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J Oral Maxillofac Surg67:2627-2635, 2009

Factors Associated With Orofacial Injuryand Willingness to Participate in

Interventions Among Adolescents Treatedin Trauma Centers

Debra A. Murphy, PhD,* Vivek Shetty, DDS,†

Claudia Der-Martirosian, PhD,‡ Diane M. Herbeck, MA,§

Judith Resell, PhD,� Mark Urata, MD, DDS,¶ and

Dennis-Duke Yamashita, DDS#

Purpose: Assault is the most common cause of facial injuries in adolescents treated at inner-city traumacenters, yet little is known about the behavioral and environmental antecedents of these injuries or thewillingness of such at-risk adolescents to participate in behavioral interventions to minimize reinjury. Thepurpose of this study was to identify possible risk and protective factors among adolescents withassault-related facial injury and to assess their willingness to participate in prospective observationalresearch and behavioral interventions.

Patients and Methods: Interviews were conducted with 67 adolescents (range 14 to 20 yrs) who weretreated in trauma centers for facial injuries. Most of these injuries were assault-related (59%), followed bymotor vehicle or other accidents (29%), gunshot wounds (9%), and sports injuries (3%). The subjectswere predominantly male (86%) and of ethnic minorities (91%).

Results: The adolescents showed high rates of intentional injuries in the past 6 months (56%), unhealthy alcoholuse, and in more than half (55%) problem levels of substance use. Compared with those with unintentional injuries,adolescents who experienced assault-related injuries were more likely to report using alcohol, tobacco, and othersubstances. Although a significant segment of the sample (55%) had been arrested previously, no differences inarrest rates or types of crimes for which adolescents were arrested were observed by injury type. Most subjectswere unwilling to participate in interventions that involved multiple sessions; however, greater family cohesionpredicted the likelihood of being willing to participate.

Conclusions: Most facial injuries in inner-city adolescents result from assault. Unhealthy alcohol use,problem levels of substance use behaviors, and family history of alcohol problems are associated markersof assault-related injuries that can be useful for risk assessment and targeted intervention. Interventionsneed to be brief if they are to engage these at-risk youth.© 2009 American Association of Oral and Maxillofacial Surgeons

J Oral Maxillofac Surg 67:2627-2635, 2009

*Research Psychologist, Health Risk Reduction Projects, Integrated Sub-

tance Abuse Programs, Department of Psychiatry, University of Califor-

ia, Los Angeles, CA.

†Professor, Section of Oral and Maxillofacial Surgery, University

f California, Los Angeles, CA.

‡Statistician, Section of Oral and Maxillofacial Surgery, University

f California, Los Angeles, CA.

§Project Director, Health Risk Reduction Projects, Integrated

ubstance Abuse Programs, Department of Psychiatry, University of

alifornia, Los Angeles, CA.

�Project Director, Health Risk Reduction Projects, Integrated Substance

buse Programs, Department of Psychiatry, University of California, Los

ngeles, CA.

¶Division Head, Division of Plastic and Maxillofacial Surgery,

Children’s Hospital of Los Angeles, CA.

#Director and Chairman, Department of Oral and Maxillofacial

Surgery, University of Southern California, Los Angeles, CA.

This research was supported by Grant #DE 16490 from the

National Institute of Dental and Craniofacial Research (to D.A.M.).

Address correspondence and reprint requests to Dr Murphy: De-

partment of Psychiatry, UCLA, 11075 Santa Monica Blvd, Suite 200,

Los Angeles, CA 90025-7539; e-mail: dmurphy@mednet.ucla.edu

© 2009 American Association of Oral and Maxillofacial Surgeons

0278-2391/09/6712-0012$36.00/0

doi:10.1016/j.joms.2009.07.053

2627

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2628 ADOLESCENTS AND OROFACIAL INJURIES

ver the past 2 decades, injury in children and ado-escents is increasingly recognized as an importantublic health problem.1,2 Between 2002 and 2004,dolescents 10 to 19 years of age had an average of 13illion emergency department visits in the US; initial

isits for injury constituted 42% of these visits.3

pirito et al4 found high rates of injury resulting fromalls (38%), sports and other physical activity (47%),nd cuts (58%), as well as fighting and assault (14.5%),n a community sample of adolescents. Although

