Introduction

Over the last two decades of the 20th century,

violence emerged as one of the most significant

public health problems in the United States

(Administration for Children and Families,

2004). While recent trends have been

encouraging, homicide remains the second

leading cause of death among adolescents

(National Center for Injury Prevention and

Control, 2004). During this period, an

increasing number of research studies has have

sought to characterize youth violence and the

contexts in which it occurs, as well as risk and

protective factors associated with such violence.

At the same time, a myriad of prevention

interventions have been developed and evaluated

with multiple youth populations and in a range of

settings. 

In the fall of 2004, the National Institute of

Mental Health (NIMH) will convene a State-ofthe-Science Conference on “Preventing Violence

and Related Health-Risking Social Behaviors in

Adolescents.” The purpose of this consensus

conference is to provide a forum to present and

review what is currently known about preventing

youth violence. In preparation for this meeting,

the Office of Medical Applications of Research

(OMAR) and the National Institute of Mental

Health (NIMH) nominated and supported the

topic for an Agency for Healthcare Research and

Quality (AHRQ)-sponsored systematic review

and analysis of the evidence. AHRQ awarded

this project to the Southern California Evidencebased Practice Center (SC-EPC) and its partner,

Childrens Hospital Los Angeles, to conduct the

review and summarize the findings in an evidence

report. Researchers were to review longitudinal

risk factor research to identify the role of

individual, family, school, community and peerlevel influences as well as interventional research

to evaluate prevention intervention effectiveness.

This evidence report addresses the following six

key questions: 

1. What are the factors that contribute to

violence and associated adverse health

outcomes in childhood and adolescence?

2. What are the patterns of co-occurrence of

these factors?

3. What evidence exists on the safety and

effectiveness of interventions for violence?

4. Where evidence of safety and effectiveness

exists, are there other outcomes beyond

reducing violence? If so, what is known

about effectiveness by age, sex, and

race/ethnicity?

5. What are commonalities of the interventions

that are effective, and those that are

ineffective?

6. What are the priorities for future research?

For the purpose of this evidence review, we

used the Centers for Disease Control and

Prevention’s definition of violence: “threatened or

actual physical force or power initiated by an

individual that results in, or has a high likelihood

of resulting in, physical or psychological injury or

death” (National Center for Injury Prevention

and Control, 2004). We made the decision to

include only the following types of violent

behavior: murder or homicide, aggravated assault,

Evidence Report/Technology Assessment

Number 107

Preventing Violence and Related Health-Risking

Social Behaviors in Adolescents

Summary

Authors: Chan LS, Kipke MD, Schneir A, Iverson E, Warf C, Limbos MA, Shekelle P

Agency for Healthcare Research and Quality

Advancing Excellence in Health Care • www.ahrq.gov

Agency for Healthcare Research and Quality Evidence-Based

Practice
2

non-aggravated assault, rape or sexual assault, robbery, gang

fight, physical aggression, psychological injury or harm, and

other serious injury or harm. Thus, we did not review the

growing literature that reports on studies of suicide, verbal

aggression, bullying, arson, weapon carrying, externalizing

behaviors (e.g., acting out), attitude about violent behavior,

youth crime against property or materials (such as burglary,

theft), or intent to commit violence as outcomes. These related

behaviors and attitudes are included in this report only to the

extent that they have been proposed as risk factors for the

forms of violence on which this report focuses. 

The definition of violence prevention interventions that we

used was developed for and published in the Surgeon General’s

Report on Youth Violence (Satcher, 2001). According to this

definition, “Primary prevention interventions are those that are

universal, intended to prevent the onset of violence and related

risk factors; secondary prevention interventions are those

implemented on a selected scale for children/youth at enhanced

risk for youth violence, intended to prevent the onset and

reduce the risk of violence; and tertiary prevention

interventions are those that are targeted to youth who have

already demonstrated violent or seriously delinquent behavior.”

