Injuries, whether intentional or unintentional, account for nearly 80% of the deaths to adolescents and young adults.¹ Although other causes of death have been decreasing, deaths from intentional injuries, in particular, have increased over the last few decades.^3,4

Concurrent with this increase in injuries and deaths from intentional trauma, there has been an increase in the number of juveniles arrested for criminal offenses. Between 1985 and 1991, arrest rates for 15- to 19-year-old males increased by 127% while they decreased for those 20 and older.^5,6

Because both injuries and offending are common during adolescence, some authors have hypothesized a relationship between the two problems under the rubric of health-compromising lifestyle behaviors.⁷ Although the core behaviors in this lifestyle involve substance abuse and delinquency, injuries has been included because of the role of alcohol in trauma etiology, and because those involved with crimes may be victims as well as perpetrators.¹¹ However, the empirical evidence to support the inclusion of injuries is limited and generally weak. This study was therefore undertaken to examine whether youth convicted of juvenile offenses would have a greater risk of serious injury compared with a group of nonoffending adolescents.

METHODS

To identify juvenile offenders among those admitted to the hospital, CHARS data were linked to the statewide Juvenile Information System (JUVIS) database for the years 1984 to 1993. Files were linked using the subject's last and first name and date of birth, as well as aliases, when available. The JUVIS file registers all adjudications for offenses committed in Washington State by individuals under 18 and is managed by the Office of the Administrator for the Courts of Washington State. It offers a complete record of all adjudications that resulted in a finding of guilt, a guilty plea, or a diversion to supervision in the community. Complete data were available on 83% of the records; identifying data were deleted in JUVIS on the remainder because the records were sealed by the courts. For those born in 1974 and 1975, the years chosen for examination allowed complete ascertainment of juvenile offending throughout their entire adolescence (ages 10 through 18). For individuals born in 1971, 1972, and 1973, a history of juvenile offending was available after age 11, 12, and 13, respectively, through age 18.

Patients admitted to the hospital were grouped according to the presence (offender) or absence (nonoffender) of an adjudication while an adolescent, determined by whether or not they linked to the JUVIS file. The frequency-of-injury mechanism was noted by using the first two E-codes for all admissions up through the fourth for each subject.

Analysis was performed using the statistical program SAS (SAS Institute, Cary, NC). In all analyses, males and females were examined separately, due to their different hospital admission and delinquency profiles. For the calculation of prevalence rates, the denominators for the offending group consisted of the total number of male or female juvenile offenders born between 1971 and 1975 whose records were complete enough for a CHARS linkage attempt. The denominator for the nonoffender group was calculated using census estimates of the gender- and birth-year-specific average number of persons living in Washington State between 1989 and 1992, for each single birth-year cohort of individuals born between 1971 and 1975,¹⁴ minus the offender population in each gender and age group.

RESULTS

Table 1. Admissions to the Hospital for Male and Female Juvenile Offenders and Nonoffenders in Washington State, 1989-1992 [View Table]

Injuries accounted for approximately 1/4 of hospitalizations for both male offenders and nonoffenders, but less than 10% of hospitalizations among their female counterparts (Table 1). Offenders had a prevalence of injury admissions per 100 000 population that was 2.7-fold greater among males and 62% higher among females as compared with nonoffenders.

Information on mechanism of injury (E-code) was available for 89.9% of injuries to male juvenile delinquents, 86.9% of injuries to female juvenile delinquents, 88.7% of injuries among male nonoffenders, and 84.4% of injuries among female nonoffenders. Male juvenile delinquents compared with male nonoffenders had higher rates for most mechanisms of injury, except for falls, injuries attributable to environmental causes, and submersions (Table 2). There was almost a fourfold difference in the rates of unintentional poisonings, including a fivefold difference for drug poisonings (odds ratio [OR] = 5.3; 95% confidence interval [CI] 2.8, 10.2). Self-inflicted injuries were 2.3 times more common among the delinquent group, with the greatest differences in self-woundings with cutting instruments (OR = 4.6; 95% CI 1.9, 11.9). Male juvenile offenders experienced a threefold increased risk of an injury due to interpersonal violence (OR = 3.4; 95% CI 2.7, 4.4). Assaults resulting in gunshot wounds and stabbings were 4.9 times and 5.3 times more likely, respectively, among offenders. In fact, being the victim of a gun injury, whether it be intentional, unintentional, or of undetermined intent, was 322.8% in excess of the rate for nonoffender males. The overall rate of any intentional injury was almost threefold greater for male juvenile delinquents as compared with nonoffenders (Table 2), while the rate of unintentional injuries was nearly the same.

