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PEDIATRICS Vol. 103 No. 1 January 1999, pp. 173-181
AMERICAN ACADEMY OF PEDIATRICS :
The Role of the Pediatrician in Youth Violence Prevention in
Clinical Practice and at the Community Level
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ABSTRACT |
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Top
Abstract
Background
Recommendation
References
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Violence and violent injuries are a serious threat to the health of children and youth in the United States. It is crucial that pediatricians define their role and develop the appropriate skills to address this threat effectively. From a clinical perspective, pediatricians should incorporate into their practices preventive education, screening for risk, and linkages to necessary intervention and follow-up services. As advocates, pediatricians should become involved at the local and national levels to address key risk factors and assure adequacy of preventive and treatment programs. There are also educational and research needs central to the development of effective clinical strategies. This policy statement defines the emerging role of pediatricians in youth violence prevention and management. It reflects the importance of this issue in the strategic agenda of the American Academy of Pediatrics for promoting optimal child health and development.
Violence has become increasingly prominent in the lives of
children in the United States, which has the highest youth homicide and
suicide rates among the 26 wealthiest nations in the world and one of
the highest rates of homicide worldwide.1-3 Homicide and
suicide have become the second and third leading causes of death of
teenagers; homicide is the leading cause of death of black
youth.3,4 Children and youth face serious short- and
long-term physical and emotional consequences as victims, witnesses,
and perpetrators of violence.5,6 Furthermore, violence is
an issue that crosses all geographic (urban to rural) and socioeconomic
boundaries.
Homicide rates for males 15 to 19 years of age increased 113% between
1985 and 1995, surpassing rates for males of all other age groups
except those 20 to 24 years of age, with firearm-related homicides
accounting for almost all of this increase.3 Teenagers are
now more likely to die of gunshot wounds than all natural causes
combined.7,8
Data on nonfatal violent injuries are less available and reliable than
those on homicide, in part, because many victims do not seek medical
attention. It is estimated that for every homicide, there may be as
many as 100 nonfatal violent assaults that receive treatment in an
emergency department.9 In 1995, children and adolescents
17 years or younger had 517 000 hospital emergency department visits
for assault-related injuries.10 Health care workers in
urban trauma centers have noted that assaultive trauma is recurrent,
with hospital readmission rates for subsequent assaults noted to be as
high as 44% and subsequent homicides as high as
20%.11-15
As youth homicide rates have continued to rise, so have permanent
physical disabilities attributable to assaults. One estimate is that
during the early 1990s, the number of severe nonfatal central nervous
system injuries attributable to gunshot wounds in Los Angeles,
California, was equal to the number of fatalities.16 More
than 15% of all spinal cord injuries are caused by intentional trauma,17 and an unknown, but presumably substantial, number of traumatic brain injuries are the result of violence. The
number, specific injury cause, and degree of long-term disability of
the victims remain poorly described in the literature because no
surveillance system has been established to document these conditions,
despite their prevalence.
The situations in which fatal and nonfatal adolescent assault injuries
occur are similar.18 Violent injury and death result from
altercations between family members and acquaintances far more often
than from robberies or other criminal activity.19 National
surveys indicate that large numbers of youth, male and female, are
involved in violent altercations.20 Furthermore, the risk
of involvement with violence has been associated with many issues
relevant to pediatric practice including disciplinary methods (such as
corporal punishment), television viewing (particularly violent
programming), exposure to domestic violence and child abuse, and
handgun ownership.21-28
A growing number of reports confirm that numerous children witness
violence.29-32 Although it is unclear how many children
are exposed to domestic and other forms of violence, no doubt exists
that children are harmed Pediatricians have a long and admirable history of addressing the
major health issues of children in the United States by: promoting
access to health care and the prevention of unintentional injury;
recognizing and treating institutional injuries and child abuse;
providing preventive care, such as immunizations; and by fostering
early care and education, such as quality child care and the Head Start
program.
This statement outlines roles for pediatricians in the prevention and
management of youth violence. It establishes an agenda for making this
a routine part of pediatric practice in four major areas: clinical
services, community advocacy, research, and education. This broad
agenda builds on a still-evolving body of knowledge, but the urgency of
youth violence prevention requires further and immediate action by
pediatricians.
