59. Counseling to Prevent Youth Violence RECOMMENDATION There is insufficient evidence to recommend for or against clinician counseling of asymptomatic adolescents and adults to prevent morbidity and mortality from youth violence. Adolescent and adult patients should be screened for problem drinking (see Chapter 52). Clinicians should also be alert for symptoms and signs of drug abuse and dependence (see Chapter 53), the various presentations of family violence (see Chapter 51), and suicidal ideation in persons with established risk factors (see Chapter 50). Burden of Suffering Violence has enormous individual and public health consequences. Victims of violence suffer psychological trauma, physical injuries, disability, and death. The most serious manifestations of violent behavior are homicide and suicide (the latter is discussed in Chapter 50).a Homicide is the 10th leading cause of death in the U.S.,1 and because of the young age of its victims is a leading cause of years of potential life lost.2,3 More than 25,000 Americans (10.0/100,000 population) were murdered in 1992.1 The age-adjusted homicide rate increased 25% between 1985 and 1991;4 a decrease of 3.7% occurred between 1991 and 1992.1 In the 1991 National Crime Victimization Survey, the rate of aggravated (i.e., involving a weapon) assault was 780/100,000 persons over 12 years of age, while the rate for all nonfatal crimes of violence (including attempted and completed rape, robbery, and assault) was 3,130/100,000.5 In 1 year, aggravated assaults alone accounted for 355,000 hospitalizations, 4 million lost workdays, and $638 million in medical costs.6 Persons at greatest risk of violence victimization include young males, minorities (including non-Hispanic black, Hispanic, and Native American), persons with a history of delinquent or criminal behavior or of violence victimization, and persons living in poor urban communities.1,6-15 Nearly half of all homicide victims in 1991 were males aged 15-34 years; most of the increase in homicide rates between 1985 and 1991 was attributable to increased rates in this age group.4 Young African Americans are at especially high risk for violent injury. Homicide is the leading cause of death in black men and women aged 15-24.1 In an urban African-American population, the average annual rate of interpersonal violence-related injuries resulting in emergency room visits or death was 3,930/100,000; this rate increased 42% between 1987 and 1990.16 Interpersonal violence-related injury rates were highest for persons aged 10-39 years, with annual rates ranging from 4,780 to 9,290/100,000. In this study, 41% of 20-29-year-olds had at least one interpersonal intentional injury in the 4-year study period. Risk factors for violence perpetration are similar to those for victimization, including young age, male sex, minority race, poverty and urbanization, and prior exposure to and victimization by violence.7,17 These risk factors are highly correlated; for example, minority race is most likely a marker for other factors, such as low socioeconomic status and urban residence, that strongly influence violent behavior. Assailants risk injury to themselves, disrupted personal lives, damaging criminal records, extended imprisonment, and, in some cases, capital punishment. In 1992, 55% of those arrested for murder were under 25 years of age and 15% were under 18.7 Between 1983 and 1992, the number of juveniles (less than 18 years of age) arrested for murder increased 128% compared to a 7% increase for adults, and the number arrested for aggravated assault (58,000) doubled, compared to a 69% increase in adults.7 Firearms, most often handguns, were used in 7 of every 10 murders committed in the U.S. in 1992, and in 25% of aggravated assaults.7 Because firearm-related homicide rates have increased markedly among teenaged and young adult populations, years of potential life lost attributable to firearm-related homicide has increased by 16% since 1980.18 Firearm-related assaults account for an estimated 22.4 nonfatal injuries requiring emergency department treatment per 100,000 population per year.19 In a nationwide survey of high school students, 22% reported that they had carried a weapon and 8% reported carrying a gun during the 30 days preceding the survey.20 Efficacy of Risk Reduction The etiology of youth violence is multifactorial, with complex interactions among personal, family, community, and societal problems.21-23 While multifaceted community programs to address risk factors such as poverty, unemployment, and poor schools are likely to be most effective in combating youth