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16. Violent and Abusive Behavior Violence and intentional injury are rampant in the United States. Homicide is the leading cause of death for Black males age 15 to 44;i suicide and homicide rank second and third, nationally, as causes of death among all adolescents;2 of all the emergency room visits made by women seeking treatment for injury, 19 percent involve battering;3 and more than 1.9 million children nationally are abused each year.4 (#420; i'697) To put an end to endemic violence in communities across the United States, more than 40 testifiers who addressed violence and intentional injury asserted that public health must help focus attention on the problem, help screen victims and perpetrators, and participate in the difficult behavior modification strategies necessary to change interpersonal relations, especially within families. Primary prevention of family violence is an important element of any effort to reduce overall abusive behavior and is "often very elusive," states Karil Klingbeil of the University of Washington. Klingbeil recommends that we reassess our childrearing practices and our socialization patterns. We know politically that violence begets violence. We know about the generational aspects of behavior. It's time that we broke the cycle of violence. (#697) Among those groups identified by witnesses as being vulnerable to violence were children, women, and the elderly, most often as victims; and males, most often as perpetrators. Minorities were identified as being at an especially high risk as both victims and per- petrators. Adolescents, especially as suicide victims, also received attention from testifiers. "Although we tend to think of police and the criminal justice systems when we think of homicide and assault," writes Allen Bukoff of Wayne State University, Health professionals are the front lines of violence in our society." According to a study in Cleveland, of those individuals treated in emergency rooms for violence, only one-fourth made reports to the police.5 (#715) Patience Drake of the Michigan Department of Management and Budget and Robert Dolsen, Chairperson of the Statewide Health Coor- dinating Council, echo the belief that "leaving the resolution of these difficult dilemmas to the criminal justice system" will not prevent more violent behavior. To reduce intentional injury, the broader social context in which violence occurs must be explored. Childhood family relations, socioeconomic status, weapons availability, social acceptance of certain behaviors, and community structures can all adversely affect individuals and lead to an inappropriate concep- tion of how to interact with others. (i'420; #537) All sectors of society must establish and maintain value systems and social relations that do not support or lead to violence and intentional ininnr Reline to testifiers. ~J __ ~ ~^-^O Many witnesses called for implementation of the recommendations of the Surgeon General's Workshop on Violence and Public Health held in October 1985.6 (#420J Recognizing the complex nature of the prob- lem, the workshop's main recommendation was reduc- tion of unemployment and poverty. Other recommen- dations emphasized a multidisciplinary approach to injury control, including changing views of appropriate behavior, especially conceptions of masculinity; reduc- ing media violence and inappropriate views of sexual- ity; increasing communin', intolerance for violence; teaching conflict resolution skills; reducing alcohol and drug consumption; reducing the availability of firearms; providing stress reduction and support ser- vices for families and parents, as well as community intervention centers; identifying and treating abused children and adults who were abused as children; teaching parenting skills; and reducing the level of violence in schools. (~420) This chapter focuses on three types of violence: homicide and interpersonal violence, suicide, and family violence, and examines several implementation issues. HOMICIDE AND INTERPERSONAL VIOLENCE To prevent homicide, it is essential to look at the etiology of interpersonal violence. According to Bukoff, at least half of all homicides occur among family and persons acquainted with the victim. (#715J Risk factors for homicide among "intimates" (husbandfwife, boyfriendJgirlfr~end) include prior wife abuse and dating violence; therefore, education programs for high school students aimed at relation- ships without violence could be especially beneficial, says Jacquelyn Campbell of Wayne State University. Violent and Abusive Behavior 135