uch of the research is focused on unintentionalnjury, there is growing interest in injuries attributableo violence, because of their disproportionate impactn vulnerable youth and the attendant morbidity andortality. In a predominantly African-American (75%)

ample of 100 adolescents and young adults (ageange 15 to 30 yrs) treated in an urban trauma center,edeker et al5 found that 89% of the injures derived

rom interpersonal violence and included firearm in-uries, stab wounds, and blunt trauma. At anotherrban level-one trauma center, 86% of youth reportedhysical violence, with the violence resulting in an

njury requiring medical attention in 22% of the cases.6

isk factors associated with the violent behaviors andictimization included depression, nonviolent delin-uency, and community exposure to violence. Rec-gnizing that some of these markers can be used to

dentify at-risk adolescents and can serve as the basisor secondary prevention efforts, organizations in-luding the American Academy of Pediatrics7 are ad-ocating that health professionals be involved proac-ively in the identification of these youth.

The use of alcohol and drugs, in particular, haseen closely linked with adolescent injury. Of alldolescents 13 to 19 years old admitted to a level-oneediatric trauma center, 34% screened positive forlcohol or drugs on admission.8 Another study ofdolescents admitted for trauma found that 48% hadositive blood alcohol levels.9 Rivara et al10 foundhat 41% of individuals 18 to 20 years old admitted forrauma had positive blood alcohol screen results. Theouth admitted for assault-related injuries were mostikely to be positive for substance use, with 49% of theouth having behavioral evidence of chronic alcoholbuse. Similarly, Loiselle et al8 found that recent usef alcohol was more common among adolescentsreated for intentional injury than those treated fornintentional injury. In a comprehensive study of

njury prevalence among adolescents in 35 countries,ickett et al2 determined that poverty was positivelyssociated with intentional injuries, and that alcoholse was positively and consistently associated with

nterpersonal violence, but not with school- andports-related injuries.

Although orofacial injuries comprise a distinct sub-

et of all injuries in adolescents, particularly urban b

inorities, even less is known about the antecedentisk factors for orofacial injury than for general injury.ordy et al11 found that in children and adolescentsresenting with traumatic orofacial injuries to an ur-an emergency department, the primary mechanismsf injury were falls and sports-related activities. In aommunity sample of Brazilian adolescents aged 13ears, orofacial injury was associated with male gen-er, non-nuclear family, high paternal punishment,nd poor school performance.12 In a hospital-basednglish sample matched to controls on age and gen-er, Odoi et al13 found dental injury more likelymong children with peer relationship problems. Ex-mining a broad range of adolescent injury, Jelalian etl and Lalloo et al reported that male gender, lowerocioeconomic status, single-parent home, hyperac-ivity, and conduct disorder were associated withccurrence of injury in a nationwide community sam-le of English children and adolescents between 4nd 15 years old (n � 5,913).14,15 The identification ofouth at risk for injury and reinjury is particularlyelevant to orofacial injury, which forms a distinctubset of injuries treated at urban trauma centers. Theace is a common target for interpersonal violence,nd thus orofacial injury, in vulnerable youth present-ng to urban trauma centers, is frequently considereds an empirical marker of an individual’s propensity toisk-taking behaviors.

Identifying the factors that place these subgroups ofouth at risk for violence and reinjury could set the stageor proactive intervention approaches that target thenderlying problem behaviors. To help guide such sec-ndary intervention strategies, we sought to clarify thessociation of possible risk (eg, substance use, criminalctivity) and protective factors (eg, family cohesion)pecific to intentional and unintentional injury amonginority adolescents seen at urban trauma centers. Con-

omitantly, we chose to assess the adolescents’ willing-ess to participate in prospective observational researchnd behavioral interventions focused on antecedent riskactors.

