Renée Boynton-Jarrett and Robert Sege
Violence is among the leading causes of death and disability for American children and adolescents. The epidemic of murder took the lives of approximately 2000 young people annually between 1980 and 2002. During this period, approximately 1 of every 4 youth homicides was committed by juveniles. Overall, homicide was the third leading cause of death for youth aged 13 to 21 and the leading cause of death for African American young men in this age category. Despite a recent national decline in the homicide rate, the United States continues to have one of the highest homicide rates in the world.1,2
While homicide is the most extreme form of community violence, many more young people are injured: The ratio of nonfatal to fatal assaults is estimated to be 100 to 1. Over 780,000 youth were treated in US emergency departments for nonfatal injuries in 2004, and twice as many are victims of physical dating violence each year. When surveyed, over one third of high school students report having been in a physical fight in the past 12 months (40% and 25% of males and females respectively); in fact, the rate of injuries due to fighting has remained steady for decades. One in 8 youths reported carrying weapons for protection, and 1 in 9 report avoiding school due to fear of violence.3
The quality of the family and community environment during childhood and adolescence has profound and lasting effects, which persist into adulthood. Recent studies have demonstrated that exposure to violence is among the earliest and most pervasive adverse experiences.4 Childhood adversities have been linked to future physical, mental, and developmental health and to all major causes of morbidity and mortality in adulthood.5,6 One of every 10 children attending a Boston, Massachusetts, city hospital pediatric primary care clinic witnessed a shooting or stabbing in their homes or communities before the age of 6.7 This high prevalence of violence exposure underscores the importance of violence as a public health problem.
Pediatricians play a crucial role in preventing, identifying, and intervening in such situations. Contrary to the perception that violence consists of random acts in society, violence is most likely to be perpetrated by individuals known to the victim. Hospital readmission for subsequent assaults and homicide are high. Moreover, violence is associated with known risk and resilience factors that may be routinely assessed during the course of medical care.8
Well-established risk factors for violence-related injury include access to firearms, history of fighting or injury, violent discipline, alcohol and drug use, exposure to familial violence, media violence, and gang involvement. As this list of risk factors makes evident, distinct forms of violence rarely occur in isolation. In addition to these individual risk factors, violence also tends to be highly correlated with other social adversities, particularly poverty, substance abuse, housing insecurity, parental mental health challenges, and neighborhood disadvantage.9
The accumulation of violence exposure and other social risks may overwhelm a young person’s ability to cope with adversities effectively.10 Indeed, the adverse effects of exposure to violence on mental, physical, and developmental health are often cumulative.11
This chapter reviews the epidemiology, health, and developmental impact of familial, dating, and community violence and violence exposure. The intent is to provide an overview of the pattern of violence exposure among youth in the United States and useful approaches to prevention, identification, and intervention for pediatricians in the clinical setting.
Family violence refers to acts of violence between family members. While all forms of family violence may have grave consequences, this section highlights intimate partner and sibling violence. Intimate partner violence (IPV) includes the actual or threatened emotional, physical, psychological, or sexual abuse between 2 individuals in a close (ie, current or former dating/marital) relationship. Although IPV is present in relationships across class, culture, race/ethnicity, and sexual orientation, this phenomenon is characterized by a gender disparity; in 2001, the US Bureau of Justice Statistics reported that 85% of victims of IPV are women. Between 3 and 10 million children are exposed to IPV annually. The risk of child maltreatment increases as the level of violence in the household increases: Children exposed to IPV are 6 to 15 times more likely to be abused. Children who witness IPV in their homes are at an increased risk of violence in future intimate relationships. Parental history of abuse in childhood, substance abuse, and poor mental health increases the likelihood of family violence. Although IPV spans the socioeconomic gradient, poorer children may be at higher risk of exposure.9
The impact of intimate partner violence on child health, behavior, cognitive development, and academic performance may vary by age and developmental stage (see Table 36-1). An expansive body of research has documented an association between toxic family environments and mental health problems, including externalizing symptoms such as aggression, conduct disorder, and antisocial behavior, and internalizing symptoms such as anxiety disorders, depression, and suicidal behavior.12 Moreover, the association between childhood adversities, such as IPV exposure and household dysfunction, with subsequent poor physical health is well-established.9,10,13 Youth residing in environments characterized by aggression, conflict, and neglect are more likely to exhibit health-threatening behaviors (eg, smoking, alcohol and drug abuse, and risky sexual practices). Violence exposure may impact development of strategies to process emotions and coping responses and ultimately lead to higher emotional reactivity. Social competence—social skills, cognition, and prosocial behaviors—may be impacted by deficits in the ability to temper emotions and by lack of role modeling and socialization in the home. Not surprisingly, adaptation to school, academic performance, and peer relations may be subsequently influenced.
