Linking Dating Violence, Peer Violence, and Suicidal Behaviors Among High-Risk Youth

Article Outline

• Abstract
• Introduction
• Methods
  • Data Collection
  • Measures
    • Date violence victimization and perpetration
    • Same-sex peer violence victimization and perpetration
    • Suicidal behaviors
  • Analysis
• Results
• Discussion
• Acknowledgment
• References
• Copyright

Background

Gaps in the understanding of how different types of violent behavior are linked have limited the ability to design violence prevention efforts that can address multiple types of violence. The objective of this study was to quantify the associations among suicide attempts, and date and peer violence victimization and perpetration and to determine any differences in these associations by gender.

Methods

Analyses, computed in 2006 and 2007, used data from the Youth Violence Survey conducted in 2004. This survey was administered to over 80% of public school students in grades 7, 9, 11, and 12 (N=4131) in a high-risk, urban school district. Analyses were restricted to adolescents who dated in the past year (n=2888). Five forms of violent behaviors (i.e., dating violence perpetration, dating violence victimization, peer violence perpetration, peer violence victimization, and suicide attempts) were examined.

Results

Peer violence victimization was the most common type of violence reported (33.0%), followed by date violence victimization (30.7%), peer violence perpetration (29.9%), date violence perpetration (24.8%), and suicide attempts (11.2%). Among all students, 9.8% reported involvement in at least four of the five violent behaviors examined. All five forms of violent behaviors were associated. The highest ORs were observed for victimization and perpetration within either the dating or peer context. However, associations across contexts were also observed.

Conclusions

There is a substantial overlap among different forms of violent behavior, suggesting that additional research is needed to better understand the factors that contribute to involvement in multiple forms of violence.

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Introduction 

Youth in the United States frequently experience several types of violence, including interpersonal (e.g., peer and dating violence) and self-directed violence (e.g., suicidal behavior). The results from the 2005 administration of the national Youth Risk Behavior Survey to nearly 14,000 high school students provide useful data on the prevalence of different types of violence.¹ The results indicate that 36% of students reported involvement in at least one physical fight in the past 12 months and 9% reported being “hit, slapped, or physically hurt on purpose” by a boyfriend or girlfriend in the past 12 months.¹ Serious thoughts of suicide were reported by 17% of students, and 8.4% reported making at least one suicide attempt in the past 12 months.¹ These behaviors and experiences can have immediate and long-term life-changing consequences since those who experience violence also may encounter significant psychological, social, and behavioral consequences that extend far beyond their risk for physical injuries.², ³ However, fatal outcomes of violence remain a significant problem among youth; homicide and suicide consistently rank as the second and third leading causes of death in U.S., respectively, among youth aged 15–24.⁴ In addition, there is evidence to suggest that many youth and adults who are exposed to one type of violence are at greater risk for experiencing another type of violence,⁵, ⁶, ⁷, ⁸, ⁹, ¹⁰, ¹¹, ¹², ¹³, ¹⁴, ¹⁵, ¹⁶, ¹⁷ and thereby compounding the risk for injury and other consequences.

Despite the obvious potential connection between using violence against dating partners and using violence against other peers, surprisingly few studies have focused on the extent to which adolescents who engage in violence with their dating partners also engage in violence with other peers.⁵, ⁶, ⁷ Previous studies have examined involvement in violent behaviors in different relationships,⁸ but have rarely assessed the specific overlap. Most of the studies that have examined violent behaviors across relationship types or contexts have focused on adults. In these studies, a strong positive association between perpetration of intimate violence and perpetration against someone other than an intimate has been reported.⁹ Among adolescents, one study shows a strong association between involvement in physical fights with someone of the same sex, and perpetration of dating violence among girls, but not boys.⁷ Another study found that adolescent boys who engage in peer violence are also at risk for perpetrating sexual aggression or dating violence.⁶ Additional research is needed to understand the association between dating violence and other peer violence and how this association differs by gender.

