- Email: [email protected]
A Framework for: What Can and Should Society Do?
27, 212–215 (1998) PM970277
PREVENTIVE MEDICINE ARTICLE NO.
A Framework for: What Can and Should Society Do? Chukwudi Onwuachi-Saunders, M.D., M.P.H.,*,1 Cimon A. Brooks, M.B.A.,* and Glenwood C. Brooks, Jr., Ph.D.† *Philadelphia Department of Public Health, 1600 Arch Street, 7th Floor, Philadelphia, Pennsylvania 19103; and †HealthSouth Chesapeake Rehabilitation Hospital, 220 Tilghman Road, Salisbury, Maryland 21801
Researchers strive to better understand the critical periods of brain development. Findings generate clearer descriptions of what the critical periods are and suggest that stress, aggression, and violent behavior affect the development process. But the question remains as to what can and should society do to nurture children through these periods and to support their continued growth and development. Operation Peace in Philadelphia, an urban community-based, violence prevention/reduction initiative using the principals of public health, represents a framework for generating fresh attitudes and innovative support systems that will nurture children through the critical periods of brain development and beyond. This framework enhances understanding of the complexities of societal issues such as violent behavior and uncovers and offers communal solutions. It is a link between research and its practical application—what society can do. Society’s challenge echoes Operation Peace’s challenge to use the combined strengths of scientific knowledge, multidisciplinary skills, sustained commitment, cultural vitality, community support, and political will to enable youth to achieve their potential, via full and active lives. q1998 American Health Foundation and Academic Press Key Words: violence; brain; research; critical period; nurture community; public health; strategies; children; prevention.
INTRODUCTION
Researchers strive to gain understanding of the “critical” periods in brain development. Findings reveal that physical changes in the brain may result from psychological stress. In animals this physical change presents itself as an alteration to the hypothalamic–pituitary– adrenal axis, resulting in stress sensitization [1]. Among humans it was documented as alterations in the hippocampal volumes of sexual abuse victims and Vietnam veterans suffering from posttraumatic stress 1
To whom reprint requests should be addressed.
disorder. Findings such as these among both animals and humans suggest the need to better understand the effects of factors such as stress, violence, and trauma on brain development [1]. Hostile destructiveness, a form of aggression described by Henri Parens, “is not present at birth.” What produces this type of behavior is the experience of “excessive unpleasure” (excessive pain or distress) [2]. This type of aggression is influenced by the relationships our children have within the social environments provided to them [2]. Others also report on the link between specific behaviors and the social environment as well as the development of psychologic responses associated with exposure to violence [3,4]. The question is, what can and should society do to prevent malformations to the brain associated with stress factors resulting from violent and aggressive behavior? Or, how can society nurture children and protect them from adverse factors in the environment? The answers to these questions are imperative given the disproportionate impact of violence on children today [2–4]. Violence, specifically interpersonal violence involving youth, has adversely affected the public’s health [5]. As the fifth largest city in the United States with a population of approximately 1.6 million, Philadelphia had a total homicide rate of 27.3 per 100,000 in 1995. Of all deaths of youths 0–21 years of age (662), homicides represented 18%. Males between the ages of 16 and 21 were the majority of victims and firearms were the leading weapon. Based on the thought as to what society can and should do about this type of behavior, a framework for consensus-driven solutions for violence prevention/reduction and peace promotion was developed. This framework would allow communities to tackle the deeply rooted and multifaceted issues surrounding interpersonal violent behavior and to enhance their efforts to find communal solutions [5]. The framework assumes: (a) the critical periods are sufficiently “wide” enough (i.e., breadth of maturity) to influence brain development; (b) brain development is
212
0091-7435/98 $25.00 Copyright q 1998 by American Health Foundation and Academic Press All rights of reproduction in any form reserved.
