Preventing Violence Where
Youth Live, Learn and Play
May 2015
BY KATE BLACKMAN
A
JULY 2015
dolescence is marked by significant and rapid growth, and health—
mental, physical, social and emotional—is an important part of this
development. Health behaviors, choices and well-being in childhood and
adolescence often extend into adulthood with lifelong implications.1 Violence is a critical issue in adolescence that can interrupt normal development. Homicide and assault-related injury affect thousands of teens each
year, and injuries or exposure to violence have consequences for numerous
aspects of health, including chronic disease, depression and unhealthy behaviors in adolescence and adulthood.
Violence in teens’ lives may
take many forms—child
maltreatment, bullying,
physical fighting, teen
dating violence and homicide—and in a variety of
settings, including homes,
schools and communities.2 Research suggests youth exposure to violence and abuse has decreased,3 but the rates
and consequences remain notable. An estimated two out of
every three youth are exposed to violence as victims or witnesses.4 Homicide, while less than 20 percent of all deaths
in 2013, remains among the leading causes of death for
adolescents each year.5 In addition, nearly 300,000 young
people ages 10-19 were treated in emergency rooms for
non-fatal assault injuries in 2013.6
Exposure to violence
includes being a direct
victim of a violent or
abusive act, or indirectly
experiencing violence as
a witness or bystander.
Many of the health issues that begin in adolescence as a
result of violence can persist or worsen in adulthood. In
addition to obvious outcomes such as injury and death,
exposure to violence can cause mental health issues, relationship problems, future violence victimization or perpetration, and risky or unhealthy behaviors.7 There are direct
health care, social services, law enforcement and education
costs associated with violence, as well as indirect costs, such
as loss of worker productivity.8
Despite this significant burden, violence is largely preventable. An overall trend of declines in youth exposure
to violence and abuse over the past decade could indicate
success of recent policies and programs related to violence
prevention and intervention.9 Many states are exploring
a public health approach to prevent youth violence while
taking into account adolescents’ larger social environment.
This brief provides an overview of the burden of violence
and state strategies to prevent and reduce violence within
the context of the social determinants of health—where
adolescents live, learn and play.
Social Determinants of Health
Violence occurs within the context of a larger set of factors,
including social, physical and economic environments.
These circumstances—where youth live, learn and play—
are referred to as the social determinants of health. For
adolescents, family, friends, peers, schools, communities
and societal messages are all part of the social environment
that affects choices, behaviors, and current and future
health.10 As a result, many adolescent health issues are challenging to address in traditional health care settings, such
as doctors’ offices and emergency rooms.
Social determinants do not exist in isolation; they are
integrated and overlap with each other.11 This integration
of factors makes it more difficult to pinpoint one strategy
for an issue like youth violence. It also means that addressing one factor has the potential to have a ripple effect on
others. Taking these social factors into account may result
in successful solutions to youth violence.
Determinants of Health
Scientists generally recognize five factors as determinants that contribute to health:
•
Biology and genetics (e.g., sex and age)
•
Individual behavior (e.g., alcohol or drug abuse, smoking, diet and exercise)
•
Social environment (e.g., discrimination, income and gender)
•
Physical environment (e.g., housing, neighborhood, school or workplace)
•
Health services (e.g., access to quality health care, having or not having health insurance)
Source: Centers for Disease Control and Prevention, 2013
2 | Preventing Violence Where Youth Live, Learn and Play
© 2015 National Conference of State Legislatures
Live
The family and home—where youth live—can have a profound effect on whether they experience violence. Youth
can be victims of child maltreatment, which includes abuse
and neglect, or witness violence among other family members. By the time children are in adolescence, 40 percent
have been exposed to family violence.12 Nationally, nearly
700,000 children were victims of abuse and neglect in
2013, and more than 1,000 died as a result of abuse or neglect.13 Experiencing child maltreatment can lead to similar
consequences as exposure to other forms of violence, such
as increased future risks of perpetrating or experiencing
violence, problems with alcohol or drugs, risky sexual
behaviors and a compromised ability to develop healthy
relationships in adulthood.14
While violence crosses socioeconomic and other boundaries, poverty can increase the risk of exposure to violence.15
Some research has also found that children may be at
greater risk for child maltreatment, family violence and
community violence when they grow up in disadvantaged
communities, or with caregivers with low education, or
substance abuse or mental health issues.16
Safe, stable and nurturing relationships with caregivers—
relationships that are free from harm, consistent and emotionally responsive—can protect against violence and help
create the emotional and physical safety adolescents need
to thrive.17 Providing caregivers with knowledge and skills
related to child development, communication, supervision
3 | Preventing Violence Where Youth Live, Learn and Play
and discipline can contribute to these supportive relationships.18
Strong caregiver relationships include:
Safety: freedom from fear and security from physical or
psychological harm.
