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Office of the Surgeon General (US); National Center for Injury Prevention and Control (US); National Institute of Mental Health (US); Center for Mental Health Services (US). Youth Violence: A Report of the Surgeon General. Rockville (MD): Office of the Surgeon General (US); 2001.

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Youth Violence: A Report of the Surgeon General.

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Chapter 1 -- Introduction

The decade between 1983 and 1993 was marked by an unprecedented surge of violence, often lethal violence, among young people in the United States. For millions of youths and their families, a period of life that should have been distinguished by good health and great promise was instead marred by injuries, disability, and death (Cook & Laub, 1998). This epidemic of violence not only left lasting scars on victims, perpetrators, and their families and friends, it also wounded communities and, in ways not yet fully understood, the country as a whole.

Since 1993, the peak year of the epidemic, there have been some encouraging signs 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. These official records reveal only a small part of the picture, however.

A fourth key indicator of violence -- confidential reports by youths themselves -- reveals that the proportion of young people who acknowledge having committed serious, potentially lethal acts of physical violence has remained level since the peak of the epidemic. In 1999, for instance, there were 104,000 arrests of persons under age 18 for robbery, forcible rape, aggravated assault, or homicide (Snyder, 2000); of those arrests, 1,400 were for homicides perpetrated by adolescents (Snyder, 2000) and, occasionally, even younger children (Snyder & Sickmund, 1999). Yet in any given year in the late 1990s, at least 10 times as many youths reported that they had engaged in some form of violent behavior that could have seriously injured or killed another person.

The high prevalence of violent behavior reported by adolescents underscores the importance of this report at this time.

Americans cannot afford to become complacent. Even though youth violence is less lethal today than it was in 1993, the percentage of adolescents involved in violent behavior remains alarmingly high. The epidemic of lethal violence that swept the United States was fueled in large part by easy access to weapons, notably firearms -- and youths' self-reports of violence indicate that the potential for a resurgence of lethal violence exists. Yet viewing homicide as a barometer of all youth violence can be quite misleading. Similarly, judging the success of violence prevention efforts solely on the basis of reductions in homicides can be unwise.

This report, the first Surgeon General's report on youth violence in the United States, summarizes an extensive body of research and seeks to clarify seemingly contradictory trends, such as the discrepancies noted above between official records of youth violence and young people's self-reports of violent behaviors. It describes research identifying and clarifying the factors that increase the risk, or statistical probability, that a young person will become violent, as well as studies that have begun to identify developmental pathways that may lead a young person into a violent lifestyle. The report also explores the less well developed research area of factors that seem to protect youths from viewing violence as an acceptable -- or inevitable -- way of approaching or responding to life events. Finally, the report reviews research on the effectiveness of specific strategies and programs designed to reduce and prevent youth violence.

As these topics suggest, the key to preventing a great deal of violence is understanding where and when it occurs, determining what causes it, and scientifically documenting which of many strategies for prevention and intervention are truly effective. This state-of-the-science report summarizes progress toward those goals.

The most important conclusion of the report is that the United States is well past the "nothing works" era with respect to reducing and preventing youth violence. Less than 10 years ago, many observers projected an inexorably rising tide of violence; the recent, marked reductions in arrests of young perpetrators and in victimization reports appear to belie those dire predictions. We possess the knowledge and tools needed to reduce or even prevent much of the most serious youth violence. Scientists from many disciplines, working in a variety of settings with public and private agencies, are generating needed information and putting it to use in designing, testing, and evaluating intervention programs.

The most urgent need now is a national resolve to confront the problem of youth violence systematically, using research-based approaches, and to correct damaging myths and stereotypes that interfere with the task at hand. This report is designed to help meet that need.

The report makes it clear that after years of effort and massive expenditures of public and private resources, the search for solutions to the problem of youth violence remains an enormous challenge (Lipton et al., 1975; Sechrest et al., 1979). Some traditional as well as seemingly innovative approaches to reducing and preventing youth violence have failed to deliver on their promise, and successful approaches are often eclipsed by random violent events such as the recent school shootings that have occurred in communities throughout the country.

Youth violence is a high-visibility, high-priority concern in every sector of U.S. society. We have come to understand that young people in every community are involved in violence, whether the community is a small town or central city, a neatly groomed suburb, or an isolated rural region. Although male adolescents, particularly those from minority groups, are disproportionately arrested for violent crimes, self-reports indicate that differences between minority and majority populations and between male and female adolescents may not be as large as arrest records indicate or conventional wisdom holds. Race/ethnicity, considered in isolation from other life circumstances, sheds little light on a given child's or adolescent's propensity for engaging in violence.

This chapter describes the scope and focus of the report and explains how the public health approach advances efforts to understand and prevent youth violence. Common myths about youth violence are presented and debunked. Uncorrected, these myths lead to misguided public policies, inefficient use of public and private resources, and loss of traction in efforts to address the problem. Documentation for the facts that counter these myths appears in later chapters. This chapter also lays out the scientific basis of the report -- that is, the standards of evidence that research studies had to meet in order to be included in the report and the sources of data cited throughout. Final sections of this chapter preview subsequent chapters and list the report's major conclusions.

