A systematic review of primary prevention strategies for sexual violence perpetration.

This systematic review examined 140 outcome evaluations of primary prevention strategies for sexual violence perpetration. The review had two goals: 1) to describe and assess the breadth, quality, and evolution of evaluation research in this area; and 2) to summarize the best available research evidence for sexual violence prevention practitioners by categorizing programs with regard to their evidence of effectiveness on sexual violence behavioral outcomes in a rigorous evaluation. The majority of sexual violence prevention strategies in the evaluation literature are brief, psycho-educational programs focused on increasing knowledge or changing attitudes, none of which have shown evidence of effectiveness on sexually violent behavior using a rigorous evaluation design. Based on evaluation studies included in the current review, only three primary prevention strategies have demonstrated significant effects on sexually violent behavior in a rigorous outcome evaluation: Safe Dates (Foshee et al., 2004); Shifting Boundaries (building-level intervention only, Taylor, Stein, Woods, Mumford, & Forum, 2011); and funding associated with the 1994 U.S. Violence Against Women Act (VAWA; Boba & Lilley, 2009). The dearth of effective prevention strategies available to date may reflect a lack of fit between the design of many of the existing programs and the principles of effective prevention identified by Nation et al. (2003).

An RCT of Dating Matters: Effects on Teen Dating Violence and Relationship Behaviors.

INTRODUCTION: Teen dating violence is a serious public health problem with few effective prevention strategies. This study examines whether the Dating Matters comprehensive prevention model, compared with a standard of care intervention, prevented negative relationship behaviors and promoted positive relationship behaviors. STUDY DESIGN: This longitudinal, cluster-RCT compared the effectiveness of Dating Matters with standard of care across middle school. Standard of care was an evidence-based teen dating violence prevention curriculum (Safe Dates) implemented in eighth grade. SETTING/PARTICIPANTS: Forty-six middle schools in high-risk urban neighborhoods in four U.S. cities were randomized. Schools lost to follow-up were replaced with new schools, which were independently randomized (71% school retention). Students were surveyed in fall and spring of sixth, seventh, and eighth grades (2012-2016). The analysis sample includes students from schools implementing Dating Matters or standard of care for >2 years who started sixth grade in the fall of 2012 or 2013 and had dated (N=2,349 students, mean age 12 years, 49% female, and 55% black, non-Hispanic, 28% Hispanic, 17% other). INTERVENTION: Dating Matters is a comprehensive, multicomponent prevention model including classroom-delivered programs for sixth to eighth graders, training for parents of sixth to eighth graders, educator training, a youth communications program, and local health department activities to assess capacity and track teen dating violence-related policy and data. MAIN OUTCOME MEASURES: Self-reported teen dating violence perpetration and victimization, use of negative conflict resolution strategies, and positive relationship skills were examined as outcomes. Imputation and analyses were conducted in 2017. RESULTS: Latent panel models demonstrated significant program effects for three of four outcomes; Dating Matters students reported 8.43% lower teen dating violence perpetration, 9.78% lower teen dating violence victimization, and 5.52% lower use of negative conflict resolution strategies, on average across time points and cohorts, than standard of care students. There were no significant effects on positive relationship behaviors. CONCLUSIONS: Dating Matters demonstrates comparative effectiveness, through middle school, for reducing unhealthy relationship behaviors, such as teen dating violence and use of negative conflict resolution strategies, relative to the standard of care intervention. TRIAL REGISTRATION: This study is registered at www.clinicaltrials.gov NCT01672541.

A meta-analytic review of components associated with parent training program effectiveness.

This component analysis used meta-analytic techniques to synthesize the results of 77 published evaluations of parent training programs (i.e., programs that included the active acquisition of parenting skills) to enhance behavior and adjustment in children aged 0-7. Characteristics of program content and delivery method were used to predict effect sizes on measures of parenting behaviors and children's externalizing behavior. After controlling for differences attributable to research design, program components consistently associated with larger effects included increasing positive parent-child interactions and emotional communication skills, teaching parents to use time out and the importance of parenting consistency, and requiring parents to practice new skills with their children during parent training sessions. Program components consistently associated with smaller effects included teaching parents problem solving; teaching parents to promote children's cognitive, academic, or social skills; and providing other, additional services. The results have implications for selection and strengthening of existing parent training programs.

