May 2015

Adolescence is marked by significant and rapid growth, and health—mental, physical, social and emotional—is an important part of this

development. Health behaviors, choices and well-being in childhood and adolescence often extend into adulthood with lifelong implications.1 Vio-lence is a critical issue in adolescence that can interrupt normal develop-ment. Homicide and assault-related injury affect thousands of teens each year, and injuries or exposure to violence have consequences for numerous aspects of health, including chronic disease, depression and unhealthy be-haviors in adolescence and adulthood.

Preventing Violence Where Youth Live, Learn and Play

BY KATE BLACKMAN JULY 2015

2 | Preventing Violence Where Youth Live, Learn and Play © 2015 National Conference of State Legislatures

Violence in teens’ lives may take many forms—child maltreatment, bullying, physical fighting, teen dating violence and homi-cide—and in a variety of settings, including homes,

schools and communities.2 Research suggests youth ex-posure to violence and abuse has decreased,3 but the rates and consequences remain notable. An estimated two out of every three youth are exposed to violence as victims or wit-nesses.4 Homicide, while less than 20 percent of all deaths in 2013, remains among the leading causes of death for adolescents each year.5 In addition, nearly 300,000 young people ages 10-19 were treated in emergency rooms for non-fatal assault injuries in 2013.6

Many of the health issues that begin in adolescence as a result of violence can persist or worsen in adulthood. In addition to obvious outcomes such as injury and death, exposure to violence can cause mental health issues, rela-tionship problems, future violence victimization or perpe-tration, and risky or unhealthy behaviors.7 There are direct health care, social services, law enforcement and education costs associated with violence, as well as indirect costs, such as loss of worker productivity.8

Despite this significant burden, violence is largely pre-ventable. An overall trend of declines in youth exposure to violence and abuse over the past decade could indicate

success of recent policies and programs related to violence prevention and intervention.9 Many states are exploring a public health approach to prevent youth violence while taking into account adolescents’ larger social environment. This brief provides an overview of the burden of violence and state strategies to prevent and reduce violence within the context of the social determinants of health—where adolescents live, learn and play.

Social Determinants of Health

Violence occurs within the context of a larger set of factors, including social, physical and economic environments. These circumstances—where youth live, learn and play—are referred to as the social determinants of health. For adolescents, family, friends, peers, schools, communities and societal messages are all part of the social environment that affects choices, behaviors, and current and future health.10 As a result, many adolescent health issues are chal-lenging to address in traditional health care settings, such as doctors’ offices and emergency rooms.

Social determinants do not exist in isolation; they are integrated and overlap with each other.11 This integration of factors makes it more difficult to pinpoint one strategy for an issue like youth violence. It also means that address-ing one factor has the potential to have a ripple effect on others. Taking these social factors into account may result in successful solutions to youth violence.

Exposure to violence includes being a direct victim of a violent or abusive act, or indirectly experiencing violence as a witness or bystander.

Determinants of Health

Scientists generally recognize five factors as determinants that contribute to health:

• Biology and genetics (e.g., sex and age)

• Individual behavior (e.g., alcohol or drug abuse, smoking, diet and exercise)

• Social environment (e.g., discrimination, income and gender)

• Physical environment (e.g., housing, neighborhood, school or workplace)

• Health services (e.g., access to quality health care, having or not having health insurance)

Source: Centers for Disease Control and Prevention, 2013

3 | Preventing Violence Where Youth Live, Learn and Play © 2015 National Conference of State Legislatures

Live

The family and home—where youth live—can have a pro-found effect on whether they experience violence. Youth can be victims of child maltreatment, which includes abuse and neglect, or witness violence among other family mem-bers. By the time children are in adolescence, 40 percent have been exposed to family violence.12 Nationally, nearly 700,000 children were victims of abuse and neglect in 2013, and more than 1,000 died as a result of abuse or ne-glect.13 Experiencing child maltreatment can lead to similar consequences as exposure to other forms of violence, such as increased future risks of perpetrating or experiencing violence, problems with alcohol or drugs, risky sexual behaviors and a compromised ability to develop healthy relationships in adulthood.14