Table 2. Circumstances Surrounding Injury Admissions for Male Juvenile Offenders and Nonoffenders: Number, Population Prevalence Rates per 100 000, and Odds Ratios for Admission [View Table]

For female delinquents, the results were similar, although the events were less common (Table 3). Female delinquents had lower rates than nondelinquents only for injuries involving environmental causes and falls. As with males, poisoning admissions were very different between the two groups, with unintentional drug poisonings 3.4-fold more likely for female delinquents than nondelinquents. Self-inflicted injuries were nearly twice as common among delinquent females than among nonoffenders. The largest excess risks of injury for female delinquents involved injuries due to interpersonal violence. The rate of admission for an injury due to interpersonal violence for female delinquents was 674.6% in excess of this rate for nonoffenders, and any injury involving a fight, brawl, or rape was 8.8 times more common among this group, compared with nonoffending adolescents (OR = 8.8; 95% CI 3.1, 25.4) (Table 3).

Table 3. Circumstances Surrounding Injury Admissions for Female Juvenile Offenders and Nonoffenders: Number, Population, Prevalence Rates Per 100 000, and Odds Ratios for Admission [View Table]

The cohort of delinquent individuals accounted for far more injury admissions, whether they be unintentional, intentional, or of undetermined intent, than expected, given their proportion in the population19.1% of males and 9.5% of females (Table 4). More than half of all male adolescents discharged due to an unintentional poisoning, hanging, stabbing, assault, or for any injury whose intent was undetermined were, or would be, adjudicated as a juvenile. Male juvenile offenders accounted for approximately two thirds of all gunshot wounds and one third of motor vehicle crashes, the most common causes of injury deaths in this age group. For female delinquents, 56% of all hospital discharges to adolescent girls for an interpersonal attack were among juvenile offenders. Although there were few gun-related incidents, more than half of hospital discharges for this cause to females were among offenders. Delinquent females accounted for one in three unintentional poisonings, one in three injuries of undetermined intent, and one in five self-inflicted injuries.

Table 4. Proportion of Admissions by Mechanism Accounted for by Male and Female Juvenile Offenders 1989-1992 [View Table]

Overall, intentional injuries accounted for 33% of injury admissions for male offenders and 50.5% for female offenders compared with 15.6% and 41.9%, resepectively, of their nonoffending counterparts (Table 5).

Table 5. Distribution of Causes of Injury Admissions in Male and Female Offenders and Nonoffenders, 1989-1992 [View Table]

DISCUSSION

The juvenile offenders in this study were more often the victims of both unintentional injuries and intentional violence, both assault and self-inflicted injury. These findings are in agreement with other studies in the literature. Lewis and Shanok¹⁵ conducted a retrospective case-control study in 1977 of 109 matched pairs of juvenile delinquents and nondelinquents; emergency room visits and admissions for injuries at some time in the past were more common among the delinquent adolescents. In a study by Lauritsen et al,¹⁶ delinquents were 2 to 3 times more likely to be victimized by assault and robbery than nondelinquents.

Our study found the greatest differences in the rates of admission for intentional trauma, being 2 to 9 times more common among offenders than nonoffenders. Conversely, assault victims are much more likely to be offenders than are victims of unintentional injury. In a recent study, Rivara et al¹⁷ reviewed the police records of 1734 assault cases treated in an accident and emergency department between July and December 1991. Of their youth sample, 16.3% of intentional injury victims 10 to 16 years of age were later convicted of a crime, while only 2.5% of the 80 unintentional injury patients of the same ages were convicted.

Among individuals of all ages, Sims et al¹⁸ found that criminality was common among admissions for intentional injuries in Detroit. Of the patients admitted during a 2-year period for treatment of a stab wound, an assault, or a gunshot wound, 54% had criminal records over the following 5-year period. Of all individuals admitted for trauma over that 2-year period, 5.3% were found in the database as homicide victims during the next 5 years, and 14.4% were located as serious offenders after their injury. Substance abuse among this population was documented to be 60%.¹⁸

One of the core elements in the cluster of health-compromising behaviors is substance abuse.¹¹ The fact that poisoning with drugs was fivefold more common among male and threefold more common among female delinquents than nondelinquents supports the hypothesis that high-risk adolescents have more than one such high-risk behavior. Although the prevalence of alcohol use on admission for injury was not assessable, alcohol use is a frequent cofactor in injuries involving motor vehicles and interpersonal violence.¹⁹

