Violence risk and protective factors among youth held back in school.

OBJECTIVE: To identify risk and protective factors for violence perpetration among youth with a history of grade retention. DESIGN: Longitudinal analysis of in-home interviews of 13,781 adolescents in grades 7 through 12 conducted in 1995 and 1996. METHODS AND MEASURES: Serious interpersonal violence perpetration at time 2 by time 1 independent variables including measures of community and school context, family context, and individual characteristics. RESULTS: The 20% of girls and 28% of boys who had repeated 1 or more grades were more likely than those who had not to be in the top quintile of violence perpetration at time 2 (P <.001). For both girls and boys with a history of grade repetition, predictive risk factors with an odds ratio of 3 or greater (P <.001) included time 1 violence perpetration, violence victimization, weapon carrying, school problems, and alcohol and marijuana use. Although a high grade point average was a significant protective factor against violence perpetration for both girls (odds ratio, 0.36; P <.05) and boys (odds ratio, 0.23; P <.001), performance on a validated measure of verbal knowledge was not associated with violence perpetration over the study period. School connectedness, parent-family connectedness, and emotional well-being were also significant universal protectors against violence perpetration. CONCLUSIONS: Youth who are held back in school are at heightened risk for violence perpetration. Violence-related behaviors and substance use considerably increase the likelihood of this outcome. The findings suggest that schools can participate in violence prevention by providing youth with a positive community and academic experience.     

Violence prevention in the emergency department: clinician attitudes and limitations

OBJECTIVE: To assess emergency department (ED) clinicians' attitudes and behaviors regarding identification, assessment, and intervention for youth at risk for violence in the ED. DESIGN: Anonymous, cross-sectional written questionnaire. SETTING: The EDs of 3 urban hospitals. SUBJECTS: Emergency medicine residents and faculty, pediatric residents, pediatric emergency medicine fellows and faculty, and ED nurses. RESULTS: A total of 184 (88%) of 208 clinicians completed the questionnaire. Only 15% correctly recognized the lack of existing protocols for addressing youth violence. Clinicians reported being most active in identification of at-risk youth (93% asking context of injury and 82% determining relationships of victim and perpetrator), with pediatricians being more active than general ED clinicians (87% vs 68%; P<.01). Clinicians less often reported performing assessments or referrals of at-risk youth. Nurses and physicians were no different in their reported identification, assessment, or referral behaviors. Barriers identified include concern over upsetting family members, lack of time or skills, and concern for personal safety. Additional clinician training, information about community resources, and specially trained on-site staff were noted by respondents as potential solutions. CONCLUSIONS: Emergency department clinicians recognize the need for evaluation of youth at risk for violence. They are able to identify violently injured youth, but less often perform risk assessment to guide patients to appropriate follow-up resources. Further investigation should address clinician barriers to the complete care of violently injured youth in the ED.     

Urban youths'' perspectives on violence and the necessity of fighting

OBJECTIVES: To assess youth perceptions of the causes and consequences of violence generally, the causes and consequences of fighting specifically, and to determine how best to approach fighting in the context of violence prevention activities. METHODS: Thirteen structured focus group interviews with youths from three high violence urban settings: a large, urban high school, a training center for disadvantaged youths, and a school for adjudicated youths. Participants were 120 urban, predominately African-American youths and young adults ages 14-22 years (mean: 17.2 years). Seven focus groups were conducted with females, and six with males. RESULTS: Adolescents identified the causes of violence on multiple levels including: individual, family, interpersonal, and community level factors. Most youths (89%) had been in a physical fight. Participants felt that fighting was not "right", but identified situations in which it was necessary. Specifically, fighting was used as a problem solving tool, and could prevent escalation of violence. Youths felt that the adults in their lives, including physicians, were generally ill equipped to give advice about violence, as adults' experiences were so removed from their own. Participants looked to experienced role models to offer problem solving and harm reduction strategies. Youths were open to receiving anticipatory guidance about violence and fighting from primary care physicians they felt comfortable with, and who showed respect for their experiences. CONCLUSIONS: Interventions that include blanket admonitions against fighting should be reassessed in light of youth perceptions that fighting plays a complex role in both inciting and preventing more serious violence.     

