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Violence is among the leading causes of death and disability for American children and adolescents. The epidemic of murder took the lives of approximately 2000 young people annually between 1980 and 2002. During this period, approximately 1 of every 4 youth homicides was committed by juveniles. Overall, homicide was the third leading cause of death for youth aged 13 to 21 and the leading cause of death for African American young men in this age category. Despite a recent national decline in the homicide rate, the United States continues to have one of the highest homicide rates in the world.1,2

While homicide is the most extreme form of community violence, many more young people are injured: The ratio of nonfatal to fatal assaults is estimated to be 100 to 1. Over 780,000 youth were treated in US emergency departments for nonfatal injuries in 2004, and twice as many are victims of physical dating violence each year. When surveyed, over one third of high school students report having been in a physical fight in the past 12 months (40% and 25% of males and females respectively); in fact, the rate of injuries due to fighting has remained steady for decades. One in 8 youths reported carrying weapons for protection, and 1 in 9 report avoiding school due to fear of violence.3

The quality of the family and community environment during childhood and adolescence has profound and lasting effects, which persist into adulthood. Recent studies have demonstrated that exposure to violence is among the earliest and most pervasive adverse experiences.4 Childhood adversities have been linked to future physical, mental, and developmental health and to all major causes of morbidity and mortality in adulthood.5,6 One of every 10 children attending a Boston, Massachusetts, city hospital pediatric primary care clinic witnessed a shooting or stabbing in their homes or communities before the age of 6.7 This high prevalence of violence exposure underscores the importance of violence as a public health problem.

Pediatricians play a crucial role in preventing, identifying, and intervening in such situations. Contrary to the perception that violence consists of random acts in society, violence is most likely to be perpetrated by individuals known to the victim. Hospital readmission for subsequent assaults and homicide are high. Moreover, violence is associated with known risk and resilience factors that may be routinely assessed during the course of medical care.8

Well-established risk factors for violence-related injury include access to firearms, history of fighting or injury, violent discipline, alcohol and drug use, exposure to familial violence, media violence, and gang involvement. As this list of risk factors makes evident, distinct forms of violence rarely occur in isolation. In addition to these individual risk factors, violence also tends to be highly correlated with other social adversities, particularly poverty, substance abuse, housing insecurity, parental mental health challenges, and neighborhood disadvantage.9


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