A life course approach
The Centre for Research & Education on Violence Against Women & Children promotes the development of community-centred, action research on gender-based violence. The Centre’s role is to facilitate the cooperation of individuals, groups and institutions representing the diversity of the community to pursue research questions and training opportunities to understand and prevent abuse.
Centre for Research & Education on Violence Against Women & Children
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Linda Baker, Ph.D., C.Psych., Learning Director, Centre for Research & Education on Violence Against Women & Children, Western University
Nicole Etherington, Ph.D., Research Consultant, Centre for Research & Education on Violence Against Women & Children, Western University
Elsa Barreto, Multi-Media Specialist, Centre for Research & Education on Violence Against Women & Children, Western University
Dianne Lalonde, Research Associate, Centre for Research & Education on Violence Against Women & Children, Western University
Sara Straatman, Program Assistant, Centre for Research & Education on Violence Against Women & Children, Western University
Etherington, Nicole A. & Baker, Linda L. (2018). Preventing Revictimization and Use of Aggression Following Girls’ Maltreatment: A life course approach. London, Ontario: Centre for Research & Education on Violence Against Women & Children. ISBN 978-1-988412-20-7
©2018 Centre for Research & Education on Violence Against Women & Children
All rights reserved. Do not reproduce without written permission of the authors.
One in three Canadian women will experience violence or abuse at least once in their lifetime, often first during childhood (Afifi et al., 2014; Burczykcka & Conroy, 2017; Public Health Agency of Canada, 2006; Sinha, 2013). Women and girls with prior experiences of victimization are at a greater risk for subsequent revictimization and/or use of relational aggression than those without this experience (Benedini, Fagan, & Gibson, 2016; Classen, Palesh, & Aggarwal, 2005; Hong, Espelage, Grogan-Kaylor, & Allen-Meares, 2012; Lee & Hoaken, 2007). This lifetime exposure to violence has significant immediate and longterm physical, psychological/emotional, behavioural, and interpersonal health consequences (Table 1). The events that take place after the initial victimization are therefore critical (Arata, 2002) and there is a substantial need to take action following childhood victimization (Simmel, Postmus, & Lee, 2012). This discussion paper provides an overview of research-based and promising programs to prevent and reduce revictimization and use of relational aggression among women and girls who have experienced childhood maltreatment.
Setting the context
Early experiences of violence create initial vulnerabilities that are exacerbated by subsequent victimizations in childhood or adolescence, making it necessary for violence and health prevention efforts to account for prior victimization history (Casey & Nurius, 2005). This requires taking a life course approach, which views individual lives as a series of pathways or trajectories spanning from early to later life, rather than examining violence at only one point in time (Greenfield, 2010). The life course perspective emphasizes how previous experiences impact current vulnerabilities to abuse or use of relational aggression as well as current and long-term health outcomes (Campbell, Greeson, Bybee, & Raja, 2008; Davies et al., 2015). Outcomes of violence result from a cumulative process, which is shaped by social, economic,
environmental, and cultural factors (i.e. the social determinants of health) that work across multiple levels (e.g. individual, interpersonal, community, societal) and are most salient at different life stages (e.g. family factors in childhood, peer factors in adolescence) (Carnochan et al., 2013; Maniglio, 2009; Roodman & Clum, 2001).
Factors that increase the likelihood for revictimization and use of relational aggression operate in dynamic ways across the lives of women and girls, and understanding these factors can facilitate reduction of vulnerability to future violence and resilience building after early victimization (Hanson, 2016; Macy, 2008). Focusing on women and girls, however, is not meant to imply that they are responsible for the occurrence or prevention of the violence they have experienced. Indeed, most perpetrators of violence against women and girls are men and boys (Sinha, 2013). Eliminating this violence remains an enormous challenge, and requires intervention to reduce risk and improve protective factors among women and girls while simultaneously working to prevent its perpetration by men and boys. It is also important to recognize that female-perpetrated violence exists, often as a result of early maltreatment, and its prevention has implications for breaking the intergenerational transfer of violence (Shorey, Strauss, Haynes, Cornelius, & Stuart, 2016).
Preventing violence and its health impacts requires attention to the systemic, social, and individual factors that affect the vulnerability, resources, resilience, and wellbeing of women and girls from childhood to adulthood (Macy, 2007). At the same time, it must be acknowledged
that women and girls are not a homogenous group, and pathways to revictimization or use of relational aggression may operate differently for different individuals (Macy, 2008). Trajectories of violence and abuse are complex, and this discussion paper should be read with the fundamental concepts outlined by Figure 1 in mind.
Finally, this paper uses the term “revictimization”, which is commonly used to refer to the link between early and later experiences of victimization. However, the authors recognize that not all women and girls who have experienced violence identify with or use the term “victim.”
Table 1. The health consequences of violence against women and girlsa
|Poor self-reported physical health and quality of life||Posttraumatic stress disorder||Substance abuse||Difficulty forming or maintaining relationships|
|High medication use||Depression||Self-harm||Social impairment|
|Arthritis||Anxiety||Eating disorders||Perpetration of abuse|
|Breast cancer||Suicidality||Risk-taking behaviours||Bullying|
|Alzheimer’s disease||Psychological distress||High-risk sexual behaviours||Vulnerable to later re-victimization|
|Injuries (e.g. cuts, bruises, sprains, broken or fractured bones)||Dysthymia||Frequent relationship conflict|
|Sleep disorders||Obsessive compulsive disorder|
|Somatoform disorders||Personality disorders|
|Chronic pelvic pain||Bipolar disorder|
|Sexually transmitted infections||Dissociation|
|Cardiovascular disease||Affect regulation difficulties|
|Increased rates of hospitalization||Conduct disorder|
|Hypertension||Anger management problems|
|Irritable bowel syndrome||Poor self-rated mental wellness|
|Reproductive and gynecological health problems|
|Traumatic brain injury|
|aBolded outcomes are unique to adulthood. Italicized outcomes are unique to childhood and adolescence. Source: Etherington & Baker, 2017|
Figure 1. Fundamental considerations in understanding the link between girls’ maltreatment and subsequent revictimization or use of relational aggression
IDENTITY IS COMPLEX
VIOLENCE AS A CONTINUUM
CONTEXT IS KEY
Women and girls affected by
Women and girls are diverse and
Violence occurs in many forms.
This includes but is not limited
to: physical violence, sexual
violence (e.g. assault, harassment),
psychological violence, harmful
sociocultural practices (e.g. female
genital mutilation), and structural
violence (e.g. sexism, ageism,
Violence, especially when it
causes serious injury or death, is
against women by men. Women
who use violence often do so in the
context of their own victimization.
The broader social context (e.g.
historical and current oppressions)
impacts these lived experiences.
GIRLS’ EXPERIENCES OF CHILDHOOD VICTIMIZATION
Evidence consistently indicates that women and girls who experience maltreatment in childhood are more likely to be victimized again or to use relational aggression in childhood, adolescence, and/or adulthood. Common forms of violence experienced or used by women and girls are summarized in Table 2.
Table 2. Definitions of common forms of violence experienced or used by women and girls
|Child maltreatment||Includes all forms of physical abuse, sexual abuse, and psychological abuse directed toward a child as well as neglect of a child and exposure to intimate partner violence|
|Sexual violence||Any sexual act committed against a person without their freely given consent. This includes physical and verbal coercion as well as non-contact acts of a sexual nature. Sexual violence can occur in partner and non-partner relationships|
|Intimate partner violence||Refers to a range of abusive behaviours perpetrated by a current or former partner, including but not limited to: physical, sexual, and psychological or emotional harm|
|Dating violence||A type of intimate partner violence often referred to in the context of adolescent relationships. It occurs between two people in a dating relationship and involves physical, psychological, and sexual abuse|
|Sibling violence*||Physical, emotional, and/or sexual violence committed against one sibling by another|
|Peer violence||Aggression or violence that occurs between peers (i.e. individuals who are not related or romantically involved)|
|Source: Etherington & Baker, 2017|
Understanding the connection between maltreatment as a girl and revictimization
Revictimization (Figure 2) is defined as the experience of victimization at two different life stages (e.g. adolescence, adulthood) or during the same life stage (e.g. throughout childhood) by more than one perpetrator (e.g. uncle, boyfriend) (Classen, Palesh, & Aggarwal, 2005; Messman & Long, 1996). Revictimization can also involve repeated victimization (i.e. multiple experiences of victimization by the same perpetrator during one life stage or across life stages) or poly-victimization (i.e. experiencing more than one type of victimization during one life stage, e.g. sexual, physical, and emotional abuse in childhood). While any experience of violence can impact the health and wellbeing of survivors, revictimization typically involves unique pathways, sequelae, and implications for prevention.
Both cross-sectional and longitudinal research finds links between childhood maltreatment and:
- maltreatment later in childhood;
- sexual assault in adolescence/adulthood;
- physical assault in adolescence/adulthood;
- dating or intimate partner violence in adolescence/adulthood;
- peer victimization (e.g. bullying) in childhood and adolescence; and,
- abuse or aggression from siblings in childhood and adolescence (for a review, see Etherington & Baker, 2017).
Studies have often focused on the strong link between sexual abuse in childhood and later sexual violence victimization, with one systematic review concluding that two out of three women sexually abused as children will be sexually revictimized at some time during their lives (Classen, Palesh, & Aggarwal, 2005). However, the links between other forms of childhood maltreatment and subsequent revictimizations have also been established (Spatz Widom, Czaja, & Ann, 2008) and proposed pathways and implications for practice from the sexual revictimization literature offer insights into revictimization following other forms of child maltreatment (Hanson, 2016).