Stability: predictability and consistency in a child’s social,
emotional and physical environment.
Nurturing: availability of a caregiver to respond to and
meet a child’s needs.
Source: Mercy and Saul, 2009
State Strategies
Evidence-based prevention programs can assist parents
and strengthen families, and limit, or eliminate, the need
for more costly interventions in the justice and welfare
systems. For example, in Washington, three parenting
programs, described below, were found to have a positive
cost-to-benefit ratio; for every $1 invested, the program
participants, taxpayers and society saved around $1 to $3
in areas such as criminal justice and health care.19 Some
state lawmakers are considering similar programs along
with other strategies, including the following.
•
Raising awareness and gathering information about
child maltreatment. Some state legislatures have
designated child abuse prevention months to raise
awareness, a strategy endorsed by the U.S. attorney
general’s task force on children and violence.20 In addition, a number of states, including Arkansas, Missouri
and Nevada, have enacted legislation in recent years to
create task forces on child sexual abuse.
•
Targeting efforts and funding to state-specific
needs. Nearly all states have a Children’s Trust Fund to
pay for programs aimed at preventing child maltreatment. These funds support proven community-based
programs, promote innovative strategies and convene
stakeholders in their states.21 State lawmakers often
oversee these funds and can focus efforts on statespecific priorities. New Mexico, for instance, recently
passed legislation to expand the fund’s function as a
statewide resource, advocate and educator around child
abuse and neglect.
© 2015 National Conference of State Legislatures
•
Investing in proven early prevention and intervention programs. Programs such as the Incredible Years,
Triple P (Positive Parenting Program) and Multi-Systemic Therapy are among those that promote healthy
families and reduce violence through parental support
and skill-building.22,23,24 At least 22 states have adopted
legislation related to early childhood home visiting, another program that supports parents and reduces child
maltreatment. In addition, the Centers for Disease
Control and Prevention (CDC) is currently funding
five state health departments to implement the Essentials for Childhood framework, which proposes
evidence-based strategies for communities to prevent
child maltreatment.25 One of the objectives in implementing the framework is to determine promising
practices, which may be informative for other states.
•
Promoting collaboration and convening partnerships. Lawmakers can facilitate partnerships within
their states through formal means, such as legislation
requiring collaboration among agencies, or by informally convening stakeholders to share experiences and
work together.
•
Learning about and supporting innovative models.
While less well studied, there is some evidence to suggest that addressing economic disadvantage can assist
in preventing violence. Programs to reduce concentrations of poverty, such as through vouchers to help
families move out of disadvantaged neighborhoods,
have shown promise.26 In addition, earned income
tax credit (EITC) programs are effective strategies in
supporting low- and moderate-income families. As of
2014, 25 states and the District of Columbia had their
own EITC program. Policymakers can learn more
about poverty alleviation efforts, support research to
develop innovative programs and demonstrate their
evidence, and help bring proven programs to their
states and communities.
