1. Moffitt TE, Caspi A, Harrington H, Milne BJ. Males on the life-course-persistent and adolescence-limited antisocial pathways: Follow-up at age 26 years. Dev Psychopathol. 2002;14(1):179–207.[PubMed]
2. Huesmann LR, Eron LD, Lefkowitz MM, Walder LO. The stability of aggression over time and generations. Dev Psych. 1984;20(6):1120–1134.
3. Bushman BJ, Huesmann LR. Short-term and Long-term Effects of Violent Media on Aggression in Children and Adults. Arch Pediatr Adolesc Med. 2006;160:348–352.[PubMed]
4. Huesmann LR, Kirwil L. Why observing violence increases the risk of violent behavior in the observer. In: Flannery D, editor. The Cambridge Handbook of Violent Behavior and Aggression. Cambridge, UK: Cambridge University Press; in press.
5. Berkowitz L, LePage A. Weapons as aggression-eliciting stimuli. J Pers Soc Psychol. 1967;7:202–7.
6. Bryant J, Zillmann D. Effect of intensification of annoyance through unrelated residual excitation on substantially delayed hostile behavior. J Exp Soc Psychol. 1979;15(5):470–80.
7. Geen RG, O’Neal EC. Activation of cue-elicited aggression by general arousal. J Pers Soc Psychol. 1969;11(3):289–92.[PubMed]
8. Huesmann LR. Imitation and the effects of observing media violence on behavior. In: Hurley S, Chater N, editors. Perspectives on imitation: From neuroscience to social science; Volume 2: Imitation, human development, and culture. Cambridge, MA: MIT Press; 2005. pp. 257–266.
9. Meltzoff AN, Moore MK. Imitation of facial and manual gestures by human neonates: Resolving the debate about early imitation. In: Muir D, Slater A, editors. Infant Development: The Essential Readings. Malden, MA: Blackwell Publishers; 2000. pp. 167–81.
10. Rizzolati G, Fadiga L, Gallese V, Fogassi L. Premotor cortex and the recognition of motor actions. Cognitive Brain Res. 1996;3:131–41.[PubMed]
11. Huesmann LR. The role of social information processing and cognitive schema in the acquisition and maintenance of habitual aggressive behavior. In: Geen RG, Donnerstein E, editors. Human aggression: Theories, research, and implications for social policy. New York: Academic Press; 1998. pp. 73–109.
12. Dodge KA. Attributional bias in aggressive children. In: Kendall PC, editor. Advances in Cognitive-Behavioral Research and Therapy. Vol. 4. San Diego, CA: Academic Press; 1985. pp. 73–110.
13. Huesmann LR, Guerra NG. Children’s normative beliefs about aggression and aggressive behavior. J Pers Soc Psychol. 1997;72(2):408–19.[PubMed]
14. Comstock G, Paik H. Television and the American child. San Diego, CA: Academic Press; 1991.
15. Wilson BJ, Kunkel D, Linz D, Potter J, Donnerstein E, et al. Violence in television programming overall: University of California, Santa Barbara study. In: Seawall M, editor. National Television Violence Study. Vol. 1. Thousand Oaks, CA: Sage Publications; 1997. pp. 3–184.
16. Roberts DF, Foehr UG, Rideout VJ. Generation M: Media in the lives of 8–18 year- olds. Menlo Park, CA: The Henry J. Kaiser Family Foundation; 2005.
17. Haninger K, Thompson KM. Content and ratings of teen-rated video games. JAMA. 2004;291(7):856–865.[PubMed]
18. Paik H, Comstock G. The effects of television violence on antisocial behavior: A meta-analysis. Commun Res. 1994;21:516–46.ress.
