U.S. Surgeon General David Satcher is expected to release a major report by the end of the year on strategies for treating violence as a disease--an approach he has long advocated. The report should reinforce the work of researchers across the country who, for the past decade, have been trying to understand youth violence as an epidemic--as a "contagion" that flourishes among susceptible individuals under specific conditions.
 AP/WIDE WORLD PHOTOS/ROBERT MECEA Allegra Alcoff, 7, and Gus Geter, 10, lead a First Monday march over New York's Brooklyn Bridge on Monday, Oct. 2., the start of a two-year anti-gun violence campaign scheduled for 50 U.S. cities. The campaign is named after the first Monday in October, when the Supreme Court begins its term. |
The massacre at Columbine High School in Colorado last year focused the national agenda on preventing youth violence, even as overall crime rates continued to decline from their peaks in the early 1990s. The most recent indications suggest that crime rates may have bottomed out in major U.S. cities, though, and some observers worry that crime will again rise along with the growing youth population. During the most recent U.S. murder spree, between 1985 and 1991, homicide rates actually fell among people over 25 but more than doubled among those under 18.
Researchers from RAND and the University of California, Los Angeles, have begun to explore the implications of viewing youth violence through the magnifying glass of public health. Phyllis Ellickson, a behavioral scientist, tracked 4,500 adolescents in California and Oregon from seventh grade through high school. She identified some likely risk factors and early warning signs of youth violence. Some of these were strongly correlated with violence among all youth. Others were uniquely correlated with violence among only boys or only girls.
Mark Schuster, a pediatrician, led a study estimating the prevalence nationwide of another possible trigger of youth violence: unlocked firearms in homes with children. Schuster believes that the public health and medical communities can reduce the easy access that many children have to firearms.
Other UCLA and RAND researchers have detected a puzzling resistance by many clinicians to follow existing clinical guidelines to counsel their patients on firearm safety. This resistance occurs at the same time that researchers are discovering new opportunities for clinicians to prevent youth violence.
Ellickson and other researchers sifted through 22 potential risk factors for violence among the California and Oregon youth. The researchers concluded that violence committed by older adolescents--either high school seniors or high school dropouts--had been correlated with several demographic, environmental, and behavioral risk factors plus some types of family trauma (see upper part of table). The researchers also found that the risk factors were cumulative: As the number of risk factors increased, so did the likelihood of violent behavior. Conversely, there appeared to be no single source of youth violence. "The sheer quantity of risk factors, rather than any specific combination, predisposes adolescents to violence," say the researchers.
The most potent demographic risk factor was not really controllable at all: being male. The odds of committing "relational" violence, or persistent hitting of family members or acquaintances, were 1.6 times higher for teenage boys than for teenage girls. Similarly, the odds of committing "predatory" violence--which includes fighting in gangs, using strong-arm methods to get money or things from people, carrying a hidden weapon other than a pocket knife, or attacking someone with the intent to hurt or kill--were 3.5 times higher for boys than girls. (Because the risk factor of being male cannot apply to girls, it does not appear in the table, which compares youth with peers of the same gender.)
The only other notable demographic risk factor was the absence of one or both biological parents from the home. This factor proved significant only for girls. As shown in the table, the odds of committing relational violence were 1.4 times higher for girls who did not live with both biological parents than for other girls. Other demographic variables--family income, parental education, and multiple moves during high school--fell out of contention in the researchers' mathematical model.
Behavioral risk factors were the strongest and most consistent. Three types of behavior were highly correlated with all forms of violence for boys and girls alike: (1) selling drugs, (2) committing nonviolent felonies (such as auto theft, arson, or breaking into a home or school), and (3) committing acts of nonviolent minor delinquency (such as minor theft, public disorder, begging, obscene phone calls, joyriding, shoplifting, truancy, and running away from home overnight). These three types of behavior were also the most significant risk factors for violence among boys.
