Prevention Institute

With the growing understanding of both the devastating lifelong impact of trauma from exposure and the large number of children who are exposed, there has been unprecedented attention to addressing children's exposure to violence. Fortunately, there is a strong and growing evidence base that confirms violence is preventable and therefore children's exposure to violence can be prevented in the first place. It's critical that prevention be included as a vital part of the solution to defend childhood.

Read Larry Cohen's written testimony submitted to the Task Force for Defending Childhood, an initiative from the Department of Justice, and get the facts on why we need to prevent childhood exposure to violence in the first place.

The Defending Childhood Initiative is an important contribution both to raising awareness and finding solutions to children's exposure to violence. We thank the Task Force for the opportunity to offer written testimony.

Addressing Childhood Exposures to Violence: A Primary Prevention Approach

With the growing understanding of both the devastating lifelong impact of trauma from exposure and the large number of children who are exposed, there has been unprecedented attention to addressing children's exposure to violence. Fortunately, there is a strong and growing evidence base that confirms violence is preventable and therefore children's exposure to violence can be prevented in the first place. It's critical that prevention be included as a vital part of the solution to defend childhood.

Defining Childhood Exposure to Violence

Addressing childhood exposures to violence, before they occur, saves lives, reduces illnesses and injuries, helps communities thrive, and saves money. Over the last twenty years, practitioners and researchers have successfully illustrated the impact of childhood exposure to violence. They established that exposures happen through multiple forms of violence (child abuse, sexual abuse, witnessing domestic violence, witnessing/experiencing violence in street, school and community settings) and while there are critical developmental time periods, such as pre-natal to five that are particularly formative in terms of brain development, there is growing evidence that exposure to violence for children and youth, ages five and older, has devastating consequences as well.

We need to recognize that exposure is not just a young children's issue. Though clearly early childhood is an important developmental time, exposure continues outside the home, and we must address this given the fact that many youth are exposed to high levels of school and community violence and studies have found one in three urban youth have PTSD. Experiencing, exposure to, and fear of violence have known emotional and mental health consequences for children and youth. These consequences are often life-long, require extensive treatment, and can, in turn, affect physical health as well as bring stress and consequences to others. In addition to preventing multiple forms of violence, it is critical to recognize the impact of exposure on children and youth.

Fortunately, there is strong and growing evidence that violence is preventable. Leaders and the general public alike have a greater understanding of the issue. This awareness has reached a tipping point over the last ten years, resulting in mobilized groups advocating for social and political solutions. So far, the response to these demands has largely focused on after-the-fact individually oriented efforts, such as screening for trauma and access to mental health services. The next step for the field requires expanding the overarching dialog, moving from a focus on the individual and after-the-fact efforts to an approach that can prevent children and youth from being exposed to violence in the first place. A primary prevention approach prevents exposure by addressing the factors in the community environment and the societal norms that contribute to its occurrence.

A prevention approach is needed because:

• The results of reacting after the fact are too great. Childhood abuse, neglect, and witnessing domestic violence, termed adverse childhood experiences (ACEs), are common. In one study, almost two-thirds of participants reported at least one ACE, and more than one in five reported three or more ACEs. The ACE framework furthers the understanding of the effects of children and youth exposed to violence because it demonstrates a link between 1) specific violence related stressors, including child abuse, neglect, and repeated exposure to intimate partner violence, and 2) risky behaviors and health problems in adulthood including: alcoholism and alcohol abuse; chronic obstructive pulmonary disease (COPD); depression; illicit drug use; ischemic heart disease (IHD); and liver disease. In addition, ACEs also strongly correlate with health-related behaviors and outcomes during childhood and adolescence including early initiation of smoking, sexual activity, and illicit drug use, adolescent pregnancies, and suicide attempts. Findings from the ACE studies confirm what we already know-that too many people in the United States are exposed early on to violence and, as a result, experience short and long term negative impacts to their health and wellbeing.