violence (see Discussion), several risk factors may be amenable to interventions by the individual clinician acting in the office setting. These risk factors include the ready availability of weapons, particularly handguns, that increase the lethality of violent behavior, and inadequate social problem-solving skills and abuse of alcohol and illicit drugs, which may increase the incidence of violent behavior. Firearm-related violence typically results in more severe injury than violence involving other weapons or no weapons. Evidence that reducing gun availability might reduce the risk of violent injury and death comes primarily from ecologic and observational studies. In national and international comparisons, an increased concentration of firearms (as measured by gun permits issued, gun prevalence indices, new firearms for sale, or surveys of gun ownership) is associated with increased rates of firearm robbery, assault, and homicide, and increased overall rates of homicide and robbery-related homicide.24-28 Several of these studies suggest a dose-response relationship between gun density and violent outcomes. It is difficult to determine from these types of comparisons what, if any, portion of the association is accounted for by social, cultural, and economic differences among populations. The results of several ecologic studies suggest that race and urbanization may modify the association between gun ownership and homicide.24,29 This modification might be attributable to factors such as poverty, drugs, and other problems characteristic of urban environments, since in a population-based case-control study of homicides in the home, there were no racial differences in the association between homicide and gun ownership after control for other covariates.30 These findings in ecologic studies may have several explanations. People may own or carry guns due to an increased risk of violence victimization; if this were the case, gun ownership or carrying would necessarily be associated with higher rates of violent injury. Many persons give self-defense as one of the most important reasons for owning or carrying a gun, particularly a handgun.31-34 There are no controlled studies evaluating the effect of youths' carrying guns outside the home on their risk of violence victimization, but several studies have evaluated the risks related to guns in the home. In a prospective case series of home invasion crimes, three victims (1.5%) employed a firearm in self-protection, while in one case (0.5%) the homeowner's gun was used against her; the total proportion of victims who kept guns in the home was not recorded, however.35 In a case series of gunshot deaths (excluding suicides), guns kept in the home were 18 times more likely to be involved in the death of a household member than in the death of an intruder.36 Stronger evidence for an adverse effect of gun ownership comes from a population-based case-control study, which demonstrated that keeping a gun in the home significantly increased the risk for homicide after adjustment for other covariates.30 Nearly 90% of the guns used in these homicides were handguns. No published studies have evaluated whether there is a reduced risk of assault or homicide when people voluntarily relinquish the firearms they own or carry. While guns may predispose to violence, it also may be that those predisposed to violence are more likely to obtain a gun. In cross-sectional surveys and case-control studies among adolescents, gun possession has been associated with more violent attitudes, increased likelihood of being involved in and starting fights, and prior delinquent or illegal behavior.37-41 A study of inner-city junior high school students reported significant associations between gun carrying and having been arrested, knowing more victims of violence, starting fights, and being willing to justify shooting someone, suggesting that gun-carrying may be a component of aggressive delinquency, rather than purely defensive behavior.38 Among suburban youths, gun carrying was associated with having been threatened with a gun, but also with drug and violent criminal activities;41 involvement in such activities is likely to increase the risk of receiving such threats. Reducing gun accessibility is unlikely to reduce the risk of violence among youth predisposed to violent behavior, but it has the potential to reduce the lethality of this behavior when it occurs. Legislative approaches to reducing gun availability and use have yielded mixed effects on violent injury. A 1978 Government report on various handgun control laws found no evidence of decreased