Peer violence and violence prevention

INTRODUCTION — An overview of peer violence and prevention of violence is reviewed here. Violence in the media, intimate partner violence, and child abuse are discussed separately.

OVERVIEW — Violence is a major cause of death and disability for American children. Violence or witnessing violence has both physical and psychiatric sequelae, including posttraumatic stress disorder, adjustment reactions, severe grief reactions, and depression [1].

Pediatric care providers play an important role in prevention of violence. Universal (primary) prevention centers on screening and anticipatory guidance for the promotion of resilience and the avoidance of risk. Secondary prevention involves treatment, counseling, and referral for children and adolescents who have experienced violence-related injury. In addition, pediatric care providers can advocate for school policies and state and federal legislation to reduce the risk of violence for children. This view of violence prevention, discussed below, puts violence squarely in the context of improving individual and family resilience, and positively engaging adolescents.

EPIDEMIOLOGY — The United States has the highest youth homicide rate among the 23 wealthiest nations [2]. Homicide is the third leading cause of death among 15- to 19-year-olds and the leading cause of death among Black youth [3].

Data describing nonfatal violence come from national surveillance systems and emergency departments. State and national data are available from the Web-based Injury Statistics Query and Reporting System. These statistics underestimate the prevalence of nonfatal violence because many victims do not seek medical treatment or because the cause of injury is not coded completely or correctly. Other government agencies track relevant data through surveys:

●In 2019 Centers for Disease Control and Prevention surveillance, 21.9 percent of high school students reported having been in a physical fight in the past 12 months, with the prevalence dropping from the 9^th (25.8 percent) to 12^th (17.6 percent) grade [4]. The low incidence of nonfatal assault-related injuries seen in emergency departments in this age group (approximately 6 per 1000) [3], indicates that most of these injuries were minor.

●Assaultive trauma recurs; hospital readmission rates for subsequent assaults remain persistently high, up to 44 percent [5-8].

●Most violence in the United States occurs between friends, acquaintances, or intimate partners, and the distinction between victim and perpetrator is not always clear [9-11]. A literature review has identified a group of individuals who may be both victim and offender on different occasions [12]. For this reason, violence prevention programs often emphasize conflict resolution skills. (See 'Anticipatory guidance' below and 'Schools' below.)

●Approximately 13 percent of high school students in the 2019 Youth Risk Behavior Surveillance Survey reported carrying a weapon (gun, knife, or club) on at least one day in the month before the survey [4]. Weapon carrying was more commonly reported among males than females (19 versus 7 percent), and 3 percent of students reported carrying their weapons to school. The percentage of students carrying weapons decreased between 1991 (26 percent) and 2019 (13 percent). Carrying a weapon to school has been associated with being a victim of bullying, particularly if the victim has other risk factors for peer violence (eg, physical fighting at school, being threatened or injured at school, school absence related to safety concerns) [13].

RESILIENCE FACTORS — Data from the National Longitudinal Survey of Youth (NLSY) and from the Vermont Youth Risk Behavior Survey each demonstrate powerful protective effects of youth engagement [14]. The NLSY analyses demonstrated that caregiver expectations and connectedness with parents, caregivers, and other adults and with school protected against violence. The results showed the power of these protective factors, even in the presence of substantial risk factors. Social assets can be measured on a population level using proprietary surveys developed by the Search Institute [15]. They describe several domains of positive developmental assets, community strengths, and self-reported attitudes and behaviors that protect against violence and drug use. In a now-classic paper, the Vermont Department of Public Health used similar constructs to add to the Youth Risk Behavior Survey. Their work showed there was an inverse correlation between measured assets and health risk behaviors [16]. In another nationally representative survey of 7^th to 12h graders, higher educational aspirations were protective against weapon-related behaviors for Black and Latin American adolescents, and higher family connectedness was protective for Latin American adolescents [17].

On a community level, the Chicago neighborhood study showed that among neighborhoods in Chicago with similar economic and demographic characteristics, improved neighborhood cohesion and self-efficacy were associated with large decreases in youth violence [18].

