Connecting The Dots To Prevent Youth Violence

Connecting
the Dots to
Prevent Youth
Violence
A Training and Outreach Guide for Physicians

and Other Health Professionals
Lyndee Knox, PhD, Author

Connecting the Dots to
Prevent Youth Violence
A Training and Outreach Guide for Physicians
and Other Health Professionals
Lyndee Knox, PhD; Keck School of Medicine at the University of Southern California, Department
of Family Medicine; The Southern California Center of Academic Excellence for Youth Violence Prevention
June 2002
Acknowledgments
This Training and Outreach Guide is a companion to American Psychiatric Association

the Commission for the Prevention of Youth Violence David Fassler, MD
report: Youth and Violence: Medicine, Nursing, and Public American Public Health Association
Health: Connecting the Dots to Prevent Violence. The Carol Easley Allen, RN, PhD
American Medical Association (AMA) convened this
Commission in October 1999, with funding by The US Department of Health and Human Services
Robert Wood Johnson Foundation, to apply the skills, Nicole Lurie, MD, MSPH
scientific rigor, and insight of medical, nursing, and The following people made important contributions
public health professionals to the issue of youth and to this guide and deserve special recognition:
school violence. While the report has been widely dis- David Fassler, MD Howard Spivak, MD
seminated and well received, the Commission felt that Nancy Guerra, EdD Stacey Zapanta
an additional component was needed to help physicians Appreciation is extended to the following
and other health professionals advocate for violence individuals for their assistance in reviewing and/or
prevention in their communities and practices. pilot testing all or portions of the material
This guide was developed by Lyndee Knox, PhD, of the contained in this manual.
Southern California Center of Academic Excellence Rob Asghar Richardo Hahn, MD
for Youth Violence Prevention with the assistance of Condessa Curely, MD David Hemenway, PhD
AMA staff. The Robert Wood Johnson Foundation pro- Paul Giboney, MD Carmela Lomonaco
vided funding. We hope this guide and the Commission Sandra Graham, PhD Julie Murray
report will motivate physicians, nurses, mental health The Youth Promotores at Latino Health Access,
professionals, community leaders, youth, and others to Santa Ana, CA
learn more about this problem and, more importantly,
to make a difference in their families, schools,
AMA Project Staff
Todd Bake
and communities.
Roger Brown, PhD
The Commission for the Prevention of Youth Violence Clair M. Callan, MD, MBA
American Academy of Child and Adolescent Psychiatry Elvia Chavarria, MPH
Marilyn Benoit, MD Arthur Elster, MD
American Academy of Family Physicians Jim Lyznicki, MS, MPH (project manager)
Bruce Bagley, MD Author
Carolyn Lopez, MD Lyndee Knox, PhD
American Academy of Pediatrics Suggested citation: Knox L. Connecting the Dots
Howard Spivak, MD to Prevent Youth Violence: A Training and Outreach
American College of Physicians-American Society Guide for Physicians and Other Health Professionals.
of Internal Medicine Chicago, IL: American Medical Association; 2002.
Whitney Addington, MD The entire guide is available online at:
American Medical Association http://www.ama-assn.org/violence
J. Edward Hill, MD For further information or additional copies,
Nancy Nielsen, MD, PhD please contact
American Medical Association Alliance Jim Lyznicki, MS, MPH
Susan Paddack American Medical Association
American Nurses Association 312 464-4520 (phone)
Elaine Williams, RN, NP 312 464-5842 (fax)
Introduction Connecting the Dots to Prevent Youth Violence

Table of Contents
Introduction & Overview ............................................................................................................................................7
Section 1 Preparing the Presentation .................................................................................................................9
Section 2 Speeches ...........................................................................................................................................15
Section 3 Slides .................................................................................................................................................45
Section 4 Case Studies ......................................................................................................................................67
Section 5 Issue Briefs .........................................................................................................................................85
Section 6 Act Now Handouts .........................................................................................................................133
Section 7 Resources: Professional and Patient/Family .................................................................................. 151
Section 8 Additional Information...................................................................................................................173
Introduction Connecting the Dots to Prevent Youth Violence

Introduction and Overview
Purpose of the guide The remainder of this guide is divided

This training and outreach manual was developed to into the following sections:
assist physicians and other health professionals increase Section 1: Preparing the Presentation
awareness of colleagues and community groups about • Goals and objectives for the speech
the serious and pervasive nature of youth violence and
• Main messages
the possibilities that now exist for prevention.
• Identifying a co-speaker
The materials contained in this manual are designed
for use in a variety of settings, from medical grand • Preparing materials and physical layout
rounds to Parent-Teacher Association meetings, and • Instructions for carrying out an on-line search for
are geared toward a broad range of audiences, including the most current national and local information
other health care professionals, students of the health on youth violence and prevention resources
professions, and adult and youth members of the • Links to useful Internet database sites
community. These materials are not intended to
Section 2: Speeches
substitute for expert knowledge or in-depth training.
• Speech for health professional audience
About this guide
• Speech for youth and community audience
This manual supplies all the information and materials
needed to deliver a speech or half-day workshop on Section 3: Slides
youth violence prevention for health and non-health • Master list of slides for health professional speech
professional audiences. Information is based on the • Master list of slides for youth and community speech
report Youth and Violence: Connecting the Dots to Prevent
Section 4: Case Studies
Youth Violence (www.ama-assn.org/violence) and Youth
Violence: A Report of the Surgeon General (www. • Bullying
surgeongeneral.gov/library/youthviolence) and is based • Firearms
on training principles for youth violence prevention • Media violence
developed by researchers and educators from the Youth
Section 5: Issue Briefs
Violence Prevention Centers of Academic Excellence,
funded by the Centers for Disease Control and • Adolescent substance abuse
Prevention. A complete list of these principles can be • Bullying in schools
found in Youth Violence and the Health Professions: • Child abuse
Core Competencies for Effective Practice (www.stopyouth
• Dating violence
violence.ucr.edu).
• Firearm-related violence
• Firearm safety
• Media violence
• Risk and protective factors for youth violence
• School violence
• Youth development and violence prevention
• Youth gangs
• Youth suicide
Introduction 7 Connecting the Dots to Prevent Youth Violence

Introduction and Overview (continued)
Section 6: Act Now Handouts

• What health professionals can do
• What families can do
• What youth can do
• What schools can do
• What law enforcement can do
• What the media can do
• What legislators can do
• What business and civic leaders can do
• What faith-based organizations can do
Section 7: Resources: Professional and
Patient/Family
Professional:
• Resources for Health Professionals
• Patient Assessment Tool
Patient/Family:
• Myths and facts about violence and how you
can help prevent it
• Teaching the basics of violence prevention
• When children witness violence in the home
• Violence prevention in the home
• Time-out
• Key education points on firearm injury and death
• Pulling the plug on TV violence
• You are the experts on raising “violence-free”
children: a guide for parents
Section 8: Additional Information
Introduction 8 Connecting the Dots to Prevent Youth Violence

Section 1
Preparing the Presentation
• Goals and objectives for the speech
• Main messages
• Identifying a co-speaker
• Preparing materials and physical layout
• Instructions for carrying out an on-line search

for the most current national and local information
on youth violence and prevention resources
• Links to useful Internet database sites

Preparing the Presentation
Establish presentation objectives Recruit a community member to

The objectives for this guide are to: co-present with you (optional)
• Define youth violence as a public health problem While this step is optional, the strength of your
presentation can be greatly increased by including
• Describe extent of the problem, with specifics on
a community member. This individual could be a
local situation when available
representative from a local community-based
• Identify risk and protective factors for violence organization working in violence prevention, a
• Describe intervention strategies and models professional from another sector such as law enforce-
that are effective ment, or a youth activist from the local community.
• Encourage audience to take action You can incorporate the co-presenter into the presenta-
tion, by dividing the materials to be presented or by
• Provide resources to support action by audience
periodically asking your co-presenter to contribute
members
information about the local situation, related resources,
Know what this guide is not and personal experiences in violence prevention work.
This guide is intended to assist you in outreach and Conduct on-line search for recent data
raising awareness about the problem of youth violence
and news on youth violence
with a wide range of audiences. It is not intended to be
a substitute for expert knowledge or in-depth training At the end of this section, you will find links to useful
in violence prevention interventions. Occasionally, on-line information sites for accessing: (a) recent news
you may need to remind your audience of this fact. stories on youth violence across the nation; (b) the most
Acknowledge that you may not know the answers to all recent national—and, where available, statewide and
of the questions your audience may ask. Welcome a spirit local—statistics on youth violence; and (c) information
of inquiry in your audience members and encourage on resources in your community (where available) for
them to join you in searching for information that you violence prevention.
may not have immediately available. While it is not necessary to complete this part of the
guide, doing so will allow you to personalize your
Determine the length of
presentation with recent news stories and with
your presentation information on the most recent youth violence statistics
The materials in this speaker’s guide can be used for and prevention resources relevant to your area. It is
presentations ranging from a 45-minute talk to a 2-hour much more difficult to obtain information on the
mini-workshop. In the case of the mini-workshop, the local level, as much of the data currently collected on
presenter would give the overview talk and then engage youth violence is gathered at county and state levels.
the audience in discussions around the 3 case studies However, where possible, we have tried to provide
contained in this guide. recommendations on how to access information on
Estimated length of presentation: local statistics and community resources.
Speech with question/answer ......................................1 hr
Speech, 1 case and question/answer ..............1 hr 20 min
Speech, 2 cases and question/answer .............1 hr 40 min
Speech, 3 cases and question/answer ........................2 hrs
Preparing the Presentation 9 Connecting the Dots to Prevent Youth Violence

Preparing the Presentation (continued)
Modify speaker’s notes by adding local www.ama-assn.org/violence or www.stopyouthviolence.

facts and personal stories ucr.edu. They are available in PowerPoint format. You
can download the presentations and load them onto your
While the speeches contained in this guide are complete
computer, or print them out and use them as masters to
and ready to present, we have identified places in the
make transparencies. You can personalize the title slide
speaker’s notes where you and/or your co-presenter might
to reflect your name and institution, and add slides to
wish to insert information about your own experiences
reflect local information you obtain during your
working with youth and violence prevention. The
preparation for the talk.
speeches are available in PDF (view only) and text
(ASCII) formats. The text file can be modified to Review, select, and copy case studies,
accommodate content and formatting changes to better fact sheets, and other handouts
suit your needs. Thoroughly familiarize yourself with the content of
A note on the power of stories. A good presentation can the case studies, issue briefs, and handouts contained in
become a great presentation through the use of carefully this guide as well as the contents of the companion
selected stories. Take the time to add stories about your report, Youth and Violence: Medicine, Nursing and Public
work and about the community to the speaker’s notes. Health: Connecting the Dots to Prevent Violence (available
You will find places scattered throughout the speeches online at: www.ama-assn.org/violence). Other good
that are designed for this purpose. One word of caution: resources are the Surgeon General’s reports on youth
be careful to maintain the confidentiality of any people violence and suicide prevention. These are available
you mention in your stories. online at: www.surgeongeneral.gov/library/.
Think of ways to involve the audience in your talk. It Suggestions for using the case studies
is particularly important when you speak to community
The three case studies included in this guide are
and youth audiences to engage them as much as possible
designed to give audience members an opportunity to
in the presentation, through questions and eliciting
apply the concepts discussed during the lectures and to
their own stories and thoughts about youth violence
“think-through” how they might respond to a young per-
and methods for its prevention. Encourage community
son in their practice or community who is at-risk for
members and youth to share their own knowledge,
involvement in youth violence. The cases deal with
their own solutions, and their own perceptions of the
common issues that audience members might be expect-
problem of youth violence, even before you share yours.
ed to encounter including media violence, bullying, and
Recognize that they are the true experts on their own
access to firearms. Each of the three cases includes a
community and involve them almost as co-presenters in
cover sheet that can be copied and distributed to the
your talk by asking them what they think is important
audience that provides a “case scenario” and discussion
and if they have any ideas on the subject. This
questions. Explanations for each question are provided
helps stimulate conversation and create a sense of
for the speaker to use that outline key points that should
collaboration between the presenter and the audience.
be covered in the discussion. The speaker may chose to
Download slides/overheads from the read these out loud to the audience following the open
Internet and personalize them. discussion of each question, or he or she may prefer to
use them as a reference. Each case presentation and
Slides to accompany both the health professional
discussion should take about 10-20 minutes to complete.
and the youth/community speech are located at

In a typical case presentation, the speaker will read the Accessing statistics online
case scenario to the audience and then lead the audience You can access links to all of the sites listed on the
in a discussion using the questions provided with the following pages at: www.stopyouthviolence.ucr.edu.
case as a starting point. The more you are able to
encourage audience members to share their own National statistics
thoughts and experiences related to the individual case Causes of Death by Age Group
scenarios, the more successful the case presentation Leading Causes of Death
will be. Use open-ended questions and liberal praise http://webapp.cdc.gov/sasweb/ncipc/leadcaus.html
to encourage audience members to speak-out. Helpful
prompts can include: “Tell me more about that,” “Ms. Child Abuse
[Smith] tell me some of your thoughts on this,” “Good Statistics and Facts on Child Abuse
point,” “Interesting,” “Humm,” etc. Breaking into http://www.ncvc.org/Infolink/Infolink_frames2.htm
smaller groups of 5-8 members to discuss the case studies Child Well-Being
can also encourage greater audience participation.
2000 Kids Count Data Book Online
Instructions for conducting an on-line http://www.aecf.org/kidscount/kc2001/
search for recent data and news on Dating Violence
youth violence and its prevention
Fact Sheet
Finding statewide and local statistics on youth http://www.cdc.gov/ncipc/factsheets/datviol.htm
violence will allow you to tailor your presentation
Statistics and Facts on Teen Dating Violence
to your particular audience, making it more relevant
http://www.ncvc.org/stats/teen.htm
to them and to you.
Firearms
In this section, we provide you with Web sites that
contain local, state, and national statistics on issues Firearm Injuries and Fatalities
related to youth violence. We also provide links to http://www.cdc.gov/ncipc/
information on programs and/or resources for violence Firearm and Crime Statistics
prevention in your community or state, as well as some http://www.ojp.usdoj.gov/bjs/guns.htm
news clipping services that allows you to review recent
Gangs
news stories on youth violence. Please note: It is
sometimes difficult to find this information on a local Highlights of the 1999 National Youth Gang Survey
level, but we recommend checking the sites suggested http://www.ncjrs.org/pdffiles1/ojjdp/fs200020.pdf
as well as contacting your local law enforcement and School Violence
health agencies.
National Center for Education Statistics
Things to consider as you incorporate http://nces.ed.gov/fastfacts/display.asp?id=54
current statistics into your presentation:
Hamilton Fish Institute
• Understand the meaning behind the statistics http://www.hamfish.org/data/national/csi/index.html
• Use them appropriately
• Know the source of the numbers, how they were
collected, and how recent and reliable they are

Substance Abuse Health Risk Behaviors

Juveniles and Drugs—Prevalence Estimates Youth Risk Surveillance Survey Information
http://www.whitehousedrugpolicy.gov/drugfact/ http://www.cdc.gov/nccdphp/dash/yrbs/pies99/index.htm
juveniles/prev_estimates.html Youth Risk Behavior Trends
Suicide http://www.cdc.gov/nccdphp/dash/yrbs/trend.html
Injury Mortality Data Suicide
http://webapp.cdc.gov/sasweb/ncipc/mortrate.html Regional Variations in Suicide Rates –
Suicide in the United States United States, 1990-1994
http://www.cdc.gov/ncipc/factsheets/suifacts.htm http://www.cdc.gov/epo/mmwr/preview/mmwrhtml/
Youth Arrest Rate 00049117.htm
FBI Arrest Statistics Injury Mortality Data

http://ojjdp.ncjrs.org/ojstatbb/ezaucr/ http://webapp.cdc.gov/sasweb/ncipc/mortrate.html
Youth Homicide Rate Youth Arrest Rates
WISQARS (Web-based Injury Statistics Query and FBI Arrest Statistics

Reporting System) http://ojjdp.ncjrs.org/ojstatbb/ezaucr/
http://www.cdc.gov/ncipc/osp/data.htm Youth Homicide Rates
Youth Risk Behavior Trends WISQARS
Youth Risk Surveillance Survey Information http://www.cdc.gov/ncipc/osp/data.htm
http://www.cdc.gov/nccdphp/dash/yrbs/index.htm
* Contact your local police and health departments to ask
Health Risk Behavior Trends about youth violence prevention activities and obtain
information on data in your area. You can find your state
http://www.cdc.gov/nccdphp/dash/yrbs/trend.htm and local government offices at this site: http://www.
statelocalgov.net/index.cfm.
State and local statistics*
Causes of Death by Age Group Programs and resources on
Leading causes of death
national level
http://webapp.cdc.gov/sasweb/ncipc/leadcaus.html Child Abuse
Child Well-Being National Clearinghouse on Child Abuse
and Neglect Information
2000 Kids Count Data Book Online
http://www.calib.com/nccanch/pubs/index.cfm#Resource
http://www.aecf.org/kidscount/kc2001/
Dating Violence
Costs of Injury
Safe Schools and Healthy Students Action Center
State by State Information on the Costs
(clearinghouse)
of Violent Crime
http://www.sshsac.org/
http://www.injuryprevention.org/info/data.htm
Firearms
Crime Mapping of Your Community
http://www.ojp.usdoj.gov/cmrc/weblinks/welcome.html SafeCities
http://www.safecities.gov
Join Together Online
http://www.jointogether.org
Gangs Gangs
National Youth Gang Center Gangs or Us – Gangs in the United States
850 385-0600 http://www.gangsorus.com
http://www.iir.com/nygc/ Mental Health Services
School Violence Center for Mental Health Services
National Resource Center for Safe Schools http://www.mentalhealth.org/
http://www.safetyzone.org/ School Violence
Substance Abuse National Resource Center for Safe Schools
Join Together Online http://www.safetyzone.org/
http://www.jointogether.org Substance Abuse
Suicide Drug Treatment Finder–SAMSHA
National Strategy for Suicide Prevention http://findtreatment.samhsa.gov/
http://www.mentalhealth.org/suicideprevention Suicide
/index.htm
National Strategy for Suicide Prevention –
National Hopeline Network State by State
1-800-SUICIDE http://www.mentalhealth.org/suicideprevention/
Youth Development stateprograms.htm
National Resource for Youth Development Programs Prevention Web – State by State
http://www.ncfy.com/ydorgs2.htm http://www.edc.org/HHD/csn/StateResources/state.htm
Youth Violence Suicide Hotlines
National Youth Violence Prevention Center http://suicidehotlines.com
http://www.safeyouth.org Youth Violence
Safe Schools/Healthy Students Action Center Partnerships Against Violence (PAVNET) Programs
(clearinghouse) http://www.pavnet.org
http://www.sshsac.org/ Community Justice Exchange
Programs and resources on http://www.communityjustice.org/
state and local level* Prevention Web – State by State
Child Abuse http://www.edc.org/HHD/csn/StateResources/state.htm
State Resources (click child abuse) SafeCities
http://ojjdp.ncjrs.org/resources/asp/search_states.asp http://www.safecities.gov
National Clearinghouse on Child Abuse and Neglect * Contact your local police and health departments to ask
Information Organization Database them about youth violence prevention activities and obtain
information on data in your area. To find state and local
http://www.calib.com/nccanch/Scripts/SearchPg.cfm government offices: http://www.statelocalgov.net/index.cfm
Dating Violence
Safe Schools and Healthy Students Action Center
(clearinghouse)
http://www.sshsac.org/
Section 2
Speeches
• Speech for health professional audience
• Speech for youth and community audience

Speeches
Health Professional Audience
Reminders
Estimated length of speech: 1 hour
Preparing for the speech
• Recruit co-presenter from community if desired.
• Conduct on-line search for recent news stories, local and national data on violence
and prevention programs.
• Personalize speaker’s notes using this information. You can make notes directly on the hardcopy
of this speech or incorporate content and formatting changes using the Microsoft Word file,
which is provided with the electronic version of this guide (www.ama-assn.org/violence).
• Review issue briefs and on-line information resource sites contained in this manual.
• Download and copy overhead masters onto transparencies or load PowerPoint
presentation on computer.
• If possible, send the PowerPoint slides to the person who will be providing the audio/visual
support for your presentation (3 to 7 days in advance).
Room set-up and preparation of materials
• Arrange room for presentation. Stadium-style seating arrangements are appropriate for the
basic presentation. If case studies are to be presented, it is optimal if seating allows audience
members to move into small groups of 5 to 6.
• Arrange for overhead projector or computer projector.
• Make copies of appropriate handouts, issue briefs, and resource list.
Speeches 15 Connecting the Dots to Prevent Youth Violence

Health Professional Audience (continued)
[Slide #1] Introduction

A generation ago, a controversial political activist asserted that
“violence is as American as cherry pie.”1 Today, that statement has
become chillingly accurate for our nation’s youth.
Option: begin with a statement on violence made by a local leader

or your favorite quote on youth violence in lieu of statement above.
The epidemic of youth violence only occasionally warrants headlines

and extended television coverage, but it is a disturbing ongoing
reality that poses one of the most significant public health risks of
our times.2
Youth violence today is more devastating to our young people than
polio, AIDS, or motor vehicle crashes. One can debate the label of
‘epidemic,’ but not the facts behind it—starting with the fact that
the United States has the highest youth homicide and suicide rates
among the world’s 25 wealthiest nations.3
[Slide #2] Why is youth violence relevant to health
professionals?
Why is a health professional talking to other health professionals
about youth violence? Isn’t it a criminal justice issue? A problem for
the police?
In fact, youth violence is a problem that involves all of us—from
police to schools to health professionals to faith institutions to
families, communities, and policy makers. Youth violence is not just
a criminal justice problem, it is a public health problem—and a
serious one. Consider this:
[Slide #3] • Homicide is the second leading cause of death among teenagers
and young adults in this country.4
• Each year, the medical costs of firearm injuries alone are estimated
to be $2.3 billion, which includes lifetime costs of these injuries.5

[Slide #4] • And finally, consider this: scientists have recently shown that
exposure to extreme and extended situations of violence or trauma
can change the structure and function of the brain in ways that
can interfere with academic performance, mood, and behavior.6
[Slide #5] The public health approach
Defining violence as a public health problem brings a new set of
resources to bear on the problem in addition to those of the criminal
justice system. Defining violence as a public health problem offers
the youth and families of this country hope—not just of “control-
ling”violence through incarceration, but of preventing it altogether.7
When polio was prevalent in this country, we did not blame our
children for falling victim to it, nor did we expect to eradicate it by
relying on young people to always make the right choices. Neither,
now, should we blame our children or parents or communities for
succumbing to an epidemic of violence.8, 9
From the public health perspective, youth violence is not an inevitable
fact of life. It is a social problem that can be prevented, using the
same rational approach that had such great effect on other
public health challenges such as drunk driving, use of seat belts,
and smoking.10, 11
[Slide # 6] The causes of violence
From research we now know that certain factors place children
at risk for violence—as victims, as perpetrators, and as witnesses.
We also know that other things protect them. Of the things that put
them at risk, most importantly, we know that violence is learned.2, 12
[Slide #7] Children learn violence from being victimized
• In 1999, roughly 826,000 children in the United States were the
victims of maltreatment.13

• Experiencing child abuse and neglect increases the likelihood

of arrest as a juvenile by 53% and of committing violent crime
by 38%.14
[Slide #8] Children learn violence from watching violence
in the home
There are intimate links between family violence and youth
violence—these links create a “cycle of violence.”
• More than 3.3 million children witness physical and verbal
abuse in their homes each year, with some estimates as high
as 10 million.15-18
• Children exposed to violence in the home are more likely to
be victimized in intimate relationships as adults. They are also
more likely to become an adult perpetrator or victim of violence
on the streets.14
[Slide #9] Children learn violence from watching violent media
• The average child watches 28 hours of television a week and will
see 200,000 violent acts by age 18.8, 19
• Studies of the effects of TV violence suggest that children
confronted incessantly by violent images in the media may become
immune to the horror of violence. Not only that, they may
come to accept violence as a way to solve problems.20, 21
Some other factors also increase the possibility
that children will become perpetrators or victims
of violence
[Slide #10] Alcohol and drugs
A strong link exists between alcohol use and violence.
• Half of youth homicide victims have elevated blood alcohol levels
on autopsy.22-24
• Those who commit homicide are also found to have elevated
blood alcohol levels when apprehended and tested.22-24

Another risk factor is gangs

Youth gangs are responsible for a disproportionate share of all
criminal offenses, both violent and nonviolent.25
[Slide #11] And finally, there is the risk created by guns.
• The rise in murders of juveniles from the mid-1980s through the
peak year of 1993 was significantly related to firearms.25, 26
• In some states, firearms have surpassed auto crashes as the
leading cause of death among children and youth.27
• Teenage boys are more likely to die from gunshot wounds than
from all natural causes combined.28
• At least 25 million households keep handguns, and 50% of
their owners keep them loaded.29
• Handgun owners typically indicate they keep the guns for
self-defense, but suicides, homicides, and accidental deaths
outnumber deaths associated with self-defense by 43 to 1.30
• Family and friends are the primary sources of guns for young
people; only 5% have asked someone else to purchase a gun
for them from legal or illegal sources.29
[Slide #12] Finally, we know that the causes of violence are not simple. No single
factor causes violence, rather it is the result of a combination of many
factors—individual, familial, societal, and situational.31
With this background on the different factors that produce youth

violence, I’d like to shift briefly to talk about youth violence in
this community.
Option: Insert stories about violence in local area (3-5 minutes).

Insert information gathered from your on-line search.

[Slide #13] What can physicians and other health

professionals do?
So what can you as a health professional do to help prevent further
death and injury to the young people in your community?
First, you can educate your patients, screen for risk factors and
exposure, and refer young persons and their families to effective
mental health and support services in the community.32-34
[Slide #14] It can be helpful to view violence prevention activities as occurring at
different stages in the injury process. The Haddon Matrix, a tool used
in identifying opportunities to prevent injury, identifies three stages
during the injury process where interventions can occur: the pre-injury
stage, the moment of injury and, finally, after the injury has occurred.35
The most obvious opportunities for health professionals to intervene
occur during the pre-injury and post-injury stages. I’d like to take a
few moments and give you an overview of the types of interventions
that health professionals can provide at these times. First, let’s discuss
post-injury interventions.
Health care interventions during post-injury
Health professionals have a unique opportunity to help prevent
re-injury of a young person at the time he or she presents with
injuries. In its most obvious manifestation, this is the child who
presents in the clinic or emergency department with violent injuries
such as contusions, broken bones, or at the most extreme, knife
and gun shot wounds. In these cases:
You can:
[Slide #15] Educate
• Educate parents on steps they can take to help their child avoid re-
injury and cope with the emotional trauma resulting from violence.
• Educate young people on these same topics.

Option: Insert your own methods of educating and stories of

clinical work.
[Slide #16] Assess

• Thoroughly document the injuries and events surrounding them,
as they could be important to any legal proceedings.
• Gather information about risk factors for re-injury, for example,
in the case of youth-on-youth violence:33
– Is the conflict settled?
– Does the young person feel safe leaving the hospital?
– Is he or she thinking about revenge?
– Is there a safe place to go while things cool off?
– Is further psychological assessment indicated?
Option: Insert your own methods of assessing and stories

about clinical work.
[Slide #17] Refer

• Refer young people and their families to mental health and crisis
intervention services, as well as long-term supportive services.
Short-term services are rarely, if ever, adequate to prevent
future violence.
• Notify the local Department of Social Services in the case of abuse
or neglect, and tell the police if plans for revenge warrant breaching
a young person’s confidentiality.
Option: Places/programs to refer in this county and stories


[Slide #18] Health care interventions during post-injury:

Responding to youth with psychological injuries
Let me pause here for a moment and say that interventions during
the post-injury stage are not just for youth with physical injuries. As
health professionals, it is important for us to recognize that many of
the injuries caused by violence are not physical. Many young people
who witness violence sustain serious emotional and psychological
injuries, even though they may not suffer physical injury. And more
times than not, these “invisible injuries” of violence often go unrecog-
nized and untreated. To give you some idea, a recent study found that
51% of youth from high-crime communities had symptoms of post
traumatic stress disorder.36 Or consider this, children are present in
40% of the homes in which intimate partner violence occurs.18
Even if they are not battered themselves, it is highly likely that they
witnessed violence. In a vicious “cycle of violence,” many young
perpetrators of violence were witnesses to serious violence when
14
they were young, and sustained psychological injuries.
[Slide #19] Health professionals can use similar processes of
screening, educating and referring with these young
people, as they do with young people who present
with obvious physical sequelae of violence
Option: Insert your own methods of referral and stories

[Slide #20] Interventions during the pre-injury stage

Now I’d like to shift from discussing post-injury interventions and talk
about interventions you can use at the pre-injury stage.
The battle against polio was not won by only treating the victims of
the epidemic. It was won through primary prevention—in this case,
the discovery and use of a vaccine.

The same is true for youth violence. The epidemic will not end only
by caring for those who are already injured. It will end through the
primary prevention of violence, by developing a “vaccine” against
violence so to speak.
From research on risk and protective factors, we know this vaccine
will be very different from that developed for polio. It will, in fact,
be much more complex and difficult to administer.
It will have many different components—some that require broad
social changes that do not involve the health professional directly,
such as reducing poverty, improving schools, community support for
family development, and reducing youth access to firearms and drugs.
But there are parts of this vaccine that do require the involvement of
health professionals—and, in fact, cannot be constructed without
them. Health professionals should help parents build protective
socioemotional competencies in their children; and work with them
to reduce children’s exposure to “risk” agents like violent media and
unsecured firearms.
In your practice you can:
[Slide #21] Educate
• Work with parents, starting with prenatal care, to design a
“strategic plan” for building protective emotional and social
competencies in their children.
• Educate parents and young people about the effects of media
violence and how to reduce exposure to it.
• Educate parents on the dangers associated with firearms and
ways to reduce this danger—such as storing firearms safely and
removing guns from homes with depressed and suicidal children.

Option: Insert your own methods of educating and stories

[Slide #22] Screen

• Identify children who are at-risk for violence—in other words,
children who are exposed to the risk factors we discussed earlier—
through screening.
• An example of a screening approach is the FISTS mnemonic,
which can guide you through the questions needed to assess
an adolescent’s risk for violence.37
F–Fighting
(How many fights were you in last year? When was the last?)
I–Injuries
(Have you ever been injured? Have you ever injured
someone else?)
S–Sex
(Has your partner hit you? Have you hit your partner? Have
you ever been forced to have sex?)
T–Threats
(Has someone with weapon threatened you? What happened?
Has anything changed to make you feel safer?)
S–Self-defense
(What do you do if someone ties to pick a fight?
Have you carried a weapon in self-defense?)

Option: Insert your own methods of screening and stories

[Slide #23] Refer

• Connect young people and their families to programs in their
communities and schools that are comprehensive and reflect the
characteristics of effective violence prevention programs.
• Effective programs start early in a child’s life. They are long-term,
intense, and involve many hours of contact. They build strong
relationships between adults and children, and are comprehensive,
meaning they involve many sectors of society, and focus on building
positive skills in youth.9, 34, 38-41
• The Surgeon General’s recent report on youth violence provides
descriptions of specific programs that have been proven to reduce
or prevent youth violence. Some programs that are effective in
reducing youth violence include positive youth development pro-
grams and multisystemic family therapy with a trained counselor.2
• Ineffective programs include boot camps, residential treatment,
and stand-alone peer mediation and counseling programs.2
[Slide #25] Preventing violence
Before I close, I want to leave you with a success story. One that
proves the statement I made at the beginning of this speech—that
violence can be prevented. That it is not inevitable. That story takes
place in Galveston, Texas.
In the late 80s and early 90s, violent crime in Galveston dropped by
78% compared to the national decline of 19%.42
Why did this happen? It happened in large part because of a highly
comprehensive series of violence interventions implemented in the

city, with each designed to address different risk factors for youth
violence at different developmental stages.
The interventions included social problem-solving skills training in
elementary school, supervised recreation programs to reduce truancy,
youth courts that involved young people convicted of misdemeanors
in community work and education, and intensive home-based
counseling services for frequent or violent offenders.
Option: Insert stories about local programs here (3-4 minutes).
[Slide #26] Get involved

So get involved. Youth violence is relevant to health care
professionals, and there are concrete things you can do in your
daily practice to help end the epidemic of violence. Never forget
that small changes can have big effects.
Incorporate basic educating, screening, and referral as part of your
daily practice. And think about moving beyond your practice setting:
• Start an intervention such as the one in Galveston, Texas.
• Work with the schools in your area to develop violence
prevention plans.
• Work with local community coalitions and groups.
• And advocate with local and national policy makers for broader
implementation of effective programs, more research, and the
resources needed to carry these out.
Option: Provide information on ways in which the audience might

become involved. Provide information on needs in local schools,
information on local coalitions, and relevant legislation.

[Slide #27] Concluding statements

In the United States, we have become accustomed to the televised
sights and sounds of war in faraway lands. But for our country’s
youngest citizens, our own streets, schools, and homes have
increasingly become danger zones in which many of our children
regularly encounter violence.
We, as health professionals, have a unique role to play in addressing
this threat to our children’s safety and to our country’s health. When
we step forward and do our part, we help ensure that our youth
will have what they deserve—the opportunity to grow, thrive, and
develop into healthy adults who can contribute to a great society.
Thank you

4 Cohen L, Potter L. Injuries and violence: risk factors and opportunities

Annotated Bibliography
for prevention during adolescence. Adolesc Med. 1999;10:125-135.
1 Attributed to H. Rap Brown, a member of the Student Nonviolent
Coordinating Committee during the 1960s civil rights movement. More adolescents in the United States die from injuries than from any
Later he is believed to have become disillusioned with nonviolent other cause. This article describes the three leading causes of death
methods and became a member of the Black Panthers. Most recently among adolescents—interpersonal violence, suicide, and motor
he was convicted for the murder of a law enforcement officer. vehicle-related injuries. The authors examine risks associated with
Excerpted from Christoffel T, Gallagher S. Injury Prevention and Public alcohol use and access to firearms as well as injuries that occur at
Health: Practical Knowledge, Skills, and Strategies. Gaithersburg, MD: work and while playing sports, and provide recommendations for pre-
Aspen Publishers, Inc;1999. venting adolescent injuries for health care providers, schools
and communities.
2 US Department of Health and Human Services. Youth Violence: a Report
of the Surgeon General. Rockville, MD: Department of Health and 5 Cook PJ, Lawrence A, Ludwig J, Ludwig M, Miller TR. The medical costs
Human Services, Centers for Disease Control and Prevention, National of gunshot injuries in the United States. JAMA. 1999;282:447-454.
Center for Injury Prevention and Control; Substance Abuse and Mental This study estimates costs for firearm injury, including lifetime
Health Services Administration, Center for Mental Health Services; and costs associated with this type of injury. The analysis is based on
the National Institutes of Health, National Institute of Mental Health; emergency department data from hospitals in three different states, as
2001. well as databases such as the National Electronic Injury Surveillance
The Surgeon General’s report summarizes recent research on the System. Furthermore, the authors delineate the burden of these costs
causes and prevention of youth violence. The report provides an (namely, government and private sector). They also produce a mean
overview of prevalence; findings on the developmental dynamics of cost-per-injury as they illustrate the effect of gun violence on the
youth violence; risk and protective factors; and model, promising, and medical sector.
ineffective prevention and intervention programs. Risk and protective 6 Niehoff D. The Biology of Violence: How Understanding the Brain, Behavior,
factors are reviewed by domain—individual, family, school, peer and Environment Can Break the Vicious Circle of Aggression. New York, NY:
group, and community. Programs are categorized as primary, second- The Free Press; 1999.
ary, and tertiary prevention programs. Effective primary prevention
7 Rosenberg M, Fenley MA. Violence in America: A Public Health Approach.
strategies include: skills training, behavior monitoring and reinforce-
New York, NY: Oxford University Press; 1991.
ment, building school capacity, and positive youth development,
Violence in America provides an overview of different forms of violence
among others. Effective secondary prevention strategies include: par-
(assault, child abuse, child sexual abuse, rape and sexual assault,
ent training, home visitation, and social problem-solving, among oth-
spouse abuse, elder abuse, and suicide) and discusses
ers. Effective tertiary prevention strategies include: multimodal inter-
implications for intervention from a public health perspective. The
vention, skills training, and marital and family therapy by clinical staff,
authors contend that violence is as much a public health issue as
among others. Ineffective programs include: peer counseling and
one of criminal justice, and that the public health approach of
mediation, gun buyback programs and firearm training, boot
surveillance, risk factor identification, intervention, and evaluation
camps, residential programs, waivers to adult court, and individual
and implementation can assist in the prevention of violence among
counseling.
adults and children.
3 Centers for Disease Control and Prevention. Rates of homicide, sui-
8 Commission for the Prevention of Youth Violence. Youth and Violence:
cide, and firearm-related death among children: 25 industrialized
Medicine, Nursing and Public Health: Connecting the Dots to Prevent
countries. Morb Mortal Wkly Rep.1997;46:101-105.
Violence. Chicago, IL: The American Medical Association; 2000:28.

