Interpreting Crime Data

Preventing Youth Violence: Opportunities for Action

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National Center for Injury Prevention and Control Division of Violence Prevention

Preventing Youth Violence: Opportunities for Action is a publication of the National Center for Injury Prevention and Control, Centers for Disease Control and Prevention.

Centers for Disease Control and Prevention Thomas R. Frieden, MD, MPH, Director

National Center for Injury Prevention and Control Daniel M. Sosin, MD, MPH, FACP, Acting Director

Division of Violence Prevention Howard Spivak, MD, Director

Suggested citation:

David-Ferdon C, Simon TR. Preventing Youth Violence: Opportunities for Action. Atlanta, GA: National Center for Injury Prevention and Control, Centers for Disease Control and Prevention, 2014.

Preventing Youth Violence: Opportunities for Action 1

Preventing Youth Violence: Opportunities for Action

Developed By: Corinne David-Ferdon, PhD

Thomas R. Simon, PhD

Copy Editing and Layout By: Alida Knuth

June 2014

Centers for Disease Control and Prevention National Center for Injury Prevention and Control

Divsion of Violence Prevention Atlanta, Georgia

Preventing Youth Violence: Opportunities for Action 3

Table of Contents

Foreword . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .4

Preventing Youth Violence: Opportunities for Action . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .5

Focus on Youth Violence Prevention . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .6

Youth Violence: A Leading Cause of Death and Physical Injury for Young People . . . . . . . . . . . . . . .7

Violence-related Behaviors Reported by Youth . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .7

Youth Violence Remains a Critical Problem . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .8

The Impact of Youth Violence Is Not the Same for All Young People and Communities . . . . . . . . .10

Youth Violence Is a Costly Problem. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .13

There Is Not Just One Cause of Youth Violence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .14

Early Prevention Is Important . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .16

Importance of Broad Prevention Strategies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .16

Evidence-based Youth Violence Prevention . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .17

Key Prevention Strategies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .18

Evidence-based Prevention Approaches and Programs, Policies, and Practices Are Available to Move Youth Violence Prevention Strategies Forward . . . . . . . . . . . . . . . . . . . . . . . . .21

Evidence that Youth Violence Can Be Prevented . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .24

Prevention Can Save Money . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .27

Partners and Leaders in Understanding and Preventing Youth Violence . . . . . . . . . . . . . . . . . . . . . . .28

Role of CDC in Youth Violence Prevention . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .29

Implementing Evidence-based Youth Violence Prevention Activities . . . . . . . . . . . . . . . . . . . . . . . . . .30

Opportunities for Action . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .31

Seizing the Opportunity and Responsibility to Prevent Youth Violence . . . . . . . . . . . . . . . . . . . . . . . .42

References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .43

Acknowledgements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .49

Appendix A. Development of Preventing Youth Violence: Opportunities for Action. . . . . . . . . . . . . . .50

4 Preventing Youth Violence: Opportunities for Action

Foreword

Every time a young person is harmed by violence, our nation’s future strength and growth are jeopardized. We are losing our next generation of young people—our future community builders and leaders—to homicide at an alarming rate. Beyond premature death, youth violence causes emotional, academic, and physical scars that limit young people’s potential independence, growth, and success. When the opportunities of our young people are curtailed by youth violence, we all suffer the negative and long-lasting consequences.

Research and experience in communities show it is possible to prevent youth violence. The Centers for Disease Control and Prevention’s (CDC) Preventing Youth Violence: Opportunities for Action and its companion guide will help communities use strategies that are known to work. We have the knowledge, experience, and scientifically supported strategies to take steps today that can make real and lasting differences in our communities. Part of what we have learned is that we can all be part of the solution. Suggested actions are provided for all members of a community who can help make neighborhoods safer and reduce youth violence.

Preventing youth violence has far reaching benefits for our health, safety, and prosperity. The prevention of youth violence can lower the risk for other youth-related problems, such as alcohol and substance abuse, obesity, and academic failure, and can result in cost savings for our justice, education, and health service systems. That is why it is so important for communities to take action to prevent youth violence.

Youth violence is not just a law enforcement problem or an issue for schools to address. Youth violence is a public health problem. Public health professionals and other community leaders have critical roles to play in working across sectors to take action to prevent violence. Community members, youth, and adults who care for youth also have important roles to play in preventing violence, and their actions can contribute to the development of safe and supportive communities where young people can reach their full potential.

For the past two decades, CDC has worked to prevent youth violence before it starts. This resource that describes evidence-based actions for communities is an example of CDC’s work to share information so that communities can more effectively prevent youth violence. The evidence-based strategies and opportunities for action presented in this resource make me confident that we can all do our part to prevent youth violence.

Howard Spivak, MD, Director Division of Violence Prevention National Center for Injury Prevention and Control Centers for Disease Control and Prevention

Howard Spivak, MD, Director Division of Violence Prevention

Preventing Youth Violence: Opportunities for Action 5

Preventing Youth Violence: Opportunities for Action All forms of violence, including youth violence, suicidal behavior, child maltreatment, sexual violence, intimate partner violence, and elder abuse, negatively affect the health and well-being of our country. Youth violence, in particular, is a significant public health problem. Each and every day, approximately 13 young people in the United States are victims of homicide and an additional 1,642 visit our hospital emergency departments because of physical assault-related injuries.1 Among high school students, 1 in 4 report being in at least one physical fight and 1 in 5 report being bullied in the last year.2 Youth who are victims of violence also have a higher risk for many other poor physical and mental health problems, including smoking, obesity, high-risk sexual behavior, asthma, depression, academic problems, and suicide.3-6 Young people are frequently the ones hurting other youth and commit a significant proportion of the violence in communities—youth aged 10–24 years represented 40% of all arrests for violent crimes in 2012.7 The damage resulting from youth violence extends beyond the young perpetrators and victims. Each year, youth homicides and nonfatal assault injuries result in an estimated $17.5 billion in combined medical and lost productivity costs.1 Violence can increase health care costs for everyone, decrease property values, and disrupt social services.8

Many of our young people and communities view the grim facts about youth violence as unavoidable and have accepted youth violence as a societal reality. However, the truth is that youth violence is not inevitable. Youth violence is preventable. The past investment into monitoring, understanding, and preventing youth violence is paying off and proving that youth violence can be stopped before it occurs. We cannot continue to just respond to violence after it happens—the public health burden of youth violence is too high and our potential to prevent youth violence is too great.

Our understanding about youth violence and our ability to prevent it is based on decades of work by the Centers for Disease Control and Prevention (CDC) and the larger field of youth violence prevention researchers and practitioners. From systematic surveillance, rigorous research on modifiable factors that predict violence, evaluation of prevention strategies, and the strengthening of the capacity of communities to use approaches that work, we have learned a great deal about how to prevent youth violence. To help communities take advantage of the available knowledge, CDC has developed, Preventing Youth Violence: Opportunities for Action. This resource summarizes what we currently know about youth violence—the health consequences, trends, disparities, causes, costs, and prevention strategies. This resource outlines important strategies for youth violence prevention that are based on strong evidence and experience. It includes examples of specific programs and activities that have been found to be effective. These evidence-based youth violence prevention strategies focus on reducing the factors that put young people at risk for violence and bolstering the factors that strengthen their positive development and buffer against violence.

Everyone has a role to play in preventing youth violence. Preventing Youth Violence: Opportunities for Action provides information and action steps that can help public health and other community leaders work with partners to prevent youth violence. This resource also describes actions that young people, families, caregivers, adults who work with youth, and other community members can take to reduce youth violence. A companion document, titled Taking Action to Prevent Youth Violence, is available to help these groups better understand the steps they can take.

6 Preventing Youth Violence: Opportunities for Action

Focus on Youth Violence Prevention The term youth violence used by the CDC and in this resource refers to when young people aged 10–24 years intentionally use physical force or power to threaten or harm others. The World Health Organization has described this behavior as “violence between individuals who are unrelated, and who may or may not know each other, generally taking place outside the home.”9 Youth violence typically involves youth perpetrating violence against other young people. A young person can be involved with youth violence as a victim, an offender, or a witness. Youth violence can take different forms, such as fighting, bullying, threats with weapons, and gang-related violence. These different forms of youth violence can vary in where and how often they occur and who is impacted. They can also vary in the harm that results and can include physical harm, such as injuries or death as well as psychological harm. However, the different forms of youth violence can be prevented. The evidence-based actions in this resource are appropriate for preventing all forms of youth violence.

Preventing Youth Violence: Opportunities for Action focuses on youth violence because there is an enormous breadth and depth of knowledge about youth violence and how to effectively guide community action to prevent it. For youth violence, research has provided a strong understanding about the burden and trends, the factors that influence the likelihood it will occur, and a variety of effective prevention strategies.10,11 However, this same level of understanding is not yet available for other forms of violence that youth may experience, such as dating violence, sexual violence, and suicide. Research demonstrates that the causes of youth violence and other forms of violence often are similar, but knowledge is limited about whether the evidence-based youth violence prevention strategies and action steps discussed in this resource also lower the risk for other forms of violence. Other forms of violence might require unique preventive action, and a full discussion of the research that is the foundation for these different prevention approaches is beyond the scope of this resource.

What is Youth Violence? Youth violence is when young people aged 10–24 years intentionally use physical force or power to threaten or harm others.

Why Focus on Youth Violence? Opportunities for Action focuses on preventing youth violence because the need for action to reduce youth violence is great and effective action is possible. Attention to all of the interrelated forms of violence that impact youth—child maltreatment, suicidal behavior, sexual assault, and teen dating violence—is beyond the scope of this resource and might require different prevention strategies.

More youth die from homicide each year

than from cancer, heart disease, birth defects,

flu and pneumonia, respiratory diseases, stroke, and diabetes

combined.

Youth Violence: A Leading Cause of Death and Physical Injury for Young People Youth homicide in the United States is a significant public health issue. In 2011, 4,708 (7.3 per 100,000) youth aged 10–24 years were victims of homicide. 1 Homicide is the third leading cause of death among young people aged 10–24 years, responsible for more deaths in this age group than the next seven leading causes of death combined (see Figure 1). For each young homicide victim, we lose an entire lifetime of contributions to families, potential employers, and communities. The number of youth who are physically harmed but do not die as the result of youth violence is significantly higher. In 2011, we saw that for every young homicide victim, there were approximately 142 youth with nonfatal physical assault-related injuries treated in U.S. emergency departments.1 A total of 599,336 youth aged 10–24 years (928 per 100,000) were treated in U.S. emergency departments for nonfatal physical assault-related injuries in 2012.1 This means that each day approximately 13 young people are victims of homicide and an additional 1,642 are treated in emergency departments for physical assault-related injuries.

Violence-related Behaviors Reported by Youth Official data from death certificates and emergency departments are critical to helping us understand and address youth violence, but they only tell part of the story. The full extent of the violence that youth perpetrate and experience as victims goes far beyond these data sources. The Youth Risk Behavior Survey conducted by CDC in 2013 indicates that 24.7% of high school students reported having been in at least one physical fight in the year before the survey.2 Nearly 18% of high school students reported they carried a weapon (e.g., gun, knife, or club), and 5.5% reported they carried a gun at least one day in the month prior to being surveyed.2

Youth violence also occurs in schools and negatively impacts students’ ability to attend and to participate fully. In 2013, nearly 20% of high school students reported being bullied at school, and 6.9% said they had been threatened or injured with a weapon on school property in the past year.2 Furthermore, 7.1% of high school students reported missing at least one day of school in the past 30 days because they felt unsafe either at school or on their way to or from school.2

Preventing Youth Violence: Opportunities for Action 7

Figure 1. More Youth Aged 10–24 Die from Homicide Than from the Next Seven Leading Causes of Death Combined

Homicide 4,708

Cancer 2,030

Stroke**

233 Diabetes

192

Respiratory Diseases

242

Flu & Pneumonia 275

Birth Defects*

608

Heart Disease 1,109

*Congenital Anomalies **Cerebrovascular Diseases

Source: 2011 fatalities; Web-based Injury Statistics Query and Reporting System (WISQARS)1

8 Preventing Youth Violence: Opportunities for Action

Youth Violence Remains a Critical Problem Although the prevalence of several forms of youth violence has declined since the early 1990’s, the declines are inconsistent and the public health burden is still too high. For instance, examination of youth homicide trends show rates have declined over time, but these declines are stalling. The overall homicide rate among youth aged 10-24 years reached a peak in 1993 at 15.9 per 100,000, and then from 1994 to 1999 declined 41% (15.2 per 100,000 in 1994 to 8.9 in 1999).12 This promising decline has slowed over the last decade. Between 2000 and 2010, youth homicide rates have declined approximately 1% per year.12 As illustrated in Figure 2, the youth homicide rate has remained between 7.3 and 9 homicides per 100,000 youth each year from 2000 to 2011 and has been substantially and consistently higher than the overall homicide rate for all ages.1 Additionally, the youth homicide rate in the United States is higher than the rate for other high income countries. For example, international research on adolescent and young adult males aged 15–24 has shown that the homicide rate in the United States is between 3 and 40 times higher than the homicide rate in other high income countries.13

Trends in other forms of youth violence also show declines over time. For instance, Figure 3 illustrates significant declines in high school students’ reports of being in a physical fight over the last decade. However, even with these declines, the levels of violence remain unacceptably high. The most recent data indicate that 1 in 4 high school students reported being in at least one physical fight, and 1 in 12 high school students reported fighting at least once on school property within the past year.2

The variability of the prevalence of youth violence over time is similar to shifts in violent crime rates.7 Although the causes for these patterns are uncertain, previous research suggests that changes in youth homicide and violent crime rates in the mid-1980s to early 1990s were related in part to the emergence of crack cocaine and the associated growth in drug use and drug-related crime, increased weapon carrying, and weak economic conditions.14 When youth violence started to decline in the mid-1990s, there were various community changes occurring, such as an increased emphasis on violence as a public health problem and the need to use evidence-based prevention approaches.14,15

National trends suggest that the prevention of youth violence is possible. But, even with promising reductions youth are still experiencing high levels of violence and youth violence persists as an important public health issue. Strategic, data-driven steps can be taken to reenergize declines in youth violence rates and to assure that downward trends are not reversed.

