Violence Prevention Through Mentoring for Youth with Emergency Department Treated Peer Assault Injuries

Youth violence, a major cause of morbidity and mortality, is a pressing issue in need of targeted action given its negative impact on population health, well-being and equity. Homicide is currently the third leading cause of death for young people ages 10-24.¹ Although youth violence impacts all communities, youth of color are disproportionately affected. Specifically, homicide is the leading cause of death for African Americans and the second leading cause of death for Hispanics in this 10-24 age group.² According to the Centers for Disease Control and Prevention, the known costs of these assault-related injuries nationally, including medical and work loss, are $18.2 billion per year.² The Healthy People 2020 objectives identify injury and violence as leading health indicators and critical objectives for youth, which includes reducing homicides, physical fighting, and weapon carrying.³ There are many prevention strategies that have demonstrated success in reducing youth violence.⁴ The purpose of this Medical Progress article is to highlight promising partnerships between emergency departments (EDs) and community-based organizations to decrease youth violence through mentoring.

Two key factors support the use of the ED as a setting for violence prevention strategies and interventions. First, this setting is a common point of contact between health care professionals and youth who experience violence. Every day, approximately 1300 youth are treated in EDs for nonfatal assault-related injuries.² Youth involved with violence are more likely to be seen in the ED than in other settings.⁵ Such assault-injured youth are at risk for negative health outcomes; a prior violent injury is a strong risk factor for future assault-related injuries and homicide.6, 7, 8, 9 Intentionally injured youth are significantly more likely to commit violent offenses compared with youth treated for unintentional injuries.¹⁰ For example, in bullying-related peer assaults, youth who have bullied and youth who have been victims of bullying often have similar risk profiles.¹¹ In addition, the majority of youth who identified as bullies also report previously being victims of bullying.¹¹ Furthermore, the risk for violence retaliation is greatest in the initial weeks after a violence-related injury.¹² Because of this, intervening when youth present to the ED can be critical to preventing future violence. Second, the ED may provide an opportunity for a “teachable moment” during a time of introspection and vulnerability after an injury event.¹³ Providers in EDs have a unique opportunity to refer young people during this likely “aha” moment where the seriousness of a violent event becomes unavoidably real. Research has characterized the concept of the “teachable moment” of the ED visit to decrease retaliatory attitudes and eliminate revenge-seeking intentions among youth and their parents.13, 14, 15 Thus, an ED visit for an intentional injury may be a prime opportunity to identify at-risk youth, initiate violence prevention interventions, and potentially interrupt this cycle.

Mentoring is an evidence-based strategy for preventing youth violence. Research has shown that the presence of a trusted adult role model can prevent youth violence and promote other positive behaviors. Relationships with caring adults, in addition to parents and caregivers, can positively influence young people's behaviors and decrease their risk for involvement in crime and violence.¹⁶

Mentoring programs can often be found in community organizations. Such organizations have partnered with EDs to intervene with youth who are treated for violence-related injuries. An ED mentoring program partnership is a promising approach to implementing youth violence prevention interventions that can provide social support, address community catalysts that trigger emotional or traumatic responses, and foster nonviolent skill building for youth living in communities with high rates of violent crime. This approach is rooted in the success of wraparound care services that provide comprehensive, youth-centered care within the community context.¹⁷ The wraparound care model is effective in decreasing negative outcomes in youth who have emotional and behavioral disturbances.^18,19 The Centers for Disease Control and Prevention's “Best Practices of Youth Violence Prevention” has comprehensively reviewed studies evaluating youth violence prevention and concluded that youth mentoring strategies are among the approaches that offer the most promising results.²⁰ Mentoring programs have been implemented in various settings including in schools, at churches, and in hospital EDs.²⁰ Although all mentoring programs have promise, this medical progress article discusses the powerful impact that partnerships between EDs treating peer assault injuries and community-based programs that provide tailored mentoring can have on reducing youth violence.

Hospital-Initiated Violence Intervention Programs

ED-mentoring program partnerships can be considered a type of hospital-initiated violence intervention program (HVIP). HVIPs focus on secondary violence prevention and aim to decrease injury recidivism. Typically, the HVIP model offers timely, intensive, and individualized support in the immediate postinjury period and may also seek to address the social environment and needs of patients.21, 22, 23 Both HVIPs and ED-mentoring program partnerships are based on the fundamental premise that hospitals are ideal locations to identify patients at risk for future intentional violence victimization or perpetration; for HVIPs, the hospital often is also the location in which services are provided. There is evidence that suggests that HVIPs are beneficial, because they generally decrease recidivism rates and contain costs.7, 8, 9 Although a limited number of these programs have been evaluated thoroughly, suggested best practices include providing intensive case management, ensuring hospital leadership buy-in, and building strong partnerships between hospitals and community organizations. These best practices can help to mitigate common barriers, such as challenges in effectively identifying appropriate participants and the lack of coordination among internal and external stakeholders.7, 8, 9 The American College of Surgeons Committee on Trauma mandates that trauma centers have violence prevention programs and HVIP programs are included in the committee's practice guidelines as meeting this requirement. The Committee on Trauma provides guidelines for such programs, through Violence Intervention Programs: A Primer for Developing a Comprehensive Program within Trauma Centers.²