Scope, Focus, and Overarching Themes

The mission of the Surgeon General is to protect and improve the public health of the Nation, and this report was developed within the responsibilities and spirit of that mission. The designation of youth violence as a public health concern is a recent development. As discussed below in greater detail, public health offers an approach to youth violence that focuses on prevention rather than consequences. It provides a framework for research and intervention that draws on the insights and strategies of diverse disciplines. Tapping into a rich but often fragmented knowledge base about risk factors, preventive interventions, and public education, the public health perspective calls for examining and reconciling what are frequently contradictory conclusions about youth violence.

Although the public health approach opens up a broad array of considerations, the focus of this initial report is the perpetration by juveniles of interpersonal physical assault that carries a significant risk of injury or death. As restrictive as it may at first appear, this focus draws on a wealth of research into individual, family, school, peer group, and community factors that are associated with serious violence in the second decade of life. This report defines serious violence as aggravated assault, robbery, rape, and homicide; hereafter, it refers simply to "violence" or "violent crime," thus avoiding repetitious use of the terms "serious violence" or "serious violent crime."

The report views violence from a developmental perspective. It examines the interactions of youths' personal characteristics and the social contexts in which they live -- as well as the timing of those interactions -- to understand why some young people become involved in violence and some do not. This perspective considers a range of risks over the life course, from prenatal factors to factors influencing whether patterns of violent behavior in adolescence will persist into adulthood. The developmental perspective has enabled scientists to identify two general onset trajectories of violence: one in which violent behaviors emerge before puberty, and one in which they appear after puberty. Of the two, the early-onset trajectory provides stronger evidence of a link between early childhood experiences and persistent, even lifelong involvement in violent behavior. The developmental perspective is important because it enables us to time interventions for the particular point or stage of life when they will have the greatest positive effect.

The young people on whom this report focuses are principally children and adolescents from about age 10 through high school. Research reviewed in Chapter 4 shows that although risk factors for violence vary by stage of development, most youth violence emerges during the second decade of life. Appropriate interventions before and -- as is increasingly well documented -- during this period have a good chance of redirecting violent young people toward healthy and constructive adult lives. The window of opportunity for effective interventions opens early and rarely, if ever, closes.

Secondary Areas of Concern

Many legitimate concerns and issues that are indisputably associated with violence by young people are not addressed in depth in this first report. Behavioral patterns marked by aggressiveness, antisocial behavior, verbal abuse, and externalizing (the acting out of feelings) are peripheral to the main focus of the report. These behaviors may include violent physical interactions, such as hitting, slapping, and fist-fighting, that can have significant consequences but generally present little likelihood of serious injury or death. Therefore, such behaviors will be discussed only to the extent that they can be considered risk factors for violence.

Research has shown that victims and offenders share many personal characteristics and that victimization and perpetration of violent behavior are often entwined. Nonetheless, this report does not focus on victims of violence perpetrated by young offenders. Rather, it blends offender-based research with traditional public health concepts of prevention and intervention in an effort to bridge the gap between criminology and the social and developmental sciences, on the one hand, and traditional public health approaches to youth violence, on the other.

The report does not address violence against intimate partners, except when such violence is committed by a young person. The plight of victims, many of whom are children and adolescents, is of the utmost importance, but a key element in helping victims of violence is understanding the perpetrators of violence. Particular categories of crime, such as dating violence and hate crimes (motivated by racist or homophobic attitudes, for example), are important manifestations of violence, including violence committed by youths, and they demand research and targeted interventions. The limited amount of research conducted in this area has focused on victims, so there is little scientific evidence about what distinguishes perpetrators of these specific types of crimes (see reviews by Bergman, 1992; Comstock, 1991; and D'Augelli & Dark, 1984).

Self-directed violence -- that is, self-inflicted injury and suicide -- is not covered either. In collaboration with other Federal health agencies, the Office of the Surgeon General developed a National Strategy for the Prevention of Suicide (U.S. Public Health Service, 1999). In directing national attention to suicide as a major, yet largely preventable public health problem, the Surgeon General is bringing together health professional organizations, educators, health care executives, and managed care clinical directors to discuss gaps in scientific knowledge that impede efforts to decrease the incidence of suicide among Americans of all ages. The vast majority of youth suicides occur in the context of mental disorders (Brent et al., 1988; Shaffer et al., 1996), a topic that was reviewed in depth in the Surgeon General's report on mental health (U.S. DHHS, 1999).

Finally, the report does not propose public policy to reduce or prevent youth violence. The purpose of this report, like others from U.S. Surgeons General, is to review and describe existing knowledge in order to provide a basis for action at all levels of society. The last chapter identifies potential courses of action, including specific areas in which research is needed, but suggesting whether and how such action will lend itself to policy development is beyond the purview of this report.

