- Email: [email protected]
The prevention of youth violence
The Prevention of Youth Violence The Rationale for and Characteristics of Four Evaluation Projects Robin M. Ikeda, MD, MPH, Thomas R. Simon, PhD, Monica Swahn, MPH Abstract:
In response to the magnitude of violence in the United States, a number of violenceprevention programs have been implemented throughout the country. However, relatively few have been rigorously evaluated for effectiveness. To encourage development and evaluation of violence-prevention interventions that focus on young children and their families, the Centers for Disease Control and Prevention (CDC) provided funding to four projects in 1996. This paper briefly describes the rationale for funding these projects, which is based on our understanding of the development of aggressive and violent behavior and on the literature regarding promising approaches to prevent problem behavior in this age group. We provide an overview of the four specific projects funded by the CDC as well as a short discussion of some of the many challenges encountered during their implementation. Medical Subject Headings (MeSH): aggression, primary prevention, violence, youth (Am J Prev Med 2001;20(1S):15–21)
Introduction
I
n response to the magnitude of violence in the United States, a number of violence-prevention programs have been implemented throughout the country. However, few have been rigorously evaluated for effectiveness. To encourage the development and evaluation of violence-prevention interventions that involve young children and their families, the Centers for Disease Control and Prevention (CDC) provided funding to four projects in 1996. Although the goal for each of these four projects was to develop, implement, and evaluate multifaceted violence-prevention interventions for children at risk for aggressive and violent behavior, this supplement to the American Journal of Preventive Medicine focuses on one specific aspect of this process— documenting some of the challenges encountered, particularly those related to implementation, and offering suggestions for solution and further scientific study. To provide background information and context for the papers that follow, this paper (1) briefly describes the rationale for funding violence-prevention programs that focus on young children and their families and (2) provides an overview of the four specific projects funded by the CDC.
From the National Center for Injury Prevention and Control, Centers for Disease Control and Prevention, Atlanta, Georgia Address correspondence and reprint requests to: Robin M. Ikeda, MD, MPH, National Center for Injury Prevention and Control, Centers for Disease Control and Prevention, 4770 Buford Highway, MS K-60, Atlanta, GA 30341. E-mail: [email protected].
Am J Prev Med 2001;20(1S) Published by Elsevier Science Inc.
The Case for Early Intervention Involving Families In the United States, rates of violent victimization and perpetration are highest among adolescents and young adults.1,2 For this reason and because our knowledge about the development of violent and aggressive behavior suggests that such behavior evolves over a long period and becomes more resistant to change as children enter adolescence, the need to intervene early has become increasingly clear.3 In addition, many of the risk factors associated with the development of violence often exist at a young age.4,5 For example, the onset of minor aggression may begin as early as age 3 and physical fighting as early as age 5.6 Such early aggressive behavior is one of the strongest predictors of subsequent aggressive behavior.7 Evidence also suggests that aggressive behavior that begins early in childhood is associated with more serious violent behavior in later years.8 Similarly, many of the family characteristics recognized as risk factors for violence are also present during childhood. In many at-risk families, precursors to violence, such as problem parental behavior (e.g., drug or alcohol use), and poor parental monitoring and supervision, are often apparent early in a child’s life, and these factors generally remain constant over time.4 Intervention at an early stage helps disrupt the effect of these factors and prevents the sustained exposure to these negative influences over many years. Given that many of the key risk factors for violence are family-related or are influenced by family dynamics (e.g., attitude toward violence, family conflict, commu-
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nication), the effectiveness of interventions designed to change individual children’s attitudes, beliefs, and behavior may be limited if the messages are not supported and reinforced in the home or if these family factors are not addressed. Improving family situations and functioning may be especially important for young children, who often have less opportunity than schoolaged children to interact with positive adult role models outside the family. Furthermore, the most significant settings for juvenile aggression are the home and school.8 Thus, for children not yet in school, the home becomes the principal location in which behavioral problems surface. This may also be true for children already in school; one cross-sectional study of fighting among school-aged boys found that 49% of them fought only at home, 30% only in school, and 21% both in school and at home.9 Promising findings from recent studies of conduct disorder in young children also support the importance of early intervention and the need to involve families and caregivers in prevention efforts. These studies suggest that combinations of cross-contextual interventions that involve parents and children10 or families and children’s teachers11 may be more effective in reducing problem behavior than are interventions with a single focus. In another study designed to determine the long-term effects of prenatal and early-childhood home-visiting programs, Olds et al.12,13 found that adolescents from at-risk families whose homes nurses visited prenatally and during the first 2 years of life exhibited less antisocial behavior and less substance abuse than adolescents from families who were not visited. Additional support for intervening early and using a comprehensive approach that includes family members or other responsible caregivers comes from reviews of other youth health-promotion programs that focused on behavioral change.14 –16 Given our current understanding of the development of violent behavior and the evidence from programs designed to prevent problem behaviors, strong justification exists for evaluating these approaches with respect to violence prevention.
