1. CHAPTER 12 PREVENTING INJURIES INTENTIONAL INJURIES INJURIES İLKNUR AVCI 24.12.2009

2.  Unintentional injuries→the leading cause of death for people in the United States below age 35  Intentional injuries→among the leading causes of death for this age group  Both suicide&homicide→among the top 10 leading causes of death for children and youth  Many young people suffer nonfatal injuries as a result of the violent acts of others.  Violence→ a more common cause of injury and death in the United States than in other industrialized nations, with violent crimes occuring at a rate of about 8 per 1, 000 people.  The settings for violence and its effects differ over the lifespan.

3. Childhood  mortality rates ↓  between ages 5 and 9 →the lowest death rate for any age group  younger and older children are somewhat more vulnerable.  Their risks are the highest for unintentional injuries, however, children are also in danger from intentional violence, most often at the hands of their parents.  Treating infants with skull and long bone fractures led pediatricians and radiologists to recognize that these injuries were caused by beatings.  Evidence began to accumulate that such beatings were common and a major source of injury for infants and children.

4.  Injuries at different ages during childhood have varying consequences, but such injuries have some consequences for all children.  One common result→ vigilant and feel threatened in a variety of situations.  Fearful about rejection, abandonment, and additional abuse→abused children  Mistrust and poor self-esteem→abused persons of all ages.  Aggressive behaviors, lacking the ability to adequately express emotions, and having inadequate cognitive and problem-solving skills→ growing adulthood  Children are particularly vulnerable and children are most likely to suffer from violence in childhood.  Abuse→the leading cause of death for infants after the prenatal period, making the first year of life the most dangerous single year during childhood.  Children injured during infancy are at risk for permanent damage to their nervous systems leading to cognitive and developmental problems.

5.  Adults who abuse children were almost always abused themselves, but not all people who were abused during childhood become abusers.  Many have experiences that compensate for the abuse, forming relationships that allow them to feel valued and safe in some ways and grow up to become good parents.  However, children who do not form such relationships are at high risk to become abusers themselves.  Abuse can prevent children from accomplishing some of the developmental tasks of young childhood, including forming attachments to others(usually parents), seeing themselves as separate individuals, and developing physical, cognitive, and language skills.  Abuse during early childhood can impede children’s ability to get along with their age-mates and to do well in school.

6.  School-age children and adolescents who are abused may exhibit symptoms of psychopathology or behavior disorders.  Physical abuse may continue during middle childhood, but it is not as likely to be initiated at this age as is sexual abuse.  Girls between ages 10 and 13 are particularly vulnerable to sexual abuse, but boys are also victims.  Biological fathers are much more likely than mothers to be perpetrators however stepfathers and boyfriends are also frequent perpetrators along with other male family members and adults in positions of trust.  Children are also exposed to violence in their communities, and children in poor urban neighborhoods are particularly vulnerable.  ↑ in youth violence that began during the late 1980s affected children, who were often witnesses to violence in their communities and schools.  Children exposed to violence can develop posttraumatic stress disorder (PTSD) and other stress-related and anxiety problems.

7. Youth  Violence is a more pervasive problem for adolescents and young adults than for children.  Adolescents are substantially more likely than adults to be victims of violance.  In opposition to children, adolescents are frequent perpetrators of both minor and serious violence.  In a survey of high school students, about 43% of boys and 24% of girls had been in a physical fight during the previous 12 months; 4% of all students were injured in a fight.  In addition to homicide, suicide is ranked among the leading causes of death beginning with 10-year-olds.

8.  A survey of high school students (Granbaum et al., 2002) found that 24% of girls and 14% of boys had seriously considered attempting suicide, and nearly 8% of all students had made at least one attempt at suicide.  The types and settings for youth violence are varied, and some young people are at much higher risk than others.  Being young and living in the United States are among conditions for risk for violence and increased risk of intentional injury or death.  Economic factors, ethnic background, and gender all influence risks for being involved in violence either as a perpetrator or as a victim.  Poverty, poor mental health, drug use, and problems at school, → violent behavior. Young men are more likely to be both perpetrators and victims of physical violence than young women.  It is a result of poverty thatYoung African American men are much more likely to die from homicide than any other segment of U.S. society, including young European American men and African American in other age groups.  For all age groups, African Americans are nearly seven times more likely to be victims of murder than European Americans.

