Victim as Offender in Youth Violence

INJURY PREVENTION/ORIGINAL

CONTRIBUTION

/ ctim as Offender in Youth Violence From the Harborview Injury Prevention and Research Center '~ and the Departments of Pediatrics~ and Epidemiology ~, Univen;ity of Washington, Seattle, Washington; Department of Oral Surgery, Medicine and Patholog& University of Wales College of Medicine, Cardiff, Walesll; Institute of Criminology, Cambridge University, Cambridge, Eng[and~; Accident and Emergency Department, Cardiff Royal Infirmary, Cardiff, Wales#; and Major Crimes Support Unit, Cardiff, Wales. **

Frederick P Rivara, MD, MPH **§ JP Shepherd, MD" DP Farrington § PW Richmond # Paul Cannon**

Received for publication November 21, 1994. Revision received March 17, 1995. Accepted for publication April 6, 1995. Copyright © by the American College of EmeTNency Physicians.

Study objective: To determine how often adolescent and young adult victims of assaultive injury are offenders in assaults and other crimes. Design: Comparison of 10- to 24-year-old males treated in the accident and emergency department for assault-related injuries to similar-aged males treated in the same department for unintentional injuries. Police records were searched on both groups for warnings or convictions.

Setting: Accident and emergency department of the Cardiff Royal Infirmary. Results: Assault patients were significantly more likely to be formally warned or convicted, and they had a higher mean number of warnings or convictions per 100 person-years of exposure, than other injury patients. These differences were most pronounced for the younger patients and for the year following the injury. Conclusion: These results suggest that many young male assault patients either have a history of criminal activity or develop criminal behavior subsequent to their assault and may benefit from appropriate intervention aimed at interrupting the cycle of crime and violence. [Rivara FP, Shepherd JR Farrington DE Richmond PW, Cannon P: Victim as offender in youth violence. Ann EmergMedNovember 1995;26:609-614.]

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INTRODUCTION

Violence between young people is a major problem confronting both the medical community and the criminal justice system. The recent conviction of two 10-year-old boys for the murder of a toddler has dramatically heightened awareness of the problem in the United Kingdom. 1 Death rates from homicide among people of all ages in England and Wales increased by 70% between 1967 and 1992, and serious nonfatal violence offenses have increased by 80% in the last decade alone. 2 The number of assault victims attending accident and emergency departments (AEDs) in England has increased as much as sixfold in recent years, 3 and such patients now constitute 3% to 7% of all individuals treated in AEDs. 4 Young adults, aged 16 to 24 years, account for as many as one half of these victims. 5 Intervention by the medical community has traditionally been limited to treatment of the victims of violence. Many of these individuals are seen repeatedly in the AED with trauma, which is often related to assault. This situation can be frustrating for the medical staff, who would like an effective way of preventing these injuries. AED staff know little about these victims in terms of past history or potential for future problems. Anecdotally, there exists a general feeling that some of these patients are not just passive victims but instead engage in activities, including criminal behavior, that predispose them to assault-related injuries. However, there is no information in the medical literature linking medical patients to criminal justice records. This study was conducted to determine how often adolescent and young adult victims of assaultive injury treated in an AED are offenders in assaults and in other crimes. These individuals were compared with patients treated in the same AED for other, unintentional injuries in order to determine the degree to which the criminal history of the assaulted victims differs from that of their nonassaulted age- and sex-matched peers. We hypothesized that assaulted patients would more frequently be involved in criminal activity and that the presence of assaultive injury could help identify individuals who need special intervention to prevent future injuries. MATERIALS AND METHODS

Subjects were males, 10 to 24 years of age, who were treated for assault-related injuries in the AED of the Cardiff Royal Infirmary during the 6-month period, July through December, 1991. During this period 1,734 assault cases were treated in the AED; we examined a