Overview of the Four Projects Background The projects received funding for a 3-year period through a competitive process, and the yearly award to support project activities ranged from $340,000 to $395,000. The four funded projects were based in separate, distinct geographic locations: the San Francisco Bay Area, California; Jacksonville, Florida; Kansas City, Missouri; and Columbia, South Carolina. As requested in the announcement, all projects targeted young children aged 3 to 10 years and their families, 16
and the intervention activities took place in a variety of settings. A second criterion for selection involved the extent to which the proposed target group had a high incidence or prevalence of the risk factors that the proposed intervention components sought to influence. In general, the interventions that the projects selected were designed to encourage pro-social behavior and attitudes among children and their families. Because the funding announcement focused on young children, applicants were also encouraged to involve other influential adults in the children’s lives such as teachers. Perhaps not surprisingly, the interventions developed at the four sites were similar to one another and to others designed for this age group in one respect—all included components to promote effective parenting as one approach to foster pro-social, nonviolent behavior among the children.10,11,17,18 Indeed, strong arguments could be made that to have significant impact, any violence-prevention efforts focused on young children must include parents or other primary caretakers. Reviews from the research literature5 have consistently shown that poor parenting practices, such as inconsistent or coercive discipline, or lack of appropriate monitoring and supervision, are linked to conduct problems in children. In the absence of supportive, stable parenting, early problem behaviors may be reinforced or exacerbated, which in turn perpetuates negative parent– child relations and threatens the child’s development of social competencies. Furthermore, poor parenting practices of adult family members or other caretakers limit their ability to serve as positive role models in the lives of their children. Fortunately, use of parent training and education programs can modify ineffective parenting practices,10 and thus these types of interventions were logical, well-justified choices to include among those selected by the four CDC-funded study sites. The parenting education and skills-building activities took place with individual families in the home or within group sessions. For three of the sites, this parenting component also included efforts to help families cope with crises or chronic stressors, because these may have a powerful impact on family dynamics and negatively affect parenting practices. In addition to the parenting component, three of the four projects also implemented strategies that targeted child care center staff or elementary school teachers as another means to positively influence the children’s development. Each of the four projects is briefly described below. One can find further details in previously published manuscripts,19,20 in the articles contained in this journal supplement,21–25 or at the CDC Web site (www.cdc.gov/ncipc/dvp/evalyv. htm). The target groups, settings, and evaluation designs are listed by site in Table 1. The project in the San Francisco Bay Area focused on preschool-aged children enrolled in child care centers
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Table 1. Selected characteristics of the four projects Project location
Target groups
Intervention setting
Evaluation design
San Francisco, California
3- to 5-year-old children, their child care center staff, and families
Child care centers Family group sessions
Experimental, random assignment of child care centers
Jacksonville, Florida
3- to 5-year-old children, their child care center staff, and families
Child care centers In-home family sessions
Experimental, random assignment of child care centers
Kansas City, Missouri
3- to 10-year-old children and their parents
County jail
Experimental, random assignment of inmate parents
Columbia, South Carolina
6- to 8-year-old children, their teachers, and families
Elementary schools In-home family sessions
Experimental, random assignment of schools
located in ethnically diverse communities. To reduce the early initiation of problem aggressive behaviors, child care center teachers enrolled in Safe Start, a three-course, college-level curriculum at local community colleges. This curriculum provided education and training on how to encourage young children to develop pro-social behavior and to avoid the use of violence. The child care center teachers earned nine academic units for participation. Center directors were offered a shorter version of the curriculum and earned three units. The children’s family members attended a separate series of group-education and skills-building sessions that paralleled the lessons of the Safe Start curriculum. Activities and education to optimize parenting practices and to improve communication were also included in these family sessions. Families were encouraged to form support networks and to work together to identify possible solutions for specific problematic issues. The Jacksonville First and Best Teacher project targeted a similar population of preschool-aged children, those receiving subsidized child care at sites located in areas at risk for violence. Similar to the San Francisco project, child care center staff received training and education designed to cultivate pro-social behavior among children and to improve problem solving and conflict resolution. In Jacksonville, this education and training consisted of an intensive, 60-hour program, followed by weekly, individual mentoring sessions between professional child care educators and center staff. In addition, child care centers sponsored family events to increase parental involvement in the center and in their children’s activities and development. The family component consisted of a series of home-based parenting-instruction sessions to strengthen parenting and supervisory skills. In Kansas City, the intervention targeted children of incarcerated parents who had mental disorders or substance-use problems. The sample included inmates from a county detention center. This population was
selected because children of mentally ill or substanceusing parents are at risk for violence, and because the disruption of care that results when a parent is incarcerated may also place the child at increased risk for violence. Through a series of sessions conducted on-site at the jail, parents learned about child development, behavioral training, and parenting skills. Effective communication and conflict-resolution techniques were also covered. All inmates received manuals that contained information on parenting skills and child development. These manuals used basic language, large print, and were supplemented with illustrations to facilitate comprehension by inmates with low reading skills. When they were released from jail and returned to their parenting roles, parents received additional written parenting materials and contact information about community-based parenting programs. When parents faced long-term incarceration, primary caregivers were offered the parent-training manuals. The project in Columbia, called EARLY ALLIANCE, intervened with children in first grade who attended schools located primarily in socioeconomically disadvantaged neighborhoods. The sample included children who showed early signs of conduct problems at school entry, based on reports by parents/caregivers and kindergarten teachers. EARLY ALLIANCE consisted of four intervention components. Similar to the Jacksonville project, the family component occurred in the home and included the promotion of parenting skills coupled with support and advocacy for the family with respect to unmet needs. The three school-based components of EARLY ALLIANCE consisted of (1) a classroom program in first and second grades to promote pro-social coping skills and to enhance positive school– home communication, (2) a peer coping-skills program delivered in small groups during first grade to coach and rehearse pro-social speaking and listening skills, and (3) an after-school reading–mentoring program involving high school students as tutors to Am J Prev Med 2001;20(1S)
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Figure 2. Percentage of caretakers/parents who had cared for the child all of the child’s life Figure 1. Age range of participants by project location
strengthen reading skills and to build interest in academic activities. The evaluation study designs for the projects were similar. All four used experimental designs with random assignment to the study condition, and all four collected pre- and post-intervention measurements. With respect to study design, the differences among the groups related primarily to the level of assignment (e.g., individual, school, or child care center) and to the timing of the follow-up. In general, the evaluations were all designed to determine whether the interventions produced desired behavioral changes among the children, such as reductions in fighting or increased pro-social behavior. The extent to which these behavioral changes were mediated by changes in knowledge, attitudes, and behavior of influential adults (i.e., parents/caretakers and teachers) in the children’s lives was also examined. At each of the project sites, several different types of data (self-report, other-report, observational) were gathered from a variety of sources. All four projects used CDC funding to build on previously existing interventions. For example, the San Francisco– based group had previously received funds from the U.S. Department of Education to develop Safe Start, a college-level curriculum designed to provide child care center staff with the skills to help young children develop pro-social behavior and to avoid the use of violence. In addition to supporting the intervention evaluation, CDC funds were also used to develop the family-education component that paralleled the lessons of Safe Start. The Children’s Commission in Jacksonville had developed and implemented a homevisiting program in 1995. It used CDC funds to develop and implement a complementary training component for child care center staff and to design and conduct the intervention evaluation. The concept for the parent training and education program used in the Kansas City– based project came from a program that focused on inner-city adults enrolled in a junior college, welfare-reform curriculum. The content of the parenttraining curriculum used social learning theory and 18
positive reinforcement techniques to address maladaptive behavior. The CDC funds supported revision of the materials, as well as evaluation of the intervention. The National Institute of Mental Health, the National Institute on Drug Abuse, and the Office of Juvenile Justice and Delinquency Prevention collaboratively funded the Columbia project, with CDC funding the implementation and evaluation of the in-home, family-based component.
