Preventing Youth Violence: Twenty Years Later (Enhanced Findings and Treatment Interventions, Part 2)

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We are not helpless in the face of the crisis.

Twenty years ago I published a book (that link goes to the new edition, with additional information by scrolling down here) on a topic of national concern: preventing youth violence. The American Mental Health Foundation (AMHF) requested I write two blogs that highlighted the contents in the book. The first blog reviewed the early/serious/urgent warning signs of youth violence. The second blog focused on a series of five treatment interventions to treat assailant youth to restore them to more normal development and, thus, to reduce the risk for violence to the community.

Most abused assailant children have themselves been abused and victimized before age 6 but do not themselves usually become violent and aggressive until after age 12. This gives society 6 years to address and treat these abused children and prevent subsequent youth violence. Whereas older child-assailants can be successfully treated by the five interventions noted above, the violence has already occurred. Treating the younger children early on brightens their lives and reduces the risk of subsequent aggression.

Two decades later, I have updated the original book to reflect clinical and neuroscience advances in understanding more fully why some youth become more violent and how to further improve treatment (Flannery, 2021). AMHF again invited me to write two blogs highlighting these important advances.

During these past 20 years, there have been several steps forward. These include four new areas of development that were not included in the first edition: the impact of maternal stress on the embryo in utero, significant advances in our understanding of the adolescent brain, the development of the Adverse Childhood Events Scale (ACE), and the important role of toxic stress.

Over these same years, there has been important increased understanding of 3 key topics covered in Preventing Youth Violence: A Guide for Parents, Teachers, and Counselors: posttraumatic stress disorder (PTSD), substance abuse, and the importance of basic childrearing styles in caring attachments. The preceding first blog of September 18, 2019, covered the four new issues. This one reviews the new findings in the areas of enhanced understanding and concludes with new treatment implications based on the findings in these seven areas.

Enhanced Understanding

PTSD. The first of the three enhanced areas is PTSD. There have been two major events of note. The first includes an expansion of the symptom cluster of traumatic events from three groupings to four. These include the original three clusters: the physical symptoms (e.g., heightened anxiety levels (exaggerated startle response), the intrusive symptoms (e.g., recurring thoughts of the event, nightmares, flashbacks), and the avoidant symptoms (e.g., avoiding the scene of the violence, withdrawal from a more active life). In 2013, the American Psychiatric Association included a fourth cluster of symptoms that is comprised of any longstanding, chronic negative thoughts or feeling states that have arisen in response to the traumatic incident.

The second area of important new trauma research includes the development of the concept of emotional abuse. Advances in neuroscience have taught us the common phrase, “sticks and stones may break your bones but words will never hurt you,” is wrong. Emotional abuse may result in marked alterations in brain functioning. Originally thought of as verbal abuse, emotional abuse has now been expanded to include yelling, name-calling, insults, derogatory statements, threats, humiliation, having a child shoulder adult responsibilities, and the like. It may result in significant psychological trauma, just as physical or sexual abuse may. Emotional abuse may turn out to be the most severe form of PTSD, as it is usually continuous.

Substance Abuse. We have seen earlier that substance abuse is one of the serious warning signs of youth violence. Recent research has continued to document that disrupted attachments, inadequate parenting, and/or untreated PTSD often leads to substance abuse and other forms of addictive behaviors, including sexual addictions, pathological gambling, and other forms of high risk behaviors that are associated with youth violence.

One question that has received continuing attention is why addictions worsen over time. This is turning out to be a most complex issue. At its center is a neurotransmitter chemical found in the brain known as dopamine. Dopamine searches out pleasurable experiences for the individual. When the individual experiences pleasure, the brain remembers this and the dopamine will again seek out this type of pleasure. However, with repeated episodes of pleasure searches, the body’s production of dopamine is reduced and the individual must work harder to obtain the original intensity of pleasure. In this way, the addiction worsens at a biological level and that affects a person’s individual psychological desire for more. This process is now understood to include other components of brain functioning in addition to the dopamine. In any case, this complex neurobiology of the brain suggests why “will power” to stop by itself is not adequate for many individuals.

