The epidemic of violence in America

What can we do about this public health emergency?

Marjorie J. Hogan, MD

VOL 105 / NO 6 / MAY 15, 1999 / POSTGRADUATE MEDICINE

Across America, countless newspaper headlines, TV news programs, and popular songs tell tragic tales of violence in the lives of young people--as victims, witnesses, and perpetrators. At the same time, we hear that violent crime rates are declining in many parts of the United States. But, in this case, the decline does not mean the problem is being solved. It represents only a very small step in a marathon effort we all need to support. What can we, as physicians, do to change the course of this enormous public health problem?

The sheer numbers of young people involved in violent activity in America and the devastating outcomes for these children demand our attention. Violence touches the lives of all of us, whether directly through personal injury, grief, loss, and anger or indirectly through the perpetuation of the cycle of violence and loss of trust and security. We are sadly misguided and dangerously deluded if we believe violence is not one of our nation's most serious public health emergencies. Intensive education, commitment, and intervention are imperative.

The statistics about youth violence paint a frightening picture. The United States has the highest youth suicide and homicide rate among the 26 wealthiest nations and one of the highest rates worldwide (1-5). Homicide is the leading cause of death for young African Americans and the second leading cause for young white men (6). More than 10 million children witness domestic abuse in their homes each year (7). Every 2 hours, a child is killed by someone using a firearm (4,8), and millions of young people carry weapons to school each year (2). A recent study in Washington, DC (7), showed that 45% of first graders had witnessed assault or murder with a deadly weapon. And not surprisingly, the average American child sees more than 200,000 violent acts on television before age 15 (9).

Domains of violence

A young person growing up in the United States today faces complex "domains of risk" for violence. Among them are child abuse and neglect, violence at home or school, media violence, access to firearms, use of illegal drugs, socioeconomic inequality, and discrimination. The question experts struggle with is, Why are some children resilient enough to cope with risks while others are not?

The first domain of risk for children is our American culture. As a nation, we are entertained and fascinated by violence. Physical punishment is still widely used and approved by many parents and professionals. In fact, corporal punishment is still legal in schools in many states (10,11). We are unable to regulate and protect ourselves from people toting guns, and children's rights tend to be the first to fall by the legal and legislative wayside. While perhaps not directly responsible for violence in America, society sets the stage and then closes its eyes to the tragedy.

Neighborhoods represent another important domain of risk. We hardly need research, although it does exist (3), to recognize that communities with impoverished families, isolation, unsafe streets, and few support or recreational services incubate violence through hopelessness, fear, and anger. These communities are described as lacking "social capital" (2).

Schools with high dropout and absentee rates, little authority, low expectations, and lack of incentive to teach and learn also feed the risk for violence (8). Children often learn more about survival and aggression than about reading, writing, and arithmetic.

As every parent knows, peers exert powerful influence on children. A child with poor social skills or one experiencing bullying and rejection may choose inappropriate friends, just to "belong." Gangs or other antisocial groups almost always expose youngsters to alcohol, drugs, or weapons (3,7,12).

For many young people, violence is modeled at home--perhaps the least safe place for many children and another powerful domain of risk (2,7,10,12). These children learn that abuse--physical and verbal--and violence are effective, inevitable, and part of a supposedly loving relationship. For them, the world is hostile and unsafe, home is an unpredictable, scary place, and children are vulnerable.

Then, of course, we have mass media as a teacher of violence (2,3,7,9,11). Young TV viewers are constantly bombarded by realistic, glorified, rewarded, and entertaining images of violence, often portrayed as being without consequence. For children living in unsafe homes and neighborhoods, these powerful images make violence even more real and inexorable. TV, in particular, all too often encourages aggressive behavior, desensitizes children to violence, and reinforces a belief that the world is a fearsome place.

The last domain of risk, individual factors, is complex but critically important. Adolescence itself is a veritable minefield of risks (2). Teens not only attempt to separate from authority figures but also are attracted to risky behaviors. Magical thinking ("I'm invincible!"), foolhardy choices, and an egocentric approach to life are compounded for youngsters who already carry heavy risks (table 1). In particular, research shows that experiencing violence at a young age is a powerful predictor of violent behavior in later life (2,8,14). Thus, child abuse and witnessing domestic violence must be considered major risk factors for perpetuation of violent behavior.

Table 1. Individual risk factors for violent behavior

Poor verbal and reading skills Attention-deficit hyperactivity disorder (ADHD) History of serious trauma Health problems     Poor prenatal care     Exposure to substances during pregnancy     Poor nutrition     Lead exposure Early exposure to violence Unique patterns of thought     Lack of cognitive skill (problem-solving ability)     Content of thought favoring violence     Impulsive style of thought Difficult temperament

In short, violence in America is sanctioned by society, socially learned, and all too often reinforced in homes, schools, communities, and the media. Social forces (ie, poverty, isolation) interact with the influences of early childhood to incubate violent behavior.

Why are some youngsters able to avoid the downward spiral into violent behavior, despite experiences and risks shared with violent youth? Research shows that several protective factors lead to resilience and help youngsters counter violent patterns of thought and behavior (table 2) (10,13-16).

Table 2. Factors that protect children from violence

Investment and opportunities in school Strong adult in the life of a child or adolescent Being well liked by peers Sense of hope about the future Belief that violence is not inevitable and will not solve     problems; willingness to try conflict resolution or     conflict avoidance Cultural identity and connectedness

Response to violence

What can we, as caretakers of the public's health, do to stem the epidemic of violence? First, we can help increase public awareness of this identifiable and preventable problem. Violence prevention requires education, collaboration, and commitment on primary as well as secondary and tertiary levels.