Clinical Care
The epidemiology of violent injury identifies contributing factors
affecting risk for involvement with violence, and the influences of
violence on children (short- and long-term).21-28 Many of
these risk factors are in areas traditionally and routinely addressed
by pediatricians in their anticipatory guidance activities and so
provide a familiar starting point for violence prevention efforts.41
Because many pediatricians encounter children and youth who are
experiencing or are at risk for violence, pediatricians are well
situated to intervene. Prevention of youth violence requires that
pediatricians recognize violence-related risk factors and diagnose and
treat violence-related problems at all stages of child development. See
section on "Safety and Screening" below.
The Academy encourages pediatricians to use a stepwise approach to
promote a healthy nonviolent environment at all phases of child and
adolescent development.
Early Nurturing
TABLE 1
BACKGROUND
Top
Abstract
Background
Recommendation
References
cognitively, emotionally, and
developmentallywhen they witness violence.6,3133-37 Exposures to violence and victimization are also strongly associated with subsequent acts of violence by the victim.38-40
THE ROLE OF PEDIATRICIANS
Infancy.
Children need loving and caring relationships early in life to develop
skills for nonviolent behavior throughout life. Pediatricians can
promote care and support systems for families to help them nurture
children. Key elements include appropriate bonding and attachment
between parents and the infant and identification of factors that
threaten bonding and attachment (ie, postpartum and other family
depression, family strife, and lack of support systems for parents).
Preschool.
During the preschool years, pediatricians can encourage parents to
spend time with their children, read to them (starting in infancy),
teach them positive social skills, and monitor and provide guidance for
their television viewing. Pediatricians can educate parents on normal
age-appropriate (see Table 1) behaviors and guide them in how to model nonviolent behavior and conflict resolution for their children.
Age-Appropriate Interventions*
School age.
During this time, children develop communication skills and
problem-solving skills. Parents can teach and model nonviolent anger
management and conflict resolution skills as well as foster appropriate
empathy skills. Pediatricians should support and encourage parents in
this process by identifying positive activities for children, such as
supervised sports, music, theater, recreational, and community life
projects that are both socially acceptable and that build useful
skills.
Adolescence.
As children mature, the pediatrician can encourage parents to foster
independence, educate their children about the responsibilities of
adulthood, but also maintain their attachment to and involvement with
their children during this process.
Limit Setting
Infancy.
Limit setting during the infant's first year should center on
educating parents about appropriate parenting and nurturing skills.
Pediatricians can ask about parental views regarding spoiling and
discipline. Parents must learn that corporal punishment is less
effective than other limit-setting strategies.
Preschool.
Pediatricians can encourage the parents and other caregivers to avoid
corporal punishment and use more effective nonviolent disciplinary
restrictions to alter misbehavior such as natural and logical
consequences and time-out strategies for specific behaviors.43 Pediatricians can advise parents against disciplining a child for age-appropriate behavior, such as exploring their environment or spilling their milk. When children knowingly misbehave, parents and others must be as consistent as possible, and
when children behave appropriately, they should be praised and
encouraged. Pediatricians can provide advice on managing assertive and
aggressive behaviors, as well as on supporting and reinforcing prosocial behaviors.
School age.
Pediatricians can help parents understand the child's need to assume
greater responsibilities. They can help parents understand the
importance of developing consistent, clearly articulated family rules
and agreed-on consequences for breaking these rules. They can also
encourage consistent discipline among different caregivers and
nonviolent disciplinary strategies.
Adolescence.
Pediatricians can help parents establish family rules that address
potential areas of conflict, such as driving privileges, curfews,
substance abuse, and school and household responsibilities. Pediatricians can discuss with the adolescent what constitutes safe,
appropriate dating and relationships, as well as strategies for
avoiding or resolving interpersonal conflicts with friends and peers.
Safety and Screening
Pediatricians need to identify the risk factors for violence among their patients. Violence-related assessment and screening should focus on the following areas:
history of mental illness, previous domestic violence, or substance
abuse in the parents or other family members;
family stresses that could lead to violence (eg, unemployment,
divorce, or death);
appropriate supervision and care and support systems (eg, child
care arrangements, the family and social network);
disciplinary attitudes and practices of the parents or caregivers
(particularly about corporal punishment and physical/emotional abuse);
exposure to violence in the home (domestic violence44
or child abuse), school, or community;
degree of exposure to media violence;
access to firearms (especially handguns) in their or a neighbor's
home, or the community;
gang involvement or gang exposure in family, school, or
neighborhood;
situations in which a child or adolescent experiences physical
assault or sexual victimization from anyone;
presence of signs of poor self-esteem, or depression; and
other factors affecting risk, such as poor school performance and
physical, emotional, or developmental disabilities.