Effects of 2 prevention programs on high-risk behaviors among African American youth: a randomized trial

OBJECTIVE: To test the efficacy of 2 programs designed to reduce high-risk behaviors among inner-city African American youth. DESIGN: Cluster randomized trial. SETTING: Twelve metropolitan Chicago, Ill, schools and the communities they serve, 1994 through 1998. PARTICIPANTS: Students in grades 5 through 8 and their parents and teachers. INTERVENTIONS: The social development curriculum (SDC) consisted of 16 to 21 lessons per year focusing on social competence skills necessary to manage situations in which high-risk behaviors occur. The school/community intervention (SCI) consisted of SDC and school-wide climate and parent and community components. The control group received an attention-placebo health enhancement curriculum (HEC) of equal intensity to the SDC focusing on nutrition, physical activity, and general health care. MAIN OUTCOME MEASURES: Student self-reports of violence, provocative behavior, school delinquency, substance use, and sexual behaviors (intercourse and condom use). RESULTS: For boys, the SDC and SCI significantly reduced the rate of increase in violent behavior (by 35% and 47% compared with HEC, respectively), provoking behavior (41% and 59%), school delinquency (31% and 66%), drug use (32% and 34%), and recent sexual intercourse (44% and 65%), and improved the rate of increase in condom use (95% and 165%). The SCI was significantly more effective than the SDC for a combined behavioral measure (79% improvement vs 51%). There were no significant effects for girls. CONCLUSIONS: Theoretically derived social-emotional programs that are culturally sensitive, developmentally appropriate, and offered in multiple grades can reduce multiple risk behaviors for inner-city African American boys in grades 5 through 8. The lack of effects for girls deserves further research.     

Prospective effects of violence exposure across multiple contexts on early adolescents’ internalizing and externalizing problems

Background: Violence exposure within each setting of community, school, or home has been linked with internalizing and externalizing problems. Although many children experience violence in multiple contexts, the effects of such cross‐contextual exposure have not been studied. This study addresses this gap by examining independent and interactive effects of witnessing violence and victimization in the community, home, and school on subsequent internalizing and externalizing problems in early adolescence. Methods: A community sample of 603 boys and girls (78% African American, 20% Caucasian) participated in a longitudinal study of youth violence. During two assessments 16 months apart, adolescents reported on witnessing violence and victimization in the community, school, and home, and their internalizing and externalizing problems. Results: Multiple regressions tested the independent and interactive effects of witnessing violence or victimization across contexts on subsequent adjustment, after controlling for initial levels of internalizing and externalizing problems and demographic covariates. Witnessing violence at school predicted anxiety and depression; witnessing at home was related to anxiety and aggression; and witnessing community violence predicted delinquency. Victimization at home was related to subsequent anxiety, depression, and aggression; victimization at school predicted anxiety; and victimization in the community was not independently related to any outcomes. Finally, witnessing violence at home was associated with more anxiety, delinquency, and aggression only if adolescents reported no exposure to community violence. Conclusions: Violence exposure at home and school had the strongest independent effects on internalizing and externalizing outcomes. Witnessing community violence attenuated the effects of witnessing home violence on anxiety and externalizing problems, perhaps due to desensitization or different norms or expectations regarding violence. However, no comparable attenuation effects were observed for victimization across contexts.     

Children and youth with special healthcare needs: there is no place like (a medical) home

PURPOSE OF REVIEW: This review highlights the importance, components, and outcomes of the medical home for children and youth with special healthcare needs. Relevant work supporting the medical home concept for this vulnerable group is highlighted for healthcare providers. RECENT FINDINGS: Developing a medical home model is garnering support from many national organizations and agencies. Having a medical home for children and youth with special healthcare needs is associated with favorable impacts on healthcare utilization and family-centered care. Achieving family-centered care is associated with increases in satisfaction and linkages to specialists, decreases in school absences and unmet medical needs. Consistent insurance coverage is important for children and youth with special healthcare needs to thrive. Further, lack of access to informational resources minimizes families' knowledge of available public programs. SUMMARY: Children and youth with special healthcare needs constitute a vulnerable population in need of comprehensive and accessible care. Provision of care via a medical home can be efficient and effective in this population of children and their families. Due to the relatively high cost of providing fragmented care to these children and youth, advances in coordinating access to services will have a cost-effective outcome.     

The emergency department approach to violently injured patient care: a regional survey.