When the family environment is a source of threat as well as protection, the parental role as physicaler emotional reactivity. Social and emotional caregiver can be severely compromised. Parent-child relationships may be strained by caregiver depression, emotional unavailability, feelings of helplessness to protect the child, and social stress associated with battering. Therefore, the parental response to violence may compound the child’s vulnerability in the context of violence exposure. Witnessing a life-threatening act against a caregiver is ranked among the most traumatic experiences a child can face and may lead to posttraumatic stress disorder or associated symptoms.7,12,14
Sibling violence is commonly discounted as more benign and less harmful than other forms of peer violence. Approximately 35% to 50% of children report being hit or attacked by a sibling annually.15Overall, sibling violence tends to result in fewer serious injuries than peer violence and involves the use of fewer potentially injurious weapons; however, sibling violence is more likely to be chronic and therefore may hold greater potential for trauma symptoms. Sibling violence may vary depending on the age of the perpetrator; for example, impulsivity and inability to foresee consequences may imbue child aggressors with the greatest potential to cause harm.16
The American Academy of Pediatrics and the American Medical Association recommend incorporating screening for Intimate Partner Violence (IPV) into routine health care maintenance. Screening should take place during new patient visits, annual well-child visits, if a new intimate relationship is disclosed, or if concerning symptoms arise. Symptoms of emotional distress, including somatic complaints and behavioral and emotional problems, or an obvious physical injury should prompt screening for family violence. Among younger children, regression from established milestones for language, communication, and bowel and bladder control should raise concern for the possibility of family violence. Details on whom, when, and how to screen are summarized in Table 36-2.
Table 36-1. Potential Effects of Witnessing Family Violence by Age and Developmental Stage
An approach to management following disclosure of IPV is provided in Figure 36-1. Safety planning may be complex and time consuming; many physicians refer affected caregivers to a social worker or advocate. Clinicians can establish a clinical protocol for IPV screening, assessment, anticipatory guidance, and response if familial violence is identified. Establishment of a multi-disciplinary team or collaboration with community agencies may enhance clinical training and resources available for patient care.
Children may benefit from referral to comprehensive mental health services or to specific programs that provide trauma-informed care and allow parent and child to communicate about violent episodes safely. Referrals are particularly warranted in the setting of behavioral change, symptoms persisting longer than 3 months, witnessing severe violence, or an emotionally unavailable caregiver. In those cases in which a report to the state child protective services is warranted, the report should include information regarding the presence of IPV, and the response of child protective services should be designed in a way to promote safety for both adult and child victims.
The acceptability of screening for IPV in the pediatric setting is high and is associated with improved parental satisfaction.17,18 Many abused parents will not seek medical care for themselves but will seek care for their children, further supporting the inclusion of IPV screening in routine care.
Parents and youth should be screened routinely regarding the nature and pattern of sibling disagreements. Screening provides a valuable opportunity for prevention and early identification. The introduction of alternative forms of conflict resolution is important. Sibling violence resulting in injuries or trauma symptoms should be referred to mental health specialists, family counselors, or family crisis intervention. Serious intentional injuries or threats and repeat injuries should be referred or reported to appropriate services.
Teen dating violence may represent a bridge between exposure to family violence in childhood and violent adult intimate relationships. Patterns of intimacy are established during adolescence. Unfortunately, approximately 10% to 25% of adolescents report experiencing physical and/or sexual dating violence.19
Dating violence includes physical, sexual, verbal, and emotional violence. Although both young men and young women inflict and receive physical abuse, females are more likely to experience severe physical and sexual violence; they are 3 to 6 times more likely to experience dating violence than males. The lifetime prevalence of dating violence is 1 in 5 among adolescent girls. In fact, 10% of intentional injuries experienced by adolescent females are perpetrated by dating partners.20 Dating violence is associated with risky health behaviors, including earlier sexual debut, a greater number of sexual partners, inconsistent condom use, and alcohol and drug use.21 Youth exposed to dating violence are more likely to have sexually transmitted infections, pregnancy during adolescence, and a history of social adversities, including exposure to family and community violence.22
Youth in same-sex relationships are at a particularly elevated risk of violence in intimate relationships. Among young men, the number of same-sex male partners correlated with higher frequency of dating violence.23 Vulnerability to violence may be linked to social isolation; moreover, concerns for social acceptance may increase challenges to seeking care.
