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Orthopaedic Nursing:
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Child and Adolescent Violence

Daane, Diane M.

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Diane M. Daane, JD, MS, University of South Carolina Spartanburg, Spartanburg, SC.

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Abstract

Although the juvenile violent crime rate has decreased steadily during the past 5 years, the problem of violence and violence-related behaviors in the lives of our children and adolescents remains. The incidence of violent victimization against children and violence and violence-related behavior by today’s youth is related to a variety of factors. Exposure to violence in the home, school, community, or video games and other entertainment significantly influences aggressive behaviors among children and adolescents. Other childhood violence predictors include alcohol and drug use, gender, and low self-esteem. The childhood violence risk indicators have implications for child and adolescent violence prevention and intervention programs. Nurses who recognize dangerous and potentially dangerous behavior in children and adolescents are better able to provide violence prevention and intervention services and referrals to children at risk or in danger. Because orthopaedic nurses often see adolescents who have already sustained injury from violence, identification of those at risk is particularly important.

Public concern about child and adolescent violence is greater than ever before. School shootings and the media attention given to them have focused national attention on the problem of children and violence. Violence is the leading cause of death in African-American adolescents and the second leading cause of death in adolescents overall (Tolmas, 1998). Although violence has become a serious health concern, especially for youth, juvenile violence is at its lowest rate in 10 years (Snyder, 2000).

Official statistics gathered and calculated by the Federal Bureau of Investigation (FBI) show that there was substantial growth in juvenile violent crime arrests starting in the late 1980s and peaking in 1994. After the peak in 1994, the juvenile violent crime rate fell for the fifth consecutive year in 1999, falling 36% between 1994 and 1999. The juvenile arrest rate for murder decreased 68% between 1993 and 1999, dropping to its lowest rate since the 1960s. The number of juvenile arrests has declined in every violent crime category collected by the FBI, despite an 8% growth in the juvenile population from 1993 to 1999 (Snyder, 2000). Table 1 shows the change in juvenile violent crime arrests from 1995 to 1999.

Table 1
Table 1
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The public perception of large numbers of out-of-control violent children is not reflected in the official crime statistics. Relatively few juveniles are arrested for violent crimes. In 1999, no more than 1 of every 290 children between 10 and 17 years of age was arrested for violent crime (Snyder, 2000). In fact, this number may be inflated because it is unlikely that every arrest was of a different juvenile. Although this number may seem high, only about one third of 1% of juveniles between the ages of 10 and 17 years was arrested for a violent crime in 1999 (Snyder, 2000).

Although the number of juveniles arrested for violence is decreasing, using only reported crimes for which an arrest has been made does not adequately assess the problem of violence in the lives of our children and adolescents. There is no standard set of indicators to describe youth violence, or even school violence, but there is evidence that children and adolescents are engaging in violence and violence-related behaviors at home, in the community, and at school. There is also evidence of interpersonal violence against children and adolescents, often by other youths.

Sixteen- to 19-year-olds have the highest rate of violent victimization for any age group. Twelve- to 15-year-olds have the second highest violent victimization rate. (Maguire & Pastore, 1999). Table 2 lists the estimated rate of all violent personal victimization by age group. Twenty-eight percent of high school seniors in the class of 1998 reported being threatened with injury, and 18% reported being threatened with a weapon. The seniors reported only slightly fewer threats at school. These same seniors ranked crime and violence as the social problem about which they worry the most (Maguire & Pastore).

Table 2
Table 2
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A nationwide study of youth risk behaviors (Youth Risk Behavior Surveillance [YRBS]) conducted semiannually by the Centers for Disease Control and Prevention found that in 1999, 5% of students missed school during the 30 days before the survey because they felt unsafe at school or unsafe traveling to or from school (Kann et al., 2000). Hispanic students were significantly more likely than black or white students to have missed school because they felt unsafe. Student fear of attending school and avoidance of certain places in the school for fear of being attacked or harmed has decreased since 1995 (Small & Tetrick, 2001). Despite national attention to school violence, schools have been largely successful keeping students and staff safe from harm. Children are less likely to be the victims of violent crime, especially serious violent crime, at school than at home or in the community (Small & Tetrick).