• The costs of reacting after the fact are too great. The burden of trauma and the drain of limited community resources makes prevention a priority. As Dr. Felitti, the co-founder of the ACE's framework recently stated to a large conference of health clinicians, "If we don't prevent violence there are huge health costs not just criminal justice costs. We know, you know, there will never be enough resources to address the impacts. Primary prevention is the only option we have to pay attention to the breadth of the problem. The costs of this exposure to the individual, family, community and society is staggering." Due to the high cost of treatment and lack of dedicated funding, after-the-fact options like treatment while important, is unlikely to ever meet the demand for services. More importantly, after-the-fact strategies will never prevent childhood exposure from occurring in the first place. Our children and youth deserve an investment in prevention.

• Violence is a health equity issue, and preventing violence is an important component of achieving equity in health and in communities. Health inequities are related both to a legacy of overt discriminatory actions on the part of government and the larger society, as well as to present-day institutional practices and policies that perpetuate a system of diminished opportunity for certain populations. An overwhelming number of risk factors for violence have accumulated in some communities, without resilience factors to protect against violence. Some communities and groups are far more exposed to the poor neighborhood conditions that give rise to violence and other health inequities. Preventing violence and therefore preventing a child or youth's exposure to it has tremendous value, not just in saving money and lives, but also as a means to foster well-being, promote health equity, and strengthen communities.

A primary prevention approach promotes safe, healthy environments and behaviors, reducing the likelihood of exposure to violence in the first place. This approach is often confused with early intervention services for victims and perpetrators. Interventions, such as universal screening in health care settings, may help to alleviate trauma and potentially prevent future incidents; however, early identification follows actual or threatened violence and seldom alters the broader community and societal environment that gave rise to the violence that caused the trauma. Primary prevention moves far upstream to change the environmental factors, such as economic inequalities, and norms such as privacy and silence around family violence, that shape behaviors of a population. Primary prevention is a systemic process capable of dramatically reshaping our environment and norms, thereby preventing violence from ever occurring.

The time is right for a greater emphasis on primary prevention. Prevention honors and builds upon past successes and complements the field's continued commitment to improving responses to this critical issue. This shift will require an increased effort to advance promising prevention approaches - a core outcome essential to achieving dramatic reductions in rates of child exposure to violence.

The Environment: Factors that Shape Behavior

Violence, and children and youth's exposure to it, arises out of a complex interplay of individual, interpersonal, social, political, cultural, and environmental factors. The socio-ecological model (see Figure 1) provides a framework for understanding how individual well-being is nested within family, community, and societal levels. Influences at any level can either increase or decrease the risk of perpetration or victimization.

This framework clarifies the societal influence on an individual and confirms why it is more important to focus on environmental change than on individual behavioral change. Root factors like sexism, racism, homophobia, classism, patriarchy, and other forms of oppression shape societal and community factors that in turn influence relationships and individuals. Environmental components in turn affect behavioral outcomes. . Both root factors and environmental contributors are determinants of child exposure to violence. The Institute of Medicine affirmed this by concluding, "It is unreasonable to expect that people will change their behavior easily when so many forces in the social, cultural, and physical environment conspire against such change." When viewed in this light, we can see childhood and youth exposure to violence becomes a complicated issue deeply embedded in the environment. By understanding and then transforming environments, we can prevent violence before it occurs.

Norms: Commonly Held Attitudes and Beliefs That Shape Behaviors

Societal and community environments play a strong role in shaping behavior, including through norms. Norms are not simply habits. Often based in culture and tradition, they are attitudes, beliefs, and standards that we take for granted. In other words, norms pattern our behavior-they are environmental signals telling people what is okay and not okay to do. Norms describe what actually occurs (i.e. descriptive) and also signify a standard of proper behavior (i.e. normative or prescriptive).

A prevention strategy must account for norms because these standards are pervasive, powerful determinants of behavior. If violence is typical, expected, and reinforced by the media, family, community, peers, or school, it is far more likely to occur. It will occur, in fact, with greater frequency and potency. If norms discourage safe behavior and are unsupportive of healthy and safe relationships, then programs focused on change at the individual level will not produce safe behavior unless social norms are changed as well. Thus, changing norms is critical in preventing childhood and youth exposure to violence.

