Skip to main content
NCBI home page
NIHPA Author Manuscripts logoLink to NIHPA Author Manuscripts
. Author manuscript; available in PMC: 2020 Apr 24.
Published in final edited form as: Adolesc Med State Art Rev. 2016 Fall;27(2):351–363.

Treating Youth Violence in Hospital and Emergency Department Settings

Jonathan Purtle a,*, Patrick M Carter b,c,d, Rebecca Cunningham e, Joel A Fein f
PMCID: PMC7182089  NIHMSID: NIHMS1583114  PMID: 29462525

INTRODUCTION

Youth violence is a significant US public health problem and a leading cause of adolescent morbidity and mortality.1 Homicide is the third leading cause of death among youth aged 10 to 24 years and has been the leading cause of death among black youth for well over a decade.2 Violently injured youth are at high risk for repeat injury; with recent data indicating that violent reinjury rates among urban youth treated in the emergency department (ED) are as high as 37%.3 Furthermore, these youth have high rates of involvement with severe and escalating forms of violence, with almost 60% reporting involvement with firearm violence as either a victim or aggressor within 2 years after receiving care for an assault injury.4

The high rate of violent injury recidivism among adolescent youth, as well as a growing body of literature highlighting the preventable nature of youth violence, mandates that health care providers (eg, physicians, nurses, social workers) address this as a public health rather than a criminal issue.5 Such an approach allows health care providers to address a wide range of modifiable risk factors. Such factors are being addressed through evidence-based prevention programs that are being implemented in hospital settings. In addition, national medical organizations, including the American Academy of Pediatrics6 and the Institute of Medicine,7 have emphasized the importance of this public health approach and the need to incorporate violence prevention into standard adolescent medical practice.8

EPIDEMIOLOGY, SEQUELAE, AND RISK FACTORS

Our review is guided by the Centers for Disease Control and Prevention (CDC) definition of youth violence.9 The CDC defines youth as adolescents and young adults between the ages of 10 and 24 years and defines violence as “the intentional use of physical force or power, threatened or actual, against another person or against a group or community that results in or has a high likelihood of resulting in injury, death, psychological harm, maldevelopment, or deprivation.” In this review, we focus on violent injury resulting from peer and community violence but exclude interpersonal violence resulting from dating violence, sexual assault, and child abuse because these types of injuries have differing medical and psychosocial needs with a distinct research literature that is the focus of other reviews.10

In 2013, violent injury resulted in the death of 4481 youth aged 10 to 24, a rate of 6.95 per 100,000 population.11 Violent injury is the third leading cause of death among youth aged 15 to 24 and fifth among those 10 to 14 years old.11 Firearms are the leading mechanism of fatal violent injuries, responsible for 85% of all youth homicides. The societal cost of these injuries is substantial, with estimates of lifetime costs for youth aged 10 to 24 who die by violence exceeding $9 billion annually when accounting for acute and long-term medical costs, legal costs, and lost wages and productivity.2 Most youth who receive hospital care for a violent injury, however, survive their injuries and are discharged.

Non-fatal hospital-treated violent injuries among youth outnumber fatal injuries 120 to 1.12 Approximately 547,000 youth aged 10 to 24 received care for a non-fatal violent injury in 2013. Most of these injures (87%) did not result in hospital admission. The average cost of medical care for treating a violently injured youth between the ages of 10 and 24 years is $27,807 when the patient is admitted and $2,666 when the patient is treated and released. This translates into a societal cost of $2.9 billion annually from medical costs alone.2,13

Race and gender disparities in violent injury among youth are pervasive. In 2013, the rate of fatal violent injury among youth aged 10 to 14 was more than 6 times higher among males than females (12 vs 2 per 100,000) and nearly 10 times higher among black males than white males (46 vs 5 per 100,000). The rate of non-fatal violent injury was also significantly higher among males than females (1035 vs 650 per 100,000), among blacks than whites (1,402 vs 847 per 100,000), and nearly 3 times higher among black males than white males (1,752 vs 616 per 100,000). These disparities are compounded by a lack of psychosocial services available in many urban low-income communities.