OBJECTIVE: Since the early 1990s public health workers have challenged healthcare practitioners to take an active role in violence prevention with patients aged 10-24 years. Emergency department (ED) clinicians are uniquely positioned to identify, assess, and refer youth involved in violent events. The objective of this study was to describe ED directors' estimate of the number of violently injured youth seen, the presence of established protocols or guidelines for handling youth violence, and the type of training programs offered to ED physicians regarding this issue. METHODS: The authors conducted a survey of EDs (n = 64) in the Philadelphia metropolitan region to determine the standard of ED care for violently injured youths. Half of the EDs were in urban areas and half in suburban. RESULTS: A total of 41 out of 64 (64.1%) ED directors completed and returned the written questionnaire. In addition to treating the specific injuries sustained, ED responses to youth violence primarily involved talking with patients about the events surrounding the injury. The estimated number of violently injured youth seen per month varied considerably. Twenty four directors (58.5%) estimated that their institution treated fewer than 10 per month; 10 (24.4%) reported 11-30, and seven (17.1%) mostly large urban hospitals, saw more than 30 per month. Although most hospitals reported that the staff counsels patients about safety concerns, only 17% offered their staff formal training programs on youth violence. CONCLUSIONS: To address the prevention of youth violence, EDs need specific training programs for ED staff, as well as systematic risk assessment and referral resources for structured intervention and follow up.     

Correlates of violent behavior among adolescents presenting to an urban emergency department

OBJECTIVE: To examine rates and correlates of self-reported perpetrated violence among teens presenting to an urban emergency department. STUDY DESIGN: Cross-sectional study of a consecutive sample of youth (12-17 years) presenting to an urban emergency department. The youth were surveyed about demographics, community violence exposure, parental monitoring, substance use, weapon carriage, group fighting, and aggression (past 12 months). Bivariate and multivariate analyses were performed to identify correlates of the severity of the violence (none, moderate, or severe) perpetrated in the past year. RESULTS: A total of 115 youth were surveyed (males, 47%; response rate, 85%). The sample group was 51% African American. A total of 77% of the youth reported that they perpetrated violence in the past year, with 37% reporting severe violence (use of a weapon, group fighting, causing an injury requiring medical care). All patients who self-reported perpetrating severe violence in the past year were discharged home from the emergency department. The diagnosis made in the emergency department (illness versus injury) was not associated with the violence perpetrated in the past year. Sex was not a significant predictor of severe perpetrated violence. CONCLUSIONS: Youth presenting to urban emergency departments report high rates of perpetrating violence in the past year that, on the basis of other studies, is likely to continue. These results suggest that future emergency department-based violence prevention efforts should consider universal screening of adolescents.     

Effects of media violence on health-related outcomes among young men

OBJECTIVE: To test the effects of media violence exposure on blood pressure, negative affect, hostile social information processing, uncooperative behavior, and attitudes toward health risk behaviors among young men varying in lifetime violence exposure within the home and community. DESIGN: Experimental laboratory study. SETTING: University campus situated within an urban environment. PARTICIPANTS: One hundred male undergraduates aged 18 to 21 years. INTERVENTION: Men who had previously reported differing amounts of lifetime home and community violence were randomly assigned to play The Simpsons: Hit and Run (low-violence condition) or Grand Theft Auto III (high-violence condition). MAIN OUTCOME MEASURES: Systolic and diastolic blood pressure; negative affect; hostile social information processing; uncooperative behavior; and permissive attitudes toward violence, alcohol use, marijuana use, and sexual activity without condom use. RESULTS: Men randomly assigned to play Grand Theft Auto III exhibited greater increases in diastolic blood pressure from a baseline rest period to game play, greater negative affect, more permissive attitudes toward using alcohol and marijuana, and more uncooperative behavior in comparison with men randomly assigned to play The Simpsons. Only among participants with greater exposure to home and community violence, play of Grand Theft Auto III led to elevated systolic blood pressure in comparison with play of The Simpsons (mean, 13 vs 5 mm Hg). CONCLUSIONS: Media violence exposure may play a role in the development of negative attitudes and behaviors related to health. Although youth growing up in violent homes and communities may become more physiologically aroused by media violence exposure, all youth appear to be at risk for potentially negative outcomes.     

Components of effective youth violence prevention programs for 7- to 14-year-olds