Interpersonal violence among youths includes fighting. The Department of Justice reports a decline in the number of students involved in fighting behavior on school property from 1993 to 1999 (Small & Tetrick, 2001). Even with the decline, 36% of students had been in at least one fight in the year before the 1999 YRBS survey, with 14% of the students fighting on school property (Kann et al., 2000). Four percent of these fights resulted in injuries that required treatment.

In another study, 18% of high school seniors reported being involved in a serious fight at work or school (Maguire & Pastore, 1999). Research has yielded contradictory results about whether adolescents comprehend the physical risk involved in fighting, but there is evidence that supports the theory that students who fight perceive fighting as less of a risk than their peers who do not engage in fighting behavior (St. George & Thomas, 1997).

More than 17% of students in the 1999 YRBS reported carrying some type of weapon to school during the 30 days before the survey (Kann et al., 2000). This is a significant reduction in weapon carrying compared with the YRBS 1993 (Small & Tetrick, 2001). At least two national studies indicate that approximately 5% of students report carrying a gun to school, which is consistent with student reports of others bringing guns to school (Kann et al.;Maguire & Pastore, 1999).

Although school-associated violent deaths are rare (Small & Tetrick, 2001), the rate of both fatal and nonfatal firearm-related injury was highest among persons between the ages of 15 and 24 years (Gotsch, Annest, Mercy, & Ryan, 2001). More than two thirds of firearm-related injuries for this group resulted from interpersonal violence, as opposed to accidental and self-inflicted injuries (Gotsch et al.). Firearm-related injury and death are significantly higher for males than for females, with black males being at the greatest risk (Gotsch et al.).

One response to the school shootings that have been so widely publicized has been to introduce additional gun control laws to keep guns out of the reach of juveniles. One problem with this approach is that juveniles are already prohibited from legally purchasing firearms. Although juveniles cannot legally buy guns, the majority of juvenile offenders report that they would have “no trouble at all” obtaining a gun (Sheley & Wright, 1991 as cited in Brezina & Wright, 2000). Adolescents in the general population also report that obtaining a gun is not difficult. Family, friends, and street sources are the most common methods for children and adolescents to acquire firearms. The majority of youths who report carrying a gun indicate that they do so for protection, which underscores the effect of violence in the home, community, and school.

Dating violence has been reported by 9% of students nationwide, with the same number reporting forced sexual intercourse (Kann et al., 2000). Black students were more likely to report dating violence, and girls were more likely to report forced sexual intercourse. Dating violence in adolescent relationships has received fairly little attention from violence researchers. Peer pressure and newly identified gender roles make violence in adolescent dating relationships unique. Predictors of dating violence are the same as the predictors of other types of adolescent violence.

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Violence Predictors

Many theories about the cause of child and adolescent violence have been proposed, but it is possible that there are several risk factors and causes of juvenile violence. Researchers have explored both individual and societal factors affecting violent behaviors in children and adolescents.

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Exposure to Violence

Exposure to violence has been shown to have a dramatic effect on children, sometimes causing both emotional scars and violent or delinquent behavior. Children encounter violence in their homes, on the streets, and in their schools. They see images of violence on television, in video games, and in the movies. Children see more than 12,000 violent acts per year on television, some of which are on programs designed for children (Tolmas, 1998). Nationwide, more than 40% of students watched television more than 2 hours per day (Kann et al., 2000).

Video games are the preferred leisure activity for many children and adolescents, yet 80% of today’s most popular video games contain violence (Vessey & Lee, 2000). The latest video games have greater sophistication and realism and, unfortunately, increasingly violent themes. Many studies support the relationship between playing violent video games and subsequent aggression and violence (Vessey & Lee), though not all research suggests a direct correlation between violent video games and violent behavior.

The majority of children are exposed to violence at some level, and this exposure has been directly correlated to the attitudes approving of violence as well as violent behavior (Owens & Straus, 1975). The bulk of the research examines violence in children’s homes, but a growing body of literature explores a similar negative effect of violence in the community on children. Living in a violent community creates stress and depression in children and is a significant predictor of aggressive acting-out behaviors, particularly among males (O’Keefe, 1997).

Children who have been exposed to violence are at a greater risk of becoming violent offenders themselves (Widom, 1989). Both exposure to violence and being the victim of violence are associated with children’s aggressive and violent behaviors (Cauffman, Feldman, Waterman, & Steiner, 1998). Some children are exposed to violence and don’t become violent offenders; however, exposure to violence as a child is a contributing factor to attitudes supporting the use of violence in personal relationships (Owens & Straus, 1975).