Repeat Violent Injury

Violently injured patients are at elevated risk for a repeat violent injury after discharge from the ED or hospital.14 Without intervention, it is estimated that approximately 30% of violently injured youth are reinjured as a result of interpersonal violence within 5 years.14,15 Cross-sectional studies suggest that roughly 9% of youth who sustain a violent injury are violently reinjured within 1 year.16–18 Prospective studies of high-risk youth have observed even higher rates. The Flint Youth Injury Study, a 2-year prospective cohort study of youth aged 14 to 24 years with recent drug use, found that 37% of those who presented to the ED with a violent injury sustained a repeat violent injury within 2 years, which is almost twice the proportion of those who presented initially for non–violence-related reasons.3 Most of these repeat violent injuries occurred within the first 6 months of the initial ED visit. The youth in the assault-injured cohort were also at high risk for involvement with firearm violence, with almost 60% of these youth reporting being either the victim or aggressor in a shooting 2 years after the initial ED visit.4

Symptoms of Post-Traumatic Stress

The psychological trauma of violent injuries can cause and exacerbate existing mental health problems.19 Compared to youth presenting to the ED for other reasons, violently injured patients have a higher prevalence of post-traumatic stress disorder (PTSD, 12.6% vs 6.8%).20 A substantial proportion of youth experience symptoms of acute stress disorder, including nightmares, hypervigilance, and emotional numbing, while in the hospital.21 Higher levels of these symptoms at baseline are predictive of elevated symptom severity at 5-month follow-up.22 Major risk factors for post-traumatic stress symptoms among youth after witnessing or being a victim of violence include prior traumatization, low social support, and financial distress.23 Although objective injury severity is not an independent risk factor for post-traumatic stress symptoms, subjective appraisals of the trauma (eg, feelings of fear and perceived life threat) are associated with increased risk.24

Risk Factors for Involvement with Violence

Individual-Level Risk Factors

At the individual level, attention and learning problems, antisocial beliefs and attitudes, and exposure to violence have been associated with higher levels of aggressive behavior.25 The symptoms of PTSD have also been associated with increased risk for violent injury. For example, PTSD was found to be twice as common among youth who went on to sustain a violent reinjury within 2 years of an initial violent injury compared to youth who visited an ED for non–violence-related reasons.4 Symptoms such as hyperarousal can increase risk for violent aggression, whereas impaired processing, hypervigilance, and concurrent substance use can decrease defensive signals (eg, decrease the ability to recognize high-risk situations) and lead to victimization.26

Social-Level Risk Factors

Family and peer relationships moderate the association between risk factors and youth involvement with violence. Elevated levels of family conflict, limited parental involvement or emotional attachment, low parental education or income, and favorable family attitudes toward violence (eg, corporal disciplinary practices) are associated with elevated risk for youth violence involvement.27 Peer relationships affect violence involvement, especially as peer influence begins to surpass parental influence during adolescent development.28 Association with delinquent peer groups and involvement with gangs can increase the risk for violence involvement and criminal behavior.29

Community-Level Risk Factors

Neighborhood factors also play a role in youth involvement with violence. Characteristics such as high rates of crime, poverty, and family disruption increase the risk that youth living in these neighborhoods will become involved with violence.30,31 Youth living in disadvantaged neighborhoods also have higher levels of exposure to violence-related traumatic stress and less exposure to positive role models and prosocial peer relationships.32

INTERVENTIONS TO ADDRESS YOUTH VIOLENCE IN EMERGENCY DEPARTMENTS AND HOSPITAL SETTINGS

Screening for Violence Risk among High-Risk Youth

Incorporating violence prevention strategies into clinical practice requires identification of youth who are at risk for future involvement in violence. The risk for repeat injury and retaliatory violence has been shown to be highest within the first 6 months after treatment for a violent injury.3,4,33 Given the elevated risk for violence among these youth, many of whom have poor school attendance34 and infrequent primary care visits,35 delaying intervention may not alter violence risk trajectories. Although barriers to screening for youth violence exist, many EDs have successfully integrated screening for other types of violence into routine clinical care. For example, physicians and nurses are trained to assess risk for intimate partner violence, child maltreatment, and suicide risk when examining patients with concerning injury patterns. Adapting training protocols and methods from successful screening practices and applying them to youth violence prevention may help health care providers overcome barriers to screening.

Several violence involvement screening tools have been empirically validated for use in primary care and school settings and could serve as templates for screening tools to be used in the ED. For example, the Brief Violence Risk-Screening Tool is a 3-item assessment developed for use in primary care settings that predicts future violence-related injury.36 Youth are asked 3 questions related to their school performance, drug use, and involvement in physical fights. Based on their responses, youth are stratified into 1 of 3 categories associated with a 5-year risk for violence-related injury. The similar but more extensive 14-item Violence Injury Protection and Risk Screen has also been validated for use in the outpatient setting to predict risk for future serious violence perpetration37 and has recently been validated to assess risk for cyber violence.38 The FiGHTS screening tool is a 5-item validated screening tool that predicts risk of firearm carriage among adolescents39 at 1-month follow-up and has 82% sensitivity and 71% specificity (Table 1).

