Report 11 of the Council on Scientific Affairs (I-99)
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School Violence

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This report does not deal with general issues of youth violence, which have been the subject of other reports. Rather it focuses on the specific issues raised in adopted Resolution 403: the incidence of school violence, media contagion, and school-based violence prevention programs. The Council also notes that an excellent review of the issues surrounding violence in schools has recently been published.¹

Methods. The literature reviewed for this report came from computer searches using  violence and schools as the search term. Searches were conducted via MEDLINE as well as the Online Computer Library Center, which permitted searches of the education literature. In addition, recent books on the topic were surveyed.

RELEVANT AMA POLICY [Editor's Note:  The discussion below represents AMA policy at the time this report was written (Fall 1999).]

The AMA has numerous policy statements pertaining to youth violence, particularly as it affects schools. These include:

Support for school-based education on violence prevention is found in two policies. Policy H-145.986, Violence as a Public Health Issue, advocates for "comprehensive health education as a means of addressing social issues such as firearms violence and urges widespread incorporation of such comprehensive health education into our societal framework." Similarly, Policy H-515.977(2)(c) states that the "AMA should collaborate and coordinate with the Centers for Disease Control and Prevention supported comprehensive school health programs initiative to develop health education curricula for grades K-12 on topics including violence avoidance [and] conflict resolution."

THE INCIDENCE OF VIOLENCE IN SCHOOL SETTINGS

Violent behavior in schools is certainly not of recent origin. Stories of school bullies and abusive teachers--oftentimes grossly exaggerated--are routinely heard and repeated, and caricatures of both are readily found. Consider, for example, the school experiences of such nineteenth century characters as Brontë's Jane Eyre or Dickens's David Copperfield and Oliver Twist, or from American literature, Tom Sawyer, who was disciplined with a switch.

Such stories notwithstanding, violence in schools is a very real problem. Bullying, for example, is a persistent and critical issue. The US Departments of Education and Justice have reported that bullying contributes to a climate of fear and intimidation in schools, and 8% of students in grades 6 through 12 report having been bullied in school, at school activities, or on the way to or from school.²

Bullying, however, is only a part of the problem. Criminal victimization of school students is a growing concern. For example, figures compiled by the Bureau of Justice Statistics (BJS) and the National Center for Education Statistics (NCES) show the number of students victimized by violent crime increased nearly 25% from 1989 to 1995.³ (Numerous factors affect the likelihood that incidents of violence will or will not be reported, meaning some figures are relatively overstated while others may be understated.) Surveys of 12- to 19-year-olds found some 270,000 incidents of violent crime at school (physical attacks or robberies by force, weapon, or threat), thus affecting 4.2% of this population.³ While these figures are distressing, schools remain relatively safe: about two and one-half times as many incidents of serious, violent crime occur among students in this age group while they are away from school.²

In the 1996-1997 school year, 1 in 10 schools reported a serious, violent crime to some law enforcement agency. These reports included murder, rape (or other sexual battery), suicide, physical attacks or fights with a weapon, and robbery. About half (47%) of schools reported a less serious violent or nonviolent crime, such as a physical attack without a weapon. On the other hand, just over 4 in 10 schools (43%) did not report any such crimes to the police.²

Elementary schools were much less likely than middle or high schools to report any type of crime to the authorities, and when they did, the most likely offense was vandalism. Among older students in middle and high schools, the most commonly reported crimes in the 1996-1997 school year were physical attacks and fights without weapons; the rate was about 8 per 1000 students.² According to the Centers for Disease Control and Prevention (CDC), in 1997 1 in 7 (14.8%) high school students reported being in a physical fight on school property during the preceding year, and more than 1 in 3 (36.6%) reported having been in a physical fight anywhere.⁴ The same data indicate that approximately one third of students had property stolen or deliberately damaged on school property, with the experience somewhat more likely for boys than for girls.

Students are not alone in experiencing crimes on school property. From 1992 to 1996, teachers were victims of more than 1.5 million nonfatal crimes at school, including 962,000 thefts and 619,000 violent crimes, such as rape, robbery and assault; on an annual basis, this is about 316,000 nonfatal crimes per year.² In 1996, 15% of teachers reported threats and injuries, while in 1991, the comparable figure was just 10%.³ (Comparable data for other occupational groups or for teachers outside schools are not available.)

