Part II
Early Childhood and Childhood

Abuse During Early Childhood

535

Definitions and Scope

Abuse During Early Childhood
Preston A. Britner1, Samantha A. Goodrich1 and
Sharon G. Portwood2
1
Department of Human Development & Family
Studies, University of Connecticut, Storrs,
CT, USA
2
Department of Public Health Sciences,
The University of North Carolina at Charlotte,
Charlotte, NC, USA

Introduction
Previously, child abuse prevention research was
fraught with problems of defining maltreatment
and its subcategories as well as a lack of strong
research studies documenting the effectiveness of
prevention efforts. Many strides have been made
in both of these areas, and, in the past decade, the
field of child abuse prevention has focused on the
risk factors associated with the occurrence
of child maltreatment. Research suggests
that there are a range of contextual and parental
characteristics that put families at an increased
risk for child maltreatment and involvement in
the child welfare system (e.g., Begle, Dumas, &
Hanson, 2010; Putnam-Hornstein, 2011).
This line of research has led to prevention
efforts that have been concerned with creating
a strong evidence base for programs that not
only reduce the identified risk factors and
cumulative stress experienced by parents but
also promote healthy parenting behaviors. This
strategy reflects a more comprehensive prevention approach, in which healthy family functioning is not viewed simply as the absence of
problems or difficulties but rather an environment
that allows children to thrive even as stressors are
faced. Addressing parenting and family factors
before their child is born or soon after birth
enables parents to improve their interaction styles
with their children and the trajectory of the
family in the long term. A primary prevention
approach is warranted because child abuse
in pervasive, problematic, and preventable
(American Psychological Association, 2009).

The US federal definition of child abuse and
neglect, according to the Child Abuse Prevention
and Treatment Act (1974), most recently
reauthorized in 2010, is “any recent act or failure
to act on the part of a parent or caretaker which
results in death, serious physical or emotional
harm, sexual abuse or exploitation; or an act or
failure to act, which presents an imminent risk of
serious harm.” However, each state decides
which situations and contexts constitute specific
types of abuse and neglect, creating some ambiguity around where the lines of abuse are drawn.
In recent years, some states, such as
California and Minnesota, have begun to
adopt an alternative response or differential
response system as a way to address some of the
ambiguity around child maltreatment definitions
(Conley & Berrick, 2010; U.S. Department of
Health and Human Services, Children, Youth &
Children’s Bureau, 2010). In this system, families
at low-to-moderate risk for maltreatment and
without substantiated maltreatment currently are
screened out of the child protective services
(CPS) system. These families receive community- and home-based services in order to redirect
families from the system and hopefully decrease
the likelihood of maltreatment occurring in the
future (Conley & Berrick, 2010). In essence,
a differential response system takes a preventive
approach, recognizing that many families are
stigmatized by the label of being involved in
CPS, and yet many families could use services
before that contact becomes necessary.
In terms of scope, CPS received just over three
million reports of child maltreatment in the USA
in 2009, showing a stable rate of reporting since
1996, and responded to over two million of the
reported cases (U.S. DHHS, 2010). Over 700,000
of the reported cases (22.1 %) were substantiated,
or 9.3 per 1,000 children were victims of abuse in
the USA (U.S. DHHS). Furthermore, parents
were the perpetrators of the maltreatment in
80 % of cases (U.S. DHHS). Whereas physical
abuse rates have fallen, there has been an increase
in neglect cases reported over the years, with
more than 75 % of cases investigated including

T.P. Gullotta, M. Bloom (eds.), Encyclopedia of Primary Prevention and Health Promotion,
DOI 10.1007/978-1-4614-5999-6, # Springer Science+Business Media New York 2014

536

neglect; in contrast, 15 % percent included physical abuse and 10 % included sexual abuse
(U.S. DHHS). Notably, these numbers only refer
to those cases that have been reported to the child
welfare system. Self-report surveys indicate that
the rates of child maltreatment reported by social
service agencies underestimate the extent of the
problem (Slep & Heyman, 2008).
Based on the available data, 33.4 % of victims
are children aged zero to three (U.S. DHHS,
2010). The costs of physical abuse and neglect
are particularly great for infants and young
children because they are at greater risk of
suffering brain dysfunction or death as a
result of maltreatment. Boys were victims of
maltreatment in 2009 almost as often as girls
(48.2 % vs. 51.1 %, respectively), and about
11 % of victims were children with disabilities
(U.S. DHHS).
Looking internationally, it is difficult to
compare rates of child maltreatment in the USA
with rates in other countries because definitions
vary and data are compiled and reported differently. Nonetheless, according to a report from the
Canadian Centre for Justice Statistics, in 2008,
451 of every 100,000 children under the age of
5 were the victims of violent crimes as reported
by a sample of police departments (Ogrodnik,
2010). Assaults on children under the age of
3 were reported the least, but these assaults are
reported the least as it is typically family members who are the perpetrators. Similar to the USA,
a majority (75–80 %) of assaults reported were
committed by individuals known by the child,
typically a family member (Ogrodnik).

Theories
Multiple theories exist to explain child maltreatment, many of which implicitly or explicitly
underlie current prevention efforts. The broadest
theories link child maltreatment to cultural and
societal conditions (Miller-Perrin & Perrin,
1999). Some theorists propose that there is a spillover effect from acceptable forms of violence
(e.g., violence on television) to unacceptable
forms of violence (e.g., child maltreatment).

Abuse During Early Childhood

Other research suggests those who turn to abuse
or neglect tend to be more socially isolated
(Coohey, 1996; Polansky, Gaudin, Ammons, &
Davis, 1985).
Theories involving social inequality and injustice view child maltreatment within a social and
ecological context, focusing on the resources and
supports available to families (Garbarino &
Crouter, 1978). According to strain theory,
deviant behavior is more likely when people
are denied access to resources (Miller-Perrin &
Perrin, 1999). These theoretical perspectives cite
the relationship between child maltreatment and
societal and cultural conditions, such as poverty,
social isolation, racism, sexism, and tolerance
of violence (Daro, 1988). According to these
theories, maltreatment would be decreased
if resources (e.g., money, information) and supports (e.g., social support) for parents were
increased and systemic changes were made
(Daro). Examining the differences between
low-income communities that have higher or
lower rates of maltreatment, Garbarino and
Kostelny (1992) found that, in low-socioeconomic
status (SES), high-maltreatment neighborhoods,
there was a greater sense of hopelessness and community members showed less positive neighboring. This finding suggests that even within the
context of poverty and inequality, there may be a
sense of community that is important to the prevention of violence.
Theories of child maltreatment also focus on
the family and the individual. Learning and
behavioral theories link child maltreatment to a
caregiver’s lack of knowledge of child development or lack of child care skills (Daro, 1988).
These theories suggest maltreatment could be
prevented if caregivers had the knowledge and
skills necessary to care for children appropriately
(Daro). In addition, cognitive–behavioral theories have pointed to a number of key cognitive
processes that affect parenting behavior, which
appear to be dysfunctional in parents who
are perpetrators of maltreatment (Bugental &
Johnson, 2000; Corcoran, 2000). Parents who
abuse or neglect their children tend to attribute
greater negative intention to their children’s
actions and view themselves as having less

Abuse During Early Childhood

control over their child’s behavior than parents
who have not engaged in maltreatment (e.g.,
Bradley & Peters, 1991; Bugental, Mantyla, &
Lewis, 1989). In addition, maltreating parents
tend to shower poorer problem-solving skills and
less empathy towards their children (Corcoran,
2000; Feshbach, 1989).
The transactional model of child maltreatment
views maltreatment as the result of interactions
over time between the parent and the child within
the family context; these interactions are the
potential targets for prevention efforts (Wolfe,
1993). Research grounded in attachment theory
supports the assertion that interactions between
caregivers and children that involve maltreatment lead to disorganized patterns of attachment
and an array of negative outcomes in family
functioning (George, 1996; Solomon & George,
2011). According to this social learning theory,
children who experience or witness violence are
more likely to become violent themselves
(Miller-Perrin & Perrin, 1999).
Currently, maltreatment is viewed from an
ecological perspective and is seen as a multifaceted issue that results from the combination of
risk factors (Black, Heyman, & Slep, 2001;
Brown, Cohen, Johnson, & Salzinger, 1998).
These factors include more distal factors, such
as past history of abuse and the parents’ history
of interactions with his or her caregivers, as well
as more proximal factors, such as parents’ level
of arousal and attributions. In addition, there are
environmental-level factors, such as poverty and
the parents’ social network, as well as individuallevel factors, such as parent–child interactions,
that influence the likelihood of the occurrence of
maltreatment. Begle et al. (2010) found that a
cumulative risk model of abuse significantly
predicted child abuse potential, suggesting that
the risk for abuse increases as additional risk
factors are present. Any one individual factor
may not directly lead to abuse or neglect. Rather
it is the combined effect of risk factors that leads
to the occurrence of child maltreatment behaviors.
Individual- and family-oriented theories suggest prevention strategies such as parenting education classes, home visiting programs, and
parent support groups to address a range of risk

537

factors that may be present within the family
environment and to simultaneously strengthen
protective factors that may buffer the effect of
risk factors (Daro, 1988). According to these
theories, changes within particular families or
individuals will prevent child maltreatment.

Current Research
In a prospective birth cohort study in California,
Putnam-Hornstein (2011) found that, even after
adjusting for other risk factors at birth, young
children with a prior child protective service
(CPS) allegation of maltreatment died at a rate
5.9 times greater than children without a prior
CPS report. These data speak to the seriousness
of maltreatment and the timeliness of prevention
efforts in the first years of children’s lives.
From a prevention perspective, research has
documented that providing preventive services
before maltreatment has occurred has not only
physical and mental health benefits for children,
as noted by Putnam-Hornstein (2011), but also
monetary benefits for society. Those who have
been maltreated in childhood have been shown to
have greater socioeconomic disadvantage later in
life (Wekerle, 2011). Furthermore, the cost of
child protective service involvement, including
court and lawyer fees and foster care, is much
more costly than the prevention programs that
could be offered prior to CPS involvement.
Although the need for child maltreatment
prevention and intervention programs is well recognized and documented, the evaluation of these
efforts has not shown clear indications of benefits
for parents by participating in these programs.
Initial evaluation studies typically did not include
a comparison group. However, situational factors,
such as barriers to participation and fidelity to the
program curriculum, that influence the efficacy of
these programs have begun to be identified and
controlled for in more recent research.
As evaluations became more refined and rigorous, programs that showed benefits began to
(1) address fidelity and logistic barriers consistently in their studies and (2) implement randomized control trials. Randomized control trials

538

(RCTs) examine the outcomes for families who
participated in the program compared to those
who did not receive services or, in some cases,
compared to those who received “service as
usual.” The outcomes tracked in the RCTs are
based on the parenting and environmental factors
targeted by the program, and these studies began
to show that well-implemented and theoretically
based programs could improve positive parenting
and reduce the likelihood of maltreatment.
Today, a strong evidence base is developing
showing the utility and efficacy of particular prevention efforts.
In some cases randomized control trials are not
possible because agencies and communities may
not be able to randomly assign families to intervention or control. Although RCTs are often
viewed as ideal, there is also a recognition that
these programs are operating within communities,
which often does not allow for the controlled
process of randomization. In these situations,
programs often carry out quasi-experimental studies or programs, using an already established community group that is not receiving services as
a comparison. As a result, researchers are still
able to garner some information about the added
benefits of participating in the prevention program
compared to parents who do not.
In addition, program evaluations have begun
to examine process factors as well as outcomes in
order to examine what enables or prevents parents from completing the program or engaging in
changes in their behaviors. These studies go
beyond outcome studies to offer possible suggestions as to why significant or nonsignificant
results may be found. They also provide programs with feedback and ideas about how to
engage parents who are often hard to reach. For
an overview of factors that affect engagement,
see McCurdy and Daro (2001).

Overview of Strategies
Given that the perpetrators of maltreatment and
in particular abuse are most often parents, the
prevention of child maltreatment (i.e., abuse and
neglect) in early childhood is fundamentally

Abuse During Early Childhood

about providing parents with the knowledge and
skills to manage their anger, frustration, fatigue,
and stress in ways that are safe for every member
of the household. Indeed, the goal for many
maltreatment prevention programs is to support
parents to be better equipped to deal with the
stressors of early parenthood, when the care
burden is greatest and time and energy are taxed
heavily. Families experiencing multiple stressors
and lacking effective coping or self-regulation
skills are at an increased risk for committing
neglect and abuse.

What Works
One of the most common approaches to child
abuse prevention involves providing support and
education to parents (American Psychological
Association, 2009; Daro & Dodge, 2009).
Although there is great variation in programs,
these parent education and support programs
have the common goal of seeking to affect the
parent–child relationship early in the child’s life,
before abuse can occur and before parents have
established themselves in their parenting role.
They also tend to be voluntary and targeted
towards families at a higher risk for child maltreatment (Conley & Berrick, 2010; Guterman, 1997).
As noted, programs vary greatly in scope,
intensity, duration, and format. There are two
general formats that effective programs typically
follow. First, there are home visiting programs,
which may begin before birth or once the baby is
born and last for a specified amount of time
(Gomby, Culross, & Behrman, 1999; Russell,
Britner, & Woolard, 2007). There are also more
short-term, group-based parent education classes,
many of which are manualized. These classes typically provide information about the effects of
parents on children’s development and help parents build the skills necessary to provide a healthy
environment for their children (Howard & BrooksGunn, 2009). Some programs provide only these
educational or training sessions, whereas others
are more comprehensive and include a number of
services in addition to the parent education component. There are currently a few promising and/or

Abuse During Early Childhood

effective programs in each type of model, and the
present discussion will focus on the evidencebased programs currently utilized.
The most widely known home visiting program that has been shown to be effective is the
Nurse–Family Partnership (see Olds, 2006). This
model, created by Olds and colleagues 30 years
ago, utilizes the expertise of nurses to work with
at-risk, first-time moms one-on-one. Nurses work
with mothers before birth and through the first
2 years of the child’s life. This program has been
shown to be effective in promoting many beneficial outcomes for mothers and children, including
a greater sense of control in mothers and more
stable relationships (e.g., Olds et al., 1999) and
higher educational achievement and lower
welfare utilization and criminal involvement for
the mothers at a 19-year follow-up (Eckenrode
et al., 2010). Additional randomized control trials
have looked at the ability of the model to reduce
child abuse and neglect and child injury and have
seen beneficial outcomes in reducing the statewide rate of maltreatment cases and the number
of children seen in health-care settings for injuries (Kitzman et al., 1997; Olds et al., 1997; Olds,
Henderson, Chamberlin, & Tatelbaum, 1986).
Another effective home-based prevention program is SafeCare (SC), which targets environmental as well as behavioral risk factors for
maltreatment in families with children under the
age of five who are at high risk for maltreatment
(Lutzker, Bigelow, Doctor, & Kessler, 1998). In
terms of the household environment, SafeCare
targets home safety and cleanliness, factors that
are often a concern for families involved in the
child welfare system (Silovsky et al., 2011).
Behaviorally, it uses a skills-based approach to
address the parenting skills that are most relevant
to the occurrence of maltreatment, such as inappropriate or harsh parenting and parent–child
bonding (Silovsky et al.). The program typically
lasts about 15–20 weeks and is implemented by
trained professionals (Lutzker et al., 1998). It can
be offered as a stand-alone home visiting program
or as a component of a larger program (Chaffin,
Hecht, Bard, Silovsky, & Beasley, 2012).
Silovsky et al. (2011) conducted a randomized
control trial of SC+, an augmented SafeCare

539

program that includes motivational interviewing
and training in the identification of risk factors for
home visitors, in a rural community with parents
at risk for child maltreatment and who had children under the age of five. Data was collected at
baseline, immediately following intervention
completion, and approximately 6-months later.
Significant differences were not found on selfreported parenting behaviors, which was likely
due to the limited sample size. However, those
who were randomized to SC+ were more likely to
complete the program, and the SC+ participants
had fewer child welfare reports post-intervention,
and a longer average amount of time passed
before child welfare reports were made
(103 days for SC+ vs. 200.5 days for service as
usual group).
Most recently, Chaffin and colleagues (2012)
conducted a scaled-up, statewide randomized
control trial of SafeCare across a 6-year period
including 2,175 maltreating families, comparing
home visiting programs that used SafeCare modules with families at high risk for maltreatment to
home visiting services as usual. Results demonstrated significant main effects in favor of
SafeCare, reducing child welfare reports among
the SafeCare population by about 26 %. Larger
effects were found among those families that fit
the typical inclusion criteria for SafeCare. These
studies suggest that SafeCare is an effective home
visiting model for families who are at highest risk
for child maltreatment and who are often the
hardest to reach through parenting services.
Other home visiting programs use trained paraprofessionals to work with families. Healthy Families America (HFA) is one example of this type of
program that has been used for 20 years and has
been demonstrated to be effective (Harding,
Galano, Martin, Huntington, & Schellenbach,
2007). Similar to the Nurse–Family Partnership
model, it provides services to expectant and new
parents and seeks to capitalize on the early years
of the child’s life to change parenting behavior
before it is strongly established. Sites vary in the
population targeted and the number of home
visits offered, but Hawaii’s Healthy Start
Program (HSP) and Healthy Families New York
(HFNY) are particular HFA programs that have

540

been subject to more rigorous evaluations.
A randomized control trial of HFNY conducted
by Rodriquez, Dumont, Mitchell-Herzfeld,
Walden, and Greene (2010) found that parents
who participated in HFNY showed more positive
parenting and less harsh parenting than those in
the control group. Duggan et al. (2004) also found
moderate effects on child neglect among families
enrolled in HSP. A review of HFA evaluations by
Harding and colleagues (2007) revealed that
five randomized control trials of HFA showed
reductions in psychological aggression or neglect;
three quasi-experimental studies also showed
reductions on child maltreatment.
Parent–Child Interaction Therapy (PCIT)
is a widely studied parent training program
that works with parents one-on-one but in a center-based setting rather than in the home. Based
on social learning theory, it works to change
parent–child interactions by working with parents as they interact with their child, coaching
parents to improve their behaviors to support
child development and outcomes (Chaffin et al.,
2004). PCIT is a performance-based rather than
a time-based program and continues until the
parent shows mastery of the skills and behavior
management strategies targeted in the intervention. Although used with a variety of parents,
a number of studies have evaluated the effectiveness of PCIT in preventing child maltreatment.
Chaffin and colleagues (2004) found that parents who participated in PCIT were less likely to
experience re-reports of child maltreatment compared to a control group who did not receive
PCIT. Interestingly, comparisons were also
made between those who received just PCIT
and those who received PCIT with additional
services (focusing on parental depression, substance use, and family violence), and results
showed that receiving additional services did
not improve the outcomes for parents. Thomas
and Zimmer-Gembeck (2011) recently reported
similar results where mothers who were at risk for
maltreatment or had a history of maltreatment
showed increased maternal sensitivity, improved
parent–child interactions, and decreased stress
after receiving PCIT when compared to the
waitlist mothers. Furthermore, PCIT completers

Abuse During Early Childhood

were less likely to be notified to child welfare
services than non-completers, suggesting an
added benefit to completing the program.
Triple P-Positive Parenting Program is an
example of a group-based parent education program that has shown to be effective in numerous
control trials. Triple P follows a public health
model offering services that range from universal
applicability (e.g., information in the media about
positive parenting) to more targeted parent training (Level 5 – Enhanced Triple P; Sanders,
Turner, & Markie-Dadds, 2002). More recently,
Sanders and colleagues (2004) have developed
Pathways Triple P, which was designed specifically to reduce child maltreatment. In a strong
randomized control trial, Prinz, Sanders, Shapiro,
Whitaker, and Lutzker (2009) randomized
18 counties in one state to receive Triple P or
not in order to examine population-level effects
on child maltreatment. The control counties were
comparable to treatment counties on county size,
rate of poverty, and child abuse rates. Large
effects were found on substantiated rates of
child maltreatment, child out-of-home placements, and emergency room and hospital visits
for child maltreatment-related injuries, with
those counties receiving Triple P faring significantly better on all three outcomes. Another randomized control trial of Triple P was conducted
in Australia by Sanders et al. (2004). Interestingly,
they compared a version of enhanced Triple P that
included attributional retraining and anger management to particularly target families at risk for
child maltreatment to typical group Triple P.
Although both conditions showed improvements
in lower levels of parent-reported dysfunctional
parenting, greater parental self-efficacy, and less
parental distress and relationship conflict, parents
that received the enhanced program showed
lower levels of negative parental attributions for
children’s disruptive behavior. These studies demonstrate the utility and efficacy of Triple P as
a child maltreatment prevention strategy.
Finally, the Incredible Years (IY) is a widely
used, group-based parent training program that
uses video vignettes of appropriate parenting
and discussions to help parents build on
their strengths and develop effective parenting

Abuse During Early Childhood

techniques (Webster-Stratton & Reid, 2010).
This program has been tested in numerous studies
and has shown to be effective. In particular,
research consistently shows improvements in
positive parenting and reductions in coercive parent–child interactions (e.g., Webster-Stratton,
1998). Recently, this program has been adapted
to be used with parents at risk for maltreatment
(Webster-Stratton & Reid, 2010). Linares,
Montalto, Li, and Oza (2006) used IY with biological and foster parent pairs, of children who
were mostly neglected, in a randomized control
trial. Biological (as well as foster) parents
showed significant gains in positive parenting
after the completion of the 12-week program,
and these findings remained at a 1-year followup. In families being monitored by CPS for child
neglect in Canada, Letarte, Normandeau, and
Allard (2010) found that those who received IY
showed improvements in parenting behavior
(e.g., decrease in harsh discipline and physical
punishment) and parent evaluations of the child’s
behavior
when
compared
to
waitlist
CPS-monitored parents. A third nonrandomized
study with court-mandated child welfare families
looked at the parenting stress levels after receiving IY, which showed significant decreases from
pre- to posttest (Webster-Stratton & Reid, 2010).
However, none of these studies looked at the
effect of IY on child welfare outcomes or on
rates of maltreatment cases, so conclusions cannot be drawn about whether improving parenting
practices leads to improved child welfare
outcomes.
The research discussed here shows the
advancements in child abuse prevention programs over the last two decades. Although
research shows the promise of these programs, it
is still critical that the programs are implemented
as intended. Programs that do not address the
barriers to participation and program fidelity
tend to show mostly nonsignificant results. Furthermore, programs that have not been studied
well are still being used in many cases. Although
these programs show positive effects on parenting
behaviors and competencies, clearer connections
to child welfare outcomes need to be made and
tracked over time.

541

What Is Promising
At the broadest level, child maltreatment takes
place in the context of a violent, individualistic
society that devalues children. Social problems
such as poverty, oppression, and inequality cause
a great deal of human suffering and are related to
child maltreatment. Moreover, parenting is a
role for which little preparation or support
is provided (Febbraro, 1994). The role of caregiver is devalued, unsupported, and unrecognized
(Febbraro).
Freisthler (2004) used spatial regression to
explore neighborhood-level characteristics that
affect the rates of child maltreatment. Not surprisingly, results show that higher rates of poverty and a higher density of bars, among other
factors, predict a higher level of maltreatment.
This study points to the idea that addressing
neighborhood- or community-level factors could
lead to a decrease in cases of child maltreatment by
affecting some of the risk factors associated with
the occurrence of maltreatment. Despite substantial evidence that community-level factors affect
child abuse and neglect, examples of communitybased child abuse prevention programs are few and
far between. One notable exception is the Prinz
et al. (2009) study that implemented the Triple
P program at the community level in order to see
if community-level rates of maltreatment could be
reduced through widespread parent intervention.
Alternatively, a goal of many parent education and
support programs is to enhance social support
and to connect families to needed resources,
based on the idea that maltreating families tend
to be isolated within their social networks or
communities (Gomby et al., 1999). However,
these aspects of parent-focused programs tend to
be underemphasized (Febbraro, 1994).
Daro and Dodge (2009) make a similar argument for an integrated neighborhood approach to
preventing maltreatment. The authors discuss the
fact that neighborhoods have an influence not
only on child development but on parenting
behavior, and the good intentions of parents can
be overridden by neighborhoods that do not
support their health and mental health. Changing
the values, customs, and services available to the

542

entire community would therefore change the
context in which adults are parenting. For example, greater emphasis on the well-being of the
neighborhood as a whole, rather than individuals
within the neighborhood, would decrease the
focus being put on any one family and increase
the degree to which parents feel responsible for
the neighborhood environment. Parents then feel
more obligated to properly support their children,
and neighborhoods would be more supportive of
parents in their efforts. Although this approach is
beginning to be implemented to a certain degree
by programs such as Triple P, it is rarely used as it
is hard to implement because it requires buy-in
from the entire community.
Recent efforts have instead begun to focus on
reaching parents within settings from which they
are already receiving services in order to provide
a more integrated service system. In particular,
parents are being targeted within primary care
settings. Utilizing doctors and nurses as the
point of access is likely more effective because
they are seen as authority figures that parents tend
to trust. Furthermore, health -care workers are in
a unique position in that they have access to
almost all families at critical time periods.
Shaken baby syndrome (SBS), or abusive
head trauma, is one form of child abuse for
which universal prevention strategies in healthcare settings have been shown to decrease the
number of SBS cases and increase parental
knowledge around triggers (e.g., inconsolable
crying) for shaking infants. Shaken baby syndrome occurs when parents vigorously shake
their infant, typically due to an inability to regulate one’s anger and frustration around the needs
of the infant (Walls, 2006). SBS can result in
brain bleeding and severe cognitive defects and
often results in the death of the infant. However,
SBS is a widely preventable form of abuse.
Research shows that educational interventions,
particularly videos, that provide information to
parents about the causes and effects of SBS are an
effective mechanism in preventing SBS. Regardless of their risk factors, information can be provided to all parents in general health-care
settings, such as the hospital after birth and in
pediatric visits (e.g., Barr et al., 2009; Russell,

Abuse During Early Childhood

Trudeau, & Britner, 2008; Walls, 2006). Indeed,
many states have begun to implement mandatory
information sessions for parents before they can
be discharged from the hospital.
Because health-care providers are usually
some of the first professionals parents have interactions with, they also provide a good opportunity for screenings of risk factors associated with
child maltreatment, such as a parental history of
abuse, substance use, and maternal depression.
For example, Dubowitz, Feigelman, Lane, and
Kim (2009) conducted a randomized control
trial of the Safe Environment for Every Kid
(SEEK) model in Baltimore. This model trained
residents at community clinics to screen for risk
factors associated with maltreatment, had parents
of children 0–5 complete a measure that further
supported this screening, and provided an on-site
social worker to meet with families and make
referrals where necessary. When compared to
clinics that received treatment as usual, the
SEEK clinics had lower rates of reported maltreatment cases, less reports in medical documents that suggested abuse, and lower scores on
a measure of harsh parenting. This study provides
an example of how small changes to the typical
health-care approach may be an effective
approach to child maltreatment.
At a more programmatic level, Child First is a
newer program that was designed to be a
comprehensive, home-based program to be
utilized within a coordinated system of care
(Lowell, Carter, Godoy, Paulicin, & BriggsGowan, 2011). They target families facing multiple risks by coordinating services, including
health-care services, to address these risks and
providing relationship skills training in order to
reduce ineffective parenting and child abuse and
neglect (Lowell et al., 2011). In the first randomized control trial of Child First, parents who participated in the program showed less parenting
stress at 6-month follow-up and less child welfare
involvement after 3 years (Lowell et al.).
Although more research studies are needed, initial results suggest that this coordinated, comprehensive model may be an effective way of
addressing families facing multiple risk factors
who are at higher risk of maltreatment.

Abuse During Early Childhood

The development of programs and policies that
seek to prevent maltreatment at the societal level
has just begun. Although it is important to address
the individual-level factors that leave particular
families at greater risk for maltreatment, it is also
important to acknowledge that these families are
embedded within the larger community (Daro &
Dodge, 2009). Community is also important in
the idea of accessing parents where they are
already receiving services in the community. By
becoming part of the community environment,
child maltreatment prevention services may
become more integrated into the community as
a whole rather than isolating particular families to
receive services. As research continues, it will be
important to combine the individual-level and
community-level efforts to bring about change
for the community and our society as a whole.

What Does Not Work
There are approaches currently in use that do not
seem to be effective. A prevention technique
sometimes used with children as young as three
or four involves teaching children to protect themselves from an abuser. There has been no evidence
that these programs lead to a decline in victimization. Moreover, they promote the message that
children are capable of protecting themselves
from an abuser (Miller-Perrin & Perrin, 1999).
Even for programs that incorporate aspects of
promising or model programs, evaluation results
tend to be less positive when the program is
implemented poorly (Guterman, 1997). Unsuccessful programs also tend to be lacking in intensity, are short term, or are not comprehensive
enough to achieve results (Guterman).

Summary
Taken as a whole, prevention efforts to address
child maltreatment are improving. Child abuse
provides a good example of where prevention
efforts are truly required in order to minimize
and eliminate the negative effects experienced
by children who are maltreated and to improve

543

the family environment in general. New conversations and efforts are arising to begin to address
child maltreatment as a community initiative, recognizing that parents are embedded within communities that support or deter their efforts in the
parenting role. Over the past decade, a growing
number of evidence-based programs, utilizing rigorous evaluation techniques, have demonstrated
that parenting programs can reduce child maltreatment rates. Future research needs to expand
such efforts and, in particular, work to engage the
most difficult-to-reach populations and families.

Cross-References
▶ Abuse and Neglect of Older Adults: Social and
Economic Issues
▶ Abuse During Childhood
▶ Parenting as Primary Prevention
▶ Resiliency During Childhood
▶ Violence Prevention During Early Childhood

References
American Psychological Association. (2009). Effective
strategies to support positive parenting in community
health centers: Report of the Working Group on Child
Maltreatment Prevention in Community Health Centers. Washington, DC: Author.
Barr, R. G., Rivara, F. P., Barr, M., Cummings, P., Taylor,
J., Lengua, L. J., et al. (2009). Effectiveness of educational materials designed to change knowledge and
behaviors regarding crying and shaken-baby syndrome
in mothers of newborns: A randomized, controlled
trial. Pediatrics, 123, 972–980.
Begle, A. M., Dumas, J. E., & Hanson, R. F. (2010).
Predicting child abuse potential: An empirical investigation of two theoretical frameworks. Journal of Clinical Child and Adolescent Psychology, 39(2), 208–219.
Black, D. A., Heyman, R. E., & Slep, A. M. S. (2001). Risk
factors for child physical abuse. Aggression and Violent Behavior, 6, 121–188.
Bradley, E. J., & Peters, R. D. (1991). Physically abusive
and nonabusive mothers’ perception of parenting and
child behavior. American Journal of Orthopsychiatry,
61, 455–460.
Brown, J., Cohen, P., Johnson, J. G., & Salzinger, S. (1998).
A longitudinal analysis of risk factors for child maltreatment: Findings of a 17-year prospective study of
officially recorded and self-reported child abuse and
neglect. Child Abuse and Neglect, 22, 1065–1078.

544
Bugental, D. B., & Johnson, C. (2000). Parental and child
cognitions in the context of the family. Annual Review
of Psychology, 51, 315–344.
Bugental, D. B., Mantyla, S. M., & Lewis, J. (1989).
Parental attributions as moderators of effective communication to children at risk for physical abuse. In
D. Cicchetti & V. Carlson (Eds.), Child maltreatment:
Theory and research on the causes and consequences
of child abuse and neglect (pp. 254–279). Cambridge,
UK: Cambridge University Press.
Chaffin, M., Hecht, D., Bard, D., Silovsky, J. F., &
Beasley, W. H. (2012). A statewide trial of the
SafeCare home-based services model with parents in
child protective services. Pediatrics, 129, 509–515.
Chaffin, M., Silovsky, J. F., Funderbunk, B., Valle, L. A.,
Brestan, E. V., Balachova, T., et al. (2004). Parent-child
interaction therapy with physically abusive parents:
Efficacy for reducing future abuse reports. Journal of
Counseling and Clinical Psychology, 72, 500–510.
Child Abuse Prevention and Treatment Act, 42 U.S.C. }}
5101–5016 (1974).
Conley, A., & Berrick, J. D. (2010). Community-based
child abuse prevention: Outcomes associated with
a differential response program in California. Child
Maltreatment, 15, 282–292.
Coohey, C. (1996). Child maltreatment: Testing the social
isolation hypothesis. Child Abuse and Neglect, 20,
241–254.
Corcoran, J. (2000). Family interventions with child physical abuse and neglect: A critical review. Children and
Youth Services Review, 22, 563–591.
Daro, D. (1988). Confronting child abuse: Research for
effective program design. New York: Free Press.
Daro, D., & Dodge, K. A. (2009). Creating community
responsibility for child protection: Possibilities and
challenges. The Future of Children, 19(2), 67–93.
Dubowitz, H., Feigelman, S., Lane, W., & Kim, J. (2009).
Pediatric primary care to help prevent child maltreatment: The Safe Environment for Every Kid (SEEK)
model. Pediatrics, 123, 858–864.
Duggan, A., McFarlane, E., Fuddy, L., Burrell, L.,
Higman, S. M., Windham, A., et al. (2004). Randomized trial of a statewide home visiting program: Impact
in prevention child abuse and neglect. Child Abuse and
Neglect, 28, 597–622.
Eckenrode, J., Campa, M., Luckey, D. W., Henderson,
C. R., Cole, R., Kitzman, H., et al. (2010). Long-term
effects of prenatal and infancy nurse home visitation
on the life course of youths: 19-year follow-up of
a randomized trial. Archives of Pediatric and Adolescent Medicine, 164(1), 9–15.
Febbraro, A. (1994). Single mothers “at-risk” for child
maltreatment: An appraisal of person-centered interventions and a call for emancipatory action. Canadian
Journal of Community Mental Health, 13, 47–60.
Feshbach, N. (1989). The construct of empathy and the
phenomenon of physical maltreatment of children. In
D. Cicchetti & V. Carlson (Eds.), Child maltreatment:
Theory and research on the causes and consequences

Abuse During Early Childhood
of child abuse and neglect (pp. 349–373). Cambridge,
UK: Cambridge University Press.
Freisthler, B. (2004). A spatial analysis of social disorganization, alcohol access, and rates of child maltreatment in neighborhoods. Children and Youth Services
Review, 26, 803–819.
Garbarino, J., & Crouter, A. (1978). Defining the community context for parent–child relations: The correlates of
child maltreatment. Child Development, 49, 604–616.
Garbarino, J., & Kostelny, K. (1992). Child maltreatment
as a community problem. Child Abuse and Neglect, 16,
455–464.
George, C. (1996). A representational perspective of child
abuse and prevention. Child Abuse and Neglect, 20,
411–424.
Gomby, D. S., Culross, P. L., & Behrman, R. E. (1999).
Home visiting: Recent program evaluations – Analysis
and recommendations. The Future of Children, 9(1),
4–26.
Guterman, N. (1997). Early prevention of physical child
abuse and neglect: Existing evidence and future directions. Child Maltreatment, 2, 12–34.
Harding, K., Galano, J., Martin, J., Huntington, L., &
Schellenbach, C. J. (2007). Healthy families America
effectiveness: A comprehensive review of outcomes.
Journal of Prevention and Intervention in the
Community, 34, 149–179.
Howard, K. S., & Brooks-Gunn, J. (2009). The role of
home-visiting programs in preventing child abuse and
neglect. The Future of Children, 19(2), 119–146.
Kitzman, H., Olds, D., Henderson, C., Hanks, C., Cole, R.,
Tatelbaum, R., et al. (1997). Effect of prenatal and
infancy home visitation by nurses on pregnancy outcomes, childhood injuries, and repeated childbearing:
A randomized controlled trial. Journal of American
Medical Association, 278, 644–652.
Letarte, M., Normandeau, S., & Allard, J. (2010). Effectiveness of a parent training program “Incredible
Years” in a child protection service. Child Abuse and
Neglect, 34, 253–261.
Linares, L. O., Montalto, D., Li, M., & Oza, V. S. (2006).
A promising parenting intervention in foster care.
Journal of Consulting and Clinical Psychology,
74(1), 32–41.
Lowell, D. I., Carter, A. S., Godoy, L., Paulicin, B., &
Briggs-Gowan, M. J. (2011). A randomized controlled
trial of Child FIRST: A comprehensive home-based
intervention translating research into early childhood
practice. Child Development, 82, 193–208.
Lutzker, J. R., Bigelow, K. M., Doctor, R. M., & Kessler,
M. L. (1998). Safety, health care, and bonding within
an ecobehavioral approach to treating and preventing
child abuse and neglect. Journal of Family Violence,
13(2), 163–185.
McCurdy, K., & Daro, D. (2001). Parent involvement in
family support programs: An integrated theory. Family
Relations, 50(2), 113–121.
Miller-Perrin, C., & Perrin, R. (1999). Child maltreatment: An introduction. Thousand Oaks, CA: Sage.

Abuse During Early Childhood
Ogrodnik, L. (2010). Child and youth victims of policereported violent crime: 2008. Retrieved March29,
2013, from the Canadian Centre for Justice Statistics:
http://www.statcan.gc.ca/bsolc/olc-cel/olc-cel?catno
=85f0033m&CHROPG=1&lang=eng
Olds, D. L. (2006). The nurse-family partnership: An
evidence-based preventive intervention. Infant Mental
Health Journal, 27(1), 5–25.
Olds, D. L., Eckenrode, J., Henderson, C., Kitzman, H.,
Powers, J., Cole, R., et al. (1997). Long-term effects of
home visitation on maternal life course and child abuse
and neglect: A 15-year follow-up of a randomized
trial. Journal of American Medical Association, 278,
637–643.
Olds, D. L., Henderson, C., Chamberlin, R., &
Tatelbaum, R. (1986). Preventing child abuse and
neglect: A randomized trial of nurse home visitation.
Pediatrics, 78, 65–78.
Olds, D. L., Henderson, C. R., Kitzman, H. J., Eckenrode,
J. J., Cole, R. E., & Tatelbaum, R. C. (1999). Prenatal
and infancy home visitation by nurses: Recent findings. The Future of Children, 9(1), 44–65.
Polansky, N. A., Gaudin, J. M., Ammons, P. W., & Davis,
K. B. (1985). The psychological ecology of the neglectful mother. Child Abuse and Neglect, 9, 265–275.
Prinz, R. J., Sanders, M. R., Shapiro, C. J., Whitaker, D. J.,
& Lutzker, J. R. (2009). Population-based prevention
of child maltreatment: The U.S. Triple P system population trial. Prevention Science, 10, 1–12.
Putnam-Hornstein, E. (2011). Report of maltreatment as
a risk factor for injury death: A prospective birth
cohort study. Child Maltreatment, 16, 163–174.
Rodriguez, M. L., Dumont, K., Mitchell-Herzfeld, S. D.,
Walden, N. J., & Greene, R. (2010). Effects of
healthy families New York on the promotion of maternal parenting competencies and the prevention of harsh
parenting. Child Abuse and Neglect, 34, 711–723.
Russell, B. S., Britner, P. A., & Woolard, J. L. (2007).
The promise of primary prevention home visiting
programs: A review of potential outcomes. Journal of
Prevention and Intervention in the Community, 34,
129–147.
Russell, B. S., Trudeau, J., & Britner, P. A. (2008). Intervention type matters in primary prevention of abusive
head injury: Event history analysis results. Child
Abuse and Neglect, 32, 949–957.
Sanders, M. R., Pidgeon, A. M., Gravestock, F., Connors,
M. D., Brown, S., & Young, R. W. (2004). Does
parental attributional retraining and anger

545
management enhance the effects of the Triple
P- Positive Parenting Program with parents at
risk of child maltreatment? Behavior Therapy, 35,
513–535.
Sanders, M. R., Turner, K. M., & Markie-Dadds, C.
(2002). The development and dissemination of the
Triple P- Positive Parenting Program: A multilevel,
evidence-based system of parenting and family support. Prevention Science, 3, 173–189.
Silovsky, J. F., Bard, D., Chaffin, M., Hecht, D., Burris, L.,
Owora, A., et al. (2011). Prevention of child maltreatment in high-risk rural families: A randomized clinical
trial with child welfare outcomes. Children and Youth
Services Review, 33, 1435–1444.
Slep, A. M. S., & Heyman, R. E. (2008). Public health
approaches to family maltreatment prevention: Resetting family psychology’s sights from the home to the
community. Journal of Family Psychology, 22,
518–528.
Solomon, J., & George, C. (Eds.). (2011). Disorganized
attachment and caregiving. New York: Guilford.
Thomas, R., & Zimmer-Gembeck, M. J. (2011). Accumulating evidence for parent-child interaction therapy in
prevention of child maltreatment. Child Development,
82, 177–192.
U.S. Department of Health and Human Services,
Administration on Children, Youth, and Families,
Children’s Bureau. (2010). Child maltreatment 2009.
Retrieved on March 29, 2013, from http://www.acf.
hhs.gov/programs/cb/stats_research/index.htm#can
Walls, C. (2006). Shaken baby syndrome education:
A role for nurse practitioners working with families
of small children. Journal of Pediatric Health Care,
20, 304–310.
Webster-Stratton, C. (1998). Preventing conduct problems
in Head Start children: Strengthening parenting competencies. Journal of Consulting and Clinical Psychology, 66, 715–730.
Webster-Stratton, C., & Reid, M. J. (2010). Adapting the
incredible years, an evidence-based parenting
programme, for families involved in the child
welfare system. Journal of Children’s Services, 5(1),
25–42.
Wekerle, C. (2011). The dollars and senselessness in failing to prioritize childhood maltreatment prevention.
Child Abuse and Neglect, 35, 159–161.
Wolfe, D. (1993). Prevention of child neglect:
Emerging issues. Criminal Justice and Behavior, 20,
90–111.

546

Abuse During Childhood
Preston A. Britner1, Jodie K. Comer1 and
Sharon G. Portwood2
1
Department of Human Development & Family
Studies, University of Connecticut, Storrs,
CT, USA
2
Department of Public Health Sciences,
The University of North Carolina at Charlotte,
Charlotte, NC, USA

Introduction
Child maltreatment is a serious and widespread
problem with well-documented negative consequences for children (e.g., Gilbert et al., 2009).
Given the impact child maltreatment often has
on the child, as well as the family, community,
and society as a whole, it is crucial to focus
research and programmatic efforts on effective
methods of preventing child maltreatment.
Abuse prevention strategies aimed specifically
at children aged 5 through 12 years are less
common than those targeting parents of children
under the age of 5 (see “▶ Abuse During Early
Childhood” entry in this volume). Nonetheless,
there is a growing body of research on correlates
of abuse during childhood and on promising
prevention programs designed to reduce rates
of maltreatment. Many of these prevention
efforts are embedded within parenting interventions that are also designed to promote a variety
of positive family interactions and outcomes.
Other (often school-based) models are targeted
to the child, and the literature on their effectiveness is less promising.

Definitions and Scope
Child maltreatment has been defined both in
terms of acts of commission (i.e., abuse) and
acts of omission (i.e., neglect). According to the
Child Abuse Prevention and Treatment Act
(CAPTA) of 1974, child maltreatment is defined

Abuse During Childhood

as “any recent act or failure to act on the part of
a parent or caretaker which results in death,
serious physical or emotional harm, sexual
abuse or exploitation; or an act or failure to act
which presents an imminent risk of serious
harm.” This definition is general in scope, and
several subcategories of child maltreatment
are more specifically defined. Despite federal
definitions and policies, child maltreatment is
addressed on the state level resulting in each
state deriving their own definition of what
specifically constitutes child maltreatment and
the different subcategories. Further, each state
establishes through statute their own requirements in terms of the level of evidence needed
to make a finding or substantiation of abuse or
neglect (Portwood, 1999). Consequently, there is
wide variation in terms of the specific behaviors
that constitute child maltreatment.
The variation in definitions of child maltreatment throughout the United States often creates
problems both in terms of research and practice.
For example, it can be difficult to determine when
maltreatment has occurred. Additionally, it creates complexity in defining the effectiveness of
any child maltreatment prevention strategies.
However, despite these definitional dilemmas,
four subcategories of child maltreatment are
generally recognized by states: physical abuse,
psychological or emotional abuse, sexual abuse,
and neglect. Physical abuse has been defined as
the infliction of non-accidental physical injury.
Psychological or emotional abuse has been
defined as the infliction of non-accidental emotional harm or injury. Sexual abuse consists of
any sexual activity with a child where consent is
not or cannot be given (Finkelhor, 1979). Neglect
is characterized by negligent acts or omissions
that harm or threaten harm to a child. Neglect
may have several subcategories, including the following: physical neglect, which includes failure to
provide for a child’s basic physical needs, including food, shelter, or clothing; emotional neglect,
which consists of inattention to a child’s emotional needs; medical neglect, which refers to
a caregiver’s failure to provide prescribed medical
treatment; and educational neglect, which has
been defined as a caregivers’ failure to comply

T.P. Gullotta, M. Bloom (eds.), Encyclopedia of Primary Prevention and Health Promotion,
DOI 10.1007/978-1-4614-5999-6, # Springer Science+Business Media New York 2014

Abuse During Childhood

with legal requirements for the education of
children (Erickson & Egeland, 1996).
Broad definitions of child maltreatment
also encompass exposure to domestic and/or
community violence and sibling abuse, topics
beyond the scope of this entry.
Given the difficulty with defining child
maltreatment and the subjective nature of many
of the subcategory definitions, it is difficult to
determine the specific magnitude of child maltreatment in the United States. Further, despite
efforts to increase awareness and reporting of
suspected child maltreatment, there are undoubtedly incidents of child maltreatment that are left
unreported. Regardless, despite these difficulties,
it is clear that the magnitude of child maltreatment is substantial. According to the US Department of Health and Human Services
(U.S. DHHS, 2010), in 2009, there were just
over three million reports of child maltreatment
in the United States. Of those three million
reports of child maltreatment, child protection
agencies responded to just over two million
reports, and just over 700,000 (22.1 %) of the
reports resulted in a finding or substantiation of
child maltreatment. Thus, 9.3 per 1,000 children
were victims of child maltreatment in the United
States in 2009 (U.S. DHHS, 2010). However, it is
important to consider this statistic in light of the
defining and reporting difficulties.
Children in the age group of birth to 1 year
are at the highest risk for child maltreatment,
with a victimization rate at 20.6 per 1,000
(U.S. DHHS, 2010). Most data suggest that the
risk of physical abuse and neglect decreases with
age. For example, statistics consistently indicate
that almost half of children victimized through
physical abuse are age seven or younger (MillerPerrin & Perrin, 2012). However, this decreased
risk is not evidenced in self-report data, suggesting
that it may not be the actual occurrence of abuse,
but rather the risk of injury that dissipates as children age. Recent efforts (e.g., Leventhal, Martin,
& Gaither, 2012) to monitor US hospital data on
the occurrence of serious injuries due to physical
abuse represent another approach to understanding
the scope of the problem, monitor trends over time,
and evaluate the effects of prevention programs.

547

Additionally, contrary to other forms of
maltreatment, the risk of sexual abuse appears to
increase with age. Although the majority of all
sexual abuse cases, at least within the United States,
occur within the 5- to 12-year age range, the majority of substantiated cases involving this age group
of children were neglect cases (U.S. DHHS, 2010).
For all types of child maltreatment, an adult known
to the child is most likely to be the perpetrator
(Miller-Perrin & Perrin, 2012).
The costs of child maltreatment are substantial,
including not only treatment for physical or emotional injuries sustained as an immediate result of
the abuse but also extending to chronic health and
socio-emotional difficulties. Research suggests
that many problems emerge in childhood and
continue well into adulthood, including drug or
alcohol dependence and other deviant behaviors.
Accordingly, the combined annual costs to special
education, public health, rehabilitation, criminal
justice, and child welfare systems have been estimated to be in the billions of dollars (Daro, 1988;
Fang, Brown, Florence, & Mercy, 2012).
Although a direct cross-cultural comparison of
the scope of the problem is not possible due to
differences in compilation and reporting procedures, child maltreatment is not unique to the
United States. Mikton and Butchart (2009), in a
review of 298 child maltreatment outcome
evaluation studies, found that 99.4 % of the studies were conducted in high-income countries
(including 83 % in the United States). Thus, we
know little about the effects of maltreatment
prevention in low- and middle-income countries.

Theories
Whereas child abuse can be viewed as an
aggressive act and thus informed by traditional
models of aggression, the special context in
which most abuse occurs (i.e., the family) has
focused most theories of child maltreatment on
group and family processes. Overall, theories on
the causes of child maltreatment have moved
from a focus on the individual to an attempt to
integrate multiple levels of analysis (Azar,
Povilaitis, Lauretti, & Pouquette, 1998).

548

One popular group of theories views abuse as
one end of a parenting continuum. These
developmentally based models are essentially
models of parenting adequacy and thus have
substantial import for the development of effective prevention strategies. Perpetrator models
that, in the extreme, propose that offenders are
psychotic or suffer from other psychological disorders were popular early explanations of child
maltreatment (Azar et al., 1998). However,
recently researchers have begun to explore perpetrator theories based on biological approaches.
Some of the more promising perpetrator theories
focus on parental social–cognitive disturbances,
positing that such parental factors as a disturbed
schema involving children, problem-solving
deficits, and lack of perspective-taking ability
may lead to maladaptive parenting. Other theories
have focused on child victims, attempting to identify characteristics of abused children that may
produce violent behavior in a vulnerable parent.
At the macrolevel, researchers have sought to
identify a variety of social and cultural factors
that contribute to child maltreatment. Foremost
among these is a general tolerance for violent
acts within the culture that may “spillover” into
the home; for example, excessive exposure to
violence through the media can contribute to a
general acceptance of violence within the family
environment. One marker of cultural standards in
regard to physical violence against children is
corporal punishment, leading some to suggest
that a general acceptance of spanking as an appropriate form of discipline contributes, at least indirectly, to child maltreatment and to physical child
abuse in particular (Miller-Perrin & Perrin, 2012).
Strain theories have also developed around
the notion that financial inequities within the
societal structure place lower-income families,
unemployed families, and families receiving
governmental assistance, who experience high
levels of stress and frustration, at higher risk of
maltreatment.
More
recent
theories,
rather
than
distinguishing among perpetrator, victim, and
environmental factors, have proposed multiple
trajectories to the development of abusive behavior that link these factors. One notable model is

Abuse During Childhood

that proposed by Belsky (1980), who suggested
that the roots of maltreatment lie in multiple
ecological systems, that is, what parents bring to
parenthood, family factors, factors in the larger
social setting, and cultural values and beliefs.
A second model was outlined by Azar and
Twentyman (1986), who identified five areas of
parental skill deficit that contribute to an increased
risk of abuse: “parenting skills (e.g., too narrow
a repertoire), cognitive dysfunctions (e.g., unrealistic expectations regarding children), and
impulse control, stress management, and social
skills problems” (Azar et al., 1998, p. 9).

Current Research
Research on child maltreatment is relatively recent,
with essentially all research being conducted since
1970 and vast amounts of research being conducted
in the last two decades. This research indicates that
the origins and consequences of child maltreatment
are complex. Research on the origins of child maltreatment and different risk and/or protective factors linked with maltreatment can generally be
grouped into four categories: perpetrator characteristics, child characteristics, family characteristics,
and the broader social context.
Perpetrator Characteristics
Given the high percentage of parents as the perpetrators of child maltreatment, which has been
reported as over 80 % (U.S. DHHS, 2010), it is
logical that much of the research on perpetrator
characteristics focuses on parents. Parental characteristics associated with child maltreatment
include substance abuse, involvement in
a domestically violent relationship, and lack of
involvement in community activities (Brown,
Cohen, Johnson, & Salzinger, 1998). Poverty
and a previous history of child abuse are also
associated with maltreating one’s child
(Ondersma, 2002). Additionally, perpetrators of
child maltreatment tend to have lower selfesteem, inappropriate expectations of their children, and less empathy with their children
(Milner, 1998). In general, five domains of parental disturbance can be considered: cognitive

Abuse During Childhood

disturbances, deficits in parenting skill, problems
with impulse control, difficulties with stress management, and social skill problems (Azar &
Twentyman, 1986). Each of these deficits, alone
or in combination, can play a role in more
systemic difficulties that heighten the risk of
abuse. For example, a parent’s deficits in social
skills may result in a smaller support network.
With regard specifically to sexual abuse, the
perpetrator tends to be male, to have interpersonal problems, and to be antisocial (Milner,
1998). However, female perpetrators are more
likely to sexually abuse younger children than
are male perpetrators (Peter, 2009). Regardless,
much of the research on characteristics of sexual
abusers has focused primarily on males and may
not necessarily be generalizable to female perpetrators. The majority of this research has also
been generated from a psychiatric model, assuming that the root cause of sexual abuse lies in the
individual psychopathology of male abusers. As
noted, there is some evidence to suggest that
sexual abusers exhibit some antisocial tendencies, including a disregard for others and lack of
impulse control, and/or deficits in heterosocial
skills (Miller-Perrin & Perrin, 2012). Other
theories center on deviant sexual arousal, which
prompts offenders to solicit sexual encounters
with children. The as yet undetermined origins of
this deviant sexual arousal are believed to be partially biological. However, this explanation does
not appear adequate to explain incest. Instead,
family dysfunction models posit that either the
family or one of its adult members contributes to
a context in which the sexual victimization of
children is permitted or even encouraged.
Child Characteristics
Child characteristics that have been associated
with maltreatment include having a disability.
There is a relatively large and consistent body of
literature suggesting the correlation between children with disabilities and increased risk of maltreatment when compared to non-disabled
children (Howe, 2006). Additional child characteristics associated with maltreatment include
having a difficult temperament, psychiatric symptoms, or behavioral problems (Brown et al.,

549

1998). However, when examining the behavior
of both parents and children, the question of directionality arises, that is, to what degree and in what
ways negative parenting behavior contribute to
behavior from the child, and vice versa.
Family Characteristics
Family characteristics are also related to the rate
of child maltreatment. Situations that contribute
to the level of stress within a family, including
illness, death of a family member, and larger than
average family size, have been established as risk
factors for physical abuse (Miller-Perrin &
Perrin, 2012). Other family factors associated
with child maltreatment include high levels of
conflict, the occurrence of partner violence,
social isolation, high levels of stress, poverty,
and a lack of support (Milner, 1998).
With regard to additional family characteristics,
poor parent–child relationships and marital conflict have been associated specifically with sexual
abuse (Finkelhor, 1984). At the macrolevel, social
and community factors, particularly social attitudes toward women and child pornography,
appear to contribute to sexual abuse. Family environments in which incest occurs are particularly
likely to be characterized by substantial power
differentials between male and female members
(Miller-Perrin & Perrin, 2012). Unlike other
forms of maltreatment, sexual abuse is not
generally related to SES (Milner, 1998).
Social Context Factors
Social context factors have also demonstrated
an association with child maltreatment. Child
maltreatment rates are higher in communities
with certain socioeconomic characteristics
(Garbarino, Kostelny, & Grady, 1993). Communities where a larger proportion of residents live
in poverty tend to have higher rates of maltreatment. Communities with more female-headed
households, a higher unemployment rate, a
lower percentage of wealthy residents, a lower
median education level, more overcrowding, and
a higher percentage of new residents tend to have
higher rates of maltreatment as well (Garbarino
et al., 1993). However, it is important to note that
child maltreatment is by no means typical of all

550

families that struggle financially, suggesting that
other factors are at work. Notable among these is
social bonding/social isolation. Abusive parents
have been found to have relatively fewer contacts
with peer networks, immediate family, and other
relatives (Miller-Perrin & Perrin, 2012).
Moreover, Emery and Laumann-Billings (1998)
found that even in low-income neighborhoods,
child maltreatment rates tend to be low when
residents know one another, there is a sense of
community pride, people are involved in community organizations, and residents feel that they
can ask their neighbors for help.

Abuse During Childhood

emerged as successful in preventing the occurrence of maltreatment in children aged five to
twelve. Specifically, some parent education programs, home visitation programs, and systemic
prevention approaches have proven effective in
the prevention of child maltreatment. Although
typically implemented with parents of infants and
toddlers, some programs also serve parents of
older children. Further, some of the programs
that target parents of younger children address
successful strategies to reduce risk factors and
enhance protective factors in parents, which
may accrue positive effects that continue beyond
the earliest stages of childhood throughout the
duration of childhood (Mikton & Butchart, 2009).

Overview of Strategies
Parenting programs that seek to reduce child maltreatment and simultaneously promote a host of
positive child outcomes are consistent with recent
priorities with the offices for violence prevention
at the Centers for Disease Control and Prevention
(CDC) and the American Psychological Association (APA) and a focus on promoting safe, stable,
nurturing relationships for children through positive parenting (American Psychological Association [APA], 2009). Most of the 46 randomized
trials of preventive parenting programs reviewed
by Sandler, Schoenfelder, Wolchik, and
MacKinnon (2011) demonstrated short-term and
long-term effects on a variety of child outcomes
(not focused on child maltreatment). What was
less clear was the mechanism of change. Sandler
et al. propose three alternative pathways to positive child effects, through program effects on
parenting, through program-induced reductions
in children’s stressors and improvements in adaptations to stress, and through effects on contexts
in which children reside and engage. Many of the
strategies in the literature on child abuse prevention share these ideas about pathways, although
specific tests of these mechanisms are limited.

What Works
With the recent expansion of the literature on
child maltreatment, a few approaches have

Parent Education Programs
Parent education is one of the most commonly used
prevention methods relative to child maltreatment
(APA, 2009; Barth et al., 2005). Parent education
programs aim to prevent child maltreatment by
equipping parents with knowledge and skills to
increase protective factors, thus reducing child
maltreatment. However, parent education programs are often focused on preventing, reducing,
and treating children with serious behavior problems, who only represent a portion of the entire
child welfare population (Barth et al.), and some of
the research on the effectiveness of parent education programs presents mixed findings (Maher,
Marcynyszyn, Corwin & Hodnett, 2011). There
are a number of studies on the effects of locally
developed parent education programs on child
maltreatment outcomes for targeted populations,
such as first-time teen parents (e.g., Britner &
Reppucci, 1997). However, only a few parent education programs have demonstrated their effectiveness with rigorous evaluation designs; these
include Parent–Child Interaction Therapy (Eyberg
& Robinson, 1982), the Nurturing Parenting
Program (Maher et al., 2011), and the Incredible
Years (Webster-Stratton, 2007).
Parent–Child Interaction Therapy (PCIT)
aims to modify parent–child interactions to support child development and positive outcomes
through coaching and direct work with the parents as they interact with their child. Participants
in PCIT have been found to have increased

Abuse During Childhood

positive parenting interactions and decreased
occurrences of re-reports of child maltreatment
relative to a community-based parenting group,
in a randomized trial of 110 physically abusive
parents (Chaffin et al., 2004). Similarly, the
Nurturing Parenting Program has demonstrated
increased positive parenting among participants,
especially when there was adequate program participation. Utilizing a statewide administrative
child welfare database, researchers found that
longer-term reductions in substantiated child maltreatment incidences (in childhood) increased as
program participation by parents (when their children were infants, toddlers, and preschoolers)
increased (Maher et al., 2011). The Incredible
Years (IY) program is a third example of a parenting education program that has demonstrated
increased positive parenting among participants
through a number of rigorous studies (WebsterStratton, 2007); however, it has not specifically
been linked with any child welfare outcomes.
Despite some mixed findings in the literature, it
seems clear that some well-developed parent education programs are responsible for positive parenting outcomes among participants (APA, 2009).
Home Visitation Programs
Home visitation programs entail providing support, parent education, crisis intervention, and
related services to parents with the goal of promoting healthy pregnancies, healthy infants and
families, and the prevention of child maltreatment
(Russell, Britner, & Woolard, 2007). Initial evaluations reported mixed findings in terms of the
effectiveness of home visitation programs; however, more recently support has emerged
highlighting the effectiveness of certain home visitation programs in reducing future occurrences of
child maltreatment. For example, the SafeCare
program and the Nurse–Family Partnership program have both demonstrated documented success with factors associated with the prevention
of child maltreatment.
The SafeCare program is a home-based
program that targets imminent maltreatment
behaviors and utilizes a skills-based approach to
changing parenting behaviors. The SafeCare program has received substantial attention in the

551

literature (e.g., Gershater-Molko, Lutzker, &
Wesch, 2003), most of which supports the notion
that the program produces changes in behavioral
domains directly proximal to child maltreatment
(Silovsky et al., 2011). Of note, Silovsky and
colleagues’ (2011) randomized clinical trial of
an augmented version of SafeCare is a rare example of a program tailored to – and studied with –
a high-risk rural population.
The Nurse–Family Partnership program has
received significant attention in the literature, as
the program has been around for over 30 years.
Relying on the expertise of nurses, at-risk
first-time mothers receive individual intensive
attention focused on parenting skills. The
program has been linked with positive outcomes
for mothers and children as well as a reduction in
child maltreatment (Olds et al., 1997).
It is clear that both the parenting education
programs and the home visitation programs are
at least associated with producing changes that
are proximal to child maltreatment, if not directly
associated with prevention of child maltreatment.
A universal approach to such programs may be an
appropriate strategy. Additionally, implications
of utilizing new technology to assist in prevention
programs indicate possibilities for reducing the
costs of such prevention efforts (e.g., Jabaley,
Lutzker, Whitaker, & Self-Brown, 2011).
A Systemic, Public Health Approach
The Triple P-Positive Parenting Program follows
a public health model offering services that range
from universal applicability (e.g., information in
the media about positive parenting) to more
targeted training for parents of children from
birth to adolescence. Although the specifics vary
by target group, the general goals are for children
to develop emotional self-regulation and for
parents to become competent problem-solvers.
Studies to date have been supportive of the
population-based model (e.g., Shapiro, Prinz, &
Sanders, 2010). Prinz, Sanders, Shapiro,
Whitaker, and Lutzker (2009) randomized
18 counties in one US state to receive Triple
P or not in order to examine population-level
effects on child maltreatment. The control
counties were comparable to treatment counties

552

on county size, rate of poverty, and child abuse
rates. Large effects were found on substantiated
rates of child maltreatment, child out-of-home
placements, and emergency room and hospital
visits for child maltreatment-related injuries,
with those counties receiving Triple P faring
significantly better on all three outcomes.

What Is Promising
Public awareness campaigns, media presentation,
and speaker programs to voluntary organizations
and civic groups may serve to increase public
awareness of the problems associated with child
maltreatment. Similarly, involvement of religious institutions may assist in preventing child
maltreatment. Mandated reporting laws may
have impacted child maltreatment, particularly
in the 5- to 12-year-old age group, as parents are
aware that school professionals are mandated to
report any suspicion of abuse or neglect. More
systematic and rigorous evaluation is needed in
order to test these possibilities.

What Does Not Work
There are a few child maltreatment prevention
strategies that have no evidence of being effective. First, strategies focused on teaching children
to protect themselves from abuse have not proven
to decrease victimization (Miller-Perrin & Perrin,
2012). In the 1980s, programs aimed at teaching
children to recognize, resist, and report abuse
became popular for school-aged children. Such
programs emphasize two goals: primary prevention of child maltreatment and detection of child
maltreatment. Programs vary regarding the
amount of time spent on lessons and on the details
of the program content, utilizing films, skits,
lectures, coloring books, songs, and/or puppet
shows to convey lessons about sexual abuse,
assertiveness, avoidance, and disclosure. However, these programs share the same core assumptions, specifically the following: (1) many
children do not know what sexual abuse is;
(2) children do not need to tolerate sexual

Abuse During Childhood

touching; (3) adults want to know about children
who experience sexual touching by adults; and
(4) disclosure of sexual touching will help to stop
it (National Research Council, 1993).
Limited data suggest that child participants in
such programs demonstrate increased knowledge
immediately following the program; however,
these gains in knowledge tend to deteriorate
over time (Finkelhor & Strapko, 1992).
More importantly, there is no evidence of a
reduction in the actual number of victimizations
as a result of participation in these school-based
programs, and there is nothing to suggest that
they help children resist abuse (Miller-Perrin &
Perrin, 2012). Additionally, numerous concerns
have emerged regarding the effect of such programs on children, including instilling feelings of
fear, vulnerability, and anxiety in children (Adler
& McCain, 1994) and sending the message to
children that they are in some way responsible
for preventing their own abuse (Melton, 1992).
Second, criminal sanctions for child maltreatment are often thought to have a deterrent effect.
However, there is no evidence that current laws
have any such deterrent effect. Moreover, there is
some suggestion that legal procedures and sanctions that lead to children’s removal from their
parents may be counterproductive, especially in
cases involving parental offenders and mild to
moderate forms of maltreatment. Finally, any
program or strategy regardless of the strength of
the substance will be ineffective if not
implemented properly. Many programs have
promising goals and structure, yet when
implemented are not comprehensive enough to
achieve significant results (Guterman, 1997).

Summary
It is clear that child maltreatment is a prominent
and pervasive concern, and given the potential
consequences of child maltreatment, future
research efforts require a focus on prevention.
Although relatively limited in terms of empirical
support, prevention strategies for child maltreatment are becoming more widely recognized,
accepted, and implemented. However, the

Abuse During Childhood

majority of child welfare resources continue to be
allocated to intervention efforts after child
maltreatment has occurred. In the last two
decades, great strides have been made relative
to the identification of risk and protective factors
associated with abuse, as well as the promotion of
other aspects of general health and well-being.
Further program development and evaluation is
needed to understand more about what works, for
whom (i.e., across more varied populations) and
how model programs may be brought up to scale
with fidelity and appropriate fit to client needs
and community systems.

See Also
▶ Abuse and Neglect of Older Adults: Social and
Economic Issues
▶ Abuse During Early Childhood
▶ Parenting as Primary Prevention
▶ Resiliency During Childhood
▶ Violence Prevention During Early Childhood

References
Adler, N., & McCain, J. (1994). Prevention of child abuse:
Issues for the mental health practitioner. Child and
Adolescent Psychiatric Clinics of North America, 3,
679–693.
American Psychological Association (APA). (2009).
Effective strategies to support positive parenting in
community health centers: Report of the Working
Group on Child Maltreatment Prevention in Community Health Centers. Washington, DC: Author.
Azar, S. T., Povilaitis, T. Y., Lauretti, A. F., & Pouquette,
C. L. (1998). The current status of etiological theories
in intrafamilial child maltreatment. In J. L. Lutzker
(Ed.), Handbook of child abuse research and treatment
(pp. 3–30). New York: Plenum Press.
Azar, S. T., & Twentyman, C. T. (1986). Cognitive
behavioral perspectives on the assessment and treatment of child abuse. In P. C. Kendall (Ed.), Advances
in cognitive behavioral research and therapy
(Vol. 5, pp. 237–267). New York: Academic Press.
Barth, R. P., Landsverk, J., Chamberlain, P., Reid, J. B.,
Rollins, J. A., & Hurlburt, M. S. (2005). Parent-training
programs in child welfare services: Planning for a more
evidence-based approach to serving biological parents.
Research on Social Work Practice, 15, 353–371.
Belsky, J. (1980). Child maltreatment: An ecological
integration. American Psychologist, 35, 320–335.

553
Britner, P. A., & Reppucci, N. D. (1997). Prevention of
child maltreatment: Evaluation of a parent education
program for teen mothers. Journal of Child and Family
Studies, 6, 165–175.
Brown, J., Cohen, P., Johnson, J., & Salzinger, S. (1998).
A longitudinal analysis of risk factors for child
maltreatment. Child Abuse and Neglect, 22, 1065–1078.
Chaffin, M., Silovsky, J. F., Funderbunk, B., Valle, L. A.,
Brestan, E. V., Balachova, T., et al. (2004). Parent–child
Interaction Therapy with physically abusive parents:
Efficacy for reducing future abuse reports. Journal of
Counseling and Clinical Psychology, 72, 500–510.
Daro, D. (1988). Confronting child abuse: Research for
effective program design. New York: The Free Press.
Emery, R. E., & Laumann-Billings, L. (1998). An
overview of the nature, causes, and consequences of
abusive family relationships: Toward differentiating
maltreatment and violence. American Psychologist,
44, 121–135.
Erickson, M. F., & Egeland, B. (1996). Child neglect. In
J. Briere, L. Berliner, J. A. Bulkley, C. Jenny, &
T. Reid (Eds.), The APSAC handbook on child
maltreatment (pp. 4–20). Thousand Oaks, CA: Sage.
Eyberg, S. M., & Robinson, E. A. (1982). Parent–child
interaction therapy: Effects on family functioning.
Journal of Clinical Child Psychology, 11, 130–137.
Fang, X., Brown, D. S., Florence, C. S., & Mercy, J. A.
(2012). The economic burden of child maltreatment in
the United States and implications for prevention.
Child Abuse and Neglect, 36, 156–165.
Finkelhor, D. (1979). A sourcebook on child sexual abuse.
Newbury Park, CA: Sage.
Finkelhor, D. (1984). Child sexual abuse: New theory and
research. New York: Free Press.
Finkelhor, D., & Strapko, N. (1992). Sexual abuse prevention
education: A review of evaluation studies. In D. Willis,
E. Holden, & M. Rosenberg (Eds.), Prevention of child
maltreatment: Developmental and ecological perspectives (pp. 150–167). New York: Wiley.
Garbarino, J., Kostelny, K., & Grady, J. (1993). Children
in dangerous environments: Child maltreatment in the
context of community violence. In D. Cicchetti &
S. Toth (Eds.), Child abuse, child development, and
social policy (pp. 167–189). Norwood, NJ: Ablex.
Gershater-Molko, R. M., Lutzker, J. R., &
Wesch, D. (2003). Project SafeCare: Improving
health, safety, and parenting skills in families reported
for, and at-risk for child maltreatment. Journal of
Family Violence, 18, 377–386.
Gilbert, R., Widom, C. S., Browne, K., Fergusson, D.,
Webb, E., & Janson, S. (2009). Burden and
consequences of child maltreatment in high-income
countries. Lancet, 373, 66–81.
Guterman, N. (1997). Early prevention of physical child
abuse and neglect: Existing evidence and future
directions. Child Maltreatment, 2, 12–34.
Howe, D. (2006). Disabled children, maltreatment and
attachment. British Journal of Social Work, 36,
743–760.

554
Jabaley, J. J., Lutzker, J. R., Whitaker, D. J., &
Self-Brown, S. (2011). Using iPhones to enhance and
reduce face-to-face home safety sessions within
SafeCare: An evidence-based child maltreatment prevention program. Journal of Family Violence, 26,
377–385.
Leventhal, J. M., Martin, K. D., & Gaither, J. R. (2012).
Using US data to estimate the incidence of
serious physical abuse in children. Pediatrics, 129,
458–464.
Maher, E. J., Marcynyszyn, L. A., Corwin, T. W., &
Hodnett, R. (2011). Dosage matters: The relationship
between participation in the Nurturing Parenting
Program for infants, toddlers, and preschoolers and
subsequent child maltreatment. Children and Youth
Services Review, 33, 1426–1434.
Melton, G. (1992). The improbability of prevention of
sexual abuse. In D. Willis, E. Holden, &
M. Rosenberg (Eds.), Prevention of child maltreatment: Developmental and ecological perspectives
(pp. 168–189). New York: Wiley.
Mikton, C., & Butchart, A. (2009). Child maltreatment
prevention: A systematic review of reviews. Bulletin
of the World Health Organization, 87, 353–361.
Miller-Perrin, C. L., & Perrin, R. D. (2012). Child
maltreatment: An introduction (3rd ed.). Thousand
Oaks, CA: Sage.
Milner, J. (1998). Individual and family characteristics
associated with intrafamilial child physical and sexual
abuse. In P. Trickett & C. Schellenbach (Eds.),
Violence against children in the family and the
community (pp. 141–170). Washington, DC:
American Psychological Association.
National Research Council. (1993). Understanding child
abuse and neglect. Washington, DC: National
Academy Press.
Olds, D., Eckenrode, J., Henderson, C., Kitzman, H.,
Powers, J., Cole, R., et al. (1997). Long-term effects
of home visitation on maternal life course and
child abuse and neglect: A 15-year follow-up of a
randomized trial. Journal of American Medical
Association, 278, 637–643.

Abuse During Childhood
Ondersma, S. J. (2002). Predictors of neglect within
low-SES families: The importance of substance
abuse. American Journal of Orthopsychiatry, 72,
383–391.
Peter, T. (2009). Exploring taboos: Comparing male- and
female-perpetrated child sexual abuse. Journal of
Interpersonal Violence, 24, 1111–1128.
Portwood, S. G. (1999). Coming to terms with
a consensual definition of child maltreatment. Child
Maltreatment, 4, 56–68.
Prinz, R. J., Sanders, M. R., Shapiro, C. J., Whitaker, D. J.,
& Lutzker, J. R. (2009). Population-based prevention
of child maltreatment: The U.S. Triple P System
population trial. Prevention Science, 10, 1–12.
Russell, B. S., Britner, P. A., & Woolard, J. L. (2007). The
promise of primary prevention home visiting
programs: A review of potential outcomes. Journal of
Prevention & Intervention in the Community, 34,
129–147.
Sandler, I. N., Schoenfelder, E. N., Wolchik, S. A., &
MacKinnon, D. P. (2011). Long-term impact of prevention programs to promote effective parenting: Lasting effects but uncertain processes. Annual Review of
Psychology, 62, 299–329.
Shapiro, C. J., Prinz, R. J., & Sanders, M. R. (2010).
Population-based provider engagement in delivery of
evidence-based parenting interventions: Challenges
and solutions. The Journal of Primary Prevention,
31, 223–234.
Silovsky, J. F., Bard, D., Chaffin, M., Hecht, D., Burris, L.,
Owora, A., et al. (2011). Prevention of child maltreatment in high-risk rural families: A randomized clinical
trial with child welfare outcomes. Child and Youth
Services Review, 33, 1435–1444.
U. S. Department of Health and Human Services,
Administration on Children, Youth, and Families,
Children’s Bureau. (2010). Child maltreatment 2009.
Retrieved March 29, 2013, from http://www.acf.hhs.
gov/programs/cb/stats_reserach/index.htm#can
Webster-Stratton, C. (2007). The Incredible Years parent
training manual: BASIC program (3rd ed.). Seattle,
WA: Incredible Years.

Aggressive Behavior Prevention During Childhood

Aggressive Behavior Prevention
During Childhood
Douglas Smith, Andrew Stuck and
Brayton Tompkins
Department of Psychology, Southern Oregon
University, Ashland, OR, USA

Introduction
Although serious acts of aggression including
assaults, robberies, and even homicides involving
children as perpetrators can and do occur,
these are, by and large, extremely rare events
(DeVoe & Bauer, 2010). Of much greater concern to teachers, parents, and others who interact
with children on a regular basis are relatively low
level acts of aggression such as teasing, arguing,
minor physical, and verbal altercations and
other forms of interpersonal conflict that
are often viewed as part of normal childhood
development. Research suggests that these types
of minor aggressive acts occur frequently
among children and if left undeterred may
evolve into more serious types of aggression
in later childhood and adolescence (Dodge
Greenberg, Malone, & Conduct Problems
Research Group, 2008; Dymnicki, Weissberg, &
Henry, 2012).
The purpose of this entry is to review the status
and evolution of aggressive behavior in children
with an eye toward identifying both the key
developmental factors in its emergence and
the most successful options for preventing or
reducing its occurrence and impact. We will
begin with a more detailed discussion of what
constitutes aggressive behavior in childhood and
its prevalence as a function of certain key
moderating variables including family, school,
and peer influences.

Definitions and Scope
Although children’s aggression can take many
forms, it typically includes relatively low-impact

555

transgressions such as teasing, name-calling,
rumoring, and physical offenses including pushing, kicking, hitting, and biting. Evidence from
a number of recent national surveys including the
California Healthy Kids Survey (California
Department of Education, 2010) and the Indicators of School Crime and Safety (Dinkes,
Kemp, & Baum, 2009) suggests that these types
of behaviors are quite common among children in
preschool through elementary school years.
One particularly widespread form of aggressive
behavior among elementary-age children is bullying. This occurs most frequently in school settings
and is differentiated from other acts of peer
aggression by an imbalance in power between
the aggressor and the victim and by the fact that
it tends to occur repeatedly over time. Current
research suggests that between 15 % and 30 %
of students report being victimized by bullies at
school and almost 10 % are subjected to bullying
on a regular basis (Davidson & Demaray, 2007;
Nansel et al., 2001). More recently, there is
widespread concern about bullying that is
perpetuated via the Internet or mobile devices.
“Cyberbullying” or “cyber-aggression” poses an
additional threat to children and youth, particularly in more developed regions of the world
(Smith, 2012). Research indicates that bullying
and being bullied, whether through traditional or
“cyber” modes, are associated with poorer social
and emotional adjustment throughout the lifespan
(Frey, Newman, Nolen, & Hirschstein, 2012).
There is also considerable evidence for the
stability of aggressive behavior over time.
Young children who engage in frequent acts of
aggression often grow up to be aggressive adults,
engaging in more serious acts of violence such as
domestic abuse, assault, armed robbery, and
other crimes against persons (Farrington, 1994;
Haapasalo & Tremblay, 1994). Furthermore, stability of aggressive behavior occurs not only
within individuals but across generations as well
(Loeber & Stouthamer-Loeber, 1998).
Until fairly recently, aggressive behavior
among children was primarily considered as
a problem among boys. It is true that boys tend
to engage in direct forms of aggression such as
fighting and physical intimidation more

T.P. Gullotta, M. Bloom (eds.), Encyclopedia of Primary Prevention and Health Promotion,
DOI 10.1007/978-1-4614-5999-6, # Springer Science+Business Media New York 2014

556

frequently than girls, but we now know that girls
also aggress against peers, albeit in less direct
ways. Nicky Crick, at the University of Minnesota, has used the term “relational aggression” to
describe indirect aggression designed to harm
social relationships through exclusion, gossip,
and spreading of negative rumors. Studies suggest that up to 20 % of elementary school females
report engaging in or being victimized by relational aggression (Crick & Bigbee, 1998).
Since relational aggression as a form of victimization is more covert than physical aggression, it often goes undetected by teachers and
other adults. By increasing our awareness of the
range of both direct and indirect behaviors that
constitute aggressive victimization, we are in a
better position to identify the perpetrators early
and establish suitable prevention and intervention
strategies.

Theories
Aggressive behavior in children is the manifestation of a dynamic developmental interplay of
individual dispositions and social and cultural
factors within the contexts of schools, families,
and communities. No single theory can account
for the multiplicity of factors that contribute to
childhood aggression or reduce the likelihood of
its occurrence across multiple settings. In this
section we will briefly discuss several theoretical
models related to childhood aggression. These
include social learning theory, informationprocessing, and social-ecological models.
Social Learning Theory
The social learning theory approach to understanding aggressive behavior places primary
emphasis on the reciprocal nature of parentchild and child-child interactions in the
development of aggressive behavior. It is within
the context of everyday social exchanges
between family members and later within peer
groups that verbal and physical patterns of
aggression are learned.
Various researchers such as Gerald Patterson
and colleagues at the Oregon Social Learning

Aggressive Behavior Prevention During Childhood

Center (Granic & Patterson, 2006; Patterson &
Yoerger, 2002) and Donald Meichenbaum at the
Melissa Institute (Meichenbaum, 2009) have
described the developmental trajectory and
potential mechanisms through which aggressive
behavior is learned in young children. Such learning can occur in the context of families through
parental modeling of overly harsh, coercive, and
inconsistent discipline tactics including use of
physical punishment. Patterson and colleagues
refer to a “coercive family process,” in which
the child’s initial and subsequent noncompliance
with parental demands may be met by more and
more “extreme” measures to achieve compliance.
As the child’s resistance to such measures
increases, there is a tendency on the part of parents
to use even more coercive, aggressive strategies in
an effort to gain compliance or, alternatively, to
give in to the child’s noncompliance. In either
case, the child perceives aggression as an effective tactic for controlling others and reducing
aversive events. At the same time, there is less
opportunity for learning and practicing more
prosocial and adaptive problem-solving skills.
A major implication of the social learning theory
perspective on aggression is that, once
established, aggressive behavior is likely to
increase in both frequency and intensity over
time as a function of the positive outcomes
associated with its use.
The social learning perspective also highlights
the critical role of peers in the instigation and
proliferation of aggressive behavior. Favorable
peer reactions are powerful reinforcers of aggressive behavior in childhood, and some children
learn to orchestrate aggressive opportunities in
the interest of maximizing their status within the
peer group. In the case of bullying, for example,
bullies may achieve power and control in the eyes
of some peers by dominating weaker victims.
Information-Processing Model
The information-processing model is characterized by the work of Dodge and colleagues
(Crozier et al., 2008; Dodge et al., 2008)
who have studied the social-cognitive processes
typical of aggressive children. Aggressive behavior is viewed as resulting from systematic biases

Aggressive Behavior Prevention During Childhood

in the understanding and processing of social
cues and behaviors. Aggressive youth are often
described as having a “hostile attributional bias,”
whereby they interpret the behavior of others as
intentionally vengeful. Based upon this perception, aggression is justified as an appropriate
response.
In addition to cognitive biases, several other
social-cognitive limitations may be present
among aggressive children. For example,
research indicates that aggressive children are
frequently insensitive to the emotional needs
and reactions of others and are also limited in
their ability to solve interpersonal conflicts in
ways that demonstrate an understanding of
others’ perspectives. These types of socialcognitive deficiencies make it more likely that
aggressive actions will be employed, particularly
in social conflict situations.
Social-Ecological Model
The social-ecological model of children’s aggression places primary emphasis on the environments within which the child operates. In
addition to family and peer influences as
discussed previously, the broader environment
includes the contexts of school and community.
For example, school factors, such as classroom
climate, play a vital role in the extent and degree
of aggression expressed by young children
(Wilson, 2004). Aggressive children thrive in
school environments characterized by high
student-teacher ratios, inadequate supervision,
and lack of a school-wide policy that not only
prohibits aggression but also consistently encourages and reinforces prosocial behaviors. Teachers
and other school personnel can also play an
important enabling role if they fail to respond to
early incidents of aggression such as teasing,
pushing, shoving, and other relatively innocuous
forms of antisocial behavior. Tacit approval of
such by adults signals that prosocial behavior is
not the expected norm within the classroom.
Community factors that support and enable
aggressive patterns of behavior include the ecology of the child’s neighborhood and overall
degree of neighborhood safety. Students who
reside in unsafe neighborhoods are more likely

557

to witness acts of violence by others, perhaps
desensitizing them to the overall impact of violence. One study (Espelage, Bosworth, & Simon,
2000) found that students who perceived their
neighborhood as less safe were significantly
more likely to bully their peers than students
from safer neighborhoods.

Current Research
Current conceptualizations of aggressive behavior in children recognize that multiple factors
operate in a cumulative and reciprocal fashion
to promote aggression. These include individual
dispositions and temperamental factors, family
and peer influences, and factors within the
broader ecology including schools and communities. A growing body of research supports a
multidimensional developmental framework
whereby children acquire and express aggressive
behaviors as a product of social learning,
information-processing deficits, and the specific
environments in which they exist.
Meichenbaum’s (2009) model, for example,
posits that early-onset aggressive behavior can
be frequently linked to high-risk genetic as well
as early environmental influences, which may
promote and reinforce antisocial behavior in
young children. Such vulnerabilities often
include parental rejection and neglect, childhood
victimization, and social and cultural norms that
directly or indirectly support aggression as
a means of resolving conflict. Subsequent patterns of aggression in school often result in peer
rejection, discipline problems, lack of school
connectedness, and increased risk for academic
difficulties and school dropout.
Given the complexity and multiple pathways
through which aggressive behavior develops
throughout childhood, it is important that prevention and intervention efforts are comprehensive
and target multiple risk and protective factors.
Effective treatments must be delivered early;
should target multiple contexts including home,
school, and community; should be evidence
based; and require substantial collaborative
efforts in terms of service delivery systems.

558

Overview of Intervention Strategies
Aggression is a highly stable behavioral trait, so it
is important that prevention and intervention programs be developed early before these patterns
are established. Most intervention programs are
school and/or home based and involve both
targeted and universal components. Targeted
programs are often skill based and target children
who are already demonstrating a propensity
toward aggressive behavior or have characteristics that might place them at risk for such outcomes. Universal programs take place within the
school context, are preventive, and provide
opportunities for all students to acquire
a repertoire of prosocial skills as an alternative
to aggression. What works best are prevention
programs that target early signs of aggressive
behavior and programs that promote prosocial
norms and behaviors across multiple settings.
The effective programs described in the following section have in common the fact that they
include skill-based instruction in social and emotional competencies, nonaggressive alternatives
to conflict resolution, and other relevant socialcognitive skills delivered in school, home,
and community settings and targeting not only
children but teachers and families as well.
What Works
In terms of what works to prevent aggression in
childhood, it is clear that effective programs are
comprehensive in scope and target individual,
family, school, and community factors. In addition, these efforts are delivered early in the developmental trajectory and include such components
as social-cognitive skills training, anger management, parent education, and efforts to promote
academic success and engagement in school and
the community. In this section we briefly target
four exemplary approaches that have received
a substantial amount of empirical support.
Promoting Alternative Thinking
Strategies (PATHS)
PATHS is a universal prevention/intervention
program focused on developing social and emotional skills in children using a systematic,

Aggressive Behavior Prevention During Childhood

developmentally based, multiyear curriculum.
The
program
includes
both
preK/K
(Domitrovich, Greenberg, Kusche, & Cortes,
2004) and elementary grade-level (Greenberg,
Kusche, & Conduct Problems Prevention
Research Group, 2011) curriculums that target
domains such as self-control, relationships with
others, interpersonal problem-solving strategies,
self-esteem, and emotional understanding. As
a primary prevention effort, PATHS is designed
to be taught within a regular education classroom
and includes activities to intentionally promote
transfer and generalization of learned skills to the
broader environment. The program focuses on
building protective factors such as reflective
thinking, accurate evaluation of social situations,
frustration tolerance, management of difficult
emotions such as anger and disappointment, and
group cohesion and bonding, especially within
the classroom context. Family participation is
also encouraged through letters and information
to parents and use of homework assignments.
The research in support of PATHS as a
deterrent to aggression in young children is substantial. In a longitudinal 3-year controlled study
involving 2,937 early elementary students
(Conduct Problems Prevention Research Group,
2010), the PATHS curriculum was implemented
at schools varying widely in socioeconomic status. According to teacher ratings at the various
sites, there were decreases in conduct and behavior problems as well as increases in concentration, attention, and amount of work completed in
classrooms that utilized the PATHS curriculum.
There were also increases in examples of
prosocial behavior and the regulation of emotional arousal. According to peer ratings, there
was a decrease in the degree of aggression
displayed by students in the PATHS classrooms.
The program had the most impact on children
with mild or minor behavioral issues rather
than those who exhibited extreme forms of
aggression.
A number of other controlled studies with
elementary students in regular and special education settings have supported the value of PATHS
for improving emotional regulation and management and the ability to resolve interpersonal

Aggressive Behavior Prevention During Childhood

conflicts in a more socially appropriate fashion
(see, e.g., Greenberg, Kusche, Cook, & Quamma
(1995) and Riggs, Greenberg, Kusche, & Pentz
(2006)). In addition, studies completed in the
Netherlands, Germany, and England demonstrated significant reductions in aggression after
children and their families received PATHS
training for 1 year (Kusche & Greenberg, 2012).
Second Step
Second Step is a commercially available, schoolbased violence prevention program that focuses
on building social and emotional competencies in
children from preschool through middle school
(Committee for Children, 2002, 2008). As a universal or primary prevention curriculum, it aims to
reduce aggressive behavior by teaching children
prosocial thoughts and behaviors that lead to positive relationships with others. The curriculum is
built upon evidence-based strategies that enhance
social skills and thereby reduce aggression.
Second Step has been widely used in schools in
the United States and Canada and also translated
for use in various countries throughout the world.
The Second Step program focuses on three
major areas of social competence including
empathy, social problem-solving, and emotional
management. These skills are acquired through
a variety of modalities such as discussions, roleplaying, modeling, and coaching. The curricula
consist of lessons delivered in scripted form for
teachers and accompanied by video and other
support materials. The program also includes
a family component and homework activities in
an effort to involve family members in the learning and use of social-cognitive skills.
The research supporting this program is substantial and enhances the notion of a universal
social-emotional approach to prevention of
aggressive behavior. Controlled studies have
been conducted across a variety of age, racial,
and socioeconomic groups in both urban and
rural settings. In general, the Second Step curriculum has been found to result in increased
prosocial knowledge and attitudes, as well as
more positive social behavior.
One evaluative study by Frey, Nolen,
Edstrom, and Hirschstein (2005) with second-

559

through fifth-grade students in several schools in
the United States found that students participating in the Second Step program were rated as
more socially competent and less antisocial by
their teachers after 1 year in the program. The
greatest gains were made by students who were
initially rated as more antisocial by their teachers,
thereby supporting Second Step’s effectiveness
as both a universal and a targeted prevention
strategy for children already manifesting aggressive behavior concerns.
A randomized control group study by
Grossman et al. (1997) with almost 800 secondand third-grade students demonstrated significant
reductions in physical aggression for Second Step
participants compared to controls, as well as
increases in positive social behaviors. These findings were based on behavioral observations by
coders blind to treatment conditions, although
parent and teacher ratings of behavior did not
reflect these differences.
In Germany, a randomized control group
study of elementary-age children by Schick and
Cierpka (2005) found significant declines in
depressed, anxious, and socially withdrawn
behavior among children introduced to Second
Step for only one semester period. Parent ratings
indicated more substantial effects for girls than
for boys within the program.
A number of other studies conducted with
children from kindergarten through middle
school who participated in the Second Step intervention suggest that the program has a significant
impact on reduction of peer conflicts and antisocial behavior at school as well as increasing
prosocial knowledge and skills and overall social
competence (See Fitzgerald & Van SchoiackEdstrom, 2012 for a review).
The Incredible Years
The Incredible Years (IY) is a research-based prevention program comprised of three interlocking
training programs designed for children, parents,
and teachers (Webster-Stratton et al., 2001). The
goals of this comprehensive series are to treat
children with aggressive behavior issues; prevent
conduct problems and delinquency or drug abuse;
promote social competence, emotional regulation,

560

and academic readiness; and provide children
with effective problem-solving skills. Other
important goals include improving the parentchild relationship, improving parental functioning
by facilitating a more nurturing environment, and
teaching parents more effective problem-solving
skills. Since a large portion of this program also
focuses on the student-teacher relationship, it provides teachers with better classroom management
skills while creating a partnership between the
teacher and parents.
The child program consists of a weekly small
group therapy session where children learn to
express the full range of emotions in socially
appropriate ways. The core of the child program
consists of a curriculum administered by the
classroom teacher that focuses on other aspects
of social-emotional development such as conflict
resolution and anger management.
The teacher module of IY includes sections
devoted to understanding the importance of
teacher attention, praise and encouragement,
motivation via incentives, being proactive
with regard to behavioral issues, and building
relationships with students in a positive manner,
among other skills and information. Similarly,
in the parent raining module, the goal is to
teach parents proactive discipline strategies
as well as strategies for providing nurturance
and support.
With regard to the effectiveness of this program, there is an abundance of research promoting the validity of the IY series. According to one
review (Borden, Schultz, Herman, & Brooks,
2010), the IY curriculum significantly improves
the relationship between the schools and the
family in addition to reducing behavior problems,
including aggression, among students. IY
has been selected as an exemplary best practice
program and model program by the Rand
Corporation’s Promising Practices Network and
the Center for the Study and Prevention of
Violence at the University of Colorado.
Steps to Respect
Steps to Respect is a comprehensive school-based
aggression prevention program targeting the
dynamic and transactional nature of bullying

Aggressive Behavior Prevention During Childhood

and other forms of aggression in the context of
elementary classrooms. Rather than focusing
exclusively on the aggressor or the victims of
aggression, the program focuses on building
a school-wide climate where aggressive behavior
stands out because it violates acceptable norms.
It is designed to help schools develop antiaggression policies; enhance awareness of
aggression, particularly in the form of bullying,
and its impact upon students; and promote and
reward prosocial behavior.
Since aggressive behavior occurs within the
context of peer relations and the broader classroom environment, Steps to Respect seeks to
assist schools by developing clear antiaggression policies within the classroom and to
educate school personnel and students about how
to respond to incidents of aggression, as well as
providing specific and systematic training in
prosocial behavior. The classroom curriculum
includes training in general social-emotional
skills including emotional regulation as well as
activities designed to change teacher and
student attitudes toward high-frequency acts of
aggression such as bullying. For example, some
parts of the curriculum encourage students
to consider the short- and long-term impacts
of aggression on victims and to coach students
in appropriate ways to respond to aggressive
violations.
Numerous studies support the efficacy of Steps
to Respect as a comprehensive intervention to
reduce bullying and other forms of aggressive
behavior in elementary-age children (See Frey
et al., 2012 for a review). In randomized controlled outcome studies of the Steps to Respect
curriculum, researchers have documented reductions in bullying behavior (Frey et al., 2005),
declines in forms of relational aggression such
as spreading rumors (Low, Frey, & Brockman,
2010), and enhanced self-efficacy on the part of
bystanders to intervene in acts of aggression
(Frey et al., 2005; Frey, Hirschstein, Edstrom, &
Snell, 2009).
What Is Promising
In addition to the comprehensive, multicontextual approaches to aggression prevention

Aggressive Behavior Prevention During Childhood

described above, there are some promising intervention strategies that promote positive behavioral alternatives to aggressive behavior by
directly involving the classroom teacher or other
supportive adults as models for socially appropriate behavior. Two of the more promising
approaches are Positive Behavioral Interventions
and Supports and Big Brothers Big Sisters of
America, each of which is described in more
detail below.
Positive Behavioral Interventions and
Supports (PBIS)

Positive Behavioral Interventions and Supports
(Simonsen, Sugai, & Negron, 2008; Sprague &
Horner, 2012) refers to a general theoretical
approach to preventing aggressive behavior in
children by proactively establishing expectations
and incentives for nonaggressive behavior both at
school and at home. The focus of PBIS is on
establishing a social climate in which prosocial
behaviors are the norm, providing instruction in
the classroom and at home about how to behave
in a prosocial manner, and reinforcing specific
instances of those behaviors. Within the PBIS
framework, behavioral strategies are utilized as
needed depending on the level of support
required by particular individuals. For example,
students who are at risk of developing aggressive
behavior patterns or are already on their way to
such a trajectory are likely to require more intensive support in the form of skill training than their
more adept peers.
Importantly, PBIS utilizes reliable and systematic data collection as a means for assessing the
utility of specific intervention efforts. PBIS
is a highly structured and comprehensive schoolwide effort that teaches appropriate social behavior as the foundation for effective prevention of
aggressive behavior in children and youth.
PBIS was developed at the University of Oregon in collaboration with the National Center on
Positive Behavioral Interventions and Supports.
Major components of PBIS are based on decades
of research examining school discipline policies
across a number of fields including psychology,
education, public health, and criminology. A vast
amount of literature has accumulated supporting

561

the use of PBIS as a means of deterring aggression in young children.
Sprague and Horner (2012) provide an
excellent overview of much of the research
conducted by groups at the University of Oregon
(e.g., Horner et al., 2009; Sprague et al., 2002).
In general, outcomes of these randomized
controlled trials indicate reductions in problem
behavior in PBIS classrooms, enhanced perceptions of safety by both students and teachers, and
improved academic performance. In addition,
many studies report reductions in specific antisocial behaviors such as aggression and vandalism as
well as alcohol, tobacco, and other drug use.
Big Brothers Big Sisters of America
Big Brothers Big Sisters of America (BBBS) is
a distinctive and nationwide program that uses
one-on-one mentoring as a preventive aid
targeting youth living with an array of disadvantages. Most children enrolled come from singleparent households or are otherwise economically
disadvantaged, but BBBS also has specialty programs for those who come from marginalized
ethnicities such as African-American, Hispanic,
and Native American backgrounds, as well as
children whose parent(s) is(are) in the military
or have a parent who has been incarcerated.
Founded in the early 1900s, Big Brothers Big
Sisters has been in existence for more than
a century and is composed of several hundred
local agencies that serve more than 250,000
youth across the country.
The basic premise of the program is that adult
mentors can serve as role models and supportive
assistants in helping at-risk children to promote
positive development and social responsibility.
Rather than providing a specific curriculum or
intervention protocol, Big Brothers Big Sisters
depends on the influential impact of positive relationships to shape desirable behaviors. All mentors are volunteers ranging from teachers and
seniors to firemen and police officers. The success behind BBBS lies within the process by
which mentors and mentees develop a nurturing
and influential bond that models and promotes
prosocial behavior. More recently, Big Brothers
Big Sisters programming has evolved to include

562

both community-based and school-based
mentoring relationships, and research indicates
that both are promising avenues for reducing
aggressive behavior in children.
A recent evaluative study by Herrera,
Grossman, Kauh, and McMaken (2011) examined outcomes associated with participation in
Big Brothers Big Sisters within a sample of
1,139 9- to 16-year-old students in 10 cities
nationwide. Results indicated that program participants, as compared to a control group, were
more likely to report feeling supported by an
adult at school, had more positive perceptions of
school, and performed better academically.
Other studies have demonstrated that Big
Brothers Big Sisters participants are also less
likely to engage in specific aggressive and antisocial behaviors, such as hitting, both within and
outside school (Herrera, Sipe, McClanahan,
Arbreton, & Pepper, 2000).
What Does Not Work
What doesn’t work to prevent or reduce aggression
in childhood are primarily punitive strategies or
exclusionary programs whereby aggressive students are suspended from school or otherwise
removed from the normal school environment.
These strategies are overly simplistic and ignore
the dynamic interplay of individual and ecological
factors that support aggressive behavior in children. Research indicates that punitive strategies
may actually increase aggressive behavior, perhaps by modeling acts of aggression. Exclusionary
strategies, based on the notion of “zero tolerance,”
serve to exclude the aggressive student from positive socialization experiences, while often
increasing contact with other antisocial peers.
In addition, short-term interventions that do
not include built in follow-up or generalization
efforts are unlikely to produce significant or
meaningful long-term changes in aggressive
behavior.

Summary
Clearly, there is no single strategy for eradicating
children’s aggression or for establishing a school,

Aggressive Behavior Prevention During Childhood

family, and community climate that promotes
prosocial actions and respect for all. The United
States Department of Education in its document
entitled “Preventing Bullying: A Manual for
Schools and Communities” (United States
Department of Education, 1998) specifies several
considerations for schools, parents, and communities who are serious about the effort to prevent
and/or reduce aggressive behavior, including bullying, in young children. These include (1) early
intervention efforts beginning as children enter
kindergarten and continuing throughout a child’s
formal education, (2) an ongoing commitment on
the part of school and community personnel and
strong leadership that will support this effort,
(3) commitment to continuing staff development
and training, (4) use of culturally sensitive
materials that are developmentally appropriate
to students, and (5) parental and community
involvement in the planning and execution of
programs. All of the above considerations illustrate the fact that prevention of childhood aggression requires a comprehensive and sustained
effort involving multiple stakeholders including
teachers and schools, families, the community,
and the larger cultural context in which aggression occurs.

References
Borden, L. A., Schultz, T. R., Herman, K. C., & Brooks,
C. M. (2010). The Incredible Years Parent Training
Program: Promoting resilience through evidencebased prevention groups. Group Dynamics: Theory,
Research, and Practice, 14, 230–241.
California Department of Education. (2010). California
Healthy Kids Survey web site. Retrieved August
14, 2012, from http://chks.wested.org/
Committee for Children. (2002). Second step: A violence
prevention curriculum, preschool/kindergarten-grade
5 (3rd ed.). Seattle, WA: Author.
Committee for Children. (2008). Second step: Student
success through prevention, middle school. Seattle,
WA: Author.
Conduct Problems Prevention Research Group. (2010).
The effects of a multiyear universal social-emotional
learning program: The role of student and school characteristics. Journal of Consulting and Clinical Psychology, 78, 156–168.
Crick, N. R., & Bigbee, M. A. (1998). Relational and overt
forms of peer victimization: A multi-informant

Aggressive Behavior Prevention During Childhood
approach. Journal of Consulting and Clinical Psychology, 66, 337–347.
Crozier, J. C., Dodge, K. A., Fontaine, R. G., Lansford,
J. E., Bates, J. E., Pettit, G. S., et al. (2008). Social
information processing and cardiac predictors of adolescent antisocial behavior. Journal of Abnormal Psychology, 17, 253–267.
Davidson, L. M., & Demaray, M. K. (2007). Social support as a moderator between victimization and internalizing/externalizing behaviors from bullying. School
Psychology Review, 36, 383–405.
DeVoe, J. F., & Bauer, L. (2010). Student victimization in
U.S. schools: Results from the 2007 school crime supplement to national crime victimization survey.
Washington, DC: National Center for Education Statistics, Institute of Education Science, U.S. Department
of Education.
Dinkes, R., Kemp, J., & Baum, K. (2009). Indicators of
school crime and safety: 2009 (NCES 2010–012/NCJ
228478). Washington, DC: National Center for Education Statistics, Institute of Education Sciences,
U.S. Department of Education, and Bureau of Justice
Statistics, Office of Justice Programs, U.S. Department
of Justice.
Dodge, K. A., Greenberg, M. T., Malone, P. S., & Conduct
Problems Research Group. (2008). Testing an idealized cascade model of the development of serious
violence in adolescence. Child Development, 79,
1907–1927.
Domitrovich, C., Greenberg, M. T., Kusche, C. A., &
Cortes, R. (2004). Preschool PATHS. Deerfield, MA:
Channing-Bete.
Dymnicki, A. B., Weissberg, R. P., & Henry, D. B. (2012).
Understanding how programs work to prevent overt
aggressive behaviors: A meta-analysis of mediators of
elementary school-based programs. Journal of School
Violence, 10, 315–337.
Espelage, D. L., Bosworth, K., & Simon, T. R. (2000).
Examining the social context of bullying behaviors in
early adolescence. Journal of Counseling & Development, 78, 326–333.
Farrington, D. P. (1994). Childhood, adolescent and adult
features of violent males. In L. R. Huesman (Ed.),
Aggressive
behavior:
Current
perspectives
(pp. 215–240). New York: Plenum.
Fitzgerald, P. D., & Van Schoiack-Edstrom, L. (2012).
Social and emotional skills training with second
step: A violence prevention curriculum. In S. R.
Jimerson, A. B. Nickerson, M. J. Mayer, & M. J.
Furlong (Eds.), Handbook of school violence
and school safety: International research and practice
(2nd ed., pp. 423–433). New York: Routledge.
Frey, K. S., Hirschstein, M. K., Edstrom, L. V., & Snell,
J. L. (2009). Observed reductions in school bullying,
nonbullying aggression, and destructive bystander
behavior: A longitudinal evaluation. Journal of Educational Psychology, 101, 466–481.
Frey, K. S., Hirschstein, M. K., Snell, J. L., Edstrom, L. V.,
MacKenzie, E. P., & Broderick, C. J. (2005). Reducing

563
playground bullying and supporting beliefs: An experimental trial of the steps to respect program. Developmental Psychology, 41, 479–491.
Frey, K. S., Newman, J. B., Nolen, S., & Hirschstein,
M. K. (2012). Reducing bullying and contributing
peer behaviors: Addressing transactional relationships
within the school social ecology. In S. R. Jimerson,
A. B. Nickerson, M. J. Mayer, & M. J. Furlong (Eds.),
Handbook of school violence and school safety: International research and practice (2nd ed., pp. 383–395).
New York: Routledge.
Granic, I., & Patterson, G. R. (2006). Toward a comprehensive model of antisocial development: A dynamic
systems approach. Psychological Review, 113,
101–131.
Greenberg, M. T., Kusche, C. A., & Conduct Problems
Prevention Research Group. (2011). Grade level
PATHS (grades 3–5). Deerfield, MA: Channing-Bete.
Greenberg, M. T., Kusche, C. A., Cook, E. T., & Quamma,
J. P. (1995). Promoting emotional competence in
school-aged children: The effects of the PATHS curriculum. Development and Psychopathology, 7,
117–136.
Grossman, D. C., Neckerman, H. J., Koepsell, T. D.,
Liu, P. Y., Asher, K. N., Beland, K., et al. (1997).
Effectiveness of a violence prevention curriculum
among children in elementary school: A randomized
controlled trial. Journal of the American Medical
Association, 277, 1605–1611.
Haapasalo, J., & Tremblay, R. E. (1994). Physically
aggressive boys from ages 6 to 12: Family background,
parenting behavior, and prediction of delinquency.
Journal of Consulting and Clinical Psychology, 62,
1044–1052.
Herrera, G., Grossman, J. B., Kauh, T. J., & McMaken, J.
(2011). Mentoring in schools: An impact study of Big
Brothers Big Sisters school-based mentoring. Child
Development, 82, 346–361.
Herrera, C., Sipe, C. L., McClanahan, W. S., Arbreton,
A. J. A., & Pepper, S. K. (2000). Mentoring school-age
children: Relationship development in communitybased and school-based programs. Philadelphia: Public/Private Ventures.
Horner, R. H., Sugai, G., Eber, L., Nakasato, J., Todd, A.,
& Esperanza, J. (2009). A randomized wait-list controlled effectiveness trial assessing school-wide positive behavioral supports in elementary schools. Journal
of Positive Behavior Interventions, 11, 133–144.
Kusche, C. A., & Greenberg, M. T. (2012). The PATHS
curriculum: Promoting emotional literacy, prosocial
behavior, and caring classrooms. In S. R. Jimerson,
A. B. Nickerson, M. J. Mayer, & M. J. Furlong (Eds.),
Handbook of school violence and school safety: International research and practice (2nd ed., pp. 435–446).
New York: Routledge.
Loeber, R., & Stouthamer-Loeber, M. (1998). Development of juvenile aggression and violence: Some common misconceptions and controversies. American
Psychologist, 53, 242–259.

564
Low, S. S., Frey, K. S., & Brockman, C. (2010). Gossip on
the playground: Changes associated with universal
intervention, retaliation beliefs, and supportive friendships. School Psychology Review, 39, 536–551.
Meichenbaum, D. (2009). How to make an aggressive
youth: Implication for prevention and treatment.
Melissa Institute for Violence Prevention. Retrieved
July 30, 2012, from http://www.melissainstitute.org/
documents/Howtomakeyouthviolent.pdf
Nansel, T., Overpeck, M., Pilla, R. S., Ruan, W. J.,
Simmons-Morton, B., & Schmidt, P. (2001). Bullying
behaviors among US youth. JAMA: Journal of the
American Medical Association, 285, 2094–2100.
Patterson, G. R., & Yoerger, K. (2002). A developmental
model for early- and late-onset delinquency. In
J. B. Reid, G. R. Patterson, & J. Snyder (Eds.), Antisocial behavior in children and adolescents:
A developmental analysis and model for intervention
(pp. 147–172). Washington, DC: American Psychological Association.
Riggs, N. R., Greenberg, M. T., Kusche, C. A., & Pentz,
M. A. (2006). The mediational role of neurocognition
in the behavioral outcomes of a social-emotional prevention program in elementary school students:
Effects of the PATHS curriculum. Prevention Science,
7, 91–102.
Schick, A., & Cierpka, M. (2005). Faustlos: Evaluation of a
curriculum to prevent violence in elementary schools.
Applied and Preventive Psychology, 11, 157–165.
Simonsen, B. M., Sugai, G., & Negron, M. (2008).
School-wide positive behavioral support: Primary
systems and practices. Teaching Exceptional

Aggressive Behavior Prevention During Childhood
Children, Special Issue: Positive Behavioral Interventions and Supports, 40, 32–40.
Smith, P. K. (2012). Cyberbullying and cyber aggression.
In S. R. Jimerson, A. B. Nickerson, M. J. Mayer, &
M. J. Furlong (Eds.), Handbook of school violence and
safety: International research and practice (2nd ed.,
pp. 93–103). New York: Routledge.
Sprague, J. R., & Horner, R. H. (2012). School wide
positive behavioral interventions and supports: Proven
practices and future directions. In S. R. Jimerson, A. B.
Nickerson, M. J. Mayer, & M. J. Furlong (Eds.), Handbook of school violence and safety: International
research and practice (2nd ed., pp. 447–462).
New York: Routledge.
Sprague, J. R., Walker, H., Golly, A., White, K., Myers,
D. R., & Shannon, T. (2002). Translating research
into effective practice: The effects of a universal
staff and student intervention on key indicators of
school safety and discipline. Education and Treatment of Children, 23, 495–511.
United States Department of Education. (1998).
Preventing bullying: A manual for schools and communities. Retrieved August 14, 2012, from http://
www.eric.ed.gov/PDFS/ED453592.pdf
Webster-Stratton, C., Mihalic, S., Fagan, A., Arnold, D.,
Taylor, T., & Tingley, C. (2001). The incredible years:
Parent, teacher, and child training series. Seattle,
WA: Incredible Years.
Wilson, D. (2004). The interface of school climate and
school connectedness and relationships with aggression and victimization. Journal of School Health, 74,
293–299.

Attention Deficit Hyperactivity Disorder During Childhood

565

Definitions

Attention Deficit Hyperactivity
Disorder During Childhood
Miriam Mulsow1, Melinda Corwin2,
Adam Schwebach3 and Shu Yuan4
1
Department of Human Development and
Family Studies, Texas Tech University,
Lubbock, TX, USA
2
Department of Speech, Language, and Hearing
Sciences, Texas Tech University Health Sciences
Center, Lubbock, TX, USA
3
The Neuropsychology Center of Utah, Clinton,
UT, USA
4
Department of Human Development & Family
Studies, Texas Tech University, College of
Human Services, Lubbock, TX, USA

Introduction
There has been an explosion of research into
various aspects of ADHD over the past several
years. Even with all of this interest, however,
there is still no confirmed method of preventing
ADHD from occurring. There are some promising studies that suggest factors that may contribute to ADHD or its severity. Much work has
been done on dietary contributions, exposure to
natural environments, working memory training, mindfulness training, and rigorous physical
activity.
Multimodal treatment that includes both
behavioral intervention and medication, as well
as neurofeedback, has been shown to help
children with ADHD to function more like their
peers without ADHD, when these treatments are
sustained. Thus, children with ADHD who are
treated with medication and behavioral interventions, with or without neurofeedback, are more
likely than children with untreated ADHD to
avoid some of the secondary problems that arise
from living with ADHD. However, no treatment
has been found, to date, that has effects that
continue over the long term after treatment is
terminated. Thus, treatment needs to be sustained
for all but those children in whom ADHD symptoms subside on their own as children mature.

Attention deficit hyperactivity disorder (ADHD)
is the most commonly diagnosed behavioral disorder of childhood. Core symptoms include developmentally inappropriate levels of attention,
hyperactivity, distractibility, and impulsivity
(National Institutes of Health [NIH], 2013) that
appear before age 7 years, persist longer than
6 months, and create problems in multiple settings
(e.g., home, school, work, peer group). Not all
symptoms need to be present for a diagnosis.
ADHD has also been called attention deficit disorder, hyperactive child syndrome, hyperkinesis,
minimal brain dysfunction, hyperkinetic syndrome of childhood, and hyperkinetic disorder.
Inattention symptoms include carelessness,
difficulty sustaining concentration, reluctance
and difficulty organizing and completing work
correctly, failure to follow through, tendency to
lose things, excessive forgetfulness, and high distractibility. Hyperactivity refers to excessive
movement, restlessness, fidgetiness, or excessive
talking. Impulsivity, an inability to inhibit behavior, makes it difficult to stop and think before
behaving or to delay gratification.
Comorbidity means the existence of two different conditions in the same person. ADHD is
commonly comorbid with conduct disorder
(CD) or oppositional defiant disorder (ODD).
These two terms are sometimes used interchangeably, although ODD may be more accurately described as an earlier, less severe
disorder similar to CD.

Scope
Prevalence estimates for ADHD range from
78–10 % to 3–10 % of the child population and
1–5 % of the adult population (NIH, 2013).
Dulcan, Dunne, Ayers, Arnold, Benson, and
associates (1997) report a prevalence of 10.1 %
of males and 3.3 % of females aged 4–11 years
in Ontario, Canada. Children with ADHD are at
risk to repeat a grade, be suspended from school,
exhibit conduct disorder and other behavioral
problems, have delays in language development,

T.P. Gullotta, M. Bloom (eds.), Encyclopedia of Primary Prevention and Health Promotion,
DOI 10.1007/978-1-4614-5999-6, # Springer Science+Business Media New York 2014

566

have memory deficits, make lower grades than
they seem to be capable of making, and experience social rejection, depression, anxiety, accidental injuries, risk-taking behavior, poor sense
of time, and sleep problems (Barkley, 1997;
Rabiner, 2013). Family relationships are also
impaired, with families of children with ADHD
reporting more stress, frustration, disappointment, guilt, fatigue, marital dysfunction,
divorce, apsychological disorders including
ADHD and depression in parents, and family
therapy (Fisher, 1990). Individuals with ADHD
consume numerous resources and attention from
the health-care system, criminal justice system,
schools, and other social service agencies (NIH,
2013). “Additional national public school
expenditures on behalf of students with ADHD
may have exceeded $3 billion in 1995”. Moreover, ADHD, often in conjunction with
coexisting conduct disorders, contributes to
societal problems such as violent crime and
illegal substance abuse (NIH).
Long-term problems are common among
adults with a history of ADHD in childhood.
Some of these are more prevalent among adults
who continue to have diagnosable levels of
ADHD symptoms, but some occur even in those
who no longer meet diagnostic criteria (Barkley,
1997; Rabiner, 2013). Among problems that have
been reported at elevated levels in adults who
have ADHD or who have a history of ADHD in
childhood are occupational underachievement;
substance abuse; depression; impulsivity; isolation; low educational attainment; early,
unintended pregnancy; marital disruption; inadequate financial and other resources; poor coping
skills; impulsive spending; arrests; gambling;
accidents;
impulsive
aggression/violence;
delayed development; poverty; excessive driving
violations; failed marriages; and antisocial
behavior. For example, among the children with
ADHD followed prospectively into adulthood in
various studies, 28 % experienced major depression, 75 % reported interpersonal problems,
almost 10 % attempted suicide, 20 % committed
acts of physical aggression, 36–52 % were
arrested at least once, 30–32 % never completed
high school, only 5 % completed a university

Attention Deficit Hyperactivity Disorder During Childhood

degree, 17 % contracted a sexually transmitted
disease, and 42 % had their licenses suspended or
revoked (Barkley, 1998).

Theories
According to Barkley (1997), children with
ADHD primarily lack self-control/self-regulation, and problems with attention are secondary.
During development, a child’s behavior gradually shifts from external to internal controls,
rules, and standards, termed “self-control.” Selfcontrol requires the ability to delay response to
stimuli long enough to consider those internal
rules and standards and possible consequences
of violating those rules and standards. Children
with ADHD know the rules but lack ability to
apply what they know before responding to
stimuli.
In true ADHD, this lack of self-control is due
to nature (biological causes) rather than nurture
(parenting or other factors in the child’s current
environment) (Barkley, 1997). These same deficits interfere with the child’s working memory,
self-talk/internalized speech, sense of time, as
well as ability to set and work toward goals.
Lacking the ability to consider and respond to
internal cues, children with these deficits respond
much more readily to external, immediate consequences for their actions than to longer-term consequences. Thus, these children need a system of
external prompts, cues, and feedback (Rabiner,
2013).
Attention restoration theory suggests that
children with ADHD respond to natural environments because they provide an opportunity to
“recharge” from situations that make high
demands on their ability to direct their attention.
This theory suggests that attention is either
voluntary/directed or involuntary/natural. Voluntary attention requires conscious effort
because it involves things to which it is not
inherently easy to attend, thus leading to fatigue.
Exposure to nature allows the child to use involuntary attention and rest from this fatigue
(Rabiner, 2013).

Attention Deficit Hyperactivity Disorder During Childhood

Current Research
Primary prevention involves identifying
methods to prevent ADHD from occurring in
the first place. ADHD has been strongly linked
to genetic factors (Rabiner, 2013). A child
with ADHD has a 64 % chance of having at
least one parent with ADHD or a history of the
disorder (Evans, Vallano, & Pelham, 1994). If
researchers can identify which genes are implicated in ADHD, they may eventually be able to
prevent the disorder from occurring; however,
further research is needed. Secondary prevention involves identifying and treating ADHD
(or risk factors for ADHD) early in hopes of
eliminating problems that could occur because
of the disorder. Tertiary prevention involves
improving treatments for persons with ADHD
so that they can function as optimally and successfully as possible throughout their lifespan.
Much of the current ADHD research involves
secondary and tertiary prevention, as described
in the following paragraphs.
Dietary factors may contribute to ADHD
symptoms in some individuals. If this is the
case, then one possible way to prevent ADHD is
to modify diet. Howard et al. (2011) found that
a Western-style diet (i.e., foods that are high in
total fat, saturated fat, refined sugars, and
sodium) may be associated with ADHD. The
researchers compared 1,799 adolescents regarding whether they had a “Western” or “healthy”
diet pattern and whether their scores were high or
low on their respective dietary type. Of those
adolescents, 115 (approximately 6 %) had been
diagnosed with ADHD. Findings revealed that
a higher score for the Western-style dietary pattern was associated with an adolescent diagnosis
of ADHD. However, because the study was
cross-sectional in design, no causal conclusions
could be made. One possible explanation could
be that individuals who already have ADHD tend
to make poorer food choices (i.e., higher score
Western diets) rather than high score Western
diets leading to ADHD. Additionally, this study
did not examine dietary changes and their effects
on ADHD symptoms. Thus, one cannot conclude
that dietary changes will alter ADHD

567

characteristics. One other interesting finding
from this study was that physical exercise at
least twice per week was associated with statistically decreased odds of having ADHD.
Some studies have examined the benefits of
physical activity for improving behavior and cognitive abilities in individuals with ADHD. Verret,
Guay, Berthiaume, Gardiner, and Beliveau
(2010) conducted an exploratory study with
21 children ages 7–12 years who had been diagnosed with ADHD. Results revealed that the
group of children who participated in a 10-week
fitness program involving moderate- to highintensity physical activity demonstrated
improved muscular capacities, motor skills,
behavior (as reported by parents and teachers),
and levels of information processing (sustained
auditory attention). However, participants were
not randomly assigned to the experimental versus
control group, and parents and teachers were
aware of the participants that received the fitness
training; thus, overall conclusions are limited.
Additional studies are needed that involve larger
samples, random assignment to groups, and
parent/teacher raters who are blind to treatment
versus control group membership.
While there is no known method for
preventing the onset of symptoms or diagnosis
of ADHD, some studies have investigated how to
prevent ADHD symptoms from worsening and/or
negatively affecting the daily lives of individuals
with ADHD in a detrimental way (i.e., tertiary
prevention). The Multimodal Treatment Study of
Children with ADHD (MTA Cooperative Group,
1999) involved 579 children from multiple sites
who were carefully diagnosed with ADHD. Participants were randomly assigned to one of four
group conditions as follows: (1) medication treatment only, (2) behavior treatment only, (3) combined medication and behavior therapy, or
(4) routine community care (control group). The
group who received combined medication and
behavioral treatment showed greater benefits in
terms of improved ADHD symptoms as well as
decreased anxiety symptoms and slightly
increased parent-child relations (as reported by
parents), social skills (as report by teachers), and
reading achievement. The experimental period

568

lasted for 14 months. However, results of a
follow-up study conducted 22 months later
revealed no indication that the benefits continued
beyond the treatment period. Also, approximately half of the children in all four groups
continued to meet the diagnostic criteria for
ADHD. Three classes of children were identified,
without respect to which treatment group they had
been assigned, as follows: Class 1, who showed
a gradual improvement over time; Class 2, who
showed an initially larger improvement that was
maintained over time; and Class 3, who initially
showed a positive response but then returned to
baseline symptom levels. It should be noted that
Class 2 children came from families with a higher
socioeconomic status (SES) and had higher scores
on baseline measures compared to children in the
other two classes.
Molina et al. and the MTA group (2009) completed a follow-up study 8 years after the initial
study which revealed no significant differences on
any of the 20 outcome measures based on the group
to which individuals were initially assigned. Children from all four groups demonstrated improvement relative to baseline measures, and there was
a decline in use of medication over time for all
groups. Relative to the three different classes identified 8 years earlier, the Class 2 participants continued to demonstrate better improvements over
time compared to Class 1 or Class 3 groups, indicating that initial response to treatment (regardless
of the type of treatment) was a better predictor of
longer-term outcomes than type of treatment.
Despite overall improvement in functioning for
the individuals with ADHD, these individuals still
had higher incidences of antisocial behavior, delinquency, and academic struggles compared to sameage peers without any history of ADHD. Thus,
additional information regarding tertiary prevention of ADHD is needed.

Overview of Strategies
Primary prevention of ADHD is not yet possible;
however, research in the area of genetics may
someday allow us to prevent the disorder before
it occurs. To date, no successful intervention has

Attention Deficit Hyperactivity Disorder During Childhood

been found that consistently prevents the dysfunction associated with ADHD throughout the
lifespan. Promising strategies related to secondary and tertiary prevention of ADHD include diet
modification, physical activity, and some combination of pharmaceutical and behavioral treatment. Individuals whose socioeconomic status
(SES) is adequate may fare better compared to
individuals with low SES. Additional research is
warranted in these areas.

What Works
Multimodal treatment consisting of medication
plus behavioral intervention (MTA Cooperative
Group, 1999) continues to be the most effective
means of preventing long-term problems among
children with ADHD, as long as that treatment is
continued. Effects are not sustained when treatment is discontinued, for most children. There
has been some concern about the abuse of medications for ADHD. Despite media attention
suggesting otherwise, nonmedical use (abuse) of
medications for ADHD among children
decreased sharply from 2000 to 2011 (Johnston,
O’Malley, Bachman, & Schulenberg, 2012),
although being asked for ADHD medications by
friends and family was still common. Furthermore, treatment with medication in childhood
reduces the likelihood of criminal behavior and
other negative outcomes in adulthood among
children with ADHD who still have ADHD as
adults (Lichtenstein et al., 2012).
While effect sizes are smaller than for multimodal treatment, a meta-analysis of studies of
neurofeedback shows that this treatment leads to
improvement in ADHD symptoms in the short
term. Long-term efficacy has not been confirmed,
but neither has it been confirmed for medication
or behavioral treatment (Lofthouse, Arnold,
Hersch, Hurt, & DeBeus, 2012).
There are credible, easily understood resources
available for learning about effective treatments
for ADHD, including websites for the National
Institutes of Health’s The Multimodal Treatment
of Attention Deficit Hyperactivity Disorder Study
(MTA): Questions and Answers (http://www.nimh.

Attention Deficit Hyperactivity Disorder During Childhood

569

nih.gov/health/trials/practical/mta/the-multimodaltreatment-of-attention-deficit-hyperactivity-disorderstudy-mta-questions-and-answers.shtml); CHADD,
Children and Adults with Attention-Deficit/
Hyperactivity Disorder (http://www.chadd.org/
Understanding-ADHD/Adults-with-ADHD/Evaluation-and-Treatment.aspx); and Dr. David
Rabiner’s Attention Research Update Archives
(http://www.helpforadd.com/archives.htm).

Essential Fatty Acids (Omega-3): Increasing
omega-3 fatty acids reduces hyperactivity, and
supplementation with EPA/DHA has been
shown to improve inattention, hyperactivity,
oppositional/defiant behavior, and conduct disorder among children with ADHD (Rabiner, 2013;
Transler, Eilander, Mitchell, & Meer, 2010).
These essential fatty acids can be found at high
levels in fatty fish such as salmon and tuna as well
as in flax seed.

What Is Promising

Exercise and Meditation
Mindfulness training has been shown to improve
parent-child relationships in families of children
with ADHD when both parents and children participate. It also was linked to reduced ADHD
symptoms in parents’, but not teachers’ reports
(van der Oord, Bögels, & Peijnenburg, 2012).
Rigorous physical activity that is done frequently and consistently is associated with
improvements in neuropsychological functioning, as reported by both teachers and parents.
However, this exercise alone is not enough to
get children with ADHD into the range of children without ADHD (Rabiner, 2013).

Diet
Breastfeeding children for a minimum of six
months has been found to be associated with
lower levels of ADHD, when breastfed children
were compared to children whose mothers did not
breastfeed or breastfed for shorter periods of time
(Kadziela-Olech & Piotrowska-Jastrzebska,
2005; Mimouni-Bloch et al., 2013).
Higher levels of DHEA were associated with
fewer symptoms of ADHD, and treatment for
ADHD increased levels of DHEA (Maayan
et al., 2003; Strous et al., 2001).
Among children with low zinc levels, zinc
supplementation was shown to reduce hyperactivity and impulsivity symptoms, but not inattention symptoms. Children with symptoms of
hyperactivity and impulsivity should be tested
for low zinc levels, but zinc supplementation by
itself is not effective to treat or prevent ADHD.
Reduction in food additives for children who
are sensitive to these additives has been shown to
be effective in reducing ADHD-like symptoms.
Meta-analysis indicates that artificial colors such
as tartrazine significantly increase ADHD symptoms among some children diagnosed with
ADHD (McCann et al., 2007; Schab & Trinh,
2004). Reduction of food additives has not been
found to work for all or even most children who
exhibit ADHD symptoms. However, it is probably worth trying with all children suspected of
having ADHD. It is important to note that a child
does not have to have ADHD to have a sensitivity
to artificial food colors that results in behavioral
or attention problems when these additives are
consumed.

Working Memory Training
Children who participate in working memory
training have fewer symptoms of ADHD as
reported by their parents. However, studies have
not shown significant improvements in academic
performance as reported by teachers. A recent
study by Green and associates (2012) reports
that children with ADHD who have five weeks
of working memory training in their homes score
higher on a measure in the lab that predicts academic performance than controls. While promising, this study will have to be replicated, and
studies using teacher reports will be needed
before working memory training can be confirmed as effective for improving academic
performance.
Environment
Children who spend more time in sunlight have
fewer symptoms of ADHD. This may be related
to sleep disorders, which are common among
children with ADHD. Places with higher solar

570

intensity have lower rates of diagnosis of childhood ADHD (Rabiner, 2013).
Several studies have suggested that time spent
in nature reduces symptoms of ADHD. Taylor
and Kuo (2011) examined this by having children
take a 20-min walk in nature, then testing them on
a standardized measure of attention and concentration. Those children who walked in nature
exhibited higher levels of attention than those
who walked in urban or suburban settings
(Taylor & Kuo).
Children who are young for their grade have
higher rates of diagnosis of ADHD, as reported
by Evans, Morrill and Parente (2010) and
Rabiner (2013). Thus, it is important to make
sure that what is being observed is actually
ADHD and not simply immaturity caused by
the child being younger than average in his or
her class. This is not a treatment or prevention
strategy for ADHD, but is an important factor
when considering whether or not a child actually
has ADHD. In these cases, the child may need
to wait a year before starting school to allow
time to catch up with the rest of the class
(Evans et al., 2010).

What Does Not Work
Although there are many other reasons to
restrict the amount of television a child watches,
and some of these reasons (e.g., lack of exposure to sunlight, lack of exercise) are related to
factors that may contribute to more severe
symptoms of ADHD, eliminating television
has not been shown to prevent ADHD from
occurring.
Elimination of Sugar. The elimination of sugar
from the diet has not resulted in significant
improvement in ADHD symptoms. There are
promising results being found from more complex dietary restrictions, but results to date suggest that most dietary restrictions may only be
effective for a small subgroup of children who
have both ADHD symptoms and food allergies or
sensitivities (Dulcan et al., 1997).
Severe Discipline. Commonly, parents will
initially deny the existence of a disorder in

Attention Deficit Hyperactivity Disorder During Childhood

their children with ADHD and will attempt to
control their children’s behavior with increasingly strict discipline. Although a highly structured environment has been shown to be
effective in helping children with ADHD to
manage their disorder, severe discipline has
not. In fact, studies indicate that severe discipline contributes to a greater probability of
negative outcomes among children with ADHD
(Hoza et al., 2000).
Medication Without Any Other Intervention.
Often, parents and teachers of children with
ADHD are so relieved at the improvements seen
in children’s behavior after medication is introduced that they overlook the problems that
still exist despite the use of medication (MTA
Cooperative Group, 1999; NIH, 2013). Findings
are clear that medication alone will not prevent
long-term problems (Dulcan et al., 1997) among
many children with ADHD.

Summary
In summary, there is no way to prevent ADHD
currently available. Multimodal treatment
involving both medication and behavioral interventions, with medication continued over
the long term, has shown the highest level of
improvements
in
long-term
outcomes.
Neurofeedback has shown more modest levels
of improvement and must also be continued in
order to remain effective. A healthy diet, beginning with breastfeeding early and fatty fish or
other sources of essential fatty acids and DHEA
later, vigorous and frequent exercise, working
memory training, mindfulness training, and
spending time in nature and sunlight have all
shown promise and are probably worth trying
for all children with ADHD, in combination
with multimodal treatment. Making sure a child
actually has ADHD and not a deficiency in zinc,
immaturity due to being one of the youngest
children in a grade level, or sensitivity to food
additives is also important. In some cases,
a child who does have ADHD may need attention for both ADHD and one or more of these
issues.

Attention Deficit Hyperactivity Disorder During Childhood

References
Barkley, R. (1997). Behavioral inhibition, sustained attention, and executive functions: Constructing a unifying
theory of ADHD. Psychological Bulletin, 121, 65–94.
Barkley, R. A. (1998). Attention deficit hyperactivity
disorder: A handbook for diagnosis and treatment.
New York: Guilford Press.
Dulcan, M., Dunne, J. E., Ayers, W., Arnold, V., Benson,
S., & Bernet, W. (1997). Practice parameters for the
assessment and treatment of children, adolescents, and
adults with attention-deficit/hyperactivity disorder:
AACAP Official Action. Journal of the American
Academy of Child and Adolescent Psychiatry, 36(Supplement), 85S–121S.
Evans, W. N., Morrill, M. S., & Parente, S. T. (2010).
Measuring inappropriate medical diagnosis and treatment in survey data: the case of ADHD among schoolage children. Journal of Health Economics, 29(5),
657–673.
Evans, S. W., Vallano, G., & Pelham, W. (1994). Treatment of parenting behavior with a psychostimulant:
A case study of an adult with attention-deficit hyperactivity disorder. Journal of Child and Adolescent
Psychopharmacology, 4, 63–69.
Fisher, M. (1990). Parenting stress and the child with
attention deficit hyperactivity disorder. Journal of
Clinical Psychology, 19, 337–346.
Green, C., Long, D., Green, D., Iosif, A., Dixon, J.,
Miller, M., et al. (2012). Will working memory training generalize to improve off-task behavior in children
with
attention-deficit/hyperactivity
disorder?
Neurotherapeutics: The Journal of The American
Society for Experimental, Neurotherapeutics, 9(3),
639–648.
Howard, A. L., Robinson, M., Smith, G. J., Ambrosini,
G. L., Piek, J. P., & Oddy, W. H. (2011). ADHD
is associated with a “Western” dietary pattern in
adolescents. Journal of Attention Disorders, 15(5),
403–411.
Hoza, B., Owens, J., Pelham, W. E., Swanson, J. M.,
Connors, C. K., Hinshaw, S. P., et al. (2000). Parent
cognitions as predictors of child treatment response in
attention-deficit/hyperactivity disorder. Journal of
Abnormal Child Psychology, 28, 569–583.
Johnston, L. D., O’Malley, P. M., Bachman, J. G., &
Schulenberg, J. E. (2012). Monitoring the future
national results on adolescent drug use: Overview of
key findings, 2011. Ann Arbor, MI: Institute for Social
Research, The University of Michigan.
Kadziela-Olech, H., & Piotrowska-Jastrzebska, J. (2005).
The duration of breastfeeding and attention deficit
hyperactivity disorder. Roczniki Akademii Medycznej
w Bialymstoku, 50, 302–306.
Lichtenstein, P., Halldner, L., Zetterqvist, J., Sjölander,
A., Serlachius, E., & Fazel, S. (2012). Medication for
attention deficit–hyperactivity disorder and criminality. New England Journal of Medicine, 367(21),
2006–2014.

571
Lofthouse, N., Arnold, L., Hersch, S., Hurt, E., & DeBeus,
R. (2012). A review of neurofeedback treatment for
pediatric ADHD. Journal of Attention Disorders,
16(5), 351–372.
Maayan, R., Yoran-Hegesh, R., Strous, R., Nechmad, A.,
Averbuch, E., Weizman, A., et al. (2003). Threemonth treatment course of methylphenidate increases
plasma levels of dehydroepiandrosterone (DHEA) and
dehydroepiandrosterone-sulfate (DHEA-S) in attention deficit hyperactivity disorder. Neuropsychobiology, 48, 111–115.
McCann, D., Barrett, A., Cooper, A., Crumpler, D., Dalen, L.,
Grimshaw, K., et al. (2007). Food additives and hyperactive behaviour in 3-year-old and 8/9-year-old children
in the community: a randomised, double-blinded,
placebo-controlled trial. The Lancet, 370, 1560–1567.
Mimouni-Bloch, A., Kachevanskaya, A., Mimouni, F. B.,
Shuper, A., Raveh, E., & Linder, E. (2013).
Breastfeeding may protect from developing attentiondeficit/hyperactivity disorder. Breastfeeding Medicine, 8, 363–367.
Molina, B. S. G., Hinshaw, S. P., Swanson, J. M., Arnold,
L. E., Vitiello, B., Jensen, P. S., Epstein, J. N., Hoza,
B., Hechtman L., Abikoff, H. B., Elliott, G. R.,
Greenhill, L. L., Newcorn, J. H., Wells, K. C,
Wigal, T. L., Severe, J. B., Gibbons, R. D., Hur, K.,
Houck, P. R., and the MTA Cooperative Group (2009).
The MTA at 8 years: prospective follow-up of children
treated for combined type ADHD in a multisite study.
Journal of the American Academy of Child and
Adolescent Psychiatry, 48, 484–500.
MTA Cooperative Group. (1999). A 14-month randomized clinical trial of treatment strategies for attentiondeficit/hyperactivity disorder (ADHD). Archives of
General Psychiatry, 56, 1073–1086.
National Institutes of Health. (2013). The Multimodal
Treatment of Attention Deficit Hyperactivity Disorder
Study (MTA): Questions and Answers. Retrieved May
10, 2013, from http://www.nimh.nih.gov/health/trials/
practical/mta/the-multimodal-treatment-of-attentiondeficit-hyperactivity-disorder-study-mta-questionsand-answers.shtml
Rabiner, D. (2013). Attention Research Update Archives.
Retrieved May 10, 2013, from http://www.helpforadd.
com/archives.htm
Schab, D. W., & Trinh, N. H. (2004). Do artificial food
colors promote hyperactivity in children with hyperactive syndromes? A meta-analysis of double-blind
placebo-controlled trials. Journal of Developmental
and Behavioral Pediatrics, 25, 423–434.
Strous, R. D., Spivak, B., Yoran-Hegesh, R., Maayan, R.,
Averbuch, E., Kotler, M., et al. (2001). Analysis of
neurosteroid levels in attention deficit hyperactivity
disorder. International Journal of Neuropsychopharmacology, 4, 259–264.
Taylor, A. F., & Kuo, F. E. (2011). Could exposure to
everyday green spaces help treat ADHD? Evidence
from children’s play settings. Applied Psychology:
Health and Well-Being, 3, 281–303.

572
Transler, C., Eilander, A., Mitchell, S., & van de Meer, N.
(2010). The impact of polyunsaturated fatty acids in
reducing child attention deficit and hyperactivity disorders. Journal of Attention Disorders, 14, 232–246.
van der Oord, S., Bögels, S. M., & Peijnenburg, D. (2012).
The effectiveness of mindfulness training for children with ADHD and mindful parenting for their
parents. Journal of Child and Family Studies, 21(1),
139–147.
Verret, C., Guay, M., Berthiaume, C., Gardiner, P., &
Beliveau, L. (2010). A physical activity program
improves behavior and cognitive functions in children
with ADHD: An exploratory study. Journal of Attention Disorders, 14(2), 1–10.

Attention Deficit Hyperactivity Disorder During Childhood

Further Reading
CHADD: Children and Adults with Attention Deficit/
Hyperactivity Disorder. http://www.chadd.org/Understanding-ADHD/Adults-with-ADHD/Evaluation-andTreatment.aspx
Dr. David Rabiner’s Help for ADHD e-newsletter is
a wonderful resource that summarizes research findings on ADHD for practitioners, educators, and parents. This link is to an archive of all of his newsletters.
http://www.helpforadd.com/archives.htm
National Institutes of Health. http://www.nimh.nih.gov/
health/trials/practical/mta/the-multimodal-treatmentof-attention-deficit-hyperactivity-disorder-study-mtaquestions-and-answers.shtml

Bullying in Childhood

Bullying in Childhood
Pamela Orpinas1 and Arthur M. Horne2
1
Department of Health Promotion and Behavior,
University of Georgia College of Public Health,
Athens, GA, USA
2
Department of Counseling and Human
Development Services, University of Georgia,
Athens, GA, USA

Introduction
Aggression among children has been common
throughout history and continues to be a major
problem today. Neighborhoods and communities
cannot support healthy child development, nor can
schools be effective institutions of learning, if they
are not first and foremost safe. Yet many young
people face serious problems of bullying and victimization in their lives that could result in many
missed opportunities for growing up as healthy
young people. During the past decades, the
problem of bullying among schoolchildren has
been a major concern for many parents and educators around the world, as they have become
aware of its negative, and sometimes deadly,
consequences.

Definitions, Consequences, and Scope
Definitions. Researchers frequently define bullying as aggressive acts that are repeated over time
and directed against an individual who has less
power. Thus from this definition, not all aggressive acts are bullying. The bullying behavior has
three components. First, similar to all aggressive
acts, the behavior is intentionally meant to hurt
another person. For example, a boy injured as part
of rough-and-tumble play would not be a victim
of bullying or aggression. Second, the bullying
acts are constant. An aggressive event that happens only once, though not desirable, would not
fit the definition of bullying. Third, the perpetrator has more power than the victim (e.g., the
victim is smaller, weaker, younger, or less

573

skilled) (Orpinas & Horne, 2006). An aggressive
act that occurs between students of equal size and
ability, without an imbalance of power, also
would not be bullying. In spite of this definition,
some researchers, educators, and policy makers
use the term bullying less restrictively to refer to
any act of aggression against school peers.
Bullying takes several forms. Bullying may
be physical (e.g., hitting, pushing, or pulling
hair), verbal (e.g., teasing, ridiculing, or threatening), gestural (e.g., making threatening or
obscene gestures, giving mean looks, or rolling
the eyes), or relational (e.g., leaving someone
out of the group, not talking to someone, or
spreading rumors). A more recent form is
cyberbullying, which refers to using electronic
devices to harass others (e.g., posting online
rumors or embarrassing information or pictures;
sending insulting or threatening messages via
email, phone, or social networking sites; or
impersonating someone else online). Bullying
in the form of sexual harassment can take any
of these forms (Orpinas & Horne, 2006).
The bullying situation frequently encompasses three persons or groups: the bully, the
victim, and the bystander. Bullies can be aggressive or passive. The aggressive bully usually initiates the aggression and most commonly uses
physical and verbal aggression. The passive
bully does not initiate the aggression, but follows
along, joins in, or encourages others to be aggressive (Newman, Horne, & Bartolomucci, 2000).
Targets of bullying are often referred to as victims. This term is misleading, as victimization
implies a lack of ability to protect oneself,
which is sometimes inaccurate. Victims can be
passive or provocative. Passive victims are singled out without provocation, because they have
some characteristics that make them more vulnerable, such as not conforming to mainstream,
having few friends, lacking social skills, or simply being different. Provocative victims are those
whose inappropriate behavior continuously
annoy or provoke the bully. Bystanders, those
who witness the bullying, can also be categorized
into two groups: those who are part of the problem and those who are part of the solution.
Bystanders who are part of the problem

T.P. Gullotta, M. Bloom (eds.), Encyclopedia of Primary Prevention and Health Promotion,
DOI 10.1007/978-1-4614-5999-6, # Springer Science+Business Media New York 2014

574

encourage others to retaliate or may pass rumors
to enrage the bully. Bystanders who are part of
the solution will try to solve or defuse the
problem.
Consequences. The effects of bullying can
be far-reaching and may have an impact long
after childhood. Consequences of being the
target of aggression may include depression
and suicidal ideation (Hawker & Boulton,
2000), somatic complaints (Wolke, Woods,
Bloomfield, & Karstadt, 2001), and low selfesteem (O’Moore & Kirkham, 2001). The
targeted students are likely to have poor social
skills, report feeling unhappy and lonely, and
have few friends (Boulton & Underwood,
1992). Having a larger number of friends reduces
the likelihood of victimization, particularly if
those friends are not being victimized themselves
(Fox & Boulton, 2006). Victims are also likely
to avoid going to school because they fear for
their safety (Berthold & Hoover, 2000). An
examination of bullying in 28 countries showed
that victims were significantly more likely
than non-victims to report physical symptoms
(headache, stomach ache, backache, dizziness)
and psychological problems (bad temper, feeling
nervous, feeling low, difficulties in getting to
sleep, morning tiredness, feeling left out,
loneliness, helplessness), and the risk of having
physical or psychological symptoms increased
with the frequency of bullying (Due et al., 2005).
In extreme situations, bullying may result in
permanent physical injuries or even death. Dramatic events of school shootings and adolescent
suicide have heightened the attention on the seriousness of the problem of aggression. In an
examination of the characteristics of students
who bring weapons to school and shoot others
revealed that over two-thirds of the incidents had
a common theme: acting out of anger or revenge
for having been victimized by other students in
the school (Vossekuil, Fein, Reddy, Borum, &
Modzeleski, 2002).
Scope. While the exact number of bullying
incidents in schools and communities is difficult
to measure, three nationwide surveys in the
United States provide a good estimate of the
extent of the problem. The Division of

Bullying in Childhood

Adolescent Health of the Centers for Disease
Control and Prevention monitors high-risk
behaviors of youth, including injuries and violence, using the Youth Risk Behavior Survey
(YRBS). A nationally representative sample of
high school students attending public and private
schools in the United States completes this biannual survey. In 2011, for the second time, the
YRBS included one question on bullying victimization. Nationwide, 20 % of high school students reported being bullied on school property,
ranging between 24 % in ninth grade and 15 % in
twelfth grade (Centers for Disease Control and
Prevention, 2012).
In the 2011 School Crime Supplement to the
National Crime Victimization Survey, 28 % of
students aged 12–18 years reported being bullied
at school, ranging between 37 % in sixth grade
and 22 % in twelfth grade. The most common
form of bullying was being made fun of (18 %);
being subject of rumors (18 %); being pushed,
shoved, tripped, or spit on (8 %); being excluded
from activities on purpose (6 %); being threatened with harm (5 %); and trying to make them
do things they did not want to do or having their
property destroyed on purpose (3 %). In addition,
9 % reported being the victims of cyberbullying
(Robers, Kemp, & Truman, 2013).
Nansel and colleagues (2001) conducted
a survey of a nationally representative sample of
students in Grades 6–10 in public and private
schools throughout the United States. Of this
sample, 44 % reported bullying others (25 %
once or twice, 11 % sometimes, and 9 %
weekly), and 41 % reported being the victim of
bullying (24 % once or twice, 9 % sometimes,
and 8 % weekly). Among those who reported
being bullied, the five most common types of
bullying behaviors were being belittled about
looks or speech (62 %); being the subject of
rumors (60 %); being hit, slapped, or pushed
(56 %); being the subject of sexual comments or
gestures (52 %); and being belittled about religion or race (26 %).
Results from the three surveys conducted in the
United States have a number of common elements.
First, bullying was a prevalent problem among
youth. Second, the prevalence of bullying

Bullying in Childhood

victimization was higher among girls than boys.
Third, the prevalence of bullying victimization
was higher among White students than students
of other races or ethnicities. Fourth, middle school
students reported the highest prevalence bullying,
and this behavior decreased through high school.
International comparisons have shown large
differences of bullying behaviors across countries. The study by Nansel and colleagues was
part of the World Health Organization’s Health
Behavior in School-aged Children survey, which
included numerous European countries and Canada. Prevalence varied greatly by country, being
lowest in Sweden (13 %) and highest in Austria
(74 %) (Mercy, Butchart, Farrington, & Cerdá,
2002).

Theories
First and foremost, bullying is a learned behavior,
as highlighted by Social Cognitive Theory
(Bandura, 1986). While evidence is increasing
that there is a genetic component on physical
aggression, the response to anger and social
aggression is learned. Similar to other behaviors,
bullying is learned by observing other people’s
behavior but most importantly by observing
which behaviors are rewarded, ignored, or
punished. This theory posits that when rewards
outweigh the punishment, the behavior will persist. Other relevant constructs are self-efficacy
for responding with aggression and, conversely,
for managing conflict in peaceful ways; outcome
expectations of the consequences of behaving
aggressively; and self-control over own behavior.
Not all children are equally likely to act as
a bully or become a victim. Understanding bullying and victimization requires recognition that
the problem, as well as the solution, may exist
at different levels or, more likely, as a function of
an interaction of different levels of influence. The
Ecological Model (Bronfenbrenner, 1979) is
a framework that can be used to understand
these multiple factors that influence students’
behavior, as well as the multiple levels of interventions that can be developed. The model can be
visualized as concentric circles, in which the

575

child is the center, surrounded by multiple levels
of influence. Most important are the family, the
school (including peers, teachers, administrators,
and staff, as well as school policies), the community where the child lives, and the greater society
that influences cultural norms about violence.
These levels provide the opportunities to observe
and learn from others’ behaviors and their consequences. Additional risk and protective factors at
each level will influence whether the bullying
behavior will be enacted (For a detailed review,
see Orpinas & Horne, 2006).
More specific to bullying, Orpinas and Horne
(2006) proposed the School Social Competence
Development and Bullying Prevention Model to
provide an organized, comprehensive view of the
critical components necessary for preventing bullying in schools. The model has two components:
the students and the school. The model highlights
six interrelated areas to address with students:
(1) awareness of the problem, (2) personal skills
for handling emotions in social situations (e.g.,
impulse control, recognition of others’ feelings,
anger management), (3) influence of cognitions
on emotions and behavior, (4) character education
for acting in ethical ways, (5) social skills for
solving conflicts and relating to others respectfully, and (6) mental health and learning abilities.
At the school level, the model highlights eight
critical areas for promoting a positive school climate and reducing bullying: (1) excellence in
teaching; (2) school values that support respect
for all and define bullying as unacceptable;
(3) awareness, at the school level, of problems to
solve and strengths to capitalize on; (4) clear policies for bullying prevention and accountability of
offenders; (5) environment of caring and respect;
(6) positive expectations of students; (7) support
for teachers to handle the daily stress, prepare
lessons, and juggle the barrage of demands placed
on them; and (8) a physical environment that is
safe, clean and aesthetically pleasant.

Current Research
While the characteristics and consequences of
bullying have been thoroughly investigated and

576

are now well known, the understanding of what
constitutes an effective bullying prevention program is still in its infancy. Probably the earliest
and most comprehensive school-wide program
for bully reduction was the Norwegian Campaign
Against Bullying (Olweus, 1994). Because of this
early success, the Center for the Study and Prevention of Violence at the University of Colorado
identified it as meeting a high scientific standard
of program effectiveness. However, this program
was implemented in the 1980s in Norway, a very
homogenous society and quite different from the
other European countries and from the United
States. So far, independent researchers have not
published a replication of its positive original
results in the United States. In a nonrandomized
study of middle schools, researchers from the
University of Washington (Seattle, WA) found
no overall effect of the Olweus program, but
pointed to a reduction in relational and physical
victimization among White students. Thus,
the authors warn about the importance of understanding the roles of culture, poverty, and race on
program development (Bauer, Lozano, & Rivara,
2007). In an evaluation of the program in six
public elementary and middle schools of mostly
African American students in Philadelphia, the
observed bullying incidents decreased in a 4-year
time period, but the self-reported victimization
did not change (Black & Jackson, 2007). Because
the study did not include control schools, the
reduction could be attributed to other external
events (e.g., changes in district policies) or
observer bias.
Numerous studies have shown inconsistent or
no results. A peer support service to counteract
bullying showed no effect on reducing bullying
among a sample of boys in England (Cowie &
Olafsson, 2000). The Toronto Anti-Bullying
Intervention showed a decrease in the number of
children who had been victimized, but an
increase in the number of children who reported
bullying (Pepler, Craig, Ziegler, & Charach,
1994). The Sheffield Anti-Bullying Project,
implemented in England in the early 1990s, is
a comprehensive school-wide program that
included anti-bullying policies, a curriculum,
environmental changes, and individual work

Bullying in Childhood

with bullies and victims. Results were inconsistent among participating schools, and the reduction of bullying was only observed among boys
and, in several schools, bullying among girls
increased (Eslea & Smith, 1998). The Flemish
anti-bullying intervention, based on the principles of the Olweus program, showed no intervention effect on secondary schools and a mixed
pattern of effects in primary school: a small,
albeit significant, reduction of bullying but no
change in reported victimization. Intervention
schools were divided into those with and without
external support from the investigators; this
external support did not affect the impact of the
intervention (Stevens, Bourdeaudhuij, & Oost,
2000). The Multisite Violence Prevention
Project, a large clinical trial involving 37 schools,
showed a reduction of aggression among students
with multiple high-risk characteristics and
an increase of aggression among low-risk
students (Multisite Violence Prevention Project,
2009).
In spite of these disappointing results, a large
meta-analysis of mostly European bullying prevention studies showed an approximately 20 %
reduction of bullying (Ttofi & Farrington, 2011).
However, many studies showed no effect, and
several had a positive effect on reducing perpetration or victimization, but not both. In general,
effects have been stronger for younger children
and for very intensive programs.
The mixed results from intervention studies
call for more research to further understand
which strategies have the strongest impact,
under which conditions programs are effective,
and how programs influence behavior. Based on
current research, most researchers agree on five
general educational best practices that will prevent and reduce bullying. These strategies have in
common that they are a process, rather than
a specific program.
Obtain strong support from administrators
and teachers. The success of violence prevention
programs partially depends on the level of support at different levels within the school and the
school district, as well as the community. Particularly important is the quality of leadership that
principals provide. Administrators should

Bullying in Childhood

embrace and model treating everyone with
respect, provide clear standards for what is
expected from all members of the school community, maintain high academic standards, and
be abreast of successful research and practices for
reducing bullying (Bosworth, 2000).
Increase awareness. As with any change program, being aware of the problem is a critical first
step to success. In the prevention of bullying,
administrators, teachers, parents, and students
should be able to define bullying, identify the
consequences of engaging in that behavior, and
know that the school administrators will take
prompt action. Most students do not believe that
teachers are aware of the extent of bullying or
equipped to handle it (Hoover, Oliver, & Hazler,
1992). Frequently, bullies remain unchallenged
as adults do not speak with them about their
behavior (O’Moore, 2000). Awareness of the
characteristics of bullying is an important component of most bullying prevention programs
(Fonagy et al., 2009; Frey et al., 2005).
Administrators and teachers can increase
their awareness of the problem through anonymous classroom or school surveys, interviews
with students and parents, and school data on
absenteeism and conduct problems. As part of
awareness training, teachers can analyze the
extent of students’ concerns and examine their
own personal beliefs that impede change (e.g.,
a belief that bullying is a normal condition all
children experience and must learn to deal with
or a belief that the problem does not even exist).
Examining teachers’ beliefs that maintain bullying and developing efficacious approaches to
addressing the problem can help motivate
teachers to take action. Awareness training
should emphasize all forms of aggression as
adults are more likely to be aware of verbal and
physical aggression but not of other forms of
bullying (Boulton, 1997).
Act promptly. Although strategies to confront
the bullies may vary (Rigby, 2010), theory,
research, and practice indicate that the problem
must be solved quickly and efficiently.
Maintain a positive school and classroom climate. A positive school climate influences behavior through several mechanisms. First, it favors

577

students’ connectedness to school, which is
related to reduced aggression. Second, in
a positive environment adults are more likely to
model good relationship skills and reinforce students’ positive behaviors. Third, implementation
of programs is extremely difficult in dysfunctional and conflict-prone schools (Bosworth,
Orpinas, & Hein, 2009).
Provide services for victims. The school
should also provide services to support children
who are the targets of bullying. Although victims
should not be blamed for the bullying, sometimes
skills training can help the victim overcome
or minimize the problem. A study conducted in
Finland showed that victims’ responses of
counteraggression or helplessness were more
likely to make bullying start or continue, while
a nonchalant attitude by the targeted student was
perceived as making bullying diminish or stop
(Salmivalli, Karhunen, & Lagerspetz, 1996).
Similarly, in a study of young children in the
United States, fighting back was associated with
maintained
victimization
among
boys
(Kochenderfer & Ladd, 1997).

What Works
No bullying prevention programs meet the
requirement of three successful randomized control trials.

What Is Promising
Three small studies evaluated the impact of the
BullyBusters program on students’ aggressive
behaviors (Newman et al., 2000). The goal of
this program is to increase teachers’ awareness
of the role and impact of bullying in schools and
to encourage them to take active steps to prevent
and reduce bullying by providing learning experiences in the classroom, increasing monitoring
of behaviors outside of the classroom, and developing an open-door policy for students who seek
help with bullying problems in the school. Sixth
grade teachers who participated in this program,
compared to teachers who did not, developed

578

a greater knowledge of and skill in using prevention and early intervention activities, had an
increased sense of self-efficacy, and had more
positive expectations for students (Howard,
Horne, & Jolliff, 2001). In a second study, middle school students of teachers engaged in the
BullyBusters program had fewer disciplinary
problems and had fewer office referrals for
aggression than students in classrooms in
which teachers did not participate in training
(Newman-Carlson & Horne, 2004). The third
study of BullyBusters examined a group training
program for teachers and students and found that
the intervention resulted in improved efficacy
and confidence, as well as better classroom
management skills (Horne, Stoddard, & Bell,
2008). Middle and high school students completed a computer-based intervention based
on the transtheoretical model. Students in the
intervention groups were four times more likely
to progress from action to maintenance of
non-bullying than students in the control condition (Evers, Prochaska, Van Marter, Johnson, &
Prochaska, 2007).
Generally, the impact of bullying prevention
programs in elementary schools has been more
promising than those in middle school. In a
single-school study, Orpinas, Horne, and
Staniszewski (2003) found a strong reduction in
aggression and victimization among lower elementary students and only a reduction in victimization among upper elementary students. This
research differs from other studies in that the
intervention was developed through a strong collaborative relationship between the school personnel and university consultants and the
educators strongly embraced the program as
their own. A school-wide program for upper elementary students based on increasing awareness
of others thoughts and feelings showed
a significant, albeit small, impact on aggression
(Fonagy et al., 2009). Steps to Respect showed
positive changes in students’ beliefs about
aggression but not self-reported aggression
(Frey et al., 2005). In Australia, PEACE Pack
showed promising results with elementary
schools, particularly when the intervention was
implemented faithfully (Slee & Mohyla, 2007).

Bullying in Childhood

Social Skills Group Intervention (S.S.GRIN) –
a program for children who are rejected, victimized, or socially anxious – showed positive
impact on social, emotional, and behavioral
domains (DeRosier & Marcus, 2005).

What Does Not Work
Several strategies do not work or may even have
negative results. First, perhaps the least effective
strategy is ignoring the problem, as the lack
of negative consequences is likely to maintain
the behaviors. Second, research from the past
20 years does not support zero tolerance policies
(American Psychological Association Zero Tolerance Task Force, 2008). These extreme policies
do not enhance a positive school environment and
discourage the reporting of bullying. Third,
because bullying is by definition an abuse of
power, not a conflict, peer mediation and conflict
resolution strategies do not work. Fourth, working with homogeneous groups of only bullies is
not only ineffective, but may reinforce the negative behaviors. Finally, bullying prevention
requires a long-term commitment from the
school. Short-term activities, an isolated curriculum, or a brief conversation with the counselor
are not likely to have a long-term effect. Schools
need to keep an ongoing monitoring of bullying
to evaluate whether or not their programs are
working.

Summary
Bullying is a prevalent problem in schools. Children who are the victims are likely to suffer severe
emotional, physical, and academic consequences.
In theory, a comprehensive program that involves
the community, neighborhoods, families, and the
school should be most effective for reducing bullying. However, most communities do not have the
resources to develop such programs, and not every
member of the community will support it. Schools
can establish a safe haven for children by defining
bullying as an unacceptable behavior and taking
specific steps to curtail it.

Bullying in Childhood

References
American Psychological Association Zero Tolerance
Task Force. (2008). Are zero tolerance policies
effective in the schools? An evidentiary review and
recommendations. American Psychologist, 63(9),
852–862.
Bandura, A. (1986). Social foundations of thought and
action: A social cognitive theory. Englewood Cliffs,
NJ: Prentice-Hall.
Bauer, N. S., Lozano, P., & Rivara, F. P. (2007). The
effectiveness of the Olweus Bullying Prevention Program in public middle schools: A controlled trial.
Journal of Adolescent Health, 40(3), 266–274.
Berthold, K. A., & Hoover, J. H. (2000). Correlates of
bullying and victimization among intermediate students in the Midwestern USA. School Psychology
International, 21(1), 65–78.
Black, S. A., & Jackson, E. (2007). Using bullying incident density to evaluate the Olweus Bullying Prevention Programme. School Psychology International,
28(5), 623–638.
Bosworth, K. (2000). Protective schools: Linking drug
abuse prevention with student success. Tucson, AZ:
University of Arizona, College of Education.
Bosworth, K., Orpinas, P., & Hein, K. (2009). Development of a positive school climate. In M. E. Kenny,
A. M. Horne, P. Orpinas, & L. E. Reese (Eds.),
Realizing social justice: The challenge of preventive
interventions (pp. 229–248). Washington, DC:
American Psychological Association.
Boulton, M. J. (1997). Teachers’ views on bullying:
Definitions, attitudes and ability to cope. British
Journal of Educational Psychology, 67(Pt2), 223–233.
Boulton, M. J., & Underwood, K. (1992). Bully/Victim
problems among middle school children. British
Journal of Educational Psychology, 62, 73–87.
Bronfenbrenner, U. (1979). The ecology of human
development: Experiments by nature and design.
Cambridge, MA: Harvard University Press.
Centers for Disease Control and Prevention. (2012).
Youth Risk Behavior Surveillance—United States,
2011. Morbidity and Mortality Weekly Report,
Surveillance Summaries, 61(4), retrieved from: http://
www.cdc.gov/mmwr/pdf/ss/ss6104.pdf.
Cowie, H., & Olafsson, R. (2000). The role of peer support
in helping the victims of bullying in a school with high
levels of aggression. School Psychology International,
21(1), 79–95.
DeRosier, M. E., & Marcus, S. R. (2005). Building friendships and combating bullying: Effectiveness of
SSGRIN at one-year follow-up. Journal of Clinical
Child and Adolescent Psychology, 34(1), 140–150.
Due, P., Holstein, B. E., Lynch, J., Diderichsen, F.,
Gabhain, S. N., Scheidt, P., et al. (2005). Bullying
and symptoms among school-aged children:
International comparative cross sectional study in
28 countries. European Journal of Public Health,
15(2), 128–132.

579
Eslea, M., & Smith, P. K. (1998). The long-term effectiveness of anti-bullying work in primary schools.
Educational Research, 40(2), 203–218.
Evers, K. E., Prochaska, J. O., Van Marter, D. F., Johnson,
J. L., & Prochaska, J. M. (2007). Transtheoreticalbased bullying prevention effectiveness trials in middle schools and high schools. Educational Research,
49(4), 397–414.
Fonagy, P., Twemlow, S. W., Vernberg, E. M., Nelson,
J. M., Dill, E. J., Little, T. D., et al. (2009). A cluster
randomized controlled trial of child-focused psychiatric consultation and a school systems-focused intervention to reduce aggression. Journal of Child
Psychology and Psychiatry, 50(5), 607–616.
Fox, C. L., & Boulton, M. J. (2006). Friendship as
a moderator of the relationship between social skills
problems and peer victimisation. Aggressive Behavior,
32(2), 110–121.
Frey, K. S., Hirschstein, M. K., Snell, J. L., Edstrom, L. V.,
MacKenzie, E. P., & Broderick, C. J. (2005). Reducing
playground bullying and supporting beliefs: An experimental trial of the steps to respect program. Developmental Psychology, 41(3), 479–490.
Hawker, D. S., & Boulton, M. J. (2000). Twenty years’
research on peer victimization and psychosocial maladjustment: A meta-analytic review of cross-sectional
studies. Journal of Child Psychology and Psychiatry,
41(4), 441–455.
Hoover, J. H., Oliver, R., & Hazler, R. J. (1992). Bullying:
Perceptions of adolescent victims in the Midwestern
USA. School Psychology International, 13, 5–16.
Horne, A. M., Stoddard, J. L., & Bell, C. D. (2008).
A parent’s guide to understanding and responding to
bullying: The Bully Busters approach. Champaign, IL:
Research Press.
Howard, N. M., Horne, A. M., & Jolliff, D. (2001). Selfefficacy in a new training model for the prevention of
bullying in schools. Journal of Emotional Abuse,
2(2/3), 181–191.
Kochenderfer, B. J., & Ladd, G. W. (1997). Victimized
children’s responses to peers’ aggression: Behaviors
associated with reduced versus continued victimization. Development and Psychopathology, 9(1), 59–73.
Mercy, J. A., Butchart, A., Farrington, D. P., & Cerdá,
M. (2002). Youth violence. In E. G. Krug, L. L.
Dahlberg, J. A. Mercy, A. B. Zwi, & R. Lozano (Eds.),
World report on violence and health (pp. 23–56).
Geneva, Switzerland: World Health Organization.
Multisite Violence Prevention Project. (2009). The ecological effects of universal and selective violence prevention programs for middle school students:
A randomized trial. Journal of Consulting and Clinical
Psychology, 77(3), 526–542.
Nansel, T. R., Overpeck, M., Pilla, R. S., Ruan, W. J.,
Simons-Morton, B. G., & Scheidt, P. (2001). Bullying
behaviors among US youth – Prevalence and association with psychosocial adjustment. Journal of
the American Medical Association, 285(16),
2094–2100.

580
Newman, D. A., Horne, A. M., & Bartolomucci, C. L.
(2000). Bully Busters: A teacher’s manual for helping
bullies, victims, and bystanders. Champaign, IL:
Research Press.
Newman-Carlson, D., & Horne, A. M. (2004). Bully
Busters: A psychoeducational intervention for
reducing bullying behavior in middle school students.
Journal of Counseling and Development, 82(3),
259–267.
O’Moore, M. (2000). Critical issues for teacher training to
counter bullying and victimisation in Ireland. Aggressive Behavior, 26(1), 99–111.
O’Moore, M., & Kirkham, C. (2001). Self-esteem and its
relationship to bullying behaviour. Aggressive Behavior, 27(4), 269–283.
Olweus, D. (1994). Annotation: Bullying at school: Basic
facts and effects of a school-based intervention program. Journal of Child Psychology and Psychiatry and
Allied Disciplines, 35(7), 1171–1190.
Orpinas, P., & Horne, A. M. (2006). Bullying prevention:
Creating a positive school climate and developing
social competence. Washington, DC: American
Psychological Association.
Orpinas, P., Horne, A. M., & Staniszewski, D. (2003).
School bullying: Changing the problem by changing
the school. School Psychology Review, 32(3),
431–444.
Pepler, D., Craig, W., Ziegler, S., & Charach, A. (1994).
An evaluation of an anti-bullying intervention in
Toronto schools. Canadian Journal of Community
Mental Health, 13(2), 95–110.
Rigby, K. (2010). Bullying interventions in
schools: Six basic approaches. Camberwell, VIC:
ACER Press.

Bullying in Childhood
Robers, S., Kemp, J., & Truman, J. (2013). Indicators of
school crime and safety: 2012 (NCES 2013–036/NCJ
241446). Washington, DC: National Center for
Education Statistics, U.S. Department of Education,
and Bureau of Justice Statistics, Office of Justice
Programs, U.S. Department of Justice.
Salmivalli, C., Karhunen, J., & Lagerspetz,
K. M. J. (1996). How do the victims respond to bullying? Aggressive Behavior, 22(2), 99–109.
Slee, P. T., & Mohyla, J. (2007). The PEACE Pack: An
evaluation of interventions to reduce bullying in four
Australian primary schools. Educational Research,
49(2), 103–114.
Stevens, V., Bourdeaudhuij, I. D., & Oost, P. V. (2000).
Bullying in Flemish schools: An evaluation of antibullying intervention in primary and secondary
schools. British Journal of Educational Psychology,
70, 195–210.
Ttofi, M. M., & Farrington, D. P. (2011). Effectiveness
of school-based programs to reduce bullying:
A systematic and meta-analytic review. Journal of
Experimental Criminology, 7(1), 27–56.
Vossekuil, B., Fein, R., Reddy, M., Borum, R., &
Modzeleski, W. (2002). The final report and findings
of the safe school initiative: Implications for the prevention of school attacks in the United States. Washington, DC: U.S. Department of Education, Office of
Elementary and Secondary Education, Safe and DrugFree Schools Program, and U.S. Secret Service,
National Threat Assessment Center.
Wolke, D., Woods, S., Bloomfield, L., & Karstadt, L.
(2001). Bullying involvement in primary school and
common health problems. Archives of Disease in
Childhood, 85(3), 197–201.

Cancer During Childhood

Cancer During Childhood
Alyce D. Fly and James E. Klaunig
Indiana University, Bloomington, IN, USA

Introduction
Cancer is a disease characterized by mutation, modified gene expression, cell proliferation, and aberrant cell growth. In the USA it ranks as the second
leading cause of death with over one million new
cases of cancer in adults diagnosed each year. In
children (under 15) in the USA, an average of over
12,000 cases of cancer are diagnosed annually
(American Cancer Society [ACS], 2012). While
childhood cancer is rare compared to adult cancer
incidence, its effects on the recipient as well as the
family can be devastating and deadly. This entry
defines cancer and reports on the major types of
cancers found in children, followed by factors that
have been associated with cause and increase
cancer risk. In addition, potential strategies to
prevent cancer are reviewed.

Definitions and Scope
Cancer is the development of abnormal cells that
proliferate with limited growth control. Cancer
cells have the ability to infiltrate and destroy normal body tissue and can spread (metastasize)
throughout the body (Mayo Foundation for
Medical Education and Research, 2012).
Neoplasia is defined as new autonomous growth
of cells. A neoplasm can be either benign or
malignant. Benign neoplasms are characterized
by expansive growth, usually having a low but
steady rate of growth that does not invade surrounding tissue or other organs. Benign neoplasms
however can impair and damage the normal function of a tissue organ by affecting normal blood
flow and lymphatic drainage. In contrast
a malignant neoplasm (cancer) shows invasive
growth characteristics and is capable of spreading
through both the tissue of origin and other tissues
via metastasis. Metastases are secondary growths

581
Cancer During
nomenclature
Tissue of
origin
Bone
Fibrous tissue
Hematopoietic
cells
Lymphoid
tissue
Renal
epithelium
Liver
Respiratory
Skin
Colon

Childhood,

Table

1 Neoplasm

Benign
Osteoma
Fibroma
–a

Malignant
Osteosarcoma
Fibrosarcoma
Leukemias

–a

Lymphoma

Renal adenoma

Renal cell carcinoma

Liver cell
adenoma
Bronchial
adenoma
Squamous cell
papilloma
Adenomatous
polyp

Hepatocellular
carcinoma
Bronchogenic
carcinoma
Squamous cell or
carcinoma
Adenocarcinoma

Created by author, James Klaunig, 2012
a
No benign lesion

of the malignant neoplasm. The term tumor is
a general term that is used to describe the neoplastic lesion as it appears in gross examination. Neoplasms are named based on the tissue they
originate from and whether they are benign or
malignant. In the case of benign neoplasms, the
tissue of origin is frequently followed by the suffix
“oma.” For example, a benign fibrous neoplasm
would be termed fibroma, and a benign glandular
epithelium neoplasm would be termed an
adenoma. Malignant neoplasms from epithelial
origin are called carcinomas, while those derived
from mesenchymal origin are referred to as
sarcoma. As such a malignant neoplasm of fibrous
tissue would be a fibrosarcoma and one from bone
would be an osteosarcoma. A malignant neoplasm
from the liver would be a hepatocellular carcinoma, while that derived from skin squamous
epithelium is a squamous cell carcinoma
(Table 1).
Childhood Cancer
Childhood cancer encompasses cancers that
develop between birth and 15 years of age
(National Cancer Institute, 2012a). Though cancer
in children is rare, it is the leading cause of death by

T.P. Gullotta, M. Bloom (eds.), Encyclopedia of Primary Prevention and Health Promotion,
DOI 10.1007/978-1-4614-5999-6, # Springer Science+Business Media New York 2014

582

Cancer During Childhood

Cancer During Childhood, Table 2 Leading causes of
death in children from preliminary data in 2009. Data are
numbers of deaths per 100,000 children
Cause of death
Unintentional injuries
Birth defects
Homicides
Cancers
Heart disease
Flu and pneumonia
Infections
Cerebrovascular
diseases
Suicide
Chronic lower
respiratory diseases

Children, 1–4
years
8.5
2.8
2.3
2.3
0.9
0.8
0.4
0.4

Children, 5–14
years
4.1
0.9
0.8
2.4
0.5
0.2
–
0.2

–a
–

0.7
0.3

Modified by author, Alyce Fly, 2012 from
U.S. Department of Health and Human Services, Health
Resources and Services Administration, Maternal and
Child Health Bureau, 2011
a
These causes of death are not among the leading causes
for children in this age range

diseases (Table 2). The National Cancer Institute
(NCI) has developed a useful fact sheet about
childhood cancer (National Cancer Institute,
2012b).
This institute also works to identify the causes of
cancers found in childhood, monitors the incidence
of childhood cancers in the USA and worldwide,
funds studies to understand the biology of childhood cancer to identify possible new treatments,
conducts animal trials in search of new medications, conducts clinical trials to identify best treatments for cancer, with less toxic side effects, and
conducts studies to improve knowledge of issues
that affect survivors of childhood cancers.
The most prevalent forms of cancer in children
are found in the blood (leukemia) or in the brain
and central nervous system (National Cancer
Institute, 2012b). Brain tumors are the most common solid tumor in children and are frequently in
the form of gliomas (from glial cells, a supportive
cell in the central nervous system) or medulloblastomas (found in the cerebellum).
Other solid tumor types seen in children
include neuroblastomas (which arise from the
adrenal gland near the spinal cord or the chest),

Cancer During Childhood, Table 3 Relative distribution of types of cancer in children
Types of cancer
Leukemias
Brain and other
nervous system
cancers
Neuroblastoma
Wilms tumor
Lymphoma
Rhabdomyosarcoma
Retinoblastoma
Bone cancer

% of all cancers in childrena
34
27

7
5
8
3
3
4

Modified by author, Alyce Fly, 2012 from ACS (2012)
a
ACS (2012)

kidney tumors (Wilms tumors), and sarcomas
such as rhabdomyosarcoma (from muscle cells),
and osteosarcoma (bone cell derived). Lymphomas, tumors of the lymphatic system, are also
found in children. The most common types of
childhood cancers as a percentage of all childhood cancers are shown in Table 3. Among the
major types of childhood cancers, leukemias and
cancers of the brain and central nervous system
account for more than half of the new cases. Over
30 % of all diagnosed childhood cancers are leukemias with the most common type being acute
lymphoblastic leukemia in children. Descriptions
of these cancers can be found on both the American
Cancer Society website and National Cancer Institute website. The incidence of childhood cancers in
2013 was expected to be 11,630 (ACS, 2013).
White and Hispanic children are more likely to
develop cancer than children from other racial/ethnic groups. There has been an increase in the incidence of childhood cancers over the past 30 years,
but the mortality rate has decreased dramatically
due to improved treatments (Ries et al., 2006).

Theories and Research
Causes
Very little is known about the causes of most
childhood cancers. Risk factors can be classified
as environmental or genetic. The geneenvironment interaction appears to be important

Cancer During Childhood

in the increased risk. It also remains unresolved if
environmental factors contribute to the cancer
development; when did the exposure occur?
Exposure could occur preconception in the
zygotes, in utero, or post birth. Since both the
fetus and children have rapidly dividing tissues
and cells during growth, they are exceptionally
susceptible to agents that interact with nuclear
DNA either directly or through epigenetic mechanisms. A number of environmental and extrinsic
causes of childhood cancer have been suggested
including ionizing radiation, nonionizing radiation, infections, drugs and medication, smoking,
and occupation of parents.
Ionizing Radiation
Environmental ionizing radiation has been proposed to cause an increase in childhood leukemia.
The strongest support for ionizing radiation as
a cause of childhood leukemia comes from studies
of children with cancer who have been treated with
radiation and found to have an increased risk for
developing a second primary cancer as a result of
the treatment. In addition, during the early second
half of the twentieth century, a source of ionizing
radiation was from the practice to use x-rays during obstetric examination in pregnancy (Stewart,
Webb, & Hewitt, 1958). This process, which has
since been replaced by ultrasound, has been linked
to increase in childhood cancer. There is no evidence that ultrasound causes childhood cancer.
Increases in incidence of leukemias have been
attributed to nuclear power plants; however, fallout from the Chernobyl nuclear power plant accident in 1986 failed to show an increase in
leukemia in children exposed to the fallout (Spix,
Schmiedel, Kaatsch, Schulze-Rath, & Blettner,
2008). Studies have also examined the risk of
childhood leukemia in subjects living near nuclear
power reactors with inconsistent findings (Bithell,
Dutton, Draper, & Neary, 1994).
Preconception exposure to ionizing radiation
has also been suggested as a cause of childhood
leukemia. Studies of children born to radiation
workers in the UK were performed and concluded that a linkage between leukemia and occupational exposure to radiation was not evident
(Draper et al., 1997). Similarly, a proposal that

583

indoor radon levels could cause an increased risk
of childhood leukemia has been generally
dismissed save for a large study in France where
an increased risk of acute myeloid leukemia was
reported to correlate with higher levels of radon
in houses (Investigators United Kingdom Childhood Cancer Study [UKCCS], 2002; Evrard
et al., 2006).
A new study showed that radiation exposure
from computed tomography (CT) scans in childhood produces very small but increased risks of
both leukemia and brain tumors within the first
10 years after exposure. These investigators calculated that the cumulative dose from two to
three head CT scans could triple the risk of
brain cancer, and the cumulative dose from five
to ten head CT scans before the age of 15 could
triple the risk of leukemia (Pearce et al., 2012).
Nonionizing Radiation
Nonionizing radiation as a cause of childhood
cancer has been studied extensively. In particular there has been extensive analysis of cancer in
children, specifically leukemia, from exposure
to electromagnetic fields from power lines and
electrical wiring (Draper, Vincent, Kroll, &
Swanson, 2005). An increased risk from high
electromagnetic exposure has been suggested,
although concerns about other confounding
factors leave this potential cause unresolved.
UV light from sunlight exposure has been linked
to melanoma induction in both adults and
children.
Drugs and Medication
While there has been conjecture that material use
of drugs and medication during pregnancy produces an increase in childhood cancer, the only
strong linkage has been the study of diethylstilbestrol (DES) given to pregnant women for prevention of miscarriage and the subsequent
induction of vaginal adenocarcinoma in young
women and in several cases of girls under the
age of 15 (Giusti, Iwamoto, & Hatch, 1995).
Other drugs, specifically those used in the treatment of cancer in young children (chemotherapeutic drugs) have been linked to an increase in
additional primary cancers.

584

Smoking
Parental smoking, during pregnancy, has been
linked to an increase in hepatoblastoma and possibly leukemia in offspring, based on four recent
studies (Pang, McNally, & Birch, 2003). This risk
is increased over fivefold when both parents
smoke.
Occupation of Parents
A number of studies have attempted to show
associations between the occupation of the
parents and the risk to childhood cancer in their
offspring. However, a review of almost 50 studies
on this topic showed little consistency and
limited associations between occupation and the
cancer risk in children (McKinney, Fear,
Stockton, & Investigators UKCCS, 2003).
Genetic Factors
Several childhood cancers have demonstrated
a genetic linkage to their development. These
include retinoblastoma, adrenocortical carcinoma, atypical teratoid and malignant rhabdoid
tumors, optic pathway tumors, juvenile
myelomonocytic leukemia, malignant peripheral
nerve sheath tumors, vestibular schwannomas,
hepatoblastomas, hemangioblastomas, medullary
thyroid cancer, pheochromocytomas, and
paragangliomas. As noted above, genetic mutations are essential for a normal cell to be
a neoplasm. Genetic changes may either be
inherited from the parents or acquired during
gestation. Retinoblastoma is an example of
a type of cancer which is known to be caused by
an inherited gene in some children. The majority
(90 %) of children born with the mutated Rb1
gene develop retinoblastoma. However, having
a genetic predisposition (having a mutation in
a cancer-related gene present) does not necessarily lead to the induction of cancer in that individual. There is evidence that children who develop
leukemia have predisposing genetic mutations
apparently acquired during gestation, though for
every child leukemia with the genetic predisposition for the disease, there appears to over
100 children that have the mutation but do not
develop leukemia. In addition, certain genetic
syndromes (e.g., Li-Fraumeni syndrome,

Cancer During Childhood

neurofibromatosis, and Gorlin syndrome) have
been linked to an increased risk of specific childhood cancers. Children with Down syndrome
have an increased risk of developing leukemia.
This further supports a role for genetic modification and mutation in the development of childhood cancer. These findings also further support
the role of the gene-environment interaction in
the development of cancer and also point to the
multistep process of cancer induction. Cancer
formation is not a single damaging genetic
event but requires multiple steps and modifications, some genetic and some epigenetic.
Pesticides and Xenobiotic Chemicals
In recent years, pesticides have been suggested
to be involved in the cause of certain forms of
childhood cancer (Metayer & Buffler, 2008).
Most of the studies to support a role for chemical
and pesticide exposure are founded on
interview-based epidemiological data. Interview results have been inconsistent and
a linkage between physical evidence of pesticides in the child’s body or environment and
the induction of specific cancers has not been
firmly established. This is an area of scientific
inquiry that is receiving additional attention.
Certainly, the role of environmental factors
whether lifestyle-derived or through xenobiotic
chemical exposure has been demonstrated in
cancer models. However, linkage either directly
or indirectly between pesticides and other xenobiotic chemicals and childhood cancer remains
unresolved.

Strategies
Early detection of childhood cancer is on the
forefront to subsequent treatment and cure. In
recent years treatment of children with cancer
has progressed to the stage where certain cancers
have a high cure and survival rate. Treatment of
cancers follows the similar approach to those
employed for adult cancers with the caveat that
children are not small adults and require different
doses and modalities for treatment. Surgery, chemotherapy, and radiation therapy remain the

Cancer During Childhood

prominent approaches to cancer treatment in children, as they are also for adults.
Surgery
Surgery involves the removal of the neoplasm in
its entirety. Of course surgery is applicable to the
solid tumors and not the liquid (leukemia) neoplasms. The most successful outcome from surgery is dependent in part on finding and
diagnosing the lesion early in its progress, prior
to subsequent metastasis. Surgery, as with adults,
is frequently followed by radiation or chemotherapy to ensure all tumor cells have been
eliminated.
Chemotherapy
Chemotherapy involves the use of drugs to kill
neoplastic cells. These drugs are designed to specifically target rapidly growing and dividing cells
(a hallmark of cancer cells). In children the
dosage, type, and duration of treatment are particularly difficult since many of the child’s cells
are normally dividing because children are still
growing (unlike adults) and the ability to specifically kill those cancer cells involves fine-tuning
of the therapeutic dosing. Chemotherapy may
involve a single drug or combinations of different
drugs. The side effects of chemotherapy can be
difficult and include fatigue, deceased appetite,
increased risk of infection and bleeding, nausea,
and gastrointestinal distress. Additional supportive care may be required to combat these side
effects.
Radiation Therapy
Radiation therapy uses x-rays or protons to selectively target and kill cancer cells. Most radiation
therapy involves application through an external
source of radioactivity and also requires multiple
treatments over a period of time. The basis of
radiation therapy is that dividing cells are usually
more sensitive to the radiation effect and thus are
more likely to be killed. Radiation therapy also,
unlike chemotherapy, usually is targeted to the
tumor itself and not the whole body and thus the
nontarget normal cells are spared. As with
chemotherapy side effects occur that include
fatigue, nausea, and diarrhea.

585

Prevention
What Works
Unfortunately, because of the lack of specific
knowledge of the cause of childhood cancer, specific guidance for the prevention of this disease is
limited. As with adult cancer, lifestyle is important in the prevention of disease. Though in the
case of childhood cancer, the lifestyle issues may
be less oriented to the child as much as the parents
both prior to conception (effects on the germ
cells) and during pregnancy.
What Might Work
Prevention Approaches Directed to the Child

Childhood prevention should include maintenance of a healthy diet with adequate antioxidants and vitamins and minerals. Reduction in
exposure to radiation (which is linked to
leukemia and possibly brain tumors in children)
is preferred both from external exposure (nuclear
power plants and radon) and medical diagnostic
approaches (x-rays). While the linkage between
these radioactive sources and childhood cancer
remains uncertain, genetic predisposition, as
noted above, may make selective children more
susceptible to the detrimental effects.
UV light exposure and melanoma (as well as
other skin tumors) have been strongly linked;
however, the induction of skin tumors usually
requires multiple decades to appear after the UV
exposure, thereby probably not being a cause of
childhood tumors. However, limited UV
exposure during childhood will reduce the
melanoma incidence in later life.
Exposures to chemicals such as pesticides and
solvents have not been definitively linked to cancer
induction in children. Pesticides have been
suspected to be involved in the development of
certain forms of childhood cancer based on interview data. While these results have been inconsistent and not validated since the linkage is uncertain,
a minimal exposure to chemical agents is warranted.
Prevention Approaches Directed to the Parent

While not firmly established, it appears that
parental exposure, prior to conception, during

586

gestation, and during early childhood, to environmental factors, may influence the development of
cancer in children. Prevention therefore should
be especially directed to parents.
Smoking cessation before conception and during
pregnancy as well as secondhand smoke exposure
to the child should be practiced. Tobacco smoke
contains numerous carcinogens that have been
linked to genetic mutations and cancer and thus
should be avoided throughout the life of the child.
Decreasing in exposure to radiation is a second
preventative measure, either through medical tests
or occupational exposure. Radiation is capable of
inducing mutation in sperm and eggs as well as
effecting cells in the fetus.
Exposure to pesticides, chemicals and drugs,
and alcohol should be limited. Although
a linkage between these factors and childhood
cancer has not been established, a role for the
effects of these agents in cancer induction in animal models has been established, and exposure
should be controlled especially to the mother during pregnancy and during breast-feeding.
Finally, lifestyle factors besides smoking,
including proper diet, reduced UV light exposure
from sunlight, proper nutrition, and exercise, are
important in maintaining the proper health of the
adult and thus will have important influences on
the sperm and egg as well as the fetus in utero.
With regard to nutrition, prenatal folic acid supplementation in mothers was shown in a case
control study to protect against the development
of childhood brain tumors (Milne et al., 2012).
Fortification of flours with folic acid in the
USA has also helped to reduce the incidence of
neural tube defects (Shaw, Schaffer, Velie,
Morland, & Harris, 1995).
The distribution of most common cancers in
children (0–15 years of age) and young adults
(15–19 years of age) in New Jersey by age is
shown in Table 4. Leukemias and CNS tumors
were more frequent in children, while lymphoma
and bone sarcomas seemed to be expressed in higher
incidence after age 15. The reason for differences
in the age of onset is not known but may point to the
time and age of tumor initiation. Further studies
are needed to confirm these findings of a difference
in age of detection and to determine causation.

Cancer During Childhood
Cancer During Childhood, Table 4 Incidence of most
common cancers in 0–14 year olds and 15–19 year olds,
from 1990–1997 in New Jersey
Number of cases
per 100,000
children <15
Types of cancer
years old
All types of cancers 141.3
Acute lymphocytic
29.3
leukemia
Acute myeloid
6.6
leukemia
Hodgkin’s
5.7
lymphoma
Non-Hodgkin’s
8.5
lymphoma
Central nervous
31.8
system tumor
Malignant bone
7.0
tumors and
osteogenic and
Ewing’s sarcoma
Rhabdomyosarcoma
5.1
Total of top 8 types
94
of cancers

Number of cases
per 100,000
children between
15 and <19
years old
206.8
11.5
8.8
34.7
17.1
20.3
15.8

3.6
111.8

Modified by author, Alyce Fly, 2013 from Task Force on
Cancer Prevention, Early Detection and Treatment in New
Jersey, (2002)

What Does Not Work
It is difficult to identify those approaches that do
not work in preventing childhood cancer since
little is known about what the agents are that
induce cancer in children.
Summary
To date the best practice for preventing childhood
cancer involves preventing exposure of the child
and the mother during pregnancy to carcinogenic
agents and providing them with good nutrition so
that the body has the resources to maintain
defense mechanisms. Thus, families and professionals should work to:
• Prevent exposure of the fetus in utero to
environmental insults including but not
limited to smoking and alcohol consumption
by the mother during pregnancy.
• Prevent exposure of children and the mother
during pregnancy to radiation from medical,
natural and environmental sources.

Cancer During Childhood

• Prevent exposure of children to secondhand
smoke.
• Provide a healthy diet to the child and the mother
during pregnancy, especially one that includes
a variety of fruits and vegetables; these food
groups are rich sources of antioxidants.
• Prevent exposure of children to carcinogens in
the home environment and also from
occupational contamination that people may
bring into the home.

References
American Cancer Society. (2012). What are the most
common types of childhood cancers? Retrieved
December 12, 2012, from http://www.cancer.org/cancer/cancerinchildren/detailedguide/cancer-in-childrentypes-of-childhood-cancers
American Cancer Society. (2013). Cancer in children.
Atlanta, GA: American Cancer Society. Retrieved
March 27 12, 2013, from http://www.cancer.org/cancer/cancerinchildren/detailedguide/cancer-in-childrenkey-statistics
Bithell, J. F., Dutton, S. J., Draper, G. J., & Neary, N. M.
(1994). Distribution of childhood leukaemias and
non-Hodgkin’s lymphomas near nuclear installations
in England and Wales. British Medical Journal,
309, 501–505.
Draper, G. J., Little, M. P., Sorahan, T., Kinlen, L. J.,
Bunch, K. J., Conquest, A. J., et al. (1997). Cancer in
the offspring of radiation workers: A record linkage
study. British Medical Journal, 315, 1181–1188.
Draper, G., Vincent, T., Kroll, M. E., & Swanson, J. (2005).
Childhood cancer in relation to distance from high voltage power lines in England and Wales: A case–control
study. British Medical Journal, 330, 1290–1292.
Evrard, A. S., Hemon, D., Billon, S., Laurier, D., Jougla, E.,
Tirmarche, M., et al. (2006). Childhood leukemia incidence and exposure to indoor radon, terrestrial and cosmic
gamma radiation. Health Physics, 90, 569–579.
Giusti, R. M., Iwamoto, K., & Hatch, E. E. (1995).
Diethylstilbestrol revisited: A review of the long-term
health effects. Annals of Internal Medicine, 122, 778–788.
Investigators United Kingdom Childhood Cancer Study
[UKCCS]. (2002). The United Kingdom Childhood
Cancer Study of exposure to domestic sources of
ionising radiation: 1: Radon gas. British Journal of
Cancer, 86, 1721–1726.
Mayo Foundation for Medical Education and Research
(MFMER). (2012). Cancer definition. Retrieved
December 12, 2012, from http://www.mayoclinic.
com/health/cancer/DS01076
McKinney, P. A., Fear, N. T., Stockton, D., & Investigators
United Kingdom Childhood Cancer Study [UKCCS].
(2003). Parental occupation at periconception: Findings

587
from the United Kingdom Childhood Cancer Study.
Occupational
and
Environmental
Medicine,
60, 901–909.
Metayer, C., & Buffler, P. A. (2008). Residential
exposures to pesticides and childhood leukaemia.
Radiation Protection Dosimetry, 132(2), 212–219.
Milne, E., Greenop, K. R., Bower, C., Miller, M., van
Bockxmeer, F. M., Scott, R. J., et al. (2012). Maternal
use of folic acid and other supplements and risk of
childhood brain tumors. Cancer Epidemiology,
Biomarkers and Prevention, 21(11), 1933–1941.
National Cancer Institute. (2012a). Dictionary. Retrieved
December 12, 2012, from http://www.cancer.gov/
dictionary
National Cancer Institute. (2012b). National Cancer Institute fact sheet: Childhood cancers. National Cancer
Institute at the National Institute of Health. Retrieved
December 12, 2012, from http://www.cancer.gov/
cancertopics/factsheet/Sites-Types/childhood
Pang, D., McNally, R., & Birch, J. M. (2003). Parental
smoking and childhood cancer: Results from the
United Kingdom Childhood Cancer Study. British
Journal of Cancer, 88, 373–381.
Pearce, M. S., Salotti, J. A., Little, M. P., McHugh, K.,
Lee, C., Kim, K. P., et al. (2012). Radiation exposure
from CT scans in childhood and subsequent risk of
leukaemia and brain tumours: A retrospective cohort
study. Lancet, 380, 499–505.
Ries, L. A. G., Melbert, D., Krapcho, M., Mariotto, A.,
Miller, B. A., Feuer, E. J., et al. (Eds.). (2006). SEER
cancer statistics review, 1975–2004. Bethesda, MD:
National Cancer Institute. Retrieved on December
12, 2012, from http://seer.cancer.gov/csr/1975_2004
based on November 2006 SEER data submission,
posted to the SEER web site, 2007.
Shaw, G. M., Schaffer, D., Velie, E. M., Morland, K., &
Harris, J. A. (1995). Periconceptional vitamin use,
dietary folate, and the occurrence of neural tube
defects. Epidemiology, 6(3), 219–226.
Spix, C., Schmiedel, S., Kaatsch, P., Schulze-Rath, R., &
Blettner, M. (2008). Case–control study on childhood
cancer in the vicinity of nuclear power plants in Germany 1980–2003. European Journal of Cancer, 44,
275–284.
Stewart, A., Webb, J., & Hewitt, D. (1958). A survey
of childhood malignancies. British Medical Journal,
1, 1495–1508.
Task Force on Cancer Prevention, Early Detection and
Treatment in New Jersey. (2002, July). New Jersey
comprehensive cancer control plan. Report to the
Governor, (sect. 1, p. 59), i–xx, 1–287. Trenton, NJ:
New Jersey Department of Health and Senior Services.
Retrieved on March 21, 2013, from http://www.state.
nj.us/health/ccp/ccc_plan.htm
U.S. Department of Health and Human Services, Health
Resources and Services Administration, Maternal and
Child Health Bureau. (2011). Child health USA 2011.
Rockville, MD: U.S. Department of Health and
Human Services.