In addition to using violence against dating partners and other peers, many adolescents also engage in self-directed violence (i.e., suicidal behavior). Research suggests that there is a strong link between interpersonal violence (either as a victim or perpetrator) and suicidal behaviors², ³, ¹⁰, ¹¹, ¹², ¹³, ¹⁴ and that they frequently co-occur.¹⁵ One study reported that 11% of high school students had experienced both suicidal and violent behavior in the past year.¹⁵ Moreover, youth who have attacked others with a weapon,¹², ¹⁶ engaged in dating violence (particularly for boys),² or perpetrated sexual violence¹⁰ have been shown to be at higher risk for suicidal behavior. Likewise, adolescents who report suicidal behavior are more likely to also report involvement in physical fighting.¹⁷

Considerable gaps remain in the understanding of the extent to which youth who are involved in dating violence as a victim or perpetrator also are involved in other forms of violent behaviors. It is not known whether the associations among different forms of violent behaviors vary by gender. The current study examined the interrelatedness of different forms of violent behavior (i.e., dating violence, same-sex peer violence, and suicide attempts) among students who live in a community with high crime and poverty rates. The study also examined whether the associations among different forms of violent behaviors vary for boys and girls. This information is needed to guide the selection and focus of future violence prevention strategies and to inform how limited youth violence prevention resources are directed.

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Methods 

Data Collection 

The Youth Violence Survey: Linkages among Different Forms of Violence was administered to all public school students enrolled in grades 7, 9, 11, and 12 in an urban school serving students at disproportionately high risk of violence. The school district was identified and selected using community indicators of risk (i.e., poverty, unemployment, single-parent households, and serious crimes). School districts, in cities, were ranked by each indicator and then a combined ranking was created to identify the 20 cities with the highest community indicators of risk nationwide. The participating school district was among the highest 25 nationally in poverty, the highest 15 in single-parent families, the highest ten in rate of serious crime, and the highest 35 in rate of unemployment. Moreover, the selected school district was racially and ethnically diverse (Table 1) and located in a city with a population of less than 250,000. This district operated 16 schools at the middle and high schools levels, including alternative school. All 16 schools agreed to participate in the study.

Table 1. Comparisons of the characteristics of the student population and the subset of students who had dated in the past year

	Total sample (n=4131)		Adolescents who dated (n=2888)		Adolescents who did not date (n=1243)		p valuea
	n	%	n	%	n	%
Gender
Boys	1982	48.2	1378	47.9	505	47.4	0.79
Girls	2127	51.8	1500	52.1	560	52.6
Missing	22		10
Race/ethnicity
Hispanic	1809	44.9	1257	44.5	478	45.8	0.079
Non-Hispanic African	1119	27.8	774	27.4	294	28.2
American
Non-Hispanic white	907	22.5	667	23.6	211	20.2
Non-Hispanic other	193	4.8	127	4.5	60	5.8
Missing	103		63
Grade
7th	1484	36.1	821	28.6	570	53.2	<0.0001
9th	1114	27.1	823	28.6	254	23.7
11th/12th	1515	36.8	1231	42.8	247	23.1
Missing	18		13
Date violence
Perpetration	—	—	696	24.8	—	—	—
Victimization	—	—	877	30.7	—	—	—
Peer violence
Perpetration	1192	30.1	836	29.9	308	30.0	0.95
Victimization	1339	34.1	918	33.0	372	36.5	0.045
Suicide attempt	390	9.7	316	11.2	62	6.0	<0.0001

Prior to data collection, active, signed parental consent and student assent were obtained. Students 18 years and older and emancipated minors were allowed to consent for themselves. Parental permission forms were provided in English, Spanish, and other major languages as requested by the schools. Students received a $5 gift card for returning the parental permission form regardless of whether the parent approved or denied the student’s participation in the survey. Students who completed the survey received an additional $5 gift card. Data collection occurred in April and May 2004. Students voluntarily completed the anonymous, self-administered 174-item questionnaire in classrooms (Flesch–Kincaid grade-level score of 4.6) during a 40-minute class period. Students lacking parental permission or not wishing to participate were assigned individual deskwork by the classroom teacher. The questionnaire, an optically scannable booklet in multiple-choice format, was administered by field staff highly experienced in school-based survey administration. The survey was administered in English only.

