Praktische suggesties tegen geweld op scholen

http://www.thecommunityguide.org

www.thecommunityguide.org

August 2007 Am J Prev Med 2007;33(2S) S111

A Major Step Forward in Violence Prevention

Deborah Prothrow-Stith, MD

Robert Hahn, his coauthors, and the Task Force

on Community Preventive Services (an independent

group staffed by the Centers for Disease

Control and Prevention) have made a significant

contribution to violence prevention programs with the

publication of their article, “Effectiveness of Universal

School-Based Programs to Prevent Violent and Aggressive

Behavior: A Systemic Review.”1 They reviewed

published evaluations of violence prevention programs

that were implemented in schools for students regardless

of their level of risk for violence, known as universal

programs. The included programs have published evaluations

that assessed the impact on violent outcomes or

proxies for violent outcomes. In the meta-analysis of

more than 50 studies, the authors conclude that universal

programs, which do not single out the troubled

or “bad” students, on average demonstrate a 15%

reduction in violent behavior regardless of whether the

school is elementary, middle, or high school, or the

socioeconomic status of the students and neighborhood.

These findings are consistent with another metaanalysis

that investigates the effects of school-based

intervention programs on mitigating aggressive behavior.2 This is great news! The Early Years

Over the nearly 30 years that I have advocated addressing

violence as a public health concern, school-based

violence prevention programs have been, from the

beginning, a part of the overall set of public health

prevention strategies we proposed. Following my medical

residency, while working on a project funded by the

Robert Wood Johnson Foundation, I presented the

findings from my first school-based health education

for violence prevention at Surgeon General Koop’s

1985 Conference addressing violence as a public health

problem.3 Needless to say, the first question I was asked

about this health education strategy, which was the

precursor to the Violence Prevention Curriculum for

Adolescents,4 was, “Does this work?” My response was

based on a medical school project, which involved

providing education on anger and homicide prevention

in a Boston 10th grade health class and using an

instrument (untested for validity or reliability) to conduct

pre- and post-tests on knowledge and attitudes

without a comparison group. I answered that knowledge

and attitudes improved significantly compared to

students’ baseline and that no harm seemed to come

from discussing violence and fighting in the classroom.

Anecdotally, the health education teacher, in whose

class I taught during my medical school project, told

me that the students attended class more often and

were more engaged when we were discussing violence

prevention. The teacher’s inspiring comments have

sustained my dedication to using a classroom/schoolbased

strategy over the years, particularly before evaluation

data were published 12 years later.5

My experience is consistent with what I have heard

from other school-based violence prevention practitioners:

We often rely on the anecdotal comments to

sustain our energy. The enthusiastic teacher, the student

who shares his experience using the skills taught

to stay out of a fight, or other shared successes, have

helped practitioners stay committed to the work and

dedicated to continually improving their programs,

even when there are no resources for a proper evaluation

or when an early evaluation shows “no effect.”

Early Demands for Evidence

The demands for rigorous evaluations and evidencebased

outcomes have been present and have preoccupied

school-based violence prevention practitioners

from the beginning. Proving that school-based violence

prevention programs (designed to help children “unlearn”

violence using Bandura’s social learning theory

model6 and other pedagogical and behavior modification

strategies) actually work to prevent violence has

been an ever-present challenge. Thus, time spent developing

and implementing curricula and school-based

violence prevention programs has been coupled with

efforts to partner with experts in program evaluation to

conduct as rigorous an evaluation as possible. Often, an

evaluation was too expensive to actually conduct, particularly

when it was hard to get funding for full

program implementation. In the early days of schoolbased

violence prevention programs, even when an

evaluation was able to be conducted, there were significant

limitations that were difficult for any one program

to address: the inevitable quasi-experimental design;

measurements of knowledge and attitude, and not

From the Harvard School of Public Health, Roxbury, Massachusetts

Address correspondence and reprint requests to: Deborah Prothrow-

Stith, MD, Professor of Public Health Practice and Associate

Dean for Faculty Development, Harvard School of Public Health, 841

Parker Street, Ground Floor Office, Roxbury MA 02120. E-mail:

dprothro@hsph.harvard.edu.

Am J Prev Med 2007;33(2S) 0749-3797/07/$–see front matter S109

behavior; instruments that had not been validated; and

the list continues. The evidence of impact that was

demanded during these early days was, in fact, slow in

coming. Sustaining programmatic efforts during this

time required tremendous passion and dedication.