588

Child Care: Promoting Healthy
Development in Children
Andrew J. Mashburn
Department of Psychology, Portland State
University, Portland, OR, USA

Child Care: Promoting Healthy Development in Children

foci of research, policy, and program improvement efforts have been to understand the ecological inputs to children’s development within these
contexts and to provide learning opportunities
that are aligned with young children’s developmental needs.

Definitions and Scope
Introduction
Upon entering kindergarten at age 5 when the
formal system of schooling begins for most children in the United States, nearly every child has
had some type of child care experience provided
by someone other than a parent or primary guardian. These experiences may include relative care
provided by another relative in the child’s home
or the relative’s home, nanny care provided by
a nonrelative in the child’s home, home-based
daycare provided in the home of a nonrelative,
and center-based care provided in a child care
center. The provision of care for young children
outside of the home by someone other than the
child’s mother is a relatively new approach to
child rearing in the United States, and it reflects
a change in beliefs about the necessity of maternal care and increased opportunities for children
to receive these alternative forms of care. In
particular, opportunities for young children to
attend publicly funded center-based programs
have rapidly expanded over the past five decades
as a result of the growing recognition that early
intervention can promote the well-being of children, families, and communities and prevent later
difficulties that many children have adapting to
formal school settings.
Despite the wide range of child care that
children may experience between birth and kindergarten, nearly all of what is currently known
about effective child care comes from studies
conducted in publicly funded centers that serve
3- or 4-year-olds who experience social and economic risks. To realize the goals of promotion
and prevention that these public programs are
intended to achieve, settings must be designed
and structured in ways that maximize opportunities for children to learn and develop. The current

Child care can be broadly grouped into two setting types – home-based and center-based – and
the nature of children’s experiences varies within
each. Home-based child care may occur within
the child’s home, a relative’s home, or
a nonrelative’s home; it typically includes small
numbers of children of mixed ages who are cared
for by a single adult; and except for home-based
childcare settings that receive licensure, there are
no regulations or requirements that govern these
settings. In contrast, center-based programs are
highly regulated and are differentiated according
to the ages of children served, the funding that
supports the programs, and the economic backgrounds of children served.
With regard to the ages of children served,
center-based programs that are attended by
4-year-olds the year prior to kindergarten are
defined exclusively as “prekindergarten” or
“pre-K” programs, and they have an explicit
goal of providing early learning experiences that
prepare children to enter kindergarten ready to
learn. Center-based programs attended by
children between birth and age 3 are defined
collectively as either “child care” programs or
“preschool” programs. Within these centers,
rooms are often separated into age categories
for infants (0–12 months), wobblers (12–23
months), toddlers (24–36 months), and preschoolers (36–48 months), as a way to accommodate the different developmental needs of
children and to adhere to the varying child-toadult ratios at each age level that is required for
centers to attain licensure.
The funding sources that support center-based
programs also vary. Programs for infants, wobblers, and toddlers are operated by either private
for-profit or private not-for-profit entities, and

T.P. Gullotta, M. Bloom (eds.), Encyclopedia of Primary Prevention and Health Promotion,
DOI 10.1007/978-1-4614-5999-6, # Springer Science+Business Media New York 2014

Child Care: Promoting Healthy Development in Children

they are currently not part of publicly funded
state or federal programs. Preschool programs
for 3-year-olds and pre-K programs may be either
privately run or publicly funded, and those that
are publicly funded vary in terms of the economic
backgrounds of children who are eligible to
attend. Within publicly funded pre-K programs,
a few state programs (e.g., Georgia, Oklahoma)
are “universal” and available to any 4-year-old
regardless of their social and economic background. However, most public programs are
“targeted” to children from socially and/or economically disadvantaged backgrounds who may
be at risk of experiencing challenges adapting to
later school settings. And prekindergarteners and
younger children with diagnosed disabilities may
receive special education services as part of the
Individuals with Disabilities Education Act
(IDEA). These three types of early intervention
programs (universal, targeted, and IDEA) represent primary, secondary, and tertiary prevention
strategies, respectively.
The prevalence of 3- and 4-year-olds who
attend center-based programs has rapidly
increased over the past five decades as a result
of the creation of these public programs by the
federal government and most states. In 1965, the
federal government established Head Start to provide comprehensive services to young children
and their families (Zigler & Muenchow, 1994),
and since its creation, it has enrolled over 30 million children and currently serves over 900,000
children annually (Administration for Children
and Families & Department of Health and
Human Services, 2012). Forty states also offer
public programs for 4-year-olds, and 26 states
offer public programs for 3-year-olds, which
together serve 1.3 million children annually
(Barnett et al., 2012). In total, in 2011–2012,
15 % of 3-year-olds and 42 % of 4-year-olds
attend a publicly funded preschool or pre-K program, respectively (Head Start, state, or special
education). According to the National Household
Education Survey in 2007, approximately 47 %
of 3-year-olds and 74 % of 4-year-olds attended
either a private or public center-based program
(Barnett, Epstein, Friedman, Sansanelli, &
Hustedt, 2009). Among 4-year-olds, this

589

represents a 400 % increase since 1965 in the
prevalence of children who attend a pre-K center
prior to enrollment in kindergarten (Barnett &
Yarosz, 2004).

Theories
Theories applied to child care that are relevant to
understanding the growth and development of
children within these settings are either childfocused that describe stages and processes of
young children’s cognitive development
(e.g., Piaget and Vygotsky) or setting-focused
that identify the ecological inputs that promote
developmental outcomes. For example, Piaget
(1954) described the progression of stages
through which children develop cognitions during the early childhood years. The first is the
sensorimotor stage from birth to age 2 that
involves achieving a series of milestones related
to the coordination of perceptions and sensations
with actions and movements. The second is the
preoperational stage lasting from age 2 to age
7 during which children first begin to mentally
represent objects that are not present and later
begin to develop reasoning skills. Similarly,
Vygotsky’s (1962) theory focuses on how children construct knowledge and understanding,
with a key determinant being the opportunities
afforded to the child through interactions with
adults and peers. Specifically, Vygotsky
describes children’s zone of proximal development (ZPD), which identifies a range of tasks that
are appropriate for a young child, the upper limit
of which requires the guidance and assistance of
a teacher or more-skilled peer. The social nature
of young children’s cognitive development
described by Vygotsky has led to the identification of the specific types of interactions in child
care settings that children need to experience to
promote learning and development.
Bronfenbrenner and Morris’ bioecological
model of development (2006) is a setting-focused
theory that elaborates the ways that features of
ecological settings impact development and
learning. According to this theory, learning and
development for individuals of any age occurs

590

through direct and sustained interactions with
both physical objects and other individuals that
are appropriate for the ability level of the individual, become increasingly complex to meet the
growing demands as the individual develops, and
are used regularly and for extended periods to
offer continual challenges. Furthermore,
Bronfenbrenner and Morris’ model postulates
that the impacts of these interactions on an individual’s development vary systematically as
a function of the environment and the person
(Bronfenbrenner & Morris, 2006).
Mashburn and Pianta (2010) applied the
bioecological
model
of
development
(Bronfenbrenner & Morris, 2006) to child care
settings in order to articulate the mechanisms
through which child care settings act to promote
children’s development. Specifically, within the
“microsystem” of the child care setting, a child’s
learning and development occurs through direct
interactions with physical resources (e.g., books,
manipulatives, art supplies, costumes) and social
interactions with peers and adults that are appropriate to the child’s ability, that become increasingly complex, and that are frequently
experienced over sustained periods of time –
these are the “proximal processes” through
which learning and development occurs within
child care settings. Bronfenbrenner and Morris
also hypothesized that the extent to which these
proximal processes affect children’s development depends upon characteristics of the child
and other characteristics of the settings.
Other characteristics of the child care setting
that may impact children’s learning and development include characteristics of the teacher
(e.g., level of education, field of training) and
characteristics of the classroom (e.g., curriculum,
number of children enrolled in the classroom, and
teacher-to-child ratio). However, these features
of the ecological settings are part of the
“macrosystem,” which are more distal to the
developing child than the proximal processes,
and they can improve children’s learning and
development in child care settings to the extent
that they affect these proximal processes. These
hypotheses about the direct impacts of physical
and social resources on development, the

Child Care: Promoting Healthy Development in Children

moderated impacts related to characteristics of
the individual child, and the indirect impacts of
classroom and teacher characteristics have been
extensively tested in research about effective
child care.

Research
The earliest studies of child care used experimental designs to address the question “does
attending a child care program impact children’s
short-term and long-term outcomes?” The
overwhelmingly positive results from these
early studies led to the creation and rapid expansion of publicly funded, center-based programs
nationwide. With the large public investment in
these programs, it is not surprising that the
predominant focus of current child care research
occurs within these settings. These studies have
been conducted both to justify the expenditure
of public funding to support these programs
and to better understand ways to improve their
effectiveness.
The primary question driving this current
research agenda is: “how should settings be
designed and structured to maximize their
impacts on the developmental outcomes of children who attend?” Specifically, current research
has sought to identify the contributions to children’s development that are attributable to
malleable features of child care settings, including characteristics of caregivers (e.g., level of
education, field of study), characteristics of the
setting (class size, child-to-teach ratio, curriculum), quality of the physical environment
(e.g., space and furnishings, learning materials),
and quality of the caregivers’ interactions with
children (e.g., emotional support, instructional
supports). Results from these studies have the
potential to inform policies and program
improvement efforts that create more effective
learning opportunities. However, across volumes
of research conducted over the past two decades,
there is mixed evidence concerning the features
of child care settings that have the strongest associations with different developmental outcomes
and for whom.

Child Care: Promoting Healthy Development in Children

Setting Characteristics
Teacher Factors. Although there is a widely held
belief that higher levels of teacher education and
specialized training in child development or early
childhood education contribute to the quality of
child care experiences and children’s learning
and development, this result has not been found
in recent studies involving contemporary pre-K
programs. For example, using data from seven
large-scale evaluations of programs that included
over 7,500 children enrolled in nearly 3,000 preschool classrooms, Early and colleagues (2007)
found that teachers’ level of education and field
of study were not significantly associated with the
quality of children’s experiences in classrooms.
Similarly, in a recent study that included nearly
700 state-funded pre-K classrooms in 11 states,
Mashburn and colleagues (2008) found that
teachers’ level of education and field of study
were not associated with children’s development
of academic, language, or literacy skills during
the school year.
Physical Environment. Class size and childto-teacher ratio are also commonly included in
studies to identify features of impactful pre-K
programs, and again, recent research has found
that pre-K programs that adhered to
recommended maximum standards for class
sizes (20 children or fewer) and minimum standards for child-to-teacher ratio (10 to 1 or lower)
did not produce greater rates of development for
children who attended (Mashburn et al., 2008).
Similarly, the type of curriculum used in child
care settings has also been a focus of study, with
the hypothesis that some curricula may better
structure learning activities in ways that ensure
children are given ongoing and systematic opportunities to develop the early skills that are critical
for later school success. However, the evidence
base on the precise effects of curricula on children’s development is mixed, with results that
vary from study to study (Preschool Curriculum
Evaluation Research Consortium, 2008).
Recent studies commonly use observational
methods to assess the quality of the physical
environment (e.g., space, furnishings, and learning materials) and social interactions (e.g., nature
of classroom activities and the emotional and

591

instructional interactions between teachers and
children) to examine their associations with children’s learning. Across this vast literature, there
is general support that higher-quality preschool
environments are positively associated with children’s development (e.g., Lamb & Ahnert, 2006;
Mashburn et al., 2008; NICHD Early Child Care
Research Network, 1999, 2002). However, there
are at least four caveats to these results. Across
studies, associations between quality and outcomes tend to be small and, in some studies,
nonsignificant (NICHD Early Child Care
Research Network & Duncan, 2003). The correlational nature of these studies may reduce the
validity of the results. The quality of the social
interactions tends to have stronger positive associations with children’s development than the
quality
of
the
physical
environment
(e.g., Mashburn, 2008). And the associations
between quality and outcomes tend to be stronger
for children who experience social and economic
risks (e.g., Mashburn, 2008; Peisner-Feinberg &
Burchinal, 1997).
In sum, the general findings across 20 years of
research to identify the features of child care programs, and more specifically pre-K programs, that
contribute to children’s development present
a complicated story about which features of these
settings influence which developmental outcomes
and for whom. However, taken generally, these
results confirm a number of postulates from
Bronfenbrenner’s
bioecological
model
(Bronfenbrenner & Morris, 2006). Specifically,
the quality of physical resources and teachers’
interactions with children are the proximal processes that promote development and have been
found to be directly associated with children’s
learning; the associations between the quality of
the physical and social environment on children’s
development depend upon characteristics of the
child, with children who experience social and
economic risks tending to benefit most from
higher-quality settings; and characteristics of
teachers and classrooms are not directly associated
with children’s learning and development, but they
may indirectly affect these outcomes to the extent
that they affect these proximal processes. The
direction for future research in child care settings

592

should be twofold: to better articulate the specific
features of the settings that are positively associated with specific developmental outcomes, and
for whom, and to move beyond center-based
pre-K settings to address these research questions
about how to design and structure learning opportunities among the entire range of settings within
which children experience child care.

Child Care: Promoting Healthy Development in Children

Curricular Strategies
The second improvement strategy is the adoption
of a comprehensive curriculum that structures the
learning activities within a given day or adoption
of a supplemental curriculum that focuses
small parts of the day on activities that build
specific competencies such as social-emotional
(e.g., Greenberg, Kusche, & Riggs, 2004) or language and literacy (e.g., Justice, McGinty,
Cabell, Knighton, & Huffman, 2010).

Strategies
There are at least four general types of improvement strategies that are common within child care
settings: (1) policy approaches, (2) curricular
strategies, (3) Quality Rating and Improvement
Systems, and (4) teacher training and professional development.
Policy Approaches
Policy changes enacted by entities that operate
and regulate public and private programs are
a common trigger for improving the quality of
children’s experiences within center-based child
care settings. Features of programs that are
affected by policies include the maximum class
size, minimum child-to-teacher ratio, requirements for the number of hours that teachers
participate in professional development activities, requirements for the minimum levels of
teacher education, and requirements for teachers’
specific field of study.
The policy question that currently receives the
most attention by state programs and Head Start
is whether to require that teachers have at least
a bachelor’s degree, as many public programs
allow lead teachers to have an associate’s degree.
Although prior research about teachers’ level of
education questions the merits of this potentially
costly policy on improving children’s experiences (Early et al., 2007) and learning outcomes
(Mashburn et al., 2008), advocates of this mandate consider among its potential benefits the
increased “professionalization” of the field of
early childhood education (Bellm & Whitebook,
2003) and better integration of pre-K teachers
into the K-12 system of education (Bogard &
Takanishi, 2005).

Quality Rating and Improvement Systems
The third strategy to improve child care experiences that is becoming increasingly popular is
participation in a Quality Rating and Improvement System (QRIS) (Zellman & Perlman,
2008). A QRIS typically has three components.
First, the quality of a participating child care
setting is rated using standardized observational
protocols that assess the quality of the environment, including the physical setting, social
interactions, number of children, and child-toadult ratio. Next, the setting is provided resources
to address the identified needs. Finally, the
quality of the setting is reassessed to document
improvements, and the final level of quality is
communicated publicly, often through the
assignment of stars denoting the level of quality
of the setting.
The intention of communicating these ratings
is to influence parents’ decisions to choose
higher-rated settings and to compel child care
settings to participate in the quality enhancement
activities. In 2008, over 26 states had
implemented a statewide QRIS and at least
20 additional states were in the process of developing a QRIS (Zellman & Perlman, 2008), most
of which involve center-based settings. Some
states were in the process of piloting this
approach to improve the quality of children’s
experiences in home-based settings.
Teacher Training and Professional
Development
The fourth strategy that is also growing in popularity in both home-based and center-based child
care settings is the adoption of teacher professional development programs that involve

Child Care: Promoting Healthy Development in Children

coaching and mentorship strategies to improve
the ways that adults interact with children. Early
approaches to professional development for caregivers and teachers involved day-long workshops
conducted outside of the caregiving environment
and used didactic instructional methods, and the
effectiveness of this approach is dubious. New
strategies involving coaching and mentoring are
derived from the adult-learning literature
(Richardson & Anders, 2005) that indicates that
effective strategies to improve knowledge and
skill should be active, collaborative, ongoing,
and linked to the caregiving context. These
approaches using coaching and mentorship are
being developed, implemented, and tested in centers (e.g., Bierman et al., 2008; Chesebrough &
King, 2004; Pianta, Mashburn, Downer, Hamre,
& Justice, 2008) as well as home-based child care
environments (e.g., Koh & Neuman, 2009).

What Works
There is unequivocal evidence that attending
a high-quality, small-scale (model) child care
program
that
focuses
on
improving
a comprehensive set of developmental outcomes
confers short-term and long-term benefits for
children. This evidence comes from three landmark experimental studies that began in the
1960s or 1970s and tracked the developmental
outcomes of participants and nonparticipants into
adulthood. The first is a longitudinal study of the
Perry Preschool program in Ypsilanti, Michigan,
that began in 1962, and results found that children
who attended had improved social and economic
outcomes at age 40 (e.g., greater earnings, more
likely to graduate from high school, fewer
arrests) compared to their counterparts who did
not attend (Schweinhart et al., 2005). The experimental study of the Chicago Parent Child
program that began in 1967 similarly found that
children who attended this program were more
likely to graduate high school and less likely to
receive special education services, be retained in
a grade, or be arrested (Reynolds et al., 2007).
The study of the Abecedarian program in
Chapel Hill, North Carolina, began in 1972,

593

and by age 21, children who attended the program
were more likely to be employed, enrolled in
higher education, and have a skilled job than
children who were randomly assigned to the control group (Campbell & Ramey, 1994).
The benefit-cost ratios derived from these
studies provide extraordinarily powerful evidence of the impacts of high-quality early intervention programs – with estimates ranging from
approximately $3–13 returned for every one dollar invested in these programs (e.g., Lynch,
2010). Although the arguments to provide public
programs for young children who experience
social and economic disadvantages are often
made on moral grounds, it is the economic benefits of early intervention programs derived from
these three experimental studies that fueled policy decisions by the federal government and most
states to create and expand programs over the
past five decades.
Experimental studies that test effects of contemporary child care programs (e.g., the Head
Start Impact Study) have produced estimates of
program impacts that are smaller than those
found in earlier studies (Puma et al., 2010), due
in part to differences in the composition of the
comparison groups then and now. As a result of
the dramatic increase in the prevalence of children who attend public programs, the comparison
group in current studies comprises children who
likely attended a program other than the one
under investigation, while in earlier studies, the
comparison group comprised children who likely
did not attend a program at all. To estimate
impacts of attending versus not attending in contemporary programs, alternative methodologies
such as regression discontinuity have been used,
which capitalize on the age cutoffs for enrolling
children into programs. This method assesses
program impacts by comparing the developmental outcomes of children who were just above the
age threshold and eligible to attend the program
with children who were just below the age threshold and not eligible to attend. Results from these
studies also provide evidence that attending these
programs produces large short-term benefits
for children (e.g., Gormley, Gayer, Phillips, &
Dawson, 2005).

594

What Is Promising
There are at least three approaches that hold
promise in improving the effectiveness of child
care in home-based and center-based programs:
(1) comprehensive and supplemental curricula,
(2) Quality Rating and Improvement Systems
(QRISs), and (3) teacher training and professional development involving coaching and
mentoring. There is a mixture of scientific
evidence for the efficacy of these approaches
from studies within center-based child care
settings, as well as theoretical support for the
soundness of each method within home-based
settings.
Comprehensive and Supplemental Curricula
The theoretical justifications for the benefits of
adopting a comprehensive curriculum are that the
curriculum provides a scope and sequence for
learning activities that promote development,
and the activities target a comprehensive set of
developmental outcomes, including literacy, language, social-emotional, math, and motor skills.
The scientific study of the effectiveness of curricula in public, center-based child care settings
was advanced by the Preschool Curriculum Evaluation Research (PCER) initiative that was
funded by the U.S. Department of Education
(Preschool Curriculum Evaluation Research
Consortium, 2008). In 2002 and 2003, the effectiveness of 14 preschool curricula was evaluated
in separate experimental trials in which centerbased classrooms serving 3-, 4-, and/or 5-yearolds were randomly assigned to either adopt the
curriculum under study or to continue using an
existing curriculum. The impact of a given curriculum on children’s learning was assessed by
comparing developmental outcomes at the end of
the school year for children in the treatment and
comparison settings. Results indicate that across
the 14 trials, there were virtually no statistically
significant impacts attributed to any given curriculum – only one had any detectable effect on
literacy outcomes, two had detectable effects on
mathematics outcomes, and none had effects on
children’s social outcomes (Preschool Curriculum Evaluation Research Consortium, 2008).

Child Care: Promoting Healthy Development in Children

However, closer review of these results indicates
that the effect sizes achieved by many curricula
were educationally meaningful, and the lack of
statistically significant differences was due to the
small numbers of settings included in each experimental study (most trials had a total of 14 settings
participate).
Another promising avenue for improving children’s experiences in child care settings is the
adoption of curricular supplements. In contrast
to adopting a comprehensive curriculum that
requires a complete overhaul of the activities
during a day, curricular supplements involve
activities that target a very specific developmental domain, take very little time during the day to
implement, and require minimal training for the
implementer. For example, Read it Again! is
a supplemental language and literacy program
in which teachers read a book to children twice
per week and provide explicit instruction to
promote vocabulary, narrative, phonological
awareness and print knowledge, and quasiexperimental studies find some promise of this
approach in promoting early language and
literacy skills (e.g., Justice et al., 2010). Promoting Alternative Thinking Strategies (PATHS)
involves story books, puppets, and other
materials that are used in lessons to improve
children’s self-control and social competence,
and evidence from experimental trials find
support for this approach (e.g., Domitrovich,
Cortes, & Greenberg, 2007; Greenberg et al.,
2004). Banking Time involves a series of
one-on-one,
child-led
interactions
with
a caregiver that are designed to strengthen the
teacher-child relationship, and results from an
experimental test also find benefits of this
approach (Driscoll & Pianta, 2010). The minimal
training required, relatively low cost, and encouraging results of these curricular supplements
make them particularly promising methods for
use in home-based child care settings.
Quality Rating and Improvement Systems
Quality Rating and Improvement Systems
(QRISs) are another promising approach to
improve children’s experiences in child care settings, and they have been widely adopted by

Child Care: Promoting Healthy Development in Children

states as a way to initiate quality improvement
activities in child care settings. The promise of
this approach is based on the theoretical premise
that quality improvement activities that address
the specific needs of a setting will improve these
settings (and, to a lesser degree, the developmental outcomes of children within these settings);
however, empirical studies that test the effectiveness of this approach are scant. There are
a number of evaluations of the validity of states’
QRIS quality standards and studies describing
quality improvements before and after participating in a QRIS; however, there are no published
results to date from experimental studies of the
impacts of a state’s QRIS on setting quality or
children’s development.
Most QRISs also communicate the quality of
each participating center by assigning a star rating, in order to affect parents’ choices about
where to send their children and to influence
child care settings to participate in the quality
enhancement activities. However, it remains
questionable that this component of the QRIS is
effective. In fact, published star ratings may compel centers with the lowest quality (and greatest
need for support) to avoid participating in these
programs altogether, which is a major limitation
with this approach. Another limitation with the
QRIS is its potential applicability to home-based
care settings. Although, some states are in the
process of piloting home-based QRIS programs,
little is known about whether implementation of
quality improvement activities and communication of the quality of these settings is a feasible
approach to improve quality in these settings.
Teacher Training and Professional
Development Involving Coaching and
Mentoring
The third promising approach to improving children’s experiences in child care settings is
through professional development programs that
use coaching and mentoring strategies. There is
evidence from recently conducted rigorous studies showing these programs can improve the
quality of interactions and children’s development in center-based and home-based settings.
For instance, using a multiple baseline design,

595

12 child care providers in center-based programs
who participated in the coaching-based TeacherChild Interaction Training program had significant gains in their positive interactions with children (Lyon et al., 2009). Similarly, in an
experimental study of the MyTeachingPartner
professional development program in a statefunded pre-K program, teachers who worked
with a consultant to build knowledge and skills
related to effective classroom interactions had
significantly greater improvements in the quality
of their classroom interactions than teachers who
did not participate (Pianta et al., 2008). And children in classrooms with teachers that participated
in the consultation made significantly greater
gains in receptive vocabulary skills than children
in classroom with teachers who did not participate (Mashburn, Downer, Hamre, Justice, &
Pianta, 2010). There is also evidence of the efficacy of coaching-based approaches in homebased settings. Koh and Neuman (2009) found
that home-based daycare providers who participated in a language and literacy course and
received coaching had greater improvements in
their literacy practices than providers who only
took the course or who had neither the course nor
the coaching.

What Does Not Work
A search of the research literature did not uncover
any strategies that consistently did not work,
which may be due in part to the bias in publishing
research with null findings.

Summary
Prior to enrolling in kindergarten, nearly every
child has received care by someone other than
a parent or primary guardian in a setting other
than the child’s home. Among the wide range of
settings within which children receive child care,
publicly funded centers for 3- and 4-year-olds
have served as the proving grounds for developing new knowledge about the ecological inputs to
children’s development and for creating new

596

strategies that facilitate children’s acquisition of
skills and competencies that prepare them to
enter school ready to learn. Specifically, the current understanding about children’s development
in these learning contexts, derived from theories
put forth by Vygotsky and Bronfenbrenner, is that
children acquire knowledge and skills through
frequent and sustained interactions with learning
materials, adults, and peers that are appropriate
for the ability of the child and that gain in complexity as the child develops. And, based on this
understanding of children’s development, the
most promising strategies for improving the
impacts of child care are those that affect children’s interactions, which include curricula and
curricular supplements, Quality Rating and
Improvement Systems, and professional development focused on improving adults’ social interaction with children. Despite the knowledge
developed and innovations created to improve
the impacts of center-based child care, little is
known about the appropriateness and feasibility
of implementing these and other strategies within
the wide range of home-based and center-based
child care contexts that children experience from
birth until kindergarten. Future work is needed to
identify usable strategies that improve the proximal processes that children experience within all
of these developmental contexts.

References
Administration for Children and Families, Department of
Health and Human Services. (2012). Head start program
fact sheet fiscal year 2012. Retrieved January 7, 2014,
from
http://eclkc.ohs.acf.hhs.gov/hslc/mr/factsheets/
2012-hs-program-factsheet.html
Barnett, W. S., Carolan, M. E., Fitzgerald, J., & Squires, J.
H. (2012). The state of preschool 2012: State preschool
yearbook. New Brunswick, NJ: National Institute for
Early Education Research.
Barnett, W. S., Epstein, D. J., Friedman, A. H., Sansanelli,
R. A., & Hustedt, J. T. (2009). The state of preschool
2009: State preschool yearbook. New Brunswick, NJ:
National Institute for Early Education Research,
Rutgers University.
Barnett, W. S., & Yarosz, D. (2004). Who goes to preschool and why does it matter? (Preschool Policy
Matters, Issue 8). New Brunswick, NJ: National Institute for Early Education Research, Rutgers University.

Child Care: Promoting Healthy Development in Children
Bellm, D., & Whitebook, M. (2003). Universal preschool
in California: An overview of workforce issues. Berkeley, CA: Center for Child care Employment.
Bierman, K. L., Domitrovich, C. E., Nix, R. L., Gest, S. D.,
Welsh, J. A., Greenberg, M. T., et al. (2008). Promoting academic and social-emotional school readiness:
The Head Start REDI program. Child Development,
79, 1802–1817.
Bogard, K., & Takanishi, R. (2005). PK-3: An aligned
and coordinated approach to education for children
3 to 8 years old. SRCD Social Policy Reports, 19(3),
1–23.
Bronfenbrenner, U., & Morris, P. A. (2006). The
bioecological model of human development. In R. M.
Lerner (Ed.), Theoretical models of human development, handbook of child psychology (6th ed.,
Vol. 1, pp. 793–828). Hoboken, NJ: Wiley.
Campbell, F. A., & Ramey, C. T. (1994). Effects of early
intervention on intellectual and academic achievement:
A follow-up study of children from low-income families. Child Development, 65(2), 684–689.
Chesebrough, E., & King, P. (Eds.). (2004). Bingham
early childhood prosocial behavior program. In
M. Bloom & T. P. Gullotta (Eds.), A blueprint for
the promotion of prosocial behavior in early childhood
(pp. 155–390). New York: Kluwer Academic/Plenum.
Domitrovich, C. E., Cortes, R. C., & Greenberg, M. T.
(2007). Improving young children’s social and emotional competence: A randomized trial of the preschool
PATHS curriculum. Journal of Primary Prevention,
28, 67–91.
Driscoll, K. C., & Pianta, R. C. (2010). Banking time in
head start: Early efficacy of an intervention designed to
promote supportive teacher – Child relationships.
Early Education & Development, 21(1), 38–64.
Early, D. M., Maxwell, K. L., Burchinal, M., Alva, S.,
Bender, R., Bryant, D., et al. (2007). Teachers’ education, classroom quality, and young children’s academic skills: Results from seven studies of preschool
programs. Child Development, 78(2), 558–580.
Gormley, W. T., Gayer, T., Phillips, D., & Dawson, B.
(2005). The effects of universal pre-k on cognitive development. Developmental Psychology, 41(6), 872–884.
Greenberg, M. T., Kusche, C. A., & Riggs, N. (2004). The
PATHS curriculum: Theory and research on neurocognitive development and school success. In J. E.
Zins, R. P. Weissberg, M. C. Wang, & H. J. Walberg
(Eds.), Building academic success on social and emotional learning: What does the research say?
(pp. 170–188). New York: Teachers College Press.
Justice, L. M., McGinty, A. S., Cabell, S. Q., Knighton, K.,
& Huffman, G. (2010). Language and literacy curriculum supplement for preschoolers who are academically at risk: A feasibility study. Language, Speech,
Hearing Services in Schools, 41, 161–178.
Koh, S., & Neuman, S. B. (2009). The impact of professional development in family child care: A practicebased approach. Early Education and Development,
20(3), 537–562.

Child Care: Promoting Healthy Development in Children
Lamb, M., & Ahnert, L. (2006). Nonparental child care:
Context, concepts, correlates and consequences.
In W. Damon, R. M. Lerner, K. A. Renninger, & I. E.
Sigel (Eds.), Child psychology in practice: Handbook
of child psychology (6th ed., pp. 664–679). New York:
Wiley.
Lynch, R. G. (2010). The cost effectiveness of public
investment in high-quality prekindergarten: A statelevel synthesis. In A. Reynolds, A. Rolnick,
M. Englund, & J. Temple (Eds.), Childhood programs
and practices in the first decade of life: A human
capital integration (pp. 315–338). New York: Cambridge University Press.
Lyon, A. R., Gershenson, R. A., Farahmand, F. K.,
Thaxter, P. J., Behling, S., & Budd, K. S. (2009).
Effectiveness of Teacher-Child Interaction Training
(TCIT) in a preschool setting. Behavior Modification,
33, 855–884.
Mashburn, A. J. (2008). Quality of social and physical
environments in preschools and children’s development of academic, language, and literacy skills.
Applied Developmental Science, 12(3), 113–127.
Mashburn, A. J., Downer, J. D., Hamre, B. K., Justice,
L. M., & Pianta, R. C. (2010). Teaching consultation
and children’s language and literacy development during pre-kindergarten. Applied Developmental Science,
14(4), 179–198.
Mashburn, A. J., & Pianta, R. (2010). Opportunity in early
education: Improving teacher-child interactions and
child outcomes. In A. Reynolds, A. Rolnick,
M. Englund, & J. Temple (Eds.), Childhood programs
and practices in the first decade of life: A human
capital integration (pp. 243–265). New York: Cambridge University Press.
Mashburn, A. J., Pianta, R. C., Hamre, B. K., Downer,
J. T., Barbarin, O., Bryant, D., et al. (2008). Measures
of pre-k quality and children’s development of academic, language and social skills. Child Development,
79(3), 732–749.
NICHD Early Child Care Research Network. (1999).
Child outcomes when child care center classes meet
recommended standards of quality. American Journal
of Public Health, 89(7), 1072–1077.
NICHD Early Child Care Research Network. (2002).
Child-care structure process outcome: Direct and indirect effects of child-care quality on young children’s
development. Psychological Science, 13(3), 199–206.
NICHD Early Child Care Research Network, & Duncan,
G. (2003). Modeling the impacts of child care quality
on children’s preschool cognitive development. Child
Development, 74, 1454–1475.

597
Peisner-Feinberg, E. S., & Burchinal, M. R. (1997). Relations between preschool children’s child-care experiences and concurrent development: The Cost, Quality,
and Outcomes Study. Merrill-Palmer Quarterly,
43(3), 451–477.
Piaget, J. (1954). The construction of reality in the child.
New York: Basic Books.
Pianta, R., Mashburn, A., Downer, J., Hamre, B., & Justice, L. (2008). Effects of web-mediated professional
development resources on teacher-child interactions in
pre-kindergarten classes. Early Childhood Research
Quarterly, 23, 431–451.
Preschool Curriculum Evaluation Research Consortium.
(2008). Effects of preschool curriculum programs on
school readiness. (NCER 2008–2009). Washington
DC: National Center for Education Research,
Institute of Education Sciences, U.S. Department of
Education. Retrieved September 16, 2011, from http://
ncer.ed.gov
Puma, M., Bell, S., Cook, R., Heid, C., Shapiro, G.,
Broene, P., et al. (2010). Head Start impact study:
Final report. Washington, DC: Administration for
Children and Families, U.S. Department of Health
and Human Services.
Reynolds, A. J., Temple, J. A., Ou, S., Robertson, D. L.,
Mersky, J. P., Topitzes, J. W., et al. (2007). Effects of
a school-based early childhood intervention on adult
health and well-being: A 19-year follow-up of
low-income families. Archives of Pediatrics &
Adolescent Medicine, 161(8), 730–739.
Richardson, V., & Anders, P. L. (2005). Professional
preparation and development of teachers in literacy
instruction for urban settings. In J. Flood & P. L.
Anders (Eds.), Literacy development of students in
urban schools: Research and policy (pp. 205–230).
Newark, DE: International Reading Association.
Schweinhart, L. J., Montie, J., Xiang, Z., Barnett, W. S.,
Belfield, C. R., & Nores, M. (2005). Lifetime effects:
The High/Scope Perry Preschool study through age 40.
In Monographs of the High/Scope Educational
Research Foundation, 14. Ypsilanti, MI: High/Scope
Educational Research Foundation.
Vygotsky, L. S. (1962). Thought and language. Cambridge, MA: The MIT Press.
Zellman, G. L., & Perlman, M. (2008). Child-care quality
rating and improvement systems in five pioneer states:
Implementation issues and lessons learned. Santa
Monica, CA: RAND Corporation.
Zigler, E. F., & Muenchow, S. (1994). Head Start: The
inside story of America’s most successful educational
experiment. New York: Basic Books.

598

Creativity in Early Childhood
Frank R. Lilly
California State University, Sacramento,
Sacramento, CA, USA

Introduction
In a world that is changing dramatically, globally,
environmentally, technologically, and economically, there is a great need to do our best to prepare
our children to be able to adapt to a world we
cannot predict. Specifically, many of the careers
young children will eventually choose on exiting
school have not been invented yet. What subjects
are most important to teach is often the emphasis
of current national and state educational standards.
However, the subjects may not be the most important thing that needs to be taught. For young children to adapt, they need to be able to critically
analyze and evaluate their surroundings, their
options, and their consequences. To be able to
critically think, students need to be encouraged to
be creative and look for multiple solutions to problems they are presented with. Creativity has not
always been associated with problem solving, critical thinking, or problem finding. Yet today, educators are beginning to understand that unless we
teach children to think and to enjoy solving problems, there will be repercussions that will leave
many unprepared to enter a workforce that
demands highly skilled workers.
Over the past 62 years, the study of creativity
has been valued as a research interest. Before this
time, few were interested in studying creativity.
The zeitgeist of psychological research during the
late nineteenth and early twentieth centuries
focused more on concrete observable behaviors
such as learning and perception. Not until the
cognitive revolution did creativity become
a construct worthy of study. Yet today, the

Special appreciation is extended to research assistant
Saugher Nojan for her invaluable contribution to this
document.

Creativity in Early Childhood

study of creativity is well established in educational and psychological research (Reilly, Lilly,
Bramwell, & Kronish, 2011). The need to
understand creativity is evidenced by the everchanging dynamics of the technological age
(Lau, 2006; Prentice, 2000) and our need as
humans to adapt to our environment. Genuinely
creative adaptation represents the only possibility
that humans can keep abreast of an evolving
world (Rogers, 1954). Therefore, creativity
should be cultivated in young children, particularly in an educational environment (Saracho,
2012; Starko, 1995). Yet, are young children
capable of being creative? If so, in what ways
are they creative? Is their creativity innate or
learned? If learned, in what ways can we help to
improve young children’s abilities to be creative?
This article discusses where, how, and when
young children are creative, what promotes
childhood creativity, and what constrains it.
The theoretical focus is developmental, including
biological, psychological, and societal systems
that influence and impede creativity.

Definitions and Scope: What Is
Creativity?
Creativity has often been interpreted by society
as synonymous with artistic expression (Eckhoff,
2011; Prentice, 2000; Saracho, 2012). Creativity
has also been interpreted as the product of
highly intelligent individuals. Similarly, other
researchers have viewed creativity as an inherent
characteristic only few possess and only to be
studied retrospectively in famous individuals.
And although research has suggested correlations
with both the arts and intelligence, creativity as
a construct has been agreed upon to be something
unique or novel that had external value, the result
of purposeful behavior, and a result of sustained
duration (Csikszentmihalyi, 1996; Gardner, 1993;
Gruber & Wallace, 1999; Reilly et al., 2011). This
definition has often been used to evaluate the
products of artists, scientists, economists, authors,
and others. Yet Taylor (1975) and others have
stressed that to understand the perceptual and
motivational hypotheses underlying creative acts,

T.P. Gullotta, M. Bloom (eds.), Encyclopedia of Primary Prevention and Health Promotion,
DOI 10.1007/978-1-4614-5999-6, # Springer Science+Business Media New York 2014

Creativity in Early Childhood

we must consider the person creating in the environment, emphasizing the importance of the creator’s dispositional style and goodness of fit with
the domain and field. Therefore, we must study the
person, the process, the product and the press of
creativity in order to more fully understand the
scope of creative behavior.
Creativity has been demonstrated as a sense of
curiosity and wonder, inventiveness, flexibility,
exploratory behavior, imagination, and originality.
Creative individuals have developed a capacity to
take risks, to tolerate ambiguity, and to possess
openness to experience and a freshness of perception (Lilly & Bramwell-Rejskind, 2004). Creativity has been correlated with intelligence, and a vast
amount of research on multiple intelligences has
provided further evidence that creativity can take
many forms. For example, Gardner (1993) states
that intelligence can be expressed through the traditional outlets of logical spatial and linguistic
expression, yet can also be expressed kinesthetically, intrapersonally, interpersonally, naturalistically, existentially, musically, and visiospatially.
Multiple intelligences suggest there are multiple
ways individuals can creatively learn and express
solutions to novel situations.
Recently, “everyday” creativity (i.e., creativity
that can be observed in humans and other animals
in a variety of settings) has been the focus of great
research. This research focuses on how traditionally average individuals can be viewed as creative
based on how they recombine symbols, systems,
and constructs in their everyday lives. As such,
children are prime examples of taking recently
learned concepts and applying them in novel
ways (i.e., the product is novel to the child)
(Starko, 1995). This has been instrumental in an
argument to reintroduce creativity into the curriculum and instruction of our public schools. It is
crucial for children to learn and then exhibit creativity in their future learning lives. Creativity must
be included in education in order for children to
practice imaginative and inventive ways of thinking and doing (Prentice, 2000).
Young children represent the purest forms of
everyday creativity as they explore their environment. Children use all their senses to explore
the objects and events they experience. All

599

experiences add to the young child’s repertoire
of behavioral possibilities. Observing young children as they recombine shapes, blocks, and toys
in novel ways can be inspiring as they smile and
wiggle with delight at their accomplishments. Or
observing the intricacies with which children
develop imaginary encounters demonstrates
how unencumbered their ideas can be. With this
unencumbered freedom to create comes the
social construct of appropriateness. Parents and
family, teachers, and peers all contribute to the
social learning of children to fit in and be part of
the group. At a very young age children are being
taught what is creative and what is not.

Theories
Learning to be creative has been studied from a
learning perspective, a cognitive perspective, a
humanist perspective, and an evolutionary perspective. Early theories of learning were often
based on contiguity theory, also called associationist/connectivist or behaviorist perspectives.
Here the learner is viewed as a passive absorber
of stimuli controlled by prior stimuli (Ormrod,
2009). More contemporary learning theories
view learning as a goal-oriented process. Learning
as a goal-oriented process makes learning purposeful. Tying information to prior knowledge,
understanding, and affect makes it meaningful.
Learning ties made by each student are original
and, if goal oriented, are appropriate to meet the
goal, then the processes of learning themselves
can be considered creative (Starko, 1995).
Learning and problem solving became associated with the study of creativity as cognitive
approaches to research became more prevalent.
First, approaches viewed the learner as needing
to locate a difficulty, then the difficulty is
defined, then possible solutions are considered,
then consequences are weighed, and finally one
of the solutions is accepted. Later, the creative
problem solving process was viewed as, first,
involving preparation, then incubation, then illumination, then verification. Later theoretical
models of the creative problem solving process
were also made up of logical steps resembling

600

the scientific method (i.e., sensing a problem,
making hypotheses about the problem, evaluating the hypotheses, and communicating the
results). However, the Parnes/Osborn model of
Creative Problem Solving (CPS) was different in
that it contained three components (i.e., understanding the problem, generating ideas, and
planning for action). These components are
implemented in six stages (i.e., mess finding,
data finding, problem finding, idea finding, solution finding, and acceptance finding). More
recent cognitive approaches take on a more technological terminology and include analyses of
retrieval, synthesis, transformation, analogical
transfer, and categorical reduction of mental
processes (Sternberg, 1999).
A more confluent approach hypothesizes
that multiple components must converge for creativity to occur. The systems approach includes
the domain, the field, and the individual.
Profiles emerging out of this research suggest
creative individuals possess somewhat contradictory characteristics. Csikszentmihalyi (1990)
describes this phenomenon as complexity of personality experienced through the concept of
“flow.” Flow states are enjoyable experiences
whereby the individual “loses themselves” in an
activity. The activity is believed to be characterized by clear goals, immediate feedback to one’s
actions, a balance between challenges and skills,
action and awareness merge, distractions being
excluded from consciousness, having no worry of
failure, self-consciousness disappearance, the
sense of time becoming distorted, and the activity
becoming autotelic (i.e., doing the activity for its
own sake).
Current research views creativity from
a positive psychology perspective. Instead of
studying behaviors and characteristics of humans
involving maladies, or a select population of
intelligence, positive psychology views creativity
as something all humans possess to varying
degrees and something that can be nurtured and
developed (Linley, Harrington, & Garcea, 2010).
The lens of positive psychology focuses on
the positive aspects of human behaviors. This
perspective focuses on how we can increase
our understanding of authenticity, abundance,

Creativity in Early Childhood

optimism, appreciative inquiry, social responsibility, commitment, leadership, and resilience.
Researchers in positive psychology suggest that
when we identify our strengths, we feel better
about ourselves and those around us. When we
feel better about ourselves, we develop the competence (ability to learn) and the commitment
(willingness to learn). Students who are competent to learn but not willing to learn will not
perform to their full potential and thus not demonstrate creative behavior. Commitment emerges
from building an individual value position that
engages students to use their energy to pursue the
institutional goals.
Therefore, when schools need to develop strategies to address curriculum and instruction or
teacher commitment, organizational development (OD) needs to occur. Appreciative Inquiry
(AI) is a creative process of discovery (an issue or
perceived problem), dream (about possible solutions), design (implement a strategy), and destiny
(creating the ideal solution) to address problem
solving. This OD model teaches teachers, administrators, and employees to value the most positive setting possible. To use this model
successfully to conduct system change, the field
of demographics studies what engages each generation to commit to their full potential and what
affects how they define fulfillment at school.
With scarce resources in education and industry,
many schools are becoming socially responsible,
concerned about their carbon footprint, philanthropy, and core values. As the nature of school
and work become more complex, often individuals work together in teams. High-performing
teams operate with the ability to learn, clear purposes, good governance, and positive member
relationships (in work and school settings). This
leads to more happiness in school settings, family
and community settings, and career settings.
Therefore, the positive psychology approach
studies how to achieve abundance in multiple
settings (Linley et al., 2010; Lopez & Snyder,
2009). Positive psychology offers a new theoretical perspective for the study of creativity in
children by working to increase potential in the
child, the parent, the teacher, the administrator,
and the school district.

Creativity in Early Childhood

Research
Creative Potential
According to Vygotsky, every human being is
equipped with a potential for creativity (Ormrod,
2009). Children can be creative on a small personal scale relevant to their environment defined
as “little c,” while the potential for “big C”
(i.e., creativity on a grand scale) later in their
development can be fostered and enhanced
through the collaboration of parents and educators. Some theorists believe expertise is
a precursor to creativity, yet experience has also
been known to inhibit creativity when associated
with inflexibility. Children’s lack of expertise
allows them to perform creatively without being
constrained to conventions and norms; however,
at the same time it may keep them from making
original assumptions. Those attributed with creative minds such as Piaget, Freud, and Darwin
moved from studying one field to another bringing new perspectives and avoiding assumptions.
In the same way, children do not have the experience to develop the same assumptions thus
avoiding routines, making it easier for them to
reach original ideas. One study found age to be
crucial to the creative process because it affects
children’s cognitive, motor, and social developments. For example, in order to estimate motor
creativity through the evaluation of divergent
movement ability in preschool and elementary
school children, older children display a higher
level of motor creativity, implying that previous
knowledge and experience enhances creativity
(Zachopoulou & Makri, 2005). And although
young children are often creative relative to
themselves, in order to promote general creativity, a greater knowledge base is required
(Sternberg, 2003). Therefore, until children
receive the basic skills training needed to create
something truly novel and display “big C,” then
creativity research should emphasize promoting
the creative process rather than the product in this
developmental period.
Process Versus Product
Drawing, an activity that includes both the
process and product, has become a topic for

601

discussion in early childhood programs, as some
question the value of the activity. Drawing is
a catalyst of thoughts that allows the child to
create something new from previously learned
themes through the direct manipulation of art
materials (Faulkner, Coates, Craft, & Duffy,
2006). According to Wright (2010), in Understanding Creativity in Early Childhood, emphasis
should be placed on promoting creativity in
children by signifying the creative process of
drawing rather than the end product. To dispel
some of the misconceptions surrounding drawing
as a “lesser practice,” 100 children between the
ages 5 and 8 were studied to understand
the significance of the drawing process at an
early age as a vehicle for creative thought and
expression. Similarly, Del Nero (2011) views
drawing as a “sign-making” process that connects
the child’s external real world with his/her inner
imagination. Both support the idea that art is
a tool for creative expression in children and
stress for the continuance of art programs in
early childhood education. When arguing process
versus product, productivity may not always be
a good indicator of creativity in young children as
the characteristics of creativity must be evaluated
in context to the child’s experience (Runco,
1999). When engaging in original ideas for themselves rather than a given domain or field, young
students need to develop the meta-cognition and
self-regulation to continuously focus on their
creative process (i.e., creating and generating
original ideas) which once acknowledged motivates them to generate more ideas (Saracho,
2012). However, children’s lack of expertise
may limit their ability to perform creativity, yet
at the same time it is this lack of experience that
allows them to disregard assumptions and
express more openness and originality (Runco,
1999). When young children seem uncreative,
they are simply unable to express their insights.
Therefore, it is essential to create this opportunity. Parents and educators are recommended to
make sure children to do not lose their capacity to
be spontaneous and flexible and encourage children to be strategically creative by promoting
originality in children while allowing them to
learn important conventions (Runco).

602

Parenting
Carl Roger’s Humanistic Theory (1954)
explaining psychological safety and freedom is
paramount according to Harrington, Block and
Block (1987). Their study focused on childrearing practices that may promote the development of such factors. The Child-Rearing Practices Report (CRPR) was formed through
descriptions provided by parents, which were
later organized using Roger’s description of a
creative-fostering environment. Items in the
CRPR consisted of “My child and I have warm,
intimate times together” and “I encourage my
child to be curious, to explore and question
things.” The study confirmed that children will
develop a higher creative potential if raised by
parents who promote psychological safety
and freedom in their child-rearing practices
(Harrington et al., 1987). Kemple and Nissenberg
(2000) discuss the various ways in which family
life can affect children’s creativity, promoting
a closer relationship between educators and parents in order to foster a better environment for the
development of children’s creativity.
Families and Enriched Environments
Parents can promote creativity by maintaining
an enriched home environment for children.
Enriched environments are filled with books,
toys, games, and multitudes of other intellectually stimulating resources. This also includes
child-centered families in which parents spend
a vast amount of time, energy, and resources on
developing their children’s interest and
enriching their experiences by holding serious
discussions with them and taking them to interesting places such as museums, zoos, and theaters (Kohanyi, 2011). Research suggests that an
authoritative style of parenting characterized by
the presence of both boundaries and flexibility is
most common among creative achievers’ parents. These parents also tend to be financially
and culturally privileged allowing for a broader
spectrum of resources and experiences available
to the potentially creative child. While parents of
high social economic status (SES) and education
level can provide for these privileges to foster
the creative potential in their children, it does not

Creativity in Early Childhood

predispose one to become creative (Kohanyi). In
fact, research suggests creative children are
likely to experience more tribulations than their
equally bright but less creative peers. However,
stress alone is not conducive to creativity; stress
accompanied with support in the form of attentive siblings, relatives, or friends, if not parents,
is the more likely contributor suggesting
a balance between challenge and support is best
for the development of creativity (Kohanyi).
Mentor as Creative Facilitator
Prentice (2000) explains that in order for creativity to flourish in young children, support from
creative adults is crucial. Creative mentors can
help children acquire the appropriate technical
skills and secure a knowledge base in order to
underpin sustained creative activity. Once this is
achieved, children are able to engage in a given
activity with greater depth and thereby allow
creativity to function. The mentor becomes the
“child’s instrument” in such creative episodes as
storytelling where an adult takes dictation for
a child who cannot write their own stories
(Doyle, 2003).
Imagination
Schaefer (1969) found implications in his study
to suggest that brighter children who are inclined
towards creativity were more likely to have experienced imaginary companions in childhood.
Therefore, imaginary companions should be
noticed as a marker of potential creativity.
Classroom Environment
Children must feel psychologically safe and free
in order to develop a creative potential demonstrated through creativity in adolescence
(Harrington et al., 1987). It is important that
teachers prepare their students to choose environments that are conducive to their creative
success in order to nurture their development
(Sternberg, 2003). Stressful environments create
emotional and psychological needs in children
which they try to fulfill through high levels of
creativity. Students will produce higher levels of
creativity and show deeper learning through the
use of Universal Design for Learning (UDL).

Creativity in Early Childhood

Because students learn in a variety of ways, they
need to be able to express their creativity and
learning through multiple modes of representation. When given assignments or homework,
students are allowed to express themselves
through multiple formats to provide responses
to the teacher (e.g., film, essay, skit, poetry,
formula). However, first, teachers must be
skilled in providing multiple modes of instruction in their classrooms and willing to accept
multiple methods of evaluation for an assignment. Based on the concept of inclusion, UDL
builds community in the classroom by honoring
diversity. All curriculum and instruction is
offered in multiple modes (e.g., lecture, film,
cooperative learning, inquiry learning, discovery learning). All materials used in the classroom must be accessible to all children and
complement their learning styles. As a result,
students learn to explore, risk, tolerate ambiguity, generate multiple solutions to problems, and
work together to solve tasks (Burgstahler &
Cory, 2008).

Strategies: How to Promote Creativity
As models, nurturers, and resources of children’s
creativity, parents and educators help facilitate
creative potential by respecting and encouraging
elements that are conducive to the development
of creativity in their homes and classrooms.
Young children that are exposed to more examples of art, mathematics, history, language, physical education, science, music, and nature will
develop the knowledge base to be able to recombine ideas within any domain to produce novel
and appropriate products. Although there are
domains with only one correct answer to
a question, most domains allow for multiple
interpretations, and therefore, students need to
learn to defend why they have made specific
responses to questions, thus teaching critical
thinking at an early age.
To nurture children’s creativity in the home,
parents need to work with all members of the
family to discuss egalitarian and equitable
exchanges of ideas and behaviors. Although

603

some children do learn to be highly creative
within restrictive environments, most children
learn best with support and guidance. Using AI
as a strategy of finding the strengths in every
family member and highlighting them without
focusing on the weaknesses of family members
will enforce positive behavior and attitudes such
as respect, trust, and love. Support from loved
ones helps children to be resilient and persevering. Both of these traits are necessary to promote
creative behavior.
The creative educator is critical in the development of childhood creativity. Teachers must
understand multiculturalism, gender and gender identity, and psychological, cognitive, and
physical developments to be able to recognize
the incredible variability and ability within
each classroom. With that variability, responsibility to reach each child where they are is
every teacher’s challenge. In addition to the
teacher, the classroom culture influences the
curriculum and prepares children for future
creativity by promoting questioning and risk
taking, creative assessments, curiosity and
open-endedness, collaboration and teamwork,
and activities that highlight children’s creative
potential such as storytelling and dramatic
play. The creativity of the educator is highly
correlated with student creativity. The creative
teacher welcomes parents into their classrooms,
encourages friendships, polices bullying and
discrimination, and designs cross-curricular
lesson plans that not only meet standards but
are exciting and fun. Creative instructors are
more likely to model and encourage creativity
in their students.
Further strategies for increasing childhood
creativity focus on extracurricular activities.
Often, teachers are not able to devote ample
time for young children to learn to play
a musical instrument and develop physical agility
and strength through dance or athletics. As children are exposed to activities that they are curious
and interested in, they develop perseverance to
develop skill and confidence in an activity. The
ability to transfer skills of success increases the
probability that the child will be creative in the
future.

604

What Works
Creativity has been a research topic of interest for
the past 60 years, yet no intervention or methodology has been replicated over three times.

What Is Promising
Creative Instructors
The more parents and teachers know about creativity and how to model it, the more they can
promote creativity regardless of domain. Creative teaching is improvisational yet intentional
(Bramwell, Reilly, Lilly, Kronish, &
Chennabathni, 2011; Sawyer, 2003). In a study
assessing the effect of creative movements during
children’s daily physical education on children’s
overall creativity, results suggest creative movement alone was insufficient in promoting creativity, and the need for a creative instructor to help
develop this process among children is crucial
(Cheung, 2010). Instructors initially encouraged
children to learn a basic movement skill, then
provided them with the opportunity to use the
skill in creative ways as a means of communication and self-expression; however, without the
mentors’ creative guidance, many children result
to imitation (Cheung). Therefore, the creative
instructor becomes a crucial component in the
promotion of early childhood creativity. The creative teacher has high levels of physical energy, is
of above average intelligence, has a playful sense
of humor, and is passionate about their interests.
They appear curious, independent, complex,
artistic, and open-minded with a deep motivation
and drive to teach and a strong intuitive nature
(Lilly & Bramwell-Rejskind, 2004).
Similar results were discovered with regard to
promoting children’s musical creativity. In
a study exploring the (1999–2000) curriculum
change in Hong Kong, Lau (2006) discovered
the significant role of educators in early childhood education of creativity. Focusing on musical creativity in three case studies of Hong Kong
kindergarten classrooms, fostering creativity was
dependent on the understanding of the teacher of
the four key areas of creativity (the environment

Creativity in Early Childhood

or press, person, process, and product). Lau also
emphasized teachers/parents setting children’s
creativity free when engaging in creative activities rather than directing, rehearsing, or controlling performance. Lau (2010) proposed three
suggestions for educators looking to enhance
the musical and overall creativity in children:
make room for play, provide time and environments rich with resources, and scaffold children’s
musical play. Similarly, an additional ethnographic study of two kindergartens in China supports the idea that the development of creativity
depends on teachers’ interpretations of cognition,
the relationship between culture and cognition
and cultural interpretation of creativity (Ang,
Waite, Goouch, Brooker, & Montgomery, 2009).
Teachers can reinforce young children’s
potential creativity by encouraging their belief
in their ability to succeed (Sternberg, 2003).
The most creative individuals are those who are
intrinsically motivated, and their ability to imagine success while doing work that they love will
help foster that creativity. Teachers can do this by
asking children to demonstrate a special talent or
ability for the class and explain it doesn’t matter
what they do (within reason), only that they love
the activity (Sternberg). Recognizing the myths
surrounding creativity is also an important step
for instructors in acknowledging that all students
have the capacity for creativity. Also, teachers
need to be self-aware and take a careful look at
the curriculum and personal preference for certain intellectual styles so they do not constrain
creative potentials in children (Plucker,
Waitman, & Hartley, 2011).
Creative Curriculum
In a study exploring whether play is mutually
exclusive with learning, Samuelsson and Carlsson (2008) suggest a curriculum for early childhood education that does not distinguish between
learning and play in order to promote creativity
for future generations. While children blend the
two when they act, they distinguish them in their
speech. The idea here is to foster the experience
of learning as joyful and related to play in order to
encourage and enhance processes such as creativity in the future. Creativity is an aspect of all

Creativity in Early Childhood

learning in preschool; therefore, a close connection (association) between learning and play will
foster this process.
The results of a longitudinal cultural study of
children’s drawings found that intentional teaching (structured lessons) at an early age can help
children display higher levels of creativity
because of the development of their representational skills that allows them to be creative. Thus,
creativity might be enhanced by the incorporation of intentional teaching in early childhood
education in order to promote the developmental
skills in young children that would give them the
opportunity to express their creative ideas
(Huntsinger, Jose, Krieg, & Luo, 2011).
On the other hand, Dababneh, Ihmeideh and
Al-Omari (2010) found a need for improvement
within teachers’ classroom practices that focus on
knowledge retention rather than children’s creative abilities. They concluded that Jordanian
teachers need more training on how to prepare
creative lesson plans in the form of preservice
training courses for developing creativity in children. The aim of the study was to create an
awareness and motivation in teachers to pursue
novel approaches in fostering creativity in
children.
Preparing for Future Creativity
Sternberg (2003) states creative thinking is characterized as “buying low and selling high” which
leads to defying the crowd. In this process it is
easy for children to lose sight of their motivation
to endure the creative process that may take
a long while before it is valued. Therefore, it is
the parents’ and teachers’ responsibility to help
prepare children for these obstacles by introducing them to stories about creative individuals who
were not supported in the early stages of their
development. Supporting children’s efforts to
“surmount an obstacle” should also be praised
whether they were entirely successful or not and
spotlight the correlation between creativity and
resilience.
Educators and parents must allow room for
children to make mistakes and discuss those mistakes in order to realize that creativity results
from a new way of thinking that formed after

605

collaborators took risks and made mistakes. Children in social situations such as school often
experience the negative ramifications of being
an independent risk taker. Often children that
think, act, and look different are disenfranchised
and may learn to avoid social disapproval. Educators and parents may promote creativity in
young children by inspiring their children to
define and redefine problems and projects. For
instance, providing children with a choice
between two projects is not as beneficial as
allowing children to decide on a project of their
own making. This gives children the ability to
develop taste and good judgment which are
essential elements of creativity. The importance
of reflection in creativity is important when
teaching children how to recognize mistakes
and in turn to redefine their choices
(Sternberg, 2003).
Here again, creativity is related to the ability to
delay gratification and maintain the motivation to
persevere. Creativity creates an environment
where hard work is not immediately rewarded.
Educators and parents can help young children
develop these skills by promoting long-term projects at home or in school where children have to
wait for a reward (Sternberg, 2003). Suggestions
for creative enhancement include the intention to
be creative. Teachers should first make it
a student’s goal to learn knowledge/basic skills
as they are essential for the development of creative potential. More knowledge allows for more
opportunities to recombine information, thus
helping build upon potential to secure creativity
(Paulus & Brown, 2003).
Questioning and Risk Taking
While constant questioning in a classroom is not
reasonable, providing children with the opportunity to ask questions and teaching students what
questions to ask and how and when to ask them is
paramount in the process of creativity. This ability will help children understand that what matters is the ability to apply facts rather than
memorize facts. In promoting creative thinking
and critical thinking, children must learn to ask
questions and develop arguments to persuade
other people of the value of their ideas

606

demonstrating why their ideas make an important
contribution. Taking internal ownership for one’s
ideas is the first step in self-advocating and developing the self-esteem and self-confidence to be
creative. External reinforcement is also important
until children can learn to self-advocate based on
the self-evaluation of their ideas.
Curiosity and Open-Endedness
Curiosity is a trait that allows children to learn to
explore, ask questions, wonder, and create.
Teachers and parents need to allow for situations
for young children to explore within a safe environment. This practice exploring, wondering, and
being exposed to a rich learning environment will
become part of the child’s learning mindset. Curiosity and open-ended activities that allow for
multiple responses and assessments include
more students in the process of creativity. For
example, Yan (2005) investigated the relationship between the open-endedness of activities
and creativity in early childhood among at risk
(i.e., low income) students and found a positive
correlation, suggesting students significantly
improved in creativity when the degree of openended activities was increased in their curriculum. Further, Kim (2008) recognized that openended assignments or open-ended components in
the classroom contribute to the success of highly
creative students in promoting intellectual
playfulness. Promoting intellectual playfulness
(i.e., finding pleasure in learning) gave rise to an
increase in productivity following the break compared to individual brainstorming continuously
without a break.
Storytelling
Child-centered storytelling and dramatization
can enhance children’s creativity in early childhood education when originality is preserved
through effective prompts employed in the process (Wright, Bacigalupa, Black, & Burton,
2008). Prompts give students a starting place to
jump off into their own direction. Having
prompts such as opening prompts, continuation
prompts, and closing prompts help to scaffold
the creative process until students can independently create (Wright, 2008). One of the most

Creativity in Early Childhood

important skills a parent or teacher can have is
patience when faced with the unsophisticated
nature of children’s stories because such situations are found to improve communication
between teachers, parents, and children. Similar
to storytelling, Gupta (2009) found that dramatic
play enhances development in creativity when
the activity was child-initiated and teacherdirected. Dramatization of children’s original
stories allowed individual development within
a social context, enhancing children’s, language,
cognitive, socio-emotional, and creative skills
(Gupta).
Cultural Influences
Culture can have an influence on how creativity is
promoted in education. In Chinese culture, children were expected to master basic skills before
exhibiting their own creativity, while the
European/American view rests on the idea that
natural development of intrinsic creativity in
children is not to be corrupted by strict guidance
(Huntsinger et al., 2011). Findings suggested that
at the same age, Chinese children exhibited
higher levels of creativity in their drawings due
to their development of representational skills.
This study compliments the Vygotskian perspective of constructivism suggesting children benefit
from adult guidance by bringing children into
their zone of proximal development in learning
to draw, as they do in learning to speak
(Huntsinger et al.). This implies creativity might
be enhanced by the incorporation of intentional
teaching (structured guidance) in early childhood
education in order to promote the developmental
skills in young children that would give them the
opportunity to express their creative ideas later in
their development (Huntsinger et al.).
Europe’s current dedication to foster creativity and cultural development in early childhood
education introduces new perspectives and ways
of thinking about young children’s creative and
cultural developments that challenge traditional
perspectives (Faulkner et al., 2006). The authors
argue children are active agents in the creation of
their own cultures rather than passive recipients,
demonstrated through the spontaneous songs that
children engage in across cultures. Barret (cited

Creativity in Early Childhood

in Faulkner et al.) draws her conclusions from
a longitudinal ethnographic case study of
a young child’s musical development in which
she states that invented song is a dialogic tool that
children use to express their identity and construct cultural meanings and understanding and
therefore should be encouraged.

What Does Not Work
Impatience
It is important not to quash curiosity; and those
who are invalidated for being curious or inquisitive will often inhibit their ability to ask future
questions and explore the mysteries of the universe that provide content to promote creativity.
Formalized and institutional public education
systems often suppress curiosity in more ways
than promote it; curiosity leads to creativity
(Sternberg, 1999; Wright et al., 2008).
Preventing Groupthink
Group interaction can significantly enhance creativity, yet group blocking can occur due to social
influence that can prevent equal contribution.
Group performance can be improved through
the use of cooperative learning techniques and
brainwriting. Brainwriting is established when
each group member shares their thoughts on
a piece of paper one at a time (Paulus & Brown,
2003). This process reduces blocking and reinforces writing and reading rather than speaking
and listening (Paulus & Brown).

Summary
During the past six decades, the study of creativity and creative behavior has escalated to more
fully understand in what ways we can observe,
measure, and nurture creativity in children and
adults. Because our world is ever-changing, we
must continually adapt to our environments. Our
environments are changing rapidly, and the
advent of technology has stimulated a cultural
evolution that demands we learn to think critically and behave creatively.

607

Parents and teachers can nurture creative
behavior in their children and students by building psychologically safe environments where
children can take risks, fail, and persevere. Children must be able to explore multiple solutions to
issues and problems presented to them. Parents
and teachers must also know enough about how
creativity can be nurtured in order to scaffold
activities and develop exciting curriculum and
instruction methods. Parents must be present in
their children’s lives and provide multiple opportunities for children to observe museums and
zoos. A healthy home life where all have
a voice is important to teach children to be confident. Knowledge and basic skills need to be
nurtured in order for children and students to
have concepts to manipulate creatively. This
knowledge can be disseminated through multiple
teaching strategies that support a variety of
learners and engage every student. Student
choice and interest are highly important in early
school years to teach children that learning is
play. Through play, students will imagine, risk,
share, and develop rich understandings of their
world. By appreciating children’s unique
strengths, mentors can guide children to selfreflect on how they learn best. Having a love for
learning will encourage curiosity and question
asking. These questions lead to more and
a personality of creativity develops.
Children must be prepared by parents,
teachers, and mentors to critically think and problem solve. Because the jobs of the future have not
been created yet, we cannot prepare children
completely. We can prepare them to be actively
engaged and curious. These positive human qualities better prepare us to adapt to novel
environments.

References
Ang, L., Waite, S., Goouch, K., Brooker, L., & Montgomery, H. (2009). Book reviews. International Journal of
Early Years Education, 17(3), 237–246. doi:10.1080/
09669760903454264.
Bramwell, G., Reilly, R. C., Lilly, F., Kronish, N., &
Chennabathni, R. (2011). Creative teachers. Roeper
Review, 33, 228–238.

608
Burgstahler, S. E., & Cory, R. C. (2008). Universal design
in higher education: From principles to practice.
Cambridge, MA: Harvard Education Press.
Cheung, R. H. P. (2010). Designing movement activities
to develop children’s creativity in early childhood
education. Early Child Development and Care,
180(3), 377–385.
Csikszentmihalyi, M. (1990). Flow: The psychology of
optimal experience. New York: Harper & Row.
Csikszentmihalyi, M. (1996). Creativity. New York:
HarperCollins.
Dababneh, K., Ihmeideh, F. M., & Al-Omari, A. A.
(2010). Promoting kindergarten children’s creativity
in the classroom environment in Jordan. Early Child
Development & Care, 180(9), 1165–1184.
Del Nero, J. R. (2011). Book review: Wright, Susan.
Understanding creativity in early childhood. Journal
of Early Childhood Literacy, 11(1), 99–104.
Doyle, C. (2003). Creativity, early childhood. In T. P.
Gullotta & M. Bloom (Eds.), Encyclopedia of primary
prevention and health promotion (pp. 335–341).
New York: Plenum.
Eckhoff, A. (2011). Creativity in the early childhood classroom: Perspectives of pre-service teachers. Journal of
Early Childhood Teacher Education, 32, 240–255.
Faulkner, D., Coates, E., Craft, A., & Duffy, B. (2006).
Creativity and cultural innovation in early childhood
education. International Journal of Early Years Education, 14(3), 191–199.
Gardner, H. (1993). Creating minds: An anatomy of creativity seen through the lives of Freud, Einstein,
Picasso, Stravinsky, Eliot, Graham, and Gandhi.
New York: BasicBooks.
Gruber, H. E., & Wallace, D. B. (1999). The case study
method and evolving systems approach for understanding unique creative people at work. In R. J. Sternberg (Ed.), Handbooks of creativity (pp. 93–115).
New York: Cambridge University Press.
Gupta, A. (2009). Vygotskian perspectives on using dramatic play to enhance children’s development and
balance creativity with structure in the early childhood
classroom. Early Child Development & Care, 179(8),
1041–1054. doi:10.1080/03004430701731654.
Harrington, D. M., Block, J. H., & Block, J. (1987). Testing aspects of Carl Roger’s theory of creative environments: Child-rearing antecedents of creative potential
in young adolescents. Journal of Personality and
Social Psychology, 52, 851–856.
Huntsinger, C. S., Jose, P. E., Krieg, D. B., & Luo, Z.
(2011). Cultural differences in Chinese American and
European American children’s drawing skills over time.
Early Childhood Research Quarterly, 26(1), 134–145.
Kemple, K. M., & Nissenberg, S. A. (2000). Nurturing
creativity in early childhood education: Families are
part of it. Early Childhood Education Journal, 25(1),
67–71.
Kim, K. H. (2008). Underachievement and creativity: Are
gifted underachievers highly creative. Creativity
Research Journal, 20(2), 234–242.

Creativity in Early Childhood
Kohanyi, A. (2011). Families and creativity. In
M. A. Runco & S. R. Pritzker (Eds.), Encyclopedia of
creativity (2nd ed., pp. 503–508). Amsterdam:
Elsevier Academic Press.
Lau, W.CM. (2006). Strategies kindergarten teachers use
to enhance children’s musical creativity: Case studies
of three Hong Kong teachers. Unpublished doctoral
dissertation, Queensland University of Technology,
Brisbane, Queensland.
Lau, W. C. M. (2010). Musical free play: A case for
invented musical notation in a Hong Kong kindergarten. Cambridge University Press, 27(2), 127–140.
Lilly, F. R., & Bramwell-Rejskind, G. F. (2004). The
dynamics of creative teaching. Journal of Creative
Behavior, 38, 102–124.
Linley, P. A., Harrington, S., & Garcea, N. (2010). Oxford
handbook of positive psychology and work. Oxford,
UK: University Press.
Lopez, S. J., & Snyder, C. R. (Eds.). (2009). Oxford
handbook of positive psychology. Oxford, UK: Oxford
University Press.
Ormrod, J. E. (2009). Essentials of educational psychology (2nd ed.). Upper Saddle River, NJ: Pearson.
Paulus, P. B., & Brown, V. R. (2003). Enhancing ideational creativity in groups: Lessons from research on
brainstorming. In P. B. Paulus & B. A. Nijstad (Eds.),
Group creativity innovation through collaboration
(pp. 110–136). New York: Oxford University Press.
Plucker, J., Waitman, G. R., & Hartley, K. A. (2011).
Education and creativity. In M. A. Runco &
S. Pritzker (Eds.), Encyclopedia of creativity
(2nd ed., Vol. 1, pp. 456–460). San Diego, CA: Academic Press/Elsevier.
Prentice, R. (2000). Creativity: A reaffirmation of its place
in early childhood education. Curriculum Journal,
11(2), 145–158.
Reilly, R., Lilly, F. R., Bramwell, G., & Kronish,
N. (2011). A synthesis of research concerning creative
teachers in a Canadian context. Teacher and Teacher
Researcher, 27, 533–542.
Rogers, C. R. (1954). Toward a theory of creativity. Etc:
A Review of General Semantics, 11(4), 249–260.
Runco, M. R. (1999). Developmental trends in creative
abilities and potentials. In M. R. Runco & S. R.
Pritzker (Eds.), Encyclopedia of creativity
(pp. 537–540). London: Academic Press.
Samuelsson, I. P., & Carlsson, M. A. (2008). The playing
learning child: Towards a pedagogy of early childhood. Scandinavian Journal of Educational Research,
52(6), 623–641.
Saracho, O. (2012). Creativity theories and related
teachers’ beliefs. Early Child Development and Care,
182(1), 35–44.
Sawyer, R. K. (2003). Group creativity music, theater,
collaboration.
London:
Lawrence
Erlbaum
Associates.
Schaefer, C. E. (1969). Imaginary companions and creative adolescents. Developmental Psychology, 1,
747–749.

Creativity in Early Childhood
Starko, A. (1995). Developing creativity in the classroom:
Schools of curious delight. White Plains, NY:
Longman Publishers.
Sternberg, R. J. (Ed.). (1999). Handbook of creativity.
New York: Cambridge University Press.
Sternberg, R. J. (2003). Wisdom, intelligence, and creativity synthesized. New York: Cambridge University
Press.
Taylor, I. A. (1975). An emergent view of creative actions.
In I. A. Taylor & J. W. Getzels (Eds.), Perspectives in
creativity (pp. 297–325). Chicago: Aldine.
Wright, S. (2010). Understanding creativity in early
childhood: Meaning-making and children’s drawing.
Thousand Oaks, CA: Sage.

609
Wright, C., Bacigalupa, C., Black, T., & Burton,
M. (2008). Windows into children’s thinking:
A guide to storytelling and dramatization. Early Childhood Education Journal, 35, 363–369.
Yan, L. (2005). An investigation of the relationship
between the open-endedness of activities and the
creativity of young children. Unpublished doctoral
dissertation, University of New Orleans, New
Orleans, LA.
Zachopoulou, E., & Makri, A. (2005). A developmental
perspective of divergent movement ability in
early young children. Early Child Development &
Care, 175(1), 85–95. doi:10.1080/03004430420002
30401.

610

Dental Health During Childhood
Charlotte W. Lewis
Department of Pediatrics, School of Medicine,
University of Washington, Seattle, WA, USA

Introduction
Dental caries (also known as dental decay) is the
most common chronic disease of childhood – five
times as common as asthma (U.S. Department of
Health and Human Services, 2000). Caries is
painful, expensive to treat, and can lead to tooth
loss, as well as serious complications. Although
almost entirely preventable on a primary level, by
the end of childhood, two-thirds of individuals
have experienced caries (Beltran-Aguilar et al.,
2005). Caries disproportionately affects certain
children, leaving other children minimally
affected. This fact points to the importance of
accurately identifying high-caries-risk children
before they develop caries so that they can then
be targeted for intensive preventive efforts.
Unfortunately, in the United States, we are not
yet at a point, either from the perspective of
caries-risk prediction or prioritizing the oral
health of vulnerable populations, that we are
effectively implementing caries-preventive programs for children at high risk for caries. This is
the case despite the fact that we have highly
effective, evidence-based modalities for prevention of caries, of which fluoride and dental sealants are the most important.

Definitions and Scope
Definitions
Dental caries results from bacterial action on
teeth. Bacteria within biofilm (also called plaque)
coat the teeth. Certain oral bacteria, Streptococcus mutans and Lactobacillus species among
others, produce acid as the end product of
carbohydrate metabolism. These acids dissolve
the calcium phosphate mineral of the tooth’s
enamel (“demineralization”). If not reversed

Dental Health During Childhood

through remineralization, the tooth structure
continues to erode until the demineralized area
collapses resulting in a “cavity” (Drury et al.,
1999). Caries is a transmissible infection, passed
vertically, usually from mother to child (Caufield,
Li, & Dasanayake, 2005).
Primary prevention of caries refers to
interventions that precede development of caries
and, as such, avoid initiation of the dental decay
process. For example, regular consumption of
fluoridated water can provide sufficient topical
fluoride exposure to tip the caries balance in the
direction of remineralization of the teeth’s
enamel, thus preventing the onset of a carious
lesion. Secondary prevention involves early
identification of caries so that the decay
process can be arrested or reversed. An example
of secondary prevention is found in fluoride varnish, which when applied to “white spot lesions,”
the first visible evidence of dental decay,
promotes remineralization and reversal of the
decay process.
Caries may affect the primary (deciduous or
“baby” teeth) or permanent dentition or both.
Patterns of dental decay differ depending on the
age of the individual when the decay process is
first apparent. When children under the age of
6 years develop caries, this is referred to as
“early childhood caries” (ECC). ECC may
initially present as caries on the smooth surfaces
of their primary mandibular (upper jaw) incisors
(front teeth) and then progress quickly to involve
most of the remaining primary dentition. This
pattern of decay is different from that seen in
the permanent teeth of older children and adults
in whom the occlusal (pit-and-fissure) surfaces of
the posterior teeth are most often affected. Older
adults may experience caries in the crown or root
surfaces of their teeth, which become susceptible
to decay if gum tissue regresses.
Scope
Results of the third National Health and Nutrition
Examination Survey (NHANES III) during
1999–2004 indicated that 24 % of 2- to 4-yearolds and 51 % of 6- to 8-year-olds had caries in
primary teeth (Tomar & Reeves, 2009). Among
12- to 19-year-olds, 59 % had caries in permanent

T.P. Gullotta, M. Bloom (eds.), Encyclopedia of Primary Prevention and Health Promotion,
DOI 10.1007/978-1-4614-5999-6, # Springer Science+Business Media New York 2014

Dental Health During Childhood
80

Parent of children with caries

Dental Health During
Childhood,
Fig. 1 Prevalence of
dental caries by age group
and income category
(Tomar & Reeves, 2009.
Adapted by author,
Charlotte Lewis, 2013)

611

* Primary teeth
** Permanent teeth

70
60
50
40

<100% FPL

30

100 –199% FPL
>=200% FPL

20
10
0

2–4 yr olds*

6–8 yr olds*

12–19 yr olds**

Age category

teeth. Children living below 200 % federal poverty
level (FPL) had significantly more caries relative to
children at/above 200 % FPL (Fig. 1) (Tomar &
Reeves, 2009). Until NHANES III, caries prevalence had declined over time in all age categories,
but this trend reversed for 2- to 4-year-olds in
1999–2004, with a 5 % increase (from 19 % to
24 %) since 1988–1994 (Tomar & Reeves, 2009).
The reasons for this increase are unclear.
The proportion of US children with untreated
caries remained approximately the same in
NHANES II and III. During 1999–2004, 16 %
of 2- to 4-year-olds and 28 % of 6- to 8-year-olds
had untreated caries in primary teeth, and 20 % of
children 12- to 19-year-olds had untreated caries
in permanent teeth (Beltran-Aguilar et al., 2005).
Children living below 100 % FPL have two to
three times as many untreated caries as children
at/above 200 % FPL (Beltran-Aguilar et al.,
2005). Insurance and income-based disparities
in access to dental care are important contributors
to differences in untreated caries by income.
Despite mandated dental care coverage for
low-income children under EPSDT (Early and
Periodic Screening, Diagnosis, and Treatment)
legislation, and more recently, S-CHIP (State
Children’s Health Insurance Program) and
CHIPRA (Children’s Health Insurance Program
Reauthorization Act), it remains difficult for
publicly insured children to access professional
dental care. In 2005, just 37 % of Medicaidenrolled children, ages 2–18 years, received
dental care in the previous year (General
Accounting Office, 2008).

Untreated caries can lead to toothache and other
more serious complications. In 2008, approximately 15,000 US children presented to emergency
departments with toothaches (Lee, Lewis,
Saltzman, & Starks, 2012). Some of these children
required hospital admission and/or surgery.
A small number of children die from complications
resulting from caries (Otto, 2007). Analysis of the
2007 National Survey of Children’s Health
documented that 14 % of grade school children
had experienced toothaches in the previous
6 months (Lewis & Stout, 2010). Being
low-income, minority race, or having special
health-care needs independently increased risk for
toothache. In a 1992 study, 51 million hours of
school were missed because of dental problems or
treatment (Gift, Reisine, & Larach, 1992).

Theory
Cariogenesis
Dental caries begins with demineralization of
a tooth’s outer structure. This in turn, allows the
infection to potentially erode further into the tooth
and invade the pulp (inner chamber of the tooth
where the blood supply and nerve are located) and
then into the surrounding tissues resulting in an
abscess or draining fistula. An infection that
begins as dental caries may spread beyond the
mouth to cause a facial infection or brain abscess,
among other serious complications.
Four factors – teeth, bacteria, fermentable
sugars, and time – are needed for caries to

612

occur. Specifically, cariogenic bacteria that are
present within biofilm on the teeth metabolize
dietary carbohydrate to produce acid, which
demineralizes the tooth structure. Saliva contains
calcium, phosphorous, fluoride, antibodies, and
buffering agents that can assist in remineralizing
the tooth. This ongoing demineralizationremineralization dynamic can be pushed in the
direction of demineralization if the biofilm pH
persistently remains below 5.5, for example, with
frequent snacking on carbohydrate-rich foods (and
subsequent acid production by cariogenic bacteria
metabolizing the carbohydrate). When snacking is
less frequent, the biofilm pH has time to return to
normal, which favors remineralization. Although
seemingly simplistic, a complex interplay of
behavioral, social, environmental, and genetic
variables – some better understood than others –
influences this process.
Caries Risk Factors
In the pre-fluoride era, dental caries was a nearly
universal experience. However, caries now
disproportionately affects poor and low-income
adults and children (Tomar & Reeves, 2009).
Furthermore, caries risk factors cluster within
families and communities since resources, habits,
cultural and other beliefs, parental role modeling,
dietary practices, and oral hygiene practices are
more likely to be similar within members of
a community and a family. Child-level risk factors for caries include higher levels of cariogenic
bacteria (Warren et al., 2009), previous caries
(Twetman & Fontana, 2009), visible plaque
(Warren et al., 2008), consumption of sweetened
liquids and candy (Ismail, Lim, Sohn, & Willem,
2008; Warren et al., 2008, 2009), suboptimal
fluoride exposure (Wang et al., 2012), and infrequent toothbrushing (Martens, Vanobbergen,
Willems, Aps, & De Maeseneer, 2006).
Colonization with cariogenic bacteria at
a younger age is another key risk factor for caries
(Harris, Nicoll, Adair, & Pine, 2004), and one
that would be more common among family members (Caufield et al., 2005). Studies utilizing
serotyping, genotyping, or bacteriocin typing of
cariogenic bacteria strongly support vertical
transmission of cariogenic bacteria from

Dental Health During Childhood

caregiver, most often the mother, to children.
Caregivers who harbor more cariogenic bacterial
loads (i.e., because of untreated caries and/or
poor oral hygiene) may transmit these bacteria
to offspring at earlier ages or to greater degrees
and thus increase risk of more severe caries in
their offspring (Berkowitz, 2006; Law, Seow, &
Townsend, 2007).
Interrupting vertical transmission of cariogenic bacteria is a potential strategy to prevent
caries in young children (Milgrom & Chi, 2011).
Other parental characteristics that increase risk
for caries in their children besides high levels of
Streptococcus mutans (Ersin, Eronat, Cogulu,
Uzel, & Aksit, 2006) and multiple decayed teeth
(Thitasomakul et al., 2009) include a history of
tooth loss from caries (Roberts, Warren &
Weber-Gasparoni, 2009), poverty (Warren
et al., 2008), fewer years of maternal education
(Ersin et al., 2006; Nunn, Dietrich, Singh,
Henshaw, & Kressin, 2009), less than twicedaily toothbrushing (Adair et al., 2004), and fatalistic oral health beliefs (Ismail et al., 2008). Less
well understood but nevertheless important are
the genetic factors underlying caries. Studies of
twins provide evidence that genetics explains
40–65 % of caries (Vieira, Marazita, &
Goldstein-McHenry, 2008).
Despite many variables associated with
increased caries risk, predicting exactly which
children are at higher risk for caries before they
develop disease is challenging. Because highcaries-risk children develop ECC within the first
few years of life, caries-risk assessment should
take place before first tooth eruption, followed by
implementation of a caries prevention program.
However, the American Academy of Pediatric
Dentistry’s caries-risk assessment tool (CAT)
and other screening tools rely on a history/presence of caries or predisposing dietary and/or oral
health habits. Yet, if caries or habits associated
with it are already present, then it is too late for
optimal primary prevention. Low-income status
(below 200 % FPL) is the only caries risk factor
that can reasonably be ascertained at first tooth
eruption and, thus, is an appropriate criterion for
initial assignment to an intensive caries prevention program.

Dental Health During Childhood

Caries Prevention Modalities
There are four proven ways that caries can be
prevented: (1) promote enamel mineralization
(e.g., fluoride), (2) decrease cariogenic bacteria
(e.g., antimicrobial agents and polyols),
(3) decrease exposure to carbohydrate substrate
(e.g., reduce sugar intake), and (4) place a barrier
on the teeth to prevent demineralization and
decay (e.g., sealants).

What Works
Fluoride
Fluoride is a mineral found in small amounts in
almost all soil, bodies of water, plants, and animals and, thus, is a normal constituent of all
diets. Early fluoride researchers believed that
fluoride achieved its decay inhibitory effects
through incorporation into teeth prior to
eruption – i.e., preeruptive. Under this assumption, fluoride was only beneficial for young children. Although fluoride does provide some
preeruptive protection against caries, we now
understand, based on in vitro, clinical, and epidemiologic evidence, that fluoride’s effects are
primarily posteruptive. Posteruptive effects
mean that fluoride promotes net mineralization
of the teeth after they are erupted (BeltranAguilar & Burt, 1988). Demineralization and
remineralization of the tooth enamel are
a dynamic process. Remineralization is
enhanced and demineralization is inhibited
when low levels of fluoride are sustained in the
saliva. When present, fluoride aids in the incorporation of calcium and phosphate ions into the
enamel and is itself incorporated in the mineralization process. Fluoride-containing enamel,
fluorapatite, is harder and less acid soluble than
the original enamel that it replaces. Implications
of fluoride’s posteruptive mechanism of action
are twofold: (1) fluoride continues to have beneficial effects throughout the lifespan (rather
than just in early childhood as was previously
believed) and (2) topical fluoride (e.g., fluoride
toothpaste – FTP) is more effective and has
fewer systemic side effects than oral fluoride
supplements that are swallowed.

613

Excess fluoride intake may result in dental
fluorosis, which refers to changes in the appearance of tooth enamel that are caused by increased
ingestion of fluoride during the time when teeth
are forming. In its mild form, fluorosis presents as
white lacey markings on teeth. Teeth with very
mild or mild fluorosis are more resistant to caries.
More severe fluorosis manifests as enamel pitting
and predisposition to staining and is rare in the
United States. The degree of fluorosis is related to
the timing, duration, and dose of fluoride ingested
from all sources (water and other beverages, dental products, supplements) in early childhood
(Adair et al., 2001). Once mineralization of the
permanent teeth is complete, usually by 8 years of
age, there is no longer a risk of additional fluorosis developing with future fluoride exposure.
Esthetic considerations for fluorosis are most
important for the permanent central incisors of
the mandible, which are most susceptible to
fluorosis before about 2 years of age (Adair
et al., 2001; DenBesten, 1999; Hong et al.,
2006). Fluorosis prevalence was assessed as part
of NHANES III; during 1999–2004, 16 % of 6- to
49-year-olds in the United States had very mild
fluorosis, 5 % had mild fluorosis, 2 % had
moderate fluorosis, and less than 1 % has severe
fluorosis (Beltrán-Aguilar, Barker & Dye, 2010).
Sources of fluoride: community water fluoridation. Fluoride is naturally present at varying
concentrations in all bodies of water. An
estimated 57.4 million people worldwide drink
naturally fluoridated water in which fluoride is
present at 1 ppm (Anonymous, 2012). Community water fluoridation (CWF), in which fluoride
is added to public water systems to bring the
fluoride concentration up to an optimal level, is
considered one of the 10 great US public health
achievements of the twentieth century.
The concept of CWF was based on the observation that people living in communities supplied
by naturally fluoridated water had fewer caries
(Dean, 1938). This led to the landmark investigation in the early 1940s of caries and fluorosis
levels in residents of 21 cities with varying levels
of naturally occurring fluoride in the water.
Results identified a concentration of about
1 ppm (1 part per million or 1 mg/L) of fluoride

614

in the water supply as that which allowed for
maximal caries prevention with minimal risk of
fluorosis (Dean, Arnold, & Elvove, 1942). In
1945, prospective field trials of community
water fluoridation (CWF) in four pairs of treatment and control cities in the United States and
Canada began. In these trials, CWF resulted in
a 50–75 % reduction in caries in children from
treatment cities compared to controls during
sequential cross-sectional surveys over 15 years
(Ast, Smith, Wachs, & Cantwell, 1956). Most
studies of CWF focused on fluoride’s effect
among children, but it is now clear that exposure
to fluoride has also decreased coronal and root
caries among adults (Stamm, Banting, & Imrey,
1990; Yeung, 2007) and, thus, reduces the
number of teeth that otherwise would have been
lost to untreated decay.
Because bottled beverages, such as juices, are
often produced with fluoridated community
water, these liquids also contain fluoride. In
a study of more than 500 juices and juice-flavored
drinks, 43 % had a fluoride concentration above
0.6 ppm (Kiritsy et al., 1996). As Americans
consume more soda and juice in place of water
and milk, these beverages “diffuse” from fluoridated into non-fluoridated areas and have become
increasingly important sources of dietary fluoride
(Institute of Medicine, 1997). This phenomenon
has two implications. First, consumption in
non-fluoridated areas of beverages manufactured
with fluoridated water means that dramatic differences in caries rates between cities with and
without CWF, observed in original studies in the
1950s, are no longer as pronounced (Whitford,
1994). More recent CWF effectiveness studies in
the United States have estimated that there are
25 % fewer caries in children who drink
optimally fluoridated water compared to those
who do not (Brunelle & Carlos, 1990). Second,
this makes it more difficult to estimate fluoride
intake for determining caries or fluorosis risk.
According to the Centers for Disease Control
and Prevention (CDC) fluoridation census in
2010, 72 % of the US population on public
water systems receive CWF (CDC, 2010). In
2011, the US Department of Health and Human
Services announced a recommendation that the

Dental Health During Childhood

optimal fluoride level in US CWF be decreased to
0.7 ppm (USDHHS, 2011). This recommendation was made because of increasing exposure
to fluoride from sources other than CWF and
concerns for increasing prevalence of dental
fluorosis. Water fluoridation is not technically or
financially feasible in many parts of the world,
including most of Central/South America and
Europe, in large part because there are not
modern, centralized water systems (Gillespie &
Baez, 2005). Instead, salt fluoridation (250 ppm),
advocated by the World Health Organization
(WHO), provides fluoride for population-based
caries prevention in more than 30 countries
(Marthaler & Petersen, 2005).
Sources of fluoride: fluoride toothpaste. The
1960s brought direct consumer marketing of
fluoride toothpaste (FTP). This provided another
source of fluoride in addition to supplements
(drops or liquids) which had been introduced in
the 1940s for children living in communities
without CWF. Toothbrushing with FTP is
a valuable delivery system for topical fluoride.
After brushing with FTP, fluoride levels in saliva
peak and then remain at low concentrations for
2–6 h, providing fluoride for enamel remineralization (Featherstone, 1999). In the United
States, over-the-counter FTP, including those
marketed for children, are allowed by the Food
and Drug Administration (FDA) to contain either
1,000 ppm fluoride (1.0 mg fluoride/g of
toothpaste, in the form of 0.76 % sodium
monofluorophosphate) or 1,100 ppm fluoride
(1.1 mg fluoride/g of toothpaste as 0.24 %
sodium fluoride or 0.0454 % stannous fluoride).
Lower concentration FTP (e.g., 250–550 ppm) is
available in other countries. However, on
systematic review, these toothpastes did not
consistently reduce caries (Walsh et al., 2010).
Lower concentration FTP is not FDA approved
for sale in the United States.
FTP has many advantages over fluoride
supplements. Acknowledging that fluoride
works best when it is delivered topically rather
than systemically (i.e., when swallowed), Canada
(HealthCanada, 2010), England (Anonymous,
2009a), Australia (Anonymous, 2006), New
Zealand (Anonymous, 2009b), and the European

Dental Health During Childhood

Union (EAPD, 2009) no longer routinely
recommended fluoride supplements, in favor of
promoting FTP use in young children instead.
Fluoride supplementation is still recommended
by the American Dental Association for
high-caries-risk children over 6 months old
who reside in communities without CWF
(Rozier et al., 2010).
Other advantages of FTP include that it is
widely available in grocery and drug stores,
does not require a prescription as supplements
do, and is much less expensive at under 1 cent/
day for FTP compared to 52 cents/day for fluoride
supplements
(e.g.,
in
2013,
Colgate
360 Anticavity Fluoride Toothpaste, Dora the
Explorer, 4.6 oz., costs $2.99 on drugstore.com
and would last more than 1 year at
50 mg/brushing or 100 mg of paste/day.
A one-month supply of fluoride supplements
(Flura-Drops 0.25 mg/drop) at Costco costs
$15.57 for a 30-day supply). Furthermore, FTP
is widely used by older children and adults thus
providing opportunities for modeling and
instilling a lifelong habit early in life.
There is a large body of evidence about
benefits of FTP in preventing caries. On systematic review and meta-analysis, daily FTP use
resulted in 24 % fewer caries in permanent teeth
and 13 % fewer caries in primary teeth, on average, when compared to non-fluoride toothpaste
(Dos Santos, Nadanovsky, & de Oliveira, 2012).
Furthermore, FTP’s beneficial effects are
increased with the following: (1) higher fluoride
concentration toothpaste; trials indicate 6 %
fewer carious lesions, on average, with every
500 ppm increase in FTP fluoride concentration
above 1,000 ppm (Biesbrock et al., 2001;
Twetman, 2009; Walsh et al., 2010); (2) twicedaily use, with a preventive fraction (PF) of 14 %
when increasing from brushing once a day to
brushing twice a day (Marinho, Higgins,
Logan, & Sheiham, 2002a; Twetman, 2009);
and (3) parent-supervised brushing (Hinds &
Gregory, 1995; Twetman, 2009).
There are fewer data assessing the cariespreventive effects of starting FTP at younger
ages, e.g., during infancy. Cross-sectional and
population-based surveys in Europe have found

615

significantly lower prevalence of caries at 5 years
of age and older when children began brushing
with FTP before 1 year of age compared to those
who started after 2 or 3 years of age (Hinds &
Gregory, 1995; Verrips, Frencken, Kalsbeek, ter
Horst, & Filedt Kok-Weimar, 1992). However,
earlier FTP use is associated with increased
fluorosis risk, presumably because very young
children will swallow some FTP until they learn
to spit out the residue. Concern over young
children swallowing toothpaste has led to ongoing questions about “the right age” to start FTP.
To make matters more confusing, commercial
messaging about the “safety” of fluoride-free
training toothpastes implies that FTP is thus
unsafe for young children. Parents may attribute
greater hazard to swallowing toothpaste than
actually exists, potentially limiting the beneficial
effects of FTP.
Empirically, using a smaller amount of FTP
means less is swallowed and thus, a lower
fluorosis risk. Two-year-olds ingest an average
of about two-thirds of the toothpaste used in
brushing (Naccache et al., 1992). Given this, if
a child uses a rice-grain-size (50 mg of paste)
amount of FTP during twice-daily brushing,
he/she not only gains the beneficial effect of
topical fluoride and ingests only 0.08 mg
of fluoride. Rinsing after brushing is
contraindicated. For young children who do not
know how to spit, rinsing causes more FTP to be
swallowed (Naccache et al., 1992). Among older
children, rinsing and spitting out the residue
reduces the beneficial effect of the fluoride and
results in more caries (Chestnutt, Schafer,
Jacobson, & Stephen, 1998; Sjogren, Birkhed, &
Rangmar, 1995).
How the balance of risks and benefits of early
FTP is perceived has led countries to adopt
different recommendations about the age to start
FTP. One approach, currently employed in the
United States, Australia, and Canada, is based
on risk stratification with high-caries-risk
children advised to begin FTP at first tooth
eruption (MCHB, 2007), while low-caries-risk
children should wait until 2 years of age
(2 years is the US recommendation. It is
18 months in Australia and 3 years in Canada)

616

before using FTP. The other approach, used in
England, recommends that all children,
beginning in infancy, have their teeth brushed
twice daily with “a smear” of at least 1,000 ppm
FTP; at 3 years of age, the recommended FTP
amount increases to pea size (250 mg of paste)
and the concentration to 1,350–1,500 ppm
(Anonymous, 2009a).
There are reasons to consider adopting
England’s strategy of universal and early FTP
initiation in the United States: (1) low-cariesrisk young children also experience caries at not
inconsequential levels; (2) caries prevalence
among young children is unacceptably high and
has increased (Dye et al., 2007); (3) even if
a child does not spit after brushing with a ricegrain-size amount of FTP during twice-daily
toothbrushing, fluoride intake from FTP is well
below the fluorosis-risk level; (4) it establishes
a habit early; and (5) it places appropriate
emphasis on disease prevention.
Sources of fluoride: professionally applied
fluoride-containing dental products. Dental professionals rely on a variety of fluoride-containing
products, including foam, gel varnish,
prescription-strength toothpaste, and mouthrinse,
for caries prevention and treatment. The most
thoroughly evaluated for pediatric use are fluoride gels and varnish. Applying these highly concentrated fluoride products to teeth, using a dual
arch tray for gel or brush to paint on varnish,
leaves a fluoride calcium compound on tooth
enamel that releases fluoride whenever plaque
pH decreases (Chestnutt et al., 2012). Both fluoride gel (Marinho, Higgins, Logan, & Sheiham,
2002a) and varnish (Marinho, Higgins, Logan, &
Sheiham, 2002b) are effective in preventing
caries, but FV has a number of advantages over
gels, including that FV can be used in young
children (gel is too easily swallowed), adheres
better to the enamel surface, and allows for longer
sustained levels of fluoride in the enamel crystal
matrix. Furthermore, FV does not require special
preparation of teeth, requires only brief training
to become adept at its application, is generally
acceptable to patients, is portable, and requires
little storage space – all which make it easy to use
in non-dental settings, e.g., in schools, public

Dental Health During Childhood

health clinics, and medical providers’ offices. In
most US states, physicians can be reimbursed to
apply FV to children insured by Medicaid.
FV is effective in preventing caries in both
primary and permanent teeth. Systematic reviews
indicate that FV prevents 46 % of permanent
tooth caries and 33 % of primary tooth caries
(Azarpazhooh & Main, 2008; O’Keefe, 2011).
FV’s impact differs depending on a population’s
caries prevalence. The number-needed-to-treat to
prevent one carious surface in primary dentition
ranged from 3.7 children in low-caries communities to 1.6 children in high-caries communities.
High-caries-risk children should be prioritized
for at least twice-yearly FV beginning at first
tooth eruption in order to optimize ECC prevention. An RCT is San Francisco demonstrated
a PF of 58 % with twice-yearly FV in children
enrolled at 20 months of age and followed for
2 years (Weintraub et al., 2006). In England,
guidelines specify that all children receive FV
2 times/year and that high-caries-risk children
receive FV 3–4 times/year (Anonymous, 2009a).
Community-based delivery of fluoride dental
products. Community-based delivery of fluoride
dental products to high-caries-risk population has
been shown to be effective in preventing caries.
Fluoride mouthrinses have been part of schoolbased caries prevention programs in the United
States; a systematic review found that in
populations with a caries increment of 2.14 caries
lesions per year (i.e., high), two children will
need to rinse to avoid one carious lesion (Poulsen,
2009). Children younger than about 7 years of
age should not use fluoride mouthrinse because
they typically are not able to spit it out and
instead tend to swallow it. Supervised classroom
toothbrushing with FTP is more common in
Europe and results in a PF of 23 %, based on
systematic review (Twetman et al., 2003). Other
community-based strategies for caries prevention
in young children include free or reduced cost
FTP distribution. An English RCT that evaluated
a free FTP mail distribution program, targeting
children living in low-income communities
beginning at 12 months of age, resulted in
significantly fewer carious teeth at 5 or 6 years
of age (Davies et al., 2002).

Dental Health During Childhood

Dental Sealants
Dental sealants, a thin coating applied to the
occlusal surfaces of molars, are another primary
prevention modality effective against caries in
pit-and-fissure surfaces of permanent teeth,
which is where school-aged children develop
the vast majority of dental decay. Pit-and-fissure
sealants can also be applied over incipient caries
thus providing secondary caries prevention
(Beauchamp et al., 2008).
Sealants are generally applied to permanent
first and second molars when they erupt, at
about 7 and 12 years of age, respectively.
Children at high risk for caries may also benefit
from sealant placement on their primary teeth
(Beauchamp et al., 2008). There are two types
of pit-and-fissure sealant materials – resin-based
sealants and glass ionomer cements – and there
are advantages and disadvantages to each. The
effectiveness of sealants depends on how long the
sealant lasts. Resin-based sealants are retained
longer but require more tooth preparation and
trained staff for effective placement. On the other
hand, glass ionomer cements are less technique
sensitive and contain fluoride, which may enhance
their caries-preventive properties, but the main
disadvantage to glass ionomer cements is that
they do not last as long as resin-based sealants
(Baseggio et al., 2010). The American Dental
Association recommends resin-based sealants
over glass ionomer (Beauchamp et al., 2008).
On an individual child level, a decision to
place sealants may be based on characteristics
of the child’s pit-and-fissure surfaces and perceived susceptibility to caries (Beauchamp
et al., 2008). A recent Cochrane Collaboration
systematic review found that, compared to control teeth without sealants, resin-based sealants
prevented caries in first permanent molars in
children aged 5–10 years, at 2 years of followup, with an odds ratio (OR) of 0.12 and 95 %
confidence interval (CI) of 0.07–0.19 (AhovuoSaloranta et al., 2013). Sealants can provide
long-term protection against caries. One study
demonstrated that, after sealants had been in
place for 9 years, only 27 % of sealed tooth
surfaces had caries compared to 77 % of tooth
surfaces without sealants (Ahovuo-Saloranta,

617

Hiiri, Nordblad, M€akel€a, & Worthington, 2008).
A decision to deliver sealants to a population
(e.g., through school-based sealant programs) is
usually based on increased risk of caries (based
on lower socioeconomic status) within the population and lower likelihood that individuals
within that population will have reliable access
to regular professional dental care. Evaluation of
school-based sealant programs directed at
high-caries-risk groups of children has found
such programs to be effective in lowering caries
rates and reducing dental care expenditures
(Chalmers, 2011; Gooch et al., 2009).
Polyols
Polyols (sugar alcohols such as xylitol, mannitol,
and sorbitol), contained in chewing gum,
lozenges, syrups, and other products, have
antimicrobial effects against cariogenic bacteria,
and their regular use is caries protective
(Lynch & Milgrom, 2003; Scheinin, Makinen, &
Ylitalo, 1976). There are more data on xylitol’s
caries-preventive effects than the other polyols;
xylitol appears to directly inhibit Streptococcus
mutans metabolism (Waaler, 1992). Polyols may
also disrupt biofilm organization and adherence
as an additional caries-inhibitory mechanism
(Milgrom, Soderling, Nelson, Chi, & Nakai,
2012). A compelling example of the benefits of
polyol-containing chewing gum on caries took
place in a 40-month double-blind cohort
study performed in 1989–1993 among 1,277
high-caries-increment, school-aged children in
Belize, Central America; in comparing caries
rates in children who had been assigned to no
gum, sucrose, sorbitol, sorbitol-xylitol combination, or xylitol-containing chewing gums, used
five times daily, the greatest caries-preventive
effect occurred in the xylitol chewing gum
group in whom caries rates were 73 % lower
than in the no-gum controls (Makinen et al.,
1996). Use of xylitol-sorbitol combination and
sorbitol chewing gum also significantly
reduced caries relative to controls but to a lesser
degree than xylitol (Makinen et al., 1996).
More recent studies of xylitol and polyol
combination chewing gum in children with
lower caries levels have, overall, demonstrated

618

significant but less dramatic reductions in caries
(Deshpande & Jadad, 2008).

What Might Work
Flossing
It is common to promote flossing along with
toothbrushing, and indeed, it makes empiric
sense to use floss to remove bacteria-containing
plaque from between teeth, where toothbrushing
cannot reach. Yet, studies of self-performed
flossing by children and adolescents have failed
to show a beneficial effect in preventing
interproximal caries (Hujoel, Cunha-Cruz,
Banting, & Loesche, 2006). It may be the
self-flossing technique or compliance is at fault.
In the Dorchester Dental Flossing Study (Wright,
Banting, & Feasby, 1979) conducted in Canada in
the early 1970s, 6-year-olds had half of their teeth
flossed (the other half of the mouth was the control) by “research assistants” (actually, mothers
helping out in the classroom who were trained in
flossing) every day that they were in school for
17 months (Wright et al., 1979). There were 40 %
fewer interproximal caries in the teeth that were
flossed, suggesting that a competent, compliant
parent who flosses his/her young child’s teeth
daily could potentially decrease caries between
teeth. The question remains about whether
competent, compliant older children could
effectively decrease interproximal caries by
flossing their own teeth on a daily basis.
Oral Health Promotion
In addition to fluoride, polyols, and sealants,
reducing exposure to the substrate for cariogenic
bacteria – specifically, carbohydrates and, in particular, sucrose (Rekola, 1989) – lowers caries
risk in efficacy trials (Loesche, 1985; Scheinin
et al., 1976). Preventive oral health promotion
such as counseling parents of young children
about reducing intake of high-sugar foods and
beverages and about the importance of
twice-daily toothbrushing with FTP may be an
effective caries-preventive strategy (SIGN,
2013). However, complying with such advice is
more complicated when it involves behavior

Dental Health During Childhood

change. There are a variety of strategies,
underpinned in theory, for promoting change in
health-related behavior although health professionals are not always well versed in effective
techniques to motivate behavior change in their
patients. Interventions relying on community lay
educators and that use a one-on-one approach
when promoting preventive oral health among
parents of young children appear to be more
successful (Rozier, 2001).
Interrupting Vertical Transmission of Caries
There is evidence indicating that interruption of
or delaying transmission of cariogenic bacteria
from adult caregiver to young child could be an
effective caries primary preventive strategy
(Milgrom & Chi, 2011). Efforts to reduce cariogenic bacteria load in caregivers (so that less
bacteria will be transmitted to offspring) have
centered on provision of restorative dental care
to excavate large reservoirs of cariogenic bacteria
in the caregiver’s mouth and regular use by
caregivers of topical antimicrobials such as
topical iodine, chlorhexidine mouthrinse, xylitol
(or other polyols), chewing gum, or
a combination of these approaches (Milgrom &
Chi, 2011). More studies are needed before definitive recommendations can be made about target
populations and which specific therapies, in what
combination, and at what dose are most effective.
An even more important barrier to implementing
this strategy on a larger scale is that there are few
resources for lower-income and uninsured parents of young children in the United States to
receive preventive or restorative dental care
such that they could effectively reduce their oral
burden of bacteria if they have untreated caries.
Disparities in dental care access and oral health
status among lower-income adults likely
perpetuate high caries levels across generations.

What Does Not Work
Ozone is toxic to certain bacteria in vitro and it
has been suggested that ozone delivered to
a susceptible tooth might prevent caries.
A Cochrane review of ozone trials for caries

Dental Health During Childhood

prevention found no sound evidence that ozone is
capable of reversing or stopping the progression
of tooth decay (McComb, 2005).

Areas of Controversy
In the United States, we have yet to answer this
important question: “What is the best way to
deliver caries primary preventive services, particularly to those children who need it most?”
Using highly trained, highly reimbursed health
professionals like dentists to deliver dental caries
primary prevention makes little sense either from
an access or cost perspective. There are
inadequate numbers of dentists to deliver primary
preventive services to all children. Most pediatric
dentists work in more populated and urban areas,
while general dentists, who may work in smaller
communities, can see young children but often do
not feel comfortable doing so (Seale &
Casamassimo, 2003). Thus, geography may
prevent a number of young children from
accessing caries-preventive care if it is relegated
solely to dentists.
The bigger problem, however, is that many
children in the United States are unable to access
professional dental care because they do not have
private dental insurance or their parents lack cash
to pay out of pocket for dental care (Smith &
Lewis, 2005). The result is that, in our current
dental care system, low-caries-risk children (i.e.,
higher-income, healthy children) are easily able
to access professional dental care in a dental
office setting where they receive relatively
expensive preventive services that they may
not need, while high-caries-risk children are
unable to access needed primary or secondary
caries-preventive care and thus suffer
a disproportionate share of more advanced dental
caries.
It is unlikely that our current, predominately
private practice dental care model will change in
the near future, at least in such a way that would
allow universal access to professional dental
care. Our public health dental care system is
substantially underfunded, and what little
resources are available are often allocated to

619

treatment, leaving caries prevention to fall by
the wayside. An alternative public-health-based
model relying on dental hygienists and dental
paraprofessionals, such as the dental therapists
(Wetterhall, Burrus, Shugars, & Bader, 2011),
could deliver cost-effective primary and secondary caries prevention to large groups of children
in community settings. However, this model
would require expanding dental therapist training
programs, establishing appropriate infrastructure
for these services to be delivered, as well as
overcoming the resistance of organized dentistry.
Nevertheless, if such a model could be further
developed such that dental therapists and dental
hygienists deliver primary and secondary
prevention to the vast majority of US children,
this would allow dentists to do exactly what they
are uniquely and best trained to do: treat dental
disease and restore function.

Summary
Expanded availability of fluoride is largely
acknowledged as the major factor responsible
for the declining prevalence of caries in the
United States over the last 40 years, saving $39
billion (1990 dollars) in dental care expenditures
in the United States from 1979 to 1989 (Brown,
Beazogdlou, & Heffley, 1994). There is an overwhelming abundance of evidence that CWF and
FTP are highly effective in preventing dental
decay, and these two modalities should form the
cornerstones of population-based strategies
aimed at primary prevention of caries in all
children (and adults as well). Other effective
fluoride-based strategies should be considered
adjuncts, which can be targeted towards
individuals and groups at high risk of caries.
These adjuncts include fluoride mouthrinses,
gels, and varnishes.
Among non-fluoride caries-preventive agents,
dental sealants are an important strategy for
prevention of caries in the pit-and-fissure
surfaces of permanent molars, particularly when
directed towards high-caries-risk children
(Chalmers, 2011). Regular use of polyols is also
effective in preventing caries; a recent systematic

620

review by the American Dental Association
found sufficient evidence to recommend threetimes-daily use (after meals) of xylitol or polyol
combination chewing gum or xylitol lozenges for
primary prevention of caries in children older
than 5 years of age.
Certain children, primarily defined by poverty,
experience large number of caries, yet we are not
yet effectively identifying and directing these
children to intensive primary prevention programs because our current dental system does
not prioritize delivery of dental care to children
from high-caries-risk groups. To realize our
potential to prevent virtually all dental caries
will require an overhaul of our current dental
care delivery model. A vision for a publichealth-centered system would ensure that all children receive cost-effective primary preventive
care and children at risk for more severe caries
could be targeted for intensive, evidence-based
primary and secondary prevention, regardless of
their insurance status or ability to pay.
Consideration should be given to initiating
FTP at first tooth eruption as “standard caries
primary prevention” for all US children. Because
poor and low-income children experience more
caries, they should receive an “intensive caries
primary prevention” program comprised of,
in addition to twice-daily FTP use, at
least twice-yearly FV, prioritization for early
and regular professional dental care, dental sealants, and targeted community-/school-based
caries-preventive interventions. A dual-track
(standard vs. intensive) primary prevention
approach emphasizes the importance of caries
prevention for all children while also addressing
the substantial oral health disparities that
adversely affect the health and well-being of millions of US children (GAO, 2008).

References
Adair, S. M., Bowen, W. H., Burt, B. A., Kumar, J. V.,
Levy, S. M., & Pendrys, D. G. (2001). Recommendations for using fluoride to prevent and control dental
caries in the United States. Morbidity and Mortality
Weekly Report, 50(RR14), 1–42.

Dental Health During Childhood
Adair, P. M., Pine, C. M., Burnside, G., Nicoll, A. D.,
Gillett, A., Anwar, S., et al. (2004). Familial and
cultural perceptions and beliefs of oral hygiene
and dietary practices among ethnically and
socio-economically diverse groups. Community
Dental Health, 21(1 Suppl.), 102–111.
Ahovuo-Saloranta, A., Forss, H., Walsh, T., Hiiri, A.,
Nordblad, A., M€akel€a, M., et al. (2013). Sealants for
preventing dental decay in the permanent teeth.
Cochrane Database of Systematic Reviews,
3, CD001830. doi:10.1002/14651858.CD001830.
pub4. PubMed PMID: 23543512.
Ahovuo-Saloranta, A., Hiiri, A., Nordblad, A., M€akel€a,
M., & Worthington, H. V. (2008). Pit and fissure
sealants for preventing dental decay in the permanent
teeth of children and adolescents. Cochrane Database
of Systematic Reviews, 4, CD001830. doi:10.1002/
14651858.CD001830.pub3.
Anonymous. (2006). The use of fluorides in Australia:
Guidelines. Australian Research Centre for Population
Oral Health, Dental School, The University of
Adelaide, South Australia. Australian Dental Journal,
51(2), 195–199.
Anonymous. (2009a). Delivering better oral health an
evidence-based toolkit for prevention (2nd ed.).
Department of Health and the British Association for
the Study of Community Dentistry. Accessed February
6, 2013, from http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGui
dance/DH_102331
Anonymous. (2009b). New Zealand Guidelines Group.
Guidelines for the use of fluorides. Wellington:
Ministry of Health. Accessed February 12, 2013,
from
http://www.health.govt.nz/publication/guidelines-use-fluorides
Anonymous. (2012). One in a million. The facts about
water fluoridation (3rd ed.). Uppermill, UK:
The British Fluoridation Society.
Ast, D. B., Smith, D. J., Wachs, B., & Cantwell, K. T.
(1956). Newburgh-Kingston caries-fluorine study.
XIV. Combined clinical and roentgenographic dental
findings after ten years of fluoride experience. Journal
of the American Dental Association, 52(3), 314–325.
Azarpazhooh, A., & Main, P. A. (2008). Fluoride varnish
in the prevention of dental caries in children and
adolescents: A systematic review. Journal of the
Canadian Dental Association, 74(1), 73–79.
Baseggio, W., Naufel, F. S., Davidoff, D. C., Nahsan, F. P.,
Flury, S., & Rodrigues, J. A. (2010). Caries-preventive
efficacy and retention of a resin-modified glass ionomer
cement and a resin-based fissure sealant: A 3-year splitmouth randomised clinical trial. Oral Health & Preventive Dentistry, 8(3), 261–268.
Beauchamp, J., Caufield, P. W., Crall, J. J., Donly, K.,
Feigal, R., Gooch, B., et al. (2008). Evidence-based
clinical recommendations for the use of pit-and-fissure
sealants: A report of the American Dental Association
Council on Scientific Affairs. Journal of the American
Dental Association, 139(3), 257–268.

Dental Health During Childhood
Beltran-Aguilar, E. D., Barker, L. K., Canto, M. T., Dye,
B. A., Gooch, B. F., Griffin, S. O., et al. (2005).
Surveillance for dental caries, dental sealants, tooth
retention, edentulism, and enamel fluorosis–United
States, 1988–1994 and 1999–2002. Morbidity and
Mortality Weekly Report, 54(3), 1–43.
Beltrán-Aguilar, E. D., Barker, L., & Dye, B. A. (2010).
Prevalence and severity of dental fluorosis in
the United States, 1999–2004. NCHS data brief,
no 53. Hyattsville, MD: National Center for Health
Statistics.
Beltran-Aguilar, E. D., & Burt, B. A. (1988). The preand posteruptive effects of fluoride in the caries
decline. Journal of Public Health Dentistry, 48(4),
233–240.
Berkowitz, R. J. (2006). Mutans streptococci: Acquisition
and transmission. Paediatric Dentistry, 28(2), 106–109.
Biesbrock, A. R., Gerlach, R. W., Bollmer, B. W., Faller,
R. V., Jacobs, S. A., & Bartizek, R. D. (2001). Relative
anti-caries efficacy of 1100, 1700, 2200, and 2800 ppm
fluoride ion in a sodium fluoride dentifrice over 1 year.
Community Dentistry and Oral Epidemiology,
29(5), 382–389.
Brown, L. J., Beazogdlou, T., & Heffley, D. (1994).
Estimated savings in U.S. dental expenditures,
1979–89. Public Health Reports, 109(2), 195–203.
Brunelle, J. A., & Carlos, J. P. (1990). Recent trends in
dental caries in U.S. children and the effect of water
fluoridation. Journal of Dental Research, 69 Spec
No, 723–727.
Caufield, P. W., Li, Y., & Dasanayake, A. (2005). Dental
caries: An infectious and transmissible disease.
Compendium of Continuing Education in Dentistry,
26(5 Suppl. 1), 10–16.
Centers for Disease Control. (2010). Community water
fluoridation. Centers for Disease Control and
Prevention. Accessed January 31, 2013, from http://
www.cdc.gov/fluoridation/benefits.htm
Chalmers, N. I. (2011). Application of sealants through
school-based sealant programs decreases dental caries
prevalence. Journal of Evidence-Based Dental
Practice, 11(1), 14–17.
Chestnutt, I. G., Chadwick, B. L., Hutchings, S., Playle,
R., Pickles, T., Lisles, C., et al. (2012). Protocol for
“Seal or Varnish?” (SoV) trial: A randomised
controlled trial to measure the relative cost and
effectiveness of pit and fissure sealants and fluoride
varnish in preventing dental decay. BMC Oral
Health, 12, 51.
Chestnutt, I. G., Schafer, F., Jacobson, A. P., & Stephen,
K. W. (1998). The influence of toothbrushing
frequency and post-brushing rinsing on caries
experience in a caries clinical trial. Community
Dentistry and Oral Epidemiology, 26(6), 406–411.
Davies, G. M., Worthington, H. V., Ellwood, R. P.,
Bentley, E. M., Blinkhorn, A. S., Taylor, G. O.,
et al. (2002). A randomised controlled trial of the
effectiveness of providing free fluoride toothpaste
from the age of 12 months on reducing caries in 5–6

621
year old children. Community Dental Health,
19(3), 131–136.
Dean, H. (1938). Endemic fluorosis and its relation to dental
caries. Public Health Reports, 3(33), 1443–1452.
Dean, H. T., Arnold, F. A., & Elvove, E. (1942). Domestic
water and dental caries. Public Health Reports,
57(32), 1155–1179.
DenBesten, P. K. (1999). Biological mechanisms of dental
fluorosis relevant to the use of fluoride supplements.
Community Dentistry and Oral Epidemiology,
27(1), 41–47.
Deshpande, A., & Jadad, A. R. (2008). The impact of
polyol-containing chewing gums on dental caries:
A systematic review of original randomized controlled
trials and observational studies. Journal of the
American Dental Association, 139(12), 1602–1614.
Dos Santos, A. P., Nadanovsky, P., & de Oliveira, B. H.
(2012). A systematic review and meta-analysis of the
effects of fluoride toothpastes on the prevention of
dental caries in the primary dentition of preschool
children. Community Dentistry and Oral Epidemiology. doi:10.1111/j.1600-0528.2012.00708.x.
Drury, T. F., Horowitz, A. M., Ismail, A. I., Maertens,
M. P., Rozier, R. G., & Selwitz, R. H. (1999).
Diagnosing and reporting early childhood caries for
research purposes. A report of a workshop sponsored
by the National Institute of Dental and Craniofacial
Research, the Health Resources and Services
Administration, and the Health Care Financing
Administration. Journal of Public Health Dentistry,
59(3), 192–197.
Dye, B. A., Tan, S., Smith, V., Lewis, B. G., Barker, L. K.,
Thornton-Evans, G., et al. (2007). Trends in oral health
status: United States, 1988–1994 and 1999–2004. Vital
Health Statistics, 11(248), 1–92.
EAPD. (2009). Guidelines on the use of fluoride in children: An EAPD policy document. European Archives
of Paediatric Dentistry, 10(3), 129–135.
Ersin, N. K., Eronat, N., Cogulu, D., Uzel, A., & Aksit,
S. (2006). Association of maternal-child characteristics as a factor in early childhood caries and salivary
bacterial counts. Journal of Dentistry for Children
(Chicago, Ill.), 73(2), 105–111.
Featherstone, J. D. (1999). Prevention and reversal of
dental caries: Role of low level fluoride. Community
Dentistry and Oral Epidemiology, 27(1), 31–40.
General Accounting Office. (2008). Medicaid. Extent of
dental disease in children has not decreased, and
millions are estimated to have untreated tooth decay.
Report to congressional requesters. Washington, DC:
United States General Accounting Office.
Gift, H. C., Reisine, S. T., & Larach, D. C. (1992). The
social impact of dental problems and visits. American
Journal of Public Health, 82(12), 1663–1668.
Gillespie, G. M., & Baez, R. (2005). Development of salt
fluoridation in the Americas. Schweizer Monatsschrift
f€
ur Zahnmedizin, 115(8), 663–669.
Gooch, B. F., Griffin, S. O., Gray, S. K., Kohn, W. G.,
Rozier, R. G., Siegal, M., et al. (2009). Preventing

622
dental caries through school-based sealant programs:
Updated recommendations and reviews of evidence.
Journal of the American Dental Association, 140(11),
1356–1365.
Harris, R., Nicoll, A. D., Adair, P. M., & Pine, C. M.
(2004). Risk factors for dental caries in young
children: A systematic review of the literature.
Community Dental Health, 21(1 Suppl.), 71–85.
HealthCanada. (2010). Fluoride and human health.
Accessed February 6, 2013, from http://www.hc-sc.
gc.ca/hl-vs/iyh-vsv/environ/fluor-eng.php
Hinds, K., & Gregory, J. R. (1995). National diet and
nutrition survey; children aged 1.5 to 4.5 years.
London: The Stationery Office.
Hong, L., Levy, S. M., Broffitt, B., Warren, J. J., Kanellis,
M. J., Wefel, J. S., et al. (2006). Timing of fluoride
intake in relation to development of fluorosis on
maxillary central incisors. Community Dentistry and
Oral Epidemiology, 34(4), 299–309.
Hujoel, P. P., Cunha-Cruz, J., Banting, D. W., & Loesche,
W. J. (2006). Dental flossing and interproximal caries:
A systematic review. Journal of Dental Research,
85(4), 298–305.
Institute of Medicine. (1997). Standing Committee on the
scientific evaluation of dietary reference intakes.
Dietary reference intakes for calcium, phosphorus,
magnesium, vitamin D, and fluoride. 8, Washington,
DC: National Academies Press. Accessed April
27, 2013, from http://www.ncbi.nlm.nih.gov/books/
NBK109832/
Ismail, A. I., Lim, S., Sohn, W., & Willem, J. M. (2008).
Determinants of early childhood caries in low-income
African American young children. Pediatric Dentistry,
30(4), 289–296.
Kiritsy, M. C., Levy, S. M., Warren, J. J., GuhaChowdhury, N., Heilman, J. R., & Marshall,
T. (1996). Assessing fluoride concentrations of juices
and juice-flavored drinks. Journal of the American
Dental Association, 127(7), 895–902.
Law, V., Seow, W. K., & Townsend, G. (2007). Factors
influencing oral colonization of mutans streptococci in
young children. Australian Dental Journal,
52(2), 93–100.
Lee, H. H., Lewis, C. W., Saltzman, B., & Starks, H.
(2012). Visiting the emergency department for
dental problems: Trends in utilization, 2001 to 2008.
American Journal of Public Health, 102(11), e77–e83.
Lewis, C., & Stout, J. (2010). Toothache in US children.
Archives of Pediatric and Adolescent Medicine,
164(11), 1059–1063.
Loesche, W. J. (1985). The rationale for caries prevention
through the use of sugar substitutes. International
Dental Journal, 35(1), 1–8.
Lynch, H., & Milgrom, P. (2003). Xylitol and dental
caries: An overview for clinicians. Journal of the
California Dental Association, 31(3), 205–209.
Makinen, K. K., Hujoel, P. P., Bennett, C. A., Isotupa,
K. P., Makinen, P. L., & Allen, P. (1996). Polyol
chewing gums and caries rates in primary dentition:

Dental Health During Childhood
A 24-month cohort study. Caries Research,
30(6), 408–417.
Marinho, V. C. C., Higgins, J. P. T., Logan, S., &
Sheiham, A. (2002a). Fluoride varnishes for
preventing dental caries in children and adolescents.
Cochrane Database of Systematic Reviews, (1), Art.
No.:CD002279. doi:10.1002/14651858.CD002279.
Marinho, V. C. C., Higgins, J. P. T., Logan, S., &
Sheiham, A. (2002b). Fluoride gels for preventing
dental caries in children and adolescents. Cochrane
Database of Systematic Reviews, (2), CD002280.
Review. PubMed PMID: 12076446.
Martens, L., Vanobbergen, J., Willems, S., Aps, J., & De
Maeseneer, J. (2006). Determinants of early childhood
caries in a group of inner-city children. Quintessence
International, 37(7), 527–536.
Marthaler, T. M., & Petersen, P. E. (2005). Salt fluoridation–
an alternative in automatic prevention of dental caries.
International Dental Journal, 55(6), 351–358.
McComb, D. (2005). No reliable evidence that ozone gas
stops or reverses tooth decay. Journal of EvidenceBased Dental Practice, 6(2), 34.
MCHB. (2007). Topical fluoride recommendations for
high-risk children. Development of decision support
matrix. Recommendations from MCHB (Maternal and
Child Health Bureau) Expert Panel. Accessed
February 6, 2013, from http://www.mchoralhealth.
org/PDFs/TopicalFluorideRpt.pdf
Milgrom, P., & Chi, D. L. (2011). Prevention-centered
caries management strategies during critical periods
in early childhood. Journal of the California Dental
Association, 39(10), 735–741.
Milgrom, P., Soderling, E. M., Nelson, S., Chi, D. L., &
Nakai, Y. (2012). Clinical evidence for polyol
efficacy. Advances in Dental Research, 24(2),
112–116.
Naccache, H., Simard, P. L., Trahan, L., Brodeur, J. M.,
Demers, M., Lachapelle, D., et al. (1992). Factors
affecting the ingestion of fluoride dentifrice by
children. Journal of Public Health Dentistry,
52(4), 222–226.
Nunn, M. E., Dietrich, T., Singh, H. K., Henshaw, M. M.,
& Kressin, N. R. (2009). Prevalence of early childhood
caries among very young urban Boston children compared with US children. Journal of Public Health
Dentistry, 69(3), 156–162.
O’Keefe, E. (2011). Fluoride varnish may be effective in
preschoolers. Journal of Evidence-Based Dental
Practice, 12(2), 41–42.
Otto, M. (2007). For want of a dentist: Pr. George’s Boy
dies after bacteria from tooth spread to brain.
Washington Post. Accessed February 14, 2012, from
http://www.washingtonpost.com.offcampus.lib.washington.edu/wp-dyn/content/article/2007/02/27/AR200
7022702116.html
Poulsen, S. (2009). Fluoride-containing gels, mouth rinses
and varnishes: An update of evidence of efficacy.
European Archives of Paediatric Dentistry,
10(3), 157–161.

Dental Health During Childhood
Rekola, M. (1989). Quantification of incipient approximal
caries during fructose and sucrose consumption.
Acta Odontologica Scandinavica, 47(2), 77–80.
Roberts, C. R., Warren, J. J., & Weber-Gasparoni, K.
(2009). Relationships between caregivers’ responses
to oral health screening questions and early childhood
caries. Journal of Public Health Dentistry, 69(4),
290–293.
Rozier, R. G. (2001). Effectiveness of methods used by
dental professionals for the primary prevention of
dental caries. Journal of Dental Education, 65(10),
1063–1072.
Rozier, R. G., Adair, S., Graham, F., Iafolla, T., Kingman,
A., Kohn, W., et al. (2010). Evidence-based clinical
recommendations on the prescription of dietary
fluoride supplements for caries prevention: A report
of the American Dental Association Council on
Scientific Affairs. Journal of the American Dental
Association, 141(12), 1480–1489.
Scheinin, A., Makinen, K. K., & Ylitalo, K. (1976). Turku
sugar studies. V. Final report on the effect of sucrose,
fructose and xylitol diets on the caries incidence
in man. Acta Odontologica Scandinavica,
34(4), 179–216.
Seale, N. S., & Casamassimo, P. S. (2003). Access to
dental care for children in the United States:
A survey of general practitioners. Journal of the
American Dental Association, 134(12), 1630–1640.
SIGN. (2013). Preventing dental caries in children at high
caries risk. Healthcare Improvement Scotland.
Accessed April 20, 2013, from http://www.sign.ac.
uk/guidelines/fulltext/47/section3.html
Sjogren, K., Birkhed, D., & Rangmar, B. (1995). Effect of
a modified toothpaste technique on approximal
caries in preschool children. Caries Research,
29(6), 435–441.
Smith, R. G., & Lewis, C. W. (2005). Availability of
dental appointments for young children in King
County, Washington: Implications for access to care.
Pediatric Dentistry, 27(3), 207–211.
Stamm, J. W., Banting, D. W., & Imrey, P. B. (1990).
Adult root caries survey of two similar communities
with contrasting natural water fluoride levels. Journal
of the American Dental Association, 120(2), 143–149.
Thitasomakul, S., Piwat, S., Thearmontree, A.,
Chankanka, O., Pithpornchaiyakul, W., & Madyusoh,
S. (2009). Risks for early childhood caries analyzed by
negative binomial models. Journal of Dental
Research, 88(2), 137–141.
Tomar, S. L., & Reeves, A. F. (2009). Changes in the oral
health of US children and adolescents and dental
public health infrastructure since the release of the
Healthy People 2010 Objectives. Academic Pediatrics, 9(6), 388–395.
Twetman, S. (2009). Caries prevention with fluoride
toothpaste in children: An update. European Archives
of Pediatric Dentistry, 10(3), 162–167.
Twetman, S., Axelsson, S., Dahlgren, H., Holm, A. K.,
Kallestal, C., Lagerlof, F., et al. (2003).

623
Caries-preventive effect of fluoride toothpaste:
A
systematic
review.
Acta
Odontologica
Scandinavica, 61(6), 347–355.
Twetman, S., & Fontana, M. (2009). Patient caries
risk assessment. Monographs in Oral Science, 21,
91–101.
U.S. Department of Health and Human Services. (2000).
US Department of Health and Human Services.
In Oral health in America: A report of the Surgeon
General. Rockville, MD: US Department of Health
and Human Services, National Institute of Dental
and Craniofacial Research, National Institutes of
Health.
U.S. Department of Health and Human Services. (2011).
HHS and EPA announce new scientific assessments
and actions on fluoride. Accessed January 31, 2013,
from
http://www.hhs.gov/news/press/2011pres/01/
20110107a.html
Verrips, G. H., Frencken, J. E., Kalsbeek, H., ter Horst, G.,
& Filedt Kok-Weimar, T. L. (1992). Risk indicators
and potential risk factors for caries in 5-year-olds
of different ethnic groups in Amsterdam.
Community Dentistry and Oral Epidemiology, 20(5),
256–260.
Vieira, A. R., Marazita, M. L., & GoldsteinMcHenry, T. (2008). Genome-wide scan finds suggestive caries loci. Journal of Dental Research, 87(5),
435–439.
Waaler, S. M. (1992). Evidence for xylitol 5-P production
in human dental plaque. Scandinavian Journal of
Dental Research, 100(4), 204–206.
Walsh, T., Worthington, H. V., Glenny, A. M., Appelbe,
P., Marinho, V. C., & Shi X. (2010). Fluoride toothpastes of different concentrations for preventing dental
caries in children and adolescents. Cochrane Database
System Reviews, (1), CD007868. Review. PubMed
PMID: 20091655. doi:10.1002/14651858.CD007868.
pub2.
Wang, X., Willing, M. C., Marazita, M. L., Wendell, S.,
Warren, J. J., Broffitt, B., et al. (2012). Genetic and
environmental factors associated with dental caries in
children: The Iowa Fluoride Study. Caries Research,
46(3), 177–184.
Warren, J. J., Weber-Gasparoni, K., Marshall, T. A.,
Drake, D. R., Dehkordi-Vakil, F., Dawson, D. V.,
et al. (2009). A longitudinal study of dental
caries risk among very young low SES children.
Community Dentistry and Oral Epidemiology, 37(2),
116–122.
Warren, J. J., Weber-Gasparoni, K., Marshall, T. A.,
Drake, D. R., Dehkordi-Vakil, F., Kolker, J. L.,
et al. (2008). Factors associated with dental caries
experience in 1-year-old children. Journal of Public
Health Dentistry, 68(2), 70–75.
Weintraub, J. A., Ramos-Gomez, F., Jue, B., Shain, S.,
Hoover, C. I., Featherstone, J. D., et al. (2006).
Fluoride varnish efficacy in preventing early
childhood caries. Journal of Dental Research,
85(2), 172–176.

624
Wetterhall, S., Burrus, B., Shugars, D., & Bader, J. (2011).
Cultural context in the effort to improve oral health
among Alaska Native people: The dental health aide
therapist model. American Journal of Public Health,
101(10), 1836–1840.
Whitford, G. M. (1994). Intake and metabolism of
fluoride. Advances in Dental Research, 8(1), 5–14.

Dental Health During Childhood
Wright, G. Z., Banting, D. W., & Feasby, W. H.
(1979). The Dorchester dental flossing study:
Final report. Clinical Preventive Dentistry, 1(3),
23–26.
Yeung, C. A. (2007). Fluoride prevents caries among
adults of all ages. Journal of Evidence-Based Dental
Practice, 8(3), 72–73.

Depression During Childhood

Depression During Childhood
Clare Roberts
School of Psychology and Speech Pathology,
Curtin University, Perth, WA, Australia

Introduction
Until the 1970s it was widely believed that
children did not get depressed (Baker, 2006).
However, we now know that even preschool children are more emotionally sophisticated (Luby,
2009). Children with depression report symptoms
such as sadness, irritability, tearfulness,
depressed mood, loss of appetite, sleep disturbance, poor concentration, loss of energy, social
withdrawal, somatic complaints, and a lack of
interest in usual activities. Their suffering leads
to impairments in home, school, and interpersonal contexts. While less common in childhood,
preschool depression has been identified, and it
can result in ongoing depression throughout
primary and secondary school.
Childhood depression includes depressed
mood which may be transient or ongoing and is
usually identified as feeling sad or unhappy
(Roberts, Bishop, & Rooney, 2008). Children
younger than 7 years may not be able to describe
these feelings and may express their symptoms
via somatic or irritable symptoms. These symptoms can lead to poor concentration, impaired
attention, social withdrawal, and sometimes hostile behavior. Childhood depression can be
chronic, up to 24 months (Luby, Si, Belden,
Tandon, & Spitznagel, 2009).

Definition and Scope
Preschool and childhood depression are similar;
they can be distinguished from other early-onset
psychiatric disorders. Depressed preschoolers
have four times the likelihood of developing
major depressive disorders compared to typical
preschoolers (Luby, 2009). Markers include low
mood, feeling bad or blue, crying more than

625

usual, irritability, as well as a lack enjoyment
and feeling pleasure. Cognitive markers include
low self-esteem, lack of confidence, trouble
making decisions, focusing, and poor concentration. Somatic symptoms may lead to changes in
appetite, sleep cycle, energy levels, and weight.
Costello, Mustillo, Erkanli, Keeler, and Angold
(2003) reported the 3-month prevalence for any
depressive disorder at 2.2 % (confidence intervals, 1.6–3.0) in children 9–13 years. The rates
rise around 13 years, where 36.7 % of the
children have met at least one or more criteria
by 16 years. This disorder shows chronicity up to
24 months. Preschoolers with MDD are 11.3
times as likely as children with no disorders to
be depressed 2 years after diagnosis (Luby et al.,
2009). Eighteen percent show a chronic course,
while 35 % recover. Depression in children
includes functional impairment and symptoms
that occur regularly for two or more weeks.
Depressive diagnoses include major depressive
disorder and dysthymia.
Symptoms include sad, depressed, or irritable
moods and loss of pleasure on most days of the
week, for at least 2 weeks. Children also experience symptoms such as suicidal ideation, loss of
appetite, sleep and weight change, loss of
pleasure, and irritability. If symptoms occur on
most days of the week for 2 weeks, a clinical
diagnosis can be made. Structured clinical interviews and questionnaires are used to assess child
depressive disorders (APA Diagnostic & Statistical, American Psychiatric Association, 2010).
Childhood depression is associated with comorbid axis I disorders and more negative events
(Fernando et al., 2011). Preschool depression
shows chronicity, recurrence, and homotypic
continuity during a 24-month period (Luby
et al., 2009).
Childhood depression is almost as prevalent
for males and females, but the burden of depression is 50 % higher for females than males.
Depression is one of the leading causes of child
mental health burden. In any given time, 15 % of
children and adolescents have symptoms of
depression (Bhatia & Bhatia, 2007). In mental
health settings, the prevalence is around 60 %
of referred children reporting depression

T.P. Gullotta, M. Bloom (eds.), Encyclopedia of Primary Prevention and Health Promotion,
DOI 10.1007/978-1-4614-5999-6, # Springer Science+Business Media New York 2014

626

symptoms and 25 % receiving a diagnosis of
major depression (Baker, 2006). Hence, childhood depression is an important target for preventive efforts.

Theories
Theories need to consider the impact of development on depression and the impact of depression
upon emerging developmental processes. Roberts et al. (2008) summarized the theories and
implications for interventions in the following
four pages.
Genetic Theories: Twin studies show 50 % of
mood disorders are genetic. However, childhood
depression can be explained more by environmental factors than heritability.
Biological Theories: Somatic and psychological symptoms relate to biological dysfunctions, in
the hypothalamic–pituitary–adrenal (HPA) axis
leading to sympathetic nervous system problems,
affecting emotions, guilt, and hopelessness
(Sharpley, 2010). Psychomotor abnormities,
weight loss, and sleep disturbances occur, in the
thyroid axis, and REM sleep can be disrupted
(Maletic et al., 2007). The amygdale is also implicated via altered emotional processing in child
major depression (Luking et al., 2011).
Cognitive Theories: Cognitive errors/schema,
attribution style, personal control, and selfcontrol theory are just a few of the diathesis–
stress theories. Children’s perception and
processing of adverse events leads to depression
rather than aversive events alone (Roberts et al.,
2008). Child depression has a more direct role
compared to teens and adults (Luking et al.,
2011). Interpersonal cognitions are strongly associated with child depression, while genetic influences are small (3 %), reflecting life experiences
(Lau, Rijsdijk, Gregory, McGuffin, & Eley,
2007). Beck (2011) found that depressed children
make systematic errors in interpretation and negative self-talk. These become stable, internal
belief systems that structure memory and guide
information processing, leading to a “negative
cognitive triad” of the self, the world, and the
future. Peterson and Seligman’s (1984) theory

Depression During Childhood

of pessimistic attribution style attributed negative
outcomes to internal, global, and stable causes
and positive outcomes to external, specific, and
temporary causes, leading to helplessness, hopelessness, and depression in the face of negative
life events.
Weisz et al.’s (1992) locus of control theory
suggest low perceived competence, external
locus of control, and depression are linked.
Bandura, Pastorelli, Barbaranelli, and Caprara
(1999) proposed that belief in one’s ability to
regulate functioning and to control events that
affect your life is strongly related to depression.
Gladstone and Kaslow’s (1995) meta-analyses
found moderate to large effect sizes for children’s
pessimistic attribution style and depressive
symptoms. However, the diathesis–stress effect
was only found in younger children. Compas,
Banez, Malcarne, and Worsham (1991) reported
that children’s perceptions of contingency,
competence, and control are not well developed
until 11 years of age.
Weisz, Sweeney, Proffitt, and Carr (1993) found
positive associations between depressive symptoms and perceived competence and contingency
beliefs in late childhood only. Cognitive deficits
occur in self-monitoring, self-evaluation, memory
impairments related to recall of success, setting
harsh standards, and negative self-cognitions, in
depressed children, but positive self-evaluations
can compensate (Roberts et al., 2008). This begins
early with negative cognitive processes, such as
worry and rumination in response to repeated environmental stressors (Topper, Emmelkamp, &
Ehring, 2010). These become habitual by late
childhood. Hence, the importance of targeting
repetitive negative thinking and worry.
Behavioral and Interpersonal Theories:
Lewinsohn (1974) conceptualized depression as
the consequence of skills deficits that are associated with low rates of response contingent positive reinforcement. However, Hammen et al.
(2011) noted an association between stressful
life events and the prevalence of depression,
anxiety, and PTSD, related to the childhood
adversity. The effectiveness of children’s solutions moderates the relationship between negative life stress and depressive symptoms.

Depression During Childhood

However, some negative self-perceptions of
depressed children may be realistic.
Environmental Stress Theories: Cognitive and
interpersonal theories of depression include
stress-reactive models and stress-generation
models. Rudolph et al. (2000) reported that
depressed children generate stressful circumstances in the interpersonal domain, which in
turn results in depression.
Family Theories: Insecure infant attachments
contribute to the development of internal selfmodels and impact upon cognition, affect, and
behavior (Cicchetti & Toth, 1998). Social learning occurs via the day-to-day parent–child interactions (Rapee, Wignall, Spence, Lyneham, &
Cobham, 2008). While attachment difficulties
include failure to attach by 6 months to 3 years,
disorganized insecure attachments, separations
and loss of attachment figures, and disorganized
attachments can result in maltreatment or parental trauma (Main, 1996).
Current Research: Treating postnatal depression
is important for childhood depression in particular
and parental depression in general (Porter & Hsu,
2003; Rishel, 2012). Also, children who experience
multiple stressful life events may benefit from
targeted interventions. Cognitive and interpersonal
strategies in children’s depression prevention programs should target cognitive errors, pessimistic
attributions, self-esteem and self-perceptions, social
and friendship skills, interpersonal problem solving, personal competencies, and coping skills.
Munoz, Beardslee, and Leykin (2012) report that
22–38 % of major depression episodes can be
reduced if children and adolescents receive
evidence-based interventions. Family models that
emphasize attachment, parent–child interaction
in child rearing, are also important. Family group
cognitive behavioral interventions have found
significant efficacy for internalizing and externalizing symptoms, and effects increase at 18- and
24-month follow-up (Compas et al., 2011).

What Works
Depression prevention strategies have increased
significantly since the last entry published

627

in 2001. A Cochrane Review of psychological
and educational interventions for prevention of
depression (Merry, McDowell, Hetrick, Bir, &
Muller, 2009); a paper on evidenced-based
psychosocial treatments for child and adolescent
depression (David-Ferdon & Kaslow, 2008); an
entry by Roberts et al. (2008) on depression disorder in childhood and adolescence; and a metaanalytic review by Stice, Shaw, Bohon, Nathan
Marti, and Rohde (2009) have been published
on prevention for childhood and adolescent
depression.
Psychosocial treatments work for childhood
depression, when conducted in community and
school settings (Compton et al., 2004; Compton,
Burns, Egger, & Robertson, 2002; Curry, 2001).
Michael and Crowley’s (2002) meta-analysis
found nine controlled trials and three pre–post
uncontrolled trials, with a large effect size 0.65
(95 % CI 0.34–0.94) for controlled trials with
children. The effect sizes were slightly lower
than those for adolescent trials (0.93), but larger
than effects for psychopharmacological treatments for depressed children (mean ES = 0.15).
Cognitive behavior therapy (CBT) works for
children. Five randomized controlled trials of
depressive symptoms have all been based on
behavior therapy or cognitive behavior therapy
(Compton et al., 2002, 2004; Curry, 2001).
Group-based interventions with school children
with elevated symptoms work as do group CBT
and individual CBT interventions (Vostanis,
Feehan, & Grattan, 1996). Three additional
studies were based on psychoeducational sessions for families that were adjunct to the child’s
intervention. These were conducted in groups in
the home (Asarnow, Scott, & Mintz, 2002).
Merry et al.’s (2009) Cochrane Collaboration
investigated psychological and educational interventions in reducing childhood depression, by
treating it early or preventing the onset of depressive disorders in children. Of the 21 studies,
18 psychological studies related to psychological
interventions and 12 psychological prevention
programs were implemented universally.
Six of these programs relate to children
(Cardemil, Reivich, Beevers, Seligman, &
James, 2007; Pattison & Lynd-Stevenson, 2001;

628

Quayle, Dziurawiec, Roberts, Kane, &
Ebsworthy, 2001; Roberts et al., 2010; Swannell,
Hand, & Martin, 2009). Eight prevention programs were targeted groups based on at-risk samples with high depression scores, four of these
included children, or social disadvantage (Roberts, Kane, Thomson, Bishop, & Hart, 2003).
Many of these prevention programs are derivative of the PENN Prevention program (Cardemil
et al., 2007; Jaycox, Reivich, Gillham, &
Seligman, 1994; Quayle et al., 2001; Roberts
et al., 2003, 2010; Rooney et al., 2006). All
programs are manualized and have training programs for implementation.
This review indicated that targeted programs
reduced depression by a standardized mean
difference of 0.26 with a 95 % confident interval of 0.40 to 0.13. The effect sizes were
small, but they resulted in significant reduction
in depressive episodes, but not depressive symptoms. Universal interventions were shown to be
not effective (SMD 0.21, 95 % CI 0.48, 0.06).
However, they did prevent depressive episodes.
The overall difference after intervention translated to treating ten children for one child to
recover. However, this is a treatment effect, not
preventative. Clarke’s et al.’s (2001) targeted
program is the most effective intervention, but
the program treats the symptoms and is not truly
preventative, with children. Stark, Hargrave,
Hersh, Greenberg, Herren, and Fisher (2008)
found that cognitive behavior therapy for children is efficacious for both adolescents and children. Psychoeducational interventions may also
be useful. Petersen and colleagues’ (1997)
16-session manualized program was delivered
to 6th- and 7th-grade students, by graduate students with good efficacy.
Nine studies reported depression outcomes in
children (Clarke et al., 1995, 2001). Effects were
evidenced at posttest only. The targeted programs
reduced depression with a SMD of 0.26 at 95 %
confidence interval ( 0.40 to 0.13). The universal programs were not effective (SMD of
0.21, CI 0.48, 0.06). At a follow-up there
were no significant effects for targeted or universal interventions. At 12 months, two studies of
targeted interventions (Clarke et al., 1995, 2001)

Depression During Childhood

found a decrease in depressive disorders
(RD 0.12, CI 0.24–0.01), while universal
interventions did not. However, these were
adolescents. Six studies of depressive disorders
showed effectiveness at posttest. However, this
was only for girls (RD 0.14, CI 0.23, 0.04)
compared to boys (RD 0.07, CI 0.15, 0.01).
There was no evidence of efficacy at follow-up,
but one study found a significant decrease in
scores for the high-risk group (Cardemil et al.,
2007). Six studies (Gwynn & Brantley, 1987;
Hains & Ellmann, 1994; Pattison & LyndStevenson, 2001; Roberts et al., 2011) reported
effects for internalizing problems at posttest but
not at follow-up. Rooney et al. (2006) reported
effects up to 4 years after the intervention. Four of
the six interventions reported reduction in symptoms. Various measures were used, but all were
compared to either usual care conditions or no
intervention.
Change in depression scores was generally
small. The numbers needed to treat (NNT) was
10, encouraging for a prevention trial. Depressive
diagnoses both targeted and universal interventions were viable, with an NNT of 8 for targeted
interventions and NNT of 13 for universal interventions. Merry et al. (2009) indicated that the
lack of placebo or comparison groups makes it
difficult to ensure that the findings are due to the
research procedure. Merry’s Cochrane Collaboration suggests that there was not sufficient evidence to implement depression programs
currently, but there is a need to compare interventions to placebo or other active comparison
groups. Booster sessions could be used to prolong
the effectiveness of the intervention. There may
also be a place for gender-based groups, as
girls and boys may respond differently to the
programs.
David-Ferdon and Kaslow (2008) reviewed
the evidence on child and adolescent depression.
They found that for children, the school-based
self-control therapy was effective with elevated
depressive symptoms (Stark, Rouse, & Livingston, 1991). This intervention met criteria for
a probably efficacious intervention. The program
is based on cognitive behavior therapy (CBT),
and the intervention includes symptoms

Depression During Childhood

monitoring, cognitive restructuring, social skills
training, social problem solving, coping skills,
relaxation, and scheduling pleasant events. Stark
et al. (2007) published The Action Treatment
Program Intervention in 1990, following
research on a comparison of the relative efficacy
of self-control therapy and behavioral problem
solving. This intervention has worked in three
successful trials, Stark et al. (1987) and Stark
et al. (1991) two randomized controlled trials
and an independent open trial, conducted by
Rehm and Sharp (1996). Adjunct psychoeducational sessions for families were also used in
groups (Rehm & Sharp, 1996) and home settings.
Six of the eight randomized control trials using
school-based samples have reported reductions in
depression, and effect sizes are large to moderate
1.68 (Kahn, Kehle, Jensen, & Clarke, 1990) and
0.48 (Weisz, Thurber, Sweeney, Proffitt, &
LeGagnoux, 1997). Weisz and Jensen (2001)
reviewed the child and adolescent psychotherapy
in research and practice contexts. The efficacy of
structured treatments administrated under controlled conditions shows significant evidence of
benefits, compared to treatment as usual. Stark
et al. (2007) have developed a therapist manual,
Treating Depressed Youth: Therapist Manual for
ACTION (Stark et al., 2007).
There have been eight intervention studies
with children at risk for depression because of
elevated symptoms (Asarnow et al., 2002;
De Cuyper, Timbremont, Braet, De Backer, &
Wullaert, 2004; Gillham, Hamilton, Freres,
Patton, & Gallop, 2006; Roberts et al., 2003).
There have also been two studies with children
who met the criteria for a clinical depressive
disorder (Trowell et al., 2007) and
a telemedicine intervention (Nelson, Barnard, &
Cain, 2003).
Stice et al. (2009) conducted a meta-analytic
review of depression prevention programs. These
researchers identified 32 prevention programs.
The average effect sizes for depressive symptoms
were small for posttest (r = 0.15) and follow-up
(r = 0.11). This study included more adolescents
than children. Programs for high-risk children,
females, and older adolescents had larger effects.
Programs of shorter duration with assigned

629

homework delivered by professional interventionists were more effective than universal interventions. Interventions included problem
solving, particularly social problem solving, and
changing negative cognitions. Selective programs of short duration were more effective,
and professional interventions rather than regular
school teachers delivering the programs were
more effective in the late primary and early secondary school years.
Two universal randomized controlled trials of
the Aussie Optimism Program with children
found modest effects. Fewer parents reported
internalizing
problems
at
posttest
in
a disadvantaged urban sample (Roberts et al.,
2010). The teacher training and coaching condition reported lower levels of mental health problems, higher levels of pro-social behavior, and
fewer clinical disorders at posttest assessments,
compared to the Health Curriculum. An independent open trial of this intervention by Swannell
et al. (2009) indicated that the program was most
beneficial for indicated students experiencing
emotional and behavioral difficulties. Rooney
et al. (2006) used a younger version of AOP for
children 8–10 years. The Positive Thinking Skills
Program (PTS) reduced depressive symptoms,
enhanced positive attributions, and lowered the
prevalence of depressive disorders. Intervention
group children had fewer depressive disorders at
9-month follow-up.
Luby, Lenze, and Tillman (2012) developed
a preschool depression intervention, with three
modules, over 14 sessions. Core modules included
child-directed interaction and parent-directed
interaction. Key elements were strengthening the
child–parent bond by teaching, modelling and
coaching of positive play techniques, giving effective commands, and handling child compliance
and disruptive behavior. Mothers and fathers
were invited as primary implementers. Group
size from 2 to 6 families completed 2-h sessions
over 12 weeks.
The aim is to reduce depressive mood, symptoms, and syndrome and reduce the incidence of
childhood depressive disorders. Depressive disorders are relatively rare in childhood, and hence,
depressive symptoms and risk factors such as

630

attribution style, coping skills, and other behavioral and interpersonal factors are used. Efforts
have focused on children with known risk
factors or elevated depressive symptoms, rather
than primary prevention programs. Strategies
include child-centered, school-based strategies
targeting cognitive and interpersonal factors.
Environment-centered programs, focus on family
context where children of depressed parents live,
plus school-based strategies are reviewed.
Early trials included working with elementary
school children with mild to moderate depressive
symptoms. Weisz, Thurber, Sweeney, Proffitt,
and LeGagnoux (1997) implemented an 8session intervention program aimed at enhancing
primary control (changing the situation) and secondary control (changing one’s interpretations).
Children who received the intervention in small
groups showed significantly greater reductions in
depressive symptoms at posttest and 9-month
follow-up than control group children. Intervention group children were more likely than control
group children to move into the nonclinical range
on depression measures. Weisz and Kazdin
(2010) have now developed an evidence-based
psychotherapy book.
Beardslee, Versage, and Gladstone (1998)
focused on family factors, using cognitive therapy and psychoeducational approaches aimed at
children whose parents have affective disorders.
The 6–10-session family intervention helps families to develop a shared perspective of the
depressive illness and to change parent’s behavior toward their children. Resilience was promoted in children by providing information
about the parent’s illness, ways of coping, and
encouraging supportive relationships outside the
home. Following the intervention, parents
reported significantly more changes in behavior
and attitudes to their illness, compared to families
that received an information-based intervention
only (Beardslee et al., 1993). These effects were
sustained at an 18-month follow-up, with the
family-based intervention associated with more
positive parent-reported and assessor-rated
changes (Beardslee et al.). Family risk factors
for childhood depression were reduced and
prevented over time. However, no measures of

Depression During Childhood

child functioning were reported, to determine if
depression was prevented in the offspring.
Depression prevention in childhood has
advanced significantly. Primary prevention
programs for 4th-grade students are now common.
Indicated programs with specific risk factors are
effective in the short term. The programs are
largely child-centered and school-based. A
family-based program published by Beardslee
et al. (1997) has shown efficacy in modifying the
home environments of children at high risk, in the
medium term. These indicate the efficacy of prevention strategies based upon cognitive, interpersonal, and family models of childhood depression.
Current trials indicate that the incidence of depression can be reduced. Meta-analyses indicate that
22–38 % of major depression can be reduced if
evidence-based interventions are applied by the
health system (Munoz et al., 2012).

Strategies That Might Work
Strategies that prevent depression in children
include interventions with short-term effects and
prevention strategies for problem disorders and
comorbidity with depression, for example, anxiety.
A number of primary prevention strategies target
variables associated with depression, for example,
social competence and social skills. Durlak,
Weissberg, and Pachan (2010) conducted a metaanalysis with 213 interventions and found that SEL
programs significantly improve children’s skills,
attitudes, and behaviors and reduced emotional
problems, such as distress from anxiety and depression symptoms. The effect size was 0.15. These
strategies have not measured depressive symptoms
or disorders, but many have shown promising outcomes with proximal factors that place children at
risk for depression or protect children from aversive life events. Durlak, Weissberg, Dymnicki,
Taylor, and Schellinger (2011) meta-analysis
found a similar impact of enhancing social and
emotional learning in schools.
Strategies targeting risk such as low social
competence and poor academic achievement in
the early and middle childhood years show promise. However, as yet no long-term intervention

Depression During Childhood

effects have been established. King and
Kirschenbaum (1990) used a nine-session social
skills and social problem-solving intervention,
plus a parent and teacher consultation service
for 4th-grade children who were at risk for
depression because of poor social competence.
The Primary Mental Health Project (Cowen
et al., 1996) combined service program showed
decreased depressive symptoms compared to the
parent/teacher consultation service at posttest
only, with social competencies improving for all
groups.
Kellam et al. (1994) proposed that pessimistic
attribution style in association with poor academic mastery leads to childhood depression.
A universal school-based prevention strategy
was designed to enhance mastery of academic
skills in 1st-grade children. It included enriched
reading curriculum and individualized correction
procedures, implemented by teachers in the first
year of school. Boys with high levels of depressive symptoms and good gains in reading
achievement reported fewer symptoms at the
end of grade 1. However, girls with high levels
of depressive symptoms who made gains in reading achievement had lower levels of symptoms
regardless of attending the intervention or not.
These interventions targeted different mechanisms for childhood depression, by way of reducing depressive symptoms in younger children.
The Primary Mental Health Project (Cowen
et al., 1996) involves the screening and identification of young children with early school adjustment problems. It then provides prompt and
effective interventions services for high-risk
youngsters. The program has been evaluated in
numerous sites throughout the United States. One
evaluation in California, where 50,000 children
from 750 schools were involved, found effect
sizes of between 0.37 and 0.49 for improvements
in adjustment variables such as acting out, shyness, and anxiety.

Strategies That Do Not Work
Interpersonal problem-solving strategies are not
effective in reducing depressive problems when

631

implemented universally, although they are
effective in increasing competence (Durlak &
Wells, 1997). Brief classroom-based programs
are not as effective as longer multiyear programs,
producing stable effects on children’s knowledge, attitudes, and behavior and social competence. School-based programs that are focused
only on the child or the environment are less
effective than those that focus on both (Durlak,
2000).

Summary
Childhood depressive symptoms and disorders
develop in the context of individual genetic and
biological vulnerabilities, insecure early attachments, impaired parent–child interactions, and
high levels of environmental stress. Early factors
result in decreased behavioral and interpersonal
skills and impairments in internal cognitive
schema and information processing mechanisms.
These deficits result in additional negative feedback from peers, teachers, and family members.
Hence, when aversive life events are encountered, children are vulnerable to depression. Vulnerability may come from few coping skills or
processes for accessing coping skills, cognitive
distortions that promote helplessness, overly high
standards or negative self-evaluations, or few
supportive relationships; these vulnerability
may subsequently lead to depression.
Prevention of depression in children includes
school- and family-based interventions with
known risk factors, such as elevated depressive
symptoms, poor social competence, and parental
affective disorder. This results in a lower in risk
for depression, fewer depressive symptoms, and
family context changes. Effects have been
maintained for up to 2 years. Interventions
based upon cognitive, interpersonal, and family
models of depression provide strategies to facilitate the process of change. School-based intervention programs have found depression
prevention effects mediated by changes in attribution style for negative events. Other empirical
strategies include school-based interventions
targeting social skills and competence in

632

children, environment-centered strategies such as
parent and teacher consultations, and enriched
curriculum materials promoting academic mastery (Durlak et al., 2011). A recent meta-analysis
(Munoz et al., 2012) indicated that 22–38 % of
major depressive episodes are preventable.
Hence, the health-care systems should provide
access to evidence-based prevention for children
and young adolescents.
Strategies not yet tested include universal
interventions with enriched curriculum materials
that promote academic mastery, for all children
regardless of risk, multiyear interventions, and
those that integrate child- and family-centered
strategies. Interventions early in children’s lives,
which promote attachment, reduce the impact of
maternal depression, promote positive parenting,
and build social competencies and school readiness, are likely to have important impacts on
child and family adjustment, hence reducing
depression vulnerability. Randomized controlled
efficacy trials have been completed but no replications trials or effectiveness studies to determine
what strategies work in regular service delivery
conditions, and there are no component analyses
of the available programs. So, it is unclear which
strategies are the active ingredients in preventing
childhood depression. In addition, there has been
only one trial of a strategy offered to all children
regardless of risk status, and only one study that
attempted to integrate child-centered and
environment-centered approaches. These are all
important areas for future research. Judy Garber
asks (2008) “are we there yet?” The answer
appears that we have effective programs, but
these programs do not always get out to the children and adolescents who need them.

References
American Psychiatric Association. (2010). Diagnostic
and statistical manual of mental disorders (4th ed.,
text revision). 8th Printing. Washington, DC: Author.
Asarnow, J. R., Scott, C. V., & Mintz, J. (2002).
A combined cognitive-behavioral family education
intervention for depression in children: A treatment
development study. Cognitive Therapy Research, 26,
221–229.

Depression During Childhood
Baker, K. (2006). Treatment and management of depression in children. Current Paediatrics, 16, 478–483.
Bandura, A., Pastorelli, C., Barbaranelli, C., & Caprara,
G. V. (1999). Self-efficacy pathways to childhood
depression. Journal of Personality and Social Psychology, 76, 258–269.
Beardslee, W. R., Salt, P., Porterfield, K., Rothberg, P. C.,
van der Velde, P., Swatling, S., et al. (1993). Comparison of preventative interventions for families with
parental affective disorder. Journal of the American
Academy of Child and Adolescent Psychiatry, 32,
254–263.
Beardslee, W. R., Salt, P., Veersage, M. A., Gladstone,
T. R. G., Wright, E. J., & Rothberg, P. C. (1997).
Sustained change in parents receiving preventive
interventions for families with depression. American
Journal of Psychiatry, 154, 510–515.
Beardslee, W. R., Versage, E. M., & Gladstone, T. R.
(1998). Children of affectively ill parents: A review
of the past 10 years. Journal of the American Academy
of Child & Adolescent Psychiatry, 37, 1134–1141.
Beck, J. S. (2011). Cognitive, behavior therapy. Basics
and beyond. New York: The Guilford Press.
Bhatia, S. K., & Bhatia, S. C. (2007). Childhood and
adolescent depression. Americans Family Physician,
75, 73–80.
Cardemil, E. V., Reivich, K. J., Beevers, C. G., Seligman,
M. E., & James, J. (2007). The prevention of depressive symptoms in low-income minority children:
Two-year follow-up. Behaviour Research and Therapy, 45, 313–327.
Cicchetti, D., & Toth, S. L. (1998). The development of
depression in children and adolescents. American Psychologist, 53, 221–241.
Clarke, G. N., Hawkins, W., Murphy, M., Sheeber, L.,
Lewinsohn, P. M., & Seely, J. R. (1995). Targeted
prevention of unipolar depressive disorder in an
at-risk sample high school adolescents: A randomised
trial of group cognitive intervention. Journal of the
American Academy of Child and Adolescent Psychiatry, 58, 312–321.
Clarke, G. N., Hornbrook, M., Lynch, F., Polen, M., Gale,
J., Beardslee, W. R., et al. (2001). A randomized trial
of a group cognitive intervention for preventing
depression in adolescent offspring of depressed parents. Archives of General Psychiatry, 58, 1127–1134.
Compas, B. E., Banez, G. A., Malcarne, V. L., &
Worsham, N. L. (1991). Perceived control, coping
with stress, and depressive symptoms in school-aged
children. Burlington, VT: University of Vermont.
Compas, B. E., Forehand, R., Thigpen, J. C., Keller, G.,
Hardcastle, E. J., Cole, D. A., et al. (2011). Family
group cognitive-behavioral preventative intervention
for families of depressed parents: 18- and 24-month
outcomes. Journal of Consulting and Clinical Psychology, 79(4), 488–499.
Compton, S. N., Burns, B. J., Egger, H. L., & Robertson,
E. (2002). Review of the evidence base for treatment
of child psychopathology: Internalizing disorders.

Depression During Childhood
Journal of Consulting and Clinical Psychology, 70,
1240–1266.
Compton, S. N., March, J. S., Brent, D., Albano, A. M.,
Weersing, V. R., & Curry, J. (2004). Cognitivebehavioral psychotherapy for anxiety and depressive
disorders in children and adolescents: An evidenced
based medicine review. Journal of Consulting and
Clinical Psychology, 70, 1240–266.
Costello, E. J., Mustillo, S., Erkanli, A., Keeler, G., &
Angold, A. (2003). Prevalence and development of
psychiatric disorders in childhood and adolescence.
Archives of General Psychiatry, 60, 837–844.
Cowen, E. L., Hightower, A. D., Pedro-Carroll, J. L.,
Work, W. C., Wyman, P. A., & Haffey, W. G.
(1996). School-based prevention for children at risk.
The Primary Mental Health Project. Washington, DC:
American Psychological Association.
Curry, J. (2001). Specific psychotherapies for childhood
and adolescent depression. Biological Psychiatry, 49,
1091–1100.
David-Ferdon, C., & Kaslow, N. J. (2008). Evidencedbased psychological treatments for child and adolescent depression. Journal of Clinical Child & Adolescent Psychology, 37(1), 62–104.
De Cuyper, S., Timbremont, B., Braet, C., De Backer, V.,
& Wullaert, T. (2004). Treating depressive symptoms
in schoolchildren: A pilot study. European Child Adolescence Psychiatry, 13(2), 105–114.
Durlak, J. A. (2000). Health promotion as a strategy in
primary prevention. In D. Cicchetti, J. Rappaport,
I. Sandler, & R. P. Weissberg (Eds.), The promotion
of wellness in children and adolescents (pp. 221–242).
Washington, DC: CWLA Press.
Durlak, J. A., Weissberg, R. P., Dymnicki, A. B., Taylor,
R. D., & Schellinger, B. (2011). The impact of enhancing students’ social and emotional learning: A meta
analysis of school-based universal interventions. Child
Development, 82(1), 405–432. doi:10.1111/j.14678624.2010.01564.x.
Durlak, J. A., Weissberg, R. P., & Pachan, M. (2010).
A meta-analysis of after-school programs that seek to
promote personal and social skills in children and
adolescents. American Journal of Community Psychology, 45(3), 294–309.
Durlak, J. A., & Wells, A. M. (1997). Primary prevention
mental health programs for children and adolescents:
A meta-analytic review. American Journal of Community Psychology, 25, 115–152.
Fernando, K., Carter, J. D., Frampton, C. M. A., Luty,
S. E., McKenzie, J., Mulder, R. T., et al. (2011). Child, teenage-, and adult-onset depression: Diagnostic and
individual characteristics in a clinical sample. Comprehensive Psychiatry, 52, 623–629.
Garber, J. (2008). Prevention of depression: Are we there
yet? Clinical Psychological: Science and Practice, 15,
336–341. doi:10.1111/j.1468-2850.2008.00145.x.
Gillham, J. E., Hamilton, J., Freres, D. R., Patton, K., &
Gallop, R. (2006). Preventing depression among early
adolescents in the primary care setting: A randomized

633
controlled study of the Penn Resiliency Program.
Journal of Abnormal Child Psychology, 34(2),
203–219.
Gladstone, T. R. G., & Kaslow, N. J. (1995). Depression
and attributions in children and adolescents: A metaanalytic review. Journal of Abnormal Child Psychology, 23, 597–606.
Gwynn, C. A., & Brantley, H. T. (1987). Effects of
a divorce group intervention for elementary school
children. Psychology in the Schools, 24, 161–232.
Hains, A. A., & Ellmann, S. W. (1994). Stress inoculation
training as a preventive intervention for high school
youth. Journal of Cognitive Psychotherapy, 8,
219–164.
Hammen, C., Brennan, P. A., & Le Brocque, R. (2011).
Youth depression and early childrearing: Stress generation and intergenerational transmission of depression.
Journal of Consulting and Clinical Psychology, 79(3),
353–363.
Jaycox, L. H., Reivich, K. J., Gillham, J., & Seligman,
M. E. P. (1994). Prevention of depressive symptoms in
school children. Behavior Research and Therapy,
32(8), 801–816.
Kahn, J. S., Kehle, I. J., Jensen, W. R., & Clarke,
E. (1990). Comparison of cognitive-behavioural relaxation, and self-modeling interventions for depression
amongst middle-school students. School Psychology
Review, 79, 195–210.
Kellam, S. G., Bebok, G. W., Mayer, L. S., Ialongo, N., &
Kalodner, C. R. (1994). Depressive symptoms over
first grade and their response to a developmental epidemiologically based prevention trial aimed at
improving achievement. Development and Psychopathology, 6, 473–481.
King, C. A., & Kirschenbaum, D. I. S. (1990). An experimental evaluation of school-based program for children at risk: Wisconsin early intervention. Journal of
Community Psychology, 18, 167–177.
Lau, J. Y. F., Rijsdijk, F., Gregory, A. M., McGuffin, P., &
Eley, T. C. (2007). Pathways to childhood depressive
symptoms: The role of social, cognitive and genetic
risk factors. Developmental Psychology, 43(6),
1402–1414.
Lewinsohn, P. M. (1974). A behavioral approach to
depression. In R. Friedman & M. Katz (Eds.), The
psychology of depression: Contemporary theory and
research (pp. 157–185). Washington, DC: WinstonWiley.
Luby, L. (2009). Early childhood depression. American
Journal of Psychiatry, 166, 974–979.
Luby, J., Lenze, S., & Tillman, R. (2012). A novel early
intervention for preschool depression: Findings from
a pilot randomized controlled trail. Journal of Child
Psychological
Psychiatry,
53(3),
313–322.
doi:10.1111/j.1469-7610.2011.02483.x.
Luby, J. L., Si, X., Belden, A. C., Tandon, M., &
Spitznagel, E. (2009). Preschool depression.
Homotypic continuity and course over 24 months.
Archives of General Psychiatry, 66(8), 897–905.

634
Luking, K. R., Repovs, G., Beldon, A. C., Gaffrey, M. S.,
Botteron, K. N., Luby, J. L., et al. (2011). Functional
connectivity of the amygdala in early childhood onset
depression. American Academy of Child & Adolescent
Psychiatry, 50(10), 1027–1041.
Main, M. (1996). Overview of the field of attachment.
Journal of Consulting and Clinical Psychology, 64,
237–243.
Maletic, V., Robinson, M., Oakes, S., Iyengar, S., Ball,
S. G., & Russell, J. (2007). Neurobiology of depression: An integrated view of key findings. International
Journal of Clinical Practice, 61(12), 2030–2040.
doi:10.1111/j.1742-1241.2007.01602.x.
Merry, S. N., McDowell, H. H., Hetrick, S. E., Bir, J. J., &
Muller, N. (2009). Psychological and/or educational
interventions for the prevention of depression in children and adolescents. Cochrane Database of Systematic Reviews, 2004(2), 1–69. doi:10.1002/14651858.
CD003380.pub2.
Michael, K. D., & Crowley, S. L. (2002). How effective
are treatments for child and adolescent depression?
A meta-analytic review. Clinical Psychology Review,
22, 247–269.
Munoz, R. F., Beardslee, W. R., & Leykin, Y. (2012).
Major depression can be prevented. American Psychologist, 67(4), 285–295. doi:10.1037/a0027666.
Nelson, E. L., Barnard, M., & Cain, S. (2003). Treating
childhood depression over videoconferencing. Telemedicine Journal & e-Health, 9, 49–55.
Pattison, C., & Lynd-Stevenson, R. M. (2001). The prevention of depressive symptoms in children: The intermediate and long-term outcomes of a school based
program. Behaviour Change, 18, 92–102.
Peterson, A. C., Leffert, N., Graham, B., Alwin, J., &
Ding, S. J. L. (1997). Promoting mental health during
the transition into adolescence. In J. Schulenberg, J. L.
Maggs, & A. K. Hierrelmann (Eds.), Health risks and
developmental transitions during adolescence
(pp. 471–497). New York: Cambridge University
Press.
Peterson, C., & Seligman, M. E. (1984). Causal explanations as a risk factor for depression: Theory and evidence. Psychological Review, 91(3), 347–374.
Porter, C. L., & Hsu, H. (2003). First-time mothers’ perceptions of efficacy during the transition to motherhood: Links to infant temperament. Journal of Family
Psychology, 17(10), 54–64. doi:10.1037/08933200.17.1.54.
Quayle, D., Dziurawiec, S., Roberts, C., Kane, R., &
Ebsworthy, G. (2001). The effect of an optimism and
life skills program on depressive symptoms in preadolescence. Behavior Change, 18, 194–203.
Rapee, R. M., Wignall, A., Spence, S., Lyneham, H., &
Cobham, V. (2008). Helping your anxious child. A step
by step guide for parents. Oakland, CA: New Harbinger Publications.
Rehm, L. P., & Sharp, R. N. (1996). Strategies in the
treatment of childhood depression. In M. Reinecke,
F. M. Dattilio, & A. Freeman (Eds.), Comprehensive

Depression During Childhood
casebook on cognitive behaviour therapy with adolescents (pp. 103–123). New York: Guilford.
Rishel, C. W. (2012). Pathway to prevention for children
of depressed mothers: A review of the literature and
recommendations for practice. Depression Research
and Treatment, 2012, 1–11. doi:10.1155/2012/313689.
Roberts, C., Bishop, B., & Rooney, R. (2008). Depression
and bipolar disorder in childhood. In T. P. Gullotta &
G. M. Blau (Eds.), Handbook of childhood behavioral
issues. Evidenced-based approaches to prevention and
treatment (pp. 239–271). New York: Taylor and Francis.
Roberts, C. M., Kane, R., Bishop, B., Cross, D., Fenton, J.,
& Hart, B. (2010). The prevention of anxiety and
depression in disadvantaged schools. Behaviour
Research and Therapy, 48, 68–73.
Roberts, C. M., Kane, R., Thomson, H., Bishop, B., &
Hart, B. (2003). The prevention of depressive symptoms in rural school children: A randomized controlled
trial. Journal of Consulting and Clinical Psychology,
71, 622–628.
Roberts, C., Williams, R., Kane, R., Pintabona, Y., Cross,
D., Zubrick, S., et al. (2011). Impact of a mental health
promotion program on substance use in young adolescents. Advances in Mental Health, 10(1), 72–82.
Rooney, R., Roberts, C. M., Kane, R., Pike, L., Winsor, A.,
White, J., et al. (2006). The prevention of depression in
8–9 year old children. A pilot study. Australian Journal of Guidance and Counselling, 16(1), 76–90.
Rudolph, K. D., Hammen, C., Burge, D., Lindberg, N.,
Herzberg, D., & Daley, S. E. (2000). Toward an interpersonal life-stress model of depression: The developmental context of stress generation. Development and
Psychopathology, 12, 215–234.
Sharpley, C. F. (2010). A review of the neurobiological
effects of psychotherapy for depression. Psychotherapy: Theory, Research, Practice, Training, 47(40),
603–615.
Stark, K. D., Hargrave, J., Hersh, B., Greenberg, M.,
Herren, J., & Fisher, M. (2008). Treatment of childhood depression: The ACTION Treatment Program. In
K. D. Stark, J. Herren, & M. Fisher (Eds.), The handbook of depression in children and adolescents
(pp. 169–528). New York: Guilford.
Stark, K., Reynolds, W., & Kaslow, N. (1987).
A comparison of the relative efficacy of self-control
therapy and a behavioural problem solving therapy for
depression in children. Journal of Abnormal Child
Psychology, 15, 91–113.
Stark, K., Rouse, L., & Livingston, R. (1991). Treatment
of depression during childhood and adolescence: Cognitive behaviour therapy for individuals and family. In
I. P. C. Kendall (Ed.), Child and adolescent therapy
(pp. 165–206). New York: Guildford.
Stark, K. D., Schnoebelen, S., Simpson, J., Hargrave, J.,
Molnar, J., & Glen, R. (2007). Treating depressed
youth: Therapist manual for action. Ardmore, PA:
Workbook Publishing.
Stice, E., Shaw, H., Bohon, C., Nathan Marti, C., &
Rohde, P. (2009). A meta-analytic review of

Depression During Childhood
depression prevention programs for children and adolescents: Factors that treatment program predict magnitude of intervention effects. Journal of Consulting
and Clinical Psychology, 77(3), 486–503.
Swannell, S., Hand, M., & Martin, G. (2009). The effects
of a universal mental health promotion programme on
depressive symptoms and other difficulties in Year
Eight high school students in Queensland, Australia.
School Mental Health, 4, 229–239.
Topper, M., Emmelkamp, P. M. G., & Ehring, T. (2010).
Improving prevention of depression and anxiety disorders: Repetitive negative thinking as a promising target. Applied and Preventative Psychology, 14, 57–71.
Trowell, J., Joffe, I., Campbell, J., Clemente, C.,
Almquist, F., Soinen, M., et al. (2007). Childhood
depression. A place for psychotherapy. An outcome
study comparing individual psychodynamic psychotherapy & family therapy. European Child and Adolescent Psychiatry, 16, 157–167.
Vostanis, P., Feehan, C., & Grattan, E. (1996). Two-year
outcome of children treated for depression. European
Child and Adolescent Psychiatry, 7, 12–18.

635
Weisz, J. R., & Jensen, A. L. (2001). Child and adolescent
psychotherapy in research and practice contexts:
Review of the evidence and suggestions for improving
the field. European Child & Adolescent Psychiatry, 10,
12–18.
Weisz, J. R., & Kazdin, A. E. (2010). Evidence-based
psychotherapies for children and adolescent
(2nd ed.). New York: Guilford Press.
Weisz, J. R., Rudolph, K. D., Granger, D. A., &
Sweeney, L. (1992). Cognition, competence, and
coping in child and adolescent depression: Research
findings, developmental concerns, therapeutic implications. Development and Psychopathology, 4, 627–627.
Weisz, J. R., Sweeney, L., Proffitt, V., & Carr, T. (1993).
Control-beliefs and self-reported depressive symptoms in late childhood. Journal of Abnormal Psychology, 102, 411–418.
Weisz, J. R., Thurber, C. A., Sweeney, L., Proffitt, V. D.,
& LeGagnoux, G. L. (1997). Brief treatment of
mild-to-moderate child depression using primary and
secondary control enhancement training. Journal of
Consulting and Clinical Psychology, 65, 703–707.

636

Drug Abuse Prevention Programs
for Children
Adam E. Barry
Department of Health Education & Behavior,
University of Florida, Gainesville, FL, USA

Introduction
Today’s youth are exposed to, and engage in,
many health and safety risks including substance
use, violence, unintentional injuries such as
motor vehicle crashes, and risky sexual behaviors. These health risks become even more
salient concerns when considering behavioral
patterns are established during the transition
from childhood to adulthood (Centers for Disease Control and Prevention [CDC], 2011).
Thus, the choices made during this time of life
have the potential to affect current and future
health status. Among those choices, alcohol,
tobacco, and other drug (ATOD) use are especially prominent. For instance, youth ATOD use
has been linked to physical violence,
unintentional injuries, illegal behaviors, as well
as academic and occupational problems (Substance Abuse and Mental Health Services
Administration, 1999). Moreover, adolescent
substance use can have lasting impacts on brain
development, negatively affecting motivation
and emotional regulation (Zucker, 2006).

Definition and Scope
The Centers for Disease Control’s Youth Risk
Behavior Survey (YRBS) monitors the foremost
health risk behaviors (e.g., tobacco use, alcohol
and other drug use, sexual risk behaviors,
unhealthy dietary behaviors, and physical inactivity) contributing to death and disability among
America’s youth. Conducted biennially since
1991, YRBS provides nationally representative
data on 9th to 12th grade students attending both
public and private secondary schools throughout
the United States using a three-stage, cluster

Drug Abuse Prevention Programs for Children

sample design. In the first stage, large-sized
counties or groups of smaller adjacent counties
are selected. Secondly, schools are then selected
from the identified counties. In the third stage,
a random sample of one or two entire classes is
chosen from each school (CDC, 2004).
In regard to tobacco use, approximately 46 %
have tried smoking cigarettes. Nearly 20 % of
youth smoked cigarettes at least 1 day in the
past month, while 9 % used smokeless tobacco
products (i.e., dip, snuff, chewing tobacco)
(CDC, 2010b). National smoking trends of
school-aged youth between 1991 and 2009 indicate a marked drop in lifetime use of cigarettes.
Specifically, approximately 46 % had ever
smoked in 2009, compared to 70 % in 1991
(CDC, 2010a). An even greater percentage of
youth have consumed at least one drink of alcohol in their lifetime (72 %). Approximately 24 %
of students have binge drank (five or more drinks
of alcohol in a row within a couple of hours),
while nearly 5 % had consumed at least one alcoholic beverage on school property on at least
1 day (CDC, 2010a). While alcohol use (ever
drank, binge drinking, and drinking on school
campus) among American youth in grades 9–12
has steadily declined since 1991, there is currently no difference between national trends
between 2007 and 2009 (CDC, 2010a). Nationally, approximately 37 % of students have used
marijuana one or more times in their life, 6.4 %
had used cocaine in any form (e.g., powder,
crack, freebase), 6.7 % had used ecstasy, and
11.7 % had used an inhalant (i.e., sniffed glue,
breathed the contents of aerosol spray cans, or
inhaled any paints or sprays to get high) (CDC,
2010a).
The Monitoring the Future (MTF) project
also represents an excellent reference for tracking the ATOD use of students. Instituted in
1975, the University of Michigan’s Institute for
Social Research has continued to survey a large,
nationally representative sample of adolescent
students in 130 public and private secondary
schools throughout the continental United States
(Johnston, O’Malley, Bachman, & Schulenberg,
2004). Originally designed to survey a national
sample of high school seniors, the project was

T.P. Gullotta, M. Bloom (eds.), Encyclopedia of Primary Prevention and Health Promotion,
DOI 10.1007/978-1-4614-5999-6, # Springer Science+Business Media New York 2014

Drug Abuse Prevention Programs for Children

expanded in 1991 to include eighth and tenth
grade students as well (Johnston et al., 2004).
From its inception, the MTF project was
designed with two unified factors: (1) yearly
nationwide surveys of high school seniors and
(2) recurrent follow-up surveys mailed to subsamples of each senior class cohort. Utilizing a
multistage area probability sample, a representative cross section of eighth, tenth, and twelfth
grade students is surveyed throughout the
United States each year. Stage one involves
selecting geographical areas to be used in the
study. High schools are then selected from identified geographical areas. Stage three then elects
students from the high schools identified in stage
two. Eighth and tenth grade student questionnaires are completely anonymous, while senior
respondents are asked to provide their name and
mailing address on separate forms to provide
a later opportunity for mailing follow-up surveys. These follow-up surveys afford investigators the ability to link individuals’ longitudinal
data to their senior-year information (Bachman,
Johnston, & O’Malley, 2001). Content areas
addressed by the MTF project include beliefs
concerning personal lifestyle, school performance and satisfaction, intergroup and interpersonal attitudes, and behaviors, attitudes, and
beliefs related to alcohol and other drug use
(Bachman et al., 2001).

Theories
Historically, many of the early prevention
efforts aimed at preventing or offsetting adolescent ATOD use either were atheoretical, guided
primarily by conventional wisdom, or lacked
rigorous evaluative research (DeJong, 2007).
Some previous (ineffective) paradigms common
to ATOD prevention include the knowledge
model (Kluger & Gallant, 2000), the social influence skill-building model (Shope, Copeland,
Kamp, & Lang, 1998), and the affective model
(Hansen & Graham, 1991). Current efforts,
however, recognize the importance of environment in shaping individual behavior. Thus,
prevention programs are recommended to

637

intervene at three levels: the intrapersonal, interpersonal, and community/institutional levels.
Such approaches are grounded in the socialecological perspective, recognizing that behavior is influenced by environmental and organizational factors in addition to personal factors
(McLeroy, Bibeau, Steckler, & Glanz, 1988).
For instance, the Higher Education Center for
Alcohol and Other Drug Abuse and Violence
Prevention has advocated for administrators to
expand prevention programming beyond traditional education and treatment programs, focusing on the consideration and integration of the
campus environment (DeJong, 2007). Consequently, it is clear that health practitioners and
administrators have been encouraged to adopt
approaches employing a social-ecological
framework (DeJong, 2007; DeJong & Langford,
2002; Stokols, 1996). The social-ecological perspective emphasizes that (1) “behavior both
affects, and is affected by, multiple levels of
influence” (National Cancer Institute [NCI],
2005, p. 10) and (2) “individual behavior both
shapes, and is shaped by, the social environment” (NCI, 2005, p. 10).
In addition to ecological perspectives, developmental perspectives are also driving current
ATOD prevention efforts. Developmental
changes can be classified into age-related segments (e.g., prenatal, early childhood, middle
childhood, adolescence, emerging adulthood),
developmental tasks and accomplishments (e.g.,
attachment, talking, learning to count, adjusting
to school, engaging in rule-abiding behavior,
achieving academic success, graduating from
high school, achieving higher education or vocational training), levels of functioning (e.g., biological,
cognitive, and
social-emotional
processes), or contextual changes (e.g., physical,
social, societal/cultural, and media/virtual environments) (Masten, Faden, Zucker, & Spear,
2009). Several conceptual models outlining the
relationship between developmental transitions
and substance abuse have been proposed
(Schulenberg & Maggs, 2002), including:
– The Overload Model: posits that health risks
result from experiencing multiple developmental transitions within a short time period

638

– The Developmental Mismatch Model: posits
that transitions alter the match between individuals and their contexts
– The Increased Heterogeneity Model: posits
that difficult transitions amplify existing
strengths and weaknesses
– The Transition Catalyst Model: posits that risk
taking itself is an important component to
navigating certain transitions
– The Heightened Vulnerability to Change
Events Model: posits that many difficulties
are relatively unpredictable, acknowledging
the role of chance in altering one’s life course
(Schulenberg & Maggs, 2002)
For a more extensive coverage of the key
developmental themes relating to the etiology of
substance use among adolescents and young
adults, please see Schulenberg and Maggs
(2001) and Schulenberg, Maggs, Steinman, and
Zucker (2001).

Research
In 2006, the National Institute on Alcohol Abuse
and Alcoholism (NIAAA) published a 5-year
strategic plan, entitled The NIAAA Strategic
Plan for Research. This strategic plan introduced a new organizing framework within
which to examine the impact of drinking on
people at different stages of development: the
Lifespan Perspective (National Institute on
Alcohol Abuse and Alcoholism [NIAAA],
2008). In terms of youth and adolescence, there
are several areas of emphasis. These research
areas include (a) exploring how social changes
associated with adolescence contribute to alcohol use, (b) exploring how biological changes
during adolescence impact drinking behaviors,
(c) exploring how alcohol influences the brain
of maturing young adults, and (d) the factors
(i.e., social, familial, biological) which may
increase risk of developing alcohol-related problems. Additionally, researchers continue to
develop diagnoses and screening instruments
for alcohol abuse/dependence, as well as refine
current definitions of alcohol use/misuse
(NIAAA, 2008).

Drug Abuse Prevention Programs for Children

Strategies
Traditionally, the vast majority of prevention
programs have been conducted in the school setting. However, prevention programs continue to
expand not only in scope but also in setting.
While most ATOD prevention programs continue to be conducted in the school, there are
a growing number of prevention programs
aimed at influencing the home setting. This
expansion is logical considering “the critical
role of the family is acknowledged in virtually
every psychological theory of child development” (Kumpfer & Alvarado, 2003, p. 457).
That said, there remains a paucity of practitioners
implementing family-strengthening programs in
comparison to school-based approaches
(Kumpfer & Alvarado). As a result, some contend “family-based interventions are still in their
infancy” (Fiese, 2005, p. 629). Many prevention
programs are multimodal, incorporating numerous components and sites. To be considered
family-based, interventions usually include
a large family component such as home visits
aimed at parental education (i.e., infant care,
developmental milestones, nutrition), skills training (i.e., developing relationships and fostering
cognitive and emotional growth), and/or
counseling.
The National Institute on Drug Abuse (NIDA)
proposes several guiding “prevention principles”
(grounded in the findings of previously funded
research projects) for ATOD programs (National
Institute on Drug Abuse [NIDA], 2003). The
following principles are common elements
found among effective ATOD prevention
programs:
Risks and Protective Factors
1. Enhance protective factors (e.g., parental
support) and reverse/reduce risk factors
(e.g., deviant behaviors such as truancy):
(a) The impact of specific risk/protective
factors changes with age. For instance,
familial risk factors are more powerful
among a younger child, while peer
relationships are more powerful among
adolescents.