Youth Violence: the Public Health Approach

In October 1985, Surgeon General C. Everett Koop convened an unprecedented Workshop on Violence and Public Health (U.S. DHHS, 1986). The participants agreed strongly that it was time public health perspectives and expertise were brought to bear on questions of crime and violence. Throughout much of the last century, these questions had been dominated by the social sciences and the criminal justice system. For the most part, health care efforts were restricted to the rehabilitation of convicted offenders (Sechrest et al., 1979; U.S. DHHS, 1986). Dissatisfaction with both the timing and the outcomes of the "rehabilitation ideal" spurred the search for a more effective role for health care in addressing violence.

With its emphasis on prevention of disease or injury, the public health approach to violence offers an appealing alternative to an exclusive focus on rehabilitation. Primary prevention identifies behavioral, environmental, and biological risk factors associated with violence and takes steps to educate individuals and communities and protect them from these risks. Central to education and protection is the principle that health promotion is best learned, performed, and maintained when it is ingrained in individuals' and communities' daily routines and perceptions of what constitutes good health practices.

Public health practitioners and advocates have taken the lead in encouraging alliances and networks among academic disciplines, professions, organizations, and communities to make health concerns permanent public priorities and part of personal practices. In that tradition, participants at the 1985 Surgeon General's conference emphasized the importance of convincing the public that violence should be treated as a public health problem. As Marvin Wolfgang, a distinguished leader in the field of criminology, told conferees, "Our nation must feel as comfortable in controlling its violent behavioral urges and practices as it does in controlling bacterial, viral, and physical manifestations of morbidity and death" (U.S. DHHS, 1986).

Just as the application of public health principles and strategies has reduced the number of traffic fatalities and deaths attributed to tobacco use (CDC, 1999), the public health approach can help reduce the number of injuries and deaths caused by violence. Broader than the medical model, which is concerned with the diagnosis, treatment, and mechanisms of specific illnesses in individual patients, public health offers a practical, goal-oriented, and community-based approach to promoting and maintaining health. To identify problems and develop solutions for entire population groups, the public health approach:

  • Defines the problem, using surveillance processes designed to gather data that establish the nature of the problem and the trends in its incidence and prevalence;
  • Identifies potential causes through epidemiological analyses that identify risk and protective factors associated with the problem;
  • Designs, develops, and evaluates the effectiveness and generalizability of interventions; and
  • Disseminates successful models as part of a coordinated effort to educate and reach out to the public (Hamburg, 1998; Mercy et al., 1993).

The chapters in this report are keyed to each of these components of the public health approach. Chapter 2 presents research describing the magnitude of the problem of violent behavior by young people. Chapter 3 explores how violence develops and emerges over time. Chapter 4 summarizes research on risk and protective factors for youth violence; Appendix 4-B elaborates on the effects of exposure to media violence (including violence in interactive media) as a risk factor for aggressive and violent behavior. Chapter 5 focuses on the design, evaluation, and refinement of numerous programs and strategies that seek to reduce or prevent youth violence; Appendix 5-B provides details on specific programs discussed in the chapter. Chapter 6 suggests future courses of action, including the necessary next steps in research. A glossary of technical and discipline-specific terms follows.

Myths About Youth Violence

An important reason for making research findings widely available is to challenge false notions and misconceptions about youth violence. Myths such as those listed below are intrinsically dangerous. Assumptions that a problem does not exist or failure to recognize the true nature of a problem can obscure the need for informed policy or for interventions. An example is the conventional wisdom in many circles that the epidemic of youth violence so evident in the early 1990s is over. Alternatively, myths may trigger public fears and lead to inappropriate or misguided policies that result in inefficient use of scarce public resources. An example is the current policy of waiving or transferring young offenders into adult criminal courts and prisons.

Myth: The epidemic of violent behavior that marked the early 1990s is over, and young people -- as well as the rest of U.S. society -- are much safer today.

Fact: Although such key indicators of violence as arrest and victimization data clearly show significant reductions in violence since the peak of the epidemic in 1993, an equally important indicator warns against concluding that the problem is solved. Self-reports by youths reveal that involvement in some violent behaviors remains at 1993 levels (see Chapter 2).

Myth: Most future offenders can be identified in early childhood.

Fact: Exhibiting uncontrolled behavior or being diagnosed with conduct disorder as a young child does not predetermine violence in adolescence. A majority of young people who become violent during their adolescent years were not highly aggressive or "out of control" in early childhood, and the majority of children with mental and behavioral disorders do not become violent in adolescence (see Chapter 3).

Myth: Child abuse and neglect inevitably lead to violent behavior later in life.

Fact: Physical abuse and neglect are relatively weak predictors of violence, and sexual abuse does not predict violence. Most children who are abused or neglected will not become violent offenders during adolescence (see Chapter 4).

