CHAPTER 7 Violence
Self-mutilation, violence toward self, is a pathological yet complex behavior of youth that commonly is expressed as cutting or injury to the body for personal comfort or relief from emotional pain. Suicide is ranked as the third leading cause of death of young people (Snyder and Sickmund, 2006). Public awareness of early subtle and overt signs must be expanded, intervention services and programs require improvement, and research is needed to broaden the knowledge base and develop additional strategies for suicide prevention in all children.
Rape is a display of sexual violence toward another person. Three relational categories are defined within adolescent rape: stranger, nonstranger (date or acquaintance rape), and incest. All can be detrimental to the victim’s health and have serious, long-lasting consequences. These categories are unique in three ways: (1) how victims process the event, which determines the prevailing cognitive and psychological behaviors; (2) how health professionals are affected by the incident, and how they sort through the salient issues; and (3) techniques and methods used for treatment. Two out of every 1000 children in the United States were confirmed victims of sexual assault in 2003 (U.S. Department of Health and Human Services [USDHHS], 2005). Sexual violence is one of the most underreported crimes.
Brain Findings
Numerous studies provide data on genetic, biological, and environmental keys to aggression and violence. A biochemical link indicating an interaction between defective genes and the environment produces abnormal levels of two mood-altering neurotransmitters, serotonin and noradrenaline. Serotonin plays a key role in regulating emotions, including control of aggression, and noradrenaline organizes the brain’s response to danger. Increased levels of serotonin are associated with high self-esteem and social status; low levels are associated with low self-esteem and social status, which can lead to aggression, impulsivity, and suicidal and violent behavior (Davidson, Putnam, and Larson, 2000). These two neurotransmitters are involved in regulating the dopamine-dependent behavioral system (Rogeness and McClure, 1996).
VIOLENCE TOWARD SELF
SELF-MUTILATION
A. A useful definition of self-mutilation (SM) that incorporates all the variables from different studies is “a direct, socially unacceptable, repeated behavior that causes minor to moderate physical injury” to oneself (Suyemoto and Kountz, 2000). Other more acceptable terms are self-injury, self-harm, self-inflicted violence (SIV), and self-injurious behavior (SIB). Such behavior is regarded as pathological, and it differs from socially acceptable bodily modifications—such as piercings or tattoos—and from indirect, risk-taking self-harm, such as driving under the influence of alcohol. Self-mutilation is not regarded as a suicide attempt, because the motivation is to inflict injury or cause suffering, not to cause death. SM is the externalization of overwhelming emotional pain. When such behavior continues, it may become chronic and debilitating.
B. SM is increasing, and a small study indicates that 13.9% of adolescents report SIB (Ross and Heath 2002). Estimates of self-mutilation in the general population range from 14 to 600 per 100,000 annually. Most researchers believe SM is underreported, because it is a secretive behavior. Rates among adolescent inpatients range from 40% to 61%. A survey of outpatient therapists showed that 47% had known a self-mutilating adolescent (Suyemoto and Kountz, 2000).
A. This is not a new phenomenon: young people who self-mutilate have been studied in the medical and psychiatric community for more than 45 years. Clinicians and researchers differ on the actual diagnosis for SM, but the consensus is that the behavior can be related to the diagnosis of borderline personality disorder, which lists self-mutilating behavior as one of its criteria (American Psychiatric Association, 2000). Some authorities associate SM with eating disorders, and others document co-occurrence with dissociative identity disorder and obsessive compulsive disorder. Youths who are mentally retarded or autistic engage in SM, but these individuals are not classified in the same manner.
A. Burning, carving, cutting, hair pulling, scratching and picking of the skin, and putting objects into body openings or under the skin. Cutting is the most common form of self-mutilation. Cuts often are made by razor blades, inflicting injury to the arms, wrists, forearms, ankles, and lower legs. Other areas include the abdomen, axilla, and beneath the breasts. Girls represent the large majority of self-mutilators, and the first incident usually occurs in middle to late adolescence. Occurrence does not vary according to ethnicity, race, or class. Self-cutting usually is a secretive behavior, but scars and wounds are often visible if left uncovered. Because of shame and self-repulsion, affected individuals are socially isolated and selective in their social relationships. Substance abuse frequently is associated with self-injury. As many as three fourths of self-mutilators describe violence, abuse, and family disruptions as common in their family of origin. Bodily injury can be severe, resulting in hospitalization and the need for institutionalization as a means of protection. Some studies indicate that as many as 25% of adolescent self-mutilators have never sought medical advice regarding their self-abuse (Suyemoto and Kountz, 2000). Medication is not the treatment of choice except to treat underlying associated disorders (e.g., depression, obsessive-compulsive behavior).
B. Episodes of SM usually are less than an hour in duration and are a part of a recurring cycle in response to stress triggers that can be seen largely as unconscious, automatic processes of cognition distortion, negative feelings, and critical self-talk.
