Report on Community Forums -
Youth Violence and Public Health

Overview of Community Forum

On January 17, 2001, David Satcher, M.D., Ph.D., then United States Surgeon General, released the landmark report Youth Violence: A Report of the Surgeon General.  This first report of the Surgeon General to focus exclusively on the topic of youth violence and its prevention reviews what is known about youth violence from a public health perspective and summarizes the state of the science about this problem and how to address it.  The report confirms that to be most effective, youth violence prevention approaches must be comprehensive and require action at the school, family, and community levels.

To examine the usefulness of this report and to affirm the importance of evidence-based youth violence prevention programs at the local levels, the Surgeon General utilized a regional planning approach and convened a series of community-based forums in four cities across the country:  Atlanta, Georgia; Chicago, Illinois; Los Angeles, California; and Philadelphia, Pennsylvania. The forums, all hosted by the United States Public Health Service Regional Health Administrators, provided an important vehicle for understanding public reactions to the report and for helping shape future directions in youth violence prevention.

Attendees

Those invited to attend the community forums included representatives from community-based, nonprofit organizations; staff of colleges and universities; local school personnel; researchers; judges and other juvenile justice and law enforcement officials; clergy and members of faith-based organizations; providers of mental health services; representatives of Federal, State, and local governments; child welfare staff; children, youths, and their families; representatives from the business community; and others concerned with youth violence.  Forum participants offered comments on the report and made recommendations for addressing the diverse issues related to youth violence.  In addition, each forum featured panel presentations by regional experts in violence prevention and representatives of community-based organizations working to implement evidence-based violence prevention strategies.  These sessions were held in both November and December 2001. Greeting by Dr. Satcher

Launching each forum, former Surgeon General David Satcher thanked the participants for attending and for focusing on the critical topic of youth violence prevention.  He explained that the impetus for this report emerged from the April 1999 Columbine High School tragedy that resulted in the deaths of 14 students.  Advancing the seminal efforts of former Surgeon General Everett C. Koop to address youth violence prevention from a public health perspective, this report summarizes the research about youth violence, its causes, and its prevention.  This scientific review of the literature strongly supports the main conclusion of the report: that our Nation does possess knowledge about youth violence and has translated that knowledge into programs that effectively prevent serious youth violence.  Only a few years ago, many leading experts involved in the study and treatment of youth violence came to a contrasting conclusion.  Yet, the past two decades have revealed the sustained, positive efforts of countless researchers, legislators, and others who labor to understand and to address the problem of youth violence.  Although much remains to be learned, tremendous accomplishments have been achieved.  We now know that violence is a problem of our entire Nation, not just our cities, isolated rural areas, or any one segment of society.  Essentially, no community is immune from violence. However, by adopting a public health perspective, we know that youth violence can be prevented.  However, our Nation must make a commitment to seriously monitor youth violence, to examine the major risk and protective related to youth violence, and to develop culturally and developmentally appropriate, research-based interventions to mitigate risk factors and enhance protective factors.

Dr. Satcher offered specific questions that one must consider when using the public health approach to problem-solving:

• How do we define the problem?  What is its nature and magnitude?  How many people does it affect?
  
  
• What is the cause of the problem?  What factors predispose a person to victimization? What factors protect one from becoming a victim?
  
  
• How can we intervene?  What works?  How can we prove that a certain intervention actually makes a difference?
  
  
• How do we organize programs in communities that will help implement an intervention?

He also explained that the most difficult challenges facing youth violence prevention practitioners include not only how to develop the best science to combat the problem but also how to translate that science into effective programs in the community.  He expressed his hope that the community forums would serve as opportunities for individuals and organizations to share information about model programs and best practices and to learn from each other.  He concluded by acknowledging his indebtedness to the countless numbers of people who value our Nation's priceless youth and who recognize the importance of peace and security in the lives of all young Americans.

Keynote Presentation at the Four Community Forums

Delbert S. Elliott, Ph.D., Director of the Program on Problem Behavior and the Center for the Study and Prevention of Violence of the Institute of Behavioral Science at the University of Colorado at Boulder, was the senior scientific editor of Youth Violence:  A Report of the Surgeon General.  Because of his expertise and intimate involvement in the development of the report, Dr. Elliott stated the facts and provided  a synopsis of how it was developed and an overview of the key findings. He also framed issues left unresolved by the report, which was somewhat limited in its scope.

Scope of the Report

Dr. Elliott explained that the Surgeon General's report was completed within a period of six months.  Because of this limited time frame, a number of broader issues related to youth violence, such as youth victimization and the continuity of youth violence into adulthood, could not be covered.  The report focuses on interpersonal violence, which is defined as such serious forms of violence as aggravated assault, forcible rape, armed robbery, and homicide.  The report does not address aggression, aggressive behavior, and antisocial behavior directly but does include them as risk factors for the more serious forms of violence.  Because this report was viewed as a beginning rather than an ending, Dr. Elliott encouraged participants in the community-based forums to ask detailed questions about the report and to identify specific issues that the report did not include, but that may be of interest for future consideration.

Dr. Elliott stated that the report was developed using a multidisciplinary knowledge base; that is, it draws from research studies in public health, psychology, criminology, education, and other related fields.  In defining an effective strategy for prevention, the authors used two criteria:  (1) evidence of the application of rigorous methods of inquiry and (2)  the existence of sufficient data to support major conclusions.  The report did not rely on any single study for its conclusions.  Rather, it based its analyses on findings replicated in several studies that have produced consistent results and no contrary outcomes.  Dr. Elliott emphasized that prevention strategies for which there is no research evidence were not included.  He encouraged attendees to increase their efforts to meet the challenges involved in obtaining research-based evidence for interventions that they consider to be effective.  Programs should not be used based on popularity and convenience.

Key Messages Confirmed by the Findings

Dr. Elliott summarized the three key messages of the report as follows:

• Caution-Americans cannot afford to become complacent; the youth violence epidemic is not over. Although it is good news that since 1993 declines in key markers of serious youth violence have been authentic, self-reports indicate that the proportion of youth involved in violent behavior and the rate of violent offenses have not declined since the peak years.  There is considerable evidence that youth involvement in serious violent behavior has been stable over time and remains a serious national problem.



• Optimism-Our Nation is well past the "nothing works" era regarding efforts to reduce and prevent youth violence. The scientific community has been successful in developing knowledge and tools to prevent serious violence and/or in eliminating major risk factors for violence.  Because these studies have met rigorous scientific standards, selected intervention methods can be implemented on a national scale with a high degree of confidence.



• Major Challenge-The Nation cannot afford to use resources on ineffective interventions or strategies. Most of the violence prevention strategies and interventions currently used have neither been evaluated with rigor nor shown through evaluation to be ineffective.  Resources should be directed and redirected toward mounting effective research-based prevention programs and strategies.

He explained that the report's findings were based on a wide range of data, prevalence rates, and self-report studies in order to dispel several myths regarding youth violence prevention.

Several of these myths and the research findings that contradict them appear below.

• The epidemic of youth violence that marked the early 1990s is over, and young people-as well as the rest of society-are much safer today than a decade ago.  Although the number of lethal acts performed by youths has declined, the overall number of violent acts committed by youths has not fallen.  For example, arrest rates for aggravated assault are 70 percent higher today than they were in 1983, the first year of a decade that witnessed dramatic increases in rates of violence by young people.  Studies of self-report data, in particular, support the conclusion that the epidemic has not ended.  In addition, the number of young females involved in serious violent acts has increased significantly.
  
  
• Most future violent offenders can be identified in early childhood.  Exhibiting uncontrollable behavior or being diagnosed with a conduct disorder as a young child is not a predictor of violence in adolescence.  Most violent offenders at age 16 and 17 have no history of conduct disorders such as antisocial behavior or aggressive behavior.  One major study, for example, demonstrated that signs of these types of disorders did not appear until after the onset of puberty.



• Most children who are abused and neglected will become violent offenders.  Physical abuse and neglect are relatively weak predictors of violence.  Most children who are abused and neglected do not become violent offenders.



