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

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

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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