Learn
The school environment—where adolescents learn—is
another determinant of health and violence. Adolescents
spend a considerable amount of time in school settings,
interacting with adults and peers. Peers are important as
young people determine their identities within the context
of relationships with others, and peers also can play a role
in youth violence through bullying, physical fights or teen
dating violence. In 2013, 8 percent of high school teens
were in a physical fight on school property and nearly 20
percent were bullied, according to the CDC’s Youth Risk
Behavior Survey.27 In addition, 7 percent of high school
students did not go to school at least once in the previous
month because of safety concerns.28
Students in grades 9-12 reported in the CDC’s 2013 Youth Risk Behavior Survey:
•
7.1 percent had not gone to school on at least one day in the previous month because they felt unsafe at
school or en route to or from school.
•
•
14.8 percent were electronically bullied at least once in the previous year.
19.6 percent were bullied on school property at least once in the previous year.
Source: Centers for Disease Control and Prevention, 2014
4 | Preventing Violence Where Youth Live, Learn and Play
© 2015 National Conference of State Legislatures
Violence can also occur in romantic relationships, in what
is typically referred to as teen or adolescent dating violence,
and can be emotional or sexual as well as physical. In 2013,
at least 10 percent of adolescents reported experiencing
physical dating violence, and a similar percentage experienced sexual dating violence at least once in the previous
12 months.29 In addition, a 2014 survey by the National
Campaign to Prevent Teen and Unplanned Pregnancy reported that 17 percent of teens felt pressure to go past their
personal sexual boundaries.30
Physical violence, bullying and dating violence have similar
consequences as other types of violence for health in adolescence and adulthood.31 Dating violence specifically can
also increase the risk of teen pregnancy.32
5 | Preventing Violence Where Youth Live, Learn and Play
State Strategies
State legislatures have adopted policies to promote school
safety in recent years through violence prevention education and bullying prevention. Strategies include:
•
Considering school policies to prevent violence and
bullying. In 2014, at least 14 states passed legislation
targeting bullying. Provisions of these laws include,
for example, training for teachers and administrators
in California, and requiring schools to develop bullying prevention and intervention plans in Oklahoma.
Anti-bullying policies are also showing promise.33
Some states include multiple bullying prevention
strategies through comprehensive legislation, as in
Rhode Island’s Safe School Act in 2012, which created
a statewide bullying policy and other requirements.34
© 2015 National Conference of State Legislatures
•
•
Supporting or funding programs that prevent violence and bullying in schools. School-based programs
can help students develop positive social behaviors and
life skills to help them counter violence, such as problem solving, conflict resolution and anger management.35 Approximately 70 percent of states provided
policy or programmatic guidance for violence prevention education between 2010 and 2012.36 Many school
violence prevention programs have strong evidence,
while bullying prevention programs are promising but
still largely being researched.37 Universal school-based
programs, delivered to an entire school or grade, have
successfully reduced violence among youth.38 These
include Life Skills Training, which teaches youth social
skills, stress management and problem solving, and
drug resistance techniques.39
Integrating healthy relationship and violence prevention education into health education. At least
19 states have enacted laws that encourage or require
school districts to incorporate healthy relationship
or teen dating violence education into their existing health education efforts. Some states also require
schools to develop policies related to dating violence
and other school violence.
bullying in after-school activities.42 The “built environment” of communities—the physical characteristics of the
environment, such as buildings, parks, streets and other
infrastructure—can also impact exposure to violence.
In all settings—including neighborhoods and schools—
nearly 18 percent of youth reported carrying a weapon in
the past month and nearly 25 percent reported being in
a physical fight in 2013.43 Gang involvement is also a significant issue as exposure to violence puts youth at risk for
joining gangs, and gang involvement increases the risk of
being a victim or perpetrator of violence.44 Preventing gang
involvement has positive implications for youth health as
well as overall community violence.
State Strategies
States can adopt policies that promote healthy and safe
communities. Strategies include:
•
•
Promoting positive youth development programs.
Positive youth development (PYD) is a proven approach that uses young people’s existing strengths and
leadership skills, rather than focusing on their problems or deficits.40 PYD strategies can be incorporated
into many of the other youth programs that states and
schools employ, or pursued as a strategy on its own.
For instance, Iowa lawmakers formalized an existing
youth development collaborative to support PYD efforts across multiple sectors and overlapping initiatives.