Drug Abuse Prevention Programs for Children

(b) The earlier one can intervene with risk
factors, the greater possible impact and
likelihood of altering a child’s life course
development and trajectory.
(c) The impact of risk/protective factors
varies as a function of one’s age, gender,
ethnicity, culture, and/or environment.
2. Address all forms of drug abuse:
(a) Prevention programs should include the
use of licit (alcohol and tobacco) and illicit
(marijuana, cocaine, heroin) drugs, as well
as the inappropriate use/abuse of prescription medicines and other legally obtained
substances (inhalants).
3. Address drug abuse issues pertinent to the
local community, target modifiable risk factors, and strengthen protective factors.
4. Tailor prevention programs to address specific
risk factors among the population/audience
at hand.
Prevention Planning: Family Programs
5. Enhance family bonding and relationships:
(a) Parental monitoring and supervision (e.g.,
rule setting, consistent discipline, rewards/
praise for appropriate behavior) should be
a focus.
(b) Parents should be knowledgeable on drug
education issues (e.g., harmful effects) so
family discussions can reinforce schoolbased learning.
Prevention Planning: School Programs
6. Intervene early (i.e., preschool or elementary
school) to address drug abuse risk factors.
7. For elementary school children, prevention
programs should target academic and socialemotional learning. Programmatic focus
should be on improving the following skills:
(a) Self-control
(b) Emotional awareness
(c) Communication
(d) Social problem-solving
(e) Academic support
8. For middle, junior high, and/or high school
students, programs should target academic
(e.g., study habits and academic support)
and social competence skills (e.g.,

639

communication, peer relationships, assertiveness, self-efficacy, and antidrug attitudes).
Prevention Planning: Community Programs
9. Prevention programs should target key life
transition times, such as the transition from
elementary to middle school, applicable to all
risk populations.
10. Combine two or more modes (e.g., familyand school-based) of effective prevention
programs. When used in combination, these
can be more effective than a single program
alone.
11. Present a consistent, community-wide message to populations through multiple settings/outlets (e.g., schools, faith-based
organizations, media).
Prevention Program Delivery
12. When adapting research-based interventions
for use in a new community, core elements
should be retained, even though modifications will be needed to address unique
needs, norms, and cultural requirements.
Core elements are associated with:
(a) Structure (organization and construction)
(b) Content (information, skills, and
strategies)
(c) Delivery (adaption, implementation, and
evaluation)
13. Prevention programs should be long term in
scope, supplemented with booster programs
(repeated interventions to reinforce original
prevention goals).
14. Include teacher training on good classroom
management practices aimed at fostering
academic motivation, school bonding, and
achievement.
15. Employ interactive techniques that allow for
active involvement.
16. For every dollar invested into prevention,
a savings of ten dollars is realized in the
treatment of substance abuse.
Readers specifically interested in evidencebased family approaches should consult reviews
conducted by the National Institute of Justice’s
Office of Juvenile Justice and Delinquency Prevention (Alvarado & Kumpfer, 2000) and Center

640

Drug Abuse Prevention Programs for Children

All of the programs presented below fall under
the Institute of Medicine’s (IOM, 1994) designation of “universal” target audience. In other
words, these programs do not have specialized
focus on any one “selective” or “indicated” population. Programs are presented based on the age
group for whom they were designed.

[(4) “homeside activities”] approaches. Studies
examining the effectiveness of the Caring
School Community program include:
Battistich, Schaps, Watson, Solomon, and
Lewis (2000); Solomon, Battistich, Watson,
Schaps, and Lewis (2000); Munoz and
Vanderhaar (2006); Chang and Munoz
(2006); and Marshall and Caldwell (2007).
• Promoting Alternative THinking Strategies
(PATHS) (Greenberg & Kusche, 1998).
PATHS, a school-based prevention program,
seeks to promote emotional health and social
competencies, reduce aggression and behavior
problems, and enhance the educational process. PATHS is designed to facilitate the
development of self-control, emotional awareness, and interpersonal problem-solving skills.
Program activities are various, including
instruction, storytelling, and role-play. Curriculum is taught by classroom teachers roughly
three times per week and encompasses 131
20- to 30-min sessions. Studies examining the
effectiveness of PATHS include: Greenberg,
Kusché, Cook, and Quamma (1995); Kam,
Greenberg, and Kusché (2004); Riggs,
Greenberg, Kusché, and Pentz (2006); and
Domitrovich, Cortes, and Greenberg (2007).

Elementary School
• Caring
School
Community
Program
(Formerly Known as the Child Development
Project) (Battistich, Solomon, Watson, &
Schaps, 1997; U.S. Department of Education,
2001). This family-plus-school program is
designed to reduce risk factors and reinforce
protective factors by focusing on strengthening
students’ core values, pro-social behavior, and
school-wide feeling of community (i.e., school
connectedness). By emphasizing a caring
school environment, the program seeks to
promote academic achievement and motivation
while preventing delinquent behaviors like
drug use, violence, and truancy. The fourcomponent program is comprised of
a mutually reinforcing set of classroom, school
[(1) cross-age “buddies,” (2) class meeting lessons, and (3) school-wide community building
activities],
and
family
involvement

Middle School
• Guiding Good Choices (Formerly Known as
Preparing for the Drug Free Years) (Hawkins,
Catalano, Kosterman, Abbott, & Hill, 1999;
Kosterman, Hawkins, Spoth, Haggerty, &
Zhu, 1997). A drug use prevention program
in which the curriculum seeks to strengthen
family bonding and educate parents on how to
reduce risk factors. Consisting of five 2-h
skill-based sessions, parents of children ages
9–14 are taught how to (a) create
age-appropriate family involvement/interaction opportunities, (b) apply consistent discipline and monitoring, (c) teach coping
strategies, (d) apply conflict management/resolution approaches, and (e) enhance family
bonding through positive expression of feelings. Studies examining the effectiveness
of Guiding Good Choices include:
Kosterman, Hawkins, Haggerty, Spoth, and

for Substance Abuse Prevention (1998). Kumpfer
and Alvarado (2003) summarize effective
family-focused intervention approaches as
follows:
1. Behavioral parent training: small groups of
parents are guided through a curriculum ranging from 6 to 15 sessions by a skilled trainer.
2. Family skills training: a multicomponent
approach including (a) the aforementioned
behavioral parent training, (b) social and life
skills training for children, and (c) practice
sessions incorporating the entire family.
3. Family therapy: therapy session implemented
by highly trained/licensed mental health practitioners who focus on individual family units,
as opposed to a group of families.

What Works

Drug Abuse Prevention Programs for Children

Redmond (2001); Mason, Kosterman,
Hawkins, Haggerty, and Spoth (2003);
Mason et al. (2007); Park et al. (2000);
Spoth, Redmond, and Shin (2001); and
Spoth, Redmond, Shin, and Azevedo (2004).
• Life Skills Training Program (Botvin, Baker,
Dusenbury, Botvin, & Diaz, 1995; Botvin,
Epstein, Baker, Diaz, & Ifill-Williams, 1997;
Botvin, Griffin, Paul, & Macaulay, 2003).
This 3-year school-based prevention program
seeks to prevent ATOD use and violence. The
program’s curriculum focuses on addressing
both risk and protective factors by teaching
personal and social skills, drug resistance
skills, and normative education. First-year
sessions (15 total) are followed by booster
sessions in years two (10) and three (5).
Major content areas include drug resistance,
self-management, and general social skills.
Session activities range from structured
small-group activities to role-playing
scenarios. Studies examining the effectiveness
of the Life Skills Training Program include:
Botvin, Griffin, Diaz, and Ifill-Williams
(2001a, 2001b); Griffin, Botvin, Nichols, and
Doyle (2003); Spoth, Randall, Trudeau, Shin,
and Redmond (2008); Trudeau, Spoth,
Lillehoj, Redmond, and Wickrama (2003);
and Botvin, Griffin, and Nichols (2006).
High School
• Project ALERT (U.S. Department of Education, 2001). A school-based ATOD prevention
program which seeks to prevent abstainers from
initiating ATOD use and decrease use/abuse
among those who have already initiated
ATOD use. Encompassing 14 sessions (11 lessons in year one and 2 in year two), students
participate in small-group activities, roleplaying, and new skill rehearsals. Studies
examining the effectiveness of Project
ALERT include: Ellickson and Bell (1990);
Ellickson, Bell, and Harrison (1993); Ellickson,
Bell, and McGuigan (1993); Ellickson, Bell,
Thomas, Robyn, and Zellman (1988);
Ellickson, McCaffrey, Ghosh-Dastidar, and
Longshore (2003); and Ghosh-Dastidar,
Longshore, Ellickson, and McCaffrey (2004).

641

In addition to the aforementioned universal
programs, there are many “selective” programs
(focusing on one group, in particular) that have
also been shown to be effective. For instance, the
multicomponent Adolescents Training and Learning to Avoid Steroids (ATLAS) program
(U.S. Department of Education, 2001) focuses on
reducing risk factors for anabolic steroid use
among high school male athletes. Moreover,
ATLAS seeks to provide alternatives to
performance-enhancing substance use, such as
healthy sports nutrition and strength-training alternatives. Studies examining the effectiveness of
ATLAS include: Goldberg et al. (2000); Goldberg,
Elliot, Clarke, MacKinnon, Moe, et al. (1996);
Goldberg, Elliot, Clarke, MacKinnon, Zoref,
et al. 1996; and MacKinnon et al. (2001).

What Is Promising
Programs are presented based on the age group
for whom they were designed.
Elementary School
• Linking the Interests of Families and Teachers
(Eddy, Reid, & Fetrow, 2000) is a 10-week
program including 20 1-h sessions designed to
improve overall social skills, preventing the
development of aggressive and antisocial
behavior. Overall, the program seeks to target
the antecedents of youth delinquency and violence. The program itself is comprised of three
primary elements: (1) classroom-based social
and problem-solving skills, (2) playgroundbased behavior modification, and (3) groupdelivered parent training. Sessions are held
during the regular school day. Studies examining the effectiveness of Linking the Interests
of Families and Teachers include: Reid, Eddy,
Fetrow, and Stoolmiller (1999) and DeGarmo,
Eddy, Reid, and Fetrow (2009).
Middle School
• All Stars (Hansen, 1996) is a multiyear
character education school-based program
focusing on (1) helping students identify how
high-risk behaviors interfere with desired

642

lifestyle and positive ideals, (2) increasing
norm of abstinence among peers, (3) building
strong personal commitments to refrain from
ATOD use, (4) developing greater bonding/
attachment with school and family, and
(5) increasing positive parental attentiveness
and monitoring. The curriculum features 13
45-min weekly sessions aimed at modifying
targeted mediating variables. Sessions employ
activities ranging from interactive group
activities, games, art projects, and smallgroup discussions. Studies examining the
effectiveness of All Stars include: Harrington,
Giles, Hoyle, Feeney, and Yungbluth (2001)
and McNeal, Hansen, Harrington, and
Giles (2004).
• Lions-Quest Skills for Adolescence (Eisen,
Zellman, Massett, & Murray, 2002). This
multicomponent 80-session (approximately
45 min each) life skills education program
teaches cognitive-behavioral skills for building
self-esteem, personal responsibility, communication, decision-making, resisting social influences, and increasing knowledge of the
negative impacts of drug use. Overall, the program seeks to promote positive family, peer,
school, and community commitment. Activities vary, including but not limited to guided
practice, service learning, inquiry, and reflection. Studies examining the effectiveness of the
Lions-Quest Skills for Adolescence include:
Laird and Roden (1991); Laird (1992); and
Eisen, Zellman, and Murray (2003).
High School
• Teenage Health Teaching Modules is
a comprehensive school-based health curriculum composed of three primary elements
which seek to engrain seven essential life
skills: (1) adolescent health tasks (e.g., building positive relationships with peers, recognizing and managing feelings), (2) health
content areas (e.g., ATOD use), and (3) health
skills (e.g., risk assessment, decision-making,
goal setting, self-management). The curriculum is an interactive, student-centered
approach to health instruction encompassing
14 modules. Each module contains between

Drug Abuse Prevention Programs for Children

10 and 15 sessions, with each session lasting
approximately 45 min. Studies examining the
effectiveness of the Teenage Health Teaching
Modules include: Errecart et al. (1991); Parcel
et al. (1991); Ross, Gold, et al. (1991); and
Ross, Luepker, et al. (1991).
Readers interested in searching for ATOD
prevention programs are directed to the following
two sources:
1. Substance Abuse and Mental Health Service
Administration’s National Registry of
Evidence-based Programs and Practices
(http://www.nrepp.samsha.gov/). The registry
includes a searchable database of approximately 150 prevention and treatment programs that have been rated by independent
reviewers.
2. Office of Juvenile Justice and Delinquency
Prevention’s Model Programs Guide (http://
www.ojjdp.gov/mpg/). The database includes
over 200 evidence-based programs spanning
prevention to youth services.

What Does Not Work
Depending on the circumstances surrounding the
implementation of an ATOD prevention program, it is possible for previously effective or
promising programs to be ineffective. However,
there are common program elements that consistently fail to produce a positive impact. These
elements include:
• Personal accounts or testimonies
• One-time assemblies/events/speakers
• Fear-based (e.g., scare) tactics
• Strictly knowledge provision
• Affective curriculum promoting only selfesteem (Anderson, Aromaa, & Rosenbloom,
2007; De Haes, 1987; Drug Strategies, 1999)

Summary
As is evident among many of the effective drug
abuse programs presented above (see the “What
Works” and “What is Promising” sections),
school connectedness represents a common

Drug Abuse Prevention Programs for Children

conceptual element. In fact, the Centers for Disease Control and Prevention’s (CDC) Division of
Adolescent and School Health (DASH) identifies
focusing on school connectedness as a promising
approach to addressing many health risk behaviors (CDC, 2009). DASH outlines the following
specific strategies as ways to promote school
connectedness (CDC, 2009, p. 9):
1. Create decision-making processes that facilitate student, family, and community engagement; academic achievement; and staff
empowerment.
2. Provide education and opportunities to enable
families to be actively involved in their children’s academic and school life.
3. Provide students with the academic, emotional, and social skills necessary to be
actively engaged in school.
4. Use effective classroom management and
teaching methods to foster a positive learning
environment.
5. Provide professional development and support
for teachers and other school staff to enable
them to meet the diverse cognitive, emotional,
and social needs of children and adolescents.
6. Create trusting and caring relationships that
promote open communication among administrators, teachers, staff, students, families,
and communities.
As is evident from the aforementioned strategies, adult support, adolescent sense of belonging, commitment to education, and the school
environment are salient issues directly influencing school connectedness. Interested readers are
directed to the CDC’s School Connectedness:
Strategies for Increasing Protective Factors
Among Youth (2009) for supporting action steps
for six strategies listed above.
Considering school connectedness can be promoted through engaging students in open communication with teachers, staff, administrators,
and peers, interactivity represents a key concern
for school-based drug prevention programs.
Tobler et al. (2000) distinguish interactive
school-based drug prevention programs as those
providing “contact and communication opportunities for the exchange of ideas among participants and encourage learning drug refusal skills”

643

(p. 287). As school-based drug prevention programs increase interactivity, students become
less likely to use licit and illicit substances. In
other words, maximizing communication among
students and school officials increases the likelihood that students will be prevented from using
alcohol, tobacco, and other drugs (Soole,
Mazerolle, & Rombouts, 2008). Furthermore,
student involvement in the delivery of
a prevention program – a potential strategy for
further enhancing school connectedness – is associated with improved efficacy of school-based
drug prevention programs (Tobler et al., 2000).
Overall, systematic meta-analyses indicate interactive (e.g., role-play, discussion, and student
interaction) school-based drug prevention programs result in significant reductions in alcohol
use, while noninteractive (e.g., structured, oral
presentations) programs fail to significantly
impact licit and/or illicit drug use (Cuijpers,
2003; Soole et al., 2008). Regardless of a drug
abuse prevention program’s format, structure, or
elements, researchers and practitioners alike are
encouraged to adopt the sentiments of No Child
Left Behind – only use those educational programs and practices that have been proven effective through rigorous scientific support. If
effective ATOD prevention programs are initiated nationwide, initiation into substance use
would be delayed for an average of 2 years and
decline for approximately 1.5 million youth
(Miller & Hendrie, 2009).

References
Alvarado, R., & Kumpfer, K. L. (2000). Strengthening
America’s families. Juvenile Justice, 7(2), 8–18.
Anderson, P., Aromaa, S., & Rosenbloom, D. (2007).
Prevention education in America’s schools: Findings
and recommendations from a survey of educators.
New York: Join Together.
Bachman, J. G., Johnston, L. D., & O’Malley, P. M.
(2001). The monitoring the future project after
27 years: Design and procedures (No. 54). Ann
Arbor, MI: Institute for Social Research.
Battistich, V., Schaps, E., Watson, M., Solomon, D., &
Lewis, C. (2000). Effects of the child development
project on students’ drug use and other problem behaviors. Journal of Primary Prevention, 21(1), 75–99.

644
Battistich, V., Solomon, D., Watson, M., & Schaps, E.
(1997). Caring school communities. Educational
Psychologist, 32(3), 137–151.
Botvin, G., Baker, E., Dusenbury, L., Botvin, E., &
Diaz, T. (1995). Long-term follow-up results of
a randomized drug-abuse prevention trial in a white
middle class population. Journal of the American
Medical Association, 273, 1106–1112.
Botvin, G., Epstein, J., Baker, E., Diaz, T., & IfillWilliams, M. (1997). School-based drug abuse prevention with inner-city minority youth. Journal of Child
and Adolescent Substance Abuse, 6, 5–19.
Botvin, G. J., Griffin, K. W., Diaz, T., & Ifill-Williams,
M. (2001a). Drug abuse prevention among minority
adolescents: Posttest and one-year follow-up of a
school-based preventive intervention. Prevention
Science, 2(1), 1–13.
Botvin, G. J., Griffin, K. W., Diaz, T., & Ifill-Williams, M.
(2001b). Preventing binge drinking during early adolescence: One- and two-year follow-up of a schoolbased preventive intervention. Psychology of
Addictive Behaviors, 15(4), 360–365.
Botvin, G. J., Griffin, K. W., & Nichols, T. R. (2006).
Preventing youth violence and delinquency through
a universal school-based prevention approach. Prevention Science, 7(4), 403–408.
Botvin, G., Griffin, K. W., Paul, E., & Macaulay, A. P.
(2003). Preventing tobacco and alcohol use among
elementary school students through Life Skills Training. Journal of Child and Adolescent Substance Abuse,
12(4), 1–18.
Center for Substance Abuse Prevention. (1998).
Preventing substance abuse among children and adolescents: Family-centered approaches Prevention
Enhancement Protocols System (PEPS) (DHHS
Publication No. SMA 3223-FY’98). Washington,
DC: U.S. Government Printing Office.
Centers for Disease Control and Prevention. (2004). Methodology of the youth risk behavior surveillance system. Morbidity and Mortality Weekly Report,
53(No. RR-12), 1–11.
Centers for Disease Control and Prevention. (2009).
School connectedness: Strategies for increasing protective factors among youth. Atlanta, GA:
U.S. Department of Health and Human Services.
Centers for Disease Control and Prevention. (2010a).
Trends in the prevalence of alcohol use: National
YRBS: 1991–2009. Atlanta, GA: U.S. Department of
Health and Human Services.
Centers for Disease Control and Prevention. (2010b).
YRBSS: 2009 national youth risk behavior survey
overview. Atlanta, GA: U.S. Department of Health
and Human Services.
Centers for Disease Control and Prevention. (2011). Adolescent health. Atlanta, GA: U.S. Department of
Health and Human Services.
Chang, F., & Munoz, M. A. (2006). School personnel
educating the whole child: Impact of character education on teachers’ self-assessment and student

Drug Abuse Prevention Programs for Children
development. Journal of Personnel Evaluation in Education, 19(1–2), 35–49.
Cuijpers, P. (2003). Three decades of drug prevention
research. Drugs: Education, Prevention and Policy,
10(1), 7–20.
De Haes, W. (1987). Looking for effective drug education
programmes: Fifteen years’ exploration of the effects
of different drug education programmes. Health Education Research, 2(4), 433–438.
DeGarmo, D. S., Eddy, J. M., Reid, J. B., & Fetrow, R. A.
(2009). Evaluating mediators of the impact of the
Linking the Interests of Families and Teachers
(LIFT) multimodal preventive intervention on substance use initiation and growth across adolescence.
Prevention Science, 10, 208–220.
DeJong, W. (2007). Experiences in effective prevention.
The U.S. Department of Education’s Alcohol and
Other Drug Prevention Models on College Campuses
Grants. Washington, DC: U.S. Department of Education, Higher Education Center for Alcohol and Other
Drug Abuse and Violence Prevention. Retrieved June
6, 2012, http://www.higheredcenter.org/pubs/effective-prevention.pdf
DeJong, W., & Langford, L. M. (2002). A typology for
campus-based alcohol prevention: Moving toward
environmental management strategies. Journal of
Studies on Alcohol, 14(Suppl.), 140–147.
Domitrovich, C. E., Cortes, R. C., & Greenberg, M. T.
(2007). Improving young children’s social and emotional competence: A randomized trial of the Preschool “PATHS” curriculum. Journal of Primary
Prevention, 28, 67–91.
Drug Strategies. (1999). Making the grade: A guide to
school drug prevention programs. Washington, DC:
Author.
Eddy, J. M., Reid, J. B., & Fetrow, R. A. (2000). An
elementary school-based prevention program targeting
modifiable antecedents of youth delinquency and violence: Linking the Interests of Families and Teachers
(LIFT). Journal of Emotional and Behavioral Disorders, 8(3), 165–176.
Eisen, M., Zellman, G. L., Massett, H. A., & Murray,
D. M. (2002). Evaluating the Lions-Quest “Skills for
Adolescence” drug education program: First-year
behavior outcomes. Addictive Behaviors, 27(4),
619–632.
Eisen, M., Zellman, G. L., & Murray, D. M. (2003).
Evaluating the Lions-Quest “Skills for Adolescence”
drug education program: Second-year behavior outcomes. Addictive Behaviors, 28, 883–897.
Ellickson, P. L., & Bell, R. M. (1990). Drug prevention in
junior high: A multi-site longitudinal test. Science,
247, 1299–1305.
Ellickson, P. L., Bell, R. M., & Harrison, E. R. (1993).
Changing adolescent propensities to use drugs: Results
from Project ALERT. Health Education Quarterly,
20(2), 227–242.
Ellickson, P. L., Bell, R. M., & McGuigan, K. (1993).
Preventing adolescent drug use: Long-term results of

Drug Abuse Prevention Programs for Children
a junior high program. American Journal of Public
Health, 83(6), 856–861.
Ellickson, P. L., Bell, R. M., Thomas, M. A., Robyn, A. E.,
& Zellman, G. L. (1988, December). Designing and
implementing Project ALERT: A smoking and drug
prevention experiment (R-3754-CHF, ISBN: 0-83300958-3). Santa Monica, CA: The RAND Corporation.
Retrieved June 19, 2012, from http://www.rand.org/
pubs/reports/R3754.html
Ellickson, P. L., McCaffrey, D. F., Ghosh-Dastidar, B., &
Longshore, D. L. (2003). New inroads in preventing
adolescent drug use: Results from a large-scale trial of
Project ALERT in middle schools. American Journal
of Public Health, 93(11), 1830–1836.
Errecart, M. T., Walberg, H. J., Ross, J. G., Gold, R. S.,
Fiedler, J. L., & Kolbe, L. J. (1991). Effectiveness of
teenage health teaching modules. Journal of School
Health, 61(1), 26–30.
Fiese, B. H. (2005). Introduction to the special issues:
Time for family-based intervention in pediatric psychology? Journal of Pediatric Psychology, 30(8),
629–630.
Ghosh-Dastidar, B., Longshore, D. L., Ellickson, P. L., &
McCaffrey, D. F. (2004). Modifying pro-drug risk
factors in adolescents: Results from Project ALERT.
Health Education & Behavior, 31(3), 318–334.
Goldberg, L., Elliot, D., Clarke, G. N., MacKinnon, D. P.,
Moe, E., Zoref, L., et al. (1996). Effects of
a multidimensional anabolic steroid prevention intervention. The Adolescents Training and Learning to
Avoid Steroids (ATLAS) Program. Journal of the
American Medical Association, 276(19), 1555–1562.
Goldberg, L., Elliot, D. L., Clarke, G. N., MacKinnon,
D. P., Zoref, L., Moe, E., et al. (1996). The Adolescents Training and Learning to Avoid Steroids
(ATLAS) prevention program. Background and
results of a model intervention. Archives of Pediatrics
and Adolescent Medicine, 150, 713–721.
Goldberg, L., MacKinnon, D. P., Elliot, D. L., Moe, E. L.,
Clarke, G., & Cheong, J. (2000). The Adolescents
Training and Learning to Avoid Steroids Program:
Preventing drug use and promoting health behaviors.
Archives of Pediatrics and Adolescent Medicine, 154,
332–338.
Greenberg, M. T., & Kusche, C. A. (1998). Preventive
interventions for school-age deaf children: The
PATHS curriculum. Journal of Deaf Studies and
Deaf Education, 3(1), 49–63.
Greenberg, M. T., Kusché, C. A., Cook, E. T., & Quamma,
J. P. (1995). Promoting emotional competence in
school-aged children: The effects of the PATHS curriculum. Development and Psychopathology, 7,
117–136.
Griffin, K. W., Botvin, G. J., Nichols, T. R., & Doyle, M. M.
(2003). Effectiveness of a universal drug abuse
prevention approach for youth at high risk for substance
use initiation. Preventive Medicine, 36(1), 1–7.
Hansen, W. B. (1996). Pilot test results comparing the All
Stars program with seventh grade D.A.R.E.: Program

645
integrity and mediating variable analysis. Substance
Use and Misuse, 31(10), 1359–1377.
Hansen, W. B., & Graham, J. H. (1991). Preventing alcohol, marijuana, and cigarette use among adolescents:
Peer pressure resistance training versus establishing
conservative norms. Preventive Medicine, 20,
414–430.
Harrington, N. G., Giles, S. M., Hoyle, R. H., Feeney, G. J., &
Yungbluth, S. C. (2001). Evaluation of the All Starts
character education and problem behavior prevention
program: Effects on mediator and outcome variables for
middle school students. Health Education & Behavior,
28(5), 533–546.
Hawkins, J. D., Catalano, R. F., Kosterman, R., Abbott, R.,
& Hill, K. G. (1999). Preventing adolescent health-risk
behaviors by strengthening protection during childhood. Archives of Pediatric & Adolescent Medicine,
153, 226–234.
Institute of Medicine. (1994). Reducing risks for mental
disorders: Frontiers for preventive intervention
research. Washington, DC: National Academy Press.
Johnston L. D, O’Malley, P. M., Bachman, J. G., &
Schulenberg, J. E. (2004). Monitoring the future
national results on adolescent drug use: Overview of
key findings, 2003 (No. 04-5506). Bethesda, MD:
National Institute on Drug Abuse.
Kam, C. M., Greenberg, M. T., & Kusché, C. A. (2004).
Sustained effects of the PATHS curriculum on the
social and psychological adjustment of children in
special education. Journal of Emotional and Behavioral Disorders, 12(2), 66–78.
Kluger, M. P., & Gallant, N. (2000). What works in
school-based substance abuse prevention: Interactive
or peer programs? In M. P. Kluger, G. Alexander, &
P. Curtis (Eds.), What works in child welfare
(pp. 329–335). Washington, DC: Child Welfare
League of America.
Kosterman, R., Hawkins, J. D., Haggerty, K. P., Spoth, R.,
& Redmond, C. (2001). Preparing for the Drug Free
Years: Session-specific effects of a universal parenttraining intervention with rural families. Journal of
Drug Education, 31(1), 47–68.
Kosterman, R., Hawkins, J. D., Spoth, R., Haggerty, K. P., &
Zhu, K. (1997). Effects of a preventive parent-training
intervention on observed family interactions: Proximal
outcomes from preparing for the Drug Free Years.
Journal of Community Psychology, 25(4), 337–352.
Kumpfer, K. L., & Alvarado, R. (2003). Familystrengthening approaches for the prevention of youth
problem behaviors. American Psychologist, 58(6/7),
457–465.
Laird, M. (1992). Evaluation of Lions-Quest “Skills for
Adolescence” program: An analysis of students’ attitudes, use patterns, and knowledge about harmful
drugs. Newark, OH: Quest International.
Laird, M., & Roden, J. (1991). Supplemental final report:
Additional technical analysis of data on quest’s skills
for adolescence program in Detroit schools. Newark,
OH: Quest International.

646
MacKinnon, D. P., Goldberg, L., Clarke, G. N., Elliot,
D. L., Cheong, J., Lapin, A., et al. (2001). Mediating
mechanisms in a program to reduce intentions to use
anabolic steroids and improve exercise self-efficacy
and dietary behavior. Prevention Science, 2(1), 15–28.
Marshall, J., & Caldwell, S. (2007). Caring School Community implementation study four-year evaluation
report. Rapid City, SD: Marshall Consulting.
Mason, W. A., Kosterman, R., Hawkins, J. D., Haggerty,
K. P., & Spoth, R. L. (2003). Reducing adolescents’
growth in substance use and delinquency: Randomized
trial effects of a preventive parent-training intervention. Prevention Science, 4(3), 203–212.
Mason, W. A., Kosterman, R., Hawkins, J. D.,
Haggerty, K. P., Spoth, R. L., & Redmond, C.
(2007). Influence of a family-focused substance use
preventive intervention on growth in adolescent
depressive symptoms. Journal of Research on Adolescence, 17(3), 541–564.
Masten, A. S., Faden, V. B., Zucker, R. A., & Spear, L. P.
(2009). Perspective on underage alcohol use. Alcohol
Research & Health, 32(1), 3–15.
McLeroy, K. R., Bibeau, D., Steckler, A., & Glanz, K.
(1988). An ecological perspective on health promotion
programs. Health Education Quarterly, 15(4),
351–377.
McNeal, R. B., Jr., Hansen, W. B., Harrington, N. G., &
Giles, S. M. (2004). How all stars works: An examination of program effects on mediating variables.
Health Education & Behavior, 31(2), 165–178.
Miller, T., & Hendrie, D. (2009). Substance abuse prevention dollars and cents: A cost-benefit analysis
(DHHS Pub. No. (SMA) 07-4298). Rockville, MD:
Center for Substance Abuse Prevention, Substance
Abuse and Mental Health Services Administration.
Munoz, M. A., & Vanderhaar, J. E. (2006). Literacyembedded character education in a large urban district:
Effects of the Child Development Project on elementary school students and teachers. Journal of Research
in Character Education, 4(1–2), 27–44.
National Cancer Institute. (2005). Theory at a glance:
A guide for health promotion practice (2nd ed.) (NIH
Publication No. 05-3896). Bethesda, MD:
U.S. Department of Health & Human Services:
National Institutes of Health.
National Institute on Alcohol Abuse and Alcoholism.
(2008). Alcohol research: A lifespan perspective.
Alcohol Alert, 74. Bethesda, MD: U.S. Department of
Health & Human Services: National Institutes of
Health.
National Institute on Drug Abuse. (2003). Preventing drug
use among children and adolescents: A researchbased guide for parents, educators, and community
leaders (2nd ed.). Bethesda, MD: U.S. Department of
Health and Human Services.
Parcel, G. S., Ross, J. G., Lavin, A. T., Portnoy, B.,
Nelson, G. D., & Winters, F. (1991). Enhancing implementation of the teenage health teaching modules.
Journal of School Health, 61(1), 35–38.

Drug Abuse Prevention Programs for Children
Park, J., Kosterman, R., Hawkins, J. D., Haggerty, K. P.,
Duncan, T. E., Duncan, S. C., et al. (2000). Effects of
the “Preparing for the Drug Free Years” curriculum on
growth in alcohol use and risk for alcohol use in early
adolescence. Prevention Science, 1(3), 125–138.
Reid, J. B., Eddy, J. M., Fetrow, R. A., & Stoolmiller, M.
(1999). Description and immediate impacts of
a preventive intervention for conduct problems.
American Journal of Community Psychology, 27(4),
483–517.
Riggs, N. R., Greenberg, M. T., Kusché, C. A., &
Pentz, M. A. (2006). The mediational role of
neurocognition in the behavioral outcomes of a
social-emotional prevention program in elementary
school students: Effects of the PATHS curriculum.
Prevention Science, 7(1), 91–102.
Ross, J. G., Gold, R. S., Lavin, A. T., Errecart, M. T., &
Nelson, G. D. (1991). Design of the teenage health
teaching modules evaluation. Journal of School
Health, 61(1), 21–25.
Ross, J. G., Luepker, R. V., Nelson, G. D., Saavedra, P., &
Hubbard, B. M. (1991). Teenage health teaching modules: Impact of teacher training on implementation and
student outcomes. Journal of School Health, 61(1),
31–34.
Schulenberg, J., & Maggs, J. L. (2001). A developmental
perspective on substance use during adolescence and
the transition to young adulthood (Monitoring
the Future Occasional Paper No. 51). Ann Arbor,
MI: Institute for Social Research.
Schulenberg, J., & Maggs, J. L. (2002). A developmental
perspective on alcohol use and heavy drinking during
adolescence and the transition to young adulthood.
Journal of Studies on Alcohol, 14(Suppl.), 54–70.
Schulenberg, J., Maggs, J. L., Steinman, K., & Zucker,
R. A. (2001). Development matters: Taking the long
view on substance abuse etiology and intervention
during adolescence. In P. M. Monti, S. M. Colby, &
T. A. O’Leary (Eds.), Adolescents, alcohol, and substance abuse: Reaching teens through brief interventions (pp. 19–57). New York: Guilford Press.
Shope, J. T., Copeland, L. A., Kamp, M. E., & Lang, S. W.
(1998). Twelfth grade follow up of the effectiveness of
a middle school-based substance abuse prevention
program. Journal of Drug Education, 28, 185–197.
Solomon, D., Battistich, V., Watson, M., Schaps, E., &
Lewis, C. (2000). A six-district study of educational
change: Direct and mediated effects of the Child
Development Project. Social Psychology of Education, 4, 3–51.
Soole, D. W., Mazerolle, L., & Rombouts, S. (2008).
School-based drug prevention programs: A review of
what works. Australian and New Zealand Journal of
Criminology, 41(2), 259–286.
Spoth, R. L., Randall, G. K., Trudeau, L., Shin, C., &
Redmond, C. (2008). Substance use outcomes 5 1/2
years past baseline for partnership-based, familyschool preventive interventions. Drug and Alcohol
Dependence, 96(1–2), 57–68.

Drug Abuse Prevention Programs for Children
Spoth, R. L., Redmond, C., & Shin, C. (2001). Randomized trial of brief family interventions for general
populations: Adolescent substance use outcomes
4 years following baseline. Journal of Consulting and
Clinical Psychology, 69(4), 627–642.
Spoth, R., Redmond, C., Shin, C., & Azevedo, K. (2004).
Brief family intervention effects on adolescent substance initiation: School-level curvilinear growth
curve analyses 6 years following baseline. Journal
of Consulting and Clinical Psychology, 72(3), 535–542.
Stokols, D. (1996). Translating social ecological theory
into guidelines for community health promotion.
American Journal of Health Promotion, 10, 282–298.
Substance Abuse and Mental Health Services Administration. (1999). The relationship between mental health
and substance abuse among adolescents. Rockville,
MD: Author.
Tobler, N. S., Roona, M. R., Ochshorn, P., Marshall,
D. G., Streke, A. V., & Stackpole, K. M. (2000).

647
School-based adolescent drug prevention programs:
1998 meta-analysis. Journal of Primary Prevention,
20(4), 275–336.
Trudeau, L., Spoth, R., Lillehoj, C., Redmond, C., &
Wickrama, K. A. S. (2003). Effects of a preventive
intervention on adolescent substance use initiation,
expectancies, and refusal intentions. Prevention
Science, 4(2), 109–122.
U.S. Department of Education. (2001). Exemplary &
promising safe, disciplined, and drug-free schools programs. Washington, DC: Office of Special Education
Research and Improvement, Office of Reform Assistance and Dissemination.
Zucker, R. A. (2006). Alcohol use and the alcohol
use disorders: A developmental-biopsychosocial
systems formulation covering the life course. In
D. Cicchetti & D. J. Cohen (Eds.), Developmental
psychopathology (2nd ed., pp. 620–656). New York:
Wiley.

648

Drug Use Prevention During
Childhood
Nadra E. Lisha1, Pallav Pokhrel2 and
Steve Sussman3
1
Psychiatry, University of California,
San Francisco, San Francisco, CA, USA
2
Cancer Prevention and Control Program,
University of Hawaii Cancer Center, Honolulu,
HI, USA
3
Institute for Health Promotion and Disease
Prevention Research, University of Southern
California, Los Angeles, CA, USA

Drug Use Prevention During Childhood

illicit drugs other than marijuana is presumed to
be under 2 % (Johnston, O’Malley, Bachman, &
Schulenberg, 2011).
Recent data show that substance use initiation
among children might be taking place at an earlier
age than in the past (Anderson & Moore, 2008;
Johnston et al., 2011). According to Monitoring
the Future survey (Johnston et al.), 36 % of eighth
graders report having had tried alcohol, 20 % having had tried cigarettes, and 17 % and 11 % report
having had tried marijuana and other illicit drugs,
respectively. By the 12th grade, 50 % high school
students are likely to have tried an illicit drug.

Theories
Introduction
Alcohol, tobacco, and drug misuse in childhood
poses a significant health concern. However, prevention programming and research generally do
not begin until middle and high school. While
substance use in childhood is low, it is possible
that children begin generating intentions for
future use as part of their developmental growth.
Some of the factors that may influence children’s
substance use intentions include difficulties in
social bonding skills and perceptions and lack of
self-control, which can be modified through prevention programming. In addition, the prevention
programming developed for adolescents is likely
not directly applicable to younger cohorts. This
entry reviews several theories implicated in substance use etiologies in children and adolescents.
We also provide a review of the current research
and highlight programs that have been shown to
be effective in substance use prevention among
children.

Definitions and Scope
While research on substance use is prevalent for
adolescents and older age groups, there is a dearth
of research examining the use of substances in
children younger than 13 years of age. Generally
substance use in childhood is confined to alcohol,
tobacco, marijuana, and inhalants; the use of

Substance use and abuse result from a complex
interplay between the individual and his or her
environment. A number of theories have been
used to explain substance use etiologies and are
useful to inform prevention programming in
children (Sussman & Ames, 2008). Risk and
protective factors are one of the more simplistic
ways to integrate influences on substance use.
Such factors might include behavior, affect,
temperament, peer group influences, genetics,
sex, family setting, and community environment
(Belcher & Shinitzky, 1998). These factors have
been integrated into subsequent theoretical
models such as the Stage Modeling (Flay,
d’Avernas, Best, Kersell, & Ryan, 1983;
Leventhal & Cleary, 1980; Sussman et al.,
1995), which delineates stages of behavior such
that various predictors function at different
points in the history of an individual’s substance
use. Five stages are thought to exist; in the first
stage, nonusers are exposed to risk factors; in the
second stage, the individual may try a drug; in
the third stage, an individual might experiment
with a drug; and in the fourth and fifth stages, the
individual becomes a regular user. Children at
risk for initiation are at the initial stage. Thus,
the goal of childhood substance use prevention
strategies should be to keep children from initiating substance use.
Several notions or classes of theories have
been developed (Flay et al., 1983). Social factors

T.P. Gullotta, M. Bloom (eds.), Encyclopedia of Primary Prevention and Health Promotion,
DOI 10.1007/978-1-4614-5999-6, # Springer Science+Business Media New York 2014

Drug Use Prevention During Childhood

such as early exposure to alcohol or drugs in the
environment play an important role in the mechanism of alcohol and substance use initiation
(Baric & Fisher, 1979). Sociodemographic variables such as socioeconomic status, school performance, and gender have also been found to be
associated with onset of substance use
(Kozlowski, 1979). In addition, certain personality variables such as sensation seeking and extroversion have also been associated with substance
use (Martin et al., 2002). In addition, psychosocial variables (concerned with the interaction of
internal variables such as personality traits and
external variables such as social influences) have
also been advanced as possible mechanisms
underlying substance use (Jessor & Jessor,
1977). New evidence points to biological predispositions to substance use (Everitt & Robbins,
2005).
One of the most widely cited health behavior
theories is the theory of planned behavior (Ajzen,
1985), which is an extension of the theory of
reasoned action (Fishbein & Ajzen, 1975). The
theory of reasoned action is grounded in various
attitude and learning theories such as the
expectancy-value theory, attitude-behavior theories, and attribution theory. According to the theory of reasoned action, an example application
might be the following: individuals are likely to
smoke cigarette if their perception of smoking is
positive (attitude) and if people important to them
approve of the behavior (subjective norm).
In such a case, the motivation to smoke is
high, which influences the intention to smoke,
which in turn will lead to the actual behavior.
Thus, intentions are thought to predict behavior
(Ajzen, 1985; Ajzen & Fishbein, 1980;
Fishbein & Ajzen, 1975). Ajzen (1985) introduced perceived behavioral control into TRA,
thus developing the theory of planned behavior
(TPB). According to TPB, perceived control
over a behavior is also an important determinant
of intention in addition to attitude and
subjective norm.
Fourteen multivariate (cognitive-affective,
social learning, commitment and attachment,
intrapersonal, and comprehensive) theories were
integrated to form Triadic Influence Theory

649

(Petraitis, Flay, & Miller, 1995). This theory
classifies factors into three substantive domains
(interpersonal, attitudinal/cultural, and intrapersonal) combined with “distances” from
performance of the substance use behavior (ultimate, distal, and proximal). Specifically in the
interpersonal domain, ultimate variables might
include home stress, distal variables include
drug use role models, and proximal variables
include social-related drug beliefs. In the attitudinal/cultural domain, ultimate variables include
community disorganization, distal variables
include alienation, and proximal variables
include expectancies of drug use benefits minus
costs. Lastly, in the intrapersonal domain,
ultimate variables might include biological
underpinnings, distal variables include low selfesteem, and proximal variables include intentions
to use substances.

Current Research
There is relative dearth of research on substance
use in childhood, possibly due to lower prevalence of substance use during this period.
Research suggests that evidence-based prevention programming should emphasize childhood
substance use prevention because age of initiation is a significant risk factor for continued use,
dependence, and other health risks (Breslau &
Peterson, 1996; Chassin, Presson, Pitts, &
Sherman, 2000; Fergusson & Lynskey, 1996;
Tennant & Detels, 1976) as well as subsequent
problem substance use later on in life (Kandel &
Davies, 1992; Kaplan, Martin, Johnson, & Robbins, 1986; Newcomb & Bentler, 1988). Findings
from longitudinal studies indicate that cigarette
and alcohol use at an early age was the strongest
indicator of future marijuana and other substance
use (Kandel, Yamaguchi, & Chen, 1992). In addition, research indicates that children at high risk
for later drug abuse can be recognized at very
early ages (Tarter & Hegedus, 1991). Such findings support prevention programming beginning
at younger ages.
Prevention programming in childhood needs
to be developmentally appropriate and target

650

behavioral irregularities that might be indicative
of future substance use (Flay et al., 1983;
Sussman & Ames, 2008). Careful considerations in program design are necessary. For
example, while peer use and perceived peer
use play a significant role in adolescent substance use, this does not seem to be an important
predictor for children’s use (Bush & Iannotti,
1992). On the other hand, young children who
are without enduring supportive adults in their
lives are at an increased risk of “acting out” and
blaming others when they find themselves in
conflict situations (Kellam et al., 1989; Shedler
& Block, 1990; Sussman & Ames, 2008). These
children feel that this is appropriate behavior,
indicating a kind of “contextual distortion”
(Sussman & Ames). Thus, prevention programming in childhood needs to be developmentally
appropriate and target behavioral irregularities
that might be indicative of future substance use
(Flay et al., 1983; Sussman & Ames, 2008).
Careful considerations in program design are
necessary; for example, while peer use and perceived peer use play a significant role in adolescent substance use, this does not seem to be an
important predictor for children’s use (Bush &
Iannotti, 1992).
As pointed out earlier, it is perhaps theoretically more valuable to assess future behavioral
intentions for this age group rather than actual use
(Andrews, Tildesley, Hops, Duncan, & Severson,
2003). Andrews et al. (2003) found in a school
district in western Oregon that for first through
seventh graders, alcohol and cigarette intentions
to use were related to future trying of the substance. Because of the predictive influence of
intentions on future use, it might be important to
determine early intentions of use as a warning
sign of future use. However, some research indicates that while children have strong convictions
and often will indicate that they will never use
drugs after having received prevention programming, but once children become adolescents,
these types of pledges are often forgotten
(Hawthorne, 1996). Future research should determine the optimal measures and constructs for
evaluating substance use prevention programs in
children.

Drug Use Prevention During Childhood

Overview of Strategies
Prevention programs can be classified by the
three main audiences for which they are
designed. Universal programs are designed for
the most general audience, for example, the entire
population of students at a school. Selective programs are designed to target subgroups of the
population who are at risk, such as
low-achieving students, children in high-risk
schools, or children of substance users and
abusers. Targeted programs are specifically
designed for individuals who have already started
experimenting with drugs. We identified 28 prevention programs that target children, using the
following three primary sources: Colorado Blueprints, the National Registry of Effective
Programs and Practices (NREPP), and the
National Institute on Drug Abuse (NIDA)
Redbook. In the following sections, we describe
programs that have had three or more successful
intervention trials as “what works”; programs
with less than three successful trials, mixed
results, or absence of research as “what is promising”; and lastly programs that do not fit into
either of the first two categories as “what doesn’t
work.”

What Works
Eleven universal programs that “work” for children have been identified. The Caring School
Community Program (formerly Child Development Project) is a program designed for elementary school children (kindergarten through sixth
grade). This program focuses on children’s sense
of community towards their school as a means to
increase academic motivation and to reduce substance use, violence, and delinquency. This program is effective when it is able to create an
atmosphere at the school that embodies a caring
environment. Long-term outcomes include
reduction or elimination of alcohol (Cohen’s
d = 0.18), cigarette, and marijuana (Cohen’s
d = 0.22) use (Battistich, Schaps, Watson,
Solomon, & Lewis, 2000). The program consists
of three primary components: (1) an intensive

Drug Use Prevention During Childhood

classroom component comprised by cooperative
learning, reading/language arts, and develops discipline; (2) school-wide activities involving
teachers, parents, and students in an effort to
create a caring community at the school; and
(3) activities for the family that encourage
classroom-type activities in the home.
The Classroom-Centered (CC) and FamilySchool Partnership (FSP) Intervention is
a program for first graders composed of two
parts. The CC intervention is designed to target
teachers’ skills at managing behaviors (e.g.,
attention problems, aggressive and shy behavior).
The FSP component of the intervention targets
early risk behaviors by focusing on cultivating
communicative relationships about behavior
management strategies between parents and
teachers (Ialongo, Poduska, Werthamer, &
Kellam, 2001). In a randomized control trial
with three classrooms – one with the CC intervention, another with the FSP intervention, and
the last as a control (Storr, Ialongo, Kellam, &
Anthony, 2002) – after 6 years, it was found that
students who were in either the CC or FSP intervention were less likely to begin smoking (26 %
versus 33 %). This program is intensive as it
requires participation of school staff and
teachers, as well as parents. Training for parents
alone takes 60 h prior to implementation.
A third program, Life Skills Training (LST),
originally designed for middle school students,
has now been developed for elementary school
students. This program seeks to teach students
skills on how to resist peer pressure, as well as
competence skills for personal and social situations concerning tobacco and alcohol (Botvin,
Griffin, Paul, & Macaulay, 2003). The program
consists of 24 classes (30–45 min each), over
a 3-year period (8 classes per year). The program
provider is instructed to act more as a coach or
skills trainer so as to ensure that personal, interpersonal, and social resistance skills are adequately acquired. One trial (Botvin et al., 2003)
found that the prevalence rate of smoking was
61 % lower and the prevalence rate of alcohol
was 25 % lower at posttest in schools that
received the intervention compared to schools
that did not receive the intervention.

651

The Promoting Alternative Thinking Strategies (PATHS) program, a universal classroombased social and emotional learning program,
was designed to reduce aggression and behavior
problems in elementary school children. This
program has existed for almost 30 years and has
recently received the highest possible rating from
the Blueprints Project of the Center for the Study
and Prevention of Violence, University of Colorado. The program is designed to be implemented
by classroom teachers two to three times per
week (30 min each) for approximately 1 year.
The program is based on the “ABCD” (affective/behavioral/cognitive/dynamic) model. The
ABCD model incorporates features of various
developmental theories including psychodynamic developmental theory, developmental
social cognition, cognitive developmental theory,
cognitive social-learning theory, and attachment
theory. One study found greater inhibitory control and verbal fluency at 1-year follow-up in
PATHS students compared to students in comparison classrooms (p < 0.01) (Riggs, Greenberg,
Kusché, & Pentz, 2006). Because the lessons are
short, and the practitioner takes a naturalistic
approach, the lessons appear to be easily integrated into normal classroom routines.
The Strengthening Families Program: For
Parents and Youth 10–14 (SFP 10–14) has been
found to reduce problem behaviors, delinquency,
and drug abuse and to develop social capabilities
and school performance in children. Originally
developed in the early 1980s, this program has
been replicated independently over 15 times with
similar results. Parenting skills, life skills, and
family skills are trained during 14 sessions
designed for high-risk families. The program
includes sessions for both parents and children,
together and separate. The program has been
shown to be associated with significantly lower
substance use initiation than controls (Molgaard,
Spoth, & Redmond, 2000). Different versions are
available for other languages, cultures, and risk
statuses. One study (Spoth, Guyll, & Day, 2002)
found that 50 % of students who received the
intervention reported having ever tried alcohol
compared to 68 % of the control group students;
33 % of intervention group students report ever

652

having smoked cigarettes compared with 50 % of
control group students, and only 7 % (compared
to 17 % of control group students) reported having ever tried marijuana. At 4-year follow-up, the
frequency of alcohol and cigarette use was lower
among the intervention group than the control
group (p < 0.05). However, the effects were
small in size (Cohen’s d = 0.26 and 0.31, respectively). The program is not very labor intensive
compared to others, so it should be possible to
implement without too much difficulty.
The All Stars program targets youths from the
late elementary school years until high school
(ages 11–15). This program’s key outcomes
include increased commitment to avoid highrisk behaviors, increased bonding to school and
peers, and positive changes in substance use and
violence. The mechanisms that the All Stars program uses to promote these changes include creating accurate beliefs about peer norms, altering
perceptions on how substance use affects lifestyles, creating commitments to stay substance
free, and encouraging social and peer bonding.
The program is taught by trained teachers in the
school’s classroom (specifically language arts,
math, and science courses). Training can be completed in person or online and takes 8 h. The
33 student activity sessions are 20–30 min long.
Evaluation results have consistently shown evidence for both the targeted mediating variables
and substance use outcomes (Harrington, Giles,
Hoyle, Feeney, & Yungbluth, 2001). When the
program was delivered by a teacher, participants
reported lower levels of alcohol use and inhalant
use at posttest compared to students who did not
receive the program (p < 0.05). This program
appears to be effective, training is minimal, and
the program can be integrated into the normal
curriculum; however, it is designed to be taught
every year all the way through high school.
Next, Project ALERT was designed to be
implemented in 11–14-year-olds. The strategies
employed by this program included building
school-wide norms against substance use, understanding social/health consequences of substance
use, identifying prodrug pressure, developing
resistance skills, and recognizing the benefits of
being drug free. These outcomes are achieved

Drug Use Prevention During Childhood

through online teacher training and 14 classroom
sessions. Key outcomes include reduced marijuana use initiation, decreased current and
heavy smoking, and reduced prodrug attitudes
and beliefs and have helped smokers quit (Bell,
Ellickson, & Harrison, 1993; Ellickson, Bell, &
McGuigan, 1993). One large-scale evaluation
found that the curriculum reduced cigarette and
marijuana use initiation and current/regular cigarette and alcohol use. The rates of reductions
ranged from 19 % to 39 % (Ellickson,
McCaffrey, Ghosh-Dastidar, & Longshore,
2003). This program is one of the highest rated
programs and appears to be relatively easy to
implement.
Another program, Keep a Clear Mind
(KACM), is a take-home education program
designed for older elementary school students
and their parents. The material in the program
consists of weekly sets of activities designed for
parents and children to complete together for
4 weeks. The materials are based on social skills
training. This intervention has been shown to
positively influence known risk factors for later
substance use (Werch et al., 1991). This study
found that from pretest to posttest, children in
the program were more likely than the comparison group to change their expectations of using
cigarettes or snuff and to realize that alcohol has
harmful effects (p < 0.05). In addition, parents
from the program were more likely than comparison group parents to change their expectations
that their child would try alcohol, tobacco, or
marijuana (p < 0.05). This program is costeffective and easy to implement but requires
compliance and time from parents.
The Positive Action (PA) program is
a multifaceted program designed to improve academic achievement, school attendance, and problem behaviors such as substance use. Curriculum
kits are available for all ages from kindergarten
through high school. Lessons last only 15 min
and are scripted for the instructor (approximately
140 lessons per grade). The name of the program
stems from its main unifying concept that one
feels good about oneself when taking positive
actions. One study found that students from intervention schools were less likely to have used

Drug Use Prevention During Childhood

alcohol, to have been drunk, and to have tried
illegal drugs than those without the intervention
(Flay & Allred, 2003). One trial (Flay, Allred, &
Ordway, 2001) found that middle schools with
higher enrollment in this program had 52–71 %
lower rates of problem behaviors such as substance use, violence, and property crime compared to schools with low enrollment in
PA. This program appears to be effective but
requires a considerable amount of time and is
rather costly in comparison to some of the other
programs available.
Another program, Too Good for Drugs
(TGFD), was designed for grades kindergarten
through 12th. This program focuses on promoting
six skills (sense of control, responsibility and selfefficacy, goal setting, decision-making, emotional management, and effective communication) in an effort to reduce intentions to use
alcohol and drugs. For the K-8 curricula, there
are 10 weekly, 30–60-min lessons. The program
is also intended to be implemented with all school
personnel (including teachers, secretaries, and
janitors) who are expected to participate in
a 10-h staff program. The program has shown
differences from pre- to posttest on intentions
to drink alcohol, smoke, and use marijuana
(p < 0.05), but long-term effects are still unclear
(Bacon, 2000, 2001). This program appears to be
effective but is rather costly, and to be properly
implemented, it requires a commitment from the
entire school staff and a long-term investment.
An additional program, Guiding Good
Choices (GGC), formerly known as Preparing
for the Drug-Free Years (PDFY), designed for
parents of children aged 4–11, uses a social
development strategy to build bonding, attachment, and commitment by providing opportunities, skills, and recognition of individual
characteristics. This program was created to prevent teen alcohol, tobacco, and illegal substance
use as well as to strengthen parenting skills and
family bonding. One study found positive
changes in norms against alcohol and other substance use, initiating alcohol use, alcohol use, and
being drunk (p < 0.05) (Park et al., 2000). While
the program has been demonstrated to be effective and the cost-benefit analysis was positive

653

(Spoth et al., 2002), it can be challenging both
to recruit and retain parents for the 5 2-h sessions.
Six targeted and selected programs have also
been identified. The Functional Family Therapy
(FFT) is a selected program designed for families
of juvenile offenders aged 6–18. This program
averages 12 sessions over 3–4 months. The
implementation typically takes place at both
clinic and home settings; however, it can also
take place in other settings such as schools,
child welfare facilities, probation and parole
offices, and mental health facilities. The focus
of this intervention is on the risk and protective
factors that impact the individual, stemming from
environmental factors and how these factors present within the therapeutic process. Numerous
research studies on substance use and other problem behaviors have demonstrated the efficacy of
this program (Alexander & Parsons, 1973;
Waldron, Slesnick, Brody, Turner, & Peterson,
2001). One report found that the 12-month felony
recidivism rate for the control group was 19.2 %
compared to 13.3 % in the intervention group
(Barnoski & W. S. I. F. P. Policy, 2002). While
this program has shown positive outcomes, most
of the research has been on adolescents, the program requires involvement of the family and
child, and the program is very expensive.
The Early Risers “Skills for Success” Risk
Prevention Program focuses on improving academic ability, self-control, social skills, and
involving parents in their child’s activities. This
program is typically school based and requires
only one family advocate for every 25–30 child/
family participants. The program is somewhat
intensive and requires 3–6 months for start-up
(e.g., screening/recruiting children and families,
obtaining school support). The first phase of the
program is a 6-week summer program that is
implemented 4 days per week; program components include social skills training, academic
instruction, cultural education, and sports
coaching. Next, the “Check and Connect Program” is implemented at the start of the school
year and runs for the full school year for 2 and
3 years; here an advocate visits the child’s classroom on a weekly basis. The “Family Program”
also begins at the same time; for this component,

654

biweekly meetings between the parent and child
take place for about 2 h each. The “FLEX Family
Support Program” begins 3 months into the
school year and varies by family need; this
portion includes home visits to the family. This
program has a strong evaluation history and has
been identified as an exemplary substance abuse
prevention program. Evaluation studies typically
had too low of substance use rates to evaluate that
element of the program and instead focused on
mediators of substance use. However, it might be
difficult to implement, as it requires consistent
parental involvement and a long time commitment. In addition, the program is yet to be evaluated for future outcomes, such as onset and
continuation of substance use in high-risk
populations.
The Fast Track Prevention Trial for Conduct
Problems runs from preschool through sixth
grade but is most intense during the early years,
specifically for children identified in kindergarten
showing problem behaviors. Parents are trained
when their child is in the first grade on ways to
foster academic achievement, communication
with schools, controlling anger, and discipline
strategies. Biweekly home visits supplement initial parent training. Children receive social skills
training, academic tutoring, and a classroom
intervention designed to enhance emotional
awareness, self-control, and problem-solving
skills, as well as activities to do at home with
parents (McMahon & Canal, 1999). One study
found that in high-risk group, intervention students had lower lifetime prevalence of conduct
disorder than the control group participants, with
the intervention group preventing more than
50 % of conduct disorder cases (Dodge &
McCourt, 2010). Long-term follow-up evaluations are needed to ensure that the program
indeed reduces substance use during childhood
and adolescence.
Another targeted program, I Can Problem
Solve (ICPS), specifically designed for nursery
school and kindergarten-age students, has also
been successfully implemented with children in
grades 5 and 6. This program is less intensive
than some of the other programs as it runs for
only 6–8 weeks. The program is taught in three

Drug Use Prevention During Childhood

sections: (1) the first section focuses on using
games to learn problem-solving vocabulary;
(2) the second section focuses on having the
children learn how to listen and to identify their
feelings and those of others; and (3) the third
section presents the children with hypothetical
problems and they are asked to analyze these
problems in regard to the feelings of those
involved, to examine consequences, and to problem solve. Parents are also involved (this could be
a challenge) and taught to think about their feelings, their children’s feelings, and how to help
their child engage in effective problem solving.
This program can be implemented within the regular class schedule, so it should not be very difficult to integrate in the curriculum. Evaluations
have shown positive results. Multiple trials have
shown effectiveness for behavioral adjustment ratings, impulsivity, and self-control (Shure, 1993).
One evaluation demonstrated effective changes
and large effect sizes (0.35–1.26) on five mediators
of substance use: school bonding, parenting skills,
social competence, family relationships, and
behavioral self-regulation (Kumpfer, Alvarado,
Tait, & Turner, 2002).
The Brief Strategic Family Therapy (BSFT) is
a targeted program created for 6–17-year-olds
who are exhibiting, or are at risk for, problem
behaviors such as substance use or abuse. This
program is delivered in 12–16 family sessions.
BSFT operates on the principle that transforming
how the family functions as a whole will help the
youth who are exhibiting problem behaviors.
Evaluations of the program have found reductions in marijuana use and overall substance use
(Szapocznik, Hervis, & Schwartz, 2003). Studies
have found greater reductions in marijuana use
(Santisteban et al., 2003) and overall substance
use (p < 0.05) (Sonrisrebon et al., 1997) in
program students compared to control group students. While this program has been effective in
numerous trials and sessions are conducted at
locations convenient to the family (such as the
home), it might be difficult to implement as it
requires a substantial commitment from the
entire family and is very expensive.
Another targeted program is CASASTART
(Striving Together to Achieve Rewarding

Drug Use Prevention During Childhood

Tomorrows, formerly known as Children at Risk).
CASASTART is a community-based, schoolcentered program targeting prevention of substance abuse and violence. Youths aged between
8 and 13 with a minimum of four identified risk
factors are the targets of the program and remain
in it for up to 2 years. Objectives include reducing
drug and alcohol use, as well positive changes in
other areas of behavior. The research that
informed this program includes social-learning
theory, social strain theory, social control theory,
and positive youth development. CASASTART
is operated by case managers and requires the
collaboration of police departments and local
social service and juvenile crime agencies. One
study (Harrell, Cavanaugh, & Sridharan, 1998)
found that 1 year after the program, past-month
use of cigarettes, alcohol, inhalants, marijuana,
psychedelics, crack, and other cocaine, heroin, or
nonmedical prescription drugs was lower in the
program group (51 %) compared to the control
group (65 %).

What Is Promising
The Know Your Body (KYB) Program is
a universal program that was initially developed
in the 1970s by the American Health Foundation.
This comprehensive school health promotion
program is designed for students in kindergarten
through the ninth grade. Educational topics are
broad and include topics such as exercise, safety,
disease prevention, prevention of cigarette
smoking, consumer health topics, dental maintenance, HIV/AIDS, substance abuse, and violence
prevention. The sessions are organized across
five “core skills”: self-esteem, decision-making,
communication, goal setting, and stress management. Parents are sent letters and community
involvement is promoted. Significant changes in
cigarette smoking have been found, but no
changes have been found for marijuana or
alcohol (Resnicow, Cross, & Wynder, 1993).
At the 6-year follow-up, the rate of cigarette
smoking was 73 % less among intervention
group students than among control group students. The program is promising but requires

655

subsequent evaluations to examine program success for other substance use behaviors.
The Protecting You, Protecting Me (PY/PM)
program is designed for children aged 6–11. This
program focuses on the importance of protecting
the brains of individuals under the age of 21 from
the biological effects of alcohol as well as helping
children avoid the risks associated with being in
a car with inebriated drivers. The program is
comprised of a series of 40 lessons (20–60 min
in length) from grades 1 to 5 (8 lessons each
grade) covering a variety of life skills including
media awareness, communication, and vehicle
safety. Lessons are taught by peer educators
who are trained for 2½ days. One evaluation
found multiple effects in a variety of domains
such as vehicle safety skills, intentions to ride
with an alcohol-impaired driver, and media literacy. However, no effects were found on decisionmaking, stress management, and rules (Bohman
et al., 2004). One study found that students in
grades 1 and 2 demonstrated significantly higher
increases in knowledge of dangers of underage
drinking compared to the control group (p <
0.05) (Bell, Padget, Kelley-Baker, & Rider,
2007). This program is relatively easy to implement but is designed to span over 5 years and thus
requires a considerable commitment.
In addition, Creating Lasting Family Connections (CLFC) targets high-risk teenagers aged
11–15 and their parents. Initially, parents of teenagers attend 42–56 h of classes, and the teenagers
attend 14–20 h of classes, over a 6–7-month
period. Parents’ classes are divided into three
modules: training on substance abuse knowledge
and issues, family management skills, and communication techniques (teenagers joined for this
module). Subsequently a 1-year booster (up to
6 months after the end of training) consisting of
bimonthly telephone consultations and/or home
visits is implemented. However, the program has
been modified and now comprises more hours of
instruction during a shorter period of time. Teenagers and their parents complete training for
2½ h a night for 15–18 weeks. Evidence for
short-term changes in alcohol, cigarette, and
other drug knowledge has been found; however,
long-term changes in use have not been found

656

(Johnson et al., 1996). The onset was delayed for
alcohol and other drugs (AOD) for youths who
participated in the program for 1 year relative to
controls. In addition, parents reported increased
AOD knowledge and beliefs were consistent with
program content (p < 0.05 for alcohol, p < 0.05 for
AOD), and youths reported decreased conflict with
their parents (p < 0.05 for alcohol, p < 0.05 for
AOD). This program was found to have important
changes in parent–child relationships; however,
the lack of reductions in alcohol and substance
use makes this program “promising.”
The Seattle Social Development Project
(SSDP) is a school-based three-part intervention
for teachers, students, and parents in grades 1 to
6 implemented in high-crime urban areas. Students and teachers receive mandatory training,
and parents receive between 5 and 7 optional
sessions per year. The Social Development
Model (Hawkins & Weis, 1985) guides the interventions by training teachers to better manage
their classrooms; training parents in behavior
management, academic support, and skills for
reducing substance use; as well as training students to problem solve and learn refusal skills.
This program has been widely tested since its
inception in 1981, but mixed effects have been
found on substance use (Hawkins, Kosterman,
Catalano, Hill, & Abbott, 2005, 2008). One
study (Hawkins et al., 1992) found that after
4 years, intervention students reported lower
rates of alcohol initiation (21 %) compared to
control students (27 %) and delinquency initiation (46 % compared to 52 %). This program is
in the “promising” category for a number of reasons. The majority of the research on this program is based on quasi-experimental designs, and
the results are mixed. Another issue is the attrition for the age 21 follow-up studies. Lastly, the
program has only been studied in one urban metropolitan area, and all the evaluations were
conducted by the program designers rather than
outside evaluators.
The universal program, Project Venture, was
designed for fifth to eighth grade American
Indian youths. This program aims to develop
social and emotional competence to enable
youths to resist alcohol, tobacco, and other

Drug Use Prevention During Childhood

substance use. The program curriculum is based
on traditional American Indian values. The program consists of 20 1-h classroom-based activities; weekly after-school, weekend, and summer
skill-building and challenge activities (e.g., hiking, camping); 3–10 days of summer camps and
wilderness treks; as well as community-oriented
service learning and service projects throughout
the year. The results have been mixed. One study
(Carter, 2005) found that both intervention and
control students increased in alcohol use from
baseline but that a leveling off occurred for intervention students (p < 0.05). This difference
represents a large effect size (partial etasquared = 0.189). A second study found similar
results; alcohol use remained the same for the
intervention group but increased for control subjects (p < 0.05) (Carter, Straits, & Hall, 2007).
Effect sizes were large for marijuana (partial
eta-squared = 0.162) and medium for other illicit
drugs (partial eta-squared = 0.097). Both studies
found that use of marijuana and other illicit substances remained the same among students in the
intervention group but increased among students
in the control group. Thus, this program is promising, but results are mixed and the intervention is
intensive.
The Linking the Interests of Families and
Teachers (LIFT) is a targeted program that is
promising for grades 1 through 5. This 1-h,
twice a week, 10-week program is designed to
decrease delinquent behaviors while promoting
positive development in at-risk youths by
improving social skills for participants (classroom and playground components) and providing
parent training. One study found that compared to
control youths, LIFT participants exhibited
a reduced average level of use of tobacco,
alcohol, and illicit drugs through 12th
grade (DeGarmo, Eddy, Reid, & Fetrow, 2009).
At 3-year post-program, lower levels of alcohol
and marijuana use were found among program
participants compared to control subjects (p <
0.05) (Eddy, Reid, & Fetrow, 2000).
Another program, Preventive Treatment Program (PTP), is a targeted program for boys aged
7–9 who exhibit problem behaviors in kindergarten. One aspect of the program includes

Drug Use Prevention During Childhood

a 17-session training for parents on how to monitor behavior, how to reinforce pro-social behaviors, how to use punishment, and how to deal with
crises. The second component teaches the boys
social skills and self-control in a 19-session program. The training is implemented in small
groups comprised of both disruptive and
nondisruptive boys; it employs coaching, peer
modeling, self-instruction, reinforcement contingency, and role playing to build skills. The program has shown effects at age 15 such that the
intervention boys were less likely than the control
boys to report having been drunk or taken drugs
in the last 12 months (p < 0.05) (Tremblay,
Masse, Pagani, & Vitaro, 1996).
Two selective programs were identified as
potentially effective programs. Coping Power is
a multicomponent parent and child program
designed for late elementary school through middle school. This 15–18-month school-based program was created to educate children on how to
cope with anxiety and anger, social competence,
self-regulation, problem solving, and positive
parental involvement. The program consists of
34 group sessions as well as periodic individual
sessions. In addition, parents receive 16 group sessions as well as individual contacts and home
sessions. There is also a shorter abbreviated version of the program currently being evaluated.
Evaluations of this program have found mixed
effects on substance use (Lochman & Wells,
2004). One evaluation showed no program effect
on boy’s self-reported substance use but did on
parent-reported substance use (p < 0.05). As this
program is rather intense to implement, more evaluations on substance use outcomes are needed.
In addition, the well-known Big Brothers Big
Sisters of America (BBBSA) program is a selected
program designed for at-risk youths aged 6–18.
Non-related mentors are matched with children to
promote positive development and social responsibility. In the traditional model, the mentor is
expected to spend approximately 3–5 h per week
with the child for 1 year. Some of the newer
BBBS programs operate slightly differently
such that the focus is on establishing schoolbased mentoring programs where students interact during school hours with their mentor. The

657

contact between the mentor and the child takes
place at the school in this model. The program
has been shown to be effective on initiation of
alcohol and illegal drugs (Tierney & Grossman,
1995). Program effects of the new model on
substance use are not yet “proven.”

What Does Not Work
The Drug and Alcohol Resistance Education
(DARE) is known to be ineffective in both
short- and long-term reduction of substance
use among students (Peterson, Kealey, Mann,
Marek, & Sarason, 2000; Resnicow & Botvin,
1993). However, even with the knowledge of
this program’s lack of substantiation, DARE is
still being implemented in some elementary
schools across the country. Other ineffective programs that have been used throughout the years
include “Here’s Looking at You 2000 and
McGruff’s Drug Prevention and Child Protection” (Hallfors & Godette, 2002; Pankratz &
Hallfors, 2004). However, there may be more
ineffective programs as those that do not work
typically remain unpublished in evaluation
studies and thus can be difficult to locate.
It must be noted that the lack of long-term
outcomes makes childhood substance use prevention difficult to evaluate. While many of the
programs have been evaluated in terms of mediators of substance use such as self-control and
problem solving, few have been evaluated with
regard to actual substance use behaviors. It is
possible that without proper booster programs in
later grades, the prevention effects will deteriorate over time (Peterson et al., 1992). As the
substance use effects of early prevention programming over the long term appear to be minimal (Peterson et al., 2000), it is crucial that
programs be maintained and extended throughout
middle school and high school years.

Summary
It appears that prevention scientists are progressively creating and evaluating developmentally

658

appropriate interventions for youths of all ages
and risk levels. However, younger aged children
have often been overlooked for substance use
prevention. There are two main reasons that prevention efforts need to focus on children. First,
substance use intentions begin to take shape early
in childhood (Andrews et al., 2003) and even
young children are at risk for initiation. Second,
early initiation has been associated with greater
substance abuse dependence and problems in
later life. Fortunately, promising programs
appear to be emerging. Many of these programs
include parents, schools, and communities and
target high-risk youths. Currently, there is
a growing acknowledgement of the need to create
and implement developmentally appropriate
interventions for children. However, there is
still a lack of longitudinal research on the effects
of the current programs.
Future research might consider neurobiology
or genetic approaches to inform prevention programming. The development and maintenance of
various addictions have been linked to specific
neurobiological underpinnings (Everitt &
Robbins, 2005; Martin-Soelch, Linthicum, &
Ernst, 2007; Volkow, Fowler, & Wang, 2004).
Developing research on the addiction process
operates with the understanding that a drug or
behavior gains saliency through reinforcement,
followed by transitions into habitual or compulsive involvement through reward-based learning
processes (Martin-Soelch et al., 2007). It is possible that genes play a fundamental role in the
addiction process by determining foundational
vulnerabilities for standard behavioral processes
to go awry. New studies on the neurobiology of
impulsivity and impulse control disorders suggest parallels with drug addictions (Lobo &
Kennedy, 2006). A relatively new concept, that
of “endophenotypes,” might provide valuable
insights into the etiology of substance use disorders (Brewer & Potenza, 2008). Endophenotypes
are “measurable components unseen by the
unaided eye” and may be neuropsychological,
endocrinological, cognitive, neuroanatomical, or
biochemical. Through the identification of
endophenotypes, it might be possible to identify
genetic predispositions to addiction at a younger

Drug Use Prevention During Childhood

age and tailor prevention efforts more specifically
as well as enhance behavioral and pharmacological treatments.

References
Ajzen, I. (1985). From intentions to actions: A theory of
planned behavior. In J. Kuhl & J. Beckman (Eds.),
Action-control: From cognition to behavior
(pp. 11–39). Heidelberg, Germany: Springer.
Ajzen, I., & Fishbein, M. (1980). Understanding attitudes
and predicting social behavior. Englewood Cliffs, NJ:
Prentice-Hall.
Alexander, J. F., & Parsons, B. V. (1973). Short-term
behavioral intervention with delinquent families:
Impact on family process and recidivism. Journal of
Abnormal Psychology, 81(3), 219–225.
Anderson, S. W., & Moore, P. A. (2008). The impact of
education and school-based counseling on children’s
and adolescents’ views of substance abuse. Journal of
Child & Adolescent Substance Abuse, 18(1), 16–23.
Andrews, J. A., Tildesley, E., Hops, H., Duncan, S. C., &
Severson, H. H. (2003). Elementary school age children’s future intentions and use of substances. Journal
of Clinical Child & Adolescent Psychology, 32(4),
556–567.
Bacon, T. (2000). The effects of the Too Good for Drugs II
drug prevention program on students’ substance use
intentions and risk and protective factors. Florida Educational Research Council, Inc., Research Bulletin,
31, 1–25.
Bacon, T. (2001). Impact on high school students’ behaviors and protective factors: A pilot study of the too
good for drugs and violence prevention program. Florida Educational Research Council, Inc., Research Bulletin, 32, 1–40.
Baric, L., & Fisher, C. (1979). Acquisition of the smoking
habit. Health Education Journal, 38, 71–76.
Barnoski, R. P., & W. S. I. F. P. Policy. (2002). Washington State’s implementation of functional family therapy for juvenile offenders: Preliminary findings.
Olympia, WA: Washington State Institute for Public
Policy.
Battistich, V., Schaps, E., Watson, M., Solomon, D., &
Lewis, C. (2000). Effects of the Child Development
Project on students’ drug use and other problem behaviors. The Journal of Primary Prevention, 21(1), 75–99.
Belcher, H., & Shinitzky, H. (1998). Substance abuse in
children. Archives of Pediatrics and Adolescent Medicine, 152, 952–960.
Bell, R. M., Ellickson, P. L., & Harrison, E. R. (1993).
Do drug prevention effects persist into high-school?
How project ALERT did with ninth graders. Preventive Medicine, 22(4), 463–483.
Bell, M. L., Padget, A., Kelley-Baker, T., & Rider,
R. (2007). Can first and second grade students benefit
from an alcohol use prevention program? Journal of
Child & Adolescent Substance Abuse, 16(3), 89–107.

Drug Use Prevention During Childhood
Bohman, T. M., Barker, E. D., Bell, M. L., Lewis, C. M.,
Holleran, L., & Pomeroy, E. (2004). Early intervention
for alcohol use prevention and vehicle safety skills:
Evaluating the Protecting You/Protecting Me curriculum. Journal of Child & Adolescent Substance Abuse,
14(1), 17–40.
Botvin, G. J., Griffin, K. W., Paul, E., & Macaulay, A. P.
(2003). Preventing tobacco and alcohol use among
elementary school students through life skills training.
Journal of Child & Adolescent Substance Abuse,
12(4), 1–17.
Breslau, N., & Peterson, E. L. (1996). Smoking cessation
in young adults: Age at initiation of cigarette smoking
and other suspected influences. American Journal of
Public Health, 86(2), 214–220.
Brewer, J. A., & Potenza, M. N. (2008). The neurobiology
and genetics of impulse control disorders: Relationships to drug addictions. Biochemical Pharmacology,
75(1), 63–75.
Bush, P. J., & Iannotti, R. J. (1992). Elementary
schoolchildren’s use of alcohol, cigarettes and marijuana and classmates’ attribution of socialization.
Drug and Alcohol Dependence, 30(3), 275–287.
Carter, S. (2005). Project venture final evaluation report.
New Mexico Department of Health, Behavioral Health
Services Division, Prevention Services Bureau. Gallup, NM: National Indian Youth Leadership Project.
Carter, S., Straits, K. J. E., & Hall, M. (2007). Project
venture: Evaluation of an experiential, culturallybased approach to substance abuse prevention with
American Indian youth. Journal of Experiential Education, 29(3), 397–400.
Chassin, L., Presson, C. C., Pitts, S. C., & Sherman, S. J.
(2000). The natural history of cigarette smoking from
adolescence to adulthood in a Midwestern community
sample: Multiple trajectories and their psychosocial
correlates. Health Psychology, 19(3), 223–231.
DeGarmo, D. S., Eddy, J. M., Reid, J. B., & Fetrow, R. A.
(2009). Evaluating mediators of the impact of the
Linking the Interests of Families and Teachers
(LIFT) multimodal preventive intervention on substance use initiation and growth across adolescence.
Prevention Science, 10(3), 208–220.
Dodge, K. A., & McCourt, S. N. (2010). Translating
models of antisocial behavioral development into
efficacious intervention policy to prevent adolescent
violence. Developmental Psychobiology, 52(3),
277–285.
Eddy, J. M., Reid, J. B., & Fetrow, R. A. (2000). An
elementary school-based prevention program targeting
modifiable antecedents of youth delinquency and violence. Journal of Emotional and Behavioral Disorders, 8(3), 165–176.
Ellickson, P. L., Bell, R. M., & McGuigan, K. (1993).
Preventing adolescent drug use: Long-term results of
a junior high program. American Journal of Public
Health, 83(6), 856–861.
Ellickson, P. L., McCaffrey, D. F., Ghosh-Dastidar, B., &
Longshore, D. L. (2003). New inroads in preventing

659
adolescent drug use: Results from a large-scale trial of
project ALERT in middle schools. American Journal
of Public Health, 93(11), 1830–1836.
Everitt, B. J., & Robbins, T. W. (2005). Neural systems of
reinforcement for drug addiction: From actions to
habits to compulsion. Nature Neuroscience, 8(11),
1481–1490.
Fergusson, D. M., & Lynskey, M. T. (1996). Alcohol
misuse and adolescent sexual behaviors and risk taking. Pediatrics, 98(1), 91–96.
Fishbein, M., & Ajzen, I. (1975). Belief, attitude, intention, and behavior: An introduction to theory and
research. Reading, MA: Addison-Wesley.
Flay, B., & Allred, C. G. (2003). Long-term effects of the
Positive Action program. American Journal of Health
Behavior, 27(Suppl. 1), S6–S21.
Flay, B., Allred, C. G., & Ordway, N. (2001). Effects of
the Positive Action program on achievement and discipline: Two matched-control comparisons. Prevention Science, 2(2), 71–89.
Flay, B., d’Avernas, J., Best, J., Kersell, M., &
Ryan, K. (1983). Cigarette smoking: Why young people do it and ways of preventing it. Pediatric and
Adolescent Behavioral Medicine: Issues in Treatment,
10, 132–183.
Hallfors, D., & Godette, D. (2002). Will the principles of
effectiveness’ improve prevention practice? Early
findings from a diffusion study. Health Education
Research, 17(4), 461–470.
Harrell, A., Cavanaugh, S., & Sridharan, S. (1998). Impact
of the children at risk program: Comprehensive final
report II. Washington, DC: The Urban Institute.
Harrington, N. G., Giles, S. M., Hoyle, R. H., Feeney,
G. J., & Yungbluth, S. C. (2001). Evaluation of the
All Stars character education and problem behavior
prevention program: Effects on mediator and outcome
variables for middle school students. Health Education
& Behavior, 28(5), 533–546.
Hawkins, J. D., Catalano, R. F., Morrison, D., O’Donnell,
J., Abbott, R., & Day, L. (1992). The Seattle Social
Development Project: Effects of the first four years on
protective factors and problem behaviors. In
J. McCord & R. Tremblay (Eds.), The prevention of
antisocial behavior in children (pp. 139–161). New
York: Guilford Press.
Hawkins, J. D., Kosterman, R., Catalano, R. F., Hill, K. G.,
& Abbott, R. D. (2005). Promoting positive adult
functioning through social development intervention
in childhood: Long-term effects from the Seattle
Social Development Project. Archives of Pediatrics
& Adolescent Medicine, 159(1), 25–31.
Hawkins, J. D., Kosterman, R., Catalano, R. F., Hill, K. G.,
& Abbott, R. D. (2008). Effects of social development
intervention in childhood 15 years later. Archives of
Pediatrics and Adolescent Medicine, 162(12), 1133.
Hawkins, J. D., & Weis, J. G. (1985). The social development model: An integrated approach to delinquency
prevention. The Journal of Primary Prevention, 6(2),
73–97.

660
Hawthorne, G. (1996). The social impact of Life Education: Estimating drug use prevalence among Victorian
primary school students and the statewide effect of the
Life Education programme. Addiction, 91(8),
1151–1160.
Ialongo, N., Poduska, J., Werthamer, L., & Kellam,
S. (2001). The distal impact of two first-grade preventive interventions on conduct problems and disorder in
early adolescence. Journal of Emotional and Behavioral Disorders, 9(3), 146–160.
Jessor, R., & Jessor, S. (1977). Problem behavior and
psychosocial development: A longitudinal study of
youth. New York: Academic Press.
Johnson, K., Strader, T., Berbaum, M., Bryant, D.,
Bucholtz, G., Collins, D., et al. (1996). Reducing alcohol and other drug use by strengthening community,
family, and youth resiliency. Journal of Adolescent
Research, 11(1), 36–67.
Johnston, L. D., O’Malley, P. M., Bachman, J. G., &
Schulenberg, J. E. (2011). Monitoring the future:
National results on adolescent drug use: Overview of
key findings, 2010. Ann Arbor, MI: Institute of Social
Research, The University of Michigan.
Kandel, D. B., & Davies, M. (1992). Progression to regular marijuana involvement: Phenomenology and risk
factors for near-daily use. In M. Glantz & R. Pickens
(Eds.), Vulnerability to drug abuse (pp. 211–254).
Washington,
DC:
American
Psychological
Association.
Kandel, D. B., Yamaguchi, K., & Chen, K. (1992). Stages
of progression in drug involvement from adolescence
to adulthood: Further evidence for the gateway theory.
Journal of Studies on Alcohol, 53, 447–457.
Kaplan, H. B., Martin, S. S., Johnson, R. J., & Robbins,
C. A. (1986). Escalation of marijuana use: Application
of a general theory of deviant behavior. Journal of
Health and Social Behavior, 27(1), 44–61.
Kellam, S., Ialongo, N., Brown, H., Laudolff, J., Mirsky,
A., Anthony, B., et al. (1989). Attention problems in
first grade and shy and aggressive behaviors as antecedents to later heavy or inhibited substance use. Problems of Drug Dependence, 2(35), 368–369.
Kozlowski, L. T. (1979). Psychosocial influences on cigarette smoking. NIDA Research Monograph, 26,
97–125.
Kumpfer, K. L., Alvarado, R., Tait, C., & Turner,
C. (2002). Effectiveness of school-based family and
children’s skills training for substance prevention
among 6–8 year-old rural children. Psychology of
Addictive Behaviors, 16(4S), S65–S71.
Leventhal, H., & Cleary, P. (1980). The smoking problem: A review of the research and theory in behavioral
risk modification. Psychological Bulletin, 88(2),
370–405.
Lobo, D., & Kennedy, J. L. (2006). The genetics of gambling and behavioral addictions. CNS Spectrums,
11(12), 931–939.
Lochman, J. E., & Wells, K. C. (2004). The coping power
program for preadolescent aggressive boys and their

Drug Use Prevention During Childhood
parents: Outcome effects at the 1-year follow-up. Journal of Consulting and Clinical Psychology, 72(4),
571–578.
Martin, C. A., Kelly, T. H., Rayens, M. K., Brogli, B. R.,
Brenzel, A., Smith, W. J., et al. (2002). Sensation
seeking, puberty, and nicotine, alcohol, and marijuana
use in adolescence. Journal of the American Academy
of Child & Adolescent Psychiatry, 41(12), 1495–1502.
Martin-Soelch, C., Linthicum, J., & Ernst, M. (2007).
Appetitive conditioning: Neural bases and implications for psychopathology. Neuroscience & Biobehavioral Reviews, 31(3), 426–440.
McMahon, S. F. T., & Canal, N. (1999). Initial impact of
the fast track prevention trial for conduct problems:
II. Classroom effects. Journal of Consulting and Clinical Psychology, 67(5), 648–657.
Molgaard, V., Spoth, R., & Redmond, C. (2000). Competency training: The Strengthening Families Program
for Parents and Youth 10-14 [OJJDP Juvenile Justice
Bulletin NCJ 182208]. Washington, DC: US Department of Justice, Office of Juvenile Justice and Delinquency Prevention.
Newcomb, M. D., & Bentler, P. M. (1988). Consequences
of adolescent drug use: Impact on the lives of young
adults. Thousand Oaks, CA: Sage.
Pankratz, M. M., & Hallfors, D. D. (2004). Implementing
evidence based substance use prevention curricula in
North Carolina public school districts. Journal of
School Health, 74(9), 353–358.
Park, J., Kosterman, R., Hawkins, J. D., Haggerty, K. P.,
Duncan, T. E., Duncan, S. C., et al. (2000). Effects of
the “Preparing for the Drug Free Years” curriculum on
growth in alcohol use and risk for alcohol use in early
adolescence. Prevention Science, 1(3), 125–138.
Peterson, J., Grinstead, O., Golden, E., Catania, J.,
Kegeles, S., & Coates, T. (1992). Correlates of HIV
risk behaviors in black and white San Francisco heterosexuals: The population-based AIDS in multiethnic
neighborhoods (AMEN) study. Ethnicity & Disease,
2(4), 361–370.
Peterson, A. V., Kealey, K. A., Mann, S. L., Marek, P. M.,
& Sarason, I. G. (2000). Hutchinson Smoking Prevention Project: Long-term randomized trial in schoolbased tobacco use prevention – Results on smoking.
Journal of the National Cancer Institute, 92(24),
1919–1991.
Petraitis, J., Flay, B., & Miller, T. (1995). Reviewing theories of adolescent substance use: Organizing pieces in
the puzzle. Psychological Bulletin, 117, 67–86.
Resnicow, K., & Botvin, G. (1993). School-based substance use prevention programs: Why do effects
decay? Preventive Medicine, 22(4), 484–490.
Resnicow, K., Cross, D., & Wynder, E. (1993). The Know
Your Body program: A review of evaluation studies.
Bulletin of the New York Academy of Medicine, 70(3),
188–207.
Riggs, N. R., Greenberg, M. T., Kusché, C. A., & Pentz,
M. A. (2006). The mediational role of neurocognition
in the behavioral outcomes of a social-emotional

Drug Use Prevention During Childhood
prevention program in elementary school students:
Effects of the PATHS curriculum. Prevention Science,
7(1), 91–102.
Santisteban, D. A., Coatsworth, J. D., Perez-Vidal, A.,
Kurtines, W. M., Schwartz, S. J., LaPerriere, A.,
et al. (2003). Efficacy of brief strategic family therapy
in modifying Hispanic adolescent behavior problems
and substance use. Journal of Family Psychology,
17(1), 121–133.
Shedler, J., & Block, J. (1990). Adolescent drug use and
psychological health. American Psychologist, 45,
612–630.
Shure, M. B. (1993). Interpersonal problem solving and
prevention. A comprehensive report of research and
training (MH-40801). Washington, DC: National
Institute of Mental Health.
Sonrisrebon, D. A., Coarsworrh, J. D., Perez-Vidal, A.,
Mirrani, V., Jean-Gilles, M., & Szapocznik, J. (1997).
Brief structural/strategic family therapy with African
American and Hispanic high-risk youth. Journal of
Community Psychology, 25(5), 453–471.
Spoth, R. L., Guyll, M., & Day, S. X. (2002). Universal
family-focused interventions in alcohol-use disorder
prevention: Cost-effectiveness and cost-benefit analyses of two interventions. Journal of Studies on Alcohol, 63(2), 219–228.
Storr, C. L., Ialongo, N. S., Kellam, S. G., & Anthony, J. C.
(2002). A randomized controlled trial of two primary
school intervention strategies to prevent early onset
tobacco smoking. Drug and Alcohol Dependence,
66(1), 51–60.
Sussman, S., & Ames, S. L. (2008). Drug abuse: Concepts, prevention and cessation. New York: Cambridge University Press.
Sussman, S., Stacy, A., Dent, C., Simon, T., Galaif, E.,
Moss, M., et al. (1995). Continuation high schools:
Youth at risk for drug abuse. Journal of Drug Education, 25(3), 191–209.

661
Szapocznik, J., Hervis, O. E., & Schwartz, S. (2003). Brief
strategic family therapy for adolescent drug abuse
(NIH publication no. 03–4751). NIDA therapy manuals for drug addiction. Rockville, MD: National Institute on Drug Abuse.
Tarter, R. E., & Hegedus, A. M. (1991). The
drug use screening inventory: Its applications in the
evaluation and treatment of alcohol and other drug
abuse. Alcohol Health & Research World, 15(1),
65–75.
Tennant, F. S., Jr., & Detels, R. (1976). Relationship of
alcohol, cigarette, and drug abuse in adulthood with
alcohol, cigarette and coffee consumption in childhood. Preventive Medicine, 5(1), 70–77.
Tierney, J., & Grossman, J. (1995). Making a difference:
An impact study of Big Brothers/Big Sisters. Philadelphia: Public/Private Ventures.
Tremblay, R. E., Masse, L., Pagani, L., & Vitaro,
F. (1996). From childhood physical aggression to adolescent maladjustment: The Montreal prevention
experiment. In R. D. Peters & R. J. McMahon (Eds.),
Preventing childhood disorders, substance abuse, and
delinquency (pp. 268–298). Thousand Oaks, CA:
Sage.
Volkow, N. D., Fowler, J. S., & Wang, G. J. (2004). The
addicted human brain viewed in the light of imaging
studies: Brain circuits and treatment strategies. Neuropharmacology, 47, 3–13.
Waldron, H. B., Slesnick, N., Brody, J. L., Turner, C. W.,
& Peterson, T. R. (2001). Treatment outcomes for
adolescent substance abuse at 4-and 7-month assessments* 1. Journal of Consulting and Clinical Psychology, 69(5), 802–813.
Werch, C. E., Young, M., Clark, M., Garrett, C., Hooks,
S., & Kersten, C. (1991). Effects of a take home drug
prevention program on drug related communication
and beliefs of parents and children. Journal of School
Health, 61(8), 346–350.

662

Health and Fitness During Childhood

Alongside the surge of childhood obesity in

Health and Fitness During Childhood the United States over recent years, a wealth of
Matthew Lee Smith1, Jeff M. Housman2,
Lauren A. Shinholster3, Justin B. Dickerson4 and
Kelly L. Wilson5
1
Department of Health Promotion and Behavior,
College of Public Health, The University of
Georgia, Athens, GA, USA
2
Department of Health and Human Performance,
Texas State University, San Marcos, TX, USA
3
Department of Health Promotion and Behavior,
The University of Georgia, Athens, GA, USA
4
Pulmonary Division, Intermountain Healthcare,
Murray, UT, USA
5
Department of Health and Kinesiology, Texas
A&M University, College Station, TX, USA

Introduction
Physical health and fitness are often discussed in
terms of physical activity (PA) and sedentary
behaviors. While a multitude of factors influence
physical health among children including immunizations, social relationships and contexts, traffic
safety, and risk-taking behaviors such as substance
use or sexual activity, this entry will hone its focus
on evidence and content related to PA (also
referred to as fitness or exercise). Regular PA in
childhood is known to improve strength and
endurance, build healthy bones and muscles,
control weight, reduce anxiety and stress, and
increase self-esteem (U.S. Department of Health
and Human Services [U.S. DHHS], 2008).
Physical activity is also acknowledged to protect
against, prevent, and/or delay the onset of chronic
conditions including high cholesterol, high blood
pressure, type 2 diabetes, heart disease, and some
cancers (U.S. DHHS, 2008). Children’s consistent
involvement in aerobic, muscle-strengthening,
and bone-strengthening activities is important for
overall health benefits; however, these benefits
transcend mere physical health and can positively
influence cognitive functioning, concentration
(Budde, Voelcker-Rehage, Pietraßyk-Kendziorra,
Ribeiro, & Tidow, 2008), and classroom performance (Dwyer, Blizzard, & Dean, 1996).

PA and weight reduction interventions have been
developed, delivered, and evaluated. While the
effectiveness of such interventions varies substantially, common characteristics and underlying threads exist, which distinguish successful
evidence-based programs from those with less
health impact. Among these elements of success
are (1) incorporating recommendations from
authoritative governing body (e.g., the Community Preventive Services Task Force, Council on
Physical Education for Children [COPEC] of the
National Association for Sport and Physical Education), (2) employing age-appropriate physical
activities, (3) focusing on specific PA behaviors,
(4) integrating social and/or familial support,
(5) involving skill building and exercise selfefficacy activities, and (6) addressing multiple
levels of influences on children’s participation
in PA. Due to the complex nature of exercise
behavior and the diverse set of related determinants, characteristics of successful PA interventions for children address multilevel influences
(e.g., individual, interpersonal, organizational,
policy), highlight the importance of involving
a variety of influential people (e.g., parents, siblings, school personnel, religious leaders), and
present opportunities for PA in a variety of settings (e.g., school, community, clinical).

Definitions and Scope
Understanding the current levels of PA and inactivity among children is critical for defining the
extent of the problem and guiding public health
efforts. The US Department of Health and
Human Services recommends that young people
ages 6–17 years participate in at least 60 min of
moderate-to-vigorous physical activity (MVPA)
daily (U.S. DHHS, 2008).
Physical activity (PA) is defined as any bodily
movement produced by skeletal muscles that
require energy expenditure (World Health Organization [WHO], 2012). Intensity of PA is measured in Metabolic Equivalents (METS) – or the
energy cost of sitting quietly – and is equivalent

T.P. Gullotta, M. Bloom (eds.), Encyclopedia of Primary Prevention and Health Promotion,
DOI 10.1007/978-1-4614-5999-6, # Springer Science+Business Media New York 2014

Health and Fitness During Childhood

to a caloric consumption of 1 kcal/kg/h.
Moderate-intensity physical activity (MPA)
requires 3–6 times more energy than sitting;
therefore, MPA is defined as an activity that
requires 3–6 METS and includes activities such
as brisk walking, dancing, and domestic chores.
Vigorous-intensity physical activity (VPA) is
defined as activity that requires more than
6 METS and includes activities such as running,
aerobics, and competitive sports (WHO, 2012).
Reports about PA participation among young
people consistently demonstrate that most children in the United States do not meet PA recommendations. In 2009, only 18 % of high school
students had participated in at least 60 min of
daily MVPA, only 33 % attended physical education (PE) class daily, and only 56 % attended
PE at least once a week (Centers for Disease
Control, 2009).

Theories
Theoretical frameworks provide an avenue to
explore determinants of PA among children.
Although theories used to explore motivation to
be physically active have historically placed
emphasis on individual-level determinants (e.g.,
attitudes, perceived susceptibility, self-efficacy,
subjective normative beliefs), current theoretical
investigations often include additional constructs
that account for interpersonal, environmental,
and social system and structure influences. This
change in focus indicates a paradigm shift and
provides us with a broader understanding of factors associated with children’s motivation(s) to
participate in PA.
Individual-Level Theories and Determinants
A large number of research studies and programs/
interventions investigating determinants of PA
among children have included theoretical constructs drawn from the Health Belief Model
(HBM), Social Learning Theory (SLT), social
cognitive theory (SCT), and the Theory of
Planned Behavior (TPB). For example, a variety
of studies have examined relationships such as
children’s perceived susceptibility to disease

663

from not participating in PA, attitudes towards
performing PA, subjective normative beliefs
about performing PA, and self-efficacy to perform PA. Studies investigating these PA determinants among children have yielded relatively
small correlations between children’s perceptions of susceptibility and subjective normative
beliefs. Conversely, children’s attitudes about
and perceived self-efficacy to perform PA have
been significantly related to children’s participation in PA; self-efficacy to perform PA most
frequently being identified as the most important
determinant for engaging in PA.
Social, Ecological, and Structural Theories
and Determinants
Social, ecological, and structural theories go a step
beyond individual-level theories by postulating
factors extraneous to the individual also impact
behavior. That is, an individual’s immediate
and extended environments (or social systems)
have the potential to influence lifestyle choices
and behavior. The most commonly cited social,
ecological, and structural theories used to
investigate determinants of PA among children
include SCT (Bandura, 1986), Social Ecological
Model (Stokols, 1992; Stokols, Grzywacz,
McMahan, & Phillips, 2003), Organizational
Change Theory (Kaluzny & Hernandez, 1998),
and Structural Ecological Theory (Cohen,
Schribner, & Farley, 2000).
Social cognitive theory hypothesizes
a constant interaction between personal factors
(e.g., attitudes, knowledge, skills), the environment, and behavior. Bandura (1986) labeled this
interaction triadic reciprocal determinism and
proposed that an individual’s environment
impacts behavior and an individual’s behavior
simultaneously impacts their environment. Stated
another way, a person is a product of their environment, yet their actions shape the environment
in which they reside.
Social and Structural Ecological Models
hypothesize that social systems and structural
elements influence behavior by interacting with
intrapersonal factors. Social Ecological Models
focus on population-level health behavior and
have four primary principles: (a) health behaviors

664

are influenced by factors at multiple levels of
influence (i.e., intrapersonal, social systems,
behavior setting, and policy); (b) behavioral
influences interact across multiple levels;
(c) behavior change occurs best when interventions address multiple levels of influence; and
(d) behavior-specific interventions are most
effective (Stokols, 1992). Structural Ecological
Models (Cohen et al., 2000) hypothesize that
health behavior is influenced by four structurallevel categories: (a) availability of protective
products (e.g., condoms, vegetables) or harmful
consumer products (e.g., tobacco, high-fat foods,
firearms), (b) physical structures (e.g., consumer
products, buildings, physical neighborhood layout), (c) social structures (i.e., laws of policies
that require or prohibit behavior), and (d) media
and cultural messages (e.g., frequently heard
messages through media, stories, cultural practices). Additionally, concepts operationalized
within theories of organizational change include
organization-level policies and practices (e.g.,
school that require physical education or offer
healthy foods at lunch) and an organizations ability to embrace change needed to successfully
reach their short- and long-term goals and objectives. These organization-based theoretical concepts have been used to explain behavior change
and – which are also commonly included in many
Social and Structural Ecological Models.

Current Research
Determinants of PA are multidimensional and
often interact across numerous levels of influence. Many researchers have attempted to understand interactions between individual factors
(e.g., attitude, self-efficacy), interpersonal factors
(e.g., peer influence, parent-child relationships),
ecological factors (e.g., social systems, policies),
and PA behavior. Findings from such investigations serve as the foundation and evidence to
inform effective programs to initiate, increase,
and sustain PA among children. The effectiveness of PA programs such as Coordinated
Approach to Child Health (CATCH), Trial of
Activity for Adolescent Girls (TAAG), and

Health and Fitness During Childhood

Sports, Play, and Active Recreation for Kids
(SPARK) has been well documented through
various research methodologies. Results from
these intervention-driven studies indicate the efficacy of these PA programs to effect PA levels
among children.
Determinants of Physical Activity
Investigations seeking to identify determinants of
PA among children indicate several intrapersonal
factors that influence PA among children. In
a comprehensive review of PA literature from
1999 to 2006, evidence strongly supported that
attitude, self-efficacy, and goal orientation/motivation were significant intrapersonal predictors
of PA among children (Van Der Horst, Paw,
Twisk, & Van Mechelen, 2007). Additionally,
perceived self-efficacy to perform PA, perceived
barriers to PA, perceived control over PA,
perceived social support related to PA, and child
interest in PA have also been identified as important antecedents to children’s PA behavior (Biddle & Mutrie, 2008; Dishman, Dunn, Sallis,
Vandenberg, & Pratt, 2010; King et al., 2011;
Trost, Kerr, Ward, & Pate, 2001).
Interpersonal and environmental factors can
also greatly influence PA among children. In
a systematic review of PA interventions, the
most commonly identified interpersonal and
environmental determinants of PA among children were social support from friends, peers, and
family and access to facilities, open spaces, and
parks (Biddle & Mutrie, 2008). Neighborhood
social characteristics, neighbors’ willingness to
“watch out” for others’ children, safe transportation, and proximity to places of interest have also
been identified as important determinants of PA
among children (Evenson, Murray, Birnbaum, &
Cohen, 2010; Franzini et al., 2009; Van der Horst
et al., 2007). For example, environmental factors
hindering children’s ability to engage in PA
include crime, poor sidewalk quality (or absence
thereof), inadequate street lighting, unleashed
dogs, and the lack of green space. While it
remains important to understand the factors
influencing PA among children, it is equally if
not more important to recognize the existing and
precursory factors that contextualize the child’s

Health and Fitness During Childhood

environment, which shapes their opportunities
and barriers to engage in PA.
School-Based Programs
Rigorous evaluation research of programs such as
CATCH and SPARK provide strong evidence
that multidimensional programs can significantly
impact moderate to vigorous physical activity
(MVPA) among children. CATCH and SPARK
are examples of broad programs that address
a wide range of PA determinants. Both CATCH
and SPARK contain individual, family, community, and school-based components, and both programs attempt to improve multiple antecedents to
PA among children including knowledge, skill
development, self-efficacy for PA, and several
others.
Using a pre- and posttest control group design,
Sallis and colleagues (1997) investigated the
influence of the SPARK program on MVPA
among elementary-aged children. On average,
students in the intervention group led by PA
specialists participated in 16 more minutes of
MVPA a week relative to their counterparts in
the control groups. Furthermore, students in
intervention groups led by teachers participated
in 13 more minutes of MVPA compared to those
in control groups. Other researchers reported students in schools using SPARK were five times
more likely to participate in 30 or more minutes
of PA per day during their physical education
classes relative to students in schools where
SPARK was not implemented (Dowda, Sallis,
McKenzie, Rosengard, & Kohl Iii, 2005).
Similarly, other studies investigating the
CATCH program reported that students in intervention groups participated in significantly more
MVPA compared to those students in control
group (i.e., 58.6 min per day compared to
45 min per day, respectively) (Luepker et al.,
1996). In addition to increased PA, students
who participated in CATCH interventions also
increased fruit and vegetable consumption and
experienced higher levels of weight loss.
Two other interventions, Take 10! and PLAY,
integrate short bouts of exercise into existing
classroom curricula. Take 10! encourages
students to perform 10 min of PA at a time during

665

academic activities such as reviewing class material and has been shown to increase participation
in PA among children (Stewart, Dennison, Kohl,
& Doyle, 2004). Using a similar approach, PLAY
incorporates 15-min exercise breaks during
existing curricula to increase the likelihood of
students attaining 30 min of MVPA each day.
Initial evaluations indicate PLAY successfully
increases MVPA among children who
participate.
Programs for Specific Populations
Although many programs have been developed
for grand-scale dissemination within diverse
populations, communities, and settings, other
programs have been specifically tailored to
address the unique needs and characteristics of
certain populations. For example, programs
including TAAG, New Moves, and LEAP were
specifically created to increase PA among middle
and high school girls. In a 3-year nationwide
study of 36 schools implementing TAAG, eighth
grade females enrolled in the intervention
showed significant PA improvements relative to
females in schools without the intervention
(Webber et al., 2008). Furthermore, intervention
group participants had significantly higher PA
levels on weekend days and significantly less
sedentary minutes compared those in the control
group participants. Similarly, New Moves,
a program designed to address psychosocial variables and PA among overweight high school
girls, has been shown to effectively increase PA
among participants and improve antecedents to
behavior (e.g., self-efficacy to perform PA).
LEAP incorporates school, community, family,
and health service components to increase PA
among high school girls. Initial evaluations
report that LEAP increases daily PA and that
participants’ PA level was mediated by girls’
enjoyment of PA and self-efficacy to perform
PA (Motl et al., 2002).
Many other PA programs have been tailored
for specific populations. For example, several
programs have been developed to increase PA
or MVPA among African American females
ages 8–12 years. The Georgia FitKid Project is
a 5-day-a-week PA program that engages

666

participants in 80 min of MVPA per day within
a school setting. Three-year evaluation results
showed an increase in MVPA and fitness as well
as reduced adiposity. Another intervention, Pathways, was created to increase PA among
American Indians in grades three through five.
Grounded in SCT, Pathways uses family,
nutrition, and PA to prevent obesity and other
associated health problems. The PA component
of the program incorporated principles from
SPARK and has initially shown minimal
effects on PA levels among American Indian
participants.
Meta-Analyses and Reviews
Over the past decade, several systematic and
meta-analytic reviews of the scholarly literature
have been conducted to determine the overall
effectiveness of PA programs for children.
Using metabolic equivalent of task (MET) as
a measure of PA, Beets, Beighle, Erwin, and
Huberty (2009) performed a meta-analysis of
after-school programs aimed at increasing PA in
children. Results of this review indicated that
three interventions (i.e., a gardening program,
a Canadian sports program, and the Georgia
FitKid Project) were most effective to increase
children’s PA levels. Other systematic reviews of
PA programs for children have identified
CATCH, SPARK, TAAG, and Take10! as having
short- and long-term influences on PA levels
among participating children (Camacho-Miñano,
LaVoi, & Barr-Anderson, 2011; Heath &
Coleman, 2002; Pate & O’Neill, 2009; Van Der
Horst, Paw, Twisk, & Van Mechelen, 2007).

Strategies
Thorough and rigorous studies have been integral
to assist school and health professionals to
identify characteristics of effective interventions
with potential to increase PA levels among children. When examined collectively, individual
studies, meta-analytic studies, and systematic
reviews of PA-related research have recognized
common essential components of interventions
that make them successful for raising

Health and Fitness During Childhood

activity levels among youth. Identified criteria
include that interventions be (a) comprehensive
and multidimensional (e.g., CATCH, SPARK,
TAAG), (b) grounded in robust theories (i.e.,
SCT and Social or Structural Ecological Models),
and (c) address multiple determinants of
PA. Interventions that incorporate short bouts
of exercise into existing class structures
(e.g., Take10! and PLAY) also appear to increase
PA among children; however, the effectiveness
of these programs to alter fitness levels and
adiposity have not been tested.
Five comprehensive reviews and two metaanalyses of PA interventions conducted between
2000 and 2012 detected significant increases in
PA for 47–100 % of interventions evaluated,
with the most effective interventions containing
school, community, and family components
(Dobbins, De Corby, Robeson, Husson, & Tirilis,
2009; De Meester, van Lenthe, Spittaels, Lien, &
De Bourdeaudhuij, 2009; Kriemler et al., 2011;
Salmon, Booth, Phongsavan, Murphy, &
Timperio, 2007; van Sluijs, 2011). It seems
clear that implementing PA interventions in
a variety of settings and targeting diverse life
dimensions are most effective to modify behavior. As such, the most effective PA interventions
and strategies to change PA behavior among
children address multiple influences including
intrapersonal (e.g., attitude, self-efficacy),
interpersonal (e.g., peer and family influence),
and environmental (e.g., physical structures,
policies) factors. Findings from PA research
highlight several themes related to successful
intervention
strategies:
(a)
developing
multidimensional programs that address
a variety of PA determinants are most effective
(as indicated previously); (b) including PA specialists in PE classes or recreational activities is
associated with positive interventions effects;
(c) delivering multicomponent programs that
focus exclusively on PA (rather than multiple
behaviors) have the greatest intervention effect;
(d) delivering programs with an emphasis on PE
result in greater PA levels among children; and
(e) involving children and the children’s family
increases the effectiveness of interventions
attempting to modify PA levels.

Health and Fitness During Childhood

What Works
Current research suggests the existence of effective interventions that promote PA among children. However, to fully understand the
effectiveness of PA interventions among this
population, criteria for what serves as “evidence”
and those programs considered to be “evidencebased” must first be defined. For the purposes of
this entry, successful interventions were defined
as interventions having three or more trials that
resulted in empirical evidence of increased PA
among children. As such, no intervention met that
criterion.

What Is Promising
There are several interventions that merit further
research but currently provide insufficient evidence about their effectiveness to promote PA
among children. Many of these strategies have
produced inconsistent findings or have been
applied to other target populations. While these
strategies show promise, the mixed set of findings
make their effectiveness inconclusive. Crosscutting themes of interventions with mixed
reviews included programs using knowledgebased curricula, short-term efforts (i.e., program
less than 6 months in duration), and programs
targeting children between the ages of 6 and
11 (especially those who were not obese)
(Hadley, Hair, & Dreisbach, 2010). More specifically, interventions that mandate PA were not
conclusively deemed effective, thus reinforcing
the need for activity variety and the incorporation
of both structure and nonstructured exercise
formats.
For the purposes of this entry, evidences of
what is promising in terms of interventions to
increase PA among children are those efforts/
initiatives that have (1) been rigorously tested
with documented success, (2) been published in
the peer-reviewed literature or supported by
a credible governing body, and (3) a history of
replicability. As such, evidence-based interventions contain common elements of a specifictarget population; specific measurable goals;

667

well-defined program structure and timeframes;
specification about staffing; training, facilities,
and equipment; and an established program evaluation to identify success. With these criteria in
mind, it is also important to consider that our
examination of the multiple determinants of PA
is only useful if knowledge and comprehension is
translated into practice. Understanding these
determinants facilitates the development of
effective interventions to not only increase PA
but also maintain this behavior. Therefore, we
must consider issues of available resources and
the feasibility/reality that such evidence-based
interventions can be delivered with fidelity.
A recent review of the literature has identified
general characteristics of successful interventions to increase MVPA among children (Hadley
et al., 2010). In this review, cross-cutting themes
deemed to be effective included programs that
purposively targeted efforts to overweight or
obese children (i.e., change is more difficult to
detect among those of normal weight or those
who are already physically active), contained
a narrow set of goals specific to the desired
behavioral outcome (i.e., focusing on PA rather
than focusing on multiple behaviors like diet and
weight loss simultaneously), and incorporated
a counseling or therapy component for the participant and/or their family to provide additional
assistance to meet behavioral objectives. More
specifically, effective programs were longer in
duration (rather than a brief intervention or
one-time delivery), tracked participants progress
over time (strong evaluation component), and
included skill-building competencies (rather
than mere education).
School-Based Physical Education
Interventions
Schools play a critical role in shifting children’s
sedentary behaviors to a more active and fit lifestyles. Children spend nearly 7 h of their day at
school, which makes these institutions an appropriate setting for PA interventions (Ward,
Saunders, & Pate, 2007). School-based interventions have been shown to increase the number of
minutes engaged in MVPA, mostly attributed to
increasing the percentage of class time dedicated

668

to activities involving this level of activity (Ward
et al., 2007). Common elements of successful
school-based interventions are the incorporation
and enhancement of school-based physical education, improved health education and nutrition
curriculum, and increased levels of social and
familial support (although not always
implemented simultaneously) (Kahn et al.,
2002). While these elements are especially
important to the initiation of PA behaviors, program deliverers must also consider the maintenance of such behaviors. To sustain PA levels
among children, programs should promote
a variety of enjoyable physical activities
(to maintain participant interest) that are age
appropriate. Examples of school-based programs
with documented success to increase PA include
CATCH (Kelder et al., 2005), Take 10! (Stewart,
Dennison, Kohl, & Doyle, 2004), PLAY
(Pangrazi, Beighle, Vehige, & Vack, 2003), and
SPARK (Sallis et al., 1997).
The effectiveness of a school-based intervention is often enhanced when considered within
the context of the Coordinated School Health
Approach (Allensworth, Lawson, Nicholson, &
Wyche, 1997; Marx & Northrop, 1998). This
means the intervention transcends merely physical education and encompasses other aspects of
school health including nutrition, psychological
services, and the built environment. Specific to
physical education, programmatic characteristics
associated with positive outcomes include assurances that adequate time is allotted for PA (i.e.,
the actual time for PA can be easily squandered
because traditional physical education periods
may be 50 min in length, this includes time to
change into gym clothes, discuss rules and activities, warm-up, cool down, and dress back into
school clothes) and class sizes are reasonable for
the proposed activity (i.e., classes that are too
small may not afford enough activity or interaction, whereas groups that are too large may cause
coordination difficulties and the need to host
multiple independent activities) (San Diego
State University, 2007). Additionally, schoolbased interventions to promote PA should
include competitive and noncompetitive activities, structured and unstructured activities, and

Health and Fitness During Childhood

time for activities throughout the day (i.e., before,
during, and after school) (Ribeiro et al., 2010).
Examples of before and after school interventions
that have been shown to improve PA include
walking/biking programs to and from school
(e.g., Safe Routes to School program, Waling
School Buses, Walking to School Days), which
are well supported by school policy, staff, parents, and others.
Individually Adapted Interventions
Individually adapted interventions focus on the
incorporation of PA into daily routines and tailoring programs to meet the specific needs and
interests of each individual (Kahn et al., 2002).
Common elements of effective individually
adapted interventions include an increased focus
on goal setting, building social support, behavioral reinforcement, problem solving, and relapse
prevention for sedentary behavior. Individuallyadapted interventions are appropriate for various
settings including schools and communities
(Kahn et al.). Multicomponent programs like
SPARK typically include individually tailored
features such as self-management and
“homeplay” activities completed by the child
and their parents. While shown to be effective,
considerable resources are often needed to offer
individually tailored interventions. For many settings and budgets, these types of approaches may
not be feasible or cost efficient.
Policies, Systems, and the Built Environment
Incorporating policies that facilitate PA has been
an effective method for increasing PA levels
among children. Furthermore, utilizing systems
that encourage participation across all ability
levels, and reducing the impact of barriers to
PA, are known to increase daily PA within this
population. Findings from existing research indicate that daily PA among children can be
increased by (1) developing and implementing
policies that increase access to and use of footpaths, bikeways, and other forms of manual transportation, rather than motorized vehicles (Pucher,
Dill, & Handy, 2010); (2) providing safe, accessible places for people to be involved in recreation, exercise, sports, walking, and cycling; and

Health and Fitness During Childhood

(3) utilizing sports systems and programs that
promote “Sport for All” policies and programs
(Australian Local Government Association et al.,
2010; WHO, 2002). Building upon the universal
appeal of sport, a comprehensive sport system
should be implemented that includes the adaption
of sports to provide a range of activities to match
the interests of girls and boys of all ages, in
addition to well-coordinated coaching and training opportunities.
Community and Public Education
Public education remains an essential component
of interventions aimed at increasing PA. For
example, utilizing mass media can raise awareness and change perceptions of social normative
behavior related to PA. This may include print,
audio, and electronic media; outdoor billboards
and posters; public relations; point of decision
prompts; mass participation events; mass distribution of information; and newer forms of media
such as text messaging and social networking.
Although mass media has the ability to reach
a large portion of the population, informationonly educational interventions are generally not
effective. Well-designed community-based
educational programs can help children utilize
information received from mass media to identify
resources, build self-efficacy, and develop
skills necessary to perform recommended levels
of daily PA. Effective community-based
educational interventions should involve multiple settings and sectors that appropriately and
synergistically integrate engagement and
resources.
Classroom-Based Health Education
Unlike school-based physical education interventions, classroom-based interventions to reduce
television viewing and video game playing have
produced inconsistent findings. The average child
spends nearly 6 h per day exposed to some form
of media (Ward et al., 2007). Research indicates
that media (primarily television) leads to PA displacement PA, reduced resting metabolism, and
increased calorie consumption during television
viewing time (Robinson, 2001). With children
spending nearly as much time watching

669

television, as they do in the classroom, it seems
plausible to design classroom-based interventions to reduce television viewing. Studies show
that interventions targeting television and video
game reduction show a consistent decrease in the
viewing activities of children (Kahn et al., 2002).
According to the Community Guide, classroombased health interventions also decreased the
amount of time spent in other sedentary behavior.
However, what is poorly understood is if these
reductions in television viewing and video game
playing correspond to increased levels of PA. A
randomized control trial showed that each hour of
reduced television viewing resulted in reduced
obesity prevalence for girl participants
(Gortmaker et al., 1999). Similar studies have
found weak and variable associations in this
form of intervention.
Social Support Interventions in the
Community
Communities provide opportunities to engage in
PA outside the confinements of school and home.
Involvement in recreational sports, youth service
organizations, and religious organizations provides children with opportunities to be physically
active and social (Ward et al., 2007).
Community-based settings are invaluable for
PA because they are accessible on the weekends,
in the summer, and after school (Ward et al.).
However, many barriers to participation in
community-based programs exist. Cost, transportation, and perceived safety can influence the
decision to engage in available community
activities (also consider some communities have
limited community program offerings) (Ward
et al.). A child’s social environment can influence
their exercise behavior; however, recent research
suggests the effectiveness of community-based
social support interventions only exists for adults.
Social support interventions increase PA through
building, strengthening, and maintaining social
networks (Kahn et al., 2002). Successful interventions typically involve the buddy system or
peer groups. Due to the success of these strategies
among diverse groups of adults, it seems promising that these interventions can be effectively
adapted to target children.

670

What Does Not Work
As previously indicated, interventions that
were too broad in scope (i.e., address multiple
behaviors simultaneously) and targeted only
one determinant of physical inactivity were
deemed ineffective. Further, knowledge-based
approaches are insufficient enough to increase
PA among children. Classroom-based health education courses designed to provide information
about PA and health generally do not devote
adequate time for students to engage in substantial levels of PA (Kahn et al., 2002). While
classroom-based health education programs can
help children attain knowledge necessary to
adopt healthy behaviors, this increase in knowledge and self-efficacy typically has little to no
impact on exercise behavior (Kahn et al.).
Despite the lack of evidence supporting the
abovementioned interventions, such approaches
should not be fully discounted. Further research
and rigorous evaluation are needed to examine
the effectiveness of promising strategies, techniques, and programs intended to increase PA
among children. This point alludes to the importance of considering evaluation and programmatic goal setting during the earliest stages of
intervention selection. Adherence to program
fidelity, long-term tracking of behavioral outcomes, and thorough documentation of findings
(and reporting in the scholarly literature) are
essential to understand the efforts and elements
of successful PA interventions and advance best
practices.

Summary
This entry highlights the existence of effective
measures to help children reach or maintain
recommended levels of PA: (1) incorporating
recommendations from authoritative governing
body, (2) employing age-appropriate physical
activities, (3) focusing on specific PA behaviors,
(4) integrating social and/or familial support,
(5) involving skill building and exercise
self-efficacy activities, and (6) addressing
multiple levels of influence. However, despite

Health and Fitness During Childhood

the ability of programs to yield significant
increases in participant PA, the majority of
children in the United States still do not
reach recommended daily PA levels. This may
be explained by the diverse needs/resources of
children, variation of existing PA programs, and
the sporadic implementation of evidencebased programs across the United States. Implementation of a systematic approach in which
effective programs and interventions are used
across the United States would best help children
meet recommended daily PA levels; however,
challenges remain to meet the individual needs
of children while simultaneously generalizing
strategies and activities to accommodate the
masses.

See Also
▶ Nutrition and Healthy Eating in Older
Adulthood
▶ Peer Relationships: Promoting Positive Peer
Relationships During Childhood

References
Allensworth, D. D., Lawson, E., Nicholson, L., & Wyche,
J. (1997). Schools & health: Our nation’s investment.
Washington, DC: National Academies Press.
Australian Local Government Association, Bus Industry
Confederation, Cycling Promotion Fund, National
Heart Foundation of Australia, & International Association of Public Transport. (2010). An Australian
vision for active transport. Deakin, VIC, Australia:
Australian Capital Territory. Retrieved April,
20, 2012, from http://www.heartfoundation.org.au/
SiteCollectionDocuments/Active-Vision-for-ActiveTransport-Report.pdf
Bandura, A. (1986). Social foundations of thought and
action. Englewood Cliffs, NJ: Prentice Hall.
Beets, M., Beighle, A., Erwin, H., & Huberty, J. (2009).
After-school program impact on physical activity and
fitness: A meta-analysis. American Journal of Preventive Medicine, 36(6), 527–537.
Biddle, S. J. H., & Mutrie, N. (2008). Psychology of
physical activity: Determinants, well-being, and interventions (2nd ed.). New York: Routledge.
Budde, H., Voelcker-Rehage, C., Pietraßyk-Kendziorra, S.,
Ribeiro, P., & Tidow, G. (2008). Acute coordinative
exercise improves attentional performance in adolescents. Neuroscience letters, 441(2), 219–223.

Health and Fitness During Childhood
Camacho-Miñano, M. J., LaVoi, N. M., & Barr-Anderson,
D. J. (2011). Interventions to promote physical activity
among young and adolescent girls: A systematic
review. Health Education Research, 26(6),
1025–1049. doi:10.1093/her/cyr040.
Centers for Disease Control. (2009). Youth risk behavior
surveillance- United States. Morbidity and Mortality
Weekly Report, 59(5), 1–142.
Cohen, D. A., Schribner, R., & Farley, T. A. (2000).
A structural model of health behavior: A pragmatic
approach to explain and influence health behaviors at
the population level. Preventive Medicine, 30,
146–154.
De Meester, F., van Lenthe, F., Spittaels, H., Lien, N., &
De Bourdeaudhuij, I. (2009). Interventions for promoting physical activity among European teenagers:
A systematic review. International Journal of Behavioral Nutrition and Physical Activity, 6(6), 1–11.
Dishman, R. K., Dunn, A. L., Sallis, J. F., Vandenberg,
R. J., & Pratt, C. A. (2010). Social-cognitive correlates
of physical activity in a multi-ethnic cohort of middleschool girls: Two-year prospective study. Journal of
Pediatric Psychology, 35(2), 188–198. doi:10.1093/
jpepsy/jsp042.
Dobbins, M., De Corby, K., Robeson, P., Husson, H., &
Tirilis, D. (2009). School-based physical activity programs for promoting physical activity and fitness in
children and adolescents aged 6–18. Cochrane Database of Systematic Reviews, 21(1), CD007651.
Dowda, M., Sallis, J. F., McKenzie, T. L., Rosengard, P.,
& Kohl Iii, H. W. (2005). Evaluating the sustainability
of SPARK pysical education: A case study of translating research into practice. Research Quarterly for
Exercise and Sport, 76(1), 11–19.
Dwyer, T., Blizzard, L., & Dean, K. (1996). Physical
activity and academic performance in children. Nutrition Review, 54(4), 27–31.
Evenson, K. R., Murray, D. M., Birnbaum, A. S., &
Cohen, D. A. (2010). Examination of perceived neighborhood characteristics and transportation on changes
in physical activity and sedentary behavior: The trial
of activity in adolescent girls. Health & Place, 16(5),
977–985. doi:10.1016/j.healthplace.2010.06.002.
Franzini, L., Elliot, M., Cuccaro, P., Schuster, M.,
Gillilard, M., Grunbaum, J., et al. (2009). Influences
of physical and social neighborhood environments on
children’s physical activity and obesity. American
Journal of Public Health, 99(2), 271–278.
Gortmaker, S. L., Peterson, K., Wiecha, J., Sobol, A. M.,
Dixit, S., Fox, M. K., et al. (1999). Reducing obesity
via a school-based interdisciplinary intervention
among youth: Planet health. Archives of Pediatric
Adolescent Medicine, 153(4), 409–418. doi:10.1001/
archpedi.153.4.409.
Hadley, A. M., Hair, E. C., & Dreisbach, N. (2010). What
works for the prevention and treatment of obesity
among children: Lessons from experimental evaluations of programs and interventions. Child trends fact
sheet. Washington, DC: Child Trends.

671
Heath, E., & Coleman, K. (2002). Evaluation of the institutionalization of the Coordinated Approach to Child
Health (CATCH) in a U.S./Mexico border community.
Health Education & Behavior, 29(4), 444–460.
Kahn, E. B., Ramsey, L. T., Brownson, R. C., Heath,
G. W., Howze, E. H., Powell, K. E., et al. (2002).
The effectiveness of interventions to increase physical
activity: A systematic review. American Journal of
Preventive Medicine, 22(4, Supplement 1), 73–107.
doi:10.1016/s0749-3797(02)00434-8.
Kaluzny, A., & Hernandez, S. (1988). Organization
change and innovation health care management:
A text in organization theory and behavior (2nd ed.).
New York: Wiley.
Kelder, S., Hoelscher, D. M., Barroso, C. S., Walker, J. L.,
Cribb, P., & Hu, S. (2005). The CATCH Kids Club:
A pilot after-school study for improving elementary
students’ nutrition and physical activity. Public Health
Nutrition, 8(02), 133–140. doi:10.1079/PHN2004678.
King, A. C., Parkinson, K. N., Adamson, A. J., Murray, L.,
Besson, H., Reilly, J. J., et al. (2011). Correlates of
objectively measured physical activity and sedentary
behaviour in english children. The European Journal
of Public Health, 21(4), 424–431. doi:10.1093/eurpub/
ckq104.
Kriemler, S., Meyer, U., Martin, E., van Sluijs, E. M. F.,
Andersen, L. B., & Martin, B. W. (2011). Effect of
school-based interventions on physical activity and
fitness in children and adolescents: A review of
reviews and systematic update. British Journal of
Sports Medicine, 45(11), 923–930. doi:10.1136/
bjsports-2011-090186.
Luepker, R. V., Perry, C. L., McKinlay, S. M., Nader,
P. R., Parcel, G. S., Stone, E. J., et al. (1996). Outcomes of a field trial to improve children’s dietary
patterns and physical activity. The Journal of the
American Medical Association, 275(10), 768–776.
doi:10.1001/jama.1996.03530340032026.
Marshall, S., & Biddle, S. (2001). The transtheoretical
model of behavior change: A meta-analysis of applications to physical activity and exercise. Annals of
Behavioral Medicine, 23(4), 229–246. doi:10.1207/
s15324796abm2304_2.
Marx, E. S. W., & Northrop, D. (1998). Health is academic: A guide to coordinated school health programs. New York: Teachers College Press.
Motl, R. W., Dishman, R. K., Saunders, R. P., Dowda, M.,
Felton, G., Ward, D. S., et al. (2002). Examining
social-cognitive determinants of intention and physical activity among black and white adolescent girls
using structural equation modeling. Health Psychology, 21(5), 459–467.
Pangrazi, R. P., Beighle, A., Vehige, T., & Vack,
C. (2003). Impact of Promoting Lifestyle Activity for
Youth (PLAY) on children’s physical activity. Journal
of School Health, 73(8), 317–321. doi:10.1111/j.17461561.2003.tb06589.x.
Pate, R. R., & O’Neill, J. R. (2009). After-school interventions to increase physical activity among youth.

672
British Journal of Sports Medicine, 43(1), 14–18.
doi:10.1136/bjsm.2008.055517.
Pucher, J., Dill, J., & Handy, S. (2010). Infrastructure,
programs, and policies to increase bicycling: An international review. Preventive Medicine, 50, S106–S125.
Ribeiro, I., Parra, D., Hoehner, C., Soares, J., Torres, A., &
Pratt, M. (2010). School-based physical education programs: Evidenced-based physical activity interventions for youth in Latin America. Global Health
Promotion, 17(2), 05–15.
Robinson, T. N. (2001). Television viewing and childhood
obesity. Pediatric Clinics of North America, 48(4),
1017–1025.
Sallis, J. F., McKenzie, T. L., Alcaraz, J. E., Kolody, B.,
Faucette, N., & Hovell, M. F. (1997). The effects of a
2-year physical education program (SPARK) on physical activity and fitness in elementary school students.
Sports, play and active recreation for kids. American
Journal of Public Health, 87(8), 1328–1334.
Salmon, J., Booth, M. L., Phongsavan, P., Murphy, N., &
Timperio, A. (2007). Promoting physical activity participation among children and adolescents. Epidemiologic
Reviews, 29(1), 144–159. doi:10.1093/epirev/mxm010.
San Diego State University. (2007). What works for PE. A
brief from the California Endowment. Los Angeles,
CA. Retrieved April 20, 2012, from http://www.
calendow.org
Stewart, J. A., Dennison, D. A., Kohl, H. W., & Doyle,
J. A. (2004). Exercise level and energy expenditure in
the TAKE 10! in-class physical activity program. The
Journal of School Health, 74(10), 397–400.
Stokols, D. (1992). Establishing and maintaining healthy
environments: Toward a social ecology of health promotion. American Psychologist, 47(1), 6–22.
doi:10.1037/0003-066x.47.1.6.
Stokols, D., Grzywacz, J. G., McMahan, S., & Phillips, K.
(2003). Increasing the health promotive capacity of
human environments. American Journal of Health
Promotion, 18(1), 4–13.

Health and Fitness During Childhood
Trost, S. G., Kerr, L. M., Ward, D. S., & Pate, R. R. (2001).
Physical activity and determinants of physical activity
in obese and non-obese children. International Journal
of Obesity and Related Metabolic Disorders, 25(6),
822–829.
United States Department of Health and Human Services.
(2008). Physical activity guidelines advisory committee report. Washington, DC: Author.
Van der Horst, K., Paw, M., Twisk, J. W. R., & Van
Mechelen, W. (2007). A brief review on correlates of
physical activity and sedentariness in youth.
Medicine and Science in Sports and Exercise, 39(8),
1241–1250.
vanSluijs, E. M. F., Kriemler, S., & McMinn, A. M.
(2011). The effect of community and family
interventions on young people’s physical activity
levels: A review of reviews and updated
systematic review. British Journal of Sports
Medicine, 45(11), 914–922. doi:10.1136/bjsports2011-090187.
Ward, D., Saunders, R., & Pate, R. R. (2007). Physical
activity intervention in children and adolescents.
Champaign, IL: Human Kinetics.
Webber, L. S., Catellier, D. J., Lytle, L. A., Murray, D. M.,
Pratt, C. A., Young, D. R., et al. (2008). Promoting
physical activity in middle school girls: Trial of activity for adolescent girls. American Journal of Preventive Medicine, 34(3), 173–184. doi:10.1016/j.
amepre.2007.11.018.
World Health Organization. (2002). A physically
active life through everyday transport with
a special focus on children and older people
and examples and approaches from Europe.
Copenhagen, Denmark: WHO Regional Office for
Europe.
World Health Organization. (2012). Physical activity
intensity. Retrieved April 20, 2012, from http://www.
who.int/dietphysicalactivity/physical_activity_intensity/
en/index.html

Healthy Development in Children of Adoptive Parents

Healthy Development in Children of
Adoptive Parents
Doreen Arcus, Nicole Mason and
Janelle Diaz
Department of Psychology, University of
Massachusetts Lowell, Lowell, MA, USA

Introduction
Children who are adopted in the USA are
a diverse group. They include children adopted
as infants whose birth parents and adoptive parents have never met, children whose birth and
adoptive parents are engaged in an ongoing relationship, children adopted long after infancy due
to abuse or neglect whose birth parents are
prohibited from contact, children adopted after
lengthy stays in institutional settings about
whose birth parents little is known, children
adopted from the local community, and children
adopted internationally.
Children are considered adopted when individuals other than their biological parents
assume legal parental responsibility for them.
Persons who adopt must have reached the age
of legal majority. They may be married or single, of higher or lower socioeconomic status,
gay or straight, related or unrelated to the
child, and of the same or different racial, ethnic,
and cultural backgrounds as the child. They may
adopt domestically or internationally through
private or public agencies. In recent years,
some countries have imposed restrictions on
adoptive parent qualifications. Since 2006, for
example, China has required adoptive parents
to be between 30 and 50 years of age (55 for
special needs adoptions; see below) of good
physical and mental health, be in a heterosexual
marriage, meet income and assets standards,
have no more than five children under the age
of 18, and have a clean criminal record with no
evidence of domestic violence or substance
(including alcohol) abuse (US Department of
State, 2011). Russia, on the other hand, has few
restrictions beyond those involving health and

673

fitness for employment and is working to implement a new agreement with the USA to enhance
protections to safeguard the welfare of internationally adopted children (US Department of
State, 2008). There are also many informal
adoptions throughout the world; since there is
scant research on these arrangements, they are
not discussed here.
Adoptions vary in their degree of openness
with respect to contact between the birth parents
and adoptive family. Children in open adoptions
have information about their birth family and
may have additional contact with one or more
members of the family, whereas children in
closed adoptions do not have continuing contact
although they may have information. Obviously,
children removed from their birth families at
later ages have the type of information characteristic of open adoptions, but contact with at
least some family members is likely to be
discontinued for safety. Special needs adoptions
involve children in categories that are associated
with lower probabilities of finding a permanent
home: sibling groups, older children, minority
group status, or medical or psychological challenges. The terminology can be confusing; children in special needs adoptions need have no
special educational need (e.g., learning or other
disabilities).
Adoption per se is a positive transaction, placing
children without families who can adequately care
for them into families who can. It is also a pervasive
phenomenon across cultures and history, bringing
with it special challenges to both the developing
child and his or her family. These challenges, as
well as the strategies that may work to minimize
them, are best understood by the circumstances that
lead to the adoption in the first place and the subsequent construction of that narrative in children’s
lives. That discussion provides the basis for this
entry, which is focused on facilitating healthy outcomes among children who are adopted.

Definitions and Scope
The most recent census data showed that
2.1 million, or slightly more than 2 % of children

T.P. Gullotta, M. Bloom (eds.), Encyclopedia of Primary Prevention and Health Promotion,
DOI 10.1007/978-1-4614-5999-6, # Springer Science+Business Media New York 2014

674

living in US family households, were adopted
(Lofquist, Lugaila, O’Connell, & Feliz, 2012).
Older children and adolescents are overrepresented among adoptees. For example, 60 % of
international adoptions in the USA in 2010 were
of infants and children from 0 to 2 years old,
while only 27 % of those adopted from foster
care were in the same age range
(US Department of Health & Human Services,
2011; US Department of State, 2010).
South Korea was long the primary country of
origin for children adopted internationally in the
USA, but that has changed. The one-child family
policy in China has resulted in a marked increase
in international adoptions of Chinese infants; in
2000, China accounted for only 3 % of all
foreign-born adopted children in the USA, but
by 2010 nearly one-third of children adopted
internationally in the USA were from China.
Another 23 % of children adopted internationally
were from Ethiopia, 10 % from Russia, 8 % from
South Korea, 4 % from the Ukraine, 3 % from
Taiwan, and about 2 % each from Colombia,
India, and the Philippines (US Department of
State, 2010). Children adopted from outside the
USA in 2010 were more likely to be girls than
boys (56 % compared with 44 %; US Department of State). However, among children
adopted from foster care, boys slightly outnumber girls as in the general population (51 % compared with 49 %; US Department of Health &
Human Services, 2011).
Complete data on the type of adoptions that
take place each year in the USA are sparse as few
states require agencies to be licensed in order to
place children in adoptive homes. In Massachusetts, a state requiring licensure, 34 % of the
adoptions finalized in 2004 were of children
from foster care, with the rest from private
sources, 57 % international and 9 % domestic
(Center for Adoption Research, 2006). Historically, the most reliable national data are from the
public child welfare system, in which the number
of adoptions has increased dramatically since
passage of the Adoption and Safe Families Act
of 1997 in large part due to the increasing number
of relatives formally adopting children from foster care, 32 % of such adoptions in FY2010

Healthy Development in Children of Adoptive Parents

(US Department of Health & Human Services,
2011). The median age of children adopted from
foster care in 2010 was 5.2 years; 43 % were
White, 24 % Black, and 21 % Hispanic;
two-thirds were placed in families headed by
a married couple, and 28 % placed in families
headed by a single woman (US Department of
Health & Human Services).
Not all adoptions last forever. Disruption is
a failure of the relationship before it is legally
finalized. Rates vary depending on the population
studied, between 9 % and 15 % overall but about
25 % for older children (Festinger, 2005). Dissolution is a failure of the relationship after finalization, which has consistently been found to
occur in between 1 % and 10 % of cases, more
often in older child adoption (Child Welfare
Information Gateway, 2004).

Theories
Major theories in child psychology can be used to
frame factors that promote healthy social and
cognitive development from conception through
adolescence, and most have application to
special challenges of adoption during middle
childhood, the period of focus for this entry. Of
particular relevance are attachment theory,
theories of cognitive development, and an ecological view of human development that
acknowledges the interplay of factors between
the individual and intertwined social contexts
from immediate relationships to the cultural and
historical setting.
Separation, loss, and attachment are at the core
of the adoption experience. Attachment theorists
generally hold that early parent-child relationships create a fundamental model on which subsequent social relationships grow (Bowlby,
1980). When parents are consistently responsive
to their child’s needs, they foster secure attachments that promote basic trust, exploratory
behavior, adaptation, social skills, and emotion
regulation; when primary relationships are
marked by loss, neglect, or mistreatment, insecure attachment patterns may place development
at risk, especially the capacity to cope with

Healthy Development in Children of Adoptive Parents

stressful situations (van IJzendoorn, Schuengel,
& Bakermans-Kranenburg, 1999).
Although attachment theory awards primacy
to early relationships, stage is more important
than age. Children’s dependency in infancy and
early childhood creates optimal conditions to
establish trust; the hungry infant must rely on
a caregiver for food. Older children have more
capacity to fend for themselves and are less
dependent on adults to meet their basic needs;
the hungry 8-year-old can go to a cabinet and
take a snack. However, in theory, children
whose early relationships were marked by instability or deprivation may still develop secure
attachments later on, although it may be more
difficult for them to do so and may require special
efforts. Engagement in nurturing relationships
and the child’s development of a secure attachment model is a central task of adoption in order
to provide a foundation for further healthy socialemotional adjustment.
Theories of cognitive development also have
special relevance to adoption. The onset of middle childhood is marked by dramatic shifts in
cognitive capacity, characterized by Piaget as
the development of concrete operations (Piaget
& Inhelder, 1969). Children become less egocentric and are able to process multiple aspects of
a problem at the same time, often exemplified by
the preschool child’s difficulty in telling that
a volume of liquid in a short wide glass has not
changed when it is poured into a tall narrow one,
compared with the school-aged child’s ability to
see that volume is conserved. Implications for
children who are adopted include an ability to
consider the perspectives of others including
birth parents (“Why did she give me away?”)
and multiple aspects of being in even the warmest
and most loving adoptive family, an event inextricably intertwined with the loss of biological
parents and perhaps secondary losses of extended
family members (i.e., having this means losing
that). Development of a theory of mind (ToM),
understanding that others may hold beliefs and
mental states different than one’s own and that
those beliefs and mental states may or may not
reflect reality, extends beyond the preschool
period (Miller, 2012). As their ToM evolves,

675

adopted children may begin to wonder about
their birth parents’ current feelings toward them
(“Does she miss me?”) in increasingly sophisticated ways across childhood (“Does she think
that I miss her?”).
Middle childhood is also marked by rapid
improvement in episodic memory, the capacity
to encode, store, and retrieve events as well as the
contexts surrounding them, emerging from development of a neural network involving the hippocampus, prefrontal cortex, and posterior parietal
cortex (Ghetti & Bunge, 2012) and forming the
basis for autobiographical memory (Nelson &
Fivush, 2004). As language skills become
increasingly complex across middle childhood,
children have the tools to understand, process,
and store experiences in ways that allow them to
create an integrated life narrative, which is especially relevant to children who are adopted.
Like all developmental processes, attachment
and cognition unfold in context. A theoretical
view that embeds the individual at the center of
a series of interrelated social contexts approaches
development in an ecological framework
(Bronfenbrenner, 1979). As in any ecology,
change is unlikely to occur in isolation, individual influencing environments and vice versa.
Moreover, the larger cultural context provides
meaning for events in the lives of individuals
and families so that the meaning of adoption
evolves as cultural ideals of family change and
an appreciation of diversity becomes more
widespread.

Current Research
The first US population-based survey to investigate the post-adoption experiences of children
from across adoption types – international, from
foster care, and other domestic placements, with
the exclusion of stepparent adoptions – was
conducted in 2007–2008 (National Survey of
Adoptive Parents (NSAP); Vandivere, Malm, &
Radel, 2009) and provides an important data set
for comparative and multivariate analyses of
children’s adjustment. Research continues to
emerge from this data set as well as the secondary

676

sample of adoptive parents of children with special needs. The following section draws heavily
from this landmark survey in addressing the
extent to which adoption is a problem or risk
factor for school-aged children.
Children who are adopted do appear to be at
heightened risk for problems across a variety of
health, social, and educational domains. On average, however, most adopted children score in the
normal range on adjustment rating scales.
Although 87 % of adopted school-aged children in the Survey of Adoptive Parents (NSAP)
were reported to be in excellent or very good
health overall, 29 % were reported to have moderate or severe health problems – significantly
more than the general school-aged population
with the highest prevalence (46 %) among children adopted from foster care. While this may
appear contradictory at first glance, adopted children also had more consistent access to health
insurance and, especially among school-aged
children, were more likely to receive coordinated
and ongoing medical care. Children who were
adopted were also less likely to live in poverty
than non-adopted children, and, among adoption
types, internationally adopted children were most
likely to have parents with college education,
high income, and full-time employment
(Vandivere, Malm, & Radel, 2009).
The NSAP revealed more social-emotional
problems among adopted children compared
with non-adopted children although the
absolute prevalence was low. Adopted schoolaged children were twice as likely to have
behavior problems (10 % vs. 5 %) and ADHD
(21 % vs. 9 %), especially among children
adopted from foster care (32 %). Fewer adopted
children were described as consistently engaged
in school (80 % vs. 86 %), and children adopted
from foster care were less likely than children
from other adoptive backgrounds to have strong
reading, language arts, and math skills. Children
who were adopted were also more likely to
be engaged in activities outside school (athletics,
clubs, etc.) than their non-adopted peers
(89 % vs. 79 %). Although parents of children
adopted from foster care were less likely to
describe their relationship with their child

Healthy Development in Children of Adoptive Parents

as very warm and close, the majority did so –
81 % compared with 90 % for international
adoptions and 93 % for other domestic adoptions
(Vandivere, Malm, & Radel, 2009).
Recent developments in neuroscience and
environmental deprivation suggest mechanisms
by which some of these problems may arise in
adopted children. In the NSAP, for example,
children living in congregate care prior to their
adoption were less likely to have strong
reading and language arts skills (Vandivere &
McKlindon, 2010), consistent with the finding
among non-adopted children that environmental
stimulation at ages 4 and 8 predicted language
skills at age 12 in a low-socioeconomic-status
(SES) sample (Farah et al., 2008), implicating
stimulation per se and not the broader
contexts of SES. The impact of deprivation on
brain structure in 8- to 11-year-olds was
demonstrated in the Bucharest Early Intervention
Project (BEIP; Sheridan, Fox, Zeanah,
McLaughlin, & Nelson, 2012) in which children
living in institutional settings between the ages of
6 and 31 months were randomly assigned to
either continue on in the setting or be placed in
family foster care (FC). The neural development
of both groups was later compared with children
never institutionalized (NI) using MRI. Although
both groups of children with institutional histories had lower cortical gray matter volume than
NI children, children placed in FC showed
greater white matter volume than those children
continuing in the institution and were not significantly different from NI, providing evidence of
compensatory potential in children removed from
institutional settings and placed in families (Sheridan, Fox, Zeanah, McLaughlin, & Nelson,
2012). These neurological findings are consistent
with the results of a meta-analysis of 62 adoption
studies including over 17,000 children in which
such consistent evidence of cognitive “catch-up”
was found among adopted children that the
authors concluded adoption itself was a natural
and effective intervention (van IJzendoorn &
Juffer, 2005).
In addition to the BEIP, extensive follow-up
of children adopted from Romanian orphanages has shown that early and prolonged

Healthy Development in Children of Adoptive Parents

institutionalization and deprivation have lasting
effects on multiple aspects of children’s development, including high rates of ADHD, language
and cognitive impairment, stereotyped and
autistic-like behaviors, and difficulties with
attachment and in social interaction (Rutter &
Sonuga-Barke, 2010). Relative to other internationally adopted children from foster care, previously institutionalized 8- to 11-year-old children
also showed elevated levels of externalizing
problems and, by their own assessment, internalizing symptoms beyond the clinical cutoff (Wiik
et al., 2011). Over 80 % of a sample of 9- to
13-year-old children adopted from Russia after
spending an average of 3 years in institutions
were found to require special education, 62 %
with language disorder, and 42 % with ADHD
(Beverly, McGuinness, & Blanton, 2008). Longterm global cognitive impairment was found in
37 % of a sample of previously institutionalized
children being raised in the USA (mean
age 9.4 years), and among the 63 % who were
globally intact, over half showed no cognitive
impairment at all; the degree of impairment
shown by the remaining children was correlated
with the amount of time institutionalized (Behen,
Helder, Rothermel, Solomon, & Chugani, 2008).
In addition to institutional deprivation, the
consequences of child abuse and neglect are
important factors to consider in the well-being
of school-aged adopted children. Among all
adoptive parents in the NSAP, 40 % believed
their child had probably experienced neglect
prior to the adoption, 26 % physical abuse, and
11 % sexual abuse (Vandivere & McKlindon,
2010). These numbers were obviously higher
for adoptions from foster care (59 % neglect,
44 % physical abuse, and 21 % sexual abuse)
but not trivial for other domestic adoptions (25
%, 18 %, and 5 %, respectively) or international
adoptions (36 %, 11 %, and 4 %). Among 6- to
8-year-old Chinese girls adopted in the USA,
those with a history of neglect showed significantly lower academic achievement and overall
competence than those adopted without a neglect
history (Tan, 2006). Adopted children with
a history of complex trauma resulting from maltreatment in the context of a caregiving

677

relationship showed significant delays in overall
adaptive behavior (age equivalent 4.4 years compared with 9.9-year chronological age) and clinically significant scores in both externalizing
and maladaptive behaviors (Becker-Weidman,
2009). Lesser amounts of adoption preparation
and poorer adoptive family function, but especially a history of sexual abuse, were found to
predict externalizing behavior in a large sample
of 6- to 18-year-old boys adopted from foster care
(Nalavany, Ryan, & Hinterlong, 2009). The relation of sexual abuse history to more placement
moves, more disruption, and inconsistent parental commitment suggests additional mediating
factors in the ongoing environment (Nalavany,
Ryan, Howard, & Smith, 2008). The centrality
of maltreatment history to externalizing problems
in adopted children is supported characteristics of
a nationally representative sample of adopted and
non-adopted adolescent boys. Although background characteristics such as early maltreatment
and family relationships were predictive, no additional risk for developing externalizing behaviors
were found as a result of adoption status
(Grotevant et al., 2006).
These data clearly demonstrate their importance, and it is heartening to observe that information about the preplacement care and
experience of the child is increasingly included
in studies of adopted children over the past
decade.

Overview of Strategies
Empirically supported strategies for promoting
healthy development in children who are adopted
are consistent with practices that would be
predicted by attachment, cognitive, and
ecocultural theories of development. Efforts to
promote the development of secure relationships,
an integrated view of oneself and understanding
of one’s own life story, and the capacity to navigate the social and cultural milieu address the
core of adoption-related challenges for the child
and his or her family. These will be discussed
below. Strategies to address neurocognitive difficulties associated with prior maltreatment,

678

neglect, or deprivation will be those that have
been demonstrated to work on the specific
presenting problems – ADHD, language delay,
learning disabilities, and developmental trauma
disorder – with non-adopted children. Please see
related entries for a discussion of those strategies.

What Works
A search of the literature did not uncover an
intervention that met the standard of three successful trials, at least in part because of the dearth
of experimental designs and the reliance on correlational data in this area.

What Is Promising
Openness. The extent to which an adoption is
open, that is, the adoptive family is open to contact with the birth parents, may affirm the reality
of multiple and complicated attachments in the
lives of adopted children. Several older studies
that investigated openness occurred when open
adoptions were relatively rare and therefore not
representative of the general population. More
recently, at least two studies provide correlational
evidence linking openness in adoptions to positive outcomes in middle childhood. Brodzinsky
(2006) examined child adjustment as a function
of openness in a sample of 73 children (8–13
years) adopted prior to 18 months of age, 25 %
of whom were adopted domestically and 15 %
adopted into interracial families. Structural openness fell into one of three categories: 45 % of
families had closed adoptions with no birth parent
contact, 27 % had mediated adoptions with some
type of contact between adoptive and birth parents through an intermediary, and 27 % had fully
disclosed adoptions in which adoptive parents –
and, in many cases, the children themselves –
maintained direct contact with birth parents.
Children also reported how comfortable they
were discussing adoption with their parents as
an index of adoption communication openness.
Greater structural openness was related to higher
child self-esteem. Greater adoption openness was

Healthy Development in Children of Adoptive Parents

associated with higher self-esteem and fewer
behavioral problems.
Eight years after adopting, parents in the
California Long-Range Adoption Study reported
on the experiences of their 231 children (mean
age, 11 years) in open (42 %) or closed (58 %)
adoptions (Frasch, Brooks, & Barth, 2000). At
least 50 % of those who maintained contact
with biological family members felt that it had
a very or mostly positive effect on both the child
and adoptive family, with a small number (13 %)
reporting a negative effect of contact. Interestingly, adopted children’s contacts with birth relatives were likely to be with individuals other
than their parents – siblings (36 %), grandparents
(22 %), and aunts or uncles (13 %). This has
important implications for conceptualizing openness beyond parent and child, especially for those
children whose adoptions are due to abusive or
neglectful relationships with their birth parents
with whom continued contact could be nonproductive at best and re-traumatizing at worst.
Other extended family members may be able to
help these children construct their life narratives
with items adoptive parents cannot provide such
as information, photos, mementos, or shared
physical characteristics in the context of an ongoing relationship.
Social Skills and Social Relationships.
Children who are adopted may be ill equipped
to handle complicated social interactions during
middle childhood, when the importance of peer
relationships is ascendant. Over 50 % of an
English sample of 5- to 13-year-olds reported
uncomfortable adoption-related comments or
teasing from peers (Neil, 2012), and 20 % of
a Finnish sample, those with attachment disorders and poor social skills, reported being bullied
(Raaska et al., 2012). Children who are adopted
into families with clearly different ethnic, racial,
and cultural backgrounds have a larger and more
public stage for resolving adoption-related issues,
and perceived discrimination, either racial or
adoption related, has been linked to child internalizing and externalizing problems among children adopted from Asia and Latin America
(Lee, 2010). However, peer victimization and
exclusion is less likely to be associated with

Healthy Development in Children of Adoptive Parents

stress, as indexed by cortisol levels, among children with more friends or better quality friendships, suggesting that enhancing social skills and
promoting peer relations may moderate these
stresses (Peters, Riksen-Walraven, Cillessen, &
de Weerth, 2011).
To help children finesse unwelcome questions
from peers, it may help to develop a “cover story”
(Fahlberg, 1991). The child who has a brief, not
particularly revealing, explanation of why he or
she is not living with parents (e.g., “My parents
couldn’t take care of me, so I needed a new
family that could”) will have a script available
for situations that might be emotionally
arousing and in which they might feel conflicted
or confused. By providing a vehicle for
negotiating such situations and the tools to protect his or her own privacy, the cover story can
contribute to a child’s sense of agency and social
competency.
Teachers should be sensitive to classroom
assignments that might raise issues for adopted
children and call undue peer attention to the child
in the important social context of school. Genetics and family tree assignments are obvious candidates, but apparently innocuous assignments
can carry emotional baggage as well. Consider
the reaction of a youngster to a geography assignment involving Seoul, Korea (the city in which he
was born), who remarked, “I understand how you
told me that my birth mother could not take care
of me, but what was wrong with all those other
billions of people?” (Pavao, 1998, p. 48).
Interventions designed to promote attachment
in families may also be effective in promoting
healthy development of adopted children, though
the empirical evidence is not strong. Wimmer,
Vonk, and Bordnick (2009) found attachment
therapy to be effective in reducing ratings of
disordered attachment behaviors and improving
ratings of functioning among adopted children
(mean age, 9.8 years) though it did not employ
a control group or conduct long-term follow-up.
Another attachment-based intervention targeting
parents during the child’s first year showed mixed
results for long-term effects among adopted children: the program was associated with increased
maternal sensitive responsiveness and child

679

attachment security and exploratory behavior in
early childhood, but positive effects extended to
school age only among some children in families
with both adoptive and biologically related children (Stams, Juffer, van IJzendoorn, &
Hocksbergen, 2001). Somewhat surprisingly, at
least two recent studies have found aspects of
enhanced social competence in children adopted
into single-parent families (Tan & Baggerly,
2009; Vashchenko, D’Aleo, & Pinderhughes,
2012), perhaps because a less complicated family
structure facilitates the establishment of attachments, especially among children with deprivation or maltreatment histories (Groze &
Rosenthal, 1991). Hence, although it seems
clear that promoting social skills and relationships through attachments would nurture positive
development, it is less clear precisely how to
do so.
Embracing Cultural Diversity. Cultural
socialization experiences have been associated
with positive outcomes in internationally adopted
children (Lee & Quintana, 2005; Vonk, Lee, &
Crolley-Simic, 2010), and recent work suggests
that parents are more likely to engage their children in such experiences when they have high
racial awareness (i.e., are less “color-blind”)
and when they reflect on their own beliefs
about enculturation and consciously decide to
engage in such practices with their children
(Lee, Grotevant, Hellerstedt, & Gunnar, 2006).
These findings have clear implications for agencies to facilitate such reflection and connect families to enculturation resources.
Developmental Trauma. Children who experience trauma often do so in the context of ongoing
relationships while their neurological, attachment, cognitive, attentional, and regulatory systems are still developing. Chronic traumatic
experiences may therefore have pervasive and
long-lasting consequences across multiple and
interrelated systems in ways not captured by
a diagnosis of post-traumatic stress disorder. Significant numbers of NSAP parents believed that
their children had experienced pre-adoptive
abuse or neglect, even those who were adopted
from other than foster care, which makes the
complex consequences of maltreatment evident

680

in developmental trauma disorder a pertinent
consideration for school-aged children who are
adopted. Especially when pre-adoptive histories
are uncertain, recognizing that a host of problems – attention, behavior, learning, and emotion
regulation – may indeed have some common core
has the potential to direct treatment in a more
efficacious manner and may help to avoid overpathologizing children with multiple diagnoses
when a host of dysregulatory symptoms may be
part of an overarching impediment to development (van der Kolk, 2005).
Sensitive diagnoses require clinicians to be
trauma informed and should include recommendations for home and school. Trauma histories
may display in children’s behavior, social relationships, and academic performance – poor
communication, organization, executive function, problem solving, perspective taking, attention and emotion regulation, reactivity,
aggression, oppositional defiance, and withdrawal. Cumulative risks may be substantial
since all of these may contribute to school failure
and disengagement, which have been associated
with poor outcomes in adolescence and adulthood. School practices that promote ongoing
relationships with caring adults, foster the modulation of emotion and reaction, and assist children to achieve learning goals and make effective
progress will nurture all students and be especially helpful for adopted children with trauma
histories (Cole et al., 2005).
Individuality. Focusing on the commonalities
of children who are adopted minimizes the
myriad sources of individual differences that
characterize these children, including the temperamental lens through which they experience the
world. Adversity may cause some to externalize
and others to turn inward. What works to help
a child with one temperament may not work for
another child in the same situation but with
a different underlying physiology or level or reactivity. Although there have been strides in understanding the role of temperament in development
and psychopathology (e.g., Kagan, 2010), understanding the role of temperament in the development of children who have been adopted is
a research area in its infancy.

Healthy Development in Children of Adoptive Parents

Looking Ahead. Perhaps the greatest opportunity in middle childhood lies in the capacity for
parents and children to lay the groundwork for
what is to come: puberty, adolescence, and the
transition to adulthood. An authoritative
approach to parenting may be particularly helpful
in establishing open lines of communication, supports, and boundaries while scaffolding the
child’s social, emotional, and cognitive development. Authoritative parents are warm and
involved. They set limits but are not harsh or
coercive. Among non-adopted children, authoritative parenting has been associated with positive
outcomes from preschool to adolescence across
ethnicity and socioeconomic status (Baumrind,
Larzelere, & Owens, 2010). Among formerly
institutionalized 10-year-old children, parental
warmth and stimulation was associated with significant reductions in inattention and overactivity, which, left unchecked, may contribute to
difficulties in peer relationships (Audet, &
LeMare, 2011).

What Does Not Work
It is highly unlikely that an authoritarian parenting style – harsh, coercive, and domineering –
will promote adjustment in adopted children.
Decades of research have linked it with poor outcomes across diverse groups. Recently, adolescents who had experienced authoritarian
parenting as preschoolers and during elementary
years were found to be poorly adjusted and less
competent compared with other groups after
controlling for initial child differences, with
preschool parenting more predictive than school
age (Baumrind, Larzelere, & Owens, 2010).

Summary
School-aged children who are adopted are
a diverse group with common challenges around
the need to integrate disparate threads into
a coherent life narrative while holding multiple
attachments to parent figures and developing
mutually supportive peer relationships. They

Healthy Development in Children of Adoptive Parents

may have additional challenges in their
pre-adoptive histories and in the cultural lens
through which children view themselves and
their families. Children may have a wide range
of developmental, neurocognitive, social, and
emotional problems depending on the circumstances of their early lives. Efforts to establish
open lines of communication and fluid family
boundaries that may include members of the
birth family, secure attachments, social skills,
and cultural awareness will very likely nurture
positive development. Specialized assistance or
intervention for problems such as ADHD or
developmental trauma disorder may also be an
important part of the adoptive child’s adjustment.
Research in adoption has improved both in quality and in quantity over the past decade, and we
hope for further advances, especially in intervention research and individual differences, in the
decade ahead.

See Also
▶ Attention Deficit Hyperactivity Disorder
During Childhood
▶ Healthy Development Among Youths in
Foster Care
▶ Peer Relationships: Promoting Positive Peer
Relationships During Childhood
▶ Resiliency During Early Childhood
▶ Social and Emotional Learning: Children

References
Audet, K., & Le Mare, L. (2011). Mitigating effects of the
adoptive caregiving environment on inattention/overactivity in children adopted from Romanian orphanages.
International Journal
of
Behavioral
Development,
35(2),
107–115.
doi:10.1177/
0165025410373313.
Baumrind, D., Larzelere, R. E., & Owens, E. B. (2010).
Effects of preschool parents’ power assertive patterns
and practices on adolescent development. Parenting:
Science and Practice, 10(3), 157–201. doi:10.1080/
15295190903290790.
Becker-Weidman, A. (2009). Effects of early maltreatment on development: A descriptive study using the
Vineland Adaptive Behavior Scales-II. Child Welfare,
88(2), 137–161.

681
Behen, M. E., Helder, E., Rothermel, R., Solomon, K., &
Chugani, H. T. (2008). Incidence of specific absolute
neurocognitive impairment in globally intact children
with histories of early severe deprivation. Child Neuropsychology,
14(5),
453–469.
doi:10.1080/
09297040802244136.
Beverly, B. L., McGuinness, T. M., & Blanton, D. J.
(2008). Communication and academic challenges in
early adolescence for children who have been adopted
from the former Soviet Union. Language, Speech, and
Hearing Services in Schools, 39(3), 303–313.
doi:10.1044/0161-1461(2008/029).
Bowlby, J. (1980). Attachment and loss. New York: Basic
Books.
Brodzinsky, D. (2006). Family structural openness and
communication openness as predictors in the adjustment of adopted children. Adoption Quarterly, 9(4),
1–18. doi:10.1300/J145v09n04_01.
Bronfenbrenner, U. (1979). The ecology of human development. Cambridge, MA: Harvard.
Center for Adoption Research. (2006). Adoption in
Massachusetts: Private and public agency placements
and practices in 2004. Retrieved August 1,
2012, from http://www.umassmed.edu/uploadedFiles/
2005AgencyReport%281%29.pdf
Child Welfare Information Gateway. (2004). Adoption
disruption and dissolution. Washington, DC: US
Department of Health and Human Services, Children’s
Bureau.
Cole, S. F., O’Brien, J. G., Gadd, M. G., Ristuccia, J.,
Wallace, D. L., & Gregory, M. (2005). Helping traumatized children learn. Boston: Massachusetts Advocates for Children.
der Kolk, B. A. (2005). Developmental Trauma Disorder:
Toward a rational diagnosis for children with complex
trauma histories. Psychiatric Annals, 35(5), 401–408.
Fahlberg, V. I. (1991). Preparing older children for adoption. In E. D. Hibbs (Ed.), Adoption: International
perspectives (pp. 103–113). Madison, CT: International Universities Press.
Farah, M. J., Betancourt, L., Shera, D. M., Savage, J. H.,
Giannetta, J. M., Brodsky, N. L., et al. (2008). Environmental stimulation, parental nurturance and
cognitive development in humans. Developmental
Science, 11(5), 793–801. doi:10.1111/j.14677687.2008.00688.x.
Festinger, T. (2005). Adoption disruption: Rates, correlates, and service needs. In G. P. Mallon & P. M. Hess
(Eds.), Child welfare for the 21st century: A handbook
of practices, policies, and programs (2nd ed.,
pp. 452–468). New York: Colombia University Press.
Frasch, K. M., Brooks, D., & Barth, R. P. (2000). Openness and contact in foster care adoptions: An eightyear follow-up. Family Relations, 49(4), 435–446.
doi:10.1111/j.1741-3729.2000.00435.x.
Ghetti, S., & Bunge, S. A. (2012). Neural changes underlying the development of episodic memory during
middle childhood. Developmental Cognitive Neuroscience. Advance online publication. Retrieved

682
August 1, 2012, from http://www.sciencedirect.com/
science/article/pii/S1878929312000576
Grotevant, H. D., van Dulmen, M. M., Dunbar, N.,
Nelson-Christinedaughter, J., Christensen, M., Fan,
X., et al. (2006). Antisocial behavior of adoptees and
nonadoptees: Prediction from early history and adolescent relationships. Journal of Research on Adolescence,
16(1),
105–131.
doi:10.1111/j.15327795.2006.00124.x.
Groze, V. K., & Rosenthal, J. A. (1991). Single parents
and their adopted children: A psychosocial analysis.
Families in Society, 72(2), 67–77.
Kagan, J. (2010). The temperamental thread. Washington,
DC: Dana Press.
Lee, R. M. (2010). Parental perceived discrimination as
a postadoption risk factor for internationally adopted
children and adolescents. Cultural Diversity and Ethnic Minority Psychology, 16(4), 493–500.
doi:10.1037/a0020651.
Lee, R. M., Grotevant, H. D., Hellerstedt, W. L., &
Gunnar, M. R. (2006). Cultural socialization in families with internationally adopted children. Journal of
Family Psychology, 20(4), 571–580. doi:10.1037/
0893-3200.20.4.571.
Lee, D. C., & Quintana, S. M. (2005). Benefits of cultural
exposure and development of Korean perspectivetaking ability for transracially adopted Korean children.
Cultural Diversity and Ethnic Minority Psychology,
11(2), 130–143. doi:10.1037/1099-9809.11.2.130.
Lofquist, D., Lugaila, T., O’Connell, M., & Feliz, S.
(2012). Households and families: 2010. Retrieved
August 1, 2012, from US Bureau of the Census: http://
www.census.gov/prod/cen2010/briefs/c2010br-14.pdf
Miller, S. A. (2012). Theory of mind: Beyond the preschool years. New York: Psychology Press.
Nalavany, B., Ryan, S. D., & Hinterlong, J. (2009). Externalizing behavior among adopted boys with
preadoptive histories of child sexual abuse. Journal
of Child Sexual Abuse, 18(5), 553–573. doi:10.1080/
10538710903183337.
Nalavany, B. A., Ryan, S. D., Howard, J. A., & Smith,
S. (2008). Preadoptive child sexual abuse as
a predictor of moves in care, adoption disruptions,
and inconsistent adoptive parent commitment. Child
Abuse & Neglect, 32(12), 1084–1088. doi:10.1016/j.
chiabu.2008.07.001.
Neil, E. (2012). Making sense of adoption: Integration
and differentiation from the perspective of adopted
children in middle childhood. Children and Youth
Services Review, 34(2), 409–416. doi:10.1016/j.
childyouth.2011.11.011.
Nelson, K., & Fivush, R. (2004). The emergence of autobiographical memory: A social cultural developmental
theory. Psychological Review, 111(2), 486–511.
doi:10.1037/0033-295X.111.2.486.
Pavao, J. (1998). The family of adoption. Boston: Beacon
Press.
Peters, E., Riksen‐Walraven, J., Cillessen, A. N., & de
Weerth, C. (2011). Peer rejection and HPA activity in

Healthy Development in Children of Adoptive Parents
middle childhood: Friendship makes a difference.
Child Development, 82(6), 1906–1920. doi:10.1111/
j.1467-8624.2011.01647.x.
Piaget, J., & Inhelder, B. (1969). The psychology of the
child. New York: Basic Books.
Raaska, H., Lapinleimu, H., Sinkkonen, J., Salmivalli, C.,
Matom€aki, J., M€akip€a€a, S., et al. (2012). Experiences
of school bullying among internationally adopted children: Results from the Finnish Adoption (FINADO)
study. Child Psychiatry and Human Development,
43(4), 592–611. doi:10.1007/s10578-012-0286-1.
Rutter, M., & Sonuga-Barke, E. J. (2010). Conclusions:
Overview of findings from the ERA study, inferences,
and research implications. Monographs of the Society
For Research in Child Development, 75(1), 212–229.
doi:10.1111/j.1540-5834.2010.00557.x.
Sheridan, M. A., Fox, N. A., Zeanah, C. H., McLaughlin,
K. A., & Nelson, C. (2012). Variation in neural development as a result of exposure to institutionalization
early in childhood. PNAS Proceedings of the
National Academy of Sciences of the United States of
America, 109(32), 12927–12932. doi:10.1073/
pnas.1200041109.
Stams, G. M., Juffer, F., Van IJzendoorn, M. H., &
Hocksbergen, R. C. (2001). Attachment-based intervention in adoptive families in infancy and children’s
development at age 7: Two follow-up studies. British
Journal of Developmental Psychology, 19(2),
159–180. doi:10.1348/026151001166010.
Tan, T. (2006). History of early neglect and middle
childhood social competence: An adoption study.
Adoption Quarterly, 9(4), 59–72. doi:10.1300/
J145v09n04_04.
Tan, T., & Baggerly, J. (2009). Behavioral adjustment of
adopted Chinese girls in single-mother, lesbiancouple, and heterosexual-couple households.
Adoption Quarterly, 12(3–4), 171–186. doi:10.1080/
10926750903313336.
US Department of Health & Human Services. (2011). The
AFCARS report #18: Preliminary FY2010 estimates
as of June, 2011. Retrieved August 1, 2012, from
http://www.acf.hhs.gov/programs/cb/stats_research
US Department of State. (2008). Russia: Who can adopt?
Retrieved August 1, 2012, from http://adoption.state.
gov/country_information/country_specific_info.php?
country-select=russia
US Department of State. (2010). FY 2010 annual
report on intercountry adoptions. Retrieved August
1, 2012, from http://adoption.state.gov/content/pdf/
fy2010_annual_report.pdf
US Department of State. (2011). China: Who can adopt?
Retrieved August 1, 2012, from http://adoption.state.
gov/country_information/country_specific_info.php?
country-select=chinavan
van IJzendoorn, M. H., & Juffer, F. (2005). Adoption is
a successful natural intervention enhancing adopted
children’s IQ and school performance. Current Directions in Psychological Science, 14(6), 326–330.
doi:10.1111/j.0963-7214.2005.00391.x.

Healthy Development in Children of Adoptive Parents
van IJzendoorn, M. H., Schuengel, C., & BakermansKranenburg, M. J. (1999). Disorganized attachment
in early childhood: Meta-analysis of precursors, concomitants, and sequelae. Development and Psychopathology,
11(2),
225–249.
doi:10.1017/
S0954579499002035.
Vandivere, S., Malm, K., & Radel, L. (2009). Adoption
USA: A chartbook based on the 2007 national survey
of adoptive parents. Washington, DC: US Department
of Health and Human Services. Retrieved August
1, 2012, from http://aspe.hhs.gov/hsp/09/NSAP/
chartbook
Vandivere, S., & McKlindon, A. (2010). The well-being
of U.S. children adopted from foster care, privately
from the United States and internationally. Adoption
Quarterly,
13(3–4),
157–184.
doi:10.1080/
10926755.2010.524871.
Vashchenko, M. M., D’Aleo, M. M., & Pinderhughes,
E. E. (2012). “Just beyond my front door”: Public

683
discourse experiences of children adopted from
China. American Journal of Community Psychology,
49(1–2), 246–257. doi:10.1007/s10464-011-9441-2.
Vonk, M., Lee, J., & Crolley-Simic, J. (2010). Cultural
socialization practices in domestic and international
transracial adoption. Adoption Quarterly, 13(3–4),
227–247. doi:10.1080/10926755.2010.524875.
Wiik, K. L., Loman, M. M., Van Ryzin, M. J., Armstrong,
J. M., Essex, M. J., Pollak, S. D., et al. (2011). Behavioral and emotional symptoms of post‐institutionalized
children in middle childhood. Journal of Child Psychology and Psychiatry, 52(1), 56–63. doi:10.1111/
j.1469-7610.2010.02294.x.
Wimmer, J. S., Vonk, M., & Bordnick, P. (2009).
A preliminary investigation of the effectiveness of
attachment therapy for adopted children with reactive
attachment disorder. Child & Adolescent Social Work
Journal, 26(4), 351–360. doi:10.1007/s10560-0090179-8.

684

Healthy Development in Children of
Divorced Parents
Anthony G. James1 and Mark A. Fine2
1
Department of Family Studies & Social Work,
Miami University Hamilton, Columbia, MO, USA
2
Department of Human Development and Family
Studies, University of North Carolina at
Greensboro, Greensboro, NC, USA

Introduction
Studies report that between 40 and 50 % of
children will experience the dissolution of their
parent’s marriage (See http://www.heritage.org/
research/reports/2000/06/the-effects-of-divorceon-america, Hetherington and Elmore, 2003).
How those children adjust to the divorce depends
largely on processes that occur both within the
individual (i.e., child/children) and within the
family. Studies over the past decade continue to
show that children whose parents divorce, when
compared to children whose parents have not
divorced, score significantly lower on behavioral,
socioemotional, cognitive, and academic outcomes (Amato, 2010). Research on whether this
gap in scores has changed over time is mixed.
One study showed a decreasing gap in scores in
the 1980s (Amato & Bruce, 1991), while another
study showed an increasing gap in the scores in
the 1990s (Amato, 2001).
Part of the explanation for why studies have
found mixed results regarding differences in outcomes across divorced and nondivorced groups is
that parents can help lessen the negative effects of
divorce through responsive and sensitive parenting behavior. When parents engage in relatively
low levels of parental conflict, keep their children
out of their conflicts, and communicate directly
with each other, their children adjust more effectively. Accordingly, work over the past decade
has increased the knowledge base for practitioners and researchers on ways to enhance children’s and youth’s adaptation to the divorce of
their parents. To that end, the focus of this entry is
a review of the empirically based and tested “best

Healthy Development in Children of Divorced Parents

practices” to help children and youth navigate
through and/or heal from the generally negative
effects of divorce.

Definitions
The term divorce refers to the legal termination of
a marriage. Legal custody is a legally binding
decision or order obligating whom is responsible
for the rearing and welfare of the child. Parents
can have joint custody (both parents have equitably shared responsibility of their child/children)
of children or one parent can have sole custody.
Legal custody is distinct from physical custody,
which refers to where the child actually resides.
When the child/children live primarily with one
of the parents, that parent is considered the residential parent and the other parent is referred to
as the nonresidential parent. When one of the
parents has sole legal custody, that parent is usually the mother with the father being the
nonresidential parent. Visitation refers to the
time spent between the nonresidential or noncustodial parent and the child. Child support refers to
financial support, usually provided by the
nonresidential or noncustodial parent, supplied
to the residential/custodial parent to help meet
the resource needs of the child. A parenting
plan is a document that describes the plan that
both parents have agreed to regarding how the
child will be raised. The parenting plan typically
includes the child support and visitation plans,
custody arrangements, where and with whom
the children will spend the holidays, how fees
for extracurricular activities will be paid, and
even plans for how the child’s college education
will be funded. Finally, a motion to modify
decree(s) is a legal mechanism whereby one parent attempts to legally change the provisions in
the original divorce settlement.

Scope
The US divorce rate has varied significantly over
the past 200 years. The rate of divorce for first
marriages in the mid-nineteenth century was

T.P. Gullotta, M. Bloom (eds.), Encyclopedia of Primary Prevention and Health Promotion,
DOI 10.1007/978-1-4614-5999-6, # Springer Science+Business Media New York 2014

Healthy Development in Children of Divorced Parents

estimated at 5 %, while studies throughout the
first decade of the twenty-first century have estimated that the US divorce rate is between 40 %
and 50 % (Cherlin, 2010). The sharp increase in
divorce rates in the USA began in the 1960s,
peaked in the 1970s, and has slightly decreased
since the early 1980s (Teachman, Tedrow, &
Crowder, 2000). The change in divorce rates did
differ by ethnicity (e.g., after 1990, the rate continued to climb for African American women but
decreased for European American women,
Teachman et al., 2000) and educational achievement (e.g., women who obtained a college
education had a rate that decreased at a sharper
rate than those women who achieved only a high
school diploma or no diploma at all; Martin,
2006). Additionally, about half of US divorces
involve children under 18 years of age, which
result in approximately 40 % of children born in
the 1990s experiencing a divorce before they turn
18 years old (Kreider, 2007). The overall divorce
rate differs for different ethnic groups, with African Americans having a divorce rate higher than
both European and Hispanic Americans (Orbuch
& Brown, 2006), with Hispanic Americans having a divorce rate similar to European Americans
(Teachman et al., 2000).
When considering cultural differences in the
divorce rate, the laws that govern the accessibility
of divorce and cultural beliefs influence the
change in rates of divorce. For instance, the
divorce rates in Western European countries
increased substantially during the latter half of
the twentieth century. This was largely due to
those countries adopting legal systems that
allowed for no-fault divorces (i.e., the marriage
is irrevocably broken without having to assign
fault to either spouse; therefore, adjudication of
the divorce can occur without either spouse
having to establish who is responsible for the
broken marriage) (Fine & Fine, 1994). However,
cultural factors (e.g., strong influence of Catholicism) have resulted in low divorce rates in countries like France and Italy. Those countries also
have relatively restrictive laws against divorce as
well. Finally, in some Eastern countries, the
divorce rate increased rapidly at the end of the
twentieth century, but their rates are still far lower

685

than in Western nations (Goode, 1994).
According to one report, the increase in the
divorce rate in one Eastern nation (i.e., Taiwan)
is due in part to individualism and women’s
financial independence and educational attainment (Yun-Tung, 2011).

Theories that Help Understand Divorce
and Its Consequences
Numerous theories have been employed to understand divorce and its subsequent effects on children and family members. The social learning
perspective highlights that children learn relationship behaviors through observing their parents. For example, children whose parents are
divorced have a higher likelihood of experiencing
divorce themselves in their own romantic relationships. Additionally, boys are more negatively
impacted by divorce because mothers are more
likely to have custody of them, which reduces
their time with a same-sex role model (i.e., their
father).
The social exchange perspective posits that
individuals decide whether to continue or end
their relationships based on perceptions of its
costs and benefits, relative to available alternatives outside the relationship. If viable alternatives exist, and if the ratio of costs/benefits is
greater than what one expects (i.e., one’s comparison level), an individual may divorce; by
contrast, if no viable alternatives exist and if
one receives more benefits relative to costs than
one expects, one will be less likely to divorce.
According to one variant of social exchange theory, the strongest predictor of whether
a relationship will continue or end is the extent
to which each of the partners is committed to the
relationship. Commitment is enhanced to the
extent that one’s benefit/cost ratio is high, one
has few attractive alternative relationships available, and when the couple has made investments
(e.g., a shared home, children, joint bank
accounts) in the relationship.
Finally, the symbolic interactionism perspective emphasizes the meaning individuals attach to
their experiences and how that meaning

686

influences behavior. Individuals actively engage
in a process of trying to understand the dissolution of their marriage. Although the partners have
experienced the same event (i.e., divorce),
spouses may construct different stories
(or narratives) to help them cope with the difficulties attached to the painful event. Each partner
is likely to develop a divorce narrative that places
him or herself in a positive light. According to the
symbolic interaction perspective, the meaning
that one assigns to the divorce and how one thinks
about it influences how individuals will behave
and cope with this stressor.
Each of these perspectives has aided in the
development of programs designed to help families adjust to the difficulties of divorce. For
example, the vast majority of parent education
programs for divorcing parents have encouraged
the parents to model adaptive behavior (the social
learning perspective), to make decisions based on
careful assessments of the benefits and costs associated with different decisions (the social
exchange perspective), and also to help parents
“make sense” of their situation by allowing them
to construct or adjust their narrative or story of
the negative experience (the symbolic interaction
perspective).

Research on the Effects of Divorce
on Children
Research has found that children from divorced
families fare somewhat more poorly than children from first-married intact families on nearly
all outcome dimensions that have been studied
(e.g., behavior problems, health, and psychological well-being) (Amato, 2005). In his follow-up
meta-analysis of children in the 1990s, Amato
(2001) found that children of divorce scored, on
average, approximately two-tenths of a standard
deviation below children from first-married intact
families on several dimensions.
With that said, one of the major critiques
against studies that compared children of divorce
to those from first-married intact families is that
such comparative or correlational studies do not
allow for an inference that the divorce caused the

Healthy Development in Children of Divorced Parents

poorer child outcomes. That critique was
followed by studies (e.g., Cherlin et al., 1991)
that found that children of divorce had adjustment difficulties prior to the divorce as well as
in the postdivorce years. This suggests that other
factors, besides the divorce, are causal to the
adjustment problems children of divorce have in
postdivorce years.
Recent research has attempted to address this
issue by measuring child outcomes before and
after divorce and examining the differences in
adjustment before and after. Sun’s (2001; Sun &
Li, 2001) longitudinal studies found that youth
whose parents later divorced had lower selfesteem, more behavior problems, and lower
scores on standardized achievement tests when
compared to youth whose parents would later
remain continuously married. In a follow-up
study, Sun and Li (2002) found that youths
whose parents divorced had lower test scores
3 years prior to divorce than youth from continuously married families. Some evidence for
divorce causing adjustment problems was found
when test scores further declined in the
postdivorce years. However, the self-esteem of
the youth declined as their parent’s neared
divorce and increased in the postdivorce years.
In a similar study examining differences between
children of continually married families and children of divorce, Strohschein (2005) found that
the children whose parents divorced had higher
levels of antisocial behavior, depression, and
anxiety prior to the divorce, with greater
increases in anxiety and depression after the
divorce; however, the children of divorce did
not exhibit more antisocial behavior after the
divorce than did the children from continuously
married families.
There are several other factors that are associated with children and family members’ levels of
adjustment following divorce. More specifically,
what the child and family experience after the
divorce, known as family processes, is related to
their adjustment to the divorce. Fine (2000) found
that children of divorce fared better when they are
exposed to very small amounts of conflict
between ex-spouses, have harmonious and
conflict-free interactions with other family

Healthy Development in Children of Divorced Parents

members, and have increased amounts of warmth
and parental supervision. Other studies have
found that declines in household income, ineffective parenting from resident parents, loss of contact with nonresident parents, and continued
conflict between parents are all related to individuals adjusting poorly to the divorce (Fabricius &
Luecken, 2007; King & Sobolewski, 2006).
Because most children continue to reside with
one of their parents after the divorce, it is important to also consider research regarding adult’s
adjustment to the divorce.

Effects of Divorce on Adults
How children adjust to a divorce can be directly
linked to how well their parents adjust to the
divorce (Walker, 2003). Crucial to a child’s
healthy adjustment is their having confidence that
their parents will be physically and emotionally
available to them. However, divorce is difficult
for adults as well and can – unfortunately – make
them less available to their children. Because of its
effects on the parent children relationship (Walker,
2003), we review some of the difficulties adults/
parents face during the process of divorce that can
impede children’s healthy development.
While researchers are appropriately cautious
in concluding that divorce causally affects children’s postdivorce adjustment, some are more
confident in their claim that going through
a divorce causes adults to have postdivorce
adjustment difficulties (Amato, 2010; Wood,
Goesling, & Avellar, 2007). Overall, divorce
has been found to negatively impact the wellbeing of adults, with difficulties being exacerbated for divorced mothers when compared to
women who divorce with no children (Williams
& Dunne-Bryant, 2006). This is likely due to the
stress of dealing with the potential problems the
child may endure from the divorce and feelings of
guilt for putting the children through it, concerns
that nonparents do not have to worry about. Further, Wade and Pevalin’s (2004) research examined adults’ mental health at multiple time points
before and after transitions out of marriage and
found that there was poor mental health before

687

the divorce, but a steep decline in mental health
afterwards, providing support for causal claims.
To understand the mechanisms undergirding
the poor adjustment to divorce, Johnson and Wu
(2002) found that poor adjustment to divorce by
adults was due primarily to higher stress levels as
a result of the divorce (i.e., being divorced is
inherently more stressful than being married).
Lucas, Clark, Georgellis, and Diener (2003)
found that divorce is strongly associated with
long-term negative changes in life satisfaction
for adults. Finally, a study with German adults
(Brockmann & Klein, 2004) using an econometric
methodology found that divorce increased the
odds of mortality for both men and women, likely
due to the accumulation of positive experiences
and connections that being married produces.
Those experiences provide individuals with “survival advantages” (e.g., larger family and social
network) that can buffer against mortality. With
their employment of longitudinal methodologies
that allow for pre- and postdivorce comparisons,
these studies increase our confidence in the claims
that divorce causes negative effects on adults’
postdivorce adjustment. However, even with
such difficulties, factors such as having supportive
social networks and establishing new and mutually
satisfying relationships can help adults heal and
better adjust to the difficulties that divorce brings.

What Works
Unfortunately, intervention trial methodologies are
not common in divorce research or more specifically
research examining children’s healthy adjustment to
divorce. To date, a search of the literature did not
uncover interventions that met the standard of three
successful trials that would promote the development of a child that has experienced a divorce.

What Is Promising: Strategies that Help
Children and Adults Adjust to Divorce
Parent Education
Toward the end of twentieth century, states
across the USA began first offering and then

688

mandating that divorcing parents attend parent
education courses as a way to help them help
their children adjust to the divorce (Amato,
2010). States such as Arizona and Missouri mandate these classes, but other states (e.g., Pennsylvania) merely recommend or offer them to
families. Studies have found that parents find
these classes to be useful to help them in terms
of reducing conflict (Criddle, Allgood, & Piercy,
2003), but research is still lacking in terms of
evidence that the courses actually have positive
effects on children (Douglas, 2006). However,
with their ability to reduce parental conflict, in
conjunction with studies showing the benefits of
low parental conflict on children of divorce, these
types of programs seem to have the potential to be
quite beneficial to children.
Mediation
Mediation continues to be the best method for
helping reduce conflict in contested divorce
cases. When successful, mediators help parents
construct and agree to a parenting plan that all
stakeholders feel is best for the child; in fact,
having mediated sessions can be part of the parenting plan itself. Studies have found that mediation lowers the cost of divorce, increases
parents’ satisfaction with the outcome, and
decreases the likelihood that couples pursue litigation (Douglas, 2006). Additionally, one
decade-long study (Emery, Sbarra, & Grover,
2005) found that for families in which couples
used mediation, there was more contact between
nonresident fathers and children, more communication and less conflict between divorced parents, and generally a greater satisfaction with
divorce outcomes. A strength of this study’s
design was that divorcing couples were randomly
assigned to mediation and no mediation groups,
which allow us to have confidence in the conclusion that mediation is responsible for the
improved outcomes that have been found to follow mediation. With that said, more representative research is needed on the actual effects of
mediation on both children and adults. Mediation
has been criticized for not adequately addressing
power differentials within families (e.g., men
having more resources and threats of domestic

Healthy Development in Children of Divorced Parents

violence), which has contributed to mediators
being advised not to provide this service with
couples that have severe relational problems or
partners with personality disorders.
Programs for Children
There are a variety of programs for children
whose parents are separating or divorcing.
Geelhoed, Blaisure and Geasler (2001) surveyed
over 80 programs in the USA that were designed
to help children adjust to their parents’ divorce.
These programs typically encouraged, but did not
mandate, children to attend, and consisted of 1–2
sessions each lasting 4–5½ h in length. Additionally, according to Grych and Fincham (1997),
these types of program have both educational
and therapeutic elements to them and help children adjust to the stress from the divorce,
improve their communication with their parents,
learn coping skills, gain a clearer understanding
of the difficulties surrounding the divorce, and
improve their self-esteem. One of the more frequently utilized programs and curriculums used
(globally) to help children adjust to their parent’s
divorce is the Children of Divorce Intervention
Project (CODIP). This program was evaluated
extensively by Alpert-Gillis, Pedro-Carroll, and
Cowen (1989). They designed a study in which
children of divorce completed the 16-week program and matched them with 81 children from
intact families, using child, parent, and teacher
adjustment ratings. The treatment group
improved significantly more than the no treatment group on multiple dimensions, which,
even though the children were not randomly
assigned to the CODIP and non-CODIP groups,
supports the effectiveness of the program.
In two other community-based intervention
programs designed to help children adjust to
divorce (Stolberg & Mahler, 1994; Wolchik
et al., 2000), the programs include a group for
parents. In the Stolberg and Mahler (1994) study,
they only found marginal gains in student’s
adjustment following participation in the program and called for more research examining
the format of the program to increase its effectiveness. Wolchik et al. (2000) study found that
immediate initial effects of their program were

Healthy Development in Children of Divorced Parents

promising. They found that children reported
having better coping skills and fewer adjustment
problems, but the effects disappeared at the
six-month follow-up. Although these programs
are quite prevalent and many children participate
in them, with the mixed evidence from the few
comprehensive evaluations of them, researchers
and practitioners should take caution in inferring
that these programs are effective (Grych, 2005).
More evaluation studies are needed to determine
the following: (1) the effectiveness of the different programs and curriculums being used in these
programs, (2) the adjustments needed to make
existing programs more efficacious, and (3) the
extent to which these programs are effective with,
and need to be modified for, diverse groups of
adults and children who have experienced
divorce.

689

• Keep lines of communication open between
the children and the nonresidential parent.
Also, parents should attempt to speak to,
speak about, and act toward the nonresidential
parent in a cordial manner (and the
nonresidential parent should reciprocate this
cordial behavior).
• Regularly give children the message that they
are not responsible for causing their parents’
divorce and dispel the children’s fantasy that
the parents are likely to reunite.
• Set a schedule and routine and stick to it. This
is helpful for reestablishing and/or strengthening the sense of security for children whose
previous security blanket (i.e., having both
parents available) has been taken away.

What Does Not Work
Aspects of Successful Interventions
While we have shown that divorce has potentially
detrimental consequences for children, there is
some hope. Although children of divorce typically fair more poorly on several adjustment
dimensions than do children from intact families,
these differences are small in magnitude. While
there are many reasons for the small-scale differences in adjustment between the two groups, one
important reason is that parents can do a number
of things to help their children cope with the
difficulties of divorce. We now provide a list of
behaviors that parents can engage in to help their
children understand and adjust to their parent’s
divorce:
• Continually convey to children that, although
their parents are divorcing each other, they are
not divorcing the children. Children need to
know that their parents will continue to be in
their lives.
• Be vigilant about providing the needed
resources for children to build a social support
system (both professional and nonprofessional)
that allows them a healthy outlet to understand
and discuss the divorce in a safe setting. Earlier,
we discussed several such programs that
research has shown to be effective.

Sometimes in the heat of the moment of divorce,
parents can become overwhelmed by the hurt
and/or pain caused by the issues surrounding the
divorce. Unfortunately, this can lead to situations
in which children are caught in the middle of
a negative feud between ex-spouses. Research
has found that the following behaviors are
unhealthy for children’s adjustment to divorce:
• Talking negatively about the ex-spouse in
front of the children.
• Using children to communicate messages
between the ex-spouses.
• Using children as a sounding board to vent
about the difficulties of the divorce.
• Directly and/or indirectly contributing to children feeling that they are the reason for the
divorce.
• Using the children as “leverage” or a “pawn”
to hurt the ex-spouse (e.g., the parent threatens
the child with not letting him or her visit or
communicate(s) with the nonresidential
parent).
• Not providing children with formal/professional or informal resources and supports to
discuss how they feel about the divorce.
• Not being considerate of – or recognizing – the
fact that the children will likely still consider
the ex-in laws as members of their family.