levels of violence because of gun control measures.42 In one study, a law banning handguns in an urban area was associated with significantly decreased gun-related homicides and annual firearm homicide mortality rates compared to non-firearm-related cases, and to rates in surrounding suburbs without such a law.43 This study did not assess other trends and differences between populations that might have contributed to the reported effect, however, nor were long-term effects evaluated. Additional studies are needed to replicate these results and determine their generalizability to other populations. Increasing the punishment for crimes committed with firearms is another legislative prevention strategy. Multiple time series studies of mandatory sentencing for illegally carrying, concealing, or using a firearm have reported small decreases in firearm violence, generally without compensatory increases in non-firearm violence, although not all such series showed statistically significant effects.44-46 This type of legislation is unlikely to have a large impact on mortality, however, because most homicides are not committed during the course of other criminal activities. In 1992, almost half of murder victims were related to or acquainted with their assailants, and arguments, brawls, or other interpersonal conflict caused at least one third of all murders.7 Case-control, cross-sectional, and case series studies of homicide and assault victims suggest that interpersonal conflict with family and acquaintances increases the risk of violent injury.30,47- 49 In large cross-sectional surveys of middle and high school students, violent or aggressive attitudes and behaviors have been associated with an increased risk of being involved in physical fights.37,50 For example, students previously involved in a physical fight were less likely to believe that apologizing or walking away was an effective way to avoid fights. Violent juvenile offenders have been reported to be more inclined to hold beliefs supporting aggression and to have less extensive skills in social problem-solving compared to control adolescents.51 These data have led some experts to suggest that changing violent or aggressive attitudes and improving conflict resolution skills might reduce the risk of violent injuries.52-54 Because attitudes toward violence, social behaviors, and interpersonal problem-solving strategies begin to develop in early childhood,54 however, it is unclear whether skills training directed to adolescents or young adults will have important effects on their behavior. There have been no evaluations of conflict resolution skills training in the clinical setting, so the effectiveness of such interventions for reducing violent injuries remains unproven. Case series in the U.S. and in other nations show that about half (range 22-60%) of homicide victims have positive blood alcohol levels at the time of death, and that there is also substantial alcohol involvement among perpetrators.55-66 Most case-control and cross-sectional studies report that individuals who consume alcohol or who are problem drinkers are at greater risk of violence perpetration and victimization,58,61,62,67-73 although many of these studies did not evaluate other variables that might confound this association. The strongest evidence in support of an association between alcohol and violence in adults comes from a large population-based prospective cohort study using multivariate analysis, in which heavy drinkers (Ú6 drinks per day) were 7 times more likely to be homicide victims than were lifelong abstainers.74 There was also a 4-fold greater risk in those consuming 3-5 drinks per day and a 2-fold greater risk in light drinkers, but these were not statistically significantly different from abstainers. There were insufficient numbers to assess the risk of homicide in ex-drinkers, although the risk for any unnatural death in ex-drinkers was similar to that of light drinkers and abstainers. Similar to gun owners versus non-owners, alcohol drinkers are likely to differ from nondrinkers in other ways, and a causal relationship between alcohol and violence is not established. Nevertheless, these data suggest that there may be a benefit of reducing alcohol intake in preventing violent injury. Legislative interventions aimed at reducing alcohol intake in young persons by raising the legal drinking age have not reduced homicide rates,75,76 but appear to have had little effect on alcohol consumption in the targeted population.75 In one evaluation of legal drinking age laws, homicide rates increased more than expected in the year