A. A common theme is that self-injury helps the individual feel physical pain on the outside instead of emotional pain on the inside. Self-injury provides immediate but temporary relief from psychological pain that the individual is unable to express verbally. It is a way to externalize the intensity of the pain and turn it into an active, physical event that can be controlled. Usually the emotional incentive to mutilate is fear, hurt, anger or perceived rejection or abandonment by others, which may be precipitated by anxiety and hostility. Self-injurers have not learned how to appropriately release emotions, or they may not have been allowed to express them. Volatile and exaggerated responses can trigger events, but individuals learn to relieve overwhelming emotions through self-injury; most report feeling calm, relief, or contentment after the injury.
A. Depends on degree of involvement and history, such as physical or sexual abuse, chaotic family life, student alcohol or drug use, or underlying psychiatric illness. Further research in this subject is needed, and school nurses are ideally suited to perform this work.
1. Be alert to behavioral cues, which may include low self-esteem, anxiety, anger, isolation, and inappropriate dress (e.g., wearing long sleeves and long pants in warm weather to cover up scars).
6. Educate staff and parents—both individually and in group meetings—regarding risk factors, which include anxiety, stress, and methods used to disassociate with the overwhelming tension and impact of chaotic or negative family dynamics.
7. Conduct health classes and encourage student participation. Discuss precursors and related issues, and be a resource for parents, staff, and students.
2. Notify parents or guardians; refer to school psychologist, social worker, or mental health worker. It is important to continue dialogue with parents, but be sensitive to the fact that the student may be fearful of a parent.
4. DO NOT tell the student to stop self-injury, and refrain from making judgmental comments; these can lower students’ feelings of self-worth and make them more likely to self-injure.
5. Project a nonjudgmental, hopeful acceptance of the youth. Most do not want attention and hide the injury. Self-mutilators act on emotional pain and are distracted by the physical pain.
6. Provide immediate first aid and medical treatment for cuts and wounds. Make student aware of potential infection; educate and monitor the student.
8. Teach alternative strategies for self-comfort and soothing (e.g., exercise, music, massage, warm bath, acupressure points).
SUICIDE
B. Nationwide, 16.9% of students have seriously considered suicide (Grunbaum, 2004). Suicide is the third leading cause of death among juveniles ages 15 to 19, and males outnumber females 4:1 in this age group. The suicide rate for American Indian juveniles is nearly double the white non-Hispanic rate and triple the rate for other racial and ethnic groups (Snyder and Sickmund, 2006).
A. Suicide is multicausal. More than 75% of youth suicide is associated with a diagnosable mental or substance abuse disorder. Causes of childhood suicide may include escape from physical or sexual abuse, chaotic family situations, feelings of being unloved, constant criticism, depression, loss of significant relationships, humiliation, potential or actual failure in school, or intent to punish friends or family.
B. Causes of adolescent suicide—in addition to the causes listed previously—may include difficulties or lack of meaningful relationships, perfectionist expectations, serious problems with parents, sexual issues, or a fight with a close friend. In some cases, copycat suicide occurs to gain attention or to identify with a peer who has committed suicide. Suicide and attempted suicide are more prevalent in cults, homosexuals, and high-risk individuals (e.g., those who use drugs and alcohol). Teenage girls attempt suicide more frequently, whereas teenage boys have a higher rate of completed suicides. Girls more often use less violent methods of suicide (e.g., pills), and boys use guns more frequently.
1. Verbal cues: somatic complaints about headaches and stomachaches. Comments indicating loneliness, isolation, and not being loved.
2. Behavioral cues: poor school performance, withdrawal from play and leisure interests, apathy, listlessness, erratic appetite, and sleep disturbance. Sometimes are careless and destructive toward property, both their own and others.
3. Affective cues: feelings of sadness, irritability, lack of empathy, tend not to be carefree or engage in spontaneous laughter. Change in routine of doing chores (i.e., cleaning their room, caring for animals).
1. Verbal cues: students may make subtle or obvious comments about suicide, e.g., “Will you miss me when I’m not here?” or “I won’t be bothering you anymore.”
2. Behavioral cues: may stockpile pills, obtain a weapon, withdraw from activities and friends, engage in risky activities, abuse drugs or alcohol, neglect appearance and self-care, dispose of personal belongings, change sleep patterns, listen to suggestive music, suddenly receive different academic grades, change friends and relationships, engage in promiscuous sex, change appetite, or report sleep problems.
3. Affective cues: chronic or acute depression, feelings of hopelessness and guilt, sadness, lack of empathy, boredom, decreased self-gratification.
IV. Health Concerns/Emergencies
F. Mental health disorder may require suicide watch or placement in a more restrictive setting for protection.
D. Feelings of loss, sadness, grief, guilt, and disbelief in family, friends, and peers after failed suicide attempt.
A. Be alert to warning signs and intervene early to prevent attempts or completion. Never ignore a warning or threat, and do not be afraid to ask: “Are you considering suicide?” “Do you have a plan?”
E. Support and teach students and others about stress, depression, sadness, coping with loss, and academic, social, and athletic challenges that may put the student at greater risk for suicide or attempts. This may be a component of the School Crisis Team or noncrisis intervention and prevention.
F. Establish and support School Crisis Team with emergency guidelines and mechanism for referring at-risk students who manifest depressive behaviors, suicidal characteristics, or both.
