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The Evidence for Violence Prevention Across the Lifespan and Around the World: Workshop Summary (2014)

Chapter: II.3 Evidence for Global Violence Prevention During Adolescence and Emerging Adulthood--Jennifer L. Matjasko and Sarah Bacon

« Previous: II.2 The Federal Role in Promoting Evidence-Based Violence Prevention Practices--Mary Lou Leary and Thomas P. Abt
Suggested Citation:"II.3 Evidence for Global Violence Prevention During Adolescence and Emerging Adulthood--Jennifer L. Matjasko and Sarah Bacon." Institute of Medicine and National Research Council. 2014. The Evidence for Violence Prevention Across the Lifespan and Around the World: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/18399.
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that will include randomized controlled trials (RCTs) to measure its effectiveness in other jurisdictions.

Moving Ahead

OJP has instituted a broad strategic approach for integrating evidence in its programmatic and policy-making activities. Its efforts have received support from both Attorney General Holder, who has used his position to call for evidence-based practices in criminal justice and has appointed a Science Advisory Board to guide science into OJP’s programs, and President Barack Obama, who with the approval of Congress has set aside 2 percent of OJP’s budget for research, statistical, and evaluation activities. Under their leadership, evidence now occupies a central position in federal criminal justice planning. The vision of President Johnson’s Crime Commission—of a justice system informed by knowledge—is coming into clearer focus.

II.3
EVIDENCE FOR GLOBAL VIOLENCE PREVENTION DURING ADOLESCENCE AND EMERGING ADULTHOOD
1

Jennifer L. Matjasko, Ph.D., and Sarah Bacon, Ph.D.2Division of Violence Prevention, National Center for Injury Prevention and Control, Centers for Disease Control and Prevention

Health is a dynamic state of well-being characterized by a physical, mental, and social potential, which satisfies the demands of a life commensurate with age, culture, and personal responsibility.

—Bircher, 2005

Adolescence is generally a healthy period of the life course characterized by relatively low morbidity and mortality rates. Adolescence is also a developmental phase characterized by rapid physical, social, emotional, and developmental changes and growth. As a result, this developmental phase represents a pivotal time in shaping behavioral trajectories by either supporting positive ones or redirecting negative ones. In our efforts to facilitate healthy development for adolescents, it is essential to meet the particular developmental needs of individuals at this stage of the life

_________________

1 The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention.

2 The authors wish to thank Linda Dahlberg, Greta Massetti, and Alana Vivolo-Kantor for their valuable feedback and input.

Suggested Citation:"II.3 Evidence for Global Violence Prevention During Adolescence and Emerging Adulthood--Jennifer L. Matjasko and Sarah Bacon." Institute of Medicine and National Research Council. 2014. The Evidence for Violence Prevention Across the Lifespan and Around the World: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/18399.
×

course. Adolescent involvement with violence disrupts the course of healthy development for many adolescents worldwide. Violence is defined as “the intentional use of physical force or power, threatened or actual, against oneself, another person, or against a group or community, that either results in or has a high likelihood of resulting in injury, death, psychological harm, maldevelopment, or deprivation” (Krug et al., 2002, p. 4). Gore et al. (2011) explored the global burden of disease in those between the ages of 10 and 24. They found that violence ranks as the fifth leading cause of morbidity for youth in that age range as measured by disability-adjusted life years. Thus, the primary prevention of youth violence (i.e., preventing the initial occurrence of violence) is critical in meeting the development needs of adolescence and setting individuals on positive behavioral trajectories during this stage of the life course. In this paper, we identify the universal developmental tasks and needs that characterize adaptive and prosocial adolescent development, and describe the evidence supporting youth violence primary prevention programs that address these needs and offer promising options for global youth violence prevention. The universal developmental tasks and needs are consistent principles that transcend global and cultural contexts. Effective global youth violence prevention efforts may vary, but it is critical that they address these universal developmental tasks and needs.

