Evidence Report/Technology Assessment: Number 107
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Under its Evidence-based Practice Program, the Agency for Healthcare Research and Quality (AHRQ) is developing scientific information for other agencies and organizations on which to base clinical guidelines, performance measures, and other quality improvement tools. Contractor institutions review all relevant scientific literature on assigned clinical care topics and produce evidence reports and technology assessments, conduct research on methodologies and the effectiveness of their implementation, and participate in technical assistance activities.
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Introduction / Methods / Results / Discussion / Availability of Full Report / References
Authors: Chan LS, Kipke MD, Schneir A, Iverson E, Warf C, Limbos MA, Shekelle P.
Over the last two decades of the 20th century,
violence emerged as one of the most significant
public health problems in the United States
(Administration for Children and Families,
2004). While recent trends have been
encouraging, homicide remains the second
leading cause of death among adolescents
(National Center for Injury Prevention and
Control, 2004). During this period, an
increasing number of research studies have
sought to characterize youth violence and the
contexts in which it occurs, as well as risk and
protective factors associated with such violence.
At the same time, a myriad of prevention
interventions have been developed and evaluated
with multiple youth populations and in a range of
In the fall of 2004, the National Institute of
Mental Health (NIMH) convened a State-of-the-Science Conference on "Preventing Violence
and Related Health-Risking Social Behaviors in
Adolescents." The purpose of this consensus
conference was to provide a forum to present and
review what is currently known about preventing
youth violence. In preparation for this meeting,
the Office of Medical Applications of Research
(OMAR) and the National Institute of Mental
Health (NIMH) nominated and supported the
topic for an Agency for Healthcare Research and
Quality (AHRQ)-sponsored systematic review
and analysis of the evidence.
this project to the Southern California Evidence-based
Practice Center (SC-EPC) and its partner,
Childrens Hospital Los Angeles, to conduct the
review and summarize the findings in an evidence
report. Researchers were to review longitudinal
risk factor research to identify the role of
individual, family, school, community and peer-level
influences as well as interventional research
to evaluate prevention intervention effectiveness.
This evidence report addresses the following six
- What are the factors that contribute to violence and associated adverse health outcomes in childhood and adolescence?
- What are the patterns of co-occurrence of these factors?
- What evidence exists on the safety and effectiveness of interventions for violence?
- Where evidence of safety and effectiveness exists, are there other outcomes beyond reducing violence? If so, what is known about effectiveness by age, sex, and race/ethnicity?
- What are commonalities of the interventions that are effective, and those that are ineffective?
- What are the priorities for future research?
For the purpose of this evidence review, we
used the Centers for Disease Control and
Prevention's definition of violence: "threatened or
actual physical force or power initiated by an
individual that results in, or has a high likelihood
of resulting in, physical or psychological injury or
death" (National Center for Injury Prevention and
Control, 2004). We made the decision to
include only the following types of violent
- Murder or homicide.
- Aggravated assault.
- Non-aggravated assault.
- Rape or sexual assault.
- Gang fight.
- Physical aggression.
- Psychological injury or harm.
- Other serious injury or harm.
Thus, we did not review the
growing literature that reports on studies of suicide, verbal aggression, bullying, arson, weapon carrying,
externalizing behaviors (e.g., acting out), attitude about violent
behavior, youth crime against property or materials (such as
burglary, theft), or intent to commit violence as outcomes.
These related behaviors and attitudes are included in this report
only to the extent that they have been proposed as risk factors
for the forms of violence on which this report focuses.
The definition of violence prevention interventions that we
used was developed for and published in the Surgeon General's
Report on Youth Violence (Satcher, 2001). According to this
definition, "Primary prevention interventions are those that are
universal, intended to prevent the onset of violence and related
risk factors; secondary prevention interventions are those
implemented on a selected scale for children/youth at enhanced
risk for youth violence, intended to prevent the onset and
reduce the risk of violence; and tertiary prevention
interventions are those that are targeted to youth who have
already demonstrated violent or seriously delinquent behavior."