drinking became legal, and increased (rather than decreased) as drinking experience increased.76 Thus, a higher legal drinking age might delay the onset of heavy drinking and associated homicides, but reductions of earlier years may be more than offset by increased homicide rates once access to alcohol becomes legal. Many victims of violence have evidence of other drugs besides alcohol on toxicologic testing, including cocaine (13-33%), barbiturates (8%), and heroin (3-5%).15,57,77-79 Adolescent, young adult, and minority homicide victims are more likely to have positive drug screens at autopsy.15,60,77,78 Evidence for a causal relationship with violence is more limited for illicit drugs than for alcohol. One case-control study found that homicide victims killed in their own home were more likely to have a history of individual or household use of illicit drugs compared with neighborhood matched controls.30 Several large surveys of high school students have reported associations between illicit drug use and involvement (as victims or perpetrators) in violence.11,47 In an epidemiologic analysis of homicides in Baltimore, drugs or drug trafficking was involved in 42% of homicides.80 While it is reasonable to conclude that treatment and referral for substance abuse might contribute to reduced violence, this has not been studied. Effectiveness of Counseling Potential victims or perpetrators of violence can be counseled by the clinician in an attempt to prevent future injuries or killings. Specifically, patients can be advised about risk factors, such as possession of firearms and alcohol and substance abuse, that may increase the likelihood of intentional injuries. Persons identified as at increased risk of committing intentional injuries in the future might also be counseled (or referred for counseling) to learn nonviolent approaches to conflict resolution. The efficacy of these measures is largely unstudied, however, and the available evidence is inadequate to determine whether any one of these strategies is successful in preventing subsequent violent injury. An ongoing trial evaluating clinician counseling combined with referral to community resources for adolescent victims of violence (personal communication, D. Stone, June 1994) may provide useful information on the efficacy of clinical counseling to prevent violence. There is limited evidence regarding the effectiveness of community- and school-based interventions for preventing violence.81 A number of schools have begun conflict resolution skills curricula, but additional evaluation is needed to determine their effectiveness.82 In one school-based program in inner-city schools, the program produced improvements in knowledge and some attitudes related to aggressive behavior; injury outcomes were not evaluated.83 A 3-year community and school-based intervention in Central Harlem that targeted both intentional and unintentional injuries was associated with a significant decline in assault injuries in the targeted community, without a corresponding decrease in the control community.84 There was little apparent effect of the intervention on overall injury rates because of declines in unintentional injuries in the control community. Recommendations of Other Groups The American Academy of Pediatrics (AAP) recommends that all clinicians promote the responsibility of the family to create a gun-safe home environment, including counseling patients, parents, and relatives on the dangers of having a gun in the home, and advising removal or secured storage of guns in the household85 ". . . emphasis should be placed on high-risk homes-those with alcohol or drug-prone or drug-addicted individuals-and those with adolescent boys."86 The AAP also supports attempts to identify adolescents at highest risk, including those with a history of violence victimization or family or peer violence, substance abuse, depression, or carrying of weapons.85 The American Academy of Family Physicians (AAFP) recommends counseling adolescents about alcohol and other drug abuse, and counseling adolescents and young adults, especially males, on violent behavior and firearms.87 The AAFP policy is under review. The American College of Physicians urges physicians to inform patients about the dangers of keeping firearms, particularly handguns, in the home and to advise them on ways to reduce the risk for injury.88 The College further supports counseling patients to keep guns away from children and recommending the voluntary removal of the gun from the home. The 1985 Surgeon General's Workshop on Violence and Public Health Report recommended