Event-level analysis of antecedents for youth violence: Comparison of dating violence with...

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Short Communication Event-level analysis of antecedents for youth violence: Comparison of dating violence with non-dating violence Quyen M. Epstein-Ngo a,b,c, , Maureen A. Walton b,c , Stephen T. Chermack c,d , Frederic C. Blow c,d , Marc A. Zimmerman b,e , Rebecca M. Cunningham b,e,f a University of Michigan Institute for Research on Women and Gender, University of Michigan, Ann Arbor, MI 48109, USA b University of Michigan Injury Center, University of Michigan, Ann Arbor, MI 48105, USA c University of Michigan Addiction Research Center, Department of Psychiatry, University of Michigan, Ann Arbor, MI 48105, USA d Serious Mental Illness Treatment Research Evaluation Center (SMITREC), VA Ann Arbor Healthcare System, Ann Arbor, MI 48105, USA e Department of Health Behavior and Health Education, School of Public Health, University of Michigan, Ann Arbor, MI 48109, USA f Department of Emergency Medicine, University of Michigan, Ann Arbor, MI 48105, USA HIGHLIGHTS Examination of differences in antecedents of dating versus non-dating violence. Prescription sedative/opioid misuse more likely prior to dating violence. Alcohol, co-ingested alcohol/marijuana more likely prior to non-dating violence. Reasons differed based on type of violence (dating versus non-dating violence). Gender interactions found. abstract article info Keywords: Adolescents Violence Reasons Substance use Background: Dating violence (DV) has emerged as a major concern among youth with links to substance use, injuries, and death. The emergency department (ED) provides an opportunity for violence screening and preven- tion interventions. Additional data are needed regarding antecedents of DV versus non-dating violence (NDV; e.g., acquaintance, stranger) to develop ED-based violence interventions for youth. Methods: Participants were 575 patients screening positive for past 6-month drug use in an urban ED who completed timeline follow-back aggression modules at baseline and 6- and 12-months, indicating event- specic antecedents of violence. Multi-level logistic regressions using event-level data, nested by individual and time (i.e. baseline, 6- and 12-month assessment intervals), were used to examine antecedents of DV vs. NDV. Post-hoc analyses examined substance use × reasons and gender interactions. Results: Prescription sedative/opioid misuse was more likely to be reported prior to DV whereas alcohol only, and co-ingested alcohol and marijuana only, were more likely to be reported prior to NDV. Reasons for DV included: personal belongings, angry/bad mood,”“jealousy,”“drunk/high on drugsand arguing about sex. Reasons for NDV included: rumors,”“retaliation,”“personal spaceand aid (someone) due to physical attack. Substance use before/during conicts and reasons for conicts were both uniquely associated with DV versus NDV. Two gender interactions were found. Conclusions: ED based interventions for urban youth need to be tailored by gender, substance use (alcohol, cocaine, sedatives), reasons for violence, and type of violence (DV vs. NDV). © 2013 Elsevier Ltd. All rights reserved. 1. Introduction Dating violence (DV) has emerged as a serious concern among youth (Healthy People: Topics and Objectives, 2010). Evidence suggests that youth often report involvement in more than one type of violence [e.g. DV; non-dating violence (NDV) acquaintance, friend] (Foshee et al., 2011; Vagi et al., 2013; Whiteside et al., 2013). Studies have consistently shown an association between substance use and vio- lence (Chermack & Blow, 2002; Epstein-Ngo et al., 2012; Rothman, McNaughton Reyes, Johnson, & LaValley, 2012; Testa, Quigley, & Leonard, 2003; Walton et al., 2009; White, Jackson, & Loeber, 2009). For example, previous studies using daily calendars show that alcohol and drugs are more likely to be used on days in which DV or NDV occurs Addictive Behaviors 39 (2014) 350353 Corresponding author at: University of Michigan Addiction Research Center, Department of Psychiatry, 2800 Plymouth Rd., Bldg. 16 200S-02, Ann Arbor, MI 48109, USA. Tel.: +1 734 232 0296; fax: +1 734 998 7992. E-mail address: [email protected] (Q.M. Epstein-Ngo). 0306-4603/$ see front matter © 2013 Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.addbeh.2013.10.015 Contents lists available at ScienceDirect Addictive Behaviors

Transcript of Event-level analysis of antecedents for youth violence: Comparison of dating violence with...