Preventing Youth Violence: Opportunities for Action 9

Figure 2. Trends in Homicide Rates in the United States, 2000–2011*

*Homicide rates for all ages are age-adjusted to the standard 2000 population; rates for those age 10–24 years are age-specific.

Source: Web-based Injury Statistics Query and Reporting System (WISQARS)1

Figure 3. Prevalence of Physical Fighting among High School Students in the United States, 1991–2013*

*Percentage of high school students fighting on school property not available for 1991.

Source: Youth Online: High School YRBS2

Ra te

p er

1 00

,0 00

Pe rc

en ta

ge o

f h ig

h sc

ho ol

s tu

de nt

s

Physical Fighting Physical Fighting on School Property

All Ages Youth 10–24 Years

10 Preventing Youth Violence: Opportunities for Action

The Impact of Youth Violence Is Not the Same for All Young People and Communities Youth violence is a significant problem that negatively impacts all young people in all communities whether they experience it as perpetrators, victims, or witnesses. The rates and types of youth violence, however, vary across communities and across subgroups of youth. These disparities can be attributed to different exposure to risk and protective factors. Some of these potential influences are discussed in a subsequent section of this resource (There is Not Just One Cause of Youth Violence). Although a complete description of all disparities in youth violence is beyond the scope of this document, some examples are provided below to show some of the variations that exist. Understanding that youth violence differs across neighborhoods and subgroups of youth can help communities plan and implement prevention approaches that have the greatest effects in reducing youth violence.

• Disproportionate burden on ethnic and racial minority youth. The risk for some forms of youth violence varies significantly by racial and ethnic group. For instance, the homicide rate in 2011 for non-Hispanic African American youth (28.8 per 100,000) was 13.7 times higher than the rate for non-Hispanic white youth (2.1 per 100,000) and 14.4 times higher than the rate for non-Hispanic Asian/Pacific Islander youth (2 per 100,000).1 The homicide rate for non-Hispanic African American youth was also 4.1 times higher than the rate for Hispanic youth (7.1 per 100,000) and 3.8 times higher than the rate for non-Hispanic American Indian/Alaska Native youth (7.5 per 100,000).1 Homicide is the leading cause of death for non-Hispanic African-American youth, the second leading cause of death for Hispanic youth, the third leading cause of death for non-Hispanic American Indian/Alaska Native, and the fourth leading cause of death among non-Hispanic White and Asian/Pacific Islander youth.1

Different patterns emerge when looking at various forms of youth violence (see Figure 4). For example, among high school students, a significantly higher percentage of non-Hispanic African American (35%) and Hispanic (28%) students than non-Hispanic White (21%) students reported that they have been in at least one physical fight in the last year.2 In contrast, a significantly higher percentage of non-Hispanic White high school students (22%) reported experiencing bullying in school than Hispanic (18%) or non-Hispanic African American (13%) high school students.2

Figure 4. Physical Fighting and Bullying Among High School Students in the United States by Race/Ethnicity, 2013

Source: Youth Online: High School YRBS2

non-Hispanic Black

Hispanic

non-Hispanic White

Pe rc

en ta

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f h ig

h sc

ho ol

s tu

de nt

s

Bullied at School Physical Fight (unspecified location)

Preventing Youth Violence: Opportunities for Action 11

• Different patterns for males and females. The prevalence of some types of youth violence also varies by sex. For example, the youth homicide rate in 2011 was 6 times higher among males (12.3 per 100,000) than females (2.1 per 100,000).1 The rate of youth who were treated in emergency departments for nonfatal physical assault-related injuries in 2012 was 1.6 times higher for males (1,141 per 100,000) than females (704 per 100,000).1 The prevalence of involvement in physical fights among high school students also was approximately 1.6 times higher for male (30%) compared to female students (19%).2 In contrast, female high school students (24%) were more likely than their male peers (16%) to report being a victim of bullying at school.2

Violence is clearly not just a problem among males. Data show violence is also a critical public health issue for young females. Among females aged 10–24 years, homicide is the fourth leading cause of death.1 Additionally, over 221,900 female youth were treated in emergency departments for physical assault-related injuries in 2012.1 Young females are also at risk for perpetrating violence. In 2012, over 30,830 females aged 10–24 years were arrested for violent crimes, including robbery, aggravated assault, and murder.7 Females represent 19% of all arrests for violent crime among those aged 10–24 years.7

• Disproportionate burden on sexual minority youth. Sexual minority youth—young people who identify as lesbian, gay, bisexual, or transgender or are questioning their sexual identity (LGBTQ)—have a heightened risk for violence.16 Relative to their heterosexual peers, LGBTQ youth report experiencing higher levels of verbal and physical violence and associated physical injury across multiple studies.16 Reports from high school students between 2001 to 2009 reflect that sexual minority students were more likely to report being in a physical fight at least once during the year before the survey (43% of bisexual students, 42% of gay or lesbian students, and 35% of questioning students) than heterosexual students (29%).17 Sexual minority students were also more likely to be injured in a physical fight (16% of gay or lesbian students, 10% of questioning students, and 9% of bisexual students) than heterosexual students (3%).17

Bullying and harassment of LGBTQ youth can happen in any community setting and at home, but violence experienced by LGBTQ youth at school has tended to get the most research attention. LGBTQ high school students are more likely than heterosexual students to report that on school property they have been threatened or injured with a weapon and have been in a physical fight.16,17 These experiences are associated with absenteeism, poor academic achievement, and higher rates of suicidal behavior.16 The prevalence of not going to school because of safety concerns is higher among gay or lesbian students (21%), students questioning their sexual identity (17%), and bisexual students (13%) than their heterosexual peers (5%).17

What Do We Know about Bullying? Bullying is a form of youth violence that can be inflicted physically, verbally, relationally, or by damaging a young person’s property.18 It can harm a youth’s physical, emotional, and academic well-being as well as hurt peers, families, schools, and neighborhoods. Bullying can increase the potential for other forms of youth violence, like weapon carrying and physical fighting.19 Research on preventing bullying is still developing, and the benefits of many school-based programs are unknown. Some promising approaches are increased supervision of students, use of behavior management techniques, and having and enforcing whole school anti-bullying policies. For more information about bullying, visit Stopbullying.gov and CDC’s Division of Violence Prevention.

12 Preventing Youth Violence: Opportunities for Action

• Violence varies across communities, and no community is immune. Youth violence affects all communities—urban, suburban, and rural. However, communities vary in terms of the subgroups of young people at greatest risk, the factors that influence the likelihood of violence, the specific types of youth violence experienced, and the consequences. Some communities are disproportionately affected by violence, and the pressure for action is intensified. For example, law enforcement data indicate that the violent crime rate in 2012 was higher in cities (469 per 100,000 population) than in metropolitan counties (259 per 100,000) or suburban areas (252 per 100,000), and the largest cities generally had the highest rates of violence.7 Youth gang activity also is more prevalent in cities but can and does occur in all types of communities. For example, data from the 2011 National Youth Gang Survey of law enforcement agencies show that 85% of larger cities, 50% of suburban counties, 30% of smaller cities, and 14% of rural counties reported gang activity.20

The level of violence often varies considerably across neighborhoods within the same city. Youth in some neighborhoods are growing up exposed to relatively higher rates of crime, family violence, poverty, and failing schools and businesses. Under these circumstances, youth often are more likely to see violence and gangs as acceptable and as a way to enhance social status and reduce vulnerability.21

Some areas of the United States experience lower levels of one type of youth violence but higher levels of another. For example, in 2013 only 17% of high school students in Maine reported having been in a physical fight in the past 12 months (national average was 25%), but 24% of students reported being bullied at school (national average was 20%).2 While the specific forms of youth violence might differ across communities, all communities face the challenge of how to prevent youth violence.

What Do We Know about Gangs? Nearly 1 in 5 students ages 12–18 reported that gangs were present in their school in 2011.22 Although youth often report joining a gang for protection, they are more likely to be both victims and perpetrators of violence after joining a gang.23 Most youth join gangs before age 15, and many children start affiliating with gangs between 11 and 12 years old.24 In addition to efforts to intervene to reduce gang violence and to help youth leave gangs, we also need to prevent young people from joining gangs in the first place.25 Prevention activities that enhance problem-solving skills, school performance, family functioning, and school safety and that reduce exposure to violence in the home and community are promising approaches to reduce gang joining. For more information about gang joining prevention research and approaches visit CDC’s Division of Violence Prevention and the National Gang Center.

Preventing Youth Violence: Opportunities for Action 13

Youth Violence Is a Costly Problem In addition to the physical, emotional, social and societal consequences of violence for youth, their families, schools, and communities, violence has a range of financial costs to society (see Figure 5). The full costs of youth violence are difficult to quantify, but there are known short-term as well as long-term impacts on the health, social, educational, employment and judicial systems. Even when looking at narrow descriptions of cost, a picture of the huge burden of youth violence begins to emerge. In 2010, the combined cost from just medical care and lost work due to homicide among youth aged 10–24 years was an estimated $9 billion.1 Nonfatal injuries among youth that result from physical assaults and are treated in hospitals and emergency departments were another $8.5 billion in medical and work loss costs.1 The combined total of $17.5 billion is an underestimate of the true toll of youth violence because it does not include the costs associated with the criminal justice system, including arrest, prosecution, incarceration, and re- entry. It also does not include costs associated with addressing the psychological and social consequences for victims, perpetrators, and their families. These estimates also do not reflect the effects of youth violence on social service agencies, functioning of schools, and property values, which can be negatively impacted by the direct or indirect effects of youth violence.8

Financial losses and required expenditures to address youth violence reduce the resources that are available to support other community needs and goals. The cost of arresting, prosecuting, incarcerating, and rehabilitating offenders is the fastest growing part of most state budgets and runs into the billions of dollars per year.26 Also, there is strong evidence that exposure to violence contributes to a range of physical and mental health consequences, including smoking, high-risk sexual behavior, depression, obesity, asthma, post-traumatic stress disorder (PTSD) symptoms, and suicide.3-6,27,28 The financial toll associated with these consequences exponentially increases the costs associated with youth violence.

Figure 5. Examples of Direct and Indirect Costs of Youth Violence

Total Cost of Youth Violence

Direct Costs • Medical and mental health care • Law enforcement and incarceration • Legal and social services

Indirect Costs • Lost earnings • Struggling schools • Fear in communities • Declining property values

What Is a Risk Factor? A risk factor is a characteristic that increases the likelihood of a person becoming a victim or perpetrator of violence.

What Is a Protective Factor? A protective factor is a characteristic that decreases the likelihood of a person becoming a victim or perpetrator of violence or buffers against the effects of risk factors.