Programs directed at reducing youth violence are largely based on the positive youth development model, which has evidence of success [19]. Programs for positive youth development are defined by the National Academy of Sciences as programs that seek to [20]:

●Promote bonding and social, emotional, cognitive, behavioral, or moral competence

●Foster resilience, self-determination, spirituality, self-efficacy, clear and positive identity, belief in the future, and prosocial norms

●Provide recognition of positive behavior and opportunities for prosocial norms

RISK FACTORS — Most serious violence-related injuries result when people who have learned to use violence to solve problems have access to weapons. Law enforcement agencies traditionally attempt to assign culpability in cases of violence, determining who was the victim and who was the perpetrator of a particular violent act. However, from a public health perspective, it most often emerges that both victims and perpetrators are caught in a culture of violence. Children and adolescents who fight regularly are at risk of severe injury.

Several key risk factors for violence and violence-related injury have been identified; they are complex, interdependent, and influenced by individual and societal variables [12,14,21-32]:

●Previous history of violence-related injury or perpetration

●Male sex

●Early childhood aggressive behavior, violent discipline

●Access to firearms and/or obsession with weapons and death

●Alcohol and other drug use

●Gang involvement or social isolation

●Exposure to intimate partner violence and child abuse

●Media violence

Children begin to develop aggressive behavior and violent habits of thought in the early years. In one prospective study, eight-year-old children in rural New York were followed for 22 years [33]. Television watching and peer-nominated aggression (being described as aggressive by peers) were independently associated with criminal conviction for violent crimes by the age of 30 years. Another study reported long-term follow-up of children observed beginning in infancy [34]. The investigators concluded that children begin to learn to control their innate aggression beginning at age 17 months, supporting the importance of influences in early childhood on subsequent violence and aggression.

Later in life, experiencing violence (being shot, stabbed, or beaten) among men aged 17 to 29 years was identified as a risk for violent behavior [35]. Those who reported more serious traumatic experiences, such as incarceration, witnessing violence, or carrying a weapon, had the highest risk of violent assault (odds ratio 10, 95% CI 4-25). Females, too, are more likely to behave violently if they have been victims of violence [36].

Physical discipline — The use of violent discipline methods teaches children that violence is an appropriate means of shaping behavior. Evidence strongly suggests that corporal punishment can set in motion a vicious cycle of increasing aggression met by further physical punishment [37-39]. Corporal punishment has been linked to later aggression, dating violence, and adult intimate partner violence [40-43]. Corporal punishment is largely ineffective [41]; children whose caregivers are unable to set effective limits may develop dysfunctional behavior patterns of interaction, particularly if corporal punishment is used extensively [44,45]. Dysfunctional interaction may lead to poor performance and social isolation in the early school years and, later, association with peer groups that reward violence and antisocial behavior [46].

Access to firearms and weapon carrying — Having a firearm in the home is associated with increased risk of homicide, suicide, and unintentional injury. The carrying of weapons increases the risk of violent behavior and violence-related injury by providing a false sense of security that contributes to impulsive behavior [47,48]. It is estimated that approximately one-half of nonfatal firearm-related hospitalizations in children and adolescents are secondary to assault [49]. Safe storage of firearms (ie, locked up and unloaded, with ammunition locked separately) is associated with decreased risk of unintentional and suicide firearms deaths. Safe storage of firearms and other interventions to prevent firearm injury in children and adolescents are discussed separately. (See "Firearm injuries in children: Prevention".)

Alcohol/drug use — Substance abuse, which alters the dynamics and decisions in violent or near-violent episodes, is associated with an increased risk of exposure to violence, carrying weapons, and homicide among adolescents and street gangs [30,50-52]. Early onset of alcohol or drug use increases the risk of abuse-related violence that continues into adulthood. In one survey of more than 40,000 adults between 18 and 44 years of age, those who began drinking alcohol before age 14 years were 14 times more likely to report having been in an alcohol-related fight within the past year than those who began drinking after age 21 years [53].

Gang participation — The National Youth Gang Survey (1996-2009) estimates that there are approximately 26,000 gangs and 775,000 gang members in the United States [54]. Children and adolescents who participate in gangs are more likely to promote aggressive attitudes, report victimization experiences, be involved in fights, carry weapons to school, and use drugs or alcohol at school [55-57]. They are also at risk for homicide at school. In Centers for Disease Control and Prevention surveillance, gang-related activity was a common motive for single-victim and multiple-victim homicides at school [58].