Addictive Behaviors 39 (2014) 350–353

Contents lists available at ScienceDirect

Addictive Behaviors

Short Communication

Event-level analysis of antecedents for youth violence: Comparison of dating violencewith non-dating violence

Quyen M. Epstein-Ngo a,b,c,⁎, Maureen A. Walton b,c, Stephen T. Chermack c,d, Frederic C. Blow c,d,Marc A. Zimmerman b,e, Rebecca M. Cunningham b,e,f

a University of Michigan Institute for Research on Women and Gender, University of Michigan, Ann Arbor, MI 48109, USAb University of Michigan Injury Center, University of Michigan, Ann Arbor, MI 48105, USAc University of Michigan Addiction Research Center, Department of Psychiatry, University of Michigan, Ann Arbor, MI 48105, USAd Serious Mental Illness Treatment Research Evaluation Center (SMITREC), VA Ann Arbor Healthcare System, Ann Arbor, MI 48105, USAe Department of Health Behavior and Health Education, School of Public Health, University of Michigan, Ann Arbor, MI 48109, USAf Department of Emergency Medicine, University of Michigan, Ann Arbor, MI 48105, USA

H I G H L I G H T S

• Examination of differences in antecedents of dating versus non-dating violence.• Prescription sedative/opioid misuse more likely prior to dating violence.• Alcohol, co-ingested alcohol/marijuana more likely prior to non-dating violence.• Reasons differed based on type of violence (dating versus non-dating violence).• Gender interactions found.

⁎ Corresponding author at: University of MichiganDepartment of Psychiatry, 2800 Plymouth Rd., Bldg. 16USA. Tel.: +1 734 232 0296; fax: +1 734 998 7992.

E-mail address: [email protected] (Q.M. Epstein-N

0306-4603/$ – see front matter © 2013 Elsevier Ltd. All rihttp://dx.doi.org/10.1016/j.addbeh.2013.10.015

a b s t r a c t

a r t i c l e i n f o

Keywords:

AdolescentsViolenceReasonsSubstance use

Background: Dating violence (DV) has emerged as a major concern among youth with links to substance use,injuries, and death. The emergency department (ED) provides an opportunity for violence screening and preven-tion interventions. Additional data are needed regarding antecedents of DV versus non-dating violence (NDV;e.g., acquaintance, stranger) to develop ED-based violence interventions for youth.Methods: Participants were 575 patients screening positive for past 6-month drug use in an urban ED who

completed timeline follow-back aggression modules at baseline and 6- and 12-months, indicating event-specific antecedents of violence. Multi-level logistic regressions using event-level data, nested by individualand time (i.e. baseline, 6- and 12-month assessment intervals), were used to examine antecedents of DV vs.NDV. Post-hoc analyses examined substance use× reasons and gender interactions.Results: Prescription sedative/opioidmisusewasmore likely to be reported prior to DVwhereas alcohol only, andco-ingested alcohol andmarijuana only, were more likely to be reported prior to NDV. Reasons for DV included:“personal belongings”, “angry/bad mood,” “jealousy,” “drunk/high on drugs” and “arguing about sex”. Reasonsfor NDV included: “rumors,” “retaliation,” “personal space” and “aid (someone) due to physical attack”.Substance use before/during conflicts and reasons for conflicts were both uniquely associated with DV versusNDV. Two gender interactions were found.Conclusions: ED based interventions for urban youth need to be tailored by gender, substance use (alcohol,cocaine, sedatives), reasons for violence, and type of violence (DV vs. NDV).

© 2013 Elsevier Ltd. All rights reserved.

1. Introduction

Dating violence (DV) has emerged as a serious concern amongyouth (Healthy People: Topics and Objectives, 2010). Evidence suggests

Addiction Research Center,200S-02, Ann Arbor, MI 48109,

go).

ghts reserved.

that youth often report involvement in more than one type of violence[e.g. DV; non-dating violence (NDV) — acquaintance, friend] (Fosheeet al., 2011; Vagi et al., 2013; Whiteside et al., 2013). Studies haveconsistently shown an association between substance use and vio-lence (Chermack & Blow, 2002; Epstein-Ngo et al., 2012; Rothman,McNaughton Reyes, Johnson, & LaValley, 2012; Testa, Quigley, &Leonard, 2003; Walton et al., 2009; White, Jackson, & Loeber, 2009). Forexample, previous studies using daily calendars show that alcoholand drugs aremore likely to be used on days inwhichDVor NDVoccurs

Table 1Sample demographics and characteristics.

