One explanation for violence is that people learn to use violence when violence is condoned or is considered an acceptable strategy in solving problems. This view is based on the principles of social learning theory, according to which children learn to respond with acts of violence by observing role models and seeing problem solving through violence portrayed as successful in the media (Warriner, 1994).

Many American cultural institutions model and even encourage violence and aggression. Aggressive actions are applauded in sports, movies, television, and video games. It is estimated that by the age of 18 years, the average television viewer has witnessed 200,000 acts of violence on television, in video games, and through other media channels (Committee on Public Education, 2001). This exposure to media violence is positively related to increases in aggressive behavior. Viewing violence on television, in movies, and in games has been linked to increased violence and aggression and increased risk taking in children and adolescents, which carries over into adulthood (Anderson et al., 2008; Carll, 2006; Huesmann et al., 2003). DuRant and colleagues (2006) reported that teens who watch televised professional wrestling programs are more likely to engage in fighting and date fighting, and to carry weapons. In its policy statement on media violence, the American Psychological Association (APA) calls for physicians and other health care professionals to get more involved in working with families and the political system to reduce children’s exposure to media violence (Carll, 2006). The American Academy of Pediatrics (2009) has urged parents to limit their children’s media exposure and to be actively involved in the selections of materials viewed by children and teens.

Adolescents are exposed to and particularly vulnerable to increasing violence at school and in the community (MacKay & Duran, 2008). An alarming number of adolescents know victims of or have witnessed assaults, rapes, or other life-threatening violence. Inner-city youth have the greatest exposure risk (Stodolska & Shinew, 2011; U.S. Department of Justice [USDJ], 2008). A cross-sectional survey of inner-city children found that 61 experienced at least one direct or witnessed victimization in the past year. Almost half had experienced a physical assault (Finkelhor et al., 2009). In 2009, 22.5% of all violent crime was committed by juveniles (Rand & Truman, 2010). Some have suggested that these family dynamics, self-concept, and self-esteem are predictive of youth violence. (Kim & Kim, 2008; Rohany et al., 2011). Bollard and colleagues (2001) found that hopelessness was relatively rare in teens; however, when present, it was predictive of fighting and carrying weapons. Other predictors of adolescent violence are poor grades, deviant behavior, weak bonds in middle school, early drug use, and association with peers using drugs (Children’s Defense Fund [CDF], 2005; RMC Research Corp, 2010). There is a high rate of co-occurrence of substance use and violence in youth (Van Dorn et al., 2009).

The National Center for Injury Prevention and Control (2010a; 2010b) at the Centers for Disease Control and Prevention (CDC) reported the following for 2007:

Bullying is a pattern of physical, verbal, or other behaviors directed by one or more children toward another child that are intended to inflict physical, verbal, or emotional harm. Many children with preexisting health conditions or disabilities are at risk for victimization because they are different or act differently from their peers. Children who are overweight or have attention-deficit/hyperactivity disorder (ADHD) are more likely to be bullied (Cook et al., 2010; Lumeng et al., 2010).

The prevalence of bullying among middle and high school students varies widely with estimates from 7% to 54% worldwide (National Center for Education Statistics, 2007; Undheim & Sund, 2010). Male students report higher rates of bullying, and bullying is most prevalent in the sixth through eighth grades. Boys use more physical forms of bullying, whereas girls use more relational forms of bullying such as exclusion, isolation, and initiation of rumors.

Bullying is a form of violence that has a significant impact on children’s health. Many somatic and mental health complaints such as bedwetting, headaches and stomachaches, neck and shoulder pain, back pain, anxiety, fatigue, loneliness, short temper, depression, suicidal ideation, increased drug and alcohol use, aggression, and delinquency are related to being bullied (Fekkes et al., 2004; Kim et al., 2005; McCenna et al., 2011; Sullivan et al., 2006). Bullying is also a risk factor for violent behavior and injury and teenage pregnancy (Perren, 2011). Young people who bully or are bullied are more likely to be involved in fights, injured in fights, and carry weapons to school (Fox et al., 2003; Nansel et al., 2003). Being rejected and bullied by peers is a characteristic common to students who commit school shootings (Leary et al., 2003; Reuter-Rice, 2008).

