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1 Connecting the Dots: An Overview of the Links Among Multiple Forms of Violence Prevention and ity we at the center of commun equity ll-being

2 Connecting the Dots: An Overview of the Links Among Multiple Forms of Violence is a publication of the Centers for Disease Control and Prevention and Prevention Institute. 1 Centers for Disease Control and Prevention Thomas R. Frieden, MD, MPH, Director National Center for Injury Prevention and Control Daniel M. Sosin, MD, MPH, FACP, Acting Director Division of Violence Prevention Howard R. Spivak, MD, Director 2 Prevention Institute Larry Cohen, MSW, Executive Director Authors 1 Natalie Wilkins, PhD 2 Benita Tsao, MPH, CHES 1 Marci Hertz, MS 2 Rachel Davis, MSW 1 Joanne Klevens, MD, PhD, MPH July 2014 Suggested citation: Wilkins, N., Tsao, B., Hertz, M., Davis, R., Klevens, J. (2014). Connecting the Dots: An Overview of the Links Among Multiple Forms of Violence. Atlanta, GA: National Center for Injury Prevention and Control, Centers for Disease Control and Prevention Oakland, CA: Prevention Institute.

3 “Gang violence is connected to bullying is connected to school violence is connected to intimate partner violence is connected to child abuse is connected to elder abuse. It’s all connected.” -Deborah Prothrow-Stith, MD, Adjunct Professor, Harvard School of Public Health Violence takes many forms, including intimate partner violence, sexual violence, child maltreatment, bullying, suicidal behavior, and elder abuse and neglect. These forms of violence are interconnected and often share the same root causes. They can also all take place under one roof, or in a given community 1 , 2 Understanding the or neighborhood and can happen at the same time or at different stages of life. overlapping causes of violence and the things that can protect people and communities is important, and can help us better address violence in all its forms. The purpose of this brief is to share research on the connections between different forms of violence and describe how these connections affect communities . It is our hope that this information, combined with your own practical experience, will help practitioners like you to think strategically and creatively about how you can: 1. Prevent all types of violence from occurring in the first place. 2. Coordinate and integrate responses to violence in a way that recognizes these connections and considers the individual in the context of their home environment, neighborhood, and larger community. “There are experiences, particularly early in childhood, that make it extremely predictable that individuals are at substantially higher risk for involvement with violence, be it interpersonal, youth violence, intimate partner violence, dating violence, or child abuse.” -Howard Spivak, MD, Director, Division of Violence Prevention, Centers for Disease Control and Prevention Vulnerability and Resilience: Risk Factors and Protective Factors Violent behavior is complex. Many things increase or decrease the likelihood of violence. The communities people live in can protect them from violence or can increase their risk of violence. Things that make it more likely that people will experience violence are called . Examples of risk risk factors factors are: rigid social beliefs about what is “masculine” and “feminine,” lack of job opportunities, and family conflict. Things that make it less likely that people will experience violence or that increase their resilience when they are faced with risk factors are called protective factors . Examples of protective factors are: connection to a caring adult or access to mental health services. Risk and protective factors can affect an entire community, and can occur in interactions with family and friends and within organizations and systems like schools, faith institutions, and workplaces. Individual experiences or traits can also be risk and protective factors, such as witnessing violence or having skills to solve problems non- violently. The table on pages 8 and 9 shows that some of the things that make it less likely for one type of violence to happen may also protect us from other types of violence. 1 Connecting the Dots

4 The Impact of Violence on Development People’s brains develop in response to their 3 , 5 , 6 4 When children grow up in safe, environments. 8 7 and nurturing relationships and environments, stable, they learn empathy, impulse control, anger management and problem-solving— all skills that 9 protect against violence. When children grow up in environments where they don’t feel safe, their brain cells form different connections with each other to 10 , 11 Children better recognize and respond to threats. in these environments may misinterpret neutral facial 12 expressions as anger, for example, and more situations may trigger a fight-or-flight response. Children living in a persistently threatening environment are more likely to respond violently (fight) or run away (flight) than children who grow up in safe, stable, and nurturing environments. Fight-or-flight responses are survival skills that people are born with and often override other skills that enable non-violent conflict resolution, such as impulse control, empathy, anger 13 , 14 , 11 , 15 management, and problem-solving skills. Childhood abuse, neglect, and exposure to other traumatic stressors, termed adverse childhood experiences (ACEs), are common. In the Adverse Childhood Experiences Study, over 17,000 adults from a Health Maintenance Organization (HMO) were asked about their experiences in childhood and subsequent behavioral and health outcomes. Almost two-thirds of participants reported at least one ACE, and more 3 The short- and long-term outcomes of these childhood than one in five reported three or more ACEs. exposures include multiple health and social problems. ACEs contribute to stress during childhood and put individuals at higher risk for health problems such as alcoholism and alcohol abuse, depression, illicit drug 16 , 3 use, intimate partner violence, and suicide attempts. The impact of ACEs is also cumulative , meaning the more ACEs a child is exposed to, the higher likelihood they will experience some of these health and social problems later in life. The life expectancy of people with six or more ACEs is 20 years shorter than those 17 without any ACEs. There are opportunities at every stage of life to remedy the negative effects of trauma and help people heal. Whether designed for children, youth, or adults, actions and activities that promote the protective factors listed in the table on pages 8 and 9 may prevent trauma for those exposed to violence and also reduce the likelihood of violence in the first place. Connecting the Dots 2