Myth: African American and Hispanic youths are more likely to become involved in violence than other racial or ethnic groups.

Fact: Data from confidential interviews with youths indicate that race and ethnicity have little bearing on the overall proportion of racial and ethnic groups that engage in nonfatal violent behavior. However, there are racial and ethnic differences in homicide rates. There are also differences in the timing and continuity of violence over the life course, which account in part for the overrepresentation of these groups in U.S. jails and prisons (see Chapter 2).

Myth: A new violent breed of young superpredators threatens the United States.

Fact: There is no evidence that young people involved in violence during the peak years of the early 1990s were more frequent or more vicious offenders than youths in earlier years. The increased lethality resulted from gun use, which has since decreased dramatically. There is no scientific evidence to document the claim of increased seriousness or callousness (see Chapter 3).

Myth: Getting tough with juvenile offenders by trying them in adult criminal courts reduces the likelihood that they will commit more crimes.

Fact: Youths transferred to adult criminal court have significantly higher rates of reoffending and a greater likelihood of committing subsequent felonies than youths who remain in the juvenile justice system. They are also more likely to be victimized, physically and sexually (see Chapter 5).

Myth: Nothing works with respect to treating or preventing violent behavior.

Fact: A number of prevention and intervention programs that meet very high scientific standards of effectiveness have been identified (see Chapter 5).

Myth: In the 1990s, school violence affected mostly white students or students who attended suburban or rural schools.

Fact: African American and Hispanic males attending large inner-city schools that serve very poor neighborhoods faced -- and still face -- the greatest risk of becoming victims or perpetrators of a violent act at school. This is true despite recent shootings in suburban, middle-class, predominantly white schools (see Chapter 2).

Myth: Weapons-related injuries in schools have increased dramatically in the last 5 years.

Fact: Weapons-related injuries have not changed significantly in the past 20 years. Compared to neighborhoods and homes, schools are relatively safe places for young people (see Chapter 2).

Myth: Most violent youths will end up being arrested for a violent crime.

Fact: Most youths involved in violent behavior will never be arrested for a violent crime (see Chapter 2).

Sources of Data and Standards of Evidence

Data Sources

Several comprehensive scholarly reviews of various facets of youth violence were published in the 1990s. Professional organizations, Federal agencies, the National Academy of Sciences, and university-based researchers have invested immense energy in reviewing research on the occurrence and patterns of youth violence, its causes and consequences, intervention strategies, and implications for society.

Key contributions to this rich information base include:

  • NIMH Taking Stock of Risk Factors for Child/Youth Externalizing Behavior Problems (Hann & Borek, in press)
  • Serious and Violent Juvenile Offenders (Loeber & Farrington, 1998). A report of the Office of Juvenile Justice and Delinquency Prevention (OJJDP) Workgroup on Violence and Serious Offending
  • The National Academy of Sciences' four-volume report Understanding and Preventing Violence (Reiss & Roth, 1993)
  • The American Psychological Association's report Violence and Youth (APA, 1993) and Reason to Hope (Eron et al., 1994)
  • Preventing Crime: What Works, What Doesn't, What's Promising. A Report to the United States Congress (Sherman et al., 1997)
  • The OJJDP national report Juvenile Offenders and Victims (Snyder & Sickmund, 1999)
  • The American Sociological Association's Social Causes of Violence: Crafting a Science Agenda (Levine & Rosich, 1996)

This report draws extensively -- but not exclusively -- on concepts, general information, and data contained in these documents. The authors gratefully acknowledge the contributors to and publishers of these earlier studies. Whenever the report draws heavily on one of these master sources, that fact is noted. Specific references to these documents are provided where appropriate.

Contributors to and editors of this report have also consulted peer-reviewed journals, books, and government reports and statistical compilations. Some information not considered in prior reviews is contained in this report. When appropriate, the editors have drawn on dissertations and forthcoming work that they judged to be of high quality.

During the development of this report, special data analyses were obtained from established surveys of U.S. adolescents. The key data sources for these analyses are the following:

  • Monitoring the Future survey conducted annually by the University of Michigan's Institute for Social Research (Johnston et al., 1995)
  • Youth Risk Behavior Surveillance Study sponsored by the Centers for Disease Control and Prevention in collaboration with Federal, state, and local partners (Brener et al., 1999)
  • The National Center for Injury Prevention and Control's Firearm Injury Surveillance Study (CDC, NCIPC, 2000)
  • Several longitudinal databases generated by the Program of Research on the Causes and Correlates of Delinquency, Office of Juvenile Justice and Delinquency Prevention, U.S. Department of Justice (Huizinga et al., 1995)
  • The National Center for Juvenile Justice's up-to-date information on juvenile arrests for violent crimes (Snyder, 2000)
  • The National Crime Victimization Survey (Rand et al., 1998)

Standards of Scientific Evidence for Multidisciplinary Research

The public health approach relies on a multidisciplinary, multijurisdictional knowledge base. Thus, in preparing this report, it was necessary to draw conclusions from research in psychology (social, developmental, clinical, and experimental), sociology, criminology, neuroscience, public health, epidemiology, communications, and education. Integrating findings and conclusions across disciplinary lines is never easy. The questions under study generally determine what approach scientists will take to designing and conducting research, and the approach often determines how investigators report their findings and conclusions. Even when scientific approaches are similar, investigators in different disciplines frequently employ different terminology to describe similar concepts.