Demographics Female(n=237, 41.2%)

Male(n=338, 58.8%)

Total(N=575)

Age 20.0 (2.3) 20.0 (2.5) 20.0 (SD=2.4)African-American 145 (61.2%) 198 (58.6%) 343 (59.7%)Caucasian/Other 92 (38.8%) 140 (41.4%) 232 (40.3%)Public assistance*** 196 (82.7%) 222 (65.7%) 418 (72.7%)Live with parents*** 91 (38.4%) 187 (55.3%) 278 (48.4%)Drop out of school 66 (27.9%) 106 (31.4%) 172 (29.9%)Some college** 69 (29.1%) 80 (23.7%) 149 (25.9%)Any violence 207 (87.3%) 290 (85.8%) 497 (86.4%)Dating violence*** 178 (75.1%) 186 (55.0%) 364 (63.3%)Non-dating violence** 161 (67.9%) 269(79.6%) 430(74.8%)Both dating andnon-dating

132 (55.7%) 165 (48.8%) 297 (51.7%)

Any alcohol 153 (64.5%) 229(67.8%) 382 (66.4%)Any marijuana 228 (96.2%) 331 (97.9%) 559 (97.2%)Any other illicit drug 21 (8.9%) 40(11.8%) 61 (10.6%)Prescription sed/opioidmisuse

34 (14.4%) 65 (19.2%) 99 (17.2%)

351Q.M. Epstein-Ngo et al. / Addictive Behaviors 39 (2014) 350–353

than on days when there is no violence (Epstein-Ngo et al., 2012;Stoddard et al., Submitted for publication).

It is not clear, however, how substance use may differ for DV versusNDV (Epstein-Ngo et al., 2012; Rothman, Stuart, et al., 2012). This infor-mation could inform youth violence interventions, particularly amongthose involved in violence across multiple relationships. This studyuses event-level data to examine substance use immediately precedingDV conflicts and the reasons for DV among high-risk, urban youth. Anal-yses of alcohol/illicit drug use and DV versus NDVwere exploratory dueto mixed findings in the literature (Chermack et al., 2010; Chermack,Walton, Fuller, & Blow, 2001). We expected prescription sedative/opioid use would be more likely prior to DV as females are more likelyto be involved with DV and to misuse prescription medications (Boyd,McCabe, Cranford, & Young, 2007; Epstein-Ngo et al., 2012), and thatmarijuana use would not differ prior to DV versus NDV (Chermacket al., 2010; Epstein-Ngo et al., 2012). Based on prior work, exploratoryanalyses examined a comprehensive list of reasons for violence. Finally,we conducted post-hoc analyses exploring gender interactions andsubstance use× reasons interactions (DV versus NDV).

Bivariate gender differences: **pb.01; ***p,.001.

2. Methods

2.1. Participants

The sample included 575 participants; mean (SD) age: 20.0 (2.4);41.2% female; 59.7% African American; 72.7% receive public assistance[see Table 1; the original study included 600 participants; we excluded1 due to missing calendar data and 24 who were married given ourfocus on DV (Shorey, Cornelius, & Bell, 2008)].

2.2. Procedures

Data for this study came from the Flint Youth Injury Study, aprospective study of substance use and violence among youth treatedin an urban emergency department. The design included oversamplingpatients (14–24 years) presenting to the ED for violent injury(i.e., assault-related) and reporting past 6-month substance use. A pro-portionally age- and gender-sampled comparison group was recruited,consisting of those treated in the ED for other medical complaints andpast 6-month substance use (see Epstein-Ngo et al., 2012 for details).Participants completed assessments at baseline and 6- and 12-monthsafter the ED visit.

2.3. Measurement

2.3.1. Dating violenceThe TLFB — Aggression Module (TLFB-AM) assessed daily acts of

physical aggression in the past 90days [adapted CTS-2 physical assaultscale; (Chermack & Blow, 2002; Chermack, Wryobeck, Walton, &Blow, 2006; Straus, Hamby, BoneyMcCoy, & Sugarman, 1996)], includ-ing: a) by whom (e.g., self, partner, acquaintance) (Chermack et al.,2010); b) reasons for each conflict (i.e., “What was the reason for thefight?”) with up to 17 response options; and c) substance use immedi-ately before or during the conflict [1) alcohol only, 2) marijuana only,3) alcohol andmarijuana only, 4) any other illicit drugs (with orwithoutalcohol, marijuana, and/or prescription drug misuse), and 5) any pre-scription sedative/opioidmisuse1 (with orwithout alcohol ormarijuanause, but excluding non-marijuana illicit drug usewhichwas included incategory 4)].

