Training EMSC Providers in Violence Prevention

Training EMSC Providers in Violence Prevention

A Report by the American Psychological Association to the Emergency Medical Services for Children Program, Maternal and Child Health Bureau, Health Resources and Services Administration, US Department of Health and Human Services.

January, 1998

Table of Contents

Introduction
Why train EMSC personnel in violence prevention?
APA?s expertise in violence prevention efforts
Crucial definitions
Chart: History of Emergency Medical Services for Children
Major Goals of EMSC Development

Understanding the Problem: How Does Violence Affect the Work of EMSC Personnel?
Violence-related injuries treated in hospital emergency departments
How violence presents in children
The psychological impact of violence
Types of prevention appropriate to the EMSC environment
Chart: Opportunities for violence prevention with children and adolescents in emergency medical settings

Training Recommendations for EMSC Personnel
Core knowledge for all EMSC personnel
Special training requirements
EMTs and paramedics
Emergency nurses
Emergency physicians
Trauma surgeons
Mental health professionals: Psychologists and social workers

Strategies for Violence Prevention and Intervention Efforts in EMSC Settings
The emergency department as nexus of violence-prevention activities
Universal violence screening in the emergency department
The emergency department waiting room
Post-intervention follow-up and referral
The referral process
Links to community resources
Intervention across the continuum of care for emergency services patients
Care for EMSC personnel

Appendix 1:References and Resources

Appendix 2:Working Conference Participants

Introduction

In mid-1996, the Office of Emergency Medical Services for Children (EMSC) of the Maternal and Child Health Bureau, Health Resources and Services Administration, Public Health Service, United States Department of Health and Human Services, contracted with the American Psychological Association (APA) to submit recommendations for the training of EMSC providers in violence prevention. In July 1997, APA convened a one-day working conference, inviting APA members who are experts in violence prevention and professionals from five other disciplines involved in providing emergency medical services to children: emergency medical technicians/paramedics, emergency nurses, emergency physicians, trauma surgeons, and social workers.

This document is the final report of that working conference and incorporates the recommendations that emerged from that conference. A copy of the briefing book developed for the participants in the working conference is included as Appendix 2.

Why train EMSC personnel in violence prevention?

The U.S. emergency medical services (EMS) system grew out of military settings during the Korean conflict and the Vietnam War, where patient triage, timely transport, and prehospital care significantly increased patient survival rates. During the 1960s, additional impetus for the development of EMS systems came from research on the treatment of injuries and on the effectiveness of early intervention in cases of sudden cardiac arrest. Federal legislation in 1966 (the Highway Safety Act) and in 1973 (the Emergency Medical Services Act, P.L. 93-154) stimulated the growth of emergency medical service systems.

These early systems made no special provision for children. Consequently, children often experienced less favorable outcomes than did adults. In the late 1970s, advocacy by the Hawaii Medical Association in collaboration with Senator Daniel Inouye (D-HI) and his staff assistant, Patrick DeLeon, PhD, a psychologist, laid the foundation for additional federal legislation addressing the specialized needs of children in emergency services. In 1984, Senator Inouye, along with Senator Orrin Hatch (R-UT) and Senator Lowell Weicker (R-CT), sponsored legislation that established the Emergency Medical Services for Children (EMSC) program as part of the Public Health Act. Initially, grants were awarded to Alabama, California, New York, and Oregon. By 1997, EMSC federal grants had enabled 48 states plus the District of Columbia, Puerto Rico, the Virgin Islands and the Commonwealth of the Northern Mariana Islands to develop improved systems of emergency care for children and adolescents.