6 10

compute>generated random sample for follow-up study of police records. The mechanism of injury was recorded at the time of admission to the AED, and this information was stored in a standard database. We selected only males because they have a higher likelihood of both victimization and criminal behavior than females5 ,
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people with convictions and the number of convicted people with cautions was not available. Risk differences were computed, and 95% confidence intervals (CIs) were calculated by the maximum likelihood method. 9 Iviean person-years of exposure in each of the four study groups was equal to the difference between the mean age of the victims and the age of criminal responsibility (ie, the 10th birthday). Rates of offending per person-years of exposure were calculated by using the number of cautions or convictions as the numerator. Significance was tested with the use of the binomial distribution, zo RESULTS

There were 72 assaulted patients between 10 and 16 years of age and 292 between 17 and 24 years of age. The comparison groups consisted of 80 younger victims (10 to 16 years old) and 322 older victims (17 to 24 years old) of unintentional injury. The mean age of those assaulted patients who were between 10 and 16 years old at the time of injury, in 1991, was approximately 1 year greater than that of patients in the matched unintentional injury group (14.2 versus 13.2 years, respectively); there was no difference in mean age between the group of older assaulted patients and their controls (20.9 versus 21.0 years, respectively). Injuries to the face accounted for 44.7% of injuries in the younger group and 46.2% in the older group of assaulted patients, and head injuries occurred in an additional 22.2% and 19.9%, respectively. In contrast, injuries to the upper and lower extremities accounted for 82.6% and 74.6% of injuries in the younger and older comparison groups of unintentional injury patients, respectively. Both the number of individuals cautioned or convicted and the total number of cautions and convictions were much higher among assaulted patients than among

patients with unintentional injuries (Table !). One in six of the younger assaulted patients had been cautioned and one in six had been convicted, but none of the younger patients with unintentional injury had been cautioned and only 2.5% had been convicted; these differences were significant. The proportion of older patients cautioned or convicted was also higher among the assault victims than among the victims of unintentional injury (6.2% versus 1.6% cautioned and 39.7% versus 30.1% convicted, respectively); the differences between groups were not as large as for the younger patients but were still significant. The total number of cautions and convictions was higher among assaulted patients than among victims of unintentional injury, even after adjusting for the person-years of exposure to risk (Table 2). As shown in Table 3, differences between the two injury groups in rates of offending were found for all time periods examined: the period before 1991, the year the injury occurred (1991), and the year after the injury (1992). Some individuals were cautioned or convicted in more than one time period. In both age groups, the difference in number of cautions between assaulted and unintentional injury patients was greatest during the years before the AED visit. This was also true for convictions in the older age group, but in the younger age group the difference in number of convictions was most pronounced for the year after the injury There were also significant differences between the two injury groups in type of conviction. In particular, wounding convictions were more common among the assaulted patients than among the unintentional injury patients, both in the older age groups (15.4% versus 1.6%) and especially the younger age groups (11.1% versus 0%). Convictions were more common among the younger assaulted patients, compared with similar-aged victims of unintentional injury, for burglary (8.3% versus 1.3%), for

Table 1. Cautions and convictions.

Patients Aged 10 to 16 Years Parameters No. of patients No. cautioned No. convicted

Patients Aged 17 to 24 Years

Assault

Unintentional Injury

Risk Difference (95% CI)

Assault

Unintentional Injury

Risk Difference (95% CI)

72 12 (16.7%) 13 (18.1%)

80 0 2 (2.5%)

16.7% (8.1%-25.3%) 15.6% (6.0%-5.1%)

292 18 (6.2%) 116 (39.7%)

322 5 (1.6%) 97 (30.1%)

4.6 (1.5%-7,7%) 9.6 (2.1%-17.1%)

Riskdifferencesare the percentageof assaultsminusthe percentageof unintentionalinjury.