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It also is important to note that the majority of murders, regardless of the sex or race of the victim, are committed by men. (#402) Several testifiers un- derline the lack of self-esteem, sense of social use- lessness, or feelings of alienation that may influence aggressive or violent tendencies in individuals, especially young males. The homicide toll is espe- cially great in minority communities, according to Carl Bell, Executive Director of the Community Mental Health Center (CMHC) in Chicago. (~018) Bell describes homicide and interpersonal violence intervention strategies that have been implemented in a poor, Black Chicago community. The overall plan is to provide primary, secondary, and tertiary preven- tion programs to the community. Key elements are (1) to publicize and provide education on the causes of homicide and violence and how to cope with stress and violence, and (2) to get the medical community involved in recognizing and stopping cycles of violence. Myths, ethnic tensions, and ignorance of homicide dynamics must be overcome, according to Bell. In CMHC's community, the task of clarifying the reality of homicide dynamics was undertaken through several steps: developing a series of radio talk shows on the facts and fables of homicide, distributing several thousand T-shirts with a slogan to Stop Black-on- Black Murder,n and persuading the staff of a local hospital emergency room to wear these T-shirts to awaken their coworkers to the possibilities of inter- vention. Other primary prevention resources have been used to redirect activities of young men, such as a karate class that Bell teaches which, he feels, Has done more to constructively influence the lives of young Black males away from violent tendencies" than has his work as a psychotherapist. (#018) The importance of drug traffic-related violence was brought up by the Public Health Education Section of the American Public Health Association. Using the recent Washington, D.C., experience of 100 drug- related murders in jUSt four months as an illustration of the magnitude of the problem, the group suggests a year 2000 objective "that addresses a reduction in violent drug-related deaths and injuries." (#616) Primary prevention of homicide must strive to establish positive value systems in community mem- bers, testifiers say. Youth gangs, for instance, give social cohesiveness to young men, but accept murder and violence as appropriate ways to resolve conflict. These gangs, says Nancy Allen of the UCLA Neuro- psychiatric Hospital, should be targeted for homicide reduction activities. (~240) The Los Angeles Gang 136 Healthy People 2000: Citizens Chart the Course Violence Reduction Project, for example, employs gang member consultants who are respected members of youth gangs in their communities to intervene in potentially dangerous situations to prevent escalation.8 (#240) Jeff Roth of the National Research Council suggests, however, that ideally interventions need to begin long before the ages of gang membership: with nutrition and parent training for expectant mothers during the prenatal period, and continuing through preschool with parental bonding; social learning about how to deal with frustrating situations nonaggressively; Head Start; etc. (#785) In addition to the psychosocial strategies useful to communities, testifiers believe that handgun control legislation could significantly reduce homicide rates. "United States citizens are the most heavily armed in the world," says Allen. A great danger with private ownership, she warns, is that gun owners are often unfamiliar with their weapons and sometimes kill unintended victims, usually family members. (~240) Steven Macdonald of the University of Washington says that an enraged person with a gun is much more likely to kill someone than an enraged person who lacks ready access to a firearm. (#322) However, given the reality of current gun ownership, Bukoff calls the 1990 objective to reduce the number of privately owned handguns by 25 percent nnaive" and Carl Bell calls it "idealistic. Instead Bell asks for a "major media effort to encourage handgun owners to unload their readily available deadly weapons, and Bukoff advocates outlawing plastic handguns in all 50 states. (~018; #715) SUICIDE Adolescent suicide rates have nearly tripled in three decades, says Martha Medrano of the University of Texas Health Science Center at San Antonio.9 (#500) Among Native American communities, ado- lescent suicide already has become a local health priority. According to Tom Barrett of the Center for Psychological Growth in Denver, American youth are finding it difficult to cope with the pressures of growing up in a rapidly changing society. (#702) Stress and substance abuse are widely prevalent and are two of the leading factors in adolescent suicide. Donna Gaffney of Columbia University emphasizes that it is not one particular stress that emerges as a significant correlate of suicidal behavior but rather "an entire constellation of life stresses that differ in severity from non-suicidal children." (#731) Adults

