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Understanding the Health of U.S. Youth in Comparison to Youth in Other Countries

Table of Contents | Executive Summary | Introduction | Chapter 1 | Chapter 2 | Chapter 3 | Chapter 4 | Chapter 5 | Chapter 6 | What Was Left Out | Summary


In this chapter:
Violence | What Didn't We Know | References


International studies comparing death rates show that violence among U.S. youth is a much more severe problem than in other countries. A multi-year analysis limited to 26 industralized published in 1997 showed the U.S. child homicide rate (children and youth <15 years old) to be five times higher than the rate of all other countries combined.1 The suicide rate was twice as high as the other countries combined. U.S. children and youth accounted for 86 percent of all firearm deaths occurring in all the countries. Of all firearm-related deaths of children under age 15, 55 percent were reported as homicides, 20 percent as suicides, 22 percent as unintentional, and 3 percent as of undetermined intent. In 1999, homicide and suicide were ranked second and third among causes of death of U.S. youth at ages comparable to those in the HBSC study, following only death rates for unintentional injury.2

Although the homicide rates among U.S. youth have decreased since the 1997 international study,1 a more recent WHO report of all counties still finds higher rates of death from violence in the U.S. than in other industrialized countries.3 The WHO comparisons for 2000 show that, apart from the U.S., where the youth and young adult homicide rate was 11 per 100,000, most countries with homicide rates above 10 per 100,000 are either developing countries or those experiencing rapid social and economic changes.3 Countries with low rates tend to be in Western Europe; several have fewer than 20 homicides a year.

Suicide fatalities and associated morbidity are more difficult to quantify in existing data systems in the U.S. and other countries.3 The WHO report comparison of youth suicides found the U.S. to have 241 suicides among 5- to 14-year-old males in 1998, for a death rate exceeded only by the Russian Federation, the Ukraine, Romania, Poland and the United Kingdom. The rate was lower for females at ages 5-14, as it is in most countries, but the U.S. rate is still among the highest. Data on injury from non-fatal violence are also difficult to obtain, either nationally or at an international level, although it is estimated that for every youth homicide there are approximately 20-40 victims of youth violence receiving hospital treatment.3

The high mortality rates from homicide and suicide among U.S. youth compared to other countries, including a number of shooting deaths in U.S. schools, raise serious concerns about related behaviors among our youth.4,5 While encouraging declines in homicide and other violent crimes have been observed over the last decade, rates of aggravated assault and self-reports of non-lethal violence remain high. Aggressive violence by youth toward others in the U.S. is described in depth in the Surgeon General's Report on Youth Violence. For U.S. adolescent suicide behavior, the known etiology (associated primarily with depressive symptoms or anxiety), risk factors, and behavioral attributes are described in the Surgeon General's Report on Mental Health.5 To understand youth violence within the context of health-related behavior, a useful definition of violence is: the threatened or actual use of physical force toward another person or group, or on oneself, encompassing acts that may be reactive or proactive, criminal or noncriminal, acts that can occur within the context of other problem behaviors, and acts that can result in lethal and nonlethal outcomes.3,6

The Surgeon General's Report on Youth Violence emphasized that there may be two general onset trajectories, or developmental pathways, for aggressive youth violence-an early one, in which violence begins before puberty, and a late one, in which violence begins in adolescence.4 Most aggressive youth violence begins in adolescence and ends with the transition into adulthood.3,4,7 Youths who become violent very early generally commit more crimes, and more serious crimes, for a longer time. Risk and protective factors vary in predictive power depending on when during the course of development they occur. As children develop, some risk factors will become more important and others less important.

Risk factors associated with the potential for youth violence at the individual level include biological, psychological, and behavioral characteristics.3 To varying degrees they may be influenced by family, peers and other social or cultural factors. During adolescence, violent behavior among youth may be one component of a syndrome that may include drugs, alcohol, precocious sex, and other problems.7,8 Violence in the media is among cultural factors influencing youth, and there is evidence linking watching violence in television and movies as an adolescent and violent behavior as an adult.3,9,10 While serious and lethal violence are extreme behaviors, other forms of aggression are recognized as part of the spectrum requiring intervention to prevent physical and psychological injury.4,11

Aggressive behavior may take many forms, ranging from that most likely to be lethal- shootings-to physical fights and bullying, which may be associated with both injury and serious psychological effects.12 The 2001 CDC Youth Risk Behavior Survey (YRBS) of students in grades nine to twelve found that 29 percent of boys and 6 percent of girls reported carrying a weapon in the past 30 days; 43 percent of boys and 24 percent of girls were in at least one physical fight on school property in the past year; and 5 percent of males and 3 percent of females were injured in a physical fight.1 Seven percent of high school students felt too unsafe to go to school on more than one of 30 days preceding the survey.