Methods

Analytic Framework

To complete the project with the resources available, it was

necessary to narrow the focus of this evidence review. To this

end, we limited our review to peer-reviewed articles published

in 1990 or later and retrievable within four search engines—

MEDLINE®‚ PsychINFO, SocioAbstracts, and ERIC. We

also limited the review to studies conducted in the United

States and focused on violent behavior perpetrated by

adolescents, ages 12 through 17 years. Thus, this review

excluded studies of violence perpetrated by children, preadolescents, and young adults. 

To assist project staff in conducting the evidence review, a

nine-member multidisciplinary Technical Expert Group (TEG)

was established, comprising individuals with both content and

methodological expertise. Specifically, the TEG brought to this

review a diverse set of expertise from a range of fields and

disciplines, including early childhood development, adolescent

development, juvenile justice, child abuse and neglect,

anthropology, psychology, sociology, social work, public health,

and public policy. 

We created a list of potential risk and protective factors

organized by domain—i.e., individual, family, school, peer,

community, and social domains—to inform data abstraction

and synthesis. We also developed a conceptual and analytical

framework to examine the associations among risk factors,

violent behavior, and interventions to guide the analysis. As

these background materials were being developed, we shared

them with the NIH Panel Chair and our Task Order Officer,

discussed them with members of our TEG, and made

numerous revisions based on the feedback that we received. 

Search

The National Library of Medicine (NLM) performed all

searches. Librarians from NLM met with project staff via

teleconference to discuss the scope, the key questions, and the

search strategy. The librarians also worked with project staff to

select the databases that were ultimately used and to evaluate

the search strategies that had been developed by the project

team. 

NLM searched four electronic databases—MEDLINE®,

PsychINFO, SocioAbstracts, and ERIC—in April/May of 2003

and again in October/November 2003. For “youth,” the

following search terms were used: adolescent, teen, juvenile,

and youth. For “violence,” the following terms were used:

violence, school violence, dangerous behavior, rape, homicide,

domestic violence, courtship violence, dating violence,

interpersonal violence, date rape, raping, rapes, rapist, bully,

bullies, bullied, bullying, physical assault, physical attack,

physical aggression, direct aggression, overt aggression, knifing,

stabbing, gunshot, brutality, bludgeoning, and murder. 

Study Selection

Three inclusion criteria were applied for citations and

manuscripts: published in 1990 or thereafter, related to the

range of risk and protective factors associated with perpetrators

of youth violence and violence-related crimes between ages 12

and 17 years, and conducted in the United States only.

Excluded were case reports, unpublished program evaluations,

editorials, letters, reviews, practice guidelines, non-English

language publications, and papers from which data could not

be abstracted.

For the questions on risk factors, we based our assessment on

prospective longitudinal cohort studies, because of the general

consensus that cross-sectional studies would not allow us to

identify temporal predictors of youth violence (Heimer, 1997;

Herrenkohl, Guo, 2001). For the evaluation of the

effectiveness of interventions, we examined the findings from

randomized controlled trials (RCTs) as well as non-RCTs or

single-group time series in which a control group was used

either concurrently or prospectively. 

Evaluation of Study Quality

We evaluated the quality of individual studies using the

criteria set forth in the Procedures for EPC Reports for Office
of Dietary Supplements (ODS) and OMAR (ODS and

OMAR, 2003). Because all the prospective longitudinal cohort

studies included in our review satisfied four of the seven criteria

in the same ways, we used the three remaining criteria—

followup rate of 80 percent or more, valid and reliable

instruments used, and appropriate control of confounding

factors—to assess the quality of individual studies. For studies

that assessed the effectiveness of interventions, we used the

OMAR criteria for RCTs and observational studies. 

According to OMAR guidelines (ODS and OMAR, 2003),

the rating of the strength of scientific evidence remains the

prerogative of the Consensus Panel. However, we conducted

two sensitivity analyses to assist the Consensus Panel to assess

the strength of the scientific evidence in our review. First, we

re-analyzed the data excluding the studies with sample size

below the thresholds set at 1,100 for the general population

and 500 for the at-risk population, to restrict the analyses to

the studies with the greatest power to detect significant

predictors. Second, we re-assessed the findings using only

studies with good quality. 