In striving to apply scientific standards consistently across the many fields of research reviewed, this report has emphasized two criteria: appropriately rigorous methods of inquiry and sufficient data to support major conclusions. The need for rigor is obvious: The tools or strategies employed in research -- like the conclusions reached -- are only as good as the precision with which research questions are framed. But the quality of a given study depends on other factors as well, including:

  • General data collection design. Data may be obtained through four major types of study design: experimental, longitudinal, cross-sectional, and case study. This report relies primarily on experimental and longitudinal designs, with some use of cross-sectional studies. (These three methods are described below.)
  • Sampling, or the selection of persons to be studied. Individuals in a study may be recruited or identified through probability or nonprobability sampling, or they may be assigned to experimental or control groups by a random process, a precision or group-matching process, or some other means. This report refers to probability samples as representative samples.
  • Validity and reliability of measures or instruments used in the research.
  • Appropriateness and level of control incorporated into the analysis of findings. Level of control refers to efforts to take into account other factors that might be influencing data or responses from subjects.
  • Appropriateness and significance of generalizations.

As noted earlier, four of the chapters in this report -- those concerned with magnitude, demographics, risk and protective factors, and intervention research and evaluation -- mirror components of the public health approach to youth violence. Each of these areas involves research from different disciplines and scientific approaches; therefore, the types of research designs and forms of analysis presented differ somewhat from chapter to chapter.

Experimental research is the preferred method for assessing cause and effect as well as for determining how effectively an intervention works. Many of the violence prevention programs reviewed in Chapter 5 meet the standard of rigorous experimental (or well-executed quasi-experimental) designs. In an experimental study, researchers randomly assign an intervention to one group of study participants, the experimental group, and provide standard care or no intervention to another group, the control group. A study with a randomly assigned control group enables researchers to conclude that observed changes in the experimental group would not have happened without the intervention and did not occur by chance. The difference in outcome between the experimental and control groups, which in this case may be the reduction or elimination of violent behaviors, can then be attributed to the intervention.

Ideally, researchers assign study participants to the experimental intervention or the control group at random. Randomization eliminates bias in the assignment process and provides a way of determining the likelihood that the effects observed occurred by chance. In this report, most weight is given to true experimental studies. In some cases, true experiments may be too difficult or expensive to conduct, or they may pose unacceptable ethical problems. In such cases, carefully designed and executed quasi-experimental studies are accepted as meeting the standard.

Evidence from an experimental study is considered stronger when, in addition to analyzing the main effects of an intervention, researchers analyze the mediating effects. This analysis permits researchers to determine whether a change in the targeted risk or protective factor accounts for the observed change in violence -- that is, did the intervention work because it changed the degree of risk? Without this information, researchers cannot explain the success of a program.

Chapters 4 and 5 make use of meta-analyses. Meta-analysis describes a statistical method for evaluating the conclusions of numerous studies to determine the average size and consistency of the effect of a particular treatment or intervention strategy common to all of the studies. The technique makes the results of different studies comparable so that an overall effect can be identified. A meta-analysis determines whether there is consistent evidence that a treatment has a statistically significant effect, and it estimates the average size of that effect.

Epidemiological research, reviewed in Chapters 2 and 3, focuses primarily on general population studies that use probability samples and cross-sectional or longitudinal designs (Kleinbaum et al., 1982; Lilienfeld & Lilienfeld, 1980; Rothman & Greenland, 1998). Probability samples let researchers generalize from their study to the entire population sampled. Cross-sectional studies involve a single contact with participants for data collection at a given point in time. Multiple cross-sectional studies involve several waves of data collection over time (annually, for example) but typically with different participants at each contact and therefore with no way to link a given person's responses at one time with those at a later time. Prospective longitudinal and panel designs involve multiple contacts with the same study participants over time. Responses at one data collection point can be linked to responses at a later point. Longitudinal studies are used for research on individual development or growth.

Longitudinal designs are necessary to estimate the predictive effect of a given risk or protective factor on later violent behavior. Although cross-sectional designs are sometimes used, they cannot provide estimates of individual-level predictive effects. They can establish simultaneous relationships between risk factors and violence, but conclusions drawn from cross-sectional studies are not as strong as those drawn from longitudinal studies. In cross-sectional studies, cause and effect are unclear and reciprocal effects may inflate the estimates.