Primary prevention is aimed at all of society, secondary prevention focuses on groups and individuals at high risk for violence, and tertiary prevention is directed toward persons already involved in violent behavior. Primary prevention looks first at defining, creating, and enhancing protective factors for all children. This means ensuring the presence of strong adults in the lives of all children, providing positive educational opportunities, promoting cultural and community connectedness, and teaching conflict resolution and conflict avoidance skills. Many sectors of society can become involved through mentoring, providing jobs, advocating, and teaching.

Secondary prevention can be creative--and lifesaving. Community-based crisis nurseries offer safe havens for infants and children of stressed parents. Shelters for battered women, mentoring programs, substance abuse treatment, support groups for parents fearful of abusing children (eg, Parents Anonymous), and early childhood family education programs through school districts are other examples of successful interventions.

Tertiary prevention strategies try to stem further violence but often offer too little too late. These strategies include incarceration, education, training, and treatment for youth already involved in violence.

It's time to get involved

Advocacy cannot be separated from prevention, and for the healthcare profession this means becoming involved in gun control, media education, improvement in economic opportunities for inner cities, and juvenile justice reform, among other initiatives.

Because parents and guardians are at the heart of violence prevention, the American Academy of Pediatrics and American Psychological Association offer a helpful brochure called "Raising Children to Resist Violence." The suggestions are worth sharing with any adult who cares for or works with children or young people (table 3 and box below).

Table 3. Suggestions for raising children to resist violence

Give your child love and affection Model appropriate behaviors Supervise Do not hit Be consistent about rules and discipline Protect children from access to guns Try to prevent children seeing violence in the community Avoid media violence Teach children to avoid being victims Help children stand up against violence Be aware of warning signs

Finally, doctors, especially pediatricians and family physicians, play a key role in violence prevention. Not only can we collaborate with community and child advocacy groups to spread the message about violence prevention, but each of us has the potential to touch many lives within our clinic or office practice (table 4). We need to become acutely aware of the strong role we can play in preventing violence, one person at a time.

Table 4. What nphysicians can do to help prevent violence

Commit to self-education about violence Be an advocate and activist to prevent violence Recognize risk factors Talk to children and teens     Identify children and teens at risk     Teach nonviolent beliefs and skills     Ensure follow-up and appropriate referrals Talk to parents about setting limits, appropriate discipline,     risk factors, violence at home, early nurturing Know the resources for safe havens, shelters, substance     abuse treatment, and support groups for parents

Summary

Despite the specter of violence looming over us, we can and must maintain a sense of purpose and hopefulness. Violence is a learned and reinforced set of behaviors and responses and can be unlearned by a society committed to nonviolent conflict resolution, fairness, and the opportunity for all children and adolescents to survive and thrive.

References

1. Calhoun AD, Clark-Jones F. Theoretical frameworks: developmental psychopathology, the public health approach to violence, and the cycle of violence. Pediatr Clin North Am 1998;45(2):281-91
2. McCord J, ed. Violence and childhood in the inner city. Cambridge, Mass: Cambridge University Press, 1997
3. Prothrow-Stith D. Deadly consequences: how violence is destroying our teenage population and a plan to begin solving the problem. New York: HarperCollins, 1991
4. Powell EC, Sheehan KM, Christoffel KK. Firearm violence among youth: public health strategies for prevention. Ann Emerg Med 1996;28(2):204-12
5. Centers for Disease Control and Prevention. Rates of homicide, suicide, and firearm-related death among children: 26 industrialized countries. MMWR Morb Mortal Wkly Rep 1997;46(5):101-5
6. Centers for Disease Control and Prevention. Homicide among young black males: United States, 1978-1987. MMWR Morb Mortal Wkly Rep 1990;39(48):869-73
7. Tolmas HC. Violence among youth: a major epidemic in America: one pediatrician's perspective. American Academy of Pediatrics, Adolescent Health Section Newsletter 1998;20:18-30
8. Karr-Morse R, Wiley MS. Ghosts from the nursery: tracing the roots of violence. New York: Atlantic Monthly Press, 1997
9. Strasburger VC. Adolescents and the media: medical and psychological impact. Thousand Oaks, Calif: Sage Publications, 1995
10. Trickett PK, Schellenbach CJ, eds. Violence against children in the family and the community. Washington, DC: American Psychological Assn, 1998
11. Spivak H, Harvey B, eds. The role of the pediatrician in violence prevention. Pediatrics (Suppl) 1994;94(4):579-86
12. Loeber R, Hay D. Key issues in the development of aggression and violence from childhood to early adulthood. Annu Rev Psychol 1997;48:371-410
13. Masten AS, Best KM, Garmezy N. Resilience and development: contributions from the study of children who overcome adversity. Dev Psychopathol 1990;2:425-44
14. Garbarino J, Kostelny K, Dubrow N. What children can tell us about living in danger. Am Psychol 1991;46(4):376-83
15. Stringham P. Violence anticipatory guidance. Pediatr Clin North Am 1998;45(2):439-48
16. Blum RW. Healthy youth development as a model for youth health promotion: a review. J Adolesc Health 1998;22(5):368-75

For copies of the brochure "Raising Children to Resist Violence," contact the American Academy of Pediatrics, Division of Publications, 141 Northwest Point Blvd, PO Box 747, Elk Grove, IL 60007. Phone 800-433-9016 or fax requests to 847-228-1281. Visit the AAP Web site at www.aap.org.

Dr Hogan is assistant professor of pediatrics, University of Minnesota, and staff pediatrician and pediatric medical education director, Hennepin County Medical Center, Minneapolis. Correspondence: Marjorie J. Hogan, MD, Hennepin County Medical Center, Department of Pediatrics, 701 Park Av S, Minneapolis, MN 55415.

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