Provided by the National Institute of Mental Health
This is a time of high concern about violent
behavior by young people. As a nation, we are in a period of reflection as to
what can be done to stem this tide. The NIMH is currently involved in a "taking
stock" activity to guide research into the areas where questions exist, with a
special emphasis on identifying when and how to intervene. Youth violence is a
complex problem and will require complex solutions. There is a natural desire to
develop a "child violence" profile, but this not only risks a negative label on
a child, but also risks missing the quiet, troubled child with a series of
problems, who may actually become the most violent.
The NIMH has gathered information about risk factors, experiences, and processes
that are related to the development of aggressive, antisocial, and violent
behavior, including mental health problems, particularly depression and
externalizing behavior, associated with childhood and adolescence. NIMH research
points to the importance of a nurturing social environment in childhood, good
early education, and success in academic areas. It has been learned that the
influence of peers, whether positive or negative, is of critical importance.
Research also suggests that current policies and approaches grouping or housing
troubled adolescents together may be the wrong approach, and it is clear that
there are no quick, inexpensive answers. Each research finding suggests possible
interventions that in turn need to be studied. Some proposed interventions have
been found to actually increase the negative behavior and so due care must be
taken. This overview highlights what is known about risk factors for the
development of antisocial and problem behavior, and the often underutilized
early prevention and intervention strategies.
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Risk Factors
Tragic events like the shootings at Columbine High School capture public
attention and concern, but are not typical of youth violence. Most adolescent
homicides are committed in inner cities and outside of school. They most
frequently involve an interpersonal dispute and a single victim. On average, six
or seven youths are murdered in this country each day. Most of these are
inner-city minority youths. Such acts of violence are tragic and contribute to a
climate of fear in schools and communities.
Research findings are identifying factors in the development of aggressive and
antisocial behavior from early childhood to adolescence and into adulthood.
Prospective longitudinal and intervention studies have identified major
correlates for the initiation, escalation, continuation, and cessation of
serious violent offending.
Many studies indicate that a single factor or a single defining situation does
not cause child and adolescent antisocial behavior. Rather, multiple factors
contribute to and shape antisocial behavior over the course of development. Some
factors relate to characteristics within the child, but many others relate to
factors within the social environment (e.g., family, peers, school,
neighborhood, and community contexts) that enable, shape, and maintain
aggression, antisocial behavior, and related behavior problems.
The research on risk for aggressive, antisocial, and violent behavior includes
multiple aspects and stages of life, beginning with interactions in the family.
Such forces as weak bonding, ineffective parenting (poor monitoring,
ineffective, excessively harsh, or inconsistent discipline, inadequate
supervision), exposure to violence in the home, and a climate that supports
aggression and violence puts children at risk for being violent later in life.
This is particularly so for youth with problem behavior, such as early conduct
and attention problems, depression, anxiety disorders, lower cognitive and
verbal abilities, etc. Outside of the home, one of the major factors
contributing to youth violence is the impact of peers. In the early school
years, a good deal of mild aggression and violence is related to peer rejection
and competition for status and attention. More serious behavior problems and
violence are associated with smaller numbers of youths who are failing
academically and who band together, often with other youth rejected by prosocial
peers. Successful early adjustment at home increases the likelihood that
children will overcome such individual challenges and not become violent.
However, exposure to violent or aggressive behavior within a family or peer
group may influence a child in that direction.
Types and Severity of Antisocial Behavior
The types and severity of antisocial behaviors exhibited by youths vary greatly
and include lying, bullying, truancy, starting fights, vandalism, theft,
assault, rape, and homicide. As a rule, the older the age of onset, the fewer
the number of antisocial youths who will engage in seriously aggressive and
violent behavior. Longitudinal studies show that many children who engage in
antisocial behavior in childhood continue to do so at least through adolescence.
Longitudinal research has identified types of youth who progress to adolescent
antisocial behavior, multiple pathways through which it develops and persists,
and the multiple factors that shape this risk. This research has identified two
types of life course trajectories: life course persistent, which is viewed as a
form of psychopathology, and adolescence limited, which is identified only in
select social situations. The distinction between these two types of individuals
is very useful, both as a way of thinking about developmental knowledge and as a
tool for targeting the right interventions for antisocial youth.