9.  Gender is also a factor in assaults.  Young men are more likely to be both targets and perpetrators, but the methods of injury differ.  Young men are more likely be shot, whereas young women are more likely to be stabbed, with injuries tending to occur in their homes.  Young women are at higher risk for sexual assault.  Between half and two thirds of all sexual assaults occur before the victims reach age 18, making late childhood and adolesce a vulnerable time.  Ethnicity is also a factor, with non-Hispanic European American women at higher risk than Hispanic American or African American women.  In addition to physical injury, assault and rape increase the risk for mental health problems that are related to suicide.

10.  The official reports of rape do not capture the magnitude of the problem, because a large majority of victims of sexual assault do not report the incident to police and are thus not counted in the official crime statistics.  When they are forced to have sex, men are even less likely than women to report to authorities.  Perhaps as few as 16% of sexual assaults are reported to police, but about half of all rape victims experience either minor or serious physical injury as a result of the sexual assault.  Access to weapons contributes to the increased deadliness of violence among adolescents versus children.  In 2001, about 29% of high school boys and 6% of girls reported that they carried a gun,kinife, or club during the 30 days preceding the survey, but it represents a drop from 1993, when 34% of high school boys and 9% of high school girls reported carrying aweapon to school.  In high-violence neighborhoods, the percentages are higher.  Although adolescents report that they believe their schools are dangerous and they are in need of self-protection, these junior high school students carried guns for more aggressive purposes than for defensive reasons.  Indeed, students in elementary and middle school who owned guns were likely to do so in order to gain respect, frighten, and bully others.

11.  Easy access to firearms which are used in a majority of homicides and suicides amoung youth is a factor in homicide and suicide among young people.  Young people with behavior problems are more likely than other adolescents to carry a gun, and over three fourths of young people with guns are involved in gangs, drugs, or other illegal activities.  About 30% of adolescents with guns have used them to shoot someone.  Weapon-related violence received a great deal of publicity due to a series of shootings in U.S. Public schools beginning in 1997.  With easy access to guns, adolescents who are troubled and angry can fantasize about revenge, and the publicity over each shooting made this action attractive to others, promoting additional shootings.  The school shootings brought publicity, but school violence has been a topic of concern to educators for years.  Bringing weapons to school has been one focus of this concern, but fights without weapons have been the most common type of school violence during recent years.  The publicity generated by the shootings has given a boost to strategies to reduce school violence.

12.  The increased access to weapons has not only led to an increase in homicide and assault-related injuries among teenagers, but it has also contributed to suicide attempts among young people.  The risk factors for suicide attempts among youth are similar to risk factors for other age groups-easy access to weapons, alcohol and drugs, feelings of isolation, lack of social support, and low self- esteem.  In young people, estrangement from family and trouble in romantic relationships can lead to the feelings of isolation that are related to suicide attempts.  Being gay or bisexual also increases the suicide risk for young men.  Because youth suicide produces so many years of lost life, many prevention strategies are aimed at this age group.

13. Adulthood  As suicide becomes a more common cause of death than homicide beginning at age 25; the number of suicides increases and homicides decreases.  Violence in the streets and workplace has an impact on adults, but homes are more dangerous.  Domestic violence is a major cause of injury and death, and partner violence and elder abuse are the two varieties of domestic abuse that affect adults.  Income level, ethnicity, and gender relate to risk of victimization.  Innercity neighborhoods, poor African American men at increased risk for street violence.  Men are more likely than women to be murder victims for all income levels, ages, and ethnicities, but adults over age 25 are much less likely than those between 15 and 25 to be victims.  Street violence becomes less of a risk for adults, but violence at home remains a major problem.

14.  In some societies, a majority of women report violence at the hands of male family members.  Similar to women in the United States, abused women around the world report that they are dependent on the men who abuse them and have no economic resources that would allow them to leave the abusive relationship.  Early publicity on domestic violence focused on husbands who physically abused their wives, but research soon appeared indicating that women also initiate partner violence.  In a representative sample of young adults in New Zealand, women were more likely to be perpetrators of violent acts than men, although serious violence was unusual for either.  For severe domestic violence, men were more common perpetrators than women.

15.  Michael Johnson(1995) argued that domestic violence can be divided into two types:  Common couple violence: the pattern of conflicts in which an argument escalates into a fight. The physical violence can be minor, but when it becomes serious, women are more likely than men to be injured.  Patriachal terrorism: a situation in which a man dominates his family by using physical force as well as other control strategies. This pattern of domestic violence is an extension of male dominance in families an results in injury and death to both women an children.  In summary, women are more likely than men to be homicide victims as a result of domestic violence and more likely to be injured or killed by an intimate partner than by a stranger.  Availability of weapons is also a factor in domestic violence and suicide.  Having a gun in the house increases the risk of both homicide and suicide.  Other factors that relate to suicide are a history of mental illness and living alone.

