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Clinical Child and Family Psychology Review (CCFP)

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C 2002) Clinical Child and Family Psychology Review, Vol. 5, No. 2, June 2002 (°

Critical Issues in the Prevention of Violence-Related Behavior in Youth Suzanne E. U. Kerns1 and Ronald J. Prinz1

Violence prevention programs with varying degrees of scientific support have proliferated in the United States and elsewhere. This paper previewed a broad range of programs involving youth, families, or systems that aimed to prevent or reduce violence-related behavior. The purpose of the review was to address critical issues concerning (1) target level of programming, (2) theory-driven versus problem-driven conceptualization, (3) cultural considerations, (4) developmental considerations, (5) intervention fidelity, and (6) outcome and impact assessment. Conclusions about these issues address tendencies and trends across programs. KEY WORDS: violence prevention; youth; intervention fidelity; developmental; outcome evaluation.

Although recent media releases celebrate a decline in overall rates of youth violence in the past 6 years (Associated Press, 2000), violence-related behavior problems and their sequelae continue to be a pervasive public health issue (Edelman & Satcher, 1993; Hamburg, 1998; Jenson & Howard, 1999). Despite the recent drop in violence-related arrests, youth in the United States more than in other industrialized countries perpetrate violent crimes and are victims of violent crimes (Zimring, 1998). One response to the youth violence epidemic has been the generation of interventions aimed at either preventing violence-related behavior problems altogether or intervening with youth showing precursory signs of risk for development of such problems. There are currently over a thousand violence prevention programs for youth in the United States with approximately half receiving federal funding (Chaiken, 1998). Despite the sheer quantity of prevention programs, the vast majority remain untested (Green, 1998), prompting ongoing debate about best practices in violence prevention (Clayton, Ballif-Spanvill,

& Hunsaker, 2001). Additionally, the field is particularly concerned about the escalating rates of early childhood aggressive behavior, a precursor to more extreme forms of violence (Loeber, Keenan, & Zhang, 1997), increasing rates of violence perpetrated by female youth (Chesney-Lind & Brown, 1999; Potter, 1999), and etiological gender differences for violence-related behavior problems (Keenan, Loeber, & Green, 1999). Current prevention programs target multiple foci, including individuals, families, schools, and communities (Thornton, Craft, Dahlberg, Lynch, & Baer, 2000). An appraisal of the many prevention programs revealed several recurring and significant issues. The critical issues selected for this paper included choice of participant groups and targeted levels of intervention, the role of theory in program development, developmental and cultural considerations, challenges related to intervention fidelity, and issues in the assessment of outcome and impact. The aim of this paper was to examine the methods and strategies employed by the different categories of violence prevention programs to overcome obstacles these critical issues impose. For this paper, “violence-related behavior problems” included any acts perpetrated by one or more youth (age 18 or younger) against another person that results in intentional threat, attempted harm, or

1 Department

of Psychology, University of South Carolina, Columbia, South Carolina. 2 Address all correspondence to Ron Prinz, Department of Psychology, University of South Carolina, Columbia, South Carolina 29208; e-mail: [email protected].

133 C 2002 Plenum Publishing Corporation 1096-4037/02/0600-0133/0 °

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134 actual physical harm (Reiss & Roth, 1993). Youthful violence takes on many forms. Examples of violencerelated behavior, ranging from milder forms of aggression to serious public health concerns, include verbal aggression, threatening, bullying, pushing, shoving, assault, rape, and murder.

SELECTION OF PROGRAMS This paper considered several documented programs that addressed prevention of violence-related behavior. Programs included ones identified in the U.S. Office of Juvenile Justice and Delinquency Prevention (OJJDP) Blueprints initiative (Center for the Study and Prevention of Violence) as well as other empirically validated programs and some emerging programs with less evidence. Inclusion criteria for programs included (1) empirically evaluated studies that consider certain critical issues; (2) programs that have violence or violence-related behaviors as outcome criteria; and (3) programs or program components fit within individual-, family-, or system-focused programming. Exclusion criteria for programs included (1) outcome variables not associated with violence or violence-related behavior problems; and (2) interventions that focused on treatment rather than prevention. Preference was given to programs that were empirically validated. Nonempirically validated programs were included only when they contributed important information relevant to exploration of a specific issue. Multisystemic Therapy (Henggeler, Mihalic, Rone, Thomas, & TimmonsMitchell, 1998) and Functional Family Therapy (Alexander et al., 1998) were considered in this review because these programs are widely used with a broad range of youth although one could also construe these programs as treatment modalities.

Kerns and Prinz components. See Table I for a list of reviewed programs and components.

Individual Programs targeted at the individual level focus on changing qualities or abilities of the participating youth. These programs train specific skills to promote cognitive resources for handling social and personal challenges. Many of these programs draw on socialcognitive social-learning theory. Programs emphasize learning processes involving observation and modeling of social skills by parents, other adult role models, mentors, peers, and sources such as the media. Conflict resolution is another popular component of individual-focused programs. Although most prevention programmers recognize the import of including other contextual factors impinging on the individual, programs focusing solely on the individual youth remain important because aggressive youth often differentially process social information (Coie & Jacobs, 1993). Individual-focused programs target these skills.

Family Programs that focus on parenting or on families emphasize influencing youth behavior by affecting parenting and family relationships. These programs typically consist of parenting-skills training, education about child development, and parental communication skills. Included within the family-focused program paradigm are home-visiting programs. A primary tenet of these programs is to bring community resources directly to families. Most often, this type of program is used for expecting or new parents, or to facilitate participation with hard-to-reach populations.

TYPES OF PREVENTION PROGRAMS

Larger Social Systems

Reviewed programs form three categories: (1) programs that focus exclusively on individual youth; (2) programs that focus on parenting or families; and (3) programs that focus on larger social systems, including classrooms, schools, and communities. These categories provide only general organization for discussion purposes because not all programs categorize neatly. For simplicity, when there is considerable overlap, programs are considered by their individual

Programs that focus on larger social systems emphasize the role larger contextual factors have on child behavior. Larger social systems typically involve programming aimed at the classroom, entire school, or community, all with the focus on prevention of violence through altering the social and environmental context in which youth reside. Nearly 10 years ago, Coie and Jacobs (1993) forecasted that systemic interventions were the future of prevention of

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Critical Issues in the Prevention of Violence

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Table I. Reviewed Programs Individual-focused programs Anger Coping Program (Lochman, Burch, Curry, & Lampron, 1984) Big Brothers Big Sisters (McGill, Mihalic, & Grotpeter, 1997) BrainPower (Hudley et al., 1998) High/Scope Perry Preschool Program (Schweinhart & Weikart, 1988) Life Skills Training (Botvin, Mihalic, & Grotpeter, 1998) Moral reasoning (Arbuthnot & Gordon, 1986) Parent and child intervention (Webster-Stratton & Hammond, 1997) PrimeTime (Cavell & Hughes, 2000) Quantum Opportunities Program (Lattimore, Mihalic, Grotpeter, & Taggart, 1998) Self-contained kindergarten (Barkley et al., 2000) Skill development program (Vitaro & Tremblay, 1994) Family-focused programs Brief Strategic Family Therapy (BSFT; Szapocznik & Williams, 2000) Comprehensive Child Development Program (St. Pierre & Layzer, 1999) EARLY ALLIANCE (Dumas, Lynch, Laughlin, Smith, & Prinz, 2001) Early Intervention Treatment Foster Care (Chamberlain & Mihalic, 1998) Fast Track (Conduct Problems Prevention Research Group, 1992) Functional Family Therapy (Alexander et al., 1998) Hawaii’s Healthy Start Program (Duggan et al., 1999) Home Instruction Program for Preschool Youngsters (Baker, Piotrkowski, & Brooks-Gunn, 1999) Multisystemic Therapy (Henggeler et al., 1998) Multidimensional Treatment Foster Care (Chamberlain & Mihalic, 1998) Nurses Home-Visiting Program (Olds, Hill, Mihalic, & O’Brien, 1998) Parent and teacher training program (Hawkins, Von Cleve, & Catalano, 1991) Preparing for the Drug-Free Years (Spoth, Redmond, & Shin, 1998) Project Back-on-Track (Myers et al., 2000) Safe Start (Alkon, Tschann, Ruane, Wolf, & Hittner, 2001) Triple P-Positive Parenting Program (Sanders, 1999; Sanders, Markie-Dadds, Tully, & Bor, 2000) System-focused programs ALPHA (Chatterji, Caffray, Jones, Lillie-Blanton, & Werthamer, 2001) Bullying Prevention Program (Olweus, Limber, & Mihalic, 2000) Classroom-based intervention (Ialongo et al., 1999) First Steps to Success (Walker, Kavanagh, et al., 1998; Walker, Severson, Feil, Stiller, & Golly, 1998) Linking the Interests of Families and Teachers (Reid, Eddy, Fetrow, & Stoolmiller, 1999) Midwestern Prevention Project (Pentz, Mihalic, & Grotpeter, 1997) Promoting Alternative Thinking Strategies (Greenberg, Kusche, & Mihalic, 1998) PeaceBuilders (Embry, Flannery, Vazsonyi, Powell, & Atha, 1996) Peer mediation (Bell, Coleman, Anderson, Whelan, & Wilder, 2000) Positive Action (Flay, Alred, & Ordway, 2001) Resolving Conflict Creatively Program (Aber, Brown, & Henrich, 1998) Second Step (Frey, Hirschstein, & Guzzo, 2000) School Transitional Environmental Program (Felner & Adan, 1988)

violence-related behavior problems. The consequential propagation of these programs indicates their popularity.

then family-targeted programs, and, finally, systemslevel programs.

TARGET LEVEL OF PROGRAMMING ANALYSIS OF CRITICAL ISSUES For each of the critical issues addressed in this review, important considerations within each issue are considered. The program analysis for each critical issue begins first with individual-targeted programs,

The programs target universal, selected, and indicated levels of intervention, or some combination of these. Universal preventive interventions target entire populations or population groups without regard to risk status or other factors. Selected preventive

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136 interventions target individuals or groups who are at elevated risk for the specified outcome even though early signs of that outcome may not yet have occurred. The selected facet can be any of a number of factors such as economic disadvantage, residence in a high-crime neighborhood, or exposure to domestic violence. Indicated preventive interventions focus on individuals who demonstrate the early, precursory symptoms of the mental disorder or other outcome but who do not yet meet diagnostic criteria (National Institutes of Health, 1997). Review of extant literature reveals significant issues and salient themes associated with targeting level. First is the ability of prevention programs to adequately target specific risk/protective factors, especially taking into account the often-limited availability of resources. Another theme involves differential potential for stigma associated with program participation. Targeting Level and Addressing Risk and Protective Factors Youth exhibiting violence-related behavior problems often experience difficulty in multiple domains, including family, peer, and community contexts (Dahlberg & Potter, 2001; Fergusson & Horwook, 1999; Kellam, Rebok, Ialongo, & Mayer, 1994; Loeber et al., 1993). The scope of a program (i.e., universal, selected, and indicated) has important implications for the choice of, and methods for targeting, risk and protective factors. Individual-Focused Programs Programs focusing on the individual generally aim to improve social or cognitive deficiencies (e.g., attributional biases) or improve conflict-resolution skills. Universal programs most commonly take place in classroom settings and involve curricula designed to facilitate individual skill building, as illustrated for example by Life Skills Training (Botvin et al., 1998). In this context, risk and protective factors often are deliberately targeted in entire classrooms of children. Although not all youth are able to get the individual attention or intensive intervention they may need through a universally administered program, most youth potentially reap benefits from program participation. An additional advantage is that all youth, regardless of risk status, are exposed to skills deemed to be important, such as effective conflict resolution.

