NCBI Bookshelf. A service of the National Library of Medicine, National Institutes of Health.

Chan LS, Kipke MD, Schneir A, et al. Preventing Violence and Related Health-Risking Social Behaviors in Adolescents. Rockville (MD): Agency for Healthcare Research and Quality (US); 2004 Oct. (Evidence Reports/Technology Assessments, No. 107.)

  • This publication is provided for historical reference only and the information may be out of date.

This publication is provided for historical reference only and the information may be out of date.

Cover of Preventing Violence and Related Health-Risking Social Behaviors in Adolescents

Preventing Violence and Related Health-Risking Social Behaviors in Adolescents.

Show details


Purpose of this Review

Over the last two decades of the 20th century, violence emerged as one of the most significant public health problems in the United States (Administration for Children and Families, 2004). While adults continue to constitute the majority of violent offenses, the decade between 1983 and 1993 was marked by an unprecedented surge of violence, often lethal violence, among young people in the United States (Administration for Children and Families, 2004). This surge of violence left countless young people and their families affected by injuries, disability, and death. Since 1993, there have been encouraging signs that youth violence may be on the decline, a trend that researchers, and the legal and policy communities are attempting to understand. The dramatic rise in youth-centered violence that began in the early 1980s precipitated an urgent and widespread drive among researchers and policy makers across multiple disciplines and sectors to understand the factors that contribute to violence and to develop interventions to address these factors and stem the tide of increasing violence. Science can play an important role in clarifying the scope of the problem, elucidating the responses needed to further reduce and/or eliminate youth violence and related harmful health behaviors, and informing both the development and evaluation of new policies and prevention interventions.

In October of 2004, the National Institutes of Health will convene a State-of-the-Science Conference on “Preventing Violence and Related Health-Risking Social Behaviors in Adolescents.” The purpose of this consensus conference is to provide a forum to present longitudinal and experimental risk factor research and intervention research that has yielded information documenting the role of individual, family, school, community, and peer level influences. In preparation for this meeting, the Office of Medical Applications of Research (OMAR) and the National Institute of Mental Health (NIMH) nominated and supported the topic. The Agency for Healthcare Research and Quality (AHRQ) awarded this project to the Southern California Evidence-Based Practice Center (SC-EPC) and its partner, Childrens Hospital Los Angeles, to conduct a systematic review and analysis of the scientific evidence that exists relative to the prevention of violence and related health-risking social behaviors in adolescence, and to summarize these findings in an evidence report. This systematic review included an evaluation of the factors that contribute to violence during childhood and adolescence as well as the effectiveness of prevention interventions. The findings contained in this report will be presented at the 2004 conference.

Epidemiology of Youth Violence

According to a seminal 2001 report by the Surgeon General, youth violence is one of the Nation's most serious, insidious, and complex problems, influencing nearly every aspect of society (Satcher, 2001). In the decade that extended from roughly 1983 to 1993, an epidemic of violent, often lethal behavior emerged in the United States, resulting in untold injury, disability, and death (Cook & Laub, 1998). Indeed, during that decade, arrests of youth for serious violent offenses surged by 70 percent; more alarmingly, the number of young people who committed a homicide nearly tripled. During that same period of time, the homicide arrest rate, increased 273 percent for adolescents, 14 to17 years (from 7.0 to 19.1 per 100,000), and 65 percent for young adults, 18 to 24 years (from 15.7 to 25.3 per 100,000). In contrast, the homicide arrest rates reported among adults 24 years and older declined by 25 percent (6.3 to 4.7 per 100,000). This increase in homicide arrest rates among adolescents and young adults has largely been attributed to an increase in gang-related activity, an increase in illicit drug use, and the increased availability of guns and other lethal weapons (Hennes, 1998). Among the youth arrested for violent offenses, most are males (84 percent), with males accounting for 94 percent of juveniles convicted for homicide (Federal Bureau of Investigations, 1999).

Yet as we mentioned above, since 1993, the peak year of the epidemic, some encouraging signs have appeared that youth violence is declining. Three important indicators of violent behavior—arrest records, victimization data, and hospital emergency room records—have shown significant downward trends nationally. Despite these encouraging trends, homicide continues to be the second and third leading cause of death in the U.S. for persons aged 15 to 24 years and 5 to 14 years, respectively, and it is the leading cause of death among African American and the second leading cause of death among Latino youth (National Center for Injury Prevention and Control, 2004).