• African-American and Hispanic youths are more likely to become involved in violence than other racial or ethnic groups. Although there are racial and ethnic differences in homicide arrest rates, data from self-reports indicate that race and ethnicity have little bearing on the overall proportion of nonfatal violent behavior.  There are differences in the timing and continuity of violence over the life span, which account in part for the over-representation of these groups in U.S. jails and prisons.



• Getting tough with juvenile offenders by trying them in adult criminal courts reduces the likelihood that they will commit more crimes.  Youths transferred to adult criminal courts have significantly higher rates of re-offending and a greater likelihood of committing subsequent felonies than youths who remain in the juvenile justice system.  They are also more likely to be victimized physically and sexually.



• Weapons-related injuries in schools have increased dramatically in the past 5 years.  Weapons-related injuries have not changed significantly in the past 20 years.  In comparison to other environments, including neighborhoods and homes, schools are relatively safe places for young people.

Risk and Protective Factors in Youth Violence

Dr. Elliott described the methodology used by the report's authors to identify the relationship of risk and protective factors for youth violence.  Risk and protective factors are grouped into individual, family, school, peer group, and community categories.  Risk factors do not necessarily cause a child or young person to become violent, and protective factors do not guarantee that a child or young person will not become violent.  However, protective factors can reduce the probability that groups of young people facing a risk factor will become involved in violence.

Risk Factors-He noted that the report developers did not consider simple correlation adequate in designating risk factors.  Two criteria had to be met.  First, scientific evidence must point to a predictive relationship between the risk factor and later involvement in violence, and second, it must be possible to identify the causal mechanism that could account for that relationship.  Risk factors, which may not show correlation when considered separately, may have an effect when combined with other factors.

The report categorizes risk factors for violent behavior by youths into three groups: strong, moderate, and weak, and further examines these factors on the basis of the age at which they appear (i.e., before or during puberty), as shown below.

Risks occurring before or during puberty:

• Strong risk factors that appear between the ages of 6 and 11 include involvement in illegal behaviors, delinquent acts, and substance abuse.



• Moderate risk factors include male gender, low family socioeconomic status or poverty, antisocial parents, and aggressive behavior (among males).



• Weak risk factors include hyperactivity, poor parent/child relationships, particularly harsh or inconsistent discipline, weak social ties to conventional adults or children, involvement in a range of problem behaviors, and exposure to television violence.  Several other factors that have a weak predictive relationship with later violence include poor school performance, poor attitudes toward school, low IQ score, dishonesty, coming from a broken home (divorced, separated, or never married parents), and abusive and neglectful parents.

Risk factors occurring in ages 15 to 18:

• Strong predictors of violence that emerge after the onset of puberty include weak social ties to conventional others, antisocial or delinquent peers, and involvement in a gang.
  
  
• Moderate risk factors include general offenses similar to those found in the younger age group, such as illegal behaviors and delinquent acts. 



• Weak predictors include aggressive behavior (in males only), poor school attitudes and performance or academic failure, poor parent/child relationships, and such psychological conditions as restlessness, difficulty concentrating, and risk-taking behavior.  Family-related risk factors are clearly less important than those related to peer groups in early adolescence.  After the onset of puberty, substance abuse is a weak predictor of violence.  The greatest predictor for involvement in serious violence is selling drugs, not using them.

Experimental studies found that the media have a significant, though small and short-term effect on youth violence.  There is relatively little consistent evidence that exposure to violence in the media has any long-term effects on serious forms of youth violence.  In addition, little research exists on the effects of other forms of media violence, such as that portrayed in video games, music videos, and the Internet.  Experimental studies do find a strong relationship between exposure to television and film violence and short-term (i.e., within 1 to 4 hours of exposure) aggression, such as shoving, pushing, and some hitting.

Protective Factors-Dr. Elliott noted that although most research defines a protective factor simply as the opposite of a risk factor, the report draws on concepts from resilience literature to define a "protective factor" as a condition that buffers one's exposure to risk.  The evidence indicates that commitment to school is the strongest buffer effect for serious forms of violence and for other forms of problem behaviors.  Children with a strong attachment and commitment to schools  are protected somewhat from exposure to other kinds of risk factors. Positive  attitudes and rejection of deviant kinds of behavior are individual protective factors both for violence and for problem behaviors.  Although a high IQ is a buffer against antisocial behavior, there is no evidence that it is a buffer for serious violence.  A positive social orientation is a protective factor against antisocial behavior.

Dr. Elliott remarked that although neither race nor ethnicity was identified as a protective factor, both of these variables do serve as "risk markers," a term that refers to an indicator that captures clusters of risk factors but that has no causal effect in and of itself.

Effective Violence Prevention Strategies

In the identification of best practices, Dr. Elliott explained that the report relied heavily upon recently published reviews of the literature on violence prevention and focused on strategies and programs with demonstrated results on youth violence and its major risk factors.  Although rapidly growing, this field of research is still relatively young.  Limited evaluation data are available for many strategies and programs.  Subsequently, the absence of a particular strategy or program does not imply that it is ineffective, but rather that the information available is insufficient to justify any conclusions about its effectiveness.  Strict criteria were applied to the selection of violence prevention strategies identified as effective in the Surgeon General's report.

Dr. Elliott explained that in the report, effective prevention programs are divided into two groups: model programs and promising programs.  The criterion for designation as a model program required a rigorous experimental or quasi-experimental design and evidence of significant deterrent or prevention effects on violence or serious delinquency.  Model programs also were required to have been replicated at multiple sites, ideally with independent implementers, and to have demonstrated sustainability for at least 1 year.  Dr. Elliott briefly described some of the programs featured in the report, including the Seattle Social Development Project, the Midwestern Prevention Project, and the David Olds Nurse Visitation Program.  He reminded attendees that a more detailed description of these programs could be found in the actual report at www.surgeongeneral.gov.

Promising programs had to exhibit at least two of the criteria used in identifying model program conditions, that is, a quasi-experimental or a rigorous experimental design, with evidence of prevention or deterrent effects and of replicability or sustainability.  Dr. Elliott briefly described some promising Head Start programs cited in the report, including the Perry Preschool Program and the Syracuse Family Development Program.

Effective violence prevention strategies were divided into three categories: primary prevention, secondary prevention, and tertiary prevention.  True prevention or primary prevention, as defined in this report, refers to lessening the likelihood that youths in a treatment or intervention program will initiate violent behavior, compared to youths in a control group.  Prevention programs target youths who have not become involved in violence or who have encountered specific risk factors for violence.

The report identified the following strategies as effective for primary prevention.  They are implemented on a universal scale with the goal of preventing the onset of youth violence and related risk factors.

• Skills and competency building programs
• Behavior monitoring and reinforcement
• Behavioral techniques for classroom management
• Building school capacity
• Continuous progress programs
• Cooperative learning
• Positive youth development programs.

The evidence suggests that contextual programs, such as building school capacity and using behavioral techniques for classroom management, are often more effective than are individual treatment strategies because the former affect the entire social climate.

Effective strategies for secondary prevention are implemented on a selected scale for children at enhanced risk of youth violence, and aimed at preventing the onset and reducing the risk of violence.  Programs targeting families of high-risk children are most effective in preventing violence, and many of these programs are included in this secondary prevention category:

• Parent training programs
• Nurse home visitation programs
• Compensatory education
• Moral reasoning
• Social problem-solving
• Thinking skills.

Effective strategies for tertiary prevention programs target young people who have already demonstrated violent or seriously delinquent behavior.  Research conclusions in this area found that effective treatment can divert a significant proportion of delinquent and violent youths from future violence and crime and that tremendous variability exists in the effectiveness of different types of programs for seriously delinquent youths.  Intervention programs for those young people already violent include:

• Social perspective training, role playing
• Multimodal interventions
• Behavioral  interventions
• Skills training
• Clinical marital and family therapy
• Wraparound services.

