Good afternoon. My name is Rory Reese, and I am a member of the board for the African American Behavioral Health Center of Excellence here at the Morehouse School of Medicine where I'm also a faculty member in the Department of Psychiatry. Today we're joined by Alex Crosby who will be doing a presentation on Do We Have to Live With It? Interpersonal Violence Prevention in the United States. First, some housekeeping. Support for the Center of Excellence and this presentation today is provided by SAMHSA. Funding for the Striving for Excellence series was made possible by SAMHSA or the United States Department of Health and Human Services. The contents of those are the authors and do not necessarily represent the official views or endorsement by SAMHSA, HHS, or the U.S. government. For those of you who are looking for continuation credit, the American Psychiatric Association is accredited by the Accreditation Council, Continuing Medical Education to provide continuing medical education for physicians. The APA designates this live event for maximum of one AMNPRA category one credit. Physicians should claim only the credit commensurate with the extent of their participation in today's activity. This slide tells you how to download the handouts. We will leave it up for a moment for those of you who may want to access the handout so that you can follow along with the presentation. Next slide. How to participate in the Q&A period, which will occur at the end of our presentation today. Again, there are instructions here for how to use the question box. And again, we'll leave that up there for a second. Next slide, please. And disclosures. There's no financial relationship to disclose the contents of this presentation, does not endorse any proprietary healthcare product or service. So with that aside, I'd like to introduce our presenter today. Dr. Alex Crosby was born in Detroit, Michigan, or raised in Detroit, Michigan, where he is the son of Merrill and Corinne Crosby, and is the husband and father of four children. He graduated with a bachelor's in chemistry from Fisk University, an MD from Howard University's College of Medicine, and an MPH in health administration and management from Emory University School of Public Health. He completed training in family medicine, general preventive medicine, and public health and epidemiology. He worked for the Centers for Disease Control and Prevention for the last 30 years, and responded to public health emergencies that address suicide clusters, civil unrest, school associated violence, sniper attacks, firearm related injuries, hurricanes, Ebola, and the coronavirus. He has authored or co-authored over 125 publications. His work focuses on the prevention of suicidal behavior, child maltreatment, intimate partner violence, interpersonal violence among adolescents, and assault injuries among minorities. He currently serves as a professor at the Morehouse School of Medicine. And as a last comment, it was my great pleasure to work with Alex for several years during my tenure at the CDC. So I am very much looking forward to his presentation today. And with that, Dr. Crosby, take it away. Thank you very much. And good afternoon to all of you who are there in the audience. Those of you who might be further west, might still be in the morning, but good afternoon, good day to all of you. I would like to thank the American Psychiatric Association for the invitation to come and to talk with you, Dr. Reese, for the introduction, and also Dr. Vincent for making the introduction to the American Psychiatric Association and Ms. Harris for kind of shepherding the process through and getting us all together. What I'm going to talk about today is addressing the issue of interpersonal violence. And do we really have to live with it? You know, I did hear, I think one legislator, one politician, talk about, you know, the level of violence that we have in the United States, it's just the price we pay for freedom. I'm going to say that I disagree with that a little bit. And so we're going to talk a little bit about interpersonal violence. And I'm going to approach it primarily from a public health approach. But I also want to those of you who are clinicians to try and identify where there may be a role for you as a clinician in the area of violence prevention. Why is this an important problem? Well, those of you who have, you know, whether you've seen what's been going on in the news, whether you've noticed what's been happening in your neighborhoods, in your cities, in your counties across the country, primarily, what you've seen in the area of violence is violence seems to be increasing. Homicides seem to be increasing. Gun violence also seems to be increasing. For a while, especially in the early part of the summer, it seemed like we were having a mass shooting event almost every week. And part of what I was doing as I was compiling some of the data is, especially through May and June and into the early part of July, continuing to have to update what was happening in regards to mass violence. So it seems like there is a problem that we have to try to address here in the United States. In order to try to make our population healthy, we can't do it and exclude that particular form of health and well-being. What I will do today is try to talk about why homicide and interpersonal violence is a public health issue, why it might also be important to clinicians. I will talk a little bit about what the public health approach is, just a systematic way of looking at a particular problem, and then show how you can apply that public health approach to violence prevention. Some of the learning objectives for today, a little bit about a description about why homicide is an important problem. I'll describe a little bit about the magnitude of this form of violence, identify some vulnerable groups for violence within the United States, then talk about kind of getting into the why. Identify risk and protective factors for this type of violence, and then hopefully allow you to get a little bit familiar with some successful interventions to prevent this type of violence and talk a little bit about what is some of the evidence-based or the most promising programs for addressing this. So why is interpersonal violence a public health issue? Well, one aspect would be the morbidity and mortality. What do we know about the number of deaths that it causes, the 16th leading cause of death in the United States in 2020. 