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No previous studies have examined this issue in a group of individuals presenting in an emergency department or AED setting. In the one study in the medical literature, Sims and colleagues found that, among patients admitted to a trauma center for assault-related injuries, 44% had repeat injuries, 54% had criminal records, and 20% died over the next 5 years. 11 Our results are similar to those obtained in the few studies that have been conducted in other settings. Surveys of crime victims in both the United States and the United Kingdom have found that violent offenders were three to four times more likely to be victims of assault themselves than those who were not violent offenders. 7,12 In a Swedish study of victims and offenders, 26% of victims of violence of all ages had previous criminal records; no control group was included to allow comparison to the baseline rate of criminal behavior in the general population. 13 Our study used ageand sex-matched controls and relied on official data, which are generally more reliable than self-reports of crime. 14 In our study, the differences between victims of assault and of unintentional injury were most striking for the 10- to 16-year-old patients. Approximately one of six assaulted patients in this age group had been cautioned, and one in six had been convicted; in comparison, no cautions and only two convictions were recorded among the younger victims of unintentional injury. It is clear that some of these young male assaulted patients are already engaged in criminal careers. This is consistent with studies showing that the peak age for initiation of criminal activity among English males is 14 to 15 years, t5 All of our convicted young offenders had convictions during the year following their injury, indicating that the incident in which they were injured did not deter them from criminal activity, The proportion of younger assaulted patients convicted actually increased from 5.6% in

motor vehicle theft (8.3% versus 1.3%), and for other theft (15.3% versus 1.3%). Older assaulted patients had more convictions than did similar-aged unintentional injury victims for robbery (2.4% versus .6%), for motor vehicle theft (21.2% versus 14.0%), for other theft (23.3% versus 17.1%), and for other offenses (30.8% versus 22.4%). The only convictions that were less common among assaulted patients than unintentional injury patients were common assaults (.3% versus 3.7%) and drug trafficking (1.0% versus 4.0%) in the older age groups. The number of cautions was too few for meaningful comparisons by type of caution. We also examined the subgroup of patients with multiple offenses (two or more offenses of any type). Only five individuals had two or more cautions: three among the younger assaulted patients and two among the older assaulted patients. However, multiple convictions were recorded for 13.9% of the younger assaulted patients, 1.3% of younger unintentional injury victims, 31.2% of older assaulted patients, and 23.9% of older unintentional injury victims. Among those individuals with multiple convictions, wounding convictions were much more frequent among the assaulted patients than among the comparison groups (80% versus 0% in the younger age groups and 41.8% versus 20.8% in the older age groups). DISCUSSION The results of this study provide support for the anecdotal experiences of many clinicians. Patients treated in the AED for assault-related injuries are much more likely to be involved in criminal activity than similar-aged patients treated in the same AED for unintentional injuries. These differences were especially striking for persons younger than age 17 years of age. Table 2. Cautions and convictions per 1O0 person-years.

Patients Aged 17 to 24 Years

Patients Aged 10 to 16 Years Parameters

Assault

Total no. of cautions Mean no. of cautions per 100 person-years

16 4.08

Total no. of convictions Mean no. of convictions per 100 person-years

95 24.21

612

Unintentional Injury 0 0 36 9.47

P

Assault 21

<.001

<.001

Unintentional Injury

P

5 .59

1,703 48.0

.13 1,087 27.6

<.001

<.001

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1991 to 18.1% in 1992, compared with an increase of only 1.2 percentage points in the comparison group (younger unintentional injury patients). The reasons for these differences are unknown, but at least part of the increase in offending that occurs after assault in the younger age group may be attributed to the well-known increase in the frequency of offending during adolescence, with peak rates reached at age 17.14,~5 Ethical restrictions on our data did not allow us to calculate the rates of offending before and after victimization in specific individuals. There are a rmmber of possible reasons why assaulted patients have such a high rate of offending. Certain lifestyles may increase the risk of both victimization and offending.7 These include abuse of alcohol and other substances, carrying of weapons, frequent fighting, gang membership, and association with other delinquents. If young males are involved in a fight, there may be little to differentiate those who are injured (ie, assault victims) from those who are not. 16 Demographic and physical factors also increase the risk of victimization. Living in high crime areas increases both the likelihood of being a victim of crime and the likelihood of being a participant. In the 1992 British Crime Survey, the characteristics of the neighborhood were important predictors of stranger violence against males. 6 Socioeconomic factors are also important risk factors for crime, but we were not able to measure socioeconomic status in our study groups or to adjust for this factor in the analysis. Regardless of other lifestyle factors, however, being a delinquent (ie, involvement in criminal activity) is