19. Anderson CA, Bushman BJ. Effects of violent video games on aggressive behavior, aggressive cognition, aggressive affect, physiological arousal, and prosocial behavior: A meta- analytic review of the scientific literature. Psych Sci. 2001;12:353–59.[PubMed]
20. Bandura A, Ross D, Ross SA. Imitation of film-mediated aggressive models. J Abnorm Soc Psych. 1963b;67:3–11.[PubMed]
21. Bjorkqvist K. Violent Films, Anxiety, and Aggression. Helsinki: Finnish Society of Sciences and Letters; 1985.
22. Josephson WL. Television violence and children’s aggression: Testing the priming, social script, and disinhibition predictions. J Pers Soc Psychol. 1987;53:882–90.[PubMed]
23. Leyens JP, Parke RD, Camino L, Berkowitz L. Effects of movie violence on aggression in a field setting as a function of group dominance and cohesion. Journal of Personality and Social Psychology. 1975;32:346–360.[PubMed]
24. Irwin AR, Gross AM. Cognitive tempo, violent video games, and aggressive behavior in young boys. J Family Violence. 1995;10:337–50.
25. Bartholow BD, Anderson CA. Effects of violent video games on aggressive behavior: Potential sex differences. J Exp Soc Psych. 2002;38:283–90.
26. Anderson CA. Effects of violent movies and trait irritability on hostile feelings and aggressive thoughts. Aggressive Behav. 1997;23:161–78.
27. Anderson CA, Berkowitz L, Donnerstein E, Huesmann LR, Johnson J, Linz D, Malamuth N, Wartella E. The influence of media violence on youth. Psychological Science in the Public Interest. 2003;4(3):81–110.[PubMed]
28. Williams D, Skoric M. Internet fantasy violence: A test of aggression in an online game. Communication Monographs. 2005;72:217–233.
29. Milavsky JR. Quantitative studies in social relations. New York: Academic Press; 1982. Television and aggression: a panel study.
30. Huesmann LR, Lagerspetz K, Eron LD. Intervening variables in the TV violence- aggression relation: Evidence from two countries. Dev Psych. 1984;20:746–75.
31. Huesmann LR, Eron LD, editors. Television and the Aggressive Child: A Cross- National Comparison. Hillsdale, NJ: Erlbaum; 1986.
32. Eron LD, Huesmann LR, Lefkowitz MM, Walder LO. Does television violence cause aggression? Am Psychol. 1972;27:253–63.[PubMed]
33. Huesmann LR, Moise-Titus J, Podolski CL, Eron LD. Longitudinal relations between children’s exposure to TV violence and their aggressive and violent behavior in young adulthood: 1977–1992. Devl Psych. 2003;39:201–21.[PubMed]
34. Huesmann LR, Miller LS. Long-term effects of repeated exposure to media violence in childhood. In: Huesmann LR, editor. Aggressive Behavior: Current Perspectives. New York: Plenum Press; 1994. pp. 153–83.
35. Slater MD, Henry KL, Swaim RC, Anderson LL. Violent media content and aggressiveness in adolescents: A downward spiral model. Commun Res. 2003;30(6):713–36.
36. Bandura A, Ross D, Ross SA. Vicarious reinforcement and imitative learning. J Abnorm Soc Psych. 1963;67:601–07.[PubMed]
37. Berkowitz L, Powers PC. Effects of timing and justification of witnessed aggression on the observers’ punitiveness. J Res Pers. 1979;13:71–80.
38. Leyens JP, Picus S. Identification with the winner of a fight and name mediation: Their differential effects upon subsequent aggressive behavior. Brit J Soc Clin Psych. 1973;12:374–77.[PubMed]
39. Abelson RP. A variance explanation paradox: When a little is a lot. Psych Bull. 1985;97:129–33.
40. Rosenthal R. Media violence, antisocial behavior, and the social consequences of small effects. J Soc Issues. 1986;42(3):141–54.
41. Bushman BJ, Huesmann LR. Effects of televised violence on aggression. In: Singer D, Singer J, editors. Handbook of children and the media. Thousand Oaks, CA: Sage Publications; 2001. pp. 223–54.
