Prevention

and

equity at the center of community well-being

Connecting the Dots: 

An Overview of the Links Among 

Multiple Forms of Violence
Connecting the Dots: An Overview of the Links Among Multiple Forms of Violence is a publication of the 

Centers for Disease Control and Prevention and Prevention Institute.

Centers for Disease Control and Prevention1

Thomas R. Frieden, MD, MPH, Director

National Center for Injury Prevention and Control

Daniel M. Sosin, MD, MPH, FACP, Acting Director

Division of Violence Prevention

Howard R. Spivak, MD, Director

Prevention Institute2

Larry Cohen, MSW, Executive Director

Authors

Natalie Wilkins, PhD1

 Benita Tsao, MPH, CHES2

 Marci Hertz, MS1

Rachel Davis, MSW2

 Joanne Klevens, MD, PhD, MPH1

July 2014

Suggested citation:

Wilkins, N., Tsao, B., Hertz, M., Davis, R., Klevens, J. (2014). Connecting the Dots: An Overview of 

the Links Among Multiple Forms of Violence. Atlanta, GA: National Center for Injury Prevention and 

Control, Centers for Disease Control and Prevention Oakland, CA: Prevention Institute.
Connecting the Dots 1

“Gang violence is connected to bullying is connected to school violence 

is connected to intimate partner violence is connected to child abuse is 

connected to elder abuse. It’s all connected.” 

-Deborah Prothrow-Stith, MD, 

Adjunct Professor, Harvard School of Public Health

Violence takes many forms, including intimate partner violence, sexual violence, child maltreatment, 

bullying, suicidal behavior, and elder abuse and neglect. These forms of violence are interconnected and 

often share the same root causes. They can also all take place under one roof, or in a given community 

or neighborhood and can happen at the same time or at different stages of life.1,2 Understanding the 

overlapping causes of violence and the things that can protect people and communities is important, and 

can help us better address violence in all its forms.

The purpose of this brief is to share research on the connections between different forms of violence 

and describe how these connections affect communities. It is our hope that this information, combined 

with your own practical experience, will help practitioners like you to think strategically and creatively 

about how you can:

1. Prevent all types of violence from occurring in the first place.

2. Coordinate and integrate responses to violence in a way that recognizes these connections and 

considers the individual in the context of their home environment, neighborhood, and larger 

community. 

“There are experiences, particularly early in childhood, that make it 

extremely predictable that individuals are at substantially higher risk for 

involvement with violence, be it interpersonal, youth violence, intimate 

partner violence, dating violence, or child abuse.” 

-Howard Spivak, MD, Director, Division of Violence Prevention, 

Centers for Disease Control and Prevention

Vulnerability and Resilience: Risk Factors and Protective Factors 

Violent behavior is complex. Many things increase or decrease the likelihood of violence. The 

communities people live in can protect them from violence or can increase their risk of violence. Things 

that make it more likely that people will experience violence are called risk factors. Examples of risk 

factors are: rigid social beliefs about what is “masculine” and “feminine,” lack of job opportunities, and 

family conflict. Things that make it less likely that people will experience violence or that increase their 

resilience when they are faced with risk factors are called protective factors. Examples of protective 

factors are: connection to a caring adult or access to mental health services. Risk and protective factors 

can affect an entire community, and can occur in interactions with family and friends and within 

organizations and systems like schools, faith institutions, and workplaces. Individual experiences or traits 

can also be risk and protective factors, such as witnessing violence or having skills to solve problems nonviolently. The table on pages 8 and 9 shows that some of the things that make it less likely for one type of 

violence to happen may also protect us from other types of violence. 
2 Connecting the Dots

