Adolescent Injuries, Aggression and Violence

Introduction

Every year, millions of children all over the world die from preventable causes. Injuries and violence are responsible for a large majority of these causes. Injury death rates are significantly higher in low- and middle- income countries, which already account for more than 95% of the world’s deaths from injuries and violence. Young people are among the most vulnerable. Apart from the high death toll, injuries during childhood and adolescence are also associated with high morbidity.

Magnitude of the problem

Worldwide, 8 of the 15 leading causes of death for people aged 15 to 29 years are injury related, including road traffic injuries, suicides, homicides, drowning, burns, war injuries, poisonings, and falls. The common causes of unnatural accidental deaths are- road traffic injuries (37.2%), poisoning(7.8%), drowning (7.8%), railway accidents and rail-road accidents (7.7%), and fire related deaths(6.8%). Age-wise,6.9% of such victims were up to 14 years of age while 53.0% were in the age-group of 15- 44 years, rest were in age more than 45 years.

Injuries

An injury consists of unintentional or intentional damage to the body that results from acute exposure to thermal, mechanical, electrical, or chemical energy, or from the absence of such essentials as heat or oxygen. Injuries can be classified based on the events and behaviors that precede them, as well as the intent of the persons involved. Aggression is intense behavior to achieve some goals and this reflects in behavior.

Violence is the intentional use of physical force or power, threatened or actual, against oneself, another person, or a group or community that either results in or is likely to result in injury, death, psychological harm, mal development, or deprivation.

Classification of Injuries

Both intentional and unintentional injuries can also be categorized according to the place where they occurred, i.e. on the road, at home, at a leisure/sport facility, at school or in the workplace, or according to the circumstances in which they occurred, e.g. during working hours (occupational injury) or during leisure time.

Why are adolescents are at risk from injuries?

Due to developmental and social factors, such as time spent without adult supervision and increasing independence, adolescents are more likely to engage in risk-taking behaviors than either younger children or adults.

Risk-taking behavior

The primary causes of injury, illness and disability in adolescents are behaviorally generated. Nearly 50% of the morbidity and mortality in adolescents stems from four behaviors: sexual activity, substance use and abuse, motor vehicle use, and interpersonal violence. These behaviors have their origin in adolescence, and are common among all age, socioeconomic and ethnic groups. While young children may inadvertently take risks because they lack appropriate skills to do otherwise, older children and adolescents may actively seek out risk. Risk-taking behavior may allow adolescents to feel a sense of control over their lives or else to oppose authority. Young people consequently seek new situations and experiences to maintain a level of psychological arousal, irrespective of the risks inherent in the experience.

Sensation-seeking frequently focuses on risky behaviors, including driving a vehicle or crossing a road. Sensation-seeking has been shown to rise between the ages 9 and 14 years, peaking in late adolescence or in early adulthood, and declining steadily with age. Risk-seeking behavior is a significant predictor of involvement in road traffic injury among child pedestrians as well as it is for young adolescent drivers aged 16–17 years across all ages and particularly among the young, sensation-seeking is more common among boys than among girls. But it is also pertinent to remember that though injuries are a frequent and sometimes devastating outcome of risk taking but risks are also inherent in the environment in which adolescents live, work, and play.

Peer influence on risk taking

As young children become adolescents, they enter a phase where the influence of their parents is reduced, and they begin to discover and assert their independence. For many young people, peers are of significant importance and can be the primary source of the social norms with which they strive to conform. Social norms, including peer pressure and the emphasis placed on rebellion in the culture of young people, can affect the manner in which young people drive a vehicle. Research has shown that young drivers experience higher peer pressure than older drivers to commit traffic violations such as speeding, driving under the influence of alcohol and dangerous overtaking. There is a close link between the presence of similarly aged passengers in the car and increasing risk levels. A number of studies have shown that young drivers, both male and female, drive faster and with a shorter following distance at road junctions if they have young passengers in the car.

Effect of gender on risk taking

There is evidence of a strong relationship between gender, road safety behavior and road traffic injury. Most studies conducted show a strong male bias. A part of the predominance of boys in road traffic injury statistics can be accounted for by differences in exposure.

Prevention of Injuries

Approaches to prevent injuries

Child and adolescent injuries can be considered as a major health problem. The traditional model of injury prevention and control rests on managing three Es ie enforcement, education and engineering . It involves changing the environment, individual behavior, products, social norms, legislation, policy, and ecology related to injury.