690

• Parents introducing new love interests to the
children too soon, especially overnight guests.
This is potentially damaging and hurtful to
children who are still mourning that their parents no longer being married. Meeting and
interacting with new love interests can
abruptly and stressfully challenge a common
fantasy that many children have – that their
parents will reunite and that they can help
make this happen.
• Letting the difficulties in the (now ended)
romantic aspects of their relationship interfere
with the ongoing, co-parenting aspects of their
relationship.

Summary
With the divorce rate still lurking around
40–45 % for first marriages, millions of children
will experience divorce before the age of 18.
From our best, empirically based, knowledge,
we know that divorce can have serious negative
effects on both children and adults. However,
parents do have behaviors at their disposal to
lessen the negative effects that divorce has on
their children. Additionally, some formal interventions, such as mediation and parenting education, and informal interventions, such as divorce
support groups in schools, can complement parents’ efforts to help their children. However,
while many of these programs have great promise
and can help children on several dimensions of
adjustment, existing evidence is less than conclusive in demonstrating that they are effective.
What is clear, though, is that effective parenting
strategies, less conflict between ex-spouses, harmonious family interactions, and allowing
children the space and opportunities to understand and respond effectively to the divorce can
facilitate children’s adjustment. The key challenge in the future will be finding the best ways,
whether through formal or informal interventions, to help divorced parents parent more
effectively, work together more cooperatively,
interact more positively with their children, and
build growth-inducing environments for their
children.

Healthy Development in Children of Divorced Parents

References
Alpert-Gillis, L. J., Pedro-Carroll, J. L., & Cowen, E. L.
(1989). The children of divorce intervention
program: Development, implementation, and
evaluation of a program for young urban children.
Journal of Consulting and Clinical Psychology,
57(5), 583–589.
Amato, P. R. (2001). Children of divorce in the 1990s: An
update of the Amato and Keith (1991) meta-analysis.
Journal of Family Psychology, 15, 355–370.
Amato, P. R. (2005). The impact of family formation
change on the cognitive, social, and emotional wellbeing of the next generation. The Future of Children,
15, 75–96.
Amato, P. R. (2010). Research on divorce: Continuing
trends and new developments. Journal of Marriage
and Family, 72, 650–666.
Amato, P. R., & Bruce, K. (1991). Parental divorce and the
well-being of children: A meta-analysis. Psychological Bulletin, 110, 26–46.
Brockmann, H., & Klein, T. (2004). Love and death in
Germany: The marital biography and its effect on
mortality. Journal of Marriage and Family, 66,
567–581.
Cherlin, A. J. (2010). Demographic trends in the United
States: A review of research in the 2000s. Journal of
Marriage and Family, 72, 403–419.
Cherlin, A. J., Furstenberg, F. F., Chase-Lansdale, L.,
Kiernan, K. E., Robins, P. K., Morrison, D. R.,
et al. (1991). Longitudinal studies of effects of divorce
on children in Great Britain and the United States.
Science, 252, 1386–1389.
Criddle, M. N., Allgood, S. M., & Piercy, K. W. (2003).
The relationship between mandatory divorce education and level of post-divorce parental conflict. Journal of Divorce and Remarriage, 39, 99–111.
Douglas, E. M. (2006). Mending broken families: Social
policies for divorced families. Lanham, MD: Rowman
& Littlefield.
Emery, R. E., Sbarra, D. A., & Grover, T. (2005). Divorce
mediation: Research and reflections. Family Court
Review, 43, 22–37.
Fabricius, W. V., & Luecken, L. J. (2007). Postdivorce
living arrangements, parent conflict, and long-term
physical health correlates for children of divorce.
Journal of Family Psychology, 21, 195–205.
Fine, M. A. (2000). Divorce and single parenting. In
C. Hendrick & S. S. Hendrick (Eds.), Close relationships: A sourcebook (pp. 139–154). Thousand Oaks,
CA: Sage.
Fine, M. A., & Fine, D. R. (1994). An examination and
evaluation of recent changes in divorce laws in five
western countries: The critical role of values. Journal
of Marriage and Family, 56, 249–263.
Geelhoed, R. J., Blaisure, K. R., & Geasler, M. J. (2001).
Status of court-connected programs for children whose
parents are separating or divorcing. Family Court
Review, 39, 393–4004.

Healthy Development in Children of Divorced Parents
Goode, W. J. (1994). World changes in divorce
patterns. Population and Development Review, 20,
899–901.
Grych, J. H. (2005). Interparental conflict as a risk factor
for child maladjustment: Implications for the development of prevention programs. Family Court Review,
43, 97–108.
Grych, J. H., & Fincham, F. D. (1997). Children’s adaptation to divorce: From description to explanation. In
S. A. Wolchik & I. N. Sandler (Eds.), Handbook of
children’s coping: Linking theory and intervention
(pp. 159–194). New York: Plenum.
Hetherington, M., & Elmore, A. M. (2003). In S. S. Luthar
(Ed.), Resilience and vulnerability: Adaptation in
the context of childhood adversities (pp. 182–212).
New York, NY: Cambridge University.
Johnson, D. R., & Wu, J. (2002). An empirical test of
crisis, social selection, and role explanations of the
relationship between marital disruption and psychological distress: A pooled time-series analysis of four
wave panel data. Journal of Marriage and Family, 64,
211–224.
King, V., & Sobolewski, J. M. (2006). Nonresident
fathers’ contributions to adolescent well-being.
Journal of Marriage and Family, 68, 537–557.
Kreider, R. M. (2007). Living arrangements of children:
2004. Current Population Reports (pp. 70–114).
Washington, DC: U.S. Census Bureau.
Lucas, R. E., Clark, A. E., Georgellis, Y., & Diener,
E. (2003). Reexamining adaptation and the set point
model of happiness: Reactions to changes in marital
status. Journal of Personality and Social Psychology,
84, 527–539.
Martin, S. P. (2006). Trends in marital dissolution by
women’s education in the United States. Demographic
Research, 15, 537–560.
Orbuch, T. L., & Brown, E. (2006). Divorce in the context
of being African American. In M. A. Fine & J. H.
Harvey (Eds.), Handbook of divorce and relationship
dissolution (pp. 481–498). Mahwah, NJ: Lawrence
Erlbaum Associates.
Stolberg, A. L., & Mahler, J. (1994). Enhancing treatment
gains in a school-based intervention for children of

691
divorce through skill training, parental involvement,
and transfer procedures. Journal of Consulting and
Clinical Psychology, 62(1), 147–156.
Strohschein, L. (2005). Parental divorce and child mental
health trajectories. Journal of Marriage and Family,
67, 1286–1300.
Sun, Y. (2001). Family environment and adolescents’
well-being before and after parents’ marital disruption:
A longitudinal analysis. Journal of Marriage and
Family, 63, 697–713.
Sun, Y., & Li, Y. (2001). Marital disruption, parental
investment, and children’s academic achievement:
A prospective analysis. Journal of Family Issues, 22,
27–62.
Sun, Y., & Li, Y. (2002). Children’s well-being during
parent’s marital disruption process: A pooled timeseries analysis. Journal of Marriage and Family, 64,
742–762.
Teachman, J. D., Tedrow, L. M., & Crowder, K. D. (2000).
The changing demography of America’s families.
Journal of Marriage and Family, 62, 1234–1246.
Wade, T. J., & Pevalin, D. J. (2004). Marital transitions
and mental health. Journal of Health and Social
Behavior, 45, 155–170.
Walker, J. (2003). Radiating messages: An international
perspective. Family Relations, 52, 406–417.
Williams, K., & Dunne-Bryant, A. (2006). Divorce and
adult psychological well-being: Clarifying the role of
gender and child age. Journal of Marriage and Family,
68, 1178–1196.
Wolchik, S. A., West, S. G., Stephen, G., Sandler, I. N.,
Tein, J., Coatsworth, D., et al. (2000). An experimental
evaluation of theory-based mother and mother-child
programs for children of divorce. Journal of Consulting and Clinical Psychology, 68, 843–856.
Wood, R. G., Goesling, B., & Avellar, S. (2007). The
effect of marriage on health: A synthesis of recent
research evidence. Washington, DC: U.S. Department
of Health and Human Services.
Yun-Tung, W. (2011). Taiwan divorce rate falling
steadily: Statistics. AsiaOne. Retrieved May 21, 2012
from
http://www.asiaone.com/News/Latest+News/
Asia/Story/A1Story20110710-288349.html

692

Healthy Development in Children of Parents Who Are Emotionally Ill

Healthy Development in Children of
Parents Who Are Emotionally Ill
Andrea Reupert1, Louisa Drost2,
Joanne Nicholson3 and Karin van Doesum4
1
Institute of Human Development &
Counselling, Faculty of Education, Monash
University, Krongold Centre, Clayton, VIC,
Australia
2
University of Groningen, Groningen,
The Netherlands
3
Dartmouth Psychiatric Research Center,
Lebanon, NH, USA
4
Mindfit/Radboud Universtiy Nijmegen p/a
Mindfit, Deventer, AJ, The Netherlands

Introduction
All children require responsive, nurturing, and
loving relationships, particularly in their early
years. These relationships impact on children’s
development, both physiologically and psychologically. Given the importance of the parentchild relationship and the challenges all parents
face, it is essential that parents are provided with
support in providing supportive environments to
their children. At the same time, parents who have
a mental illness face the same demands that all
parents do, in addition to managing their mental
illness. This entry considers the various risk and
protective factors associated for children, aged
5–12, whose parent has a mental illness. Interventions that promote positive determinants on children’s well-being and/or aim to reduce risk factors
for families will also be presented. This entry
might be read in conjunction with another entry
in this edition, which focuses on adolescents
whose parent has a mental illness.

Definitions and Scope
For the purposes of this entry, we define “emotionally ill” as a mental health problem, illness, or
disorder. While mental health is a complex and
multifaceted domain, mental health problems and

illnesses tend to refer to a range of cognitive,
emotional, and behavioral disorders that persist
over time and are functionally disabling in living
skills, social interactions, family relationships,
jobs, and/or education (Johnson, 1997). The
debilitating nature of a mental illness is not necessarily a function of the diagnosis but instead
depends on a range of factors, including whether
an individual has access to adequate treatment,
medication, and support. In this entry we exclude
developmental and substance use disorders. Most
of the research in the area of parental mental
illness has focused on parental depression, but
other disorders have also been examined including parental psychosis, anxiety, bipolar disorder,
the various eating disorders such as anorexia
nervosa and bulimia, attention deficit hyperactivity disorder, M€unchausen syndrome, and borderline personality disorder.
According to the National Survey on Drug Use
and Health, in 2008, 45 million Americans –
approximately one in five adults – suffer from
some form of mental illness and that among
these adults, 4.8 % (or 11 million people) have
a serious disorder (meeting the diagnostic criteria
of the Diagnostic and Statistical Manual of Mental Disorders: DSM-IV). Many of these same
adults have dependent children in their care.
There have been several attempts to estimate
the number of families where a parent has
a mental illness. In the USA, Nicholson and colleagues (2004) found 68 % of women and 54.5 %
of men with a non-substance psychiatric
disorder are parents and that they are more likely
to be parents than those without a psychiatric
disorder (62.4 % and 52.9 %). A UK national
survey of psychiatric conditions reported that
approximately 10 % of women and 6 % of men
were parents (Parker et al., 2008). Reviews
conducted across several Australian mental
health agencies identified 28 % of clients as
parents (Howe, Batchelor, & Bochynska, 2009).
It needs to be noted, however, that there are many
people who do not seek treatment for mental
illness, and so, data extracted from client/patient
records may well be an underestimate of the
prevalence of children whose parents have
a mental illness.

T.P. Gullotta, M. Bloom (eds.), Encyclopedia of Primary Prevention and Health Promotion,
DOI 10.1007/978-1-4614-5999-6, # Springer Science+Business Media New York 2014

Healthy Development in Children of Parents Who Are Emotionally Ill

One of the first studies aimed at determining
child, as opposed to parent, prevalence
(of children whose parents have a mental illness)
examined the issue from three estimation
approaches (Maybery, Reupert, Patrick, Goodyear, & Crase, 2009). The first approach examined census data from the Australian Bureau of
Statistics and found that 23.3 % of all Australian
children lived in a family where a parent had
a mental illness. The second employed mental
health service usage data for the year
2003–2004 across one Australian state and
found 20.4 % of patients were parents, who had
an estimated 14,403 children. Finally, a crosssectional community study of 701 Australian
families found 14.4 % of children had a parent
with a mental illness. Collectively, such data
indicate that up to one in five children live in
families where a parent has a mental illness
(Maybery et al., 2009).

Theories
One theory that provides a framework for understanding how children are affected by parental
mental illness was developed by Hosman, van
Doesum, and van Santvoort (2009; see Fig. 1).
Central to this model is appreciating that while
parental mental illness is a significant risk factor
for adverse outcomes in offspring, the presence of
parental mental illness alone is not a direct pathway to problems in children. Even though many
children whose parents have a mental illness
develop problems themselves, a significant number grow up without any serious difficulties
(Hosman et al., 2009). As outlined here, there
are various factors, across child, parent, family,
and community domains, which convey risk or
alternatively serve to promote healthy development or prevent problems from occurring in
children.
In the first instance, several twin, family,
adoption, and high-risk cohort studies indicate
a genetic contribution to the transmission of serious mental illness in offspring (e.g., schizophrenia, major depression, bipolar disorder)
(as reviewed by Dean et al. (2010)). However, it

693

has also been found that the offspring of mothers
with schizophrenia were found not only to have
elevated risks of schizophrenia but also a range of
psychotic, affective, and personality disorders
(Dean et al.). Such a result suggests that the
general vulnerability to the development of
a mental disorder in offspring is mediated by
both genetic and environmental factors. The biological transmission of risk is also a factor during
pregnancy, for example, through prenatal substance use and maternal stress.
In terms of environmental factors, mental illness can compromise a parent’s ability to care for
children and the manner in which a parent interacts with his or her children. A parent’s mental
illness might cause him or her to be withdrawn,
emotionally unavailable, or preoccupied
(Brockington et al., 2011). The family context,
including the presence of marital discord, violence, and the presence/absence of the other
parent (and the presence of a disorder in the
other parent), will also influence the level of
risk children are exposed to. Conversely, a supportive partner and extended family members can
buffer the negative impact of a partner’s mental
illness. Other factors associated with mental illness, such as unemployment, housing issues,
poverty, and isolation, can also adversely impact
on outcomes for children (Hosman et al., 2009).
Children’s characteristics (e.g., their temperament, age) and their social environment (such as
their schools and neighborhoods) all play a role in
determining outcomes as well.
It is also important to acknowledge that children’s needs change depending on their age and, in
particular, their age at the time of the parents’
mental illness. For children, the early years are
critical. Positive, early parent-child attachment
establishes the foundation for children’s healthy
development and influences their future interpersonal relationships. A child who has had a calm,
stable early childhood prior to the onset of
a parent’s mental illness may fare much differently
and possibly better than a child whose early years
were disrupted by the presence of parental mental
illness and related poor parenting functioning that
emerged before the child was born (Brockington
et al., 2011).

694

Healthy Development in Children of Parents Who Are Emotionally Ill
Child

Parent

Vulnerability & Resilience

Risk & protective factors
of parental mental illness

temperamental features
stress reactivity (HPA)
age (timing) and gender

genetic
transfer
Mentally ill parent
disorder & impairment
chronicity
comorbid disorders
coping skills & self esteem
parenting competence

life span
development

insecure attachment
cognitive and social skills
disorder knowledge & self-blame
Self-esteem; parentification

pregnancy
stress, smoking,
premature delivery

Parent-child interaction
Child outcomes

P insensitive responsiveness
Family context
marital discord, divorce
violence & life events &
low income, poverty

hostility & rejection
low involvement
inadequate parenting
model behavior
abuse and neglect

stress
coping
support

C response & imitation

healthy
development
problem behavior
psychopathology
social outcomes

problem behavior
Other parent
Absent or present
positive care
parenting competence
knowledge about partner's
psychiatric disorder

Social support, social isolation & stigmatization
Availability and quality of professional care

Family

Social environment

Social network & Professional care
family, neighbors, friends, school, professionals

Healthy Development in Children of Parents Who
Are Emotionally Ill, Fig. 1 A developmental model of

transgenerational transmission of psychopathology
(Adapted from authors, Hosman et al., 2009)

Moreover, relationships between parents and
children are bidirectional (Beardslee, Gladstone,
& O’Connor, 2011). This means that each family
member responds to, and contributes to, family
interactions. The reciprocity between family members implies that parental mental illness may undermine healthy development, and in turn, children’s
responses may contribute to parents’ emotional and
functional status (Nicholson, Cooper, Freed, &
Isaacs, 2008). Relationships involve continuous
interactions and feedback over time, and outcomes
are multiply determined (van Doesum, Hosman, &
Riksen-Walraven, 2005).
In sum, interactions among genetic, biological, psychosocial, and social factors underlie the
transmission of mental health problems from parents to children. Such a model acknowledges that
not all children whose parent has a mental illness
will be adversely affected nor will all children in
the same family will be affected in the same way.

Research
Hosman and colleagues’ model (2009; Fig. 1)
identifies various risk and protective factors
across several domains for parents, of either gender, across a full range of mental illnesses. This
means that resilience in children is supported by
the presence and promotion of protective factors
and the absence or mitigation of risk factors. The
model differentiates between successive developmental stages in the child’s life, starting from
a mother’s pregnancy. A parent’s caregiving
responsibilities are determined by, and related
to, a child’s developmental age and stage. Each
stage is linked to specific developmental
processes and tasks and age-related onset of risk
factors and psychiatric disorders. A parent may
be well suited, in spite of mental illness, to
meeting the needs of a younger child but may
be extremely challenged by a teenaged child, as

Healthy Development in Children of Parents Who Are Emotionally Ill

different developmental ages and stages require
different parenting styles and skills.
Parents. Several parental characteristics have
been found to be associated with increased risk in
children, including disorder severity and chronicity, parental age of onset, timing in the developmental stages of the child, family history of
psychopathology, comorbidity with substance
use or other illnesses, and psychopathology in
both parents, rather than just one (Brockington
et al., 2011). Parental behavior and the nature and
quality of parent-child interactions mediate the
impact of parental mental illnesses on outcomes
for children (Hipwell, Goossens, Melhuish, &
Kumar, 2000). Positive parenting was found to
have a protective influence on the development of
conduct problems in children of depressed
mothers (Chronis, Lahey, & Pelham, 2007).
Parents might also provide children with pathological role model behavior and coping styles,
which will be copied by their offspring, for
instance, in the case of emotional eating or
the use of alcohol as a mood manager
(Sidebotham & Heron, 2006).
Child. The major child-related vulnerabilities
or risk factors identified in multiple studies
include difficult temperament, behavioral
inhibition, negative emotionality, stress reactivity, insecure attachment, negative self-esteem,
poor cognitive and social skills, lack of knowledge about the parental disorder, the taking-on of
age-inappropriate family responsibilities, and
self-blame (as reviewed by Goodman & Gotlib
(1999)). Resilience may be characterized by positive emotionality, safe attachment, cognitive and
social competence, positive self-esteem, selfreliance, relevant knowledge about parental disorders, and perceived social support (e.g.,
Beardslee & Podorefsky, 1988). Positive characteristics such as adequate coping skills, interests
and talents, and positive experiences such as success at school and in friendships protect children
from negative outcomes (Nicholson, Albert,
Gershenson, Williams, & Biebel, 2009).
Family. Family discord, domestic violence,
and family-related stress can be both
consequences of and contributors to parental
mental illnesses (Brockington et al., 2011).

695

The second parent may play a protective role
or can represent an additional risk factor. For
instance, the presence of a parent who is caring
and supportive to the child and who understands
the disorder of the partner and can answer
children’s questions about a parent’s mental illness can successfully buffer the negative impact
of maternal depression (Chang, Halpern, & Kaufman, 2007). However, the presence of a partner
who also suffers from mental illness or shows
abusive behavior will further increase risk to
the young person (e.g., Birmaher et al., 2009).
In the case of single-parent families, more prevalent when parents have mental illnesses,
support from the other parent might be totally
absent; alternatively, the child might be spared
the negative impact of a poorly functioning second parent.
Social Environment. Just as in other domains,
the social environment outside the family can
play both a protective and a risk-increasing role
for children of parents with a mental illness.
Research in this domain has primarily been
sourced from retrospective and qualitative
studies, such as in-depth interviews with adolescents and adult children of parents with mental
illness (e.g., Knutsson-Medin, Edlund, &
Ramklint, 2007). Networks may include grandparents, neighbors, friends, teachers, or peers living in similar circumstances. Relatives and
friends may offer cognitive, emotional, and practical support to both parents and children, for
instance, by providing respite and care when
a parent is unavailable or by offering parenting
advice, a listening ear, or opportunities for positive family or neighborhood events. Professionals
in diverse systems may be supportive to youth
depending, in part, on the context in which
a parent’s mental illness, youth’s needs, or family
issues emerge and are addressed. Additionally,
Rutter and Quinton (1984) found that the direct
effects of parental mental illness were less
detrimental than the social adversity associated
with mental illness, such as poverty, stigma, and
housing issues.
In sum, factors in each of these domains contribute to the socio-emotional development of
children whose parents live with mental illnesses.

696

Healthy Development in Children of Parents Who Are Emotionally Ill

The high risk and potential for negative outcomes
in children underscore the need to carefully
assess the risk factors within and across domains,
the presence of protective factors, and the interactions between risk and protective factors. Risks
may be additive and the ratio of risks to protective
factors, that is, the balance of these factors, is key
(Beardslee et al., 2011). Many of these factors are
malleable and so provide an opportunity for
interventions to target the parent, the child, the
parent-child relationship, the family, and/or the
community.

Strategies
Hosman and colleague’s (2009) integrative,
developmental model offers a scientific framework for the development of a comprehensive,
multicomponent prevention program for children
of parents with a mental illness and their families.
Approaches are further informed by the lived
experiences of parents, children, and workforce
members reported in the literature. These
strategies aim to support the optimal functioning
of parents, children’s achievement of
age-appropriate developmental tasks, positive
parent-child interactions, and the responsiveness
of a family’s social and professional networks.
Parents and Families. It is important, in the
first instance, to support parents’ health,
well-being, and functioning. All parents benefit
from support, even when they are healthy and
especially when they are ill. The early identification of mental illnesses, treatment, and support
for parents is paramount, particularly as the
remission of illness and enhanced functioning of
one parent is likely to have benefits for all
children in a family (Beardslee et al., 2011).
Family members need to be supportive of
a parent’s efforts and, if necessary, assist in
meeting basic family needs, to provide adequate
security, safety, nurturance, and care to children.
Child. Children whose parents have mental
illnesses are likely to benefit from the types of
support that would benefit any children with ill
parents. They require the caregiving and nurturance an ill parent may be unable to provide – from

a “well” parent, another relative, close family
friend, or community member. Children may
take on additional family responsibilities when
parents are ill that conflict with age-appropriate
activities or even attending school (Aldridge &
Becker, 2003) and so require support in
maintaining age-appropriate pursuits. As
children may be concerned that they will develop
the illness or that they caused their parent’s illness (Fudge & Mason, 2004), they benefit from
information about the illness, course of treatment,
and expectations for the future. Adult children of
parents with mental illness, in retrospective
accounts, describe their panic and fear when
a parent was hospitalized, typically with no
explanation and with no understanding of when
or under what circumstances the parent would
return (Foster, 2010). If parents are hospitalized,
arrangements should be made for supporting
appropriate contact with children, in person or
via telephone or email, to reassure both children
and parents about the situation.
Workforce. Service providers and, in particular, adult mental health service providers should
routinely “screen” for parenting status and
concerns as well as mental health issues. As
well, professionals should be acquainted with
community resources, mental health and family
advocacy networks, and web-based resources
that may be helpful to children and families living
with parental mental illnesses. An online
resource, Keeping Families and Children in
Mind, has been recently developed for
professionals, which aims to enhance awareness
and skill when working with this target group,
with promising evaluation results (Reupert,
Foster, Maybery, Eddy, & Fudge, 2011).

What Works
We identified the following interventions for
children, aged 5–12 years of age, whose parents
have a mental illness, on the basis of a review of
the literature, our collective experience as
clinicians and researchers in the field, and from
consultation with various consumer, carer,
clinician, and researcher networks. Note that

Healthy Development in Children of Parents Who Are Emotionally Ill

many interventions listed here do not fit precisely
within the 5–12 age group but at times extend into
younger and/or older age groups.
Beardslee’s Prevention Intervention Program
(PIP) is the most rigorously evaluated program in
this area, though it must be noted that most of
these evaluations were based on the same sample
group and the focus is parental depression only
(e.g., Beardslee, Wright, Gladstone, & Forbes,
2007). PIP targets families where a parent is
diagnosed with a major depressive disorder or
bipolar disorder, with children aged between
8 and 15 who have never been treated for an
affective disorder. The intervention is based on
a cognitive psychoeducational primary prevention model and consists of between 6 and 10 sessions, conducted with the parents, the
children, and the whole family. The aim of the
program is to increase parents’ knowledge about
the symptoms and causes of depression and
encourage families to talk about their experiences
of depression and the effects on the family.
Follow-up occurs for up to 1 year to monitor
and support the family. A comparison intervention was developed, consisting of a two-session
lecture discussion group with parents only,
regarding psychoeducation about mood disorders
and strategies to foster children’s resiliency. The
aim of both interventions is to decrease the effect
of family and marital risk factors, enhance
parental and family functioning, and prevent the
onset of depression and other mental health
problems in children.
Following both clinician-led and lecture-style
interventions, parents reported increased
discussion and knowledge about depression and
children’s internalizing symptoms improved
(Beardslee et al., 2007). Compared to the lecture
intervention, the clinician-led intervention
recorded improved family communication and
improved parental reports of children’s behavior
and children reported greater understanding of
depression, at follow-up periods (Beardslee
et al.). Numbers of children within both groups
diagnosed with depression 4.5 years after
intervention were similar, suggesting that both
the clinician-led and the lecture conditions were
equally effective in preventing the development

697

of depression in children whose parent has an
affective disorder (Beardslee et al.). PIP has
been adapted for a low-income, cultural diverse
family though at this point has not been evaluated
(Beardslee et al., 2011).

What Is Promising
There are other family-based programs for
children where a parent has depression, also
employing a cognitive-behavioral model, that
have not been as rigorously evaluated as
Beardslee’s intervention outlined above. For
example, Sanders and McFarland’s (2000)
Cognitive-Behavioral
Family
Intervention
(CBFI) is an intervention for mothers who have
depression and their 3- to 9-year-old children that
targets mothers’ depression and the mother-child
relationship. It must be noted however that this
program was designed for children who had
either a conduct disorder or an oppositional
defiant disorder. Therapy is provided to individual families involving eight clinic sessions and
four feedback sessions in mother’s homes. The
program consists of behavioral parenting strategies, such as the use of contingent praise and
token economies, plus cognitive principles, so
that mothers could identify and interrupt dysfunctional parenting-related cognitions and attributions (“I’m a failure as a mother”). CBFI was
evaluated against an intervention consisting of
the behavioral components only (Behavioral
Family Intervention: BIF). Both interventions
were effective in reducing mothers’ depression
and children’s disruptive behavior. However, the
CBFI demonstrated additional benefits in that
6 months post intervention, families showed
concurrent clinically reliable reductions in
maternal depression and child disruptive
behavior than families in the BIF intervention.
Other family-focused programs for children
and their depressed parent employing
a cognitive behavior approach can be seen from
Germany (EFFEKT-E: B€uhler, Kötter, Jaursch,
& Lösel, 2011), Finland, (Let’s Talk: Solantaus,
Paavonen, Toikka, & Punam€aki, 2010), and the
USA (the Family Group Cognitive-Behavioral

698

Healthy Development in Children of Parents Who Are Emotionally Ill

Prevention Intervention; Compas et al., 2011;
Keeping Families Strong; Riley et al., 2008).
The overall aim of these programs is to
strengthen the parent-child relationship and provide psychoeducation about parental depression
and the effect of depression on children. While all
programs have been evaluated using randomized
controlled trials (RCTs), and demonstrate promising results, they have yet to demonstrate longterm sustained change in participants.
Other family-oriented programs can be found
not limited to parental depression but instead
designed for families where a parent has any severe
and/or chronic mental illness. From the Netherlands, Child Talk is a two- to three-session program
that aims to provide information to families about
the parent’s disorder and improve parenting and
competence in children aged 2–23 years (van
Doesum & Koster, 2009). Family Options is a US
rehabilitation program, where Family Coaches
conduct individually tailored meetings with families, focusing on multiple domains (Nicholson
et al., 2009). The goals of the program are to
enhance community networks and maintain the
family’s desired level of well-being. While children’s outcomes are not as yet available, results
demonstrate significant improvements in mothers’
social support and well-being (Nicholson et al.).
Finally, in Australia, the Family Care Model is
a care coordination model for individual families
where a parent has a dual diagnosis and their under
18 years of age children. Early results demonstrate
that over the 12- to 18-month program families
make progress to their nominated goals (Reupert,
Maybery, & Goodyear, 2010). The striking feature
among this group of family programs is that strategies are tailored to meet the individual needs of
family members, drawing on formal and informal
community supports.
Another commonly reported form of intervention for children whose parents have a mental
illness are peer support groups, which can be
found in Australia (Goodyear, Cuff, Maybery,
& Reupert, 2009), the USA (Riebschleger,
Tableman, Onaga, Rudder, & Whalen, 2009),
Germany (Dierks, 2001), the Netherlands (van
Doesum & Hosman, 2009), and Canada (Richter,
2006). The aim of these programs is for children

to learn more about mental illness and well-being
and practice adaptive coping skills in a group
format. The programs also provide an opportunity
for children to talk about and share their
experiences with other children living in similar
circumstances. While mostly quasi-evaluation
methodologies have been employed (in Australia
at least), with results shown to be promising, more
rigorous evaluation is required in this area, to
establish the efficacy of this approach (Reupert
& Maybery, 2009a).

What Does Not Work
Children living in families in which a parent has
a mental illness have lives that are complex and
multifaceted and unique to each family and individual. Given the range of risk and protective
variables that impact on children’s outcomes, it
is erroneous to believe that all children will
require or want the same intervention. Thus,
there needs to be various interventions on offer
to fully meet the needs and competencies of children and their parents.
As well, not all children will be necessarily
suited to all available interventions. One peer
support program found that some children fared
worse, post intervention (Goodyear et al., 2009).
Specifically, the difficulties and emotional
subscale scores on children’s Strengths and Difficulties Questionnaire (SDQ) increased, rather
than decreased, post intervention. For this program, however, it must be noted that prescores for
this particular group of children on the SDQ
identified a clinically unwell group of children,
suggesting the intervention was not suited for
children who are clinically unwell. Indeed for
other children, who were clinically well, evaluation data were promising. Overall, such evaluation information indicates that there needs to be
different types of interventions, depending on the
mental health status of the presenting child.
Additionally, there needs to be greater specificity
in interventions for different family groups and
for children with different ages and offered at
different times because needs and strengths in
families change over time.

Healthy Development in Children of Parents Who Are Emotionally Ill

Moreover, given the importance of family in
the development of children, it may be ineffective
to provide an intervention that focuses only on
the child. Children’s parents; other family members, including siblings and extended family
members; and community and school networks
and supports all need to be acknowledged in
terms of impacting on children’s outcomes. This
means that any assessment of risk and resilience
needs to assume a broader ecological view of the
child, which will then ensure that appropriate
referrals and/or interventions can be delivered
(Steer, Reupert, & Maybery, 2011).

Summary
While there are repeated calls for interventions
that engage children in their environmental
context (Nicholson, 2009; Reupert & Maybery,
2009b), the schism between research, policy, and
practice is wide, to the point that children living
in families where a parent has mental illness are
often considered “invisible” by those clinicians
treating their parents (Fudge & Mason, 2004).
It is clear that there needs to be a fundamental
shift in the way that programs are developed for
these families, with a particular emphasis on
early intervention. Despite the heterogeneity of
interventions, some common factors can be
identified across programs for families where
a parent has a mental illness that aim to
either minimize risks for families or promote
protective and resilience factors. The repeated
message here is that there needs to be multimodal
focus of intervention that focuses on multiple
stakeholders.
In the first instance, it is imperative that clinicians identify the parenting status of their clients
by asking the question, “Do you have children?”
While there are a number of workforce barriers
(emulating from the policy, the organization, and
the clinician; Maybery & Reupert, 2009), intervening with family members, especially children,
is crucial, as contributors to a client’s treatment
and in terms of early intervention for children.
Acknowledging and celebrating the role of
the parent is at the core of many family-focused

699

interventions. When working with parents, clinicians need to provide appropriate, sensitive,
and timely assessment and intervention that
focus on his/her mental illness and parenting
role. Parents need to be sensitively informed
about the impact of their mental illness on
parenting behavior and their children, without
feeling blamed but in a manner that acknowledges the strengths they bring as a parent to their
children. When feeling unwell, parents might
need support in their parenting role, especially
around practical issues of running a household
and child care.
Strategies directed to stabilizing the family
unit are also important. Thus, planning for potential crises such as a parent being hospitalized or
becoming very unwell can assist in managing,
averting, or minimizing potential stress for the
family. Establishing a crisis plan involves
negotiating with stakeholders what needs to
occur in a time of crisis, such as where a child
might stay if his/her parent is hospitalized.
Children need to be actively involved in this
process, as they are often the first to identify
early warning signs in their parent and need to
know who to contact for themselves and for their
parent (Reupert, Green, & Maybery, 2008).
Another common feature across various programs is the provision to children of accurate and
developmentally appropriate knowledge about
a parent’s mental illness. Beardslee and
Podorefsky (1988) found that resilient young
people whose parent had depression were able
to distinguish between themselves and their parents’ illness and, importantly, appreciated that
they were not the cause of their parents’ illness.
Such data underscore the importance of
informing children about their parent’s mental
illness and providing this at several points over
their childhood, in recognition that young people
will require additional information and have different questions as they mature.
Most existing interventions target parental
depression, and so other interventions need to
be developed and evaluated for families where
a parent has disorders other than, or in addition to,
depression. Perhaps it is not surprising that there
are limited program evaluations for families,

700

Healthy Development in Children of Parents Who Are Emotionally Ill

given the importance funders and government
bodies place on the traditional RCT program
evaluation paradigm. RCTs are complex but
typically involve two or more groups being
randomly allocated to different interventions.
Groups are tightly controlled so that participant
variables are the same (e.g., they all have the
same disorder) and each participant within
a certain group receives the same intervention.
Families where a parent has a mental illness vary
in terms of their needs and strengths and where
they are placed in the lifespan, and so program
foci vary, as Nicholson (2009, p. 223) points out:
“A multimodal intervention may be provided in
different doses or levels of intensity for different
families or even different family members within
the same family”. Thus, it is difficult to consider
how family-focused programs might “fit” an
RCT model. Indeed, it has been argued that
RCTs are less sensitive to contextual issues and
unanticipated causal factors that typically exist in
community settings (Patton, 2008). As well,
many clinicians lack the knowledge, resources,
and time to implement RCTs (Reupert et al.,
2009). Alternative though equally rigorous
forms of program evaluation are required, with
a particular focus on building researchcommunity partnerships (Nicholson, 2009),
though such activities need to be supported with
time, funding, and resources.
In sum, it is crucial that there are procedures in
place to identify the parenting status of clients
and, rather than assume on the basis of parental
mental illness alone, to sensitively screen for
competence and need across various domains,
such as parenting, child well-being, family
dynamics, and social support. At a minimum,
clinicians should at least be referring parents
and/or children to appropriate services if
required, for either early intervention support
and/or treatment. Parenting support, education
to children about mental illness, as well as
opportunities for families to openly discuss
what the parent’s mental illness means for
each member of the family also need to be
made available, depending on a family’s need
and the context from which the service is
provided.

References
Aldridge, J., & Becker, S. (2003). Children caring for
parents with mental illness. Bristol, England:
The Policy Press.
Beardslee, W. R., Gladstone, T. R., & O’Connor, E. E.
(2011). Transmission and prevention of mood disorders among children of affectively ill parents:
A review. Journal of the American Academy of Child
and Adolescent Psychiatry, 50(11), 1098–1109.
Beardslee, W. R., Paez-Soto, A., Herrera-Amighetti, L.,
Diego, L., Montero, F., Herrera, H., et al. (2011).
Adaption of a preventive intervention approach to
strengthen families facing adversities, especially
depression. The International Journal of Mental
Health Promotion, 13(2), 5–13.
Beardslee, W. R., & Podorefsky, M. A. (1988). Resilient
adolescents whose parents have serious affective and
other psychiatric disorders: Importance of selfunderstanding and relationships. Psychiatry, 145(1),
63–69.
Beardslee, W. R., Wright, E. J., Gladstone, T. R. G., &
Forbes, P. (2007). Long-term effects from
a randomized trial of two public health preventive
interventions for parental depression. Journal of
Family Psychology, 21(4), 703–713.
Birmaher, B., Axelson, D., Monk, K., Kalas, C., Goldstein,
B., Hickey, M. B., et al. (2009). Lifetime psychiatric
disorders in school-aged offspring of parents with bipolar disorder: The Pittsburgh Bipolar Offspring study.
Archives of General Psychiatry, 66(3), 287–296.
Brockington, I., Chandra, P., Dubowitz, H., Jones, D.,
Moussa, S., Nakku, J., et al. (2011). WPA guidance
on the protection and promotion of mental health in
children of persons with severe mental disorders.
World Psychiatry, 10(2), 93–102.
B€
uhler, A., Kötter, C., Jaursch, S., & Lösel, F. (2011).
Prevention of familial transmission of depression:
EFFEKT-E, a selective program for emotionally
burdened families. Journal of Public Health,
19, 321–327.
Chang, J. J., Halpern, C. T., & Kaufman, J. S. (2007).
Maternal depressive symptoms, father’s involvement,
and the trajectories of child problem behaviors in a US
national sample. Archives of Pediatrics & Adolescent
Medicine, 161(7), 697–703.
Chronis, A. M., Lahey, B. B., & Pelham, W. E. (2007).
Maternal depression and early positive parenting predict
future conduct problems in young children with
attention-deficit/hyperactivity disorder. Developmental
Psychology, 43(1), 70–82.
Compas, B., Forehand, R., Thigpen, J., Keller, G.,
Hardcastle, E., Cole, D., et al. (2011). Family group
cognitive-behavioral preventive intervention for
families of depressed parents: 18 and 24 month
outcomes. Journal of Consulting and Clinical
Psychology, 79(4), 488–499.
Dean, K., Stevens, H., Mortensen, P. B., Murray, R.,
Walsh, E., & Pedersen, C. (2010). Full spectrum of

Healthy Development in Children of Parents Who Are Emotionally Ill
psychiatric outcomes among offspring with parental
history of mental disorder. Archives of General
Psychiatry, 67(8), 822–829.
Dierks, H. (2001). Prevention groups for school-aged
children of mentally ill parents. Praxis der Kinderpsychologie und Kinderpsychiatrie, 50(7), 560–568.
Foster, K. (2010). ‘You’d think this roller coaster was
never going to stop’: Experiences of adult children of
parents with serious mental illness. Journal of Clinical
Nursing, 19(21–22), 3143–3151.
Fudge, E., & Mason, P. (2004). Consulting with young
people about service guidelines relating to parental
mental illness. Australian e-Journal for the
Advancement of Mental Health, 3(2), 50–58.
Goodman, S. H., & Gotlib, I. H. (1999). Risk for
psychopathology in the children of depressed mothers:
A developmental model for understanding
mechanisms of transmission. Psychological Review,
106(3), 458–490.
Goodyear, M., Cuff, R., Maybery, D., & Reupert,
A. (2009). CHAMPS: A peer support program for
children of parents with a mental illness. Australian
e-Journal for the Advancement of Mental Health,
8(3), 296–304.
Hipwell, A. E., Goossens, F. A., Melhuish, E. C., &
Kumar, R. (2000). Severe maternal psychopathology
and infant-mother attachment. Development and
Psychopathology, 12(2), 157–175.
Hosman, C. M. H., van Doesum, K. T. M., & van Santvoort,
F. (2009). Prevention of emotional problems and psychiatric risks in children of parents with a mental illness
in the Netherlands: I. The scientific basis to
a comprehensive approach. Australian e-Journal for
the Advancement of Mental Health, 8(3), 250–263.
Howe, D., Batchelor, S., & Bochynska, K. (2009).
Estimating consumer parenthood within mental health
services: A census approach. Australian e-Journal for
the Advancement of Mental Health, 8(3), 231–241.
Johnson, D. L. (1997). Overview of severe mental illness.
Clinical Psychology Review, 17, 247–257.
Knutsson-Medin, L., Edlund, B., & Ramklint, M. (2007).
Experiences in a group of grown-up children of
mentally ill parents. Journal of Psychiatric and Mental
Health Nursing, 14, 744–752.
Maybery, D. J., & Reupert, A. E. (2009). Parental mental
illness: A review of barriers and issues for working
with families and children. Journal of Psychiatric and
Mental Health Nursing, 16(9), 784–791.
Maybery, D., Reupert, A., Patrick, K., Goodyear, M., &
Crase, L. (2009). Prevalence of children whose parents
have a mental illness. Psychiatric Bulletin, 33, 22–26.
Nicholson, J. (2009). Building the evidence base for
families living with parental mental illness. Australian
e-Journal for the Advancement of Mental Health,
8(3), 222–226.
Nicholson, J., Albert, K., Gershenson, B., Williams, V., &
Biebel, K. (2009). Family options for parents with mental
illnesses: A developmental, mixed methods pilot study.
Psychiatric Rehabilitation Journal, 33(2), 106–114.

701

Nicholson, J., Biebel, K., Katz-Leavy, J., & Williams, V.
(2004). Prevalence of parenthood among adults with
mental illness. Implications for State and Federal policy makers, programs and provider. Psychiatry Publications and Presentations. Paper 153. Retrieved
October 28, 2011, from http://works.bepress.com/
joanne_nicholson/19/
Nicholson, J., Cooper, J., Freed, R., & Isaacs, M. (2008).
Children of parents with mental illness. In G. Blau &
T. P. Gullotta (Eds.), Handbook of child behavioral
issues: Evidenced-based approaches (pp. 231–266).
London: Taylor & Francis.
Parker, G., Beresford, B., Clarke, S., Gridley, K., Pitman,
R., Spiers, G., et al. (2008). Research reviews on
prevalence, detection and interventions in parental
mental health and child welfare: Summary report.
York: Social Policy Research Unit, University of
York. Retrieved November 8, 2012, from http://php.
york.ac.uk/inst/spru/pubs/1125/
Patton, M. (2008). Utilization-focused evaluation
(4th ed.). London: Sage.
Reupert, A., Foster, K., Maybery, D., Eddy, K., &
Fudge, E. (2011). “Keeping families and children in
mind”: An evaluation of a web based workforce
resource. Child & Family Social Work, 6(2), 192–200.
Reupert, A., Goodyear, M., Eddy, K., Alliston, C.,
Mason, P., Maybery, D., et al. (2009). Australian programs and workforce initiatives for children and their
families where a parent has a mental illness. Australian
e-Journal for the Advancement of Mental Health, 8(3),
277–285.
Reupert, A., Green, K., & Maybery, D. (2008). Family
care plans for families affected by parental mental
illness. Families in Society: The Journal of Contemporary Social Sciences, 89(1), 39–43.
Reupert, A., & Maybery, D. (2009a). A “snapshot” of
Australian programs to support children and adolescents whose parents have a mental illness. Psychiatric
Rehabilitation Journal, 33(2), 125–132.
Reupert, A., & Maybery, D. (2009b). Practice, policy and
research: Families where a parent has a mental illness.
Australian e-Journal for the Advancement of Mental
Health, 8(3), 210–214.
Reupert, A., Maybery, D., & Goodyear, M. (2010). A
model of care for families where parents have drug
and alcohol and mental health issues. Northern Kids
Care – On Track Community Programs. Melbourne,
Australia: Monash University.
Richter, G. (2006). Fostering resilience: Evaluating the
effectiveness of Kids in Control. Unpublished thesis,
Trinity Western University, Langley, Canada.
Riebschleger, J., Tableman, B., Onaga, E., Rudder, D., &
Whalen, P. (2009). Early outcomes of a pilot
psychoeducation group intervention for children of
a parent with a psychiatric illness. Psychiatric
Rehabilitation Journal, 33(2), 133–141.
Riley, A. W., Valdez, C. R., Barrueco, S., Mills, C.,
Beardslee, W., Sandler, I., et al. (2008). Development
of a family-based program to reduce risk and promote

702

Healthy Development in Children of Parents Who Are Emotionally Ill

resilience among families affected by maternal
depression: Theoretical basis and program description.
Clinical Child & Family Psychology Review, 11, 12–29.
Rutter, M., & Quinton, D. (1984). Parental psychiatric
disorder: Effects on children. Psychological Medicine,
14, 853–880.
Sanders, M., & McFarland, M. (2000). Treatment of
depressed mothers with disruptive children:
A controlled evaluation of cognitive behavioral family
intervention. Behavior Therapy, 31, 89–112.
Sidebotham, P., & Heron, J. (2006). Child maltreatment in
the “children of the nineties”: A cohort study of risk
factors. Child Abuse Neglect, 30(5), 497–522.
Solantaus, T., Paavonen, E., Toikka, S., & Punam€aki, R.
(2010). Preventive interventions in families with
parental depression: Children’s psychosocial
symptoms and prosocial behaviour. European Child
and Adolescent Psychiatry, 19, 883–892.
Steer, S., Reupert, A., & Maybery, D. (2011). Programs
for children of parents who have a mental illness:
Referral and assessment practices. “One size fits
all?”. Australian Social Work, 64(4), 502–514.
van Doesum, K. T. M., & Hosman, C. M. H. (2009).
Prevention of emotional problems and psychiatric
risks in children of parents with a mental illness in
the Netherlands: II. Interventions. Australian
e-Journal for the Advancement of Mental Health, 8(3),
264–267.
van Doesum, K. T. M., Hosman, C. M. H., &
Riksen-Walraven, J. M. (2005). A model based intervention for depressed mothers and their infants. Infant
Mental Health Journal, 26(2), 157–176.

van Doesum, K., & Koster, C. (2009). Child talk:
Manual of preventive home-visits for mentally ill parents and their children. Unpublished report, Deventer,
The Netherlands.

Further Reading
The Australian Children of Parents with a Mental Illness
(COPMI) site provides resources to families and
clinicians working with families where a parent has
a mental illness. Retrieved November 8, 2012, from
http://www.copmi.net.au/
The Social Care Institute for Excellence in the UK has
developed an e-learning resource regarding the nature
of parental mental health and its impact on families.
Retrieved November 8, 2012, from http://www.scie.
org.uk/publications/elearning/parentalmentalhealthan
dfamilies/index.asp
In the USA there is FAMpod (Families Preventing and
Overcoming Depression) that provides information
about the Beardslee program and parental depression
generally. Retrieved November 8, 2012, from http://
fampod.org/
A template for crisis plans “Supporting Our Family Kit”
can be downloaded from COMIC, (Children of
Mentally Ill Consumers) Adelaide, Australia.
Retrieved November 8, 2012, from http://www.
howstat.com/comic/
Nicholson, J., Henry, A. D., Clayfield, J. C., & Phillips, S.
(2001). Parenting well when you’re depressed:
A complete for maintaining a healthy family. Oakland,
CA: New Harbinger Publications.

Healthy Development in Children with Autism Spectrum Disorder

703

Healthy Development in Children
with Autism Spectrum Disorder

aware of warning signs, diagnostic procedures,
and effective interventions in order for the child
to be put in the best possible position for healthy
lifespan development.

Patrick Chambers1 and Douglas Frye2
1
Department of Psychology, Northwestern
University, Evanston, IL, USA
2
University of Pennsylvania, Philadelphia,
PA, USA

Definitions and Scope

Introduction
Autism is a pervasive developmental disability
marked by deficits in communication, symbolic
or imaginative activities, and reciprocal social
interaction (Maurice, Green, & Luce, 1996).
Though the cause of autism is unknown, it is
widely presumed to be a biological disorder stemming from atypical neurological development.
The diverse range of symptom severity and
cognitive ability that can accompany a diagnosis
of autism is acknowledged with the term autism
spectrum disorders (ASD), which includes
classic autism, Asperger’s syndrome, Pervasive
Developmental Disorder-Not Otherwise Specified (PDD-NOS), Rett’s syndrome, and childhood disintegrative disorder. Children with
autism spectrum disorders are a heterogeneous
population. They display various levels of
cognitive ability and symptom severity, but they
share a universal impairment in social and communicative ability that compromises social and
emotional development.
Increased awareness and broadened diagnostic criteria have contributed to a surge in ASD
diagnoses over the last decade, and autism is
being studied extensively from scientists in
multiple disciplines, including neurologists,
epidemiologists, and behaviorists, to develop an
understanding of the cause of, and optimal treatments for, ASD. There remains a great deal of
mystery surrounding ASD, but science has
uncovered important strategies for promoting
social and emotional development in children
with ASD. Overcoming the impairments and
harnessing the strengths associated with ASD is
a challenging task; therefore, parents must be

A diagnosis of childhood autism (also known as
classic autism) is made by a clinician through
behavioral criteria set by the DSM-IV (2000)
that includes items of qualitative impairment in
social interaction (such as lack of eye-to-eye gaze
and facial expression) and communication (lack
of conversational language and social imitative
play), as well as the presence of restricted,
repetitive, and stereotyped patterns of behavior,
interests, and activities (such as hand flapping,
nonfunctional routines, and persistent preoccupation with parts of objects). The onset of these
delays or impairments occurs prior to 3 years of
age. Similar criteria have been set by the World
Health Organization, ICD-10 (World Health
Organization [WHO], 1993).
Individuals with Asperger’s syndrome display
symptoms of autism, such as poor motor skills,
bizarre interests, and impaired communicative
ability, but demonstrate average or above average
cognitive ability and no clinically significant
delay in language (American Psychiatric Association, 2000). Asperger’s is often referred to as
high-functioning autism (Frith, 2003).
Other autism spectrum disorders may show
some symptoms of classic autism, such as childhood disintegrative disorder, in which the child
develops normally, but have severe regression in
language, cognitive ability, and motor skills at
age 3–10 years. Rett’s syndrome, a genetic
disorder reported almost entirely in girls, is characterized by normal development that is followed
by regression in hand skills, speech, and cognitive ability at 7–24 months. Individuals with
Pervasive Developmental Disorder-Not Otherwise Specified (PDD-NOS) also demonstrate
some symptoms of autism, but not enough to
fulfill the complete diagnostic criteria to be
diagnosed as having classic autism or Asperger’s.
The upcoming DSM-V will eliminate Asperger’s

T.P. Gullotta, M. Bloom (eds.), Encyclopedia of Primary Prevention and Health Promotion,
DOI 10.1007/978-1-4614-5999-6, # Springer Science+Business Media New York 2014

704

Healthy Development in Children with Autism Spectrum Disorder

syndrome and PDD-NOS by consolidating
them into one category: autism spectrum disorder. This reclassification has created controversy
within the autism community, as it may lead
to a more restrictive diagnosis (Carey &
Harmon, 2012).
Further complicating our understanding of
ASD is the fact that it is often, but not necessarily,
accompanied by other developmental disabilities
such as mental retardation, attention deficit disorder, gastrointestinal issues, motor coordination
disorder, and hypo- or hypersensitivity. The
remainder of this entry considers the ASDs of
childhood autism, Asperger’s syndrome, and
PDD-NOS. Rett’s syndrome and childhood
disintegrative disorder, while classified as being
on the autism spectrum, have specific characteristics, outcomes, and treatments that are different
from the other ASDs (Levy & Hyman, 2008) so
they are not reviewed here.
Scope
The exact prevalence of ASD’s is unknown, but
Kim et al. (2011) analyzed six studies and found
estimated rates ranging from 0.07 % to 1.8 %.
Epidemiological research has demonstrated
a dramatic increase of prevalence rates over the
past 20 years. Autism was once estimated at
0.002–0.004 % of the population (Lord & Rutter,
1994). The increased prevalence appears to be
attributable to greater public awareness, broadening ASD diagnostic criteria, lower age at diagnosis, and diagnostic substitution (Fombonne,
2008). Essentially, parents and clinicians today
have a better understanding of autism spectrum
disorders than previous generations, and consequently, children are being diagnosed on the
autism spectrum who may not have been
years ago.

Theories
There are countless theories across multiple
disciplines that attempt to explain the cause of
autistic symptomatology (see section “Current
Research”); however, this section will focus on
a small scope of well-recognized ASD theories

that directly relate to social and emotional
development.
The social cognitive characteristics of autism
spectrum disorder are commonly associated with
having a deficit or delay in theory of mind,
that is, the ability to infer mental states to others.
Children with ASD have demonstrated
lower performance levels on theory of mind
tasks than children with Down’s syndrome and
younger neurotypical children with lower mental
ages (Baron-Cohen, Leslie, & Frith, 1984;
Sodian & Frith, 1994). Frith (2003) refers to the
act of theory of mind utilization as “mentalizing”
because it is an automatic and intuitive
process for most people. However, mentalization
does not come intuitively to individuals with
autism, which explains their difficulty in
understanding the thoughts and feelings of
other people. The lack of theory of mind ability,
or “mindblindness” (Baron-Cohen, 1995), is
universal to varying degrees in all individuals
on the autism spectrum, and it may
explain impairments in other domains such as
relationship building, intention, and social
learning.
Another core symptom of autism is delayed
and impaired language. There are a multitude of
linguistic impairments that are commonly associated with autism, such as echolalia, delayed
speech, pronoun reversal, and problems with
inflection and articulation (Tager-Flusberg,
Paul, & Lord, 2005); however, the most prominent characteristic of autistic language is impairment in pragmatics or conversational skills. This
impairment can be further broken down into failure to understand the point of nonliteral messages, a narrower range of linguistic function,
and a failure to view narratives as a means of
communication (Tager-Flusberg, 2000). Though
many high-functioning autistic individuals display a large lexical semantic vocabulary, pragmatic impairment is present in some degree to all
individuals on the autism spectrum. Conversation
skills are additionally difficult for children on the
autism spectrum, as they often have an impaired
ability to read facial expressions and make
appropriate eye contact and personal space
(Frith, 2003).

Healthy Development in Children with Autism Spectrum Disorder

The impaired pragmatic and mental state language ability and mindblindness found in individuals with ASD appear to overlap. Essentially,
if an individual cannot infer someone else’s mental state, having a conversation will be quite challenging. Evidence of mindblindedness is first
seen in a lack of shared gaze, which is a form of
joint attention in infancy (Charman et al., 1997).
Joint attention is extremely important to communication development because it is an understanding of others as intentional agents, and the
language delay found in children with ASD
could be related to a lack of infant joint attention.
Children on the autism spectrum engage in
a variety of bizarre interests and behaviors. For
example, young children with ASD often line up
or stack their toys, rather than play with them, and
watch segments of movies, instead of the entire
film. The interests of children on the spectrum are
often narrow and limited to unusual topics, such
as ceiling fan switches or weather patterns. If the
child is able to communicate, these interests will
tend to dominate their end of the conversation.
Stereotypic behaviors, such as hand flapping and
rocking, are often present in children on the
autism spectrum. These abnormal interests and
behaviors, combined with impairments in mental
state understanding and conversational skills,
make it difficult for children on the autism spectrum to develop appropriate peer relationships.

Current Research
Neurology
Autism is considered to be a neurologically based
disorder, so scientists are examining the brains of
ASD individuals and their family members to
gain insight into potential neurological abnormalities. Using functional magnetic resonance imaging, Kaiser et al. (2010) recently discovered
a pattern of brain activity that may characterize
genetic susceptibility to ASD. By examining the
brains of children with autism, their unaffected
siblings, and neurotypical controls, the authors
found patterns of reduced activity in certain
areas of the brain for ASD children and their
siblings, as well as enhanced activity in other

705

brain areas found only in the sibling group. The
authors believe that this enhanced activity may
act as compensatory mechanism that allows the
child to overcome their genetic predisposition to
develop ASD.
Neurological researchers are also exploring
the role of the mirror neuron system in social
impairment. The mirror neuron system is the
brain circuit that appears to enable individuals
to understand the actions of others, and there is
debate over whether or not a faulty mirror neuron
system is responsible for the social learning
impairment in ASD. Bastiaansen et al. (2011)
examined mirror neuron activity during facial
recognition tasks and found evidence that the
mirror neuron system of ASD individuals is not
impaired, but rather it is delayed. These findings
coincide with developmental delays found in
autism and place importance on early social stimulation that could promote timely mirror neuron
activation.
Autism is characterized by an impairment in
theory of mind ability, though the basis of this
impairment is widely debated (Frith, 2003).
Young, Camprodon, Hauser, Pascual-Leone,
and Saxe (2010) provided neurological evidence
that representational beliefs are controlled by
an area of the brain known as the right
temporoparietal junction (rTPJ) by using
transcranial magnetic stimulation (TMS) to disrupt the rTPJ during moral judgment tasks. The
authors found that participants who received
TMS were less likely to rely on the actors’ mental
states than controls. By isolating the region of the
brain responsible for representing mental states,
scientists can begin focusing on interventions that
will improve neural activity in this region and
potentially lessen the theory of mind impairment
in ASD individuals.
Nature Versus Nurture
The age-old scientific question of genetics versus
environment is being extensively examined in
relation to the cause of ASD. The California
Autism Twin Study (Hallmayer et al., 2011)
assessed twin pairs in which at least one child
had an ASD diagnosis (54 identical pairs and
138 fraternal pairs) and found a 70 % overlap

706

Healthy Development in Children with Autism Spectrum Disorder

among identical twins and a 35 % overlap among
fraternal twins. The authors also used modeling
to estimate that shared environmental factors
may account for 58 %, while genetic heritability
accounts for 38 % of ASD liability. These findings suggest an interactional relation between
heredity and environment in the development
of ASD.
Environmental Toxins
The role of environmental toxins in contributing
to ASD development has also been a popular
topic in the last decade. Wakefield et al. (1998)
claimed evidence that linked autism to the
mercury found in MMR vaccinations, which
contributed to a global debate over the safety of
vaccines. Wakefield’s study was found to have
multiple ethical violations, the article has since
been retracted, and Hornig et al. (2008) report
that 20 epidemiological studies since Wakefield
et al. (1998) have failed to demonstrate a causal
link between MMR vaccine and ASD. Nevertheless, the possible link between environmental
agents and autism remains important, as recent
epidemiological studies have found correlational
evidence between autism prevalence and prenatal
exposure to mercury (Palmer, Blanchard, Stein,
Mandell, & Miller, 2006), air pollutants (Windham, Zhang, Gunier, Croen, & Grether, 2006),
and antidepressants (Croen, Grether, Yoshida,
Odouli, & Hendrick, 2011). More research is
needed before any definitive causal link can be
claimed.
Early Identification
Autism spectrum disorder interventions are most
effective when implemented at an early age, so
research in early identification is crucial to ensuring that intervention can be implemented as early
as possible. Studies in genetics and neurology are
beneficial in this regard because they help identify children who are at risk. Recent behavioral
investigations have contributed to early detection
by providing evidence for behavioral markers
that can be found in infancy. In a review of
early investigations, Tager-Flusberg (2010)
found no evidence that infants who will receive
a future ASD diagnosis demonstrate any clear

differences from their neurotypical peers at age
0–6 months; however, a set of behavioral markers
are demonstrated between the ages of 6–12
months that, taken together, can predict future
ASD diagnosis. These may include repetitive
motor movements (Iverson & Wozniak, 2007),
atypical looking at objects (Ozonoff et al., 2008),
and reduced social interest (Ozonoff et al., 2010).
Research in early identification, including infant
behavioral criteria, is essential to making sure
that the child will be eligible for treatment as
early as possible, thereby giving the child the
best chance at healthy lifespan development.

Overview of Strategies
It is important to remember that children with
ASD are a heterogeneous population; therefore
no singular approach to treating autistic symptomatology can be recommended. However,
there are general strategies that parents of
children with ASD should follow in order to
promote optimal social development.
Learn the Warning Signs
Parents should be aware of early signs of ASD, as
infants who will receive a future ASD diagnosis
may demonstrate behavioral markers as early as
6 months of age (Tager-Flusberg, 2010).
According to the Centers for Disease Control
and Prevention [CDC] (2010), these behaviors
may include:
• Not responding to their name by 12 months of
age
• Not pointing at objects to show interest (point
at an airplane flying over) by 14 months
• Not playing “pretend” games (pretend to
“feed” a doll) by 18 months
• Avoiding eye contact and want to be alone
• Trouble understanding other people’s feelings
or talking about their own feelings
• Delayed speech and language skills
• Repeating words or phrases over and over
(echolalia)
• Giving unrelated answers to questions
• Getting upset by minor changes
• Having obsessive interests

Healthy Development in Children with Autism Spectrum Disorder

• Flapping hands, rocking their body, or
spinning in circles
• Having unusual reactions to the way things
sound, smell, taste, look, or feel
Seek Diagnosis
Parents should contact their child’s pediatrician
if the child is exhibiting signs of ASD. The
pediatrician will then refer the family to
a developmental pediatrician, neurologist, psychiatrist, or another mental health professional
who specializes in the diagnosis of ASD. The
specialist uses a battery of behavioral criteria
for diagnosing ASD and often utilizes professionals from multiple disciplines, such as audiologists, speech language pathologists, and
occupational therapists to assess any additional
developmental complexities.
Understand Legal Rights to Services and
Education
According to the Individuals with Disabilities
Education Improvement Act (IDEA) of 2004,
all children, even those with disabilities, are entitled to a “free appropriate education” in the “least
restrictive environment.” The act requires states
to locate children with disabilities so they can be
evaluated to receive special education services,
a policy known as “Child Find” (20 USC
1412(3)). If the child is determined to have met
this definition and is between 3 and 21 years old,
then he or she is entitled to publicly funded services under an Individualized Education Program
(IEP). If the child is age three or over and is
showing signs of ASD, parents should contact
the district immediately because, under IDEA,
they have the right to have the school assess the
child and bear the cost of that assessment. Ideally,
children who demonstrate signs of ASD will
already be diagnosed and enrolled in services
before age three. If so, parents should contact
their school district 6 months before the child’s
third birthday so that the transition to publically
funded service will not be interrupted.
Choosing the Right Intervention
Since the cause of autism is still unknown, there
is no definitive prevention method. This situation

707

has lead to an overwhelming abundance of
options for parents, as over 100 interventions
have been identified in the United States (Green
et al., 2006). There are many initiatives that claim
effectiveness, but too often they are not empirically validated through scientific testing. Considering the behavioral problems associated with
ASD, parents are often desperate to seek
a “cure,” and there are many proponents of
pseudoscientific methods that profit from these
desperate parents (Maurice et al., 1996). In
order to sift through ineffective treatments,
parents should rely on empirical testing and
evidence-based conclusions.
Callahan, Henson, and Cowan (2008) surveyed parents, teachers, and administrators of
children with autism and asked them to identify
specific components of a model hypothetical
intervention program. Their results yielded consistent support for interventions that addressed
what the authors referred to as IDEAL: individualized programming, data collection, the use of
empirically demonstrated strategies, active collaboration, and a focus on long-term outcomes.
Below is a list of primary and complimentary
interventions categorized using IDEAL principles as effective, promising, and ineffective. As
ASD children are a heterogeneous population,
the right treatment (or combination of treatments)
should be customized based on the needs of the
individual, as well as the established efficacy of
the intervention.

What Works
Discrete Trial Teaching
Discrete Trial Teaching (DTT) is a behavioral
strategy that is based on the principles of Applied
Behavioral Analysis (ABA), which involve the
breakdown of skills into small, discrete tasks,
taught in a highly structured and hierarchical
manner (Maurice et al., 1996). DTT therapists
teach, or “shape,” behaviors through one-on-one
reinforced discrete trial instruction. The purpose
of DTT is to create an active learning environment that can restructure developing neural circuitry. Though DTT is not specific to autism, it

708

Healthy Development in Children with Autism Spectrum Disorder

addresses ASD-impaired social learning by
teaching the individual to focus on another person, especially the person’s words and interactions, thereby creating an active social learning
environment (Maurice et al.). Critics of DTT
claim that the shaped behaviors are not generalizable, and the treatment was once considered
highly controversial for its inclusion of aversives
(a practice that has since been removed).
DTT was first popularized by Lovaas (1987),
who found that participants receiving DTT
gained an average of 30 IQ points over the control
group, and that 47 % of the treatment group
achieved normal intellectual and educational
functioning, and were able to successfully complete first grade in mainstream public schools
(as compared to 2 % of the control group). The
results of Lovaas were extraordinary. Subsequent
DTT studies have shown them to be atypically
positive. Nevertheless, a recent meta-analytic
DTT review indicates that the intervention results
in increased levels of adaptive behavior and
cognitive ability (Reichow & Wolery, 2009).
DTT is a data-driven intervention, making it
easy to study. Because of its empirical support
and the lack of empirical support for other interventions, DTT remains one of the most popular
and influential interventions for autism.
Pivotal Response Treatment
Pivotal Response Treatment (PRT) is a
naturalistic intervention that also derives from
ABA principles, but unlike EIBI, PRT focuses
on critical or “pivotal” areas of child development that encompasses a multitude of behaviors,
rather than targeting discrete trials and individual
behaviors. It is based on the principle that intervention in areas such as motivation, responsivity,
and social initiations will lead to widespread
improvements in social and communicative
development. PRT is implemented through
child choice, task variation, interspersing maintenance tasks, rewarding attempts, and the use of
direct and natural reinforcers (Koegel, Koegel,
Harrower, & Carter, 1999). This adherence
to direct natural reinforcers in PRT is
a differentiating characteristic from EIBI. For
example, a child in EIBI might receive a piece

of candy as reinforcement for initiating a verbal
request for a ball, whereas in PRT the ball itself
would be the reinforcer. PRT has not been as data
driven as EIBI, but there are several empirical
studies supporting its efficacy in social communication (Baker-Ericzen, Stahmer, & Burns,
2007; Koegel et al., 1999; Pierce & Schreibman,
1997).
TEACCH
Treatment and education of autistic and
related communication-handicapped children
(TEACCH) is an autism-specific behavioral therapy designed to create a highly structured learning environment. TEACCH is based on
a philosophy known as “the culture of autism,”
that is, the pattern of neuropsychological
deficits and strengths associated with ASD individuals (Mesibov, Shea, & Schopler, 2005).
Accordingly, TEACCH adapts to meet the
needs of this “culture” by placing emphasis on
highly organized teaching areas, visual schedules
of learning activities, work systems that inform
students of their progress, and identification of
within-task actions (Mesibov et al., 2005).
TEACCH has been demonstrated to be an
effective treatment for individuals with autism.
Studies have found improvement in the amount
of communication and appropriate engagement
with materials (Short, 1984); imitation, fine
motor, gross motor, and nonverbal conceptual
skills (Ozonoff & Cathcart, 1998); and
Psychoeducational Profile-Revised (PEP-R) and
Vineland Adaptive Behavior Scales (VABS)
scores (Ozonoff & Cathcart; Panerai et al., 2009).
Medicinal Intervention
Behavioral and educational interventions are
often the primary treatment for children with
ASD; however, medical treatment is often used
as an adjunct. It has been reported that more than
45 % of children with an ASD are treated with
psychotropic medication (Rossignol, 2009).
Despite this level of utilization, comprehensive
medical management reviews in ASD are lacking
(Huffman, Sutcliffe, Tanner, & Feldman, 2011).
Currently, the only FDA-approved medication
for treatment of ASD is the antipsychotic

Healthy Development in Children with Autism Spectrum Disorder

risperidone. In a review of medical management
studies in ASD, Huffman et al. (2011) found that
risperidone has been demonstrated to safely
reduce ASD core symptoms, as well as
maladaptive behavior, hyperactivity, and irritability, but may include side effects like weight
gain and sedation. The authors also found
empirical
support
for
methylphenidate,
a psychostimulant that has been demonstrated to
be effective in reducing symptoms of inattention
and hyperactivity in children with ASD, though
response rate is lower than neurotypical children
with ADHD.

Promising Primary Interventions
Floortime
Floortime (also referred to as the Developmental
Individual
Difference
Relationship-Based
Model) is a promising non-autism-specific
behavioral intervention that is organized around
the child’s emotions and relationships in the
context of their current developmental level
(Greenspan & Wieder, 1997). It is used as an
intervention for ASD children, as an impaired
ability to form relationships is a core symptom
of ASD. Floortime is built heavily upon engaging
play, with the therapist or parent following the
child’s lead. For example, the Floortime model
would address a child’s stereotypic wandering in
circles by having the therapist wander along with
occasional stops in the child’s path, thereby
creating an interconnected experience (Greenspan & Wieder, 1997).
Greenspan and Wieder (1997) administered
Floortime intervention to a group of 200 children
with ASD (age 2–4 years) and found that after
2 years of intervention, 58 % of the children
showed improvements and no longer met the
criteria for ASD. The results are encouraging;
however, the study has several methodological
weaknesses including a sample of convenience
and no control group and therefore must be
interpreted with caution. Presently, no rigorous
empirical studies have been published, so
Floortime’s effectiveness as an intervention can
only be considered promising.

709

Promising Complimentary Treatments
Social Stories
Social Stories is a set of brief, individualized
stories designed to help people understand social
situations (Sansosti & Powell-Smith, 2008). The
story describes a situation, as well as the thoughts
and feelings of the involved characters. The goal
is to increase insight that will help guide future
social behavior, by simulating isolated situations
through storytelling. Numerous studies have
demonstrated improved social ability in ASD
children (Quirmbach, Lincoln, Feinberg-Gizzo,
Ingersoll, & Andrews, 2009; Sansosti & PowellSmith, 2008) but more tightly controlled studies
are necessary to understand the role of social
stories.
Vitamins
Vitamin B6 and magnesium has been a popular
treatment for autism over the past 20 years,
though more research is necessary to determine
its effectiveness. Kuriyama et al. (2002) reported
improvement in IQ and social quotient scores in
8 children treated with vitamin B6 and magnesium, and Mousain-Bosc et al. (2006) studied
33 children with ASD who were reported to
improve in symptoms after magnesium and
vitamin B6 treatment.
Vitamin C therapy is also a popular treatment,
despite findings that children with ASDs do not
typically suffer from a severe lack of Vitamin
C (Adams & Holloway, 2004). Dolske, Spollen,
McKay, Lancashire, and Tolbert (1993) reported
a decrease in stereotyped behavior in a 30-week,
double-blind, placebo-controlled trial in 18 children with ASD. To date, this study has not been
replicated. Studies in vitamin therapy and autism
have yielded some positive results, but most
suffer from methodological weaknesses; therefore, more clinical trial research is necessary to
establish its effectiveness.
Music Therapy
Music therapy is often used as tool for improving
communication in special education programs.
Though effects on overall behavior have not
been established, music therapy has been found

710

Healthy Development in Children with Autism Spectrum Disorder

to improve spoken and gestural communication
in children with autism compared to controls
(Gold, Wigram, & Elefant, 2006).
Gluten-/Casein-Free Diets
Gastrointestinal disorders are commonly
reported in individuals with ASD, though exact
prevalence rates are incompletely understood
(Buie et al., 2010). Comorbidity of GI and ASD
can lead to additional challenging behaviors for
children, so specialized diets, such as ones without gluten and casein, that alleviate GI issues may
be used as an effective complimentary treatment.
There is no evidence that supports gluten-/caseinfree diets as a primary treatment for ASD, and
evidence of its effectiveness in treating ASD
symptoms is largely anecdotal (Buie et al.).
Given the lack of evidence, as well as the difficulty in implementing these diets, ASD children
must be given a thorough GI evaluation before
parents attempt this treatment.

What Does Not Work
Holding Therapy
For decades, autism was thought to be the result
of inattentiveness from the child’s mother,
a phenomenon referred to as “refrigerator
mothers” (Bettelheim, 1967). This theory has
since been discredited, but the idea that creating
appropriate attachment between the mother and
child in order to alleviate ASD symptoms continues to persist. Holding therapy is a treatment
based on this psychoanalytic principle, in which
the parent holds the child for periods of time
while attempting to make eye contact, even if
the child is resistant. There is no empirical
evidence of treatment efficacy, and considering
that hypersensitivity to touch is common in ASD
children (Frith, 2003), holding therapy is not
recommended.
Facilitated Communication
Facilitated communication (FC) is a method
designed to assist individuals with communication disorders communicate through the use of
a keyboard device. It involves an FC therapist, or

“facilitator,” who holds the individual’s hand or
arm to assist them in typing messages on the
device. It has been used as a treatment for ASD
children because of suspected childhood apraxia
of speech, a disorder of the brain and nervous
system in which the child cannot physically communicate their thoughts. FC was popularized
mainly through encouraging parental testimonials, including reports of “I love you” sent by
the child, but studies have found that the messages generated by FC are biased by the facilitators and could not be replicated when facilitators
were blind to the subject matter (Herbert, Sharp,
& Gaudiano, 2002).
Chelation
As researchers continue to search for potential
environmental causes of autism, treatments that
remove potentially harmful toxins from the body
are becoming an increasingly popular treatment
for ASD. Chelation is the process of administering intravenous agents that bind heavy metals,
such as mercury and lead, and assist removal
of these metals from the body. There are no
empirical studies that have established
efficacy of chelation treatment for children with
ASD. Chelation therapy also has side effects that
include nausea and hypocalcemia, and a botched
chelation therapy given to a 5-year-old boy
resulted in death (Atwood, Woeckner, Baratz, &
Sampson, 2008).

Summary
Autism is a pervasive developmental disability
marked by deficits in communication, symbolic
or imaginative activities, and reciprocal social
interaction. Children with autism spectrum disorders are a heterogeneous population, displaying
various levels of cognitive ability and symptom
severity, but sharing a universal impairment in
social and communicative ability that compromises social and emotional development. These
social impairments, combined with the presence
of abnormal interests and behaviors, make it
difficult for children on the autism spectrum to
develop appropriate peer relationships.

Healthy Development in Children with Autism Spectrum Disorder

Though the cause of autism is still unknown,
recent research provides evidence that genetics
and environment, specific neurological activity,
and environmental toxins may all play a role in
the development of ASD. This understanding is
becoming increasingly vital, as epidemiological
research has demonstrated a dramatic increase of
prevalence rates over the past 20 years.
Parents should be aware of early signs of ASD,
as infants may demonstrate behavioral markers as
early as 6 months of age. Families of children
with ASD must also become familiar with the
process of seeking and obtaining a diagnosis, as
well as their legal rights to services and education. When choosing an intervention, parents
must base their decision on empirically validated
methods, as there is an abundance of pseudoscientific treatments for ASD. Methods such as
DTT, PRT, and TEACCH have demonstrated
effectiveness, while Floortime and social stories
are examples of promising treatments. Holding
therapy and chelation are treatments that should
be avoided.
This entry has largely focused on the social
impairments associated with ASD, but it is
important to also recognize the strengths.
Individuals with mild autism struggle socially
but are often skilled, even prodigious, at mathematical and analytic reasoning ability required in
science and engineering fields (Frith, 2003).
There are countless examples of successful individuals on the autism spectrum and even more
who exist on the often-blurred line between mild
autism and creative eccentricity. ASD is a serious
condition, and the social learning impairments
can have lifelong detrimental effects. But when
the right strategies are utilized, including early
assessment and a commitment to effective intervention, children with ASD can go on to live
independent and enriching lives.

References
Adams, J. B., & Holloway, C. (2004). Pilot study of
a moderate dose multivitamin/mineral supplement for
children with autistic spectrum disorder. Journal of Alternative and Complementary Medicine, 10(6), 1033–1039.

711

American Psychiatric Association. (2000). Diagnostic
and statistical manual of mental disorders (4th ed.,
Text Rev.). Washington, DC: Author.
Atwood, K. C., Woeckner, E., Baratz, R. S., & Sampson,
W. I. (2008). Why the NIH Trial to Assess Chelation
Therapy (TACT) should be abandoned. Medscape
Journal of Medicine, 10(5), 115.
Baker-Ericzen, M. J., Stahmer, A. C., & Burns, A. (2007).
Child demographics associated with outcomes in
a community-based pivotal response training program.
Journal of Positive Behavior Interventions, 9(1),
52–60.
Baron-Cohen, S. (1995). Mindblindedness: An essay on
autism and theory of mind. Cambridge, MA: Bradford
Books/MIT Press.
Baron-Cohen, S., Leslie, A. M., & Frith, U. (1984).
Mechanical, behavioural and intentional understanding of picture stories in autistic children. British
Journal of Developmental Psychology, 4, 113–125.
Bastiaansen, J. A., Thioux, M., Nanetti, L., van der Gaag, C.,
Ketelaars, C., Minderaa, R., et al. (2011). Age-related
increase in inferior frontal gyrus activity and social
functioning in autism spectrum disorder. Biological
Psychiatry, 69(9), 832–838.
Bettelheim, B. (1967). The empty fortress; infantile autism
and the birth of the self. New York: Free Press.
Buie, T., Campbell, D. B., Fuchs, G. J., 3rd, Furuta, G. T.,
Levy, J., Vandewater, J., et al. (2010). Evaluation,
diagnosis, and treatment of gastrointestinal disorders
in individuals with ASDs: A consensus report.
Pediatrics, 125(1), S1–S18.
Callahan, K., Henson, R. K., & Cowan, A. K. (2008).
Social validation of evidence-based practices in autism
by parents, teachers, and administrators. Journal of
Autism and Developmental Disorders, 38(4), 678–692.
Carey, B., & Harmon, A. (2012, January 19). New
definition of autism will exclude many, study suggests.
The New York Times. Retrieved March 18, 2012, from
http://www.nytimes.com/2012/01/20/health/research/
new-autism-definition-would-exclude-many-studysuggests.html?pagewanted=all
Centers for Disease Control and Prevention. (2010).
Autism spectrum disorders: Signs and symptoms.
Retrieved August 25, 2011, from http://www.cdc.
gov/ncbddd/autism/signs.html
Charman, T., Swettenham, J., Baron-Cohen, S., Cox, A.,
Baird, G., & Drew, A. (1997). Infants with autism: An
investigation of empathy, pretend play, joint attention,
and imitation. Developmental Psychology, 33(5),
781–789.
Croen, L. A., Grether, J. K., Yoshida, C. K., Odouli, R., &
Hendrick, V. (2011). Antidepressant use during
pregnancy and childhood autism spectrum disorders.
Archives of General Psychiatry, 68(11), 1104–1112.
Dolske, M. C., Spollen, J., McKay, S., Lancashire, E., &
Tolbert, L. (1993). A preliminary trial of ascorbic
acid as supplemental therapy for autism. Progress
in Neuro-Psychopharmacology and Biological
Psychiatry, 17(5), 765–774.

712

Healthy Development in Children with Autism Spectrum Disorder

Fombonne, E. (2008). Is autism getting commoner?
British Journal of Psychiatry, 193(1), 59.
Frith, U. (2003). Autism: Explaining the enigma.
New York: Blackwell.
Gold, C., Wigram, T., & Elefant, C. (2006). Music therapy
for autistic spectrum disorder. Cochrane Database of
Systematic Reviews, 2, CD004381.
Green, V. A., Pituch, K. A., Itchon, J., Choi, A.,
O’Reilly, M., & Sigafoos, J. (2006). Internet survey
of treatments used by parents of children with autism.
Research in Developmental Disabilities, 27(1), 70–84.
Greenspan, S. I., & Wieder, S. (1997). Developmental
patterns and outcomes in infants and children with
disorders in relating and communicating: A chart
review of 200 cases of children with autistic spectrum
diagnoses. The Journal of Developmental and
Learning Disorders, 1(1), 87–141.
Hallmayer, J., Cleveland, S., Torres, A., Phillips, J.,
Cohen, B., Torigoe, T., et al. (2011). Genetic heritability and shared environmental factors among twin
pairs with autism. Archives of General Psychiatry,
68(11), 1095–1102.
Herbert, J. D., Sharp, I. A., & Gaudiano, B. A. (2002).
Separating fact from fiction in the etiology and treatment of autism: A scientific review of the evidence.
Scientific Review of Mental Health Practice, 1, 23–43.
Hornig, M., Briese, T., Buie, T., Bauman, M. L., Lauwers,
G., Siemetzki, U., et al. (2008). Lack of association
between measles virus vaccine and autism with
enteropathy: A case–control study. PLoS One, 3(9),
e3140.
Huffman, L. C., Sutcliffe, T. L., Tanner, I. S., & Feldman,
H. M. (2011). Management of symptoms in children
with autism spectrum disorders: A comprehensive
review of pharmacologic and complementaryalternative medicine treatments. Journal of Developmental & Behavioral Pediatrics, 32(1), 56–68.
Iverson, J. M., & Wozniak, R. H. (2007). Variation in
vocal-motor development in infant siblings of children
with autism. Journal of Autism and Developmental
Disorders, 37(1), 158–170.
Kaiser, M. D., Hudac, C. M., Shultz, S., Lee, S. M.,
Cheung, C., Berken, A. M., et al. (2010). Neural
signatures of autism. Proceedings of the National
Academy of Science of the United States of America,
107(49), 21223–21228.
Kim, Y. S., Leventhal, B. L., Koh, Y. J., Fombonne, E.,
Laska, E., Lim, E. C., et al. (2011). Prevalence of
autism spectrum disorders in a total population
sample. American Journal of Psychiatry, 168(9),
904–912.
Koegel, L. K., Koegel, R. L., Harrower, J. K., &
Carter, C. M. (1999). Pivotal response intervention I:
Overview of approach. Journal of the Association for
Persons with Severe Handicaps, 24(3), 174–185.
Kuriyama, S., Kamiyama, M., Watanabe, M.,
Tamahashi, S., Muraguchi, I., Watanabe, T.,
et al. (2002). Pyridoxine treatment in a subgroup of
children with pervasive developmental disorders.

Developmental Medicine & Child Neurology, 44(4),
284–286.
Levy, S. E., & Hyman, S. L. (2008). Complementary and
alternative medicine treatments for children with
autism spectrum disorders. Child and Adolescent
Psychiatric Clinics of North America, 17(4),
803–820, ix.
Lord, C., & Rutter, M. (1994). Autism and pervasive
developmental disorders. In M. Rutter, E. Taylor, &
L. Hersov (Eds.), Child and adolescent psychiatry:
Modern approaches (3rd ed., pp. 569–593). Oxford,
UK: Blackwell.
Lovaas, O. I. (1987). Behavioral treatment and normal
educational and intellectual functioning in young
autistic children. Journal of Consulting and Clinical
Psychology, 55(1), 3–9.
Maurice, C., Green, G., & Luce, S. C. (1996). Behavioral
intervention for young children with autism: A manual
for parents and professionals. Austin, TX: Pro-Ed.
Mesibov, G. B., Shea, V., & Schopler, E. (2005). The
TEACCH approach to autism spectrum disorders.
New York: Kluwer Academic/Plenum.
Mousain-Bosc, M., Roche, M., Polge, A., Pradal-Prat, D.,
Rapin, J., & Bali, J. P. (2006). Improvement of
neurobehavioral disorders in children supplemented
with magnesium-vitamin B6. II. Pervasive developmental disorder-autism. Magnesium Research, 19(1),
53–62.
Ozonoff, S., & Cathcart, K. (1998). Effectiveness of
a home program intervention for young children
with autism. Journal of Autism and Developmental
Disorders, 28(1), 25–32.
Ozonoff, S., Iosif, A. M., Baguio, F., Cook, I. C., Hill,
M. M., Hutman, T., et al. (2010). A prospective study
of the emergence of early behavioral signs of autism.
Journal of American Academy of Child Adolescent
Psychiatry, 49(3), 256–266.
Ozonoff, S., Macari, S., Young, G. S., Goldring, S.,
Thompson, M., & Rogers, S. J. (2008). Atypical object
exploration at 12 months of age is associated with
autism in a prospective sample. Autism, 12(5),
457–472.
Palmer, R. F., Blanchard, S., Stein, Z., Mandell, D., &
Miller, C. (2006). Environmental mercury release,
special education rates, and autism disorder: An
ecological study of Texas. Health & Place, 12(2),
203–209.
Panerai, S., Zingale, M., Trubia, G., Finocchiaro, M.,
Zuccarello, R., Ferri, R., et al. (2009). Special
education versus inclusive education: The role of
the TEACCH Program. Journal of Autism and
Developmental Disorders, 39(6), 874–882.
Pierce, K., & Schreibman, L. (1997). Multiple peer use of
pivotal response training to increase social behaviors
of classmates with autism: Results from trained and
untrained peers. Journal of Applied Behavioral
Analysis, 30(1), 157–160.
Quirmbach, L. M., Lincoln, A. J., Feinberg-Gizzo, M. J.,
Ingersoll, B. R., & Andrews, S. M. (2009). Social

Healthy Development in Children with Autism Spectrum Disorder
stories: Mechanisms of effectiveness in increasing
game play skills in children diagnosed with autism
spectrum disorder using a pretest posttest repeated measures randomized control group design. Journal of
Autism and Developmental Disorders, 39(2), 299–321.
Reichow, B., & Wolery, M. (2009). Comprehensive
synthesis of early intensive behavioral interventions
for young children with autism based on the UCLA
Young Autism Project Model. Journal of Autism and
Developmental Disorders, 39(1), 23–41.
Rossignol, D. A. (2009). Novel and emerging treatments
for autism spectrum disorders: A systematic review.
Annals of Clinical Psychiatry, 21(4), 213–236.
Sansosti, F., & Powell-Smith, K. (2008). Using computerpresented social stories and video models to increase
the social communication skills of children with
high-functioning autism spectrum disorders. Journal
of Positive Behavior Interventions, 10(3), 162–178.
Short, A. (1984). Short-term treatment outcome using
parents as co-therapists for their own autistic children.
Journal of Child Psychology and Psychiatry, 25(3),
443–458.
Sodian, B., & Frith, U. (1994). Deception and sabotage in
autistic, retarded and normal children. Journal of Child
Psychology and Psychiatry, 33(3), 591–605.
Tager-Flusberg, H. (2000). Language and understanding
minds in autism. In S. Baron-Cohen, H. TagerFlusberg, & D. J. Cohen (Eds.), Understanding other
minds: Perspectives from autism (pp. xiii, 515 p.).
London: Oxford University Press.

713

Tager-Flusberg, H. (2010). The origins of social
impairments in autism spectrum disorder: Studies
of infants at risk. Neural Networks, 23(8–9),
1072–1076.
Tager-Flusberg, H., Paul, R., & Lord, C. (2005).
Language and communication in autism. In F. R.
Volkmar, R. Paul, A. Klin, & D. Cohen (Eds.),
Handbook of autism and pervasive developmental
disorders: Vol. 1. Diagnosis, development, neurobiology, and behavior (pp. 335–364). Hoboken, NJ:
Wiley.
Wakefield, A. J., Murch, S. H., Anthony, A., Linnell, J.,
Casson, D. M., Malik, M., et al. (1998). Ileal-lymphoid-nodular hyperplasia, non-specific colitis, and
pervasive developmental disorder in children. Lancet,
351(9103), 637–641.
Windham, G. C., Zhang, L., Gunier, R., Croen, L. A., &
Grether, J. K. (2006). Autism spectrum disorders in
relation to distribution of hazardous air pollutants in
the San Francisco bay area. Environmental Health
Perspectives, 114(9), 1438–1444.
World Health Organization. (1993). International
classification of diseases (10th ed.). Geneva,
Switzerland: Author.
Young, L., Camprodon, J. A., Hauser, M., Pascual-Leone, A.,
& Saxe, R. (2010). Disruption of the right temporoparietal
junction with transcranial magnetic stimulation reduces
the role of beliefs in moral judgments. Proceedings of the
National Academy of Science of the United States of
America, 107(15), 6753–6758.

714

Healthy Development of Children in Nuclear Families

Kevin Ray Bush and Gary W. Peterson
Department of Family Studies and Social Work,
Miami University, Oxford, OH, USA

improving parental socialization strategies that
foster children’s social competence. A closely
related strategy is to provide supports to parents
so they, in turn, are able to maintain effective
childrearing approaches as they cope more
effectively with crises and adverse circumstances
of everyday life (Bush & Peterson, 2008).

Introduction

Definitions and Scope

Although nuclear families decreased substantially in the USA during the latter half of the
twentieth century and the first decade of the
twenty-first century, families with a mother,
father, and biologically related children remain
a common setting for socializing the young
(Carlson, McLanahan, & England, 2004; Cherlin,
2005; Teachman, Tedrow, & Kim, 2013).
Current family structures vary extensively and
include many combinations of parents, children,
parental roles, legal ties, and blood relations.
Compared to alternative family forms, two
parent families have often been found to provide
modest advantages that benefit the positive development of children. However, rather than specific
kinds of family structural variation being the
primary reason for advantage or disadvantage,
children’s psychosocial differences are more
often linked to the greater socioeconomic obstacles and fewer support systems that are a more
common circumstance for alternative families
(Bianchi & Casper, 2000; Coontz, 2000, 2005;
Peterson & Bush, 2013; Teachman et al., 2013).
The most frequent alternative to “structural
explanations” for differences in children’s socialization outcomes, however, is substantial empirical support for the view that sociopsychological
aspects of parent–child relationships are more
relevant to children’s prosocial or problematic
outcomes than are family structural variables
(Bush & Peterson, 2008; Peterson & Hann,
1999). Consequently, effective prevention strategies are less often designed to address family
structural variations per se, but instead, the most
effective approaches seek to improve the quality
of parent–child relationships. These enhancement efforts often take the form of directly

The concept social competence is viewed as a set
of attributes or psychological resources that assist
children in adapting to their everyday social
circumstances and in developing coping abilities
for warding off problematic behavior (i.e.,
externalizing and internalizing behavior) (Bush
& Peterson, 2008, 2013). Social competence is
composed of multiple subdimensions including
(1) balancing progress toward autonomy with
continuing emotional bonds and receptivity to
the influence of parents, (2) psychological or
cognitive resources (e.g., self-esteem, problemsolving skills, achievement orientation), and
(3) social skills (e.g., cooperation and social
assertiveness) (Bush & Peterson, 2013; Peterson
& Hann, 1999).
Internalizing and externalizing behavior, two
general categories of problematic outcomes, can
be viewed as collections of attributes that are
contrary to social competence (Bush & Peterson,
2008, 2013). Externalizing behaviors refer to
psychological difficulties in the form of behavior
problems (e.g., conduct disorder) in which
children “act out” against parents and society.
In contrast, internalizing behaviors involve
psychological disturbances in which children
focus on and act against the self (e.g., depression,
social withdrawal, anxiety).
Authoritative or competence-promoting
parenting consists of parenting that involves the
consistent application of nurturance and firm
control to encourage an age-appropriate balance
between gaining autonomy and continuing
responsiveness to parental/adult authority by the
young (Bush & Peterson, 2013). Competencepromoting parents focus on reinforcing prosocial
behavior, clearly communicated expectations,

Healthy Development of Children in
Nuclear Families

T.P. Gullotta, M. Bloom (eds.), Encyclopedia of Primary Prevention and Health Promotion,
DOI 10.1007/978-1-4614-5999-6, # Springer Science+Business Media New York 2014

Healthy Development of Children in Nuclear Families

firm and consistent rule enforcement, use of
positive induction, and the provision of a secure
base from which to grant autonomy.

Theories
A number of theoretical approaches have been
influential in developing and/or guiding prevention programs aimed at increasing children’s
positive outcomes in general, as among nuclear
families as the focus of this entry. Theories that
focus solely or mainly on nuclear families have
not been influential in this area. However,
ecological approaches such as Bronfenbrenner’s
Ecological Systems Theory (1979, 2005), which
is sensitive to multidirectional influences and all
levels of the contextual environment, are common. Ecological approaches relate to and/or have
influenced several school and family-based
multicomponent prevention programs (e.g., Families and Schools Together, Crozier, Rokutani,
Russett, Godwin, & Banks, 2010; McDonald,
Bradish, Billingham, Dibble, & Rice, 1991).
That is, the most comprehensive way of conceptualizing family-based prevention strategies is to
view parent–child relationships within nuclear
families as subcomponents of much larger social
environments. In this sense, nuclear families
may provide a cleaner fit to family systemsbased models, yet ecological models are broad
enough to apply across family structural organizations. These ecological perspectives can provide insight for a broad range of prevention
strategies aimed at levels of society ranging
from dyadic relationships within nuclear families
(e.g., parenting programs) to macro-level institutions (e.g., social policy) (Bronfenbrenner, 1979,
2005; Tudge, Mokrova, Hatfield, & Karnik,
2009). Thus, children are viewed as being nested
within a complex array of interconnected systems
that encompass individual, family, and
extrafamilial (e.g., peer, school, and neighborhood) settings. Both problematic and socially
competent outcomes are viewed as products of
dynamic exchanges between children and their
diverse settings in addition to the interconnections
among the social systems in which children

715

develop (Bronfenbrenner, 1979, 2005; Tudge
et al., 2009).
Several developmental theories, including
social learning theory and attachment theory,
also are relevant and can be used to specify particular parent–child dynamics within the larger
social ecology. For example, social learning theory focuses on modeling and interactions within
parent–child relationships, where socially competent behaviors are developed and reinforced.
Similarly, dysfunctional and non-nurturing parenting behaviors can also influence dysfunctional
child behavior and development, such as internalizing and externalizing behaviors, which in
turn influence parenting behavior (e.g., Bandura,
2001), and can develop into coercive cycles
(Patterson, 1982; Granic & Patterson, 2006).
Attachment theory also highlights the importance
of parent–child interactions in the development
of attachment styles, where poor or dysfunctional
parenting behaviors are likely to result in poor
attachment (e.g., insecure) styles, while nurturant
and responsive parenting behavior are more
likely to result in positive attachment (e.g.,
secure) styles (Ainsworth & Bowlby, 1991,
Bowlby, 1988, Bretherton & Munholland, 2008;
Cassidy, 2008).

Current Research
Among the growing variety of domestic contexts,
the nuclear family continues to serve as
a principal context for socializing children and
is a prime target for prevention programs aimed
at increasing positive and decreasing negative
child outcomes. Although many evidence-based
programs exist that focus on family interaction to
prevent poor child outcomes, an approximate
estimate is that only 10 % of the programs
implemented by practitioners have adequate scientific support (Kumpfer, 2008). Definitions that
specify what an effective program consists of
vary widely, making it difficult for practitioners
to identify the most effective programs to use. As
a result, this entry seeks to identify illustrative
programs having strategies found to be effective
(i.e., in at least three randomized control trials)

716

for targeting family/parenting processes that
prevent problematic children’s outcomes and
foster children’s social competence.
The Incredible Years. The first of these programs, the Incredible Years (IY), consists of
a series of three interventions that target changes
in (1) parenting behavior, (2) children’s socialemotional regulation, and (3) teacher’s classroom
management skills and teacher-child interaction.
Although originally designed for promoting
social competence and reducing, treating, and
preventing conduct problems in children aged
3–8, recent studies also have found that each
component also is effective in decreasing children’s internalizing problems (Herman, Borden,
Reinke, & Webster-Stratton, 2011; WebsterStratton & Herman, 2010). The IY Parent Training (PT) program focuses on parent competence
and school involvement (Webster-Stratton &
Herman). Parents are taught to model positive
attitudes and thoughts as they encourage
prosocial behaviors and social skills, as well as
how to work with teachers and schools to foster
children’s academic performance.
The IY Teacher Training Program
(TT) focuses on disrupting negative cycles in
teacher and peer interactions/relationships. The
TT program is a 6-day training that focuses on
decreasing negative peer relationships (e.g., bullying, negative reputations) and conduct problems, while increasing the emotional regulation
and social competence of children in school.
The program targets improving classroom
management strategies and teaches coaching
strategies to help teachers/school staff foster
positive relationships among children and
improve children’s social skills. Teachers and
other school staff are taught collaborative
problem-solving processes, positive communication and relationships with parents, the value
of home visits, and the importance of parentteacher conferences (Webster-Stratton &
Herman, 2010).
The IY Child Training program (CT), referred
to as the Dinosaur School, is an 18–22 weekly,
2-hour, small group therapeutic program. The
Dinosaur School CT targets social, communication, and conflict management skills; negative

Healthy Development of Children in Nuclear Families

attributions; and emotional literacy (Herman
et al., 2011). The CT works well with the
Parent Training (PT) and Teacher Training
(TT) IY programs, such as through weekly letters
to teachers and parents about encouraging the
reinforcement of targeted skills, and homework
assignments that children complete with their
parents.
Families and Schools Together. The second
program, entitled Families and Schools Together
(FAST), is composed of unique multiple domains
(i.e., families and schools) that also involves the
community context. FAST is a two-stage prevention program seeking to improve child and family
outcomes by focusing on the improvement of
parenting skills, parent–child relationships, and
child and family outcomes through building relationships with community and schools supports
(McDonald et al., 1991, 1997, 2006). Although
FAST has been adapted for several age groups,
including
the
Baby
FAST
version
(McDonald et al., 2009), most of the RCT studies
have focused on implementations of Kids FAST
(K-5) with elementary school students. The
components of these implementations consist of
an 8-week set of multifamily group meetings
(lasting approximately 2½ hour each), followed
by monthly meetings for 1–2 years (Ackley &
Cullen, 2010; Kratochwill, McDonald, Levin,
Scalia, & Coover, 2009).
Core components of FAST include a shared
governance approach, active recruitment and
retention, collaboration with community agencies, as well as parents and schools as active
partners (Ackley & Cullen, 2010). Implementation begins with the creation of a collaborative
team who are culturally sensitive to the context
and population being served by involving individuals from community agencies and schools as
well as the parents of participating families. The
composition of the implementation team is likely
to vary somewhat across locations/sites as they
are based on local needs assessments conducted
by the implementing agency (Kratochwill et al.,
2009).
The Triple P. The third program, referred to as
the Triple P or Positive Parenting Program, is
a complex multiple level system of interventions

Healthy Development of Children in Nuclear Families

designed to increase effective parenting and
decrease dysfunctional parenting for families of
children from 2 to 16 (Sanders, Markie-Dadds, &
Turner, 2003). Sanders et al. (2003) provide
a table describing the five levels of the Triple
P system. Level one is the universal Triple
P that uses a “media-based parent information
campaign” which targets “all parents interested
in information about promoting their child’s
development” (Sanders et al., p. 2). Methods
include self-directed resources such as fact sheets
and other media strategies as well as brief
consultations and group presentations. Levels
two and three vary from brief selective interventions to more narrow-focused consultation or
active skills training, typically in the context of
routine well-child health care. Most of the RCT
studies with the Triple P have been conducted
with the level four and five programs. Level
four interventions utilize broad-focused parent
training models, including the Standard
Triple P, Group Triple P, Group Teen Triple P,
and the Self-Directed Triple P Programs. These
programs focus on parents of children with more
severe behavior problems who want intensive
training in competence-promoting parenting to
improve their child’s behavior (Sanders et al.).
Both level four and level five strategies can vary
from being self-directed to phone or face-to-face
clinician contact or group sessions. Level five
interventions are the most intensive and consist
of the Enhanced Triple P and Pathways Triple
P behavioral family intervention modules. The
Enhanced Triple P intervention targets “parents
of children with concurrent child behavior problems and family dysfunction such as parental
depression or stress or conflict between partners”
and includes home visits (Sanders et al., p. 2).
The other level 5 intervention, the Pathways
Triple P, targets parents of children at risk for
child maltreatment, focusing on parent’s anger
management and other parental skill deficits that
place children at higher risk for being maltreated.
More information and detail on the Triple
P (Positive Parenting Program) system can be
obtained from the Triple P (n.d.) website (http://
www1.triplep.net/), including links to evaluation
studies.

717

Overview of Strategies
A review of the literature consisting of prevention
trials, meta-analyses of prevention trials, reviews
of the literature, and reports from expert panels
reviews (e.g., Kumpfer & Alvarado, 2003) highlights evidence for several effective prevention
approaches or strategies for preventing or
decreasing problematic outcomes during childhood applicable to nuclear families. Effective
primary prevention strategies include skills training, behavior monitoring and reinforcement, and
behavioral techniques for classroom management. Effective secondary prevention strategies
include parenting training, home visitation, social
skills problem-solving, and cognitive/thinking
skills programs. These strategies vary from
targeting parents, children, teachers, or communities, including multicomponent programs that
combine approaches. Various methods of
implementing these strategies are used such as,
media campaigns that disseminate self-directed
resources and intensive parent and teacher training programs delivered by trained therapists,
facilitators, or teachers who follow manuals and
a standardized curriculum.
Child training (CT) approaches focus on
promoting children’s protective factors and buffering children’s risk factors such as through
social-emotional skills training and typically
take place in school. Parent training programs
(PT) focus on facilitating cognitive, affective,
and behavioral changes in parents through teaching skills to increase effective communication,
engage in positive play with their child, and
develop effective child management strategies.
PT programs typically are offered at schools or
community locations but also during home visits.
Teacher training (TT) programs focus on enhancing teacher-child and teacher-parent relationships
through teaching classroom management skills
and encouraging communication/work with
parents.
In addition to effective strategies, steps must
be taken to ensure appropriate and effective
implementation of the program. Besides a welldesigned evaluation study, implementation
should include removal of attendance barriers.

718

Common approaches include the provision of
reminders, transportation, child care, and even
meals. The cultural context must also be considered, such as approaching the appropriate
person in the family for permission/recruitment
as well as ensuring that the curriculum itself is
culturally sensitive/appropriate for the target
population.

What Works
Several strategies were identified that have been
found effective in at least three RCT studies.
Evaluations have found the parent training (PT),
teacher training (TT)/classroom behavior management programs of the Incredible Years
(IY) program to be effective. In a recent article
describing the research related to the IY program,
Webster-Stratton and Herman (2010) summarize
results indicating the program to be effective in
decreasing child conduct problems, co-occurring
child depressive symptoms, harsh parenting, and
increasing positive parent–child interaction and
parenting attitudes. More specifically, the PT
component of the IY has been found to be effective in seven RCT studies by Webster-Stratton
and colleagues with 2- to 8-year-olds. For example, a recent RCT study indicated positive
evidence for improving children’s internalizing
problems (Herman et al., 2011) and externalizing
problems (Webster-Stratton & Herman, 2010).
Specific to the teacher training IY program,
three RCT studies have been conducted as it was
implemented as part of the IY series of programs
(See Webster-Stratton & Herman, 2010). For
example, in one RCT comparing a child component and teacher component with and without this
teacher program, teachers who participated were
more nurturing and consistent than controls.
Moreover, children in the participating teachers’
classrooms were more cooperative and less
aggressive than children in classrooms of control
teachers. Results from a similar RCT reveal
that children in classrooms with programparticipating teachers had increases in prosocial
behavior and on task behavior and had lower
levels of aggression.

Healthy Development of Children in Nuclear Families

A unique multicomponent prevention program with three RTC studies indicating effectiveness is the Families and Schools Together
(FAST) program (McDonald et al., 1991, 2006).
The FAST combines several strategies including,
social skills training, parent training, home visitation, academic tutoring, and classroom behavior management. Several RCT studies for the
Kids FAST program have revealed successful
results and program effectiveness with elementary school children (Kratochwill et al., 2009;
Kratochwill, McDonald, Levin, Young BearTibbetts, & Demaray, 2004; McDonald et al.,
2006). Although conducted with a small sample
of 50 Native American school children,
compared to controls, 4- to 7-year-olds who participated in FAST had lower levels of aggressive
and withdrawn behavior at posttest (Kratochwill
et al., 2004). An analyses at 1-year follow-up
indicated that FAST participants had maintained
less withdrawn levels and exhibited higher
academic competence. Similarly, in a study of
children (first through fourth grades) from
low-income Latino families, the FAST children
(n = 80) fared better than the children in the
control group (n = 50) (McDonald et al., 2006).
More specifically, the 2-year follow-up revealed
that the FAST group scored significantly higher
on academic achievement and lower on externalizing behavior compared to children in the parent
education control group.
In a more recent study, Kratochwill
et al. (2009) found that the 67 FAST children
(K-3) scored higher on family adaptability
than controls. A 1-year follow-up analysis
indicated that although family adaptability
scores declined in both groups, FAST participants had significantly less decline compared
to controls. Additionally, FAST participants
experienced a statistically significant reduction
in externalizing behaviors compared to control
group members (Kratochwill et al.). Thus,
based on these three RCT studies of the FAST,
positive effects for academic achievement
remained at least 1 year post for 2 of the 3 RCT
studies. Externalizing behaviors were lower than
controls for 2 of the 3 RCT studies at least
1 year post.

Healthy Development of Children in Nuclear Families

Twenty-nine manualized RCT studies have
been conducted and demonstrated the efficacy
and effectiveness of the Triple P (Positive Parenting Program) system (Nowak & Heinrichs,
2008). Most of these RCTs have been conducted
with the level four (standard) and five (enhanced)
programs. In a comparative RTC of a level four
program, level five program, and a wait-list control, both programs were found to be effective
(Bor, Sanders, & Markie-Dadds, 2002). Parents
of 87 preschoolers with co-occurring disruptive
behavior and attentional/hyperactive problems
participated in one of the three groups. Those in
the level four and level five groups experienced
significantly lower levels of child behavior
problems, dysfunctional parenting, and higher
levels of competence-promoting parenting.
A key finding was that contrary to expectations,
the enhanced program (level 5) was not superior
to the standard program (level 4).
A more recent RCT study found a level four
program, with the addition of a work-family balance component, to be effective among a group of
62 working parents of 1- to 16-year-olds (mean of
6.6) in a large metropolitan area in Australia
(Sanders, Stallman, & McHale, 2011). The
work-family balance component targeted
difficult areas for working parents, such as key
transition times (departure to work and arrival
home). Parents were taught cognitive and affective strategies for coping with stress and dysfunctional attributions. Parents who participated in
the combination of the level four program and
work-family balance component scored significantly lower than nontreatment controls at posttest on anxiety, stress, and dysfunctional
parenting and significantly higher on work satisfaction and work commitment, with moderate to
large effect sizes.

What is Promising
Results for two RCT studies of the IY Child
Training (CT) program (See Webster-Stratton &
Herman, 2010) suggest much promise for program effectiveness. One RCT study compared
the IY CT, the IY PT, and a control group to

719

a group receiving both the PT and CT. Children
experiencing the CT alone were found to improve
their conflict management and problem-solving
skills compared to children who received only the
PT and those in the control group. Children
receiving both the PT and CT, however, experienced the most improvements at the 1-year
follow-up assessment.
Another promising program is the level one
universal Triple P, which primarily focuses on
parent education. This program uses a “mediabased parent information campaign” ranging
from dissemination of fact sheets to media
messages targeting parents who are interested in
fostering their child’s development (Sanders
et al., 2003, p. 2). A recent RCT study found
positive impact of this program on reducing population indicators of child maltreatment for this
universal program for families of children from
birth to 8 years of age (Prinz, Sanders, Shapiro,
Whitaker, & Lutzker, 2009).

What Does Not Work
Many nicely packaged a-theoretical programs are
marketed to and used by many schools, organizations, and family providers. However, since
most of these are not tested empirically and/or
the results are not published, it is difficult to
accumulate evidence and prove the particular
program does not work. When determining
which strategies or programs are not effective,
many considerations must be made, including
proper implementation and fidelity. That is, taking evidence-based programs that have been
developed in controlled and well-funded settings,
and maintaining the fidelity of the program is not
always easy and must be considered. The literature search for this entry focused mainly on RTC
studies and did not find any family-focused
programs that were found to be in ineffective.
However, there were many programs for which
RTC studies were not found. One of the more
well-researched ineffective prevention programs
for children is the traditional curriculum for the
Drug Abuse Resistance Education (DARE) program, which has been shown to be ineffective

720

(West & O’Neal, 2004). Critiques of DARE
include that the implementation targets children
too young (five and six grades) before they can
understand peer dynamics and peer pressure, as
well as not including social skills training.

Summary
Multicomponent ecological approaches that
implement several strategies (e.g., skills training,
behavioral classroom training, behavioral monitoring and management) appear to be emerging
as a best practice. Although single-strategy
approaches such as a parent training program
have been found to be effective on their own,
studies have found advantages to implementing
multiple strategies. For example, the implementation of all three IY component programs leads
to additive effects as they simultaneously address
multiple risk factors of children’s internalizing
and externalizing behavior. A multicomponent
approach can function, therefore, to increase
protective factors such as children’s social
competence, nurturing and consistent parenting,
positive teacher-child interactions, and positive
family/parent-school/teacher relations.
The three family-focused interventions
targeting the improvement of children’s social
competence and preventing internalizing and
externalizing programs highlighted here show
great promise, but much more work is needed.
More specifically, although each of the three
programs have similar goals, the approaches
vary (and each with pros and cons) but have
been found to be successful. Despite this success,
there is a lack of RCTs examining the comparative effectives of these three programs. There is
also a lack of examinations of multicomponent
programs (targeting children) for costeffectiveness, an essential task in these times of
economic hardship. There has, however, been
work in both of these areas regarding familyfocused prevention programs for adolescents
(see ▶ Healthy Development of Youth in Nuclear
Families in this volume), which can serve as
a model to examine these issues within prevention programs targeting children.

Healthy Development of Children in Nuclear Families

References
Ackley, M. K., & Cullen, P. M. (2010). Strengthening
families
through
community
collaboration:
Implementing the Families and Schools Together
(FAST) Program. Children & Schools, 32(3),
183–186.
Ainsworth, M. D., & Bowlby, J. (1991). An ethological
approach to personality development. American
Psychologist, 46, 333–341.
Bandura, A. (2001). Social cognitive theory: An agentic
perspective. Annual Review of Psychology, 52, 1–26.
Bianchi, S. M., & Casper, L. M. (2000). American
families. Population Bulletin, 55(4), 3–43.
Bor, W., Sanders, M. R., & Markie-Dadds, C. (2002). The
effects of the Triple P-Positive Parenting Program on
preschool children with co-occurring disruptive
behavior and attentional/hyperactive difficulties. Journal of Abnormal Child Psychology, 30(6), 571–587.
Bowlby, J. (1988). A secure base: Parent–child
attachment and healthy human development.
New York: Basic Books.
Bretherton, I., & Munholland, K. A. (2008). Internal
working models in attachment relationships:
Elaborating a central construct in attachment theory.
In J. Cassidy & P. R. Shaver (Eds.), Handbook of
attachment (2nd ed., pp. 102–127). New York:
Guilford.
Bronfenbrenner, U. (1979). The ecology of human
development. Cambridge, MA: Harvard University
Press.
Bronfenbrenner, U. (Ed.). (2005). Making human beings
human: Bioecological perspectives on human
development. Thousand Oaks, CA: Sage Publications.
Bush, K. R., & Peterson, G. W. (2008). Family influences
on childhood development. In T. P. Gullotta (Ed.),
Handbook of
childhood
behavioral issues
(pp. 43–67). New York: Taylor & Francis.
Bush, K. R., & Peterson, G. W. (2013). Parent–child
relationships in diverse contexts. In G. W. Peterson
& K. R. Bush (Eds.), Handbook of marriage and the
family (3rd ed., pp. 275–302). New York: Springer.
Carlson, M., McLanahan, S., & England, P. (2004). Union
formation in fragile families. Demography, 41,
237–261.
Cassidy, J. (2008). The nature of the child’s ties.
In J. Cassidy & P. R. Shaver (Eds.), The handbook
of attachment: Theory, research, and clinical
applications (2nd ed., pp. 3–22). New York: Guilford.
Cherlin, A. (2005). American marriage in the early
twenty-first century. The Future of Children, 15,
33–55.
Coontz, S. (2000). The way we never were: American
families and the nostalgia trap. New York: Basic
Books.
Coontz, S. (2005, July 5). The heterosexual revolution.
New York Times, 17.
Crozier, M., Rokutani, L., Russett, J. L., Godwin, E., &
Banks, G. E. (2010). A multisite program evaluation of

Healthy Development of Children in Nuclear Families
Families and Schools Together (FAST): Continued
evidence of a successful multifamily communitybased prevention program. The School Community
Journal, 20, 187–207.
Granic, I., & Patterson, G. R. (2006). Toward
a comprehensive model of antisocial development:
A dynamic systems approach. Psychological Review,
113, 101–131.
Herman, K. C., Borden, L. A., Reinke, W. M., &
Webster-Stratton, C. (2011). The impact of the
Incredible Years parent, child, and teacher training
programs on children’s co-occurring internalizing
symptoms. School Psychology Quarterly, 26(3),
189–201.
Kratochwill, T. R., McDonald, L., Levin, J. R.,
Scalia, P. A., & Coover, G. (2009). Families and
Schools Together: An experimental study of multifamily support groups for children at risk. Journal of
School Psychology, 47(4), 245–265.
Kratochwill, T. R., McDonald, L., Levin, J. R.,
Young Bear-Tibbetts, H., & Demaray, M. K. (2004).
Families and Schools Together: An experimental analysis of a parent-mediated multi-family group program
for American Indian children. Journal of School
Psychology,
42(5),
359–383.
doi:10.1016/j.
jsp.2004.08.001.
Kumpfer, K. L. (2008). Why are there no effective child
abuse prevention parenting interventions? Substance
Use & Misuse, 43, 1262–1265.
Kumpfer, K. L., & Alvarado, R. (2003). Family-strengthening
approaches for the prevention of youth problem behaviors. American Psychologist, 58(6/7), 457–465.
McDonald, L., Billingham, S., Conrad, T., Morgan, A.,
Nancy, O. O., & Payton, E. (1997). Families and
Schools Together (FAST): Integrating community
development with clinical strategies. Families in
Society, 78(2), 140–155.
McDonald, L., Bradish, D., Billingham, S., Dibble, N., &
Rice, C. (1991). Families and Schools Together: An
innovative substance abuse prevention program.
Social Work in Education, 13(2), 118–128.
McDonald, L. L., Conrad, T. T., Fairtlough, A. A.,
Fletcher, J. J., Green, L. L., Moore, L. L.,
et al. (2009). An evaluation of a groupwork intervention for teenage mothers and their families. Child &
Family Social Work, 14(1), 45–57.
McDonald, L., Moberg, D., Brown, R., RodriguezEspiricueta, I., Flores, N., Burke, M., et al. (2006).
After-school multifamily groups: A randomized
controlled trial involving low-income, urban, Latino
children. Children & Schools, 28(1), 25–34.

721
Nowak, C., & Heinrichs, N. (2008). A comprehensive
meta-analysis of Triple P-Positive Parenting Program
using hierarchical linear modeling: Effectiveness and
moderating variables. Clinical Child & Family
Psychology Review, 11(3), 114–144.
Patterson, G. R. (1982). Coercive family process. Eugene,
OR: Castalia.
Peterson, G. W., & Bush, K. R. (2013). Conceptualizing
cultural influences on socialization: Comparing
parent-adolescent relationships in the United States
and Mexico. In G. W. Peterson & K. R. Bush (Eds.),
Handbook of marriage and the family (3rd ed.,
pp. 177–208). New York: Springer.
Peterson, G. W., & Hann, D. (1999). Socializing
parents and children in families. In M. Sussman &
S. K. Steinmetz (Eds.), Handbook of marriage and
the family (pp. 471–507). New York: Plenum Press.
Prinz, R., Sanders, M., Shapiro, C., Whitaker, D., &
Lutzker, J. (2009). Population-based prevention of
child maltreatment: The U.S. Triple P System
Population Trial. Prevention Science, 10(1), 1–12.
Sanders, M. R., Markie-Dadds, C., & Turner,
K. M. T. (2003). Theoretical, scientific, and clinical
foundations of the Triple P Positive Parenting
Program: A population approach to the promotion of
parenting competence. Parenting Research and
Practice Monograph, 1, 1–24.
Sanders, M. R., Stallman, H. M., & McHale, M. (2011).
Workplace Triple P: A controlled evaluation of
a parenting intervention for working parents. Journal
of Family Psychology, 25(4), 581–590. doi:10.1037/
a0024148.
Teachman, J., Tedrow, L., & Kim, G. (2013). The
demography of families. In G. W. Peterson &
K. R. Bush (Eds.), Handbook of marriage and the
family (3rd ed., pp. 39–64). New York: Springer.
Triple P. (n.d.). Triple P – Positive parenting program.
Retrieved November 15, 2011, from http://www1.
triplep.net/
Tudge, J. R., Mokrova, I., Hatfield, B. E., & Karnik, R. B.
(2009). Uses and misuses of Bronfenbrenner’s
bioecological theory of human development. Journal
of Family Theory & Review, 1, 198–210.
Webster-Stratton, C., & Herman, K. C. (2010). Disseminating Incredible Years Series early-intervention
programs: Integrating and sustaining services between
school and home. Psychology in the Schools, 47(1),
36–54.
West, S. L., & O’Neal, K. K. (2004). Project D.A.R.E.
outcome effectiveness revisited. American Journal of
Public Health, 94, 1027–1029.

722

HIV/AIDS During Early Childhood
Deborah H. Cornman1, Katelyn Sileo2 and
Blair T. Johnson3
1
Center for Health, Intervention, and Prevention
(CHIP), University of Connecticut, Storrs,
CT, USA
2
Department of Community Medicine and Health
Care, University of Connecticut, Farmington,
CT, USA
3
Department of Psychology, Center for Health,
Intervention, & Prevention (CHIP), University of
Connecticut, Storrs, CT, USA

HIV/AIDS During Early Childhood

Due to the seriousness of the HIV pandemic,
the current entry and the four that follow it will
focus primarily on prevention of HIV, with less
attention given to other STIs. Generally, though,
prevention of HIV is similar to prevention of
many of the other STIs, so many of the HIV
prevention recommendations that appear here
logically extend to other STIs. It is important to
note that preventive recommendations for HIV
and other STIs vary widely across the life span,
owing to both the different routes with which
these diseases can be acquired (e.g., sharing
drug injection equipment vs. mother to child
vs. sexual intercourse) and the differing cognitive
capacities of the targeted group (e.g., infants
vs. adolescents vs. adults vs. the elderly).

Introduction
Human immunodeficiency virus (HIV) and other
sexually transmitted infections (STIs) are among
the most common infectious diseases today, with
over 25 STIs having been identified now. Individuals become infected with STIs through contact
with infected body fluids during sex, sharing of
injection drug equipment, pregnancy and delivery,
or breastfeeding. The impact of STIs varies widely
across diseases, from little or none (e.g., scabies,
pubic lice) to moderate (e.g., human papillomavirus virus [HPV], gonorrhea) to life-threatening
(e.g., HIV, syphilis). These diseases affect men
and women of all backgrounds, ages, and economic levels, presenting wide-ranging challenges
for public health around the world.
The STI that currently presents the greatest
challenge worldwide is HIV, which causes
AIDS, a disease that progressively destroys the
body’s ability to fight infections and certain
cancers and usually results in death. Although
healthy individuals rarely succumb to these
“opportunistic” infections, the weakened immune
systems that characterize people with AIDS render
them more susceptible to infections and less able
to fight them off. Concurrent infection with other
STIs weakens their immune system even more and
worsens their prognosis. Yet the use of antiretroviral medications can prevent or delay the onset of
AIDS and significantly prolong the life span of
those who are living with HIV.

Definitions and Scope
Approximately 2.5 million of the estimated 33.3
million people currently living with HIV are children less than 15 years of age (Joint United
Nations Programme on HIV/AIDS, 2010). During 2009 alone, 370,000 children became newly
infected with HIV and 260,000 children died
from AIDS. Over 90 % of these HIV-infected
children are living in Africa, with the highest
prevalence rates in sub-Saharan Africa (Joint
United Nations Programme on HIV/AIDS). The
Joint United Nations Programme on HIV/AIDS
estimates that over 90 % of HIV-infected children become infected perinatally, or through
mother-to-child transmission (MTCT), at the
rate of 1,000 children per day. These children
acquire the virus either in the uterus (antepartum),
at the time of labor and delivery (intrapartum), or
during breastfeeding (postpartum). Studies show
about half the transmissions occur in the days
before delivery and during labor, with another
third occurring during the actual passage through
the birth canal in late labor; infection in early
pregnancy is relatively infrequent (Kourtis, Lee,
Abrams, Jamieson, & Bulterys, 2006). Of those
children who become infected with HIV, about
half of them die before they are 2 years of age if
they do not receive any treatment for HIV (World
Health Organization [WHO], 2010a).

T.P. Gullotta, M. Bloom (eds.), Encyclopedia of Primary Prevention and Health Promotion,
DOI 10.1007/978-1-4614-5999-6, # Springer Science+Business Media New York 2014

HIV/AIDS During Early Childhood

Prior to the advent of antiretroviral (ARV)
medications and other strategies for the prevention of mother-to-child transmission, approximately 15–30 % of infants born to HIV-infected
women became infected during pregnancy and
delivery, and another 5–20 % became infected
during breastfeeding (De Cock et al., 2000). Consequently, perinatal transmission rates in countries where breastfeeding was not the primary
infant feeding method, such as Europe and the
United States, were significantly lower
(15–30 %) than the rates in breastfeeding countries such as South Africa (20–45 %).

Theories
The vast majority of HIV prevention research
with very young children has focused on how to
prevent the transmission of HIV from mother to
child during pregnancy, labor, delivery, and
breastfeeding. This has resulted in research with
a predominantly biomedical focus with minimal
use of health behavior theories.

Research
Prevention of Mother-to-Child Transmission
The prevention of mother-to-child transmission
(PMTCT) of HIV has been one of the greatest
successes in the field of HIV. It comprises a set of
highly effective biomedical and behavioral interventions that have significantly improved both
maternal and child health (WHO, 2010a).
ARV Medications. The ability of ARV medications to reduce the risk of MTCT was first
discovered in the Pediatric AIDS Clinical Trials
Group (PACTG) 076 trial, a study examining the
effectiveness of zidovudine (AZT) in preventing
MTCT of HIV (Connor et al., 1994). The treatment regimen consisted of the use of AZT by the
mother during pregnancy and labor (intravenously delivered to the mother) and by the infant
for a period of 6 weeks during the postpartum
period (syrup formulation delivered to the newborn). This groundbreaking study revealed that
the risk of perinatal HIV transmission was

723

reduced by two-thirds with the use of this threestep AZT regimen, from 25 % in infants of
women who received the placebo to 8 % of
infants in women who received AZT. This regimen, paired with increased testing and counseling, became the standard of care throughout the
1990s in the United States and Europe, leading to
rapid declines of transmission in the developed
world. The PACTG 076 study was followed in
1999 by a meta-analysis demonstrating that the
combination of the three-step AZT regimen with
a cesarean section performed before the onset of
labor reduced the MTCT rate even further to 2 %
(International Perinatal HIV Group, 1999). Subsequent to this finding, studies found that administering a combination of three antiretroviral
(ARV) medications to pregnant women and
performing a cesarean section only on women
with viral loads greater than 1,000 copies/mL
decreased the MTCT rate to between 1 % and
2 % (e.g., Shapiro et al., 2010).
Combination Therapy. Combination therapy
is now considered to be the most effective
therapy available for the prevention of motherto-child transmission. With the widespread
availability of ARV medications in developed
countries, combination therapy has played
a major role in nearly eliminating MTCT of
HIV in North America and Western Europe
(Lopez-Cortes et al., 2007; Mofenson, 2004).
Use of these medications along with other
PMTCT interventions has the potential to reduce
the risk of MTCT to 5 % or less in developing
countries where breastfeeding is the primary
infant feeding method (WHO, 2010a), but such
a decline has not occurred because of the regimen’s expense and complexity of usage
(Mofenson & McIntyre, 2000).
Consequently, several simpler and less expensive short-course antiretroviral regimens were
developed for use in resource-poor countries.
A single dose of nevirapine (sd-NVP), given to
the mother at the onset of labor and to the infant
after birth (Guay et al., 1999; Jackson et al.,
2003), became the most widely used intervention
to prevent mother-to-child transmission in
resource-limited settings and continues to be
used in many settings. Though it is less effective

724

than administration of combination therapy,
sd-NVP has been found to decrease transmission
by nearly half (Guay et al., 1999; Jackson et al.,
2003) and to be much more feasible in resourcelimited settings due to its relatively low cost and
easy administration.
While the administration of sd-NVP has been
shown to be effective at reducing the risk of
transmission to infants in settings that could not
otherwise provide mother-to-child interventions,
there is now substantial evidence of the development of drug resistance when on this regimen.
Studies found that about a third of the women
taking sd-NVP developed drug resistance as did
approximately half of the infants exposed to sdNVP by the time they were 6–8 weeks of age
(Arrive et al., 2007); development of drug resistance is a potentially serious problem that can
make subsequent treatment less effective.
Based on these findings, researchers explored
alternative regimens that balanced feasibility in
resource-limited settings with safety and levels of
resistance. The research indicated that starting
women on AZT in the third trimester of pregnancy, providing a single dose of nevirapine at
the onset of labor, giving them a combination of
two ARV medications (AZT+ lamivudine [3TC])
during delivery and 1 week postpartum, and
administering an ARV medication to infants for
1 week after birth not only more effectively
reduced MTCT but also decreased the development of resistance by over 80 % compared to
sd-NVP (McIntyre et al., 2009). The recommendation to administer ARV medications to newborn infants is grounded in recent research
showing that prophylaxis use provided added
protection to infants from HIV (Chasela et al.,
2010), which is particularly important in situations where the mother has poor ART adherence,
begins ART late in pregnancy, or has a high viral
load (amount of HIV in the blood). In 2006, the
World Health Organization (WHO) translated
these research findings into new PMTCT guidelines entitled Antiretroviral Drugs for Treating
Pregnant Women and Preventing HIV Infection
in Infants, which included the aforementioned
regimen as well as the recommendation that pregnant women with weakened immune systems

HIV/AIDS During Early Childhood

(CD4 count  200 cells/mm3) be provided with
lifelong ART for their own health (WHO, 2006).
Because of the progress made on the development of simpler and more cost-effective regimens
and the commitment of governments to
expanding PMTCT programs, a greater number
of pregnant women with HIV have access to
ARV medications in low- and middle-income
countries. According to the 2009 report, Towards
Universal Access: Scaling Up Priority HIV/AIDS
Interventions in the Health Sector, nearly half
(45 %) of HIV-infected pregnant women in
low- and middle-income countries received
ARV medications in 2008 to prevent HIV transmission to their child. This represented
a significant increase from 2007, when 35 % of
pregnant women received medications, and from
2004, when only 10 % did (World Health Organization, Joint United Nations Programme on
HIV/AIDS, & United Nations Children’s Fund,
2009). However, this percentage remains well
below the United Nations General Assembly
Special Session (UNGASS) goal of 80 % of pregnant women and their children having access to
ARV medications and other PMTCT services by
2010. The sub-Saharan African countries that
have achieved the UNGASS goal of 80 % coverage (e.g., Botswana, Namibia, and Swaziland)
have done so because of a strong national commitment to PMTCT and international support;
this coverage has resulted in a significant reduction in new infant infections in these countries
(WHO, 2010a).

Strategies
To prevent the transmission of HIV from mothers
to their children, WHO (2010a) promotes a fourpronged approach that includes (1) “primary prevention of HIV infection among women of childbearing age,” (2) “preventing unintended
pregnancies among women living with HIV,”
(3) “preventing HIV transmission from
a woman living with HIV to her infant,” and
(4) “providing appropriate treatment, care and
support to mothers living with HIV and their
children and families.”

HIV/AIDS During Early Childhood

Since the vast majority of HIV-infected children acquire HIV from their mothers through
perinatal transmission, the primary strategy for
preventing pediatric HIV infection should be the
prevention of HIV infection in women of childbearing age. Because the majority of these
women become infected through unprotected
heterosexual intercourse, it is important to offer
primary prevention programs that provide information about HIV/AIDS and its prevention, promote safer sex and the use of condoms, counsel
women in family planning and avoiding
unwanted pregnancies, offer routine testing for
HIV, and provide access to facilities that can
diagnose and treat other sexually transmitted
infections that can significantly increase the risk
of HIV transmission. In addition, policies and
programs that are aimed at improving women’s
status in society should also be prioritized
because women’s social and economic vulnerability ultimately makes them and their children
susceptible to HIV as well. These evidence-based
prevention strategies that focus on keeping
mothers free from HIV will not be discussed in
this entry but will be described elsewhere in the
book (see “▶ HIV/AIDS During Adulthood,” by
Lennon & Johnson).
The remainder of this entry will focus on current recommendations for preventing mother-tochild transmission once women become infected
with HIV. It will discuss the most up-to-date,
evidence-based guidelines around (1) the use of
antiretroviral medications by the mother, during
pregnancy, delivery, and following birth, and by
the newborn, (2) infant feeding practices, and
(3) delivery by cesarean section. It will include
interventions that are feasible to implement in
resource-limited settings.

Strategies That Work
In 2010, WHO released new PMTCT guidelines
based on what has been demonstrated to work in
the abovementioned studies and other research.
The new guidelines were developed in conjunction with the new WHO guidelines on adult and
adolescent antiretroviral therapy (ART) and

725

pediatric ART, and they focus on how to most
effectively use ARV medications and infant feeding practices to minimize the risk of HIV transmission from mother to child. Changes from the
2006 guidelines include the recommendations
that pregnant women start ARV medications earlier, that women with relatively strong immune
systems who do not need ARV medications for
their own health take them longer prophylactically for the benefit of their infant, and that
women take ARV medications while
breastfeeding (WHO, 2010b). The Department
of Health and Human Services (HHS) published
additional guidelines for use in the United States
that specify when to use cesarean delivery versus
vaginal delivery for the birth of an HIV+
woman’s infant (Panel on Treatment of
HIV-Infected Pregnant Women and Prevention
of Perinatal Transmission, 2010). These guidelines highlight the roles of resources possessed by
individuals and their networks (Johnson et al.,
2010).
Antiretroviral Therapy
The latest WHO guidelines (2010b) on the use of
ARV medications to treat pregnant women and
prevent HIV infections in infants recommend
lifelong ARV medications for HIV+ women in
need of treatment for their own health (which also
reduce mother-to-child transmission of HIV) and
short-term use of ARV medications to prevent
MTCT during pregnancy, delivery, and
breastfeeding for HIV-infected women not in
need of treatment. The guidelines indicate that
the treatment options offered to a woman should
be based on whether the woman needs ARV
medications for her own health in addition to
her infant’s. To make this determination, it is
critical for HIV+ pregnant women to be tested
for their CD4 count, an indication of the strength
of their immune system. Whereas the 2006 guidelines recommended starting women on lifelong
ARV medications when their CD4 count fell
below 200 cells/mm3 (the point at which the
immune system is typically no longer strong
enough to prevent opportunistic infections), the
current guidelines recommend doing so when the
CD4 count drops to 350 cells/mm3 or below.

726

Since women with a low CD4 count (350 cells/
mm3) are at greatest risk for transmitting HIV to
their child, the use of ART during pregnancy and
while breastfeeding is the most effective way to
reduce the risk of mother-to-child transmission
and infant death while also protecting the
mothers’ health. It is recommended that women
with a low CD4 count start taking ARV medications daily as soon as possible, regardless of the
gestational age of the fetus, and should continue
to take them throughout pregnancy, delivery, and
for the rest of their lives. The regimens
recommended by WHO for pregnant women eligible for ARV medications are the same threedrug regimens recommended for nonpregnant
HIV+ individuals. The decision about which regimen should be used should be made based on
several factors including cost and operational
feasibility within the country in which it is
being administered.
HIV+ pregnant women with a stronger
immune system (CD4 count above 350 cells/
mm3) do not need to take ARV medications for
their own health; however, they do need to take
medications to prevent HIV transmission to
their infant. WHO (2010b) provides two
recommended drug options for women taking
ARV medications for the health of their infant.
Option A requires that the woman start taking
AZT twice daily when she is 14 weeks pregnant
(or as soon after as possible) and that she continue
doing so throughout her pregnancy. When labor
begins, the woman should be administered
a single dose of nevirapine, and twice daily
doses of AZT and 3TC should be started and
continued for 7 days after the baby is born.
Additionally, daily nevirapine (or twice daily
AZT) should be administered to the infant for
6 weeks after birth if the infant is not
breastfeeding. If the infant is breastfeeding,
daily nevirapine should be continued until
1 week after breastfeeding has finished. Option
B is a three-drug regimen for the mother to take
during pregnancy and throughout the
breastfeeding period. Additionally, the infant
should take nevirapine daily for a period of
6 weeks after birth, regardless of whether the
infant is breastfeeding. Option A is more likely

HIV/AIDS During Early Childhood

to be implemented in developing countries where
resources are limited, while option B is usually
offered to HIV+ women in high-income
countries.
Breastfeeding
The transmission of HIV through breastfeeding
has been well established. It is estimated that
200,000 infants a year worldwide acquire HIV
through breastfeeding (Chasela et al., 2010).
Transmission via breastfeeding is much more
prevalent among developing countries where
breastfeeding is an extremely high-prevalence
behavior; women in Africa, for example, typically breastfeed for about 2 years. In these developing countries where breastfeeding has been the
norm, approximately one-third to one-half of all
instances of mother-to-child transmission have
occurred through breastfeeding (De Cock et al.,
2000; Fowler & Newell, 2002).
The solution to this problem is straightforward
in developed countries, where it is relatively easy
for HIV+ mothers to avoid breastfeeding altogether and feed their infants with breast milk
replacements such as commercial infant formula
or homemade infant formula. In fact, this solution
has been adopted by the majority of HIV+
mothers in these countries, which has contributed
to a significant reduction of transmission through
breastfeeding. In contrast, in developing countries where there are limited resources, finding
viable and effective infant feeding solutions for
HIV+ women is much more complex. Replacement feeding is often not feasible due to cost
(e.g., breast milk substitutes are not affordable),
practical considerations (e.g., nutritionally adequate substitutes are not consistently available, or
there is no access to clean water for making the
milk replacement), and cultural reasons (e.g.,
there is a stigma attached to not breastfeeding)
(Coutsoudis, Goga, Rollins, Coovadia, & Child
Health Group, 2002). Additionally, it has been
well documented that breastfeeding contributes
to both maternal and infant health. Breastfeeding
prolongs the interval between births and helps to
protect the mother from developing ovarian
or breast cancer. For the child, breast milk
provides the nutrition that the child needs in

HIV/AIDS During Early Childhood

order to thrive and grow. These nutrients can of
course be supplied by acceptable milk replacements. However, milk replacements cannot
replace maternal antibodies, which can protect
the child against common childhood illnesses
such as diarrhea, pneumonia, neonatal sepsis,
acute otitis media, and other potentially fatal
diseases (Bahl et al., 2005; Kuhn & Aldrovandi,
2010). Thus, having HIV+ women stop
breastfeeding in resource-limited settings is
often not an option and can be life-threatening
to the infant.
WHO’s 2010 revised infant feeding guidelines
are based on a thorough review of the research
literature and an attempt to “balance the risk of
infants acquiring HIV through breast milk with
the higher risk of death from causes other than
HIV, in particular malnutrition and serious illnesses such as diarrhea, among non-breastfed
infants” (World Health Organization, Joint
United Nations Programme on HIV/AIDS,
United Nations Population Fund, & United
Nations Children’s Fund, 2010, p. 16). In countries with sufficient resources to support healthy
and sustainable replacement feeding, this is the
recommended infant feeding method for HIV+
women and breastfeeding is to be avoided. In
countries where breastfeeding is judged to be
the best option and women have access to ARV
medications, WHO and other international organizations (2010) recommend that women exclusively breastfeed for the first 6 months of an
infant’s life and then continue with mixed feeding (breastfeeding supplemented with complimentary foods) until the infant is 12 months old.
They recommend stopping breastfeeding only
when “a nutritionally adequate and safe diet without breast milk can be provided” (World Health
Organization et al., 2010, p. 31). If a woman has
access to ARV medications, she should take them
for the duration of breastfeeding (and beyond if
she is taking them to maintain her own health).
Similarly, the infant should take ARV medications while breastfeeding and up until a week
after breastfeeding ends. There is now ample
empirical evidence to support the safety and
effectiveness of ART during breastfeeding.
More specifically, it has been shown to lower

727

postnatal transmission rates to below 1 %
(Shapiro et al., 2010).
Evidence is so strong in support of the benefits
of breastfeeding for mother and child that even
for women who do not have ARV medications
available, breastfeeding may provide infants with
a higher chance of HIV-free survival (Kuhn &
Aldrovandi, 2010; Slater, Stringer, & Stringer,
2010). Studies in developing countries have
shown higher mortality rates among infants
receiving mixed feeding or replacement feeding
during the first 6 months of life than among
infants exclusively breastfed by HIV+ mothers
during the same time period (Homsy et al.,
2010). Thus, in situations where the woman
does not have regular access to ARV medications
and cannot safely use replacement feeding,
WHO currently recommends that women exclusively breastfeed for the first 6 months of an
infant’s life and then engage in mixed
feeding between 6 and 12 months of age
(WHO et al., 2010).
Research shows that there is little benefit to the
infant from continuing to breastfeed beyond
12 months (Kuhn & Aldrovandi, 2010; Slater
et al., 2010). Thus, combining breastfeeding with
ARV medications offers the best balance of protection from morbidity and mortality and HIV
transmission in developing countries. Regardless
of whether or not women are taking ARV medications while breastfeeding, WHO recommends
that when a woman weans her infant from
breastfeeding, she should do it gradually over
a 1-month period and not stop abruptly as doing
so has been associated with adverse consequences
for the infant, such as growth failure and diarrhea
(Kuhn & Aldrovandi, 2010; WHO et al., 2010).
The 2010 WHO guidelines recommend that
the national health authorities in each country
decide which strategy will give infants born to
HIV+ mothers the greatest chance of HIV-free
survival: exclusive breastfeeding (hopefully
accompanied by ARV medications) or replacement feeding and avoidance of all breastfeeding
(WHO et al., 2010). Replacement feeding should
not be recommended unless it is acceptable,
feasible, affordable, sustainable, and safe in that
country.

728

Cesarean Section Versus Vaginal Delivery
Whether or not to deliver the infant of an HIV+
women via cesarean section should be based on
a consideration of the risks versus the benefits for
that particular mother and child. Cesarean section
can lower transmission rates by protecting the
infant from direct contact with the mother’s genital tract secretions and blood, which may contain
HIV. However, cesarean deliveries are also
accompanied by an increased risk of maternal
morbidity and mortality compared with vaginal
deliveries (Read & Newell, 2005); the risks
include maternal hemorrhage (uncontrolled
bleeding), infection, and other complications.
In the case of HIV+ women with viral loads
above 1,000 copies/mL, the benefits of cesarean
delivery are believed to outweigh the risks.
A meta-analysis of data from 15 studies revealed
a significant reduction (50 %) in the risk of
transmission to infants when they were delivered
via scheduled cesarean from mothers with viral
loads > 1,000 copies/mL (International Perinatal
HIV Group, 1999). Based on this and other
research, the Panel on Treatment of
HIV-Infected Pregnant Women and Prevention
of Perinatal Transmission (2010) recommends
scheduled cesarean delivery at 38 weeks gestation for HIV+ women with viral loads above
1,000 copies/mL near the time of delivery
(irrespective of whether they were taking ARV
medications during their pregnancy) and for
women with unknown viral loads near the time
of delivery. There is strong evidence supporting
the benefits of elective cesarean delivery if it is
performed prior to the rupture of membranes and
onset of labor, but it is not clear whether cesarean
delivery is beneficial for women who present
with ruptured membranes or who are in labor.
Determining the mode of delivery for women
with viral loads below 1,000 copies/mL is less
straightforward. The recommendation that cesarean delivery only be considered for women with
viral loads above 1,000 copies/mL was based
largely on data from the Women and Infants
Transmission Study (Garcia et al., 1999). Of the
women in that study with viral loads below 1,000
copies/mL, not one transmitted HIV to her child.
Subsequent studies, however, demonstrated that

HIV/AIDS During Early Childhood

HIV transmission can still occur even at very low
viral loads and that cesarean delivery may help
reduce the risk of HIV transmission (Ioannidis
et al., 2001; Townsend et al., 2008). However,
given the low rate of transmission among women
with a low viral load, it is unclear whether cesarean delivery provides any additional benefit in
terms of PMTCT. Based on these mixed findings,
HHS currently recommends that the decision on
mode of delivery for women with viral loads
below 1,000 copies/mL should be individualized
to the patient and decided between the woman
and her physician.
Elective cesarean section is a viable option in
the United States and in other developed countries, but it is not a feasible option for HIV+
women in most developing countries because of
limited resources. Prior to implementing a policy
of elective cesarean sections to reduce HIV transmissions to infants, it is critical to consider the
costs and human resource implications of
doing so.

Strategies That Are Promising
Immunization
Currently, researchers are examining immunization as a possible strategy for preventing motherto-child transmission of HIV. Immunization is
the process whereby a person is made resistant
to an infectious disease, generally by the
administration of a vaccine. Immunization has
successfully been used with other viral infections, such as the hepatitis B virus, to prevent
perinatal transmission. Given the challenges
around implementing mother-to-child prevention
services in resource-limited settings, an HIV
vaccine that could prevent transmission from
mother to child would have a tremendous impact
globally, especially in developing nations.
Although an HIV vaccine with demonstrated
safety and effectiveness has not yet been developed for either children or adults, there are several ongoing trials evaluating vaccines that could
have major implications for the future of motherto-child prevention. Examples include HPTN
027 in Uganda and the PedVacc trial in Gambia

HIV/AIDS During Early Childhood

and Kenya, both of which are evaluating vaccines
for the prevention of mother-to-child transmission during breastfeeding.
Minimizing HIV Transmission During
Breastfeeding
With respect to breastfeeding, there is some evidence that exclusive breastfeeding during the first
6 months of life not only reduces mortality among
infants in developing countries but may also reduce
the transmission of HIV from mother to child.
A large study of over 4,000 newborn infants born
to HIV+ mothers in Zimbabwe found that those
who received mixed feeding were 2.6 times as likely
to become HIV+ as infants who were exclusively
breastfed (Iliff et al., 2005). The authors suggested
that the reason for the difference may be because
other foods can cause abrasions in the mucous linings of the infant’s digestive tract, making it easier
for HIV to enter the infant’s bloodstream. Additional research is needed to confirm these findings.
Another promising strategy for reducing
MTCT during breastfeeding is the use of heattreated, expressed breast milk. There is laboratory evidence that heating expressed breast milk
from HIV+ mothers, if done correctly, can inactivate HIV (e.g., Israel-Ballard et al., 2007). Several different heating methods have been tried
and none of the methods appears to affect the
nutritional or immunological composition of
breast milk (Chantry et al., 2009; Israel-Ballard
et al., 2008). Therefore, this appears to be
a potentially effective method for HIV+ mothers
to safely provide HIV-free breast milk to their
infants. However, there is a limited amount of
empirical data supporting the acceptability and
sustainability of using heat-treated breast milk, so
WHO currently recommends it only as an
“interim strategy” to be used during specific
periods of time rather than the full duration of
breastfeeding (WHO et al., 2010).

Strategies That Do Not Work
In terms of ARV medications, it is recommended
that efavirenz not be used to treat HIV+ pregnant
women during their first trimester of pregnancy

729

because of potential risks to the fetus during that
time. Animal data has revealed the possible risk
to the fetus of blindness, absence of one or both
eyes, facial clefts, and neural tube defects
(resulting in lack of development of portions of
the brain and/or spine) if the mother takes
efavirenz during this critical period of fetal development (Panel on Treatment of HIV-Infected
Pregnant Women and Prevention of Perinatal
Transmission, 2010).
Regarding breastfeeding, evidence has demonstrated that cessation of breastfeeding prior to
6 months of age or mixed feeding (breastfeeding
and supplementary food) during the first 6 months
of life can be harmful to the health of infants who
live in resource-limited settings. Research suggests that the first 6 months of an infant’s life are
a critical period in which the protective antibodies of breast milk are necessary for infant
survival in developing countries. Infants born to
HIV+ mothers who are weaned prior to 6 months
or who are not exclusively breastfed during that
period are more likely to contract diarrhea,
vomiting, and gastroenteritis, which can be fatal
(Homsy et al., 2010; Kourtis et al., 2007;
Onyango-Makumbi et al., 2010). A study in
Uganda, for example, found a six-fold greater
risk of death among infants born to HIV+
women who breastfeed for less than 6 months as
compared to those who breastfed for 6 months or
longer (Homsy et al., 2010). These findings further highlight the significant health benefits of
breastfeeding for infants in resource-limited
settings.

Synthesis
The primary mode of HIV acquisition for children 6 years of age and younger is perinatal or
mother to child. Consequently, the most effective
way to prevent HIV in young children is to prevent it in their mothers. If these prevention efforts
are unsuccessful and the mother becomes
infected, other interventions must be
implemented to reduce the risk of transmission
from mother to child. Currently, treating HIV+
women and their newborns with antiretroviral

730

medications has been demonstrated to be the
most effective intervention available for the prevention of mother-to-child transmission. In
developed countries, the use of three-drug regimens in the mother during pregnancy, delivery,
and postpartum; use of prophylaxis medication
administered to the infant after birth; and use of
formula instead of breast milk to feed the infant
have reduced the risk of MTCT to less than 2 %
in developed countries.
This combination of interventions is not feasible, however, in many developing countries
where resources are more limited and
breastfeeding is critical to infants’ survival. Consequently, simpler and less expensive shortcourse ARV regimens for the mother and child
along with exclusive breastfeeding of the child
for the first 6 months of his/her life are being
recommended as a way to reduce HIV transmission to children in these countries. Although not
as effective as the long-term use of combination
regimens and replacement feeding, these interventions are having a significant impact on the
prevention of MTCT.
The research in the area of PMTCT has
underscored the importance of designing interventions that are customized to meet the needs of
the individual within her culture. Developing an
intervention that is biologically sound is useless if
there are social, cultural, political, financial, psychological, and practical barriers that prevent its
implementation. Although there continues to be
a long way to go before mother-to-child transmission is eliminated worldwide, the evidence-based
guidelines that the World Health Organization
has recommended are an important step to reducing MTCT in both developed and developing
countries.

References
Arrive, E., Newell, M. L., Ekouevi, D. K., Chaix, M. L.,
Thiebaut, R., Masquelier, B., et al. (2007). Prevalence
of resistance to nevirapine in mothers and children
after single-dose exposure to prevent vertical transmission of HIV-1: A meta-analysis. International Journal
of Epidemiology, 36(5), 1009–1021. doi:10.1093/ije/
dym104.

HIV/AIDS During Early Childhood
Bahl, R., Frost, C., Kirkwood, B. R., Edmond, K.,
Martines, J., Bhandari, N., et al. (2005). Infant
feeding patterns and risks of death and
hospitalization in the first half of infancy: Multicentre
cohort study. Bulletin of the World Health
Organization, 83(6), 418–426. doi:10.1590/S004296862005000600009.
Chantry, C. J., Israel-Ballard, K., Moldoveanu, Z.,
Peerson, J., Coutsoudis, A., Sibeko, L., et al. (2009).
Effect of flash-heat treatment on immunoglobulins in
breast milk. Journal of Acquired Immune Deficiency
Syndromes,
51(3),
264–267.
doi:10.1097/
QAI.0b013e3181aa12f2.
Chasela, C. S., Hudgens, M. G., Jamieson, D. J., Kayira,
D., Hosseinipour, M. C., Kourtis, A. P., et al. (2010).
Maternal or infant antiretroviral drugs to reduce HIV-1
transmission. New England Journal of Medicine, 362,
2271–2281.
Connor, E. M., Sperling, R. S., Gelber, R., Kiselev, P.,
Scott, H., O’Sullivan, M., et al. (1994). Reduction of
maternal-infant transmission of human immunodeficiency virus type I with zidovudine treatment. Pediatric AIDS clinical trials group protocol 076 study
group. New England Journal of Medicine, 331,
1173–1180.
Coutsoudis, A., Goga, A. E., Rollins, N., Coovadia, H. M.,
& Child Health Group. (2002). Free formula
milk for infants of HIV-infected women: Blessing or
curse? Health Policy and Planning, 17(2), 154–160.
De Cock, K. M., Fowler, M. G., Mercier, E., de Vincenzi,
I., Saba, J., Hoff, E., et al. (2000). Prevention of
mother-to-child HIV transmission in resource-poor
countries: Translating research into policy and practice. Journal of the American Medical Association,
283(9), 1175–1182.
Fowler, M. G., & Newell, M. L. (2002). Breast-feeding
and HIV-1 transmission in resource-limited settings.
Journal of Acquired Immune Deficiency Syndromes
(1999), 30(2), 230–239.
Garcia, P. M., Kalish, L. A., Pitt, J., Minkoff, H., Quinn,
T. C., Burchett, S. K., et al. (1999). Maternal levels of
plasma human immunodeficiency virus type 1 RNA
and the risk of perinatal transmission. Women and
Infants Transmission Study Group. New England
Journal of Medicine, 341(6), 394–402.
Guay, L. A., Musoke, P., Fleming, T., Bagenda, D., Allen,
M., Nakabiito, C., et al. (1999). Intrapartum and
neonatal single-dose nevirapine compared with
zidovudine for prevention of mother-to-child
transmission of HIV-1 in Kampala, Uganda: HIVNET
012 randomised trial. Lancet, 354(9181), 795–802.
doi:10.1016/S0140-6736(99)80008-7.
Homsy, J., Moore, D., Barasa, A., Were, W., Likicho, C.,
Waiswa, B., et al. (2010). Breastfeeding, mother-tochild HIV transmission, and mortality among
infants born to HIV-infected women on highly
active antiretroviral therapy in rural Uganda. Journal
of Acquired Immune Deficiency Syndromes (1999),
53(1), 28–35. doi:10.1097/QAI.0b013e3181bdf65a.

HIV/AIDS During Early Childhood
Iliff, P. J., Piwoz, E. G., Tavengwa, N. V., Zunguza, C. D.,
Marinda, E. T., Nathoo, K. J., et al. (2005). Early
exclusive breastfeeding reduces the risk of postnatal
HIV-1 transmission and increases HIV-free survival.
AIDS (London, England), 19(7), 699–708.
International Perinatal HIV Group. (1999). The mode of
delivery and the risk of vertical transmission of human
immunodeficiency virus type 1–a meta-analysis of
15 prospective cohort studies. New England Journal
of Medicine, 340(13), 977–987.
Ioannidis, J. P., Abrams, E. J., Ammann, A., Bulterys, M.,
Goedert, J. J., Gray, L., et al. (2001). Perinatal transmission of human immunodeficiency virus type 1 by
pregnant women with RNA virus loads <1,000 copies/
ml. Journal of Infectious Diseases, 183(4), 539–545.
Israel-Ballard, K. A., Abrams, B. F., Coutsoudis, A.,
Sibeko, L. N., Cheryk, L. A., & Chantry, C. J.
(2008). Vitamin content of breast milk from HIV-1infected mothers before and after flash-heat
treatment. Journal of Acquired Immune Deficiency
Syndromes,
48(4),
444–449.
doi:10.1097/
QAI.0b013e31817beb8d.
Israel-Ballard, K., Donovan, R., Chantry, C., Coutsoudis,
A., Sheppard, H., Sibeko, L., et al. (2007). Flash-heat
inactivation of HIV-1 in human milk: A potential
method to reduce postnatal transmission in developing
countries. Journal of Acquired Immune Deficiency
Syndromes,
45(3),
318–323.
doi:10.1097/
QAI.0b013e318074eeca.
Jackson, J. B., Musoke, P., Fleming, T., Guay, L. A.,
Bagenda, D., Allen, M., et al. (2003). Intrapartum and
neonatal single-dose nevirapine compared with zidovudine for prevention of mother-to-child transmission of
HIV-1 in kampala, uganda: 18-month follow-up of the
HIVNET 012 randomised trial. Lancet, 362(9387),
859–868. doi:10.1016/S0140-6736(03)14341-3.
Johnson, B. T., Redding, C. A., DiClemente, R. J.,
Mustanski, B. S., Dodge, B., & Fishbein, M. (2010).
A network-individual-resource model for HIV prevention. AIDS and Behavior, 14(Suppl. 2), 204–221.
doi:10.1007/s10461-010-9803-z.
Joint United Nations Programme on HIV/AIDS. (2010,
December). Global report: UNAIDS report on the
global AIDS epidemic 2010. Geneva, Switzerland:
Joint United Nations Programme on HIV/AIDS.
Retrieved December 1, 2011, from http://www.
unaids.org/globalreport/documents/20101123_Global
Report_full_en.pdf
Kourtis, A., Fitzgerald, D., Hyde, L., Tien, H. C., Chavula,
C., Mumba, N., et al. (2007, February 25–28). Diarrhea in uninfected infants of HIV-infected mothers who
stop breastfeeding at 6 months: The BAN study experience. Poster 772 presented at 14th conference on
retroviruses and opportunistic infections, Los Angeles,
CA. Retrieved November 18, 2011, from http://www.
retroconference.org/2007/Abstracts/29630.htm
Kourtis, A. P., Lee, F. K., Abrams, E. J., Jamieson, D. J., &
Bulterys, M. (2006). Mother-to-child transmission of
HIV-1: Timing and implications for prevention.

731
The Lancet Infectious Diseases, 6(11), 726–732.
doi:10.1016/S1473-3099(06)70629-6.
Kuhn, L., & Aldrovandi, G. (2010). Survival and health
benefits of breastfeeding versus artificial feeding in
infants of HIV-infected women: Developing versus
developed world. Clinics in Perinatology, 37(4),
843–862. doi:10.1016/j.clp.2010.08.011. x.
Lopez-Cortes, L. F., Ruiz-Valderas, R., Rivero, A.,
Camacho, A., Marquez-Solero, M., Santos, J.,
et al. (2007). Efficacy of low-dose boosted saquinavir
once daily plus nucleoside reverse transcriptase inhibitors in pregnant HIV-1-infected women with
a therapeutic drug monitoring strategy. Therapeutic
Drug Monitoring, 29(2), 171–176. doi:10.1097/
FTD.0b013e31803bb54e.
McIntyre, J. A., Hopley, M., Moodley, D., Eklund, M.,
Gray, G. E., Hall, D. B., et al. (2009). Efficacy of shortcourse AZT plus 3TC to reduce nevirapine resistance
in the prevention of mother-to-child HIV transmission:
A randomized clinical trial. PLoS Medicine, 6(10),
e1000172. doi:10.1371/journal.pmed.1000172.
Mofenson, L. M. (2004). Successes and challenges in the
perinatal HIV-1 epidemic in the United States as illustrated by the HIV-1 serosurvey of childbearing
women. Archives of Pediatrics & Adolescent Medicine,
158(5),
422–425.
doi:10.1001/
archpedi.158.5.422.
Mofenson, L. M., & McIntyre, J. A. (2000). Advances and
research directions in the prevention of mother-tochild HIV-1 transmission. The Lancet, 355,
2237–2244.
Onyango-Makumbi, C., Bagenda, D., Mwatha, A., Omer,
S. B., Musoke, P., Mmiro, F., et al. (2010). Early
weaning of HIV-exposed uninfected infants and risks
of serious gastroenteritis: Findings from two perinatal
HIV prevention trails in Kampala, Uganda. Journal of
Acquired Immune Deficiency Syndromes, 53(1),
20–27. doi:10.1097/QAI.0b013e3181bdf65a.
Panel on Treatment of HIV-Infected Pregnant Women and
Prevention of Perinatal Transmission. (2010, May 24).
Recommendations for use of antiretroviral drugs in
pregnant HIV-1-infected women for maternal
health and interventions to reduce perinatal HIV transmission in the United States. Retrieved December
1, 2010, from http://aidsinfo.nih.gov/ContentFiles/
PerinatalGL.pdf
Read, J. S., & Newell, M. K. (2005). Efficacy and safety of
cesarean delivery for prevention of mother-to-child
transmission of HIV-1. Cochrane Database of Systematic Reviews (Online), 4(4), CD005479. doi:10.1002/
14651858.CD005479.
Shapiro, R. L., Hughes, M. D., Ogwu, A., Kitch, D.,
Lockman, S., Moffat, C., et al. (2010). Antiretroviral
regimens in pregnancy and breast-feeding in
Botswana. The New England Journal of Medicine,
362(24), 2282–2294. doi:10.1056/NEJMoa0907736.
Slater, M., Stringer, E. M., & Stringer, J. S. (2010).
Breastfeeding in HIV-positive women: What can be
recommended? Pediatric Drugs, 12(1), 1–9.

732
Townsend, C. L., Cortina-Borja, M., Peckham, C. S., de
Ruiter, A., Lyall, H., & Tookey, P. A. (2008). Low
rates of mother-to-child transmission of HIV following
effective pregnancy interventions in the United Kingdom and Ireland, 2000–2006. AIDS (London,
England),
22(8),
973–981.
doi:10.1097/
QAD.0b013e3282f9b67a.
World Health Organization. (2006). Antiretroviral drugs
for treating pregnant women and preventing HIV
infection in infants: Towards universal access.
Geneva, Switzerland: WHO Press. Retrieved November 25, 2011, from http://www.who.int/hiv/pub/mtct/
arv_guidelines_mtct.pdf
World Health Organization. (2010a). World Health Organization PMTCT strategic vision 2010–2015:
Preventing mother-to-child transmission of HIV to
reach the UNGASS and millennium development
goals. Geneva, Switzerland: WHO Press. Retrieved
November 23, 2011, from http://www.who.int/hiv/
pub/mtct/strategic_vision.pdf
World Health Organization. (2010b). Antiretroviral
drugs for treating pregnant women and prevention

HIV/AIDS During Early Childhood
HIV infection in infants: Recommendations for
a public health approach. Geneva, Switzerland:
WHO Press. Retrieved December 1, 2011, from
http://whqlibdoc.who.int/publications/2010/97892415
99818_eng.pdf
World Health Organization, Joint United Nations
Programme on HIV/AIDS, & United Nations Children’s Fund. (2009). Towards universal access:
Scaling up priority HIV/AIDS interventions in
the health sector. Progress report 2009. Geneva,
Switzerland: WHO Press. Retrieved November
25, 2011, from http://www.who.int/entity/hiv/pub/
tuapr_2009_en.pdf
World Health Organization, Joint United Nations
Programme on HIV/AIDS, United Nations Population
Fund, & United Nations Children’s Fund. (2010).
Guidelines on HIV and infant feeding 2010: Principles
and recommendation for infant feeding in the context
of HIV and a summary of evidence. Geneva,
Switzerland: WHO Press. Retrieved December
2, 2011, from http://whqlibdoc.who.int/publications/
2010/9789241599535_eng.pdf

HIV/AIDS During Childhood

HIV/AIDS During Childhood
Erika A. Montanaro1, Angela D. Bryan1 and
Blair T. Johnson2
1
Department of Psychology and Neuroscience,
University of Colorado Boulder, Boulder,
CO, USA
2
Department of Psychology, Center for Health,
Intervention, & Prevention (CHIP) University of
Connecticut, Storrs, CT, USA

Introduction and Definitions
This entry reviews research and knowledge relating to the development and implementation of
HIV/AIDS prevention programs for school-aged
children (see definitions in Cornman, Sileo, and
Johnson, (2013) in this encyclopedia). This entry
reviews the scope of the problem and outlines the
current
recommendations
for
effective
HIV/AIDS prevention programs for school-aged
children between the ages of 6 and 12.

Scope
UNAIDS, the Joint United Nations Program on
HIV/AIDS, and the Global Fund’s goal of virtually eliminating mother-to-child transmission of
HIV by 2015 is within reach. From 2001 to 2009
mother-to-child HIV infection rates declined by
26 % (United Nations AIDS, 2010). However,
there is still much more to be done to prevent
the HIV/AIDS pandemic from affecting the
world’s children. United Nations AIDS estimates
that over 370,000 children were infected with
HIV in 2009 and 2.5 million children are currently living with HIV or AIDS. Many more
children are affected by the epidemic in that
they have lost their parents to the disease. To
date, more than 16 million children have lost
one or both parents to AIDS.
The picture is not so bleak in the industrialized
world, but HIV/AIDS among children still presents a substantial public health threat. In the
USA, the number of pediatric AIDS cases has

733

been reduced dramatically, from 195 cases
reported in 1999 to only 57 reported in 2005
(Centers for Disease Control and Prevention,
2007). This decrease is largely due to the use of
antiretroviral (ARV) prophylaxis during pregnancy among HIV-positive (HIV+) women.
Despite these advances, the CDC estimates that
over 9,500 children under the age of 13 are currently living with HIV or AIDS (Centers for
Disease Control and Prevention, 2008). More
important from a prevention standpoint, a large
percentage of HIV infections are detected in early
adulthood (e.g., 21–30 years). Given the latency
from infection to detection of the HIV virus, these
figures suggest that patterns of risk behavior
established in late childhood and early adolescence place young people at high risk for HIV
infection later in life. For these reasons, United
Nations AIDS (1997) urged that HIV prevention
programs, and particularly school-based HIV
prevention programs, be implemented “at the
earliest possible age, and certainly before the
onset of sexual activity” (p. 2). Recent reports in
the USA suggest that average age of first intercourse is approximately 17 years old (Alan
Guttmacher Institute (AGI), 2002), and in
higher-risk groups, such as criminally involved
adolescents, first intercourse occurs much earlier,
between the ages of 12 and 14. Thus, both parents
and schools must undertake HIV prevention
efforts, preferably before children reach the age
of 12; these efforts can have the added benefit of
protection from sexually transmitted infections
(STIs). The focus of this entry is the current
state of HIV prevention efforts for these young
people. Specifically, we review HIV prevention
programs for children between the ages of 6 and
12. Given the extremely high costs associated
with HIV/AIDS in both economic and personal
terms, it is crucially important to start prevention
programs early so as to avoid as many infections
as possible.

Theories and Research
Despite the importance of HIV/STD prevention
for school-aged children, theories directed

T.P. Gullotta, M. Bloom (eds.), Encyclopedia of Primary Prevention and Health Promotion,
DOI 10.1007/978-1-4614-5999-6, # Springer Science+Business Media New York 2014

734

towards this group remain poorly developed.
Moreover, the vast majority of all HIV prevention programs for young people, and particularly
school-based programs, have been conducted
with adolescents of high school age (see White
and Johnson (2013) in this encyclopedia). We
could find only one example of a program
conducted with school-aged children: Schonfeld
et al. (1995) designed and implemented an AIDS
education curriculum in a randomized controlled
trial in one elementary school. The participants
were children in grades ranging from kindergarten to 6th grade, and the program was developmentally tailored. The educational program
involved discussions of general concepts of illness (e.g., germs, the immune system) followed
by a specific discussion of the transmission and
prevention of HIV and the progression of AIDS.
This program was successful at increasing conceptual understanding of HIV transmission and
prevention and did not increase fears about
HIV/AIDS among the children. Schonfeld
et al. concluded that young children are indeed
capable of understanding and processing factual
information regarding HIV transmission and
prevention.
Based on this program and those conducted
with adolescents (White & Johnson, 2013), some
conclusions regarding the development of effective HIV prevention programs for school-aged
children are reasonable. First, the CDC guidelines for Effective School Health Education to
Prevent the Spread of AIDS (Centers for Disease
Control and Prevention, 2003) recommend that
HIV preventive interventions are most likely to
be effective when they are integrated into a health
education curriculum. The overall health education curriculum should emphasize the strong connection between personal behavior and health in
all domains (e.g., sexual behavior, exercise,
nutrition, substance use). Such an integrative
approach to health education is expected to foster
an early belief in the controllability of health
outcomes later in life.
In a review of 20 years of school-based sexuality education, Kirby (1999a) concluded that
simply imparting correct knowledge about sex,
contraception, and disease prevention has been

HIV/AIDS During Childhood

shown to be insufficient to influence risk behavior, a conclusion that squares with meta-analytic
evidence (Johnson, Scott-Sheldon, HuedoMedina, & Carey, 2011). While behaviorally relevant information regarding HIV transmission
and prevention is a necessary component of an
HIV prevention educational program (Fisher &
Fisher, 2000), it is clear that increases in such
knowledge are only weakly related to behavior.
Thus, a focus on the complex set of skills necessary to manage sexual risk behavior becomes
crucial. United Nations AIDS (1997) recommends a “life skills approach,” wherein young
people are given the self-confidence and ability
to handle risky situations in all domains, including that of sexual behavior (i.e., Gilchrist &
Schinke, 1985). Importantly, the same findings
applicable to all other populations targeted for
HIV prevention appear to be true of school-aged
children. Interventions that are theoretically and
empirically based, and tailored to the population
of interest, are most likely to be successful (Glanz
& Maddock, 2000; Kirby, 1999b). Examples of
theoretical underpinnings of successful HIV prevention programs for older adolescents and for
adults include the Theory of Reasoned Action/
Planned Behavior (Ajzen & Madden, 1986;
Fishbein & Ajzen, 1980), Social Cognitive
Theory (Bandura, 1992), and the InformationMotivation-Behavioral Skills Model (Fisher &
Fisher, 1992). Central to each of these theories
is the notion that information alone is not enough
and that in order to engage in HIV prevention,
individuals must have positive attitudes towards
prevention, perceive normative support for
prevention, perceive skills (i.e., self-efficacy)
necessary to engage in prevention, and strong
intentions to engage in preventive behavior.
At present, the exact content necessary to optimally promote each of these prevention components for children between the ages of 6 and
12 has not been empirically investigated. Of
note is the work of Schonfeld et al. (1995),
which only examined the effectiveness of their
program for increasing factual knowledge. But it
is clear that such children should have developmentally appropriate information designed to
increase positive attitudes, normative support,

HIV/AIDS During Childhood

perceived self-efficacy, and intentions to engage
in safer behavior. For example, a self-efficacy
intervention component on the intricacies of
negotiating condom use with a sexual partner,
while crucial for teenagers, would be wholly
inappropriate for a 10-year-old. Later in the
entry, we review some suggestions made by
developmental psychologists about what content
an HIV prevention program for young children
should contain.
A final theoretical perspective that is important when considering children’s risk behavior is
more ecological. Problem Behavior Theory
(Jessor & Jessor, 1977; Jessor, Turbin, & Costa,
1998) asserts that there are multiple distal personality and environmental characteristics that
serve as risk and protective factors and that
often these factors do not have obvious, contentrelated similarity to the risk behavior at focus
(Jessor et al., 1998). For example, Jessor and
colleagues have shown that distal personality
factors such as high self-esteem and environmental factors such as community service involvement serve as protective factors that decrease
risky behaviors including early and unprotected
sexual behavior (Jessor et al.). Similarly, Johnson
et al.’s (2010) Network Individual Resource
Model highlights how individuals are linked to
multiple networks in resource-rich exchanges
and that risk for HIV acquisition hinges not just
on the individual but on the networks with which
they are linked. Because they are vulnerable,
children’s risk levels for HIV usually hinge
more critically on their families than on other
networks. These perspectives suggest that factors
that strengthen structures (e.g., improve family
health, give a sense of hope for the future, and
community involvement) ultimately protect
younger individuals who can progress into
adolescence and adulthood in good health and
HIV negative.

Overview of Strategies
The following outline of an age-appropriate
HIV/STD prevention curriculum is taken partially from Pozen (1995, pp. 249–251) and from

735

Kirby (1999b, pp. 202–205; 2007) and includes
suggestions from Schonfeld.
The outline also includes specific sample content based on each of the components of the
Theory of Planned Behavior (TPB; Ajzen &
Madden, 1986) in order to demonstrate how
a theoretical model guides intervention content.

What Works
What Is Promising
The editors of the Encyclopedia of Primary Prevention define empirically evidenced studies
(i.e., what works) as three or more successful
trials of an intervention . . . that either prevents
the dysfunction or promotes the health in individuals as relevant to our topic. Nevertheless, there
is evidence for other interventions and strategies
that – while not meeting the above criteria for
school-aged children – yield considerable
amounts of evidence among other populations
and therefore are widely considered as empirically based. These interventions and strategies
are described in the next section. Meanwhile,
efforts continue to conduct rigorous research on
HIV prevention interventions among school-aged
children.
Thus far, there are no large-scale research projects in the literature that adequately address the
success of HIV prevention interventions among
school-aged children.
The research that does exist is largely descriptive and typically compares “high-risk” children
(e.g., children of HIV + mothers, children of
drug-dependent parents, children in highseroprevalence areas) to age and gender-matched
community controls (e.g., Armistead et al., 1999;
Sigelman, Goldenberg, Siegel, & Dwyer, 1998).
Generally speaking, young people directly
affected by HIV disease tend to have slightly
higher knowledge about the disease and its
sequellae, but few differences in attitudes or
behavior are observed. Schonfeld et al.’s (1995)
study of a program for elementary school children demonstrated that knowledge levels regarding HIV/AIDS can be increased through
classroom-based education, but this study did

736

not target or measure crucial variables known to
be more predictive of behavior (e.g., attitudes
towards prevention, normative support for prevention, self-efficacy for prevention or intentions
to engage in preventive behavior).
Healthy People 2020 (2012) reports goals of
cumulative health education programs for elementary, middle, and senior high school children.
These are commendable goals, but progress
reports from Healthy People 2010 do not bode
well for accomplishing these goals. One Healthy
People 2010 progress report stated that school
health education, especially HIV/AIDS prevention programs, declined in priority. Subsequently,
children in grades K–12 are not receiving
age-appropriate HIV/STD curricula they desperately need (Progress Toward Healthy People
2010 Targets, 2010).
One problem is the dearth of available curricula with proven effectiveness for children
between the ages of 6 and 12. According to
a review by Wolff and Schoeberlein (1999),
those middle schools that do implement any
HIV preventive education at all tend to use
locally developed programs with unproven efficacy. Although the CDC maintains a list of
HIV/STD prevention “Programs that Work”
(Centers for Disease Control and Prevention,
2009), all listed programs are targeted to
older students and thus little formal information is available for developing curricula for
students under the age of 12. Preventive education efforts are further hampered by local control and local decision-making, both of which
are often unsupportive of HIV prevention
efforts that include frank discussions of sexual
issues with young people (Wolff &
Schoeberlein, 1999).
The following outline of an age-appropriate
HIV/STD prevention curriculum is taken partially from Pozen (1995, pp. 249–251) and from
Kirby (1999b, pp. 202–205; Kirby et al. 2007)
and includes suggestions from Schonfeld (2000).
The TPB specifies that intentions to carry out
a behavior are the most proximal predictor of
engaging in the behavior. Intentions, in turn,
may be determined by individuals’ attitudes
towards the behavior, perceptions of subjective

HIV/AIDS During Childhood

normative support for the behavior, and perceptions of behavioral control (PBC) or self-efficacy
with respect to the act in question. This model has
been successfully applied to condom use in
numerous studies, although it is known that for
preteens, intentions are less likely to relate to
behavior and normative influences are more
marked (Johnson & Boynton, 2010).
Kindergarten through third grade (ages 5–8):
In early elementary school, there are two important goals for HIV/STD preventive education.
The first is to reduce anxiety related to AIDS.
Numerous descriptive studies of young children’s views about HIV/AIDS suggest a high
level of fear and misconception and an
overestimate of both the prevalence of
HIV/AIDS and the ease with which one can contract the disease (Schonfeld, 2000). Thus, children should be taught that it is not possible to
contract the disease via casual contact or insect
bites and that only very intimate contact between
two people results in HIV transmission. The
second goal of HIV/STD prevention education
is to lay the groundwork for healthy patterns of
behavior that are linked to later risk reduction.
For example, a basic description of viruses and
bacteria and how they cause disease is important.
Children should understand that usually the body
can fight off these organisms, and sometimes we
need medicines to help, but that there is currently
no medicine available that will help a body
completely “kill” HIV. At this point, it is appropriate to teach children the importance of good
hygiene and of not touching others’ blood or
bodily fluids. An HIV prevention curriculum
should include a drug abuse prevention component, and children at this age can be taught about
the link between the abuse of alcohol and illicit
drugs and the propensity to make bad decisions
regarding one’s health. Further, they can be
taught that injection drug use is one way that the
virus is spread and that they should never touch
discarded needles or syringes. Finally, the link
between personal behavior and health should be
stressed in order to increase self-efficacy.
Children should be taught that it is both their
right and their responsibility to be assertive in
protecting their own health.

HIV/AIDS During Childhood

This is the goal to which TPB content can be
directed. Interventions can include exercises
encouraging positive attitudes towards being
responsible for one’s health, e.g., that it is important and that it is a good thing to do. Telling
children that their parents and teachers believe it
is important for them to take responsibility for
their health can generate normative support. Peer
group discussions of ways in which individuals
can protect their health also promote a strong
descriptive norm for responsibility. Finally,
fostering a sense of general self-respect and
self-esteem is crucial in the development of
a sense of behavioral control over and selfefficacy for protecting one’s health. Finally students can be asked to describe their intentions to
protect their health and give specific examples of
how they will accomplish this.
Fourth and fifth grades (ages 9–10): The goal
of HIV/STD prevention in this age group is to
prepare young people to make decisions with
regard to their participation in sexual and
alcohol/drug use activity. At this stage, it is
appropriate to begin basic sex education, including anatomy and the physiology of reproduction.
Some educators recommend that this introduction to sex education is most effective when
boys and girls are taught separately. Once the
basics of sexual intercourse are explained, children should be taught that this type of intimate
sexual activity is a primary way that HIV and
other sexually transmitted diseases are spread.
The anxiety-reduction component can be
reintroduced at this point both to reinforce earlier
education and to highlight the ways in which HIV
can be spread (e.g., sexual contact) versus the
ways it cannot (e.g., hugging, sharing bathroom
facilities).
More specific information regarding the link
between alcohol and drug abuse and dangers
associated with HIV transmission can be given
at this age. Children should be taught not only
about the transmission of HIV via certain types of
drug use (e.g., sharing needles) but also that the
use of such substances can impede one’s
decision-making abilities and make them less
likely to make healthy choices. An explanation
of the effects of alcohol and illicit drugs on the

737

body and the process of addiction may also be
appropriate. Primary education on the role of
viruses and bacteria in the disease process can
be increased. The role of the immune system can
be made more concrete, and the general effects of
HIV on the immune system can be elucidated.
Children can also be taught about the formation
of antibodies and how HIV screening tests work
via the detection of these antibodies in a person’s
blood. A continuing focus on assertiveness and
responsibility training is also important, as these
young people will soon encounter opportunities
to engage in risky behaviors including alcohol
and substance use.
Behavioral goals to be targeted by TPB intervention content can be more concrete at this
stage, perhaps focusing on the ability to resist
becoming sexually active and to resist involvement in drug and alcohol use. To encourage positive attitudes towards these behaviors, students
can be told to list all the benefits of not being
sexually active and of not being involved in drug
use. Discussion can focus on abstinence as the
most certain way of protecting oneself from HIV
and STD infection. Normative support can again
be generated by discussions about parents’ and
teachers’ beliefs that it is important for young
people to delay intercourse and refrain from
drug and alcohol use. Perceived behavioral control can be enhanced through role plays of ways
to resist peer pressure to engage in sexual activity
and drug or alcohol use. Young people can then
write down or discuss their intentions to delay
sexual activity and avoid substance use.
Sixth through eighth grades (ages 11–13): At
this stage, the HIV/STD preventive education
should be focused heavily on equipping young
people with correct and specific information
regarding HIV/STD transmission and prevention, positive attitudes towards important preventive behaviors such as delaying sexual
intercourse or using condoms consistently, normative support for prevention from peers and
important others, and an enhancement of their
belief in their ability to negotiate risky situations
and engage in safer behaviors. Kirby (1999b,
Kirby et al. 2007, in a review of school sexuality
education programs, emphasized that successful

738

programs incorporated goals that were appropriate to the age of the students. In the case of
11–13-year-olds, depending on the demographic
makeup of the young people, most are probably
not sexually active, so an abstinence-focused
program is most appropriate. However,
a subset of this age group is very likely to
become sexually active during this time frame
(Aarons et al., 2000), so adequate information
about effective condom and contraception use
should also be included. Exercises to enhance
attitudes towards prevention behaviors should
include the generation of benefits of abstinence
and the benefits of condom use if one chooses to
be sexually active. Young people should be
asked to discuss why they believe abstinence or
condom use is important in order to enhance
descriptive normative support for prevention.
While parents are still crucially important as
sources of normative support, in the early teenage years, the focus shifts from parents to peers,
so believing one’s peers think abstinence and/or
condom use is important is likely to heavily
influence behavior. Research with adolescents
across domains of risk behavior consistently
shows a strong association between perception
of peer norms and levels of risk behavior (Kirby,
2002a). In the case of sexual risk behavior, perceived peer norms are strongly related to both
age at first intercourse (Kirby, 2002b) and frequency of condom use (Kirby, 2001).
By the 7th and 8th grades, HIV prevention
education should begin to focus more on specific
information about the proper use of condoms
including a condom demonstration in order to
help young people begin to develop a sense of
behavioral control over this activity. Young people this age are likely to be uncomfortable
handling condoms themselves but should be
shown how to properly apply, remove, and dispose of a condom by a teacher/facilitator. Behavioral control also involves social skills for
negotiating risky situations in a number of
domains. These skills should be fostered in this
age group, ideally using a variety of methods
including role play and rehearsal, written strategies for dealing with particular situations, and
modeling by peers or facilitators of ways to

HIV/AIDS During Childhood

communicate with peers and romantic partners
regarding risk behavior (Kirby, 1999b; Kirby
et al., 2007; Schmiege, Broaddus, Levin, Levin,
& Bryan, 2009). Such skill rehearsal can be
focused on less sensitive areas first (e.g., a peer
tries to get you to try a cigarette) and move on to
more sensitive areas (e.g., a boyfriend tries to get
you to have sexual intercourse) once the former
are mastered. Skill rehearsal is an extremely
effective method for increasing both perceived
self-efficacy and actual ability for dealing with
risky situations. Further, watching peers model
risk reduction during role playing is likely to
further increase normative support for preventive
behavior. Finally, young people should again be
encouraged to think about their particular behavioral goal (e.g., to remain abstinent or to use
condoms consistently if they become sexually
active) and how they can go about achieving
it. Many programs for older adolescents use the
strategy of having young people write down their
behavioral goal and why they chose it in order to
strengthen a sense of commitment to the goal
(cf. “Reducing the Risk” by Kirby, Barth, Leland,
& Fetro, 1991; Schmiege et al., 2009).
Aarons et al. (2000) reported on the effectiveness of an intervention to postpone sexual intercourse among junior high school students. The
program took place in Washington, D.C., and
included the use of a standard of care comparison
group. Health professionals implemented the
program, which included reproductive health
classes, the Postponing Sexual Involvement
Curriculum in the 7th-grade year, and a variety
of educational activities in the 8th-grade year
meant to bolster program effectiveness. There
were large gender differences at baseline in
terms of sexual activity; while 81 % of girls
reported being virgins at baseline, only 44 % of
boys were virgins. The intervention appeared to
have some desired effects for girls, in that significantly more of the intervention girls remained
virgins at the end of the 8th-grade follow-up year
compared to the control group girls. In addition,
intervention girls who reported being sexually
active were significantly more likely to have
used some form of birth control at last intercourse
at all post-intervention measurements. The

HIV/AIDS During Childhood

program appeared unsuccessful with boys, as
there was no difference in intervention versus
control boys’ rates of virginity, attitudes regarding abstinence, or the use of birth control.
Coyle, Kirby, Marin, Gomez, and Gregorich
(2004) reported on the effectiveness of
a preventive intervention to reduce sexual risk
behaviors among middle school adolescents.
This randomized controlled trial took place
in northern California. Health educators
implemented the program, which included
three separate programs for sixth, seventh, and
eighth graders. The sixth-grade curriculum
focused on refusal skills in nonsexual situations.
The seventh-grade curriculum concentrated on
determining personal limits, the consequences
of unprotected sex, and negotiation skills. The
eighth-grade class had an HIV-infected speaker,
had a condom demonstration, and focused on
negotiation skills with a romantic partner.
Unlike the Aarons et al. (2000) program, Draw
the Line/Respect appeared to have significant
results among boys, not girls. Intervention boys
delayed sexual initiation, perceived fewer peer
norms supporting sexual intercourse, had stronger sexual limits, and were less likely to be
a part of a risky sexual situation. The program
appeared unsuccessful with girls.
These studies highlight the importance of tailoring intervention content to the age, maturity,
and gender of the students with whom one is
intervening (cf. Jemmott & Jemmott, 2000;
Pedlow & Carey, 2004). For the girls participating in the Aarons et al. (2000) intervention, the
vast majority of whom were not sexually active,
a focus on postponing sexual activity, while also
providing adequate information about reproductive health, condom use, and contraception,
seemed a successful strategy. For boys participating in the Coyle et al. (2004) program,
a developmentally appropriate progression
through negotiation and practical skills to avert
risky sexual situations seemed a successful strategy. These findings also highlight the potential
necessity of a different program focus for boys
and girls of the same age. A consistent finding
both in the USA and cross-culturally is that boys
initiate sexual activity at a younger age than girls.

739

Formative research on the current sexual activity
level of the population at focus becomes very
important in the determination of the use of an
abstinence-focused or condom use-focused intervention strategy.

Strategies That Do Not Work
While the definitive formula for an effective program has yet to be ascertained, there is some
converging evidence to suggest strategies that
are unlikely to be effective. It is clear that
information-only strategies, while they definitely
increase knowledge related to HIV transmission
and prevention, have little or no effect on actual
risk behavior (Johnson et al., 2011; Kirby,
1999a). This finding is completely consistent
with HIV prevention research among other
populations and is now assumed by virtually all
HIV prevention researchers and practitioners.
The lack of success of a second strategy may
seem somewhat counterintuitive. Although many
people would consider parent–child communication about sexual issues to be an important part of
an overall strategy for reducing sexual risk, studies of such interventions show that “there is no
reasonably simple and robust relationship
between parent-adolescent communication
about sexuality and delay in the onset of intercourse” (Kirby, 1999b, p. 196). The same is true
of the influence of specific parent–child discussion of contraceptive use and HIV/STDs. There
appears to be no clear relationship of such discussion to higher rates of health-protective
behavior, and in fact some studies have shown
that parents who engage in discussions of HIV
and STDs have children who engage in higher
levels of sexual risk behavior (Kirby, 1999b). The
causal direction of that particular relationship is
not clear, and there are serious methodological
limitations involved in research on this
topic. Nevertheless, both parents and adolescents
believe that such discussion is important, and
thus programs should endeavor to improve such
communication where possible. Further, in
a recent study by Blake, Simkin, Ledsky, Perkins,
and Calabrese (2001), parent–child “homework”

740

exercises were designed to reinforce schoolbased sexual risk reduction curricula in a middle
school. Their results suggested that the classroom
curriculum enhanced with parent–child homework assignments resulted in stronger effects on
self-efficacy for refusing high-risk behaviors and
stronger intentions to delay intercourse than did
the classroom curriculum alone. These results are
encouraging, but without more reliable evidence
of effectiveness, the responsibility for teaching
young children HIV/STD preventive behavior
should not be left to parents alone. On a more
positive note, and consistent with problem behavior theory, family connectedness including
warmth, closeness, good parental supervision,
and boundary setting does appear to be related
to the delay of sexual intercourse as well as to
other health-protective behaviors.
Finally, reviews of different preventive interventions for HIV/STD conclude definitively that
abstinence-only interventions – that is, those that
focus explicitly on delaying intercourse (typically until marriage) and only mention condom
and contraceptives in the context of their failure
to completely protect against unwanted pregnancy or STDs – are wholly ineffective. The
weight of the evidence is that such programs fail
to delay the onset of intercourse (Johnson et al.,
2011; Kirby, 2002c). Further, since they give
only passive coverage to ways to make sexual
behavior safer, they also fail to increase condom
and contraceptive use among those who become
sexually active. It has become increasingly obvious that the inclusion of both abstinence and safer
sex content is crucial for program success. The
weight of program time devoted to a focus on
abstinence versus a focus on safer sexual behavior should be determined, as has been reviewed,
by the age and maturity of those who are the
targets of the intervention.

Summary
The best HIV prevention program for young children between the ages of 6 and 12 years of age is
one that integrates HIV prevention into an ongoing health behavior curriculum in schools.

HIV/AIDS During Childhood

Typically, there is not a high dropout rate in this
age group, so interventions implemented in the
school setting are likely to cover the broadest
audience of young people. Yet, placing the burden on the shoulders of elementary educators
brings up the most important barrier to the provision of HIV prevention programs (Schonfeld,
2000). Because of discomfort discussing sexual
issues with children, a lack of training in human
sexuality in general or HIV/STDs more specifically, and fear of reprisal from parents or administrations for explicitly answering frank questions
about sex, teachers are reluctant to participate as
facilitators in HIV prevention programs.
Schonfeld (2000) reviews ways of helping
teachers to become more comfortable addressing
such sensitive topics, including in-service trainings by HIV prevention professionals. It is also
important that teachers are fully supported by
school administrators in their efforts and that
both teachers and administrators be made aware
that parents overwhelmingly support the provision of HIV/AIDS information in schools
(Schonfeld, 2000).
An ideal health behavior curriculum should
include an early and direct focus on individual
responsibility for one’s own health and on the
link between personal choices about health
behavior and health outcomes. Specific content
with regard to drug use and sexual behavior
should be included at age-appropriate intervals,
and techniques to address these behaviors should
be grounded in behavioral science theories (e.g.,
Theory of Reasoned Action/Planned Behavior
and Social Cognitive Theory, used in Jemmott,
Jemmott, & Fong, 1998; Protection-Motivation
Theory used in Stanton et al., 1996; Social Learning Theory used in Kirby et al., 1991) with
proven empirical success in HIV risk reduction
with older adolescents.
As of 2010 the USA had withdrawn Federal
support for ineffective abstinence-only programs
and reattributed $100 million dollars to empirically supported teenage pregnancy prevention
programs (U.S. Department of Health and
Human Services, 2009). The empirical evidence
suggests that this money is well spent. It is absolutely crucial that for every age group HIV/AIDS

HIV/AIDS During Childhood

prevention programs include comprehensive
information on methods of making sexual
behavior safer. Finally, key to the success of
interventions meant to discourage risky sexual
behavior is that they be implemented well before
young people are sexually active. It is far easier to
establish healthy patterns of behavior early on
than to attempt to change risky behaviors once
they have been initiated.