Treatment and Referral
When pediatricians identify risk factors for violence or actual violence-related problems during the screening process, appropriate treatment or referral should occur. Some of the problems can be handled by the pediatrician through follow-up visits and office-based counseling, particularly when the issues are television viewing, removal of handguns, and nonurgent behavioral issues. The issue of gun ownership is a particularly frustrating and difficult one. Pediatricians should be prepared for resistance. Maintaining a focus specifically on the risks of handgun ownership can help keep the message clear and reduce controversy.
Some problems require referral for additional services to child welfare agencies (eg, for suspected child abuse), mental health services (eg, for victims of and witnesses to violence), emergency shelters and other domestic violence counseling and legal services, substance abuse treatment, or high-risk youth services. Repeated referral efforts may be required to achieve linkage to services.
Advocacy
Pediatricians should apply their proven professional influence to violence-prevention efforts. Pediatricians can advocate at patient, community, or broader public policy levels.
The first level of advocacy focuses on individual patients and families who present in the pediatrician's office. Individual advocacy might involve interventions and interactions with patients' insurance companies, schools, hospitals, mental health services, and other specific programs.
The second level of advocacy focuses on the community where pediatricians can partner with others to increase services, promote prevention activities, and influence community attitudes that affect risk and incidence of violence. Examples include reducing corporal punishment in schools and homes, participating in child death review teams, reducing or eliminating access to handguns, working with hospitals to develop protocols for treatment of victims and witnesses of violence (eg, using the American Academy of Pediatrics' [AAP] Adolescent Assault Victim statement45), and educating the local media.
The third level of advocacy focuses on public policy. Pediatrician involvement can influence legislation and regulation.21 Laws and regulations pertinent to violence prevention include those that require safe gun storage, trigger locks, and other gun control measures, (particularly the reduction or elimination of handguns); prohibition of corporal punishment in schools; programs to provide home visitation for new parents, after-school care and recreational opportunities for youth, quality child care, and programs that educate parents and children.
Advocacy is an integral activity of the Academy, its state chapters, and other state medical societies. By working with the AAP individual pediatricians can achieve more than any single individual. Other organization collaborators include education groups (the state and local parent-teacher associations, state and local teacher associations, local chapters of the National Association for the Education of Young Children), youth service programs (Girl Scouts and Boy Scouts, girls and boys clubs, YMCA, YWCA), public health associations, community service organizations (Lions, Jaycees, Junior League), law enforcement agencies and organizations, religious institutions, organizations of child care providers, gun control organizations (eg, the Handgun Epidemic Lowering Plan [HELP] Network), and groups of local business leaders and associations. The AAP Department of Government Liaison and Division of State Government and Chapter Affairs can help pediatricians plan advocacy at the federal and state levels.
Education
Pediatricians need comfort and familiarity with the issues and the strategies related to violence prevention. Education on the issue should occur at all levels for trainees, from undergraduate to residency and fellowship programs, and for practicing clinicians through continuing medical education.
Research
Although the literature includes substantial data on risks and causes of violence, little published research addresses the effectiveness of prevention and treatment strategies.
Practicing pediatricians can be involved directly in violence-related research through practice-based research projects. Practicing pediatricians are crucial in this work because they bring direct clinical experience to choosing the right questions that will lead to useful interventions.
Pediatricians also need to advocate for resources to support research activities. Ongoing public health tracking of violent injuries should be a cornerstone for monitoring trends and characteristics of violence, as well as for measuring the effectiveness of prevention and intervention programs. To do this, the public and private sectors should invest in research on youth violence prevention. Investing in understanding youth violence and how to reduce it should match the level of concern about the issue. In particular, further research should explore what can be done early in the lives of children, given the research on early brain and child development.46
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RECOMMENDATIONS |
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Top
Abstract
Background
Recommendation
References
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Clinical Practice
Clinical practice guidelines for the prevention and management of youth violence need to be established that include:
promoting a healthy environment for all children, in the family and
in the community;
assessing for high-risk situations and behaviors;
responding to problems identified with appropriate treatment and
referrals;
violence-prevention counseling and screening as early as the
pediatric prenatal visit and continuing into adulthood; and
maintaining familiarity with the relevant and appropriate
counseling and treatment services in communities.
