Youth victims of peer assault injuries demonstrated high rates of problematic behavioral symptoms on the CBCL. Externalizing behavioral symptoms including aggression and delinquency were common as might be expected. Also many youth scored in the clinical range for attention problems and anxiety / depression. More than half of youth with symptoms suggestive of common mental health conditions including ADHD, anxiety, and depression had no formal diagnosis of these conditions. Only 27-52% of symptomatic individuals were currently receiving mental health treatment.
The design of this study does not allow us to determine if behavioral symptoms were present before the assault injury or developed in the days-to-weeks after the event. However, a history of past fighting-related injuries was common in our study population with 65% having been in one or more fights in the past 12 months requiring medical attention, not including the fight that brought them into the study. Rates of previously diagnosed mental health conditions, clinical range CBCL subscale scores, and mental health service use were not significantly different for youth who had received medical treatment for at least one other fighting-related injury in the prior 12 months as compared to those who had not. This pattern suggests peer assault injuries are a chronic problem, that youth who have had prior contact with the medical system for treatment of assault injuries are not any more likely to have been identified with and treated for a mental health problem than those with no prior contact, and that problematic mental health symptoms, whether they precede or follow assault-injury, should be identified and treated.
Other studies have also described the chronic nature of violence in assault-injured youth with rates of recurrence reported to be as high as 44%.14,15
Exposure to violence has been associated with psycho-emotional symptoms that are further associated with increased risk of injury. Specifically, the presence of depression symptoms at the time of an assault injury has been associated with subsequent engagement in risk behaviors for violence 6-18 months after injury,16
underscoring the importance of recognizing mental health symptoms at the time of injury as a potential mechanism for reducing rates of re-injury in the future.
It is important to note that the CBCL is a dimensional mental health screening tool that does not map directly onto DSM-IV diagnoses. When used in isolation the CBCL is not diagnostic for specific mental health conditions, such as ADHD, anxiety, and depression. However, the presence of clinical range symptoms should raise suspicion for a mental health problem and warrants further evaluation. While some may argue the validity of comparing our sample of largely minority, inner-city youth living in poverty to the U.S. population-normed samples on which the 1991 CBCL was developed, this is a commonly accepted research approach in behavioral medicine11
and one that has been used in studies of behavioral characteristics of youth exposed to violence.17
Other studies that have used the CBCL to measure behavioral symptoms in high risk, low-income, minority youth exposed to family interpersonal or community violence have found that rates of problem behaviors in youth in the community not exposed to violence (community controls) are similar to the CBCL’s non-referred normed population while victims of violence in these communities have higher rates of behavioral symptoms17,18
Since aggressive behavior was prevalent in the study population, analyses were conducted to evaluate the association between elevated scores on the aggression scale and scores on the other mental health symptom domains of the CBCL. Both males and females with elevated scores on the aggressive behavior scale were significantly more likely than their non-aggressive, same gender peers to score in the clinical range on the withdrawn, anxious / depressed, social problems, attention problems, and delinquent behavior scales. This finding suggests that high levels of aggression are associated with mental health co-morbidity.
This study also sought to describe gender differences in the mental health symptoms of assault-injured youth. Our study population was about two thirds male, which is similar to other studies. Assault injuries tend to occur more frequently in males than females, although the prevalence of female assault injuries has been increasing.7,8
Within our study population, the most notable gender difference was that females had significantly higher rates of clinical range aggressive behavior on the CBCL as compared to males. Since aggression problems were significantly associated with co-morbid mental health symptoms across domains for both genders, but females in our sample had a higher prevalence of clinical range aggression than males, we suggest that assault-injured females may be a particularly vulnerable group. This finding is consistent with a study by Moskowitz et al. who analyzed serious injuries and deaths from interpersonal violence and found that assault-injured females were more likely to have had pre-existing psychosocial impairments, such as problems with social interactions and violent or physically aggressive behaviors, as compared to assault-injured males.19
While all assault-injured youth should be assessed for mental health concerns, it is particularly important that female victims do not fall through the cracks as they have a higher prevalence of aggression and are therefore at increased risk for also having greater behavioral symptom co-morbidity.
The limitations of this study include the length of time between the ED visit and the collection of mental health data, the possibility of selection bias and recall bias, and the validity of parent-report data. There is a possibility that there was selection bias in recruitment for the study, as none of the participants had been hospitalized for their injuries. This is likely due to hospitalization being a rare outcome, but also sicker patients may have been more likely to refuse to participate in interviews. Our study protocol was to schedule the initial study interview with participating families as soon as possible after the assault injury, but due to complex social circumstances, it was difficult to schedule the interview promptly after the injury in some cases. Therefore, the CBCL data were collected an average of 2.9 months after the ED visit. Rates of clinical range CBCL subscale scores were not significantly different for participants in our study who were interviewed within 1 month of the event as compared to those who were interviewed later, suggesting that time was not a factor in reporting of symptoms. However, CBCL responses may more heavily reflect recent behaviors after the assault injury and may be influenced by the parent reporter’s emotions related to the assault event. Relying only on parent report CBCL data can underestimate internalizing symptoms compared to having both parent and youth self-report ratings. Finally, it is possible that parents may have demonstrated a gender bias when reporting on their children’s behavior. Parents of girls requiring an ED visit for an assault injury may view their daughters’ behavior as highly aggressive, whereas, parents of boys may describe the same behavioral traits as more normative in their sons.
The American Academy of Pediatrics (AAP) Task Force on Adolescent Assault Victim Needs emphasized the integral role of mental health care, along with medical care, in the treatment of assault-injured youth.14
The findings of this study strongly support this approach to care. An ED visit for an assault injury provides an important intervention opportunity to screen patients for mental health symptoms and link them to appropriate mental health services. Treatment of underlying mental health conditions may help to reduce the risk of future violence and injury.