There are at least five damaging norms that contribute to childhood and youth exposure to violence:

1. A Narrow Definition of Manhood, where society promotes domination, exploitation, objectification, control, oppression, and dangerous risk-taking behavior in men and boys, too often victimizing women and children.
2. Limited Roles for Women, where from a young age females are often encouraged, through subtle and overt messages, to act and be treated as objects, used and controlled by others.
3. Power, where value is placed on claiming and maintaining control over others. Traditional power expectations promote the notion that children should be seen and not heard, making them an especially vulnerable population.
4. Violence, where aggression is tolerated and accepted as normal behavior and can be used as a way to solve problems and get what one wants.
5. Privacy and Silence, where norms associated with individual and family privacy are considered so sacrosanct that secrecy and silence is fostered, and children who experience violence may keep it secret and those who witness violence are discouraged from intervening. Though changing, the value placed on privacy enables people in a shame-based culture to perpetuate the abuse, rendering victims and their families immobile in the face of fear, public shame and stigma.

In our society, we glamorize violence, overlook it, accept it as a private matter, and regularly encourage it through "egging" others on. Most people do not believe children should be exposed to violence. However, when the five norms are taken as a composite, it is not surprising that many children are exposed to violence and that bystanders don't speak up or act against it. This set of norms promulgates an unsafe environment that enables exposure and inhibits preventive action. While condoning children's exposure to violence is certainly not the norm, we have an overarching set of norms that insidiously contributes to the likelihood it will happen. We must acknowledge these norms and change them if we are to make major strides in preventing childhood and youth exposure to violence.

The Spectrum of Prevention: A Tool for Changing Norms and Environments

We must tip the balance in communities and replace unhealthy norms and environments with ones that promote well-being. The Spectrum of Prevention offers a framework for developing effective and sustainable primary prevention initiatives that have the potential to affect community and systems-level changes (See Table 2). The inter-relatedness, or synergy, among levels of the Spectrum maximizes the results of each activity and creates a more transformative force. While all levels of the Spectrum are essential for sustaining change, community and systems-level change require efforts at the broadest levels of the Spectrum. These include changing organizational practices and influencing policy and legislation.

 

Level	Description	Sample strategies
Influencing Policy & Legislation	Developing strategies to change laws and policies to influence outcomes	Advocate for policies that support family mental health, including expanding health insurance coverage to include infant and parental mental health and providing adequate training to ensure quality services and programs
Changing Organizational Practices	Adopting regulations and shaping norms to improve health and safety	Incorporate violence screening and assessment tools into existing healthcare protocols and training and promote their use to increase identification and intervention with pregnant women, caregivers, and young children who are at risk of violence
Fostering Coalitions & Networks	Bringing together groups and individuals to achieve broader goals and have greater impact	Foster collaboration between city planners, transportation and housing authorities, law enforcement, business leaders, funders, and health and education service providers in the development of neighborhoods and services that promote young children's health and well-being
Educating Providers	Informing community leaders and other providers who will transmit skills and knowledge to others	Ensure that professionals who work with youth children and families are trained to identify substance abusing caregivers and affected children and provide them with developmentally and culturally appropriate care and support
Community Education	Reaching groups of people with information and resources to promote health and safety	Educate community members about the vulnerability of young children and the detrimental effects of abuse, neglect, and witnessing violence
Individual Knowledge & Skills	Enhancing an individual's capacity to prevent injury and illness, and promote wellness and safety	Provide caregivers with information about child development and teach them stress management, problem solving and boundary setting skills, and positive communication and discipline techniques

Table 2. The Spectrum of Prevention. The Spectrum of Prevention was developed in 1983 by Larry Cohen and is based upon the clinical work of Dr. Marshall Swift from Hahnemann College in developmental disability prevention.

Level 6, Influencing Policy and Legislation, has the greatest potential to achieve broad impact across society and influence large numbers of people at once. By mandating what is expected and required of institutions, organizations and individuals, sound policies can prompt widespread reductions in violent behavior so peace ultimately becomes the new social norm.

A focus on systems is a salient feature of quality prevention, since various networks and institutions play an important role in creating safe environments for all individuals. Policies are key levers for change and for achieving equitable conditions that protect all young people from violence. In some cases, laws and policies already exist that could promote safety, and can be supplemented by an additional law, change in policy, better enforcement, or change in an organization's practices to ensure effectiveness.