Advocacy
Pediatricians should advocate for:
provision of affordable, quality child care for all families who
require it, as well as other family support programs, such as postnatal
home visitation;
elimination of corporal punishment as a recommended form of child
discipline in all settings;
reduction of violence and expanded reporting of healthful
activities in the media;
reduced availability or elimination of handguns in all communities
through handgun regulation and public education;
increased treatment resources and services for substance abuse and
domestic violence in all communities; and
increased recreational, therapeutic, and occupational services and
programs for children and youth, particularly in low-income communities.
Pediatricians should work as a group to strengthen such efforts and should link with other disciplines and advocacy groups to maximize effectiveness in these efforts.
Education
Many pediatricians lack education to acquire the skills and comfort they need to participate effectively in violence prevention. To remedy this situation:
Medical schools and pediatric residency programs should develop and
institute appropriate curricula on prevention and management of youth
violence.
Practicing pediatricians should enhance their knowledge and comfort
in violence prevention and management through continuing medical
education.
Research
Pediatricians can contribute to needed research by:
participating in violence-related practice-based research projects;
advocating for resources to:
enhance the level of violent injury tracking activities;
enhance the level of public and private funding for violence
prevention and management research.
TASK FORCE ON VIOLENCE, 1997-1998
Howard Spivak, MD, Chairperson
Katherine Kaufer Christoffel, MD, MPH
Herman B. Gray, Jr, MD
Maxine Hayes, MD
Renee Jenkins, MD
Luis Montes, MD
C. Damon Moore, MD
LIAISON REPRESENTATIVES
Stephanie Bryn, MPH
Maternal and Child Health Bureau
Alex Crosby, MD
Centers for Disease Control and Prevention
CONSULTANT
Carl Bell, MD
Community Medical Health Center
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ABBREVIATIONS |
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AAP, American Academy of Pediatrics; HELP, Handgun Epidemic Lowering Plan; TFOV, (AAP) Task Force on Violence; VIPP, Violence Intervention and Prevention Program.
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REFERENCES |
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Abstract
Background
Recommendation
References
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[Abstract/Free Full Text] - Sosin DM, Koepsell TB, Rivara FP, Mercy JA Fighting as a marker for multiple problem behaviors in adolescents. J Adolesc Health. 1995; 16:209-215 [CrossRef][Medline]
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REPORT TO THE AAP BOARD OF DIRECTORS FROM THE TASK FORCE ON VIOLENCE
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INTRODUCTION |
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Violence and violent injuries are a serious threat to the health of children and youth in the United States. It is crucial that pediatricians define their role and develop the appropriate skills to effectively address this threat. From a clinical perspective, pediatricians should incorporate into their practices: preventive education, screening for risk, and linkages to necessary intervention/follow-up services. As advocates, pediatricians should become involved at the local and national levels to address key risk factors and assure adequacy of preventive and treatment programs. There are also educational and research needs central to the development of effective clinical strategies.
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BACKGROUND |
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Violence has become increasingly prominent in the lives of children in the United States, which has the highest youth homicide and suicide rates among the 26 wealthiest nations in the world and one of the highest rates of homicide worldwide. Homicide and suicide have become the second the third leading causes of death of teenagers; homicide is the leading cause of death of black youth. Children and youth face serious short- and long-term physical and emotional consequences as victims, witnesses, and perpetrators of violence. Furthermore, violence is an issue that crosses all geographic (urban to rural) and socioeconomic boundaries.
Homicide rates for males 15 to 19 years of age increased 113% between 1985 and 1995, surpassing rates for males of all other age groups except those 20 to 24 years of ages, with firearm-related homicides accounting for almost all of this increase. Teenagers are now more likely to die of gunshot wounds than all natural causes combined. Data on nonfatal violent injuries are less available and reliable than those on homicide, in part, because many victims do not seek medical attention. It is estimated that for every homicide, there may be as many as 100 nonfatal violent assaults that receive treatment in an emergency department. In 1995, children and adolescents ages 17 years or younger had 517 000 hospital emergency department visits for assault-related injuries. Health care workers in urban trauma centers have noted that assaultive trauma is recurrent, with hospital readmission rates for subsequent assaults noted to be as high as 44% and subsequent homicides as high as 20%.