For the purposes of this paper, we are defining adolescence and emerging adulthood as individuals between ages 10 and 24. There are noteworthy cultural variations in the extent to which adolescence is recognized as a distinct stage in the life course. Most cultures differentiate between childhood and adulthood with a period of preparation for adult roles and responsibilities. Despite these variations, the developmental tasks and needs of adolescence are universal. A list of developmental tasks is included in Table II-1. All of these tasks are necessary precursors for developing into a positive and productive (i.e., healthy) adult, regardless of culture or context. Also, a list of developmental needs is included in Table II-2, and these needs must be met to successfully accomplish the universal developmental tasks of adolescence.

In terms of opportunities to meet these developmental needs, the social ecological model locates where there may be resources and/or deficits for adolescents. The ecological framework specifies that an individual operates within family, school, and community contexts. Yet, that individual is not just acted upon by influences in those contexts; the various attributes and needs that the individual expresses interact with the forces exerted by each level of the social ecology. As to these other levels of the social ecology, the family/relational, school, community, and societal contexts either fulfill the adolescents’ developmental needs or they create deficits in meeting those needs. Because the social ecological context of adolescence is critical in pinpointing opportunities for meeting the developmental needs of adolescence,

Suggested Citation:"II.3 Evidence for Global Violence Prevention During Adolescence and Emerging Adulthood--Jennifer L. Matjasko and Sarah Bacon." Institute of Medicine and National Research Council. 2014. The Evidence for Violence Prevention Across the Lifespan and Around the World: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/18399.
×

TABLE II-1 The Universal Developmental Tasks of Adolescence


Developmental Tasks Definition

Achieving emotional autonomy The skills to deal with and handle emotions without having to heavily rely on others to process emotions
Achieving behavioral autonomy The skills to act without having to heavily rely on others to take action
Understanding one’s emerging sexuality The ability to recognize, process, and manage one’s emerging sexuality during a period when hormonal changes occur
Acquiring the interpersonal skills for dealing with romantic relationships The skills to form healthy intimate relationships with a romantic partner which will aid in mate selection and the transition to adult intimate relationships and marriage
Resolving identity issues The identity exploration is aided by the ability to think abstractly about who you are and who you would like to be and involves reflection about one’s values in different domains of life
Acquiring education and other experiences needed for adult work Acquiring educational and occupational experiences will aid in the transition to an independence during adulthood

SOURCE: Havighurst, 1953.

the framework has also been used to explore opportunities for preventing violence at this stage of the life course. Programs designed to prevent youth violence are often described according to the social ecological model. Below, we summarize the evidence base based a slight variation of the model.

Evidence Base for Violence Prevention During Adolescence and Emerging Adulthood

For the purposes of this paper, we will summarize the evidence base for youth violence prevention and identify the universal developmental needs that are met by various programs and strategies. We identify the various types and broad categories of prevention programs that have demonstrated evidence of effectiveness, and then provide one specific example of an effective program at each level of the social ecology. We use the social ecological model as a general guide in classifying the evidence base, but expand it to provide a more cohesive grouping of programs that have

Suggested Citation:"II.3 Evidence for Global Violence Prevention During Adolescence and Emerging Adulthood--Jennifer L. Matjasko and Sarah Bacon." Institute of Medicine and National Research Council. 2014. The Evidence for Violence Prevention Across the Lifespan and Around the World: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/18399.
×

TABLE II-2 The Universal Developmental Needs of Adolescence


Developmental Needs Links to Developmental Tasks

Positive social interaction with adults and peers Positive social interaction can be a sounding board for identity issues, encourage a developmentally appropriate level of autonomy, and the development of prosocial interpersonal skills
Structure and clear limits While autonomy is an important task of adolescence, the need for structure and clear limits is constant, making it important that adolescents’ families and schools are structured with clear limits on what is acceptable and unacceptable behavior
Opportunities for self-definition within communities Communities are important contexts for the identity exploration process making it critical that there be adequate community resources to aid in the process
Meaningful participation within schools and families In order to build autonomy and interpersonal skills, adolescents must have opportunities to contribute to their households and schools in meaningful ways
Competence and achievement Competence and achievement in multiple domains (e.g., education, sports) aids in identity exploration, acquiring education, and other experiences needed for adult work
Creative expression and physical activity The need for outlets for creativity and physical expression aids in the identity exploration process and helps adolescents to understand what their values are