atients and Methods

PARTICIPANTS

We conducted interviews with a sample of 67 ad-lescents aged 14 to 20 years who presented to 2

evel-one trauma centers in Los Angeles County fromuly 2006 to March 2008. To be considered eligible,he adolescents had to meet the following inclusionriteria: received emergency treatment for orofacialnjury at either Los Angeles County/University ofouthern California Medical Center (LAC/USC) orhildren’s Hospital Los Angeles (CHLA) as verified

y hospital records; was under 21 years old at the

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MURPHY ET AL 2629

ime of treatment; was at least 14 years old at the timef interview; the injury occurred within the past 12onths; the injury affected the orofacial area; the

nterview could be conducted in English or Spanish;he adolescent/young adult consented (18 yrs orlder) or assented (14 to 17 yrs) to participation in thetudy. For patients under 18 years of age, a parent oregal guardian provided written permission for theirhild’s participation. The presence of injury in therofacial region was verified by clinician report. Ac-ording to clinician report, 59% of the adolescentsere treated for injuries that were assault related,

9% for motor vehicle or other accidents, 9% forunshot wounds, and 3% for sports injuries. Exclusionriteria were refused consent; injury was self-inflicted;dolescent/young adult was currently in detention byhe California Youth Authority; adolescent/youngdult was not physically or mentally capable of par-icipating in a 1-hour interview as determined byelf-report, parental report, or clinician report.

PROCEDURES

Clinic staff and project staff at the recruitment siteseviewed patient files, identified potentially eligibleamilies, and obtained verbal consent for the projectnterviewers to contact potential participants. In ad-ition, flyers and brochures for the project were dis-ributed so that interested patients could contacttudy staff directly. Institutional review board–ap-roved recruitment procedures differed slightly be-ween the 2 sites. Potentially eligible patients at LAC/SC with orofacial injuries were identified from the

rauma log at the hospital. At CHLA, potentially eligi-le patients were identified by the current proceduralerminology (CPT) recorded for them at the time ofhe emergency room visit. At both sites, potentiallyligible patients were then screened for eligibility inerson or by telephone and a time scheduled foronsent and interview if the patient screened eligible.ritten informed consent was obtained if the adoles-

ent was of legal age (�18 yrs); parental consent (inerson or by phone) and adolescent assent werebtained if the adolescent was a minor. Trained bilin-ual interviewers with prior experience interviewingdolescents conducted face-to-face interviews inhe clinic or at a convenient location closer to thearticipant’s home, depending on the preference ofhe participant or family. A majority of interviewsere conducted at LAC/USC and CHLA and the

nterviews averaged 1 hour in length. Interviewsere conducted separately in a private locationsing SCANTRON forms designed to be marked byen on paper and then scanned into an electronicatabase, which was then uploaded into the statis-

ical package for the social sciences (SPSS, Chicago, (

L) for analysis. All enrolled subjects received $35or their participation.

The screening procedures at the 2 hospitals variedn efficiency for recruitment purposes. At CHLA, 356dolescents who were treated in the emergency roomithin the past 12 months were identified as poten-

ially eligible using CPT codes. When the criteria ofnjury only (excluding congenital orofacial abnormal-ty and disease) and specificity to the orofacial regionexcluding injuries to the head and neck) were ap-lied to the 356 potential cases, 179 remained eligi-le. Of those 179 patients, 8 refused to participate, 17ompleted interviews, and the remainder had movedr had their phones disconnected since their treat-ent at CHLA. LAC/USC differed from CHLA in that

dolescents were identified through trauma logs andost were informed about the study at the time of

reatment, although the time between injury date andnterview did not differ by study site. Of 108 poten-ially eligible LAC/USC patients, 31 declined to partic-pate; 27 screened ineligible, and 50 completed inter-iews for the study. Overall, more than half (54%) ofhe interviews occurred within 1 month after thenjury date reported on the admission form; 80% ofnterviews occurred within 2 months after the injury;0% of interviews occurred within 6 months after the

njury; and 100% occurred no more than 9 monthsfter the injury. Consequently, most of the orofacialnjuries for which adolescents were treated were cap-ured on the adolescent injury checklist (AIC) de-cribed below.

MEASURES

Injury TypeThe AIC was used to assess the type of injuries (eg,

alls, motor vehicle accidents, intentional injuries) ad-lescents experienced in the past 6 months. The AIC

s an established self-report measure that assesses 16ypes of injuries and the circumstances associatedith these injuries.14 Two types of injuries, “being inphysical fight with someone” and “being physically

ttacked” were combined to estimate the extent thatdolescents experience intentional injuries.