9 Task Force on Violence, American Academy of Pediatrics. The role of 14 Widom CS. The cycle of violence. Research in Brief. Washington DC:
the pediatrician in youth violence prevention in clinical practice and at US Department of Justice, Office of Justice Programs; 1992.
the community level, policy statement. Pediatrics. 1999;103:173-171. This longitudinal study tested the cycle of violence hypothesis by
10 Centers for Disease Control and Prevention. Ten great public health tracking more than 1,500 cases from childhood to adulthood. The
achievements-United States, 1990-1999. Morb Mortal Wkly Rep. study utilized a multi-method research design by incorporating arrest
1999;48:241-243. data, interviews, and comparison groups. The focus encompassed vari-
During the 20th century, the health and life expectancy of persons ous forms of abuse, including neglect, in the overall effect on future
residing in the United States improved dramatically. Since 1900, the violent behavior.
average lifespan of persons in the United States has lengthened by 15 Carlson BE. Children’s observations of interparental violence.
more than 30 years; 25 years of this gain is attributable to advances In: Roberts AR, ed. Battered Women and Their Families. New York, NY:
in public health. To highlight these advances, MMWR profiles Springer; 1984:147-167.
10 public health achievements. 16 Horn D. Bruised Inside: What Our Children Say About Youth Violence, What
11 Hawley T. Safe Start: How Early Experiences Can Help Reduce Violence. Causes It and What We Need to Do About it. Washington, DC: National
Chicago, IL: The Ounce of Prevention Fund; 2000. Association of Attorneys General; 2000.
Many initiatives have been proposed and implemented to reduce This report chronicles meetings held with youth, parents,
the incidence of violent crime, including community policing, stiffer teachers, and school administrators. It is a description of the findings
sentences for convicted criminals, and programs to keep adolescents from these meetings. The authors recommend steps that can be taken
involved in positive activities and “off the streets.” However, many by parents, youth, schools, communities of faith, and others
communities have overlooked what a national organization of law to help prevent youth violence, and describe state-by-state
enforcement officials and crime victims cite as the most promising efforts that attorneys general are making to curb youth violence.
approach to reducing violence: prevention and intervention programs 17 Jaff PG, Wolfe D, Wilson S. Children of Battered Women. Newbury Park,
for very young children aged birth to 5 years. Built on decades of CA: Sage Publications;1990.
research on child development, these programs are making lasting dif-
18 Rennison CM, Welchans S. Intimate partner violence. Bureau of Justice
ferences and helping young children receive a safer start in life.
Statistics Special Report. Washington, DC: US Department of Justice;
12 da Silva JM, Sterne M, Anderson P. ACT (Adults and Children Together) 2000.
Against Violence. Washington, DC: American Psychological Association,
19 American Psychiatric Association, Fact Sheet. Psychiatric Effects of Media
National Association for the Education of Young Children; 2001.
Violence. Available at: http://www.psych.org/public_ info/media_
13 US Department of Health and Human Services. Ten Years of Reporting violence.cfm.
Child Maltreatment 1999. Washington, DC: US Government Printing
20 American Medical Association. Physician’s Guide to Media Violence.
Office; 1999.
Chicago, IL: American Medical Association; 1996.
The project spans 10 years of research on the methods by which child
This guide provides suggestions and options for dealing with violence
maltreatment is assessed and reported in the United States. The study
in the media and for protecting our children from its notorious and
is nationwide and focuses on the mode by which referrals parlay
insidious effects. It primarily addresses television, where the most
into investigation by child protective services. It also provides demo-
evidence exists, but other media are implicated as well, and these
graphic information on the children as well as the characteristics of
effects are also reviewed. It offers physicians an overview of the
the perpetrators. The future of child protective services is analyzed in
health consequences of such exposure and offers specific
the context of the information provided within this project.
recommendations about reducing the effects of media violence for
physicians to pass onto parents.

21 Donnerstein E, Slaby R, Eron L. The mass media and youth violence. 26 Federal Bureau of Investigation (various). Supplementary Reports for
In: Murray J, Rubenstein E, Comstock G, ed. Violence and Youth: the Years 1980-1997 [machine-readable data files]. Washington, DC:
Psychology’s Response, Vol. 2. Washington, DC: American Psychological FBI.
Association; 1994. 27 Fingerhut LA, Jones C, Makuc DM. Firearm and motor vehicle injury
This chapter contributes to the literature on media effects and mortality—variations by state, race and ethnicity: United States,
violence. It reinforces the findings over a span of 20 years about this 1990-1991. Advance Data From Vital and Health Statistics, No. 242.
relationship. Specifically, violence in media can lead to aggression Hyattsville, MD: National Center for Health Statistics; 1994.
and aggressive attitudes as well as desensitize youth to violence This study is part of the Healthy People 2000 initiative that seeks
and the use of violence in interpersonal relationships. to reduce both fatal motor vehicle accidents and homicides. The
22 Adams PF, Schoenborn CA, Moss AJ. Health Risk Behaviors Among initiative’s focus is on individuals aged 15-24 years as well as the
Our Nation’s Youth: United States, 1992. (DHHS publication 95-1520). impact on people of color. The study compares death rates in these
Hyattsville, MD: National Center for Health Statistics; 1994. two categories delineated by race and age as well as within the
23 Mann RP, Borosowsky I, Stolz A, Latts E, Cart C, Brindis C. Youth states. Furthermore, the analysis compares across states by these
Violence: Lessons From the Experts. Washington, DC: Maternal and Child variables.
Health Bureau, Health Resources and Services Administration, Public 28. Coordinating Council on Juvenile Justice and Delinquency Prevention.
Health Service, US Department of Health and Human Services; 1998. Combating Violence and Delinquency: The National Juvenile Justice Action
This report presents responses from both professionals and Plan/Report. Washington, DC: US Department of Justice; 1996.
youth as to what professionals, parents, youth, and citizens can do to The report builds on the Comprehensive Strategy for Serious, Violent,
protect themselves from violence. It also includes descriptions of some and Chronic Juvenile Offenders (Wilson and Howell, 1993) and
violence prevention programs that appear to have a good chance of describes federal activities and resources to help communities
success. This is a tool for health professionals and educators; maternal address eight critical objectives. The overarching goal is to rebuild
and child health directors and adolescent health coordinators, community confidence in the system’s ability to have an impact
societies, and professional organizations that work with children and on this serious problem.
youth; and the hundreds of government policymakers at local, county, 29 Sheley J, Wright J. High school youths, weapons, and violence:
and state levels. a national survey. Research in Brief. Washington, DC: National Institute
24 Prothrow-Stith D, Spivak HR. Violence. In McAnarney ER , Kreipe RE, of Justice, US Department of Justice; 1998.
Orr DP, Comerci GD, eds. Textbook of Adolescent Medicine. Philadelphia, This Research in Brief examines the extent to which a national
PA: Harcourt Brace Jovanovich; 1992;1113-1118. sample of male high school sophomores and juniors was involved in,
25 Snyder H, Sickmund M. Juvenile Offenders and Victims: 1999 National or otherwise affected by, firearm-related activity. Surveys were mailed
Report. Washington, DC: US Department of Justice; 1999. to high school students that sought information on their firearm and
This report offers a comprehensive overview of the pervasive problems crime-related activities for the 12 months prior to the survey as well
of juvenile crime and reviews the response of the juvenile justice as social, demographic, and personal information for each respondent.
system. It contains statistics from a variety of sources on a wide array

of topics, including juvenile population characteristics, juvenile victims,
juvenile offenders, juvenile justice system structure and process,
law enforcement and juvenile crime, juvenile courts, and juveniles in
correctional facilities.

30 Kellermann AL, Reay DT. Protection or peril? An analysis 34 Cohn F, Salmon ME, Stobo JD, eds. Confronting Chronic Neglect: The
of firearm-related deaths in the home. N Engl J Med. Education and Training of Health Professionals on Family Violence.
1986;314:1557-1560. Washington, DC: National Academy Press; 2001.
The paper reviews deaths that occurred in King County, Washington, 35 National Committee for Injury Prevention and Control. Injury Prevention:
from 1978 through 1983 due to firearms. A total of 743 Meeting the Challenge. New York, NY: Oxford University Press
firearm-related deaths occurred during the six-year period, of which (published as a supplement to the Am J Prev Med. 1989; 5:4-8).
54% occurred in homes where firearms were kept. For every case of 36 Nadel H, Spellmann M, Alvarez-Canino T, Lausell-Bryan LL, Landsberg
self-protection homicide involving a firearm kept in the home, there G. The cycle of violence and victimization: a study of the school-based
were 1.3 accidental deaths, 4.6 criminal homicides, and 37 suicides intervention of a multidisciplinary youth violence-prevention program.
involving firearms. Only 2 of the 398 deaths involved an intruder Am J Prev Med. 1996; 12 (5 Suppl):109-119.
shot during attempted entry. Handguns were used in 70.5% of
This study evaluates a multi-disciplinary school-based intervention for
these deaths.
youth violence. The findings illustrate that violence is pervasive in the
31 National Youth Violence Prevention Resource Center. Risk lives of these youth at home, in the community, and at school. The
and Protective Factors for Youth Violence. Available at: study reports on large percentages of exposure to violence in these
http://www.safeyouth.org/topics/risk.htm. Accessed: June 2001. environments as well as some of the norms and beliefs surrounding
Current research indicates that the presence of a single risk factor in violence on a societal level and community level.
an individual does not, by itself, cause antisocial or violent behavior. 37 Alpert E, Bradshaw S, Ylisabyth S, Sege RD. Interpersonal violence and
Rather, it is now generally believed that multiple factors combine to the education of physicians. Acad Med. 1997; 42:541-551.
contribute to and shape behavior over the course of adolescent
38. Burt M, Resnick G, Matheson N. Comprehensive Service Integregation
development. Studies suggest it is the confluence of certain “risk”
Programs for At Risk Youth: Final Report. Washington, DC:
factors that contributes to violent behavior, and the existence of cer-
Urban Institute;1992.
tain “protective” factors that creates resiliency. The design of effective
prevention and intervention strategies should take into consideration 39 Dryfoos J. Adolescents at Risk: Prevalence and Prevention. New York, NY:
the dynamics and inter-relationship of both types of factors. Oxford University Press; 1990.
32 Brandt EN. Curricular principles for health professions education about 40 Dryfoos J. Full Service Schools: A Revolution in Health and Social Services for
family violence. Acad Med. 1997; 72: 51-58. Children, Youth and Families. San Francisco, CA: Jossey-Bass; 1995.
33 Sege R, Licenziato V, eds. Recognizing and Preventing Youth Violence: A 41 Knox L. Youth Violence Prevention and the Health Professions: Core
Guide for Physicians and Other Health Care Professionals. Waltham, MA: Competencies for Effective Practice. Riverside, CA: Southern California
Massachusetts Medical Society; 2001. Developing Center on Youth Violence Prevention; 2001.
The purpose of this guide is to incorporate physicians and other 42 Thomas C, Holzer C, Wall J. The Island Youth Programs: community
health care professionals into the prevention of youth violence. The interventions for reducing youth violence and delinquency.
guide provides extensive materials in an easily assessable format on Adolesc Psychiatry. 2002;26:125-143.
issues such as the basics of youth violence, screening for risk factors,
and the utilization of protective factors. Furthermore, the guide gives
concrete suggestions for prevention from a health care perspective as
well as advocates the need for health care professionals as leaders to
help prevent youth violence.

Speeches
Youth and Community Audience
Reminders
Estimated length of speech: 1 hour
Preparing for the speech
• Recruit co-presenter from community if desired
• Conduct on-line search for recent news stories, local and national data on
violence and prevention programs.
• Personalize speaker’s notes using this information. You can make notes directly on
the hardcopy of this speech or incorporate content and formatting changes using the
Microsoft Word file, which is provided with the electronic version of this guide
(www.ama-assn.org/violence).
• Review issue briefs and on-line information resource sites contained in this manual.
• Download and copy overhead masters onto transparencies or load PowerPoint
presentation on computer.
• If possible, send the PowerPoint slides to the person who will be providing the audio/visual
support for your presentation (3 to 7 days in advance).
Room set-up and preparation of materials
• Arrange room for presentation. Stadium-style seating arrangements are appropriate for
the basic presentation. Arrange for overhead projector or computer projector.
• Make copies of appropriate handouts, issue briefs, and resource list.
Note: This talk is intended to be more interactive than the health professional speech. It includes
several opportunities for discussion among the participants about issues related to youth violence.

Youth and Community Audience (continued)
[Slide #1] Introduction

It is a pleasure to be here with all of you today. I hope to help you
think in new ways about an enormous challenge that faces our
country: The problem is youth violence.
Option: Insert local story on youth violence (3-4 minutes)
[Slide #2] The United States is one of the most violent nations in the world.
We have the highest youth homicide and suicide rates among the
world’s 25 wealthiest nations.1
[Slide #3] Youth violence is an epidemic that has been more devastating to
our young people than polio, AIDS, or motor vehicle crashes.2, 3
• Violence is the second leading cause of death among young
people ages 15 to19 in this country and suicide is the third
leading cause of death.4
• Sixteen million adolescents in the United States have witnessed
some type of violent assault in their lifetime.2
• Each year the medical cost of firearm injuries alone is estimated
to be $2.3 billion, which includes lifetime costs of these injuries.5
There is a common belief that a certain amount of youth violence is
an inevitable reality of the world we live in. All too often our daily
news is punctuated by stories of random acts of violence, from hate
crimes to tragic school shootings, from workplace rampages to
attacks on churches and community centers.
[Slide # 5] Yet violence is not inevitable; it can be prevented. Youth violence has
damaged many, many young lives. But it doesn’t have to continue
to be such a destructive force.
We have real reasons for hope. In fact, the numbers show that
progress is being made, because youth violence has been in decline
from 1994 to 1999.6, 7

The causes of violence

A British author once said “Violence among young people is an
aspect of their desire to create. They don’t know how to use their
energy creatively, so they do the opposite and destroy.”8 I’d like to
take a moment to hear some of your own perspectives.
[Slide #6] Do you think this man was right?
What do you believe causes young people
to act violently?
Stop for discussion (3-4 minutes)
Research findings agree with some of the opinions you have just
expressed. This is what experts tell us about violence:
[Slide #7] We know that violence is learned, and that children
often learn it in their homes 2, 9
• More than 3.3 million children witness physical and verbal
abuse in their homes each year, with some estimates as high
as 10 million.10-13
• Witnessing domestic violence, even among very young children,
can result in depression and anxiety, attention and learning
problems, and a greater likelihood of developing aggressive and
anti-social behavior.14
[Slide #8] We know that children learn violence by being
victimized by family members or other intimates
• In 1999, roughly 826,000 children in the United States were
victims of abuse.15
• Experiencing abuse increases the likelihood that a child will
be arrested as a juvenile by 53% and will commit a violent
crime by 38%.16

[Slide #9] We know that children learn violence by

being victimized by peers
• One in 7 school children is either a bully or has been a victim
of a bully.17,18
• Between 10% and 30% of teens are victims of dating violence.19
[Slide # 10] We know that children learn violence through
watching violent media
• The average child watches 28 hours of television a week and will
see 200,000 acts of violence by age 18.3
• Research suggests that young people who are confronted by
frequent violent images in the media can become immune to the
horror of violence, and come to accept violence as a way to solve
problems.20
[Slide #11] What are some examples of violent media that
concern you?
Other factors also increase risk

[Slide #12] Alcohol and drugs. Research has found that substance
abuse is one of the risk factors that is most predictive of violence.
• Half of youth homicide victims have elevated blood alcohol
levels at autopsy.21-23
• Those who commit homicide also have elevated blood alcohol
levels when apprehended and tested.21-23

[Slide #13] Another risk factor is gangs. Youth gangs are responsible
for a disproportionate share of all criminal offenses, both violent
and nonviolent.6
[Slide #14] And finally, guns. The rise in murders of juveniles from
the mid-1980s through the peak year of 1993 was mainly
firearm-related, as was the subsequent decline in juvenile
murders through 1997.6, 7
• In some parts of the country, firearms have surpassed auto crashes
as the leading cause of death among children and youth.24
• Teenage boys are more likely to die from gunshot wounds than
from all natural causes combined.25
• Guns are easy for young people to get. Family and friends
are the primary source of guns for young people.26
[Slide #15] What risk factors do you see in your community
(school)? Which ones concern you the most?
Preventing violence
Just as there are many risk factors for violence—we just covered a
few of the most important ones—there also are many factors that
can prevent violence.
[Slide #16] These include:2, 27
• Having a strong relationship with a caring, responsible adult
• A positive and welcoming school environment and experiencing
success in school
• Having dreams and plans for the future (future orientation)
• Having the ability to not act on strong emotions and impulses
(impulse control)

• Effective prevention programs—like family counseling with a

trained clinician and positive youth development programs.
[Slide #17] At the beginning of this speech, I made the statement that violence is
not inevitable, and that it can be prevented. To prove it, I want to tell
you about a success story. In the 1990s, violent crime across the
nation declined 19%, but in Galveston, Texas, it dropped by 78%.28
This was due in part to the Galveston Island Youth Programs. These
programs included supervised recreational activities, training in critical
social and problem-solving skills in elementary school, peer courts,
and intensive home-based counseling services for frequent or violent
offenders.
Insert local success story (3-4 minutes)
[Slide #18] Do you have programs like this in your community?

What resources are there for violence prevention in
your community? What can you do to prevent
violence in your community?
Those are some great ideas. And here are a few

more ideas you may not have thought of
(include as needed)3:
[Slide #19] • First and most important. Get involved! Many people
get the idea that the problem is too big and there is nothing they
can do. But even just a few of you can make a big difference in
your community (schools, homes). So get involved. Get a group of
your friends together and work with your school or with a program
in your community to increase the peace. Start a program like
Galveston. Always think you can make a difference.

• Let others know that violence isn’t normal and that

it can be prevented. Tell them about the success stories you
learned about during this presentation today. Sometimes people
just need a little inspiration.
[Slide #20] • Become informed consumers of the media. Be critical
about what you and your family see on TV or at the movies, what
you listen to on the radio, and look at on the computer. Watching
excessive violence can make you a different person—and not a
better one.
[Slide #21] Optional: Mini-Skill-Building Exercise in Media Literacy:

optional Visit the American Academy of Pediatrics “Media matters”
Web site for recommendations for teaching media literacy skills:
http://www.aap.org/advocacy/mmguide.pdf.
[Slide #22] • Don’t keep guns in the home. If you must, use
[Slide #23] • safe storage procedures.29 Keep guns unloaded and store
guns and ammunition separately. Store both in locked containers,
with a responsible adult holding the keys or access codes securely
on his/her person at all times. Use trigger locks and other devices
to immobilize firearms. And remember, young people are not only
at risk in their own homes. Be sure other homes your children or
siblings visit use safe firearm storage procedures as well.

[Slide #24] • For young people: talk to a trusted adult about

problems with violence and walk away if you see a
firearm. If you or one of your friends is having a problem with
violence—such as bullying or gangs or violence in the home—talk
to a trusted adult about this. The adult may be a parent, a teacher,
even a parent of one of your friends. Let them know what is going
on and ask for their help. It’s not “tattling”—it’s being responsible
and a good friend. If you are in a situation where firearms are
present, even if one of your friends is just “showing off,” walk away
and tell a responsible adult about the weapon. Again, it’s not “
tattling”—it’s being responsible and a good friend.
[Slide #25] Concluding statements
Some years ago, a wise person wrote, “In violence we forget who we
are.”30 The tragedy of youth violence is that so many young people,
who either caused violence or were themselves the victims, lost the
chance to find out who they really were. We must work together to
stop the violence. Get involved so that all young people will have a
chance to discover who they are.
Thank you

4 Cohen L, Potter L. Injuries and violence: risk factors and opportunities

Annotated Bibliography:
for prevention during adolescence. Adolesc Med. 1999;10:125-135.
1 Centers for Disease Control and Prevention. Rates of homicide,
suicide, and firearm-related death among children: 26 industrialized More adolescents in the United States die from injuries than from any
countries. Morb Mortal Wkly Rep. 1997; 46:101-105. other cause. This article describes the three leading causes of death
among adolescents—interpersonal violence, suicide, and motor
2 US Department of Health and Human Services. Youth Violence: A Report
vehicle-related injuries. The authors examine risks associated with
of the Surgeon General. Rockville, MD: Department of Health and
alcohol use and access to firearms as well as injuries that occur at
Human Services, Centers for Disease Control and Prevention, National
work and while playing sports, and provide recommendations for pre-
Center for Injury Prevention and Control; Substance Abuse and Mental
venting adolescent injuries for health care providers, schools, and
Health Services Administration, Center for Mental Health Services; and
communities.
the National Institutes of Health, National Institute of Mental Health;
2001. 5 Cook P, Lawrence J, Bruce A, Ludwig J, Miller, TR. The medical costs
of gunshot injuries in the United States. JAMA. 1999; 282:447-454.
The Surgeon General’s report summarizes recent research on the
causes and prevention of youth violence. The report provides an This study estimates costs for firearm injury, including lifetime costs
overview of prevalence, findings on the developmental dynamics of associated with this type of injury. The analysis is based on emergency
youth violence, risk and protective factors, and model, promising, and department data from hospitals in three different states, as well as
ineffective prevention and intervention programs. Risk and protective databases such as the National Electronic Injury Surveillance System.
factors are reviewed by domain—individual, family, school, peer Furthermore, the authors delineate the burden of these costs (namely,
group, and community. Programs are categorized as primary, government and private sector). They also produce a mean cost-per-
secondary, and tertiary prevention programs. Effective primary injury as they illustrate the effect of gun violence on the medical sec-
prevention strategies include: skills training, behavior monitoring tor.
and reinforcement, building school capacity, and positive youth 6 Snyder H, Sickmund M. Juvenile Offenders and Victims: 1999 National
development, among others. Effective secondary prevention strategies Report. Washington, DC: US Department of Justice; 1999.
include: parent training, home visitation, and social problem solving,
This report offers a comprehensive overview of the pervasive problems
among others. Effective tertiary prevention strategies include:
of juvenile crime, and it reviews the response of the juvenile justice
multimodal intervention, skills training, and marital and family therapy
system. It contains statistics from a variety of sources on a wide array
by clinical staff, among others. Ineffective programs include peer
of topics, including juvenile population characteristics, juvenile victims,
counseling and mediation, gun buyback programs and firearm
juvenile offenders, juvenile justice system structure and process, law
training, boot camps, residential programs, waivers to adult court,
enforcement and juvenile crime, juvenile courts, and juveniles in
and individual counseling.
correctional facilities.
3 Commission for the Prevention of Youth Violence. Youth and Violence:
7 Federal Bureau of Investigation (various). Supplementary reports
Medicine, Nursing and Public Health: Connecting the Dots to Prevent
for the years 1980-1997 [machine-readable data files].
Violence. Chicago, IL: American Medical Association; 2000:31.
Washington, DC: FBI.
8 Anthony Burgess (b. 1917), In: Independent L. ed. London 1990.
9 da Silva, Julia M, Sterne M, Anderson P. ACT (Adults and Children

Together) Against Violence. Washington, DC: American Psychological
Association, National Association for the Education of
Young Children; 2001.

10 Horn D. Bruised inside: What our Children Say About Youth Violence, 16 Widom CS. The cycle of violence. Research in Brief. Washington, DC:
What Causes It and What We Need to Do About It. Washington, DC: US Department of Justice, Office of Justice Programs; 1992.
National Association of Attorneys General; 2000. This longitudinal study tested the cycle of violence hypothesis by
This report chronicles meetings held with youth, parents, tracking more than 1,500 cases from childhood to adulthood. The
teachers, and school administrators. It is a description of the findings study utilized a multi-method research design by incorporating arrest
from these meetings. The authors recommend steps that can be taken data, interviews, and comparison groups. The focus encompassed vari-
by parents, youth, schools, communities of faith, and others ous forms of abuse including neglect in the overall effect of future
to help prevent youth violence and describe state-by-state violent behavior.
efforts that attorneys general are making to curb 17 Brooks K, Schiraldi V, Ziedenberg J. School House Hype: Two Years Later:
youth violence. Executive Summary. Washington, DC: Justice Policy Institute, Children’s
11 Carlson BE. Children’s observations of interparental violence. In: Law Center; April 2000.
Roberts AR, ed. Battered Women and Their Families. New York, NY: 18 Batsche G, Moore B. Bullying fact sheet. In: Behavioral Interventions:
Springer; 1984:147-167. Creating a Safe Environment in Our Schools. Bethesda, MD: National
12 Jaff PG, Wolfe D, Wilson S. Children of Battered Women. Mental Health and Education Center for Children and Families,
Newbury Park, CA: Sage Publications; 1990. National Association of School Psychologists;1998:14-16.
13 Rennison CM, Welchans S. Intimate partner violence. Bureau of Justice 19 American Medical Association Alliance, Inc. SAVE (Stop America’s
Statistics Special Report. Washington, DC: US Department of Justice; Violence Everywhere) Schools From Violence. Chicago, IL:
2000. AMA Alliance, Inc; summer 1999.
14 Hawley T. Safe Start: How Early Experiences Can Help Reduce Violence. 20 Donnerstein E, Slaby R, Eron L. The mass media and youth violence. In:
Chicago, IL: The Ounce of Prevention Fund; 2000. Murray J, Rubenstein E, Comstock G. eds. Violence and Youth:
Many initiatives have been proposed and implemented to reduce Psychology’s Response, Vol. 2. Washington, DC: American Psychological
the incidence of violent crime, including community policing, stiffer Association; 1994.
sentences for convicted criminals, and programs to keep adolescents This chapter contributes to the literature on media effects and vio-
involved in positive activities and “off the streets.” However, many lence. It reinforces the findings over a span of 20 years about this
communities have overlooked what a national organization of law relationship. Specifically, violence in media can lead to aggression and
enforcement officials and crime victims cites as the most promising aggressive attitudes as well as desensitizing youth to violence and the
approach to reducing violence: prevention and intervention programs use of violence in interpersonal relationships.
for very young children ages birth to 5. Built on decades of research 21 Adams PF, Schoenborn CA, Moss AJ. Health Risk Behaviors among
on child development, these programs are making lasting differences our Nation’s Youth: United States, 1992 [DHHS publication 95-1520].
and helping young children receive a safer start in life. Hyattsville, MD: National Center for Health Statistics; 1994.
15 US Department of Health and Human Services. Ten Years of Reporting 22 Prothrow-Stith D, Spivak HR. Violence. In: McAnarney ER, Kreipe RE,
Child Maltreatment 1999. Washington, DC: US Government Printing Orr DP, Comerci GD, ed. Textbook of Adolescent Medicine. Philadelphia,
Office; 1999. PA: Harcourt Brace Jovanovich; 1992:1113-1118.
The project spans 10 years of research on the methods by which child
maltreatment is assessed and reported in the United States. The study
is nationwide and focuses on the mode by which referrals parlay into
investigation by child protective services. It also provides demographic
information on the children as well as the characteristics of the perpe-
trators. The future of child protective services is analyzed in the con-
text of the information provided within this project.

23 Mann RP, Borosowsky I, Stolz A, Latts E, Cart C, Brindis C. Youth 27 Search Institute. 40 Developmental Assets. Available
Violence: Lessons From the Experts. Washington, DC: Maternal and Child at:http://www.search-institute.org/assets/forty.htm.
Health Bureau, Health Resources and Services Administration, Public Accessed: May 23, 2000.
Health Service; US Department of Health and Human Services; 1998. 28 Thomas C, Holzer C, Wall J. The Island Youth Programs: community
This report presents responses from both professionals and interventions for reducing youth violence and delinquency.
youth as to what professionals, parents, youth, and citizens can do to Adolesc Psychiatry. 2002; 26:125-143.
protect themselves from violence. It also includes descriptions 29 TIPP. The Injury Prevention Program: Firearms Injury Prevention.
of some violence prevention programs that appear to have a good Elk Grove Village, IL: American Academy of Pediatrics; 2000.
chance of success. This is a tool for health care professionals and
30 McCarthy (1912-1989). In: Characters in Fiction, On the Contrary,
educators; maternal and child health directors and adolescent health
pt. 3; 1961.
coordinators, societies, and professional organizations that work with
children and youth; and the hundreds of government policymakers
at local, county, and state levels.
24 Fingerhut LA, Jones C, Makuc DM. Firearm and motor vehicle injury
mortality—variations by state, race and ethnicity: United States,
1990-1991. Advance Data From Vital and Health Statistics, No. 242.
Hyattsville, MD: National Center for Health Statistics; 1994.
This study is part of the Healthy People 2000 initiative, which seeks
to reduce both fatal motor vehicle accidents and homicides. The
initiative’s focus is on individuals aged 15 to 24 years as well as the
impact on people of color. The study compares death rates in these
two categories delineated by race and age as well as within the
states. Furthermore, the analysis compares across states by these
variables.
25 Coordinating Council on Juvenile Justice and Delinquency Prevention.

Combating Violence and Delinquency: The National Juvenile Justice Action
Plan/Report. Washington, DC: US Department of Justice; March 1996.
26 Sheley J, Wright J. High school youths, weapons, and violence: a

national survey. Research in Brief. Washington, DC: National Institute
of Justice, US Department of Justice; 1998.
This Research in Brief examines the extent to which a national sample

of male high school sophomores and juniors was involved in, or
otherwise affected by, firearm-related activity. Surveys were mailed to
high school students that sought information on their firearm—and
crime-related activities for the 12 months prior to the survey as well
as social, demographic, and personal information for each respondent.

Section 3
Slides
• Master list of slides for health professional speech
• Master list of slides for youth and community speech

Slides
Slides to accompany speeches

A good speech includes effective audiovisual To increase the visual appeal of your slide presentation,
materials. Slides are available for you to use with consider adding photographic images to the
each speech and can be downloaded free of charge PowerPoint file. Two good sites for viewing and
from http://www.stopyouthviolence.ucr.edu and purchasing images are: http://www.fotosearch.com and
http://www.ama-assn.org/violence. http://www.blackstar.com. These sites allow you to
The slides are available in Powerpoint and can be purchase single images or an entire series of images relat-
modified to include your name and institution, and ed to specific themes.
information on the local community you identify
during your online search.
Based on the resources available to you at the
presentation site, you may decide to download the
PowerPoint presentation and use a computer projector
to display the images directly from your computer;
or you may opt to download the files and print the
visual aids onto transparencies for use with an
overhead projector.
Slides 45 Connecting the Dots to Prevent Youth Violence

Slides
Health Professional Presentation
Introduction

A Training and Outreach Guide for
Physicians and Other Health Professionals
Slide 1
Youth violence opportunities

for prevention
Name
Date
Institution
Health Professional Training
Slide 2
The problem
• The United States has highest youth homicide
and suicide rate among the wealthiest developed
nations (Task Force on Violence, 1999).

Health Professional Presentation (continued)
Slide 3
Impact of violence on health

• Homicide is second leading cause of death for
youth ages 15-19 (Cohen & Potter, 1999).
• Medical costs just for firearm injuries are
estimated at $2.3 billion a year
(Cook et al, 1999).
Slide 4
Impact on health
• Recent research shows changes to brain structure
and chemistry following exposure to extreme
violence (Niehoff,1999).
Slide 5
The public health approach

• Like polio and other public health threats,
violence can be prevented.

Slide 6
The causes of youth violence

➔
Risk factors
➔
Protective factors
Slide 7
Violence is learned by
being victimized
• Approximately 826,000 children were victims
of maltreatment in 1999 (US DHHS).
• Experiencing child abuse and neglect increases
the likelihood of arrest as a juvenile by 53% and
of committing violent crimes by 38%.
(Widom, 1992).
Slide 8
Violence is learned
• The 3.3 million children who witness domestic
abuse each year are 15 times more likely to
become victims or perpetrators of violence
(Carlson, 1994; Horn, 2000).
• They are also more likely to be victimized in
intimate relationships as adults as well as to
become a perpetrator or victim of violence on
the streets (Widom, 1992).

Slide 9
Violence is learned by exposure
to violent media
• By age 18, a child has seen 200,000 acts of
violence on TV and other media.
• Studies suggest that children confronted
incessantly by violent images may become immune
to the horror of violence and may come to accept
violence as a way to solve problems
(AMA, 1996; Donnerstein et al, 1994).
Slide 10
Alcohol and drugs are risk factors

• 50% of youth homicide victims have elevated
blood alcohol levels (Mann, et al, 1998; Adams et
al, 1992; Prothrow-Stith, 1992).
• 50% of youth who perpetrate homicide have
elevated blood alcohol levels (Mann, et al, 1998;
Adams et al, 1992; Prothrow-Stith, 1992).
Slide 11
Firearms
• Teenage boys are more likely to die from gunshot
wounds than from all natural causes combined
(Coordinating Council on Juvenile Justice and
Delinquency Prevention, 1996).
• Family and friends are the primary source of guns
for young people (Sheley & Wright, 1998).

Slide 12
A combination of factors
• Violence is not the result of a single factor.
• Violence is the result of the interaction of
multiple individual, situational, contextual,
and society influences (National Youth Violence
Prevention Resource Center, 2001).
Slide 13
What health care professionals

can do:
• Educate youth about ways to reduce risk and
increase protection.
• Screen youth for risk and exposure.
• Refer them to comprehensive support programs.
(Brandt, 1997; Sege et al, 2001; Cohn, 2001)
Slide 14
Three Phases of the Haddon Matrix
Pre-injury Prenatal care
Routine preventive care
Acute care unrelated to injury
from violence
Injury
Post-injury Acute
Urgent
Emergency care related to injury
from violence
(National Committee for Injury Prevention
and Control, 1989)

Slide 15
Post-injury: educate
• Educate parents on methods to help child avoid
re-injury, and to cope with emotional trauma.
• Educate young people on the same topics.
Slide 16
Post-injury: assess
• Document injuries and surrounding events.
• Seek further psychiatric evaluation.
• Risk factors for re-injury:
– Is conflict settled?
– Does person feel safe leaving health setting?
– Is he/she thinking about revenge?
– Is there a safe place to go while things cool off?
Slide 17
Post-injury: refer
• Refer young people and families to mental health
and crisis services.
• Refer to long-term comprehensive services.
• Notify authorities in case of abuse/neglect or when
plans for revenge warrant.

Slide 18
Don’t forget “invisible victims”

of violence
• Child witnesses to domestic violence are victims—
we often forget them.
• In a “cycle of violence,” many young perpetrators
have also been witness to and victims of violence.
(Widom, 1992).
Slide 19
Post-injury—“invisible injuries”
• Educate caregivers on emotional impact of
witnessing violence and methods to help
child cope.
• Screen young people for exposure.
• Refer to comprehensive programs with mental
health services.
Slide 20
Three Phases of the Haddon Matrix
Pre-injury Prenatal care
Routine preventive care
Acute care unrelated to injury
from violence
Injury
Post-injury Acute
Urgent
Emergency care related to injury
from violence
(National Committee for Injury Prevention
and Control, 1989)

Slide 21
Pre-injury: educate
• Educate parents on strategies to build protective
socio-emotional competencies.
• Educate on the effects of media violence and ways
to reduce exposure.
• Educate on firearms and ways to reduce risk such
as safe storage procedures.
Slide 22
Pre-injury: screen
• Age-appropriate screening for risk factors
throughout child’s development.
• Examples of tools for use with adolescents:
– Fighting
– Injuries
– Sex
– Threats
– Self-defense
Slide 23
Pre-injury: refer
• Connect young people who show risk and
their families to comprehensive and effective
prevention programs.

Slide 24
Effective programs
• Early start
• Long-term
• Intense
• Strong connection with supportive adult
• Involve many sectors (health care, schools, police,
community, business).
(Dryfoos, 1990; Burt and Resnick, 1992;
US DHHS, 2001).
Slide 25
Galveston, Texas–
Island Youth Programs
Slide 26
Beyond the clinic
The Ecological Framework
• Work with
schools. Environment
Community
• Work with
community Family
coalitions. Individual
• Advocate for
effective policy.
(Commission for the
Prevention of Youth Violence, 2000).

Slides
Youth and Community Presentation
Introduction

A Training and Outreach Guide for
Physicians and Other Health Professionals
Slide 1
Youth violence—What you can do

Name
Date
Institution
Youth and Community Outreach
Slide 2
The problem
• The United States has the highest youth homicide
and suicide rate among the wealthiest developed
nations (CDC,1997).

Youth and Community Presentation (continued)
Slide 3
Magnitude and scope of violence

• Homicide is second leading cause of death
for youth ages 15 to 19 and suicide is the third
(Cohen & Potter, 1999).
• Sixteen million adolescents in the United States
have witnessed some type of violent assault in
their lifetimes, including up to 95% of children in
our inner cities (US DHHS, 2001).
Slide 4
Impact on health
• Firearm injuries cost up to $2.3 billion
annually in medical costs (Cook, 1999).
• Recent research shows changes to brain
structure and chemistry following exposure
to extreme violence (Niehoff, 1999).
Slide 5
Violence can be prevented

• Violence is not inevitable. Like polio and other
public health threats, violence can be prevented.
• Numbers show that some progress is being made
because youth violence has been in decline from
1994 to 1999 (Snyder, 1999; FBI, 1997).

Slide 6
Discussion
Violence among young people is an output
of their desire to create. They don’t know
how to use their energy creatively, so they
do the opposite and destroy.
Slide 7
Violence is learned in
the home
• More than 3 million children witness physical
and verbal domestic abuse in their homes each
year (Horn, 2000; Carlson, 1984; Jaff, 1990).
• Effects of witnessing domestic violence can
include traumatic stress reflected in higher levels
of depression and anxiety, attention and learning
problems, and greater likelihood of developing
aggressive and anti-social behavior
(Hawley, 2000).
Slide 8
Violence is learned by being

victimized by intimates
• 826,000 children in the United States were mal-
treated in 1999 (US DHHS).
• Experiencing child abuse and neglect increases
the likelihood of arrest as a juvenile by 53%
and of committing a violent crime by 38%
(Widom, 1992).

Slide 9
Violence is learned from peers
• One in 7 school children is either a bully or has
been the victim of a bully (Brooks, et al, 2000;
Batsche G, et al, 1998).
• Between 10% and 30% of teens experience
violence while dating. This is not surprising in
light of a survey of two Chicago high schools,
in which 28% of boys responding believed that
“girls needed to be punched or slapped sometimes”
(American Medical Association Alliance, 1999).
Slide 10
Violence is learned from media

• A child views about 25 acts of violence a day
on television. By age 18, that child will view
16,000 simulated murders and some 200,000 acts
of violence (Commission for the Prevention of
Youth Violence, 2000; Donnerstein et al, 1994).
Slide 11
Discussion questions
• What are examples of violent media that
concern you? Why?

Slide 12
Alcohol & drugs

• 50% of youth homicide victims have elevated
blood alcohol, as do 50% of youth who commit
homicide (Adams et al, 1992; Prothrow-Stith et al,
1992; Mann et al, 1998).
Slide 13
Gangs
• Youth gangs are responsible for a disproportionate
share of all criminal offenses, both violent and
nonviolent (Snyder et al, 2000).
Slide 14
Guns
• Teenage boys are more likely to die from gunshot
wounds than from all natural causes combined
(Coordinating Council on Juvenile Justice and
Delinquency Prevention, 1996).
• Family and friends are the primary source of guns
for young people (Sheley & Wright, 1998).

Slide 15
• What risk factors do you see in your community
and/or school?
• Which ones concern you the most?
Slide 16
Factors that “protect” youth

• Relationship with a responsible adult
• Positive school experiences
• Plans and dreams (future orientation)
• Ability to control impulses
(Search Institute, 2000)
Slide 17
A success story
• Galveston, Texas, and the Island Youth Programs
(Thomas, 2002).

Slide 18
• What resources are there for violence prevention
in your community?
• What can you do to prevent youth violence?
Slide 19
What you can do to

prevent violence…
• Get involved.
• De-normalize violence—it’s not normal.
(Commission for the Prevention of Youth
Violence, 2000).
Slide 20
Media—
What you can do to
prevent violence
• Watch what you and your family watch.
• Become media literate.