Barriers to Participation in Parenting Programs: The Relationship between Parenting Stress, Perceived Barriers, and Program Completion.

Families experiencing child maltreatment or risk factors for child maltreatment often receive referrals to interventions focused on changing parenting practices. Compliance with specific parenting programs can be challenging as many of the stressors that place families at-risk may also interfere with program participation. Because families may receive limited benefit from programs they do not fully receive, it is critical to understand the relationship between parenting stress and barriers to program completion. We used structural equation modeling to examine the relationship among parenting stress, perceived barriers to program participation, and program completion in two datasets involving low-income parents. Data were collected at two time points from a sample of parents involved with child welfare services and a sample of parents considered at-risk of future involvement (total study n = 803). Direct paths from parenting stress at time 1 to barriers to participation and parenting stress at time 2, and from parenting stress at time 2 to program completion were significant. Interestingly, increased barriers to participation were related to increased parenting stress at time 2, and greater parenting stress was related to increased program completion. Results suggest that with increasing levels of parenting stress, parents have an increased likelihood of completing the program. Assessing and addressing the influence of perceived barriers and parenting stress on program participation may decrease the likelihood of treatment attrition.

Lessons Learned in Evaluating a Multisite, Comprehensive Teen Dating Violence Prevention Strategy: Design and Challenges of the Evaluation of Dating Matters: Strategies to Promote Healthy Teen Relationships.

OBJECTIVE: This paper describes the multisite, longitudinal cluster randomized controlled trial (RCT) design of the evaluation of the Dating Matters: Strategies to Promote Healthy Relationships initiative, and discusses challenges faced in conducting this evaluation. METHOD: Health departments in 4 communities are partnering with middle schools in high-risk, urban communities to implement 2 models of teen dating violence (TDV) prevention over 4 years. Schools were randomized to receive either the Dating Matters comprehensive strategy or the "standard of care" strategy (an existing, evidence-based TDV prevention curriculum). Our design permits comparison of the relative effectiveness of the comprehensive and standard of care strategies. Multiple cohorts of students from 46 middle schools are surveyed in middle school and high school, and parents and educators from participating schools are also surveyed. RESULTS: Challenges discussed in conducting a multisite RCT include site variability, separation of implementation and evaluation responsibilities, school retention, parent engagement in research activities, and working within the context of high-risk urban schools and communities. We discuss the strengths and weaknesses of our approaches to these challenges in the hopes of informing future research. CONCLUSIONS: Despite multiple challenges, the design of the Dating Matters evaluation remains strong. We hope this paper provides researchers who are conducting complex evaluations of behavioral interventions with thoughtful discussion of the challenges we have faced and potential solutions to such challenges.

The role of alcohol policies in preventing intimate partner violence: a review of the literature.

OBJECTIVE: This article summarizes existing research on the relationship between alcohol policies and intimate partner violence (IPV). Because alcohol use represents an important risk factor for IPV, interventions and policies aimed at decreasing problem drinking may also lead to reductions in IPV. METHOD: Electronic databases were searched to identify relevant peer-reviewed journal articles on alcohol policies and IPV, as well as reference sections of appropriate articles. Only policies that have been studied specifically for their impact on IPV were included. RESULTS: Three alcohol policy areas (outlet density, hours and days of sale, and pricing/taxation) have been studied in relation to IPV outcomes. Research on outlet density has the most consistent findings, with most studies indicating that higher densities of alcohol outlets are associated with higher rates of IPV. Fewer studies have been conducted on pricing policies and policies restricting hours/days of sale, with most studies suggesting no impact on IPV rates. CONCLUSIONS: A higher density of alcohol outlets appears to be associated with greater rates of IPV. However, there is limited evidence suggesting that alcohol pricing policies and restrictions on hours and days of sale are associated with IPV outcomes. Knowledge about the impact of alcohol-related policies on IPV and violence in general is limited by several significant research gaps. Additional research is needed to assess the impact of alcohol policies on IPV and other forms of violence.