Witnessing violence — The witnessing of violence by children increases the risk that they will react violently later in life [59]. More than one-half of the six-year-old urban children living below the poverty threshold in a cross-sectional study of exposure to violence had witnessed some form of violence [60]. The children who witnessed violence had more behavioral, emotional, attention, and social problems than did those who did not. Chronic exposure to violence may lead to toxic stress, a syndrome associated with changes in brain development and resultant deficits in executive function [61].

Intimate partner — Intimate partner violence and child abuse are the greatest risk factors for violence for infants and toddlers. Exposure to violence and victimization is associated with subsequent acts of violence by the witness [62,63]. Children who witness intimate partner violence are harmed cognitively, emotionally, and developmentally [64,65]. (See "Intimate partner violence: Childhood exposure", section on 'Effects'.)

Television/media violence — Children and adolescents in the United States spend an average of >2 hours per day watching television and at least six hours per day when all types of media are included (eg, movies, videos, digital music, video/computer/mobile games, social media, digital devices, etc) [66]. (See "Television and media violence", section on 'Quantity of media violence exposure'.)

According to the National Television Violence Study [67]:

●Nearly two-thirds of all programming contains violence

●Children's shows contain the most violence

●Portrayals of violence usually are glamorized

●Perpetrators often go unpunished

Television/media violence differs from real violence in important ways. Violence on television/media typically is socially acceptable, being used by heroes and villains alike. Young children, unable to separate fact from fantasy, are more affected by television/media violence than are adults. Viewing violence can lead to increased aggressive attitudes, values, and behavior, particularly in children [68]. Exposure to television/media violence also may be associated with increased aggressive behavior. (See "Television and media violence".)

Bullying — Bullying is the repeated infliction of harm on younger, smaller, or less powerful peers [69]. Almost 10 percent of students in grades 6 through 12 report having been bullied at school, school activities, or on the way to or from school [69,70]. Both the bully and the victim are affected by bullying. Effects on victims include physical injury, difficulty concentrating, physical symptoms (eg, nausea, anorexia), symptoms of anxiety or depression, poor self-esteem, and high rates of school absence [71-73]. Bullies, however, often feel powerful and effective. In contrast to the situation in childhood, the long-term outcome (at age 30 years) for bullies themselves is especially poor. They are more likely to be incarcerated and are less likely to be employed, married, or in other stable adult relationships than are their peers [74].

Community violence — Studies conducted in poor urban neighborhoods identified a pattern of violence in which fighting and the willingness to fight are key components of a protective strategy for coping with dangerous environments [75]. Young people who are unwilling or unable to defend themselves are prey to multiple and repeated attacks in the "code of the streets." Some caregivers understand this culture and may actually encourage their children to become able fighters to defend themselves. However, caregivers can play a crucial role in encouraging safe behavior. They can teach their children how to defuse tense situations [76,77]. Resources to help caregivers encourage safe behaviors are available through the American Academy of Pediatrics (eg, the "Talking with your teen: Tips for parents" and "Staying cool when things heat up" brochures) [76]. (See 'Resources' below.)

Certain neighborhood factors can mitigate community violence. In an observational study, a higher concentration of resources for young people and adults was associated with lower levels of community aggression [78]. Programs that focus on building school and community resources may reduce violence [79,80].

SCREENING — Pediatric care providers should screen for violence and violence risk factors at routine health care visits. The screening questions depend upon the child's age and developmental stage and the cultural background of the family. In most cases, children may be asked directly whether they have been involved in or witness to any violence [11]. The assessment of family functioning, family stress, coping mechanisms, and support systems, always a key component of routine health care maintenance, is also an important dimension of preventing violence. Environmental factors, chiefly access to guns, should be assessed periodically. Finally, abrupt deterioration in school performance may indicate violence or a related health risk factor including bullying, depression, substance use, intimate partner violence, or family illness. Emotional and behavioral problems can be assessed using the Pediatric Symptom Checklist or the Child Behavior Checklist. (See "Developmental-behavioral surveillance and screening in primary care", section on 'Choice of screening test'.)

