The programme, developed with the West Midlands Violence Reduction Partnership, is built on a deceptively simple premise: if the seeds of later violence and antisocial behaviour are often sown in the earliest years of life, then prevention efforts should begin there too. Tizz Time is described as a protective behaviours-infused, trauma-informed programme informed by Adverse Childhood Experiences (ACEs) research, delivered through play-based, child-led sessions designed to promote the voice of the child and support those who may have experienced adversity or trauma at home or within their communities.

The scientific rationale behind targeting such young children is grounded in decades of epidemiological research. The landmark ACE studies, beginning with Felitti’s influential 1998 work, established that childhood abuse, neglect and household dysfunction are strongly associated with poor adult health outcomes and health-harming behaviours. Subsequent studies have extended this picture: UK research by Bellis and colleagues found that ACEs have measurable impacts on adult health behaviours across the British population, while work by Burke and colleagues in urban paediatric populations demonstrated that adversity accumulates and that its effects follow a dose-response pattern. Crouch and colleagues estimated that ACEs are widespread among children in the United States, underscoring that the problem is not confined to any single country or community.

What makes early intervention particularly compelling is the developmental science of violence prevention. Research by Lösel and Farrington on the development of youth violence identified direct protective and buffering protective factors that can interrupt trajectories toward aggression, many of which are established in early childhood. Webster-Stratton and Taylor argued in Prevention Science that intervening in the first eight years of life offers the best chance of nipping early risk factors for substance abuse, delinquency and violence in the bud. Yet the new study’s authors, Sophie Badger and Isha Chopra of the University of Wolverhampton’s Institute of Community Research and Development and Dean Wilkinson of Edge Hill University, note that programmes specifically designed for children aged three to six remain strikingly rare.

To understand why, the team conducted a systematic review of the existing evidence on early years interventions for trauma and violence prevention, published in the journal Trauma, Violence, & Abuse. The review found that the evidence base for this age group is thin, with most trauma-informed programmes aimed instead at older children and adolescents. This gap matters because the mechanisms of violence prevention differ across developmental stages. Young children are not yet capable of the reflective, discussion-based approaches used with teenagers; they learn through play, repetition, relationships and embodied experience. Tizz Time was designed with exactly these constraints in mind, drawing on the protective behaviours framework, an anti-victimisation and empowerment process first articulated by West in 1989, which teaches children to recognise feelings of safety and unsafety and to develop strategies for seeking help.

The published evaluation of Tizz Time employed a process analysis research methodology, an approach that, as Munro and Bloor have argued in Qualitative Research, has become an increasingly vital ingredient in public health research because it illuminates how and why interventions work, or fail to work, rather than merely whether they produce measurable outcomes. Using this methodology, the researchers reviewed and refined the aims, outcomes and objectives of the programme and constructed a formal Logic Model, following the logic modelling methods for programme evaluation described by Frechtling. A Logic Model maps the causal chain from programme inputs and activities through to short-term, intermediate and long-term outcomes, providing a testable theoretical framework that future evaluations can interrogate.

At the heart of the evaluation were qualitative interviews with teachers and the programme’s facilitator, analysed using thematic analysis, the widely used approach to qualitative data developed by Clarke and Braun. The interviews sought to assess initial indicators of success and to explore the feasibility and implementation of the programme in real school settings, including the facilitators and barriers that emerged during delivery. This implementation focus is critical in the emerging science of trauma-informed education. A 2021 systematic review by Avery and colleagues of school-wide trauma-informed approaches, published in this same journal, highlighted that schools often adopt the language of trauma-informed practice without the structural changes needed to sustain it, while Cavanaugh’s work on trauma-informed classrooms and models such as the HEARTS programme developed by Dorado and colleagues have emphasised that creating genuinely trauma-informed environments requires multi-level, whole-school change rather than isolated sessions.

The findings from the Tizz Time evaluation were encouraging on several fronts. Staff and teachers responded positively to the trauma-informed training component of the programme, reporting increased knowledge of trauma-informed practice and, crucially, sharing what they had learned widely throughout their schools. This diffusion effect suggests that the training component may act as a multiplier, embedding trauma-informed principles beyond the immediate participants in the programme. Equally significant, teachers reported observing positive changes in children’s behaviour and emotion regulation, an outcome that aligns with theoretical expectations: children exposed to chronic adversity often struggle with emotional self-regulation, and play-based interventions provide repeated, low-stakes opportunities to practise these skills in a supportive relational context.

