Adolescence violence as clinical entity: parameters, prevention and treatment
By Michael G. KALOGERAKIS.
1 Jul, 2007
The World Health Organization reports that, in the year 2000, violence among young people left an estimated 199,000 youths dead - a rate of 9.2 per 100,000 - and that, in all countries, young males are both the principal perpetrators and victims of homicide (World Report on Violence and Health, 2002). For every youth who dies from violence, 20-30 are sufficiently injured to require hospital treatment. In the United States, the prevalence* of serious violence by age 17 is 30-40% of males and 15-30% of females (Youth Violence: A Report of the Surgeon General, 2001). The cost of this violence is enormous, both in shattered lives and economically. In the United States alone, the estimated annual cost, direct and indirect, is $425 billion (Illinois Center for Violence Prevention, 1998).
. A cursory glance at some of the factors contributing to the violence we are witnessing shows that both individual (internal) and environmental (external) factors play a role. From the plethora of risk factors that have emerged in extensive research in various countries, the World Health Organization (World Report, 2002) singles out the following as having particular validity: Individual factors contributing to adolescent violence include involvement in violent or delinquent behavior prior to 13 years of age, impulsivity, aggressive attitudes, and low educational achievement. Family factors that have been identified include harsh physical punishment, witnessing violence at home, and lack of supervision by parents. Extra-familial factors include associating with delinquent peers as another risk factor, not, however, specific to violence but generally to various forms of delinquency. Alcohol and a variety of drugs may play an important role in reducing the control over violent impulses.
Studies of societal and community factors have identified the following risk factors:
High crime rates and impoverished neighborhoods; times of armed conflict and repression; times of social and political change; weak social protection policies; high
*Footnote: Having committed a serious act of violence at some point in their lives.
inequality of income; and a culture of violence. Questions always arise about the role of media violence. Extensive studies indicate that it has an impact on growing children,
inciting aggressive behavior in the days following the exposure, but with no clear link to violence.
Thus adolescent violence is a world-wide phenomenon, which, because of its powerful impact on society, constitutes, wherever it occurs, a major public health problem. Yet public health approaches to dealing with it have proved frustrating. It has become increasingly apparent that reducing adolescent violence will require the collaborative efforts of government, public health officials, communities, schools, social services, families, the police, sociologists, criminologists, pediatricians, and mental health professionals. Collaboration is key, because in most cases of individual violence, a monolithic approach to solving the problem, no matter of what kind, has failed.
Historical trends are noteworthy. In the decade starting in 1983, the United States witnessed a sharp rise in the level of individual violence among adolescents, generally attributed to the arrival of crack cocaine on the street and the concomitant increase in violent gangs and availability of handguns. Here in Eastern Europe, the break-up of the Soviet Union and subsequent waves of migration have been accompanied by many social problems, among them increased violence by youth. Contagion is often a striking element, in particular for adolescents. In the past month in the United States, in the course of one week, there were three violent school attacks.
Although adolescent violence has many forms, the form we are apt to hear most about, the one that captures the headlines, is the one associated with street crime. The major violent crimes listed by the criminal justice system are assault, robbery, rape, and murder. Not surprisingly, therefore, this became the major focus of government interest in research aimed at its prevention and treatment. Spurred by the epidemic of the eighties, the United States government funded a massive research effort in the past two decades, focusing on violence as a form of delinquency, and spearheaded by psychology and criminology. It looked at etiology, risk factors, preventive factors, developmental psychopathology, trajectories and impact, in large segments of the population. The major initiatives involved four longitudinal epidemiological studies, the nationwide National Youth Survey running from 1976 to 1993, and three city surveys in Rochester, Pittsburgh and Denver, all of which began in 1986. All are sociological in nature, address the problem of serious juvenile delinquency, in which serious violence is included, and were largely conducted via self-reports by the participants in the studies. In a comprehensive review of the subject (Youth Violence: A Report of the Surgeon General 2001), the Surgeon General of the U.S. points out, and I quote, "Because public health research is based on observations and statistical probabilities in large populations, risk factors can be used to predict violence in groups with particular characteristics or environmental conditions but not in individuals" (italics mine) (p.61). Another report issued by the National Institutes of Health following a consensus-building conference on "Preventing Violence and Related Health-Risking Social Behaviors in Adolescents", that brought together experts from all pertinent agencies and professions in October of 2004, states that "no meta-analysis of individual-level data has ever been done in the field of violence". (NIH State-of-the Science Conference Statement, (2006, p.12). It is very clear from all this that, as mental health professionals, who, in our clinical work, are totally focused on the individual patient, our input is vitally needed to supplement prior research by adding clinically based research that a) covers all forms of adolescent violence, and b) collects data from extensive evaluations of individual patients. The following is a sampling of the kinds of violent behavior that clinicians are apt to encounter that illustrate a highly varied diagnostic picture: [slide #1]