As the most common form of interpersonal violence in adolescence, physical fighting often precedes substance use and other problem behaviors.2,3 The YRBS estimates that 50 percent of ninth grade males and 30 percent of females had one or more physical fights during the preceding year and rates decreased in each succeeding year as students grew older.14 Little national prevalence information is available for fighting behavior in the younger years, but Nansel et al. find that according to U.S. HBSC data at grades six to ten, fighting behavior is strongly associated with bullying involvement, but less prevalent.12

The U.S. HBSC survey data were used to describe the prevalence and psychosocial adjustment of students who are bullies, bullied, or both a bully and a target of bullying.12 Bullying behavior, as distinct from fighting, is defined by an implicit imbalance of power.4 About 30 percent of U.S. students in grades six to ten report moderate or frequent (weekly) involvement in bullying, either at school or away. Thirteen percent report bullying others, 11 percent report being bullied, and 6 percent report both bullying and being bullied. Prevalence of bullying involvement is higher among sixth to eigth grade students than among ninth and 10th graders Boys are more likely than girls to be both perpetrators and targets of bullying. Bullying may take both physical and psychological forms. Boys are more likely to be bullied physically while girls are more like to be recipients of rumors and sexual comments.

Other HBSC study countries asked only about bullying behavior at school, in contrast to the U.S., which asked multiple questions about bullying either at school or away. International HBSC data on bullying at school are shown at age 15 in this chartbook to be consistent; international comparisons at age 13, when bullying is more prevalent, are available elsewhere.3,5 Attributes of 15-year-old students approaching physical maturity who bully may be different than in younger students for whom early pubertal influences and feelings of vulnerability are higher.6

Only a few HBSC countries asked about weapon-carrying or fighting. The question on weapon-carrying defines weapons to include guns, knives, or clubs for self-defense because investigators in other countries determined that prevalence of carrying guns would be too low to provide statistically reliable estimates. The 2001 YRBS high school survey found that about one-third of U.S. high school students who report carrying a weapon were carrying a gun.14 Recent school shooting incidents in the U.S. have heightened anxiety and concern about school safety among students, parents, schools, and communities.6 Neither of the HBSC questions on weapons or fighting were limited to behavior only at school.

U.S. students rank eighth among countries for students who never or rarely feel safe. Only 38 percent of U.S. students always feel safe at school; 30 percent rarely or never feel safe, and a third sometimes or often feel safe. However, in only five countries did 50 percent or more of the students always feel safe at school. The majority of students across countries said they sometimes, rarely or never feel safe at school and an alarming two-thirds of students in Greenland and the Czech Republic report that they only sometimes, rarely, or never feel safe at school.

U.S. students rank about in the middle among students who are bullied sometimes, once a week, or more often combined. However, U.S. students rank in the top third (ninth) among countries for students who are bullied at least once a week or more often at 4.5 percent, following Lithuania, Germany, Greenland, Latvia, Estonia, and Switzerland. U.S. students are in the middle range for students who report being bullied only sometimes (22 percent). About three-fourths of U.S. 15-year-olds say they are not bullied or were bullied only once or twice in the current school term. Students reported a wide variation in the proportion having been bullied sometimes (54 percent in Lithuania compared to 11 percent in the Slovak Republic) or at least once a week or more (11 percent in Lithuania compared to 2 percent in the Slovak Republic and Sweden).

  Graph: "Do You Feel Safe At School?"[d]   Graph: "How Often Have You Been Bullied In School This Term?"[d]

The proportion of U.S. students who report bullying others once a week or more (5.5 percent) is similar to those who report being bullied, ranking among the top third of countries. However, 31 percent bully others sometimes, significantly more than U.S. students who report being bullied, but in the middle ranking of students from other countries. Half or more of the students in Austria, Germany, Lithuania and Switzerland report bullying others sometimes during the previous school term.