Table 1:

FiGHTS screening tool

Fighting During the last 12 months, have you been in a physical fight?
Gender Male
Hurt During the last 12 months, have you been in a fight in which you were injured and had to be treated by a doctor or a nurse?
Threatened During the last 12 months, have you been threatened with a weapon (gun/knife) on school property?
Smoker Have you ever smoked cigarettes regularly? (1 cigarette per day for 30 days)
Open in a new tab

The Children’s Hospital of Philadelphia has developed a 5-item safety screening tool to assess retaliatory risk among youth aged 11 to 24 seeking care for a violent injury (Table 2). The tool is used to identify and triage youth at low, medium, and high risk for repeat injury and retaliation. Patients identified as being at high risk are referred for a lengthier assessment.

Table 2:

Children’s Hospital of Philadelphia safety screening tool

  1. Do you know who the person is who hurt you?

  2. Do you think that the conflict that caused this incident is over?

  3. Do you plan to hurt anyone because of what happened today?

  4. Do you think that any of your friends or family members will hurt anyone because of what happened today?

  5. Have you reported the incident to the police or other authority?
Open in a new tab

Hospital-Based Violence Interventions

The purpose of screening for violence risk is to identify youth who would benefit from interventions to prevent future involvement with violence. A growing number of hospital-based violence prevention programs have been developed to meet this need. Existing programs are supported by varying levels of evidence and range from programs that focus solely on identifying at-risk youth and linking them to available community resources to more comprehensive programs that provide treatment of modifiable risk factors related to violent injury risk (eg, substance use, PTSD). Many interventions also incorporate cognitive behavioral skills training (eg, conflict resolution) to provide a foundation in strategies for managing conflict in ways that will not escalate to more severe forms of violence.

A growing number of interventions extend beyond the patient’s initial hospital encounter and provide services during the extended acute postinjury period when retaliatory risk is highest. Although there is no one-size-fits-all approach, effective prevention strategies have several common themes, including a focus on assessment and treatment of acute psychosocial needs, positive youth development, mentoring and skill development, and coordination of posthospital services. Research has clearly established that prevention strategies that emphasize scare tactics (eg, trauma bay or morgue tours) are ineffective at reducing violence risk.40 Given the high number of youth who are discharged after a violent injury (approximately 90% in ED samples), initiating intervention at the time of care has been suggested as the optimal strategy for engaging at-risk youth. However, it is prudent for health care providers to consider these hospital-based options for any youth whom they identify as being at high risk for future violent injury. Violence prevention programs utilize a variety of strategies to deliver such interventions in busy clinical settings, including social workers, peer volunteers, and tablet-based programs that do not require intensive on-site personnel. In this section, we outline several examples of interventions that have been successfully used in clinical settings.

SafERteens

Motivational interviewing (MI) is a goal-oriented, patient-centered counseling style that elicits behavior change by allowing patients to explore and resolve their ambivalence about changing risky behaviors in a non-confrontational and non-judgmental manner.41 An example of how MI can be applied to violence prevention is SafERteens, a screening and 30-minute brief counseling intervention for decreasing violence and substance use behaviors among teens aged 14 to 18 who report recent fighting and alcohol use.42,43 The brief, therapist-guided counseling intervention uses MI and role-playing within a cognitive behavioral framework and provides tailored feedback and skill-building to reduce risk behaviors such as fighting and weapon carrying.5,42 Teens also receive information and referrals to psychosocial services.43,44

The SafERteens intervention was tested in a 5-year randomized controlled trial (RCT) using 2 parallel delivery modes, a therapist-guided version supported by a computer and a fully computerized version. Both delivery modes were found to positively change alcohol- and violence-related attitudes and to reduce alcohol-related consequences up to 6 months after the ED visit.43 Although both delivery modes also enhanced self-efficacy for avoiding violence, only the therapist intervention significantly reduced violent behaviors (eg, peer victimization, peer aggression, consequences of fighting) at 3 months, with the decrease in peer aggression and victimization maintained at 12 months.43,44 SafERteens was cost-effective, with an estimated cost of $17 per event or violence consequence averted.43 Information on implementing SafeERteens is available at www.saferteens.org.

Collaborative Care

Originally emerging out of primary care settings, collaborative care is a multi-component model in which care managers (eg, social workers) collaborate with physicians across specialties to enhance care coordination and improve health outcomes among patients with comorbid physical and mental health conditions.45 Collaborative care combines case management techniques (eg, help contacting social services, aid in navigating health care system, addressing barriers to follow-up) with components such as MI, cognitive behavioral therapy, and pharmacotherapy. The intervention is often implemented as a stepped model in which intervention intensity varies according to patient need. Care managers continuously monitor patient progress with validated assessment instruments and have flexibility to target needs and behaviors that are recognized as most important. Collaborative care is an established, evidence-based strategy that reduces depression and has demonstrated effectiveness in decreasing post-traumatic stress symptoms among injured adults.46,47 Collaborative care has recently been adapted to target violent risk behaviors among injured youth.