WHAT CAN AND SHOULD SOCIETY DO?
sufficiently plastic—the capacity in which the central nervous system can adapt or change after environmental stimulation—to modify thoughts and behavior; and (c) the possibility exists that the brain, by the process of diaschisis—a mechanism by which recovery occurs after damage—can correct or compensate for malformations, thus leading to minimization of violent thoughts and behavior [6–11]. Called Operation Peace in Philadelphia (OPP), it represents a city-wide, community-based, comprehensive, long-term approach. It uses public health principles to address interpersonal violence involving youth [5,8,12–18]. The structure involves the entire community. This allows attitudes and support systems to be tailored to protect youth and to develop a nurturing environment. Interpersonal violence—a societal issue—denotes that the community as a whole must work on the solutions. The goal is to be as inclusive as possible. The vision promises a significant reduction in violent behaviors, thus an enhanced quality of life for all. The mission entails establishing new ideals, beliefs, and lifestyles relating to interpersonal violence. The proverb states, “It takes an entire village to raise a child.” OPP’s philosophy is to strengthen “hope” within the community by echoing three principles: 1. Interpersonal violence is unacceptable and preventable. 2. Violence prevention/peace promotion is a marathon and not a sprint. 3. Every segment of the community must contribute to its solution. Strengthening hope within communities allows for the production of nurturing environments. The framework is made up of three components: a long-term Collaboration, a Media and Awareness Campaign, and a Data/Information System to enhance research and evaluation. Each component feeds and supports the others. THE COLLABORATION
The Collaboration is long-term and is composed of action teams. Changing behavior takes time, and all segments of the community have a role to play. The framework must provide the foundation for this to happen. In Philadelphia, this collaboration is made up of action teams derived from various segments of the community, e.g., media/arts, interfaith, legislation, business, teens, neighborhoods, and schools. The teams are charged with identifying, developing, and implementing immediate and long-term peace promotion, violence prevention/reduction strategies within their discipline (the players are all committed to collective action through community-based efforts).
213
Strategies involve efficient child care, teaching parenting skills to adults and children, incorporating stress reduction in the workplace, comprehensive health education curricula including life skills and anger management, adequate and safe housing, a 24hour Children’s Response Team for children who witness violence, etc. The collaboration represents everyone working on the problem. “When the spider webs unite, they can tie up a lion.” The goal is to create a nurturing environment (village) for all youth that will stimulate and support healthy behaviors and disallow negative ones. MEDIA AND AWARENESS CAMPAIGN
The negative impact of viewing violence on television has been well documented [19–22]. This, in addition to thoughtless and careless messages, affects behavior, especially youth behavior. Efforts should be developed to stop and counter the negative effects of the media and to emphasize its power to bring about positive change. The development of a city-wide media and awareness campaign based on the slogan “I hear what you say, but I see what you do” is another important component of the framework. This slogan represents the unspoken message behind much of youth behavior today. Youth behavior is reflective of adult behavior. Therefore, the target audience for the campaign encompasses all adults and adult youth service providers. The goal is to disseminate the message that adults are collectively responsible for youth. Adults/parents/caretakers are the “first” teachers. Aesop’s fable The Crab and His Mother highlights this. In the fable the old crab asks her son to walk straight. Her son replies, “Show me how and I’ll follow your example.” The old crab tries in vain and then realizes how foolish she was to find fault with her child. Many youth are OK, and they need to hear this regularly through “recovery-type” messages [23]. These are often missing from traditional media channels. Although targeted to youth, these messages encourage and support positive behavior change and subsequently have a positive effect on all of society. The Philadelphia experience highlighted the need to better understand the effects of inappropriate messages but, most importantly, how to develop counter messages. Innovative positive messages are ideal and benefit the greater society if they are inclusive. For example, a message targeted to teenage mothers encouraging nurturing may say: “Talk to your baby, touch your baby, feed your baby . . .” This type of nurturing message could also benefit all children and therefore could say “Talk to your child, touch and feed your child daily.” Messages targeting adults on reading to children could say, “read or tell stories to your child daily.” This would include communities with high illiteracy rates or strong
214
ONWUACHI-SAUNDERS, BROOKS, AND BROOKS
verbal communication. The importance of talking to children can never be underestimated. Inclusive messages help produce nurturing environments for all children. THE DATA/INFORMATION SYSTEM
The proverb states: “Knowledge is better than riches.” Therefore more information is needed. There is a need to continue to uncover potential risk factors, barriers, and enablers for stress and violent behavior. Expanding on existing information systems, creating new ones, and exploring for answers will involve engaging multidisciplinary research teams. Developing a multidisciplinary platform through which information from communities can be collected and analyzed will foster better understanding and allow anecdotes to be viewed as science. The benefits of viewing an issue/ problem from multiple perspectives hastens the solution(s). To better understand the issues that may affect the critical periods in brain development, i.e., stress and violent behavior, there is a need to continually ask the right questions. The third component of OPP involves the creation of multidisciplinary research efforts that would ask the questions, generate the solutions, and subsequently evaluate them. One of these efforts is a city-wide Weapon-Related Injury Surveillance System. In Philadelphia, nonfatal weapon-related injuries are reportable by law to the health department in the same manner as tuberculosis, AIDS, sexually transmitted diseases, and other reportable diseases. Philadelphia may be the first city to pass such a law mandating another discipline other than criminal justice to collect and analyze data on violent behavior outcomes. This process will offer information on variables traditionally not collected [24]. The Philadelphia Interdisciplinary Youth Fatality Review Team (PIYFRT) is the other effort. The PIYFRT consists of two multiagency child death review teams that review the deaths of all youth, 21 years of age and under, who die in Philadelphia [25]. This process allows the creation of prevention policies and guidelines. Such strategies include domestic violence training for all school nurses, a comprehensive death scene protocol for all unexplained infant deaths, a mandatory program for first-time juvenile violators of the Uniform Firearm Act, etc. Both processes have proven that, when shared with practitioners, data or information will augment efforts to better understand the complexities of violent behavior and enhance strategies to reduce it. The caveat of course is that this is still challenging and not always clear. But, the proverb states, “If you are building a house and the nail breaks, do you stop building or do you change the nail?” Society must continue to change the nails.