The World Health Organization has defined violence as “the intentional use of physical force or power, threatened or actual, against oneself, another person, or against a group or community, which either results in or has a high likelihood of resulting in injury, death, psychological harm, maldevelopment, or deprivation.”1
Violence occurs at an alarming rate in the United States. Among Americans aged 15 to 34 years, two of the top three causes of death are homicide and suicide.2 In a given year, more U.S. children will die from gunfire than will die from cancer, pneumonia, influenza, asthma, and HIV/AIDS combined.3
The rate of firearm-related death or injury in the United States is the highest among industrialized countries, with more than 32,000 deaths each year. In recent years, this has meant that 88 people die each day from firearm-related homicides, suicides, and unintentional deaths. Further, the number of nonfatal injuries due to firearms is more than double the number of deaths.4
While there are multiple factors that lead to violent actions, a growing body of literature shows a strong association between the perpetration of violence and the exposure to violence through the media.
Media Violence in the United States
Children and adolescents in the U.S. spend an average of about seven and a half hours a day using various forms of entertainment media, such as television, video games, the Internet, and recorded music. Research suggests that the time they spend interacting with various media surpasses all other activities except sleep.5
Moreover, studies have shown that by the time young people living today reach their 70s, they will have spent the equivalent of 7 to 10 years of their lives watching television.6
Today’s children live in environments where, on average, families own nearly four televisions, nearly three DVD players, one DVR, two CD players, two radios, two video game consoles, and two computers.5 Television still dominates children’s media consumption, but the number of kids watching television are dropping with each age group. At the same time, media consumption through mobile devices and the Internet is increasing in every age group.7
Studies demonstrating an association between exposure to violence in the media and real-life aggression and violence began appearing in the 1950s. Since then, various government agencies and organizations have examined the relationship. These include a 1972 Surgeon General’s report,8 a 1982 National Institute of Mental Health (NIMH) review,9 and a 2000 Congressional summit which issued a joint statement on the impact of entertainment violence on children.10 In 2000, the Federal Bureau of Investigation (FBI) released a report noting that media violence is a risk factor in shootings in school.11 A 2003 NIMH report noted media violence to be a significant causal factor in aggression and violence.12 The Federal Communications Commission (FCC) issued a 2007 report on violent programming on television, and noted that there is “strong evidence” that exposure to violence through the media can increase aggressive behavior in children.13
These reports and others are based on a body of literature that includes more than 2,000 scientific papers, studies, and reviews demonstrating the various effects that exposure to media violence can have on children and adolescents. These include increases in aggressive behavior, desensitization to violence, bullying, fear, depression, nightmares and sleep disturbances.14,15,16
Some studies found the strength of association to be nearly as strong as the association between cigarette smoking and lung cancer, and stronger than the well-established associations between calcium intake and bone mass, lead ingestion and IQ, and failure to use condoms and acquisition of HIV.17
Violence is ubiquitous in mass media in the U.S., whether consumed through television, video games, music, movies, or the Internet.
An average American youth will witness 200,000 violent acts on television before age 18.18 Violence is often considerable, even in programs not advertised as violent. Overall, weapons appear on prime time television an average of nine times each hour.19 An estimated 54 percent of American children can watch this programming from the privacy of their own bedrooms.20,21,22
Children’s shows are particularly violent. Watching Saturday morning cartoons used to be a common aspect of American life. Now, networks feature cartoons continuously. Studies analyzing the content of popular cartoons noted that they contain 20 to 25 violent acts per hour, which is about six times as many as prime time programs.23 Overall, 46 percent of television violence occurs in cartoons.20,21,22 Additionally, these programs are more likely to juxtapose violence with humor (67 percent) and less likely to show the long-term consequences of violence (5 percent).21,22,23,24 Although some claim that cartoon violence is not as “real” and therefore not as damaging, cartoon violence has been shown to increase the likelihood of aggressive, antisocial behavior in youth.24 This makes sense in light of children’s developmental difficulty discerning the real from the fantastic.25