OBJECTIVE: To classify features of effective violence prevention programs for 7- to 14-year-olds according to children's risk groups and targeted behaviors. DATA SOURCES: Articles published between 1980 and 1999 were identified via electronic databases (MEDLINE, ERIC, PsychINFO) using the key words violence, violence prevention, youth violence, or aggressive behavior. Reference lists were hand-searched for additional publications. STUDY SELECTION: One hundred fifty-three articles were reviewed with a modified scale by one of the principal investigators/authors (W.O.C. or M.L.) and a research assistant (K.F.); the other principal investigator resolved any discrepancies. Articles were included if they reported prevention efforts in 7- to 14-year-olds and compared outcome measures, met requirements for scientific rigor, and reported significant improvements (effect size, >0.1 or P< or =.05). Sixty-seven percent (n = 102) did not meet the inclusion criteria. Of the remaining 51 articles (33%), 38 met requirements for scientific rigor, and 32 articles describing 25 programs reported significant improvements in at least 1 area. RESULTS: Twenty-five programs indicated significant improvements in attitudes, knowledge, or intentions (n = 10) and/or reduction in delinquency rates and violent and/or aggressive behavior (n = 11); significant changes in both types of outcomes were indicated in 4 programs. Most programs (n = 13) targeted older children (aged 11-14 years) and focused on fighting (n = 13) and conflict management (n = 14). Classroom teaching was the most common process (n = 18) used. Few programs (n = 7) involved family intervention. CONCLUSIONS: Although limited in number, effective youth violence prevention programs were identified from current literature. Study findings were compiled into a database outlining effective processes for specific sociodemographic and risk behavior groups that will be helpful to future program planning.     

Perceptions of social conflicts among incarcerated adolescents with callous-unemotional traits: 'you're going to pay. It's going to hurt, but I don't care.'

Background: Delinquent youth with callous‐unemotional (CU) traits may have a unique social‐cognitive processing pattern that perpetuates their violent behavior. The current study examined the association between CU traits and the endorsement of deviant social goals during peer conflicts as well as expectancies and values regarding victim suffering following aggression. Methods: Participants included 156 (84 males, 72 females) adjudicated juveniles residing at two gender‐specific residential facilities in an urban city within the southeastern United States. The association between CU traits and participants’ ratings of their social goals in hypothetic conflict situations and outcome expectancies/values regarding victim suffering were examined after controlling for prior violence, intelligence, and demographic covariates. Results: CU traits were associated with an increased endorsement of social goals associated with revenge, dominance, and forced respect in social conflict situations. Adjudicated youth with CU traits were also less likely to endorse conflict avoidance and friendship building as important social goals when provoked by peers. There was no association between CU traits and expectations for victim suffering following aggression, but CU traits were significantly associated with lower levels of concern about victim suffering. These findings were significant after controlling for participants’ prior history of violence, intelligence, and demographic covariates. Conclusions: Adjudicated youth with CU traits tend to emphasize power‐oriented goals when provoked by peers and have little interest in rectifying social conflicts to build potential friendships with others. Juveniles with CU traits seem to be aware that their aggressive behavior will cause others to suffer, but they do not care when it does.     

School-based violence prevention programs: systematic review of secondary prevention trials

OBJECTIVE: To quantify the effectiveness of school-based violence prevention programs for children identified as at risk for aggressive behavior. DESIGN: Systematic review and meta-analysis of randomized controlled trials. Electronic databases and bibliographies were systematically searched and authors and organizations were contacted to identify randomized controlled trials. Standardized, weighted mean effect sizes were assessed by meta-analysis. SETTING: Elementary, middle, and high schools. PARTICIPANTS: Children at risk for aggressive behavior. MAIN OUTCOME MEASURES: Violent injuries, observed or reported aggressive or violent behaviors, and school or agency responses to aggressive behaviors. RESULTS: Of the 44 trials identified, none reported data on violent injuries. For the 28 trials that assessed aggressive behaviors, the pooled difference between study groups was -0.36 (95% confidence interval, -0.54 to -0.19) in favor of a reduction in aggression with intervention. For the 9 trials that reported data on school or agency responses to aggression, the pooled difference was -0.59 (95% confidence interval, -1.18 to 0.01). Subgroup analyses suggested greater effectiveness in older students and when administered to mixed-sex groups rather than to boys alone. CONCLUSIONS: School-based violence prevention programs may produce reductions in aggressive and violent behaviors in children who already exhibit such behavior. These results, however, need to be confirmed in large, high-quality trials.     

Behavior-oriented approaches to reducing youth gun violence

Advocacy groups on both sides of the guns issue frequently point to changing personal behavior--of both parents and children--as a key element in reducing gun violence among youth. Efforts to bring about these changes range from community-based campaigns, to laws and programs that encourage parents to store their guns safely, to educational initiatives that focus on keeping young children away from guns and encouraging youth to resolve disputes without violence. Unfortunately, these behavior-oriented programs have not shown great success in reducing youth gun violence. This article reviews the research surrounding behavioral approaches to gun violence prevention and highlights obstacles that hamper the effectiveness of these programs. Supportive communities can play a key role in protecting youth from violence in general, but the few community-based violence prevention programs that focus on youth have not been shown to decrease youth access to or use of guns. By and large, behavioral programs and legal interventions aimed at parents have not been proven to reduce youth gun violence. This may be due in part to parental misperceptions about children's risk of injury and ability to protect themselves. Children and youth are particularly difficult targets for behavioral change programs. Cognitive immaturity among younger children and perceptions of invulnerability among adolescents may be part of the reason. Most programs that seek to persuade youth to stay away from guns have not been proven effective. The author concludes that, although behavioral programs could be improved, overall they hold only limited promise for reducing youth gun violence.     

