This is the current release of the guideline.

Adolescent violent behavior

Prevention
Risk Assessment
Treatment

Family Practice
Pediatrics
Preventive Medicine
Psychiatry
Psychology

Advanced Practice Nurses
Allied Health Personnel
Health Care Providers
Nurses
Patients
Physician Assistants
Physicians
Psychologists/Non-physician Behavioral Health Clinicians
Social Workers

To provide health care providers, patients, and the general public with a responsible assessment of currently available data on preventing violence and related health-risking social behaviors in adolescents

Adolescents ages 12 through 17 in the United States

1. Successful violence intervention programs:
   • Are derived from sound theoretical rationales
   • Address strong risk factors
   • Involve long-term treatments, often lasting a year and sometimes much longer
   • Work intensively with those targeted for treatment and often use a clinical approach
   • Follow a cognitive/behavioral strategy
   • Are multimodal and multicontextual
   • Focus on improving social competency and other skill development strategies for targeted youth and/or their families
   • Are developmentally appropriate
   • Are not delivered in coercive institutional settings
   • Have the capacity for delivery with fidelity
2. Violence intervention programs that fail:
   • Aggregate high-risk youth in ways that facilitate contagion
   • Implement protocols that are not clearly articulated
   • Staff are not well-supervised or held accountable
   • Are limited to scare tactics
   • Are limited to toughness strategies
   • Consist largely of adults lecturing to youth

• Rates of adolescent violence
• Rate of death due to homicide
• Rates of co-occurrence
• School drop-out rate
• Economic cost of adolescent violence

Searches of Electronic Databases

Note from the National Guideline Clearinghouse (NGC): A systematic review of the literature was prepared by the Southern California Evidence-based Practice Center for the Agency for Healthcare Research and Quality's Evidence-based Practice Centers Program for use by the National Institutes of Health (see the "Availability of Companion Documents" field).

The National Library of Medicine (NLM) performed all the searches that were used for this evidence review. Librarians from NLM met with project staff via teleconference to discuss the evidence review, the scope of the review, and the key questions. They also worked with project staff to select the literature databases that were ultimately used and evaluated 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. Refer to Table 1 of the Evidence Report (see the "Availability of Companion Documents" field). 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, 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.

The review was limited 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.

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, the assessment was based 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. For the evaluation of the effectiveness of interventions, 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 were examined.

To ensure that articles published during the course of this project were included, the NLM conducted a second supplemental search in October of 2003, using the same search strategies and databases. This search yielded an additional 344 citations; thus a total of 11,196 citations were identified during the course of this project.

Two members of the team independently screened each citation. One screener was a member of the faculty with specific expertise related to adolescent development and/or youth violence, and the other screener had a masters 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 screeners, resolved discrepancies, and recorded the decisions in the Excel master file. For the rejected citations, the reason for rejection was recorded (i.e., the first reason for rejection that was identified by the screeners). This protocol was followed throughout all screening processes.

Refer to Chapter 2 in the Evidence Report (see the "Availability of Companion Documents" field) for further information.

Full-length articles included in evidence assessment: n=67

• Risk factors: 35 articles
• Interventions: 32 articles

Weighting According to a Rating Scheme (Scheme Not Given)

Not applicable

Review of Published Meta-Analyses
Systematic Review with Evidence Tables

Note from the National Guideline Clearinghouse (NGC): A systematic review of the literature was prepared by the Southern California Evidence-based Practice Center for the Agency for Healthcare Research and Quality's Evidence-based Practice Centers Program for use by the National Institutes of Health (see the "Availability of Companion Documents" field).

The quality of individual studies was evaluated using the criteria set forth in the Procedures for EPC Reports for Office of Dietary Supplements and Office of Medical Applications of Research (OMAR). 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—follow-up 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, the rating of the strength of scientific evidence remains the prerogative of the Consensus Panel. However, two sensitivity analyses were conducted to assist the Consensus Panel to assess the strength of the scientific evidence in our review. First, 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 were reanalyzed, to restrict the analyses to the studies with the greatest power to detect significant predictors. Second, the findings using only studies with good quality were reassessed.

Risk factor identification. To identify homogeneous subgroups for data pooling, the eligible studies were stratified 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, a factor was considered 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.

Consistency was evaluated 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. The accepted studies were stratified by the level of intervention and the type of study design. Initially, the plan was 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, findings across studies were not pooled. Instead, the findings of the programs were summarized as effective or ineffective. An intervention was considered 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.

Refer to Chapter 2 in the Evidence Report (see the "Availability of Companion Documents" field) for additional information.

Expert Consensus (Consensus Development Conference)

Not applicable

Guideline developers reviewed published cost analyses.

External Peer Review
Internal Peer Review

To identify a group of Peer Reviewers, nominations were solicited from the Technical Expert Group, the Panel Chair, and national associations recommended by the Project Officer (including the American Academy of Pediatrics, the American Public Health Association, the American Association of Health Plans, the American Academy of Family Physicians, the American Society of Internal Medicine, the American Psychological Association, and the American College of Physicians, and the Society of Adolescent Medicine). The role of Peer Reviewers is to provide independent feedback about the report. As a result of these solicitations, Evidence-based Practice Center staff received nominations for 24 individuals. These individuals represented federal agencies, academia, philanthropy, clinical practice, and managed care. From this list, the Task Order Project Director invited eight individuals — representing a variety of expertise and geography — to participate. This list of peer reviewers was approved by the Task Order Officer.

