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AJN, American Journal of Nursing:
doi: 10.1097/10.1097/01.NAJ.0000395229.07616.36
AJN Reports

Reducing Violent Behavior in Adolescents

Potera, Carol

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Nurses can intervene to prevent bullying and aggression.

Nearly a third of teens ages 12 to 17 participate in violent behavior each year, according to a new national study conducted by the Substance Abuse and Mental Health Services Administration. About 23% took part in a serious fight at school or work, 16% were involved in group fighting, and 7.6% reported attacking others to intentionally harm them. Boys were only slightly more likely to be violent than girls (34.6% versus 27%). The report, which can be found at, is based on data gathered from 2004 to 2008 through interviews with 112,685 adolescents nationwide.

Two key demographic and socioeconomic factors were found to be linked to violent behaviors—family income and academic performance. Adolescents living in homes with annual incomes below $20,000 were 1.6 times more likely to be involved in violence than teens from families with annual incomes of $75,000 or more (40.5% versus 24.6%). And students with D averages were three times as likely to be involved in violent acts as teens with A averages (53.8% versus 17.7%). In fact, poor academic performance seemed to override the protective effect of higher family income. Among students with D averages, those coming from families with annual incomes of $75,000 or more reported nearly identical rates of violent behavior as those from families making less than $20,000 yearly (54.5% versus 55.9%).

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These high rates of violent behavior underscore the need for efforts to prevent bullying and violence and help the victims. And nurses—especially school nurses and those who work in primary care—are in ideal positions to intervene. According to the National Association of School Nurses (NASN), community leaders and school officials need to create safe learning environments and treatment programs to promote safety and rebuild young lives (read the NASN position statement on the role of the school nurse in preventing violence: Nurses can educate parents, teachers, and administrators regarding the physical and psychological consequences of violence and bullying.

Once considered a normal part of growing up, bullying is now recognized as a precursor to extreme violence with mental health consequences for both victim and perpetrator. Exposure to bullying, threats, and violence triggers significant emotional, behavioral, and cognitive problems, including fear, poor concentration, and difficulty achieving academic success. Bullying and violence have always been a problem among youths, says Cheryl Dellasega, an NP and professor of humanities and women's studies at Penn State University and the Milton S. Hershey Medical Center. "But now we're seeing more serious consequences, such as suicide, in victims." Dellasega has written several books on female aggression and created the Camp and Club Ophelia programs ( to help girls learn healthy relationship skills.

Providing safe haven. School nurses can offer safe haven to victims of bullying or violence. "We're not going to give them homework or detention," says Sandi Delack, MEd, RN, NCSN, president of the NASN and a school nurse at Ferri Middle School in Johnston, Rhode Island. She says that the first step is establishing trust with students; then over time they'll disclose whether they're victims of bullying or violence. "This assessment role for nurses gets to the bottom of what's going on," she says. "If it's beyond our scope, we refer them for professional help."

Unfortunately, only 45% of schools in the United States have a full-time nurse on staff (75% offer some nursing care). When staffing is limited, students with chronic health problems take priority. The NASN recommends one nurse for every 750 healthy students, but ratios vary widely, from one to 300 students in Vermont to one to 5,000 in Michigan.

Students visit school nurses with headaches, upset stomachs, and other physical conditions, some of which stem from being targets of tormentors. In an informal survey of girls in her Ophelia program, Dellasega found that 5% of girls had considered not coming to school to avoid various bullying situations and another 5% had feigned illness and stayed home.

"Sometimes the environment is so tense they're afraid for themselves and others," says Dellasega. Victims particularly dread eating lunch in school cafeterias. Setting up an alternative eating place helps, and some school nurses even invite students to eat in their offices.

School nurses can teach both bullies and their victims coping skills like stress- and anger-management techniques. Violent youths lash out because they don't know how to handle emotions. They need to learn how to channel emotions into more productive responses. Boys, in particular, tend to fight physically, says Dellasega. "We need to teach boys verbal skills and that talking out anger doesn't make them less macho."

Initiating conversations about bullying. Nurses and NPs working in primary care settings should ask all children about problems at school. "Having that conversation is important, especially if students have headaches or stomach aches or are missing a lot of school" and there seems to be no physiologic reason, Dellasega says. Nurses can broach the subject by telling teens that many others have trouble at school, too, then asking what's going on with them. Talking with youths alone, after obtaining parental permission, encourages honest replies.

Nurses can make a big difference in efforts to prevent youth violence by getting involved, adds Dellasega, and they need to "rise up and take more ownership of the issue." Not only do nurses understand the health consequences of violence and bullying, they're also trained in communication skills that could benefit communities and schools. And many are also parents themselves.

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Cell phones, e-mail, and social networking Web sites like Facebook provide a new outlet for bullies. The social networking sites "are an enormous problem," says Delack, because they depersonalize bullying, eliminate face-to-face contact, and extend bullying to 24 hours a day. Delack sees cases of violence at school that trace back to online bullying the night before. Stopping this type of bullying takes a community effort, and parents must become involved, according to Delack, who suggests monitoring students at home.

Teens are also bombarded with violence on television, in movies, and in video games, which can lead to aggressive behavior, bullying, fear, depression, and nightmares. According to the American Academy of Pediatrics (AAP) position statement on media violence (, the association between media violence and aggressive behavior is stronger than the well-established connections between calcium intake and bone mass or lead ingestion and low IQ.

Children learn to be violent by imitating behaviors seen in the media. Although media violence makes some young people afraid of becoming victims, it motivates others to become aggressive to protect themselves.

To mitigate the impact of media violence, the AAP recommends that televisions, Internet connections, and video games be removed from children's rooms to limit exposure and encourage more healthful alternatives like exercise or reading. Counseling parents during office visits to limit screen time has been shown to be effective. NPs who handle primary care visits can also push for reduced media time.

Although this may seem impractical, if not impossible, in today's media-saturated society, a quarter of kids report watching "none" or "almost no" violent media according to recent studies.

"So there are families doing this. And nurses can empower parents who want to make this choice—because it's worth doing," says Michelle Ybarra, PhD, who studies media-related violence at the nonprofit research organization Internet Solutions for Kids in Santa Ana, California (and whose study on the subject was covered in In the News in the February 2009 issue of AJN.—Carol Potera

© 2011 Lippincott Williams & Wilkins, Inc.


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