the most important predictor of becoming a victim of violence, i 7 The rates of offending in the control groups in this study, although high, were similar to those in the general population. Data for England and Wales from the Home Office2 indicate that 3.7% of 10- to 16-year-olds and 6.3% of 17- to 24-year-olds were cautioned or convicted of an offense in 1992. The figure for younger unintentional injury patients in our study was comparable, 2.5% convicted in 1992. However, 13.7% of the older unintentional injury patients had convictions in that year. This difference, in part, may result from the fact that the rate of cautions and convictions in the male population is 11.6% higher in South Wales than in England and Wales as a whole. 2 Cumulative rate of conviction among the older victims of unintentional injury in our study was identical to the rate of 30% for convictions up to the age of 24 for males in England and Wales. is The high rate of offending found for both control groups in this study is therefore quite congruent with the rates found in other studies and reflects the fact that peak age for criminal behavior in the United Kingdom, as in the United States, is 16 to 18 years. 15 This study has implications for AED care of assauhed victims. The findings suggest that many young male assaulted patients either have a history of criminal activity or develop criminal behavior after their assault and may benefit from identification and intervention. Lifestyle factors that place the patient at risk for violence, both as an offender and as a victim, should be identified so that appropriate prevention and treatment measures can be offered. Abuse of alcohol and other substances is ex-

Table 3.

Number of offenders and number of offenses by year of offense. Patients Aged 10 to 16 Years

Parameters

Assault

Unintentional Injury

Patients Aged 17 to 24 Years Risk Difference (95% CI)

Assault

Unintentional Injury

292

322

Risk Difference

No. of patients

72

80

No. cautioned Before 1991 1991 1992

8 (11.1%) 3 (4.2%) 4 (5,6%)

0 0 0

11.1% (3.9% to 18.4%) 4.2% 65% to 8.8%) 5.6% (.3% to 10,8%)

15 (5.1%) 2 (.7%)

4 (1.2%) 0

3,9% (1.1% to 6.7%) .7% (-,3% to 1.6%)

4 (1.4%)

1 (.3%}

1.1% (-.4% to 2.5%}

No, convicted Before 1991 1991 1992

5 (6.9%) 4 (5.6%) 13 (18.1%)

1 (1.3%) 1 (1.3%) 2 (2.5%)

5.7% (-.7% to 12,1%} 4.3% (-1.5% to 10.1%) 15.6% (6.0% to 25,1%)

93 (31.8%) 55 08.8%) 60 (20.5%)

74 (23.0%) 45 (14.0%} 44 (13,7%)

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8.9% (1.8%to 15.9%) 4.9% (-1,0% to 10.7%) 6.9% (.9% to 12.8}

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tremely common among patients with assault-related injury, particularly in the late teen to early adult years. A recent prospective study found that almost 60% of assaulted patients aged 18 to 20 years who required hospital care had positive blood alcohol levels in the AED, and one half of these patients had evidence of chronic alcohol abuse. 19 In addition, more than 40% of assaulted patients of all ages have evidence of abuse of other substances at the time of presentation for care in the AED. 2° Most AEDs fail to attend to these substance abuse problems 2 t despite the fact that intervention, even in the acute care setting, can make a difference. 22 Assessment of the readiness to change one's drinking pattern and the provision of appropriate counseling advice is feasible in medical settings. 23,24 Such findings have prompted the Institute of Medicine in the United States to recommend that trauma patients be screened routinely for alcoholism and referred to appropriate treatment programs. 25 Victim support groups should also be aware of the potential histories of assault patients. If these groups wish to provide services to all types of victims, they must be aware of the special needs of young male assault patients, such as substance abuse counseling 25 and anger management programs. Victim groups are heterogeneous in nature and, as indicated by this study, may include individuals who are offenders as well. There are also possible implications for the safety of AED personnel. Crime in hospitals is not uncommon, 26 and exposure of AED personnel to the threat of assault represents an important occupational hazard. The risk may be particularly great with assaulted patients, given the high frequency of offending and violence among these patients. CONCLUSION