A copy of the draft evidence report was mailed to each peer reviewer, along with an instruction sheet (refer to Appendix B-10 of the Evidence Report (see the "Availability of Companion Documents" field) for reviewing the draft evidence report. A copy of the draft evidence report was also mailed to the members of the Technical Expert Group. All reviewers were asked to respond within three weeks. Six of the eight peer reviewers, six of the nine technical experts, and one Agency for Healthcare Research and Quality-appointed peer reviewer provided comments. Appendix D-2 of the Evidence Report (see the "Availability of Companion Documents" field) lists the names and affiliations of the six peer reviewers who submitted their comments.

Upon receipt of all responses from the peer reviewers and technical experts, the project staff compiled a summary of the comments and changes and revised the draft evidence report accordingly. A complete copy of each reviewer's comments, together with the report of disposition of those comments, were submitted to the Task Order Officer for review and approval.

The National Institutes of Health State-of-the-Science Panel highlights the following findings and recommendations:

• Violence affects all of us at some level and represents an issue of vital national and international importance.
• Some interventions have been shown by rigorous research to reduce violence precursors, violence, and arrest. However, many interventions aimed at reducing violence have not been sufficiently evaluated or proven effective, and a few widely implemented programs have been shown to be ineffective and perhaps harmful.
• Programs that seek to prevent violence through fear and tough treatment appear ineffective. Intensive programs that aim at developing skills and competencies can work.
• Interventions to reduce violence may be context dependent. Research must proceed in varying contexts and take account of local culture.
• Attention to diversity among investigators involved in violence prevention research is important. Universities and funding agencies should make improving the situation a priority.
• The panel encourages funding sufficient to promote the dissemination of violence prevention programs that have been shown to be effective through rigorous randomized controlled trial (RCT) research. Funding must include support for research, and monitoring must continue as these programs are more widely implemented.

None provided

The type of supporting evidence is not specifically stated for each recommendation.

Improved knowledge of currently available data on violence prevention and related health-risking social behaviors in adolescents and improved understanding of directions for future research

Not stated

An implementation strategy was not provided.

Staying Healthy

Effectiveness
Patient-centeredness

Not applicable: The guideline was not adapted from another source.

2004 Oct 13-15

National Institutes of Health (NIH) State-of-the-Science Panel - Independent Expert Panel

United States Government

National Institutes of Health State-of-the-Science Panel

Panel Members: Robert L. Johnson, M.D., (Panel and Conference, Chairperson), Professor and Chair, Department of Pediatrics, Professor of Psychiatry, Director of Adolescent and Young Adult Medicine, University of Medicine and Dentistry of New Jersey, New Jersey Medical School, Newark, New Jersey; Shrikant I. Bangdiwala, Ph.D., Professor, Collaborative Studies Coordinating Center, Department of Biostatistics and Injury, Prevention Research Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina; Michael F. Cataldo, Ph.D., Professor of Behavioral Biology, Departments of Pediatrics and Psychiatry, The Johns Hopkins University, School of Medicine , Director, Department of Behavioral Psychology, Kennedy Krieger Institute, Baltimore, Maryland; J. Virgil Costley, Jr., J.D., Juvenile Court Judge (Retired), Professor of Paralegal Studies and Criminal Justice, Dekalb Technical College, Covington Campus, Covington, Georgia; Angela Diaz, M.D., M.P.H., Professor of Pediatrics and Community Medicine, Mount Sinai School of Medicine, Director, Mount Sinai Adolescent Health Center, Mount Sinai Medical Center, New York, New York; Leon Eisenberg, M.D., Presley Professor of Social Medicine, Professor of Psychiatry, Emeritus, Department of Social Medicine, Harvard Medical School, Boston, Massachusetts; Richard O. Lempert, Ph.D., J.D., Eric Stein Distinguished University Professor of Law and Sociology, University of Michigan, Director, Division of Social and Economic Sciences, National Science Foundation, Arlington, Virginia; Angela Barron McBride, Ph.D., R.N., F.A.A.N., Distinguished Professor Indiana University School of Nursing, Indianapolis, Indiana; Lisa Schwartz, M.D., M.S., Senior Research Associate Veterans Affairs Outcome Group, Associate Professor of Medicine and Community and Family Medicine, Dartmouth Medical School Hanover, New Hampshire, Veterans Affairs Medical Center, White River Junction, Vermont; Freya L. Sonenstein, Ph.D., Professor and Director, Center for Adolescent Health Promotion and Disease Prevention, The Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland; Bonita Stanton, M.D., Schotanus Professor and Chair; Carman and Ann Adams, Department of Pediatrics, Children's Hospital of Michigan, Wayne State University Detroit, Michigan; David T. Takeuchi, Ph.D., Professor, School of Social Work and Department of Sociology; University of Washington, Seattle, Washington; Steven Woloshin, M.D., M.S., Senior Research Associate Veterans Affairs, Outcomes Group, Associate Professor of Medicine and Community and Family Medicine, Dartmouth Medical School, Hanover, New Hampshire, Veterans Affairs Medical Center, White River Junction, Vermont

All of the panelists who participated in this conference and contributed to the writing of this statement were identified as having no financial or scientific conflict of interest, and all signed forms attesting to this fact. Unlike the expert speakers who present scientific data at the conference, the individuals invited to participate on National Institutes of Health (NIH) Consensus and State-of-the-Science panels are reviewed prior to selection to assure that they are not proponents of an advocacy position with regard to the topic and are not identified with research that could be used to answer the conference questions.

This is the current release of the guideline.

None available

This summary was completed by ECRI on December 15, 2008.

No copyright restrictions apply.