Research in this area has generated evidence for this way of thinking about how
adolescents grow and has investigated the relationship between adolescent
problem behavior and cognitive deficits. Life course persistent individuals
begin antisocial behavior early in childhood and continue into adulthood, after
their adolescence limited counterparts stop. Life course persistent behavior has
been correlated with neurological deficits and pathological behaviors, (e.g.,
impulsivity) which are exacerbated when they are combined with stressful home
situations. In one study of 13 year olds, individual differences—such as
deficits in sensory, perceptual, and cognitive abilities, including the use of
language were shown to predict participation in crime 5 years later. For
instance, boys with poorer verbal functioning initiated delinquent behavior at
younger ages. It has also been demonstrated that boys with poorer
neuropsychological functioning, especially verbal functioning at age 13, were
more likely to have committed crimes at age 18 than were their counterparts with
better neuropsychological functioning at age 13.
Gender Differences
From about 4 years of age on, boys are more likely than girls to engage in both
aggressive and nonaggressive antisocial behavior. Much remains to be learned
about the causes of gender differences in antisocial behavior, but based on what
is known, it is suspected that antisocial behavior might need to be defined
somewhat differently for the two genders. In contrast to overt aggression, which
inflicts harm through physical damage or the threat of such damage more common
in boys, social aggression by girls harms through damage to peer relationships;
study of this form of aggression may be crucial to understanding the aggressive
development of girls. The NIMH is currently funding research on the antecedents
and consequences of aggression for girls, as well as for boys, knowledge that
can be used to develop empirically-based interventions for aggressive children
of both sexes.
Antisocial Behavior Co-Occurring with Child Psychopathology
There is strong evidence for the co-occurrence of two or more syndromes or
disorders among children with behavioral and emotional problems. Many people
think that children either act out or turn their feelings inward, but the truth
is more complex. The obviously angry adolescent has other conditions such as
anxiety disorders and depression (as seen in the quiet withdrawn young person)
more often than would occur by chance. Research in this area indicates that very
young children with conduct problems and anxiety disorders or depression display
more serious aggression than youths with only conduct problems. It is not
entirely clear whether depression precipitates acting out, whether impairments
and predispositions for acting out lead to depression, or whether there are
underlying causal factors that are responsible for the joint display of such
problems.
It is very common for youth with conduct problems to also display symptoms of
attention deficit hyperactivity disorder (ADHD), the most commonly diagnosed
behavioral disorder of childhood. The diagnosis is made by the presence of
persistent age-inappropriate inattention and impulsivity, often coexisting with
hyperactivity. This co-occurrence is often associated with an early onset of
aggression and impairment in personal, interpersonal, and family functioning.
Furthermore, academic underachievement is common in youth with early onset
conduct problems, ADHD, and adolescents who display delinquent behavior.
Individual Liability and Genetic Factors
Identifying numerous genes that may play a role in any complex disorder is a
formidable task and is only the first step in understanding how a gene or genes
affect an individual. Genes act by producing specific proteins that may
contribute to a particular biological or behavioral trait. Every human carries
between 80,000 and 100,000 genes; the products of these genes acting together
and in combination with the environment help shape every human characteristic.
It has become clear that the genetics of vulnerability to certain behaviors or
mental disorders is complex. We still do not know how many different genes might
contribute to vulnerability for any personality trait or specific mental
disorder, nor do we know the nature of the nongenetic effects (such as
environmental factors) that convert vulnerability into illness.
Our understanding of the nature of genetic influences on antisocial behavior is
similarly incomplete. However, research on differences in the magnitude of
genetic and environmental influences on different kinds of conduct problems is
providing a key to understanding the developmental origins of antisocial
behavior. Many twin and adoption studies indicate that child and adolescent
antisocial behavior is influenced by both genetic and environmental factors,
suggesting that genetic factors directly influence cognitive and temperamental
predispositions to antisocial behavior. These predisposing child factors and
socializing environments, in turn, influence antisocial behavior.