Data Abstraction

For primary screening, two members of the team

independently reviewed each title or abstract: one reviewer was

a member of the faculty with specific expertise related to

adolescent development and/or youth violence, and the other

reviewer had a master’s degree in public health or was a

doctoral student in the field of psychology, public health, or

prevention research. The Task Order Manager or the Task

Order Coordinator compared the screening results of the two

reviewers and resolved discrepancies. The same procedure was

followed for secondary screening of full-length articles. For

articles selected for inclusion, data were abstracted by a member

of the project team onto a specially prepared form. Completed

forms were checked by the Task Order Manager. 

Data Synthesis

Risk factor identification. To identify homogeneous

subgroups for data pooling, we stratified the eligible studies

according to the following criteria: demographics of the study

population; characteristics of the study; outcomes; and type of

analysis. We used a systematic approach to summarize the

findings. When findings for a single cohort were reported in

multiple articles, the cohort was considered the unit of analysis.

In the summary, findings for one cohort that were reported in

more than one article were counted as only one article.

However, if several articles reported findings for one cohort but

each reported the findings for different outcome measures, each

was counted. When a risk factor was assessed using both

bivariate and multivariate analysis, the results of the

multivariate analysis took precedence. Findings were

considered significant if the p statistic was less than 0.05. 

For summarizing the evidence, we considered a factor to be

consistently associated with violence if 75 percent or more of

the cohort studies reported a significant association for the

factor. Likewise, factors reported not to be associated with

violence in at least 75 percent of the studies under

consideration were considered not associated with violence.

Otherwise, the findings were considered inconclusive. We

evaluated consistency for factors that were reported in two or

more cohort studies. Evidence was considered inadequate if the

results for a particular factor were reported in only one cohort

study.

For evaluating the effectiveness of interventions. We

stratified the accepted studies by the level of intervention and

the type of study design. Initially, we planned to stratify the

studies further by the various characteristics of interventions

that might ultimately contribute to the effectiveness of the

intervention (such as intervention setting and target

population). However, many of the reports omitted mention

of these study characteristics. 

Because of the diversity of the studies, we did not pool

findings across studies. Instead, we summarized the findings of

the programs as effective or ineffective. We considered an

intervention to be effective if one or more violence outcome

indicators was reported to be significantly different at the

p<0.05 level, based on the findings reported in the article(s). If

none of the violence outcome indicators was reported to be

significantly different, we considered the program ineffective. 

Results

We screened 11,196 titles and abstracts, reviewed 1,612 fulllength articles, and included 67 articles in our evidence

assessment (35 for the risk factor questions and 32 for the

intervention questions). 

Factors Contributing to Youth Violence (Key

Question #1)

The 35 articles that addressed risk factors contributing to

youth violence were based on 23 prospective cohort studies

covering 11 study populations defined by gender,

race/ethnicity, and at-risk population. Findings for specific

racial/ethnic groups suffered from small numbers of cohorts or

small numbers of subjects.

Across all studies, only one risk factor, male gender, was

consistently reported to be significantly associated with youth

violence perpetration (Rivera and Widom, 1990; Roitberg and

Menard, 1995; Saner and Ellickson, 1996; Komro, Williams,

1999; Foshee, Bauman, 2000; Herrenkohl, Guo, 2001;

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4

McCloskey and Lichter, 2003). Low family socioeconomic

status (SES) was consistently reported not to be an independent

risk factor for youth violence (Roitberg and Menard, 1995;

Saner and Ellickson, 1996; Herrenkohl, Egolf, 1997; Brezina,

1999; Herrenkohl, Guo, 2001; Herrera and McCloskey, 2001).