Pregnant teens also experience a sharply elevated risk of violence in intimate relationships. An estimated 7% to 26% of adolescent females report violence during pregnancy inflicted by a partner or family member. Unfortunately, violence during pregnancy predicts continuing violence: 75% of teens who report exposure to violence during pregnancy also report violence 2 years postpartum.24,25
There is consistent evidence that both the perpetrators and victims of youth dating violence are at an elevated risk of serious health concerns, including suicidal ideation, lower health-related quality of life, risky sexual behaviors, illicit drug use, antisocial behaviors, disordered eating, and unhealthy weight control behaviors. Greater awareness of the multiple health risks associated with dating violence may elevate the index of suspicion and lead to more timely identification and intervention.
Table 36-2. Intimate Partner Violence: When, Who, and How to Screen
Pediatricians should routinely screen for both victims and perpetrators of dating violence. Screening should occur during visits for annual health maintenance, family planning, emergency contraception, and following disclosure of a new intimate relationship. Recommended screening questions are included in Table 36-3. Special attention should be paid to pregnant and postpartum teens who should be screened repeatedly. Additionally, young people with a history of school failure, multiple pregnancies, repeat sexually transmitted infections, and multiple requests for emergency contraception may be particularly vulnerable to dating violence. A climate that avoids assumptions of a heterosexual orientation will allow for an open dialog on intimate relationships with all teens.
Pediatricians should routinely provide anticipatory guidance on the characteristics of healthy relationships and strategies for resolving conflicts. Providers should assess the safety of youth who reveal dating violence, seek support from mental health specialists, and refer patients and their parents to community-based youth development and asset-building programs. As discussed later in this chapter, resources related specifically to the prevention of dating violence are available to clinicians from the American Academy of Pediatrics and the Centers for Disease Control and Prevention.
In modern society, youth are at heightened risk of being victims of, witnessing, and hearing about violence or knowing a relative or peer who died violently. In comparison to suburban youth, youth residing in urban areas report higher rates of witnessing severe violence—stabbings and shootings—while youth in rural areas report high rates of witnessing threats, psychological abuse, and beatings by peers.12,14
Minority youth are at particularly high risk of exposure to community violence. Racial/ethnic disparities in the homicide rate exist, and African American young men are at greater risk of homicide; between ages 18 and 24 years, they are 8 times more likely than their white counterparts to be murdered. In addition, all children, regardless of race, are at high risk of violence-related injury. The risk of being killed at home increases dramatically whenever there is a handgun in the home. Alcohol and drug use are associated with violent events and injury.
Witnessing violence has been associated with psychological, social, academic, cognitive, and physical challenges as well as with propensity to engage in violent acts in the future. Young persons in violent communities have a higher likelihood of weapon-carrying and aggression. Although exposure to firearm violence has been associated with a heightened risk for perpetration of serious violence, the majority of youth exposed to violence do not perpetrate abuse or engage in criminal behavior. Moreover, youth are less likely to carry concealed firearms if they reside in neighborhoods that are safe, have greater social and physical order, and have higher collective efficacy—social cohesion and informal social control.
Exposure to community violence influences perceptions of safety and security, which may undermine development of trust and autonomy and thereby hinder efforts to obtain mastery of the social environment. Somatic symptoms, anxiety, depressive symptoms, irritability, sleep disturbances, and posttraumatic stress disorder and associated symptoms result from acute or chronic exposure to community violence. Approximately one third of urban youth exposed to community violence meet criteria for post-traumatic stress disorder, and nearly two thirds of adolescent girls exposed to community violence have the symptomatology.4
FIGURE 36-1. Assessment and management of intimate partner violence. (Figure provided courtesy of Wendy Gwirtzman Lane and Howard Dubowitz.)
Exposure to violence impacts global developmental and social morbidity for children and adolescents. Peer relations may suffer from violence exposure; these youth appear to be more antisocial and socially isolated and may have difficulty building healthy relationships with peers. Academically, violence exposure is linked to difficulties with memory and concentration and poorer school performance. Finally, witnessing violence is linked to substance abuse and dependency.
