On the positive side, there exists today a diverse array of highly promising strategies for preventing and treating serious youth violence. Some of these have been subject to rigorous efficacy testing, and conclusions of these studies militate against the idea that the problem of youth violence is intractable.

These are among the key findings of "Youth Violence: A Report of the Surgeon General," the fourth major report from David Satcher, M.D., on topics of immediate relevance to the mental health field and psychiatry. Previous reports include his "Call to Action to Prevent Suicide" (1999); the landmark surgeon general’s report on mental health (1999); and early this year, the "National Action Agenda for Child Mental Health" (see page 1).

Each of the surgeon general’s reports has adhered to the public health model. This is a population-based model that encompasses surveillance to track incidence and prevalence; epidemiologic research into risk and protective factors; studies of the effectiveness and generalizability of interventions, with particular emphasis on evaluation of programs that have been instituted in "real world" settings; and active dissemination of information to both practitioners and to the public.

Other cross-cutting themes of the reports have included a developmental, life-span perspective in examining risks for and onset of disorders. The reports also have emphasized the importance of early detection of mental disorders or problem behaviors; their appropriate treatment; and, where the science has advanced adequately, targeted preventive interventions.

Calls for a surgeon general’s report on youth violence came in the wake of the shootings at Colorado’s Columbine High School. Dr. Satcher invited sociologist Delbert Elliott, Ph.D., a long-time research grantee of NIMH and other federal agencies, to serve as scientific editor. He also is director of the Program on Problem Behavior and Director of the Center for the Study and Prevention of Violence at the University of Colorado.

Within the past year, Dr. Elliott orchestrated a comprehensive review of a vast, multidisciplinary literature, with the aim of blending offender-based research with public health concepts of intervention and prevention.

In reviewing the extent of youth violence, the report reconciles the apparent discrepancies that I referred to earlier between official arrest data and systematic self-report data by youths across the country. The analysis makes clear that the 1983-93 epidemic of violence represented an epidemic of arrests driven by the accessibility of guns and the readiness of youth to use guns in violent encounters. For reasons that are not fully clear, fewer youth today are carrying guns. Thus, while self-reports indicate that interpersonal violence among youth persists at the very high levels seen at the height of the epidemic, the reduced likelihood of lethal injury lowers the odds of police involvement.

A separate chapter is devoted to the developmental dynamics of youth violence, especially the well-documented early- and late-onset trajectories into patterns of violent behavior. Onset data reveal that the proportion of youth who first engage in serious violence in childhood is smaller than the proportion of those who begin violent behavior in adolescence; still, the early-onset group tends to commit quantitatively more, and qualitatively more serious, crime for a longer period than the later-onset group. Thus, while the violence "careers" that come out of the early-onset group tend to be more severe, the epidemiology reveals that limiting prevention programs solely to younger children with problem behaviors will miss more than half of those children who eventually become serious violent offenders.

Noting that the relationship between mental health and violence has been studied more intensively in adults than in young people, the report’s authors reprise the conclusion of the earlier mental health report that the contribution of mental disorders to overall violence in the United States is very small. Still, while only a small proportion of youth who have mental and behavioral disorders will ultimately become involved in serious violence, a disproportionate number of youth incarcerated for violent offenses have histories of psychopathology. The National Youth Survey, for example, classified youth as having "mental health problems" on the basis of their responses to questions about emotional problems, social isolation, and feelings of loneliness; serious violent offenders were found to be more likely than either nonserious offenders or nonoffenders to report such problems. To the same point—although not discussed in the report—are preliminary data from an NIMH-supported study that found that of 1,800 youth in a typical detention center in Chicago, two-thirds have one or more alcohol, drug, or mental disorder and are at increased risk of early death compared with other youth.

A wealth of research has provided insights into risk factors involved in the onset and developmental course of violence, and the report considers these in some depth. Among key points drawn from the review is that the predictive power of many risk and protective factors is linked to the context and timing of their occurrence; substance abuse, for example, is a more powerful risk factor for subsequent violent behavior at age 9 than at age 14, for example.

The surgeon general’s report confirms observations that at first blush may seem obvious but that all too often are not reflected at the policy level. One is that the aggregation of antisocial or delinquent peers is a powerful risk factor for careers of criminal offending. A cornerstone of model interventions such as therapeutic foster care, developed with NIMH support by researchers at the Oregon Social Learning Center, is preventing high-risk youth from spending time together. Still, despite accumulating research documenting the general ineffectiveness of interventions that cluster large numbers of delinquent and violent youths together in such settings as boot camps and residential psychiatric or correctional institutions, these approaches remain popular.

Observations that the bulk of violent offending occurs in the after-school hours underscore the importance of supervision of children. Buttressed by research showing that association with antisocial, delinquent peers is a strong risk factor for violence, the importance of parental supervision again would seem obvious, but too many children spend the hours between 3 p.m. and 10 p.m. unwatched and unaccounted for.

Equally important, the youth violence report reappraises much conventional wisdom. Research that has dissected the components of conduct disorder to understand its linkage to youth violence suggests that physical aggressiveness, more than antisocial attitudes and beliefs, account for most of the predictive power of the diagnosis. Risk research indicates that other childhood disorders, such as ADHD and depression, while not risk factors for violence, can negatively affect family, social, and academic functioning and thus contribute to risk for violent behavior indirectly.

The final major chapter identifies and applies a set of scientific standards to the literature on youth violence prevention to identify programs that work, that are promising, or that do not work to prevent youth violence.

The chapter examines and rates the effectiveness of both broad intervention strategies and 27 specific programs. While the details and caveats contained in the report argue against my summarizing findings in this brief commentary, the authors offer a general conclusion that most highly effective programs combine components that address both individual risks and environmental conditions: building individual skills and competencies, enhancing parenting skills, improving the social climate of schools, and effecting appropriate changes in type and level of involvement in peer groups. Given trends in juvenile justice that in recent years have called for "adult time for adult crime," it is noteworthy that the report identifies as ineffective the practice of waiving juvenile offenders to adult courts and prisons

We at NIMH are confident that the "Surgeon General’s Report on Youth Violence" will be an influential source in helping to guide future research in this critical area, and we are pleased to have participated in its development.

A full copy of the report is available on the surgeon general’s Web site at www.surgeongeneral.gov/library/youthviolence/default.htm and through the Knowledge Exchange Network (KEN) at (800) 789-2647. ▪