Although ED-mentoring program partnerships share many of these characteristics and challenges, there are some additional distinguishing features. Although ED-mentoring program partnerships often identify the eligible participant at the time of the ED visit, the mentoring intervention may not occur until weeks or months later. When enrollment with the mentoring program is completed, youth are matched with a mentor and mentoring commences. Thus, there may be limited intervention in the immediate postinjury period. Additionally, although there are HVIPs that target a wide age range, the literature suggests that they tend to be directed toward older adolescents and young adults (ie, those 15-24 years of age), whereas mentoring programs may target younger age groups (ie, those 10-15 years of age), and possibly younger age groups.7, 8, 9^,19 Finally, although HVIPs may focus on patients with more severe injuries and, in many cases, injuries owing to gun violence, younger assault-injured youth that are at risk for negative health outcomes (including future assault-related injuries and homicide), can present with more minor injuries from physical fighting without weapon involvement that do not require treatment by pediatric trauma specialists.7, 8, 9^,21, 22, 23, 24, 25 Given the positive outcomes of mentoring for youth with injuries under these circumstances, it is important that the population be included in ED-based violence prevention programs, and that mentoring is recognized as a promising strategy to mitigate recidivism for younger children with less severe injuries.

Case Management Interventions in EDs

Case management violence prevention programs for assault-injured youth in EDs may have served as the foundation for the development of mentor-based interventions.²⁶ In these programs, a case management model was initiated in the ED for youth treated with assault-related injuries. In a Chicago-based study, intervention patients received a case manager who helped them to identify psychosocial needs and developed individualized case management plans. They also provided referrals to resources, such as primary health care, social services, anger management programs, and conflict resolution training. The case managers met with the youth weekly for the first 2 months, every other week for the next 2 months, and monthly thereafter. Although limited by high losses to follow-up and projected high costs of wider implementation, the intervention was associated with a significant decrease in self-reported repeat violence at 12 months. Their study also concluded that there was a need to work with youth over a longer time period to yield a greater impact.²⁷ In another randomized, controlled trial based in Baltimore, intervention families received case management services over a 4-month period by a counselor who discussed the sequelae of assault injury, assessed family needs, and facilitated service use. Specifically, the case manager made follow-up telephone calls on a weekly to monthly basis as a part of an ongoing needs assessment and assisted in the identification of community services for the family. Additionally, the case manager provided service information and application forms, made appointments, assisted with transportation, provided linkage to primary care providers, and occasionally accompanied families to community services. Referrals made included mental health treatment, medical services, addiction treatment, anger management programs, recreational and afterschool programs, legal aid, and tutoring programs. This study, limited by high rates of attrition, found that youth and parents were receptive to a violence prevention intervention initiated after an ED visit. This pilot case management study, however, did not find an association between an increase in service use and a significant decrease in fighting, fight injury, or weapon carrying, concluding that more intensive violence prevention strategies were needed.¹⁶ The next iteration of violence prevention research by these investigators included a mentor-implemented intervention for a more intensive and tailored approach.²⁵

Mentoring and Youth Violence Prevention

The presence of a positive trusted adult role model is a protective factor against violence and other maladaptive outcomes among youth. Mentoring improves academic achievement, school attendance, and family and peer relationships; it also decreases problem behavior and drug use.17, 18, 19, 20^,28, 29, 30, 31 Mentoring also improves decision-making skills and fosters future planning abilities for youth engaged in high-risk behavior.¹⁸ Evidence supports a dose-response effect of youth mentoring on outcomes; the longer a mentoring relationship lasts, the better the outcomes for the mentored youth.^32,33

Challenges for youth to participate in mentoring programs have been identified and include long waiting lists and parental concerns about how their children will be treated in the program.³⁴ There is evidence that mentoring relationships that end prematurely are harmful to the youth, and that the time it takes for a well-suited match to occur often results in a lengthy process or no match.³⁵ Mentoring programs may require months for matches to be made because of the time that it takes to recruit mentors (including the completion of a background check and successful interview) for the number of youth who have applied or been referred for mentoring services.³² It is not unusual for the wait period to be more than 1 year, and longer waits may be experienced by older youth and those who are male. In addition, these waiting periods can be frustrating for families and youth living in low-resource communities because of the limited accessible programs that exist for positive youth development.^35,36

Research suggests that the long-term outcomes of mentoring tailored to decrease youth violence outweighs slightly higher programmatic costs when compared with a standard youth center mentoring program.36, 37, 38 The limited research that has provided robust cost analyses of mentor programs has found that there are differences for costs of mentoring programs when reviewing the initial mentor match month vs ongoing support of the subsequent months of mentoring.^7,8 Evidence suggests that the resources needed to create a successful mentor-youth match requires substantial program personnel for tasks such as completing the application process, interviewing parents, children, and mentors, and screening of mentors (eg, background check and reviewing references); however, more evaluation is needed to examine the ongoing support for youth and their mentors. Overall, more comprehensive research is needed to further build the evidence base for youth violence prevention and mentoring.