SOURCE: Scales, 1991.

demonstrated effectiveness for youth violence prevention. The groupings include (1) school-based programs, (2) parenting and family approaches, (3) therapeutic approaches for high-risk youth, (4) mentoring and other relationship-building strategies, and (5) community-level strategies. The evidence base includes programs that are implemented during the period of adolescence and emerging adulthood. It also includes programs implemented during other phases of the life course that have demonstrated impacts on youth violence-related outcomes. Youth violence includes acts of violence perpetrated by youth between the ages of 10 and 24 and excludes sexual violence, teen dating violence, intimate partner violence, and suicide.

Before we explore the evidence base for youth violence prevention, we point out several important considerations. First, the evidence is based primarily on rigorous evaluations conducted in the United States or other high-resource, primarily English-speaking countries typically delivering the programs within existing infrastructures. In the United States, this means working in both the public and the private sectors with the various service

Suggested Citation:"II.3 Evidence for Global Violence Prevention During Adolescence and Emerging Adulthood--Jennifer L. Matjasko and Sarah Bacon." Institute of Medicine and National Research Council. 2014. The Evidence for Violence Prevention Across the Lifespan and Around the World: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/18399.
×

providers and systems that interface with youth and their families during childhood, adolescence, and early adulthood. The systems and service providers are different in developing countries. Thus, keeping these differences in context in mind is important when considering whether and how to implement evidence-based programs outside of high-resource countries, and research is considering how to best adapt evidence-based programs for use in varying contexts (Kumpfer et al., 2012). Second, we will summarize some general approaches that have been shown to be effective in reducing violent behaviors among adolescents, but it is important to bear in mind that there is significant variation within each general category. That is, for the approaches mentioned at each level of the social ecology, there are programs within each class that are not effective, or that simply have not been evaluated. We encourage readers to consult registries such as Blueprints for Violence Prevention of the Center for the Study and Prevention of Violence at the University of Colorado at Boulder to explore the specific programs that have demonstrated effectiveness in reducing youth violence-related outcomes. In addition, systematic reviews of youth violence prevention programs and approaches offer useful resources in summarizing the evidence base (Fagan and Catalano, 2012; Matjasko et al., 2012).

School-Based Approaches

School-based programs include a range of approaches that are implemented within the school setting. Generally, they are aimed at reducing student misbehavior, improving teacher management of student behavior, and improving school climate. Many evidence-based school programs have shown moderate to strong effects on youth violence-related outcomes (Matjasko et al., 2012). These include conduct problem prevention programs implemented in elementary schools, drug use prevention programs, conflict resolution programs, social and emotional learning programs, achievement mentoring, early childhood education, and multitiered school climate improvement programs. The developmental needs addressed in these categories include (1) positive social interactions with adults and peers, (2) structure and clear limits provided by teachers so that classrooms are more manageable, (3) opportunities for meaningful participation within these schools, and (4) facilitation of adolescent competence and achievement within the school environment.

One example of an evidence-based school program is Life Skills Training (LST). LST is implemented within the school setting and aims to address the major risk factors that are associated with substance use, delinquency, and violence. The program addresses multiple risk factors and teaches the personal and social skills necessary for youth to successfully navigate the developmental tasks of adolescence. LST provides educational materials

Suggested Citation:"II.3 Evidence for Global Violence Prevention During Adolescence and Emerging Adulthood--Jennifer L. Matjasko and Sarah Bacon." Institute of Medicine and National Research Council. 2014. The Evidence for Violence Prevention Across the Lifespan and Around the World: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/18399.
×

about the major life transitions of adolescence, as well as opportunities to practice the social skills that are taught in the curriculum. The program also uses culturally sensitive and developmentally appropriate content and has demonstrated significant impacts on reducing youth violence and delinquency-related outcomes (Botvin et al., 2006). The program is now undergoing global implementation.