Research suggests that for some youth with early onset behavior problems,
genetic factors strongly influence temperamental predisposition, particularly
oppositional temperament, which can affect experiences negatively. When
antisocial behavior emerges later in childhood or adolescence, it is suspected
that genetic factors contribute less, and such youths tend to engage in
delinquent behavior primarily because of peer influences and lapses in
parenting. The nature of the child's social environment regulates the degree to
which heritable early predisposition results in later antisocial behavior.
Highly adaptive parenting is likely to help children who may have a
predisposition to antisocial behavior. Success in school and good verbal ability
tend to protect against the development of antisocial behavior, pointing to the
importance of academic achievement.
Parent and Family Factors
Research has demonstrated that youths who engage in high levels of antisocial
behavior are much more likely than other youths to have a biological parent who
also engages in antisocial behavior. This association is believed to reflect
both the genetic transmission of predisposing temperament and the maladaptive
parenting of antisocial parents.
The importance of some aspects of parenting may vary at different ages. For
example, inadequate supervision apparently plays a stronger role in late
childhood and adolescence than in early childhood. There is evidence from many
studies that parental use of physical punishment may play a direct role in the
development of antisocial behavior in their children. In longitudinal studies,
higher levels of parental supervision during childhood have been found to
predict less antisocial behavior during adolescence. Other researchers have
observed that parents often do not define antisocial behavior as something that
should be discouraged, including such acts as youths bullying or hitting other
children or engaging in "minor" delinquent acts such as shoplifting.
Research examining the mental health outcomes of child abuse and neglect has
demonstrated that childhood victimization places children at increased risk for
delinquency, adult criminality, and violent criminal behavior. Findings from
early research on trauma suggest that traumatic stress can result in failure of
systems essential to a person's management of stress response, arousal, memory,
and personal identity that can affect functioning long after acute exposure to
the trauma has ended. One might expect that the consequences of trauma can be
even more profound and long lasting when they influence the physiology,
behavior, and mental life of a developing child or adolescent.
Peer Influences
Antisocial children with earlier ages of onset tend to make friends with
children similar to themselves. Consequently, they reinforce one another's
antisocial behavior. Children with ADHD are often rejected due to their
age-inappropriate behavior, and thus are more likely to associate with other
rejected and/or delinquent peers. The influence of delinquent peers on
late-onset antisocial behavior appears to be quite strong. Association with
antisocial peers has been shown to be related to the later emergence of new
antisocial behavior during adolescence among youths who had not exhibited
behavior problems as children.
Less adult supervision allows youths to spend more time with delinquent peers.
Thus, improving parental supervision may be an important way to reduce the
effects of delinquent peer influence. Ongoing research is examining how
neighborhood effects on antisocial behavior are mediated by the willingness of
neighbors to supervise youths and possibly reduce the likelihood of association
with delinquent peers in the neighborhood.
Socioeconomic Factors
An inverse relationship of family income and parental education with antisocial
behavior has been found in many population-based studies. Across gender and
ethnicity, much of the inverse relationship between family income and antisocial
behavior is accounted for by less parental monitoring at lower levels of
socioeconomic status.
Prevention and Intervention
In recent years, several effective programs and strategies to prevent youth
violence have been developed and tested.
Pre-School Children
The Nurse Home Visitation Program, partly funded by the NIMH, is a 20-year model
of research in which nurses visit mothers beginning during pregnancy and
continuing through their child's second birthday to improve pregnancy outcomes,
promote children's health and development, and to strengthen families' economic
self-sufficiency. This program, currently underway in New York, Colorado, and
Tennessee, appears to benefit high-risk families, particularly low-income
unmarried women, reducing rates of childhood injury, child abuse and neglect,
and other risk factors for early-onset antisocial behavior in children.
Long-term follow-up of the children in two of the studied locations indicated
that by age 15, they had fewer behavioral problems related to the use of drugs
and alcohol, fewer instances of running away, fewer arrests and convictions, and
fewer sexual partners, as compared to counterparts randomly assigned to receive
comparison services.