Nearly all American teens – one survey documenting 97 percent – play video games. Studies have shown the average time spent playing to be around 13 hours per week.26 Many games have violent content and studies have shown a significant association between violent content with increases in aggression, desensitization to violence, decrease in positive social behaviors, and increases in delinquent behaviors.27,28,29 Video games offer players the opportunity to be “virtual perpetrators,” by assuming the roles of aggressors and soldiers. These interactive games also reward players for successful violent behavior. Studies have shown that the general effects of violence may be more profound when children play these interactive games than when they watch violence in a more passive manner, such as when watching television.30,31
Music (Lyrics and Music Videos)
Music plays a central role in adolescent and young adult lives, helping them sort through emotions and identify with certain peer groups and develop a sense of self. Children 8 to 18 years of age have been found to listen to at least two and a half hours of music a day.5
Fewer studies have looked at the effects of violence portrayals in music. One study by the American Psychological Association (APA) found a correlation between violent lyrics, and aggressive thoughts and emotions, but not actions.32
Music videos have been sources of violent content for decades. Content analysis has shown that in music videos more than 80 percent of violence is perpetrated by attractive people, and that it depicts acts of violence mainly against women and minorities.33 Violent scenes were of a sexual nature in many, with one study showing that 81 percent of videos that portrayed violence contained sexual imagery, often intertwined. Additionally, artistic features and editing may juxtapose violence with beautiful scenery, potentially linking it to pleasurable or pleasing experiences.34
Several studies have focused on rap music, and found them to contain more violence than other genres. They also found viewers to be more likely to accept the use of violence, to accept violence against women, and to commit violent or aggressive acts themselves.34
Studies have found that 91 percent of movies on television contained violence, even extreme violence.35 Several researchers have described an increase of violent content in movies, despite a national rating system. They note that the amount of gun violence in top grossing PG-13 films has more than tripled since the introduction of the rating in 1985.36 It was also noted that, in 2012, popular PG-13 films contained significantly more gun violence than R-rated films.37
Children, adolescents and young adults consume entertainment from a variety of sources that are accessible 24 hours a day, are mobile, and offer passive, as well as more active engagement. Many of these media platforms feature entertainment that contains significant doses of violence, and portrays sexual and interpersonal aggression. Multiple studies have shown a strong association, and suspicion or suggestion of causality between exposure to violence in the media, and aggressive or violent behavior in viewers. This is a serious public health issue that should concern all family physicians.
What Can Family Physicians Do
1. Clinical Setting
a. Consider discussing media use during well-child visits
- Ask at least two media-related questions: 1) How much entertainment media per day is the child or teenager watching? 2) Is there a television set or Internet connection in the child's or teenager's bedroom?
- Question patients about excessive exposure to media violence.
- If you identify heavy use (more than 2 hours daily), take additional history of aggressive behaviors, sleep problems, fears, and depression.
- Suggest healthy alternatives.
- Children under two years of age should be discouraged from watching television.
- Incorporate warnings about the health risks of violent media consumption into the well-child visit.
b. Encourage parents and caregivers to monitor content. Parental monitoring has been shown to have protective effects on several academic, social and physical outcomes, including aggressive behaviors.36
- Urge parents to co-view shows and content with their children.
- Encourage parents to discuss the content of television, films, video games, music videos, and the Internet with their children and make comparisons to real-life situations and consequences.
- Consider and discuss movie and video game ratings and labels with parents to set expectations and guide choice of content.
Although film ratings and advisory labels can help parents decide on programs to be avoided, there are two major problems with relying on this system. First, certain labels, such as “parental discretion advised” and “R” have been shown to attract children, especially boys.20,21,22 Second, violence is present is many programs not considered to be violent, such as children’s cartoons.
c. Counsel parents and caregivers to limit exposure duration
- Exposure can be limited by removing televisions, video games, computers, and Internet connection from the bedroom.
- Limit screen time to no more than two hours a day.
- Use technology that locks certain channels or turns off the computer or television after a certain amount of time.
d. Clinical environment
- Limit video and television use in waiting rooms.
- Provide only nonviolent media choices in outpatient waiting rooms and inpatient settings.
- Provide books, toys, and other alternative activities for patients who are waiting.