education on the association of alcohol with violence, and education of health professionals in identification, treatment, and/or referral of victims, perpetrators, and persons at high risk for interpersonal violence.89 In 1992, the Assistant Secretary for Health, U.S. Public Health Service, recommended that clinicians offer counsel on the risks of firearms and on conflict resolution skills.90 Discussion Violent injuries and death exact a terrible toll on adolescents and young adults in this country, yet there is surprisingly little evidence on effective interventions. Although youth violence has been associated with alcohol and substance abuse, availability and ownership of guns, and interpersonal conflict, it is not clear whether these factors predispose to violence, or whether those already predisposed to violence are more likely to obtain a gun, use alcohol and illicit drugs, and become involved in conflict. Most evidence suggests a complex, multifactorial relationship among violent attitudes and behaviors, guns, substance abuse, and violent injury. The ability of clinician counseling to change these behaviors is largely unstudied, however. There is fair evidence that keeping a gun in the home substantially increases the risk of homicide among those living in or visiting the home. Given that guns in the home are also associated with increased risks of suicide (see Chapter 50) and of unintentional injury deaths (see Chapter 58), removal or secured storage of guns in the home is likely to be an effective intervention for reducing injury-related mortality. Current evidence is insufficient to determine whether clinician advice will influence patients to remove or safely store guns, however. Although the effectiveness of screening followed by brief counseling to reduce problem drinking has not been evaluated in adolescents and young adults, such screening can be recommended based on its proven efficacy in middle-aged adults (see Chapter 52), the limited adverse effects from such screening, and the large potential impact on both intentional and unintentional injuries, including youth violence, suicide (see Chapter 50), motor vehicle injuries (Chapter 57), and household and recreational injuries (Chapter 58). As with domestic violence (see Chapter 51), the etiology of youth violence is multifactorial, related to social conditions, cultural attitudes, and personal and family characteristics that begin their influence early in childhood.21-23 Therefore, the clinician acting alone in the medical setting will have difficulty in preventing violent injuries among adolescents and young adults. Comprehensive prevention programs that address multiple contributors to violence are more likely to be effective in combating morbidity and mortality from youth violence but are beyond the scope of this report. Evaluations of a number of multifaceted violence prevention interventions and programs, including several sponsored by the National Center for Injury Prevention and Control, Centers for Disease Control and Prevention, are ongoing. These projects involve such diverse elements as adult mentoring, job training and placement, peer mediation training among "natural leaders" in schools, social skills training, parenting skills training for the parents of at-risk youths, training of neighborhood violence prevention advocates, school-based conflict resolution programs, counseling and education for violence victims, and schoolwide antiviolence campaigns (T. Thornton, personal communication, 1994).52,81,84 If these types of multifaceted programs prove effective, the most useful role for clinicians may be to support and act as advocates for such programs in their own communities. Environmental, regulatory, or legislative interventions may also prove to be effective in preventing violence. For example, although they do not reduce violent behavior (i.e., threats and fights), metal detectors in schools appear to reduce the prevalence of carrying weapons to school, which would be likely to reduce the morbidity and mortality resulting from any fight that did occur.37 Again, the most effective role for the clinician might be to sponsor and support interventions that are proven effective in preventing violent injury. CLINICAL INTERVENTION There is currently insufficient evidence to recommend for or against clinician counseling to prevent morbidity and mortality from youth violence ("C" recommendation). Adolescent and adult patients should be screened for problem drinking (see Chapter 52). Clinicians may wish to inform patients (and the parents of child and adolescent patients) of the risk to