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must "create a less threatening and more supportive setting for youth, one with less social isolation, despair, and depression" in order to prevent suicide and other intentional injuries, says Michael Greenberg of Rutgers University. (#537) Damien Martin of the Hetrick-Martin Institute in New York says that reducing communication barriers is especially vital in preventing suicide among adoles- cent homosexuals. Many of these adolescents have no cognitive, emotional, or social role models. Many are afraid to admit their homosexuality for fear of rejec- tion. Educational interventions in the school, coun- seling for those who have attempted suicide, and research into the reasons for suicide, should all include "the possibility of social and psychological factors related to the stigmatization of homosexuality as contributing to teenage suicide." (~466) Education against suicide must take place in the schools and in the community, argues Medrano. Stress-coping and communication skills need to be taught. Teacher strategies should include "breaking the taboo of keeping a suicide secret, especially for the students themselves." (#500J In the community, health professionals need to be informed of the signs of suicidal behavior, how to deal with them, and where to refer potential suicidal individuals. Because drug and alcohol abuse also are related to suicide among adolescents, intervention programs in these areas should include a component of suicide intenen- tion, according to Barrett. (~702J The media need to be made aware of what factors increase the "contagious phenomenon of suicide and what factors decrease this effect. (#500) To do this, greater understanding of the role of the media in so- called copycat suicides is required, says Greenberg. For example, did the media coverage of recent widely publicized teen suicides increase the likelihood of similar incidents, or did it reduce them by conveying calming messages? (#537) Although Lou Large of Houston believes that television has the potential for "improving the physical, emotional, and intellectual health of this nation," she also says it can contribute to violent behavior, especially among young children. Large proposes objectives for the year 2000 to reduce violence in children's programming and during hours when children watch television, along with a campaign to educate parents and children about appropriate selective viewing for youngsters. (#304) After a suicide has occurred, schools and com- munities must move quickly to prevent other suicides, according to Medrano. This involves "assisting stu- dents, staff, and parents to ventilate feelings of grief, guilt, rejection, and anger" produced by the suicide. (~5~) Meyer Moldeven of Del Mar, California, says that volunteer training is an important component of suc- cessful suicide interventions for all ages: HA commu- nity's suicide intervention and prevention resources~f which the suicide prevention center, crisis center, and 'hotline' are elements~epend to an enormous degree on local paraprofessionals and trained volunteers. In the workplace, employers already provide programs for stress management, as well as cardiopulmonary resuscitation and first-aid training. Thus, "why not a lay worker on the job site who is trained to function in an emergency suicide intervention? asks Moldeven. The United States Army and Navy already have estab- lished formal suicide prevention programs, and the groundwork laid can be used to tailor programs for other employers. (~602) FAMILY VIOLENCE Millions of people a year are affected by family violence, and the majority are women and children. A history of abuse, early parenthood, low socioecono- mic status, and poor coping skills for stress-all can produce aggression and violent conflict resolution within households. Children of battered mothers also are at high risk for stress-related physical problems, as well as behavioral and developmental problems, and show a propensity for family violence in adulthood, especially if male, according to Jacquelyn Campbell. (#402) David Besaw, representing the Wisconsin Tribal Health Directors, says that most domestic violence in Native American populations occurs under the influence of alcohol or other drug abuse. (#514) The single biggest correlate of interpersonal violence, say witnesses, is poverty. (#420; #715) According to Bukoff, reductions in poverty would improve our ability to prevent violence. (#715) The community, especially health professionals, can intervene in domestic violence by recognizing per- petrators and victims. Emergengy rooms could screen for victims of abuse, and alcohol and drug abuse programs could screen for violence, as well as provide stress-coping techniques. One such model emergency room program has been established at Rush-Pres- byterian-St. Luke's Medical Center in Chicago. (~402) Community programs involving health pro- fessionals, in tandem with criminal justice efforts, could effectively change the nature of conflict resolu- t~on and childrearing in many communities. (#293) Violent and Abusive Behavior 137