Just as the types of crime vary by the level of education offered in a school, they also vary with school enrollment, with larger schools more likely to experience violent crime. During the 1996-1997 school year, one third of schools having more than 1000 students reported at least one serious violent crime compared to just 4% to 9% of schools with fewer than 1000 students.³ Reiss and Roth^{5(p 155)} note that violence rates in secondary schools are highest in areas with higher crime rates and more street gangs, likely reflecting the situation in the surrounding community, and Simon and colleagues⁶ note that school violence tends to reflect violence among youths in the community. Interestingly, rates of violence vary little between schools with and without security measures such as hallway patrols and visitor check-in, procedures that are relatively easily implemented.⁷

Deaths in School. -- Obviously the greatest fears and the most news are generated by deaths at school, and multiple occurrences of homicides in schools around the country over the last few years have raised concerns among both the public and professionals. However, while tragic, most murders and suicides among school-aged youths take place outside the school setting. According to the NCES and BJS report, 76 students were murdered or committed suicide at school in the 1992-1993 and 1993-1994 school years, during which time there were an additional 29 non-student, violent deaths at schools.² In the same period, more than 7300 young people aged 5 to 19 years old were murdered, and nearly 4400 committed suicide. Students in urban schools were nine times more likely than their rural peers and twice as likely as students in suburban schools to die violently at school. According to news reports, the Department of Justice reports that during the past year, there were about half as many violent, school-related deaths as there were in 1993.⁸

The National School Safety Center (NSSC) has issued a report on school-associated violent deaths, counting "any homicide, suicide, or weapons-related violent death in the United States in which the fatal injury occurred: on the property of a functioning public, private or parochial elementary or secondary school; on the way to or from regular sessions at such a school; while [a] person was attending or was on the way to or from an official school-sponsored event; [or] as [an] obvious direct result of school incident/s, function/s or activities, whether on or off school bus/vehicle or school property."⁹> Using this definition, the NSSC reports some 251 violent deaths from July 1992 through the 1998-1999 school year. About 80% (195) were attributable to firearms, another 14% (35) to stabbings, and the remainder to a variety of methods, including beating and strangulation.

Weapon-Carrying Behavior. -- As just noted, the implements of school violence are deadly, and weapon-carrying behavior has become all too common among older school-aged youths. According to the Youth Risk Behavior Surveillance Survey, nearly one fifth (18.3%) of high school students nationwide had carried a weapon (gun, knife, or club) on at least one day in the 30 days preceding the survey. More than 1 in 12 (8.5%) had done so on school property, and male students were more than three times as likely as female students to have engaged in such behavior (12.5% vs 3.7%).⁴ About 3% of high school seniors reported carrying a gun to school on at least one day in the four weeks preceding the survey. According to BJS and NCES data, the proportion of male high school seniors carrying weapons to school declined from 14% to 9% between 1993 and 1996, while the figure for female students climbed slightly from 2% to 3%.² A more recent report in JAMA shows that between 1991 and 1997, high school students became less likely to carry weapons, fight, or be injured in fights; in addition, from 1993 to 1997 they became less likely to carry firearms but not other weapons, to carry weapons on school property, or to engage in fights on school property.¹⁰

The 1997 Youth Risk Behavior Surveillance Survey indicates that 7.4% of high school-aged students were threatened or injured by a weapon on school property in the 12 months preceding the survey, with males more than twice as likely as females to make such reports (10.2% vs 4.0%).⁴ Such threats may be related to an increase in the percentage of students reporting they feel unsafe while at school or while going to or from school. Between 1989 and 1996, the percentage of students fearing they would be attacked or harmed at school rose from 6% to 9%, and in the same period, the percentage of students who avoided one or more places at school for fear of their own safety climbed from 5% to 9%.²

Drug Use and School Violence. --As Hamburg^11(p46) notes, "there is little question that a strong relationship exists between & violence and the acquisition and use of drugs and alcohol," but the connections between school violence and drug use and abuse have not been well studied. Perpetrators frequently are under the influence of alcohol or other drugs, and Lowry¹²> suggests that the availability of alcohol and other drugs may be directly related to the probability that students will be attacked or fear being attacked at or on their way to or from school. Johnston and colleagues¹³> report that deviant activities such as illicit drug use and violent behavior tend to co-occur during routine activities among school-aged youth when authority figures are absent. The use of illegal or illicit drugs may be associated with other risk-taking behavior such as weapon carrying,¹⁴ but a causal connection is purely speculative. Beyond that, data are insufficient to draw conclusions about drug use and school violence, although, like the levels of violence in schools, substance use and abuse among youths in school probably correlate with substance use in the surrounding community.