1 Prescription sedative/opioid misuse was defined as more than prescribed, for longerthan prescribed (medical misuse) or without a prescription (non-medical use).

2.3.2. Aggregate measures of violenceDV andNDV in the6monthsprior to the ED visitwere assessedusing

a modified version of the physical assault scale of the CTS-2 (Strauset al., 1996).

2.3.3. Aggregate measures of substance useFrequency of drug use in the 6 months prior to ED visit was

assessed using the Alcohol, Smoking and Substance Use InvolvementScreening Tests [ASSIST; (The Alcohol, Smoking, Substance InvolvementScreening Test (ASSIST): development, reliability, & feasibility, 2002;Humeniuk et al., 2008)]. Response options ranged from “never” (0) to“daily or almost daily” (6).

Past 6-month alcohol use was assessed using the Alcohol Use Disor-ders Identification Test — Consumption [AUDIT-C; (Bush, Kivlahan,McDonell, Fihn, & Bradley, 1998)].

2.3.4. DemographicsDemographic characteristics (age, sex, race, ethnicity, and receipt of

public assistance) were assessed (Harris et al., 2003).

2.4. Data analysis

Because this study focuses on the characteristics of conflict incidents(i.e., not characteristics of individuals), conflicts reported by participantsin the 90 days prior to baseline, 6-month, and 12-month assessmentswere combined and analyzed cross-sectionally usingmulti-level, multi-nomial logistic regressions, with data nested by individual and assess-ment time point (Raudenbush & Bryk, 2002). We first separatelytested associations between alcohol/drugs used immediately prior toconflicts and the type of conflict, and then reasons for conflicts andtype of conflict (DV versus NDV). Significant reasons and substanceuse were then included in the same model to test whether reasonsand substance use were uniquely associated with type of violencewhen both factors were included (see Appendix A for model equations;prescription sedatives and opioidswere combined due to low base ratesof misuse). We then ran post-hoc interaction analyses to exploregender differences and possiblemotivation×substanceuse interactions,including race, age, and gender as covariates.

3. Results

Fifty-eight percent presented to the ED with a violent injury(n= 336). Aggregate measures of physical violence (CTS-2) indicated

Table 2Full model multilevel logistic regression: substance use prior to conflict and reasons forconflict predicting dating violence vs. non-dating violence.a

Predictors AOR (95% CI) p-Value

Age 1.54 (1.32, 1.79) 0.000⁎⁎⁎

Gender 77.71 (25.83, 233.81) 0.000⁎⁎⁎

Race group (African-American) 2.16 (0.55, 8.55) 0.271Alcohol use 0.23 (0.11, 0.46) 0.000⁎⁎⁎

Marijuana and alcohol use 0.48 (0.25, 0.92) 0.027⁎

Prescription sed/opioid misuse 9.81 (2.34, 41.09) 0.002⁎⁎

Rumors 0.39 (0.21, 0.72) 0.003⁎⁎⁎

Personal belongings 1.44 (1.21, 1.72) 0.000⁎⁎⁎

Retaliation 0.39 (0.22, 0.68) 0.001⁎⁎

Angry/bad mood 17.99 (8.41, 38.49) 0.000⁎⁎⁎

Personal space 0.05 (0.03, 0.1) 0.000⁎⁎⁎

Jealousy 46.11 (18.43, 115.39) 0.000⁎⁎⁎

Drunk/high drugs 6.97 (1.63, 29.91) 0.009⁎⁎

Aid due to physical attack 0.04 (0.01, 0.15) 0.000⁎⁎⁎

Argue about sex 17.01 (7.17, 40.38) 0.000⁎⁎⁎

a Odds ratios N1 indicate greater likelihood for dating violence; b1 is greater likelihoodwith other types of violence; comparison groups for analyses: gender: males; race:Caucasian/others.⁎ p b 0.05.⁎⁎ p b 0.01.⁎⁎⁎ p b 0.001.

352 Q.M. Epstein-Ngo et al. / Addictive Behaviors 39 (2014) 350–353

comparable rates of violence and substance use at baseline by gender.However, females were more likely to be involved in DV, and maleswere more likely to be involved in NDV (Table 1).