All English-speaking students in the targeted grades were invited to participate in the study. However, students who could not complete the questionnaire independently (e.g., required the assistance of a translator or had cognitive disabilities that would prevent adequate understanding and responding to the survey) (n=151) were ineligible. Likewise, students who were no longer attending school (e.g., had dropped out, had been expelled, or were on long-term out-of-school suspension) (n=202), were ineligible. Of the 5098 students who met eligibility criteria, 4131 participated, yielding a participation rate of 81%. Participants were enrolled from four grade levels; 1491 in 7th grade, 1117 in 9th grade, and 1523 in 11th and 12th grades combined due to the low enrollment in each of those grades.

Measures 

All participants were asked if they had been on a date in the past 12 months. A date was broadly defined as “hanging out with someone, eating out, playing a game, watching a movie, or doing other things with someone they like.” The measures of victimization and perpetration of physical violence in dating and same-sex peer relationships within the past 12 months were adapted from previous research on adolescent dating violence¹⁸, ¹⁹, ²⁰, ²¹ and have been described elsewhere.²²

All those who had been on a date in the past 12 months were asked about their experiences with physical violence victimization and perpetration within dating relationships. The frequency of ten behaviors was assessed, with four response options ranging from “never” to “ten or more times.” Students were asked to report how often the person: scratched them; hit or slapped them; threw something at them that could hurt; slammed or held them against the wall; kicked them; pushed, grabbed, or shoved them; punched or hit them with something that could hurt; threatened or injured them with a knife or gun; forced them to have sex or do something sexual; or hurt them badly enough to need bandages or care from a doctor or nurse. Nine of these ten questions were worded either exactly like the original dating violence scale¹⁸ or slightly modified to combine questions that asked about similar behaviors. One question was added to assess whether the participant had received injuries requiring treatment. Directly following the victimization questions were identical questions about perpetration.

The same questions used to assess violence victimization and perpetration within dating relationships, were asked for same-sex peer relationships (e.g., strangers, friends, or other people they know). The same-sex peer violence perpetration and victimization scales included the identical ten behaviors assessed in the dating violence context.

All students were also asked: During the past 12 months, how many times did you actually attempt suicide?¹ Response options ranged from 0 to 6 or more times. Responses were coded to indicate any suicide attempt(s) versus no suicide attempt.

Analysis 

Analyses, conducted in 2006 and 2007, included eight parts: (1) evaluate and code the variables, (2) conduct factor analyses, (3) create dichotomous variables indicating any involvement in a particular violent behavior, (4) create dichotomous variables indicating any involvement in severe or moderate forms of violent behavior, (5) create a scale indicating the number of violent behaviors the students reported, (6) determine if involvement in violent behaviors varied by demographic characteristics or by dating status, (7) determine if there were statistically significant associations among different violent behaviors, and (8) determine if observed associations between violent behaviors varied for boys and girls.

The four violence perpetration and victimization scales had high reliability with Cronbach’s alphas ranging from 0.84 to 0.92. These scales were extremely skewed (skewness coefficients ranged from 5.9 to 7.3) and statistical analyses indicated extreme deviations from normality (Kolmogorov–Smirnov tests were significant at p<0.0001). Therefore, dichotomous measures were created for each of the four violence scales to indicate any involvement in the behavior in the past year. In addition to examining the overall physical violence score, previous research¹⁸ using the original scales also presented data using subscales based on the severity of violence. Factor analyses on each of the interpersonal violence outcome variables supported a two-factor structure (e.g., moderate and severe violence). The subscale indicating moderate violence included questions related to being scratched, hit, or slapped; slammed/held against a wall, kicked, and pushed; grabbed; or shoved (Cronbach’s alpha ranged from 0.87 to 0.89 across the four moderate violence perpetration and victimization scales). The subscale indicating severe violence included questions related to throwing something that could hurt, punched/hit with something that could hurt, threatened or injured with a knife/gun, sexual violence, and hurt badly enough to need bandages or care from a doctor or nurse (Cronbach’s alpha ranged from 0.80 to 0.88 across the four severe violence perpetration and victimization scales).