Prevalence of teen dating violence and co-occurring risk factors among middle school youth in high-risk urban communities.

PURPOSE: This study describes the lifetime prevalence of teen dating violence (TDV) perpetration in a sample of middle school students from high-risk urban communities and examines the relation between TDV and related cognitive and behavioral risk factors. METHODS: Surveys were administered to 2,895 middle school students in four U.S. cities; 1,673 students (58%) reported having dated and were included in analyses. The sample was 52.3% female, 48.2% non-Hispanic black/African-American, 38.2% Hispanic, 4.8% non-Hispanic white, and 7.6% other race. Six types of TDV perpetration were assessed: threatening behaviors, verbal/emotional abuse, relational abuse, physical abuse, sexual abuse, and stalking. RESULTS: Of the students who had dated, 77% reported perpetrating verbal/emotional abuse, 32% reported perpetrating physical abuse, 20% reported threatening a partner, 15% reported perpetrating sexual abuse, 13% reported perpetrating relational abuse, and 6% reported stalking. Girls were more likely than boys to report perpetrating threatening behaviors, verbal/emotional abuse, and physical abuse, and boys were more likely to report perpetrating sexual abuse. Involvement in bullying positively predicted perpetration of TDV, albeit, in different ways for boys and girls. Other risk factors differed by sex. For instance, alcohol use and sex initiation predicted multiple forms of TDV perpetration for boys, whereas weapon carrying and emotional symptoms predicted several forms of TDV perpetration for girls. CONCLUSIONS: The prevalence of TDV was high in our sample. Important sex differences in rates of perpetration and risk factors emerged. Comprehensive prevention programs that target TDV and related risk factors, such as bullying and other risk factors, seem warranted.

Parent-child interaction therapy with physically abusive parents: efficacy for reducing future abuse reports.

A randomized trial was conducted to test the efficacy and sufficiency of parent-child interaction therapy (PCIT) in preventing re-reports of physical abuse among abusive parents. Physically abusive parents (N=110) were randomly assigned to one of three intervention conditions: (a) PCIT, (b) PCIT plus individualized enhanced services, or (c) a standard community-based parenting group. Participants had multiple past child welfare reports, severe parent-to-child violence, low household income, and significant levels of depression, substance abuse, and antisocial behavior. At a median follow-up of 850 days, 19% of parents assigned to PCIT had a re-report for physical abuse compared with 49% of parents assigned to the standard community group. Additional enhanced services did not improve the efficacy of PCIT. The relative superiority of PCIT was mediated by greater reduction in negative parent-child interactions, consistent with the PCIT change model.

Dynamic prediction characteristics of the Child Abuse Potential Inventory.