The role of the school in children's out-of-school time

As the primary community institution in the lives of children, schools have much to contribute to plans for addressing the needs of today's youngsters during the time when classes are not being held. In recent years, demands have escalated for after-school child care, educational enrichment, and safe havens that also foster positive youth development. Many programs that respond to these needs are housed in school buildings. Some are operated by the schools, some by community-based organizations, and others by partnerships between schools and outside groups. New public funding for after-school programs often flows through the school system. This article reports the prevalence of school-based programs and discusses extracurricular activities, child care and extended-day programs, enrichment programs, and ambitious efforts to transform the schools into full-time community hubs offering something for residents of all ages. Implementation challenges accompany program expansion, and this article also examines major issues that arise in school-based programs: governance, space, program quality, funding, and accountability. If these programs fulfill their promise, the school of the future may, indeed, be open extended hours for the enrichment of the children and the sustenance of the family.     

Use of the emergency Incident Command System for school-located mass influenza vaccination clinics

In Palm Beach County, Florida, the fall 2005 influenza vaccination season was interrupted by Hurricane Wilma, a particularly destructive storm that resulted in flooding, power outages, extensive property damage, and suspension of many routine community services. In its aftermath, all public health resources were immediately turned to the response and recovery process. School-located mass influenza vaccination (SLV) clinics were scheduled to begin in 1 week, but were necessarily postponed for a month. The juxtaposition of these 2 major public health events afforded the school district, health department, and other community services an opportunity to see their similarities and adopt the Incident Command System structure to manage the SLV clinics across West Palm Beach County, Florida, a geographically large county. Other lessons were learned during the hurricane concerning organizations and people, processes, and communications, and were applicable to school-located mass influenza vaccination programs, and vice versa. Those lessons are related here.     

Family Composition and Youth Health Risk Behaviors: the Role of Patental Relation and the School Context

Children not residing with both parents have been shown to be more at risk of negative developmental outcomes than children residing in two-parent families. Few studies have explored how other central contexts may interact with family characteristics to hinder or facilitate youth adjustment. This study examines how aspects of family structure and family processes are associated with youth health risk behaviors and interact with the structural characteristics of schools. The analyses are based on data from the Stockholm School Survey and consist of 5 002 ninth-grade students distributed over 92 schools in the Stockholm area in 2010. School information has been gathered from the Swedish National Agency for Education. Random intercept and fully random models have been used. Results show that adolescents not living with both their parents are more involved in health risk behaviors than adolescents that do. Poor parent–child relations accounts for more of the disadvantage associated with non-traditional family structures than differences in socioeconomic background. Results further suggest that health risk behaviors are more prevalent in more advantaged school settings, net the effect of individual background characteristics. Moreover, advantage school settings are found to accentuate the detrimental effects of poor parent–child relations on health risk behaviors. In conclusion, the study suggests that the effect of family type and family processes on youth behavior is susceptible to contextual effects of the school environment and that more advantage school settings have detrimental direct and indirect effects on youth health risk behaviors.     

What pediatricians can do to further youth violence prevention—a qualitative study

OBJECTIVE: Youth violence is a public health problem world wide. However, the United States has the worst rate of youth violence among industralized countries. This study was conducted to learn what pediatricians, community leaders, and parents think the doctor's role is in youth violence prevention during the well-child examination for children. METHODS: Interviews were conducted with pediatricians, community leaders, and parents living or working in Los Angeles, California. RESULTS: All three groups interviewed believed that the physician should incorporate violence prevention counseling as part of the well-child examination. The mechanism of action differed for the three groups. Almost half of pediatricians' statements focused on their role as prevention counselor, with respect to such issues as appropriate discipline and gun safety. One third of community leaders' statements, however, related to physician referral to existing community resources. More than half of parents' statements referred to the pediatrician as someone who can directly educate their child about making positive choices. CONCLUSIONS: Although pediatricians cannot solve the problem of youth violence alone, findings from this study suggest that they should address this issue with their patients and should work in tandem with existing community resources to further a solution to this growing epidemic.