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To complete the project with the resources available, it was
necessary to narrow the focus of this evidence review. To this
end, we limited our review to peer-reviewed articles published
in 1990 or later and retrievable within four search engines—MEDLINE®, PsychINFO, SocioAbstracts, and ERIC. We
also limited the review to studies conducted in the United
States and focused on violent behavior perpetrated by
adolescents aged 12 through 17 years. Thus, this review
excluded studies of violence perpetrated by children, preadolescents,
and young adults.
To assist project staff in conducting the evidence review, a
nine-member multidisciplinary Technical Expert Group (TEG)
was established, comprising individuals with both content and
methodological expertise. Specifically, the TEG brought to this
review a diverse set of expertise from a range of fields and
disciplines, including early childhood development, adolescent
development, juvenile justice, child abuse and neglect,
anthropology, psychology, sociology, social work, public health,
and public policy.
We created a list of potential risk and protective factors
organized by domain—i.e., individual, family, school, peer,
community, and social domains—to inform data abstraction
and synthesis. We also developed a conceptual and analytical
framework to examine the associations among risk factors,
violent behavior, and interventions to guide the analysis. As
these background materials were being developed, we shared
them with the NIH Panel Chair and our Task Order Officer,
discussed them with members of our TEG, and made
numerous revisions based on the feedback that we received.
The National Library of Medicine (NLM) performed all
searches. Librarians from NLM met with project staff via
teleconference to discuss the scope, the key questions, and the
search strategy. The librarians also worked with project staff to
select the databases that were ultimately used and to evaluate
the search strategies that had been developed by the project
NLM searched four electronic databases—MEDLINE®,
PsychINFO, SocioAbstracts, and ERIC—in April/May of 2003
and again in October/November 2003.
For "youth," the
following search terms were used: adolescent, teen, juvenile,
For "violence," the following terms were used:
violence, school violence, dangerous behavior, rape, homicide,
domestic violence, courtship violence, dating violence,
interpersonal violence, date rape, raping, rapes, rapist,
bully, bullies, bullied, bullying, physical assault, physical attack,
physical aggression, direct aggression, overt aggression, knifing,
stabbing, gunshot, brutality, bludgeoning, and murder.
Three inclusion criteria were applied for citations and
manuscripts: published in 1990 or thereafter, related to the
range of risk and protective factors associated with perpetrators
of youth violence and violence-related crimes between ages 12
and 17 years, and conducted in the United States only.
Excluded were case reports, unpublished program evaluations,
editorials, letters, reviews, practice guidelines, non-English
language publications, and papers from which data could not
For the questions on risk factors, we based our assessment on
prospective longitudinal cohort studies, because of the general
consensus that cross-sectional studies would not allow us to
identify temporal predictors of youth violence (Heimer, 1997;
Herrenkohl, Guo, 2001).
For the evaluation of the
effectiveness of interventions, we examined the findings from
randomized controlled trials (RCTs) as well as non-RCTs or
single-group time series in which a control group was used
either concurrently or prospectively.
Evaluation of Study Quality
We evaluated the quality of individual studies using the
criteria set forth in the Procedures for EPC Reports for Office
of Dietary Supplements (ODS) and OMAR (ODS and
OMAR, 2003). Because all the prospective longitudinal cohort
studies included in our review satisfied four of the seven criteria
in the same ways, we used the three remaining criteria—followup rate of 80 percent or more, valid and reliable
instruments used, and appropriate control of confounding
factors—to assess the quality of individual studies. For studies
that assessed the effectiveness of interventions, we used the
OMAR criteria for RCTs and observational studies.
