Most peer violence in the United States results from conflicts among friends, acquaintances, or intimate partners. Estimates of the incidence of stranger violence range from 6% to 40% of new cases among all instances of personal violence.[1] [2]

Violence of all levels of severity is often a result of conflicts between persons who know each other, often quite well. Although physicians have traditionally viewed patients as the victims, the distinction between victim and perpetrator is more fluid and varied than previously thought. From a public health perspective, the conclusion from years of research is dramatically simple: Young people who fight get hurt, whether in their families or in their communities.

Primary prevention in pediatrics must extend beyond preventing a child from becoming a victim; it must help the child learn nonviolent problem-solving skills and attitudes. Developing these skills and attitudes begins in infancy. Effective, nonviolent discipline throughout childhood and adolescence is 1 key to developing resilient children who can resist being drawn into violence.[3] In addition, parents can help reduce the risk of serious violence through attention to the child's environment—both decreased exposure to media violence and domestic violence and decreased access to firearms effectively reduce serious violence. Parents can encourage a nonviolent attitude by resisting toys that promote violence, such as toy guns, violent video games, and toys that encourage racial or ethnic stereotypes.[4]

In the 1980s, Patterson proposed a model based on an extensive review of the literature that accounted for the developmental progression of antisocial behavior.[5] These results have been confirmed by more recent longitudinal studies conducted. Aggression naturally increases during early childhood; parents serve to temper and redirect these impulses before school entry.[6] Thus the foundations of antisocial behavior begin with coercive or inadequate parenting in early childhood. Children whose parents are unable to set effective limits, particularly in households where extensive use of corporal punishment is used, develop dysfunctional behavior patterns in interactions with their peers and with adult authorities, including teachers. These children then have behavioral problems even before they enter school. In school, the children are both rejected by normal peers and have difficulties academically. In later childhood and adolescence, these ostracized children find each other and form peer groups that reward violence and antisocial behavior. The result of this cycle, which began in early childhood, is juvenile delinquency.

More recent descriptions of growing up in violent urban settings have reiterated the importance of peer relationships but stressed the central role that being willing to fight plays in establishing social hierarchy.[7] Boys, in particular, need to establish themselves as courageous fighters early in life, or else they fear that they will be harassed by others. Nevertheless, the majority of the young men growing up in these communities have figured out how to avoid participating in violence; they repeatedly state that they are able to walk away from potential fights. Their resilience begins early in life.

This overall trajectory model provides a focus for interventions in the pediatric office. In 1999 the American Academy of Pediatrics (AAP) Task Force on Violence endorsed a similar, far-reaching model that traces the origins of violent behavior to earliest childhood,[8] which formed the foundation of the new Connected Kids: Safe, Strong, Secure anticipatory guidance program. The Connected Kids program includes parent and patient education materials that encourage the development of resilience as a means of preventing child abuse and youth violence.[9]

Although many social and environmental factors place children at high risk for violence, countervailing resilience factors, many beginning in early childhood, help reduce the risk.

The greatest risks of violence for infants and toddlers revolve around the family through domestic violence and child abuse. One of the goals of the pediatric provider in speaking with families of new babies can be to assess family functioning, including the risks of domestic violence. Pediatricians who are suspicious that a patient's parent has been the victim of spousal abuse should ask directly, but confidentially. The physician should have information available in the office concerning battered women's advocates or shelters, legal aid resources, and safety plans.[10] Many offices place small cards with relevant telephone numbers in the restroom so this information can be obtained discreetly.

Children in the United States spend more time watching television than any other activity except sleep. While watching television, they observe an enormous amount of violence; the average child will see more than 10,000 deaths resulting from violence before completing high school.[11]

Television violence differs from real-life violence in quality and quantity. On television, violence is used by both heroes and villains and is therefore generally viewed as socially acceptable behavior. Although adults feel competent to separate fiction from reality, research suggests that even adults who are exposed to television violence have a more negative view of society and feel more hopeless and alienated than do less frequent viewers. Adults who rely on television as their major news source, for example, feel less safe in their homes and neighborhoods than do other adults.

