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Tips for detecting and preventing violent behavior in teens

From the May 1998 ACP Observer, copyright 1998 by the American College of Physicians.

By Maureen Glabman

SAN DIEGO—The recent shooting spree by two boys in Jonesboro, Ark., should serve as a wake-up call to screen all teenagers for psychosocial risk factors, according to Philadelphia pediatrician Kenneth R. Ginsburg, MD. And the best people to screen for teen violence, he said, are the individuals who suture adolescents' lacerations, set their broken bones and remove bullets from them: physicians.

"Who else meets confidentially with teens?" asked Dr. Ginsburg during a session on preventing teen violence.

Dr. Ginsburg said that guns and violence are a leading cause of death among teenagers, second only to motor vehicle accidents. Of teens who are screened, he said, about 25% will show potential for violence.

Screening tips

To screen teens for violence, Dr. Ginsburg said, physicians should start by blocking out an hour with adolescents to conduct an assessment. "Teenagers in crisis are quick to talk behind a closed door," he said. "When that door closes, they melt."

Adolescents come to a doctor expecting to get a check-up, shots and forms completed, not to be asked personal questions, Dr. Ginsburg said, so it's important to set the stage. He advised starting off by saying something like: "For me to be a good doctor, I need to help you stay alive and safe."

Getting through to teens requires that doctors gain trust. To do so, Dr. Ginsburg suggested telling teens they can expect honesty and that their privacy will not be violated unless lives are in danger. Dr. Ginsburg noted, however, that limits to patient confidentiality vary from state to state in cases of homicide, suicide and sexual abuse.

Dr. Ginsburg suggested that physicians conduct screening following the seven categories of the SHADESS model, which stands for school, home, activities, drugs, emotions, sexuality and safety. Sample questions include: Do you feel safe at home or in school? What do you do to feel safer? Would I like your friends? What makes you mad enough to fight?

To identify teenagers with a penchant for violence, try asking patients what they want to be when they grow up. "Kids who have a goal are low risk. When teens say 'who knows?' they often don't expect to live," Dr. Ginsburg said. "Hopelessness is a major variable."

It's also important to keep in mind that teenagers exposed to violence in the home, on the streets or through the media may be inured to it. They may view violence as an appropriate means to handle stress or conflict. Physicians can judge risk by asking the following questions: What do people in your family do when they are angry? What about people in your school and in your neighborhood?

Basic behaviors

Another way to identify teens at risk for violence is to look for the four basic levels of behavior that lead to provocation. Teens at the highest risk will start a fight after what they perceive is a personal insult, Dr. Ginsburg said. Others will respond to a situation with violence only after an insult has been made about the teen's family. Still another group won't initiate violence until an "in your face" threat is made. The last group of potentially violent teens only react when they are touched or pushed.

Some teens carry weapons because they do not feel safe. To find out if your patient is doing so, appropriate questions might include: Are there a lot of fights at your school? Do you feel safe at home? Does anyone hurt you or touch you when you don't want to be touched? What do you do to make yourself feel safe?

Once an inclination for violence has been identified, Dr. Ginsburg suggested that physicians use strategies for dealing with anger such as teaching skills to avoid conflict, removing despondency by establishing a future goal and talking about ways to achieve it, and making teens aware of consequences. "Teens don't think abstractly enough to consider consequences," he said. "But when you show them consequences, they understand."

For example, one 14-year-old female patient at a school clinic showed Dr. Ginsburg a knife and explained how she planned to kill another girl because the girl had punched her. The doctor asked her the following questions: How would her family feel if she were sent to jail? How old did she think she'd be when she got out? How would a younger sibling who looks up to her feel about what she had done? How would she feel if she just walked away from the fight?

Finally, intervention is easiest when physicians are treating such things as a black eye. Besides asking how the teen got the bruise, doctors should ask whether the patient plans to retaliate, what response a retaliation would provoke, and whether the patient realizes that he could end up dead.

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