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Child Abuse According to Blanche Russ of Parent-Child in San Antonio, child abuse destroys individuals and families, and the victims of child abuse often become abusers of their own children. Russ stresses the need to "break the cycle of repeated abuse and to stop or reduce the devastating effects of sexual, physical, and emotional abuse and neglect for victims, survivors, and perpetrators." To achieve this, she suggests several strategies: (1) provide parenting education for new parents to help them understand the stress involved in parenting and how to deal with it, and (2) involve health care providers in the screening and treatment of child abuse. (~748) A number of other witnesses call for parenting education, which is discussed in Chapter 14. Comparisons of two large, national surveys con- ducted in 1975 and 1985 show a reduction in the rate of violence against children.~ Among the possible reasons for this reduction, suggests Blair Justice of the University of Texas Health Science Center at Houston, are methodological differences in the two surveys, increased reluctance to report abuses, econo- mic factors, and changes in family structure. However, Justice believes at least some of the credit must be given to treatment and prevention programs established during the decade. She recommends that the Year 2000 Health Objectives specify that hospitals and communities put in place programs that have been found to be effective for preventing child (and spouse) abuse. (#293) Anne Helton of Bellaire, Texas, calls for protective services for children who have been abused. Battered children often are returned home to their abusers, she says, even when it has been determined that they have been abused. She agrees with Justice that "health care providers should be involved in every aspect of the problem of child abuse, assessment, education, re- search, intervention, and advocacy. I feel it is appro- priate for health care providers to call for more pro- active approaches to the problem of the abused child." (~094) Spouse Abuse Campbell is "dismayed" that there are no current objectives relating to bettered women. (#402) Judith McFarlane of Texas Woman's University says from 2 to 4 million women are physically battered each year. The problem is especially severe for pregnant women. "Although research documents that battered 138 Healthy People 2000: Citizens Chart the Course women report spontaneous abortions and stillbirths following episodes of battering, and battered women begin alcohol and drug use to cope with the violence, battering still is not included as a prenatal risk factor meritorious of surveillance and prevention. (~310) Justice reports that police and community policies reduced the incidence of wife abuse between 1975 and 1985. In 1975, there were few shelters for battered women; in 1985, there were 700.~2 A carefully-evaluated change in police policy also came about in many parts of the country. In 1975, the traditional police approach at the scene of domestic violence was to separate the warring parties and to leave. By 1985, laws and policies had changed so that police were man- dated to deal with wife abuse the same as with any other assault, by arresting and jailing the alleged offender. A significant effect on recidi- vism has been demonstrated by such action. (#293) Women need to have community resources and be aware of them; battered women need to perceive health care providers as resources. Community awareness and education can prevent violence. Routine assessment by health care providers is essen- tial to prevent further abuse. (~310) According to Campbell, the community must provide protective and social seIvices because the risk of being killed is greatest when the woman attempts to leave the battering relationship. (~402) Elder Abuse "Far too many of our nation's senior citizens are victims of crime,n states Allen. In the White popula- tion in Los Angeles, those 65 and over have the highest rate as victims of homicide.~3 Objectives to prevent and treat elder abuse and neglect, and to focus on the impact of this abuse on the quality of life of the elderly, are very important. (~240) Melanie Hwalek of SPEC Associates in Detroit emphasizes the need for valid and reliable measure- ment instruments both to assess the risk of elder abuse in community populations and to substantiate elder abuse among suspect cases that arise in state reporting systems and human senice agencies. She also advocates developing professional and public educational programs on detection, assessment, and treatment of elder abuse; community outreach pro- grams; research on incidence and prevention; a