Baseline Data To facilitate general comparisons across project sites at baseline, pre-intervention demographic information about the children and their families and measures of aggressive and pro-social behavior were collected in a uniform fashion at each of the four sites. This was in addition to the more comprehensive site-specific process and outcome measures that each gathered. Among the persons deemed eligible at each of the four project sites, the percentage who agreed to participate at baseline ranged from 48% to 96% (Table 2). The resulting sample sizes ranged from 111 to 406. Children. The descriptive data shown in Figure 1 and Table 3 highlight some of the similarities and differences in the samples of children across the four projects. Across the studies, the mean age of participating children varied from 4.1 to 6.4 years (Figure 1). Within three of the four projects, the age range covered four years or less. The Kansas City sample had the largest age range (11 years). All four projects had a fairly even distribution of boys and girls, with boys comprising between 49% and 55% of the samples. Most
Table 2. Baseline participation rates and sample sizes Project Columbia Jacksonville Kansas City SanFrancisco
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% of target sample providing baseline data
No. at baseline
87 48 96 58
251 406 111 227
Table 3. Gender and racial/ethnic characteristics of participating youth Race/ethnicity (%) Project
Male (%)
Hispanic
Non-Hispanic black
Non-Hispanic white
Asian
Other
Missing
55 49 53 54
1 3 14 7
95 87 61 20
4 3 21 21
0 0 0 27
1 2 3 25
0 4 2 0
Columbia Jacksonville Kansas City San Francisco
of the prevention programs focused on ethnic minority populations; none of the samples had more than 25% Caucasian non-Hispanic youth. As shown in Table 3, participants in three projects were primarily non-Hispanic black children, and the fourth project recruited mostly Asian children and children of “other” (i.e., not Asian, Hispanic, black, or white) racial/ethnic backgrounds. In general, these demographic distributions reflect the characteristics of the youth served by these agencies. The distributions are not caused by an effort to specifically include or exclude any particular subgroups.
of families with household incomes below the poverty threshold was 32%, 38%, 51%, and 73% for Kansas City, San Francisco, Jacksonville, and Columbia, respectively. The percentage of children who changed residence in the previous year ranged from 21% to 45% across the four projects (Table 5). This pattern indicates that all four projects will face potential challenges when collecting follow-up data. Measures of aggressive and pro-social behavior. To facilitate comparisons of behavioral outcomes across studies, all four projects included the same measures of aggressive and pro-social behaviors. The measure of aggressive behavior was adapted from the Conduct Disorder and Peer Conflict subscales of the Early Childhood Inventory Parent Checklist.26 The pro-social behavior scale was adapted from the Penn Interactive Play Scale.27,28 For both scales, the caretaker was instructed to indicate how often the child engaged in each behavior during the past month. The four response choices were “never,” “sometimes,” “often,” and “very often.”b In all four studies, the measures of aggression and pro-social behavior had a high level of internal consistency and reliability. Table 6 shows the ␣ coefficients, means, ranges, and standard deviations for these scales. Mean scores for the aggression and pro-
Caretakers. Most of the parents/caretakers reported having responsibility for the children’s care for all of the children’s lives (64% to 89%; see Figure 2). In the Columbia, Jacksonville, and San Francisco projects, the parents/caretakers were almost exclusively women (94%, 96%, and 98%, respectively). The parents in the Kansas City project, on the other hand, were almost exclusively men (only 9% were women). Most of the parents/caretakers had completed high school or had received general equivalency diplomas (i.e., the number reporting less than a high school education ranged from 14% to 31%), and most were currently employed for wages (Table 4). However, many of the children’s families were economically impoverished. Poverty status was assessed using parent/caretaker reports of household income and the number of household members. The poverty threshold established by the Bureau of Census for 1998 was used as a guide to classify poverty status.a Across the four projects, the percentage
Census Bureau poverty threshold fell within a category, we coded any household income that was reported as within or below that category as meeting the poverty threshold. Therefore, the poverty cutoffs used in the four studies were as follows: 2-person household⫽$12,499; 3 persons⫽$14,999; 4 or 5 persons⫽$19,999; 6 persons⫽$24,999; 7 or 8 persons⫽$29,999; 9 or more persons⫽$34,999. b With the exception of Kansas City, all projects included the same four response choices for the aggression and pro-social behavior scales: “never,” “sometimes,” “often,” and “very often.” In Kansas City, the first response option was worded “never/rarely.”
a We assessed household income using either a continuous scale or discrete categories. To calculate poverty status across the four projects, we used the discrete categories for all four studies. When the
Table 4. Educational level and current employment status of parents/caretakers Highest year of education (%) Project Columbia Jacksonville Kansas City San Francisco
Current employment (%)
High school grad./GED
Beyond high school
Refused/ missing
Employed
Unable/ out of work
Homemaker
Other
Refused
22 14 31 19
45 37 44 43
34 41 23 38
0 8 2 0
70 77 75 83
15 7 24 4
9 4 0 4
6 5 1 8
0 8 0 ⬍1
GED, general equivalency diploma
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Table 5. Number of times the child changed residence during the previous 12 months Project
None (%)
1 (%)
>2 (%)
Don’t know/ refused (%)
Columbia Jacksonville Kansas City San Francisco
79 58 55 75
16 27 22 20
4 10 23 4
0 5 0 ⬍1
social behavior scales were quite similar across all four projects. Although the mean scores on aggressive behavior were relatively low, the prevalence of some specific aggressive behaviors confirms the need for violence-prevention programs. For example, the percentage of children who had “hit, pushed, or tripped other children” ranged from 35% to 55%, and the percentage who had “started a physical fight” ranged from 27% to 41%. At the same time, the prevalence of pro-social behavior indicates the high potential for empathy and appropriate resolution of conflict among these young children. For example, the percentage of children who had “often” or “very often” comforted others when they were hurt or sad ranged from 44% to 58%, and the percentage who had “often” or “very often” disagreed without fighting ranged from 31% to 49%.