The evaluation process, or assessing the effectiveness of any and all efforts, is difficult. There is a need to develop benchmarks and outcomes allowing for the realities of the community. The proverb states: “Truth and morning become light with time.” Evaluating the successful development of children into responsible adults through a nurturing environment has to be done efficiently (truth) and with caution (time). Many of the instruments used for assessment do not take into consideration the sociocultural context of child development within individual communites. What is needed is an evaluation scheme structured so it could serve as a template for the visual representation of functional responsible development or measurable youth behaviors. Such behaviors would include loyalty to the community, respect for others and elders, excellent health, honor of self, appropriate sexuality and spirituality, etc. [26]. This type of scheme could be used by everyone and would serve as a vital element within the challenge to ensure the successful development of children. Many efforts at evaluating violence are based on measuring knowledge, attitudes, and psychosocial/cultural behavioral factors. Studies range from observing how individuals and families interact within a community to surveying communities on their perceptions of violence and safety. The verdict is still out as to what will make the difference. As the wait continues for good outcome evaluation, process measures or objectives are acceptable and in many instances more understandable. They offer fuel for keeping many organizations and community efforts going. The OPP framework has three major objectives: 1. fostering long-term collaborations that work, 2. ensuring continual positive messages, and 3. translating the quality and quantity of data/information to enhance multidisciplinary community-based research efforts. Meeting these objectives will result in the reduction of violent behaviors. All three of the framework components will lead to solutions but together they yield community-based, comprehensive efforts that are likely to be successful. Creating a nurturing environment for children is necessary, and this framework offers cities/communities a method for action. The proverb states: “He who upsets a thing should know how to rearrange it.” Society’s challenge echoes Operation Peace’s challenge, which is to use the combined strengths of scientific knowledge, multidisciplinary skill, sustained commitment, cultural vitality, community support, and political will to enable children to achieve their potential through full and active lives, by understanding what it can do and then doing it.
WHAT CAN AND SHOULD SOCIETY DO? ACKNOWLEDGMENTS Special acknowledgments are given to Robert K. Ross, M.D., James Mills, and Ivan Juzang and also to Marie Onwuachi for assistance in preparing the manuscript.
14.
REFERENCES
15.