Differences between boys and girls were most prominent regarding environmental risk factors and negative family events. Both genders appeared susceptible to violence given a "low academic orientation," as measured by poor grades and negative attitudes toward school. Both genders also appeared susceptible to violence given a lack of parental affection or support. But girls were especially vulnerable to parental inattention and uniquely vulnerable to parental drug use, parental job loss, parental death, parental separation or divorce, and peer drug use.
Teenage boys and girls who did become violent also tended to exhibit different related problems. Comparatively more violent girls than violent boys suffered from poor mental health, became a parent, or dropped out of school. All of these problems were likely to further damage the girls' personal relationships and life chances. In contrast, comparatively more violent boys than violent girls sold drugs and committed felonies, behaviors that were likely to damage the larger society in addition to putting the boys at risk of arrest. In these ways, violent girls tended to be more likely to hurt themselves, whereas violent boys tended to be more likely to hurt others.
The sometimes overlapping yet sometimes distinctive risk factors for teenage boys and girls complicate efforts to prevent youth violence. On the one hand, the strong links between drug involvement, other forms of delinquency, and youth violence argue for programs that take into account the clustering of these behaviors among all youth. But addressing many different problems all at once often tends to have little effect, researchers warn. In particular, programs such as group homes that gather problem adolescents together often merely strengthen the deviant behaviors that adolescents learn from one another. One promising alternative to such group homes is "therapeutic foster care," a form of closely supervised foster parenting with round-the-clock professional backup. The Oregon Social Learning Center has found this approach to be effective.
On the other hand, teenage girls with a unique vulnerability to family disruption present unique needs. "Programs for violent girls alone would have somewhat different emphases than programs aimed solely at violent boys," explains Ellickson. A violence-prone teenage girl may benefit from general efforts to curb deviant behavior as well as from specific efforts to strengthen bonds with her own family and school. "But changing these institutions is a particularly difficult task requiring sustained efforts over time," Ellickson says. Even more worrisome for girls, "the association between violence, early parenthood, and poor mental health raises serious concerns about the nature of the parenting and the environment such girls are likely to give their children."
Daunted by the difficulties of preventing or stopping violence among teenagers already at risk, researchers have begun to suggest strategies to keep adolescents from experiencing too many risk factors in the first place. These strategies target the early warning signs of potential violence in an attempt to nip them in the bud before they metastasize out of control, comparable to targeting the earliest signs of cancer.
Among the California and Oregon teens in her study, Ellickson detected warning signs in seventh grade that predicted violent behavior five years later. As with the risk factors measured during high school, the predictors apparent as early as seventh grade applied sometimes to all youth but other times only to boys or girls (see lower part of table).
Two early predictors of violence applied to boys and girls alike: deviant behavior and poor grades. Deviant behavior in the seventh grade consisted of stealing, skipping school, cheating on tests, or being sent out of class. Seventh graders involved in these activities were significantly more likely to become violent five years later than those not involved in these activities. Poor grades in middle school also foretold violent times ahead for both genders.
Two early predictors applied to seventh-grade boys only: drug offers and high mobility during elementary school. Boys were uniquely vulnerable to repeated offers of drugs from their seventh-grade peers and to repeated moves that had involved shifting from one elementary school to another. Both conditions predicted future relational violence for boys but not girls.
Seventh-grade girls, on the other hand, were uniquely susceptible to low self-esteem and to living in neighborhoods of low socioeconomic status. Girls who exhibited low self-esteem in seventh grade were more likely to engage in relational violence five years later. Girls who attended schools in poor neighborhoods were more likely to commit both relational and predatory violence later on. Neither predictor applied to seventh-grade boys.
 AP/WIDE WORLD PHOTOS/THE ENTERPRISE JOURNAL/AARON RHOADS Local residents Jeremy Roberts, left, and Ben Legg look over four of the crosses put on display at East McComb Baptist Church in McComb, Miss., in September. The crosses, erected in Littleton, Colo., in memory of the victims of the Columbine High School shooting spree, came to McComb as part of a tour to discourage youth drug use and violence. |
Ellickson found one additional early predictor of violence: attending a middle school with high levels of cigarette and marijuana use. Such middle schools appeared to foster overall violence among boys and girls alike but did not predict the specific forms of relational and predatory violence. (Therefore, this predictor does not appear in the table.) Other variables not studied by RAND were family violence and low parental supervision, both of which have been linked with later violence among children.