According to OMAR guidelines (ODS and OMAR, 2003),
the rating of the strength of scientific evidence remains the
prerogative of the Consensus Panel. However, we conducted
two sensitivity analyses to assist the Consensus Panel to assess
the strength of the scientific evidence in our review. First, we
re-analyzed the data excluding the studies with sample size
below the thresholds set at 1,100 for the general population
and 500 for the at-risk population, to restrict the analyses to
the studies with the greatest power to detect significant
predictors. Second, we re-assessed the findings using only
studies with good quality.
For primary screening, two members of the team
independently reviewed each title or abstract: one reviewer was
a member of the faculty with specific expertise related to
adolescent development and/or youth violence, and the other
reviewer had a Master's degree in public health or was a
doctoral student in the field of psychology, public health, or
prevention research. The Task Order Manager or the Task
Order Coordinator compared the screening results of the two
reviewers and resolved discrepancies. The same procedure was
followed for secondary screening of full-length articles. For
articles selected for inclusion, data were abstracted by a member
of the project team onto a specially prepared form. Completed
forms were checked by the Task Order Manager.
Risk Factor Identification
To identify homogeneous
subgroups for data pooling, we stratified the eligible studies
according to the following criteria:
- Demographics of the study population.
- Characteristics of the study.
- Type of analysis.
We used a systematic approach to summarize the
findings. When findings for a single cohort were reported in
multiple articles, the cohort was considered the unit of analysis.
In the summary, findings for one cohort that were reported in
more than one article were counted as only one article.
However, if several articles reported findings for one cohort but
each reported the findings for different outcome measures, each
was counted. When a risk factor was assessed using both
bivariate and multivariate analysis, the results of the
multivariate analysis took precedence. Findings were
considered significant if the p statistic was less than 0.05.
For summarizing the evidence, we considered a factor to be
consistently associated with violence if 75 percent or more of
the cohort studies reported a significant association for the
factor. Likewise, factors reported not to be associated with
violence in at least 75 percent of the studies under
consideration were considered not associated with violence.
Otherwise, the findings were considered inconclusive. We
evaluated consistency for factors that were reported in two or
more cohort studies. Evidence was considered inadequate if the
results for a particular factor were reported in only one cohort
Effectiveness of Interventions
For evaluating the effectiveness of interventions, we
stratified the accepted studies by the level of intervention and
the type of study design. Initially, we planned to stratify the
studies further by the various characteristics of interventions
that might ultimately contribute to the effectiveness of the
intervention (such as intervention setting and target
population). However, many of the reports omitted mention
of these study characteristics.
Because of the diversity of the studies, we did not pool
findings across studies. Instead, we summarized the findings of
the programs as effective or ineffective. We considered an
intervention to be effective if one or more violence outcome
indicators was reported to be significantly different at the
p<0.05 level, based on the findings reported in the article(s). If
none of the violence outcome indicators was reported to be
significantly different, we considered the program ineffective.
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We screened 11,196 titles and abstracts, reviewed 1,612 full-length
articles, and included 67 articles in our evidence
assessment (35 for the risk factor questions and 32 for the
Factors Contributing to Youth Violence (Key Question #1)
The 35 articles that addressed risk factors contributing to
youth violence were based on 23 prospective cohort studies
covering 11 study populations defined by gender,
race/ethnicity, and at-risk population. Findings for specific
racial/ethnic groups suffered from small numbers of cohorts or
small numbers of subjects.
Across all studies, only one risk factor, male gender, was
consistently reported to be significantly associated with youth
violence perpetration (Rivera and Widom, 1990; Roitberg and
Menard, 1995; Saner and Ellickson, 1996; Komro, Williams,
1999; Foshee, Bauman, 2000; Herrenkohl, Guo, 2001;
McCloskey and Lichter, 2003).
Low family socioeconomic
status (SES) was consistently reported not to be an independent
risk factor for youth violence (Roitberg and
Menard, 1995; Saner and Ellickson, 1996; Herrenkohl, Egolf, 1997; Brezina,
1999; Herrenkohl, Guo, 2001; Herrera and McCloskey, 2001). Co-occurrence of family SES with other risk factors was
associated with youth violence.