While violence crosses socioeconomic and other boundar-ies, poverty can increase the risk of exposure to violence.15 Some research has also found that children may be at greater risk for child maltreatment, family violence and community violence when they grow up in disadvantaged communities, or with caregivers with low education, or substance abuse or mental health issues.16

Safe, stable and nurturing relationships with caregivers—relationships that are free from harm, consistent and emo-tionally responsive—can protect against violence and help create the emotional and physical safety adolescents need to thrive.17 Providing caregivers with knowledge and skills related to child development, communication, supervision

and discipline can contribute to these supportive relation-ships.18

State StrategiesEvidence-based prevention programs can assist parents and strengthen families, and limit, or eliminate, the need for more costly interventions in the justice and welfare systems. For example, in Washington, three parenting programs, described below, were found to have a positive cost-to-benefit ratio; for every $1 invested, the program participants, taxpayers and society saved around $1 to $3 in areas such as criminal justice and health care.19 Some state lawmakers are considering similar programs along with other strategies, including the following.

• Raising awareness and gathering information about child maltreatment. Some state legislatures have designated child abuse prevention months to raise awareness, a strategy endorsed by the U.S. attorney general’s task force on children and violence.20 In addi-tion, a number of states, including Arkansas, Missouri and Nevada, have enacted legislation in recent years to create task forces on child sexual abuse.

• Targeting efforts and funding to state-specific needs. Nearly all states have a Children’s Trust Fund to pay for programs aimed at preventing child maltreat-ment. These funds support proven community-based programs, promote innovative strategies and convene stakeholders in their states.21 State lawmakers often oversee these funds and can focus efforts on state-specific priorities. New Mexico, for instance, recently passed legislation to expand the fund’s function as a statewide resource, advocate and educator around child abuse and neglect.

Strong caregiver relationships include:

Safety: freedom from fear and security from physical or psychological harm.

Stability: predictability and consistency in a child’s social, emotional and physical environment.

Nurturing: availability of a caregiver to respond to and meet a child’s needs.

Source: Mercy and Saul, 2009

4 | Preventing Violence Where Youth Live, Learn and Play © 2015 National Conference of State Legislatures

• Investing in proven early prevention and interven-tion programs. Programs such as the Incredible Years, Triple P (Positive Parenting Program) and Multi-Sys-temic Therapy are among those that promote healthy families and reduce violence through parental support and skill-building.22,23,24 At least 22 states have adopted legislation related to early childhood home visiting, an-other program that supports parents and reduces child maltreatment. In addition, the Centers for Disease Control and Prevention (CDC) is currently funding five state health departments to implement the Es-sentials for Childhood framework, which proposes evidence-based strategies for communities to prevent child maltreatment.25 One of the objectives in imple-menting the framework is to determine promising practices, which may be informative for other states.

• Promoting collaboration and convening partner-ships. Lawmakers can facilitate partnerships within their states through formal means, such as legislation requiring collaboration among agencies, or by infor-mally convening stakeholders to share experiences and work together.

• Learning about and supporting innovative models. While less well studied, there is some evidence to sug-gest that addressing economic disadvantage can assist in preventing violence. Programs to reduce concen-trations of poverty, such as through vouchers to help families move out of disadvantaged neighborhoods, have shown promise.26 In addition, earned income tax credit (EITC) programs are effective strategies in supporting low- and moderate-income families. As of 2014, 25 states and the District of Columbia had their own EITC program. Policymakers can learn more about poverty alleviation efforts, support research to

develop innovative programs and demonstrate their evidence, and help bring proven programs to their states and communities.