Although a majority of parents believe that pediatricians should discuss community violence during routine office visits, only 10% of parents reported that their pediatricians did so. The American Academy of Pediatrics and other professional societies have developed violence prevention training programs, such as Connected Kids, to provide resources for practitioners and families. These programs provide training and resources that support child health care providers in clinical, community, and social advocacy and policy settings. Specific approaches to prevention and intervention around community violence exposure are discussed in the “Assessment of Risk” and “Prevention and Intervention” sections of this chapter.
Table 36-3. Screening Youth for Dating Violence
I ask all teenage patients about violence because it is so common. Is it okay if I speak with you about this?
Assess perspective on healthy relationships
Are you in an intimate relationship or dating anyone?
What do people do when they disagree in your family?
How do you fight with your partner? Do you have fights with yelling or screaming? Do they involve hitting or shoving?
Direct questions on dating abuse
Have you ever felt afraid of someone you were dating?
Has anyone you were dating hurt or threatened you?
SPECIAL RISKS AND GROUPS AT RISK FOR VIOLENCE
Bullying, a worldwide phenomenon of middle childhood, occurs when a bully (usually larger and stronger than the victim) repeatedly acts and behaves negatively toward a specific victim, often at school or on the way to or from school. Nearly 10% of students in 6th through 12th grade report having been bullied at school, during school-related activities, or en route to or from school. Bullying not only causes injury to the victim but may engender resentment and lead to retaliatory violence. Bullied youth are at greater risk of low self-esteem, disordered eating, anxiety, depression, somatic symptoms, and school absence.26
Bullies themselves have the greatest risk of long-term adverse outcomes and are more likely to come from disordered homes. Unchecked, bullying behavior becomes destructive and ineffective for the bully in the middle school and high school years. Male bullies, in particular, are unlikely to complete their schooling and are at elevated risk of unemployment, incarceration, and living in poverty as adults. They are also less likely to have stable adult relationships.
An effective antibullying strategy for use in schools37 has been adapted from a Scandinavian model by the US Maternal and Child Health Bureau. This evidence-based approach can reduce bullying in the school by 90%. For the individual parent who brings the child who is the victim of bullying to the physician’s office, it is most important to acknowledge the difficulty that the victim faces and suggest that the caregiver talks with the principal and school counselor at the school in order to ensure a safe environment for the child. At the same time, introduction of the child to an alternative social environment may help insulate him or her from the negative effects of bullying. For example, many parents enroll their child in a martial arts program, scouting, or a youth program sponsored by faith-based organizations. In each of these settings, the youngster may experience social success and ameliorate the negative consequences of bullying. Efforts to prevent bullying provide an opportunity for the health care practitioner to engage with the school administrators and identify important research backed approaches.
GLBTQ YOUTH AND VIOLENCE
Gay, lesbian, bisexual, transgender, and questioning (GLBTQ) youth are at an increased risk of violent victimization. GLBTQ youth are more likely to be harassed, attacked, and/or threatened at school. Approximately 17% of anti-GLBTQ incidents of violence reported in a national study in 2002 occurred among individuals 22 years old and younger. Hate crimes, or incidents of violence fueled by discrimination, can be unusually humiliating, cruel, and brutal acts. GLBTQ youth are also at increased risk of depression, hopelessness, alcohol abuse, and suicidal ideation and attempts.23 As discussed earlier, GLBTQ youth are at greater risk of violence in intimate relationships, possibly due, in part, to social isolation.
YOUTH IN THE JUVENILE JUSTICE SYSTEM
Despite a decline in crimes committed by juveniles over the past decade, 2.3 million youth were arrested in 2001. Approximately 14% of those involved in juvenile crimes are placed in correctional facilities, where young men in racial/ethnic minority groups are significantly overrepresented. Over the past decade, the number of adolescent girls involved in juvenile arrests and incarceration has increased dramatically; girls now account for 28% of all juvenile arrests for violent crime.