There was very little
consistency of reported significance or non-significance for all
other risk factors. Few studies examined a comparable set of
risk factors (i.e., risk factors were often examined only by a
single study) limiting our ability to draw conclusions based on
the available evidence. Among studies that specifically focused
on adolescent males, a consistent finding was the significant
association between violence and anger (Felson, 1992; Foshee,
Linder, 2001), cigarette smoking (Dornbusch, Lin, 1999;
Ellickson, Tucker, 2001) and non-violent delinquency (Becker
and McCloskey, 2002; Saner and Ellickson, 1996). For
adolescent females, a consistent finding was the significant
association between violence and non-violent delinquency
(Becker and McCloskey, 2002; Herrera and McCloskey, 2001;
Saner and Ellickson, 1996).
For research conducted with at-risk
youth populations, a consistent finding was the significant
association between being Latino and repeated physical
aggression among adolescent males (Loeber, Wei, 1999; Loeber,
Wung, 1993); there were no consistent findings for research
conducted with at-risk adolescent females.
Patterns of Co-occurrence of These Factors (Key Question #2)
In addition to our search for independent risk factors that
have a high likelihood of leading to youth violence, we were
also interested in clusters of risk factors that may lead to youth
violence. A number of factors that were found to be
statistically significant when no other risk factors were taken
into account were found not to be significant when other risk
factors were taken into consideration. For example, low SES or
low family income was reported as a significant risk factor
associated with youth violence when the co-occurrence of other
risk factors was not taken into consideration. But when the
effect of other risk factors was taken into consideration, its
significance disappeared, implying that the other risk factor(s)
were stronger predictor(s) of youth violence than was low SES.
Menard, 1995; Saner and Ellickson, 1996; Herrenkohl, Egolf, 1997; Brezina,
1999; Herrenkohl, Guo, 2001; Herrera and McCloskey, 2001).
We defined co-occurrence of factors as the simultaneous
presence of two or more risk or protective factors that together
predict violence in an individual. We identified five articles on
four cohort studies that addressed different aspects of cooccurrences.
These articles reported the following findings:
- Pre/perinatal risk exposure combined with disadvantaged familial environment at age 7 increased the chances of criminal offending during early adulthood among a high-risk, inner-city group (Piquero and Tibbetts, 1999).
- Polydrug use was associated with increased violence in both boys and girls, a finding not identifiable from analyses that focused on the use of a specific drug (Dornbusch, Lin, 1999).
- Youth exposed to multiple risk factors were found to be more likely than others to engage in later violence (Herrenkohl, Egolf, 1997).
- The co-occurrence of parent-family connectedness, school connectedness/parental presence, and grade point average in both boys and girls significantly decreased the risk of youth violence (Borowsky, Ireland, 2002).
- Beyers et al. (Beyers, Loeber, 2001) reported the following combinations of risk factors associated with repeated youth violence:
- Living in a low-SES neighborhood, lack of guilt, sexual activity, carrying a hidden weapon, and poor communication at home.
- Living in a high-SES neighborhood and physical aggression.
The following combinations of risk factors were reported not to be associated with repeat youth violence:
- Living in a low-SES neighborhood and any or a combination of the following: age, impulsive/hyperactive behavior, low school motivation, positive attitude toward problem behavior, boy not involved at home, poor parental supervision, peer delinquency, or bad friends.
- Living in a high-SES neighborhood plus any or a combination of the following: impulsive/hyperactive behavior, lack of guilt, positive attitude toward problem behavior, sexual activity, or peer delinquency.
Effectiveness of Interventions for Violence (Key Questions #3, #4, and #5)
We identified 32 intervention evaluation studies, of which
13 employed randomized controlled trial (RCTs) design and 19
employed other study designs. The following provides a
summary of the key findings.