household members associated with the presence of firearms in the home. Clinicians should also be alert for symptoms and signs of drug abuse and dependence (see Chapter 53), the various presentations of family violence (see Chapter 51), and suicidal ideation in persons with established risk factors (see Chapter 50). In settings where the prevalence of violence is high, clinicians should ask adolescents and young adults about previous violent behavior or victimization, current alcohol and drug use, and the availability of handguns and other firearms. Clinicians should inform those identified as being at high risk for violence about the risks of violent injury associated with easy access to firearms and with intoxication with alcohol or other drugs. The draft of this chapter was prepared for the U.S. Preventive Services Task Force by Carolyn DiGuiseppi, MD, MPH. REFERENCES 1. Kochanek KD, Hudson BL. Advance report of final mortality statistics, 1992. Monthly vital statistics report; vol 43, no 6 (suppl). Hyattsville, MD: National Center for Health Statistics, 1995. 2. Centers for Disease Control and Prevention. Trends in years of potential life lost before age 65 among whites and blacks-United States, 1979-1989. MMWR 1992;41:889-891. 3. Centers for Disease Control and Prevention. Years of potential life lost before age 65- United States,1990 and 1991. MMWR 1993;42:251-253. 4. Centers for Disease Control and Prevention. Homicides among 15-19-year-old males- United States, 1963-1991. MMWR 1994;43:725-727. 5. Bureau of Justice Statistics, Department of Justice. Criminal victimization in the United States, 1991. A National Crime Victimization Survey report. Washington, DC: Department of Justice, 1992. (Publication no. NCJ-139563.) 6. Rosenberg ML, Gelles RJ, Holinger PC, et al. Violence: homicide, assault, and suicide. In: Amler RW, Dull HB, eds. Closing the gap: the burden of unnecessary illness. New York: Oxford University Press, 1987:164-178. 7. Federal Bureau of Investigation. Uniform crime reports for the United States, 1992. Washington DC: Government Printing Office, 1993:31-34. (Publication no. 342-498/94321.) 8. Department of Health and Human Services. Report of the Secretary's Task Force on Black and Minority Health. Volume V. Homicide, suicide, and unintentional injuries. Washington DC: Government Printing Office, 1986. 9. Fingerhut LA, Ingram DD, Feldman JJ. Firearm and nonfirearm homicide among persons 15 through 19 years of age. Differences by level of urbanization, United States, 1979 through 1989. JAMA 1992;267:3048-3053. 10. Ropp L, Visintainer P, Uman J, et al. Death in the city: an American childhood tragedy. JAMA 1992; 267:2905-2910. 11. Lauritsen JL, Laub JH, Sampson RJ. Conventional and delinquent activities: implications for the prevention of violent victimization among adolescents. Viol Vict 1992;7:91- 109. 12. Smith MD, Brewer VE. A sex-specific analysis of correlates of homicide victimization in United States cities. Viol Vict 1992;7:279-286. 13. Gladstein J, Slater Rusonis EJ, Heald FP. A comparison of inner-city and upper-middle class youths' exposure to violence. J Adolesc Health 1992;13:275-280. 14. Guyer B, Lescohier I, Gallagher S, et al. Intentional injuries among children and adolescents in Massachusetts. N Engl J Med 1989;321:1584-1589. 15. Tardiff K, Marzuk PM, Leon AC, et al. Homicide in New York City: cocaine use and firearms. JAMA 1994;272:43-46. 16. Schwarz DF, Grisso JA, Miles CG, et al. A longitudinal study of injury morbidity in an African-American population. JAMA 1994;271:755-760. 17. DuRant RH, Cadenhead C, Pendergrast RA, et al. Factors associated with the use of violence among urban black adolescents. Am J Public Health 1994;84:612-617. 18. Centers for Disease Control and Prevention. Firearm-related years of potential life lost before age 65 years-United States, 1980-1991. MMWR 1994;43:609-611. 19. Annest JL, Mercy JA, Gibson DR, et al. National estimates of nonfatal firearm-related injuries: beyond the tip of the iceberg. JAMA 1995;273:1749-1754. 20. Kann L, Warren CW, Harris WA, et al. Youth risk behavior surveillance-United States, 1993. MMWR 1995;44(SS-1):1-56. 21. Christoffel KK. Reducing violence-how do we proceed [editorial]? Am J Public Health 1994;84:539-540. 22. Spivak H, Harvey B. The role of the pediatrician in violence prevention. Pediatrics 1994;94(suppl): 577-651. 23. American Psychological Association Commission on Violence and Youth. Violence and youth: psychology's response. Vol 1: summary report. Washington, DC: American Psychological Association, 1993. 