The Impact of Violence on Development 

People’s brains develop in response to their 

environments.3 When children grow up in safe,4,5,6

stable,7 and nurturing8 relationships and environments, 

they learn empathy, impulse control, anger 

management and problem-solving—all skills that 

protect against violence.9 When children grow up in 

environments where they don’t feel safe, their brain 

cells form different connections with each other to 

better recognize and respond to threats.10,11 Children 

in these environments may misinterpret neutral facial 

expressions as anger,for example,12 and more situations 

may trigger a fight-or-flight response. Children 

living in a persistently threatening environment are 

more likely to respond violently (fight) or run away 

(flight) than children who grow up in safe, stable, and 

nurturing environments. Fight-or-flight responses 

are survival skills that people are born with and often 

override other skills that enable non-violent conflict 

resolution, such as impulse control, empathy, anger 

management, and problem-solving skills.13,14,11,15

Childhood abuse, neglect, and exposure to other traumatic stressors, termed adverse childhood experiences 

(ACEs), are common. In the Adverse Childhood Experiences Study, over 17,000 adults from a Health 

Maintenance Organization (HMO) were asked about their experiences in childhood and subsequent 

behavioral and health outcomes. Almost two-thirds of participants reported at least one ACE, and more 

than one in five reported three or more ACEs.3 The short- and long-term outcomes of these childhood 

exposures include multiple health and social problems. ACEs contribute to stress during childhood and put 

individuals at higher risk for health problems such as alcoholism and alcohol abuse, depression, illicit drug 

use, intimate partner violence, and suicide attempts.16,3 The impact of ACEs is also cumulative, meaning the 

more ACEs a child is exposed to, the higher likelihood they will experience some of these health and social 

problems later in life. The life expectancy of people with six or more ACEs is 20 years shorter than those 

without any ACEs.17

There are opportunities at every stage of life to 

remedy the negative effects of trauma and help 

people heal. Whether designed for children, 

youth, or adults, actions and activities that 

promote the protective factors listed in the 

table on pages 8 and 9 may prevent trauma for 

those exposed to violence and also reduce the 

likelihood of violence in the first place.
Connecting the Dots 3

Community Context and the Co-Occurrence of Multiple Forms of Violence

Community risk and protective factors are 

critical because they make it more or less 

likely that entire communities will suffer 

from violence. The level of safety someone 

feels varies so much from community to 

community and even from block to block 

because safety is not evenly distributed. Often, 

a community experiences an overwhelming 

number of risk factors without an equal 

balance of protective factors. This means 

that families and children living in some 

communities where there are many risk 

factors (e.g., high poverty, unemployment, 

and crime) are more likely than families 

and children living in other communities to 

experience multiple forms of violence. 18,19,20

For example:

•	 Neighborhoods where there is low cohesion, or where residents don’t support and trust each other, are 

more likely to have residents that also experience child maltreatment,21,22 intimate partner violence,19

and youth violence.20

•	 People who are socially isolated and who don’t have social support from family, friends, or neighbors are 

more likely to perpetrate child maltreatment,23 intimate partner violence,24 suicide,25,26 and elder abuse.27

•	 Lack of economic opportunities and unemployment are associated with perpetration of child 

maltreatment,23 intimate partner violence,28,19 self-directed violence,29,30 sexual violence,31 and youth 

violence.32

•	 Norms in society or in communities that support aggression or coercion are associated with physical 

assaults of children,33,34 intimate partner violence,19 sexual violence,35 youth violence,36 and elder 

maltreatment.27

•	 Witnessing community violence puts people at higher risk of being bullied37 and perpetrating sexual 

violence.38

However, this also means that community protective factors may make it less likely that an entire community 

will experience violence. Things that increase peoples’ and communities’ resilience to violence include:

•	 Coordination of resources and services among community agencies.39,40,41,27

•	 Access to mental health and substance abuse services.42,41

•	 Support and connectedness, including connectedness to one’s community,42,19,38,43,41,27,44 family,42,45,46,47,41

pro-social peers,45,48 and school.45,49,50,46,37,41
4 Connecting the Dots

Other Shared Risk and Protective Factors 

In addition to the things in communities that put people at risk for and/or protect them from violence, 

there are other things in people’s relationships and past experiences that increase their risk or protect 

against violence. These other risk and protective factors are important because they often occur at the 

same time as larger community risk and protective factors and can further increase people’s risk or 

resilience related to violence. For example, parents may have a harder time preventing their children 

from using substances (drugs, alcohol) or weapons when there are high levels of community violence in 

their neighborhood, putting youth already exposed to violence in their community at even higher risk 

for experiencing other forms of violence.51 There are a number of these risk factors that occur as a result 

of people’s experiences, skills, behaviors, and relationships that put them at higher risk of acting violently. 