G. Refer for intensive counseling and treatment for underlying mental health disorders. Can utilize Columbia TeenScreen Program to screen for depression, substance abuse, and suicidal ideation (see Appendix A, Assessment Tools).
H. Provide counseling to intervene in affective, behavioral, and self-esteem issues. Suicide attempts should always be professionally evaluated.
I. Implement intervention centered around family support system; listen to students, show them loved ones need and respect them, set high but realistic expectations, encourage caring and nurturing, spiritual or religious involvement, and allow staff to be supportive.
J. Counsel and refer students (friends of the victim) to a support group after the suicide and around the anniversary of the event.
A. More people are killed by suicide than by homicide (U.S. Public Health Service, 2000). The actual rate may be higher than reported, because suicide deaths sometimes are concealed to avoid stigma, and some accidents are actually suicides. With constant media exposure to violence and homicidal behavior, youth may become desensitized to life-threatening behavior and may experience increased feelings of omnipotence or invulnerability to death. Suicide attempts may be a nonverbal cry for help. Issues related to sexual orientation and gender identity increase the risk for depression and subsequent suicide attempts and completions.
WEB SITES
ANSWER: Adolescents Never Suicide When Everyone Responds http://www.teenanswer.org
The American Association of Suicidology (AAS) http://www.suicidology.org
The American Foundation for Suicide Prevention (AFSP) http://www.afsp.org
Yellow Ribbon International Suicide Prevention Program http://www.yellowribbon.org
VIOLENCE TOWARD OTHERS
SEXUAL ASSAULT
Lisa Lewis-Javar, RN, SANE-P, FNC, and Vickie Whitson, RN, BSN, SANE-A
A. Sexual assault is a broad term to describe intentional sexual contact that is made without consent. It can range from kissing and fondling to penetration. Consent is a vital concept, because people cannot give consent when they are not in full command of their cognitive ability (e.g. from alcohol, drug use, or mental illness).
B. Rape is a type of sexual assault that involves penetration with both male and female victims—oral, anal, or vaginal, however slight. Most states define penetration as anything deeper than the labia majora, but statues may vary from state to state.
C. Family members or acquaintances commit 95% of all confirmed cases of child sexual assault. This includes members of the child’s family or other persons known to or trusted by the child. Furthermore, 83% of all confirmed cases of child sexual abuse occur in the privacy of a home or residence (Snyder and Sickmund, 2006). Statistics show that 1 in 5 girls and 1 in 10 boys are sexually exploited before they reach adulthood—yet less than 35% of those child sexual assaults are reported to authorities, according to the National Center for Missing and Exploited Children. According to the Youth Internet Safety Survey II (2006) conducted by the U.S. Department of Justice, 1 in 7 children and adolescents 10 to 17 years old received unwanted sexual solicitations online (Wolak, Mitchell, and Finkelhor, 2006).
1. Physical and emotional responses associated with sexual assault and abuse are as unique as the victims who experience them.
2. There is no “normal” or “abnormal” response. Initially the victim’s response may include shock, disbelief, shame, and self-blame.
3. The victim’s outward behavior may include a broad spectrum of emotions—anger, sobbing, crying, and inappropriate laughter—or may more often present with a quiet, calm demeanor.
4. Common concerns after a person has been sexually assaulted include pregnancy and contraction of a sexually transmitted disease.
1. Phobias, depression, suicidal thoughts, nightmares or sleep disturbances, anxiety that manifests as chest pain, palpitation, and diaphoresis; or, individual may appear normal but may be in denial and suppressing the responses.
A. Evidence is best gathered within 72 hours by health care professionals with special training and equipment and with scientific knowledge of DNA advances. DNA sperm has been recovered from the cervix up to 19 days post-assault with a sexual assault history of penile vaginal penetration without a condom.
B. Victims need time to express feelings; proceed slowly. Most states have sexual advocacy organizations with twenty-four hour hotlines available. These organizations provide advocacy and emotional support to the victim even before the crime has been reported. A national hotline is available—800-656-HOPE (4673)—or contact the Rape Abuse and Incest National Network at http://www.rainn.org.
C. Advise regarding transmission of sexually transmitted diseases (STDs), including human immunodeficiency virus (HIV) and acquired immunodeficiency syndrome (AIDS). The data available regarding the transmission of HIV through a single sexual assault is limited but suggests that the rate of contraction is extremely low. Follow up with primary medical provider for HIV and hepatitis baseline testing and recommended CDC guidelines.
D. Victim may have vaginal or anal pain, tenderness, swelling, abrasions, lacerations, bruising, and bleeding. In most sexual assaults in people 12 years of age and older, there are no genital findings at least 70% of the time (Giardino, Datner, and Asher, 2003).
D. Sexual assault is one of life’s most devastating experiences with recurrent flashbacks and recall in long-term memory.
E. Individuals of any age who have been sexually assaulted appear to be at higher risk for depression, suicidal tendencies, self-mutilation, poor self-esteem, aggression, and inappropriate sexual behavior; these effects may manifest at any time.
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