14 Preventing Youth Violence: Opportunities for Action

There Is Not Just One Cause of Youth Violence Youth violence is not the result of one factor, so there is not one definitive way to prevent it from occurring. A growing body of research indicates that youth violence is influenced by the interplay of multiple individual, relationship, community, and societal risk and protective factors that affect youth over the course of their development from early childhood through young adulthood.29-31 These factors can interact to increase or reduce the likelihood that youth will become involved in violence. Some communities and subgroups of youth experience relatively more risks and fewer protective influences, which contributes to disparities in youth violence. The good news is that many of these factors are modifiable.

The field of youth violence prevention has come to recognize that attention needs to be given to both risk and protective factors in order to have bigger reductions in youth violence.32 Risk factors are complex, interactive, and cumulative over time, and not everyone exposed to risk factors will develop violent behaviors. Protective factors can directly reduce violence or they can buffer against risk factors. Research demonstrates that individuals with more protective factors and fewer risk factors are less likely to engage in violence and other high-risk behaviors.33-35 Protective factors have not been studied as extensively or rigorously as risk factors.36 The knowledge about protective factors is growing. Presented below and shown in Figure 6 are examples of risk and protective factors that influence the likelihood of youth violence. Because youth violence is influenced by multiple factors, our ability to prevent youth violence is stronger when multiple levels of risk and protection are understood and addressed by prevention strategies.

Figure 6. Examples of Contributing Factors by Level of Influence

Societal Norms about violence, policies that

influence job opportunities or that support prevention programming

Community Sense of social connectedness,

residential instability, gang activity Individual

Past exposure to violence, impulsiveness, poor school achievement

Relationship Peer delinquency, parental conflict,

monitoring and supervision

Preventing Youth Violence: Opportunities for Action 15

• Individual level. Individual youth have a unique set of experiences and traits that influence their likelihood of experiencing violence. Many individual level risk factors have been identified, including impulsiveness, substance abuse, antisocial or aggressive beliefs and attitudes, weak school achievement, and a prior history of exposure to violence or abuse.37-39 Unsupervised access to a firearm is also a contributing risk for lethal youth violence.40 Examples of youth violence protective factors include the development of healthy social, problem-solving, and emotional regulation skills, and a young person’s school readiness and academic achievement.34,38

• Relationship level. The nature and quality of the relationships young people have with friends, peers, parents, and other adults, such as teachers and community members, can influence their behavioral choices, opportunities for engaging in violence, and perceptions of what behavior is acceptable and appropriate. Young people who associate with peers who engage in violent or delinquent behavior or gang activity are at substantially greater risk for experiencing and perpetrating violence.38,39 Examples of family risk factors include parental conflict and violence, poor parental attachment and monitoring, lack of appropriate supervision, and the use of harsh or inconsistent discipline.37-39 Whether adults are supportive, encouraging of youth to use nonviolent ways to solve problems, and willing to intervene with conflicts also contribute to youth’s beliefs about the acceptability of violence and their likelihood to act violently.41 Youth’s well-being and behavioral choices can be strengthened through a positive and nurturing relationship with caring adults. The development of this relationship begins in infancy with responsive parenting and the building of strong parent-infant attachment.42 Positive and warm parent-youth relationships in which parents set consistent, developmentally-appropriate limits are associated with positive child and adolescent developmental outcomes and the prevention of violent behavior.36,38,43 Additional factors that have been found to positively influence adolescent adjustment and decrease aggressive behavior include stable connections to school and school personnel and feelings of connectedness to prosocial, nonviolent peers who are concerned about the well-being of others and demonstrate a willingness to help and cooperate with others.36,41

• Community level. Individuals and relationships are embedded within settings, such as schools, businesses, and neighborhoods. The characteristics of these settings influence how people interact with each other and affect the likelihood that a person will become involved in violence. Community factors, such as residential instability, crowded housing, density of alcohol-related businesses, poor economic growth or stability, concentrated poverty, lack of positive relationships among residents, and views that violence is acceptable behavior are all associated with an increased risk for youth violence.38,39,44,45 High levels of crime, gang activity, unemployment, and drug use or sales are additional risk factors. We are only beginning to learn about the community-level factors that provide a buffer to violence, and existing research suggests that factors which enhance a sense of belonging, residents’ willingness to intervene to help others, and attachment to a community can lower the risk for youth violence.38 Physical environments of schools, parks, and business and residential areas that are regularly repaired and maintained and designed to increase visibility, control access, and promote positive interactions and appropriate use of public spaces provide additional buffers to violence.46-49 Policies related to the density of alcohol outlets and sales could contribute to lower rates of violence and injury.50,51 While research is mixed about whether youth employment or vocational training impact violence, economic growth of a community and job training and employment opportunities for community adults may be additional protective factors.52,53

• Societal level. Broad societal factors influence population-wide health and safety, including rates of youth violence. These factors include social and cultural norms about the acceptability of youth violence and the presence of broad determinants of health inequalities, such as poverty and social disadvantage.39,52 Societal influences, including media violence and policies related to health, education, and economic opportunities, can serve to increase or lower the risk for youth violence.9 Societal factors can impact youth violence through a variety of mechanisms, including how the community formally and informally responds to youth violence, the availability and accessibility of prevention resources, the coordination of prevention activities, the use of evidence-based prevention strategies, and opportunities for education and employment. Societal factors can contribute to inequities in risks for violence and access to prevention resources.

16 Preventing Youth Violence: Opportunities for Action

Early Prevention Is Important Youth violence statistics tend to focus on youth aged 10–24 years. However, we should not wait until the teenage years to act to prevent youth violence. Changing behaviors after they are already established is harder than developing healthy behaviors from a young age. The emergence of risks that put young people on a path to violence often begins during early childhood. Research shows that physical aggression is common among toddlers, and most children learn alternatives to violence before starting elementary school.54 A subset of children continues to be aggressive, and if their behavior and other risk factors are not addressed their aggression can persist and increase.55

Effective prevention activities should begin early to address risks. CDC’s Essentials for Parenting Toddlers and Preschoolers is an example of a resource that offers videos, interactive activities and other tools to help parents build healthy relationships with their young children and to prevent violence. Prevention activities should continue throughout childhood, adolescence, and young adulthood, and these activities should be adapted to address varying risks at different stages of development. A life- course prevention approach includes promoting and establishing healthy problem- solving skills, relationships, and experiences during early childhood to prevent the establishment of violent beliefs and behaviors and to promote healthy development across the lifespan.56

Far too often, we wait until youth violence occurs before we act instead of working to prevent it before it starts. Medical, law enforcement, and justice responses to violence are important to minimize the physical and emotional consequences for victims, to hold perpetrators accountable, and to repair the harm caused by violence. Responses are critical, but they are not enough.

Communities are increasingly including prevention strategies as part of their overall approach to addressing youth violence.57 By prioritizing prevention, communities can have greater reductions in youth violence and realize multiple economic and health benefits compared to communities that solely react to violence after it occurs.58 Additionally, because adolescent risk behaviors have common causes, youth violence prevention activities that address underlying risk factors may lower the occurrence of other problems, such as alcohol and substance abuse, gang membership, criminal behavior, and academic failure.59,60 These cross-cutting positive effects can contribute to significant cost savings for numerous service systems, including justice, education, and health care, and increase the availability of resources for other community priorities. Most importantly, they could preserve young people’s lives, protect their health, and promote their positive development.

Importance of Broad Prevention Strategies We often begin our prevention activities by identifying youth, families, and communities that are at relatively higher risk for youth violence and putting into place prevention approaches to address their needs. At-risk groups may include young people who have experienced abuse or behaved aggressively in childhood

“We have to stop violence from starting because it gets worse

over time and increases fear and the pressure to be violent in other

people.”

Jacob, age 13

Preventing Youth Violence: Opportunities for Action 17

and families with high levels of conflict. At-risk settings may include schools and communities that have a relatively higher concentration of risk factors, such as poverty, crime, gang activity, school dropout, and unemployment. At-risk groups and settings often require more intensive prevention efforts that are longer in duration and utilize different types of strategies relative to those with less known risk.61,62 Because a small proportion of young people are responsible for the majority of serious violent incidents and some communities are disproportionately impacted by violence, including prevention activities for at-risk groups and communities is an important part of an effective prevention strategy.63

Our success will be limited, though, if we only implement prevention activities that meet the needs of the more obvious at-risk groups. Broad prevention approaches that positively affect all youth, their relationships, and the environments in which they grow and learn are the most likely to be effective in eliminating youth violence and other adolescent health problems.30,64 Broad prevention strategies help all individuals or groups regardless of their level of risk and are important to achieving widespread and sustained reductions in youth violence. For example, universal youth violence prevention activities include providing information and skill development to all children in a school rather than only to students who have been aggressive or have other risk factors.65 Prevention approaches that can benefit all members of a community also include changing norms about the acceptability of violence and addressing the physical characteristics of housing, communities, and schools to improve perceived and actual safety, to reduce opportunities for crime and violence, and to promote positive behaviors and interactions.

Evidence-based Youth Violence Prevention Our research investment has resulted in knowledge about how to effectively prevent youth violence. This knowledge can be expressed as evidence-based prevention strategies, which communities can use to design their comprehensive prevention plan. These broad strategies, which are summarized in the next section, are based on consistent underpinnings of effective youth violence prevention activities as well as the growing understanding of modifiable youth violence risk and protective factors.8,10,11,32,66,67 These prevention strategies also reflect our understanding that effective and sustained prevention of youth violence comes from reaching beyond strengthening young people’s knowledge, skills and abilities to include working with families, schools, and entire communities to enhance the relationships and environments that impact youth.

To make progress on their youth violence prevention strategies, communities can use multiple evidence-based prevention approaches (e.g., school-based approaches, parenting skill and family relationship approaches) and implement various specific programs, policies, and practices (see Figure 7). Many of the available prevention approaches and specific activities can be used to advance more than one prevention strategy. Examples of these approaches and programs, policies, and practices that communities can use to realize their youth violence prevention goals are presented in a subsequent section (Evidence-based Prevention Approaches and Programs, Policies, and Practices Are Available to Move Youth Violence Prevention Strategies Forward). This resource also concludes with a list of Opportunities for Action that can further help bridge the gap between our prevention knowledge and activities.

Figure 7. Evidence-based Youth Violence Prevention

Program

Approach Approach

Practice Policy Program Practice

Strategy

Approach

Policy

18 Preventing Youth Violence: Opportunities for Action

Key Prevention Strategies

Evidence-based youth violence prevention strategies have become more evident as our research has grown. Rather than focusing on the problems that need to be reduced, these broad and overlapping strategies emphasize how the strengths within individuals, families, communities, and society can be enhanced. The implementation of a combination of these strategies is likely to result in stronger and more sustainable improvements in health and safety than the implementation of a single strategy.

• Build children’s and adolescents’ skills and competencies to choose nonviolent, safe behaviors. This strategy focuses on providing opportunities for young people to build their skills, knowledge, and motivation to choose nonviolent behaviors and conflict resolution approaches. By fostering the development of protective factors, such as effective problem-solving, communication, anger management, impulse control, and emotional regulation abilities, young people’s risk for violence decreases and their health and safety increases. The risk for violence can also be lowered by strengthening youth’s beliefs that violence is never an acceptable way to resolve conflicts, minimizing their unsupervised access to firearms, and helping them to avoid substance use, succeed in school, and cope effectively with past exposure to violence or abuse. For very young children, prevention activities may include helping them to understand and label emotions, control aggressive impulses, experience empathy, and nonviolently communicate and solve interpersonal problems. Prevention activities for older youth may seek to develop their skills for understanding the thoughts and feelings of others, managing anger, and feeling positive about the future, and being a leader. These opportunities can be provided in a variety of different formats and settings, including schools, after-school youth serving organizations, and faith-based institutions.

• Foster safe, stable, nurturing relationships between young people and their parents and caregivers. Parents and other caregivers (e.g., grandparents, foster parents) have a profound influence on young people’s beliefs and behaviors, and this influence extends from early childhood through late adolescence and beyond.68,69 The risk for youth violence is increased by elements of some caregiver-child relationships and home environments, such as family violence and abuse, lack of supervision, and inconsistent discipline. Other characteristics, such as parental monitoring of youth’s activities, strong parent-child connectedness, and good parent-child communication, can protect against the development of violent behavior, even when young people are exposed to violence in their communities. The risk of youth violence and other problem behaviors can be lowered by providing caregivers with support and knowledge about healthy child development, and by building caregivers’ skills related to strong communication, setting age-appropriate boundaries and rules, monitoring young people’s activities and relationships, and using consistent and nonviolent discipline.70,71 These skills and other activities can contribute to a supportive bond between caregivers and their children and to a conflict-free home, which lowers the risk for youth violence and other difficulties.

