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Module B9 : Injuries and violence, including accidents, self-harm, and abuse
Entry Scenario
The entry scenario addresses a variety of issues and problems associated with the module topic. It may be used in class to identify the needs and interests of the students, which may then be translated into training objectives.
A 14 year-old girl is brought to you by her mother who has just realized that her daughter has been cutting herself across both forearms. At the first meeting, the girl stubbornly refuses to answer questions and says little other than that she feels very unhappy and that she hates her stepfather whom she accuses of being violent to her, without being specific. Because the mother is very concerned that her daughter is at risk of committing suicide, she requests immediate help.
General Goals for Learners
by completing the module the participant will be able to :
- Know the variety and range of injuries, violence, bullying and abuse occurring to and by young people, and identify factors associated with the occurrence of these events
- Recognize the signs and symptoms of major injuries, violence, bullying and abuse occurring in young people, skilfully approach individual cases, and bring them into the care system
- Advocate for, and practice, early detection, intervention, and prevention of the major forms of injury and violence by and to adolescents
Goal 1 : Know the variety and range of injuries, violence, bullying and abuse occurring to and by young people, and identify factors associated with the occurrence of these events
Knowledge
Training Objectives
Key topics to be covered
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Educational Methodology
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Activities, Issues, and Questions
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Pertinent resources
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A. Categorize the modes of unintentional and intentional violence and injuries experienced by young people - Intentional self injury:
- suicide
- attempted suicide
- deliberate self harm such as cutting
- Unintentional self injury
- self induced accidents-sports injuries and tests of courage
- experimentation with harmful substances (alcohol, tobacco, illegal drugs)
- Intentional injury (violence) by others
- bullying, assault
- physical and sexual abuse
- ritual female circumcision
- murder
- war/armed conflict
- Unintentional injury by others
- accidents caused by others
- industrial/occupational injuries
- Other
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Data presentation with class discussion
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Using the suggested 4 categories of modes of violence and injury as a reference, trainer introduces epidemiological information (from police, accident prevention groups, etc) about adolescent mortality and morbidity to illustrate the prevalence and trends of violence and injury in the local population. Participants offer information about own areas or countries. What are their most serious concerns? Class discusses briefly how and why the rates may vary from one country to another, and within countries. Further questions: - Which figures may represent under reported, hidden, or unrecognised events of violence and injury?
- What is the prevalence of reported rape, sexual abuse and incest? Do participants feel the rates are different in their countries, and why?
- Observe any gender differences in the rates of different forms of violence and injury; are the reasons for differences obvious or not?
- What is the prevalence and importance of sports injuries? Of traffic accidents?
- What are the trends in self-injury?
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Refs 1, 2, 3 Module C1
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B. Delineate factors of adolescent development possibly associated with violence and injury - experimentation and risk taking
- psychological vulnerability, moodiness
- differences in rates of physical maturation
- vulnerability due to development of secondary sex characteristics
- life phase activities (team sports, inexperienced driver, first job)
C. List other factors associated with violence and injury in youth, and understand the multifactorial nature of risk
- health problems, esp. mental health problems
- familial risk factors , esp. family suicide, family disruption
- previous incidents
- drug use
- socio-economic factors
- media violence
- sexual orientation
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Group discussion
of objectives B and C together
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Trainer gives introduction as needed, e.g. review the function and normality of experimentation and risk taking in adolescence. Class discusses how the developmental factors may ‘set the stage’ for violence and injury events, using examples from their own experiences or practices.
How accurate it is to say, “All adolescents are at risk”? Using the listings under Objectives B and C, discuss the possible interaction of factors associated with usual adolescent development and other risk factors.
(For example, how violence and injury from childhood years may affect developmental tasks or be expressed in adolescent behaviour that ‘sets the stage’ for receiving further violence and injury or for becoming an abuser.) What factors has research shown to be particularly associated with certain types of injury and violence, esp. self-injury? Further questions: Which groups of teenagers may be particularly vulnerable to physical and sexual abuse (e.g. young people with mental and physical disabilities)?