The multi-level factors that increase vulnerability to revictimization can be generally grouped as:
- those that increase vulnerability to both the initial and subsequent victimizations (e.g. poverty, neighbourhood violence, gender inequality, parental mental health and substance use issues); and,
- those that are set in motion by the initial experience of abuse (e.g. affect dysregulation, low self-esteem, post-traumatic stress disorder) (Hanson, 2016).
Most hypotheses on revictimization focus on the second group of factors, and maintain that alterations in psychological and psychosocial adjustment, abilities to recognize risk, and expectations of adult relationships increase vulnerability to later victimization (for a review, see Etherington & Baker, 2017). The first group of factors, however, are equally if not more important to address in preventing revictimization. Further, factors from each group can interact with each other in complex ways across the life course. Each of these factors is summarized in Table 3.
Figure 2. Revictimization across the life course
Table 3. Factors that increase the likelihood of revictimization for women and girls
|Individual factors||Characteristics of abuse||Interpersonal factors||Community factors||Societal factors|
|Multiple traumas||Recency of abuse||Relationship to perpetrator (greatest risk if family member)||Poverty||Gender inequality|
|Childhood physical abuse||High Frequency||Poor parental attachment||School environment (e.g. violence, bullying)||Structural violence (e.g. colonization, institutionalized racism, sexism, ageism)|
|Childhood sexual abuse||High Severity||Change in caregivers||Neighborhood violence/crime||Socio-cultural norms and beliefs about violence, masculinity and femininity|
|Running away||Long Duration||Drug/alcohol problems of family member|
|Involvement in prostitution||Type of contact (abuse involving intercourse = greatest risk of revictimization)||Family/parental conflict|
|Psychological difficulties (e.g. post-traumatic stress symptoms, emotional dysregulation)||Presence of physical abuse or neglect|
|Adolescent sexual victimization||Mental health problems in family|
|Risky sexual practices (e.g. not using condoms, multiple partners)|
Some risk factors are shared with other forms of victimization (e.g. single or repeated episodes of violence).
Table adapted from: Etherington & Baker, 2017, with supplemental information from: Hanson, 2016
Understanding the connection between maltreatment as a girl and later use of relational aggression
Evidence suggests the use of relational aggression by women and girls is intricately linked to their early experiences of victimization (for a review, see Etherington & Baker, 2017), although more work is needed to further examine this relationship and understand gender-specific
pathways. Currently, most research on the association between childhood maltreatment and later use of relational aggression is based on samples comprised of both boys and girls rather than girls only. Nevertheless, both cross-sectional and longitudinal studies demonstrate
a strong association between childhood maltreatment, sibling violence, bullying victimization, or future use of relational aggression by girls and women (Auslander, Sterzing, Threlfall, Gerke, & Edmond, 2016; Bair-Merritt, Crowne, Thompson, Sibinga, Trent, & Campbell, 2010;
Capaldi, Knoble, Shortt, & Kim, 2012; Carvalho & Nobre, 2015; Costa et al., 2015; Dixon, Browne, & Hamilton-Gilchristis, 2009; D. L. Espelage & De La Rue, 2013; (Benedini, Fagan, & Gibson, 2016; Classen, Palesh, & Aggarwal, 2005; Hong, Espelage, Grogan-Kaylor, & Allen-Meares, 2012; Massetti, Vivolo, Brookmeyer, Degue, Holland, Holt, & Matjasko, 2011; Milaniak & Spatz Widom, 2015; Odgers & Moretti, 2002; Schelbe & Geiger, 2017; Swan, Gambone, Caldwell, Sullivan, & Snow, 2008; Voisin & Hong, 2012; Wood & Sommers, 2011). The relational aggression used by women and girls is typically targeted at peers, dating or intimate partners, or children (Mahony, 2011). Limited research has examined the link between childhood victimization and adult use of aggression against aging parents.
Girls who have been maltreated often begin to use violence in late childhood and adolescence, although the effects of victimization on relational aggression have been observed as early as age 4 (Villodas et al., 2015). Childhood maltreatment is associated with the following
forms of relational aggression during late childhood and adolescence:
- physical assault/fighting (Dehart & Moran, 2015; Duke, Pettingell, McMorris, & Borowsky, 2010; D. K. Smith, Leve, & Chamberlain, 2006),
- aggressive behaviour toward peers (Auslander et al., 2016; Ballif-Spanvill, Clayton, & Hendrix, 2007; Villodas et al., 2015),
- bullying (Hong, Espelage, Grogan-Kaylor, & Allen-Meares, 2012; Massetti, Vivolo, Brookmeyer, Degue, Holland, Holt, & Matjasko, 2011; Odgers & Moretti, 2002; Voisin & Hong, 2012; Wood & Sommers, 2011),
- cyberbullying (Hébert, Cénat, Blais, Lavoie, & Guerrier, 2016),
- sexual harassment (Espelage, Basile, De La Rue, & Hamburger, 2015; Espelage, Basile, & Hamburger, 2012),
- sexual assault (Carvalho & Nobre, 2015; Krahé & Berger, 2016; Zurbriggen, Gobin, & Freyd, 2010),
- physical dating violence (Dardis, Edwards, Kelley, & Gidycz, 2013; Kendra, Bell, & Guimond, 2012; McMahon, Hoertel, Wall, Okuda, Limosin, & Blanco, 2015),
- and young mothers’ maltreatment of their own children (Dixon et al., 2009; Schelbe & Geiger, 2017).
In general, violent offence rates are greater among female youth under 18 years of age than among adult women (Mahony, 2011).
Most theories linking early victimization to later use of aggression are not gender-specific, and like revictimization models, focus primarily on individual factors. More work is needed in this area, but one promising approach is the feminist ecological model, which accounts for multiple complex interactions between individual, interpersonal, community, and societal risk factors (Grauerholz, 2000). Risk factors for use of relational aggression by women and girls across all levels are summarized in Table 4.
Table 4. Risk factors for use of relational aggression by women and girls
|Individual risk factors||Interpersonal risk factors||Community risk factors||Societal risk factors|
|Unemployment||Parental violence||Poverty||Gender inequality|
|Low academic achievement||Sibling violence||Limited educational and vocational opportunities||Structural violence (e.g. institutionalized racism, sexism, ageism)|
|Exposure to family violence||Parental substance abuse||Neighborhood violence/crime||Sociocultural norms that promote rigid, narrow stereotypes of masculinity and femininity, and that support the use of violence|
|Physical or sexual victimization in childhood||Parental mental health problems|
|Substance or alcohol use||Incarcerated parent|
|Psychological difficulties (e.g. depression, anxiety, anger management problems)||Risky behavior by peers|
|Gang membership||Peer violence|
|Abuse from an intimate partner||Low parental monitoring|
|Personality disorders (e.g. antisocial)||Delinquent friends|
|Suicide ideation/previous suicide attempts||Parent-child conflict|
|Conduct disorders||Parent criminality|
|Source: Etherington & Baker, 2017|
Childhood maltreatment is strongly linked to subsequent revictimization or use of relational aggression among women and girls. Numerous individual, interpersonal, community, and societal factors impact these trajectories of violence. Lifetime exposure to violence, through both victimization and use, has significant short- and long-term consequences for health. It is critical for prevention efforts to consider women’s and girl’s histories of violence using a sociological and life course perspective.
THE COMPELLING CASE FOR PREVENTION
Primary, secondary, and tertiary prevention
Primary prevention aims to intervene before the occurrence of victimization or use of aggression by preventing the development of associated risk factors (e.g. limited educational opportunities, parental substance use) (Perlson & Greene, 2015). Secondary prevention targets girls or women at high risk of experiencing victimization or using aggression, such as those who live in low-income neighborhoods. It aims to prevent the occurrence or progression of these outcomes. Tertiary prevention takes place after victimization or use of aggression has been identified, with interventions intended to minimize the impact of victimization for survivors and decrease the risk of recurring use of aggression (Perlson & Greene, 2015).
Levels of Prevention
Primary prevention: aims to intervene before the occurrence of victimization or use of aggression by preventing the development of associated risk factors (e.g. limited educational opportunities, parental substance use).
Secondary prevention: targets girls or women at high risk of experiencing victimization or using aggression, such as those who live in low-income neighborhoods.
Tertiary prevention: takes place after victimization or use of aggression has been identified, with interventions intended to minimize the impact of victimization for survivors and decrease the risk of recurring use of aggression.
Literature searches were conducted in the electronic databases PsycINFO, Embase (via OVID), Medline and Medline in Process (via OVID), as well as grey literature sources (e.g. child development websites, government health agency websites, prevention program websites), from inception to February 2018. Reference lists of identified relevant studies and previously published systematic reviews were also searched. Search results were first screened by title and abstract to determine eligibility for inclusion in this review. The full-texts of those studies identified as potentially relevant were then examined. Studies were included if they assessed a program intended to prevent (at any level) victimization, revictimization, or use of aggression and if girls/women were the target population of the intervention (or part of it, if sample
included both boys/men and girls/women).
Included studies were classified as research-based (i.e. based on randomized controlled trials, quasi-experimental designs, or another design with a control group such as a prospective/retrospective cohort study) or promising programs (i.e. strategies with emerging research but without experimental evaluation). Given the breadth of research on preventing victimization or use of violence, the list provided here is not intended to be exhaustive, but rather, to provide an overview of primary, secondary, and tertiary prevention programs which have been evaluated.