Play
Neighborhoods and communities where youth play comprise the third overarching determinant that affects violence exposure among youth. Exposure to violence in the
community, like the other settings, can put young people
at risk for physical and psychological harm that affects
health and relationships in adolescence and adulthood.41
Community violence encompasses peer and adult violence
in public settings, from shootings in neighborhoods to
6 | Preventing Violence Where Youth Live, Learn and Play
Supporting local initiatives or partnering with community organizations to reach high-risk communities. Minnesota enacted legislation in 2014 to prevent
youth violence through community-based programs.
It mandated collaboration between local organizations
and required programs to address certain prevention
strategies, such as strengthening families and supporting school engagement. The legislation also directed
the commissioner of health to support violence
prevention programs through technical assistance
and other means. In addition, West Virginia passed a
comprehensive law in 2012 to support at-risk youth
through a community-based pilot project. The project
had numerous goals, including reducing child abuse
and neglect as well as juvenile delinquency through
wrap-around family support services.
The built environment encompasses
the physical characteristics of a community,
including:
•
Businesses, residences and schools
•
Streets and sidewalks
•
Lighting
•
Parks, playgrounds and public spaces
•
Access to healthy foods
© 2015 National Conference of State Legislatures
•
Promoting environmental approaches to reducing violence. Business Improvement Districts (BID)
offer a local economic development strategy in which
property and business owners pay an additional tax
to fund supplemental services, such as street cleaning,
security or capital improvements. In Los Angeles, BIDs
spent a large portion of their budgets on crime prevention and environmental redesign, and were associated
with significant reductions in crime.45 Nearly all states
have passed legislation enabling or outlining guidelines
for BIDs in their states. Another promising approach
for communities is Crime Prevention through Environmental Design (CPTED), which uses the built
environment—such as shrubbery, lighting, building
maintenance and area surveillance—to limit opportunities for crime and violence.46
•
Adopting or enforcing policies related to youth
access to alcohol. Due to the potential of alcohol to
contribute to community violence, lawmakers may
also look at policies to reduce youth access to alcohol.47
One evidence-based approach supported by the CDC
is to consider zoning and density of alcohol-related
businesses.48 Lawmakers may wish to study these policies, while balancing economic development and local
business interests.
•
Exploring innovative approaches to gang and violence prevention. Promising approaches to preventing
youth from joining gangs are similar to other violence
prevention initiatives, such as programs that develop
problem-solving skills or strengthen families, or
programs that reduce violence in communities.49 For
example, the Cure Violence program, which reduced
violence in cities such as Chicago and Baltimore, uses
trained community workers to respond to all types of
community violence.50
Conclusion
Youth violence is a significant public health issue for states,
causing injuries and death to thousands of young people
each year and affecting their long-term health. Exposure
to violence in any form, whether as victims, perpetrators
or witnesses, can affect the physical, social and emotional
health of adolescents. Incorporating the social determinants of health—the contexts in which youth live, learn
and play—can be an effective framework in which states
can address prevention efforts. States are actively pursuing
numerous proven and emerging approaches in all three
environments through innovative policies, evidence-based
programs and partnerships. By looking at youth violence
through the lens of the social determinants, policymakers
have the ability to address multiple issues that contribute
to the well-being of adolescents and promote a healthy
future for their constituents.
This publication was made possible by grant number 1U50CE002586-01 from the
Centers for Disease Control and Prevention. Its contents and the links to non-CDC
websites are solely the responsibility of the authors and do not necessarily represent the
official views of the Centers for Disease Control and Prevention, the National Center for
Injury Prevention and Control, or the U.S. Department of Health and Human Services.
Notes
1. Centers for Disease Control and Prevention, Adolescent Health,
www.cdc.gov/healthyyouth/adolescenthealth/, accessed Feb. 5, 2015.
2. World Health Organization, Youth Violence, www.who.int/
mediacentre/factsheets/fs356/en/, accessed Feb. 5, 2015.