Summary. Violent behavior and criminal activities are a significant concern in US elementary and secondary schools, particularly in the light of brutal homicides perpetrated by students on their peers and teachers over the past few years. However, while students are victims of numerous violent crimes at or around schools, they are much more likely to be victimized in non-school-related settings or situations. In fact, school-associated violent deaths are rare compared to violence inflicted on youths in the community.¹⁵ Moreover, even at school, students are far more likely to suffer unintentional injuries than criminal victimization of any kind. Between 2.2 and 5.5 million unintentional injuries are estimated to occur each year in and around schools, including injuries involving school buses, sporting activities, and routine class activities. The ratio of unintentional injuries to violence-related injuries is at least 9 to 1.¹⁶ 

EFFECTS OF MEDIA REPORTS OF SCHOOL VIOLENCE

The authors of Resolution 403 expressed concerns about the effects of media reporting of violent events on others, referring to this as "contagion or copycat" effects. Few question the negative effects of media depictions of violence on children,¹⁷> and a summary is available in the AMA s Physician Guide to Media Violence.¹⁸ However, the scientific literature on the effects of news reports of violence is limited, and virtually nil with respect to the particular issues of concern here.

A substantial literature exists on suicide contagion, which has been characterized as a process by which exposure to the suicide or suicidal behavior of one or more persons influences others to commit or attempt suicide.¹⁹ Adolescents seem to be the most prone to such effects, and the CDC has identified several suicide clusters associated with such events in local areas.^20,21

After examining these suicide clusters, the CDC categorized seven elements of media coverage that can promote suicide contagion.²² These include:

• Presenting simplistic explanations for suicide: reports should indicate that suicide generally involves a history of psychosocial problems rather than a single precipitating event.   
• Engaging in repetitive, ongoing or excessive reporting: repetitive and ongoing or prominent coverage tends to promote and maintain a preoccupation with suicide among at-risk persons.    
• Providing sensational coverage of suicide: news coverage tends to heighten public preoccupation with suicide, suggesting that less prominent news reports would be less likely to provoke copycat behaviors.     
• Reporting "how-to" descriptions of suicide: providing details of the mechanism and procedures used in a suicide may facilitate imitation.    
• Presenting suicide as a tool for accomplishing certain ends: presenting suicide as a means of coping with personal problems may suggest suicide as a coping mechanism for at-risk individuals.    
• Glorifying suicide or persons who commit suicide: news coverage is less likely to exhibit contagion effects if reports of community expressions of grief (e.g., flags flown at half-staff, public eulogies) are minimized. Glorifying accounts may suggest to susceptible individuals that the suicidal behavior is being honored.    
• Focusing on the suicide completer's positive characteristics: statements venerating the deceased person, particularly in the absence of comments on the completer's problems, may appear attractive to at-risk persons.

While this list was drawn up in response to suicide clusters and published in the hope of averting suicide cases, it appears to be applicable to media coverage of school violence. Indeed, a number of commentators have written at some length on the effects of news coverage following recent, widely publicized school shootings. (See Keller²³ for one example.)

Phillips²⁴ has presented some evidence to indicate that the copycat phenomenon occurs in homicide cases as well, but few other data are available for non-suicidal violent behaviors. News reports in the spring of 1999 were suggestive of such an effect for school violence, but no empirical work has appeared in the peer-reviewed literature.

Interestingly, as the 1999-2000 school year was just getting underway, a number of commentaries appeared in the press questioning concerns about school violence (see, for example, references 25 through 27) These seem to have been sparked by the JAMA article on youth violence cited above,¹⁰ and all have expressed concern that news of school violence has been overblown and has led to increased and unfounded fear among both school children and their parents about school safety.