Prevention strategies are organized by life stage given the importance of the timing of prevention programs for program efficacy (Langhinrichsen-Rohling & Capaldi, 2012) and the emphasis of a public health/life course approach on optimal times for intervention (Lutzker & Wyatt, 2006). In addition, timing of initial victimization has important implications for revictimization prevention (Macy, 2007). Programs with applications across multiple life stages (e.g. pre-school and school age) are reviewed in a later section.
Not all studies included are based on female-only samples and of these, only a small number test for differences in program effectiveness between girls/women and boys/men. Yet, research indicates that there are often gender differences in experiences of victimization and use of aggression, as well as in the development of particular vulnerabilities (for a review, see Massetti, Vivolo, Brookmeyer, Degue, Holland, Holt, & Matjasko, 2011). Results from mixed-gender samples included in this paper should therefore be interpreted in light of this limitation.
It is also important to note that some evidence suggests violence prevention programs targeted at women and girls are not effective for those who have already experienced victimization (i.e. do not prevent re-victimization) (Classen, Palesh, & Aggarwal, 2005; Hanson, 2016). Women and girls who have already been victimized in the past may have unique needs relative to those with no victimization experiences and this might have implications for preventing future victimization or use of aggression. Thus, interventions designed for those without any history of victimization or that do not take into account prior experiences of victimization may not be as effective as those which do consider victimization history. Nevertheless, the significant body of work on violence prevention in general can help to inform prevention efforts with women and girls who have experienced prior victimization (Macy, 2007). Where possible, this paper will highlight programs specifically intended for girls and women with victimization histories as well as those specifically designed to address revictimization.
There are many mechanisms involved in revictimization and it may be important for violence prevention strategies to specifically target these mechanisms. Evidence suggests the psychosocial impacts of victimization, including posttraumatic stress symptomology (Auslander
et al., 2016; Berlin, Appleyard, & Dodge, 2011; Fortier, Peugh, Dililio, Messman-moore, Denardi, & Gaffey, 2009; Grauerholz, 2000; Messman-Moore, Ward, & Brown, 2009), depression (Auslander et al., 2016; Hong & Espelage, 2012), reduced threat detection capacity (Berlin et al., 2011), hypervigilance (Berlin et al., 2011), social isolation (Berlin et al., 2011; Grauerholz, 2000), affect dysregulation (Berlin et al., 2011; Lee & Hoaken, 2007), substance use (Breitenbecher, 2001; Fortier, Peugh, Dililio, Messman-moore, Denardi, & Gaffey, 2009; Grauerholz, 2000), and certain sexual behaviours (e.g. initiation of sex at an early age, unprotected sex, multiple partners, prostitution) (Fargo, 2009; Grauerholz, 2000), are primary mechanisms through which vulnerability to later victimization or use of aggression develops.Some of these mechanisms, like emotional dysregulation, predict many other high-risk behaviours (e.g. substance abuse), and may be key targets for prevention strategies (Messman-Moore, Walsh, & DiLillo, 2010). The research on revictimization prevention, however, is still in its initial stages and more work is needed to develop programs intended specifically for this experience of violence. Due to the limited number of studies on reducing revictimization, we also include programs for suvivors of violence that reduce the consequences of vicitmization discussed above, which may in turn reduce risk of subsequent victimization.
Finally, when addressing the violence experienced by women and girls across the life course, it is clear that preventing violence from being disproportionately perpetrated against them by men and boys in the first place is ideal. While the strategies designed to reduce vulnerabilities to violence and its consequences among women and girls reviewed in this paper are important, there is a need for macro-level (e.g. community/societalbased) interventions to address the root causes of gender-based violence (e.g. gender inequality, unhealthy masculinities, intersecting systems of oppression). These community and societally-based factors can be critical mechanisms in the pathways from early to later experiences of violence (Grauerholz, 2000). There has, however, been limited systematic evaluation of macrolevel
approaches. Accordingly, these programs are not reviewed extensively within the context of this paper but should be a focus of future work.
PREVENTION ACROSS THE LIFE COURSE
Risk of maltreatment is highest for infants and pre-school aged children, largely due to their relative dependency, vulnerability, and social invisibility compared to older children (Gewirtz & Edleson, 2007; World Health Organization & International Society For Prevention of Child Abuse Neglect, 2006). Table 5 summarizes four research-based programs for children 0-5 years old, which mainly occur in the home. Three programs (Psychoeducational Parenting Intervention, Nurse-Family Partnership, Healthy Start Program) target children and families at high risk of victimization or use of aggression (i.e. secondary prevention). Child-Parent Psychotherapy, a tertiary program, is aimed at children who have experienced victimization.
Each program has been shown to reduce early life risk factors for future victimization or use of aggression. These risk factors include child developmental and behavioural problems, poor parenting skills, insecure attachment, post-traumatic stress disorder symptoms, and actual
incidents of abuse or neglect. Studies on these programs involved both girls and boys. Child-Parent Psychotherapy is described in more detail here. Additional information on the other mentioned programs can be found in Table 5.
Child-parent psychotherapy (CPP) is specifically targeted to children five years of age and younger who have experienced abuse, neglect, or exposure to intimate partner violence. Since CPP takes place after victimization has occurred, it can be considered a tertiary-level intervention. CPP focuses on the parent-child relationship, providing treatment to both the child and primary caregiver. Together, the child and caregiver develop an account of the traumatic event, working to identify and address associated triggers. This is accomplished through
weekly supervised sessions over the course of one year. The components of CPP are summarized in Table 6.
Research demonstrates that CPP successfully improves secure attachment and reduces behaviour problems and traumatic stress symptoms among children (Cicchetti, Rogosch, & Toth, 2006, 2011; Guild et al., 2017; Lieberman et al., 2006; Stronach et al., 2013). Insecure attachment, behaviour problems, and traumatic stress symptoms are all risk factors for revictimization and future use of aggression (Auslander et al., 2016; Berlin et al., 2011; Breitenbecher, 2001; Fargo, 2009; Fortier, Peugh, Dililio, Messmanmoore, Denardi, & Gaffey, 2009; Grauerholz, 2000; Hong, Espelage, Grogan-Kaylor, & Allen-Meares, 2012; Lee & Hoaken, 2007; Messman-Moore et al., 2009).
Table 5. Summary of research-based revictimization/future use of aggression prevention
|Program name, Country of implementation||Level of prevention||Purpose/description||Significant outcomes||Selected references|
Nurse-Family Partnership, Netherlands and United States
*Feasibility and acceptability tested in Canada, RCT underway (Catherine et al., 2016; Jack et al., 2015)
Targets low-income families experiencing first-time pregnancy with the goal of assessing quality of relationships and identifying violence before it starts. Program also aims to improve pregnancy outcomes, child health and development, and economic selfsufficiency of family
Home visits by registered nurse from pregnancy until baby is 2 years old
Improvement in parenting skills (mothers) and children’s developmental outcomes
Reduction in child abuse and neglect
Increase in father involvement
Reduction in emergency room visits for accidents and poisoning
Reduction in child arrests at age 15
Reduction in behavioural/intellectual problems at age 6
Reduction in child protective services reports
Improvement in children’s internalizing behaviour
|(Canadian NFP Network, 2011; Eckenrode et al., 2017; Mejdoubi, Van Den Heijkant, Van Leerdam, Heymans, Crijnen, & Hirasing, 2015; Nurse-Family Partnership, 2014)|
|Healthy Start Program, United States||Secondary||
Aims to prevent child abuse/neglect and promote child health and development among families with newborns at risk for poor child outcomes (e.g. families with intimate partner violence, poor mental health, parental substance use, etc.)
Two components: (1) early identification of families with newborns at risk of abuse/neglect; (2) home
Frequency of home visits decreases as family functioning improves
Moderate prevention of neglect
Reduction in incidents of physical partner
Reduction in hospitalizations from child maltreatment
Greater accessibility, engagement, and sharing of responsibility among violent fathers who saw child’s mother infrequently at baseline
|(Dew & Breakey, 2014; Duggan, Fuddy, Burrell, et al., 2004; Duggan, Fuddy, McFarlane, et al., 2004; Duggan et al., 1999)|
|Psychoeducational parenting intervention, United States||Secondary||
Visitation by nurses to homes of low-income teenage mothers of newborns over 2-year period; nurses provided home-based education program supplemented with cognitive and
behavioural techniques to address parenting skill deficits and socialecological factors
|Improvement in children’s secure attachment||
(Cicchetti, Rogosch, & Toth, 2006, 2011; Guild, Toth,
Handley, Rogosch, & Cicchetti, 2017; Lieberman, Ghosh
Ippen, & VAN Horn, 2006; Lieberman, Van Horn, & Ippen,
2005; Stronach, Toth, Rogosch, & Cicchetti, 2013)
|Child-Parent Psychotherapy, United States||Tertiary||
Targets children aged 0-5 who have experienced a trauma and their caregivers
Child and primary caregiver participate in treatment together with goal of strengthening caregiver-child relationship to restore and protect child’s mental health
Recommended intensity and duration: Weekly 1-1.5 hour sessions for 52 weeks
Reduction in parent and child traumatic stress disorder symptoms
Reduction in child behaviour problems
Increase in secure attachment among children
|(Cicchetti et al., 2006, 2011; Guild, Toth, Handley, Rogosch, & Cicchetti, 2017; Lieberman, Ghosh Ippen, & Van Horn, 2006; Lieberman, Van Horn, & Ippen, 2005; Stronach, Toth, Rogosch, & Cicchetti, 2013)|
Table 6. Essential components of child-parent psychotherapy
|Focus on safety||
a) Attend to safety issues in the environment as needed
b) Promote safe behavior
c) Legitimize feelings while highlighting the need for safe/appropriate behavior
d) Foster appropriate limit setting
e) Help establish appropriate parent-child roles
a) Provide developmental guidance regarding how children regulate affect and emotional reactions
b) Support and label affective experiences
c) Foster parent’s ability to respond in helpful, soothing ways when child is upset
d) Foster child’s ability to use parent as a secure base
e) Develop/foster strategies for regulating affect
|Reciprocity in relationships||
a) Highlight parent’s and child’s love and understanding for each other
b) Support expression of positive and negative feelings for important people
c) Foster ability to understand the other’s perspective
d) Talk about ways that parent and child are different and autonomous
e) Develop interventions to change maladaptive patterns of interactions
|Focus on the traumatic event||
a) Help parent acknowledge what child has witnessed and remembered
b) Help parent and child understand each other’s reality with regards to the trauma
c) Provide developmental guidance acknowledging response to trauma
d) Make linkages between past experiences and current thoughts, feelings, and behaviors
e) Help parent understand link between her own experiences and current feelings and parenting practices
f) Highlight the difference between past and present circumstances
g) Support parent and child in creating a joint narrative
h) Reinforce behaviors that help parent and child master the trauma and gain a new perspective
|Continuity of daily living||
a) Foster prosocial, adaptive behavior
b) Foster efforts to engage in appropriate activities
c) Foster development of a daily predictable routine
|From: Etherington & Baker, 2016|
Table 7 summarizes 13 programs that can be implemented to prevent victimization or use of aggression among school-aged children and are mainly implemented in a school setting. Of these, six are primary-level prevention programs, two are secondary-level, and six are tertiarylevel. One program, Friend to Friend, is specifically intended to reduce social aggression among urban, predominantly African-American fifth-grade girls. It will be described in detail here. It should be noted that this program does not account for prior victimization history, which may be why girls are using aggression to begin with, but may be useful to inform prevention of aggression among maltreated girls given the positive results of the program. Information on the other 12 programs can be found in Table 7.