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Ref 4 Module A6
Refs 5, 6
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Goal 2 : Recognize the signs and symptoms of major injuries, violence, bully and abuse occurring in young people, skilfully approach individual cases and bring them into the care system
Knowledge
Training Objectives
Key topics to be covered
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Educational Methodology
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Activities, Issues, and Questions
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Pertinent resources
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A. Recognize the signs and symptoms in a teenager of injuries inflicted by others as well as by self - obvious/ not obvious signs
- modes of concealment, hidden agendas
- utility of screening tools
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Group discussion
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Discuss participants’ experiences in detection. Which signs and symptoms are most likely to be significant? Which may signal self-inflicted injury, and which may signal other-inflicted? Which particular kinds of injury/violence are more likely to be concealed and why? What questions may be most useful to uncover a hidden agenda? Case example: A bulimic14 year-old girl is brought to you with burn marks on the back of her hands. How would you determine whether they were self inflicted or represented abuse by another person? If a teenager is not ready to disclose abuse, what is the appropriate response by the practitioner? Review the utility of using HEADSSS, or brief screening tool reported in Pediatrics. (ref 12) Case example: A 12 year-old girl is referred by her school because she is behaving in an inappropriately sexually provocative way with boys and the male teacher in her class. What questions do you ask about her circumstances? Would a screening tool be helpful?
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Refs 7- 10
Refs 11 - 13
Website 1
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Attitudes
Training Objectives
Key topics to be covered
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Educational Methodology
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Activities, Issues, and Questions
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Pertinent resources
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B. Confront personal feelings and experiences which could interfere with health provider’s ability to offer the best care to adolescents suffering from injury or violence
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Written narratives or video, if available, of adolescent giving his/her story and how he/she recovered.
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Trainer presents written or video description(s) of assault, abuse, or suicide case(s) while participants make personal notes about their emotional reactions.
Organize a discussion (in small groups if class is large) with the purpose of sharing and examining these feelings. Trainer underlines the importance to practitioners of recognizing and grappling with their personal feelings regarding violence, self-inflicted injury, and death.
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Skills
Training Objectives
Key topics to be covered
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Educational Methodology
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Activities, Issues, and Questions
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Pertinent resources
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C. Skilfully bring a suspected or obvious case of injury or violence into the care system - appropriate history taking
- appropriate physical examination
- elements of immediate medical care
- elements of extended management (counselling, referral, legal issues)
- post traumatic stress syndrom
- referrals, referral service
- multidisciplinary team organization
D. Be informed of appropriate measures to take in emergency cases of sexual violence or abuse
- securing evidence
- emergency medical measures (incl. post
- coital contraception and STI prevention)
- legal obligations of health provider
E. Be informed of appropriate measures to take in case of high risk for suicide
- informing the parents/guardian
- providing advice to parents and peers
- protection against further attempts
- hospitalization
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Introductory remarks Video of appropriate interaction with an injury case Role play in small groups with discussion
(Activity combines objectives C, D, and E.)
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Review the essentials of interviewing adolescents. Would the sensitivity of the topic of abuse and violence change anything?
Groups role play case intake to management. Case study of injury inflicted by another
A 14 year-old boy is brought to see you because his mother has noticed fresh blood on his underpants. On examination you find an anal fissure and anal warts. He is being tutored privately for his exams by a 20 year-old university undergraduate. Questions: What are the key questions to ask when abuse is suspected? What is acceptable when examining a teenager for either physical or sexual abuse? What other professionals are available to help in the case, and how do you go about tapping into the network? What are the issues of consent and confidentiality when non-accidental injury is suspected, and how would you disclose the limits of confidentiality to the injured teenager?
What are the symptoms of posttraumatic stress? Discuss the practical implications of securing evidence (e.g. no shower or bath for victim). List the most important measures to be taken.
Participants should inform themselves of legal responsibilities, as well as the specific services of their areas.