Co-occurrence of family SES with other risk factors was

associated with youth violence. There was very little

consistency of reported significance or non-significance for all

other risk factors. Few studies examined a comparable set of

risk factors (i.e., risk factors were often examined only by a

single study) limiting our ability to draw conclusions based on

the available evidence. Among studies that specifically focused

on adolescent males, a consistent finding was the significant

association between violence and anger (Felson, 1992; Foshee,

Linder, 2001), cigarette smoking (Dornbusch, Lin, 1999;

Ellickson, Tucker, 2001) and non-violent delinquency (Becker

and McCloskey, 2002; Saner and Ellickson, 1996). For

adolescent females, a consistent finding was the significant

association between violence and non-violent delinquency

(Becker and McCloskey, 2002; Herrera and McCloskey, 2003;

Saner and Ellickson, 1996). For research conducted with atrisk youth populations, a consistent finding was the significant

association between being Latino and repeated physical

aggression among adolescent males (Loeber, Wei, 1999; Loeber,

Wung, 1993); there were no consistent findings for research

conducted with at-risk adolescent females. 

Patterns of Co-occurrence of These Factors

(Key Question #2)

In addition to our search for independent risk factors that

have a high likelihood of leading to youth violence, we were

also interested in clusters of risk factors that may lead to youth

violence. A number of factors that were found to be

statistically significant when no other risk factors were taken

into account were found not to be significant when other risk

factors were taken into consideration. For example, low SES or

low family income was reported as a significant risk factor

associated with youth violence when the co-occurrence of other

risk factors was not taken into consideration. But when the

effect of other risk factors was taken into consideration, its

significance disappeared, implying that the other risk factor(s)

were stronger predictor(s) of youth violence than was low SES.

(Roitberg and Menard, 1995; Saner and Ellickson, 1996;

Herrenkohl, Egolf, 1997; Brezina, 1999; Herrenkohl, Guo,

2001; Herrera and McCloskey, 2001). 

We defined co-occurrence of factors as the simultaneous

presence of two or more risk or protective factors that together

predict violence in an individual. We identified five articles on

four cohort studies that addressed different aspects of cooccurrences. These articles reported the following findings.

Pre/perinatal risk exposure combined with disadvantaged

familial environment at age 7 increased the chances of criminal

offending during early adulthood among a high-risk, inner-city

group (Piquero and Tibbetts, 1999). Polydrug use was

associated with increased violence in both boys and girls, a

finding not identifiable from analyses that focused on the use of

a specific drug (Dornbusch, Lin, 1999). Youth exposed to

multiple risk factors were found to be more likely than others

to engage in later violence (Herrenkohl, Egolf, 1997). The cooccurrence of parent-family connectedness, school

connectedness/parental presence, and grade point average in

both boys and girls significantly decreased the risk of youth

violence (Borowsky, Ireland, 2002). Beyers et al. (Beyers,

Loeber, 2001) reported the following combinations of risk

factors associated with repeated youth violence: (a) living in a

low-SES neighborhood, lack of guilt, sexual activity, carrying a

hidden weapon, and poor communication at home and (b)

living in a high-SES neighborhood and physical aggression.

The following combinations of risk factors were reported not to

be associated with repeat youth violence: (a) living in a low-SES

neighborhood and any or a combination of the following: age,

impulsive/hyperactive behavior, low school motivation, positive

attitude toward problem behavior, boy not involved at home,

poor parental supervision, peer delinquency, or bad friends and

(b) living in a high-SES neighborhood plus any or a

combination of the following: impulsive/hyperactive behavior,

lack of guilt, positive attitude toward problem behavior, sexual

activity, or peer delinquency. 

Effectiveness of Interventions for Violence

(Key Questions #3, #4, and #5)

We identified 32 intervention evaluation studies, of which

13 employed randomized controlled trial (RCTs) design and 19

employed other study designs. The following provides a

summary of the key findings.

Effectiveness by level of intervention. Direct within-study

comparisons of the effectiveness of interventions by the level of

intervention (primary, secondary, tertiary) were not identified,

but some measure of the effectiveness of interventions by level

can be made by simply comparing the proportion of studies at

each level that report beneficial effects. Not considering the

study design and excluding one inconclusive study, effectiveness

was reported in five of 15 (33 percent) primary interventions,

four of 10 (40 percent) secondary interventions, and five of six

(83 percent) tertiary interventions. When only RCTs were

considered, effectiveness was reported in one of five (20

percent) primary intervention, three of six (50 percent)
secondary intervention, and two of two (100 percent) tertiary

interventions. 