References
Aarons, S. J., Jenkins, R. R., Raine, T. R., El-Khorazaty,
M. N., Woodward, K. M., Williams, R., et al. (2000).
Postponing sexual intercourse among urban junior
high school students – A randomized controlled
evaluation. Journal of Adolescent Health, 27,
236–247.
Ajzen, I., & Madden, T. (1986). Prediction of goaldirected behavior: Attitudes, intentions, and perceived
behavioral control. Journal of Experimental Social
Psychology, 22, 453–474.
Alan Guttmacher Institute (AGI). (2002). In their own
right: Addressing the sexual and reproductive health
needs of American Men. New York: AGI.
Armistead, L., Summers, P., Forehand, R., Morse, P. S.,
Morse, E., & Clark, L. (1999). Understanding of
HIV/AIDS among children of HIV-infected mothers:
Implications for prevention, disclosure, and bereavement. Children’s Health Care, 28, 277–295.
Bandura, A. (1992). A social cognitive approach to the
exercise of control over AIDS infection. In R. J.
DiClemente (Ed.), Adolescents and AIDS:
A generation in Jeopardy (pp. 89–116). Newbury
Park, CA: Sage.
Blake, S. M., Simkin, L., Ledsky, R., Perkins, C., &
Calabrese, J. M. (2001). Effects of a parent–child
communications intervention on young adolescents’
risk for early onset of sexual intercourse. Family Planning Perspectives, 33, 52–61.
Centers for Disease Control and Prevention. (2003).
Sexual behaviors: School health guidelines. Retrieved
January 14, 2011 from http://www.cdc.gov/heal
thyyouth/sexualbehaviors/guidelines/technicalupdate.
htm
Centers for Disease Control and Prevention. (2007). Pregnancy and childbirth. Retrieved January 14, 2011 from
http://www.cdc.gov/hiv/topics/perinatal/index.htm
Centers for Disease Control and Prevention. (2008). Estimated rates of diagnoses of HIV infection among
adults and adolescents, by sex and race/ethnicity,
2008–37 states with confidential name-based HIV
infection reporting. Retrieved January 14, 2011 from
http://www.cdc.gov/hiv/surveillance/resources/reports/
2008report/index. htm

741
Centers for Disease Control and Prevention. (2009). Bestevidence interventions. Retrieved January 14, 2011
from
http://www.cdc.gov/hiv/topics/research/prs/
best-evidence-intervention.htm
Cornman, D. H., Sileo, K., & Johnson, B. T. (2013).
HIV/AIDS during early childhood. In M. Bloom &
T. Gullotta (Eds.), Encyclopedia of primary prevention
and health promotion (2nd ed.). New York: Springer.
Coyle, K. K., Kirby, D. B., Marin, B. V., Gomez, C. A., &
Gregorich, S. E. (2004). Draw the line/respect the line:
A randomized trial of a middle school intervention to
reduce sexual risk behaviors. American Journal of
Public Health, 94, 843–851.
Fishbein, M., & Ajzen, I. (1980). Understanding attitudes
and predicting behavior. Englewood Cliffs, NJ: Prentice-Hall.
Fisher, J. D., & Fisher, W. A. (1992). Changing AIDS-risk
behavior. Psychological Bulletin, 111, 455–474.
Fisher, J. D., & Fisher, W. A. (2000). Theoretical
approaches to individual-level change in HIV risk
behavior. In J. L. Peterson & R. J. DiClemente
(Eds.), Handbook of HIV prevention (pp. 3–55). New
York: Kluwer Academic/Plenum Publishers.
Gilchrist, L. D., & Schinke, S. P. (Eds.). (1985).
Preventing social and health problems through life
skills training. Seattle, WA: University of Washington
Press.
Glanz, K., & Maddock, J. (2000). On judging models and
theories: Research and practice, psychology and public
health. Journal of Health Psychology, 5, 151–154.
Healthy People 2020. (2012). National health promotion
and disease prevention objectives. Washington,
DC: US Department of Health and Human Services.
Retrieved January 14, 2011 from http://healthypeople.
gov/2020/topicsobjectives2020/objectiveslistaspx?
topicid=10.
Jemmott, J. B., & Jemmott, L. S. (2000). HIV risk reduction behavioral interventions with heterosexual adolescents. AIDS, 14, S40–S52.
Jemmott, J. B., Jemmott, L. S., & Fong, G. T. (1998).
Abstinence and safer sex HIV risk-reduction interventions for African American adolescents: A randomized
controlled trial. Journal of the American Medical
Association, 279, 1529–1536.
Jessor, R., & Jessor, S. L. (1977). Problem behavior and
psychosocial development: A longitudinal study of
youth. New York: Academic Press.
Jessor, R., Turbin, M. S., & Costa, F. M. (1998). Protective
factors in adolescent health behavior. Journal of
Personality and Social Psychology, 75, 788–800.
Johnson, B. T., & Boynton, M. B. (2010). Putting attitudes
in their place: Behavioral prediction in the face of
competing variables. In J. P. Forgas, J. Cooper, &
W. Crano (Eds.), The psychology of attitudes: The
Sydney symposium of social psychology (pp. 19–38).
London, UK: Cambridge University Press.
Johnson, B. T., Redding, C. A., DiClemente, R. J.,
Mustanski, B. S., Dodge, B. M., Sheeran, P.,
et al. (2010). A network-individual-resource model

742
for HIV prevention. AIDS and Behavior, 14,
S204–221.
Johnson, B. T., Scott-Sheldon, L. A. J., Huedo-Medina,
T. B., & Carey, M. P. (2011). Interventions to reduce
sexual risk for HIV in adolescents: A meta-analysis of
trials, 1985–2008. Archives of Pediatrics and Adolescent Medicine, 165(1), 77–84. doi:10.1001/
archpediatrics.2010.251.
Kirby, D. (1999a). Reflections on two decades of research
on teen sexual behavior and pregnancy. Journal of
School Health, 69, 89–94.
Kirby, D. (1999b). Sexuality and sex education at home
and school. Adolescent Medicine: State of the Art
Reviews, 10, 195–209.
Kirby, D. (2001). Emerging answers: Research findings to
reduce teen pregnancy. Washington, DC: National
Campaign to Prevent Teen Pregnancy.
Kirby, D. (2002a). The impact of schools and school programs upon adolescent sexual behavior. The Journal of
Sex Research, 39, 27–33.
Kirby, D. (2002b). Antecedents of adolescent initiation of
sex, contraceptive use, and pregnancy. American Journal of Health Behavior, 26, 473–485.
Kirby, D. (2002c). Do abstinence-only programs delay the
initiation of sex among young people and reduce teen
pregnancy? Washington, DC: National Campaign to
Prevent Teen Pregnancy.
Kirby, D., Barth, R. P., Leland, N., & Fetro, J. V. (1991).
Reducing the risk: Impact of a new curriculum on
sexual risk-taking. Family Planning Perspectives, 23,
253–263.
Kirby, D. B., Laris, B. A., & Rolleri, L. A. (2007). Sex and
HIV education programs: Their impact on sexual
behaviors of young people throughout the world. Journal of Adolescent Health, 40, 206–217.
Pedlow, C. T., & Carey, M. P. (2004). Developmentally
appropriate sexual risk reduction interventions for
adolescents: Rationale, review of interventions, and
recommendation for research and practice. Annals of
Behavioral Medicine, 27, 172–184.
Pozen, A. S. (1995). HIV/AIDS in the schools. In
N. Boyd-Franklin & G. L. Steiner (Eds.), Children,
families, and HIV/AIDS: Psychosocial and therapeutic
issues (pp. 233–255). New York: The Guilford Press.
Progress Toward Healthy People 2010 Targets. (2010).
National health promotion and disease prevention
objectives. Washington, DC: US Department of Health
and Human Services. Retrieved January 14, 2011 from
http://www.unaids.org/documents/20101123_Global
Report_Chap2_em.pdf

HIV/AIDS During Childhood
Schmiege, S. J., Broaddus, M. R., Levin, M., Levin, M., &
Bryan, A. D. (2009). Randomized trial of group
interventions to reduce HIV/STD risk and change
theoretical mediators among detained adolescents.
Journal of Consulting and Clinical Psychology, 77,
38–50.
Schonfeld, D. J. (2000). Teaching young children about
HIV and AIDS. Child and Adolescent Psychiatric
Clinics of North America, 9, 375–387.
Schonfeld, D. J., O’Hare, L. L., Perrin, E. C.,
Quackenbush, M., Showalter, D. R., & Cicchetti,
D. V. (1995). A randomized, controlled trial of a school-based, multi-faceted AIDS education program
in the elementary grades: The impact on comprehension, knowledge and fears. Pediatrics, 95, 480–486.
Sigelman, C. K., Goldenberg, J. L., Siegel, C. B., &
Dwyer, K. M. (1998). Parental drug use and the
socialization of AIDS knowledge and attitudes in
children. AIDS Education and Prevention, 10,
180–192.
Stanton, B. F., Li, X., Ricardo, I., Galbraith, J., Feigelman,
S., & Kaljee, L. (1996). A randomized, controlled
effectiveness trial of an AIDS prevention program
for
low-income
African-American
youths.
Archives of Pediatric and Adolescent Medicine, 150,
363–372.
U.S. Department of Health and Human Services. (2009).
The budget for fiscal year 2010. Washington, DC:
Center on Budget and Policy Priorities.
United Nations AIDS. (1997). Integrating HIV/STD
prevention in the school setting: A position paper.
Retrieved January 14, 2011 from http://www.unaids.
org/publications/documents/children/schools/Pos_
Paper_Schools-E. doc
United Nations AIDS. (2009). Epidemic update. Global
report 2010. Retrieved January 14, 2011 from http://
www.unaids.org/documents/20101123_GlobalReport_
Chap2_em. pdf
United Nations AIDS. (2010). Vertical transmission and
maternal mortality. Retrieved January 14, 2011 from
http://www.unaids.org/en/strategygoalsby2015/vertical
transmissionandmaternalmortality/
White, A. C., & Johnson, B. T. (2013). HIV/AIDS during
adolescence. In M. Bloom & T. Gullotta (Eds.), Encyclopedia of primary prevention and health promotion
(2nd ed.). New York: Springer.
Wolff, W. J., & Schoeberlein, D. R. (1999). The status of
middle level HIV/STD education as assessed by state
and local education agencies. Journal of School
Health, 69, 239–242.

Homicide During Childhood

Homicide During Childhood
Laura Kate Corlew
The East-West Center, Honolulu, HI, USA

Introduction
Child homicide is a rare, though devastating, phenomenon that includes a range of violent acts.
Whether perpetrated by a caretaker, stranger, or
peer, child homicide upsets societal values calling
for the protection of our young. Child homicide
follows multiple patterns depending on the age of
the child, the relationship between the perpetrator
and victim, and the purpose or deliberateness of
the killing. For this reason, multiple prevention
efforts are recommended to address the multiple
avenues leading to child homicide.

Definition and Scope
The current child homicide rate in the United
States is 2.3 deaths per 100,000, with 80 %
of the victims aged four or younger
(U.S. Department of Health and Human Services,
Children & Youth and Families, 2010). The US
rate is much higher than other Western countries
(Pritchard & Butler, 2003) and is as much as five
times higher than that of 25 other industrialized
nations combined (Centers for Disease Control
and Prevention [CDC], 1997). This rate, though
low, includes multiple types of child death. Each
will be addressed here.
Filicide and other intrafamilial homicide are
child homicide perpetrated by a caretaker, typically a parent or other close relative. Filicide may
follow multiple patterns of violence. Fatal child
abuse (sometimes referred to as fatal
non-accidental injury) is the most common mechanism for filicide and all child homicide
(Cavanagh, Dobash, & Dobash, 2007). Fatal
child abuse is often preceded by nonfatal abuse
(Baralic et al., 2010; Fujiwara, Barber,
Schaechter, & Hemenway, 2009). In many
cases, the nonfatal abuse has been recorded by

743

hospitals or social services prior to the fatal child
abuse event. Neglect often co-occurs with fatal
child abuse but is rarely the cause of death
(Connell-Carrick, 2003; Sidebotham, Baily,
Belderson, & Brandon, 2011). Neonaticide is
the deliberate killing of a child within 24 h of
its birth (Baralic et al., 2010). Neonaticide is
often associated with an unwanted or secretive
pregnancy. Filicide may also be part of a murder/
suicide event in which a parent or stepparent
takes the life of the child and perhaps the spouse,
followed by suicide (Flynn et al., 2009).
Despite media sensationalism, stranger homicide is far more rare than fatal child abuse.
Stranger homicide follows two main distinct pathways. When perpetrated by adults, stranger homicide is often coupled with sexual assault of the
victim. The perpetrator is most likely to be a single
man with a history of violence and experienced
abuse (Cavanagh, Dobash, & Dobash, 2005).
Child homicide perpetrated by juvenile offenders
(such as juvenile gang homicide) is similarly rare
(Densley, 2011; Douglas & Bell, 2011; Rodway
et al., 2011). The underdevelopment of juveniles’
frontal lobes means they are more impulsive, and
the homicide is more likely to be committed with
a lack of clear intention, compared to adult perpetrators (Heide, Solomon, Sellers, & Chan, 2011).
Stranger homicide also includes mass murders
(e.g., school shootings), which are also extraordinarily rare (Levin & Madfis, 2009). Risk factors
for juvenile homicide perpetration as a singleperson killing or mass murder largely overlap
and will be discussed together.
According to age category, the children at the
highest level of risk for homicide are under age
4, especially children aged 1 and under, and newborn infants (Cavanagh et al., 2005). Recent
increases in infant homicide during the past few
decades are likely due to an increased sensitivity
to violence against children and infants. The
same time period has seen a decrease in accidental deaths reported (Riggs & Hobbs, 2011). Children age 5–14 have the lowest risk. Adolescents
experience an upswing in risk, including threat
from caretakers and other adults as well as from
other adolescents (Adams, Bennion, Openshaw,
& Bingham, 1990).

T.P. Gullotta, M. Bloom (eds.), Encyclopedia of Primary Prevention and Health Promotion,
DOI 10.1007/978-1-4614-5999-6, # Springer Science+Business Media New York 2014

744

There are mixed results as to whether females
or males are more likely to die from homicide in
younger age groups (Adams et al., 1990; Baralic
et al., 2010; Burgess & Roberts, 1996; Cavanagh
et al., 2007), though males are at a much higher
risk of homicide perpetration and victimization
than females in the adolescent years (Adams
et al., 1990). Younger children are most
likely to be killed inside the family and older
children are most likely to be killed outside the
family (Cavanagh et al., 2005). In all age
brackets, African American children are more
likely to die than Caucasian children from homicide (Adams et al., 1990; Bernard, Paulozzi, &
Wallace, 2007).

Theories
There are two major intervention pathways to
preventing childhood homicide. One is to utilize
early intervention strategies to prevent the development of violent and aggressive tendencies,
thereby reducing risk of homicide perpetration.
The perpetrators of child homicide, including
fatal child abuse and stranger homicide, were
often subjected to multiple risk factors in their
early lives. Childhood abuse, including sexual
abuse, is positively correlated with later perpetration of violent crime up to and including homicide (Brewer-Smyth & Burgess, 2008; Burgess &
Roberts, 1996; Cavanagh et al., 2005; Friday,
1995). Child abuse is therefore correlated with
both risk of homicide and potential to commit
homicide. Consistent with attachment theory,
children who are abused, have a high number of
placements in foster care, and have other insecure
relationship attributes with their parents or caregivers, will have a higher level of risk for aggression or violence later in life (Douglas & Bell,
2011).
From a developmental perspective, violence
and aggression follow two main trajectories:
early-onset trajectory and late-onset trajectory
(Douglas & Bell, 2011). The early-onset trajectory is typified by violence, aggression, and other
behavior problems beginning in early childhood.
Early-onset violent offenders tend to commit

Homicide During Childhood

more crimes, including crimes that are more serious, and tend to commit crimes for a longer
period of their life. Early-onset offenders often
follow a pattern of escalating violence. The lateonset trajectory is typified by an absence of violence until adolescence. Violent activity peaks at
age 16 and typically declines by age 20. In both
early-onset and late-onset trajectories, most
offenders will abruptly end their violent offenses
as they transition into adulthood and their frontal
lobes reach full development. As of yet, there are
no screening tools available to identify which
juvenile violent offenders in either trajectory
will continue to offend into adulthood nor which
juvenile violent offenders are at the highest risk
for perpetrating homicide. As Douglas and Bell
(2011) note, “Risk factors are not predictive
factors due to protective factors” (p. 208). Family, neighborhood, and other situational factors
influence outcomes in both positive and
negative ways.
The second major theoretically derived pathway for childhood homicide prevention is to
intervene in contexts in which there is an immediate risk of homicide. Fatal child abuse is commonly preceded by nonfatal abuse. This abuse
often takes the form of violent punitive discipline, and very often the intention of the perpetrator in the fatal child abuse event was to harm
the child but not to kill the child. In a study of
male perpetrators of child abuse, Cavanagh
et al. (2007) found that in cases of caretaker
fatal child abuse, the caretaker often had unreasonable expectations of the child’s capacity to
self-regulate behaviors and a low tolerance for
normal childhood behaviors. These caretakers
also overestimated their own child care abilities
and frequently turned to violence as punishment
during child care. Fatal child abuse tends to occur
in immediate response to a “trigger,” such as
a child who will not stop crying. The perpetrator
responds violently with the intention of forcibly
disciplining or silencing the child. In most cases
of fatal child abuse, this pattern of trigger and
response has occurred before in which the child
was harmed but not killed. The intention during
the fatal abuse event was no different than previous abuse events.

Homicide During Childhood

Fatal child abuse should therefore be distinguished from stranger homicide by adults and
juveniles. In many cases, stranger homicide by
adults includes homicidal intention, possibly for
the purpose of covering up a sexual assault
(McCann, 1995; Zagar, Busch, Grove, & Hughes,
2009). Many of the incarcerated perpetrators of
nonfamilial child homicide had previous sexual
assault convictions, showing a pattern of behavior distinct from perpetrators of fatal child abuse
(Cavanagh et al., 2005). Though patterns of violent aggression are shared, the type of violence in
the pattern contains different motives and is not
relational to the victim. The potential victim pool
is much wider. Interventions can only focus on
potential perpetrators based on previous convictions; a potential victim would be difficult at best
to determine.
Juvenile homicide offenders are most likely to
be male and are most likely to commit homicide
impulsively during an altercation. The victims
are also most likely to be males, within a peer
age range. Victims are least likely to be a family
member and most likely to be a stranger,
followed by an acquaintance (Heide et al.,
2011). Though patterns of violent or aggressive
behavior may be apparent, there is rarely a pattern
of violence with the victim. Interventions focused
on immediate risk of homicide must therefore
focus on potential perpetrators based on previous
behaviors or convictions.

Research
Because childhood homicide is so rare, exploring
the effectiveness of preventions can be difficult
(Douglas & Bell, 2011). Longitudinal analyses of
aggregated statistics are used to show change in
incidence rates over time (Adams et al., 1990).
Unfortunately, archival databases on child homicides are often prone to misreporting. During
active investigations, local or state databases
may record child homicides as accidental deaths
or accidental deaths as child homicides, or fields
may be left blank. The CDC’s National Violent
Death Reporting System has a high accuracy rate;
archival research often turns to this database or

745

others that are highly correlated with it (Barber &
Hemenway, 2011). Archival research of this
nature can show general trends in child homicide
at societal (CDC, 1997; Pritchard & Butler, 2003)
and regional (Lester, 1993) levels, giving a broad
overview of the effectiveness of popular
interventions.
More targeted studies mine archival records
reporting on homicide events to analyze the number and category of deaths, demographic information of victims and perpetrators, victim
relationship to perpetrator, and cause of death
and injury (Baralic et al., 2010; Rodway et al.,
2011). Such studies explore patterns of risk which
can then be addressed in prevention efforts. Other
approaches include studying perpetrators of
homicide in qualitative or quantitative studies
with prison inmates to search for similarities
among event characteristics or perpetrator characteristics (Brewer-Smyth & Burgess, 2008;
Cavanagh et al., 2007).
In community-level studies, epidemiology
and other public health strategies can map
community-level risk and protective factors
(Douglas & Bell, 2011; Jason, 1984). Not only
does this approach allow for an exploration of
patterns in the homicide event to inform prevention efforts, but it further can be used to assess the
real-world effectiveness of local preventions that
have been put into place. A public health
approach in research is particularly beneficial
when tied to the evaluation of prevention efforts
that are based from a hospital setting. Case studies of prevention efforts evaluate the intervention
itself, the participant outcomes, and regional
impacts of the prevention’s implementation
(Douglas & Bell, 2011; Hicks & Gaughan, 1995).

Overview of Strategies
Explorations of the patterns and categories of
child homicide have clearly shown that fatal
child abuse is the most common type of child
homicide. While fatal child abuse is not always
associated with previous instances of nonfatal
abuse (Hicks & Gaughan, 1995), it is most commonly reported as a final incident within a pattern

746

of violence between perpetrator and victim
(Cavanagh et al., 2005, 2007; Finkelhor &
Jones, 2006). Therefore, a major strategy in
preventing child homicide is to address instances
of child abuse. Child abuse can be addressed
through primary prevention efforts to prevent
any abuse from occurring or as a secondary prevention measure to prevent child abuse from
recurring and potentially escalating into
homicide.
Prevention efforts may focus on addressing
known high-risk populations, such as children
under the age of five living in low-income areas
(Birken, Parkin, To, Wilkins, & Macarthur, 2009)
or parents who have shown a tendency toward
abusive discipline (Cavanagh et al., 2007). Poverty and other risk factors often co-occur with
violence, both in terms of current risk of victimization and future risk of perpetration. Risk factors that correlate with violence, such as harsh
parenting and exclusion from school, should be
addressed to prevent the outcomes associated
with cumulative risk (Friday, 1995; Hill-Smith,
Hugo, Hughes, Fonagy, & Hartman, 2002;
Rutter, 1979). To prevent perpetration of violence in both juveniles and adults, interventions
should address mental health issues that often
co-occur with violence. In adults, psychiatric
issues such as depression and personality disorder are highly associated with homicide offenders
(Falkov, 1997; Finkelhor & Jones, 2006; Reder &
Duncan, 1997). Mental health issues such as
ADHD and major depressive disorder are commonly linked to violent youth, including juvenile
homicide offenders (Douglas & Bell, 2011). Psychopathic traits in violent or aggressive youth
should also be assessed (Lindberg et al., 2009).
Substance abuse also commonly co-occurs
with violent offenses, including homicide, in
both juveniles and adults. Direct interventions
targeting drug users and indirect interventions
seeking to lower overall drug use rates in
a community or region are both appropriate strategies for reducing this risk. Similarly, juvenile
and adult homicide offenders often show patterns
of violent or aggressive behaviors, as well as
general offense arrests, prior to the homicide
event. Indicated prevention measures addressing

Homicide During Childhood

individuals with these risk factors for homicide
perpetration may be appropriate when there are
children in their lives. Finally, addressing general
community risk factors, such as gang activity,
crime, drug use, and community disorganization,
is advised. Improving support services and other
protective factors in the lives of potential victims
and perpetrators can reduce general levels of risk
(Douglas & Bell, 2011).

What Works
The editors of the Encyclopedia of Primary Prevention require that the empirical research in this
section include only interventions with
documented success in three or more trials.
Given the relative rarity of childhood homicide
and the social complexities of the identified risk
factors, a search of the literature did not yield
results that meet these criteria. However,
a significant amount of promising research does
exist in the field of child homicide prevention and
will be discussed in the next section.

What Is Promising
Effective and comprehensive child homicide prevention interventions often operate through multiple agencies working in collaboration with one
another to address risk factors and protective
factors at multiple ecological levels (Douglas &
Bell, 2011; O’Connell, Boat, & Warner, 2009;
Rodway et al., 2011). Such interventions are
often catered toward general prevention of violence against children rather than specifically
child homicide. Because child homicide is so
rare an occurrence, many programs instead
focus on preventing child abuse at individual,
family, social, and community levels. With
a reduction in child abuse in a community
comes a reduction in abuse culminating in fatality. Such interventions include multiple “staples”
associated with reducing risk factors in a family
or community and promoting protective factors.
This includes increasing individual and family
connectedness to social supports, accessing

Homicide During Childhood

resources, and addressing instances of trauma.
Risk factors specifically associated with homicide perpetrators include early childhood trauma,
developmental failure, interpersonal failure or
weak social ties, antisocial behavior, and poor
executive function (Burgess & Roberts, 1996;
Cavanagh et al., 2005; Douglas & Bell, 2011;
Hughes, Zagar, Busch, Grove, & Arbit, 2009;
Zagar et al., 2009). Interventions addressing
these risk factors reduce perpetration of violence
later in life, thereby having an indirect impact on
child homicide.
It should be noted that interventions
addressing such risk factors are beneficial to
many people in addition to those at risk for
becoming a victim or perpetrator of child
homicide. Due to the large number of negative
outcomes associated with these risk factors, preventions designed to address them can be considered “no regrets” interventions. Over time, they
are likely to reduce childhood homicides in
a community and/or directly prevent a child
homicide in a family. However, these interventions are beneficial to society regardless and can
therefore be implemented in connection with
a wide variety of prevention and promotion
programs.
Several interventions have been tied directly
to the prevention of fatal child abuse in a family
or community. One of the most successful and
commonly implemented is that of the domestic
violence shelter (Burgess & Roberts, 1996). Shelters and other protective services provide safety
to women who are victims of domestic violence
and their children, thereby reducing the immediate risk of fatal child abuse and other child homicide. These programs are particularly effective in
preventing abuse and homicide, as well as promoting safety, when combined with services to
increase self-sufficiency. An opening of economic and social opportunities increases the protective factors available in the long term which
reduce the possibility of child homicide once the
protective services are no longer utilized. In
a review of preventions relating to child abuse,
Burgess & Roberts also note that foster care
placement is commonly used and may help prevent fatal child abuse. Unfortunately, multiple

747

placements in the foster care system cause instability during the child’s development, which is
a risk factor that increases the likelihood that the
protected child may later become a perpetrator of
violence.
Parenting interventions for new parents in
high-risk populations, including teen parents and
parents in high-risk neighborhoods, have also
shown success in preventing fatal child abuse
(Cavanagh et al., 2007; Douglas & Bell, 2011).
These interventions typically take the form of
parenting classes in a hospital (or high school for
the case of teen parents). The classes discuss new
infant care, dealing with triggers for violence
(babies who will not stop crying, wetting the bed,
unrealistic expectations of discipline or obedience
for very young children, etc.), and expectations for
infant and child behavior. These classes may also
focus on appropriate forms of discipline, including
alternatives to “frustration punishment” that is
commonly associated with fatal child abuse
(Cavanagh et al., 2007). For example, one such
hospital intervention showed a 47 % decrease in
child head injuries associated with abusive care in
the hospital region but not in adjacent regions
(Fujiwara et al., 2009).
New parent intervention classes may or may
not be conducted jointly with home nurse visitation programs, which are also successful in child
abuse and homicide prevention (Burgess &
Roberts, 1996). Nurses make periodic visits to
the homes of infants or small children to assess
the health of the child, family, and environment.
The nurses will also offer guidance, lessons, supports, and assistance in accessing resources to the
family. In addition to reducing abuse, violence,
and drug use, home nurse visitation programs
have been shown to increase intellectual functioning and ameliorate the negative impacts of
poverty (Fujiwara et al., 2009). However, neighborhood effects such as community poverty and
lack of employment opportunities may counteract the benefits accrued by home nurse visitation
programs (Douglas & Bell, 2011).
Prevention efforts also take the form of
preventing the escalation of violent or aggressive
tendencies to reduce the risk of later homicide
perpetration. In the case of gang violence and

748

other adolescent violence, early interventions
that are most successful work within
a comprehensive model to address multiple risk
and protective factors, such as parental supervision, peer interactions, community connectedness, or social-emotional learning (Douglas &
Bell, 2011; Friday, 1995). These interventions
will include individual and systemic aspects to
target youth who have shown aggressive behavior while simultaneously reducing normative violence in a community (Densley, 2011; Rodway
et al., 2011). For all types of violence, early
interventions may be provided through school
health programs or community support systems
and agencies (Friday, 1995).
Given the multiple categories of victimization
within the purview of child homicide, the best
comprehensive prevention approach would
include multiple avenues of prevention. Especially because child homicide is so rare, effective
preventions should address the patterns of behavior that often culminate in child homicide. For
example, neglect is very rarely a cause of death,
but it is an indicator of risk for fatal child abuse
(Connell-Carrick, 2003). Interventions that
address instances of child maltreatment, including abuse and neglect, can prevent the escalation
of child maltreatment into child fatality. Another
correlate that ought to be addressed is that of
undereducation and underemployment, which
are both risk factors for male homicide offenders
(Cavanagh et al., 2007). Improving the quality
and standard of life in communities and specifically for those who are at high risk for perpetration of violence reduces risk for violence and may
in fact increase factors that protect against it.
Interventions aimed at increasing protective
factors are also recommended (Douglas & Bell,
2011). Such interventions should address multiple ecological levels from high-risk individuals
and families to neighborhoods and schools. Individual and community-level protective factors
that reduce risk for violence perpetration include
positive peer interactions, social connectedness,
supportive and sufficient parental monitoring,
and community involvement. Risk factors that
may be addressed in associated interventions
include aggressive behaviors and an intolerant

Homicide During Childhood

attitude to deviance. Some evidence also exists
that an increase in the availability of birth control
can reduce unwanted children that may become
victims of homicide, especially neonaticides
associated with secretive pregnancies (Finkelhor
& Jones, 2006).
Various psychiatric issues are associated with
violence perpetration, up to and including homicide. Connections between psychiatric services,
health-care providers, and social service agencies
could potentially address risk. Parents who are
receiving psychiatric services should be
connected to health and human services to help
reduce the risk to their children and increase their
social supports and access to other resources, as
well as to develop collaborative communication
and services between various providers who
work with these individuals (Falkov, 1997;
Reder & Duncan, 1997).
Policy changes may also have a positive
impact on the rates of child homicide
(Finkelhor & Jones, 2006). Though in many
cases the weapon that was the cause of death
were the perpetrator’s hands, guns are also highly
employed. Gun law changes over the years have
been shown to reduce homicides in general,
although little research has been done on their
impact on fatal child abuse. There is also evidence to suggest that changes in drug laws can
reduce the general levels of homicide, although
again little research has been done linking policy
changes specifically to child homicide.
Stranger homicide may be addressed most
effectively though policy changes. Although the
early interventions to prevent later violence perpetration discussed above would apply to perpetrators of stranger child homicide, there are few to
no indicators that could possibly be employed to
connect a potential perpetrator with a potential
victim. The anti-stalking laws that have been
effective in dissuading stalking behaviors that
may culminate in a physical or sexual assault of
adults may be adapted at the state level to fit the
unique characteristics inherent in cases with child
victims. For example, definitions of threat and
who can make claims of stalking behavior (e.g.,
parent claim versus self-claim) can be adapted to
protect child victims of stalking who may have

Homicide During Childhood

been targeted for assault (McCann, 1995).
Finally, incarceration may prove to be among
the most effective methods to prevent stranger
homicide. A perpetrator of child sexual assault
and homicide who has been imprisoned is
prevented from perpetrating similar crimes with
other children (Finkelhor & Jones, 2006).

What Does Not Work
In the quest to eradicate juvenile homicide
offense, a number of tactics have been employed
to prevent violence and gang activity. Gang suppression is widely used and is not effective
(Densley, 2011; Douglas & Bell, 2011). Gang
suppression includes interventions meant to
squash gang activity by assigning extreme punishment for minor offenses. For example,
a juvenile caught with a weapon may be incarcerated even without actually perpetrating violence. Jail sentences for such activities do not
deter others from conducting the activity, do not
deter gang involvement, do not deter violence,
and also do not address the demonstrated issue –
how the youth obtained the weapon and why they
felt compelled to carry it (Densley, 2011). In
addition, incarceration in prisons and juvenile
detention facilities has been demonstrated to
actually increase gang involvement. Juvenile
offense is better addressed through the multilevel
interventions described above.
Another folly in child homicide prevention is
to address “risk markers” that are not “risk factors” (Douglas & Bell, 2011). For example, race
is highly correlated with child homicide for both
victims and perpetrators. African American children are at much greater risk than their Caucasian
counterparts. However, the risk does not stem
from their race; it stems from risk factors that
disproportionately affect African Americans in
this country. Low socioeconomic status,
undereducation, underemployment, and social
fragmentation are risk factors that can increase
the possibility of child homicide through
a cumulative risk effect. Race in and of itself
does not contribute to risk for or protection from
child homicide. Interventions that target

749

populations based on risk markers may miss the
true factors at play. For example, in confidential
surveys, adolescents reported the same rates of
committing serious violent offenses with no correlation to their race (Office of the Surgeon General, 2001). African American youths report
a proportionate level of violent activity, but are
arrested at an extremely disproportionate rate.
That violence escalates to homicide at higher
levels has to do with associated risk and protective factors rather than race itself.

Summary
Future research in child homicide prevention will
focus on the three distinct categories of child
homicide perpetration: fatal child abuse, adult
stranger homicide, and juvenile homicide
offense. Fatal child abuse research will continue
to explore patterns and similarities between perpetrators, victims, the homicide event including
triggers and context, and the risk factors associated with perpetration of violence and homicide.
Adult stranger homicide will explore stalking and
repeat offenders of child sexual assault and child
homicide. Juvenile homicide offense research
will explore the pathways to violence, the triggers
or altercations that lead to homicide, as well as
gang and violent youth interventions that effectively prevent violent offense.
With all types of child homicide, early intervention strategies at the individual, family, and
community levels can reduce risk of both homicide perpetration and homicide victimization. In
addition, early intervention strategies for child
homicide can cross over widely with other early
intervention projects. Child homicide research
will benefit from collaboration with other risk
reduction and protective factor promotion interventions. The rarity of child homicide means that
widespread prevention and promotion interventions with numerous potentially beneficial outcomes can have a positive impact on child
homicide rates, while interventions focused on
preventing child homicide can produce other beneficial outcomes as well. Aggregated studies of
incidence over time can help connect child

750

homicide prevention with research in other social
issues. Case study research of targeted interventions will also connect child homicide prevention
with other positive social outcomes.

References
Adams, G. R., Bennion, L. D., Openshaw, D. K., & Bingham, C. R. (1990). Windows of vulnerability: Identifying critical age, gender, and racial differences
predictive of risk for violent deaths in childhood and
adolescence. Journal of Primary Prevention, 10(3),
223–240.
Baralic, I., Savic, S., Alempijevic, D. M., Jecmenica,
D. S., Sbutegal-Milosevic, G., & Obradovic, M.
(2010). Child homicide on the territory of Belgrade.
Child Abuse & Neglect, 34, 935–942.
Barber, C., & Hemenway, D. (2011). Too many or too few
unintentional firearm deaths in official U.S. mortality
data? Accident Analysis and Prevention, 43, 724–731.
Bernard, S. J., Paulozzi, L. J., & Wallace, L. J. D. (2007). Fatal
injuries among children by race and ethnicity – United
States, 1999–2002. Morbidity and Mortality Weekly
Report. Surveillance Summaries, 55(S S05), 1–16.
Birken, C. S., Parkin, P. C., To, T., Wilkins, R., &
Macarthur, C. (2009). Neighborhood socioeconomic
status and homicides among children in urban Canada.
Pediatrics, 123(5), e815–e819.
Brewer-Smyth, K., & Burgess, A. W. (2008). Childhood
sexual abuse by a family member, salivary cortisol,
and homicidal behavior of female prison inmates.
Nursing Research, 57(3), 166–174.
Burgess, A. W., & Roberts, A. R. (1996). Family violence
against women and children: Prevalence of assaults
and fatalities, family dynamics, and intervention.
Crisis Intervention, 1996(3), 65–80.
Cavanagh, K., Dobash, R. E., & Dobash, R. P. (2005).
Men who murder children inside and outside the family. The British Journal of Social Work, 35(5),
667–688.
Cavanagh, K., Dobash, R. E., & Dobash, R. P. (2007). The
murder of children by fathers in the context of child
abuse. Child Abuse & Neglect, 31(7), 731–746.
Centers for Disease Control and Prevention. (1997). Rates
of homicide, suicide, and firearm-related death among
children – 26 industrialized countries. Journal of the
American Medical Association, 277, 704–705.
Connell-Carrick, K. (2003). A critical review of the empirical literature: Identifying correlates of child neglect.
Child and Adolescent Social Work Journal, 20(5),
389–425.
Densley, J. A. (2011). Ganging up on gangs: Why the gang
intervention industry needs an intervention. British
Journal of Forensic Practice, 13(1), 12–23.
Douglas, K., & Bell, C. C. (2011). Youth homicide prevention. Psychiatric Clinics of North America,
34, 205–216.

Homicide During Childhood
Falkov, A. (1997). Adult psychiatry – A missing link in the
child protection network: A response to Reder and
Duncan. Child Abuse Review, 6, 41–45.
Finkelhor, D., & Jones, L. (2006). Why have child maltreatment and child victimization declined? Journal of
Social Issues, 62(4), 685–716.
Flynn, S., Swinson, N., While, D., Hunt, I. M., Roscoe, A.,
Rodway, C., et al. (2009). Homicide followed by suicide: A cross-sectional study. The Journal of Forensic
Psychiatry & Psychology, 20(2), 306–321.
Friday, J. C. (1995). The psychological impact of violence
in underserved communities. Journal of Health Care
for the Poor and Underserved, 6(4), 403–409.
Fujiwara, T., Barber, C., Schaechter, J., & Hemenway, D.
(2009). Characteristics of infant homicides: Findings
from a U.S. multisite reporting system. Pediatrics,
124, e210–e217.
Heide, K. M., Solomon, E. P., Sellers, B. G., & Chan,
H. C. O. (2011). Male and female juvenile
homicide offenders: An empirical analysis of
U.S. arrests by offender age. Feminist Criminology,
6(1), 3–31.
Hicks, R. A., & Gaughan, D. C. (1995). Understanding
fatal child abuse. Child Abuse & Neglect, 19(7),
855–863.
Hill-Smith, A. J., Hugo, P., Hughes, P., Fonagy, P., &
Hartman, D. (2002). Adolescents murderers: Abuse
and adversity in childhood. Journal of Adolescence,
25, 221–230.
Hughes, J. R., Zagar, R. J., Busch, K. G., Grove, W. M., &
Arbit, J. (2009). Looking forward in records of youth
abused as children: Risks for homicidal, violent, and
delinquent offenses. Psychological Reports, 104,
77–101.
Jason, J. (1984). Centers for Disease Control and the
epidemiology of violence. Child Abuse & Neglect, 8,
279–283.
Lester, D. (1993). The regional variation of suicide and
homicide in the USA and Taiwan. Crisis, 14(3),
126–128.
Levin, J., & Madfis, E. (2009). Mass murder at school and
cumulative strain. American Behavioral Scientist,
52(9), 1227–1245.
Lindberg, N., Laajasalo, T., Holi, M., Putkonen, H.,
Weizmann-Henelius, G., & Hakkanen-Nyholm, H.
(2009). Psychopathic traits and offender characteristics –
A nationwide study consecutive sample of homicidal
male adolescents. BMC Psychiatry, 9(18), 1–11.
McCann, J. T. (1995). Obsessive attachment and the victimization of children: Can antistalking legislation
provide protection? Law & Psychology Review, 19,
93–112.
O’Connell, M. E., Boat, T., & Warner, K. E. (Eds.).
(2009). Preventing mental, emotional and behavioral
disorders among young people: Progress and possibilities. Washington, DC: National Academies Press.
Office of the Surgeon General. (2001). Youth violence:
A report of the Surgeon General. Rockville, MD:
Department of Health and Human Services.

Homicide During Childhood
Pritchard, C., & Butler, A. (2003). A comprehensive study
of children and adult homicide rates in the USA and
the major western countries 1974–1999: Grounds for
concern? Journal of Family Violence, 18(6), 341–350.
Reder, P., & Duncan, S. (1997). Adult psychiatry –
A missing link the in the child protection network:
Comments on Falkov’s ‘Fatal child abuse and parental
psychiatric disorder’. Child Abuse Review, 6, 35–40.
Riggs, J. E., & Hobbs, G. R. (2011). Infant homicide and
accidental death in the United States, 1940–2005:
Ethics and epidemiological classification. Journal of
Medical Ethics, 37, 445–448.
Rodway, C., Norrington-Moore, V., While, D., Hunt, I. M.,
Flynn, S., Swinson, N., et al. (2011). A populationbased study of juvenile perpetrators of homicide in
England and Wales. Journal of Adolescence, 34, 19–28.
Rutter, M. (1979). Protective factors in children’s
response to stress and disadvantage. In M. W. Kent &

751
J. E. Rolf (Eds.), Primary prevention of psychopathology: Social competence in children (pp. 49–74). Hanover, NH: University Press of New England.
Sidebotham, P., Baily, S., Belderson, P., & Brandon, M.
(2011). Fatal child maltreatment in England,
2005–2009. Child Abuse & Neglect, 35, 299–306.
U.S. Department of Health and Human Services, Administration on Children, Youth and Families. (2010).
Child maltreatment 2008. Washington, DC: U.S.:
Government Printing Office. Retrieved October
27, 2012, from http://archive.acf.hhs.gov/programs/
cb/pubs/cm08/cm08.pdf
Zagar, R. J., Busch, K. G., Grove, W. M., & Hughes, J. R.
(2009). Summary of studies of abused infants
and children later homicidal, and homicidal,
assaulting
later
homicidal,
and
sexual
homicidal youth and adults. Psychological Reports,
104, 17–45.

752

Injury Prevention During Childhood
Kristi Alexander and Nicole Lightman
California School of Professional Psychology,
Alliant International University, San Diego,
CA, USA

Introduction
Unintentional injuries are among the leading
causes of death and disability for children
between the ages of 1 and 20 years worldwide
(Center for Disease Control and Prevention
[CDC], 2009; World Health Organization
[WHO], 2008). In the USA, Canada, and most
of Europe, unintentional injuries result in more of
the fatalities to children over 1 year of age than
any other cause, accounting for over a third of all
childhood deaths (Vincenten, 2006). Most of
the fatal injuries to children around the world
result from motor vehicle accidents, falls,
burns, poisonings, and drownings, with low- and
middle-income countries having the highest
rates (Harvey, Towner, Peden, Soori, &
Bartolomeos, 2009). However, child injury
remains a significant problem in high-income
countries, such as the USA and Canada, where
unintentional injuries account for more than
40 % of child deaths (WHO, 2008).
While it is commonly believed that most injuries are preventable, the multiple factors that
contribute to injury rates impede the development and implementation of effective prevention
programs. Unfortunately, across the world, the
prevention of injuries has been thwarted by
a variety of factors, the least of which has been
awareness (Peden, 2008). In addition, the perception that injuries are the result of fate or “bad
luck” further impedes progress in developing
and
implementing
effective
prevention
(Morrongiello & Dayler, 1996; Morrongiello &
House, 2004). In 2008, WHO published a report
outlining prevention efforts for the five leading
causes of injury deaths: road injuries (pedestrian,
passenger, or driver), drowning, poisoning,
burns, and falls. This WHO report represents

Injury Prevention During Childhood

one of the first efforts to illuminate the global
significance of child injury and attempts to
reduce the incidence of injuries.

Definitions and Scope
Unintentional injuries are defined as unplanned
events that result in physical damage to persons
when energy is transferred to them or when they
are deprived of essential elements (e.g., oxygen)
(WHO, 2008). Consequently, injuries sustained
from war or child abuse are not considered to be
unintentional, although some debate has emerged
around this definition (Peterson & Brown, 1994).
In the USA alone, more than 12,000 children
(0–19 years) die each year due to an unintentional
injury, and over nine million children sustain
nonfatal injuries that require emergency treatment (CDC, 2009). Males experience almost
twice as many fatal unintentional injuries as
females in all childhood age groups (CDC,
2009). Additionally, boys ages 1–19 are 9 %
more likely to sustain nonfatal unintentional injuries than girls the same age (CDC, 2009; Currie &
Hotz, 2004). The leading cause of nonfatal
unintentional injuries is falls (50.4 %), with
2.8 million children visiting the emergency
room each year as a result of a fall (CDC, 2009;
LeBlanc et al., 2006).
Because of the pervasive impact of children’s
unintentional injuries, prevention has become an
area of increasing focus. The public health model
defines prevention as the avoidance of injury or
the control of injury if it occurs (Freire & Runyan,
2006). This model defines the levels of influence
as primary, secondary, or tertiary. Primary prevention is focused on the prevention of new injuries, secondary prevention aims to reduce the
severity of injuries, and tertiary prevention refers
to the avoidance of future injury events. In addition to the level of intervention, the specific strategy employed may be defined as passive or
active. Passive prevention refers to interventions
that require no action from an individual to prevent injury. Historically, this type of injury prevention has been legislatively mandated and
environmentally focused and has been very

T.P. Gullotta, M. Bloom (eds.), Encyclopedia of Primary Prevention and Health Promotion,
DOI 10.1007/978-1-4614-5999-6, # Springer Science+Business Media New York 2014

Injury Prevention During Childhood

effective in reducing specific types of injuries
(Christoffel & Gallagher, 1999). For example,
legislation requiring the packaging of medicine
in child-resistant containers has been effective in
reducing, although not eliminating, poisoning
deaths in the USA and Sweden (Assargaard &
Sjoberg, 1995; Walton, 1982). Similarly,
environmental changes, such as nonflammable
children’s pajamas, have been effective in
reducing burn injuries; however, the scope of
passive prevention interventions is often limited
by the complexity of the interacting factors that
increase children’s risk for injury (Finney et al.,
1993).
In contrast to passive prevention, active
prevention requires participation from others
for the safety benefits to be realized. Buckling
a child into a car seat, using helmets while
bicycling, and supervising children swimming
in a pool are all examples of active prevention.
Unfortunately, because this type of prevention
requires action every time for it to be effective,
consistent implementation is often derailed by
children and their caregivers who may decide
to forgo the bike helmet or seat belt “just this
one time.”
The scope of the child injury problem is not
limited to the serious physical and psychological
consequences for the victims. Parents of children
who have experienced unintentional injuries are
at risk for psychological problems such as
depression, anxiety, and post-traumatic stress
disorder, as well as financial difficulties (Hall
et al., 2006; LeBrocque, Hendrikz, & Kenardy,
2010; Meiser-Stedman, Yule, Dalgleish, Smith, &
Glucksman, 2006; Osberg, Kahn, Rowe, &
Brooke, 1996). Clearly, childhood injury has
a major impact on children, families, and society
(Harvey et al., 2009).

Theories
Although many different theoretical models have
been applied to health behaviors, few have been
applied to the childhood injury prevention
(Trifiletti, Gielen, Sleet, & Hopkins, 2005). One
of the most frequently cited models has been the

753

Haddon Matrix (Freire & Runyan, 2006). The
Haddon Matrix may be used to identify potential
points of intervention across phases of an injury
event (pre, during, and post) as well as the characteristics of the host, agent, and environment
that may increase risk. Specifically, Haddon’s
model implies that injuries occur when there is
a transfer of energy from an agent (hazard) to
a host (victim). As such, Haddon and Baker
(1981) identified ten countermeasures to impede
this process that focus primarily on reducing contact with the agent or reducing the amount of
energy an agent releases. For example, burns
result when the host (a child) is exposed to an
agent (space heater) in an environment
(the home). According to this model, prevention
may impact any one of these variables and realize
a decrease in injury rates (Haddon & Baker,
1981). Indeed, designs of space heaters that interrupt power when they are knocked over would
theoretically decrease injuries to children. Inherent to the model is consideration of the characteristics of the host, such as activity level, gender,
and economic status, which may increase injury
risk. Several researchers have argued that not
only are the characteristics of the child important
in developing effective prevention but that the
“host’s” parents or caregivers play a major role
in injury prevention (Morrongiello, Klemencic,
& Corbett, 2008; Tsoumakas, Dousis, Mavridi,
Gremou, & Matziou, 2009).
Another social science theory that has been
applied to the prevention of unintentional injuries
to children has been Protection Motivation
Theory (PMT, Rogers, 1975). This model states
that individuals engage in preventive behaviors
as a function of their beliefs about their ability to
act effectively (self-efficacy), their beliefs about
the efficacy of the preventive behavior (response
efficacy), and the psychological and pecuniary
“costs” of engaging in the preventive behavior
(response cost). This model has been used to
examine various parental safety behaviors such
as the use of gate stairs and the storage of poisons
(Beirens et al., 2008, 2010). Although these studies found that PMT constructs accounted for differences in the safety behaviors of parents, more
research is needed.

754

Current Research
Currently, the vast majority of research has
focused on primary prevention, that is, the prevention of an injury event, with specific attention to
the development and evaluation of behaviorally
based interventions (Gielen & Sleet, 2003). This
focus may be attributed, in part, to a perception that
environmental and legislative changes may have
been “exhausted” or limited in their scope and/or
ultimately require human participation (e.g., batteries in smoke detectors must be changed) (Gielen
& Sleet). Within the last decade, caregiver supervision practices have become a major foci of investigation, based on research suggesting that around
90 % of injuries to young children occur while they
are being supervised (Morrongiello, 2005;
National Safety Council, 2005).
In addition to the interest in primary prevention efforts, research has shifted from a focus on
“single independent risk factors that predict
injury” (Schwebel & Barton, 2005, p. 553), such
as gender, temperament, and parental characteristics, to investigations of the simultaneous contributions of the child, the environment, and the
caregiver that increase injury risk. Research
examining these interactive factors has found
significant relationships between parent and
child characteristics. For example, Morrongiello
and Hogg (2004) found a tendency for parents of
girls to attribute their daughters’ injuries to child
behavior, while the parents of boys believe that
their injured sons were “unlucky.” Similarly,
child risk taking appears to be significantly
influenced by the proximity of the supervising
parent (Morrongiello & House, 2004). It is
strongly believed that more research on the interaction of the various risk factors will provide
critical information necessary to reduce childhood unintentional injuries (Gielen & Sleet,
2006; Morrongiello & Schwebel, 2008;
Schwebel & Barton, 2005).

Overview of Strategies
Many strategies to prevent unintentional injuries
in children have been implemented throughout

Injury Prevention During Childhood

history. Most, but not all, of these interventions
have been focused on changing the behavior of
children or parents with varying degrees of success (Ameratunga & Peden, 2009; Gaines &
Schwebel, 2009; Gardner & The Committee on
Injury, Violence, and Poison Prevention, 2007;
Kendrick, Barlow, Hampshire, Stewart-Brown,
& Polnay, 2008; Koulouglioti, Cole, & Kitzman,
2008; LeBlanc et al., 2006; Marshall et al., 2005;
Morrongiello, Corbett, Lasenby, Johnston, &
McCourt, 2006; Munro, van Niekerk, & Seedat,
2005; Ricketts, Shanteau, McSpadden, &
Fernandez-Medina, 2010; Tsoumakas et al.,
2009). Currently, research suggests that the
most effective prevention strategies include environmental manipulation, parental interventions,
legislative interventions, and community-based
interventions (Ameratunga & Peden, 2009;
Gaines & Schwebel, 2009; Gardner &
The Committee on Injury, Violence, and Poison
Prevention, 2007; Gulotta & Finney, 2000;
Kendrick et al., 2008; Koulouglioti et al., 2008;
LeBlanc et al., 2006; Marshall et al., 2005;
Morrongiello et al., 2006, 2008; Munro et al.,
2005; Schwebel, 2004; Simpson, Turnbull,
Ardagh, & Rischardson, 2010; Towner &
Dowswell, 2002). Each of these areas has been
further deconstructed to explore the components
of effective prevention.
Specifically, it has been found that environmental manipulations, such as replacing asphalt
below playground equipment with cushioned
materials and limiting children’s access to poisons and medications through childproofing,
have been effective in preventing unintentional
injuries in children (Ameratunga & Peden, 2009;
Gaines & Schwebel, 2009; Gardner &
The Committee on Injury, Violence, and Poison
Prevention, 2007; Kendrick et al., 2008; LeBlanc
et al., 2006; Marshall et al., 2005; Munro et al.,
2005). Further, parental interventions that
increase supervision and teaching are effective in
decreasing childhood injury rates (Morrongiello
et al., 2008; Schwebel, 2004; Simpson et al.,
2010). In addition, there have been many
legislative interventions, such as mandatory child
safety seats and bicycle helmet laws, which have
assisted in preventing unintentional injuries in

Injury Prevention During Childhood

(Ameratunga & Peden, 2009; Gardner &
The Committee on Injury, Violence, and Poison
Prevention, 2007). Finally, community-based
interventions have been effective in reducing the
risk for sustaining an unintentional injury through
socioecological measures aimed at making
the community a safer place (Ameratunga &
Peden, 2009; Gulotta & Finney, 2000; Kendrick
et al., 2008; Munro et al., 2005; Towner &
Dowswell, 2002).
Moreover, several promising interventions are
currently being implemented as well as ineffective strategies to prevent unintentional injuries in
children. The promising interventions to prevent
children’s injuries that are currently being
used include childcare regulations, and safety
training for parents via classes, parenting magazines, and pediatricians (Currie & Hotz, 2004;
Gaines & Schwebel, 2009; Ricketts et al.,
2010). In contrast, ineffective strategies for
preventing unintentional injuries in children,
such as environmental changes that ignore
individual differences and having knowledge,
but not acting on it, have been implemented
(Gaines & Schwebel, 2009; Rowe & Maughan,
2009; Schwebel, 2004; Schwebel & Bounds,
2003; Schwebel & Plumert, 1999; Simpson
et al., 2010; Tsoumakas et al., 2009; Watson
et al., 2004). Unfortunately, despite being unsuccessful in reducing children’s injury rates, such
programs may be costly and utilize valuable
resources that may be put to better use.

What Works
Environmental Manipulation
Child Proofing and Protective Devices. Infants
and children are unable to control their own
environments to be safe. Thus, adults need to
take preventive action. Interventions that
employ child proofing, or protective devices, to
reduce the number of hazards easily accessible to
children are effective in reducing the number of
unintentional injuries in children (Ameratunga &
Peden, 2009; Gaines & Schwebel, 2009;
Gardner & The Committee on Injury, Violence,
and Poison Prevention, 2007; LeBlanc et al., 2006;

755

Marshall et al., 2005; Munro et al., 2005). Most of
these interventions are “passive” and once
implemented need no further activity to realize
the protective benefits. Further, most necessitate
only minimal changes to the environment such
as requiring handrails on all stairways, securing
heavy furniture to the wall that could fall on
the child, and requiring window bars in highrise apartments (Ameratunga & Peden, 2009;
Gardner & The Committee on Injury, Violence,
and Poison Prevention, 2007; LeBlanc et al., 2006;
Marshall et al., 2005). Unfortunately, children’s
environments contain many different hazards for
which specific preventive interventions must be
made in order to increase child safety.
With regard to pediatric burns, there are several effective childproofing and protective
devices that help reduce these specific types of
injuries to children. Both active interventions,
like removing matches or lighters within child’s
reach, and passive approaches such as installing
functioning smoke detectors and having fire
extinguishers in the home have been shown to
be effective in reducing fire-related injuries
(Ameratunga & Peden, 2009; Gardner & The
Committee on Injury, Violence, and Poison Prevention, 2007; LeBlanc et al., 2006; Marshall
et al., 2005; Munro et al., 2005). Similarly, effective preventive measures have also been developed to help reduce unintentional injuries in
children related to poisoning. These preventive
measures included minor manipulations in the
environment such as child-resistant lids on medications and household supplies and storage of
hazardous substances, so they are difficult for
children to see and access (Ameratunga &
Peden, 2009; Gardner & The Committee on
Injury, Violence, and Poison Prevention, 2007).
In addition, environmental interventions aimed to
promote firearm safety have been a recent phenomenon. By storing unloaded firearms away
from where children live and play and, when
storing firearms in the home, separating the storage of guns and ammunition, firearm-related
unintentional injuries in children may be
prevented (Gardner & The Committee on Injury,
Violence, and Poison Prevention, 2007). Similarly, unintentional drowning may be decreased

756

through effective interventions such as building
fences around swimming pools, removing or covering water hazards, and using personal flotation
devices (Ameratunga & Peden, 2009; Gardner &
The Committee on Injury, Violence, and Poison
Prevention, 2007).
Multifaceted
In-Home
Interventions.
Multifaceted in-home interventions have been
shown to be effective in reducing unintentional
child injury rates. According to Kendrick and
his colleagues (2008), families that received
multifaceted interventions implement more
safety practices and have safer home environments with fewer hazards present. Examples of
such programs include Project 12-Ways and
Project SafeCare (Gershater-Molko, Lutzker, &
Wesch, 2003).
Parental Interventions
Supervision. Parental and caregiver supervision
have been implicated as an important factor in
children’s injury risk (Morrongiello, 2005). In
most cases, children do not have sufficient
knowledge to understand the hazards in their
environment and, consequently, cannot always
act in ways to protect themselves (Munro et al.,
2005). However, children are not the only ones
who have difficulty accurately assessing the hazards present in their environment. In most cases,
parents do not adequately anticipate risk for injuries in their children, and even when parents were
aware of the potential for injury, they often do not
intervene because they perceive moderately
severe injuries to be a “normal” part of childhood
(Simpson et al., 2010).
Several characteristics of the child appear to
affect the level of supervision that he or she
receives. For instance, a child’s gender, age, and
temperamental attributes all influence adult’s
supervision behaviors (Morrongiello et al.,
2008; Munro et al., 2005; Schwebel, 2004;
Simpson et al., 2010). In terms of gender, it has
been found that girls tend to be monitored more
closely than boys despite the higher rates of medically attended injuries for male children and
adolescents (Morrongiello et al., 2008). In addition, the child’s age in consort with the parent’s
expectations about what a child can do at that age

Injury Prevention During Childhood

play a role in the level of supervision the child
receives. Parents who hold developmentally
unrealistic expectation of their child’s abilities
leave their child in situations where he/she is
particularly vulnerable to risk for injury
(Simpson et al., 2010). For example, Simpson
and his colleagues (2010) found 24- to
47-month-old children who were left
unsupervised sustained more injuries. Lastly, in
terms of temperamental attributes, when parents
supervise temperamentally difficult children
closely, they sustain fewer unintentional injuries
(Morrongiello et al., 2008; Schwebel, 2004).
In summary, proximity of supervision, realistic expectations of children’s developmental
level and abilities to identify hazards, and being
aware of their children’s attributes all assist parents in implementing interventions to decrease
unintentional injuries (Morrongiello et al., 2008;
Munro et al., 2005; Simpson et al., 2010).
Because there is no universal definition of
adequate supervision, consideration of individual
child characteristics (and their interactions)
should help determine the level of supervision
that is necessary for each child in order to
prevent unintentional injury (Morrongiello
et al., 2008).
Teaching and Parenting Style. Parents can
also decrease the risk of their children sustaining
unintentional injuries through their parenting
styles (authoritative versus permissive) and
teaching the child to act in a safer manner.
According to Morrongiello and her colleagues
(2006), an authoritative parenting style is better
at promoting the development of instrumental
competence in a child than is a permissive
approach. Since permissive parents are high in
responsiveness and low in control, they are more
likely to explain safety concerns to children, but
are less likely to develop and enforce rules
regarding safety (Morrongiello et al., 2006).
Further, permissive parents leave more decisions
up to their children and are less likely to closely
supervise than are authoritative parents
(Morrongiello et al.). This approach to parenting
results in children having higher levels of medically attended injuries due to their lack of knowledge about how to behave safely and as to what

Injury Prevention During Childhood

constitutes appropriate behavior when faced with
a risky situation (Morrongiello et al.).
In contrast, authoritative parents are highly
responsive and controlling; they both explain
and enforce safety rules (Morrongiello et al.,
2006). Consequently, authoritative parents are
more likely to supervise their children, and their
children are more likely to understand
acceptable behaviors in different environments
(Morrongiello et al.). Thus, both supervision
and the ways in which a parent teaches their
child about safety and how to attain it are directly
related to parenting style and have implications
for the child’s risk of unintentional injuries
(Morrongiello et al.).
Sleep. Children’s sleep has recently emerged
as an important risk factor for unintentional injuries in children. Higher rates of medically attended
injuries have been found in children who do not
get enough sleep (Koulouglioti et al., 2008).
Therefore, interventions that highlight the importance of children’s sleep hygiene to parents target
and reduce a common risk factor to unintentional
injuries in children (Koulouglioti et al.).
Legislative Interventions
Legislation has been able to help prevent
unintentional injuries in children in some passive
ways. Implementing and enforcing laws about
minimum drinking age, blood alcohol limits in
drivers, bicycle helmets, car seats and seat belts,
speed reduction in school zones and residential
areas and designing roads for safety have assisted
in reducing the number of unintentional injuries
children sustain (Ameratunga & Peden, 2009;
Gardner & The Committee on Injury, Violence,
and Poison Prevention, 2007). Further,
a reduction in unintentional injuries related to
burns has been achieved by implementing laws
requiring functioning smoke detectors and
requiring maximum thermostat settings for the
temperature for tap water (Ameratunga &
Peden, 2009; Gardner & The Committee on
Injury, Violence, and Poison Prevention, 2007).
However, legislation that affects childcare or
businesses and protect children from
unintentional injuries can be difficult to pass
and implement properly.

757

Community-Based Interventions
Injury prevention has a long history of effectively
employing community-based interventions to
reduce injuries (Gielen & Sleet, 2003). The important aspects of community-based interventions are
that they are long term, multiagency collaborations, successful and focused in their leadership,
surveillance based, and tailored to the needs of the
community (Towner & Dowswell, 2002). For
example, community-level interventions such as
reducing the littering of hazardous materials,
enforcing driving laws, and providing safe playgrounds have helped reduce the rate of
unintentional
injuries
children
sustain
(Ameratunga & Peden, 2009; Munro et al., 2005).
Other interventions at the community level
focusing on reducing unintentional injuries in
children have been based on a socioecological
model. This model emphasizes the importance
of the system’s social, behavioral, and psychological factors on maternal and child health.
Application of this model includes home visits
by nurses to address factors influencing maternal
and child outcomes, targeting families at greater
risk for health problems due to poverty, age, and
lack of personal and social resources (Gulotta &
Finney, 2000; Towner & Dowswell, 2002).
Home visits may offer mothers vital, developmentally appropriate information about their
children as well as the opportunity to learn
home safety skills and techniques for providing
positive attention for proper safety behaviors
exhibited by their children (Gulotta & Finney,
2000). Consequently, home visits based on providing parents with additional knowledge and
skills may further assist with preventing
unintentional injuries in children (Gulotta &
Finney; Kendrick et al., 2008; Towner &
Dowswell, 2002).

What Is Promising
Childcare Regulations
Mixed results have been found regarding the
relationship between childcare regulations and
unintentional injuries in young children. Currie
and Hotz (2004) found that regulations, such as

758

those regarding staff to child ratios and minimum
education for day-care directors, were associated
with lower unintentional injury rates. However,
these regulations appear to differentially exclude
certain groups of children which inadvertently
increase their risk for injury because they receive
childcare in less-regulated settings (e.g., informal
home day care). Therefore, the resultant exclusion of particular groups of children appears to
cancel out the positives of creating regulations in
childcare agencies (Currie & Hotz).
Despite this edging out, some childcare regulations, such as increasing the education level of all
childcare workers by 2 years, may assist in decreasing the rate of unintentional injuries in children
(Currie & Hotz, 2004). The cost of increasing the
education level of childcare workers would be
minimal in comparison to the billions of dollars
spent on childhood unintentional injuries each year
(Currie & Hotz). Therefore, further research is
needed to determine if there is a way to implement
these regulations, reduce unintentional injuries,
and cut costs, without decreasing access to highquality care for all children.
Parenting Classes and Magazines
Parenting classes and magazines appear to be
promising interventions for unintentional injuries
in children. Parents with more education and training are able to recognize more hazards in their
children’s environment than those without education and training (Gaines & Schwebel, 2009).
Although critical, simple recognition is not
enough to prevent unintentional injuries in children; parents need to also teach their children how
to identify danger and how to act when this danger
is present (Gaines & Schwebel). Currently, parents
receive information about injury prevention from
their child’s pediatrician (Tsoumakas et al., 2009;
Vincenten, Sector, Rogmans, & Bouter, 2005).
Given the limited time and competing demands
present during a well-child visit, increasing parent
knowledge through magazines and classes on
child development and hazard reduction may significantly reduce the unintentional injury rate
(Gaines & Schwebel, 2009; Tsoumakas et al.,
2009). However, even with these parenting magazines and classes, parents still have a tendency to

Injury Prevention During Childhood

not recognize, or explain to their children, many of
the hazards in their homes (Gaines & Schwebel,
2009).
Telling Stories
Telling stories appears to be a very promising
intervention for unintentional injuries in children
that is currently under researched. Ricketts and
his colleagues (2010) conducted a study to examine the impact of stories on childhood
unintentional injuries. They found that stories
appear to be effective in preventing injury as
long as they are brief and about people who
have been injured in the past (Ricketts et al.,
2010). However, they were only able to impact
behavioral aspects of the child, not psychological
ones, which may lessen the degree of impact
these stories had on reducing unintentional injuries (Ricketts et al.). Further, despite the contributions made by Ricketts and his colleagues
(2010), there is no evidence that these stories
are any better than just any normal communication about injury risk. More research is needed to
determine if this promising intervention is worthwhile to pursue.

What Does Not Work
Environmental Changes That Ignore
Individual and Developmental Differences
Although environmental interventions have historically been effective in reducing injuries, consideration of temperamental and developmental
differences has not been included (Schwebel,
2004). Individual interventions may better protect children when they account for temperamental differences and rely on educating and training
the individual to act in safe manners to prevent
injuries (Schwebel). In order to prevent
unintentional injuries in children, parents need
to recognize their child’s vulnerability to the hazards in their environments. Gaines and Schwebel
(2009) found that parents identified more hazards
for children in general, than for their own children, because parents tend to see their children as
invulnerable. Therefore, in order to prevent
unintentional injuries, parents need to take

Injury Prevention During Childhood

actions to safeguard their homes as well as be
proactive in the development and behavior management of their children (Gaines & Schwebel;
Schwebel, 2004).
Further, developmental aspects of the child
play a role. It is important to ensure that parents,
as well as the child themselves, are not
overestimating the child’s physical abilities
(Schwebel & Bounds, 2003; Schwebel &
Plumert, 1999). When overestimations of physical abilities occur, children are more likely to
enter situations that place them at greater risk
for injury (Schwebel & Bounds, 2003; Schwebel
& Plumert, 1999). Underestimating abilities may
result in the child being social isolated or delayed
in their physical development (Schwebel &
Bounds, 2003; Schwebel & Plumert, 1999). As
a result, injury prevention interventions that just
focus on the implementation of environmental
changes and ignore individual differences, particularly in terms of accuracy of estimate of abilities, are ineffective in preventing injuries and
may even lead to an increase in negative outcomes (Schwebel & Bounds, 2003; Schwebel &
Plumert, 1999). Overall, being aware of different
developmental and individual aspects of their
children would help parents better tailor their
approaches to preventing unintentional injuries
in children (Gaines & Schwebel, 2009; Rowe &
Maughan, 2009; Schwebel, 2004; Schwebel &
Bounds, 2003; Schwebel & Plumert, 1999).
Knowledge Without Action
A major reason why interventions to prevent
unintentional injuries from occurring have been
ineffective is that even when parents know about
the preventive measures, 64.8 % of them do not
implement the measures in their homes
(Tsoumakas et al., 2009). This lack of implementation occurs despite the fact that when parents
adhere to these preventive measures, the rate of
unintentional injuries in children decreases by
36 % (Tsoumakas et al.). According to Watson
and his colleagues (2004), even when families
were provided with consultation, education, and
free safety equipment, the rates of medically
attended unintentional injuries for children did
not decrease. This could be due to the fact that in

759

most cases parents did not adequately anticipate
risk for injuries in their children and thus did not
implement most of protective measures available
to them (Simpson et al., 2010; Watson et al.,
2004). Thus, providing people with safety equipment and knowledge is not enough. Without
a greater level of compliance in the implementation of the protective measures, unintentional injuries cannot be reduced (Simpson et al., 2010;
Tsoumakas et al., 2009; Watson et al., 2004).

Summary
The prevention of unintentional injuries to children is a very difficult task that requires the integrated work of children, parents, the community,
and legislators. The changing world, with increasing reliance on motor vehicles and urbanization,
has increased risk for children (Harvey et al.,
2009). Passive prevention techniques such as nonflammable pajamas and child-resistant medication
packaging have been very effective in reducing
specific types of injuries, but their scope is limited
(Christoffel & Gallagher, 1999). However,
because many hazards are not amenable to passive
prevention efforts, developmentally and temperamentally appropriate supervision is needed to
ensure children’s safety. Allowing children unfettered access to hazards, such as a swimming pool
or hot stove, “just for a minute” because the parent
“knows” how her child will behave has resulted in
countless tragedies for many families.
Recent research on supervision has found that
not all children who are unsupervised are injured,
highlighting the role that individual differences
play in determining risk (Morrongiello et al.,
2008). However, characteristics of the environment increase child risk also and increase the
demands on parents to provide appropriate supervision. Future research is needed to determine the
role of supervision in keeping children safe
across a variety of settings (WHO, 2008).
In addition to supervision, other effective
interventions are known, yet limited in their dissemination. While high-income countries have
legislated changes in products and laws to
increase child safety, these practices have not

760

been implemented in low- and middle-income
countries. Clearly, more research, more coordinated, multiagency efforts, and more funding are
needed to provide all children with safe environments and lives free from the distress and disability of unintentional injuries.

References
Ameratunga, S. N., & Peden, M. (2009). World report on
child injury prevention: A wake-up call. Injury International Journal of the Care of the Injured, 40,
469–470. doi:10.1016/j.injury.2008.11.015.
Assargaard, U., & Sjoberg, G. (1995). The successful
introduction of child resistant closures for liquid paracetamol preparations. Safety Science, 21, 87–91.
Beirens, T. M. J., Brug, J., van Beeck, E. J., Dekker, R.,
den Hertog, P., & Raat, H. (2008). Assessing psychosocial correlates of parental safety behaviour using
Protection Motivation Theory: Stair gate presence
and use among parents of toddlers. Health Education
Research, 23, 723–731.
Beirens, T. M. J., Eduard, E. F., van Beeck, E. J., Brug, J.,
den Hertog, P., & Raat, H. (2010). Why do parents
store poisonous products safely? International Journal
of Pediatrics, 2010, 1–8. doi:10.1155/2010/702827.
Center for Disease Control and Prevention. (2009). CDC
childhood injury report [Data file]. Retrieved
August 20, 2011, from http://cdc.gov/safechild/
Child_InjuryData.html
Christoffel, T., & Gallagher, S. S. (1999). Injury prevention and public health: Practical knowledge, skills and
strategies. Gaithersburg, MD: Aspen.
Currie, J., & Hotz, V. J. (2004). Accidents will happen?
Unintentional childhood injuries and the effects of
child care regulations. Journal of Health Economics,
23, 25–59. doi:10.1016/j.jhealeco.2003.07.004.
Finney, J. W., Christophersen, E. R., Friman, P. C.,
Kalnins, I. V., Maddux, J. E., Peterson, L.,
et al. (1993). Society of Pediatric Psychology task
force report: Pediatric psychology and injury control.
Journal of Pediatric Psychology, 18, 499–525.
Freire, K., & Runyan, C. W. (2006). Planning
models – PRECEDE-PROCEED and Haddon Matrix.
In A. C. Gielen, D. A. Sleet, & R. J. DiClemente (Eds.),
Injury and violence prevention: Behavioral science
theories, methods, and applications (pp. 407–433).
San Francisco: Jossey-Bass.
Gaines, J., & Schwebel, D. C. (2009). Recognition of
home injury risks by novice parents of toddlers. Accident Analysis and Prevention, 41, 1070–1074.
doi:10.1016/j.aap.2009.06.010.
Gardner, H. G., & The Committee on Injury, Violence,
and Poison Prevention. (2007). Office-based counseling for unintentional injury prevention. American
Academy of Pediatrics, 119, 202–206.

Injury Prevention During Childhood
Gershater-Molko, R. M., Lutzker, J. R., & Wesch,
D. (2003). Project SafeCare: Improving health, safety,
and parenting skills in families reported for, and at-risk
for child maltreatment. Journal of Family Violence,
18, 377–386. doi:10.1023/A:1026219920902.
Gielen, A., & Sleet, D. A. (2003). Application of behaviorchange theories and methods to injury prevention.
Epidemiologic Review, 25, 65–76.
Gielen, A., & Sleet, D. A. (2006). Injury prevention and
behavior: An evolving field. In A. C. Gielen, D. A.
Sleet, & R. J. DiClemente (Eds.), Injury and violence
prevention: Behavioral science theories, methods, and
application (pp. 1–16). San Francisco: Jossey-Bass.
Gulotta, C. S., & Finney, J. W. (2000). Intervention models
for mothers and children at risk for injuries. Clinical
Child and Family Psychology Review, 3, 25–36.
Haddon, W., & Baker, S. P. (1981). Injury control. In
D. Clarke & B. MacMahon (Eds.), Preventive and
community medicine (pp. 109–140). New York: Little
Brown.
Hall, E., Saxe, G., Stoddard, F., Kaplow, J., Koenen, K.,
Chawla, N., et al. (2006). Posttraumatic stress symptoms in parents of children with acute burns. Journal of
Pediatric Psychology, 31, 403–412. doi:10.1093/
jpepsy/jsj016.
Harvey, A., Towner, E., Peden, M., Soori, H., &
Bartolomeos, K. (2009). Injury prevention and the
attainment of child and adolescent health. Bulletin of
the World Health Organization, 87, 390–394.
doi:10.2471/BLT.08.059808.
Kendrick, D., Barlow, J., Hampshire, A., Stewart-Brown,
S., & Polnay, L. (2008). Parenting interventions and
the prevention of unintentional injuries in childhood:
Systematic review and meta-analysis. Child: Care,
Health and Development, 34, 682–695. doi:10.1111/
j.1365-2214.2008.00849.x.
Koulouglioti, C., Cole, R., & Kitzman, H. (2008). Inadequate sleep and unintentional injuries in young children. Public Health and Nursing, 25, 106–114.
doi:10.1111/j.1525-1446.2008.00687.x.
LeBlanc, J. C., Pless, I. B., King, W. J., Bawden, H.,
Bernard-Bonnin, A. C., Klassen, T., et al. (2006).
Home safety measures and the risk of unintentional
injury among young children: A multicentre case–
control study. Canadian Medical Association Journal,
175, 883–887. doi:10.1503/cmaj.050592.
LeBrocque, R. M., Hendrikz, J., & Kenardy, J. A. (2010).
Parental response to child injury: Examination of
parental posttraumatic symptom trajectories following
child accidental injury. Journal of Pediatric Psychology, 35, 646–655.
Marshall, S. W., Runyan, C. W., Yang, J., Coyne-Beasley,
T., Waller, A. E., Johnson, R. M., et al. (2005). Prevalence of selected risk and protective factors for falls in
the home. American Journal of Preventive Medicine,
28, 95–101. doi:10.1016/j.amepre.2004.09.015.
Meiser-Stedman, R. A., Yule, W., Dalgleish, T., Smith, P.,
& Glucksman, E. (2006). The role of the family in child
and adolescent posttraumatic stress following

Injury Prevention During Childhood
attendance at an emergency department. Journal of
Pediatric Psychology, 31, 397–402. doi:10.1093/
jpepsy/jsjoo5.
Morrongiello, B. A. (2005). The role of supervision in childinjury risk: Assumptions, issues, findings, and future
directions. Journal of Pediatric Psychology, 30, 536–552.
Morrongiello, B. A., Corbett, M., Lasenby, J., Johnston,
N., & McCourt, M. (2006). Factors influencing young
children’s risk of unintentional injury: Parenting style
and strategies for teaching about home safety. Journal
of Applied Developmental Psychology, 27, 560–570.
Morrongiello, B. A., & Dayler, L. (1996). A communitybased study of parents’ knowledge, attitudes, and
beliefs related to childhood injuries. Canadian Journal
of Public Health, 87, 383–388.
Morrongiello, B. A., & Hogg, K. (2004). Mothers’ reactions to children misbehaving in ways that can lead to
injury: Implications for gender differences in children’s
risk taking and Injuries. Sex Roles, 50, 103–118.
doi:10.1023/B:SERS.0000011076.43831.a6.
Morrongiello, B. A., & House, K. (2004). Measuring
parent attributes and supervision relevant to childinjury risk: Examining the usefulness of questionnaire
measures. Injury Prevention, 10, 114–118.
Morrongiello, B. A., Klemencic, N., & Corbett, M. (2008).
Interactions between child behavior patterns and parent supervision: Implications for children’s risk of
unintentional injury. Child Development, 79, 627–638.
Morrongiello, B. A., & Schwebel, D. C. (2008). Gaps in
childhood injury research and prevention: What can
developmental scientists contribute? Child Development Perspectives, 2, 78–84.
Munro, S.-A., van Niekerk, A., & Seedat, M. (2005).
Childhood unintentional injuries: The perceived
impact of environment, lack of supervision and child
characteristics. Child: Care, Health and Development,
32, 269–279.
National Safety Council. (2005). What are the odds of
dying? [Data file]. Retrieved August 27, 2011, from
http://www.nsc.org/lrs/statinfo/odds.htm
Osberg, J. S., Kahn, P., Rowe, K., & Brooke, M. M.
(1996). Pediatric trauma: Impact on work and family
finances. Pediatrics, 98, 890–897.
Peden, M. (2008). World report on child injury prevention
appeals for action. Acta Paediatrica, 98, 206.
Peterson, L., & Brown, D. (1994). Integrating child injury
and abuse-neglect research: Common histories, etiologies, and solutions. Psychological Bulletin, 116,
293–315. doi:10.1037/0033-2909.116.2.293.
Ricketts, M., Shanteau, J., McSpadden, B., & FernandezMedina, K. M. (2010). Using stories to battle
unintentional injuries: Narratives in safety and health
communication. Social Science and Medicine, 70,
1441–14449. doi:10.1016/j.socscimed.2009.12.036.
Rogers, R. (1975). A protection motivation theory of fear
appeals and attitude change. Journal of Psychology,
91, 93–114.

761
Rowe, R., & Maughan, B. (2009). The role of risk-taking
and errors in children’s liability to unintentional
injury. Accident Analysis and Prevention, 41,
670–675. doi:10.1016/j.aap.2009.03.004.
Schwebel, D. C. (2004). Temperamental risk factors for children’s unintentional injury: The role of impulsivity and
inhibitory control. Personality and Individual Differences,
37, 567–578. doi:10.1016/j.paid.2003.09.027.
Schwebel, D. C., & Barton, B. K. (2005). Contributions of
multiple risk factors to child injury. Journal of Pediatric Psychology, 30, 553–561. doi:10.1093/jpepsy/
jsi042.
Schwebel, D. C., & Bounds, M. L. (2003). The role of
parents and temperament on children’s estimation of
physical ability: Links to unintentional injury prevention. Journal of Pediatric Psychology, 28, 505–516.
doi:10.1093/jpepsy/jsg041.
Schwebel, D. C., & Plumert, J. M. (1999). Longitudinal
and concurrent relations among temperament, ability
estimation, and injury proneness. Child Development,
70, 700–712.
Simpson, J. C., Turnbull, B. L., Ardagh, M., &
Rischardson, S. (2010). Child home injury prevention:
Understanding the context of unintentional injuries to
preschool children. International Journal of Injury
Control and Safety Promotion, 16, 159–167.
doi:10.1080/17457300903135636.
Towner, E., & Dowswell, T. (2002). Community-based
childhood injury prevention interventions: What
works? Health Promotion International, 17, 273–284.
Trifiletti, L. B., Gielen, A. C., Sleet, D. A., & Hopkins,
K. (2005). Behavioral and social sciences theories and
models: Are they used in unintentional injury prevention research? Health Education Research, 20,
298–307. doi:10.1093/her/cyg126.
Tsoumakas, K., Dousis, E., Mavridi, F., Gremou, A., &
Matziou, V. (2009). Parent’s adherence to children’s
home-accident preventive measures. International
Nursing Review, 56, 369–374.
Vincenten, J. A. (2006). Focus on children. Eurosafe
Alert, 1, 5–6.
Vincenten, J. A., Sector, M. J., Rogmans, W., & Bouter,
L. (2005). Parents’ perceptions, attitudes and behaviours towards child safety: A study in 14 European
countries. International Journal of Injury Control
and Safety Promotion, 12, 183–189. doi:10.1080/
17457300500136557.
Walton, W. W. (1982). An evaluation of the Poison Prevention Packaging Act. Pediatrics, 69, 363–370.
Watson, M., Kendrick, D., Coupland, C., Woods, A.,
Futers, D., & Robinson, J. (2004). Providing child
safety equipment to prevent injuries: Randomised controlled trial. British Medical Journal, 330, 178–181.
doi:10.1136/bmj.38309.664444.8F.
World Health Organization (WHO). (2008). World report
on childhood injury prevention. Geneva, Switzerland:
Author.

762

Promotion of Intellectual Growth

Definitions and Theories

Promotion of Intellectual Growth
Thomas J. Kehle1, Melissa A. Bray2 and
Sandra M. Chafouleas2
1
University of Connecticut, Storrs, CT, USA
2
Department of Educational Psychology,
University of Connecticut, Storrs, CT, USA

Introduction
This entry provides information to the degree intellectual growth can be promoted. Emphasis is placed
on the significance of general cognitive ability (g)
with regard to predicting academic and social outcomes, and consideration of strategies designed to
enhance cognitive functioning. The concept of
intelligence and cognitive functioning has a long
history including various theories to explain it,
methods of assessment, debate over improving it,
and associations with a myriad of outcomes. It is
a difficult variable to ignore and has intrigued many
over the years. Furthermore, it is clear that there is
a real advantage to being intelligent – there exists
no threshold where being more intelligent does not
translate into measureable advantage. “For example, children who scored in the 99.9th percentile on
the math section of the SAT by age 13 were found
to be 18 times more likely to go on to earn a PhD in
a Science, Technology, Engineering, and
Mathematics (STEM) discipline than children
who “only” scored in the 99.1th percentile”
(Hambrick & Meinz, 2011, p. 276).
The areas that are related to intelligence are
vast including academic achievement, occupational performance, and physical (Lubinski,
2009) and mental health (Gale, Hatch, Batty, &
Deary, 2009). There are strategies and interventions that can be employed that may promote
intellectual functioning. There are many in the
academic realm, such as story mapping to
enhance reading comprehension, to folic acid
for young brain development. Therefore, in
summary it is not wise to view intelligence as
an area to be avoided; the promotion of
a well-educated and healthy person is certainly
attainable by all.

Intelligence has been defined differently by
several major theorists. In concert with Brody
(1992), Kehle and Bray (2004) defined g as the
first principle component in a factor analysis of
a large and varied set of mental tasks. The content
of any cognitive task is irrelevant. It is the degree
that the task requires the individual to grapple
with complexity, or the “degree the task is
g-loaded, that affords its predictive utility”
(Kehle & Bray, 2011, p. 63). “The great preponderance of the prediction that is possible from any
set of cognitive tests is attributable to the general
ability that they share. . ..“empirical g” is not
merely an interesting psychometric phenomenon,
but lies at the heart of the prediction of real-life
performances” (Thorndike, 1994). Lubinski
(2004, p. 100) stated, “g” is clearly the most
important dimension of individual differences
uncovered in the study of cognitive abilities to
date. Further, it is “among the most important
individual differences dimension for structuring
the determinants of Freud’s two-component characterization of life, lieben and arbeiten, working
and living” (p. 100).
Consequently, as Gottfredson (2003) noted,
g defines everyday life as an intelligence test.
She credited Gordon (1977) for showing how
daily life “mimics rather than departs from the
properties of a reliable, valid test of
intelligence. . .” (p. 294). The ability to grapple
with complexity or g influences all aspects of
one’s life and provides understanding of “how
individual differences in g shape our individual
fates (Gottfredson, 2003, p. 294).” She
concluded, “life as a mental test containing subtests with a wide range of g loadings (p. 294).”
Therefore, living requires a continuous series of
decisions that require some degree of g (Kehle &
Bray, 2011).
In contrast to g-oriented definitions, others
such as Gardner (1983) have posited the existence of multiple intelligences that are not amenable to traditional indices of intellectual
assessment. He suggested that intelligence is
comprised of eight competencies that include
linguistic, musical, logical mathematical, spatial,

T.P. Gullotta, M. Bloom (eds.), Encyclopedia of Primary Prevention and Health Promotion,
DOI 10.1007/978-1-4614-5999-6, # Springer Science+Business Media New York 2014

Promotion of Intellectual Growth

bodily kinesthetic, intrapersonal, interpersonal,
and naturalist (Sattler, 2008). These eight
competencies are assessed using observational
techniques and a questionnaire (MIDAS)
developed by Gardner (1983).
Sternberg (2005) proposed a triarchic theory
of intelligence that connotes intelligence as
a combination of componential, experiential,
and contextual dimensions. These dimensions
allow the individual to adapt to the environment
and to accomplish one’s goals. Similar to
Gardner, these dimensions are typically not
measured in a traditional manner.
There are a myriad of definitions and theories
of intelligence including cultural differences. For
example, most Western cultures focus on
problem-solving, logical, and reasoning components of intelligence. In contrast, Eastern cultures
tend to view intelligence as holistic, social, and
complex linguistic (Sattler, 2008). Nevertheless,
according to Gardner (2011), most theories of
intelligence can be grouped into four major types
based on their theoretical bases: psychometric,
cognitive, cognitive-contextual, and biological.
The psychometric theory is based on cognitive
test performance and focuses on the structure of
intelligence based on performance scores. The
notion of Spearman’s (1904) g was derived
from the study of intercorrelations of tasks that
comprised the psychometric test. Cognitivebased theories focus on simple to complex mental
processing. Included in this grouping are sensory
testing, inspection time, reaction time, working
memory, and processing speed. Cognitivecontextual theories explain the influence or
interaction between cognitive function and the
context of the environment. Sternberg’s (2005)
triarchic theory, Gardner’s multiple intelligences,
and Piaget’s stage theory are examples of the
cognitive-contextual theories (Gardner, 2011).
There have been recent attempts to examine the
biological foundation of intellectual functioning.
Examining brain size, EEG wave length, and
glucose metabolism are some examples of biologically based correlates of intelligence. To date,
there is preliminary empirical evidence isolating
brain function or brain physiology related to
intelligence (Gardner, 2011). According to

763

Neubauer and Fink (2009), at the neural level,
highly intelligent individuals are substantially
more capable in problem-solving and employ
less cortical activity than those who are not
highly intelligent.

Current Research
The most novel and current research in the area of
intelligence relates to the biological and
physiological aspects such as heterosis and
epigenetics, nutrition including breastfeeding,
and educational practices. Heterosis is defined
as hybrid vigor or the result when mating occurs
between two distinctly different genetic lines
(Mingroni, 2004). Heterosis may account for the
Flynn effect (1999) which is defined as the substantial rise (about 3.6 IQ points every 10 years)
in the average IQ scores over the last 100 years.
Epigenetics refers to the genetic transmission of
traits over generations that is not based solely on
DNA but also on environmental conditions.
Therefore, the question is what environments
produce the most favorable outcomes in human
behavior? For instance, the observation that monozygotic twins where one twin has autism and the
other does not supports epigenetics or the occurrence of a genetic/environment interaction leading
to this outcome. Other new areas of interest relative
to intelligence are related to brain anatomy and
physiology. For example, neurons appear to fire
faster in those with higher measured IQs (Neubauer
& Fink, 2009). In consideration of heterosis and
particularly epigenetics, the areas of biology, physiology, and genetics and how they interact with the
environment will undoubtedly change the future of
how we view intellectual growth. With the major
question being then, can anything be done to intercede and change the trajectory of intellectual
growth in these scientific areas?

Overview of Strategies
The strategies that promote intellectual functioning that will be subsequently reviewed are based
on the recent research findings that intelligence is

764

influenced by not only transmission of
generational genes but also environmental
variables. It is expected that this interaction of
genetics with environment will usher in new
research paradigms to investigate environmental
“triggers” that eventually alter cognitive
functioning. Nonetheless, existing promising
treatments will be reviewed. The promotion of
intellectual functioning may occur with such
things as proper nutrition, favorable environments, and efficacious treatments. It just may be
that genetics and environmental factors interact
to alter intelligence.

IQs Are Rising
The secular rise of IQ scores in both industrial and
developing countries has been documented. The
rise in scores has been evident for over 80 years
and is noted primarily on indices of problemsolving and nonverbal reasoning (Wai & Putallaz,
2011). To quote Flynn (1999, p. 6), “it is as if some
unseen hand is propelling scores upward.” Amazingly, the gain in IQ scores is approximately
3.3–3.6 points per decade and the rise is at
a monotonic rate. However, it was unclear whether
or not this rise in IQ scores was evident in the top
5 % of the population. However, in a study
conducted by Wai and Putallaz (2011), it was
found the Flynn effect was both evident and similar in both male and females in the top 5 % of the
distribution and at the same rate as the general
population. Their results “provided evidence for
the first time that the entire curve is likely increasing at a constant rate” (Wai & Putallaz, p. 1).
Why IQ scores are rising is not known.
Theoretical explanations proposed for the effect
have been varied. They include nutritional,
educational, economical, social, test-taking
skills, more sophisticated television and video
games, and genetic explanations such as heterosis
and epigenetics (Kehle & Bray, 2011; Rodgers &
W€anstrom, 2007; Wai & Putallaz, 2011). However, given that there exists no relationship
between adopting parents and the IQ scores
of unrelated adopted children would suggest
educational, environmental, and economical

Promotion of Intellectual Growth

explanations are not plausible (Lynn, 2007).
It has been argued by several researchers, including Jensen (1998), that investigators should adopt
a “multiplicity hypothesis” where each of the
different proposed explanations “is involved to
some (as yet undetermined) degree in producing
the secular rise in scores” (p. 323).
However, Kehle and Bray (2011) have
suggested a genetic explanation based on the
observation that other human traits have also
increased in incidence rates and appear to mimic
the secular rise in IQ. According to Mingroni
(2004, p. 68) “it is actually difficult to find
a heritable human trait that has not undergone
large secular change in recent history including
height, growth rate, myopia, asthma, autism, attention deficit hyperactivity disorder, head circumference, and brain size.” Kehle, Bray, Theodore,
Zhou, and McCoach (2004) have also argued that
there has been an increase in rates of depression,
anxiety, mood disorders, and aggression.
The increase of phenotypic changes appears to
be in concert with Mingroni’s (2004) notion that
the Flynn effect is the result of heterosis: “The
condition that most probably causes heterosis to
occur is the existence of microdifferentiation, or
small-scale genetic heterogeneity between
groups, that shifts to panmixia, or random mating
throughout the larger population” (Mingroni,
p. 864). Heterosis, or hybrid vigor, is the product
of individuals from different ancestral lines
mating, which tends to enhance dominant
polygenetic traits (Kehle & Bray, 2011) – the
opposite of inbreeding depression (Kehle &
Bray). “Mingroni’s prediction that children who
are more heterozygous than their parents should
evidence higher intergenerational IQs, and children who are less heterozygous than their parents
should evidence a mean intergenerational decline
in IQ, and supposedly other heritable traits with
recessive alleles” (Kehle et al., 2004, p. 864).
In other words, hybrid vigor results in
intergenerational increases in IQ, and inbreeding
depression decreases it (Nisbett et al., 2012).
However, Nisbett et al. (2012) dismissed
Mingroni’s (2004) argument that the secular rise
in IQ was due to heterosis, or hybrid vigor. They
employed the argument that hybrid vigor did not

Promotion of Intellectual Growth

appear significant by stating, “that a trend from
substantial isolation to little isolation lies behind
IQ gains seems implausible” (p. 140). In contrast,
they believe that the Industrial Revolution was
the ultimate reason for the secular rise in IQ.
Wai and Putallaz (2011) stated that after
a decade, they still are in a similar state of mind
as Rodgers (1998, p. 339) who said, “Having read
all of the literature I can find pertaining to the Flynn
effect, I am still not sure what it really is.” Nevertheless, they further stated, “Our findings lead us to
suggest that the environment may have a role to
play in the rise of scores among those in the right
tail, in particular early education and cognitive
stimulation” (Wai & Putallaz, 2011, p. 10).
Another intriguing theory to explain the
secular rise in IQ is epigenetics. According to
Champagne (2009), environmental factors that
influenced one’s grandparents can permanently
alter physiology and behavior in subsequent
generations. Champagne and Mashoodh (2009)
stated that “it is becoming increasingly clear that
creating a division between genes and environment limits our understanding of the complex
biological processes through which individual
differences are achieved” (p. 127). Champagne
and Mashoodh believe that epigenetic mechanisms can influence “the activity of the genome
in response to environmental cues and demonstrate the plasticity that is possible through shifts
in DNA methylation” (p. 129). “Therefore, the
transmission of traits across generations is not
limited in scope to the inheritance of DNA”
(Champagne & Mashoodh, p. 130). Environmental variables, as well as the educational processes,
increase the probability that genetically based
predispositions will occur (Kehle & Bray, 2011).
Finally, high levels of cortisol may cause
socially deviant and psychopathological behaviors and various physical health problems. Children living in poverty have relatively higher
cortisol levels than those from middle-class
homes (Chen, Cohen, & Miller, 2009). If children
perceive their environment as threatening, stress
and concomitant alteration of gene expression
may be realized (Kim-Cohen & Gold, 2009).
Nonetheless, relative to educational practices,
and according to Nisbett et al. (2012),

765

interventions such as an extended school day,
small class size, and interactive academic computer software function to promote academic
achievement; therefore, we can assume,
according to Jensen (1969), that cognitive ability
also was enhanced. Similarly, Neisser
et al. (1996) reported that instruction designed
to improve reasoning skills also tends to promote
intellectual functioning.
With respect to nutrition, there exist several practices that should be considered. Although there is
ambiguity in studies examining the efficacy of
breastfeeding relative to increasing intelligence, it
has been recommended that new mothers should
breastfeed their infants (Nisbett et al., 2012), where
feeding on demand appears to be more efficacious in
promoting intelligence. As the individual grows,
nutrition continues to be important in brain development and associated intellectual functioning.
The schooling process can further support cognitive development by employing empirically
based treatments to promote academic functioning. In other words, schooling may help children
reach their fullest potential. Nisbett et al. (2012)
reviewed aspects of education that may be related
to promoting intelligence. These included
instruction in logical reasoning, higher-order
mathematical thinking skills, and the inclusion
of working memory in primary grades curricula.
With respect to working memory, Nisbett et al.
suggested that mnemonic strategies, and pharmaceuticals such as Ritalin, Aricept, and Modafinil,
may improve working memory.
Finally, in the academic areas including
reading, writing, mathematics, and spelling, there
are empirically validated treatments that can
increase achievement. In particular, reading comprehension, highly related to g, can be improved
with strategies such as story mapping, story grammar, and passage retell. These techniques facilitate
reading comprehension so that the individual can
comprehend written material up to their g level.

What Works
At the present time, no intervention meets the
standard of three successful trials.

766

What Is Promising
The most exciting prospect of cognitive ability
appears to be based on the interaction of genetics
and environment. The study of epigenetics will
increase our understanding of how genetics and
environment interact (Mehler, 2007), and
because it is feasible now to assume that genes
interact differently with different environments
(Ogren & Lombroso, 2008), the design of environments that promote cognitive functioning
becomes more promising. Wai and Putallaz
(2011) stated that future studies should
examine what has caused gains in IQ among the
upper 5 % of the distribution in that it may aid in
improvements in education, “maybe even
intelligence” (p. 10).
Nisbett et al. (2012) suggested that there exists
an interaction between genetics and environment
that results in the heritability of IQ being attenuated in lower-class children. Further, if this is the
case, the children who are impoverished would
not develop their full intellectual potential, and
therefore interventions designed to promote intellectual growth should have substantial effects.
An interesting and apparently contradictory
observation is that South Korean and Finish children are the highest achieving students in the
developed world. However, they have diametrically opposed methods of instruction. The South
Korean system is lockstep, involves long
hours of study, longer school days, and more of
them in comparison to the United States
educational system. It is a highly prescribed curriculum that requires considerable student commitment and near total allocation of their time to
studying.
The Finish system is quite the opposite.
Although they have a national curriculum,
teachers have considerable freedom to teach
want they want. The students have considerable
freedom to learn what they want. Their study and
class involvement is relaxed and informal.
There is little, if any, after school assignments,
the school day and academic year, is considerably
less than the South Korean. Finish children spend
the fewest number hours in class; however, the
students routinely evidence the highest, or near

Promotion of Intellectual Growth

highest, average scores in science, reading, and
mathematics Sahberg and Oldroyd (2010).
Why is this true? Is it that South Korean and
Finish children are smarter than those in the
United States and, if so, would this suggest that
the curriculum is irrelevant? Jensen (1969) and
Gottfredson (2003) would concur with this
statement. However, there is an interesting
phenomenon that is becoming very popular in
the United States that further muddles the
explanation of why some children learn at a rate
beyond that would be expected based on their
level of intelligence. This is a method called
Khan Academics. It is a free Internet-based
program with a library of over 2,700 videos that
provide instruction and practice exercises with
numerous subjects ranging from basic arithmetic
to thermodynamics. What is similar to the Finish
educational system is that the child progresses at
his or her own rate in areas that they are
interested.

What Does Not Work
What preschool children watch on television may
negatively affect their ability to learn.
Lillard and Peterson (2011) randomly assigned
64-year-old children to one of three conditions:
watching 9 min of a fast-paced fantastical cartoon
(SpongeBob SquarePants), a slow-paced Public
Broadcasting Service educational cartoon, or
drawing pictures with crayons. The results were
dramatic. Watching the brief 9-min SpongeBob
clip immediately and substantially impaired the
children’s ability to learn, at least in the short
term. The researchers did not examine how long
the detrimental effects endured.

Summary
Certainly, intellectual functioning is influenced
by both genetic and environmental factors. In
consideration of the research findings associated
with heterosis and epigenetics, it is without doubt
that there are not just genetics and environment
but also genetics interacting with the

Promotion of Intellectual Growth

environment. Studying how the environment is
conducive to gene expression may lead to both
revolutionary developments in education and
promotion of intellectual functioning.

References
Brody, N. (1992). Intelligence. New York: Academic
Press.
Champagne, F. A. (2009). “Nurturing nature” social experiences and the brain. Journal of Neuroendocrinology,
21, 867–868.
Champagne, F. A., & Mashoodh, R. (2009). Genes in
contest: Gene-environment interplay and the origins
of individual differences in behavior. Current
Directions in Psychological Science, 18, 127–131.
Chen, E., Cohen, S., & Miller, G. E. (2009). How low
socioeconomic status affects 2- year hormonal trajectories in children. This Week in Psychological Science.
Retrieved April 11, 2010, from http://pss.sagepub.com/
content/early/2009/11/30/0956797609355566.full
Flynn, J. R. (1999). Searching for justice: The discovery
of IQ gains over time. American Psychologist, 54,
5–20.
Gale, C., Hatch, S., Batty, G., & Deary, I. (2009). Intelligence in childhood and risk of psychological distress
in adulthood: The 1958 national child development
survey and the 1970 British cohort study. Intelligence,
37, 592–599.
Gardner, H. (1983). Frames of mind: The theory of multiple intelligences. New York: Basic.
Gardner, M. (2011). Theories of intelligence. In M. A.
Bray & T. J. Kehle (Eds.), The Oxford handbook of
school psychology (pp. 79–100). Oxford, UK: Oxford
University Press.
Gordon, R. A. (1977). Everyday life as an intelligence test:
Effects of intelligence and intelligence context. Intelligence, 24, 203–320.
Gottfredson, L. S. (2003). g, jobs and life. In H. Nyborg
(Ed.), The scientific study of general intelligence: Tribute to Arthur Jensen (pp. 203–342). London, UK:
Pergamon.
Hambrick, D. Z., & Meinz, E. (2011). Limits on the
predictive power of domain-specific experience and
knowledge in skilled performance. Current Directions
in Psychological Science, 20, 275–279.
Jensen, A. R. (1969). How much can we boost I.Q. and
scholastic achievement? Harvard Educational
Review, 39, 1–123.
Jensen, A. R. (1998). The g factor: The science of mental
ability. Westport, CT: Praeger.
Kehle, T. J., & Bray, M. A. (2004). R.I.C.H.: The
promotion of happiness. Psychology in the Schools,
41, 43–49.
Kehle, T. J., & Bray, M. A. (2011). Individual differences.
In M. A. Bray & T. J. Kehle (Eds.), The Oxford

767
handbook of school psychology (pp. 63–78). Oxford,
UK: Oxford University Press.
Kehle, T. J., Bray, M. A., Theodore, L. A., Zhou, Z., &
McCoach, D. B. (2004). Emotional disturbance/social
maladjustment: Why is the incidence increasing? Psychology in the Schools, 33, 417–421.
Kim-Cohen, J., & Gold, A. L. (2009). Measured geneenvironment interactions and mechanisms promoting
resilient development. Current Directions in Psychological Science, 18, 138–142.
Lillard, A. S., & Peterson, J. (2011). The immediate
impact of different types of television on young
children’s executive function. Pediatrics, 128, 1–6.
doi:10.1542/peds.2010-1929.
Lubinski, D. (2004). Introduction to the special section on
cognitive abilities: 100 years after Spearman’s
(1904) “general intelligence, objectively determined
and measured”. Journal of Personality and Social
Psychology, 86, 96–111.
Lubinski, D. (2009). Cognitive epidemiology: With
emphasis on untangling cognitive ability and
socioeconomic status. Intelligence, 37, 625–633.
Lynn, R. (2007). What is intelligence? Beyond the Flynn
effect. [Review of the book. What is intelligence?
Beyond the Flynn effect, by R. R. Flynn]. Intelligence,
35, 515–516.
Mehler, M. (2007). NOVA Production (produced by
S. Holt & N. Paterson). Ghost in your genes [DVD].
Retrieved May 9, 2010, from http://www.pbs/wgbh/
nova/transcripts/3413_genes.html
Mingroni, M. A. (2004). The secular rise in IQ: Giving
heterosis a closer look. Intelligence, 32, 65–83.
Neisser, U., Boodoo, G., Bouchard, T. J., Jr., Boykin,
A. W., Brody, N., Ceci, S. J., et al. (1996). Intelligence:
Knowns and unknowns. American Psychologist, 51,
77–101.
Neubauer, A., & Fink, A. (2009). Intelligence and neural
efficiency: Measures of brain activity versus measures
of functional connectivity in the brain. Intelligence,
37, 223–229.
Nisbett, R. E., Aronson, J., Blair, C., Dickens, W., Flynn,
J., Halpern, D., et al. (2012). Intelligence: New
findings and theoretical developments. American
Psychologist, 67, 130–159.
Ogren, M. P., & Lombroso, P. J. (2008). Epigenetic:
Behavior influences on gene function. Part
I. Maternal behavior permanently affects adult
behavior in offspring. Journal of the American
Academy of Child and Adolescent Psychiatry, 47,
240–244.
Rodgers, J. L. (1998). A critique of the Flynn effect:
Massive IQ gains, methodological artifacts, or both?
Intelligence, 26, 337–356.
Rodgers, J. L., & W€anstrom, L. (2007). Identification of
a Flynn effect in the NLSY: Moving from the center to
the boundaries. Intelligence, 35, 187–196.
Sahberg, P., & Oldroyd, D. (2010). Pedagogy for
economic competetiveness an sustainable development. European Journal of Education, 45, 280–299.

768
Sattler, J. M. (2008). Assessment of children: Cognitive
foundations. La Mesa, CA: Sattler.
Spearman, C. (1904). “General intelligence” objectivity
determined and measured. American Journal of
Psychology, 15, 201–293.
Sternberg, R. J. (2005). The triarchic theory of successful
intelligence. In D. P. Flanagan & P. L. Harrison (Eds.),
Contemporary intellectual assessment: Theories, tests
and issues (2nd ed., pp. 103–119). New York:
Guilford.
Thorndike, R. L. (1994). g [editorial]. Intelligence, 19,
145–155.

Promotion of Intellectual Growth
Wai, J., & Putallaz, M. (2011). The Flynn effect
puzzle: A 30-year examination from the right tail
of the ability distribution provides some missing
pieces. Intelligence, 39, 443–456. doi:10.1016/j.
intell.2011.07.006.

Further Reading
Pembrey, M. E. (2007). NOVA Production (produced by
S. Holt & N. Paterson). Ghost in your genes [DVD].
Retrieved May 11, 2010, from http://www.pbs/wgbh/
nova/transcripts/3413_genes.html

Mentoring During Childhood

769

Definitions and Scope

Mentoring During Childhood
Preston A. Britner and Kellie G. Randall
Department of Human Development &
Family Studies, University of Connecticut,
Storrs, CT, USA

Introduction
In recent years, mentoring has become a popular
strategy for fostering health development and
preventing negative outcomes for youth, particularly those considered at risk. It is estimated
that three million youth are in mentoring relationships based in formal programs in the U.S.
(Rhodes & Lowe, 2009). Additionally, government agencies have invested money in programs
that provide mentoring to at-risk children.
Enthusiasm for mentoring as a practice has,
at times, run ahead of the research base regarding its effectiveness. Increasingly, however,
researchers are focusing on documenting
program outcomes and effective practices in
mentoring relationships. We explain the concept
of mentoring children as a prevention strategy,
including a review of theory, research, and
practice.
Much of the research in youth mentoring has
focused on adolescents or has used samples that
range from childhood to adolescence. However,
there are issues unique to mentoring children;
Cavell and Smith (2005) discuss both the
potential barriers and benefits in mentoring children rather than adolescents. They suggest that
a potential disadvantage of focusing on younger
children is that the children’s verbal and cognitive capacities can limit the scope of mentoring
(e.g., make communication more difficult or not
allow for explorations of identity). Advantages
are that most potential mentors will find children
(rather than adolescents) to be more approachable, receptive, and malleable, and that prevention – before significant problem behaviors and
patterns exist – will be more effective than
intervention after the fact.

Rhodes (2002) provided a useful definition of
mentoring as “. . .a relationship between an
older, more experienced adult and an unrelated,
younger protégé – a relationship in which the
adult provides ongoing guidance, instruction,
and encouragement aimed at developing the
competence and character of the protégé” (p. 3).
Mentoring may occur informally or in structured
programs. In this entry, we focus on formal
mentoring programs, because much of the
research on childhood mentoring is done in the
context of formal programs. Instead of relying on
mentoring relationships to form naturally,
programs use a systematic approach to help
youth and adults develop partnerships. Formal
mentoring programs may use evidence-based
and standardized policies, or best practices, to
match adults and children and to ensure that
mentoring relationships effectively meet the
needs of the population being served (Britner
& Kraimer-Rickaby, 2005; Thompson &
Kelly-Vance, 2001).
Formal programs mostly fall into two
categories: community-based and school-based.
In community-based mentoring, the mentor and
protégé usually determine the frequency of their
meetings, which may be an hour a week or a little
as once a month, as well as the location. In-person
meetings can take place at school or other
community settings, such as a movie theater or
a recreational center.
Alternatively, in school-based programs,
mentoring takes place during the school day;
typically the mentor and protégé spend 1 h a
week together engaging in academic and
social activities (Herrera, 2004). Compared to
community-based
programs,
school-based
programs are more likely to serve children who
are having academic or behavioral difficulties in
school and/or who have repeated a grade (Herrera,
Sipe, & McClanahan, with Arbreton, & Pepper,
2000). In this endeavor, school-based mentoring
programs are often more structured and place
greater emphasis on improving students’ academic
performance than community-based programs
(Portwood & Ayers, 2005). Traditionally, most

T.P. Gullotta, M. Bloom (eds.), Encyclopedia of Primary Prevention and Health Promotion,
DOI 10.1007/978-1-4614-5999-6, # Springer Science+Business Media New York 2014

770

mentoring programs have been community based,
but the simplified logistics (i.e., taking place during school hours and using the schools as
a meeting place) of mentoring within schools combined with schools’ needs to find ways to help
individual students succeed has led to an increase
in school-based mentoring.

Theories
Several models have been presented to describe
the process of how mentoring might “work.” The
most widely cited of these models is Rhodes’
“pathways of mentoring influence” model. The
model of youth mentoring proposed by Rhodes
(2002) suggests that there is a crucial step to
mentoring in which mentor and youth protégé
form an emotional bond. Theoretically, only
then can the mentor influence the youth’s developmental outcomes by (a) enhancing social skills
and emotional well-being, (b) improving cognitive skills through dialogue, and (c) serving as
a role model and advocate for the youth.
Positive mentoring relationships can foster
social and emotional development by challenging
the children’s views of themselves in relationships, by providing a “corrective experience”
that generalizes to other relationships, by helping
children regulate their emotions, and by alleviating relationship stress. Mentoring relationships
can enhance identity development through
positive role modeling and also enhance cognitive development through dialogue and listening
(Rhodes, 2002).
Whereas Rhodes’ model is the most popular,
other researchers have proposed ideas to explicate how mentoring works. For example, Parra,
DuBois, Neville, Pugh-Lilly, and Povinelli
(2002) presented a structural model in which
mentoring, followed by the development of
a significant bond, widens the youths’ social support networks, which in turn bolsters self-esteem.
By encouraging trust, autonomy, and initiative,
mentors enhance resilience in development.
Many mentoring researchers place a strong
emphasis on self-esteem as a key variable for
determining resilience in childhood (see entry

Mentoring During Childhood

on “Self-Esteem During Childhood”). Larose
and Tarabulsy’s (2005) sociomotivational
perspective portrays structure, involvement, and
support for autonomy as key elements for student
motivation and academic achievement in
mentoring programs for academically at-risk
children. Keller’s (2005) systemic conceptual
model considers the interdependent network of
relationships established between mentor, child,
parent/guardian, and caseworkers against the
ecological backdrop of agency policies and procedures. Ironically, this important “relationship”
focus has rarely been applied to studies of
mentoring as embedded within larger social systems (Britner & Kraimer-Rickaby, 2009).

Current Research
The prevalence of and support for mentoring programs has grown in recent years at a faster rate
than the body of research on their practices and
outcomes. When studies have been conducted in
the past, many have suffered methodologically
from an over-reliance on anecdotal, observational, and/or self-report data and a failure to
conduct rigorous statistical analyses (Rhodes,
2002). However, there is an increasing body of
literature on the efficacy and effectiveness of
various mentoring programs to meet the needs
of children.
In this section, we begin by presenting broad
results from two meta-analyses on the impact of
mentoring. We then examine some specific studies that address child outcomes and mentoring.
Many studies of mentoring utilize samples that
include both children and adolescents. Therefore,
we conclude this section with a brief discussion
of what is known about the differences in
mentoring children versus adolescents.
Meta-analyses
DuBois, Holloway, Valentine, and Cooper
(2002) published a widely cited and comprehensive meta-analysis of the impact of mentoring in
studies published through 1998. Five outcomes
were
examined:
emotional/psychological,
problem/high-risk behavior, social competence,

Mentoring During Childhood

academic/educational, and career/employment.
Mentoring was found to have a measurable,
significant effect on children and adolescents;
however, the effect size was relatively small
(0.14 and 0.18 under the assumptions of fixed
and random effects, respectively). In particular,
it was found that career development outcomes,
academic outcomes, and problem behaviors were
influenced by mentoring (DuBois et al., 2002).
More recently, DuBois, Portillo, Rhodes,
Silverthorn, and Valentine (2011) completed
a meta-analysis of 73 independent evaluations
of mentoring programs published from 1999 to
2010 (i.e., the era after the first meta-analysis).
Findings were largely consistent with the earlier
analysis, with additional support for gains in
social competence or emotional well-being.
The authors conclude that modest effects
(i.e., approximately a 9 % point advantage for
mentored children over non-mentored children)
are typical, across domains, within the programs
profiled in the analysis.
An important consideration in using
mentoring as a prevention strategy is its usefulness with certain at-risk populations. The DuBois
et al. (2002, 2011) meta-analyses both found that
children from backgrounds of moderate levels of
risk (defined broadly) have the most to gain
and tend to benefit the most from mentoring,
especially when best practices are employed and
strong relationships are formed. This finding
supports the use of mentoring as a prevention
strategy.
Specific Study Outcomes
Whereas a variety of outcomes were examined in
the meta-analyses cited above, most of the individual studies on mentoring in childhood focus
on academic outcomes. These are discussed here
in two categories: school performance and
academic self-concept. There have also been
some findings relating to social development,
which are also discussed.
School performance. Mentoring is often promoted as a remedy for children who are academically at risk or already failing in school (Larose
& Tarabulsy, 2005). Research exploring this
assertion has yielded mixed results. Thompson

771

and Kelly-Vance (2001), using a small sample
of 12 boys involved in Big Brothers Big Sisters
and 13 boys who were on the waiting list for the
program, reported that mentored children made
significantly higher gains on a standardized
intelligence test than the control group, even
after controlling for ability.
Herrera, Grossman, Kauh, and McMaken
(2011), with a large sample of 1,139 youth,
conducted a random assignment study of the
Big Brothers Big Sisters School-Based
Mentoring program; 565 youth were assigned to
the treatment group to receive mentoring and
547 youth were placed on agency wait lists to
serve as a control group. Youth were followed for
1.5 schools years; after the first year, the
mentored youth performed better academically
(as measured by teacher reports) than did the
control group youth.
Not all studies find improvement in academic
performance. Kolar and McBride (2011) studied
a sample of 160 at-risk students in first through
sixth grade who participated in a Big Brothers
Big Sisters mentoring program. At the end of the
program, there were a number of improvements
on some psychological variables, but no
improvements in grades were found. Similarly,
Karcher (2008), in a study of 516 (mostly Latino)
youth randomized to supportive services or
supportive services plus mentoring, found no
effect on grades but several positive social
outcomes (which varied by sex and age).
Academic self-concept. Previous research
suggests that mentored students may benefit academically from the presence of a mentor by
a change in their academic self-perceptions.
A meta-analysis suggests that although the effect
is small, positive self-beliefs, in fact, predict later
achievement, particularly for the academic
domain (Valentine, DuBois, & Cooper, 2004).
Guay, LaRose, and Boivin (2004) found that
school-age children’s academic self-concept
predicted educational attainment level 10 years
later.
In the Herrera et al. (2011) Big Brothers Big
Sisters School-Based Mentoring study, the
randomly assigned treatment group reported
greater improvement in perceptions of their

772

academic abilities than youth in the control
group. Given the promise of past research and
the constant pressure on public schools to “leave
no child behind,” school-based mentoring and its
possible link to enhanced academic outcomes
should continue to be explored.
Social and emotional development. Elledge,
Cavell, Ogle, and Newgent (2010) studied the
impact of a school-based lunchtime mentoring
program for bullied children in grades 4 and 5.
The 24 students in the treatment group met with
a college student mentor twice a week for one
semester. In the study, there were two control
groups: a “same” control group made up of
12 students and the same school and
a “different” control group of 12 children from
another school. At the conclusion of the program,
treatment children experienced greater reductions in peer reports of peer victimization than
children in the “different” control group.
However, there were no statistically significant
differences between treatment children and the
“same” control group; the small sample sizes
might have made it difficult to detect changes,
but until further research is done, it is unclear
what the full impact one-on-one mentoring
might have on children who are bullied.
In the Kolar and McBride (2011) study, there
were improvements on a number of psychological variables. Pre-/post-analyses found that children liked school better, had better classroom
behavior, got along better with peers, and had
increased self-esteem after a year spent with
a mentor. The authors conclude that a relatively
short period of school-based mentoring can have
important impacts on at-risk youth; while these
results are positive, they should be interpreted
with caution, as there was no control group
included in the study.
Focusing on different risk populations, several
recent studies have found effects of mentoring,
often combined with other skills training, on
social and emotional outcomes. Jent and Niec
(2009) randomly assigned 86 children (ages
8–12 years) accessing services at a community
mental health center to a group mentoring intervention or wait-list control group; the mentored
children reported improved social problem-solving

Mentoring During Childhood

skills, and their parents reported that the children
had decreased internalizing and externalizing
behavior problems. Kuperminc, Thomason,
DiMeo, and Broomfield-Massey (2011) found
that urban girls in a youth development program
who were also mentored were more likely
than the program’s non-mentored girls to experience gains in social acceptance and body
image. Taussig and Culhane (2010) employed
a randomized control trial design to test the effectiveness of the Fostering Healthier Futures (FHF)
intervention with 9- to 11-year-old children in
foster care. The intervention group (n = 79)
received an assessment, a manualized skills curriculum, and a 30-week mentoring program with
graduate social work students. At a 6-month
follow-up, the intervention group – relative to
the control group (n = 77) – had fewer mental
health problems and symptoms of dissociation,
and they were also less likely to have received
mental health treatment.
Research on Childhood Versus Adolescent
Mentoring
The age and developmental characteristics of the
mentee can impact mentoring relationship. There
is a larger literature on adolescents (see entry
“▶ Mentoring During Adolescence,” this volume). Some researchers have found that the
mentoring relationships of children are closer
than those of older adolescents (Britner &
Kraimer-Rickaby, 2009; Herrera et al., 2000).
Additionally, mentoring relationships with children have a lower risk of early termination
(Grossman & Rhodes, 2002) and generally have
a longer duration (Rhodes & Lowe, 2009) than
those of older adolescents. In their meta-analyses,
however, DuBois et al. (2002, 2011) found
that effect sizes were similar across different
mentee age groups (childhood/early adolescence
vs. middle/late adolescence).

Overview of Strategies
Research on mentoring has primarily been
concerned with whether specific programs are
associated with improved outcomes for children.

Mentoring During Childhood

There are many different mentoring programs;
they range from programs with a single site to
programs that are widely administered across
many sites. Due to this variability in the nature
of programs, very few have been able to conduct
large-scale, high-quality evaluations to provide
the needed evidence to conclude they “work.”
These programs are presented in the next section.
There has been a recognition among researchers
that much of the impact of mentoring depends on
the quality of implementation (DuBois et al.,
2002, 2011). Moving beyond simply determining
if a program “works” or not, many researchers
have focused on determining program-related
practices that contribute to the success of
mentoring relationships. Because these studies
often do not focus on any one particular program,
they provide generalizable findings that can be
implemented in a variety of mentoring practice
settings.

What Works
A search of the research literature did not uncover
an intervention that met the standard of three
successful trials. Nevertheless, there is evidence
for other interventions and strategies that – while
not meeting the above criteria – yield considerable amounts of evidence and therefore are
widely considered as empirically based. These
interventions and strategies are described in the
next section. Meanwhile, efforts continue to
conduct rigorous research on mentoring during
childhood.

What Is Promising
There are some general program characteristics
that seem to enhance the likelihood of producing
positive outcomes. The DuBois et al. (2002,
2011) meta-analyses found that programs demonstrate a larger effect for mentoring when certain best practices are present. Examples of these
practices, which increased relationship intensity
and longevity, include more than 2 h of intensive
training for mentors, structured group activities

773

for mentors and youth, and a system for ongoing
monitoring of the mentor-protégé match (DuBois
et al., 2002). Other research supports the impact
of “best practices.” For example, practices such
as mentor screening, support, and supervision
were identified as predictors of more positive
outcomes for mentored children (Grossman &
Tierney, 1998; Herrera, 2004).
Most program-level mentoring strategies can
be considered “promising practices.” Many have
shown positive results, but only in a few studies
or in studies that have methodological flaws
and/or small sample sizes. Some have shown
mixed results across studies and more research
is needed to clarify the circumstances under
which the strategies are most effective. To
date, two programs have been studied frequently
enough with consistently positive results to confidently say they stand out as “promising” during
childhood: Big Brothers Big Sisters and Across
Ages. Presented below are summaries of these
two programs and an overview of the research
that supports their effectiveness.
Big Brothers Big Sisters
Big Brothers Big Sisters is a highly structured
program that facilitates one-on-one mentoring
relationships for 5- to 18-year-olds who primarily come from single-parent families. Big
Brother Big Sisters is purely a mentoring program; this makes it unique from other programs
which provide mentoring as one part of an array
of services. Big Brothers Big Sisters is one of the
most widely recognized programs; the agency
estimates that it serves 245,000 youth across
370 separate agencies (Big Brothers Big Sisters,
2009).
Big Brothers Big Sisters is the focus of the
most influential study on the impact of one-onone mentoring on the lives of youth conducted to
date. The study followed 959 youth (487 received
mentors; 472 were waiting list controls) between
the ages 10 and 14 years over a period of
18 months, while the treatment youth were participating in the Big Brothers Big Sisters program
(Tierney, Grossman, & Resch, 1995). Many of
the youth had experienced several parental factors that placed them at risk, including parental

774

divorce or separation or a family history of substance abuse or domestic violence (Grossman &
Tierney, 1998).
Following the intervention, youth in the
treatment group showed significant differences
relative to the waiting list control group in the
domains of antisocial behavior, academic
achievement, and family and peer support.
Compared to youth who did not have a mentor,
youth who had mentors for at least 1 year were
46 % less likely to initiate drug abuse (70 %
less for minority youth) and 27 % less likely to
start using alcohol. These youth were also 32 %
less likely to hit someone, and they skipped, on
average, 42 % fewer days of school (Tierney
et al., 1995).
In the evaluation of the school-based Big
Brothers Big Sisters model (Herrera et al.,
2011), mentees exhibited higher academic
achievement (as measured by teacher report)
and more positive perceptions of their academic
abilities. Herrera et al. did not find any differences between mentees and wait-list youth in
perceptions of their self-worth, relationships
with their parents, or rates of problem behavior.
They suggest that the school-based programs
may impact primarily school-related outcomes,
whereas community-based models may influence
a broader range of outcomes.
Mentoring Plus: Across Ages
According to Sipe (1996), combining mentoring
with other services may increase the efficacy of
the mentoring relationship to promote positive
outcomes for youth. The most widely cited
example of a “mentoring plus” model is Across
Ages. Across Ages is an intergenerational and
comprehensive drug prevention program that
provides youth with older mentors (aged
55 and older). In addition to mentoring, Across
Ages provides youth with community service
activities, positive youth development (e.g., life
skills development), and parental involvement.
It is the only program with a mentoring component that has been identified as a “model
program” through the Substance Abuse and
Mental Health Administration’s National Registry of Evidence-based Programs and Practices

Mentoring During Childhood

(Substance Abuse and Mental Health Service
Administration, 2008).
LoSciuto, Rajala, Townsend, and Taylor
(1996) investigated the effectiveness of the
Across Ages program using a random assignment
pretest-posttest design; 159 youth were divided
into three groups: group C, the control group;
group PS, which was comprised of youth who
received positive youth development, participated in community services activities, and had
parent workshops; and group MPC, which was
made up of youth who received mentoring in
addition to positive youth development, community services activities, and participated in parent
workshops. Youth were followed for one
academic year. Youth who received mentoring
in combination with other services had fewer
absences from school, used drugs less frequently,
and had a more positive attitude toward school,
the future, and elders.
In another study of the Across Ages program
(Aseltine, Dupre, & Lamlein, 2000), the most
dramatic changes in self-confidence also were
attributable to the combination of mentoring,
community service, and positive youth development curriculum. Perhaps because of the experimental research findings and the program’s
flexible delivery (in school- or communitybased settings), Across Ages has maintained its
popularity, while some other models have fallen
out of favor.

What Does Not Work
Poor mentoring relationships and matches that
disrupt within 3 months or matches that meet
inconsistently can have negative emotional,
psychological, and cognitive consequences
(Grossman & Rhodes, 2002; Sipe, 1996). For
example, Grossman and Rhodes (2002) found
that Big Brothers Big Sisters youth whose
matches terminated within the first 3 months suffered significant declines in their global selfworth and their perceived scholastic competence;
conversely, relationships that lasted more than
12 months reported the greatest number of positive outcomes (Grossman & Rhodes, 2002).

Mentoring During Childhood

In a study of the Big Brothers Big Sisters SchoolBased program (using the same samples as the
Herrera et al. study discussed above), Grossman,
Chan, Schwartz, and Rhodes (2011) found that
although treatment children on average had
academic improvements, children whose match
terminated prematurely did not experience any
such improvement. Additionally, children who
were rematched after a failed mentoring relationship actually showed negative impacts. In order
to detect any benefit, Rhodes (2002) has
suggested that mentors meet with their protégés
for a minimum of 4 h per month for at least
1 year.

Summary
Whereas some questions remain about the overall
effectiveness of mentoring in childhood, we do
know that when implemented effectively
mentoring can be an effective prevention strategy. Both community- and school-based programs have demonstrated impacts on children’s
academic performance, academic self-concepts,
and social/emotional development, though there
are often limits to the effectiveness of any one
program (e.g., attitudes toward school improve
but grades do not). Mentoring usually works best
for children who have a moderate level of risk,
making it an appealing prevention strategy. Additionally, the idea has been put forth that
mentoring that begins in childhood, as opposed
to in adolescence, might be more effective as it
serves a protective function and can help prevent
children from going on to develop negative
behaviors.
Perhaps most important to keep in mind when
reviewing the effectiveness of mentoring is that
most of the benefits of mentoring accrue only
after mentor and mentee have spent a significant
amount of time together; short-term or failed
matches can have no effect or even negative
effects. When mentoring takes place within
formal programs, as is the case in many instances,
it is important that programs follow best practices
as far as recruiting, training, and assigning
mentors.

775

See Also
▶ Mentoring During Adolescence
▶ Resiliency During Childhood
▶ Social and Emotional Learning During Early
Childhood

References
Aseltine, R. H., Dupre, M., & Lamlein, P. (2000).
Mentoring as a drug prevention strategy: An evaluation of across ages. Adolescent and Family Health, 1,
11–20.
Big Brothers Big Sisters. (2009). Big Brothers Big Sisters
of America: Annual report. Philadelphia: Author.
Retrieved March 1, 2012, from http://www.bbbs.org/
atf/cf/%7B8778d05c-7ccb-4dee-9d6e-70f27c016cc9%
7D/ANNUAL%20REPORT%20WEB%20(3).PDF
Britner, P. A., & Kraimer-Rickaby, L. (2005). Abused and
neglected youth. In D. L. DuBois & M. J. Karcher
(Eds.), Handbook of youth mentoring (pp. 482–492).
Thousand Oaks, CA: Sage.
Britner, P. A., & Kraimer-Rickaby, L. (2009). Mentoring
and its role in promoting academic and social
competency. In T. P. Gullotta, M. Bloom, C. F.
Gullotta, & J. C. Messina (Eds.), A blueprint for
promoting academic and social competence in
after-school programs (pp. 79–100). New York:
Springer.
Cavell, T. A., & Smith, A.-M. (2005). Mentoring children.
In D. L. DuBois & M. J. Karcher (Eds.), Handbook of
youth mentoring (pp. 160–176). Thousand Oaks, CA:
Sage.
DuBois, D. L., Holloway, B. E., Valentine, J. C., &
Cooper, H. (2002). Effectiveness of mentoring
programs for youth: A meta-analytic review.
American Journal of Community Psychology, 30,
157–192.
DuBois, D. L., Portillo, N., Rhodes, J. E., Silverthorn, N.,
& Valentine, J. C. (2011). How effective are mentoring
programs for youth? A systematic assessment of the
evidence. Psychological Science in the Public Interest,
12, 57–91.
Elledge, L., Cavell, T. A., Ogle, N. T., & Newgent, R. A.
(2010). School-based mentoring as selective
prevention for bullied children: A preliminary test.
The Journal of Primary Prevention, 31, 171–187.
Grossman, J. B., Chan, C. S., Schwartz, S. E. O., &
Rhodes, J. E. (2011). The test of time in school-based
mentoring: The role of relationship duration and
re-matching on academic outcomes. American Journal
of Community Psychology, 49, 43–54.
Grossman, J. B., & Rhodes, J. E. (2002). The test of time:
Predictors and effects of duration in youth mentoring
relationships. American Journal of Community
Psychology, 30, 199–219.

776
Grossman, J. B., & Tierney, J. P. (1998). Does mentoring
work? An impact study of the Big Brothers Big Sisters
program. Evaluation Review, 22, 403–426.
Guay, F., LaRose, S., & Boivin, M. (2004). Academic
self-concept and educational attainment level:
A ten-year longitudinal study. Self and Identity, 3,
53–68.
Herrera, C. (2004). School-based mentoring: A closer
look. Philadelphia: Public/Private Ventures.
Herrera, C., Grossman, J. B., Kauh, T. J., &
McMaken, J. (2011). Mentoring in schools: An impact
study of Big Brothers Big Sisters school-based
mentoring. Child Development, 82, 346–361.
Herrera, C., Sipe, C. L., McClanahan, W. S.,
Arbreton, A. J. A., & Pepper, S. K. (2000). Mentoring
school-age children: Relationship development in
community-based and school-based programs.
Philadelphia: Public/Private Ventures.
Jent, J., & Niec, L. N. (2009). Cognitive behavioral
principles within group mentoring: A randomized
pilot study. Child and Family Behavior Therapy, 31,
203–219.
Karcher, M. J. (2008). The Study of Mentoring in the
Learning Environment (SMILE): A randomized evaluation of the effectiveness of school-based mentoring.
Prevention Science, 9, 99–113.
Keller, T. E. (2005). A systemic model of the youth
mentoring intervention. The Journal of Primary
Prevention, 26, 169–188.
Kolar, D. W., & McBride, C. A. (2011). Mentoring at-risk
youth in schools: Can small doses make a big change?
Mentoring & Tutoring: Partnership in Learning, 19,
125–138.
Kuperminc, G. P., Thomason, J., DiMeo, M., &
Broomfield-Massey, K. (2011). Cool Girls, Inc.:
Promoting the positive development of urban
preadolescent and early adolescent girls. The Journal
of Primary Prevention, 32, 171–183.
Larose, S., & Tarabulsy, G. M. (2005). Academically
at-risk students. In D. L. DuBois & M. J. Karcher
(Eds.), Handbook of youth mentoring (pp. 440–453).
Thousand Oaks, CA: Sage.
LoSciuto, L., Rajala, A. K., Townsend, T. N., &
Taylor, A. S. (1996). An outcome evaluation of Across

Mentoring During Childhood
Ages: An intergenerational mentoring approach to
drug prevention. Journal of Adolescent Research, 11,
116–129.
Parra, G. R., DuBois, D. L., Neville, H. A.,
Pugh-Lilly, A. O., & Povinelli, N. (2002). Mentoring
relationships for youth: Investigation of a processoriented model. Journal of Community Psychology,
30, 367–388.
Portwood, S. G., & Ayers, P. M. (2005). Schools. In
D. L. DuBois & M. J. Karcher (Eds.), Handbook of
youth mentoring (pp. 336–347). Thousand Oaks, CA:
Sage.
Rhodes, J. E. (2002). Stand by me: The risks and rewards
of mentoring today’s youth. Cambridge, MA: Harvard
University Press.
Rhodes, J. E., & Lowe, S. R. (2009). Mentoring in
adolescence. In R. M. Lerner & L. Steinberg (Eds.),
Handbook of adolescent psychology: vol 2. Contextual
influences on adolescent development (pp. 152–190).
New York: Wiley.
Sipe, C. (1996). Mentoring: A synthesis of PP/PV’s
research: 1988–1995. Philadelphia: Public/Private
Ventures.
Substance Abuse and Mental Health Service Administration. (2008). SAMHSA’s National Registry of
Evidence-based Programs and Practices. Rockville,
MD: SAMHSA. Retrieved March 1, 2012,
from
http://nrepp.samhsa.gov/ViewIntervention.
aspx?id=138
Taussig, H. N., & Culhane, S. E. (2010). Impact of
a mentoring and skills group program on mental health
outcomes for maltreated children in foster care.
Archives of Pediatrics and Adolescent Medicine, 164,
739–746.
Thompson, L. A., & Kelly-Vance, L. (2001). The impact
of mentoring on academic achievement of at-risk
youth. Children and Youth Services Review, 23, 7–42.
Tierney, J. P., Grossman, J. B., & Resch, N. L. (1995).
Making a difference: An impact study of Big Brothers
Big Sisters. Philadelphia: Public/Private Ventures.
Valentine, J. C., DuBois, D. L., & Cooper, H. (2004).
The relation between self-beliefs and academic
achievement: A meta-analytic review. Educational
Psychologist, 39, 111–133.

Nutrition During Early Childhood

Nutrition During Early Childhood
David L. Katz1, Valentina Vinante2 and
Kimberly Doughty3
1
Yale-Griffin Prevention Research Center,
Derby, CT, USA
2
Department of Public Health, University of
Florence, Florence, Italy
3
Yale-Griffin Prevention Research Center,
Derby, CT, USA

Introduction
Nutritional status between conception and the age
of 5 years is strongly associated with growth and
development. Children in this age group are
uniquely vulnerable to the adverse effects of dietary deficiencies, both physiologically, because of
high metabolic demand, and socially, because of
lack of autonomy. This age group may be particularly vulnerable to the long-term sequelae of
overnutrition as well, with increasing evidence
that overweight early in life predicts later obesity –
as does maternal overnutrition during pregnancy.
The primary prevention of short- and long-term
sequelae of both over- and undernutrition in this
age group is achievable through the application of
health and nutrition knowledge, the provision of
social services, and the exercise of political will.

Definitions
In utero growth and development is divided into
the embryological period (approximately first
12 weeks following conception) during which
organ systems are forming and the fetal period
(the latter two trimesters of pregnancy) during
which organ systems have all formed and are
maturing. The neonatal period refers to the first
1 month of life following birth. Infancy begins at
the end of the neonatal period and lasts until
12 months of age. The definition of early childhood varies but usually refers to the period of
time before formal schooling begins, up to age
5. Malnutrition generally refers to deficient

777

intake of macronutrients (i.e., protein, carbohydrate, fat) and/or micronutrients (i.e., vitamins,
minerals). However, adverse nutriture may be
either deficient or excessive; overnutrition is
also a form of malnutrition.
Scope
Optimal nutriture has the potential to promote
cognitive and physical development and to prevent infectious disease or mitigate its consequences (Haider, Yakoob, & Bhutta, 2011). In
contrast, varying degrees of suboptimal nutrition
threaten physical and cognitive development,
impair sensory organ function and impair
immune function, and increase susceptibility
to infectious disease and its consequences.
In developing countries, the most prevalent and
dire hazards of malnutrition during the period
from conception through early childhood are
undernutrition and hunger (manifesting as
wasting, stunting, and vulnerability to infection)
and specific nutrient deficiency syndromes
(e.g., deficiency of vitamin A resulting in xerophthalmia, of iron resulting in anemia, of zinc leading to increased respiratory infections and
diarrhea). In developed countries, the most prevalent nutrition-related problems in early childhood include congenital abnormalities, low birth
weight (LBW), macrosomia or large for gestational age (LGA), obesity, micronutrient
deficiencies, and suboptimal nutrient status,
such as relative deficiency of omega-3 fatty acid
intake. Although severe undernutrition and
hunger are not common in the developed world,
food insecurity and micronutrient deficiencies
resulting from “hidden hunger” are salient,
particularly among children from low-income
families.
The prevalence of birth defects in the USA is
approximately 32 % of all live births. The prevalence of some severe birth defects is higher
when stillbirths and terminations are considered.
For example, the rate of anencephaly is 0.55 per
10,000 live births but 2.54 per 10,000 including
stillbirths and terminations. Birth defects account
for 20 % of infant mortality in the USA and in
2004 were associated with $2.6 billion in hospital
costs alone (Parker et al., 2010).

T.P. Gullotta, M. Bloom (eds.), Encyclopedia of Primary Prevention and Health Promotion,
DOI 10.1007/978-1-4614-5999-6, # Springer Science+Business Media New York 2014

778

Excess energy intake, a particular threat in
countries of the West, has the potential to promote childhood obesity, diabetes, and susceptibility to other chronic degenerative diseases in
adulthood. The rate of obesity among young children aged 2–5 years was approximately 10 % in
2005–2008 (U.S. Department of Health and
Human Services, n.d.). There is some evidence
that fetal undernutrition or overnutrition may
predispose infants to obesity, insulin resistance,
and cardiovascular disease in adulthood. Both
large for gestational age and low birth weight,
particularly when combined with subsequent
excess energy intake and weight gain, are associated with these long-term risks (Cox & Phelan,
2008). In 2010, the rate of LBW in the USA was
8.15 % (Martin et al., 2012). The rate of LGA
was 8.9 % in the overall population in 2005
(Donahue, Kleinman, Gillman, & Oken, 2010).
It is estimated that two billion people worldwide
subsist on diets lacking essential nutrients needed
for growth, development, and physiological
maintenance, and 925 million people are undernourished, lacking sufficient food to meet their
basic nutritional needs for protein and energy
(World Hunger Education Service, 2011). On
the contrary, people from Western, affluent countries suffer mainly from overnutrition.
Micronutrient deficiencies are relatively
uncommon in the USA compared with developing countries. However, deficiencies are of concern for certain micronutrients in specific
populations. Subclinical insufficiency is also
fairly prevalent for several nutrients.
Anemia is the most common nutrient-related
abnormality of pregnancy and is attributable to
iron deficiency nearly 90 % of the time, with the
remainder due primarily to folate deficiency.
Maternal hemoglobin during pregnancy should
consistently be higher than 11 gm/dl to assure adequate oxygen delivery to the fetus. Iron deficiency
anemia has been found to be associated with LBW,
preterm births, and developmental delays in infants
and children (Sachdev, Gera, & Nestel, 2005;
Scholl, 2011). In 2003–2006, 16.1 % of pregnant
women in their third trimester were anemic, and the
target for Healthy People 2020 is to reduce the
number to 10 % or less. During the period of

Nutrition During Early Childhood

2005–2008, the rates of iron deficiency were
15.9 % for children aged 1–2 years and 5.3 % for
children aged 3–4 years. The goals are to reduce the
rates to 10 % and 1 % for these respective age
groups by 2020 (U.S. Department of Health and
Human Services, n.d.).
Deficiency of vitamin D, typically defined as
serum 25-hydroxyvitamin D concentration
between 10 and 15 ng/mL, is rare among young
children in the USA; in 2003–2006, the prevalence of low serum 25-hydroxyvitamin
D (<12 ng/mL) was 0.7 % among children ages
1–5 years (Centers for Disease Control and
Prevention [CDC], 2012). Approximately 9 %
of this population had suboptimal vitamin
D status (12–20 ng/mL). However, infants and
children living in the northern USA, particularly
during winter months, are at greater risk for deficiency. Among neonates born in Boston, Massachusetts, between October and February,
prevalence rates of vitamin D deficiency and
insufficiency were 9.7 % and 56.4 %, respectively, among white neonates and 45.6 % and
46.8 % among black neonates. Exclusively
breastfed infants are also at risk if they do not
receive supplements. In one study, 78 % of these
infants were vitamin D insufficient in the winter
(Rovner & O’Brien, 2008). Vitamin D status is
also a concern during pregnancy. In the USA,
approximately 7 % of pregnant or lactating
women are at risk of deficiency and 21 % are at
risk of inadequacy (Looker et al., 2011).
In the USA alone, it is estimated that national
health-care expenditures for 2010 totaled $2.6
trillion, of which 30 % were related to inappropriate diet (Thorpe, 2006). However, these estimates are crude, as the actual costs over time of,
for example, subtle impairments in cognitive
function attributable to suboptimal nutriture at
a population level are largely incalculable.

Theories
Childhood overweight and obesity, arguably the
most pressing nutrition problem among children
in the USA, is often conceptualized using one of
several variations of a social ecological model.

Nutrition During Early Childhood

One such model, ecological systems theory
(EST), emphasizes the importance of context in
human development (Davison & Birch, 2001).
The contexts that are important to child development include, from the most to least immediate,
the family, school, community, and society. Individual child characteristics, such as age and gender, interact with characteristics within the other
contexts to influence children’s weight status.
Research based on EST acknowledges the multiple levels of influence in the environment. An
adaptation of EST that emphasizes the specific
contextual factors influencing behaviors within
the family is the Family Ecological Model
(Davison, Jurkowski, & Lawson, 2012). This
model may be particularly useful for research
focused on parenting and family characteristics.
The theory of planned behavior (TPB) is
another prominent behavioral theory in child
nutrition. The TPB describes the interaction of
perceived behavioral control, attitudes, and social
norms influencing behavioral intention. Behavioral intention is assumed to predict behavior.
(Ajzen, 1991). The TPB has been applied to
research in breastfeeding (REF) and child feeding
practices (Swanson et al., 2011).

Current Research
During pregnancy, the increased micronutrient
requirements exceed the increased energy
requirements. Therefore, vitamin supplementation during pregnancy is universally indicated,
and the nutrient density of foods assumes
increased importance. The prevention of
micronutrient deficiencies is a prime concern for
pregnant women, even in developed countries.
There
is
definitive
evidence
that
periconceptional
folate
supplementation
decreases the incidence of neural tube defects
(Cox & Phelan, 2008). The maternal diet is
often deficient in calcium, iron, vitamin D, and
other micronutrients, and supplementation with
a prenatal vitamin throughout pregnancy is indicated. Vitamin A at doses in the range of
10,000 IU per day is teratogenic and to be
avoided during pregnancy. Carotenoids with

779

vitamin A activity are safe. Caloric needs rise in
pregnancy, but excessive weight gain is potentially disadvantageous to both mother and fetus.
The Institute of Medicine recommends that
women who are normal weight prior to pregnancy gain between 25 and 35 lb. Underweight
women should gain 28–40 lb, overweight women
15–25 lb, and obese women just 15 lb. Underweight in the mother is associated with preterm
birth, low birth weight, and perinatal morbidity
and mortality. Maternal overweight is associated
with increased risks of gestational hypertension,
diabetes, and preeclampsia in the mother and
macrosomia, congenital anomalies, neonatal
infections, hypoglycemia, and respiratory distress in infants. Delivery complications including
Cesarean sections and stillbirths are also more
likely (Cox & Phelan, 2008). Nutritional support
of malnourished women during pregnancy is, in
general, approached as is malnutrition under
other circumstances. The topic has been previously reviewed (Hamaoui & Hamaoui, 2003).
In general, pregnancy requires a calorie
increase over baseline of approximately
300 kcal/day, and lactation requires 500 kcal/
day. Nutrients for which the recommended daily
allowance (RDA) is specifically raised in pregnancy include total protein, total energy, magnesium, iodine, zinc, selenium, vitamin E,
vitamin C, thiamin, niacin, iron, calcium, and
folate. Lactation requires further increases in protein, zinc, vitamin A, vitamin E, vitamin, C, and
niacin. Requirements for iron and folate actually
decline (see Table 1). These adaptations in the
maternal diet are necessary to assure optimal
nutrition for the fetus/newborn.
Human milk is appropriate as the sole source
of infant nutrition for up to 6 months provided it
is free of dangerous contaminants or pathogens
(e.g., the HIV). There is uncertainty whether milk
meets all of the infant’s nutritional needs beyond
this point. Breastfeeding, under most circumstances, is the preferred nutritional source for
neonates. A generous intake of dietary calcium,
and continued use of prenatal vitamins, is indicated throughout the period of lactation.
Breast milk and infant formulas differ substantially in a variety of nutrients (Huisman

780

Nutrition During Early Childhood

Nutrition During Early Childhood, Table 1 Recommended nutrient intake changes associated with pregnancy and
lactation, select nutrients. Entries are recommended dietary allowances (RDA) or adequate intake (AI) levels
Nutrient
Calcium
Chromium
Folatea,b
Iodine
Iron
Magnesium
Niacinc
Protein
Riboflavin
Selenium
Thiamin
Vitamin Ad
Vitamin B12
Vitamin B6
Vitamin C
Vitamin De,f
Vitamin Eg
Vitamin K
Zinc

Recommended intake by subject category
Female, age 19–30
Female, age 31–50
1,000 mg
1,000 mg
25 mg
25 mg
400 mg
400 mg
150 mg
150 mg
18 mg
18 mg
310 mg
320 mg
14 mg NE
14 mg NE
46 g
46 g
1.1 mg
1.1 mg
55 mg
55 mg
1.1 mg
1.1 mg
700 mg RE
700 mg RE
2.4 mg
2.4 mg
1.3 mg
1.3 mg
75 mg
75 mg
15 mg
15 mg
15 mg TE
15 mg TE
90 mg
90 mg
8 mg
8 mg

Pregnancy age 19–30
1,000 mg
30 mg
600 mg
220 mg
27 mg
350 mg
18 mg NE
71 g
1.4 mg
60 mg
1.4 mg
770 mg RE
2.6 mg
1.9 mg
85 mg
15 mg
15 mg TE
90 mg
11 mg

Lactation age 19–30
1,000 mg
45 mg
500 mg
290 mg
9 mg
310 mg
17 mg NE
71 g
1.6 mg
70 mg
1.4 mg
1,300 mg RE
2.8 mg
2.0 mg
120 mg
15 mg
19 mg TE
90 mg
12 mg

Adapted by author, 2012
Sources: Dietary Reference Intakes for Calcium, Phosphorous, Magnesium, Vitamin D, and Fluoride (1997); Dietary
Reference Intakes for Thiamin, Riboflavin, Niacin, Vitamin B6, Folate, Vitamin B12, Pantothenic Acid, Biotin, and
Choline (1998); Dietary Reference Intakes for Vitamin C, Vitamin E, Selenium, and Carotenoids (2000); Dietary
Reference Intakes for Vitamin A, Vitamin K, Arsenic, Boron, Chromium, Copper, Iodine, Iron, Manganese, Molybdenum, Nickel, Silicon, Vanadium, and Zinc (2001); Dietary Reference Intakes for Water, Potassium, Sodium, Chloride,
and Sulfate (2005); and Dietary Reference Intakes for Calcium and Vitamin D (2011). These reports may be accessed via
www.nap.edu
a
As dietary folate equivalents (DFE). 1 DFE = 1 mg food folate = 0.6 mg of folic acid from fortified food or as
a supplement consumed with food = 0.5 mg of a supplement taken on an empty stomach
b
In view of evidence linking folate intake with neural tube defects in the fetus, it is recommended that all women capable
of becoming pregnant consume 400 mg from supplements or fortified foods in addition to intake of food folate from
a varied diet
c
As niacin equivalents (NE). 1 mg of niacin = 60 mg of tryptophan; 0–6 months = preformed niacin (not NE)
d
As retinol activity equivalents (RAEs). 1 RAE = 1 mg retinol, 12 mg b-carotene, 24 mg a-carotene, or 24 mg bcryptoxanthin. The RAE for dietary provitamin A carotenoids is twofold greater than retinol equivalents(RE), whereas
the RAE for preformed vitamin A is the same as RE
e
As cholecalciferol. 1 mg cholecalciferol = 40 IU vitamin D
f
Under the assumption of minimal sunlight
g
As a-tocopherol. a-Tocopherol includes RRR-a-tocopherol, the only form of a-tocopherol that occurs naturally in
foods, and the 2R-stereoisomeric forms of a-tocopherol (RRR-, RSR-, RRS-, and RSS-a-tocopherol) that occur in
fortified foods and supplements. It does not include the 2S-stereoisomeric forms of a-tocopherol (SRR-, SSR-, SRS-,
and SSS-a-tocopherol), also found in fortified foods and supplements

et al., 1996). The significance of all of the differences has yet to be established. Human milk
contains a variety of nutrient and non-nutrient
compounds, including secretory IgA (sIgA),
oligosaccharides which promote the growth of
beneficial gut bacteria, cytokines, lactoferrin,

essential fatty acids, enzymes, hormones, and
growth factors, among others. Provided that
a sanitary water supply is available, the safety
of formula is generally not of concern.
Soy-based formulas are available for infants
intolerant of bovine milk protein. Properly

Nutrition During Early Childhood

nourished, the healthy infant should double in
weight by 4–5 months and triple in weight by
12 months. Demand feeding is the preferred
method of assuring adequate energy intake.
The epidemiology of nutrition-related health
problems in children in developed countries has
changed dramatically in the latter half of the twentieth century. Childhood obesity is considerably
more common in the USA than is over malnutrition. Most children consume calories, sugar, and
total dietary fat in excess of recommendations and
fail to consume the recommended quantities of
fruits and vegetables (Garipagaoglu et al., 2008;
St-Onge, Keller, & Heymsfield, 2003).
In the USA, dietary guidelines for the general
population begin at or around age 2 years;
a transition from breast milk to a variety of nutritious foods is advised starting at about 6 months
of age and extending through the first year of life
(Gidding et al., 2006; U.S. Department of Agriculture [USDA], 2010).

781
Nutrition During Early Childhood, Table 2 Nutritionrelated goals for early childhood by stage of development
Stage of early
childhood
Conception
through birth

Birth through
12 months

Ages 1–5 years

Goals
Prevent birth defects
Ensure optimal brain development
Achieve appropriate birth weight and
gestational length
Ensure adequate growth
Ensure optimal cognitive and motor
development
Prevent anemia and iron deficiency
Prevent vitamin D deficiency
Prevent infections and allergy
Promote development of healthy
eating habits to prevent later obesity
Ensure adequate growth
Prevent obesity
Promote healthy eating habits to
prevent later obesity and chronic
disease

Strategies That Work
Overview of Strategies
The period of early childhood encompasses
a wide range of developmental stages. Therefore,
the discussion of nutrition-related goals for health
promotion in this age group is broken down further into three periods: conception to birth, birth
through 12 months, and ages 1–5 years.
A summary of the most salient goals for each
stage is provided in Table 2. In general, strategies
for improving nutrition during early childhood
include those aimed at preventing micronutrient
deficiencies, preventing adverse pregnancy and
birth outcomes that may have long-term health
consequences, preventing overweight and obesity throughout the life span, and improving overall diet quality by encouraging consumption of
healthy foods (e.g., fruits, vegetables, whole
grains, low-fat dairy, lean proteins, and unsaturated fat sources) and discouraging consumption
of energy-dense/nutrient-poor foods (e.g., added
sugars and salt, saturated and trans fats, and
refined carbohydrates). The prevention of autoimmune diseases including type 1 diabetes and
allergies is also relevant.

Conception to Birth
Optimal development in utero is associated with
several nutrients in particular. Supplementation
with approximately 400 mg of folic acid per day
beginning prior to conception markedly reduces
the risk of neural tube defects, including anencephaly and spina bifida. Evidence for this association has been extensively reviewed and is
considered definitive (Wolff, Witkop, Miller, &
Syed, 2009). Ingestion of more than 1 mg per day
of folate is generally not recommended. However, in women with prior pregnancies leading
to neural tube defects, the ingestion of up to 4 mg
per day of folate may confer additional benefit.
Pregnancy consumes approximately 1,040 mg
of iron in total, of which 200 mg is recaptured
after pregnancy from the expanded red cell mass
and 840 mg is permanently lost. An intake of
between 13 and 40 mg per day is recommended
during the third trimester for all women. Vitamin/
mineral supplements generally contain 30 mg of
iron, and diet (in the USA) provides an additional
15 mg, easily meeting the needs of most women
without anemia. Women with iron deficiency

782

anemia during pregnancy require increased
intake to replete bone marrow stores and still
provide for the metabolic needs of the fetus.
In this situation, daily intake of between
120 and 150 mg of iron is typically required.
Iron supplementation prior to conception will
facilitate meeting the iron needs of pregnancy
and lactation, which together result in a net loss
of between 420 and 1,030 mg of elemental iron.
To minimize the risk for preterm delivery, low
birth weight, macrosomia, and pregnancy and
neonatal complications, maternal weight gain
should be neither inadequate nor excessive.
Ideally, a healthy body weight should be
achieved prior to pregnancy. Adverse outcomes
are significantly reduced in normal weight, overweight, and obese pregnant women who gain
weight within recommended ranges, compared
with those who gain excess weight (Crane,
White, Murphy, Burrage, & Hutchens, 2009).
A 2012 meta-analysis of randomized controlled
trials found significant benefits of diet and
lifestyle interventions during pregnancy, particularly those that were diet based, on several
pregnancy outcomes relevant to infant health
(Thangaratinam et al., 2012). Overall, interventions were associated with a significant 1.42 kg
reduction in gestational weight gain relative to
control conditions. Dietary interventions specifically were associated with a greater reduction of
3.84 kg (95 % CI [2.45, 5.22]). Although there
were no significant differences in birth weight or
incidence of LGA or SGA, interventions were
associated with reduced relative risks of preeclampsia (RR 0.74, 95 % CI [0.60, 0.92]) and
shoulder dystocia (RR 0.39, 95 % CI [0.22,
0.70]). Likewise, evidence to date suggests that
treatment of gestational diabetes significantly
reduces risks of macrosomia, preeclampsia, and
shoulder dystocia, without increasing risk of
SGA (Falavigna et al., 2012). Among women at
risk for hypertension who also have low calcium
intakes, calcium supplementation during pregnancy is effective in reducing the risk for preeclampsia (Patrelli et al., 2012).
The Special Supplemental Nutrition Program
for Women, Infants, and Children (WIC) is
designed to meet the nutritional needs of

Nutrition During Early Childhood

women and infants in the USA and assists nearly
one million women annually in meeting nutritional needs during pregnancy. Prenatal WIC
participation has been consistently associated
with lower rates of low birth weight and very
low birth weight, but this association is weakened
by adjustment for gestational age bias (USDA,
2012).
Birth to 12 Months
Evidence is convincing that breastfeeding confers protection against infections, particularly
gastrointestinal infections and ear infections.
There is also considerable evidence for protection
against asthma, obesity, and eczema and possible
evidence for protection against atopy (allergy),
childhood leukemia, type 1 and type 2 diabetes,
Crohn’s disease, and respiratory infections
(Agostini et al., 2009). The prevailing view is
that breast milk favors optimal brain development, and breastfeeding is associated with greater
intelligence, at least during childhood, although
such observations are subject to confounding.
There are few contraindications to breastfeeding. These include maternal HIV infection
or exposure to radiation and the presence of
certain inborn errors of metabolism in the
infant, such as galactosemia or congenital lactase
deficiency. Although medications and environmental contaminants pass into breast milk,
most do so in negligible concentrations and pose
little to no risk. In most cases, the benefits of
breastfeeding outweigh these risks. However,
careful selection of medication is advised to minimize the potential for adverse effects (Agostini
et al., 2009).
Maternal diet strongly influences the fatty acid
and vitamin composition of breast milk but generally exerts a modest influence on minerals, with
the exception of iodine (Valentine & Wagner,
2013). Continued use of prenatal vitamins during
lactation to maintain sufficient maternal micronutrient status is recommended. It is also
recommended that pregnant or breastfeeding
women consume 300–1,000 mg of DHA per
day. Vitamins D and K are generally at low levels
in breast milk, and supplementation is
recommended. Breastfed infants should receive

Nutrition During Early Childhood

400 IU of vitamin D per day beginning within
a few days of birth. Infant formulas already
contain this amount of vitamin D. Vitamin K is
usually given by injection to all newborns shortly
after birth.
Recommended dietary allowances (RDAs)
have been established for essential nutrients
for both the first and second 6-month intervals
of life (see Table 2). Iron deficiency is the
most common nutrient deficiency in early childhood. Strategies useful in the prevention of
iron deficiency among children include promoting breastfeeding, using iron-fortified formulas
if formulas are used, and introducing ageappropriate, iron-rich solid foods (CDC, 1998).
Another often overlooked but simple and effective strategy for improving iron status in infants is
delayed clamping of the umbilical cord after
birth. A 2007 meta-analysis concluded that
delaying cord clamping for at least 2 minutes
reduced the risks of anemia and iron deficiency
at ages 2–3 months by 47 % and 33 %, respectively. Measures of iron status were improved for
as long as 6 months (Hutton & Hassan, 2007).
Infant formula is fortified with iron; as a result,
iron deficiency is of little concern in formula-fed
infants. The American Academy of Pediatrics
(AAP) recommends that all breastfed infants
receive 1 mg of supplemental iron per kg of
body weight beginning at age 4 months and that
preterm breastfed infants, who have lower iron
stores at birth, receive 2 mg/kg of body weight
beginning at 1 month of age and continuing until
12 months (Baker, Greer, & The Committee on
Nutrition, 2010). However, the appropriateness
of a recommendation for universal supplementation has been questioned because it was based on
the findings of few short-term studies demonstrating only modest benefit (Schanler et al.,
2011). Ziegler and colleagues assessed iron status
among unsupplemented breastfed infants in the
USA (Ziegler, Nelson, & Jeter, 2011). Among the
291 infants included, 2.75 % developed iron deficiency anemia (IDA) in the first 6 months of life,
but all were born with low plasma ferritin levels,
indicating low birth iron endowment. Another
2.75 % developed iron deficiency (ID) in the
first 6 months, not all of whom were born with

783

low birth iron endowment. No infant developed
IDA in the second 6 months of life, but 5.6 %
developed ID. Iron supplementation beginning as
early as 1 month of age is almost certainly advisable in infants who have risk factors for
deficiency, namely, preterm delivery, intrauterine growth restriction, low birth weight, maternal
iron deficiency, and poorly controlled maternal
diabetes (Rao & Georgieff, 2007). Although
current guidelines include supplementation in
breastfed babies without risk factors beginning
at 4 months of age, the effectiveness of this
strategy in improving long-term outcomes like
growth and cognitive development is not entirely
clear.
By 6 months of age, gastrointestinal physiology is substantially mature, and infants metabolize most nutrients comparably to adults. Nutrient
needs can be met with breast milk or formula (see
Table 3), but most authorities advocate the gradual introduction of solid foods beginning at or
around 6 months. Completion of weaning to
solid food by 1 year of age is common practice
and appropriate. Cow’s milk should not be used
as a main drink until 1 year of age, mainly
because it is not an adequate source of iron
(Agostini et al., 2008).
The nutrient recommendations for infants
6–12 months of age are based largely on extrapolation from the first 6-month period; less is
known about the nutrient needs of infants 6–12
months old. There is controversy regarding
whether introduction of complementary foods
should begin at 4 or 6 months of age. However,
there is a consensus on the practice of delaying
solid foods until at least 4 months. Prior to this
time, infants do not have a sufficiently mature
gastrointestinal system to digest non-milk foods,
nor do they have the motor skills needed to safely
eat solid foods. Breast milk and formula supply
adequate nutrients during this period of rapid
development. Of note, some studies have
observed associations between early introduction
of complementary foods (before 4 months of age)
and greater risk of excess weight gain in childhood (Paul et al., 2009).
In regard to prevention of allergic diseases
(e.g., cow’s milk allergy, atopic eczema),

784

Nutrition During Early Childhood

Nutrition During Early Childhood, Table 3 Recommended nutrient intake levels in infancy/early childhood, select
Nutrients. Entries are recommended dietary allowances (RDA) or adequate intake (AI) levels
Nutrient
Protein
Vitamin Aa
Vitamin Db,c
Vitamin Ed
Vitamin K
Vitamin C
Thiamin
Riboflavin
Niacine
Vitamin B6
Folatef,g
Vitamin B12
Calcium
Phosphorous
Magnesium
Iron
Zinc
Iodine
Selenium
Biotin
Pantothenic acid
Copper
Manganese
Fluoride
Chromium
Molybdenum

Age 0–6 months
9.1 g
400 mg RE
10 mg
4 mg a-TE
2 mg
40 mg
0.2 mg
0.3 mg
2 mg NE
0.1 mg
65 mg
0.4 mg
200 mg
100 mg
30 mg
0.27 mg
2 mg
110 mg
15 mg
5 mg
1.7 mg
200 mg
0.003 mg
0.01 mg
0.2 mg
2 mg

Age 6–12 months
11 g
500 mg RE
10 mg
5 mg a-TE
2.5 mg
50 mg
0.3 mg
0.4 mg
4 mg NE
0.3 mg
80 mg
0.5 mg
260 mg
275 mg
75 mg
11 mg
3 mg
130 mg
20 mg
6 mg
1.8 mg
220 mg
0.6 mg
0.5 mg
5.5 mg
3 mg

Age 1–3 years
13 g
300 mg RE
15 mg
6 mg a-TE
30 mg
15 mg
0.5 mg
0.5 mg
6 mg NE
0.5 mg
150 mg
0.9 mg
700 mg
460 mg
80 mg
7 mg
3 mg
90 mg
20 mg
8 mg
2 mg
340 mg
1.2 mg
0.7 mg
11 mg
17 mg

Age 4–8 years
19 g
400 mg RE
15 mg
7 mg a-TE
55 mg
25 mg
0.6 mg
0.6 mg
8 mg NE
0.6 mg
200 mg
1.2 mg
1,000 mg
500 mg
130 mg
10 mg
5 mg
90 mg
30 mg
12 mg
3 mg
440 mg
1.5 mg
1.0 mg
15 mg
22 mg

Adapted by author, 2012
Sources: Dietary Reference Intakes for Calcium, Phosphorous, Magnesium, Vitamin D, and Fluoride (1997); Dietary
Reference Intakes for Thiamin, Riboflavin, Niacin, Vitamin B6, Folate, Vitamin B12, Pantothenic Acid, Biotin, and
Choline (1998); Dietary Reference Intakes for Vitamin C, Vitamin E, Selenium, and Carotenoids (2000); and Dietary
Reference Intakes for Vitamin A, Vitamin K, Arsenic, Boron, Chromium, Copper, Iodine, Iron, Manganese, Molybdenum, Nickel, Silicon, Vanadium, and Zinc (2001); Dietary Reference Intakes for Water, Potassium, Sodium, Chloride,
and Sulfate (2005); and Dietary Reference Intakes for Calcium and Vitamin D (2011). These reports may be accessed via
www.nap.edu
a
As retinol activity equivalents (RAEs), 1 RAE = 1 mg retinol, 12 mg b-carotene, 24 mg a-carotene, or 24 mg
b-cryptoxanthin. The RAE for dietary provitamin A carotenoids is twofold greater than retinol equivalents(RE), whereas
the RAE for preformed vitamin A is the same as RE
b
As cholecalciferol, 1 mg cholecalciferol = 40 IU vitamin D
c
Under the assumption of minimal sunlight
d
As a-tocopherol, a-tocopherol includes RRR-a-tocopherol, the only form of a-tocopherol that occurs naturally in
foods, and the 2R-stereoisomeric forms of a-tocopherol (RRR-, RSR-, RRS-, and RSS-a-tocopherol) that occur in
fortified foods and supplements. It does not include the 2S-stereoisomeric forms of a-tocopherol (SRR-, SSR-, SRS-,
and SSS-a-tocopherol), also found in fortified foods and supplements
e
As niacin equivalents (NE), 1 mg of niacin = 60 mg of tryptophan; 0–6 months = preformed niacin (not NE)
f
As dietary folate equivalents (DFE), 1 DFE = 1 mg food folate = 0.6 mg of folic acid from fortified food or as
a supplement consumed with food = 0.5 mg of a supplement taken on an empty stomach
g
In view of evidence linking folate intake with neural tube defects in the fetus, it is recommended that all women capable
of becoming pregnant consume 400 mg from supplements or fortified foods in addition to intake of food folate from
a varied diet

Nutrition During Early Childhood

exclusive breastfeeding for 4–6 months is the
most effective strategy. For infants at high risk
of allergic disease who are not breastfed, an
extensively hydrolyzed formula should be given
until 4 months of age (Muraro et al., 2004).
Ages One to Five Years
Means of assuring optimal nutritional exposure
for all children up to age 5 are elusive. Practices
of clear value in the prevention of nutritional
deficiencies include food supply fortification,
nutrient supplements for children at weaning,
and the continued efforts of food assistance programs in the USA (e.g., WIC) to protect access to
an adequate supply of food energy and nutrients.
WIC participation is associated with increased
iron density of the diet, increased fruit and vegetable consumption, reduced intake of added
sugars, and increased dietary variety. Evidence
for effects of WIC on obesity risk is mixed, but
the rate of failure to thrive by age 5 is lower
among participants than nonparticipants
(USDA, 2012).
Although childhood obesity prevention initiatives usually target school-age children, there are
several reasons to begin these efforts sooner.
By the time children enter school, 20 % are
already overweight or at risk for overweight,
and many learned eating habits and preferences
are already in place (Birch & Ventura, 2009).
Efforts to identify effective interventions for
this age group are ongoing. There is sufficient
evidence, however, that parents and caregivers
play a pivotal role in shaping children’s eating
habits. The frequency and diversity of food exposures and observation of caregivers greatly influence a child’s food preferences and willingness to
try new foods (Anzman, Rollins, & Birch, 2010).
Interventions to improve diet or prevent obesity
in preschool settings without a family component
have generally been unsuccessful (Hesketh &
Campbell, 2010). Therefore, effective strategies
will likely require considerable parent involvement. Although experimental evidence in this
area is limited, the following parent practices
are supported by research: (1) offering healthy
foods repeatedly to encourage acceptance and
liking, (2) avoiding coercion or restriction of

785

food intake, and (3) reducing the energy density
and portion sizes of foods served to children by
age 3–5 years (Birch & Ventura, 2009). There is
a strong agreement among experts that minimizing sugar-sweetened beverage intake by young
children is a key strategy for reducing obesity
risk, as they contribute significant amounts of
empty calories to the diet (Paul et al., 2009).

Strategies That Might Work
Whereas vitamin D supplementation in infants is
advised to prevent deficiency, the value of supplementation for pregnant women is uncertain
and currently under investigation. Low maternal
vitamin D status has been consistently associated
with increased risk of inflammatory and atopic
disorders in children (e.g., asthma and allergies)
(Brannon, 2012). There is also some observational evidence for associations between low
vitamin D levels and increased risk of preeclampsia, gestational diabetes, and obstructed labor in
the mother and type 1 diabetes in children. Given
the low risk of adverse effects, vitamin
D supplementation during pregnancy may be
a useful strategy for promoting infant and child
health.
Essential fatty acids are of particular interest
with regard to early childhood development. Preliminary evidence suggests that high consumption of marine oils in pregnancy is associated
with longer gestation and that maternal dietary
supplementation with n-3 polyunsaturated oils
may increase the proportion of term births in
diverse populations (Koletzko et al., 2008). However, a recent Cochrane review concluded that
there was insufficient evidence to support marine
oil supplementation in pregnant women as
a means to prevent preeclampsia, preterm birth,
low birth weight, or small-for-gestational age
(Makrides, Duley, & Olsen, 2006). The n-3 fatty
acid docosahexaenoic acid (DHA) is critical for
normal eye and brain development. In observational studies, higher DHA levels in infants have
been associated with improved visual and cognitive function, but a benefit of supplementation in
pregnant and lactating women has not been

786

consistently
demonstrated
(Dziechciarz,
Horvath, & Szajewska, 2010). Increased consumption of n-3 fatty acids may confer health
benefits to both mother and baby, but more
research is needed. Relative to the prehistoric
dietary pattern, the modern diet is deficient in
n-3’s (Eaton, Eaton, & Konner, 1997) lending
the support of an evolutionary context to the
hypothesis that increased intake may be
beneficial.
The n-3 content of breast milk is mediated by
maternal intake. Both eicosapentaenoic acid
(EPA) and DHA are relatively abundant in
human breast milk and prominently incorporated
into the developing brain (Koletzko &
Rodriguez-Palmero, 1999). Breastfeeding is
associated with enhancement of both IQ and
visual acuity in infants (Golding, Rogers, &
Emmett, 1997). The apparent health benefits of
breastfeeding relative to formula feeding may
relate in part to the DHA content of breast milk.
Increasingly, long-chain PUFAs including DHA
are being added to commercial formulas
(Auestad et al., 2003). Although the essential
fatty acid, a-linolenic acid, is a precursor to
DHA as well as EPA, conversion to DHA in
particular appears to be limited and variable.
The putative benefits of DHA apparently require
that it be administered directly in the diet
(Gibson, Muhlhausler, & Makrides, 2011).
Maternal diet influences the flavor of breast
milk and thereby serves as a means of introducing
the neonate to a variety of taste experiences
(Beauchamp & Mennella, 2011). Strong flavors,
and the familiarity or novelty of such flavors, may
influence the feeding behaviors of infants. Thus,
variation in the maternal diet during lactation
may play some role in determining childhood
food preferences. There is some evidence to suggest that breastfeeding, especially if protracted,
may confer protection against the later development of obesity (Agostini et al., 2009). This topic
remains subject to some ongoing debate
(Disantis, Collins, Fisher, & Davey, 2011), with
some recent evidence suggesting preferential
benefit for infants born large for gestational age
(Camurdan, Camurdan, Polat, & Beyazova,
2011).

Nutrition During Early Childhood

While the principal goal of nutrition management in early childhood is the preservation of
optimal growth and development, children in
the USA and other developed countries are
increasingly susceptible to the adverse effects of
dietary excess, particularly obesity. As a result,
there is intense interest regarding the age at which
dietary restrictions might first be safely imposed.
In general, restriction of macronutrients (dietary
fat being of particular concern) is discouraged
prior to age 2, but it is generally accepted that
after this age, restrictions comparable to those
recommended for adults are safe and appropriate.
The American Academy of Pediatrics (AAP) recommends that children consume a diet that is
generally low in saturated fat, based on evidence
that cardiovascular disease risk factors appear in
childhood, are related to saturated fat intake, and
track into adulthood (Gidding et al., 2006). To
limit the saturated fat content of the diet, the AAP
recommends that children drink whole milk until
the age of 2 years and low-fat or nonfat milk
thereafter. Although this particular guideline is
based in sound logic, it has not been consistently
supported by evidence. A recent longitudinal
study in over 10,000 American children found
that those drinking nonfat or 1 % milk were significantly more likely to be overweight or obese
than those drinking 2 % or whole milk at ages
2 and 4 years and were more likely to become
overweight or obese between the two time points
(Scharf, Demmer, & DeBoer, 2013). The results
were adjusted for several potential confounders.
Therefore, the effectiveness of promoting low-fat
milk for young children has not yet been conclusively determined.
Fruit juice has also been targeted as a potential
contributor to excess calorie intake and weight
gain in infants and young children. The AAP
recommends delaying introduction of 100 %
fruit juice until 6 months of age and limiting
intake thereafter to 4–6 oz/day as a means to
prevent excessive energy intake (Gidding et al.,
2006). Some have argued that 100 % fruit juice
should be considered similarly as candy and desserts and avoided entirely until at least preschool
age, reasoning that fruit juice may contribute to
excess fructose consumption and metabolic

Nutrition During Early Childhood

syndrome and that calories from juice cannot
effectively trigger satiety because of its liquid
form (Wojcicki & Heyman, 2012). Nevertheless,
the association of 100 % fruit juice consumption
with obesity is not as well documented as that
of sugar-sweetened beverage intake and has
been observed only at excessive intake levels
(Paul et al., 2009). Therefore, limiting fruit juice
is a strategy whose basis is still mostly
theoretical.

Strategies That Do Not Work
There is currently no convincing evidence that
diet restrictions during pregnancy or lactation are
effective in preventing allergic disease in infants
(Muraro et al., 2004). Likewise, the longaccepted practice of delaying the introduction of
potentially allergenic foods (e.g., peanuts, cow’s
milk, eggs, fish, shellfish) beyond 6 months of age
is not supported by research (Szajewska, 2013).
Because parents play such an important role in
shaping children’s food environments and eating
habits, interventions in preschool or child care
settings that do not involve parents appear to
have limited success (Hesketh & Campbell,
2010). Some common feeding practices are ineffective in, or counterproductive to, improving the
quality of children’s diets. For example, controlling behaviors such as using food as a reward or
punishment, coercing children to eat, or
prohibiting unhealthy foods have been associated
with reduced self-regulation of intake, overeating, increased liking of restricted foods, and
weight gain (Paul et al., 2009).
In the industrialized world, children are early
exposed to a vast array of nutrient-dilute, energydense foods. Vast sums of money are spent by the
food industry on advertisements aimed at children.
It is against this backdrop that an epidemic of
childhood obesity has developed and progressed.
Providing “guidelines” on healthy eating in
a “toxic” nutritional environment is clearly ineffective. Strategies for the prevention and control of
childhood obesity include an array of interventions
mostly aimed at children older than age 6 years;
strategies for infants emphasize enhancing

787

maternal nutrition and weight control and
breastfeeding and promoting appropriate complementary feeding practices (Waters et al., 2011).

Synthesis
The provision of optimal nutrition during infancy
and early childhood is of vital importance to growth
and development and is likely related to a wide
array of health outcomes in later life. The establishment of good nutriture for an infant begins in utero,
during which maternal dietary practices may influence fetal metabolism. The most reliable way to
assure optimal nutrition for a newborn is
breastfeeding. Therefore, based on the confluence
of multiple lines of evidence, breastfeeding for
a period of 6 months is advisable unless the practice
is contraindicated by communicable disease. The
maintenance of salutary maternal nutrition during
lactation is of importance to the health of both
mother and baby. While commercial infant formulas provide generally balanced nutrition, there is
a concern that they are deficient in long-chain polyunsaturated fatty acids, DHA in particular. As evidence of the importance of DHA and other essential
fatty acids continues to accrue, the composition of
commercial formulas will likely be revised. In the
interim, there is preliminary evidence that both
cognition and vision are enhanced by breastfeeding
as compared to formula feeding (Table 4).
Weaning to solid food should generally begin
at approximately 6 months; earlier weaning may
increase the risk of food allergies and possibly
obesity. Weaning from breast milk or formula is
generally complete by around 12 months,
although such practices are culturally determined; medically, weaning at 12 months is
appropriate. Children will generally self-select
foods that meet micronutrient requirements
when provided with an array of healthy food
choices. This practice is to be encouraged.
Children with access to an adequate diet reliably meet their energy needs, although energy
intake may vary considerably by meal and even
day. Parents should be reassured in this regard
and discouraged from placing too great emphasis
on “plate cleaning.” Whether or not such

788

Nutrition During Early Childhood

Nutrition During Early Childhood, Table 4 Composition of commonly available commercial formulas compared to
that of breast milk
Nutrient (quantity
per liter)
Energy (kcal)
Protein (g)
Fat (g)
% polyunsaturated
% monounsaturated
% saturated
Carbohydrate (g)
Calcium (mg)
Phosphorous (mg)
Magnesium (mg)
Iron (mg)
Zinc (mg)
Manganese (mg)
Copper (mg)
Iodine (mg)
Sodium (mg)
Potassium (mg)
Vitamin A (mg)
Vitamin D (mg)
Vitamin E (IU)
Vitamin K (mg)
Thiamin (mg)
Riboflavin (mg)
Pyridoxine (mg)
Vitamin B12 (mg)
Niacin (mg)
Folate (mg)
Pantothenic acid
(mg)
Vitamin C (mg)
Biotin (mg)

Human milk
680
10.5
39
14.2
41.6
44.2
72
280
140
35
0.3
1.2
6
252
110
179.4
526.5
675
0.5
4
2.1
210
350
205
0.5
1.5
50
1.8

Similac (Ross)
676
14.5
36.5
37
17
46
72.3
492
380
41
12.2
5.1
34
610
95
184
706
676
10
20
54
680
1,010
410
1.7
7.1
100
3

Enfamil (Mead
Johnson)
680
14.2
35.8
29
16
55
73.7
528
358
54
12.2
6.8
101
507
68
184
729
630
10.8
13.6
54
541
947
406
2.0
6.8
108
3.4

ProSobeea (Mead
Johnson)
660
19.7
34.8
18.8
37.6
42.5
65.6
690
540
70
11.8
7.9
NA
490
NA
240
790
590
NA
9.7
NA
530
590
NA
2.0
6.6
110
NA

Isomila (Ross)
660
16.1
35.8
23.5
38.3
32.7
67.6
690
490
50
11.8
4.9
160
490
NA
290
710
590
NA
13.2
NA
390
590
NA
3
8.9
100
4.9

40
4

60
30

81.2
20.3

79
NA

59
NA

Adapted by author, 2012
Values in the table are derived from Kleinman (1998); and U.S. Department of Agriculture (n.d.)
NA not available in the sources used
a
Soy-based formulas

a practice contributes to later obesity is unknown,
but an association is plausible.
There is evidence that adult dietary recommendations are safe and reasonable for children
beginning at age 2 years. This provides the added
benefit of unifying family dietary practices earlier. There is evidence that dietary preferences
established in childhood tend to persist,
highlighting the importance of establishing
a prudent dietary pattern early. Therefore, the

diet that should be advocated to adults and older
children to promote health may be provided
promptly, or approximated gradually, in children
beginning at age 2 years. When plausible, regular
consumption of fish should be encouraged. The
consistent intake of DHA may offer considerable
health benefits, supported by preliminary, but
accumulating, evidence.
With regard to the prevention of overnutrition
and its consequences among children in the

Nutrition During Early Childhood

industrialized world, there is support for the promotion of breastfeeding for 6–12 months as
appropriate and for efforts to promote physical
activity. There is increasing emphasis on the
quality of the maternal diet and on maternal
weight management. Increasingly, and appropriately, attention is turning to modification of
a “toxic” nutritional environment, in which
young children are exposed and acclimated to
a dietary pattern linked to a host of chronic diseases in adulthood. The combination of improved
nutrition education and modification of the environment to support improved dietary and activity
patterns offers promise for the future.
Acknowledgment The technical assistance of Mrs.
Michelle Pinto-Evans is gratefully acknowledged.

References
Agostini, C., Braegger, C., Desci, T., Kolacek, S.,
Koletzko, B., Fleischer Michaelsen, K., et al. (2009).
Breast-feeding: A commentary by the ESPGHAN
committee on nutrition. Journal of Pediatric Gastroenterology and Nutrition, 49(1), 112–125.
Agostini, C., Desci, T., Fewtrell, M., Goulet, O., Kolacek,
S., Koletzko, B., et al. (2008). Complementary feeding: A commentary by the ESPGHAN Committee on
Nutrition. Journal of Pediatric Gastroenterology and
Nutrition, 46(1), 99–110.
Ajzen, I. (1991). The theory of planned behavior. Organizational Behavior and Human Decision Processes, 50,
179–221.
Anzman, S. L., Rollins, B. Y., & Birch, L. L. (2010).
Parental influence on children’s early eating environments and obesity risk: Implications for prevention.
International Journal of Obesity, 34, 1116–1124.
Auestad, N., Scott, D. T., Janowsky, J. S., Jacobsen, C.,
Carroll, R. E., Montalto, M. B., et al. (2003). Visual,
cognitive, and language assessments at 39 months:
A follow-up study of children fed formulas containing
long-chain polyunsaturated fatty acids to 1 year of age.
Pediatrics, 112(3 Pt. 1), e177–e183.
Baker, R. D., Greer, F. R., & The Committee on Nutrition.
(2010). Diagnosis and prevention of iron deficiency
and iron-deficiency anemia in infants and young children (0–3 years of age). Pediatrics, 126(5),
1040–1050.
Beauchamp, G. K., & Mennella, J. A. (2011). Flavor
perception in human infants: Development and functional significance. Digestion, 83(Suppl. 1), 1–6.
Birch, L. L., & Ventura, A. K. (2009). Preventing childhood obesity: What works? International Journal of
Obesity, 33, S74–S81.

789
Brannon, P. M. (2012). Vitamin D and adverse pregnancy
outcomes: Beyond bone health and growth. The Proceedings of the Nutrition Society, 71(2), 205–212.
Camurdan, M. O., Camurdan, A. D., Polat, S., &
Beyazova, U. (2011). Growth patterns of large, small,
and appropriate for gestational age infants: Impacts of
long-term breastfeeding: A retrospective cohort study.
Journal of Pediatric Endocrinology and Metabolism,
24(7–8), 463–468.
Centers for Disease Control and Prevention. (1998). Recommendations to prevent and control iron deficiency
in the United States. Morbidity and Mortality Weekly
Report, 47, 1–29.
Centers for Disease Control and Prevention. (2012).
Second national report of biochemical indicators of
diet and nutrition in the U.S. population. Retrieved
May
27,
2013,
from
http://www.cdc.gov/
nutritionreport/pdf/Nutrition_Book_complete508_
final.pdf#zoom=100
Cox, J. T., & Phelan, S. T. (2008). Nutrition during pregnancy. Obstetrics and Gynecology Clinics of North
America, 35, 369–383.
Crane, J. M., White, J., Murphy, P., Burrage, L., &
Hutchens, D. (2009). The effect of gestational weight
gain by body mass index on maternal and neonatal
outcomes. Journal of Obstetrics and Gynaecology
Canada, 31(1), 28–35.
Davison, K. K., & Birch, L. L. (2001). Childhood overweight: A contextual model and recommendations for
future research. Obesity Reviews, 2(3), 159–171.
Davison, K. K., Jurkowski, J. M., & Lawson, H. A. (2012).
Reframing family-centered obesity prevention using
the Family Ecological Model. Public Health Nutrition,
22, 1–9.
Disantis, K. I., Collins, B. N., Fisher, J. O., & Davey, A.
(2011). Do infants fed directly from the breast have
improved appetite regulation and slower growth during early childhood compared with infants fed from
a bottle? International Journal of Behavioral Nutrition
and Physical Activity, 8, 89. doi:10.1186/1479-58688-89.
Donahue, S. M. A., Kleinman, K. P., Gillman, M. W., &
Oken, E. (2010). Trends in birth weight and gestational
length among singleton term births in the United
States. Obstetrics & Gynecology, 115(2 Pt. 1),
357–364.
Dziechciarz, P., Horvath, A., & Szajewska, H. (2010).
Effects of n-3 long-chain polyunsaturated fatty acid
supplementation during pregnancy and/or lactation on
neurodevelopment and visual function in children:
A systematic review of randomized controlled trials.
Journal of the American College of Nutrition, 29(5),
443–454.
Eaton, S., Eaton, S. B., III, & Konner, M. (1997). Paleolithic nutrition revisited: A twelve-year retrospective
on its nature and implications. European Journal of
Clinical Nutrition, 51, 207–216.
Falavigna, M., Schmidt, M. I., Trujillo, J., Alves, L. F.,
Wendland, E. R., Torloni, M. R., et al. (2012).

790
Effectiveness of gestational diabetes treatment:
A systematic review with quality of evidence assessment. Diabetes Research and Clinical Practice, 98(3),
396–405.
Garipagaoglu, M., Sahip, Y., Budak, N., Akdikmen, O.,
Altan, T., & Baban, M. (2008). Food types in the diet
and the nutrient intake of obese and non-obese children. Journal of Clinical Research in Pediatric Endocrinology, 1(1), 21–29.
Gibson, R. A., Muhlhausler, B., & Makrides, M. (2011).
Conversion of linoleic acid and alpha-linolenic acid to
long-chain polyunsaturated fatty acids (lcpufas), with
a focus on pregnancy, lactation and the first 2 years of
life. Maternal & Child Nutrition, 7(Suppl. 2), 17–26.
Gidding, S. S., Dennison, B. A., Birch, L. L., Daniels,
S. R., Gillman, M. W., Lichtenstein, A. H.,
et al. (2006). Dietary recommendations for children
and adolescents: A guide for practitioners. Pediatrics,
117(2), 544–559.
Golding, J., Rogers, I., & Emmett, P. (1997). Association
between breast feeding, child development and behaviour. Early Human Development, 49, S175–S184.
Haider, B. A., Yakoob, M. Y., & Bhutta, Z. A. (2011).
Effect of multiple micronutrient supplementation during pregnancy on maternal and birth outcomes. BMC
Public Health, 11(Suppl. 3), S19. doi:10.1186/14712458-11-S3-S19.
Hamaoui, E., & Hamaoui, M. (2003). Nutritional assessment and support during pregnancy. Gastroenterology
Clinics of North America, 32(1), 59–121.
Hesketh, K. D., & Campbell, K. J. (2010). Interventions to
prevent obesity in 0–5 year olds: An updated systematic review of the literature. Obesity, 18(Suppl. 1),
S27–S35.
Huisman, M., Beusekom, C. V., Lanting, C., Nijeboer, H.,
Muskiet, F., & Boersma, E. (1996). Triglycerides, fatty
acids, sterols, mono- and disaccharides and sugar alcohols in human milk and current types of infant formula
milk. European Journal of Clinical Nutrition, 50,
255–226.
Hutton, E. K., & Hassan, E. S. (2007). Late vs early
clamping of the umbilical cord in full-term neonates.
Journal of the American Medical Association,
297(11), 1241–1252.
Kleinman, R. E. (Ed.). (1998). Pediatric nutrition handbook (4th ed.). Elk Grove Village, IL: American Academy of Pediatrics.
Koletzko, B., Lien, E., Agostoni, C., Bohles, H.,
Campoy, C., Cetin, I., et al. (2008). The roles of
long-chain polyunsaturated fatty acids in pregnancy,
lactation and infancy: Review of current knowledge
and consensus recommendations. Journal of Perinatal
Medicine, 36(1), 5–14.
Koletzko, B., & Rodriguez-Palmero, M. (1999). Polyunsaturated fatty acids in human milk and their role in
early infant development. Journal of Mammary Gland
Biology and Neoplasia, 4, 269–284.
Looker, A. C, Johnson, C. L., Lacher, D. A.,
Pfeiffer, C. M., Schleicher, R. L., & Sempos, C. T.

Nutrition During Early Childhood
(2011). Vitamin D status: United States, 2001–2006.
NCHS Data Brief, 59, 4.
Makrides, M., Duley, L., & Olsen, S. F. (2006). Marine
oil, and other prostaglandin precursor, supplementation for pregnancy uncomplicated by pre-eclampsia or
intrauterine growth restriction. Cochrane Database of
Systematic Reviews, 3, CD003402.
Martin, J. A., Hamilton, B. E., Ventura, S. J., Osterman
M. J. K., Wilson, E. C., & Mathews, T. J. (2012).
Births: Final data for 2010. National Vital Statistics
Reports, 61(1), 11.
Muraro, A., Dreborg, S., Halken, S., Høst, A.,
Niggemann, B., Aalberse, R., et al. (2004). Dietary
prevention of allergic diseases in infants and small
children. Part II: Critical review of published peerreviewed observational and interventional studies and
final recommendations. Pediatric Allergy and Immunology, 5(4), 291–307.
Parker, S. E., Mai, C. T., Canfield, M. A., Rickard, R.,
Wang, Y., Meyer, R. E., et al. (2010). Updated national
birth prevalence estimates for selected birth defects in
the United States, 2004–2006. Birth Defects Research
(Part A), 88, 1008–1016.
Patrelli, T. S., Dall’asta, A., Gizzo, S., Pedrazzi, G.,
Jasonni, V. M., & Modena, A. B. (2012). Calcium
supplementation and prevention of preeclampsia:
A meta-analysis. Journal of Maternal-Fetal and Neonatal Medicine, 25(12), 2570–2574.
Paul, I. M., Bartok, C. J., Downs, D. S., Stifter, C. A.,
Ventura, A. K., & Birch, L. L. (2009). Opportunities
for the primary prevention of obesity during infancy.
Advances in Pediatrics, 56(1), 107–133.
Rao, R., & Georgieff, M. K. (2007). Iron in fetal and
neonatal nutrition. Seminars in Fetal & Neonatal Medicine, 12(1), 54–63.
Rovner, A. J., & O’Brien, K. O. (2008). Hypovitaminosis
D among healthy children in the United States:
A review of the current evidence. Archives of Pediatrics & Adolescent Medicine, 162(6), 513–519.
Sachdev, H., Gera, T., & Nestel, P. (2005). Effect of iron
supplementation on mental and motor development in
children: Systematic review of randomised controlled
trials. Public Health Nutrition, 8(2), 117–132.
Schanler, R. J., Feldman-Winter, L., Landers, S.,
Noble, L., Szucs, K. A., & Viehmann, L. (2011).
Concerns with early universal iron supplementation
of breastfeeding infants. Pediatrics, 127(4), e1097.
Scharf, R. J., Demmer, R. T., & DeBoer, M. D. (2013).
Longitudinal evaluation of milk type consumed and
weight status in preschoolers. Archives of Disease in
Childhood, 98, 335–340.
Scholl, T. O. (2011). Maternal iron status: Relation to fetal
growth, length of gestation, and iron endowment of the
neonate. Nutrition Reviews, 69(Suppl. 1), S23–S29.
St-Onge, M. P., Keller, K. L., & Heymsfield, S. B. (2003).
Changes in childhood food consumption patterns:
A cause for concern in light of increasing body
weights. American Journal of Clinical Nutrition,
78(6), 1068–1073.

Nutrition During Early Childhood
Swanson, V., Power, K. G., Crombie, I. K., Irvine, L.,
Keizebrink, K., Wrieden, W., et al. (2011). Maternal
feeding behaviour and young children’s dietary quality: A cross-sectional study of socially disadvantaged
mothers of two-year old children using the Theory of
Planned Behaviour. International Journal of Behavioral Nutrition and Physical Activity, 8, 65.
Szajewska, H. (2013). The prevention of food allergy in
children. Current Opinion in Clinical Nutrition and
Metabolic Care, 16(3), 346–350.
Thangaratinam, S., Rogozinska, E., Jolly, K.,
Glinkowski, S., Roseboom, T., & Tomlinson, J. W.
(2012). Effects of interventions in pregnancy on maternal weight and obstetric outcomes: A meta-analysis of
randomised evidence. British Medical Journal, 344,
e2088.
Thorpe, K. E. (2006). Factors accounting for the rise in
health-care spending in the United States: The role of
rising disease prevalence and treatment intensity. Public Health, 120(11), 1002–1007.
U.S. Department of Agriculture. (n.d.). National nutrient
database for standard reference. Retrieved May
25, 2013, from http://www.nal.usda.gov/
U.S. Department of Agriculture. (2010). Dietary guidelines for Americans, 2010. Retrieved May 27, 2013,
from http://www.health.gov/DietaryGuidelines/
U.S. Department of Agriculture, Food and Nutrition Service, Office of Research and Analysis. (2012). Effects

791
of the special supplemental nutrition program for
Women, Infants, and Children (WIC): A review of
recent research. Retrieved May 27, 2013, from http://
www.fns.usda.gov/Ora/menu/Published/WIC/FILES/
WICMedicaidLitRev.pdf
Valentine, C. J., & Wagner, C. L. (2013). Nutritional
management of the breastfeeding dyad. Pediatric
Clinics of North America, 60(1), 261–274.
Waters, E., de Silva-Sanigorski, A., Hall, B. J., Brown, T.,
Campbell, K. J., Gao, Y., et al. (2011). Interventions
for preventing obesity in children. Cochrane Database
of Systematic Reviews, 12, CD001871.
Wojcicki, J. M., & Heyman, M. B. (2012). Reducing
childhood obesity by eliminating 100 % fruit juice.
American Journal of Public Health, 102(9),
1630–1633.
Wolff, T., Witkop, C. T., Miller, T., & Syed, S. B. (2009).
Folic acid supplementation for the prevention of neural
tube defects: An update of the evidence for the
U.S. Preventive Services Task Force. Annals of Internal Medicine, 150(9), 632–639.
World Hunger Education Service. (2011). 2011 world
hunger and poverty facts and statistics. Retrieved
May 27, 2013, from http://www.worldhunger.org/articles/Learn/world%20hunger%20facts%202002.htm
Ziegler, E. E., Nelson, S. E., & Jeter, J. M. (2011). Iron
supplementation in breastfed infants. Nutrition
Reviews, 69(Suppl. 1), S71–S77.

