The present findings show that adolescents presenting to an urban ED have alarming rates of violent behaviors. Specifically, ~75% of adolescents reported peer violence in the past year; the majority of this violence (~60%) was severe and could likely result in injury. Although direct comparisons are limited by differences in violence measures, these rates of peer violence appear to exceed those of national samples[2
] and prior school- and ED-based studies in Flint[15
]. For example, data from the school-based Youth Risk Behavior Survey shows that 31% of adolescents in Michigan, and 43% of adolescents in Detroit (data is not reported for Flint), report any past year fighting[2
]. There are several reasons why adolescent patients presenting to an urban ED may report elevated rates of violence. Urban ED patients over-represent economically disadvantaged groups living in high crime neighborhoods where there is a higher risk of morbidity and mortality due to violence-related injuries[1
]. In addition, these youth are less likely to attend school regularly and may be missed in school-based surveys.
To our knowledge, no prior ED studies have assessed adolescents’ dating violence (i.e., physical aggression). About a quarter of youth reported dating violence, which exceeds rates from community samples of adolescents[3
]. Consistent with the literature, most adolescents who reported dating violence also reported peer violence[3
]. Surprisingly, the reason for the current ED visit (e.g., medical, acute injury) was not related to past year history of peer violence; however, adolescents reporting severe dating violence were more likely to present for a medical complaint. Together, these findings highlight the importance of universal screening protocols for peer and dating violence among adolescents in the urban ED.
Although research suggests that male adolescents are involved in more violence than female adolescents [29
], in recent years national data has indicated a shift in this gender pattern with females increasingly likely to be involved in violence[30
]. Overall rates of peer violence in this study were similar for males and females; however, gender differences were noted in specific violent behaviors. Understanding these differences may be important to inform and tailor future interventions by gender. Males were more likely than females to report causing someone to need medical attention and to report weapon carriage. Females were more likely than males to report dating violence (i.e., physical aggression), although males may underreport due to negative social stigmas. Furthermore, violent behavior by males towards a dating partner is more likely to cause injury than violent behaviors by females, perhaps reflecting physical size differences[32
]. In addition, females are more likely than males to report reciprocal violence (aggression and victimization) in dating relationships[33
] and qualitative studies show gender differences in contexts and motivations for dating violence. For example, male use of dating violence is motivated by a need for respect and control[34
]. In contrast, females describe using dating violence for playing, or baiting their male partner to hit them as a sign of commitment or love [34
] and report that over half of violent acts are in response to violence initiated by their boyfriend[35
African-American adolescents reported more severe violence (both peer and dating) after controlling for socio-economic status (i.e., public assistance), but were less likely to report alcohol-related fighting. These findings are consistent with previous research on dating and peer violence [12
] and may reflect unmeasured socioeconomic factors and/or neighborhood violence[37
Although alcohol-related fighting was more likely among those who met criteria for alcohol problems, when examined together, most violent behavior did not occur under the influence of alcohol. Only 6% of adolescents reported alcohol-related fighting whereas rates of peer violence were 75%. Thus, our data is consistent with community surveys suggesting that the majority of violent behaviors are not related to acute alcohol consumption[12
]. Rather, consistent with theories of problem behavior clustering, adolescents who are [8
] binge drinking, smoking marijuana, and carrying a weapon were also likely to be involved in peer and dating violence. These behaviors increase the risk for injury during adolescence[38
] and may be related to long-term problems into adulthood (e.g., substance abuse/dependence and psychosocial problems).[39
Several limitations of this study require mentioning, including the cross-sectional design, which limits interpretation of causality, lack of information regarding other illicit drugs, and lack of distinction regarding the gender of the dating partner. A variety of constructs were not assessed because of feasibility issues inherent to screening adolescents in the ED and based on assessment priorities specific to the randomized controlled trial. Although chart reviews were audited regularly to ensure reliability for classifying the ED visit, errors cannot be completely ruled out. Future studies should assess victimization, injury, and sexual violence. Findings may not generalize to suburban or rural settings, particularly of higher socio-economic samples. Although our sample reflects the racial/ethnic composition of adolescents in Flint, Michigan, the study requires replication with Hispanic adolescents. Further, findings require replication given that adolescents presenting on midnight and day shifts were not surveyed and severely injured/ill patients could not be included. Given IRB restrictions, it was not possible to obtain information regarding adolescents presenting to the ED without a parent or guardian providing consent. Future multi-site, population-based ED studies should examine these issues among a nationally representative sample of adolescents. Despite these limitations, these findings offer important, unique information regarding violent behaviors among a large, inner-city ED sample of adolescents.
Conclusions and Future Directions
Research suggests that the ED visit may represent a unique “teachable moment” during which adolescents may be receptive to behavioral interventions [40
] and linkage to community resources[13
]. Prior ED-based intervention programs have focused either on violence[13
]) or alcohol[17
]. Results from this study suggest that peer and dating violence are common among adolescents presenting to urban EDs, and that alcohol use, marijuana use, and weapon carriage are concomitant risk factors for violence. Given these findings and the potential impact of violence and substance use on future morbidity and mortality, future studies are needed to develop and test screening and interventions protocols that address multiple risk behaviors among adolescents presenting to urban EDs.