Ineffective Violence Prevention Strategies

Several popular approaches to preventing continued criminal behavior in delinquent youths have been demonstrated to be consistently ineffective.  Those shown to be ineffective for primary prevention include peer counseling, peer mediation, peer leaders, and peer-based programs.  Retaining a student at a grade level without promotion to a succeeding grade likewise is ineffective.  Ineffective secondary prevention strategies include gun buy-back programs, arms training, mandatory gun ownership, and positive peer culture programs, such as redirecting youth behavior and shifting peer group norms.  Ineffective tertiary prevention strategies include boot camps, residential programs, milieu treatment programs, behavioral token programs, waivers into adult courts, social case work, and individual counseling.  Dr. Elliott did note, however, that individual counseling has been shown to be effective with non-institutionalized individuals who are already seriously delinquent.

Cost Effectiveness

Violence costs the United States an estimated $425 billion in direct and indirect costs annually.  Dr. Elliott emphasized that the most logical way to reduce costs associated with violence is to prevent violence altogether.  The report provides an overview of comparative costs and benefits of various prevention and intervention programs with respect to benefits.  Overall, these analyses underestimate the benefits of prevention programs because of failure to consider the indirect benefits of preventing serious or violent offenses, including increased work productivity, reduced welfare assistance, and reduced victim medical costs.

Summary of Report Recommendations

Dr. Elliott concluded his presentation with a summary of the eight key potential next steps for preventing youth violence.  Although not policy recommendations, these action steps can chart a vision for the future built on the information possessed today.  These action steps can be used to engage an expanding base of citizens willing to accept the challenge of addressing the problem of youth violence.

• Continue to build the science base for violence prevention-Research that has been appropriately designed and conducted offers a factual rather than opinion-based framework for proposing and debating social policy that will influence the direction of youth violence prevention.  People with diverse interests must have a voice in identifying urgent research questions.  They, in turn, must be informed about the conclusions drawn from research.



• Take measures to accelerate the decline in gun use by youth-Steps must be taken to understand the dramatic decline in possession and use of guns since the 1993 peak of the violence epidemic.  Additional research is needed to answer questions about what happened in communities to reduce the frequency in gun use.  Otherwise, data suggest a return to lethal violence could occur if youths return to carrying and using guns in violent encounters.



• Facilitate the entry of youth into effective intervention programs rather than incarcerating them-New evidence supports the cost effectiveness of intervention programs that reduce the likelihood of repeat offenses by youth.  Because these programs are not available in every community, special efforts must be employed to increase awareness so that youths can be reclaimed from violent lifestyles, thus reducing the burden on the criminal justice system.



• Disseminate model programs with incentives that will ensure fidelity to the original program design-Experience confirms that intervention programs effective in their original sites do not yield uniform outcomes when replicated elsewhere.  Evaluators found that subtle modifications introduced into model programs create these inconsistencies.  Therefore, incentives must be developed to ensure the integrity of model programs when they are replicated.



• Provide training and certification programs for intervention personnel-Guaranteeing a well-trained staff that understands specific interventions and their limitations represents an ongoing challenge when implementing effective programs on a national scale.  The supply of appropriately trained individuals to do this work could be enhanced with the establishment of formal training and university-certified programs.



• Improve public awareness of effective interventions-All those concerned with youth violence prevention (advocacy organizations, child and family serving systems, government officials, private businesses, etc.) need to be educated regarding existing effective and promising interventions.  Media campaigns offer a strategy for providing this education.



• Convene youths and families, researchers, and representatives of private and public organizations for periodic youth violence prevention summits-With the move to a public health approach to youth violence prevention, new players and new partners will be involved.  Currently, there is no common forum for all parties to exchange information.  This issue could be addressed with a periodic, highly visible national summit that receives specialized media coverage as a method to disseminate information on new research findings, effective programs, and other related information for diverse audiences.



• Improve Federal, State, and local strategies for reporting crime information and violent deaths-The accuracy of national statistics would be enhanced with an increase in the number of agencies reporting data to the FBI's Uniform Crime Reports Program.   This strategy would require the development of a standard set of questions for national self-report surveys.

Dr. Elliott concluded his presentation by emphasizing that political issues may supersede financial issues as the real challenges to designing and implementing programs to reduce the rates of violence, crime, and drug use in the United States.  The most critical risk factor for violence in children is the behavior of their peers.  Therefore, it is imperative that parents and families know their children's friends and encourage healthy relationships.  School administrators and teachers must be attentive to the social climate in schools and acknowledge the problems observed.  Communities should implement programs that combine components to address both individual risks and environmental conditions.  Program effectiveness depends as much on the quality of the implementation as it does on the type of intervention.  Many programs are ineffective, not because their strategy is misguided but because the quality of implementation is poor.  There is a need for more research in all domains of public health, but the good news is that violence is not an intractable problem.

Summary of Key Themes and Ideas from Public Testimony

Each of the four community forums featured a public testimony session during which individuals offered personal and/or organizational perspectives on the report and presented recommendations for addressing the violence in their communities.  Although the testimony at each session differed, several overarching themes and ideas were consistent throughout all of the sessions.  These themes were as follows:

• Funding-Community-based groups described their difficulty in finding long-term, sustainable funding for violence prevention programs.  Many representatives of organizations expressed hope that the Surgeon General's report would  help them leverage funding at the State and local levels.  They are particularly eager to secure funding that will enable them to carry out the rigorous scientific evaluations documented as essential in the report.



• Collaborative Efforts-Community-based collaborative violence prevention efforts received strategy endorsement from presenters for their effectiveness.  Important ingredients for success noted by presenters include: involvement of families, schools, law enforcement agencies, physical health agencies, mental health professionals, faith-based communities, businesses, and other nonprofit and/or community-based organizations, and use of a comprehensive approach.  The federally funded Safe Schools/Healthy Students Initiative consistently received positive comments at all four community forums and included representation at each of the sessions.  This newly created interdepartmental effort, supported by the Departments of Education, Justice, and Health and Human Services, is viewed as a model for community collaboration.



• Implementation Challenges-Concerns were expressed frequently about how to ensure fidelity when replicating model programs on the local level. Participants requested additional funding, technical assistance, and research on the core components of programs in order to ensure the retention of critical elements when the programs are replicated in new and culturally diverse communities.



• Effective Programs-Commentators  frequently raised issues about programs and strategies that seem to be working at the local level but that are not cited as effective in the Surgeon General's report.  Dr. Elliott reiterated the high scientific standards used by the scientists whose work was included in the report.  He explained that although programs may seem effective, and indeed may be working, they could not be included in the report if there were no rigorous scientific evidence of their effectiveness.  He explained that in a community-level study, it is difficult to create an experimental design that meets the criteria required for the report.  He again stressed that lack of rigorous scientific evidence does not mean that an intervention is not effective, but simply that researchers have not yet developed a means of evaluating it properly.



• Broad Definition of Violence-Many of those who commented recommended the inclusion of an expanded definition of youth violence.  These individuals would like to see the definition include, for example, violence against intimate partners (dating violence), suicide, and hate crimes.  Many participants also recommended that future reports address violence as it relates specifically to gay, lesbian, bisexual, and transgendered youths.

Summary of Community Forum Proceedings

Overview of Forum in

Chicago, IL
November 27, 2001

Presentations in Chicago

• Sylvia Furner, Ph.D., Senior Associate Dean, School of Public Health Administration, University of Illinois at Chicago



• Steven Potsic, M.D., M.P.H., Regional Health Administrator, Region V



• Delbert S. Elliott, Ph.D., Senior Scientific Editor, Youth Violence: A Report of the Surgeon General



• Susan Curry, Ph.D., Director of Health Research and Policy Centers, University of Illinois at Chicago



• Leslie Paige, Ed.S., Project Director, RURAL (Rural Underpinnings for Resiliency and Linkages), Hays, Kansas



• Gary Slutkin, M.D., Executive Director, CeaseFire: The Chicago Project for Violence Prevention



• Faith Covici, Principal Advisor to the Regional Health Administrator, Region V

Dr. Sylvia Furner, who partnered with Dr. Potsic in the development of the forum, welcomed participants and offered opening remarks.  She provided an overview of the youth violence efforts employed by the University of Illinois at Chicago, School of Public Health.  She invited the audience to offer comments and recommendations regarding the specific issues of youth violence that affect their communities.