Another scale was created, ranging from 0 to 5, to indicate the number of different types of violent behaviors (including victimization, perpetration, and suicide attempts) that students reported.

Students who had dated were compared with students who had not dated on demographic characteristics (i.e., gender, race/ethnicity, and grade) and also the prevalence of involvement in violent behaviors using chi-square tests. Chi-square tests also were used to determine the associations between demographic characteristics and involvement in any of the five violent behaviors examined as well as the number of violent behaviors reported. For the chi-square tests, 0.05 was set as the p-value for statistical significance. Finally, logistic regression analyses adjusted for gender, grade, and race/ethnicity were used to determine the associations among all five violent behaviors. Analyses were also computed to determine if there were any significant interaction effects for gender or grade level in the associations among different forms of violent behaviors.

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Results 

Demographic characteristics of all study participants are reported in Table 1. Comparisons between those who had dated and those who had not dated showed that the two groups did not differ by gender or race/ethnicity. However, those who had dated were older, less likely to report peer violence victimization, and more likely to report suicide attempts than those who had not dated. All analyses in this report are based on those adolescents who had dated (n=2888).

Peer violence victimization was the most common type of violence reported (33.0%) followed by date violence victimization (30.7%), peer violence perpetration (29.9%), date violence perpetration (24.8%), and suicide attempts (11.2%). Demographic characteristics of those who reported any violence, any moderate violence, and any severe violence victimization or perpetration within date or same-sex peer relationships in the past year are reported in Table 2. Significant differences were observed for gender, race/ethnicity, and grade.

Table 2. Prevalence, demographic characteristics, and statistical differences^a in involvement in any, moderate and severe forms of violent behaviors in the past year among adolescents who had dated (n=2888)

Type of violent behavior reported in the past year
	Date violence perpetration (%)			Date violence victimization			Peer violence perpetration			Peer violence victimization			Suicide attempts
	Any	Moderate	Severe	Any	Moderate	Severe	Any	Moderate	Severe	Any	Moderate	Severe	Any
Total	24.8	22.5	11.0	30.7	27.1	13.8	29.9	27.3	19.2	33.0	28.7	19.7	11.2
Sex
Boys	18.6⁎⁎⁎	16.0⁎⁎⁎	9.7⁎	32.6⁎	29.4⁎⁎	13.4	32.8⁎⁎	29.7⁎⁎	23.2⁎⁎⁎	37.0⁎⁎⁎	31.5⁎⁎	24.1⁎⁎⁎	6.4⁎⁎⁎
Girls	30.3	28.3	12.1	28.8	24.9	14.0	27.3	25.2	15.3	29.5	26.1	15.7	15.4
Race/ethnicity	⁎							⁎		⁎	⁎
Hispanic	26.6	24.0	12.1	31.2	28.2	13.0	30.4	27.6	19.7	31.6	27.1	18.2	12.6
African American	25.8	24.1	11.1	31.3	27.8	14.3	30.5	28.7	20.4	31.4	27.0	20.0	8.7
White	20.5	18.6	8.7	27.5	23.7	14.2	28.8	25.9	16.8	37.6	33.6	21.9	11.3
Other	25.8	21.1	12.2	34.1	30.4	14.3	28.8	25.0	17.6	34.4	30.3	20.5	10.3
Grade			⁎⁎⁎				⁎⁎⁎	⁎⁎⁎	⁎⁎⁎	⁎⁎⁎	⁎⁎⁎		⁎⁎⁎
7th	23.2	21.4	10.5	29.5	25.2	14.2	30.7	28.4	18.3	37.4	32.3	21.6	14.0
9th	26.8	24.2	11.9	31.9	28.7	11.5	36.2	33.8	23.5	35.1	31.6	19.7	12.6
11th/12th	24.4	22.0	10.6	30.7	27.3	15.0	25.3	22.3	16.8	28.8	24.1	18.4	8.4

The number of different types of violent behaviors that students reported was also examined. The majority of students reported involvement, as a victim or perpetrator, in at least one type of violent behavior (58.5%); 21.0% were involved in one form of violent behavior, 17.4% were involved in two forms, 10.3% were involved in three forms, 8.1% were involved in four forms, and 1.7% reported all five violent behaviors. Involvement in multiple violent behaviors did not differ significantly by gender and race/ethnicity, but differed by grade. Younger students tended to report involvement in more violent behaviors in the past 12 months.