Learn

The school environment—where adolescents learn—is another determinant of health and violence. Adolescents spend a considerable amount of time in school settings, interacting with adults and peers. Peers are important as young people determine their identities within the context of relationships with others, and peers also can play a role in youth violence through bullying, physical fights or teen dating violence. In 2013, 8 percent of high school teens were in a physical fight on school property and nearly 20 percent were bullied, according to the CDC’s Youth Risk Behavior Survey.27 In addition, 7 percent of high school students did not go to school at least once in the previous month because of safety concerns.28

Students in grades 9-12 reported in the CDC’s 2013 Youth Risk Behavior Survey:

• 7.1 percent had not gone to school on at least one day in the previous month because they felt unsafe at school or en route to or from school.

• 14.8 percent were electronically bullied at least once in the previous year.

• 19.6 percent were bullied on school property at least once in the previous year.

Source: Centers for Disease Control and Prevention, 2014

5 | Preventing Violence Where Youth Live, Learn and Play © 2015 National Conference of State Legislatures

Violence can also occur in romantic relationships, in what is typically referred to as teen or adolescent dating violence, and can be emotional or sexual as well as physical. In 2013, at least 10 percent of adolescents reported experiencing physical dating violence, and a similar percentage experi-enced sexual dating violence at least once in the previous 12 months.29 In addition, a 2014 survey by the National Campaign to Prevent Teen and Unplanned Pregnancy re-ported that 17 percent of teens felt pressure to go past their personal sexual boundaries.30

Physical violence, bullying and dating violence have similar consequences as other types of violence for health in ado-lescence and adulthood.31 Dating violence specifically can also increase the risk of teen pregnancy.32

State StrategiesState legislatures have adopted policies to promote school safety in recent years through violence prevention educa-tion and bullying prevention. Strategies include:

• Considering school policies to prevent violence and bullying. In 2014, at least 14 states passed legislation targeting bullying. Provisions of these laws include, for example, training for teachers and administrators in California, and requiring schools to develop bully-ing prevention and intervention plans in Oklahoma. Anti-bullying policies are also showing promise.33 Some states include multiple bullying prevention strategies through comprehensive legislation, as in Rhode Island’s Safe School Act in 2012, which created a statewide bullying policy and other requirements.34

6 | Preventing Violence Where Youth Live, Learn and Play © 2015 National Conference of State Legislatures

• Supporting or funding programs that prevent vio-lence and bullying in schools. School-based programs can help students develop positive social behaviors and life skills to help them counter violence, such as prob-lem solving, conflict resolution and anger manage-ment.35 Approximately 70 percent of states provided policy or programmatic guidance for violence preven-tion education between 2010 and 2012.36 Many school violence prevention programs have strong evidence, while bullying prevention programs are promising but still largely being researched.37 Universal school-based programs, delivered to an entire school or grade, have successfully reduced violence among youth.38 These include Life Skills Training, which teaches youth social skills, stress management and problem solving, and drug resistance techniques.39

• Integrating healthy relationship and violence pre-vention education into health education. At least 19 states have enacted laws that encourage or require school districts to incorporate healthy relationship or teen dating violence education into their exist-ing health education efforts. Some states also require schools to develop policies related to dating violence and other school violence.

• Promoting positive youth development programs.

Positive youth development (PYD) is a proven ap-proach that uses young people’s existing strengths and leadership skills, rather than focusing on their prob-lems or deficits.40 PYD strategies can be incorporated into many of the other youth programs that states and schools employ, or pursued as a strategy on its own. For instance, Iowa lawmakers formalized an existing youth development collaborative to support PYD ef-forts across multiple sectors and overlapping initiatives.

Play

Neighborhoods and communities where youth play com-prise the third overarching determinant that affects vio-lence exposure among youth. Exposure to violence in the community, like the other settings, can put young people at risk for physical and psychological harm that affects health and relationships in adolescence and adulthood.41 Community violence encompasses peer and adult violence in public settings, from shootings in neighborhoods to

bullying in after-school activities.42 The “built environ-ment” of communities—the physical characteristics of the environment, such as buildings, parks, streets and other infrastructure—can also impact exposure to violence. In all settings—including neighborhoods and schools—nearly 18 percent of youth reported carrying a weapon in the past month and nearly 25 percent reported being in a physical fight in 2013.43 Gang involvement is also a sig-nificant issue as exposure to violence puts youth at risk for joining gangs, and gang involvement increases the risk of being a victim or perpetrator of violence.44 Preventing gang involvement has positive implications for youth health as well as overall community violence.