Dr. Steven Potsic asked the audience to reflect on the usefulness of the Surgeon General's report, the gaps it identifies, and the steps to be taken to fill those gaps.  He reminded participants that health promotion is a local issue that is best maintained, developed, and integrated at the community and family levels.  He stressed the importance of expanding the scientific base for violence prevention, disseminating effective model programs, decreasing gun use by youths, and increasing training for all those involved in violence prevention-all documented courses of action identified in the report as potential next steps.

Dr. Delbert S. Elliott, recognized as the Senior Science Editor for the report, provided the keynote presentation on Youth Violence: A Report of the Surgeon General and responded to inquiries and comments specific to the report findings.(Refer to the Keynote Presentation, which appears in the Forum overview.)

Dr. Susan Curry moderated a panel discussion on best practices. She shared  three criteria for defining effective programs: (1) they must be systematic; (2) they must be replicable; and (3) they must include evaluation.  She urged the audience to listen to the panel presentations from this perspective.

Ms. Leslie Paige spoke about Project RURAL (Rural Underpinnings for Resiliency and Linkages) a federally funded Safe Schools/Healthy Students Initiative program site in Ellis County, Kansas.  All Safe Schools/Healthy Students projects must include six elements: a safe school environment, programs for intervention and prevention of substance abuse and violence, safe school policies, school reform, early childhood social and emotional development, and school and community mental health prevention and treatment services.  There are approximately 100 Safe Schools/Healthy Students sites in the United States, all of which are mandated to use evidence-based programs and interventions.

Ms. Paige explained that Project RURAL is a community-based model program that uses a public health approach.  Staff are organized into three teams: prevention, treatment, and intervention. The program identifies behavioral, environmental, and biological risk factors in the community.  Next, it employs a number of research-based programs, including Life Skills training, the Second Step violence prevention program, functional family therapy, a bullying prevention program, and a Big Brothers, Big Sisters mentoring program, to address them.  Project RURAL uses a universal prevention model to provide a basic foundation for all students; in addition, a treatment team provides interventions for at-risk youths and their families.  These interventions include home nurse visitation, a support group for single parents, treatment for families referred to a local mental health center, and a learning center for students who have dropped out or are at risk of dropping out of school.  Because it is part of the national Safe Schools/Healthy Students Initiative, Project RURAL has a required evaluation component with a full-time evaluator devoted to the project.

Ms. Paige described the elements that she feels are responsible for the effectiveness of this program.  They include use of a comprehensive approach; providing intervention and treatment for at-risk and high-risk individuals; use of evidence-based strategies; delivering staff development training for teachers, mental health, and law enforcement personnel; making a commitment to destigmatize mental health; placing an emphasis on linkages; and ensuring sufficient resources.

Dr. Gary Slutkin described CeaseFire, a violence prevention program that uses a strategic public health approach to promote behavior change at the neighborhood level.  The program involves local clergy, the office of the mayor, law enforcement officials, and youth-serving organizations in a comprehensive approach that includes program involvement in response to every shooting that occurs in a designated group of neighborhoods.  The goal of the program is to change cultural norms surrounding the acceptance of gun violence and to offer alternatives to violence.  The program is undergoing an evaluation that entails comparing neighborhoods participating in the project with those communities that do not participate.  Adults and youths in the targeted neighborhoods are being surveyed to determine which program components are most effective in changing behaviors and attitudes.  After the first year of implementation, the five neighborhoods covered by the program witnessed a 30 percent to 40 percent reduction in killing, and this reduction has been sustained for 9 months.  With expansion of the program to 10 neighborhoods in these communities, killings decreased by 10 percent to 20 percent in 1 year.  During this period, the overall murder rate in the city remained constant.  When CeaseFire was introduced in one to three police beats, shootings decreased by 60 percent to 70 percent.  CeaseFire's eight-point plan is available on it's Web site at www.ceasefirechicago.org .

Ms. Faith Covici thanked the panelists and invited attendees to offer public comments on the Surgeon General's report and issues related to the prevention of youth violence.

Summary of Public Testimony in Chicago

The following key ideas and themes emerged from the public testimony in Chicago:

Collaborative Efforts

• Community-based violence prevention efforts that involve schools, law enforcement agencies, health care service providers, mental health professionals, faith-based communities, businesses, and community-based organizations seem to work most effectively.  The federally funded, interagency Safe Schools/Healthy Students Initiative received several positive comments.  Many participants advocated continued funding for this initiative.



• One forum participant and representative of the Safe Schools/Healthy Students Initiative commented on the advantages of a public health approach to violence prevention.  It offers community groups an opportunity to focus on an intervention and to identify behavioral, environmental, and biological risk factors in communities.  It also enables communities to integrate strategies into daily routines that will be both sustainable and cost-effective.



• Involving more local businesses in violence prevention efforts was cited as an opportunity to offer jobs to youths and to assist them in developing meaningful life goals.

Research-Based Programs

• Representatives from community-based programs expressed a desire to see the Surgeon General's report focus more on community-level interventions and less on individual interventions.  Dr. Elliott explained that it is difficult to create a scientifically valid experimental design in a community-level study.  He also stated that the lack of attention paid in the report to community-level interventions does not mean that they are not working.  Researchers simply have not yet developed the mechanisms to evaluate these programs in a scientifically rigorous way.



• Program managers expressed concern about how to ensure fidelity to model programs when replicating them at the local level.  They requested more research to identify the core components of effective programs in order to ensure the retention of these components when the programs are replicated in different communities, for example, in areas whose residents are not of the same race or ethnicity as those in the original program.

Funding

• Finding long-term funding is a major concern for most of the representatives of the community-based groups that testified at the forum.  Representatives from many groups hope that the Surgeon General's report will help them leverage funding on the State and local levels.  They are particularly interested in being able to carry out scientifically valid evaluations of program effectiveness.

Gender Issues

• Participants recommended that future reports of the Surgeon General be expanded to address violence as it relates to gay, lesbian, bisexual, and transgendered youths.

Special Interest Concerns

• It was recommended that future reports should give detailed attention to events in pregnancy and prenatal issues as possible risk factors associated with violence.



• It was noted that the report findings needed to underscore the enforcement of existing gun laws and that the report should be used to advocate for legislation to reduce youth access to guns.



• A representative of the legal profession urged the Surgeon General to examine the research on the lack of adequately trained attorneys for youths in the justice system and to recommend that States provide youths with counsel specially trained in juvenile justice issues.

Overview of Forum in

Atlanta, GA
November 30, 2001

Presentations in Atlanta

• David Satcher, M.D., Ph.D., 16^th United States Surgeon General



• Amanda Robinson, Acting Secretary's Regional Representative, Region IV



• CAPT Joseph Iser,  M.D., Regional Health Administrator, Region VI



• CAPT Clara Cobb,  R.N., M.S.N., C.F.N.P., Acting Regional Health Administrator, Region IV



• Delbert S. Elliott, Ph.D., Senior Scientific Editor, Youth Violence: A Report of the Surgeon General



• Rodney Hammond, Ph.D., Director, Division of Violence Prevention, NationalCenter for Injury Control, Centers for Disease Control and Prevention, Atlanta, Georgia



• Vera White, Office of Minority Health, Region IV



• Kathy Dobbins and Terri Mattress, Anderson School District Five, Anderson, South Carolina



• Charlotte Gish, C.N.M., M.S.N., Regional Women's Health Coordinator, Office on Women's Health, Region VI



• Kathy Middleton, M.S.N., M.H.R., C.A.D.C., Program Coordinator, Sexual Assault Prevention Education, Oklahoma State Department of Health

Ms. Amanda Robinson, CAPT Joseph Iser, and CAPT Clara Cobb provided preliminary remarks and welcomed the participants.