Effectiveness by age, gender, and race/ethnicity. The focus

of this assessment was on adolescents ages 12 through 17; thus,

all programs determined to be effective reduced violent

behavior in this age group. The data did not permit further

analysis according to age. Similar to our assessment with the

level of interventions, within study comparisons are the

strongest analytic approach to study differential effectiveness by

demographic groups. However, none of the studies provided

the information needed to evaluate differential effectiveness by

age, gender, or race/ethnicity. Instead, effectiveness was

reported primarily within each gender or ethnic group. 

Effectiveness by selected characteristics of intervention

programs. Overall, we did not observe any differences in

program effectiveness among different settings, between single

or multimodal programs, among programs with different

durations, or among programs implemented at different school

levels. However, we observed that four of four (100 percent)

secondary interventions that lasted a year or longer were

effective (four of four), whereas five of five (100 percent)

secondary interventions that lasted less than 6 months were

ineffective. 

Discussion

The overarching goal of this review was to bring greater

scientific rigor to the evaluation process to identify the highest

quality research findings in the field of youth violence. With

the severely restricted scope of the project, much of the value of

this report was the identification of the current status of

research on youth violence, the existing research gaps and

inconsistencies, and the need for additional scientifically

rigorous studies. Despite the limited scope, we identified a

voluminous literature that is rather fragmented in nature. We

found little agreement with respect to the definitions used to

measure youth violence and the ways in which risk/protective

factors are conceptualized, operationally defined, measured,

analyzed, and reported. As a result, the findings showed little

consistency across individual studies and the research literature

is not growing cumulatively. Consequently, we are limited in

our ability to draw conclusions and make recommendations. 

Specifically, for the review of risk factors contributing to

youth violence, we were unable to perform a quantitative

synthesis for the risk factors by developmental stages, by type of

at-risk population, by type of violent outcome, and by type of

statistical analysis due to the limited number of prospective

cohort studies. Efforts to examine the effects of co-occurrence

of risk factors have been limited, although some efforts have

been made to examine the multifactorial nature of risk and

protective factors contributing to youth violence. 

With respect to the review of the effectiveness of prevention

interventions, the number of studies was too small for the

detection of any systematic differences among programs with

different characteristics. The characterization of intervention

programs was not consistently or uniformly reported in

published articles, making it difficult to evaluate program

effectiveness by program characteristics. 

Priorities for Future Research (Key Question

#6)

Risk factors contributing to youth violence. Considerable

effort is needed to develop uniformity in the ways in which

youth violence and violence-related outcomes are both defined

and operationalized, and these definitions should be

incorporated into future research to begin to build some

consistency and uniformity in study findings. We therefore

recommend initiation of a national effort to develop

comparable approaches to defining, measuring, and analyzing

research data related to youth violence, and the funding of new

initiatives to facilitate the collection of comparable data across

multiple sites and with multiple youth populations. Such

multi-site cooperative agreement studies would permit the use

of a combined prospective cohort from which a common

standardized dataset could be assembled and analyzed. 

Further, additional research is needed to examine both

sequential and simultaneous co-occurrences of risk factors that

contribute to youth violence. Future research should

concentrate on minimizing both non-participation and

attrition in longitudinal studies. 

Natural prospective cohorts must be established, pseudo

prospective cohorts could also be considered. We have

identified many prospective cohort studies focused on various

stages of development, different types of study population, and

different types of outcomes that could be coordinated and

assembled to form a pseudo prospective cohort from which a

common dataset could be assembled and advanced statistical

analysis conducted. Such an effort would require strong central

support, cooperation from all parties involved, and long-term

financial commitments.