State StrategiesStates can adopt policies that promote healthy and safe communities. Strategies include:

• Supporting local initiatives or partnering with com-munity organizations to reach high-risk communi-ties. Minnesota enacted legislation in 2014 to prevent youth violence through community-based programs. It mandated collaboration between local organizations and required programs to address certain prevention strategies, such as strengthening families and support-ing school engagement. The legislation also directed the commissioner of health to support violence prevention programs through technical assistance and other means. In addition, West Virginia passed a comprehensive law in 2012 to support at-risk youth through a community-based pilot project. The project had numerous goals, including reducing child abuse and neglect as well as juvenile delinquency through wrap-around family support services.

The built environment encompasses the physical characteristics of a community, including:

• Businesses, residences and schools

• Streets and sidewalks

• Lighting

• Parks, playgrounds and public spaces

• Access to healthy foods

7 | Preventing Violence Where Youth Live, Learn and Play © 2015 National Conference of State Legislatures

• Promoting environmental approaches to reduc-ing violence. Business Improvement Districts (BID) offer a local economic development strategy in which property and business owners pay an additional tax to fund supplemental services, such as street cleaning, security or capital improvements. In Los Angeles, BIDs spent a large portion of their budgets on crime preven-tion and environmental redesign, and were associated with significant reductions in crime.45 Nearly all states have passed legislation enabling or outlining guidelines for BIDs in their states. Another promising approach for communities is Crime Prevention through En-vironmental Design (CPTED), which uses the built environment—such as shrubbery, lighting, building maintenance and area surveillance—to limit opportu-nities for crime and violence.46

• Adopting or enforcing policies related to youth access to alcohol. Due to the potential of alcohol to contribute to community violence, lawmakers may also look at policies to reduce youth access to alcohol.47 One evidence-based approach supported by the CDC is to consider zoning and density of alcohol-related businesses.48 Lawmakers may wish to study these poli-cies, while balancing economic development and local business interests.

• Exploring innovative approaches to gang and vio-lence prevention. Promising approaches to preventing

youth from joining gangs are similar to other violence prevention initiatives, such as programs that develop problem-solving skills or strengthen families, or programs that reduce violence in communities.49 For example, the Cure Violence program, which reduced violence in cities such as Chicago and Baltimore, uses trained community workers to respond to all types of community violence.50

Conclusion

Youth violence is a significant public health issue for states, causing injuries and death to thousands of young people each year and affecting their long-term health. Exposure to violence in any form, whether as victims, perpetrators or witnesses, can affect the physical, social and emotional health of adolescents. Incorporating the social determi-nants of health—the contexts in which youth live, learn and play—can be an effective framework in which states can address prevention efforts. States are actively pursuing numerous proven and emerging approaches in all three environments through innovative policies, evidence-based programs and partnerships. By looking at youth violence through the lens of the social determinants, policymakers have the ability to address multiple issues that contribute to the well-being of adolescents and promote a healthy future for their constituents.

This publication was made possible by grant number 1U50CE002586-01 from the Centers for Disease Control and Prevention. Its contents and the links to non-CDC

websites are solely the responsibility of the authors and do not necessarily represent the official views of the Centers for Disease Control and Prevention, the National Center for Injury Prevention and Control, or the U.S. Department of Health and Human Services.