Kerns and Prinz The universal programs assume that competent youth could model prosocial behavior for the less competent youth learning the skills perhaps for the first time. This form of social modeling plays a potentially important role in prevention programming (Bierman & Furman, 1984). Selected and targeted programs raise other considerations. By nature, programs that select participants on the basis of known risk factors are able to concentrate resources more intensively on those most likely to benefit from services. This approach, however, is predicated on being able to accurately determine which children later progress to adverse outcomes, a formidable assumption (Reid et al., 1999). Participating youth who would not ultimately exhibit the problematic behavior consume valuable resources and could be exposed to potential stigma associated with program participation, without long-term benefit. Despite this drawback, prosocial youth under some program conditions can acquire benefit from programs designed to target violence-related behavior problems (Prinz, Blechman, & Dumas, 1994), and inclusion of prosocial youth is a meaningful component of many successful preventive interventions. It is important to note that research substantiates undesirable iatrogenic effects when deviant youth participate in programming in the absence of prosocial peers (Dishion, McCord, & Poulin, 1999). Programs that group deviant youth together for skills training may encourage unintended socialization of aggressive behavior problems (Arnold & Hughes, 1998). Constructing interventions to include a range of youth may facilitate positive outcomes, reduce stigmatizing effects associated with program participation, and promote positive socialization, an important protective factor.

Family-Focused Programs One advantage of family-focused programs over individual-focused programs is the ability to target multiple contextual factors associated with youth functioning. Generally, universal family-focused programs are rare (for an exception, see Spoth, Redmond, Shin, & Lepper, 2000). However, the potential importance of such programs should not be underscored considering their low prevalence in the United States. In Australia, one component of a multilevel program, the Triple P-Positive Parenting Program (Sanders, 1999), is a universal media campaign that targets broad-based risk and protective factors.

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Critical Issues in the Prevention of Violence This program component is able to target common behavioral difficulties of children that may ultimately lead to more problematic behaviors. An additional benefit of the universal informational campaign is that the process of getting help for child behavior problems is normalized, thus increasing subsequent parental receptivity to the program. Compared with universal approaches, selected and indicated family-focused programs usually target specific risk and protective factors in a more intensive manner. However, the nature of the family-focused programs that target specific populations contributes to practical obstacles regarding program participation in that often the factors that made families eligible for the program were the same factors that were associated with lower rates of recruitment and participation. For example, Functional Family Therapy (FFT) developers recognize this limitation and invoke methods to increase participation, including a primary focus on engaging and motivating participants before initiation of behavior change. The goal is to develop a productive therapeutic alliance and promote cultural sensitivity and relevance among the participants. Once the therapeutic alliance is solidified, modifiable risk and protective factors are targeted (Alexander et al., 1998).

Systems-Focused Programs Universal prevention programs focused at the systems level are more common. Universal systemslevel programs include classroom, schoolwide, or community programming aimed at altering the general climate or culture of a macrosystem. Universal programs are the gold standard for altering a climate to promote positive behavior and prevent violence-related behavior problems. These programs are preferable to selected programs when intervening with very young children because it is difficult to determine which children subsequently develop violence-related behavior problems, as noted earlier. Therefore, concentrated intensive individual-focused interventions with young children may not be costeffective (Reid et al., 1999). An added consideration is that programs that target one system often have limited to no impact on other contextual systems. For example, the Promoting Alternative THinking Strategies (PATHS) curriculum is administered universally at the school level without evidence of meaningful change at the family level (Greenberg et al., 1998).

137 Other programs target this drawback by promoting multicontextual programming. The Bullying Prevention Program (Olweus et al., 2000) combines universal and selected strategies to optimize program impact and address risk factors within individual, family, peer, and school contexts. At the universal level, schoolwide rules against bullying are enforced and prosocial behavioral norms are established. At an indicated level, identified bullies and victims participate in an intensive intervention involving both youth and parents. Stigma Associated With Program Participation Participation in programming occasionally results in the experience of stigma or shame, often as a result of being selected to participate in a preventive intervention on the basis of known risk factors. This is particularly problematic when the perception of stigma interferes with recruitment and retention of participants. Targeting level influences this experience. Individual-Focused Programs In general, individual-focused programs are selected or indicated in nature, focusing either on youth with known risk factors or on youth who are already demonstrating the precursors to aggressive behavior. Universal programs that focus on individual skill-building techniques are an exception (e.g., LST; Botvin et al., 1998). Because these programs are administered without consideration of risk status, program participation may not have stigmatizing effects. However, selected programs may carry stigma associated with program participation because youth are purposely chosen on the basis of either a personal, family, or neighborhood characteristic that is theoretically related to adverse outcomes or greater life challenge. Other considerations also mediate a youth’s experience in a program. For example, siblings and other family members who are excluded from participation may react unfavorably to the target youth’s participation. The Quantum Opportunities Program (QOP) found that siblings or friends occasionally tried to undermine the success of the participants, perhaps in reaction to the participants’ access to financial incentives and program-based opportunities (Lattimore et al., 1998). Although this may manifest in jealousy or other problems, stigma issues are understudied and represent an empirical question.

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138 As established in the previous section, selected or indicated interventions have more intensive program delivery. Arguably, the positive outcomes from effective programs may outweigh stigma impact. For example, Lochman et al. (1984) implemented a program in which fourth through sixth grade boys who were recognized as having aggressive and disruptive behavior problems were removed from their classrooms to participate in an anger-coping program. Conventional wisdom suggests that because these youth were removed from their classrooms they were potentially labeled as the “aggressive kids.” However, results based on 3-year follow-up data indicate that youth retain many positive outcomes, including less substance use and higher self-esteem and social problem-solving skills (Lochman & Curry, 1986). These benefits occur despite participation in a potentially stigmatizing intervention. The question remains: do the benefits outweigh the costs?

Family-Focused Programs The majority of family-focused programs are also selected or indicated in nature. Universal familyfocused preventive interventions are uncommon and rarely comprehensively evaluated (Spoth et al., 1998). Triple P (Sanders, 1999) is one notable exception. The universal components of Triple P provide broadbased services and help destigmatize the process of seeking assistance for child behavior problems. In addition to increasing receptivity to the program in general, there is the additional benefit that presence of the universal program components facilitates participation in the more intensive program components. Another exception is Preparing for the Drug-Free Years (Spoth et al., 1998), a family competency training program. Spoth et al. teamed up with local schools and the Cooperative Extension to provide the intervention, which consisted of five 2-hour sessions designed to strengthen parent–child interactions and reduce risk for early substance use. The success of Preparing for the Drug-Free Years is encouraging for the future of universal family-based preventive interventions. Selected and indicated family-focused programs, by and large, have similar issues as individual-focused programs. However, one family-based program, the Prenatal and Infancy Home Visitation by Nurses Program (Olds, 1988; Olds et al., 1998), provides services to high-risk populations while reducing the potential for stigma associated with program participation. Sensitive recruitment of participants has enabled par-

Kerns and Prinz ticipation by low-income mothers in a nonstigmatizing way. Program designers are mindful that printed material and recruitment strategies include a general invitation for all first-time mothers, regardless of risk status. To promote specific participation by lowincome mothers, concentrated recruitment efforts are staged in locations where they can be identified by referral sources (e.g., obstetrician’s office).

System-Focused Programs Successful universal interventions require a “buy-in” by members of the targeted system (e.g., teachers at a school). The stigma represented here may be less concerning the effects of personal program participation and more concerning the lore and reputation of previous program implementation efforts. For school-based preventive efforts, it is often a significant challenge to secure agreement for participation by all personnel (Greenberg et al., 1998). The perception of the ability of a particular intervention to produce positive effects is an essential factor contributing to the program adoption, especially within a school environment (Newmann, Rutter, & Smith, 1989). However, schools often do not maintain programs long enough to expect optimum benefit (Elias & Weissberg, 1989). Premature extermination may contribute to the perception that program implementation is a waste of time and resources, making it unlikely that without careful consideration of this barrier teachers or other personnel would be excited about learning yet another program. Additionally, insensitive researchers may spoil the pot for future programs, for example, by not following through with promises, engendering an “us versus them” attitude, or spending only a short time in a school without sustaining benefits. A media component to universal interventions assists with community or system-level “buy-in.” For example, The Midwestern Prevention Project (Pentz et al., 1997) offers multiple levels of intervention, with the most broad-based being a mass media campaign designed to explain the purposes of the program to the community. The primary purpose for this campaign is to educate community members about the program’s purposes and rationale, as a way of promoting community acceptance. A promising indicated intervention administered classroomwide is the School Transitional Environmental Program (STEP; Felner & Adan, 1988). STEP targets youth attending large, urban junior high

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Critical Issues in the Prevention of Violence schools with a low-income minority demographic and multiple feeder schools. Because the focus of this program is on organizational restructuring rather than burdening teachers with unwieldy additional programming, teacher satisfaction and morale increases as a result of participation. Such positive experiences promote continuation of the program in pilot schools and facilitate further expansion into new schools (Felner & Adan, 1988). Therefore, it is critically important for the future of a program to attend to the experiences of primary stakeholders and ensure that such experiences are as positive and successful as possible.