Behavioral Approaches

It is a very important component of the effective structural, automatic, environmental, or engineering protections. For example,

• Bicycle and motorcycle helmets protect against head injury, but they must be fitted properly and used consistently.
• Seat belts can prevent injuries, but they must be worn even when it is not mandatory or otherwise.
• Driver must abstain from over speeding and
• Drunk driving even if there are penalties for them. Effective injury prevention always involves both behavioral (active) and environmental (passive) countermeasures.

Ecological Approaches

The most effective injury prevention efforts are structured within an ecological framework, focusing on individual modifiable factors and family, peer group, work site, and community and socio-cultural factors simultaneously.

• Legislation requiring bicycle helmet use should be accompanied by an educational campaign for children and parents
• Police enforcement in the community
• Programs addressing the safety of employees can also be extended
• Local enforcement of laws designed to protect adolescents.
• An efficient rehabilitation services (including immediate post trauma management services) are essential.
• Road traffic injuries and drowning are the two important preventable cause of injury in adolescents and will be discussed in detail.

Road traffic injuries

• Children and adolescents suffer fatal injuries in motor vehicle crashes.
• Young drivers may also lack experience to recognize, assess, and respond to the situation or hazards.
• These risks may be fueled by emotions, peer pressure, and other adolescent stressors.
• Adolescence is characterized by increased independence from parents and social pressure from peers.
• Other factors can be cell phones, texting, in-vehicle internet use, and on-board navigation systems.

Preventing Road Traffic Injuries

• Road safety management
• Safer roads and mobility
• Safer vehicles
• Safer road users
• Post-crash response

Delivering Care after Crash

Access to pre-hospital services and quick evacuation and transport to hospital can save many lives and limit disability, since majority of these who die do so before they reach a hospital.

Evidence based strategies to reduce road traffic injuries in adolescents

Among the most important strategies are graduated licensing and safety belt and helmet use.

Seat Belts and Helmets

Wearing a standard, good quality motorcycle helmet can reduce the risk of death by 40% and the risk of serious injury by over 70%. Seat belt usage protects the driver and the occupants from severe crash injuries. Legislation mandating seat belt and helmet use, together by family members, and community climate are some of the factors related to non-use. Building a culture of safety for seat belts and helmet-wearing among adolescents will be one with enforcement and education has proven to be the most effective strategy.

Unintended injuries

Injuries are a leading cause of death and disability among adolescents. Many adolescents die or are seriously hurt as a result of road traffic crashes (including as riders of bicycles and motorcycles, as drivers of cars, as passengers and as pedestrians). Many adolescents also lose their lives through drowning and falls. Injuries can occur anywhere – in homes, places of study and work, on the roads and elsewhere in the community. They can, and should be, prevented.

Management of injuries

Inquire about the nature and extent of participation in all health risk behaviors. It is important to remember that an adolescent may be indulging in more than one risk taking behavior at a time. Interview the adolescents and their parents about the adolescent’s functioning in areas of family, peers, and school or work to find out how he/she is meeting the expected development outcomes in these contexts. While doing look for physical signs of trauma like lacerations, ecchymosis, or other musculoskeletal injuries. Manage such injuries appropriately.

Guidance to adolescents

Realistic goals for counseling should not focus on convincing the youth to cease all risk behaviors, but rather encouraging the adolescent to modify the behaviors so that, he or she is protected from the most harmful outcomes. For example, parents can be informed that their own behavior, such as the use of tobacco or the wearing of seat belts, serves as a; powerful message to their children.

Drowning

Drowning is the process of experiencing respiratory impairment from unintentional submersion/immersion in liquid. Apart from mortality it may also result in non fatal injury which may lead to brain damage and long term disability. Around 96% of unintentional drowning deaths take place in low- and middle-income countries. Males are especially at risk of drowning, with twice the overall mortality rate of females. Studies suggest that the higher drowning rates among males are due to increased exposure to water and riskier behavior such as swimming alone, drinking alcohol before swimming alone and boating. Increased access to water is another risk factor for drowning.

Prevention of Drowning

Victims of drowning have a very slim chance of survival after immersion. Therefore, prevention strategies are more important.

Drowning prevention strategies should be comprehensive and include: and engineering methods which help to remove the hazard, legislation to enforce prevention and assure decreased exposure, education for individuals and communities to build awareness of risk and to aid in response if a drowning occurs.