Slide 21
Media literacy skills

• Plan ahead what you are going to watch/hear.
• Ask yourself about the motivations of producers.
• Ask yourself how the problems depicted could be
solved without the use of violence.
• Imagine what the real-life consequences of the
violence you see in the show would be.
(American Academy of Pediatrics, 1999).
Slide 22
Firearms—
What you can do to
prevent violence
• Walk away if you see a gun.
• Don’t keep guns in the home.
• Use safe firearm storage procedures and know
if parents in homes youth visit also do so.
Slide 23
Firearm safety
procedures
• Store ammunition and guns separately.
• Keep both in locked containers.
• Adult keeps keys/access code secure on
person at all times.
• Put trigger locks on firearms.
(American Academy of Pediatrics, 2000).

Slide 24
What you can do to

prevent violence
• Talk to a trusted adult if you or one of your friends
is being bullied.
• About problems with alcohol and drugs.
• About violence in the home or school.

Section 4
Case Studies
• Bullying
• Firearms
• Media violence
Case Studies
Bullying
Case: Antonio
Age: 10 years old
Grade: 5th grade
Problem: Bullying
Antonio is 10 years old and attends Main Elementary School just a few blocks from his home. He is in the 5th grade
and is an average student. Antonio has always been a bit shy and somewhat anxious around his peers. He just moved
to his new city 3 months ago and has not developed any close friends at his new school, although he does have a
“best friend” who lives in a different city. Antonio is unusually tall and thin for his age and is very self-conscious
about his appearance.
Over the past month Antonio has become increasingly withdrawn. Several weeks ago he came home with a tear
in his favorite jacket. When his mother asked him what happened, he hurriedly said it was an “accident.” He
talks less and less to his peers at school, and when he comes home he goes straight to his room and shuts the door.
When his mother tries to talk to him he says nothing is wrong and tells her to go away. She has noticed that
recently he is more irritable and is often tearful. His mother worries about him but believes he is going through a
phase and will “grow out of it.” She also worries about making Antonio too dependent on her if she gets overly
involved in his problems.
You hear through others that Antonio is being teased at school by some of his classmates. You also hear that this
is not a one-time event, rather, that it happens several times a week. In particular, you hear that there are two
children—a girl, Rebecca, and a boy, Jonathon—who make fun of the way he looks and have convinced most of
his classmates to make him sit alone at lunch.
Discussion Questions:
Do you see a problem and, if so, what is it?
Why is bullying a serious problem?
How could you encourage Antonio to talk about what is going on?
What could you do to help Antonio?
Case Studies 67 Connecting the Dots to Prevent Youth Violence

Bullying (continued)
1. Do you see a problem and if so Common adult responses. Parents of children who
what is it? are involved in bullying, either as a perpetrator or as the
victim, are frequently unaware that their children are
Antonio is a victim of teasing or bullying involved. In some instances, adults—teachers includ-
by his peers. ed—believe that bullying is a “rite of passage” in a child’s
Definition. Bullying is a serious problem and is a form maturation process. They believe that children must be
of violence. Bullying involves repeated negative acts left to sort it out on their own, or they will not be able
committed by one or more children against another.1 to handle problems when they grow up. A common
Bullying includes verbal teasing and abuse by peers, statement made about bullying is that “kids will be kids.”
pushing and shoving, or even psychological abuse Others may be uncomfortable with watching children
through playing “tricks” or “practical jokes” on the engage in bullying, but not knowing how to respond,
victim. Approximately 10% to 15% of youth are bullied they do nothing.
or are initiators of bullying behavior on a regular basis.2, 3
Risk factors. Children who are at risk for being bullied
2. Why is bullying a serious problem?
or teased often are shy and feel awkward with their
peers. They may be described as “lacking social skills.” Impact on the victim. Bullying is a serious form of
They may have characteristics that make them different violence, and the effects of bullying can be life-long.
from their peers. For example, a child may have Children who are bullied may be at increased risk
unusual physical features like Antonio’s awkward height for depression, anxiety, poor self-esteem, and other
or a child may be of a different race or ethnic group problems.2 In extreme and unusual instances, bullied
or have a disability, such as a speech impediment, that youngsters may resort to aggressive and violent acts
sets him or her apart from peers.4 to defend themselves, or may attempt to harm
themselves through suicide.
Children may be particularly at risk for bullying and
other forms of violence during important transitions Impact on the perpetrator. Children who do the
in their lives—times when they are going through bullying are also at increased risk for negative outcomes.
important changes. Such changes may include a Chronic bullies are several times more likely than their
major family transformation such as a divorce or, as nonbullying peers to commit antisocial acts, including
in Antonio’s case, a recent move to a new city and a vandalism, fighting, and truancy, and to have an arrest
new school. by young adulthood.2, 5, 6
Warning signs. Children who are bullied frequently are Impact on the school/community. Not only does
isolated from others and may not have a social support bullying affect the victim and the bully, but allowing
system to turn to for assistance. They may withdraw bullying to occur in a school or community can
from their peers and from the adults in their lives. Like contribute to negative climate in the school or
Antonio, they may retreat to their room and refuse to neighborhood, and contribute to all of the children
answer family members’ questions about what is happen- feeling unsafe and anxious.
ing in their life. They may also appear irritable, even
angry, or they may cry frequently. They may come home
with unexplained injuries or damaged property, like
Antonio did with his jacket. Children who are bullied
may try to avoid going to school in the morning, or may
appear upset when they return home from school.

3. How can you encourage Antonio to • Give Antonio a copy of information on bullying
talk about what is going on? for young persons such as Bullying Prevention:
Recommendations for Kids from the CSPV.9
You can tell Antonio that you care and are concerned
• Work with Antonio’s school to implement a
about him. Ask him to tell you what is going on and
comprehensive violence prevention plan that includes
give him opportunities to talk to you openly. Explain
an anti-bullying component such as the promising
that telling is not tattling and that telling will help you
program from the Blueprints series, The Bullying
help him. When he begins to talk, respond to him in an
Prevention Program.11
accepting and positive way, and tell him that it’s not his
fault and that he did the right thing by telling you. As a parent or trusted adult:9
4. What might you do to help Antonio? • Ask Antonio what he thinks should be done, what
he’s already tried, and whether it worked or not.
Interventions that have proven to be effective in reduc-
• Talk to Antonio’s teacher, principal, or school
ing bullying in schools and other settings are compre-
counselor and ask for their help. Ask them to find
hensive and involve developing a culture of intolerance
out about programs other schools and communities
for bullying among young people and adults, and training
have used, such as the promising program from the
in identifying and interrupting bullying behavior. While
Blueprints series, The Bullying Prevention Program.11
in the past most anti-bullying programs have emphasized
building social and conflict management skills in the • Encourage Antonio to try walking away to avoid
victimized child, more recently, research is suggesting the bully, or to ask for help from a nearby adult.
that programs that target the peers of bullied children Do not encourage him to fight the bully.
and teach them to intervene during episodes of bullying • Help Antonio practice what to say to the bully
may be effective methods for reducing victimization. to defuse the situation.
As a health professional:7, 8 • Help him practice being assertive—for example,
• Add a violence history to patient examinations that insisting that the bully leave him alone.
addresses exposure to violence, safety issues, stressors • Suggest he stay with his friends as much as possible
in school, family, and community. Gather this history and avoid being alone, since bullies are less likely
on Antonio. to pick on a child in a group.10
• Talk to Antonio’s parents/caregivers about bullying As a young person who is being bullied:10
and its seriousness. Address any myths they might
• If you are being bullied, tell your parents or a trusted
hold about bullying being a normal part of childhood
adult. Telling is not tattling. Your parents or another
or rite of passage.
adult can help you figure out what to do.
• Provide information to Antonio’s parents about
• Tell your teacher or principal or school counselor.
bullying and how to help their child respond to
If you are uncomfortable, you can bring someone
bullying. Give them materials such as the American
with you or you can have a trusted adult talk to
Academy of Child and Adolescent Psychiatry’s
them for you.
Facts for Families No. 80 on Bullying,8 or Bullying
Prevention: Recommendations for Parents from the • Do not fight the bully. Try to walk away or defuse
Center for the Study and Prevention of Violence the situation or respond calmly and firmly. A bully
(CSPV).9 likes to see you get upset.

• To prevent being bullied, develop friendships with References

other young people. Bullies are less likely to bother 1 Limber SP, Nation MM. Bullying among children and youth.
you if you are in a group. Juvenile Justice Bulletin. NCJ167888. April 1998;4-5. Available
at: http://ojjdp.ncjrs.org/jjbulletin/9804/bullying2.html.
• Act confident; make eye contact and walk with
your head up. Bullies are less likely to pick on you 2 Olweus D. Bullying at School: What We Know and What We
Can Do. Cambridge, MA: Blackwell;1993.
if you look sure of yourself.
3 Limber SP, Cunningham P, Florx V. “Bullying among school
• Avoid unsupervised areas of the school or children: preliminary findings from a school-based interven-
neighborhood where you are isolated from your tion program.” Read before the Fifth International Family
peers or adults. Violence Research Conference, Durham, NH. June 1997.
As a young person who is the friend of someone 4 Batsche GM, Knoff HM. Bullies and their victims:
being bullied:10 understanding a pervasive problem in the schools.
School Psychol Rev. 1994;23:165-174.
• To help a person who is being bullied, do not join
5 Oliver R, Hoover JH, Hazler H. The perceived roles
in if you see that someone is being bullied, even if of bullying in small-town Midwestern schools.
the bully tries to get you to participate. J Counseling Development. 1994;72:416-419.
• Get a teacher or responsible adult to come help. 6 Enron LD, Husemann LR, Dublow E, Romanoff R, Yarmel PW.
This is not tattling. This is you showing compassion Aggression and its correlates over 22 years. In: Crowell DH,
for someone who is being hurt, and you saying that Evans IM, O’Donnell CR, eds. Childhood Aggression and
Violence: Sources of Influence, Prevention and Control.
you think bullying is not acceptable and do not
New York, NY; Plenum;1987:249-262.
want anyone to get hurt.
7 Commission for the Prevention of Youth Violence. Youth and
• Try to get the person being bullied to tell his or her Violence: Medicine, Nursing, and Public Health: Connecting
parents or a trusted adult. Go with the person if it the Dots to Prevent Violence. Chicago, IL: American Medical
makes him or her more comfortable. Association; 2000.
• If your friend is unwilling to report the bullying, tell a 8 American Academy of Child and Adolescent Psychiatry.
Bullying. In: Facts for Families. Washington, DC: American
trusted adult yourself. Do not let the bully know so
Academy of Child and Adolescent Psychiatry; 1998. Available
that he or she does not become aggressive toward you. at: http://www.aacap.org/publications/factsfam/80.htm.
• Encourage your school to start an anti-bullying 9 Center for the Study and Prevention of Violence.
program if they do not have one. Bullying: Recommendations for Parents. Available at:
http://www.Colorado.EDU/cspv/infohouse/factsheets.html.
Accessed: January 2002.
10 Center for the Study and Prevention of Violence.

Bullying: Recommendations for Kids. Available at:
http://www.Colorado.EDU/cspv/infohouse/factsheets.html.
Accessed: January 2002.
11 Olweus D, Limber S, Mihalic SF. Bullying Prevention Program.

Boulder, CO: Center for the Study and Prevention of Violence,
Institute of Behavioral Science, University of Colorado; 1998.

Case Studies
Firearms
Case: Thomas
Age: 16 years old
Grade: 11th grade
Problem: Firearms and Violent Environment
This morning, Thomas, who is 16 years old, was caught carrying a gun onto his high school campus. The campus
police were called and Thomas explained to them that he brought the gun from home and is carrying it for
“protection.” There has been an increase in violence in the community surrounding the school and Thomas looks
nervous when describing his recent encounters with some gang members at the school. Until now, Thomas has been
doing fairly well in school. He is making Bs and Cs in his classes and talks about enrolling at the local community
college after he graduates to study computers. He is popular with his peers, but several of his teachers are concerned
about his friendships with several youths whom they believe to be active in a local gang.
Thomas has a close relationship with his mom and younger brother. Thomas’ father no longer lives with them.
When he did, he was distant and occasionally was physically abusive to Thomas’ mother. There have been several
shooting incidents and robberies in Thomas’ neighborhood in the past year, and because of this Thomas’ mother
keeps a loaded gun in the home for self-defense. She keeps the gun hidden under her sweaters in her closet and
believes that, “Thomas will never find it there.” To be certain, she has instructed Thomas never to touch a gun
if he ever finds one.
Because Thomas has no previous criminal record and no gang affiliation, he spends minimal time in custody and is
released to his mother. The school suspends him for a period of time. During his suspension, Thomas and his mother
will begin a life skills training program at the local Boys Club. They will also see a trained counselor for family
therapy, who will use a multisystemic therapy approach. At the end of the suspension period, Thomas will complete
the school year at the Alternative Learning Center adjacent to the school.
What factors place Thomas at risk for becoming involved in serious violence?
What elements in Thomas’ life can help protect him against involvement in serious violence?
What can you do to help Thomas and his family?

Firearms (continued)
1. What factors place Thomas at Living in a distressed community. Thomas lives in a

risk for becoming involved in community that is distressed, a place where violence is
serious violence? common and gangs are evident. Young people who live
in communities like Thomas’ and who are involved with
The presence of a firearm in the home and failure to street gangs, whether voluntarily or involuntarily, are at
store it properly. A major risk factor for Thomas and greater risk both for becoming the victim of violence and
for his younger brother is the presence of a firearm in for becoming a perpetrator.8
their home. Guns in the home are much more likely
Peer group. During adolescence, young people are
to be used in a suicide attempt or to intimidate family
influenced by the behavior of their peers. In fact, many
members than in self-defense against an intruder.1, 2
researchers believe that at this stage, young people are
To increase the risk further, Thomas’ mother does more influenced by their peers than by the adults in the
not use safe storage procedures. Instead of storing the their lives.7 Young people whose friends are involved
ammunition and firearm in separate locked containers, in gangs or other high-risk activities, are more likely to
having the only set of keys that she keeps engage in these high-risk activities themselves.9 Several
inaccessible to others, or using a safety device such of Thomas’ friends are involved in gangs, which engage
as a trigger lock to secure her gun, Thomas’ mother in high-risk behaviors that are frequently violent. His
keeps the gun loaded, unlocked, and believes her association with these individuals increases the risk that
children will not touch it if they find it. Thomas will become involved in the high-risk behaviors,
Young people often do not adhere to parental including violence.
prohibitions to not touch a gun. In fact, these The influence of peers is also an important factor to
prohibitions may make a young person even more consider when Thomas returns to school. Being placed
likely to handle a gun because of the attraction in an alternative learning center may actually increase
of the “forbidden.” A recent study of young people’s Thomas’ exposure to peers who engage in high-risk
behavior around guns found that 76% handled behaviors and could increase his risk for involvement in
a hidden gun they “discovered” despite prior instructions serious violence. The pros and cons of such a placement,
from their parents not to touch guns.3 especially given the fact that this appears to be Thomas’
It is interesting and disturbing to note that most young first offense, should be carefully evaluated.
people caught with guns report they got the gun from The role of younger siblings. It is important to note
their home or from friends.4 that many of the factors that place Thomas at risk
Exposure to violence in the home. There is a close rela- increase risk for his younger brother as well. When
tionship between violence in the home and youth vio- addressing Thomas, it is also important to consider
lence, what one might describe as a “cycle of violence.” risk reduction for the younger brother.
From an early age, Thomas has watched the adults in his
life use violence to “solve” their problems. Research sug-
gests that violence is learned, learned early, and often Option: Insert a story from the local community
learned in the home.5 Children who witness violence about firearms and youth.
in their homes may come to believe that it is acceptable
and even necessary to use violence to solve problems
with others.6 In addition, Thomas’ early exposure to
violence and traumatic stress may have affected his brain
chemistry, making him more susceptible to depression
and problems with impulse control.7
2. What elements in Thomas’ life not been found to be effective in reducing risk. It will
may help protect him against be important to learn more about intervention methods
involvement in serious violence? used in the alternative learning center to ensure that
they are consistent with “model” and “promising”
While there are many risk factors for violence in programs described in the Surgeon General’s report.9
Thomas’ life, there are a number of important
Important note about his brother: Again, many of these
protective factors as well.
resources and protective factors will apply to Thomas’
Positive experiences in school and future orientation. younger brother too. Also, although it is unclear from
Thomas has dreams and plans for the future (a future the case study whether Thomas is close to his younger
orientation) and a commitment to education, both of brother, encouraging him to be a good role model for
which have been proven to protect young people against his brother can be a strong motivator for change for
involvement in violence and other high-risk behaviors.4 older siblings.
This is a personal resource that Thomas, you, and others 3. What might you do to help Thomas
in Thomas’ life can build on to reduce the chance he
and his family?
will become involved in serious violence.
There are many things that a health professional,
Strong relationship with an adult figure. Thomas has a
Thomas’ mother, Thomas, and others can do to help:
close and positive relationship with his mother. Young
people who have a strong relationship with a parent or For health professionals:10, 11
another responsible adult are significantly less likely to History and screen
engage in high-risk behavior, including violence, than
• Take a violence history on Thomas and his family that
those who do not.8 While it is unclear from the case
addresses exposure to violence, safety/security issues,
description just how responsible Thomas’ mother actual-
effects of trauma, attitudes toward weapon carrying,
ly is, her presence at the school and obvious concern for
and stressors in the family and the community.
Thomas are good signs.
• Document history of family violence in the medical
Thomas’ mother and his strong connection with her are
record.
resources you can build on to reduce the likelihood
of his involvement in serious violence. • Screen Thomas and his family for access to firearms
and use of safe storage procedures.
Access to effective violence prevention services.
Finally, Thomas and his problems have come to the Patient education
attention of his school and the local authorities. As a • Encourage Thomas’ mother to remove firearms from
result, both he and his family have been referred to the home. If she insists on keeping a gun in the
mental health and supportive services in the community. home, strongly encourage her to take a training course
The recent Surgeon General’s report on youth violence on the safe handling, storage, and use of this weapon.
lists a number of interventions that have been proven to
• Educate Thomas and his family on firearm safety and
be effective in preventing violent behavior among youth.
work with them to develop a safety plan. Provide
Life Skills Training programs and Multisystemic Therapy
them with educational materials on safe firearm
are included on the list of programs that are effective in
storage such as the American Academy of Pediatrics
preventing youth violence.9 It is important to note that
patient brochure, Keeping Your Family Safe from
other popular types of interventions, including boot
Firearm Injury.12 Counsel Thomas’ mother and the
camp, residential treatment, and peer counseling, have
family to ask about gun possession and storage in

other homes that Thomas and his brother visit, and • Become knowledgeable of firearm training programs in
ask the adults in these homes to consider removing your community. Information on training programs is
the guns from their homes or using safe firearm available from organizations such as the Brady Center
storage procedures. to Prevent Gun Violence, Physicians for Social
• Discuss Thomas’ concerns about his safety, and Responsibility, and the National Rifle Association.14-16
work with him to make a plan to increase his safety For parents and a community audience:10, 17
from gangs and other violence-related threats in his • Do not keep firearms. If you must, make sure to keep
community and school. them safely stored and locked up with ammunition
• Educate Thomas’ mother on resources for victims of stored separately. Make sure the parents of Thomas’
domestic violence and provide her with the telephone friends do the same.
numbers of a hotline or support center where she can • Talk to Thomas about the dangers of firearms and
discuss her experience and receive assistance. work with him to find other methods to protect
Refer himself. Insist he not use firearms as a way to increase
• Provide referrals to Thomas and his family to youth his feeling of safety.
programs in the surrounding community that provide • Develop a safety plan with Thomas. Encourage him
comprehensive services for youth violence prevention. to go to a reliable adult when he encounters problems
• Provide referrals to Thomas’ mother to a local at school or in the community.
battered women’s shelter and hotline. • Supervise Thomas’ activities and know his schedule
Work with schools and community and his friends.
• Work with Thomas’ school to develop a safety • Maintain two-way communication with Thomas and
plan for Thomas and to address problems with talk to him about the violence he has witnessed and
violence in the school. may be experiencing.
• Volunteer to work with the school as an • Seek out a support group to increase parenting skills
epidemiologist or crisis team member and assist staff and effective and protective methods for responding
in violence prevention planning for the school. to anger and aggression from others.
• Volunteer to serve on community prevention • Urge school and community organizations including
initiatives. police to implement a comprehensive violence
prevention program in the community. Participate
Enhance resources in clinical practice setting
in this effort.
• Establish a network of referral services for youth
• Urge Thomas to participate in organized after-school
and family violence prevention. Know how the
activities provided by responsible groups.
programs in this network compare to the list of
effective programs in the Surgeon General’s report For young people:10, 18
on youth violence.9 • Do not use or handle firearms. If one of your peers
• Implement practice guidelines and practice protocols has one, walk away and notify a responsible adult.
for firearm injury prevention such as the Physician • Talk to a responsible person—physician, teacher,
Firearm Safety Guide available through the American clergy, counselor, parent, or friend—about violence
Medical Association (312 464-5066).13 you have witnessed or experienced.

• Report incidents of violence to school authorities, 7 Niehoff D. The Biology of Violence: How Understanding the
parents, or other responsible adults. Brain, Behavior, and Environment Can Break the Vicious
Circle of Aggression. New York, NY; The Free Press;1999.
• Participate in organized and supervised recreational,
8 Rintoul B, Thorne J, Wallace I, Mobley M, Goldman-Fraser J,
educational, and cultural after-school activities. Luckey H. Factors in Child Development. Part I: Personal
• Act as a role model for children and other adolescents Characteristics and Parental Behavior. Research Triangle Park,
NC: Research Triangle Institute; 1998.
by refusing to have anything to do with firearms,
alcohol, and illicit drugs. 9 US Department of Health and Human Services. Youth
Violence: A Report of the Surgeon General. Rockville, MD:
• Become involved in or start a violence prevention Department of Health and Human Services, Centers for
program in your school or community. Disease Control and Prevention, National Center for Injury
Prevention and Control; Substance Abuse and Mental Health
• Promote television programs, movies, music, and
Services Administration, Center for Mental Health Services;
video games that portray nonviolent alternatives
and National Institute of Health, National Institute of Mental
to conflict resolution. Health; 2001.
• Talk with friends and family members about concerns 10 Commission for the Prevention of Youth Violence. Youth and
about violence and how it affects their lives. Violence: Medicine, Nursing, and Public Health: Connecting
the Dots to Prevent Violence. Chicago, IL: American Medical
Association; 2000.
References 11 Task Force on Violence. The role of the pediatrician in youth
1 Kellermann AL, Reay DT. Protection or peril? An analysis violence prevention in clinical practice and at the community
of firearm-related deaths in the Home. N Engl J Med. level. Pediatrics. 1999;103:173-181.
1986;314:1557-1560. 12 American Academy of Pediatrics. Keeping Your
2 Azrael D, Hemenway D. In the safety of your own home: Family Safe; 1996. Available at: http://www.aap.org/
results from a national survey on gun use at home. advocacy/d1family.htm.
Soc Sci Med. 2000;50:285-91. 13 American Medical Association. Physician Firearm Safety
3 Jackman G, Farah M, Kellermann A, Siman HK. Seeing is Guide. Chicago, IL: 1998.
believing: what do boys do when they find a real gun? 14 Brady Center to Prevent Gun Violence.
Pediatrics. 2001;107:1247-1250. Available at: http://www.bradycampaign.org/.
4 Sheley J, Wright J. High school youths, weapons, 15 Physicians for Social Responsibility.
and violence: a national survey. Research in Brief. Available at: http://www.psr.org/.
Washington, DC: National Institute of Justice;
16 National Rifle Association. Available at: http://www.nra.org.
US Department of Justice; 1998.
17 Hemmenway D, Prothrow-Stith D, Bergstein JM, Andes R,
5 Karr-Morse R, Wiley MS. Ghosts From the Nursery:
Kennedy BP. Gun carrying adolescents. Law Contemporary
Tracing the Roots of Violence. New York, NY:
Problems. 1996;59:39-54.
Atlantic Monthly Press; 1997.
18 Excerpted from Center for Study and Prevention of
6 Blyth DA, Roehlkepartain EC. What youth need
Violence. Fact Sheets: Preventing Firearm Violence.
from communities. Source Newsletter. Minneapolis, MN:
Boulder, CO: University of Colorado.
Search Institute; 1992. Available at: http://www.
Available at: http://www.colorado.edu/cspv/.
searchinstitute.org/archives/wt.htm; 1992.

Case Studies
Media Violence
Case: Jonathan and Raquel

Age: 6 and 10
Grade: 1st and 5th
Problem: Media Violence
Jonathan and his sister, Raquel, live in a middle-income community near Los Angeles. Jonathan is 6 years old
and began attending the local elementary school this year. Raquel is 10 and goes to the same school as Jonathan.
They both like the school, are doing well academically, and get along well with their peers.
They live with their mother, who has a very demanding job that requires her to work long hours. Many times she
does not return home until 8 or 9 at night. She is very conscientious about the care of her children and has arranged
for in-home child care for her children.
When the children return home, the babysitter allows them to play until 6 PM, which is when they eat dinner.
They then do homework and get ready for bed. Their favorite activities are to watch TV and play video games.
They enjoy imitating the shows or games after they see them, switching off playing “good guy” and “bad guy.”
Raquel is also becoming a fan of music videos and often watches them on the TV in her room after she has gone to
bed. Last week Jonathan’s teacher mentioned to the mother that he is overly aggressive with the other children, and
the mother has been concerned about drawings her daughter brought home last month depicting her in a fist fight
with a “bad guy.”
What elements of Jonathan and Raquel’s lives may be contributing to their aggressive behavior?
What elements in Jonathan and Raquel’s lives are protective against violence?
What can their mother do to address Jonathan’s aggressive behavior and Rachel’s depictions of violence
in her drawings?
What can you do to help Jonathan and Raquel?

Media Violence (continued)
1. What elements of Jonathan and Specific effects on youth. While exposure to a single
Raquel’s lives may be contributing risk factor such as violent media typically does not lead
to their aggressive behavior? to violent behavior in children, frequent exposure to
violent media can: 6
Exposure to violence in the media. Jonathan and
• Teach children aggressive behaviors and attitudes
Raquel, like many children in the United States, are
exposed to a great amount of media violence. This • Desensitize them to the negative aspects of
exposure occurs through television shows, movies, video violence
games, the Internet, music and music videos, and print. • Cultivate fearful and pessimistic attitudes about
On average, American children spend 28 hours a week the real world
watching television.1 Other caregivers. While Jonathan and Raquel’s mother
The largest study of violent content on television, the has arranged for childcare in the home, it is unclear how
National Television Violence Survey, found that 61% effective this care is. Lack of adequate adult monitoring
of television programs contain some violence, and that is a risk factor for a wide range of behavioral and
58% depict no pain resulting from the violence, 47% social problems.
depict no harm, and 40% depict harm unrealistically.
Finally, 44% of violent interactions on TV are perpetrat-
ed by individuals who exhibit qualities that are attractive
to youth.1 Option: Insert a story on media violence from the
local community.
Evidence that violent media increases aggressive
and violent behavior. There is strong evidence
that exposure to violence in the media can increase
children’s aggressive behavior and emotions over the 2. What elements in Jonathan
short-term, and some evidence (albeit contested), and Raquel’s lives are protective
that there may also be long-term effects.2 against violence?
A leading researcher in this subject stated in testimony
Positive school climate and success in school. There
to the US Congress, “There can no longer be any doubt
are many factors that are protective against violence in
that heavy exposure to televised violence is one of the
Jonathan and Raquel’s lives. First, Jonathan and Raquel
causes of aggressive behavior, crime, and violence in
feel welcome in their school and are both doing well
society. The evidence comes from both the laboratory
academically. Positive school climate and academic
and real-life studies. Television violence affects
mastery are both protective against violence and other
youngsters of all ages, of both genders, at all socio-
high-risk behaviors, such as substance abuse, and are
economic levels and all levels of intelligence.” 3
strong predictors of positive developmental outcomes for
This position is supported by findings of the most com- young people.
prehensive meta-analysis to date of the impact of violent
Good social skills. Jonathan and Raquel get along well
media, which shows a clear link between brief exposure
with their peers. Good social skills with peers is one of
to violence on TV or movies and increases in aggressive
five socioemotional competencies that research suggests
and even physically violent behavior in young persons.4
can protect children against involvement in violence
This is true even of cartoons.5
and in a wide range of other problem behaviors. The
other four socioemotional competencies are the ability

to monitor and regulate feelings, thoughts, and actions • What are the most watched shows?
(impulse control); the capacity to show empathic • Are there rules regarding music videos? Video games?
concern for others; the ability to cope with and solve
• Do you use Internet blocking software?
interpersonal problems; and a positive identity and
future orientation.7 Inform parents and children old enough to understand
about the effects of media violence and encourage them
Adult monitoring. Although their mother is often
to increase their general media literacy. See “Media
unavailable because of her demanding work schedule,
Matters” at the American Academy of Pediatrics Web
she is concerned about her children and is attempting
site for a self-training brochure for teaching patients
to provide them with a supportive adult in the home
media literacy.12
when she is not able to be there.
Become involved in organizations that seek to decrease
Finally, both Jonathan and Raquel have teachers who
the use of violence. Speak at public meetings, join
are attentive to early warning signs for violence, and
media watch and literacy groups, and help in advocacy
there is good communication between the teacher and
efforts directed at the media industry, and state and
parents. Responsive adults can be an important source
federal legislators.
of protection for young people. Teachers, physicians,
neighbors, and parents can identify red flags that may As a parent you can:11, 12
indicate problems and help the child and his or her Become familiar with the media your children
family access help early on before the problem consume. Watch at least one episode of shows they
becomes severe. watch regularly, listen to the lyrics of their music,
3. What can you do to reduce and observe the computer and video games they play.
Jonathan and Raquel’s exposure Teach your child to be informed and critical consumers
to violent media?6, 8-10 of the media.
A former US Commissioner of Education, Ernest Boyer, • Who created this (media product) and why?
wrote, “It is no longer enough to simply read and write. • Is it real or make believe?
Students must also become literate in the understanding • Is this a good way to solve a problem? What are
of visual images.” Children must learn to read and some alternate ways that do not involve violence?
understand media messages for what they really are,
• What would happen if someone in real life were to do
rather than passively accepting them.10
the same thing that the character on the show, song,
As a health professional you can:11 or video did? Injury? Prison? Upset and hurt family
Take a media history as part of the health care visit. members? Other consequences?
Ask questions such as:
• How do you decide what shows to watch?
• What are the rules about watching shows or movies?
• How many hours a day do you watch TV and is
there a limit?

Limit your children’s access to violent content. References

To do this you can: 1 National Television Violence Study Executive Summary:
• Avoid using television, videos, or computers as 1994-1995. Los Angeles, CA: Mediascope, Inc; 1996.
babysitters. Instead plan other activities to engage 2 US Department of Health and Human Services. Youth
and keep your children busy. Violence: A Report of the Surgeon General. Rockville, MD:
Department of Health and Human Services, Centers for
• Limit media viewing; allow only 1 to 2 hours a day. Disease Control and Prevention, National Center for Injury
• Keep televisions and video players out of children’s Prevention and Control; Substance Abuse and Mental Health
Services Administration, Center for Mental Health Services;
bedrooms.
National Institutes of Health, National Institute of Mental
• Only turn on the TV when you have something Health; 2001.
specific to view. 3 Enron LD. The impact of televised violence. In: Senate
Committee on Governmental Affairs. Congressional Record;
Model healthy use of media for your children.
1992.
Advocate with policymakers and media industries for
4 Paik H, Comstock G. The effects of television violence
quality programming and reductions in violent media. on antisocial behavior: a meta-analysis. Commun Res.
1994;21:516-546.
5 Huston AC, Donnerstein E, Fairchild H. Big World, Small

Screen: The Role of Television in American Society. Lincoln,
NE: University of Nebraska Press; 1992.
6 American Psychological Association. Violence on Television:

What Do Children Learn? What can Parent’s Do?
Washington, DC: American Psychological Association; 2001.
7 Guerra N. Preventing school violence promoting wellness.

J Appl Psychoanal Stud. In press.
8 Aidman A. Television violence: content, context, and

consequences. ERIC Digest. 1997. EDO-PS-97-26.
9 American Academy of Pediatrics. Understanding the Impact

of Media on Children and Teens. Elk Grove Village, IL:
American Academy of Pediatrics; 2002.
10 Rich M. Pediatricians should educated parents, youths about

media’s effects. AAP News. Elk Grove Village, IL: American
Academy of Pediatrics; 1999:28-29.
11 American Medical Association. Physicians Guide to Media

Violence. Chicago, IL: American Medical Association; 1996.
12 See http://www.aap.org/advocacy/mediamatters.htm.

Section 5
Issue Briefs
• Adolescent substance abuse
• Bullying in schools
• Child abuse
• Dating violence
• Firearm-related violence
• Firearm safety
• Media violence
• Risk and protective factors for youth violence
• School violence
• Youth development and violence prevention
• Youth gangs
• Youth suicide
Issue Brief
Adolescent Substance Abuse
Introduction In 2000, although overall rates of illicit drug use

Adolescent substance abuse is a serious concern remained stable, the rate for teens ages 12 to 17 dropped
nationwide. From the 1980s to the 1990s, the slightly to 9.7% from 9.8% in 1999.5
percentage of American youth aged 14 to 18 years who Alcohol
required treatment for substance abuse doubled.1 Alcohol use among 12- to 20-year-olds has remained
Furthermore, beginning in 1992, rates of substance constant for several years. In 2000, 9.7 million (27.5%)
use by teens rose steadily and have only recently youth in this age group reported drinking alcohol in the
leveled off or slightly decreased.2 past month. Of those, 6.6 million (18.7%) were binge
Substance use by youth has serious health and social drinkers, and 2.1 million (6%) were heavy drinkers.5
implications. For example, although most youth who Rates of alcohol use by adolescents increase with age.
use drugs do not commit violent crimes, there is a For example, in 2000, prevalence at age 12 was 2.4%
correlation between frequency and severity of juvenile and reached a peak of 65.2% at age 21. In addition,
delinquency and frequency and severity of drug use.3 college students ages 18 to 22 were more likely than non
In addition, health issues such as the long-term physical college students of the same age group to drink, binge
effects of tobacco use and increased risk of childhood drink, and drink heavily.5
injuries are critical concerns related to substance
Tobacco
abuse by adolescents.4
Tobacco use includes cigarette smoking, cigar smoking,
Scope of the problem and use of smokeless (chewing) tobacco.
Illicit drugs
Unlike drug and alcohol use among adolescents, tobacco
According to the National Household Survey on use among youth aged 12 to 17 declined significantly
Drug Abuse (NHSDA), illicit drugs include marijuana from 14.9% in 1999 to 13.4% in 2000. The decrease
(includes hashish), cocaine (includes crack), heroin, was attributed to a decline in tobacco use among boys,
hallucinogens, inhalants, and non medical use of which declined significantly from 14.8% in 1999 to
prescription-type pain relievers, sedatives, 12.8% in 2000. The rate of tobacco use among females
and stimulants.5 also decreased in 2000, but not significantly.5
The rate of illicit drug use varies by age. The 2000 Tobacco use also varies greatly by age, increasing steadily
NHSDA indicated that 3% of 12- to 13-year-olds up to age 20. For example, in 2000 the rates of tobacco
used illicit drugs within the past month; 6% of 18- to use were 1.8% for 12-year-old youth, and 13.4% for
20-year-olds used illicit drugs within the past month; and 13- to 17-year-old youth, and rose to 41.4% by age 20.5
for those 20 years and older, the rates generally declined.
Smoking can lead to using other substances. Youth who
However, after age 20, the rate of use declined only to
smoke are 3 times more likely to use alcohol, 8 times
age 40, when use increased among the 40 to 44 year-old
more likely to use marijuana, and 22 times more likely to
age group and then dropped again at age 45. This is
use cocaine.4
particularly interesting to note, since those in
their early 40s in 2000 were teenagers in the 1970s Risk factors
when drug use was drastically on the rise.5 A variety of biological, psychosocial, and environmental
In the 1980s, 5% of adolescents aged 14 to 18 factors act alone or in combination to place youth at risk
experienced drug-related problems that required for substance abuse.3, 6
treatment, and by 1991, the percentage rose to 10%.1
Issue Brief 85 Connecting the Dots to Prevent Youth Violence

Adolescent Substance Abuse (continued)
Genetics and biology Risk factors for substance abuse also are found in the
Studies of twins indicate that genes may account for community. Risks include low levels of community
some degree of risk in substance abuse. It is likely that resources and opportunities, lack of community bonding,
a combination of genes, rather than one gene alone, pro-drug attitudes within the community, pro-drug
contributes to drug and alcohol use.6 Independent of the messages in the media, and lack of services and
genetic factor, however, prenatal exposure to tobacco, opportunities for youth.3
alcohol, and drugs puts infants at risk to develop Promising strategies
substance problems later. In addition, biological Traditional intervention and prevention strategies such
factors such as temperament (impulsivity, aggression, as incarceration, detoxification and rehabilitation, and
hyperactivity, sensation seeking, and rigidity) and public health education have not had much sustainable
brain chemistry (dopamine/drug interaction) are impact on reducing adolescent substance use and abuse.
associated with substance abuse.6 Some recent successes have been documented using
Psychosocial influences the social influence approach and the competence
Some psychosocial factors have been associated with enhancement approach. Botvin described these two
adolescent substance abuse. For example, childhood approaches in detail.7
psychopathology such as conduct disorder and The social influence approach focuses on the social and
attention deficit hyperactivity disorder (ADHD), aca- psychological factors that contribute to onset of use. Two
demic failure and learning difficulties, low self-esteem, major components of this approach include normative
and deficits in social competency have been linked to education and resistance skills training. The purpose of
tobacco, alcohol, and drug use in teenagers. Adolescent normative education is to rid teenagers of the belief that
antisocial behavior such as aggression, fighting, and “everybody does it.” Resistance skills training teaches
truancy, as well as antisocial beliefs and values about teens skills to resist pro-drug influences from peers,
substance use, are also considered to be risk factors. media, and society. Studies show social influence
Environment approaches to yield a 30% to 50% reduction in smoking
prevalence, alcohol, and marijuana use.7 In addition,
Various aspects of family life, peer groups, school
follow-up studies show positive behavioral changes for
environment, and community contribute to adolescents’
up to 3 years. However, long-term follow-up studies
proclivity toward substance abuse. Risk factors within
indicate a decay of positive effects over time.
the family include a family history of substance abuse;
access to tobacco, alcohol, or drugs in the home; poor Life skills training (LST) represents a variation of the
family management, lack of discipline, and low parental social influence approach known as competence
monitoring; low levels of nurturing and attachment; enhancement. LST is based on social learning theory
and abuse in the home.3 and problem behavior theory. The underlying assump-
tion is that drug use is a learned behavior influenced by
Having peers who use drugs or hold positive beliefs about
the interaction of social and personal factors. Thus,
substance use increases adolescents’ risk for substance
LST teaches youth social and personal management
abuse. The opposite is also true. That is, the likelihood
skills. Examples of skills taught are decision making and
of using drugs decreases among youth whose peers have
problem solving, cognitive skills for resisting social and
positive values and anti-drug attitudes. In addition,
media influences, personal control, goal setting, stress
school-related factors influence youth substance abuse.
and anxiety management, assertiveness, and general
For example, lack of belonging or bonding to school and
low achievement and poor academic performance are
indicators of risk for drug use.3

Adolescent Substance Abuse (continued)
social skills. Prevention efforts are generally aimed Internet resources

at 7th to 10th graders and typically vary in length Center for Substance Abuse Prevention
from 7 to 20 sessions. Skills are taught by teachers http://www.samhsa.gov/centers/csap/csap.html
and/or outside professionals such as project staff,
graduate students, and social workers. Centers for Disease Control and Prevention
http://www.cdc.gov
This approach has been empirically tested and
demonstrated to reduce tobacco, alcohol, marijuana, National Clearinghouse for Alcohol and
and polydrug use in adolescents.2 Furthermore, the Drug Information
effects seem to be stable over time. A long-term http://www.health.org
follow-up study with 6000 participants who received National Institutes of Health
LST in the 7th grade showed lower drug use at the end http://www.nih.gov
of the 12th grade for LST youth than for controls. National Institute on Alcohol Abuse
Issue brief prepared by Roxie Alcaraz for the Southern and Alcoholism
California Center of Excellence on Youth Violence http://www.niaaa.nih.gov
Prevention, University of California, Riverside, National Institute on Drug Abuse
Winter 2002. http://www.nida.nih.gov
References Office of National Drug Control Policy
1 Vakalahi H. Adolescent substance use and family-based risk http://www.whitehousedrugpolicy.gov/pubs/fastfind.html
and protective factors: literature review. J Drug Educ.
2001;31:29-46. US Department of Health and Human Services
2 Botvin GJ, Griffin KW, Diaz T, Scheier LM, Williams C, http://www.dhhs.gov
Epstein JA. Preventing illicit drug use in adolescents: Your Time, Their Future
long-term follow-up data from a randomized control trial of
a school population. Addict Behav. 2000;25:769-774.
http://www.health.org/yourtime
3 National Youth Violence Prevention Resource Center.
Substance Abuse; 2001. Available at:
http://www.safeyouth.org. Accessed: October 19, 2001.
4 Centers for Disease Control and Prevention. Facts on Youth
Smoking, Health, and Performance. 2001. Available at:
http://www.cdc.gov/tobacco/research_data/youth/ythsprt.htm.
Accessed: November 9, 2001.
5 US Department of Health and Human Services, SAMHSA.
Summary of Findings from the 2000 National Household
Survey on Drug Abuse; 2001.
6 Weinberg NZ. Risk factors for adolescent substance abuse.
J Learning Disabil. 2001;34:343-351.
7 Botvin GJ. Preventing drug abuse in schools: social and
competence enhancement approaches targeting individual
level etiologic factors. Addict Behav. 2000;25:887-897.
8 Kosterman R, Hawkins JD, Guo J, Catalano RF, Abbott RD.
The dynamics of alcohol and marijuana initiation:
patterns and predictors of first use in adolescence.
Am J Public Health. 2000;90:360-366.