Parenting and Family Approaches

Programs and strategies at this level of the social ecological model include family-based interventions and parenting skills programs. These approaches generally aim to improve functional (i.e., healthy) family processes and improve parenting skills. Across systematic reviews and meta-analyses, family/relational approaches show moderate effects on youth violence prevention (Matjasko et al., 2012). Specific evidence-based approaches include family therapeutic approaches and parenting skills training during childhood and adolescence. They also include various forms of cognitive behavioral therapy (CBT) and multilevel programs that include individual therapeutic approaches focused on changing adolescent maladaptive behavior. Generalizing from these effective family/relational-level treatment approaches, the developmental needs addressed in these categories include

  • encouraging positive interaction with adults and peers by changing relational processes so that they are healthy and adaptive;
  • providing structure and clear limits for the adolescents;
  • allowing adolescents to engage in meaningful ways with their families by fostering more functional relational processes; and
  • establishing relationships with prosocial adult mentors in the communities who may introduce adolescents to opportunities for self-definition within a community.

Brief Strategic Family Therapy (BSFT) offers one example of an evidence-based parenting and family strategy. BSFT is a short-term, problem-focused intervention with an emphasis on modifying maladaptive patterns of interactions. Therapy is based on the assumption that each family has unique characteristics that emerge when family members interact, and that this family “system” influences all members of the family, thus the family is viewed as a whole organism. BSFT works to transform any maladaptive interactional patterns into more functional ones and has been found to reduce symptoms of conduct disorder and aggression (Szapocznik and Williams, 2000).

Additionally, one example of a multilevel parenting and family approach that also includes individual therapeutic approaches is multisystemic

Suggested Citation:"II.3 Evidence for Global Violence Prevention During Adolescence and Emerging Adulthood--Jennifer L. Matjasko and Sarah Bacon." Institute of Medicine and National Research Council. 2014. The Evidence for Violence Prevention Across the Lifespan and Around the World: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/18399.
×

therapy (MST), which addresses the multiple factors known to be related to delinquency across the key settings in which youth lives unfold. Working closely with parents and families, MST strives to promote behavior change in each youth’s natural environment, using the strengths of each system (e.g., family, peers, school, neighborhood) to facilitate change. One of the major goals of MST is to empower youth to cope with family, peer, school, and neighborhood problems. This program has been found to reduce delinquency and recidivism in rigorous evaluation trials (Henggeler et al., 1998).

Therapeutic Approaches for High-Risk Youth

Therapeutic approaches for high-risk youth share the general goal of reducing maladaptive behaviors—like aggression and violence—and promoting prosocial behavior. Specific evidence-based approaches include CBT and social skills training with high-risk youth. Many approaches also include parents and families within treatment, and have been found to have moderate effects on reducing youth violence (Matjasko et al., 2012). In terms of the developmental needs addressed by individual approaches, they include (1) encouraging positive interaction with adults and peers by reducing maladaptive behaviors, (2) promoting healthy physical activity and creative expression (particularly with CBT), and (3) increased competence and meaningful participation in families and schools.

One example of an evidence-based cognitive behavioral therapy program that also includes a family component is Trauma-Focused Cognitive Behavioral Therapy (TF-CBT). TF-CBT aims to alleviate symptoms of stress by teaching participants the skills necessary to process thoughts and feelings from a traumatic event in a functional manner. The program is composed of individual sessions with children/adolescents and their therapists. It also includes a family component that teaches parents the skills necessary to better support their children and several parent–child sessions with the therapist. In a rigorous evaluation of the program, TF-CBT was found to significantly reduce child behavior problems (Cohen et al., 2000).

Mentoring and Relationship-Building Strategies

Mentoring and relationship-building strategies aim to foster prosocial relationships with adults and peers. They include structured mentoring strategies, through which adults from the community are paired with adolescents. Focused on achievement or social activities, the pair meets for a specified number of hours and the adult serves as a positive role model for the adolescent. Approaches in this category also include strategies that connect youth with prosocial peers of the same age or slightly older ones who can also serve as positive influences for adolescents. Programs in this

Suggested Citation:"II.3 Evidence for Global Violence Prevention During Adolescence and Emerging Adulthood--Jennifer L. Matjasko and Sarah Bacon." Institute of Medicine and National Research Council. 2014. The Evidence for Violence Prevention Across the Lifespan and Around the World: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/18399.
×

category have demonstrated moderate impacts on reducing violent behaviors (Matjasko et al., 2012).