Flannery, Singer, and Wester (2001) compared dangerously violent adolescents with a sample of nonviolent adolescents and found that dangerously violent adolescents reported higher levels of exposure to violence and victimization. Dangerously violent adolescents were adolescents who reported attacking someone with a knife or shooting at someone within the past year. Adolescents who engaged in shooting and/or attacks with a knife were more likely to be witnesses or victims to violence in their homes, their neighborhoods, and at schools (Flannery et al.).

O’Keefe (1997) found that exposure to community and school violence alone is sufficient to predict aggressive behaviors in boys. For girls, only exposure to school violence was a significant predictor of aggression. Youths who also experience violence in their homes are at the greatest risk for developing aggressive acting-out behaviors.

“Childhood victimization increases arrests for violence among males and females, but in different ways” (Widom & Maxfield, 2001, p. 4). Their research found that abused and neglected girls were at increased risk for violence and arrest as juveniles and adults. Boys who were abused and neglected were not more likely than other boys to be arrested at least once. However, abused and neglected boys were more likely to have a significantly larger number of arrests for violence than nonabused boys. Physically abused children were more likely to be arrested for a violent crime than children who were sexually abused or neglected (Widom & Maxfield).

Exposure to violence not only increases the risk that a child or adolescent will behave in a violent or aggressive manner but also is related to significant stress, depression, and other mental health disorders in children (Cauffman et al., 1998;Veenema, 2001). Depression, stress, and mental health disorders may then increase the adolescent’s risk for violent and aggressive behavior. Adolescents who engage in aggressive behaviors have higher levels of posttraumatic stress disorder and depression than nonviolent adolescents (Cauffman et al.). Messer and Gross (as cited in Flannery et al., 2001) also found that depression is associated with the risk of aggressive behavior among younger children.

Flannery et al. (2001) found that dangerously violent females were more likely to score in the clinical range of depression, anxiety, posttraumatic stress, anger, and dissociation than nonviolent females and violent males. The suicide potential of these dangerously violent females was also significantly higher. Flannery et al. further found that dangerously violent adolescent males were significantly more likely to exhibit clinical levels of anger, dissociation, and posttraumatic stress than the adolescent males in the control group. Educational problems, such as extremely low IQ scores and reading ability, occupational difficulties, prostitution, and alcohol abuse, are also consequences of childhood victimization (Widom & Maxfield, 2001).

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Societal Approval of Violence

Children learn that violence is acceptable in some situations not only through exposure to actual violence but also through observing the approval of violence. Research has consistently found significant portions of the population approving of violence in specified contexts, including some adolescent peer relationships (Baron, Straus, & Jaffee, 1988). This legitimate violence is defined as socially approved use of force to cause pain or injury. Although the use of force in a variety of contexts is often appropriate, the use of force is generally not unconditionally approved. For example, a national survey found that 92% of the respondents approved of disciplining children by hitting or spanking them (Blumenthal, Chodiha, Cole, & Jayaratne, 1975).

Blumenthal et al. (1975) also found that 65% of the respondents approved of the use of a belt or a paddle to discipline children, and 29% approved of spanking a child until he or she could not sit down.

Early studies found no relationship between approval of violence and rates of violent behavior (Ball-Rokeach, 1973). More recent research, however, links legitimate violence with rates of violent behavior (Baron et al., 1988;Dibble & Straus, 1980). Although connections between approval of violence and rates of violent behavior have been established, little is known about the reasons why people approve of violence. One study of 3,357 middle and high school students in an Indiana community found that several hundred students consistently approved of the use of violence in domestic and peer relationships. In addition, the majority of students surveyed indicated approval of violence in some contexts where its use is not only socially inappropriate but also illegal (Daane, Carson, Brown, & Nead, 1991). Students most strongly approved of the use of violence for self-defense, but they also supported the use of violence for status maintenance, conflict resolution, and punishment. Use of violence was most strongly supported by middle-school students.

Children learn the use of legitimate violence from many sources. Students are exposed to violence-condoning attitudes in the school environment through corporal punishment and through teacher behavior. According to the U.S. Department of Education, corporal punishment in schools has been banned in only 27 states. Nearly half a million children received corporal punishment during the 1996-1997 academic year (Shidler, 2001). In addition to teacher or administrator use of violence, Shidler suggests that teachers’ lack of action when they observe verbal taunts, pushing, shoving, and other types of physical contact between students teaches children that the behavior is sanctioned by the teachers. This implied approval of violence teaches a destructive type of conflict management.