The mental health profile of juvenile offenders differs by sex. Girl offenders have a higher prevalence of reported traumatic exposures and psychiatric disorders. Nearly two thirds of male and three fourths of female detainees meet criteria for at least 1 psychiatric disorder. Among this population, approximately 93% have experienced at least 1 traumatic incident (often child abuse), and 11% meet criteria for post-traumatic stress disorder. Nearly half have substance use disorders, and a large percentage have disruptive behavior disorders. Youth who have been involved in the juvenile justice system have higher rates of suicide attempts and tend to use more lethal means. Youth in juvenile detention are also at an elevated risk of intentional injuries, including physical and sexual abuse perpetrated by other detainees or staff. Not surprisingly, many develop physical and mental health problems during incarceration, and access to health services is often limited.
FIREARMS IN THE HOME
The safest home for a child is a home without guns. Firearms are the third leading cause of death among children 10 to 14 years old and the second leading cause of death among those 15 to 19-years old. Approximately 43% of homes in the United States have firearms. The presence of firearms in the home is associated with a fivefold increase in the risk of adolescent suicide. More than 50% of adolescent suicides involve the use of firearms; moreover, greater than 90% of suicide attempts involving the use of firearms are lethal.
Firearms in the home present a unique risk factor for adolescents, both for interpersonal violence and for suicide attempts. Providers should routinely screen parents and youth for the presence of guns in the home, their storage, and the ability to access a fatal weapon.28 Developmentally, adolescents are inclined to make more spontaneous decisions, a characteristic that poses an even greater risk for the impulsive use of firearms. Public health data suggest that access to firearms increases the rate of completed suicide. Families should be counseled regarding the dangers of in-home firearms and advised to remove guns from the home for the sake of those who are at high risk, including adolescents with a history of depression, drug abuse, or affective disorders.
Television viewing is the most time-consuming activity for youth aside from sleep. Increasing numbers of violent incidents are aired on television. Presently, nearly two thirds of television shows contain violence. By the end of grade school, children will witness an estimated 8000 murders and 100,000 acts of violence on television. Not only is violence often glamorized on television, it often exists to the exclusion of other means of resolving conflicts, and televised perpetrators do not suffer consequences for their actions, thus endorsing violent behavior as socially acceptable.
Younger children tend to have difficulty distinguishing fantasy from reality on television and appear to be more affected by television violence. Media violence has been associated with an increased state of arousal for youth, identification with the aggressor, and justification of the acts of violence. Television viewing has been associated with aggressive behavior, desensitization to witnessed violent acts, increased feelings of threat and danger, and fear of victimization. Reduction in television viewing has been associated with reduced fighting-related behaviors.29
The American Academy of Pediatrics recommends that parents monitor and provide guidance for television viewing, limit television viewing to less than 2 hours daily, remove televisions from bedrooms or potentially unmonitored locations, discuss the content of television shows, and supervise DVDs and video games. At the community level, pediatricians can support campaigns to increase media literacy among children and their parents and support community-based programs that encourage alternative forms of entertainment for youth.
Resilience factors help children overcome adversities; in particular, they may buffer stressors by promoting recovery, facilitating adaptation during exposure, or protecting an individual from exposure to a stressor. The interplay of the type of exposure, developmental stage, and specific vulnerability determines the ability for resilience factors to help buffer stressors. Individual traits associated with resiliency include social competence, self-esteem, problem-solving skills, autonomy, and sense of purpose. Establishment of a secure attachment between child and primary caregiver in early life also contributes to resiliency. Parents also model resilient behaviors and attitudes for their children. Supportive family relationships, parental monitoring, clearly established rules, high expectations for prosocial behavior, and participation of children in family activities can help improve resiliency in children exposed to violence in the community. Finally, meaningful connections to the larger community promote resiliency in youth.
Positive youth development programs provide settings for adolescent development that view young people as important contributors to their communities. Afterschool arts programs, music programs, volunteer opportunities, and athletic programs have all been adopted as a method of reducing youth risk behavior. There is strong evidence to support the effectiveness of these programs. From a clinical perspective, helping young people engage with these programs is one key to successful modification of risk factors and is likely to be more effective than brief in-office behavioral counseling. Neighborhood characteristics, such as collective efficacy—related to social cohesion and informal social control—and the availability of institutional resources in the community have been linked to increased resilience of youth exposed to violence.