Little in the RAND study argued for differential violence prevention efforts by race, ethnicity, or social class. Most of the relationships between violence and these demographic categories disappeared when behavioral and environmental factors were taken into account. The differences between boys and girls, however, were highly significant as early as the seventh grade. "Violence prevention efforts should be sensitive to the special needs of both sexes," concluded Ellickson, "particularly the higher-risk profiles of girls with low self-esteem and of boys who have experienced substantial discontinuity in their early school environment."
For boys, the additional link between early exposure to drug offers and subsequent violence suggests the need for extra training to help boys resist social pressures to use drugs. For boys alone, the greater the frequency of drug offers in middle school, the greater the likelihood of committing relational violence down the road. Therefore, programs to prevent drug use in middle school might yield the added benefit of reduced violence among males several years later. Furthermore, because middle schools with high rates of actual drug use also appear to foster later violence among boys and girls alike, reducing overall levels of drug use in these middle schools could also reduce overall levels of violence several years later.
Of course, violence prevention efforts should also target the two strongest and most common early warning signs of violence among seventh graders: early deviance and poor grades. Because troublesome behavior and poor grades appear at least as early as the sixth grade and probably even earlier, some prevention efforts need to begin in elementary school.
Although debate over gun control has intensified in the wake of school shootings nationwide, there has been a fair amount of consensus that firearms should be in-accessible to children. The American Academy of Pediatrics (AAP) and the National Association of Pediatric Nurse Associates and Practitioners (NAPNAP) recommend that parents remove firearms from homes with children. If the firearms are not removed from these homes, then the AAP recommends, at the very least, that parents store the firearms locked, unloaded, and separate from locked ammunition. The Sporting Arms and Ammunition Manufacturers' Institute also recommends storing firearms and ammunition secured in a safe place, separate from each other. And the National Rifle Association recommends storing firearms unloaded and inaccessible to children.
Unfortunately, practice does not square with principle. There are 11 million homes in the United States with children and firearms. These homes account for a third of the country's children--or more than 22 million children. However, just 39 percent of these homes store their firearms locked, unloaded, and separate from ammunition, according to Mark Schuster, of RAND and UCLA.
In contrast, 9 percent of all homes with children and firearms keep firearms unlocked (either in an unlocked place or with no trigger lock or other locking mechanism) and loaded, while another 4 percent keep firearms unlocked and unloaded but stored with ammunition. Thus, a total of 13 percent of homes with children and firearms--accounting for 1.4 million homes with 2.6 million children--store firearms in a manner that makes them most accessible to children (see pie chart).
Although it is ultimately the responsibility of parents and other adults to ensure proper storage and usage of firearms among children, Schuster believes that physicians can help adults reduce the dangers. The American Medical Association (AMA) advises physicians to ask if patients or their families own a gun, to educate them about the dangers of guns in the home, and to inform them how to store guns safely. The AAP offers physicians a self-training program that goes into greater detail: Physicians can obtain a history of family exposure to violence, teach parents and children about nonviolent problem-solving techniques, review firearm risks and safety, and reinforce ongoing efforts to reduce violence.
Many clinicians fail to provide firearm safety counseling, even when they know they should. That is the troubling conclusion of a RAND and UCLA research team led by Shari Barkin, a pediatrician from the UCLA School of Public Health.
The team surveyed 465 pediatricians, family physicians, and pediatric nurse practitioners serving families with children aged five years and younger in Los Angeles County. Of the 325 clinicians who responded, 70 percent said counseling on firearm safety would be beneficial. However, only 38 percent said they provided such counseling. Of those who did, only 20 percent counseled more than 10 percent of their clientele.
