Abstract
Purpose
We examined the self-identified, post-assault psychosocial needs of male adolescents in order to guide recovery and healing after being seen in an Emergency Department (ED) for a violence-related injury.
Methods
We analyzed de-identified data from 49 adolescent male youth who participated in a post-discharge case management program following a violence-related injury. Descriptive statistics summarized youths’ demographic characteristics and self-identified needs and goals for post-assault recovery.
Results
Most participants (80%) were treated for non-penetrating injuries and discharged from the ED (76%). Nearly two-thirds of youth reported clinically significant traumatic stress symptoms and 89% self-identified mental health needs following injury. Legal and educational needs were also commonly identified.
Conclusions
Despite experiencing minor physical injuries, assault-injured youth report clinically significant traumatic stress symptoms and recognize post-injury mental health needs. Results suggest that youth-focused, early intervention services, particularly related to mental health, are acceptable and desired by youth soon after a violent injury.
Keywords: adolescent, mental health, male, crime victim, violence, health service needs
Compared to female peers, adolescent males experience a greater burden of injuries from interpersonal violence [1]. Youth who have experienced interpersonal violence may require medical care, but also on-going psychosocial support to address the adverse sequelae of their injuries [2]. Engaging violently-injured young men in post-hospital services may help to improve mental health outcomes and reduce the likelihood of injury recidivism [3]. Community-focused case management following violent injury provides support to assault-injured youth and is recognized as an important violence prevention tool [4].
Limited data exist regarding the diversity and frequency of adolescent males’ self-identified post-assault needs. As male youth are less likely than female adolescents to seek help or receive mental health care [5], understanding male adolescents’ perceived needs may inform services to overcome these barriers. The present study explores the self-identified recovery needs of assault-injured male adolescents participating in a voluntary post-discharge case management program. Recognizing the needs of male youth following violent injury provides a novel opportunity to examine the alignment of goals with available services and programs to promote successful healing and recovery.
METHODS
This retrospective study utilized data from a violence intervention program at a large, urban children’s hospital. Eligible youth were between 8 and 18 years old, resided within city limits, and sought care at this hospital’s Emergency Department (ED) or Trauma Unit for any injury resulting from an interpersonal assault, which was not attributable to child abuse, sexual assault, or self-inflicted injuries. Eligible youth were referred by hospital social workers and participation was voluntary. Analyses were limited to male youth who agreed to receive services between January 2012 and August 2016. Because we analyzed existing, de-identified data, this study was deemed exempt by the hospital’s Institutional Review Board.
Demographic, injury, and psychosocial variables, including youth-reported traumatic stress symptoms (Child Post-Traumatic Stress Symptom Scale (CPSS) [6]) were summarized. CPSS scores were dichotomized, with scores greater ≥11 reflecting clinically significant traumatic stress symptoms. In partnership with program staff, youth identified goals, both at the time of program intake, as well as throughout the course of post-assault case management.. Goals were discrete and measurable objectives related to 14 need domains shown in Table 2. We reported, without prioritization, frequencies and percentages of all need domains and goals identified by participants. We compared the proportion of youth reporting each need domain by discharge status (admitted vs. discharged from ED) using Fisher’s exact tests. For continuous variables, we calculated means and standard deviations or medians and interquartile ranges (IQR), as appropriate. Data were analyzed using SAS (Version 9.3).
Table 2.
Descriptive Summary of Male Participants’ Identified Needs and Goals (N=45)
| Need Domain | Examples of Youth Identified Goals | Youth Reporting Need | Median Number of Goals Within Domain | Interquartile Range | |
|---|---|---|---|---|---|
| N | % | ||||
| Mental Health |
|
40 | 88.9 | 1.0 | 1–2 |
| Legal |
|
27 | 60.0 | 2.0 | 1–2 |
| Education/School |
|
26 | 57.8 | 1.5 | 1–2 |
| Psycho-educational groups |
|
25 | 55.6 | 1.0 | 1–2 |
| Employment |
|
21 | 46.7 | 1.0 | 1–2 |
| Medical |
|
18 | 40.0 | 2.0 | 1–3 |
| Safety |
|
18 | 40.0 | 1.0 | 1–2 |
| Basic Needs Assistance a |
|
15 | 33.3 | 2.0 | 1–4 |
| Parent Training |
|
7 | 15.6 | 1.0 | 1 |
| Substance Use Treatment |
|
4 | 8.9 | 1.5 | 1–4.5 |
| Public Income/Social Security Income |
|
4 | 8.9 | 1.5 | 1–2.5 |
| Health Insurance |
|
3 | 6.7 | 1.0 | 1–2 |
| Extracurricular Activities |
|
3 | 6.7 | 1.0 | 1 |
| Child Protection |
|
2 | 4.4 | 2.5 | 2–3 |
This domain addresses needs related to housing, food, clothing, and other basic needs.
RESULTS
Between January 2012 and August 2016, 49 male youth enrolled in the program. Table 1 summarizes the demographic, injury, and psychosocial characteristics of youth at program intake. The majority of youth were referred by ED social workers and sought care for non-penetrating injuries. Consistent with racial demographics of our ED patients, most program participants were Black. Most youth were between the ages of 12 and 17 years (88.8%, Range: 8–17 years), 75.5% were discharged directly from the ED, and slightly more than half previously received mental health care. At intake, 63.4% of youth reported clinically significant traumatic stress symptoms.
Table 1.