• Availability of properly-fitted and appropriate personal flotation devices
• Non consumption of alcohol while boating and swimming appear to be effective drowning prevention strategies.
• Individual and community education on drowning awareness, risks associated with drowning and learning waters survival skills appear promising strategies to prevent drowning.
• Ensuring the presence of lifeguards at swimming areas.
• Ensuring immediate resuscitation by increasing the capability of first responders to provide first aid in cases of drowning can decrease the potential severity of outcomes.

Adolescent Aggression and Violence

Violence results from aggressive behavior. When intensity of behavior increases and impact becomes more severe, aggression become violence. Relationship between normal behavior and violent behavior is shown in figure 1. It is important to understand that not all aggressive behavior is antisocial/ criminal and not all antisocial behavior is violence.

Factors related to aggression and violence in adolescents.

Violence is a learned behavior and exposure to violence at home teaches adolescent how to use violence to exert social control over others and to resolve interpersonal conflicts. Substance misuse is associated with an increased risk of exposure to violence. Adolescents with mental illness are at risk of becoming violent and adolescents with opposition defiant disorder, conduct disorder or intermittent explosive disorder often resort to heightened aggressive and to have ‘killer instinct’ to win. Sometimes, this behavior continues on side the sport too. Hate crimes including terror acts are not uncommon and sometimes adolescents are forced to participate in it. Easy access to weapons including five arms increases chances of violence.

Violence during the time spent together with a friend is not uncommon. Dating violence can take many forms including physical abuse (i.e., hitting, slapping, biting, punching); psychological abuse (for example: constant criticism, threats, insults, emotional outburst, etc), sexual abuse (i.e., unwanted touching, kissing or fondling, sexual intercourse, date rape, use of date drugs to obtain sexual contact, etc).

Parents and teachers are required to teach adolescents about the dating violence and how to cope with it. Parental monitoring is also required. Awareness and educational programs should be organized to create awareness and facilitate learning appropriate skills for dealing with dating violence. The adolescent girls should be equipped with assertive skills required to say “no” to sexual advantages of the boyfriend.

Co-ercion and abuse

Abuse or maltreatment constitutes all forms of physical, sexual and/or emotional ill-treatment, neglect or negligent treatment or commercial or other exploitation, resulting in actual or potential harm to the child’s health, survival, development or dignity, in the context of a relationship of responsibility, trust or power.

Child abuse is widely prevalent irrespective of caste, religion, socioeconomic status, regional, and other factors. While sitting in our chambers we tend to overlook the glaring signs /symptoms of child abuse because of shortage of time but the high index of suspicion should always alert the concerned doctor to look deeper in a sympathetic and child friendly manner and whatever may be the reasons enough time and attention should be devoted on this child.

The role and responsibilities of the attending clinician in cases of child abuse broadly has two aspects; (1) to provide immediate medical care and (2) to ensure the future safety and welfare of the child but most often we either fail or choose to ignore the second aspect because of lack of knowledge/experience of handling such situations or fear of getting involved in the legal situations. But the truth is by avoiding we invite more problems for ourselves and always carry guilt of not acting in a justified manner to save the life / dignity of a child.

Immediate goal should be to take care of the medical condition and provide him/her with the best that center can offer. In case of any life threatening injuries, recent sexual assault or potentially grievous injuries police has to informed immediately and meanwhile medical care should be continued and if the child needs to be referred best available first aid treatment should be instituted before transporting the child. In other conditions, depending upon the situation, either the family or the care taker or the child welfare committee of the district or the child helpline (telephone number - 1098) or the NGOs dealing with the welfare of the children can be contacted.

Violence in Adolescents

Precautions to take in dealing with adolescents victim of violence

• A detailed hand written history to be recorded separately from child and accompanying person
• All factors leading to violence
• Written consent for Medical examination from parents
• Appropriate samples to be collected for lab tests.
• Record to be kept confidential and in secure place.