2020 is the most recent full data that we've got for the United States. Soon 2021 will be coming out, and there's actually some provisional data looking at, you know, death certificate information from across the country that show that it is also seems to be increasing. It is the second leading cause of death among adolescents and young adults. So while it might look at 16th overall, it disproportionately affects adolescents and young adults and is the second leading cause of death, especially for those 15 to 24. There's an estimated 1.5 million emergency department visits for assaults across all ages. So the magnitude is multiplied when you go from the number of deaths to the number of non-fatal injuries, and it has health consequences across a broad number of areas in the physical realm, mental, behavioral, reproductive, including things like sexually transmitted diseases. Another reason why we believe that interpersonal violence is a public health issue is that there is an impact, a potential impact for public health. The focus of public health is on prevention. So while many may think of violence as being primarily a criminal justice issue, we believe that in public health, we try to focus on trying to prevent it from occurring in the first place. But then there are also opportunities for addressing the issue in terms of primary, secondary, tertiary prevention. There is also a science base. Epidemiology is one of the science bases that help us look at the problem and identify the risk factors, the protective factors, identify associations, causation, if possible, and then also do the evaluation, identify the programs, evaluate them, see what works, what doesn't work, and be able to communicate that out to the public. And then lastly, we believe that the mission of public health includes this issue. And here, just a definition from Dictionary of Epidemiology, to reduce the amount of disease, premature death and disease-producing disability and discomfort in the population, that we believe that interpersonal violence and homicide fit into that definition. So it's something that we should be concerned about. Violence and the different forms of violence go across the lifespan. You know, from when we talk about things like intimate partner violence or dating violence, sexual violence, elder abuse, some of which start in childhood, whether you're talking about looking at the victims or even the perpetrators, going across into other age groups. So from child maltreatment to self-directed violence, all of those are aspects in which we can look across the lifespan from basically zero to 85 plus, that in all of those age groups, there's aspects of violence that manifest themselves. This is the public health approach. And I'm depicting it here as kind of a cycle of four different steps in the cycle. Oftentimes, they're interacting together, that you'll see all four of these different aspects occurring at the same time. But really, the public health approach is just a systematic way of trying to examine the problem and try to identify why it's occurring. And then what can we do about it? So you kind of start with that, that green circle, which is defining and monitoring the problem, which includes activities like surveillance. How do we do surveys? How do we look at death certificate information? What about emergency department information? How do we get that information and use that data to inform us about what we need to do about this particular issue? From there, you kind of move to the orange, which is identifying risk and protective factors. And especially when you're talking about an issue like interpersonal violence, in some cases, we might talk about what's the why? What's the etiologic agent? But when you're talking about a societal problem like violence, you're oftentimes talking about an interaction of several different factors. It's not just caused by one thing, like we might talk about COVID-19. There is a SARS-CoV-2 virus that causes COVID-19. And that's the etiology. But with violence, oftentimes, there's a mixture of different kinds of factors, whether you're talking about at the individual level, at the family and peer level, at the community level, at the societal level, that interact that put, you know, a population at risk, or there may be the protective factors. So identifying those risk and protective factors, then you move towards developing and testing intervention strategies. In that case, what you've identified in terms of those risk and protective factors, how do you use that information to develop a prevention activity? If we understand kind of what we've done with that orange circle, in terms of the why question, now we can take that and say, okay, here's what we're going to do about it. Let's see if we can test this out. If we know what are the risk factors, can we decrease risk in a certain area, in a certain population in a certain community? Or can we look at it a different way and say, okay, what do we know about the protective factors? And can we enhance protection in a certain place? So we develop and we test those prevention strategies, we do evaluation there, and then we move towards the purple, disseminating successful strategies widely. It's not just disseminating the strategies, we may have tried it in a pilot, but it's also disseminating and implementing what we've learned in those first three blocks. So what we've learned about monitoring the problem, what do we see about, you know, whether it's going up or whether it's going down? What do we see about the populations that might be more vulnerable or at risk? What do we know about the why question? All of those kind of things help inform us as we move to the next part of what's going on and getting that information out to communities, decision makers, policy makers, community based organizations, whoever it is, that's taking action on the problem. And oftentimes, we're doing all four of these things at the same time. So as we're learning about the problem, we're also taking action for trying to make a difference. So let's start off and kind of define the problem a little bit, give you some idea about the magnitude and what we know about some of the information and the data that is occurring in regards to interpersonal violence. This is just a graph looking at homicide rates over the past about 80 years, going back to 1933. That was the first year for which we had all 48 states at the time in the vital statistics system. And one of the things you might notice about this is that homicides are not flat. You can see where there are ups and downs, peaks and valleys, as you look across the occurrence of homicides in the United States. You can also notice that some of the highest homicide rates that we ever had in the United States occurred in the late 80s, early 90s. Then you can kind of shift your attention, you know, as you look towards the right side of this graph into 2020, especially since about 2017, 2018, up to 2020, that you can see a sharp increase in regards to violence. Well, what are some of the factors that may have influenced that are some of the things that we'd be looking at in regards to what do we know about those risk and protective factors that's coming in just a little bit. This is a wait a minute, I saw something pop up there on my screen. This is just a chart looking at causes of death, leading causes of death for selected age groups. And part of what you see here is where homicide disproportionately affects young people. And you can see for 10 to 14 year olds, it was the fourth leading cause of death. 