3. David Finkelhor, Anne Shattuck, Heather A. Turner, and Sherry
L. Hamby, “Trends in Children’s Exposure to Violence, 2003-2011,”
JAMA Pediatrics, (2014): E1-E7, www.academia.edu/9598220/Trends_
in_Childrens_Exposure_to_Violence_2003-2011.
4. Attorney General’s National Task Force on Children Exposed to
Violence, Defending Childhood (Washington, D.C.: U.S. Department of
Justice, 2012), www.justice.gov/sites/default/files/defendingchildhood/
cev-rpt-full.pdf.
7 | Preventing Violence Where Youth Live, Learn and Play
5. Centers for Disease Control and Prevention. Web-based Injury
Statistics Query and Reporting System (WISQARS) (Atlanta, Ga.:
National Center for Injury Prevention and Control, CDC, 2003), www.
cdc.gov/ncipc/wisqars, queried Feb. 4, 2015.
6. Ibid.
7. Attorney General’s National Task Force on Children Exposed to
Violence, Defending Childhood; Corinne David-Ferdon and Thomas R.
Simon, Preventing Youth Violence: Opportunities for Action (Atlanta, Ga.:
National Center for Injury Prevention and Control, CDC, 2014), www.
cdc.gov/violenceprevention/youthviolence/pdf/opportunities-for-action.
pdf.
8. World Health Organization, Youth Violence.
9. Finkelhor, “Trends in Children’s Exposure to Violence, 20032011.”
© 2015 National Conference of State Legislatures
10. Centers for Disease Control and Prevention, Adolescent Health.
11. Centers for Disease Control and Prevention, Social Determinants of Health, www.cdc.gov/socialdeterminants/Definitions.html,
accessed Feb. 5, 2015.
12. Attorney General’s National Task Force on Children Exposed
to Violence, Defending Childhood.
13. U.S. Department of Health and Human Services, Child
Maltreatment 2013 (Washington, D.C.: Children’s Bureau, Administration on Children, Youth and Families, Administration for Children and
Families, U.S. DHHS, 2015), www.acf.hhs.gov/sites/default/files/cb/
cm2013.pdf.
14. World Health Organization, Youth Violence; Attorney General’s National Task Force on Children Exposed to Violence, Defending
Childhood.
15. World Health Organization, Youth Violence.
16. James A. Mercy and Janet Saul, “Creating a Healthier Future
Through Early Interventions for Children,” Journal of the American
Medical Association 301, no. 21 (2009): 2262-2264, http://jama.jamanetwork.com/article.aspx?articleid=183991.
17. Ibid.
18. Ibid; David-Ferdon, Preventing Youth Violence.
19. Stephanie Lee, S. Aos, and A. Pennucci, What works and what
does not? Benefit-cost findings from WSIPP (Olympia, Wash.: Washington
State Institute for Public Policy, 2015), www.wsipp.wa.gov/ReportFile/1602/Wsipp_What-Works-and-What-Does-Not-Benefit-CostFindings-from-WSIPP_Report.pdf.
20. Attorney General’s National Task Force on Children Exposed
to Violence, Defending Childhood.
21. National Alliance of Children’s Trust and Prevention Funds,
www.ctfalliance.org/initiative.htm, accessed Feb. 6, 2015.
22. The Incredible Years, The Incredible Years: Series Goals, http://
incredibleyears.com/about/incredible-years-series/series-goals/, accessed
Feb. 6, 2015
23. Triple P – Positive Parenting Program, The System At Work,
www.triplep.net/glo-en/the-triple-p-system-at-work/, accessed Feb. 6,
2015.
24. MST Services, What Is MST, http://mstservices.com/what-ismst/what-is-mst, accessed Feb. 6, 2015.
25. Centers for Disease Control and Prevention, Essentials for
Childhood Framework: Steps to Create Safe, Stable, and Nurturing Relationships and Environments for all Children, www.cdc.gov/violenceprevention/childmaltreatment/essentials.html, accessed Feb. 6, 2015.