Experimental studies are sometimes used to estimate the effects of risk and protective factors, but this practice is rare because of ethical and cost considerations. For example, it would be unthinkable to introduce drug use to a group of adolescents to see whether drugs are a risk factor for violence. However, it would be ethical to conduct a predictive study that selects persons who are not violent and follows them over time. Those who began to use illicit substances would be compared with those who did not, to determine whether drug users are more likely to become involved in violent behaviors at some later date. If they were, then the results would indicate that drug use predicts violence or that drug use increases the probability of future violence.

Level of Evidence

No single study, however well designed, is sufficient to establish causation or, in intervention research, efficacy or effectiveness. Findings must be replicated before gaining widespread acceptance by the scientific community. The strength of the evidence amassed for any scientific fact or conclusion is referred to as the level of evidence.

This report does not rely on any single study for conclusions. Only findings that have been replicated in several studies, consistently and with no contrary results, are reported as part of the contemporary knowledge base. When the report cites unreplicated studies that are of high quality, that have not been refuted by other evidence, and that point in a clear direction, the findings are described as tentative or suggestive. These findings may point to future research needs and directions, but the report takes a conservative approach to drawing conclusions from them.

Overview of the Report's Chapters

The Surgeon General's report on youth violence reviews a vast, multidisciplinary, and often controversial research literature. Chapters 2 through 5 address, respectively, the extent and magnitude of youth violence; the developmental characteristics of, or paths to, youth violence; personal and environmental factors that may either place a child or adolescent at risk of violent behavior or protect a young person from succumbing to those risk factors; and violence intervention and prevention programs. The final chapter in the report identifies areas of opportunity for future efforts to combat and prevent youth violence.

This section provides a brief overview of each chapter, while the following section presents a summary of key conclusions drawn from each.

Chapter 2 examines the magnitude of and trends in youth violence over the last two decades. It describes two different, but complementary ways of measuring violence -- official reports and self-reports. Official arrest data offer an obvious means of determining the extent of youth violence. Indeed, a surge in arrests for violent crimes marked what is now recognized as an epidemic of youth violence from 1983 to 1993. Arrests were driven largely by the rapid proliferation of firearms use by adolescents engaging in violent acts and the likelihood that violent confrontations would -- as they did -- produce serious or lethal injuries. Today, with fewer young people carrying weapons, including guns, to school and elsewhere than in the early 1990s, violent encounters are less likely to result in homicide and serious injury and therefore are less likely to draw the attention of police. By 1999, arrest rates for homicide, rape, and robbery had all dropped below 1983 rates. In contrast, arrest rates for aggravated assault remained higher than they were in 1983, having declined only 24 percent from the peak rates in 1994.

Another way of measuring violence is on the basis of confidential reporting by youths themselves. Confidential surveys find that 10 to 15 percent of high school seniors report having committed an act of serious violence in recent years. These acts typically do not come to the attention of police, in part because they are less likely to involve firearms than in previous years. Over the past two decades, self-reported violence by high school seniors increased nearly 50 percent, a trend similar to that found in arrests for violent crimes. But this proportion has not declined in the years since 1993 -- it remains at peak levels. Chapter 2 considers how and to what extent arrest data and self-report data vary, including variations by sex and race or ethnicity. In the aggregate, the best available evidence from multiple sources indicates that youth violence is an ongoing national problem, albeit one that is largely hidden from public view.

Chapter 3 examines routes that may lead a young person into violence. Viewed from a developmental perspective, violence stems from a complex interaction of individuals with their environment at particular times in their lives. Longitudinal research has enabled investigators to describe the emergence of violence in terms of two, and possibly more, life-course trajectories. Chapter 3 discusses the early-onset and late-onset emergence of violence, which occur before and after puberty, respectively. These trajectories offer insights into the likely course, severity, and duration of violence over the life course and have practical implications for the timing of intervention programs and strategies. The chapter reviews research on the co-occurrence of serious violence and other problems, including drug use and mental disorders. Finally, it underscores the importance -- and the paucity -- of research on factors associated with the cessation of youth violence or its continuation into adulthood.

Extensive research in recent decades has sought to identify various personal characteristics and environmental conditions that either place children and adolescents at risk of violent behavior or that seem to protect them from the effects of risk. Risk and protective factors, which are the focus of Chapter 4, can be found in every area of life. They exert different effects at different stages of development, they tend to appear in clusters, and they appear to gain strength in numbers. As the chapter notes, risk probabilities apply to groups, not to individuals. Although risk factors are not necessarily causes, a central aim of the public health approach to youth violence is to identify these predictors and determine when in the life course they typically come into play. Such information enables researchers to design preventive programs that can be put in place at just the right time to be most effective.

The chapter examines risk from the perspectives of both childhood and adolescence and, within each of these developmental periods, considers risk factors occurring in the individual, family, school, peer group, and community domains. Childhood risk factors for violence in adolescence include involvement in serious (but not necessarily violent) criminal acts and substance use before puberty, being male, aggressiveness, low family socioeconomic status/poverty, and antisocial parents -- all either individual or family risk factors. The influence of family is largely supplanted in adolescence by peer influences, thus risk factors with the largest predictive effects in adolescence include weak social ties, ties to antisocial or delinquent peers, and belonging to a gang. Having committed serious (but not necessarily violent) criminal offenses is also an important risk factor in adolescence.