16.  Angry spouses entered a workplace and attacked or killed their partners as well as others happened to be present(domestic violence).  angry employees or former employees who threaten, harm, or kill supervisors or coworkers(workplace violence).  These two types of violence may be related, and perpetrators of domestic violence are at increased risk for workplace violence as well.  A failure to set limits on harrasment and intimidation or insensitive disciple and terminations can lead to employee violence.  In addition, a failure to take the possibility of violence seriously can endanger managers and human resources personnel.

17.  The gender difference in risk for violence applies to suicide:  Men are more likely to commit suicide than women, especially in younger ages.  Also, suicide rate vary among countries: Hungary has the highest rate and Greece the lowest.  In most developed countries, suicide rates increased during the past 15 years.  In the United States, variation occurs among ethnic groups, and European Americans have the highest suicide rates, followed by Native Americans.  African Americans, Hispanic Americans, and Asian Americans commit suicide only about half as often, and some Native American tribes have much lower rates than others do.

18.  Alcohol is connected to suicide and suicide attempts in people nearly every age and ethnic background.  This connection may come through alcohol’s disinhibiting effects; some people may decide to kill themselves while sober and then use alcohol as an anesthetic.  However, an inability to control alcohol consumption of attempting suicide, and people diagnosed with alcoholism are at increased risk for suicide.  People with drinking problems are often also depressed; feelings of despair and hopelessness lead some people to both abuse alcohol and to attempt suicide.  Suicide also varies with age.  Youth suicide has gained a great deal of publicity, but adults are even more likely to commit suicide.  Suicides among older adults account for a lower percentage of their deaths but only because older people have higher rates of death from other causes.  Suicide rates are higher for middle-aged adults than for youth and even higher among older people.  Indeed, individuals over age 85 have the highest suicide rate of any age category.

19.  Older people are also at risk for violence from others, which can come from family caregivers in the home or from professional caregivers in institutions.  Elder abuse which is less common than child abuse and partner violence includes physical, psychological, sexual, or financial abuse or neglect of older people.  Risk factors for elder abuse include functional impairment and cognitive disability as well as age and economic dependence.  Thus, factors that make caregiving more stressful increase the risk for abuse.  In addition, lack of awareness of the specific needs of older people can contribute to neglect.  Like other types of domestic violence, elder abuse can be difficult to diagnose because the abused person depends on the abusers and may be reluctant to complain to athorities.  In addition, physicians may not be alert to the possibility of abuse or reluctant to intervene.

20. Strategies to Reduce Intentional Injuries  Aimed at specific problems, and some strategies for reducing intentional behavior combine changes in individual behavior, the environment, the law.  Indeed, changes in three will be necessary to make substantial progress in reducing intentional injuries.  Joyce Osofsky(1997)→ individual efforts to reduce various types of violence must be supplemented by a national campaign in the media to ‘change the image of violence from one that is acceptable, even admired, to something disdained and considered unacceptable’(p.326).  Strategies→presidential proclamation about domestic violence and child abuse, community programs to raise awareness of domestic and family violence, and school based programs to decrease sexual abuse, interpersonal conflicts, and bullying.

21. Domestic Violence  Three types of domestic violence: child abuse, partner violence, and elder abuse  Although child abuse prevention differs from partner violence interventions, and both differ from programs aimed at elder abuse.  According to the report of a special committee assembled to evaluate domestic violence interventions, services are fragmented by jurisdiction and specialty, and evaluations for effectiveness are not routine.  However, information about evaluations is beginning to collect, and these findings suggest that interventions can be effective.

22. Child Abuse Programs  Aimed at both parents and children.  The programs for parents: help parents do a better job(and thus prevent abuse) as well as legal interventions to restrain violence or to remove the child from an abusive environment.  Other programs: minimize the harm that violence has done to children who have been abused.  Legal strategies: compulsory reporting of suspected child abuse to remove children from abusive environments before more harm can occur.  Some programs have targeted high-risk parents, attempting to prevent initial incidents of abuse.  Factors that contribute to risk include poverty, young age, and a history of abuse, either as a victim or as perpetrator.  Programs: parent support in the form of education or support groups, home visits, and mental health counseling.  These interventions are beneficial for the mother-child relationship and for these children’s early development.