OBJECTIVES: Risk measures are commonly used to evaluate outcomes in child abuse prevention and intervention programs. This study examined whether pre-intervention to post-intervention changes on the Child Abuse Potential Inventory (CAP) Abuse Scale corresponded to actual changes in risk for future reports of maltreatment and evaluated the validity of several algorithms for classifying clinically significant change. METHOD: Participants in the study were 459 parents participating in any one of 27 community-based family preservation and family support programs. Most parents were low-income mothers with a variety of social risk indicators, about a third of whom would be classified as high-risk by the CAP Abuse Scale. Participants were administered the CAP at program enrollment, then at completion of the intervention (median time=150 days), then followed for an average of approximately 2 years for future official maltreatment reports. Dynamic predictive validity of the CAP Abuse Scale was modeled by comparing survival models using a time-dependent structure of pre- and post-intervention scores to identically structured models using only a pre-intervention score. RESULTS: Pre-intervention CAP Abuse Scale scores demonstrated incremental future predictive validity. However, score changes failed to correspond to changes in likelihood of future abuse. Models using pre-intervention scores only were more predictive than time-dependent score models, and pre-intervention scores were better predictors than post-intervention scores of post-intervention CPS referrals. Common algorithms for classifying clinically significant change yielded results that could be counter-intuitive and misleading. For example, participants classified as improved on these algorithms were actually at similar or even higher risk than those classified as unchanged or worse. CONCLUSIONS: The results strongly supported the static predictive validity of the CAP and the use of the CAP for screening purposes. The results did not support the dynamic predictive validity of the CAP. Results of exploratory analyses suggested the possibility that the changes observed on the CAP Abuse Scale reflected changes in subscales assessing subjective distress or parenting attitudes, which may be markers for initial risk but when changed, do not necessarily translate into actual changes in future maltreatment behavior. Although replication and extension are needed before drawing firm conclusions, the current study raises questions about the common practice of using risk instruments as proxy measures for child maltreatment risk in intervention and prevention programs.

Attributions and adjustment following child sexual and physical abuse.

Individuals who experience child physical orsexual abuse are at greater risk for adjustment problems. However, the heterogeneity of symptomatology observed across individuals following child abuse suggests that outcome is determined by multiplefactors. The authors review literature examining the relationships among childhood physical or sexual abuse, attributions, and adjustment. Implications for application and future research are discussed.

DIFFERENT TYPES OF INTIMATE PARTNER VIOLENCE LIKELY REQUIRE DIFFERENT TYPES OF APPROACHES TO PREVENTION: A RESPONSE TO BUZAWA AND BUZAWA.

Buzawa and Buzawa (this issue) assert that there are different typologies of intimate partner violence (IPV) defined by the extent to which the violence is part of a general pattern of coercive control. They center their discussion on batterers, who are understood to be responsible for the most severe forms of abuse and injury. Economic factors are believed to be "only a weak predictor of violence" in these cases. Thus, they argue that, in the face of severe budget constraints, there is a need to focus on the chronically violent offender and support-coordinated services for IPV victims. We agree that there are different types of IPV distinguishable by the extent to which the violence is occurring within a pattern of general coercive control and that each type has different risk and protective factors. We also agree economic factors interact with other factors in complex ways and vary in the extent to which they predict different types of IPV. However, we argue economic factors should not be ignored as an important strategy in preventing situational couple violence (SCV) and helping victims to escape from intimate terrorists (ITs). Relying on response (rather than prevention) strategies, such as coordinated community response-for which there is limited evidence of effectiveness-is unlikely to significantly impact rates of all types of IPV.

Components associated with home visiting program outcomes: a meta-analysis.

BACKGROUND: Although several systematic reviews have concluded that home visiting has strong evidence of effectiveness, individual evaluations have produced inconsistent results. We used a component-based, domain-specific approach to determine which characteristics most strongly predict outcomes. METHODS: Medline and PsycINFO searches were used to identify evaluations of universal and selective home visiting programs implemented in the United States. Coders trained to the study criterion coded characteristics of research design, program content, and service delivery. We conducted random-effects, inverse-variance-weighted linear regressions by using program characteristics to predict effect sizes on 6 outcome domains (birth outcomes, parenting behavior and skills, maternal life course, child cognitive outcomes, child physical health, and child maltreatment). RESULTS: Aggregated to a single effect size per study (k = 51), the mean effect size was 0.20 (95% confidence interval: 0.14 to 0.27), with a range of -0.68 to 3.95. Mean effect sizes were significant and positive for 3 of the 6 outcome domains (maternal life course outcomes, child cognitive outcomes, and parent behaviors and skills), with heterogeneity of effect sizes in all 6 outcome domains. Research design characteristics generally did not predict effect sizes. No consistent pattern of effective components emerged across all outcome domains. CONCLUSIONS: Home visiting programs demonstrated small but significant overall effects, with wide variability in the size of domain-specific effects and in the components that significantly predicted domain-specific effects. Communities may need complementary or alternative strategies to home visiting programs to ensure widespread impact on these 6 important public health outcomes.