Hawaii's Healthy Start Program is designed to prevent child abuse and neglect
and promote child health and development in newborns of families classified as
highly stressed and/or at risk for child abuse and neglect. Following a
successful pilot study, this program is now operating statewide, and has
inspired adaptations in other locations. The program uses a home visitation
model to help family members cope with the challenges of child rearing, to teach
effective parenting and problem-solving skills, and to link families to
necessary services such as childcare, income and nutritional assistance, and
pediatric primary care. After two years of service, mothers reported improved
parenting efficacy, decreased parenting stress, more use of non-violent
discipline, better linkage with pediatric care, as well as decreased injury due
to partner violence in the home, as compared with a control group.
The Administration on Children, Youth and Families (ACYF) and the NIMH have
awarded several research grants as the core component of a new young children's
mental health research initiative designed to develop and test applications of
theory-based research or state-of-the-art techniques for the prevention,
identification and/or treatment of children's mental health disorders within a
Head Start context. Among these are projects to develop screening tools for
identifying behavior problems in preschool children, to test the effectiveness
of research-based classroom interventions for very young children with serious
disruptive behavior problems, and to assess the mental health needs of this
vulnerable population.
School-Age Children
Recent studies have indicated that between 70 and 80 percent of children with
diagnosable mental disorders who receive services are served within the school
system, primarily by school psychologists and guidance counselors. The NIMH has
supported many projects that seek to develop, establish, and improve
school-based mental health service delivery systems. These projects range from
broad programs intended to enhance the social and problem solving skills of all
students, to highly specific programs designed to treat children already showing
symptoms of mental health problems. Programs also range from those that
intervene at multiple levels, including the child, parents, peers, and teachers,
to those that focus solely on the child. For example, research is aimed at
developing techniques for teachers to manage disruptive students. Several
strong, multi-faceted programs that aim to prevent severe and persistent conduct
problems in children have been launched.
The Families and Schools Together (FAST) Track Program is a multi-faceted,
multi-year program designed for aggressive children in kindergarten starting at
age 6. A four-site study in North Carolina, Pennsylvania, Tennessee, and
Washington, the program involves working with the child, the family in their
home, and school system, including teachers. Preschool children at high risk
were identified at 55 different schools. These children were randomly assigned
for intervention or no intervention.
The children initially enrolled in the study are now young adolescents. An
evaluation of FAST TRACK indicated that by the third grade, students who took
part in the program showed less oppositional and aggressive behavior and were
less likely to require special education services than students who did not take
part.
The Linking the Interests of Families and Teachers (LIFT) Program (in Oregon) is
a 10-week intervention created for children and families who are at risk for the
development of conduct problems due to residence in neighborhoods characterized
by high rates of juvenile delinquency. The LIFT Program is a multi-component
intervention that includes parent training, social skills training, a playground
behavioral program, and regular communication between teachers and parents.
Following program participation, students engaged in significantly less
aggressive behaviors on the playground, parents demonstrated fewer negative
behaviors during family problem-solving activities, and teachers reported
improved student social behavior and peer interactions. Three years following
the intervention, students who received the program were less likely to engage
in consistent alcohol use, less likely to have troublesome friends, and less
likely to have been arrested for the first time than students who did not
receive the program. Students were also less likely to demonstrate inattentive,
impulsive, overactive, and disruptive behaviors in the classroom than students
who did not receive the program.
Programs have also been initiated which seek to enhance the skills and knowledge
of all children in order to decrease their risk of future emotional and
behavioral problems. NIMH has sponsored the Promoting Alternative Thinking
Strategies (PATHS) Curriculum, based in Washington state, which teaches children
about self-control, understanding emotions, and problem solving. The PATHS
curriculum has been evaluated using students in both regular education and
special education classrooms. Students who received the PATHS curriculum
demonstrated better knowledge of emotions than children who did not receive the
curriculum. This emotional knowledge is thought to underlie the development of
necessary social skills such as friendship development and maintenance, anger
management, conflict resolution, and appropriate problem solving.
Development of Depression
NIMH research is investigating promising and successful interventions to prevent
and treat adolescent depression, which often coexists with conduct problems—a
combustible mix that can result in violence, both against self and others.