24. Sloan JH, Kellermann AL, Reay DT, et al. Handgun regulations, crime, assaults, and homicide: a tale of two cities. N Engl J Med 1988;319:1256-1262. 25. Lester D. Firearm availability and the incidence of suicide and homicide. Acta Psychiatr Belg 1988;88:387-393. 26. Cook PJ. The effect of gun availability on robbery and robbery murder. Policy Stud Rev Annu 1979;3:743-781. 27. Wintemute GJ. Firearms as a cause of death in the United States, 1920-1982. J Trauma 1987;27:532-536. 28. Killias M. International correlations between gun ownership and rates of homicide and suicide. Can Med Assoc J 1993;148:1721-1725. 29. Centerwall BS. Homicide and the prevalence of handguns: Canada and the United States, 1976 to 1980. Am J Epidemiol 1991;134:1245-1260. 30. Kellermann AL, Rivara FP, Rushforth NB, et al. Gun ownership as a risk factor for homicide in the home. N Engl J Med 1993;329:1084-1091. 31. Patterson PJ, Smith LR. Firearms in the home and child safety. Am J Dis Child 1987;141:221-223. 32. Weil DS, Hemenway D. Loaded guns in the home: analysis of a national random survey of gun owners. JAMA 1992;267:3033-3037. 33. Senturia YD, Christoffel KK, Donovan M. Children's household exposure to guns: a pediatric practice-based survey. Pediatrics 1994;93:469-475. 34. Sheley JF, Wright JD. Gun acquisition and possession in selected juvenile samples. In: Research in brief. Washington, DC: Department of Justice, 1993. (Publication no. NCJ 145326.) 35. Kellermann AL, Westphal L, Fischer L, et al. Weapon involvement in home invasion crimes. JAMA 1995;273: 1759-1762. 36. Kellermann AL, Reay DT. Protection or peril? An analysis of firearm-related deaths in the home. N Engl J Med 1986; 314:1557-1560. 37. Centers for Disease Control and Prevention. Violence-related attitudes and behaviors of high school students-New York City, 1992. MMWR 1993;42:773-777. 38. Webster DW, Gainer PS, Champion HR. Weapon carrying among inner-city junior high school students: defensive behavior vs aggressive delinquency. Am J Public Health 1993;83:1604-1608. 39. Callahan CM, Rivara FP. Urban high school youth and handguns. JAMA 1992;267:3038-3047. 40. Callahan CM, Rivara FP, Farrow JA. Youth in detention and handguns. J Adolesc Health 1993;14:350-355. 41. Sheley JF, Brewer VE. Possession and carrying of firearms among suburban youth. Public Health Rep 1995;110: 18-26. 42. Comptroller General of the United States. Report to the Congress. Handgun control: effectiveness and costs. Washington, DC: Government Printing Office, 1978. 43. Loftin C, McDowall D, Wiersema B, et al. Effects of restrictive licensing of handguns on homicide and suicide in the District of Columbia. N Engl J Med 1991;325:1615-1620. 44. Fife D, Abrams WR. Firearms' decreased role in New Jersey homicides after a mandatory sentencing law. J Trauma 1989;29:1548-1551. 45. O'Carroll PW, Loftin C, Waller JB, et al. Preventing homicide: an evaluation of the efficacy of a Detroit gun ordinance. Am J Public Health 1991;81:576-581. 46. Loftin C, McDowall D, Wiersema B. Evaluating effects of changes in gun laws. Am J Prev Med 1993;9 (Suppl 1):39-43. 47. Valois RF, Vincent ML, McKeown RE, et al. Adolescent risk behaviors and the potential for violence: a look at what's coming to campus. J Am Coll Health 1993;41:141-147. 48. Hausman AJ, Spivak H, Roeber JF, et al. Adolescent interpersonal assault injury admissions in an urban municipal hospital. Pediatr Emerg Care 1989;5:275-279. 49. Graham PM, Weingarden SI. Victims of gun shootings. A retrospective study of 36 spinal cord injured adolescents. J Adolesc Health Care 1989;10:534-536. 50. Cotten NU, Resnick J, Browne DC, et al. Aggression and fighting behavior among African-American adolescents: individual and family factors. Am J Public Health 1994;84:618- 622. 51. Slaby RG, Guerra NG. Cognitive mediators of aggression in adolescent offenders: 1. Assessment. Dev Psychol 1988; 24:580-588. 52. Forum on youth violence in minority communities: setting the agenda for prevention. Summary of the proceedings, December 10-12, 1990, Atlanta, GA. Public Health Rep 1991;106:225-279. 53. Prothrow-Stith D. Can physicians help curb adolescent violence? Hosp Pract 1992;193-207. 54. Slaby RG, Stringham P. Prevention of peer and community violence: the pediatrician's role. Pediatrics 1994;94:608-616. 55. Abel EL, Zeidenberg P. Age, alcohol and violent death: a postmortem study. J Stud Alcohol 1985;46:228-231. 56. Batten PJ, Hicks LJ, Penn DW. A 28-year (1963-90) study of homicide in Marion County, Oregon. Am J Forensic Med Pathol 1991;12:227-234. 57. Garriott JC. Drug use among homicide victims. Changing patterns. Am J Forensic Med Pathol 1993;14:234-237. 