• Build and maintain positive relationships between young people and caring adults in their community. Young people’s risk for violence can also be buffered by healthy and safe relationships with adults who are not their primary caregivers.72 These adults include individuals who have formal and stable relationships with youth, such as mentors, teachers, and coaches. Youth are also influenced by other adults with whom they interact in more narrow ways including neighbors, academic tutors, and members of the faith-based institutions they attend. These individuals provide informal monitoring and guidance to youth and have the potential to lower the risk for youth violence. The prevention of youth violence can be strengthened by increasing the number of positive relationships that youth have with adults in their community. This relationship-focused strategy lowers young people’s risk for violence by promoting their feelings of connectedness to caring adults and their school and community, having adults available to reduce opportunities for violence, and increasing exposure to nonviolent and positive role models who demonstrate a willingness to help and cooperate with others.

• Develop and implement school-wide activities and policies to foster social connectedness and a positive environment. When students believe that adults in their school care about their individual well-being as well as their learning, they are more likely to succeed academically and engage in nonviolent behaviors.73 Communities can lower the risk for violence when they implement activities and develop and enforce school policies that promote a shared understanding that violence in any form is not acceptable at school and build the connectedness of their students, families, teachers, and other school personnel to their school environments. These policies can help all students to feel supported and safe at school. They can help students understand what behaviors are acceptable in the school environment and what are consequences for misbehavior. They may include specific policies and clubs to support at-risk groups, such as LGBTQ youth.74,75 These activities also include strategies and policies related to professional development of school personnel (e.g., teachers, coaches, counselors, nurses, administrators), ongoing engagement of students in prevention activities, opportunities for meaningful student and family participation, and teachers’ classroom management practices.

• Improve and sustain a safe physical environment in communities and create spaces to strengthen social relationships. The physical characteristics of the environments in which individuals interact influence safety, crime, and violence. Examples of these characteristics include lighting, availability of green spaces, and repair and upkeep of neighborhoods and schools.48 An important youth violence prevention strategy is the examination and potential modification of the physical characteristics of housing, schools, and community areas (e.g., parks, business areas, public transportation hubs) to improve perceived and actual safety and to reduce opportunities for crime and violence. By addressing the physical landscape of a community, residents may feel more comfortable accessing these areas, which can increase prosocial interactions between residents and supports for young people.

• Build viable and stable communities by promoting economic opportunities and growth. The economic climate of a community is created by the presence of legal and prospering businesses, the income level of residents, and stable employment of residents. When a community has limited legal economic and occupational opportunities, many residents and businesses will leave the neighborhood and the concentration of low income residents increases. Because these factors increase the risk for youth violence, this prevention strategy increases the stability and potential growth of a community by enhancing the success of local businesses and the employment and training opportunities for adults in the community.52 By providing the infrastructure and incentives for businesses to expand their operations and invest in the community and the next generation of workers, a community can become more economically stable. Additionally, this stability can attract other families and businesses to the area and encourage the further investment of human and financial resources into improving the health, safety, and prosperity of the community.

Businesses Taking Action The business community can help reduce youth violence through public- private partnerships that collect resources from businesses and invest them in local services and activities, such as street cleaning, security, and adding green spaces, to increase the appeal and use of the area. These approaches have different names. In Los Angeles they are called Business Improvement Districts (BIDs). An evaluation of 30 BIDs found a 12% drop in robberies and an 8% drop in violent crime as well as substantial economic benefits.49

Preventing Youth Violence: Opportunities for Action 19

20 Preventing Youth Violence: Opportunities for Action

• Facilitate the social cohesion and collective efficacy of the community. When individuals, groups, and organizations within a community do not have meaningful and positive social interactions and are not collaborating to improve their community, the risk for youth violence increases.44,52 In contrast, when community residents are connected (i.e., strong social cohesion) and willing to help others (i.e., high collective efficacy), violence is less likely. Activities aligned with this prevention strategy seek to build the community’s connectedness by increasing opportunities for residents to form positive relationships with their neighbors and to actively participate and contribute to their community’s health, safety, and prosperity. Examples include the willingness to help neighbors, talk with parents about their child’s unsafe behavior, and volunteer with community activities. These activities can create an increased understanding and respect for differences, promote trust, support the development of a shared community vision, and engender a willingness to act in ways to achieve their community vision. The meaningful and appropriate engagement of youth in these activities is especially important since they represent the future of communities and are particularly vulnerable to experiencing negative health and safety outcomes associated with a disorganized community.

• Change societal norms about the acceptability of violence and willingness to intervene. Far too often, violence is viewed as normative and an acceptable way for young people to resolve conflicts.76 Some youth and adults believe carrying a weapon or instigating violence is necessary to protect themselves from becoming a victim.77 Additionally, some individuals believe it is appropriate for youth to use violence to settle disputes and that some experiences of violence, such as bullying, are simply rites of passage. This acceptance of youth violence and reluctance to intervene increase the likelihood that youth violence will occur and, in some instances, escalate.78 A part of a community’s prevention plan can focus on changing norms about youth violence from being an acceptable behavior to being an unacceptable behavior. This work may include changes to how social interactions and conflict resolution are discussed and portrayed in the media, movies, television, video games, and other forms of communication. Changing societal norms about violence requires time and multiple data- driven strategies, similar to how changes pertaining to normative beliefs about smoking tobacco required efforts to change pro-tobacco attitudes, policies to limit smoking and reduce minors’ access to cigarettes, and strategies to support cessation.79 Communities can also encourage the belief that individuals have the power and responsibility to prevent violence, and then help residents have the knowledge and skills necessary to intervene safely and appropriately.

• Change the social and structural conditions that affect youth violence and lead to health inequity. Deficits in education, limited access to health care, and concentrated poverty are associated with higher rates of youth violence.52 Youth violence in turn reinforces these gaps and health inequities. By altering the underlying social and structural conditions that affect youth violence and lead to health inequity, population-wide reductions in youth violence could occur. Activities may include improving early learning and educational opportunities (e.g., access to libraries, parenting support, pre-schools, tutoring), modifying housing policies, increasing access to high quality child care, enhancing high school graduation rates and workforce development, and supporting the provision of evidence-based mental health and social service supports to children, youth, and their families. Policies, including organizational and regulatory policies and laws or ordinances, have the potential to provide support to families and create positive environments for children.80

Preventing Youth Violence: Opportunities for Action 21

Evidence-based Prevention Approaches and Programs, Policies, and Practices Are Available to Move Youth Violence Prevention Strategies Forward Most communities will need to identify a range of potential approaches and implement several specific activities in order to make progress on their prevention strategies and achieve local goals. Table 1 provides some examples, but it is not meant to be a comprehensive list of evidence-based approaches or an endorsement of any specific program, policy, or practice. Rather, the information is offered to help provide a concrete sense of how youth violence prevention strategies can be advanced through the selection and implementation of evidence-based approaches and activities. Detailed information about each example listed in Table 1 is available online, including a description of the program, the intended recipients, evidence for effectiveness, and how to acquire program materials. The next section of this document (Evidence that Youth Violence Can Be Prevented) describes some of the online resources that communities can use to learn more about particular evidence-based programs, policies, and practices, including the examples listed in Table 1 and many more that are not listed. The selection of specific programs, policies, and practices depends on the needs and resources of the community. The development of a strategic and data-driven plan for selecting and implementing these approaches is also described in a later section (Implementing Evidence-based Youth Violence Prevention Activities).

22 Preventing Youth Violence: Opportunities for Action

Table 1. Youth Violence Prevention Approaches Based on the Best Available Evidence*

Approach Description Examples of Programs, Policies, and Practices

Universal School-based Youth Violence Prevention

Provide students and school staff with information about violence, change how youth think and feel about violence, and teach nonviolent skills to resolve disputes.

Life Skills Training (LST) teaches anger management and conflict resolution. Evaluations of this program have shown significant reductions in fighting and delinquency, including a 26% reduction in high frequency fighting within one year.81

Other evidence-based universal school programs include: Good Behavior Game, Positive Action, Project Towards No Drug Abuse, and Promoting Alternative Thinking Strategies.

Parenting Skill and Family Relationship Approaches

Provide caregivers with support and teach communication, problem- solving, monitoring, and behavior management skills.

The Strengthening Families program teaches parents to use discipline, mange their emotions, and communicate with their child and teaches youth strategies to deal with peer pressure, manage stress, and solve problems. Evaluations of this program have shown significant reductions in aggression, hostility, and conduct problems and improvements in parent’s limit-setting, parent-child communication, and youth’s prosocial behavior.82,83

Other examples of evidence-based parenting and family programs include: the Incredible Years, Triple P (Positive Parenting Program), and Guiding Good Choices.

Intensive Family-focused Approaches

Provide therapeutic services to high-risk, chronic youth offenders and their families to address individual, family, school, and community factors that contribute to violence and delinquency.

Multidimensional Treatment Foster Care is for youth who need out-of-home placements and includes extensive training of foster parents, family therapy for biological parents, skills training and support for youth, and school- based academic and behavioral supports. This program has been shown to significantly reduce delinquency, violence, and violent crime and sustain improvments over time.84, 85

Other examples of evidence-based intensive family-focused approaches include: Multisystemic Therapy and Functional Family Therapy.

Policy, Environmental, and Structural Approaches

Involve changes to community environments that can enhance safety and affect youth violence and youth violence risk/ protective factors.

Business Improvement Districts (BIDs) are public-private partnerships that collect resources from businesses and invest in local services and activities. Significant reductions in violence have been documented in BIDs neighborhoods.49

Other examples include: policies to reduce youth access to alcohol and changes in the physical environment using principles of Crime Prevention Through Environmental Design (CPTED).

Preventing Youth Violence: Opportunities for Action 23

Approach Description Examples of Programs, Policies, and Practices

Street Outreach and Community Mobilization

Connects trained staff with at-risk youth to conduct conflict mediation, make service referrals, and change beliefs about the acceptability of violence.

Cure Violence (formally known as CeaseFire) works to interrupt violence, particularly shootings, and change norms about the acceptability and inevitability of violence. An evaluation found reduced shootings and killings and fewer retaliatory killings in most communities where the program was implemented.86

Other examples include: Richmond Comprehensive Homicide Initiative, Operation Ceasefire, and Safe Streets.

Early Childhood Home Visitation

Provides information, caregiver support, and training about child health, development, and care to families in their homes.

Nurse-Family Partnership (NFP) provides training and support to mothers during pregnancy and two years after giving birth to support a healthy pregnancy and increase mothers’ knowledge and skills about child development and care. It has been shown to decrease risk factors for youth violence, such as child maltreatment and early behavior problems, and reduce adolescent arrests and delinquency.87-89

Another example includes: Triple P

Early Childhood Education Provides high-quality, early childhood education to disadvantaged children to build a strong foundation for future learning and healthy development.

The Highscope Perry Preschool Project provides small classroom instruction by staff trained to address the needs of disadvantaged children and their families. Evaluations have found beneficial outcomes, including better academic achievement and classroom behavior and lower delinquency and lifetime arrests for violent crimes.90-92

Other examples include: Early Risers Skills for Success and Raising Healthy Children Program

*More information about the specific programs, policies, and practices listed as examples can be found from online resources, such as CDC’s STRYVE Strategies Selector Tool and Blueprints for Healthy Youth Development. These resources also provide information about other programs, policies, and practices that have also been found to help prevent youth violence.

24 Preventing Youth Violence: Opportunities for Action

Evidence that Youth Violence Can Be Prevented Over the last two decades, much has been learned about many of the specific prevention programs, policies, and practices that fall under the prevention approaches described in Table 1. Linking this knowledge to community practice has been a challenge. Many communities are not aware of, or are unable to take advantage of, the approaches known to work to improve health and safety. This section highlights some online resources that provide in-depth information about effective youth violence prevention activities and describes a few of the specific prevention programs that are included in these resources. The resources listed vary in terms of the extent to which they focus on prevention versus responding to youth violence and the extent to which they focus exclusively on youth violence or include other outcomes, such as substance abuse and mental health. All include examples of evidence-based youth violence prevention programs, policies, and practices, but the resources differ in the level of scientific rigor necessary to be included in their materials.