1. Capri J. Trauma sensitizes brain to stress. Clinical Psychiatry News, 1995 Nov. 2. Parens H. Aggression in our children. Northvale (NJ): Jason Arson, 1987. 3. Miedzian M. Boys will be boys: breaking the link between masculinity and violence. New York: Doubleday, 1991. 4. Sanders-Phillip K. The ecology of urban violence: its relationship to health behaviors in low-income black and Latino communities. Am J Health Promot 1996;10:308–17. 5. Onwuachi-Saunders C, Ross RK. The epidemiology of injury and violence: a public health perspective on violence prevention. In: Majumdar SK, Rosenfeld LM, Nash DB, Audet AM, editors. Medicine and health care into the twenty first century. (PA): Pennsylvania Acad. Sci., 1995;350–64. 6. Spreen O, Risser A, Edgell D. Development neuropsychology. New York: Oxford Univ. Press, 1995. 7. Heilman K, Valenstein E. Clinical neuropsychology. New York: Oxford Univ. Press, 1993. 8. McEwen BS, Angulo J, Cameron H, Chao H, Daniels D, Gannon M, et al. Paradoxical effects of adrenal steroids on the brain: protection versus degeneration. Biol Psychol 1992;31:177–99. 9. McEwen BS. The plasticity of the hippocampus is the reason for its vulnerability. Semin Neurosci 1994;6:239–46. 10. McEwen BS, Sapolsky RM. Stress and cognitive function. Curr Opinion Neurobiol 1995;5:205–16. 11. Meancy MS, Tannebaum B, Francis D, Bhatnagar S, Shanks N, Viau, et al. Early environmental programming of hypothalamic– pituitary–adrenal responses to stress. Semin Neurosci 1994; 6:239–46. 12. Donzinger SR, editor. The real war on crime. New York: Harper Perennial, 1996:210–3. 13. Moore MH, Prothrow-Stith D, Guyer B, Spivak H. Violence and intentional injuries: criminal justice and public health perspective on an urgent national problem. In: Reiss AJ, Roth JA, editors.
16. 17. 18.
19.
20.
21. 22. 23. 24.
25.
26.
215
Understanding and preventing violence, Vol. 4, Consequences and control. Washington: Natl. Acad. Press, 1994:167–216. 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. Lacerva V. Pathways to peace. Tesuque (NM): Heartsongs Publications, 1996. Prothrow-Stith D, Weissman M. Deadly consequences. New York: Harper Collins, 1991. Mercey JA, Rosenberg ML, Powell KE, et al. Public health policy for preventing violence. Health Affairs 1993;4:7–29. U.S. Department of Justice, Office of Juvenile Justice and Deliquency Prevention. Guide for implementing the comprehensive strategy for serious, violent and chronic juvenile offenders. Washington: U.S. Govt. Printing Office, 1993. Huesman LR. Psychological processes promoting the relation between exposure to media violence and aggressive behavior by the viewer. J Soc Issues 1986;42:125–39. Hennigan KM, Del Rosario ML, Health L, Cook TD, Wharton JD, Calder BJ. Impact of the introduction of television on crime in the United States: empirical findings and theoretical implications. J Pers Soc Psychol 1989;42:461–77. Centerwall, BS. Exposure to television as a risk factor for violence. Am J Epidemiol. 1989;129:643–52. Centerwall, BS. Television and violence: the scale of the problem and where to go from here. JAMA 267:3059–63. Juzang I, McLaurin P. The MEE report: reaching the hip-hop generation. (PA): MEE Productions, 1992. Onwuachi-Saunders C, Brooks C. A call to action: violent deaths are preventable when information is available. EMS J Emerg Care Rescue Transportat 1997;26:74–5. Onwuachi-Saunders C, West P, Berney D. Youth as victims of homicides: prevention of child homicide with an interdisciplinary youth fatality review team. In: Data needs in an era of health reform: Proceedings of the 25th Public Health Conference on Records and Statistics and the National Committee on Vital and Health Statistics 45th Anniversary Symposium. Washington. [DHHS Publication No. (PHS) 1995;96-1214, 25–29] Onwuachi-Saunders C, Clark N. Fostering growth towards communicality: an evaluation scheme for child emergence. [Manuscript in preparation]
PREVENTIVE MEDICINE ARTICLE NO.
A Framework for: What Can and Should Society Do? Chukwudi Onwuachi-Saunders, M.D., M.P.H.,*,1 Cimon A. Brooks, M.B.A.,* and Glenwood C. Brooks, Jr., Ph.D.† *Philadelphia Department of Public Health, 1600 Arch Street, 7th Floor, Philadelphia, Pennsylvania 19103; and †HealthSouth Chesapeake Rehabilitation Hospital, 220 Tilghman Road, Salisbury, Maryland 21801
Researchers strive to better understand the critical periods of brain development. Findings generate clearer descriptions of what the critical periods are and suggest that stress, aggression, and violent behavior affect the development process. But the question remains as to what can and should society do to nurture children through these periods and to support their continued growth and development. Operation Peace in Philadelphia, an urban community-based, violence prevention/reduction initiative using the principals of public health, represents a framework for generating fresh attitudes and innovative support systems that will nurture children through the critical periods of brain development and beyond. This framework enhances understanding of the complexities of societal issues such as violent behavior and uncovers and offers communal solutions. It is a link between research and its practical application—what society can do. Society’s challenge echoes Operation Peace’s challenge to use the combined strengths of scientific knowledge, multidisciplinary skills, sustained commitment, cultural vitality, community support, and political will to enable youth to achieve their potential, via full and active lives. q1998 American Health Foundation and Academic Press Key Words: violence; brain; research; critical period; nurture community; public health; strategies; children; prevention.