792

Nutrition During Childhood
David L. Katz1, Valentina Vinante2 and
Kimberly Doughty1
1
Yale-Griffin Prevention Research Center,
Derby, CT, USA
2
Department of Public Health, University of
Florence, Florence, Italy

Introduction
Nutritional status between the ages of 5 and
12 years is strongly associated with physical and
cognitive development. The primary prevention
of both short-term developmental delays and
long-term sequelae of over- and undernutrition
is possible with optimal nutritional patterns
during this period.

Definitions and Scope
Definition of Terms
Malnutrition, the inadequacy of micronutrients,
macronutrients, or both, takes many forms. Macronutrients are the three major classes from
which nutrient energy is derived: carbohydrate,
fat, and protein. Micronutrients are the myriad
organic and inorganic constituents of food that
play a role, essential or otherwise, in metabolism. Xerophthalmia is a scarring of the eyes
induced by inadequate intake of vitamin A; the
condition can lead to blindness. While also a
form of adverse dietary exposure, overnutrition
tends to be defined independently of malnutrition. In general, the term refers to intake of
macronutrients and energy. Overnutrition is
associated with the development of overweight
(more than 10 % above ideal weight for height)
and obesity (more than 20 % above ideal weight
for height).
Scope of Poor Nutrition Among Children
More than one-third of children worldwide are
malnourished and 43 % stunted in their growth as

Nutrition During Childhood

a result (World Hunger Education Service, 2012).
In industrialized countries, children are more
often subject to overnutrition than deficiency.
The prevalence of overweight among children
in the USA varies with the definition applied
but has certainly been rising for decades
(Ogden, Carroll, & Flegal, 2008) with some
recent evidence of a plateau (Centers for Disease
Control, 2010).
The costs of suboptimal nutriture during this
period are uncertain. The direct consequences of
severe malnutrition, such as xerophthalmia,
marasmus and kwashiorkor, are more readily
measured than are potential long-term subtle
cognitive deficits resulting from mild-moderate
malnutrition or micronutrient deficiencies. Similarly, the costs associated with chronic disease,
including cancer, referable in part to childhood
dietary patterns, are perhaps impossible to measure due to the multitude of interposing variables. Perhaps the best estimates of the impact
of nutrition during this period of life on society
are cast in terms of simple assumptions rather
than dollars. One may assume, as the evidence
suggests, that diets established in childhood
have long-term health effects either directly or
because of their tendency to track into adulthood. One may also assume, as is often done in
transcultural analyses, that all cultures/societies
(barring specific genetic predispositions to disease) could achieve or approach the lowest rate
for any particular disease seen among the
populations of the world by adopting the pertinent salutary behaviors and/or environmental
conditions. Under the constraints of such supposition, improvements in childhood nutrition
could reasonably be projected to reduce dramatically the incidence of many infectious diseases,
blindness, skeletal deformity, obesity, diabetes,
cardiovascular disease, and cancer, to name only
a few of the more evident physiologic benefits.
Improved nutrition in developing countries
could also have potentially far-reaching positive
ramifications by increasing the physical and
mental capacities of the individuals living
there. The financial implications of such projections are truly incalculable.

T.P. Gullotta, M. Bloom (eds.), Encyclopedia of Primary Prevention and Health Promotion,
DOI 10.1007/978-1-4614-5999-6, # Springer Science+Business Media New York 2014

Nutrition During Childhood

Theories
The link between nutrition and healthy childhood
development is sufficiently self-evident as to be
largely atheoretical. Theoretical aspects of
childhood nutrition thus relate less to the nature
of existing problems and more to the interventions best suited to their resolution. With regard
to undernutrition, there is little debate that both
physical and cognitive development is threatened
when nutrient intake is grossly inadequate.
It appears that malnutrition earlier in life (less
than 2 years of age) is more deleterious, but there
is unlikely to be a sharp age cutoff, and longer
periods of malnutrition later in childhood may
have equally deleterious effects. The human
brain is, however, remarkably resilient, and given
enough nutrition and psychosocial stimulation,
children appear to be able to essential completely
recover both in growth and cognitive development
(Lifshitz, 2009). Thus, the degree of malnutrition,
the duration, the timing, and the quality of the
subsequent environment all interact in complex
ways that are not yet fully elucidated, to determine
the long-term mental and physical outcomes of
children who have been malnourished.
A wide array of theoretical considerations also
relates to the control of overnutrition in childhood
and is the issue which is more likely to be encountered in the developed world. The determination
and alteration of dietary preferences and patterns
are informed by several related theories. Social
scientists contend that dietary preferences derive
in part from familiarity and are reinforced by
it. Factors underlying the selection of a particular
diet, and thus its becoming familiar, include palatability, accessibility, convenience, and cost. These
factors influence adult selection, which in turn
influences childhood exposure. Taste preferences
in childhood are apparently the product of both
nature and nurture. A preference for sugar in the
diet is innate, while other taste preferences are
more likely to be acquired. Diets high in fat or
salt, for example, may tend to reinforce themselves. Children apparently tend to prefer diets
similar to their earliest exposures, including the
maternal diet during pregnancy and lactation.

793

Childhood overweight and obesity is often conceptualized using one of several variations of
a social ecological model. One such model, ecological systems theory (EST), emphasizes the importance of context in human development (Davison &
Birch, 2001). The contexts that are important to
child development include, from most to least
immediate: the family, school, community, and
society. Individual child characteristics, such as
age and gender, interact with characteristics within
the other contexts to influence children’s weight
status. Research based on EST acknowledges the
multiple levels of influence in the environment. An
adaptation of EST that emphasizes the specific
contextual factors influencing behaviors within the
family is the family ecological model (Davison,
Jurkowski, & Lawson, 2012). This model may be
particularly useful for research focused on parenting and family characteristics.
Social cognitive theory (SCT) is one of the most
popular theories serving as a basis for childhood
obesity interventions. The theory is predicated on
the idea that there are reciprocal interactions among
the individual, the environment (including the social
environment), and behavior (Bandura, 1986).
According to SCT, the major determinants of health
behavior are knowledge, perceived self-efficacy,
outcome expectations (physical, social, and selfevaluative), goals, perceived facilitators, and social
and structural impediments (Bandura, 2004).
There is increasing support for the consideration
of evolutionary biology in efforts at modifying
children’s diets. While there are substantial uncertainties regarding human ancestry, and even greater
uncertainties regarding particular behaviors, including dietary behaviors, of paleolithic humans, there
is sufficient anthropologic consensus to support
a model. This model may be of use in explaining
the basis for dietary tendencies and preferences in
children and thus in suggesting means of promoting
more judicious diets when such are indicated.

Current Research
Strategies directed at the control of overnutrition
in childhood are comparable to those for adults.

794

The maintenance of near-ideal weight for height
is considered desirable. There is general consensus that adipocyte number influences susceptibility to obesity and capacity for obesity control.
Variation in weight in adults is more related to
adipocyte size than number (adipocyte hypertrophy), while children are vulnerable to adipocyte
proliferation (hyperplasia). Thus, the control of
adiposity in childhood is thought to portend
future weight control.
Regular physical activity in childhood is
thought to be protective against obesity. Television viewing and other sedentary activities such
as computer use are thought to contribute to obesity risk. Dietary fat restriction is thought to help
control weight in children as in adults, as is compliance with guidelines for intake of fruits and
vegetables. Practical strategies for achieving
adherence to guidelines at the population level
are lacking to date. In addition, there is increasing
interest in the role of specific fatty acid classes in
human health. N-3 fatty acid intake in childhood
may be of particular importance to cognitive
development, atopy, and immune function.
In the USA, dietary guidelines for the general
population pertain beginning at or around age 2;
a transition from breast milk to a variety of
nutritious foods is advised starting at 6–12
months of age and extending through the first
year of life (Gidding et al., 2006; U.S. Department
of Agriculture [USDA], 2010).
The prudence of advocating the same diet for
adults and children has been challenged, based
largely on the lack of evidence that dietary
restrictions in childhood prevent chronic disease
in adults (Olson, 2000). However, obtaining evidence that dietary interventions in early childhood prevent chronic disease in late adulthood
is a daunting challenge. Indirect, epidemiologic,
and inferential evidence may be the best guidance
available. The safety of the AHA Step 1 diet for
children over the age of 2 has received fairly
widespread support (Van Horn, Obarzanek,
Friedman, Gernhofer, & Barton, 2005).
A working group in Canada involving the Canadian Paediatric Society, Dietitians of Canada, and
Health Canada has issued similar guidance
(Health Canada, 2005). Proponents of dietary

Nutrition During Childhood

fat restriction beginning at age 2 cite evidence
that atherosclerosis begins in childhood and that
a diet with not more than 30 % of calories from
fat beginning at age 2 is compatible with optimal
growth. Attention is increasingly directed to the
quality of dietary fat rather than the quantity as
a priority in childhood as well as adulthood
(Barlow, 2007; Spear et al., 2007).
National surveys in the USA have revealed
excessive intake of saturated fat in children over
the age of 1 year (Kimm, Gergen, Malloy, Dresser,
& Carroll, 1990). Niinikoski and colleagues studied over 500 7-month-olds assigned to a dietary
counseling intervention aimed at reducing fat
intake and promoting compliance with adult dietary guidelines or to a control group. At 3 years,
cholesterol was lower in the intervention subjects
(significantly in males, not significantly in
females) than the controls, with no discernible
differences in height, weight, or rate of growth
(Niinikoski et al., 1997). Of note is that
growth was preserved despite a decline in energy
intake associated with the intervention. While the
debate in the USA and Canada has focused on the
safety of restricting dietary fat after age 2, this
study would suggest that such an intervention
may be safe at even a much earlier age (Niinikoski
et al., 1996). These findings have been confirmed
by the Turku Coronary Risk Factor Intervention
Project for Babies (STRIP). The study has shown
that repeated, individualized counseling in early
childhood aimed at reducing consumption of
saturated fat and cholesterol was effective and
feasible and did not restrict growth in circumstances in which children were regularly
monitored (Simell et al., 2000).
Thus, there is increasing evidence that efforts to
modify the diets of children to reduce long-term
cardiovascular risk are likely to be safe. Whether or
not such diets do reduce long-term risk is less clear.
Obviously, evidence of long-term outcome effects
is difficult to obtain. To be considered in the debate
is the importance of providing a single, consistent,
dietary pattern for a family, as well as the issue of
dietary patterns tracking over time. Data from the
Bogalusa Heart Study demonstrate that there is
tracking, between the ages of 6 months and
4 years, of both dietary pattern and cardiovascular

Nutrition During Childhood

risk factors (Nicklas et al., 1988). In light of these
considerations, it appears that the recommendation
in the USA to advocate a similar diet for everyone
over the age of 2 years is reasonable and safe and
may offer long-term benefits. Conclusive evidence
of benefit from early dietary modification efforts
will accrue very slowly (Table 1).
Even in the midst of overall nutritional excess,
there is some threat of nutrient deficiencies,
incipient or overt, in children living in industrialized nations. Long-chain n-3 polyunsaturated
fatty acids are particularly concentrated in the
brain and retina. Docosahexaenoic acid (DHA)
in particular is considered essential to healthy
brain development. Although the essential fatty
acid, a-linolenic acid, is a precursor to DHA as
well as eicosapentaenoic acid (EPA), conversion
to DHA in particular appears to be limited and
variable; the putative benefits of DHA apparently
require that it be administered directly in the
diet (Brenna, Salem, Sinclair, & Cunnane,
2009; Gerster, 1998). While health benefits of
DHA supplementation are likely on the basis
of confluent lines of evidence, they are as yet
not conclusively proved. There is evidence of
widespread nominality, if not deficiency, of zinc
in both adults and children, and that supplementation may enhance immune function (Tomkins,
2000; Wintergerst, Maggini, & Hornig, 2007).
Girls are particularly subject to inadequate
calcium metabolism and its long-term sequelae,
a susceptibility greatly compounded if low
levels of body fat induce amenorrhea; calcium
supplementation may be indicated. Other nutrients
likely to be consumed at less than optimal levels in
this age group include B vitamins (particularly
folate), vitamin A, and possibly vitamin D; multivitamin/mineral supplementation is a not unreasonable practice, although lacking substantiating
evidence.
Indigent populations in industrialized nations,
and general populations in developing nations,
are susceptible to malnutrition and nutritional
deficiency states. Children susceptible to malnutrition benefit from the provision of a diet providing variety, and in particular, animal fat and
protein. Micronutrient supplements are generally
appropriate, especially of vitamin A to protect

795

against xerophthalmia, vitamin D where sun
exposure is limited, and certain minerals. For
example, nominal zinc deficiency may be fairly
widespread, even in developed countries as
noted above, and zinc supplementation may
enhance immune function in children (Imdad &
Bhutta, 2011; Tomkins, 2000). Iron deficiency
contributes to both cognitive impairment and
anemia and is very common in developing
nations; supplementation in children is appropriate. The threshold relationship between
malnutrition and cognitive development (e.g.,
IQ, communication skills, social skills, fine
and gross motor skills) remains to be fully
elucidated.

Part II. Prevention/Promotion Strategies
Related to the Topic
Strategies That Work
The recommended diet for adults and children
over the age of 2 is schematically represented in
the USA by MyPlate (U.S. Department of
Agriculture, 2011). The guidance emphasizes
plant foods, allocating the majority of space on
the plate to vegetables, fruits, and whole grains.
Additional recommendations include the
restriction of added sugar and refined starches;
an emphasis on lean protein sources; and the
inclusion of low- and nonfat dairy products.
These guidelines are strongly supported by
extensive literature.
Long-term weight losses are achieved more
successfully in children than in adults. Evidence
supports the inclusion of dietary change, behavior modification, parental involvement, and
follow-up in a pediatric obesity program. Programs have emphasized both reduction in sedentary behaviors and dietary modification.
Childhood food preferences are greatly
influenced by parents’ food choices and eating
habits; therefore, family-based approaches are
encouraged. While clear evidence of effective
strategies to prevent or reverse childhood overweight and obesity is scant, there is support for
the promotion of breastfeeding until age 1, restriction of television viewing, encouraging or

796
Nutrition During
Childhood,
Table 1 Recommended
nutrient intake in children
age 4–8 expressed as
recommended dietary
allowance (RDA) or
adequate intake (AI)

Nutrition During Childhood

Nutrient
Protein
Vitamin Aa
Vitamin Db,c
Vitamin Ed
Vitamin K
Vitamin C
Thiamin
Riboflavin
Niacine
Vitamin B6
Folatef
Vitamin B12
Calcium
Phosphorous
Magnesium
Iron
Zinc
Iodine
Selenium
Biotin
Pantothenic acid
Copper
Manganese
Fluoride
Chromium
Molybdenum

Daily intake
24 gm
400 mg RE
15 mg
7 mg a-TE
55 mg
25 mg
0.6 mg
0.6 mg
8 mg NE
0.6 mg
200 mg
1.2 mg
1,000 mg
500 mg
130 mg
10 mg
5 mg
90 mg
30 mg
12 mg
3 mg
440 mg
1.5 mg
1.0 mg
15 mg
22 mg

Sources: Dietary Reference Intakes for Calcium, Phosphorous, Magnesium, Vitamin D,
and Fluoride (1997); Dietary Reference Intakes for Thiamin, Riboflavin, Niacin, Vitamin
B6, Folate, Vitamin B12, Pantothenic Acid, Biotin, and Choline (1998); Dietary Reference Intakes for Vitamin C, Vitamin E, Selenium, and Carotenoids (2000); Dietary
Reference Intakes for Vitamin A, Vitamin K, Arsenic, Boron, Chromium, Copper, Iodine,
Iron, Manganese, Molybdenum, Nickel, Silicon, Vanadium, and Zinc (2001); Dietary
Reference Intakes for Water, Potassium, Sodium, Chloride, and Sulfate (2005); and
Dietary Reference Intakes for Calcium and Vitamin D (2011). These reports may be
accessed via www.nap.edu
a
As retinol activity equivalents (RAEs). 1 RAE = 1 mg retinol, 12 mg b-carotene, 24 mg
a-carotene, or 24 mg b-cryptoxanthin. The RAE for dietary provitamin A carotenoids is
twofold greater than retinol equivalents(RE), whereas the RAE for preformed vitamin
A is the same as RE
b
As cholecalciferol. 1 mg cholecalciferol = 40 IU vitamin D
c
Under the assumption of minimal sunlight
d
As a-tocopherol. a-Tocopherol includes RRR-a-tocopherol, the only form of atocopherol that occurs naturally in foods, and the 2R-stereoisomeric forms of atocopherol (RRR, RSR, RRS, and RSS-a-tocopherol) that occur in fortified foods and
supplements. It does not include the 2S-stereoisomeric forms of a-tocopherol (SRR,
SSR, SRS, and SSS-a-tocopherol), also found in fortified foods and supplements
e
As niacin equivalents (NE). 1 mg of niacin = 60 mg of tryptophan; 0–6
months = preformed niacin (not NE)
f
As dietary folate equivalents (DFE). 1 DFE = 1 mg food folate = 0.6 mg of folic acid
from fortified food or as a supplement consumed with food = 0.5 mg of a supplement
taken on an empty stomach

Nutrition During Childhood

requiring (in school) regular physical activity,
and providing a diet at home and in school that
corresponds with guidelines (Centers for Disease
Control, 2011; U.S. Department of Health and
Human Services, 2011).
In developing nations and among the indigent
in industrialized nations, strategies for the prevention or amelioration of malnutrition vary with
culture and environment. In urban areas, access to
food may be limited by purchasing power but not
distance; subsidy and aid programs for families
such as food subsidies or food drives have been
shown to be helpful in the USA (Epstein,
Dearing, Roba, & Finkelstein, 2010; Kim &
Kawachi, 2006; Rose, 1999). In rural areas both
in developed and developing nations, adequate
distribution of existing food stores may be
more limiting than cost. Access to food with
high nutrient contents, such as fresh produce or
in some areas meat protein, may be precluded by
poor distribution, the expense of travel, or
inconvenience. Some supplementation programs,
such as the provision of vitamin A by WHO, are
well established and have been shown to be
beneficial.
Strategies That May Work
Micronutrient supplementation with a multivitamin/mineral tailored for children is a reasonable
practice, although definitive evidence of
long-term benefit is lacking. Regular consumption of fish should be encouraged in nonvegetarians; the consistent intake of DHA may offer
considerable health benefits, supported by
preliminary, but accumulating, evidence. Parents
should avoid overly restrictive or coercive
feeding practices, as these have been associated
with overeating and weight gain (Birch &
Ventura, 2009).
The single most important principle in dietary
health promotion is that a single diet is appropriate for the prevention of most diseases. Children
at eventual risk of cardiovascular disease may be
at risk of diabetes, cerebrovascular disease,
hypertension, renal insufficiency, and cancer
and are constantly vulnerable to infectious disease. If each disease required a different diet,
consistent recommendations could not be made

797

to an individual, let alone a population. The emergence of a “one diet” approach to nutritional
health is a logical outgrowth of confluent lines
of evidence and the clinical and public health
imperative for consistent and practicable advice.
That families tend to eat at least some meals
together argues for dietary recommendations for
adults and children that are comparable, if not
identical. The benefits of a health-promoting
diet should be combined with regular physical
activity for maximal benefit; a sedentary lifestyle
may undermine many of the potential health
benefits of an otherwise salutary dietary pattern
in childhood.
While a balanced diet provides the needed
micronutrients, many children and adolescents
do not meet this goal and consume processed
and fast foods in excess and consequently excess
sugar, salt, and fat. A multivitamin/mineral
supplement is an appropriate recommendation,
although clearly not compensatory for an imprudent dietary pattern. Evidence of health benefits
of multivitamin/mineral supplements is lacking
at the population level, but supplement use has
been associated with reduced prevalence of inadequate intakes of some nutrients, particularly in
older children (ages 9–18) (Bailey, Fulgoni,
Keast, Lentino, & Dwyer, 2012). However,
supplement use has also been associated with
intakes above the tolerable upper intake level
(UL) for iron, zinc, vitamin A, and folic acid in
all age groups and for vitamin C, selenium, and
copper in 2–8-year-olds (Table 2).
Methods to achieve widespread compliance
with recommendations for dietary and physical
activity patterns in children remain speculative
for the most part; limited success has been
achieved. Among the practices that warrant both
further study and on the basis of such evidence as
has been gathered, current applications are
distribution of food, and in particular, food
sources of protein of high biologic value, to
displaced children and families; widespread use
of multivitamin/mineral supplements in both
industrialized and developing nations; the provision of school food choices that reflect nutrition
guidelines; and the promotion, both in school and
at home, of regular physical activity in children.

798
Nutrition During
Childhood,
Table 2 Recommended
dietary allowances (RDAs)
and adequate intake
(AI) levels in early
adolescence

Nutrition During Childhood

Nutrient
Protein
Vitamin Aa
Vitamin Db,c
Vitamin Ed
Vitamin K
Vitamin C
Thiamin
Riboflavin
Niacine
Vitamin B6
Folatef
Vitamin B12
Calcium
Phosphorous
Magnesium
Iron
Zinc
Iodine
Selenium

Ages 9–13
Female
34 gm
600 mg RE
15 mg
11 mg a-TE
60 mg
45 mg
0.9 mg
0.9 mg
12 mg NE
1.0 mg
300 mg
1.8 mg
1,300 mg
1,250 mg
240 mg
8 mg
8 mg
120 mg
40 mg

Male
34 gm
600 mg RE
15 mg
11 mg a-TE
60 mg
45 mg
0.9 mg
0.9 mg
12 mg NE
1.0 mg
300 mg
1.8 mg
1,300 mg
1,250 mg
240 mg
8 mg
8 mg
120 mg
40 mg

Sources: Dietary Reference Intakes for Calcium, Phosphorous, Magnesium, Vitamin D,
and Fluoride (1997); Dietary Reference Intakes for Thiamin, Riboflavin, Niacin, Vitamin
B6, Folate, Vitamin B12, Pantothenic Acid, Biotin, and Choline (1998); Dietary Reference Intakes for Vitamin C, Vitamin E, Selenium, and Carotenoids (2000); Dietary
Reference Intakes for Vitamin A, Vitamin K, Arsenic, Boron, Chromium, Copper, Iodine,
Iron, Manganese, Molybdenum, Nickel, Silicon, Vanadium, and Zinc (2001); Dietary
Reference Intakes for Water, Potassium, Sodium, Chloride, and Sulfate (2005); and
Dietary Reference Intakes for Calcium and Vitamin D (2011). These reports may be
accessed via www.nap.edu
a
As retinol activity equivalents (RAEs). 1 RAE = 1 mg retinol, 12 mg b-carotene, 24 mg
a-carotene, or 24 mg b-cryptoxanthin. The RAE for dietary provitamin A carotenoids is
twofold greater than retinol equivalents(RE), whereas the RAE for preformed vitamin
A is the same as RE
b
As cholecalciferol. 1 mg cholecalciferol = 40 IU vitamin D
c
Under the assumption of minimal sunlight
d
As a-tocopherol. a-Tocopherol includes RRR-a-tocopherol, the only form of atocopherol that occurs naturally in foods, and the 2R-stereoisomeric forms of atocopherol (RRR, RSR, RRS, and RSS-a-tocopherol) that occur in fortified foods and
supplements. It does not include the 2S-stereoisomeric forms of a-tocopherol (SRR, SSR,
SRS, and SSS-a-tocopherol), also found in fortified foods and supplements
e
As niacin equivalents (NE). 1 mg of niacin = 60 mg of tryptophan; 0–6
months = preformed niacin (not NE)
f
As dietary folate equivalents (DFE). 1 DFE = 1 mg food folate = 0.6 mg of folic acid
from fortified food or as a supplement consumed with food = 0.5 mg of a supplement
taken on an empty stomach

Strategies That Do Not Work
The obstacles to combating under- and
overnutrition effectively are generally quite distinct. Among undernourished children, especially
among members of a displaced population, barriers to optimal nutrition are more likely to be

environmental and political than either cultural or
behavioral. In such populations, food distribution
programs may or may not achieve their goals
depending on how distribution channels are controlled. Problems of sanitation or facilities for
storage may also compromise the effectiveness

Nutrition During Childhood

of a well-intended program. Nonetheless, so long
as children and adults are subject to social
upheavals and poverty, such programs are clearly
indicated, with every effort made to ensure that
food is both culturally appropriate (e.g., no meat
is provided to a vegetarian culture) and delivered
to its intended recipients.
Barriers to the prevention of overnutrition
represent a constellation of environmental,
sociocultural, and behavioral factors. The environment in developed countries provides convenient access to energy-dense, nutrient-dilute
food, and technology that largely obviates the
need for physical activity and even lures children
from physically active pursuits (e.g., video
games). This is compounded by a food industry
that spends large sums on advertising directed at
children. Schools often enter into financial relationships with food or beverage distributors and,
as a result, do not practice the nutrition that is
preached to the children. Physical activity is
increasingly deemphasized in schools, and as
there has been little improvement in the rate of
physical activity among adults in the USA over
the past decade, few adults set an example in this
regard worthy of emulation. Efforts to promote
salubrious diet and activity patterns in children in
such an environment are largely ineffective.
Given the worsening epidemic of obesity and
diabetes among children as well as adults in the
USA, one may conclude, without undue
pessimism, that virtually nothing being done to
combat overnutrition and underactivity to date is
effective at the population level. However, the
failure of efforts to promote individual behavior
change against the resistance of environmental
factors is generating increasing attention to social
and environmental determinants of dietary
patterns that offers promise for the future.

Summary
There are two principal considerations in
determining best strategies to promote optimal
nutrition among the world’s children. The first
is what the dietary pattern should be, and the
second is to ensure that it is adopted.

799

With regard to the first consideration, confluent lines of evidence are increasingly compelling
with regard to a dietary pattern, or range of
patterns, associated with optimal health
outcomes. The utility of the paleolithic model is
enhanced because of the degree to which best
estimates of our ancestral dietary patterns
correspond with the best available science. Estimates of paleolithic intake suggest that we are
adapted to a fat intake of approximately 25 % of
total calories (Konner & Eaton, 2010). Further,
our ancestral intake of trans fat was negligible,
and saturated fatty acid intake is thought to have
made up less than 5 % of total calories. Nearly
half of the fat in our “natural” diets derived from
polyunsaturated fat, with an n-3 to n-6 ratio of
between 1:1 and 1:4. The other half derived from
monounsaturated fat. The inclusion of adequate
n-3 fatty acids in the diet may be particularly
important during childhood.
On the basis, therefore, of both evidence and
theory, a recommendation may be made, to
children and adults, to consume approximately
25 % of total calories as fat, in a nearly even
distribution between poly- and monounsaturated
fatty acids. The combination of trans and saturated fat should be kept below 5 % of total calories. This can be achieved in part by following the
consensus recommendations captured in MyPlate
(U.S. Department of Agriculture, 2011) emphasizing intake of whole grains, vegetables, and
fruit. However, unless fish consumption is very
consistent, n-3 fatty acid intake is apt to be lower
than optimal given the near-complete elimination
of n-3 fatty acids from the flesh of domestic food
animals. Consumption of soybeans and seeds, in
particular flaxseeds, as a means of raising n-3
fatty acid intake is recommended. Regular
physical activity among children should of course
be encouraged.
The second consideration, the means to
achieving these goals, is considerably more
intractable. For children subject to malnutrition,
food subsidy programs are a transient, discontinuous, and incomplete solution. Social interventions directed at the sources of poverty and
displacement, while beyond the scope of this
entry, are clearly the definitive interventions

800

for malnutrition. For children subject to
overnutrition, education about eating well in the
midst of a toxic nutritional environment is a tepid
and ineffective response. Dietary guidelines, not
convenience or financial expediency, should be
the basis for school nutrition programs and
nutrition assistance programs. Physical activity
should be promoted by schools both during and
after hours. Nutrient-dense, energy-dilute foods
should be made as available and appealing to
children as fast food now is, although the political
and financial opposition to such reforms may be
insurmountable in the short term. Until or unless
the political will is gathered to modify the toxic
nutritional environment in which children are
being raised, we may realistically expect that
relatively few will know the benefits of truly
optimal nutrition. If such diets can be widely
achieved among the world’s children, the benefits
to long-term health are likely to be profound.

References
Bailey, R. L., Fulgoni, V. L., Keast, D. R., Lentino, C. V.,
& Dwyer, J. T. (2012). Do dietary supplements
improve micronutrient sufficiency in children and
adolescents? Journal of Pediatrics, 161, 837–842.
Bandura, A. (1986). The social foundations of thought and
action: A social cognitive theory. Upper Saddle River,
NJ: Prentice Hall.
Bandura, A. (2004). Health promotion by social cognitive
means. Health Education and Behavior, 31(2), 143–164.
Barlow, S. E. (2007). Expert committee recommendations
regarding the prevention, assessment, and treatment of
child and adolescent overweight and obesity: Summary
report. Pediatrics, 120(Suppl 4), S164–S192.
Birch, L. L., & Ventura, A. K. (2009). Preventing childhood obesity: What works? International Journal of
Obesity, 33, S74–S81.
Brenna, J. T., Salem, N., Jr., Sinclair, A. J., & Cunnane,
S. C. (2009). Alpha-linolenic acid supplementation
and conversion to n-3 long-chain polyunsaturated
fatty acids in humans. Prostaglandins, Leukotrienes,
and Essential Fatty Acids, 80(2–3), 85–91.
Centers for Disease Control. (2010). Childhood
overweight and obesity. Retrieved May 27, 2013,
from http://www.cdc.gov/obesity/childhood/index.html
Centers for Disease Control. (2011). Healthy weight – It’s
not a diet, it’s a lifestyle! Retrieved May 27, 2013,
from http://www.cdc.gov/healthyweight/children/
Davison, K. K., & Birch, L. L. (2001). Childhood overweight: A contextual model and recommendations for
future research. Obesity Reviews, 2(3), 159–171.

Nutrition During Childhood
Davison, K. K., Jurkowski, J. M., & Lawson, H. A. (2012).
Reframing family-centered obesity prevention using
the Family Ecological Model. Public Health Nutrition,
22, 1–9.
Epstein, L. H., Dearing, K. K., Roba, L. G., & Finkelstein,
E. (2010). The influence of taxes and subsidies on
energy purchased in an experimental purchasing
study. Psychological Science, 21(3), 406–414.
Gerster, H. (1998). Can adults adequately convert alphalinolenic acid (18:3n-3) to eicosapentaenoic acid
(20:5n-3) and docosahexaenoic acid (22:6n-3)? International Journal for Vitamin and Nutrition Research,
68, 159–173.
Gidding, S. S., Dennison, B. A., Birch, L. L., Daniels,
S. R., Gillman, M. W., Lichtenstein, A. H.,
et al. (2006). Dietary recommendations for children
and adolescents: A guide for practitioners. Pediatrics,
117(2), 544–559.
Health Canada. (2005). Nutrition for healthy term infantsstatement of the joint working group: Canadian
Paediatric Society, Dietitians of Canada, and Health
Canada. Retrieved January 1, 15, 2012, from http://
www.hc-sc.gc.ca/fn-an/pubs/infant-nourrisson/nut_in
fant_nourrisson_term-eng.php
Imdad, A., & Bhutta, Z. A. (2011). Effect of preventive
zinc supplementation on linear growth in children
under 5 years of age in developing countries: A metaanalysis of studies for input to the lives saved tool.
BMC Public Health, 11(Suppl. 3), S22. doi:10.1186/
1471-2458-11-S3-S22.
Kim, D., & Kawachi, I. (2006). Food taxation and pricing
strategies to “thin out” the obesity epidemic. American
Journal of Preventive Medicine, 30(5), 430–437.
Kimm, S., Gergen, P., Malloy, M., Dresser, C., &
Carroll, M. (1990). Dietary patterns of us children:
Implications for disease prevention. Preventive
Medicine, 19, 432–442.
Konner, M., & Eaton, S. B. (2010). Paleolithic nutrition:
Twenty-five years later. Nutrition in Clinical Practice,
25(6), 594–602.
Lifshitz, F. (2009). Nutrition and growth. Journal of
Clinical Research in Pediatric Endocrinology,
1(4), 157–163.
Nicklas, T., Farris, R., Smoak, C., Frank, G., Srinivasan,
S., Webber, L., et al. (1988). Dietary factors relate to
cardiovascular risk factors in early life. Bogalusa heart
study. Arteriosclerosis, 8, 193–199.
Niinikoski, H., Lapinleimu, H., Viikari, J., Ronnemaa, T.,
Jokinen, E., Seppanen, R., et al. (1997). Growth until
3 years of age in a prospective, randomized trial of
a diet with reduced saturated fat and cholesterol.
Pediatrics, 99(5), 687–694.
Niinikoski, H., Viikari, J., Ronnemaa, T., Lapinleimu, H.,
Jokinen, E., Salo, P., et al. (1996). Prospective
randomized trial of low-saturted-fat, low-cholesterol
diet during the first 3 years of life. The strip baby
project. Circulation, 94, 1386–1393.
Ogden, C. L., Carroll, M. D., & Flegal, K. M. (2008). High
body mass index for age among us children and

Nutrition During Childhood
adolescents, 2003–2006. Journal of the American
Medical Association, 299(20), 2401–2405.
Olson, R. (2000). Is it wise to restrict fat in the diets of
children? Journal of the American Dietetic Association, 100(1), 28–32.
Rose, D. (1999). Economic determinants and dietary
consequences of food insecurity in the United States.
Journal of Nutrition, 129, 517S–520S.
Simell, O., Niinikoski, H., Ronnemaa, T., Lapinleimu, H.,
Routi, T., Lagstrom, H., et al. (2000). Special Turku
Coronary Risk Factor Intervention Project for
babies (STRIP). American Journal of Clinical
Nutrition, 72(5 Suppl), 1316S–1331S.
Spear, B. A., Barlow, S. E., Ervin, C., Ludwig, D. S.,
Saelens, B. E., Schetzina, K. E., et al. (2007).
Recommendations for treatment of child and
adolescent overweight and obesity. Pediatrics, 120
(Suppl. 4), S254–S288.
Tomkins, A. (2000). Malnutrition, morbidity and mortality in children and their mothers. Paper presented at
the Proceedings of the Nutrition Society. Held on June
29–July 2, 1999 at the University of Glasgow.
Glasgow, Scotland, UK. (Proceedings of the Nutrition
Society (2000), 59, 135–146).

801
U.S. Department of Health and Human Services. (2011).
Health.Gov – Dietary guidelines for americans, 2010.
Retrieved January 15, 2012, from http://health.gov/
dietaryguidelines/2010.asp
U.S. Department of Agriculture. (2010). Dietary
guidelines for Americans, 2010. Retrieved
January 15, 2012, from http://www.cnpp.usda.gov/
DGAs2010-PolicyDocument.htm
U.S. Department of Agriculture. (2011). Choosemyplate.
Gov. Retrieved January 15, 2012, from http://www.
choosemyplate.gov/
Van Horn, L., Obarzanek, E., Friedman, L. A., Gernhofer,
N., & Barton, B. (2005). Children’s adaptations
to a fat-reduced diet: The Dietary Intervention
Study in Children (DISC). Pediatrics, 115(6),
1723–1733.
Wintergerst, E. S., Maggini, S., & Hornig, D. H. (2007).
Contribution of selected vitamins and trace elements to
immune function. Annals of Nutrition and
Metabolism, 51(4), 301–323.
World Hunger Education Service. (2012). World child
hunger facts. Retrieved January 15, 2012, from http://
www.worldhunger.org/articles/Learn/child_hunger_fac
ts.htm

802

Obesity Prevention During Childhood

Definitions and Scope

Obesity Prevention During
Childhood
Karen M. Myrick
Quinnipiac University School of Nursing,
Hamden, CT, USA

Introduction
Childhood obesity is a worldwide pandemic.
Obesity has the propensity to increase the risk
of type 2 diabetes, cardiovascular disease, and
cancer; decrease quality of life; and limit
musculoskeletal function (Lu et al., 2010). The
prevention of childhood obesity has the potential
to also prevent the comorbidities associated and
to prevent progression to adult obesity and the
comorbidities associated as well.
The prevalence of obesity among US adults
(34 %) is twice that observed in children and
translates into nearly 73 million adult men and
women (Centers for Disease Control and
Prevention [CDC], 2011). US adults weigh
24 lb more than they did in 1960 on average
and are at increased risk for health conditions
such as diabetes, cardiovascular disease, and
certain cancers (CDC, 2011). The prevalence
has remained mostly flat in the past decade,
yet the costs associated with obesity have
increased substantially during the same
period (CDC). One study estimated that approximately 9 % of all medical costs in 2008 were
obesity related and amounted to $147 billion,
compared with $78.5 billion 10 years before
(CDC).
The causation for the problem is difficult to
narrow down, as it has been described as
multifactorial, which then, in turn, makes the
solution difficult. Likely causative factors
include a genetic predisposition, a positive
energy balance over the long term, and
overnutrition coupled with increasingly sedentary lifestyles (Schwager, 2010; Veerman, Van
Beeck, Barendregt, & Mackenbach, 2009;
Xi et al., 2011).

Body mass index (BMI) is the standard technique
for assessing overweight and obesity in pediatric
patients as well as in adults. However, this
method does not distinguish between fat and
lean mass, and interpretation of BMI must
account for the individual characteristics of the
person (Freedman & Sherry, 2009). In children
and adolescents, BMI varies significantly with
age, and there is no single value that corresponds
to overweight or obesity. The US Centers for
Disease Control and Prevention (CDC) developed growth charts from nationally representative surveys conducted over the last three
decades, which include sex-specific BMI-forage growth curves for 2–19 years of age (CDC,
2011; Freedman & Sherry, 2009). According to
the CDC guidelines, children with a BMI
between the 85th and the 95th percentiles are
considered overweight, and children with a BMI
in the 95th percentile are defined as obese (CDC,
2011; Guo, Wu, Chumlea, & Roche, 2002;
Schwager, 2010). The International Obesity
Task Force (IOTF) uses sex-specific BMI
cutoff values based on the standard deviation of
nationally representative datasets from the
United States, Great Britain, Brazil, the
Netherlands, Singapore, and Hong Kong
(CDC, 2011).
Childhood obesity affects approximately 12.5
million children and teens (17 % of that population) in the United States (CDC, 2011). Changes
in obesity prevalence from the 1960s show
a rapid increase in the 1980s and 1990s, when
obesity prevalence among children and teens tripled, from nearly 5 % to approximately 15 %,
and the rapid increase has plateaued in the
last 10 years (CDC). Alarmingly, among the
heaviest boys, a significant increase in obesity
has been detected, with the heaviest getting
even heavier (CDC). Substantial racial/ethnic
disparities exist, with Hispanic boys and
non-Hispanic black girls disproportionately
affected by obesity. Also, older children and
teens are more likely to be obese compared with
preschoolers (CDC).

T.P. Gullotta, M. Bloom (eds.), Encyclopedia of Primary Prevention and Health Promotion,
DOI 10.1007/978-1-4614-5999-6, # Springer Science+Business Media New York 2014

Obesity Prevention During Childhood

803

Theories, Major Explanations

Current Research

Theories regarding obesity range from frameworks that are grounded in the medical model,
social cognitive model, family theory, and social
ecological theory. Many feel that the problem
stems as a multifaceted issue, with medical,
social cognitive, and family all being
contributory.

Community social marketing campaigns, such as
5-4-3-2-1-Go!, have been utilized (Evans et al.,
2011). The objectives were to determine effects
of the 5-4-3-2-1 Go! community social marketing
campaign on obesity risk factors. The methods
used were to randomly assign 524 parents of
3–7-year-old children to receive 5-4-3-2-1 Go!
counseling or not. Parents were surveyed about
behaviors and perceptions of children’s behaviors
at baseline and at 1 year. A multivariable logistic
regression for each outcome was calculated, and
the results demonstrated that parents who received
counseling consumed more fruits and vegetables at
follow-up (OR 1.749, [95 % CI: 1.01–3.059]).
Parental exposure to messaging at children’s
school events was associated with higher water
consumption (6.879, [1.954–24.212]).
Breastfeeding promotion and support has been
studied for reduction in childhood obesity. The
CDC has a specific obesity initiative, and
breastfeeding has been suggested as a means of
child obesity prevention by the White House
Task Force on childhood obesity (GrummerStrawn, 2010).
Programs that increase the physical activity
levels of children have demonstrated positive
results. The ABC (Activity Bursts in the Classroom) for Fitness program evaluated the effects
of a physical activity program in the elementary
school classroom on health outcomes. The
methods used were to use three schools in
the Independence School District in Independence, Missouri, that were assigned to receive
the ABC program and 2 comparable schools
served as controls. The program, led by classroom teachers, provides multiple, brief,
structured physical activity breaks throughout
the day. The results demonstrated that physical
fitness measures of upper-body strength,
abdominal strength, and trunk extensor improved
(P < .001). Medication use for asthma (P = .03),
attention-deficit hyperactivity disorder (P = .07),
or either medication combined (P = .005)
decreased. The study demonstrated that the
effects of the program on daily physical activity,

Biological and Genetic Factors and Theories
The obesity epidemic is thought to be caused by
a combination of genetic predisposition to
increased adiposity and body mass and longterm positive energy balance caused by over
nutrition and a sedentary lifestyle (Schwager,
2010; Veerman, Van Beeck, Barendregt, &
Mackenbach, 2009; Xi et al., 2011). Television
advertising and time spent viewing have been
viewed as an issue as well. The recent rapid
proliferation in the prevalence of obesity both in
certain populations, such as the United States,
and globally suggests the significance of
nongenetic causes.
Family Factors
The family has a large influence on nutrition and
exercise. The risk for obesity and overweight
increases due to both poor dietary habits and
lack of physical activity (Schwager, 2010).
These may both be suggested by the family theories and practices.
Environmental, Social, and Community
Factors and Theories
Environmental determinants of childhood obesity in the United States include shifts in food
consumption, changes in physical activity
levels, increasing levels of television viewing,
and the subsequent inactivity and marketing
of food to children (CDC, 2011; Many kids
aware of CDC obesity campaign, 2004). Access
to safe areas to play and participate in healthy
activities decreases the likelihood of obesity
(Evans, Christoffel, Necheles, Becker, &
Snider, 2011).

804

Obesity Prevention During Childhood

fitness, and measures of health are beneficial
(Katz et al., 2010).
In another school intervention program,
STOPP, Marcus et al. demonstrated a decrease
in the prevalence of overweight and obesity
and possibly an effect in the home, through
improving healthy eating habits at school
versus increasing physical activity (Marcus
et al., 2009).
Programs using the primary care provider to
identify and discuss the problem of obesity with
patients when they were identified as empowered
demonstrated a 63 % decrease in BMI, compared
to control group who’s BMI increased
(Kwapiszewski & Lee Wallace, 2011).
Resistance training has been shown to increase
lean body mass, decrease the percentage of body
fat, and increase strength and power in children
who are overweight and obese (McGuigan,
Tatasciore, Newton, & Pettigrew, 2009).
Muckelbauer found that an interventional
and educational program on promoting water
consumption was effective in the prevention of
obesity (Muckelbauer et al., 2009).
Community-based group interventions, such
as “active8,” have shown that it compares well
to similar interventions; however, further studies
are required to evaluate long-term efficacy, to
eliminate the possible confounding effect of
factors such as ethnicity and comorbidities, and
to strengthen the quality of the evidence by the
use a control group and randomization (Norton,
Samani-Radia, & Van Tonder, 2011; Smpokos,
Linardakis, Kogevinas, & Kafatos, 2010).

to obesity have been trialed. Programs that
increase lean mass while decreasing body fat,
such as resistance training programs, have been
attempted.
Programs that work on increasing the
consumption of water and other healthy foods as
their strategy have been tried. The feasibility of
an email campaign has been demonstrated.

Overview of Strategies

What Does Not Work

Strategies to prevent childhood obesity include
social marketing campaigns. School-based
education and intervention programs that focus
on healthy eating and/or increasing physical
activity have been attempted. The promotion of
breastfeeding is an approach to the problem that
has had impact even on the national level.
Approaches utilizing the primary care
provider to identify and address the problem of
overweight and hopefully prevent the extension

Wake studied the theory that short sleep duration
may contribute to childhood obesity. Being that
sleep could be amenable to intervention, sleep was
thought to provide a potential path for prevention.
The authors aimed to determine the impact of
a behavioral intervention that successfully reduced
parent-reported infant sleep problems on adiposity
at age 6. The study failed to show an association
with sleep and obesity (Wake, Price, Clifford,
Ukoumunne, & Hiscock, 2011).

What Works
A search of the literature did not uncover the
standards of an intervention that met 3 successful
trials.

What Is Promising
Community social marketing campaign on
obesity risk factors, such as the 5-4-3-2-1
Go! program, demonstrated results that showed
this is a promising intervention (Evans et al.,
2011).
Programs such as the ABC program that
increased physical activity demonstrated positive
outcomes (Katz et al., 2010).
Breastfeeding promotion programs have also
demonstrated promising effects and outcomes
(Grummer-Strawn, 2010).
Primary care provider programs that identify
and then deal with the obesity diagnosis have
shown promise in treating overweight and possibly
preventing obesity (Schwager, 2010).

Obesity Prevention During Childhood

Summary
Additional work might be done in the area of
national campaigns which advertise during child
and family programs. Work in decreasing the
direct advertisement to children and promotion
of healthy habits is promising. Providing safe
environments where children can engage in physical activity daily is also encouraging.
The best practices are headed in a direction of
problem identification and solid programs with
education and intervention incorporated. Multifaceted programs that take genetics, environmental influences, and prevention into account will
likely yield the best results.

References
Centers for Disease Control and Prevention. (2011). CDC
grand rounds: Childhood obesity in the United States.
MMWR: Morbidity & Mortality Weekly Report, 60(2),
42–46.
Evans, W. D., Christoffel, K. K., Necheles, J., Becker,
A. B., & Snider, J. (2011). Outcomes of the 5-4-3-2-1
go! childhood obesity community trial. American
Journal of Health Behavior, 35(2), 189–198.
Freedman, D. S., & Sherry, B. (2009). The validity of BMI
as an indicator of body fatness and risk among
children. Pediatrics, 124, S23–S34. doi:10.1542/
peds.2008-3586E.
Grummer-Strawn, L. (2010). CDC efforts and leadership
on breastfeeding. Breastfeeding Medicine, 5, 207–208.
doi:10.1089/bfm.2010.0065.
Guo, S. S., Wu, W., Chumlea, W. C., & Roche, A. F.
(2002). Predicting overweight and obesity in adulthood from body mass index values in childhood and
adolescence. American Journal of Clinical Nutrition,
76(3), 653–658.
Katz, D. L., Cushman, D., Reynolds, J., Njike, V., Treu,
J. A., Walker, J., et al. (2010). Putting physical activity
where it fits in the school day: Preliminary results of
the ABC (activity bursts in the classroom) for fitness
program. Preventing Chronic Disease, 7(4),
A82–A82.
Kwapiszewski, R. M., & Lee Wallace, A. (2011). A pilot
program to identify and reverse childhood obesity in
a primary care clinic. Clinical Pediatrics, 50(7),
630–635. doi:10.1177/0009922811398389.

805
Lu, A. S., Baranowski, J., Cullen, K. W., Thompson, D.,
Baranowski, T., & Jago, R. (2010). Interactive media
for childhood obesity prevention. Health Communication, 25(6), 581–582.
Many kids aware of CDC obesity campaign. (2004).
Medical Letter on the CDC,,59–60.
Marcus, C., Nyberg, G., Nordenfelt, A., Karpmyr, M.,
Kowalski, J., & Ekelund, U. (2009). A 4-year,
cluster-randomized, controlled childhood obesity
prevention study: STOPP. International Journal of
Obesity, 33(4), 408–417. doi:10.1038/ijo.2009.38.
McGuigan, M. R., Tatasciore, M., Newton, R. U., &
Pettigrew, S. (2009). Eight weeks of resistance training
can significantly alter body composition in children
who are overweight or obese. Journal of Strength &
Conditioning Research (Lippincott Williams &
Wilkins), 23(1), 80–85.
Muckelbauer, R., Libuda, L., Clausen, K., Toschke, A. M.,
Reinehr, T., & Kersting, M. (2009). Promotion and
provision of drinking water in schools for overweight
prevention: Randomized, controlled cluster trial.
Pediatrics, 123(4), e661–e667. doi:10.1542/peds.20082186.
Norton, D., Samani-Radia, D., & Van Tonder, A. (2011).
Evaluation of activ8: The effectiveness of a joint
dietetic and physiotherapy weight management group
intervention in children and adolescents. Journal of
Human Nutrition & Dietetics, 24(3), 297–297.
doi:10.1111/j.1365-277X.2011.01175 26.x.
Schwager, T. (2010). Defeating childhood OBESITY.
American Fitness, 28(6), 18–20.
Smpokos, E. A., Linardakis, M., Kogevinas, M., &
Kafatos, A. G. (2010). Does a health education
program for 5–8 year old children improve
physical activity and fitness indices? International
Journal of Child Health & Human Development,
3(1), 57–67.
Veerman, J. L., Van Beeck, E., Barendregt, J. J., &
Mackenbach, J. P. (2009). By how much would limiting TV food advertising reduce childhood obesity?
European Journal of Public Health, 19(4), 365–369.
doi:10.1093/eurpub/ckp039.
Wake, M., Price, A., Clifford, S., Ukoumunne, O. C., &
Hiscock, H. (2011). Does an intervention that
improves infant sleep also improve overweight at age
6? follow-up of a randomised trial. Archives of Disease
in Childhood, 96(6), 526–532.
Xi, B., Wang, C., Wu, L., Zhang, M., Shen, Y.,
Zhao, X., et al. (2011). Influence of physical inactivity
on associations between single nucleotide polymorphisms and genetic predisposition to childhood obesity. American Journal of Epidemiology, 173(11),
1256–1262.

806

Parenting as Primary Prevention
Donald G. Unger1 and Amanda Rich2
1
College of Education and Human Development,
Department of Human Development &
Family Studies, University of Delaware,
Newark, DE, USA
2
York College of Pennsylvania, York, PA, USA

Introduction
While debates will inevitably continue into the
next decades as to the relative influence of nature/
biology versus environment on a child’s development, research continues to support the finding
that “parents matter.” Prevention programs for
parents focus on supporting all types of parents
and children, ranging from universal programs
for all to programs for populations of young children and their families who have specific, indicated risks or challenges. The primary goals of
these prevention programs for parents of young
children are to (a) enable parents to nurture and
safely care for their young children; (b) help
parents ensure that their young children will be
academically, socially, and emotionally ready for
success in school; and (c) promote the well-being
and positive healthy development of children by
strengthening families and their communities.
By accomplishing these goals, it is expected that
young children will eventually become productive and contributing members of their
communities.
Unfortunately, however, there has never been
a “how to parent” handbook that everyone agrees
is the “right” way to be a parent and to deliver
prevention programs. This is in part due to our
increasingly diverse, global society and the vast
variations in experiences of parenting. Being
a parent today is a journey into the known and
unanticipated, the private and public, the predictable and unforeseen. Parenting can bring both the
young child and the adult into complex, dynamic,
and new multidimensional relationships and
challenges. Parenting may extend between
a biological parent(s) and his or her child living

Parenting as Primary Prevention

together and at times include other family members, friends, partners, and nonresidential fathers
as caregivers. Parenting may even involve additional “created families” through foster care,
adoption, and government involvement.
Resources and challenges vary for parents and
can come in the forms of developmental delays
and early intervention programs, variations in
parent work schedules, income, and the quality
of childcare arrangements. Ethnic and racial
disparities in resources, differences in gender
roles and expectations, changes in sociopolitical
and moral climates that affect funding for service
provision, and traditions, values, and conflicts
between generations, as well as between different
countries of immigrant, global families affect the
parenting experience. Many parents effectively
navigate this complex environment for childrearing, having access to sufficient social and
community resources, along with the personal,
family, and physical assets necessary to meet
their children’s needs. Other parents, however,
face many obstacles associated with living in
the contexts of limited economic, social, or
community resources and/or are parenting
children with complex needs, such as children
with developmental disabilities, mental health
concerns, and chronic health conditions. Still
others struggle to maintain positive parent-child
relationships under strained, separate living
arrangements, whether due to war and military
service, incarceration, drug and alcohol abuse
treatment, divorce, or domestic violence. Parenting prevention programs have the challenge of
meeting the wide-ranging needs of all parents and
children in an increasingly diverse global society.

Definitions and Scope
A parent in this entry is broadly defined, and this
definition is intended to reflect the increasing
diversity in families. Being a parent can include
a biological relative (e.g., grandparent),
nonrelative (e.g., foster parents), and/or
nonresidential (e.g., divorced father) caregiver
who assumes primary responsibility for carrying
out one or more of the roles of caring for a young

T.P. Gullotta, M. Bloom (eds.), Encyclopedia of Primary Prevention and Health Promotion,
DOI 10.1007/978-1-4614-5999-6, # Springer Science+Business Media New York 2014

Parenting as Primary Prevention

child (prenatal – age 8). These roles include the
following: (a) providing for the child’s basic
needs so that a child has adequate food, nutrition,
health care, shelter, and clothing; (b) guiding
a child’s cognitive, physical, and socialemotional development by encouraging exploration, mentoring and modeling basic skills,
celebrating developmental advances, rehearsing
and extending new skills, comforting and communicating, and providing limits (Ramey &
Ramey, 1998); (c) preventing psychological and
physical neglect and abuse by providing adequate
nurturance and supervision and engaging in
actions to prevent accidents and related injuries;
(d) ensuring quality early care and education in
the home (preparing for school entry by providing learning opportunities for children) and/or
school-/childcare setting (taking into account
factors such as child to teacher ratios, teacher/
caregiver behavior with children, parental school
involvement); (e) advocating within the wider
community on behalf of his or her child, e.g., to
promote safe communities, good schools and
recreational facilities, policies of inclusion,
and acceptance of children with disabilities; and
(f) balancing and attending to adult self-care
strategies while at the same time caring for
a young child in order to cope with and buffer
parenting and relationship/marital stress, challenges to one’s sense of efficacy and mastery
and a sense of isolation when caring for an infant
(Cochran & Niego, 1995). Lastly, these roles may
change and vary over time, depending upon the
needs of the child, parent(s), and family.

Theories
Prevention programs for parents of young children are guided by many different theoretical
frameworks. However, we believe that three
frameworks, in particular, are relevant for
addressing the needs of young children through
parenting prevention programs. First, an ecological framework emphasizes that children’s development has multiple, intertwining determinants
(Bronfenbrenner, 1979). Child development
occurs within a series of nested and overlapping

807

contextual subsystems in which the child interacts, either directly or indirectly, in a dynamic,
bidirectional fashion that changes and develops
over time. These systems include parents and
families where there is typically the most direct
or frequent contact, the child’s and parent’s
genetic predispositions, early care and education
settings, workplace and government policies that
impact caregivers, as well as communities where
a child lives and plays. An implication of an
ecological approach to prevention is the need to
address multiple levels and determinants of
behavior, and that change can be brought about
through change in interconnected systems.
Attachment theory focuses attention on the
affective bond that typically develops between
parent and child that endures across both time
and context (Bowlby, 1988). Attachment theorists believe that the infant-caregiver relationship
serves as a foundation for social-emotional development for a child. A secure infant-caregiver
attachment eases a child’s distress in novel situations, provides a secure base to explore new
situations with confidence, and supports the overall confidence and self-efficacy of the developing
child. When secure attachments to caregivers do
not develop, children are more apt to display
behavior that reflects distrust or uncertainty in
the caregiver’s responsiveness to the child’s
needs. An implication of this theory for prevention programs with young children is the importance of providing opportunities that promote
parental understanding of their children’s behavior and temperament. This understanding, along
with the skills to adjust a parent’s behavior to
become more responsive to his or her child’s
needs and signals, can result in positive, reciprocal parent-child relationships, which in turn
facilitate a child’s feelings of attachment and
well-being.
A social support or mutual aid framework is
a cornerstone of most prevention programs.
Social support refers to the emotional, informational, and material resources that are provided
by a parent’s informal social network and/or by
others experiencing similar life circumstances
and stressors. These informal resources are
viewed as important and distinct from assistance

808

provided by professionals because they are typically offered in ways that are more flexible and
timely and perceived as genuine, caring, and freely
offered. Help in the form of informal social support
can buffer stress, promote well-being, and facilitate
resiliency to adverse circumstances. An implication of a social support and mutual aid framework
is that parents often benefit from help that is locally
based, culturally sensitive, and provided by other
parents from similar life circumstances.

Current Research
There is a growing body of research on parenting
and risk and resilience in children that can inform
prevention efforts (Whittaker, Harden, See,
Meisch, & Westbrook, 2011). Parenting itself
can be either a protective or risk factor for children. Sensitive, nurturing parenting is associated
with positive physical, cognitive, and socialemotional outcomes in young children (TamisLeMonda, Briggs, McClowry, & Snow, 2009).
There are both affective and behavioral components involved in positive parenting, including
warmth and responsiveness to a child’s needs
and perspective, appropriate limit setting, and
creating a predictable environment for the child.
Sensitive, responsive parenting is thought to promote secure attachments between an infant and
her caregiver. Secure attachment relationships
may help regulate the neurological activity of
stress-sensitive systems in the brain helping children develop better emotional regulation and
self-soothing skills (Bernard & Dozier, 2010).
Parents with fewer mental health problems,
good general health, and healthy social support
systems are more likely to engage in positive
parenting (Whittaker et al., 2011).
When parents experience multiple risk factors
and a pileup of stressors, parents themselves can
be a source of risk for young children. Child abuse
and neglect is a significant problem among families with young children and a major focus of
many parenting prevention programs. In the
United States in 2008, approximately 700,000
children were victims of maltreatment, 33 % of
them being children under 5 years of age; the

Parenting as Primary Prevention

majority of maltreatment cases are ones of neglect
(U.S. Department of Health and Human Services,
2010). Parental risk factors include maternal age,
family size and structure, poverty and related
stressors, maternal health and substance abuse,
lack of social support, domestic violence, lack of
parenting efficacy, and challenging child health
and behavior problems (Whittaker et al., 2011).
Harsh, abusive, and/or neglectful parenting is
associated with cognitive, behavioral, social, and
emotional problems in children (Repetti, Taylor,
& Seeman, 2002) that can persist even long after
the maltreatment has ended (Currie & Widom,
2010).
Parenting may also mediate the impact of risk
factors for negative outcomes in a child’s life. Poverty remains a significant risk factor for children’s
development throughout the globe. In 2009, 20.7 %
of children under the age of 18 were living in
poverty in the United States (U.S. Census Bureau,
2010). Poverty is associated with wide-ranging negative outcomes for children (Raver, 2004). Prevention programs often focus on supporting parents in
poverty to offset the potentially devastating consequences on children as well as the potential impact
of poverty on parental depression, stress, family
discord, and overall efficacy in parenting
(Henderson, Sayger, & Horne, 2003).
Lastly, research increasingly documents the
changing nature and diversity of families. For
instance, more households than ever before in
the United States are comprised of grandparents
raising young children (Dolan, Casanueva,
Smith, & Bradley, 2009). Prevention programs
need to embrace such changes from a strengths
perspective and find ways to support these new
family structures. For instance, in comparison to
foster care, kinship care provided by grandparents can provide greater stability and warm,
positive parenting behaviors (Dolan et al.,
2009). At the same time, grandparents cannot be
expected to assume such responsibility without
adequate supports, given that grandparents
providing care are more likely to experience
poverty, social isolation, and physical health
problems than younger caregivers (Dolan et al.).
A greater number of openly gay men and
women are becoming parents. Research shows

Parenting as Primary Prevention

that children from gay and lesbian families have
similar social-emotional, physical, and psychological development as children living with
heterosexual couples (Patterson, 2006). However,
gay and lesbian fathers and mothers may face additional challenges and stress due to social stigma and
discriminatory legal policies. Many gay and lesbian
parents even fear that disclosing their sexual identity may result in them loosing custody of their
children (Shapiro, Peterson, & Stewart, 2009).
Gay parents may also face concerns that differ
from heterosexual parents and by region of the
world. For instance, lesbian mothers in the United
States report having more anxiety regarding legal
issues and discrimination based on sexual orientation than lesbian mothers in Canada where there is
greater legal support for gay and lesbian parents
(Shapiro et al., 2009).
Families with children with intellectual
disabilities increasingly are enrolling their children in early care and education programs with
typically developing peers. However, while they
may have legal access, these parents still face
significant challenges in ensuring quality,
inclusive, and supportive caregiving environments. Prejudices, misinformation about intellectual disabilities among individuals with typically
developing children and a lack of quality services
and supports constrains opportunities for full
inclusion. Moreover, these parents are at
increased risk for stress, isolation, and depression
(Glidden, Bamberger, Turek, & Hill, 2010). In
addition to financial strain associated with
meeting a young child’s special needs, their
children are more likely to experience challenging behaviors although few early care and education programs are prepared to help with these
issues. Prevention programs have to address
diversity not only among caregivers but also
among their children. Knowing these challenges
may help ensure that prevention programs are
meeting the needs of all families.

Overview of Strategies
There are essentially four strategies or
approaches that are used to support parents in

809

engaging in positive parenting, for filling their
parental roles and promoting positive outcomes
for young children. They include (a) parent
education, (b) family support, (c) family strengthening, and (d) family preservation.
In parent education, parents receive information about child development that they can use to
engage in child centered activities to promote
their children’s development. Opportunities are
provided to try out these different approaches to
facilitating development. Parent education may
also include a focus on parent-child relationships
and parenting skills, as well as learning techniques for managing stressors that might affect
their parenting.
A family support approach works on
establishing relationships between parents and
others to strengthen parents’ abilities to draw
upon available resources to enhance their
well-being and that of their families. A family
support approach is “holistic”; while child development information is often provided, additional
forms of support that are associated with multiple
spheres of the parent’s and family’s life are
addressed as well. Helping parents develop
long-term support systems, manage stress, access
community resources, obtain employment, and
strengthen the home-preschool link is an important aspect of family support. Family support
interventions involve parents, volunteers, professionals, and paraprofessionals and offer
numerous family services that build upon family
and community strengths.
The family strengthening approach is very
similar to family support but focuses specifically
on enhancing key protective factors (i.e., parental
resilience, social connections, knowledge of parenting and child development, concrete support,
and social and emotional competence of children) with the explicit goal of preventing child
abuse and neglect (Center for Study of Social
Policy, 2007). This approach works toward
helping existing community-based organizations
such as early care and education programs to
become more family centered and a broader
source of support for parents.
Lastly, family preservation programs provide
intensive clinical and concentrated short-term

810

support services to families who are at risk for
out-of-home placements.
These strategies for supporting parents are
quite diverse and consequently employ
a number of different methods to implement
their strategy. Methods used to implement
a strategy are distinct from the strategy itself.
For example, home visiting is a method that can
be used to deliver a variety of strategies or
approaches (e.g., parent education, family
support, family preservation). For high-risk and
teen parent families, combining intensive childfocused early intervention and center-based
services, along with home visiting and other
high-quality parent- and family-focused services,
has a significant potential for improving child and
family outcomes (Ramey et al., 2000). Another
method of implementing family support is to
explicitly offer services related to adult education
and development, in addition to parenting. Some
preschool programs, for instance, offer literacy
training and general education for parents,
becoming a “two-generation” program, based
on the premise that children’s educational experience is closely tied to parent literacy (Smith &
Zaslow, 1995). Similarly, programs may incorporate conflict resolution with their adult partners
and relationship enhancement as part of their
family support curriculum. Lastly, programs
may incorporate group methods. Groups,
conducted by parents and/or professionals, are
organized around parent and/or child concerns
(e.g., parents with children with cancer, teen parenting, adults transitioning to parenthood, parents
in lesbian relationships). The support of group
members can provide opportunities to learn
from each other, reinforce and enhance parents’
competencies, and establish a nonthreatening
environment to acquire new information (Rosenberg & Reppucci, 1990).

What Works
There are several commonalties in how effective
prevention programs for parents of young children are constructed and implemented, rather
than any one most effective framework or method

Parenting as Primary Prevention

(Borkowski & Weaver, 2006; Nation et al.,
2003). Prevention programs that work are
typically theoretically driven. Theories act like
spotlights in prevention research, helping to identify which issues are of importance, how concepts
may be connected to one another, how change
comes about, and which issues are beyond the
scope of the intervention. Effective prevention
programs also tend to use a combination of interventions to address multiple components of
a particular problem. Effective programs are
delivered with sufficient dosage and with intensity that matches the need of the participants
(Borkowski & Weaver, 2006). The most effective
prevention programs are implemented before the
onset of the problems and are initiated at periods
of developmental transitions and/or new challenges and family stressors.
Four programs are highlighted here that have
been found to yield positive outcomes and have
many of the components of effective prevention:
The Nurse-Family Partnership, Healthy Families
America, Early Head Start, and Child/Parent
Center programs. The Nurse-Family Partnership
program utilizes professional public health
nurses to go to the homes of expecting or new
mothers, many of who have been identified as
being at risk. The Nurse-Family Partnership program targets at-risk families, identified by socioeconomic status, geographic area, and maternal
age. In the program, nurses work to educate parents on child development, support parents in
involving friends and extended family to gain
support for parents and children, as well as help
families connect to appropriate services in the
community. The goals of the Nurse-Family Partnership program are to improve the outcome of
pregnancy, parental caregiving skills, and the
mother’s overall life course development (Olds,
2006). The Nurse-Family Partnership program
has been evaluated across diverse samples and
regions in the United States, with findings of
reductions in preterm births, in the percentage
of low birth weight infants, in subsequent pregnancies and births, and in problems resulting
from substance abuse (Olds et al., 2007).
Healthy Families America (HFA) is a national
home visiting program that extends across the

Parenting as Primary Prevention

first 5 years of a child’s life (Prevent Child Abuse
America, 2002). The goals of the program are to
promote positive parent-child relationships,
reduce child maltreatment, and promote positive
child development (Prevent Child Abuse America). Healthy Families America is a more universally targeted program than most other home
visiting programs. HFA reaches out to 90 % of
all new or first-time parents within a particular
community (Prevent Child Abuse America).
There have been four randomized controlled trials of the HFA home visiting programs all of
which have shown encouraging program impacts
on child health, cognitive and socio-emotional
developmental outcomes, but mixed results
regarding effects of positive parenting in contrast
to the prevention of abuse and neglect (Harding,
Galano, Martin, Huntington, & Schellenbach,
2007).
Early Head Start, an expansion of the Head
Start preschool program, includes low-income
families with infants and toddlers (Raikes &
Love, 2002). Early Head Start utilizes home visiting, center-based care, advocacy training, and
a combination of these approaches to promote
healthy child development and assist parents in
developing positive child-rearing behaviors as
well as promote community development
(Raikes & Love). Early Head Start has been
extensively evaluated and has been found to
have positive results on parenting behavior and
child development. In a recent evaluation, children at 14, 24, and 36 months of age in the Early
Head Start group had larger vocabularies, higher
scores on standardized developmental tests, and
more positive social-emotional development than
children in the control group. Measures of parenting behavior also showed to be more positive
in the Early Head Start parents versus the control
group. Parents were more knowledgeable about
infant-toddler development, were more engaged
in language and literacy activities, were less
likely to have engaged in harsh parenting styles
in the past week, and reported less marital conflict
than did others in the control group (Ayoub,
Vallotton, & Mastergeorge, 2011).
The Child/Parent Center program has been
systematically evaluated and found to have

811

positive impacts on child development and family and community functioning (Reynolds & Ou,
2011). This program utilized a center-based
approach to connect families of low-income
preschool children with resources and offered intensive preschool services as well as a parent resource
and educational center. Children and their families
entered the program at age 3 and were followed into
adulthood to evaluate any long-lasting impact of
the program (Reynolds & Ou). Children demonstrated greater cognitive gains and had lower rates
of special educational services in preschool.
In kindergarten children in this group scored higher
on reading and math scores and had fewer grade
retentions and fewer rates of special education.
Educational gains persisted until middle school.
At 24 years of age, children in the experimental
group demonstrated lower rates of incarceration,
higher occupational prestige, and lower rates of
depressive symptoms than children in the control
group (Reynolds & Ou).

What Is Promising?
Some promising practices that have not been
extensively researched have come from programs
that were originally designed for children with
behavioral challenges and disabilities and then
applied to families experiencing more general
risk. Programs such as The Incredible Years
(Webster-Stratton, 2007), while designed for parents of children with severe behavioral challenges, have been found to improve parent and
child outcomes for children and families from
a range of at-risk populations (Barth et al.,
2005; Letarte, Normandeau, & Allard, 2010).
Programs targeted at promoting positive
attachment behavior in young children who are
at risk due to disruptions in their caregiving experience are also promising (Heinicke et al., 1999).
Due to disruptions in caregiving experiences, or
maltreatment, children who enter foster care, for
instance, are more likely to have difficulty
forming secure attachments than other children.
Dozier et al. (2009) developed the Attachment
and Biobehavioral Catch-up Intervention (ABC)
for foster parents of young children, with the goal

812

of supporting the development of positive attachment behavior in the children. The ABC intervention consists of parent training for foster
parents conducted by experienced social workers
or psychologists. Foster parents learn to provide
nurturing behavior even when the child does not
elicit it and receive help in examining their own
issues that interfere with providing nurturance
and support to create a predicable environment
that supports the child’s self-regulatory behavior
(Dozier et al.). In a randomized trial Dozier et al.
found that foster parents who received the intervention reported their children demonstrated less
avoidant and resistant behavior when distressed
than parents in a control group, and the intervention had benefits on the child’s functioning
including behavioral and neurobiological regulation as well (Dozier et al., 2006).
Most of the evaluations on prevention programs have targeted families labeled as “at risk”
rather than using a universal design. However, of
the existing universal programs, there are some
promising results. For instance, the Family Foundations Project is a transition to parenthood program for couples and focuses on the co-parenting
relationship (Feinberg, Kan, & Goslin, 2009).
The program consists of eight interactive
psychoeducational, skill-based classes designed
for expectant, cohabiting, or married couples.
Effects have been documented on parental stress,
efficacy, co-parenting, harsh parenting, children’s emotional adjustment, and maternal
depression among cohabitating couples when
their children were 6 months and 3 years of age
(Feinberg et al., 2009).
Other universal programs have utilized tiered,
multiple interventions and had promising results.
Triple P (Positive Parenting Program) follows
a public health, population-based approach and
has found positive results on reducing rates of
child maltreatment in one randomized controlled
study (Prinz & Sanders, 2007). The program uses
five levels of intensity of programming. For
instance, media is used along with mass mailings
to reach families, educating them on typical child
development and positive parenting practices.
Another level consists of brief and flexible consultation to individual parents and parenting

Parenting as Primary Prevention

seminars. The most intensive level includes
10 session programs with families, using
a combination of skill training, home visits, clinic
observations, practice, feedback, mood management, and stress and coping skills (Prinz &
Sanders).
Parents as Teachers is designed as a universal
prevention program using home-based and group
methods but, because of funding constraints,
often is provided only to parents who are determined to be “at risk.” PAT begins with parents
during pregnancy and throughout the child’s
early years. Parent educators use the PAT
curriculum (Born to Learn, 2005) and receive
ongoing training and certification. The goals of
the program are to increase parents’ knowledge
of early childhood development, promote
positive parenting behaviors, detect developmental delays and health problems in children,
prevent child abuse, and promote school readiness (Parents as Teachers National Center
[PATNC], 2005). Evaluations of the effectiveness of the program have been generally positive,
with some mixed findings (Bryant et al., 2003).
For instance, Drotar, Robinson, Jeavons, and
Kirchner (2008) conducted a controlled, experimental design of the Parents as Teachers program
and found significant effects on a child’s mastery
motivation, though there was no significant
impact on a wide range of other developmental
outcomes. A significant strength of PAT is its
research-based curriculum that is routinely
updated, and numerous opportunities for training
are provided annually by the national PAT
organization.
Other promising practices come from
programs exploring creative ways to maneuver
barriers to parent participation and subsequently
reach diverse families. For instance, programs
using Internet-based parent-to-parent and professional-to-parent support are being implemented
for parents of young children with disabilities.
This may be exceptionally helpful for reaching
these families in rural areas. Programs are
piloting child developmental milestone information, synced with the age of their young child,
being sent to parents on their smartphones. Programs are even available online to help parents

Parenting as Primary Prevention

become advocates for their children with disabilities and to learn how to join with policy makers
to effect systems-level change, for instance,
Partners in Policy Making (2010).
To ensure that an intervention “works,” attention must be addressed not only to intervention
strategies and their outcomes but also to the
process of how a program is implemented. In
a qualitative process program evaluation with
African-American mothers who participated in
Parents as Teachers program (Parents as
Teachers National Center, 2005), for example,
there were distinct within group variations in
mothers’ perceptions of the purpose, focus, and
meaningfulness of their home visits, even though
parent educators were all implementing the same
PAT curriculum (Woolfolk & Unger, 2009).
While much has been learned from outcomefocused program evaluations, there remains
much to know about the nuances of recruiting
parents, parent perceptions, and maintaining
their involvement over the course of
a prevention program.
Preliminary evidence suggests that programs
are more likely to engage parents and develop
trusting relationships when they address a range
of parental emotional and developmental needs,
based on positive, culturally competent
approaches and trust. Among high-risk parents,
the relationship between the parent and the
service provider(s) is crucial to the success of
the intervention. Needed are approaches that
involve and collaborate with parents in choosing
program design and content, build on parents’
strengths, and incorporate cultural beliefs and
practices of parents. Early intervention programs
for children with disabilities and children at risk
for developmental delays, for example, have
increasingly adopted a family-centered philosophy that addresses family needs and goals for the
child and family, provides choices in services for
parents, and promotes collaborative, trusting
relationships between parents and professionals
(Dunst, Trivette, & Deal, 1994).
Parent education and support services are
more successful when offered in the context of
family and community diversity. Multiple caregivers that include not only fathers and mothers

813

but also grandmothers, aunts, and other kin need
to be recognized as important caregivers.
Community-based programs must be “of” the
community so that effective linkages with
resources in the community can be made and
community values and norms can be understood
and respected by making variations in service
delivery strategies.
Programs need to be flexible yet have
a curriculum. Flexibility is needed to respond to
family crises and stresses while at the same time
having a curriculum; social support is not
enough. Determining how to balance support
services and program protocol is a constant
challenge. Parents with multiple risk factors
may need more intensive and comprehensive
services. Curricula also need to be presented
with methods that fit with parents’ learning
styles. When printed material is used, the reading
level must be geared to the audience. For audiences with limited literacy skills, videos can provide information and modeling with the added
advantage of being available for repeat viewing.
Practical barriers to participation need to be
addressed, such as time constraints and competing responsibilities. In populations with limited
resources, providing transportation, child care,
convenient times and locations, and meals or
refreshments may improve retention. Fathers, in
particular, might be recruited where they work or
participate in recreational activities. Interested
but very busy parents may gain as much from
learn-at-home formats such as newsletters,
which can be adapted to individual schedule
needs and challenges. Incentives for continued
participation – and rewards to celebrate milestones – may be effective, especially in
populations with limited economic resources.
Promising programs ensure that staff have
access to high-quality professional development,
supervision, and training. Staff need significant
training and ongoing supervision to help them
sort out the complex issues they confront when
working with families who are difficult to
engage, to learn about culturally diverse families
and parenting practices, as well as to deal with
their own reactions to emotionally charged situations in their work with parents. One promising

814

approach to professional development that is
cost-effective, flexible, and user-friendly is a
Web-based training and certification program
for early care and education providers to learn
about parent-child interaction through the KIPS
(Keys to Interactive Parenting Scale) (Comfort,
Gordon, & Unger, 2006). Research has
documented that practitioners from a variety of
backgrounds can efficiently learn, through
Web-based instruction, to use this valid and reliable evidenced-based assessment tool in their
work with families.
Lastly, promising programs use program evaluation to guide program implementation, assess
program fidelity, monitor the integrity of program
implementation, identify and address barriers to
implementation, identify areas in which additional
training is needed, and determine what program
modifications are needed. Program evaluation
approaches such as empowerment and participatory program evaluation are particularly a good
fit with the needs and conceptual frameworks of
parenting prevention programs.

What Does Not Work
Not all programs that are designed to support
parents and promote positive child and family
development effectively do so. Programs that do
not address the complexity and diversity of families and communities are not likely to be effective.
Prevention programs that do not foster a sense of
trust and positive relationship between staff and
parents due to lack of cultural relevance or poorly
matching staff and parent personalities are also
likely to fail. There have been mixed results
among programs that utilize paraprofessionals,
and this may be due to a lack of sufficient training
of staff in certain programs and/or a lack of support from professionals with whom they are collaborating. Parent education programs that attempt
to teach skills without allowing parents time for
active practice or trying to teach skills that parents
deem as irrelevant are not likely to result in
a change in parent behavior. Programs that have
insufficient dose or are inappropriately timed are
also not likely to be successful. Prevention

Parenting as Primary Prevention

programs are also challenged by high rates of
dropout. In order for prevention programs that
target parents to be effective, programs need to
address practical barriers to participation such as
time restraints and competing responsibilities.

Summary
Parenting programs have developed in response
to the changing needs of parents and families in
a global society. The most effective prevention
programs address multiple sources of risk as well
as build upon family strengths. They utilize multiple teaching methods and work to build trusting
positive relationships between all involved.
In doing so, prevention programs support
families of young children in achieving positive
outcomes across multiple domains for both
parents and children, and sometimes this even
extends to positive community development.
There remains a need for ongoing process and
outcome program evaluation for prevention
programs targeting families of young children.
Program evaluation is essential not only for
monitoring the quality and challenges of program
implementation but also to determine what types
of interventions are most effective. Program evaluation can help determine the best fit between
parents with varying needs and various programs.
There continues to be a need for innovations in
the development and implementation of prevention programs for families of young children that
reflect and address the diversity of children,
families, and their communities.
Research that reflects the complexity of the
relationship between children, parents, and their
communities will continue to help advance the
science of prevention and lead to better supports
for young children and their families.

References
Ayoub, C. A., Vallotton, C. D., & Mastergeorge, A. M.
(2011). Developmental pathways to integrated social
skills: The roles of parenting and early intervention in
raising healthy children. Child Development, 82,
331–345.

Parenting as Primary Prevention
Barth, R. P., Landsverk, J., Chamberlain, P., Reid, J. B.,
Rolls, J. A., Hurlburt, M. S., et al. (2005). Parent-training
programs in child welfare services: Planning for a more
evidence-based approach to serving biological parents.
Research on Social Work Practice, 15, 353–371.
Bernard, K., & Dozier, M. (2010). Brief reports: Examining infant’s cortisol responses to laboratory tasks
among children varying in attachment disorganization:
Stress reactivity or return to baseline? Developmental
Psychology, 46, 1771–1778.
Borkowski, J. G., & Weaver, C. M. (2006). Prevention:
The science and art of promoting healthy child and
adolescent development. Baltimore: Paul H. Brooks.
Born to learn: Parents as teachers curriculum prenatal to
3 years. (2005). St. Louis, MO: Parents as Teachers
National Center.
Bowlby, J. (1988). A secure base: Parent-child attachment and healthy human development. New York:
Basic Books.
Bronfenbrenner, U. (1979). The ecology of human development. Cambridge, MA: Harvard University Press.
Bryant, D., Espinosa, M. L., Guskin, K. A., Harden, B. J.,
Powell, D. R., Reynolds, A. J., et al. (2003). Future
research directions for the parents as teachers program:
Final report of the Scientific Advisory Committee to
the Parents as Teachers National Center. Retrieved
July 24, 2011, from http://www.kintera.org/atf/cf/%
7B7A832E5A-3E17-4576-8C7E-F921E4ABDCA5%
7D/finalSACreport1.pdf
Center for Study of Social Policy. (2007). Strengthening
families: A guidebook for early childhood programs.
Retrieved July 24, 2011, from http://www.cssp.org/
publications/neighborhood-investment/strengtheningfamilies/top-five/strengthening-families-a-guidebookfor-earlly-childhood-programs.pdf
Cochran, M., & Niego, S. (1995). Parenting and social
networks. In M. Bornstein (Ed.), Handbook of parenting: Vol. 3. Status and social conditions of parenting
(pp. 303–418). New York: Lawrence Erlbaum
Associates.
Comfort, M., Gordon, P. R., & Unger, D. G. (2006). The
Keys to Interactive Parenting Scale: A window into
many facets of parenting. Journal of Zero to Three,
26(5), 37–44.
Currie, J., & Widom, C. (2010). Long-term consequences
of child abuse and neglect on adult economic wellbeing. Child Maltreatment, 15(2), 111–120. http://
www.acf.hhs.gov/programs/cb/pubs/cm08/cm08.pdf
Dolan, M. M., Casanueva, C., Smith, K. R., & Bradley,
R. H. (2009). Parenting and the home environment
provided by grandmothers of children in the welfare
system. Children and Youth Services Review, 31,
784–796.
Dozier, M., Lindhiem, O., Lewis, E., Bick, J., Bernard, K.,
& Peloso, E. (2009). Effects of a foster parent training
program on young children’s attachment behaviors:
Preliminary evidence from a randomized clinical
trial. Child and Adolescent Social Work Journal, 26,
321–332.

815
Dozier, M., Peloso, E., Lindhiem, O., Gordon, M. K.,
Manni, M., Sepulveda, S., et al. (2006). Preliminary
evidence from a randomized clinical trial: Intervention
effects on foster children’s behavioral and biological
regulation. Journal of Social Issues, 62, 767–785.
Drotar, D., Robinson, J., Jeavons, L., & Kirchner, L.
(2008). A randomized, controlled evaluation of early
intervention: The Borne to Learn curriculum. Child:
Care, Health and Development, 35, 643–649.
Dunst, C. J., Trivette, C. M., & Deal, A. G. (Eds.). (1994).
Supporting and strengthening families: Methods,
strategies, and practice (Vol. 1). Cambridge, MA:
Brookline Books.
Feinberg, M. E., Kan, M. L., & Goslin, M. (2009).
Enhancing coparenting, parenting, and child selfregulation at the transition to parenthood: Effects of
family foundations one year after birth. Prevention
Science, 10, 276–285.
Glidden, L. M., Bamberger, K. T., Turek, K. C., & Hill,
K. L. (2010). Predicting mother/father-child interactions: Parental personality and well being, socioeconomic variable and child disability status. Journal of
Applied Research in Intellectual Disabilities, 23, 3–13.
Harding, K., Galano, J., Martin, J., Huntington, L., &
Schellenbach, C. J. (2007). Healthy Families America
effectiveness: A comprehensive review of outcomes.
Journal of Prevention and Intervention in the Community: Special Issue on Healthy Families America, 34,
149–179.
Heinicke, C., Fineman, N., Ruth, G., Recchia, S., Guthrie,
D., & Rodning, C. (1999). Relationship-based
intervention with at-risk mothers: Outcome in the
first year of life. Infant Mental Health Journal, 20,
349–374.
Henderson, A. D., Sayger, T. V., & Horne, A. M. (2003).
Mother and sons: A look at the relationship between
child behavior problems, marital satisfaction, maternal
depression, and family cohesion. Family Journal:
Counseling and Therapy for Couples and Families,
11, 33–41.
Letarte, M.-J., Normandeau, S., & Allard, J. (2010). Effectiveness of a parent training program “Incredible
Years” in a child protection service. Child Abuse &
Neglect, 34, 253–261.
Nation, M., Crusto, C., Wandersman, A., Kumpfer, K. L.,
Seybolt, D., Morrisey-Kane, E., et al. (2003). What
works in prevention: Principles of effective prevention
promotion. American Psychologist, 58, 449–456.
Olds, D. L. (2006). The nurse-family partnership: An
evidence based preventative intervention. Infant Mental Health Journal, 27, 2–25.
Olds, D. L., Kitzman, H., Hanks, C., Cole, R., Anson, E.,
Sidora-Arcoleo, K., et al. (2007). Effects of nurse
home visiting on maternal and child functioning:
Age-nine follow-up of a randomized trial. Pediatrics,
120, 832–845.
Parents as Teachers National Center. (2005). What we do.
Retrieved July 29, 2011, from http://www.parentsasteachers.org/about/what-we-do

816
Partners in Policy Making. (2010). Partners in policy
making: Curriculum highlights. Retrieved August
5, 2011, from http://www.partnersinpolicymaking.
com/curriculum.html
Patterson, C. J. (2006). Children of lesbian and gay parents. Current Directions in Psychological Science, 15,
241–244.
Prevent Child Abuse America. (2002). Healthy families
America: A distinctive approach to home visiting.
Retrieved on July 8, 2011, from www.preventchildabuse.org/about_us/downloads/annual_report_2002.
pdf
Prinz, R. J., & Sanders, M. R. (2007). Adopting a
population-level approach to parenting and family
support interventions. Clinical Psychology Review,
27, 739–749.
Raikes, H. H., & Love, J. M. (2002). Early Head
Start: A dynamic new program for infants and toddlers
and their families. Infant Mental Health Journal, 23,
1–13.
Ramey, C. T., Campbell, F. A., Burchinal, M., Skinner,
M. L., Gardner, D. M., & Ramey, S. L. (2000). Persistent effects of early childhood education on high-risk
children and their mothers. Applied Developmental
Science, 4, 2–14.
Ramey, C. T., & Ramey, S. L. (1998). Early intervention and
early experience. American Psychologist, 53, 109–120.
Raver, C. C. (2004). Placing emotional self-regulation in
sociocultural socioeconomic contexts. Child Development, 75, 346–353.
Repetti, R. L., Taylor, S. E., & Seeman, T. E. (2002).
Risky families: Family social environments and the
mental and physical health of offspring. Psychological
Bulletin, 128, 330–366.
Reynolds, A. J., & Ou, S. (2011). Paths of effects from
preschool to adult well-being: A confirmatory analysis
of the Child-parent Center Program. Child Development, 82(2), 555–582.

Parenting as Primary Prevention
Rosenberg, M. S., & Reppucci, N. D. (1990). Primary
prevention of child abuse. Journal of Counseling and
Clinical Psychology, 53, 576–583.
Shapiro, D. N., Peterson, C., & Stewart, A. J. (2009).
Legal and social contexts and mental health among
lesbian and heterosexual mothers. Journal of Family
Psychology, 23, 255–262.
Smith, S., & Zaslow, M. (1995). Rationale and policy
context for two-generation interventions. In S. Smith
(Ed.), Two generation programs for families in poverty
(pp. 1–36). Norwood, NJ: Alex.
Tamis-LeMonda, C., Briggs, R., McClowry, S., & Snow,
D. (2009). Maternal control and sensitivity, child gender,
and maternal education in relation to children’s behavioral outcomes in African American families. Journal of
Applied Developmental Psychology, 30, 321–331.
U.S. Census Bureau. (2010). American Community Survey: Poverty status in the past 12 months. Retrieved
July 1, 2011, from http://factfinder.census.gov/servlet/
STTable?_bm=y&geo_id=01000US&qr_name=ACS_
2009_5YR_G00_S1701&ds_name=ACS_2009_5Y_
G00_&-redoLog=false
U.S. Department of Health and Human Services. (2010).
Child maltreatment 2008. Retrieved July 1, 2011,
from http://www.acf.hhs.gov/programs/cb/pubs/cm08/
cm08.pdf
Webster-Stratton, C. (2007). The Incredible Years parent
training manual: BASIC program (3rd ed.). Seattle,
WA: Incredible Years.
Whittaker, J. E. V., Harden, B. J., See, H. M., Meisch,
A. D., & Westbrook, T. R. (2011). Family risk and
protective factors: Pathways to early head start toddlers’ social-emotional functioning. Early Childhood
Research Quarterly, 26, 74–86.
Woolfolk, T. N., & Unger, D. G. (2009). The relationship
between low-income African American mothers and
their home visitors: A Parent as Teachers program.
Family Relations, 58, 188–200.

Pediatric Preventive Medicine in Early Childhood

Pediatric Preventive Medicine in
Early Childhood
Jennifer B. Blau1, Gary M. Blau2 and
Okori T. Christopher3,4
1
Inova Fairfax Hospital for Children, Falls
Church, VA, USA
2
Child, Adolescent and Family Branch, Center
for Mental Health Services, Substance Abuse and
Mental Health Services Administration,
Rockville, MD, USA
3
American Institutes for Research, Washington,
DC, USA
4
Center for Mental Health Services, Substance
Abuse and Mental Health Services
Administration, Rockville, MD, USA

Introduction
Health promotion and disease prevention in the
pediatric population became a focus of physicians in the early 1900s when 35 pediatricians
met in response to a national calling for an independent pediatric forum to address children’s
health-care needs. The discussion during this
meeting focused on attaining optimal physical,
mental, and social health for infants, children,
and adolescents. The outcome of these conversations became a national organization now known
as the American Academy of Pediatrics (AAP).
Since its inception in 1930, the AAP has
expanded from 35 original members to over
60,000 members with 29 committees and 9 councils all aimed at promoting health and improving
health care for children (American Academy of
Pediatrics [AAP], 2011).
There is no question that the time to eliminate
adult disability and mortality is during childhood
and adolescence (Pratt & Tsitsika, 2007; Kvaavik,
Kleep, Tell, Meyer, & Batty, 2008). The role of the
pediatrician and family practitioner is to encourage positive lifestyle choices to improve health
status, prevent or minimize disease, and eliminate
preventable causes of death. Currently, the most
influential and successful health promotion and
preventive medicine strategies for children are

817

the use of vaccinations, nutrition – inclusive of
breast-feeding and a well-balanced pediatric
diet – routine well-child examinations, anticipatory guidance to avoid future disorders and conditions, and the increasing understanding of how
environmental, social, cognitive, genetic, and psychological factors influence the development of
a child (National Research Council and Institute
of Medicine, 2000).

Definition and Scope
Health promotion is the use of strategies to help
people make lifestyle choices that move them
towards optimal health (Centers for Disease Control and Prevention [CDC], 2011b). Preventive
health care is defined as stopping disease from
developing or detecting illness or disease in the
earliest stages. Primary care is term used to
describe services provided by health-care professionals who specialize in first contact and continuing care for persons that have an undiagnosed
symptom or health concern (AAP, 2011). Primary
care providers include pediatricians, family physicians, and internists. Secondary care relates to
treatment provided by specialists (e.g., coronary
care), and tertiary care is the term used to describe
treatment provided by highly trained specialists
often using advanced technology. Preventive medicine can occur under all of these circumstances.
For example, even when a child is sick or diagnosed with a disease, the goal of reclaiming health
status, achieving optimal functioning, or avoiding
other conditions is still appropriate.
Chronic conditions such as cardiovascular
diseases, cancer, and chronic respiratory diseases
will be the leading cause of death in 2020 (World
Health Organization [WHO], 2002), and the
majority of these diseases are caused by risk
factors, often avoidable, that begin in childhood
and adolescence. To address these risk factors,
which are often referred to as negative determinants of health, there has been an increasing focus
on health promotion and prevention in the pediatric population in the past 80 years, and there are
evolving research and policy that identify and
encourage the use effective preventive medicine

T.P. Gullotta, M. Bloom (eds.), Encyclopedia of Primary Prevention and Health Promotion,
DOI 10.1007/978-1-4614-5999-6, # Springer Science+Business Media New York 2014

818

that will improve health, reduce health-care
costs, and save lives.
A critical component to promote health and
decrease disease is childhood immunization and
vaccination. Immunization is the process of creating protections against a specific disease by
administering a vaccine or toxin that will stimulate the immune system to produce antibodies
against the disease. Typically, the vaccine contains a small amount of the actual disease-causing
microorganism. Because of the small dose, the
body’s immune system fights off and destroys the
disease and then has the ability to more easily
recognize and destroy the disease in the future. In
most cases, once the human body initiates an
immune response, it will continuously fight that
disease, and a person will never be affected. With
the advent of vaccinations, there has been
a 99–100 % decrease in some of the most deadly
diseases including rubella, measles, polio, diphtheria, and mumps (CDC, 2011b). Even more
impressive is that there has been a complete
eradication of smallpox worldwide (Hagan &
Duncan, 2010; Nelson & Williams, 2007).
Another critical component in promoting health
and preventing chronic disease is the development
of the Bright Futures guidelines. The Bright
Futures guidelines encompass all aspects of the
well-child exam, including surveillance of development, physical exams, laboratory work and vaccinations, and the use of anticipatory guidance for
families. Bright Futures was developed through
collaboration between the American Academy of
Pediatrics, the Centers for Disease Control, and the
Maternal and Child Health Bureau of the Health
Resources and Services Administration. As a result
of these efforts, a detailed package of information
was compiled to guide pediatric practitioners in
evaluation of children at all stages of development
(Bright Futures, 2011).
The focus of these guidelines is on family support, child development, mental health, healthy
weight, breast-feeding and nutrition, physical
activity, universal screening, and physical exams,
all of which are designed to ensure appropriate
development and preventive health care in the
pediatric population. These guidelines are used
nationally and encourage standardization of

Pediatric Preventive Medicine in Early Childhood

practice across pediatric practitioners to improve
the quality and access to preventive medical care.

Theories
The overarching theory in pediatric preventive
care comes from the public health model. There
are four basic concepts to virtually all views of
what it means to take public health approach.
First is that a public health model focuses on
populations. This means that the health of an
entire population is the benchmark and intervention efforts should be directed to every person
within a population group. Second is that the
model emphasizes promotion and prevention.
The key is to promote conditions that support
optimal health and prevent problems before they
occur by addressing the source of those problems.
Third is that interventions guided by a public
health approach must focus on addressing determinants of health. Determinants are those factors
that are part of the social, economic, physical, or
geographic environment that can be changed or
influenced. And fourth is that the public health
model requires a series of action steps that
include defining the problem, assessing for risk
and protective factors, developing and testing
intervention strategies, and assuring that best
practices are provided (Miles, Espiritu, Horen,
Sebian, & Waetzig, 2010; Taylor, Peckham, &
Turton, 1998). Currently, the focus of a public
health model in pediatrics is preventive care
through such strategies as vaccinations, wellchild checkups, nutritional guidance (including
breast-feeding), and obesity prevention.

Research
Research in pediatrics is constantly evolving and
expanding. In terms of understanding the effects
of childhood disease in adulthood, studies have
typically been either retrospective (looking back)
or prospective (looking forward). Studies involving the effectiveness of vaccines, breast milk,
nutrition, and well-child visits and their effectiveness in preventing disease in childhood and adulthood have used retrospective and prospective

Pediatric Preventive Medicine in Early Childhood

approaches. The studies have been able to review
and evaluate past data or follow children to adulthood to determine effectiveness and outcomes of
specific interventions starting at birth. Perhaps
the most significant research advancement, and
the future of preventive medicine in pediatrics,
will be impacted by the National Children’s
Study, a prospective study occurring throughout
the United States. Funded as a result of the Children’s Health Act of 2000, this study is a multiyear investigation that examines the effects of
environmental influences on the health and development of more than 100,000 children. This will
be the largest prospective study in pediatrics and
will follow children by observation for 21 years
to determine etiologies of some of the most prevalent diseases (National Children’s Study, 2011).

Strategies
The collection of data over the years in the areas
most important in disease prevention and preventive medicine in pediatrics has resulted in many
sets of guidelines to allow pediatric primary care
physicians to effectively guide patients to a healthy
adult life. More specifically, the ability to follow
the outcomes of vaccination use, the incidence of
disease in children who are and aren’t breast-fed,
the percentage of obesity in children with nutrition
and physical activity education, and the decrease in
chronic disease with episodic visits with a primary
pediatric practitioner have all been imperative in
the guidelines for preventive disease in pediatrics.
With the addition of the National Children’s
study that will look at all possible factors
influencing childhood and chronic diseases, the
future of pediatric morbidity will be greatly
decreased. The goal of all of these studies is to
ensure healthy living in childhood and ultimately
a decrease in chronic disease in adults.

What Works
Vaccinations
Vaccinations are the most well-studied and most
successfully documented preventive medicine

819

intervention in pediatrics. Modern vaccines started
more than 200 years ago when Edward Jenner
developed a smallpox vaccine in 1789 (Kids
Growth, 2007). Routine vaccination against infectious disease is one of the greatest accomplishments in public health. Since the original
smallpox vaccine was developed, dozens of vaccines have been created and are part of the routine
care of children in this country (Jacobson, 2009).
Vaccines have saved countless lives and have
reduced or eliminated some of the most deadly
and rampant diseases in the world, such as smallpox and polio. Currently, in the United States, state
laws require particular vaccinations before entering school. Mandated vaccines typically include
polio (IPV), measles/mumps/rubella (MMR),
diphtheria/tetanus/pertussis (DTaP), Haemophilus
influenzae type b (Hib), pneumococcus (PCV),
rotavirus, varicella, hepatitis A, and hepatitis
B given in a standardized schedule (CDC, 2011a).
To truly understand the significant impact
immunizations have had worldwide, it is important to understand the threat and morbidity associated with some of the diseases. Polio is a virus
that leads to paralysis, physical disability, and
death that killed up to 20,000 people per year in
the United States before the polio vaccination
was created (CDC, 2011b). With the advent of
the vaccine and implementation worldwide, polio
currently does not exist in the United States
and has been reduced by over 80 % universally.
Similar to polio, measles was once one of
the deadliest diseases of childhood. Before the
immunization was available, a significant number of people contracted the disease, and there
were thousands of deaths a year secondary to the
disease. With the vaccine, measles is nearly eradicated. Without the vaccine, it is estimated that up
to 2.7 million deaths would occur every year
worldwide (CDC).
A lesser known but similarly deadly disease is
Haemophilus influenzae type b (Hib), which
accounted for the majority of neonatal meningitis
before the development of a vaccine in 1985.
Since the inception of the Hib vaccine, the incidence of Hib meningitis has been reduced by
98 %, and since 1994 there have only been
10 fatal cases of Hib disease a year (CDC, 2011b).

820

Diphtheria is a serious illness that causes
a thick film to form at the back of the throat and
produces a toxin that can cause heart failure and
neurological symptoms. In the 1920s, diphtheria
was a major cause of illness and death for children. In 1921, for example, a total of 206,000
cases and 15,500 deaths were reported (CDC,
2011b). In 1923, a vaccine was developed and
new cases of diphtheria were drastically reduced.
In fact, by the year 2001, only two cases were
reported in the United States (CDC). Mumps,
varicella (chickenpox), rubella, and pertussis,
which were major causes of illness in the United
States before the advent of vaccinations, have
now become a rare phenomenon (CDC).
Breast-Feeding
One of the most highly effective preventive measures a mother can take to promote the health of
her infant and protect against disease is to breastfeed (U.S. Department of Health and Human
Services, 2001). Breast milk contains lymphocytes, neutrophils, cytokines, and antibodies that
actively support and stimulate the infant’s
immune system and help facilitate development
and protect infants against infections (Fisk et al.,
2011). A series of studies conducted in
industrialized countries have shown that children
who are not breast-feed for at least 6 months
are 3.5 times more likely to be hospitalized
for respiratory infections, 2 times more likely to
suffer from diarrhea, 1.6 times more likely to
suffer from ear infections, and 1.5 times
more likely to become overweight during childhood (Li, Fein, Chen, & Grummer-Strawn,
2008).
Currently, new mothers are encouraged to
breast-feed, and many have access to lactation
consultants and mechanical breast pumps in the
hospital. Even more recently, breast pumps are
now available to order through insurance, free of
cost. In addition to research about the importance
of breast-feeding, public awareness has increased
through the La Leche League (LLL). LLL was
founded in 1956 by seven women who joined
together after reading that US breast-feeding
rates had dropped to 20 %. Over the last
50 years, the league has been influential in

Pediatric Preventive Medicine in Early Childhood

providing educational material to new mothers
about the importance of breast-feeding, contributing to an increase in the rate of breast-feeding to
75 % in the United States (La Leche League,
2006). With the encouragement and advocacy
provided by LLL and the many studies
supporting the importance of breast-feeding on
a child’s long-term health, the number of women
who breast-feed has continued to increase. Now,
in most cultures, breast-feeding is widely
accepted and is considered important for both
physical and emotional development. In fact,
breast-feeding has been correlated with higher
perceptions of mother-child bonding along with
lower rates of childhood obesity (DiSantis,
Collins, Fisher, & Davey, 2011).
Nutrition
Good nutrition and exercise can lead to healthy
brain development and muscle growth, better
academic performance, improved self-esteem,
and a better ability to cope with stress (American
Psychological Association [APA], 2011;
Wethington, Sherry, & Polhamus, 2011). Unfortunately, there has been a dramatic increase in the
prevalence of obesity in the United States in both
children and adults. This dramatic trend has been
paralleled by increased rates in cardiovascularrelated disease such as high cholesterol, strokes,
high blood pressure, and heart attacks and an
increasing prevalence of diabetes. Studies have
shown a direct correlation between obesity and
early mortality from stroke, heart disease, and
complications of diabetes (Schwimmer,
Burwinkle, & Varni, 2003; Kindblom et al.,
2009).
To help aid in the development of healthy
eating habits, the US Department of Agriculture
(USDA) developed dietary guidelines, which
were revised in 2010 (U.S. Department of Health
and Human Services, 2010). These guidelines
formed the foundation for the “My Plate”
program for healthier eating, which was launched
by First Lady Michelle Obama in 2011. The
current recommendations focus on maintaining
balance in caloric intake, consuming nutrient
dense foods, building healthy eating patterns,
and increasing physical activity.

Pediatric Preventive Medicine in Early Childhood

An example of a successful health promotion
and preventive intervention has been the national
school lunch program. This initiative was
launched in 1946 with the National School
Lunch Act signed by President Harry Truman,
which was followed in 1966 when President
Lyndon Johnson signed the National Child Nutrition Act establishing the school breakfast program. These programs offer federally assisted
meals in public and private schools that are low
cost or free and nutritionally balanced. The
school lunch program serves more than 29 million
students daily at a cost of $7.6 billion (Newman
& Ralston, 2006). In January of 2010, President
Barak Obama signed the Healthy, Hunger-Free
Kids Act which expands eligibility and adds more
fruits, vegetables, whole grains, and fat-free and
low-fat milk to school lunches. The goal, starting
with Harry Truman over 70 years ago, is to provide healthy and nutritious meals to improve
health and decrease rates of obesity.
There is clear evidence that nutrition education at an early age improves the likelihood of
healthy food choices later in life (Falter et al.,
2011). In one particular study, students from kindergarten to second grade took a pretest on nutrition and then received nutrition education.
After the intervention, 61 % of kindergarten students, 55 % of first grade students, and 53 % of
second grade students significantly increased
their posttest scores and demonstrated improved
food choices (Falter et al., 2011). The USDA
has many age-specific teaching materials, and
there is a specific food pyramid for children to
encourage learning and understanding about
nutritional concepts (U.S. Department of
Agriculture, 2011).
Well-Child Checks
Although well-child examinations have been
occurring for decades, it wasn’t until 1994 that
actual guidelines were established to standardize
care for all children nationwide. Under the leadership of the Maternal and Child Health Bureau
of the Health Resources and Services Administration (HRSA), the Bright Futures initiative was
launched to improve the quality of health services
and encourage health promotion throughout the

821

country. The recommended guidelines from
Bright Futures include frequency of visits, developmental milestones, family and community support, promotion of mental health, healthy weight,
nutrition, physical activity and oral health,
growth charts, and anticipatory guidance in
areas such as safety and injury, sexual development, and substance abuse (Bright Futures,
2011). It is the role of the primary physician to
provide guidance after a periodic visit by
assessing the child and family through observation, surveillance, history, physical exam, and
screening examinations (laboratory tests such as
lead levels and blood counts). After information
is gathered, the most important step to provide
quality care to children and families is discussing
results and offering anticipatory guidance about
how to handle potential problems. For example,
depending on the age of the child, anticipatory
guidance can be offered regarding techniques for
discipline, diet and nutrition, physical activity,
sleep habits, toilet training, emotional health,
child care, school attendance, “childproofing,”
seatbelt use, pool safety, understanding inappropriate sexual behavior, substance use, and sexually transmitted disease prevention. With
periodic surveillance of every child, chronic diseases and developmental delays can be recognized earlier, and preventable causes of
mortality can be avoided.
The use of the Bright Futures guidelines has
decreased the number of unnecessary emergency
room visits (Lannon et al., 2008). As an example,
in a study using North Carolina pediatric offices
providing services to Medicaid recipients,
increased access to preventive medical care
resulted in a decrease in emergency room visits
(Piehl, Clemens, & Joines, 2000). Specifically,
there were 24 % fewer visits to the emergency
room for children who had regularly scheduled
and consistent preventive care compared to those
who did not. Even more impressive, there was
a 37 % reduction in non-urgent emergency room
visits. This was attributed to the anticipatory
guidance given at all well-child checkups and
availability of primary care physicians who
were able to divert unnecessary use of the emergency room (Piehl et al., 2000).

822

Another tool in the arsenal of preventive medicine is the use of growth charts. Growth charts
monitor the growth of a child’s weight, height,
weight vs. height, body mass index (BMI), and
head circumference. The charts reflect typical
child and adolescent development and are used
to identify abnormalities in growth, which can
suggest the potential of various diseases. For
example, there are specific diseases related to
a lack of weight gain, such as cystic fibrosis,
that would warrant evaluation if a child is below
the fifth percentile in weight and therefore considered “failure to thrive.” Growth charts ensure
that anomalies are not overlooked so that prevention and early intervention can occur. On the
opposite end, trends towards the 90–95th
percentiles can assist with early diagnosis of
metabolic disorders and obesity, also allowing
for early intervention to address the condition or
decrease the progression of the disease. Growth
charts have increased disease awareness, and as
a result they have led to the early diagnosis
and early intervention of chronic diseases
that are linked to long-term morbidity and
mortality.
The combination of periodic well-child
checks and the use of trending tools, such as
growth charts, has significantly improved the
ability of health-care practitioners and families
to detect disease, develop early intervention strategies, decrease unnecessary emergency room
visits, and reduce unnecessary medical costs.
With continued availability of primary care, particularly if provisions in the Patient Protection
and Affordable Care Act are implemented, more
children will have access to preventive services.

What Is Promising
The most promising activities occurring in pediatric primary care are related to legislation
and research. Legislation, in the form of the
Patient Protection and Affordable Care Act (simply called the Affordable Care Act), has the possibility of expanding access to preventive
services to millions of children. Research, in the
form of the National Children’s Study (NCS),

Pediatric Preventive Medicine in Early Childhood

will provide information about the most effective
prevention strategies for decades to come.
Legislation
The Patient Protection and Affordable Care Act
(PPACA), signed into law by President Obama
on March 23, 2010, along with the Health Care
and Education Reconciliation Act of 2010 represents the most significant reform of the healthcare system ever undertaken. Often referred to as
the Affordable Care Act (ACA), the law recognizes that chronic diseases, such as heart disease,
cancer, and diabetes, are responsible for 7 of
10 deaths among Americans each year and
account for 75 % of the nation’s health spending –
and often are preventable. As such, the ACA
intends to make prevention affordable and accessible by expanding access to insurance to over
30 million Americans, increasing insurance coverage of preexisting conditions, and requiring
health plans to cover recommended preventive
services without charging a deductible,
co-payment or coinsurance (U.S. Department of
Health and Human Services, 2011a). During the
writing of this entry, a number of states, organizations, and individual persons have filed suit in
federal court challenging the constitutionality of
the PPACA; however, federal appellate judges
appear evenly divided on the issue, and plans
are underway to implement many of the ACA
provision, particularly those that address
preventive care.
High-quality preventive care helps Americans
stay healthy, avoid or delay the onset of disease,
lead productive lives, and reduce costs. And yet,
despite the proven benefits of preventive health
services, too many Americans go without needed
preventive care because of financial barriers.
Even families with insurance may be deterred
by co-payments and deductibles from getting
cancer screenings, immunizations for their children and themselves, and well-baby checkups
that they need to keep their families healthy.
Plans covered by the ACA rules must offer coverage for a comprehensive range of preventive
services that are recommended by physicians
and other experts without imposing any
cost-sharing requirements. Specifically, these

Pediatric Preventive Medicine in Early Childhood

recommendations include evidence-based preventive services (e.g., screening for vitamin deficiencies during pregnancy), routine vaccinations
(including childhood immunizations), and preventive care for children as recommended under
the Bright Futures guidelines (e.g., regular pediatrician visits, hearing and vision screening,
developmental assessments, and screening/
counseling to address obesity).
As reported on the government website, health
insurance plans or insurance policies beginning
on or after September 23, 2010, will be required
to provide an array of mental health (e.g., depression and autism screening, behavioral assessments), substance use (e.g., alcohol and drug
use assessments for adolescents), and physical
health (including dental and vision) preventive
services without a co-payment or coinsurance
when these services are delivered by a network
provider (U.S. Department of Health and Human
Services, 2011b).

Research
Currently, there is ongoing research related to all
forms of preventive medicine in the pediatric
population from diet to physical activity to vaccinations to breast-feeding. Perhaps the most
exciting and promising research is the National
Children’s Study (NCS). The National Children’s
Study will follow all enrolled children from birth
to 21 years of age. The study is designed to
investigate the influence of biologic, environmental, genetic, and social factors on the health
and development of children and will include
children from approximately 105 geographic
areas from approximately 3,000 counties in the
United States. Currently, the enrolled participants
include women who anticipate becoming pregnant, pregnant women, children born to pregnant
women enrolled in the study, or the father of
a child from an enrolled pregnant woman. The
enrolled participants provide data including
physical, community, social, and familial environments (National Children’s Study, 2011).
The ultimate goal of the study is to understand
all possible factors that influence the health of

823

children and therefore adults in the United States.
The rationale behind the study is primarily from
the President’s Task Force on Environmental
Health and Safety Risks to Children, which
focused on the vulnerability of children compared to adults in disease processes. This task
force focused on environmental exposures that
could lead to developmental effects; high burden
conditions associated with environment including autism, diabetes, asthma, and prematurity;
and the multiple outcomes attributed to the multiple exposures.
Priority exposures include physical environment, chemical exposures, biologic environment,
genetics, and psychosocial milieu. Physical environment will focus on housing quality and neighborhood that the child grows up in. Chemical
exposures include pesticides, heavy metals,
phthalates (used to make plastic), and
Bisphenol-A (also known as BPA). Biologic
environment includes infectious agents, endotoxins (found in specific bacteria), and diet.
Genetics include the relationship between environment and specific genes. And, finally, psychosocial milieu includes family structure,
socioeconomic status, parenting style, social networks, and exposure to media and violence.
Priority health outcomes include pregnancy
outcomes, neurodevelopment and behavior,
injury, asthma, and obesity and physical development. Pregnancy outcomes will focus on prematurity and birth defects. Neurodevelopment
and behavior includes autism, learning disabilities, schizophrenia, and conduct and behavior
problems. Injuries include head trauma or injuries requiring hospitalizations. Asthma will focus
on the diagnosis of asthma and subsequent exacerbations. And obesity and physical development
will focus on obesity outcomes, diabetes, and
altered puberty.
These specific exposures and outcomes will be
followed for the 21 years of life before adulthood
in an observational fashion. The NCS will be the
largest long-term study of children’s health and
development ever conducted in the United States
with approximately 100,000 children enrolled.
With the large subject count and multiple variables being studied, it is hoped that there will be

824

a true understanding regarding the role of environment, genetics, and social interaction on the
health and development of children.

What Does Not Work
Opting Out of Vaccinations
Although vaccinations are highly successful in
decreasing disease and death in children worldwide, they have also produced significant controversy. Congress passed the National Childhood
Vaccine Injury Act (NCVIA) in 1986 to reduce
liability and respond to public health concerns
(CDC, 2011c) and to ensure that all children
were equally vaccinated and protected against
disease. With the mandating of vaccines, there
has been controversy over the efficacy, safety,
and morality of compulsory immunizations
resulting in long-standing tension between two,
sometimes divergent, goals: protecting individual
liberties and safeguarding the public’s health
(CDC).
To add to the controversy, there have recently
been new claims that vaccinations and the apparent mercury found in the vaccinations have led to
autism. The original paper claiming the relationship between vaccination and autism was
published in 1998 by Andrew Wakefield in the
British Medical Journal. He had evidence from an
8-year study concluding that vaccinations caused
intestinal disorders that correlated with the symptoms of autism. Based on this study, many leaders
and celebrities, not necessarily in the medical
field, began to follow this belief and start their
own foundations supporting the cessation of vaccination usage, leading many parents to refuse to
vaccinate their children. This one paper spawned
numerous studies to further evaluate the accuracy
of the original finding. The studies focused on the
relationship between thimerosal (the additive in
the majority of vaccinations) or the MMR vaccine specifically and the characteristics of autism.
All of the controlled studies with large participation concluded that neither thimerosal nor MMR
exposure had any statistically significant relationship to autism spectrum disorders. More recently,
Wakefield’s original study was found to be

Pediatric Preventive Medicine in Early Childhood

falsified and not performed under international
guidelines for research (Harrell, 2010). The ultimate result was that this study has been labeled
fraudulent and there is now no factual evidence
supporting a link between autism and vaccinations. Unfortunately, in the time for these studies
to be completed and published, many parents
chose to withhold vaccinations from their children, and previously rare or eradicated diseases in
the United States returned. Hundreds of children
were infected with mumps, measles, or rubella,
and there were multiple deaths attributed to these
diseases (Park, 2011).
Although there has been some controversy
that the use of vaccines may harm some children
or cause disorders such as autism, the overwhelming professional opinion is that vaccines
are the safest, most effective strategy to improve
the health of children and adolescents (Third
Age, 2011).
Opting Out of Breast-Feeding or Early
Weaning
Although breast-feeding rates have continued to
climb and have now reached 75 % in the United
States, it was found that only 13 % of infants are
exclusively breast-fed at 6 months of age and that
this rate is even lower in the African-American
community (Fewtrell, Wilson, Booth, & Lucas,
2011). The main reason for this difference in
breast-feeding rates for African-Americans is
social perception and acceptance (Fewtrell
et al., 2011). In fact, social perception and stigma
may hinder breast-feeding across all groups. For
example, in a national survey of infant feeding
practices, fewer than 60 % of respondents
believed that women should have the right to
breast-feed in public, and less than 40 % agree
that it is appropriate to show a woman breastfeeding her baby on TV programs (PleshetteMurphy, 2007). Such perceptions may lead to
reductions in breast-feeding as women may
choose to bottle-feed with formula just to avoid
embarrassment (U.S. Department of Health and
Human Services, 2011c). To ensure that the 75 %
of infants who are breast-fed at birth continue to
be breast-fed until 1 year of age, there needs to be
a change in social perception.

Pediatric Preventive Medicine in Early Childhood

Unhealthy Diet
Unfortunately, one of the most significant barriers to the success of nutrition and physical
activity in the pediatric population is access to
care and cost. Maintaining a healthy diet can be
expensive. When a family can purchase a large
pizza for less than ten dollars to feed an entire
family, as compared to perhaps double the cost
for fresh vegetables and lean meat, eating healthy
can be cost prohibitive. With the constant advertising of lower-priced, high-fat, low-nutrient fast
food, it is no wonder that children and youth eat
poorly.
In addition to the cost of eating healthy, nutrition education funding is not typically a high
priority in ever-decreasing budgets. Also, despite
legislation mandating meals in schools, many
school lunches are often too expensive for
low-income families who don’t qualify for free
lunch (on average, $540 per child per year). Furthermore, school systems, primarily in
low-income areas, do not have the money to put
towards the cost of fresh and nutrient-rich foods.
As a result, schools turn to foods that are less
costly, which often means foods that are
processed, high in fat, high in sodium, and high
in sugar – all of which having been shown to
cause poor health outcomes. Simply put, providing school lunches, despite the best intentions of
lawmakers, is not working because students who
eat them are more likely to be overweight and
unhealthy.
Lack of Access to Preventive Health Care
Unfortunately, as with many areas of medical
access, cost of health care and availability of
services have had a major effect on well-child
check effectiveness. One of the most significant
causes of poor health care and lack of preventive
care in pediatrics is socioeconomic status and
access to primary health care. Children from
low-income homes, particularly minority youth,
have decreased access and do not get the benefits
of positive guidance to promote good health and
prevent illness. In 2002, over one-quarter of the
children living in the United States did not
receive the care and periodic visits recommended
by AAP and the Bright Futures guidelines. In the

825

Medicaid program, only two states (Delaware
and Massachusetts) met the recommended participation rate for child health screenings. Eight
states were actually below 49 % (Cooper, Masi,
& Vick, 2009).
Also limiting the effectiveness of well-child
checks is a gap in evidence for well-child care
(Moyer & Butler, 2004) and a lack of consistency
in utilization. Although many primary care physicians use the Bright Futures guidelines in their
practice, almost half of the practicing clinicians
caring for children do not (Zimmerman,
Gallagher, Botsko, Ledsky, & Gwinner, 2005).
Because of lower reimbursement rates and
increased time demands (the average office visit
is now less than 7 min), many physicians are
unable to comply with the guidelines. While
guidelines and standardized care have been
important, they are not able to work if there is
no adequate time to ensure that all children in the
nation have the opportunity to benefit.

Summary
“An ounce of prevention is worth a pound of
cure.” This well-known quote sums up the importance of health promotion strategies in primary
care. Quite simply, preventive medicine
improves health outcomes and decreases the likelihood of early death. For young children, the role
of the primary care physician is extremely important in establishing a trusting relationship and
providing appropriate preventive medical care,
including immunizations, recommendations
about diet and physical activity, and periodic
well-child checks to review growth and development trends. Education and anticipatory guidance
are also significant interventions, and many studies have shown the effectiveness of these strategies in producing a healthy child. Although there
is evidence that regular, periodic visits with
a pediatrician can improve the health of a child,
there needs to be additional research to more fully
understand the connection between antecedent
conditions, health determinants, and outcomes
and to develop more efficient and effective
prevention and early intervention methods.

826

Also, preventive medicine in pediatrics does not
work if people are unable to participate due to
access, capacity, and cost challenges.
And yet, the future of pediatric preventive
medicine is bright when considering the possibilities envisioned by the Affordable Care Act and
the National Children’s Study. Access to preventive care will be improved, and knowledge about
how to address the effects of environmental,
genetic, and societal factors that contribute to
disease in children will be advanced. Pediatric
preventive medicine is perhaps the single most
important public health strategy to improve the
lives of children in the United States and around
the world. Promoting healthy behaviors and lifestyles, identifying and intervening early when
emotional and physical problems are detected,
and mitigating against the effects of chronic disease must be supported in order to maintain the
health of all children.

References
American Academy of Pediatrics. (2011). AAP fact sheet.
Retrieved August 30, 2011, from http://www.aap.org/
visit/facts.htm
American Psychological Association. (2011). Acting
boldly to change diet and exercise for kids. Retrieved
September 1, 2011, from http://www.apa.org/topics/
children/healthy-eating.aspx
Bright Futures. (2011). Overview. Retrieved August
30, 2011, from http://brightfutures.aap.org/about.html
Centers for Disease Control and Prevention. (2011a). 2011
Recommended immunizations for children from
7 through 18 years old. Retrieved August 30, 2011,
from http://www.cdc.gov/vaccines/who/teens/downloads/parent-version-schedule-7-18yrs.pdf
Centers for Disease Control and Prevention. (2011b).
What would happen if we stopped vaccinations?
Retrieved August 30, 2011, from http://www.cdc.
gov/vaccines/vac-gen/whatifstop.htm
Centers for Disease Control and Prevention. (2011c). A
history of vaccine safety. Retrieved August 30, 2011,
from http://www.cdc.gov/vaccinesafety/Vaccine_Monitoring/history.html
Cooper, J. L., Masi, R., & Vick, J. (2009). Socialemotional development in early childhood: What
every policymaker should know. New York: National
Center for Children in Poverty.
DiSantis, K. I., Collins, B. N., Fisher, J. O., & Davey, A.
(2011). Do infants fed directly from the breast have
improved appetite regulation and slower growth during early childhood compared with infants fed from

Pediatric Preventive Medicine in Early Childhood
a bottle? International Journal of Behavioral Nutrition
and Physical Activity, 8, 1–25.
Falter, R. A., Pignotti-Dumas, K., Popish, S. J., Petrelli,
H. M., Best, M. A., & Wilkinson, J. J. (2011). A service
learning program in providing nutrition education to
children. American Journal of Pharmaceutical Education, 75(5), 85.
Fewtrell, M., Wilson, D. C., Booth, I., & Lucas, A. (2011).
Six months of exclusive breast feeding: How
good is the evidence? British Medical Journal, 342,
c5955.
Fisk, C., Crozier, S., Inskip, H., Godfrey, K., Cooper, C.,
Roberts, G., et al. (2011). Breastfeeding and reported
morbidity during infancy: Findings from the Southampton Women’s Survey. Maternal & Child Nutrition, 7, 61–70.
Hagan, J. F., & Duncan, P. M. (2010). Maximizing children’s health: Screening, anticipatory guidance, and
counseling. In R. Kleigman (Ed.), Nelson textbook of
pediatrics (19th ed., p. 2680). Philadelphia: Saunders.
Harrell, E. (2010). Doctor in MMR-autism scare ruled
unethical. Retrieved August 30, 2011, from http://
www.time.com/time/health/article/0,8599,1957656,
00.html
Jacobson, R. M. (2009). An update on childhood and
adolescent vaccines. Mayo Clinic Proceedings, 84(5),
457–459.
Kids Growth. (2007). A short history of vaccination development. Retrieved August 30, 2011, from http://www.
kidsgrowth.com/resources/articledetail.cfm?id=1372
Kindblom, J. M., Lorentzon, M., Hellqvist, A., Lonn, L.,
Brandberg, J., Nilsson, S., et al. (2009). BMI changes
during childhood and adolescence as predictors of
amount of adult subcutaneous and visceral adipose
tissue in men. Diabetes, 58, 867–874.
Kvaavik, E., Kleep, K.-I., Tell, G. S., Meyer, H. E., &
Batty, D. (2008). Physical fitness and physical activity
at age 13 years as predictors of cardiovascular disease
risk factors at ages 15, 25, 33, and 40 years: Extended
follow-up of the Oslo Youth Study. Pediatrics, 123,
80–86.
La Leche League. (2006). La Leche league purpose and
philosophy. Retrieved August 30, 2011, from http://
www.llli.org/philosophy.html?m=1,0,1
Lannon, C. M., Flower, K., Duncan, P., Strazza-Moore,
K., Stuart, J., & Bassewitz, J. (2008). The bright
futures training intervention project: Implementing
systems to support preventive and developmental services in practice. Pediatrics, 122(1), e163–e171.
Li, R., Fein, S. B., Chen, J., & Grummer-Strawn, L. M.
(2008). Why mothers stop breastfeeding: Mother’s
self-reported reasons for stopping during the first
year. Pediatrics, 122(2), S69–S76.
Miles, J., Espiritu, R. C., Horen, N., Sebian, J., & Waetzig,
E. (2010). A public health approach to children’s
mental health: A conceptual framework. Washington,
DC: Georgetown University Center for Child and
Human Development, National Technical Assistance
Center for Children’s Mental Health.

Pediatric Preventive Medicine in Early Childhood
Moyer, V. A., & Butler, M. (2004). Gaps in the evidence
for well-child care: A challenge to our profession.
Pediatrics, 114(6), 1511–1521.
National Children’s Study. (2011). What is the national
children’s study? Retrieved August 30, 2011, from
http://www.nationalchildrensstudy.gov/Pages/default.
aspx
National Research Council and Institute of Medicine.
(2000). The science of early childhood development
Committee on Integrating the Science of Early Childhood Development. In J. P. Shonkoff & D. A. Phillips
(Eds.), From neurons to neighborhoods (p. 588).
Washington, DC: National Academy Press.
Nelson, K. E., & Williams, C. (2007). Infectious disease
epidemiology: Theories and practice (2nd ed.). Burlington, MA: James and Bartlett.
Newman, C., & Ralston, K. (2006). Profiles of participants
in the national school lunch program: Data from two
national surveys. Economic Information Bulletin, 17,
1–29.
Park, A. (2011). Study linking vaccines to autism is
“fraudulent”. Retrieved September 1, 2011, from
http://healthland.time.com/2011/01/06/study-linkingvaccines-to-autism-is-fraudulent/
Piehl, M. D., Clemens, C. J., & Joines, J. D. (2000).
“Narrowing the gap”: Decreasing emergency department use by children enrolled in the Medicaid program
by improving access to primary care. Archives of Pediatric Adolescent Medicine, 154, 791–795.
Pleshette-Murphy, A. (2007, July 15). Breast feeding:
Public act or private right. ABC News. Retrieved September 15, 2011, from http://abcnews.go.com/GMA/
Health/story?id=3378982&page=1
Pratt, H. D., & Tsitsika, A. K. (2007). Fetal, childhood,
and adolescence interventions leading to adult disease
prevention. Primary Care: Clinics in Office Practice,
34(2), 203–217.
Schwimmer, J. B., Burwinkle, T. M., & Varni, J. W.
(2003). Health-related quality of life of severely
obese children and adolescents. Journal of the American Medical Association, 289(14), 1813–1819.
Taylor, P., Peckham, S., & Turton, P. (1998). A public
health model of primary care: From concept to reality.
Birmingham, AL: Public Health Alliance.

827
Third Age. (2011, September). CDC: More adolescents are
getting recommended vaccinations. Retrieved September 1, 2011, from http://www.thirdage.com/news/cdcmore-adolescents-are-getting-recommended-vaccinations_09-06-2011
U.S. Department of Agriculture. (2011). About USDA.
Retrieved September 1, 2011, from www.usda.gov
U.S. Department of Health and Human Services. (2001).
The Surgeon General’s Call to action to prevent and
decrease overweight and obesity. Rockville, MD:
U.S. Department of Health and Human Services, Public Health Service: Office of the Surgeon General.
U.S. Department of Health and Human Services. (2010).
Dietary guidelines for Americans. Retrieved
September 1, 2011, from http://www.health.gov/
dietaryguidelines/
U.S. Department of Health and Human Services. (2011a).
Reducing costs, protecting consumers: The Affordable
Care Act on the one year anniversary of the Patient’s
Bill of Rights. Retrieved September 29, 2011,
from http://www.healthcare.gov/law/resources/reports
/patients-bill-of-rights09232011a.pdf
U.S. Department of Health and Human Services. (2011b).
Preventive services covered under the Affordable Care
Act. Retrieved September 29, 2011, from http://www.
healthcare.gov/news/factsheets/2010/07/preventiveservices-list.html#CoveredPreventiveServicesforChildren
U.S. Department of Health and Human Services. (2011c).
The Surgeon General’s Call to action to support
breastfeeding. Washington, DC: U.S. Department of
Health and Human Services, Office of the Surgeon
General.
Wethington, H. R., Sherry, B., & Polhamus, B. (2011). Physician practices related to use of BMI-for-age and counseling for childhood obesity prevention: A cross-sectional
study. BioMedical Center Family Practice, 12, 1–9.
World Health Organization. (2002). Integrating prevention into health care. Retrieved August 2011, from
Fact Sheet Number 172: http://www.who.int/
mediacentre/factsheets/fs172/en/index.html#
Zimmerman, B., Gallagher, J., Botsko, C., Ledsky, R., &
Gwinner, V. (2005). Assessing the bright futures for
infants, children and adolescents initiative (pp. 1–160).
Washington, DC: Health Systems Research.

828

Peer Relationships: Promoting Positive Peer Relationships During Childhood

Peer Relationships: Promoting
Positive Peer Relationships During
Childhood
Cynthia A. Rohrbeck and Laura Schaffner Gray
Psychology Department, George Washington
University, Washington, DC, USA

Introduction
As children begin elementary school, opportunities for peer interactions significantly increase
(Parker, Rubin, Erath, Wojslawowicz, &
Buskirk, 2006). Friendships and other peer
relationships become more important and more
supportive than when children were younger
(Buhrmester & Furman, 1987). As children progress through elementary school, the peer group
tends to reorganize into subgroups such as clusters or cliques. Peer interactions become less
supervised, while the pool of available peers
increases. The contexts in which interactions
occur also broaden to include schools, extracurricular activities, phone conversations, and more
recently, social media opportunities. Increased
contact with peers provides opportunity for children to learn appropriate social interactions, form
friendships, and identify with peer groups. Children are also exposed to negative aspects of peer
relationships, such as exclusion or bullying.
Successful development of peer relationships
is important to future development. Children with
friends are more socially competent and have
fewer psychological problems than those without
friends (Hartup & Stevens, 1997). Friendships
are also important for school adjustment, motivation, and engagement (Ryan, 2000).
Difficulties with peer interaction skills can
lead to behavioral inhibition and even social phobias (Rubin, Coplan, & Bowker, 2009). Children
with negative peer relationships, such as bullying, and children who are neglected or withdrawn
in larger social networks are at risk for internalizing and externalizing disorders. Interactions
with deviant peers may result in increased aggression, drug use, and violence in later childhood

and adolescence. Finally, social network analyses
suggest that peer contagion may contribute to
obesity, unhealthy body images, and educational
failure (Dishion & Tipsord, 2011).
With regard to prevention and health promotion, peer relationships may be viewed as
a valued outcome in their own right. In addition,
positive and negative peer relationships can predict later adaptive and problematic outcomes,
respectively. Finally, peer relationships can also
serve as risk or protective factors in the relationships among other variables, especially relationships between stressors (e.g., victimization) and
outcomes such as depression.

Definitions and Scope
Research on peer relationships examines the
types, quality, and outcomes of interactions
among same-age peers. Children’s peer relationships occur at multiple and interrelated levels of
social behavior (Hinde & Stevenson-Hinde,
1987). Social interactions or social skills (e.g.,
taking turns) may be perceived as intrapersonal
skills and considered part of social competence.
Social competence also includes the ability to
form dyadic peer relationships and to function
in group settings. Peer dyads (voluntary, mutual
relationships) include friendships, based on
mutual affection. Peer groups are often based
on similarities of individuals and sometimes specific identities (e.g., cliques, social networks) in
larger peer groups who usually interact due to
a context (e.g., a classroom). Peer groups have
varying levels of homogeneity, cohesiveness, and
norms (Rubin, Bukowski, & Laursen, 2009).
Negative peer relationships include bullies and
victims. Bullying has been defined as aggressive
behavior repeated over time towards a victim of
lesser power or strength (Olweus, 1993). Peer
acceptance reflects the child’s social status or popularity within a large group and can be positive or
negative. Sociometric measures have resulted
in several peer categories including average,
popular, controversial, rejected (including withdrawn and aggressive), and neglected peers. There
may also be subtypes of these categories, for

T.P. Gullotta, M. Bloom (eds.), Encyclopedia of Primary Prevention and Health Promotion,
DOI 10.1007/978-1-4614-5999-6, # Springer Science+Business Media New York 2014

Peer Relationships: Promoting Positive Peer Relationships During Childhood

example, “mean girls” who are popular, but
also high in relational aggression (Cillessen &
Mayeux, 2004). Other descriptions of peers
differentiate between children who are actively
isolated (spending time alone because their peers
reject and isolate them) and those who are socially
withdrawn who choose to isolate themselves from
the peer group (Rubin, Coplan, et al., 2009).

Theories
There are several theories that explain aspects of
peer relationships. Attachment theory argues that
peer relationships in childhood can be predicted
by early infant-caretaker attachments. Cognitive
developmental theory emphasizes the role of
peer relationships in adaptation and cognitive
growth, whether deriving from conflict with
peers (Piaget, 1932) or cooperation with peers
(Vygotsky, 1978). Social learning theory may
be the most influential theory on the study of
peer relationships. In this theory, children can
punish or reinforce each other’s social behaviors
and learn appropriate social behaviors through
modeling (Bandura & Walters, 1963). More
recently, social ecological theory (e.g.,
Bronfenbrenner & Morris, 1998) suggests that
social and historical changes may also impact
the acceptance and importance of peer relationships. Contextual-developmental theory proposes
that perceptions of peer relationships differ
depending on a culture’s values. Ethological theory suggests that social relationships are
influenced by evolutionary purposes. Aspects of
peer relationships (e.g., attachments, altruism)
have developed to help support survival. More
recently, group socialization theory, based on
behavioral genetics research, has suggested that
peer relationships are a significant contributor to
personality development (Harris, 1995).

829

relationships could be perceived as a positive outcome in their own right, and interventions could be
developed to promote peer relationships; however,
we found no interventions of that type in an extensive literature review. Alternatively, (positive)
peer relationships can be a factor or mechanism
in the development of other positive outcomes, or
they can serve as a buffer in the relationship
between stressors and problem outcomes. Similarly, negative peer relationships and influences
can lead to negative outcomes or be a moderator
of relationships between stressors and maladaptive
behaviors.
School is a primary setting for programs that
include peer relationships. Promotion programs
tend to include some combination of social skills,
peer relationships, and/or class/school cohesiveness as common areas of focus. Programs focused
more on preventing negative outcomes, such as
bullying and externalizing behaviors, may also
include rules, guidelines, and consequences for
negative peer behaviors. Schools are ideal settings
for these interventions since children are in
age-based classrooms, the school system has control over the curriculum, and children’s outcomes
can be followed over time. In school interventions,
professionals, paraprofessionals, or teachers
administer the programs to individuals or groups.
Current research on peer relationships is beginning to apply statistical techniques (e.g,, multilevel
modeling), that may be helpful in understanding the
contextual influences on peer relationships. These
techniques should also help to disentangle effect of
social competence skills and those due to dyadic
relationships from the peer contexts in which they
occur. Most peer relationship research has failed to
use longitudinal designs, preventing conclusions
about causal relationships or directions among variables. Current research is predominately focused on
the US and Western cultures, and there is little
research on how peer relationships may differ in
other contexts (Chen & French, 2008).

Current Research
Overview of Strategies
Current research in prevention and health promotion focuses on peer relationships at several stages
of intervention models. Theoretically, peer

Although positive peer relationships contribute
to a variety of positive outcomes and healthy

830

Peer Relationships: Promoting Positive Peer Relationships During Childhood

development, they are not usually the direct
focus or goal of such interventions. Instead,
interventions have used positive peer relationships to (a) promote adaptive behaviors
or (b) reduce or prevent negative behaviors
(i.e., bullying, drug/alcohol use, behavior problems). Interventions with a universal health
promotion or prevention focus are typically
implemented school-wide by teachers or
trained paraprofessionals in their classrooms.
New skills and information tend to be taught
through role-playing, group discussions,
problem-solving
strategies/practice,
and
games. Many programs include revisions or
separate manuals to guide intervention implementation across different ages or grades as
children develop.
It should be noted that even those programs
that appear more promotion oriented often
include a rationale for decreasing externalizing
symptoms or disorders. Such programs tend to
measure decreases of negative outcomes as
a long-term, more distal goal, instead of an immediate post-program goal. Another differentiating
characteristic of programs is the level of intervention; some programs are designed to be
applied universally to all children, others include
additional intervention components for children
at risk, and some programs target children
who already exhibit externalizing problems.
Programs that include components for selective
or indicated subgroups of children are often
implemented in small groups or used in individual interventions by paraprofessionals or school
professionals (e.g., school counselors or
psychologists).
Interventions that included positive peer relationships as an important component and/or
a measured outcome were included in this
review. Certainly negative peer relationships
and influences can lead to or be a mechanism
for maladaptive behaviors, and there are
a variety of studies that include avoidance of
negative peers. Nonetheless, studies that only
teach children to avoid negative peer relationships are not included in this review since they
did not fit the goal of improving peer
relationships.

What Works
A review of the literature revealed several empirically supported interventions (three or more successful trials) designed to increase positive
(healthy) peer relationships or peer interactions,
in addition to other goals.
Some interventions have been primarily
designed to promote positive peer interactions/social skills and peer relationships universally, generally with the distal goal of
preventing negative peer interactions or externalizing behavior problems. For example, I Can
Problem Solve (ICPS) focuses on increasing positive peer interactions in order to help children
learn to resolve interpersonal problems and prevent antisocial behaviors. ICPS is a universal
school-based intervention program with three
different age-appropriate programs administered
by trained teachers (preschool, kindergarten and
primary grades, and intermediate grades). The
20-min ICPS lessons are taught three to five
times per week throughout the school year. The
program uses role-plays, games, puppets, and
illustrations to help children learn problemsolving vocabulary, identify feelings, and evaluate alternative solutions to interpersonal problems. Evaluations of ICPS have shown
increased positive prosocial behaviors, including
empathy and likability by peers (Shure, 2001;
Shure & Healey, 1993). Solution skills have positively correlated with prosocial behaviors, particularly for younger children (Shure & Healey).
This program has been rated as effective by the
Office of Juvenile Justice and Delinquency
Prevention (OJJDP).
Some universal school-wide intervention programs have a broad aim of creating students who
have a positive impact in their community. Such
programs promote core values in addition to
a focus on prosocial behaviors to enhance positive child outcomes while also decreasing negative child outcomes. One example, the Caring
School Community program (derived from the
“Child Development Project”) is a school
improvement program for children in grades
K-6 (Battistich, 2003). This program includes
four primary components: class meetings that

Peer Relationships: Promoting Positive Peer Relationships During Childhood

provide a forum to discuss and solve problems
and to help students better know each other,
cross-age buddies, related home activities to reinforce class topics, and school-wide community
building activities involving students, parents,
teachers, and school personnel. Outcome studies
have shown increased student concern for others,
improved social problem-solving strategies, and
reduced involvement in negative behaviors and
drug use (Battistich; Solomon, Battistich, Watson, Schaps, & Lewis, 2000). This program has
been highlighted by the US Department of Education, SAMHSA’s National Registry of
Evidence-based Programs and Practices
(NREPP), and OJJDP as an effective program.
Other interventions have emphasized the
promotion of positive peer relationships with
both universal and selective components. The
Incredible Years (Webster-Stratton & Hammond,
1997; Webster-Stratton, Reid, & Hammond,
2004) is a school-based intervention, consisting
of curricula for children from preschool to second
grade. This prevention program can be
implemented universally and includes over
60 lessons for teachers to deliver through group
discussions 2–3 times per week. Activities for
both home and school reinforce the skills taught
in those discussions, including developmentally
appropriate social skills, problem-solving, and
school rules. For children who already show
behavior problem symptoms, the program has
a selective prevention component that can be
added; counselors or therapists lead 2-h weekly
sessions for those indicated children. Those sessions include training in friendship development,
interpersonal problem-solving, and anger management skills. Research has shown positive
impacts of this program on social competence
with peers, parent and teacher ratings of prosocial
behavior, positive problem-solving solutions, and
conflict management skills (Webster-Stratton,
Reid, & Hammond, 2001, 2004). This program
has also been promoted by OJJDP as an effective
program.
Teaching children social skills and the ability
to regulate their behavior early can help prevent
future social, school, and family problems.
Greenberg and Bierman designed the Fast

831

Track program, a universal preventive intervention that includes academic lessons and tutoring
in social skills to promote healthy child development (Conduct Problems Prevention Research
Group, 2010; Winn, Newall, Coie, & The Conduct Problems Prevention Research Group,
2007). Fast Track has been used and evaluated
in several geographical locations. Teachers in
grades 1–5 (with a primary focus on 1st graders)
teach the PATHS (Promoting Alternative Thinking Strategies) curriculum, which focuses on
communication, social understanding, selfcontrol, and problem-solving. Furthermore, Fast
Track includes a selective preventive component
for those children most at risk for developing
conduct disorder problems. That component
includes social skills training groups, in-class
friendship enhancement, parent training, home
visits, and child tutoring. Parent groups teach
behavior management skills and home visits
address broader problem-solving skills and help
promote family-school partnerships. Program
evaluations have shown increased prosocial
behaviors, with stronger effects for boys, along
with fewer peer nominations of aggression and
increased peer nominations of likability
(Conduct Problems Prevention Research Group,
2010). Recent research has shown decreased lifetime conduct disorder diagnoses for children in
Fast Track, although only for those considered
most highly at risk (Conduct Problems Prevention Research Group, 2011).
Several empirically supported interventions
have less of a focus on promotion of positive
peer interactions, although they often teach
social skills and problem-solving techniques
while intervening to prevent proximal negative peer outcomes. One such program is the
Olweus Bullying Prevention Program (OBPP:
Olweus & Limber, 2010). This school-based
program aims to reduce the prevalence of current bullying, to prevent the incidence of future
bullying, and generally to improve peer relationships in elementary, middle, and high schools.
When a school implements the OBPP, preliminary steps include the formation of a committee
that then collects bullying data, reviews the
school’s specific problem areas, and organizes

832

Peer Relationships: Promoting Positive Peer Relationships During Childhood

a school “kickoff” for the program. The OBPP
suggests setting clear school-wide rules and
trains teachers to consistently punish rule violations. Teachers are trained to hold class discussions and role-plays, to host individual and
group parent meetings, and to work with individual children on their personal (interpersonal
and academic) goals. Weekly class discussions
are held to discuss bullying issues, to promote
cohesion in the classroom and throughout the
school, and to problem -solve problematic peer
interactions. More than three studies have provided effectiveness data for the OBPP including
evidence of reduced bullying and antisocial
behaviors (Kallestad & Olweus, 2003; Olweus
& Limber, 2010). While the program has been
successful in Norway (Olweus, 2005), evaluations in the USA have shown inconsistent results
(Bauer, Lozano, & Rivara 2007).
Some programs focus on reducing negative
peer interactions through selective targeting
of children at risk for future difficulties. One
empirically supported example is the Primary
Project (Wohl & Hightower, 2001), previously
known as the Primary Mental Health Project. In
this program, children between preschool to third
grade who have been identified with school
adjustment problems through early screening
participate in one-on-one child-directed play
therapy sessions. Children typically receive
10–14 weekly sessions (30–40 min each) with
a trained paraprofessional. The program emphasizes identifying and encouraging children’s
strengths, ongoing consultation to teachers, and
continued assessment to ensure that the intervention meets the child’s needs. It provides an
alternative to universally administered prevention programs by providing more intensive
interventions for children at risk for increased
future social and school difficulties. Outcome
studies show that children have improved
on social skills, self-confidence, and learning
skills while at the same time showing
decreased negative behaviors (Crean &
Lotyczewski, 1995; Nafpaktitis & Perlmutter,
1998). This program is listed on SAMHSA’s
National Registry of Evidence-based Programs
and Practice.

What Is Promising
Some programs that promote peer relationships
have shown initial evidence of effectiveness (less
than three successful evaluations of their success). These programs are theoretically based,
have some research support, and are associated
with positive outcomes in children’s peer relationships. Promising programs may make sense
to implement, particularly if they target outcomes
of interest not addressed by programs included in
the “What Works” category above. The Open
Circle Curriculum is a classroom-based universal
program for children in grades K-5 that focuses
on strengthening problem-solving, social and
emotional skills, interpersonal relationships, and
supportive classroom environments (Hennessey,
2007). Based on the theory that early social relationships can foster future academic and social
success, this program provides early intervention
and training to improve children’s future relationships. The classroom-based curriculum focuses
on social and emotional learning, with a variety
of topics discussed during class-wide open-circle
time, followed by in-class activities, like games
and role-plays to reinforce the topic. The curriculum includes training on including others, being
a good listener, problem-solving, and regulating
emotions. The classroom setting enables students
to practice their skills and provides an opportunity for excluded children to feel connected to
their classmates and teacher. Outcome studies
have shown increased teacher ratings of children’s empathy, problem-solving, and consideration of others, along with increased
empowerment and self-worth (Taylor, Liang,
Tracy, Williams, & Seigle, 2002). Girls reported
reduced adjustment problems and boys reported
less fighting and improved social skills
(Hennessey, 2007). Although such research support is promising, three successful trials of this
program are not yet available.
Interventions focusing on teaching social and
emotional learning can utilize a variety of methodologies to introduce new skills. Talking with TJ
is a school-based, video-presented intervention
program for children in grades K-8 that focuses
on improving social competence, including

Peer Relationships: Promoting Positive Peer Relationships During Childhood

teamwork, diversity appreciation, and group
planning (Dilworth, Mokrue, & Elias, 2002;
Mokrue, Elias, & Bry, 2005). The current program evolved from the original Improving Social
Awareness-Social Problem Solving program
(ISA-SPS; Elias & Tobias, 1996). The program
has been successfully implemented school-wide
(Romasz, Kantor, & Elias, 2004) although program evaluations have shown mixed results. One
study found a dosage effect; urban students in
schools that included more TJ hours or components had higher ratings in social skills and lower
ratings in problem behaviors than student in
schools with less exposure to the program.
However, another evaluation of the program in
a high-risk urban school showed improvements
on student self-concept, but no improvement on
behaviors (Dilworth et al., 2002). Additional
research is needed to move this program from
“promising” to “what works.”
Intervention programs may also use school
mental health professionals (e.g., counselors,
psychologists) to administer the curriculum. The
Social Skills Group Intervention (S.S. GRIN) was
designed as a universal intervention focused on
social skills enhancement and bullying reduction;
however, it is often implemented selectively,
with children at risk for peer problems. S.S.
GRIN consists of ten scripted lesson plans that
are taught in small groups using 60-min weekly
sessions. The lessons include social-emotional
skills training by didactic instruction and practice
with games and activities. The program employs
modeling, positive reinforcement, and cognitive
reframing to enhance skills in each session. This
program is designed for children in grades 3–5
(ages 8–12 years), but has been adapted for prekindergarten children, kindergarten through second graders, and adolescents (ages 13–16 years).
Evaluation studies have shown increased peer
acceptance, decreased aggression, decreased victimization, higher self-esteem, and higher selfefficacy (DeRosier, 2004; DeRosier & Marcus,
2005; Harrell, Mercer, & DeRosier, 2009). It
should be noted that there are more than three
successful trials for this program, but only two
have included child-aged participants. Several
interventions have applied a manualized

833

intervention approach designed to improve social
skills in heterogeneous groups of children (some
with and some without diagnoses) (e.g., Lefler
et al., 2009; Sim, Whiteside, Dittner, & Mellon,
2006). Such programs might be altered and
applied more universally as preventive or promotive programs in the future.

What Does Not Work
It is difficult to state specific examples of peer
interventions that fail to improve peer relationships at this time. It is likely that such examples
suffer from publication bias. From the current
literature, it appears that mere exposure to
peers, without specific instruction in social skills
(e.g., coaching) or specific required peer interactions (e.g., peer tutoring), is not enough to lead to
improvements in peer relationships.

Summary
Similar to this entry in the first edition, it is
notable that there remains a dearth of programs
dedicated specifically or primarily to the promotion of peer relationships, despite how important
those relationships are to social development and
long-term outcomes.
There are also areas in which the role of peer
relationships appears to be understudied. For
example, given relationships between academic
performance, internalizing and externalizing
symptoms, and future outcomes, it is important
to understand how peer relationships may
improve positive outcomes and mitigate against
negative ones. With regard to academic success,
one would expect that negative aspects of peer
relationships (e.g., peer rejection) leads to disengagement, while for other children, the peer
group could reinforce successful school behaviors. Similarly, although there are documented
negative outcomes linked to shyness or social
anxiety, including peer relationship problems,
there are few preventive interventions with shy
or anxious children and fewer still that include
peers or focus on promoting positive peer

834

Peer Relationships: Promoting Positive Peer Relationships During Childhood

relationships (Greco & Morris, 2001).
Researchers have begun to examine how fostering social skills may help children with externalizing disorders such as ADHD in clinical settings
(e.g., Sim et al., 2006).
Whether peer relationships are studied in their
own right or as important in promoting other
outcomes, additional generative, contextual, and
longitudinal research is needed. For example,
little is known about cultural or cross-cultural
differences in the importance and development
of peer relationships (most of the research
included in this entry is from Western sources).
Newer statistical techniques (i.e., multilevel
modeling) may help to separate contributions of
social competence skills, dyadic relationships
and group or contextual influences when examining peer relationships. Finally, cause and effect
relationships between peer relationships and
other variables will be better understood with
longitudinal designs.
There are also aspects of peer relationships
themselves that are understudied. For example,
the dyadic peer relationship research examines
same-sex, non-romantic relationships. Research
on romantic relationships exists only for adolescents, despite reports of romantic relationships in
preteens. That research that exists on romantic
peer relationships is constrained to heterosexual
romantic bonds and should be broadened in the
future. Peer contagion is another understudied
area. Despite research indicating the role of peer
contagion in negative behaviors, there is little
known about whether positive behaviors can be
spread by peer contagion processes.

References
Bandura, A., & Walters, R. H. (1963). Social learning and
personality. New York: Holt, Rinehart and Winston.
Battistich, V. (2003). Effects of a school-based program to
enhance prosocial development on children’s peer
relations and social adjustment. Journal of Research
in Character Education, 1(1), 1–17.
Bauer, N. S., Lozano, P., & Rivara, F. P. (2007). The
effectiveness of the Olweus Bullying Prevention Program in public middle schools: A controlled trial.
Journal of Adolescent Health, 40(3), 266–274.
doi:10.1016/j.jadohealth.2006.10.005.

Bronfenbrenner, U., & Morris, P. A. (1998). The ecology
of developmental processes. In W. Damon, R. M. Lerner, W. Damon, & R. M. Lerner (Eds.), Handbook of
child psychology: volume 1: Theoretical models of
human development (5th ed., pp. 993–1028). Hoboken, NJ: Wiley.
Buhrmester, D., & Furman, W. (1987). The development
of companionship and intimacy. Child Development,
58(4),
1101–1113.
doi:10.1111/1467-8624.
ep8590161.
Chen, X., & French, D. C. (2008). Children’s social competence in cultural context. Annual Review of Psychology, 59, 591–616.
Cillessen, A. N., & Mayeux, L. (2004). Sociometric status
and peer group behavior: Previous findings and current
directions. In J. B. Kupersmidt & K. A. Dodge (Eds.),
Children’s peer relations: From development to
intervention (pp. 3–20). Washington, DC: American
Psychological Association. doi:10.1037/10653-001.
Conduct Problems Prevention Research Group. (2010).
The effects of a multiyear universal social-emotional
learning program: The role of student and school
characteristics. Journal of Consulting and Clinical
Psychology, 78(2), 156–168. doi:10.1037/a0018607.
Conduct Problems Prevention Research Group. (2011).
The effects of the fast track preventive intervention
on the development of conduct disorder across childhood. Child Development, 82(1), 331–345.
doi:10.1111/j.1467-8624.2010.01558.x.
Crean, H. F., & Lotyczewski, B. S. (1995). An evaluation
of the Early Mental Health Initiative’s Primary
Intervention Program and Enhanced Primary
Intervention Program for the 1994–95 academic year
(Tech. Rep. T95-428.1). Rochester, NY: Children’s
Institute.
DeRosier, M. E. (2004). Building relationships and combating bullying: Effectiveness of a school-based social
skills group intervention. Journal of Clinical Child and
Adolescent Psychology, 33(1), 196–201. doi:10.1207/
S15374424JCCP3301_18.
DeRosier, M. E., & Marcus, S. R. (2005). Building friendships and combating bullying: Effectiveness of S.S.
GRIN at one-year follow-up. Journal of Clinical
Child and Adolescent Psychology, 34(1), 140–150.
doi:10.1207/s15374424jccp3401_13.
Dilworth, J., Mokrue, K., & Elias, M. J. (2002). The
efficacy of a video-based teamwork-building series
with urban elementary school students: A pilot investigation. Journal of School Psychology, 40(4),
329–346. doi:10.1016/S0022-4405(02)00102-4.
Dishion, T., & Tipsord, J. (2011). Peer contagion in child
and adolescent social and emotional development.
Annual Review of Psychology, 62, 189–214.
Elias, M. J., & Tobias, S. E. (1996). Social problem solving: Interventions in the schools. New York: Guilford
Press.
Greco, L. A., & Morris, T. L. (2001). Treating childhood
shyness and related behavior: Empirically evaluated
approaches to promote positive social interactions.

Peer Relationships: Promoting Positive Peer Relationships During Childhood
Clinical Child and Family Psychology Review, 4(4),
299–318.
Harrell, A. W., Mercer, S. H., & DeRosier, M. E. (2009).
Improving the social-behavioral adjustment of adolescents: The effectiveness of a social skills group intervention. Journal of Child and Family Studies, 18(4),
378–387. doi:10.1007/s10826-008-9241-y.
Harris, J. R. (1995). Where is the child’s environment?
A group socialization theory of development. Psychological Review, 102, 458–489.
Hartup, W. W., & Stevens, N. (1997). Friendships and
adaptation in the life course. Psychological Bulletin,
121(3), 355–370. doi:10.1037/0033-2909.121.3.355.
Hennessey, B. A. (2007). Promoting social competence in
school-aged children: The effects of the Open Circle
Program. Journal of School Psychology, 45(3),
349–360. doi:10.1016/j.jsp.2006.11.007.
Hinde, R. A., & Stevenson-Hinde, J. (1987). Interpersonal
relationships and child development. Developmental
Review, 7(1), 1–21. doi:10.1016/0273-2297(87)
90002-5.
Kallestad, J. H., & Olweus, D. (2003). Predicting teachers’
and schools’ implementation of the Olweus Bullying
Prevention Program: A multilevel study. Prevention &
Treatment, 6, 3–21. doi:10.1037/1522-3736.6.1.621a.
Lefler, E. K., Hartung, C. M., Scambler, D. J., Page, M. C.,
Sullivan, M. A., Armendariz, M. L., et al. (2009).
Effects of a social skills intervention administered in
mixed diagnostic groups for children with peer relationship problems. National Head Start Association
Dialog: A Research-to-Practice Journal, 12, 18–32.
doi:10.1080/15240750802590750.
Mokrue, K., Elias, M. J., & Bry, B. H. (2005). Dosage
effect and the efficacy of a video-based teamworkbuilding series with urban elementary school children.
Journal of Applied School Psychology, 21(1), 67–97.
doi:10.1300/J370v21n01_04.
Nafpaktitis, M., & Perlmutter, B. F. (1998). School-based
early mental health intervention with at-risk students.
School Psychology Review, 27, 420–432.
Olweus, D. (1993). Bullying at school: What we know and
what we can do. Oxford, UK/Cambridge, USA:
Blackwell.
Olweus, D. (2005). A useful evaluation design, and effects
of the Olweus Bullying Prevention Program. Psychology, Crime & Law, 11(4), 389–402. doi:10.1080/
10683160500255471.
Olweus, D., & Limber, S. P. (2010). Bullying in school:
Evaluation and dissemination of the Olweus Bullying
Prevention Program. American Journal of Orthopsychiatry, 80(1), 124–134. doi:10.1111/j.19390025.2010.01015.x.
Parker, J. G., Rubin, K. H., Erath, S. A., Wojslawowicz,
J. C., & Buskirk, A. A. (2006). Peer relationships, child
development, and adjustment: A developmental psychopathology perspective. In D. Cicchetti & D. J.
Cohen (Eds.), Developmental psychopathology,
vol 1: Theory and method (2nd ed., pp. 419–493).
Hoboken, NJ: Wiley.

835

Piaget, J. (1932). The moral judgement of the child. New
York: Harcourt Brace.
Romasz, T. E., Kantor, J. H., & Elias, M. J. (2004).
Implementation and evaluation of urban school-wide
social-emotional learning programs. Evaluation and
Program Planning, 27(1), 89–103. doi:10.1016/j.
evalprogplan.2003.05.002.
Rubin, K. H., Bukowski, W. M., & Laursen, B. (Eds.).
(2009). Handbook of peer interactions, relationships,
and groups. New York: Guilford Press.
Rubin, K. H., Coplan, R. J., & Bowker, J. C. (2009). Social
withdrawal in childhood. Annual Review of Psychology, 60, 141–171.
Ryan, A. M. (2000). Peer groups as a context for the
socialization of adolescents’ motivation, engagement,
and achievement in school. Educational Psychologist,
35(2), 101–111.
Shure, M. B. (2001). I Can Problem Solve (ICPS): An
interpersonal cognitive problem solving program for
children. Residential Treatment for Children & Youth,
18(3), 3–14. doi:10.1300/J007v18n03_02.
Shure, M. B., & Healey, K. N. (1993, August). Interpersonal problem solving and prevention in urban 5th and
6th graders. Paper presented at the meeting of the
American Psychological Association, Toronto,
Canada.
Sim, L., Whiteside, S. P., Dittner, C. A., &
Mellon, M. (2006). Effectiveness of a social skills
training program with school age children: Transition
to the clinical setting. Journal of Child and Family
Studies, 15(4), 408–417. doi:10.1007/s10826-0069049-6.
Solomon, D., Battistich, V., Watson, M., Schaps, E., &
Lewis, C. (2000). A six-district study of educational
change: Direct and mediated effects of the Child
Development Project. Social Psychology of Education, 4, 3–51.
Taylor, C. A., Liang, B., Tracy, A. J., Williams, L. M., &
Seigle, P. (2002). Gender differences in middle school
adjustment, physical fighting, and social skills: Evaluation of a social competency program. The Journal of
Primary Prevention, 23(2), 259–272. doi:10.1023/
A:1019976617776.
Vygotsky, L. S. (1978). Mind and society: The development of higher psychological processes. Cambridge,
MA: Harvard University Press.
Webster-Stratton, C., & Hammond, M. (1997). Treating
children with early-onset conduct problems:
A comparison of child and parent training interventions. Journal of Consulting and Clinical Psychology,
65(1), 93–109. doi:10.1037/0022-006X.65.1.93.
Webster-Stratton, C., Reid, J., & Hammond, M. (2001).
Social skills and problem-solving training for children
with early-onset conduct problems: Who benefits?
Journal of Child Psychology and Psychiatry, 42(7),
943–952. doi:10.1111/1469-7610.00790.
Webster-Stratton, C., Reid, M., & Hammond, M. (2004).
Treating children with early-onset conduct problems:
Intervention outcomes for parent, child, and teacher

836

Peer Relationships: Promoting Positive Peer Relationships During Childhood

training. Journal of Clinical Child and Adolescent
Psychology,
33(1),
105–124.
doi:10.1207/
S15374424JCCP3301_11.
Winn, D. M., Newall, E., Coie, J. D., & The Conduct
Problems Prevention Research Group. (2007). Fast
track morphs into on track: The dissemination of
a conduct prevention program in Manchester,

England. Child and Family Policy and Practice
Review, 3(1), 7–10.
Wohl, N., & Hightower, A. (2001). Primary Mental Health
Project: A school-based prevention program. In A. A.
Drewes, L. J. Carey, & C. E. Schaefer (Eds.), Schoolbased play therapy (pp. 277–296). Hoboken, NJ:
Wiley.

Prevention of Birth Defects and Preterm Delivery

Prevention of Birth Defects and
Preterm Delivery
Patricia M. Newcomb
Rochester General Hospital/University of
Rochester Medical School, Rochester, NY, USA
RIT College of Science, RIT, Rochester,
NY, USA

Introduction
Across the world today, birth defects (BD) and
preterm delivery (PTD) are recognized as
significant problems facing humankind today.
New energy, evidenced by new initiatives, is
moving us closer to the prevention and amelioration of these conditions.
Primary prevention of birth defects would
seem to be the ideal approach, but alleviation of
the morbidity of some congenital defects and
diseases is also a worthy goal. Early delivery
(premature delivery, PTD, and premature labor,
PTL) is an entity deeply intertwined with birth
defects, causing some of them, increasing the
morbidity of many of them, and, when appropriately initiated by physicians and caregivers,
preventing a handful of them.

Definitions
A birth defect is an abnormality of structure,
function, or metabolism (body chemistry) present
at birth that results in physical or intellectual
disabilities or death. In a broad sense, a very
large set of suboptimal birth outcomes can be
classed as defects with this definition. Processes
include physical constraints (amniotic band syndromes, clubfoot, etc.) within the womb; pathological conditions in the womb, before, during,
and immediately after birth (maternal transfer of
infections, birth events such as asphyxiation,
environmental toxins and exposures (such as
smoking, medications, and chronic maternal conditions like diabetes)); and changing sociological/environmental realities (e.g., congenital

837

blindness might not be a survivable defect in
a preindustrial setting, just as obstructive
uropathy in some parts of the world which lack
capacity for fetal surgery is still lethal).
Because a person’s phenotype (their complete
appearance and function down to the cellular
level) is accomplished by the daily (and minuteto-minute) production of molecules by
genes which interact with the environments
(macroscopic, tissue, cellular, extra- and intracellular), classification systems for birth defects can
be very intricate. However, these “boil down” to
three etiological categories: variant or mutated
genes (genetic birth defects), both inherited
and
spontaneous;
environmental
causes
(environmental exposures); and complex conditions (involving both genes and environments).
Included in complex conditions are unknown etiologies for BD (Bale, Stoll, & Lucas, 2003).
Examples of genetic birth defects include
holes in the heart (atrial and ventricle septal
defects or ASDs and VSDs, most of which are
spontaneous and not inheritable (passed on in
families from one generation to the next)) and
also Marfan’s syndrome, Tay-Sachs disease,
and polydactyly (which are inherited in various
patterns) (Harris, 2000). Examples of
environment-caused birth defects include contractures and limb defects due to amniotic bands
(strands of membrane or scar in the uterus), direct
trauma, direct poisons, and true asphyxia.
Environmental suboptimal birth outcomes and
preterm deliveries also can stem from infection,
such as the “TORCH” illnesses: toxoplasmosis,
“other” (includes syphilis), rubella, cytomegalovirus (CMV), and herpes. The fetus may be
permanently affected (while in the environment
of the womb) by maternal conditions such
as diabetes, obesity, and malnutrition or deficit
(Davis,
Peck,
Thompson,
Wild,
&
Langlois, 2010; Stothard, Tennant, Bell, &
Rankin, 2009).
Complex birth defects result when both genes
and environments are involved and include
second-generation effects of exposures, and
generational effects passed on without direct
alteration of genes (epigenetic effects). Examples
of epigenetic effects are changes in the

T.P. Gullotta, M. Bloom (eds.), Encyclopedia of Primary Prevention and Health Promotion,
DOI 10.1007/978-1-4614-5999-6, # Springer Science+Business Media New York 2014

838

grandchildren of individuals exposed to famine in
WWII and to DES in pregnancy.
In addition, clearly, many conditions which
cause difficulty in later life have both a genetic
predisposition (a problem in a gene makes it more
likely for that individual to develop the condition) and an environmental component. (Some
other exposure must occur to cause the individual
to develop the problem.) Viewed this way, many
chronic diseases of adulthood such as hypertension and heart disease could be technically
termed “birth defects” and potentially prevented
by optimizing the pre-birth environment! This
entry cannot address so broad a group of “birth
defects” and will be confined to conditions currently being addressed by societies throughout
the world, and in the time frame of just before
conception, during pregnancy and delivery, and
immediately after birth.
In some cases, a tiny change in a single gene
creates a systemic illness (monogenetic disease),
as in maple sugar urine disease, which affects
neurological development and the excretory system. In other cases, multiple genes must be
affected to cause the problem. A heart defect
where the blood vessels are reversed in position,
called Tetralogy of Fallot, is an example of the
latter.
In many cases of single-gene defects, the gene
involved is known (as in sickle cell disease).
A large portion of birth defects, however, have
the complex or unknown etiology. One wellknown example of a congenital problem with an
unknown, complex, etiology is cerebral palsy.
Other examples would be intrauterine growth
restriction (IUGR) and preterm delivery (birth
before 37 weeks of gestation). Cerebral palsy is
highly associated with preterm birth.
The definition of preterm birth is a birth occurring by any means at above 20 weeks of gestation
but below 37 completed weeks of gestation
(below 20 weeks is a miscarriage (spontaneous
abortion in medical language)). Being born with
no signs of life at a gestation above 20 weeks is
a stillbirth (fetal demise or intrauterine fetal
death, FDIU, IUFD). Countries and even individual US states have variable definitions of which
losses constitute stillbirth and when and how any

Prevention of Birth Defects and Preterm Delivery

such losses are reportable to state agencies and/or
health departments.
The subcategories of preterm delivery are:
Extreme preterm
Very preterm
Moderate
preterm
Late preterm
(or “near term”)

Less than 28 weeks completed
28–32 weeks
32–33 weeks
34–36 weeks and 6 days

Gestational age (completed weeks of pregnancy) and not actual birth weight is the key
feature determining survival and morbidity of
prematurity (March of Dimes (MOD), PMNCH,
Save the Children, & WHO, 2012).

Scope
Worldwide incidence of birth defects is 3.2
million births per year and represents 30 per
1,000 births (or 1 in 33 births) (World Health
Organization [WHO], 2012a). As a comparison
for the magnitude of the problem, 15 million
babies are born preterm worldwide. Premature
birth (delivery prior to 37 completed weeks)
occurs at a rate of 117 per thousand deliveries
each year in the USA (1 in 8) and at about
60–90 per 1,000 worldwide overall (WHO,
2012b).
Birth defects (BD) would seem to be a much
smaller problem than preterm birth (PTD), but
infant mortality research reveals the morbidity
of BD. Birth defects cause 20 % of US infant
deaths in each year, while PTD causes 17 %.
These are raw numbers of deaths using death
certificate data (Heron et al., 2009).
Recently, an incisive analysis by Callaghan
et al., in 2006, pointed out flaws in the definitions
and associations of PTD with US infant mortality, revealing that, in the USA, prematurity
and specifically the very low birth weight infants
born under 32 weeks actually comprise the
highest rates of death (Callaghan, MacDorman,
Rasmussen, Qin, & Lackritz, 2006). Thus, prematurity is the true worldwide leading cause of
neonatal morbidity and mortality. Still, worldwide, the mortality of birth defects has been

Prevention of Birth Defects and Preterm Delivery

839

under-recognized, leading to new initiatives
discussed shortly.
Even more complexity exists within and
between birth defects and PTD: prematurity is
highly associated with and may be the major
cause of the complex/unknown etiology birth
defect cerebral palsy (Centers for Disease Control and Prevention [CDC], 2011, 2012). Preterm
premature rupture of the membranes (pPROM) at
early gestations, when it does not result in prompt
preterm labor and PTD, causes lung
malformations and contracture defects of the
limbs. Similar risk factors are involved in both
conditions (smoking, closely spaced pregnancies,
multiple gestation, genetic factors). In fact, the
morbidity of BD may be underestimated even in
countries, like the USA, with strong epidemiological infrastructures, which previously ranked
BD as the most frequent cause of infant mortality
(Christianson, Howson, & Modell, 2006;
Copeland & Kirby, 2007; U.S. Agency for
Healthcare Research and Quality [AHRQ],
2007).
Just as the effects of PTD are lifelong, so too
are the sequelae of BDs. Fully half of the childhood (aged 1–2) deaths in a recent Michigan
study were in children also identified on the
birth defect registry (Copeland & Kirby, 2007).

Prevention of Birth Defects and Preterm Delivery,
Table 1 Estimated contributions of BD risk factors

Incidence of BD and PTD
Three to five percent of live-born children in the
USA (150,000–250,000 per year) have
a recognizable birth defect. By later childhood
the incidence becomes 6–7 % as cognitive deficits become apparent (Cunningham et al., 1997).
The estimated contribution of various causes
follows.

a distinct injury or inflammation pathway. Nonetheless, three types of PTD are useful constructs:
indicated iatrogenic PTD (doctors initiate labor
to improve chances of maternal or fetal survival),
spontaneous PTD, and rupture of the membranes (pPROM). Increased relative risk can
be determined, but contribution of individual
risk factors to the overall prevalence and incidence of PTD is exceedingly difficult to elucidate. About 50 % of preterm births are estimated
to be from unexplained/unknown causes overall
(March of Dimes (MOD) et al., 2012).

BD: Estimated Contributions of BD Risk
Factors
See Table 1.
The causes of preterm delivery are poorly understood, are multifactorial, and vary by ethnicity.
PTD is a “final pathway” and results from varied
starting points or triggers. Very little is known
about the normal human initiation of labor; it is
not even determined whether most PTL is premature initiation of “normal” labor or results from

Genetic (chromosomal [0.5] and single gene
[1.0)]
Environmental
Infections (cytomegalovirus (CMV),
rubella, etc.)
Maternal disease (diabetes, alcohol, seizure,
malnutrition, vitamin deficit, etc.)
Drugs, medications, chemicals, radiation
Mechanical problems (deformations)
Multifactorial (complex genetic) and unknown

25–30 %
5–10
3–5 %
4%
<1–2 %
1%
65–70 %

Information compiled from Brent (2011) and Christianson
et al. (2006)
Adapted by author, Pat Newcomb, 2013

Prevention of Birth Defects and Preterm Delivery,
Table 2 PTD types and proportions
Indicated PTD
Hypertension of pregnancy
(preeclampsia) related
Fetal distress
Growth restriction, abruption, FDIU
Spontaneous PTL
pPROM

30
50
15
25
25
45
25

%
% (of 30 or
%)
% (9)
% (9)
%
%

Compiled from Goldenberg, Culhane, Iams, and Romero
(2008) and Cunningham et al. (2005)
Adapted by author, Pat Newcomb, 2013

PTD Types and Proportions
See Table 2.
PTL/PTD: Possible Contributions to Rates by
Risk Factors/Mechanisms
See Table 3.

840

Prevention of Birth Defects and Preterm Delivery

Prevention of Birth Defects and Preterm Delivery,
Table 3 PTL/PTD: Possible contributions to rates by risk
factors/mechanisms
History of prior PTD
Infection
Maternal
Chorioamnionitis
pPROM associated
non-pPROM associated
Stretch/volume increase or imbalance
Multiple gestation (twins an d more)
Cervical incompetence
Infertility treatment/in vitro fertilization
Environmental/lifestyle factors
Smoking
Environmental toxins
Endocrine disruptors
Illicit substances (cocaine primarily)
Low maternal weight
Obesity
Close-spaced pregnancy
Vitamin C, other nutrient deficit
SES
Violence against women
Depression
Unexplained
Genetics (African descent)
Stress
Proinflammatory/immune state

10 %
12 %
?
?
?
?
–
20 %
<1 %
?
?
8%
?
?
?
?
?
?
?
?
?
?
50 %
?
?

Compiled from Offiah, O’Donoghue, and Kenny (2012),
Goldenberg, Culhane, Iams, and Romero (2008), Tsai
et al. (2009), and Cunningham et al. (2005)
Adapted by author, Pat Newcomb, 2013

In the USA, the most common antecedent to PTD
in white women is preterm labor; but in African
American women, who suffer a three times
greater rate of PTD, pPROM is the precursor.
Prevalence of BD and Preterm Delivery
Prevalence of specific conditions varies widely
by country and location. Whenever a country
lacks basic public health services, more serious
birth defects are prevalent and preterm delivery is
more deadly (March of Dimes (MOD) et al.,
2012).
About 10,000 of the 200,000 US children born
with defects each year have cerebral palsy (CDC,
2011). About 2,750 live-born children per year
have a neural tube defect (failure of the spine to

close) per year in the USA (Honein, Paulozzi,
Mathews, Erickson, & Lee-Yang, 2001). One percent of all births in the USA are affected by CMV
infection. About 3,000 of these suffer congenital
anomalies (Morrison, 2000). Approximately
13,200 infants are born to mothers who have
a seizure disorder each year (Lewis, Van Dyke,
Stumbo, & Berg, 1998). Conotruncal heart defects
(which include major malpositions of the great vessels, Tetralogy of Fallot, and duplications in the
heart structure) affect 3,000 infants a year in the
USA (Botto, Khoury, Mulinare, & Erickson, 1996).
Data on congenital anomalies are usually
reported per birth, but with the incidence of
3–5 %, and a vast majority surviving, even
though the current existing cases out of the total
population of the USA are not reported, the prevalence is probably 9–10 million/330 million.
Costs to Host/Society of BD and PTD
The costs to the affected individuals from birth
defects vary from negligible (polydactyly, or extra
fingers) to devastating. Similarly, the costs for
a near-term premature delivery (say at 36 weeks
instead of term (40 weeks)) may be zero, but for
a birth near the viability limit of 23–24 weeks,
astronomical (potentially one million dollars
within the first year of life) (CDC, 2004b).
A victim of the birth defect of cerebral palsy,
for example, averages a lifetime cost of $503,000
in 1992 dollars ($892,000 in 2013 dollars if general rates of inflation applied. Medical costs in
general outpace inflation) (CDC, 2004b).
A rough estimate of the cost to the US health
system for cerebral palsy alone, per year, is now
about 177 million dollars. The annual cost of
treating CMV complications alone was two billion dollars in 2000 (Morrison, 2000).
The annual costs of PTD in the USA top
25 billion a year and may exceed 50 billion annually when indirect expenses are considered
(CDC, 2004b).

Theories of BD and PTD
Major entities such as WHO and the March of
Dimes (MOD) recognize the magnitude of these

Prevention of Birth Defects and Preterm Delivery

intertwined problems (birth defects and PTD),
and, since the first edition of this handbook,
increased efforts have focused on the prevention
and amelioration of birth defects and prematurity.
Meanwhile, research into genetics and the capacity to decode entire genomes has massively
expanded, leading to an explosion of information
on genes associated with the human condition.
From knowing a handful of human genes directly
linked to disease and anomalies in the 1960s, we
now know of more than 8,000 such genes. This
number is rapidly increasing daily (Brent, 2011).
The power of genomic science (evaluating all
the DNA of individuals and groups) and of proteome analyses (studying the complete array of
proteins individuals and groups make) is being
focused on the problem of preterm delivery. This
approach is identifying truly novel targets for
prevention and therapy (Plunkett et al., 2011).
In 2006 MOD reported on the global effect of
birth defects and noted there are two populations
affected by the problem in different ways: low- to
middle-income countries (the developing world)
and high-income countries (industrialized countries like the USA).
They found that 94 % of the births with serious congenital anomalies occur in low- to
middle-income countries, as do 95 % of the
deaths from birth defects. Nonetheless, in highincome countries, birth defects are a leading
cause of death in newborns and infants. Worldwide, the most common genetic or partially
genetic defects are congenital heart defects, neural tube defects, hemoglobin disorders (such as
sickle cell and thalassemias), Down syndrome
(Trisomy 21), and glucose-6-phosphatase deficiency (G6PD) (an enzyme deficiency which,
when a trait, helps prevent infection of the individual by malaria – sickle cell trait and minor
thalassemias also protect from malarial infection)
(Christianson et al., 2006).
Nongenetic defects (environmental defects)
such as fetal alcohol syndrome (FAS) and fetal
alcohol spectrum disorders (FASD – in which
one or a few features of FAS manifest, but not
the entire syndrome) and malnutrition effects are
harder to analyze but likely affect hundreds of
thousands of births each year; and millions of

841

individuals worldwide are living with the
sequelae. The important conditions are four:
FAS, iodine deficiency disorders, congenital
rubella (German measles) syndrome, and congenital syphilis (Christianson et al., 2006;
Strandberg-Larsen et al., 2011).
Experts estimate that 70 % of birth defects can
be prevented or ameliorated. Amelioration
includes a wide range of therapies such as corrective surgery for heart defects and cleft palates
and special diets for phenylketonurics
(Carmichael et al., 2012; Correa et al., 2012).
Just as occurs with birth defects, the country in
which the affected infant is born determines the
outcome: there are more preterm deliveries in
low- and middle-income nations, with more
than 60 % occurring in Africa and Asia. Mortality is starkly increased in these majority locales,
where 90 % of moderately and extremely preterm babies expire within a few days, in contrast
to high-income countries such as the USA, where
90 % of babies born at 28 weeks survive without
significant permanent impairment.
Yet there are lower-tech solutions achievable
by low- to middle-income countries which could
reduce the death toll for premature infants
(March of Dimes (MOD) et al., 2012).
Preconception Counseling
Preconception counseling is advising parents
before they attempt pregnancy how best to optimize their outcome. Preconception and early
pregnancy advisement have allowed the USA to
reduce the infant mortality from birth defects by
46 % from 1980 to 2001. Low- to middle-income
countries have not experienced a similar
improvement. Thus, MOD and WHO have developed phased recommendations for the prevention
of birth defects and prematurity.
Recommendations: Phase 1

• Educate the community, health professionals
and workers, policy makers, the media, and
other stakeholders about birth defects and
the opportunities for effective care and
prevention. To achieve this end, each ministry
of health should designate an expert or an
individual with the responsibility for

842

•

•

•
•

•

•

•
•

coordinating strategies for care and prevention. These strategies need to be woven
into existing public health strategies. Ministries do not need to create a new position, but
they should ensure that a knowledgeable,
trained, and effective person holds this
responsibility.
Promote family planning, allowing couples to
space pregnancies, plan family size, define the
ages at which they wish to complete their
family, and reduce the proportion of
unintended pregnancies.
Ensure a healthy, balanced diet during
a woman’s reproductive years through an adequate intake of macronutrients (protein, carbohydrates, and fats) and a broad range of
micronutrients. Special attention should be
given to adding 400 micrograms of synthetic
folic acid daily to the diet through fortification
and/or supplementation while also promoting
a diet rich in food folates; correcting iodine
and iron deficiencies; and removing teratogenic substances, the most important of
which is alcohol, from the diet.
Control infections in all women of
reproductive age.
Optimize maternal health through control of
chronic illnesses associated with an increased
risk of birth defects. These include insulindependent diabetes mellitus, epilepsy and its
control with antiepileptic drugs, and heart disorders for which sodium warfarin is
prescribed.
Train physicians, nurses, and allied health professionals and workers in the fundamentals of
the recognition of causes and care of children
with birth defects.
Conduct physical examinations of all newborns by a physician, nurse, or allied health
professional trained to recognize birth defects
before hospital or clinic discharge.
Establish appropriate child health services to
care for infants with birth defects.
Establish national capacity for surveillance
and monitoring of common birth defects to
inform policy and to allow for more robust
evaluation of national interventions, such as
fortification of the food supply with folic acid.

Prevention of Birth Defects and Preterm Delivery

• Promote lay support organizations, including
patient/parent support groups, to improve
patient care and birth defect prevention
by facilitating community and professional
education and advocating for increased
funding for research on the causes of birth
defects.
Recommendations: Phase 2

• Train physicians, nurses, and allied health
professionals in the essentials of medical
genetics. This training should include the recognition of birth defects; means of treatment
where possible in the primary health-care setting; knowing when to refer a patient for more
specialized treatment; basic genetic counseling, including best practices in communicating unfavorable health information to parents;
and support for families who have a child or
are at risk of having a child with a birth defect.
• Establish peri-conception medical services to
assist women and their partners to attain optimal physical and mental health and well-being
at the beginning of pregnancy to facilitate
a normal pregnancy and delivery of a healthy
infant. These include screening for the risk of
genetic, partially genetic, and teratogenic birth
defects.
• Implement preconception or prenatal medical
genetic screening to identify couples at risk of
having a baby with hemoglobin disorders,
Down syndrome, blood type incompatibility,
congenital
syphilis,
and
congenital
malformations, particularly neural tube
defects.
• Establish newborn screening to identify congenital hypothyroidism, phenylketonuria,
galactosemia, sickle cell disease, G6PD deficiency, and other metabolic disorders.
• Educate the public about birth defects and the
steps mothers and fathers can take with their
health-care provider to maximize the chances
of a healthy pregnancy.
Reproduced with permission from
Christianson, A., Howson, C. P., and Modell,
B. M. (2006). March of Dimes Global report
on birth defects: The Hidden toll of dying and
disabled children, (Executive Summary),

Prevention of Birth Defects and Preterm Delivery

pp. 6–7. White Plains, NY: March of Dimes
Birth Defects Foundation.
In particular, dispelling myths about congenital and exposure-related anomalies; promoting
women’s health and family planning to reduce
risks from unplanned, closely spaced, and
advanced maternal age pregnancies; and controlling teratogenic infections (rubella, syphilis) and
morbid infections (which cause death or sterility
in women) are essential. Equally important are
optimizing maternal health (control diabetes, epilepsy, and conditions needing blood thinners for
treatment) and medicines needed to do so;
establishing health services for affected children;
identifying and monitoring birth defects (to plan
for prevention and management); and promoting
lay support organizations, research efforts, and
education for all.
In the USA, primarily the second phase activities apply. First, it makes sense to avoid disease
in the mother whenever possible. If disease is
already established in the mother, control its
effects, minimizing morbidity. (For example,
congenital anomalies in the offspring are reduced
if blood sugar is controlled in diabetic women
prior to pregnancy.) Second, avoid vitamin or
micronutrient deficiencies and toxicities. (For
example, folate supplementation helps prevent
neural tube defects.) Third, avoid toxins and radiation exposures in both parents. (The paternal
contribution is often overlooked.) Fourth, by
obtaining complete histories and, at times,
genetic testing of the parents, recognize specific
inherited conditions for which the couple’s offspring are at elevated risk.
Technology now allows us, in the case of
in vitro fertilization, to test a potential embryo
for genetic defects prior to implantation into the
uterus (preimplantation, single cell, genetic
screening (PGD)). This is one extreme of treating
the problem on an individual basis.
In the general population, antenatal testing for
some genetic birth defects can now be accomplished very early in gestation without invasive
testing such as amniocentesis. The technique is
called “cell-free DNA testing” and finds and
amplifies the fetus’ DNA from the mother’s
bloodstream. The obstetric standard of care for

843

screening average-risk individual pregnant
women for Down syndrome now includes this
new technology.
Public health theory and practice, on the other
hand, hold that population-wide efforts at education or intervention will reach more people with
less cost per person (Boyle & Cordero, 2005;
Weinhold, 2009). Universal free prenatal visits
(as in the Netherlands), financial bonuses for
early prenatal care (as in France), nationwide
public information campaigns, and supplementation of food products (e.g., with iron or folate) are
examples (Agha, Glazier, Moineddin, Moore, &
Guttmann, 2011). The USA has markedly
reduced the incidence of neural tube defects
from folate deficiency by universally
supplementing grain products (CDC, 2004a;
Parker et al., 2010). From 1995 to 2001, neural
tube defect birth incidence was reduced by 27 %.
This is less than the predicted 50 % reduction
predicted by the initial studies. What factors
contribute to achieving only about half of the
expected benefit? The CDC noted that healthcare providers seldom (37 % of the time) advocated to reproductive-age female patients on
folate use (Oakley, 2012). The high rate of
unplanned pregnancy in the USA (50 % of pregnancies are unplanned) is undoubtedly another
contributing factor (Murphy, 2007). Nonetheless,
the current reduction of morbidity and mortality
in the USA is an example of primary prevention
of a birth defect succeeding (CDC, 2004a).
PTD: WHO Recommendations for Prevention
WHO recommendations to prevent and ameliorate PTD include three major areas: preconception health care and antenatal care, management
of preterm labor, and simple improved care of the
premature newborn. They also call for
a consistent, worldwide classification and surveillance (gathering and sharing data) of preterm
deliveries.
Prevention of Preterm Birth
• Preconception care package, including family
planning (e.g., birth spacing and adolescentfriendly services), education and nutrition
especially for girls, and STI prevention

844

• Antenatal care packages for all women,
including screening for and management of
STIs, high blood pressure, and diabetes;
behavior change for lifestyle risks; and
targeted care of women at increased risk of
preterm birth
• Provider education to promote appropriate
induction and cesarean
• Policy support including smoking cessation
and employment safeguards of pregnant
women
Management of Preterm Labor
• Tocolytics to slow down labor
• Antenatal corticosteroids
• Antibiotics for pPROM
Care of the Premature Baby
• Essential and extra newborn care, especially
feeding support
• Neonatal resuscitation
• Kangaroo mother care
• Chlorhexidine cord care
• Management of premature babies with complications, especially respiratory distress syndrome and infection
• Comprehensive neonatal intensive care,
where capacity allows
Reproduced with permission from March
of Dimes (MOD), PMNCH, Save the Children, & WHO. (2012). Born Too Soon: The
Global Action Report on Preterm Birth. In
C.P. Howson, M.V. Kinney, & L.E. Lawn
(Eds.), (pp. 6–7), Geneva, Switzerland:
World Health Organization (WHO).
In the WHO recommendations above, key
concepts and terms include:
• Adolescent-friendly care, as younger women
are less empowered to control the spacing of
their pregnancies and maintain health care
(closely spaced pregnancies are also associated with higher rates of BD).
• Prevention, screening, and treatment for
STDs, especially syphilis and HIV, as they
have devastating effects on the newborns and
the mothers’ ability to care for them.
• Healthy nutrition including micronutrient fortification (such as Vitamin C (deficiency

Prevention of Birth Defects and Preterm Delivery

possibly associated with PTD) and folate
(associated with neural tube defects which
frequently cause preterm delivery)).
• Addressing smoking (which reduces the
weight of babies, is associated with PTD, and
also causes BD).
• Addressing pollution, indoor and outdoor
(which affect the mother’s health and are associated with PTD, and many pollutants cause
BD also).
• Effective management of preterm labor
includes facility birth and home midwives
trained to care for preterm infants; medications to slow labor (tocolysis); medications to
improve premature baby lung function (corticosteroids); and antibiotics for women with
preterm, premature rupture of the membranes
(pPROM).
• Essential (warm, dry, stimulate infant, and
feeding support) care and extra care for preterm includes neonatal resuscitation.
• Kangaroo mother care is continuous skin to
skin care of preterm infant using slings or
pouches (which keep baby on mother for
warmth, prevention of dehydration, and feeding access).
• Antiseptics for umbilical cord stump care
(prevent infection of these) include
chlorhexidine.
• Then, as infrastructure allows:
• Respiratory distress syndrome (RDS) and
infection management
• Full neonatal intensive care units (NICU)
It is estimated that 75 % of the current deaths
in the most low- to middle-income countries
(sub-Saharan Africa and South Asia) could be
prevented without significant investment in
sophisticated, expensive, high-technology solutions such as used in the USA.
An important concept to understand in the
prevention of birth defects is the window of effect
during the pregnancy. Doses of a toxin or exposure might be tolerated without any effect on the
fetus if occurring after a critical vulnerable time.
Organogenesis (the forming of organ systems in
the fetus) lasts from about the third week after
conception to the ninth week. This is frequently
the most vulnerable time for the fetus and the

Prevention of Birth Defects and Preterm Delivery

time at which exposure will cause a serious
defect. For this reason, many doctors advise
patients to avoid all medications in the first trimester (first 12 weeks after last menstrual
period). Other windows of vulnerability exist
for other substances. The nervous system takes
the longest to develop in the fetus (continues fast
development after birth), and is frequently
affected by third trimester exposures (CDC,
2013; Willford, Chandler, Goldschmidt, & Day,
2010).
Similar to the window of effect in birth
defects, timing of intervention and amelioration
of risk factors for PTD (and PTL itself) is variable
and key. Thus, the successful and recently
FDA-approved progesterone treatment to prevent
PTD must be initiated around 14–16 weeks of
gestation (and definitely at least 4 weeks prior to
the earliest PTD the woman experienced) and
continued to 28–32 weeks to be effective
(American College of Obstetricians and
Gynecologists [ACOG], 2012b). Similarly,
a cerclage (a stitch holding the cervix together),
which may be an effective treatment for
women with an incompetent cervix, needs to be
placed at 14 weeks’ gestation (Cunningham et al.,
2005).
Latency (the length of time from rupture of
membranes to delivery) in pPROM can be
increased only by early initiation of therapies
(antibiotics and anti-inflammatories) (ACOG,
2007). Tocolytics are minimally effective and
may only achieve brief delays in delivery (but
there may still be an overall benefit in extreme
early PTL, by allowing a course of steroids which
hasten fetal lung maturity to be given (ACOG,
2012a).
Infections in BD and Preterm Delivery
Rubella, which causes congenital rubella
syndrome (a constellation of hearing defects,
congenital cataracts, microcephaly, miscarriage,
and infant death) has been eliminated in the USA,
as evidenced by the occurrence of only four
non-imported cases between 2005 and 2011
(McClean, Redd, Abernathy, Icenogle, &
Wallace, 2012). But in the rest of the world
(low- to middle-income countries), 100,000

845

cases per year are still occurring. Investment in
rubella vaccine programs carries the promise of
eliminating rubella worldwide, as has occurred
with smallpox (and soon will occur with polio).
Meanwhile, maintenance of immunity by
encouraging vaccination of US women *prior*
to conception (as the live-attenuated vaccine
cannot be given during pregnancy) is important
(Berger & Omer, 2010).
In contrast, congenital syphilis continues to
occur in the USA at a rate of 8.7 per 100,000
births in 2010 (about 370 cases) (CDC, 2010) and
150,000 cases yearly worldwide (arising from 1.4
million infected women in pregnancy each year).
The morbidity of congenital syphilis does not
stop at congenital infection of the fetus, but
includes causing stillbirth (250,000 per year)
and preterm delivery (65,000 per year) worldwide (WHO, 2013). Currently, efforts are ongoing to develop a syphilis vaccine, but these are
hampered by the organism’s unique life cycle and
poorly understood immunological responses in
humans (WHO).
Infections are a key player in PTD also. Both
maternal infections such as pyelonephritis
(kidney infection) and lower genital tract
infections (in certain immunological haplotype
subsets) increase the chance of PTD (Hamilton
& Tower, 2013). Infections may cause PTD by
triggering the inflammation or immune
systems in the mother. Infection of the
amniotic fluid, placental membranes (chorioamnionitis), placenta, and fetus are all associated
with PTD.
Detection of birth defects in utero allows time
for definitive action (e.g., termination in lethal
defects such as Potter’s disease, in which the
kidneys and subsequently the lungs do not
form, or anencephaly, in which the brain
does not form). In nonlethal diseases, early
detection clearly improves the infant’s outcome,
when a therapy that can be promptly
initiated exists. Examples would be early
detection of heart defects, which allows for
planning neonatal surgery, and urethral
obstruction, which allows for near normal outcomes for infants undergoing sometimes risky
fetal surgery.