2. Promote Media Education
In addition to limiting exposure to violent media, educational efforts should be developed to help children understand the divide between real and fictionalized violence. Such media literacy programs have been shown to be effective, both in limiting the negative effects of media, as well as in exploring the potential positive social uses of media.39,40,41
- Encourage patients, children, families, and caregivers to participate in media education, and media literacy programs.
- Advise adults to watch with their children, and help them process media violence. Taping programs beforehand enables pausing for discussion or processing.
- Support the development of media education programs that focus on demystifying and processing media violence. Emphasis should be placed on the inappropriate and unrealistic nature of violence on television and films, and the consequences, responsibility, and complexity involved with true violence.
3. Support and Engage in Professional Education
- Become familiar with the research of trends of media use, and the effects of medial violence on patients.
- Disseminate this knowledge via teaching at medical schools, residencies, grand rounds, and via community–based lectures.
- Request, attend, or create CME.
4. Advocacy and Policy Changes
- Partner with other medical organizations, government entities, and educators to advocate keeping this issue on the public’s health agenda.
- Partner with families and community-based organizations to demand that media producers limit the amount and type of violence portrayed in mass media.
- Advocate for research funding to continue studying this topic.
- Advocate for enhancements to media rating systems to enable parents and caregivers to guide their children to make healthy media choices.
- World Health Organization. Health Topics. Violence. 2015. www.who.int/topics/violence/en(www.who.int). Accessed July 10, 2015.
- Centers for Disease Control and Prevention. Deaths: final data for 2013. National vital statistics reports; vol. 64, no. 2. National Center for Health Statistics. 2013. http://www.cdc.gov/nchs/data/nvsr/nvsr64/nvsr64_02.pdf(www.cdc.gov). Accessed June 30, 2015.
- Children’s Defense Fund. Protect children instead of guns, 2004.
http://www.childrensdefense.org/library/data/protect-children-not-guns-report-2004.pdf(www.childrensdefense.org). Accessed June 18, 2015.
- Weinberger SE, et al. Firearm-related injury and death in the United States: a call to action from 8 health professional organizations and the American Bar Association. Ann Intern Med. 2015;162(7):513-516.
- A Kaiser Family Foundation Study. Generation M2: media in the lives of 8- to 18-year-olds. http://kff.org/other/report/generation-m2-media-in-the-lives-of-8-to-18-year-olds/(kff.org). Accessed March 29, 2015.
- American Academy of Pediatrics. Council on Communications and Media. Policy Statement. Children, adolescents, and the media. Pediatrics. 2013;132;(5):958-961.
- Adweek. The Kids Issue. Infographic: a look at kids’ media consumption. Where different age groups tend to spend their time online. 2015. http://www.adweek.com/news/television/infographic-look-kids-media-consumption-163087(www.adweek.com). Accessed July 10, 2015.
- U.S. Public Health Service. Television and growing up: the impact of televised violence. Report to the Surgeon General. 1972.
- U.S. Department of Health and Human Services. National Institute of Mental Health. Television and behavior. Ten years of scientific progress and implications for the eighties. Volume I: summary report. 1982. http://eric.ed.gov?id=ED222186(eric.ed.gov?id=ED222186).
- American Academy of Pediatrics, et al. Joint statement on the impact of entertainment violence on children, Congressional Public Health Summit. 2000.
http://www2.aap.org/advocacy/releases/jstmtevc.htm(www2.aap.org). Accessed March 29, 2015.
- FBI Academy. Critical Incidence Response Group. National Center for the Analysis of Violent Crime. The school shooter: a threat assessment perspective.
http://www.fbi.gov/stats-services/publications/school-shooter(www.fbi.gov). Accessed March 29, 2015.
- Anderson CA, et al. The influence of media violence on youth. Psychol Sci Public Interest. 2003(4)3:81-110.
- Federal Communications Commission. In the matter of violent television programming and its impact on children. 2007. https://apps.fcc.gov/edocs_public/attachmatch/FCC-07-50A1.pdf(apps.fcc.gov).
- Gentile D. Media Violence and Children: A Complete Guide for Parents and Professionals. Westport, CT: Praeger; 2014.