THEORY-DRIVEN VERSUS PROBLEM-DRIVEN CONCEPTUALIZATIONS Multiple factors contribute to the etiology of various program designs. For some programs, design is based on sound, empirically derived theory. The strands of the underlying theory or theories are salient throughout the program’s rationale and evaluative criteria. For other interventions, the roots of the program design are less obvious. Some programs are developed as a response to a particular problem facing the youth in the community. Many of these are “feel good” programs, with little empirical support justifying program design. Several significant subissues arise in this debate: consideration of social–ecological context, mediating and moderating variables, and mechanisms of program success. Consideration of Social–Ecological Context Social and ecological contexts (i.e., family, neighborhood, school, etc.) are theoretically important and critical aspects bearing on the etiology of violence (Coie & Jacobs, 1993; Stevahn, Johnson, Johnson, & Real, 1996). Nonetheless, some programs fail to address the broader contextual factors that influence child development and the etiological factors that are associated with violence-related behavior problems. Individual-Focused Programs Neglecting to consider the influence of larger social–ecological factors on behavior is a pervasive limitation of many individual-focused programs. As mentioned above, individual-focused programs tend to focus on cognitive distortions or skill building. One

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139 counterargument is that generalization of skills enables youth to function better within a variety of social contexts. The fact remains that there is little consideration of the youth–environment interplay responsible for the emergence and sustenance of violence-related behavior problems. Individualfocused programs need to better take into account environmental and macrosystemic factors affecting the youth (Coie & Jacobs, 1993; Thornton et al., 2000). It may be too optimistic to assume generalization from individual-focused programs to the broader ecosystem. One program, the High/Scope Perry Preschool Program (Schweinhart & Weikart, 1988), did consider the social–ecological context of the participating youth. The tenets of this program recognize the necessity of addressing poverty and other factors of adversity in concert with educational goals. Through consideration of these other important factors, meaningful change is possible. Boot camps and alternative schools, two popular methods to address aggressive and violent behavior, are predicated on removing youth from a debilitating social context. This approach has not been substantiated as an effective method of intervention (Group for the Advancement of Psychiatry, 1999) for several reasons. Because boot camps and alternative schools are themselves a unique ecological context it may be difficult for youth to generalize intervention benefits to their native environment, which has not been altered as a result of intervention. Many youth learn to successfully function within the camp or school, but flounder once they return to their home environment or mainstream school. Efforts to remediate this problem are challenging. To illustrate, Barkley et al. (2000) evaluated an intervention with self-contained kindergarten classrooms containing children with behavior problems. A combination of parent and classroom intervention was compared with no intervention, parent training only, and full-day classroom intervention only. Children placed in the experimental kindergarten classrooms improved greatly in selfcontrol, social-skills, and home-adaptive functioning. However, there was no difference when the intervention was combined with parenting training. This was largely due to uninvolved parents who either never or rarely attended the training sessions. Involving parents in school-based programming was, in this case, ineffective and attempting to do programming with parents who did not seek out services was nearly futile. This leaves open the question of how well the beneficial effects will remain over time without the support of parents, the primary socialization agents for youth

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140 of this age. Issues such as challenges with parental involvement illustrate the difficulty of producing effective programs that benefits children within multiple contexts. Family-Focused Programs Family-focused programs have the advantage over individual-focused programs in being able to address factors such as family adversity and coercive family processes, and build on family strengths. Multisystemic Therapy (Henggeler et al., 1998) is the most comprehensive example of this approach. The social–ecological underpinnings of the program are salient both in intervention theory and approach. For example, targets of the intervention focused on improving caregiver discipline, enhancing family relations, decreasing youth association with deviant peers, increasing youth association with prosocial peers, improving academic performance, and establishing a positive support network. The final intervention target, network support, is an important way for the effects of the program to achieve sustainability. Other family-focused programs also utilize the support network for reaching out to multiple contexts affecting the family (e.g., FFT; Alexander et al., 1998; NHVP; Olds et al., 1998; Hawaii’s Healthy Start Program; Duggan et al., 1999). Some family-focused programs concentrate on family-based skill acquisition without linkage to other resources. One example is the Home Instruction Program for Preschool Youngsters (HIPPY; Baker et al., 1999). The focus of this home-visiting program is to instruct parents on use of program materials aimed at helping children develop skills necessary for school success. Program content did not address neighborhood norms, program sustainability, or means to connect parents with outside resources. Although successful in the aim to increase school readiness, the challenge with this approach was that once the program staff had gone, natural support was not strong or substantial enough to promote continued application of learned skills or generalization of skills to other situations. System-Focused Programs Presumably, system-focused programs, more so than family and individual programs, are in a better position to enact broad-scale influence. However, some system-focused programs have not adopted

Kerns and Prinz a social–ecological framework. For example, zerotolerance policies with regard to weapons at school did not effectively alter the school climate or promote feelings of safety among students, teachers, and administrators. Although federally mandated through the Gun-Free Schools Act (“Gun-Free Schools Act of 1994,” 1994), the danger in these policies is that minor incidents are equivocated with more serious offenses, thus undermining the sense of safety these programs were designed to provide (Tolan, 2000). Therefore, it is important to consider the social–environmental impact of legislation and of broad-based programs that have good intentions yet do little service for the prevention of violence-related behavior problems. Significantly, programs that target multiple contexts are theoretically best suited to address this issue. Role of Mediating and Moderating Variables Consideration of mediating and moderating variables is helpful when determining the salience of an underlying theory of behavior change (Holmbeck, 1998). Although often overlooked, it is through this type of exploration that the suitability of a theory for prevention of violence is revealed and modifications are made. Additionally, particular consideration of moderating variables is critical when considering factors affecting violence-related behavior problems because these factors may explain behavior change more parsimoniously than the intervention (Baron & Kenny, 1986). Inclusion of such factors in the primary analysis helps confirm the presumption that it is the intervention that produces change in violence-related behavior problems, rather than other unaccounted factors. Individual-Focused Programs Elucidation of critical mediating factors, and their subsequent incorporation into program design, contributes towards more rigorous programming. To illustrate, it has been established that a key mediating factor contributing towards youthful aggression is association with deviant peers (Coie, 1989; Patterson, DeBaryshe, & Ramsey, 1989). Consideration of this mediating factor in an intervention program teaching social and cognitive problem-solving skills to youth, and additional training to parents, further confirmed the salience of specifically targeting peer groups in prevention of aggression (Vitaro & Tremblay, 1994). The parenting training component focuses on

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Critical Issues in the Prevention of Violence increasing monitoring of the child outside of the home, thus countering the ability of the child to associate with deviant peers. Inclusion of prosocial peers in social-skills training groups provides positive models and reinforcement agents. The cognitive problemsolving component assists youth in learning prosocial ways to react when angry or when confronting the aggression of others. As a result of this intervention, participating youth are both more likely to associate with prosocial peers and are less aggressive compared with the control group, thus providing evidence for the mediational impact of association with deviant peers on the relationship between aggression and delinquency. Several moderating factors are commonly assessed in the literature. Parenting factors (e.g., supervision and monitoring, parental functioning) are the most commonly evaluated and substantiated (Long, 1996). Individual-focused programs are generally incapable of affecting these extra-individual variables, thus compromising the ability of the intervention to make lasting and meaningful change. Moderational factors impinging on the individual have the potential to (1) dilute intervention efficacy or (2) assist with intervention specificity. Intervention efficacy can be diluted when other factors are more salient than the intervention. Some examples of critical factors to consider are parental involvement (Morrissey-Kane & Prinz, 1999), school climate (Welsh, 2000), level of behavior problem (e.g., Moffitt, 1993), and perception of program benefits (Spoth et al., 2000). To illustrate the latter point, intervention specificity is indicated for a mentoring program, PrimeTime (Cavell & Hughes, 2000). Researchers examined two moderating relationships: maternal history of maternal rejection (MHR) and peer-rated narcissism (PN). These two factors were assessed with regard to intervention effectiveness and were found to moderate intervention effects. Specifically, standard mentoring was more efficacious when youth had low MHR and PN. The PrimeTime intervention was contraindicated for these youth and was found more efficacious for youth with high levels of MHR and PN. In fact, youth with low MHR placed in PrimeTime were more aggressive at follow-up, indicating iatrogenic effects of intervention for this group. The value of assessing factors associated with treatment specificity is highlighted in this example. Examination of moderating factors provided additional clarity on the theoretical role of intervention components. Results from an anger coping program (Lochman, 1992) substantiated that aggressive boys receiving intervention had higher levels of

141 self-esteem than untreated aggressive boys. Findings suggested that since the anger coping program was principally problem solving, treated boys were able to resolve conflict through avoiding illogical solutions as opposed to conflict resolution through other means such as generation of more problem solutions.

Family-Focused Programs In family-focused programs, multiple mediating and moderating factors are found to influence intervention success. Assessment of mediating factors at a theoretical level is critical for subsequent incorporation into theoretically driven preventive interventions. To illustrate, a recent study of the relationship between parental and youth variables found that parental trait anger mediated the relationship between parental depression and behavioral problems in adolescents in important ways. Specifically, parental disposition towards displaying anger was related to child behavior problems and was mediated by gender. Father–son dyads were differentiated from mother–son dyads in inward versus outward anger expression (Renk, Phares, & Epps, 1999). This information can be useful for future program specificity. Families contribute many moderating factors associated with the prevention of violence-related behavior problems in youth (Reese, Vera, Simon, & Ikeda, 2000). Family-focused programs are specifically able to target these factors, thus increasing the possibility of successful and effective program benefits. MST (Henggeler et al., 1998) and Multidimensional Treatment Foster Care (Chamberlain & Mihalic, 1998) are two examples of programs that recognize important family factors purporting change. Special attention is given to assure that families are full collaborators in the intervention and that they feel empowered to incite change; the role of families as collaborators and change agents has been identified as a key moderator. MTFC specifically dedicates a proportion of the intervention to individual family intervention, attempting to alter discouraging and defeated feelings on the part of parents that may interfere with intervention goals. A “clinical map” is utilized by FFT to understand moderating and mediating factors affecting therapy outcome (Alexander et al., 1998). This map demonstrates the importance of flow between engagement/ motivation, behavior change, and generalization over time. To reach the generalization phase, families must first enter the engagement/motivation stage and then

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142 progress through behavior change. There is then a transactional relationship between these three phases, informing intervention and promoting success. System-Focused Programs Mediating mechanisms are observed in the theoretical underpinnings and subsequent analyses of many system-focused programs. For example, mediation was examined for Second Step (Frey et al., 2000), a school-based universal violence-prevention program. Social–emotional competence was the primary mediating mechanism through which effective change occurs. Second Step aims to mediate conduct problems through focusing their curriculum structure on specific theoretical mediators, including empathy, social problem solving, and anger management. Frey et al. (2000) demonstrated that social–emotional competence mediated decrements in physical aggression and verbal hostility. Moderating factors are also critical considerations for theory development and program success. One such program was Positive Action (Flay et al., 2001), a curricular preventive intervention with schoolwide climate and community components. The theoretical components of this program posited that the school climate and the learning environment is a moderating factor that impinges on the potential effectiveness of a preventive intervention. Therefore, the theoretical model included the role of the sociocultural learning environment in program outcome. Immediate outcomes were tailored to improve the learning environment prior to analysis of shortand long-term effects. Once the learning environment was improved, short-term effects became the mediators for longer-term outcomes, therefore merging of mediating and moderating factors in program theory and design. Mechanisms of Program Success Some problem-driven models are successful despite lack of evidence-based practices in program design. A critical issue was to understand and evaluate the mechanisms whereby these programs function to decrease or prevent violence-related behavior problems. A significant advantage of having a theory-driven versus a problem-driven preventive intervention is the ability to examine the role of theory as change agent. Although this represents a clear conceptual advantage, some programs are effective

Kerns and Prinz despite a lack of theoretical orientation. Gaining a greater grasp of the mechanisms at work with these interventions is more difficult, but just as important.