Much progress has been made in the care of children with emergency medical needs, but EMS providers are the first to acknowledge that prevention is crucial. For this reason, EMSC providers have been a significant force in aiding and promoting injury prevention efforts, such as the work of the National SAFE KIDS Coalition. For today?s children and youth, however, interpersonal violence in the home and on the streets presents an equally grave danger and is increasingly likely to be the direct or indirect cause of their entry into the emergency medical care system. Homicide is the second leading cause of death for persons 15 to 24 years old, and it is the leading cause of death for African American and Hispanic youth in this age group (Powell, Dahlberg, et al., 1996, p. 3). For every young victim who dies violently, there are another 40 who are injured seriously enough to require medical attention. Younger children, too, are at significant risk from violence. Child abuse accounts for about 10 percent of the injuries to children under the age of 7 who are examined in emergency rooms.

The problem of violence involving children and teenagers in the U.S. is so pervasive and damaging that only a systematic, sustained, and comprehensive approach to preventing violence can make significant inroads to protect young people from tragedy. Training emergency medical personnel in effective prevention and intervention strategies is an important piece of the solution. Because emergency medical personnel frequently are faced with the immediate effects of violent crimes, they are in a unique position to intervene and to help ensure that the victims receive the help they need to address both the physical and psychosocial aftermath of violence and to prevent future victimization.

APA?s expertise in violence prevention efforts

More than 50 years ago, psychologists first brought the study of violence and aggression into the realm of science. Since then, psychology has amassed a considerable body of knowledge about the causes, consequences, and prevention of violence. Psychological research strongly supports the idea that violence is not random, uncontrollable, or inevitable, and that the individual and social factors leading to violence are responsive to prompt, systematic, and sustained intervention and prevention efforts.

The APA Public Interest Directorate made violence a priority program area in 1990. Since then, much of psychology?s knowledge about violence has been distilled into major reports issued by the Committee on Women in Psychology Task Force on Male Violence Against Women; the Commission on Violence and Youth; Working Groups on Treatment, Prevention, and Legal Issues in Child Abuse and Neglect; the Task Force on Television and Society; and the Task Force on Violence and the Family. In addition, the APA Committee on Children, Youth, and Families sponsored a conference on violence against children, and the Committee on Ethnic Minority Affairs initiated the Criminal Justice Policy Project to explore the impact of the federal crime bill on ethnic minorities. This broad commitment, experience, and knowledge base makes APA an appropriate partner for EMSC in the effort to identify training needs in violence prevention for EMSC personnel.

Definitions

The following definitions of terms apply in this report:

• Interpersonal violence is behavior by persons against persons that threatens, attempts or completes intentional infliction of physical or psychological harm. (APA, 1993)
• Primary prevention is a category of health and/or related interventions that aim to eliminate a disease or disordered state before it can occur.
• Secondary prevention is an intervention that strives to shorten the course of an illness or injury by early identification and rapid intervention.
• Tertiary prevention is an intervention that attempts to reduce the complications after a violent event has occurred.
• Cultural sensitivity is an awareness of the nuances of one?s own and other cultures. (Orlandi et al, 1992, p. vi.)
• Cultural competence is a set of academic and interpersonal skills that allow individuals to increase their understanding and appreciation of cultural differences and similarities within, among, and between groups. This requires a willingness and ability to draw on community-based values, traditions, and customs and to work with knowledgeable persons of and from the community in developing focused interventions, communications, and other supports. (Orlandi et al, 1992, p. vi.)

Understanding the Problem: How Does Violence Affect the Work of EMSC Personnel?

During the late 1980s and 1990s, both the incidence and the intensity of violence among youth in the United States have increased dramatically. The National Center for Injury Prevention and Control Division of Violence Prevention at the U.S. Centers for Disease Control and Prevention reported the following statistics in 1997:

• In 1995, 7,204 young people ages 15-24 were victims of homicide. That is an average of 20 youth homicides every day in the United States.
• Of all homicide victims in 1994, 38 percent were younger than 24 years old.
• The homicide rate among males 15 to 24 years old in the United States is 10 to 28 times higher than in Canada, Australia, France, and Germany
• Annual rates of firearm homicide for youth 15 to 19 years old increased 155 percent between 1987 and 1994.
• In 1995, 7.6 percent or one in 12 students in a national survey reported carrying a firearm for fighting or self-defense at least once in the previous thirty days. In 1990, this was true of 4.1 percent, or one in 24 students.
• Nearly 20 percent of all violent crime arrests in 1994 involved a juvenile younger than 18 years old.
• Arrest rates for homicide, rape, robbery, and aggravated assault are consistently and substantially higher for young people 15 to 34 years old than for all other age groups.
• Arrest rates for homicide among younger adolescents 14 to 17 years increased 41 percent between 1989 and 1994. By comparison, arrest rates for older youth 18 to 24 years old increased 18 percent. Homicide rates for adults older than 25 decreased by 19 percent during the same period.

The1995 Massachusetts Youth Risk Behavior Survey Results, published by the Commonwealth of Massachusetts Department of Education, reports the following data:

• Each year in the United States, approximately 100,000 deaths result from the misuse of alcohol. Alcohol is a contributing factor in at least half of all homicides, suicides, and motor vehicle crashes.
• Binge drinking (5 or more drinks in a row) is linked conclusively to physical fighting, property destruction, and trouble with law enforcement authorities.
• Youth gangs account for a disproportionate amount of youth violence across the nation, and gang involvement is associated with high levels of delinquency, illegal drug use and drug trafficking, high-risk sexual activity, physical violence, weapon carrying, and death. The survey results showed that students across all demographic groups report gang involvement, although males, black students and students in lower grades are more likely to report being involved with gangs (p. 39, 44-45).

Violence-Related Injuries Treated in Hospital Emergency Departments

A study released in 1997 reported that during 1994, 1.4 million people were treated in hospital emergency departments for injuries from confirmed or suspected interpersonal violence. Of those 1.4 million people, 94 percent were injured during an assault, 2 percent during a robbery, and 5 percent by an offender in a rape or sexual assault. These patients represented about 1.5 percent of all visits to hospital emergency departments and 3.6 percent of the injury-related emergency visits in 1994. About half the number were younger than age 25. Males were 60 percent of all persons treated in emergency departments for injuries sustained in violence. African Americans, who constitute about 13 percent of the population, represented 24 percent of those treated for violence-related injuries.

Of the 1.4 million cases treated in emergency departments in 1994 for violence-related injuries, 14.2 percent reported that the victim or someone else involved in the incident had been drinking alcohol or using drugs. About 92 percent of violence victims were released after treatment in the ED; about 8 percent were hospitalized for further treatment.

Estimates are that one of six victims of violent crime requires medical attention, often by emergency medical services. A number of studies in the U.S. and abroad suggest that a substantial majority of victims treated by EMS services do not report the attacks to the police. Together, those statistics suggest that EMSC services are a vital point at which to initiate violence prevention and intervention activities for children and adolescents. Emergency medical services may be a victim?s only contact with professionals who can intervene to prevent further harm.

Children and youth are affected not just by street violence and peer violence but by child abuse and domestic violence. They also are victims of violence based on their racial or ethnic characteristics or on their sexual orientation. Below are some statistics suggesting the scope of such violence:

• In 1995, there were one million cases of substantiated or indicated child maltreatment in the U.S. Of the victims in those cases, 25 percent experienced physical abuse and 13 percent experienced sexual abuse. More than half of all victims were less than 8 years old. About 26 percent were between 8 and 12 years old.
• One-third of victims of physical abuse are less than 1 year old.
• One-third of victims of physical abuse are between the ages of 1 and 6, and one third are more than 6 years old.
• Approximately one-third of all sexual abuse cases involve children younger than 6 years old.
• A 1997 publication from the National Injury and Violence Prevention Resource Center reported on the incidence of violence among pregnant teenagers. Estimates are that abuse occurs in from 6 to 17 percent of all pregnancies. Studies of pregnant teens show consistently higher rates of abuse, ranging from a low of 22 percent to a high of 41.5 percent (Guard, 1997, p.2).
• Research suggests that young lesbians and gay males often are the victims of assaults (D?Augelli and Dark, 1994). The 1995 Massachusetts Youth Risk Behavior Survey (Massachusetts Department of Education, 1996, p. 53) found that students who describe themselves as gay, lesbian, or bisexual and/or who have had same-sex sexual contact are more likely than their peers to report being involved in violence-related incidences including:

• Being in a physical fight in the past year (62.3 percent vs. 37.3 percent)
• Being threatened/injured with a weapon at school in the past year (66.7 percent vs. 28.8 percent)
• Carrying a weapon in the past month (43.5 percent vs. 19.0 percent)

In a study of 50 hospital emergency departments in the greater Chicago area, Bell et al. (1994) found that the majority of emergency rooms do not conduct adequate epidemiological surveillance of injuries resulting from interpersonal violence. Many hospitals reported standard operating procedures to address types of violence for which intervention is mandated, such as sexual assault and child abuse. However, the authors concluded that "protocols, services, and referrals for victims of family violence, peer violence, and other forms of interpersonal violence should be mandated by law or by standards of treatment" (Bell, 1994, p. 142).

How Violence Presents in Children

Children and adolescents may be victims?or perpetrators?of nearly all forms of violence that affect adults. In addition, children and adolescents may be subjected to various forms of abuse by their caretakers, by other adults in authority, or by other children. The list below describes the types of violence EMSC personnel may observe in emergency medical settings.

• Child abuse. Child abuse can be physical, verbal, or psychological and may be perpetrated by parents, caretakers, or siblings. Signs of abuse can be obvious or subtle, and the child as well as the adult may deny that the injuries are caused by abuse.
• Neglect. This type of violence includes neglect of a child?s physical, educational, health care, or emotional needs. It may have obvious manifestations, such as malnutrition, but is often indirectly seen in the child?s poor hygiene, lack of medical care, or improper dress for the weather. Neglect sometimes is a result not of the parent?s purposeful acts but of poverty or lack of access to supportive resources. Regardless of the circumstances, neglect harms children and adolescents physically and often psychologically.
• Sexual abuse or incest. Sexual abuse is not limited to sex acts performed on a child but may also include such acts as inappropriate touching, forcing the child to perform sex acts with adults or children, photographing the child nude or in sexual situations, or placing the child in situations where she or he must witness sex acts. Most often, the perpetrators are family members or trusted adults in positions of authority over the child. Sexual abuse does not always have physical manifestations. It has severe psychological consequences for the victims.
• Stranger assault or rape. This type of violence occurs when children or adolescents are abducted or overpowered by someone they do not know. Such violence may have serious medical consequences and may cause psychological trauma.
• Peer violence. This type of violence can take many different forms?fighting, gang violence, bullying of a child or adolescent, or mob violence. The physical manifestations range from cuts and bruises to broken limbs and knife or gunshot wounds.
• Intimate violence. The perpetrator of this type of violence is someone in a close relationship with the victim. It may include physical and sexual violence?date rape"as well as psychological terrorization, stalking, and other tactics to maintain power and control over the victim.
• Hate crimes. This type of violence occurs in response to the victim?s race or ethnicity, sexual orientation or religion. It may include a range of violent acts inflicting injuries such as black eyes, burns, broken bones and gunshot wounds.
• Political violence or torture. In the United States, the types of political violence or torture most likely to be seen by emergency medical services are the aftermath of a terrorist attack and the use of unwarranted force by peace officers (police, military police). The physical manifestations of such violence range from abrasions or other wounds caused by restraining devices; cuts, bruises and other injuries caused by beatings; and burns, gunshot wounds, and other severe trauma.
• In utero violence. This type of violence may occur to a fetus when a pregnant woman is the victim of violence.
• Witnesses to violence. Even though witnesses are not the direct recipients of a violent act, they suffer the psychological effects of having seen a violent act committed.