School nurses and nurses working with children and adolescents can screen for bullying during routine health care visits such as school physicals. School nurses are more likely to see students who are bullies or have been bullied (Vernberg et al., 2011). Lyznicki and colleagues (2004) listed the following questions the nurse can ask children to help identify bullying issues:

School violence takes many forms; for example, excessive teasing, pushing and shoving, bullying, intimidation, stalking, serious physical assault, and murder. In 2008 to 2009, students were exposed to 1.2 million nonfatal crimes at school, including 626,800 violent crimes such as assault, rape, and robbery (Robers et al., 2010). Many of these children showed signs of anxiety and depression, and 61% worried about their safety. Higher exposure to violence was associated with lower grade point average and more days absent from school. According to the U.S. Department of Education and Justice, approximately 5% of students skip school, avoid places within school, or avoid school activities because they are fearful (Robers et al., 2010). The presence of youth gangs in elementary and secondary schools increases the rate of serious crime in those schools. Approximately 20% of public schools report gang activity in their schools (Robers et al., 2010). Mulvey and colleagues (2010) described the links between gangs and drug use. This link is both at the individual level and within peer groups. When students are preoccupied with their safety and schools must divert energy and resources to deal with potential violence and violent behavior, the educational mission of the schools suffers.

There were an estimated 774,000 gang members and 27,900 gangs active in the United States in 2008. This is an increase of 28% in the number of gangs and 6% in that of gang members since 2002 (Egley et al., 2010). Most gang members are male, but female membership is growing. Although most gang members are adolescents and young adults, gang members range in age from 8 to 55 years.

Gangs are flourishing in both rural and urban communities. Gangs can provide a sense of stability and family for many disenfranchised adolescents with unstable family situations (Egley et al., 2010). Gang members identify five reasons for joining gangs: (1) only option, no jobs available; (2) peer pressure; (3) protection; (4) companionship; and (5) excitement (Morrissey, 2011; Palm Bay Police Department, 2007). Having a previous conduct disorder and having friends who joined gangs or engaged in aggressive behaviors are predictive of joining a gang among adolescents (Palm Bay Police Department, 2007).

Violence is part of everyday life for gang members. Youth gang members are more likely to engage in drug use, drug trafficking, and violence than other youth and are three times more likely to be involved in violent activities than non–gang members (Morrissey, 2011; Mulvey et al., 2010; National Drug Intelligence Center, 2009). Violence is a part of their neighborhoods and families, and violence is an expected part of their role and individual status as gang members. Over half the homicides in Los Angeles and Chicago are gang related (Egley et al., 2010). In Rochester, New York, 68% of all adolescent violent offenses were committed by gang members (Howell, 2006). A sense of belonging, peer pressure, or the threat of retaliation makes it difficult for individuals to leave gangs.

Entire communities must come together to reduce gang membership and violence. Preventing young men and women from joining gangs should be the first priority. Strategies include preventing youth from dropping out of school and strengthening social institutions to better provide activities and legitimate economic opportunities for youth (CDF, 2005; USDJ, 2008). Several cities—including Boston, Massachusetts; Indianapolis, Indiana; and Stockton, California—have initiated successful comprehensive gang violence reduction programs. These entail concentrated police enforcement, involvement of community leaders and pastors in violence reduction messages, and a network of support services for at-risk youth.

Firearms are the second leading cause of death among youth aged 10 to 19 years (Morbidity and Mortality Weekly Report [MMWR], 2011). Over a 28-year period, 110,645 children were killed by firearms. In 2007, the 3042 gun related deaths in children were almost the same as the number of U.S. deaths in Iraq (CDF, 2010). Regulations regarding the manufacture and licensing of firearms are more lenient in the United States than in other developed countries, which makes firearms easily accessible. Higher rates of household ownership and accessibility of firearms are associated with disproportionately higher homicide rates (Miller et al., 2002).

A number of interventions have been tried to reduce firearm violence in the United States. An evaluation of the laws enacted to prevent firearm violence found inconclusive evidence that bans, restrictions and waiting periods, registration and licensing regulations, laws regulating the carrying of concealed weapons, child-access laws, and zero-tolerance laws in schools and other public places have had little if any impact in reducing firearm violence (Centers for Disease Control and Prevention [CDC], 2003). Opponents of gun control such as the National Rifle Association (NRA) argue that criminal assault and injury will continue despite gun control and that assailants will simply switch to other weapons. Proponents argue that stricter gun control laws will help to bring murder and injury rates in line with those of other nations. The National Research Council (2005) conducted a systematic literature review in 2004 and did not find significant data to support the effect of gun-control laws on reducing violence.

Poverty is an important risk factor associated with victimization through violence. Individuals are at greater risk for being the victims of violent acts if they are poor (Bureau of Justice Statistics, 2007). Poverty and living in impoverished neighborhoods also increase the risk for IPV (Caetano and Ramisetty-Minker, 2010; CDC, 2010a; Fox & Benson, 2006). In addition, the increasing levels of drug, alcohol, and tobacco use among adolescents were associated with their increasing exposure to violence, not only in the United States but internationally (Vermeiren et al., 2003). Using drugs exposes adolescents to victimization through violence, delinquent peers, and drug dealing. Adolescents subsequently develop favorable attitudes toward violence that continue even when they are not using drugs any longer (Kuhns, 2005).