Partnerships between EDs and Community Mentoring Programs

Owing to clinical demands and limited resources, it is likely not feasible for EDs to create and sustain a mentoring program for youth in-house. To decrease violence-related recidivism, some EDs have partnered with community organizations that provide mentors and mentoring programs and referred youth that have been injured as a result of violence for these interventions.⁹ In 1 such ED-mentoring program partnership between 2 pediatric EDs and Big Brothers/Big Sisters of America (BBBS), the Take Charge! program showed promise for improved self-efficacy in avoiding violence, decreased aggression and problem behavior at six months in 10- to 15-year-old assault-injured youth.²² The Take Charge! intervention significantly decrease reported misdemeanors and aggression and increased self-efficacy.²²

ED partnerships with community-based organizations with established infrastructure, mentoring protocols and experience in working with the target population, such as the BBBS, can help to mitigate these many challenges. The BBBS is the oldest, largest, and best-known community-based mentoring program in the US. In this program, youth are matched by agency staff with carefully screened community volunteers for 1-on-1 mentoring relationships.²⁵ Similar to many programs, mentors often meet the family in a convenient location, which may include the family home, and subsequently spend time together as mentor-mentee. The BBBS has a match process that has been studied and found effective in creating child-adult pairs based on interest and often some demographic commonalities (eg, sex and/or race). For example, limited published data available (from 2008) shows that BBBS community-based mentoring program served 255 000 youth ages of 6-18.³⁹ The majority of these youth were African American (37%) or Hispanic (17%). Approximately 41% of the youth served came from low-income families, and 74% were from a single-parent household, under the care of an extended family member, or living in a foster home, group home, or institution.²⁶ As mentioned elsewhere in this article, these youth may be disproportionately impacted by violence.^2,4 Furthermore, research has found that the BBBS has a history of improving health and behavioral outcomes of children. A large-scale randomized controlled trial involving 959 youth ages 10-16 provided evidence of the community-based mentoring program program's efficacy for reducing problem behaviors (eg, aggression, alcohol and drug use, truancy), improving school achievement, and improving the quality of relationships with parents and peers.⁴⁰

Community-based programs are ideally positioned to decrease violence recidivism and at the same time increase positive youth outcomes. First, they are able to provide staff support to both the youth and the mentor for developing and sustaining a relationship in the community.⁴¹ These relational supports can mitigate any conflict or challenges that arise and threaten the relationship. Second, established community-based programs can also include a plethora of structured activities that strengthen connections between youth and adult mentors, which are essential for positive youth development.^41,42 These activities can include leveraging partnerships with other services and programs, such as sports teams and art centers, for bonding experiences. These activities are often inaccessible to youth from under-resourced communities and families with limited discretionary funds for enrichment activities. A community-based program often has a specific population for their service, highlighting their ability to maximize the program/person match.⁴³ Third, mentoring programs provide an opportunity for a bidirectional, mentor-mentee relationship that builds a sustained relationship. A relationship, lasting longer than a year, is the foundation of youth mentoring success.³⁰ For an ED-community partnership, the ED is in a strategic position to refer youth to community programs that may best suit their needs. This referral process should include how the ED would assess the ability of the community mentoring program to create a timely youth-mentor match based on the characteristics of the youth (eg, age, sex, and address) as well as the type of mentoring program (eg, location based, group mentoring, and hours).

Although community-ED partnerships to decrease youth violence through mentoring often focus on youth living in urban areas, it is important to note the dearth of information on rural adolescent violence and ED-based mentoring. Violence research in rural communities focuses largely on school-based violence, such as school shootings.⁴⁴ Existing discussions of rural school violence as it relates to EDs explore the preparedness needs of local hospitals to support victims, not intervention strategies to prevent future perpetrators. This key gap should be addressed with future efforts, including consideration of how virtual mentoring may be a practical, alternative option to face-to-face mentoring to expand access. Given that telehealth-based behavioral health care is becoming a widely accepted mechanism in many rural mental health care provider shortage areas and is associated with positive outcomes,45, 46, 47 the potential role for virtual mentoring in improving access to violence prevention programs should be explored.