15 to 19 year olds, the older adolescents, number two, those in their 20s, number three, those in their 30s, the fifth leading cause of death. When you get into the 40s, it's down there at number nine. Suicide, as I just mentioned, just as a form of interpersonal violence, there in the 50 to 59 year old group. So you can see that it disproportionately affects young people. That's another thing for which we'd be taking a look at. What several researchers did back several years ago, and you can see this is 2016 data, just to give you an idea, is they said, you know, based on the leading causes of death, those are based on international classification of disease codes, that what we can do is we can look at those codes, how they determine this was a cause of death, we use a code that corresponds to that, and then identify that. When you look at those leading causes of death, they don't really show you any of the why. So even though, for example, heart disease was number one in 2016, it doesn't tell you what were some of the risk factors for that heart disease, doesn't say anything about high cholesterol, doesn't say anything about high blood pressure, doesn't say anything about tobacco use and cigarette smoking. And yet we know that those are some of the factors that play a role in heart disease, same kind of thing with malignant neoplasms or cancer. It's something to know that cancer was the second leading cause of death in the United States. But it's also better to know a little bit more about what were some of the causes. Okay, so then you shift over and you look at that right table. And that was what these researchers did is said, okay, well, let's look at some of the underlying causes of those particular leading causes, tobacco being one of the leading preventable causes of death. We know that tobacco can play a role in heart disease, can play a role in malignant neoplasms, can play a role in number four, which is chronic lower respiratory disease, poor diet and physical activity. All right, so all of those things can play a role and underlying causes in regards to the leading causes of death. I'll skip on down to number eight, which I've got highlighted. One of the things they identified was that firearms were one of the leading mechanisms, the leading mechanism, when you talk about looking at especially certain kinds of injury causes of death, especially violent causes, you know, whether you're talking about suicides, or homicides, including unintentional firearm injuries. So it's important for us to know what are some of the underlying contributing causes to those actual leading causes of death. These are what the rates of suicide look like when you distinguish between males and females. You can see, you know, dramatic increase in homicides, in which males were the victim, especially in the adolescents and young adults, that the rates for males are about five times higher than the rates for females in that adolescent and young adult age group. When you look at rates according to race and ethnicity, you can also start to see where there are some vulnerable populations in terms of high rates among African American non Hispanics, you can also see high rates among American Indian, Alaskan Native, and then followed by Hispanic populations. So you can see that some of the communities of color are at risk in terms of being a decedent as a result of interpersonal violence. The population, the color of the population or the race and ethnicity of the population is not necessarily the risk factor. But what are some of the factors that put those populations at risk? And we'll talk about those in just a minute. When you look at homicides by method in the United States, that the blue part of that pie shows up pretty, pretty dramatically, that almost 80% of all the homicides in the United States, a firearm was the mechanism. They're not evenly distributed across the United States, you can see there, especially those states in the orange, and they tend to be concentrated kind of in the south, especially towards the southeast, that you can see those states, especially kind of Missouri, Arkansas, Louisiana, Mississippi, Alabama, Tennessee, South Carolina, some of the highest states in regards to homicides across the United States, and then also New Mexico. This is looking at mass shootings in the United States. And it really does depend quite a bit on how you define it. This is some information that came from Everytown. This was an organization that's funded actually by Bloomberg, former mayor of New York, that you can see, you know, where the the ups and downs of mass homicides, mass shootings in the United States, and depending upon how you define it, you can see here the way Everytown defines it in which four or more people are shot and killed in excluding the shooter now depends, FBI defines it a little bit differently, some departments of justice or criminal justice to find those a little bit differently. 2022, it looks like it's going down. But that's only because we're only in August. And so it more than likely, we'll see that, that that number come up a little bit just in regards to mass shootings that have occurred in the United States. This is another thing for us to try to understand in regards to mass shooting by location and circumstance in the United States. Let me kind of focus on the right pie, just for a minute, just in terms of the circumstance that you see that over half were family violence related, that then oftentimes spilled out into other places. If you think about the mass violence that occurred in Newtown, Connecticut, that occurred at the school there, one of the things to recall is that the perpetrator there shot his mother first, then went to the school and shot the students and the teachers at the school. Same kind of thing, similarly, same kind of thing happened in Uvalde, Texas. That perpetrator shot his grandmother first in the house. He actually survived and she's the one that called 911. Then he goes to the school and shoots up the school. You can look at, then shift your attention over to the location where it's home only. Many of these mass shootings occur in the home in which the perpetrator shoots spouse, ex-spouse, ex-girlfriend, and then shoots some of the family, the children in the household. Some start in the home and then move out to the public. Other occur primarily in the public realm. Just something to think about. I saw this cartoon in the newspaper and thought, well, maybe this is something for us to consider only in the United States. You look at the Pinto, those of you who remember that Pinto had the gas tank in the back of the car. There were several crashes in which somebody ran into the back of the car and the car was engulfed in flames, caught on fire, recalled after 27 deaths. Remember in terms of Tylenol, that they started putting those safety caps on them and also tamper resistant stuff after someone had included some poison in the Tylenol, recalled after seven deaths. We've got firearms, 32,000 deaths in the United States, and yet we haven't done much. There was a law passed this year to try to add on some more stringent legislation, but there's also some issues regarding what more could we be doing to try to decrease firearm related violence in the United States. Just some other aspects. I showed you a little bit about some of the death certificate information, but there's also other ways in which we're measuring what's happening in terms of the magnitude of violence. This information comes from the Youth Risk Behavior Survey. This