Notes 1. Centers for Disease Control and Prevention, Adolescent Health, www.cdc.gov/healthyyouth/adolescenthealth/, accessed Feb. 5, 2015. 2. World Health Organization, Youth Violence, www.who.int/mediacentre/factsheets/fs356/en/, accessed Feb. 5, 2015. 3. David Finkelhor, Anne Shattuck, Heather A. Turner, and Sherry L. Hamby, “Trends in Children’s Exposure to Violence, 2003-2011,” JAMA Pediatrics, (2014): E1-E7, www.academia.edu/9598220/Trends_in_Childrens_Exposure_to_Violence_2003-2011. 4. Attorney General’s National Task Force on Children Exposed to Violence, Defending Childhood (Washington, D.C.: U.S. Department of Justice, 2012), www.justice.gov/sites/default/files/defendingchildhood/cev-rpt-full.pdf.

5. Centers for Disease Control and Prevention. Web-based Injury Statistics Query and Reporting System (WISQARS) (Atlanta, Ga.: National Center for Injury Prevention and Control, CDC, 2003), www.cdc.gov/ncipc/wisqars, queried Feb. 4, 2015. 6. Ibid. 7. Attorney General’s National Task Force on Children Exposed to Violence, Defending Childhood; Corinne David-Ferdon and Thomas R. Simon, Preventing Youth Violence: Opportunities for Action (Atlanta, Ga.: National Center for Injury Prevention and Control, CDC, 2014), www.cdc.gov/violenceprevention/youthviolence/pdf/opportunities-for-action.pdf. 8. World Health Organization, Youth Violence. 9. Finkelhor, “Trends in Children’s Exposure to Violence, 2003-2011.”

10. Centers for Disease Control and Prevention, Adolescent Health. 11. Centers for Disease Control and Prevention, Social Determi-nants of Health, www.cdc.gov/socialdeterminants/Definitions.html, accessed Feb. 5, 2015. 12. Attorney General’s National Task Force on Children Exposed to Violence, Defending Childhood. 13. U.S. Department of Health and Human Services, Child Maltreatment 2013 (Washington, D.C.: Children’s Bureau, Administra-tion on Children, Youth and Families, Administration for Children and Families, U.S. DHHS, 2015), www.acf.hhs.gov/sites/default/files/cb/cm2013.pdf. 14. World Health Organization, Youth Violence; Attorney Gen-eral’s National Task Force on Children Exposed to Violence, Defending Childhood. 15. World Health Organization, Youth Violence. 16. James A. Mercy and Janet Saul, “Creating a Healthier Future Through Early Interventions for Children,” Journal of the American Medical Association 301, no. 21 (2009): 2262-2264, http://jama.jama-network.com/article.aspx?articleid=183991. 17. Ibid. 18. Ibid; David-Ferdon, Preventing Youth Violence. 19. Stephanie Lee, S. Aos, and A. Pennucci, What works and what does not? Benefit-cost findings from WSIPP (Olympia, Wash.: Washington State Institute for Public Policy, 2015), www.wsipp.wa.gov/Report-File/1602/Wsipp_What-Works-and-What-Does-Not-Benefit-Cost-Findings-from-WSIPP_Report.pdf. 20. Attorney General’s National Task Force on Children Exposed to Violence, Defending Childhood. 21. National Alliance of Children’s Trust and Prevention Funds, www.ctfalliance.org/initiative.htm, accessed Feb. 6, 2015. 22. The Incredible Years, The Incredible Years: Series Goals, http://incredibleyears.com/about/incredible-years-series/series-goals/, accessed Feb. 6, 2015 23. Triple P – Positive Parenting Program, The System At Work, www.triplep.net/glo-en/the-triple-p-system-at-work/, accessed Feb. 6, 2015. 24. MST Services, What Is MST, http://mstservices.com/what-is-mst/what-is-mst, accessed Feb. 6, 2015. 25. Centers for Disease Control and Prevention, Essentials for Childhood Framework: Steps to Create Safe, Stable, and Nurturing Rela-tionships and Environments for all Children, www.cdc.gov/violencepre-vention/childmaltreatment/essentials.html, accessed Feb. 6, 2015. 26. World Health Organization, Youth Violence; Mercy, “Creating a Healthier Future Through Early Interventions for Children.” 27. Laura Kann et al., “Youth Risk Behavior Surveillance – United States, 2013,” MMWR 63, no. 4 (2014), www.cdc.gov/mmwr/pdf/ss/ss6304.pdf. 28. Ibid. 29. Ibid. 30. The National Campaign to Prevent Teen and Unplanned Preg-nancy, Survey Says: February 2014: Under Pressure (Washington, D.C.: TNC, 2014). 31. Centers for Disease Control and Prevention, Understanding School Violence (Atlanta, Ga.: CDC, 2015), www.cdc.gov/violencepre-