A pattern of abusive behavior in families continuing one generation after another, also called the intergenerational transmission of violence, has been widely documented. However, the relationship between being abused and witnessing abuse as a child and being abusive or victimized as an adult is complex. Not all children who grow up in violent homes become violent in later life. Lackey (2003) found that exposure to violence at home as an adolescent was strongly related to partner violence in men but not in women. Hamby and Jackson (2010) found that witnessing partner violence was closely associated with several forms of maltreatment and other forms of victimization and called for a need to better integrate services to adult and child victims of family violence. This has important leader in coordination of care.

Gelles and Straus (1988) contend that people abuse family members because there are few or no repercussions. There continues to be inequity in arrest or criminal prosecution for IPV. Social attitudes, the private nature of family violence, and the structural inequalities in family relationships combine to create a climate in which violence is acceptable and tolerated. Violent acts against family members often go unpunished, although similar actions against other people would be criminally prosecuted. Parental use of physical punishment is widely practiced and often socially condoned. Increased visibility of family violence and national campaigns are slowly changing public attitudes and acceptance of family violence.

What happens within the family has been considered a private “family matter.” Because of the strong belief in family privacy, neighbors, family members, and authority figures such as teachers, health care professionals, police, and prosecutors often hesitate to intervene (Jecker, 1993). Culturally, the values of men, women, and children have been considered unequal. Historically, this was supported by legal statutes under which women and children were considered property and had few rights under the law. Children could be sold into slavery, loaned to work for wages collected by the father, or bartered into marriage without legal recourse. In fact, it is still very difficult for minor children to establish rights independent of their parents. Since the late 1900s, state by state, women have slowly been granted the right to personal assets and property, independent of a spouse. It was 1929 before women in the United States were granted the right to vote nationwide. Social inequalities among family members persist, creating a climate in which violence continues.

Abuse is inflicted sometimes on all of the children in a family, but often one child is singled out or targeted to receive most or all of the abusive attention. A child who is considered different or has a physical or emotional disability is at special risk of abuse (Hibbard & Desch, 2007; United Nations Children’s Fund [UNICEF], 2005). Children with disabilities are nearly 3.5 times more likely to be abused than children without disabilities (Govindshenoy & Spencer, 2007; Sullivan & Knutson, 2000). The study by Mandell and colleagues (2005) reported that 18.5% of children with autism had been physically abused. It is important to note that other siblings in the family, although spared the immediate abuse, are also affected. Removal of one child does not guarantee a solution to the problem. Another child in the household usually becomes the next target.

The nurse should exercise caution in generalizing from reported case data because these data may be biased. Although child abuse and neglect occur across the socioeconomic spectrum, poverty seems to be a risk factor, whereas parental education is a poor predictor. The rate of abusive incidents is relatively uniform across educational levels (CDF, 2005). Social expectations about race and poverty often influence who is reported as abusive.

Black children are at highest risk of substantiated maltreatment and Asian American children have the lowest risk (Federal Interagency Forum on Child and Family Statistics, 2011). Children who live in homes at lower socioeconomic levels are at greater risk of substantiated maltreatment than those from higher income homes. Large national family surveys do not show African American families to be at greater risk for child abuse (Gelles & Cornell, 1990). The discrepancy between substantiated reported cases and family survey data might be explained by reporting bias. The larger number of reported cases of child abuse and neglect among the poor (more of whom are African American families) is probably the result of those families’ involvement with public social and health services and emergency departments (CDF, 2005). These caregivers are more likely to report abuse and neglect. Family cultural practices might provide supports to reduce risks for abusive situations. For example, African American and Hispanic families tend to have greater extended family involvement and use family networks for emotional, financial, and child-rearing support. These characteristics might offset the stressors of higher unemployment and less socioeconomic power.

Child abuse and neglect are crimes in all 50 states. All 50 states, plus the District of Columbia, have mandatory child abuse and neglect reporting laws that require certain professionals and institutions to report suspected cases of maltreatment to a designated child protection agency. More than 60% of all reports of alleged child abuse or neglect are made by professionals (USDHHS, 2009). These laws emerged from the moral concerns of protecting the vulnerable and promoting nurturing families (see the Ethics in Practice box). Each state has different criteria and procedures for reporting suspected cases. Child protective services is the agency assigned to investigate reports of child abuse or neglect. The emotional aspect of abuse is not clearly addressed in most laws and has been difficult to prosecute in practice. Physical neglect of a persistent nature with severe consequences is more likely to incur legal prosecution than are subtler forms of physical and emotional neglect.

To prove neglect, an adult’s recognition that his or her actions have or could cause adverse consequences to the child is usually a legal requirement to show intent. Economic, emotional, and mental health factors might cloud the issue.

Does this constitute deliberate neglect? Are there cultural or religious factors that might impact parents’ decisions to seek and follow medical care? Some of the issues the authorities would examine before deciding to prosecute include parental understanding of the risks of withholding medication, ability to pay for the prescription, and, finally, intent. Was the decision not to provide medication deliberate or the result of multiple stressors or poor coping skills?