In a 1995 survey of nearly 600 teachers (Shidler, 2001), Shidler found that many of the teachers suggested that some violent behavior is acceptable under certain circumstances. This societal approval of violence reinforces violent behaviors and often leads to more violence (Dibble & Straus, 1980;Widom, 1989). Children learn violence through interaction with their family, peers, and teachers. Children’s observations of violence as well as their observations of the lack of consequences for violent behavior may reinforce their beliefs in the acceptance of violence and their use of violence.

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Low Self-Esteem

Self-esteem is closely linked to violence in several ways. Exposure to violence negatively affects a child’s mental health, including self-esteem. Self-esteem is also a factor in the use of violence. Children and adolescents with low self-esteem may be more likely to engage in aggressive and violent behavior than children who have positive feelings about themselves (Lowenstein, 1994).

A Canadian study found that the most aggressive children were more likely to describe themselves as less happy than the other children. They found the very aggressive girls and boys were more likely than the other children to report feeling miserable, feeling left out at school, having trouble enjoying themselves, and having a negative self-image (Sprott & Doob, 2000).

Sprott and Doob also found that the very aggressive children were more likely than other children to have negative relations with family and friends and more likely to feel rejected by their parents and treated unfairly by their teachers. The aggressive children were more likely to be made fun of and be bullied by other children than the children with lesser scores on aggression.

Low self-esteem is believed to have a relationship with both relational and predatory violence. Relational violence refers to violence that arises from interpersonal disputes between family members, friends, and acquaintances. Predatory violence refers to violent behaviors performed to obtain some gain or as a part of a pattern of criminal behavior. Relational violence is more common in children and adolescents than predatory violence (Ellickson & McGuigan, 2000).

There may be a stronger correlation between low self-esteem and violence in girls than in boys. Ellickson and McGuigan (2000) found that low self-esteem predicted both relational and predatory violence, however, adolescent girls were more vulnerable to low self-esteem, and girls who exhibited low self-esteem as early as grade 7 were more likely to engage in relational violence 5 years later.

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Gender and Grade in School

Research indicates that gender and grade in school may be predictors of school-related violence. Males were more likely to be involved in violence and violence-related behavior and were more likely to be threatened or injured with a weapon on school property than females (Hill & Drolet, 1999). Males were significantly more likely to be involved in fighting behavior than females, both on and off school property (Kann et al., 2000). This finding supports previous YRBS findings and other research that males are involved in physical fights more often than females (Hill & Drolet). Male students were also significantly more likely than female students to have carried a weapon or gun to school, as shown in Table 3 (Kann et al., 2000).

Table 3
Table 3
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Hill and Drolet (1999) also found that students in lower grades at school participate in and are victims of violence more often than older students. Kann et al. (2000) had similar findings in the 1999 YRBS, which is consistent with the strongest support of violence by middle school students in the study by Daane et al. (1991). Students in grade 9 were more likely to report being in a fight than were students in grades 11 or 12. This finding supports previous YRBS findings and other research that students in the lower grades are involved in physical fights more often than students in upper grades (Hill & Drolet). Table 4 compares physical fighting behavior by sex and grade.

Table 4
Table 4
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Alcohol, Drug, and Tobacco Use

Alcohol, drug, and tobacco use among adolescents plays an important role in interpersonal violence and delinquency. In an analysis of the 1995 YRBS, Lowry et al. (1999) found that tobacco, alcohol, and marijuana use are associated with school violence. The more substances used by students, the more school violence-related behaviors and victimization. “The likelihood of involvement in school violence was greater among students who reported use of a substance on school property, lower among those who used a substance only off school property, and lowest among those who did not use a substance at all.” (Lowry et al., p. 353).

Studies of youth from grade 6 through 12 in California show that both self-reported substance use and perception of frequency of substance use on school property were significantly associated with school violence (Furlong, Casas, Corral, Chung, & Bates, 1997). Substance use at school was associated with being both the victim of violence and an aggressor.

