Youth Violence - A Report of the Surgeon General
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Posted On: July 13, 2003
July 15, 2003
© Terence T. Gorski, 2001
Youth Violence: A Report of the Surgeon General
<Read It On The Surgeon General's Website>
Youth violence is a high-visibility, high-priority concern in every
sector of U.S. society. No community, whether affluent or poor, urban,
suburban, or rural, is immune from its devastating effects. In the decade
extending from roughly 1983 to 1993, an epidemic of violent, often lethal
behavior broke out in this country, forcing millions of young people and
their families to cope with injury, disability, and death (Cook & Laub,
1998). This epidemic left lasting scars on victims, perpetrators, and
their families and friends. It also wounded entire communities and, in
ways not yet fully understood, the United States as a whole.
Since 1993, when the epidemic peaked, youth violence has declined
significantly nationwide, as signaled by downward trends in arrest
records, victimization data, and hospital emergency room records. But the
problem has not been resolved. Another key indicator of violence--youths'
confidential reports about their violent behavior--reveals no change since
1993 in the proportion of young people who have committed physically
injurious and potentially lethal acts. Moreover, arrests for aggravated
assault have declined only slightly and in 1999 remained nearly 70 percent
higher than pre-epidemic levels. In 1999, there were 104,000 arrests of
people under age 18 for a serious violent crime--robbery, forcible rape,
aggravated assault, or homicide (Snyder, 2000). Of these, 1,400 were for
homicides committed by adolescents (Snyder, 2000) and, on occasion, even
younger children (Snyder & Sickmund, 1999). But viewing homicide arrests
as a barometer of all youth violence is quite misleading, as is judging
the success of violence prevention efforts solely on the basis of
reductions in homicides.
Arrest records give only a partial picture of youth violence. For every
youth arrested in any given year in the late 1990s, at least 10 were
engaged in some form of violent behavior that could have seriously injured
or killed another person, according to the several national research
surveys in which youths report on their own behavior. Thus, despite
reductions in the lethality of violence and consequent arrests, the number
of adolescents involved in violent behavior remains disconcertingly high,
underscoring the urgency of this report.
This is no time for complacency. The epidemic of lethal violence that
swept the United States from 1983 to 1993 was fueled in large part by easy
access to weapons, notably firearms. If the sizable numbers of youths
still involved in violence today begin carrying and using weapons as they
did a decade ago, this country may see a resurgence of the lethal violence
that characterized the violence epidemic.
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
This report--the first Surgeon General's report on youth violence--is a
product of extensive collaboration. It reviews a massive body of research
on where, when, and how much youth violence occurs, what causes it, and
which of today's many preventive strategies are genuinely effective. Like
other reports from the Surgeon General, this report reviews existing
knowledge to provide scientifically derived bases for action at all levels
of society. Suggesting whether and how the areas of opportunity listed in
the final chapter might lend themselves to policy development to reduce
youth violence is beyond the report's purview.
Focus on Violence by Youths
The research described here focuses on physical assault by a youth that
carries a significant risk of injuring or killing another person. It
includes a wealth of studies into the many individual, family, school,
peer group, and community factors associated with serious
violence--aggravated assault, robbery, rape, and homicide--in the second
decade of life, when most such violence emerges.1
Thus, the young people who are the focus of this report are principally
children and adolescents from about age 10 through high school.
Appropriate interventions during as well as before this period stand a
good chance of helping redirect violent young people toward healthy and
constructive adult lives. The window of opportunity for effective
interventions opens early and rarely, if ever, closes.
The Developmental Perspective
This report views violence from a developmental perspective. To
understand why some young people become involved in violence and some do
not, it examines how youths' personal characteristics interact over time
with the social contexts in which they live. 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. The early-onset trajectory shows stronger links
between childhood factors and persistent, even lifelong involvement in
violent behavior. Identifying such pathways to violence can help
researchers target interventions to the periods in development where they
will be most effective.
The Public Health Approach
This report reflects the responsibilities and spirit of the Surgeon
General's public health mission: to protect and improve the Nation's
health. The designation of youth violence as a public health concern
invites an approach that focuses more on prevention than on
rehabilitation. Primary prevention identifies behavioral, environmental,
and biological risk factors associated with violence and takes steps to
educate individuals and communities about, and protect them from, these
risks. Central to this process 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.