vention/pdf/school_violence_fact_sheet-a.pdf; Centers for Disease Con-trol and Prevention, Teen Dating Violence, www.cdc.gov/violencepre-vention/intimatepartnerviolence/teen_dating_violence.html, accessed Feb. 4, 2015. 33. David-Ferdon, Preventing Youth Violence. 34. Rhode Island State Department of Elementary and Secondary Education, Safe School Act: Statewide Bullying Policy, http://sos.ri.gov/documents/archives/regdocs/released/pdf/DOE/6774.pdf, accessed Feb. 6, 2015. 32. The National Campaign to Prevent Teen and Unplanned Preg-nancy, Why It Matters: Teen Pregnancy and Violence (Washington, D.C.: TNC, 2007), https://thenationalcampaign.org/resource/why-it-matters-teen-pregnancy-and-violence. 35. Centers for Disease Control and Prevention, School Violence: Prevention, www.cdc.gov/violenceprevention/youthviolence/schoolvio-lence/prevention.html, accessed Feb. 6, 2015; World Health Organiza-tion, Youth Violence. 36. Centers for Disease Control and Prevention, School Health Policies and Practices Study, 2012 (Atlanta, Ga.: CDC, 2013), www.cdc.gov/healthyyouth/shpps/2012/factsheets/pdf/FS_ViolencePreven-tion_SHPPS2012.pdf. 37. David-Ferdon, Preventing Youth Violence. 38. Robert Hahn, et al., “Effectiveness of Universal School-Based Programs to Prevent Violent and Aggressive Behavior: A Systematic Re-view,” American Journal of Preventive Medicine 33, no. 2S (2007): S114–S129, www.thecommunityguide.org/violence/School_Evidence_review.pdf. 39. David-Ferdon, Preventing Youth Violence; National Health Pro-gram Associates, Life Skills Training: Program Overview, www.lifeskill-straining.com/, accessed Feb. 7, 2015. 40. Attorney General’s National Task Force on Children Exposed to Violence, Defending Childhood. 41. Ibid. 42. Ibid. 43. Kann et al., Youth Risk Behavior Surveillance – United States, 2013. 44. James C. Howell, Gang Prevention: An Overview of Research and Programs (Washington, D.C.: Office of Juvenile Justice and Delin-quency Prevention, U.S. Department of Justice, 2010), www.ncjrs.gov/pdffiles1/ojjdp/231116.pdf; David-Ferdon, Preventing Youth Violence. 45. John MacDonald, Daniela Golinelli, Robert J. Stokes, and Ricky Bluthenthal, “The effect of business improvement districts on the incidence of violent crimes,” Injury Prevention (2010), http://inju-ryprevention.bmj.com/content/early/2010/06/29/ip.2009.024943.full.pdf+html. 46. Julie Samia Mair and Michael Mair, “Violence Prevention and Control through Environmental Modification,” Annual Review of Public Health 24: (2003):209-225. 47. David-Ferdon, Preventing Youth Violence. 48. Ibid. 49. Ibid. 50. Cure Violence, The Cure Violence Health Model, http://curevio-lence.org/the-model/essential-elements/, accessed Feb. 7, 2015.

William T. Pound, Executive Director

7700 East First Place, Denver, Colorado 80230, 303-364-7700 | 444 North Capitol Street, N.W., Suite 515, Washington, D.C. 20001, 202-624-5400

www.ncsl.org

©2015 by the National Conference of State Legislatures. All rights reserved.

ISBN 978-1-58024-773-3