In addition to substance use, Lowry et al. (1999) found that the mere availability of illegal drugs on school property was associated with school violence. Students who reported that it was possible to obtain drugs at school were more likely to also report being the victim of a violent crime at school, seeing another student with a weapon, and being concerned about their safety at school. Ellickson and McGuigan (2000) found that adolescents who attended middle schools with relatively high levels of drug use among the student population were more likely to engage in violence in high school.

Illegal drugs are fairly easily available to older adolescents. More than 90% of high school seniors in a 1998 nationwide study reported that marijuana would be easy to get, compared with 51% of 8th-grade students and 78% of 10th-grade students (Maguire & Pastore, 1999). Fewer students found other drugs as readily available as marijuana. Younger students were more likely to report drug activity at school to the proper authority. Seventy-eight percent of 12-year-old students indicated that they would report someone selling drugs at school, whereas only 26% of 17-year-old students would report such behavior (Maguire & Pastore).

Ellickson and McGuigan (2000) found that attending a middle school with high levels of cigarette and marijuana use was linked to subsequent violence and therefore was an early predictor of adolescent violence. “The greater the frequency of one’s own drug use during middle school and the higher the perceived level of drug use among one’s peers, the greater the likelihood of frequent predatory violence” (Ellickson & McGuigan, p. 8). Cirillo et al. (1998) found that students who used drugs or alcohol and fought in school were more likely to believe that using violence was an acceptable means of resolving conflict than were students who did not engage in those behaviors.

Alcohol use among adolescents is clearly more common than other drug use. Nationwide, 81% of students reported having had at least one drink of alcohol during their lifetime (Kann et al., 2000). Half of all students nationwide had had at least one drink of alcohol during the 30 days preceding the survey, and nearly one third had at least five drinks of alcohol on one or more occasions during the 30 days before the survey. Older students reported more drinking overall, and males reported more episodic heavy drinking.

Nationwide, more than 47% of students have used marijuana during their lifetime and more than one fourth have used marijuana at least once during the 30 days before the 1999 YRBS survey (Kann et al., 2000). Overall, male students reported more marijuana use than females. Fewer than 10% of the students in the YRBS for 1999 reported using cocaine, heroin, methamphetamine, or steroids. Nearly 15% of students, however, had sniffed glue, breathed the contents of aerosol spray cans, or inhaled paints or spray to get high. Younger students more commonly reported inhalant use.

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Aggressive Behavior of Young Children

Aggressive and acting-out behavior of young children has also been linked to delinquency and violence as the child reaches adolescence. A study by Tobin and Sugai (1999) attempting to predict violent behavior in high school examined discipline referrals for sixth-grade students. Students who were referred for fighting in the sixth grade were also referred for fighting in the 8th grade.

The frequency of referrals in the sixth grade was also a predictor of chronic discipline in late middle school. Boys referred for fighting more than twice and girls referred as few as once for harassing behavior were more likely to drop out of school before graduation (Tobin & Sugai). Poor performance in middle school, as well as acting out, predicts violent behavior.

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Subculture Influence on Delinquency and Violence

Many researchers studying violence suggest that there is a subculture of violence that supports violent values and attitudes and uses group pressure to encourage adolescents to use violence (Wolfgang & Feracutti, 1967, as cited in Bernberg & Thorlindsson, 1999). However, more recent research suggests that violence exists as part of a broader subculture of delinquency, with violence-oriented values predicting not only violence but also other types of delinquency (Bernberg & Thorlindsson). Theorists believe that adolescents are more likely to engage in delinquent and violent behavior as they become more involved in peer culture and associate in groups that use alcohol and illegal drugs and participate in delinquent activity, such as vandalism. Violence is learned and developed through peer interaction in the same manner as other forms of delinquency.

Conventional institutions, such as family and school, may deter delinquent and violent behavior through conventional values and beliefs. Adolescents who engage in delinquent and violent activity are more likely to have weak ties to family and school and thus stronger ties to the delinquent peer subculture. When social control mechanisms breakdown, adolescents become more vulnerable to delinquent subgroups (Bernberg & Thorlindsson, 1999).

Bernberg and Thorlindsson (1999) found that adolescents who engage in violent activity are likely to engage in other forms of nonviolent delinquency. However, they also found violence more strongly related to illegal activities than to smoking or alcohol use.

