Violence: A Public Health Perspective Josh Knox, PA-C, M.A. PHAS 7090 Summer 2011

Educational Objectives Discuss the root causes of violence and its effects on self, women, children, youth, elders & society from a health perspective. Recognize that violence is preventable & the role of the PA in that prevention. Discuss prevention strategies for self- directed, child, intimate partner, and youth violence.

Violence Defined World report on violence and health (WRVH): "the intentional use of physical force or power, threatened or actual, against oneself, another person, or against a group or community, that either results in or has a high likelihood of resulting in injury, death, psychological harm, mal-development, or deprivation."

Types of Violence Intrapersonal Violence: Suicide Interpersonal Violence Child Maltreatment Youth Violence Intimate Partner Violence Elder abuse Sexual Violence Collective Violence: War/Uprisings

Impact of Violence on Society > 50, 000 per year die d/t violence in U.S. (2005) million injuries due to interpersonal & self- directed violence 2. The total costs associated with nonfatal injuries and deaths due to violence was more than $70 billion (2000). $64.4 billion or 92% due to lost productivity. $5.6 billion was spent on medical care

Why should a PA bother? There is strong evidence that violence can be prevented and its impact reduced similar to what has been done for: Traumatic injuries Infectious diseases Pregnancy complications

What Causes Violence? Bad neighborhoods/housing or unemployment/dead- end jobs. Bad genes or bad morals.

In reality it looks like…..

Biologic Causes of Violence “No patterns precise enough to be considered reliable biological markers for violent behavior have yet been identified”-NAS 1

Sociologic Factors in Violence Drastic differences in violence rates. In general, smaller communities have lower rates of violence. Within the same city, some neighborhoods have rates of violent crime 300 times higher than other neighborhoods. People who commit violence (on the street) are disproportionately poor and unemployed. The overwhelming majority of people arrested for crimes of violence are men. Violence is primarily the work of the young. People in their late teens and twenties are much more likely to be arrested for violence than younger or older people. The arrest rate--and the victimization rate--for violent crime for African-Americans is six times higher than for whites.

Neighborhoods & Violence Collective Efficacy- social cohesion among neighbors combined with their willingness to intervene on behalf of the common good. Collective efficacy is negatively associated with violence

Psychological Factors Mental illness plays a small role in interpersonal violence 1. Effects of family are the most powerful influence across most forms of violence.

Suicidal Violent Behavior & Consequences Suicidal behavior exists along a continuum 1 : Thinking about ending one's life "suicidal ideation“ Developing a plan Non-fatal suicidal behavior "suicide attempt“ Ending one's life "suicide“ 33,000 suicides each year (CDC, 2010). 392,000 people with self-inflicted injuries sought treatment in emergency departments (CDC, 2010). It is estimated that for every one suicide there are 25 attempts 1.

Suicide was the 11th leading cause of death among persons ages 10 years and older, accounting for 33,289 deaths in 2006.

Suicide Risk Factors Risk Factors: Family history of suicide Family history of child maltreatment Previous suicide attempt(s) History of mental disorders, particularly clinical depression History of alcohol and substance abuse Feelings of hopelessness Impulsive or aggressive tendencies Cultural and religious beliefs Local epidemics of suicide Isolation, a feeling of being cut off from other people Loss (relational, social, work, or financial) Physical illness Easy access to lethal methods

Suicide Protective Factors Protective Factors Effective clinical care for mental, physical, and substance abuse disorders Easy access to a variety of clinical interventions and support for help seeking Family and community support (connectedness) Support from ongoing medical and mental health care relationships Skills in problem solving, conflict resolution, and nonviolent ways of handling disputes Cultural and religious beliefs that discourage suicide and support instincts for self-preservation

Guns and Suicide Guns in the home are the primary source for firearms that teenagers use to kill themselves in the United States 1.

Suicide Prevention: The Evidence Treatment of Mental Health Disorders Treatment of Substance Abuse Behavioral Therapy Restrictive firearm licensing and purchase policies? Increasing Social Connectedness? Suicide Prevention Centers?

Child Maltreatment Child maltreatment: all types of abuse and neglect of a child under 18 by a parent, caregiver, or another person in a custodial role. There are four common types of abuse: Physical Abuse Sexual Abuse Emotional Abuse Neglect

Child maltreatment prevalence & consequences 763,000 children victims of maltreatment in ,755,000 children were victims of child maltreatment during a one- year time frame 2. (essentially 1/7 U.S. children) 1,770 children across the country died from abuse 1. (2008) Long-term consequences on cognitive, language, and socio- emotional development, and mental health. Severe or fatal head trauma. Nonfatal consequences of abusive head trauma include visual impairment, motor impairment & cognitive impairments. 3 Increased risk for adverse health effects &chronic diseases 4. Increased risk of addictive disorders, mental health conditions, low academic achievement & relationship dysfunction.