23.  The goal of many social service interventions: preserving the family by changing dysfunctional family interactions.  The goal may not be realistic unless interventions are long term, and programs with additional follow-up indicate more success than those without continued attention.  Placing an abused child in foster care or a group home may not be sufficient, because the experience of violence has already produced damage.  Children placed in alternative living environments need services to help them recover from the violence that prompted their placement.  Whereas interventions to decrease child abuse focus on parents’ behavior, sexual abuse prevention is aimed at changing children’s behavior.  The goal of these programs, which are often school based, is to change the individual behavior of children so that they avoid sexual abuse.  Children are taught to flee from people or situations in which a person tries to touch them sexually and to tell about such attempts.  Evaluations for these programs indicate that they increase knowledge, and a survey of college women who had participated in ‘good touch-bad touch’ sschool sexual abuse programs reported substantially lower levels of sexual abuse (8%) than women who had not (14%).

24.  Changes in the law have made reporting of child abuse mandatory for health care and education professionals.  The rationale is that, by requiring physcians, psychologists, nurses, counselors, and teachers to report suspicious cases, children can be protected from escalating violence.  Physicians must overcome many barriers to question their patients about abuses and, thus, often do not learn enough to report, which makes these mandatory reporting laws ineffective.  In addition, these laws may have unexpected and negative consequences for children, forcing the disintegrationof families.  In summary, the interventions aimed at changing prents’ behavior and teaching children to avoid and report sexual abuse have some effect.  Changing the environment is not a strategy used to prevent child abuse, and changing the law has been very effective in decreasing risks of violence to children.

25. Partner Abuse Intervention  The ideal strategy to prevent partner abuse would be to change social values so that violence is not an acceptable way to resolve conflicts and to allow women the power and resources to leave violent relationships.  That level of social change is beginning to happen in many societies around the world, but others retain values that allow husbands to behave violently toward the wives.  Strategies for reducing partner abuse focus on caring for victims and preventing additional incidents : social services and legal interventions.  The majority of social services programs are shelters to which abused women can escape, although some inventive approaches exist.  Donate a Phone Program for victims of domestic violence  Shelters offer a range of services such as counseling, job training, legal advice, and housing assistance, making evaluation of these programs, making evaluation of these programs difficult.  Women who participated in this program experienced an improved quality of life and a decreased risk of partner violence two years later.

26.  Legal interventions→decrease partner violence.  Legal strategies: protective orders to keep batterers away from their partners, mandatory arrest and prosecution, and legal reporting requirements.  Protective orders can be good short-term solutions to partner abuse, but studies that evaluate their effectiveness are lacking, and protective orders are typically part of a legal response that involves arrest and prosecution.  Incidents of partner violence prompt mandatory arrest in some states and many jurisdictions→ the most common legal intervention.  Some evidence suggest that mandatory arrest deters further violence, but the policy can also create unwanted effects and possibly even increase violence in some cases.

27.  Less than 15% of physicians questioned female assault victims about partner abuse,  and few women who sought emergency room services for physical assault were referred for additional services.  In addition, physicians did not want to question women about domestic abuse because such inquiries would be personal and distressing and would make physicans responsible for taking additional action.This attitude is a barrier to identifying and decreasing partner abuse.  The acceptance of violence as a way of resolving conflicts is another barrier.  Nearly 3 million married couple each other each year.  A survey of American couples(Straus, Gelles, & Steinmetz, 1980) found that 25% of wives and over 30% of husbands considered violence an acceptable way to resolve some disputes.  This attitude is a major barrier to reducing partner violance.

28. Reducing Elder Abuse  Less common and less frequently evaluated than other types of domestic abuse programs.  In many ways, efforts to reduce elder abuse parallel approaches to decrease child abuse; both concentrate on protecting individuals who cannot protect themselves, and both use social and legal interventions.  Such services investigate cases of suspected abuse or neglect combined with case management that include medical, educational, and legal services.  These services may help either older people or their caregivers.  caregivers for Alzheimer’s disease patients  Services to older people include assisstance with the things that would allow them to live independently and care for themselves.  Legal interventions include mandatory of voluntary reporting laws in most states in the United States, protective orders, arrest and prosecution, legal counseling, and appointment of guardians.  Those who abuse the elderly→likely to be prosecuted than child abusers, and social and legal service workers typically seek a resolution to a problem situation that allows for the care of the older person.

