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Youth Violence as a
Chronic Health Condition

By Heather Tiede, MA

Tyler has been in and out of child protective services for most of his 19 years. His mother is alcohol dependent and he’s never met his biological father. At age 12, Tyler began running away from foster and group homes and by the time he was 16, he was living on the street. With no money and nowhere to live, he initially turned to petty crimes to feed himself and his growing addiction to methamphetamine. During a night of binge drinking, Tyler and some of his buddies got involved in a fight at a house party that resulted in him getting stabbed in the abdomen. Unwilling to call an ambulance, he walked the three blocks to the nearest hospital. Tyler received seven stitches before being discharged later that morning.

Sadly, Tyler’s story is all too common, according to Heather Woodward, RSW, a registered social worker who has been working frontline with high-risk youths and their families for more than 15 years. In fact, in both the United States and in Canada, intentional injury is one of the primary reasons young people aged 12 to 24 visit an emergency department, and is one of the leading causes of hospitalization and death among males aged 20 to 24 (Cunningham, Knox, Fein, Harrison, Frisch, Walton, et al., 2009). She notes a growing trend for professionals in the fields of health care and social services to recognize injury due to violence as a chronic health condition.

“By viewing [injuries due to violence] as a medical concern, the focus shifts away from thinking of these injuries as simply a societal problem or law enforcement issue,” Woodward explains. “Instead, it offers a framework which enables me to support each individual’s specific needs. I help build on their strengths and provide guidance to empower the youths to address some of the risk factors that they themselves identify and recognize as promoting a violence-free lifestyle.”
And just as others who experience chronic medical conditions such as heart disease or stroke often receive assistance managing their health concerns outside the hospital and in the community, Woodward argues that victims of violence should also receive the same follow-up care. 

“My role as a helper is not unlike that of an occupational therapist providing support to a victim of a motor vehicle collision, or a respiratory therapist following a diagnosis of emphysema. These individuals need the same guidance and encouragement to make positive changes in their lifestyle in order to maximize their chances of living a full and healthy life.”

Perhaps even more alarming to Woodward is that many youths who have been treated in a hospital emergency department with an injury due to violence will return with another injury—sometimes more severe than the first—within one year.

In Winnipeg, 20% of youth treated in a hospital with an injury due to violence will return with another violent injury within the following year (Parveen & Snider, 2013), Woodward says. “To me, that is a completely unacceptable number.”

The Emergency Department Violence Intervention Program
Carolyn Snider, MD, MPH, FRCPC, an emergency physician and injury researcher, agrees with Woodward. Snider is the medical director for the Emergency Department Violence Intervention Program (EDVIP), a pilot project that began in November 2013 in order to assess the feasibility and efficacy of providing a hospital-based violence intervention program that offers wraparound care to youths both in the hospital and in the community for approximately one year starting at the time of the initial injury. It is located in Winnipeg, Manitoba, Canada—a midsized city with one of the highest homicide rates in Canada.

“My job as an emergency physician is not just to treat injuries, but also to prevent further injuries from occurring,” Snider says. “Given the very high rate of return for young people seen in an emergency department with a violent injury, we have a responsibility to be involved in that preventative initiative.”

Unlike many other violence intervention programs in Canada and the United States, EDVIP is a pilot research study funded by the Canadian Institutes of Health Research and, therefore, uniquely poised to demonstrate the actual efficacy of an intervention program on reducing repeat intentional injury among youth injured by peer violence. Snider and her team are optimistic that a full-scale, randomized control trial will demonstrate the effectiveness of the intervention not only on reducing repeat injury, but also reducing substance use, improving mental health, and decreasing involvement in the criminal justice system.

Woodward, who now serves as the social worker for EDVIP and leads the intervention team of five support workers, suggests that one of the key components to this intervention is having a support worker or herself meet with the youth at their bedside at the time of their injury (i.e., in the emergency department). For many young people, the reality of being treated in an emergency department because they’ve been the victim of an intentional assault often creates a situation in which the young person is open and receptive to making changes in their life; this is often referred to as the ‘teachable moment.’