INTRODUCTION
Researchers strive to gain understanding of the “critical” periods in brain development. Findings reveal that physical changes in the brain may result from psychological stress. In animals this physical change presents itself as an alteration to the hypothalamic–pituitary– adrenal axis, resulting in stress sensitization [1]. Among humans it was documented as alterations in the hippocampal volumes of sexual abuse victims and Vietnam veterans suffering from posttraumatic stress 1
To whom reprint requests should be addressed.
disorder. Findings such as these among both animals and humans suggest the need to better understand the effects of factors such as stress, violence, and trauma on brain development [1]. Hostile destructiveness, a form of aggression described by Henri Parens, “is not present at birth.” What produces this type of behavior is the experience of “excessive unpleasure” (excessive pain or distress) [2]. This type of aggression is influenced by the relationships our children have within the social environments provided to them [2]. Others also report on the link between specific behaviors and the social environment as well as the development of psychologic responses associated with exposure to violence [3,4]. The question is, what can and should society do to prevent malformations to the brain associated with stress factors resulting from violent and aggressive behavior? Or, how can society nurture children and protect them from adverse factors in the environment? The answers to these questions are imperative given the disproportionate impact of violence on children today [2–4]. Violence, specifically interpersonal violence involving youth, has adversely affected the public’s health [5]. As the fifth largest city in the United States with a population of approximately 1.6 million, Philadelphia had a total homicide rate of 27.3 per 100,000 in 1995. Of all deaths of youths 0–21 years of age (662), homicides represented 18%. Males between the ages of 16 and 21 were the majority of victims and firearms were the leading weapon. Based on the thought as to what society can and should do about this type of behavior, a framework for consensus-driven solutions for violence prevention/reduction and peace promotion was developed. This framework would allow communities to tackle the deeply rooted and multifaceted issues surrounding interpersonal violent behavior and to enhance their efforts to find communal solutions [5]. The framework assumes: (a) the critical periods are sufficiently “wide” enough (i.e., breadth of maturity) to influence brain development; (b) brain development is
212
0091-7435/98 $25.00 Copyright q 1998 by American Health Foundation and Academic Press All rights of reproduction in any form reserved.
WHAT CAN AND SHOULD SOCIETY DO?
sufficiently plastic—the capacity in which the central nervous system can adapt or change after environmental stimulation—to modify thoughts and behavior; and (c) the possibility exists that the brain, by the process of diaschisis—a mechanism by which recovery occurs after damage—can correct or compensate for malformations, thus leading to minimization of violent thoughts and behavior [6–11]. Called Operation Peace in Philadelphia (OPP), it represents a city-wide, community-based, comprehensive, long-term approach. It uses public health principles to address interpersonal violence involving youth [5,8,12–18]. The structure involves the entire community. This allows attitudes and support systems to be tailored to protect youth and to develop a nurturing environment. Interpersonal violence—a societal issue—denotes that the community as a whole must work on the solutions. The goal is to be as inclusive as possible. The vision promises a significant reduction in violent behaviors, thus an enhanced quality of life for all. The mission entails establishing new ideals, beliefs, and lifestyles relating to interpersonal violence. The proverb states, “It takes an entire village to raise a child.” OPP’s philosophy is to strengthen “hope” within the community by echoing three principles: 1. Interpersonal violence is unacceptable and preventable. 2. Violence prevention/peace promotion is a marathon and not a sprint. 3. Every segment of the community must contribute to its solution. Strengthening hope within communities allows for the production of nurturing environments. The framework is made up of three components: a long-term Collaboration, a Media and Awareness Campaign, and a Data/Information System to enhance research and evaluation. Each component feeds and supports the others. THE COLLABORATION
The Collaboration is long-term and is composed of action teams. Changing behavior takes time, and all segments of the community have a role to play. The framework must provide the foundation for this to happen. In Philadelphia, this collaboration is made up of action teams derived from various segments of the community, e.g., media/arts, interfaith, legislation, business, teens, neighborhoods, and schools. The teams are charged with identifying, developing, and implementing immediate and long-term peace promotion, violence prevention/reduction strategies within their discipline (the players are all committed to collective action through community-based efforts).