The results of the logistic regression analyses examining the associations among involvement in any forms of violent behaviors are presented in Table 3. There were strong associations among all forms of violent behavior. Those who reported date violence perpetration had significantly increased odds of also reporting date violence victimization (AOR=12.12; 95% CI=9.81–14.99), relative to those who did not report any date violence perpetration. Likewise, those who reported peer violence perpetration had significantly increased odds of also reporting peer violence victimization (AOR=9.05; 95% CI=7.47–10.95), relative to those who did not report any peer violence perpetration. The associations were also significant across contexts. For example, those who reported date violence perpetration had significantly increased odds of also reporting peer violence perpetration (AOR=4.90; 95% CI=4.03–5.96), relative to those who did not report any date violence perpetration. Involvement in any date violence victimization or perpetration in either date or peer context also increase the odds of attempting suicide attempts relative to those who did not report any peer or date violence. None of the associations observed in Table 3 differed by gender.

Table 3. Prevalence^a of involvement in any date or peer violence and suicide attempts and the associations^b between involvement in one violent behavior in the presence or absence of another form of violent behavior

	Outcome variables
	Any date violence				Any peer violence
	Perpetration		Victimization		Perpetration		Victimization		Any suicide attempts
Predictor variables	n	ORadj. (95% CI)c	n	ORadj. (95% CI)c	n	ORadj. (95% CI)c	n	ORadj. (95% CI)c	n	ORadj. (95% CI)c
Any date violence
Perpetration
No	—	—	17.7	1.00	21.5	1.00	26.9	1.00	8.2	1.00
Yes	—	—	69.8	12.12 (9.81–14.99)	55.0	4.90 (4.03–5.96)	51.4	3.24 (2.68–3.91)	20.4	2.62 (2.01–3.40)
Victimization
No	10.7		—	—	21.2	1.00	23.5	1.00	8.4	1.00
Yes	56.4		—	—	49.7	3.62 (3.03–4.32)	54.3	3.97 (3.33–4.73)	17.3	2.47 (1.92–3.17)
Any peer violence
Perpetration
No	15.8		21.8		—	—	18.4	1.00	8.6	1.00
Yes	45.6		50.6		—	—	67.5	9.05 (7.47–10.95)	17.6	2.35 (1.83–3.04)
Victimization
No	18.0		20.9		14.5		—	—	8.4	1.00
Yes	38.7		50.4		60.9		—	—	17.1	2.39 (1.85–3.07)
Any suicide attempt
No	21.9		28.3		27.5		30.9		—	—
Yes	44.8		47.3		46.4		50.0		—	—

The associations between suicide attempts and involvement in any severe forms of date and peer violence victimization and perpetration are presented in Table 4. All ten associations tested were significant with ORs ranging from 2.63 to 11.43. The highest ORs were observed between severe date violence perpetration and severe date violence victimization (OR=11.43; 95% CI=8.70–15.02) and also between severe peer violence perpetration and severe peer violence victimization (OR=11.23; 95% CI=8.94–14.11).

Table 4. Prevalence^a of involvement in severe^b date or peer violence and suicide attempts and the associations^c between involvement in one severe form of violent behavior in the presence or absence of another severe form of violent behavior