Descriptive Summary of Male Violence Intervention Program Participants (N=49)
| Characteristic | N | % |
|---|---|---|
| Age at Injury, Mean (SD) | 14.2 (2.1) | |
| Race | ||
| Black | 44 | 89.8 |
| White | 2 | 4.1 |
| Other or More than One Race | 3 | 6.1 |
| Hispanic | 3 | 6.1 |
| Referral Source: ED | 39 | 79.6 |
| Referral Source: Trauma Unit | 10 | 20.4 |
| Grade in School at Injury | ||
| Not currently attending school | 2 | 4.1 |
| Elementary school (grades 4 & 5) | 5 | 10.2 |
| Middle school (grades 6–8) | 9 | 18.4 |
| High school (grades 9–12) | 26 | 53.1 |
| Missing grade data | 7 | 14.3 |
| Mechanism of Injury | ||
| Assault (Blunt Trauma/Non-penetrating) | 39 | 79.6 |
| Gun Shot Wound | 5 | 10.2 |
| Stab Wound | 5 | 10.2 |
| ED Disposition: Discharged | 37 | 75.5 |
| ED Disposition: Admitted | 12 | 24.5 |
| Previous violence-related injury (n=37) | 11 | 29.7 |
| Fight in school or community in prior year (n=35) | 19 | 54.3 |
| Previously received mental health care (n=41) | 22 | 53.7 |
| ADHD (n=22)a | 10 | 45.5 |
| Anger (n=22)a | 7 | 31.8 |
| PTSD/trauma-symptoms (n=22)a | 6 | 27.3 |
| Depression (n=22)a | 4 | 18.2 |
| Intellectual disability (n=22)a | 1 | 4.5 |
| Not specified (n=22)a | 3 | 13.6 |
| Clinically Significant CPSS Score | 26 | 63.4 |
Reasons cited by participants for receiving mental health care prior to program participation. Categories are not mutually exclusive and reflect self-reported reasons for treatment, not necessarily the clinical diagnosis provided by a clinician.
Four youth withdrew or were lost from contact before program intake. Among the remaining 45 participants, the majority identified between one and three need domains, with most identifying mental health needs (88.9%) and more than half reporting needing legal support, education, or psycho-educational peer groups (Table 2). Nearly two-thirds of youth (62.5%) identified mental health needs within one week of program initiation. Youth discharged from the ED were significantly more likely to identify safety needs compared to youth who were admitted (p<0.04). Youth could identify multiple need domains, as well as multiple goals within each domain (examples in Table 2). Youth identified a median of five goals (IQR: 4–11) across the need domains; one “outlier” youth with 83 goals had medical complications, prolonging participation. Participants identified the highest number of goals within the domains of child protection, medical, legal, and basic needs assistance (e.g. food, clothing, and housing).
DISCUSSION
Youth identified a vast need for mental health care in the aftermath of violent injury. Adolescent males experience a disproportionally high burden of interpersonal victimization, as well as exposure to additional forms of violence, which are associated with poor mental health [7]. Although most youth were discharged from the ED following minor injuries, many reported clinically significant traumatic stress symptoms and nearly all reported a mental health need, despite nearly half of the youth having never received mental health care. Youth identified multiple discrete recovery goals, indicating openness to support following violent injury, representing a critical moment for teaching and intervention [4].
A greater proportion of youth self-identified mental health needs as compared to prior studies [8, 9]. By employing a trauma-informed approach, whereby youth are empowered with voice and choice [10], goals are likely more relevant and sensitive to youths’ needs. Many youth reported legal and educational needs, highlighting the urgency of support across diverse areas of their lives following assault injury. Further, youth discharged from the ED were more likely to identify safety needs than youth admitted for inpatient care, emphasizing the need for safety planning. Since the violence intervention program addresses multiple youth-identified goals simultaneously, program staff can provide trauma-informed advocacy and expertise within multiple youth-serving systems.
These results may not generalize to all settings, given our sample of male youth who voluntarily participated in a single hospital-based violence intervention program. However, the majority of violence intervention programs like ours nationally, provide services to demographically similar populations. Future research is needed to examine the needs of other programs’ participants, as well as female youth.
Study results suggest that male adolescents self-identify a diverse range of post-injury needs. Despite limited prior utilization of mental health services, youth articulated a desire for mental health support. Providing youth with access to trauma-informed case management following violent injury may reduce the burden of post-victimization mental health morbidity, improve outcomes across multiple domains of youth functioning, and reduce the likelihood for future injury.
Implications and Contribution.
This study examined the self-identified recovery needs of recently injured male adolescents. Findings highlight that youth self-identified multiple post-assault needs, which overwhelmingly included support in accessing mental health care. Early, trauma-informed interventions, which provide youth with voice in their recovery, may help overcome barriers to engaging male youth in services.
Acknowledgments
We are deeply grateful to the youth who have participated in the Violence Intervention Program and honestly and openly shared their goals and needs with Violence Intervention Program staff. We would like to acknowledge the tremendous efforts of VIP team members: Ayana Bradshaw, MPH; Danielle Centeno, MA; Caroline Menapace, MSW; Brooke Paskewich, PsyD; and Jody Thigpen, MSW.
Funding Sources: Dr. Culyba received support from the National Institutes of Health (NIH), Eunice Kennedy Shriver National Institute of Child Health and Human Development, grant F32 HD084028. The content is solely the responsibility of the authors and does not necessarily represent the official views of the NIH. There were no other specific grants from funding agencies in the public, commercial, and not-for-profit sectors.
Abbreviations
- ED
Emergency Department
- CPSS
Child Post-Traumatic Stress Symptom Scale
- IQR
Interquartile ranges
- ADHD
Attention Deficit Hyperactivity Disorder
- PTSD
Post-Traumatic Stress Disorder
- SD
Standard Deviation
Footnotes
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