Effectiveness by Level of Intervention
comparisons of the effectiveness of interventions by the level of
intervention (primary, secondary, tertiary) were not identified,
but some measure of the effectiveness of interventions by level
can be made by simply comparing the proportion of studies at
each level that report beneficial effects. Not considering the
study design and excluding one inconclusive study, effectiveness
was reported in 5 of 15 (33 percent) primary interventions,
4 of 10 (40 percent) secondary interventions, and 5 of 6
(83 percent) tertiary interventions. When only RCTs were
considered, effectiveness was reported in one of five (20
percent) primary intervention, 3 of 6 (50 percent)
secondary intervention, and 2 of 2 (100 percent) tertiary
Effectiveness by Age, Gender, and Race/ethnicity
of this assessment was on adolescents aged 12 through 17; thus,
all programs determined to be effective reduced violent
behavior in this age group. The data did not permit further
analysis according to age. Similar to our assessment with the
level of interventions, within study comparisons are the
strongest analytic approach to study differential effectiveness by
demographic groups. However, none of the studies provided
the information needed to evaluate differential effectiveness by
age, gender, or race/ethnicity. Instead, effectiveness was
reported primarily within each gender or ethnic group.
Effectiveness by Selected Characteristics of Intervention
Overall, we did not observe any differences in
program effectiveness among different settings, between single
or multimodal programs, among programs with different
durations, or among programs implemented at different school
levels. However, we observed that 4 of 4 (100 percent)
secondary interventions that lasted a year or longer were
effective (4 of 4), whereas 5 of 5 (100 percent)
secondary interventions that lasted less than 6 months were
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The overarching goal of this review was to bring greater
scientific rigor to the evaluation process to identify the highest
quality research findings in the field of youth violence. With
the severely restricted scope of the project, much of the value of
this report was the identification of the current status of
research on youth violence, the existing research gaps and
inconsistencies, and the need for additional scientifically
Despite the limited scope, we identified a
voluminous literature that is rather fragmented in nature. We
found little agreement with respect to the definitions used to
measure youth violence and the ways in which risk/protective
factors are conceptualized, operationally defined, measured,
analyzed, and reported. As a result, the findings showed little
consistency across individual studies and the research literature
is not growing cumulatively. Consequently, we are limited in
our ability to draw conclusions and make recommendations.
Specifically, for the review of risk factors contributing to
youth violence, we were unable to perform a quantitative
synthesis for the risk factors by developmental stages, by type of
at-risk population, by type of violent outcome, and by type of
statistical analysis due to the limited number of prospective
cohort studies. Efforts to examine the effects of co-occurrence
of risk factors have been limited, although some efforts have
been made to examine the multifactorial nature of risk and
protective factors contributing to youth violence.
With respect to the review of the effectiveness of prevention
interventions, the number of studies was too small for the
detection of any systematic differences among programs with
different characteristics. The characterization of intervention
programs was not consistently or uniformly reported in
published articles, making it difficult to evaluate program
effectiveness by program characteristics.
Priorities for Future Research (Key Question #6)
Risk Factors Contributing to Youth Violence
effort is needed to develop uniformity in the ways in which
youth violence and violence-related outcomes are both defined
and operationalized, and these definitions should be
incorporated into future research to begin to build some
consistency and uniformity in study findings. We therefore
recommend initiation of a national effort to develop
comparable approaches to defining, measuring, and analyzing
research data related to youth violence, and the funding of new
initiatives to facilitate the collection of comparable data across
multiple sites and with multiple youth populations. Such
multi-site cooperative agreement studies would permit the use
of a combined prospective cohort from which a common
standardized dataset could be assembled and analyzed.
Further, additional research is needed to examine both
sequential and simultaneous co-occurrences of risk factors that
contribute to youth violence. Future research should
concentrate on minimizing both non-participation and
attrition in longitudinal studies.