Children, because they have more difficulty separating facts from fantasy, are even more likely to be affected by television violence. The American Psychological Association, in reviewing hundreds of research studies, has concluded that exposure to television violence is a major risk for children.[12] Children who view television are more likely to experience violence as victims or aggressors and are much less likely to intervene in tense situations, as bystanders, to reduce the likelihood of violence.

The AAP Committee on Communications has recommended that pediatricians counsel families to reduce the amount of television viewed by young children. Television and its influence on children are discussed further in Chapter 123, Children, Adolescents, and the Media.

Ethnographic research conducted in some of America's poorest urban neighborhoods has identified another pattern of violence in which fighting and the willingness to fight are key components of a broader protective strategy for coping with extremely dangerous environments. Young people have observed that individuals who are unable to defend themselves are likely prey to multiple and repeated attacks. Parents also understand this phenomenon and encourage their children to stand up for themselves by becoming able fighters.[7] This pattern of violence is known as the code of the streets or as the sucker phenomenon. Other parents adopt protective strategies that keep their children out of harm's way in the first place, often by enrolling them in supervised after-school programs or keeping them safely in the house, watching television, rather than risking participation in the street culture.

In counseling patients in these communities, physicians need to be aware of this logic and refrain from offering unrealistic or counterproductive advice. Nevertheless, in discussions with most young people, we need to remember that these same communities also contain nonviolent problem solvers who are well known to their classmates. Thus the reality of the code of the streets need not prevent individual children and adolescents from avoiding violent injuries through avoiding the culture of violence.

During infancy and early childhood, patterns of behavior and family interactions are established. The proper role of the pediatric provider is to ameliorate risk factors and reinforce factors that protect the child from harm. In this age group, the following topics should be addressed to the parents during anticipatory guidance: (1) reduction in exposure to violence, including both domestic violence and television violence, and (2) teaching appropriate, nonviolent methods of discipline (violence-free parenting). Because patients and families see their physicians often during this period, opportunities for brief, focused interventions are numerous. Our research has demonstrated the effectiveness of focused guidance at changing parental use of alternatives to corporal punishment and awareness of the effects of television violence during early childhood.[13]

As children enter the second year of life, patterns of discipline become established in families. Developmentally, this age is the time when children are typically separating emotionally and cognitively from their parents, a time of potential stress in the family. Several lines of research evidence suggest that a link exists between the use of corporal punishment and the subsequent use of violence by children as they grow. The AAP issued a policy statement in 1998 advocating that pediatricians counsel families in the use of alternatives to corporal punishments.[14] This approach forms a cornerstone of the new Connected Kids: Safe, Strong, Secure program from the AAP.[15]

Many families, however, believe in the need for corporal punishment. A direct challenge to family beliefs is unlikely to lead to successful behavior change. Instead, the pediatrician may incorporate several salient observations about families who use corporal punishment. First, most of the parents who use corporal punishment do not like to hit their children. Instead, they use corporal punishment when all other methods of correcting their child's behavior seem to have failed.[16] This approach results in an erratic pattern of punishment because parents end up using threats and cajoling to avoid spanking. Second, these same parents often believe that some children “don't need to be spanked.” One appropriate goal for guiding these families is to teach them effective techniques for discipline that will allow their children to be among those who do not need to be spanked.

Most importantly, many parents have little knowledge of other effective alternatives to corporal punishment. Faced with a choice of spanking a child or letting him or her run wild, many parents will opt for corporal punishment. The goal for anticipatory guidance at this age therefore is to describe and endorse specific effective behavioral techniques to help discipline children. Maintaining toddler discipline is understood best from the child's perspective; toddlers gain power over their world by being able to understand what is happening and predict what will happen next. Maintaining a schedule for children—for example, bedtimes, naptimes, mealtimes, bath time, and playtime—helps give the child this feeling of mastery.

Toddlers crave parental attention. The best kind of attention, of course, is parental praise for good behavior. In the absence of this positive reinforcement, toddlers may feel ignored and misbehave simply to grab the attention of their parents. The parental misperception that children who are praised will become self-centered and egotistical blocks the effective use of parenting and parental attention to encourage good behavior. Parents can be told very simply to tell their child, “I love it when you….”