Other studies have documented the significant relationship between substance abuse and juvenile offending. The national youth survey found that drug-using adolescents were disproportionately offenders: 25% of those admitting to heroin or cocaine use were responsible for 40% of index crimes.²⁰ Substance abuse, predominantly alcohol abuse, is also a known risk factor for future offending in adulthood.²¹ The review of Bradford et al²¹ listed six studies in which the prevalence of alcohol use was 45% to 80% among persons who committed homicide. Another study showed that 23% of all delinquents in Illinois satisfied diagnostic criteria for alcohol abuse, with a higher percentage of substance abusers among the more serious offenders.²² In our study, 49% of drug dependency admissions for boys and 30% of admissions for girls were to adolescents who were, or would be, adjudicated for an offense. Because fairly effective treatment exists for persons with substance abuse problems, substance abuse screening among adolescent hospital admissions, especially among those with injuries, and subsequent in-hospital treatment or treatment referrals may be fruitful in the prevention of future criminal behavior. One study²³ which instituted an in-depth referral system for trauma admissions co-diagnosed as alcoholics found that the hospital admission, along with staff efforts and family involvement, was a successful impetus to initiate substance abuse treatment for these individuals. Early substance abuse treatment may also prevent the revolving emergency room door phenomenon and high mortality rates, which have been described among certain substance-abusing populations.^18,19,24

Another preventable cause of injury, firearms, is much more common among youthful offenders than nonoffenders. Although the use of handguns in crimes committed by adults has remained fairly stable over the last two decades, the use of handguns in crimes by adolescents was almost three times more common in 1992 than in 1976.²⁵ The ease with which an adolescent can get a gun is probably underestimated by the majority involved in public health. In Seattle, a city with a relatively low rate of youth violence, one survey of 11th-grade students found that 34% reported easy access to firearms, with 11.4% of males reporting owning a handgun. Ownership was more common among adolescents with problem behaviors.²⁶ Findings from the National Youth Risk Behavior survey indicated that 20% of high school students carried weapons to school for self-protection during the previous month.²⁷ Besides the obvious implications of firearms in interpersonal injuries, a handgun in the home has been found to be a strong risk factor for adolescent suicide.^28,29

Limitations

Second, court referrals for an offense are not the only indicator of delinquency. For offenses committed by adults, National Crime Survey responses suggest that only about half of all crimes are ever reported to the police. Of crimes reported to the police, only 25% to 35% of most crimes result in an arrest.³⁰ It can be estimated, then, that less than 20% of offenses that adolescents commit will be recorded in court files. This implies that a substantial number of adolescents never appeared in the juvenile justice system, even though they were juvenile offenders. In addition, about 5% of offenders younger than 18 in a national survey were tried in adult courts.³¹

Admissions of these adolescentsthose who had hospital admissions and whose JUVIS records had been sealed, those who were offenders but never were adjudicated, and those who were tried as adults and had no juvenile adjudicationswould appear as nonoffender admissions. Furthermore, some of the adolescents born in 1971, 1972, or 1973 may have had an adjudication at a very early age (10, 11, or 12) and none thereafter. These early offenses for those cohorts of children would not have been identified due to the nature of data available. This latter group of juvenile offenders, while probably small in magnitude, would have been misclassified as nonoffenders. Because injury was more common among offenders, and unidentified offenders were undoubtedly counted in the nonoffender numerator, the results reported here would be underestimates of the true associations.

Third, because this research was limited to Washington State offenders and Washington State hospital admissions, the impact of migration should be addressed. In-migration and out-migration during the adolescent years might have resulted in some changes in the rates calculated. Because there is some support to the theory that a propensity to offend is associated with a history of migration,³² some adolescents who were offenders in other states and had hospital admissions but no adjudications in Washington would be counted as never-offenders. Likewise, adolescents who had admissions here and moved out of state where they became offenders would be recorded as never-offenders. Individuals with adjudications may also be more likely to leave the state after their adjudication. It is thus likely that the in-migrant adolescents were disproportionately offenders and that the out-migrants were also disproportionately offenders. In the former case, unless these adolescents were also adjudicated at some point in Washington State, their hospital admissions would be included in the nonoffender group. In the latter case, the denominator for the rates of admission among offenders would be an inflated estimate of the true numbers of offenders at risk for a Washington State hospital admission. This again would result in underestimates of the true associations.

CONCLUSIONS

Although this article points to the utility of the hospital in secondary prevention of juvenile delinquency, such interventions are probably of less value than primary prevention. Strong predictors of delinquency emerge much earlier in childhood,^8,33,34 and include poor scholastic performance, early behavior problems, a history of poor parenting, and adverse family and living conditions. The predictive value of non-health-care-based screening tests, such as those administered in the schools, should not be underestimated.²⁶ Interventions that take place much earlier hold greater promise in reducing the numbers of children who initiate delinquent behaviors. Thus, this study proposes that preventing offending is also a wise step in preventing injuries among young adults.