Message from Donna E. Shalala Secretary of Health and Human Services

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The first, most enduring responsibility of any society is to ensure the health and well-being of its children. It is a responsibility to which multiple programs of the Department of Health and Human Services are dedicated and an arena in which we can claim many remarkable successes in recent years. From new initiatives in child health insurance and Head Start, to innovative approaches to child care, to the investment in medical research that has ameliorated and even eliminated the threat of many once lethal childhood diseases, we have focused directly and constructively on the needs of millions of children. Through programs designed to enhance the strength and resiliency of families and family members across the life span and through our investments in diverse community resources, we are also helping to enhance the lives and enrich the opportunities of millions more of our children.

Although we can take rightful pride in our accomplishments on behalf of U.S. youths, we can and must do more. The world remains a threatening, often dangerous place for children and youths. And in our country today, the greatest threat to the lives of children and adolescents is not disease or starvation or abandonment, but the terrible reality of violence.

We certainly do not know all of the factors that have contributed to creating what many citizens–-young and old alike—view as our culture of violence. It is clear, however, that as widespread as the propensity for and tolerance of violence is throughout our society—and despite efforts that, since 1994, have achieved dramatic declines in official records of violence on the part of young people—every citizen must assume a measure of responsibility for helping to reduce and prevent youth violence. Information is a powerful tool, and this Surgeon General's report is an authoritative source of information.

In directing the Surgeon General to prepare a scholarly report that would summarize what research can tell us about the magnitude, causes, and prevention of youth violence, President Clinton sought a public health perspective on the problem to complement the extraordinary work and achievements in this area that continue to be realized through the efforts of our criminal and juvenile justice systems. Over the past several months, the Department of Health and Human Services has worked with many hundreds of dedicated researchers, analysts, and policy makers whose interests and expertise lie outside the traditional domains of health and human services. What has become clear through our collaboration is that collectively we possess the tools and knowledge needed to throw safety lines to those young Americans who already have been swept up in the currents of violence and to strengthen the protective barriers that exist in the form of family, peers, teachers, and the countless others whose lives are dedicated to the futures of our children.

This Surgeon General's report seeks to focus on action steps that all Americans can take to help address the problem, and continue to build a legacy of health and safety for our young people and the Nation as a whole.

Foreword

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The opportunity for three Federal agencies, each with a distinct public health mission, to collaborate in developing the Surgeon General's report on youth violence has been an invigorating and rewarding intellectual challenge. We and our respective staffs were pleased to find that the importance that we collectively assign to the topic of youth violence transcended any impediments to a true, shared effort. Obstacles that one might have anticipated—for example, difficulties in exchanging data and discussing concepts that emanate from many different scientific disciplines—proved to be surmountable. Indeed, many of the differences in perspective and scientific approach that distinguish the Centers for Disease Control and Prevention (CDC), the National Institutes of Health (NIH), and the Substance Abuse and Mental Health Services Administration (SAMHSA), when combined, afforded us a much fuller appreciation of the problem and much firmer grounds for optimism that the problem can be solved than is obvious from within the boundaries, or confines, of a single organization.

The mission of CDC is to promote health and quality of life by preventing and controlling disease, injury, and disability. The NIH, of which the National Institute of Mental Health (NIMH) is one component, is responsible for generating new knowledge that will lead to better health for everyone. SAMHSA is charged with improving the quality and availability of prevention, treatment, and rehabilitation services in order to reduce illness, death, disability, and cost to society resulting from substance abuse and mental illnesses. Common to each of the agencies is an interest in preventing problems before they have a chance to impair the health of individuals, families, communities, or society in its entirety. Toward this end, CDC, NIH/NIMH, and SAMHSA each support major long-term research projects involving nationally representative samples of our Nation's youth. These studies, which are introduced and described in the report that follows, are designed both to monitor the health status of young Americans and to identify factors that can be shown to carry some likelihood of risk for jeopardizing health—information that lends itself to mounting effective interventions.

The designation of youth violence as a public health issue complements the more traditional status of the problem as a criminal justice concern. Here again, it has been satisfying for all of us in the public health sector to reach across professional and disciplinary boundaries to our colleagues in law, criminology, and justice and work to meld data that deepen our understanding of the patterns and nature of violence engaged in by young people throughout our country.