Summary. There is a general consensus that media depictions of violence as entertainment leads to some increase in violence, although the magnitude of the effect, those persons at-risk, and the long-term effects are all unclear. (See Felson²⁸ for a critical review.) Research dealing with news accounts of violent behavior is more limited, with most conducted in the area of suicide. At this time, no definite statement is possible regarding links between news reports of school violence and copycat actions taken by other youths. However, media pundits apparently believe that news accounts can and do have adverse effects on children by increasing fears about their safety at school.

SCHOOL-BASED VIOLENCE PREVENTION PROGRAMS

Widespread concern about youth violence has led to the development of numerous programs intended to prevent it. The CDC prepared a report on community programs with this goal in 1993,²⁹ and in direct response to school shootings that have occurred in the last few years, the Department of Education has prepared a document on safe schools, emphasizing roles in maintaining safe schools and identifying youths at risk for violent behavior.³⁰ Unfortunately, few programs--whether or not they are based in the schools--have been thoroughly evaluated, making it impossible to draw conclusions about their value.^31,32 A thorough review of school-based violence prevention programs is available from Samples and Aber.³³

Among the interventions that have been developed, some are targeted at youths identified as having risk factors, and others are addressed to a broader, essentially universal, audience (e.g., to all students in a school). Risk factors for youth violence include both individual characteristics as well as aspects of the family and community features.³⁴ Included are early childbearing, low intelligence, poor academic performance or failure, early aggression, victimization as a child, and weak family bonding.^31,32

Many of the broad-based or universal violence prevention efforts are based in schools not only because they presumably provide a means to avert or prevent serious and possibly catastrophic events but also because the schools provide a captive audience. As noted above, the environment within a school typically reflects the circumstances in the surrounding neighborhoods, making primary prevention of violence key to ensuring safety in the school. In addition, public elementary and secondary schools receive the lion's share of public monies expended on children, so fiscal realities are likely to compel schools to include violence prevention efforts in their curricula.³⁴

A number of approaches to school violence prevention have been tried, with most attempting to enhance skills or change individual attitudes toward violent behavior.³² Among the skill-building programs are those that focus on problem solving and social skills. Building problem-solving skills has emerged as a violence prevention tool because violent youths tend to have lower cognitive ability than their non-violent peers, and these programs aim to improve the capacity of violent youths to observe a problem, see alternative solutions, identify consequences, and choose a proper course of action.³¹ Skill-building interventions are thought to address the underlying causes of youth violence.

In essence, these programs teach basic interpersonal skills.³⁴ Two of the better known are the Interpersonal Cognitive Problem-Solving (ICPS) program and Providing Alternative Thinking Strategies (PATHS),^31,34 both designed for elementary grades. The ICPS curriculum "consists of daily lessons & focused on generating alternative solutions to interpersonal problems, consequential thinking, and recognizing and being sensitive to others' feelings,"^{34(p 203)} while the PATHS program teaches "emotional literacy, self-control, social competence, positive peer relations, and interpersonal problem-solving skills."³⁵ Both programs have received favorable evaluations, although their long-term effectiveness (beyond two years) is not yet known.^31,34,35 The PATHS program, in particular, has been commended as a model curriculum by the University of Colorado's Center for the Study and Prevention of Violence.³⁵ 

Another set of programs is referred to as violence prevention curricula or conflict resolution. Unlike the above programs, which focus on elementary grades, these programs have tended to focus on older students, those in junior high and high school. According to Hawkins and colleagues,^{34(p 203)} these "curricula seek to improve students' social, problem-solving, and anger management skills and to promote beliefs favorable to non-violence [and] typically teach skills of empathy, appropriate social behavior, interpersonal problem solving, and anger management using discussion, modeling, and role play methods to assure skills acquisition." They are also intended to "promote beliefs favorable to nonviolence and increase knowledge about conflict and violence."^{31(p 278)}

Despite these lofty goals, few of these programs have been found effective. According to Kellerman and associates,³¹ violence-prevention curricula generally have not been shown to change attitudes about violence nor have they reduced the incidence of violent behavior; effects seem limited to self-reports of aggressive behavior. Typical are findings reported by Gainer and collaborators,³⁶ which found inconsistent results. In this study of fifth through seventh grade students in Washington, DC, participants were more likely than a control group to identify risks associated with violent behavior and less likely to define problems in adversarial ways but no more likely to identify nonviolent solutions to problems.