Strategies to Address Barriers to Partnerships between EDs and Community Mentoring Programs

Despite the demonstration of positive outcomes in violence prevention through mentoring and the potential for such collaborations to bridge the science-practice gap, building and sustaining these ED-mentoring program partnerships can be challenging.³¹ Although the population of youth receiving treatment for peer-to-peer violence is a prime group to benefit from referral to community mentoring programs, consideration of how this referral system should be implemented is important. There are differences between community-based organizations and academic medical institutions in communication, expectations, and goals that can negatively impact efforts. Factors that facilitate or hinder the collaborative process have been consistently identified, including both interpersonal and operational processes.⁴⁸ To effectively support partnerships between community-based mentoring programs and EDs, practical ways to achieve equitable partnerships must be identified and enacted. Strategies to achieve this goal include the use of formal and informal facilitation of the referral process and communication between locations to ensure meaningful involvement and participation of partners to optimize communication and engagement.⁴⁹

In addition, specific issues to consider include challenges related to recruitment and engagement. The complexities inherent to enrollment and participation in a mentoring program, such as waitlists before a mentor match, require that the ED and community organization find ways to keep youth and families engaged, especially given the need to address retaliation during the first 6 months after a medically treated assault-related injury.⁵⁰ Mentoring organizations may also have limited experience in working with mentees that have experienced violence-related injuries. To support mentoring success, staff and volunteers should be trained in trauma informed care practices to support youth with these experiences.⁵¹ The staff of mentoring organizations as well as EDs can use the 4 Rs of a trauma-informed approach, which includes first having a realization and understanding of trauma, knowing how to recognize signs of trauma, then to respond to youth who have experienced trauma by applying the 6 key principles of a trauma informed approach, and to resist retraumatization.⁴⁸ There may be constraints placed by limited staffing and budgets for both community-based organizations and EDs to implement mentoring with a trauma-informed approach.⁴⁸ In addition, ED and academic partners may not understand these constraints or have adequate experience in the challenges inherent to implementing programs in community settings. Similarly, community organizations may have limited experience with the academic or health care culture and/or research practices and requirements.

Given these considerations, we suggest the following strategies to address barriers to partnerships. (1) Identify personnel who can consistently serve as liaisons between the hospital and community organization, such as community-based health navigators and patient advocates who can help to facilitate enrollment in mentoring programs. (2) Coordinate the enrollment and application processes to increase efficiency and minimize the duplication of materials and forms. (3) Consider options for other HVIP components to bridge the gap between the hospital visit and the enrollment in the mentoring program, particularly to maintain engagement during the waiting period, a critical time of high risk for violent injury recidivism. (4) Identify opportunities for the hospital to support mentor recruitment and solicit volunteers. (5) Promote ongoing staff education for both the hospital and the community organization, with a focus on how to optimize ED-community partnerships as well as the shared mission of violence prevention and trauma-informed care within both settings. (6) Explore the role of virtual mentoring in improving access to these programs, particularly in rural communities.

Suggestions

For decades, the American Academy of Pediatrics has provided guidelines on the role of pediatricians in youth violence prevention.⁵² The guidance includes clinical practice integration (eg, screening and providing anticipatory guidance), advocacy (support for community programs), education (prevention in education), and research (contributing data to injury surveillance systems and participating in practice-based injury prevention research). Similarly the American Academy of Pediatrics' Management of Pediatric Trauma policy statement highlights the importance of injury prevention, including the role of community-based injury-prevention programs that extend beyond primary pediatrics.⁵³ The need for an integrated public health approach is acknowledged as is the need to identify and refine the approach to injury-prevention initiatives that are specific to individual regions.

Although the current guidelines acknowledge the role of community-based injury prevention programs, more specific guidance for EDs is needed on how to effectively partner with community organizations to provide mentoring for violence injured youth. We recommend setting realistic goals, such as for EDs to connect youth and families to community-based interventions within the first 6 months of their medically treated assault-related injury.⁴⁴ We additionally recommend that EDs connect families at an increased risk of violence exposure with services that can mitigate risk factors of community violence and trauma after a medically treated assault injury, including minor injuries that may have resulted from physical fighting.

Conclusions

Thousands of dollars are spent to treat victims of youth violence annually and thousands of youth are injured or die needlessly from peer assault injuries.^1,2 EDs have become key providers of the health care and treatment of peer assault injuries.⁵⁴ Although HVIP models exist and offer effective interventions for the immediate postinjury period, few target younger adolescents and the high rate of recidivism of youth violence suggests that additional violence prevention activities such as partnerships between EDs and community-based programs, are needed. Because evidence suggests that mentoring is successful in improving youth outcomes, there is the potential for HVIP's and community-based mentoring programs to work in tandem to decrease the youth violence epidemic.⁵⁰ More broadly, the field needs more comprehensive research to assess the impact, quality and return on investment of these partnerships.