While students are safer in school than out of school, recent shootings in the nation's schools have focused public attention on school-related violence and crime (DeVoe, Peter, 2002). From July 1, 1992 through June 30, 1999, there were 358 school-associated violent deaths in the United States. Overall, school-associated homicide rates appear to have increased in recent years due to an increase in students killed in multiple-victim homicide events. In a 1992-1993 survey of the National School Boards Association, 82 percent of school districts nationwide reported student involvement in violence had increased over the past 5 years (Lowry, Sleet, 1995). Violent behaviors reported by districts included student-on-student assault (78 percent of districts), shootings or knifings (39 percent), and rape (15 percent of districts). An examination of more recent trends in student-on-student assaults shows that the percentages of students who reported fighting on school property declined from 16 percent in 1993 to 13 percent in 2001.

Not all violence reaches the level of homicide. Indeed, one of the most common forms of violence perpetrated by youth is physical fighting. According to the 1999 Youth Risk Behavior Survey, 36 percent of students nationwide reported having been in a physical fight one or more times on 1 or more days during the 12 months preceding the survey, amounting to 105.9 incidents of physical fighting per 100 students. Overall, male students (44 percent) were significantly more likely than female students (27 percent) to have participated in a physical fight; this finding was consistent across racial/ethnic groups and within grades (Kann, Kinchen, 2000). However, encouraging trends have emerged in the percentage of youth reporting involvement in physical fighting, with a significant decrease between 1993 and 1999.

Young males are disproportionately represented as both victims and perpetrators of all forms of violence in the United States. Of the 18,272 homicides committed in the United States in 1998, 35 percent of all victims were younger than age 25 years and 82 percent of these victims were male (Dahlberg and Potter, 2001). Males, 10 to 17, are also significantly more likely to be involved in aggravated assault and robbery than their female peers, while male students in grades 9 through 12 were more likely to report having been in a physical fight and to have engaged in physically aggressive behaviors while at school (Lowry, Sleet, 1995).

Further, the risk of violent death and of committing a violent crime is greater for young people of color and those who are economically disadvantaged. Homicide is the leading cause of death among African-American and Latino youth, 15 to 24. (Dowd, 1998) In 1998, homicide rates for African-American youth were more than twice the rate of Latino youth and more than 13 times the rate of Caucasian, non-Hispanic youth (56.5 vs. 23.3 vs. 4.2 per 100,000, respectively) (Dahlberg and Potter, 2001). In addition to having the highest homicide victimization rate, African-American male youth also have the highest homicide arrest rate. In 1991, African-Americans were 7 times more likely to be arrested for homicide than Whites. Between 1985 and 1994, African-American males, ages 14 to 17 years, had the largest increase in homicide arrest rates (315 percent) (Hennes, 1998). However, racial differences in homicide rates appear to be mediated by both poverty and race-specific homicide victimization; homicide arrest rates become similar after controlling for socioeconomic status (Hennes, 1998).

Over the past two decades, a growing body of research has begun to identify the range of individual, social, environmental and community-level factors that are associated with an increased risk for youth violence, delinquency, and juvenile crime. Researchers generally agree that behavior, including violent and antisocial behavior, is the result of a complex interplay of individual, biological, genetic, and environmental factors that begin to exert their effects during or even prior to fetal development and continue throughout life (Bock and Goode, 1996). Evidence is also emerging regarding developmental precursors in early childhood to youth antisocial and delinquent behavior (McCord, Widom, 2001; Shonkoff and Phillips, 2000). The literature documents the exploration by researchers of potential causes for or contributors to youth violence from early childhood such as child abuse, particular parenting styles, and features of the environment or the community. A wealth of literature also documents investigations of adolescents themselves and their involvement with gangs and other peer groups, the availability of firearms in their community, and their relationships with their sexual partners, all as potential cofactors for violence. Another body of research literature looks at resiliency in an effort to find clues to why the majority of young people with similar individual, familial, and community exposures to these risk factors do not become involved in violence.