Graph: "How Often Have You Taken Part In Bullying Other Students In School This Term?"[d]

As described for U.S. students above, the prevalence of bullying behavior in all countries is higher among younger students than in 15-year-olds.12 At age thirteen, when bullying behavior is more common, U.S. students ranked seventh among all countries for bullying others at least once a week (data not shown).3

Only six countries queried students about fighting behavior: U.S., Sweden, Republic of Ireland, Portugal, Israel, and Estonia. U.S. students rank in the middle of these countries, with 27.9 percent having been in one to three fights and 7.0 percent in four or more fights. While the majority of students in six countries had not been in a physical fight during the past 12 months, approximately 40 percent had been in one or more fights. Students in the Republic of Ireland were most likely to have fought, with 38.4 percent having been in 1-3 fights and 9.3 percent in 4 or more fights.

Graph: "During The Past 12 Months, How Many Times Were You In A Physical Fight? (%)"[d]

Across countries, students who had been in a physical fight report they most often fought with someone known to the student, such as a friend, family member, or boyfriend/girlfriend, rather than a stranger. The highest proportions of fights are with a friend, followed by family members. Fighting with acquaintances or someone else they knew is also common, as is fighting with people across these relationship categories.

Graph: "The Last Time You Were In A Physical Fight, With Whom Did You Fight?"[d]

Only Flemish Belgium, Estonia, Hungary, Israel, Portugal, Republic of Ireland, and the U.S. asked about weapon-carrying. Three percent of U.S. students report carrying a weapon for self-defense once during the past month, while 8 percent had carried a weapon on two or more days. Though approximately 85 percent of students in seven countries had not carried a weapon in the past 30 days, a small proportion had carried a gun, knife, or club for self-defense, in most cases on more than one occasion. Students in Flemish Belgium and Israel appeared particularly concerned with personal safety: 15 percent and 13 percent, respectively, had carried a weapon on two or more days.

Graph: "During The Past 30 Days, On How Many Days Did You Carry A Weapon, Such As A Knife Or Club For Self Defense?"[d]

What Didn't We Know?

Overall, U.S. youth are no more likely to be involved in bullying others at school than students in many other European countries and Canada. However, U.S. students are among the higher ranking countries for frequent bullying (at least once a week) and, similarly, U.S. youth rank among the top third of all countries for being bullied frequently. In 1997-98, before the more recent deadly school shootings, U.S. youth were also among the top third of countries for rarely or never feeling safe at school. Among the few countries asking about fighting or weapon-carrying (gun, knife or club) for self-protection, U.S. students are no more likely to fight or carry weapons, but they are just as likely to fight with friends, family members or acquaintances, rather than with strangers.

The 2001 YRBS provides national prevalence estimates of fighting, bullying, weapon-carrying and feeling safe at school for grades nine to twelve, but it doesn't include data on younger students, among whom bullying and fighting are more common, nor does it place this behavior in the context of student relations with family, peers, and school.14 Violent behavior is monitored by the YRBS in the U.S. partly because of our concern about our high homicide and suicide rates when compared to other industrialized countries.1 These results from the international HBSC study show that our students are not the most violent nor most likely to be bullied, but we lead the world in rates of homicide and youth suicide, due to the greater lethality of the weapons used by students in the U.S. compared to other countries.

An analysis of homicides perpetrated by U.S. juveniles between 1981 and 1997 found that the rate of nongun-related homicides remained constant and that all of the increase was from gun-related incidents, indicating that the nature of youth violence had changed over this 25-year period.7 The relatively high U.S. ranking of frequent (> once a week) bullying or being bullied, but not in infrequent involvement in bullying, suggests differences in associated patterns of weapon-carrying. Analysis of the U.S. HBSC data on students involved in bullying shows strong associations with violent behavior, including weapon-carrying and frequent fighting (>4 physical fights in the previous year).8 Students involved in frequent bullying (as either the bully or the victim) were more likely than other students to report carrying a weapon for protection either at school or away. The likelihood of weapon-carrying was particularly high when students either bullied others or were bullied away from school grounds. Bullies (including bullies who are also bullying victims) were most likely to carry weapons for self-defense.