As youth homicide rates have continued to rise, so have permanent
physical disabilities attributable to assaults. One estimate is that in
the early 1990s, the number of severe central nervous system injuries
from gunshots in Los Angeles was equal to the number of fatalities.
Over 15% of all spinal cord injuries are caused by intentional trauma,
and an unknown, but presumably significant, number of traumatic brain
injuries are the result of violence. These victims remain poorly
described in the literature-in terms of the number, specific injury
cause, and degree of long-term disabilitybecause no surveillance
system has been established to document these conditions, despite their
prevalence.
The situations in which fatal and nonfatal adolescent assault injuries occur are similar. Violent injury and death result from altercations between family members and acquaintances far more often than they are related to robberies or other criminal activity. National surveys indicate that large numbers of youth, male and female, are involved in violent altercations. Furthermore, risk of involvement with violence has been associated with many issues relevant to pediatric practice including disciplinary methods such as corporal punishment, television viewing (particularly violent programming), exposure to domestic violence and child abuse, and handgun ownership.
A growing number of reports confirm that numerous children
witness violence. Although it is unclear how many children are exposed
to domestic and other forms of violence, no doubt exists that children
are harmed when they witness violencecognitively, emotionally, and
developmentally. Exposure to violence and victimization are also
strongly associated with subsequent acts of violence by the victim.
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HISTORY OF THE AAP TASK FORCE ON VIOLENCE |
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The Task Force on Violence (TFOV) was established in June 1996 and included seven members, two governmental agency liaison representatives, and a consultant from the field of community psychiatry. The Task Force held four meetings that primarily focused on the following activities:
a) the development of a policy statement on the role of the pediatrician in violence prevention that is broken down into the following categories: clinical care, advocacy, research, and education and training;
b) the development of a report to the Board of Directors recommending strategies and action steps for the organization to take related to violence prevention in each of the four categories listed above; and
c) consideration of goals/objectives for the possible convening of an interorganizational council on youth/peer violence including an assessment of more than 20 select health- and education-related national organizations to determine interest in participating on this council.
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OTHER HIGHLIGHTS/ACTIVITIES OF THE TASK FORCE |
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The Task Force worked very closely with staff from the
Division of Child Health Research on the development and fielding of a
Periodic Survey on violence and violence prevention. The survey is
currently underway. The Task Force served as a
reviewing body and resource for the development of an ACQIP exercise on violence/violence prevention that was distributed to ACQIP
subscribers in January 1998. The Task Force developed
questions on violence prevention for inclusion in a survey on managed
care and children with special health care needs that was disseminated
to major managed care organizations (by the Division of Physician
Payment Systems); survey results have been analyzed by staff and will
be written up for a possible article in AAP
News. The Task Force submitted program proposal recommendations to the Committee on Scientific Meetings for
consideration at the 1998 Spring Session (not approved) and the 1998 Annual Meeting (approved as a Plenary SessionHoward Spivak, MD,
Faculty). Staff developed an AAP violence prevention
resource compendium that is available in hard copy format and on the
Academy's Website (Advocacy Page). The Task Force
outlined ideas for the components to be included in a Violence
Intervention and Prevention Program (VIPP) anticipatory guidance
program if funding is secured for its development, implementation, and
evaluation. The Task Force has encouraged other
Academy committees to develop policy statements on specific areas of
violence prevention that relate to issues that fall under their
purview. The Task Force encouraged staff involvement
throughout the process of the development of the policy statement,
recommendations to the Board of Directors, and in educational issues.
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RECOMMENDATIONS TO THE AAP BOARD |
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Clinical Care
1. That the Academy undertake the development of a VIPP anticipatory guidance program.
Action Necessary:
Identify resources for the development and evaluation of
the program and subsequent training of pediatricians and other health
professionals in its use. Inventory current Academy patient education materials to determine what might be repackaged to be
utilized as part of the program.