Prevention of adolescent violence hinges on prevention of the larger problem of juvenile delinquency, tr Approaches that begin in early childhood and seek both to decrease risk factors for delinquency and to strengthen those characteristics that are protective offer the greatest hope for solutions to these important problems of our society, 27,28

6. Mayhew P, Maung NA, Mirrlees-Black C: The 1992British Crime Survey.London: Her Majesty's Stationery Office, 1993. 7. Lauritsen IL, Sampson RJ, Laub JH: The link between offending and victimization among adolescents. Criminology1991;29:265-291. 8. Barclay G6: The Criminal Justice System in Englandand Wales, ed 2. London: Home Office, 1993. 9. Rothman K: Modem Epidemielogy. Boston: Little, Brown, 1988. 10. Fleiss JL: Statistical Methods for Rates and Proportions, ed 2. New York: John Wiley & Sons, 1981. 11. Sims DW, Bivins BA, Obeid FN, et al: Urban trauma: A chronic recurrent disease. J Trauma 1989;29:940-947. 12. Sampson RJ. Lauritsen JL: Deviant lifestyles, proximity to crime, and the offender-victim Iink in personal violence. Journal of Research in Crimeand Delinquency 1990;27:110-139.

13. Kulhorn E: Victims and offenders of criminal violence. J Quantitative Crimino11990;8:51-59. 14. Farrington DP: Criminal career research in the United Kingdom. BrJ Crimino11992;32:521536. 15. Fardngten DP. Age and crime, in Tonry M, Morris N (eds): Crimeand Justice: An Annual Review of Research,vol 7. Chicago, University of Chicago Press, 1986, pp 198-249. 16. Wolfgang ME: An analysis of homicide-suicide. J Clin Exp Psychopatho11958;19:208-217. 17. Lauritsen JL, Laub JH. SampsonRJ: Conventional and delinquent activities: Implications for the prevention of violent victimization among adolescents. Violenceand Victimization 1992;7:91108. 18. Home Office: Criminal and custodial careers of those born in 1953, 1958 and 1963. Home Office Statistical Bulletin 32. London,Her Majesty's Stationery Office, 1989. 19. Rivara FP, GurneyJG, Ries RK, et ah A descriptive study of trauma, alcohol and alcoholism in young adults. JAdelesc Health 1992;13:663-667. 20. RivaraFP, Mueller BA, Fligner CL, et ah Drug use in trauma victims. J Trauma1989;29:462-470. 21. SoderstrornCA, Cowley RA: A national alcohol and trauma center survey: Missed opportunities and failed responsibilities. Arch Surg 1987;122:1067-1071. 22. Gentilleio LM, Dugan P, Drummond D, et ah Major injury as a unique opportunity to initiate treatment in the alcoholic. Am J Surg 1988;156:558-561. 23. Rollnick S, Kinnersley P, Stott N: Methods of helping patients with behaviour change. BMJ 1993;307:188-190. 24. Rollnick S, Heather N, Gold R, et ah Development of a short "readiness to change" questionnaire for use in brief, opportunistic interventions among excessivedrinkers. BrJAddict 1992;87:743-754. 25. Institute of Medicine. Broadening the Base of Treatment for AIcehol Problems.Washington DC: National Academy Press, 1990. 26. Cemhrowitz S, Ritter S: Attacks on doctors and nurses, in ShepherdJP (ed): Coping With Violence:A PracticalHandbeokferHealth-care Workers. Oxford: Oxford University Press, 1994. 27. Rivara FP, Farrington DP: Prevention of violence: Role of the pediatrician. Arch Pediatr Adelesc Med 1995;149:421-429. 28. Werner EE: High-risk children in young adulthood: A longitudinal study from birth to 32 years. Am J Orthopsychiatr1989;59:72-81.

Reprint no. 47/1/67569 Address for reprints:

REFERENCES

Frederick P Rivara, MD, MPH

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Harborview Injury Prevention and Research Center

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Box 359960 325 Ninth Avenue

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Seattle, Washington 98104

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206-521-1530

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Fax 206-521-1562

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