is a national survey that's done in high schools across the country. A few states actually do it in junior high. There's some questions that deal with interpersonal violence. You can see in terms of skipped school for safety reasons, didn't feel safe in school. You can see that in the case of females, a national sample, almost 10% of females said that at some point in the past 30 days, they skipped school because they didn't think it was safe. They carried a weapon on school property. You can see in terms of males and females that about three to 4% of males carried a weapon on school property. Have they been threatened or injured with a weapon on school property? Over 5%. That's one out of every 20. Then also bullied on school property. You can see there females reporting more, almost a quarter of females, about one in six males reporting being bullied on school property. Not going to go through all the questions because there are even more in terms of cyber bullying, in terms of dating violence, in terms of sexual violence. I'll talk maybe a little bit about those. Here is looking at differences, not just by male and female, but here is looking at differences by sexual orientation or sexual contact. Here you can see that those that identify as LGB, it doesn't have the LGBTQ in this survey, but those that identify as lesbian, gay, and bisexual report more issues regarding skipping school for safety reasons, being threatened or injured with a weapon or being bullied on school property. Here are questions again by males and females looking at dating violence, physical dating violence, and sexual dating violence. You see it again, almost 10% of females say that in the past 12 months, they've been a victim of physical dating violence. In terms of sexual dating violence, about one in eight females say that they've been a victim of that. What about identifying the risk and protective factors regarding that? This just gave you a little bit about what was some of the magnitude of the problem, but how about the risk and protective factors? There are various ways that you can do it. One way is looking at what's called the social ecological model, just one model, but there are various other aspects of trying to identify what the problem might be and how it manifests itself. One way with the social ecological model is looking at the individual level. What are some of the factors that might play a role at the individual level? Whether those are demographic, psychological, or personality disorders, a history of violent behavior, someone who's experienced abuse. Some of you may be familiar with a survey called the adverse childhood experiences that look at experiences in the household. Oftentimes, it's adults that are asked about their experiences when they were children, whether they had lost a parent, whether that was through incarceration, or separation, or divorce. What about a parent that may have had a mental illness or substance abuse issue? It asked about whether the person may have actually been a victim of child abuse and neglect, whether that was physical abuse, sexual abuse, emotional abuse. There's about nine or 10 different measures of that adverse childhood experiences. There are others that have looked at what are called adverse community experiences in order to try to identify those that might be at risk for violence and other kinds of chronic diseases, too. There's also at the close interpersonal level, at the family and peer level, what about ineffective parenting seems to have an effect on increasing the risk for violence, marital conflict. Oftentimes, those who are exposed to intimate partner violence in the home, the children may just be witnesses of violence between mom and dad. That actually increases their risk of either being a perpetrator or a victim of interpersonal violence later on. Also, peers can have an influence. Friends who engage in violence may be more likely to promote violence in certain individuals. At the community level, concentration of poverty, high residential mobility in which there are neighborhoods in which a lot of people moving in, moving out makes it more difficult to identify who might be the strangers in the community, who might be those that might be potential troublemakers, for example. High residential mobility can also lead to increases in violence, high unemployment, and then also social isolation. You might think social isolation, connection to COVID-19 in which we are talking about physical distancing, but also isolating and quarantining, that may have also led to and increased an association with interpersonal violence in the United States. How about at the societal level, inequalities, whether those socioeconomic inequalities, the norms that support violence, again, communities or cultural areas that promote violence, those individuals might be more likely to engage in violence. The availability of means, whether you're talking about firearms or other kinds of means, can also increase the likelihood that violence might be perpetrated, and then violence may be more lethal. Weak police or criminal justice activities, cultural values, and then also media influence where there may be promotion of violence. This is the adverse childhood experiences pyramid. This was just an effort to try to look at how adverse childhood experiences might play a role in not just interpersonal violence, but there have been also studies that have looked at adverse childhood experiences and their connections to chronic disease, such as high blood pressure, such as clinical depression, such as substance abuse, so adverse childhood experiences down at the bottom of the pyramid, disrupted neurodevelopment. I don't have time to kind of go through, but there are actually brain imaging studies that have shown that there are certain areas of the brain that are underdeveloped and do not develop because of those that have been exposed to adverse childhood experiences. It leads to social, emotional, cognitive impairment, adoption of health risk behaviors, disease, disability, and social problems, and then oftentimes death life expectancy is lower among those that have experienced, especially when they've looked at kind of the number of childhood experiences, and oftentimes the scales are nine or 10 adverse childhood experiences. Those who've experienced four or more tend to have, you know, the worse manifestations of health and the association with early or lower life expectancy. This is a conceptual framework for the social determinants of health from the World Health Organization. This also can help us to look at the issues of interpersonal violence and how there might be influences from those social determinants in terms of health inequities and looking at the consequences of violence, and especially want you to kind of take a look at that rectangle kind of in the middle, and I'll put a little highlight on it. Socioeconomic position of groups can also lead to increased rates and increased prevalence of interpersonal violence, so whether that's social class, whether that's gender, especially when there are gender biases in certain communities, race and ethnicity. If there's discrimination and racism in certain