The traumatic events surrounding the recent school shootings at Virginia Tech remind us that a disturbing aspect of our current culture is the rate at which America's youth are exposed to violence. Whether it is graphic episodes of violence on television, violent music, aggressive video games, hearing about or witnessing violence in the home or neighborhood, or being the direct victim of violence—violence is a pervasive part of society that disproportionately affects youth.1 In fact, between 3 and 10 million children annually witness acts of violence in their homes.2,3 Of these, about 60% have been victimized multiple times by physical or sexual abuse.4
Rates of child abuse and neglect in the United States range from 15 to 42 cases per 1000 children5,6 and of the 3 million cases of child abuse that are reported each year, 1 million are eventually substantiated.7 Similarly, as many as 60% to 70% of American youth have witnessed serious community violence,8-11 and homicide remains the second leading cause of death among youths aged 15 to 24 years.12 The fact that violence has become such a routine part of many children's lives raises serious concerns about the consequences of violence exposure. The issue of violence exposure and violence victimization has received considerable attention, and it is now regarded as a serious health problem affecting adolescents in nearly every sector of society.13
Cycle of violence
For decades, mental health professionals and social scientists have used the phrases "cycle of violence" and the "intergenerational transmission of violence" to describe the premise that "violence begets violence."14,15 Researchers have consistently found that children exposed to violence, either as witnesses or victims, are at high risk for having their own patterns of aggressive behavior develop. A considerable body of research points to a number of family, social, and community factors that increase the probability of violence. Specifically, family issues such as inadequate home environments,16 parental alcohol and drug abuse,17,18 witnessing domestic violence, and harsh parental discipline19 increase the risk for violent behavior in children and adolescents.
Children who are witnesses or the victims of community violence20-24 are also at increased risk for subsequent violent behavior. In addition, childhood maltreatment25,26 has a strong association with risk for violence. Childhood physical abuse in particular is thought to be one of the most frequent correlates of aggressive and delinquent behaviors in later life.27 For instance, in a large-scale prospective study using data taken 22 years after abuse or neglect, childhood abuse and neglect victims were significantly more likely to have been arrested for nontraffic offenses and violent crimes than nonvictimized controls.28 Astoundingly, nearly half of the victims of physical abuse and neglect in this sample had been arrested by the age of 32.
Numerous cognitive and behavioral models have been proposed for understanding the cycle of violent and aggressive behavior. Social learning theory provides an explanation for the high violence potential observed in patients who have witnessed violence.29 For example, numerous studies confirm a link between observed violence and aggressive behavior in children and adolescents. These studies find that the link is an enduring one, in part because of the strength of vicarious social learning. Repeated exposure to community, domestic, or media violence is thought to promote the development of beliefs that violence and aggression are normal, acceptable responses, thereby increasing the potential to act aggressively. Furthermore, exposure to violence contributes to the development of a negativity bias, in that affected youth may exhibit more negative emotions, attribute negative intent to others, and be hypervigilant to negative stimuli.
Cicchetti and Lynch30 have described an ecological-transactional model to understand the process by which maltreatment occurs and development is shaped as a result of potentiating and compensatory risk factors at each level of social ecology—culture, community, and family. On the other hand, Nofziger and Kurtz31 have proposed a lifestyle model that focuses on the interaction between the person and his or her environment, noting that some adolescents are exposed to violence because they are involved in high-risk activities that put them at greater risk for violence exposure and subsequent victimization or perpetration. Along these lines, Stewart and colleagues32 found that adolescents who adopt a "code of the street" mentality actually have higher rates of victimization beyond what would be expected from living in a dangerous and disorganized neighborhood.
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