The public health perspective 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, prevention, and public education, the public health
perspective calls for critically examining and reconciling what are
frequently contradictory conclusions about youth violence. Thus, the
approach taken in the current report, which blends offender-based research
with public health concepts of prevention and intervention, constitutes an
effort to bridge the gap between criminology and the social and
developmental science approaches on the one hand, and conventional public
health approaches on the other.
The public health approach can help reduce the number of injuries and
deaths caused by violence just as it reduced the number of traffic
fatalities and deaths attributed to tobacco use (CDC, 1999). Broader than
the medical model, which is concerned with the diagnosis, treatment, and
mechanisms of specific illnesses in individual patients, the public health
approach offers a practical, goal-oriented, and community-based strategy
for 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.
Myths about Youth Violence
An important reason for making research findings widely available is to
challenge false notions and misconceptions about youth violence. Ten myths
about violence and violent youth are listed and debunked. Examples of
these myths include:
||Most future offenders can be identified in early
||Child abuse and neglect inevitably lead to
violent behavior later in life.
||African American and Hispanic youths are more
likely to become involved in violence than other racial or ethnic
||A new, violent breed of young superpredators
threatens the United States.
||Getting tough with juvenile offenders by trying
them in adult criminal courts reduces the likelihood that they will
commit more crimes.
||Nothing works with respect to treating or
preventing violent behavior.
||Most violent youths will end up being arrested
for a violent crime.
These false ideas 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 or counterproductive use of scarce public
resources. An example is the current policy of waiving or transferring
young offenders into adult criminal courts and prisons.
This report reviews a vast, multidisciplinary, and often controversial
research literature. In the process, it seeks to clarify the discrepancies
between official records of youth violence and young people's own reports
of their violent behaviors. It identifies factors that increase the risk,
or statistical probability, that a young person will gravitate toward
violence and reviews studies that have begun to identify developmental
pathways that may lead a young person into a violent lifestyle. Also
explored is a less well developed area of research--the factors that seem
to protect youths from the effects of exposure to risk factors for
violence. Finally, the report reviews research on the effectiveness of
specific strategies to reduce and prevent youth violence.
The most important conclusion of this report is that youth violence is
not an intractable problem. We now have the knowledge and tools needed to
reduce or even prevent much of the most serious youth violence, with the
added benefit of reducing less dangerous, but still serious problem
behaviors and promoting healthy development. 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. However, after
years of effort and massive expenditures of public and private resources,
the search for solutions to the issue of youth violence remains an
enormous challenge. 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 school shootings that have occurred in
recent years in communities throughout the country. Thus, the most
urgent need 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.
More specific major findings and conclusions are summarized below by
Trends in Youth Violence (Chapter 2)
Two distinctly different, complementary ways of measuring violence are
used by scientists--official reports and self-reports. Official arrest
data are an obvious means of determining the extent of youth violence, and
a surge in arrests for violent crimes marked the epidemic of youth
violence between 1983 and 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, 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. Arrest rates
for aggravated assault, however, were nearly 70 percent higher than they
were in 1983, having declined only 24 percent from the peak rates in 1994.
Youth violence can also be measured on the basis of confidential
reporting by youths themselves. Confidential surveys find that 13 to 15
percent of high school seniors report having committed an act of serious
violence in recent years (1993 to 1998). These acts typically do not come
to the attention of police, in part because they are less likely than in
years past to involve firearms. Over the past two decades, the number of
violent acts by high school seniors increased nearly 50 percent, a trend
similar to that found in arrests for violent crimes. But neither this
incident rate nor the proportion of high school seniors involved in
violence has declined in the years since 1993--they remain at peak levels.
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.
Major Findings and Conclusions
- 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
- 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
- Despite the present decline in gun use and in lethal violence, the
self-reported proportion of young people involved in nonfatal violence
has not dropped 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 1997.
- 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
- 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.
Pathways to Youth Violence (Chapter 3)
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. In the early-onset trajectory, violence begins before
puberty, whereas in the late-onset trajectory it begins after puberty, at
about age 13. These two trajectories offer insights into the likely
course, severity, and duration of violence over the life span and have
practical implications for the timing of intervention programs and
strategies. Some research has examined the co-occurrence of serious
violence and other problems, including drug use and mental disorders, and
some has looked at factors associated with the cessation of youth violence
or its continuation into adulthood. Both of these areas need--and
Major Findings and Conclusions
- 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
- 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 in adolescence without warning signs in childhood. A
comprehensive community prevention strategy must address both onset
patterns and ferret out their causes and risk factors.