Issue Brief
Bullying in Schools
Introduction Victims
Bullying in American schools and neighborhoods is Surveys show that 10% of school-age children are
not a new phenomenon. This form of aggression among bullied on a regular basis and that half of all children are
children typically has been viewed as an acceptable and bullied at some time during their school years.3 Victims
normal part of growing up. However, in recent years, of bullying tend to avoid going to school. In 1999, 7%
bullying has come to the forefront of media and public of American 8th graders reported staying home from
scrutiny, particularly in the aftermath of school shootings school at least once a month due to fear of bullies.4
in the late 1990s and early 2000s. In fact, bullying is Common characteristics among victims are isolation,
cited as a major contributing factor in the Columbine depression, and low self-esteem. Victims are at higher
High School incident.1 risk for a range of problems, including impairment in
Educators, parents, communities, and policy makers psychological and social functioning and deficits in
have responded to bullying and its possible detrimental school performance. In the most extreme cases, victims
outcomes with increased attention to the causes and may contemplate or attempt suicide as an alternative
impact of bullying behavior and with implementation to harassment and terrorization by their peers.1
of innovative anti-bullying programs across the country. Bystanders
Scope of the problem Most studies of bullying focus on identified bullies
Olweus defines bullying as follows: “A student is and victims. Such research often overlooks the effect
being bullied or victimized when he or she is exposed, of bullying on “bystanders” who witness bullying even
repeatedly and over time, to negative actions on the part though they do not participate directly. Among junior
of one or more other students.” 2 Such negative actions high and high school students, 88% report having
are generally aggressive in nature and may take three observed bullying at some time.5
forms: physical (eg, hitting, kicking, pushing), verbal Bystanders are distracted from learning in school for
(eg, taunting, name calling), and psychological a number of reasons. For example, they may be afraid
(eg, intimidation, spreading rumors, social exclusion). to associate with victims for fear of becoming victims
Bullies themselves, or they may fear reporting incidents of
Boys are bullies more often than girls and they usually bullying for fear of gaining a reputation as a snitch.
bully other boys. Regardless of the gender of the victim, Additionally, they may develop feelings of guilt and
boys tend to use physical force or threats. Likewise, helplessness from being unable to control incidents
girls typically bully other girls, but do so verbally and of bullying. In some cases, they may even succumb
indirectly more often than physically.3 to peer pressure and become bullies themselves.5
There are also long-term consequences for bullies. Risk factors

Children identified by age 8 as bullies are 6 times more Bullies
likely to commit a crime by the time they are 24 and Several characteristics of children and families have
5 times more likely by age 30 to have a serious criminal been identified as risk factors for bullying behavior.
record.4 Crimes linked to bullying behavior include In particular, children who thrive on power, need to be
vandalism, shoplifting, and drug-related offenses. Other in control, and have little empathy for others are at
behaviors such as truancy, dropping out of school,5 and risk of becoming bullies. Rather than displaying low
fighting are also related to bullying.1 self-esteem and anxiety, these children appear to have
an over-inflated sense of self and high self-esteem.4

Bullying In Schools (continued)
This type of aggressive bravado may be linked to prob- Another effective anti-bullying strategy is mixing age
lems in other settings. Indeed, research on how families groups within programs.4 Bullying behavior tends to
can contribute to bullying has shown that children at be higher in same-age peer groups. However, mixing
risk of becoming bullies often come from homes where older and younger children in activities tends to foster
physical discipline and punishment are common and nurturing and protective behavior by older children
parental warmth is lacking. In these settings, children toward younger children and bullying is reduced. In
learn that the best way to deal with their problems is addition, allowing bullies to take on protective roles,
by dominating and controlling others.4 such as on a safety patrol, helps reduce bullying
Victims behavior.
Victim research has identified two types of victims: Issue brief prepared by Roxie Alcaraz for the
passive and provocative. The majority of victims Southern California Center of Excellence on Youth
of bullying typically are passive. These victims are Violence Prevention, University of California,
often loners; younger than the bullies; and socially, Riverside, Winter 2002.
emotionally, and physically weak. However, physical References
characteristics such as clothing, weight, and wearing 1 US Department of Justice. Addressing the Problem of Juvenile
eyeglasses, do not appear to be significant factors Bullying. Washington, DC: US Department of Justice; 2001.
in victimization.4 A smaller number, 10% to 15%, are 2 Olweus F. Bullying at School. Oxford, England: Blackwell
identified as provocative victims. Provocative victims Publishers, Ltd; 1993.
are both victims and bullies. They often tease bullies 3 American Academy of Child and Adolescent Psychiatry.
Facts for Families: Bullying. Washington, DC: American
and are often easily aroused emotionally.4
Academy of Child and Adolescent Psychiatry; 2001. Available
Promising strategies at: http://www.aacap.org/publications/factsfam/80.htm.
Accessed: February 2002.
Most successful efforts to prevent or reduce bullying
4 National Resource Center for Safe Schools. Recognizing and
utilize an integrated and comprehensive approach.2, 4-8 Preventing Bullying. Portland, OR: National Resource Center
According to Olweus, anti-bullying efforts must for Safe Schools; 1999.
incorporate schools, administrators, teachers, parents, 5 US Department of Education. Preventing Bullying:
and communities.2 In addition, creating a safe school A Manual for Schools and Communities. Washington, DC:
US Department of Education; 1998.
environment depends on early intervention efforts,
strong leadership, ongoing commitment, ongoing staff 6 Stephens RD. National trends in school violence: statistics and
prevention strategies. In: Goldstein AP, Conoley JC, eds. School
development and training, cultural sensitivity, and
Violence Intervention: A Practical Handbook.
parental and community involvement in planning New York, NY: The Guilford Press;1997:72-90.
and implementation. 7 Hawkins JD, Farrington DP, Catalano RF. Reducing violence
A number of anti-bullying programs have shown through the schools. In: Elliott D, Hamburg B, Williams KR,
eds. Violence in American Schools. New York, NY: Cambridge
positive effects. For example, an elementary school University Press; 1998:188-216.
in Englewood, Colorado, reported that in a 2-year
8 Prinz R. Research based prevention of school violence and
period, its bully-proofing integrative program had a youth antisocial behavior: a developmental and educational
positive impact on the school environment. Another perspective. In: National Institute of Justice. Preventing School
comprehensive program at a middle school in Violence: Plenary Papers of the 1999 Conference on Criminal
Justice Research and Evaluation—Enhancing Policy and
Caruthersville, Missouri, resulted in a 16% reduction Practice Through Research. Volume 2. Washington, DC:
in physical fighting among students in the first year US Department of Justice; Office of Justice Programs; National
and a 25% reduction in the second year. Institute of Justice; 2000:23-36.

Bullying In Schools (continued)
Related publications on bullying Internet resources

Fried S, Fried P. Bullies & Victims: Helping Your Child American Academy of Child and Adolescent
Through the Schoolyard Battlefield. New York, NY: Psychiatry
M. Evans & Co; 1996. http://www.aacap.org
Garrity C, Jens K, Porter W, Sager N, Short-Camilli C. Center for the Prevention of School Violence
Bully-Proofing Your School: A Comprehensive Approach for http://www.ncsu.edu/cpsv
Elementary Schools. Longmont, CO: Sophris West; 2001. Center for the Study and Prevention of Violence
Olweus D, Limber S. Blueprints for Violence Prevention: http://www.colorado.edu/cspv/
Bullying Prevention Program. Book Nine. Boulder, CO: Children, Youth, and Families Education and
Center for the Study and Prevention of Violence, Research Network
University of Colorado; 1999. http://www.cyfernet.org/
Family Education Network
http://www.familyeducation.com
National Resource Center for Safe Schools
http://www.safetyzone.org
Office of Juvenile Justice and Delinquency
Prevention
http://www.ojjdp.ncjrs.org

Issue Brief
Child Abuse
Introduction legal procedures for validating instances of sexual abuse

Although the incidence of child abuse has declined are difficult.3 In addition, more than one third (35.9%)
within the United States during the last year, it contin- of all victims of child abuse were reported to be victims
ues to be a serious problem.1 Children all over the coun- of other or additional types of maltreatment.
try are neglected, beaten, and sexually and emotionally Rates of many types of maltreatment were similar for
abused every day. Although some children may be more male and female children. However, the sexual abuse
at risk for victimization, child abuse is often difficult to rate for female children was higher than that for male
detect. Various programs have been implemented at the children (1.6 and 0.4 per 1000 in the population,
individual and family levels to prevent child abuse and respectively). The highest victimization rates were
to help victims and perpetrators of child abuse. in the 0- to 3-year age group (13.9 per 1000 in the
Child abuse is defined as harm inflicted on children population) and declined as age increased.1
by anyone, including other children, and encompasses Children who were victimized before 1999 were almost
physical abuse, sexual abuse, psychological abuse, and 3 times more likely to experience recurrence during the
neglect.2 Signs of physical abuse include unexplained 6 months after their first victimization in 1999 than
injuries such as welts, bruises, burns, and injuries that are children without a prior history of victimization.1
in the shape of objects such as belt buckles or electrical
Risk factors
cords. Signs of emotional abuse may include aggressive
or withdrawn behavior, shying away from physical Although there is no specific abusive personality type,
contact with parents or other adults, and/or being afraid some families are at greater risk for experiencing child
to go home. Physical signs of sexual abuse are often abuse.4 Child abuse tends to happen more frequently
difficult to detect by anyone other than a physician,3 but in families that are isolated and have no friends or
may include difficulty in walking or sitting; stained or relatives, families with parents who were abused as chil-
bloody underwear; and genital or rectal itching, swelling, dren, families with parents who abuse drugs or alcohol,
redness, or discharge. The child may also show behav- and families with parents who are under a lot of stress or
ioral or emotional signs such as difficulty in eating or are often in crisis (financial difficulties or move often).5
sleeping, soiling or wetting pants or bed after being Empirical research has also shown a concurrence of
toilet trained, withdrawing from activities with others, intimate partner violence against mothers and abuse of
and/or excessive crying or sadness. Victims of prolonged children in up to 50% of cases.5 A study by McKibben
sexual abuse often develop low self-esteem, a feeling of and colleagues found that 40% to 60% of mothers of
worthlessness, and an abnormal or distorted view of sex.3 32 abused children were also victimized, compared to
13% of mothers of 32 matched children with no record
Scope of the problem of abuse.6 In a related study, McGuigan and Pratt found
There were an estimated 826,000 victims of child mal- that among at-risk parents, domestic violence during the
treatment nationwide in 1999. This rate of victimization first 6 months of child-rearing tripled the likelihood of
was 11.8 per 1000 children, a decrease from the 1998 physical abuse occurring during the child’s first 5 years.7
rate of 12.6 per 1000 children. More children (58.4%)
Reporting guidelines
suffered from neglect than from any other form of
maltreatment. One fifth (21.3%) suffered physical In most states, reporting suspected child abuse or neglect
abuse, while 11.3% were sexually abused.1 However, is required by law. Federal agencies have no jurisdiction
this number may be an underestimation because of the to intervene in child abuse and neglect cases; therefore,
possible number of unreported cases. Children are often the state agency must be contacted. Guidelines require
afraid to tell anyone about what has happened, and the that if there is suspicion of child abuse, the child
should be taken to a quiet area and encouraged to give
Child Abuse (continued)
enough information to evaluate whether abuse may 5 Centers for Disease Control and Prevention. Issues in
Child Care Settings. Available at:
have occurred. The child should be told that the adult
http://www.cdc.gov/ncidod/hip/abc/intro5.htm.
believes him/her, that the child isn’t bad and that he Accessed: October 18, 2001.
or she has the right to tell about the abuse. 6 McKibben L, DeVos E, Newberger E. Victimization
If abuse or neglect is suspected within the family, the of mothers of abused children: A controlled study.
Pediatrics. 1989;84:531-535.
state’s Child Protection Agency should be contacted.
7 McGuigan WM, Pratt CC. The predictive impact of
If the abuse is outside of the family, it should be reported
domestic violence on three types of child maltreatment.
to the police or district attorney’s office.8 If there is no Child Abuse Neglect. 2001;25:869-883.
toll-free number available, the Childhelp National 8 American Academy of Child and Adolescent Psychiatry.
Child Abuse Hotline at 1-800-A-CHILD will provide Responding to Child Sexual Abuse; 1999. Available at:
assistance. http://www.aacap.org/publications/factsfam/rspdabus.htm.
Accessed: October 21, 2001.
Promising strategies
Related publications and
Various preventive strategies have been used to combat
child abuse. In an increased effort to reduce risk factors
Internet resources
leading to child maltreatment, preventive services used American Academy of Child and
include respite care, parenting education, housing Adolescent Psychiatry
assistance, substance abuse treatment, day care, home http://www.aacap.org
visits, individual and family counseling, and crisis and Becker WJ. Child Abuse; 1991. Available at:
domestic violence services.1 http://www.cdc.gov/niosh/nasd/docs/as02600.html.
Remedial services have also been made available to Accessed: October 18, 2001.
families who have already suffered child maltreatment. National Center for Injury Prevention and
These include family-based services such as Control Home Page
counseling and family support, foster care services, http://www.cdc.gov/ncipc
and court services such as proceedings to determine
National Clearinghouse on Child Abuse and
temporary custody of the victim.1
Neglect Information
Prepared by Olivia Pillado for the Southern California Center http://www.calib.com
of Excellence on Youth Violence Prevention, University of
Sedlak AJ, Broadhurst DD. Executive Summary of the
California, Riverside, Winter 2002.
Third National Incidence Study of Child Abuse and Neglect.
References Washington, DC: US Department of Health and Human
1 US Department of Health and Human Services, Administration Services Administration for Children and Families,
on Children, Youth and Families. Child Maltreatment 1999. Administration on Children, Youth and Families,
Washington, DC: US Government Printing Office; 2001.
National Center on Child Abuse and Neglect; 1996.
2 Centers for Disease Control and Prevention. Available at: http://www.calib.com/nccanch/pubs/
The Co-Occurrence of Intimate Partner Violence Against
Mothers and Abuse of Children. Available at:
statinfo/nis3.cfm. Accessed: October 18, 2001.
http://www.cdc.gov/ncipc/factsheets/dvcan.htm. US Department of Health and Human Services,
The Administration for Children and Families
3 American Academy of Child and Adolescent Psychiatry. Child
http://www.acf.dhhs.gov
Sexual Abuse; 1998. Available at: http://www.aacap.org/publi
cations/factsfam/sexabuse.htm. Accessed: October 21, 2001.
4 Berk L. Infants, Children, and Adolescents.
Boston, MA: Allyn and Bacon;1993.

Issue Brief
Dating Violence
Introduction being punched or forced to engage in sexual activity;

Violent behavior that occurs in the context of a dating boys were more likely to report being pinched, slapped,
relationship is not a rare event among adolescents in scratched, and kicked.
the United States. In fact, teens are the fastest growing In the Massachusetts Youth Risk Behavior Survey, 1 in 5
population at risk for dating violence. It is estimated that girls from grades 9 to 12 reported experiencing physical
1 in 8 high school students and 1 in 5 college students and/or sexual violence by a date, with 1 in 10 reporting
will be involved in a violent relationship. Yet, despite physical abuse and 1 in 25 reporting sexual violence.6
these alarming statistics, many teens do not view dating Males also report experiencing sexual violence. Eight
violence as destructive or unhealthy, and some actually percent to 16% of college males report being pressured
believe it can improve a relationship. This perception is and/or forced to have sexual intercourse with a dating
worrisome, as it may prevent adolescents involved in partner.7, 8 When young people are asked about
dating violence from seeking help. Dating violence is their experiences with emotional and psychological
not limited to a specific demographic; instead, teenagers abuse, 96% say they have experienced this in a
are vulnerable regardless of race, gender, socioeconomic dating relationship.9
status, or sexual orientation. Dating violence can take In a review of the dating violence literature, 39.3% of
many forms, including psychological, emotional, physi- females and 32.9% of males reported being a perpetrator
cal, and sexual abuse. In less severe forms, it includes of violence in their dating career.10 Some studies
jealousy, possessiveness, verbal put-downs, and coercive indicate that more females than males report engaging
behavior. More extreme forms of dating violence in violent behavior in dating relationships. In one study,
involve punching, slapping, shoving, pulling hair, threats 51% of high school females reported behaving violently
involving a weapon, and rape. While limited research with their romantic partners, in contrast to 20% of
exists on effective strategies for prevention, several males.11 While rates of perpetration for males and
programs show promise for reducing dating violence in females may appear similar and, in some instances, be
national and local evaluations. Typically, these programs even higher for females, males far exceed females in the
are multidimensional and focus on education and use of severe violence in dating relationships. Males are
development of effective relationship and conflict 2 to 4 times more likely than females to use weapons
resolution skills.1-3 against a dating partner and to use physical violence
Scope of the problem that results in serious injury.10,12-14
Adolescent dating violence is a common occurrence, Risk factors
with estimates of incidence ranging from 28% to 96%.4 Adolescent dating violence is a complex phenomenon
Studies that include emotional and verbal abuse in resulting from a combination of individual, familial,
their definition of dating violence report the highest and societal factors.
incidence rates. Studies that limit definitions to overt
Individual and peer influences. Low self-esteem, prior
physical or sexual violence report somewhat lower rates.
antisocial and aggressive behavior, and prior exposure to
Both male and female adolescents can be victims of dat- violence in the home have all been associated with an
ing violence. In a recent survey of high school students, increased likelihood of being a victim or perpetrator of
36.4% of girls and 37.1% of boys reported experiencing dating violence.15,16 Alcohol and substance use are other
physical violence in a dating relationship.5 In this risk factors.17,18 In one study, 33% of the adolescents
instance, while the rates of those reporting violence were reported that both partners were drinking at the time of
similar, the nature of the violence was different. Girls the violent incident, and 25% reported use of other con-
were more likely to report more severe forms such as trolled or illegal substances.19 Negative gender identities

Dating Violence (continued)
also increase the risk of dating violence. Adolescents 32

out-of-school youth. Preliminary evaluation findings
who ascribe to stereotyped perceptions of males as show an increase in youth knowledge about dating
dominant and aggressive, and females as submissive and violence and an increase in intention to seek help for
passive, are more likely to be involved in violent dating violence. Participants also demonstrated a decline in
relationships. Finally, peer group norms can be a attitudes supportive of dating violence.
powerful influence. Young people whose friends are in
The Dating Violence Prevention Program focuses on
violent dating relationships are themselves more likely
promoting equity in dating relationships, challenging
to be perpetrators or victims of dating violence. This is
attitudes about violence as a means of conflict resolu-
especially true for females.20
tion, improving communications skills, supporting
Family and community factors. Family plays a critical victims of dating violence, and seeking help for those
role in influencing adolescent dating behaviors. Parents involved in violent experiences. In 1998, the Annual
model behaviors, values, and attitudes about the Report on School Safety identified it as a model program
management of conflict in intimate relationships.21 based on evidence of attitude changes among youth
Children—especially males—who are exposed to family about the use of violence in dating relationships and on
violence, are more likely to use aggression in their the program’s focus on developing positive relationship
relationships with peers and romantic partners later in skills in participants.33
life.22-24 Exposure to community violence has also been
Boston’s Dating Violence Intervention Project (DVIP)
linked with increased risk for dating violence.25
is recognized as an outstanding program by the
Societal factors. Adolescents receive many messages Department of Health and Human Services and the
from the media about how males and females should US Department of Education. DVIP’s programs include
behave and how intimate relationships should be assemblies and performances built around the theme
conducted. Much of the content in movies, videos, song of respect, and 3-session courses in which former
lyrics, comic strips, and television programs is violent, victims and abusers train students to identify abusive
and contains stereotyped and negative images not only behaviors, engage in respectful communication, and
of gender roles, but also of different racial and ethnic manage conflict. Other initiatives include weekly
groups. On television alone, 57% of programming counseling groups for male students who abuse or
contains violence.26 Many studies have linked depictions threaten a female peer, training for school staff and
of violence and stereotyped gender roles in the media police officers, and a 24-hour hotline and counseling
with increased rates of interpersonal aggression.27-30 service. The curriculum has been used in other
Promising Strategies Massachusetts communities, as well as in Canada,
New Zealand, and Australia.34
Interventions that define violence as an unacceptable
part of dating relationships, and provide education The Safe Dates Project targets eighth and ninth graders
and training in effective relationship and conflict and is a combination of school (a 10-session curriculum,
management strategies, show promise for reducing a play, and a poster contest) and community components
dating violence among adolescents.31 (training for service providers, a crisis line, and a support
group). Initial evaluations of the program show a 25%
The Southside Teens About Respect (STAR) includes
reduction in self-reported psychological abuse perpetra-
classroom-based education for students in grades 7 to 12,
tion, 60% reduction in sexual violence perpetration, and
teacher workshops, parent workshops, peer leadership/
60% reduction in violence perpetrated against a current
activism training, a community-wide public awareness
dating partner.35
campaign, and community-based workshops for

Developed by Stacey Zapanta for the Southern California 4 Johnson-Reid M, Bivens L. Foster youth and dating violence.
J Interpersonal Violence. 1999;14:1249-1262.
Center of Academic Excellence for Youth Violence
Prevention; Winter 2002. Appreciation is expressed to 5 Molidor C, Tolman RM, Kober J. Gender and contextual
factors in adolescent dating violence. Prevention Researcher.
David B. Sugarman and Jan E. Stets for their insight 2000;7:1-4.
and suggestions.
6 Silverman JG, Raj A, Mucci LA, Hathaway JE. Dating violence
against adolescent girls and associated substance use,
unhealthy weight control, sexual risk behavior, pregnancy,
Internet resources and suicidality. JAMA. 2001;286:572-579.
Dating Violence: It is your business.com 7 Anderson PB, Struckman-Johnson C, eds. Sexually Aggressive
Women: Current Perspectives and Controversies. New York:
http://www.itisyourbusiness.com/
Guilford Publications, Inc;1998.
Dating Violence 8 Larimer ME, Lydum A, Anderson B, Turner A. Male and
(National Network for Family Resiliency) female recipients of unwanted sexual contact in a male
http://www.nnfr.org/adolsex/fact/adolsex_viol.html college student sample: prevalence rates, alcohol use, and
depressive symptoms. Sex Roles. 1999;40:295-308.
Dating Violence (CDC) 9 Johnson-Reid, Biven L. Foster youth and dating violence.
http://www.cdc.gov/ncipc/factsheets/datviol.htm J Interpersonal Violence. 1999;14:1249-1262.
Dating Violence Among Adolescents 10 Sugarman DB, Hotaling GT. Dating violence: prevalence,
(Advocates for Youth) context and risk markers. In: Pirog-Good MA, Stets JE, eds.
Violence in Dating Relationships: Emerging Social Issues.
http://www.cyfernet.mes.umn.edu/youth/sexuality.html New York: Prager;1987:3-32.
Recognize the Early Warning Signs of a Violent 11 Avery-Leaf S, Cano A, Cascardi M, O'Leary, KD. Evaluation of
Teen Relationship and What Parents Need to Know a Dating Violence Prevention Program: Changing Attitudes
Justifying the Use of Aggression. Paper presented at the
http://ww2.mms.org/pages/violent_teen_relationships.asp
meeting of the Association for the Advancement of Behavior
What You Need to Know About Dating Violence: Therapy. Washington, DC; 1985.
A Teen’s Handbook 12 Arias I, Samios M, O’Leary KD. Prevalence and correlates of
http://www.lizclaiborne.com/lizinc/lizworks/women/pdf/te physical aggression during courtship. J Interpersonal
Violence. 1987;2:82-90.
en_handbook.pdf
13 Foo L, Margolin G. A multivariate investigation of dating
2001: A Parent’s Guide to Teen Dating Violence: aggression. J Fam Violence. 1995;10:351-377.
Questions to start the conversation 14 Makepeace JM. Courtship violence among college students.
http://www.lizclaiborne.com/lizinc/lizworks/women/pdf/1 Fam Relations. 1983; 32:101-109.
0questions_hand.pdf 15 Stets JE. Psychological aggression in dating relationships: the
role of interpersonal control. J Fam Violence. 1991;6:97-114.
16 Capaldi DM, Crosby L. Observed and reported psychological
References and physical aggression in young, at-risk couples.
1 Avery-Leaf S, Cascardi M, O'Leary K D, Cano A. Efficacy of a Soc Development. 1997;6:184-206.
dating violence prevention program on attitudes justifying
17 Burcky W, Reuterman N, Kopsky S. Dating violence among
aggression. J Adolesc Health. 1997;21: 11-17.
high school students. School Counselor. 1988;35:353-358.
2 Hamnett M, Marker N, Davidson-Coronado J, Silverio M.
18 O’Keefe NK, Brockopp K, Chew E. Teen dating violence.
Evaluation of Sexual Assault Prevention Curriculum in
Social Work. 1986;31:465-468.
Hawaii’s Peer Education Program. Manoa, Hawaii: University
of Hawaii at Manoa, Social Science Research Institute;1999. 19 Matthews WJ. Violence in college couples. College Student J.
1984;18:152-155.
3 Macgowen MJ. An evaluation of a dating violence
prevention program for middle school students. Violence
Victims. 1997;12:223-225.

20 Johnston J, ed. Violence and Hate in the Family and 33 Office of Juvenile Justice and Delinquency Prevention, US
Neighborhood: New Perspectives, Policy and Programs. Department of Education. Annual Report on School Safety,
Corte Madera, CA: Center for the Family in Transition;1992. 1998. Washington, DC: US Department of Education, US
Department of Justice;1998.
21 Patten P. Marital relationships, children and their friends:
what’s the connection? an interview with E. Mark Cummings. For more information on this program contact: KD O'Leary,
Parent News (Online). 2000;6(3). Available at: Department of Psychology, State University of New York;
http://npin.org/pnew500/int500a.html. 516 632-7852, E-mail: [email protected]
22 O'Keefe M. Predictors of dating violence among high school 34 Palmer-Castor J. Teen dating violence intervention and pre-
students. J Interpersonal Violence. 1997;12:546-568. vention project evaluation report to the Massachusetts
Department of Public Health and Massachusetts Department
23 Simons RL, Lin KH, Gordon LC. Socialization in the family
of Education;1998.
or origin and male dating violence: a prospective study.
J Marriage Family. 1998;60:467-478. For more information on this program contact: Carole Sousa,
P.O. Box 398114, Cambridge, MA 02139, 617 492-0395.
24 Lewis SF, Fremouw W. Dating violence: a critical review of the
literature. Clin Psychol Rev. 2001;21:105-127. 35 Foshee VA, Bauman KE, Arriaga XB, Helms RW, Koch GG,
Linder GF. An evaluation of Safe Dates, an adolescent dating
25 Malik S , Sorenson SB, Aneshensel CS. Community and dating
violence prevention program. Am J Public Health.
violence among adolescents: perpetration and victimization.
1998;88:45-50.
J Adolesc Health. 1997;21:291-302.
For more information contact: Vangee Foshee, Department
26 Center for Communication Policy, University of California at
of Health Behavior and Health Education, School of Public
Los Angeles. National Violence Study, Volume 1. Thousand
Health, University of North Carolina at Chapel Hill;
Oaks, CA: Sage Publications; 1996.
919 966-6616 or 919 966-6353, E-mail: [email protected].
27 Donnerstein E, Berkowitz L. Effects of film content and victim
association on aggressive behavior and attitude. 1983.
Unpublished manuscript.
Linz D. Sexual violence in the media: effects on male viewers
and implications for society. 1985. Unpublished doctoral
dissertation, University of Wisconsin at Madison.
29 Linz D, Donnerstein E, Penrod S. The effects of multiple
exposure to filmed violence against women.
J Communication. 1984;34:130-147.
30 Malamuth N, Check JVP. The effects of mass media exposure
on acceptance of violence against women: a field experi-
ment. J Res Personality. 1981;15:436-446.
31 McNutty RJ, Heller DA, Binet T. Confronting dating violence.
Educ Leadership. 1997;55:26-28.
32 Meyer H, Stein N. Review of Teen Dating Violence
Prevention. National Violence Against Women Prevention
Research Center. Available at:
http://www.vawprevention.org/research/teendating.shtml.
Accessed: March 25, 2002.
For additional information view:
http://tigger.uic.edu/~schewepa/MPApres.htm

Issue Brief
Firearm-Related Violence
Introduction kept loaded on any given day in the United States.

The United States has the highest rate of youth violence Furthermore, 40% of American households with
in the industrialized world. Many premature deaths children under 18 have guns, and a quarter of those
and injuries are related to youth gun violence. During households keep their guns loaded and unlocked at
the late 1980s and early 1990s, youth firearm-related least some of the time.3 The Congressionally mandated,
violence increased dramatically in the United States. federally funded National Longitudinal Study of
Juvenile gun arrests rose sharply as more teens began to Adolescent Health found that almost one quarter (24%)
carry guns, and the number of gun homicides committed of those adolescents surveyed reported having easy access
by juveniles more than doubled. Youth suicides with to guns at home. The study also found that adolescents
handguns also increased rapidly during that time period. living in homes where guns are kept are more likely to
Since 1994, however, the tide has begun to turn. In behave violently, using a weapon in a fight or shooting
recent years, we have seen significant decreases in youth or stabbing someone, and are also more likely to attempt
suicides and in homicides involving a juvenile offender. or contemplate suicide with a weapon.4
However, much remains to be done. Each year in the Firearm carrying and use
United States, too many teens still illegally access Clearly, one factor that contributes significantly to
firearms and harm others and themselves. adolescent gun violence is that gun possession and
Firearm access carrying have become common among adolescents,
particularly in urban areas. Male teens, in particular,
The Youth Handgun Safety Act of 1994 prohibits
are likely to possess and carry firearms. In a nationwide
possession of handguns by anyone under the age of 18,
survey of high school students in 1999, 9% of male
and under the Gun Control Act of 1968 it is unlawful
students (and 4.9% of all students) reported carrying a
for federally licensed firearms dealers to sell handguns
gun at least once in the 30 days preceding the survey.5
to persons under 21. Yet, youth appear to have little
While still high, this represents a significant decrease
difficulty in obtaining handguns. In one survey of 7th
since 1993, when 13.7% of male students (and 7.9%
and 10th graders in Milwaukee and Boston, 42%
of all students) reported having carried a gun in the
reported that they could get a gun if they wanted one,
30 days preceding the survey.6 The main reason given
and 28% reported having handled a gun without adult
by adolescents for obtaining or carrying guns is self-
knowledge or supervision.1 How do teenagers acquire
protection. Additional motivational factors include
guns? When juvenile offenders in detention centers were
involvement in delinquent activities, such as drug
interviewed about how they acquired their first gun,
dealing, and a propensity for aggressive behavior.7
42% indicated that they were given their first gun by a
It is important to note that adolescent gun carrying
peer, an older youth, or a relative, while 38% purposely
has serious consequences even when it does not lead
acquired their first gun by borrowing (17%), buying
to physical injuries. It increases community members’
(11%), or stealing (10%). Of those who possessed guns,
exposure to intimidation and threats and creates an
84% said that they had obtained them before they
environment of fear and distrust in communities.
were 15 years old.2
Juvenile arrests for weapons violations increased sharply
Many youth gain access to guns in their homes. A recent
during the late 1980s and early 1990s before declining
study found that 41% of households in the United States
in the mid-1990s.8 A variety of factors may have
have at least one gun and 27% have a handgun. One in
contributed to the reduction in youth firearm carrying
3 firearm owners keep their guns loaded at least some of
and use in recent years, including changes in legislation
the time, and 1 in 5 keep them permanently loaded.
and law enforcement practices; improvements associated
This means that as many as 44 million firearms are

Firearm-Related Violence (continued)
with violence prevention programs; demographic once settled by fistfights often escalates to shooting
changes; changes in the market for illegal drugs; and incidents. Youth in states with high levels of household
the broad economic expansion in the United States.9 gun ownership are more likely to be homicide victims
Still, it is important to note that even with the than youth in states with low levels of gun ownership–
impressive declines, there were still more than 40,000 due to their increased likelihood to be murdered with a
juvenile weapons arrests in the United States in 1999, gun.11 Between 1985 and 1993, the number of gun-
accounting for 24% of all weapons arrests.8 related homicides committed by juveniles nearly tripled
(increasing from 909 to 3486), with little accompanying
Firearm-related suicide
growth in non-gun homicides. By 1993, 81% of homi-
More youth die from suicide attempts with firearms cides committed by juveniles involved the use of a gun.
than any other method. This is true for both males and In recent years, the number of killings committed by
females, younger and older adolescents, and all races. juveniles has decreased dramatically. From 1993 to 1999,
More than 60% of youth suicide deaths in 1998 were the number of homicides by juveniles decreased by a
firearm-related. The rate of youth suicides involving a remarkable 59%. This decline was attributable almost
firearm increased 38% between 1981 and 1994, and entirely to a decline in homicides by firearms, as gun
although firearm-involved suicides declined more than homicides committed by juveniles declined 65% in that
20% from 1994 to 1998, these numbers are still much time period. The number of gun homicides committed
too high. Among young people 10 to 19 years old, there by juveniles is still far too high, however, accounting for
were 1240 suicides with guns in 1998—more than 3 on 11% of all gun homicides in 1999 for which the age of
average every day of the year.10 Youth in states with high the offender is known.
levels of household gun ownership are more likely to
commit suicide than youth in states with low levels Non-fatal firearm crime17
of gun ownership–due entirely to firearm suicides; the Firearm-related homicides are just the tip of the iceberg.
number of non-firearm suicides are similar.11 The most From 1993 through 1997 there were 3.3 nonfatal
common location of firearm suicides by youth is in their gunshot injuries from assault treated in hospital emer-
homes, and there is a positive association between the gency departments for every firearm-related homicide.
accessibility and availability of firearms in the home and Because suicide attempts with firearms seldom fail,
the risk for youth suicide. The risk conferred by guns in nonfatal gunshot injuries from suicide attempts were
the home is proportional to the accessibility (eg, loaded much less likely, with only 0.3 firearm-related attempted
and unsecured firearms) and the number of guns in the suicides for every completed suicide. Just as homicides
home.12, 13 One study found that guns were twice as likely and suicides decreased from 1993 to 1997, nonfatal
to be found in the homes of adolescent suicide victims as firearm injuries from crime declined 39% and firearm
in the homes of those who attempted suicide and failed.14 injuries from suicide attempts decreased by 45% in that
The use of guns in a suicide attempt leads to a fatal same time period.
outcome 78% to 90% of the time.13, 15
Other strategies to reduce
Firearm-related homicide 16
firearm-related violence18
Along with the increase in the number of youth carrying In recent years, federal, state, and local governments
firearms in the late 1980s and early 1990s came a sharp have had considerable success in reducing youth firearm
increase in gun-related homicides. Male teenagers have violence. They have passed new laws and employed
always tended to resort to violence to settle arguments, strategies to interrupt sources of illegal guns through gun
but the increased presence of guns means that disputes tracing and monitoring of both licensed and illegal gun

Firearm-Related Violence (continued)
dealers and by aggressively prosecuting and sentencing 6 Centers for Disease Control and Prevention.
Youth risk behavior surveillance—United States, 1993.
those who sell guns to youth. They have worked to deter
Morb Mortal Wkly Rep. 1995;44:1-55, Table 4.
illegal possession and carrying of guns by those at risk
7 Mercy JA, Rosenberg ML. Preventing firearm violence in and
for violence by using community allies to report illegal around schools. In: Elliott DS, Hamburg B, Williams KR, eds.
gun trafficking; targeting probationers, gang members, Violence in American Schools: A New Perspective. New York,
and drug traffickers; prosecuting those who possess illegal NY: Cambridge University Press; 1998:159-187.
guns; and imposing strong sanctions on those who are 8 Snyder HN. Juvenile Arrests, 1999. Juvenile Justice Bulletin.
involved in gun violence. They have implemented Washington, DC: Office of Juvenile Justice and Delinquency
Prevention; 1999:3.
programs to educate youth, families, and community
9 Cole TB. Ebbing epidemic: youth homicide rate at a
residents about the dangers and consequences of gun
14-year low. JAMA. 1999;281:25-26.
violence. They have also increased and coordinated
10 WISQARS (Web-based Injury Statistics Query and Reporting
services and resources for at-risk youth, providing System). National Center for Injury Prevention and Control,
positive opportunities such as tutoring, mentoring, Centers for Disease Control and Prevention.
job-training, and after-school activities, and educating http://www.cdc.gov/ncipc/wisqars.
them about peaceful conflict resolution. Finally, they 11 Miller M, Azrael D, Hemenway D. Firearm availability and
have mobilized community residents and organizations unintentional firearm deaths, suicide, and homicide among
5-15 year-olds. Trauma. 2002;52:267-275.
to work together in their communities to respond to
12 Brent DA, Perper JA, Moritz G, Baugher M, Schweers J,
the problem of youth violence.
Roth C. Firearms and adolescent suicide: a community
Developed by The National Youth Violence case-control study. Am J Dis Child. 1993;147:1066-1071.
Prevention Resource Center. Accessed on-line at 13 Kellerman AL, Rivara FP, Rushford NB, et al. Suicide in
http://www.safeyouth.org/topics/firearm.htm the home in relationship to gun ownership. N Engl Med.
1992; 327:467-472.
on January 2002.
14 Brent DA, Perper JA. The presence and accessibility of
References firearms in the homes of adolescent suicides: a case-control
1 Bergstein JM, Hemenway D, Kennedy B, Quaday S, Ander RJ. study. JAMA. 1991;266:2989-2995.
Guns in young hands: a survey of urban teenagers’ attitudes 15 Brent DA, Perper JA, Moritz G, Baugher M, Schweers J, Roth,
and behaviors related to handgun violence. C. Firearms and adolescent suicide: a community case-control
Trauma.1996;41:794-798. study. Am J Dis Child. 1993;147:1066-1071.
2 Ash P, Kellerman AL, Fuqua-Whitley D, Johnson A. 16 Fox JA, Zawitz MW. Homicide Trends in the United States
Gun acquisition and use by juvenile offenders. JAMA. (Weapons Used). Washington, DC: Bureau of Justice
1996;275:1754-1758. Statistics; 2001.
3 Peter D. Hart Research Associates. Americans’ Attitudes on 17 Strom KJ, Zawitz MW. Firearm Injury and Death from Crime,
Children’s Access to Guns. Washington DC: Peter D. Hart 1993-97, Washington, DC: Bureau of Justice Statistics,
Research Associates; 1999. Special Findings; 2000.
4 Blum RW, Rinehart PM. Reducing the Risk: Connections that 18 Reiss AJ, Roth JA, eds. Understanding and Preventing
Make a Difference in the Lives of Youth. Minneapolis, MN: Violence. Washington DC: National Academy Press; 1993.
Division of General Pediatrics and Adolescent Health,
University of Minnesota;1998:17.
5 Centers for Disease Control and Prevention. Youth risk
behavior surveillance—United States, 1999. Morb Mortal
Wkly Rep. 2000;49:1-96, Table 6.