Striving To Reduce Youth Violence Everywhere (STRYVE) Strategies Selector Tool. STRYVE, CDC’s national youth violence prevention initiative, is working to bridge the gap between what is known about effective youth violence prevention activities and what is happening in communities. As part of the many STRYVE Online resources that assist communities with developing and implementing comprehensive prevention plans, the STRYVE Strategies Selector Tool helps communities connect their unique risks and needs to specific evidence- based youth violence prevention programs, policies, and practices. Other online resources about prevention approaches, some of which are described below, include information about approaches for a wide range of health, social, and academic issues. These other resources also vary in how rigorously an approach has been evaluated before it is included. The STRYVE Strategies Selector Tool pulls together information from multiple sources to help communities connect specifically with youth violence prevention approaches that have been rigorously evaluated and shown to impact risk and protective factors for youth violence and/or lower the occurrence of youth violence. This tool combines rigorous evaluation science with the flexibility required for communities to devise a tailored approach to youth violence prevention.

National Centers of Excellence in Youth Violence Prevention CDC’s National Centers of Excellence in Youth Violence Prevention are an example of a federal investment in promoting partnerships to continue to build the evidence base for youth violence prevention. Starting in 2000, the Centers have promoted collaboration between youth violence prevention researchers and communities. They have improved community capacity to work collaboratively on violence prevention, increased the evidence base for prevention approaches, and disseminated the results in numerous ways, including over 500 presentations and journal articles. Their activities have led to reductions in youth violence and have also informed local policy efforts for enhancing youth violence prevention. For more information, visit CDC’s Division of Violence Prevention.

Preventing Youth Violence: Opportunities for Action 25

Blueprints for Healthy Youth Development. The University of Colorado’s Center for the Study and Prevention of Violence is one of several research consortiums that has sought to increase the use of evidence-based approaches by reviewing and summarizing the available scientific information. Their Blueprints for Healthy Youth Development project includes the review of more than 1,100 programs that address problem behavior (e.g., youth violence, crime, and drug abuse) and other adolescent health issues (e.g., education, emotional well- being, physical health, and positive relationships).10 To assist communities in identifying which programs have strong evidence of effectiveness, very strict criteria are applied to determine if a program can be deemed a “model” or “promising” approach based on the program’s evaluation quality, impact, specificity, and dissemination readiness. The Blueprints project has identified over 30 model or promising programs that reduce violence or key risk factors for violence, such as delinquency and substance abuse. Programs identified as effective in reducing the risk for youth violence include several school-based programs that are designed to promote the health and safety of all students (e.g., Life Skills Training), parenting and family programs that bolster caregivers’ skills and parent-youth relationships (e.g., The Incredible Years: Parent and Family Training), and intensive family and community-based treatment programs that address the skill development and social support needs of high-risk youth and their families (e.g., Functional Family Therapy, Multisystemic Therapy). With only a small number of the more than 1,100 programs examined meeting the Blueprints project criteria, this review demonstrates that most existing programs have not been adequately evaluated or have been evaluated and shown not to work. Some programs are known to even be harmful (see Task Force for Community Preventive Service description below). The Blueprints project helps connect communities to prevention approaches with the strongest evidence and illustrates more research about different prevention strategies is needed.

Task Force for Community Preventive Services. Another source for guidance on what works to prevent youth violence is the Task Force for Community Preventive Services, a nonfederal group of experts in public health and prevention. The Task Force is appointed by CDC’s Director but functions independently to systematically review the research in an area of public health and to issue recommendations based on the strength of the evidence. The Task Force has examined several strategies related to youth violence, including firearms laws, therapeutic foster care, universal school-based violence prevention programs, and the transfer of juveniles to adult courts. Based on the availability of strong research evidence, the Task Force has issued recommendations for preventing youth violence with universal school- based programs and therapeutic foster care for chronically delinquent juveniles.66 Work by the Task Force also helps communities understand which prevention approaches are not effective or even harmful. For example, the Task Force’s review of policies that facilitate the transfer of juvenile offenders to the adult criminal system rather than maintaining them in the juvenile justice system demonstrates an increase in the risk of young people re-offending. The review found an increase of 34% in re-arrests for violent crimes among juveniles who had been transferred, suggesting this policy is an ineffective way of preventing future violence. The Task Force issued a recommendation against this approach.93 The Task Force has also evaluated the impacts of eight types of federal and state firearms laws on violence-related outcomes and has concluded that there is insufficient evidence to determine the evidence of effectiveness of the laws to prevent violence (see text box on page 26 for more information about reducing minors’ unsupervised access to firearms).

Universal School-based Youth Violence Prevention Programs Universal school-based violence prevention programs are designed to reach all students in a given school or grade. Many different programs have been developed, and their curricula vary. In general, they provide students with information about violence, change how youth think and feel about violence, and develop youth’s skills to avoid violence and resolve disputes through nonviolent means. When looking across evaluations, the Task Force for Community Preventive Services found these programs result in a 15% relative reduction in students’ violent behavior.65 It is important to recognize that not all school-based violence prevention programs are effective or achieve similar reductions.

26 Preventing Youth Violence: Opportunities for Action

Crime Solutions. The U.S. Department of Justice’s Office of Justice Programs established CrimeSolutions.gov to provide practitioners and policy makers with information about what works in criminal justice, juvenile justice, and crime victims’ services. Reviewers assess the quality, strength, and extent of the evidence for different programs. Programs are rated as “effective,” “promising,” or having “no effects.” Effective approaches have strong evidence to indicate that they achieve their intended outcomes when implemented with fidelity, and promising approaches are ones that have also been demonstrated to achieve their intended outcomes but have relatively less support. Programs listed as having no effects are ones that have strong evidence indicating that they had no effects or had harmful effects when implemented with fidelity. This resource currently includes 41 entries for violence with an evidence rating of “effective,” and these approaches address a number of outcomes, such as youth violence, dating violence, and child maltreatment.104

National Registry of Evidence-based Programs and Practices (NREPP). The Substance Abuse and Mental Health Services Administration (SAMHSA) supports NREPP to help connect the public to information about evidence-based approaches that promote mental health, prevent substance abuse, and treat mental health and substance abuse. Approaches that address a number of outcomes are included (e.g., violence, mental health, homelessness, tobacco, drugs, education, and employment). The online registry includes over 300 interventions that have been reviewed for “quality of research” and “readiness for dissemination.”67 The quality of research rating is based on six criteria that reflect measurement, intervention fidelity, and appropriateness of the design and analysis. The readiness for implementation rating is based on three criteria reflecting availability of materials, training and support, and quality assurance procedures. The registry is searchable with a variety of fields, such as age, race/ethnicity, setting, geographic location, and outcome. The registry currently includes 48 entries that are listed with a focus on violence outcomes, including youth violence, dating violence, and suicide.67

Taken together, these resources demonstrate that evidence-based approaches exist and are available for communities to utilize. These easily accessible systematic reviews of prevention strategies help communities learn more about approaches that work. Beyond these resources, communities are also learning from each other and accessing other tools, training, and technical assistance to select and implement evidence-based approaches that address a community’s unique needs. CDC’s STRYVE Online provides some of these prevention supports and narratives of communities in action to share how some groups are using evidence-based approaches to prevent youth violence.

Unsupervised Access to Firearms Over 80% of youth homicides are committed with a firearm.1 Young people can acquire a firearm from their own home or from a relative or friend or obtain it illegally.94-97 Identifying ways to reduce minors’ unsupervised access to firearms has been a challenge with very few tried and tested solutions. Schools and communities have implemented various approaches focused on curbing weapon-carrying and reducing violent behavior (e.g., metal detectors, neighborhood gun buy-back programs). The few studies that have examined the effectiveness of these measures find either mixed results or no effect.95,98 With the exception of safe storage interventions, which are associated with fewer firearm injuries and deaths of children and young people, most other measures, such as educational strategies for gun owners and technological changes, have not been adequately evaluated making it difficult to know which ones are the most effective in reducing lethal violence among youth.95,99-102 The Institute of Medicine, in collaboration with the National Research Council, has convened a committee of experts and developed a research agenda to address firearm violence as a public health problem. This agenda includes a priority focused specifically on minors’ access, possessing, and carrying firearms.103

Preventing Youth Violence: Opportunities for Action 27

Prevention Can Save Money The evidence about the benefits of some youth violence prevention programs has grown considerably in recent years to include demonstrations of their substantial cost savings. Researchers are systematically assessing the benefits relative to costs of prevention programs for a range of outcomes including crime, educational attainment, substance abuse, child abuse and neglect, teen pregnancy, and public assistance, and they are finding that many prevention programs are cost effective.105 Table 2 lists the benefit-cost information for some programs that have been shown in one or more studies to have significant preventive effects on youth violence or key risk factors for youth violence and that have financial benefits that exceed costs. The benefits can be substantial, often with several dollars saved for each dollar spent.106

Table 2. Estimates of Benefits Relative to Costs of Selected Prevention Programs*

Evidence-based Program

Benefits per $1 of cost

Communities that Care $3.69

Functional Family Therapy $11.50

Good Behavior Game $84.63

Guiding Good Choices $8.93

Life Skills Training $28.19

Multidimensional Treatment Foster Care $4.86

Multisystemic Therapy $4.54

Nurse-Family Partnership $2.73

Parent-Child Interaction Therapy $3.28

Triple P–Positive Parenting Program $5.46

*Dollar estimates are specific to the state of Washington and likely vary across states and communities. The benefit-cost estimates are continually updated, and cost estimates presented are based on information published by Washington State Institute for Public Policy as of May 2014.106 The latest information is available online from the Washington State Institute for Public Policy. Example programs include those designated as model or promising by Blueprints for Healthy Youth Development and are included in CDC’s STRYVE Strategies Selector Tool.

Source: Washington State Institute for Public Policy.106

28 Preventing Youth Violence: Opportunities for Action

Collaborating to Address Youth Violence The National Forum on Youth Violence Prevention is an example of coordinated partners at the national level working to increase multisector collaboration at the local level.57 The National Forum pulls together the unique expertise of multiple federal agencies, including the Departments of Justice, Education, Labor, Health and Human Services, and Housing and Urban Development. Through technical assistance and peer-to-peer learning, the national partners are increasing local capacity to build multisector collaboration, develop strategic plans with a prevention component, and implement data- driven approaches to address youth violence. For more information, visit Find Youth Info.

Partners and Leaders in Understanding and Preventing Youth Violence Effective prevention of youth violence is possible and sustainable with coordinated action and solid leadership by partners. No single person, group, or organization can do everything needed to prevent youth violence. To achieve a community’s youth violence prevention goals, a wide range of governmental and non-governmental representatives need to collaborate on a strategic plan and the selection and implementation of multiple evidence-based prevention activities. President Obama’s initiative, My Brother’s Keeper, is an example of partners working together to help boys and young men of color reach their full potential. This initiative includes a focus on reducing violence and emphasizes the importance of public health approaches as part of an integrated strategy that includes federal, state, and local leadership in violence prevention.

The partners necessary to the success of local prevention activities will vary from community to community. Partners will generally include representatives from diverse sectors and systems, such as justice, education, labor, social services, medical and mental health, and public health and safety. Community partners, such as businesses, youth serving organizations, and faith institutions, also have unique strengths and resources to help reduce youth violence.

Additional critical partners to preventing youth violence include community residents. Parents, other caregivers, and supportive community adults are pivotal in creating safe and nurturing environments for youth to develop adaptive behaviors. Also, research on the benefits of involving youth themselves in prevention activities is growing. Early indications suggest that when youth are prevention partners, their risk behaviors can decline, young people and adults enhance their skills and connection to the community, organizations and researchers strengthen their ability to engage hard-to-reach youth, and communities have improvements in their programs and policies.107-110

Historically, the justice system and medical institutions have been the primary leaders in addressing youth violence. Based on their expertise, their approaches have typically emphasized law enforcement and medical and mental health responses to violent incidents after they occur. Law enforcement and medical responses are necessary to minimize and address consequences of violence. They also have the potential to deter future acts of violence. This work is critical, but these responses do not stop youth violence from occurring in the first place. These groups have increasingly encouraged communities to include prevention as part of their activities.15

Youth violence has a significant impact on learning, and the education sector has been another visible leader and partner in understanding, tracking, and addressing violence that occurs within school settings. A safe and healthy school environment can promote academic success and reduce the risk for many short- and long-term health and occupational difficulties. Guidelines and tools have been developed to increase the use of strategic planning and evidence-based approaches to promote the development of safe places for students to learn.111

Preventing Youth Violence: Opportunities for Action 29

The public health community is an often underutilized youth violence prevention leader and partner. The public health community includes local and state health departments, federal public health institutions, researchers, practitioners, and schools of public health. It brings a focus on prevention and the promotion of population-wide well-being that is essential to helping any community stop youth violence before it starts. The expertise of public health professionals to apply science to challenging health problems and to coordinate the actions of multiple partners can greatly strengthen youth violence prevention planning, implementation, and monitoring of prevention activities and effects. The public health community has a key role to play as a convener, partner, and leader in increasing the use of existing evidence-based strategies and in expanding surveillance and research for our youth violence prevention actions to be more effective and sustained. This work includes collecting and interpreting data on the subgroups most impacted by youth violence, conducting research on modifiable risk and protective factors, designing rigorous evaluations of innovative prevention strategies, and supporting the dissemination, implementation, and monitoring of the most promising prevention approaches.