213
Strategies involve efficient child care, teaching parenting skills to adults and children, incorporating stress reduction in the workplace, comprehensive health education curricula including life skills and anger management, adequate and safe housing, a 24hour Children’s Response Team for children who witness violence, etc. The collaboration represents everyone working on the problem. “When the spider webs unite, they can tie up a lion.” The goal is to create a nurturing environment (village) for all youth that will stimulate and support healthy behaviors and disallow negative ones. MEDIA AND AWARENESS CAMPAIGN
The negative impact of viewing violence on television has been well documented [19–22]. This, in addition to thoughtless and careless messages, affects behavior, especially youth behavior. Efforts should be developed to stop and counter the negative effects of the media and to emphasize its power to bring about positive change. The development of a city-wide media and awareness campaign based on the slogan “I hear what you say, but I see what you do” is another important component of the framework. This slogan represents the unspoken message behind much of youth behavior today. Youth behavior is reflective of adult behavior. Therefore, the target audience for the campaign encompasses all adults and adult youth service providers. The goal is to disseminate the message that adults are collectively responsible for youth. Adults/parents/caretakers are the “first” teachers. Aesop’s fable The Crab and His Mother highlights this. In the fable the old crab asks her son to walk straight. Her son replies, “Show me how and I’ll follow your example.” The old crab tries in vain and then realizes how foolish she was to find fault with her child. Many youth are OK, and they need to hear this regularly through “recovery-type” messages [23]. These are often missing from traditional media channels. Although targeted to youth, these messages encourage and support positive behavior change and subsequently have a positive effect on all of society. The Philadelphia experience highlighted the need to better understand the effects of inappropriate messages but, most importantly, how to develop counter messages. Innovative positive messages are ideal and benefit the greater society if they are inclusive. For example, a message targeted to teenage mothers encouraging nurturing may say: “Talk to your baby, touch your baby, feed your baby . . .” This type of nurturing message could also benefit all children and therefore could say “Talk to your child, touch and feed your child daily.” Messages targeting adults on reading to children could say, “read or tell stories to your child daily.” This would include communities with high illiteracy rates or strong
214
ONWUACHI-SAUNDERS, BROOKS, AND BROOKS
verbal communication. The importance of talking to children can never be underestimated. Inclusive messages help produce nurturing environments for all children. THE DATA/INFORMATION SYSTEM
The proverb states: “Knowledge is better than riches.” Therefore more information is needed. There is a need to continue to uncover potential risk factors, barriers, and enablers for stress and violent behavior. Expanding on existing information systems, creating new ones, and exploring for answers will involve engaging multidisciplinary research teams. Developing a multidisciplinary platform through which information from communities can be collected and analyzed will foster better understanding and allow anecdotes to be viewed as science. The benefits of viewing an issue/ problem from multiple perspectives hastens the solution(s). To better understand the issues that may affect the critical periods in brain development, i.e., stress and violent behavior, there is a need to continually ask the right questions. The third component of OPP involves the creation of multidisciplinary research efforts that would ask the questions, generate the solutions, and subsequently evaluate them. One of these efforts is a city-wide Weapon-Related Injury Surveillance System. In Philadelphia, nonfatal weapon-related injuries are reportable by law to the health department in the same manner as tuberculosis, AIDS, sexually transmitted diseases, and other reportable diseases. Philadelphia may be the first city to pass such a law mandating another discipline other than criminal justice to collect and analyze data on violent behavior outcomes. This process will offer information on variables traditionally not collected [24]. The Philadelphia Interdisciplinary Youth Fatality Review Team (PIYFRT) is the other effort. The PIYFRT consists of two multiagency child death review teams that review the deaths of all youth, 21 years of age and under, who die in Philadelphia [25]. This process allows the creation of prevention policies and guidelines. Such strategies include domestic violence training for all school nurses, a comprehensive death scene protocol for all unexplained infant deaths, a mandatory program for first-time juvenile violators of the Uniform Firearm Act, etc. Both processes have proven that, when shared with practitioners, data or information will augment efforts to better understand the complexities of violent behavior and enhance strategies to reduce it. The caveat of course is that this is still challenging and not always clear. But, the proverb states, “If you are building a house and the nail breaks, do you stop building or do you change the nail?” Society must continue to change the nails.