Caring Attachments. Caring attachments give life itself through birth, provide for the survival of the newborn, and teach the child coping skills to ensure its ability to survive over time. We are learning that, if this process is disrupted or does not occur at all, youth violence is a frequent outcome. Recent research has documented four parenting styles that are rated for both warm parental support and strategies for controlling and educating children. The four styles are normal secure, anxious, avoidant, and disorganized attachments styles.

In the normal secure attachment, the parent/caregiver is emotionally close to the child, teaches the necessary coping skills, and fosters a prosocial value system for a normal life. The ambivalent style has limited closeness with inconsistent parental communications, which the child is unable to predict. Social skills are not learned and, over time, the child becomes anxious.

In the avoidant style, parents are emotionally unavailable and rejecting. Prosocial coping skills are not learned, and the child avoids others. The disorganized style is characterized by extreme erratic behavior of the parents. The child becomes confused in the chaos, and adequate skills and a prosocial value system are not learned.

The last three types of attachment styles often result in youth violence.

Treatment Implications

Both books on youth violence (Flannery, 2012a, 2021) list five basic steps to restore angry, violent youth to more normal growth and development. They are especially helpful, if implemented before age 12. The steps include: safety first, restoring attachments, restoring mastery, special resources for some psychiatric conditions (e.g., acute suicidal ideation), and instilling or restoring a prosocial value system. These steps are as accurate and helpful today as they were when the first edition was issued.

What is new is the implications from the findings herewith noted in parts 1 and 2. Clinical experience and research has taught us the central importance of caring attachments. Teachers and counselors need to focus on building caring attachments. Those working with these children need to know which adverse childhood events the youngster has experienced. The needs of the child reared in anxious, avoidant, and disorganized homes will differ. Common to all of them is the need to learn to trust others. Situations of trust need to be created. Explain why it is safe to trust in the current circumstances, encourage he child to interact, and explore that there were no harmful consequences.

In addition to the importance of repairing the quality of caring attachments, science is continuing to learn that many of our violent youth were themselves victims of some form of violence that was never addressed. Counselors should routinely assess for the presence of a history of untreated PTSD and, if present, see that it is addressed. If agencies are assisting violent youth, the agencies may want to consider an in-house crisis-counseling program to respond to violent incidents, when they occur. Adequate treating of victim incidents precludes those incidents from becoming additional incidents of untreated PTSD. The Assaulted staff Action Program (ASAP) (Flannery, 2012b) is a system-wide, peer help, crisis counseling approach to address the psychological aftermath of violence. It is the most widely researched crisis-intervention program in the published literature, and it has been chosen as a best innovative practice by the federal governments of Canada and the U.S.

Recent clinical and experimental research has taught us the importance of toxic stress and substance abuse as contributing factors in youth violence. Children should be assessed for the presence of these issues and, if present, each ought to be addressed in the child’s treatment plan.

* * *

Our epidemic of youth violence continues but it need not be this way. Each assailant child has been abused in some way and is hurting. Addressing this pain early on before the child erupts in violence treats the child’s pain, avoids traumatic events for others, reduces the risk for violence, and enhances a sense of safety for the community.

Youth violence need not be a war that never ends. Let us work together to prevent youth violence before it begins.


1. Flannery, R. B. Jr. Preventing Youth Violence: A Guide for Parents, Teachers, and Counselors. Riverdale, New York: American Mental Health Foundation, 2012a.

2. Flannery, R. B. Jr. Preventing Youth Violence Before It Begins. Riverdale, New York: American Mental Health Foundation, 2022.

3. American Psychiatric Association. Updated Diagnostic and Statistical Manual 5. Washington, D.C.: American Psychiatric Association, 2013.

4. Flannery, R. B. Jr. The Assaulted Staff Action Program: Coping with the Aftermath of Violence. Riverdale, New York: American Mental Health Foundation, 2012b.

Raymond B. Flannery Jr., Ph.D., FACLP, a licensed clinical psychologist, is Associate Professor of Psychology (Part Time), Department of Psychiatry, Harvard Medical School, as well as Adjunct Assistant Professor of Psychiatry, Department of Psychiatry, University of Massachusetts Medical School and Adjunct Professor of Psychology (Part-Time), the Woods College of Advancing Studies, Boston College. He is an internationally recognized and award-winning scholar and lecturer on the topics of violence, victimization, and stress management. Dr. Flannery is available for lectures and workshops, for all types and sizes of groups, and may be reached at The American Mental Health Foundation.

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