Challenges to Implementation As anticipated, all four projects faced numerous challenges while implementing these multicomponent intervention and evaluation projects. Although these challenges are common to any research-related effort, some unique aspects surfaced because these projects targeted young children and their families or because of the specific types of intervention activities used. Some of the major challenges included recruiting and retaining study participants, monitoring and maintaining fidelity of the intervention, working with diverse populations (including those with special needs), building academic and community partnerships, and minimizing threats to the overall evaluation design of the project. Recruitment and retention are challenges to any research effort, but this was particularly true for these projects, in which participation was solicited from both
individuals (children and their families) and institutions (child care centers and elementary schools). Accordingly, incentives to participate and to minimize attrition needed to be tailored to these various groups. The number of residential changes seen in these study populations (Table 5) presented challenges to collecting follow-up data. Monitoring and maintaining the fidelity of the intervention presented another particularly difficult issue. Because of the nature of the interventions (in-home sessions, training, and education of child care staff and parents), traditional methods to monitor fidelity were not always feasible or adequate. Working with diverse populations and those with special needs also presented interesting challenges. For example, relatively few instruments exist to assess violence-related behavior in very young children. In addition, much of the psychometric testing of these instruments has been conducted in racially homogenous samples. Much less information exists about how these instruments perform in the racially and ethnically diverse populations that these four projects targeted. Similarly, many of the interventions (e.g., parent training) also required tailoring to address the different stages of development seen in young children and to ensure that the interventions were culturally sensitive and relevant. Finally, building successful academic and community partnerships necessary to conduct these projects is, itself, a daunting task with its own set of challenges. For example, balancing the need for scientific rigor with the flexibility necessary to conduct community-based interventions may result in tension or conflicts about goals and methods. In this supplement, we describe these challenges in greater detail, as well as some ideas for their solution. Each of the four projects selected one or two challenges particularly salient to their intervention and evaluation, which are expanded on in the following papers.21–25 We hope that this focus on overcoming challenges to implementation not only will provide practical information but also will motivate and stimulate others who are considering initiating community-based violence-prevention work. Although the challenges faced when developing and implementing violence-prevention programs for young children and their families may seem overwhelming, it has become increasingly clear that this is vitally important if we are to create safe, violencefree environments for our youth.
Table 6. Mean scores, standard deviation (SD), range, and ␣ coefficients for youth aggressive and pro-social behavior Aggressive behavior
Pro-social behavior
Project
Mean (SD)
Range
Cronbach’s ␣
Mean (SD)
Range
Cronbach’s ␣
Columbia Jacksonville Kansas City San Francisco
1.5(0.4) 1.3(0.4) 1.4(0.5) 1.3(0.3)
1–3.5 1–3.6 1–3.3 1–3.1
0.89 0.91 0.92 0.88
2.5(0.4) 2.5(0.6) 2.7(0.6) 2.7(0.5)
1.5–4.0 1.0–3.9 1.1–4.0 1.5–3.9
0.76 0.86 0.87 0.83
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References 1. Centers for Disease Control and Prevention. National summary of injury mortality data, 1986 –1996. Atlanta, GA: National Center for Injury Prevention and Control, 1998. 2. Sampson RJ, Lauritson JL. Violent victimization and offending: individual-, situational-, and community-level risk factors. In: Reiss AJ, Roth JA, eds. Understanding and preventing violence: panel on the understanding and control of violent behavior, vol. 3: social influences. Washington, DC: National Academy Press,1994:1–114. 3. Dahlberg LL, Potter LB. Youth violence: developmental pathways and prevention challenges. Am J Prev Med 2000(suppl 1): 3–14. 4. Buka S, Earls F. Early determinants of delinquency and violence. Health Affairs 1993;12:46 – 64. 5. Hawkins JD, Herrenkohl T, Farrington DP, Brewer D, Catalano RF, Harachi TW. A review of predictors of youth violence. In: Loeber R, Farrington DP, eds. Serious and violent juvenile offenders: risk factors and successful interventions. Thousand Oaks, CA: Sage Publications, 1998:106 – 46. 6. Loeber R, Wung P, Keenan K, et al. Developmental pathways in disruptive child behavior. Dev Psychopath 1993;5:101–32. 7. Farrington DP. Childhood aggression and adult violence: early precursors and later-life outcomes. In: Pepler DJ, Rubin KH, eds. The development and treatment of childhood aggression. Hillsdale, NJ: Lawrence Erlbaum, 1991:5–29. 8. Loeber R, Stouthamer-Loeber M. Juvenile aggression at home and at school. In: Elliot DS, Hamburg BA, Williams KR, eds. Violence in American schools: a new perspective. New York, NY: Cambridge University Press, 1998:94 –126. 9. Loeber R, Dishion TJ. Boys who fight at home and in school: family conditions influencing cross-setting consistency and discontinuity. J Consult Clin Psychol 1984;52:759 – 68. 10. Webster-Stratton C, Hammond M. Treating children with early-onset conduct problems: a comparison of child and parent training interventions. J Consul Clin Psychol 1997;65:93–109. 11. Webster-Stratton C. Preventing conduct problems in Head Start children: Strengthening parenting competencies. J Consul Clin Psychol 1998;66: 715–30. 12. Olds DL, Henderson CR, Cole R, et al. Long-term effects of nurse home visitation on children’s criminal and antisocial behavior: 15-year follow-up of a randomized trial. JAMA 1998;280:1238 – 44. 13. Olds D, Hill P, Mihalic S, O’Brien R. Blueprints for violence prevention, book seven: prenatal and infancy home visitation by nurses. Boulder, CO: Center for the Study and Prevention of Violence, 1998. 14. Kumpher KL, Alverado R. Effective family strengthening interventions. Washington, DC: U.S. Department of Justice, Office of Juvenile Justice and Delinquency Prevention, 1998. 15. Catalano RF, Berglund ML, Ryan JAM, Lonczak HC, Hawkins JD. Positive