Dr. David Satcher officially opened the forum.  He thanked the participants for attending and for focusing on the critical topic of youth violence prevention.  He provided an overview of the impetus for the report, the April 1999 Columbine High School tragedy.  Emphasizing that no community is immune from violence, Dr. Satcher stressed that youth violence prevention is a concern for our entire Nation.  He explained that the report addresses youth violence prevention from a public health perspective.  According to this health-oriented view, youth violence is a preventable condition, provided our Nation makes a commitment to monitor the problem, to address the major risk and protective factors related to youth violence, and to develop research-based interventions that mitigate risk factors and enhance protective factors.

Dr. Satcher presented four issue groupings that must be addressed in designing a public health approach to any problem:

• How do we define the problem? What is its nature and magnitude? How many people does it affect?



• What is the cause of the problem? What factors predispose one to be a victim of the problem? What factors protect one from becoming a victim?



• How can we intervene? What works? How can we prove that a certain intervention actually makes a difference?



• How do we organize programs in communities that will help implement an intervention?

He explained that the most difficult challenges facing youth violence prevention practitioners are not only how to develop the best science to combat the problem but also how to translate that science into effective programs in the community.

Dr. Satcher concluded by expressing his hope that the forums would serve as an opportunity for individuals and organizations to share information about model programs and best practices at the community level.  As a Surgeon General who takes pride in attending to the needs of communities, former Surgeon General Satcher welcomed comments, listened to the issues presented, and responded to the concerns of participants.

Recognizing Dr. Delbert S. Elliott as the Senior Science Editor for the report, Dr. Satcher presented him with the Surgeon General's Medallion, one of the highest honors in the public health field.  This award conveyed formal recognition and appreciation for his work on this distinguished report.  Dr. Elliott expressed his thanks for the honor bestowed upon him and then delivered his keynote presentation on Youth Violence: A Report of the Surgeon General.  With Dr. Satcher, he responded to inquiries and comments specific to the report findings and its implications for the future. (Refer to the Keynote Presentation, which appears in the Forum overview.)

Ms. Vera White welcomed Ms. Kathy Dobbins and Ms. Terri Mattress, who presented information on the Families and Schools Together (FAST) Program in Anderson, South Carolina, a project funded by a grant under the Safe Schools/Healthy Students Initiative.  This collaborative prevention and parent involvement program was developed by Dr. Lynn McDonald of the University of Wisconsin in Madison to address substance abuse, school dropout rates, and youth violence.  It addresses these problems using family-based models by strengthening the protective factor of family cohesion.  The program accomplishes this objective by replicating a sequence of activities using research-based techniques that recognize the parent's role as the primary prevention agent.  FAST activities are planned and implemented by a team of school personnel; parents; staff from the local mental health agency, drug and alcohol abuse commission, and juvenile justice department; and school nurses.

The program targets families with children who are identified as being at risk.  Families participate in multifamily meetings with collaborative team partners for a period of 8 weeks to increase feelings of affiliation with the school, the community, and other FAST families.  The FAST Program has three modules-one targeted to children in early childhood, another to elementary school students, and the third to middle school students.  This program can be implemented in an elementary school for as little as $3,000 per 8-week cycle if volunteers are used.  Employing  paid staff would raise the cost of each cycle to $6,000.  Team members receive intensive training on the model program and refresher courses each year.

A national evaluation performed at 53 sites across the country showed that teachers and parents reported statistically significant changes in the child's behavior in the home and at school, including improvement in the child's attention span and self-esteem, following completion of the program.  Family cohesion and communication improved, parent participation in the schools and in the community rose, and social isolation decreased.  The evaluation also revealed that parents who graduated from FAST continued to spend 15 minutes of one-on-one special play time with their child every night and reported stronger family relationships.

Ms. Charlotte Gish introduced Ms. Kathy Middleton, who spoke on a bullying prevention initiative implemented by the Oklahoma State Department of Health.  Ms. Middleton developed a school-based program to prevent bullying based on the work of Norwegian researcher Dr. Dan Olweus.  This program is predicated on the belief that bullying is not normal peer conflict but the exploitation of a less powerful person by an individual who is taking unfair advantage.  It uses interactive exercises to teach school faculty to understand the differences between bullying, teasing, and normal peer conflict and helps them recognize that bullying is a form of violence.

This bullying prevention program encourages parent meetings that are designed to help participants understand bullying and learn how to model positive behavior at home.  It encourages teachers to work with students, to post antibullying rules in classrooms, and to hold class meetings to discuss how to deal with bullying.  Ms. Middleton provided findings from an Oklahoma middle school involved in this program that demonstrated a yearly incremental reduction in suspensions for fighting, from 114 in 1998 to 16 in 2001.  She described the impact of this program in terms of reduced bullying problems, vandalism, theft, drunkenness, fighting and discipline disruptions, as well as increased student morale and safety.

The Violence Against Women Act block grant funds these programs.  It mandates that students between the ages of 10 and 18 receive assault prevention education.  The program has reached an estimated 5,000 teachers in 65 school districts.

Summary of Public Testimony in Atlanta

The following key ideas and themes emerged from the public testimony in Atlanta:

Funding

• Organizations and local communities will need technical assistance and training in grant writing in order to become proficient and successful in obtaining prevention program funding.



• The high cost of program evaluation is a tremendous barrier for many community-based organizations.  Because it is essential to develop evidence-based interventions, the evaluation component cannot be considered optional.  Related discussions on this issue centered on defining the most cost-effective strategy to conduct evaluations, (e.g., developing partnerships with university-based researchers, educating local and State governments, cultivating relationships with businesses, etc.).

Legal and Policy Issues

• Concerns about the continued use of zero tolerance policies without any attempts to understand the family dynamics was underscored.  Both Dr. Satcher and Senior Science Writer, Dr. Elliott, acknowledged that zero-tolerance policies have not been sufficiently evaluated to make any determination regarding their success with youth violence prevention.



• Judges in the juvenile justice system need to become partners in violence prevention efforts, according to a participant who serves as a juvenile judge.  He recommended that this report be disseminated to juvenile and family court judges.  The information on risk factors and other statistics can help the judges as they work collaboratively with the child-serving systems to determine the type of intervention most effective for a specific child involved in youth violence and his/her family.

Gender Issues

• It was acknowledged that the report did not address the issues of dating related violence including date rape.  Several participants expressed the need to obtain more information about appropriate interventions for both the perpetrator and victim for use in any future reports on this topic from the Office of the Surgeon General.

Content of the Report

• Participants questioned the construct of resilience and its varied meanings.  If the term resilience, as currently used, refers only to survival in the face of adversity and multiple risk factors, it may be important to consider whether these young people should also be able to experience joy.  A better understanding of resilience might be conveyed by depicting it as a dynamic process, highly influenced by protective factors.  This information might be useful in the efforts to improve the design of youth violence prevention programs.



• Prevention was addressed by an official from the Centers for Disease Control and Prevention who suggested that violence prevention is a naturally occurring phenomenon.  Therefore, it seems critical that these processes be identified in order to find more effective youth violence prevention strategies.



• Although not explored in this report, the depth of involvement and overall effectiveness of the faith-based community and its initiatives in youth violence prevention may merit exploration.



• Several participants suggested increasing public awareness of the potential consequences of negative media portrayals of violence as new research findings become available.



• Participants observed that links might exist between untreated mental health problems and violence.  They advocated further efforts to combine mental health approaches with efforts to prevent all forms of violence and suggested going beyond youth violence prevention to address bioterrorism as well.



• Forum attendees sought clarification concerning the role of the States as leaders in youth violence prevention efforts.  They also requested more information about the support provided through federally funded State programs.

Observations by Youths

• Several youths related that bullying is one of their constant concerns at school.  These student participants felt that other students, teachers, and parents need to be more involved in addressing this problem because it is frequently neglected in both schools and communities.