A pragmatic RCT of a stepped collaborative care intervention evaluated the effect on violence risk behaviors, drug and alcohol use, PTSD, and depression over the course of 12 month among injured adolescents who received trauma center care.48 The intervention combined trauma center-based care management, MI targeting violence risk behaviors, cognitive behavioral therapy focused on PTSD and depressive symptoms, and pharmacotherapy delivered by a social worker and a nurse practitioner. The intervention significantly reduced weapon carrying behavior, with 7% of intervention group participants reporting the behavior at 12-month follow-up compared to 21% in the control group, but did not significantly alter other intervention targets (eg, PTSD, depression, substance misuse). More research is needed to understand how collaborative care interventions may be optimally designed to address violence and injury risk in the ED and primary care settings.

Programs Serving Youth with Assault Injuries

In contrast to the collaborative care intervention model, which was initially developed for primary care and subsequently adapted for trauma center settings, many programs have been developed specifically for youth experiencing violent injuries receiving hospital-based care through either the ED or inpatient services. Injured youth and their families are invited to participate in intensive individual- and family-based interventions that offer support and referrals after hospital discharge.49 These programs connect patients with psychosocial resources that promote protective factors and reduce risk factors.50 The logistics through which these programs operate vary between hospitals and are detailed elsewhere,5,51,52 but they generally align with the process outlined here.

Violently injured youth are either met in person or contacted by phone by program staff, usually social workers or peer specialists, after reviews of the medical record system or referrals from physicians, nurses, and hospital-based social workers. The first encounter may be in the hospital or after discharge. The encounter focuses on establishing trust and assessing immediate risk for reinjury and retaliation while frequently providing trauma-focused psychoeducation. Together, program staff, the patient, and the family address safety needs and other immediate goals (eg, arranging temporary housing in a safe neighborhood) and then make follow-up appointments if the patient and family elect to continue. At this juncture, some programs link patients to community-based programs such as Safe Streets and Cure Violence (previously known as Cease-Fire).53 Other programs use hospital-supported staff to meet clients and families in community settings. A comprehensive psychosocial assessment conducted at the hospital, or in a community setting, informs longer-term goals targeting physical and mental health, education, employment, criminal justice, peers, and family relationships, which are then addressed through case management services. Throughout the case management phase, staff help clients manage symptoms of post-traumatic stress, resist peer pressure to retaliate, and envision a safe future. The frequency of patient-staff encounters varies according to need. Patients are typically engaged in programs for 4 months to 1 year.

The practice of many programs is guided by the tenets of trauma-informed care.54 These programs view violent injury as a traumatic event and acknowledge the high prevalence of trauma exposure among violently injured youth and the social, emotional, biologic, and cognitive effects of these exposures. Accordingly, trauma-informed programs cultivate adaptive coping skills, foster a supportive social environment, and develop a cognitive framework that promotes healing. This approach is antithetical to “scared safe” violence intervention programs that attempt to spur behavioral change through fear and education about the risks of violence.38

Five RCTs and 3 quasi-experimental evaluations have assessed program effectiveness51; however only 2 of these evaluations have exclusively focused on youth.55,56 Among samples of young adults, the program model has demonstrated effectiveness across the domains of preventing violent reinjury, violent perpetration, involvement with the criminal justice system, and improving employment. The 2 evaluations that have exclusively focused on youth—one limited to youth aged 10 to 1555 and the other to youth aged 12 to 2056—have found benefits in decreasing youth involvement with the criminal justice system but not reinjury. Systematic reviews have highlighted that the strength of program evaluations has been limited by inconsistent outcome measures, lack of fidelity measures, high attrition rates, and small sample sizes.5,57 Despite these limitations, economic evaluations indicate that the programs could generate substantial cost savings for health care and criminal justice sectors.16,58–59 The National Network of Hospital-based Violence Intervention Programs, a national organization with more than 25 member programs that provide training and technical assistance (http://nnhvip.org), is promoting multisite research to address these issues. This includes the development of standardized measures for outcome evaluations and a Web-based repository to collect multisite program data.

Programs are funded through a variety of mechanisms, including hospital operating budgets, philanthropic grants, and public sector contracts. Some programs receive partial reimbursement for services through Medicaid and Victim of Crime Assistance agencies. Although many programs struggle to maintain financial viability, the Patient Protection and Affordable Care Act presents opportunities for programs to become more sustainable.49 For example, not-for-profit hospitals can implement a program to help satisfy community benefit requirements and maintain tax exempt status.