Child maltreatment risk factors Individual Risk Factors Children < 4 Special needs child Risk Factors for Perpetration Parents' lack of understanding of children's needs, child development & parenting skills Parental history of maltreatment Substance abuse and/or mental health issues including depression Parental characteristics such as young age, low education, single parenthood, large number of children, &d low income Non-biological caregivers in the home Family Risk Factors Social isolation Family disorganization, dissolution, & violence. Parenting stress, poor parent- child relationships, and negative interactions Community Risk Factors Violence Concentrated neighborhood disadvantage & poor social connections.

Evidenced Based Interventions with Impact on Child Maltreatment Child-Parent Centers Nurse family Partnerships Positive Parenting Program

Youth Violence Definition & Consequences Youth violence: the intentional use of physical force or power, threatened or actual, against another person or against a group or community that results in or has a high likelihood of resulting in injury, death, psychological harm, mal- development, or deprivation typically including persons between the ages of 10 and ,000 youth ages 10 to 24 are treated in ER’s/yr for injuries sustained due to violence-related assaults. 16 persons b/t 10 and 24 are murdered each day in the U.S. YV increases the cost of health care, reduces productivity, decreases property values, and disrupts social services

Youth Violence Risk Factors Individual Risk Factors Attention deficits, hyperactivity or learning disorders History of early aggressive behavior Involvement with drugs, alcohol or tobacco Low IQ or deficits in social cognitive or information-processing abilities Antisocial beliefs and attitudes Exposure to violence and conflict in the family Family Risk Factors Harsh, lax or inconsistent disciplinary practices Low parental involvement Low emotional attachment to parents or caregivers Low parental education and income Parental substance abuse or criminality Poor family functioning Peer/Social Risk Factors Association with delinquent peers/Involvement in gangs Lack of involvement in conventional activities Poor academic performance Low commitment to school and school failure Community Risk Factors High concentrations of poor residents High level of transiency High level of family disruption Low levels of community participation Socially disorganized neighborhoods

Youth Violence Protective Factors Individual/Family Protective Factors High IQ/GPA Positive social orientation Religiosity Connectedness to family or adults outside the family Consistent presence of parent during at least one of the following: when awakening, when arriving home from school, at evening mealtime or going to bed Involvement in social activities Peer/Social Protective Factors Commitment to school Involvement in social activities

Youth Violence Prevention: The Evidence Parent training Skills training Social development programs Big Brothers/Big Sisters Urban Ecology Center Regulating access to alcohol Restrictive firearm licensing & purchase Enforced bans on public firearms

Intimate Partner Violence Intimate partner violence: physical, sexual, or psychological harm by a current or former partner or spouse. This type of violence can occur among heterosexual or same-sex couples and does not require sexual intimacy*. Costs of intimate partner violence (IPV) against women in 1995 exceeded $5.8 billion. Victims of severe IPV lose nearly 8 million days of paid work- the equivalent of more than 32,000 full-time jobs-and almost 5.6 million days of household productivity/yr. 329 males and 1181 females were murdered by an intimate partner (Bureau of Justice Statistics 2007)

Intimate Partner ViolenceRisk Factors Individual Risk Factors Low income/unemployment Low academic achievement Young age Heavy alcohol and drug use Mental health condition Belief in strict gender roles (e.g., male dominance and aggression in relationships) Being a victim of physical or psychological abuse (consistently one of the strongest predictors of perpetration) History of experiencing poor parenting as a child History of experiencing physical discipline as a child Relationship Factors Marital conflict-fights, tension, and other struggles Marital instability-divorces or separations Community Factors Poverty and associated factors (e.g., overcrowding) Low social capital-lack of institutions, relationships, and norms that shape a community's social interactions Societal Factors Traditional gender norms (e.g., women should stay at home, not enter workforce, and be submissive; men support the family and make the decisions)

Intimate Partner Violence: Prevention Interventions Interventions for problem drinking partners School based programs addressing gender norms Screening and referral Advocacy support programs Protection orders

A final word on firearm violence A gun in the home is 22 times more likely to be used in an unintentional shooting, than to be used to injure or kill in self- defense 1. What ways could diverse communities benefit from the examples of engagement in Monday’s film? What situations could you potentially encounter as PA’s in Monday’s film?