ASSESSMENT OF RISK
Several risk-based screening instruments are published for use in identifying adolescents at risk for interpersonal violence. The American Medical Association’s Guidelines for Adolescent Preventive Services (GAPS) provides the most widely used general adolescent primary care protocols. GAPS includes the recommendation that health care providers “counsel (patients) to resolve interpersonal conflicts without violence and to avoid the use of weapons and/or promote weapon safety.” The American Academy of Pediatrics’ Connected Kids program, discussed in the next section, recommends the FISTS (fighting, injuries, sex, threats, self-defense) screener, which probes specific risk factors associated with subsequent violence (Table 36-4). Youth at moderate risk for violence exposure report fighting once or twice in the past 12 months or occasional drug or alcohol use. High-risk individuals are truant from school or have dropped out, report 2 or more fights in the past year, or use illicit drugs. Counseling and referral may be needed for moderate to high-risk individuals.
PREVENTION AND INTERVENTION
Universal strategies to prevent violence include efforts to reach all children and families. Resources and websites for families, schools, children and medical professionals are listed in Table 36-5. From a clinical standpoint, these strategies can be directed at promoting resilience and risk reduction. Effective strategies are developmentally appropriate and comprehensive—intervening at individual, family, school, and community-levels—and begin with infants and toddlers. This comprehensive developmental philosophy forms the basis for the American Academy of Pediatrics’ Connected Kids: Safe, Strong Secure program for prevention of violence in the primary care setting.30,31Preschool anticipatory guidance focuses on development of family support and highlights parent understanding of child behavior and the use of alternatives to corporal punishment. Violence prevention for school-age children focuses specifically on the issue of bullying and more generally on helping children acquire adequate communication and conflict resolution skills.
Universal prevention for adolescents centers on identifying engaging, prosocial activities for adolescents that allow them to develop and grow and meet their developing need for independence, mastery, and belonging.32 Health care providers may serve as resources for information about afterschool and community-based programs for teenagers and young adults. In some communities, information may need to be gathered and maintained by the personnel at the clinical site. In many others, however, city, school, or community organizations may collect and disseminate this type of information.
Table 36-4. FISTS: Fighting, Injuries, Sex, Threats, Self-Defense
Providers also have an opportunity to engage in community and social policy efforts to prevent exposure to community violence and intervene in a systematic and efficacious manner. Clinicians may lead efforts to reduce violence in society by coordinating educational campaigns to raise awareness of the impact of violence on child health, community-based prevention efforts and interventions, and support for socially responsible gun laws.
Table 36-5. Resources and Web Sites
Web resources for families and schools
http://www.stopbullyingnow.hrsa.gov provides information and technical support for school-based bullying prevention. The site features webisodes, brief video scenarios to support better understanding of bullying and bullying prevention.
http://www.chooserespect.org/scripts/index.asp provides an interactive environment to help adolescents and their parents better understand dating violence. Adolescents have the opportunity to make their own music videos.
http://www.girlsinc.org is the home page of Girls Incorporated National Resource Center, a national youth organization dedicated to inspiring girls.
Web resources for health professionals
http://www.aap.org/connectedkids is the home page for the American Academy of Pediatrics’ youth violence prevention program Connected Kids: Safe, Strong, Secure. Connected Kids provides clinical information and parent/patient handouts to support resilience-based anticipatory guidance.
http://www.ama-assn.org/ama/pub/category/8197.html is the link to the American Medical Association’s comprehensive collection of youth violence prevention training materials for health professionals, based on its 2002 report “Connecting the Dots to Prevent Youth Violence.”
http://www.massmed.org/AM/Template.cfm?Section=Violence links to the Massachusetts Medical Society’s youth violence prevention program, which includes informational brochures for the public in English and Spanish, a clinical guide, and an online continuing medical education program.
http://www.endabuse.org is sponsored by the Family Violence Prevention Fund (FVPF), a national nonprofit organization that provides resources and materials for health care settings and professionals focusing on domestic violence education, prevention, and policy reform.
Selective prevention interventions are focused on youth identified as high-risk on the basis of risk behavior profiles or because of exposure to violence. Selective interventions directly address the social networks and resources for adolescents and their families, particularly by establishing adult mentors, supporting supervised enrichment activities, providing intensive psychotherapy for individuals and families exposed to violence, and providing meaningful career pathways.
Tertiary interventions are activated once adolescents have been injured or become involved in the juvenile justice system. These include facilitating appropriate physical and mental health services for youth, comprehensive programs to help reform criminal behavior, addressing the root causes of antisocial and/or violent behavior, and providing options to gang involvement.