This study found that assault-injured youth and their families were receptive to violence prevention intervention initiated after an ED visit. The study also found that intervention may reduce aggression and problem behavior and increase self efficacy. Literature suggests that these youth are at high risk for repeated visits and injury,5
have significant psychosocial needs,36,37
and are less likely to have advised follow-up after ED treatment.38
The ED may be an important access point to these high risk youth and provides an opportunity to intervene. When these participants were asked, “How likely is it that [you/your child] may have another physical fight with the same people who caused [your/his/her] injury?” 28% of youth and 36% of parents stated this was somewhat or very likely.39
Previous studies have found that many youth assault injuries are related to long-standing, repeated disagreements that may not be over after an ED visit.40
Retaliatory feelings may fuel violence.41,42
Interrupting the cycle of reactive perpetration and traumatic re-injury could reduce the burden of injury among adolescents.
Though there has been a call to address the psychosocial needs of assault-injured youth presenting to the ED, there has been limited evaluation of this approach. ED protocols and programs have been developed, but few have published outcomes. Zun and colleagues tested an ED case management model with assault-injured individuals age 10–24 and found some increased social service utilization but no change in attitudes, delinquency or return visits to the ED.43,44,45
With follow-up at 6 and 12 months they found a reduction in self-reported reinjury rate in the intervention group but no program impact on arrests, incarceration or state-reported re-injuries via the trauma registry. They concluded that there was need for a more intensive intervention with a younger population and over a longer time period. Our study suggested that focusing on a younger population and using a family approach offers promise.
Based on enrollment into the study and reported satisfaction with the intervention, families were receptive to violence prevention intervention after assault injury. There were trends toward differences between intervention and comparison groups on youth-reported aggression, misdemeanor problem behavior and self efficacy at 6 months. This study did not find significant impact of the intervention on youth reports of fighting and weapons carrying in the last 30 days, nor on parent report of youth aggression. No differences were found for other intervention targets, including social competence and attitudes about retaliation. However, study power was limited and all outcomes trended in the direction of decreased risk for violence. In addition, in adherence level analysis there was an adherence response association between treatment group and youth-reported outcomes. Our analyses addressed program effectiveness, not efficacy. Overall program impact was likely diminished because some intervention families did not start or complete all sessions, however, these families were included in analyses if follow-up assessment was completed. Also, the comparison group received limited case management services beyond what was usual care from the participating EDs and this minimal intervention may have been beneficial. This would have reduced our ability to detect effects and may partially account for the decrease in fighting in both groups at 6 months.
Our intervention incorporated components of CDC’s Best Practices in Youth Violence Prevention including a mentoring relationship with youth, home visitation, involvement of parents and a social cognitive approach. It is difficult to know which component had the greatest impact or whether the combination of strategies accounted for youth change. However, study staff felt that the relationship-based mentoring aspect of the intervention was powerful and youth and parents were very positive about their mentors. The presence of a positive trusted adult role model has been recognized as a protective factor against violence and other maladaptive outcomes among youth. Studies have found that mentoring can significantly improve academic achievement, school attendance, reduce violent behavior and drug use, and improve family and peer relationships.46,47,48
Mentoring program evaluations have found that more frequent mentoring contacts, knowing families and longer mentoring relationships are associated with better outcomes.45
Though there was a trend toward program impact at follow-up, it is not known if effects would be sustained since some mentoring relationships did not continue after completion of the curriculum. Finding a supply of reliable and committed mentors was a challenge in this study and in other mentoring programs.45
Further study of mentoring models that go beyond the traditional one-on-one method and utilizes other means of contact (e.g. group mentoring, instant messaging, phone contact) and targeted efforts to high risk populations are needed.
Limitations of this study include concern regarding generalizability, validity of data, study recruitment and attrition, and limited power. The study was conducted in two high-risk communities and results may not be generalizable to other regions. The validity of self-report data is a persistent concern in behavioral research. Additionally, because of the limited number of validated measures in the field at the time, the need to adapt measures was another potential limitation. However, during pre-testing we found that participants’ responses had face validity and internal consistency.
It is possible that there existed bias in convenience sampling and nonparticipation. Despite our best efforts, only 71% of families completed follow-up assessments further limiting power to show a difference. The varying time to follow-up past six months is also of concern but might be expected to underestimate program effect. Those who did and did not complete follow-up did not differ with regard to baseline demographics or violence risk factors. Recognizing that many families were very mobile and had complex and difficult family circumstances made this research especially challenging, however, the refusal rate and attrition in our study were similar to other studies of assault-injured youth.17
Our refusal rate of 23% was also consistent with school-based violence prevention studies with high risk middle schoolers in the Multisite Violence Prevention Study (participation rate 55–80%).49
These high risk populations of assault-injured youth deserve support and study and we present lessons learned. Finally, despite limited study power and a comparison group that received some intervention, we were able to identify trends of an effect of the intervention.
This study is one of the first studies evaluating a violence prevention intervention with assault-injured youth presenting to the ED. We found that a community-based, mentor-implemented program with assault-injured youth presenting to the ED demonstrated trends toward reduced aggression scores and misdemeanors and increased self efficacy. Further, the ED may be an important contact location, and injuries an important context, for augmenting self efficacy for violence prevention.
Despite the call 12 years ago by the American Academy of Pediatrics to intervene with assault victims in emergency departments, there has been a paucity of research. This study demonstrates the promise of intervention with this population. Additional research is needed to corroborate associations found and to further explore the potential of social cognitive and mentoring approaches to youth violence prevention. Research should also focus on engagement of high risk populations, cost-effectiveness, and use of administrative databases (e.g. juvenile justice records) for additional measures and participant tracking.50