The HBSC survey was performed before the heightened alarm from the 1999 Columbine?9 and later school shootings, but U.S. students at ages 11-15 years in the HBSC still ranked among the highest third of countries in feeling unsafe at school. According to two studies of school shootings after the 1999 Columbine incident, perpetrators were likely to have felt bullied, persecuted or injured by others prior to the attack, with some of the abuse being long-standing and severe; many of them were likely to have expressed suicidal thoughts, plans or actual attempts before the event.10,11

As noted in the study on psychosocial correlates of bullying by Nansel et al., using U.S. HBSC data, bullies are more likely to find it easy to make friends while those who are bullied report more difficulty making friends, have poorer relationships with classmates, and feel more lonely.12 Individuals who are both a bully and a victim of bullying report poorer relationships with classmates and increased loneliness although they do not report difficulty in making friends. Comparisons showing that U.S. students are among the least likely to feel that other students are supportive is suggestive of alienation in the school environment related to friendship networks and groups who form for a sense of identity and protection.

Students may select friends who share their values and attributes, including delinquency or a perceived need for protection. Students may also loosely refer to others' friendship networks as gangs, attributing to them behaviors different from their own. 'Street' gangs may be more likely to be identified with violence, but a 1998 report from the U.S. Departments of Education and Justice on student perceptions of gangs they see at their schools found that about one-third of U.S. students at ages 12 to 19 identified either members of their own school or outsiders 'coming around' their school as 'street' gangs.12 Street gang presence as either students or 'outsiders' was estimated to occur in 37 percent of middle and high schools. Surveyed students identified 'street' gangs by various attributes such as having a name, spending time together, or wearing identifying clothing. Hispanic students were more likely to report the presence of gangs in their schools (61 percent), compared with 44 percent of black students and 33 percent of white students. Only 50 percent of students included commission of violent acts as one way of identifying 'street' gangs. This indicates that students often, but not always, associate the groups they call 'gangs' with violent acts and the study finds that street gangs may be involved in relatively small amounts of violence compared to overall criminal activity.

The HBSC data do not allow in-depth assessment of friendship networks as does the AddHealth study. Research from the longitudinal AddHealth study addresses the multifaceted nature of friendship networks, including their association with peer delinquency, an adolescent's own delinquent involvement, and feelings of isolation or exclusion.13 The density of the peer network and an adolescent's own centrality and popularity in the network may indicate the degree of identity and belonging that the group provides. Group membership may be fluid, changing over the school year. The AddHealth study also finds that while a student might claim to be part of a friendship network, other students in that network may not identify the student as a member. Findings from the HBSC and other studies indicate that many students, particularly females, feel bullied through exclusionary tactics, belittling, or being subjects of rumors, sexual or other teasing.12 Males are bullied more often and more likely to be hit, slapped or pushed.

As with aggressive violence and homicide, suicide rates tend to be higher for males than females and are associated with cultural and racial/ethnic factors both in the U.S. and in other countries.3,5 Not only may adolescents who are recipients of bullying or anti-social behavior be more likely to be vulnerable to depression and isolation associated with suicidal behavior, but they may be more likely to exhibit 'acting-out' - such as truancy from school, declining school grades, substance abuse, or violence.3,5

The higher proportion of males involved in physical bullying is consistent with the higher prevalence of physical fighting among males than females. This is demonstrated in an analysis of U.S. HBSC data by Nansel et al. correlating frequent bullying, fighting and weapon-carrying.21 Students report the highest proportion of fights as occurring among friends and family, followed by fights with other acquaintances. This fighting behavior is consistent with the relative lack of supportive peer and family relationships addressed in earlier chapters and with follow-up community studies reported for U.S. youth and in other countries.3 The international WHO report on youth violence suggests that the basic need to belong to a group and create a self-identity is also an underlying feature of 'gangs' worldwide, whose composition range from mainly social groupings to organized criminal networks.3

Distinguishing between troublesome groups of youths and gangs involved in criminal behavior is critical to understanding youth violence. Gangs involved in criminal activity defined by distribution of illicit drugs, violence and/or robbery and weapon-carrying may be a contributing factor in the higher homicide rates in the U.S. than in other countries. An overview of youth gangs by the U.S. Office of Juvenile Justice and Delinquency Prevention notes 'street' gangs are more likely to recruit adolescents who own firearms, and gang members are more than twice as likely as non-members to own a gun for protection, more likely to have peers who own guns for protection, and more likely to carry their guns outside the home.14 However, the overview notes that violence is a rare occurrence in proportion to all gang activities and most gang violence occurs between gangs, rather than against outsiders. The overview and the 2002 WHO report cite follow-up studies related to gang activity and summarizes risk factors during early adolescence that may predict later gang membership: “youth who grow up in more disorganized neighborhoods; who come from impoverished, distressed families; who do poorly in school and have low attachment to school and teachers; who associate with delinquent peers; and engage in various forms of problem behaviors.”3,27