29. Creating Safer Workplace  Although unintentional injuries are common in the workplace, three types of intentional workplace violence pose hazards.  One type is violent crime; assault and homicide at work is the most common source of workplace violence.  Another type is an extension of partner abuse and occurs when domestic disputes are carried into the workplace.  The third occurs when angry employees or former employees come into the workplace and retaliate against supervisors and coworkers.  Efforts to decrease workplace violence have concentrated on robbery and other violent crimes perpetrated by those who come into a workplace.  Strategies such as bright external lighting, forbidding working alone at night, and keeping doors locked decreases the chances of worksite homicide from robbers;however, these same strategies do not combat violence from other employees or from workers’ partners.

30.  Unhappy employees or former employees create conflicts and do damage that diminishes productivity, creates workplace tension, and adds to health care costs.  The realization that domestic violence has workplace implications led Polaroid Corporation to start a women’s group for battered employees.  The group helped women get out of their abusive situations and put the company in a position to respond to threats to workers by employees or former employees.

31.  Businesses should complete a risk assessment that includes an examination of the physical work environment as well as workplace climate for situations that promote risk.  Managers of others or initiate such interactions create a hostile working environment, which increases risks of frustrated, angry employees within their organization.  Supervisors who are authoritarian and insensitive in handling discipline of layoffs increase the possibility for violence among former employees.  Companies should formulate a plan for dealing with dangerous employees, develop a reason able grievance procedure to defuse employee anger, safeguard against dismissed employees, and protect potential targets such as supervisors, managers, and human resources personnel.

32.  The Occupational Safety and Health Administration(1996) issued guidelines for prevention of violence in the workplace for workers in health care and social service settings.  These regulations encourage employers to develop violence prevention plans for their employees.  Therefore, workplace violence prevention has been attempted through changes in individual behavior, altering the environment, and enacting laws to control workplace violence.

33. Reducing Community and School Violence  Changing the behavior of a large segment of the population seems an overwhelming task, but the violence of all types decreased in the late 1990s in the United States(USBC,2001).  Programs that attempt to change individual behavior take a variety of approaches.  the American Psychological Association teamed with Music Television (MTV) in a program, brochure, and Web site called ‘Warning Signs’(APA, 1999).  Programs aimed at alcohol and drug use can also decrease violence because use of these substances often increases aggression.

34.  Conflict resolution programs often appear as part of the school curriculum and teach problem solving skills as well as violence prevention.  the Teaching Students to be Peacemakers program.  Long considered an inevitable part of childhood, bullying has now been identified as generating violence and a poor learning environment.  By sensitizing teachers to its negative effects and providing family support, bullying can be decreased.

35.  In some communities, the most attractive employment options involve illegal activities, and offering meaningful alternatives can be apowerful deterrent to crime.  Altering the environment can also help to decrease school violence.  Some schools have hired consultants to perform safety ‘audits’ in which dangerous features of the school environment are located and changed.

36.  Legal approaches include removing violent youth form communities, restricting access to weapons, and arrest and incarceration.  Residential treatment programs for violent youth are not a new approach, but the latest version is the ‘boot camp’ in which young offenders are placed in military-type programs.  Restricting weapons is an important component of reducing commnity and school violence, and this approach has shown more promise of decreasing violence than residential programs or incarceration.

37. Cutting Suicide Rates  In 1999, the U.S. Surgeon General called for the developmet of a national strategy to prevent suicide, which resulted in a comprehensive plan that includes many levels of prevention.  The national strategy includes all three approaches to intervention, but many of its goals are oriented toward changing the environment.  This program aims to change societal attitudes toward disorders such as depression, which elevate the risk for suicide, and toward seeking mental health care, which decreases risk.  Goals also include making the means of suicide less available, such as limiting access to guns and drugs.

38.  A meta-analysis of studies over a 70-year period indicated that traditional hot line services had little or no effect on the rate of suicide for people who call.  The sharp increase in suicide among adolescents during the 1980s led to the development of school-based programs.  These suicide prevention programs often include training faculty to identify warning signs, forming mental health teams for counseling at-risk students, and developing written formal suicide policies.

39.  One study(Kalafat, 1997) found a county with a suicide prevention program had a lower suicide rate than the state average.  Another suicide reduction strategy is limiting access to the means to commit suicide, including drugs and firearms.  Use of firearms to commit suicide has increased, and a majority of completed suicides involves firearms.

40.  Training or mandating parents to take precautions with their firearms as well as other strategies to limit access may be helpful.  Restricting access to drugs can also make suicide more difficult.  Changes in societal attitudes and environment, laws, and individual behavior will be necessary to cut suicide rates.

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