What has emerged with startling clarity from an exhaustive review of the scientific literature and from analyses of key new data sources is that we as a Nation have made laudable progress in gaining an understanding of the magnitude of the problem. We have made great strides in identifying and quantifying factors that, in particular settings or combinations, increase the probability that violence will occur. And we have developed an array of interventions of well-documented effectiveness in helping young people whose lives are already marked by a propensity for violence as well as in preventing others from viewing violence as a solution to needs, wants, or problems.

CDC, NIH/NIMH, and SAMHSA look forward to continuing collaborations, begun during the development of this report, that will extend further the abilities of policy makers, communities, families, and individuals to understand youth violence and how to prevent it.

Jeffrey P. Koplan, M.D., M.P.H.
Director
Centers for Disease Control and Prevention

Joseph H. Autry III, M.D.
Acting Administrator
Substance Abuse and Mental Health Services Administration

Steven E. Hyman, M.D.
Director
National Institute of Mental Health for The National Institutes of Health

Preface
from the Surgeon General
U.S. Public Health Service

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The immediate impetus for this Surgeon General's Report on Youth Violence was the Columbine High School tragedy that occurred in Colorado in April 1999, resulting in the deaths of 14 students, including 2 perpetrators, and a teacher. In the aftermath of that shocking event, both the Administration and Congress requested a report summarizing what research has revealed to us about youth violence, its causes, and its prevention.

Our review of the scientific literature supports the main conclusion of this report: that as a Nation, we possess knowledge and have translated that knowledge into programs that are unequivocally effective in preventing much serious youth violence. Lest this conclusion be considered understated or muted, it is important to realize that only a few years ago, substantial numbers of leading experts involved in the study and treatment of youth violence had come to a strikingly different conclusion. Many were convinced then nothing could be done to stem a tide of serious youth violence that had erupted in the early 1980s. During the decade extending from 1983 to 1993, arrests of youths for serious violent offenses surged by 70 percent; more alarmingly, the number of young people who committed a homicide nearly tripled over the course of that deadly decade. In many quarters, dire predictions about trends in youth violence yielded to resignation; elsewhere, fear and concern prompted well-meaning officials and policy makers to grasp at any proposed solutions, often with little, if any, systematic attention to questions of the efficacy or effectiveness of those approaches.

Fortunately, the past two decades have also been distinguished by the sustained efforts of researchers, legislators, and citizens from all walks of life to understand and address the problem of youth violence. One seminal contribution to these efforts was an initiative taken by one of my predecessors, Surgeon General C. Everett Koop, to address violence as a public health issue; that is, to apply the science of public health to the treatment and prevention of violence. As evident throughout this report, that endorsement was key to encouraging multiple Federal, state, local, and private entities to invest wisely and consistently in research on many facets of youth violence and to translate the knowledge gained into an exciting variety of intervention programs.

Although much remains to be learned, we can be heartened by our accomplishments to date. For one, our careful analyses, together with those conducted by components of the justice system, have demonstrated the pervasiveness of youth violence in our society; no community is immune. In light of that evidence, it has been most encouraging to me to see that the citizens with whom I have interacted in hundreds of communities around the Nation want us to find answers that will help all of our youth. There is a powerful consensus that youth violence is, indeed, our Nation's problem, and not merely a problem of the cities, or of the isolated rural regions, or any single segment of our society.

Equally encouraging have been our findings that intervention strategies exist today that can be tailored to the needs of youths at every stage of development, from young childhood to late adolescence. There is no justification for pessimism about reaching young people who already may be involved in serious violence. Another critical bit of information from our analyses of the research literature is that all intervention programs are not equally suited to all children and youths. A strategy that may be effective for one age may be ineffective for older or younger children. Certain hastily adopted and implemented strategies may be ineffective—and even deleterious—for all children and youth.

Understanding that effectiveness varies underscored for us the importance of bridging the gap between science and practice. Only through rigorous research and thorough, repeated evaluations of programs as they operate in the real world will we be assured that we are using our resources wisely.

In presenting this Surgeon General's report, I wish to acknowledge our indebtedness to the many scientists who have persisted in their work in this difficult, often murky area and whose results we have scrutinized and drawn on. We are also immensely grateful to the countless parents, police officers, teachers, juvenile advocates, health and human service workers, and people in every walk of life who recognize the inestimable value of our Nation's youth and the importance of peace, security, and comity in their lives.

David Satcher, M.D., Ph.D.
Surgeon General