Friend to Friend
Friend to Friend (F2F) is a school-based program designed for urban, mostly African American fifth-grade girls with the aim of reducing physical and relational aggression among those exhibiting these behaviours (S. S. Leff et al., 2009). The program also aims to improve girls’ problem-solving skills and increase prosocial behaviours. F2F was developed in collaboration with parents, teachers, community members, and girls themselves using a participatory action framework (S. Leff et al., 2007). This strength of the F2F has enabled it to be highly accepted by participants and their teachers as well as culturally sensitive (S. S. Leff, Waasdorp, & Crick, 2010). Relationally aggressive girls are also grouped with prosocial role models. F2F has been found to significantly decrease relational and physical aggression, loneliness, and hostile attributions, and to increase prosocial behaviour and problem solving abilities (S. S. Leff et al., 2009; S. S. Leff, Paskewich, Waasdorp, Waanders, Bevans, & Jawad, 2015; S. S. Leff, Waasdorp, & Paskewich, 2016). Peer likeability, as reported by teachers, also improved for relationally aggressive girls who received the F2F intervention. Of course, given the specific target group of this intervention, it may not be generalizable to other populations. Nevertheless, it is a noteworthy example of a program for girls who live at the intersection of two systems of oppression (i.e. race and gender).
The Early Childhood Friendship Project, a school-based primary prevention program, is summarized in Table 8 (Ostrov et al., 2009; Ostrov & Keating, 2004). The intervention was tested using groups of both boys and girls; however, the study did not test for gender differences in its effect. The program was found to reduce physical and relational aggression as well as physical victimization. It also increased prosocial behaviour.
Table 7. Research-based revictimization/future use of aggression programs: School-age
|Program name, Country of implementation||Level of prevention||Purpose/description||Significant outcomes||Selected references|
|I Can Problem Solve (ICPS), United States||Primary||Curriculum-based program designed to reduce aggressive behaviour and increase prosocial behaviour among kindergarten and elementary-aged children||
Increase in prosocial behaviour
Reduction in overt and relational aggression
|(Boyle & Hassett-Walker, 2008)|
|Walk Away, Ignore, Talk, Seek Help (WITS), Canada||Primary||
Comprehensive multi-setting program (i.e. schools, families, and communities) designed to improve social/emotional competence, increase social responsibility, and reduce victimization
Kindergarten to third grade
Reduction in relational and physical victimization
Increase in social competence
|(Leadbeater & Hoglund, 2006; Leadbeater, Hoglund, & Woods, 2003)|
|Second Step, United States||Primary||Classroom-based program designed to address social competence and aggression among sixth and seventh grade students||
Improvement in social competence and behaviour
Reduction in bullying, physical aggression and antisocial behaviours
|(D. L. Espelage, Low, Polanin, & Brown, 2013; D. L. Espelage, Rose, & Polanin, 2015; Frey, Bobbitt Nolen, Van, Edstrom, & Hirschstein, 2005; Low, Cook, Smolkowski, & Buntain-Ricklefs, 2014; Van Schoiack- Edstrom, Frey, & Beland, 2002)|
|Life Skills Training, United States||Primary||
School-based intervention with material on violence and the media, anger management, and conflict resolution skills
Targets sixth-grade students
verbal aggression, physical aggression, delinquency, and alcohol, marijuana, polydrug use
|(Botvin et al., 2006; Spoth, Randall, Trudeau, Shin, & Redmond, 2008)|
|PATHS (Promoting Alternative Thinking Strategies), United Kingdom and United States||Primary||
Multi-year prevention program for elementary schoolaged children
Classroom curriculum is designed to promote emotional and social competencies
Reduction in peer problems, emotional symptoms, conduct problems, externalizing and aggressive behaviours
Increase in social-emotional competence and prosocial behaviour
|(Crean & Johnson, 2013; Group, 1999; Humphrey et al., 2016; Kam, Greenberg, & Kusché, 2004)|
|Linking the Interests of Families and Teachers (LIFT), United States||Secondary||
Targets first and fifth grade children (and their families) living in at-risk neighborhoods
Three main components: classroom-based child social skills training, playground “Good Behaviour Game”, parent management training
|Reduction in physical aggression, disruptive behaviour, and substance use||(DeGarmo, Eddy, Reid, & Fetrow, 2009; Eddy, Reid, & Fetrow, 2000; Reid, Eddy, Fetrow, & Stoolmiller, 1999)|
|Seattle Social Development Project, United States||Secondary||
3 part school-based intervention for students in grades 1-6 and their teachers and parents
Tested in elementary schools from high crime urban areas
Teacher training: proactive classroom management, interactive teaching, cooperative learning
Parent training: child behaviour managegment, academic support, skills to reduce drug use risk
Child training: interpersonal problem solving and refusal skills
Reduction in aggression, antisocial, externalizing behaviours; alcohol and delinquency initiation; and violent delinquency
Improved functioning in school, work, emotional health, mental health
|(Hawkins Catalano, Morrison, O’Donnell, Abbott, & Day, 1992; J. Hawkins, Von Cleve, & Catalano, 1991; J. D. Hawkins, Kosterman, Catalano, Hill, & Abbott, 2005; O’Donnell, Hawkins, Catalano, Abbott, & Day, 1995)|
|Community-provided trauma-focused cognitive behaviour therapy, United States||Tertiary||45-minute individual therapy sessions provided over 8 weeks to parents and children 7-14 years old exposed to IPV and exhibiting symptoms of PTSD||Decrease in children’s IPV-related PTSD and anxiety symptoms||(Cohen, Mannarino, & Iyengar, 2011; de Arellano et al., 2014)|
|Making Choices: Social Problem Skills for Children (MC), United States||Tertiary||School-based intervention addressing social information processing deficits in aggressive children 6-12 years||
Improvement in prosocial behaviour, emotional regulation, social contact, goal formation, response decision, and cognitive concentration
Reduction in hostile attribution biases, relational and social aggression
|(Fraser et al., 2005; Fraser, Day, Galinsky, Hodges, & Smokowski, 2004)|
|Friend to Friend (F2F), United States||Tertiary||
School-based program to address aggressive behaviour, improve problem-solving skills, and increase prosocial behaviour
For relationally aggressive girls in grades 3 to 5 (urban, primarily African American)
Improvement in teacher-reported peer likeability
Reduction in relational and physical aggression, hostile attributions, and loneliness
Increase in prosocial behaviours and knowledge of social problem solving skills
|(Leff, Angelucci, Goldstein, Cardaciotto, Paskewich, & Grossman, 2007; S. S. Leff et al., 2009; S. S. Leff, Paskewich, Waasdorp, Waanders, Bevans, & Jawad, 2015; S. S. Leff, Waasdorp, & Paskewich, 2016)|
|Community-Based Intervention Program, United States||Tertiary||
Targets children 6-12 exposed to IPV with goal of improving knowledge, attitudes, beliefs about family violence as well as emotional/social adjustment
Lessons provided in group therapy format spanning 10 weeks
Decrease in children’s externalizing and internalizing behaviours
Positive change in children’s attitudes
|(Graham-Bermann, Lynch, Banyard, DeVoe, & Halabu, 2007)|
|Project Support I and II, United States||Tertiary||
Aims to reduce conflict problems and harsh parenting and provide support in transition from abusive home for children aged 4-9 who have been exposed to IPV (and their mothers) Involves weekly home visits by therapist for up to 8 months.