One example of an evidence-based mentoring program is Big Brothers/Big Sisters of America (BB/BS), a program that matches young people with an adult volunteer. The volunteer provides support and serves as a positive role model for youth. The volunteer makes a 1-year commitment to meeting with the youth an average of 3 to 5 hours per week and engaging in social and cultural activities within the community. BB/BS has demonstrated significant impacts on reducing violent behavior among youth (Tierney et al., 1995).

Community- and Societal-Level Approaches

Community and societal interventions include strategies at the local, state, and national levels that aim to improve community conditions or affect social change or norms. This area of research, as it applies to youth violence prevention, is in its early stages with fewer rigorously tested interventions. Because of this, it is important to note that the rigor of the evidence base is different than for the other levels of the social ecology. Still, several approaches that have been evaluated for their effects on youth violence have yet to be replicated, thus we can discuss these approaches as promising. They include policies limiting access to alcohol; establishing business improvement districts; manipulating the built environment with Crime Prevention Through Environmental Design strategies; and using prevention planning operating systems (e.g., Communities That Care). The developmental needs addressed at this level are relatively few compared to the strategies at other levels of the social ecology. The appeal is that strategies at this level have the capacity to impact a larger number of individuals. The developmental needs addressed include (1) the provision of more space for physical activity through the built environment approaches, which often involve the development of parks and green space with the aim of bringing community members outside, increasing physical activity, and possibly even encouraging positive social interaction with adults and peers in the community; and (2) increased chances to find opportunities for self-definition within communities because of improved community conditions.

One example of a promising strategy is Business Improvement Districts (BIDs). BIDs are grassroots, self-organizing public–private initiatives that provide economic development opportunities within communities. Communities that have implemented BIDs experienced significant reductions in violent crime. Research has found that how BIDs allocate their resources matter. In particular, BIDs that focus resources on private security and sanitation experience the largest share of the reduction in homicides (MacDonald et al., 2010).

Suggested Citation:"II.3 Evidence for Global Violence Prevention During Adolescence and Emerging Adulthood--Jennifer L. Matjasko and Sarah Bacon." Institute of Medicine and National Research Council. 2014. The Evidence for Violence Prevention Across the Lifespan and Around the World: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/18399.
×

Gaps and Future Directions in Building an Evidence Base for Global Youth Violence Prevention

Even after 25 years (and more) of assessing the effectiveness of programs at all levels of the social ecology on youth violence prevention, many gaps and unanswered questions remain. First, it is important to point out that most of the evidence is based on research on youth up to age 18. We know much less about the effectiveness of interventions during emerging adulthood. Second, there are significant questions in the field about the necessity and effectiveness of cultural adaptations to evidence-based interventions. Certainly, language adaptations are necessary, and ongoing work seeks to clarify whether cultural adaptations improve the effectiveness of interventions. Third, given that most of this work has occurred in the United States or other high-income countries, it is difficult to know the extent to which this evidence translates into countries with fewer resources that have key differences in infrastructure. One of the key questions here is what prevention delivery systems are available in other countries. Much of the prevention research has focused on school-based programs because they are one of the most efficient ways to reach youth. The adaptation and translational work in other areas, such as HIV prevention, need to be leveraged to understand how evidence-based interventions can be adapted and disseminated in other contexts. For example, researchers in the HIV field have used the concepts of accommodation, incorporation, and adaptation when adapting evidence-based interventions within a global context (Copenhaver et al., 2011). The process of accommodation accounts for the differences in communication styles. Incorporation involves the integration of community practices and customs into the evidence-based intervention. Adaptation involves the idea that the intervention should promote adjustment to these community norms. Finally, the field of implementation science on youth violence prevention is burgeoning (Fagan et al., 2008; Wandersman et al., 2008; Fixsen et al., 2009). We now have a host of programs that we know work with specific populations and under specific conditions. How do we effectively bring these programs to scale, and how do we sustain these efforts within communities?