Interventions for the prevention of youth violence. More

randomized controlled interventions are needed to evaluate

program effectiveness in general and for various groups of

youth in particular, e.g., those of different ages, both genders,

all ethnicities/races, and possessing the various characteristics

that appear to increase risk. We therefore recommend that

researchers increase the scientific rigor, including the use of

control populations and extended followup, to evaluate the

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sustained effectiveness of youth violence prevention

interventions. While RCTs with individual subjects are ideal,

they are difficult to implement in “real world” settings,

especially for the behavioral and social sciences, and group

RCTs are the best alternatives. Therefore, it is important that

more research effort be focused on the design, implementation,

and analysis of group RCTs. Research in this area will

contribute greatly to the scientific methods in the social

sciences. 

A national consensus building effort is also needed to

identify and clarify the science related to (a) the use of

conceptual frameworks and causal pathways related to youth

violence; (b) risk factors and mechanisms leading to violent

outcomes; (c) strategies and interventions to reduce violent

outcomes; (d) methodologies and scientifically grounded

approaches that should ideally be used to evaluate prevention

interventions; (e) the effective use of policy to reduce youth

violence; and (f) methodologies for evaluating such policies. 

Rating of study quality. For prospective longitudinal

studies, we have shown that a high retention rate alone is

inadequate to measure sample bias. We believe that the

participation rate, followup or retention rate, and proportion of

participants with complete data should be considered when

assessing the possibility of bias in the study sample, especially

for outcomes such as violence. For intervention studies, we do

not believe that the OMAR study quality criteria truly assessed

the quality of the studies we reviewed because they were derived

primarily from clinical studies. Unlike many clinical

interventions for medical conditions, youth violence

interventions are often multifaceted, involve the efforts of

multiple parties (e.g., teachers, parents, school administrators,

and so on), are conducted over long periods of time, and can

be adversely affected by factors that cannot be anticipated,

characteristics that make the studies difficult to evaluate. The

nature of the interventions in social science studies can also

preclude some of the methodological components critical to

clinical trials. The need to develop valid instruments to

evaluate the quality of studies in the social sciences is apparent.

Quality of publications. Special efforts are needed to

improve the quality of publications, including the consistency

and adequacy with which the study characteristics, such as

research questions, conceptual framework, study design, and

description of the study population, are specified.

Evidence assessment methods. Because of the multifactorial nature of the factors contributing to youth violence,

alternatives to quantitative synthesis of published information

should be sought. Unlike many clinical interventions,

interventions to prevent or stop youth violence are often multifaceted, involving the efforts of multiple parties (e.g., teachers,

parents, and school administrators), requiring long time

commitments, and being sensitive to factors that cannot be

anticipated. We propose that social science researchers consider

an “individual-level-data-meta-analysis” method (Olkin and

Sampson, 1998; Mathew and Nordstrom, 1999; Stewart and

Clarke, 1995; Stewart and Parmar, 1993; Nagin and Tremblay,

1999) for future systematic reviews to identify both

independent predictors and clusters of predictors that lead to

youth violence. The method is described further in the report.

Availability of the Full Report

The full evidence report from which this summary was taken

was prepared for the Agency for Healthcare Research and

Quality (AHRQ) by the Southern California Evidence-based

Practice Center, under Contract No. 290-02-0003. It is

expected to be available in October 2004. At that time, printed

copies may be obtained free of charge from the AHRQ

Publications Clearinghouse by calling 800-358-9295.

Requesters should ask for Evidence Report/Technology

Assessment No. 107, Preventing Violence and Related HealthRisking Social Behaviors in Adolescents. In addition, Internet

users will be able to access the report and this summary online

through AHRQ’s Web site at www.ahrq.gov.

Suggested Citation

Chan LS, Kipke MD, Schneir A, Iverson E, Warf C,

Limbos MA, Shekelle P. Summary, Evidence

Report/Technology Assessment No. 107. (Prepared by the

Southern California Evidence-based Practice Center, under

Contract No. 290-02-0003.) AHRQ Publication No. 04-E032-

1. Rockville, MD: Agency for Healthcare Research and Quality.

September 2004.

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www.ahrq.gov

AHRQ Pub. No. 04-E032-1

September 2004

ISSN 1530-440X