1. Youth Violence and African Americans: Perspectives from Emergency Medicine Rob Gore, MD SUNY Downstate - Kings County Department of Emergency Medicine February 10, 2007 Rob Gore, MD SUNY Downstate - Kings County Department of Emergency Medicine February 10, 2007

2. Outline  Epidemiology, Demographics and Trends  Youth Violence Risk Factors  Intervention and Prevention  Epidemiology, Demographics and Trends  Youth Violence Risk Factors  Intervention and Prevention

3. Youth Violence  > 800, 000 violent acts involving youth  5,570 homicides – U.S. 2003  Firearm homicide rate 17 times higher than other industrialized nations (5-14 yrs)  Homicide is the #2 cause of death for U.S. Youth (10-19 years)  #1 cause of death in African American youth  > 800, 000 violent acts involving youth  5,570 homicides – U.S. 2003  Firearm homicide rate 17 times higher than other industrialized nations (5-14 yrs)  Homicide is the #2 cause of death for U.S. Youth (10-19 years)  #1 cause of death in African American youth National Center for Injury And Prevention Control

4. Youth Homicide  Most murder victims ages 12-17 are black  Males account for > 67% of homicides US Dept of Justice - OJJDP Image by Hank Willis Thomas

7. Violence and the Emergency Department  3 million ED visits/year related to violence  Traumatic assault is recurrent  Hospital readmission rates  Subsequent assault – 44%  Subsequent homicides – 20%  3 million ED visits/year related to violence  Traumatic assault is recurrent  Hospital readmission rates  Subsequent assault – 44%  Subsequent homicides – 20% Denninghoff, et al.

8. Recent Observed and Projected Firearm- and Motor Vehicle Related Injury and Deaths

9. Nonfatal Violent Injury  Increased rates across U.S.  Major cause of disability  94 nonfatal injuries for every homicidal death  Recurrent rates between 5% and 45% over the 5 years subsequent to the initial injury  Increased rates across U.S.  Major cause of disability  94 nonfatal injuries for every homicidal death  Recurrent rates between 5% and 45% over the 5 years subsequent to the initial injury Rich, et al.

10. Economic Costs of Gun Violence  > $18,000 for gun assault injuries  Indirect costs:  $800 million – 1997  $100 – 126 billion per year (Cook et al.)  > $18,000 for gun assault injuries  Indirect costs:  $800 million – 1997  $100 – 126 billion per year (Cook et al.) http://www.bradycampaign.org/

11. Re-injury Risk Factors  Substance abuse  School failure  Weapon possession  Poverty  Male gender  Black race  Gang involvement  Exposure to television violence  Substance abuse  School failure  Weapon possession  Poverty  Male gender  Black race  Gang involvement  Exposure to television violence Rich, et al.

12. Urban Youth Perspectives on Violence and the Necessity of Fighting  Johnson et al.  13 focus groups  120 Urban youth  Causes of Violence – Multi-factorial  Stress  Substance abuse  Witnessing violence  Disrespect  Standing up for friends  Neighborhood “Beef”  Johnson et al.  13 focus groups  120 Urban youth  Causes of Violence – Multi-factorial  Stress  Substance abuse  Witnessing violence  Disrespect  Standing up for friends  Neighborhood “Beef”

13. Pathways to Recurrent Trauma Among Young Black Men  Rich et al.  Qualitative analysis  49 Black male violence victim narratives  Factors Related to safety after violent Injury  Loss of Respect  Code of the Street  Lack of Faith in Police  Trauma Stress  Rich et al.  Qualitative analysis  49 Black male violence victim narratives  Factors Related to safety after violent Injury  Loss of Respect  Code of the Street  Lack of Faith in Police  Trauma Stress Rich, et al.

14. “Code of the Street”  “Informal rules governing interpersonal public behavior, particularly violence”  Lack of aggressive response associated as “tolerating victimization”  “Informal rules governing interpersonal public behavior, particularly violence”  Lack of aggressive response associated as “tolerating victimization”

15. Pathways to Recurrence Rich, et al.

16. Risk Factors in School Shootings  Verlinden et al. – 2000  9 incidents of multiple homicides in Secondary schools  Risk Factors identified  Verlinden et al. – 2000  9 incidents of multiple homicides in Secondary schools  Risk Factors identified

17. Columbine, Oregon, Conyers - Risk Factors for School Shootings  School Failure  Frequent fighting  Weapon possession  Alcohol abuse  Exposure to violence  Gang involvement  Family problems  School Failure  Frequent fighting  Weapon possession  Alcohol abuse  Exposure to violence  Gang involvement  Family problems Verlinden et al

18. Where we (EM Physicians) Fail  Inadequately prepared to conduct interventions  Lack of available resources for appropriate referral  Lack of established intervention protocols  Focus on consequences of violence  Inadequately prepared to conduct interventions  Lack of available resources for appropriate referral  Lack of established intervention protocols  Focus on consequences of violence Denninghoff, et al.