Individual-Focused Programs Several individual-focused programs have achieved success without being theory driven. Big Brothers Big Sisters of America (BBBS) is one such program (McGill et al., 1997). BBBS began in the early 1900s when a group of adults formed lasting, meaningful relationships with disadvantaged youth. Although commonly termed “mentoring” today, this nomenclature was not included in the BBBS mission statement until the 1980s. In this case, the theoretical basis for the program temporally followed program conception by over 80 years. Nevertheless, BBBS has proven to be successful. After further exploration, one can see that the change agent responsible for the program’s success is social control theory whereby youth become attached with prosocial role models, make a commitment to socially appropriate goals, and become involved in activities that directly compete with their ability to participate in delinquent behaviors (McGill et al., 1997). In this case, the problem-driven approach dovetails with established theories after the fact. This is not just the case with long-standing programs. QOP (Lattimore et al., 1998), founded in 1989, had a similar story because an underlying model did not dictate intervention design. After the program was conceived, Lattimore et al. noted the similarity of the program with the Social Development Model (Catalano & Hawkins, 1996). Other programs start first with a theoretical question or position and this theory is tested out through intervention specifically targeting malleable factors proposed to affect violence-related behavior problems. An example of how theory played out in intervention design and subsequent intervention success is LST (Botvin et al., 1998), which is based on a person– environment interactionist model of drug use and deviant behavior. Therefore, program design includes this consideration through primary methods of program delivery, addressing biological, sociocultural, social–environmental, and individual-level risk factors. Specifically, targeted areas include drug-related knowledge, attitudes and norms, drug resistance skills, and promotion of general personal self-management and social skills. Outcome assessment reveals that improvements in these areas contribute towards decreased substance use.

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Critical Issues in the Prevention of Violence Family-Focused Programs Although some successful programs are developed out of a clear need for problem-specific services, theory-driven intervention development is considered. For example, the Safe Start intervention and evaluation project was developed because of community recognition of increases in neighborhood violence and a lack of violence prevention training for parents and child care workers (Alkon et al., 2001). From that need, the intervention model was guided by Bronfenbrenner’s ecological model (Bronfenbrenner, 1979). The Safe Start program illustrates the journey from program conception to development, integrating problem-driven and theory-driven aspects. In this regard, the foundations of the program are based on sound theory and the perceived need of the community. This increases the opportunity for success and program acceptance. The marriage between intervention theory and program design is clearly illustrated by NHVP (Olds, 1988; Olds et al., 1998). This program is based on components of human–ecology, self-efficacy, and attachment theory. The human–ecology theory is important for identifying the participant families as well as timing of the intervention. Women experiencing the transition to motherhood for the first time are the targeted participants. This theory also focused nurse attention on the family home environment, both material and social. The self-efficacy theory is a critical aspect for promoting behavior change. Mothers are assisted in setting attainable goals. By achieving these goals the mothers gain confidence as they increase their perception of their own self-efficacy. Finally, attachment theory is applied to the nurse– mother relationship, the relationship the mother had with her own mother, and finally the mother–child relationship. Prevention interventions in this area can inform theory when tested within an appropriate design. For example, to better understand the essential components of the Triple P-Positive Parenting Program (Triple P) family intervention (Sanders et al., 2000), the effectiveness of four conditions were evaluated: enhanced Triple P, standard Triple P, self-directed Triple P, or wait-list. Enhanced Triple P consists of a multimodal therapeutic intervention (including partner support and cognitive coping skills training). Standard Triple P consists of parenting training and planned activities. Self-directed Triple P has similar content as standard Triple P but intervention is delivered in a self-administered written format. Find-

143 ings revealed that enhanced Triple P has the greatest reduction in child behavior problems, supporting the contentions that the family ecosystem is critical and that attending to family issues produces better outcomes.

System-Focused Programs In response to public demand following episodes of school violence, many schools implemented programs that are intuitively appealing without regard to proven effectiveness (Coleman & Deutsche, 2000). Conflict resolution and mediation programs are primary examples of common programs with little evidence of effectiveness. Although some of these programs have shown beneficial effects (e.g., Aber, Brown, & Henrich, 1999), they are generally not adequate for changing the overall climate of schools, especially ones already experiencing high levels of violence (Webster, 1993). Conflict resolution programs are often launched without adequate consideration of overall school climate. Given relatively weak evidence for such programs, this is an example of a problem-driven approach to solving violencerelated behavior problems that potentially wastes sparse resources that could support evidence-based programs. In contrast to a problem-driven approach, theory-driven programs enable researchers and consumers to better understand the mechanisms through which a program brings about change. An example of a successful theory-driven system-focused program is First Steps to Success (Walker, Severson, Feil, et al., 1998), which was originally developed out of the perceived need to service at-risk children in early elementary school. This program is based on a risk-factors exposure model that states a clear developmental trajectory from early exposure to risk factors to serious behavioral issues. Children are first exposed to risk factors during their development and these risk factors foster antisocial behavior patterns that result in short-term adverse outcomes (e.g., truancy and low academic achievement). These short-term outcomes subsequently lead to more serious longer-term outcomes (e.g., delinquency, school failure, drug and alcohol use, violent acts; Walker, Severson, Stiller, et al., 1988). Three modular components to the program, screening, school intervention, and home intervention, were all developed based on research on school and home interventions for aggressive and antisocial youth.

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144 CULTURAL CONSIDERATIONS Successful dissemination of an effective violenceprevention program rests on the ability of the program to resonate within multiple sociocultural contexts. This issue is particularly challenging considering the diversity inherent in the United States. The complication arises, in part, because many of the factors influencing the foundation of effective violence prevention programs (e.g., validated instrumentation) were derived from research with predominantly European American, middle-class populations (Alkon et al., 2001). Even if programs are tested on diverse populations, almost half fail to report participant ethnicity or socioeconomic status (Brestan & Eyberg, 1998). In addition to general issues involving program development and evaluation, there are ethnic, cultural, and regional concerns with recruitment and retention of program staff and participants. Finally, there is a paucity of research examining program replication with diverse populations.

Kerns and Prinz staff found that youth are more responsive to caring and committed adults who are perceived as stable resources. Recruitment of participant families is facilitated by both written and verbal versions of the informed consent, enabling parents who are unable to read the written materials to be able to consent without acknowledging that reading is difficult for them. Family-Focused Programs

What follows is an illustration of methods by which programs were able to address cultural issues pertinent to recruitment and retention of staff or participants. For many of the programs, these strategies evolved after unsuccessful recruitment or retention of culturally diverse personnel or participants was observed.

The NHVP program (Olds, 1988; Olds et al., 1998) was originally evaluated on a rural population of European American single mothers. When the program was attempted with African American and Mexican American populations, some adjustments were made to increase cultural sensitivity. In addition to modifying protocols to be more culturally relevant, the employment of ethnically diverse staff is used to promote community approval, although nurses and clients are not specifically matched on ethnicity. Mexican American clients are also provided with Spanish-speaking nurses. Cultural competence in program delivery is especially salient for another program, FFT. Issues of resistance are particularly prevalent in under served populations where families are difficult to engage. Intervention utilization is especially compromised for Hispanic/Latino families. Retention is facilitated through increasing focus on therapeutic alliance, helping the client families’ feel empowered over the intervention process (Alexander et al., 1998).

Individual-Focused Programs

System-Focused Programs

BBBS (McGill et al., 1997) programmers had a difficult time recruiting African American men and Hispanic/Latino men and women volunteers. As a response, they began to target recruiting efforts in diverse high schools, local universities, and among the elderly. Men are targeted through jobs and sports in which they are engaged. Recruitment efforts are staged at clubs and programs servicing multiethnic members (e.g., NAACP, Alpha Phi Alpha fraternity, and the Urban League). Having Spanish-language materials and recruiters available increases the number of interested Hispanic/Latino volunteers. QOP (Lattimore et al., 1998) programmers found their retention strategies (provision of stipends and accrual accounts) to be ineffective with youth living in poverty, where their own family was dependent on welfare. Upon further investigation, program

One of the most difficult challenges towards recruitment for system-focused programs is the ability to convince teachers or administrators that the program is worth both the time and money required for successful program implementation. Program implementers are often forced to first rectify the legacy of poor prior programs. Here, school and neighborhood sociocultural factors are particularly salient. For school-based violence-prevention programming, the entire school environment may need to be the target of intervention before any specific programming can be effective. This is particularly true for disorganized schools (Laub & Lauritsen, 1998). The PeaceBuilders program illustrates the ability of a program to influence school climate, thereby increasing teacher receptivity to programming efforts (Embry et al., 1996). The PeaceBuilders’ ideals are incorporated into daily life

Recruitment and Retention

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Critical Issues in the Prevention of Violence through explicit strategies, thus altering overall culture and norms about violence.

Replication With Diverse Populations Replication is the foremost way to test program generalizabilty across diverse populations. This is an essential component for dissemination, the culminating phase of program development. The initial focus of many programs is on homogenous ethnic, racial, and sociodemographic groups. Although this provides insight for culturally specific programming, little information is gathered about programming effectiveness for multiethnic populations or the generalizabilty of programming beyond the cultural group targeted for the outcome study.

Individual-Focused Programs Some culturally specific programs are able to foster ethnic pride and relevance for the participating youth. For example, African American youth in QOP (Lattimore et al., 1998) participate in a triad of programming components that includes educational, development, and service opportunities. Regarding the development opportunities, youth participate in cultural enrichment and personal development activities. Learning about their own history and culture is a major component of these opportunities. Youth also participate in service activities, which are located in their own communities and neighborhoods. Programs such as QOP are developed to specifically address challenges faced by minority inner-city youth. On the other hand, some programs that have been evaluated for only one ethnicity may forego generalizabilty and the ability to integrate knowledge gained from program evaluation into theoretical models. One example is a moral-reasoning development intervention for high-risk behavior-disordered adolescents (Arbuthnot & Gordon, 1986). Participating youth were European Americans from rural backgrounds. The program consisted of weekly discussion groups in which moral norms, issues, and dilemmas were discussed. All moral dilemmas were consistent with “mainstream” values. The ability of such a program to succeed with inner city youth or within other diverse cultural contexts was obviously questionable. LST (Botvin et al., 1998) assumes that the etiology of substance use and deviancy is similar across

145 ethnicity, and therefore presents a similar program regardless of the ethnic background of the participants. Small modifications are made to include cultural sensitivity, relevance, and acceptability. Through this consideration, heterogeneous classrooms are able to receive a similar benefit.