Along the way, there were demoralizing moments

like the publication of a Health Affairs article that

challenged the very concept of teaching violence prevention.

7 There were encouraging moments as well.

Some programs partnered with evaluators who were

able to creatively design and publish evaluation data

showing a positive impact.8–11 Pushing forward, many

school-based violence prevention practitioners continued

to develop cutting-edge programs and curricula

undaunted by the rather constant call for evaluation

data and buoyed by Centers for Disease Control and

Prevention’s efforts and the attention of the philanthropic

community. Two foundation executives (David

Nee of the Ittleson Foundation and Luba Lynch of the

A.L. Mailman Family Foundation) brought colleagues

from other foundations together to fund the National

Funders Collaborative on Violence Prevention12 to stay

abreast of the state-of-the-art work in this new arena and

fund the development and evaluation of school-based

programs.

The Evidence Is In

The reasonable and important question, “Does schoolbased

violence prevention make a difference?” has taken

many years to answer in a convincing and publishable

manner. The Hahn et al.1 article is a landmark in summarizing

the data and offering conclusions that take us to

the next steps to full implementation. Over the years, the

evaluation methodology for school-based programs has

improved. Sustaining the work long enough to get the

kind of substantial evidence that is contained in the review

by Dr. Hahn and colleagues has been a labor of passion

and dedication. Without the persistence of many practitioners

and evaluators to offset the skepticism and sometimes

daunting requests for evidence, this article would

not have been possible. By continuing to work in schools

offering universal prevention programs, practitioners encouraged

by the responses of students and teachers have

helped achieve the milestone reflected in the article by

Hahn et al. Attention can be turned to expanding our

reach to all schools, improving the programs so that

everyone receives maximum benefit and in making

school-based violence prevention a permanent part of the

curriculum.

The growth of the efforts to use universal programming

in schools is remarkable. Prentice Hall was the first high

school health textbook to include a chapter on violence;

now all of the major texts have such information. Most

schools report providing some universal anger management,

conflict resolution or social skill-building program.

13 We must take our work to the next level: making

violence prevention instruction a requirement for all

schools, fully integrating school-, home- and communitybased

activities, constantly improving the programming,

and encouraging youth leadership for violence prevention.

It appears that many of the students in classrooms

across the country are exposed to violence.14 Newer

efforts must help students handle hurtful and traumatic

experiences in healthy ways.

A Shift in Public Opinion Is Needed

Despite the years of effort, more than 50 published

evaluation articles in the literature, and now this landmark

article from Hahn and colleagues, we must continue

to address a current public opinion conundrum. When

the citizenry calls for violence prevention, joined by their

elected officials, the demand is for more policing. Not

only is the efficacy of school-based programs still much

debated, but, such efforts are considered “long-term”

strategies that do not help in a crisis. We must take the

Hahn et al. article, along with all the other evidence, to

those who shape public opinion. School-based universal

violence prevention programs should be required in all

schools, funded through mainstream mechanisms (i.e., a

part of the approved school budget), and the public

should demand more school-based prevention when crises

arise. Ironically, law enforcement, incarceration, and

school-based punishments are not held to the same

evaluation standard as universal school-based programs.

What is the evidence that suspending a student helps to

change his or her behavior? What are the alternatives? Are

they more or less effective? What does incarcerating a

juvenile offender for 5 years do? Does it improve his or

her behavior? The challenges to our current practices

must continue. Just as the dedicated school-based violence

prevention practitioners persisted with efforts to

create and implement programs, we must continue to

take the steps to have punitive strategies evaluated.

The public’s demand for solutions to the problem of

violence in America often generates questions for police

chiefs and not commissioners of public health. Schoolbased

violence prevention practitioners from across the

country are now able to provide evidence for implementing

the anger-management, conflict-resolution, peacebuilding

work in elementary, middle, and high schools.

UNITY: Urban Networks to Increase Thriving Youth

Through Violence Prevention,15 which is funded by CDC,

provides violence prevention tools and technical assistance

to cities. UNITY is now on solid ground to recommend

universal school-based programming as a strategy

to reduce violence in urban settings.

This review provides a much-needed boost of evidence

for those working to generate political will for

violence prevention. It successfully challenges skepticism

about the length of time it takes to observe an

impact and responds to pessimism regarding the efficacy

of such programs. Parents and school principals

S110 American Journal of Preventive Medicine, Volume 33, Number 2S www.ajpm-online.net

will be able to use this review to effectively advocate

violence prevention programming in their local

schools. Additionally, those who have been working to

include violence prevention in the public health

agenda will be able to more effectively demand universal

prevention for violence in the schools, now strongly

supported by evidence-based research.