Family FunctioningEight of the 15 subscales comprising the Family

unctioning Scale16 were used: family cohesion, ex-ressiveness, conflict, sociability, disengagement,emocratic style, laissez-faire style, and authoritariantyle. The scales consist of 5 items each with adoles-ents/young adults rating the degree to which eachtem was “like” his or her family on a 4-point responsecale (“Not at all like my family” to “Very much or justike my family”). For the current study, alphas wereohesion (0.78); sociability (0.63); expressiveness

0.60); conflict (0.38); disengagement (0.41); laissez-

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2630 ADOLESCENTS AND OROFACIAL INJURIES

aire style (0.61); democratic style (0.46), and author-tarian style (0.07). Conflict, disengagement, and dem-cratic and authoritarian style subscales wereropped from the study and not included in the anal-ses, due to the low alphas.

Substance-Related ProblemsThe CRAFFT17 is a 6-item screen for lifetime sub-

tance-related problems specifically validated for useith adolescents. The name is a mnemonic of the first

etters of key words in the test’s 6 questions (eg, “c”s from the first question: “Have you ever ridden in aar driven by someone who was high”). A validationtudy with 538 participants aged 14 to 18 years pro-uced a sensitivity of 0.76 and a specificity of 0.94 for

dentification of any problem, a sensitivity of 0.80 andpecificity of 0.86 for any disorder, and a sensitivity of.92 and specificity of 0.80 for dependence.17 For thistudy, the CRAFFT was internally consistent, with aronbach’s alpha of 0.87.

Alcohol UseThe Alcohol Use Disorders Identification test (AUDIT)18

as used to assess problem drinking in the past year.he AUDIT is a 10-item instrument developed by theorld Health Organization and designed to assess 3

elated constructs: alcohol consumption, drinking-re-ated problems, and alcohol dependence. The AUDITs widely used and has excellent reliability and validitys a screening instrument for use in medical settingso assess potentially hazardous drinking.19 Two stud-es20,21 assessed adolescents under treatment in emer-ency departments and found a 2-factor structure,ith alcohol dependence not a separate factor for

dolescents/young adults, based on work with indi-iduals aged 12 to 20 years and a Cronbach � of.86.21 The � value for the 67 adolescents in theurrent sample was 0.86.

Drug HistoryEach participant was asked a series of questions

egarding that participant’s use of specific illegalrugs, alcohol, and tobacco to determine the follow-

ng: age at first use, age at which that individual beganegular use, how many months ago was the mostecent use, how many days of the past 30 was theubstance used, how many days ago was the mostecent use, and how many days ago was the mostecent medical use. The instrument assessed for usef inhalants, marijuana, hallucinogens, amphetamines,arbiturates, heroin, other opiates, crack, cocaine,ranquilizers, PCP, synthetic drugs, any alcohol, andlcohol to intoxication (5 or more drinks per sitting).or the present analyses, any lifetime use, and use

n the past 30 days of tobacco, alcohol, alcohol use w

o intoxication, and marijuana/hashish use werexamined.

CrimeA series of 8 items assessed number of arrests,

harge at time of arrest, age at first arrest, number ofonvictions, number of incarcerations, and whetherhese occurred before age 18 or before the first use ofocaine or narcotics.

Willingness to Participate in Researchand InterventionsTo assess their willingness to participate in obser-

ational research studies, participants were asked toate, on a 4-point scale ranging from “definitelyould” to “definitely wouldn’t,” how willing theyould be to participate in studies with interview

ontent similar to the interview they had just com-leted that contained: 1) zero follow-ups; 2) 1 follow-p; and 3) 2 follow-ups. Subjects were asked theeasons for their choices. To assess their willingnesso participate in intervention studies of causes, out-omes and prevention of facial injuries in adolescents,he same 4-point scale was used to evaluate 4 possibleypes of intervention: 1) single 10- to 20-minute sessionith a clinician face-to-face; 2) 2 sessions, 1 face-to-face

nd a phone follow-up; 3) an hour-long counseling ses-ion face-to-face; 4) 2 hour-long sessions, 1 week apart.he participants were also asked to provide the reasons

or their choices. Three open-ended questions con-luded the evaluation of willingness to participate inuture research: what the participant liked and did notike about the alternatives for interviews and clinicianessions offered; what would be improvements in thelternatives offered; and what interventions might betterddress the problems or circumstances that led to thearticipant’s injury.