Support and positive role modelling by trained university students provided to child
Improvement in children’s social relationships and happiness
Reduction in children’s oppositional defiant/ conduct disorders, behavioural problems, emotional problems
Reduction in harsh parenting, ineffective parenting practices, and referrals to child protective services for child maltreatment
|(Jouriles McDonald, Rosenfield, Stephens, Corbitt-Shindler, & Miller, 2009; Jouriles et al., 2010; McDonald, Dodson, Rosenfield, & Jouriles, 2011; McDonald, Jouriles, & Skopp, 2006)|
|Strengths- and Community-Based Support and Advocacy, United States||Tertiary||
Weekly group sessions over 2.5 months to provide safety and emotions education for children aged 7-11 exposed to IPV. Program also features advocacy component for mothers
Program activities to educate children about safety, feelings and respect were varied and frequently used physical activity
Increased child self-competence
Decreased daily contact with perpetrator
Improvement in mother’s depression symptoms and selfesteem over time
|(Sullivan, Bybee, & Allen, 2002)|
Table 8. Promising revictimization/future use of aggression programs: School-age
|Program name, Country of implementation||Level of prevention||Purpose/description||Significant outcomes||Selected references|
|Early Childhood Friendship Project, United States||Primary||
Classroombased preventive intervention for preschool aged children
Uses activities (e.g. puppet shows, art projects, role play) to teach lessons with reinforcement during free play (20-30 minute lessons every week)
Designed to increase prosocial behaviours and reduce physical aggression, relational aggression, and peer victimization
Reduction in physical aggression/victimization and relational aggression
Increase in prosocial behaviour
|(Ostrov et al., 2009; Ostrov & Keating, 2004)|
Adolescence/secondary school and young adulthood
Adolescence and young adulthood may be a particularly important time for revictimization prevention given it is when women are simultaneously engaging in dating/intimate romantic relationships and are at significant risk of sexual victimization (Rinehart, Yeater, Musci, Letourneau, & Lenberg, 2014). This is not to say that women are responsible for their own victimization, but rather, that this is a key time to develop their resilience and reduce their vulnerability to future violence, particularly for those who have already been maltreated in childhood. Therefore, prevention strategies may include the development of risk-recognition, self-protection/self-defense skills, assertiveness, problem-solving and communication skills, self-esteem, and self-efficacy as well as strategies to address the psychological consequences of childhood victimization (Bair-Merritt, Crowne, Thompson, Sibinga, Trent, & Campbell, 2010; Breitenbecher, 2001; Chiodo, Crooks, Wolfe, McIsaac, Hughes, & Jaffe, 2012; Kearns & Calhoun, 2010; R. Macy, 2008; R. J. Macy, 2007; Van Bruggen, Runtz, & Kadlec, 2006)
Fourteen research-based programs for adolescents and young adults are summarized in Table 9. These programs typically take place in a group setting (school, peers, or family). Of the 14 programs, four engage in primary prevention (Sisters of Nia; The Fourth R; Enhanced Assess, Acknowledge, Act Sexual Assault Resistance Program; Families for Safe Dates), two in secondary prevention (Web-based combined sexual assault risk and alcohol use reduction program, Moms and Teens for Safe Dates), and seven in tertiary prevention (DePrince Group Interventions, Revictimization Prevention Program, Youth Relationships Project, Multidimensional Treatment Foster Care, Functional Family Therapy, Multisystemic Therapy, Sexual Assault Risk Reduction Program). One program, Safe Dates, has both primary and secondary components.
Six of the programs are intended specifically for girls/young women (Sisters of Nia; DePrince Group Interventions; Web-based combined sexual assault risk and alcohol use reduction program; Revictimization Prevention Program; Sexual Assault Risk Reduction Program; Enhanced Assess, Acknowledge, Act Sexual Assault Resistance Program) and of these, three explicitly address or investigated revictimization (Revictimization Prevention Program; Sexual Assault Risk Reduction Program; Enhanced Assess, Acknowledge, Act Sexual Assault Resistance Program). The Revictimization Prevention Program and Enhanced Assess, Acknowledge, Act Sexual Assault Resistance Program are discussed in further detail below.
Table 9. Research-based revictimization/future use of aggression programs: Adolescence/secondary school and young adulthood
|Program name, Country of implementation||Level of prevention||Purpose/description||Significant outcomes||Selected references|
|Enhanced Assess, Acknowledge, Act Sexual Assault Resistance Program, Canada||Primary||
Targets first-year female university students
Program includes: four 3-hour units involving informationproviding games, mini-lectures, facilitated discussion, application and practice activities
Goal: teach women how to assess risk, acknowledge danger, engage in self-defence
Reduction in 1-year risk of completed rape and attempted rape
Reduction in risk of completed and attempted rape, attempted coercion, and non-consensual sexual contact at 2 years
Increase in perception of personal risk, self-defense selfefficacy, knowledge of effective verbal and physical resistance strategies
Reduction in rape myth acceptance and woman blaming
Increase in risk detection
|(Senn et al., 2015, 2017)|
|The Fourth R, Canada||Primary||
School-based program integrated into Grade 9 Health and Physical Education curriculum through 21, 75-minute lessons
Sex-segregated classes aim to define and practice healthy relationships skills, increase interpersonal and problem-solving skills, and reduce risk behaviours associated with dating violence among adolescents
Reduction in perpetration of physical dating violence but more effective for boys
Reduction in likelihood of engaging in violent delinquency, especially for maltreated youth
|(Crooks, Scott, Ellis, & Wolfe, 2011; Wolfe et al., 2009)|
|Sisters of Nia, United States||Primary||
Small group program that addresses gender roles, ethnic identity, and appropriate social behaviours
Designed for African American female adolescents
Higher ethnic identity scores
Lower levels of relational aggression
Reduction in verbally aggressive behaviour
|(Aston, Graves, McGoey, Lovelace, & Townsend, 2018; Belgrave et al., 2004)|
|Families for Safe Dates Program, United States||Primary||
Family-based program consisting of 6 booklets delivered to families by mail
Booklets include activities for caregivers and teens to complete together to reduce risk factors for dating abuse
Booklets are completed in-home and health educator calls caregiver 2 weeks after each booklet is mailed
Reduction in teen and caregiver acceptance of dating abuse Improvement in caregiver’s perceived severity of dating abuse, self-efficacy for talking about dating abuse, knowledge of dating abuse, belief in importance of involvement in teen dating
Reduction in onset of physical abuse victimization
|(Foshee, McNaughton Reyes, Ennett, Cance, Bauman, & Bowling, 2012)|
|Safe Dates Program, United States||Primary/Secondary||
School-based program targeting students in grades 8 and 9 with focus on changing dating norms and gender stereotyping, developing conflict management skills, and promoting positive help-seeking behaviour
Program aims to prevent first perpetration of dating violence and to stop further perpetration of violence
Decrease in acceptance of dating violence
Increased perception of negative consequences for engaging in dating violence
Enhanced awareness of victim and perpetrator services
Reduction in psychological, physical, sexual violence perpetration at 4-year follow-up
|(Foshee, Bauman, Arriaga, Helms, Koch, & Linder, 1998; Foshee et al., 2000)|
|Moms and Teens for Safe Dates, United States||Secondary||
Prevention program for teens exposed to intimate partner violence
Mothers formerly victimized by IPV deliver program to their teens
Program consists of 6 booklets of IPV prevention information and interactive activities
Improvement in teen conflict management skills and feelings of family closeness/cohesion
Improvement in awareness of dating abuse, self-efficacy in enacting prevention efforts, comfort in communication with teen
|(Foshee et al., 2016)|
|Web-based combined sexual assault risk and alcohol use reduction program, United States||Secondary||College women between ages of 18 and 20 who engaged in heavy episodic drinking provided with psychoeducational web-based program for alcohol use and sexual assault risk reduction||Less incapacitated attempted or completed rapes, less severity of sexual assault, less heavy episodic drinking among women who had a higher severity of sexual assault at baseline||(Gilmore, Lewis, & George, 2015)|
|Multidimensional Treatment Foster Care, United States||Tertiary||
Targets adolescents aged 15-19 in the juvenile justice system; originally developed for boys but subsequently adapted for girls
Standardized components: (a) Daily telephone contact with foster parents; (b) weekly foster parent group training, supervision and support meetings; (c) individual therapy for each girl; (d) family therapy (for family of origin) to improve parent management strategies; (e) close monitoring of school functioning; (f) program staff on call for youth, foster and biological parents; (g) psychiatric consultation
Gender-sensitive approach to social/relational aggression and developing strategies for handling stress
|Reduction in delinquency, criminal behaviour, assaults||(Chamberlain, Leve, & Degarmo, 2007; Fisher & Gilliam, 2012)|
|Functional Family Therapy, Australia, Canada, Denmark, England, Ireland, Netherlands, New Zealand, Norway, Scotland, Singapore, United States||Tertiary||
Targets adolescents in juvenile justice system
12 family-based sessions over a 3-6 month period delivered by therapists in youths’ home
|Reduction in conduct problems, youth violence, drug abuse, delinquency and crime||(Alexander, Pugh, Parsons, & Sexton, 2000; Gordon, Graves, & Arbuthnot, 1995; Hartnett, Carr, Hamilton, & O’Reilly, 2017; Sexton & Turner, 2010)|
|Multisystemic Therapy, Australia, Canada, Chile, Denmark, Germany, Iceland, Netherlands, New Zealand, Norway, Sweden, United Kingdom, United States||Tertiary||
Targets 12-17 year old adolescent offenders
Multidimensional therapeutic approach that uses present-focused, action-oriented interventions to address intrapersonal and systemic factors associated with adolescent antisocial behaviour
|Reduction in peer aggression, arrests (including for violent offenses), violent delinquency, revictimization, PTSD, out-of-home placements, substance use||(Borduin et al., 1995; Henggeler, Melton, & Smith, 1992; Henggeler & Schaeffer, 2016; MST Services, 2018; Schaeffer & Borduin, 2005)|
|DePrince Group Interventions, United States||Tertiary||
Two 12-session group interventions
Targets teen girls with existing child protection concerns
Risk detection/executive (RD/EF) function intervention taught mindfulness, problem-solving, recognition of social threat
Social learning/feminist (SL/F) intervention focused on developing health relationship skills and teaching young women about societal influences on abuse
RD/EF group 5x less likely to report sexual revictimization in the 6 months following
SL/F group 3x less likely to report physical violence re-victimization at follow-up
|(DePrince, Chu, Labus, Shirk, & Potter, 2015)|
|Revictimization Prevention Program, United States||Tertiary||
Combined psychoeducational and modified relapse prevention program (two 2-hour sessions) targeted at undergraduate women with histories of sexual victimization as adolescents or adults
Overall objective to reduce incidence of acquaintance sexual revictimization
Reduced incidence of sexual assault revictimization
Improvement in selfefficacy
Decreased overall ratings of distress
|(Marx, Calhoun, Wilson, & Meyerson, 2001)|
|Sexual Assault Risk Reduction Program, United States||Tertiary||Psychoeducational group-based program (two 4-hour sessions) for undergraduate women who have experienced revictimization||Reduction in PTSD symptoms||(Mouilso, Calhoun, & Gidycz, 2011)|
|Youth Relationships Project, Canada||Tertiary||
Group program targets adoelscents 13-17 maltreated as children to facilitate development of healthy, non-abusive relationships
Involves 18 weekly two-hour sessions focusing on understanding gender-based violence, skill development, and social action
Reduction in incidents of physical and emotional abuse and symptoms of emotional distress
Greater reduction in threatening behaviours for girls than boys
|(Wolfe Wekerle, Scott, Straatman, Grasley, & Reitzel-Jaffe, 2003)|
Revictimization Prevention Program
The Revictimization Prevention Program (Marx et al., 2001) targets undergraduate women who have experienced sexual victimization in adolescence or young adulthood. The combined psychoeducational and modified relapse prevention program aims to accomplish the following goals:
- Increase factual knowledge of sexual assault
- Increase understanding of social factors that facilitate environments which are conducive to sexual violence
- Teach practical strategies to prevent unwanted sexual experiences (e.g. meeting in a public place)
- Alter dating behaviours associated with sexual assault (e.g. alcohol safety)
- Develop effective problem solving, assertiveness, communication, and risk-recognition
These goals are accomplished over two sessions, which are each two hours in length. The content of the sessions is summarized in Table 10. Completion of the program is associated with improved self-efficacy, decreased ratings of distress, and reduced incidences of sexual assault revictimization.