Although violence may be an outcome of subcultural preferences of the peer group, it is likely to be a general subculture of delinquency that includes violence more than a subculture of violence. Peer groups have a stronger influence on less serious delinquent behavior, such as smoking and alcohol use, than on illegal activities or violence. Smoking and drinking alcohol may be more acceptable to the peer group than violence because violence may be disruptive and potentially harmful to the group itself (Bernberg & Thorlindsson, 1999).

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Implications for Juvenile Violence Prevention and Intervention

Exposure to violence is a critical factor in child and adolescent violence. Because violence in the home is generally a child’s first exposure to violence, prevention efforts must address family violence through a variety of programs. At-risk families should be provided with community resources, as well as conflict-resolution and parenting skills, ideally before abuse occurs. Societal attitudes about violence and victim blaming must be challenged, and perpetrators of family violence must be held accountable (Office of Juvenile Justice and Delinquency Prevention, 2000).

Children exposed to violence in their homes generally experience violence before starting school; therefore, programs addressing children’s exposure to violence must start early in a child’s schooling. Children who are exposed to violence in their homes are forced to cope with the fear, anger, and hopelessness, all while undergoing crucial developmental tasks (Office of Juvenile Justice and Delinquency Prevention, 2000). The need for early prevention and intervention programs is also indicated by research that shows that violence predictors are already present by middle school.

Both violence prevention and intervention programs for children must recognize the developmental stage of the targeted children. Programs for younger children must be presented in a manner that younger children can comprehend. Programs for adolescents must recognize their needs for increased independence and the pressures that come with being an adolescent. Violence-prevention programs aimed at younger adolescents should also address academic performance and behavior problems, because these are often the first indicators of future violence.

Violence-prevention measures must also address the indicators of violence and not just the violent behaviors. Although the link between drugs and violence does not necessarily mean that drugs lead to aggressive behavior, research does indicate that a small group of serious and violent juvenile offenders are also serious drug users who account for a disproportionate amount of all serious crimes committed by delinquents (Vanderwaal, McBride, Terry-McElrath, and VanBuren, 2001).

Successful prevention programs must address the connection between drugs, alcohol, cigarettes, and violence through offering substance-abuse education and violence-prevention skills simultaneously. Reducing drug use in middle school may not only prevent those children who would use drugs from becoming violent drug users but also reduce the overall levels of drug use in the school, which in itself may reduce the risk of violence.

Prevention programs should also be targeted for specific times. Crime statistics indicate that juvenile violent crime peaks twice during the school day and once on nonschool days. The highest level of violent crime by juvenile offenders on school days is immediately after school. Juvenile violent crime also peaks at about 10 p.m. each day (Office of Juvenile Justice and Delinquency Prevention, 1999). Juvenile violence-prevention programs should also be geared toward high violence times of year. School-associated homicide rates are usually highest near the start of fall and spring semesters (U.S. Department of Health and Human Services, 2001).

The difference in levels of violent and aggressive behaviors between males and females indicates that different strategies and techniques should be used in developing programs for boys and girls. Low self-esteem and exposure to school violence may be more important for girls than for boys. Although boys who are exposed to violence in the home may be more prone to violent behavior, particularly in relationships, the family violence literature suggests that girls exposed to family violence become victims again in dating and marital relationships. Targeting boys for prevention and intervention programs because there is an indication that boys are more likely to engage in violence and violence-related behaviors may ignore the fact that girls exposed to violence suffer serious consequences.

The fact that youths who carry guns report that they are easy to find and that they carry them for protection indicates the need for weapon awareness education, not only for the juveniles but also for those who can legally obtain guns and supply them to juveniles. Efforts to make children’s homes, schools, and communities safer may help keep firearms and other weapons out of the hands of juveniles.

Prevention and intervention programs must reflect the needs of the children, the community, the school, and the family. Successful programs are flexible and based in knowledge of the problem of violence and violence-related behaviors among youths. Prevention and intervention programs must be comprehensive programs looking at the child or adolescent as a whole person, not just isolating one problem behavior. Intervention programs must address specific issues presented by each individual child. Individual counseling may need to be offered along with interpersonal skills training, conflict-resolution classes, self-esteem enhancement, problem-solving skills, and substance-abuse education. Successful prevention and intervention programs cannot be one-size-fits-all programs, they must fit varied needs and problems they are intended to address.

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References

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© 2003 National Association of Orthopaedic Nurses

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