Many clinicians said they would be more likely to provide counseling if more educational materials were available to them. But materials have already been made available; in 1994, for example, the AAP sent materials to all its members. Likewise, about a quarter of the clinicians said an endorsement of firearm safety counseling from major medical organizations would increase the likelihood of their providing counseling. But the AMA, AAP, NAPNAP, and the American Association of Family Physicians already provide endorsements. Still, few clinicians offer counseling.
Worse yet, some who do offer counseling contradict the clinical guidelines. As noted above, the AAP and NAPNAP prefer that firearms be removed from homes with children. The AAP also recommends that if a household does not already have a gun, clinicians should discourage families from purchasing one. Once again, however, practice does not square with principle. In the survey, 22 percent of the clinicians reported owning a firearm themselves. Of these clinicians, 30 percent advised parents that "children in families that keep firearms should be taught how to use them safely when they are old enough." Clinicians who owned guns were also among the most likely clinicians to offer counseling. It is clear that something else besides unfamiliarity with guidelines or unavailability of materials impedes routine and proper firearm safety counseling by pediatric providers.
"Considering the amount of gun violence in our society," Barkin concludes, "it is appropriate to conduct a clinical trial of efforts to increase counseling about firearm safety in primary care, to test experimentally the effects of such counseling on parental knowledge and behavior, and to evaluate the effects on their children."
Meanwhile, pediatricians can do plenty to prevent youth violence, according to another study led by Barkin. First, they should continue counseling parents about gun safety. Second, they can educate children and teenagers directly about choices they can make to stay safe. Third, they can refer families to community resources, especially to clubs that offer young people the chance to interact with positive peer groups and strong adult mentors. Pediatricians alone cannot solve the problem of youth violence. But pediatricians, parents, and community leaders can work together as important links in the chain of youth violence prevention, according to the study.
In summary, researchers have only begun to suggest potential antidotes to youth violence:
The field of violence epidemiology is still in its infancy. Continued cooperation among researchers, clinicians, and community leaders will be necessary to ensure that the public health approach to youth violence can eventually yield early prescriptions to help young people avoid the later quarantine of incarceration.
"African American Mothers in South Central Los Angeles: Their Fears for Their Newborn's Future," Archives of Pediatrics & Adolescent Medicine, Vol. 152, March 1998, pp. 264-268, Mark A. Schuster, Neal Halfon, David L. Wood. Also available as RAND/RP-705, no charge.
"Concurrent Risk Factors for Adolescent Violence," Journal of Adolescent Health, Vol. 19, No. 2, August 1996, pp. 94-103, Hilary Saner, Phyllis L. Ellickson. Also available as RAND/RP-580, no charge.
"Early Predictors of Adolescent Violence," American Journal of Public Health, Vol. 90, No. 4, April 2000, pp. 566-572, Phyllis L. Ellickson, Kimberly A. McGuigan.
"Firearm Storage Patterns in U.S. Homes with Children," American Journal of Public Health, Vol. 90, No. 4, April 2000, pp. 588-594, Mark A. Schuster, Todd M. Franke, Amy M. Bastian, Sinaroth Sor, Neal Halfon. Also available as RAND/RP-890, no charge.
"Profiles of Violent Youth: Substance Use and Other Concurrent Problems," American Journal of Public Health, Vol. 87, No. 6, June 1997, pp. 985-991, Phyllis L. Ellickson, Hilary Saner, Kimberly A. McGuigan. Also available as RAND/RP-675, no charge.
"The Smoking Gun: Do Clinicians Follow Guidelines on Firearm Safety Counseling?" Archives of Pediatrics & Adolescent Medicine, Vol. 152, August 1998, pp. 749-756, Shari Barkin, Naihua Duan, Arlene Fink, Robert H. Brook, Lillian Gelberg.
"What Pediatricians Can Do to Further Youth Violence Prevention: A Qualitative Study," Injury Prevention, Vol. 5, 1999, pp. 53-58, Shari Barkin, Gery Ryan, Lillian Gelberg.