For example:

•	 Conflict within the family is linked to almost all forms of violence perpetration including child 

maltreatment (children in homes with high conflict are at higher risk for being victims),42 teen dating 

violence,52 intimate partner violence,53 sexual violence,31 youth violence,46 and bullying.37

•	 Youth who associate with delinquent peers or friends are at higher risk of harming others through 

bullying,37 youth violence,46 teen dating violence,45 and later in life sexual violence,31 and intimate 

partner violence.54

•	 Experiencing one form of violence places individuals at a higher risk of experiencing other forms of 

violence (See “Violence Can Lead to More Violence” on page 4).

•	 Lacking skills to cope with problems non-violently42,27,55,37,46,56,57,53,52 and problems with substance 

abuse42,27,41,58,46,31,53,52 also place individuals at higher risk for acting violently. 

Relationships and past experiences and skills can 

also help protect people from violence even if 

they are exposed to violence in their community.59

For example, we know that people who live in 

communities that are violent can be “protected” 

from the effects of this violence (are less likely to 

perpetrate violence or engage in other destructive 

behaviors like substance use) if they have nonviolent, supportive relationships with family, 

friends, and other groups, like schools or faithorganizations.59,51,60 For example:

•	 Youth who feel connected and committed to 

school are at a lower risk of harming others 

through dating violence,45 youth violence,46 and 

bullying,37 and are at lower risk for suicide.41

•	 Strong family support 42,41,47,46,45 and non-violent 

problem solving skills 45,41,37,46,56,57,31,53,52 have been 

shown to be protective against almost all forms 

of violence.
Connecting the Dots 5

Violence Can Lead to More Violence

Most people who are victims of violence do not act violently. However, people who experience or are 

exposed to one form of violence are at a higher risk for both being a victim of other forms of violence and 

for inflicting harm on others: 

•	 Survivors of one form of violence are more likely to be victims of other forms of violence. 

» Girls who are sexually abused are more likely to suffer physical violence and sexual re-victimization, 

engage in self-harming behavior, and be a victim of intimate partner violence later in life.61

» Youth who have been physically abused by a dating partner are also more likely to have suffered 

abuse as a child, been a victim of sexual assault, and witnessed violence in their family.62

» Youth who report attempting suicide are approximately five times more likely to have also been in 

a physical fight in the last year.63

» Women and girls involved in gangs often experience physical, emotional, and sexual abuse 

by other gang members, and are more likely to have been physically or sexually abused as 

children.64,65

» Children who have been bullied are at greater odds for becoming involved in physical violence 

(e.g. weapon carrying, physical fighting).58

•	 Survivors of violence are at higher risk for behaving violently.

» Children who experience physical abuse or neglect early in their lives are at greater risk for 

committing violence against peers (particularly for boys),66 bullying, 67 teen dating violence,67 and 

committing child abuse,68 elder abuse,68 intimate partner violence,68 and sexual violence35 later in life.

» Youth who bully others are more likely to have witnessed parental violence (intimate partner 

violence) than those who do not bully others.69,70

•	 People who behave violently are more likely to commit other forms of violence.

» Adults who are violent toward their partners are at higher risk of also abusing their children.72

» Youth who bully are more likely to carry weapons and be physically violent.58 They are also more 

likely to sexually harass peers over time73 and commit violence against partners as teens74 and as 

adults75 than those who did not bully.

Despite these connections, we know people who experience violence in their communities or 

relationships can be protected from experiencing other forms of violence through protective factors such 

as the ones listed in the table on pages 8 and 9.59
6 Connecting the Dots

Breaking Down the Silos: Working Together to Create Safer Communities 

 “We have to figure out how we break down these barriers and work in a 

more collaborative way not just within the health system but across the 

social services system and the criminal justice system” 

–Georges Benjamin, MD, Executive Director, 

 American Public Health Association

Understanding shared risk and protective factors of violence can help us plan how to prevent multiple 

forms of violence at once. Violence prevention and intervention efforts that focus on only one form 

of violence can be broadened to address multiple, connected forms of violence and increase public 

health impact. For example, organizations working on child maltreatment, youth violence, and suicide 

prevention could work together on strategies that increase families’ connectedness to the community. 