3.1. Descriptive analyses of TLFB-AM

Participants reported 1262 conflict incidents summed across timepoints (baseline, 6-, and 12-months), 41.4% of which were DV. Femalesreported themajority of DV [464 (88.7%) incidents by 120 females vs. 59incidents by 47 males]. The majority of NDV was reported by males[502 (67.9%) incidents by 242 male participants vs. 237 incidents by136 females].

3.1.1. Substance use prior to violenceSubstance use occurred immediately prior to 44.2% of conflicts:

20.5% alcohol, 24.6% marijuana, 8.6% other illicit drug, and 2.5%prescription sedative or opioid misuse. Approximately 50% of DVincidents (n= 263) were preceded by substance use as opposed to39.9% of NDV (n=295). A larger proportion of NDV was preceded byalcohol use (23.3% versus 16.6% for DV) whereas a larger proportionof DV was preceded by drug use [marijuana only: 25.6%; other illicitdrugs: 18.7%; prescription drugs: 2.9%] than NDV [marijuana only23.8%; other illicit drugs: 1.4%; prescription drugs: 2.2%].

3.1.2. Reasons for violenceThe three most common reasons for DV were: 1) angry or bad

mood (43.2% of conflicts), 2) jealousy (28.8%), and 3) personal belong-ings (e.g. cell phones; 28.1%). The top three reasons for NDV were:1) personal belongings (23.0%), 2) power or respect (21.0%), and3) angry or bad mood (14.7%). For DV, females were most likely to re-port angry/badmood (44.3%);malesweremost likely to report jealousy(51.7%). For NDV, females were most likely to report jealousy (19.8%);males were most likely to report personal belongings (25.8%).

3.2. Multi-level multinomial models

3.2.1. Substance use prior to conflicts: DV versus NDVMulti-level, multinomial modeling was conducted with relationship

type as the dependent variable (DV vs. NDV; reference group=NDV).Independent variables included the 5 substance use categories de-scribed above, with age, race, and gender as covariates. Prescriptionsedative/opioid misuse was more likely immediately prior to DV thanNDV (AOR= 6.24, 95% CI = 2.81–13.88). In contrast, alcohol only orco-ingesting alcohol and marijuana was more likely to occur prior toNDV than DV (AOR = 0.29, 95% CI = 0.16–0.53; AOR = 0.43, 95%CI = 0.24–0.77, respectively). Finally, older participants, females, andAfrican Americans were more likely to report DV than NDV (AOR =1.61, 95% CI = 1.32–1.96; AOR = 89.57, 95% CI = 20.12–398.82;AOR=1.87, 95% CI=0.46–7.59, respectively).

3.2.2. Reasons for conflicts: DV versus NDVParallel analyses examined reasons for conflicts and relationship

type, using the same dependent variable and covariates. Four reasonswithout sufficient cell sizes (bullying, aid due to verbal attack, gotshot, other) were excluded. Reasons that were significantly more likelyto be attributed to DV versus NDV included: personal belongings(AOR = 1.70, 95% CI = 1.14–2.52), angry/bad mood (AOR = 18.90,95% CI = 9.50–37.60), jealousy (AOR= 47.13, 95% CI = 25.27–87.91),being drunk/high on drugs (AOR=4.53, 95% CI=1.38–14.83), and/orarguing about sex (AOR=11.93, 95% CI= 7.19–19.78). Reasons moreoften associated with NDV conflicts as opposed to DV included: rumors(AOR= 0.38, 95% CI = 0.26–0.55), retaliation (AOR= 0.43, 95% CI =0.25–0.72), personal space (AOR= 0.04, 95% CI= 0.03–0.07), and aiddue to physical attack (AOR=0.05, 95% CI=0.02–0.12).

3.2.3. Combined multi-level modelIn order to test whether substance use prior to conflicts and reasons

for conflicts uniquely contributed to variance in DV versus NDV, signif-icant results from the previous analyses were combined into onemodelusing the same dependent variables and covariates (see Table 2). Alco-hol use only and alcohol and marijuana use prior to conflict incidentsremained more likely prior to NDV (AOR= 0.23, 95% CI= 0.11–0.46;AOR = 0.48, 95% CI = 0.25–0.92, respectively). Prescription sedative/opioid misuse remained more likely prior to DV than NDV (AOR =9.81, 95% CI=2.34–41.09). The association between reasons and typeof violence was similar to that described above.