Strategies for Health Care Settings without Violence Intervention Programs

Many health care settings do not have the infrastructure to support a hospital-based violence prevention program. However, there are a growing number of resources to support individual providers who are interested in improving the standard of care for violently injured patients. The CDC has created a compendium of screening and assessment tools to measure violence-related behaviors, as well as an overview of methods for evaluating youth violence prevention programs.60 In addition, the CDC has developed an online resource titled “Connecting the Dots: An Overview of the Links among Multiple Forms of Violence.” Although not specific to youth violence, the overview provides educational resources for health care providers interested in the topic. Finally, many hospital-based violence prevention programs and national organizations have developed online resources for health care providers with interest in providing violence prevention services (Table 3).

Table 3:

Resources for youth violence prevention

Resource Web site
National Network of Hospital-based Violence Intervention Programs www.nnhvip.org
Reinjury Prevention for Youth Presenting with Violence Related Injuries: A Training Curriculum for Trauma Centers www.stopyouthviolence.ucr.edu
American Academy of Pediatrics “Connected Kids Program: Safe, Strong, Secure” http://www2.aap.org/connectedkids
SafERteens Youth Violence Prevention Program www.injurycenter.umich.edu/programs/saferteens
University of Michigan Injury Center “Parents Guide to Home Firearm Safety” www.injurycenter.umich.edu
Children’s Hospital of Philadelphia “After the Injury” www.aftertheinjury.org
The Society for Advancement of Violence and Injury Research “Instrument Library” savir.wildapricot.org/SAVIR_Inst_Lib
Open in a new tab

Hospital-Community Partnerships

In most cities across the United States, there are non-profit and municipal agencies dedicated to reducing the incidence and effect of youth violence. Hospitals that develop strong, mission-focused relationships with these agencies can reap large benefits through the provision of in-house and post-discharge services. For example, primary prevention efforts in schools, in which hospital-based experts help to formulate and design curricula, have been shown to reduce relational aggression in girls.61 Tertiary prevention can also be enhanced by referring violently injured youth to well-established programs such as Big Brother Big Sister and other community-based support agencies. The goal is to create a win-win situation in which the community agency gains credit for its specific service goals and the hospital or practice gains a reliable referral resource and partners for system improvement.

CONCLUSION

Physicians have repeatedly been called upon to address violence in America. In 1985, C. Everett Koop convened the Surgeon General’s Workshop on Violence and Public Health and issued a charge to determine “how the health professions might provide better care for victims of violence and also how they might contribute to the prevention of violence.”62 In 2015, the Annals of Internal Medicine published a call to action to address violence that was endorsed by 8 professional medical societies, including the American Academy of Pediatrics.63 During the 30-year interim, a substantial body of research has identified the correlates and consequences of violence and strategies for preventive intervention. In most health facilities, however, the standard of care for treating youth violence has remained largely unchanged; physical wounds are treated and patients are discharged, often to only return with a repeat injury.3,14 Today, physicians’ commitment to addressing violence and the quality of evidence to inform action are stronger than ever, and the evolving evidence base for identification, assessment, and interventions is encouraging.