Identifying Links Between Sexual Violence and Youth Violence Perpetration: New Opportunities for Sexual Violence Prevention.

OBJECTIVE: One promising opportunity for advancing sexual violence (SV) research and identifying new avenues for prevention involves examining other forms of violence that may share risk factors with SV. Youth violence (YV) is ideal for consideration given evidence of overlap in SV and YV risk factors, a large set of established YV risk factors across the social ecology, and the number of evidence-based YV prevention strategies available. The current paper identifies shared and unique risk factors for SV and YV and highlights evidence-based YV prevention strategies that impact these shared risk factors. CONCLUSIONS: Researchers and program developers should consider adapting and evaluating evidence-based YV prevention strategies to prevent SV. Modifying these programs to address SV's unique risk factors may maximize their potential effectiveness. In addition, expanding SV research at the outer levels of the social ecology is critical to developing community-level prevention strategies. The YV literature suggests several potential risk factors at these levels in need of research for SV, including school connectedness, social disorganization, and availability of alcohol and drugs. Using the YV literature as a starting point for expanding SV research leverages prior investments in YV research, may help identify new SV prevention strategies at a limited cost, and moves the field more quickly toward implementation of cost-effective, multidomain violence prevention strategies in communities.

A systematic qualitative review of risk and protective factors for sexual violence perpetration.

The current review summarized results of 191 published empirical studies that examined the risk and protective factors for sexual violence perpetration. Studies in the review examined factors for perpetration by and against adolescents and adults, by male and female perpetrators, and by those who offended against individuals of the same sex or opposite sex. Factors associated with child sexual abuse (CSA) perpetration were not included. In all, 2 societal and community factors, 23 relationship factors, and 42 individual-level factors were identified. Of these 67 factors, consistent significant support for their association with SV was found for 35, nonsignificant effects were found for 10, 7 factors had limited or sample-specific evidence that they were associated with SV but were in need of further study, and 15 demonstrated mixed results. The factors identified in the review underscore the need for comprehensive prevention programs that target multiple risk and protective factors as well as factors that occur across the social ecology. Moreover, we identified two domains of factors--the presence and acceptance of violence and unhealthy sexual behaviors, experiences, or attitudes--that had consistent significant associations with SV but are not typically addressed in prevention programs. Therefore, SV prevention may also benefit from learning from effective strategies in other areas of public health, namely sexual health and youth violence prevention.

Looking ahead toward community-level strategies to prevent sexual violence.

The Division of Violence Prevention within CDC's National Center for Injury Prevention and Control recently undertook a systematic review of primary prevention strategies for sexual violence (SV) perpetration. This review identified the lack of community-level strategies to prevent SV as a critical gap in the literature. Community-level strategies function by modifying the characteristics of settings (e.g., schools, workplaces, neighborhoods) that increase the risk for violence victimization and perpetration. Identification of evidence-based strategies at the community level would allow implementation of ecologic approaches to SV prevention with a greater potential for reducing the prevalence of SV perpetration. The field will face several challenges in identifying and evaluating the effectiveness of promising community-level strategies to prevent SV. These challenges include limited knowledge of community-level and societal-level risk factors for SV, a lack of theoretical or empirical guidance in the SV literature for identification of promising community-level approaches, and challenges in evaluating SV outcomes at the community level. Recognition of these challenges should guide future research and foster dialogue within the SV prevention field. The development and evaluation of community-level approaches to SV prevention represent a vital and logical next step toward the implementation of effective, multilevel prevention efforts and a population-level reduction in the prevalence of SV.

Expect respect support groups: preliminary evaluation of a dating violence prevention program for at-risk youth.