Identifying and understanding how protective factors influence behavior is potentially as important to preventing and stopping violence as identifying and understanding risk factors. Several protective factors have been proposed, but to date only two have been found to buffer the risk of violence -- an intolerant attitude toward deviance and commitment to school. Protective factors warrant, and are beginning to receive, more research attention.

Despite past contentions that "nothing works" to prevent youth violence, the evidence presented in Chapter 5 demonstrates that prevention efforts can be effective against both early- and late-onset violence in the general youth population, high-risk youths, and even youths who are already violent or seriously delinquent. The chapter highlights 27 specific programs that, based on existing data, help prevent youth violence. The most effective of these programs combine components known to prevent violence by themselves, particularly social skills training for youths and interventions that include parents or entire families.

Chapter 5 also highlights important limitations in the current research on youth violence prevention. Little is known about the scientific effectiveness of hundreds of programs now being used in U.S. schools and communities. This situation is disconcerting, given that many well-intentioned youth violence prevention programs have been found ineffective or harmful to youths. Even less is known about how to implement effective programs on a national scale without compromising their results.

The information presented in Chapter 5 shows that youth violence prevention not only works, it can also be cost-effective. In a number of cases, the long-term financial benefits of prevention are substantially greater than the costs of the programs themselves. These promising findings indicate that prevention plays an important role in providing a safe environment for youths.

Finally, Chapter 6 presents several options for future action. First, the scientific base must continue to be expanded. Effective interventions exist, but only continued research can document those programs that meet a standard of effectiveness and those that do not -- and should therefore be discarded. The chapter identifies the following courses of action:

  • Continue to build the science base
  • Accelerate the decline in gun use by youths in violent encounters
  • Facilitate the entry of youths into effective intervention programs rather than incarcerating them
  • Disseminate model programs with incentives that will ensure fidelity to original program design when taken to scale
  • Provide training and certification programs for intervention personnel
  • Improve public awareness of effective interventions
  • Convene youths and families, researchers, and private and public organizations for a periodic youth violence summit
  • Improve Federal, state, and local strategies for reporting crime information and violent deaths

Chapter Conclusions

Chapter 2


The decade between 1983 and 1993 was marked by an epidemic of increasingly lethal violence that was associated with a large rise in the use of firearms and involved primarily African American males. There was a modest rise in the proportion of young persons involved in other forms of serious violence.


Since 1994, a decline in homicide arrests has reflected primarily the decline in use of firearms. There is some evidence that the smaller decline in nonfatal serious violence is also attributable to declining firearm use.


By 1999, arrest rates for violent crimes -- with the exception of aggravated assault -- had fallen below 1983 levels. Arrest rates for aggravated assault remain almost 70 percent higher than they were in 1983, and this is the offense most frequently captured in self-reports of violence.


Despite the present decline in gun use and in lethal violence, the self-reported proportion of young people involved in nonfatal violence has not declined from the peak years of the epidemic, nor has the proportion of students injured with a weapon at school declined.


The proportion of schools in which gangs are present continued to increase after 1994 and has only recently (1999) declined. However, evidence shows that the number of youths involved with gangs has not declined and remains near the peak levels of 1996.


Although arrest statistics cannot readily track firearm use in specific serious crimes other than homicide, firearm use in violent crimes declined among persons of all ages between 1993 and 1998.


The steep rise and fall in arrest rates for homicide over the past two decades have been matched by similar, but less dramatic changes in some of the other indicators of violence, including arrest rates for all violent crimes and incident rates from victims' self-reports. This pattern is not matched by arrests for selected offenses, such as aggravated assault, or incident rates and prevalence rates from offenders' self-reports.


Young men -- particularly those from minority groups -- are disproportionately arrested for violent crimes. But self-reports indicate that differences between minority and majority populations and between young men and young women may not be as large as arrest records indicate or conventional wisdom holds. Race/ethnicity, considered in isolation from other life circumstances, sheds little light on a given child's or adolescent's propensity for engaging in violence.


Schools nationwide are relatively safe. Compared to homes and neighborhoods, schools have fewer homicides and nonfatal injuries. Youths at greatest risk of being killed in school-associated violence are those from a racial or ethnic minority, senior high schools, and urban school districts.

Chapter 3


There are two general onset trajectories for youth violence -- an early one, in which violence begins before puberty, and a late one, in which violence begins in adolescence. Youths who become violent before about age 13 generally commit more crimes, and more serious crimes, for a longer time. These young people exhibit a pattern of escalating violence through childhood, and they sometimes continue their violence into adulthood.


Most youth violence begins in adolescence and ends with the transition into adulthood.