In addition, pediatric care providers should screen for intimate partner violence at all health care visits, particularly in the perinatal period. Pregnant and postpartum women should be asked about a history of intimate partner violence [81]. The 2017 Bright Futures Guidelines suggest screening during the newborn, one month, and one year visit [82]. Many health care providers post intimate partner violence hotline numbers in women's restrooms. (See "Intimate partner violence: Childhood exposure", section on 'The process of asking about caregiver intimate partner violence' and "Intimate partner violence: Epidemiology and health consequences", section on 'Pregnancy' and "Intimate partner violence: Diagnosis and screening".)

Adolescent screening — Violence clusters with other high-risk behaviors in adolescents. In addition to being questioned regarding drug use and sexual risk, all teenagers should be asked directly about violence. The "FISTS" questions help to identify those who are at risk of violence-related injury (table 1) [83]:

●Fighting

●Injuries

●Sexual violence

●Threats

●Self-defense

Risk stratification — Additional information is used to assess the level of risk for violence-related injury in teenagers because risky behaviors tend to cluster [47,84-87].

●Low risk – Adolescents who are in school and neither fight nor use drugs are at low risk for violence-related injury. These patients deserve a positive comment about their ability to handle conflict without fighting.

●Moderate risk – Adolescents who attend school with passing grades but who either fight or use drugs are at approximately three times the risk for violence-related injury than are those who neither fight nor use drugs. Many moderate-risk patients can be counseled successfully in the office. Identify specific risk factors (eg, trouble on the school bus) and help the teenager work out a strategy to avoid the situation.

●High risk – Adolescents who are failing or have dropped out of school, or who both fight and use drugs, are at approximately seven times the risk for violence-related injury than are low-risk teens. Prompt referral to a social worker or other counselor is indicated. Adolescents who are treated in the emergency department after an assault are at high risk of future firearms injury [88]. Those who are admitted to the hospital with violent injury are at increased risk of drug- or alcohol-related death; males who are admitted to the hospital with violent injury are at increased risk of suicide [89]. (See "Suicidal behavior in children and adolescents: Epidemiology and risk factors", section on 'Exposure to violence or victimization'.)

Caregivers of all teenagers should be counseled concerning the dangers of storing a firearm, particularly a handgun, in the home. (See "Firearm injuries in children: Prevention", section on 'Family counseling'.)

ANTICIPATORY GUIDANCE — The American Academy of Pediatrics (AAP) and the American Medical Association recommend violence prevention counseling [90,91] (see "Guidelines for adolescent preventive services", section on 'Anticipatory guidance for adolescents'). Children visit their health care provider frequently during infancy and early childhood. These visits furnish multiple opportunities for the provider to provide focused interventions toward prevention of violence. The provider can identify and attempt to modulate risk factors for violence. In addition, they can attempt to enhance the protective factors (eg, intact family structure, positive peer groups, self-esteem, and confidence). Pediatric health care providers can encourage caregivers to model nonviolent behavior, anger management, and conflict resolution for their children. In addition, children should be encouraged to participate in activities that are socially acceptable and build useful life skills [90].

Some aspects of violence prevention counseling, such as the presence of guns in the home, media violence, or the need to maintain family relationships, apply to all age groups. Other aspects should be adapted to the age and developmental stage of the child. Conversations with older children and adolescents, for example, may be initiated by specific events or by a history that indicates a risk of violence-related injury. Topics related to violence prevention are included in guidelines for health supervision [92].

Firearms — Although the safest home for children is a home without guns, evidence suggests that there is incremental benefit in safer storage of firearms when they are present in the home. Centers for Disease Control and Prevention surveillance indicates that most of the firearms used in school-associated homicides were obtained from the perpetrator's home or the home of a relative or friend [93].

Families who have guns at home should be counseled that the weapons should be stored locked and unloaded, and the ammunition stored in a separate locked location. Some pediatric health care providers in regions with a high prevalence of handgun ownership distribute gun locks (see www.projectchildsafe.org for information concerning one such program). (See "Firearm injuries in children: Prevention", section on 'Family counseling'.)

Media — The AAP recommends that pediatric health care providers ask caregivers [94]:

●"How much recreational screen time does your child or teenager consume daily?"

●"Is there a TV or internet-connected device in the child's bedroom?"

Children and teens should be limited to less than two hours of entertainment screen time per day, and caregivers should monitor media use, including websites. (See "Television and media violence", section on 'Family and individual'.)