• High school students asked about the status of the research on peer mediation as a strategy to reduce bullying and violence.  Dr. Hammond responded that peer mediation programs were effective in teaching negotiation and other skills, but were not sufficient in dealing with the anger and frustration of potentially violent students.  He stated that peer mediation programs require further development and research to ensure that they address the needs of the children at greatest risk.  Affirming Dr. Hammond's response, Dr. Elliott noted that evaluations have shown peer programs such as conflict resolution and/or mediation to be ineffective unless implemented in combination with programs that provide reinforcement by parents, teachers, and other adults in the community.



• Several young people expressed their concern about the way in which statistics on youth violence are calculated, including differences between calculation strategies used in the United States and in other countries.  These youths also inquired about the accuracy of data showing declining trends noted in the United States. They suggested that these declines might  be related to the fact that large numbers of possible perpetrators are in jails and prisons.

Overview of Forum in

Los Angeles, CA
December 11, 2001

Presentations in Los Angeles

• RADM Ronald Banks,  M.D., Regional Health Administrator, Region IX



• Karen Matsuda, M.N., M.S.N., Deputy Regional Health Administrator, Region X
• Delbert S. Elliott, Ph.D., Senior Scientific Editor, Youth Violence: A Report of the Surgeon General



• CAPT Allan S. Noonan,  M.D., Senior Advisor, Office of the Surgeon General, Rockville, Maryland
• Jerry Tello, Director, National Latino Fatherhood and Family Institute, Los Angeles, California



• Father Gregory Boyle and Danny Marcia, Jobs for a Future/Homeboy Industries, Los Angeles, California



• Mary Anne Foo and Susan Sany, Orange County Asian and Pacific Islander Community Alliance, Los Angeles, California



• Hamish Sinclair and Emile Brock, Manalive, San Francisco, California
• Patti Colston and Lelani Ching, Omega Boys Club/Street Soldiers, San Francisco, California



• Steven Hicks, Gay, Lesbian, and Straight Education Network, Los Angeles, California



• Elizabeth Hargrove, Principal, Cordova Primary School, Phoenix, Arizona



• RADM Hugh Sloan,  D.S.W., Regional Health Administrator, Region VIII

RADM Ronald Banks convened the forum and welcomed the participants.  He invited forum participants to comment candidly on the report and to share their successes, challenges, and overall learning about youth violence prevention.  He stressed that the forum was a "listening" session designed to provide important community feedback to the Surgeon General and others who work in the U.S. Department of Health and Human Services.  He emphasized that the forum provides an opportunity to share information specific to youth violence prevention efforts, to learn about what is being done to address the problem, and to offer recommendations regarding what must be done to increase the overall effectiveness of current programs.

Ms. Karen Matsuda and RADM Hugh Sloan emphasized that comments from participants would be essential to increasing the understanding of youth violence prevention from the perspective of those doing the work at the local level and identifying the most effective strategies to disseminate information on model programs.

Dr. Delbert S. Elliott, Senior Science Editor, gave the keynote presentation on Youth Violence: A Report of the Surgeon General.  He also responded to participant inquiries specific to the report findings and to issues related to information not captured in the report. (Refer to the Keynote Presentation, which appears in the Forum overview.)

Mr. Jerry Tello, an internationally recognized authority in family strengthening, leadership development, and cross-cultural issues, chaired a panel on community-based violence prevention programs.  His presentation centered on the importance of building self-esteem in children.  Mr. Tello emphasized that parents face incredible fears of losing their children to a society that does not honor parents.  He underscored the importance of supporting parents in the difficult job of rearing children in a violent society.

Father Gregory Boyle spoke about his involvement with Jobs for a Future and Homeboy Industries, a gang-prevention program in the Boyle Heights neighborhood of Los Angeles.  This outreach program places gang members in jobs in order to give them a positive outlet and a chance to learn new skills while being supervised by caring adults.  Fr. Boyle believes that the community needs to provide three things to reduce youth violence:  appropriate prevention, intervention, and enforcement, with intervention being the most neglected area. 

Danny Marcia, a 21-year-old parolee and current employee of Homeboy Industries, asked the audience to give youths a "second chance."  He offered some insight regarding his personal situation as part of this appeal for renewed confidence in our young people.

Ms. Mary Anne Foo and Ms. Susan Sany gave a presentation on Southeast Asian and Pacific Islander youths.  Ms. Foo spoke about the special challenges faced by Southeast Asian immigrant parents in Los Angeles, many of whom work 18-hour days for low wages and, in turn, cannot directly supervise their children.  In addition, many of these immigrants and refugees (children and their families) come from countries at war and require mental health services that are frequently unavailable.  Their neighborhoods are not safe and there are few community centers.  The lure of gangs can become overwhelming in distressed communities where there are no after-school programs or jobs for youths.  She stressed the importance of developing programs comparable to the Orange County Asian and Pacific Islander Community Alliance, in which youths are supported by adults.  In this program, participants learn to identify problems independently and cultivate the leadership skills needed to talk to policy makers and legislators.  They also develop skills to use a basic understanding of research in designing programs  and writing  grants.

Ms. Sany, a founder of the Youth-to-Youth Pacific Islander Program and a community outreach worker with Guam Communications Network, spoke about a program that she co-designed with a colleague to teach leadership skills to vulnerable youths.  This program, organized, planned, and implemented by youths, focuses on topics such as tobacco awareness, HIV/AIDS advocacy and education, sexually transmitted diseases, safe sex, and relationships.  She emphasized the importance of outreach, networking, and seeking appropriate resources for developing programs for youths at risk for violence.

Mr. Hamish Sinclair, an experienced community organizer, discussed Manalive, a community-based program for men who batter.  The program, which focuses on accountability, requires those who enter to sign agreements acknowledging that they are violent to themselves and to their victims and to state their willingness to stop their violence.  Manalive, which is being conducted in several counties, includes a large program held in cooperation with the San Francisco County Sheriff's Department and a local high school-based program for violent youths.  Harvard researchers studied this program, which reduced recidivism rates up to 80 percent among those who stayed in the program for at least 4 months.

Ms. Patti Colston and Ms. Lelani Ching described the Omega Boys Club youth violence prevention program, a 6-week academic preparation program founded by Dr. Joseph Marshall.  As Ms. Colston explained, students who complete the program are eligible for college scholarships.  Results have included successful enrollment of an estimated 160 students in college, and graduation of 72 students.  The Omega Boys Club also runs a training institute that helps teachers and other school administrators understand the risk factors associated with youth violence prevention and learn how to encourage and support young people as they adopt new principles for living that lead to more positive outcomes.  The institute has trained more than 300 people from 32  States and  two foreign countries who have expressed a desire to adapt the model to their own communities.  A third program component, Street Soldiers, an outreach program in schools and communities, operates a call-in radio talk show dedicated to youth violence prevention.  The second presenter, Ms. Lelani Ching, described herself as a "product of violence" who spent her childhood in a crack house and in a series of foster homes.  She heard about the Omega Boys Club through the radio show.  She emphasized the need for adults to serve as strong role models, to listen nonjudgmentally to youths, and to advocate for media without violence.

Mr. Steven Hicks discussed the work of the Gay, Lesbian, and Straight Education Network to make schools safer.  Activities of the network include advocacy to support protection for gay, lesbian, bisexual, and transgendered youths and programs to show teachers and administrators how these youths can be better integrated into the school community.  Mr. Hicks discussed the importance of increasing faculty training, strengthening protection policies, providing on-site support and counseling in schools for students who identify as gay or lesbian, and addressing specifically, rather than generally, incidents of harassment in schools that are related to sexual orientation.