Issue Brief
Firearm Safety
Introduction devices, with the keys or access codes kept secure at all
Firearm-related injuries and deaths may be reduced times by a responsible adult. Safes and other locked
through firearm safety education and training, regulation storage devices may also prevent impulsive acts such
of firearm access and distribution, and design enhance- as suicide that occur in the home, especially among
ments that reduce the risk of accidental discharge and adolescents. Somewhat less secure alternatives to safes
unauthorized use. A combination of these factors include lock boxes designed specifically for firearms.
will be required to produce meaningful reductions in Trigger Locks. Trigger locks are also available to secure
firearm fatalities.1 a firearm, particularly when more secure storage, such
as a safe, is not available. The trigger lock simply fastens
Design and storage issues
to the gun and prevents the trigger from being pulled.
Regardless of ownership patterns or the rationale for The lock must be removed before use and reattached to
owning firearms, authorities agree on the need to store the gun after use, forcing the owner or shooter to take
guns safely and securely and that guns that are not in additional steps to ensure protection, steps that, if
use should be unloaded. For example, the National Rifle ignored, will decrease safety. Disabling the trigger is
Association’s A Parents Guide to Gun Safety outlines critical not only because the trigger allows the gun to
three fundamental safety rules: fire but because most triggers can easily be operated by
• Always keep the gun pointed in a safe direction children. Other locks are made with cables that fit
• Always keep your finger off the trigger until through the barrel and chamber, thereby preventing a
ready to shoot cartridge from entering the chamber. Trigger and cable
locks are relatively inexpensive and readily available,
• Always keep the gun unloaded until ready to use while gun safes are comparatively expensive. Groups
The same brochure also notes that one should “store such as the National Shooting Sports Foundation
guns so that they are inaccessible to children and other sponsor programs to distribute trigger locks.5
unauthorized users.”2 Design Enhancements. Built into many firearms are
Unfortunately, many gun owners violate these basic so-called manual safeties, mechanical devices that can
rules, particularly those on safe storage, securing, and be manipulated (up or down, in or out) to allow or pre-
loading practices. Multiple surveys have found that as vent the firing of a gun. These safeties are manufacturer
many as half of firearm owners keep their guns loaded dependent, so there are no standards. A few handguns
part of the time, and many of these firearms are feature grip safeties, which are built into the weapon’s
accessible by children or others.3 A national survey of handle. They allow the gun to fire only when the grip
gun owners found that 20% keep a firearm both loaded safety is depressed, as would be the case when the gun is
and unlocked at home; a significant number of these properly held. Interlocking devices, which prevent the
gun owners had children.4 firing of a semiautomatic pistol when the magazine has
Devices for storing and securing firearms been removed, serve a similar purpose. In a related vein,
some guns feature load indicators, which tell a person
Safe Storage. A number of devices can help with the safe
that a round of ammunition is in the chamber. This is
storage of firearms. These include safes or vaults designed
particularly valuable for a semiautomatic pistol from
to hold firearms and ammunition, protecting them from
which the magazine has been removed but which still
unauthorized users such as children or thieves. Firearms
holds a cartridge in the chamber.
and ammunition should be stored in separate locked

Firearm Safety (continued)
Other devices and technologies exist or are being

developed to improve firearm safety. These include
electromechanical locks, personalized firearms, and guns
that fire only for an individual wearing or using the
proper technology. These are not yet generally available
but are under development; prototypes exist for some of
these devices.
Contents excerpted from the American Medical Association’s
Physician Firearm Safety Guide. (Chicago, IL; 1998)
by Stacey Zapanta, BS. Additional content and updates
were provided by Art Elster, MD of the American Medical
Association. Information about the National Rifle
Association’s Gun Safety Rules is available at:
http://www.nra.org/. Accessed: February 5, 2002.
References
1 Elster A. American Medical Association. Personal
communication to Lyndee Knox. January 2002.
2 National Rifle Association. NRA Gun Safety Rules. Available at:
http://www.nrahq.org/safety/education/guide.asp. Accessed:
November 20, 2001.
3 Cook PJ, Ludwig J. Guns in America: National Survey of Private
Ownership and Use of Firearms. Rockville, MD: National
Institute of Justice; 1997.
4 Hemenway D, Azrael D. Gun Use in the United States: Results
of a National Survey. Rockville, MD: National Institute of
Justice; 1998.
5 National Shooting Sports Foundation. Project HomeSafe.
Available at: http://www.projecthomesafe.com.

Issue Brief
Media Violence
Introduction Movies, music videos, video games, and the Internet also
Children and adolescents have access to and consume a contain high levels of violent content. For example,
variety of different media forms, including television, the music videos targeting youth audiences (12 to 19 years
Internet, music and music videos, film and video games, of age) depict an average of 6.1 violent acts per video.5
many of which contain high levels of violent content. Media as a risk factor
The concern—and the controversy—lies in whether The relationship between exposure to violent media and
violent content in media affects a young person’s beliefs aggression has been researched extensively over the past
and behaviors and, more specifically, if frequent exposure 20 years.6 A review of 217 studies found that exposure
contributes to increased aggression and violence in to violent media was consistently correlated with
young people. increases in aggressive behavior in youth.7 Exposure to
Much of the research that has been conducted on the media violence also has been correlated with changes in
relationship between media exposure and aggression youth attitudes about the use of violence in interpersonal
supports such a connection. Although critics have relationships.8 While the evidence may be compelling,
challenged the validity of these findings, suggesting translation of these findings to the “real” world has been
that they focused only on short-term effects and were problematic.9 Findings are criticized on the grounds that
conducted in controlled laboratory settings, a recent most studies were conducted under controlled laboratory
study suggests that exposure to violent media in home conditions and focused on short-term changes in behav-
environments has long-term implications.1 ior. It is unclear whether violent media has similar
Promising strategies for reducing exposure to media effects when viewed in home or community settings and
violence are available and include limit setting by whether such exposure has long-term consequences.8
parents/guardians, technological innovations such as Recently, the Children in the Community Study
the v-chip (which blocks inappropriate shows or addressed these limitations and demonstrated a
content from being viewed by children), and media relationship between consistent consumption of media
literacy training. (3 hours a day) in the home/community and an
increased likelihood of aggression toward others.1
Scope of the problem
Researchers followed 707 families for a 17-year period
Most American homes have a television set, which is and examined the relationship between consumption of
in use for at least 7 hours each day.2 The National media and aggression, using youth self-report, parental
Television Violence Study, a 3-year assessment of violent report, and criminal arrest data. Forty-two percent of
content on television, found that 57% of current televi- males who viewed television more than 3 hours per day
sion programming contains some form of violence.3 at age 14 were reported to have been involved in
Researchers found that the negative consequences of this aggressive acts that resulted in injury when they were 1
violence were rarely portrayed. In 2,693 television 6 or 22 years old, this compared to 9% of males who
programs reviewed, 73% of perpetrators were not held viewed less than 1 hour of television per day. This
accountable for their violent acts and 47% of victims relationship persisted even after controlling for other
showed no evidence of harm; 67% of programming factors such as prior history of aggressive behavior, child
targeted at children not only contained violence, but neglect, neighborhood violence, family income,
consistently juxtaposed violence with humor.3 By age psychiatric disorders, and gender.
10, the average American child witnesses 108,000 acts
of such violence, including 8,000 acts of murder.4

Social learning theory provides an explanation for how exposure occurs in the home, parents/caretakers play a
violent media may influence childhood aggression. pivotal role in limiting consumption both by monitoring
Social learning theory posits that a child learns how to their child’s viewing habits and by regulating what and
act and forms his or her attitudes from observing impor- how much media they consume. Parents/guardians
tant role models in his or her life. Characters portrayed should engage their children in discussion of this issue
in the media may become models who influence the but realize that they may not share their children’s
child’s attitudes, beliefs, and behavior. He or she may opinions or interpretations of violent programming
learn to see violence as a part of everyday life and an and content.8
acceptable way to solve interpersonal problems. Because In 1996 Congress passed the Telecommunications Act,
violence in the media is so frequently presented without which was intended to assist parents and caregivers in
negative consequences, youth may fail to accurately reducing children’s exposure to violent media. The
assess or even understand the real-life consequences of legislation calls for the inclusion of v-chips in all new
violent actions against others.8 televisions and for the development of a rating system to
While children of all ages can be affected by violent enable parents/caretakers to assess the violence content
media content, young children are particularly vulnera- of specific shows.11 Unfortunately, implementation has
ble.7 Developmentally, they are less able to discern reali- been slow to nonexistent. Organizations such as the
ty from fantasy and are more likely to be emotionally American Civil Liberties Union are contesting the
and cognitively affected by the violence they observe.8 legislation on censorship grounds.12 The networks have
Finally, the effects of violent media appear to be race, been slow in developing effective rating systems for their
class, and gender-blind. Violent media influences both programming. To some extent, industry is responding
males and females (although some data suggest that with devices such as Weemote and TVGuardian, which
males may be slightly more affected), and while some can filter out certain television channels and even
studies suggest a connection between socioeconomic offensive language, thereby providing some level of
and community factors and vulnerability to the effects parental control over children’s viewing preferences.13,14
of media violence, most research shows that all groups Developing media literacy in parents and youth.
can experience the effects of media violence on attitudes Another strategy to reduce the effects of violent media is
and behaviors.8,10 media literacy training. Parents/caregivers and children
are taught to critically appraise the media they consume
and develop strategies for reducing exposure to violence.
At present, little research exists on the effectiveness of They are taught to distinguish between real and fantasy
different interventions for reducing the effects of violent violence, identify the real-life consequences of violent
media on children. Some common sense approaches acts that occur in the media, critically assess the motiva-
such as limiting children’s access to violent media and tions of the producers in making the media product, and
teaching them to be informed media consumers have describe nonviolent alternatives to the violent actions
gained support from professional and legislative groups. contained in the programming.
Despite the lack of research, available interventions
have both intuitive and theoretical appeal. Media literacy training resources include The Just Think
Foundation, which focuses on children by providing
Limiting access to and consumption of violent educational programs that can be utilized during or after
media. Researchers have found that limiting media school and on-line15; the Center for Media Literacy,
consumption, including television viewing and video which offers media literacy training for teachers and
game playing, can reduce short-term aggressiveness parents, and community, civic, and youth leaders
in children.6 Since the majority of children’s media through exercises and activities in small group settings16;

and the American Academy of Pediatrics’ Media 6 Robinson TN, Wilde ML, Navracruz LC, Haydel KF, Varady A.
Effects of reducing children’s television and video game use
Matters program, which provides training for health care
on aggressive behavior: a randomized controlled trial.
professionals in media literacy and educational materials Arch Pediatr Adolesc Med. 2001;155:17-23.
for use in the health care setting.17 7 Paik H, Comstock G. The effects of television violence on
Developed by Carmela Lomonaco for the Southern California antisocial behavior: a meta-analysis. Communication Res.
1994;21:516-546.
Center of Academic Excellence on Youth Violence
8 Bushman BJ, Huesmann LR. Effects of Televised Violence
Prevention; Winter 2002. Appreciation is expressed to
on Aggression. In: Singer DG, Singer JL, eds. Handbook of
Dr. L. Rowell Huesmann for his insight and suggestions. Children and the Media. Thousand Oaks, CA: Sage
Publications; 2001.
9 US Department of Health and Human Services. Youth
Internet resources Violence: A Report of the Surgeon General. Rockville, MD:
American Academy of Pediatrics Media Matters US Department of Health and Human Services, Centers for
Disease Control and Prevention, National Center for Injury
http://www.aap.org/advocacy/mediamatters.htm Prevention and Control, Substance Abuse and Mental Health
The Center for Media Literacy Services Administration, Center for Mental Health Services
and National Institutes of Health, National Institute of
http://www.medialit.org Mental Health; 2001.
Children Now 10 Eron LD, Huesmann LR, Lefkowitz MM, Walder LO.
http://www.childrennow.org/media Does television cause aggression? Am Psychologist.
1972;27:253-263.
The Just Think Foundation
11 See http://www.familysafemedia.com/v-chip.html;
http://www.justthink.org see also http://www.fcc.gov/telecom.html
Mediascope 12 See http://www.aclu.org/library/aavchip.html
http://www.mediascope.org/ 13 See http://www.tvguardian-online.com
New Mexico Media Literacy Project 14 See http://www.tvguardian-online.com/weemote

http://www.nmmlp.org 15 See http://www.justthink.org
16 See http://www.medialit.org
17 See http://www.aap.org/advocacy/mediamatters.htm
References
1 Johnson J, Cohen P, Smailes E, Kasen S, Brook J. Television
viewing and aggressive behavior during adolescence and
adulthood. Science. 2002;295:2468-2471.
Additional references
Anderson CA, Dill KE. Video games and aggressive thoughts,
2 Neilson Media Research. Galaxy Explorer. New York: Neilson
feelings, and behavior in the laboratory and in life.
Media Research; 1998.
J Personality Social Psychol. 2000;78:772-790.
3 Center for Communication Policy, University of California at
Bushman BJ. Effects of television violence on memory of
Los Angeles. National Violence Study, Volume 1. Thousand
commercialized messages. J Exper Psychol Applied.
Oaks, CA: Sage Publications; 1996.
1998;4:291-307.
4 Huston AC, Donnerstein E, Fairchild H, Feshbach ND, Katz PA,
Tangney JP, Feshbach S. Children’s television viewing frequency:
Murray JP, Rubinstein EA, Wilcox BL, Zuckerman D. Big World,
individual differences and demographic correlates. Personality
Small Screen: The Role of Television in American Society.
Social Psychol Bull. 1998;14:145-158.
Lincoln: University of Nebraska Press; 1992.
Willis E, Strasburger VC. Media violence. Pediatr Clin North Am.
5 Rich M, Woods ER, Goodman E, Emans SJ, DuRant RH.
1998;45:319-331.
Aggressors or victims: gender and race in music video
violence. Pediatrics. 1998;101:669-674.

Issue Brief
Risk and Protective Factors for Youth Violence
Introduction or her surroundings. Recently, other disciplines,

Numerous factors can contribute to and influence the including mental health and criminal justice, have
range of behaviors that are defined as youth violence. begun to adopt this multi-level approach in their
It is important to consider these factors in order to efforts to understand the nature of violence and identify
develop a comprehensive understanding of the nature potential points of intervention that reach beyond
of the problem. It is also necessary to understand those the individual.
factors that build resiliency and potentially “protect” Individual-level factors, for example, are identified as
youth from engaging in violence. those behaviors or characteristics that affect one person’s
Current research indicates that the presence of a single risk of, or resistance to, potentially engaging in violent
risk factor in an individual does not, by itself, cause behavior. Family factors are typically related to a
antisocial or violent behavior.1 Rather, it is now general- family’s structure, support, culture, and functioning and
ly believed that multiple factors combine to contribute ultimately affect the behavior of the individual members.
to and shape behavior over the course of adolescent Community factors consider physical environment,
development. Studies suggest it is the confluence of available economic and recreational opportunities,
certain “risk” factors that contribute to violent behavior, existing social supports, and other issues that influence
and the existence of certain “protective” factors that the successful functioning of the residents. Finally,
create resiliency. The design of effective prevention and environmental factors encompass larger issues such
intervention strategies should take into consideration as social values and the impact of media, policy, or
the dynamics and inter-relationship of both types legal decisions.
of factors.
The ecological model
Overview
Risk factors are defined as scientifically established
factors or determinants for which there is strong Environment
objective evidence of a causal relationship to a problem.
Protective factors, on the other hand, are those that Community
potentially decrease the likelihood of engaging in a risk Family
behavior. These factors can influence the level of risk an
individual experiences or can moderate the relationship Individual
between the risk and the outcome or behavior.2
One way to understand the dynamic between risk and
protective factors is to view them within an ecological
framework.3-5 The ecological model recognizes that
each person functions within a complex network of
individual, family, community, and environmental
contexts that affect their capacity to avoid risk.
The ecological framework is based on a public health
Specific risk and protective factors
perspective for reducing risks and preventing disease,
illness, and injury. Instead of focusing just on the Violence prevention experts have identified a number of
individual who is at risk for, or who engages in, a risk and protective factors that can be directly attributed
particular behavior such as violence, the public health to violent behavior.
approach considers the individual’s relationship to his

Risk and Protective Factors for Youth Violence (continued)
Below is an overview of some of the specific factors youth may find it difficult to engage in meaningful and
that have been linked to youth violence. The factors substantive relationships with adults both individually
are organized into categories that reflect their level of and within the larger community. This lack of connec-
influence, though some may cut across the different tion may contribute to youth’s feelings of alienation and
levels. While many have been scientifically studied, oth- disassociation from mainstream society, thus increasing
ers require more research. However, all have been identi- risk for delinquent or violent behavior.
fied as having some contributing connection to youth Protective factors that can help build resiliency and
violence and delinquency. Given that individuals oper- reduce overall risk for violent behavior at the environ-
ate within the context of their surroundings, the section mental level include national, state, and local policies
moves from the broader, environmental factors to the that support child- and youth-oriented programs. Such
specific factors that relate directly to individual behavior. programs can help adults build a base of understanding
Environmental-level factors and commitment to working with and engaging young
Environmental factors play an important role in creating people. One of the most powerful protective factors
conditions that can contribute to a culture of violence emerging from resiliency studies is the presence of
among a particular group of people or in a given caring, supportive relationships.9 Thus, the commitment
community. Some of the factors at this level that have of resources to programs that support meaningful
been linked to violence include poverty, media exposure opportunities for adult-youth interaction will help more
to violence, and the general disenfranchisement of adults understand youth perspectives and behaviors,
young people in our society. and can contribute to a culture of caring instead of
one that ignores youth or, worse, labels them as deviant
Socioeconomic status has been consistently found to be
or antagonistic.
an important contributing factor to violence in many
studies. Depressed economic conditions coupled with Community-level factors
individual cases of unemployment and limited economic Some of the community-level factors that contribute
opportunity contribute to higher levels of violence in to the risk for youth violence include the availability
a given community. Researchers have confirmed that of drugs and firearms, community deterioration or
youth living in poverty are more likely to engage in disorganization, and access to quality educational and
violent behavior.6 These youth often also experience recreational opportunities.
specific barriers when seeking employment, such as Researchers have found that the prevalence of drugs
employers who would prefer not to hire them, limited and firearms in a community predicts a greater likelihood
job skills or vocational training, or physical obstacles, of violent behavior.6 Legislation, enforcement, and
such as poor transportation. community dynamics combine to influence the local
Other research indicates that exposure to violence in the accessibility of drugs and weapons. Within individual
media, particularly prolonged exposure by children, may communities, the availability of drugs or weapons may
contribute to aggressive behavior and desensitization to vary, influenced by the presence of existing violence,
violence.7, 8 The media also may contribute to the per- gang activity, or an active firearm trade. These factors
ception of violence as a normative behavior, reinforcing are clearly linked to existing socioeconomic conditions.
and sensationalizing violence as an appropriate and For example, limited economic opportunities in a given
justifiable problem-solving strategy. community may legitimize a local drug trade, creating an
Finally, many adults have a disregard and mistrust of underground secondary economy offering the potential
young people, and our culture has largely failed to of significant financial gain, status, and power.
recognize youth as a valuable asset. As a result, many

Community disorganization is another predictor of non-kin support network that offers access to a variety of
violent activity.6 This factor is defined as the presence of adult viewpoints and experiences. Other family-level
high crime rates, gang activity, poor housing, and general protective factors include clear boundaries for behavior
deterioration in a given community. These communities that enforce structure and rules within the household
also may have a lack of appropriate institutions and and reasonable disciplinary actions when rules are
services for young people, such as quality schools and violated.
recreational facilities, limiting youth access to positive Individual-level factors
and productive development experiences.
The majority of research related to risk factors has
On the other hand, a strong community infrastructure focused on individual-level characteristics or behaviors
has been identified as a protective factor against youth that predict or contribute to violence. It is important
violence in the resiliency literature. Communities can to be cautious in assessing these factors to avoid
create opportunities for youth to participate in activities inappropriately labeling or stigmatizing individual young
where they have choices, decision-making power, and people because they possess certain characteristics or fit
shared responsibility. Such experiences help them to a specific profile. It is also necessary to view individual
develop new skills, increase self-confidence, and offer a factors within a developmental framework, to understand
chance to make a difference. what is appropriate behavior at certain ages, and to
Family-level factors avoid misinterpretation of the signs. Finally, it is
Research demonstrates that family dynamics and necessary to remember that violent behavior is a product
parental or caregiver involvement are significantly of multiple factors operating on many levels in the
correlated with an individual’s propensity to engage in absence of protective factors and that individual youth
violent behavior. A lack of parental interaction and are acting largely within the context of their
involvement increases the risk for violence, particularly environment and experiences.
among males.10 Failure to set clear expectations, An analysis of findings from many studies conducted
inadequate youth supervision and monitoring, and by the US Department of Justice found consistent
severe or inconsistent family discipline practices can evidence of a correlation between violent behavior and
also contribute to delinquency and violent behavior. hyperactivity, concentration problems, restlessness, and
Child abuse and neglect are additional family-level risk taking. Further research appears to be necessary to
risk factors. Research evidence suggests that children understand causal pathways. Other research indicates
or youth who have been physically abused or neglected strong evidence for the co-occurrence of mental health
are more likely than others to commit violent crimes disorders, such as depression, among children or youth
later in life.11, 12 Exposure to high levels of marital and with antisocial or delinquent behavioral problems.
family discord or conflict also appears to increase risk, Aggressive behavior during childhood (from ages 6 to
as does antisocial or delinquent behavior by siblings 13) appears to consistently predict later violence among
and peers. males, although research results for aggressive females are
Family members, especially parents or primary caregivers, less consistent.13 Early onset of violence and delinquency
can play a significant role in protecting youth from is also associated with later acts of more serious and
violence by emphasizing the importance of education chronic violence,14, 15 as is involvement in other forms
and offering support and affection. Frequent, in-depth of antisocial behavior, such as substance use, stealing,
conversations and communication between parents and and destruction of property.6
children help build resilience as does the existence of a

Poor academic achievement and school failure are 6 Hawkins JD, Herrenkohl TI, Farrington DP, Brewer D,
Catalano RF, Harachi TW, Cothern L. Predictors of Youth
other individual-level factors that contribute to risk for
Violence. Rockville, MD: Office of Juvenile Justice and
violence. Some research indicates that this relationship Delinquency Prevention; 2000.
is stronger for females than for males.16 Young people 7 Centerwall BS, Television and violence: the scale of the
who are consistently absent from school during early problem and where to go from here. JAMA.
adolescence (ages 12-14) appear to be more likely to 1992;267:3059-3063.
engage in violence as adolescents and adults. Leaving 8 American Medical Association. Physicians Guide to Media
school before age 15 has been found to correlate with Violence; Chicago, IL: American Medical Association; 1996.
increased risk as well. 9 Benard B. Resilience research: a foundation for youth

development. New Designs for Youth Development.
Individual-level traits and characteristics that have been 1996;12:4-10.
identified as protective factors include a sense of purpose 10 Widom CS. The cycle of violence. Science. 1989;244:160-165.
and belief in a positive future, a commitment to educa- 11 Zingraff MT, Leiter J, Myers KA, Johnson M.
tion and learning, and the ability to act independently Child maltreatment and youthful problem behavior.
and feel a sense of control over one’s environment. The Criminology. 1993;31:173-202.
ability to be adaptable and flexible and have empathy 12 Smith C, Thornberry TP. The relationship between childhood
and caring for others is also significant, as is the ability maltreatment and adolescent involvement in delinquency.
Criminology. 1995;33:451-481.
to solve problems, plan for the future, and be resourceful
13 Piper E. Violent recidivism and chronicity in the 1985
in seeking out sources of support. Conflict resolution and
Philadelphia Cohort. J Quantitative Criminol.
critical thinking skills are additional factors that help 1985;15:319-344.
protect youth from violence, delinquency, and antisocial 14 Thornberry TP, Huizinga D, Loeber R. The prevention of
behavior. serious delinquency and violence: Implications from the
Program of Research on the Causes and Correlates of
Developed by The National Youth Violence Prevention Delinquency. In: Howell JC, ed. Serious, Violent, and Chronic
Resource Center. Available at: Offenders. Thousand Oaks, CA: Sage Publications; 1998.
http://www.safeyouth.org/topics/risk.htm. 15 Howell JC, Krisberg B, Hawkins JD, Wilson JJ, eds. Sourcebook
Accessed: January 2002. on Serious, Violent, and Chronic Offenders. Thousand Oaks,
CA: Sage Publications; 1995.
References 16 Farrington DP. Early predictors of adolescent aggression and
1 National Institute for Mental Health. Child and Adolescent adult violence. Violence Victims. 1989;4:79-100.
Violence Research at the NIMH. Bethesda, MD: NIMH; 2000.
2 Jessor R. Successful adolescent development among youth
in high-risk settings. Am Psychol. 1993;48:117-126.
3 Tolan P, Guerra N. What Works in Reducing Adolescent
Violence: An Empirical Look at the Field. Chicago, IL:
University of Illinois at Chicago, Center for the Study and
Prevention of Violence; 1994.
4 Garbarino J. Adolescent Development: An Ecological
Perspective. Columbus, OH: Charles E. Merrill; 1985.
5 Brofenbrenner U. The Ecology of Human Development:
Experiments by Nature and Design. Cambridge, MA:
Harvard University Press; 1997.

Issue Brief
School Violence
Introduction nearly half, from 12% to 7%. Self-report of fighting

In recent years a number of highly publicized school at school dropped from 16% to 14% during the same
shootings have occurred. While this type of school vio- time period.3
lence has raised public awareness and concern, overall Perception of safety
levels of school violence actually have declined in recent Students feel safer at school than in the past. In 1995,
years. In fact, schools are safer today than they have nearly 10% of students reported not feeling safe at school
been for several years1. Nonetheless, schools and commu- sometimes or most of the time. In 1999, this number
nities still face many challenges in creating a safe and dropped to 5%.2 In addition, clear differences were seen
healthy learning environment for our nation’s youth. among ethnic groups as to how safe students feel at
Scope of the problem school. Latinos and African Americans are the most
fearful at school. Students who do not feel safe at school
Fatal crime
report avoiding one or more places at school, such as
School-related death is rare. In the 1998-1999 school hallways, stairs, cafeterias, and restrooms.3
year, less than 1% (50 total) of youth homicides in the
Crimes against teachers and classroom disruption
United States occurred on school property, at school
events, or on the way to or from school.2 Of the In general, violence in school has declined steadily since
50 school-associated deaths, 34 were student homicides, the early 1990s. However, from 1994 to 1998 crimes
9 were attributed to suicide, and 1 to an unintentional against teachers remained constant at about 31
shooting. Only 2 incidents involved multiple victims. violent crimes per 1000 teachers and 51 thefts per 1000
teachers. In addition, classroom disruption continues
Nonfatal crime
to be a problem. Although not considered violence,
Nonfatal crimes including theft, rape, sexual assault, misbehavior in the classroom interferes with the learning
robbery, aggravated assault, and simple assault declined environment. More than 85% of students report that
from 1992 to 1998. In 1992, these types of crimes their teachers stopped class to deal with disruptive
occurred at the rate of 144 per 1000 students and students at least once a week. This number remained
dropped to 101 per 1000 students in 1998. Students are constant from 1992 to 1998.3
less likely to be victims of serious violent crimes (eg,
rape, robbery, and aggravated assault) at school than Risk factors
away from school. In 1998, 9 per 1000 students were Because youth spend much of their day at school, the
victims of serious violent crimes at school or going to or school is a likely context for violence to occur. Although
from school, while 21 per 1000 students were victims studies have shown that certain characteristics of schools
of serious violent crimes away from school. Conversely, can increase risk of violent acts, most of the risk factors
theft is more likely to occur at school than away from for school violence are, indeed, the same as those for
school. In 1998, there were 58 thefts per 1000 students youth violence. These include individual characteristics
at school and 48 per 1000 students away from school. such as age, gender, and certain personality characteris-
These numbers decreased, however, from 95 per 1000 tics as well as socialization influences of those closest to
at school and 68 per 1000 away from school in 1992.3 the child, particularly family and peers. In addition,
Weapons and fighting although a 2000 report of the US Secret Service stated
that there is no accurate profile for school shooters,
Carrying a weapon and fighting also declined in the late the specific set of risk factors for school shooters is
1990s. From 1993 to 1999, the percentage of students somewhat distinct.4,5
who reported carrying weapons to school dropped by

School Violence (continued)
Age and gender guidance. Thus, already alienated children form peer
Youth are at highest risk of initiation of violent crime groups where negative behavior is the norm and the
between 15 and 16 years of age and at highest risk for violent or criminal behavior of one or more is likely
participation in violent crime from 16 to 17. After age to be followed by others.8
17, participation drops greatly and, by 21, participation School environment
in serious violent crime drops by 80%. Boys are much While violence in schools stems predominantly from
more likely than girls to use physical aggression and vio- sources outside the school, the school environment itself
lence, although some studies indicate that girls are more may exacerbate the problem.9 For example, an unsafe
likely to use indirect forms of aggression such as name- school environment, in and of itself, may precipitate
calling and social exclusion. Because aggression begins more aggressive behavior among students, resulting in a
early and is relatively stable over time, it is likely that cyclic pattern of violence in the school. In addition,
the 15 to 17 year-olds committing violent crimes in high methods and policies implemented in schools to reduce
school may have been among the more disruptive and school violence can make matters worse.10 For example,
aggressive children in elementary school.6 already alienated students who crave attention may be
Personality encouraged by the presence of metal detectors and
Characteristics such as hyperactivity, limited attention cameras to commit violent acts simply for the recogni-
span, restlessness, impulsivity, and risk-taking have been tion. Furthermore, policies of zero tolerance and punitive
linked to violent and delinquent behavior in school.7,8 or coercive punishment tend to further alienate and
upset students. After 4 years of implementation, reports
Social environment show that schools using zero-tolerance policies are
Many factors that normalize violence also lead to less safe than schools that have not implemented
increased risk. Societal factors such as exposure to such policies.11
media violence, easy access to weapons, and gang and School shooters
hate group affiliation can increase the likelihood of
youth violence at school.8 There is no typical profile of the school shooter. Some
are loners and some have close friends. Some are from
Family and home environment single-parent homes and some are from intact families.
The most crucial influences in healthy youth develop- In fact, school shooters typically do not have behavior
ment come from the family and home environment. problems in school. In terms of academic performance,
Negative factors originating within the family, such some may be failing and others may be honor students.
as harsh physical discipline; alcohol and drug abuse; School shooters do, however, share some similar behav-
parental discord, domestic violence, and divorce; child ior patterns. For example, although popular belief is that
abuse and neglect; incarceration of parents or other they “snap,” this is generally not the case. Rather, they
family members; or simply poor parenting practices, typically plan carefully and they do so for a long time,
have profound implications for children. Children raised maybe months or years. In addition, they spend a long
in problem home environments tend to be stressed, time gathering weapons, or considering which weapons
frustrated, alienated, confused, and violent.6-8 to use. It is also common for school shooters to have told
Peer group someone something about their plan or to talk about
wanting to kill people. Frequently, they write their plans
Another area of risk for youth is the peer group.
and feelings in diaries or poetry. Revenge generally
Children tend to choose friends who are like themselves,
surfaces as the primary motive for school shootings.
and they turn to friends and peers for support and
Shooters, for example, may be victims of constant

bullying, may feel continuously rejected or ignored by classroom behavior in participating children. The Perry
teachers, or may feel that no one ever listens or cares. Preschool Program targets low socioeconomic status fam-
Lastly, school shooters have all been male.4,5 ilies and provides high-quality early childhood education
in an effort to improve later school and life performance.
Program outcomes for Perry Preschool children include
Evidence indicates that successful school violence less delinquent behavior and fewer arrests by age 19, less
prevention and intervention strategies require integra- antisocial behavior and misconduct during elementary
tive, proactive approaches. The literature abounds school, higher academic performance and commitment
with evidence and discussion in favor of comprehensive to school, and lower rates of school dropout. These
multidimensional prevention efforts for school and other validated violence prevention programs are
safety.2, 7, 8, 12-17 Furthermore, because violence in the described in detail on the Center for the Study of
schools reflects violence in the community as well as Prevention of Violence Web site under “Blueprints
other social and familial aspects of children’s lives, for Violence Prevention” (see Internet resources at the
collaboration among schools, parents, communities, end of this paper).19
social services, and law enforcement agencies is
necessary for the efficacy of prevention programs.2,8 Regardless of the particular prevention or intervention
selected for a safe school plan, program planners should
One such collaborative program is currently being understand risk and protective factors; know what
piloted by the Riverside Unified School District research finds to be effective; determine the needs of
(RUSD) in Riverside, California. RUSD’s Healthy their particular school and community, as well as identify
People, Healthy Places is an interagency Wellness individual students at risk and most in need of immedi-
Center program. RUSD, County Departments of Mental ate intervention; develop school-wide policies and
Health and Probation, the police department, and the curriculum that support development of social skills and
University of California, Riverside, have come together help students manage anger, solve problems, and treat
to form Wellness Centers at several school sites that others with respect; ensure that all aspects of prevention
provide a variety of personal, mental health, law plans are developmentally and culturally appropriate;
enforcement, and social services to students and their and include all collaborative partners in the planning
families. The objective of the Wellness Center model is and implementation of the program.8, 12, 13, 16, 20 Clearly,
to provide evidence-based activities to promote mental issues of school and youth violence are complex.
health and prevent violence and other problem Furthermore, the solutions appear to be as multifaceted
behaviors in school.18 as the problems. The major components of successful
Other examples of successful school violence prevention prevention of school violence are proactive, comprehen-
programs are LIFT (Linking the Interests of Families sive, and collaborative, and each of these holds within it
and Teachers) and the Perry Preschool Program.19 LIFT a number of essential elements. Intensive planning that
is a school-based program that targets first- through fifth- takes into consideration research-based evidence for
graders, the focus being reduction of conduct problems, effectiveness will increase the possibilities for successfully
association with delinquent peers, and drug and alcohol reducing violence in America’s schools.
use. LIFT uses classroom and playground activities Prepared by Roxie Alcaraz for the Southern California
to role-play, problem solve, and build social skills. Center of Excellence on Youth Violence Prevention,
Parenting education is also part of the program. University of Southern California, Riverside, Winter 2002.
LIFT programs decreased physical aggression on the
playground and increased positive social skills and

References 14 Vera EM, Reese LE Preventive interventions with school-aged

youth. In: Brown SD, Lent RW, eds. Handbook of Counseling
1 US Department of Education and US Department of Justice.
Psychology. New York, NY: John Wiley & Sons Inc;
2000 Annual Report on School Safety. Washington, DC:
2000:411-434.
US Department of Education, US Department of Justice;
2000. 15 Hurford DP, Lindskog CO, Mallett SL. School violence:
issues and strategies for prevention. In: Sandhu D, ed.
2 National Youth Violence Prevention Resource Center.
Faces of Violence. New York, NY: Nova Science Publishers,
School Violence. Available at: http://www.safeyouth.org/
Inc; 2001: 23-44.
topics/school/htm. Accessed: October 30, 2001.
16 Pollack I, Sundermann C. Creating safe schools: a
3 Small M, Tetrick KD. School violence: an overview.
comprehensive approach. Juvenile Justice. 2001:8:13-20.
Juvenile Justice. 2001;8:3-12.
17 Sink CA, Rubel L. The school as community approach
4 Dedman B. Deadly lessons, Part I: examining the psyche of
to violence prevention. In: Sandhu D, ed. Faces of Violence.
an adolescent killer. Chicago Sun Times. 2000. Available at:
New York, NY: Nova Science Publishers, Inc; 2001:417-438.
http://www.ustreas.gov/usss/ntac/chicago_sun/shoot15.htm.
Accessed: February 2002. 18 Riverside Unifies School District. Healthy People,
Healthy Places; 2001. Available at: http://www.rusd.k12.ca.us/
5 Gaugham E, Cerio JD, Myers RA. Lethal Violence in Schools
ourcurriculum/hp-hp/Default.htm. Accessed: November 25,
A National Study. Alfred, NY: Alfred University; 2001.
2001.
6 Loeber R, Stouthhamer-Loeber M. Juvenile aggression at
19 Center for the Study and Prevention of School Violence.
home and at school. In: Elliott D, Hamburg B, Williams KR,
Blueprints for Violence Prevention. Boulder, CO.
eds. Violence in American Schools. New York, NY:
Center for the Study of Prevention of Violence
Cambridge University Press; 1998:94-126.
University of Colorado; 2001. Available at:
7 Christle CA, Kristine J, Nelson CM. Youth aggression http://www.colorado.edu/cspv/blueprints/default.htm.
and violence: risk, resilience, and prevention. ERIC Digest.
20 Elliott DS, Hamburg B, Williams KR. Violence in American
E602. Arligton, VA: ERIC Clearingouse on Disabilities
schools: an overview. In: Elliott D, Hamburg B, Williams KR,
and Gifted Education;2000.
8 Sandhu DS, Arora M, Sandhu VS. School violence: risk factors, University Press; 1998:3-30.
psychological correlates, prevention and intervention
strategies. In: Sandhu D, ed. Faces of Violence. New York, NY
Nova Science Publishers, Inc; 2001;45-71.
9 Hamburg MA. Youth violence is a public health concern. In:
Elliott D, Hamburg B, Williams KR, eds. Violence in American
Schools. New York, NY: Cambridge University Press;
1998:31-54.
10 Edwards D, Mullis F. Creating a sense of belonging to build
safe schools. J Individual Psychol. 2001;57:196-203.
11 Skiba R, Peterson R. The dark side of zero tolerance.
Phi Delta Kappan. 1999;80:372-378.
12 Elliott DS, Williams KR, Hamburg B. An integrated approach
to violence prevention. In: Elliott D, Hamburg B, Williams KR,
University Press; 1998:379-386.
13 Marans S, Schaefer M. Community policing, schools, and
mental health: the challenge of collaboration. In: Elliott D,
Hamburg B, Williams KR, eds. Violence in American Schools.
New York, NY: Cambridge University Press;
1998:312-347.