3.3. Interaction analyses

Post-hoc analyses of substance use × reasons interactions didnot reveal significant interactions. Post-hoc analyses of substanceuse×gender interactions revealed an alcohol/marijuana×gender inter-action; namely, alcohol andmarijuanaweremore likely to be combinedby females prior to DV and by males prior to NDV (AOR = 5.44, 95%CI = 1.16–25.6). Analyses examining reasons × gender interactionsshowed that jealousy was more often associated with DV than NDVfor males, but not for females (AOR=0.13, 95% CI=0.06–0.27).

4. Discussion

Our findings indicate that, at the event-level, high-risk youth tend touse alcohol and alcohol in combination with marijuana, prior to NDVand prescription sedative/opioid misuse prior to DV. Given that nearlyhalf of the violent conflicts were precipitated by substance use, violenceprevention and intervention programs need to be tailored to addresssubstance use and violence type. Our analyses also support tailoring ofinterventions by gender where the co-ingestion of alcohol andmarijua-na needs to be addressed among female youth involved in DV andamong male youth involved in NDV. Being in an angry or bad moodand jealousy were also common reasons for DV cited by both femalesand males, suggesting that a key area to be addressed in the context ofDV is the ability to regulate emotional responses. For NDV, rumors andretaliation were commonly mentioned, as was personal space. Youthviolence interventions which focus on individual motivation and self-efficacy for non-violence, including skills building for conflict resolutionand anger management may be key to addressing NDV. Further, inter-ventions for youth who have already experienced violence are critical

353Q.M. Epstein-Ngo et al. / Addictive Behaviors 39 (2014) 350–353

to decrease the recurrence of violence after an injury, particularly as re-taliatory violence may confer increased morbidity, perpetuating a cycleof violence (Cunningham et al., 2012;Walton et al., 2010). Finally, com-ing to the aid of someone else who was being physically attacked wasassociated with NDV, which may reflect increased levels of communityviolence. In this regard, interventions that focus on the individual leveland also on the family or neighborhood level are needed (Caldwell,Rafferty, Reischl, De Loney, & Brooks, 2010; Okvat & Zautra, 2011; Xu,Fiedler, & Flaming, 2005).

The retrospective nature of the study design limits our ability toattribute causation, although the event-specific, temporal nature ofthe data provides information about antecedents which likely contrib-ute causally to these violent conflicts. Generalizability may be limiteddue to this specific, high-risk sample recruited in an urban ED. Overall,findings indicate that youth involved in violence report distinct sub-stance use characteristics and contextual reasons which distinguishDV from NDV. Our findings indicate that interventions which addressviolence among youth should address substance use and psychologicalfactors (communication, problem solving), as well as be tailored bytype of violence (DV versus NDV) and by gender.

Role of funding sourcesFunding for this study was provided by NIDA Grants R01 024646 and T32 DA007267.

NIDA had no role in the study design, collection, analysis or interpretation of the data,writing the manuscript, or the decision to submit the paper for publication. The viewsexpressed in this article are those of the authors and do not necessarily represent theviews of NIDA, the University of Michigan, or the Department of Veterans Affairs.

ContributorsAll authors contributed to the conceptualization and writing of the manuscript, and

reviewed and approved the final manuscript. Drs. Cunningham, Walton, Zimmerman,and Blowwere responsible for designing the overall study and supervising data collection.Drs. Epstein-Ngo, Cunningham, Walton, and Chermack were responsible for initiallyconceptualizing and analyzing the current paper, and preparing the initial manuscript.Drs. Cunningham, Walton, Chermack, Zimmerman, and Blow provided critical feedbackon analyses and editing of the final manuscript.

Conflict of interestNone of the authors have any conflicts of interest to disclose.

AcknowledgmentsThe authors wish to thank themedical staff and patients at HurleyMedical Center for

their support of this research and Linping Duan who assisted with statistical analyses.

Appendix A. Structure of hierarchical linear models inequation format

Type of relation (partner vs. non-partner)

Level I

VioRelationit ¼ β0i þ β1i � timeþ β2i � Alcoholþ β3i�MarijuanaAlcoholþ β4i � Prescriptionþ β5i� Rumorsþ β6i � PersonalBelongingsþ β7i� Retaliationþ β8i � Angry=Badmoodþ β9i� PersonalSpaceþ β10i � Jealousyþ β11i� Drunk=HighDrugsþ β12i � ArgueDrugUseþ β13i � AidduePhysicalAttackþ β14i � Sexþ rit

Level II

β0i ¼ γ0 þ γ1 � ageþ γ2 � genderþ γ3 � raceþ u0i:

Note: i=individual; t=time.

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