communities, that can also lead to increased victimization from violence, educational attainment, certain occupations, and then also income and wealth. Just to give you an example of a study looking at the issue of poverty and interpersonal violence, this was a study done in California looking at about 20 years worth of data. One of the things to kind of note here, looking at this poverty bracket, which is kind of along the bottom, along the horizontal axis, when the poverty bracket, less than 10 percent under poverty, 10 to 14 percent, 15 to 19, 20 to 24, and 25 plus, so as the percentage of those that are in poverty goes up as you go from left to right, and one of the things to kind of note with the bars, and this is looking at different age groups, is for the majority of the bars, not all of them, because there's a few that actually drop when you get to 25 percent plus, but for the majority of the bars, as you move towards increasing percentage of that population, that age group being in poverty, the rates of homicide go up, and it's almost kind of a stepwise increase as you go from less than 10, 10 to 14, 15 to 19, 20 to 24. All of that, and now talking about what about prevention, and one of the things to recall is that there have been multiple studies that have shown that violence is preventable, especially when you're talking about youth violence, that there are aspects in which you can develop interventions that not only are focused on interpersonal violence, but it may actually prevent other forms of violence, too, so there are programs that have been shown that while you target physical violence, you may also impact sexual violence and intimate partner violence as part of those particular programs, depending upon what their focus is on the risk factors and the protective factors. There's also a significant cost benefit, and we may get to that slide in a minute, requires a comprehensive focus. If we believe, which I think is the truth, that violence is a societal problem, it really does take a comprehensive focus. There's no one organization. There's no one group that can handle all the violence, that has all the tools, has all the resources, but oftentimes it requires what that last point talks about, a multi-sector collaboration between public health, education, social services, justice, and many others, so what about developing and testing the strategies? One of the things that the Centers for Disease Control and Prevention did, but there are other groups, too. There's a Blueprints group out in Colorado at Colorado State University, University of Colorado Boulder, if I'm mistaken, that has also developed a strategy and a menu of programs that have an evidence base to them. What the Centers for Disease Control did is went through and developed some technical packages, and I'll define a little bit what a technical package is. They did one for child abuse and neglect, sexual violence, youth violence, suicide, intimate partner violence, adverse childhood experiences, but what it does is it takes the best available evidence, talks about the strategies, the approaches, and the evidence. It takes a select group of strategies based on the best available evidence, and this was to help communities to be able to have a place to go or a resource document that they could look at and say, oh, here's where there are some evidence-based programs so that they wouldn't have to try to look for them themselves. A community member is not necessarily going to be reading the latest issue of the New England Journal of Medicine or the Journal of the American Medical Association or even the American Journal of Public Health, so where are there places in which somebody has compiled that information together that communities can go and look at that? A technical package is just one of six key components for effective public health program implementation, so a technical package has three components to it, those strategies, those approaches, and the evidence. What is the quality of the data is included in that evidence piece. When the Centers for Disease Control went through and looked at this, they had some set criteria for inclusion in that technical package, so looked at programs, looked at policies, looked at practices, so it wasn't just programs but also looked at health policy, looked at meta-analyses, systematic reviews, rigorous evaluation studies to try to look at the impacts on youth violence, victimization, perpetration, risk and protective factors, especially if these programs, kind of the second point, if it had beneficial effects on multiple forms of violence, that kind of increased it a little bit. If it was effective on one form of violence, it could be included, but if it had multiple impacts, that was actually even better. If it had similar outcomes in different settings, did it show that it was effective in a rural setting and in an urban setting? Did it show that it was effective in the east as well as in the west? That also helped improve the kind of the status, if you will, of those particular programs in terms of us being able to recommend it and feasibility and implementation in the United States, so they also looked at some international programs and said, you know, could that be applied here? Could we translate that over here? And then no evidence of harmful effects or specific outcomes. Let me show you a little bit about the table in terms of youth violence. Six different strategies that were identified as the best available evidence and having an evidence base to them, and one of the things you might notice is that many of these, you know, their strategy name doesn't really talk about violence prevention, but it talks about some of the different factors and just kind of looking at the first one of promoting family environments that support healthy development, early childhood home visitation. Those kind of programs in which, you know, some of the early versions had nurses that came out to homes, and those were primarily designed to prevent child abuse and neglect, but they found they also had implications on other forms of violence, and then also parenting skill and relationship programs. I'm going to skip on down to universal school-based programs were another one that were identified mentoring programs and after-school programs, so there are a number of different programs that were identified. I skipped over one, but I want to go back to it. It's kind of the second one on the list. Preschool enrichment, there are actually some evaluations of things like Head Start programs that have shown when they did follow-up of those children that were in Head Start programs, did a control group, followed them over almost 30 years, so now that some of those populations were in their mid to early 30s, found less likely to be perpetrators or victims of violence, more likely to be employed, more likely to have stayed in school, less likely to have dropped out, many beneficial aspects of those early preschool programs. Here's some of the information about the benefits relative to the cost, and for some of you, when you talk especially to funders or decision makers or politicians, maybe in your city council or county council, sometimes