Ms. Elizabeth Hargrove presented an overview of Character Counts, a program being implemented in the State of Arizona.  It focuses on six character traits:  caring, fairness, respect, responsibility, trustworthiness, and good citizenship.  These traits, all integrated into the school curriculum and reinforced through positive messages placed throughout the schools, are fully supported by the entire school administration.  This statewide program has included provision of 16 train-the-trainer seminars, three parent symposia, follow-up seminars, and the dissemination of five parent booklets.  Approximately 90,000 copies of the parent books, written both in English and in Spanish, have been disseminated.  It is estimated that more than 150,000 youth have been touched by the program since 1999.  Among the effects of the program, as demonstrated in one elementary school in Phoenix, are decreased absence and suspension rates, increased learning, and more positive attitudes among school staff.  A 3-year  outcome-based evaluation is being developed to clearly define the benefits of this effort.

RADM Ronald Banks with RADM Hugh Sloan and CAPT Noonan, moderated the public listening session, highlighting several issues.  Their summary of the forum highlighted the key elements, underscored the importance of the public health approach to youth violence prevention, and offered reassurance that the concerns voiced had been heard, and the present challenges understood.  They thanked the participants, reminded them that youth violence is a public health concern for all Americans, and urged them to remain fully engaged in the youth violence prevention efforts in their communities.

Summary of Public Testimony in Los Angeles

The following key ideas and themes emerged from the public testimony in Los Angeles.

Collaborative Efforts

• Community-based collaborative violence prevention efforts that involve all of the child serving systems, including schools, law enforcement agencies, health agencies, mental health professionals, faith-based communities, businesses, and nonprofit and other community-based organizations, seem to be working effectively.  The federally funded Safe Schools/Healthy Students Initiative received many positive comments from the many diverse participants representing numerous community-based programs.  Collectively, they expressed the need for the continuation of this important program so that additional communities might receive its promising benefits.

Research-Based Programs

• Participants indicated that the Surgeon General's references to specific evidence-based programs were viewed as helpful.  However, training and technical assistance will be required to assist organizations with limited resources to effectively target their assets and select culturally and developmentally appropriate programs with an evidence base to meet the evolving, diverse needs of their populations.



• Concerns were voiced that many community-based programs or strategies that seem to work on the local level are not cited as effective in the Surgeon General's report.  Dr. Elliott responded to these issues by reaffirming that the interventions included in the report were all based on high, yet consistent, scientific standards established by the Surgeon General and his panel of experts involved in the development of the report.  Any program that did not meet these criteria was not included.  This does not necessarily mean that programs excluded from the report are not effective, but only that their effectiveness has not yet been validated through rigorous research.  Dr. Elliott emphatically stated that programs may seem to work but must be evaluated to determine effectiveness.

• Communities must be sufficiently funded and provided with training and technical assistance to make certain that they maintain the fidelity of an evidence-based program or intervention when they are replicated.

• Participants expressed the challenges encountered when their limited resources cannot support qualified evaluators and providers of evidence-based programs.  Concerns were expressed that important program elements, such as compassion,  cannot necessarily be measured.  Dr. Elliott decisively affirmed the importance of evaluation.  He noted that although strong motivation and compassion may be critical ingredients for success, a strategy needs to be directly related to the onset, reduction, or elimination of a particular problem.

Funding

• Sustaining long-term funding was a major issue for most of the community-based representatives who testified.  Participants concluded that the Surgeon General's report represented a single source of data that could support their efforts to leverage funding at the State and local levels.



• Obtaining sufficient funding to support recreational programs that offer youth positive alternatives to violence remains a challenge for many community-based organizations.

Legal and Policy Issues

• The need for improved sharing of records and information among schools, law enforcement agencies, and mental health professionals was a concern to some commentators.  Representatives indicated that existing laws create barriers to identifying and assisting potentially violent students.  Although these laws protect the confidentiality of students, records needed to be shared among the child serving systems.



• One participant who identified himself as an administrator in the criminal justice system recommended the reallocation of funding that is currently used for building secure youth detention facilities.  He suggested that this funding be redirected to support community-based youth violence prevention interventions.

Rural Issues

• Participants expressed regret that the report did not specifically address the issues faced by rural communities, including such cultural norms as those surrounding the use and possession of weapons that may have an impact on violence prevention efforts.



• One recommendation focused on the need to address rural isolation as a specific risk factor under "disorganized neighborhoods."

Gender Issues

• There was broad support that the Surgeon General's report should specifically address any correlation between gender differences and violent behavior.



• There was consensus that the report would have been more useful had it  addressed violence from the perspective of gay, lesbian, bisexual, and transgendered youths.  These youths may experience more violence, especially bullying, at the hands of other youths.  Teachers may not be experienced intervening in bullying and other acts of violence directed toward these youths.  Moreover, these youths may not identify with social norms regarding gender and, therefore, may not benefit from the limited number of evidence-based model programs.

Special Concerns

• The Surgeon General's report failed to focus on the obstacles that a previous or current history of arrest or incarceration poses for young men who are African-American, Native American, or Hispanic.



• Although the report did not address this population, foster children who are emancipated at age 18 seem to be at a heightened risk to become perpetrators and victims of violent behavior.



• The needs of youths who are Alaskan natives, American Indian, immigrants, and/or refugees are not specifically addressed in the report.  Information is needed in this area.



• Funding remains a paramount challenge for community agencies.  They require technical assistance in order to achieve sustainability.



• Although addressed in a separate report of the Surgeon General, it would have been helpful if issues related to youth who are suicidal were included in this report as well.

Content of the Report

• Concern was expressed that the report defines "myths and facts" in an extreme form, unfamiliar to some forum participants.  Other participants did not fully understand the current status of the epidemic of youth violence.



• There was discussion regarding the lack of effectiveness attributed to peer programs in the report.  Dr. Elliott recognized that the high scientific standards used to evaluate the "sustainability of the effects" might  make it difficult to prove that many peer programs are effective in preventing youth violence.  However, peer programs may have effective outcomes in other areas, such as HIV/AIDS prevention.

Overview of Forum in

Philadelphia, PA
December 14, 2001

Presentations in Philadelphia

• Dalton G. Paxman, Ph.D., Regional Health Administrator, Region III



• Gary Gurian, Secretary's Regional Representative, Region III



• Paul Laurenzo, Director of Children's Policy, City of Philadelphia



• Albert Yee, M.D., M.P.H., Regional Health Administrator, Region I



• Delbert S. Elliott, Ph.D., Senior Scientific Editor, Youth Violence: A Report of the Surgeon General

• Gilberto Cardona, MD, Regional Health Administrator, Region II



• Calvin Johnson, MD, M.P.H., Medical Director, Philadelphia Safe and Sound



• Howard Spivak, MD, Chief, Division of General Pediatrics and Adolescent Medicine, and Vice President of Community Health Programs, New England Medical Center, Boston, Massachusetts



• Gerard Fergerson, Ph.D., Director of Research, Planning, and Evaluation, Executive Office of the Mayor, Washington, D.C.



• Michael Roberts, M.S.W., Director of Training and Youth Development, Safe Horizons, New York, New York

Dr. Dalton Paxman welcomed participants and explained that the goals of the community forum were to share information about the Surgeon General's report, to listen to the diverse perspectives from those who have read and/or used the findings in the report, to provide participants with an opportunity to describe activities that address youth violence in their communities, and to offer an opportunity to foster community partnerships.

Mr. Gary Gurian stressed the commitment of both President George W. Bush and Secretary Tommy Thompson, United States Department of Health and Human Services, to systematically address the problem of youth violence.  Mr. Laurenzo spoke about Philadelphia's Youth Violence Reduction Partnership, a multiagency initiative aimed at reducing youth homicides and delinquent behavior; the Weapons Related Injuries Surveillance System, the city's hospital-based tracking system for weapons-related injuries and fatalities among youths; and the Multi-systemic Therapeutic Intervention Program, a community-based treatment program for youths with serious and chronic behavior disorders.

Dr. Albert Yee reminded participants that although we now have a better understanding of factors that influence violent behaviors and of the effectiveness of various interventions, we are challenged by the need for consistent evaluation and additional research on successful strategies.

Dr. Delbert S. Elliott, Senior Science Editor, gave the keynote presentation on Youth Violence: A Report of the Surgeon General.  (Refer to the Keynote Presentation, which appears in the Forum overview.)