Enhanced Assess, Acknowledge, Act Sexual Assault Resistance Program
The Enhanced Assess, Acknowledge, Act Sexual Assault Resistance Program was developed, pilot tested, and implemented in Canada (Senn et al., 2015). The program consists of four 3-hour units, summarized in Table 11, which aim to teach young women how to assess risk, acknowledge danger, and engage in self-defence (either verbal or physical).
In a randomized-controlled trial involving 3 Canadian universities (Windsor, Guelph, Calgary), first-year university women were assigned to the resistance group or a control group involving the common university prevention practice of making brochures available in clinics and counselling centers on campus (Senn et al., 2015). At 1-year followup, women in the resistance group had a significantly lower risk of both reported attempted rape and reported completed rape (Senn et al., 2015). The program also found that while previously victimized women had an elevated risk of completed rape, the resistance group still had a lower risk of reported completed rape at 1-year compared to the control group.
There was also no significant difference in the effect of the intervention according to women’s prior victimization history, suggesting it may have similar effects for women regardless of past victimization (Senn et al., 2015).
After 2 years, the program was still found to significantly reduce the risk of attempted and completed rape, as well as attempted coercion and non-consensual contact, with reductions ranging from 30-64% (Senn et al., 2017). Significant increases were also found in perceptions of personal risk, risk detection, self-defense self-efficacy, and knowledge of effective verbal and physical resistance strategies. General rape myth acceptance and woman blaming decreased over the 2-year period (Senn et al., 2017).
There are two primary prevention programs (Sexual Assault Education and Prevention Program, The Fourth R: Uniting Our Nations), one secondary prevention program (MAC-UK), and two tertiary prevention programs (Trauma Systems Therapy, Brief Acceptance and Mindfulness-Based Program) which show promise in their potential to prevent revictimiztaion or future use of aggression (Table 12). Two target young women (Sexual Assault Education and Prevention Program, Brief Acceptance and Mindfulness-Based Program), while the others are not gender-specific.
The Brief Acceptance and Mindfulness-Based Program
specifically aims to reduce risk for revicitmization among young women with a history of childhood sexual abuse. This program is summarized below.
The Brief Acceptance and Mindfulness-Based Program
The Brief Acceptance and Mindfulness-Based Program involves two, 2-hour group sessions spaced one week apart (Hill et al., 2011). The program does not contain any sexual assault-specific content, but instead uses psychoeducational and experiential exercises to: (a) increase awareness of internal responses to events; (b) encourage observation of the present moment; (c) improve awareness of self-judgements about one’s own thoughts and experiences; (d) cultivate compassion toward one’s internal experience; and (e) learn to differentiate between internal experiences and behaviour. At twomonth follow-up, the program was found to reduce likelihood of sexual assault for women with a history of childhood sexual abuse who participated. A program overview is included in Table 13.
Table 10. Revictimization Prevention Program Session Content (Marx et al., 2001)
Table 11. The Enhanced Assess, Acknowledge, Act Sexual Assault Resistance Program (Senn et al.,
|Unit 1: Assess||
|Unit 2: Acknowledge||
|Unit 3: Act||
|Unit 4: Sexuality and Relationships||
Table 12. Promising revictimization/future use of aggression programs: Adolescence and young
|Program name, Country of implementation||Level of prevention||Purpose/description||Significant outcomes||Selected references|
|The Fourth R: Uniting Our Nations, Canada||Primary||Promote healthy relationships, cultural connectedness, and educational success among Indigenous Grade 8 youth through mentoring programs and cultural leadership initiatives||Improved relationships, sense of belonging, student success, confidence, leadership skills||(Crooks, Hughes, & Sisco, 2015)|
|Sexual Assault Education and Prevention Program, United States||Primary||One-hour didactic education program on sexual assault (e.g. prevalence, risk factors, general prevention, options when assault occurs) presented to undergraduate sorority women||Increased knowledge of sexual assault issues but did not reduce risky sexual behaviours, victimization, or substance use||(Davis, DeMaio, & Fricker-Elhai, 2004)|
|MAC-UK, United Kingdom||Secondary||
Works with young people who are typically offending, in gangs, and experiencing mental health difficulties
Engages them in projects of interest (involving music or sport) and offers “street therapy” where and when young people feel comfortable
Reduction in criminal offending
Increased engagement in employment, education, and training
|(Chakkalackal & Cyhlarova, 2013; Ruback, Clark, & Warner, 2014)|
|Brief Acceptance and Mindfulness- Based Program, United States||Tertiary||Two 2-hour group sessions involving psychoeducational and experiential exercises targeted at undergraduate women with history of childhood sexual assault||Reduction in likelihood of sexual assault at 2-month follow-up||(Hill, Vernig, Lee, Brown, & Orsillo, 2011)|
|Trauma Systems Therapy, New York||Tertiary||Aims to enhance engagement of children and families in trauma-focused work through multiple methods including education about trauma, problem-solving, and collaboratively mapping the therapeutic journey||
Reduction in posttraumatic stress and aggression
Slight improvement in home safety
|(Saxe, Ellis, Fogler, & Navalta, 2012)|
Table 13. Overview of Brief Acceptance and Mindfulness-Based Program (Hill et al., 2011)
The Healing Our Women (HOW) Project (Table 14) is a trauma-focused intervention for HIV-positive African American and Latina women with child sexual abuse histories (Wyatt et al., 2004, 2011). The HOW Project involves peer-facilitated sessions with weekly trauma writing, communication skills training, relaxation techniques, peer modeling of disclosure, and problemsolving strategies. The program has been found to reduce psychological distress, PSTD symptoms, and sexual symptoms stemming from trauma.
Table 15 summarizes three promising tertiary programs offered in institutional settings for women who have used violence. There are also three programs for women who have used violence which are not shown since they have not yet been evaluated, but are worth noting given their emphasis on addressing past experiences of victimization. Two of the programs, Sex Offender Therapy for Women and the Anger and Emotion Management Program, are both offered at women’s correctional facilities across Canada (Correctional Service Canada, 2008). Each addresses histories of abuse as a factor influencing women’s use of aggression/violence. Women are taught key skills for managing anger and other emotions associated with violence. The Anger and Emotion Management Program in particular addresses the relational context in which women’s use of aggression or violence tends to occur (Correctional Service Canada, 2008). The third program, Emotion Control Therapy, is offered by many correctional facilities and includes individual sessions to address experiences of past abuse or traumatic events, recognizing the role these experiences play in women’s pathways to violence (Correctional Service Canada, 2008).