DATA ANALYSES

�2 tests and t tests were conducted to examine thessociation of injury type (ie, assault-related, com-ared with unintentional injury as reported on theIC) with adolescent demographic characteristics,

amily variables, substance use, arrests, and criminalehavior. �2 tests and t tests were conducted to ex-mine factors associated with adolescents’ willing-ess (definitely or probably) to participate in a 2-ses-ion counseling intervention each lasting 45 to 60inutes compared with those who were definitely orrobably not willing to attend this type of interven-ion. Logistic regression analyses were performed tossess which factors were most strongly associated

ith willingness to participate in the intervention

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hile controlling for other relevant factors. Unlesstherwise indicated, the significance level (2-tailed)as set at P less than .05.

esults

PARTICIPANTS

The background and sociodemographic character-stics of the patient population by injury type areummarized in Table 1. Overall, patients were pre-ominately male (86%), with an average age of 17.8ears (range 14 to 20 yrs). The ethnic makeup of thearticipants was primarily Latino/Latina (72%), andhe remainder primarily African American (19%). Six-een percent were born outside the US, but noneeported that he or she was more comfortable speak-ng Spanish than English. Approximately half (52%) ofhe adolescents reported that they were not currentlyn school; 9% were currently enrolled in 10th grade,0% in 11th grade, and 20% in 12th grade. Thirtyercent were currently employed and an additional4% were seeking employment. Of those who weremployed, 11% reported working full-time (35 orore hours per week), and most were employed in

Table 1. ADOLESCENT DEMOGRAPHIC AND FAMILY VAR

Unintention(% or

enderMale 75.Female 24.ean (SD) age 17.3

thnicityAfrican American 10.Mexican 65.South or Central American 6.Other 17.

rade*10th 22.11th 31.12th 22.Not in school now 22.

ountry of birthUS 81.Other 18.

amily member has/had alcohol problem 17.amily member has/had drug problem 20.umber of close friends who ever had drug

problemsNone 55.One 41.Two or more 3.ean (SD) family cohesion score 12.45

Study sample is 67 but for grade there are 9 missing.

urphy et al. Adolescents and Orofacial Injuries. J Oral Maxillof

nskilled or low-skilled occupations such as shipping, n

tocking, movie theater work, babysitting, or furni-ure delivery. Adolescents who experienced assault-elated injuries were more likely to be male, older,nd not in school. African American and South/Cen-ral American youth had marginally higher rates ofntentional injuries than those from other racial/eth-ic groups. Family members of youth who were as-aulted also had a higher rate of alcohol problems.

INJURY-RELATED RISK BEHAVIORS

As reported on the Adolescent Injury Checklist, theost frequent cause of injury was “being in a physical

ght with someone” (46%). “Being physically at-acked” (40%) was the second most common re-orted cause of injury. Fifty-six percent of adolescentseported having been intentionally injured in a fightr physical attack in the past 6 months. Although noteported as intentional, 13% of adolescents reportednjuries resulting from gunshots (eg, bystander inang shooting), cuts, or having been hit by objectsuch as rocks or glass. Other causes of injury werealls (25%), riding a bike, skateboarding or rollerblad-ng (25%), and sports injuries (19%) (categories were

S BY TYPE OF INJURY IN PAST 6 MONTHS (n � 67)*

riesAssault-Related

Injuries(% or mean) Statistical Test

�2(1) � 4.8, P � .02894.6%5.4%

18.1 (1.4) t(64) � �2.05, P � .044�2(3) � 7.9, P � .075

24.3%56.8%16.2%2.7%

�2(3) � 12.1, P � .0072.8%

13.9%16.7%66.7%

�2(1) � 0.6, P � .43885.0%15.0%40.5% �2(1) � 4.2, P � .04135.1% �2(1) � 1.7, P � .198

�2(2) � 3.7, P � .16137.8%45.9%16.2%

11.95 (2.30) t(64) � 0.91, P � .368

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2632 ADOLESCENTS AND OROFACIAL INJURIES