Several NIMH projects focus on determining whether cognitive therapy techniques
that have been found to be effective for treating depression in adults can be
applied to prevent depression in adolescents. Such research tests, among other
things, the effects of after-school programs, which are based on cognitive
therapy and social problem-solving techniques and delivered by school staff.
Findings from this type of research are mixed, with more intensive interventions
appearing to have at least initial effects of reducing or preventing depressive
symptoms. Additional work is needed to determine the optimal length and
intensity of interventions as well as approaches for sustaining their effects.
For example, the Coping with Stress Course was designed to prevent the onset of
depressive disorders among adolescents who report high levels of depressive
symptoms. With programs in Oregon, Maryland, and Ohio, this group course teaches
adolescents cognitive skills to identify and challenge negative or irrational
thoughts and beliefs that may contribute to the development of depression.
Evaluation showed that the course was successful in reducing the number of cases
of depressive disorder among adolescents at risk. In fact, twice as many
students in the no-treatment group developed a depressive disorder than in the
treatment group. Students in the treatment group also reported fewer depressive
symptoms and better adjustment than students in the untreated group. However,
with the passage of time, differences between the treatment and no-treatment
groups decreased.
Other projects are testing the effects of pharmacological and psychosocial
treatments for youth with depression (aged 12-17 years). Going beyond the
effects of treatment on symptoms of depression, this research also focuses on
the impact of the interventions on functioning in school, at home, and in the
community.
Effective Interventions for Delinquent Youth
It is important in evaluating interventions for delinquents to document what has
not worked, as well as what has. For example, group-home approaches that pool
delinquent youth together will, in some cases, exacerbate and escalate youth
violence. Even promising interventions for delinquent youth can be overwhelmed
by the negative effect of grouping such youth together.
This research finding has led to two highly successful treatment models for
serious offending delinquents. One is multisystemic therapy (MST), in which
specially trained therapists work with the youth and family in their home, with
a particular focus on changing the peers with whom the youths associate. MST
therapists identify strengths in the families and use these strengths to develop
natural support systems and to improve parenting. Specific interventions are
individualized to the family and address the needs of the child, family, school,
peers, and neighborhood. Multiple, rigorous outcome evaluations have
demonstrated the efficacy of this approach, and an independent cost-benefit
analysis found that this model had a very high cost-benefit payoff. Although a
number of states are now attempting to implement this model, the majority of
programming for delinquent youth is based on models that bring together youth
with problem behavior, rather than target separation of youth from problem
peers.
The other model is Therapeutic Foster Care. This model offers a community-based
intervention for serious and chronic offending delinquents. Therapeutic foster
parents are carefully selected and supported with research-based procedures for
working with serious and chronic delinquents in their homes. Treatment typically
lasts 6 to 7 months. This intervention results in fewer runaways and fewer
program failures than the usual placement in group homes is less expensive, and
is dramatically more effective in reducing delinquency than traditional group
homes. The Foster Family-based Treatment Association, developed under NIMH
leadership, now has some 400 members across the U.S. who promote the use of this
research-based and effective model.
Conclusion
As important as the problem of violence is, there will be no quick, inexpensive,
and fail-safe solution. Recent years have witnessed a strong growth in our
understanding of the risk factors and processes that contribute to and shape
child and adolescent antisocial behavior. Yet gaps remain in our scientific
understanding of how child, family, school/community, and peer factors interact,
and which are the most appropriate targets for prevention and early intervention
in different settings. We are also learning that being "at risk" does not doom
any one child to become violent; conversely, the apparent absence of certain
risk does not necessarily protect any one child from problem behavior. The
development of serious behavior problems is best understood as a dynamic
interaction between child predispositions and various influences on children's
lives (family, peer, and school/community) that change over critical periods of
development.
Successful programs that produce long-term sustained effects may need to involve
long-term intense interventions to target the multiple factors that can lead to
negative outcomes such as family conflict, depression, social isolation, school
failure, substance abuse, delinquency, and violence. The fundamental premise of
some of these interventions—which separate youth with problem
behaviors—challenges the policies, programs and procedures that currently bring
problem youth together. Continued research is needed to determine the most
appropriate targets for prevention and early intervention that will produce
lasting change. Answers are emerging about which programs are most successful,
but assessments need to be made about their costs, as well as if they will work
for all groups of children and adolescents.