Level 5, Changing Organizational Practices, calls for reshaping how organizations and institutions carry out their work, whether these are internal processes or govern external relationships. Many organizations are also influential community members and can encourage other groups in a neighborhood to adopt similar practices.

Level 4, Fostering Coalitions and Networks, highlights the advantages of working across disciplines and pooling the resources and assets of many people and organizations to maximize impact and use resources most efficiently. No one group or sector can do everything required to raise healthy children, support their families and prevent violence. Coalitions and networks rally critical mass behind a community-based effort and can achieve more than any one group or individual could alone.

Level 3, Educating Providers, leverages the extensive social and professional networks that community leaders cultivate. The term "providers" should be applied broadly to include anyone with influence in the community, and can transmit information, skills and motivation to many people.

Level 2, Promoting Community Education, provides groups of people or the general public with information and resources to prevent violence and improve safety. Effective community education also helps change public attitudes and shift norms in favor of safety and health.

Level 1, Strengthening Individual Knowledge and Skills, equips individuals to prevent violence as far as they are able, regardless of their particular circumstances. It is society's responsibility to create safe environments that protect all people from violence, but changing the environment so it prevents violence does not happen overnight. In the meantime, it is important to provide individuals with the knowledge and skills, and increase their resources and capacity to do everything they can to ensure personal safety.

Preventing violence requires activities at all levels of the Spectrum, but too often, people equate prevention practice with one-on-one education. Quality prevention requires implementing complementary activities at all levels of the Spectrum, rather than stopping at Level 1 or 2. Strategies that act in tandem to prevent violence coalesce into a transformative force for safety and community health. According to Ottoson and Green, "Activities must be coordinated and mutually supportive across levels and channels of influence, from individual to family to institutions to whole communities." The Spectrum of Prevention fosters collaboration and synergy, and mobilizes a community's unique resources and assets in a way that no single program at any one level of the Spectrum can.

Strategies to Prevent Violence

In the three examples below diverse communities have come together and mobilized their resources to prevent violence and thereby prevent childhood and youth exposure to violence. In the case of Minneapolis coordination of existing effort brought better outcomes and a larger investment of funding. In the second example, in Alameda County, the focus was not on program but developing shared principles that could guide the efforts of multiple agencies and organizations. Finally, the UNITY City Network provides an example of the impact of local leaders coming together with a unified ask for their federal support. In all of these examples the focus is on changing norms and environments to make violence less likely to occur by using strategies from across the Spectrum of Prevention.

Coordinating a Multisector Approach: Minneapolis' Blueprint for Action
The City of Minneapolis is demonstrating that a strategic prevention plan can transform a city for the better. The Minneapolis City Council passed a resolution declaring youth violence a public health issue in 2007 and created a steering committee to develop the Blueprint for Action. The Blueprint guides the city's overall direction and explicitly calls for coordinated prevention activities. Violent crime in the four prioritized neighborhoods fell by 43 percent in the first two years of the initiative, and homicides of youth decreased by 77 percent between 2006 and 2009. The number of people under 18 years old either suspected or arrested for violent crime had steadily increased starting in 2001, peaking at 2,652 in 2006. This decreased by more than half after Minneapolis launched the Blueprint for Action, and the number in 2010 is the lowest in a decade. Minneapolis also tracks a number of other indicators to gauge progress. High school graduation rates, for example, have increased from 55 percent in 2005 to 73 percent in 2010.

Due to this remarkable early success, the city expanded the Blueprint for Action in 2009 from the four initial neighborhoods to 22 neighborhoods, and the National League of Cities recognized Minneapolis' approach as among the most innovative models for preventing violence affecting youth. Developing and implementing a local strategic plan grounded in prevention is paying off for Minneapolis and across the region.

Adopting Guiding Principles to Shift Norms and Change Environments: Alameda County
We acknowledge not all communities are ready to engage in a coordinated approach. In these cases adopting a set of shared, overarching principles can begin to shift norms and environments to address the inequitable conditions that perpetuate violence. The principles below, adapted from "Life and Death from Unnatural Causes in Alameda County," served as a guide to bring together diverse agencies all concerned with preventing violence.