Since community connectedness is a shared protective factor across these types of violence (and other 

types of violence as well), pooling resources to take action on this shared protective factor could have 

a broad violence prevention impact in the community. Also, knowing that experiencing one form of 

violence can increase families’ and individuals’ risk for other forms of violence can help practitioners 

develop services and strategies that would have the most impact for their clients. For example, 

practitioners working with survivors of intimate partner violence may recognize that children in families 

experiencing conflict and violence are at higher risk of being victims of bullying, or becoming bullies 

themselves69,70 and coordinate with schools to ensure that all members of the family are receiving the help 

and support they need to prevent future violence. 

“Professionally we have silos, and we operate in these silos we’ve got to 

break down. Across the country, people working to prevent child abuse are 

right across the hall from people working on violence against women, and 

they don’t work together. As we go into communities to bring everybody to 

the table, don’t let people say, ‘I work on child abuse, but this is about gang 

violence.’ Don’t let people say, ‘I work on violence against women, and this 

is about child abuse.’ This thing, all this violence, is connected.” 

-Deborah Prothrow-Stith, MD, 

Adjunct Professor, Harvard School of Public Health

Practitioners can address the unique aspects of a form of violence, while still supporting joint action 

wherever possible. Understanding how different forms of violence are linked to one another is an 

important first step in coordinating strategies, activities, and resources to effectively prevent multiple 

forms of violence. This understanding might increase support for braided and blended funding streams 

and additional infrastructure for increased collaboration, which would advance the field as a whole. 

Together we can make a difference in preventing all forms of violence in our lives, families, relationships, 

and communities. Effective prevention efforts address common risk and protective factors, reduce overall 

violence, and improve outcomes. As the relationships among multiple forms of violence become clearer, it’s 

increasingly important for practitioners and researchers to consider these linkages in their work.
Connecting the Dots 7

To Learn More

•	 WHO Guide to Implementing the Recommendations of the World Report on Violence, 

http://whqlibdoc.who.int/publications/2004/9241592079.pdf

•	 Lifetime Spiral of Gender Violence, www.apiidv.org

•	 Public Health Contributions to Preventing Violence, www.preventioninstitute.org/unitylinks

•	 The Relationship Between Bullying and Suicide: What We Know and What it Means for Schools, 

http://www.cdc.gov/violenceprevention/pdf/bullying-suicide-translation-final-a.pdf

•	 The Bully-Sexual Violence Pathway in Early Adolescence, 

http://www.cdc.gov/violenceprevention/pdf/asap_bullyingsv-a.pdf

•	 Harvard University’s Center on the Developing Child- Science of Early Childhood Series, 

http://developingchild.harvard.edu/topics/science_of_early_childhood/

•	 Adverse Childhood Experiences Study, http://www.cdc.gov/ace/index.htm

•	 Adverse Childhood Experiences Infographic, 

http://vetoviolence.cdc.gov/childmaltreatment/phl/resource_center_infographic.html

•	 Webinar: Links Between Multiple Forms of Violence, http://www.preventioninstitute.org/unityresources/training-a-events/989-webinar-links-between-multiple-forms-of-violence-3182013.html

•	 Webinar: The Relationships between Child Maltreatment and Suicide & A Comprehensive Approach 

to Suicide Prevention, http://www.childrenssafetynetwork.org/webinar/youth-suicide-preventioncommunity-practice-relationship-between-child-maltreatment-and-suic

Acknowledgements

For their review of this fact sheet and thoughtful feedback, the authors thank:

•	 Cordelia Anderson, Sensibilities Prevention Services

•	 Emily Austin, Peace Over Violence

•	 Chic Dabby, Asian & Pacific Islander Institute on Domestic Violence

•	 Heather Fitzpatrick, American Academy of Pediatrics

•	 Sally Fogerty, Children’s Safety Network

•	 Annie Gebhardt, Donna Greco and Liz Zadnik, National Sexual Violence Resource Center