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national clearinghouse for coordinating research; training and program development; and services to elder abuse victims and to families caring for older people. (#403) IMPLEMENTATION One hindrance to the development of prevention programs, especially primary interventions, is inap- propriate assessment of the level of injury and the cost to families and society. Klingbeil refers to confusion about definitions, terminologies, classifica- tions, and psychologies: waif we can't count it it doesn't exist. (~697) In addition, "we don't even know what the cost of these injuries are," says Bukoff. "We don't have good methods yet of estimating the health costs, economic costs, in terms of days of work lost, etc.n (~715) Clinical protocols for the prediction, assessment, and diagnosis of various forms of family violence, and better definitions of family violence nationwide will permit better reporting and provide better statistical evaluation, according to Klingbeil. f#697) Hwalek offers an example of a definition of abuse for one population, the elderly, that consists of six distin- gllishable categories: physical abuse, physical neglect, REFERENCES psychological abuse, psychological neglect, material abuse (exploitation), and violation of personal rights. Each component of this comprehensive definition of elder abuse can be related to important health implications," she says. (~403) Several testifiers encouraged the establishment of a national center for the study and prevention of homicide. It would, among other things, coordinate and fund research projects on homicide; promote the use of standardized reporting methods and records; establish a state and national homicide registry; coordinate homicide information and education; assist communities in establishing homicide prevention services; coordinate and develop restitution and victim-assistance programs; and develop hypotheses and theories regarding perpetrators and victims. (~240) Other suggestions for more and better data collection and surveillance included a comprehensive data capability to monitor and evaluate the status and impact of substance abuse on criminal behavior because of the "links known to exist" between the two (#0939; more information about external causes and circumstances surrounding injuries, particularly internal injuries (#7154; the establishment of trauma registries in all states (~108J; and the use of E-codes (external cause of injuIy codes) in hospitals (#322; #334~. 1. Centers for Disease Control: Homicide Surveillance, High-Risk Racial and Ethnic Minorities. Draft report. Atlanta: 1986 2. National Center for Health Statistics: Health United States, 1987 (DHHS Publication No. [PHS] 88-1232), 1988 3. Amler RW, Dull HB (Eds.): Closing the Gap: The Burden of Unnecessary Illness. New York: Oxford University Press, 1987 4. Flanagan TJ, Jamieson KM (Eds.): Sourcebook of Criminal Justice Statistics, 1987. U.S. Department of Justice. Bureau of Justice Statistics Publication No. NJC-111612, 1988 5. Barancik JI, Chatterjee BE, Greene YC, et al.: Northeastern Ohio trauma study: 1. Magnitude of the problem. Am J Pub Health 73(7):746-751' 1983 6. U.S. Department of Health and Human Selvices: Surgeon General's Workshop on Violence and Public Health: A Report (DHHS Publication No. tHRS-D-MCi86-1), 1986 7. Federal Bureau of Investigation: Uniform Crime Reports for the U.S., 1987 8. Allen NH: Homicide Perspectives on Prevention. New York: Human Sciences Press, 1980 Violent and Abusive Behavior 139

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9. National Center for Health Statistics: op. cit., reference 2 10. Straus MA, Gelles RJ: Societal change and change in family violence from 1975 to 1985 as revealed by two national surveys. J Marriage Family 48~3~:465-479, 1986 11. Hotaling G. Sugarman D: An analysis of risk markers in husband to wife violence: The current state of knowledge. Violence and Victims 1~2~:101-124, 1986 12. Straus MA, Gelles RJ: op. cit., reference 10 13. University of California at Los Angeles, Centers for Disease Control: The Epidemiology of Homicide in the City of Los Angeles, 1970-1979. U.S. Department of Health and Human Services, August 1985 TESTIFIERS CITED IN CHAPTER 16 018 Bell, Carl; Community Mental Health Council (Chicago) 093 Heckmann, Glenn; Texas Board of Pardons and Paroles 094 Helton, Anne; Bellaire, Texas 108 Jarrett, Michael; South Carolina Department of Health and Environmental Control 240 Allen, Manor; University of California, Los Angeles 293 Justice, Blair; University of Texas Health Science Center at Houston 304 310 322 334 Large, Lou; La Porte Independent School District (Texas) McFarlane, Judith; Texas Woman's University Macdonald, Steven; University of Washington Rivara, Frederick; Harborview Injury Prevention and Research Center (Seattle) 402 Campbell, Jacquelyn; Wayne State University 403 Hwalek, Melanie; SPEC Associates (Detroit) 420 Drake, Patience; Michigan Department of Management and Budget, and Dolsen, Robert; Statewide Health Coordinating Council 466 Martin, ~ Damien; Hetrick-Martin Institute (New York) 500 Medrano, Martha; University of Texas Health Science Center at San Antonio 514 Besaw, David; Wisconsin Tribal Health Directors 537 Greenberg, Michael; Rutgers University 602 Moldeven, Meyer; Del Mar, California 616 Windle, Anne; American Public Health Association, Public Health Education Section 697 Klingbeil, Karil; University of Washington 702 Barrett, Tom; Center for Psychological Growth (Denver) 715 Bukoff, Allen; Wayne State University 731 Gaffney, Donna; Columbia University 748 Russ, Blanche; Parent-Child, Inc. (San Antonio) 785 Roth, Jeff; National Research Council 140 Healthy People 2000: Citizens Chart the Course