Risk and Protective Factors (Chapter 4)
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 can be
found in every area of life. Exerting different effects at different
stages of development, they tend to appear in clusters, and they appear to
gain strength in numbers. These 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 to determine when in the life course they typically come
into play. Armed with such information, researchers are better equipped to
design well-timed, effective preventive programs. Identifying and
understanding how protective factors operate 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 effects of exposure to specific risks
for violence: an intolerant attitude toward deviance, including violence,
and commitment to school. Protective factors warrant, and are beginning to
receive, more research attention.
Major Findings and Conclusions
- 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.
- 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.
- 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 attributes or
- 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.
- 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.
- 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.
- 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.
Preventing Youth Violence (Chapter 5)
Research clearly demonstrates that prevention programs and strategies
can be effective against both early- and late-onset forms of violence in
general populations of youths, high-risk youths, and even youths who are
already violent or seriously delinquent. Chapter 5 highlights 27 specific
youth violence prevention programs that are not only effective at
preventing youth violence but cost-effective as well. In a number of
cases, the long-term financial benefits of prevention are substantially
greater than the costs of the programs. These promising findings indicate
that youth violence prevention has an important role to play in overall
efforts to provide a safe environment for youths.
Despite these positive findings, current research on youth violence
prevention has important limitations. For example, relatively little is
known about the scientific effectiveness of hundreds of youth violence
programs currently in use in schools and communities in the United States.
This situation invites concern because in the past, many well-intentioned
youth violence prevention programs were found to have been ineffective or
to have had negative effects on youths. Even less is known about the best
strategies for implementing effective programs on a national scale without
compromising their results.
Major Findings and Conclusions
- A number of youth violence intervention and prevention programs have
demonstrated that they are effective; assertions that "nothing works"
- 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.
- 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.
- 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.
- 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.
- 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.
- Program effectiveness depends as much on the quality of
implementation as on the type of intervention. Many programs are
ineffective not because their strategy is misguided, but because the
quality of implementation is poor.
A Vision for the Future (Chapter 6)
The most important conclusion of this report is that an array of
intervention programs with well-documented effectiveness is now in place
to reduce and prevent youth violence. Such programs are the outcome of a
large body of research that has examined the paths and trajectories that
lead some youths toward lives marred by violence. Multiple studies have
identified and examined specific risk factors--personal and environmental
features of young people's lives that heighten the statistical probability
of their engaging in violent behaviors. Research has also begun to
identify protective factors that appear to buffer the effects of exposure
to risk. While this information has been accumulating, researchers, youth
service practitioners, and others have been actively engaged in designing,
implementing, and evaluating a variety of interventions to reduce and
prevent the occurrence of youth violence. The best of these interventions
target specific populations of young people, as defined by particular
constellations of risk and life experience.
Chapter 6 highlights courses of action for the Nation to consider.
Given the focus of the report, particular emphasis is placed on
consideration of research opportunities and needs. Although effective
interventions exist today, only through continued research will all
intervention programs be shown to meet a standard of effectiveness--or be
discarded. Although the research options and other courses of action
suggested here are not formal policy recommendations, they offer a vision
that may inform the generation of policies that will build on information
we possess today. They are intended for policy makers, service and
treatment providers, individuals affiliated with the juvenile justice
system, researchers, and, most important, the people of the United States.
This vision for the future is presented with the hope that it will engage
an expanding number of citizens in the challenge of redressing the problem
of youth violence. The following are possible 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
|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. |
Senior Scientific Editor
Delbert Elliott, Ph.D., Director, Program on Problem Behavior and Director
of the Center for the Study and Prevention of Violence, University of
Colorado, Boulder, Colorado.
CAPT Norma J. Hatot, Senior Nurse Consultant, Office of Policy, Planning
and Administration, Center for Mental Health Services, Substance Abuse and
Mental Health Services Administration, Rockville, Maryland.
Paul Sirovatka, M.S., Science Writer, Office of Science Policy and Program
Planning, National Institute of Mental Health, National Institutes of
Health, Bethesda, Maryland.
Senior Science Writer
Blair Burns Potter, M.A., Senior Science Writer and consultant, Annapolis,
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