Summary and Conclusions

In conclusion, youth violence prevention programs should meet the universal developmental needs that are unique to adolescents and emerging adults. We highlighted ways in which individual needs vary and how families, adults, peers, schools, and communities can be supported to meet those needs. We also have a solid evidence base at the individual, relational, and school levels about effective ways to meet those needs. Yet, we need

Suggested Citation:"II.3 Evidence for Global Violence Prevention During Adolescence and Emerging Adulthood--Jennifer L. Matjasko and Sarah Bacon." Institute of Medicine and National Research Council. 2014. The Evidence for Violence Prevention Across the Lifespan and Around the World: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/18399.
×
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Suggested Citation:"II.3 Evidence for Global Violence Prevention During Adolescence and Emerging Adulthood--Jennifer L. Matjasko and Sarah Bacon." Institute of Medicine and National Research Council. 2014. The Evidence for Violence Prevention Across the Lifespan and Around the World: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/18399.
×
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Suggested Citation:"II.3 Evidence for Global Violence Prevention During Adolescence and Emerging Adulthood--Jennifer L. Matjasko and Sarah Bacon." Institute of Medicine and National Research Council. 2014. The Evidence for Violence Prevention Across the Lifespan and Around the World: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/18399.
×
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Suggested Citation:"II.3 Evidence for Global Violence Prevention During Adolescence and Emerging Adulthood--Jennifer L. Matjasko and Sarah Bacon." Institute of Medicine and National Research Council. 2014. The Evidence for Violence Prevention Across the Lifespan and Around the World: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/18399.
×
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Suggested Citation:"II.3 Evidence for Global Violence Prevention During Adolescence and Emerging Adulthood--Jennifer L. Matjasko and Sarah Bacon." Institute of Medicine and National Research Council. 2014. The Evidence for Violence Prevention Across the Lifespan and Around the World: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/18399.
×
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Suggested Citation:"II.3 Evidence for Global Violence Prevention During Adolescence and Emerging Adulthood--Jennifer L. Matjasko and Sarah Bacon." Institute of Medicine and National Research Council. 2014. The Evidence for Violence Prevention Across the Lifespan and Around the World: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/18399.
×
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Suggested Citation:"II.3 Evidence for Global Violence Prevention During Adolescence and Emerging Adulthood--Jennifer L. Matjasko and Sarah Bacon." Institute of Medicine and National Research Council. 2014. The Evidence for Violence Prevention Across the Lifespan and Around the World: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/18399.
×
Page 73
Suggested Citation:"II.3 Evidence for Global Violence Prevention During Adolescence and Emerging Adulthood--Jennifer L. Matjasko and Sarah Bacon." Institute of Medicine and National Research Council. 2014. The Evidence for Violence Prevention Across the Lifespan and Around the World: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/18399.
×
Page 74
Suggested Citation:"II.3 Evidence for Global Violence Prevention During Adolescence and Emerging Adulthood--Jennifer L. Matjasko and Sarah Bacon." Institute of Medicine and National Research Council. 2014. The Evidence for Violence Prevention Across the Lifespan and Around the World: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/18399.
×
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The Evidence for Violence Prevention Across the Lifespan and Around the World is the summary of a workshop convened in January 2013 by the Institute of Medicine's Forum on Global Violence Prevention to explore value and application of the evidence for violence prevention across the lifespan and around the world. As part of the Forum's mandate is to engage in multisectoral, multidirectional dialogue that explores crosscutting approaches to violence prevention, this workshop examined how existing evidence for violence prevention can continue to be expanded, disseminated, and implemented in ways that further the ultimate aims of improved individual well-being and safer communities. This report examines violence prevention interventions that have been proven to reduce different types of violence (e.g., child and elder abuse, intimate partner and sexual violence, youth and collective violence, and self-directed violence), identifies the common approaches most lacking in evidentiary support, and discusses ways that proven effective interventions can be integrated or otherwise linked with other prevention programs.

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