Principles include:

• Because of the cumulative impact of multiple stressors, our overall approach should shift toward changing community conditions and away from blaming individuals or groups for their disadvantaged status.
• Acknowledging the cumulative impact of stressful experiences and of multiple risk factors in the environment is crucial, especially since these sources of chronic stress and risk factors tend to occur in areas of concentrated poverty. For some families, poverty lasts a lifetime and is perpetuated to next generations, leaving its family members with few opportunities to make healthful decisions.
• Meaningful public participation is needed with attention to outreach, follow-through, language, inclusion, and cultural understanding. Government and private funding agencies should actively support efforts to build resident capacity to engage.
• Preventing violence is an opportunity to invest in community. The social fabric of neighborhoods needs to be strengthened. Residents need to be connected and supported and feel that they hold power to improve the safety and well-being of their families. All residents need to have a sense of belonging, dignity and hope.
• The developmental needs and transitions of all age groups should be addressed.
• Working across multiple sectors of government and society is key to making the structural changes necessary. Such work should be in partnership with community advocacy groups that continue to pursue a more equitable society.
• Groups that are the most impacted by violence must have a voice in identifying policies that will make a difference and must be empowered to hold government accountable for implementing these policies.
• Setting a Policy Agenda: The UNITY City Network
• Faced with fragmented and inadequate funding streams, a lack of coordination across supporting agencies, and hit hard by the nation's economic downturn, local efforts, more than ever, need federal support to achieve and sustain their efforts. Through UNITY (Urban Networks to Increase Thriving Youth, a Prevention Institute Initiative, representatives from the largest US cities identified and prioritized strategies that, if adopted at the federal level, will enhance the ability of local leaders to prevent violence and thereby prevent childhood exposure to violence. The UNITY Urban Agenda for Preventing Violence was endorsed by 13 U.S. Cities and serves as a guiding document for national and local systems change.

Recommendations include:

• Allocate and align resources. Whether through allocation of existing resources or the development of new revenue sources, cities need adequate, flexible financial resources to implement effective strategies on the ground, bring them to scale and coordinate them.
• Create a high-level focal point for preventing violence in federal and state governments. Given that responsibility for preventing violence spans multiple agencies, a high-level focal point could foster accountability and support coordination.
• Establish supportive data, research and evaluation systems. A national research agenda on effective prevention and disseminating multi-sector surveillance data on key risk and protective factors would inform and enhance local efforts. This information could be used to establish national baseline measures and standards.
• Develop a communications campaign. A national campaign would lend local efforts heightened visibility and added credibility. Conveying positive messages about youth and making the case for prevention can foster buy-in.
• Enhance public health's capacity and infrastructure at the federal, state and local levels to address violence. Versed in prevention and charged with protecting the public's health, public health has a track record and proven methodology for changing behaviors that contribute to poor health and safety outcomes.
• Establish a mechanism for multisector collaboration in federal and state governments. This would provide a vehicle to align federal funding initiatives, establish joint funding streams or blended and braided funding, coordinate data systems, and share evaluation strategies.
• Equip people with the necessary skills through high-quality training. Cross-sector training can build a common language and foster understanding about one's own role each sector's contribution.

Conclusion

The Task Force for Defending Childhood provides an important challenge to our current norms and environments for children and adults: We must begin to expand our focus from individuals to environments and from criminal acts to healthy norms in order to build national momentum for a childhood free of violence.

Childhood and youth exposure to violence is rooted in norms and environments and no single program can address the magnitude of the issue or the diverse root factors underlying it. It is a complex problem that requires a comprehensive solution and participation from stakeholders in multiple sectors. Prevention of violence is often seen as unachievable, because prevention is rarely approached with the level of commitment and attention required for long-term success. Childhood exposure to violence is preventable. Its prevention requires an investment of resources, people, and leadership. By building on the wisdom of communities, the experience of national experts, and the infrastructure built though coalitions and networks over the last twenty years, we can harness the willingness and capture the opportunity to collectively construct a national movement to prevent childhood and youth exposure to violence.