5 Community Context and the Co-Occurrence of Multiple Forms of Violence Community risk and protective factors are critical because they make it more or less likely that entire communities will suffer from violence. The level of safety someone feels varies so much from community to community and even from block to block because safety is not evenly distributed. Often, a community experiences an overwhelming number of risk factors without an equal balance of protective factors. This means that families and children living in some communities where there are many risk factors (e.g., high poverty, unemployment, and crime) are more likely than families and children living in other communities to 1 8, 20 , 19 experience multiple forms of violence. For example: Neighborhoods where there is low cohesion, or where residents don’t support and trust each other, are • , 21 19 22 intimate partner violence, more likely to have residents that also experience child maltreatment, 20 and youth violence. • People who are socially isolated and who don’t have social support from family, friends, or neighbors are 23 25 , 26 24 27 suicide, intimate partner violence, more likely to perpetrate child maltreatment, and elder abuse. Lack of economic opportunities and unemployment are associated with perpetration of child • 23 28 31 , 19 30 29 , self-directed violence, sexual violence, maltreatment, and youth intimate partner violence, 32 violence. • Norms in society or in communities that support aggression or coercion are associated with physical 33 , 34 36 19 35 intimate partner violence, and elder assaults of children, youth violence, sexual violence, 27 maltreatment. 37 Witnessing community violence puts people at higher risk of being bullied and perpetrating sexual • 38 violence. However, this also means that community protective factors may make it less likely that an entire community will experience violence. Things that increase peoples’ and communities’ resilience to violence include: 27 39 , 40 , 41 , Coordination of resources and services among community agencies. • 42 , 41 • Access to mental health and substance abuse services. , 42 , 19 , 38 41 43 , 41 , 27 , 44 , 42 , 45 , 46 , 47 family, • Support and connectedness, including connectedness to one’s community, 41 45 , 48 45 , 49 , 50 , 46 , 37 , pro-social peers, and school. 3 Connecting the Dots

6 Other Shared Risk and Protective Factors In addition to the things in communities that put people at risk for and/or protect them from violence, there are other things in people’s relationships and past experiences that increase their risk or protect against violence. These other risk and protective factors are important because they often occur at the same time as larger community risk and protective factors and can further increase people’s risk or resilience related to violence. For example, parents may have a harder time preventing their children from using substances (drugs, alcohol) or weapons when there are high levels of community violence in their neighborhood, putting youth already exposed to violence in their community at even higher risk 51 There are a number of these risk factors that occur as a result for experiencing other forms of violence. of people’s experiences, skills, behaviors, and relationships that put them at higher risk of acting violently. For example: Conflict within the family is linked to almost all forms of violence perpetration including child • 42 maltreatment (children in homes with high conflict are at higher risk for being victims), teen dating 52 53 31 46 37 intimate partner violence, youth violence, violence, and bullying. sexual violence, • Youth who associate with delinquent peers or friends are at higher risk of harming others through 37 46 45 31 teen dating violence, and later in life sexual violence, youth violence, bullying, and intimate 54 partner violence. • Experiencing one form of violence places individuals at a higher risk of experiencing other forms of violence (See “Violence Can Lead to More Violence” on page 4). , 52 , 42 , 27 , 55 , 37 , 46 , 56 , 57 53 Lacking skills to cope with problems non-violently • and problems with substance 42 , 27 , 41 , 58 , 46 , 31 , 53 , 52 also place individuals at higher risk for acting violently. abuse Relationships and past experiences and skills can also help protect people from violence even if 59 they are exposed to violence in their community. For example, we know that people who live in communities that are violent can be “protected” from the effects of this violence (are less likely to perpetrate violence or engage in other destructive behaviors like substance use) if they have non- violent, supportive relationships with family, friends, and other groups, like schools or faith- 59 , 51 , 60 organizations. For example: • Youth who feel connected and committed to school are at a lower risk of harming others 46 45 youth violence, and through dating violence, 41 37 and are at lower risk for suicide. bullying, 42,41,47,46,45 • Strong family support and non-violent 45,41,37,46,56,57,31,53,52 problem solving skills have been shown to be protective against almost all forms of violence. Connecting the Dots 4

