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OCR for page 135
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
OCR for page 137
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
OCR for page 138
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
OCR for page 139
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
OCR for page 140
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
Representative terms from entire chapter:
elder abuse