Most highly aggressive children or children with behavioral disorders do not become serious violent offenders.


Surveys consistently find that about 30 to 40 percent of male youths and 15 to 30 percent of female youths report having committed a serious violent offense by age 17.


Serious violence is part of a lifestyle that includes drugs, guns, precocious sex, and other risky behaviors. Youths involved in serious violence often commit many other types of crimes and exhibit other problem behaviors, presenting a serious challenge to intervention efforts. Successful interventions must confront not only the violent behavior of these young people, but also their lifestyles, which are teeming with risk.


The differences in patterns of serious violence by age of onset and the relatively constant rates of individual offending have important implications for prevention and intervention programs. Early childhood programs that target at-risk children and families are critical for preventing the onset of a chronic violent career, but programs must also be developed to combat late-onset violence.


The importance of late-onset violence prevention is not widely recognized or well understood. Substantial numbers of serious violent offenders emerge without warning signs in their childhood. A comprehensive community prevention strategy must address both onset patterns and ferret out their causes and risk factors.

Chapter 4

  1. Risk and protective factors exist in every area of life -- individual, family, school, peer group, and community. Individual characteristics interact in complex ways with people and conditions in the environment to produce violent behavior.
  2. Risk and protective factors vary in predictive power depending on when in the course of development they occur. As children move from infancy to early adulthood, some risk factors will become more important and others less important. Substance use, for example, is a much stronger risk factor at age 9 than it is at age 14.
  3. The strongest risk factors during childhood are involvement in serious, but not necessarily violent criminal behavior, substance use, being male, physical aggression, low family socioeconomic status or poverty and antisocial parents -- all individual or family characteristics or conditions.
  4. During adolescence, the influence of family is largely supplanted by peer influences. The strongest risk factors are weak ties to conventional peers, ties to antisocial or delinquent peers, belonging to a gang, and involvement in other criminal acts.
  5. Risk factors do not operate in isolation -- the more risk factors a child or young person is exposed to, the greater the likelihood that he or she will become violent. Risk factors can be buffered by protective factors, however. An adolescent with an intolerant attitude toward deviance, for example, is unlikely to seek or be sought out by delinquent peers, a strong risk factor for violence at that age.
  6. Given the strong evidence that risk factors predict the likelihood of future violence, they are useful for identifying vulnerable populations that may benefit from intervention efforts. Risk markers such as race or ethnicity are frequently confused with risk factors; risk markers have no causal relation to violence.
  7. No single risk factor or combination of factors can predict violence with unerring accuracy. Most young people exposed to a single risk factor will not become involved in violent behavior; similarly, many young people exposed to multiple risks will not become violent. By the same token, protective factors cannot guarantee that a child exposed to risk will not become violent.

Chapter 5

  1. A number of youth violence intervention and prevention programs have demonstrated that they are effective; assertions that "nothing works" are false.
  2. Most highly effective programs combine components that address both individual risks and environmental conditions, particularly building individual skills and competencies, parent effectiveness training, improving the social climate of the school, and changes in type and level of involvement in peer groups.
  3. Rigorous evaluation of programs is critical. While hundreds of prevention programs are being used in schools and communities throughout the country, little is known about the effects of most of them.
  4. At the time this report was prepared, nearly half of the most thoroughly evaluated strategies for preventing violence had been shown to be ineffective -- and a few were known to harm participants.
  5. In schools, interventions that target change in the social context appear to be more effective, on average, than those that attempt to change individual attitudes, skills, and risk behaviors.
  6. Involvement with delinquent peers and gang membership are two of the most powerful predictors of violence, yet few effective interventions have been developed to address these problems.
  7. Program effectiveness depends as much on the quality of implementation as the type of intervention. Many programs are ineffective not because their strategy is misguided, but because the quality of implementation is poor.

Preparation of the Report

To address the troubling presence of violence in the lives of U.S. youths, the Administration and Congress urged the Surgeon General to develop a report on youth violence, with particular focus on the scope of the problem, its causes, and how to prevent it. Surgeon General Dr. David Satcher requested three agencies, all components of the Department of Health and Human Services, to share lead responsibility for preparing the report. The agencies are the Centers for Disease Control and Prevention (CDC), the National Institutes of Health (NIH), and the Substance Abuse and Mental Health Services Administration (SAMHSA).

Under Dr. Satcher's guidance, these agencies established a Planning Board comprising individuals with expertise in diverse disciplines and professions involved in the study, treatment, and prevention of youth violence. The Planning Board also enlisted individuals representing various Federal departments, including particularly the Department of Justice (juvenile crime aspects of youth violence), the Department of Education (school safety issues), and the Department of Labor (the association between youth violence and youth employment, and out-of-school youth). Invaluable assistance was obtained as well from individual citizens who have founded and operate nonprofit organizations designed to meet the needs of troubled and violent youths. Most important, young people themselves accepted invitations to become involved in the effort. All of these persons helped to plan the report and participated in its prepublication reviews.


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