References

  • 1.Krug EG, Mercy JA, Dahlberg LL, Zwi AB. The world report on violence and health. Lancet. 2002;360(9339):1083–1088 [DOI] [PubMed] [Google Scholar]
  • 2.Centers for Disease Control and Prevention, National Center for Injury Prevention and Control. Web-based Injury Statistics Query and Reporting System (WISQARS). www.cdc.gov/injury/wisqars. Updated April 15, 2016. Accessed April 25, 2016
  • 3.Cunningham RM, Carter PM, Ranney M, et al. Violent reinjury and mortality among youth seeking emergency department care for assault-related injury: a 2-year prospective cohort study. JAMA Pediatr. 2015;169(1):63–70 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 4.Carter PM, Walton MA, Roehler DR, et al. Firearm violence among high-risk emergency department youth after an assault injury. Pediatrics. 2015;135(5):805–815 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 5.Cunningham R, Knox L, Fein J, et al. Before and after the trauma bay: the prevention of violent injury among youth. Ann Emerg Med. 2009;53(4):490–500 [DOI] [PubMed] [Google Scholar]
  • 6.Dowd MD, Sege RD; American Academy of Pediatrics Council on Injury Violence, Poison Prevention Executive Committee. Firearm-related injuries affecting the pediatric population. Pediatrics. 2012;130(5):e1416–e1423 [DOI] [PubMed] [Google Scholar]
  • 7.Leshner AI, Altevogt BM, Lee AF, McCoy MA, Kelley PW. Priorities for research to reduce the threat of firearm-related violence. Washington, DC: The National Academies Press, 2013 [Google Scholar]
  • 8.Frattaroli S, Webster DW, Wintemute GJ. Implementing a public health approach to gun violence prevention: the importance of physician engagement. Ann Intern Med. 2013;158(9):697–698 [DOI] [PubMed] [Google Scholar]
  • 9.Centers for Disease Control and Prevention, National Center for Injury Prevention and Control. Youth violence: definitions. www.cdc.gov/violenceprevention/youthviolence/definitions.html. Updated March 21, 2016. Accessed May 4, 2016
  • 10.Lin AJ, Raymond M, Catallozzi M, Ryan O, Rickert VI. Relationship violence in adolescence. Adolesc Med State Art Rev. 2007;18(3):530–543 [PubMed] [Google Scholar]
  • 11.Centers for Disease Control and Prevention, National Center for Injury Prevention and Control. Web-based Injury Statistics Query and Reporting System (WISQARS). Fatal injury data. www.cdc.gov/injury/wisqars/fatal.html. Updated April 15, 2016. Accessed April 25, 2016
  • 12.Centers for Disease Control and Prevention, National Center for Injury Prevention and Control. Web-based Injury Statistics Query and Reporting System (WISQARS). 10 leading causes of death by age group, United States—2013. Available at: www.cdc.gov/injury/images/lc-charts/leading_causes_of_death_by_age_group_2013-a.gif. Accessed February 22, 2016
  • 13.Centers for Disease Control and Prevention, National Center for Injury Prevention and Control. Web-based Injury Statistics Query and Reporting System (WISQARS). Nonfatal injury data. www.cdc.gov/injury/wisqars/nonfatal.html. Updated April 12, 2016. Accessed April 25, 2016
  • 14.Rowhani-Rahbar A, Zatzick D, Wang J, et al. Firearm-related hospitalization and risk for subsequent violent injury, death, or crime perpetration: a cohort study. Ann Intern Med. 2015;162(7): 492–500 [DOI] [PubMed] [Google Scholar]
  • 15.Mikhail JN, Nemeth LS. Trauma center based youth violence prevention programs: an integrative review. Trauma Violence Abuse. 2015;[Epub ahead of print] [DOI] [PubMed] [Google Scholar]
  • 16.Purtle J, Rich LJ, Bloom SL, Rich JA, Corbin TJ. Cost-benefit analysis simulation of a hospital-based violence intervention program. Am J Prev Med. 2015;48(2):162–169 [DOI] [PubMed] [Google Scholar]
  • 17.Cunningham RM, Walton MA, Roahen Harrison S, et al. Past-year intentional and unintentional injury among teens treated in an inner-city emergency department. J Emerg Med. 2011;41(4): 418–426 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 18.Chang JJ, Chen JJ, Brownson RC. The role of repeat victimization in adolescent delinquent behaviors and recidivism. J Adolesc Health. 2003;32(4):272–280 [DOI] [PubMed] [Google Scholar]
  • 19.Kelly VG, Merrill GS, Shumway M, Alvidrez J, Boccellari A. Outreach, engagement, and practical assistance: essential aspects of PTSD care for urban victims of violent crime. Trauma Violence Abuse. 2010;11(3):144–156 [DOI] [PubMed] [Google Scholar]
  • 20.Bohnert KM, Walton MA, Ranney M, et al. Understanding the service needs of assault-injured, drug-using youth presenting for care in an urban Emergency Department. Addict Behav. 2015;41:97–105 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 21.Fein JA, Kassam-Adams N, Vu T, Datner EM. Emergency department evaluation of acute stress disorder symptoms in violently injured youths. Ann Emerg Med. 2001;38(4):391–396 [DOI] [PubMed] [Google Scholar]