The evaluation process, or assessing the effectiveness of any and all efforts, is difficult. There is a need to develop benchmarks and outcomes allowing for the realities of the community. The proverb states: “Truth and morning become light with time.” Evaluating the successful development of children into responsible adults through a nurturing environment has to be done efficiently (truth) and with caution (time). Many of the instruments used for assessment do not take into consideration the sociocultural context of child development within individual communites. What is needed is an evaluation scheme structured so it could serve as a template for the visual representation of functional responsible development or measurable youth behaviors. Such behaviors would include loyalty to the community, respect for others and elders, excellent health, honor of self, appropriate sexuality and spirituality, etc. [26]. This type of scheme could be used by everyone and would serve as a vital element within the challenge to ensure the successful development of children. Many efforts at evaluating violence are based on measuring knowledge, attitudes, and psychosocial/cultural behavioral factors. Studies range from observing how individuals and families interact within a community to surveying communities on their perceptions of violence and safety. The verdict is still out as to what will make the difference. As the wait continues for good outcome evaluation, process measures or objectives are acceptable and in many instances more understandable. They offer fuel for keeping many organizations and community efforts going. The OPP framework has three major objectives: 1. fostering long-term collaborations that work, 2. ensuring continual positive messages, and 3. translating the quality and quantity of data/information to enhance multidisciplinary community-based research efforts. Meeting these objectives will result in the reduction of violent behaviors. All three of the framework components will lead to solutions but together they yield community-based, comprehensive efforts that are likely to be successful. Creating a nurturing environment for children is necessary, and this framework offers cities/communities a method for action. The proverb states: “He who upsets a thing should know how to rearrange it.” Society’s challenge echoes Operation Peace’s challenge, which is to use the combined strengths of scientific knowledge, multidisciplinary skill, sustained commitment, cultural vitality, community support, and political will to enable children to achieve their potential through full and active lives, by understanding what it can do and then doing it.
WHAT CAN AND SHOULD SOCIETY DO? ACKNOWLEDGMENTS Special acknowledgments are given to Robert K. Ross, M.D., James Mills, and Ivan Juzang and also to Marie Onwuachi for assistance in preparing the manuscript.
14.
REFERENCES
15.
1. Capri J. Trauma sensitizes brain to stress. Clinical Psychiatry News, 1995 Nov. 2. Parens H. Aggression in our children. Northvale (NJ): Jason Arson, 1987. 3. Miedzian M. Boys will be boys: breaking the link between masculinity and violence. New York: Doubleday, 1991. 4. Sanders-Phillip K. The ecology of urban violence: its relationship to health behaviors in low-income black and Latino communities. Am J Health Promot 1996;10:308–17. 5. Onwuachi-Saunders C, Ross RK. The epidemiology of injury and violence: a public health perspective on violence prevention. In: Majumdar SK, Rosenfeld LM, Nash DB, Audet AM, editors. Medicine and health care into the twenty first century. (PA): Pennsylvania Acad. Sci., 1995;350–64. 6. Spreen O, Risser A, Edgell D. Development neuropsychology. New York: Oxford Univ. Press, 1995. 7. Heilman K, Valenstein E. Clinical neuropsychology. New York: Oxford Univ. Press, 1993. 8. McEwen BS, Angulo J, Cameron H, Chao H, Daniels D, Gannon M, et al. Paradoxical effects of adrenal steroids on the brain: protection versus degeneration. Biol Psychol 1992;31:177–99. 9. McEwen BS. The plasticity of the hippocampus is the reason for its vulnerability. Semin Neurosci 1994;6:239–46. 10. McEwen BS, Sapolsky RM. Stress and cognitive function. Curr Opinion Neurobiol 1995;5:205–16. 11. Meancy MS, Tannebaum B, Francis D, Bhatnagar S, Shanks N, Viau, et al. Early environmental programming of hypothalamic– pituitary–adrenal responses to stress. Semin Neurosci 1994; 6:239–46. 12. Donzinger SR, editor. The real war on crime. New York: Harper Perennial, 1996:210–3. 13. Moore MH, Prothrow-Stith D, Guyer B, Spivak H. Violence and intentional injuries: criminal justice and public health perspective on an urgent national problem. In: Reiss AJ, Roth JA, editors.
16. 17. 18.
19.
20.
21. 22. 23. 24.
25.
26.
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