Family-Focused Programs Some programs are effective for multiple ethnic groups. One such program is MST (Henggeler et al., 1998), where assessment of ethnicity effects reveals no difference in intervention efficacy. The collaborative relationship between therapists and families is a critical factor for promoting the perception of cultural relevance. Because of this relationship, cultural barriers are addressed and consideration is given to a family’s unique cultural values. Consideration can also be given to match family and interventionist by ethnicity to promote initial participation (Dumas, Rollock, Prinz, Hops, & Blechman, 1999), although this may not be necessary with competent and sensitive staff (Olds et al., 1998). Other considerations are important for program replication. For example, a parent and teacher training program was evaluated for effectiveness with both European American and African American families (Hawkins et al., 1991). Intervention effects were found for European American youth but not for African American youth. Authors attributed this difference to the possibility that the predominantly European American teachers (who were the source for information on behavior change) were more sensitive to changes in European American than African American students. The authors did recognize, however, that the intervention may have been better suited for European American students. Findings such as these warrant further inquiry because differential intervention responses were detected. Regard should be given when instituting programming with diverse populations. The most comprehensive intervention of culturally specific programming comes from evaluation of Brief Strategic Family Therapy (BSFT; Szapocznik & Williams, 2000). Initial work focused on differences between Cuban adolescents and their families and mainstream European American families in response to intervention. Differences between these cultures were revealed and further intervention efforts were tailored to meet specific cultural needs. Evaluation of BSFT was informed through culturally relevant

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146 instrumentation. Later program adaptations incorporated structural ecosystems theory, keeping pace with new developments in risk and protective factor research and with concerns about sensitivity to sociocultural contexts. The developers produced a variation of BSFT called Structural Ecodevelopmental Preventive Intervention.

System-Focused Programs Systems-level programs often have the added complication of serving a heterogeneous group of youth or families, each with unique cultural norms and customs. One way that specific needs of a neighborhood, school, or community are addressed is through a needs assessment. This is an important step preceding any implementation efforts. For system-focused programs specifically, needs assessments are seen as a particularly valuable cultural consideration regarding program acceptance by the community as well as assisting to determine the willingness of organizations to participate in programming. Determining and depicting community capacity helps clarify the role the prevention program plays in servicing community needs (e.g., The Midwestern Prevention Project; Pentz et al., 1997). Needs assessments also provide “hard” epidemiological information that confirms or displaces perceived norms and revealed systemic characteristics that could facilitate or hinder program acceptance and success (Olweus et al., 2000). For example, a unique challenge facing urban schools concerns normative expectations about violence and aggression, with perpetuation of the belief that fighting is a viable means of attaining status. Expectations about violence result in part because youth residing in urban neighborhoods are more frequent witnesses to, and victims of, violence. Therefore, prevention programs focusing on school safety should focus on norms and beliefs about community violence, community safety standards, and reduction of gang presence (Tolan, 2000).

DEVELOPMENTAL CONSIDERATIONS Over the past 15 years, developmental considerations have been increasingly incorporated into violence-related prevention programs. Most notably, program designs are relying increasingly on developmentally based theoretical frameworks that take into

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Kerns and Prinz account developmental trajectories. Examination of the developmental pathways contributing to violence and delinquency illustrates the importance of this critical issue. For many youth, aggression and disobedience is a phase that desists after childhood. For other youth, aggression and problem behavior are pervasive from childhood through adolescence and into adulthood (Moffitt, 1993). Additionally, developmental patterns of aggression and other antisocial behavior differ by gender (Moffitt, Caspi, Rutter, & Silva, 2001), although this is complicated by questions about the gender appropriateness of diagnostic criteria (Zoccolillo, 1993) and about the forms that antisocial behavior might take in girls (Crick & Grotpeter, 1995). Because of the discontinuity of behavior patterns, it is necessary to scrutinize the broader developmental and social behavioral contexts (Dahlberg & Potter, 2001). Despite progress in the integration of developmental theory with prevention, some important developmental issues are unresolved. Two such issues are considered here but should not be considered exhaustive. The first concerns the flexible adaptation of interventions in ways that are developmentally responsive. The second issue pertains to the downward extension to younger children programs that were intended for older youth, without adequately taking developmental variables into account.

Developmentally Adapted Interventions To optimize programming, interventions need to be well adapted developmentally to the target population. A key consideration is that the content, activities, materials, modeling examples, and delivery methods are appropriately matched to the developmental levels of the participants. Programs should be crafted in ways that are commensurate with a particular age group’s common developmental tasks and challenges. For younger children, this means that the programming level is not too difficult or abstract. For older youth, this means that a program addresses age-appropriate topics using an approach that does not insult the youth with methods meant for younger ages. An additional consideration is that even at a particular age group, youth differ widely in development. In some contexts, programming may need to be sufficiently flexible to take into account developmental variation. This issue is more challenging for

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Critical Issues in the Prevention of Violence standardized program content or curricula that is not easily tailored to individuals.

147 change agent, it would be inappropriate to jeopardize program integrity for the sake of promoting a developmental approach.

Individual-Focused Programs Family-Focused Programs The developmental considerations in individualfocused programs play out, for example, in terms of tension between what has been referred to as a “prescriptive” versus a “developmental” approach (McGill et al., 1997). Deriving these concepts primarily from mentoring-type programs, McGill et al. suggested that a prescriptive approach invokes a standardized plan for the participating youth, whereas a developmental approach tailors the plan to the characteristics and unique needs of each youth. Developmental approaches might be more satisfactory for consumers. However, it may also be the case that involving youth in a short-term prescriptive approach, where they learn discrete skills and participate in more intensive programming, could be more time efficient and cost effective. An evaluation of the BBBS program compared prescriptive and developmental approaches in the context of mentoring (McGill et al., 1997). Evaluators of BBBS found that developmental approaches were more likely to result in strong, trusting friendships and effective mentoring. Youth were more likely to utilize their mentor for advice, guidance, or intervention. Volunteers using more prescriptive approaches were more likely to experience a premature end to the relationship and both members were more likely to not feel satisfied with the match. Nonmentoring programs, which may rely less on establishing and maintaining longer-term relationships with individual youth, tend to lend themselves better to the prescriptive approach. For example, LST (Botvin et al., 1998) is predominantly prescriptive in nature. Youth participate in modules specifically designed to (1) promote decision-making and problemsolving skills; (2) promote skills associated with interpreting media impressions; (3) promote self-control when experiencing anxiety; and (4) improve personal behavior change and self-improvement. Rather than relying on a positive relationship to change youth’s perceptions about deviant activities, LST aims to promote personal skills that generalize for resistance to drugs, alcohol, and other challenging life experiences. This program is most effective when implemented without modification. Therefore, in this case, since the relationship is not hypothesized to be the primary

Similar issues arise with family-focused programs. Some family programs address the tension between prescriptive and developmental approaches by combining the approaches. To illustrate, FFT (Alexander et al., 1998) balances both approaches to the intervention protocol. Although the main thrust of the program is prescriptive in nature (i.e., each phase of FFT has standardized goals), the program does build in options that match goals and techniques to the developmental level of the youth. MST addresses a developmentally appropriate approach towards intervention whereby the specific needs of the youth are intentionally addressed by the intervention (Henggeler et al., 1998). The intervention focuses more closely on effective discipline and parenting strategies when applied to parents who are struggling with behavior problems of younger children. On the other hand, parents of children nearing late adolescence find the intervention focuses more closely on the ability of the youth to achieve autonomy and independence. The ability of two-generation programs to address family developmental challenges is a corollary issue related to developmental versus prescriptive approaches. Although these programs theoretically target multiple developmentally-related family issues in a comprehensive intervention, these programs have met with only modest success (St. Pierre & Layzer, 1998). The Comprehensive Child Development Program (St. Pierre & Layzer, 1999), for example, involves home visiting for low-income families that did not yield results with respect to enhancing child development or family economic self-sufficiency.

System-Focused Programs In system-focused programs, the merging of prescriptive and developmental approaches is sometimes evident, for example in the comprehensively designed PATHS program. Prescriptively, the PATHS curriculum takes into account the components of developmental integration that occur at five roughly defined ages (infancy, toddlerhood, preschool years, school

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148 years, and adolescence), tailoring program demands appropriately. On the other hand, there is a clear psychodynamic flavor towards promotion of personal growth and effective functioning. This is achieved through encouragement of classroom climates conducive to taking responsibility for one’s own actions and development of self-control and self-motivation (Greenberg et al., 1998). The main thrust of a developmental approach is the ability to change or alter the focus of the intervention to match current individual, family, or contextual needs. Recognizing the dynamic interaction between a youth and their ecosystem is a crucial aspect of successful programs (Elliott, Hamburg, & Williams, 1998). Programs that take a prescriptive approach may not always be in a position to address contextual variation particularly as it relates to developmental variables. Comprehensive programming may overcome this, as long as there is adequate coordination across staff and intervention components. The Fast Track program, for example, utilizes five different program components (parenting training, home visiting/case management, socialskills training, academic tutoring, and teacher-based classroom program), which blend prescriptive and developmental approaches and require careful coordination to maintain cohesive programming for each child (Conduct Problems Prevention Research Group, 1992).

Downward Extension Initiating violence prevention efforts for young children (i.e., infants, toddlers, and preschoolers) has been gaining in popularity (Buka & Earls, 1993). Too often, programs designed for older youth are being extended downward to serve younger children without adequately taking into account development differences. Typically, an established program expands to serve a wider age range of children to meet public demand. The major issue with downward extension of programs is that it is done without sufficient empirical evidence for program effectiveness with younger children. It has been well established that there are clear periods for children and adolescents in which particular developmental tasks are salient (Elias et al., 1997). Consideration of these stages is paramount for effective violence prevention programming. Unfortunately, programs that downward extend often falter when programming ignores what we know about developmental tasks and appropriate-

Kerns and Prinz ness with younger children. Even when surface-lexical or material-related aspects of a program are changed, the revised program may not target the most salient developmental issues and themes for the younger partcipants. Individual-Focused Programs An example of detrimental effects of downward extension is exemplified in the BrainPower program (Hudley et al., 1998), initially designed for youth in fourth through sixth grades. The intervention was found to reduce hostile attributional bias, anger, and retaliatory behavior. Previously aggressive youth looked only slightly more aggressive than previously nonaggressive youth after the intervention and were less aggressive than the control group. However, when the investigators tried to extend the program to third graders, they found that the younger children had more difficulty integrating lessons into their repertoire and actually increased their hostile attributions. This example illustrates how downward extension of a program that was not developmentally well matched led to undesirable outcomes. Family-Focused Programs When an important need is realized for younger children, it is occasionally possible to alter programming components in a developmentally appropriate and successful manner. MTFC (Chamberlain & Mihalic, 1998) is an example of a family-focused program that downward extends its capabilities (previously with those who are 9–18 years old) to serve those who are 3–7 years old. The new program, Early Intervention Treatment Foster Care, serves youth who have been removed from their homes. The core elements of MTFC were retained, although some adaptations were made. For example, some behavior management techniques were changed to mirror the developmental age. The introduction of immediate reinforcers rather than the delayed reinforcers used with older children was another critical adaptation. The addition of new program components also guided the downward extension of the program. Service delivery takes place in the home setting, and there is an additional assessment of developmental delays. Although this version of MTFC has not yet been thoroughly evaluated, it is obvious that the research team considered developmental needs in adapting the program.