- Coker TR, et al. Media violence exposure and physical aggression in fifth-grade children. Acad Pediatr. 2015;(15)1:82-88.
- Ybarra ML, et al. Linkages between Internet and other media violence with seriously violent behavior by youth. Pediatrics. 2008;(122)5:929-937.
- Singer DG, Singer JL. Handbook of Children and the Media. Thousand Oaks, CA: Sage Publications, Inc.; 2001.
- American Psychological Association. Violence & youth: psychology’s response. Volume I: summary report of the American Psychological Association Commission on Violence and Youth. 1993. http://eric.ed.gov/?id=ED379056(eric.ed.gov).
- Strasburger VC, et al. Children, adolescents, and the media in the 21st century. Adolesc Med. 2000;11(1):51-68.
- Seawell M. National television violence study. Volume 1. Thousand Oaks, CA: Sage Publications, Inc. 1996.
- Federman J. National television violence study. Volume 2. Thousand Oaks, CA: Sage Publications, Inc. 1997.
- Seawell M. National television violence study. Volume 3. Thousand Oaks, CA: Sage Publications, Inc. 1998.
- American Academy of Pediatrics. Committee on Communications. Media violence. Pediatrics. 1995(6):949-951.
- Leung LR, et al. Children and television. Am Fam Physician. 1994;50:909-918.
- Huesmann LR, et al. Mitigating the imitation of aggressive behaviors by changing children’s attitudes about media violence. J Pers Soc Psychol. 1983;44(5):899-910.
- Greitemeyer Y, Mugge DO. Video games do affect social outcomes: a meta-analytic review of the effects of violent and prosocial video game play. Pers Soc Psychol Bull. 2014;40(5):578-589.
- Brockmyer JF. Playing violent video games and desensitization to violence. Child Adolesc Psychiatr Clin N Am. 2015;24(1):65-77.
- Exelmans L, Clusters K, Van den Bulck J. Violent video games and delinquent behavior in adolescents: a risk factor perspective. Aggress Behav. 2015;41(3):267-279.
- Willoughby T, Adachi PJ, Good M. A longitudinal study of the association between violent video game play and aggression among adolescents. Dev Psychol. 2012;48(4):1044-1057.
- Hollingdale J, Greitemeyer T. The effect of online violence video games on levels of aggression. PLoS ONE. 2014;9(11):e111790.
- Anderson, CA, Gentile DA, and Buckley KE. Violent Video Game Effects on Children and Adolescents. New York, NY: Oxford University Press; 2007.
- Anderson CA, Carangey NL, Eubanks J. Exposure to violent media: the effects of songs with violent lyrics on aggressive thoughts and feelings. J Pers Soc Psychol. 2003;(84)5:960-971.
- Rich M, et al. Aggressors or victims: gender and race in music video violence. Pediatrics. 1998;101(4 Pt 1):669-674.
- Ashby SL, et al. Video killed the radio star: the effects of music videos on adolescent health. Adolesc Med Clin. 2005;(16)2:371-393.
- Worth KA, et al. Exposure of US adolescents to extremely violent movies. Pediatrics. 2008;(122)2:306-312.
- Romer D, et al. Parental desensitization to violence and sex in movies. Pediatrics. 2014;(134)5:877-884.
- Bushman BJ, et al. Gun violence trends in movies. Pediatrics. 2013;132(6):1014-1018.
- Gentile DA, et. al. Protective effects of parental monitoring of children's media use: a prospective study, JAMA Pediatr. 2014;(168)5:479-484.
- American Academy Pediatrics. Committee on Public Education. Media education.Pediatrics. 1999;104(2):341-343.
- Brown JA. Television, ‘Critical Viewing Skills,’ Education: Major Media Literacy Projects in the United States and Selected Countries (Routledge Communication Series). Mahwah, NJ: Lawrence Erlbaum Associates, Inc.; 1991.
- Voojis MW, van der Voort THA. Learning about television violence: the impact of a critical viewing curriculum on children's attitudinal judgments of crime series. J Res Dev Educ. 1993;26(3):133-142.
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