19. Ideal Place for Intervention – Emergency Department  First to encounter individuals after violence  Parental/guardian availability when treating underage youth  # of high risk groups receive majority of care in the ED  First to encounter individuals after violence  Parental/guardian availability when treating underage youth  # of high risk groups receive majority of care in the ED Denninghoff, et al.

20. Competencies for Effective Practice  Three Levels of Competence in Youth Violence  Level 1 – Generalist  Level 2 – Specialist  Level 3 – Scholars / Leaders  Three Levels of Competence in Youth Violence  Level 1 – Generalist  Level 2 – Specialist  Level 3 – Scholars / Leaders Denninghoff, et al.

21. Level 1 - Generalist  Basic knowledge of youth violence  Understanding of risk and protective factors  Self knowledge - personal experience  Basic knowledge of youth violence  Understanding of risk and protective factors  Self knowledge - personal experience

22. Level 2 - Specialist  Specific clinical interventions  Initiation of violence related injury referrals  Screening persons at risk for violence related injury  Aware of community programs and advocacy groups  Specific clinical interventions  Initiation of violence related injury referrals  Screening persons at risk for violence related injury  Aware of community programs and advocacy groups

23. Level 3 - Scholars and Leaders  Training other health professionals in violence prevention

24. Strategies to Reduce Youth Violence  Kellerman et al. 1998  Types of Programs Studied  Early Childhood Family Interventions  Youth and Adolescent Interventions  Community Level Interaction  Kellerman et al. 1998  Types of Programs Studied  Early Childhood Family Interventions  Youth and Adolescent Interventions  Community Level Interaction

25. Take Home  Youth violence is a public health issue  Screen for risk factors  Educate those at risk  Get Involved!!!!  Youth violence is a public health issue  Screen for risk factors  Educate those at risk  Get Involved!!!!

26. Youth Violence Organizations  Doctors Against Murder (New York)  (917) 440-9526  Project Brotherhood (Chicago)  (773) 753 – 5508  Omega Boys Club (San Francisco)  (800) 765 - 3437  Violence Prevention Institute (New Jersey)  (973) 395 - 0311  Doctors Against Murder (New York)  (917) 440-9526  Project Brotherhood (Chicago)  (773) 753 – 5508  Omega Boys Club (San Francisco)  (800) 765 - 3437  Violence Prevention Institute (New Jersey)  (973) 395 - 0311