The researchers were careful not to overclaim. Recognising that the evaluation was an early process study rather than a definitive outcome trial, they established data monitoring format recommendations designed to allow for future impact review and outcome analysis. This staged approach reflects best practice in intervention science, where promising programmes are first assessed for feasibility, acceptability and implementation fidelity before being subjected to resource-intensive randomised controlled trials. It also mirrors the approach taken in related evaluations of trauma-informed elementary school interventions, such as the study by Rishel and colleagues published in Children & Schools, which similarly found early positive signals alongside a need for more rigorous outcome measurement.

The wider policy context gives this work particular urgency. Violence in England and Wales remains a significant public health concern, and the public health approach to violence reduction, championed by Public Health England and adopted by Violence Reduction Partnerships across the country, treats violence not as an inevitability to be policed but as a preventable phenomenon to be addressed through its upstream determinants. This approach, discussed critically by scholars such as Mitton and by Fraser and Irwin-Rogers in their strategic briefing on public health approaches to violence reduction, draws explicitly on the World Health Organization’s framing of violence as a global public health problem. Central to this framing is the recognition that exposure to violence begets violence: children who witness or experience violence, including domestic violence as documented in population-based research by Fantuzzo and Fusco, are at elevated risk of later violent behaviour, mental health difficulties and diminished life opportunities, as Metzler and colleagues described in their work on shifting the ACE narrative.

What distinguishes Tizz Time within this landscape is its combination of direct child-facing delivery and workforce development. Meta-analytic evidence from Olaghere and colleagues on trauma-informed interventions for at-risk and justice-involved youth suggests that trauma-informed approaches can produce meaningful reductions in offending-related outcomes, but almost all of this evidence concerns older age groups. By extending the logic of trauma-informed prevention down into the early years, Tizz Time addresses a structural blind spot. Its emphasis on the voice of the child is also notable; child-led, play-based design respects the agency of very young children, an ethos that resonates with children’s rights perspectives in youth justice scholarship, such as the future-of-youth-justice arguments advanced by Haines and Case.

The study also situates the programme within the risk and protective factors paradigm that dominates contemporary prevention science. Sabina and Banyard have argued that violence research should move decisively toward the study of protective factors, the strengths and resources that buffer children against harm, rather than focusing solely on risk accumulation. Tizz Time operationalises this shift by aiming to build children’s internal protective capacities, including emotional literacy, help-seeking and an embodied sense of safety, while simultaneously building external protective capacity through a more trauma-informed adult workforce around each child.

The research team acknowledges that significant questions remain. Whether the positive changes observed by teachers translate into durable, measurable reductions in problem behaviour, and ultimately in longer-term outcomes related to violence, will require the outcome data collection infrastructure now being recommended. Questions of scalability, fidelity of delivery beyond a single facilitator, and sustainability in schools facing competing pressures all loom. Yet the process evaluation demonstrates that a trauma-informed, play-based violence prevention programme can be implemented feasibly in early years settings and embraced by the professionals who deliver it.

For a field in which the youngest children have long been an afterthought in violence prevention planning, Tizz Time represents both a practical innovation and a conceptual challenge: a demonstration that prevention science can, and perhaps must, begin before children can even read. As the researchers put it in considering the programme’s potential against the wider public health approach to violence prevention, the earliest years may be where the greatest returns lie. The study was conducted for and commissioned by the West Midlands Violence Reduction Partnership, with ethics approval granted by the University of Wolverhampton Ethics Committee and informed consent provided by all participants. The authors report no competing interests.

The NCMD, established in 2019, serves as the first comprehensive repository to collect data on all child deaths in England from birth through age 17. Researchers leveraged this database, integrating demographic data and health records with 2021 census information to adjust for population differences, thereby providing refined mortality rates. Over the five-year period studied, 145 children succumbed to knife wounds, with a sharp rise in incidents recorded since 2021. This spike highlights an intensifying crisis that disproportionately affects young males—who account for 90% of the fatalities.