an adolescent patient in a psychiatric hospital assaults another patient because "he was looking at him strangely"
a youth pushes another person off the subway platform in front of an oncoming train because "the devil told him to do it"
a youngster with no prior history of violence attacks his 4 year old sister with a hammer because she keeps turning off the television
a sixteen year old student systematically amasses an arsenal with which he plans to kill off as many of his fellow students as possible
another teenager shoots to death a mother he has always loved because he hates his stepfather
a gang member involved in a turf war takes it upon himself to kill and dismember another youth from the rival gang
a frequent abuser of alcohol crashes his car killing several passengers in an oncoming car
a depressed seventeen year old girl draws up a suicide pact with her boyfriend because their parents are opposed to the relationship
a hospitalized youth, with no evidence of psychosis, assaults his female therapist during a session, after she began inquiring into sexual feelings he had for his mother, strangling her into unconsciousness
a mentally retarded adolescent girl in a residential treatment center runs amok, destroying property and assaulting fellow residents and staff
We can add the school bully, the date rapist, and others. It is evident from these examples that a wide range of psychopathology is associated with the commission of violence and that choosing the appropriate interventions must rely heavily on the underlying diagnosis. Despite this, a comprehensive typology of adolescent violence that would cover all varieties with appropriate emphasis, has been elusive. The one having the widest currency to date is by Tolin and Guerra (1994), and I show it on slide #2:
Predatory (5-8%) - intentional violence, for gain, that is part of a delinquent or antisocial trajectory
Relationship (26%) - violence involving family or friends
Situational (25%) - defined by the external conditions prevailing at the time of the act
Psychopathological (<1%) - mental illness or organic brain disease trajectory, tending to be malignant and repetitive
Note that the type of adolescent violence ranked as "psychopathological" is less than 1% of the whole. The use of this term implies that the other types listed are free of any psychopathology, which would strike any mental health professional as absurd. An earlier typology, by Cornell, et al (1989), who studied homicidal juveniles, also used the term only for the most severely mentally ill, i.e., psychotic and brain damaged individuals. Personality disorders, a major group of psychiatric disorders in DSM-IV, or psychoneurotic disturbances, as listed in the new Psychodynamic Diagnostic Manual (PDM, 2006), somehow did not rank as psychopathological. As a result, many considered "predatory" adolescents and virtually all listed as "relationship" or "situational" types, though thoroughly diagnosable, would not reach the level of psychopathology.
This point has more than mere academic importance, for the personality issues underlying the violent behavior will in part dictate the nature and goals of any intervention. We know that personality development begins with a child's genetic heritage, and continues as normal biological growth processes interact with the environment of the child, first and foremost within the family, but ultimately with the larger social domain. The final outcome is thus an amalgam born of internal and external forces interacting, which guarantee the uniqueness of the individual. Both internal and external forces contain risk factors that threaten a normal course of development, and protective factors that serve to assure a healthy outcome. The extent to which normal, healthy growth is disrupted and the ways in which this occurs at each stage of development, will determine the severity and nature of resulting psychopathology. Such psychopathology has been described as internalizing (anxiety, depression), or externalizing, i.e., manifested in a variety of self-destructive behaviors that are often disruptive or antisocial. The developmental trajectories followed by each of the many kinds of resulting disorders will differ and our science is continually at work trying to trace them. This is basic child development theory. As of today, it is safe to say that, though we may have many good clues about the roads that lead to violence, we lack hard data that would allow us to determine with any clarity or reliability what distinguishes the trajectories of the non-violent and violent delinquent, or the psychoneurotic individual who could commit a violent act from the one who never would.
In the remarks that follow, while extrapolating freely from the findings in the studies of delinquency where applicable, I tackle the issues of the developmental trajectory of adolescent violence and intervention for both prevention and treatment from the perspective of individual psychodynamic psychiatry and mental health.
Origins & Development
What brings out violent feelings in normally non-violent people? Perhaps the only condition that can regularly cause such a reaction is a life-threatening situation directed at an individual or his or her family. It is not unreasonable to assume that the same thing can occur in a child being repeatedly subjected to serious abuse, in whom there develops a fear of annihilation. It is an old saw that violence breeds violence. It may well be that this is the only invariable, direct cause of violent feelings and, ultimately, depending on the co-existence of other risk factors, violent behavior.