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youth development in the United States: research findings of positive youth development programs. Washington, DC: U.S. Department of Health and Human Services, National Institute for Child Health and Human Development, 1998. Tolan PH, Guerra NG. What works in reducing adolescent violence: an empirical review of the field. Boulder, CO: The Center for the Study and Prevention of Violence, University of Colorado, 1994. Miller L. Preventive intervention for families of preschoolers at risk for conduct disorders. In: Briesmeister JM, Schaefer CE, eds. Handbook of parent training: parents as co-therapists for children’s behavior problems. New York, NY: John Wiley and Sons, 1998:177–201. Wasserman GA, Miller LS. The prevention of serious and violent juvenile offending. In: Loeber R, Farrington DP, eds. Serious and violent juvenile offenders: risk factors and successful interventions. Thousand Oaks, CA: Sage Publications, 1998:197–247. Dumas JE, Prinz RJ, Smith EP, Laughlin J. The Early Alliance prevention trial: an integrated set of interventions to promote competence and reduce risk for conduct disorder, substance abuse, and school failure. Clin Child Fam Psych Rev 1999;2:37–53. Prinz RJ, Dumas JE, Smith EP, Laughlin J. The Early Alliance prevention trial: a dual design to test reduction of risk for conduct problems, substance abuse, and school failure in childhood. Control Clin Trials 2000;21:286 – 302. Dumas JE, Lynch AM, Laughlin J, Smith EP, Prinz RJ. Promoting intervention fidelity: conceptual issues, methods, and preliminary results from the Early Alliance prevention trial. Am J Prev Med 2000;20(suppl 1): 38 – 47. Evans GD, Rey J, Hemphill MM, Perkins DF, Austin W, Racine P. Academic and community collaboration: an ecology for early childhood violence prevention. Am J Prev Med 2000;20 (suppl 1):22–30. Eddy BA, Huffman MJ, Szubka MH, McCool ML, Kuntz S. Challenges in research with incarcerated parents and importance in violence prevention. Am J Prev Med 2000;20(suppl 1):55– 62. Prinz RJ, Smith EP, Dumas JE, Laughlin J, White D, Barron R. Recruitment and retention of participants in prevention trials involving family-based interventions. Am J Prev Med 2000;20(suppl 1):31–37. Alkon A, Tschann JM, Ruane SH, Wolff M, Hittner A. A violenceprevention and evaluation project with multi-ethnic populations. Am J Prev Med 2000;20(suppl 1):48 –54. Sprafkin J, Gadao K. Early Childhood Inventory: Parent Checklist. Stonybrook, NY: Checkmate Plus, 1996. Fantuzzo J, Sutton-Smith B, Coolahan KC, et al. Assessment of preschool play interaction behaviors in young low-income children: Penn Interactive Peer Play Scale. Early Child Res Q 1995;10:105–20. Fantuzzo J, Mendez J, Tighe E. Parental assessment of peer play: development and validation of the parent version of the Penn Interactive Peer Play Scale. Early Child Res Q 1998;13:659 –76.
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In response to the magnitude of violence in the United States, a number of violenceprevention programs have been implemented throughout the country. However, relatively few have been rigorously evaluated for effectiveness. To encourage development and evaluation of violence-prevention interventions that focus on young children and their families, the Centers for Disease Control and Prevention (CDC) provided funding to four projects in 1996. This paper briefly describes the rationale for funding these projects, which is based on our understanding of the development of aggressive and violent behavior and on the literature regarding promising approaches to prevent problem behavior in this age group. We provide an overview of the four specific projects funded by the CDC as well as a short discussion of some of the many challenges encountered during their implementation. Medical Subject Headings (MeSH): aggression, primary prevention, violence, youth (Am J Prev Med 2001;20(1S):15–21)
Introduction
I
n response to the magnitude of violence in the United States, a number of violence-prevention programs have been implemented throughout the country. However, few have been rigorously evaluated for effectiveness. To encourage the development and evaluation of violence-prevention interventions that involve young children and their families, the Centers for Disease Control and Prevention (CDC) provided funding to four projects in 1996. Although the goal for each of these four projects was to develop, implement, and evaluate multifaceted violence-prevention interventions for children at risk for aggressive and violent behavior, this supplement to the American Journal of Preventive Medicine focuses on one specific aspect of this process— documenting some of the challenges encountered, particularly those related to implementation, and offering suggestions for solution and further scientific study. To provide background information and context for the papers that follow, this paper (1) briefly describes the rationale for funding violence-prevention programs that focus on young children and their families and (2) provides an overview of the four specific projects funded by the CDC.
From the National Center for Injury Prevention and Control, Centers for Disease Control and Prevention, Atlanta, Georgia Address correspondence and reprint requests to: Robin M. Ikeda, MD, MPH, National Center for Injury Prevention and Control, Centers for Disease Control and Prevention, 4770 Buford Highway, MS K-60, Atlanta, GA 30341. E-mail: [email protected].
Am J Prev Med 2001;20(1S) Published by Elsevier Science Inc.