Interestingly, better support for these curricula can be found in evaluations of the Second Step program administered to younger children.³⁷The Second Step program is designed for children from preschool through the ninth grade and is intended to prevent aggressive behavior by increasing prosocial behavior. In their study of second and third graders in Seattle, Grossman and colleagues³⁷ showed that the curriculum decreased the number and frequency of aggressive behaviors among participants even while these behaviors increased among control groups. The effects persisted for at least six months. As Kellerman³¹ points out, the effects of violence prevention curricula may be dependent on the ages of participating students, which might explain some of the inconsistent findings across programs.

A third common school-based intervention is peer counseling or peer mediation. In peer counseling, participating students discuss their differences in a setting designed to encourage the recognition of problem attitudes and behavior, mixing students with risk factors for or a history of violence with students lacking these traits. In peer mediation, which is most often implemented with a conflict resolution program, participating students agree to have their differences mediated by a peer who has been given special training.³¹ Both sorts of programs are popular, but neither has been shown to reduce violence. In fact, Hawkins and associates cite evidence to suggest that peer counseling may tend to produce negative effects, at least in the short term.³⁴

Some evidence suggests that changes in the organization of schools and increased participation by parents may lessen the likelihood of violence in a school. School-based interventions that deal directly with at-risk students or increase parent involvement and collaboration with school personnel can reduce risk for in-school violence.³⁸ In a widely acclaimed effort, researchers at Yale developed a program to build and strengthen bonds among elementary students, their parents and the schools.³⁹ That program eventuated in school-wide measures of academic success that were well above national norms and better than non-program schools, and students continued to perform well in middle school.³⁴ Hawkins and colleagues conclude that there is growing "evidence that changing the opportunity and reward structure & of schools can promote academic achievement & and reduce misbehavior including violent behavior."^{34(p 209-210)}

Finally, other broad-based programs involving the community as well as the schools support the idea that multifaceted programs may be beneficial. The efforts of Deborah Prothrow-Stith and her colleagues are well known and have many proponents. Their program is not strictly school-based as it includes both an educational curriculum and messages delivered via the mass media.⁴⁰ The program is believed responsible for a dramatic decline in youth homicides in Boston over the last few years, including one 18-month period in which there were no homicides perpetrated by youths. The experience has led to the publication of Peace by Piece: A Violence Prevention Guide for Communities, which provides strategies for developing a broad-based coalition and strengthening community collaborations

Summary. School-based violence prevention programs have not generally been adequately evaluated. Even among programs found to produce positive outcomes, almost no studies have been conducted to assess their long-term effects. Moreover, few programs have demonstrated deterrent effects on violent behavior. Rather, the effects have focused on anti-social and aggressive behavior.³⁸  In addition, cost-benefit studies have been neglected. At this time, findings are more supportive of skill development programs and programs designed to build family involvement, but caution should be exercised in generalizing from one program to the next.

CONCLUSION

Although school violence is an old problem, recent events have raised concerns that schools may no longer be safe havens for children. Public awareness of this violence in schools demands attention to its causes and to possible preventive efforts. While this alarm should not displace concerns about more common sources of injury among school-aged youth, these issues must be addressed.

Moreover, despite the fact that schools in the United States remain relatively safe, students do suffer injuries attributable to violence and other incidents. They are more likely to be victimized away from school than while attending school or participating in school-related activities, and elementary and secondary students are far more likely to suffer unintentional injuries while at school than they are intentional injuries. However, all of these injuries, regardless of cause, can have long-term effects or even result in death, and all these sources of morbidity require attention. The pending AMA project on youth violence will address these concerns, including issues of school violence, which as noted above is generally reflective of other conditions in the community.

Factors that contribute to school violence are likely no different than the factors that lead to violence generally or youth violence in particular. For the most part, violence is learned behavior, and a variety of social ills and individual characteristics contribute to violent expressions and behavior, including substance abuse, poverty, poor academic achievement, racism, and victimization as a child. The effect of media reports about school violence on further instances of school violence is unknown.

Finally, a wide variety of programs to address youth violence has evolved, many of which have been implemented in schools. The success and value of most of these programs remain unanswered questions as rigorous evaluations have not been conducted, and even where short-term studies have shown positive outcomes, long-term evaluations have not been carried out. To the extent that conclusions are possible, it appears that programs involving parents as collaborators in the schools, efforts to enhance the social skills of students, and other multifaceted programs that involve diverse elements of the community are most likely to yield positive results.