846

Research in BD and PTD
Evidence-based medicine (EBM) employs the
principles of best evidence to determine the
most valuable strategy in treatment or in understanding prognosis. The strongest evidence in
therapeutic studies comes from randomized,
blinded, placebo-controlled clinical studies. Due
to a long history of infamous outcomes (such as
thalidomide and diethylstilbestrol (DES)), very
few new drug trials are currently being carried
out in populations of pregnant women. Prognosis
studies involve case-matched control studies,
whether prospective or retrospective. Data from
very large cross-sectional studies are also used
(Bermejo-Sanchez et al., 2011).
Randomized controlled trials (RTC) are sorely
needed for therapies of PTD. Screening tools
need to be developed and validated for the identification of highest risk individuals. And basic
research into the etiologies and pathophysiology
of both PTD and normal labor (especially initiation of labor) needs to be carried out to fully
advance and prevent and ameliorate the majority
of PTD.

Strategies That Work
The best-studied intervention to prevent
a specific birth defect is the provision of folic
acid to pregnant women to prevent neural tube
defects. Multiple studies (with, unfortunately,
different dosing regimens) were carried out in
several countries in the 1980s and 1990s. Both
primary (new, spontaneous neural tube defects)
and secondary (prevention in mothers with an
affected previous child) preventions were studied. Randomized controlled studies showed
a 72 % reduction in the rate of neural tube defects
when women received at least 400 micrograms of
folate per day. These strong results led the USA
to recommend 400 micrograms of folate per day
in an average-risk pregnancy and 4 mg/day for
women at high risk (or with prior history of an
affected infant.) In 1996, the US Food and Drug
Administration (FDA) mandated the supplementation of cereals and grains throughout the USA

Prevention of Birth Defects and Preterm Delivery

with a goal of increasing by approximately 50 %
the daily intake of folate among all reproductiveage women in the USA to 400 micrograms a day.
A classic study showed a 19 % decrease in liveborn infants with neural tube defects (Honein
et al., 2001).
Substances
Surely the avoidance of substances known to
cause birth defects is an obvious strategy. Yet
a bewildering array of substances and exposures
have been linked to congenital defects. Substance
use is a highly complex behavior both more
entrenched and less amenable to treatment than
once previously thought. Entire volumes can be
written on the risks of defects caused by medicinal and other compounds. The most frequent substances and preventable defects and diseases will
be addressed.
Alcohol
Maternal alcohol intake in pregnancy causes
a group of defects known as fetal alcohol
syndrome (FAS) and fetal alcohol spectrum disorders (FASD, in which a subset of FAS features
are present) in the offspring involving facial and
musculoskeletal defects, growth defects, and
mental retardation of varying degrees. There is
a strong dose response, with increasing defects
with increasing alcohol intake (Keelean,
Pierpont, Wiley, & McGinty, 2004). Cessation
of drinking at any point will improve the outcome
(indicating the window of risk extends through
the later parts of pregnancy). Fully 70 % of
Americans drink some alcohol. Some recent
studies indicate that continued drinking occurs
in at least 1.4 % of pregnancies. Over the last
decades, the incidence of FASD has increased
to six births in each 10,000. FAS and FASD are
the most commonly identified specific cause of
mental retardation in the USA (Cunningham
et al., 1997). Progress in the past decade has
emphasized recognizing binge drinking as an
important cause of FAS/FASD and redefining
binge drinking for women as four drinks and
more per binge (CDC, 2013).
Widespread education campaigns and warnings on packages have increased awareness of

Prevention of Birth Defects and Preterm Delivery

alcohol’s deleterious effects and also the stigma
of drinking while pregnant. It is hoped that specific repeated screening in each trimester of pregnancy will aid in identifying problem pregnant
drinkers.
Tobacco
As many as 18 % of pregnant women smoke
(Morrison, 2000). Recent large studies have demonstrated that fetuses of smokers are at increased
risk for placental abruption (early separation of
the placenta, often with life-threatening
hemorrhage), placenta previa (placenta covering
the exit from the uterus), preterm birth, low
birth weight, preeclampsia (hypertension caused
by pregnancy), developmental delay, sudden
infant death syndrome (SIDS), asthma and
poor lung function, and congenital anomalies
such as neural tube defect, cleft palate, and
cleft lip.
While cigarettes are very addicting, more so
for women, pregnancy is a window of opportunity for cessation. Often women can delay, cut
down, or eliminate use with the benefit for their
child as a goal. Counseling should include support strategies, review of facts about quitting
(such as that the vast majority of successful quitters had to quit more than once or twice), and
consideration of medication. Nicotine causes
withdrawal syndromes in infants (has vasoactive
effects) and is contraindicated. Bupropion
(Wellbutrin ®, Zyban ®) is an effective antidepressant which reduces craving and is acceptable in
pregnancy.
Other Substances of Abuse
Many substances are abused, but few are proven,
in and of themselves, to cause significant birth
defects. Cocaine, for example, has been widely
studied and deeply feared for potentially causing
neurological and development delays. Use of
cocaine is associated with preterm delivery,
abruption, and preeclampsia. However, no studies have yet identified a long-lasting or permanent ill effect to the infant or increased incidence
of birth defects. The “shaking, withdrawing crack
baby” is more frequently withdrawing from
nicotine.

847

The true issues to address are complex biological, social, and political factors leading to an
overall unhealthy environment for pregnant
women. This malignant milieu includes
polysubstance abuse, poor self-esteem, domestic
violence, poor nutrition, limitations on access to
health care, and inability to control the outside
environment of the pregnancy (e.g., inability to
undertake work with fewer exposures, or to live
further from polluted areas, or to space pregnancies appropriately).

Strategies That Might Work (What Is
Promising)
Preconception Counseling
Advance preparation with guidance carries hope
for preventing many birth defects. Identifying
risk factors facing potential parents, and beginning prevention efforts before conception, may
offer great potential for optimizing outcomes.
However, there are no definitive studies to support this concept overall.
Identification of patients with a high risk of
preterm delivery similarly carries hope for continuing to lower the rates of preterm birth in the
USA (Martin, Osterman, & Sutton, 2010). These
rates have slightly decreased in recent years,
including very modest decreases for the past
5 years – to a rate of 11.7, the lowest since 2000
(National Center for Health Statistics & Final
Datality Data, 2012).
Nutritional Supplementation Prevents BD
The best-supported preconception intervention
(or support) to prevent BD is folic acid supplementation. Some evidence supports the use of
multivitamin (prenatal vitamins) to help prevent
defects such as cleft palate.
Immunizations
Immunizations carry significant promise for preconception prevention. Many illnesses, such as
rubella, can cause defects, stillbirth, or loss.
Because immunization for rubella is inexpensive
and can prevent severe defects, it is very costeffective. However, since the vaccine

848

(an attenuated live vaccine) cannot be given during pregnancy, preconception counseling is the
only option (usually, in fact, immediately after
the pregnancy in which lack of immunization was
noted) (Morrison, 2000).
Other significant infections such as STDs
(sexually transmitted diseases), especially syphilis, which causes severe congenital defects, are
tracked by state health departments. Adequate
preconception or early pregnancy treatment is
essential. Varicella zoster (chicken pox), herpes,
toxoplasmosis, measles, and mumps are other
examples (Klebanoff & Keim, 2011).
Paternal Effects/Factors
Birth defects can also stem from the paternal
genetic contribution, and some opportunities for
prevention exist. Data are incomplete but indicate
certain paternal occupation exposure (agricultural, chemical- and heavy metal-exposed occupations), environmental factors, and personal
history or lifestyle factors such as a history of
needing anticancer agents, paternal diabetes, or
smoking (Garry et al., 2002) may put the fetus
at risk.
Older paternal age is also associated with
increased PTD, and, in India, increased paternal
education is associated with reduced PTD
(Shaikh et al., 2011).
It is easy to connect the presence of a chemical
in the fetus’ direct environment to a defect in the
child when a clear-cut mechanism of transport
across the placenta from the maternal circulation
exists. It is harder to understand possible paternal
mechanisms. The most obvious and easy-toaccept mechanism is direct damage to the gamete
(sperm) which fertilizes the egg. This mechanism
is known to transmit birth defects in the case of
radiation exposure and possibly thalidomide
(thalidomide binds to sperm). The damage done
can be either genetic (direct damage to the DNA
molecule in the sperm) or epigenetic (alterations
to the “support” atoms in the DNA, such as methylation (addition of carbon molecules) changes to
sperm DNA).
Other possible mechanisms include the transfer of molecules from the male to the female in
seminal fluid during intercourse. These

Prevention of Birth Defects and Preterm Delivery

chemicals, once inside the body, affect the fetus
or mother directly. Another indirect source of
genetic damage is substances brought into the
home on the father’s clothing. Heavy metals
have been shown to be transported this way.
When clothing is handled or washed, the mother
receives an exposure. Mercury, lead, and beryllium exposures have occurred this way (Olshan &
Faustman, 1993). More studies are needed to
fully identify these risks and to develop prevention strategies.
Some chronic diseases of later life involve not
only a genetic predisposition but also a long,
subclinical period in infancy and childhood, during which environmental changes are crucial.
Adequate prevention will no doubt improve
length and quality of life more than current
advances in medication or surgery. Pregnancy is
an opportunity to create a better home environment for the child through smoking cessation,
reduction of fat in the diet, and decreased alcohol
consumption. Currently 80 % of children in the
USA exceed dietary recommendations for fat
intake. Likewise, reducing tobacco and alcohol
use in parents may reduce the prevalence of these
habits in adolescents (currently 1/3 are habitual
users) (Harris, 2000).

Strategies That Do Not Work
Medications in Pregnancy
Disastrous consequences have arisen whenever
the balance of risk to benefit has not been carefully considered in treating pregnant women with
medication. For example, in mammals, progesterone (the major steroid of pregnancy) is essential for maintaining the pregnancy. Doctors and
researchers extrapolated from this and used DES
(diethylstilbestrol), a synthetic progesterone with
a significantly different structure than natural
progesterone which was also active as an estrogen, to combat repetitive miscarriage in humans.
The children from these exposed pregnancies
suffered deformations of the uterus and cervix,
infertility, and a rare form of cancer (clear cell
adenocarcinoma of the vagina). Some secondgeneration effects (in the grandchildren of the

Prevention of Birth Defects and Preterm Delivery

DES-treated women) are now noted, such as prematurity and hypospadias (a defect of the urethra
in males).
In the case of thalidomide, the fallacy was
presuming a drug could be devoid of risks. The
medication was widely believed to lack side
effects, even though studies of effects were
poorly done and very incomplete. When taken
during organogenesis, the medication caused
shortening and absence of the limbs of the child
(phocomelia).
It is important to remember, however, that
severe consequences can result in the fetus
when maternal disease is allowed to progress
unchecked (Mølgaard-Nielsen & Hviid, 2011).
Fear of exposure leads many women with severe
depression or seizure disorders to stop their medications. But uncontrolled mental illness may
incapacitate the mother, result in suicide
(or homicide by her of her children), or simply
prevent adequate mothering of the child, leading
to failure of the infant to thrive. Similarly,
uncontrolled seizures in pregnant women may
result in prolonged oxygen deprivation of the
fetus and severe neurological and developmental
problems. Each patient and each drug must
be considered for the complete benefit-risk
relationship before continuing or stopping
medications.
Infant Support
For PTD, through the bulk of the twentieth
century, improvement in preterm neonatal
survival advanced based on ever-improving
infant resuscitation and support techniques and
technologies, such as incubators, culminating in
the astonishing impairment-free survival of
28-week infants today. However, experts feel
the threshold of viability has been reached, as
revealed in the fact that no further improvement
has been achieved for survival and disability risk
for 22-, 23-, and 24-week infants since 1993
(20 years). The conclusion is that further
increases in survival rates must await improved
basic understanding of risk factors, etiologies,
and physiology which will frame rational and
ethical approaches for intervention and prevention (Cunningham et al., 2005).

849

Synthesis
Historically, the concept of improving genetic
outcomes was limited by the level of intervention
possible. This leads to ethically unacceptable
actions such as eugenics in Germany, sterilization of non-consenting adults in the USA, and
laws concerning miscegenation elsewhere
(Fineman & Walton, 2000). In response, genetic
health-care professionals have practiced two
tenets: (1) never to attempt to influence the outcome of a pregnancy and (2) always to use nondirective counseling techniques. Meanwhile,
advances in medical science have allowed
options other than abortion to prevent the birth
of babies with congenital defects and to significantly improve the quality of life and decrease
morbidity for infants born with a genetic defect.
Indeed, the public health credo mandates
certain interventions such as preventing
isoimmunization of future pregnancies by administering RhoGAM to Rh-negative mothers in
pregnancy.
The core ethical principles of autonomy
(respect for a person’s control over his or her
own body) and beneficence (the health-care professional’s obligation to provide benefit and balance risk versus benefit for patients) come into
play in these sorts of decisions. In addition, physicians have an obligation to the health of communities and populations. There are signs that
genetic health-care professionals are moving to
consider some of the public health-care precepts
and to adopt more directive counseling techniques (Fineman & Walton, 2000).
Currently the continued expansion of genomics (and proteomics) and the ever-increasing
complexity of and sophistication needed to arrive
at rational decisions about birth defects and prematurity risks complicate assisting patients to
make decisions. Some indications exist that nondirective counseling in proponent countries may
in effect be directive due to many factors, not
least of which is this need for simplification
(McCabe & McCabe, 2011; Toth, Nyari, &
Szabo, 2008). Thus, differences continue to
occur among countries in the results of counseling: the UK and some European countries have

850

seen a drop in the actual population of individuals
with Down syndrome (and a very high rate of
termination of pregnancy upon diagnosis of
Down syndrome), but the USA has not (Cocchi
et al., 2010). While terminations for Down syndrome have risen, the fact that a significant
minority of women decline all counseling and
that more frequently US women and families
facing the diagnosis choose to proceed with the
pregnancies has resulted in a stable to slightly
increased Down population.
This variation of practice and result has led
some to sound an alarm of genetic discrimination
(Dixon, 2008; Smith & Irvine, 2009). Given that
Down syndrome has an extremely variable
presentation (ranging from a need for extremely
intensive care and early death without ever
achieving independent function to a normalspan life with complete independence and
significant contribution to society) and that
Down syndrome may hold the keys to our eventual
full understanding of Alzheimer’s and the inner
workings of intelligence, it seems short sighted
to conclude that nondirective counseling has
been achieved or perhaps is even the most ethical
path. (Costa, Scott-McKean, & Stasko, n.d.;
Einfeld & Brown, 2010). Also, Down syndrome
is but the tip of the iceberg, with over 8,000 genetic
causes of BD identified, and the cost of individual
genotyping halving each 4–6 months.
Meanwhile, the excruciating decisions parents
of extremely preterm infants face daily in highincome countries and the utter hopelessness and
inequality parents of moderately preterm babies
in low- to middle-income countries cope with
(when the mere chance of their location dictates
the survival of their child) must be averted where
possible and compassionately and rationally
eased where avoidance is impossible.
The ongoing efforts of global and local entities
such as WHO, MOD, and CDC should be
supported and applauded, while efforts continue
worldwide in research, surveillance, and political
and ethical discourse to better discern the best,
equitable, just, and right course of action for all.
It is heartening to see discernment on these
issues has proceeded this past decade but clear
also that the road stretches out before us still.

Prevention of Birth Defects and Preterm Delivery

References
Agha, M. M., Glazier, R. H., Moineddin, R., Moore, A. M.,
& Guttmann, A. (2011). Socioeconomic status and
prevalence of congenital heart defects: Does universal
access to health care system eliminate the gap? Birth
Defects Research (Part A), 91, 1011–1018.
doi:10.1002/bdra.22857.
American College of Obstetricians and Gynecologists
[ACOG]. (2007). Premature rupture of the membranes. Practice bulletin no. 80. American College of
Obstetricians and Gynecologists. Obstetrics & Gynecology, 109, 1007–1009.
American College of Obstetricians and Gynecologists
[ACOG]. (2012a). Management of preterm labor.
Practice bulletin no. 127. American College of Obstetricians and Gynecologists. Obstetrics & Gynecology,
119, 1308–1317.
American College of Obstetricians and Gynecologists
[ACOG]. (2012b). Prediction and prevention of preterm birth. Practice bulletin no. 130 American College
of Obstetricians and Gynecologists. Obstetrics &
Gynecology, 120, 964–973.
Bale, J. R., Stoll, B. J., & Lucas, A. O. (2003). Reducing
birth defects: Meeting the challenge in the developing
world. Washington, DC: National Academies Press.
Berger, B. E., & Omer, S. B. (2010). Could the United
States experience rubella outbreaks as a result of vaccine refusal and disease importation? Human Vaccines,
6(12), 1016–1020. doi:10.4161/hv.6.12.13398.
Bermejo-Sanchez, E., Cuevas, L., Amar, E., Bianca, S.,
Bianchi, F., Botto, L. D., et al. (2011). Phocomelia:
A worldwide descriptive epidemiologic study in
a large series of cases from the International Clearinghouse for Birth Defects Surveillance and Research,
and overview of the literature. American Journal of
Medical Genetics Part C, 157, 305–320.
Botto, L. D., Khoury, M. J., Mulinare, J., & Erickson, J. D.
(1996). Periconceptual multivitamin use and the
occurrence of conotruncal heart defects: Results from
a population-based, case-control study. Pediatrics,
98(5), 911–917.
Boyle, C. A., & Cordero, J. F. (2005). Birth defects and
disabilities a public health issue for the 21st century –
Editorial. American Journal of Public Health, 95(11),
1884–1886.
Brent, R. L. (2011). The role of the pediatrician in
preventing congenital malformations. Pediatrics
in Review, 32(10), 411–423. doi:10.1542/pir.32-10411.
Callaghan, W. M., MacDorman, M. F., Rasmussen, S. A.,
Qin, C., & Lackritz, E. M. (2006). The contribution of
preterm birth to infant mortality rates in the United
States. Pediatrics, 118, 1566–1573. doi:10.1542/
peds.2006-0860.
Carmichael, S. L., Yang, W., Feldkamp, M. L.,
Munger, R. G., Siega-Riz, A. M., Botto, L. D.,
et al. (2012). Reduced risks of neural tube defects
and orofacial clefts with higher diet quality. Archives

Prevention of Birth Defects and Preterm Delivery
of Pediatric and Adolescent Medicine, 160(2),
121–126. doi:10.1001/archpediatrics.2011.185.
Centers for Disease Control and Prevention [CDC].
(2004a). Spina bifida and anencephaly before and
after folic acid mandate – United States, 1995–1996
and 1999–2000. Morbidity and Mortality Weekly
Report, 53(17), 362–365.
Centers for Disease Control and Prevention [CDC].
(2004b). Economic costs associated with mental retardation, cerebral palsy, hearing loss and vision impairment – US 2003. Morbidity and Mortality Weekly
Report, 53(03), 57–59.
Centers for Disease Control and Prevention [CDC].
(2010). 2010 Sexually transmitted diseases surveillance. Table 1, Cases of sexually transmitted diseases
reported by state health departments and rates per
100,000 population, United States, 1941–2010.
Retrieved May 25, 2013, from http://www.cdc.gov/
std/stats10/tables/1.htm
Centers for Disease Control and Prevention [CDC].
(2011). Causes and risk factors of cerebral palsy.
Retrieved May 25, 2013, from http://www.cdc.gov/
ncbddd/cp/causes.html
Centers for Disease Control and Prevention [CDC].
(2012). Fact sheet. Cerebral palsy among children.
Retrieved May 28, 2013, from http://www.cdc.gov/
ncbddd/fact/cpfs.htm
Centers for Disease Control and Prevention [CDC].
(2013). Fetal Alcohol Spectrum Disorders (FASD)
homepage – Data and statistics. Retrieved November
26, 2012, from http://www.cdc.gov/ncbddd/fasd/data.
html
Christianson, A., Howson, C. P., & Modell, B. M. (2006).
March of dimes global report on birth defects: The
hidden toll of dying and disabled children, (Executive
summary) (pp. 6–7). White Plains, NY: March of
Dimes Birth Defects Foundation.
Cocchi, G., Gualdi, S., Bower, C., Jonsson, B., Myrelid, A.,
Mastroiacovo, P., et al. (2010). International trends of
Down syndrome 1993–2004: Births in relation to maternal age and terminations of pregnancies. Birth Defects
Research (Part A), 88, 474–479. doi:10.1002/
bdra.20666.
Copeland, G. E., & Kirby, R. S. (2007). Using birth
defects registry data to evaluate infant and childhood
mortality associated with birth defects: An alternative
to traditional mortality assessment using underlying
cause of death statistics. Birth Defects Research
(Part A), 79, 792–797.
Correa, A., Gilboa, S. M., Botto, L. D., Moore, C. A.,
Hobbs, C. A., Cleves, M. A., et al. (2012). Lack of
periconceptional vitamins or supplements that contain
folic acid and diabetes mellitus–associated birth defects.
American Obstetrics & Gynecology, 2006(218), e1–
e13. doi:10.1016/j.ajog.2011.12.018.
Costa, A. C., Scott-McKean, J. J., & Stasko, M. R. (n.d.).
Acute injections of the NMDA receptor antagonist
memantine rescue performance deficits of the
Ts65Dn mouse model of Down syndrome on a fear

851
conditioning test. Neuropsychopharmacology, 33,
1624–1632. doi:10.1038/sj.npp.1301535
Cunningham, F., Leveno, K., Bloom, S., Hauth, J.,
Gilstrap, L., & Wenstrom, K. (2005). Preterm birth.
In Williams obstetrics (22nd ed., pp. 855–880). New
York: McGraw-Hill Professional.
Cunningham, G. F., MacDonald, P. C., Gant, N. F.,
Leveno, K. J., Gilstrap, L. C., III, Hankins, G. D. V.,
et al. (1997). From the chapters on teratology, birth
defects and preterm birth. In Williams obstetrics
(20th ed., pp. 895, 958–959). Stamford, CT: Appleton
and Lange.
Davis, E. M., Peck, J. D., Thompson, D., Wild, R. A., &
Langlois, P. (2010). Maternal diabetes and renal agenesis/dysgenesis. Birth Defects Research (Part A), 88,
722–727. doi:10.1002/bdra.20702.
Dixon, D. P. (2008). Informed consent or institutionalized
eugenics? How the medical profession encourages
abortion of fetuses with Down syndrome. Issues in
Law & Medicine, 24(1), 1–59.
Einfeld, S. L., & Brown, R. (2010). Down syndrome –
New prospects for an ancient disorder (commentary).
Journal of the American Medical Association,
303(24), 2525–2526.
Fineman, R. M., & Walton, M. T. (2000). Should genetic
health care providers attempt to influence reproductive
outcome using directive counseling techniques?
A public health prospective. Women & Health,
303(3), 39–46.
Garry, V. F., Harkins, M. F., Erickson, L. L., LongSimpson, L. K., Holland, S. E., & Burroughs, B. L.
(2002). Birth defects, season of conception, and sex of
children born to pesticide applicators living in the Red
River Valley of Minnesota, USA. Environmental
Health Perspectives, 110(Suppl. 3), 441–449.
Goldenberg, R. L., Culhane, J. F., Iams, J. D., & Romero, R.
(2008). Epidemiology and causes of preterm birth. Lancet, 371(9606), 75–84. doi:10.1016/S0140-6736(08)
60074-4.
Hamilton, S. A., & Tower, C. L. (2013). Management of
preterm labour. Obstetrics, Gynaecology and Reproductive Medicine, 23(4), 114–120.
Harris, G. D. (2000). Heart disease in children. Primary
Care, 27(3), 767–784.
Heron, M., Hoyert, D. L., Murphy, S. L., Xu, J.,
Kochanek, K. D., & Tejada-Vera, B., et al. (2009).
Deaths: Final data for 2006. National vital statistics
reports. (Vol. 57, no 14). Hyattsville, MD: National
Center for Health Statistics.
Honein, M. A., Paulozzi, L. J., Mathews, T. J., Erickson,
J. D., & Lee-Yang, C. W. (2001). Impact of folic acid
fortification of the US food supply on the occurrence of
neural tube defects. Journal of the American Medical
Association, 285(23), 2981–2986.
Keelean, D. B., Pierpont, J. H., Wiley, J., & McGinty,
K. (2004). Birth defects. In L. A. Rapp-Paglicci, C. N.
Dulmus, & J. S. Wodarski (Eds.), Handbook of preventive interventions for children and adolescents
(pp. 133–135). Hoboken, NJ: Wiley.

852
Klebanoff, M. A., & Keim, S. A. (2011). Epidemiology: The
changing face of preterm birth. Clinics of Perinatology,
38(2011), 339–350. doi:10.1016/j.clp.2011.06.006.
Lewis, D. P., Van Dyke, D. C., Stumbo, P. J., & Berg, M. J.
(1998). Drug and environmental factors associated
with adverse pregnancy outcomes part I: Antiepileptic
drugs, contraceptives, smoking, and folate. The Annals
of Pharmacotherapy, 32, 802–817.
March of Dimes (MOD), PMNCH, Save the Children, &
WHO. (2012). In C. P. Howson, M. V. Kinney, & L. E.
Lawn (Eds.), Born too soon: The global action report
on preterm birth (pp. 1–7). Geneva, Switzerland:
World Health Organization (WHO).
Martin, J. A., Osterman, M. J. K., & Sutton, P. D. (2010).
Are preterm births on the decline in the United States?
Recent data from the National Vital Statistics System.
NCHS data brief no. 39. Hyattsville, MD: National
Center for Health Statistics.
McCabe, L. L., & McCabe, E. R. B. (2011). Down
syndrome: Coercion and eugenics (commentary).
Genetics in Medicine, 13(8), 708–710.
McClean, H., Redd, S., Abernathy, E., Icenogle, J., &
Wallace, G. (2012). Chapter 15: Congenital rubella
syndrome. In Manual for surveillance of vaccine preventable disease (VPD) (5th ed., 2008-current).
Atlanta, GA: Centers for Disease Control and Prevention. Retrieved June 14, 2013, from http://www.cdc.
gov/vaccines/pubs/surv-manual/
Mølgaard-Nielsen, D., & Hviid, A. (2011). Newergeneration antiepileptic drugs and the risk of major
birth defects. Journal of the American Medical Association, 305(19), 1996–2002.
Morrison, E. H. (2000). Periconception care. Primary
Care, 27(1), 1–12.
Murphy, J. P. (2007). Epidemiology and environmental
factors in preterm labour. Best Practice & Research
Clinical Obstetrics and Gynaecology, 21(5), 773–789.
doi:10.1016/j.bpobgyn.2007.03.001.
National Center for Health Statistics, Final Datality Data.
(2012). Table: Percent of live births in U.S. Which are
preterm 2000–2010. Retrieved June7, 2013, from
www.marchofdimes.com/peristats
Oakley, G. P., Jr. (2012). Failing to prevent birth defects
caused by maternal diabetes mellitus (editorial). American Journal of Obstetrics and Gynecology, 206,
179–180. doi:10.1016/j.ajog.2011.12.019.
Offiah, I., O’Donoghue, K., & Kenny, L. (2012).Clinical
risk factors for preterm birth. In J. Morrison (Ed.),
Preterm birth – mother and child (Chapter 3,
pp. 74–94). ISBN: 978-953-307-828-1, In Tech.
Retrieved from http://www.intechopen.com/books/
preterm-birth-mother-and-child/clinical-risk-factorsfor-preterm-birthdoi:10.5772/27439
Olshan, A. F., & Faustman, E. M. (1993). Male mediated
developmental toxicity. Annual Review of Public
Health, 14, 159–181.
Parker, S. E., Mai, C. T., Canfield, M. A., Rickard, R.,
Wang, Y., Meyer, R. E., et al. (2010). Updated national
birth prevalence estimates for selected birth defects in

Prevention of Birth Defects and Preterm Delivery
the United States, 2004–2006. Birth Defects Research
(Part A), 88, 1008–1016. doi:10.1002/bdra.20735.
Plunkett, J., Doniger, S., Orabona, G., Morgan, T.,
Haataja, R., Hallman, M., et al. (2011). An evolutionary genomic approach to identify genes involved in
human birth timing. PLoS Genetics, 7(4), e1001365.
doi:10.1371/journal.pgen.1001365.
Shaikh, K., Premji, S. S., Rose, M. S., Kazi, A., Khowaja,
S., & Tough, S. (2011, November). The association
between parity, infant gender, higher level of
paternal education and preterm birth in Pakistan:
A cohort study. BMC (Bio Med Central) Pregnancy
and Childbirth, 11, 88, 1–10. doi: 10.1186/1471-239311-88
Smith, R., & Irvine, C. (2009, October 26). Three babies
aborted every day due to Down’s syndrome. The Daily
Telegraph/The
Sunday
Telegraph.
London,
UK. Retrieved December 3, 2012, from www.telegraph.co.uk/
Stothard, K. J., Tennant, P. W., Bell, R., & Rankin, J.
(2009). Maternal overweight and obesity and the risk
of congenital anomalies a systematic review and metaanalysis. Journal of the American Medical Association, 301(6), 636–650.
Strandberg-Larsen, K., Skrubbeltrang Skov-Ettrup, L.,
Grønbæk, M., Nybo Andersen, A.-M., Olsen, J., &
Tolstrup, J. (2011). Maternal alcohol drinking pattern
during pregnancy and the risk for an offspring with an
isolated congenital heart defect and in particular
a ventricular septal defect or an atrial septal defect.
Birth Defects Research (Part A), 91, 616–622.
doi:10.1002/bdra.20818.
Toth, A., Nyari, T., & Szabo, J. (2008). Changing views on
the goal of reproductive genetic counselling in Hungary. European Journal of Obstetrics & Gynecology
and Reproductive Biology, 137, 3–9. doi:10.1016/j.
ejogrb.2007.10.003.
Tsai, H.-J., Yu, Y., Zhang, S., Pearson, C., Ortiz, K., Xu,
X., et al. (2009). Association of genetic ancestry with
preterm delivery and related traits among African
American mothers. American Journal of Obstetrics
and Gynecology, 201, e1–e10. doi:10.1016/j.
ajog.2009.02.027.
U.S. Agency for Healthcare Research and Quality
[AHRQ]. (2007, January). HCUP statistical brief:
Vol. 24. Hospitalizations for birth defects, 2004
(Issue Brief No. 24). In C. A. Russo & A. Elixhauser
(Authors). Healthcare cost and utilization project,
(pp. 1–9). Rockville, MD: U.S. Agency for Healthcare
Research and Quality.
Weinhold, B. (2009). Environmental factors in birth
defects: What we need to know. Environmental Health
Perspectives, 117(10), A440–A447.
Willford, J. A., Chandler, L. S., Goldschmidt, L., & Day,
N. L. (2010). Effects of prenatal tobacco, alcohol and
marijuana exposure on processing speed, visual–motor
coordination,
and
interhemispheric
transfer.
Neurotoxicology and Teratology, 32, 580–588.
doi:10.1016/j.ntt.2010.06.004.

Prevention of Birth Defects and Preterm Delivery
World Health Organization. (2012a). Media centre: Congenital anomalies. Fact sheet no. 370. Retrieved May,
25, 2013, from http://www.who.int/mediacentre/
factsheets/fs370/En/
World Health Organization. (2012b). Media centre: Preterm birth. Fact sheet no. 363. Retrieved May,
25, 2013, from http://www.who.int/mediacentre/
factsheets/fs363/en/

853
World Health Organization. (2013). Over a million pregnant women infected with syphilis. WHO
website
(2013):
Sexual
and
reproductive
health>Topics>Sexually transmitted and reproductive tract infections>Eliminating congenital syphilis
worldwide. Retrieved May, 26, 2013, from http://
www.who.int/reproductivehealth/topics/rtis/syphilis/
pregnancy/en/index.html

854

Promoting the Healthy Development of Children Whose Parents Are Alcoholic/Drug Dependent

Promoting the Healthy
Development of Children Whose
Parents Are Alcoholic/Drug
Dependent
Laura Jacobus-Kantor1, James G. Emshoff2 and
Jeannette Johnson3
1
Substance Abuse and Mental Health Services
Administration (SAMHSA), Rockville,
MD, USA
2
Department of Psychology, Georgia State
University, Atlanta, GA, USA
3
Columbia, MD, USA

Introduction
Nature of the Problem
Children of alcoholics and other substanceabusing parents (COSAPs) are considered to be
at high risk because there is a greater likelihood
that they will develop alcoholism or substance
abuse, as well as a range of other psychosocial
problems. COSAPs are especially vulnerable to
the risk for maladaptive behavior because they
tend to have multiple risk factors present in their
lives. One of the most potent risk factors is
their parent’s substance-abusing behavior.
This single risk factor can place children of
substance abusers at biological, psychological,
and environmental risk. Taken as a whole,
research reports that children of alcoholics and
other substance abusers are at risk for a variety
of cognitive, psychological, biological, and
neuropsychological deficits. Not surprisingly,
the findings of these diverse studies are
inconsistent; thus, a unified concept of risk for
alcoholism or substance abuse has not yet
emerged.

Definitions and Scope
Definition of Unfamiliar Critical Terms
The term “children of alcoholics” (COAs) was
established earlier in the literature and is perhaps
best recognized by researchers and practitioners.

Although research has suggested that children are
impacted differently by exposure to different
substances, there are more similarities than
differences. Thus, we will refer to the more
generic term of children of substance-abusing
parents.
Scale of the Problem in the USA
Approximately 9 % of US adults, or 20 million
people, meet the diagnostic criteria for alcohol or
illicit drug abuse or dependence (Substance
Abuse and Mental Health Services Administration, 2009). Estimates also suggest that one in
four children is exposed to alcohol abuse or
dependence in their family (Grant, 2000). There
are roughly 74 million children under the age of
18 currently living in the USA, which suggests
that approximately 18 million US children have
been exposed to alcohol in their family.
Conflicting estimates from data derived from
the 2002–2007 National Household Survey on
Drug Abuse reveal that an estimated 8.3 million
children in the USA, or 12 % of all children in
the USA, live in households in which at least
one parent is either alcoholic or in need of
substance-abuse treatment. Approximately 7.3
million of these children live in families in
which a parent abuses or is dependent on alcohol,
and 2.1 million live with a parent who abuses or is
dependent on illicit drugs. The children living in
substance-abusing households are spread across
the age spectrum, with 14 % of children under the
age of three living with an affected parent and
10 % of children ages 12–17 (Substance Abuse
and Mental Health Services Administration,
2009).
Substance abuse is a major public health problem that affects millions of people and places
enormous financial and social burdens on society.
It destroys families, damages the economy, victimizes communities, and places extraordinary
demands on the education, criminal justice,
and social service systems. Estimates suggest
that alcohol alone costs society 185 billion
dollars per year in 1998 and that illicit drug
use costs were in excess of 161 billion dollars
in 2000 (Office of National Drug Control
Policy, 2001).

T.P. Gullotta, M. Bloom (eds.), Encyclopedia of Primary Prevention and Health Promotion,
DOI 10.1007/978-1-4614-5999-6, # Springer Science+Business Media New York 2014

Promoting the Healthy Development of Children Whose Parents Are Alcoholic/Drug Dependent

Theories
What Significant Theory and Research
Studies Pertain to This Topic?
Risk Theory. Risk and protective theory states
that a person’s probability of engaging in substance abuse is predictable from the combination
of risk and protective factors she/he is exposed
to. Longitudinal research has identified a number
of risk and protective factors that are associated
with adolescent and young adult substance use
(Arthur, Hawkins, Pollard, Catalano, & Baglioni,
2002; Hawkins, Catalano, & Miller, 1992). These
factors exist across multiple levels: peer/individual, family, community, and school. One of the
most potent and consistent risk factors for child
and adolescent drug use is parental substance
abuse (see Thatcher & Clark, 2008, for a brief
review of the pathways through which these risk
factors may operate). The literature on children of
alcoholics far outweighs the literature on children
of other drug abusers (Thatcher & Clark). Significantly less is known about children of heroin
addicts, cocaine abusers, or polydrug abusers.
Many researchers, nonetheless, suggest that the children of addicted parents are at greater risk for later
dysfunctional behaviors and that they, too, deserve
significant attention to prevent intergenerational
transmission of drug abuser later in life.
Children of substance-abusing parents are at
great risk for behavioral problems and physiological damage when exposed in utero to their mother’s
drug addiction. Some of these problems may last
well through maturation, although we currently
lack the necessary longitudinal data allowing any
firm conclusions about the long-term effects of
parental substance abuse. Even if children are not
exposed to chemicals in utero, they are at greater
risk for childhood behavioral problems if their
parents are involved in the drug culture.
In 1974, Anthony (1974) discussed the possibility that there were different groups of children
of substance abusers and that all children of substance abusers could not be considered a single,
unitary entity. Similar experiences affect children
differently due to individual differences in things
such as temperament, intelligence, and environmental resources – these act as additional risk

855

and/or protective factors. Given these differences, there is most likely no single profile of
children of substance abusers.
Resilience Theory. Most important among the
varied outcomes observed among COSAPs, there
are subgroups of children of substance abusers
who, despite all odds, enjoy good health from
birth, experience a positive environment at
home, and develop normally into socialized,
competent, and self-confident individuals. Certain individuals, often referred to as “resilient,”
may be more competent in adapting to stressful
living environments than others (see Kumpfer &
Summerhays, 2006, for a review of resilience
theory as it applies to COAs). Such a child is
able to compensate and cope with the various
negative biological or environmental influences
in his/her life. These individuals may be able to
manipulate their environment by choosing roles
and goals in life that stabilize their developmental
process and bring them the positive reinforcement
they need to develop a positive self-image and
eventually a relatively healthy life. Other individuals may be able to master the environment and to
conceptualize the environment in such a way so
as to choose positive behaviors that compensate
for whatever problems are present. Research
examining resilience in COSAPs has identified
that resilience is associated with a variety of different factors that stretch across individual-,
family-, and community-level domains (Skinner,
Haggerty, Fleming, & Catalano, 2009).
Research on Heritability. Reviews of the
literature on children of substance-abusing
parents (Johnson & Leff, 1999) have typically
categorized the research into four basic groups
of studies. The first group emphasizes the heritability of alcoholism. A recent review of family,
adoption, and twin studies concluded that there
are moderate to high genetic influences on addiction to a variety of substances (Agrawal &
Lynskey, 2008). In one early adoption study,
Goodwin, Schulsinger, Hermansen, Guze, and
Winokur (1973) compared rates of problems in
a group of male children of birth parents who fit
the criteria for alcohol dependence and another
group of children whose birth parents had no
alcohol problems. Results suggested that the

856

Promoting the Healthy Development of Children Whose Parents Are Alcoholic/Drug Dependent

adopted children with a genetic history of alcoholism had significantly higher rates of psychiatric treatment (15 % vs. 3 %) and alcoholism
(18 % vs. 5 %) than adopted children without
the genetic history. Goodwin (1985) also reported
that the prevalence of alcoholism among both
male (25 %) and female (5–10 %) relatives of
alcoholics exceeds the estimated population
prevalence for alcoholics which are 3–5 % for
men and up to 3 % for women. The pathway by
which the genetic diathesis is expressed is currently a subject of great interest.
Teratogenic Effects. The second group of studies consists of those investigating the teratogenic
effects of maternal alcohol and other drug use.
These studies report strong relationships between
in utero alcohol and other drug use and later childhood problems such as minor physical anomalies,
hyperactivity, mental retardation, and EEG anomalies (Jones & Smith, 1973). Jones and Smith first
described fetal alcohol syndrome as a cluster of
four characteristics occurring in the offspring of
mothers who drank excessively during pregnancy:
central nervous system dysfunction, abnormal
facial features, behavioral deficits, and growth
deficiency.
Family Systems Theory and Research. A third
group of studies highlight different aspects of the
addicted family environment and family interaction (see Ellis, Zucker, and Fitzgerald (1997) for
a review of studies examining aspects of the
addicted family environment that impact COAs’
risk of developing substance-abuse and mental
health problems). Family studies view children
from a family illness perspective with regard to
the dynamics of the illness and its effects on
family functioning. Family studies involve two
separate areas of research: the impact of addiction upon family functions and the impact of
addiction on the adult COSAPs specifically.
These studies typically conclude that the transmission of alcoholism is complex and involves
multiple genetic, psychological, sociological,
and cultural interactions.
Developmental Theory and Research. The
fourth group of studies centers on various biological and psychosocial characteristics of children
of differing maturational stages who grow up in

addicted families. These studies attempt to isolate
biological and psychological variables that differentiate children at risk for alcoholism. Isolating biological mechanisms that may distinguish
populations at high or low risk for alcoholism has
involved a variety of techniques. Children of
alcoholics are differentiated from children
of nonalcoholics, for example, on the basis of
fMRI activity showing increased activity related
to areas of the brain that are related to impulsivity, EEG results, event-related potentials, and
enhanced antagonistic placebo response to alcohol cues (Andrews et al., 2011; Newlin, 1985;
Rangaswamy, Jones, et al., 2007; Rangaswamy,
Porjesz, et al., 2004; Schuckit, Parker, &
Rossman, 1983). A significant amount of recent
research has also attempted to identify specific
chromosomal regions and genes that may
partially explain why COAs are at heightened
risk for developing alcohol problems themselves.
Results of these studies have been mixed
(Campbell & Oei, 2010) with some studies
concluding that alcohol dependence is associated
with specific chromosomal abnormalities or
variations, with others failing to detect these
differences. Despite many promising leads, this
line of research has not yet successfully identified
a premorbid biological marker that will
accurately predict those who become alcoholic
from those who will not.

What Works
Strategies That Work
For the purposes of this encyclopedia, “What
Works” is defined as interventions and/or
programs demonstrating success in three or
more trials. To date, a search of the literature
did not uncover interventions that met the
standard of three successful trials.

What Is Promising
Strategies That Are Promising
Although prevention programs that are targeted
to COSAPs use a variety of strategies, there are

Promoting the Healthy Development of Children Whose Parents Are Alcoholic/Drug Dependent

some elements that are relatively common across
programs. These common components include
information about alcohol and other drugs,
problem and emotion-focused coping behaviors,
and social and emotional support. Programs for
which there is some preliminary empirical
evidence all use some combination of these. For
a more complete review of these and other
programs, see Johnson, Gryczynski, and
Moe (2011).
Information About Alcohol and Other Drugs

Prevention programs for COSAPs often include
a component that helps children learn about
substance-related issues in a developmentally
appropriate manner. Although many children
may benefit from this information, this type of
education may be especially important for
COSAPs, as they are more likely than
other children to have misconceptions
concerning the positive effects of drinking on
cognitive and social performance (Brown,
Creamer, & Stetson, 1987; Colder, Chassin,
Stice, & Curran, 1997). Although the amount
and type of information that a child is able to
handle will vary depending on a child’s developmental level and maturity, programs can help to
clear up some of the misconceptions that
COSAPs often hold about addiction and
substance use.
Another common component of prevention
programs is to help COSAPs understand their
risk status in a developmentally appropriate manner. Prevention programs can help COSAPs to
understand that although they may be at
increased risk for a variety of psychosocial problems including alcoholism and substance use,
having an addicted parent does not ensure that
they will become addicted themselves. However,
it is important to convey the information that
these children are at higher risk for alcoholism
and substance abuse and that their risk of
transitioning from casual use to addiction is
higher than the general population. Children
who are aware of their risk status drink significantly less (in both quantity and frequency) than
do COSAPs who are unaware of this information
(Kumpfer, 1989).

857

Skill Building

The majority of prevention programs targeted at
COSAPs include a component that involves teaching emotion-focused and problem-focused coping
skills (Nastasi & DeZolt, 1994). Emotion-focused
coping skills may be especially important for
COSAPs to acquire because they often do not
have control over their parent’s drinking habits.
By addressing these issues indirectly, COSAPs
may be able to regain some sense of control over
their lives. Additionally, COSAPs also often
benefit from problem-focused coping skills in
which the children are taught strategies for living
with an addicted parent, such as avoiding driving
with an intoxicated parent and explaining parental
behaviors to their friends. Other skills often
addressed in COSAP prevention programs include
communication, stress management, decisionmaking, and peer resistance.
Social Support

Social support may be especially important for
COSAPs who often face substantial stresses with
relatively little support. By offering COSAPs
additional sources of support, programs may
assist these children in dealing with the difficult
issues that they face on a daily basis. Furthermore, there is evidence that children may benefit
not only from receiving support but also from
offering support. Some research demonstrates
that programs that allow participants to both
provide and receive support have the most
positive outcomes (Maton, 1987).
Evaluation of Prevention Programs in the
Literature
Although there are a number of general strategies
that have proven successful with COSAP
populations, and there is a substantial literature
documenting the success of certain substanceabuse prevention programs for the general youth
population, there is limited information based on
well-designed evaluations regarding prevention
programs. A recent review of primary prevention
programs designed to reduce alcohol misuse by
children and young adults reported that many
evaluation reports suffer from serious methodological shortcomings that make interpretation of

858

Promoting the Healthy Development of Children Whose Parents Are Alcoholic/Drug Dependent

their results and generalizability to other
populations problematic (Foxcroft, Ireland,
Lister-Sharp, Lowe, & Breen, 2003). Specifically,
they note that many evaluation designs and reports
are hampered by high levels of attrition and inadequate randomization procedures. The results of
their review suggest only limited support for
programs that utilize short-term (up to 1 year)
and medium-term (1–3 years) follow-up periods.
Significantly stronger support was found for the
few programs that reported longer-term follow-up
periods. While this review was not limited to programs that targeted a COSAP-specific population,
many of its findings also likely apply to COSAPspecific programs and populations. To the extent
that these programs are successful in reducing
alcohol misuse in a primary population, COSAPs
will also likely benefit as they are also part of the
intended target group.
In a review of COSAP-specific interventions,
Kumpfer (1999) notes that many programs utilize
self-developed measurement tools whose
psychometric properties are unknown. The vast
majority of these instruments are used only
once, prohibiting the comparability of results
across studies (Johnson, Rolf, Tiegel, & McDuff,
1996).
Kumpfer also notes that many evaluations fail
to be sensitive to the fact that prevention programs may be differentially successful with different types of children. Thus, in order to
demonstrate the true effectiveness of an intervention, evaluations should examine not only the
overall effectiveness of programs but also the
ways in which different subpopulations of participants responded to the intervention. Additionally, because many prevention programs are
designed to address a number of risk factors, the
results of prevention programs may not be immediately apparent and may not be manifest until
several years after the intervention has
completed. In order to effectively measure these
outcomes, researchers must investigate and
utilize more effective ways to collect longitudinal
information with this population.
Despite these numerous design and measurement issues, several prevention programs have
documented considerable success with COSAP

populations. Listed below is a brief overview of
several of these programs.
Strengthening Families Program

The Strengthening Families Program (SFP) is
a family-based prevention program that has
been shown to increase resilience and decrease
alcohol, tobacco, and drug use among
elementary-aged children of substance abusers
(Kumpfer, DeMarsh, & Child, 1989). The basic
intervention includes providing participating
adults with parenting skills, children with social
skills training, and a family enhancement
program in which children and their parents
both participate. Typically the program is
conducted in churches or community centers in
brief sessions of 2–3 h. Although originally
designed for children ages 6–11, modified
versions of the SFP have been developed for
children in varying age ranges from 3 to 16.
The Strengthening Families Program is the most
widely replicated and studied of the programs
described here, though most studies have not
focused specifically on the subpopulation of
COSAPs.
Long-term follow-up with participating children has shown that its effects persist over time.
A 5-year follow-up study demonstrated that the
program was effective in reducing rates of alcohol
and drug abuse among children age 10–14 (Spoth,
Guyll, & Day, 2002) and resulted in an estimated
cost-benefit ratio of $9.60–1. Ten-year follow-up
studies have demonstrated that participating
children reported significantly lower levels of
lifetime mental health disorders compared
to other children (Spoth et al., 2005; Trudeau &
Spoth, 2005).
The Strengthening Families Program has been
modified for a variety of cultural groups including rural and urban African-American COSAs,
Hawaiian COSAs, Hispanic COSAs, and rural
preteens (Kumpfer, Pinyuchon, Teixeria de
Melo, & Whiteside, 2008). Evaluation studies
showed that the basic program with minor
cultural revisions was more effective than
a substantially revised program. The authors
concluded that the core content of the program
should not be deleted when making cultural

Promoting the Healthy Development of Children Whose Parents Are Alcoholic/Drug Dependent

revisions. As a result of positive outcomes of SPF
replications, NIDA has chosen SFP as a model
substance-abuse prevention program for
dissemination.
Focus on Families Program

The Focus on Families Program (Catalano,
Haggerty, Fleming, Brewer, & Gainey, 2002) is
a family-based program that targets chemically
dependent parents and their children. By providing families with parent-management skills and
at-home case-management services, the Focus on
Families Program attempts to reduce the risk of
relapse by parents and prevent substance abuse
among their children.
Evaluations have indicated that parents participating in the program demonstrate increased
general problem-solving skills and drug-refusal
skills at a 24-month follow-up assessment than
parents in a control group. Parents also reported
using significantly less heroin at the completion
of the program and at the 12-month follow-up, as
well as less cocaine at the 12-month follow-up.
The evaluation also revealed a reduction in both
drug use and delinquent behaviors at the
24-month follow-up. Although this program did
not demonstrate statistically strong changes in
child behaviors, the evaluators suggested that
the sample of children used in the evaluation
might have been too young for the program to
demonstrate efficacy in reducing problem
behaviors (Catalano, Gainey, Fleming, Haggerty,
& Johnson, 1999).
Long-term (12–15 years) follow-up of participants has revealed that overall children who
participated in the Focus on Families Program
were equally likely to develop a substanceabuse disorder as a randomized control group.
However, further analyses suggested significant
gender differences. While male participants demonstrated lower rates of substance-abuse disorders, female participants did not (Haggerty,
Skinner, Fleming, Gainey, & Catalano, 2008).
Creating Lasting Connections

The Creating Lasting Connections (CLC)
program (Johnson et al., 1996) is designed to
address a number of risk and resiliency factors

859

that are associated with alcohol and other drug
(AOD) use among high-risk youth. Although this
program is not specifically targeted at COSAPs, it
includes several components that might be
effectively utilized with COSAP populations.
The CLC program attempts to increase family
resilience to AOD by increasing parent’s
knowledge of AOD issues, improving family
management skills and communication skills,
providing positive role modeling of alcohol use,
increasing community involvement with their
children, and the utilization of community
services if the need arose. In addition, the CLC
program attempted to increase youth resilience
by improving communication and refusal skills,
family bonding, community involvement, and
use of community services when situation
warranted. Families participating in the program
also receive follow-up care for 1 year.
Evaluations of the CLC program have utilized
an experimental design. Evaluations have indicated that parents participating in the program
demonstrate increased knowledge about AOD
information and family use of community services. In addition, the program demonstrated
some success in increasing youth resiliency by
increasing the utilization of community services
when need arose, increased bonding with family
members, improved communication skills, and
increased community involvement under some
conditions. As a result of these successful
prevention efforts, the Creating Lasting Family
Connections program has been chosen as 1 of
16 exemplary prevention programs by the Center
for Substance Abuse Prevention and the National
Prevention Network.
Students Together and Resourceful

Students Together and Resourceful (STAR) is an
intervention that is based on a community
psychology orientation. One goal was to provide
students accurate information concerning
alcohol, alcoholism, and family reactions to
alcoholism in order to understand the etiology
of alcoholism and to reduce self-blame.
A secondary goal was to increase social competence and both the quantity and quality of peer
relations. Group exercises were designed to

860

Promoting the Healthy Development of Children Whose Parents Are Alcoholic/Drug Dependent

facilitate the identification, acceptance, and
expression of feelings. A related goal was that
of improving the social network of participants.
Specific skills such as problem-solving, decisionmaking, stress management, and refusal skills
were emphasized. In short, the intervention was
designed to do what parents normally do: help
children learn to live with themselves in their
environments, to establish good relationships,
and to make constructive decisions and follow
them through.
A strength of this program was the use of a wait
list control group who received the intervention at
a later time. The analyses consisted of comparisons
between the control and treatment groups over
time, strengthening the argument that outcomes
were a result of the intervention. Participants were
successful in establishing stronger social relations,
a sense of control, and improved self-concept. Participants reported increases in the number of
friends, peer involvement, and perceived social
support. Participants also reported decreased loneliness and depression (Emshoff, 1990).
CASASTART (Striving Together to Achieve
Rewarding Tomorrows)

CASASTART is a school-based prevention program for high-risk youth developed by the
National Center for Addiction and Substance
Abuse at Columbia University (CASA). The program targets children age 8–13 who report at least
four risk factors, one of which is parental substance abuse. CASASTART provides children
with intensive case-management, educational,
and mentoring services. Case managers work
closely with both children and their families to
help identify and secure additional services such
as family counseling, parent training, and
substance-abuse treatment as necessary. Evaluation results suggested that children engaged in
CASASTART demonstrated lower rates of drug
and alcohol use and lower rates of violent crime
in the previous year compared to a control group
(Harrell, Cavanagh, & Sridharan, 1998, 1999).
Celebrating Families! Program

Celebrating Families! is a 16-week program
designed to address the needs of children age

6–11 and their families. The program targets
families in which at least one parent is in the
early stages of substance-abuse treatment and
there is deemed to be a high risk for child abuse
or neglect. Children and parents participate in
weekly education and skill-building sessions
that are designed to help break family cycles of
substance abuse. Evaluation results (Lutra
Group, 2006) have suggested that participating
parents demonstrated improved parenting
skills, decreased alcohol and drug use, and
lower rates of depression. Participating
children reported lower rates of depression and
increased social skills, but also higher rates of
hyperactivity and aggression. While early results
are promising, these findings should be
interpreted with caution, as the evaluation design
did not include a control for most analyses, and
instead reported pre- and post-intervention
differences.
The Betty Ford Children’s Program

The Betty Ford Center Children’s Program
operates a four-day, intensive prevention program for COSAPs ages 7–13. The program is
based on the philosophy that addiction is
a family disease and that the whole family,
including children, can benefit from treatment.
Children are required to attend with at least one
parent or caregiver, who is required to abstain
from substance use during the duration of the
program.
Counselors and trained volunteers use
a variety of developmentally appropriate techniques, such as art, games, storytelling, and role
playing to provide children with education about
substance use and addiction, to help them identify
and talk about their feelings, to gain assertiveness, and to learn coping and stress reduction
techniques. On the last day of the program,
children and parents work together to develop
plans outlining how they will practically apply
the information and skills gained during the
program. Additional ongoing support is provided
for families. Local families can participate in
weekly continuing care groups, and all children
are provided with access to a 24-h hotline that
provides a mean of ongoing support.

Promoting the Healthy Development of Children Whose Parents Are Alcoholic/Drug Dependent

Evaluation results (Moe, Johnson, & Wade,
2008) suggest that this brief, intensive program
suggested that participating children reported
lower levels of loneliness, increased knowledge
about substance abuse and addiction, as well as
an increased recognition that they cannot control
their parent’s substance-abusing behaviors.
Children’s Program Kit

An additional resource for programs that serve
COSAP populations is SAMHSA’s Children’s
Support Kit – Supportive Education for Children
of Addicted Parents (Substance Abuse and
Mental Health Services Administration, 2003).
This comprehensive toolkit, which was
developed by the National Association for
Children of Alcoholics (National Association
for Children of Alcoholics, 1998), includes information, materials, and practical assistance to help
program design and implement interventions that
target children from addicted families. The
toolkit includes materials that are appropriate
for use with a variety of developmental stages:
from elementary-school-aged children to young
adults. The toolkit also includes practical advice
designed to assist programs to implement
interventions, such as information on assessing
program readiness to offer services, and evaluation advice and materials. A second version of the
kit, which focuses on Native American
populations, the Native American Children’s
Program Kit, is also available. Although no
formal evaluation of these materials exists,
these remain a popular and commonly utilized
resource, with over 100,000 copies of the toolkits
having been distributed by SAMHSA to date.
Incorporating Prevention into Existing
Practice Settings

Another promising primary prevention strategy is
to incorporate screening and referral for familial
substance abuse into the normal procedures used
by those that see children on a regular basis.
Towards that end, the National Association of
Children of Alcoholics, assisted by the Office of
National Drug Policy, the Center for Substance
Abuse Prevention, as well as other leading health
organizations, has developed a set of core

861

competencies for use within primary-care health
settings (Adger, McDonald, & Wenger, 1999).
Pediatricians, who tend to have frequent contact
with both children and their parents, are in an
opportune position to conduct a brief screening
to assist in the early identification of COSAPs and
to provide information and referrals that may
help to prevent future difficulties (Werner,
Joffe, & Graham, 1999). Recent guidelines from
the American Academy of Pediatrics have
acknowledged this role and have suggested that
pediatricians “screen for and evaluate the nature
of substance use among patients and their families” (Kulig, 2005). Although many health-care
providers still believe that substance-abuse
problems are the domain of mental health
professionals, a growing number of health-care
providers are becoming involved in the identification and referral of COSAPs to appropriate
services. There is also growing evidence that
parents are both willing to participate in screening for alcohol problems in a pediatrician’s office
and are also willing to accept brief interventions
if they screen positive for alcohol problems
(Wilson et al., 2008).

What Does Not Work
The research base on interventions with children
of alcoholics is still largely incomplete. Many
interventions are provided with little, if any,
evaluation. While some quality intervention studies have been conducted, relatively few report
long-term follow-up data on participants, and
few studies have been even modestly replicated.
Thus, similar to the “What Works” section, it is
premature to either endorse any specific strategy
as conclusively effective or ineffective based on
the available empirical evidence.

Summary
The risk status of COSAPs is undeniable. While
risk for some specific outcomes may be questionable, there is no doubt that COSAPs experience
an increased probability for substance abuse and

862

Promoting the Healthy Development of Children Whose Parents Are Alcoholic/Drug Dependent

other negative psychosocial characteristics.
Given the epidemiologic research, there is no
doubt that COSAPs are a worthy target for primary prevention. To date, there is no single program that has been tested with sufficient rigor,
using psychometrically sound instruments, with
multiple replications, overextended periods of
time, and diverse samples of COSAPs to warrant
its identification as the model preventive
program. However, a number of programs and
practitioners have provided convergent evidence
regarding some principles of intervention that
seem worthy of consideration.
Successful prevention programs that are
targeted to COSAP populations share many of
the same characteristics of successful prevention
programs designed for other populations. Prevention programs that are of a longer duration offer
participants an opportunity to participate in some
form of follow-up care or “booster” sessions and
have characteristics that allow intervention
results to be generalized to everyday settings
and are more likely to demonstrate success than
interventions that do not share these characteristics (Botvin, Baker, Filazzola, & Botvin, 1990;
Lochman, 1992).
Programs targeted at this population must
remain cognizant of the fact that COSAPs represent a remarkably heterogeneous group. Thus,
prevention programs targeted to COSAP
populations should avoid utilizing a narrow
focus. A broad range of strategies that address
a number of different risk and protective factors
and the diverse needs and characteristics of
COSAPs is recommended.
One dimension of diversity is the range of
outcomes experienced by COSAPs. While
COSAP status implies risk, it does not imply
a predetermined inescapable outcome. The resilience and normality of many COSAPs must be
recognized. Prevention programs targeted at
COSAP populations should remain cognizant of
the negative impact of assuming pathology and
the consequent effects of labeling on COSAP
populations. One way in which these effects can
be lessened is if programs are designed to be
delivered to all children, not only COSAPs. This
approach has the added benefit of allowing

programs to reach COSAPs who would not ordinarily be identified as such. By allowing larger
numbers of individuals access to these programs,
researchers can ensure that their prevention
services are received by all affected children,
while also reducing the stigma attached to their
delivery. The use of non-stigmatizing settings
(e.g., schools, community centers, and churches)
may also reduce the stigma attached to receiving
COSAP services.
Because peers exert such a powerful influence
on substance-use decisions (Hawkins et al.,
1992), interventions that are broadly targeted to
include both COSAPs and their peers may prove
to be more effective prevention strategies than
those that utilize more narrowly targeted groups.
Interventions that are designed to target COSAP
populations may also prove more successful, and
more easily generalized, when peers are included
as facilitators. Past research has demonstrated
that substance-abuse prevention programs in
which peers instruct and practice program
components with participants are better
generalized than are programs that do not incorporate the use of peers (Botvin et al., 1990).
Continued and expanded research is imperative. We need to know more about the differences
between COSAPs and children from other
dysfunctional families and stressful environments. The epidemiology and etiology of diverse
subpopulations of COSAPs need to be explored.
The development and evaluation of prevention
programs could benefit by attention to many of
the issues described in this entry. Despite these
limitations, there is no doubt that the effort and
concern focused on this population has improved
the lives of many children.

References
Adger, H., McDonald, D. I., & Wenger, S. (1999). Core
competencies for involvement of health care providers
in the care of children and adolescents affected by
substance abuse. Pediatrics, 103(5), 1083–1084.
Agrawal, A., & Lynskey, M. T. (2008). Are there
genetic influences on addiction: Evidence from
family, adoption and twin studies. Addiction, 103,
1069–1081.

Promoting the Healthy Development of Children Whose Parents Are Alcoholic/Drug Dependent
Andrews, M. M., Meda, S. A., Thomas, A. D., Potenza,
M. N., Krystal, J. H., Worhunsky, P., et al. (2011).
Individuals family history positive for alcoholism
show functional magnetic resonance imaging
differences in reward sensitivity that are related to
impulsivity factors. Biological Psychiatry, 69(7),
675–683.
Anthony, E. (1974). The child in his family (Children at
psychiatric risk, Vol. 3). New York: Wiley.
Arthur, M. W., Hawkins, J. D., Pollard, J. A., Catalano,
R. F., & Baglioni, A. J. (2002). Measuring risk and
protective factors for substance use, delinquency, and
other adolescent problem behaviors: The communities
that care youth survey. Evaluation Review,
26, 575–601.
Botvin, G. J., Baker, E., Filazzola, A. D., & Botvin, E. M.
(1990). A cognitive-behavioral approach to substance
abuse prevention: One-year follow-up. Addictive
Behaviors, 15(1), 47–63.
Brown, S. A., Creamer, V. A., & Stetson, B. A. (1987).
Adolescent alcohol expectancies in relation to
personal and parental drinking patterns. Journal of
Abnormal Psychology, 96, 117–121.
Campbell, J. M., & Oei, T. P. (2010). A cognitive model
for the intergenerational transference of alcohol use
behavior. Addictive Behaviors, 35(2), 73–83.
Catalano, R. F., Gainey, R. R., Fleming, C. B., Haggerty,
K. P., & Johnson, N. O. (1999). An experimental
intervention with families of substance abusers:
One-year follow-up of the focus on families project.
Addiction, 94(2), 241–254.
Catalano, R. F., Haggerty, K. P., Fleming, C. B., Brewer,
D. D., & Gainey, R. R. (2002). Children of substance
abusing parents: Current findings from the Focus on
Families project. In R. J. McMahon & R. D. V. Peters
(Eds.), The effects of parental dysfunction on children
(pp. 179–204). New York: Kluwer/Plenum.
Colder, C. R., Chassin, L., Stice, E. M., & Curran, P. J.
(1997). Alcohol expectancies as potential mediators of
parent alcoholism effects on the development of adolescent heavy drinking. Journal of Research on Adolescence, 7(4), 349–374.
Ellis, D. A., Zucker, R. A., & Fitzgerald, H. E. (1997). The
role of family influences in development and risk.
Alcohol Health and Research World, 21(3), 218–226.
Emshoff, J. G. (1990). A preventive intervention with
children of alcoholics. Prevention in Human Services,
7(1), 225–253.
Foxcroft, D. R., Ireland, D., Lister-Sharp, D. J., Lowe, G.,
& Breen, R. (2003). Longer-term primary prevention
for alcohol misuse in young people: A systematic
review. Addiction, 94(4), 397–411.
Goodwin, D. W. (1985). Alcoholism and genetics:
The sins of the fathers. Archives of General
Psychiatry, 42, 171–174.
Goodwin, D. W., Schulsinger, F., Hermansen, L., Guze,
S. B., & Winokur, G. (1973). Alcohol problems in
adoptees raised apart from alcoholic biological parents.
Archives of General Psychiatry, 28, 238–243.

863

Grant, B. F. (2000). Estimates of U.S. children exposed to
alcohol abuse and dependence in the family. American
Journal of Public Health, 90, 112–115.
Haggerty, K. P., Skinner, M., Fleming, C., Gainey, R., &
Catalano, R. (2008). Long-term effects of the Focus on
Families project on substance use disorders among
children of parents in methadone treatment. Addiction,
103, 2008–2016.
Harrell, A., Cavanagh, S., & Sridharan, S. (1998). Impact
of the Children at Risk Program: Comprehensive final
report (Vol. II). Washington, DC: The Urban Institute.
Harrell, A., Cavanagh, S., & Sridharan, S. (1999). Evaluation of the Children at Risk Program: Results 1 year
after the end of the program (National Institute of
Justice Research Brief). Washington, DC:
U.S. Department of Justice, Office of Justice
Programs, National Institute of Justice.
Hawkins, J. D., Catalano, R. F., & Miller, J. Y. (1992).
Risk and protective factors for alcohol and other drug
problems in adolescence and early adulthood:
Implications for substance abuse prevention.
Psychological Bulletin, 112(1), 64–105.
Johnson, J. L., Gryczynski, J., & Moe, J. (2011).
Treatment issues and interventions with young
children and their substance-abusing parents. In
S. L. A. Straussner & C. H. Fewell (Eds.), Children
of substance abusing parents: Treatment issues and
interventions (pp. 101–126). New York: Springer.
Johnson, J. L., & Leff, M. (1999). Children of substance
abusers: Overview of research findings. American
Academy of Pediatrics, 103(5 Pt 2), 1085–1099.
Johnson, J. L., Rolf, J. E., Tiegel, S., & McDuff, D. (1996).
Developmental assessment of children of alcoholics.
In S. Abbott (Ed.), Children of alcoholics: Selected
readings (pp. 99–133). Rockville, MD: National
Association of Children of Alcoholics Press.
Jones, K. L., & Smith, D. W. (1973). Recognition of
the fetal alcohol syndrome in early infancy. Lancet,
2, 999–1001.
Kulig, J. W. (2005). American Academy of Pediatrics,
Committee on Substance Abuse. Tobacco, alcohol,
and other drugs: The role of the pediatrician in prevention, identification, and management of substance
abuse. Pediatrics, 115, 816–821.
Kumpfer, K. L. (1989). Promising prevention strategies
for high-risk children of substance abusers. OSAP
High Risk Youth Update, 2, 1–3.
Kumpfer, K. L. (1999). Outcome measures of interventions in the study of children of substance-abusing
parents. Pediatrics, 5(2), 1128–1144.
Kumpfer, K. L., DeMarsh, J. P., & Child, W. (1989).
Strengthening families program: children’s skills training curriculum manual, parent training manual, children’s skill training manual, and family skills training
manual. Salt Lake City, UT: Social Research Institute,
Graduate School of Social Work, University of Utah.
Kumpfer, K., Pinyuchon, M., Teixeria de Melo, A., &
Whiteside, H. O. (2008). Cultural adaptation process
for international dissemination of strengthening

864

Promoting the Healthy Development of Children Whose Parents Are Alcoholic/Drug Dependent

families program. Evaluation & The Health Professions, 31, 226–239.
Kumpfer, K. L., & Summerhays, J. F. (2006). Prevention
approaches to enhance resilience among high-risk
youth: Comments on the papers of Dishion & Connell
and Greenberg. Annals of the New York Academy of
Sciences, 1094, 151–163.
Lochman, J. E. (1992). Cognitive-behavioral intervention
with aggressive boys: Three year-follow-up and
preventive effects. Journal of Consulting and Clinical
Psychology, 60(3), 426–432.
Lutra Group. (2006). Year one (FY 05–06) evaluation
report for the Celebrating Families! grant.
Unpublished report. Salt Lake City, UT. Retrieved on
August 20, 2012 from http://www.celebratingfamilies.
net/PDF/YearOneEvaluationReport_new.pdf
Maton, K. I. (1987). Patterns and psychological correlates
of material support within a religious setting: The
bi-directional hypothesis. American Journal of
Community Psychology, 15, 185–207.
Moe, J., Johnson, J. L., & Wade, W. (2008). Evaluation of
the Betty Ford Children’s Program. Journal of Social
Work Practice in the Addictions, 8(4), 464–489.
Nastasi, B. K., & DeZolt, D. M. (1994). School interventions for children of alcoholics. New York: Guilford.
National Association for Children of Alcoholics. (1998).
Children of alcoholics: Important facts. Rockville,
MD: National Clearinghouse for Alcohol Information.
Newlin, D. B. (1985). The antagonistic placebo response
to alcohol cues. Alcoholism, Clinical and Experimental Research, 9(5), 411–416.
Office of National Drug Control Policy. (2001). The
economic costs of drug abuse in the United States,
1992–1998
(Publication
No.
NCJ-190636).
Washington, DC: Executive Office of the President.
Rangaswamy, M., Jones, K. A., Porjesz, B., Chorlian,
D. B., Padmanabhapillai, A., Kamarajan, C.,
et al. (2007). Delta and theta oscillations as risk markers
in adolescent offspring of alcoholics. International
Journal of Psychophysiology, 63(1), 3–15.
Rangaswamy, M., Porjesz, B., Chorlian, D. B., Wang,
K. M., Jones, K. A., Kuperman, S., et al. (2004).
Resting EEG in offspring of male alcoholics: Beta
frequencies. International Journal of Psychophysiology, 51(3), 239–251.
Schuckit, M. A., Parker, D. C., & Rossman, L. R. (1983).
Ethanol-related prolactin responses and risk for
alcoholism. Biological Psychiatry, 18(10), 1153–1159.

Skinner, M. L., Haggerty, K. P., Fleming, C. B., &
Catalano, R. F. (2009). Predicting functional
resilience among young-adult children of opiateaddicted parents. Journal of Adolescent Health,
44(3), 283–290.
Spoth, R., Guyll, M., & Day, S. (2002). Universal
family-focused interventions in alcohol-use disorder
prevention: Cost-effectiveness and cost-benefit
analyses of two interventions. Journal of Studies on
Alcohol, 63(2), 219–228.
Spoth, R., Redmond, C., Mason, A., Kosterman, R.,
Haggerty, K., & Hawkins, J. D. (2005, May). Tenyear follow-up assessment of brief, family-focused
intervention effects on lifetime conduct and antisocial
personality disorders: Preliminary results. Poster
presented at the Society for Prevention Research 13th
Annual Meeting, Washington, DC.
Substance Abuse and Mental Health Services Administration. (2003). Children’s program kit: Supportive
education for children of addicted parents (DHHS
Publication Number (SMA) 03–3825). Rockville,
MD: Center for Substance Abuse Treatment,
Substance Abuse and Mental Health Services
Administration.
Substance Abuse and Mental Health Services Administration. (2009). The NSDUH report: Children living with
substance-dependant or substance-abusing parents:
2002 to 2007. Rockville, MD: Office of Applied
Studies.
Thatcher, D. L., & Clark, D. B. (2008). Adolescents at risk
for substance abuse disorders: Role of psychological
dysregulation, endophenotypes and environmental
influences.
Alcohol
Research
&
Health,
31(2), 168–176.
Trudeau, L., & Spoth, R. (2005, May). Universal
family-focused preventive intervention effects on
non-targeted adolescent outcomes: Generalization of
effects. Paper presented at The Society for Prevention
Research 13th Annual Meeting, Washington, DC.
Werner, M. J., Joffe, A., & Graham, A. V. (1999).
Screening, early identification, and office-based
intervention with children and youth living in
substance-abusing
families.
Pediatrics,
5(2),
1099–1112.
Wilson, C. R., Haris, S. K., Sherritt, L., Lawrence, N.,
Glotzer, D., Shaw, J. S., et al. (2008). Parental alcohol
screening in pediatric practices. Pediatrics,
122, 1022–1029.

Religion and Spirituality During Childhood

865

Definitions and Scope

Religion and Spirituality During
Childhood
Wendy L. Kliewer1, Kathryn Reid Quiñones2,
Nikola Zaharakis3 and Everett L.
Worthington Jr.3
1
Department of Psychology, Virginia
Commonwealth University, Richmond,
VA, USA
2
Children’s Hospital of the King’s Daughters,
Norfolk, VA, USA
3
Virginia Commonwealth University,
Richmond, VA, USA

Introduction
There is a growing recognition among
researchers, educators, and health professionals
that children are spiritual beings (Adams, Hyde,
& Woolley, 2008; Hart, 2003). That is, children,
as all humans, have the capacity to connect and
relate to others, to the world, and to a transcendent dimension. This recognition stems in part
from a holistic view of education – a desire to
focus on the development of the whole child –
and from health-care professionals who attend to
children’s physical, emotional, social, and
psychological needs. Worldwide children today
face a range of stressors – both acute
and chronic – which heighten their risk for mental and physical maladjustment. Yet not all children are at equal risk for developing adjustment
problems. Some children show resilience, which
refers to a dynamic process encompassing positive adaptation within the context of significant
adversity (Luthar, Cicchetti, & Becker, 2000).
The religiosity and spirituality of a child (or a
child’s family) are among the factors that may
help children weather the stressors and crises
that come their way. In the past decade,
researchers have made progress in understanding how religiosity and spirituality affect
a child’s ability to cope with stressors and how
religiosity and spirituality influence normative
development. However, this area of research is
still in its infancy.

Scholars recognize that religion and spirituality
are distinct, albeit overlapping, constructs
(Grimes, 1999; Hill et al., 2000). Religion is
defined here as the individual and corporate
search for the sacred that has been formalized
into an institution. Spirituality, which is the
broader construct, refers to one’s experience of
closeness and connection to what one considers
to be sacred (e.g., God, Divine being, or nature;
Hill et al., 2000). Spirituality can be classified
based on the object that one considers to be
sacred. For example, within religious spirituality,
a person experiences a sense of closeness or connection with the sacred – usually God or a Divine
being – by involvement in a religious community
with agreed-upon beliefs and practices that frame
one’s experience of the sacred.
The percentage of children (preadolescents) in
the United States or elsewhere who consider
themselves either religious or spiritual has not
been quantified. However, relatively recent data
on American adolescents (Smith & Denton,
2005) revealed that most (84 %) American adolescents believe in the existence of God and most
(51 %) indicated that their faith is extremely or
very important. An additional 31 % indicated
that faith was somewhat important; 18 % of
those surveyed indicated that faith was not very
or not at all important. A 28-country survey of
14-year-olds (see Torney-Purta, Lehmann,
Oswald, & Schulz, 2001) revealed that
a minority of adolescents participate in religious
organizations. Highest participation rates were in
the United States and Cyprus; low participation
rates were observed in Northern, Western, and
Eastern Europe. A country and culture’s religious
traditions influence the extent to which children
and adolescents will participate in organized religious activities (Inglehart, Basañez, Dı́ezMedrano, Halman, & Luijkx, 2004). The extent
to which children seem themselves as “spiritual”
worldwide is unknown.
Several authors have argued that spirituality is
an integral part of the human experience. For
example, Hart (2003) suggests that it is helpful
to think of humans as spiritual beings who have

T.P. Gullotta, M. Bloom (eds.), Encyclopedia of Primary Prevention and Health Promotion,
DOI 10.1007/978-1-4614-5999-6, # Springer Science+Business Media New York 2014

866

human experiences rather than human beings
who may have spiritual experiences. Thus, Hart
places a central focus on individuals’ capacity to
interact with the transcendent and thus normalizes this kind of experience. Newberg and
Newberg (2008) propose a neuropsychological
model for developmental spirituality that people
are – in the words of the title of their article –
“hardwired” for God. Adams and colleagues
(2008) note that for many people, connectedness
to the self, to others, to the world, and to something that transcends themselves (i.e., God or the
sacred) is at the core of spirituality. In their book
The Spiritual Dimension of Childhood, Adams
et al. (2008) describe ways in which children
have spiritual experiences. Adams et al. do not
treat religion as a mere cognitive framework, but
they include natural moments of awe and wonder.
There often does seem to be a sense of mystery in
what children see or sense. Another variety of
spiritual experience is children’s inquisitive and
uninhibited interest in death and related issues.
These observations by Adams et al. are consistent
with Braatvedt’s (2007) view that childhood is
a “natural sanctuary for the spiritual qualities for
which adults must constantly struggle.” That is,
children are less apt than adults to quash their
curiosity and sense of mystery about things we
cannot see or explain in the natural world. In an
Internet article, Braatvedt identified qualities of
children that make them especially sensitive to
spiritual experiences including “an uncluttered
simplicity that enables free thinking and exploring, an openness to spiritual matters, an ability to
be trusting in relationships and to be dependent
on others, an everyday sensitivity to experiences
of the sacred, and keen awareness of the immanent presence of God in everyday life.”

Theories
A variety of theorists have speculated about how
people develop faith. The theory most relevant to
childhood is by Elkind (1970), whose ideas were
based both on his own research and on Piagetian
perspectives on development. Elkind found that
a child’s learning of object permanence in early

Religion and Spirituality During Childhood

childhood prepared him or her for the notion of
a God who is not physically present. School-aged
children who became aware of death – even
though death might not have actually touched
their experience – “solved” their problem of
loss by developing the notion of life after death.
The need to “conserve” life provided a platform
for developing theological conceptions, regardless of whether children were raised in explicitly
religious families. Elkind also found the emergence of logical thinking readied children to
think of how God might be represented symbolically and perhaps worshipped. Barrett (2011a)
has updated Elkind’s (1970) seminal thinking.
Barrett has championed the cognitive science of
religion, in which he has shown how human cognitive systems inform and constrain religious
thought, experience, and expression.
Barrett (2011a, 2011b) based his conceptions
on four premises. First, scholars in the cognitive
science of religion reject full-blown cultural relativism. Second, they believe that some aspects
of the content of human behavior and cognition
(and in this case religion) are extra-cultural or
“universal,” suggesting that virtually all normally
functioning people share them. That is, some
religious thoughts, experiences, and expressions
are human regardless of culture. The desire for
meaning might be one such example. Analogously, these universals are like the foundation
and frame of a building. Third, cultural learning
informs and constrains religious thought, experience, and expression. Analogously, culture
builds different looking and functioning houses
on the universal frames. Fourth, the focus of
cognitive science of religion is across individuals, not within individuals. Thus, Barrett
(2011a) points out that experiences like James’
religious experiences, which are highly mystical
and not experienced by all, are not the focus of
cognitive science of religion (but that does not
invalidate them as individual or minority experiences worthy of scientific study). Barrett
(2011a) has shown that scholars in the cognitive
science of religion have found universal foundations of children’s ideas about (1) the design and
origin of the natural world; (2) death and beliefs
about afterlife; (3) magic; (4) religion and its

Religion and Spirituality During Childhood

relation to morality; (5) religious development
in children as they age and gain capabilities;
(6) religious ritual; (7) religious social relations;
(8) the relationship among souls, minds, and
bodies, (9) spirit possession; (10) transmission
of religious ideas; and (11) various concepts
about superhuman agents.
In addition to theories of faith development
and the development of religious thought, experience, and expression, there are several perspectives on the mechanisms by which religion and
spirituality influence child development and
well-being. Although children may have natural
inclinations toward spirituality (Barrett, 2011b),
the religiosity and spirituality of parents play
a considerable role in the types of formalized
experiences children will have (Clark,
Worthington, & Danser, 1988). Some of this
influence by parents might occur due to psychodynamic theoretical propositions of attachment to
God as a projection from relationships with primary caregivers. Psychologists of religion (e.g.,
Miner, 2009) do not doubt that such influence
occurs, but it cannot account for all of children’s
(and later adults’) attachment to God. Modeling
might account for some effects of parents. But the
power of the situation also might account for much
of the influence (Ross & Nisbett, 2011). Most children have little choice about whether and to what
extent they will participate in religious activities
within or outside of the home. Parents determine
whether and where the family will attend religious
services, to which and how many religious activities the child will be exposed, and how, when, and
how often religious activities will be incorporated
within the home. Parents decide whether children
will attend public or religious schools or (increasingly) whether children will be homeschooled.
Parents decide who the majority of playmates of
their children are. In addition, parents determine
the degree to which religious experiences that
the child is exposed to will be more a matter of
form (which might promote a low-spirituality
religious orientation in the child) or warm personal
experiences (which might promote vibrant
religious commitment and spirituality).
Of course, how the child will ultimately
respond to the early religious or spiritual

867

experiences also depends on the child’s personality and disposition, which in turn is dependent
on both genes and experiences. Is the child fundamentally agreeable? Perhaps the child will go
along with the parents more than a child who is
not agreeable. Is the child conscientious? Perhaps
the child will filter his or her experiences to be
more receptive to conscientiousness-based religions (Worthington, Berry, & Parrott, 2001). Is
the child extraverted? People-oriented influences
might be received more readily than less peopleoriented influences. Is the child fundamentally
open to experience? Perhaps the child will be
more influenced by peers and other adults and
less so by parents. Is the child high on neuroticism (i.e., emotional instability)? Perhaps the
child will react strongly and emotionally to
salient religious experiences.
In addition to formalized religious experiences, parents with spiritual or religious commitments may encourage healthy coping. There are
a number of mechanisms through which the religiosity or spirituality of a child or of a child’s
parents could possibly affect a child’s physical
and emotional well-being. Kliewer and her colleagues (1996) have discussed three theoretical
mechanisms by which parents influence children’s coping processes, and these can be used
to understand how parental spirituality might
affect children’s well-being. Of course,
nonreligious parents also influence their children.
The discussion below, however, highlights the
ways in which a parent’s religiosity or spirituality
could affect children’s physical and emotional
well-being.
First, parents might influence children by
coaching them to engage in particular ways of
thinking about and responding to stressors. That
is, parents suggest to children how they might
interpret events that occur and suggest options
for how they might respond. Although all parents,
regardless of their level of religiousness or spirituality, coach their children, parents with spiritual or religious commitments may suggest
strategies that tend to encourage more healthy
coping (e.g., seeking support, thinking about the
situation, forgiving others, prayer) and discourage coping that is less adaptive (e.g., avoidant and

868

aggressive behavior). For example, in a study of
coping socialization with 310 families of late
elementary school-age youth, maternal use of
religious coping was associated with her active
and cognitive restructuring suggestions to her
children (Kliewer, Fearnow, & Miller, 1996).
Parents also may help their children find meaning
in the events that occur to them by suggesting that
their children interpret events from a religious
viewpoint. This conceptual framework that religious parents can provide actually goes far
beyond helping children merely cope with life
events. The religious narrative adopted within
a family can provide a cognitive scaffold on
which the child’s worldview might be
constructed – having wide-ranging effects on
the remainder of the child’s life (McAdams,
1996). For example, if parents encourage their
children to view the world as under God’s control, children may come to view events in their
lives as purposeful versus random. If children are
taught that humans have free will, then they
might interpret their own and others’ life choices
differently than children who were not socialized
to believe in free will.
Parental coaching may apply to physical, as
well as emotional, needs. Most religions are associated with a host of pro-health behaviors and
discouragement of behaviors that are unhealthy,
and religion has been strongly related to longer
life even after major confounds (i.e., smoking,
drug and alcohol abuse, risky behavior, lifestyle
behaviors) have been statistically removed
(McCullough, Hoyt, Larson, Koenig, &
Thoresen, 2000). Unfortunately, some religions
are also associated with biases against outgroups
and at times have shown ethnic or other prejudices. Human history has been characterized by
a long and unendingly brutal history of wars, and
religion (like social class, tribal loyalties, intelligentsia versus working folks, economics, and
sheer lust for power) has been involved in far
too many of them, and war can also affect health.
While spirituality might be associated with
pro-health lifestyles, the research, at this point, is
unclear. Parents who are spiritual might coach
their children to engage in healthier habits (e.g.,
eating right, taking care of one’s body, sleeping

Religion and Spirituality During Childhood

enough) than parents who are less spiritual. Evidence for this possible association comes from
a meta-analysis showing that religion/spirituality
in adults was associated with less alcohol and
illicit drug use and with fewer negative mental
health outcomes (Koenig, 2001). In addition,
recent results of one small qualitative study suggest that girls may have attitudes about sexuality
more similar to their mothers’ when mothers and
daughters discuss sexuality and spirituality with
each other and when mothers value their daughters
having a strong relationship with God which influences their actions (Baier & Wampler, 2008).
The spiritual and religious values of parents
undergird the coaching messages they relay to
their children. For example, in a meta-analytic
review of religion in the home, Mahoney,
Pargament, Tarakeshwar, and Swank (2001)
found that more parent religiousness was linked
to greater positivity in family relationships. In
a study of 90 rural African American families
with 9- to 12-year-old children, self-report and
observational data revealed that greater parent religiosity was associated with more cohesive family
relationships, lower levels of interparental conflict,
and fewer externalizing and internalizing problems in the adolescents. There was also some
evidence that formal parent religiosity indirectly
influenced youth self-regulation via family cohesion and low levels of interparental conflict
(Brody, Stoneman, & Flor, 1996). Gunnoe,
Hetherington, and Reiss (1999) in a study of parental religiosity, parenting style and adolescent social
responsibility that parental religiosity was positively related to authoritative parenting (coded
from an interaction task) and maternal religiosity
were negatively associated with authoritarian
parenting. Parental religiosity had direct and
indirect effects on youth’s social responsibility.
Second, parents might influence children
through modeling. Parents who are spiritually or
religiously committed may be more likely than
parents who are not to cope adaptively with life
stressors (e.g., seek support, pray, forgive others,
take action to solve the problem, not turn to drugs
or alcohol) and to take good care of their own
physical needs (e.g., eat right, exercise, have regular medical care). For adults, strong and

Religion and Spirituality During Childhood

replicable intercorrelations have been found
between religious measures and positive health
behaviors (Lawler-Row & Elliott, 2009). In addition, parents with religious or spiritual commitments might be more likely than other parents to
model prosocial behavior in the community
(again, virtually all the research has been on
religion, not spirituality). Children observe their
parents’ behavior and imitate them, particularly
when they are young. As parents participate in
activities that lead to enhanced physical and emotional well-being and that foster community connectedness, children might be encouraged to do
likewise. Furthermore, by coping adaptively and
taking care of themselves, parents who are religious or spiritual may enjoy better physical and
emotional adjustment, which enables them to be
more effective at attending to their children’s
needs. Evidence suggests that religious/spiritual
adults enjoy better physical health and are happier than less religious/spiritual people (Green &
Elliott, 2010). Parents who are spiritually committed may be more intentional about modeling
particular ways of coping – specifically spiritually focused coping and interacting with the community to their children than other parents
(Kliewer et al., 1996).
Third, parents might influence children by
creating a context in which behaviors are learned
and enacted. Parents are architects of the home
environment. The extent to which the home is
a safe haven in which family members communicate and care about one another is largely the
responsibility of adults in the home. Parental
spirituality and religious commitment might
affect the context in which children are raised in
a myriad of ways depending on their beliefs. For
example, if parents have the financial means,
spiritual parents may locate in environments
that are less toxic (e.g., less crime ridden or less
value discrepant). If parents have little choice
about where they live, they may invest in creating
what they consider to be safe and healthy environments within the confines of their home. As
another example, parents with religious commitments might be more likely to invest in their
child’s development and have more effective
parenting styles than less religious parents.

869

For instance, spiritual or religious parents may
be more loving and accepting of and less hostile
toward their children, more likely to establish
boundaries that provide security, and more able
to provide support to their children. On the other
hand, spiritual or religious parents might also
have some prejudices or harmful beliefs that are
associated with their religious or secular spiritual
beliefs. Those too might be likely to be transmitted to children. At present, there is little empirical
evidence that bears on these hypotheses.
In addition to parental influences, children’s
own spirituality may influence their well-being in
several ways. First, children’s religiosity may
provide them with a sense of support, either
from God or from members of a religious community to which they belong (Smith, 2003). This
support may buffer children from stressors by
enhancing their sense of control or esteem or
bolstering their connections with others (Sandler,
Miller, Short, & Wolchik, 1989). Second, children who are spiritual (who understand and
engage in the “search for the sacred” themselves)
might be more likely than children who are not
spiritual to exhibit traits such as respect for
authority and community that will encourage
them to follow the prescriptions and example of
their parents and communities. The interaction
between the child’s personal religious or
nonreligious spirituality and his or her
community’s religious or nonreligious spirituality further encourages positive behaviors that
lead to healthy outcomes. Thus, a child’s religion
or spirituality might act as a protective factor by
encouraging and fostering healthy behaviors,
which in turn serve as additional protective factors, even in the face of difficult cultural, environmental, or personal situations (Smith, 2003).
Third, a child’s religion or spirituality may provide him or her with a sense of coherence or
meaning, which can assist with coping with difficult situations.

Research
The exploration of religion and spirituality in
childhood remains in its infancy despite

870

increased calls from researchers over the past
10 years to determine how spiritual development
emerges in childhood (e.g., Benson et al., 2003).
A special issue of Child and Adolescent Psychiatric Clinics of North America in 2004 addressed
the “new frontier” of religion and spirituality in
child and adolescent mental health in which they
called for researchers and clinicians to consider
religion and spirituality in the provision of mental
health care to children, adolescents, and their
families. Despite these calls to researchers and
as noted above, there is limited evidence linking
parent or child spirituality or religiosity to children’s well-being. However, there is evidence
indicating that parental spirituality within their
religiosity affects martial adjustment and parenting behavior (Desrosiers, Kelley, & Miller,
2011), that individual and community spirituality
foster a sense of support (Smith, 2003), that children who live in religious environments tend to
adopt the religious beliefs and customs of their
community (Kelley & DeGraaf, 1997), and that
the sense of meaning children gain from this
religious organization and rituals acts as
a protective factor (Park, 2010).
Building on previous work that demonstrated
support for the link between parental religiosity
and child adjustment, Christian and Barbarin
(2001) examined the impact of parental religiosity
on parent reports of child behavior problems in
a sample of low-income, African American families. Parents who attended church regularly
reported fewer problems with oppositional behavior, peer conflict, depression, headstrong behaviors, and immaturity in their children than parents
who attended church infrequently. Data from
Christian and Barbarin’s community sample also
suggest the support of a church community may
strengthen the child’s perception of their parents’
authority and may induce children to be more
compliant (Christian & Barbarin, 2001).
While a multitude of studies have established
the relation between happiness and spirituality and
religiousness in adolescents and adults, there have
been few empirical investigations on this relation
in children (see Diener and Biswas-Diener (2008),
for a review). Holder, Coleman, and Wallace
(2010) recently assessed 320 children attending

Religion and Spirituality During Childhood

public and private schools in order to explain this
association in children. For children ages 8–12,
spirituality was more strongly linked to happiness
than was religious practice (e.g., attending church,
praying, and meditating). Spirituality accounted
for up to 26 % of the unique variance in children’s
happiness even when controlling for the variance
in happiness associated with temperament, while
religious practice accounted for no greater than
1 % of the variance depending on how happiness
was assessed. The authors suggest that the lack of
a strong relation between religious practice and
happiness among children is that parents, not the
children, determine the frequency of religious
activities.
The limited research on the mental health
impact of religion and spirituality in childhood
has for most part examined only Caucasian or
African American samples. In efforts to enhance
our understanding of religion and spirituality in
diverse groups of children, Van Dyke, Glenwick,
Cecero, and Kim (2009) examined the relation of
religious coping and spirituality to adjustment
and psychological distress in a sample of primarily Hispanic, urban youth ages 11–14. They
revealed that both positive religious coping and
daily spiritual experiences were associated with
positive affect and life satisfaction. Additionally,
they found that negative religious coping (i.e.,
reframing negative life events as punishments
from God, seeking but not receiving congregational social support, experiencing spiritual
discontent or conflict, and passively deferring
responsibility for oneself and one’s situation to
God) was related to higher levels of depression,
anxiety, somatization, and negative affect. Van
Dyke et al. (2009) also examined the results by
grade level to identify any age differences in the
impact of religious coping. For sixth graders,
higher levels of positive religious coping were
associated with lower levels of negative affect.
Additionally, sixth-grade youth reporting higher
levels of negative religious coping also endorsed
higher levels of anxiety. Among seventh graders
only, higher levels of negative religious coping
were associated with both higher levels of depression and lower levels of life satisfaction. Both
sixth and seventh graders demonstrated

Religion and Spirituality During Childhood

a significant positive correlation between negative religious coping and overall psychological
distress. When examined separately, eighth
graders did not demonstrate significant associations between religious coping and psychological
outcomes suggesting that as children enter adolescence they may develop other mechanisms for
managing emotions and stress which results in
less reliance on religion (Van Dyke et al., 2009).
Given that prior research has linked disparities
in parent and adolescent religiosity to youth
adjustment (Pearce & Haynie, 2004), Davis and
Epkins (2009) sought to explain the process by
which family conflict has an impact on preadolescents’ depressive and anxiety symptoms by
assessing whether private religious practices,
such as prayer at meals, meditation, and reading
religious material, moderated this relation in
a sample of 11- and 12-year-olds. While youths’
private religious practices were not directly
related to symptomatology, they did reveal that
private religious practices moderated the relation
between family conflict and youths’ depressive
and anxiety symptoms. Specifically, they found
that the associations between family conflict and
depression and anxiety symptoms were significantly stronger for those youth low, versus high,
in the private religious practices. David and
Epkins asserted that youth who partake in regular
private religious practices may be more resilient
to the impact of family conflict than youth who do
not engage in such activities on a frequent basis.
Finally, Garbarino (1999b) argues that not
only is children’s spirituality a protective factor
against potentially negative outcomes, but also
negative events themselves spur children toward
greater spirituality. In extensive work with children in difficult circumstances, from the horrors
of war to the struggle of poverty, Garbarino
observed that trauma can create in some children
a desire for answers that leads to a spiritual quest.
This search for meaning in response to
a traumatic event will often lead to personal
growth and answers that allow for better functioning later in life. Expanding on previous work
by Garbarino (2007) demonstrated that engagement in religious practices, such as prayer and
participating in organized religious activities,

871

was protective for African American children
who were exposed to community violence. Specifically, she found that for children who engaged
in religious practices less frequently, increases in
exposure to community violence were associated
with increases in post-traumatic stress disorder
(PTSD) while increases in exposure were
unrelated to increases in PTSD for children who
engaged in more frequent religious practices.

Strategies That Work
The extant literature is silent when it comes to
proven ways of enhancing children’s health
through religiosity or spirituality. Although
there is adequate correlational evidence linking
parent and child religiosity and parent religiosity
and well-being, there have been no longitudinal
studies documenting how change in a child’s religiosity or spirituality affects well-being nor studies documenting the efficacy of attempts to
enhance child religiosity or spirituality.

Strategies That Are Promising
In contrast to the above, there is much correlational and clinical evidence to suggest that
encouraging children to explore the spiritual and
their religious context and institution has beneficial effects. The literature documents robust associations between parental spirituality and
religious commitment and better parental wellbeing, greater family cohesion and marital harmony, and more positive parenting techniques
(e.g., Bartkowski, Xu, & Levin, 2008; Desrosiers
et al., 2011; Wilcox, 2002). Further, children’s
religiosity and spirituality is linked to better
adjustment. Given these associations, a viable
avenue to promoting health in preadolescents
seems to be promoting religiosity and spirituality
in children or parents who desire to become more
spiritual or religious (or both). Obviously, it
would be a moral and ethical transgression for
professionals to conduct a religious or spiritual
intervention on people who do not give informed
consent or who are coerced to accept a religious

872

intervention. The “how” by which one (such as
a parent, church worker, or professional working
consistently with a parents’ bidding) might intentionally promote increased religion or spirituality
among normally developing children has not
been explored much empirically, and we offer
some places to begin in our synthesis section.
Much of work that has shown children to demonstrate religious spirituality and that has advocated religious or spiritual interventions for
children has emanated from studies of children
facing trauma, including serious illness and
potential death. Parents and caregivers can play
an important role in fostering spiritual development in children who are confronting these types
of stressors. Professionals can intervene more
tentatively and only after informed consent. One
stressor can serve as an example; children with
cancer have unique spiritual needs. Hart and
Schneider (1997) encourage oncology nurses to
enact interventions that assist children with cancer in finding meaning and purpose in life, continuing relationships, and transcending beyond
the self. Finally, as Garbarino (1999b) has noted
that exposure to trauma is often the impetus for
children to begin seeking meaning for the events
that they have observed or experienced. As adults
are sensitized to this tendency, they can aid children in their quest for answers. Furthermore,
Garbarino (1999a) notes that spiritual exploration
is one of the factors that contributes to the success
of “lost boys” – boys who have turned to violence, substance use, and other behaviors that
compromise their well-being. Because spiritual
exploration contributes to success, Garbarino
argues that spiritual literacy – for example, exposure to religious texts and practices like meditation and prayer – should be part of educational
programs for boys at risk. Once this spiritual
foundation is in place, then traditional intervention strategies (educational programs, vocational
experiences, counseling, or psychotherapy) can
help children move to a more positive life path.
The importance of incorporating children’s
religious and spiritual beliefs in psychological
interventions has become more increasingly evident. Walker and colleagues (Walker, Reese,
Hughes, & Troskie, 2010) recently presented

Religion and Spirituality During Childhood

a model for assessing and incorporating religion
and spirituality in the treatment of childhood
physical and sexual abuse. They provide guidance on how clinicians can integrate a child’s
preexisting religious and spiritual functioning as
well as changes in religion and spirituality after
abuse in the provision of trauma-focused cognitive behavior therapy (TF-CBT), the most empirically supported treatment for childhood physical
and sexual abuse (see Cohen, Mannarino,
Deblinger, and Berliner (2009) for a detailed
explanation of this treatment). While Walker
et al. (2010) focus on how religion and spirituality can be incorporated into treatments for childhood physical and sexual abuse, children who
have experienced other traumas (e.g., war, natural disaster, terrorism) which have an impact on
their beliefs and worldview may also benefit from
the inclusion of their religious and spiritual
beliefs in treatment. Additionally, religion and
spirituality should be considered as a necessary
area of assessment during the treatment planning
for children participating in other evidencedbased treatments for mental health problems.

Strategies That Do Not Work
Some strategies do not appear to promote children’s health via spirituality or religious beliefs.
There is little evidence that religious school for
elementary school children affects their religious
development (Greeley & Gockel, 1971). What
parents coach and model is much more relevant
to preadolescents’ spiritual development.
Harsh parenting practices likely impede the
development of childhood spirituality (Larzelere,
1998). In fact, ineffective discipline and low
emotional support each contributes to generally
poor child outcomes and specifically to children
who might respond poorly to God because they
might identify God with parents.

Summary
In this section, we offer our own views on the best
mechanisms to promote children’s health through

Religion and Spirituality During Childhood

religiosity and spirituality. We believe a primary
strategy that would likely promote children’s religiosity and spirituality is to assist parents (who
wish to do so) in developing religious values and
commitments themselves. This recommendation
is based on cross-national evidence showing that
children, particularly children who reside in less
religious nations, are strongly influenced by family religiosity (Kelley & DeGraaf, 1997). Furthermore, a study of how religious beliefs and actions
are passed along to children documented the
importance of family context in transmitting family values (Myers, 1996). In that study, several
factors aided in the transmission of religiosity to
children: parental religiosity, parental marital
happiness, parent–child support, moderate strictness, and a traditional family structure. Thus, it is
important to note that parental religious and spiritual commitments cannot be divorced from other
aspects of parenting in order to promote health
in children.
As part of a strategy to enhance children’s
health through religiosity and spirituality, parents
should be encouraged to coach children to
(a) look for meaning in events that happen to
them using developmentally appropriate concepts (Park, 2010), (b) help children recognize
they have coping resources that are outside of
their own capabilities (Pargament, 1997), and
(c) use religious coping strategies when appropriate. Two particularly important coping mechanisms are prayer and forgiveness. Wachholtz
and Sambamoorthi (2011) studied national trends
in the use of prayer to cope with health concerns.
Generally, prayer was an effective coping mechanism and its use appears to have risen substantially within the last ten years. In addition,
forgiveness is likely to be related to the connection between religion and spirituality and health
as a moderator and mediator (for a review and
model, see Worthington et al. (2012); for
a review, see Worthington, Witvliet, Pietrini,
and Miller (2007)). Many family researchers
argue that good family relationships are those in
which family members can form, maintain, grow,
and repair when damaged the emotional bonds.
Forgiveness is one primary way that people repair
damaged relationship bonds. Parents should also

873

be encouraged to teach their children directly
about God and other religious concepts that are
a part of their worldview.
In addition to coaching, parents should be
encouraged to model their religious commitments and values in their own pursuit of what
is sacred; the way they cope with their own
stresses; and in how they interact with people,
inside and outside of the home. For example, if
parents want their children to be prayerful, they
will be most effective if they both encourage
their children to pray and model praying. If
parents want their children to be forgiving,
they should model seeking and giving forgiveness. The values that are core to their religious
and spiritual commitments should be reflected in
daily interactions with others around them.
Religious routines and family activities that
are consistent with parents’ religious values
should also be encouraged in parents. Children
gain security and a sense of control from routines
(Boyce, Jensen, James, & Peacock, 1983), which
provide children with a sense of security but also
help them to develop spiritual habits that can be
built on as children mature and begin to explore
their own spiritual values. Engaging in activities
as a family that enacts parental values, such as
serving the community, is also a way to actively
transmit spiritual values to children.
A second strategy to strengthen children’s
health and mental health through promoting children’s spirituality and religion is to encourage
parents to commit themselves to a faith community. There are benefits to children of belonging
to a faith community that are different from
merely having parents with a strong religious or
spiritual commitment. Communities of faith can
reinforce what parents are trying to communicate
to their children about spiritual issues, provide
emotional and instrumental support for children
(Smith, 2003), and act a buffer between parents
and children when parents are undergoing a lot of
stress. Faith communities may also provide
a sense of working together for a common goal.
Health can be affected through (a) affecting children’s health behaviors, (b) providing increased
social support, and (c) reducing risky healthcompromising behaviors.

874

A third strategy that would likely promote
children’s spirituality is to encourage children to
develop friendships with other children who have
spiritual and religious sensitivities. Research
shows that while parents remain important in
children’s lives as they enter adolescence, peers
gain influence (Harris, 1998). If children interact
with peers who support, rather than denigrate
religion, children may be more likely to engage
in religious behaviors, perhaps including the personal search for the sacred. This suggestion is
slightly different than strategy two. Children can
be members of a faith community without having
close friends or peers in that community.
A fourth strategy that would likely promote
children’s spirituality is to directly encourage
children to explore these issues, independent of
parental religious or spiritual commitment. Webster (1998) has advocated using stories, poetry,
and art in the context of the educational system to
foster spirituality through promoting narrative
and emotional connections between life and
meaning. Webster’s ideas might be incorporated
into the curriculum of youth organizations (e.g.,
Boy Scouts, Girl Scouts, 4-H) or after-school
programs (e.g., Boys and Girls clubs).
In summary, there is evidence that parental
spiritual and/or religious commitments are associated with a child’s religious beliefs and actions
and to a lesser degree spirituality. Furthermore,
religion and spirituality are protective for children. While the efficacy of interventions to
enhance children’s religiosity and spirituality is
unknown, research from the parenting literature
suggests that encouraging parents to develop
spiritual and religious commitments themselves,
to become involved with a faith community, and
to encourage their children to interact with peers
who have spiritual interests will help foster religious and spiritual development and perhaps
physical and mental health. Also, directly encouraging children to explore the sacred, either as
a part of educational or extracurricular activities
or in response to trauma, illness, or poor life
choices, may promote spiritual development.
Research is needed that critically evaluates
these efforts in awakening children to religious
and spiritual possibilities.

Religion and Spirituality During Childhood

References
Adams, K., Hyde, B., & Woolley, R. (2008). The spiritual
dimension of childhood. London: Jessica Kingsley.
Baier, M. E., & Wampler, K. S. (2008). A qualitative study
of Southern Baptist mothers’ and their daughters’ attitudes toward sexuality. Journal of Adolescent
Research, 23, 31–54.
Barrett, J. L. (2011a). Cognitive science of religion:
Looking back, looking forward. Journal for the Scientific Study of Religion, 50(2), 229–239.
Barrett, J. L. (2011b). Cognitive science, religion, and
theology: From human minds to divine minds. Philadelphia: Templeton Press.
Bartkowski, J. P., Xu, X., & Levin, M. L. (2008). Religion
and child development: Evidence from the Early
Childhood Longitudinal Study. Social Science
Research, 37, 18–36.
Benson, P. L., Roehlkepartain, E. C., & Rude, S. P. (2003).
Spiritual development in childhood and adolescence:
Toward a field of inquiry. Applied Developmental
Science, 7, 205–213.
Boyce, W. T., Jensen, E. W., James, S. A., & Peacock,
J. L. (1983). The family routines inventory: Theoretical origins. Social Science and Medicine, 17,
193–200.
Braatvedt, C. (2007). Spirituality in childhood. Retrieved
September 11, 2011, from http://www.holytrinity.gen.
nz/Pages/sermons/spirity_in_childhood.htm
Brody, G. H., Stoneman, Z., & Flor, D. (1996). Parental
religiosity, family processes, and youth competence in
rural, two-parent African American families. Developmental Psychology, 32, 696–706.
Christian, M. C., & Barbarin, O. A. (2001). Cultural
resources and psychological adjustment of African
American children: Effects of spirituality and racial
attribution. Journal of Black Psychology, 27, 43–63.
Clark, C. A., Worthington, E. L., Jr., & Danser, D. S.
(1988). The transmission of religious beliefs and practices from parents to first-born early adolescent sons.
Journal of Marriage and the Family, 50, 463–472.
Cohen, J. A., Mannarino, A. P., Deblinger, E., & Berliner,
L. (2009). Cognitive-behavioral therapy for children
and adolescents. In E. B. Foa, T. M. Keane, M. J.
Friedman, & J. A. Cohen (Eds.), Effective treatments
for PTSD: Practice guidelines from the International
Society for Traumatic Stress Studies (2nd ed.,
pp. 223–244). New York: Guilford Press.
Davis, K. A., & Epkins, C. C. (2009). Do private religious
practices moderate the relation between family conflict
and preadolescents’ depression and anxiety symptoms? Journal of Early Adolescence, 29, 693–717.
Desrosiers, A., Kelley, B. S., & Miller, L. (2011). Parent
and peer relationships and relational spirituality in
adolescents and young adults. Psychology of Religion
and Spirituality, 3, 39–54.
Diener, E., & Biswas-Diener, R. (2008). Happiness:
Unlocking the mysteries of psychological wealth. Malden, MA: Blackwell.

Religion and Spirituality During Childhood
Elkind, D. (1970). The origins of religion in the child.
Review of Religious Research, 12, 35–42.
Garbarino, J. (1999a). Lost boys. New York: Free Press.
Garbarino, J. (1999b). The effects of community violence
on children. In L. Balter, C. S. Lawrence, & C. S.
Tamis-LeMonda
(Eds.),
Child
psychology:
A handbook of contemporary issues (pp. 412–425).
Philadelphia: Psychology Press.
Greeley, A. M., & Gockel, G. L. (1971). The religious
effects of parochial education. In M. P. Strommen
(Ed.),
Research
on
religious
development
(pp. 264–301). New York: Hawthorne Books.
Green, M., & Elliott, M. (2010). Religion, health, and
psychological well-being. Journal of Religion and
Health, 49, 149–163.
Grimes, R. L. (1999). Forum: American spirituality. Religion and American Culture, 9, 145–152.
Gunnoe, M. L., Hetherington, E. M., & Reiss, D. (1999).
Parental religiosity, parenting style, and adolescent
social responsibility. Journal of Early Adolescence,
19, 199–225.
Harris, J. R. (1998). The nurture assumption: Why children turn out the way they do. New York: Free Press.
Hart, T. (2003). The secret spiritual world of children.
New York: New World Library.
Hart, D., & Schneider, D. (1997). Spiritual care for children with cancer. Seminars in Oncology Nursing, 13,
263–270.
Hill, P. C., Pargament, K. I., Hood, R. W., Jr.,
McCullough, M. E., Swyers, J. P., Larson, D. B.,
et al. (2000). Conceptualizing religion and spirituality:
Points of commonality, points of departure. Journal
for the Theory of Social Behaviour, 30, 51–77.
Holder, M. D., Coleman, B., & Wallace, J. M. (2010).
Spirituality, religiousness, and happiness in children
aged 8–12 years. Journal of Happiness Studies, 11,
131–150.
Inglehart, R., Basañez, M., Dı́ez-Medrano, J., Halman, L.,
& Luijkx, R. (2004). Human beliefs and values:
A cross-cultural sourcebook based upon the
1999–2002 values surveys. Mexico City, MX:
SigloVeintiunoEditores.
Jones, J. M. (2007). Exposure to chronic community violence: Resilience in African American children. Journal of Black Psychology, 33, 125–149.
Kelley, J., & DeGraaf, N. D. (1997). National context,
parental socialization, and religious belief: Results
from 15 nations. American Sociological Review, 62,
639–659.
Kliewer, W., Fearnow, M. D., & Miller, P. A. (1996).
Coping socialization in middle childhood: Tests of
maternal and paternal influences. Child Development,
67, 2339–2354.
Koenig, H. G. (2001). Religion and medicine IV: Religion,
physical health, and clinical implications. International Journal of Psychiatry in Medicine, 31, 321–336.
Larzelere, R. E. (1998). Effective vs. counterproductive
parental spanking: Toward more light and less heat.
Marriage and Family: A Christian Journal, 1, 179–192.

875
Lawler-Row, K. A., & Elliott, J. (2009). The role of
religious activity and spirituality in the health and
well-being of older adults. Journal of Health Psychology, 14, 43–52.
Luthar, S. S., Cicchetti, D., & Becker, B. (2000). The
construct of resilience: A critical evaluation and guidelines for future work. Child Development, 71,
543–562.
Mahoney, A., Pargament, K. I., Tarakeshwar, N., &
Swank, A. B. (2001). Religion in the home in the
1980s and 1990s: A meta-analytic review and conceptual analysis of links between religion, marriage, and
parenting. Journal of Family Psychology, 15,
559–596.
McAdams, D. P. (1996). Personality, modernity, and the
storied self: A contemporary framework for studying
persons. Psychological Inquiry, 7, 295–321.
McCullough, M. E., Hoyt, W. T., Larson, D. B., Koenig,
H. G., & Thoresen, C. (2000). Religious involvement
and mortality: A meta-analytic review. Health Psychology, 19, 211–222.
Miner, M. (2009). The impact of child–parent attachment,
attachment to God and religious orientation on psychological adjustment. Journal of Psychology and
Theology, 37(2), 114–124.
Myers, S. M. (1996). An interactive model of religiosity
inheritance: The importance of family context. American Sociological Review, 61, 858–866.
Newberg, A. B., & Newberg, S. K. (2008). Hardwired for
God: A neuropsychological model for developmental
spirituality. In K. K. Kline (Ed.), Authoritative communities: The scientific case for nurturing the whole
child (The Search Institute series on developmentally
attentive community and society, pp. 165–186). New
York: Springer.
Pargament, K. I. (1997). The psychology of religion and
coping: Theory, research, and practice. New York:
Guilford Press.
Park, C. L. (2010). Making sense of the meaning literature: An integrative review of meaning making and its
effects on adjustment to stressful life events. Psychological Bulletin, 136, 257–301.
Pearce, L. D., & Haynie, D. L. (2004). Intergenerational
religious dynamics and adolescent delinquency. Social
Forces, 82, 1553–1572.
Ross, L., & Nisbett, R. E. (2011). The power of the situation: Perspectives of social psychology. London: Pinter & Martin.
Sandler, I. N., Miller, P., Short, J., & Wolchik, S. A.
(1989). Social support as a protective factor for children in stress. In D. Belle (Ed.), Children’s social
networks and social supports (pp. 277–301). New
York: Wiley.
Smith, C. (2003). Theorizing religious effects among
American adolescents. Journal for the Scientific
Study of Religion, 42, 17–30.
Smith, C., & Denton, M. L. (2005). Soul searching: The
religious and spiritual lives of American teenagers.
New York: Oxford University Press.

876
Torney-Purta, J., Lehmann, R., Oswald, H., &
Schulz, W. (2001). Citizenship and education in
twenty-eight countries: Civic knowledge and engagement at age fourteen. Amsterdam: International
Association for the Evaluation of Educational
Achievement.
Van Dyke, C. J., Glenwick, D. S., Cecero, J. J., & Kim,
S. (2009). The relationship of religious coping and
spirituality to adjustment and psychological distress
in urban early adolescents. Mental Health, Religion
& Culture, 12, 369–383.
Wachholtz, A., & Sambamoorthi, U. (2011). National
trends in prayer use as a coping mechanism for health
concerns: Changes from 2002 to 2007. Psychology of
Religion and Spirituality, 3, 67–77.
Walker, D. F., Reese, J. B., Hughes, J. P., & Troskie, M. J.
(2010). Addressing religious and spiritual issues in
trauma-focused cognitive behavior therapy for children and adolescents. Professional Psychology:
Research and Practice, 41, 174–180.

Religion and Spirituality During Childhood
Webster, D. (1998). Fostering the spiritual dimension of
education in young children. Early Child Development
and Care, 146, 13–20.
Wilcox, W. B. (2002). Religion, convention, and paternal
involvement. Journal of Marriage and Family, 64,
780–793.
Worthington, E. L., Jr., Berry, J. W., & Parrott, L., III.
(2001). Unforgiveness, forgiveness, religion, and
health. In T. G. Plante & A. Sherman (Eds.), Faith
and health: Psychological perspective (pp. 107–138).
New York: Guilford Press.
Worthington, E. L., Jr., Davis, D. E., Hook, J. N., Gartner,
A. L., Webb, J., Toussaint, L., et al. (2012). Forgiveness. In T. Plante (Ed.), Religion, spirituality, and
positive psychology: Understanding the psychological
fruits of faith (pp. 63–78). SantaBarbara, CA: Praeger/
Greenwood (ABC/CLIO).
Worthington, E. L., Jr., Witvliet, C. V. O., Pietrini, P., &
Miller, A. J. (2007). Forgiveness and health. Journal of
Behavioral Medicine, 30, 291–302.

Resiliency During Early Childhood

Resiliency During Early Childhood
Lennis G. Echterling and Anne Stewart
Department of Graduate Psychology, James
Madison University, Harrisonburg, VA, USA

Introduction
There has been a great deal of recent attention on
resiliency in the primary prevention and health
promotion literature, but most studies and programs have focused on school-aged children,
adolescents, or adults. Less attention has been
given to promotion of resiliency in early childhood. Nevertheless, there are promising trends in
both relevant research and practice. This entry
explores the promotion of resiliency in young
children, including infants, toddlers, and preschoolers. The fundamental assumption behind
these interventions is that it capitalizes on the
opportunity to promote positive trajectories of
growth and development by actualizing the
strengths and resources of young children for
successfully coping with adversities.

Definitions and Scope
Resiliency is derived from the Latin word
resilire. To resile literally means to bounce
back, rebound, or resume shape after compression. The concept was originally applied to
physics, in which resiliency refers to the elastic
strain energy of material. Ecologists, political
scientists, and economists have also found productive ways to apply the concept of resiliency
to their fields. Since the 1970s, primary prevention and health promotion researchers and practitioners have taken the notion of resiliency and
applied it metaphorically to characterize the
ability of a child to bounce back after enduring
the strain of adverse, or even traumatic, events
(Masten, 2001).
The concept of resiliency has provided
a promising conceptual framework, particularly
in the areas of primary prevention and health

877

promotion. Instead of concentrating on identifying the psychological casualties of harsh conditions and traumas, many researchers now are
studying how children can achieve their developmental potential and flourish under fire. As
a consequence of this focus on strengths and
resources, the study of resiliency in children
already has overturned many negative assumptions about their readiness and ability to cope
with adversity. Adding momentum to this emphasis on resiliency, many researchers and practitioners have been endorsing positive psychology,
a recent conceptual shift in the field (Donaldson,
Csikszentmihalyi, & Nakamura, 2011).

Theories
Some early theorists of resiliency conceptualized
it as an innate personality trait that characterized
those rare children who withstood seemingly
overwhelming stressors. Several scholars used
such terms as “invincible” to portray such children (Werner & Smith, 1982). Theorists proposed that these resilient individuals had
identifying personality traits, such as selfefficacy, self-esteem, autonomy, temperament,
and positive emotionality. The assumption of
this conceptualization was that a few extraordinary children have stable and generalized dispositions that make them consistently resilient
across all situations and virtually throughout
their lives. Resiliency was a quality that emanated from within these exceptional children.
Although researchers have found links
between personality characteristics and childhood resiliency, critics of this perspective have
expressed concerns and identified several limitations of this theoretical perspective. First, grandiose labels, such as invincible, suggested that
these children came through all adversities,
including catastrophic events, virtually unscathed
and untroubled. This characterization proved to
be highly inaccurate and an unfortunate stereotype. Second, the narrow focus on personality
failed to acknowledge the vital roles that
a child’s relationships and environment can play
in promoting resiliency. Third, the theorists

T.P. Gullotta, M. Bloom (eds.), Encyclopedia of Primary Prevention and Health Promotion,
DOI 10.1007/978-1-4614-5999-6, # Springer Science+Business Media New York 2014

878

assumed that personality traits were preceding
factors that led to resiliency, but many studies
have documented that an experience of coping
successfully with a challenge can actually
enhance such traits as optimism, self-efficacy,
and positive emotionality. In other words, resiliency is not a static personality trait, but
a complex, systemic, dynamic, and reciprocal
process (Masten, 2001).
Some theorists have defined resiliency as
the ability to recover from a trauma without
developing any psychopathology, such as
posttraumatic stress disorder (PTSD) or clinical
depression. Resiliency, therefore, is the absence
of any psychological disorder following a significant stressor or crisis event – to resile psychologically is to survive by recovering from
a trauma and returning to a state of normal functioning without pathology (Bonanno, Galea,
Bucciarelli, & Vlahov, 2006). Other scholars
have pointed out that the primary limitation of
this conceptualization of resiliency is that it is
defined by the absence, rather than the presence,
of a condition. Just as wellness is much more than
merely the absence of illness, the notion of resiliency suggests a more positive, nuanced, and
complex construct.
A number of recent theorists are conceptualizing resiliency as a process of overcoming
adversity to achieve a positive transformation
and transcendence. Resiliency is more than
merely coping with harsh circumstances and surviving them to return to the previous level of
functioning. Instead, children have the potential
to achieve posttraumatic growth (PTG) (Calhoun
& Tedeschi, 2006). Ultimately, from this perspective, resiliency is the process of young survivors emerging from adverse conditions to
become thrivers in their lives.

Research
Research has documented a remarkable level of
resiliency in children across cultures and under
a variety of adversities, including traumatic and
catastrophic events, such as disasters and acts of
terrorism (Watson, Brymer, & Bonanno, 2011).

Resiliency During Early Childhood

Resiliency researchers have discovered that
many young children are surprisingly robust,
thriving under difficult chronic conditions,
including extreme poverty, family violence, institutional settings, and prejudice (Masten & Reed,
2002). The research consistently has found that
the majority of children who experienced specific
traumas, such as sexual assault and death of
a parent, do not develop psychiatric disorders.
Resiliency, in fact, is the rule, rather than the
exception (Ryff & Singer, 2003). Life history
studies of psychological well-being provide compelling evidence for the resiliency of most – not
just a few – children in the face of adversity.
Researchers have investigated both those who
have directly confronted traumas and those who
are indirectly involved – witnesses, relatives, and
friends. Their findings have consistently demonstrated that the overwhelming majority of survivors overcome catastrophes and other adversities
(McNally, Bryant, & Ehlers, 2003). Sapienza and
Masten (2011) are encouraging researchers to
explore the neuroscience of resilience and
resilience-related processes of interaction that
impact individuals across system levels, from
genetic to neural, to behavioral and social levels.
Using this perspective, they believe we may document the progressive, cumulative effects of
nonlinear change, termed developmental cascades, not of risk, but of resilience, moving across
systems.
Over four decades, hundreds of studies on the
process of resiliency have consistently identified
four general factors that promote resiliency
among children. These factors include supportive
caregivers, meaning making, effective regulation
of emotional arousal, and coping abilities.
Supportive Caregivers
Resilient children are not islands unto themselves. Instead, their lives are interwoven in an
intricate tapestry of relationships that nurture,
protect, enliven, and enrich them. Social support
in general has been demonstrated to be
a powerful factor for promoting resiliency. In
particular, supportive caregivers provide buffers
to the inevitable crises, adversities, and challenges of life that the vast majority of children

Resiliency During Early Childhood

face. Resiliency evolves from these dynamic
everyday interactions within the caregiver-child
relationship (Papousek, 2011). Researchers
working within the framework of attachment theory have been particularly productive in
documenting that the quality of the relationship
between caregiver and child during the first years
of life is central to a child’s resiliency. In particular, the mother-child relationship has been
found not only to buffer the impact of socioeconomic stressors but also to promote the resiliency
of young children (Malmberg & Flouri, 2011).
Complementing an attachment perspective
are other characteristics of successful caregiverchild relationships. These include using a developmental perspective, accurately reading and
responding to the child’s needs, conveying positive and clear expectations for performance and
behavior, providing frequent and constructive
feedback, recognizing the power differential,
and, most importantly, acknowledging the reciprocal and dynamic relationship as the focus.
Typically and ideally, caregivers gradually
learn to concentrate effective displays when
baby is attending to them and enable the dyad to
develop an interactional synchrony, the smooth
intermeshing of behaviors. The degree to which
babies trust or have faith in the reliability of their
caregivers’ abilities impacts the security and
quality of future relationships between the children and their environment (Lamb, Ketterlinus,
& Fracasso, 1992). Importantly, this initial tie to
one’s caregiver is the formative relationship in
the course of which the infant develops a sense of
self (Klaus & Kennell, 1982). Thus, early
caregiver-infant interactions are important as
a foundation for the infant’s social and emotional
development (Ainsworth et al., 1978) and the
overall quality of the caregiver-infant
relationship.
Meaning Making
Humans are the only meaning-making species,
but psychology has practically ignored the subject of human meaning. Meaning making is the
process of giving narrative form to raw experience, gaining cognitive mastery, and discovering
possible resolutions (Echterling & Stewart,

879

2008). Children make meaning in a variety of
ways, such as playing, reenacting, drawing, and
telling stories. The meaning that children create
does more than organize their life experiences. It
affirms fundamental beliefs, guides important
decisions, and offers comfort in times of distress.
Even though they have confronted traumas as children, adults who lead meaningful lives have
greater satisfaction, experience more positive
emotions, and evidence greater vitality (Emmons,
2003). Although young children have limited abilities to verbalize the complexities of their experiences, especially with adversities and traumas,
they nevertheless give expression to these experiences through a variety of creative ways, such as
drawing, reenacting and playing, to gain some
sense of cognitive mastery over the adversity
(Echterling & Stewart, 2008). Furthermore, particularly with young children, much of the meaningmaking process takes place in the relationship with
the caregiver. Through attunement, the responsive
caregiver accurately reflects the child’s attempts to
give form to their raw experiences.
Closely related to meaning making and cognitive mastery, numerous studies in the emerging
field of social neuropsychology have documented
the neuroplasticity of brains, especially those of
young children. The ability to create new neural
pathways following an insult or trauma is
a testimonial to the resilience of the brain. Moreover, there is substantial evidence that the brain is
a social organ. As a consequence, the process of
interacting with caregivers activates and transforms the neural networks of infants and toddlers
(Cozolino, 2010). As the young child’s brain
continues to mature, the social interactions with
adult caregivers provide countless opportunities
for optimal brain development, adaptive neural
pathways, and integrated brain systems. Consistent and regular attunement between caregiver
and child is vital in this process by not only
strengthening interpersonal bonds but also providing a rich, fertile environment for optimal
brain development (Cozolino, 2010). Ideal relationships with their caregivers offer infants and
toddlers both a safe haven of security and
countless stimulating opportunities to explore
their world.

880

Regulatory Capacity
The study of human emotions, for the most part,
has been a study of negative feelings. Recently,
researchers are turning their attention to positive
emotions (e.g., Frederickson, 2002). They see
positive emotions as a frontier of uncharted territory that holds vast potential for primary prevention and promotion interventions. Adversity is
a time of intense emotions, but a common
assumption is that children enduring harsh circumstances experience only negative feelings,
such as fear, shock, and grief. Children actually
experience not only painful reactions but also
feelings of resolve, such as courage, compassion,
and hope (Snyder et al., 1997).
Similar to the process of meaning making,
young children achieve their potential for richer
and more sophisticated emotional regulation
through their encounters with an attuned caregiver. During interactions, the adult develops
sensitivities to the infant’s intricate set of behavior cues, comforting, protecting, and helping the
child organize feelings. This dance of
co-regulation persists over countless small but
significant everyday exchanges which in turn
enable the infant to begin to learn to regulate
his or her emotions. Caregivers must learn to
identify, respect, and scaffold their infants’
developing regulatory capacity. Over time, the
young child develops an expectation that there
will be a caring adult, responding in a contingent, helpful way. This attunement promotes
important factors that engender resiliency.
First, the caregiver’s empathy sensitizes the
adult to the wonder and magic of the infant’s
world. Consequently, both adult and infant share
in the small miracles and joys, increasing the
number of shared positive emotions. Second,
the caregiver’s responsiveness to distress signals
provides countless opportunities for the young
child to begin to understand the role that
emotions play in relationships and to practice
emotional regulation.
Besides expressing their feelings in more
productive ways, resilient young children learn
to use other strategies to manage their emotions.
These strategies include bringing their needs to
caregivers, redirecting their attention, relying

Resiliency During Early Childhood

on others for support, reframing the events,
and beginning to take the perspective of others.

Successful Coping
In general, research on children’s coping strategies have found that problem-focused, active
coping – although unsophisticated and seemingly
simplistic compared to older children – leads to
greater resiliency. On the other hand, avoidant
coping tends to be negatively associated with
resiliency (Compas et al., 2001).
Rituals and routines provide young children,
families, and communities a way to affirm their
identity and celebrate their roots. In a young
child’s family, he or she learns to identify and
savor customs that offer structure, meaning, and
connectivity. In times of adversity, parents can
design new rituals and routines that safeguard,
as much as possible, the sense of safety and
security while accommodating the new
circumstances.

Strategies
The most successful interventions appear to recognize the need for interprofessional collaboration in both research and practice. The promotion
of resiliency in young children benefits greatly
when educators, parents, anthropologists, health
professionals, epidemiologists, cognitive scientists, policy makers, and community leaders
work together to assess needs, plan interventions,
implement programs, and carefully evaluate their
effectiveness. A second strategy is to remain
committed to intensive, comprehensive, and
interactive interventions. Although there are tremendous needs, the most effective programs are
those that are firmly based on a solid theoretical
foundation, informed by the research, clearly
described in manuals, and implemented by welltrained and supervised practitioners. Finally, both
research and practice benefit greatly by drawing
on Bronfenbrenner’s (1979) ecological systems
theory to appreciate the complex, dynamic, and
broad factors that can contribute to the resiliency
of young children.

Resiliency During Early Childhood

What Works
It is important to keep in mind that although the
programs described below have been demonstrated to be effective interventions for the promotion of resiliency, practitioners also use them
to prevent specific problems, such as disruptive
behaviors. Furthermore, many therapists rely on
these interventions as treatment strategies. The
protocols for these interventions require varying
amounts of training, but the concepts and
methods they include reflect vital aspects for
promoting resilience, namely, supporting healthy
caregiver-child
attachment
relationships,
decreasing problematic behaviors, and creating
responsive caregiver-child interactions. The
reader is encouraged to explore ways to incorporate dimensions of resilience in their clinical
work and to continue professional development
to acquire the knowledge and skills needed to
design and implement effective treatments. The
evidence-based interventions are Circle of Security, Incredible Years Parent Training Program,
Parent–child Interaction Therapy, and ChildParent Psychotherapy.
Circle of Security
Circle of Security (COS) is an intervention based
on attachment theory and research. The fundamental goal of the intervention is to enhance the
attachment relationships between caregivers and
their young children. The COS interventions may
be delivered as individual therapy, intensive
in-home treatment, or as a psychoeducational
course. The psychoeducational program includes
a curriculum that emphasizes how findings from
attachment theory and the field of child development can inform parenting practices. A major
theme of COS is that young children have sophisticated capabilities to communicate their needs
but that foster, adopted, and children with other
high-risk patterns may send hard to read and
confusing cues about their needs. Therefore, the
intervention relies heavily on supporting caregivers as they view multiple videotapes of their
interactions with their own and other children.
Taking a strengths-based approach, trained
course instructors highlight positive moments of

881

attunement and pleasure that the videotapes capture. Such a strategy not only enhances the motivation of caregivers, it also builds on their
successes. The program facilitators also invite
caregivers to consider alternative interpretations
of their children’s subtle behaviors.
Evaluations of this program have found that
caregivers become more appropriately responsive to their children’s cues for safety and exploration; more able to reflect on their own and their
children’s thoughts, feelings, and behaviors; and
more aware of how their previous experiences
affect their current caregiving (Marvin, Cooper,
Hoffman, & Powell, 2002). More recently, the
COS developers have created effective parenting
DVDs that provide educational content and
include opportunities for caregivers to reflect on
the needs of their own children and the challenges
they face in meeting those needs (Cooper,
Hoffman, & Powell, 2009). Another study demonstrated the efficacy of the COS intervention in
creating more securely attached toddlers with
parents in a jail-diversion program (Cassidy
et al., 2010).
Incredible Years Parent Training Program (IY)
The Incredible Years Parent Training Program
(IY) (Webster-Stratton & Reid, 2010a) is an
empirically supported intervention that takes
full advantage of a group format and dynamics.
The purpose of the IY program is to strengthen
the competencies of parents, who can then be
more successful in actualizing their children’s
potential for resiliency while reducing the risk
for future conduct problems, substance abuse,
and violence. The IY curriculum topics include
positive parenting skills, managing disruptive
behavior, and strengthening emotional regulation. During the sessions, the group facilitators
present videotaped vignettes, lead discussions,
and involve parents in role-plays to practice skills
of offering positive attention, encouragement,
clear commands, consistent rules, and logical
consequences (Webster-Stratton & Reid, 2010b).
A number of randomized studies have shown
that IY enhances the competencies of both parents and children, reduces child problem behaviors, and enhances child resiliency (Borden,

882

Schultz, Herman, & Brooks, 2010). Importantly,
the participants have included ethnically diverse
and multi-stressed families (Reid, WebsterStratton, & Baydar, 2004).
Child-Parent Psychotherapy
Child-Parent Psychotherapy (CPP) (Lieberman
& Van Horn, 2005) is a therapeutic treatment
program that has been demonstrated to be an
effective intervention. The primary target
populations have been infants and preschoolers
of high-risk caregivers, including abusive,
depressed, or violent parents. Like other programs influenced by attachment theory, the process of CPP involves enhancing the emotional
attunement between parents and young children
in order to promote childhood resiliency. CPP
also includes such traditional psychotherapeutic
techniques as exploring how the parental childhood experiences have had an impact on their
current perceptions of, and emotional responses
to, their children’s behavior. Like other clinicians, CPP interveners invite parents to consider
on how they may be distorting the meaning of
their children’s emotional communications. In
sessions that can take place at home or in the
office, parents also explore how the stressors of
their current life circumstances can impair their
ability to be sensitive and nurturing caregivers.
The sessions, which are less structured than most
other programs, include both the parent and child
so that their interactions can become opportunities for reflection, discovery, and behavior
change.
The effectiveness of CPP has been demonstrated in randomized clinical trials involving
partner violence (Lieberman, Ghosh Ippen, &
Van Horn, 2006), depressed mothers (Toth,
Rogosch, Manly, & Cicchetti, 2006), and
maltreating families (Cicchetti, Rogosch, &
Toth, 2006). Associated outcomes for children
have included a decrease in PTSD symptoms,
fewer behavior problems (Lieberman, Van
Horn, & Ghosh Ippen, 2005), and more positive
mother-child relationship expectations (Toth,
Maughan, Manly, Spagnola, & Cicchetti, 2002).
In addition, the percentage of children whose
attachment classification changed from insecure

Resiliency During Early Childhood

to secure was significantly higher for the PCP
intervention group (Toth et al., 2002).
Parent–Child Interaction Therapy
Parent–child Interaction Therapy (PCIT) is
a treatment program for young children with conduct disorders that places emphasis on improving
the quality of the parent–child relationship. PCIT
was developed for children ages 2–7 years with
externalizing behavior disorders. PCIT uses
a psychoeducational approach, teaching parents
specific observation and communication skills to
encourage prosocial behavior and reduce negative behavior. PCIT treatment has two phases,
focusing on first on child-directed interactions,
where the parent follows the child’s lead, and
then parent-directed interactions, where the parent sets limits and makes age appropriate
demands of the child. Outcomes include fewer
oppositional and defiant behavior problems and
more positive parent–child interactions (Nixon,
Sweeney, Erickson & Touyz, 2003).

What is Promising
Promising practices programs have empirical
evidence that they are effective but overall have
fewer studies completed and/or have not yet
conducted randomized studies with control
groups (Promising Practice Network, 2011).
Video-Based Intervention to Promote
Positive Parenting
The Video-Based Intervention to Promote Positive Parenting is a prevention program which
makes extensive and productive use of video
recording technology in working with parents of
infants. The Video-Based Intervention to Promote Positive Parenting (VIPP) involves a series
of four home visits with families (Juffer,
Bakermans-Kranenburg, & van IJzendoorn,
2007). Similar to the COS program, VIPP educates caregivers on the principles of infant development and attachment theory. It also videotapes
parent-infant interactions in the home for
in-depth reviews and reflections. The approach
of the intervention is strengths-based and

Resiliency During Early Childhood

includes positives goals of helping parents to
become more sensitive and nurturing caregivers.
Studies of the effectiveness of this preventive
program include interventions with adoptive
families (Juffer, Bakermans-Kranenburg, &
van IJzendoorn, 2005), parents of highly reactive
infants
(Klein
Velderman,
BakermansKranenburg, Juffer, & van IJzendoorn, 2006),
and with infants at risk of preschool externalizing
behaviors (Klein Velderman et al., 2006).
Psychological First Aid
Psychological First Aid (PFA) shows potential
for being an effective early intervention for promoting the resiliency of children and their families following major catastrophic events, such as
natural disasters (Brymer et al., 2006). PFA techniques have the basic goals of ensuring safety,
attending to practical needs of survivors, offering
comfort, reducing distress, enhancing efficacy,
and connecting survivors to resources, all of
which are empirically supported intervention
principles (Hobfoll et al., 2007).
Neurosequential Model of Therapeutics
The Neurosequential Model of Therapeutics
(NMT) was designed by Bruce Perry, founder of
the Child Trauma Academy. It has been described
as a “developmentally-informed, biologicallyrespectful approach to working with at-risk children” (Child Trauma Academy, 2010). NMT is
not a specific intervention; rather, it is a comprehensive method of intervention which guides the
practitioner in organizing and conceptualizing
a child’s history and current functioning. Practitioners are taught how to structure the assessment
process and developmental information, analyze
the findings and design therapeutic activities that
address the child’s challenges, and capitalizes on
their strengths. NMT has three key components –
assessment, staffing/training, and recommended
therapeutic, educational, and enrichment activities (Perry, 2009). NMT requires active participation from caregivers and other adults in the
child’s world. Outcome research is underway in
a broad range of clinical and educational settings,
including therapeutic foster care, therapeutic
preschools, and outpatient treatment.

883

Active Parenting Now
Active Parenting Now is a parenting program
based on Adlerian theory. Parents meet with
a program facilitator to view a video and discuss
ways to apply the information to challenging
child behaviors. The program teaches parents to
use encouragement to build self-esteem and to
create a relationship with the child based upon
active listening, honest communication, and
problem solving. Consistent with Adlerian theory, the program also emphasizes the use of natural and logical consequences for misbehavior.
Child outcomes for the program show dramatic
differences in parent–child relationship and the
ratio of positive and negative behaviors exhibited
(Pindar, 1994).
Play and Expressive Arts Therapy
Crisis and disaster interveners (Echterling &
Stewart, 2008) have developed a variety of
play-based techniques to help children give
expression to their own resiliency. Indeed childcaregiver play is a component in almost all of the
programs discussed. Supporting very young children as they explore their world through play is
a powerful, culturally congruent, and developmentally appropriate way to engage and foster
all aspects of resilience. Incorporating playful
rituals and routines helps children establish and,
if needed, regain confidence in the predictability
of their world. Using creative activities to tell
one’s story offers children an opportunity to
begin to give form to raw experience, gain perspective, regulate their emotions, and make
important discoveries about their resiliency.
Children tell their stories in a variety of ways –
talking, drawing, sculpting, singing, writing, and,
of course, playing – but whatever form their
stories take, the process helps them to create
meaning from the adversity.
Similarly, play therapy has been widely used
by child and family therapists for children in
crisis or with affective, regulatory, and behavioral problems. A meta-analysis of 93 controlled
outcome studies assessed the efficacy of play
therapy, finding an overall treatment effect for
interventions of 0.80 (Bratton, Ray, Rhine &
Jones, 2005). Further analysis revealed that

884

effects were most positive for humanistic treatments and, consistent with other programs for
promoting children’s well-being, found that
using parents in play therapy (filial play therapy)
produced the largest effects. Play therapy
appeared equally effective across age, gender,
and presenting issue.

What Does Not Work
Psychological Debriefing
Originally developed as an early intervention for
first responders to critical incidents, psychological debriefing techniques have not been found to
be effective with survivors of traumatic events. In
fact, there is some evidence that suggests that
such techniques have been harmful to adult participants of psychological debriefing groups
(Brymer et al., 2006). Moreover, the application
of such adult interventions that are verbally based
to young children appears developmentally inappropriate and should be viewed with caution.

Summary
As the study of resiliency enters its fifth decade,
the questions to be answered will no longer be
whether young children are resilient, but how
their resiliency can best be promoted. Many
researchers are intrigued by these unanswered
questions. And many more practitioners are
committed to dedicating their efforts to develop
evidence-informed interventions that promote
resiliency in young children. Focusing on
approaches that build on strengths, capitalize
on natural resources, and moving beyond psychopathology are only some of the promising
beginnings for the promotion of resiliency.
Consistent with Bronfenbrenner’s ecological
model and developmental cascades, interventions that address risks and protective factors at
the individual, family, and community level are
more likely to result in positive outcomes.
Young children are embedded within a broader
familial and cultural context, so it is clear that
more ethnocultural research is needed to assist

Resiliency During Early Childhood

planners in designing programs that resonate
with diverse values and worldviews.

References
Ainsworth, M. D. S., Blehar, M. C., Waters, E., & Wall, S.
(1978). Patterns of attachment: A psychological study
of the strange situation. Hillsdale, NJ: Lawrence
Erlbaum.
Bonanno, G. A., Galea, S., Bucciarelli, A., & Vlahov, D.
(2006). Psychological resilience after a disaster: New
York City in the aftermath of the September 11th
terrorist attack. Psychological Science, 17, 181–186.
doi:10.1111/j.1467-9280.20006.01682.x.
Borden, L. A., Schultz, T. R., Herman, K. C., & Brooks,
C. M. (2010). The incredible years parent training
program: Promoting resilience through evidencebased prevention groups. Group Dynamics: Theory,
Research,
and
Practice,
14(3),
230–241.
doi:10.1037/a0020322.
Bratton, S., Ray, D., Rhine, T., & Jones, L. (2005). The
efficacy of play therapy with children: A meta-analytic
review of the outcome research. Professional Psychology: Research and Practice, 36(4), 375–390.
Bronfenbrenner, U. (1979). The ecology of human development. Cambridge, MA: Harvard University Press.
Brymer, M., Jacobs, A., Layne, C., Pynoos, R., Ruzek, J.,
Steinberg, A., et al. (2006). Psychological first aid:
Field operations guide (2nd ed.). Retrieved February
14, 2012, from http://www.nctsnet.org/nctsn_assets/
pdfs/pfa/2/PsyFirstAid.pdf
Calhoun, L. G., & Tedeschi, R. G. (Eds.). (2006). Handbook of posttraumatic growth: Research and practice.
Mahwah, NJ: Lawrence Erlbaum.
Cassidy, J., Ziv, Y., Stupica, B., Sherman, L. J., Butler, H.,
Karfgin, A., et al. (2010). Enhancing attachment security in the infants of women in a jail-diversion program. Attachment and Human Development, 12,
333–353.
Child Trauma Academy. (2010). What is the
neurosequential model? Retrieved February 14,
2012, from http://childtrauma.org/index.php/services/
neurosequential-model-of-therapeutics
Cicchetti, D., Rogosch, F. A., & Toth, S. L. (2006). Fostering secure attachment in infants in maltreating families through preventive interventions. Development
and Psychopathology, 18, 623–649.
Compas, B. E., Connor, J. K., Saltzman, H., Thomsen,
A. H., & Wadsworth, M. E. (2001). Coping with stress
during childhood and adolescence: Problems, progress, and potential in theory and research. Psychological Bulletin, 127, 87–127. doi:10.1037/00332909.127.1.87.
Cooper, G., Hoffman, K. T., & Powell, B. (2009). Circle
of security: COS-P facilitator DVD manual 5.0.
Unpublished manuscript, Marycliff Institute, Spokane,
WA.

Resiliency During Early Childhood
Cozolino, L. (2010). The neuroscience of psychotherapy:
Healing the social brain (2nd ed.). New York: W. W.
Norton.
Donaldson, S. I., Csikszentmihalyi, M., & Nakamura, J.
(Eds.). (2011). Applied positive psychology: Improving everyday life, health, schools, work, and society.
New York: Routledge/Taylor & Francis Group.
Echterling, L. G., & Stewart, A. L. (2008). Creative crisis
intervention techniques with children and families. In
C. Malchiodi (Ed.), Creative interventions with traumatized children (pp. 189–210). New York: Guilford
Press.
Emmons, R. A. (2003). Personal goals, life meaning, and
virtue: Wellsprings of a positive life. In C. L. M. Keyes
& J. Haidt (Eds.), Flourishing: Positive psychology
and the life well-lived (pp. 105–128). Washington,
DC: American Psychological Association.
Frederickson, B. L. (2002). Positive emotions. In C. R.
Snyder & S. J. Lopez (Eds.), Handbook of positive
psychology (pp. 120–134). New York: Oxford University Press.
Hobfoll, S. E., Watson, P. J., Bell, C. C., Bryant, R. A.,
Brymer, M. J., Friedman, M., et al. (2007). Five essential
elements of immediate and mid-term mass trauma intervention: Empirical evidence. Psychiatry, 70, 283–315.
Juffer, F., Bakermans-Kranenburg, M. J., & van
IJzendoorn, M. H. (2005). The importance of parenting in the development of disorganized attachment:
Evidence from a preventive intervention study in
adoptive families. Journal of Child Psychology and
Psychiatry, 46, 263–274.
Juffer, F., Bakermans-Kranenburg, M. J., & van
IJzendoorn, M. H. (2007). Promoting positive parenting: An attachment-based intervention. Mahwah, NJ:
Lawrence Erlbaum.
Klaus, M. H., & Kennell, J. H. (1982). Maternal-infant
bonding (2nd ed.). St. Louis, MO: Mosby.
Klein Velderman, M., Bakermans-Kranenburg, M. J.,
Juffer, F., & van IJzendoorn, M. H. (2006a). Effects
of attachment-based interventions on maternal sensitivity and infant attachment: Differential susceptibility
of highly reactive infants. Journal of Family Psychology, 20, 266–274.
Klein Velderman, M., Bakermans-Kranenburg, M. J.,
Juffer, F., van IJzendoorn, M. H., Mangelsdorf, S. C.,
& Zevalkink, J. (2006b). Preventing preschool externalizing behavior problems through video-feedback
intervention in infancy. Infant Mental Health Journal,
27, 466–493.
Lamb, M. E., Ketterlinus, R. D., & Fracasso, M. P. (1992).
Parent-child relationships. In M. H. Bornstein & M. E.
Lamb (Eds.), Developmental psychology: An
advanced textbook (3rd ed., pp. 465–518). Hillsdale,
NJ: Lawrence Erlbaum.
Lieberman, A. F., Ghosh Ippen, C., & Van Horn, P.
(2006). Child–parent psychotherapy: 6-month followup of a randomized controlled trial. Journal of the
American Academy of Child and Adolescent Psychiatry, 45, 913–918.

885
Lieberman, A. F., & Van Horn, P. (2005). Don’t hit my
mommy: A manual for child–parent psychotherapy
with young witnesses of family violence. Washington,
DC: Zero to Three Press.
Lieberman, A. F., Van Horn, P., & GhoshIppen, C. (2005).
Toward evidence-based treatment: Child-parent
psychotherapy with preschoolers exposed to marital
violence. Journal of the American Academy of Child
and Adolescent Psychiatry, 44(12), 1241–1248.
Malmberg, L., & Flouri, E. (2011). The comparison and
interdependence of maternal and paternal influences
on young children’s behavior and resilience. Journal
of Clinical Child & Adolescent Psychology, 40(3),
434–444.
Marvin, R., Cooper, G., Hoffman, K., & Powell, B.
(2002). The circle of security project: Attachmentbased intervention with caregiver – pre-school child
dyads. Attachment & Human Development, 4(1),
107–124.
Masten, A. S. (2001). Ordinary magic: Resilience processes in development. American Psychologist, 56,
227–238. doi:10.1037/0003-066X.56.3.227.
Masten, A. S., & Reed, M. G. (2002). Resilience in
development. In C. R. Snyder & S. J. Lopez (Eds.),
The handbook of positive psychology (pp. 74–88).
New York: Oxford University Press.
McNally, R. J., Bryant, R. A., & Ehlers, A. (2003). Does
early psychological intervention promote recovery
from posttraumatic stress? Psychological Science in
the Public Interest, 4, 45–79.
Nixon, R. D. V., Sweeney, L., Erickson, D. B., & Touyz,
S. W. (2003). Parent-child interaction therapy: A
comparison
of
standard
and
abbreviated
treatments for oppositional defiant preschoolers.
Journal of Consulting and Clinical Psychology,
71(2), 251–260.
Papousek, M. (2011). Resilience, strengths, and regulatory
capacities: Hidden resources in developmental
disorders of infant mental health. Infant
Mental Health Journal, 32(1), 29–46. doi:10.1002/
imhj.20282.
Perry, B. D. (2009). Examining child maltreatment
through a neurodevelopmental lens: Clinical application of the neurosequential model of therapeutics.
Journal of Loss and Trauma, 14, 240–255.
Pindar, C. (1994). Effects of the Active Parenting program
on the interpersonal behavior of children in
a playroom setting. Unpublished manuscript.
Promising Practices Network. (2011). Promising practices network. Retrieved February 14, 2012, from
http://www.promisingpractices.net/
Reid, M. J., Webster-Stratton, C., & Baydar, N. (2004).
Halting the development of conduct problems in head
start children: The effects of parent training. Journal of
Clinical Child and Adolescent Psychology, 33,
279–291. doi:10.1207/s15374424jccp3302_10.
Ryff, C. D., & Singer, B. (2003). Flourishing under fire:
Resilience as a prototype of challenged thriving. In
C. L. M. Keyes & J. Haidt (Eds.), Flourishing: Positive

886
psychology and the life well-lived (pp. 15–36). Washington, DC: American Psychological Association.
Sapienza, J., & Masten, A. (2011). Understanding and
promoting resilience in children and youth. Child and
Adolescent Psychiatry, 224, 267–273. doi:10.1097/
YCO.0b013e32834776a8.
Snyder, C. R., Hoza, B., Pelham, W. E., Rapoff, M., Ware,
L., Danovsky, M., et al. (1997). The development and
validation of the Children’s Hope Scale. Journal of
Pediatric Psychiatry, 22, 399–421.
Toth, S. L., Maughan, A., Manly, J. T., Spagnola, M., &
Cicchetti, D. (2002). The relative efficacy of two interventions in altering maltreated preschool children’s
representational models: Implications for attachment
theory. Development and Psychopathology, 14(4),
877–908.
Toth, S. L., Rogosch, F. A., Manly, J. T., & Cicchetti, D.
(2006). The efficacy of toddler–parent psychotherapy
to reorganize attachment in the young offspring of
mothers
with
major
depressive
disorder:
A randomized preventive trial. Journal of Consulting
and Clinical Psychology, 74, 1006–1016.

Resiliency During Early Childhood
Watson, P. J., Brymer, M. J., & Bonanno, G. A. (2011).
Postdisaster psychological intervention since 9/11.
American Psychologist, 66(6), 482–494. doi:10.1037/
a0024806.
Webster-Stratton, C., & Reid, M. J. (2010a). The incredible years parents, teachers and child training series:
A multifaceted treatment approach for young children
with conduct problems. In J. R. Weisz & A. E. Kazdin
(Eds.), Evidence-based psychotherapies for children
and adolescents (2nd ed., pp. 194–210). New York:
Guilford Press.
Webster-Stratton, C., & Reid, M. J. (2010b). Parents,
teachers, and therapists using child-directed play
therapy and coaching skills to promote children’s
social and emotional competence and build
positive relationships. In C. E. Schaefer (Ed.),
Play therapy for preschool children (pp. 245–273).
Washington,
DC:
American
Psychological
Association.
Werner, E. E., & Smith, R. S. (1982). Vulnerable but
invincible: A study of resilient children. New York:
McGraw-Hill.

Resiliency During Childhood

Resiliency During Childhood
Anna Tielsch-Goddard
Vanderbilt University, School of Nursing
Nashville, TN, USA

887

the emerging infant mental health field to the
integration of resiliency programs for the
school-aged and adolescent child. Successful
resilience is often the result of individuals
circumnavigating through their environment
and overcoming risk factor influences to
avoid psychological vulnerability, resulting into
a healthy adult construct.

Introduction
The study of resilience is just as broad and
dynamic as the definition. Resilience can be
referred to as a process, an experience, or a
characteristic of adaptation to adversity, stress,
or tragedy. One of the most famous examples of
thriving after facing a series of life’s perils is
Helen Keller who, armed with protective factors
throughout adolescence, despite an array of psychological vulnerability, was able to avoid potential negative outcomes from being deaf and
blind at an early age and triumphantly navigate
life as an author and public speaker. The term
“resilience” is often used when discussing coping
or coping strategies and is an essential and fundamental area of study in the field of pediatrics.
The resilience concept, also regarded as
“mental hardiness,” is the understanding of why
some people thrive in circumstances where others
have faltered and is a complex and intriguing
topic to many. Promoting childhood resilience
in order to foster positive developmental outcomes and success into adulthood can provide
coping for individuals in challenging situations
and has shown to reduce negative mental health
consequences and poor emotional outcomes.
Pediatric resilience is a multifactorial interaction
between risk factors such as a sociocultural
influences and individual characteristics and
protective factors entailing a diverse interface of
individual factors, family, and extrafamilial elements. Most interventions to promote childhood
resiliency focus on reducing health risk behaviors
and enhancing these protective factors, hence
“fostering resilience.”
Current research has moved beyond basic definitions and foundations of identifying protective
and risk factors and is now focusing on the
protective process across all age ranges from

Definitions and Scope
Disagreement on the operational definition of
“resilience” exists across a multidisciplinary
review of the term, but the concrete meaning is
always the same. The term “resilience” is defined
in terms of a skill, personality, an individual trait,
or as a psychological concept. “Resilience” is
used throughout literature and across multiple
disciplines, including psychology, medicine,
nursing, and sociology, as a noun, an adjective,
and a process and is synchronous with “psychological resilience,” “emotional resilience,” “hardiness,” and “mental resourcefulness.” As
a compiled definition, resilience is also known
as the ability to have positive outcomes or persistent competence while recovering from trauma,
high stress, or high-risk situations (Reivich &
Shatté, 2002; Resnick, 2000; Werner, 1994).
“Resilience” as a term is also used
interchangeably within the literature with
“protective factors” and “resilient personality.”
Risk factors, which are thought to be cumulative, are intrapersonal or environmental factors
that are associated with resilience and include
poverty or low socioeconomic status, prematurity, difficult temperament, insecure attachment,
inconsistent or harsh parenting, parental conflict
or divorce, single-parent households, school
failure, peer rejection, neighborhood violence,
racial discrimination, child abuse or neglect, and
external locus of control (Kumpfer, 1999; Rak &
Patterson, 1996; Rew & Horner, 2003). Resilient
children are thought to be capable of positive
coping despite an accumulation of risk factors
(Garmezy, 1974; Herrman et al., 2011). Protective
factors reduce the impact of risk factors and are
correlated to a higher or stronger resiliency.

T.P. Gullotta, M. Bloom (eds.), Encyclopedia of Primary Prevention and Health Promotion,
DOI 10.1007/978-1-4614-5999-6, # Springer Science+Business Media New York 2014

888

Protective factors include resourcefulness, healthy
birth, calm temperament, secure attachment, warm
parenting, family harmony (also known as family
cohesiveness), school success, support systems,
good neighborhoods, humor, high self-esteem, an
internal locus of control, and intelligence (Armstrong, Birnie-Lefcovitch, & Ungar, 2005;
Garmezy, Masten, & Tellegen, 1984; Masten,
Morrison, Pellegrini, & Tellegen, 1990; Myers &
Taylor, 1998; Rutter, 1987).

Theories
In 1973, epidemiologist Garmezy first published
research findings on resilience and initially
defined risk and protective factors which are
now tools to support the development of resilience (Garmezy, 1973). Garmezy (1974) found
that at-risk children raised by mothers with severe
mental illness developed normally despite undesirable circumstances. His research led to further
understanding of these factors and their correlation to resilience. In the 1980s, the concept of
pediatric resilience further gained popularity
after research findings of Emmy Werner had further defined family and individual traits that
impact childhood resilience. Werner first started
using the term “resilience” as she was studying
children in Kaui from poor families with either
alcoholic or mentally ill parents (Werner &
Smith, 1982). She found that two-thirds of the
children of these parents exhibited poor outcomes
late in life such as unemployment, substance
abuse, and teenage pregnancies. However, the
other one-third of the children had traits
that made them different and were coined the
“resilient” group. Werner’s longitudinal studies
followed participants from birth to 32 years of
age and led to pediatric resilience emerging as
a major theoretical framework and area of
research for the next 30 years to present day.
Werner continued to study pediatric resilience
protective factors and contributed to over
40 years of research concluding that “one caring
adult in a child’s life” is one of the most critical
protective factors (Werner, 1994; Werner &
Smith, 1982; Werner & Smith, 1992).

Resiliency During Childhood

Protective factors became a major investigative focus in order to help explain adaptation
to adverse conditions with positive outcomes.
Longitudinal studies have since shown the importance of different personality factors, or intrinsic
factors, within an individual (Garmezy et al.,
1984; Werner, 1994; Werner & Smith, 1982).
Consensus among major theories and scientific
school of thought maintains that resilient children
will share similar traits; including an active
approach toward problem-solving, an ability
to gain positive attention, an optimistic view
of experiences (even in tragedy), a positive
goal-setting mentality, and the ability to be autonomous; seek out novel experiences; and have
a proactive perspective (Garmezy et al., 1984;
Kumpfer, 1999; Rak & Patterson, 1996; Reivich
& Shatté, 2002). A further look into childhood
protective factors reveals the concept of protective resources which further modify the child’s
response to adverse outcomes and include competence (which includes social skills, scholastic
and physical ability, and a sense of self-worth),
positive coping styles, a sense of humor, connectedness with caring parents or adults (also referred
to as external support perception), and knowledge of health behaviors and risks (Garmezy &
Masten, 1991; Herrenkohl, Herrenkohl, & Egolf,
1994; Resnick, 2000; Rew & Horner, 2003).
Renowned researcher Ann Masten, Ph.D.
(1989) demonstrated the importance of parental
caregiving as a major component of resilience
in her work with schizophrenic mothers. Environmental components in one’s life have since
been well recognized as a significant impact on
resiliency in pediatrics. Role models outside the
family have been found to act as “buffers” for
vulnerable children and may include teachers,
school counselors, coordinators or instructors
of after-school programs, coaches, mental
health workers, and neighbors (Beadsless &
Podorefsky, 1988; Dugan & Coles, 1989; Rak &
Patterson, 1996).
The “self-concept” plays a major role across
the resiliency literature referring to the capacity
to understand the self and self-boundaries in
relation to long-term family stressors like psychological illness, positive self-esteem, and the

Resiliency During Childhood

ability to cope with stress and tragedy (Beadsless
& Podorefsky, 1988; Rak & Patterson, 1996).
Werner (1994, p. 71) best explains self-concept
in resilient children as “contribution to their
effective coping appeared to be a feeling of
confidence or faith that things will work out as
well as can be reasonably expected, and that odds
can be surmounted.”
The Resilience Framework is a well-accepted,
now international, theory identifying major
resilience processes into three major categories:
first, the individual characteristics of resilience
such as the child’s personal strengths; second,
the environmental or community precursors
(which are also referred to as risk and protective
factors as they relate to resilience); and finally,
the family construct or interpersonal dynamic
(Kumpfer, 1999). Building on prior universally
accepted social ecology, this metatheory focuses
on caretakers using different socialization
processes to improve their child’s resiliency characteristics into five different resilience areas:
(1) Spiritual, by supporting the development of
talents, goal-oriented self-esteem, knowledge,
and academic skills; (2) cognitive, by developing
self-esteem and providing knowledge and academic skills; (3) behavioral, through modeling,
coaching, and reinforcing behavioral competence; (4) emotional, by reflecting feelings,
modeling, and reinforcing management of
emotions; and (5) Physical, by teaching and
reinforcing good health and healthy choices
(Kumpfer).

Current Research
The current research in pediatric resilience is as
broad as the concept and definition. Up-to-date
research ranges from looking at resiliency factors
in high-risk youth, environmental components of
resilience, resiliency promotion in the child with
a chronic condition to the neurobiological and
genetic confounds of resilience. A current shift
in research involving resiliency programs
has moved from the creation and presentation
of intervention programs to the promotion of
resilience across different youth genres and

889

analysis of the reproducibility, validity, and reliability of these programs.
Following the constructs formed by the early
theorists of pediatric resilience, an outburst of
intervention programs began to emerge, while
researchers are now focusing on statistically significant results of these programs to further prevent psychological vulnerability. Researchers are
looking at protective and risk factors of resilience
among different genders, twin studies, divorce,
single-parent households, and socioeconomic statuses as both pilot and repetitive studies looking at
promotion interventions (Bowes, Maughan, Caspi,
Moffitt, & Arseneault, 2010; Gillham & Reivich,
2011; Greenberg, 2006; Reivich & Shatté, 2002).
Some research focuses on single components of
resiliency, while others take a multifaceted
approach to the constructs of resilience.
Interventions beginning in utero and immediately postnatal have shown promising results
in resiliency promotion. For example, in
a population of low socioeconomic status, single,
unwed mothers receiving prenatal care, social
support, and behavioral interventions found that
the infants had superior mental capacity when
there was a resilience protective measure against
maternal stress (Olds, Sadler, & Kitzman, 2007;
Ozbay, Fitterling, Chamey, & Southwick, 2008).
Maternal nutrition in pregnancy, avoidance of
maternal smoking and alcohol consumption,
maternal social support, and access to prenatal
and antenatal care have now been proven
as effective strategies in the earliest years of
pediatric development to build resilience later in
life (Newman, 2004).
Important to note is the recent surge of investigators linking resilience factors and resiliency
beyond the environmental components and recognizing psychobiological contributing factors.
The role of individual development (ontogeny)
and evolutionary development (phylogeny)
appears to play a major role in resilience that is
not yet entirely understood (Stein, 2009). Early
developmental in utero and postnatal environments affect the developing neurobiological system affecting brain size, neural networks,
receptor sensitivity, and neurotransmitter synthesis and reuptake that can later reduce

890

vulnerability to psychopathology (Cicchetti &
Curtis, 2006; Herrman et al., 2011). Further studies of both maltreated and non-maltreated children revealed that high morning cortisol levels
correlate to higher resilient functioning in the
abused children with further studies showing personality, cortisol, and dehydroepiandrosterone as
independent contributors to resilience (Cicchetti
& Rogosch, 2007). An onslaught of genetic studies on resilience provides evidence of geneenvironment interaction effects on coping strategies in high risk and the effects of genetic polymorphisms which is furthering the understanding
of promotion of resilience from a biological
standpoint (Cicchetti, Rogosch, & SturgeApple, 2007; Parent et al., 2005).
Emphasis on the protective role of the family, or
social system resources, has emerged across disciplines both in the United States and internationally.
A longitudinal study in the United Kingdom with
a nationally diverse sample showed the importance
of family factors, including maternal warmth, positive home atmosphere, and positive sibling relations, as a strong resiliency factor against bullying
victimization (Bowes et al., 2010). Correlation of
the family resilience factor as a preventative measure against risk factors has also emerged in promotion literature. For example, the Center for
Substance Abuse Prevention (CSAP) has funded
a large implementation for a community-based
church program that targets strengthening family
resilience as a way to prevent alcohol and drug use
in preteens and teens with positive results in the
communities (Johnson et al., 1998).
Resiliency research continues to flourish
among children in different environments such
as the rural, urban, and suburban settings as well
as resiliency studies in different ethnicity groups.
In a recent study of parental support as a protective factor in Latino youth, researchers found that
the community-academic partnership benefited
these youth and predicted later success among
the children, whereas Latino parents’ beliefs on
seeking outside assistance became a barrier in the
resilience promotion programs in the community
(Shetgiri et al., 2009). Researchers found the
Latino young people in the United States

Resiliency During Childhood

are currently one of the highest cohorts of risk
exposure including violence among family and
friends, gang-related violence, homicide, suicide
rates, school dropout, and poverty levels (Eaton
et al., 2007; Fergus & Zimmerman, 2005).
Shetgiri and colleagues (2009) explored barriers
to success including lack of parental involvement, low family expectations, and negative
influence of the family as major themes of risk
within this group. Interestingly, researchers
found that the Latino youth’s teachers held
a major importance in helping them succeed and
move out of the projects, whereas, parents often
had a negative perception of teachers and support
staff at the schools (Shetgiri et al.).
Finally, the emergence of the resiliency
concept as a metatheory to guide interventions
has been utilized across multiple disciplinary
treatment plans. Vinson (2002) incorporated the
Child Resilience Model ® to look at pediatric
management of a chronic health condition.
Studying children with asthma, researchers incorporated resilience components of family influences and specific interpersonal characteristics
of coherence, internal locus of control,
competence, problem-solving, and self-esteem
as integral to treating and caring for a child with
chronic illness (Vinson).

Overview of Strategies
Promotion strategies will often focus on one or
more of the well-defined resilience protective
factors that have been established through
over 50 years of research. Interventions focus
on multiple levels of individual (intrapersonal,
interpersonal, or group), family-level (instrumental, social or moral support), or community
(neighborhood, school) factors and will often
incorporate more than one into a successful
design. These broad categories and subcategories
of terms are referenced in the literature by
a multitude of terminology but ultimately
are synchronous in meaning. (See Table 1 for
overview of resilience protective factors used
throughout promotion interventions.)

Resiliency During Childhood
Resiliency During Childhood, Table 1 Resilience
protective factors
Individual protective
factors

Family-level protective
factors

Community protective
factors

Intrapersonal
Cognitive functioning
Creativity
Adaptability
Self-efficacy
Self-esteem
Anger
Impulse control
Positive temperament
Motivation
Purpose
Interpersonal
Social skills
Empathy
Communication skills
Group membership
Activism
Religiosity
Racial identity
Instrumental support
Stable family resources
Parenting skills
Parental support
Parental monitoring and
supervision
Consistent discipline
Household rules and
responsibilities
Authoritative parenting style
Family communication
Social support
Family connectedness
Parent-child relationships
Moral support
Spirituality
Religion
High academic expectations
Neighborhoods
Schools
High levels of community
resources
Racial diversity
Low unemployment
High community
expectations

Adopted by authors (Armstrong et al., 2005; Lazarus &
Folkman, 1984; Rak & Patterson, 1996; Resnick, 2000;
Sapienza & Masten, 2011; Werner & Smith, 2001)

891

Reducing barriers or decreasing risk factors is
often coupled with the promotion of protective
factors. In many incidences, the very act of reducing a risk factor will create a protective factor in
its place. For example, by teaching parenting
skills or strengthening the parent-child relationship and hence enhancing a protective factor, the
corresponding risk factors, inconsistent, harsh
parenting models and insecure attachments, are
replaced and the individual resilience traits are
enhanced.
As Werner discovered in her early research,
family connectedness has repeatedly been shown
as one of the strongest predictors for health outcomes in pediatrics (Resnick, Harris, & Blum,
1993; Werner, 1994). Preventative interventions
that help families develop strong protective factors are more cost-effective than supplying aid for
families in crisis (Patterson, 2002). Research
focusing on family communication skills training
as well as the parent’s role in supporting a healthy
environment and lifestyle has continued to flood
the literature as one of the prime interventions in
promoting pediatric resilience (Resnick et al.,
1993). An understanding of family resilience as
a protective process is best explained by the
Family Adjustment and Adaptation Response
(FAAR) model ® (Patterson, 2002). In this
construct, the emphasis on family cohesiveness,
flexibility (through family routines), and communication as core protective factors allows the
individual to learn adaptive conflict resolution
and decision making (Patterson).
Identifying the child’s coping style and building on healthy stress management skills continues to be included as successful promotion
interventions. Adapting a variety of coping skills
has been referenced as a hallmark of resilience
and positive outcomes throughout life and
development and strengthens problem-solving
capabilities (Puskar, 2010; Rew & Horner,
2003; Shelton & Lyon-Jenkins, 2006). For
example, Kurdek and Berg (1987) found children have more difficulty if they blame themselves for parental discord and divorce. By
teaching coping management, replacing avoidance or self-blame with reflection and

892

acclamation, children have healthier outcomes
(Kurdek & Berg; Wolchik, Schenck, & Sandler,
2009). In a follow-up study of preventative interventions for children after divorce, researchers
found significantly less substance abuse, externalizing behavior, and fewer symptoms of mental disorders after completion of a program
which incorporates coping into its framework
(Wolchick et al., 2002).

What Works
Successful interventions will focus on building
strengths and resources of the child and family
while addressing the overall functioning of the
child as opposed to the concentration on solitary
discrete problems. In other words, successful
programs must address a number of factors and
avoid concentrating on a sole intervention. Fostering resilience through the enhancement of
protective resources and intervening in early
childhood greatly reduces any negative impact
from risk factors and bad outcomes. Programs
that provide consultation and training to parents,
schools, neighborhoods, and individuals which
emphasize the importance of coping, selfesteem, and other protective factors tend of the
have most success.
Family and child strengthening approaches
have an impact on increased resilience such as
improving child outcomes indicated by programs
such as WIC, childcare, early preschool, and
family support programs. Urie Bronfenbrenner
(1979), well known for his Ecological
Systems Theory, was the cofounder of the United
States’ HeadStart® program for disadvantaged
pre-schoolers. HeadStart ® is a nationally
established program in the United States that provides education to the child and family, health,
and nutrition; fosters parental involvement;
fosters parental resiliency interventions; and
offers support services for at-risk children
(National Head Start Association [NHSA],
2011; Rak & Patterson, 1996). Other major
organizations have been founded with this
concept such as Big Brothers Big Sisters and the
Police Athletic League in order to mentor parents

Resiliency During Childhood

and role model and help promote resiliency by
meeting a major protective factor component of
environmental support (Big Brothers Big Sisters,
2011; Rak & Patterson, 1996).
The New Beginnings Program ® (NBP),
originally developed in the 1980s, is a
resiliency-based prevention intervention program for families of divorce by reducing the
child’s exposure to risk factors and increasing
resilience resources (Wolchik et al., 2009).
NBP ® is designed for divorced parents who
have children between the ages of 3 and 17 with
the goal of promoting resilience among children
following parental divorce. The NBP ® consists of
10 weekly group sessions and two individual
sessions. Parents learn skills to improve parentchild relationship quality and effectiveness of
discipline, reduce exposure to interparental conflict, and decrease barriers to nonresidential
parent-child contact. Each session includes
a short lecture, skill demonstration, and skill
practice. Participants are assigned homework
after each session; difficulties and successes in
implementing the skills at home are discussed in
subsequent sessions. Each group is co-led by two
master’s-level clinicians. With focus on modifying risk factors while also adding protective factors to the family system, the NBP ® has shown to
improve the quality of parenting, such as the
mother-child relationship, effective discipline,
and parenting skills. Repeated evaluations have
showed that the NBP ® has had positive youth
adaptation outcomes lasting into adolescence
(Wolchik et al.).
Teaching Kids to Cope® (TKC) is a noteworthy
cognitive-behavioral education program for teenagers aged 12–18 years old with symptoms of
depression or thoughts of suicidal ideation
(Puskar, 2010). Through group sessions, based
on Lazarus and Folkman’s Stress and Coping
Theory, participants review principles of stressors,
self-image, coping, family relationships, and
communications. Participants are then aided in
problem identification exercises through experiential learning (Lazarus & Folkman, 1984; Puskar,
2010). The program consists of 10 sessions, 1 h
a week, and is taught by a health-care professional
fully versed in the TKC® intervention program.

Resiliency During Childhood

Follow-up studies have found an improvement in
depression symptoms and higher use of cognitive
problem-solving coping strategies after completion of the TKC® curriculum (Puskar, Sereika, &
Tusaie-Mumford, 2003).

What Is Promising
The Penn Resiliency Program ® (PRP) is a
curriculum based on cognitive-behavioral and
social problem-solving skills which focuses on
group interventions for late elementary and middle school students (Gillham & Reivich, 2011).
This program is based on the Adversity-BeliefsConsequences (ABC) model where students are
taught to detect and evaluate inaccurate thoughts
and challenge negative thoughts by considering
other interpretations. The PRP ® addresses
problem-solving and coping through difficult
situations and negative thoughts while
learning assertiveness, negotiation, and relaxation (Gillham & Reivich). The curriculum
includes lessons where these resilience concepts
and skills are practiced and demonstrated
through examples with the goal to incorporate
these skills into real-life situations. Evaluated in
over a dozen randomized controlled designs, the
PRP ® has now been implemented internationally (Gillham & Reivich). For example, the UK
Resilience Program ® is training teachers to use
the PRP ® curriculum in order to teach resilience
skills to middle school students. A similar program using PRP ® in Australia known as the
“Geelong Grammar School Positive Psychology
Project” is being implemented at boarding
schools to incorporate resilience skills into the
school’s
culture.
Canada’s
“Reaching
In. . .Reaching Out ®” (RIRO) program combines the PRP ® program with Reivich and
Shatté’s The Resilience Factor to reach youth
from birth to seven years by training adults in
role model thinking and coping strategies, which
focuses on the adult-child relationship components of resilience (Child and Family Partnership, 2010; Reivich & Shatté, 2002).
The Promoting Alternative Thinking Strategies ® (PATHS) curriculum aims at strengthening

893

executive functioning behaviors at a schoolbased prevention level. Executive functioning
refers to inhibitory control and planning,
problem-solving, emotional regulation, and
attention skills (Greenberg, 2006). Based
on the Affective-Behavioral-Cognitive-Dynamic
(ABCD) model integrating cognition, affect,
language, and behavior, the PATHS ® program
aims at preventing resilience by reducing aggression and behavior problems by promoting the
development of social-emotional competence in
the school-aged years. Children are taught vertical control, which is control over limbic impulses,
by providing opportunities for self-control. Verbal processing of action-based curriculum helps
focus children on identifying and labeling different feelings and how to manage these feelings
(Greenberg). Outcome trails have shown the
PATHS® curriculum results in decreased externalizing and internalizing of problems and has
increased both social and emotional competence
(Kam, Greenberg, & Kusché, 2004). A randomized control study showed great improvements in
inhibitory control and verbal fluency with the
PATHS program with continued improvement
at the 1 year follow-up (Greenberg, 2006).
The Solihull Approach Model ®, developed
and being implemented in the United Kingdom,
was constructed to better support emotional
health and well-being between children and
their parents (Douglas, 2010). The program
focuses on family risk resilience factors and
works one-on-one with families as well as parent
support groups (Douglas). Focusing on the
child’s main relationships, the model integrates
child development and behavioral research in
order to develop emotionally healthy children.
Parents are taught a variety of processes to help
their child manage emotions and understand
reciprocity concepts as well as “containment”
referring to emotional communication between
two parties. The Solihull Approach ® is currently
being implemented in UK programs and used by
the UK Department for Education. Further
evidence-based studies are needed to examine
reliability and construct validity of the program
as well as the implementation of longitudinal
studies.

894

What Does Not Work
As distress occurs in all contexts, socioeconomic
status and areas of life, and does not discriminate
across ethnicities, completely altering the exposure to vulnerability to children is impossible.
Certain situations are uncontrollable such as the
death or illness of a parent or prolonged chronic
child stressors such as neighborhood problems
and violence. Although resiliency programs and
implementation of therapeutic resiliency
strengthening are fundamental to pediatric emotional health, psychological vulnerability will
always factor into the patient’s character.
Because of this limitation, the evaluation of resilience programs faces multiple obstacles.
Controversy exists on whether we can actually
train or teach resilience versus resilience as an
innate, hardwired trait within the personality or
inner self. An antagonistic theory of resilience
training argues that due to biological programming or damage to neural structures, resilience
can only be taught to a certain degree (Herrman
et al., 2011). Since the psychobiology of resilience is a very novel and emerging field, further
studies are indicated before any consensus on this
theory may materialize. Other researchers argue
that this controversy is rooted in the multiple uses
of different terminology in the resiliency field
(Herrman et al.). Famed resiliency expert,
Dr. Al Siebert (1996), for example, argues that
resiliency cannot be taught, but it can be learned
by developing unique combination of inborn
attributes and abilities (Siebert).
Limitations in the resiliency research, which
further complicate the understanding of what
does or does not work in certain populations, are
the methodological considerations of research
studies. For example, not all studies use standardized measures; some are small and have very
specific population groups which may limit generalizability, while other cross-sectional designs,
for example, cannot account for cumulative factors (Herrman et al., 2011). Generalizability of
intervention programs to other groups outside the
defined population of the original intervention
study is often in question or stated as
a limitation in published resiliency studies

Resiliency During Childhood

(Herrman et al.). Therefore, further research is
needed across the resiliency field to provide
evidence-based practice guidelines and support
for the best model of practice in implementing
resiliency promotion programs. There is not
enough evidence to clearly state what strategies
do not work in promoting positive resilience
factors.

Summary
Promoting pediatric resiliency, especially those
at risk due to poverty, family discord, illness,
violence, or other risk factors, is essential in
long-term success and adjustment into adulthood.
Focusing on protective factors as a conceptual
base for prevention programs enhances the pediatric resilience concept in youth. Building resiliency, especially in at-risk youth populations, has
become a major goal of different community,
medical, and personal intervention programs. Promoting pediatric resilience is generally seen as
a positive approach to minimize adverse mental
health sequelae and, therefore, decreases psychological vulnerability. Cognitive-behavioral techniques include increasing optimism, cognitive
plasticity, strengthening coping skills, while
focusing on family involvement is becoming
a standard for resilience promotion interventions.
Further external validity and reliability studies
are needed in the evaluation of the numerous
resiliency promotion programs that have materialized to include multiple community settings in
both rural, suburban, and inner city settings alike.
The continued longitudinal follow-up with participants in resiliency programs will further contribute to understanding resilience strategies that
are successful versus those that still need further
evidence of sustainability.

References
Armstrong, M., Birnie-Lefcovitch, S., & Ungar, M.
(2005). Pathways between social support, family
well-being, quality of parenting, and child resilience:
What we know. Journal of Child and Family Studies,
14(2), 269–281.

Resiliency During Childhood
Beadsless, M., & Podorefsky, M. A. (1988). Resilient
adolescents whose parents have serious affective and
other psychiatric disorders: Importance of selfunderstanding and relationships. American Journal of
Psychiatry, 145, 63–69.
Big Brothers Big Sisters. (2011). Mentoring. Accessed
July 26, 2011. Available at: http://www.bbbs.org/site/
c.9iILI3NGKhK6F/b.5962335/k.BE16/Home.htm
Bowes, L., Maughan, B., Caspi, A., Moffitt, T. E., &
Arseneault, L. (2010). Families promote emotional
and behavioral resilience to bullying: Evidence of an
environmental effect. The Journal of Child Psychology
and Psychiatry, 51(7), 809–817.
Bronfenbrenner, U. (1979). The ecology of human development. Cambridge, MA: Harvard University Press.
Child and Family Partnership. (2010). Reaching
In. . .Reaching Out (RIRO): Promoting resilience in
young children. Retrieved January 23, 2012. Available
at: http://www.reachinginreachingout.com/
Cicchetti, D., & Curtis, W. J. (2006). The developing brain
and neural plasticity; implications for normality,
psychopathology, and resilience. In D. Cicchetti &
D. Cohen (Eds.), Developmental psychopathology.
vol 2: Developmental neuroscience (2nd ed.,
pp. 1–64). New York: Wiley.
Cicchetti, D., & Rogosch, F. A. (2007). Personality, adrenal steroid hormones, and resilience in maltreated
children: A multilevel perspective. Developmental
and Psychopathology, 19, 787–809.
Cicchetti, D., Rogosch, F. A., & Sturge-Apple, M. L.
(2007). Interactions of child maltreatment and serotonin
transporter and monoamine oxidase A polymorphisms:
Depressive symptomatology among adolescents from
low socioeconomic status backgrounds. Developmental
and Psychopathology, 19, 1161–1180.
Douglas, H. (2010). Supporting emotional health and
wellbeing: The Solihull approach. Community Practitioner, 83(8), 22–25.
Dugan, T., & Coles, R. (Eds.). (1989). The child in our
times: Studies in the development of resiliency. New
York: Burner/Mazel.
Eaton, D., Kann, L., Kinchen, S. Shanklin, J., Ross, J.,
Hawkins, J., et al. (2007). Youth risk behavior surveillance: United States. Morbidity and Mortality Weekly
Report, 2008, 57(4), 1–131.
Fergus, S., & Zimmerman, M. A. (2005). Adolescent
resilience: A framework for understanding healthy
development in the face of risk. Annual Review of
Public Health, 26, 399–419.
Garmezy, N. (1973). Competence and adaptation in
adult schizophrenic patients and children at risk. In S. R.
Dean (Ed.), Schizophrenia: The first ten dean award
lectures (pp. 163–204). New York: MSS Information.
Garmezy, N. (1974). The study of competence in children
at risk for severe psychopathology. In E. J. Anthony &
C. Koupernick (Eds.), The child in his family: Children
at psychiatric risk (pp. 77–97). New York: Wiley.
Garmezy, N., & Masten, A. (1991). The protective role of
competence indicators in children as risk. In E. M.

895
Cummings, A. L. Green, & K. H. Karraki (Eds.),
Lifespan developmental psychology: Perspectives on
stress and coping (pp. 151–174). Hillsdale, NJ: Lawrence Erlbaum Associates.
Garmezy, N., Masten, A., & Tellegen, A. (1984). The
study of stress and competence in children:
A building block for developmental psychopathology.
Child Development, 55, 97–111.
Gillham, J., & Reivich, K. (2011). Positive psychology program. Resilience research in children:
The Penn Resiliency Project. Retrieved January
23, 2012. Available at: http://www.ppc.sas.upenn.
edu/prpsum.htm
Greenberg, M. T. (2006). Promoting resilience in children
and youth; preventive interventions and their interface
with neuroscience. Annals of the New York Academy of
Sciences, 1094, 139–150.
Herrenkohl, E. C., Herrenkohl, R. C., & Egolf, B. (1994).
Resilient early school-age children from maltreating
homes: Outcomes in late adolescence. American Journal of Orthopsychiatry, 64, 301–309.
Herrman, H., Stewart, D. E., Diaz-Granados, N., Berger,
E. L., Jackson, B., & Yuen, T. (2011). What is resilience? La Revue canadienne de psychiatrie, 56(5),
258–265.
Johnson, K., Bryant, D. D., Colins, D. A., Noe, T. D.,
Strader, T. N., & Berbaum, M. (1998). Preventing
and reducing alcohol and other drug use among highrisk youths by increasing family resilience. Social
Work, 43(4), 297–308.
Kam, C., Greenberg, M. T., & Kusché, C. A. (2004).
Sustained effects of the PATHS curriculum on the
social and psychological adjustment of children in
special education. Journal of Emotional and Behavioral Disorders, 12, 66–78.
Kumpfer, K. L. (1999). Factors and processes contributing
to resilience: The resilience framework. In M. D.
Glantz & J. L. Johnson (Eds.), Resilience and development: Positive life adaptations (pp. 179–224). New
York: Kluwer Academic Plenum.
Kurdek, L., & Berg, B. (1987). Children’s beliefs about
parental divorce scale: Psychometric characteristics
and concurrent validity. Journal of Consulting and
Clinical Psychology, 55(5), 712–718.
Lazarus, R. S., & Folkman, S. (1984). Stress, appraisal
and coping. New York: Springer.
Masten, A. S. (1989). Resilience in development:
Implications of the study of successful adaptation for
developmental psychopathology. In D. Cicchetti (Ed.),
The emergence of a discipline: Rochester symposium on
developmental psychopathology (Vol. 1, pp. 261–294).
Hillsdale, NJ: Erlbaum.
Masten, A. S., Morrison, P., Pellegrini, D., & Tellegen, A.
(1990). Competence under stress: Risk and protective
factors. In J. Roll, A. S. Masten, D. Cicchetti,
K. Nuechterlein, & S. Eitraub (Eds.), Risk and protective factors in the development of psychopathology
(pp. 236–256). Cambridge, UK: Cambridge
University Press.

896
Myers, H. F., & Taylor, S. (1998). Family contributions to
risk and resilience in African American children.
Journal of Comparative Family Studies, 29, 215–229.
National Head Start Association (NHSA). (2011).
HeadStart mission statement. Accessed July 9, 2011.
Available at: http://www.nhsa.org/
Newman, T. (2004). What works in building resilience.
Illford, UK: Barnardos.
Olds, D. L., Sadler, L., & Kitzman, H. (2007). Programs
for parents of infants and toddlers: Recent evidence
from randomized trials. Journal of Child Psychology
and Psychiatry, 48(3), 355–391.
Ozbay, F., Fitterling, H., Chamey, D., & Southwick, S.
(2008). Social support and resilience to stress across
the life span: A neurologic framework. Current Psychiatry Reports, 10(4), 304–310.
Parent, C., Zhang, T., Caldji, C., Bagot, R., Champagne, F.,
Pruessner, J., et al. (2005). Maternal care and individual
differences in defensive responses. Current Directions
in Psychological Science, 14(5), 229–233.
Patterson, J. M. (2002). Understanding family resilience.
Journal of Clinical Psychology, 58, 233–246.
Puskar, K. (2010). Teaching Kids to Cope (TKC) ®. Substance Abuse and Mental Health Services Administration. National Registry of Evidence Based Programs and
Practices. Retrieved February 8, 2012. Available at:
http://nrepp.samhsa.gov/ViewIntervention.aspx?id=83
Puskar, K., Sereika, S., & Tusaie-Mumford, K. (2003).
Effect of the Teaching Kids to Cope (TKC) program
on outcomes of depression and coping among rural
adolescents. Journal of Child and Adolescent Psychiatric Nursing, 16(2), 71–80.
Rak, C. F., & Patterson, L. W. (1996). Promoting resilience in at-risk children. Journal of Counseling and
Development, 74, 368–373.
Reivich, K., & Shatté, A. J. (2002). The resilience factor.
New York: Broadway Books.
Resnick, M. D. (2000). Protective factors, resiliency, and
healthy youth development. Adolescent Medicine:
State of the Art Reviews, 11, 157–164.
Resnick, M. D., Harris, L. J., & Blum, R. W. (1993). The
impact of caring and connectedness on adolescent
health and well-being. Journal of Paediatrics and
Child Health, 29(Suppl 1), S3–S9.
Rew, L., & Horner, S. (2003). Youth resilience framework
for reducing health-risk behaviors in adolescents.
Journal of Pediatric Nursing, 18(6), 379–388.
Rutter, M. (1987). Psychosocial resilience and protective
mechanisms. American Journal of Orthopsychiatry,
57, 316–331.
Sapienza, J. K., & Masten, A. S. (2011). Understanding
and promoting resilience in children and youth. Current Opinion in Psychiatry, 24(4), 267–273.

Resiliency During Childhood
Shelton, D., & Lyon-Jenkins, N. (2006). Mental health
promotion for vulnerable African American youth.
Journal of Forensic Nursing, 2(1), 7–32.
Shetgiri, R., Kataoka, S., Ryan, G., Miller Askew, L.,
Chung, P., & Schuster, M. (2009). Risk and
resilience in Latinos: A community-based participatory
research study. American Journal of Preventive
Medicine, 37(6SI), S217–S224.
Siebert, A. (1996). The survivor personality. New York:
Berkley Publishing Group.
Stein, D. J. (2009). The psychobiology of resilience. The
International Journal of Neuropsychiatric Medicine:
CNS Spectrum, 14(2), 41–47.
Vinson, J. A. (2002). Children with asthma: Initial
development of the child resilience model. Pediatric
Nursing, 28(2), 149–158.
Werner, E. (1994). Overcoming the odds. Journal of
Developmental Behavioral Pediatrics, 15(2), 131–136.
Werner, E., & Smith, R. S. (1982). Vulnerable but invincible: A longitudinal study of resilient children and
youth. New York: McGraw Hill.
Werner, E., & Smith, R. (1992). Overcoming the odds:
High risk children from birth to adulthood. Ithaca, NY:
Cornell University Press.
Werner, E., & Smith, R. S. (2001). Journeys from childhood to midlife: Risk, resilience, and recovery. Ithaca,
NY: Cornell University Press.
Wolchick, S. A., Sandler, I. N., Millsap, R. E.,
Plummer, B. A., Greene, S. M., Anderson, E. R.,
et al. (2002). Six-year follow-up of preventative interventions for children of divorce. JAMA: The Journal of
the American Medical Association, 288(15),
1874–1881.
Wolchik, S. A., Schenck, C., & Sandler, I. N. (2009).
Promoting resilience in youth from divorced families:
Lessons learned from experimental trails of the New
Beginnings Program. Journal of Personality, 77(6),
1833–1868.

Further Reading: Books
Brooks, R., & Goldstein, S. (2001). Raising resilient children. New York: McGraw-Hill.
Brooks, R., & Goldstein, S. (2003). Nurturing resilience in
our children. New York: McGraw-Hill.

Further Reading: Films
Helen Keller. (1962). The miracle worker [Movie]. MGM
Studio.
Temple Grandin. (2010). HBO Home Video Studios.
The Shawshank Redemption. (1994). Castle Rock Studio.