Of course, times will occur when a child's misbehavior necessitates negative consequences. The most effective yet simple negative reinforcement technique for parents to use is time out from positive reinforcement. Parents can be taught that time-out periods can be used judiciously, in the background of positive reinforcement, and consistently whenever the child has certain behavior patterns that need to be stopped. Children should be placed in time-out for approximately 1 minute per year of age. Parents should explain clearly to the child why the time-out was deserved and ignore the child during the time-out. Longer explanations and discussions should be deferred until things have calmed down.

As children get older, the external influences of their behavior become more important. Television has an enormous effect at this age, and children also begin dealing with playground fights and bullying.

Bullying prevention is an important task for school administrators. Bullying—the repeated infliction of harm on younger, smaller, or less powerful peers—is a nearly universal problem for school-age children. Severe and even lethal bullying has been described in the United Kingdom, Japan, and Scandinavia, as well as in the United States. Bullies are usually larger and stronger (among boys) or more socially powerful (among girls) than are their victims. Typically, bullies will begin the school year by trying to pick on several children. Children who become singled out as targets are weaker, physically and emotionally, and are unable to strike back, either physically or verbally. Although bullying is a problem of school-age children, the negative behaviors often happen outside of school supervision: before school, after school, or at recess. Thus classroom teachers are often unaware of the problem and are almost always unable to solve it without significant support from their administrators.

Bullying has severe adverse consequences for both bully and victim. Victims may be hurt physically, often cannot concentrate on their studies, and develop poor self-esteem. Recent news reports suggest that several perpetrators in school shootings in the United States were victims of bullies, and their lethal outbursts may have resulted from the effects of being bullied.

Children who are bullies, in contrast, often feel powerful and effective. They typically come from chaotic households, and their parents feel ineffective in controlling their child's behavior. In many instance, bullies do not experience effective limit-setting at home. In the long term, the outcome for bullies is poor: by age 30, they are more likely to be incarcerated and less likely to be employed, married, or in other stable adult relationships than their peers.

Olweus has developed an effective antibullying program in Scandinavia, where it has led to a dramatic reduction in bullying.[17] Reports in the United States suggest that this program may also be effective here. Antibullying programs begin with information gathering. Students, who are asked to complete anonymous surveys, are quite willing to report to school administrators where and when bullying usually occurs. Active efforts to control bullying occur on 3 levels: (1) in the school building and grounds, (2) in the classroom, and (3) with individual students.

School-wide interventions focus on 2 issues: (1) ensuring a safe physical environment and (2) endorsing and coordinating classroom activities. To ensure a safe physical environment, staff monitoring is improved before and after school and at lunch, and any architectural or landscaping changes needed to improve supervision are made. A school-wide assembly is convened in which the announcement is made that bullying will not be tolerated anywhere in the school environment and that all necessary steps will be taken to control it.

Classroom teachers lead discussions with their students. These discussions identify roles of bullies, victims, and bystanders and establish that bullying behavior will not be tolerated. The students themselves are helped to generate rules to prevent bullying and to prevent the social isolation of victims. The students agree to (1) report bullying behavior, and (2) resist attempts by the bullies to ostracize their victims. Successful antibullying programs work, in part, by mobilizing the large number of bystanders. In so doing, they make bullies less respected and accepted by their peers and thereby reduce the allure of bullying.

Individual measures reinforce the antibullying messages. When bullies are identified, the child receives a stern message from the principal, and the principal also speaks with the child's parents. Parents are told of the possible short- and long-term consequences for their child, and a social worker or guidance counselor is assigned to work with them on setting appropriate and enforceable behavioral limits at home.

Recently, bullying has also been identified as an important precursor to other forms of violence. The federal government has launched Stop Bullying Now, a comprehensive set of resources for parents, schools, and communities (see www.stopbullyingnow.hrsa.gov). This approach implements the approach of Olweus in the American context.