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Critical Issues in the Prevention of Violence System-Focused Programs The most prevalent example of downward extension within system-focused programs is the expansion of alternative education programs from a previous focus on adolescents to a broader inclusion of younger children (Tobin & Sprague, 1999). Alternative education programs were initially developed for aggressive or violent youth who were excessively suspended or expelled from the mainstream school system. Programs targeting younger children attempt to intervene with overtly aggressive or disruptive students before they reach the stage of being expelled from school. First Step to Success (Walker, Severson, Feil, et al., 1998) is an early intervention program designed to address at-risk kindergarten children who already have violence-related behavior problems at the point of school entry. Evaluation of this program indicates that First Step to Success is an effective alternative education program for kindergarten and first grade children displaying the beginning signs of antisocial behavior.

INTERVENTION FIDELITY Fidelity, or adherence to program protocol, is an essential component for comprehensive evaluation of program effectiveness. Assessment of fidelity as one component of outcome evaluation adds credibility to determinations that the designed program is responsible for change in the participant and that the program is delivered as intended. Additionally, planning for fidelity assessment from the outset, prior to implementation, increases statistical power and reduced error variance (Dumas et al., 2001). The use of manualized interventions, staff and participant retention, and other influential factors are among the most significant currently discussed and debated fidelity-related issues. These issues are paramount to meaningful program evaluation; however, they are grossly underreported or unaccounted for in the literature. A meta-analysis of intervention for conduct disorder/oppositional defiant disorder revealed that only 29% of studies report intervention fidelity issues (Brestan & Eyberg, 1998).

Treatment Manuals Use of treatment manuals is a fervidly discussed issue related to fidelity. Although manuals are the gold

149 standard for equivalent program replication and adherence analyses they are often less than optimal once programs move from efficacy trials to the effectiveness phase, with both a general population of clients and a general population of practitioners (Clarke, 1998). Two major barriers to use of manualized interventions are practitioner resistance/competence and the relevance of manuals for youth with complex issues, including comorbid disorders.

Individual-Focused Programs Intervention protocol, including manuals, varies widely regarding degree of specificity. For individualfocused programs, specificity ranges from completely open-ended programs (e.g., BBBS; McGill et al., 1997) to strict manual-based programs, including individual skill-based curricula (e.g., BrainPower; Hudley et al., 1998). The benefit of having a more open-ended program, such as BBBS, is that program emphasis is solely on the quality of the volunteer–child relationship, and program goals can be adjusted to consider individual needs. The theoretical belief of this program was that mere association with positive role models promotes positive functioning and inhibits challenging behaviors (McGill et al., 1997). The quandary with this approach is that, despite a general common mission, it is difficult to know how the volunteers specifically contribute towards the positive change in the youth since it is different for each mentor–youth relationship. On the other hand, programs like the BrainPower Program (Hudley et al., 1998) emphasize individual skill acquisition through a manualized 12-lesson curriculum. The active ingredients of such a program are readily measurable. Therefore, evaluation of program fidelity is more straightforward. Another specific example of the ability to assess “active ingredients” through manual-based intervention is Webster-Stratton and Hammond’s evaluation of the utility of different program components for intervention of early-onset conduct disorder (WebsterStratton & Hammond, 1997). Intervention categories include a child treatment group (CT), parent training group (PT), child treatment group plus parent training group (CT+PT), and a wait-list control group. Fidelity assessment ensures that each component is delivered as designed. Findings reveal that children improve in problem solving and conflict management when they are in the CT or CT+PT group. Children in the PT or CT+PT group improve behavior at home. At

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150 1-year follow-up, children’s behavior is most improved for the CT+PT condition. All intervention conditions produce better results than are found for the control group. It is possible to find differences in component utility through this methodological design and conclusions about program effectiveness are substantiated through an assessment of fidelity. Family-Focused Programs Similar issues arise concerning use of intervention manuals for family-focused programs. A challenge to the use of intervention manuals is that some therapists have difficulty accepting and internalizing the intervention protocols. For example, an evaluation of FFT (Alexander et al., 1998) revealed that practitioner resistance existed because many felt as though program protocol encouraged “prescribing and manipulating” child behavior. Despite use of manuals, Olds et al. (1998) also found challenges regarding differences in experience among practitioners when they examined the employment of nurses and paraprofessionals for service delivery. The paraprofessionals had a higher rate of staff turnover, and there were systematic differences in the length of visits (paraprofessionals spent more), time spent addressing physical health (nurses spent more), time spent on life course development (paraprofessionals spent more), and time spent on environmental health and safety (nurses spent more). Therefore, how specific manual-based program goals were influenced by use of nurses versus paraprofessionals was disputable. System-Focused Programs The merits of manual-based interventions receives less ardent debate for system-focused programs, largely because programs are designed to alter a culture rather than an individual or family and the majority are universally administered. Therefore it is not as appropriate to consider individual differences (e.g., comorbid disorders)—programs are designed to make the greatest impact on most youth. Although the focus of programming is less on the individual and more on the holistic system, process issues remain. For example, despite clearly defined expectations from program staff, PATHS (Greenberg et al., 1998) encountered some teacher resistance (e.g., among 5–20% of teachers per school). It is important to understand the contributing factors of this resistance and develop strategies to overcome them. These

Kerns and Prinz strategies are not outlined in manuals per se. Rather, they are important considerations prior to program implementation. Especially when programming focuses on a school or community culture, it is important to continually evaluate the program’s effectiveness as well as ability to achieve goals. Programs with continual evolution are able to respond better to the changing needs of the school or community; however, assessment of fidelity must also follow. For example, the Midwestern Prevention Project (Pentz et al., 1997) annually reviews programming, adding or changing components when necessary. This program is a universally administered community-based program with multiple implementation sites. Because consistent and uniform instruction across sites is essential for program evaluation, changes in protocol are addressed through continued teacher retraining and review sessions. Promoting a spirit of collaboration for program implementation facilitates a climate among service delivery personnel that is open to change.

Staff Recruitment and Retention Recruitment and retention of staff has a tremendous impact on the ability of a program to achieve and effectively complete goals, consequently either promoting or compromising intervention fidelity. Recruitment of quality staff across programs is an essential determinant of success. Additionally, some intensive programs inadvertently encourage staff turnover and therefore jeopardize the quality of program implementation and the ability of practitioners or volunteers to foster stable relationships with clientele. Contributing to this issue is the consequential high ratios of therapists, clinicians, or volunteers to program participants.

Individual-Focused Programs Programs focusing on the individual child appreciated the importance of developing and implementing strategies to recruit quality staff and increase retention. Incompetent staff or high turnover is directly noticeable and has the potential to impact program effectiveness. BBBS (McGill et al., 1997) employs diverse strategies including word of mouth, media campaigns, speeches to community and professional groups, written materials, and newspaper articles to promote community visibility and activities such as

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Critical Issues in the Prevention of Violence kick-off parties and pep rallies to identify potential volunteers. Staff retention is also promoted through regular supervision and monitoring (Botvin et al., 1998; Lattimore et al., 1998; McGill et al., 1997). QOP has a particularly intensive schedule; staff are expected to be available around the clock. Supervisors train staff to balance their program-related responsibilities with their own personal quality of life. Additionally, supervisors spend extra time establishing realistic expectations for success (Lattimore et al., 1998). Increasing training and supervision for LST also greatly improves protocol fidelity through promoting knowledge, skills, and confidence (Botvin et al., 1998). Family-Focused Programs MTFC (Chamberlain & Mihalic, 1998) developed a unique approach towards recruitment and retention of foster parents. MTFC parents who recruit a new participant family are paid a “finder’s fee.” They also utilize specific newspaper ads, ensuring that potential families know details about youth as well as compensation. To guarantee quality parents, a stringent screening is required. Through this screening, it could be determined that the families have adequate resources and can provide quality care. This approach is essential to retention of families; over half of families continue participation, caring three or more youth. Staff retention is repeatedly challenging for home-visitation programs (Gomby, Cultross, & Behrman, 1999). In fact, when Olds et al. were unclear as to the reasons why programming was effective in one implementation site and not another, further examination revealed that there was an extremely high turnover rate in the less successful site (Olds et al., 1999). This is an illustration of the damaging effects of poor staff retention as well as a harbinger for further examination of effective staff retention strategies. Although some strategies have been successful (e.g., increased quality supervision), attending to other factors that may impede satisfactory levels of staff retention is a necessary process issue with important ramifications for both program delivery fidelity as well as ultimate program success. System-Focused Programs It is important to employ strategies to improve or maintain motivation directed at the program. The

151 Bullying Prevention Program (Olweus et al., 2000) utilizes teacher discussion groups. These groups serve two purposes: (1) to increase program-related competencies and (2) to maintain motivation. The PATHS program (Greenberg et al., 1998) utilizes close supervision and collaboration between school personnel and site consultants, to promote positive working relationships. Through these positive working relationships, increased teacher retention as well as commitment to the program ideals is possible. A key “lessons learned” issue from a peer mediation program serving poor, rural youth is that effective communication between the program coordinator and principal is essential to program fidelity and success (Bell et al., 2000). Bell et al. found that securing the support of administration is necessary for quality program implementation and continued longer-term program support. Additionally, to address this potential barrier before it became problematic, a planning meeting is held between the intervention team and school faculty and staff. During this meeting, concerns about program implementation are acknowledged, as was the provision of technical assistance throughout the implementation phase. Through this open communication and discourse, teachers and staff are able to have more confidence in the program and therefore participated more fully with protocol.

Influential Factors A final issue pertains to the assessment of other factors that may impact program fidelity. Clark (1998) lists six influential factors: (1) therapist training, degree of intervention structure, monitoring, protocol compliance; (2) combined or multiple interventions; (3) multiple roles versus single role for therapist; (4) participant selection (homogeneity versus heterogeneity, comorbidity); (5) control group; and (6) intervention parameters (duration, dose, modality, location). These factors are often underreported in the literature. It is beyond the scope of this review to dissect each of the six factors within each program target area. However, scrutiny of accountability for these influential factors reveals that therapist variables are rarely reported and, with a few notable exceptions, are poorly defined. When there are combined or multiple interventions, the unique contributions of each component are rarely assessed (see Pentz et al., 1997, for an exception). Finally, there is often variability in many intervention parameters, such as large ranges

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152 in number of sessions or weeks the program is provided (e.g., 16–20 weeks for moral reasoning program; Arbuthnot & Gordon, 1986). Few programs account for this variability or consider how this “dosage” effect may alter program outcomes. Although some programs, such as LST (Botvin et al., 1998) and Resolving Conflict Creatively Program (RCCP; Aber et al., 1998, 1999), assess dosage effects and variability of intervention, the majority of programs do not.