  • 22.Fein JA, Kassam-Adams N, Gavin M, et al. Persistence of posttraumatic stress in violently injured youth seen in the emergency department. Arch Pediatr Adolesc Med. 2002;156(8):836–840 [DOI] [PubMed] [Google Scholar]
  • 23.Lowe SR, Galea S, Uddin M, Koenen KC. Trajectories of posttraumatic stress among urban residents. Am J Commun Psychol. 2014;53(1–2):159–172 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 24.Kassam-Adams N, Marsac ML, Hildenbrand A, Winston F. Posttraumatic stress following pediatric injury: update on diagnosis, risk factors, and intervention. JAMA Pediatr. 2013;167(12): 1158–1165 [DOI] [PubMed] [Google Scholar]
  • 25.Centers for Disease Control and Prevention, National Youth Violence Prevention Resource Center. Youth violence: risk and protective factors. www.cdc.gov/violenceprevention/youthviolence/riskprotectivefactors.html. Updated March 21, 2016. Accessed April 25, 2016
  • 26.Orcutt HK, Erickson DJ, Wolfe J. A prospective analysis of trauma exposure: the mediating role of PTSD symptomatology. J Trauma Stress. 2002;15(3):259–266 [DOI] [PubMed] [Google Scholar]
  • 27.Youngblade LM, Theokas C, Schulenberg J, Curry L, Huang I. Risk and promotive factors in families, schools, and communities: a contextual model of positive youth development in adolescence. Pediatrics. 2007;119(Suppl 1):S47–S53 [DOI] [PubMed] [Google Scholar]
  • 28.Herrenkohl TI, Maguin E, Hill KG, Hawkins JD, Catalano RF. Developmental risk factors for youth violence. J Adolesc Health. 2000;26(3):176–186 [DOI] [PubMed] [Google Scholar]
  • 29.Ferguson CJ, Meehan DC. Saturday night’s alright for fighting: antisocial traits, fighting, and weapons carrying in a large sample of youth. Psychiatr Q. 2010;81(4):293–402 [DOI] [PubMed] [Google Scholar]
  • 30.Molnar BE, Cerda M, Roberts AL, Buka SL. Effects of neighborhood resources on aggressive and delinquent behaviors among urban youth. Am J Public Health. 2008;98:1086–1093 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 31.Sampson RJ, Morenoff JD. Ecological perspectives on the neighborhood context of urban poverty: past and present In: Brooks-Gunn J, Duncan GJ, Aber JL, eds. Neighborhood Poverty: Policy Implications in Studying Neighborhoods. New York: Russell Sage Foundation; 1997:1–22 [Google Scholar]
  • 32.Bolland JM. Hopelessness and risk behavior among adolescents living in high-poverty inner-city neighborhoods. J Adolesc. 2003;26(2):145–158 [DOI] [PubMed] [Google Scholar]
  • 33.Copeland-Linder N, Johnson SB, Haynie DL, Chung SE, Cheng TL. Retaliatory attitudes and violent behaviors among assault-injured youth. J Adolesc Health. 2012;50(3):215–220 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 34.Ramirez M, Wu Y, Kataoka S, et al. Youth violence across multiple dimensions: a study of violence, absenteeism, and suspensions among middle school children. J Pediatr. 2012;161(3):542–546, e542 [DOI] [PubMed] [Google Scholar]
  • 35.Grove DD, Lazebnik R, Petrack EM. Urban emergency department utilization by adolescents. Clin Pediatr (Phila). 2000;39(8):479–483 [DOI] [PubMed] [Google Scholar]
  • 36.Sege R, Stringham P, Short S, Griffith J. Ten years after: examination of adolescent screening questions that predict future violence-related injury. J Adolesc Health. 1999;24(6):395–402 [DOI] [PubMed] [Google Scholar]
  • 37.Sigel E, Hart J, Hoffenberg A. Dodge M. Development and psychometric properties of a violence screening tool for primary care. J Adolesc Health. 2011;48:358–365 [DOI] [PubMed] [Google Scholar]
  • 38.Sigel EJ. Violence risk screening: predicting cyber violence perpetration and victimization. J Adolesc Health. 2013;52(2 Suppl 1):S53 [Google Scholar]
  • 39.Hayes DM, Sege R. FIGHTS: a preliminary screening tool for adolescent firearm carrying. Ann Emerg Med. 2003;42:798–807 [DOI] [PubMed] [Google Scholar]
  • 40.Purtle J, Cheney R, Wiebe D, Dicker R. Scared safe? Abandoning the use of fear in urban violence prevention programs. Injury Prev. 2015;21:140–141 [DOI] [PubMed] [Google Scholar]
  • 41.Hettema J, Steele J, Miller WR. Motivational interviewing. Annu Rev Clin Psychol. 2005;1:91–111 [DOI] [PubMed] [Google Scholar]