Expect Respect support groups, a selective prevention strategy, are designed to prevent and reduce dating violence among at-risk middle and high school students. This preliminary, uncontrolled evaluation examined changes in healthy relationship skills and emotionally and physically abusive behaviors in participants' peer and dating relationships. Self-reports (N = 144) showed significant increases in healthy relationship skills from baseline to program completion, whereas levels of victimization and perpetration remained unchanged. A subgroup of students who reported baseline levels of victimization and perpetration with means at least one standard deviation above the group mean reported significantly less victimization and perpetration at program completion.

A combined motivation and parent-child interaction therapy package reduces child welfare recidivism in a randomized dismantling field trial.

OBJECTIVE: A package of parent-child interaction therapy (PCIT) combined with a self-motivational (SM) orientation previously was found in a laboratory trial to reduce child abuse recidivism compared with services as usual (SAU). Objectives of the present study were to test effectiveness in a field agency rather than in a laboratory setting and to dismantle the SM versus SAU orientation and PCIT versus SAU parenting component effects. METHOD: Participants were 192 parents in child welfare with an average of 6 prior referrals and most with all of their children removed. Following a 2 x 2 sequentially randomized experimental design, parents were randomized first to orientation condition (SM vs. SAU) and then subsequently randomized to a parenting condition (PCIT vs. SAU). Cases were followed for child welfare recidivism for a median of 904 days. An imputation-based approach was used to estimate recidivism survival complicated by significant treatment-related differences in timing and frequency of children returned home. RESULTS: A significant orientation condition by parenting condition interaction favoring the SM + PCIT combination was found for reducing future child welfare reports, and this effect was stronger when children were returned to the home sooner rather than later. CONCLUSIONS: Findings demonstrate that previous laboratory results can be replicated in a field implementation setting and among parents with chronic and severe child welfare histories, supporting a synergistic SM + PCIT benefit. Methodological considerations for analyzing child welfare event history data complicated by differential risk deprivation are also emphasized.

Commentary on Foubert, Godin, & Tatum (2010): the evolution of sexual violence prevention and the urgency for effectiveness.

Foubert, Godin, and Tatum describe qualitative effects among college men of The Men's Program, a one-session sexual violence prevention program. This article and the program it describes are representative of many sexual violence prevention programs that are in practice and provide an opportunity for a brief discussion of the development and evaluation of sexual violence prevention approaches. In this commentary, we will focus on two considerations for an evolving field: the adherence to the principles of prevention and the use of rigorous evaluation methods to demonstrate effectiveness. We argue that the problem of sexual violence has created urgency for effective prevention programs and that scientific and prevention standards provide the best foundation to meet this need.

Considerations for the definition, measurement, consequences, and prevention of dating violence victimization among adolescent girls.

Violence experienced by adolescent girls from their dating partners poses considerable threat to their health and well-being. This report provides an overview of the prevalence and consequences of heterosexual teen dating violence and highlights the need for comprehensive prevention approaches to dating violence. We also discuss some considerations and future directions for the study and prevention of dating violence. We begin with a discussion of the definition of dating violence and also discuss measurement concerns and the need for evaluation of prevention strategies. Although women and men of all ages may be the victims or perpetrators, male-to-female dating violence experienced by adolescent girls is the main focus of this article. We incorporate research regarding girls' perpetration of dating violence where appropriate and as it relates to prevention.

A motivational intervention can improve retention in PCIT for low-motivation child welfare clients.

A motivational orientation intervention designed to improve parenting program retention was field tested versus standard orientation across two parenting programs, Parent-Child Interaction Therapy (PCIT) and a standard didactic parent training group. Both interventions were implemented within a frontline child welfare parenting center by center staff. Participants had an average of six prior child welfare referrals, primarily for neglect. A double-randomized design was used to test main and interaction effects. The motivational intervention improved retention only when combined with PCIT (cumulative survival = 85% vs. around 61% for the three other design cells). Benefits were robust across demographic characteristics and participation barriers but were concentrated among participants whose initial level of motivation was low to moderate. There were negative effects for participants with relatively high initial motivation. The findings suggest that using a motivational intervention combined with PCIT can improve retention when used selectively with relatively low to moderately motivated child welfare clients.