brother, encouraging him to be a good role model for his brother can be a strong motivator for change for older siblings.
   
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3. What might you do to help Thomas and his family?
   There are many things that a health professional, Thomas' mother, Thomas, and others can do to help:

For health professionals:10, 11

History and screen

• Take a violence history on Thomas and his family that addresses exposure to violence, safety/security issues, effects of trauma, attitudes toward weapon carrying, and stressors in the family and the community.
• Document history of family violence in the medical record.
• Screen Thomas and his family for access to firearms and use of safe storage procedures.

Patient education

• Encourage Thomas' mother to remove firearms from the home. If she insists on keeping a gun in the home, strongly encourage her to take a training course on the safe handling, storage, and use of this weapon.
• Educate Thomas and his family on firearm safety and work with them to develop a safety plan. Provide them with educational materials on safe firearm storage such as the American Academy of Pediatrics patient brochure, Keeping Your Family Safe from Firearm Injury.12 Counsel Thomas' mother and the family to ask about gun possession and storage in other homes that Thomas and his brother visit, and ask the adults in these homes to consider removing the guns from their homes or using safe firearm storage procedures.
• Discuss Thomas' concerns about his safety, and work with him to make a plan to increase his safety from gangs and other violence-related threats in his community and school.
• Educate Thomas' mother on resources for victims of domestic violence and provide her with the telephone numbers of a hotline or support center where she can discuss her experience and receive assistance.

Refer

• Provide referrals to Thomas and his family to youth programs in the surrounding community that provide comprehensive services for youth violence prevention.
• Provide referrals to Thomas' mother to a local battered women's shelter and hotline.

Work with schools and community

• Work with Thomas' school to develop a safety plan for Thomas and to address problems with violence in the school.
• Volunteer to work with the school as an epidemiologist or crisis team member and assist staff in violence prevention planning for the school.
• Volunteer to serve on community prevention initiatives.

Enhance resources in clinical practice setting

• Establish a network of referral services for youth and family violence prevention. Know how the programs in this network compare to the list of effective programs in the Surgeon General's report on youth violence.9
• Implement practice guidelines and practice protocols for firearm safety such as the Physician Firearm Safety Guide available through the American
• Medical Association (312 464-5066).13
• Become knowledgeable of firearm training programs in your community. Information on training programs is available from organizations such as the Brady Center to Prevent Gun Violence, Physicians for Social Responsibility, and the National Rifle Association.14-16
  

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References

1. Kellermann AL, Reay DT. Protection or peril? An analysis of firearm-related deaths in the Home. N Engl J Med. 1986;314:1557-1560.
2. Azrael D, Hemenway D. In the safety of your own home: results from a national survey on gun use at home. Soc Sci Med. 2000;50:285-91.
3. Jackman G, Farah M, Kellermann A, Siman HK. Seeing is believing: what do boys do when they find a real gun? Pediatrics. 2001;107:1247-1250.
4. Sheley J, Wright J. High school youths, weapons, and violence: a national survey. Research in Brief. Washington, DC: National Institute of Justice; US Department of Justice; 1998.
5. Karr-Morse R, Wiley MS. Ghosts From the Nursery: Tracing the Roots of Violence. New York, NY: Atlantic Monthly Press; 1997.
6. Blyth DA, Roehlkepartain EC. What youth need from communities. Source Newsletter. Minneapolis, MN: Search Institute; 1992. Available at: http://www.
7. searchinstitute.org/archives/wt.htm; 1992.
8. Niehoff D. The Biology of Violence: How Understanding the Brain, Behavior, and Environment Can Break the Vicious Circle of Aggression. New York, NY; The Free Press;1999.
9. Rintoul B, Thorne J, Wallace I, Mobley M, Goldman-Fraser J, Luckey H. Factors in Child Development. Part I: Personal Characteristics and Parental Behavior. Research Triangle Park, NC: Research Triangle Institute; 1998.
10. US Department of Health and Human Services. Youth Violence: A Report of the Surgeon General. Rockville, MD: Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Injury Prevention and Control; Substance Abuse and Mental Health Services Administration, Center for Mental Health Services; and National Institute of Health, National Institute of Mental Health; 2001.
11. Commission for the Prevention of Youth Violence. Youth and Violence: Medicine, Nursing, and Public Health: Connecting the Dots to Prevent Violence. Chicago, IL: American Medical Association; 2000.
12. Task Force on Violence. The role of the pediatrician in youth violence prevention in clinical practice and at the community level. Pediatrics. 1999;103:173-181.
13. American Academy of Pediatrics. Keeping Your Family Safe; 1996. Available at: http://www.aap.org/advocacy/d1family.htm.
14. American Medical Association. Physician Firearm Safety Guide. Chicago, IL: 1998.
15. Brady Center to Prevent Gun Violence. Available at: http://www.bradycampaign.org/.
16. Physicians for Social Responsibility. Available at: http://www.psr.org/.
17. National Rifle Association. Available at: http://www.nra.org.
18. Hemmenway D, Prothrow-Stith D, Bergstein JM, Andes R, Kennedy BP. Gun carrying adolescents. Law Contemporary Problems. 1996;59:39-54.
19. Excerpted from Center for Study and Prevention of Violence. Fact Sheets: Preventing Firearm Violence. Boulder, CO: University of Colorado. Available at: http://www.colorado.edu/cspv/.

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