Whatever the precursors or the developmental trajectory, every child can be presumed to go through three stages: Stage I is the stage of general vulnerability, which is generic and can lead to any of a variety of psychosocial disturbances. Stage II is the stage of violence-proneness, which is specific and in which conditions which would not generally seriously affect a normal child will suffice to precipitate violent behavior, and Stage III, the stage of imminent danger, when even a minor provocation can produce the violent response. It is evident that interventions will vary depending on which stage the child appears to be in at the time of the diagnostic evaluation. For example, if we are confronted with a young child behaving aggressively in a nursery school class, a careful evaluation of the home situation is indicated. With the Stage II violence-prone child, we would want to identify the provocative elements in his or her environment, and, internally, re-enforce existing controls. At a later time, when an adolescent feels overwhelmed by violent impulses and appears to be ready to explode, we may need to consider medication and, for some, institutionalization.
A feature that one can expect to find almost invariably in the trajectory of violence is the progression from violent thought (cognitive), to violent impulse (emotional), to violent behavior. We know little about what it takes to move from one step to the next in this sequence but it is clear that many more people have violent thoughts than ever feel driven by an impulse to commit violence, and the majority of those who have violent impulses never act on them. At the same time, almost every person who commits violence can remember a time when there was nothing more than a violent thought and, at a later point, an impulse. This is clearly an area for further study.
The degree of vulnerability to be found in a child will depend on the extent to which normal development has been compromised, increasing weaknesses (e.g., anger, impulsivity, asocial values), while diminishing strengths (e.g., resilience, competence, the power to resist antisocial influences). Environmental forces, in particular the family, can serve to either increase the risk or re-enforce protective factors that together will determine whether a child will descend into a developmental trajectory that can lead to violence. These forces interweave in unique ways at different stages of development so that interventions that work at one stage may have no effect or even be irrelevant at another.
Violence is learned behavior, the notable exceptions being violence resulting from organic brain dysfunction and command hallucinations in paranoid schizophrenia, or when caused by alcohol or drugs. Precisely how it is learned remains a question to examine although imitation is certainly one method. More complicated mechanisms are in play when there is no other overtly violent family member to serve as a role model. In the absence of knowledge of direct causes, we are left to construct our theories from the study of identifies risk factors. Although there are conflicting data about the predictive value of early childhood risk factors, the histories of violent adolescents are, on the other hand, replete with internal and external factors that might well have set the stage for the future violent behavior. In addition to the individual and family factors already mentioned, social conditions such as extreme poverty, a criminal environment or membership in a minority group that is subjected to discrimination are commonly found risk factors in early childhood. Whether they result in violent behavior in later childhood or adolescence will depend partly on what protective factors were operating throughout the period of growth and partly on conditions present at the time of the violence, such as academic failure or peer group influences.
In a series of studies, Moffit, et al (1996) have found that, developmentally speaking, adolescent violence falls into two groups: one with an early or pre-pubertal onset and the other having a late or adolescent onset. The former has been found to be more severe and to have a significantly greater likelihood of continuing into adulthood, whereas the late onset violence often ends in adolescence, often after a brief course. An as yet unexplained phenomenon is the many youths who first behave violently in adolescence without having shown any of the known predictive signs in earlier childhood.
Dissecting the anatomy of violence by psychic domains, we can identify a number of components that seem regularly to be present. At the cognitive level, there is frequently poor social judgment, a failure to appreciate potential consequences, a tendency to think short-term rather than of the more distant future, confused priorities, and underdeveloped problem-solving ability. Emotionally, the violent adolescent is characterized by impulsivity, low frustration tolerance, insecurity, aggressiveness and anger and hostility, the latter directed at a specific individual (who might be a family member), or at hated groups such as ethnic minorities, adherents of other religions, or members of another socio-economic class. In some, fear and anxiety may play a crucial role. Some are depressed and may actually be suicidal. This last group tends to be particularly dangerous: if one no longer cares about his own life, there is little reason to value the life of another. Socially, there is obviously a profound lack of consideration for others, associated narcissism, failure of attachment (some being quite isolated), and an exploitative or criminal character.
Prevention
These are the personality traits that we need to trace, starting with the conditions present when their precursors first appeared. This would tell us where we need to direct our interventions for primary prevention, in general, the family. Quite simply, since the different kinds of adolescent violence involve different underlying personality organizations, their developmental trajectories will differ, much as the developmental course of neurosis, psychosis, and personality disorder differ. How the personality organization changes from one developmental stage to the next, the ways in which the unfolding propensity to commit violence is re-enforced, and what external factors serve to mitigate this development, are critical pieces of information that inform our interventions for primary, secondary or tertiary prevention.
As of this writing, we have not yet been able to separate out the risk factors for violence from those for severe delinquency. Future success in doing so is important for a coherent theory of violence. It is, however, not needed if our goal is to prevent violence. Whatever works to foster healthy development, whatever combination of fewest risk factors for psychosocial adolescent disturbances and maximum protective personality traits, will serve to prevent violent behavior and is an appropriate goal for any psychiatrically-based preventive effort. Our interventions must be tailored not only to the individual risk factors present but to the stage of development of the child and to the related external conditions, beginning with the family. They must begin at the earliest possible point, when problems are first identified, and continue right through to adolescence, for the dangers are forever changing.