7 Violence Can Lead to More Violence Most people who are victims of violence do not act violently. However, people who experience or are exposed to one form of violence are at a higher risk for both being a victim of other forms of violence and for inflicting harm on others: Survivors of one form of violence are more likely to be victims of other forms of violence. • Girls who are sexually abused are more likely to suffer physical violence and sexual re-victimization, » 61 engage in self-harming behavior, and be a victim of intimate partner violence later in life. » Youth who have been physically abused by a dating partner are also more likely to have suffered 62 abuse as a child, been a victim of sexual assault, and witnessed violence in their family. » Youth who report attempting suicide are approximately five times more likely to have also been in 63 a physical fight in the last year. Women and girls involved in gangs often experience physical, emotional, and sexual abuse » by other gang members, and are more likely to have been physically or sexually abused as , 65 64 children. » Children who have been bullied are at greater odds for becoming involved in physical violence 58 (e.g. weapon carrying, physical fighting). • Survivors of violence are at higher risk for behaving violently. » Children who experience physical abuse or neglect early in their lives are at greater risk for 66 67 67 bullying, committing violence against peers (particularly for boys), teen dating violence, and 68 68 68 35 committing child abuse, and sexual violence intimate partner violence, later in life. elder abuse, » Youth who bully others are more likely to have witnessed parental violence (intimate partner 69 , 70 violence) than those who do not bully others. • People who behave violently are more likely to commit other forms of violence. 72 Adults who are violent toward their partners are at higher risk of also abusing their children. » 58 » Youth who bully are more likely to carry weapons and be physically violent. They are also more 73 74 likely to sexually harass peers over time and commit violence against partners as teens and as 75 adults than those who did not bully. Despite these connections, we know people who experience violence in their communities or relationships can be protected from experiencing other forms of violence through protective factors such 59 as the ones listed in the table on pages 8 and 9. 5 Connecting the Dots

8 Breaking Down the Silos: Working Together to Create Safer Communities “We have to figure out how we break down these barriers and work in a more collaborative way not just within the health system but across the social services system and the criminal justice system” –Georges Benjamin, MD, Executive Director, American Public Health Association Understanding shared risk and protective factors of violence can help us plan how to prevent multiple forms of violence at once. Violence prevention and intervention efforts that focus on only one form of violence can be broadened to address multiple, connected forms of violence and increase public health impact. For example, organizations working on child maltreatment, youth violence, and suicide prevention could work together on strategies that increase families’ connectedness to the community. Since community connectedness is a shared protective factor across these types of violence (and other types of violence as well), pooling resources to take action on this shared protective factor could have a broad violence prevention impact in the community. Also, knowing that experiencing one form of violence can increase families’ and individuals’ risk for other forms of violence can help practitioners develop services and strategies that would have the most impact for their clients. For example, practitioners working with survivors of intimate partner violence may recognize that children in families experiencing conflict and violence are at higher risk of being victims of bullying, or becoming bullies 69 70 , themselves and coordinate with schools to ensure that all members of the family are receiving the help and support they need to prevent future violence. “Professionally we have silos, and we operate in these silos we’ve got to break down. Across the country, people working to prevent child abuse are right across the hall from people working on violence against women, and they don’t work together. As we go into communities to bring everybody to the table, don’t let people say, ‘I work on child abuse, but this is about gang violence.’ Don’t let people say, ‘I work on violence against women, and this is about child abuse.’ This thing, all this violence, is connected.” -Deborah Prothrow-Stith, MD, Adjunct Professor, Harvard School of Public Health Practitioners can address the unique aspects of a form of violence, while still supporting joint action wherever possible. Understanding how different forms of violence are linked to one another is an important first step in coordinating strategies, activities, and resources to effectively prevent multiple forms of violence. This understanding might increase support for braided and blended funding streams and additional infrastructure for increased collaboration, which would advance the field as a whole. Together we can make a difference in preventing all forms of violence in our lives, families, relationships, and communities. Effective prevention efforts address common risk and protective factors, reduce overall violence, and improve outcomes. As the relationships among multiple forms of violence become clearer, it’s increasingly important for practitioners and researchers to consider these linkages in their work. Connecting the Dots 6