The studies cited above measured risk factors based on community, family, school, peer group and individual attributes. Chapters 3 and 4 of this report discussed HBSC findings that show comparatively high proportions of U.S. students struggling with family and peer relations and feeling that they are not in a supportive school environment. These findings are related to the development of networks and resources that can lead to or prevent violence. For example, the finding that a high proportion of U.S. students find other students not kind or helpful is pertinent to the establishment of positive, pro-social friendship networks and anti-social and gang behavior both at school and away. The early role of the family has also been stressed before, including the influence of the home environment on outcomes associated with violence. Adolescents with easy access to guns, alcohol, tobacco, and illicit substances have an increased risk of suicide, involvement in interpersonal violence and substance use.26 One nationally representative study of girls at grades 5 through 12 who were physically or sexually abused in early childhood finds this abuse predicts such adolescent outcomes as severe depressive symptoms, increased reporting of life stress symptoms, substance abuse, and fair to poor health status.15 These health symptoms and behaviors are also reported in relative high proportions among U.S. youth compared to other HBSC countries, suggesting that the effects of violence on youth health and behavior should be investigated more thoroughly.

Other studies on youth violence stress the importance of early family influences, particularly as they shape developmental pathways and violence trajectories.5,7 This research shows that children learn from the kind of environment that adults or other caretakers unconsciously create in the family. Family environments that include harsh discipline, child maltreatment, spousal/partner violence, and a climate of conflict and hostility place children at increased risk for later violence. Children who have been physically abused at home are more likely to exhibit aggression in school and in the community and to engage in serious violent behavior as adolescents. Studies tracking the developmental pathways of violent behavior and the context in which the behavior occurs demonstrate the complex nature of biological, psychosocial and environmental factors through transitions from early childhood to adolescence.7

Previous sections of this report suggest that U.S. cultural, social, and structural trends increase the difficulty of providing families and students with supportive environments that reduce violence. Family structure in the U.S., with higher proportions of single-parent and step-families, may provide more stressors and make it more difficult for families to access school and community resources. Schools and communities may be particularly challenged with more racial and ethnic diversity than most of the other countries included in the HBSC study and by the challenges inherent in the 50 percent increase in the population of children of immigrants during the 1990's.16 Yu, et al’s analysis indicates that U.S. adolescents raised in non-English speaking homes are particularly vulnerable to behaviors associated with violence.17 In these analyses, these students are more likely to have difficulty making new friends, be involved in bullying (either as a victim, a bully, or both), not feel accepted by other students, not feel as though they belong at school, and have difficulty talking to either parent about things that bothered them. They feel that their parents are less supportive and less willing to help with school problems or talk with teachers. Some of the associations of school environment with overall health and well-being, fitness, family and peer relations, substance use and violence demonstrated from the HBSC and other studies should be examined further in special populations.

The school environment, particularly lack of connectedness, and feelings of non-support from other students, teachers, and parents is highly associated with alienation and participation in violence towards the self or others.18,19 The HBSC's measures of student perceptions of the school environment have been studied extensively by researchers in other countries, partly due to concerns with effects of bullying and alienation of students both at school and in the community.20 Since relatively high proportions of U.S. students appear to struggle with real and perceived violence, these data suggest the need to investigate both the social and structural aspects of school and community life in the U.S. that detract from the creation of supportive school and family environments.


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  3. World Report on Violence and Health. Geneva, Switzerland: World Health Organization, 2002. (Available at: last accessed October 3, 2002.)
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  23. Howell JC, Lynch JP. Youth gangs in schools. Washington, DC: Office of Justice Programs, Office of Juvenile Justice and Delinquency Prevention. Juvenile Justice Bulletin, August 2000.
  24. Haynie DL. Delinquent peers revisited: Does network structure matter? American Journal of Sociology 2001;106:1013-57.
  25. Howell JC. Youth gangs: An overview. Washington, CD: Office of Justice Programs, Office of Juvenile Justice and Delinquency Prevention. Juvenile Justice Bulletin, August 1998.
  26. Diaz A, Simantov E, Rickert VI. Effect of abuse on health: Results of a national survey. Arch Pediatr Adolesc Med 2002;156:811-817.
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Table of Contents | Executive Summary | Introduction | Chapter 1 | Chapter 2 | Chapter 3 | Chapter 4 | Chapter 5 | Chapter 6 | What Was Left Out | Summary

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