Although violence prevention, antibullying, and anger

management programs are widely implemented,16

funding is often a concern. Now, we must begin to

advocate implementation of the existing programs as

part of the curriculum in all schools.

A Way Forward

Twenty-two years ago, in 1985 when Surgeon General

Koop hosted the first conference to address violence as a

public health problem, many who attended had great

expectations of the possibilities that would emerge if we

truly viewed violence as a preventable problem.17 We

imagined that we would no longer “stitch people up and

send them out” of emergency rooms without addressing

their risk for revenge or subsequent violence. We imagined

that we would teach conflict resolution with results

that would help end the youth violence problem. We

imagined that we would bring together all of those

addressing the different forms of violence prevention to

work together. We had high hopes and expectations. All

of the dreams have not been realized, but this article and

the accompanying community guidelines fulfill one of the

goals. We must now take seriously and make mandatory

the school-based instruction necessary to teach our children

to get along, and handle conflict and anger.

I authored and receive royalties on a curriculum that is one of

the 50 included in the meta-analysis reported in the article on

which I wrote this commentary.

References

1. Hahn RA, Fuqua-Whitley DS, Lowy J, et al. Effectiveness of universal

school-based programs to prevent violent and aggressive behavior: a

systematic review. Am J Prev Med 2007;33(suppl 2)confused smiley114 –S129.

2. Wilson SJ, Lipsey MJ. The effects of school based intervention programs on

aggressive behavior: a meta-analysis. Am J Prev Med 2007;33(suppl 2):

S130–S143.

3. Prothrow-Stith D. Prevention of interpersonal violence and homicide in

black youth. Report of the Surgeon General’s Workshop on Violence and

Public Health, Leesburg, VA, October 27–29, 1985. Washington, DC: U.S.

Government Printing Office. Public Health Reports No. HRS-D-MC 86-1.

35–43.

4. Prothrow-Stith D. Violence prevention curriculum for adolescents. Newton,

MA: Education Development Center, Inc., 1987.

5. DuRant RH. Comparison of two violence prevention curricula for middle

school adolescents. J Adolesc Health 1996;19:111–7.

6. Bandura A. Social foundations of thought and action: A cognitive theory.

Englewood Cliffs, NJ: Prentice Hall, 1986.

7. Webster D. Commentary: The unconvincing case for school-based

conflict resolution programs for adolescents. Health Affairs Winter

1993:126 –141.

8. Kelder SH, Orpinas P, McAlister A, Frankowski R, Parcel GS, Friday J. The

Students for Peace Project: a comprehensive violence-prevention program

for middle school students. Am J Prev Med 1996;12:22–30.

9. Grossman DC, Neckerman HJ, Koepsell TD, et al. Effectiveness of a

violence prevention curriculum among children in elementary school: a

randomized controlled trial. J Am Med Assoc 1997;277:1605–11.

10. Greenberg MT, Kusche C, Mihalic SF. Blueprints for violence prevention,

Book Ten: Promoting Alternative Thinking Strategies (PATHS). Boulder,

CO: Center for the Study and Prevention of Violence, 1998.

11. DuRant RH. Comparison of two violence prevention curricula for middle

school adolescents. J Adolesc Health 1996;19:111–7.

12. The Institute for Community Peace was formally known as the National

Funders Collaborative for Violence Prevention, created in 1994. http://

www.peacebeyondviolence.org/icp/historyandaccomplishments.htm#history.

13. Centers for Disease Control and Prevention. School Health Policy and Programs

Study (SHPPS 2000). Available at

factsheets/pdf/violence.pdf.

14. Groves B. Children who see too much: lessons from the child witness to

violence project. Boston, MA: Beacon Press; 2002.

15. The Prevention Institute website:

UNITY.html.

16. Centers for Disease Control and Prevention. School Health Policy and

Programs Study (SHPPS 2000). Available at

healthYouth/shpps/factsheets/pdf/violence.pdf.2000.

17. Surgeon General’s Workshop on Violence and Public Health Report,

Leesburg, VA, October 27–29, 1985. Washington, DC: U.S. Government

Printing Office. Public Health Reports No. HRS-D-MC 86-1.

http://www.thecommunityguide.org

www.thecommunityguide.org

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