Typically, in the first three years of life, the vulnerable child is the one with developmental delays and other inborn problems who is exposed to damaging family conditions such as physical or emotional abuse, domestic violence, criminality, or alcohol or drug abuse. Later, external factors such as the school and neighborhood cultures and the peer group assume increasing importance while, internally, impulsivity, poor judgment, anger and hostility, and amoral or antisocial traits may make the child more prone to violent actions. The presence or absence of a number of protective factors in both the individual and environmental domains play a major role in both the ultimate personality structure and in associated behaviors.
Treatment
Attempts to curb violent behavior in established violent delinquents through short-term interventions such as anger management and conflict resolution programs in the schools, or via community-based or family-based programs that do not address individual personality issues or neurotic disturbance that may be present in the youth, have either proven to be of no value or end up being band-aid solutions at best, producing benefits that do not last. It must be acknowledged, however, that, to date, psychodynamic and other individual therapeutic interventions have not been shown to be effective, at least with the population studied, namely serious delinquents (Lipsey), possibly because these interventions are often not buttressed by simultaneous attention to external risk factors. In addition, there is the matter of cost: individual treatment takes time, is, relatively speaking, more expensive, and may require keeping a youngster in residential placement while the therapy is being conducted, at least as long as the threat of further violence continues. How to fund such treatment remains a major problem for all societies. As a result, most treatment programs have concentrated on group approaches such as the Blueprint Programs of the Center for the Study and Prevention of Violence at the University of Colorado. [SLIDE]. This is not likely to change, at least for government-funded programs, where cost-effectiveness is paramount. Continued research is needed to determine precisely which programs remain effective over time. What seems clear, however, is that the group approach will not benefit every youth. A sizable number will require intensive individual approaches, whether psychotherapeutic or psychopharmacological, or both. This is the primary argument for assuring that every at risk child or adolescent receives a competent diagnostic assessment, the only means of reliably determining the appropriate treatment, and unfortunately all too rare at the present time.
When such an evaluation establishes the need for an individualized approach, what that should consist of will depend on the symptomatology, the underlying personality disorder, the psychodynamic formulation, and the external relationships with family and peers. Where the issues with which the adolescent patient is struggling seem to be primarily in the cognitive domain, the appropriate psychotherapy should probably be Cognitive-Behavioral Therapy (CBT). When the issues involve identifiable unconscious conflict, or significant affective dysfunction, especially when there is a history of significant anger and/or hostility (Kalogerakis, 2004), psychodynamic psychotherapy must be the treatment of choice. Such research as has addressed the value of individual psychotherapeutic interventions has tended to find that only CBT is of value but this may be a function of the methodology used and the population being studied.
The actual conduct of therapy does not differ from the standard approaches to the treatment of personality disorders and psychoneurotic disturbances in adolescents. The specific focus will differ from one patient to another but is certain to include attention to affective aspects involving, fear, anxiety, depression, and, of course, anger and hostility. Conflict areas are likely to involve issues of power and impotence, dependence-independence, sexual orientation, and concerns over adequacy, competence and self-esteem.
[SLIDE]
Summary
In summary, though it may often seem otherwise, the present state of knowledge about the causes and prevention of violence is adequate to help reduce the current level of adolescent violence, if we can provide the needed services, but adjustments have to be made in how we approach the problem and research needs to shift the focus of its attention. The sociological and behavioral psychology bias that has guided the bulk of the studies conducted to date has left gaping holes in our knowledge base, especially with regard to the role of unconscious conflict and the emotions in the developing child. At bottom, the problem of the roots of youth violence and its ultimate elimination is an issue for developmental psychology and mental health. This is inherent in the fact that prevention begins with assuring healthy child development in the context of healthy homes, and this is the domain of the child psychiatrist and child psychologist. The fortunate child is better able to resist the temptations and pressures of destructive environmental forces that take such a heavy toll on the vulnerable adolescent. When intervention becomes necessary, a thorough evaluation which includes a psychodynamic formulation that goes beyond the phenomenological, exposing underlying conflicts and anxieties, is a necessary preliminary to an appropriate and comprehensive treatment plan.
As we have learned more and more about violence and its prevention, it has become increasingly clear that the pre-eminent challenge to public health in general and mental health in particular is to educate and strengthen families so as to foster healthy and stable personality development in all domains, and to intervene at the earliest possible moment to correct developmental disturbances. The challenge to government is to mount a major, sustained commitment of financial and programmatic support, that reaches out to all segments of the scientific community that have a role to play in reducing the problem, at the same time that it is seeking to correct the environmental conditions that foster violence and other ills.