“In our [EDVIP] program, we make every effort to develop trust and rapport with youths right there in the emergency department,” Woodward says. “We will often assist the hospital staff and youth themselves in finding adequate and appropriate clothing to leave the hospital in and arrange transportation to a safe location after discharge. Upon leaving the hospital, we will assist the youth in making connections with longer-term resources that the youth identifies as a need. This could include anything from assistance with mental health conditions, addictions, finding food banks, employment, or even a safe place to sleep that night.”

Trauma-Informed Care
Woodward stresses that it is not her job or the job of the support workers to tell the youth what they need to do in order to avoid future injuries due to violence. Instead, their role as helpers is to “walk beside” the youths on their own journey towards healing. Many youths she sees in the program come from broken and unstable homes pervaded by intergenerational grief and trauma, as well as grinding poverty. Wanda Chernomas, PhD, RN, is an advocate of the use of trauma-informed care and a member of the EDVIP advisory board. She suggests that interventions directed at youths injured by violence must consider not only one's personal experiences, but also the impact of intergenerational, familial, and societal trauma.

“Trauma-informed care is an approach to care that recognizes the serious impact trauma can have on an individual’s life,” Chernomas says. “Services and programs are informed by core principles including: acknowledgement, safety, trust, compassion, collaboration, choice, and empowerment. Working with individuals collaboratively, focusing on individual strengths rather than limitations, and offering real choices within the context of a safe, respectful, helping relationship are foundational in healing from trauma. Individuals are assisted in constructing a safe physical, social, and emotional environment that supports their healing and development.”

Challenges Faced by Youth Injured by Interpersonal Violence
A recent multilevel analysis of the risk and protective factors associated with youths injured by violence completed by Snider and her research team revealed that youths are at a significantly higher risk of serious violent injury or homicide if they have ever been charged with a crime, have ever been in child protective care, or live in a neighborhood with low socio-economic status or high levels of assault. Their multilevel analysis, which is in submission for publication, looks at 1,222 youth aged 12 to 24 who were admitted for injury due to or killed by violence between April 1, 2004 and December 31, 2011. These were compared against 11,984 randomly assigned controls (1:10). Their findings suggest that youths who are enrolled in school or previously graduated have about at 50% less chance of being injured due to violence.

“One of the interesting outcomes of this study is that it is not just individual characteristics that matter,” Snider explains. “There are also significant societal and environmental risk factors to consider. For example, youths are at a greater risk of being injured or killed as a result of violence if they live in a poorer neighborhood or one in which there are a high number of assaults, irrespective of whether the youth themselves live in poverty or have had personal experience with violence.”

The road to healing often includes having a strong connection with a support worker. Especially with young people like Tyler, regular in-person and telephone contact with their support worker allows youths to explore the root causes of their addictions and other risk factors. Although many experience setbacks, Woodward emphasizes that it is important for workers in the helping professions to realize that many of the problems and challenges facing youths injured by violence are not solved overnight.

“We must be patient with these young people,” Woodward says. “As professionals working with youths it is important for us to meet the young person where they are at, rather than where we would like them to be,” she explains. “If all the small successes are celebrated—even if it is something as simple as staying sober for one night or attending school for a day—then even larger successes will be sure to follow.”

Because, as Woodward knows, even small achievements can make a huge impact on the lives of youth who have been affected by violence.

— Heather Tiede, MA, is research coordinator for the Emergency Department Violence Intervention Program (EDVIP) in Winnipeg, Manitoba, Canada.

Heather Woodward, MA, contributed to this article. She has more than 15 years of experience working with children and youths affected by violence and leads the EDVIP team.

Cunningham, R., Knox, L., Fein, J., Harrison, S., Frisch, K., Walton, M., et al. (2009). Before and after the trauma bay: The prevention of violent injury among youth. Annals of Emergency Medicine. 53(4), 490-500.

Parveen, S., Snider, C. Recurrent intentional injury among youth: a chronic condition. Paper presented at: Canadian Injury Prevention & Safety Promotion Conference; November 7, 2013; Montreal, Canada.