The Case for Early Intervention Involving Families In the United States, rates of violent victimization and perpetration are highest among adolescents and young adults.1,2 For this reason and because our knowledge about the development of violent and aggressive behavior suggests that such behavior evolves over a long period and becomes more resistant to change as children enter adolescence, the need to intervene early has become increasingly clear.3 In addition, many of the risk factors associated with the development of violence often exist at a young age.4,5 For example, the onset of minor aggression may begin as early as age 3 and physical fighting as early as age 5.6 Such early aggressive behavior is one of the strongest predictors of subsequent aggressive behavior.7 Evidence also suggests that aggressive behavior that begins early in childhood is associated with more serious violent behavior in later years.8 Similarly, many of the family characteristics recognized as risk factors for violence are also present during childhood. In many at-risk families, precursors to violence, such as problem parental behavior (e.g., drug or alcohol use), and poor parental monitoring and supervision, are often apparent early in a child’s life, and these factors generally remain constant over time.4 Intervention at an early stage helps disrupt the effect of these factors and prevents the sustained exposure to these negative influences over many years. Given that many of the key risk factors for violence are family-related or are influenced by family dynamics (e.g., attitude toward violence, family conflict, commu-
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nication), the effectiveness of interventions designed to change individual children’s attitudes, beliefs, and behavior may be limited if the messages are not supported and reinforced in the home or if these family factors are not addressed. Improving family situations and functioning may be especially important for young children, who often have less opportunity than schoolaged children to interact with positive adult role models outside the family. Furthermore, the most significant settings for juvenile aggression are the home and school.8 Thus, for children not yet in school, the home becomes the principal location in which behavioral problems surface. This may also be true for children already in school; one cross-sectional study of fighting among school-aged boys found that 49% of them fought only at home, 30% only in school, and 21% both in school and at home.9 Promising findings from recent studies of conduct disorder in young children also support the importance of early intervention and the need to involve families and caregivers in prevention efforts. These studies suggest that combinations of cross-contextual interventions that involve parents and children10 or families and children’s teachers11 may be more effective in reducing problem behavior than are interventions with a single focus. In another study designed to determine the long-term effects of prenatal and early-childhood home-visiting programs, Olds et al.12,13 found that adolescents from at-risk families whose homes nurses visited prenatally and during the first 2 years of life exhibited less antisocial behavior and less substance abuse than adolescents from families who were not visited. Additional support for intervening early and using a comprehensive approach that includes family members or other responsible caregivers comes from reviews of other youth health-promotion programs that focused on behavioral change.14 –16 Given our current understanding of the development of violent behavior and the evidence from programs designed to prevent problem behaviors, strong justification exists for evaluating these approaches with respect to violence prevention.
Overview of the Four Projects Background The projects received funding for a 3-year period through a competitive process, and the yearly award to support project activities ranged from $340,000 to $395,000. The four funded projects were based in separate, distinct geographic locations: the San Francisco Bay Area, California; Jacksonville, Florida; Kansas City, Missouri; and Columbia, South Carolina. As requested in the announcement, all projects targeted young children aged 3 to 10 years and their families, 16
and the intervention activities took place in a variety of settings. A second criterion for selection involved the extent to which the proposed target group had a high incidence or prevalence of the risk factors that the proposed intervention components sought to influence. In general, the interventions that the projects selected were designed to encourage pro-social behavior and attitudes among children and their families. Because the funding announcement focused on young children, applicants were also encouraged to involve other influential adults in the children’s lives such as teachers. Perhaps not surprisingly, the interventions developed at the four sites were similar to one another and to others designed for this age group in one respect—all included components to promote effective parenting as one approach to foster pro-social, nonviolent behavior among the children.10,11,17,18 Indeed, strong arguments could be made that to have significant impact, any violence-prevention efforts focused on young children must include parents or other primary caretakers. Reviews from the research literature5 have consistently shown that poor parenting practices, such as inconsistent or coercive discipline, or lack of appropriate monitoring and supervision, are linked to conduct problems in children. In the absence of supportive, stable parenting, early problem behaviors may be reinforced or exacerbated, which in turn perpetuates negative parent– child relations and threatens the child’s development of social competencies. Furthermore, poor parenting practices of adult family members or other caretakers limit their ability to serve as positive role models in the lives of their children. Fortunately, use of parent training and education programs can modify ineffective parenting practices,10 and thus these types of interventions were logical, well-justified choices to include among those selected by the four CDC-funded study sites. The parenting education and skills-building activities took place with individual families in the home or within group sessions. For three of the sites, this parenting component also included efforts to help families cope with crises or chronic stressors, because these may have a powerful impact on family dynamics and negatively affect parenting practices. In addition to the parenting component, three of the four projects also implemented strategies that targeted child care center staff or elementary school teachers as another means to positively influence the children’s development. Each of the four projects is briefly described below. One can find further details in previously published manuscripts,19,20 in the articles contained in this journal supplement,21–25 or at the CDC Web site (www.cdc.gov/ncipc/dvp/evalyv. htm). The target groups, settings, and evaluation designs are listed by site in Table 1. The project in the San Francisco Bay Area focused on preschool-aged children enrolled in child care centers
American Journal of Preventive Medicine, Volume 20, Number 1S
Table 1. Selected characteristics of the four projects Project location
Target groups
Intervention setting
Evaluation design
San Francisco, California
3- to 5-year-old children, their child care center staff, and families
Child care centers Family group sessions
Experimental, random assignment of child care centers
Jacksonville, Florida
3- to 5-year-old children, their child care center staff, and families
Child care centers In-home family sessions
Experimental, random assignment of child care centers
Kansas City, Missouri
3- to 10-year-old children and their parents
County jail
Experimental, random assignment of inmate parents
Columbia, South Carolina
6- to 8-year-old children, their teachers, and families
Elementary schools In-home family sessions
Experimental, random assignment of schools