58. Haberman PW, Baden MM. Alcoholism and violent death. Q J Stud Alcohol 1974;35:221-231. 59. Welte JW, Abel EL. Homicide: drinking by the victim. J Stud Alcohol 1989;50:197- 201. 60. Goodman RA, Mercy JA, Loya F, et al. Alcohol use and interpersonal violence: alcohol detected in homicide victims. Am J Public Health 1986;76:144-149. 61. Norton RN, Morgan MY. The role of alcohol in mortality and morbidity from interpersonal violence. Alcohol Alcoholism 1989;24:565-576. 62. Shepherd J, Irish M, Scully C, et al. Alcohol consumption among victims of violence and among comparable U.K. populations. Br J Addict 1989;84:1045-1051. 63. Gottlieb P, Gabrielsen G. Alcohol-intoxicated homicides in Copenhagen, 1959-1983. Int J Law Psychiatry 1992;15: 77-87. 64. Virkkunen M. Alcohol as a factor precipitating aggression and conflict behavior leading to homicide. Br J Addict 1974;69: 149-154. 65. Albrektsen SB, Thomsen JL, Aalund O, et al. Injuries due to deliberate violence in areas of Denmark IV. Alcohol intoxication in victims of violence. Forensic Sci Int 1989;41:181-191. 66. Moller-Madsen B, Dalgaard JB, Grymer F, et al. Alcohol involvement in violence. A study from a Danish community. Z Rechtsmed 1986;97:141-146. 67. Busch KG, Zagar R, Hughes JR, et al. Adolescents who kill. J Clin Psychol 1990;46:472-485. 68. Collins JJ, Schlenger WE. Acute and chronic effects of alcohol use on violence. J Stud Alcohol 1988;49:516-521. 69. Leonard KE, Bromet EJ, Parkinson DK, et al. Patterns of alcohol use and physically aggressive behavior in men. J Stud Alcohol 1985;46:279-282. 70. Murdoch D, Pihl RO, Ross D. Alcohol and crimes of violence: present issues. Int J Addict 1990;25:1065-1081. 71. Cherpitel CJ. Alcohol and violence-related injuries: an emergency room study. Addiction 1993;88:79-88. 72. Roslund B, Larson CA. Crimes of violence and alcohol abuse in Sweden. Int J Addict 1979;14:1103-1115. 73. Langevin R, Paitich D, Orchard B, et al. The role of alcohol, drugs, suicide attempts, and situational strains in homicide committed by offenders seen for psychiatric assessment. Acta Psychiatr Scand 1982;66:229-242. 74. Klatsky AL, Armstrong MA. Alcohol use, other traits, and risk of unnatural death: a prospective study. Alcohol Clin Exp Res 1993;17:1156-1162. 75. Hingson R, Merrigan D, Heeren T. Effects of Massachusetts raising its legal drinking age from 18 to 20 on deaths from teenage homicide, suicide, and nontraffic accidents. Pediatr Clin North Am 1985;32:221-232. 76. Jones NE, Pieper CF, Robertson LS. The effect of legal drinking age on fatal injuries of adolescents and young adults. Am J Public Health 1992;82:112-115. 77. Hanzlick R, Gowitt GT. Cocaine metabolite detection in homicide victims. JAMA 1991;265:760-761. 78. Goodman RA, Mercy JA, Rosenberg ML. Drug use and interpersonal violence: barbiturates detected in homicide victims. Am J Epidemiol 1986;124:851-855. 79. Hanzlick R, Koponen M, Floyd V, et al. Homicides of persons aged Û18 years-Fulton County, Georgia, 1988-1992. MMWR 1994;43:254-255, 261. 80. Wood NP Jr, Amanfo J, Rodgers D, et al. Intentional injury-homicide as a public health problem. Md Med J 1993;42: 771-773. 81. National Center for Injury Prevention and Control. The prevention of youth violence: a framework for community action. Atlanta: Centers for Disease Control and Prevention, 1993. 82. Webster DW. The unconvincing case for school-based conflict resolution programs for adolescents. Health Aff (Millwood) 1993;12:126-141. 83. Gainer PS, Webster DW, Champion HR. A youth violence prevention program. Description and preliminary evaluation. Arch Surg 1993;128:303-308. 84. Davidson LL, Durkin MS, Kuhn L, et al. The impact of the Safe Kids/Healthy Neighborhoods injury prevention program in Harlem, 1988 through 1991. Am J Public Health 1994;84:580-586. 85. American Academy of Pediatrics. Firearms and adolescents. Pediatrics 1992;89:784- 787. 86. American Academy of Pediatrics. Firearm injuries affecting the pediatric population. Pediatrics 1992; 89:788-790. 87. American Academy of Family Physicians. Age charts for periodic health examination. Kansas City, MO: American Academy of Family Physicians, 1994. (Reprint no. 510.) 88. American College of Physicians. Preventing firearm violence: a public health imperative. Ann Intern Med 1995;122: 311-313. 89. Department of Health and Human Services and Department of Justice. Report of the Surgeon General's workshop on violence and public health. Washington, DC: Health Resources and Services Administration, 1986. (Publication no. HRS-D-MC 86-1.) 90. Mason J. Reducing youth violence-the physician's role. JAMA 1992;267:3003.