Role of CDC in Youth Violence Prevention CDC examines trends in violence, studies risk and protective factors, evaluates prevention strategies, and works with communities to use this information to implement and monitor the most promising approaches. CDC also actively disseminates the research knowledge gathered so that communities can better understand and prevent youth violence. This resource is one example of CDC’s prevention support to communities and draws upon CDC’s surveillance systems, research investments, and programmatic activities as well as other sources for youth violence prevention. CDC’s focus on prevention complements the work of law enforcement agencies to hold perpetrators accountable and the efforts of healthcare agencies to provide services to victims. CDC’s work represents a pipeline of prevention activities that move from research to practice. Below are some examples of current activities along this pipeline. More information about each of these examples and other CDC activities that help prevent youth violence is available from CDC’s Division of Violence Prevention.

National Violent Death Reporting System (NVDRS). NVDRS combines data from death certificates, law enforcement reports, and coroner or medical examiner reports to provide rich information on the circumstances of violent deaths, including information on youth and gang homicides. NVDRS operates in 18 states (as of March 2014) and will be expanding to more states.

School-Associated Violent Death Study (SAVD). Since 1992, CDC has been collecting data on each homicide or suicide that happens on school grounds, on the way to or from school, or at a school-sponsored event. The SAVD collects information about the victims, alleged perpetrators, and the lethal incident.

Youth Risk Behavior Survey (YRBS). The YRBS has been conducted biennially since 1991 with a large, nationally representative sample of students in grades 9–12. The YRBS collects data on a range of health risk behaviors, including bullying, weapon carrying, and fighting on and off school property.

Crime Prevention Through Environmental Design (CPTED). CDC has developed a tool that uses CPTED principles to assess the physical environment in school settings. CDC is currently testing the extent to which scores on the tool are associated with students’ reports of fear and violence.

30 Preventing Youth Violence: Opportunities for Action

National Centers of Excellence in Youth Violence Prevention. CDC currently supports six National Centers of Excellence in Youth Violence Prevention that connect academic and community partners to implement and evaluate a comprehensive youth violence prevention strategy in a high-risk community. The Centers are using approaches that have the best available research evidence and are assessing their impact on assault, homicide, and other youth violence outcomes. They are a catalyst for prevention efforts in the communities they serve and are models for other communities.

Striving To Reduce Youth Violence Everywhere (STRYVE). STRYVE, CDC’s national youth violence prevention initiative, helps public health departments and community partners stay abreast of the latest information and implement evidence-based prevention strategies.11 Components of STRYVE, such as STYRVE Online, connect communities to tools that help them convene partners, use data to design local prevention approaches, select evidence- based strategies, and conduct evaluations to help ensure community youth violence prevention goals are being achieved. Additionally, training and technical assistance are provided directly to select local public health departments in order to build their leadership, infrastructure, and capacity to use evidence-based youth violence prevention approaches.

Youth Violence Prevention Training and Technical Assistance. To further build local capacity to prevent youth violence, CDC provides training and technical assistance to help communities better understand youth violence, evidence-based prevention approaches, and strategies to develop partnerships and comprehensive plans. Some of this guidance is found on CDC’s Violence Education Tools Online (Veto Violence). CDC also provides training and technical assistance to local health departments and their partners working in high- risk communities. This support is intended to build the infrastructure of local public health departments to plan and implement strategies based upon the best available evidence.

Implementing Evidence-based Youth Violence Prevention Activities Communities around the country are making significant progress in using what is known about effective youth violence prevention. CDC’s STRYVE Online Communities in Action and Veto Violence Success Stories provide examples of communities working to prevent violence. Communities have learned that there is not one program, practice, or policy that solves their youth violence problem. Rather, they have to examine their unique strengths and needs and design a comprehensive plan that puts in place multiple prevention activities that have the best available evidence. A systematic, data-driven approach increases the likelihood that implemented youth violence prevention activities will be effective. A strategic plan also aids in aligning resources with prioritized youth violence prevention goals and reduces redundancy in efforts.

The success of a youth violence prevention strategic plan also rests on the community’s capacity to select evidence-based approaches that help achieve community goals and an infrastructure that enables the implementation and sustainability of effective approaches. Communities may need a youth violence prevention coordinator at the public health

Data-Driven Strategic Action Communities that Care (CTC) is an example of a prevention system that uses a data-driven strategic approach to prevent youth problem behaviors, such as violence, delinquency, school dropout, and substance abuse. With CTC, a coalition of community stakeholders assess local risk and protective factors and then selects and implements evidence- based prevention programs.64 An evaluation of the CTC prevention system in 24 communities found that between 5th and 7th grades youth in the CTC settings were 27% less likely to initiate delinquent behavior (e.g., stealing, attacking someone) compared to their peers in non-CTC settings.112 The most recent wave of analyses indicates that these significant differences were sustained through 10th grade.113 Cost benefit analyses of the effects through 8th grade estimate that the net benefit is $5,250 per youth. This equates to a return of about $5.30 for every $1.00 invested.114 For more information, visit Communities that Care.

department or other partner organization who can provide leadership and focused attention to building collaboration and identifying prevention strategies based on local data. Many communities may also need training and technical assistance to improve their capacity and infrastructure to take better advantage of what is known to work. Free tools and training available through such resources as CDC’s STRYVE Online can help communities learn how to forge partnerships, use local data to guide prevention planning, identify and implement multiple evidence-based prevention strategies, evaluate whether community goals are being met by prevention activities, and modify and expand prevention activities as necessary.

Population-wide reductions in youth violence are possible by expanding the implementation of evidence-based prevention strategies throughout a community to ensure that as many people who can benefit from the activity as possible are participating. Examples include reaching an entire county instead of just one neighborhood, impacting an entire school district rather than just one school, embedding a strategy within a state agency instead of just one organization, or adapting a school-based strategy for community settings. This expansion includes being strategic about the mix of prevention strategies used, building on existing capacity and infrastructures, addressing the needs of diverse groups, and ensuring the quality of the implementation is maintained.115,116 Widespread adoption of an effective approach throughout an organization or a community or even across a city or state can occur with the appropriate infrastructure in place, support from leadership, and knowledge of community context and community experience of what strategies work, with whom (e.g., specific age groups, specific risk groups), and in what contexts (e.g., schools, community settings).

Opportunities for Action Youth violence can take many forms, including fighting, bullying, and gang violence. Regardless of the form, the consequences of youth involvement in violence are felt by everyone—young victims, families, neighbors, schools, and local organizations. Typically when we think about who should be working to reduce youth violence, we point to someone else instead of looking in the mirror. We think it is a law enforcement issue or a school problem or a family matter. Or, we naively believe youth violence happens to other people’s kids or in other communities and we are immune.

The reality is that youth violence is a public health problem that touches us all, and each of us has a role to play in prevention. The research presented in this document demonstrates that there are strategies that can stop youth violence before it occurs. This knowledge helps us identify the actions community leaders and members, public health professionals, adults who care for or work with youth, and young people can take to reduce youth violence. Actions are presented below for each of these groups and summarized in Table 3. People can be in multiple categories. For example, community leaders can also be caregivers. Consequently, individuals will likely see action steps in multiple categories that they can take. Each potential action step is supported by the research summarized in this document about modifiable youth violence risk and protective factors and youth violence prevention strategies that have been shown to be effective.

Preventing Youth Violence: Opportunities for Action 31

32 Preventing Youth Violence: Opportunities for Action

Table 3. Summary of Actions to Prevent Youth Violence

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rs Pu

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th

Pr of

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na ls

Fa m

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, C ar

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Action 1. Enhance the skills and experiences of individual youth.

• Serve as a mentor, tutor, or volunteer at schools and youth-serving organizations to support the healthy development of all young people.

• Provide meaningful and appropriate opportunities through businesses and social/civic groups for youth to develop their interests, skills, and talents.

• Praise good behavior and take immediate action to stop youth violence when it occurs.

Action 2. Use and promote youth violence prevention strategies that are based on evidence to benefit the entire community.

• Support local action by joining or starting a youth violence prevention coalition that works across groups and sectors.

• Make prevention a community priority. • Insist on the use of data to make decisions and put in place evidence-based approaches. • Use a comprehensive set of approaches to support and strengthen youth, families, schools, and communities. • Seek out and use existing resources to learn about effective youth violence prevention activities and programs. • Share progress and successes to raise awareness that youth violence is a preventable public health problem.

Action 3. Help communities build their capacity to prevent youth violence.

• Actively disseminate the latest information about what works. • Join with partners to strategically plan and support widespread implementation of evidence-based youth

violence prevention approaches. • Expand and enhance data systems on youth violence and risk/protective factors and improve data integration

and dissemination. • Establish and maintain dedicated youth violence prevention staff. • Enhance public health leadership for youth violence prevention.

Action 4. Continue innovative research to address gaps.

• Continue research about factors that protect youth, families, and neighborhoods from violence. • Rigorously evaluate promising youth violence prevention strategies. • Study ways to strengthen communities’ ability to implement youth violence prevention strategies well.

Action 5. Reduce the risk for violence and promote the strengths of young people.

• Be a consistent model for how to respond nonviolently to conflict, stress, and fear. • Pay attention when youth behave well and help them see the benefits that come from their good choices. • Build a connection with young people that allows them to feel comfortable discussing violence and related

concerns. • Carefully monitor youth’s activities and behavior, help youth make safe choices, and talk with others who have

a strong influence on young people. • Prevent minors from getting unsupervised access to firearms at home, from family, and from friends. • Take advantage of help and share information and resources with others.

Action 6. Make choices that promote safety and opportunities to thrive.

• Stop and think before saying or doing anything that could hurt others, act in nonviolent ways, and get help from a trusted adult or safe place.

• Spend time with people and in places that are at low risk for violence.

Action 7. Help others be violence-free.

• Help others be violence-free, and support those who have been hurt by violence. • Show others how to stay safe. • Get involved in violence prevention work.

Preventing Youth Violence: Opportunities for Action 33

Community Leaders and Members

All adults, including neighbors, business owners, health care providers, appointed and elected leaders, and members of faith-based groups have reasons and opportunities to support the development and safety of young people and to contribute to community-wide efforts to prevent violence.

Action 1. Enhance the skills and experiences of individual youth. All adults can consider ways to help youth learn new problem-solving and communication skills and to have life-enriching experiences. These connections may occur between adults and youth who already interact as neighbors or members of the same faith-based groups. New relationships can also be formed. Implementation steps include:

• Serve as a mentor, tutor, or volunteer at schools and youth-serving organizations to support the healthy development of all young people. Even activities that are not specifically described as youth violence prevention can make a difference in the lives of young people. Community members can look for ways to use their experiences, skills, time, and talents to help guide youth. These opportunities can vary from being a trained mentor to volunteering at an afterschool program or joining with other community residents and youth to assist with community activities. These connections should be made with at-risk youth as well as young people who do not show obvious signs of difficulties. All young people can make better decisions in multiple aspects of their lives, including their involvement in violence, when they have a stable relationship with a caring adult who supports them and models nonviolence.

• Provide meaningful and appropriate opportunities through businesses and social/civic groups for youth to develop their interests, skills, and talents. Action by adults does not necessarily require joining new organizations. Adults can look for ways to incorporate young people into existing work or volunteer activities in order to provide training, educational, and networking experiences. Scheduling these opportunities immediately after school and during school breaks—when young people’s time is less structured and unsupervised—can be a powerful youth violence prevention approach.

• Praise good behavior and take immediate action to stop youth violence when it occurs. Community members should encourage and praise youth for making wise, nonviolent choices. Recognition and reinforcement of positive behaviors increases the likelihood of recurrence. All adults in the community have a role to play in letting youth know that violence is not acceptable. Adults should model nonviolence in all of their interactions and coach youth on how to resolve disputes calmly and nonviolently. Community members can involve other adults, such as the youth’s parents, siblings, neighbors, or teachers, to help deescalate conflict, support victims and perpetrators, and create a community belief that violence is never okay.