The AMA's youth violence program may help answer some of these questions.

RECOMMENDATION

The following statement, recommended by the Council on Scientific Affairs, was adopted  by the AMA House of Delegates as an AMA directive at the 1999 AMA Interim Meeting: 

The American Medical Association will collaborate with the US Surgeon General on the development of a comprehensive report on youth violence prevention, which should include such issues as bullying, racial prejudice, discrimination based on sexual orientation, and similar behaviors and attitudes.

References

1. Elliott DS, Hamburg BA, Williams KR, eds. Violence in American Schools. New York: Cambridge University Press; 1998.    
2. Kaufman P, Chen X, Choy SP, et al. Indicators of School Crime and Safety, 1998. US Departments of Education and Justice. NCES 98-251/NCJ-172215. Washington, DC; 1998.    
3. Safe Schools, Safe Students: A Guide to Violence Prevention Strategies. Washington, DC: Drug Strategies; 1998.    
4. Kann L, Kinchen SA, Williams BI, et al. Youth risk behavior surveillance United States, 1997. In CDC Surveillance Summaries, August 14, 1998. MMWR. 1998;47(SS-3):1-31.    
5. Reiss AJ, Roth JA. Understanding and Preventing Violence. Washington, DC: National Academy Press; 1993.    
6. Simon TR, Crosby AE, Dahlberg LL. Students who carry weapons to high school: comparison with other weapon-carriers. J Adollesc Health. 1999;24:340-348.    
7. Gellert GA. Confronting Violence. Boulder, CO: Westview Press; 1997.    
8. Gwynne SC. Reaching new heights in school security. The [Portland] Oregonian. August 22, 1999.    
9. National School Safety Center. School Associated Violent Deaths. Available at: http://www.nssc1.org/savd/savd.pdf. Accessed July 7, 1999.    
10. Brener ND, Simon TR, Krug EG, Lowry R. Recent trends in violence-related behaviors among high school students in the United States. JAMA. 1999;282:440-446.    
11. Hamburg BA. Youth violence is a public health concern. In: Elliott DS, Hamburg BA, Williams KR, eds. Violence in American Schools. New York: Cambridge University Press; 1998:31-54.    
12. Lowry R, Sleet D, Duncan C, Powell K, Kolbe L. Adolescents at risk for violence. Educational Psychology Review. 1995;7:7-39. Cited by: Hamburg BA. Youth violence is a public health concern. In: Elliott DS, Hamburg BA, Williams KR, eds. Violence in American Schools. New York: Cambridge University Press; 1998:31-54.    
13. Johnston LD, O Malley PM, Bachman JG. National Survey Results on Drug Use from the Monitoring the Future Study, 1975-1997. Volume 1, Secondary School Students. Rockville, Maryland: National Institute on Drug Abuse; 1998 (NIH Publication No 98-4345).    
14. DuRant RH, Krowchuk DP, Kreiter S, Sinai SH, Woods CR. Weapon carrying on school property among middle school students. Arch Pediatr Adolesc Med. 1999;153:21-26.    
15. Kachur SP, Stennies GM, Powell KP, et al. School-associated violent deaths in the United States, 1992 to 1994. JAMA. 1996;275:1729-1733.    
16. Children's Safety Network at Education Development Center, Inc. Injuries in the School Environment: A Resource Guide. (2^nd ed.). Newton, MA: Education Development Center, Inc.; 1997.    
17. Strasburger VC, Donnerstein E. Children, adolescents, and the media: issues and solutions. Pediatrics. 1999;103:129-139.    
18. Walsh D, Goldman LS, Brown RL. Physician Guide to Media Violence. Chicago: American Medical Association; 1996.    
19. Davidson LE, Gould MS. Contagion as a risk factor for youth suicide. In: Alcohol, Drug Abuse, and Mental Health Administration. Report of the Secretary's Task Force on Youth Suicide. Vol 2. Risk Factors for Youth Suicide. Washington DC: US Department of Health and Human Services (DHHS Publication ADM 89-1622); 1989:88-109.    
20. Centers for Disease Control. Cluster of suicides and suicide attempts--New Jersey. MMWR. 1988;37:213-216.    
21. Centers for Disease Control. Adolescent suicide and suicide attempts--Santa Fe County, New Mexico, January 1985-May 1990. MMWR. 1991;40:329-331.    