Geographic analysis points to London as the epicenter of these knife-related deaths, representing 43% of the total cases. Urban centers like the West Midlands and the North West follow in incidence but far behind London’s elevated rates. These findings correlate with broader criminological and social data demonstrating the concentration of serious youth violence in densely populated metropolitan areas, where socioeconomic pressures are often acute. Contrastingly, regions such as the South East and East of England experience substantially lower fatal stabbing rates, indicating possible regional protective factors or differing social dynamics.

Ethnicity emerges as a significant determinant of risk, with children identified as Black being 13 times more likely to suffer fatal stab wounds compared to their White counterparts. This disparity is compounded by socioeconomic deprivation; children living in England’s most deprived areas face a fatality rate seven times higher than those in the country’s most affluent neighborhoods. These intersecting factors of race and poverty emphasize the structural inequalities underpinning youth violence and highlight a critical need for multifaceted public health approaches that address these root causes.

Detailed forensic and medical examination of 57 available case files reveals that the majority of fatal injuries target vital regions, with chest and neck wounds accounting for 76% of deaths. The lethality of such injuries is compounded by prehospital mortality, as over half of these victims (60%) died before reaching medical care. These findings underscore gaps in both emergency response and possible preventive surveillance mechanisms that might intervene before lethal injury occurs.

The study also delves deeply into the psychosocial dimensions preceding these deaths. A striking 75% of the children were known to social services prior to their fatal injuries, indicating existing vulnerability and contact with protective systems. Moreover, 59% of these children had documented experiences of domestic abuse, and 51% had endured the loss of an important adult figure—through death, separation, or bereavement—highlighting the critical role of trauma and adverse childhood experiences in the pathway to violence-related mortality.

Gang involvement is identified in over one-third of analyzed cases, affirming the connection between organized youth violence and lethal knife crime. Furthermore, illicit substance use was noted in 68% of the children before their deaths, implicating complex behavioral health issues that intertwine with violent outcomes. Concerns about knife carrying were documented in approximately one-quarter of cases, suggesting that early recognition of weapon possession might offer an opportunity for targeted preventive strategies.

Mental health and neurodiversity concerns were also prominent, with half of the children exhibiting such diagnoses, and just over a quarter (28%) having been referred to Child and Adolescent Mental Health Services (CAMHS). These statistics reveal significant intersections between cognitive, emotional health issues, and violent victimization and perpetration, demanding integrated responses that encompass mental health, social support, and violence prevention frameworks.

A troubling insight from the investigation is the dual role many victims played as both perpetrators and victims of violence—60% of cases involved children who were engaged in violent behavior themselves. This bidirectional involvement calls for nuanced understanding and interventions that address the cyclical nature of youth violence, emphasizing rehabilitation and support alongside law enforcement measures.

Researchers highlight critical gaps in preinjury identification and support for marginalized children, especially those exposed to domestic violence and other adverse experiences. Despite frequent contacts with social and statutory services, many children did not receive adequate targeted interventions to mitigate exposure to violence and trauma. This lack of early and focused intervention marks a failure point in safeguarding vulnerable youth populations and contributes to preventable loss of life.

The UK government’s commitment in 2024 to halving knife crime within the parliament’s lifetime is noted as a vital policy response. Nonetheless, this study signals that success will depend heavily on deploying resources toward early detection of risk factors, culturally sensitive outreach in racialized and deprived communities, and a concerted focus on social determinants of health. Holistic strategies incorporating education, mental health services, family support, and community engagement are essential to reversing these trends.

In conclusion, the comprehensive review of fatal knife crimes against children in England presents a stark portrait of contemporary youth violence—intertwined with racial, socioeconomic, and psychological complexities. The data compel public health officials, policymakers, and practitioners to reevaluate current intervention paradigms, prioritizing early, sustained, and multifaceted efforts to disrupt the trajectory from childhood adversity to deadly violence. Only through systemic changes and dedicated support to the most vulnerable can the tide of youth knife crime begin to recede.

Subject of Research: People

Article Title: Preinjury, injury and postinjury factors leading to death in children and young people who were victims of knife crime in England between 2019 and 2024: a review of the National Child Mortality Database

News Publication Date: 20-Apr-2026

Web References: National Child Mortality Database (NCMD)

References: DOI: 10.1136/emermed-2025-215154

Keywords: Violence, Children, Adolescents, Domestic violence