Violence among adolescents has long been a major concern of urban teens and their parents.[18] The recent outbreaks of school violence have led to the same concerns among many other groups. Pediatric providers have several clear roles to play in working with their adolescent patients to reduce the risk of violence: (1) screening all adolescents to identify those at high risk, (2) preventing reinjury to injured adolescents, and (3) referring high-risk or traumatized adolescents for appropriate treatment. (See also Chapter 146 Posttraumatic Stress Disorder.) In addition to screening for risk, recent research strongly supports identifying and reinforcing teen resilience factors. Attachment to school, family, community, and pro-social peer groups all exert strong protective effects, even in the face of risk factors. Programs that provide opportunities for teenagers to belong to a pro-social group and develop mastery of particular activities—ranging from academics to dance—protect young adults from health-risk behaviors, including fighting. Based on these successes, over the next few years, social programs for youth will likely move from focused risk reduction to positive youth development models.

Screening for violence risk can take either of 2 forms: (1) a specific violence history or (2) a general screen for related risk factors.

Teenagers can be asked directly about their experiences with violence, using the acronym FISTS and asking the screening questions listed in BOX 31-1.

• Fighting: When was your last pushing or shoving fight? How many fights have you been in the last month? In the last year?
• Injuries: Have you ever been injured in a fight? Has anyone you know been injured in a fight? Has anyone you know been injured or killed?
• Sexual violence: What happens when you and your boyfriend or girlfriend have an argument? Have you ever been forced to have sex against your will?
• Threats: Have you ever been threatened with a knife? With a gun?
• Self-defense: How do you avoid getting in fights? Do you carry a weapon for self-defense?

¹Alpert EJ, Sege RD, Bradshaw YS. Interpersonal violence and the education of physicians. Acad Med 1997;72(1 suppl):S41-S50. Used with permission from Lippincott-Williams & Wilkins.

Teens who have been in more than 1 physical fight in the preceding 12 months are at increased risk of violence-related injury.

A review of medical records of teens who were seriously injured or killed through violence usually reveals previous episodes of injuries that required medical attention. Multiple or serious previous injuries may indicate an increased risk of future injury.

Teen-dating violence is both a serious problem in itself and a harbinger of future domestic violence.

Previous threats with a weapon indicate that the patient is at future risk of weapons-related injury, either through the circumstances that led to the original threat or because these young people are far more likely to arm themselves than are those who have never been threatened directly.

Young people who have learned to deescalate situations of conflict (or to avoid them altogether) deserve praise and encouragement. On the other hand, teens who arm themselves in self-defense are at extremely high risk, as discussed previously. (See the discussion on “Bullying,” earlier in this chapter.)

A second, broader set of risk factors influences the likelihood of serious violence-related injury. Problem teen behaviors tend to cluster as a result of both intrapersonal and social factors. As shown in Figure 31-1, analysis of office-based risk factor screening results has identified three classes of risk. Young people in school who report neither drug use nor fighting to their primary care provider are at low risk of violence-related injuries.[19] Teens who are in school and are passing their courses but who report either fighting or drug use are at medium risk—approximately three times that of low-risk students. Adolescents who are failing school, already dropped out of school, or report both fighting and drug use are at approximately a 7-fold increased risk for future violence-related injury than are low-risk students. In the clinical setting, most practitioners already inquire about school performance and drug use as part of the HEADS screening; the addition of a single question, “How many fights have you been in the past 12 months?” completes the screening. Patients who are in school and deny fighting or drug use are at low risk. Patients who are in school but report either drug use or fighting are at intermediate risk. Patients who have either dropped out of school or report both drug use and fighting are at high risk and should be referred to appropriate community-based intervention services.

Finally, clinicians should be aware of the strong clustering of health risk behaviors among teens. For example, male teenagers who smoke are at increased risk for carrying weapons.

Figure 31-1 Classification of patients into high, medium, and low risk for future violence-related injury. (Reprinted from Sege RD, Stringham P, Short S, et al. Ten years after: examination of adolescent screening questions that predict future violence-related injury. J Adolesc Health. 1999;24:395-402. Used with permission from the Society for Adolescent Medicine.)