9 To Learn More • WHO Guide to Implementing the Recommendations of the World Report on Violence, Lifetime Spiral of Gender Violence, • • Public Health Contributions to Preventing Violence, • The Relationship Between Bullying and Suicide: What We Know and What it Means for Schools, • The Bully-Sexual Violence Pathway in Early Adolescence, • Harvard University’s Center on the Developing Child- Science of Early Childhood Series, Adverse Childhood Experiences Study, • • Adverse Childhood Experiences Infographic, • Webinar: Links Between Multiple Forms of Violence, resources/training-a-events/989-webinar-links-between-multiple-forms-of-violence-3182013.html • Webinar: The Relationships between Child Maltreatment and Suicide & A Comprehensive Approach to Suicide Prevention, community-practice-relationship-between-child-maltreatment-and-suic Acknowledgements For their review of this fact sheet and thoughtful feedback, the authors thank: • Cordelia Anderson, Sensibilities Prevention Services Emily Austin, • Peace Over Violence • Chic Dabby, Asian & Pacific Islander Institute on Domestic Violence Heather Fitzpatrick, • American Academy of Pediatrics • Sally Fogerty, Children’s Safety Network • Annie Gebhardt, Donna Greco and Liz Zadnik, National Sexual Violence Resource Center • Karthryn Harding and Jim Hmurovich, Prevent Child Abuse America • Futures Without Violence Laura Hogan and Lisa Sohn, • Gayle Jaffe, Suicide Prevention Resource Center • David Lee, PreventConnect , California Coalition Against Sexual Assault • Anne Menard, National Resource Center on Domestic Violence • Charles Ransford, Cure Violence • Kaile Shilling and Billie Weiss, Violence Prevention Coalition of Greater Los Angeles FRIENDS National Resource Center Valerie Spiva Collins, • 7 Connecting the Dots

10 Shared Risk and Protective Factors Across Multiple Forms of Violence. Research on risk and protective factors for violence is continuing to evolve. In this table, “X’s” indicate NOTE: the existence of at least one study published in a peer reviewed journal demonstrating an association between the risk or protective factor and that type of violence. Also, some of the “community” risk and protective factors were measured through surveys of individuals (e.g. surveys asking people about neighborhood support and cohesion) versus measures at the actual community level (e.g. city alcohol licensing lists to measure alcohol outlet density), so may be considered proxies for community level risk and protective factors. Type of Violence Perpetration Teen Dating Child Intimate Elder Suicide Sexual Bullying Youth maltreat- Violence Violence Partner Maltreat- Violence Violence ment ment Risk Factors Cultural norms that , , 77 78 , 33,76 81 53 31 80 27 79 x x x x support aggression toward x x others , 85 57 , 82 37 83 84 x x x Media Violence x 86 87 , 88 , 89 47 108 Societal income inequity x x x x Weak health, educational, Societal 90 53 31 91 economic, and social x x x x policies/laws Harmful norms around 92 54 53 31 , 73 , 74 93 94 x x x x x x masculinity and femininity 31 53 42 46 95 Neighborhood poverty x x x x x High alcohol outlet 99 42 98 96 , 97 x x x x density 42 38 100 37 x x x Community violence x Diminished economic 30 , 29 42 46 28 , 19 31 x x x opportunities/high x x Community unemployment rates Poor neighborhood 45 53 41 46 , 20 42 x x x x x support and cohesion Social isolation/Lack of 27 42 45 53 46 58 41 x x x x x x x social support Poor parent-child 55 37 42 46 52 , 101 49 53 , 57 x x x x x x x relationships 42 52 53 37 31 46 x x x x x Family conflict x 46 42 53 41 27 x x x x x Economic stress Relationship Associating with 37 45 54 31 46 x x x x x delinquent peers 64 46 64 64 x x Gang Involvement x x Connecting the Dots 8

11 Type of Violence Perpetration Teen Dating Intimate Child Sexual Youth Bullying Suicide Elder Partner Violence Violence maltreat- Violence Maltreat- ment Violence ment Low educational 55 42 58 52 46 53 x x x x x x achievement Lack of non-violent social 55 42 37 52 46 53 27 57 , 56 x x x x x x x x problem-solving skills Poor behavioral control/ 41 46 42 31 52 53 x x x x x x Impulsiveness History of violent 27 42 41 102 67 53 46 31 x x x x x x x x Individual victimization 52 45 31 46 103 , 37 85 42 x x x Witnessing violence x x x x Psychological/mental 27 42 52 53 46 41 x x x x x x health problems 42 52 53 31 46 58 41 27 x x x x x x x Substance use x Protective Factors Coordination of resources 39 40 41 27 x x x and services among x community agencies Access to mental health 42 41 and substance abuse x x services Community Community support/ 27 42 19 38 , 44 43 41 x x x x x x connected-ness Family support/ 27 41 42 47 45 46 x x x x x x connected-ness Connection to a caring 41 45 46 x x x adult Association with pro- 104 45 48 x x x social peers Relationship Connection/commitment 41 47 45 , 105 , 49 , 50 37 46 x x x x x to school Skills in solving problems 46 41 107 106 x x x x non-violently Individual 9 Connecting the Dots

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