they're persuaded not just by the numbers of you being able to say that this program actually prevents it, but by the money, and so you're able to say with a number of these different programs that for every dollar spent, you're saving from $1.61, $1.65, you're saving $5. You can look at the Good Behavior Game, which was an early childhood intervention, a school-based program primarily focused on first and second graders, that for every dollar spent, it saves $64. So you can also make the case that in terms of a return on investment, you want to talk about a business case, here is the business case for doing violence prevention, especially with some of these evidence-based programs, that they actually save us money in the long run by investing early in children and in youth and in adolescents. Lastly, talk a little bit about disseminating successful strategies widely, not only dissemination, but the implementation of programs. One of the things is with the programs, it's also important to have timely and reliable data, monitoring the extent of the program, evaluating the impact of the prevention efforts to make sure that it's working, and it's working for the populations that you have designed it for, and understanding where we might have to make some modifications in the program. Is it working for the boys but doesn't seem to be working for the girls? All right, well, maybe we've got to look at how we're designing the examples or the role-playing or exactly what we're doing in terms of the forms of violence that might be more prevalent in one group versus another. Program planning, implementation, and assessment are other parts of making sure that the program is operating the way it's supposed to. Sector involvement is another important aspect of implementation and dissemination. Here's just a number of different groups that we've got to think about. Again, if it's a societal problem, you've got to get multiple sectors within our society involved with preventing the issue, public health, education, government, social services, the business sector, other non-governmental organizations, health services, those that provide clinical care, justice, housing, the media, and faith organizations too. One of the things that we also realized, and again I'm saying we as in I was still at CDC, I'm not anymore, so I'm just going to talk about when I was there, as in developing these technical packages, is we realized the technical packages kind of gave the what. Here are the programs that have the best available evidence to them, but we didn't really give people the, how do you take these programs and put them into place? And so we actually developed some implementation guidance for communities or for those that might want to take these programs and actually put them into place. So it went through the planning, the partnerships, implementation, adaptation, policy, and evaluation. I'll just show you a little bit about the seven phases that were identified, and it is there if you look at the, kind of the bottom of the screen, the website, but it's actually an interactive website that kind of takes you through each of these different aspects depending upon what kind of program you want to do across the different forms of violence. So maybe you're trying to do an intimate partner prevention, intimate partner violence prevention program. Okay. It'll take you through the stages. If you're trying to do a youth violence prevention program, a suicide prevention program takes you through identifying the strategies. What's the population that you're working with? Is it a youth group, 15 to 24 year olds? Is it an older adult group, 65 and above? Okay. So here's some of the strategies that might be applicable. What about going through the planning, adaptation? You got to take a program that may have been developed in a different part of the country, see how you might adapt it to where you are going to put it into place. What are some of the partnerships that you might be looking for in terms of bringing others alongside that might have some other resources, some other tools, access to populations, implementation policy efforts and evaluation are all parts of those seven phases, but that website kind of takes you through that. All right. So I will wrap it up with this and definitely look forward to kind of entertaining some questions and some dialogue in regards to this issue. Violence affects many parts of our society. It disproportionately affects young minority males. So we definitely got to have activities, programs, and efforts that focus on those vulnerable populations and especially when we're looking at within cities, but that's not the only places, urban areas. There's also manifestations of violence that occur in suburban and in rural areas. A need exists for partnerships in prevention and public health can play a major role as one of those partners. As I mentioned, there's no one sector. There's no one organization that can handle all of it. Public health can't do it all by themselves. Clinicians cannot do it all by themselves. Criminal justice can't do it all by themselves. Schools can't do it all by themselves. So there really have to be partnerships that bring together the skills, the expertise of different organizations to try to work together. A focus on primary prevention is a key part. You can also deal with rehabilitation, tertiary prevention, but primary prevention is also a key piece of doing these activities. Prevention works and it has been demonstrated by research and successful programs in several communities. Don't believe the naysayers that say that we really can't do much about violence. We actually can. So the last point is to answer the question that I asked at the beginning. Do we have to live with the level of violence that we have in this country? No, we don't. There are ways in which we can implement some of these programs that are the most promising that have an evidence base to them so that we can make a difference. Thank you very much for your attention. I've talked about kind of the magnitude of the problem, the public health approach, how you apply the public health approach to violence prevention, and then what can we start doing about it. And then we will entertain questions and answers. So, Dr. Crossman, thank you so much for an excellent presentation, a lot of rich information here. You're talking today to a group of largely applied behavioral health providers who are either psychiatrists or psychologists, perhaps nurse practitioners, et cetera. What is it you think that clinicians can do in this space? One of the things, there's several different things. As clinicians, you are oftentimes very focused on this particular individual that is your client or your patient. And so it's important that you as a clinician, you can think of part of your role is also an advocate for this particular person. So how do I make sure that I'm doing the best I can for this particular individual? And it might be something that's occurring in that clinical environment. You work in one-on-one with that particular patient, but you've also got to think about what setting, what environment, what's the home, what's the community look like