Extensive data on drug and alcohol use by injuryype are summarized in Table 2. All but 8% of thearticipants had used alcohol, and 41% had used itithin the 30 days before the interview. Two thirds

66%) had used alcohol to intoxication. More partici-ants had smoked marijuana (66%) than tobacco59%); among marijuana users, 36% had used mari-uana in the 30 days before the interview. The meanSD) CRAFFT score for participants was 2.54 (2.27),bove the cut-point of 2.0 for identification of prob-em substance abuse in this population. More thanalf (55%) of the enrolled subjects scored 2.0 origher on the CRAFFT screener. The mean (SD) AUDITcore of 5.95 (7.02) was well below the cut-point of 8or problem identification and also well below theean (SD) score of 7.74 (7.14) for a sample of 103

dolescents (mean age 17.5 yrs; 80% white) who hadlso received treatment in emergency departments.ates of recent tobacco, alcohol, and drug use were

Table 2. DRUG AND ALCOHOL USE AMONG ADOLESCE

Unintentional Injuries(% or mean)

Lifetime use*Tobacco 44.8%Any alcohol 86.2%Alcohol to intoxication 58.6%Marijuana/hashish 55.2%Used in last 30 days†

Tobacco 11.1%Alcohol 19.2%Alcohol to intoxication 13.8%Marijuana/hashish 10.3%ean (SD) AUDIT score 3.8 (4.8)ean (SD) CRAFFT score 2.0 (2.2)

Based on the question, “How old were you the first time yBased on the question: “How long ago did you last use [d

urphy et al. Adolescents and Orofacial Injuries. J Oral Maxillof

Table 3. ANY ARRESTS AND TYPE OF CRIME WHEN AR

Unintentiona

ny arrests (n � 67) 55.6%ype of crime (n � 38)Assault and battery 14.3%Weapons violations 14.3%Vandalism 7.1%Truancy, curfew 14.3%Theft 21.4%Robbery 0%Alcohol and drugs 21.4%Probation violation, obstructing justice 7.1%

A total of 55.2% (38 of 67) reported being arrested.

urphy et al. Adolescents and Orofacial Injuries. J Oral Maxillofac Sur

igher for adolescents with assault-related injuries.he mean AUDIT score was also significantly higher

or youth who were assaulted.A majority of the participants had been arrested at

east once (55%). A larger majority (64%) had relativesho had been arrested, and 80% reported that one orore of their close friends had been arrested. Reasons

or arrest ranged from school truancy and curfewiolations to assault with a weapon, grand theft, andobbery. No statistically significant differences in ad-lescent arrests were observed for youth who re-orted intentional or unintentional injuries (Table 3).

WILLINGNESS TO PARTICIPATE IN OBSERVATION/INTERVENTION RESEARCH

Most adolescents/young adults in the study ex-ressed willingness to participate in research studiesn topics similar to the current study. Scenarios forbservational studies were most acceptable to the

Y INJURY TYPE (n � 67)

Assault-RelatedInjuries

(% or mean) Statistical Test

67.6% �2(1) � 3.4, P � .06497.3% �2(1) � 2.9, P � .09173.0% �2(1) � 1.5, P � .22073.0% �2(1) � 2.3, P � .132

40.0% �2(1) � 4.6, P � .03146.3% �2(1) � 5.1, P � .02421.6% �2(1) � 0.8, P � .41335.1% �2(1) � 5.4, P � .020

7.4 (8.0) t(60) � �2.07, P � .0432.9 (2.3) t(64) � �1.61, P � .112

ed [drug/alcohol]?”cohol]?” Reported percentage is among users.

g 2009.

D FOR FIRST TIME BY INJURY TYPE*

iesAssault-Related

Injuries Statistical Test

57.5% �2(1) � .0, P � .898�2(7) � 6.2, P � .515

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MURPHY ET AL 2633

articipants, with 80% reporting they definitely orrobably would join a study “with interview contentimilar to the one just completed,” 77% expressingillingness if that study also included a single fol-

ow-up 3 to 6 months later, and 79% willing to join ifhere were 2 or more follow-up interviews occurringver the next 12 months.Intervention research scenarios were less accept-

ble: 72% definitely or probably would participate insingle session of clinician advice (10 to 20 min,

ace-to-face); 68% were willing to participate in 2essions of clinician advice, 1 month apart (10 to 20in face-to-face for the first session and 5 to 10 min byhone for the second session); 61% would participate

n a single face-to-face counseling session lasting 45 to0 minutes; 55% were willing to participate in 2ace-to-face counseling sessions lasting 45 to 60 min-tes and scheduled 1 week apart. When asked torovide reasons for their choices in an open-endeduestion, the most frequent reason for disliking theounseling scenarios was that it was more comfort-ble to deal with the psychology of trauma and toxpress personal feelings in a relatively short, multi-le-choice format rather than a longer, open-endedounseling format in which the individual is expected