Intimate partner violence — Pediatric offices should provide information and support to adults who are experiencing intimate partner violence. Social work contacts and referral phone numbers should be available to providers and other office staff. Health care providers should be aware of the strong associations between intimate partner violence and child abuse [95], and of the long-term consequences of witnessing intimate partner violence. (See "Intimate partner violence: Childhood exposure".)

Age-specific anticipatory guidance — According to the AAP, health care providers can incorporate violence prevention into routine practice [90].

Birth to four years — The pediatric health care visits from birth to age 4 years typically center on the establishment of good caregiver practices, environmental safety, and behavior concerns. These topics are related directly to violence prevention. Careful screening and support in the primary care setting is associated with measurable decreases in child maltreatment [96].

Violence-free discipline — Family discipline patterns usually are established as children enter the second year of life. The AAP recommends that caregivers be encouraged and assisted in developing methods other than spanking to shape the behavior of their children [40].

Some of these techniques include [40,90]:

●Maintaining a schedule of meal, nap, play, bath, and bed times to foster the child's feeling of mastery of their environment

●Satisfying the toddler's need for caregiver attention by providing positive reinforcement and praise for good behavior

●Using time-out from positive reinforcement, natural, or logical consequences when the child's misbehavior requires negative consequences

●Establishing family rules to address potential areas of conflict

The short-term effectiveness of anticipatory guidance by trained providers and written materials on the use of time-outs was demonstrated in a controlled clinical trial of 559 parents [97]. An increase occurred in the report of the use of time-out in the intervention group two to three weeks after the intervention (35 versus 2 percent of parents). Video-based caregiver education for violence prevention also is available and appears effective in short-term trials [98,99]. Finally, a large national trial demonstrated the effectiveness of the use of brief motivational interviewing (an assessment of family interest and confidence in changing behavior to generate patient-centered solutions) and of giving families a kitchen timer (to monitor media-time and time-outs) [100].

School-age — Families of school-aged children (5 to 12 years) should continue to be counseled regarding guns, television, and exposure to violence. In addition, the pediatric health care provider should ask about bullying and fighting in school.

The caregivers of children who are victims of bullies should be encouraged to discuss the problem with the school principal or guidance counselor. They have a right to expect a physically and emotionally safe school environment for their children. School officials can intervene to control bullying. (See 'Schools' below.)

Bullies often come from disordered families, and their caregivers may be unwilling or unable to establish clear rules at home. Effective intervention programs include a strong caregiver education program for the caregivers of bullies, helping them learn to provide a structured home environment for their children [74]. Given the poor long-term outcomes for bullies, this intervention may be the most important component of a bullying prevention program.

Adolescents — Teenagers and their caregivers should be educated about violence; in particular, they should know that:

●Engagement in prosocial groups provides powerful protection for adolescents [14].

●Clinicians should inquire regarding participation in after-school programs, athletics, or church-based youth activities. Adolescents and their caregivers should be counseled regarding the importance of engagement during the summer with employment, camp, or volunteer activities.

●Skills-based intervention conducted in school interventions have been shown to be effective in reducing violence [101].

●Most violent injuries occur in fights between friends or acquaintances [10]. Teens should learn how to walk away from a fight. Caregivers should know their children's friends.

●The carrying of guns and other weapons encourages impulsive behavior and increases the risk of injury.

Adolescents who are identified to be at increased risk for violence-related injury should be counseled according to their personal situation and risk category. (See 'Risk stratification' above.)

Those who are at low risk should receive reinforcement for their ability to avoid physical confrontation. Counseling may focus on their progress toward independence, with a focus on positive peer and social group relationships. They should be warned of the dangers of carrying a weapon, encouraged to avoid dangerous places and situations, and cautioned to use nonviolent conflict resolution strategies (table 2).

Those who are at moderate risk should be told that the risk of injury is real and should receive education about techniques to defuse tense situations (table 2). These adolescents, who may not yet be able to think abstractly, may need to generate or be given lists of appropriate ways to react in tense situations. Making the list in anticipation of the situation provides the concrete-thinking adolescent with alternative behaviors before the situation arises. Moderate-risk teens should be counseled to evaluate their own risk-taking behavior. Their existent nonviolent problem-solving skills should be reinforced, and the clinician may provide support for their abilities to solve conflict without violence.