Related publications and

Internet resources
Attorney General and State Superintendent of Public
Instruction Safe Schools Task Force (2001).
Great Ideas for Safe Schools. Available at:
http://www.cde.ca.gov/spbranch/safety.
Accessed: August 23, 2001.
Elliott D, Hamburg B, Williams KR. Violence in American
Schools. New York, NY: Cambridge University Press;
1998.
Farrell AD, Meyer AL, Kung EM, Sullivan TN.
Development and evaluation of school-based violence
prevention programs. J Clin Child Psychol.
2001;30:207-220.
Riley PL. How to Establish and Maintain Safe, Orderly,
and Caring Schools; 2001. Available at:
http://www.ncsu.edu/cpsv/special_feat.html.
American Academy of Child and
Adolescent Psychiatry
http://www.aacap.org
Center for the Prevention of School Violence
http://www.ncsu.edu/cpsv
Center for the Study and Prevention of Violence
http://www.colorado.edu/cspv/
Comer School Development Program
http://info.med.yale.edu/comer/index.html
Family Education Network
http://www.familyeducation.com
National Resource Center for Safe Schools
http://www.safetyzone.org
National Youth Violence Prevention Resource Center
http://www.safeyouth.org

Issue Brief
Youth Development and Violence Prevention:
Core Competencies
Introduction Core competencies for healthy

Many youth violence prevention programs seek to youth development
identify “risk” factors that increase risk for violence and Despite the existence of a number of taxonomies of
“protective” factors that moderate that risk. Indeed, positive developmental outcomes,2,3 most youth develop-
there is a large body of literature on risk and protective ment and prevention efforts select certain competencies
factors related to youth violence1. Efforts are therefore (eg, problem-solving skills) or contextual supports
aimed at reducing specific risk factors and enhancing (eg, family functioning) that are not connected system-
protective factors. In some cases, programs are directed atically. In many cases these are mixed together in long
towards entire populations believed to be at risk, such as lists of “good things.” For example, a large number of
inner-city, low-income youth. In other cases, certain communities have embraced the 40 assets of healthy
youth are identified for participation in a variety of youth development promoted by the Search Institute.4
programs based on the presence of selected risk factors, Many of these assets reflect ways to build individual
such as early aggressive behavior, low self-control, poor competencies (eg, family support), rather than
social problem-solving skills, or significant family prob- delineating what these competencies are and how
lems. A number of federal agencies such as the Office of they are linked to youth violence.
Juvenile Justice and Delinquency Prevention and the
Rather than providing a listing of assets or protective
Centers for Disease Control and Prevention have rallied
factors that often do not differentiate clearly between
around this public health perspective that emphasizes
individual outcomes (eg, self-control) and supports that
reduction of risk for youth violence.
facilitate those outcomes (eg, effective parenting), a
A slightly different approach to violence prevention focus on core competencies provides a specific guide
emphasizes the importance of positive youth for youth development programming by emphasizing
development. Rather than focus on selected risk factors measurable outcomes. Development of core competen-
and how to reduce them, a youth development approach cies begins at birth or before and extends through
emphasizes strengthening the capacity of youth to adolescence and beyond. A number of different programs
become healthy and successful adolescents and adults and supports can facilitate the development of these
through skill building and development of opportunities competencies at different ages.
for engagement and support. Youth development
Five core competencies are important for healthy social
programs are typically broad-based and include all youth
and emotional development and are important for youth
rather than targeting those deemed to be at risk. Terms
violence prevention.5, 6 In other words, youth who are
such as positive development, social competence, and asset-
skilled in these five areas should be less likely to engage
building are used. The overall goal of the youth develop-
in violence and other problem behaviors. These are
ment approach is to maximize positive outcomes.
described in the following table.

Core Competencies (continued)
Core competency Related terms Links to youth violence
Positive identity Positive self-concept, Violence associated with

hopefulness, future goals negative identity
Personal agency Self-efficacy, effective coping, Violence associated with

attributional style hostile attributional bias
Self-regulation Affective, behavioral, and Violence associated with

cognitive self-regulation poor impulse control
Social relationship skills Social problem-solving skills, Violence associated with

empathy, conflict resolution skills, poor social problem-solving skills
capacity for intimacy and lack of empathy
System of belief Attitudes, norms, values, Violence associated with

moral engagement aggressive norms and
moral disengagement
A youth development approach to violence prevention Promising strategies

that highlights core competencies emphasizes under- Healthy youth development begins early and can be
standing and attending to the specific developmental fostered in many ways. A major emphasis is on the
needs of youth. It integrates a risk-focused approach by creation of supportive environments in families, schools,
recasting many risk and protective factors in terms of and communities. Most youth development efforts
these core competencies. However, developmental issues also emphasize integrated services within communities
alone are not the only predictors of youth violence. It is rather than disconnected and fragmented programs.
also important to identify problem-specific factors that
are not directly related to development. For example, The development of the five core competencies begins
easy access to firearms can increase the risk of violence, at birth or before. Thus, programming to foster this
while community policing can decrease that risk. The development must begin early and continue throughout
impact on risk of these community factors is not directly childhood and adolescence. This programming should
related to the mastery of specific competencies; rather, involve specific instruction and opportunities to practice
it is through other mechanisms such as opportunities discrete skills as well as promotion of contextual supports
and deterrence. An integrated approach to violence for development. Clearly, some strategies are more
prevention should build on youth development but appropriate for selected age groups. Examples of positive
also recognize other violence-specific risk factors and strategies to foster healthy development include the
how they can be addressed. following:

Promoting a positive identity in children and youth • Availability of mental health counseling and services,
• Opportunities for engagement and involvement in including diagnoses of children with problems such as
school and community activities that are available to attention deficit hyperactivity disorder
children regardless of academic achievement, income, Promoting social relationship skills
or other prerequisites that exclude some children • Opportunities for safe and structured play
• Parent and teacher training programs that emphasize (eg, community playgrounds)
positive reinforcement and acknowledgement of • After-school recreation and social development
positive behaviors programs
• Opportunities to explore various skill and career • Direct instruction (eg, individual, classroom, small
options and to build on individual strengths group) in social relationship skills
and talents
• Conflict resolution and peer mediation programs
• Youth employment training programs that prepare
• Mentoring programs that provide positive role models
youth for meaningful and rewarding careers
and teach children how to engage others successfully
• Mentoring programs that provide positive role
• Community service opportunities that involve chil-
models and encouragement
dren and youth in the lives of others, including those
Developing a sense of personal agency most in need
• Youth involvement in decision making and Helping youth develop a prosocial system of belief
governance at school and in the community
• School- and community-wide campaigns to
• Attribution retraining programs that encourage youth promote prosocial norms and discourage aggressive
to accurately attend to and interpret social cues and and antisocial norms
decrease hostile attributional biases
• Media campaigns that encourage prosocial and
• Providing children and youth with safe and supportive responsible behavior
environments that minimize exposure to stressors
• Rules and laws that set guidelines for acceptable
• Training families and children in effective and appropriate behavior
coping skills
• Social development, moral reasoning, and character
Building self-regulation skills education programs that emphasize social
• Direct instruction (eg, individual, classroom, responsibility
small group) in self-regulation skills such as anger Prepared by Nancy Guerra and Kirk Williams for the
management and cognitive self-control Southern California Center of Excellence on Youth Violence
• Parent training programs that emphasize de-escalation Prevention, University of California, Riverside,
rather than escalation of aggressive behavior Winter 2002.
• Opportunities for engagement in group activities that
provide structure as well as short-term and longer-term
reinforcements

References
1 Lipsey M, Wilson DB. Effective Interventions for Serious
Juvenile Offenders: A Synthesis of Research. Thousand Oaks,
CA: Sage Publications; 1998.
2 Sroufe LA, Rutter M. The domain of developmental
psychopathology. Child Dev. 1984;83:1348-1357.
3 WT Grant Consortium on the school-based promotion of
social competence. Drug and alcohol prevention curricula.
In: Hawkins D, ed. Communities That Care. San Francisco, CA:
Jossey-Bass;1992.
4 Benson P. Forty Assets for Youth. Minneapolis, MN: Search
Institute; 1997.
5 Guerra NG. Preventing violence by promoting wellness.
J Appl Psychoanal Stud. In press.
6 Williams KR, Guerra, NG. Supporting Youth by
Strengthening Communities. Boulder, CO: Center
for the Study and Prevention of Violence; 1996.
Related publications on
youth development
Eccles JG. Community Programs to Promote Youth
Development. Washington, DC: National Academy
Press; 2001.
Shinkoff J, Phillips D. From Neurons to Neighborhoods.
Washington, DC: National Academy Press; 2000.
Internet resources
Youth Learn
http://www.youthlearn.org
National Youth Development Information Center
http://www.nydic.org
Institute for Youth Development
http://www.youthdevelopment.org
Positive Youth Development in the United States
http://www.aspe.hhs.gov
Reconnecting Youth and Community
http://www.ncfy.com

Issue Brief
Youth Gangs
Introduction neighborhoods or location. Rivalries tend to stem from

Gang members represent a relatively small proportion of these neighborhood divisions. Asian gangs tend to be
the adolescent population. However, they commit the motivated more by profit than by neighborhood rivalries.
majority of serious youth violence.1, 2 Along with the Violence between ethnic gangs is normally intra-ethnic
rapid proliferation of gangs since 1980, there have been (eg, one Latino gang vs another Latino gang), based
growing concerns among lawmakers, law enforcement, on neighborhood or location-based affiliation, rather
educators, practitioners, and parents about gang behavior than inter-ethnic (eg, Latino gang vs African-American
and gang violence. Researchers have studied the gang gang).
phenomenon since the early 1900s but have yet to delin- Gang members commit more serious and violent offenses
eate clearly the reasons why some youth join gangs.1,2 than adolescents who are non-gang members.1,2 They are
Little is also known about the effectiveness of many of not only more involved in committing delinquent acts,
the intervention programs that exist to combat the gang they are responsible for the majority of all delinquent
problem.1 Overall, the dynamics of gang behavior and its acts that are committed.2,4 Respondents to the 1999
persistence in the United States are not well National Youth Gang Survey reported that the most
understood.3 prevalent offenses committed among gang members were
larceny/theft, aggravated assault, and burglary/breaking
and entering.4
Results from the 1999 National Youth Gang Survey
Gangs tend to be composed of young males, ranging in
suggest that the youth gang problem continues to be
age from 12 to 25 years, but there have been instances of
widespread and substantial across the United States.4
gang members much younger and much older than this
On the basis of 3,911 police and sheriff’s departments
range. Some gangs are loosely knit and lack structure,
that responded to the survey, there were an estimated
while others are highly organized and regimented.
26,000 gangs and 840,500 gang members across the
Indeed, gangs are organizations that develop strategies
nation. The majority of these gang members reside in
to optimize the chances of organizational survival, some
large cities. For example, Chicago has an estimated
more successfully than others. In many cases, gangs
30,000 to 50,000 gang members. However, Los Angeles
engage in a range of entrepreneurial activities designed
ranks first in the United States in gang-involved youth,
to provide money, power, and prestige to members.
with more than 58,000 gang members. California
continues to have the most gangs and gang-related Risk factors
problems compared to any other state in the country, Many of the risk factors for youth violence and
with more than 200 communities seriously affected by delinquency also predict increased risk of gang
gang-related problems. involvement. In particular, researchers emphasize the
Most gangs are formed along racial or ethnic lines. importance of neighborhood, family, school, and peer
In California, these include Latino gangs, African- influences.
American gangs, Asian gangs, and white gangs. There Neighborhood
are also further ethnic distinctions within these larger
The majority of research on neighborhood influences on
groups, such as Chicano, Central American, and Puerto
gangs has focused on the role of social disorganization.
Rican gangs, all considered Latino. In California, Latino
The basic idea is that poverty has caused a disintegration
gangs compose the majority of the gang population,
of social organization and social control that, in turn, has
although Asian gangs are on the rise. Most (but not all)
led to the emergence of gangs as alternate mechanisms
Latino and African-American gangs are divided by
that provide order, safety, and economic opportunities.

Youth Gangs (continued)
Thus, youth growing up in these communities are that can be appealing to youth. In many cases, older
enticed by gang life because it provides something to do, gang members recruit younger children for a variety
material possessions, and protection from the existing of tasks, essentially creating a cadre of “trainees” who
violence on the streets. Indeed, studies have shown that are socialized into gang life from an early age.
the probability of joining a gang is higher in neighbor-
hoods with low resources and high levels of community
social disorganization.2,5 Because of the complex interplay of factors that lead to
gang membership, various types of intervention programs
Family have been developed. These programs mainly focus on
Family disorganization is another salient influence in prevention, intervention, or suppression.6 Prevention
joining a gang. Poor family management strategies strategies aim to prevent youth from joining gangs
increase the risk of gang membership.2 Poor strategies through education-type programs. Intervention programs
include low family involvement, inappropriate parental aim to divert youth from crime by providing alternatives
discipline, low parental control or monitoring, poor such as after-school programs, counseling, and job
affective relationships, and parental conflict. Facing training. Suppression strategies use enforcement tactics
poor family relationships, a youth may be lured by a that identify, isolate, and punish criminal offenders. A
gang because it provides a “family” that is lacking at mixture of approaches is currently being tried across the
home. In some cases, parents who are themselves United States, with considerable efforts directed towards
gang members may model and encourage the gang police suppression programs.6 Although there are many
involvement of their children. programs representing a variety of approaches, very
School few of these programs have been carefully evaluated.
Educational variables have also been assessed as risk An exception is the Bureau of Alcohol, Tobacco, and
factors for gang membership. Studies have found that Firearms’ Gang Resistance Education and Training
youth who have a low educational expectation have a Program (GREAT). This prevention program utilizes law
higher risk of joining a gang. It is also a risk factor if a enforcement officers to teach a 9-week curriculum to
youth’s parent(s) have low educational expectations for elementary and junior high school students on resisting
their child. Poor school performance and low commit- gang involvement and avoiding the use of violence.
ment and involvement are also correlated with gang A number of evaluations of this program have been
membership. Essentially, a high commitment to school conducted. For example, a survey of 5935 eighth-grade
indicates an attachment to conventional institutions. students in 11 sites found that students who
The less a youth bonds to these conventional institu- participated in the program reported more prosocial
tions the more likely he/she will participate in gangs. attitudes and lower rates of some types of delinquent
behavior than students who did not participate in the
Peers
program.7 These results suggest that large school-based
One of the most robust findings in the literature is the preventive programs may be effective in curtailing the
link between having deviant peers and joining a gang. gang problem, or at least in influencing attitudes and
Having peers who are gang members greatly increases behaviors associated with gang involvement.
the likelihood of joining a gang. Peers who are engaged
Interventions should include multiple components,
in this type of behavior may construe gang behavior as
incorporating prevention, social intervention, treatment,
attractive and fun. Gangs also provide a sense of
suppression, and community mobilization approaches.6
comradship and expectations of safety and protection
One such program began in the Little Village area of

Chicago and has been extended to other sites across the References
United States. The Little Village program targeted the 1 Howell JC. Youth Gangs: An Overview. Washington, DC:
older members of two of the most violent Latino gangs US Department of Justice, Office of Juvenile Justice and
Delinquency Prevention; 1998.
via two coordinated strategies: (1) increased probation
department and police supervision and suppression to 2 Thornberry TP. Membership in youth gangs and involvement
in serious violent offending. In: Loeber R, Farrington DP, eds.
control violent or potentially hard-core violent youth; Serious and Violent Juvenile Offenders: Risk Factors and
and (2) efforts to encourage at-risk youth to engage in Successful Interventions. Thousand Oaks, CA: Sage
conventional activities through education, jobs, job Publications; 1998:147-166.
training, family support, and brief counseling. 3 Jankowski MS. Islands in the Street: Gangs and American
Preliminary evaluation results (after 4 years of program Urban Society. Berkeley, CA: University of California Press;
1991.
operation) point to a reduction in the rate of increase in
4 Egley A. Highlights of the 1999 National Youth Gang Survey.
gang violence in the Little Village area compared to the
Washington, DC: US Department of Justice, Office of Juvenile
control area. Justice and Delinquency Prevention; 2000.
Still, effective prevention of gang involvement and 5 Covey HC, Menard S, Franzese RJ. Juvenile Gangs. 2nd ed.
gang activity remains a pressing challenge. In contrast Springfield, IL: Charles C Thomas; 1992.
to individual acts of violence that can be addressed by 6 Howell JC. Promising programs for youth gang violence
programs designed to reduce individual risk, gangs are prevention and intervention. In: Loeber R, Farrington DP, eds.
Serious and Violent Juvenile Offenders: Risk Factors and
also social organizations that provide an alternative Successful Interventions. Thousand Oaks, CA: Sage
option for youth competing for scarce resources in Publications; 1998:284-312.
low-income neighborhoods. Social interventions that 7 Esbensen F, Osgood DW. National Evaluation of G.R.E.A.T.
provide entry-level skills and low-paying jobs may simply Washington, DC: US Department of Justice, National Institute
not be able to compete with the social and economic of Justice; 1997.
opportunities provided by gangs. Similarly, harsher Related publications on youth gangs

sentencing seems to exacerbate rather than prevent the
Battin SR, Hill KG, Abbott RD, Catalano RF,
problem, as gang members continue and escalate their
Hawkins, JD. The contribution of gang membership to
gang activity in prison. A sustainable reduction in gang
delinquency beyond delinquent friends. Criminology.
problems may require a focus on the multiple functions
1998; 36:93-115.
they serve and on programs that can provide reasonable
and viable options for youth. Curry GD, Spergel IA. Gang involvement and
delinquency among Hispanic and African-American
Prepared by Tia Kim for the Southern California Center of
adolescent males. J Res Crim Delinquency.
Excellence on Youth Violence Prevention, University of
1996;29:273-291.
California, Riverside, Winter 2002.
Decker SH. Collective and normative features of gang
violence. Justice Q. 1996;13:243-264.
Decker SH, Van Winkle B. Life in the Gang: Family,
Friends, and Violence. New York, NY: Cambridge
University Press; 1996.
Esbensen F. Preventing Adolescent Gang Involvement.
Washington, DC: US Department of Justice, Office of
Juvenile Justice and Delinquency Prevention; 2000.

Esbensen F, Huizinga D. Gangs, drugs, and Maxson CL. Gang Members on the Move. Washington,
delinquency in a survey of urban youth. Criminology. DC: US Department of Justice, Office of Juvenile Justice
1993;31:565-589. and Delinquency Prevention; 1998.
Goldstein AP, Huff CR. The Gang Intervention McCarthy TLA. Gangs are back. Time. 2001:46-49.
Handbook. Champaign, IL: Research Press; 1993. Sanders WB. Gangbangs and Drive-bys: Grounded Culture
Gulotta TP, Adams GR, Montemayor R. Delinquent and Juvenile Gang Violence. New York, NY: Aldine de
Violent Youth: Theory and Interventions. Thousand Oaks, Gruyter; 1994.
CA: Sage Publications; 1998. Song JH, Dombrink J, Geis G. Lost in the melting pot:
Hazlehurst K, Hazlehurst C. Gangs and Youth Subcultures: Asian youth gangs in the United States. Gang J.
International Explorations. New Brunswick, NJ: 1992;1:1-12.
Transaction Publishers; 1998. Spergel IA, Grossman SF. The little village project: A
Howell JC. Youth Gang Homicides and Drug Trafficking. community approach to the gang problem. Social Worker.
Washington, DC: US Department of Justice, Office of 1997;42:456-470.
Juvenile Justice and Delinquency Prevention; 1997. Vigil JD. Barrio gangs: Street life and identity in southern
Howell JC, Decker SH. The Youth Gangs, Drugs, and California. Austin,TX: University of Texas Press; 1988.
Violence Connection. Washington, DC: US Department
Internet resources
of Justice, Office of Juvenile Justice and Delinquency
Prevention; 1999. Center for the Study and Prevention of Violence
http://www.colorado.edu/cspv
Howell JC, Lynch JP. Youth Gangs in Schools.
Washington, DC: US Department of Justice, Office National Alliance of Gang Investigators
of Juvenile Justice and Delinquency Prevention; 2000. Associations
http://www.nagia.org
Huff CR. Gangs In America. 2nd ed. Thousand Oaks,
CA: Sage Publications; 1996. National Criminal Justice Reference Service
http://www.ncjrs.org
Huff CR. Comparing the Criminal Behavior of Youth Gangs
and At-Risk Youth. Washington, DC: US Department of National Institute of Justice
Justice, National Institute of Justice; 1998. http://www.ojp.usdoj.gov/nij/
Joe KA, Chesney-Lind M. Just every mother’s angel: National Youth Gang Center
an analysis of gender and ethnic variations in youth http://www.iir.com/nygc
gang membership. Gender Society. 1995;9:408-431. Office of Juvenile Justice and
Loeber R, Farrington DP, eds. Serious and Violent Delinquency Prevention
Offenders: Risk Factors and Successful Interventions. http://www.ojjdp.ncjrs.org
Thousand Oaks, CA: Sage Publications; 1998. US Department of Justice
Los Angeles County Sheriff’s Department. L.A. Style: http://www.usdoj.gov
A Street Gang Manual of the Los Angeles County Sheriff’s
Department. Los Angeles, CA: Los Angeles County
Sheriff’s Department; 1994.

Issue Brief
Youth Suicide
Introduction completed suicide is most likely accounted for by the

Youth suicide is a major public health problem in the differences in suicide methods. A greater proportion of
United States today. It is the third leading cause of death female suicides is accounted for by poisoning than male
for youth between the ages of 15 and 24 years.1 As such, suicides among youth, whereas firearms, which have
the reduction of adolescent suicide is one of the major higher lethality, account for a greater proportion of male
objectives of the Healthy People 2010 Initiative.2 suicides compared to females.
Secular trends
Although the overall suicide rate has declined during
Age and gender differences
the past two decades, from 12.1 per 100,000 in 1979 to
Suicide is not a common phenomenon during childhood 11.3 per 100,000 in 1998, among male youth aged 15 to
and early teens.3 Suicide mortality increases considerably 19 years, the suicide rate increased during that period.
in the late teens, and the increase continues into the However, more recently (1994 to 2001), there has been
early 20s regardless of gender. Youth suicide is marked by a decline in suicide rates among adolescent and young
a distinct gender difference; although females are more adult males. One speculation is that the decline is
likely than males to attempt suicide, males are roughly a consequence of more effective antidepressant
five times as likely to commit suicide. medications for youth and a decrease in substance
Differences by ethnicity abuse,7 but the exact reasons remain unknown.
Generally, European-American youth have a higher Geographical distribution
prevalence of suicide than African-American, Latino, In general, youth suicide mortality is highest in the
and Asian-American/Pacific Islander youth, except for Mountain states of the United States and lowest in the
American Indian/Alaska Native youth, who have the Middle Atlantic states.8 The rate for 1996-1998 ranges
highest prevalence of suicide across all age groups. In from the lowest of 4.4 per 100,000 population (New
particular, American Indian/Alaska Native males have Jersey) to the highest of 22.0 per 100,000 per population
the highest youth suicide rate in the United States, with (Alaska). The differential youth suicide rates by geo-
substantial variation by factors such as tribal affiliation graphical location may be related to differential ethnic
and geographical area.4 Whereas research suggests that diversity of the population and/or the availability of
Latino youth are not overrepresented among completed firearms by states.
suicides,5 they are overrepresented among attempted
Nonlethal suicide behaviors
suicides.6
The significance of youth suicide as a major public
Methods of youth suicide
health problem is even more evident when considering
In 1998, firearm death was the most prevalent method the high rates of nonlethal suicidal behaviors such as
of suicide, regardless of age and ethnicity. In fact, attempted suicides and suicidal ideation. For example,
firearm-related suicide accounted for more than 60% it has been documented that 1 in 5 high school
of all youth suicides. Moreover, firearm suicides more students report expressing suicidal ideation and 8%
than tripled between 1981 and 1994. Although firearm- report having attempted suicide, of whom approximately
related suicide rates among youth have declined more 3% need medical attention.3, 6, 9 It is noteworthy that
than 20% between 1994 and 1998, the rates have still these responses are not with regard to the entire lifespan
been high. The second and third most prevalent of the responding high school student but, rather, within
methods of youth suicide are hanging and poisoning, the last year. Whereas male youth have a higher
respectively. The gender difference in the rates of

Youth Suicide (continued)
prevalence of completed suicide than female youth, Maladaptive coping skills

female youth have a higher prevalence of suicidal Maladaptive coping skills and poor interpersonal
ideation and attempts than their male counterparts. problem-solving ability may limit the adolescent’s ability
Risk factors to generate solutions to a problem, resulting in
Suicidal behaviors are complex. Past research has considering suicide as the only solution.14 Suicidal youth
identified multiple risk factors associated with experience a greater number of stressful life events
these behaviors. compared with their nonsuicidal peers. Consequently,
when negative stressors are compounded by other
Psychopathology multiple negative events, problem-solving difficulties
The majority of youth who have completed suicide had may become paramount.
significant psychiatric problems, including depressive Stressful life events
disorders and substance abuse disorders. Major depression
has been the most prevalent condition.10 Female youth Multiple negative life events are typically experienced
suicide victims have a higher prevalence of an affective by adolescents who attempt and/or complete suicide.15
disorder than male suicide victims. Substance abuse These stressors are likely to overtax the adolescent’s
is also a significant risk factor, especially for older coping skills because of inexperience with such life
adolescent male victims.10 Substance abuse has situations.16 Completed suicide among youth is associated
consistently been a significant psychiatric risk factor with experiencing life stressors such as interpersonal
when it is co-occurring with an affective disorder.11 losses (eg, breaking up with a boyfriend/girlfriend) and
legal or disciplinary problems (eg, getting into trouble
Previous suicide attempts at schools or with a law enforcement agency).
One quarter to one third of youth suicide victims had Suicide contagion
made suicide attempts before the completed suicide.
Moreover, the risk of completed suicide after suicide A significant increase in the number of suicides occurs
attempts is also higher. For male adolescents the risk after the appearance of suicide stories in the mass media,
is 30 times higher, whereas for female adolescents the including newspaper articles, television news reports, and
risk is 3 times higher.11 fictional and non-fictional dramatization.3 In particular,
the influence of suicide stories on subsequent completed
Access to lethal methods suicides is greatest for adolescents.17 However, the linking
Firearms are the most common method of suicide of the media’s report of suicide and prospective suicide
among youth, and the youth’s own home is the single rates dissipates for those beyond the age of 24.18
most common location for firearm suicides to take Family history
place.12 Associations have been found between the
accessibility and availability of firearms in the home and Although it is unknown exactly how familial psy-
the risk for youth suicide.12, 13 Moreover, the availability chopathology increases the suicide risk among youth, a
of loaded guns has been associated with an elevated risk family history of suicidal behaviors is known to elevate
of youth suicide, regardless of presence of diagnosable the risk of completed suicide in youth.19 Additionally,
psychiatric disorder(s).12 parental psychopathology (depression and substance
abuse) is associated with suicidal behaviors,20 and
completed suicide among youth.19 Some suggest that
the association between parental and youth suicide

may reflect a genetic factor rather than family Biological risk factors
dysfunction per se.21 Research suggests that abnormalities in the serotonergic
Socioeconomic status system are associated with suicidal behaviors, as well
Little is known about the association between as impulsivity and aggression. For example, it has been
socioeconomic status (SES) and youth suicide. Gould found that low levels of serotonin among suicide
and colleagues found a differential effect of ethnicity in attempters were predictive of future completion of
comparing adolescent suicide victims with community suicide.25
controls.19 These researchers found that only African- Promising prevention strategies
American suicide victims had a higher SES than their
Whereas advances in knowledge have led to increased
general population controls. Psychopathology such as
understanding of the risk factors for child and adolescent
untreated depression and substance abuse disorders is
suicide, applying this knowledge to the design of
one of the major causes of adolescent suicide. However,
prevention strategies and program evaluation to
a variety of barriers to seeking treatment exist especially
examine effectiveness of suicide prevention programs
among those with the low SES, thus elevating the risk
has just begun. According to the Centers for Disease
for suicidal behaviors among youth. Some of these
Control and Prevention, the main goal of youth suicide
health disparities are accounted for by differences of
prevention strategies is twofold: risk factor reduction
gender, ethnicity, education level, income, disability,
strategies and case-finding strategies.9, 26
geographic location, or sexual orientation.
Risk factor reduction strategies are primarily targeted at
Acculturative stress suicide prevention for youth and at the community.
One feasible explanation for the higher risk of They include: (a) promoting overall mental health
non-lethal suicidal attempts among Latino youth is that among school-aged youth by reducing early risk factors
the risk is associated with the unique life experience of for depression, substance abuse, and aggression, and
immigration. The association between psychopathology building resiliency (eg, self-esteem and stress manage-
and suicidal behavior depends on the degree of ment); (b) providing crisis counseling; and (c) restricting
acculturative stress. A higher level of suicide attempts access to lethal means, especially handguns.
has been associated with drug use among Latino youth
Promotion of mental health among school-aged youth is
who were experiencing greater acculturative stress,
typically achieved by general suicide education and peer
perceived discrimination, poor opportunities, and
support programs. General suicide education is designed
language difficulties.22
to develop healthy peer relationship and social skills
Sexual orientation among high-risk adolescents.9 It provides youth with
Research suggests that gay, lesbian, and bisexual (GLB) information about suicide, including its warning signs,
youth are at an elevated risk for attempting suicide.20, 23 and how to seek professional help for themselves or
More GLB students report suicide attempts compared others. Crisis counseling through crisis centers and
with their heterosexual counterparts. Research also hotlines involves trained volunteers and paid staff
suggests that GLB youth are at high risk for associated providing counseling via phone or drop-by services for
maladaptive risk behaviors, including fighting, suicidal youth. “Postventions” are interventions after
victimization, and frequent use of alcohol and drugs.24 an incidence of both successful and unsuccessful suicide
These mental health problems and substance abuse attempts. These programs aim at preventing suicide
disorders are crucial predisposing factors for suicide in contagion and helping youth and family cope effectively
GLB youth. with an interpersonal loss after a suicide. Restrictions

of access to lethal means are interventions designed to possibility of suicide contagion. Screening programs
reduce a person’s access to lethal means of completing have been found to be effective in identifying high-risk
suicide. Disposing of medications and removing and/or students. There is a severe shortage of evaluation
locking up firearms from the home of a suicidal research for crisis centers and hotlines.
adolescent are types of means restrictions.9 An evaluation of C-CARE and CAST
Case-finding strategies aim at detecting suicidal youth by Suicide prevention programs often incorporate both
referral to mental health care.9 There are two general case-finding and risk factor reduction strategies. For
types of prevention strategies, active and passive. An instance, Thompson and colleagues evaluated the effica-
example of an active strategy is the administering of cy of two indicated suicide prevention programs targeted
screening programs (general screening or a targeted at potential high school dropouts.27 In this study, high
screening after a suicide). An example of a passive school students who were identified as “at risk” for
strategy is providing gatekeeper training for schoolteach- suicide participated in 1 of 3 interventions randomly
ers and community adults, providing general suicide assigned to schools: (1) counselors CARE (C-CARE), a
education in schools, and offering crisis counseling. comprehensive assessment of risk and protective factors
General education strategies often aim at reducing the followed by a brief intervention to improve a youth’s
stigma associated with accessing mental health care to personal resources and social network; (2) Coping and
increase self-referral and/or referrals by persons who Support Training (CAST), a 12-session small-group
recognize suicidality in someone they know.9 skill-training (eg, problem-solving coping, personal
In screening programs, self-reports and individual control) and social support intervention added to the
interviews are administered to identify depression, C-CARE; and (3) regular care control.
alcohol or substance abuse problems, recent suicidal Questionnaire instruments were administered before
ideation, and past suicide attempts. Further detailed the intervention, after C-CARE (4 weeks), after CAST
assessment and treatment are provided where necessary. (10 weeks), and at a 9-month follow-up. A significant
Gatekeeper training involves educating and training decline occurred in attitudes toward suicide and suicidal
adults in contact with suicidal youth such as school staff ideation among students who received interventions.
(eg, teachers, counselors, and coaches) and community C-CARE and CAST were effective in reducing
members (eg, physicians, clergy, and police) to identify depression and hopelessness compared with regular
and refer children and adolescents at risk for suicide.3 care. Female students had a greater reduction than male
General suicide education is also categorized as a students in anxiety and anger in response to these
case-finding strategy because of its emphasis on gaining programs. CAST was most effective in enhancing and
knowledge about suicide and its warning signs, maintaining personal control and problem-solving
including information about how and where to get coping strategy. Overall, the study demonstrated the
professional help. feasibility and effectiveness of school-based prevention
Overall, there is a shortage of evaluation studies on programs in reducing suicidal behaviors and associated
many ongoing prevention strategies. Restrictions of distress and for enhancing resiliency among youth at
access to lethal means are considered the most promis- risk for suicide.
ing. The findings for general suicide education curricu- Clearly, additional prevention efforts to reduce
lum in schools are equivocal. One ethical concern of youth suicide need to be designed, implemented, and
general suicide education is that, while some programs evaluated. Because of the enormous effort and financial
reported shifts in desirable attitudes, other programs may cost involved in launching and maintaining programs,
increase maladaptive coping responses with a their efficacy and safety should be guaranteed before they

are promoted. The Centers for Disease Control and 9 Centers for Disease Control and Prevention. Programs for
the prevention of suicide among adolescents and young
Prevention’s recommendations include ensuring that
adults; and suicide contagion and the reporting of suicide:
prevention programs are matched with access to mental recommendations from a national workshop.
health resources in the community; incorporating Morb Mortal Wkly Rep. 1994;43:1-18.
several prevention strategies in developing programs; and 10 Shaffe, D, Gould MS, Fisher P, et al. Psychiatric diagnosis in
incorporating rigorous scientific evaluation of studies, child and adolescent suicide. Arch Gen Psychiatry.
1996;53:339-348.
including planning, process, and outcome evaluations.9
11 Gould MS, Kramer RA. Youth suicide prevention.
Prepared by Michiko Otsuki for the Southern California Suicide Life Threatening Behav. 2001;31(Suppl):6-31.
Center of Excellence on Youth Violence Prevention, 12 Brent DA, Perper JA, Moritz GM, Baugher M, Schweer J,
University of California, Riverside, Winter 2002. Ross C. Firearms and adolescent suicide: a community case
control study. Am J Dis Child. 1993;147:1066-1071.
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1998;37:612-619. Depression in Children and Adolescents:
A Fact Sheet for Physicians
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Section 6
Act Now Handouts
• What health professionals can do
• What families can do
• What youth can do
• What schools can do
• What law enforcement can do
• What the media can do
• What legislators can do
• What business and civic leaders can do
• What faith-based organizations can do

Act Now Handouts
What Health Professionals Can Do to Prevent Youth Violence
• Become educated in firearms injury prevention, including adolescent assault, homicide, and suicide.
• Encourage training programs to provide undergraduate, graduate, and continuing education in the causes and prevention
of violence and competencies in understanding and working with communities.
• Routinely screen for and counsel patients about firearm safety.
• Regularly screen for and treat or refer patients for help for alcohol and other drug abuse problems.
• Participate in practice-based violence research and advocate for resources to support research, including ongoing public
health data collection and surveillance.
• Advocate for and adhere to practice guidelines or protocols for assessing high-risk violence situations and behaviors,
appropriate treatment and referrals, and counseling and screening from the prenatal period through adulthood.
• Disseminate information about the root causes and risk factors for violence.
• Add to patient examinations a violence history that addresses exposure to violence; safety/security issues; effects of
trauma; attitudes toward weapon carrying, aggression, and fighting; and stressors in the family and community.
• Strengthen the documentation of abuse and histories of family violence in both individual and group records.
• Volunteer to serve local schools as epidemiologists, health care providers, and crisis team members and local community
prevention initiatives as mentors, supervisors, and advocates.
• Establish a network of referral services to make it easier for youth and their parents or caretakers to access resources.
• Advocate for public policies and resources to address the sources of violence.
• Promote the use of family-based strategies such as multisystemic therapy and functional family therapy for troubled youth.
Excerpted from The Commission for the Prevention of Youth Violence. Youth and Violence: Medicine, Nursing and
Public Health: Connecting the Dots to Prevent Violence. Chicago, IL: American Medical Association; 2000:28.
Where to go to get started:

Visit the National Youth Violence Prevention Center on-line at
http://www.safeyouth.org/home.htm
Or a regional Center of Excellence on Youth Violence Prevention at
http://www.stopyouthviolence.ucr.edu/resource_agencies/cdc.html
Act Now Handouts 133 Connecting the Dots to Prevent Youth Violence
Act Now Handouts
What Families Can Do to Prevent Youth Violence
• Act as role models, settle conflicts nonviolently.