Dr. Gilberto Cardona introduced Dr. Calvin Johnson, who chaired a panel presentation on community-based violence prevention programs.

Dr. Howard Spivak attributed the success of violence prevention in Boston to multiple efforts from multiple programs involving virtually every segment of the community.  He counseled participants not to use "cookie cutter" approaches to violence prevention and emphasized the need for program customization.  He suggested that communities develop coalitions that include local residents and youths and their families.  These efforts should help convince people that they have the power to reduce violence in their neighborhoods.

He also shared his thoughts on the four points regarding the roles of the health care system in youth violence prevention.  First, the health care system has an important role to play in the education of children, families, and the community about safety and the effects of exposure to violence on children.  Second, this system plays a role in screening situations and circumstances that create risk.  Third, this system plays a role in response to violent injuries¾it can simply provide needed medical care and send the patient back into the community, or it can assess the needs of the patients and refer them to follow-up services.  Fourth, the health care system must "come to the table" with the community to explore comprehensive strategies for violence prevention.

Dr. Gerard Fergerson spoke of sharp declines in youth crime and violence in Washington, DC, where youths are now responsible for less than 6 percent of violent crimes.  He also highlighted the issue of disparity in terms of race and ethnicity, noting that the juvenile justice system in the District of Columbia incarcerates primarily African-American and Latino youths.  He denounced the "superpredator" theories of youth violence that were popular in the late 1990s and lauded the Surgeon General's report for providing a new lexicon with which to talk about violence among youth.

Dr. Fergerson provided an overview of violence prevention programs and policy strategies being implemented in Washington, DC, including investing resources in asset-based youth development initiatives, creating structured after-school programs in areas with high levels of youth arrests, and conducting extensive research on youth violence and crime in order to build programs based on accurate assessments of need.  In addition, the city is working to provide a wraparound delivery of services by increasing support for low-income mothers and children, developing juvenile justice policies that treat children as children, and decreasing recidivism through programs that target youths who are leaving the juvenile justice system.

Mr. Michael Roberts spoke about the New York City Safe Horizons Project, which provides multidisciplinary services to youths through interagency collaboration.  He emphasized the "five C's" of prevention program design: clarity of message, consistency (sustainability), comprehensiveness, cost-effectiveness, and congruency (asking the individual what services he or she needs).

Summary of Public Testimony in Philadelphia

The following key ideas and themes emerged from the public testimony in Philadelphia:

Collaborative Efforts

• Interdisciplinary partnerships and community coalitions are important strategies for addressing the issues of youth violence.



• Improved cooperation among multiple Federal agencies and State governments in support of violence prevention programming would be helpful to organizations at the local level with regard to issues such as service integration, adult waivers, and confidentiality.

Research-Based Programs

• Concerns were expressed about funding programs that emphasize collecting data rather than taking care of young people.  In addition, participants emphasized the difficulty in obtaining funding for long-term, complex, and expensive replications of model programs.



• The hard work and commitment of many individuals in local prevention programs was recognized by many providing testimony as they pointed out the highly positive outcomes of many of these programs.  Several young people with histories as perpetrators or victims of violence gave compelling personal accounts about how local programs had helped them direct their lives toward more positive paths.  These spokespersons often advocated a particular program model or approach.  They also expressed concern that by focusing only on programs that have been replicated and subjected to rigorous evaluation, the report may have overlooked many other effective efforts.



• Although it takes several years to document the effectiveness of comprehensive programs at the community level, funding organizations require stringent evaluation measures and expect short-term outcomes that cannot be achieved without a long-term commitment.

Legal and Policy Issues

• The adequacy of the public health model in recognizing the role of criminal justice approaches was discussed.  Although punishment for crimes is important, it is also vital to create public policies that help parents and children prevent youth crime.



• There was consensus that corporal punishment in the school system should remain banned because it conveys the implied message that violence is an appropriate way to handle problems.



• There was discussion about measures that could be employed to address the need to change the attitudes of those in the judicial system, at both the national and local levels, about sentencing for youth violence.

Gender Issues

• Several participants suggested that the report would have been more helpful if there had been an emphasis on sexual abuse.



• The Surgeon General's Call to Action to Promote Sexual Health, which advocates respect for one's self and one's partner and avoidance of physical or emotional harm, is highly relevant to the issue of youth violence.



• Prevention strategies aimed at strengthening male-female relationships between African-American youths were suggested as an important element in an effective approach to reducing youth violence.



• More attention needs to be placed on violence against girls and on the link between violence and such problems as HIV/AIDS, sexually transmitted diseases, date rape, disabilities, and gay and lesbian youth issues.

Special Concerns

• Cultural competency is essential in making youth programs more relevant.  One way to achieve this objective is training youth workers to gather information from their peers about preferred services and modes of access.



• A renewed interest in volunteerism can be supportive of a national initiative to address societal problems, including youth violence.



• Integrating adolescent development courses into the teacher preparation curriculum would enhance understanding by teachers of student behaviors and permit them to implement violence prevention and intervention strategies.



• Communities need interventions that support youth violence prevention and a "safety net" for youths at a time when public hospitals are closing and insurance companies are limiting reimbursement for social services.



• To promote prevention among preschool children, panel members recommended Head Start, home visitation programs, and other programs mentioned in the Surgeon General's report that reach children in violent circumstances.  These programs provide services that can nurture positive values in the family and community.

• According to a child advocacy group and other participants, the report does not address homelessness and its connection to youth violence.  These speakers recommended local collaboration to identify crisis shelters, street outreach programs, and transitional living programs.



• There is a need to focus on adult services, including parent skills training and family therapy, to protect children and prevent the cycle of victimization.



• Participants were pleased to have youths involved in the forum and recommended that youths be involved in planning and implementing prevention and intervention efforts as well.

Content of the Report

• Appreciation for the Surgeon General's leadership and for the quality and scientific credibility of the report were common themes in the comments.  Commentators also saw great value in the identification of approaches that work and in the report's emphasis on prevention.



• Many individuals felt that the Surgeon General's report is valuable in setting a direction; however, reinforcement and resources also will be required.



• Concerns were expressed repeatedly about the report's conclusion that portrayals of violence in the mass media cannot be identified as a major cause of youth violence.



• Speaking for a State Conference of the National Association for the Advancement of Colored People, a commentator pointed out that violence has had particularly devastating effects on the African-American community.  This presenter expressed hopes that this community will now begin to focus on a public health approach that emphasizes prevention as strongly as it now emphasizes punishment for youths who commit violent acts.



• A pediatrician representing a health care collaborative commented that the report does not adequately address strategies to develop community support for violence prevention among disenfranchised youths at highest risk.  He suggested that more attention be given to the potential role of the health care system in general and of emergency and trauma department workers in particular.

Observations by Youths

• Youths suggested that only young people fully understand what will work for their age group.  The perceptions of young people need to be considered, and more youth involvement is essential.  Youths in trouble should be treated rather than adjudicated.



• A young presenter who had been charged as a minor with Federal offenses and now is a college student, attributed her progress to a high school teacher who helped her identify her specific skills and offered the attention that she did not receive in a violent home.  She cited a local organization, Children Service Incorporated, as an effective resource for job training and life skills.  Other youths noted the value of specific programs such as the Adolescent Initiative Program, Big Brothers Big Sisters, and the Bully Prevention Program.



• A former gang member spoke about how a caring community of inmates helped him turn his life around.   He advocated active outreach on the streets and empowerment of the churches.



• A poem written by an adjudicated teen participant contained messages about the importance of respect, concern, nurturing, and truthfulness and asked that youths not be neglected, lied to, or judged.

Conclusion

As with Youth Violence: A Report of the Surgeon General, these community-based forums reaffirmed the importance of the safety and well-being of all children and adolescents to citizens in all walks of life throughout the United States.

This heartfelt, urgent testimony will be used to inform the future decisions that must be made in youth violence prevention to protect and ensure the healthy growth and development and safety of every child.

Back to Top