Adolescents who are at high risk for violence-related injury should be screened for mental health problems (eg, depression, posttraumatic stress disorder, drug use) and referred appropriately. Those who do not have mental health problems should be referred to a social worker, counselor, or street outreach worker. They may benefit from community agencies that offer adult mentoring or activities.

Adolescent health providers should stress the importance of follow-up to the high-risk teen and to their caregivers. Involvement of the caregivers and/or the extended family of the teenager is important. Caregivers should be taught to ask how fights started or could have been avoided, but not who won. If necessary, follow-up visits can be scheduled for another medical matter (eg, acne) to monitor the patient's progress.

Violence prevention counseling for adolescents is based upon a behavior change model that includes precontemplation, contemplation, and resolution.

●Precontemplation – Teenagers in this stage do not recognize that the behavior is a problem. They should be informed of their own personal risk and that other young people from their communities have managed to avoid fighting without losing face, as in, "I am concerned about you. You haven't yet learned how to avoid fighting, and some of my patients who fight a lot get seriously hurt." Clinicians embarking on this approach should understand the role that fighting plays in the lives of teens, and the real and perceived dangers inherent in being labeled as a "sucker" [75].

●Contemplation – Teenagers in this stage recognize that violence is a problem, but they have not yet begun to change their behavior. They should receive information about nonviolent conflict resolution (table 2).

●Resolution – Teenagers in this stage have adopted new behavior patterns to avoid violence. Those who are trying to use nonviolent techniques of problem solving should be encouraged for their efforts.

Counseling may involve reviewing specific skills that can be used to defuse situations of potential conflict.

SECONDARY PREVENTION — Secondary prevention involves treatment, counseling, and referral for children and adolescents who have experienced violence-related injury. Children and adolescents who have been injured in a fight are at high risk for further violence, and crisis intervention is needed [88,102,103]. They should be asked:

●Is the fight over?

●Do you feel safe leaving here?

●Is there someone who can mediate if the fight is ongoing?

Referral to a mental health provider may be necessary if traumatic stress symptoms are present or if the situation is volatile and cannot be resolved [104]. When a specific individual is threatened, health care providers may have a "duty to warn," and the police should be notified. The child or adolescent and the caregivers should be informed of the risk of serious injury and techniques for successful injury prevention (eg, methods to de-escalate conflicts) (table 2).

The following steps are recommended for providers who care for children and adolescents who have experienced a serious violence-related injury:

●Ask the child to tell you about the problem; listen without interruption and avoid judgment. This approach permits the child to express feelings of vengefulness and allows the provider to understand the child's perspective before offering advice.

●Assess the other risks (eg, weapon carrying, alcohol or drug use, gang involvement) and discuss the risk factors for violence with the child or adolescent.

●Develop a plan for safety after leaving the hospital or clinic (eg, staying with a friend or relative who lives out of the neighborhood and involving the police if necessary).

●Discuss strategies for conflict avoidance at the time of injury and at subsequent visits. These strategies must respect the patient's need for peer approval. One strategy of conflict avoidance is for the patient to tell the person who insists on fighting that they will fight them later (eg, at 3 PM) but will not fight now. The forced time interval may reduce the fury and make it easier to talk about the conflict.

●Screen the child for emotional/behavioral symptoms (eg, using the Pediatric Symptom Checklist or the Child Behavior Checklist) [105]. (See 'Screening' above.)

●Refer the child for support services (eg, psychology, social work, church members, recreation departments, mentoring programs) [106,107]. Children and adolescents who are depressed should be referred to a mental health professional; those who were innocent victims may need posttraumatic stress counseling [108].

ADVOCACY — Youth violence is a serious health risk and complex social problem that requires broad-based public action for prevention. Pediatric health care providers, through the American Academy of Pediatrics and other organizations (eg, Children's Defense Fund), can advocate for social policies that benefit children. Violence prevention programs can be cost-effective and have lasting results [109,110].

Individuals — Pediatric care providers advocate for their patients to receive the care and services that they need (eg, mental health service, family support). Individual adolescent patients may be encouraged to discover activities and social groups that promote the mastery of new skills and that lead to membership in prosocial groups. Adolescents who have experienced loss may benefit from grief counseling or specific evidence-based treatment for posttraumatic stress. Caregivers of teenaged patients should be advised to restrict access to firearms.