26. World Health Organization, Youth Violence; Mercy, “Creating
a Healthier Future Through Early Interventions for Children.”
27. Laura Kann et al., “Youth Risk Behavior Surveillance – United
States, 2013,” MMWR 63, no. 4 (2014), www.cdc.gov/mmwr/pdf/ss/
ss6304.pdf.
28. Ibid.
29. Ibid.
30. The National Campaign to Prevent Teen and Unplanned Pregnancy, Survey Says: February 2014: Under Pressure (Washington, D.C.:
TNC, 2014).
31. Centers for Disease Control and Prevention, Understanding
School Violence (Atlanta, Ga.: CDC, 2015), www.cdc.gov/violencepre-
vention/pdf/school_violence_fact_sheet-a.pdf; Centers for Disease Control and Prevention, Teen Dating Violence, www.cdc.gov/violenceprevention/intimatepartnerviolence/teen_dating_violence.html, accessed
Feb. 4, 2015.
33. David-Ferdon, Preventing Youth Violence.
34. Rhode Island State Department of Elementary and Secondary
Education, Safe School Act: Statewide Bullying Policy, http://sos.ri.gov/
documents/archives/regdocs/released/pdf/DOE/6774.pdf, accessed Feb.
6, 2015.
32. The National Campaign to Prevent Teen and Unplanned Pregnancy, Why It Matters: Teen Pregnancy and Violence (Washington, D.C.:
TNC, 2007), https://thenationalcampaign.org/resource/why-it-mattersteen-pregnancy-and-violence.
35. Centers for Disease Control and Prevention, School Violence:
Prevention, www.cdc.gov/violenceprevention/youthviolence/schoolviolence/prevention.html, accessed Feb. 6, 2015; World Health Organization, Youth Violence.
36. Centers for Disease Control and Prevention, School Health
Policies and Practices Study, 2012 (Atlanta, Ga.: CDC, 2013), www.
cdc.gov/healthyyouth/shpps/2012/factsheets/pdf/FS_ViolencePrevention_SHPPS2012.pdf.
37. David-Ferdon, Preventing Youth Violence.
38. Robert Hahn, et al., “Effectiveness of Universal School-Based
Programs to Prevent Violent and Aggressive Behavior: A Systematic Review,” American Journal of Preventive Medicine 33, no. 2S (2007): S114–
S129, www.thecommunityguide.org/violence/School_Evidence_review.
pdf.
39. David-Ferdon, Preventing Youth Violence; National Health Program Associates, Life Skills Training: Program Overview, www.lifeskillstraining.com/, accessed Feb. 7, 2015. 40. Attorney General’s National Task Force on Children Exposed
to Violence, Defending Childhood.
41. Ibid.
42. Ibid.
43. Kann et al., Youth Risk Behavior Surveillance – United States,
2013.
44. James C. Howell, Gang Prevention: An Overview of Research
and Programs (Washington, D.C.: Office of Juvenile Justice and Delinquency Prevention, U.S. Department of Justice, 2010), www.ncjrs.gov/
pdffiles1/ojjdp/231116.pdf; David-Ferdon, Preventing Youth Violence.
45. John MacDonald, Daniela Golinelli, Robert J. Stokes, and
Ricky Bluthenthal, “The effect of business improvement districts on
the incidence of violent crimes,” Injury Prevention (2010), http://injuryprevention.bmj.com/content/early/2010/06/29/ip.2009.024943.full.
pdf+html.
46. Julie Samia Mair and Michael Mair, “Violence Prevention and
Control through Environmental Modification,” Annual Review of Public
Health 24: (2003):209-225.
47. David-Ferdon, Preventing Youth Violence.
48. Ibid.
49. Ibid.
50. Cure Violence, The Cure Violence Health Model, http://cureviolence.org/the-model/essential-elements/, accessed Feb. 7, 2015.
William T. Pound, Executive Director
7700 East First Place, Denver, Colorado 80230, 303-364-7700 | 444 North Capitol Street, N.W., Suite 515, Washington, D.C. 20001, 202-624-5400
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