ASSESSMENT OF OUTCOME AND IMPACT Assessing program effectiveness is one of the most critical issues pertinent to long-term program survival. Continued funding from agencies is often dependent on proving program success. Many facets of program evaluation are observed, including the effectiveness of the program on reducing violencerelated behavior problems, the success of the process of implementation, and consumer satisfaction with program design and components. Two program outcome assessment issues with a paucity of consideration in the extant literature is the rationale for choice of outcome variables and benefit–cost analysis.

Choice of Outcome Variables Most often, programs report the effect that program participation has on decreasing youthful violence-related behavior problems. Basic outcome criteria should also include, at the minimum, (1) use of a comparison group, (2) random assignment, (3) choice of reliable and valid instrumentation, and (4) descriptive statistics (Brestan & Eyberg, 1998). These criteria, as well as other outcome-relevant information, have a dramatic impact on the ability to understand change mechanisms and best practices. A meta-analysis of juvenile delinquency intervention reveals that there is extraordinary variability of effects across studies, raising an important methodological issue (Lipsey, 1992). It is difficult to know if the variability across studies is due to bias introduced by methodology or to the nature of the intervention. This information is critical to tease apart the various programs. Additionally, there is lack of continuity regarding measurement of outcomes for programs targeting violence-related behavior problems. Specifically, the following variety of factors associated with violence prevention are observed: delinquent and crimi-

Kerns and Prinz nal behavior; withdrawal from school; conduct problems, low self-control, aggression; various risk and protective factors; and alcohol and other drug use. It is also common for programs to assess factors related to violence-related behavior rather than actual violencerelated behavior (Gottfredson, 2000). The determination effectiveness of these programs at reducing aggression and violence is undermined by reliance on the presence of an association between the outcomes mentioned above with violence-related behavior. Although this may be a theoretically sound decision, the ability to make strong determinations and test theoretical ideas is compromised.

Individual-Focused Programs The LST program (Botvin et al., 1998) thoroughly evaluated multiple outcomes of program implementation. These outcomes included (1) prevention of cigarette smoking, (2) effectiveness of peer leaders, (3) teachers, scheduling format, and booster effects, (4) prevention of alcohol use, (5) prevention of alcohol and marijuana use, (6) evaluation of results from a large-scale prevention trial, (7) evidence of long-term effectiveness, (8) prevention of illicit drug use, and (9) generalizability with minority youth. Although evaluation of any one of these outcomes may have been suitable to deem the program effective enough to include in peer-refereed literature, the comprehensive evaluation ensured that multiple aspects were evaluated and enabled determination that program was globally effective. Several of the approaches used by Botvin et al. are somewhat rare in other prevention studies and deserve discussion. First, the examination of teachers, scheduling format, and booster effects determines the efficacy of this prevention approach with the following: a general population of teachers implementing programming; the effectiveness and benefits of two different implementation schedules; and the ability to maintain positive program effects through booster sessions (Botvin et al., 1998). Determination of the effectiveness of different implementation methodology has important implications for future program success. Second, a concern of other prevention programs is that the effects of the program might be watered down when the program is scaled up. The LST research team (Botvin et al., 1998) examined the effectiveness of their program when it was brought to scale in 56 schools. They found similar intervention effects

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Critical Issues in the Prevention of Violence both at the individual and the school unit of analysis, lending credence to the program’s effectiveness on a larger scale (Botvin et al., 1998). Additionally, BBBS (McGill et al., 1997) evaluators wanted to determine how different program practices changed outcome. They found that recruitment was improved with ethnically/racially diverse staff and board members, matches were more suitable for programs that took parent and volunteer preferences into consideration, and training was improved when agencies provided training prior to the match. Through examination of these differences across programs, BBBS was able to incorporate this new knowledge into recommendations for future programming. Following program participants over time is a desirable and informative outcome variable. However, long-term follow-up is often costly and challenging (Gillham, Shatte, & Reivich, 2001). Differential attrition rates skew the evaluation of effectiveness without a comparable control group with similar attrition rates. The LST (Botvin et al., 1998) team was able to follow youth for 6 years after their initial experience with the program. Attrition was commensurate across experimental and control groups, and long-term effectiveness of program participation was identified. Demonstrating program effects over time enhanced the credibility of the program. Finally, demonstrating the generalizabilty of program effects to other populations is tantamount for consideration of dissemination. For example, LST (Botvin et al., 1998), which was originally evaluated with white students, was later evaluated for effectiveness with African American and Hispanic/Latino youth. It appears that the program is also successful with multiethnic youth and therefore has gained recognition as a pragmatic preventive intervention.

Family-Focused Programs As is noted in the above section, it is critical to evaluate multiple dimensions of program effectiveness. As indicated by Reid et al. (1999), there are four levels of outcome assessment that are critical for efficacy trials: the proximal impact of the prevention program on targeted antecedents; variation in impact across contextual factors; the distal impact on later antecedents and ultimate outcomes; and the relationship between changes in antecedents because of the original intervention and changes in the outcome of interest. This ensures that not only the effectiveness of the program is tested, but the fundamental theoretical

153 model as well. It is also critical to evaluate the process factors (Alexander et al., 1998). Through gaining understanding of process effects, more parsimonious programming is possible. Researchers with MTFC (Chamberlain & Mihalic, 1998) evaluated methodology aimed at enhancing adherence to program protocol. Specifically, a study was conducted to determine how to increase retention rates of foster parents. This evaluation revealed that regular meetings and enhanced support did, in fact, increase the retention rates of foster parents. Other researchers have evaluated program impact across sites to determine other process issues associated with successful program implementation and outcomes. One such home-visiting program is Hawaii’s Health Start Program (Duggan et al., 1999). An assessment of multiple administering agencies revealed that there are systematic outcome differences across agencies. This finding reinforces the notion that it is important to evaluate programs across multiple sites. When differences are found, consideration of differences in program delivery and servicing protocol should be evaluated and determinations made about which process issues are affecting the differential outcomes. Evaluation of a single site may lead to shortsighted determinations of program outcomes. Gathering qualitative data for outcome assessment is a revealing technique enabling rich data collection for specific process and outcome variables. The HIPPY program (Baker et al., 1999) conducted two qualitative studies aimed at clarifying implementation challenges and barriers. As a result of these studies, program staff were able to determine that (1) parents were not always adequately prepared for the time commitment of the program, (2) many parents did not return for the second year of programming because they perceived the topics to be redundant, and (3) home-visitor turnover was responsible for some family attrition. Additionally, patterns of parental involvement were assessed and it was determined that there were some barriers to participation. Assessment and further determination of these barriers were assumed to ease the future implementation of the program.

System-Focused Programs Multiple assessment strategies are most informative for outcome assessments, enabling informed implementation decisions by program administrators or community leaders. Many programs are beginning

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154 to look beyond answering whether or not the program reduced delinquency or violence-related behavior problems, and extend their examination to include other essential program factors. For example, Linking the Interests of Families and Teachers (LIFT) uses a multiple assessment strategy to include information on participant satisfaction and participation, fidelity of implementation, and the ability of the program to change targeted antecedents (Reid et al., 1999). RCCP (Aber et al., 1998, 1999) has been found effective in reducing aggressive behavior and hostile attributions. The program has been shown to be especially successful for youth participating in 2 years of programming (as opposed to 1 year). An additional outcome measurement reveals a dosage effect—students in classrooms in which RCCP is fully implemented increase academic achievement above students in classrooms with partial or no RCCP implementation. Findings such as this promote the recommendation to assess for dosage effects. Failure to consider the differential effects of partial implementation of programming may result in the perception of a watered-down intervention effect. Evaluation of positive change is also an important consideration for some outcome assessment. Often, programs want to demonstrate that they reduced overall levels of violence-related behavior problems. However, inclusion of evaluation of positive change may also reveal beneficial program benefits. The First Steps to Success program (Walker, Kavanagh, et al., 1998; Walker, Severson, Feil, et al., 1998) aims to prevent aggression through promoting positive behaviors such as social and academic success. A randomized, experimental design study of this intervention found that children participating in the First Steps Program significantly reduced their level of aggression and maladaptive behaviors. A secondary, but high-impact, finding was that students spent significantly more time engaged in academic activities. A final substantial consideration for outcome assessment is relating program components and the underlying theoretical orientation with choice of outcome measurement. For example, Ialongo et al. (1999) designed a plan of analysis that enabled testing of the underlying theoretical model as it related to intervention implementation. They were able to draw these conclusions because the effects of their classroomcentered intervention were due to changes in the targeted practices and processes. Researchers were better able to draw theoretical conclusions, allowing theory to influence research and research to influence theory.

Kerns and Prinz Benefit–Cost Analysis Evaluation of program benefits and costs allows a more comprehensive examination of actual societal advantages (or disadvantages) associated with program implementation. This is an especially important consideration when the public perceives a particular program to be too expensive or cumbersome. There are some challenges to this area, however, because judging the true savings of a program proves illusive (Max & Rice, 1993). Regarding prevention programs, this is a daunting task because the charge is to prove that the program prevents a behavior or set of behaviors from occurring, a determination that violence-related behavior problems do not happen as a result of the programming efforts. Conducting a benefit–cost analysis elucidates not only the societal monetary savings, but also sheds light on the practical differences between different types of programming (Durlak, 1997). Specifically, a community with limited resources would likely decide on a program that both meets community needs and maximizes the benefit– cost ratio. However, the field has not yet arrived at a consistent or uniform approach towards this analysis. Ratios for programs are calculated on the basis of different factors, making it more difficult to compare programs (Durlak, 1997).

Individual-Focused Programs Evidence of benefit–cost analysis is missing in most reports of individual-focused programs. In fact, there is only one example of such an analysis, in which QOP (Lattimore et al., 1998) assessed the societal benefit of participation for youth. They first determined that the cost of program implementation was $1,118,000 for 125 youth over 4 years. These youth participated in programming, from 0 to 3,000 hr. The outcome variables used were (1) rate of high school graduation, (2) those with 2-year degrees compared with high school graduates, (3) those with 4-year degrees compared with high school graduates, and (4) children born into a Medicaid household. Both liberal and conservative estimates of public benefit placed the benefit–cost ratio favoring benefit by over 3 million dollars per 100 in earnings. Few other programs list just the cost of program implementation, sometimes breaking down the cost of implementation per participating youth. For example, BBBS (McGill et al., 1997) costs approximately $1,000 per year to sustain a match. LST (Botvin et al.,

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Critical Issues in the Prevention of Violence 1998) costs a mere $7 per student per year plus an additional $2,000 per day for training. However, by and large, conducting these analyses is not a common practice for individual-focused programs. Despite encouraging results in many studies, authors are unlikely to project relative monetary costs for the program, nor are they likely to assess the economic benefit or cost to society.