Action Necessary:
Identify lead staff and AAP members to assist in the
development of key messages to be shared with managed care
organizations related to violence prevention.
Advocacy and Policy
1. That the Academy continue and intensify its focus on violence prevention in its goals and objectives.
Action Necessary: That the Academy promote and enhance,
where possible, its involvement in handgun regulatory
activities. That the Academy promote and enhance,
where possible, its involvement in child death investigations at the
federal and state levels including working with the American Bar
Association and others, and to promote the AAP model state legislation
on this issue. That the Academy advocate for
additional funding for research on the aforementioned
topics. That the Committee on Adolescence and the
Department of Government Liaison expedite and prioritize the
development of Academy policy on juvenile justice
issues. That the Department of Communications continue
to emphasize messages regarding preventing media violence via the
Academy's Media Matters campaign. That the Academy
continue to prioritize its efforts in the area of media education
specifically related to combatting media
violence. That the Academy's leadership take a
strong stand against corporal punishment in the home as they have done
with respect to other settings such as schools.
2. That the Academy focus on the development
of materials for use in education and training of pediatricians as
advocates in the area of violence prevention.
Action Necessary:
That a public speaking and media training session
specifically focused on violence prevention be coordinated and
facilitated by the Division of Public Relations. That
the Division of Public Relations develop and promote speaking points
and key media messages on violence prevention specifically focusing on positive images of youth in ways that emphasize nonviolence,
resilience, and special accomplishments of youth. That
the Division of Member Communications continue to prioritize articles
on violence, and that a feature article be included in a future issue
of AAP News that discusses the root causes of violence,
encourages members to become involved in local/community-based
coalitions and efforts related to violence prevention, and includes a
section on additional resources. That the
Violence Prevention Resources pages on the Academy's Website be
promoted to the membership and others via AAP News and other
publications.
Action Necessary:
That the Academy allocate funds for the production and
distribution of the violence prevention resource folder/packet so that
an offer of the materials can be made to the full Academy membership
via AAP News and other publications.
Action Necessary:
That the Academy allocate a nominal amount of funding for
planning and convening a preliminary meeting of an interorganizational council on youth/peer violence. (Funds for AAP representatives' travel
and expenses and for the council members' meals are being requested). That lead staff and AAP members be
identified to coordinate and plan this activity.
Research
1. That the Academy identify opportunities to promote expanded attention to research in the area of violence prevention.
Action Necessary:
That the Academy leadership promote violence prevention
as a topic to be addressed by the soon-to-be established Child Health
Research Center. That the Academy's Department of
Research place emphasis on pediatric practice-based research projects
on violence prevention via ongoing AAP research programs.
Action Necessary:
Work with appropriate staff from Centers for Disease
Control and Prevention, the Department of Health and Human
Services, the Maternal and Child Health Bureau, and the Department of
Justice to identify opportunities to support violence prevention
research in the budget process.
Action Necessary:
Work with the Centers for Disease Control and Prevention
to identify opportunities for funding of surveillance in the budget process.
Action Necessary:
Upon completion of the fielding of the Periodic Survey on
violence prevention and tabulation of the results, the Division of
Child Health Research will write up the results and submit an
article(s) for publication in a peer-reviewed journal. Information about the results also will be published in AAP News.
Education and Training
1. That the Academy recommend the development of enhanced continuing medical education programming, enhanced undergraduate medical education, and enhanced medical school education in the area of violence prevention.
Action Necessary:
That the Board of Directors encourage the Section and
Committee on Injury and Poison Prevention to make efforts to submit program proposals on violence prevention to the Committee on Scientific Meetings for consideration. That the Section on
Injury and Poison Prevention focus at least one session on this topic at each national meeting as part of its educational
programming. That the Practical Pediatrics Course
Workgroup include violence prevention training in their future program
planning. That the Committee on Scientific Meetings
include the topic of violence prevention as part of their
curriculum. That the PREP Planning Group consider
including one article per year on violence prevention in
Pediatrics in Review.
Pediatrics (ISSN 0031 4005). Copyright ©1999 by the American Academy of Pediatrics
The following policy statement is a revision:
- Role of the Pediatrician in Youth Violence Prevention
- Committee on Injury, Violence, and Poison Prevention
Pediatrics 2009 124: 393-402.[Abstract] [Full Text] [PDF]
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