	Outcome variables
	Any severe date violence				Any severe peer violence
	Perpetration		Victimization		Perpetration		Victimization		Any suicide attempt
Predictor variables	%	ORadj. (95% CI)d	%	ORadj. (95% CI)d	%	ORadj. (95% CI)d	%	ORadj. (95% CI)d	%	ORadj. (95% CI)d
Any severe date violence
Perpetration
No	—		9.0		14.7		16.7		9.7
Yes	—		52.5	11.43 (8.70–15.02)	55.0	7.56(5.79–9.89)	44.3	4.21(3.24–5.49)	23.3	2.70(1.96–3.73)
Victimization
No	6.0		—		15.5		15.3		9.2
Yes	41.5		—		41.8	4.19(3.29–5.33)	46.7	5.04(3.97–6.39)	23.2	3.06(2.30–4.09)
Any severe peer violence
Perpetration
No	6.1		9.8		—		10.7		9.3
Yes	31.6		29.9		—		57.6	11.23(8.94–14.11)	19.5	2.69(2.04–3.56)
Victimization
No	7.8		9.1		10.0		—		9.3
Yes	24.5		32.8		55.8		—		19.2	2.63(1.99–3.47)
Any suicide attempt
No	9.3		11.8		17.2		17.9		—
Yes	22.6		28.4		32.3		33.3		—

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Discussion 

In this study of the overlap among different forms of violent behavior, there are several important findings. First, the prevalence of involvement in multiple forms of violent behaviors was found to be consistent for boys and girls. While there are gender differences in the prevalence of specific forms of violent behavior, there are no significant gender differences in the number of different types of violence that boys and girls experience. Second, there are significant and consistent overlaps among different forms of violent behaviors. Students who report one form of violent behavior are at significant and increased odds of reporting another form of violent behavior. The strongest associations were found within relationship contexts (e.g., the associations between dating violence perpetration and dating violence victimization, or peer violence perpetration and peer violence victimization). However, the associations across context also were significant. These findings were consistent whether or not analyses focused on any involvement in a particular form of violence or on only severe types of that form of violence. Third, the associations among forms of violent behaviors were consistent for boys and girls.

The finding that each type of violence examined was strongly associated with risk for involvement in the other four types of violence measured suggests that research and prevention programs that focus on only one aspect of violence perpetration or victimization, or of violence within one relationship context, such as among peers or dates, may be neglecting experiences and risks that could lead to negative outcomes. An integrated approach to the development and evaluation of prevention strategies that addresses the range of contexts in which youth are exposed to violence, the high level of retaliation and mutual violence in youths’ relationships, and the risk for suicidal behavior among victims and perpetrators of violence may lead to cross-cutting prevention strategies. A first step toward applying these findings may be to use one form of violent behavior as a marker for involvement in other forms of violence for targeted violence prevention efforts. For example, since nearly half (45.6%) of the adolescents who reported peer violence perpetration also reported date violence perpetration, peer violence perpetration could be used as a marker of risk for dating violence perpetration.⁶ Using peer violence as a marker for date violence perpetration may be advantageous because it is usually a more recognized or visible form of violent behavior.

This study has several limitations. The findings are based on students attending school in a single school district with elevated levels of poverty and crime. Thus, the findings may not generalize to students who live in other settings or to adolescents who have dropped out of school. The lack of data on dropouts may have affected the grade-specific prevalence estimates since the youth at highest risk for violence are more likely to be among those who dropped out and dropouts are more likely at the higher grades. Also, these analyses included only those adolescents who had been on a date in the past 12 months, therefore, the results may not generalize to adolescents who have not dated. However, to better understand this issue, the association between reports of suicide attempts and peer violence victimization and perpetration among adolescents who had not dated was examined; the associations were remarkably similar to those observed among adolescents who had dated (finding is not reported in the manuscript). Moreover, the study is based on self-reported data without corroboration from other sources. The magnitude of potential sex differences in participants’ recall biases, misreporting or willingness to disclose sensitive information in this study is unknown. However, it is likely that the use of anonymous data collection strategies minimized the motivation for misreporting. Also, all analyses are based on adolescents who had dated in the past year without specifying whether those dates were of the opposite or same-sex as the participants. The prevalence of involvement in violent behaviors may vary for same-sex versus opposite-sex dating partners, and adolescents involved in same-sex dating relationships also may be at increased risk of victimization from their peers.²³ Finally, the current analyses only controlled for demographic characteristics. Future analyses examining the associations among specific forms of violent behaviors also could include other factors such as norms supporting violent behavior, parental monitoring, peer delinquency and substance use.