Additional issue: Although rare, there exists the possibility of false allegations, including allegations against the health professional. What elements of the clinical setting, procedure and attitude may eliminate this factor? Cases of self-inflicted injury - A 13 year-old boy is brought by his parents because the previous week he drank two bottles of whiskey with a friend, and was admitted comatose to the local hospital emergency center with severe alcohol poisoning. The hospital has referred him to you for follow up to prevent a recurrence
- A 14 year-old with developing anorexia nervosa is brought to you by her parents because she started ‘cutting’ her arms. Her parents are concerned that she may be suicidal.
Participants practice skillful questioning of a young person who has been self-injuring. How would one assess the dangers of subsequent suicide? How can the practitioner aid families and friends to helpfully respond to the self-injuring teenager?
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Ref 14 Module A3
Ref 15
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Goal 3 : Advocate for early detection, intervention, and prevention of the major forms of injury and violence by and to adolescents.
Knowledge
Training Objectives
Key topics to be covered
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Educational Methodology
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Activities, Issues, and Questions
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Pertinent resources
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A. Clarify for oneself and others the role of the health practitioner as an ‘advocate’ for young people in relation to injury and violence - responsibility limits
- confidentiality issues
- legal backing
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Class discussion
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Case study bullying : A 15 year-old boy complains to a health professional that he and other students are being bullied at school. Neither his school nor his parents have done anything. - How would you act as an advocate for the boy?
- Who else would you involve with helping you?
- How would follow up the case so as to insure that action was being taken?
Case study sexual abuse: The grandmother of a young female patient confides in you that she suspects the father is abusing the child’s teenaged sister. She says she does not want the family to know she gave the tip, and she would refuse to be a witness. What are your responsibilities as an advocate? Trainer gives examples of protective legislation. Do participants know the legal structure for advocacy in their countries? How can legislation be improved?
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Refs 16, 17 Module C3
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B. Identify the risk factors amenable to intervention, and identify promising approaches to the prevention of intentional and unintentional injury and violence to and by adolescents, especially: - self-harm, including suicide and attempted suicide
- physical and sexual abuse
- bullying
- traffic accidents
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Literature results Group work (Objective B and C together) Groups work on the same or different activity options.
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Activity option 1
Small groups select or are assigned one of the major modes of injury and violence. Giving consideration of the risk factors discussed earlier (Goal I), what are plausible approaches to decreasing mortality and morbidity due to the type of injury/abuse as experienced in participants’ locales? (Trainer may provide research results on intervention programs for the different categories.) Discuss effectiveness, political and legal issues, and problems of implementation in the participants’ countries.
Plenary summarizes approaches that participants have decided would be promising.
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Refs 18 - 21
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C. Design an approach to intervene with a local problem of violence or injury affecting teenagers
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Activity option 2
Discuss the newspaper article summarized in appendix 1. How may the factors suggested as contributing to indigent youth suicide apply to cases of adolescent suicide and self-injury in other parts of the world, and specifically in participants’ countries ?
Questions :What measures might the individual practitioner promote that could lessen the impact on youth of war and terrorism ?
Do participants consider factors relating to ‘modernity’ amenable to intervention ?
What actions could be considered preventive measures for more than one mode of injury/abuse (e.g. supporting families who live in adverse conditions, training teachers to spot trouble signs). Activity option 3
Small groups identify a local problem relating to youth violence or injury, and design an intervention to be presented in plenary.
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Ref 22 Appendix 1 Refs 20, 23
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References
- Trends in injury mortality among young people in the European Union: A report from the EURORISC Working Group. Morrison A, Stone DH and EURORISC working group. Journal of Adolesc Health 2000; 27: 130-135.
- Office of the Surgeon General. Youth Violence: A Report of the Surgeon General. Released January 17, 2001. Available at: http://www.surgeongeneral.gov/library/youthviolence/report.html.
- Krug EG, Dahlberg LL, Mercy JA, Zwi AB, Lozano R (eds.). World report on violence and health [serial online]. 2004 May. Available online from: URL: http://www.who.int/violence_injury_prevention/violence/world_report/wrvh1/en
- Herrenkohl TI, Maguin E, Hill KG, Hawkins JD, Abbott RD, and Catalano RF. Developmental risk factors for youth violence. J Adolesc Health 2000; 26(3) :176-186.