Despite this growing evidence, it has been exceedingly difficult to evaluate the strength of this evidence regarding the reported relationships between youth violence and a wide range of risk factors and protective influences. This difficulty is in part due to the fact that numerous disciplines and fields of research, including but not limited to epidemiology and public health, psychology, child development, sociology, anthropology, social work, medicine, education, and public policy, have collectively contributed to this literature, each potentially looking at and operationally defining violence, as well as risk and protective influences, in different ways. Moreover, a wide range of research study designs have been used to evaluate risk and protective influences, with varying degrees of scientific rigor. As a result, the current literature is fragmented in nature, with inconsistent findings often reported across individual studies. While numerous attempts have been made to review the literature (Dahlberg and Potter, 2001; Raine, 2002; Sampson, Morenoff, 2002; Villani, 2001), it remains unclear which risk factors are most salient across different research settings and subject populations. Consequently, it remains relatively unclear which risk and protective factors are most amenable to change through prevention. Moreover, few have attempted to perform a systematic review of the strength of the existing evidence, or to limit their scope to those studies conducted with the greatest scientific rigor. Thus, questions remain about what future research is needed to extend the current literature. It is for all these reasons that the National Institutes of Health commissioned a systematic review of the literature and the strength of the evidence reported in this literature, the results of which are summarized in this report.

Violence Prevention Programs

As the rates of violence began to increase in the 1980s, an entire field of violence prevention emerged with the design and development of many new violence prevention intervention approaches and programs. Prevention and early intervention programs are now in place in cities and regions throughout the country; many target youth violence through early child interventions, others are specifically targeted to adolescents. And while many of these interventions have been evaluated to determine their effectiveness in preventing violent behavior that is perpetrated by youth, the quality and scientific rigor of those evaluations has varied considerably. Moreover, the research on youth violence prevention remains fragmented in nature, in part because of the wide range of interventions approaches used, some better described than others, with the specific targets for the interventions often poorly defined. In addition, given the wide range of program designs and the settings in which they are likely to be delivered, it is difficult to determine what scientific standard should be set and/or methodological approach used to evaluate existing programs with the utmost in scientific rigor. A number of youth violence interventions and prevention programs have been demonstrated to be effective (Satcher, 2001). Unfortunately, few interventions effectively address involvement with delinquent peers and gang membership. Moreover, determining which type of intervention approach might be most effective for which individuals remains largely an unsolved problem, as do sustaining positive outcomes associated with these interventions over time and enacting the kinds of national, state, and local policies that will address the underlying risk and protective factors that are so closely associated with youth violence, delinquency, and other potentially harmful behaviors.

Societal Burden of Youth Violence

The economic costs of violence can be difficult to measure. The cost of violence can be considered in terms of economic, emotional, and social costs, but no reliable estimates exist for expenditures associated with medical care, legal and social investigations, and interventions related either to nonfatal assaults or to homicide. Some estimates for medical care costs do exist. For example, medical treatment for fatal and non-fatal gunshot wounds is estimated to cost one billion dollars per year. The costs of other potential medical consequences of violence including the need for long-term institutional care, rehabilitation services, and support services to victims and their families, have not been estimated. The costs of forensic investigations, court proceedings, incarceration, or processes related to legal execution can also be considered among the economic costs of violence. One unique measure that can incorporate both financial and societal costs is Years of Potential Life Lost. . In 1994, more than 470,000 premature years of life were lost due to the homicide deaths of individuals younger than 25 years old (Dowd, 1998).

Even more difficult to measure than the economic costs of violence are the social and emotional costs. The social and emotional costs of violence include long-term physical and mental disabilities and adverse psychological and behavioral consequences for perpetrators, surviving victims, their families, entire communities, and society as a whole.


Given this growing yet fragmented knowledge base regarding a critically important public health problem, it is important to conduct a systematic review of the literature in an effort to bring the best available science to bear on future programs and policies. Summarized herein are the findings from a review of the evidence that was conducted on behalf of the National Institutes of Health's Office of Medical Applications and Research (OMAR) and the Agency for Healthcare Research and Quality's Evidence-based Practice Center.

PubReader format: click here to try


  • PubReader
  • Print View
  • Cite this Page

Recent Activity

Your browsing activity is empty.

Activity recording is turned off.

Turn recording back on

See more...