The question of what should be done with the children who are victims of child abuse is a social policy challenge. Approximately 20% of child victims are removed from their homes by court order. Most are placed in foster care (USDHHS, 2009). Many of these children will bounce between foster care and a parent before parental rights are terminated. Most will not be adopted and will remain in foster care until adulthood.

Family preservation programs are being tested as an alternative to parental punishment, jail time, or removal of children from their parents. It has been many experts’ belief that abusive families can benefit from intense, long-term community support and supervision that addresses the myriad social and family issues that precipitated the abuse or neglect. Preservation programs stress intensive intervention with all family members and stringent supervision. The intent is to provide basic needs, educate, and build on family strengths to keep families together rather than to place children in foster care. Evaluation of such programs has shown disappointing results. Some studies have found fewer subsequent reports of child maltreatment, decreased frequency of out-of-home placements of children, and use of a broader array of community support services among families linked to a family preservation caseworker who provided strong collaboration in developing a treatment plan than among families without a family preservation caseworker (CDF, 2005; Littell, 2001; Walton, 2001). Others, however, have found no improvement in the level of family functioning, effectiveness in preventing future maltreatment, or risk of future foster home placement (Chaffin et al., 2001; Walton, 1996; Westat et al., 2002).

Children who are abused or mistreated are at increased risk for learning disorders, mental retardation, and developmental delays, including delays in language development, speech, and gross motor activities. Abused and neglected children generally have lower IQ (intelligence quotient) scores than children with similar characteristics who have not been abused and are much more likely to have academic difficulties in school (USDHHS, 2005). Physical abuse in childhood and the cumulative effects of experiencing maltreatment and witnessing family violence are also related to chronic physical and mental health problems throughout childhood and into adulthood (DePanfilis, 2006; Turner et al., 2006).

Mistreated children find it difficult to initiate mutually satisfying interpersonal relationships with peers and adults. Their social skills and self-concept suffer. They have difficulty setting limits or boundaries with others. Classmates might describe them as socially withdrawn or as troublemakers. Physically abused individuals are more likely to be suicidal, use drugs, and exhibit aggressive behaviors (Chen et al., 2010; Currie & Widom, 2010; Rew, 2003). Children who are abused and/or neglected are at greater risk of involvement in juvenile or other criminal activity. Compared with children who are not maltreated, those who are abused and neglected are up to six times more likely to be involved in the juvenile justice system and up to three times more likely to be arrested as adults (CDF, 2005, p. 117).

Children who run away from home often do so to escape sexual and other abuse in the home (Brandford et al., 2004; National Runaway Switchboard [NRS], 2011). Girls run away more often than boys do and also run away multiple times. This suggests that girls may be subject to more dysfunctional relationships or feel less able to protect themselves at home. Once on the street, runaways are vulnerable to predators, sex traffickers, drug dealers, and those engaging in other types of exploitation (see Chapter 21). Girls and boys often engage in sex acts for money, which can lead to a lifetime of problems. Prostitution and promiscuous sexual activity are more prevalent among adults who were sexually assaulted as children. Victims of sexual abuse report lifelong difficulty in maintaining healthy adult relationships.

In this chapter, the assailant is referred to as male and the victim or survivor as female because in 80% of IPV incidents, the assailant is male and the victim female (Rennison, 2003). However, the size and strength differences between men and women create a perception that male-on-female violence is more frightening, which possibly draws more attention to them. There is legitimacy to the claim that cases in which the woman is the aggressor are underreported because the male victims fear ridicule (Hamby & Jackson, 2010). Whitaker and colleagues (2007) found that 25% of all relationships had some violence and that half of those were reciprocally violent. Nurses should be aware that anyone can be a victim or an assailant, so careful evaluation is critical during assessment.

IPV includes physical, sexual, verbal, and emotional abuse. Physical assault ranges in degree from slapping to murder. Sexual abuse includes unwanted or forced sexual acts. All the abusive actions are aimed at controlling the other person, humiliating the person, and reducing the victim’s self-esteem and identity. Verbal and emotional abuse breaks down women’s self-esteem. A common theme of verbal abuse is criticism of the victim’s ability to adequately perform her roles as mother and wife. Verbal abuse convinces the victim that she deserves harsh treatment, and it serves to reinforce the abuser’s belief that his actions are justified, even required, to ensure that the spouse acts appropriately.

The Domestic Abuse Intervention Project (also called the Duluth Model) has been a pioneer in intervening to prevent men’s violence against their female partners. This treatment and education model is based on the theory that power and control are at the heart of IPV. The power and control wheel (Figure 23-2) illustrates the variety of strategies used for controlling others’ behaviors. These behaviors should serve as warning signs of potentially abusive relationships.