• Take an active role in their children’s school; talk regularly with teachers; volunteer.
• Maintain two-way communication with their children; talk with them about violence they may have witnessed.
• Do not keep firearms or keep them safely stored and locked up with ammunition stored separately.
• Initiate or participate in community or school violence prevention groups.
• Monitor/supervise their children’s use of the Internet, television, reading material, movies, music, and video games.
• Seek out support groups to improve parenting skills and manage anger, if needed.
• Establish and enforce household rules and reward positive behavior.
• Demand involvement in violence prevention programs initiated by schools and communities and in disciplinary
actions imposed on their own children.
• Supervise the activities of their children; know their schedule and their friends.
• Urge their children to participate in organized after-school activities provided by responsible groups.
• Practice zero tolerance for bullying in the family and take proactive steps to eliminate bullying in schools.
• Provide foster homes and safe havens for abused children.
• Encourage community service.

Act Now Handouts
What Youth Can Do to Prevent Youth Violence
• Speak out against bullying at home and at school.

• Report all incidents of bullying to school authorities, parents, or other responsible adults.
• Mentor younger students.
• Participate in organized and supervised recreational, educational, and cultural after-school programs.
• Talk to a responsible person—physician, teacher, clergy, counselor, parent, or friend—about violence they witness
or experience.
• Act as a role model for other children and adolescents in refusing to have anything to do with firearms, alcohol,
and illicit drugs.
• Promote television programs, movies, music, and video games that portray nonviolent alternatives to conflict resolution.
• Become involved in violence prevention programs offered by the community, church, or school.
• Encourage friends who seem depressed or angry to seek help from a parent, physician, teacher, counselor,
or member of the clergy.
• Talk with friends and family members about concerns about violence and its effects in their lives.
• Seek opportunities for community service.

Act Now Handouts
What Schools Can Do to Prevent Youth Violence
• Create a school-wide ethos that fosters positive discipline, academic success, and mental and emotional wellness.
• Intervene early with the 10% to 15% of students at risk for severe academic or behavioral problems.
• Directly provide or arrange for immediate and intensive intervention for problem students in the form of coordinated,
comprehensive, sustained, and family-focused services.
• Eliminate bullying and promote tolerance.
• Improve awareness and communication, so that children are knowledgeable about the signs of mental illness
and violence and the importance of telling a responsible adult when they see troubling behavior in classmates.
• Appoint multidisciplinary teams to design and implement comprehensive violence prevention and response plans.
• Be active participants in community discussions and decisions on violence prevention.
• Enlist law enforcement professionals in the development of a school safety plan that addresses weapons and
drug search policies; visitor protocols; use of screened and trained parents as volunteer monitors; positive incentives
for good school citizenship; suspension and expulsion policies; and codes of student conduct.
• Involve parents in all school activities.
• Encourage participation in on-site after-school programs by offering such programs free or providing scholarships and
transportation and by partnering with external program sponsors.
• Implement a school health program that features comprehensive health education; provide counseling and social
services; ensure a safe physical and psychosocial environment; and promote family and community involvement.
• Advocate for smaller schools that counter competitive pressures and social isolation.
• Promote on-site screening and intervention, including mental health care services for trauma, loss, use of alcohol and
other drugs, and abuse.
• Integrate violence prevention into all curriculum levels; teach conflict resolution; and encourage community service.
• Make parenting classes mandatory.
• Ensure that all students, including those who violate disciplinary codes, are in either regular or alternative classrooms
rather than on the street.
• Expand access to alcohol and drug dependency treatment programs.

Act Now Handouts
What Law Enforcement and the Justice Community
Can Do to Prevent Youth Violence
• Actively enforce laws that reduce youth access and exposure to firearms, alcohol, and illicit drugs.
• Work with schools and parents to promote the removal of firearms from environments in which children live and play.
• Help school personnel perform security surveys of their facilities.
• Consult with schools about security on an ongoing basis.
• Train the entire school community in personal safety.
• Develop partnerships with area schools.
• Work with schools and parents to lower truancy rates.
• Serve on school disciplinary action assessment teams.
• Provide comprehensive information about the consequences of violence.
• Provide comprehensive screening for youth entering the juvenile justice system in order to facilitate early
intervention for problems.
• Provide intake officers with tools to distinguish between serious/less serious and occasional/frequent juvenile offenders.
• Promote the use of unified family courts that handle the full range of family-related cases, including family
violence, mental health, delinquency, and dependency.
• Institute Court Appointed Special Advocate Programs (CASAs), which use trained volunteers (guardians ad litem)
to stabilize the lives of victimized children.
• Enhance local efforts to investigate and prosecute child abuse and neglect cases and strengthen child protective services.
• Include alcohol and mental health assessment and mandatory treatment in all criminal justice responses to
children and youth.
Public Health: Connecting the Dots to Prevent Violence. Chicago: The American Medical Association. 2000;29.

Act Now Handouts
What the Media Can Do to Prevent Youth Violence
• Minimize the sensationalist aspects of coverage of school crime; place such crimes in statistical context.
• Reinforce anti-violence messages and ideas provided by schools and communities.
• Portray the consequences of violence realistically.
• Provide parents and other adult caretakers of children with guidelines to help them supervise and monitor
their children’s use of the media.
• Promote and participate in community coalitions for the prevention of youth violence.
• Promote and publicize anti-violence programs, policies, and community efforts.
• Facilitate community discussion forums about violence prevention.
Public Health: Connecting the Dots to Prevent Violence. Chicago: American Medical Association. 2000;30.

Act Now Handouts
What Legislators Can Do to Prevent Youth Violence
• Enact meaningful gun control legislation designed to limit children’s access to firearms.
• Mandate full health and mental health care coverage for all children.
• Enact legislation mandating parity for coverage of comprehensive mental health care services.
• Fully fund early intervention and prevention programs, including early childhood development.
• Encourage collaboration and coordination among education, mental health, social service, and juvenile justice agencies.
• Support comprehensive and coordinated school health care services, including mental health care.
• Enact legislation to address the physical and mental health care needs of detained and incarcerated youth.
• Ensure access to and availability of long-term programs in prevention, education, screening, and treatment of
alcohol and other drug abuse.
• Support public education on media influences on violence.
• Ensure screening and appropriate intervention and treatment for abuse, neglect, and alcohol and other drug abuse for all
youth entering the juvenile justice system, for all children of violent adult offenders, and for siblings of youth offenders.
• Support improved access to and availability of community mental health care services, including education, screening,
and early intervention for victims, perpetrators, and witnesses of violence.
• Support the inclusion of violence reduction criteria in the education and training of teachers, administrators,
and school staff.
• Re-establish and strengthen the mandate of juvenile judges to use discretion and creativity in sentencing
children and adolescents.
• Support access to and availability of after-school programs to create safe places for elementary and secondary
school children.
• Ban the use of corporal punishment in schools, juvenile facilities, child care facilities, and all other institutions
where children are cared for and educated.
• Establish a comprehensive national, state, and local data collection and surveillance system for tracking intentional
and unintentional injuries.
• Urge congressional support for a national violence prevention campaign involving all media.
• Urge federal support for violence prevention research.

Act Now Handouts
What Business and Civic Leaders Can Do
to Prevent Youth Violence
• Promote and participate in community efforts to prevent youth violence. Assign responsibility for prevention education,
screening, and early intervention to an existing agency or coalition or establish a new public entity for this purpose.
• Adopt a school and become involved in its programs and activities.
• Develop creative arts and media competitions with an anti-violence theme.
• Help students access job skill development, part-time employment, and internships.
• Advocate for violence prevention and intervention program funding.
• Ensure that all parents have access to affordable parenting skills programs.
• Promote firearm safety to prevent firearm-related injuries to young people. This includes safe storage and handling
as well as the removal of firearms from homes of children with mental health problems.
• Develop scholarship programs to promote and reward academic success.
• Encourage employees to become involved in school activities and provide the flexibility for them to do so.
• Provide services, facilities, and equipment to enhance violence prevention and youth development programs in schools.
• Serve as mentors for youth at risk for or involved in violence in the community.
• Support Head Start programs for all children.
• Ensure proper training and technical assistance for agencies serving children and families.
• Promote a reduction in the amount of alcohol consumption in the community through environmental interventions
such as limiting alcohol at sports events and increasing the cost of alcohol.
• Provide local youth with opportunities for community service.

Act Now Handouts
What Faith-Based Organizations Can Do
to Prevent Youth Violence
• Promote and participate with other groups in community coalitions for the prevention of youth violence.
• Encourage children and adolescents to talk openly with responsible adults about their concerns about violence.
• Provide or support parenting classes and programs that promote parent-child interaction.
• Teach social tolerance, model ethical behavior, and promote empathy among children.
• Establish a mentoring program to foster supportive relationships between youth and responsible adults.
• Provide recreational services and after-school programs for children and adolescents.
• Work with local law enforcement to provide creative alternatives to detention for young offenders.
• Hold meetings and symposia where concerned adults and children can come together to address violence-related
issues in the community.

Visit the National Youth Violence Prevention Center on-line at http://www.safeyouth.org/home.htm
Section 7
Resources: Professional and Patient/Family
Professional:
• Resources for Health Professionals
• Patient Assessment Tool
Patient/Family:
• Myths and facts about violence and how you

can help prevent it
• Teaching the basics of violence prevention
• When children witness violence in the home
• Violence prevention in the home
• Time-out
• Key education points on firearm injury and death
• Pulling the plug on TV violence
• You are the experts on raising “violence-free”

children: a guide for parents
Resources: Professional
Resources for Health Professionals
Recommended publications for health professionals: Resources for patient education

Commission for the Prevention of Youth Violence. American Academy of Child and Adolescent
Youth and Violence: Medicine, Nursing, and Public Health: Psychiatry (AACAP) - The AACAP has launched a
Connecting the Dots to Prevent Violence. Chicago, IL: Violence Initiative to assure that child and adolescent
American Medical Association; 2000. The report can be psychiatrists join the effort to prevent violence. The
accessed online at: http://www.ama-assn.org/violence. AACAP’s Web site provides youth violence-related
Hard copies are available at no cost from the American Facts for Families, which can be accessed at
Medical Association by calling 312 464-4526. http://www.aacap.org/clinical/violence.htm.
Sege R, Licenziato V, eds. Recognizing & Preventing Youth American Academy of Pediatrics (AAP) has many
Violence: A Guide for Physicians & Other Health Care violence prevention resources for health care
Professionals. Waltham, MA: Massachusetts Medical professionals including resources on media literacy
Society;2001. The full guide can be accessed online at: training for physicians and patients. Information can be
http://www2.mms.org/pages/youthviolence.asp. found at http://www.aap.org/advocacy/mediamatters.htm
Hard copies are available for $7.00 each by calling and http://www.aap.org/advocacy/violence.htm.
800 843-6356. American Medical Association (AMA) -
US Department of Health and Human Services. Youth Physician guidelines developed by the AMA on
Violence: A Report of the Surgeon General. Rockville, MD: media violence, firearm violence, and family
Department of Health and Human Services; 2001. violence can be accessed online at
This report can be accessed online at: http://www.sur http://www.ama-assn.org/ama/pub/category/3242.html.
geongeneral.gov/library/youthviolence/default.htm. American Psychological Association (APA) - The
APA has developed a number of violence prevention
Resources for screening and risk identification resources. Parent information material titled Raising
Sege R, Stringham P, Short S, Griffith J. Ten years after: Children to Resist Violence can be accessed at
examination of adolescent screening questions that http://www.apa.org/pi/pii/raisingchildren.html.
predict future violence-related injury. J Adolesc Health. The Children’s Safety Network (CSN) - Funded by the
1999;24: 395-402. This article describes the validation of Health Resources and Services Administration (HRSA)
a three-item questionnaire to identify risk for violence and administered through the Maternal and Child
among young persons. Health Bureau, the CSN has produced a series of vio-
FISTS (Fighting, Injuries, Sex, Threats, lence prevention information resources for parents and
and Self-Defense) - This mnemonic is used to identify health professionals. Parent education material can be
a young person’s level of risk for involvement in accessed at
violence. Alpert E, Sege R, Bradshaw YS. Interpersonal http://www.edc.org/HHD/csn/PDF/Parents0.pdf.
violence and the education of physicians. Acad Med.
1997;72:S41-S50.
HEADS (Home, Education, Activities/ Abuse, Drugs,
Sex, and Suicide) - A commonly used
mnemonic that includes assessment of a youth’s risk for
involvement in serious violence. More information can
be found in: Schubiner H. Preventive health screening
in adolescent patients. Prim Care. 1989;16:211-230.
Resources 151 Connecting the Dots to Prevent Youth Violence

Resources for Health Professionals (continued)
Referral resources For more information and training

Center for the Study and Prevention of Violence Academic Centers of Excellence in Youth Violence
(University of Colorado at Boulder) - “Blueprints” Prevention. In 2000, the Centers for Disease Control
is a national violence prevention initiative to and Prevention funded 10 Academic Centers of
identify and replicate effective violence prevention Excellence in Youth Violence Prevention. Each Center
programs. More information can be found at is developing resources for health professional training
http://www.colorado.edu/cspv/blueprints/Default.htm. in youth violence prevention. Contact information is
National Center for Injury Prevention and Control - available at http://www.stopyouthviolence.ucr.edu.
Thornton T, Craft C, Dahlberg LL, Lynch B, Baer K. Knox L. Youth Violence and the Health Professions:
Best Practices of Youth Violence Prevention: A Sourcebook Core Competencies for Effective Practice. Riverside, CA:
for Community Action. Atlanta, GA: Centers for Disease Southern California Developing Center for
Control and Prevention, National Center for Injury Youth Violence Prevention; 2001.
Prevention and Control; 2000. One free copy can be This report outlines the recommendations of an
obtained by calling 888 252-7751; the sourcebook also expert panel on the training needs of health professional
can be downloaded from http://www.cdc.gov/ncipc/dvp/ training in youth violence prevention. It can be
bestpractices.htm. accessed online at http://www.stopyouthviolence.ucr.edu/
Partnerships Against Violence Network (PAVNET) - health_care/articles.html.
PAVNET has a “virtual library” of information about National Youth Violence Prevention Resource
violence and youth-at-risk, representing data from Center (NYVPRC) - The NYVPRC is the national
7 different federal agencies. It provides a searchable clearinghouse for information on youth violence and
database for promising programs and curricula on its prevention. Information is available online at
violence prevention. For more information on http://www.safeyouth.org or call the center at
PAVNET, visit them at http://www.pavnet.org/. 866-SAFEYOUTH (723-3968).

Resources: Professional
Patient Assessment Tool
Screening tools and mnemonics are being developed Sex

for use in the health care setting to identify youth at risk • Has your partner ever tried to hit you?
for or involved in violence and to help make appropriate
referral decisions. Most tools are still being validated and • Have you ever hit or hurt your partner?
are limited for use with adolescents. As resources become • Have you ever been forced to have sex against
available for risk identification in younger children, your will?
consider incorporating these into your practice as well. • Do you think that couples stay in love when one
partner makes the other one afraid?
FISTS Sometimes adolescents are hesitant to talk about
FISTS is a mnemonic that has been successfully adapted violent relationships. They may be embarrassed
for clinical practice. It is a practical screening tool that or may not have had experience with healthy
can be used to ask youth about fighting, injuries, sex, relationships; they may not even be aware that a
threats, and self-defense. Based on a risk determination, relationship is unhealthy.
the physician can choose an intervention strategy and Threats
make appropriate referrals. Use of this tool provides an • Has someone carrying a weapon ever threatened you?
opportunity to discuss nonviolent solutions for problem
• What happened?
solving and conflict resolution with young patients and
their families. • Has anything changed since then to make you
feel safer?
Fighting
Use these questions to assess how a youth reacts to a
• How many fights have you been in during the
threatening situation, and the likelihood that he or she
past year?
will be a perpetrator or victim of future violence. The
• When was your last fight? more explosively youth act in these situations, the more
Try to get a detailed account of the fight once the likely they are to be involved in violence.
adolescent discloses such information. Ask if a weapon Self-defense
was involved and how the fight was started, and explore
• What do you do if someone tries to pick a fight
with the adolescent if there was a nonviolent way to
with you?
resolve the conflict.
• Have you ever carried a weapon in self-defense?
Injuries
When you ask about weapons in the context of
• Have you ever been injured in a fight?
self-defense, you will receive more candid responses.
• Have you ever injured someone else in a fight? A youth who carries a firearm should be considered
By asking these two questions, physicians can assess at high risk for lethal violence. Carrying a knife,
the severity of any previous fights. Patients who especially a small pocketknife, is not as clearly
have been injured in a fight are more likely to have identified with violent behavior.
unresolved conflicts and be re-injured in the future.

Patient Assessment Tool (continued)
Assessing the level of risk High-risk youth:

After obtaining the violence history, the physician • Are in more than four physical fights.
can estimate the adolescent’s risk for involvement in • Are failing or dropping out of school.
violence as low, moderate, or high. This information can
• Carry a weapon.
be used to select interventions and make appropriate
referrals for the youth and his or her family. • Report illicit drug use.
Low-risk youth: Discuss recent incidents of fighting with the youth and
with his or her family. Discuss different ways to avoid
• Have not been in a fight in the past year.
future confrontations such as walking away and anger
• Do not report the use of drugs. management. High-risk adolescents may require
• Are passing courses in school. interventions that are beyond the scope of the primary
• Do not carry weapons. provider, including referral for more specialized mental
health and social services.
Reinforce low-risk behavior, and ask how the young
person avoids a fight when resolving a conflict.
Moderate-Risk Youth: Information on the FISTS mnemonic was adapted and
reproduced with permission of the Association of
• Talk about recent fights.
American Medical Colleges. Alpert EJ, Bradshaw YS,
• Are struggling with school work. Sege, RD. Interpersonal violence and the education of
• Report other behavior that the health care physicians. Acad Med. 1997;42:546.
professional identifies as risky.
Discuss the most recent fight and ideas to defuse
future situations, such as anger management. Consider
referring this adolescent to a counselor to discuss risk
issues and behavior. Ask the teen for his or her consent
to discuss intervention ideas with parents
or caretakers.

Resources: Patient/Family
Some Myths and Facts about Violence and Tips
on How You Can Help Prevent It
Myth: Most homicides result from drug Myth: Adolescent violence is an inner-city problem.
dealing-related crimes. Fact: Violence occurs throughout America. Firearm
Fact: According to the FBI, less than 40% of violent injuries are the number one cause of injury-related death
deaths are associated with another crime. Most in 7 states and the District of Columbia. The federal
violence, including homicide, results from arguments government estimates that by the year 2003, they will be
or conflicts between friends, acquaintances, or lovers. the leading cause of injury-related death in all states.
Myth: Most violence is racially motivated. Violence is associated with poverty. Since half of all
Fact: Most assaults and murders involve two people African-American teenagers live in poverty, violence
of the same race. rates among black adolescents are high, but they are also
high among poor white Americans.
Myth: Carrying a gun gives protection.
Myth: Kids who fight well—the ones who are good
Fact: Carrying a weapon can result in a sense of boldness
with their hands—are safest.
that leads to foolish behaviors. If another person sees the
gun, he or she may draw and shoot first. Carrying a gun Fact: The safest, most popular kids are problem solvers.
can give a false sense of protection; it may actually make They know how to use their minds and mouths to
a person less safe! solve problems, rather than their fists. Kids who fight
a lot—even if they’re good at it—eventually run into
Myth: “I would be safer with a gun in my home
someone who is armed.
because there is so much violence.”
Myth: In order to gain respect from peers, boys have
Fact: A person with a gun at home is nearly 3 times
to be willing to fight.
more likely to be killed than a neighbor who doesn’t
have a gun. Shootings at home often occur when a Fact: Youths who are neither bullies nor aggressors—who
friend or family member is mistaken for an intruder, are called problem solvers by peers—are the most
when a fight between a husband and wife or boyfriend successful and popular kids in school.
or girlfriend gets out of control, or when a child finds a
gun. All have potentially deadly consequences. To change behavior, it is important to identify the
Myth: Young children don’t use guns. risk factor(s) that apply to that child. The following
are some specific tips for counseling youth at risk
Fact: Young children may not know the difference
for violence.
between toy guns and real guns. Their curiosity is
stronger than their awareness of danger; they need Tip: When a youth gets into a fight, always ask how the
protection from guns. Even young children are strong fight started, not how it ended. Help youth think about
enough to pull the trigger. what led up to and caused the fight and help them find
alternative words or actions that could have prevented
the fight. In the long run, a youth will be safer by
avoiding fights through problem solving than by winning
them. Teach children how to resolve their differences
and conflicts in nonviolent ways.

Some Myths and Facts about Violence and Tips
on How You Can Help Prevent It (continued)
Tip: The safest home for the children is a home without

handguns. If a gun is in the home, it must be kept
unloaded and locked with the ammunition stored and
locked separately.
Tip: Encourage youth to develop other skills and
interests in order to reduce the amount of time spent
watching violence on television and in the movies.
Tip: Support initiatives to get guns off the streets and
out of the hands of children.
Tip: Get involved in your neighborhood.
Tip: Encourage schools to teach youth about conflict
resolution, to set up peer mediators, and to teach
youths the truth about violence.
Tip: Be aware of warning signs for post traumatic
stress disorder (PTSD). Previously associated with war
veterans, PTSD is now evident among children and
youth who have experienced or witnessed violence.
Some of the warning signs are reliving the event,
avoiding behaviors, decreased interest in usual activities,
trouble sleeping, outbursts of anger, nightmares, numbing
of feelings, and difficulty concentrating. Anyone
experiencing symptoms of PTSD can get help by
contacting a health care provider or a violence
prevention counselor.
Reproduced with permission of the Massachusetts

Medical Society, “Some Myths and Facts About
Violence and Tips on How You Can Help.” Sege R, ed.
Violence Prevention for Children and Youth: Parent
Education Cards. Waltham, MA; Massachusetts Medical
Society; 2000. To order copies of this tip card, contact
the Massachusetts Medical Society, Public Health and
Education, 860 Winter Street, Waltham, MA 02451-
1411; phone: 800-322-2303; e-mail: [email protected]

Teaching the Basics of Violence Prevention
Violence is becoming a more frequent occurrence in In addition to offer guidance about conflict resolution,
today’s society. Children are being exposed to more parents should act as role models for healthy problem
violence in their communities and schools. Conflict solving. Keep in mind that children often learn by exam-
resolution and violence prevention are important ple. The behavior, values, and attitudes of parents and
subjects to discuss with your children. This information siblings have a strong influence on children. Values of
can help guide these discussions and offers practical respect, honesty, and pride in your family and heritage
advice that you and your child can use in everyday can be important sources of strength for children, espe-
situations. cially if they are confronted with negative peer pressure,
It is important that you and your children learn to take live in a violent neighborhood, or attend a rough school.
precautions against becoming the victims of a violent Most children act aggressively sometimes and may hit
crime. Here are some important steps that you can take another person. Be firm with your children about the
to keep yourself and your children safe: possible dangers of violent behavior. Remember also
• Teach your children safe routes for walking in your to praise your children when they solve problems
neighborhood. constructively without violence. Children are more
likely to repeat good behaviors when they are rewarded
• Encourage them to walk with a friend at all times
with attention and praise. You can teach your children
and only in well-lighted, busy areas.
non-aggressive ways to solve problems by:
• Stress how important it is for them to report any
• Discussing problems with them
crimes or suspicious activities they see to you, a
teacher, another trustworthy adult, or the police. • Asking them to consider what might happen if they
Show them how to call 911 or the emergency use violence to solve problems
service in your area. • Talking about what might happen if they solve
• Make sure they know what to do if anyone tries problems without violence
to hurt them: Say “no,” run away, and tell a This kind of “thinking out loud” together will help
reliable adult. children see that violence is not a helpful solution.
• Stress the dangers of talking to strangers. Tell them Parents sometimes encourage aggressive behavior
never to open the door to or go anywhere with without knowing it. For example, some parents think
someone they don’t know and trust. it is good for a boy to learn to fight. Teach your children
that it is better to settle arguments with calm words,
It is important to support your children in standing up
not fists, threats, or weapons.
against violence. Teach them to respond with calm but
firm words when others insult, threaten, or hit another Help your children learn constructive, nonviolent
person. Help them understand that it takes more courage ways to enjoy their free time. Teach them your favorite
and leadership to resist violence than to go along with it. games, hobbies, or sports, and help them develop their
own talents and skills. Read stories to younger children,
Help your children accept and get along with others
take older children to the library, or tell family stories
from various racial and ethnic backgrounds. Teach
about admired relatives who have made the world a
them that criticizing people because they are different
better place.
is hurtful, and that name-calling is unacceptable.
Make sure they understand that using words to start
or encourage violence—or quietly accepting violent
behavior—is harmful. Warn your child that bullying
and threats can be a setup for violence.

Teaching the Basics of Violence Prevention (continued)
Hitting, slapping, or spanking children as punishment difficult times. Reducing stress and social isolation can
shows them that it’s okay to hit others to solve problems help in raising your children.
and can train them to punish others in the same way Get involved in your community and get to know
they were punished. Physical punishments stop your neighbors. Try to make sure guns are not available
unwanted behavior only for a short time. Even with in your area as well. Volunteer to help in your
very harsh punishment, children may adapt so that it neighborhood’s anti-crime efforts or in programs to
has little or no effect. Using even more punishment is make schools safer for children. If there are no programs
equally ineffective. like this nearby, help start one!
Nonphysical methods of discipline help children deal
with their emotions and teach them nonviolent ways
This patient education information was reproduced
to solve problems. Here are some suggestions:
with the permission of the American Academy of
• Give children a “time out”—making them sit Pediatrics, “Teaching the Basics of Violence Prevention.”
quietly, usually 1 minute for each year of age It can be accessed from the “Children’s Health” section
(this is not appropriate for very young children). from the Medical Library at Medem.com:
• Take away certain privileges or treats. http://www.medem.com/MedLB/bufferpage_aap.cfm.
• “Ground” them and don’t allow children to play
with friends or take part in school or community
activities (this is only appropriate for older children
or adolescents).
Punishment that involves taking away privileges
or “grounding” should be consistently applied for
realistic, brief periods.
Children need to feel that if they make mistakes, they
can correct them. Show them how to learn from their
errors. Help them figure out what they did wrong and
how they can avoid making similar mistakes in the
future. It is especially important not to embarrass or
humiliate your children at these times. Children always
need to feel your love and respect.
A positive approach to changing behaviors is to
emphasize rewards for good behavior instead of
punishments for bad behavior. Remember that praise
and affection are the best rewards.
It’s also helpful to stay involved in your community.
A network of friends, neighbors, and family can offer
fun, practical help, and support when you have

When Children Witness Violence In the Home
Helping children cope How you can help

Children can be deeply affected by violence in the Help children talk about violence with a trusted adult.
community and at home. They see violence on TV When children can share their worries and fears with
and in video games, and hear it in music. Children a parent, relative, teacher, school counselor, clergy
may also witness fights that involve yelling, screaming member, or family friend, they will feel less frightened
or hitting. Sometimes these fights end with someone and alone. It may be hard for children to begin talking
getting hurt, badly beaten, or even shot. But witnessing about the violence they have witnessed. Sometimes
violence at home is especially troubling for children. children blame themselves for the violence they see and
Did you know that: hear. Tell the child: “The violence is not your fault.”
• Children see, hear, and remember more than adults Remember:

think they do. Parents may think that their children • Children who witness violence can become
are asleep or watching TV, but children often know frightened. They should have a chance to talk to
when their parents are fighting. someone about what they are thinking and feeling.
• Children react differently at different ages, but ALL • Doctors and other health professionals can help
children—even infants and toddlers—can be affected parents learn how to raise children in a home
by witnessing violence. without violence.
How children react when they see or • The goal is for everyone—children and adults—to
hear violence live in a world without violence.
Children may react immediately to the violence they For additional information or help when you know
witness; however, some will have a delayed response. someone is being hurt or feels afraid, contact your doctor
Symptoms vary by age and personality, but these are or call: Parental Stress Line: 800 632-8188; National
some of the common reactions children might have: Domestic Violence Hotline: 800 799-SAFE (7233);
• Difficulty with sleeping, poor appetite, stomachaches, and/or Massachusetts Society for the Prevention of
nightmares, and bed-wetting Cruelty of Children (MSPCC): 617 587-1500.
• Becoming fearful or moody

• Worrying about the safety of loved ones Reproduced with permission of the Massachusetts
Medical Society, “When Children Witness Violence
• Finding it hard to concentrate, learn, and
in the Home: Helping Children Cope.” Sege R, ed.
behave in school
Violence Prevention for Children and Youth: Parent
• Trouble making or keeping friends Education Cards. Waltham, MA: Massachusetts Medical
• Running away Society, 2000. To order copies of this tip card, contact
the Massachusetts Medical Society, Public Health and
• Involvement with drugs and alcohol
Education, 860 Winter Street, Waltham, MA 02451-
1411; phone: 800 322-2303; e-mail: [email protected]

Violence Prevention in the Home
Introduction Here are some ideas to prevent violence

• Guns and children can be a deadly combination. in the home:
Teach your children about the dangers of firearms or • Limit television viewing time to 1 to 2 hours a day.
other weapons if you own and use them. If you keep a • Make sure you know what television shows your
gun in your home, unload it and lock it up separately children watch, which movies they see, and what
from the bullets. Never store firearms, even if kinds of video games they play.
unloaded, in places where children can find them.
• Talk to your children about the violence that they
• Don’t carry a gun or a weapon. If you do, this tells see on television shows, in the movies, and in video
your children that using guns solves problems. games. Help them understand how painful it would
• Violence in the home can be frightening and harmful be in real life and the serious consequences for
to children. Children need a safe and loving home violent behaviors.
where they do not have to grow up in fear. Children • Discuss with your children ways to solve problems
who have seen violence at home do not always without violence.
become violent, but they may be more likely to try
to resolve conflicts with violence.
This patient education information was reproduced
• Work toward making home a safe, nonviolent place
with the permission of the American Academy of
and always discourage violent behavior between
Pediatrics, “Violence Prevention in the Home.” It
brothers and sisters. Keep in mind as well that hostile,
can be accessed from the “Children’s Health” section
aggressive arguments between parents frighten
from the Medical Library at Medem.com:
children and set a bad example for them.
http://www.medem.com/MedLB/bufferpage_aap.cfm.
• If the people in your home physically or verbally hurt
and abuse each other, get help from a psychologist or
counselor in your community. He or she will help you
and your family understand why violence at home
occurs and how to stop it.
• Sometimes children cannot avoid seeing violence in
the street, at school, or at home, and they may need
help in dealing with these frightening experiences.
A psychologist, counselors at school, and a religious
leader are among those who can help them cope with
their feelings.
• Seeing a lot of violence on television, in the movies,
and in video games can lead children to behave
aggressively. As a parent, you should control the
amount of violence your children see in the media.

Time-Out
How do I use a time-out? Why use time-outs?

When your child does something good, be sure to offer • Young children respond best to praise for good
praise: “I’m proud of you!” or “Good job!” However, behavior. However, sometimes they need to have
every child occasionally needs to be disciplined. A limits set for them. Time-outs let you do this safely
time-out is a form of discipline that can be used when and effectively.
your child does something wrong on purpose. So, every • Sometimes, children misbehave just to get your
time your child breaks an important rule make him or attention. A time-out teaches your child that
her take a time out. Make sure all other adults (parents, misbehaving is not a good way to get attention.
grandparents, baby-sitter) use the same rules.
• A time-out stops the situation that led your child to
To use a time-out: misbehave in the first place.
• Warn your child: “If you don’t stop, you’ll have • Children copy their parents. For example, if parents
a time out!” spank their child for hitting a brother or sister, the
• When your child ignores the warning, have your child gets a mixed message: “Mommy and Daddy can
child go to a quiet place (like a corner of a room) hit, but I can’t.”
and start the timer.
• Explain the reason for the time-out: “You hit your Reproduced with permission of the Massachusetts
sister. That’s not allowed. Now you must have a Medical Society, “Time-Out!” Sege R, ed. Violence
time-out.” Prevention for Children and Youth: Parent Education Cards.
How long does a time-out last? Waltham, MA: Massachusetts Medical Society; 2000.
It lasts 1 minute for each year of age: To order copies of this tip card, contact the
Massachusetts Medical Society, Public Health and
Two-year-old .....................................................2 minutes
Education, 860 Winter Street, Waltham, MA
Three-year-old ..................................................3 minutes 02451-1411; phone: 800-322-2303;
Four-year-old.....................................................4 minutes e-mail: [email protected].
Five-year-old.................................................... 5 minutes
If it’s too long, young children forget why they are there!
If your child leaves the time-out area, have your child go
back. You need to restart the timer and explain the need
to stay put until the time-out is over.

Key Educational Points on Firearm Injury and Death
• A firearm in the home is more likely to result in a • Patients should discuss firearm safety and
death during a household quarrel, a suicide attempt, health-related issues with their doctors and other
or an unintentional shooting than in protecting health care providers.
members of the household. • If the decision is made to own a firearm, be sure to
• Firearms are especially dangerous in homes where learn all about handling, storing, securing, cleaning,
children are living, someone in the household abuses carrying, and firing the weapon safely.
alcohol or other drugs, there is a person with
depression, or there is any family violence.
Reproduced with permission from the American Medical
• If a firearm is kept in the home, it should be kept Association (AMA). It was excerpted from
unloaded and securely stored locked up, with the Physician Firearm Safety Guide, which is one of a
ammunition stored separately. series of violence-related diagnostic and treatment
• Children should be taught never to play with firearms guides published by the AMA. An order form is
anywhere and to seek an adult immediately if they available on the AMA Web site at http://www.ama-
encounter one. assn.org/ama/pub/category/3548.html. For more
• Parents should ask about the presence and accessibili- information, contact the AMA Unit on Medicine and
ty of firearms in homes their children will be visiting Public Health, 515 N. State St., Chicago, IL 60610;
and restrict visits to homes that are not safe. phone: 312 464-4526.
• Firearms that are no longer desired should be turned

in to local law enforcement authorities or made
unusable, but only by a professional properly trained
to render the firearm inoperative and safe.
• Children and adolescent should be taught to resolve
conflicts nonviolently.
• Parents should monitor children’s use of television
and other media and block access to messages that
glorify firearm use or justify irresponsible firearm use.
If children are exposed to such messages, parents
should draw attention to the behaviors as undesirable
and/or maladaptive and highlight the suffering caused
to victims and their loved ones.
• Family members should remove firearms from the
home when a member becomes depressed, develops a
major mental illness, has a drug or alcohol problem,
or is exhibiting memory problems.
• Family members should remove firearms from
the home if there is an escalating pattern of family
violence.

Pulling the Plug on TV Violence
Facts and tips for parents • Watch programs with your child. If a program
Some disturbing facts regarding TV violence contains violence, talk about it with your child
and ask:
• Did you know that television teaches your child
about violence? As adults, we know that real violence – Is this real or pretend?
causes pain and sadness, but on TV, violence is often – Is this the way to solve a problem
painless, and sometimes funny. American children see – What would happen if you did that?
over 12,000 violent acts per year on TV. And some
• Tell your child how you feel about violence.
of the most violent shows are children’s shows!
• Tell your child that real violence is painful and
• TV characters often use violence to solve problems.
makes people sad and angry.
Children need to learn how to solve problems in a
nonviolent way.
• Just as children learn from brothers and sisters, they “Pulling the Plug on TV Violence: Facts and Tips for
also learn from their TV heroes—both good and bad Parents” is reproduced with permission of the
habits. According to experts in the field: Massachusetts Medical Society. Sege R, ed. Violence
Prevention for Children and Youth: Parent Education
– Some children learn to fight by watching violence
Cards. Waltham, MA: Massachusetts Medical Society;
on TV
2000. To order copies of this tip card, contact the
– Other children learn to become victims Massachusetts Medical Society, Public Health and
– Many learn that violence is fun to watch and, Education, 860 Winter Street, Waltham, MA 02451-
as a result, friends encourage friends to fight 1411; phone: 800-322-2303; e-mail: [email protected]
Helpful tips for parents and caregivers
• Limit your child’s TV watching to 2 hours a
day or less.
• Know what your child is watching. Help your child
choose programs that are less violent.
• Don’t put a TV in your child’s room. You won’t know
what programs your child is watching or how much
time is spent in front of the TV.
• When you’re watching a program that has violence,
don’t allow your child to watch it with you.
• Stop unauthorized viewing with a blocking device
if necessary.

You are the experts on raising violence-free children
A guide for parents • Keep your children “drug-free.”

You have the most power to keep your child free • Review this information and other safety tips
from violence when you spend time, show love, and with them.
communicate well with your child about: Show concern and love
• Respect Warm family relationships protect children from
• Education and personal achievement violence and many other risky behaviors.
• Substance abuse To show love and concern:
• Gangs • Every day, tell your child you love him or her.
• Guns • Show affection daily with a hug, a kiss, or a touch.
• Bullying • Make time for your family to spend playing and
• Dealing with emotions going out.
• Peaceful solutions • Meet your child’s friends to ensure he or she has

positive influences.
• Witnessing violence
• Reward your child for good behavior or a job
Do you know these facts about violence? well done.
• Homicide is the second leading cause of death • Set clear rules for behavior and monitor your child.
for teenagers.
Communication is a two-way street
• It is the No. 1 cause of death for black teens.
Children who have good communication with their
• Most homicides occur because of an argument. parents are more likely to ask for their advice than
• Alcohol is involved in most cases of violence. turn to peers.
• Every year, 32,000 people die from gunshot wounds. When talking to your child, always keep this in mind:
Here is what we can all do for our children: • Listen to your child.
• Be a role model. • Find out what your child knows about violence
• Talk to them and listen to them. and its prevention before you start talking.
• Spend valuable time with them that includes • Let your child know he or she can always talk to
fun activities. you about anything.
• Find out who their friends are and if they are a R-E-S-P-E-C-T
positive influence. Find out what it means to me
• Find out where they hang out and make sure it’s safe. Many youth fight because they feel “dissed” and as
a result feel angry, humiliated, or embarrassed.
• Have them set short-term and long-term goals and
help them plan to reach their dreams. To stay violence-free with respect means:
• Be involved with their education. • Give respect so you may get respect.
• Review their homework, meet teachers, and • Stand up for yourself without putting yourself
participate in school activities. in danger.
• Let them know you disapprove of fighting. • Discuss ways to solve problems without fighting.