22. Centers for Disease Control and Prevention. Suicide contagion and the reporting of suicide: recommendations from a national workshop. MMWR. 1994;43(No. RR-6):13-18.    
23. Keller J. The media barrage: immediate, incessant coverage depletes our souls. Chicago Tribune. April 25, 1999: Section 2:1, 6.    
24. Phillips DP. The impact of mass media violence on US homicides. Am Sociolog Rev. 1983;48:560-568.    
25. Glassner B. School violence: the fears, the facts. New York Times. August 13, 1999; sect A:21.    
26. No. 1 from Shepherd Smith: don t scare the kids about school violence. Pittsburgh Post-Gazette. August 29, 1999.    
27. Chapman S. The naked truth about keeping kids safe at school. Chicago Tribune. September 2, 1999; sect 1:31.    
28. Felson RB. Mass media effects on violent behavior. Annu Rev Sociol. 1996;22:103-128.    
29. 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.    
30. Dwyer K, Osher D, Warger C. Early Warning, Timely Response: A Guide to Safe Schools. Washington, DC: US Department of Education; 1998.    
31. Kellerman AL, Fuqua-Whitley DS, Rivara FP, Mercy JA. Preventing youth violence: what works? Annu Rev Public Health. 1998;19:271-292.    
32. Dahlberg LL. Youth violence in the United States: major trends, risk factors, and prevention approaches. Am J Prev Med. 1998;14:259-272.    
33. Samples F, Aber L. Evaluations of school-based violence prevention programs. In: Elliott DS, Hamburg BA, Williams KR, eds. Violence in American Schools. New York: Cambridge University Press; 1998:217-252.    
34. Hawkins JD, Farrington DP, Catalano RF. Reducing violence through schools. In: Elliott DS, Hamburg BA, Williams KR, eds. Violence in American Schools. New York: Cambridge University Press; 1998:188-216.    
35. Center for the Study and Prevention of Violence. Blueprints for violence prevention. Available at: http://www.colorado.edu/cspv/blueprints/model/index.html. Accessed July 13, 1999.    
36. Gainer PS, Webster DW, Champion HR. A youth violence prevention program: description and preliminary evaluation. Arch Surg. 1993;128:303-308.    
37. Grossman DC, Neckerman HJ, Koepsell TD, et al. Effectiveness of a violence prevention curriculum among children in elementary school. JAMA. 1997;277:1605-1611.    
38. Elliott DS, Tolan PH. Youth violence prevention, intervention, and social policy: an overview. In: Flannery DJ, Huff CR, eds. Youth Violence: Prevention, Intervention and Social Policy. Washington, DC: American Psychiatric Press; 1998:3-46.    
39. Comer JP. Educating poor minority children. Sci Am. 1988;259(5):42-48.    
40. Hausman AJ, Spivak H, Prothrow-Stith D. Evaluation of a community-based youth violence prevention project. J Adolesc Health. 1995;17:353-359.

Also see AMA's Violence prevention Web site.

Resolution 403 (I-98)

Resolution 403, introduced by the American Academy of Child and Adolescent Psychiatry, the American Academy of Pediatrics, and the American Psychiatric Association, was adopted at the 1998 Interim Meeting. The resolution asked the American Medical Association (AMA) to study the issue of violence in school settings, addressing three particular elements: the incidence of such violence, the effects of media coverage, and the efficacy of school-based violence prevention programs.

Responsibility for the resolution was given to the Council on Scientific Affairs, and the Council has prepared this informational report for the House of Delegates. In addition, the Council is preparing another report as part of the AMA's broader initiative to address school violence in the context of youth violence. This initiative involves multiple members of the Federation as well as relevant groups such as the American Nurses Association, the American Public Health Association, and the Office of the Surgeon General. Reports on the outcome of this effort and recommendations for policy will be forthcoming in 2000. The youth violence effort complements the AMA's decade-old Campaign Against Family Violence, which has dealt with violence among intimates and the role of physicians in identifying, referring, and treating such victims. Back to Top