Table 14. Research-based revictimization/future use of aggression programs: Adulthood
|Program name, Country of implementation||Level of prevention||Purpose/description||Significant outcomes||Selected references|
|Healing Our Women Project, United States||Tertiary||
11-session gender specific and culturally congruent intervention provided to HIV- positive African-American and Latina women with histories of sexual abuse and violence
Involved peerfacilitated sessions with weekly trauma writing in journals
|Reduction in PTSD symptoms, psychological distress, and sexual symptoms||(Wyatt et al., 2004, 2011)|
Table 15. Promising revictimization/future use of aggression programs: Adulthood
|Program name, Country of implementation||Level of prevention||Purpose/description||Significant outcomes||Selected references|
|Sexual Assault Education/Prevention Program for Female U.S. Navy Personnel||Primary||Program for women in the U.S. Navy; uses lectures, slides, discussions, films to provide information on sexual assault (risk factors, consequences, prevention, relevant military regulations)||Increased knowledge of sexual assault and empathy for victims||(Rau et al., 2011)|
|Intensive Treatment Program for Female Offenders, Canada||Tertiary||
Targets incarcerated women who have used violence
Aims to address aggression/violence through group exercises that promote insight into own behaviours and pro-social alternatives to dealing with anger
Other program goals include: improving communication and social skills, taking responsibility for one’s actions, changing criminal attitudes
Increase in confidence, empathy, patience, selfawareness
Ability to reduce violent behaviour remains unknown
|(Irving, Taylor, & Blanchette, 2002)|
|Spirit of a Warrior Program, Canada||Tertiary||
Targets incarcerated Indigenous women who have used violence
Aims to help women understand their use of violence and the impact of intergenerational violence on their behaviour; also focuses on improving family relations, communication, and coping skills
|Initial results indicate positive changes in emotional awareness and anger management; viewed favourably by participants and staff||Correctional Service Canada, 2008)|
Prevention programs with applications for multiple life stages
Table 16 summarizes 11 research-based programs. Primary programs include the Incredible Years Program and Raising Healthy Children while Parent-Child Interaction Therapy and Brief Strategic Family Therapy are secondary programs. Tertiary programs include Trauma-focused Cognitive Behavioural Therapy, Game-based Cognitive Behavioural Therapy, Dialectical Behaviour Therapy, and Multisystematic therapy. The Strengthening Families Program and Triple P Parenting Program provide both primary and secondary interventions, while the Olweus Bullying Prevention Program has applications across all three levels of prevention. None of the interventions listed are specific to girls/women, and evaluations of some interventions, such as the Incredible Years Program, have been based on samples including more boys than girls (Menting, Orobio de Castro, & Matthys, 2013). Nevertheless, these are all well-established approaches for preventing or addressing victimization or use of aggression, with applications spanning from infancy/preschool to adolescence and young adulthood. We highlight the Raising Healthy Children intervention below.
Raising Healthy Children
Raising Healthy Children (RHC) is a multi-faceted, school-based prevention program that uses a social developmental approach to promote positive development. The program includes teacher, parent, and student components and targets both risk and protective factors across multiple levels (Table 17). RHC has applications for grades one through twelve. Though not specifically intended to prevent revictimization or future use of violence among those who have experienced child maltreatment, RHC effectively reduces many risk factors associated with each (e.g. substance use, family conflict).
Table 16. Research-based revictimization/future use of aggression programs: Applications across
|Program name,Country of implementation||Level of prevention||Purpose/description||Significant outcomes||Selected references|
|Incredible Years Program, United States||Primary||
Psycho-educational group program design to develop selfesteem of parents and skills for managing children’s behaviour in socioeconomically disadvantaged families
Five programs: Baby (0-12 months), Toddler (1-3), Preschool (3-6), School Age (6-12), Advance (4-12)
Improvement in parent-child interactions, positive family relationships, and children’s problem-solving, emotional regulation, school readiness
Reduction in children’s externalizing and internalizing problems
|(Carnochan et al., 2013; Menting, Orobio de Castro, & Matthys, 2013; Perlson & Greene, 2015)|
|Raising Healthy Children, United States||Primary||
Multi-faceted, longitudinal schoolbased prevention program for teachers, parents, and students
Aims to promote positive development, reduce academic risks, and reduce early aggressive behaviours among elementary to high school students
Teacher workshops: instructional improvement and classroom management
Parenting workshop: how to help children succeed in school
Student intervention: school summer camp and in-home services
|Reduction in antisocial behaviour; alcohol and marijuana use||(Brown, Catalano, Fleming, Haggerty, & Abbott, 2005; Catalano Mazza, Harachi, Abbott, Haggerty, & Fleming., 2002)|
|Strengthening Families Program, United States||Primary/Secondary||
Group-based parenting program developed to strengthen parenting for both high-risk and general population families
Programs available for children 3-5, 6-11, 12-16, and 7-17
Improvement in parenting skills and family relationships
Reduction in child maltreatment
Reduction in children’s problem behaviours, delinquency, and substance abuse
Improvement in children’s social competence and school performance
|(Kumpfer, Magalhaes, & Greene, 2015; Kumpfer, Whiteside, Greene, & Allen, 2010)|
|Triple P Parenting Program, Australia, Austria, Belgium, Canada, Curacao, France, Germany, Hong Kong, Iran, Ireland, Japan, New Zealand, Netherlands, Romania, Scotland, Singapore, Sweden, Switzerland, United Kingdom, United States, Wales||Primary/Secondary||
Parenting and family support system designed to prevent social, emotional, behavioural, and developmental problems in children by enhancing knowledge, skills, and confidence of parents
Five intervention levels matched to intensity of family needs
Families with children 0-12 with extensions available for families with teens 13-16
Reduction in child behavioural and emotional problems
Improvement in parents’ well-being and parenting skills
Decreased rates of child abuse
Decreased hospitalizations from child abuse injuries
|(Graaf, Speetjens, Smit, & Wolff, 2008; Prinz, Sanders, Shapiro, Whitaker, & Lutzker, 2009; Sanders, 2012; Sanders, Kirby, Tellegen, & Day, 2014)|
|Olweus Bullying Prevention Program, Norway and United States||
Intervention targets students ages 5-15
All students participate in most aspects of program; students identified as bullies or bullying victims receive additional interventions
Includes long-term school-level, classroom-level, individual-level, and community-level components
Reduction in bullying and bullying victimization
Reduction in general antisocial behaviour (e.g. vandalism, fighting, truancy)
Improvement in classroom social climate
|(Black, 2003; Limber, 2004; D Olweus, 1991; Dan Olweus & Limber, 2010)|
|Parent Child Interaction Therapy, Australia, Cyprus, Germany, Japan, Hong Kong, Indonesia, South Korea, New Zealand, Netherlands, Norway, Singapore, Switzerland, Taiwan, United States||Secondary||
Parent training program to develop parenting skills and improve parent-child interactions
For families with children 2-6 years old exhibiting emotional and behavioural problems
Reduction in children’s behaviour and conduct problems, recurrence of maltreatment, mother’s stress, coercive discipline techniques
Improvement in parenting outcomes
|(Chaffin et al., 2004; Nixon, Sweeney, Erickson, & Touyz, 2004; Thomas, Abel, Webb, Avdagic, & Zimmer-Gembeck, 2017; Thomas & Zimmer-Gembeck, 2007)|
|Brief Strategic Family Therapy, Australia, Chile, Norway United States||Secondary||Targets children and adolescents ages 8-17 displaying behavioural problems or at risk of developing them 100-minute sessions once a week for 12 weeks||Reduction in conduct problems, physical aggression, delinquency, substance use||(Nickel et al., 2006; Robbins et al., 2011; Santisteban, Coatsworth, Perez-Vidal, Mitrani, Jean-Gilles, & Szapocznik, 1997; Santisteban, Coatsworth, & Perez-Vidal, 2003)|
|Trauma-focused Cognitive Behavioural Therapy, United States||Tertiary||
Individual counselling for children and adolescents 3-17 who were abused or exposed to IPV and their parents
Treatment is comprised of psychoeducation, parenting sessions, skill development, and processing trauma
|Reduction in emotional and behavioural problems in children, including PTSD and anxiety||(Cohen & Mannarino, 2008; Cohen et al., 2011)|
|Game-based Cognitive Behaviour Therapy, United States||Tertiary||
Group-based approach for children aged 5-13 years and their parents; treatment delivered in “fun” manner using developmentally appropriate games
Topics include communication skills, emotional expression skills, self-protection skills, coping skills, and psychoeducation about child abuse, exposure, and processing of sexual abuse
|Reduction in anxiety, depression, withdrawal, oppositional behaviour, disobedience, conduct disordered behaviour, sexually inappropriate behaviours Improvement in children’s knowledge of abuse and personal safety skills||(Misurell & Springer, 2013; Springer & Misurell, 2010)|
|Dialectical Behaviour Therapy, United States||Tertiary||
Offered as group or individual approach
Focuses on developing emotion regulation, distress tolerance, mindfulness, interpersonal skills
|Reduces self-harm and suicidal behaviour in young people||(Fleischhaker Böhme, Sixt, Brück, Schneider, & Schulz, 2011; Goldstein TR, Axelson DA, Birmaher B, & Brent DA., 2007; Linehan, 2014)|
|Multisystemic therapy, Australia, Canada, Chile, Denmark, Germany, Iceland, Netherlands, New Zealand, Norway, Sweden, United Kingdom, United States||Tertiary||
Home-based and clinical therapy for children and adolescents 10-17 of families being followed by child protective services for child abuse/neglect
Treatment aims to mitigate effects of abuse/neglect and keep children at home with their families
Reduction in child mental health symptoms and problematic behaviours, parent emotional distress, parenting behaviours associated with maltreatment, and child out-of-home placements
Decrease in neglectful parenting, minor/severe child abuse, psychological aggression
|(Henggeler & Schaeffer, 2016; MST Services, 2018; Swenson, Schaeffer, Henggeler, & Mayhew, 2010)|
Table 17. Risk and protective factors addressed by Raising Healthy Children
Skills for social interaction
Early initiation of antisocial behaviour
Favourable attitudes towards drug use
|Peer||Interaction with prosocial peers||Interaction with antisocial peers|
Attachment to parents
Opportunities for prosocial involvement with parents
Parent social support
Parental involvement in education
Rewards for prosocial involvement with parents
Parental attitudes favourable to antisocial behaviour
Parental attitudes favourable to drug use
Poor family management
Opportunities for prosocial involvement in education
Rewards for prosocial involvement in school
Low school commitment and attachment
Poor academic performance
Opportunities for prosocial involvement
Rewards for prosocial involvement
|Laws and norms favourable to drug use/crime|
|Blueprints for Healthy Youth Development, 2017|
Developing protective resources and resilience
Beyond focusing on reducing risk factors, building strengths and promoting resilience may be especially important to preventing revictimization and future use of aggression by girls/women who have experienced childhood maltreatment (Chiodo, Crooks, Wolfe, McIsaac, Hughes, & Jaffe, 2012; Macy, 2008). Although many of the prevention programs listed in the preceding section include components to develop protective resources, little research has actually examined what factors may have been involved to prevent revictimization among survivors of early abuse or violence who never experienced subsequent victimization or use of aggression. Initial research suggests that higher levels of protective factors in adolescence among youth with high levels of cumulative risk exposure may be particiularly important for reducing later odds of violence (Kim, Gilman, Hill, & Hawkins, 2016). Self-efficacy, sense of mastery, proactive coping, and situational assertiveness may play a role in breaking the links between early and later victimization (Breitenbecher, 2001; Macy, 2007). Empowering women, improving self-esteem, and teaching anger management strategies may also be helpful in preventing their use of aggression (Bair-Merritt et al., 2010). Feminist therapy and empowerment strategies may also assist girls/women in recognizing the gendered context of the violence they experience and how this may put them at risk for future victimization or use of aggression (Kearns & Calhoun, 2010).