You are the experts (continued)
• Respect is not gained by physical force or Gangs: the dangerous “family”

intimidation, but by the quality of your character. Many youth join gangs looking for affection.
• Fighting doesn’t solve a problem or get you respect. Gangs are not family:
• It takes more guts to walk away from a fight than • Gangs only look out for their own interests and easily
to fight. turn against their members if they fall out of line.
Education/personal achievement • Gangs are violent. They intimidate, hurt,
Children who have an interest in and plans for and kill people.
education and personal growth don’t use drugs and • Gangs lead to self-destruction.
don’t fight. Household chores or employment teaches
them responsibility, time management, and the • Join nonviolent groups/peers for support.
value of money. Guns are not for protection!
Show interest in your child’s education and growth: The presence of guns turns conflicts into violent
• Read to your child and encourage your child to read. confrontations resulting in serious injury or death.
Guns are more likely to kill a friend or a family member
• Meet with your child’s teachers periodically to discuss (unintentionally or through suicide) than an enemy.
expectations and learn about your child’s progress.
Tips for gun safety:
• Review homework and tests.
• Parents—don't own a gun. If you must, store it
• Set short- and long-term educational goals. unloaded and locked in a secure place.
• Have your child participate in an after-school • Children should be taught not to touch or play
program. with firearms or hang out with peers who do.
• Give your child household responsibilities. • If threatened by someone holding a gun, cooperate
Substance abuse immediately.
Alcohol is involved in most homicides. Children who • Don’t get into a conflict with someone who
aren’t interested in school, who have friends who owns a gun.
use drugs, and who are not bound by rules, are more Bullying
likely to use drugs.
Prevent your child from becoming a victim:
Keep your child “drug-free”:
• Instill self-confidence in your child.
• Let your child know you disapprove of drug use,
including alcohol. • Assist your child in establishing good social skills.
• Let your child know why you disapprove of drugs. • Teach your child to speak out for him or herself.
• Be a role model—either refrain from drinking or do it • If harassed, teach your child to seek help from
in moderation. you, teachers, and the principal.
• Don’t let your child associate with friends who • Try to meet with the bully to work things out; if
use drugs, including alcohol. the problem continues, call or meet with the parent
of the bully.

You are the experts (continued)
Prevent your child from becoming a bully: Witnessing violence

• Teach your child to respect him- or herself and others. Children who have seen violence are more likely to
• Clearly state that violence is not acceptable. become involved in violence as victims or perpetrators.
Children who witness violence at home or in the
• Assist your child in finding nonviolent strategies for
community may suffer from emotional and mental
anger management and conflict resolution.
disorders.
• Present yourself as a model of nonviolent behavior.
You can:
• Seek help from school counselors for bullying and
• Minimize your child’s exposure to violence.
aggressive behavior.
• Talk to your child about the violence he or she
Dealing with emotions
witnessed
Children who don’t know how to control their anger
• Tell your child that media violence is not real—it
are more likely to fight. Teach children how to calm
is glamorized, misleading, and fails to depict the real
down and talk over their problems.
pain and suffering of the victims.
Tips for keeping cool and solving a problem:
If your child’s behavior changes after witnessing violence:
• Keep in mind that anger is a temporary emotion
Talk to school counselors or your child’s pediatrician;
and it will pass.
some warning signs of emotional or mental disorders
• To calm down, think about or do things you enjoy. related to witnessing violence include sleeplessness,
• Once you have calmed down, think about the lack of appetite, lack of attention, anxiety, and frequent
problem with a clear head. thoughts or flashbacks of the event.
• Take steps to solve the problem.

Peaceful solutions: getting your way Adapted from a brochure of the Children’s Safety
without fighting Network National Injury and Violence Prevention
Resource Center; Education Development Center, Inc.,
Talk—clearly and calmly, state the problem and
55 Chapel Street, Newton, MA; 617 969-7100, ext.
your desire to solve it without fighting.
2207. The Resource Center is funded by the US
Humor—make fun of the problem. Department of Health and Human Services Health
Compromise—both give up something and Resources and Services Administration (HRSA).
get something in return. Reprinted with permission of HRSA. A color version of
this brochure with graphics is available for reproduction
Avoid/ignore—sometimes it’s not worth the bother.
on the electronic version of this guide, located at
Let the other person have what he or she wants.
http://www.ama-assn.org/violence.
Way out—look for a reason not to fight (eg, “My
parents will ground me”).
Remember, it takes more guts and self-respect to
walk away from a fight than to fight, risk your life,
and hurt your family.

Section 8
Additional Information
Additional Information
Child abuse Child advocacy and protection

Child Abuse Prevention Network Child Welfare League of America (CWLA)
http://www.child-abuse.com http://www.cwla.org/
This site provides several resources such as free CWLA, which is dedicated to improving lives of
subscriptions to e-mail lists for professionals in the area endangered youths and their families, provides various
of child abuse, an annotated Prevention Bookmarks services that deal with the prevention and treatment
index, daily press reports about child abuse, and several of child abuse.
downloadable documents as well as multimedia Children’s Defense Fund
resources. http://www.childrensdefense.org/
Childhelp USA The Children’s Defense Fund provides a voice for the
http://www.childhelpusa.org children of America who are unable to vote or lobby
Childhelp USA focuses on many facets of child abuse, for themselves, with an emphasis on the needs of those
from personal suffering to legal issues. Childhelp USA with disabilities and poor or minority children.
incorporates research, prevention, and treatment into National Association of Child Advocates (NACA)
one organization dealing with the problem of child abuse http://www.childadvocacy.org/
in our country. Child advocacy leaders from across the country are
National Clearinghouse on Child Abuse able to share ideas and increase the impact of the
and Neglect child advocacy movement through the existence
http://www.calib.com/nccanch/ of the NACA.
The Clearinghouse provides resources on child abuse,
neglect, and child welfare. Links to statistics, sources
Children, youth, and family resources
of funding, calendar of events, and publications, among
others, can be found on its Web site. Adolescent Directory On-Line
http://www.educ.indiana.edu/cas/adol/adol.html
National Resource Center on Child Adolescence Directory On-Line (ADOL) is an
Maltreatment (NRCCM) electronic service of the Center for Adolescent Studies
http://www.gocwi.org/nrccm/ at Indiana University. Web resources on adolescent
NRCCM provides consultation, training, and technical issues can be accessed by teens, parents, counselors,
assistance services to maltreated children and their fami- researchers, health practitioners, and educators on
lies. Their program was created to enhance the expan- ADOL.
sion, development, and strengthening of service delivery
to these families. Community Justice Exchange
http://www.communityjustice.org/
Prevent Child Abuse America Provides a National Programs Database that you can
http://www.preventchildabuse.org/ search by city/state or program type.
Prevent Child Abuse America is an organization
dedicated to preventing child abuse and neglect through
chapters in 39 states and the District of Columbia.
Additional Information 173 Connecting the Dots to Prevent Youth Violence

Additional Information (continued)
Connect for Kids National Clearinghouse on Families and Youth

http://www.connectforkids.org/ http://www.ncfy.com/ydorgs2.htm
This site addresses various issues on crime and violence. Provides a small list of national resource programs
Drug Treatment Finder—SAMHSA that focus on developing youth.
http://findtreatment.samhsa.gov/ National Parent Information Network
This directory provides the location of drug and alcohol http://npin.org/
treatment programs around the country. The mission of the National Parent Information
Family Education Network Network’s is to provide research-based information
http://fen.com/aboutfen/ about parenting family involvement in education.
Provides information that enables parents to help SafeCities
their children cope with school violence. http://www.SafeCities.gov/
Family Resource Coalition of America This community of people work together to
http://www.familysupportamerica.org/content/home.htm significantly decrease gun violence in 11 cities/regions
The Family Resource Coalition of America is an alliance across the country.
of those who believe that to do the best for America’s State and Local Government on the Web
children, we need to strengthen and support our http://www.statelocalgov.net/index.cfm
nation’s families. Created by Piper Resources, this directory provides links
Family Web Talk to government sponsored and controlled resources.
http://www.familywebtalk.com/ State Resources
This is a forum for parents and children to discuss http://ojjdp.ncjrs.org/resources/asp/search_states.asp
pertinent family and school issues, such as violence This database can be used to find resources for a
and abuse. specific state.
Injury Prevention Web— The Bureau for At-Risk Youth
State by State Resources http://www.at-risk.com/
http://www.edc.org/HHD/csn/StateResources/state.htm The Bureau for At-Risk Youth is an educational
KidsPeace publisher/distributor of products, programs, videos,
http://www.KidsPeace.org/ and publications for youth at-risk and their families.
KidsPeace is a private, non-profit organization that United Way of America
provides families with comprehensive programs dealing http://www.unitedway.org/uwsearch/
with mental health treatment, intervention services, United Way of America provides you with
and public education initiatives. resources in your community.
National Association of Child Advocates
http://www.childadvocacy.org/
This association advocates for the safety and
well-being of all children.

Criminal justice Crime Mapping

Center on Juvenile and Criminal Justice http://www.ojp.usdoj.gov/cmrc/weblinks/welcome.html
http://www.cjcj.org/ Provides simple maps that identify locations where
The center’s mission is to reduce the use of institutional- crimes have occurred—only available for some
ization as a solution to many social problems. This site communities.
provides information on the Center’s Justice Policy Federal Justice Statistics Program (FJSP)
Institute, which encourages effective approaches to the http://fjsrc.urban.org/
justice system. The FJSP describes the details of juvenile offenses
Federal Bureau of Investigation processed in the federal criminal justice system.
http://www.fbi.gov/ Hamilton Fish Institute
The FBI is the principal investigative arm of the US http://www.hamfish.org/index.html
Department of Justice. The Hamilton Fish Institute on School and
Community Violence at George Washington University
is a national resource on effective programs that can
Data search be replicated to reduce violence in America’s schools
Ambulatory Health Care Data—CDC and communities.
http://www.cdc.gov/nchs/about/major/ahcd/ahcd1.htm Monitoring the Future (MTF)—
Provides national data on emergency department and National Institute on Drug Abuse
physician visits. http://monitoringthefuture.org/
Ambulatory Medical Care Survey—CDC This is a comprehensive national survey composed of a
http://www.cdc.gov/nchs/about/major/ahcd/ahcd1.htm sample of 8th, 10th, and 12th graders. A longitudinal
Database that includes information about the provision follow-up of a subset of students also exists. The survey
and use of ambulatory medical care services in the reveals data about drug use (by type of drug), tobacco
United States. use, alcohol use, related attitudes, and use of weapons.
American Society of Suicidology National Archive of Criminal Justice Data
http://www.suicidology.org/index.html (NACJD)
Devoted to the understanding and prevention of http://www.icpsr.umich.edu/NACJD/index.html
suicide, this non-profit organization is a resource The NACJD facilitates and encourages research of
for anyone concerned about suicide. criminal justice issues by preserving and sharing
Annie E. Casey Foundation— important data resources.
Kids Count Data Book
http://www.aecf.org/kidscount/kc2001/
This on-line database allows you to generate custom
state-by-state profiles, graphs, maps, and ranked lists.
Bureau of Justice Statistics (BJS)
http://www.ojp.usdoj.gov/bjs/welcome.html
BJS collects and analyzes data on crime. It also provides
support to state agencies to help them improve their
crime databases and reporting systems.

National Crime Victimization National Youth Gang Survey

Survey (NCVS) http://ojjdp.ncjrs.org/pubs/gangsum.html#183109
http://www.ojp.usdoj.gov/bjs/cvict.htm#ncvs This annual gang survey was conducted by OJJDP’s
The NCVS serves as America’s primary source of National Youth Gang Center. A sample of police and
information on criminal victimization. It provides sheriff’s departments throughout the United States
annual statistics on sexual assaults, rapes, robberies, provides information about youth gang activity in
thefts, household burglaries, and motor vehicle thefts their jurisdictions.
experienced by residents aged 12 years or older. Office of Juvenile Justice Statistical Briefing Book
National Electronic Injury Surveillance System— http://www.ojjdp.ncjrs.org/ojstatbb/index.html
Consumer Product Safety Commission (CPSC) Provides basic information on crime for youth involved
http://www.cpsc.gov/cpscpub/pubs/3002.html in the juvenile justice system. Provides reliable statistical
NEISS identifies and assesses the risks of injury data to common questions asked by policymakers, media,
associated with consumer products. Injury data are and the general public.
abstracted from a sample of emergency department School Crime Supplement to the National Crime
records. The Centers for Disease Control and Prevention Victimization Survey
works with the CPSC to collect data on all types and http://www.nces.ed.gov/pubs2001/crime2000/
causes of nonfatal injuries, including firearm-related These organizations periodically collect data on school
injuries, treated in emergency departments. crime by using a supplement to the NCVS. The survey
National Incident-Based Reporting System asked youth aged 12 years or older, who attended school,
(NIBRS) questions about availability of drugs at school, street
http://www.ojp.usdoj.gov/bjs/nibrs.htm gangs, gang fights, presence of guns at school,
Provides national reports on offense arrests and victimizations, and fear of being attacked or harmed.
crimes according to demographic information Sourcebook of Criminal Justice Data
about those involved. http://www.albany.edu/sourcebook/index.html
National Mortality Followback Survey This sourcebook incorporates data from more than
http://www.cdc.gov/nchs/about/major/nmfs/nmfs.htm 100 sources regarding all aspects of criminal justice
This is a survey of all resident deaths in the United in America.
States of people aged 15 years or older. This survey Uniform Crime Reports
investigates socioeconomic differentials in mortality, http://fisher.lib.virginia.edu/crime/
possible prevention of premature death, and associated The crime rates for juveniles in states and counties,
risk factors. are provided at this site.
National Vital Statistics System—Mortality Data White House Drug Policy Center
http://www.cdc.gov/nchs/about/major/dvs/mortdata.htm http://www.whitehousedrugpolicy.gov/drugfact/
Through the National Vital Statistics System, the index.html
National Center for Health Statistics gathers and Provides comprehensive data on major drug categories
releases data on deaths in the nation. and special populations along with source materials.

WISQARS (Web-based Injury Statistics Query National Parent Information Network

and Reporting System) http://npin.org/pnews/2000/pnew700/int700c.html
http://www.cdc.gov/ncipc/osp/data.htm
Provides an article on dating violence that describes
Provides customized injury-related mortality data that
how it fits into the cycle of violence, with risk factors
enables informed public health decision-making.
and web resources.
Youth Risk Behavior Surveillance
System (YRBSS) National Youth Violence Prevention Resource
http://www.cdc.gov/nccdphp/dash/yrbs/
Center
Monitors risk behaviors associated with the leading http://www.safeyouth.org/teens/topics/teen_dating.htm
causes of death by providing various surveys for different The “Hot Topics” section provides a fact sheet on teen
age ranges. The survey includes race, ethnicity, age, and dating violence with statistics, warning signs and more.
sex; tobacco and alcohol use, and well as other drug use;
Rhode Island Coalition Against Domestic Violence
sexual behaviors (including sexually transmitted disease
(RICADV)
and HIV risk); dietary behaviors; physical activity; and
injury risk behavior (motorcycle and bicycle helmet use, http://www.ricadv.org/violence.html
seat belt use, drinking and driving, fighting, weapon RICADV developed resources for educators and teens,
carrying, suicide attempt). which address teen dating violence. Two main projects
include “Dating Violence: It is Your Business,” which is
part of a public education campaign and a Resource
Dating violence Guide for Educators.
American Psychological Association- Love Doesn’t
Transform Communities—Tools for Youth
Have to Hurt Teens
Relationship Violence
http://www.apa.org/pi/pii/teen/homepage.html
http://transformcommunities.org/tctatsite/ttools_yrv.html
Provides a packet of information with warning signs,
Provides a list of teen dating violence prevention
statistics, risk factors, resources and ideas for stopping
curriculum and programs.
the violence for friends and/or family members.
Dating Violence Fact Sheet
Family violence
http://www.cdc.gov/ncipc/factsheets/datviol.htm
Minnesota Center Against Violence
Concise summary of dating violence statistics and and Abuse (MINCAVA)
risk factors from the Centers for Disease Control http://www.mincava.umn.edu
and Prevention. MINCAVA, which is housed at the School of Social
Massachusetts Medical Society Work at the University of Minnesota, supports
education, research, and access to information about
http://www2.mms.org/pages/tip_teendating.asp
violence. MINCAVA promotes this mission through
Provides two articles on teen dating violence. One thefollowing projects: MINCAVA Electronic
is geared towards recognizing the signs of a violent Clearinghouse, The Link Research Project, Violence
relationship and the other is for parents. Against Women Online Resources, Child Abuse
Prevention Studies Program (CAPS), and the applied
research section of the Violence Against Women
Web site.

Center for the Prevention of Sexual and provides information and referral services, as well as
Domestic Violence educational publications. The Give Back a Smile,
http://www.cpsdv.org/ FACE TO FACE, and SCORES programs help remove
This interreligious educational resource concentrates the scars of abuse and help address national public
on topics relating to sexual and domestic violence, with policy issues.
an emphasis on education and prevention.
Firearms and substance abuse
Family and Intimate Violence Bureau of Alcohol, Tobacco and Firearms (ATF)
http://www.cdc.gov/ncipc/dvp/fivpt/fivpt.htm http://www.atf.treas.gov/
This division addresses many issues related to family This law enforcement organization is dedicated to
and intimate partner violence, including tracking the reducing violent crime and protecting the public. The
problem and research and evaluation of programs. ATF’s National Tracing Center coordinates the Youth
Family Violence Department—National Council Crime Gun Interdiction Initiative, which is a national
of Juvenile and Family Law Judges program that monitors the illegal supply of firearms to
http://www.nationalcouncilfvd.org/ youth by tracing the guns used in crimes.
In 1987, the National Council of Juvenile and Family Center on Addiction and Substance Abuse at
Court Judges launched a Family Violence Project. Since Columbia University (CASA)
then, it has grown into the Family Violence Department, http://www.casacolumbia.org
and it serves as a major force in addressing family This organization focuses on informing Americans of the
violence in the United States. costs of substance abuse, such as the economic, social,
Family Violence Prevention Fund and personal impacts. It encourages them to take action
http://www.endabuse.org on combating substance abuse.
The Family Violence Prevention Fund works to end Join Together Online
domestic violence and help women and children whose http://www.jointogether.org
lives are affected by violence and abuse. Resources are Join Together’s searchable gun violence site
available to help health professionals and employers provides information about issues related to gun
identify and aid victims of abuse. possession and violence.
National Crime Victims Research and Treatment National Clearinghouse for Alcohol
Center—Medical University of South Carolina and Drug Information (NCADI)
http://www.musc.edu/cvc/ http://www.health.org
The NCVC conducts important scientific research The world’s largest resource provides information
projects on different aspects of child abuse and criminal and materials about substance abuse. NCADI is the
victimization. Recently, its research efforts include the information service of the Center for Substance Abuse
analysis of the mental health impact of urban violence Prevention of the Substance Abuse and Mental Health
and natural disasters. Services Administration in the US Department of
National Coalition Against Domestic Violence Health and Human Services.
(NCADV)
http://www.ncadv.org/
NCADV goals are to empower battered women and
children. The program “Remember My Name” is an
ongoing project dedicated to compiling the names of
women killed due to domestic violence. The NCADV

National Youth Anti-Drug Media Campaign Join Together On-Line

http://www.mediacampaign.org http://www.jointogether.org
The National Youth Anti-Drug Media Campaign is
JTO provides daily updates on topics in the news on
designed to educate and empower youth to avoid
violence prevention including information on funders.
illicit drugs. A variety of media, including TV ads and
school-based educational materials, are used to reach National Resource Directory of Victim Assistance
parents and youth. Funding Opportunities for 2000
Substance Abuse and Mental Health Services http://www.ojp.usdoj.gov/ovc/fund/nrd/
Administration (SAMHSA) National Youth Violence Prevention
http://www.samsha.org Resource Center
SAMHSA’s mission is to improve the quality and
availability of treatment, prevention, and rehabilitation
services in order to reduce illness, disability, death, The Center provides links to a broad range of
substance abuse and mental illnesses. information on youth violence prevention
including funders.
White House Office of National Drug Control
Policy (ONDCP) Office of Juvenile Justice and Delinquency
http://www.whitehousedrugpolicy.gov/ Prevention
The goals of the ONDCP are to reduce the use of http://ojjdp.ncjrs.org/
illicit drugs, manufacture of these substances, and
The OJJDP is a federal agency that works with states and
drug-related health consequences and issues.
local communities to develop, implement and evaluate
violence prevention programs. They provide technical
Sites for Identifying Funding for Youth assistance, funding, and materials to those wishing to
Violence Prevention Programs: start programs.
Children’s Safety Network
http://www.edc.org/HHD/csn/
The CSN is sponsored by the Health Resources and
Services Administration of the federal government. It
provides information on violence and injury prevention
including information on funding.
Foundation Center
http://fdncenter.org
The Foundation Center provides an on-line searchable
directory of funding sources for a broad range of issues
including youth violence prevention.

Health care professional resources many resources on this issue, including the Firearm
Injury Prevention Resource Guide for community
ACT-Adults and Children Together— leaders and health professionals and the STOP Firearm
Against Violence Injury Kit.
http://www.actagainstviolence.org/ American College of Obstetricians
This violence-prevention campaign involves communi- and Gynecologists
ty-based training programs and a national multimedia http://www.acog.org/
campaign. The campaign focuses on adults who interact This organization has developed educational bulletins
with children ages zero to 8 years of age, emphasizing the and policies on violence topics, with an emphasis on
importance of a positive role model in the health and sexual assault. Downloadable brochures and publications
mental well-being of youth. are available on its Web site.
Allina Health Systems Foundation American College of Physicians/American Society
http://www.unitedhospital.com/ahs/foundation.nsf/ of Internal Medicine (ACP/ASIM)
page/AF_vp_HCCV http://www.acponline.org/home/policy.htm
This is a statewide coalition of health care, health plans, The goal of the ACP/ASIM is to foster excellence and
and community organizations that work to implement professionalism in the area of medicine in order to
violence prevention strategies in the health care system. enhance the quality of care. A list of advocacy issues can
This foundation also provides training, curriculum, be viewed online at their Legislative Action Center.
resources, and publications for use by all health American Medical Association
care providers. http://www.ama-assn.org/violence
American Academy of Child and The AMA addresses the issue of youth violence in
Adolescent Psychiatry (AACAP) two major ways. First, it convened the Commission for
http://www.aacap.org the Prevention of Youth Violence. The Commission
The AACAP has multiple resources for families, health included a multidisciplinary group of organizations that
care professionals, and communities that address the explored the causes of violence among youth and issued
issue of youth violence. To motivate child recommendations on how health professionals and
and adolescent psychiatrists to join the fight to prevent communities could make a positive impact on the
violence, it recently launched a violence initiative. prevention of youth violence. The AMA also addresses
American Academy of Family Physicians violence among youth through organizational policy and
http://www.aafp.org/ its National Advisory Council on Violence and Abuse.
The AMA Alliance, a grass roots organization composed
Provides position papers on the role of family physicians of spouses of AMA members, is very active in bringing
and patient information on violence-related issues. anti-violence messages to communities nationwide.
American Academy of Pediatrics (AAP) Information about the Alliance can be found at
http://www.aap.org http://www.ama-assn.org/ama/pub/category/2141.html.
The AAP works to prevent violence by and against
children and adolescents, with particular focus on the
prevention of firearm injuries. The AAP has developed

American Medical Association and Health American Psychological Association (APA)

Resources and Services Administration (HRSA) http://www.apa.org
http://www.ama-assn.org/ama/upload/mm/39/ The APA has many divisions that address youth
parentinfo.pdf violence. It has a Commission on Violence and Youth,
The AMA and HRSA developed and released “The which has created and published many reports; the APA
Parent Package” in 2001. “The Parent Package” is Presidential Task Force on Violence and the Family; and
designed to help physicians share important information it has also teamed up with MTV to provide information
about adolescents with parents. The sheets provide on the warning signs of violent behavior to youth and
useful tips on violence, alcohol, drugs, depression, sex, steps to getting help when they recognize these signs.
parenting, making responsible choices, and growth and American Public Health Association
development issues, among many others. These sheets http://www.apha.org
can be reproduced for widespread distribution.
The American Public Health Association’s journal
American Medical Student Association (AMSA) provides access to many articles and publications on
http://www.ama-assn.org/resource/pgres.cfm youth violence and prevention.
The AMSA Foundation’s Generalist Physicians in Center for Injury Prevention
Training project, funded by the Robert Wood Johnson and Control—CDC
Foundation, has created Projects in a Box. Some of the http://www.cdc.gov/ncipc/default.htm
topics included are: child abuse and neglect, guns and
The National Center for Injury Prevention and Control
violence, preventing adolescent violence, substance
(NCIPC) works to reduce disability morbidity, mortality,
abuse prevention, teen mentor programs, and more.
and costs associated with injuries.
American Nurses Association (ANA)
http://www.nursingworld.org/rnkids/index.htm
Division of Violence Prevention
http://www.cdc.gov/ncipc/dvp/dvp.htm
The ANA addresses the issue of youth violence through
The Division has four major areas for violence
its campaign: Kids in the Crosshairs: RNs Confront the
prevention: suicide, youth violence, family
Causes and Consequences of School Violence. This
and intimate violence, and firearm injuries.
campaign explores the role of nurses in reducing youth
violence. Youth Violence and Suicide Prevention Team
http://www.cdc.gov/ncipc/dvp/youth/youth.htm
American Psychiatric Association
http://www.psych.org Center for Mental Health Services (CMHS)
http://www.mentalhealth.org/cmhs/
The American Psychiatric Association has position
statements on many violence issues, and it is involved Provides general mental health information, information
in three major projects related to youth violence about services, and information from the School
prevention: (1) organizing the Youth Violence Violence Prevention Initiative, the Emergency Services
Prevention Project; (2) creating the National Prevention and Disaster Relief Branch, and the Child, Adolescent,
Coalition; and (3) being part of the Commission on and Family Branch.
Youth and School Violence, which is studying the
problem of youth violence in schools.

Children’s Safety Network—Maternal and (PATHS) curriculum, which teaches children about
Child Health Bureau problem solving, understanding emotions, and
http://www.edc.org/HHD/csn/ self-control.
The Children’s Safety Network is located at Education Pacific Center for Violence Prevention
Development Center, Inc. and is part of the National http://www.pcvp.org
Injury and Violence Prevention Resource Center. The Pacific Center for Violence Prevention is the policy
The network provides resources and technical assistance center of the California Wellness Foundation’s statewide
to maternal and child health agencies and other Violence Prevention Initiative, established in 1993.
organizations looking to decrease unintentional injuries Policy goals are to reduce consumption and advertising
and violence to children and youth. of alcohol to youths, reduce access to firearms, and
Doctors Against Handgun Injury (DAHI) shift society’s definition of youth violence from a law
http://www.doctorsagainsthandguninjury.org/ enforcement model only, to include a public health
DAHI works to bring collective experiences and model.
expertise from physicians about the danger of handgun Physicians for a Violence-Free Society
injury in order to reduce the level of injuries and deaths. http://www.pvs.org/main/index.html
Family Violence Prevention Fund Physicians for a Violence-Free Society helps to develop
http://endabuse.org/ leadership and advocacy in the health care community
Health care providers and employers are able to in order to promote violence prevention. It recently
identify and aid victims of abuse with the assistance created the California Physician’s Network.
of the Family Violence Prevention Fund. The group Physicians for Social Responsibility
also works to enable all Americans to end abuse. http://www.psr.org/violence.html
National Institutes of Health Its Violence Prevention Program is a national
http://www.nih.gov/ network of public health professionals and physicians.
The NIH supports research on new ideas and programs Information on gun violence training and related issues
that will aid in overall better health of the public. is available on its Web site.
National Institute of Child Health and Human PubMed—National Library of Medicine

Development (NICHD) http://www.ncbi.nlm.nih.gov/PubMed
http://www.nichd.nih.gov/ This database allows for searches of international
The NICHD explores the developmental issues and literature on the topic of violence.
related health of infants, children, youth, and families. The HELP Network
National Institute of Mental Health (NIMH) (Handgun Epidemic Lowering Plan)
http://www.nimh.org http://www.helpnetwork.org/main.html
The NIMH has supported programs that address the The HELP Network is dedicated to reducing
related issues of mental health: Families and Schools firearm-related injuries and deaths. HELP is an
Together (FAST) Track Program and Linking the international organization that promotes public health
Interests of Families and Teachers (LIFT) Program, science strategies and is also a clearinghouse for
and the Promoting Alternative Thinking Strategies information on the growing trend of firearm casualties.

Key reports on youth Preventing Youth Hate Crime: A Manual for

violence prevention Schools and Communities
http://www.ed.gov/offices/OESE/SDFS/encl26.pdf
Best Practices of Youth Violence Prevention:
A Sourcebook—CDC (2000) Safeguarding Our Children: An Action Guide—
http://www.cdc.gov/ncipc/dvp/bestpractices.htm# US Department of Justice and US Department
of Education (2000)
Blueprints for Violence Prevention
http://www.air.dc.org/cpcp/guide/act:onguide.html
http://www.colorado.edu/cspv/blueprints/
The School Shooter: A Threat Assessment
Confronting Chronic Neglect: The Education
Perspective—FBI (2000)
and Training of Health Professionals on Family
http://www.fbi.gov/publications/school/school2.pdf
Violence—Institute of Medicine (2001)
http://www.nap.edu/catalog/10127.html Toolkit to End Violence Against Women—
Creating Safe and Drug Free Schools (1996) National Advisory Council on Violence Against
http://www.ncjrs.org/pdffiles/safescho.pdf Women and the Violence Against Women Office.
http://toolkit.ncjrs.org
Early Warning, Timely Response: A Guide to
Safe Schools—Department of Education Violence Prevention: A Vision of Hope—California
http://www.air.org/cecp/guide/pdf.htm Attorney General Dan Lungren (1995)
http://www.lapdonline.org/
Healthy People 2010—Department of Health
and Human Services (2000) Youth and Violence: Medicine, Nursing,
and Public Health: Connecting the Dots to Prevent
http://www.health.gov/healthypeople/
Violence—Commission for the Prevention of Youth
Indicators of School Crime and Safety, 2001 — Violence (2000)
Department of Justice (2001) http://www.ama-assn.org/violence
http://www.ojp.usdoj.gov/bjs/pub/pdf/iscs01.pdf
Youth Violence: A Report of the Surgeon
Juvenile Offenders and Victims, General—Surgeon General David Satcher (2001)
1999 National Report http://www.surgeongeneral.gov/library/youthviolence/
http://www.ncjrs.org/html/ojjdp/publist2000/ default.htm
violence.html
Never Too Early, Never Too Late...To Prevent
Youth Crime & Violence—Little Hoover
Commission
http://www.lhc.ca.gov/lhcdir/report159.html
New Directions from the Field: Victims’ Rights
and Services for the 21st Century—Office for
Victims of Crimes (2000)
http://www.ojp.usdoj.gov/ovc/new/directions/pdftxt/
direct.pdf
Preventing Crime: What Works, What Doesn’t,
What’s Promising: A Report to the US Congress—
http://www.ncjrs.org/works/wholedoc.htm

Media violence National Alliance for Safe Schools

Kids-In-Mind http://www.safeschools.org/
http://www.kids-in-mind.com/ The alliance’s main goal is to make and keep schools a
Kids-In-Mind is primarily addressed to parents, and it safe learning environment for children and youth. Its
deals with assessing objectionable material in movies and Web site provides information on current anti-violence
other media with a non-critical approach. programs and provides training links.
KIDSNET National Mental Health and Education Center

http://www.kidsnet.org for Children and Families
http://www.naspcenter.org/index2.html
KIDSNET, a national computerized non-profit
clearinghouse dedicated to children’s video program- The National Association of School Psychologists
ming, audio, and television, promotes the quality of created this public service program to provide
children’s media. information on current issues and programs as well
as provide resources for crisis response and safe
Mediascope school programs.
http://www.mediascope.org/
National Parent-Teacher’s Association
This national, not-for-profit research and policy http://www.pta.org/
organization was founded in 1992. Since its roots, it
has worked to promote the responsible portrayal of The National Parent-Teacher’s Association develops
content and images in film, television, advertising, community violence prevention kits to help combat
music, and other forms of mass media. school violence, and provides other information on pre-
vention and education.
National School Safety Center
School violence and safety http://www.nssc1.org/
Center for the Prevention of School Violence The Center provides information and resources to
http://www.ncsu.edu/cpsv/ train school educators, parents, law enforcement, and
The Center is dedicated to getting violence out of our other youth serving individuals on the topic of school
schools, and it is currently working on special projects violence prevention.
to attain this goal. Safe and Drug Free Schools Program (SDFS)—
Division of Adolescent and School Health Department of Education
(DASH)—CDC http://www.ed.gov/offices/OESE/SDFS/
http://www.cdc.gov/nccdphp/dash/ This program is the federal government’s primary vehicle
DASH coordinates the Youth Risk Behavior for reducing alcohol, drug, and tobacco use, as well as
Surveillance System, conducts the School Health preventing violence in and around schools. With the
Policies and Programs Study (SHPPS), and has help of federal, state, and community efforts and
developed a library of federal activities that address resources, they are able to help strengthen programs that
violence in schools. promote these topics.

Safe Schools/Healthy Students Initiative— The October Center for the Study and
Center for Mental Health Services Prevention of Youth Violence
http://www.mentalhealth.org/schoolviolence/default.asp http://www.octobercenter.vcu.edu/
This grant program is designed to evaluate what works Southern California Center on Youth
best to reduce the incidence school violence. School Violence Prevention
districts use the funds to assist communities with the http://www.stopyouthviolence.ucr.edu/
implementation of many comprehensive educational University of California at San Diego Center
services for youth. The goal is to prevent youth violence, on Youth Violence Prevention
foster resilience, and healthy childhood development. http://www.sdhealth.org/yvp/yvp.html
The University of Hawaii at Manoa’s
Youth violence—an overview Comprehensive Center on Youth
Violence Prevention
Academic Centers of Excellence on the
http://www.api-center.org/
Prevention of Youth Violence
The University of Michigan, Developing Center
Asian/Pacific Islander Youth Violence
on Youth Violence Prevention
Prevention Center (API)
http://www.sph.umich.edu/prc/projects/yvpc.html
http://www.api-center.org/
Center for the Study and Prevention
The University of Alabama at Birmingham,
of Violence
Comprehensive Center on Youth Violence
http://patch.Colorado.edu/cspv
Prevention. For more information, contact:
Kurt Denninghoff, MD, 205 975-7387 or The Center provides information about many issues
[email protected], and Frank Romanowicz related to violence, spanning from bibliographical
205 975-0520. information to national violence prevention programs.
Columbia University’s Comprehensive Center National Youth Violence Prevention
on Youth Violence Prevention Resource Center
For more information, contact Karen Rose http://www.safeyouth.org
212 305-8213. This Resource Center is a collaboration between the
The Developing Center on Hispanic Youth Centers for Disease Control and Prevention and other
Violence Prevention federal agencies, and it serves as a central source of
For more information, contact information on statistics, research, programs, and
Brenda Mirabel-Colon, MD publications about violence and youth.
787 758-2525 or at [email protected]. Partnerships Against Violence
Harvard Youth Violence Prevention Center http://www.pavnet.org/
http://www.hsph.harvard.edu/hicrc/prevention.html This “virtual library” provides information from multiple
The Johns Hopkins Comprehensive Center on federal agencies on violence-related issues, and it is
Youth Violence Prevention the basis for the Pavnet mailgroup in which violence
For more information, contact Philip Leaf, PhD prevention professionals can share ideas and resources.
410 955-3962 or at [email protected]

Connecting The Dots To Prevent Youth Violence

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Connecting

A Training and Outreach Guide for Physicians

Lyndee Knox, PhD, Author

This Training and Outreach Guide is a companion to American Psychiatric Association

Introduction Connecting the Dots to Prevent Youth Violence

Introduction & Overview ............................................................................................................................................7

Section 1 Preparing the Presentation .................................................................................................................9

Section 2 Speeches ...........................................................................................................................................15

Section 3 Slides .................................................................................................................................................45

Section 4 Case Studies ......................................................................................................................................67

Section 5 Issue Briefs .........................................................................................................................................85

Section 6 Act Now Handouts .........................................................................................................................133

Section 7 Resources: Professional and Patient/Family .................................................................................. 151

Section 8 Additional Information...................................................................................................................173

Introduction Connecting the Dots to Prevent Youth Violence

Purpose of the guide The remainder of this guide is divided

Introduction 7 Connecting the Dots to Prevent Youth Violence

Section 6: Act Now Handouts

Introduction 8 Connecting the Dots to Prevent Youth Violence

• Goals and objectives for the speech

• Preparing materials and physical layout

• Instructions for carrying out an on-line search

• Links to useful Internet database sites

Establish presentation objectives Recruit a community member to

Preparing the Presentation 9 Connecting the Dots to Prevent Youth Violence

Modify speaker’s notes by adding local www.ama-assn.org/violence or www.stopyouthviolence.

Preparing the Presentation 10 Connecting the Dots to Prevent Youth Violence

Preparing the Presentation 11 Connecting the Dots to Prevent Youth Violence

Substance Abuse Health Risk Behaviors

FBI Arrest Statistics Injury Mortality Data

Youth Homicide Rate Youth Arrest Rates

WISQARS (Web-based Injury Statistics Query and FBI Arrest Statistics

• Speech for health professional audience

• Speech for youth and community audience

Speeches 15 Connecting the Dots to Prevent Youth Violence

[Slide #1] Introduction

Option: begin with a statement on violence made by a local leader

The epidemic of youth violence only occasionally warrants headlines

Speeches 16 Connecting the Dots to Prevent Youth Violence

Speeches 17 Connecting the Dots to Prevent Youth Violence

• Experiencing child abuse and neglect increases the likelihood

Speeches 18 Connecting the Dots to Prevent Youth Violence

Another risk factor is gangs

With this background on the different factors that produce youth

Option: Insert stories about violence in local area (3-5 minutes).

Speeches 19 Connecting the Dots to Prevent Youth Violence

[Slide #13] What can physicians and other health

Speeches 20 Connecting the Dots to Prevent Youth Violence

Option: Insert your own methods of educating and stories of

[Slide #16] Assess

Option: Insert your own methods of assessing and stories

[Slide #17] Refer

Option: Places/programs to refer in this county and stories

Speeches 21 Connecting the Dots to Prevent Youth Violence

[Slide #18] Health care interventions during post-injury:

Option: Insert your own methods of referral and stories

[Slide #20] Interventions during the pre-injury stage

Speeches 22 Connecting the Dots to Prevent Youth Violence

Speeches 23 Connecting the Dots to Prevent Youth Violence