All adults can consider ways to

help youth learn new problem-solving

and communication skills and to have

life-enriching experiences.

34 Preventing Youth Violence: Opportunities for Action

Action 2. Use and promote youth violence prevention strategies that are based on evidence to benefit the entire community. Communities can effectively prevent youth violence but far too often wait for violence to occur before acting. By increasing the use of evidence-based strategies that address local needs, communities can prevent youth violence from happening in the first place. Implementation steps include:

• Support local action by joining or starting a youth violence prevention coalition that works across groups and sectors. Critical partners to preventing youth violence will vary from community to community and will likely include education, public health, faith-based organizations, law enforcement, and local businesses. Encouraging collaborative action and creating opportunities for others to participate, including youth and residents impacted by youth violence, can help ensure planned activities will address local needs, build on local strengths, and be sustained over time. A collaborative approach also helps to ensure that a range of evidence-based prevention activities are used.

• Make prevention a community priority. Many prevention activities have been shown to have benefits that result in significant returns on investment, including savings to participants, victims, and taxpayers. A community can experience significant savings over time by making prevention a priority. Community members can work with partners to increase attention to acting before violence starts and having prevention be an essential complement to law enforcement and medical responses to violence. They can identify the public and private resources needed to achieve prevention goals and keep the activities going over time. This might include pooling existing resources across systems and coordinating with other violence prevention and health promotion activities in the community.

• Insist on the use of data to make decisions and put in place evidence- based approaches. When youth violence prevention strategic plans are based on data, implemented approaches are more likely to work. The opportunity for success increases by having information about violence in the community, differences across groups or neighborhoods, local risk and protective factors, and evidence that programs being considered or used actually reduce risk or enhance protective factors. Information can come from existing sources, such as police, school, or emergency department records, or new sources like neighborhood surveys.

• Use a comprehensive set of approaches to support and strengthen youth, families, schools, and communities. No one approach will solve an entire community’s youth violence problem. By implementing multiple activities that are based on the best available evidence, communities can address the needs of all youth, including those who are at immediate risk for violence. Complementary approaches can be identified that help strengthen young people’s skills and relationships as well as address issues in schools, communities, and society that influence the likelihood of violence. Examples of potential prevention approaches are presented in Table 1, on pages 22–23.

Data-Driven Strategic Planning and Implementation Models • STRYVE Online

• Communities that Care

• PROSPER Partnerships

• Mobilizing for Action through Planning and Partnerships

Examples of Youth Violence Prevention Approaches Based on the Best Available Evidence Approaches for use in schools, homes, or communities:

• Universal School-based Youth Violence Prevention

• Parenting Skill and Family Relationship Approaches

• Policy, Environmental, and Structural Approaches

Approaches that focus on those at immediate risk:

• Intensive Family-focused Approaches

• Street Outreach and Community Mobilization

Approaches that focus on very young children:

• Early Childhood Home Visitation • Early Childhood Education

Preventing Youth Violence: Opportunities for Action 35

• Seek out and use existing resources to learn about effective youth violence prevention activities and programs. In addition to learning from the experience of other communities and coalitions, online resources provide helpful information about effective youth violence prevention activities and programs, including descriptions of the risk and protective factors addressed, program effects found by research, types of participants helped, and the costs. When existing approaches are available and fit a community’s needs, their use should be promoted over the development or use of approaches that have not been evaluated. Online resources, including those listed on the right and and described in greater detail on pages 24-26, can be helpful in choosing the best programs to meet community needs as well as offer training and guidance on strengthening partnerships, strategic planning, and coordinating resources.

• Share progress and successes to raise awareness that youth violence is a preventable public health problem. Everyone can become a visible spokesperson for prevention by explaining how violence is not just a problem for law enforcement or schools. The facts that violence is also a public health issue and prevention is possible can be shared. Information about what is working can be provided through multiple formats, such as fact sheets, training/information sharing lecture series, and annual reports. Increased awareness of this information can help youth violence prevention efforts take hold and grow.

Online Resources to Learn More on Evidence-based Youth Violence Prevention Activities

• STRYVE Strategies Selector Tool

• Blueprints for Healthy Youth Development

• Task Force for Community Preventive Services

• Crime Solutions

• National Registry of Evidence-based Programs and Practices

36 Preventing Youth Violence: Opportunities for Action

Public Health Professionals

Public health professionals can include researchers and practitioners working for local and state health departments, federal public health agencies, or schools of public health, as well as professionals from diverse backgrounds who are taking a public health approach to youth violence prevention. These groups have a clear responsibility to help reduce the health burden of youth violence. The ability of public health professionals to apply science to challenging health problems to reduce risk within large groups of people can be used to decrease youth violence.

Action 3. Help communities build their capacity to prevent youth violence. Public health has a role to play in ensuring that existing information about what works to reduce youth violence is being used and our knowledge and evidence-based prevention strategies continue to grow. These professionals have the skills and expertise to help strengthen and coordinate the activities of multiple partners to plan and implement youth violence prevention activities. Implementation steps include:

• Actively disseminate the latest information about what works. Public health organizations can synthesize, translate, and disseminate the best and most recent information available from youth violence prevention research and practice. Multiple channels can be used, including in-person meetings or training sessions, webinars, distance learning programs, fact sheets, and action briefs.

• Join with partners to strategically plan and support widespread implementation of evidence-based youth violence prevention approaches. Public health organizations focus on improving the health of the entire community. Their skills and experiences can be applied to helping communities prevent violence by facilitating collaboration among community partners, assessing local needs, selecting strategies that work, implementing approaches well, and monitoring the outcomes.

• Expand and enhance data systems on youth violence and risk/protective factors and improve data integration and dissemination. Accurate and timely information is crucial to planning, implementing, and evaluating youth violence prevention strategies. Public health practitioners must work with partners to improve the availability, quality, and integration of relevant data systems from police, hospitals, schools, social services, housing, and labor. Particular attention can be given to integrating or creating information resources about circumstances of violence and contributing factors, establishing procedures to improve the efficiency of data sharing through secure, web-based systems, and analyzing data by neighborhood. This information should be shared to inform local prevention approaches.

• Establish and maintain dedicated youth violence prevention staff. A key challenge to preventing youth violence is the limited availability of staff with the necessary training and time to engage in these activities. The responsibility of coordinating youth violence prevention activities can be assigned to a staff person or team in the public health department who are supported and have protected time to sustain partnerships, implement approaches, and evaluate effects. Public health organizations can utilize existing networks of prevention researchers and mentoring/ training programs to connect graduate students and interns with on-the-ground opportunities to gain valuable experience in applying new knowledge and skills to preventing violence in real-world situations.

Minneapolis: Implementing Prevention and Tracking Success Homicide was the leading cause of death for youth in Minneapolis between 2003 and 2006. In 2006, the City Council declared youth violence a public health problem and established a multisector Steering Committee. This group developed the Blueprint for Action to Prevent Youth Violence by reviewing research, meeting with local youth, consulting national experts, and assessing existing youth violence prevention programs. A prevention coordinator was hired in the public health department to oversee the implementation of this strategic plan, which included evidence-based approaches to strengthen families, mentoring, and employment opportunities. Through a collaborative data system called Results Minneapolis, prevention effects are monitored on 18 indicators. Between 2006 and 2010, Minneapolis had a 56% reduction in juvenile crime, 58% reduction in incidents involving firearms and juveniles, and 36% reduction in firearm-related injuries of youths and young adults.58 For more information, visit Minneapolis’ Health Department.

Preventing Youth Violence: Opportunities for Action 37

• Enhance public health leadership for youth violence prevention. Public health leaders can provide high-level support and guidance for youth violence prevention. Public health leaders can develop local, state, and national strategic plans for youth violence prevention. Public health leaders at multiple levels can also work to educate decision makers about the opportunities for prevention, help prioritize prevention resources for evidence-based approaches, and provide information to guide the development of policies that enhance protective factors and reduce risks for youth violence.

Action 4. Continue innovative research to address gaps. To successfully prevent youth violence, gaps in knowledge must be filled. Continued research is needed about the factors that influence the likelihood of youth violence, prevention strategies that address community factors, and the best ways to disseminate and implement what works. Implementation steps include:

• Continue research about factors that protect youth, families, and neighborhoods from violence. Knowledge about risk and protective factors for youth violence is the backbone of effective prevention strategies, and knowledge about protective factors is limited. Continuing research in this area can inform the development of innovative prevention strategies to enhance protective factors for all youth as well as efforts directed at buffering against the risks faced by vulnerable youth, families, and communities.

• Rigorously evaluate promising youth violence prevention strategies. Researchers’ development of new evidence-based, youth violence prevention approaches must continue until youth violence is prevented across all communities. Researchers can replicate and evaluate promising youth violence prevention strategies in different populations and settings to determine whether cultural and community adaptations are needed. Evaluation of new strategies should also consider the broader community factors that increase the likelihood of youth violence, including strategies that build the social cohesion of communities, improve physical environments, decrease inappropriate access to and use of firearms among minors, and modify societal norms about the acceptability of violence.

• Study ways to strengthen communities’ ability to implement youth violence prevention strategies well. Research provides youth violence prevention approaches that have demonstrated effectiveness with diverse populations in different settings; however, many of these approaches are underutilized. Research should focus on strategies that bridge the gap between science and action so that more individuals, organizations, and communities are able to implement effective approaches and achieve positive outcomes. This research includes strategies to synthesize, translate, package, and implement evidence- based prevention approaches. Research is also needed to identify the types of technical assistance that are most helpful to communities.

VCU Clark-Hill Institute for Positive Youth Development: Advancing Prevention Research The Virginia Commonwealth University (VCU) Clark-Hill Institute for Positive Youth Development is one of CDC’s National Centers of Excellence in Youth Violence Prevention. Clark-Hill researchers collaborate with education and public health partners to build local infrastructure, capacity, and activities to prevent youth violence. One activity is the continuous gathering, analysis, and interpretation of local data to engage the community, educate community leaders, and evaluate innovative prevention activities. For example, surveillance data analyzed by Clark-Hill researchers found that single-serve alcohol beverages were associated with increased rates of injury and violence. Local policy makers used these data to develop a new alcohol licensing policy. An evaluation of this policy by Clark-Hill researchers found that rates of violence-related ambulance pick-ups declined from 19.6 to 0 per 1,000 youth ages 15–24 years in the intervention community.51 For more information, visit the Clark-Hill Institute.

CDC’s Injury Research Agenda CDC’s Injury Center developed a research agenda to describe research needs and priorities for 2009–2018. The research agenda includes chapters on multiple forms of intentional and unintentional injury, including youth violence. The research agenda is accessible from CDC’s Injury Center.

38 Preventing Youth Violence: Opportunities for Action

Families, Caregivers, and Adults Who Work with Youth

Parents, other caregivers, and adults who work with youth, including teachers, mentors, coaches, faith-based and club leaders, have a profound influence on young people’s beliefs and behaviors throughout their lives.

Action 5. Reduce the risk for violence and promote the strengths of young people. Young people’s risk for violence can be buffered by stable, healthy, and safe relationships with caring adults that are developed in early childhood and are sustained throughout adolescence. These adults can be powerful role models for how to successfully navigate difficult situations. They are also critical guides to young people throughout their development. Implementation steps include:

• Be a consistent model for how to respond nonviolently to conflict, stress, and fear. Parents, other caregivers, and adults who work with youth can show young people how to stay calm in difficult situations, seek help when needed, and use nonviolent solutions. This modeling teaches young people how to avoid violence and choose positive ways to deal with difficulties.

• Pay attention when youth behave well and help them see the benefits that come from their good choices. Violence prevention is about more than reducing risks. It is also about increasing positive behaviors. When adults praise youth for positive behaviors as they happen, such as sharing, talking through disputes, and respecting others, young people are more likely to repeat these behaviors. When adults help youth see how their good choices benefit them in other ways, like increasing opportunities to spend time with friends or to have fun, they are more likely to change their behaviors.

Preventing Youth Violence: Opportunities for Action 39

• Build a connection with young people that allows them to feel comfortable discussing violence and related concerns. The challenges faced by young people change over time as their relationships, experiences, and environments change. Youth can cope more effectively with these difficulties when adults who care about them continually monitor and discuss those concerns. Conversations about violence and related issues are best started in pre-school and continue throughout the teen years. Adults can build and strengthen the connections with positive activities that show they care by:

• Spending time each day talking to youth about their activities and experiences, asking who they spent time with and what they did, listening to how they are doing, and talking about possible future difficulties and solutions.