- Cheng TL, Schwarz D et al. Adolescent Assault Injury: Risk and Protective Factors and Locations of Contact for Intervention. Pediatrics 2003; 112(4): 931-938.
- Remafedi G. Sexual orientation and youth suicide. JAMA 1999;282:1291.
- Jones DPH. Child Abuse and Neglect. In Gelder MG, Lopez-Ibor JJ, and Andreasen N (eds). The New Oxford Textbook of Psychiatry. Oxford University Press, Oxford 2000, Ch. 9.3.1.
- Frankenfeld DL, Keyl PM, Gielen A. et al. Adolescent Patients- Healthy or Hurting? Missed opportunities to screen for suicide risk in the primary care setting. Arch Pediatr Adolesc Med. 2000;154:162-168.
- Cappelli M, Clulow MK, Goodman JT et al. Identifying depressed and suicidal adolescents in a teen health clinic. J Adolesc Health 1995;16:64.
- Boggio N, Cohall AT. Evaluating the adolescent: the search for the hidden agenda. Emerg Med 1990; January 30:18.
- van Amstel LL, Lafleur DL, Blake K. Raising our HEADSS: Adolescent Psychosocial Documentation in the Emergency Department. Acad. Emerg. Med. June 1, 2004; 11(6):648-655.
- Horowitz LM, Wang PS, Koocher GP et al. Detecting suicide risk in a paediatric emergency department: development of a brief screening tool. Pediatrics 2001; 107(5):1133-1137.
- Goldenring JM, Rosen DS. Getting into adolescent heads: an essential update. Contemporary Pediatrics 2004; 21 (1): 64-90.
- American Academy of Pediatrics Task Force on Adolescent Assault Victim Needs. Adolescent assault victim needs: a review of issues and a model protocol. Pediatrics 1996; 98(5):991-1001.
- Hawton K and Van Heeringen K (eds.) The International Handbook of Suicide and Attempted Suicide. John Wiley and Sons 2002.
- Abbasi K, The Children's Advocate. British Medical Journal, 1998; 316:960.
- Smith P, Morita Y, Junger-Tas J, Olweus D, Catalano R, and Slee P (eds.). The nature of school bullying : a cross-national perspective. Routledge, London and New York 1999.
- The Cochrane Library data base on effective interventions for injuries due to accidents. http://www.cochrane.org
- Reducing Fatal Crash Risk Amongst Teenage Drivers; structuring an effective graduated licensing system JAMA. 2000:12; 1617-1618.
- Southall DP et al. Strategies to Protect Children from the Effects of War. International Child Health. Oct 1995;6:111-116.
- Stevens V, Van Oost P, and De Bourdeaudhuij I. The effects of an anti-bullying intervention programme on peers’ attitudes and behavior. J of Adolesc 2000 Feb; 23(1)21-34.
- Forero J. Where modernity brings suicide. International Herald Tribune; Nov.25, 2004: p.11.
- Plunkett MCB, Southall DP. The Effects of War On Children. Current Paediatrics 1996:6. 211-216.
Website
- www.complab.nymc.edu/pediatrics/HEADSS.htm
Appendix 1
An international newspaper (reference 22) reported a troubling surge of adolescent suicides among native tribes in Columbia, and discussed possible reasons for this previously little known phenomenon. One obvious cause may be the guerrilla war raging within the country for 40 years; the article cites the note left by a 15 year-old who hung herself, in which she voiced her fear that Columbia’s armed conflict would engulf her family. Other factors identified by researchers refer to an encroaching modernity that promotes loss of traditional tribal identities, a disintegration of traditional support systems and an erosion of values and sustaining lifestyles. One expert in adolescent suicide who studies multiple suicides among youth proposes that the idea of suicide can spread when one or two events gain attention, making a previously unacceptable behaviour appear to a troubled teenager to be an option.
Discuss how this report has elements that may apply in to adolescent suicide in other areas of the world, specifically in participant’ countries, and may not be necessarily restricted to indigenous cultures.
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