Table 4. ADOLESCENTS’ CHARACTERISTICS ASSOCIATECOUNSELING INTERVENTION*

Unwilling to Pa(% or mea

ssault (vs unintentional) injuries 69.4%ean (SD) age 17.89

thnicityAfrican American 22.2%Mexican 69.4%South or Central American 8.3%Other 0.0%ean (SD) family cohesion score 11.61 (2.3ean (SD) AUDIT Score 7.49 (7.8ean (SD) CRAFFT score 3.08 (2.2

ifetime tobacco use 72.2%ifetime alcohol use 97.2%ifetime alcohol use to intoxication 77.8%ifetime marijuana use 75.0%amily member has/had alcohol

problem 41.7%amily member has/had drug problem 38.9%umber of close friends who ever had

drug problemsNone 38.9%One 41.7%Two or more 19.4%

ny arrests 63.9%

No significant differences in willingness to participate in airth, grade/school attendance, or recent tobacco, alcohol,

urphy et al. Adolescents and Orofacial Injuries. J Oral Maxillof

o express his or her feelings and deal with them at 1

ength. When asked if they would be willing to join atudy in which adolescents were randomized to theype of care that they received, 13% said that theyefinitely would and 61% said that they probablyould.The cohesion subscale of the Family Functioning

cale significantly related to whether the adolescent/oung adult reported willingness to participate in a-session counseling intervention (2 face-to-face ses-ions 1 week apart, each 45 to 60 min), the mostntensive and least accepted of the intervention pos-ibilities presented to participants. In addition, injuryype, adolescent race/ethnicity, lifetime tobacco use,amily alcohol problems, drug problems among closeriends, the CRAFFT score, and the AUDIT score werelso predictive of willingness to participate in theost intensive intervention scenario (Table 4). Inultivariate logistic regression analyses, independent

ariables significantly (P � .05) related to whether theatient expressed a willingness to participate in fu-ure intervention research were the cohesion sub-cale of the FFS and injury type. The multivariateogistic regression equation that was the best fit to theata indicated that the combination of greater familyohesion (odds ratio � 1.30, 95% confidence interval �

H WILLINGNESS TO PARTICIPATE IN A

te Willing to Participate(% or mean) Statistical Test

41.4% �2(1) � 5.2, P � .02317.52 T(63) � 0.96, P � .343

�2(3) � 10.3, P � .01613.8%48.3%17.2%20.7%

12.83 (2.02) t(63) � �2.24, P � .0293.88 (5.09) t(59) � 2.03, P � .0471.83 (2.09) t(63) � 2.29, P � .026

41.4% �2(1) � 6.3, P � .01286.2% �2(1) � 2.7, P � .09855.2% �2(1) � 3.8, P � .05355.2% �2(1) � 2.8, P � .093

17.2% �2(1) � 4.5, P � .03417.2% �2(1) � 3.6, P � .056

�2(2) � 6.6, P � .03755.2%44.8%

0.0%48.3% �2(1) � 1.6, P � .206

rvention were observed by adolescent gender, country ofol use to intoxication, or drug use.