Macro-level approaches to prevention
Violence against women and girls is ultimately a systemic issue, rooted in gender inequality, which must be eradicated in order to prevent victimization, revictimization, and use of aggression (World Health Organization, 2009). Achieving gender equality is a key Sustainable Development Goal and involves removing all legal, social, and economic barriers to women’s and girls’ empowerment (UNDP, 2015). This requires policy-changes and programs to: eliminate childhood poverty, increase access to educational and economic opportunities, recognize and reduce unpaid work, achieve food security, increase access to clean water and sanitation, and make all rural and urban areas safe, inclusive, and sustainable (UNDP, 2015). Challenging gender norms and attitudes and raising awareness of gender-based violence is also important and may be achieved through media interventions and public awareness campaigns (World Health Organization, 2009) such as the White Ribbon Campaign.
At the community level, it is also important to note that neighbourhood risk factors are among the most salient and consistent predictors of violence (Herrenkohl, Lee, & Hawkins, 2012). Community interventions must therefore focus on reducing poverty, increasing safety and
neighborhood cohesion, and economically empowering women in addition to addressing gender norms and attitudes (Popkin, Acs, & Smith, 2009; World Health Organization, 2009). It is also essential to engage men and boys as partners in ending violence against women and girls (World Health Organization, 2009). One promising approach may be fostering healthy masculinities in a community-based setting. There is currently an ongoing cluster-randomized controlled trial to test this type of intervention among adolescent males from disadvantaged communities (Miller, 2018).
This section has summarized research-based and promising strategies which may be used to prevent future victimization or use of aggression among women and girls who have experienced neglect, abuse, or violence earlier in life. There are a wide range of primary, secondary, and tertiary programs available for specific and multiple life stages, although the adult-specific programs reviewed were tertiary in nature. Programs exist at the individual, family, and school level and there is a need for further development and evaluation of prevention strategies that target community and societal-level factors. Not all programs for preventing victimization or use of aggression are specifically intended for girls and women with victimization histories, but rather, are intended to prevent initial victimization or use of aggression in general. However, these programs may still be useful in breaking the links between childhood maltreatment/early life victimization and later experiences of violence given overlapping risk factors. Most programs addressing revictimization specifically are targeted toward adolescence and young adulthood, a key time for prevention. These programs primarily focus on preventing sexual assault. More work is needed to incorporate other forms of violence along the continuum.
CONSIDERATIONS AND FUTURE DIRECTIONS
Previous victimization increases the risk of revictimization and the potential of using aggression for women and girls. Though not inevitable, this strong association has important implications for initiatives aiming to prevent or reduce victimization and use of aggression, their reoccurrence, and their negative health impacts. Due to the complexity of these pathways over the life course, a public health approach emphasizing interdisciplinary partnerships and multi-level prevention is key. This type of approach can ensure services for women and girls address their victimization histories as well as risk factors that occur not only at the individual level, but also, at a wider systemic level. Coordination between all stakeholders and sectors directly and indirectly involved in providing services to survivors of violence and those who use aggression as a result is also essential for building resilience and protective capacities.
The prevention strategies reviewed in this paper include research-based and promising approaches to preventing victimization and use of aggression among women and girls. However, not all programs address revictimization specifically. For example, there are some programs intended to prevent initial victimization or reduce its consequences, but it is unclear whether these prevention and intervention strategies can effectively disrupt the pathway toward additional victimization. Further, child maltreatment prevention programs should always consider later revictimization as a possibility, and where possible, work to reduce this risk (Leff, Waasdorp, & Crick, 2010). In addition, revictimization should be considered a risk of child maltreatment regardless of whether the child develops other associated risk factors, such as post-traumatic stress symptoms or behavioural difficulties (Hanson, 2016). Although many of the prevention programs reviewed include components to develop protective resources, little research has actually examined what factors may have been involved to prevent revictimization among survivors of early abuse or violence who never experienced subsequent victimization or use of aggression. Initial research suggests that higher levels of protective factors in adolescence among youth with high levels of cumulative risk exposure may be particiularly important for reducing later odds of violence (Kim, Gilman, Hill, & Hawkins, 2016).
Another limitation of victimization and aggression prevention programs is that not all are gender specific. It will therefore be important for future work to focus on a girl and woman-centered approach to prevention, including systematic evaluation of program effectiveness with girls/woman-identified samples. Existing prevention efforts can better reduce risk and build resilience if factors unique to girls and women are identified and addressed (Massetti et al., 2011). This is especially needed for aggression prevention and intervention programs, which are often based on boys/men. For example, one program identified in our initial search, the Good Behaviour Game (Kellam, Brown, & Poduska, 2008), found a significant impact of the intervention for boys only. The authors hypothesized that the programs may not have adequately addressed gender-specific early developmental processes that impact later aggression.
For adult women who have used aggression, in particular, there is a need to assess victimization history, no matter how distal it may seem. Currently, there are a limited number of prevention programs for adult women using aggression, and these largely take place in a prison context. Not all women who use aggression will be incarcerated and it will be important to reach these women through other avenues. Similarly, for children and adolescents, school-based interventions may not always be optimal as students at risk of revictimization or using aggression may not always be accessible in this way or may not engage in school-based activities (Whitaker et al., 2006). Other potential venues to reach women and girls might include community, cultural and faith-based organizations. As prevention efforts strive to reach women and girls through multiple channels, it will also be important to address the complexities of revictimization and use of aggression for diverse groups who are typically underresearched and under-served (Leff, Waasdorp, & Crick, 2010). Programming must not only take into account important developmental (i.e. life stage) and genderrelated considerations, but also, contextual considerations such as race/ethnicity, culture, socioeconomic status, sexual orientation, immigration or refugee status, living with a disability, and housing status. Just as it is important to take into account how women’s and girl’s experiences of victimization and aggression are directly related to their status within a gendered society, it is also important to recognize that these experiences are simultaneously complicated by racism, homophobia, classism, ableism, and other systems of oppression.
Despite the importance of intersectionality to understanding violence, only five of the programs reviewed in this paper took into account additional categories beyond gender. One school-age program (Friend to Friend) and one adolescent/young adulthood program (Sisters of Nia) targeted African American females. Another school-age program (Second Step) was assessed for children with disabilities. One adult program (Healing Our Women) targeted African American and Latina women and one adult program (Spirit of a Warrior) targeted Indigenous women. The success of these programs demonstrates the value of addressing diverse experiences within violence prevention work. This may be especially needed in programs for infancy/pre-school and multiple life stages as intersectionality considerations were noticeably limited in this area. Programs also need to be developed for women who are older, as this population was notably overlooked. Finally, programs were primarily urban-based, highlighting the need for development and evaluation of programs for women and girls who live in rural and remote areas. Longitudinal research encorporating an intersectionality-informed qualitative design would help identify differences in trajectories that extend our understanding beyond individuals and individual behaviour to include the influence of factors such as colonization, racialization, socioeconomics, and discrimination. Further, this approach would help identify the salient signposts at different stages of development for different groups of girls/women along pathways of safety and nonviolence, and in turn, better inform prevention programs.
Ultimately, a holistic and intersectional approach is needed at all levels of prevention (primary, secondary, tertiary) as well as across all ecological levels (individual, family, school, community, society) and life stages (from infancy to adulthood and old age). Continued longitudinal research, integration into public policy and community structures, and program evaluation within diverse contexts is key to reducing revictimization and use of aggression among women and girls.
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