Intervention for patients who are identified as being at increased risk for violence-related injuries through either screening approach must be tailored to fit both the degree of risk and the individual circumstances of each child. Teens at low risk deserve acknowledgment of their success at avoiding this problem, particularly noting that courage is often needed to walk away from a fight. Teens at moderate risk need to hear that the risks are real and individual: “You are strong and healthy. However, I am worried about your telling me that you have been in several fights this year.” Basic information concerning techniques for defusing particularly tense situations should be discussed. Teens who carry weapons, have left school, or are otherwise at high risk deserve intense social service or psychologic intervention. Adolescent health providers need to maintain a roster of appropriate community-based referral agencies or individual counselors for these children and emphasize the importance of followup to both the patient and parents.

Patients who have been hurt in a fight are at high risk for further violence, either as the victim of another violence-related injury or by attempting to exact revenge on the assailants. The immediate need after an injury is for crisis intervention. Ask the patient: “Is the fight over? Do you feel safe leaving here? If the fight is ongoing, is there someone who can mediate?” If the situation is volatile, then the patient and family should be referred to social services or, occasionally, the police. Police intervention is warranted whenever the patient is in danger or reveals specific plans to harm another person. At a minimum, parents and patients should be advised of the risk of serious injury and that successful injury prevention involves learning how to deescalate conflicts.

After a serious injury, the following steps have been advocated:

• Have the child tell you about the problem. Allow the narrative to flow freely, avoiding judgments. This approach allows feelings of revenge to be expressed and offers an opportunity to learn of the patient's perspective before offering advice.
• Evaluate the youth's other risks: Does he or she carry a weapon? Does he or she use alcohol or other drugs? Is the youth involved in a gang?
• Discuss with the patient the known risk factors for violence, including the fact that most violent injuries occur between friends or acquaintances and often involve alcohol or drugs. Carrying weapons increases the risk of serious injury by encouraging the patient to take unnecessary risks and by encouraging his or her opponent to draw first.
• Develop a plan to stay safe after leaving the hospital or clinic. Does he or she have a relative with whom to stay who lives out of the neighborhood? Do the police need to be involved?
• Discuss conflict-avoidance strategies. This discussion can start with the particular incident involved and may need to be continued on subsequent visits. Health care professionals need to respect the patient's need not to be labeled as a sucker by peers.
• Refer to others, including a psychologist or social worker. For many patients, this referral may involve reaching out to church members, recreation departments, or mentoring programs.

As is apparent from the previous discussion, youth violence, although a serious health risk, is a complex social problem that requires broad-based public action. Pediatric providers, in addition to caring for their own patients, are often able to influence public debate in areas that affect child health. The AAP and other organizations have advocated for social policies that benefit children.

Pediatric providers who serve as school consultants have a critical role to play. School boards and principals should be advised of the importance of age-appropriate violence-prevention programs. A significant number of successful school programs are available for adaptation and use in other schools. Primary schools can focus on adequate supervision of playgrounds, teaching and modeling nonviolent problem-solving skills, and implementing effective antibullying programs. Middle schools can use proven antiviolence and conflict-resolution curricula that can be incorporated into health education programs. Successful high school programs can involve the use the school health clinics to provide services to students who have problems of violence, drug abuse, or pregnancy. Schools have successfully developed peer education programs to help reinforce these areas of concern. Peer mediation, which allows students another formal venue for resolving conflict, has been widely adopted and appears to be quite successful, both in school and in the communities in which the students live.

Media violence has recently received greater public attention, in part because of concerted efforts by pediatricians and child psychologists to call attention to the dangers of excess exposure to media violence. In addition to counseling individual families, many pediatricians have provided testimony at public hearings or endorsed community television tune-out weeks.

Despite a general reduction in traumatic injury and death, child and adolescent deaths caused by firearms continue to soar. Individual families can be counseled that the safest home for children is one without handguns, and that any guns present in the home should be locked and unloaded. State and federal regulations now under consideration would mandate the provision of trigger locks and prevent the marketing of certain kinds of weapons. Physician testimony and endorsement by medical professional organizations have helped push forward these initiatives.