POCSO Act

The Protection of Children from Sexual Offences Act 2012 (POCSO) came into force from 14 th November, 2012. The Protection of Children from Sexual Offences Act, 2012 has been drafted to strengthen the legal provisions for the protection of children from sexual abuse and exploitation. For the first time, a special law has been passed to address the issue of sexual offences against children. The salient features of the landmark act are appended below :

1. The Protection of Children from Sexual Offences Act, 2012 defines a child as any person below the age of 18 years and provides protection to all children under the age of 18 years from the offences of sexual assault, sexual harassment and pornography.
2. The Act provides for stringent punishments, which have been graded as per the gravity of the offence. The punishments range from simple to rigorous imprisonment of varying periods. There is also provision for fine, which is to be decided by the Court
3. An offence is treated as “aggravated” when committed by a person in a position of trust or authority of child such as a member of security forces, police officer, public servant, etc.
4. Punishments for Offences covered in the Act are:
• Penetrative Sexual Assault (Section 3) on a child – Not less than seven years which may extend to imprisonment for life, and fine (Section 4)
• Aggravated Penetrative Sexual Assault (Section 5) – Not less than ten years which may extend to imprisonment for life, and fine (Section 6)
• Sexual Assault (Section 7) i.e. sexual contact without penetration – Not less than three years which may extend to five years, and fine (Section 8)
• Aggravated Sexual Assault (Section 9) by a person in authority – Not less than five years which may extend to seven years, and fine (Section 10)
• Sexual Harassment of the Child (Section 11) – Three years and fine (Section 12)
• Use of Child for Pornographic Purposes (Section 13) – Five years and fine and in the event of subsequent conviction, seven years and fine (Section 14 (1))
5. The Act provides for the establishment of Special Courts for trial of offences under the Act, keeping the best interest of the child as of paramount importance at every stage of the judicial process. The Act incorporates child friendly procedures for reporting, recording of evidence, investigation and trial of offences.
• Recording the statement of the child at the residence of the child or at the place of his choice,     preferably by a woman police officer not below the rank of sub-inspector
• No child to be detained in the police station in the night for any reason.
• Police officer to not be in uniform while recording the statement of the child
• The statement of the child to be recorded as spoken by the child
• Assistance of an interpreter or translator or an expert as per the need of the child
• Assistance of special educator or any person familiar with the manner of communication of the child in case child is disabled
• Medical examination of the child to be conducted in the presence of the parent of the child or any other person in whom the child has trust or confidence.
• In case the victim is a girl child, the medical examination shall be conducted by a woman doctor.
• Frequent breaks for the child during trial
• Child not to be called repeatedly to testify
• No aggressive questioning or character assassination of the child
• In-camera trial of cases
6. The Act recognizes that the intent to commit an offence, even when unsuccessful for whatever reason, needs to be penalized. The attempt to commit an offence under the Act has been made liable for punishment for upto half the punishment prescribed for the commission of the offence.
7. The Act also provides for punishment for abetment of the offence, which is the same as for the commission of the offence. The Act makes it mandatory to report commission of an offence and also the recording of complaint and failure to do so would make a person liable for punishment of imprisonment for six months or / and with fine.
8. For the more heinous offences of Penetrative Sexual Assault, Aggravated Penetrative Sexual Assault, Sexual Assault and Aggravated Sexual Assault, the burden of proof is shifted to the accused. This provision has been made keeping in view the greater vulnerability and innocence of children. At the same time, to prevent misuse of the law, punishment has been provided for making false complaint or proving false information with malicious intent. Such punishment has been kept relatively light (six months) to encourage reporting. If false complaint is made against a child, punishment is higher (one year) (Section 22)
9. The media has been barred from disclosing the identity of the child without the permission of the Special Court. The punishment for breaching this provision by media may be from six months to one year (Section 23)
10. For speedy trial, the Act provides for the evidence of the child to be recorded within a period of 30 days. Also, the Special Court is to complete the trial within a period of one year, as far as possible (Section 35).
11. To provide for relief and rehabilitation of the child, as soon as the complaint is made to the Special Juvenile Police Unit (SJPU) or local police, these will make immediate arrangements to give the child, care and protection such as admitting the child into shelter home or to the nearest hospital within twenty-four hours of the report. The SJPU or the local police are also required to report the matter to the Child Welfare Committee within 24 hours of recording the complaint, for long term rehabilitation of the child.
12. The Act casts a duty on the Central and State Governments to spread awareness through media including the television, radio and the print media at regular intervals to make the general public, children as well as their parents and guardians aware of the provisions of this Act.
13. The National Commission for the Protection of Child Rights (NCPCR) and State Commissions for the Protection of Child Rights (SCPCRs) have been made the designated authority to monitor the implementation of the Act.

Source : Rashtriya Kishor Swasthya Karyakram - Resource Book by Ministry of Health and Family Welfare