Schools — School-based violence prevention programs are an effective means of reducing violent and aggressive behavior [111]. Pediatric consultants can help school systems reduce the incidence of violence. Middle and high school conflict resolution curricula have reduced the incidence of school fights and of suspensions or expulsions for fighting or weapon carrying. The Centers for Disease Control and Prevention's sourcebook provides detailed information concerning numerous innovative curricula developed and evaluated during the 1990s [112]. Peer mediator programs also reduce serious violence at and near schools and provide a model for nonviolent conflict resolution.

Pediatric health care providers who serve as school consultants can advise school boards and principals regarding the importance of age-appropriate violence prevention programs and peer mediation programs [113].

●Primary schools can teach/model nonviolent problem-solving skills, focus on adequate playground supervision, and implement antibullying programs.

●Middle schools can incorporate antiviolence and conflict resolution curricula into health education programs.

●High school programs can use the school health clinic to provide services to students who have problems of violence, drug abuse, or pregnancy.

Antibullying programs — Antibullying programs are effective in reducing bullying [74,112,114,115]. Successful programs work, in part, by mobilizing the large number of bystanders to make bullying less acceptable. Bullying at school is addressed through increased adult supervision before school, during lunch and recess, and after school, and through the development of classroom discussions to reduce the social acceptability of bullying among the majority of children, depriving the bully of an appreciative audience.

Media — Pediatric health care providers can address violence in the media by endorsing community television "tune-out weeks," encouraging schools to develop curricula for critical viewing skills, and working with local, state, and federal regulators and television producers to reduce the exposure of children to televised violence [116].

Youth development — A variety of programs that provide resources for adolescents, including after-school programs, summer jobs programs, and programs that find ways for young persons to participate in the community, are associated with improved outcomes, including decreased risk of violence [78,117,118].

Firearms — Pediatric health care providers can advocate for the prevention of firearm injury by supporting state and federal initiatives to mandate the provision of trigger locks and prevent the marketing of certain kinds of weapons. (See "Firearm injuries in children: Prevention", section on 'Framework for prevention'.)

RESOURCES

●The American Academy of Pediatrics information on helping children cope with conflict and Connected Kids (Violence Prevention).

●The Centers for Disease Control and Prevention offer a number of resources related to youth violence, including materials for the general public, public health professionals, and health care providers.

●The Massachusetts Medical Society provides caregiver handouts, a guidebook, and links to more recent seminars and conferences.

●The Substance Abuse and Mental Health Services Administration provides resources for school violence prevention.

SUMMARY

●Epidemiology – Violence is a major cause of death and disability for American children. Pediatric care providers play an important role in prevention of violence through screening and providing anticipatory guidance for promotion of resilience and avoidance of risk. (See 'Overview' above and 'Epidemiology' above.)

●Resilience factors – Factors that protect against youth violence include youth engagement (eg, caregiver expectations, connectedness with parents, caregivers, other adults, and school), neighborhood cohesion and self-efficacy, and programs that promote positive youth development (eg, bonding, social, emotional, cognitive, behavioral, and moral competence, self-determination, spirituality, self-efficacy, belief in the future). (See 'Resilience factors' above.)

●Risk factors – Risk factors for violence include a history of fighting or violence-related injury, violent discipline, access to firearms, alcohol and other drug use, gang involvement, and exposure to violence in the home, media, school, or community. (See 'Risk factors' above.)

●Screening – Pediatric care providers should screen for violence and violence risk factors at routine health care visits. The screening questions depend upon the child's age and developmental stage and the cultural background of the family. (See 'Screening' above.)

Teenagers should be asked directly about violence (table 1). Their risk for violence-related injury is stratified according to other factors, including school attendance, performance, violence history, and drug use. (See 'Adolescent screening' above and 'Risk stratification' above.)

●Anticipatory guidance – The American Academy of Pediatrics and the American Medical Association recommend violence prevention counseling. Health care visits during infancy, childhood, and adolescence provide opportunities to identify and attempt to modulate violence risk and resilience factors. (See 'Anticipatory guidance' above and 'Resources' above.)

●Secondary prevention – Secondary prevention involves treatment, counseling, and referral for children and adolescents who have experienced violence-related injury. (See 'Secondary prevention' above.)