27. Questions? “Priceless” by Hank Willis Thomas

28. Bibliography  Denninghoff, K.R., Knox, L., Cunningham, R., Paratain, S. (2002). “Emergency Medicine: Competencies for youth violence prevention and control.” Academic Emergency Medicine (9): 9, p.947.  Johnson, S.B., Frattaroli, S., Wright, J.L., Pearson-Fields, C.B. and Cheny, T.L. (2004). Urban Youths Perspective on Violence and the Necessity of Fighting. Injury Prevention (10): 287-291  Miller M, Azrael D, Hemenway D (2002) Firearm Availability and Unintentional Firearm Deaths, Suicide and Homicide among 5-14 Year Olds. J Trauma 52(2):267-275  Rich JA, Grey CM, (2005). Pathways to Recurrent Trauma Among young Black Men: Traumatic Stress, Substance Use and the “Code of the Street”. Am J Public Health 95(5): 816-824  Twemlow, S.W., Sacco, F.C. (1998). The Application of Traditional Martial Arts Practice and Theory to the Treatment of Violent Adolescents. Adolescence 30(131): 505-518  Verlinden, S., Hersen, M., Thomas, J. (2000). Risk Factors in School Shootings. Clinical Psych Review (20): 3-56  Wintemute, G. (2002) Where the Guns Come From: The Gun Industry and Gun Commerce. Future of the Children (12): 55-71  Yonas, MA (2004). Addressing Youth Violence. J Public Health Management Practice 10(6):567-568  Child and Adolescent Injury in Chicago, 1999-2001. Children’s Memorial Research Center June 2005  National Center for Injury Prevention and Control [Website]. Available at http://www.cdc.gov/ncipc/factsheets/yvfacts.htm http://www.cdc.gov/ncipc/factsheets/yvfacts.htm  Almighty Latin King and Queen Nation [Website]. Available at http://www.gripe4rkids.org/Lkhis.html http://www.gripe4rkids.org/Lkhis.html  The Brady Law: Preventing Crime and Saving Lives [Website]. Available at http://www.bradycampaign.org/facts/research/?page=bradyprev&menu=gvr http://www.bradycampaign.org/facts/research/?page=bradyprev&menu=gvr  Denninghoff, K.R., Knox, L., Cunningham, R., Paratain, S. (2002). “Emergency Medicine: Competencies for youth violence prevention and control.” Academic Emergency Medicine (9): 9, p.947.  Johnson, S.B., Frattaroli, S., Wright, J.L., Pearson-Fields, C.B. and Cheny, T.L. (2004). Urban Youths Perspective on Violence and the Necessity of Fighting. Injury Prevention (10): 287-291  Miller M, Azrael D, Hemenway D (2002) Firearm Availability and Unintentional Firearm Deaths, Suicide and Homicide among 5-14 Year Olds. J Trauma 52(2):267-275  Rich JA, Grey CM, (2005). Pathways to Recurrent Trauma Among young Black Men: Traumatic Stress, Substance Use and the “Code of the Street”. Am J Public Health 95(5): 816-824  Twemlow, S.W., Sacco, F.C. (1998). The Application of Traditional Martial Arts Practice and Theory to the Treatment of Violent Adolescents. Adolescence 30(131): 505-518  Verlinden, S., Hersen, M., Thomas, J. (2000). Risk Factors in School Shootings. Clinical Psych Review (20): 3-56  Wintemute, G. (2002) Where the Guns Come From: The Gun Industry and Gun Commerce. Future of the Children (12): 55-71  Yonas, MA (2004). Addressing Youth Violence. J Public Health Management Practice 10(6):567-568  Child and Adolescent Injury in Chicago, 1999-2001. Children’s Memorial Research Center June 2005  National Center for Injury Prevention and Control [Website]. Available at http://www.cdc.gov/ncipc/factsheets/yvfacts.htm http://www.cdc.gov/ncipc/factsheets/yvfacts.htm  Almighty Latin King and Queen Nation [Website]. Available at http://www.gripe4rkids.org/Lkhis.html http://www.gripe4rkids.org/Lkhis.html  The Brady Law: Preventing Crime and Saving Lives [Website]. Available at http://www.bradycampaign.org/facts/research/?page=bradyprev&menu=gvr http://www.bradycampaign.org/facts/research/?page=bradyprev&menu=gvr

29. Bibliography cntd.  The Brady Law: Preventing Crime and Saving Lives [Website]. Available at http://www.bradycampaign.org/facts/research/?page=bradyprev&menu=gvr http://www.bradycampaign.org/facts/research/?page=bradyprev&menu=gvr  National Rifle Association Institute for Legislative Action. http://www.nraila.org/News/Read/InTheNews.aspx?ID=6371 http://www.nraila.org/News/Read/InTheNews.aspx?ID=6371  New Yorkers Against Gun Violence: http://www.nyagv.org/facts.htmhttp://www.nyagv.org/facts.htm  U.S. Department of Justice - Bureau of Justice Statistics: Homicide Trends in the U.S. http://www.ojp.usdoj.gov/bjs/homicide/teens.htm#vagehttp://www.ojp.usdoj.gov/bjs/homicide/teens.htm#vage  House Research Organization: Texas House of Representatives Focus Report. April 2002. http://www.hro.house.state.tx.us/focus/gunshow.pdfhttp://www.hro.house.state.tx.us/focus/gunshow.pdf  The Coalition to Stop Gun Violence. http://www.csgv.org/issues/illegalmarkets/gunshowloop/  The Brady Law: Preventing Crime and Saving Lives [Website]. Available at http://www.bradycampaign.org/facts/research/?page=bradyprev&menu=gvr http://www.bradycampaign.org/facts/research/?page=bradyprev&menu=gvr  National Rifle Association Institute for Legislative Action. http://www.nraila.org/News/Read/InTheNews.aspx?ID=6371 http://www.nraila.org/News/Read/InTheNews.aspx?ID=6371  New Yorkers Against Gun Violence: http://www.nyagv.org/facts.htmhttp://www.nyagv.org/facts.htm  U.S. Department of Justice - Bureau of Justice Statistics: Homicide Trends in the U.S. http://www.ojp.usdoj.gov/bjs/homicide/teens.htm#vagehttp://www.ojp.usdoj.gov/bjs/homicide/teens.htm#vage  House Research Organization: Texas House of Representatives Focus Report. April 2002. http://www.hro.house.state.tx.us/focus/gunshow.pdfhttp://www.hro.house.state.tx.us/focus/gunshow.pdf  The Coalition to Stop Gun Violence. http://www.csgv.org/issues/illegalmarkets/gunshowloop/