• Setting age-appropriate expectations for behavior and noticing and praising good choices.

• Having clear and nonviolent consequences for misbehavior and consistently addressing rule breaking.

• Noticing warning signs, such as changes in how a youth is acting, and immediately and repeatedly discussing concerns with the youth and work with the youth as well as other adults, when necessary, to identify solutions.

• Talking with youth about violence, letting young people know that adults expect them to be nonviolent, helping youth develop the skills to be violence-free, and encouraging young people to talk about and seek help when violence occurs or they are concerned about potential threats.

• Carefully monitor youth’s activities and behavior, help youth make safe choices, and talk with others who have a strong influence on young people. Adults who have a positive relationships and good communication with young people are better able to know who youth are spending time with, where they are, and what they are doing in the community and online. Parents, other caregivers, and adults who care for young people can also know what young people are doing by regularly talking with important people in young people’s lives, including the parents of youth’s closest friends, parents, teachers, mentors, and neighbors. This monitoring can significantly reduce the likelihood of violence. Adults can closely supervise young people’s activities and reduce time youth spend with peers who make poor choices and in environments where the likelihood of violence is high. Exposure to television programs, movies, music, and video games that promote violence can be limited. The level and type of monitoring needed will depend on the young person’s maturity and past behavior. Appropriate monitoring is not easy and is often not appreciated by young people, but it is a critical part of helping them make wise choices.

• Prevent minors from getting unsupervised access to firearms at home, from family, and from friends. When minors have unsupervised access to firearms, the potential for children to experience serious or deadly violence or unintentional injury can increase. By storing firearms safely and assuring that minors do not have unsupervised access to firearms at home or in the homes that they visit, adults can reduce the risk for firearm injuries and deaths of children and young people.

• Take advantage of help and share information and resources with others. All adults want the young people in their lives to be healthy, happy, and safe, but the lack of information and other resources can make that a challenging goal. Parents, other caregivers, and adults who care for youth can take advantage of effective prevention approaches that help improve and strengthen adult-youth relationships, increase safety, and lower the risks for violent behavior. Help is available and should be sought out if violence is suspected in a child’s home, if a family is dealing with mental health or substance abuse problems, or if more guidance is needed on how to support the healthy development of a child. Parents and other caregivers can access local support with the help of teachers, pediatricians, and mental and behavioral health providers. Online resources also are available and provide information and guidance.

• Parent Resources on USA.gov links to information about health, education, safety, child care, and other resources for parents and grandparents.

• National Parent Helpline (or 1-855-4 A PARENT) provides parents access to information, emotional support from a trained provider by phone, and assistance connecting to local resources.

• CDC Parent Information provides information from CDC about how to protect the health of children. The information is organized by age group and covers topics like safety and milestones in development and includes CDC’s Division of Violence Prevention Essentials for Parenting Toddlers and Preschoolers, which offers videos, interactive activities, and other resources to help parents build healthy relationships with their young children and to prevent violence.

• Department of Education provides checklists, tips, and tools to help parents meet their child’s educational needs.

• StopBullying offers information for service providers, parents, and youth about bullying, prevention approaches, and responses to bullying.

• FindYouthInfo provides access to information, tools, and other resources developed by multiple federal agencies for youth, families, schools, and community organizations to address a broad range of adolescent health topics, including youth violence, and to support higher risk groups, such as runaway and homeless youth.

• Violence Education Tools Online (Veto Violence) is developed by CDC’s Division of Violence Prevention and includes youth violence prevention information, free accredited prevention training, resources for program planning, and success stories from other communities.

40 Preventing Youth Violence: Opportunities for Action

Preventing Youth Violence: Opportunities for Action 41

Michigan Youth Developing Skills and Strengthening Prevention The Michigan Youth Violence Prevention Center is one of CDC’s National Centers of Excellence in Youth Violence Prevention. It brings the University of Michigan School of Public Health and Medical school together with community- based organizations and residents to prevent youth violence. One prevention component is Youth Empowerment Solutions (YES), which promotes positive development and prevents risky behaviors among youth by empowering them to change their physical and social environments. The 16-week curriculum and community project are youth-led. In 2013, YES youth talked with their congressmen about their ideas for a safer future. Youth are also an energizing force in the Safe and Healthy Futures Youth Festival in Flint, which showcases performances by local youth organizations. For more information, visit the Michigan Youth Violence Prevention Center.

Young People

Young people are an important part of the solution to youth violence. They can contribute in meaningful and significant ways to preventing the violence that they and their peers experience.

Action 6. Make choices that promote safety and opportunities to thrive. Young people are the most directly affected by violence. By strengthening communication skills, avoiding or heading off risky situations, and choosing positive activities and relationships young people can help create opportunities for success for themselves and their peers, be buffered from some community risks, and help reduce violence. Implementation steps include:

• Stop and think before saying or doing anything that could hurt others, act in nonviolent ways, and get help from a trusted adult or safe place. When young people stay in control of their feelings and resolve conflicts in nonviolent ways, they reduce the chances that they or someone else could get hurt. Youth should seek help from a trusted adult, such as a family member, teacher, coach, faith-based leader, or neighbor to learn about ways to stay in control and to find nonviolent solutions. Minors who feel that they need to carry a weapon for protection should talk with an adult about safer ways to protect themselves.

• Spend time with people and in places that are at low risk for violence. Young people should think carefully about their close friends and what they do together. Friends who do not use drugs and alcohol, try to do well at school, and believe violence should be avoided can help youth stay safer. Young people can reduce their risk for violence by spending time with friends in places that are supervised by adults. Gangs and gang-like groups try to make youth think that they offer safety, but people in a gang are much more likely to be a victim of violence than those who do not join. That is one of the reasons that most young people do not join gangs, and those who do typically leave within a year. Youth can consider nonviolent alternatives to television programs, movies, music, and video games that promote violence. Activities such as sports, clubs, and volunteering provide opportunities to develop skills, interests, and connections with peers and adults who make good choices.

Action 7. Help others be violence-free. The actions of one young person can greatly influence the actions of others. Youth can help prevent violence by speaking out and letting others know that violence is never okay. Implementation steps include:

• Help others be violence-free, and support those who have been hurt by violence. Young people are encouraged to not just wait and watch when violence is about to happen or is occurring around them. When youth see that their friends are getting upset, they can help them calm down and deal with the situation in a nonviolent way. Whenever it is safe to do so, youth can stop an argument from getting violent and let others know that they do not agree with bullying or other forms of violence. Young people should get help from others, like trusted adults, especially when it is not safe to address the problem on their own. It is also important for youth to support others who have been victims of violence so that they do not continue to be victimized or become violent themselves.

42 Preventing Youth Violence: Opportunities for Action

• Show others how to stay safe. By avoiding alcohol, drugs, or any form of violence, youth can increase their own safety and health and be positive models for their peers. Youth can also encourage their peers to make safe and healthy choices. When minors resolve conflicts in nonviolent ways and without involving weapons, they help keep themselves, their friends and families, their schools, and their neighborhoods safe.

• Get involved in violence prevention work. Young people can become involved in or initiate violence prevention work in their schools or communities. Having young people involved helps to ensure that violence prevention efforts are focusing on the right issues and working in ways that will engage youth. These are also opportunities for youth to build and share their experiences, skills, and talents to help others and to make connections with other nonviolent peers. Youth-led activities can help raise support for youth violence prevention among other youth and adults.

Seizing the Opportunity and Responsibility to Prevent Youth Violence The advances in our knowledge about youth violence and effective prevention strategies give us the opportunity to do more than simply wait and respond when violence occurs. We have learned how to proactively stop youth violence before our young people die or are injured. We have a responsibility to our young people and communities to use the evidence- based prevention approaches that are already available and to continue research to expand our ability to stop youth violence before it starts. This work includes ensuring that prevention is a prominent element of a community’s approach to violence and implemented prevention activities are based on what works. Communities are more likely to have an impact on youth violence and save money by using evidence-based prevention approaches over unproven ones. Existing knowledge about youth violence gives us the tools to act today and a solid foundation to continue to develop and test innovative prevention approaches that benefit all communities.

Part of the opportunity and responsibility to prevent youth violence includes activating, integrating, and utilizing public health professionals. They have the expertise and skills to strengthen communities’ efforts to prevent youth violence. By partnering with and complementing the work of other sectors, including law enforcement, education, social services, and medical systems as well as faith-based, media, non-profit, and businesses, public health can contribute to and help lead the advancement of youth violence prevention activities. No matter who we are—community residents and leaders; public health practitioners; parents, teachers and others who work with youth; or young people—we all have an important role and actions we can take to protect America’s youth and to help prevent youth violence.

Preventing Youth Violence: Opportunities for Action 43

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Acknowledgments Many federal and nonfederal organizations share the Centers for Disease Control and Prevention (CDC) Division of Violence Prevention’s (DVP) concern about the health and safety of America’s young people. During the development of the Preventing Youth Violence: Opportunities for Action, representatives from many partner organizations, including the Office of the Surgeon General, graciously gave their time and expertise as they reflected on early working drafts. Their constructive suggestions helped us ensure that this resource is grounded in research and guided by the best available evidence and practice. More information about the development of this resource is provided in Appendix A. Many of our CDC colleagues also provided considerable support during the development of this resource and its companion document, Taking Action to Prevent Youth Violence. We greatly appreciate the assistance offered by Sarah Bacon, Tiffany Cain, Linda Dahlberg, Linda Degutis, Alan Dowell, Sarah Foster, Jeffrey Hall, Sarah Harrier, Marci Hertz, Alida Knuth, Joanne Klevens, Greta Massetti, Jennifer Matjasko, James Mercy, Sara Patterson, Richard Puddy, Neil Rainford, Elizabeth Reimels, and Howard Spivak. The knowledge and experience offered by all of these experts greatly strengthened this work.

50 Preventing Youth Violence: Opportunities for Action

Appendix A. Development of Preventing Youth Violence: Opportunities for Action

Preventing Youth Violence: Opportunities for Action was prepared by the Division of Violence Prevention (DVP), National Center for Injury Prevention and Control (NCIPC), Centers for Disease Control and Prevention (CDC). CDC is a part of the U.S. Department of Health and Human Services (HHS), which works to promote the health and safety of all Americans and provides essential human services. CDC is also a part of a larger community of federal and nonfederal organizations who support the healthy development of youth, families, and neighborhoods.

Representatives from many federal and nonfederal partners reviewed selections of early working drafts of this resource and provided constructive suggestions. From HHS, these partner agencies include the Administration on Children, Youth, and Families; National Institutes for Health; Offices of the Assistant Secretary of Health; Office of the Assistant Secretary for Planning and Evaluation; Office of the Surgeon General; and Substance Abuse and Mental Health Services Administration. Additional suggestions were sought from more than 25 nonfederal individuals and organizations that have expertise in youth violence prevention and in public health approaches to promoting youth and community safety and well-being. These nonfederal experts were drawn from diverse sectors, including city and state public health departments, public health practitioners, research and academic institutions, law enforcement, education, business, youth serving organizations, and other health promotion and violence prevention organizations.

As CDC developed the initial outline and drafts for Preventing Youth Violence: Opportunities for Action, suggestions were sought from partners through a process spanning a year and a half. The purpose of this process was to receive candid and critical comments to assist in the development of this resource and to ensure that it is grounded in research and guided by the best available evidence and practice. First, comments on the development of the document were solicited from the general public through the Federal Registry between January 19 and February 21, 2012. All received comments were considered during the development and revision of this resource. Then, between March and April 2012, representatives from HHS and nonfederal organizations provided input on drafted sections. Working drafts were shared and comments were solicited multiple times from HHS partners during this period. Between May and June 2012, external peer reviews were conducted by David Hawkins, Ph.D. and Deborah Gorman-Smith, Ph.D. Finally, through the end of 2012 and into mid-2013, federal and nonfederal partners gave input into clarifying language and examples that could help the evidence-based action steps be clear and useful to groups who have a role in preventing youth violence, such as parents and youth. Each of these stages helped to strengthen Preventing Youth Violence: Opportunities for Action and informed the development of its companion resource, Taking Action to Prevent Youth Violence. Throughout the development process, many constructive comments were received that helped to shape these materials. However, partners were not asked to approve the final documents.

For more information

To learn more about youth violence prevention, call 1-800-CDC-INFO or visit CDC’s violence prevention pages at www.cdc.gov/violenceprevention.

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National Center for Injury Prevention and Control Division of Violence Prevention