that that individual has to go back to? And now, what can I also be doing to try to make this individual as healthy as possible? Are there some things that I need to be thinking about in terms of trying to get this person access to other kinds of resources that might make, whether it's their home life or their school life or some other things that might make it safer? So you can be an advocate. That's one aspect. You can also be an advocate, not just for that individual patient, but also what about the community, either where your practice is located or even where you live? It might be a matter of going to the decision makers in that community, your own community or where your setting is, and talking to them about what can we do to improve life here? So being an advocate, there may be also opportunities for clinicians to think about, can I get involved with some of the research to try to identify what might be effective programs for the population that I'm working with? Because I'm seeing programs that work for that group over there, but my group is slightly different. Maybe there's something that they can do there. So there's several different roles that clinicians can play, and especially doing some assessment of not just the individual, but also what are some of the surrounding circumstances or environments of that individual and try to address some of those too. Thank you very much. I appreciate, this is a question for me. I appreciated the slide on return on investment, because oftentimes the financial argument can be more persuasive than doing the right thing because it's the right thing. But I wonder, given that we know as much as we do about preventing, intervening in violence, you spent 30 years at the CDC, what do you think are the barriers to us acting on what we know? I think there are some things that are not just unique to violence, but they're unique to some other problems that we've seen in terms of health problems and societal problems. One of the things that I'll mention is that oftentimes some people look at it as, it's their problem over there. They got an issue over there, but we over here, we're okay, we're safe. We don't have to worry about it. And unfortunately, part of what you've seen with some of the mass shootings that have occurred is oftentimes the media go and interview folks and say, I never thought it could happen in my community. But when you look at violence across the United States, you ought to think, yep, this thing could be happening tomorrow right here where I live. So I need to be doing something about it and not just think I'm safe because it's happening over there in that part of town or in that city. We've seen some of that same kind of stuff with COVID-19. We're seeing some of that same kind of stuff with HIV. When it first started, oh yeah, it's just that group over there, the IV drug users, the males that have sex with other males, it's just them. It's going to stay over there. We don't have to worry about it over here. So therefore, we're not going to do anything about it. And then once that thing starts spreading, COVID-19, when it starts spreading to other populations, oh, oh, wait, we ought to be doing something about this. At that point, it's going to take more resources. You can still do something about it, but it's going to take more resources. So I think part of the issue in regards to violence prevention in the United States is just like I said, we know enough that we could be doing more about it right now, but oftentimes it's a perception that it's just over there. It's just them over there. And so I don't really need to be concerned about it or to worry about it until it hits my neighborhood, then, oh, wait a minute, I ought to be doing something. So I think that's part of the issue. So you mentioned the COVID-19 epidemic, and one of the things that we've seen here in Atlanta and also other urban centers like Chicago is that as the pandemic seems to be winding down to the endemic phase, that there have been upticks in the personal violence. What's your thinking about how COVID impacted violence and its occurrence? I'm going to give you a few kind of theories. I don't know that we've got the definitive answer, but several different things. One of the things that happened as a result of COVID-19 and what happened with the kind of the massive layoffs, especially kind of in the entertainment industry, in the recreation industry, is this has been historically identified in terms of criminologists and others that have looked at patterns in terms of violence, that when unemployment goes up, homicide and violence goes up. So we saw that, especially with some of the early parts of COVID-19, unemployment in some sectors and actually across a widespread in the United States, unemployment went up. We almost could have anticipated that homicide and interpersonal violence was going to go up. We also saw substance abuse start to go up. We've had some problems with opioids anyway, but also we saw alcohol start going up, alcohol consumption start going up. And we know the connection between alcohol, that it's highly associated with interpersonal violence. So COVID-19 in and of itself, it wasn't the virus, right? It wasn't the COVID, the SARS-CoV-2 that caused people to be more violent, but it was all the associated societal changes and factors, and if you want to say upheaval, that occurred as a result of COVID-19. Whether it was in the employment realm, whether it was in the school realm of folks not being able to go to school and having some challenges there, we understand that we wanted to do something to try to protect children from being exposed to the virus, but that also had some impact on children falling behind school. My oldest son is a school teacher. His perception was there were some of his students that when they went home early in, I think, March of 2020, and they were supposed to be logging in and doing it, some of them thought, this is early summer vacation. They did not log into school. We know that there were issues in regards to disparities for people that had Wi-Fi, that had devices, but there were some that had them, and depending, again, on their perception, they thought, oh, school's out for the summer, and so you have children that fall behind in school, more likely to be at risk for dropping out of school, so those kind of things also contribute to violence within neighborhoods. Okay. Would you expect that to continue or abate as the economy stabilizes? You know, I would expect it to reverse a little bit as the economy stabilizes, but we also have to look at what parts of the economy stabilize, and if we don't have, you know, the jobs going to, you know, some of those vulnerable populations, if we don't have the, I guess I would say, enhancements to schools in terms of, you know, in some places they estimated that some children lost, you know, six months to a year just in terms of their academic progress because of that, so if we don't have the kind of programs that try to focus on those students that may have fallen behind and try to bring them back up to speed, if we don't have the kind of employment kind of opportunities that help bring people back into the