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.01 to 1.68, P � .048) and unintentional, rather

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2634 ADOLESCENTS AND OROFACIAL INJURIES

han assault-related injuries (odds ratio � 0.32, 95%onfidence interval � 0.11 to 0.93, P � .036) pre-icted adolescents’ willingness to participate in theounseling intervention.

iscussion

This study assessed adolescents presenting withrofacial injury to 2 urban trauma centers who com-rised a primarily male (86%), minority sample (72%atino/Latina, 19% African American; 16% born out-ide of the United States) whose mean age was 17.8ears. The study was conducted to identify risk fac-ors and problem behaviors associated with assault-elated (compared with unintentional) injuries. In ad-ition, we surveyed the participants for motivationnd willingness to participate in proactive, secondaryrevention approaches that would target any escalat-

ng causal behaviors for interruption and interven-ion. Most of the orofacial injuries in this sample werententional in nature, either through violent actionsie, being in a physical fight with someone) or victim-zation (ie, being physically attacked). This finding isn sharp contrast to other surveys of adolescent inju-ies in majority populations,22,23 which tend to reportostly accidental or sports injuries. Factors that dis-

inguished these at-risk, predominantly ethnic minor-ty youth who experienced assault-related injuriesrom those with unintentional injuries included un-ealthy alcohol use (ie, higher AUDIT scores), highates of recent substance use, and having a familyistory of alcohol problems.Similar to previous findings in adult populations,24

ubstance use was fairly high among this sample ofdolescents. The mean screening score for substancese indicated problem-level behaviors for this sample,ith more than half of the adolescents scoring above

he cut-point. Although the mean score on the screenpecific to alcohol use was below problem level be-avior indications, it should be noted that 46% ofdolescents with assault-related injuries reportedrinking within the past month, and 22% reportedsing alcohol to the point of intoxication within theast 30 days. These data indicate that problem sub-tance use patterns may be developing in adolescentsho have experienced assault-related injury. As Li et

l25 noted, alcohol dependence (alcoholism) is bestnderstood as a chronic disease with a peak onset byhe age of 18.

Notably, among this sample of urban youth, mostrofacial injuries were from assault or victimization,

ndicating a critical need for violence prevention in-ervention efforts with this population. An alarmingnding from this study was the high rate of previouselinquency for both injury types. A majority of the

njured adolescents had been arrested at least once, l

nd some of these arrests were for serious crimesassault and battery, 14%; weapons violations, 14%).ll of these findings indicate there is a tremendouseed for intervention among this inner-city popula-ion of adolescents treated at trauma centers, whichould include approaches from crime-prevention,amily-based intervention, and injury prevention mod-ls of treatment. Moreover, in addition to the need forntervention to prevent future reinjury, a significantubset of these at-risk youth also needs interventionhat addresses their substance use. In fact, a strongssociation of alcohol/drug use with injury andith reinjury among adult trauma patients26-32 hasrompted investigators to argue for treating traumaenter admission as a secondary symptom of under-ying substance use problems. Any efforts to reducehe risk of reinjury are unlikely to be successful if thenderlying problem is not addressed.One objective of this study was to assess the will-

ngness of the injured youth to participate in inter-entions addressing the underlying risk behaviors. Weound that although youth were highly willing toarticipate in survey-only studies (such as the currenttudy), they were less willing to participate in inter-entions, especially if these would entail more than 1ession. This willingness was related to family func-ioning—specifically, the family cohesion subscale,ith greater cohesion predicting a greater likelihoodf being willing to participate. In addition, a greaterillingness was observed for adolescents whose inju-

ies were assault-related rather than unintentional,nd those with lower problematic substance use.owever, these are the youth less likely to need

reatment, who may not benefit as much. For exam-le, previous studies have found that more seriousdolescent substance users are motivated better tohange at the outset of treatment and experienceore rapid declines in substance use after treatment

egins.33

Consistent with the recommendations of the Amer-can Academy of Pediatrics and other organizations,iolence risk–screening protocols need to be inte-rated into the care of adolescents with orofacialnjuries treated at urban trauma centers. A history ofubstance use problems, detected by brief screensuch as the AUDIT, is a likely indicator that adoles-ents with orofacial injury should be referred forntervention. Knowledge of the risk factors as well asensitivity to the willingness of the patient should beritical in choosing a target intervention. In previoustudies, adolescent willingness to participate in anntervention trial (eg, a human immmunodeficiencyirus vaccine trial) has been related to the length ofhe adolescents’ community involvement and the pre-alence of risk in their community.34 Thus, for ado-

escent orofacial injury associated with violence and/

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MURPHY ET AL 2635

r substance use, information presented at the time ofnjury that addresses these factors may motivate youtho seek treatment.

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