Findings from this large study of a census of students in a high-risk setting highlight the importance of research and prevention programs that address violent victimization and perpetration across contexts. In particular, a very strong association was documented between violence within date relationships and violence within peer relationships. Exposure to violence, as a victim or perpetrator, within date relationships and peer relationships is also shown to be associated with suicide attempts. These analyses focused on physical violence specifically across different contexts. Therefore, it will be important for future research to also examine the associations between experiences with psychological abuse across contexts.

Previous gaps in the understanding of how different types of violent behavior are linked have limited the ability to design violence prevention and intervention efforts that can address multiple types of violence. Current violence prevention and intervention programs generally focus on one type of violent behavior. More specific information about the overlap among multiple types of violent behavior, as provided in the current and previous studies,⁵, ⁶, ⁷, ⁸, ⁹, ¹⁰, ¹¹, ¹², ¹³, ¹⁴, ¹⁵, ¹⁶, ¹⁷, ²⁴ can inform efforts to develop prevention programs that are either specific to a particular type of violence or relevant across multiple types of violence. It is clear that different forms of violence often appear in combination. Additional research is needed to identify the potentially modifiable factors that place adolescents at risk for a range of violent behaviors so that programs can be designed to prevent or reduce multiple forms of violent behaviors.

There are three main implications of these findings. First, additional research is needed to study the potentially shared risk and protective factors across forms of violence. Previous research suggests that there are potentially shared risk factors between suicidal behavior and interpersonal violence (e.g., problem-solving and coping skills; characteristics of school and community environments such as bullying, intolerance and prejudice; mental health problems including, depression, hopelessness, and substance use).²⁵ Second, there are a number of available prevention programs and strategies designed to reduce involvement in dating violence perpetration or attitudes justifying aggression,²⁰, ²⁴, ²⁶, ²⁷ that might be incorporated into broader violence prevention programs targeting both peer and dating violence. Moreover, existing and effective prevention strategies²⁸, ²⁹ should be evaluated to determine if they have an impact on additional outcomes, not only on the main outcome that the program was designed to prevent. It is possible that existing programs already have a positive impact on multiple outcomes, and if that is the case, these programs should be widely disseminated and implemented.²⁵ Finally, given the significant overlap across violence-related behaviors, researchers and service providers need to consider an integrative approach when designing and conducting new projects or services. This approach should proactively consider the interrelatedness among forms of violent behaviors and avoid contributing to artificial fragmentation in efforts to improve the health and safety of adolescents. More specifically, recognizing that involvement in peer violence may be a marker for date violence and that those who are exposed to dating or peer violence, as a victim or perpetrator, are at increased risk for suicidal behavior, is an important step toward a more thorough understanding of the person in need and the range of experiences they may have. Researchers have already called for a common approach in the study of suicide and youth violence prevention²⁵ and also for child maltreatment, youth violence and adult domestic violence prevention.³⁰ The addition of published strategies for advancing prevention research on child abuse, youth violence and domestic violence³¹ also indicates that the field is ready for a more integrated approach to violence prevention.

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We thank the entire Linkages Study team from ORC Macro, CDC, and Battelle who contributed to the planning and implementation of the study. We also thank the school district for their enthusiasm and logistic support of this project. Finally, we thank the students for their time and willingness to participate in this study.

The findings and conclusions in this report are those of the authors and do not necessarily represent the views of the Centers for Disease Control and Prevention.

No financial disclosures were reported by the authors of this paper.

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References 

1. Centers for Disease Control and Prevention (CDC). Youth risk behavior surveillance: United States, 2005. Surveillance Summaries. MMWR Morb Mortal Wkly Rep. 2006;55(SS–5):1–108
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2. Silverman JG, Raj A, Mucci LA, Hathaway JE. Dating violence against adolescent girls and associated substance use, unhealthy weight control, sexual risk behavior, pregnancy, and suicidality. JAMA. 2001;12:572–579286
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3. Coker AL, McKeown RE, Sanderson MD, Keith E, Valois RF, Huebner ES. Severe dating violence and quality of life among South Carolina high school students. Am J Prev Med. 2000;19:220–227
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