workplace, if we don't have the things, and especially we saw, you know, evictions and foreclosures, while there was a moratorium for a while, I've seen recent newspaper articles and articles, you know, on the internet that have shown that eviction and foreclosures, all of a sudden, when that moratorium went off, people getting kicked out, so that too is going to contribute to interpersonal violence, so it depends on whether we start to implement some of those programs, especially in those vulnerable communities, then we definitely would see violence start to drop back down, but if we don't, you know, it might go up and then maybe just kind of flatten out, it might not come back down for a while until we start to get other things in place. So a couple other questions here, one that deals with trauma, but one that also deals with, you presented a lot of information, and as an expert in this space, what are the knowledge gaps that you would identify, both in terms of the intervention that helps us understand what's going on, and the research that helps us understand what needs to be done about violence? Yeah, in terms of, you know, some of the underlying risk and protective factors, and I'll just pick out one, just as an example, while there had been a number of studies on adverse childhood experiences, and basically it just, many of the studies just quantify the adverse childhood experiences, as I mentioned, in some surveys, they have nine different items on the adverse childhood experiences, and basically just add them up, so if a person says, I had this one, I had that one, I had that one, it's just three, but we don't really estimate the magnitude of how those might differ, you know, so it might ask, for example, you know, were you a victim of physical child abuse, were you a victim of sexual child abuse, were you in a household in which there was divorce, were you in a household in which a parent had a mental illness or substance abuse problem, those things, and I just named out four of them, those things might have differential impact on a particular child, but oftentimes, when they're measured, it's just measured as you had one, or you had two, or you had three, or you had four, not thinking that, you know, maybe divorce is actually the strongest impact is actually the strongest impact in terms of that adversity on that child, so that's something that we've got to do a better job, and I know there's some that are moving in that area to try to give some qualitative information about those adverse childhood experiences, so that's just one example, so there's something we could do a little bit better to understand risk factors, also one of the, I'll say, the historic kind of weaknesses in public health is a whole lot on risk factors, we haven't done as much on protective factors, and to be able to identify, well, you know, does it take one protective factor to balance out three or four risk factors, or maybe not, does it have to be one-to-one, so I think our understanding of protective factors and how they play a role in keeping the majority of the population from engaging in interpersonal violence, I think that's some of what we can understand in terms of, you know, what we can do about it, there's still a lot that I'm going to say that, you know, we should be implementing some of the stuff we already know, but the other stuff in terms of thinking about implementing these programs is also thinking about programs that you can implement in what I will call under-resourced communities, so you've got communities in which, you know, they do not have a whole lot of resources, how can we implement programs there that don't require, you know, graduate students coming in and actually carrying out the intervention, how can we do something which we can train lay community health workers to actually carry this out, you know, even when I mentioned in terms of some of the nurse home visitation programs, right, you're talking about registered nurses that are going out to homes, well, they've actually tried that program out in terms of community health workers, in terms of lay people going out and doing those, probably not quite the level of prevention, but it did show that they worked, so now, can we try out some of these other programs, you know, including something like I think I had on that list, that good behavior game, you know, can you do the good behavior game in which you can train community, or maybe parents in the community to actually be some of the implementers of that, you definitely got to do some training of teachers, that's a given, but in terms of those that might help out in the classroom, can you train parents and people that live in the community, residents of community help carry that out, so those are some of the things we need to know about some of the, you know, if we want to talk about the implementation science, so can we do something with maybe a lower level of trainees, so we don't have to have, you know, master's level students or PhD students, you know, to carry out these programs, can we do that with, you know, other kinds of community residents. Awesome, thank you so much, so clearly you're a busy man because your calendar just popped up that you have a meeting right now, but so one, thank you again on behalf of the Center of Excellence in African-American Behavioral Health at Morehouse School of Medicine and my colleagues in the audience, we want to thank you for your time, again there are ways to access Dr. Crosby's presentations for those of you who want it. Alex, do you have a parting word for us? You know, it has been a pleasure to be here, it is always good to kind of talk with different disciplines, different sectors to say, yep, there's a role that you can have to play, so definitely thank the American Psychiatric Association for their interest in this particular topic, thank the audience, you know, for those that were able to tune in and to try to hear, you know, what they can do and really, you know, my last word of encouragement is, you know, take some action, think about, you know, within your community, within your professional organization, what can you do to kind of promote the activities to say, yeah, we need to be doing a little bit more in this particular area. Awesome, well stated, so we have some closing business, it's the next slide, oh, let's see, yep, there we go, right, so for those of you who are claiming credits, here are the instructions here, the email at learningcenteratpsych.org will answer any questions that you might have, we'll leave this up for a minute so that you can take note of the directions, okay, I think, Alex, there may be one more, I think that's it, actually, that's it, well, good enough, all right, so we'll let you go put out some more fires in this important work, thank you so much again, thank you for putting that slide back up, I'm going to turn it over to our colleagues at the APA to close us out. Thank you, everyone, that concludes today's webinar.

interpersonal violence prevention

United States

leading cause of death

adolescents

young adults

public health issue

comprehensive approach

social ecological model

violence prevention

evidence-based programs