  • 42.Cunningham RM, Walton MA, Goldstein A, et al. Three-month follow-up of brief computerized and therapist interventions for alcohol and violence among teens. Acad Emerg Med. 2009;16(11):1193–1207 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 43.Walton MA, Chermack ST, Shope JT, et al. Effects of a brief intervention for reducing violence and alcohol misuse among adolescents: a randomized controlled trial. JAMA. 2010;304(5):527–535 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 44.Sharp AL, Prosser LA, Walton M, et al. Cost analysis of youth violence prevention. Pediatrics. 2014;133(3):448–453 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 45.Katon W, Von Korff M, Lin E, Simon G. Rethinking practitioner roles in chronic illness: the specialist, primary care physician, and the practice nurse. Gen Hosp Psychiatry. 2001;23(3):138–144 [DOI] [PubMed] [Google Scholar]
  • 46.Zatzick D, Roy-Byrne P, Russo J, et al. A randomized effectiveness trial of stepped collaborative care for acutely injured trauma survivors. Arch Gen Psychiatry. 2004;61(5):498–506 [DOI] [PubMed] [Google Scholar]
  • 47.Zatzick D, Jurkovich G, Rivara F, et al. A randomized stepped care intervention trial targeting posttraumatic stress disorder for surgically hospitalized injury survivors. Ann Surg. 2013;257(3):390. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 48.Zatzick D, Russo J, Lord SP, et al. Collaborative care intervention targeting violence risk behaviors, substance use, and posttraumatic stress and depressive symptoms in injured adolescents: a randomized clinical trial. JAMA Pediatr. 2014;168(6):532–539 [DOI] [PubMed] [Google Scholar]
  • 49.Purtle J, Rich JA, Fein JA, James T, Corbin TJ. Hospital-based violence prevention: progress and opportunities. Ann Intern Med. 2015;163(9):715–717 [DOI] [PubMed] [Google Scholar]
  • 50.James TL, Bibi S, Langlois BK, Dugan E, Mitchell PM. Boston Violence Intervention Advocacy Program: a qualitative study of client experiences and perceived effect. Acad Emerg Med. 2014;21(7):742–751 [DOI] [PubMed] [Google Scholar]
  • 51.Purtle J, Dicker R, Cooper C, et al. Hospital-based violence intervention programs save lives and money. J Trauma Acute Care Surg. 2013;75(2):331–333 [DOI] [PubMed] [Google Scholar]
  • 52.Purtle J, Corbin TJ, Rich LJ, Rich JA. Hospitals as a locus for violence intervention In: Donnelly PD, Ward CL, eds. Oxford Textbook of Violence Prevention: Epidemiology, Evidence, and Policy. Oxford, UK: Oxford; 2014: 231–238 [Google Scholar]
  • 53.Petrosino A, Campie P, Pace J, et al. Cross-sector, multi-agency interventions to address urban youth firearms violence: a rapid evidence assessment. Aggress Violent Behav. 2015;22:87–96 [Google Scholar]
  • 54.Ko SJ, Ford JD, Kassam-Adams N, et al. Creating trauma-informed systems: child welfare, education, first responders, health care, juvenile justice. Prof Psychol. 2008;39(4):396 [Google Scholar]
  • 55.Shibru D, Zahnd E, Becker M, et al. Benefits of a hospital-based peer intervention program for violently injured youth. J Am Coll Surg. 2007;205(5):684–689 [DOI] [PubMed] [Google Scholar]
  • 56.Cheng TL, Haynie D, Brenner R, et al. Effectiveness of a mentor-implemented, violence prevention intervention for assault-injured youths presenting to the emergency department: results of a randomized trial. Pediatrics. 2008;122(5):938–946 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 57.Snider C, Lee J. Youth violence secondary prevention initiatives in emergency departments: a systematic review. Can J Emerg Med Care. 2009;11:161–168 [DOI] [PubMed] [Google Scholar]
  • 58.Juillard C, Smith R, Anaya N, et al. Saving lives and saving money: hospital-based violence intervention is cost-effective. J Trauma Acute Care Surg. 2015;78:252–257 [DOI] [PubMed] [Google Scholar]
  • 59.Chong VE, Smith R, Garcia A, et al. Hospital-centered violence intervention programs: a cost-effectiveness analysis. Am J Surg. 2015;209(4):597–603 [DOI] [PubMed] [Google Scholar]
  • 60.Dahlberg LL, Toal SB, Swahn M, Behrens CB. Measuring Violence-Related Attitudes, Behaviors, and Influences Among Youths: A Compendium of Assessment Tools. 2nd ed. Atlanta, GA: Centers for Disease Control and Prevention, National Center for Injury Prevention and Control; 2005 [Google Scholar]
  • 61.Leff SS, Gullan RL, Paskewich BS, et al. An initial evaluation of a culturally adapted social problem-solving and relational aggression prevention program for urban African-American relationally aggressive girls. J Prev Interv Community. 2009;37(4):260–274 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 62.Cron T. The Surgeon General’s Workshop on Violence and Public Health: Review of the recommendations. Public Health Rep. 1986;101:8–14 [PMC free article] [PubMed] [Google Scholar]
  • 63.Weinberger SE, Hoyt DB, Lawrence HC III, et al. Firearm-related injury and death in the United States: a call to action from 8 health professional organizations and the American Bar Association. Ann Intern Med. 2015;162(7):513–516 [DOI] [PubMed] [Google Scholar]

RESOURCES