Family-Focused Programs Benefit–cost analyses are considered for several family-focused programs. The cost to run FFT (Alexander et al., 1998) is $2,000 per family. Because of decreased incarceration or institutionalization rates, the savings (system cost and crime victim cost savings) are approximately $14,000 per treated family. No other program that conducted these analyses found such significant benefit. However, MST (Henggeler et al., 1998) is another extraordinarily cost-effective program. An analysis revealed that the average cost per youth is $400–550 and the societal savings are in excess of $4,500 per youth. NHVP (Olds et al., 1998) found that program costs are recovered by the time the first child turns four and there are continued savings throughout the child’s lifetime. Project Back-on-Track (Myers et al., 2000) evaluated the societal benefits of program participation and found that because of lowering criminal recidivism rates, the program benefits outweighed the costs by $1,800 per youth after 1 year. Home-visiting programs, in general, have not duplicated the program benefit–cost ratio that Olds et al. found. Programs varied greatly in their cost per participant per year. For example, CCDP compared their cost of implementation to other home-visiting programs. Whereas CCDP cost approximately $10,849 per family per year, other program costs varied, but were significantly less. By way of illustration, Head Start cost $4,500, the Infant Health and Development Program cost $10,000, the Even Start Family Literacy Program cost $2,700, NHVP cost $2,300, Child/Survival/Fair Start cost $2,800, and New Chance cost $8,300 per family per year (St. Pierre & Layzer, 1999). It is obvious from these findings that the costs associated with CCDP far exceed the cost for many other, similar, home-visiting programs. However, without the full benefit–cost analysis, it is impossible to determine the real implications of the program. Unfortunately, the details of these program analyses are not addressed in the literature, making it

155 also impossible to consider the merits of different approaches towards conducting this analysis for familyfocused intervention programs. However, societal benefits such as later age at first arrest, later age of first childbirth, reduction of victim hospitalization costs, and reduction of court and incarceration costs, should be taken into consideration. Seemingly costly interventions may have benefits that far outweigh the costs associated with implementation. Therefore conducting only a cost analysis, although an important consideration for institutions with limited resources, only tells half of the story.

System-Focused Programs In an effort to make a case for using cost analysis methods with school-based prevention efforts, Chatterji et al. (2001) illustrate the importance of such methodology using the ALPHA program. Six steps are outlined. The first step is to define the objective of the cost analysis. This entails determination of which costs are to be included in the analysis and competing alternatives. Both the immediate costs to the school system are considered as well as the societal costs. The second step is to describe the intervention and its alternatives. All aspects of the program are exemplified and competing programs are assessed. The third step is data collection, which requires making a cost inventory, including direct and indirect expenses and societal costs (e.g., volunteers). The fourth step is making economic adjustments. This includes accounting for opportunity cost of programs, recognizing the shared and unique program costs. There are accounting cost categories (direct and indirect expense) and specific economic adjustments (costs of educational space, equivalent annual equipment costs, and volunteers), with consideration given that resources used for economic adjustments could have been spent in other programming efforts. The fifth step is the sensitivity analysis. Key parameters are hypothetically altered, producing credible alternatives, and a new cost analysis is performed, producing a “worst case” and “best case” scenario. Finally, the sixth step is reporting and interpreting results. Results are reported as cost per participant. The danger in conducting benefit–cost analyses is that the true program cost efficiency, or lack thereof, is revealed. The outcome for the ALPHA program is disappointing. Costs per participant are substantially higher than other similar available programs (Chatterji et al., 2001). This clarification is helpful

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156 for school administrators when making the delicate decision about which program to implement. But, as is illustrated by the ALPHA program, costly interventions may meet their fate during dissemination to communities or schools with limited resources.

Longitudinal Follow-Up Conducting short-term versus long-term followup outcome assessment is considered briefly here. This is an important issue because some outcomes take multiple years to manifest and the true impact of an intervention may not be revealed for many years (Gillham et al., 2001). However longitudinal data collection is often expensive and unwieldy, and is contraindicated if the research focused on traditionally transient or unstable families (e.g., single-parent households). The merits of this debate are especially salient for researchers aiming to work with a population of parents or youth who already have been detained or charged with criminal conduct. Specifically, whereas one can expect about 16% of a sample to change households within a year, 62% of families in which one or both parents were incarcerated move within a year. Across studies in this area, rates of the ability to locate participants for 1-year follow-up ranged from 50 to 93%, and actual follow-up rates were around 40% (Eddy, Powell, Szubka, McCool, & Kuntz, 2001). Although challenging, demonstration of long-term effects, if possible, lends credence to the program effectiveness.

CONCLUSION Although we are beginning to develop a better understanding about what works in prevention of violence-related behavior problems, the field faces many remaining challenges. The goal of this paper was to address some of unresolved issues concerning the state of violence prevention. No prototype program works for everyone or in every setting (Cornell, 1999), which was apparent across all of the issues considered. Although this review drew predominantly from the violence area for illustration, many of the points are applicable to prevention in general. Universal, selected, and indicated interventions present important options for matching target level to prevention goals and contexts. Universal interventions are particularly appropriate for targeting broadrange risk and protective factors, particularly factors

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Kerns and Prinz influencing an entire culture of youth, without the stigmatizing effects sometimes noted in more targeted interventions. Because resources are equally spread across participants regardless of risk status, universal interventions however are less able to address the specific or the more intensive needs of individuals. Universal interventions can be particularly cost-efficient with younger children for whom identification of risk is illusive. Selected and indicated preventive interventions are generally able to intervene more intensively because smaller proportions of the population are targeted. Targeting enables a more strategic allocation of resources for more thorough intervention at the expense of potentially stigmatizing program participation. Some of the most comprehensive and successful programs combine universal and selected or indicated programming. Incorporation of each of these methods in program design maximizes the potential to both benefit the general population and to allocate needed resources to youth with more significant challenges. For theory-driven programs more so than problem-driven ones, social–ecological context is important. Many programs fail to address the multiple contexts affecting participating youth, limiting generalization to contexts outside the program setting. Programs addressing multiple social–ecological contexts have greater chance for success. Although only infrequently assessed, mediating and moderating variables are critical for progressing violence prevention models. Only a few programs explicitly incorporate wellsupported models into the design of the intervention. Determination of the mechanisms of program success is facilitated by theory-driven program development and hampered when program development is problem-driven. Although both approaches have led to some positive outcomes, the identification of program elements tied to specific theory contributes to a better understanding of program effects. Cultural concerns are salient for many facets of prevention programming, including staff recruitment and retention, engagement of participants, and dissemination, which in turn can affect program replicability. The ability of a program to operate successfully across cultural contexts is a challenge faced by most of the reviewed programs. Some programs specifically tailored programming to target one specific culture whereas other programs target broader, heterogeneous populations. Regardless of program focus, creative strategies are developed to encourage recruitment and retention of diverse program staff and participants. Sensitivity of replication efforts to assess

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Critical Issues in the Prevention of Violence impact with diverse populations is observed. Several programs specifically alter program material to promote cultural relevance. These programs tended to have better outcomes than programs that failed to consider subtle cultural variation and engendered barriers for participation. Community needs assessments and culturally informed programming can strengthen violence prevention. State of the art violence-prevention programming requires careful attention to developmental issues. The field is experiencing some tension associated with degree of emphasis on a developmental versus a prescriptive approach. Developmentally informed approaches may produce greater consumer satisfaction and better address some of the unique needs of participants. However, prescriptive approaches have advantages with respect to time efficiency, standardization of materials, and replicability. Some programs have been able to combine both approaches in ways that are developmentally well adapted and that potentially heighten gains. Another developmental issue concerns the problem of downward extension. Despite theoretical advances, some programming still reflects the practice of taking a program intended for an older age group and applying it to a younger group without validation or modifications. This practice can lead to developmentally mismatched programming. The discussion of intervention fidelity necessitates consideration of program manuals, staff recruitment and retention, and factors influencing implementation. Manualized programming, which is an essential component for the promotion of intervention fidelity, is not sufficient without attending to relevant process issues. For example, some practitioners have difficulty accepting program protocol as specified in the manuals because of perceived lack of flexibility and regard for individual difference. On the other hand, for some programs, the success of the program rests on the commitment to program protocol such that changes in delivery reduce impact. Program fidelity depends not only on the use of manuals but also on competent supervision. Supervision contributes as well to staff retention. Programs with high staff turnover have found compromised program adherence. Successful programming depends on strategic planning to prevent staff burnout and turnover. Additionally, promotion of effective and productive communication between staff, supervisors, and other personnel is profitable. Finally, assessment of major implementation variables affecting fidelity is largely ignored. Therapist variables, unique contributions of

157 intervention components, and intervention parameters are rarely accounted for. There was considerable variation in assessment of primary outcome variables for reviewed programs. Outcome variables assessed in each program varied widely and included such dimensions as violent acts, delinquency, fighting, aggressive behavior, externalizing behavior problems, and deviant behavior. Outcome evaluations were impacted further by choice of methodology, such as type of data collection (e.g., questionnaires, interviews, observation), time frame of design, and nature of the data (e.g., quantitative, qualitative, latent). Benefit–cost analyses are helpful for determining the cost utility of a program. Programs that conducted such analyses were able to approximate the societal impact of their program and advance credibility for future program implementation. However, the lack of an agreed-upon convention or consistent method for conducting benefit–cost analyses makes comparison across programs difficult. Overall, the field of violence prevention has made strides in terms of accumulating evidence for the efficacy of specific programs. The field has particularly benefited from the development of programs that are developmentally sensitive, ecologically valid, and built on an empirical analysis of the environmental factors maintaining youth violence (Ollendick, 1996). Nonetheless, this paper has identified several issues that are still being tackled as the research base develops. REFERENCES Aber, J. L., Brown, J. L., & Henrich, C. C. (1999). Teaching conflict resolution: An effective school-based approach to violence prevention. New York: National Center for Children in Poverty. Aber, J. L., Jones, S. M., Brown, J. L., Chaudry, N., & Samples, F. (1998). Resolving conflict creatively: Evaluating the developmental effects of a school-based violence prevention program in neighborhood and classroom context. Development and Psychopathology, 10, 187–213. Alexander, J., Barton, C., Gordon, D., Grotpeter, J. K., Hansson, K., Harrison, R., et al. (1998). Blueprints for violence prevention. Book three: Functional family therapy. Boulder, CO: Center for the Study and Prevention of Violence. Alkon, A., Tschann, J. M., Ruane, M. A., Wolff, M., & Hittner, A. (2001). A violence-prevention and evaluation project with ethnically diverse populations. American Journal of Preventive Medicine, 20, 48–55. Arbuthnot, J., & Gordon, D. A. (1986). Behavioral and cognitive effects of a moral reasoning development intervention for highrisk behavior-disordered adolescents. Journal of Consulting and Clinical Psychology, 54, 208–216. Arnold, M. E., & Hughes, J. N. (1998). First do no harm: Adverse effects of grouping deviant youth for skills training. Journal of School Psychology, 37, 99–115.

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