•	 Karthryn Harding and Jim Hmurovich, Prevent Child Abuse America

•	 Laura Hogan and Lisa Sohn, Futures Without Violence

•	 Gayle Jaffe, Suicide Prevention Resource Center

•	 David Lee, PreventConnect, California Coalition Against Sexual Assault

•	 Anne Menard, National Resource Center on Domestic Violence

•	 Charles Ransford, Cure Violence

•	 Kaile Shilling and Billie Weiss, Violence Prevention Coalition of Greater Los Angeles

•	 Valerie Spiva Collins, FRIENDS National Resource Center
8 Connecting the Dots

Shared Risk and Protective Factors Across Multiple Forms of Violence. 

NOTE: Research on risk and protective factors for violence is continuing to evolve. In this table, “X’s” indicate 

the existence of at least one study published in a peer reviewed journal demonstrating an association between the 

risk or protective factor and that type of violence. Also, some of the “community” risk and protective factors were 

measured through surveys of individuals (e.g. surveys asking people about neighborhood support and cohesion) 

versus measures at the actual community level (e.g. city alcohol licensing lists to measure alcohol outlet density), so 

may be considered proxies for community level risk and protective factors.

Type of Violence Perpetration

Child 

maltreatment

Teen Dating 

Violence

Intimate 

Partner 

Violence

Sexual 

Violence

Youth 

Violence

Bullying Suicide Elder 

Maltreatment

Risk Factors Societal

Cultural norms that 

support aggression toward 

others

x33,76,77 x78,79 x53 x31 x80 x27,81

Media Violence x57,82 x83 x37 x84,85

Societal income inequity x108 x86 x87,88,89 x47

Weak health, educational, 

economic, and social 

policies/laws

x90 x53 x31 x91

Harmful norms around 

masculinity and femininity x92 x54 x53 x31,73,74 x93 x94

Community

Neighborhood poverty x42 x53 x31 x46 x95

High alcohol outlet 

density x42 x96,97 x98 x99

Community violence x42 x38 x100 x37

Diminished economic 

opportunities/high 

unemployment rates

x42 x28,19 x31 x46 x29,30

Poor neighborhood 

support and cohesion x42 x45 x53 x46,20 x41

Relationship

Social isolation/Lack of 

social support x42 x45 x53 x46 x58 x41 x27

Poor parent-child 

relationships x42 x52,101 x53 x57,49 x46 x37 x55

Family conflict x42 x52 x53 x31 x46 x37

Economic stress x42 x53 x46 x41 x27

Associating with 

delinquent peers x45 x54 x31 x46 x37

Gang Involvement x64 x64 x64 x46
Connecting the Dots 9

Type of Violence Perpetration

Child 

maltreatment

Teen Dating 

Violence

Intimate 

Partner 

Violence

Sexual 

Violence

Youth 

Violence

Bullying Suicide Elder 

Maltreatment

Individual

Low educational 

achievement x42 x52 x53 x46 x58 x55

Lack of non-violent social 

problem-solving skills x42 x52 x53 x57,56 x46 x37 x55 x27

Poor behavioral control/

Impulsiveness x42 x52 x53 x31 x46 x41

History of violent 

victimization x42 x102 x53 x31 x46 x67 x41 x27

Witnessing violence x42 x52 x45 x31 x46 x103,37 x85

Psychological/mental 

health problems x42 x52 x53 x46 x41 x27

Substance use x42 x52 x53 x31 x46 x58 x41 x27

Protective Factors Community

Coordination of resources 

and services among 

community agencies

x39 x40 x41 x27

Access to mental health 

and substance abuse 

services

x42 x41

Community support/

connected-ness x42 x19 x38,44 x43 x41 x27

Relationship

Family support/

connected-ness x42 x45 x46 x47 x41 x27

Connection to a caring 

adult x45 x46 x41

Association with prosocial peers x45 x48 x104

Connection/commitment 

to school x45,105 x49,50 x46 x37,47 x41

Individual

Skills in solving problems 

non-violently x106 x107 x46 x41
10 Connecting the Dots

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For more information please contact:

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