located in ethnically diverse communities. To reduce the early initiation of problem aggressive behaviors, child care center teachers enrolled in Safe Start, a three-course, college-level curriculum at local community colleges. This curriculum provided education and training on how to encourage young children to develop pro-social behavior and to avoid the use of violence. The child care center teachers earned nine academic units for participation. Center directors were offered a shorter version of the curriculum and earned three units. The children’s family members attended a separate series of group-education and skills-building sessions that paralleled the lessons of the Safe Start curriculum. Activities and education to optimize parenting practices and to improve communication were also included in these family sessions. Families were encouraged to form support networks and to work together to identify possible solutions for specific problematic issues. The Jacksonville First and Best Teacher project targeted a similar population of preschool-aged children, those receiving subsidized child care at sites located in areas at risk for violence. Similar to the San Francisco project, child care center staff received training and education designed to cultivate pro-social behavior among children and to improve problem solving and conflict resolution. In Jacksonville, this education and training consisted of an intensive, 60-hour program, followed by weekly, individual mentoring sessions between professional child care educators and center staff. In addition, child care centers sponsored family events to increase parental involvement in the center and in their children’s activities and development. The family component consisted of a series of home-based parenting-instruction sessions to strengthen parenting and supervisory skills. In Kansas City, the intervention targeted children of incarcerated parents who had mental disorders or substance-use problems. The sample included inmates from a county detention center. This population was
selected because children of mentally ill or substanceusing parents are at risk for violence, and because the disruption of care that results when a parent is incarcerated may also place the child at increased risk for violence. Through a series of sessions conducted on-site at the jail, parents learned about child development, behavioral training, and parenting skills. Effective communication and conflict-resolution techniques were also covered. All inmates received manuals that contained information on parenting skills and child development. These manuals used basic language, large print, and were supplemented with illustrations to facilitate comprehension by inmates with low reading skills. When they were released from jail and returned to their parenting roles, parents received additional written parenting materials and contact information about community-based parenting programs. When parents faced long-term incarceration, primary caregivers were offered the parent-training manuals. The project in Columbia, called EARLY ALLIANCE, intervened with children in first grade who attended schools located primarily in socioeconomically disadvantaged neighborhoods. The sample included children who showed early signs of conduct problems at school entry, based on reports by parents/caregivers and kindergarten teachers. EARLY ALLIANCE consisted of four intervention components. Similar to the Jacksonville project, the family component occurred in the home and included the promotion of parenting skills coupled with support and advocacy for the family with respect to unmet needs. The three school-based components of EARLY ALLIANCE consisted of (1) a classroom program in first and second grades to promote pro-social coping skills and to enhance positive school– home communication, (2) a peer coping-skills program delivered in small groups during first grade to coach and rehearse pro-social speaking and listening skills, and (3) an after-school reading–mentoring program involving high school students as tutors to Am J Prev Med 2001;20(1S)
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Figure 2. Percentage of caretakers/parents who had cared for the child all of the child’s life Figure 1. Age range of participants by project location
strengthen reading skills and to build interest in academic activities. The evaluation study designs for the projects were similar. All four used experimental designs with random assignment to the study condition, and all four collected pre- and post-intervention measurements. With respect to study design, the differences among the groups related primarily to the level of assignment (e.g., individual, school, or child care center) and to the timing of the follow-up. In general, the evaluations were all designed to determine whether the interventions produced desired behavioral changes among the children, such as reductions in fighting or increased pro-social behavior. The extent to which these behavioral changes were mediated by changes in knowledge, attitudes, and behavior of influential adults (i.e., parents/caretakers and teachers) in the children’s lives was also examined. At each of the project sites, several different types of data (self-report, other-report, observational) were gathered from a variety of sources. All four projects used CDC funding to build on previously existing interventions. For example, the San Francisco– based group had previously received funds from the U.S. Department of Education to develop Safe Start, a college-level curriculum designed to provide child care center staff with the skills to help young children develop pro-social behavior and to avoid the use of violence. In addition to supporting the intervention evaluation, CDC funds were also used to develop the family-education component that paralleled the lessons of Safe Start. The Children’s Commission in Jacksonville had developed and implemented a homevisiting program in 1995. It used CDC funds to develop and implement a complementary training component for child care center staff and to design and conduct the intervention evaluation. The concept for the parent training and education program used in the Kansas City– based project came from a program that focused on inner-city adults enrolled in a junior college, welfare-reform curriculum. The content of the parenttraining curriculum used social learning theory and 18
positive reinforcement techniques to address maladaptive behavior. The CDC funds supported revision of the materials, as well as evaluation of the intervention. The National Institute of Mental Health, the National Institute on Drug Abuse, and the Office of Juvenile Justice and Delinquency Prevention collaboratively funded the Columbia project, with CDC funding the implementation and evaluation of the in-home, family-based component.
Baseline Data To facilitate general comparisons across project sites at baseline, pre-intervention demographic information about the children and their families and measures of aggressive and pro-social behavior were collected in a uniform fashion at each of the four sites. This was in addition to the more comprehensive site-specific process and outcome measures that each gathered. Among the persons deemed eligible at each of the four project sites, the percentage who agreed to participate at baseline ranged from 48% to 96% (Table 2). The resulting sample sizes ranged from 111 to 406. Children. The descriptive data shown in Figure 1 and Table 3 highlight some of the similarities and differences in the samples of children across the four projects. Across the studies, the mean age of participating children varied from 4.1 to 6.4 years (Figure 1). Within three of the four projects, the age range covered four years or less. The Kansas City sample had the largest age range (11 years). All four projects had a fairly even distribution of boys and girls, with boys comprising between 49% and 55% of the samples. Most
Table 2. Baseline participation rates and sample sizes Project Columbia Jacksonville Kansas City SanFrancisco
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% of target sample providing baseline data
No. at baseline
87 48 96 58
251 406 111 227
Table 3. Gender and racial/ethnic characteristics of participating youth Race/ethnicity (%) Project
Male (%)
Hispanic
Non-Hispanic black
Non-Hispanic white
Asian
Other
Missing
55 49 53 54
1 3 14 7
95 87 61 20
4 3 21 21
0 0 0 27
1 2 3 25
0 4 2 0
Columbia Jacksonville Kansas City San Francisco
of the prevention programs focused on ethnic minority populations; none of the samples had more than 25% Caucasian non-Hispanic youth. As shown in Table 3, participants in three projects were primarily non-Hispanic black children, and the fourth project recruited mostly Asian children and children of “other” (i.e., not Asian, Hispanic, black, or white) racial/ethnic backgrounds. In general, these demographic distributions reflect the characteristics of the youth served by these agencies. The distributions are not caused by an effort to specifically include or exclude any particular subgroups.