Identifying child victims of violence is complicated by the fact that such violence does not always present as bruises, broken bones, or weapons injuries. Sometimes, an abused child or a child living in a violent household will present with stress-related symptoms or with ordinary childhood illnesses that have not received medical attention. Other times, the child may not appear to have injuries but may simply be accompanying a parent who has been injured.

A further obstacle in identification is the fact that children are often dependent upon the persons who bring them in for medical care and so would be reluctant to identify the cause of their injuries as abuse or violence. Many times, the victim arrives at the emergency department with classic symptoms of child abuse?and the parents have classic excuses. For example, a child appears with a black eye or a hematoma. The parent explains that the child fell down the stairs. The child may remain silent or may concur to avoid later retribution. Children may be more likely to be disbelieved when they report violence that leaves no physical scars or other tangible evidence.

The difficulty of identifying child victims of violence?or adult victims, for that matter?has led many experts to advocate universal screening measures for all EMS patients. This issue is discussed in Part III of this report.

The psychological impact of violence

Violence of any kind has an emotional and psychological effect on a child, regardless of the extent of the physical damage. In some cases, the child may have minor or even no apparent physical injuries, but will nevertheless have severe psychological injuries. Psychological trauma often occurs when children or adolescents

• are abused by someone with whom they have a relationship of trust, such as a parent or other adult living in the home, a teacher, a coach, or a religious leader
• are sexually assaulted or abused by a known assailant who uses coercion or manipulation
• witness an incident of serious violence or witness chronic violence in their neighborhoods or in their homes
• live with an immediate or chronic threat of violence to themselves or to their families.

Children who witness domestic violence are the invisible victims, and the long-term implications of childhood exposure to domestic violence are substantial. Witnessing such violence can lead to violent behaviors in adolescence or adulthood and to high-risk behaviors as adolescents. It also can affect how children learn to relate to others, how they develop their self-concepts and self-control. EMSC providers, therefore, need to be aware of the broader social implications of their work with children who witness violence, not just the diagnosable outcomes (Osofsky, 1995). Psychological First Aid for Children Who Witness Violence, a program funded by the University of Missouri at Kansas City, has established a network of organizations to work with children who have witnessed violence (Knapp, 1996).

The benefits of intervening in cases of psychological trauma?indeed, in any form of violence?are twofold. First, intervention can reduce the child?s immediate distress and prevent additional psychological and physical injury. Second, research evidence clearly shows that a history of involvement with violence is a significant risk factor for involvement in violence?as victim or as perpetrator?later in life. Therefore, the intervention may be a life-changing contribution to the child?s future well-being and may contribute to the overall reduction of violence in the community.

Types of prevention appropriate to the EMSC environment

Professionals who provide care for children and adolescents in emergency department settings will find many opportunities for intervention if they know what to look for and have a plan or protocol for action. Because violence involving children and adolescents is multidimensional, prevention efforts must include a full range of prevention methods. In the public health model of violence prevention, violence prevention efforts are categorized asprimary, secondary ortertiary:

• primary prevention: efforts that are taken before violence occurs and seek to eliminate the problem before it can occur.
• secondary prevention: efforts that attempt to minimize violence or its aftermath by early identification and rapid intervention
• tertiary prevention: efforts that attempt to reduce complications after a violent event has occurred

In practical terms, interventions in the EMSC environment can include a range of options:

• providing parents and other adults with opportunities to educate themselves about violence
• steering at-risk youth into existing violence prevention programs
• reporting suspected cases of abuse and connecting children and families with resources for physical rehabilitation and psychological treatment after violence has occurred.

The tasks involved in designing violence prevention protocols across the continuum include acknowledgement of the problem; screening and identification mechanisms; education efforts directed to victims and perpetrators; direct services to victims; and referrals for victims and perpetrators to community services.

Fundamental to any such efforts is training of all EMSC personnel to recognize cases in which intervention is necessary and to take steps appropriate to their roles in the EMSC environment.

(Dutton, 1997)

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