Natural prospective cohorts must be established, pseudo
prospective cohorts could also be considered. We have
identified many prospective cohort studies focused on various
stages of development, different types of study population, and
different types of outcomes that could be coordinated and
assembled to form a pseudo prospective cohort from which a
common dataset could be assembled and advanced statistical
analysis conducted. Such an effort would require strong central
support, cooperation from all parties involved, and long-term
Interventions for the Prevention of Youth Violence
randomized controlled interventions are needed to evaluate
program effectiveness in general and for various groups of
youth in particular, e.g., those of different ages, both genders,
all ethnicities/races, and possessing the various characteristics
that appear to increase risk. We therefore recommend that
researchers increase the scientific rigor, including the use of
control populations and extended followup, to evaluate the
sustained effectiveness of youth violence prevention
While RCTs with individual subjects are ideal,
they are difficult to implement in "real world" settings,
especially for the behavioral and social sciences, and group
RCTs are the best alternatives. Therefore, it is important that
more research effort be focused on the design, implementation,
and analysis of group RCTs. Research in this area will
contribute greatly to the scientific methods in the social
A National consensus-building effort is also needed to
identify and clarify the science related to:
- The use of conceptual frameworks and causal pathways related to youth violence.
- Risk factors and mechanisms leading to violent outcomes.
- Strategies and interventions to reduce violent outcomes.
- Methodologies and scientifically grounded approaches that should ideally be used to evaluate prevention interventions.
- The effective use of policy to reduce youth violence.
- Methodologies for evaluating such policies.
Rating of Study Quality
For prospective longitudinal
studies, we have shown that a high retention rate alone is
inadequate to measure sample bias. We believe that the
participation rate, followup or retention rate, and proportion of
participants with complete data should be considered when
assessing the possibility of bias in the study sample, especially
for outcomes such as violence.
For intervention studies, we do
not believe that the OMAR study quality criteria truly assessed
the quality of the studies we reviewed because they were derived
primarily from clinical studies. Unlike many clinical
interventions for medical conditions, youth violence
interventions are often multifaceted, involve the efforts of
multiple parties (e.g., teachers, parents, school administrators,
and so on), are conducted over long periods of time, and can
be adversely affected by factors that cannot be anticipated,
characteristics that make the studies difficult to evaluate. The
nature of the interventions in social science studies can also
preclude some of the methodological components critical to
clinical trials. The need to develop valid instruments to
evaluate the quality of studies in the social sciences is apparent.
Quality of Publications
Special efforts are needed to
improve the quality of publications, including the consistency
and adequacy with which the study characteristics, such as
research questions, conceptual framework, study design, and
description of the study population, are specified.
Evidence Assessment Methods
Because of the multifactorial
nature of the factors contributing to youth violence,
alternatives to quantitative synthesis of published information
should be sought. Unlike many clinical interventions,
interventions to prevent or stop youth violence are often multifaceted,
involving the efforts of multiple parties (e.g., teachers,
parents, and school administrators), requiring long time
commitments, and being sensitive to factors that cannot be
We propose that social science researchers consider
an "individual-level-data-meta-analysis" method (Olkin and
Sampson, 1998; Mathew and Nordstrom, 1999; Stewart and
Clarke, 1995; Stewart and Parmar, 1993; Nagin and Tremblay,
1999) for future systematic reviews to identify both
independent predictors and clusters of predictors that lead to
youth violence. The method is described further in the report.
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Availability of Full Report
The full evidence report from which this summary was taken was prepared for the Agency for Healthcare Research and Quality (AHRQ) by the Southern California Evidence-based Practice Center (EPC) Contract No. 290-02-0003. It is
expected to be available in October 2004. At that time, printed
copies may be obtained free of charge from the AHRQ
Publications Clearinghouse by calling 800-358-9295.
Requesters should ask for Evidence Report/Technology
Assessment No. 107, Preventing Violence and Related Health-Risking Social Behaviors in Adolescents.
The Evidence Report is also online on the National Library of Medicine Bookshelf, or can be downloaded as a PDF File (11 MB). Plugin Software Help.
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AHRQ Publication Number 04-E032-1
Current as of September 2004