of families with household incomes below the poverty threshold was 32%, 38%, 51%, and 73% for Kansas City, San Francisco, Jacksonville, and Columbia, respectively. The percentage of children who changed residence in the previous year ranged from 21% to 45% across the four projects (Table 5). This pattern indicates that all four projects will face potential challenges when collecting follow-up data. Measures of aggressive and pro-social behavior. To facilitate comparisons of behavioral outcomes across studies, all four projects included the same measures of aggressive and pro-social behaviors. The measure of aggressive behavior was adapted from the Conduct Disorder and Peer Conflict subscales of the Early Childhood Inventory Parent Checklist.26 The pro-social behavior scale was adapted from the Penn Interactive Play Scale.27,28 For both scales, the caretaker was instructed to indicate how often the child engaged in each behavior during the past month. The four response choices were “never,” “sometimes,” “often,” and “very often.”b In all four studies, the measures of aggression and pro-social behavior had a high level of internal consistency and reliability. Table 6 shows the ␣ coefficients, means, ranges, and standard deviations for these scales. Mean scores for the aggression and pro-
Caretakers. Most of the parents/caretakers reported having responsibility for the children’s care for all of the children’s lives (64% to 89%; see Figure 2). In the Columbia, Jacksonville, and San Francisco projects, the parents/caretakers were almost exclusively women (94%, 96%, and 98%, respectively). The parents in the Kansas City project, on the other hand, were almost exclusively men (only 9% were women). Most of the parents/caretakers had completed high school or had received general equivalency diplomas (i.e., the number reporting less than a high school education ranged from 14% to 31%), and most were currently employed for wages (Table 4). However, many of the children’s families were economically impoverished. Poverty status was assessed using parent/caretaker reports of household income and the number of household members. The poverty threshold established by the Bureau of Census for 1998 was used as a guide to classify poverty status.a Across the four projects, the percentage
Census Bureau poverty threshold fell within a category, we coded any household income that was reported as within or below that category as meeting the poverty threshold. Therefore, the poverty cutoffs used in the four studies were as follows: 2-person household⫽$12,499; 3 persons⫽$14,999; 4 or 5 persons⫽$19,999; 6 persons⫽$24,999; 7 or 8 persons⫽$29,999; 9 or more persons⫽$34,999. b With the exception of Kansas City, all projects included the same four response choices for the aggression and pro-social behavior scales: “never,” “sometimes,” “often,” and “very often.” In Kansas City, the first response option was worded “never/rarely.”
a We assessed household income using either a continuous scale or discrete categories. To calculate poverty status across the four projects, we used the discrete categories for all four studies. When the
Table 4. Educational level and current employment status of parents/caretakers Highest year of education (%) Project Columbia Jacksonville Kansas City San Francisco
Current employment (%)
High school grad./GED
Beyond high school
Refused/ missing
Employed
Unable/ out of work
Homemaker
Other
Refused
22 14 31 19
45 37 44 43
34 41 23 38
0 8 2 0
70 77 75 83
15 7 24 4
9 4 0 4
6 5 1 8
0 8 0 ⬍1
GED, general equivalency diploma
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Table 5. Number of times the child changed residence during the previous 12 months Project
None (%)
1 (%)
>2 (%)
Don’t know/ refused (%)
Columbia Jacksonville Kansas City San Francisco
79 58 55 75
16 27 22 20
4 10 23 4
0 5 0 ⬍1
social behavior scales were quite similar across all four projects. Although the mean scores on aggressive behavior were relatively low, the prevalence of some specific aggressive behaviors confirms the need for violence-prevention programs. For example, the percentage of children who had “hit, pushed, or tripped other children” ranged from 35% to 55%, and the percentage who had “started a physical fight” ranged from 27% to 41%. At the same time, the prevalence of pro-social behavior indicates the high potential for empathy and appropriate resolution of conflict among these young children. For example, the percentage of children who had “often” or “very often” comforted others when they were hurt or sad ranged from 44% to 58%, and the percentage who had “often” or “very often” disagreed without fighting ranged from 31% to 49%.
Challenges to Implementation As anticipated, all four projects faced numerous challenges while implementing these multicomponent intervention and evaluation projects. Although these challenges are common to any research-related effort, some unique aspects surfaced because these projects targeted young children and their families or because of the specific types of intervention activities used. Some of the major challenges included recruiting and retaining study participants, monitoring and maintaining fidelity of the intervention, working with diverse populations (including those with special needs), building academic and community partnerships, and minimizing threats to the overall evaluation design of the project. Recruitment and retention are challenges to any research effort, but this was particularly true for these projects, in which participation was solicited from both
individuals (children and their families) and institutions (child care centers and elementary schools). Accordingly, incentives to participate and to minimize attrition needed to be tailored to these various groups. The number of residential changes seen in these study populations (Table 5) presented challenges to collecting follow-up data. Monitoring and maintaining the fidelity of the intervention presented another particularly difficult issue. Because of the nature of the interventions (in-home sessions, training, and education of child care staff and parents), traditional methods to monitor fidelity were not always feasible or adequate. Working with diverse populations and those with special needs also presented interesting challenges. For example, relatively few instruments exist to assess violence-related behavior in very young children. In addition, much of the psychometric testing of these instruments has been conducted in racially homogenous samples. Much less information exists about how these instruments perform in the racially and ethnically diverse populations that these four projects targeted. Similarly, many of the interventions (e.g., parent training) also required tailoring to address the different stages of development seen in young children and to ensure that the interventions were culturally sensitive and relevant. Finally, building successful academic and community partnerships necessary to conduct these projects is, itself, a daunting task with its own set of challenges. For example, balancing the need for scientific rigor with the flexibility necessary to conduct community-based interventions may result in tension or conflicts about goals and methods. In this supplement, we describe these challenges in greater detail, as well as some ideas for their solution. Each of the four projects selected one or two challenges particularly salient to their intervention and evaluation, which are expanded on in the following papers.21–25 We hope that this focus on overcoming challenges to implementation not only will provide practical information but also will motivate and stimulate others who are considering initiating community-based violence-prevention work. Although the challenges faced when developing and implementing violence-prevention programs for young children and their families may seem overwhelming, it has become increasingly clear that this is vitally important if we are to create safe, violencefree environments for our youth.
Table 6. Mean scores, standard deviation (SD), range, and ␣ coefficients for youth aggressive and pro-social behavior Aggressive behavior
Pro-social behavior
Project
Mean (SD)
Range
Cronbach’s ␣
Mean (SD)
Range
Cronbach’s ␣
Columbia Jacksonville Kansas City San Francisco
1.5(0.4) 1.3(0.4) 1.4(0.5) 1.3(0.3)
1–3.5 1–3.6 1–3.3 1–3.1
0.89 0.91 0.92 0.88
2.5(0.4) 2.5(0.6) 2.7(0.6) 2.7(0.5)
1.5–4.0 1.0–3.9 1.1–4.0 1.5–3.9
0.76 0.86 0.87 0.83
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