The NIMH is committed to encouraging and supporting this research, and has a
long and enduring history of support for research and research training on
violence. Throughout the 1950s, and early '60s, NIMH provided research and
research training support that built much of the modern field of behavioral
science, and much subsequent research on violence has built upon that
foundation. In 1966, NIMH created a Center for Studies of Crime and Delinquency,
which was the locus of pioneering research on aggressive, antisocial, and
violent behavior and its consequences. NIMH-supported research has generated
information needed to identify, treat, and prevent not only the causes of
violent behavior but also the effects of violence on victims, for example, child
abuse. Most recently, the NIMH has assumed a lead role, along with the Substance
Abuse and Mental Health Services Administration and the Centers for Disease
Control and Prevention, in developing a Surgeon General's report on the topic of
youth violence. The NIMH believes that this report, as follow-up to the Surgeon
General's Report on Mental Health, will be an effective and highly credible
means of educating the public about the interaction of mental disorders and
youth violence.
The Broad NIMH Research Program
In addition to research on violence, NIMH supports and conducts a broad based,
multi-disciplinary program of scientific inquiry aimed at improving the
diagnosis, prevention, and treatment of mental disorders. These illnesses
include schizophrenia, manic-depressive illness, clinical depression, panic
disorder, and obsessive-compulsive disorder.
Increasingly, the public as well as health care professionals are recognizing
these disorders as real and treatable medical illnesses of the brain. Still,
there is a need for more research that examines in greater depth the
relationships among genetic, behavioral, developmental, social, and other
factors to find the causes of these illnesses. NIMH is meeting this need through
a series of research initiatives.
NIMH Human Genetics Initiative
This project has compiled the world's largest registry of families affected by
schizophrenia, manic-depressive illness, and Alzheimer's disease. Scientists are
able to examine the genetic material of these family members with the aim of
pinpointing genes involved in the diseases.
Human Brain Project
This multi-agency effort is using state-of-the-art computer science technologies
to organize the immense amount of data being generated through neuroscience and
related disciplines, and to make this information readily accessible for
simultaneous study by interested researchers.
Prevention Research Initiative
Prevention efforts seek to understand the development and expression of mental
illness throughout life so that appropriate interventions can be found and
applied at multiple points during the course of illness. Recent advances in
biomedical, behavioral, and cognitive sciences have led NIMH to formulate a new
plan that marries these sciences to prevention efforts.
While the definition of prevention will broaden, the aims of research will
become more precise and targeted.
More Than 2,000 Grants and Contracts
In total, NIMH supports more than 2,000 research grants and contracts at
universities and other institutions across the nation and overseas. It also
conducts basic research and clinical studies involving 9,000 patient visits per
year at its own facilities on the National Institutes of Health campus in
Bethesda, MD, and elsewhere. NIMH research projects focus on:
basic research on behavior, emotion, and cognition to provide a knowledge base
for a better understanding of mental illnesses
basic sciences, including cellular and molecular biology, developmental neuro-biology,
neurochemistry, neurogenetics, and neuropharmacology, to provide essential
information about the anatomical and chemical basis of brain function and brain
disorders
neuroscience and behavioral aspects of acquired immune deficiency syndrome
(AIDS) and behavioral strategies to reduce the spread of HIV (human
immunodeficiency virus)
interventions to treat, prevent, and reduce the frequency of mental disorders
and their disabling consequences
mental health services research, including mental health economics and improved
methods of services delivery
comorbidity among mental disorders and with substance abuse and other medical
conditions, such as depression and heart disease
the prevalence of mental disorders
risk factors for mental disorders
differences in mental health and mental illness among special populations
children and adolescents who suffer from or who are at risk for serious mental
disorders and learning disabilities
psychotherapies and pharmacotherapies for specific disorders
For More Information
Please visit the following link for more information about organizations that
focus on children and adolescents.
NIH Publication No. 00-4706
Printed 2000
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