School Absenteeism During Childhood

School Absenteeism During
Childhood
Christopher A. Kearney and Rachele Diliberto
Department of Psychology, University of
Nevada, Las Vegas, Las Vegas, NV, USA

Introduction to School Absenteeism
Introduction
Problematic school absenteeism is a vexing issue
for educators, mental health and medical professionals, and those working in juvenile justice
settings. Absenteeism from school is a national
and international problem (Kearney, 2008) that
has received burgeoning research attention from
experts in many disciplines. The prevalence,
scope, and potentially devastating outcomes of
prolonged school absenteeism are pervasive and
have thus led to the development of early intervention and prevention strategies to be covered in
this entry.
Definitions and Scope
Problematic absenteeism has no consensual definition because researchers and school district
officials often employ idiosyncratic parameters
to delineate excessive absences. A recently
proposed definition of problematic school absenteeism based on a review of outcome studies
includes school-aged youths who (1) have
missed at least 25 % of total school time for at
least 2 weeks, (2) experience severe difficulty
attending classes for at least 2 weeks with
significant interference in a youth’s or family’s
daily routine, and/or (3) are absent for at least
10 days of school during any 15-week period
while school is in session, with an absence defined
as 25 % or more of school time missed (Kearney,
2008). Problematic school absenteeism has also
been equated with the term school refusal behavior that refers to child-motivated refusal to attend
school and/or difficulties remaining in classes for
an entire day. Problematic school absenteeism or
school refusal behavior thus covers different
forms of absences such as complete or partial

897

days missed, skipped classes, chronic tardiness,
morning misbehaviors in an attempt to miss
school, and severe distress at school that precipitates pleas for future nonattendance (Kearney &
Silverman, 1996). School absenteeism may be
a singular problem or one embedded in comorbid
behavioral, psychiatric, or familial problems
(McShane, Walter, & Rey, 2001).
The prevalence and scope of school absenteeism are substantial. A community survey of
youths with truancy and anxiety-based school
refusal revealed a prevalence rate of 8.2 %
(Egger, Costello, & Angold, 2003). National
statistics indicate that 19 % of fourth graders
and 20 % of eight graders missed at least 3 days
of school in the past month (National Center
for Education Statistics, 2006). In addition, graduation rates are below 50 % in several major
American cities (Editorial Projects in Education
Research Center, 2008). The overall prevalence
of school refusal behavior, which includes
absentee-related behaviors such as tardiness,
reportedly ranges up to 28–35 % (Kearney,
2001; Pina, Zerr, Gonzales, & Ortiz, 2009).
Problematic school absenteeism is associated
with a myriad of poor outcomes such as substance
abuse, violence, suicide attempt, risky sexual
behavior, pregnancy, delinquency, injury, illness,
and school dropout as well as long-term economic
deprivation and social, marital, occupational, and
psychiatric problems (Hibbett & Fogelman, 1990;
Hibbett, Fogelman, & Manor, 1990; Kogan, Luo,
Murry, & Brody, 2005; Tramontina et al., 2001).

Theories
Theories of problematic school absenteeism have
been historically limited in scope and restricted to
subsets of youth. Researchers of various disciplines have tended to conceptualize youth with
problematic absenteeism based on specific forms
of behavior. Psychologists, for example, often concentrate on fear- and anxiety-based absenteeism in
the form of school phobia, separation anxiety, or
school refusal. These conditions apply to youths
who miss school due to excessive fear of a schoolrelated stimulus (e.g., bus, teacher), difficulty

T.P. Gullotta, M. Bloom (eds.), Encyclopedia of Primary Prevention and Health Promotion,
DOI 10.1007/978-1-4614-5999-6, # Springer Science+Business Media New York 2014

898

separating from major attachment figures such as
parents, and anxiety regarding social and evaluative situations at school (e.g., peer interactions,
tests) (Suveg, Aschenbrand, & Kendall, 2005).
Educators, criminal justice professionals, and
social workers, on the other hand, often concentrate on delinquent-based truancy. Truancy is a
legal term that refers to illicit and/or surreptitious
absences from school and is typically based on
a set number of absences (e.g., 10+ absences in
one school semester). Truancy has additional
meanings in the research literature that include
school absenteeism associated with poor parental
knowledge or supervision, low anxiety, academic
problems, and conditions such as homelessness
or poverty (Fremont, 2003). An important drawback of disparate theories of problematic school
absenteeism is that little consensus has evolved
regarding effective assessment, intervention,
and prevention practices for this population
(Kearney, 2003).
More contemporary theoretical approaches
have focused on efforts to integrate disciplinespecific constructs to provide a comprehensive
model that includes all youth with problematic
school absenteeism. Researchers have thus begun
to focus on constructs that “cut across” traditional
distinctions (e.g., anxiety-based school refusal,
truancy), eschew models of school absenteeism
based purely on symptomatology, and emphasize
ecological variables such as school climate
(Claes, Hooghe, & Reeskens, 2009; Williams,
Sanchez, & Hunnell, 2011).
One such model was designed by Kearney and
colleagues who emphasized the function of
absenteeism instead of behavior form (e.g., Kearney & Albano, 2004). Youths are hypothesized to
refuse school for reinforcers that include
(1) avoidance of school-based stimuli that provoke negative affectivity (general anxiety/
depression), (2) escape from aversive social
and/or evaluative situations, (3) pursuit of attention from significant others, and (4) pursuit of
tangible rewards outside of school such as time
with friends, sleeping late, or watching television
(Kearney & Silverman, 1996). The first two functions involve negative reinforcement, or a desire
to terminate an aversive school-related event.

School Absenteeism During Childhood

The latter two functions involve positive
reinforcement, or a desire to pursue more alluring
activities outside of school. Youths may also
refuse school for two or more functions.
This functional model has received extensive
empirical support with respect to classifying,
assessing, and treating school refusal behavior
(Haight, Kearney, Hendron, & Schafer, 2011;
Kearney, 2007; Kearney & Silverman, 1999).
Other researchers have proposed multidisciplinary models that encompass broader
ecological and contextual variables that impact
problematic absenteeism (Reid, 2003; Rodriguez
& Conchas, 2009). Kearney (2008) summarized
these efforts by arranging contextual factors in
hierarchical order. These contextual factors
include those pertinent to a youth with problematic absenteeism as well as his or her parents,
family, peers, school, and community. Contextual factors include child psychopathology, parenting style, family communication dynamics,
deviant peer associations, school climate, and
disorganized neighborhoods, among others.
Each contextual factor can occur alone or in
combination with other contextual factors.
Efforts that involve greater resources (e.g.,
school-based personnel, clinicians, school district task force) and complexity will be necessary
to address and prevent problematic absenteeism
impacted by multiple contextual variables.

Research
Research to explore the dimensions of problematic
absenteeism has primarily concentrated on classification, assessment, treatment, and prevention.
Research in this area tends to be dominated by
psychologists who study specific aspects of school
refusal behavior as well as professionals in other
disciplines (education, criminal justice, law, social
work) who study broader aspects of truancy.
Research methods from both approaches are
described next.
Psychologists who study youths with school
refusal behavior generally emphasize quantitative
research methods with a particular focus on
behavioral assessments. These methods are

School Absenteeism During Childhood

utilized to gain a clearer picture of epidemiology,
specific symptomatology and subtypes, and treatment effectiveness regarding this population.
Psychologists emphasize the psychopathology
associated with school refusal behavior and tend
to focus on child, parent, and family variables that
impact the behavior. An advantage of this
approach is that the methods are highly empirical
and the measures have good reliability and
validity. Another advantage, discussed later, is
that assessment measures in this area have been
linked directly to effective treatments. A key
disadvantage of the traditional psychological
approach, however, is that complicated school
absenteeism impacted by broader variables (e.g.,
school, community) has not been examined
closely (Lyon & Cotler, 2007, 2009). Examples
of psychological research in this area are
presented next.
Egger and colleagues (2003) examined the
prevalence and symptomatology of youths with
problematic absenteeism via structured diagnostic interview. Youths were classified as pure
anxious school refusers, pure truants, mixed
school refusers, and nonschool refusers. The
overall prevalence of problematic absenteeism
was 8.2 %. Those with pure anxious school
refusal had significantly more diagnoses of separation anxiety and generalized anxiety disorder,
simple and social phobia, and depression than
pure truants. Pure truants had significantly more
diagnoses of oppositional defiant and conduct
disorder than pure anxious school refusers.
Hansen, Sanders, Massaro, and Last (1998)
also utilized a structured diagnostic interview
and found that older age, lower levels of fear,
and less active families were most predictive of
greater levels of school absenteeism.
Other psychologists have examined the
classification of school refusal behavior. Kearney
(2007) tested the validity of the functional model
of school refusal behavior outlined earlier.
Children and parents completed questionnaires
of internalizing and externalizing behavior
problems. Function of school refusal behavior
(assessed via the measure described next) was
found to mediate the relationship between
(1) forms of behavior often related to absenteeism

899

(e.g., school-based fear, anxiety, depression) and
(2) absenteeism severity. Function was also
found to be a better predictor of absenteeism
severity than behavior form and was thus
proposed as a more accurate and useful way to
classify youths with school refusal behavior.
Psychological research strategies to evaluate
school refusal behavior have involved assessment as well. For example, Haight and colleagues
(2011) tested the construct validity of the School
Refusal Assessment Scale-Revised, a measure of
the relative strength of function of school
refusal behavior for a particular child. Youths
were recruited from truancy court and truancy
diversion settings and assessed via a battery of
questionnaires regarding internalizing and externalizing behavior problems. Confirmatory factor
analysis revealed that child and parent versions of
the measure largely held their four-factor structure in this sample and that individual functions
were associated with symptom sets as predicted
(e.g., negative reinforcement functions with
anxiety and depressive symptoms). The findings
replicated and extended previous work in clinical
outpatient samples (Kearney, 2002, 2006).
Psychologists also employ specific behavioral
approaches to examine treatment of youths with
anxiety-based school refusal. King et al. (1998)
randomly assigned children to cognitive behavioral treatment or waitlist control. Treatment
included (1) child-based rapport building,
coping skills training, relaxation training,
cognitive therapy, and imaginal and in vivo
exposure; (2) parent-based training in behavior
management; and (3) a meeting with a child’s
teacher regarding treatment. Treatment for
six sessions was superior to control regarding
school attendance, fear, anxiety, and depression.
Treatment was especially effective if a youth
returned swiftly to school and if parents and
youth were involved in the intervention.
As mentioned, professionals in other disciplines tend to study broader aspects of truancy
and often emphasize qualitative research methods.
Much of this work has involved prevention
of problematic school absenteeism that will be
described more in the following sections. A sample of research in this area is thus presented here.

900

Claes et al. (2009) utilized survey data from
93,096 14-year-olds in 28 countries to identify
causes of truancy, which was measured qualitatively by asking principals about the frequency
(never, sometimes, often) of absenteeism at their
school. The researchers found that lower rates of
truancy were associated with broader contextual
factors such as supportive school climate, teachers
that encourage participation, and private schools.
Rodriguez and Conchas (2009) utilized interviews
and observations to conclude that improved peer
relations and teacher-student relationships were
important for preventing dropout.
Survey data have also been used to examine
treatment outcome for truancy court and related
interventions. Hendricks, Sale, Evans, McKinley,
and Carter (2010), for example, examined
the effectiveness of a school-based truancy
court intervention for youths in middle school.
Students were expected to attend regular truancy
court sessions in school, complete assigned work,
and avoid substance use and confrontations with
peers. The survey measured student attachment
toward school and the truancy court. Absenteeism decreased significantly over the course of two
semesters.

Strategies
The empirically based research strategies and
resulting data sets from the aforementioned and
other studies are beginning to produce guidelines
for clinical practice for youths with problematic
school absenteeism. A key example is the
prescriptive approach that flows directly from
the functional model of school refusal behavior
described earlier. For example, Kearney
and Silverman (1999) found that intervention
administered on the basis of a youth’s primary
function of school refusal behavior was superior
to an intervention administered on the basis of a
youth’s least influential function of school refusal
behavior.
Empirical data also indicate that broader variables such as school climate and a student’s relationships with peers and teachers at school are
impact factors that can play a central role in

School Absenteeism During Childhood

a systemic intervention. A good example is the
Check and Connect program that emphasizes
relationship building, routine monitoring of
attendance, school-based support tailored to
individual student needs, academic motivation,
conflict resolution skills, and facilitating student
access to school-related activities and events.
This program has been shown to significantly
boost student participation at school and reduce
full absences and tardiness rates (Lehr, Sinclair,
& Christenson, 2004).

What Works
The following sections focus more specifically on
early intervention and prevention strategies that
have been designed to curb absenteeism and
dropout. One of the most successful systemic
methods of curbing absenteeism and dropout
involves alternative educational programs within
a particular school. Alternative educational
programs typically encompass a “school within
a school” approach that emphasizes small class
size, project-based and cooperative learning,
individualized and interdisciplinary instruction
such as vocational or technical skills training,
apprenticeships, and diverse instructional
methods such as computers, direct experience,
and service-learning activities. These programs
are also known as career academies or small
learning communities. Students in these
programs are supervised closely, receive
extended instruction for troublesome subjects,
obtain specialized training that fits the business
needs of a local community (e.g., finance,
tourism), and earn equivalent college course
credit. Career academies are often joint ventures
between school officials and business owners
who supply funding, curriculum input and
review, and later employment internships and
opportunities (Detgen & Alfeld, 2011).
A meta-analysis of truancy and dropout prevention programs for middle and high school
students revealed that alternative educational
programs were best for reducing dropout and
enhancing attendance, academic achievement,
and graduation rates compared to other methods

School Absenteeism During Childhood

(Klima, Miller, & Nunlist, 2009). Others report
that career academy graduates are more likely to
be engaged in the academic process and to plan
for college than controls (Orr, Bailey, Hughes,
Kienzl, & Karp, 2007). In addition, a consistent
finding is that graduates of career academies have
greater earning potential than control groups
(Fleischman & Heppen, 2009).
A related systemic strategy is alternative
schools that comprise completely separate
learning facilities for students with histories of
academic achievement difficulty, disruptive
behavior problems, and nonattendance. Alternative schools may involve a specific type of vocational training, a combination of home study and
in-class or laboratory work, extended class time,
summer coursework, work release, or afternoon
or evening classes, among other nontraditional
options. Alternative schools emphasize academic
remediation and credit accrual at a modified
pace, individualized curricula and psychosocial
services, and links to the business community.
Alternative schools may be more educational or
disciplinary in nature, though the former has
tended to be more effective for preventing school
dropout (Dupper, 2008).
Another systemic model to reduce problematic absenteeism is to move traditional truancy
courts into school buildings. These “hybrid”
efforts are designed to reduce stigmatization
and transportation problems, emphasize a
multidisciplinary problem-solving approach to
minimize obstacles to attendance, increase parental involvement, and provide psychosocial and
other services. Judgments from these courts
often involve sanctions that promote school
attendance such as school-based community
service and extracurricular activities, drug testing, family-based and other therapies, requiring
students to eat lunch at school, tutoring, and
teacher mentors (Smink & Reimer, 2005).
Shoenfelt and Huddleston (2006) evaluated
a truancy court diversion program involving
school personnel home visits to investigate
factors related to absenteeism, meetings with
a judge, and parenting classes, academic tutoring,
anger management, mentoring, and support
groups. The truancy diversion group evidenced

901

significant reductions in unexcused absences and
improved grades compared to a control group.
Richtman (2007) examined a truancy intervention program that referred absentee students and
their parents to school-based meetings with a
county attorney, school social worker or counselor, and probation officer to create a school
attendance plan. The meetings also included
referrals to social services agencies, substance
use and mental health evaluations, and student or
family counseling to address nonattendance. Truancy petitions were reduced nearly 60 % over a
10-year period for youths under age 16 years.
Fantuzzo, Grim, and Hazan (2005) found that
placing court proceedings within school buildings
and linking families with caseworkers from various service organizations improved attendance
compared to a control group at 1-year follow-up.
Other systemic strategies have involved
restructuring an existing school to address
broader climate factors that may be affecting
attendance rates. The Positive Behavioral Intervention and Supports (PBIS; www.pbis.org) program is designed to emphasize prosocial skills
and behaviors, monitor student attendance and
other disciplinary issues regularly, and implement evidence-based behavioral practices such
as the psychological methods described earlier.
This program may be integrated with response to
intervention practice to address academic issues
that contribute to disciplinary concerns such as
school absenteeism (Sailor et al., 2006). PBIS is
typically implemented by a small, school-based
team of teachers, psychologists, counselors, or
social workers, though some have advocated
that the team be expanded to include administrators, parents, and community members (Sugai &
Horner, 2006). PBIS has been linked primarily to
academic gains, though some have found that
office disciplinary referrals and school suspensions are reduced as well (Lassen, Steele, &
Sailor, 2006).
Sutphen, Ford, and Flaherty (2010) reviewed
16 studies of truancy interventions that used
group comparison or one-group pretest/posttest
designs. Broader interventions that seemed effective for reducing truancy included school-based
structural changes such as smaller and more

902

independent academic units as well as alternative
educational programs. Others have concluded that
school dropout prevention programs are most successful if they involve an individualized approach
that tailors intervention to the specific academic,
health, skill, social, and resource needs of students
and their families. Such interventions are
designed to maintain student and family investment in the educational process (Christenson &
Thurlow, 2004; Dynarski & Gleason, 2002).
Others suggest that the most effective schoolwide programs are those that target middle school
students who are behind in grade level and those
that provide occupational training programs with
GED assistance (Mac Iver, 2011).

What Is Promising?
Other early intervention and prevention strategies
have shown promise with respect to curbing truancy and school dropout, though additional
empirical support is needed. These promising
strategies tend to be less systemic in nature than
those discussed in the previous section. Instead,
these strategies focus on providing supplemental
services to at-risk youth within the context of an
existing school (Rumberger, 2011). The reader
should note that psychological strategies for individual students with school refusal behavior are
effective (see earlier section) but that this section
focuses on broader prevention efforts.
One promising strategy is academic remediation or tutoring. These programs focus on identifying students who are struggling academically
and addressing their skill deficiencies (Teasley,
2004). Many of these programs also include
a mentoring component whereby a teacher or
other school official serves as an advocate, role
model, and/or service coordinator for a student
who is missing school on a regular basis. The
Check and Connect program mentioned
earlier is a good example. Anderson, Christenson,
Sinclair, and Lehr (2004) found that the closeness
and quality of the student-mentor relationship
was associated with improved engagement with
respect to attendance. In our own work with
a truancy diversion program, academic

School Absenteeism During Childhood

remediation was found to be the key variable
that predicted whether students would remain in
school (Chapman & Kearney, 2009). A related
strategy is to utilize peers as mentors who
contact an absentee youth at night, encourage
him to return to school, and offer to help remove
obstacles to attendance (DeSocio et al., 2007).
Peer mentors may be especially helpful for
youths with social skill deficits or those in
single-parent families (Teasley, 2004; White &
Kelly, 2010).
Another promising strategy is to offer healthbased services in schools to minimize illness on
a grand scale, manage asthma symptoms, provide
specialized educational services for students with
a chronic medical condition, and supply routine
medical care for pregnant youth. Strategies to
minimize illness include hand washing, flu
immunization, and lice management (Andresen
& McCarthy, 2009; Sandora, Shih, & Goldmann,
2008). Barnet, Arroyo, Devoe, and Duggan
(2004) established a school-based prenatal care
program to provide routine medical examinations
for pregnant youth that would minimize
absences due to doctor visits. Results indicated
significant reductions in absenteeism and dropout
rates.
Youth development programs also have some
benefit for ameliorating school absenteeism.
These programs often include mental health
strategies to reduce emotional, learning, and disruptive behavior disorders and substance use or to
enhance coping skills (Weist, Stiegler, Stephan,
Cox, & Vaughan, 2010). Other programs focus on
conflict resolution, anger management, peer mediation, coping with divorce or family conflict, and
sex education (Brown & Bolen, 2008). Youth and
parent support groups are sometimes advocated as
well to develop social and family communication
and parenting skills and to reduce obstacles to
attendance (White & Kelly, 2010). Anti-bullying
and school safety efforts may also be part of absenteeism reduction strategies (Vreeman & Carroll,
2007). Academic skills training (e.g., study, organization, time management) may be useful as well
(Prevatt & Kelly, 2003).
Researchers sometimes combine many of
these elements on a more systemic level.

School Absenteeism During Childhood

Snyder et al. (2010), for example, implemented a
social-emotional and character development program that consisted of 140 interactive lessons.
These lessons involved (1) self-concept (relationship among thoughts, feelings, and behaviors),
(2) physical and intellectual actions (e.g.,
hygiene, nutrition, decision-making skills),
(3) social and emotional actions (self-control,
time management), (4) interpersonal skills (e.g.,
empathy, conflict resolution), (5) integrity and
self-appraisal, and (6) self-improvement (e.g.,
goal setting, problem solving, persistence).
Schools with the intervention had significantly
higher reading and math scores, lower absenteeism, and fewer suspensions and retentions than
control schools.
Other strategies to curb absenteeism and dropout have been explored at a more preliminary
level. These strategies are theoretically sound
for reducing absenteeism but require substantially greater empirical support. One such idea
involves increasing parental involvement with
respect to a child’s academic progress and school
attendance (Hill & Tyson, 2009). Suggestions for
boosting parental involvement include daily
communications from a school official about
attendance, regular conferences or home visits
to establish a collaborative intervention plan,
delay of referral to juvenile justice settings,
adjustments to academic load and assignments,
parenting skills training, assisting parents with
their child’s homework instruction, and referrals
to mental health and social service agencies
(Kearney & Bates, 2005). In a related fashion,
language or cultural differences between
parents and school officials could hinder
parental involvement. Suggestions for addressing
these differences include home visits, use of
interpreters, culturally responsive curricula,
school-based child care during parent-teacher
conferences, and invitations to special schoolbased events that are conducted in various languages and geared toward all family members
(Broussard, 2003).
Other
preliminary
strategies
include
restructuring the role of the homeroom teacher
to quickly identify and counsel youths at risk for
school absenteeism, implementing school-wide

903

practices to reward attendance, maintaining a
student’s peer group across homeroom and morning classes, and increasing student involvement
in school policies (Kearney, 2008). Alternative
class schedules and modified makeup work
policies have also been advocated for at-risk
youth (Teasley, 2004). In addition, Sutphen
et al. (2010) found that the most promising
truancy interventions often involved studentand family-based approaches that relied on contingency management and increased monitoring
of attendance.

What Does Not Work?
Other methods to curb truancy have involved
formal adjudication of students and parents with
an emphasis on punitive practices. These
methods include police sweeps of a community
to return truant students to campus, referral of
youths by school officials to traditional truancy
courts (often within a family court system), juvenile detention, mandated community service outside of school, and residential care (Desai et al.,
2006; Hendricks et al., 2010; White, Fyfe, Campbell, & Goldkamp, 2001). In addition, many
states have passed laws meant to deter truancy
by fining students or parents, jailing parents,
revoking driver licenses, or depriving access to
public assistance.
No empirical data has indicated that these
strategies are highly effective at reducing problematic school absenteeism over time. Some
theorists have also been highly critical of
such practices for their excessive financial cost
(e.g., Zhang, 2004). In addition, some truancy
laws paradoxically exacerbate absenteeism by
increasing barriers to attendance by depriving
youths of transportation, jailing parents, or mandating community-based service outside of the
school setting (Mogulescu & Segal, 2002).
Others have referred to these “zero tolerance”
strategies as “repressive” interventions that are
unlikely to solve chronic absenteeism unless
they are accompanied by systemic strategies
designed to improve school climate (Claes
et al., 2009).

904

Other strategies to try to curb absenteeism
and dropout involve increasing the legal age
at which youths must attend school, boosting
the number of courses or credits needed to
graduate high school, requiring students to pass
an exit examination prior to graduation, and
offering dual enrollment in college classes
(Rumberger, 2011). Some states and countries
have increased the compulsory schooling age
from 16 years to 17 or 18 years. Some data
indicate that higher compulsory schooling ages
tend to be associated with lower dropout
and higher graduation rates, but others argue
that the variable that explains most of this effect
is an educational system that is responsive
to a student’s individual academic needs
(Markussen & Sandberg, 2011). The other strategies mentioned have little supporting evidence
as well.

Summary
Strategies to reduce or prevent problematic
school absenteeism, including school dropout,
are generally promising but far from standardized
or empirically strong. Part of the reason for this is
that school absenteeism is impacted by a multitude of variables that range from individual
student problems to widespread, systemic problems such as neighborhood disorganization. In
addition, professionals from various disciplines
who study problematic absenteeism often employ
different terminologies, research methods, and
assessment and intervention strategies. Effective
prevention strategies in this area must emphasize
a collaboration of approaches with a heavy
concentration on addressing young children,
attending to individual student academic and
mental health needs, removing obstacles to
attendance, enhancing parental involvement,
improving school climate, and integrating
community members and agencies into the
prevention process. Effective prevention strategies must also consider overarching themes
such as comprehensive school reform, cultural
attitudes regarding education, and structural
economic pressures.

School Absenteeism During Childhood

References
Anderson, A. R., Christenson, S. L., Sinclair, M. F., &
Lehr, C. A. (2004). Check & connect: The importance
of relationships for promoting engagement with
school. Journal of School Psychology, 42, 95–113.
Andresen, K., & McCarthy, A. M. (2009). A policy
change statement for head lice management. Journal
of School Nursing, 25, 407–416.
Barnet, B., Arroyo, C., Devoe, M., & Duggan, A. K.
(2004). Reduced school dropout rates among adolescent mothers receiving school-based prenatal care.
Archives of Pediatric & Adolescent Medicine, 158,
262–268.
Broussard, C. A. (2003). Facilitating home-school partnerships for multiethnic families: School social
workers collaborating for success. Children and
Schools, 25, 211–222.
Brown, M. B., & Bolen, L. M. (2008). The schoolbased health center as a resource for prevention and
health promotion. Psychology in the Schools, 45,
28–38.
Chapman, G., & Kearney, C. A. (2009, November 21).
Evaluating the effectiveness of a truancy diversion
program in middle school: Predictors of treatment
completion and dropout. Symposium presented at the
meeting of the Association for Behavioral and Cognitive Therapies, New York.
Christenson, S. L., & Thurlow, M. L. (2004). School
dropouts: Prevention considerations, interventions,
and challenges. Current Directions in Psychological
Science, 13, 36–39.
Claes, E., Hooghe, M., & Reeskens, T. (2009). Truancy as
a
contextual
and
school-related
problem:
A comparative multilevel analysis of country and
school characteristics on civic knowledge among
14 year olds. Educational Studies, 35, 123–142.
Desai, R. A., Goulet, J. L., Robbins, J., Chapman, J. F.,
Migdole, S. J., & Hoge, M. A. (2006). Mental health
care in juvenile detention facilities: A review. Journal
of the American Academy of Psychiatry and the Law,
34, 204–214.
DeSocio, J., VanCura, M., Nelson, L. A., Hewitt, G.,
Kitzman, H., & Cole, R. (2007). Engaging truant
adolescents: Results from a multifaceted intervention
pilot. Preventing School Failure, 51, 3–11.
Detgen, A., & Alfeld, C. (2011). Replication of a career
academy model: The Georgia Central Educational
Center and four replication sites. Washington, DC:
U.S. Department of Education, Institute of Education
Sciences, National Center for Education Evaluation
and Regional Assistance, Regional Educational
Laboratory Southeast.
Dupper, D. R. (2008). Guides for designing and
establishing alternative school programs for
dropout prevention. In C. Franklin, M. B. Harris, &
P. Allen-Meares (Eds.), The school practitioner’s
concise companion to preventing dropout and
attendance problems (pp. 23–34). New York: Oxford.

School Absenteeism During Childhood
Dynarski, M., & Gleason, P. (2002). How can we help?
What we have learned from recent federal dropout
prevention evaluations. Journal of Education for
Students Placed at Risk, 7, 43–69.
Editorial Projects in Education Research Center. (2008).
Closing the graduation gap: Educational and economic conditions in America’s largest cities.
Bethesda, MD: Author.
Egger, H. L., Costello, E. J., & Angold, A. (2003). School
refusal and psychiatric disorders: A community study.
Journal of the American Academy of Child and Adolescent Psychiatry, 42, 797–807.
Fantuzzo, J., Grim, S., & Hazan, H. (2005). Project
START: An evaluation of a community-wide schoolbased intervention to reduce truancy. Psychology in
the Schools, 42, 657–667.
Fleischman, S., & Heppen, J. (2009). Improving
low-performing high schools: Searching for evidence
of promise. The Future of Children, 19, 105–133.
Fremont, W. P. (2003). School refusal in children and
adolescents. American Family Physician, 68
(1555–1560), 1563–1564.
Haight, C., Kearney, C. A., Hendron, M., & Schafer, R.
(2011). Confirmatory analyses of the School Refusal
Assessment Scale-Revised: Replication and extension
to a truancy sample. Journal of Psychopathology and
Behavioral Assessment, 33, 196–204.
Hansen, C., Sanders, S. L., Massaro, S., & Last, C. G.
(1998). Predictors of severity of absenteeism in children with anxiety-based school refusal. Journal of
Clinical Child Psychology, 27, 246–254.
Hendricks, M. A., Sale, E. W., Evans, C. J., McKinley, L.,
& Carter, S. D. (2010). Evaluation of a truancy court
intervention in four middle schools. Psychology in the
Schools, 47, 173–183.
Hibbett, A., & Fogelman, K. (1990). Future lives of truants:
Family formation and health-related behaviour. British
Journal of Educational Psychology, 60, 171–179.
Hibbett, A., Fogelman, K., & Manor, O. (1990). Occupational outcomes of truancy. British Journal of Educational Psychology, 60, 23–36.
Hill, N. E., & Tyson, D. F. (2009). Parental involvement in
middle school: A meta-analytic assessment of the
strategies that promote achievement. Developmental
Psychology, 45, 740–763.
Kearney, C. A. (2001). School refusal behavior in youth: A
functional approach to assessment and treatment.
Washington, DC: American Psychological Association.
Kearney, C. A. (2002). Identifying the function of school
refusal behavior: A revision of the School Refusal
Assessment Scale. Journal of Psychopathology and
Behavioral Assessment, 24, 235–245.
Kearney, C. A. (2003). Bridging the gap among
professionals who address youth with school absenteeism: Overview and suggestions for consensus.
Professional Psychology: Research and Practice,
34, 57–65.
Kearney, C. A. (2006). Confirmatory factor analysis of the
School Refusal Assessment Scale-Revised: Child and

905
parent versions. Journal of Psychopathology and
Behavioral Assessment, 28, 139–144.
Kearney, C. A. (2007). Forms and functions of school
refusal behavior in youth: An empirical analysis of
absenteeism severity. Journal of Child Psychology
and Psychiatry, 48, 53–61.
Kearney, C. A. (2008). An interdisciplinary model of
school absenteeism in youth to inform professional
practice and public policy. Educational Psychology
Review, 20, 257–282.
Kearney, C. A., & Albano, A. M. (2004). The functional
profiles of school refusal behavior: Diagnostic aspects.
Behavior Modification, 28, 147–161.
Kearney, C. A., & Bates, M. (2005). Addressing school
refusal behavior: Suggestions for frontline professionals. Children and Schools, 27, 207–216.
Kearney, C. A., & Silverman, W. K. (1996). The evolution
and reconciliation of taxonomic strategies for school
refusal behavior. Clinical Psychology: Science and
Practice, 3, 339–354.
Kearney, C. A., & Silverman, W. K. (1999). Functionallybased prescriptive and nonprescriptive treatment for
children and adolescents with school refusal behavior.
Behavior Therapy, 30, 673–695.
King, N. J., Tonge, B. J., Heyne, D., Pritchard, M.,
Rollings, S., Young, D., et al. (1998). Cognitivebehavioral treatment of school-refusing children: A
controlled evaluation. Journal of the American Academy of Child and Adolescent Psychiatry, 37, 395–403.
Klima, T., Miller, M., & Nunlist, C. (2009). What works?
Targeted truancy and dropout programs in middle and
high school. Olympia, WA: Washington State Institute
for Public Policy.
Kogan, S. M., Luo, Z., Murry, V. M., & Brody, G. H.
(2005). Risk and protective factors for substance use
among African American high school dropouts. Psychology of Addictive Behaviors, 19, 382–391.
Lassen, S. R., Steele, M. M., & Sailor, W. (2006). The
relationship of school-wide positive behavior support
to academic achievement in an urban middle school.
Psychology in the Schools, 43, 701–712.
Lehr, C. A., Sinclair, M. F., & Christenson, S. L. (2004).
Addressing student engagement and truancy prevention during the elementary school years: A replication
study of the Check & Connect model. Journal of
Education for Students Placed at Risk, 9, 279–301.
Lyon, A. R., & Cotler, S. (2007). Toward reduced bias and
increased utility in the assessment of school refusal
behavior: The case for divergent samples and evaluation of context. Psychology in the Schools, 44,
551–565.
Lyon, A. R., & Cotler, S. (2009). Multi-systemic intervention for school refusal behavior: Integrating
approaches across disciplines. Advances in School
Mental Health Promotion, 2, 20–34.
Mac Iver, M. A. (2011). The challenge of improving urban
high school graduation outcomes: Findings from a randomized study of dropout prevention efforts. Journal of
Education for Students Placed at Risk, 16, 167–184.

906
Markussen, E., & Sandberg, N. (2011). Policies to reduce
school dropout and increase completion. In S. Lamb,
E. Markussen, R. Teese, N. Sandberg, & J. Polesel
(Eds.), School dropout and completion: International
comparative studies in theory and policy
(pp. 391–406). New York: Springer.
McShane, G., Walter, G., & Rey, J. M. (2001). Characteristics of adolescents with school refusal. Australian
and New Zealand Journal of Psychiatry, 35, 822–826.
Mogulescu, S., & Segal, H. (2002). Approaches to truancy
prevention. New York: Vera Institute of Justice, Youth
Justice Program.
National Center for Education Statistics. (2006). The condition of education 2006. Washington, DC: US
Department of Education.
Orr, M. T., Bailey, T., Hughes, K. L., Kienzl, G. S., &
Karp, M. M. (2007). The National Academy
Foundation’s
career
academies:
Shaping
postsecondary transitions. In D. Neumark (Ed.),
Improving school-to-work transitions (pp. 169–209).
New York: Russell Sage.
Pina, A. A., Zerr, A. A., Gonzales, N. A., & Ortiz, C. D.
(2009). Psychosocial interventions for school refusal
behavior in children and adolescents. Child Development Perspectives, 3, 11–20.
Prevatt, F., & Kelly, F. D. (2003). Dropping out of school:
A review of intervention programs. Journal of School
Psychology, 41, 377–395.
Reid, K. (2003). The search for solutions to truancy and
other forms of school absenteeism. Pastoral Care in
Education, 21, 3–9.
Richtman, K. S. (2007). The truancy intervention program
of the Ramsey County Attorney’s Office:
A collaborative approach to school success. Family
Court Review, 45, 421–437.
Rodriguez, L. F., & Conchas, G. Q. (2009). Preventing
truancy and dropout among urban middle school
youth: Understanding community-based action from
the student’s perspective. Education and Urban Society, 41, 216–247.
Rumberger, R. W. (2011). High school dropouts in the
United States. In S. Lamb, E. Markussen, R. Teese,
N. Sandberg, & J. Polesel (Eds.), School dropout and
completion: International comparative studies in theory and policy (pp. 275–294). New York: Springer.
Sailor, W., Zuna, N., Choi, J.-H., Thomas, J., McCart, A., &
Roger, B. (2006). Anchoring schoolwide positive behavior support in structural school reform. Research and
Practice for Persons with Severe Disabilities, 31, 18–30.
Sandora, T. J., Shih, M.-C., & Goldmann, D. A. (2008).
Reducing absenteeism from gastrointestinal and respiratory illness in elementary school students:
A randomized, controlled trial of an infection-control
intervention. Pediatrics, 121, e1555–e1562.
Shoenfelt, E. L., & Huddleston, M. R. (2006). The Truancy Court Diversion Program of the Family Court,
Warren Circuit Court Division III, Bowling Green,

School Absenteeism During Childhood
Kentucky: An evaluation of impact on attendance
and academic performance. Family Court Review,
44, 683–695.
Smink, J., & Reimer, M. S. (2005). Fifteen effective strategies for improving student attendance and truancy
prevention. Clemson, SC: National Dropout Prevention Center.
Snyder, F. J., Flay, B. R., Vuchinich, S., Acock, A.,
Washburn, I. J., Beets, M. W., et al. (2010). Impact
of a social-emotional and character development program on school-level indicators of academic achievement, absenteeism, and disciplinary outcomes:
A matched-pair, cluster randomized, controlled trial.
Journal of Research on Educational Effectiveness, 3,
26–55.
Sugai, G., & Horner, R. R. (2006). A promising approach
for expanding and sustaining school-wide positive
behavior support. School Psychology Review, 35,
245–259.
Sutphen, R. D., Ford, J. P., & Flaherty, C. (2010). Truancy
interventions: A review of the research literature.
Research on Social Work Practice, 20, 161–171.
Suveg, C., Aschenbrand, S. G., & Kendall, P. C. (2005).
Separation anxiety disorder, panic disorder, and school
refusal. Child and Adolescent Psychiatric Clinics of
North America, 14, 773–795.
Teasley, M. L. (2004). Absenteeism and truancy:
Risk, protection, and best practice implications for
school social workers. Children and Schools, 26,
117–128.
Tramontina, S., Martins, S., Michalowski, M. B.,
Ketzer, C. R., Eizirik, M., Biederman, J., et al.
(2001). School dropout and conduct disorder in Brazilian elementary school students. Canadian Journal
of Psychiatry, 46, 941–947.
Vreeman, R. C., & Carroll, A. E. (2007). A systematic
review of school-based interventions to prevent bullying. Archives of Pediatric and Adolescent Medicine,
161, 78–88.
Weist, M. D., Stiegler, K., Stephan, S., Cox, J., &
Vaughan, C. (2010). School mental health and prevention science in the Baltimore city schools. Psychology
in the Schools, 47, 89–100.
White, M. D., Fyfe, J. J., Campbell, S. P., &
Goldkamp, J. S. (2001). The school-police partnership:
Identifying at-risk youth through a truant recovery
program. Evaluation Review, 25, 507–532.
White, S. W., & Kelly, F. D. (2010). The school counselor’s role in school dropout prevention. Journal of
Counseling and Development, 88, 227–235.
Williams, T. T., Sanchez, B., & Hunnell, J. (2011).
Aligning theory with practice: Understanding schoolfamily partnerships at an inner-city high school.
Children and Youth Services Review, 33, 689–697.
Zhang, M. (2004). Time to change the truancy laws?
Compulsory education: Its origin and modern
dilemma. Pastoral Care, 22, 27–33.

Sexuality: Promoting Healthy Sexuality During Childhood

Sexuality: Promoting Healthy
Sexuality During Childhood
Catherine M. Sherwood-Laughlin
Indiana University, Bloomington, IN, USA
Department of Applied Health Science, Indiana
University, Bloomington, IN, USA

Introduction
When the topic of sex and sexuality comes up, for
some, strong feelings emerge. Some of these
feelings are embarrassment, anxiety, discomfort,
and, for others, contentment and ease. While
there are many reasons for causing the array of
emotions, many are rooted in the way individuals
were exposed, or not exposed, to sexual health
issues and sexuality education as a young child.
As our society becomes more accepting of sexuality, it is imperative that young children are
taught how to navigate the conflicting and complex messages. Although our society is becoming
more open to sexual expressions and sexual
health education, in most cases these messages
are not delivered in a sequential and comprehensive manner that makes sense in young children,
let alone to their parents, caregivers, educators,
and medical providers. This entry provides information for public health and health promotion
professionals regarding the appropriate scope
and sequence of sexual health education for
young children beginning in infancy through preteen (ages 0–11) which can help to build
a foundation which children can begin to develop
a healthy sexuality.

Definitions and Scope
There are a number of terms being used interchangeably in the sexual health literature; therefore, it is imperative to define terms associated
with childhood sexuality.
Sex is defined as male or female based on
genetic and anatomical sex characteristics
(Yarber, Sayad, & Strong, 2010).

907

Sexuality is a term that can be difficult to
define because it can depend on the context in
which it is used by the individual(s) using this
term. We must take into consideration that context, which is rooted in life experiences, educational attainment, and culture; therefore, a basic
and general definition is provided here. Yarber
et al. (2010, p. G-11) define sexuality as “the
emotional, intellectual, and physical aspects of
sexual attraction and expression.”
Sexuality education is defined as “a lifelong
process of acquiring information and forming
attitudes, beliefs and values” (Sexuality Information and Education Council of the United States
[SIECUS], n.d.-b).
Sexual health, as defined by the World Health
Organization [WHO] (n.d.), is “a state of physical, mental and social well-being in relation to
sexuality. It requires a positive and respectful
approach to sexuality and sexual relationships,
as well as the possibility of having pleasurable
and safe sexual experiences, free of coercion,
discrimination and violence.”

Theories
One of the primary goals of sexual health education is to provide information so individuals have
the tools and skills to reduce their risk-taking
behaviors and to make choices and decisions that
lead to a healthy lifestyle. There are numerous
theories in the area of sexuality to help explain
sexual health and behaviors. Human sexuality is
not one dimensional, rather its foundation is comprised of philosophies and theories that exist
within the fields of biology, psychology, sociology, anthropology, and applied behavioral health
sciences. Additionally, human sexuality is further
explained and understood by including both ethical and cultural dimensions. Biopsychosocial
models combine the notions of the biological,
psychological, and socioenvironmental factors to
help understand behavior (Ehrhardt, 2000). It is
important to link biology and social behavior
when studying human sexuality in order to determine the variables which lead to decisions and
outcomes involved in sexual health.

T.P. Gullotta, M. Bloom (eds.), Encyclopedia of Primary Prevention and Health Promotion,
DOI 10.1007/978-1-4614-5999-6, # Springer Science+Business Media New York 2014

908

The biopsychosocial model that is utilized
most often to understand human sexuality is the
main-effect model (Ehrhardt, 2000). This particular model posits that a behavior is based on one
strong, predominate factor. An example that
Ehrdardt uses to explain this model is sexual
orientation. She states that if there is a prenatal
event that causes sexual orientation, that “event”
is the reason a child is homosexual or bisexual
and not because of the environment in which the
child was raised. The use of this model is simplistic; however, it does not allow for researchers
to take into account other variables that could
have an effect on the behavior. Therefore,
researchers must consider utilizing the interactional model. This model takes into account
a variety of factors and variables to explain and
predict behavior and is not merely a cause and
effect model.
There also exist a number of theories in human
sexuality to help explain gender identity development, which begins to form during childhood.
In the two theories presented here, parent(s)
play(s) an important role as to who influences
the development of gender identity in children.
Freud’s work in psychological development was
founded on aspects related to sexual development
and was one of the first psychologists to infer that
children were sexual and subsequently connected
his research on developmental stages to gender
identity development (King, 2009). Freud
explained that when boys act like their fathers
and girls act like their mothers, and when these
actions are not deliberate, but conducted on an
unconscious level, this is called identification.
The child is identifying with the parent that
looks most like him or her and responds
accordingly.
The second theory is based on social learning
theorists’ beliefs that children learn how to act
and behave like a certain gender based on imitating children and adults of their own sex. Children
bond with their parents, and the concepts within
the social learning theory support the notion
that children will do what their parents do especially if the behavior is positively reinforced
as a stereotypical male or female action
(King, 2009).

Sexuality: Promoting Healthy Sexuality During Childhood

Theories help us predict and understand
behaviors. Based on the concepts embedded in
theories, it is understood that children will
express their sexual behaviors based on
a socioecological perspective. They will respond
and act in certain ways based on a multitude of
factors and in tandem will lead to the specific
sexual behavior. Children will also express themselves in a way that is comfortable and assuring to
them based on the reinforcements they received
from their parents and society. It is important to
realize that one environmental or social factor
does not lead to a behavior; rather there are
many factors to consider. Therefore, when determining what is the best approach towards educating children about a healthy sexual lifestyle,
parents, caregivers, educators, and health-care
providers must consider all of the ecological
and environmental influences in a child’s life.

Research
When we discuss sexuality, most do not consider
these types of discussions to include infants and
children mainly because it is difficult to accept or
imagine that infants and children are sexual
beings. However, as mentioned earlier, we are
sexual beings from birth to death. As we grow
and develop, there are specific periods in an individual’s life when physical and psychosexual
developments are marked and identified. These
changes during infancy and childhood, along
with social and environmental factors, impact
the way children cope with their own, evolving,
sexuality.
In infancy, between the ages 0–2, much of the
physical and psychosexual developmental
changes are related to touch and comfort. Since
language is not developed until later in the infant
state, the comfort of a parent and/or caregiver
signals to the infant that he/she will be comforted
to a desired level of contentment. This is the
foundation for the subsequent stages of growth
and development; therefore, it is important for
parents and caregivers to be able to respond to
the basic needs of infants. If bonding and attachment is secure between the parent and child, then

Sexuality: Promoting Healthy Sexuality During Childhood

909

Sexuality: Promoting Healthy Sexuality During Childhood, Table 1 Selected frequency of sexual behaviors (%)
Item
Touches genitals at home
Undresses in front of others
Touches breasts
Tries to look at people undressing
Interested in opposite sex
Looks at nude pictures
Masturbates with hand
Uses sexual words
Talks about sex acts

Overall
45.8
41.2
30.7
28.5
23.0
15.5
15.3
8.8
5.7

2–6 boys
64.1
49.6
43.5
33.9
21.0
11.3
22.6
4.8
2.4

2–6 girls
54.4
61.9
48.4
33.3
20.6
7.9
16.3
1.2
2.8

7–12 boys
36.4
21.4
11.7
27.7
19.9
27.2
11.2
19.9
9.2

7–12 girls
18.4
23.0
9.2
14.9
32.8
18.4
8.6
12.1
10.3

From Friedrich et al. (1991)

the child is more likely to have more stable and
secure emotional attachments in adulthood
(DeLamater & Friedrich, 2002). It is also during
this stage when infants begin to learn about gender roles and how they are expected to express
themselves. For example, girls are expected to
play with dolls and boys are expected to play
with trucks.
Research shows that infants do experience
sexual response. According to Martinson
(1976), infants and children have the physiological capacity to move beyond just pleasure seeking and pain avoidance. They have the capacity
for sexual response at the physiological-reflexive
level and perhaps orgasmic capacity. DeLamater
and Friedrich (2002) state that male infants can
get erections and female infants have evidence of
vaginal lubrication. By age 2.5–3, toddlers have
expressed rhythmic manipulation of their genitals
in addition to expressing other sensual and
comforting experiences such as sucking
a thumb, rocking back and forth, and being
held. Although infants can experience adult-like
physiological sexual expression, they obviously
do not have the capacity to associate these experiences to sexual fantasies and purposeful selfstimulation as an adult can.
As the infant matures into childhood,
between the ages of 3 and 7, the concept of
gender identity begins to form and solidify by
around age 3 (DeLamater & Friedrich, 2002). At
this age, children are becoming more interested
in gender roles, identities, and how their bodies

are different than the other sex. It is also at this
age when children begin sexual play with their
friends or siblings. This is a very natural and an
expected developmental experience for this age
because children are trying to emulate their parent’s behaviors and want to feel grown up. It is
important that parents and caregivers normalize
this stage of self-sexual exploration and sexual
play but also recognize that this type of behavior
is to be done alone and in a private place in the
home, for example, the child’s bedroom. It is also
at this age when children begin to ask more questions about sex and sexuality. They are beginning
to discover that their bodies look different, they
want to know the answers to some more difficult
questions like how babies are made, what is an
erection, and why can men not have babies.
A study was conducted by Friedrich,
Grambsch, Broughton, Kuiper, and Beilke
(1991) to determine the sexual behaviors in normal preadolescent children. In their study, children ages 2–12 were evaluated by their mothers
to determine the type and frequency of sexual
behaviors. One of the findings for both sexes
was that there was a decline in overt sexual
behavior as the children aged. Another finding
was that even though there was a wide variety
of sexual behaviors reported (Table 1), there
were a few behaviors that were either more
aggressive or more like adult behaviors. The
researchers indicate that the family context may
have influenced the type and frequency of aggressive and adult-like sexual behaviors.

910

Strategies
All strategies suggested in this section are based
on the developmental capacities of typically
developing children. One of the most confusing
and frustrating aspects of sexual health education
for adults who are responsible for providing this
information to children is where to begin, at what
age, and how much information is too much or
too little. Most adults do not know what information is considered age appropriate, and while they
tend to be more on the conservative side when
providing information, it is important to be able
to understand that children must receive developmentally appropriate information.
Sexuality education is a lifelong educational
process. A sexuality health educational program
includes information surrounding the topics of
sexual development, reproductive health, interand intrapersonal relationships, intimacy, body
image, and gender roles. It is critical for parents
to take on the role of the primary sexuality educators of their children as they are the initiators of
this lifelong educational process.
Parents, caregivers, and health-care providers
provide the foundation of this journey the
moment the child’s sex is discovered. The adults
in the child’s life begin assigning gender roles
and identifying for the child, how he or she is
different than the other sex. It starts once toddlers
can begin to understand and name parts of the
body. Toddlers can differentiate the unique outer
appearances between boys and girls, and as siblings and friends are added to their lives, they
begin to see that body parts are different under
clothing. There are numerous teachable moments
in a child’s life that leads to his or her understanding of sexuality and sexual health issues. This
continuous evolution of sexuality and sexual
health education lasts a lifetime as the body
changes and as children age.
Dr. Sol Gordon, a sexuality educator, coined
the term “askable parent.” Gordon fully
supported the concept that parents must take on
the responsibility as the primary sexuality educator of their children, but realized the apprehensions and anxieties that accompany that role.
Therefore, Gordon and his wife, Judith Gordon,

Sexuality: Promoting Healthy Sexuality During Childhood

published a number of books for parents to help
them become “askable” and approachable,
regardless of their child’s age. In their book,
Raising a Child Responsibly in a Sexually
Permissive World, Gordon and Gordon (2000)
provide ways for parents to discuss the sexually
sensitive topics in an open and informed manner.
Specifically, this book helps parents to become
their child’s primary sex educator, to be able to
answer the most difficult questions about sex, to
provide practical and common sense guidance,
and to help their children develop a healthy sexuality, along with healthy attitudes, behaviors,
and values about sex.
Huberman (2002), Director of Education and
Outreach at Advocates for Youth, provides developmental guidelines for parents and educators
that are helpful to gage what is considered
age-appropriate sexual health messages for children zero to age 3 (Table 2), ages 4–5, (Table 3),
and ages 6–8 (Table 4). It should be noted that
children grow and develop at different rates;
therefore, parents should consult with their
child’s teacher, child development professional,
or a health-care provider if they are concerned
about their child’s developmental process.

What Works
In its most basic context, sexuality education provides critical information and skills for individuals, starting at a young age, the opportunity to
learn about how to form attitudes, beliefs, and
values about self-identity, relationships with
others, and sexual intimacy. Sexuality education
also provides life-saving information and
decision-making skills regarding unintended
pregnancy and disease prevention. What has
been shown to work in research is that comprehensive sexuality education program also works.
School-based programs complemented with educational messages from parents and sexuality
education programs provided in various community settings allow for children to receive information. A comprehensive sexuality education
program is defined by SIECUS (n.d.-b) as programs that begin in kindergarten and continue

Sexuality: Promoting Healthy Sexuality During Childhood

911

Sexuality: Promoting Healthy Sexuality During Childhood, Table 2 Most children, aged 0–3 years old
Physical
development
Double their height
between birth and
age 3
Triple their weight
between birth and
age 3
Develop teeth and
the ability to eat
solid foods
Develop 75 % of
their brain capacity
Learn to crawl and
walk
Develop large
motor skills such as
running, jumping,
and climbing up
stairs
Begin to take off
and put on clothes
Begin to control
body functions
through toilet
training

Cognitive development
Learn language and
communication skills and
advance from using single
words to phrases to complete
sentences
Develop an imagination and
begin to create imaginary
scenarios and friends
Understand the world
primarily through their family
Begin to interact with peers
through imitation (Although
some children at this age do not
yet play directly with each
other, they often engage in
parallel play)
Think concretely, retain some
information, and process
information primarily through
their five senses – by seeing,
touching, hearing, tasting, and
smelling
Identify with and begin to
imitate their same-sex parent
or guardian
Begin to understand the
differences between male and
female (gender differences and
gender roles)
Imitate the language and
behavior of trusted adults

Emotional development
Develop trust for caregivers
who fulfill their needs, such as
responding when the child is
hungry or wet
Begin to test independence and
explore limits, but still seek
closeness to primary caregiver
Have relationships primarily
with family members who are
the most important people in
the child’s life at this time
Physically demonstrate
feelings, such as kissing and
hugging, to show love and
hitting to show anger
Master the idea of being happy,
sad, or angry, but will generally
choose to express emotions
physically rather than verbally
(The “terrible twos” occur
when a child is developing
a sense of self outside of and
distinct from others, and
expresses this individuality by
saying “no” and by insisting on
doing things himself/herself)

Sexual development
Be curious and explore their
own body and others’ bodies
Experience an erection or
vaginal lubrication
Touch their genitals for
pleasure
Talk openly about their bodies
Be able to say and understand,
when taught, the appropriate
names for body parts (head,
nose, stomach, penis, vulva,
etc.)

From Huberman (2002)

through the 12th grade. The sexuality education
programs include knowledge and skills building
age-appropriate, medically accurate information
related to topics which include human development, relationships, decision-making, abstinence, contraception, and disease prevention.
Abstinence-based or abstinence-plus programs
also provide a basis for sexuality education programs, but these programs emphasize the benefits
of abstinence but include information about intercourse and other sexual behaviors in addition to
contraception and disease-prevention methods.
There is evidence that indicates that parents
and adults support and desire comprehensive sexuality programs to be made available in schools.
Bleakley, Hennessy, and Fishbein (2006)
conducted a study to examine the public opinion

on sex education in schools in order to determine
if the public’s preferences matched those of
policymakers and research scientists. Among
their nationally representative sample of US
adults ages 18–83, it was discovered that more
than 80 % of these adults supported comprehensive sexuality education. In another nationally
representative study of adults aged 18 and older,
including 1,001 parents of middle and high
school students, coordinated by National Public
Radio/Kaiser
Family
Foundation/Kennedy
School of Government (2004) found that 90 %
of these parents felt it is important to have sexuality education as part of the school curriculum.
In addition, the majority of middle school and
high school parents supported comprehensive
sexuality education instead of abstinence-only

912

Sexuality: Promoting Healthy Sexuality During Childhood

Sexuality: Promoting Healthy Sexuality During Childhood, Table 3 Most preschoolers, aged 4–5 years old
Physical development
Continue to grow, but at
a slower rate than during
infancy and the toddler years
(Some parts grow faster or
sooner than others. For
example, organs grow faster
than the body, giving
preschoolers a rounded
tummy)
Reach at least 50 % of their
adult height and about 20 %
of their adult weight by age 5
Develop more coordinated
large motor skills, enabling
them to skip, run, and climb
up and down stairs
Develop fine motor skills,
enabling them to tie
shoelaces, button shirts, use
scissors, and draw
recognizable figures
Continue significant brain
development, completing
90 % of such development by
age 5
Develop increased lung
capacity and the ability to
breathe more deeply
Lose their “baby look” as their
limbs grow longer
Appear about the same size,
regardless of gender
Increase in overall health and
gain resistance to germs

Cognitive development
Interact with and learn
about the world through
play activities
Begin to experience the
world through exploration
and feel inquisitive about
self and surroundings
Begin separation from
family as they experience
less proximity to caregivers
and more independence
Understand what is good
and bad (though they may
not understand why) and be
able to follow the rules
Be able to understand and
accomplish simple
activities to be healthy, such
as brushing teeth or washing
hands
Understand the concept of
privacy

Emotional development
Still rely on caregivers, while
no longer needing or wanting
as much physical contact with
caregivers as they received in
infancy and as toddlers
Continue to express emotions
physically and to seek hugs
and kisses
Socialize with peers, begin to
develop relationships, and
learn to recognize some peers
as friends and others as people
they do not like
Have more opportunities to
interact with peers, either
through school or recreational
activities, and will play with
other children

Sexual development
Experience vaginal
lubrication or erection
Touch their genitals for
pleasure
Feel curiosity about
everything, and ask about
where babies come from
and how they were born
Feel curiosity about
bodies and may play
games like doctor
Feel sure of their own
gender and have the
ability to recognize males
and females
Begin to recognize
traditional male and
female gender roles and
to distinguish these roles
by gender
Become conscious of
their own body, how it
appears to others, and
how it functions

From Huberman (2002)

programs. These results indicate that parents, and
the general public, believe that sexuality education should begin in kindergarten and continued
until their child graduates from high school.
According to Gordon and Gordon (2000),
children who are knowledgeable about sex and
sexual health issues and are comfortable talking
about these topics are not more likely to experiment, engage in premature sexual activity, or
engage in risk-taking behaviors. In research that
focused on the behaviors of young people who
received comprehensive sexuality education, it
was found that providing sexuality education
starting at a young age and continuing the educational and skills-based methods was shown to not
encourage young people to have sexual

intercourse, and these programs were more likely
to delay the onset of intercourse, reduce the
frequency of intercourse, reduce the number of
sexual partners, and increase condom and contraceptive use (SIECUS, n.d.-a).
There are four primary goals of
a comprehensive sexuality program and they are
(SIECUS, 2004) as follows:
1. To provide information about human sexuality which includes reproductive development,
inter- and intrapersonal relationships, sexual
behavior, sexual health, society, and culture.
2. To provide opportunities to ask questions,
explore new concepts and ideas, and assess
sexual attitudes. By learning about all of the
dimensions of human sexuality along with

Sexuality: Promoting Healthy Sexuality During Childhood

913

Sexuality: Promoting Healthy Sexuality During Childhood, Table 4 Most grade school, aged 6–8 years old
Physical development
Experience slower growth
of about 2½ in. and 8 lb
per year
Grow longer legs relative
to their total height and
begin resembling adults in
the proportion of legs to
body
Develop less fat and grow
more muscle than in
earlier years
Increase in strength
Lose their baby teeth and
begin to grow adult teeth
which may appear too big
for their face
Use small and large motor
skills in sports and other
activities

Cognitive development
Develop the skills to process
more abstract concepts and
complex ideas (e.g.,
pregnancy and addition/
subtraction)
Begin elementary school
Spend more time with the
peer group and turn to peers
for information (They need
information sources outside
of family, and other adults
become important in their
lives)
Be able to focus on the past
and future as well as the
present
Develop an increased
attention span
Improve in self-control,
being able to conform to
adult ideas of what is
“proper” behavior and to
recognize appropriateness in
behavior
Understand the concepts of
normality/abnormality, feel
concern with being normal
and curiosity about
differences
Begin to develop as an
individual
Think for themselves and
develop individual opinions,
especially as they begin to
read and to acquire
information through the
media

Emotional development
Become more modest and
want privacy
Develop relationships with
and love people outside the
family as their emotional
needs are met by peers as
well as family
Develop less physically
demonstrative relationships
and express love through
sharing and talking (They
may be embarrassed by
physical affection)
Need love and support, but
feel less willing to ask for it
Understand more complex
emotions, such as confusion
and excitement
Want more emotional
freedom and space from
parents
Become better at controlling
and concealing feelings
Begin to form a broader selfconcept and recognize their
own strengths and
weaknesses, especially with
regard to social, academic,
and athletic skills
Have friends and sustained
peer group interaction

Sexual development
Prefer to socialize with their
own gender almost
exclusively and maintain
a fairly rigid separation
between males and females
(They will tease someone
who acts in a way that does
not adhere to predefined
gender roles)
Recognize the social stigmas
and taboos surrounding
sexuality, especially if
parents are nervous about the
subject, and will be less open
about asking questions
Understand more complex
ideas with regard to sexuality
and begin to understand
intercourse apart from
making a baby
Look to peers, media, and
other sources for information
about sex
Understand gender role
stereotypes, if presented as
such
May engage in same-gender
sexual exploration
Have a stronger self-concept
in terms of gender and body
image

From Huberman (2002)

cultural and societal attitudes and values, children can begin to develop their own sense of
their sexual identity and develop relationships
with others.
3. To help develop interpersonal skills which
includes being able to communicate needs
and making good decisions that promote
a healthy lifestyle, and peer refusal skills.
4. To help children create a sense of responsibility regarding their sexual relationships with
others. This includes making responsible
choices surrounding abstinence, resisting
peer pressure and premature sexual activity,

and the ability to make decisions to reduce
sexual risk-taking behaviors.
Kirby (1997) conducted research to determine
if sexuality education does reduce the risk-taking
behaviors and concluded that effective sexuality
education programs include the following
characteristics:
1. Utilizes behavioral goals, teaching methods,
and materials that are age appropriate and
based on the sexual experiences and culture
of the students.
2. The educational programs must be grounded
in theories that have been shown to be

914

effective in influencing students to not engage
in health-related risky behaviors.
3. Enough time is allowed in the curriculum to
adequately cover all of the human sexuality
topics and concepts.
4. A variety of teaching methods are used to
engage all types of learners.
5. Includes medically accurate information
about the negative consequences related to
unprotected intercourse and how to avoid
unprotected intercourse.
6. Addresses issues surrounding social and peer
pressures related to sexual behavior.
7. Allows the student ample opportunities to
practice decision-making, negotiation, and
refusal skills.
8. Teacher and peer educators are trained to be
effective sexuality educators.
In 2008, Kirby reported on the results of his
review of 56 studies focused on either abstinence
programs or comprehensive sexuality education
programs to determine the impact on adolescents’
sexual behavior. The results showed that most
abstinence programs did not delay the initiation
of sexual activity among the adolescents that
were exposed and participated in these types of
programs. The comprehensive sexuality programs assessed by Kirby showed a positive
impact on behavior where adolescents delayed
sexual activity and were more likely to use contraceptives and condoms when they engaged in
sexual activities. Kirby states that the results
show strong evidence that comprehensive sexuality education programs do reduce the risk of
premature sexual activity, unintended pregnancy,
and acquiring a sexually transmitted infection.
The Centers for Disease Control and Prevention
(CDC) have developed, on their website, Replicating Effective Programs Plus (REP+) (CDC, 2008).
The programs on this site have been tested, sciencebased behavioral interventions in reducing risky
sexual behaviors and encouraging safer sexual
behaviors. The REP+ programs can be modified
and implemented in different community settings
to meet specific needs of target populations. Programs for youth include Cuidate, a program to
reduce HIV sexual risks among Latino youth,
RESPECT, which is a program aimed at

Sexuality: Promoting Healthy Sexuality During Childhood

heterosexual youth aged 14 and older, and Project
AIM for African American youth aged 11–14.
In 2008, Advocates for Youth released their
second edition of their report that provides information about programs implemented in school-,
community-, and clinic-based settings that have
shown to prevent teen pregnancy, HIV, and STIs
(Advocates for Youth, 2008). The programs that
were included in this document that were deemed
to be effective at reducing teen pregnancy, HIV,
and STI infection rates were those programs
which were published in peer-reviewed journals;
they were evaluated using experimental or quasiexperimental evaluation design using treatment
and control groups and included at least
100 youth in those treatment and control groups.
In addition, further criteria included follow-up
data at least 3 months after the implementation
of the intervention, and that the program outcomes were at least two positive behavioral
changes among the youth who participated in
the program as compared to the control groups.
The positive behavioral outcomes were (p. V) as
follows:
• Postponement or delay of sexual initiation
• Reduction in the frequency of sexual
intercourse
• Reduction in the number of sexual partners/
increase in monogamy
• Increase in the use, or consistency of use, of
effective methods of contraception and/or
condoms
• Reduction in the incidence of unprotected sex
• Showed effectiveness in reducing rates of
pregnancy, STIs, or HIV
Twenty-six programs met the criteria set by
Advocates for Youth. Examples of effective
school-based programs are Get Real About
AIDS, Reducing the Risk, and Safer Choices.
Community-based programs included Making
Proud Choices, and an example of a clinicbased program is Project SAFE.

What Is Promising
During the Clinton and Bush administrations,
funding for comprehensive sexuality was

Sexuality: Promoting Healthy Sexuality During Childhood

eliminated, and Title V, Section of the 510 Social
Security Act was enacted to provide funding
abstinence-only-until-marriage programs. Since
the implementation of Title V, more than $1.5
billion in federal funding has been spent on abstinence-only-until-marriage programs (SIECUS,
n.d.-a). These programs do not include information on how to delay sexual initiation or prevent
pregnancy or STDs, including HIV/AIDS. There
is compelling evidence that federally funded
abstinence-only-until-marriage programs are not
effective in stopping or even delaying
adolescent sex.
Under the new Obama administration, what is
promising is the work of two politicians, Senator
Frank Lautenberg (D-NJ) and Representative
Barbara Lee (D-CA), who have initiated the
repeal of Title V and the transfer of funding
from Title V to the Personal Responsibility
Education Program (PREP) (SIECUS, n.d.-a).
The PREP was made possible through the
health-care reform legislation and thus will provide states with the opportunities to apply for
funding to support comprehensive sexuality education for children in grades kindergarten through
12th grade. The PREP-funded programs must
provide complete and medically accurate information on abstinence, contraception, and prevention of sexually transmitted diseases and HIV. In
addition, students are required to learn healthy
life skills so they have the necessary information
to make healthy decisions.

915

that sex outside of marriage is an immoral
behavior. In addition, if information about pregnancy and disease prevention are included, the
emphasis is placed only on the failure rates. The
last type of abstinence program is the fear-based
program. These programs provide students with
negative messages about sexuality and try to
control behaviors by emphasizing shame and
guilt. The educational messages also include
strong messages that are intended to make the
students fearful while giving inaccurate and
morally based information about condom use,
sexual orientation, marriage, and pregnancy.
The information is biased and not medically
accurate (SIECUS, n.d.-b).
Over the course of 10 years, a comprehensive
study was conducted to determine the impact of
the abstinence-only-until-marriage programs
(Trenholm et al., 2007). The researchers concluded that these types of programs did not
delay premature sexual activity and these programs did not have a positive impact on behavior,
rather those students who participated in these
programs did not have differing levels of abstinence from sexual activity than those in
a comprehensive program (Trenholm et al.,
2008). In Kirby’s (2007) research on the impact
these programs have on the reduction of teen
pregnancy, it was concluded that funding should
cease as these programs were not meeting their
intended goals of impacting teen sexual behavior.

Summary
What Does Not Work
What does not work is not talking to children
about sexuality and sexual health issues. There
are three types of abstinence education programs currently offered in the United States.
The first type is an abstinence-only program,
and these programs emphasize abstinence from
all sexual behaviors, but do not include
information about contraception or prevention
of diseases. The second is an abstinence-onlyuntil-marriage program. This type of program
emphasizes abstinence from all sexual behaviors
if the individuals are not married and indicate

In summary, it is important to understand the
roles adults have in the developing sexuality
and sexual health of children. Between the ages
of 0 and 10, children are not only physically
changing, but they are also gathering information
from a variety of sources about how their sexuality is changing, developing, and evolving. This
time of gathering information is an opportunity,
on a daily basis, for parents to share their values
with their children. Children will also seek out
information from a variety of sources, and other
adults in a child’s life must be prepared to answer
those questions in a comfortable and honest

916

manner. Children need adults in their lives to
whom they can trust and turn to for honest
answers. Parents must take on the role of their
child’s primary sexuality educator, and if parents
are uncomfortable or need guidance, they should
seek out the assistance of a child development
professional or their pediatrician. Additional
websites and professional organizations for parents, caregivers, educators, and health-care providers are listed below.
Advocates for Youth: Champions efforts that
help young people make informed and
responsible decisions about their reproductive
and sexual health (http://www.advocatesforyouth.org)
American Academy of Pediatrics: Organization of over 60,000 pediatricians dedicated
to the attainment of optimal health for
infants, children, adolescents and young
adults (www.aap.org)
National Association for the Education of
Young Children: Serve and act on behalf of
the needs, rights, and well-being of all young
children with primary focus on the provision
of educational and developmental services
and resources (http://www.naeyc.org/)
Sexuality Information Education Council of
the United States: Provide education and
information about sexuality and sexual and
reproductive health (www.siecus.org)

References
Advocates for Youth. (2008). Science and success
(2nd ed.). Sex education and other programs that
work to prevent teen pregnancy, HIV and sexually
transmitted infections. Retrieved February 12, 2011,
from
http://www.advocatesforyouth.org/storage/
advfy/documents/sciencesuccess.pdf
Bleakley, A., Hennessy, M., & Fishbein, M. (2006). Public opinion on sex education in US schools. Archives of
Pediatric & Adolescent Medicine, 2160, 1151–1156.
Retrieved August 12, 2011, from http://archpedi.amaassn.org/cgi/content/full/160/11/1151
Centers for Disease Control and Prevention. (2008). Replicating effective programs plus. Retrieved February
12, 2012, from http://www.cdc.gov/hiv/topics/
prev_prog/rep/index.htm
DeLamater, J., & Friedrich, W. (2002). Human sexual
development. Journal of Sex Research, 2, 10–14.

Sexuality: Promoting Healthy Sexuality During Childhood
Retrieved August 17, 2011, from http://www.jstor.
org/stable/3813417
Ehrhardt, A. A. (2000). Gender, sexuality and human
development. In J. Bankcroft (Ed.), The role of theory
in sex research (pp. 3–16). Bloomington, IN: Indiana
University Press.
Friedrich, W., Grambsch, P., Broughton, D., Kuiper, J., &
Beilke, R. (1991). Normative sexual behavior in children. Pediatrics, 88, 456–464. Retrieved August
15, 2011, from http://pediatrics.aappublications.org/
content/88/3/456.short
Gordon, S., & Gordon, J. (2000). Raising a child responsibly in a sexually permissive world. Avon, MA:
Adams Media Corporation.
Huberman, B. (2002). Growth and development.
Retrieved September 1, 2011, from http://www.
advocatesforyouth.org/growth-and-development-psec
King, B. (2009). Human sexuality today. New York: Pearson Education.
Kirby, D. (1997). School-based programs to reduce sexual risk-taking behaviors: A review of effectiveness. Public
Health Reports, 190, 339–360. Retrieved August
15, 2011, from http://www.jstor.org/stable/3813420
Kirby, D. (2007). Emerging answers 2007: Research findings on programs to reduce teen pregnancy and sexually transmitted diseases. Washington, DC:
National Campaign to Prevent Teen and Unplanned
Pregnancy. Retrieved August 15, 2011, from http://
www.thenationalcampaign.org/EA2007/EA2007_
full.pdf
Kirby, D. (2008). The impact of abstinence and comprehensive sex and STD/HIV education programs on adolescent sexual behavior. Sexuality Research and Social
Policy, 5, 18–27.
Martinson, F. M. (1976). Eroticism in infancy and childhood. Journal of Sex Research, 12, 251–262.
Retrieved August 18, 2011, from http://www.jstor.
org/stable/3811331
National Public Radio/Kaiser Family Foundation/Kennedy School of Government. (2004). Sex education
in America: General public parent survey. Retrieved
August 19, 2011, from http://www.kff.org/newsmedia/
upload/Sex-Education-in-America-General-PublicParents-Survey-Toplines.pdf
Sexuality Information and Education Council of the United
States. (2004). Guidelines for comprehensive sexuality
education: Kindergarten-12th grade (3rd ed.). Retrieved
August 19, 2011, from SIECUS website http://www.
siecus.org/_data/global/images/guidelines.pdf
Sexuality Information and Education Council of the United
States. (n.d.-a). End funding for the failed Title V abstinence-only-until-marriage program; support comprehensive sex education. Retrieved August 19, 2011, from
SIECUS website http://www.siecus.org/document/
docWindow.cfm?fuseaction=document.viewDocument
&documentid=2 &documentFormatId=2
Sexuality Information and Education Council of the United
States. (n.d.-b). Sexuality Q & A. Retrieved August
27, 2011, from SIECUS website http://www.siecus.org/

Sexuality: Promoting Healthy Sexuality During Childhood
index.cfm?fuseaction=page.viewpage&pageid=521&
grandparentID=477&parentID=514
Trenholm, C., Devaney, B., Fortson, K., Clark, M., Quay,
M., & Wheeler, J. (2008). Impacts of abstinence education on teen sexual activity, risk of pregnancy, and
risk of sexually transmitted diseases. Journal of Policy
Analysis and Management, 27, 255–276. Retrieved
August 25, 2011, from http://onlinelibrary.wiley.
com/doi/10.1002/pam.20324/pdf
Trenholm, C., Devaney, B., Fortson, K., Quay, K.,
Wheeler, J., & Clark, M. (2007). Impacts of four

917
Title V, Section 510 abstinence education programs:
Final report. Trenton, NJ: Mathematica Policy
Research. Retrieved August 25, 2011, from http://
www.eric.ed.gov/PDFS/ED496286.pdf
World Health Organization. (n.d.). Health topics:
sexual health. Retrieved August 27, 2011,
from WHO website http://www.who.int/topics/
sexual_health/en/
Yarber, W. L., Sayad, B., & Strong, B. (2010). Human
sexuality: Diversity in a contemporary America
(7th ed.). New York: McGraw-Hill.

918

Sibling Relationships During
Childhood
Michelle L. Hostetler1 and Mark E. Feinberg2
1
Edna Bennett Pierce Prevention Research
Center, The Pennsylvania State University,
University Park, PA, USA
2
Prevention Research Center, The Pennsylvania
State University, University Park, PA, USA

Relatively little research has been conducted on
sibling relationships, especially considering the
large volume of research on other key family
relationships, such as parent–child and marital
relationships. The daily companionship of childhood siblings and the lifelong nature of sibling
bonds, combined with the intense positive and
negative emotional nature of sibling relations,
yield a family relationship whose power and
importance has often been overlooked by
scholars and practitioners. However, a growing
body of research is emerging that illustrates the
impact sibling relationships have on individual
development and family functioning, making the
sibling relationship an appealing target for future
research and prevention efforts.

Scope
The vast majority of children in the United
States grow up in households with at least one
sibling (Hernandez, 1997), and US children are
more likely to grow up in a household with
a sibling than with a father (McHale & Crouter,
2005). Sibling relationships are often the longest
lasting relationships in one’s life and are
typically emotionally intense in both positive
and negative ways. Moreover, children spend
more of their free time with siblings than with
parents or peers (McHale & Crouter, 1996;
Updegraff, McHale, Whiteman, Thayer, &
Delgado, 2005).
Given these factors, it is not surprising that
siblings and sibling relationships have a strong
influence on a wide range of child and adolescent

Sibling Relationships During Childhood

mental and behavioral health outcomes, such as
depression, academic performance, peer and
romantic relationship quality, conduct problems,
and substance use (Feinberg, Solmeyer, &
McHale, 2012). The influence of siblings persists
throughout the lifespan into old age (Waldinger,
Vaillant, & Orav, 2007). Siblings provide a key
context for learning fundamental social skills
beginning in early childhood, but sibling conflict
and aggression can be problematic. Observational
research has documented the occurrence of sibling
conflict at a rate of up to eight times per hour
(Berndt & Bulleit, 1985; Dunn & Munn, 1986),
and sibling aggression is common, with 70 % of
families reporting physical violence between siblings (Steinmetz, Straus, & Gelles, 1981). Indeed,
sibling violence occurs more frequently than other
forms of child abuse (Button & Gealt, 2009). Negative sibling relationships are one of the most significant challenges for parents, and the parental
stress that results from chronic sibling conflict
may contribute to ineffective parenting and diminished parental well-being, which can have profound impacts on the entire family system.

Theories
In a recent review of theoretical perspectives and
research on sibling relationships, Whiteman,
McHale, and Soli (2011) noted that sibling relationships are multidimensional and vary across
time and space, making it unlikely that a single
theory can explain all the developmental, family,
and group differences found in sibling relationships. Most research on sibling relationships to
date has been guided by three theoretical frameworks: social learning theory, social comparison
theory, and family systems theory.
Social learning theory centers on the idea that
individuals learn new behaviors and attitudes
through reinforcement and observing others
(Bandura, 1977). For example, children learn
social competencies from their interactions with
parents and siblings. Most of the sibling research
in social learning focuses on how siblings influence one another’s individual adjustment, especially conduct problems, substance use, and risky

T.P. Gullotta, M. Bloom (eds.), Encyclopedia of Primary Prevention and Health Promotion,
DOI 10.1007/978-1-4614-5999-6, # Springer Science+Business Media New York 2014

Sibling Relationships During Childhood

sexual practices through the processes of reinforcement and modeling. Patterson and colleague’s (1984) coercive processes model
theorizes that repeated negativity and coercion
in the sibling relationship is internalized over
time into an entrenched pattern of behavior and
then generalized to interactions with peers and
others. Some research has also examined how
sibling’s reinforcement of each other’s deviant
talk or behavior can promote negative adjustment
(Bullock & Dishion, 2002).
According to social comparison theory, people evaluate themselves based on comparisons
with other individuals in their immediate environments and are driven by the motivation to
enhance one’s self-esteem (Festinger, 1954).
Given that siblings must share parental attention
and love, they can view each other as competitors
such that a gain in parental recognition for one is
experienced as a loss for the other. Sibling
research within the social comparison framework
includes work on the ways that parental differential treatment (PDT) of siblings can affect
children’s adjustment (McHale, Updegraff,
Jackson-Newsom, Tucker, & Crouter, 2000) –
especially if PDT is considered unfair – and the
ways that siblings may seek to differentiate
themselves to create separate niches in which to
attract recognition and praise (Feinberg, McHale,
Crouter, & Cumsille, 2003).
According to family systems theory
(Minuchin, 1985), individual development must
be considered within the context of family
relationships. Sibling research within this
perspective focuses on the reciprocal influences of
individual adjustment, the dynamics of the sibling
subsystem, and the interplay with other family subsystems (e.g., marital and parent–child relations).

Research
Research on sibling influence generally focuses on
two broad questions: (1) What are the processes
that make two children from the same family
similar or dissimilar from one another? (2) What
factors influence sibling relationship quality, and
what dimensions of sibling relationships help

919

shape individual development and psychosocial
adjustment? Studying sibling relationships is
complex due in part to the range of structural
features that define these relationships, e.g.,
gender constellation, age and age spacing, biological relatedness, as well as the dyad’s place in the
overall family constellation of siblings.
Social Learning Sibling Research
Most sibling research in the social learning area
has focused on how siblings influence one
another’s individual adjustment, including
conduct problems, substance use, and risky
sexual practices. Researchers have documented
a number of links between mental and behavioral
health of one sibling and those of the other. For
example, Shortt, Stoolmiller, Smith-Shine, Mark
Eddy, and Sheeber (2010) reported that older
siblings’ externalizing behavior was associated
with increased externalizing behavior in the
younger sibling over time. And researchers have
found moderately strong positive associations
between levels of siblings’ substance use (Epstein,
Bang, & Botvin, 2007; Pomery et al., 2005;
Rende, Slomkowski, Lloyd-Richardson, &
Niaura, 2005), which are often interpreted as
evidence of social learning through modeling and
reinforcement. Because siblings can learn that
escalating negativity in sibling interaction often
leads to getting their way, sibling relationships
have been described as a training ground for
aggression (Patterson, 1986). Siblings may also
promote each other’s negative behavior through
reinforcement of deviant talk (Bullock & Dishion,
2002). It is not surprising, then, that hostility,
aggression, and violence between siblings also
predict antisocial behavior and substance use, in
some reports, beyond what is accounted for
by parent–child and peer relationships
(Bank, Burraston, & Snyder, 2004; Brody et al.,
2003; Conger & Conger, 1994; Garcia, Shaw,
Winslow, & Yaggi, 2000; Snyder, Bank, &
Burraston, 2005).
Social Comparison and Differentiation
Sibling Research
Only a handful of studies assess sibling differentiation and social comparison processes, such as

920

the ways that siblings react to parental differential treatment (PDT). Research indicates that
parental differential treatment of siblings is
common across the life span (McHale & Crouter,
2003). Evidence suggests that parental differential
treatment is linked to less positive sibling relationships from early childhood through adolescence
(Shanahan, McHale, Crouter, & Osgood, 2008),
with the disfavored sibling showing higher levels
of depression (Feinberg & Hetherington, 2001),
antisocial, and delinquent behavior (Richmond,
Stocker, & Rienks, 2005), including substance
use. Children’s own perceptions of fairness or
unfairness in PDT is an important moderator of
the effects of PDT (Kowal, Kramer, Krull, &
Crick, 2002; McHale et al., 2000).
Parents often cite differences in children’s
behavior, personality, and needs as motivation
for treating their children differently (McHale &
Crouter, 2003). Indeed, the direction of effect
between PDT and sibling characteristics must
be considered given evidence that, for example,
youths’ externalizing behaviors have been shown
to predict an increase in mother’s hostility over
time (Richmond & Stocker, 2008). Thus, it is
plausible that PDT may also arise as a reaction
to existing sibling differences. Family context
has also been shown to be related to PDT. For
instance, some findings suggest stronger negative
effects for girls than for boys and for older than
for younger siblings (Feinberg, Neiderhiser,
Simmens, Reiss, & Hetherington, 2000).
Research on Mexican American families suggests that cultural factors also may be at play:
Among adolescents who endorsed the traditional
value familismo (which highlights concern for the
needs and interests of the family above oneself),
disfavored sibling status was less strongly linked
with risky behavior and depression (McHale,
Updegraff, Shanahan, Crouter, & Killoren,
2005). Findings such as these highlight the
complexity of sibling relationships and the need
to study siblings longitudinally in the context of
the larger culture.
Family Systems Sibling Research
Family systems research studies siblings within
the context of broad family processes. A number

Sibling Relationships During Childhood

of studies have linked sibling relationship quality
to marital and parent–child relations, and these
links appear to be reciprocal (Kim, McHale,
Osgood, & Crouter, 2006; Yu & Gamble, 2008).
Early parent–child relationships have been linked
to later sibling relationships, with more secure
attachment to the mother predicting more
positive sibling relationships (Volling, 2001).
Not surprisingly, siblings may turn to each other
for emotional support during times of marital
conflict (Jenkins, 1992). Supportive, close, and
warm sibling relationships may buffer the impact
of negative influences on individual well-being.
For example, Gass, Jenkins, and Dunn (2007)
reported that positive sibling relations help buffer
youth from the impact of stressful life events. Family systems are not closed but are open to influence
by external factors. For example, factors such as
socioeconomic status and financial stress have
potential to impact marital and parent–child relations, and possibly through these factors the sibling
relationship as well (Conger et al., 1992).

Strategies
How has the existing sibling research been
translated into prevention and intervention
practices? Research demonstrates that the
influences of sibling relationships are extensive,
long lasting, and generally stable over time. Such
stability indicates that poor childhood sibling relationships do not tend to change into positive ones
(although certainly fluctuations and large reversals
of sibling dynamics are possible in any single case).
Thus, some practitioners and researchers have
developed interventions to help children develop
positive, prosocial sibling relationships in order to
enhance youth developmental outcomes.
Kramer (2010) reviewed the sibling research
literature and suggested a number of essential competencies for prosocial sibling relationships in early
childhood; these competencies can serve as a list of
potential targets for sibling-focused interventions.
Individual level skills and factors include social
and emotional understanding and perspective taking, emotion regulation, behavioral control,
forming neutral or positive attributions, conflict

Sibling Relationships During Childhood

management, and problem-solving skills. Factors
specific to the sibling relationship include positive
engagement with each other, cohesion, and shared
experiences that build supportive bonds. A family
level competency is also suggested – the ability to
evaluate parental differential treatment practices as
a family and come to a shared understanding of
what constitutes fair treatment.
In fostering these underlying competencies,
sibling-oriented interventions often seek to
enhance parenting given the parents’ powerful
role in guiding and shaping sibling relations.
Intervention programs have been designed to
train parents in how to effectively manage sibling
relationships to reduce sibling conflict, promote
positivity, and improve children’s conflict
resolution skills (Siddiqui & Ross, 2004). Very
few interventions target the sibling dyad itself,
typically along with the intervention directed
towards parenting practices.
A review by Kramer (2004) identified several
gaps in intervention research on sibling
relationships: the vast majority of studies target
parents (usually mothers) rather than siblings themselves, focus on minimizing problem behaviors
and problematic relationship characteristics rather
than promoting positive ones, examine small and
often clinical samples, fail to include nonintervention comparison groups, assess only immediate but
not long-term intervention effects, and have not
been disseminated for widespread use.

What Works?
We define “what works” as three or more
well-designed and executed studies on a given
method or program. To date, no sibling intervention program meets these criteria. It is expected
that sibling research will continue, and evidencebased sibling programs will emerge.

What Is Promising?
Parent Mediation Training
Parent mediation training has demonstrated
positive outcomes on sibling conflict resolution

921

for both parents and young children (Siddiqui &
Ross, 2004; Smith & Ross, 2007). In Ross’s work
to date, mediation training involved only the
mothers and emphasized allowing children to
resolve conflicts themselves, under the guidance
of the mothers. Training required 1–1.5 h and
covered the four stages of the mediation process:
(1) discussing and gaining consent to the ground
rules and the roles of each participant, (2) clarifying each disputant’s position and interests,
(3) developing empathy and understanding, and
(4) helping to develop a realistic agreement on
the issue. Mothers were also trained in active
listening skills such as clarifying, restating,
reframing, reflecting, and summarizing and
were given the opportunity to watch a video clip
of mother-child mediation and to practice with
the researcher as part of the training.
A randomized trial of the program indicated
that mothers who were trained in mediation
techniques and asked to mediate their children’s
disputes talked more about emotions, interests
and the negotiation process, provided more information and guidance, and reasoned more than
control group mothers, who intervened as usual
(Siddiqui & Ross, 2004). Intervention condition
children talked more about emotions and negotiation processes, supplied more information about
the dispute, and reasoned more than did their
control group counterparts. Mediation training
also affected who resolved the disputes. Intervention group mothers initiated resolutions less often
than control group mothers, younger siblings in
the intervention group suggested resolutions
more often than younger siblings in the control
group, and intervention group siblings had better
understanding of their siblings’ conflict goals
compared to control group siblings.
In a second study, both mothers and fathers in
two-parent families received mediation training
in their home (Smith & Ross, 2007). Siblings in
the intervention group were more constructive
during conflict than were those in the control
group, talking calmly, sharing perspectives, listening, explaining their actions, apologizing, and
suggesting solutions more often than the control
group. Mediations produced more compromises,
and the mediated conflicts were more often

922

resolved by children with the parents’ help, rather
than by the parent alone, as was the case in the
control group. The resolutions themselves were
more constructive in the intervention group than
the resolutions the parents offered in the control
group. Children in the intervention group were
better able to identify their siblings’ goals and
emotions, and the younger siblings took a more
active role, offering more suggestions and
resolutions than the control group younger
siblings.
Sibling Emotional and Social Competence
Training
There are only a few promising prevention
programs in which intervention involves the sibling dyad. The More Fun with Sisters and Brothers
program (Kennedy & Kramer, 2008) was designed
to improve sibling relationship quality among
4–8-year-old siblings by teaching emotional and
social competencies and training their parents to
support and maintain these skills at home. The
program was designed to meet the social demands
of 4–8-year-old siblings and targeted competencies such as initiating play with sibling, perspective taking, regulating emotions, problem solving,
and conflict management. Skills were taught
through modeling, role-playing, performance
feedback, and coaching. In order to facilitate the
transfer of training to real-life situations,
a generalization training session was conducted
in each family’s home. Sibling dyads in the experimental condition received five 1-h training sessions, four in a lab playroom once a week and the
final session in the home. The program showed
modest positive effects for increasing sibling
warmth and reducing parents’ need to intervene
around children’s emotionality, high activity
levels, and misbehavior.
Bank, Kothari, Snyder, Wilson, and Feingold
(2011) have focused on siblings at elevated risk
for antisocial behavior and conduct problems.
Grounded in a social learning approach, Bank
and colleagues (2011) tested a sibling relationship intervention for dyads in which the older
sibling evidenced significant antisocial behavior.
Sibling pairs attended eight sessions that focused
on enhancing their relationship, fostering each

Sibling Relationships During Childhood

sibling’s socially skilled behavior, and reducing
conflict and aggression. The sibling intervention
was embedded in parent management training as
a whole family approach. Parents were provided
with information about what was taught in each
session and coached in how to support and reinforce their children’s practice of behaviors
at home.
Bank and colleagues (2011) compared
families who received only parent management
training (PMT) and families who received only
community partner training (CPT) to families
who received PMT in conjunction with the
sibling dyad intervention (SPMT) to test
the effects of the sibling intervention. After the
intervention, older siblings in the SPMT condition were reported by teachers to demonstrate
reduced conduct problems and were coded by
observers as less negative on the school
playground compared to both PMT and CPT
children. At the end of the intervention, older
siblings in the SPMT group had a 70 % reduction
in observed frequency of negative interaction on
the school playground, which was significantly
larger than the reductions seen in PMT or CPT
groups. Results were not as strong for younger
siblings and were not maintained at the 18-month
follow-up, though patterns of improvement were
stable. This work has been submitted but not yet
published in a peer-review publication.
Feinberg and colleagues (2013) conducted
a randomized control pilot of Siblings are Special
(SAS), a universal program that targets both
sibling relationship and parenting mediating
processes in middle childhood to prevent behavior problems in adolescence. The after-school
program consisted of 12 weekly group sessions
for each group of four sibling dyads, delivered by
two trained group leaders. The sessions included
limited didactic presentation, active games, some
written exercises, role-playing, and discussion.
Three “family fun night” sessions were scheduled
to be evenly spaced throughout the 12 afterschool sessions and the entire family was encouraged to participate. In the preliminary analysis
based on the first cohort of families, program
families had positive outcomes in several areas,
including more sibling fair play, higher sibling

Sibling Relationships During Childhood

social competence, lower mother depressive
symptoms, and lower mother involvement in
sibling conflicts compared to control families
(Solmeyer et al., 2010).
Thomas and Roberts (2009) trained 4–8-yearold children in sibling conflict resolution skills in
a series of five clinic training sessions. All
participating children had at least one sibling
within 3 years of their age, but only one child
was trained. Children who were trained improved
their repertoire of verbal reasoning, assertiveness,
and acceptance to solve sibling conflicts, whereas
children in the control condition did not change
over the same time period. Parents reported
improved social competence in the home for children in the training condition but not for those in
the control condition. The sample size in this study
was very small, only 10 children in each condition,
but the study does suggest that social competence
and sibling conflict resolution skills can be successfully taught to young children.

What Does Not Work?
We have not found any studies that have
conclusively demonstrated that certain practices
or interventions do not foster positive sibling
relationships.

Summary
Given the recency of intervention and research
interest in sibling relationships, it is not entirely
surprising that no sibling intervention program to
date has been able to demonstrate effectiveness in
three or more well-designed research trials.
However, it is likely that research will continue
and that program developers will continue to
explore ways to leverage the power of the sibling
relationship to improve individual and family
functioning. Ideally, sibling intervention programs will be designed to improve one or more
of the competencies outlined by Kramer (2010)
as essential for prosocial sibling relationships.
Future sibling interventions could focus on common family transition periods in order to improve

923

their impact. There is evidence that the family
system is more open to changes during transition
periods, such as transition to adolescence
(Kim et al., 2006), parental divorce (Sheehan,
Darlington, Noller, & Feeney, 2004), and the
transition period when the first born sibling
moves out of the family home (Whiteman,
McHale, & Crouter, 2011). At this point in time,
the most promising prevention programs for
improving sibling relationships focus on parent
mediation training and/or emotional and social
competence training.

References
Bandura, A. (1977). Self-efficacy: Toward a unifying
theory of behavioral change. Psychological Review,
84(2), 191–215.
Bank, L., Burraston, B., & Snyder, J. (2004). Sibling
conflict and ineffective parenting as predictors of adolescent boys’ antisocial behavior and peer difficulties:
Additive and interactional effects. Journal of Research
on Adolescence, 14(1), 99–125.
Bank, L., Kothari, B., Snyder, J., Wilson, D., & Feingold,
A. (2011). Sibling intervention for children with
conduct problems: Testing the benefits for older and
younger siblings. Unpublished manuscript.
Berndt, T. J., & Bulleit, T. N. (1985). Effects of sibling
relationships on preschoolers’ behavior at home and at
school. Developmental Psychology, 21(5), 761–767.
Brody, G. H., Ge, X., Kim, S. Y., Murry, V. M., Simons,
R. L., Gibbons, F. X., et al. (2003). Neighborhood
disadvantage moderates associations of parenting and
older sibling problem attitudes and behavior with
conduct disorders in African American children.
Journal of Consulting and Clinical Psychology,
71(2), 211–222.
Bullock, B. M., & Dishion, T. J. (2002). Sibling collusion
and problem behavior in early adolescence: Toward
a process model for family mutuality. Journal of
Abnormal Child Psychology, 30(2), 143–153.
Button, D. M., & Gealt, R. (2009). High risk behaviors
among victims of sibling violence. Journal of Family
Violence, 25, 131–140.
Conger, K. J., & Conger, R. D. (1994). Differential
parenting and change in sibling differences in
delinquency. Journal of Family Psychology, 8,
287–302.
Conger, R. D., Conger, K. J., Elder, G. H., Lorenz, F. O.,
Simons, R. L., & Whitbeck, L. B. (1992). A family
process model of economic hardship and adjustment
of early adolescent boys. Child Development,
63(3), 526–541.
Dunn, J., & Munn, P. (1986). Sibling quarrels and
maternal intervention: Individual differences in

924
understanding and aggression. Journal of Child
Psychology and Psychiatry, 27, 583–595.
Epstein, J. A., Bang, H., & Botvin, G. J. (2007). Which
psychosocial factors moderate or directly affect
substance use among inner-city adolescents? Addictive
Behaviors, 32(4), 700–713.
Feinberg, M., & Hetherington, E. M. (2001). Differential
parenting as a within-family variable. Journal of
Family Psychology, 15(1), 22–37.
Feinberg, M. E., McHale, S. M., Crouter, A. C., &
Cumsille, P. (2003). Sibling differentiation: Sibling
and parent relationship trajectories in adolescence.
Child Development, 74(5), 1261–1274.
Feinberg, M. E., Neiderhiser, J. M., Simmens, S., Reiss,
D., & Hetherington, E. M. (2000). Sibling comparison
of differential parental treatment in adolescence:
Gender, self-esteem, and emotionality as mediators
of the parenting-adjustment association. Child
Development, 71(6), 1611–1628.
Feinberg, M. E., Sakuma, K. K., Hostetler, M, & McHale,
S. M. (2013). Enhancing sibling relationships to prevent adolescent problem behaviors: Theory, design
and feasibility of siblings are special. Evaluation and
Program Planning, 36, 97–106.
Feinberg, M. E., Solmeyer, A. R., & McHale, S. M.
(2012). The third rail of family systems: Sibling
relationships, mental and behavioral health, and
preventive
intervention
in
childhood
and
adolescence.
Clinical
Child
and
Family
Psychology Review, 15, 43–57. doi:10.1007/s10567011-0104-5.
Festinger, L. (1954). A theory of social comparison
processes. Human Relations, 7(2), 117–140.
Garcia, M. M., Shaw, D. S., Winslow, E. B., & Yaggi,
K. E. (2000). Destructive sibling conflict and the
development of conduct problems in young boys.
Developmental Psychology, 36(1), 44–53.
Gass, K., Jenkins, J., & Dunn, J. (2007). Are sibling
relationships protective? A longitudinal study. Journal
of Child Psychology and Psychiatry, 48(2), 167–175.
Hernandez, D. J. (1997). Child development and the social
demography of childhood. Child Development, 68(1),
149–169.
Jenkins, J. M. (1992). Sibling relationships in disharmonious homes: Potential difficulties and protective
effects. In F. B. J. Dunn (Ed.), Children’s sibling
relationships: Developmental and clinical issues
(pp. 125–138). Hillsdale, NJ: Erlbaum.
Kennedy, D. E., & Kramer, L. (2008). Improving emotion
regulation and sibling relationship quality: The more
fun with sisters and brothers program. Family
Relations, 57(5), 567–578.
Kim, J.-Y., McHale, S. M., Osgood, D. W., & Crouter, A. C.
(2006). Longitudinal course and family correlates of
sibling relationships from childhood through adolescence. Child Development, 77(6), 1746–1761.
Kowal, A., Kramer, L., Krull, J. L., & Crick, N. R. (2002).
Children’s perceptions of the fairness of parental
preferential treatment and their socioemotional

Sibling Relationships During Childhood
well-being. Journal of Family Psychology,
16(3), 297–306.
Kramer, L. (Ed.). (2004). Experimental interventions in
sibling relationships. Mahwah, NJ: Lawrence
Erlbaum.
Kramer, L. (2010). The essential ingredients of successful
sibling relationships: An emerging framework for
advancing theory and practice. Child Development
Perspectives, 4(2), 80–86.
McHale, S. M., & Crouter, A. C. (1996). The family
contexts of children’s sibling relationships. In G. H.
Brody (Ed.), Sibling relationships: Their causes and
consequences. Advances in applied developmental
psychology (Vol. 10, pp. 173–195). Norwood, NJ:
Ablex Publishing.
McHale, S. M., & Crouter, A. C. (2003). How do children
exert an impact on family life? In A. C. Crouter &
A. Booth (Eds.), Children’s influence on family
dynamics: The neglected side of family relationships
(pp. 207–220). Mahwah, NJ: Lawrence Erlbaum.
McHale, S. M., & Crouter, A. C. (2005). Sibling relationships in childhood: Implications for life course study. In
V. L. Bengtson (Ed.), Sourcebook of family theory &
research (pp. 184–187). Thousand Oaks, CA: Sage.
McHale, S. M., Updegraff, K. A., Jackson-Newsom, J.,
Tucker, C. J., & Crouter, A. C. (2000). When does
parents’ differential treatment have negative implications for siblings? Social Development, 9(2), 149–172.
McHale, S. M., Updegraff, K. A., Shanahan, L., Crouter,
A. C., & Killoren, S. E. (2005). Siblings’ differential
treatment in Mexican American families. Journal of
Marriage and Family, 67(5), 1259–1274.
Minuchin, P. (1985). Families and individual development: Provocations from the field of family therapy.
Child Development, 56(2), 289.
Patterson, G. R. (1986). The contributions of siblings to
training for fighting: A microsocial analysis. In
J. B. D. Olweus & M. Radke-Yarrow (Eds.), Development of antisocial and prosocial behaviors: Research,
theories, and issues (pp. 235–261). New York:
Academic Press.
Patterson, G. R., Dishion, T. J., & Bank, L. (1984). Family
interaction: A process model of deviancy training.
Aggressive Behavior, 10(3), 253–267.
Pomery, E. A., Gibbons, F. X., Gerrard, M., Cleveland,
M. J., Brody, G. H., & Wills, T. A. (2005). Families
and risk: Prospective analyses of familial and social
influences on adolescent substance use. Journal of
Family Psychology. Special Issue: Sibling
Relationship Contributions to Individual and Family
Well-Being, 19(4), 560–570.
Rende, R., Slomkowski, C., Lloyd-Richardson, E., &
Niaura, R. (2005). Sibling effects on substance use in
adolescence: Social contagion and genetic relatedness.
Journal of Family Psychology. Special Issue: Sibling
Relationship Contributions to Individual and Family
Well-Being, 19(4), 611–618.
Richmond, M. K., & Stocker, C. M. (2008). Longitudinal
associations between parents’ hostility and siblings’

Sibling Relationships During Childhood
externalizing behavior in the context of marital discord. Journal of Family Psychology, 22(2), 231–240.
Richmond, M. K., Stocker, C. M., & Rienks, S. L. (2005).
Longitudinal associations between sibling relationship
quality, parental differential treatment, and children’s
adjustment. Journal of Family Psychology,
19(4), 550–559.
Shanahan, L., McHale, S. M., Crouter, A. C., & Osgood,
D. W. (2008). Linkages between parents’ differential
treatment, youth depressive symptoms, and sibling
relationships. Journal of Marriage and Family, 70(2),
480–494.
Sheehan, G., Darlington, Y., Noller, P., & Feeney, J. (2004).
Children’s perceptions of their sibling relationships during parental separation and divorce. Journal of Divorce
& Remarriage, 41(1–2), 69–94.
Shortt, J. W., Stoolmiller, M., Smith-Shine, J. N., Mark
Eddy, J., & Sheeber, L. (2010). Maternal emotion
coaching, adolescent anger regulation, and siblings’
externalizing symptoms. Journal of Child Psychology
and Psychiatry, 51(7), 799–808.
Siddiqui, A., & Ross, H. (2004). Mediation as a method of
parent intervention in children’s disputes. Journal of
Family Psychology, 18(1), 147–159.
Smith, J., & Ross, H. (2007). Training parents to mediate
sibling disputes affects children’s negotiation and
conflict
understanding.
Child
Development,
78(3), 790–805.
Snyder, J., Bank, L., & Burraston, B. (2005). The consequences of antisocial behavior in older male siblings
for younger brothers and sisters. Journal of Family
Psychology, 19, 643–653.
Solmeyer, A. R., Feinberg, M. E., Sakuma, K., Hostetler,
M., McHale, S. M., & Jones, D. (2010, November
3–6). Siblings are special: A universal program to
promote sibling relationships and prevent substance

925
use in early adolescents. Paper presented at the
conference of national council on family relations,
Minneapolis, MN.
Steinmetz, S. K., Straus, M. A., & Gelles, R. J. (1981).
Behind closed doors: Violence in the American family.
Garden City, NY: Anchor Books.
Thomas, B., & Roberts, M. (2009). Sibling conflict
resolution skills: Assessment and training. Journal of
Child and Family Studies, 18(4), 447–453.
Updegraff, K. A., McHale, S. M., Whiteman, S. D.,
Thayer, S. M., & Delgado, M. Y. (2005). Adolescent
sibling relationships in Mexican American families:
Exploring the role of familism. Journal of Family
Psychology, 19(4), 512–522.
Volling, B. L. (2001). Early attachment relationships as
predictors of preschool children’s emotion regulation
with a distressed sibling. Early Education and
Development, 12(2), 185–207.
Waldinger, R. J., Vaillant, G. E., & Orav, E. J. (2007).
Childhood sibling relationships as a predictor of
major depression in adulthood: A 30-year
prospective study. American Journal of Psychiatry,
164, 949–954.
Whiteman, S. D., McHale, S. M., & Crouter, A. C. (2011).
Family relationships from adolescence to early
adulthood: Changes in the family system following
firstborns’ leaving home. Journal of Research on
Adolescence, 21(2), 461–474.
Whiteman, S. D., McHale, S. M., & Soli, A. (2011).
Theoretical perspectives on sibling relationships.
Journal of Family Theory & Review, 3(2), 124–139.
Yu, J., & Gamble, W. (2008). Pathways of
influence:
Marital
relationships
and
their
association with parenting styles and sibling relationship quality. Journal of Child and Family Studies,
17(6), 757–778.

926

Social and Emotional Learning
During Early Childhood
Susanne A. Denham1 and Katherine M. Zinsser2
1
Department of Psychology MS 3F5, George
Mason University, Fairfax, VA, USA
2
Department of Psychology, University of
Illinois at Chicago, Chicago, IL, USA

Introduction
Social and emotional aspects of preschoolers’
development are crucial for their concurrent and
later well-being and mental health, as well as
their learning and early school success (Denham,
2006). As Zins, Bloodworth, Weissberg, and
Walberg (2007) have noted, “schools are social
places, and learning is a social process” (p. 191).
Even young students learn alongside and in collaboration with teachers and peers and must be
able to utilize their emotions to facilitate learning. A child’s abilities to understand emotions of
self and others; regulate emotion, attention, and
behavior; make good decisions regarding social
problems; express healthy emotions; and engage
in a range of prosocial behaviors – their socialemotional learning (SEL) skills – all work
together to grease the cogs of a successful school
experience and facilitate satisfying relationships
with others (Denham, Brown, and Domitrovich,
2010). But SEL success may not be easy for
children just entering pre-academic and academic settings, because preschool and kindergarten contexts are taxing for them to navigate – they
must learn to sit still, attend, follow directions,
and master group play, all very challenging tasks!
Unfortunately, many children have deficits in
these skills by school entry (Rimm-Kaufman,
Pianta, & Cox, 2000).

Definitions and Scope
Emotional competence has recently been
acknowledged for its central role in the development of pathways to social competence, to school

Social and Emotional Learning During Early Childhood

success, and to mental health and risk, from foundations laid during preschool and early primary
grades. Emotional competence includes
expressing emotions that are, or are not, experienced, regulating emotions in ways that are age
and socially appropriate, and decoding these processes in others (Halberstadt, Denham, and
Dunsmore, 2001). More specifically, emotionally
competent children purposefully express a broad
variety of emotions without incapacitating intensity or duration. They understand the emotions of
themselves and others, and they regulate their
emotions when feeling or expressing “too
much” or “too little.”
Social competence, the result of organized
behaviors that meet short- and long-term developmental needs, can be summarized as effectiveness in interaction (Rose-Krasnor, 1997). Such
social competence in the early years has been
recognized as key to school success and satisfying relationships. In the case of preschoolers,
socially competent behaviors are organized
around the developmental tasks of positive
engagement in developmentally appropriate
activities in the physical, social, and cognitive/
attentional environment, and self-regulation during peer interaction. Given this overarching definition and specific developmental tasks, social
competence during early childhood includes very
specific abilities, behaviors, and motivations,
such as initiation of peer interaction, response to
provocation, cooperativeness, empathy, inhibition of aggression, and positive demeanor during
interaction.
Social and emotional learning (SEL) refers to
the constituents of both emotional and social
competence, as promoted by parents, early childhood educators, and preventionists. Thus, the
skills of emotional competence are essential for
social competence, and the specific abilities we
want to promote include all elements of emotional and social competence.
As already noted, the presence of emotional or
social competence (i.e., SEL) during early childhood is related to contemporaneous and later
success in school – both with peers and academically. Such success, indexed by peer status (i.e.,
overall popularity, rejection, or isolation),

T.P. Gullotta, M. Bloom (eds.), Encyclopedia of Primary Prevention and Health Promotion,
DOI 10.1007/978-1-4614-5999-6, # Springer Science+Business Media New York 2014

Social and Emotional Learning During Early Childhood

friendship, and school success, is in turn related
to later well-being and successful negotiation of
developmental tasks into adulthood.
SEL Theory
At the center of our theoretical framework are the
core SEL skills that contribute to children’s
school success and other important outcomes.
These primarily individual skills are vital contributors to ultimately successful, effective interactions with other people and other associated
age-appropriate tasks. SEL skills can be located
in five domains (Payton et al., 2000; see
alsohttp://casel.org/why-it-matters/what-is-sel/).
These domains include both observable behaviors and internal processes, such as perceptions or
beliefs. Some of these domains are self-oriented
while others are relational in nature. These
domains are:
• Self-management includes regulating one’s
emotional experience and expression in productive ways, being aware of feelings, monitoring them, and modifying them when
necessary, so that they aid rather than impede
the child’s ability to cope with varying situations. Important nonemotional aspects of selfmanagement also are crucial to success in
early childhood; these include executive function skills (e.g., working memory, attention,
and inhibitory control), used in the service of
regulating both SEL and academic behavior.
• Self-awareness refers to abilities to accurately
assess personal feelings, interests, values, and
strengths, and maintaining a well-grounded
sense of self-confidence. Preschoolers have
a well-defined, stable sense of self, but much
development in this area occurs later.
The ability to identify and label one’s own
feelings does develop during early childhood,
via an increasingly broad and rich emotion
vocabulary (Denham, 2006).
• Social awareness includes understanding the
feelings of others, being able to take their
perspective and empathize with these feelings,
as well as recognizing and appreciating individual and group similarities and differences.
Emotion knowledge is key – children constantly attempt to understand their own and

927

others’ behavior, and emotions convey critical
interpersonal information that enhances such
understanding while guiding interaction.
Inability to interpret emotions can make the
classroom a confusing, overwhelming place.
• Relationship skills include establishing and
maintaining positive and effective exchanges
with others and, ultimately, healthy and
rewarding relationships that last over time.
Numerous skills are crucial in this domain,
including making positive overtures to play
with others, initiating and maintaining conversations, cooperating, listening, taking turns,
seeking help when needed, and developing
friendship skills (e.g., joining another child
or small group, expressing appreciation, negotiating, and giving feedback). In addition,
asserting oneself; preventing, managing, and
resolving
interpersonal
conflict;
and
addressing others’ needs through negotiation
develop during the preschool-to-primary
period.
• Responsible decision-making includes making
decisions, in both social and academic situations, based on consideration of ethical standards, safety concerns, appropriate social/
moral norms, respect for others, and likely
consequences of various actions. This domain
of SEL becomes important as children’s
everyday social interactions increase in frequency and complexity. They must learn to
solve social problems – to analyze social situations, identify problems, set prosocial goals,
and determine effective ways to solve differences that arise within their peer group.

Current Research
Each SEL competency has its own theoretical
traditions and voluminous empirical literatures
on its links with developmentally appropriate
conceptions of children’s social and school success. These include children’s (1) overall social
competence; (2) classroom learning behaviors,
approaches to learning, and feelings about
school; and (3) achievement, particularly in
preliterary,
pre-numeracy,
reading,
and

928

mathematics, as well as grades and other aspects
of the school experience (e.g., retentions, disciplinary referrals).
Self-management is related to social/classroom adjustment and academic achievement
(Bierman, Nix, Greenberg, Blair, & Domitrovich,
2008; Denham et al., 2003). Children less able to
deal with negative emotions may not have personal resources to focus on learning, whereas
those who can maintain a positive emotional
tone might be able to remain positively engaged
with classroom tasks (Trentacosta & Izard,
2007).
More cognitive/behavioral forms of regulation
are also related to young children’s academic
success. Young children’s abilities to carry out
complex directions, finish tasks, and to concentrate are directly related to kindergarten
achievement, for example (Howse, Calkins,
Anastopoulos, Keane, & Shelton, 2003). Furthermore, Liew, McTigue, Barrois, and Hughes
(2008) found that first-grade inhibitory control
(e.g., being able to walk on a line and trace
a star) predicted third grade reading scores
(see also Ponitz, McClelland, Matthews, &
Morrison, 2009).
The components of self-awareness are related
to positive child outcomes, with the strongest
findings for academic outcomes in parallel
domain areas. For example, Marsh, Ellis, and
Craven (2002) found positive associations
between preschoolers’ academic self-concepts
and achievement. Preschoolers’ self-perceptions
of achievement motivation during were correlated with reading and math scores in 1st grade
(Measelle, Ablow, Cowan, & Cowan, 1998). Few
research reports focus on children’s conceptions
of their own emotions and such outcomes.
Young children’s social awareness, their
emotion knowledge, contributes to their overall
social competence; it is related to their positive
peer status and prosocial reactions to peers’ and
adults’ emotions (Denham et al., 2003). Research
by Izard and colleagues (e.g., Izard et al., 2001)
corroborates these assertions: Head Start children’s emotion knowledge predicted both contemporaneous and later teacher reports of social
functioning.

Social and Emotional Learning During Early Childhood

Increasingly, researchers are also confirming
a link between early academic success and young
children’s emotion knowledge. Leerkes, Paradise, O’Brien, Calkins, and Lange (2008) showed
that emotion knowledge – but not emotion
regulation – was related to preschoolers’
pre-academic achievement. Similarly, Izard and
colleagues (2001) found strong evidence that
5-year-olds’ emotion knowledge predicted both
their age 9 social and academic competence.
Thus, it is evident that children’s ability to understand emotions, especially in context, plays an
important role in their concurrent and later academic success.
Links have been found between social
problem-solving and both social and academic
success, as well as the advantages of specifically
prosocial problem solutions (e.g., Denham &
Almeida, 1987; Youngstrom et al., 2000).
Specifically, specific aspects of social problemsolving are related to preschoolers’ social
competence and behavior problems (Coy, Speltz,
DeKlyen, & Jones, 2001). Children’s emotional
and behavioral responses to hypothetical peer
dilemmas were related to teachers’ concurrent
and later assessments of school adjustment and
their kindergarten academic progress (Bierman,
Domitrovich, et al., 2008).
Children with poorer relationship skills are
more likely to have social difficulties and thus,
indirectly, with school adjustment. Unpacking
this indirect relation, Normandeau and Guay
(1998) have found that kindergartners’ prosocial
behavior predicts their cognitive self-control in
1st grade, which then predicts 1st grade
achievement.
Numerous researchers have found that the
social skills constituting this component of SEL
are even directly related to early academic success. Elias and Haynes (2008) showed that initial
social competence and improvements in social
competence (i.e., cooperation, self-control, and
assertion) predicted third graders’ end-of-year
grades in reading and mathematics. Relationship
skills play significant roles in predicting promotion and retention after 1st grade (Agostin &
Bain, 1997). In fact, children with relationship
skills are at increased risk of dropout. Thus, social

Social and Emotional Learning During Early Childhood

behaviors appear to form a solid foundation for
early school success.

Overview of Strategies
The foregoing discussion boldly underscores the
importance of SEL for children’s success at
important developmental tasks. Concurrently,
young children who master developmentally
appropriate facets of SEL are better equipped to
be invested in play, initiate peer interaction, and
master preliteracy and numeracy skills. They feel
better about themselves and succeed in many
age-appropriate experiences. Their SEL also predicts success at the next level of developmental
tasks as they enter school – thriving academically
and in the demanding world of peers. Early SEL
attainment set them on a course for even later
well-being, mental health, and other positive
outcomes.
Because of this crucial nature of early childhood SEL and the considerable risk associated
with their lack, there has been a call for primary
prevention programs targeted at preschoolers’
emotional and social competence needs. For
those at special risk and for children in general,
the learning of emotional and social competence
should not be left to chance. In fact, theoretical
and empirical evidence reviewed so far suggests
the utility of universal prevention programming
to maximize young children’s short- and longterm relationship and academic success. Efforts
to provide programs focusing on these goals for
preschool children are increasing, although historically early childhood educators’ concerns
with SEL often remain implicit.
What overarching principles can inform
prevention programs to promote SEL and deter
early behavior problems and their sequelae?
Durlak and colleagues’ meta-analyses (Durlak
& Wells, 1997; Durlak, Weissberg, Dymnicki,
Taylor, & Schellinger, 2011) provide guidelines
for successful prevention programs. First, programs must work from a theoretical perspective
and implement specific, SEL-focused strategies
to alter developmental trajectories. Durlak
et al. (2011, p. 410; see also Denham & Burton,

929

2003; Elias, Zins, Graczyk, & Weissberg, 2003)
note that these strategies should be executed
using a “connected and coordinated set of activities,” using active, varied, and engaging learning
approaches. Such components must be monitored
for effective implementation (Elias et al., 2003).
Intervening in multiple contexts is necessary, to
facilitate both person-centered and environmental change by involving peers, parents, teachers,
principals and other personnel, and school district
leaders. SEL should become a goal for the
school’s entire climate and a key element in
learning standards of the system. Further, to be
effective, programs should span multiple years.
Realistically, it takes time to assist development
and change existing behavior patterns. To be able
to evaluate the effectiveness of programs, experimental or quasi-experimental designs should be
utilized, and the fidelity and dosage of implementation must be specified. Finally, “the earlier the
better” are the watchwords for primary prevention of deficits in social and emotional learning.
Although the focus of the preceding discussions of strategies and following review of effective programming is the universal promotion of
SEL among young children, it is important to
recognize other, more targeted ways of promoting SEL as well. Current strategic thinking has
broadened from the blanket intervention
approach to include a “Teaching Pyramid”
model with a multitiered approach to programming (Hemmeter, Ostrosky, & Fox, 2006).
The four components of the Teaching Pyramid
move from a foundation of building positive relationships with children, families, and colleagues,
to designing supportive and engaging environments, then teaching social and emotional skills
within these environments, and, when necessary,
developing individualized interventions for children with the most challenging behavior. At the
same time, the pyramid’s early education programs’ efforts at promoting SEL are
implemented at four multitiered levels of service,
which universal promotion strategies to promote
SEL for all children, selected prevention strategies for addressing the SEL instructional needs of
children at risk for challenging behavior, and
targeted implementation of assessment-based

930

behavior support plans for children with persistent challenging behavior.
At the top level of the Teaching Pyramid,
young children show difficulties in SEL and
need careful assessment, intervention, and monitoring to achieve cessation of difficult behaviors
and increases in SEL. The process used to
develop such assessment-based plans for the individualized intervention to improve persistent
challenging behavior (i.e., at the selected or
targeted level) is described as positive behavior
support (PBS; Dunlap & Fox, 1996). The individualized application of PBS is an effective process that includes functional behavioral
assessment, individualized behavior support
plans appropriate for implementation by caregivers and professionals within natural contexts,
and response to intervention (RTI) assessment
informing further refinement of support plans.
Although the Teaching Pyramid puts forward
a blueprint for SEL promotion and problem
behavior cessation that could fit all children during early childhood and acknowledges many of
the issues mentioned by Durlak et al. (1997,
2011), it and the PBS/RTI approaches originate
in special education contexts. As such, their
potential broader usefulness is only partially realized. These approaches have not as yet fully
integrated the lessons from basic science on
SEL and the accompanying universal and
targeted applications that will be described here.

What Works
There are relatively few programs that fully and
directly address the promotion of SEL during
early childhood, according to the guidelines set
out by Durlak and colleagues (1997, 2011).
Fewer still have been rigorously and systematically evaluated, and only some of these can be
seen as effective (Joseph & Strain, 2003). However, efforts are mounting to identify more
clearly the elements of effective and promising
programming. For example, The Head Start
CARES (Classroom-based Approaches and
Resources for Emotion and Social skill promotion; MDRC, 2012) project is currently using

Social and Emotional Learning During Early Childhood

a randomized design to test the effects of four
evidence-based strategies designed to improve
children’s SEL in Head Start classrooms. We
will focus here on two programs whose effectiveness in increasing SEL in young children has
been supported by multiple rigorous studies:
Promoting Alternative THinking Strategies
(Preschool PATHS) and the Incredible Years
curriculum.
The Preschool PATHS curriculum is a younger extension of an effective elementary school
program (PATHS; Greenberg & Kusché, 1998).
Its theoretical underpinnings emphasize that SEL
milestones do not unfold automatically; on the
contrary, they are heavily influenced, even at the
neuronal level, by environmental inputs throughout early childhood. This curriculum is grounded
in the understanding that much of the individual
variation in the components of children’s emotional competence derives from experiences
within the family and preschool classroom.
Hence, this SEL programming maximizes the
environmental conditions that nurture and reward
the development and application of SEL skills.
The preschool version of PATHS delivers
30 “circle time” lessons to promote social and
emotional competences including compliments,
basic and advanced feelings, problem-solving,
and the “Turtle Technique” to increase preschoolers’ self-control. As with the original
PATHS program for older children, the preschool
curriculum aims to develop children’s awareness
of their own and other’s emotions, teach selfcontrol, increase children’s self-concept and
peer relations, develop problem-solving skills,
and create an overall positive classroom environment supporting SEL. Crucial to the success of
the PATHS curriculum is the training of teachers
to use extension activities and integrate PATHS
concepts throughout the preschool day.
Children’s learning and use of newly acquired
social-emotional skills are scaffolded by teachers
throughout the day whenever they experience an
emotional reaction or a challenging situation.
The original curriculum was evaluated multiple times with elementary school samples. The
Conduct Problems Prevention Research Group
study (1999) showed significant differences

Social and Emotional Learning During Early Childhood

between the control group and the PATHS group
in peer-related aggression, teacher’s ratings of
conduct problems, and overall positive classroom
atmosphere. A second study by Kam, Greenberg,
and Kusché (2004) used a randomized control
methodology to find that children participating
in the PATH curriculum were more likely to
demonstrate
self-control
and
choose
non-confrontational solutions to peer problems,
had a larger affective vocabulary, and were less
likely to be rated by their teachers as displaying
internalizing and externalizing behavior problems. Finally, the preschool version of the
PATHS curriculum (Domitrovich, Cortes, &
Greenberg, 2007) increased children’s emotion
knowledge, social skills, social competence, and
social independence and decreased social withdrawal when compared to the control group.
The Incredible Years curriculum spans both
age and contexts to reduce challenging behaviors
in children from infancy to early adolescence by
reinforcing programmatic themes both in school
and at home. The program integrates parent education on play interaction and relationship skills,
teacher training workshops on classroom management techniques and promoting children’s
prosocial behavior, and child training emphasizing empathy, emotional literacy, problemsolving, and self-control. The Incredible Years
curriculum is grounded in social learning theory
and recognizes the value of adults modeling
appropriate interactions and behaviors for
children’s development; thus the program incorporates both the home and school environments
in the positive socialization process (The Incredible Years Inc., 2012).
Posttests immediately following the conclusion of the program (Webster-Stratton, Reid, &
Hammond, 2004) have shown decreases in
mother’s negative parenting, improvements in
child conduct problems at home and at school,
and improvements in social competence with
peers when compared to the control groups.
Working with a sample of preschoolers at risk
for antisocial behavior, Brotman et al. (2005)
found improvements in families’ provision of
stimulation for learning and children’s engaging
behaviors in the treatment groups in addition to

931

replicating the decreases in negative parenting
behaviors previously discussed. Finally,
Webster-Stratton, Reid, and Stoolmiller (2008)
used a quasi-experimental design with random
assignment of Head Start students and found
improvements in teaching style, children’s
school readiness, positive classroom atmosphere,
along with positive changes in children’s
problem-solving skills.

What Is Promising
The growing recognition, over the past two
decades, of SEL’s importance during early
childhood has led to the development of several
promising programs. Following we will discuss
four such programs that we believe could be
contenders with additional rigorous study – Al’s
Pals: Kids Making Healthy Choices, I Can Problem Solve, the Emotions Course, and
Second Step.
Al’s Pals: Kids Making Healthy Choices
(Geller, 1999) is a resilience-based early childhood curriculum and teacher training program
that develops social, emotional, and behavioral
skills in children 3–8 years old. Al’s Pals uses
twice weekly puppet-based discussions, role
playing, songs, and movement to introduce
social-emotional skills and decrease precursors
to aggressive behavior. An evaluation of the program showed promising results. Lynch, Geller,
and Schmidt (2004) conducted a randomized
control multiyear trial of the program and found
that intervention children received better behavior ratings by teachers. Additionally, teachers
rated children lower on problem behavior scales
such as antisocial/aggressive, social withdrawal,
and anxiety. Although promising, this evaluation
relied on teacher reports of child behavior, which
the authors acknowledge may be positively
biased within the intervention group. The addition of observational measures or direct child
assessment will strengthen future evaluations of
this curriculum.
The program I Can Problem Solve (ICPS;
Shure, 1993) was originally introduced
under the name Interpersonal Cognitive

932

Problem-Solving in the 1970s. The three age
components (preschool, kindergarten and early
elementary, and intermediate elementary)
together have been implemented in schools,
after-school programs, and community centers.
As the name suggests, this program focuses on
teaching children a problem-solving vocabulary,
to understand their own as well as others’ feelings, to think of alternative solutions, and to think
through the consequences associated with their
action choices. By impacting children’s conceptualizations of their conflicts with others, ICPS
aims to reduce impulsivity and enhance positive
peer relationships.
Several evaluations of ICPS have been
conducted over the decades since its original
implementation. Positive impacts on cognitive
problem-solving have been found immediately
following the intervention as well as 6 and
12 months afterwards (Shure & Spivack, 1982).
Although differences did not immediately appear
in children’s problem behaviors, posttests at
1 year and 5 years after participating in the
ICPS program showed fewer problem behaviors
and better classroom behavior overall (Shure,
1993). In older students, participation in the
early elementary school version of ICPS has
also been linked to increases in school bonding
(Kumpfer, Alvarado, Tait, & Turner, 2002).
However, evaluations of ICPS by its original
developers and independent investigators have
shown mixed results. Several studies have suffered from poor instrument reliability, missing
data, inconsistent adherence to the curriculum,
and lack of independent observers and reports
(Boyle & Hassett-Walker, 2008; Kumpfer et al.,
2002; Shure & Spivack, 1982).
The Emotion-Based Prevention Program
(EBP) for Head Start children (Izard,
Trentacosta, King, & Mostow, 2004; Izard
et al., 2008) uses Differential Emotions Theory
to teach preschool-aged children how to understand, regulate, and utilize emotions appropriately (i.e., effective and constructive use of
emotion motivation, as when modulated, vicarious sadness promotes sympathy). As with other
programs discussed, EBP uses puppets, vignettes,
storybooks, and interactive reading to help

Social and Emotional Learning During Early Childhood

structure children’s learning. Unique to this program is the substantial focus on the four “basic”
emotions: happiness, sadness, anger, and fear, as
well as its reliance on the intrinsic rewards associated with greater emotional competence (Izard
et al., 2008).
This program was first tested by Izard and
colleagues in rural Head Start centers (Izard
et al., 2004), and then a second study using
inner city Head Starts reevaluated the program
after some adaptations were made based on previous results. Both studies used randomized controlled trials of the EBP program and study
2 added the comparison of EBP to the established
treatment program, I Can Problem Solve (ICPS;
Shure, 1993). Results of the two studies were
drawn from teacher report, direct child assessment, and independent observation and showed
that EBP increased emotion knowledge and regulation in participating children when compared
to the control groups. Additionally, EBP had beneficial impacts positive social behaviors in study
2 and on maladaptive and aggressive behaviors in
study 1. It is not yet clear why there was variability in the specificity of findings from the two
studies (although operationalizations of emotion
knowledge and emotion regulation did differ
between them); additional research will need to
evaluate the final version of the program to determine necessary duration of treatment and implementation feasibility.
Second Step: A Violence Prevention Curriculum (Frey, Hirschstein, & Guzzo, 2000) is a
school-based universal intervention program
developed to reduce aggressive behavior through
three separate curricula for preschool/kindergarten, elementary, and middle school children. All
three age levels of the programs build on cognitive
behavioral intervention models and social learning
theory to teach children social-emotional skills to
reduce impulsive and aggressive behavior while
increasing social competence. Classroom lessons
include labeling emotions, managing emotional
reactions, decision-making, and choosing positive
goals. Younger students are encouraged to interact
with the Impulsive Puppy, Slow Down Snail, and
Be-Calm Bunny puppets and toys throughout the
curriculum.

Social and Emotional Learning During Early Childhood

In elementary and middle school populations,
Second Step has been linked to decreases in
observed antisocial behavior and increases in
prosocial behavior when compared to the control
groups (Grossman et al., 1997; Taub, 2002).
McMahon, Washburn, Felix, Yakin, & Childrey
(2000) examined the effectiveness of the Second
Step program in improving social skills knowledge and social competence among urban
low-income, ethnically diverse children in preschool and kindergarten. Teacher ratings, child
reports, and observational data were used to
assess children’s social skills knowledge and
social competence over a year. After 1 year of
program involvement, children demonstrated
increased knowledge of social skills and
decreased observed behavioral problems.
Although promising, there is limited research
evaluating the implementation of Second Step
in early childhood classrooms.

What Does Not Work
The admonitions and recommendations in Durlak
and colleagues’ meta-analyses (1997, 2011), as
well as Denham and Burton’s 2003 book and
Elias and colleagues’ 2003 article, are clear.
Early childhood SEL programming takes the
planning and commitment of all personnel in
childcare programs, preschools, and schools
housing kindergartens, as well as careful training,
implementation, and evaluation. Short-term programs don’t work. Most programs begun now, as
opposed to those of the 1970s and 1980s, try to
heed this caveat. Isolated behavior modification
programs or add-on programming that is not fully
integrated into daily activities of classroom are
unlikely to succeed in promoting long-lasting
social and emotional learning. Similarly, social
skills training alone (i.e., teaching children to
increase their competence in specific skills but
not from an overarching SEL approach) may
work, but only in the short term. Long-term
impacts of behavior and relationships will only
come from incorporating multiple components of
SEL consistently across multiple developmental
contexts (home, child care, school, etc.) Finally,

933

behavioral interventions are often methodologically rigorous, showing high effectiveness, but
there are definite concerns about ecological
validity, fading delivery fidelity, and the generalization of the behavior change as well as its
simplistic nature.

Summary
A case has been made for the importance of SEL
during early childhood and thereafter. Further,
many necessary qualities of effective SEL programming in early childhood, and several effective programs, have been introduced. Thus,
although there is much evidence-based research
to support the importance of early childhood SEL,
as well as growing support for specific SEL practices during early childhood, even more focused
research attention on evaluating effective SEL
programming and its successful implementation
is needed. Making the need for SEL programming
explicit within early childhood education, rather
than implicit, is a priority that we can no longer
postpone. Governmental and nongovernmental
entities alike (e.g., kindergartens within state
school systems, private childcare centers) must
have standard goals for young children’s SEL
development and work to meet them. The scientific and education communities are coming
together to bring early childhood SEL programming to scale. Our children deserve this care.

References
Agostin, T. M., & Bain, S. K. (1997). Predicting early
school success with developmental and social skills
screeners. Psychology in the Schools, 34, 219–228.
Bierman, K. L., Domitrovich, C. E., Nix, R. L., Gest, S. D.,
Welsh, J. A., Greenberg, M. T., et al. (2008). Promoting academic and social-emotional school readiness:
The Head Start REDI program. Child Development,
79, 1802–1817.
Bierman, K. L., Nix, R. L., Greenberg, M. T., Blair, C., &
Domitrovich, C. E. (2008). Executive functions and
school readiness intervention: Impact, moderation,
and mediation in the Head Start REDI program. Development and Psychopathology, 20, 821–843.
Boyle, D., & Hassett-Walker, C. (2008). Reducing overt
and relational aggression among young children: The

934
results from a two-year outcome evaluation. Journal of
School Violence, 7, 27–42.
Brotman, L. M., Gouley, K. K., Chesir-Teran, D., Tracy,
D., Klein, R. G., & Shrout, P. (2005). Prevention for
preschoolers at high risk for conduct problems: Immediate outcomes on parenting practices and child social
competence. Journal of Clinical Child and Adolescent
Psychology, 34, 724–734.
Conduct Problems Prevention Research Group. (1999).
Initial impact of the fast track prevention trial for
conduct problems: The high-risk sample. Journal of
Consulting and Clinical Psychology, 67, 631–647.
Coy, K., Speltz, M. L., DeKlyen, M., & Jones, K. (2001).
Social-cognitive processes in preschool boys with and
without oppositional defiant disorder. Journal of
Abnormal Child Psychology, 29, 107–119.
Denham, S. A. (2006). Social-emotional competence as
support for school readiness: What is it and how do we
assess it? Early Education and Development, 17, 57–89.
Denham, S. A., & Almeida, M. C. (1987). Children’s
social problem-solving skills, behavioral adjustment,
and interventions: A meta-analysis evaluating theory
and practice. Journal of Applied Developmental
Psychology, 8, 391–409.
Denham, S. A., Blair, K. A., DeMulder, E., Levitas, J.,
Sawyer, K. S., Auerbach-Major, S. T., et al. (2003).
Preschoolers’ emotional competence: Pathway to
mental health? Child Development, 74, 238–256.
Denham, S. A., Brown, C. A., & Domitrovich, C. E.
(2010). “Plays nice with others”: Social-emotional
learning and academic success. Early Education and
Development, 21, 652–680.
Denham, S. A., & Burton, R. (2003). Social and emotional
prevention and intervention programming for preschoolers. New York: Kluwer-Plenum.
Domitrovich, C. E., Cortes, R. C., & Greenberg, M. T.
(2007). Improving young children’s social and emotional competence: A randomized trial of the preschool
PATHS curriculum. The Journal of Primary Prevention, 28, 57–91.
Dunlap, G., & Fox, L. (1996). Early intervention and
serious problem behaviors: A comprehensive
approach. In L. K. Koegel, R. L. Koegel, &
G. Dunlap (Eds.), Positive behavior support. Including
people with difficult behavior in the community
(pp. 31–50). Baltimore, MD: Brookes.
Durlak, J. A., Weissberg, R. P., Dymnicki, A. B., Taylor,
R. D., & Schellinger, K. B. (2011). The impact of
enhancing students’ social and emotional learning:
A meta-analysis of school-based universal interventions. Child Development, 82, 405–432.
Durlak, J. A., & Wells, A. M. (1997). Primary prevention
mental health programs for children and adolescents:
A meta-analytic review. American Journal of Community Psychology, 26, 115–152.
Elias, M. J., & Haynes, N. M. (2008). Social competence,
social support, and academic achievement in minority,
low-income, urban elementary school children. School
Psychology Quarterly, 23, 474–495.

Social and Emotional Learning During Early Childhood
Elias, M. J., Zins, J. E., Graczyk, P. A., & Weissberg, R. P.
(2003). Implementation, sustainability, and scaling up
of social-emotional and academic innovations in public schools. School Psychology Review, 32, 303–319.
Frey, K. S., Hirschstein, M. K., & Guzzo, B. A. (2000).
Second step: Preventing aggression by promoting
social competence. Journal of Emotional and Behavioral Disorder, 8, 102–110.
Geller, S. (1999). Al’s pals: Kids making healthy choices.
Richmond, VA: Wingspan LLC.
Greenberg, M. T., & Kusché, C. A. (1998). Preventive
interventions for school-age deaf children: The
PATHS curriculum. Journal of Deaf Studies and
Deaf Education, 3, 49–63.
Grossman, D. C., Neckerman, H. J., Koepsell, T. D., Liu, P.,
Asher, K. N., Beland, K., et al. (1997). Effectiveness of
a violence prevention curriculum among children in elementary school: A randomized controlled trial. Journal
of the American Medical Association, 277, 1605–1611.
Halberstadt, A., Denham, S. A., & Dunsmore, J. (2001).
Affective social competence. Social Development, 10,
79–119.
Hemmeter, M. L., Ostrosky, M., & Fox, L. (2006). Social
and emotional foundations for early learning:
A conceptual model for intervention. School Psychology Review, 35, 583–601.
Howse, R., Calkins, S., Anastopoulos, A., Keane, S., &
Shelton, T. (2003). Regulatory contributors to children’s kindergarten achievement. Early Education
and Development, 14, 101–119.
Izard, C. E., Fine, S., Schultz, D., Mostow, A., Ackerman,
B., & Youngstrom, E. (2001). Emotions knowledge as a
predictor of social behavior and academic competence
in children at risk. Psychological Science, 12, 18–23.
Izard, C. E., King, K. A., Trentacosta, C. J., Morgan, J. K.,
Laurenceau, J.-P., Krauthamer-Ewing, E. S.,
et al. (2008). Accelerating the development of emotion
competence in Head Start children: Effects on adaptive
and maladaptive behavior. Development and Psychopathology, 20, 369–397.
Izard, C. E., Trentacosta, C. J., King, K. A., & Mostow,
A. J. (2004). An emotion-based prevention program
for Head Start children. Early Education and Development, 15, 407–422.
Joseph, G. E., & Strain, P. S. (2003). Comprehensive
evidence-based social-emotional curricula for young
children: An analysis of efficacious adoption potential.
Topics in Early Childhood Special Education, 23,
65–76.
Kam, C.-M., Greenberg, M. T., & Kusché, C. A. (2004).
Sustained effects of the PATHS curriculum on the
social and psychological adjustment of children in
special education. Journal of Emotional and Behavioral Disorders, 12, 66–78.
Kumpfer, K. L., Alvarado, R., Tait, C., & Turner, C.
(2002). Effectiveness of school-based family and children’s skills training for substance abuse prevention
among 6-8-year-old rural children. Psychology of
Addictive Behaviors, 16(4 Suppl.), S65–S71.

Social and Emotional Learning During Early Childhood
Leerkes, E. M., Paradise, M., O’Brien, M., Calkins, S. D.,
& Lange, G. (2008). Emotion and cognition processes
in preschool children. Merrill-Palmer Quarterly, 54,
102–124.
Liew, J., McTigure, E. M., Barrois, L., & Hughes, J. N.
(2008). Adaptive and effortful control and academic
self-efficacy beliefs on achievement: A longitudinal
study of 1st through 3rd graders. Early Childhood
Research Quarterly, 23, 515–526.
Lynch, K. B., Geller, S. R., & Schmidt, M. G. (2004).
Multi-year evaluation of the effectiveness of a
resilience-based prevention program for young children. Journal of Primary Prevention, 24, 335–353.
Marsh, H. W., Ellis, L. A., & Craven, R. G. (2002). How
do preschool children feel about themselves?
Unraveling measurement and multidimensional selfconcept structure. Developmental Psychology, 38,
376–393.
McMahon, S. D., Washburn, J., Felix, E. D., Yakin, J., &
Childrey, G. (2000). Violence prevention: Program
effects on urban preschool and kindergarten children.
Applied and Preventive Psychology, 9, 271–281.
MDRC. (2012). Head Start CARES Project. MDRC.
Retrieved October 19, 2012, from http://www.mdrc.
org/project_11_89.html
Measelle, J. R., Ablow, J. C., Cowan, P. A., & Cowan,
C. P. (1998). Assessing young children’s views of their
academic, social, and emotional lives: An evaluation
of the self-perception scales of the Berkeley Puppet
Interview. Child Development, 69, 1556–1576.
Normandeau, S., & Guay, F. (1998). Preschool behavior
and first-grade school achievement: The mediational
role of cognitive self-control. Journal of Educational
Psychology, 90, 111–121.
Payton, J. W., Wardlaw, D. M., Graczyk, P. A.,
Bloodworth, M. R., Tompsett, C. J., & Weissberg,
R. P. (2000). Social and emotional learning:
A framework for promoting mental health and reducing risk behaviors in children and youth. Journal of
School Health, 70, 179–185.
Ponitz, C. C., McClelland, M. M., Matthews, J. S., &
Morrison, F. J. (2009). A structured observation of
behavioral self-regulation and its contribution to kindergarten outcomes. Developmental Psychology, 45,
605–619.

935
Rimm-Kaufman, S. E., Pianta, R. C., & Cox, M. J. (2000).
Teachers’ judgments of problems in the transition to
kindergarten. Early Childhood Research Quarterly,
15, 147–166.
Rose-Krasnor, L. (1997). The nature of social competence:
A theoretical review. Social Development, 6, 111–135.
Shure, M. B. (1993). Interpersonal problem solving and
prevention: A comprehensive report of research and
training. A five-year longitudinal study, kindergarten
through grade 4 (#MH-40801). Washington, DC:
National Institute of Mental Health.
Shure, M. B., & Spivack, G. (1982). Interpersonal
problem-solving in young children: A cognitive
approach to prevention. American Journal of Community Psychology, 10, 341–356.
Taub, J. (2002). Evaluation of the Second Step Violence
Prevention Program at a rural elementary school.
School Psychology Review, 32, 186–200.
The Incredible Years, Inc. (2012). The incredible years
series. The Incredible Years: Parents, Teachers and
Children Training series. Retrieved October 19, 2012,
from http://www.incredibleyears.com/
Trentacosta, C. J., & Izard, C. E. (2007). Kindergarten
children’s emotion competence as a predictor of their
academic competence in first grade. Emotion, 7,
77–88.
Webster-Stratton, C., Reid, M. J., & Hammond,
M. (2004). Treating children with early-onset conduct
problems: Intervention outcomes for parent, child, and
teacher training. Journal of Clinical Child and Adolescent Psychology, 33, 105–124.
Webster-Stratton, C., Reid, M. J., & Stoolmiller,
M. (2008). Preventing conduct problems and improving school readiness: Evaluation of the Incredible
Years teacher and child training. Journal of Child
Psychology and Psychiatry, 49, 471–488.
Youngstrom, E., Wolpaw, J. M., Kogos, J. L., Schoff, K.,
Ackerman, B., & Izard, C. T. (2000). Interpersonal
problem solving in preschool and first grade: Developmental change and ecological validity. Journal of
Clinical Child Psychology, 29, 589–602.
Zins, J. E., Bloodworth, M. R., Weissberg, R. P., & Walberg,
H. J. (2007). The scientific base linking social and emotional learning to school success. Journal of Educational
and Psychological Consultation, 17, 191–210.

936

Social and Emotional Learning:
Children
Kimberly A. Schonert-Reichl1 and
Roger P. Weissberg2
1
Department of Educational and Counseling
Psychology, and Special Education, University
of British Columbia, Vancouver, BC, Canada
2
Department of Psychology (MC 285),
University of Illinois at Chicago, Chicago,
IL, USA

Introduction
A fundamental mission of schools is to educate
children and youth to master essential subject
content areas such as reading, writing, math,
science, and social studies. In addition, there is
a general consensus among educators, students,
parents, and the public at large for a more comprehensive vision of education – one that includes
an explicit focus on educating “the whole child”
and fostering a wide range of life skills,
dispositions, and knowledge including social
and emotional competencies, character, and
social responsibility (Association for Supervision
and Curriculum Development, 2007; Bushaw &
Lopez, 2013; Greenberg et al., 2003). In other
words, in addition to promoting academic skills,
schools have a role in preparing students to graduate with the capacities to get along with others in
social and emotionally skilled ways, to practice
healthy behaviors, and to make decisions in
responsible ways. In the face of current societal,
economic, environmental, and social challenges,
enhancing these intrapersonal and interpersonal
competencies is more critical than ever before
with business and political leaders urging schools

The Authors would like to thank 1,440 Foundation,
Einhorn Family Charitable Trust, NoVo Foundation, and
Robert Wood Johnson Foundation for their support of the
Collaborative for Academic, Social, and Emotional
Learning (CASEL) and for their commitment to advancing efforts to enhance the social and emotional learning of
all children.

Social and Emotional Learning: Children

to pay more attention to equipping students
with skills such as problem solving, critical thinking, communication, collaboration, and selfmanagement – or “twenty-first century skills”
(Heckman, 2007; National Research Council,
2012). For students to achieve their full potential
as adult citizens in a pluralistic society and to be
prepared for their future roles as employees,
parents, and volunteers, high-quality education
must provide explicit and intentional attention
to helping students develop the necessary skills
they need to be successful in school and in life.
One approach that has been suggested as
a way to improve students’ success is through
universal school-based approaches designed to
promote students’ social and emotional competencies that are integrated into the day-to-day
interactions of students, teachers, and staff in
ways that are meaningful, consistent, and embedded into the contexts of classrooms and schools.
This entry profiles contemporary research and
theory on social and emotional learning (SEL),
the evidence-base that links SEL with student
well-being and school success, and the practices
and strategies that can be used to promote SEL.

Defining Social and Emotional Learning
Social and emotional learning, or SEL, involves
the processes through which individuals acquire
and effectively apply the knowledge, attitudes,
and skills necessary to understand and manage
their emotions, feel and show empathy for others,
establish and achieve positive goals, develop and
maintain positive relationships, and make responsible decisions (Collaborative for Academic,
Social, and Emotional Learning, 2013; Weissberg,
Payton, O’Brien, & Munro, 2007). That is, SEL
teaches the personal and interpersonal skills we all
need to handle ourselves, our relationships, and
our work effectively and ethically.
Historically, SEL has been characterized in
a variety of ways, often being used as an organizing framework for an array of promotion and
prevention efforts in education and developmental science, including conflict resolution, cooperative learning, bullying prevention, and positive

T.P. Gullotta, M. Bloom (eds.), Encyclopedia of Primary Prevention and Health Promotion,
DOI 10.1007/978-1-4614-5999-6, # Springer Science+Business Media New York 2014

Social and Emotional Learning: Children

youth development (Devaney, O’Brien, Resnik,
Keister, & Weissberg, 2006; Elias et al., 1997).
SEL builds from work in child development,
classroom management, prevention, and emerging knowledge about the role of the brain in selfawareness, empathy, social-cognitive growth
(e.g., Gallese & Goldman, 1998; Greenberg,
2006), and focuses on the skills that allow children to calm themselves when angry, make
friends, resolve conflicts respectfully, and make
ethical and safe choices. Moreover, SEL offers
educators, families, and communities relevant
strategies and practices to better prepare students
for “the tests of life, not a life of tests” (Elias,
2001, p. 40). SEL is sometimes called “the missing piece,” because it represents a part of education that is inextricably linked to school success,
but has not been explicitly stated or given much
attention until recently.
Since 1994, the Collaborative for Academic,
Social, and Emotional Learning (CASEL)
(www.casel.org), a nonprofit organization in
Chicago, IL, has been at the forefront in North
American and international efforts to promote
SEL. Since its inception, CASEL has defined
SEL more specifically and has served as a guide
to school-based SEL programming (CASEL,
2003). Based on extensive research, CASEL
(2013) has identified five interrelated sets of
cognitive, affective, and behavioral competencies that are central to SEL.
Self-Awareness: The ability to accurately
recognize one’s feelings and thoughts and their
influence on behaviors. This includes accurately
assessing one’s strengths and limitations, and
possessing a well-grounded sense of confidence
and optimism.
Self-Management: The ability to regulate
one’s emotions, thoughts, and behaviors in
different situations. This includes delaying
gratification, managing stress, controlling
impulses, motivating oneself, and setting
and working toward achieving personal and
academic goals.
Social Awareness: The ability to take the
perspective of and empathize with others from
diverse backgrounds and cultures, to understand
social and ethical norms for behavior, and to

937

recognize family, school, and community
resources and supports.
Relationship Skills: The ability to establish
and maintain healthy and rewarding relationships
with diverse individuals and groups. This includes
communicating clearly, listening actively,
cooperating, resisting inappropriate social
pressure, negotiating conflict constructively, and
seeking help when needed.
Responsible Decision Making: The ability
to make constructive choices about personal
behavior, social interactions, and school and life
expectations based on consideration of ethical
standards, safety concerns, social norms, realistic
evaluation of consequences of various actions,
and the well-being of self and others.
Although page limitations preclude a comprehensive review of the existing SEL literature, the
past decade has witnessed a surge in the number
of excellent books and reviews on SEL and we
encourage the reader to explore these for further
information (for books on SEL see: Elias, 2003;
Elias & Arnold, 2006; Elias et al., 1997;
Humphrey, 2013; Merrell & Gueldner, 2010;
Zins, Weissberg, Wang, & Walberg, 2004; for
articles/reports, see: Denham & Weissberg,
2004; Elbertson, Brackett, & Weissberg, 2010;
Greenberg, 2010; Jones & Bouffard, 2012; Kress
& Elias, 2006; Lantieri & Nambler, 2012; Payton
et al., 2000; Schonert-Reichl & Hymel, 2007;
Schonert-Reichl & Utne O’Brien, 2012; Zins &
Elias, 2006).

Theories of Social and Emotional
Learning
Given that SEL has been characterized and
defined in a multitude of ways (Humphrey,
2013), it comes as no surprise that SEL programs
and approaches are founded on a variety of theoretical perspectives. Several program developers
cite social learning theory (Bandura, 1977)
as the foundation for their SEL program, while
others indicate that their programs draw
from social-cognitive (Coie & Dodge, 1998)
or cognitive-behavioral approaches (Tobler
et al., 2000). Several SEL programs draw

938

from research and theory in the area of emotional
intelligence (e.g., Goleman, 1995; Mayer &
Salovey, 1997) and hence are predicated on the
notion the capacity to process, reason about, and
use emotion can enhance cognitive activities,
such as thinking and decision making, facilitate
the development and maintenance of social
relationships, and promote personal growth and
well-being (Brackett, Rivers, Reyes, & Salovey,
2012). SEL programming also draws from theories that emphasize the primacy of relationships
(Ainsworth & Bowlby, 1991; Ryan & Deci,
2000) and is based on the understanding that
learning is a social process – that is, students’
learning occurs in collaboration with their
teachers and in interactions with their peers,
and that the best learning emerges in the context
of supportive relationships that make learning
challenging, engaging, and meaningful.
As can be surmised, SEL includes both an
environmental focus and a person-centered
focus (Zins et al., 2004). Hence, in addition to
focusing on specific instruction in social and
emotional skills, SEL is a process of creating a
school and classroom community that is caring,
supportive, and responsive to students’ needs.
Indeed, effective SEL interventions and skill
development should occur in an environment
that is safe, caring, supportive, and wellmanaged, an environment that supports a child’s
development and provides opportunities for practicing the skills. Issues including communication
styles, high performance expectations, classroom
structures and rules, school organizational
climate, commitment to the academic success of
all students, district policies, teacher social and
emotional competence (Jennings & Greenberg,
2009), and openness to parental and community
involvement are all important components of an
SEL approach.
In a recent and excellent review of SEL theory
and practice, Jones and Bouffard (2012)
have put forth a conceptual model that
draws from “developmental-contextual models”
(Bronfenbrenner & Morris, 1998) of human
development that takes into account the nested
and interactive layers of influences on development from those ecologies in which the child

Social and Emotional Learning: Children

directly interacts (e.g., family, peer systems,
classrooms, school), and proceeding to increasingly distant levels of influence (e.g., culture and
political contexts). At the center of their model
are core SEL skills that Jones and Bouffard (2012)
have categorized into three conceptual domains:
emotional processes, social/interpersonal skills,
and cognitive regulation. These, in turn, are seen
as having both short- and long-term outcomes on
academic achievement, behavioral adjustment,
and emotional health and well-being.

Research Demonstrating the
Effectiveness of SEL Programs
What does the research say about the effectiveness of SEL programs? At present, some of
the most compelling evidence in support of the
effectiveness of SEL in demonstrating improvements in both social and emotional skills and
academics comes in the form of a meta-analyses
conducted by Durlak and colleagues (2011).
Durlak, Weissberg, Dymnicki, Taylor and
Schellinger (2011) located 213 studies that
included 270,034 students aged 5–18 without
any identified adjustment or learning problems,
included a control group, and that reported sufficient data to allow calculation of effect sizes
(an index that provides information on the magnitude of the relationship). Almost half (47 %) of
the studies employed randomized designs. More
than half (56 %) were implemented in elementary school, 31 % in middle school, and the
remainder in high school. The majority were
classroom based, delivered either by teachers
(53 %) or by personnel from outside the school
(21 %). Most of the programs (77 %) lasted less
than a year, 11 % lasted 1–2 years, and 12 %
lasted more than 2 years.
Durlak et al. (2011) analyzed the effectiveness
of these school-based programs in terms of six
student outcomes in the cognitive as well as
intrapersonal and interpersonal domains: social
and emotional skills, attitudes toward self and
others, positive social behaviors, conduct problems, emotional distress, and academic performance. Their findings revealed significant and

Social and Emotional Learning: Children

positive effects for students in SEL programs
relative to controls for all six outcomes.
To provide the “practical value” for academic
achievement gains for students in the SEL intervention group versus students in the control
group, Durlak et al. (2011) next calculated
Cohen’s U3 “improvement” index to translate
the mean effect size on measures of achievement
to a score that reflects the average percentile rank
for the average student of the intervention compared to the average student in the control group
(who, by definition, would be at the 50th percentile; Institute of Education Sciences, 2008). Their
analysis revealed that an effect size of 0.27 translated into an 11 % percentile difference. Put
another way, the average student in the control
group would demonstrate an 11 percentile
increase in academic achievement if he/she had
received an SEL program. Taken together, these
results provide strong empirical evidence for
the “value-added” of SEL programs in fostering
students’ social and emotional skills, attitudes,
and behaviors, and also counter the claim that
taking time to promote students’ SEL would be
detrimental to academic achievement.
Do students maintain their SEL competencies
after the SEL program has ended? Findings from
Durlak et al.’s (2011) meta-analysis provide
additional support for the durability of effects
of SEL programming on students’ social and
emotional competencies. Among the smaller
group of 33 interventions that included followup data (with an average follow-up period of
92 weeks), the positive effects at the time of
follow-up remained statistically significant,
although the effect sizes were smaller. Thus,
Durlak and his colleagues provide some empirical evidence about the sturdiness of the effects of
SEL interventions longitudinally.
Researches by Hawkins, Kosterman,
Catalano, Hill, and Abbott (2008) exemplify the
potential long-term positive effects of multiyear
SEL programming on student outcomes. Specifically, Hawkins et al. (2008) found significantly
reduced diagnosable mental health disorders
(e.g., major depression, generalized anxiety disorder) at age 24 and age 27, 12, and 15 years after
their SEL intervention had ended. Their results

939

also showed intervention effects indicating better
educational and economic achievement among
those individuals who received the SEL intervention in contrast to those who did not. Although
more research is clearly needed, Hawkins et al.’s
research provides important evidence about the
potential long-term benefits of SEL interventions.
Most recently, Sklad and colleagues (2012)
conducted a meta-analysis of 75 recently
published studies of SEL programs and found
results that mirror those of Durlak et al. (2011).
Sklad, Diekstra, De Ritter and Ben (2012) found
that universal school-based SEL programs had
significant positive effects in the desired direction
on seven outcomes: social-emotional skills,
prosocial behavior, positive self-image, academic achievement, antisocial behavior, mental
health problems, and substance abuse. Similarly,
as with the Durlak et al. findings, the most positive effects were found for social-emotional
skills; Sklad et al. (2012) found an effect size of
0.70. In other words, students participating in
SEL programs, in contrast to controls, had
social-emotional skills seven standard deviations
higher, indicating that the average SEL program
student had better social-emotional skills than
76 % of non-SEL students. Moderate effect
sizes – those in which program effects were
nearly a half of a standard deviation – emerged
for four of the outcomes: academic achievement,
positive self-image, prosocial behavior, and
antisocial behavior. As for follow-up effects,
the largest effects were found for academic
achievement followed by substance abuse.

Strategies for Promoting SEL
Classrooms and schools operate as systems
and decades of research suggest that the unique
culture and climate of classrooms and schools
effects how and what students learn (e.g., Thapa,
Cohen, Guffey, & Higgins-D’Alessandro, 2013).
Whereas school culture refers to a general set of
norms, beliefs, and practices or “the way things
are done around here” (Hemmelgarn, Glisson, &
James, 2006), school climate “is based on patterns
of people’s experiences of school life and reflects

940

norms, goals, values, interpersonal relationships,
teaching and learning practices, and organizational structures” (National School Climate
Council, 2007, p. 4). Culture and climate in combination influence the interactions and relationships among administrators, teachers, school
staff, and students and of their approaches to
teaching and learning (Gottfredson, Gottfredson,
Payne, & Gottfredson, 2005). Therefore, any
approach to promoting SEL needs to take into
account both school culture and climate and
systematically and intentionally embed SEL into
the fabric of a school.
SEL interventions and skill development
should occur within supportive classroom
and school environments, as well as help to
create such a climate. Additionally, successful
SEL-related school and classroom activities
foster active student voice in decision making,
problem solving, and engagement for lifelong
learning. Research also has shown that effective
programs provide repeated opportunities to practice new skills and behaviors within the program
structure and beyond to real-life situations.
That is, providing opportunities to practice
within classroom lessons is important, but actual
opportunities to practice in real-life situations
are likely to have even more impact
(Durlak et al., 2011; Nation et al., 2003; Weare
& Nind, 2011).
In their meta-analyses, Durlak and colleagues
(2010, 2011) provided solid evidence that SEL
programs promote better student outcomes
when program implementers follow “SAFE”
procedures: They use a S equenced step-by-step
training approach; they emphasize A ctive forms
of learning that require students to practice new
skills; they F ocus specific time and attention on
skill development; and they are E xplicit in
defining the social and emotional skills they are
attempting to promote. Durlak et al. (2011) also
found that classroom teachers and other
school personnel effectively implemented
SEL programs – a finding that suggests that
SEL programs can be incorporated into routine
school practices and do not require staff from
outside the school to successfully deliver an
SEL program.

Social and Emotional Learning: Children

What Works in SEL Programming?
A large corpus of SEL programs have been developed in recent years and there is considerable
diversity among programs in terms of the scope
of SEL skills addressed, intervention design, content of the curriculum, target audience (e.g., elementary vs. high school, teacher), and research
evidence supporting the program’s effectiveness.
Whereas some SEL programs include lessons
that focus on the explicit instruction of students’
SEL competencies, others integrate SEL content
into core academic subject areas, such as Language Arts or Social Studies. There also exist
SEL programs and approaches that target teacher
instructional practices and pedagogy to create
and promote safe, caring, engaging, and participatory learning environments that foster student
attachment to school, motivation to learn, and
school success (Zins et al., 2004). Research has
shown that the most beneficial school-based prevention and promotion programs are based on
sound theory and research, and provide sequential and developmentally appropriate instruction
in SEL skills (Bond & Hauf, 2004). They are
implemented in a coordinated manner, schoolwide, from preschool through high school. Lessons are reinforced in the classroom, during
out-of-school activities, and at home. In effective
SEL programs, educators receive ongoing professional development in SEL, and families and
schools work together to promote children’s
social, emotional, and academic success (Nation
et al., 2003). In short, SEL can be seen as
a template for effective school reform.
In 2003, CASEL created a program review of
80 SEL programs for kindergarten through
12 grade entitled Safe and Sound: An Educational
Leader’s Guide to Evidence-Based Social and
Emotional Learning (SEL) Programs. This
groundbreaking review provided educators with
practical information on the features of different
programs that could help them select a program
most relevant and suited for their particular needs.
Although extensive, the program review included
many programs for which there was little or no
empirical evidence regarding their effectiveness. To address this limitation, in 2013,

Social and Emotional Learning: Children

CASEL reviewed more than 200 SEL preschool
and elementary school programs and identified
23 programs that met high standards for program
design, implementation supports, evidence of
effectiveness, and applicability to specific grades.
To be included in the 2013 CASEL Guide
(CASEL, 2013) and be designated as SELect,
the program had to meet the following three
criteria: (a) be a well-designed classroom-based
program that systematically promotes students’
social and emotional competence, provides
opportunities for practice, and offers multiyear
programming, (b) delivers high-quality training
and other implementation supports, including
initial training and ongoing support to ensure
sound implementation and, (c) be evidencebased with at least one carefully conducted evaluation that documents positive impacts on student
behavior and/or academic performance. The
2013 CASEL Guide summarizes objective
information about the characteristics of these
nationally available, multiyear programs via
a “consumer report” format that is clear and easy
to read. Included in the Guide is information on
23 programs identified as CASEL SELect programs. Of the 23, 4 programs target preschoolage children, 16 target children in elementary
school (K-5), and 3 serve both preschool and
elementary aged children. A similar guide for
middle school and high school programs will be
published by CASEL in late 2013. In the following section, we briefly summarize two of the
programs in the 2013 CASEL Guide for which
there were at least three or more successful
experimental-control group trials supporting
their effectiveness. Each program is discussed,
in turn, in the following section.
The Caring School Community (CSC) program was developed by researchers at the Developmental Studies Center (www.devstu.org),
a nonprofit organization with a focus on
developing and disseminating programs that
promote children’s social, emotional, and
academic development. The program targets
children in Kindergarten to sixth grade and
teaches teachers to employ participatory instructional practices such as cooperative learning
groups, mastery teaching, and experiential

941

activities that promote relevant, interactive classroom learning. The program consists of four program elements: (a) class meeting lessons to
promote dialogue among students, (b) a
cross-age “buddies” program that pairs students
across grades to build relationships and trust,
(c) “home-side” activities that promote family
involvement and inform parents of school activities while providing them with opportunities to
participate, and (d) school-wide community
building activities that involve school, home,
and community. The CSC is unique in that it
involves both extensive classroom-wide and
school-wide efforts to create a sense of common
purpose and commitment to prosocial norms and
values such as caring, justice, responsibility,
and learning, elements necessary for a “caring
community” of learners.
Research conducted over the past two decades
evaluating the effectiveness of CSC has
shown that students who have participated in
the program demonstrate more prosocial and
less aggressive behaviors, and a range of positive
school and motivation outcomes compared
to children who have not received it (Battistich,
Schaps, Solomon, & Watson, 1991; Battistich,
Schaps,
Watson,
&
Solomon,
1996;
Battistich, Solomon, Watson, & Schaps, 1997;
Battistich, Solomon, Watson, Solomon, &
Schaps, 1989; Battistich, Schaps, & Wilson,
2004). In the schools in which CSC has been
implemented, increases in students’ sense of
the school as a caring community have been
reflected in a positive orientation toward school
and learning, mutual trust in and respect for
teachers, and overall increases in prosocial
behavior and social skills. These positive effects
remained stable in high-poverty schools with
the highest sense of community, suggesting
the effectiveness of this program for high-risk
settings (Battistich et al., 1997). A follow-up
study evaluated program effects on 525 students
after they reached middle school. Findings at
follow-up included higher grade point averages
and achievement test scores, greater involvement
in positive youth activities, and less frequent
problem behavior at school and acts of violence
(Battistich et al., 2004).

942

The PATHS ® (Promoting Alternative
THinking
Strategies)
curriculum
is
a comprehensive program for promoting emotional and social competencies and reducing
aggression and behavior problems in preschool
and elementary school children. The PATHS curriculum was designed to be used by educators and
counselors in a multiyear, universal prevention
model. The PATHS curriculum, taught three
times per week for a minimum of 20- to 30-min
per day, provides teachers with systematic,
developmentally based lessons, materials, and
instructions for teaching their students emotional
literacy, self-control, social competence, positive
peer relations, and interpersonal problem-solving
skills. Students have many opportunities to
practice identifying a wide range of feelings and
their associated bodily sensations, calming
themselves through breathing techniques, and
taking others’ perspectives while solving interpersonal problems.
PATHS ® has been field-tested and researched
with children in regular education classroom settings, as well as with a variety of special needs
students (deaf, hearing-impaired, learning disabled, emotionally disturbed, mildly mentally
delayed, and gifted). The PATHS program has
robust evidence from well-designed and methodological rigorous studies showing its effectiveness in reducing children’s aggression and
hyperactive-disruptive behavior and in increasing their positive and prosocial behaviors (e.g.,
Conduct Problems Prevention Research Group,
1999, 2010; Domitrovich, Cortes, & Greenberg,
2007; Greenberg, Kusche, Cook, & Quamma,
1995). Specific positive outcomes found across
a range of studies inclusive of a range of
populations have included better understanding
of emotional and social situations, greater toleration of frustration, improved problem solving and
conflict resolution, and decreased sadness and
disruptive behaviors.

What Is Promising in SEL Programming?
The 2013 CASEL Guide provides descriptions of
several other SEL programs that have empirical

Social and Emotional Learning: Children

evidence supporting their effectiveness; however, they did not meet the criteria of three experimental trials. The programs for Preschool
include: Al’s Pals, HighScope Educational
Approach for Preschoolers, I Can Problem
Solve, The Incredible Years Series, Peaceworks:
Peacemaking Skills for Little Kids, and Tools of
the Mind. The programs for Elementary School
include: 4 Rs (Reading, Writing, Respect, and
Resolution), Competent Kids Caring Communities, I Can Problem Solve, The Incredible Years
Series, Michigan Model for Health, MindUp,
Open Circle, Positive Action, Second Step, Raising Healthy Children, Resolving Conflict Creatively Program, Social Decision Making/Problem
Solving Program, Second Step, Steps to Respect,
Responsive Classroom, RULER Approach, Too
Good for Violence, and Tribes Learning Community. Rather than focus on these promising programs, this section briefly describes some of the
emerging work aimed at the systematic implementation of SEL programming at the school
district level.
The new generation of promising approaches
in SEL includes systemic approaches specifically
targeted at the school or district levels. Indeed,
school districts need to make the promotion of
SEL an important part of education that is equal
to efforts to promote students’ academic achievement, high school completion, and college- and
career-readiness (Dymnicki, Sambolt, & Kidron,
2013). Researchers and educators at CASEL have
heeded this call, and in 2011, they initiated
a groundbreaking project to systematically infuse
SEL into the core of education. Titled as the “Collaborating Districts Initiative” or CDI, CASEL is
partnering with eight large urban districts in the
USA (Anchorage, Austin, Chicago, Cleveland,
Nashville, Oakland, Sacramento, and Washoe
County, Nevada) to encourage systemic changes
that will influence students’ social-emotional
development and academic performance.
CASEL’s CDI theory of action highlights ten
district practices for systemic SEL implementation that will lead to beneficial school-wide and
classroom programming and services for all students (see http://casel.org/collaborating-districtsinitiative/): (a) conduct SEL-related resource

Social and Emotional Learning: Children

and needs assessment across the district and
individual schools, (b) develop a district-wide
vision that prioritizes academic, social, and emotional learning, (c) develop central-office and
school leadership expertise in SEL theory,
research, and practice, (d) communicate about
SEL with all district stakeholders, (e) align
resources to support SEL programming,
(f) design and implement effective professional
development programs to foster the quality planning, implementation, and sustainability of coordinated SEL programming, (g) establish
preschool through high school learning standards
for students’ social and emotional competence,
(h) adopt and implement evidence-based SEL
programs in all schools across all grades levels,
(i) integrate SEL programming with other academic and student-support initiatives and priorities, and (j) establish systems to continuously
improve SEL programming through monitoring
implementation and assessing student outcomes.
The CDI aspires to develop districts’ capacities to plan, implement, and sustain systemic
changes that support school-wide and classroom
efforts to enhance students’ social-emotional
development and academic performance.
Throughout this multiyear project, CASEL and
the districts are working with a third-party evaluator, the American Institutes for Research, to
document essential strategies and processes that
work to successfully bring evidence-based SEL
to all students. Their findings will be used to
inform future efforts to foster high-quality implementation in school districts across the country.

What Does Not Work in SEL?
The effective implementation of an SEL program
plays a crucial role in influencing student outcomes. Unfortunately, some well-designed SEL
programs do not promote positive student outcomes, often due to variability in way the program is implemented in the “real world” setting
of a school and/or classroom. To determine the
influence of implementation or “what a program
consists of when it is delivered in a particular
setting” (p. 329) on program outcomes, Durlak

943

and DuPre (2008) conducted an extensive review
of over 500 quantitative studies. Their analysis
revealed several contextual factors that influence
program implementation, including: Community
Level Factors (e.g., prevention theory, funding,
policy), Provider Characteristics (e.g., perceived
need for the intervention, perceived benefits of
the intervention), Characteristics of the Innovation (e.g., compatibility or “fit”), Factors Relevant to the Prevention Delivery System (i.e.,
organizational capacity), and Factors Related to
the Prevention Support System (i.e., training,
technical assistance).
Durlak and DuPre (2008) highlighted two
findings that emerged as particularly noteworthy.
First, positive outcomes were obtained with
implementation levels around 60 %, few studies
achieved implementation levels over 80 %, and
not one of the studies achieved an implementation level of 100 %. They concluded that program developers and researchers therefore do
not need to expect perfect or near-perfect program implementation to achieve successful outcomes. Second, their analysis revealed
considerable variability in levels of implementation among program providers. Program implementation data were found to range as much as
87 %, with differences as much as 20–40 % commonly found among program providers in the
same study. This indicates that even if
researchers report the average level of implementation in their study, they can obfuscate the fact
that some program providers are better in
implementing programs than others.
A recent study by Reyes, Brackett, Rivers,
Elbertson, and Salovey (2012) serves as an illustration of the critical role of the program provider
in determining an SEL program’s effectiveness.
They examined whether the amount of training
teachers received, the quality of delivery of the
SEL program, and the amount of lessons students
received (dosage) were associated with student
outcomes of social and emotional competence
during the initial implementation phase (i.e., the
first year of adoption) of a theoretically derived
SEL program – the RULER Approach. Participants included 812 sixth grade students and their
teachers from 28 elementary schools in a large

944

urban school district in the northeastern USA that
were part of a large randomized controlled trial
(RCT). Statistical analysis clustered teachers into
one of three groups: low quality implementers
(i.e., teachers initially very resistant to the program and delivered it poorly but became open to
the program by the end of the school year), moderate-quality implementers (i.e., teachers who
were moderate in their attitudes toward the program and in their delivery of the program from
beginning to end), and high-quality implementers
(i.e., teachers who were consistently open to and
delivered the program very well from beginning
to end). Analysis revealed no overall main effects
for training, implementation quality, or dosage.
There were, however, more positive outcomes
for students when their teachers attended more
trainings and implemented more lessons, and
were classified as either “moderate” or “high”
implementers. Further analyses revealed that
teachers categorized as “low implementers”
were lower in their sense of teaching efficacy
(i.e., beliefs about their capabilities to modify
their teaching practices to influence students’
engagement and learning even among difficult
and unmotivated students) than teachers categorized as “high implementers.” These findings
underline the importance of not only considering
training and program fidelity when examining
effective SEL program implementation, it is
also critical to take into account teachers’ beliefs
and attitudes about an SEL program and their
teaching efficacy when assessing the influence
of implementation on students’ outcomes.

Summary
Recent research indicates that the myopic focus
on academics as the sole purpose of education
appears to be shifting, at least among teachers and
the general public. Particularly noteworthy is
a recently published report of a nationally representative survey by Civic Enterprises and Peter
D. Hart Research Associates of more than
600 teachers (Bridgeland, Bruce, & Hariharan,
2013). Their report showed that most preschool
to high school teachers believe that social and

Social and Emotional Learning: Children

emotional skills are teachable (95 %) and that
promoting SEL will benefit students from both
rich and poor backgrounds (97 %), and will have
positive effects on their school attendance and
graduation (80 %), standardized test scores and
overall academic performance (77 %), college
preparation (78 %), workforce readiness
(87 %), and citizenship (87 %). Additionally,
these same teachers reported that in order to
effectively implement and promote SEL in their
classrooms and schools, they need strong support
from district and school leaders. These findings
are important, because they demonstrate that
although there is a readiness among teachers to
promote SEL, there is a need for a systemic
approach that supports implementation at the district level.
The results from the latest 2013 PDK/Gallup
Poll of the Public’s Attitudes Toward the Public
Schools indicate that sentiments of general public
echo those espoused by teachers (Bushaw &
Lopez, 2013). The report found that most
Americans agree that public schools should
teach students a full range of social, emotional,
and cognitive competencies including how to set
meaningful goals (89 %), communication skills
(94 %), how to collaborate on projects (84 %),
and character (76 %).
Yet, despite the strong consensus that exists
among educators and the public regarding the
enormous potential of SEL as a fundamental
component of school reform, to make SEL
a national priority, it is essential that policy
makers in Congress and the federal education
department take action. One way to do this
would be to have them modify the Elementary
and Secondary Education Act to include
language that gives specific attention to SEL,
and include specific support for it in early
learning and in federal assistance to schools in
high-poverty communities. Some of this work to
include SEL into Federal Legislation is already
underway. Bipartisan groups of legislators have
demonstrated their interest in SEL by repeatedly
introducing the Academic, Social, and Emotional
Learning Act in the U.S. House of Representatives. The latest bill – The Academic Social and
Emotional Learning Act (H.R. 1875) – was

Social and Emotional Learning: Children

introduced on May 8, 2013, in the 113th Congress
by Representative Tim Ryan (D-Ohio). This bill
defines SEL and SEL programming, delineates
the core areas of social and emotional competency, and amends the Elementary and Secondary
School Act to allow funding for teacher and
administrator professional development and
training in SEL programming. For the bill to
become law, however, it is crucial that elected
officials listen to public opinion regarding the
central role of SEL in promoting students’ school
and life success, and that all schools in the nation
need to intentionally address SEL so that all
students can succeed in a complex, globalized
society (Weissberg & Cascarino, 2013).
Many educators, however, have not been
adequately prepared to apply and understand the
effective implementation of SEL programs and
practices. Given recent breakthroughs in the science of SEL, it is critical now more than ever that
teacher preparation programs include both the
science and practice of SEL into coursework
and pre-service field experiences in schools.
To date, we have limited knowledge of the degree
to which this is occurring. Schonert-Reichl and
colleagues (in press) are currently conducting
a scan to determine the extent to which US state’s
require any coursework or knowledge for teacher
certification and whether Colleges of Education
in the USA and Canada include any course content on SEL in teacher preparation programs.
Their report will inform educators, policy
makers, and practitioners about strategies and
tools to increase the effective and broad implementation of research-based, coordinated practices to promote SEL into teacher preparation.
Recent evidence indicates that efforts to
improve teachers’ knowledge about SEL alone
are not sufficient for successful SEL implementation. Indeed, teachers’ own SEL competence
and well-being appears to play a crucial role in
influencing the infusion of SEL into classrooms
and schools (Jones, Bouffard, & Weissbourd,
2013). Jennings and Greenberg (2009) reviewed
literature linking teachers’ SEL competence
and student outcomes and convincingly
argued that teacher social-emotional competence
is an important contributor to the nature of

945

a teacher’s relationships with students and
“that the quality of teacher–student relationships,
student and classroom management, and effective social and emotional learning (SEL) program
implementation all mediate classroom and
student outcomes (p. 492).” They recommend
the development and implementation of interventions designed to specifically address teachers’
SEL competence that focus on reducing teacher’s
stress and burnout and improving teacher’s
well-being.
Although limited, the past few years have seen
the emergence of interventions specifically
targeted at improving teachers’ SEL and stress
management. For example, two programs
designed to promote teachers’ SEL competence
by incorporating mindfulness-based approaches
are CARE (Cultivating Awareness and Resilience in Education) and SMART-in-Education
(Stress Management and Resiliency Training).
Mindfulness is typically described as an attentive, nonjudgmental, and receptive awareness of
present moment experience in terms of feelings,
images, thoughts, and sensations/perceptions
(e.g., Kabat-Zinn, 1990). Both programs aim to
increase teacher’s “mindfulness, job satisfaction,
compassion and empathy for students, efficacy
for regulating emotions, and decrease in stress
and burnout.” Initial research to date has
supported the effectiveness of both the CARE
(Jennings, Frank, Snowberg, Coccia, &
Greenberg, 2013; Jennings, Snowberg, Coccia,
& Greenberg, 2011) and SMART-in-Education
(e.g., Benn, Akiva, Arel, & Roeser, 2012; Roeser
et al., 2013) programs in promoting teacher’s
SEL competence and well-being. Nonetheless,
further research is needed to examine whether
such positive changes in teacher’s well-being
spill over into the classroom and lead to improvements in students’ SEL competence.
Although much has been learned in the past
decade about SEL programs and their effects on
children’s social and emotional competence and
academic success, the field has further to go
before firm conclusions can be made about the
specific ways in which an SEL approach
advances children’s short-term and long-term
school and life success. Indeed, many questions

946

still remain regarding the ways in which programs and practices designed to promote children’s SEL skills can forecast children’s future
success. For example, what are the processes and
mechanisms that lead to successful improvements in children’s social and emotional competence across programs? Which programs work
best for which children? And under what conditions is optimal development fostered? These are
the types of questions that are being asked among
both educators and researchers, and are the types
of questions asked by those who share a focus on
determining the factors underlying the development of children’s social and emotional competence and school and life success.
There exists a clear need for greater efforts to
translate science for practice and policy so that
SEL approaches can be better integrated into
schools and communities. Such efforts can help
to build the processes and structures needed to
foster high-quality implementation and promote
sustainability of programs (Elias, Zins, Graczyk,
& Weissberg, 2003). Also necessary is a greater
degree of collaboration between researchers and
educators to learn from one another. In today’s
complex society, we need to take special care to
encourage and facilitate our young people to
reach their greatest potential and to flourish and
thrive. It is therefore critical that we make intentional efforts to devise the most effective preventions and educational practices that promote SEL
in all children. Such efforts must be based on
strong conceptual models and sound research.
Then will we be in a better position to advance
the development of all children and youth.

References
Ainsworth, M. D. S., & Bowlby, J. (1991). An ethological
approach to personality development. American Psychologist, 46, 333–341.
Association for Supervision and Curriculum Development.
(2007). The learning compact redefined: A call to action
– A report of the Commission on the Whole Child.
Alexandria, VA: Author. Retrieved on September
26, 2013, from Association for Supervision and
Curriculum Development website: http://www.ascd.
org/ASCD/pdf/Whole%20Child/WCC%20Learning
%20Compac

Social and Emotional Learning: Children
Bandura, A. (1977). Social learning theory. New York:
General Learning Press.
Battistich, V., Schaps, E., Solomon, D., & Watson, M.
(1991). The role of the school in prosocial development. In H. E. Fitzgerald, B. M. Lester, & M. W.
Yogman (Eds.), Theory and research in behavioral
pediatrics (pp. 89–127). New York: Plenum Press.
Battistich, V., Schaps, E., Watson, M., & Solomon, D.
(1996). Prevention effects of the child development
project: Early findings from an ongoing multi-site
demonstration trial. Journal of Adolescent Research,
11, 12–25.
Battistich, V., Schaps, E., & Wilson, N. (2004). Effects of
an elementary school intervention on students’ “connectedness” to school and social adjustment during
middle school. The Journal of Primary Prevention,
24, 243–262.
Battistich, V., Solomon, D., Watson, M., & Schaps, E.
(1997). Caring school communities. Educational Psychologist, 32, 137–151.
Battistich, V., Solomon, D., Watson, M., Solomon, J., &
Schaps, E. (1989). Effects of an elementary school program to enhance prosocial behavior on children’s cognitive social problem-solving skills and strategies. Journal
of Applied Developmental Psychology, 10, 147–169.
Benn, R., Akiva, T., Arel, S., & Roeser, R. W. (2012).
Mindfulness training effects for parents and educators
of children with special needs. Developmental Psychology, 48(5), 1476–1487. doi:10.1037/a0027537.
Bond, L. A., & Hauf, A. M. C. (2004). Taking stock and
putting stock in primary prevention: Characteristics of
effective programs. Journal of Primary Prevention,
24, 199–221.
Brackett, M. A., Rivers, S. E., Reyes, M. R., & Salovey, P.
(2012). Enhancing academic performance and social
and emotional competence with the RULER feeling
words curriculum. Learning and Individual Differences, 22, 218–224.
Bridgeland, J., Bruce, M., & Hariharan, A. (2013). The
missing piece: A national survey on how social and
emotional learning can empower children and transform schools. Washington, DC: Civic Enterprises.
Bronfenbrenner, U., & Morris, P. (1998). The ecology
of developmental processes. In W. Damon &
R. M. Lerner (Eds.), Theoretical models of human
development: Vol. 1 of the Handbook of child psychology (5th ed., pp. 993–1028). New York: Wiley.
Bushaw, W. J., & Lopez, S. J. (2013). Which way do we
go? The 45th annual PDK/Gallup poll of the public’s
attitudes toward the public schools. Phi Delta Kappan,
95(1), 8–25.
Coie, J. D., & Dodge, K. A. (1998). Aggression and
antisocial behavior. In N. Eisenberg (Ed.), Handbook
of child psychology: Vol. 3. Social, emotional, and
personality development (Vol. 5, pp. 779–862). New
York: Wiley.
Collaborative for Academic, Social, and Emotional
Learning. (2003). Safe and sound: An educational
leader’s guide to evidence-based social and

Social and Emotional Learning: Children
emotional learning programs. Retrieved January
26, 2012, from http://casel.org/wp-content/uploads/
1A_Safe__Sound-rev-2.pdf
Collaborative for Academic, Social, and Emotional
Learning, (2013). 2013 CASEL guide: Effective social
and emotional learning programs – Preschool and
elementary school. Chicago, IL: Author.
Conduct Problems Prevention Research Group. (1999). Initial impact of the fast track prevention trial for conduct
problems II: Classroom effects. Journal of Consulting
and Clinical Psychology, 67, 648–657.
Conduct Problems Prevention Research Group. (2010).
The effects of a multiyear universal social- emotional
learning program: The role of student and school characteristics. Journal of Consulting and Clinical Psychology, 78, 156–168.
Denham, S. A., & Weissberg, R. P. (2004). Socialemotional learning in early childhood: What we
know and where to go from here. In E. Chesebrough,
P. King, T. P. Gullotta, & M. Bloom (Eds.), A blueprint
for the promotion of prosocial behavior in early childhood (pp. 13–50). New York: Kluwer Academic/
Plenum.
Devaney, E., O’Brien, M. U., Resnik, H., Keister, S., &
Weissberg, R. P. (2006). Sustainable schoolwide
social and emotional learning: Implementation guide
and toolkit. Chicago: Collaborative for Academic,
Social, and Emotional Learning.
Domitrovich, C. E., Cortes, R. C., & Greenberg, M. T.
(2007). Improving young children’s social and
emotional competence: A Randomized trial of the
preschool “PATHS” curriculum. Journal of Primary
Prevention, 28, 67–89.
Durlak, J. A., & DuPre, E. P. (2008). Implementation
matters: A review of research on the influence of
implementation on program outcomes and the factors
affecting implementation. American Journal of Community Psychology, 41, 327–350.
Durlak, J. A., Weissberg, R. P., Dymnicki, A. B., Taylor,
R. D., & Schellinger, K. B. (2011). Enhancing students’
social and emotional development promotes success in
school: Results of a meta-analysis. Child Development,
82, 474–501.
Durlak, J. A., Weissberg, R. P., & Pachan, M. (2010).
A meta-analysis of after-school programs that seek to
promote personal and social skills in children and
adolescents. American Journal of Community Psychology, 45, 294–309.
Dymnicki, A., Sambolt, M., & Kidron, Y. (2013). Improving college and career readiness by incorporating
social and emotional learning. Washington, DC: College & Career Readiness & Success Center at American Institutes for Research.
Elbertson, N., Brackett, M. A., & Weissberg, R. (2010).
School-based social and emotional learning (SEL) programming: Current perspectives. In A. Hargreaves,
M. Fullan, D. Hopkins, & A. Lieberman (Eds.), The
second international handbook of educational change
(pp. 1017–1032). New York: Springer.

947
Elias, M. J. (2001). Prepare children for the tests of life,
not a life of tests. Education Week, 21(4), 40.
Elias, M. J. (2003). Academic and social-emotional learning: Vol. 11. Education practices series. Brussels,
Belgium: International Academy of Education.
Elias, M. J., & Arnold, H. (Eds.). (2006). The educator’s
guide to emotional intelligence and academic achievement: Social-emotional learning in the classroom.
Thousand Oaks, CA: Corwin Press.
Elias, M. J., Zins, J. E., Graczyk, P. A., & Weissberg, R. P.
(2003). Implementation, sustainability, and scaling-up
of social-emotional and academic innovations in public schools. School Psychology Review, 32, 303–319.
Elias, M. J., Zins, J. E., Weissberg, K. S., Greenberg,
M. T., Haynes, N. M., Kessler, R., et al. (1997). Promoting social and emotional learning: Guidelines for
educators. Alexandria, VA: Association for Supervision and Curriculum Development.
Gallese, V., & Goldman, A. I. (1998). Mirror neurons and
the simulation theory of mind-reading. Trends in Cognitive Science, 2, 493–501.
Goleman, D. (1995). Emotional intelligence. New York:
Bantam.
Gottfredson, G. D., Gottfredson, D. C., Payne, A. A., &
Gottfredson, N. C. (2005). School climate predictors
of school disorder: Results from a national study of
delinquency prevention in schools. Journal of
Research in Crime and Deliquency, 42, 412–444.
doi:10.1177/0022427804271931.
Greenberg, M. T. (2006). Promoting resilience in children
and youth: Preventive interventions and their
interface with neuroscience. Annals of the New York
Academy of Sciences, 1094, 139–150. doi:10.1196/
annals.1376.013.
Greenberg, M. T. (2010). School-based prevention: Current status and future challenges. Effective Education,
2, 27–52.
Greenberg, M. T., Kusche, C. A., Cook, E. T., & Quamma,
J. P. (1995). Promoting emotional competence in
school-aged deaf children: The effects of the PATHS
curriculum. Development and Psychopathology, 7,
117–136.
Greenberg, M., Weissberg, R., O’Brien, M., Zins, J.,
Fredericks, L., Resnik, H., et al. (2003). Enhancing
school-based prevention and youth development
through coordinated social, emotional, and academic
learning. American Psychologist, 58, 466–474.
H.R. 1875–113th Congress: Academic, Social, and Emotional Learning Act of 2013 of (2013). www.
GovTrack.us. Retrieved September 26, 2013, from
http://www.govtrack.us/congress/bills/113/hr1875
Hawkins, J. D., Kosterman, R., Catalano, R. F., Hill, K. G.,
& Abbott, R. D. (2008). Effects of a social development
intervention in childhood 15 years later. Archives of
Pediatric and Adolescent Medicine, 162, 1133–1141.
Heckman, J. J. (2007). The economics, technology and
neuroscience of human capability formation. Proceedings of the National Academy of Sciences, 104,
13250–13255.

948
Hemmelgarn, A. L., Glisson, C., & James, L. R. (2006).
Organizational culture and climate: Implications for
services and interventions research. Clinical Psychology: Science & Practice, 13, 73–89. doi:10.1111/
j.1468-2850.2006.00008.x.
Humphrey, N. (2013). Social and emotional learning:
A critical appraisal. Thousand Oaks, CA: Sage.
Institute of Education Sciences. (2008). What works
clearinghouse procedures and standards workbook,
version 2.0. Retrieved November 29, 2010,
from http://ies.edgov/ncee/wwc_procedures_v2_standards_handbook.pdf
Jennings, P. A., Frank, J. L., Snowberg, K. E., Coccia, M.
A., & Greenberg, M. T. (2013). Improving classroom
learning environments by Cultivating Awareness and
Resilience in Education (CARE): Results of a randomized controlled trial. School Psychology Quarterly, 28,
374–390.
Jennings, P. A., & Greenberg, M. T. (2009). The prosocial
classroom: Teacher social and emotional competence
in relation to student and classroom outcomes. Review
of Educational Research, 79, 491–525.
Jennings, P. A., Snowberg, K. E., Coccia, M. A., &
Greenberg, M. T. (2011). Improving classroom learning environments by Cultivating Awareness and Resilience in Education (CARE): Results of two pilot
studies. Journal of Classroom Interaction, 46, 37–48.
Jones, S. M., & Bouffard, S. M. (2012). Social and emotional learning in schools: From programs to strategies.
Society for Research on Child Development Social
Policy Report, 25(4), 1–22.
Jones, S. M., Bouffard, S. M., & Weissbourd, R. (2013).
Educators’social and emotional skills vital to learning.
Phi Delta Kappan, 94, 62–65.
Kabat-Zinn, J. (1990). Full catastrophe living: Using the
wisdom of your body and mind to face stress, pain, and
illness. New York: Bantam Doubleday Dell.
Kress, J. S., & Elias, M. J. (2006). School-based social and
emotional learning programs. In W. Damon & R. M.
Lerner (Series Eds.), K. A. Renninger & I. E. Sigel
(Vol. Eds.), Handbook of child psychology: Vol.
4. Child psychology in practice (6th ed.,
pp. 592–618). Hoboken, NJ: Wiley.
Lantieri, L., & Nambler, M. (2012). Cultivating the social,
emotional, and inner lives of children and teachers.
Reclaiming Children and Youth, 21, 27–33.
Mayer, J. D., & Salovey, P. (1997). What is emotional
intelligence? In P. Salovey & D. Sluyter (Eds.),
Emotional development and emotional intelligence:
Implications for educators (pp. 3–31). New York:
Basic Books.
Merrell, K. W., & Gueldner, B. A. (2010). Social and
emotional learning in the classroom: Promoting mental health and academic success. New York:
The Guilford Press.
Nation, M., Crusto, C., Wandersman, A., Kumpfer, K. L.,
Seybolt, D., Morrisey-Kane, E., et al. (2003). What
works in prevention: Principles of effective prevention
programs. American Psychologist, 58, 449–456.

Social and Emotional Learning: Children
National Research Council. (2012). Education for life
and work: Developing transferable knowledge and
skills in the 21st century. Committee on Defining
Deeper Learning and 21st Century Skills, J. W.
Pellegrino, & M. L. Hilton (Eds). Board on Testing
and Assessment and Board on Science Education,
Division of Behavioral and Social Sciences and Education (pp. 37–68). Washington, DC: The National
Academies Press.
National School Climate Council. (2007). The school climate challenge: Narrowing the gap between school
climate research and school climate policy, practice
guidelines and teacher education policy. Retrieved
September 26, 2013, from http://www.schoolclimate.
org/climate/advocacy.php
Payton, J. W., Wardlaw, M. D., Graczyk, P. A.,
Bloodworth, M. R., Tompsett, C. J., & Weissberg, R. P.
(2000). SEL: A framework for promoting mental health
and reducing risk behavior in children and youth. Journal of School Health, 70, 179–185.
Reyes, M. R., Brackett, M. A., Rivers, S. E., Elbertson,
N. A., & Salovey, P. (2012). The interaction effects of
program training, dosage, and implementation quality
on targeted student outcomes for the RULER approach
to social and emotional learning. School Psychology
Review, 41, 82–99.
Roeser, R. W., Schonert-Reichl, K. A., Jha, A., Cullen, M.,
Wallace, L., Wilensky, R., et al. (2013). Mindfulness
training and reductions in teacher stress and burnout:
Results from two randomized, waitlist-control field
trials. Journal of Educational Psychology, 105,
787–804. doi:10.1037/a0032093.
Ryan, R. M., & Deci, E. L. (2000). Self-determination
theory and the facilitation of intrinsic motivation,
social development, and well-being. American
Psychologist, 55, 68–78.
Schonert-Reichl, K. A., Hanson-Peterson, J. L., & Hymel, S.
(in press). Social and emotional learning and pre-service
teacher education. In J. A. Durlak, C. E. Domitrovich, R.
P. Weissberg, & T. P. Gullotta (Eds.), Handbook of
social and emotional learning: Research and practice.
New York: Guilford Press.
Schonert-Reichl, K. A., & Hymel, S. (2007). Educating
the heart as well as the mind: Why social and emotional learning is critical for students’ school and life
success. Education Canada, 47, 20–25.
Schonert-Reichl, K. A., & Utne O’Brien, M. (2012).
Social and emotional learning and prosocial education:
Theory, research, and programs. In A. HigginsD’Alessandro, M. Corrigan, & P. Brown (Eds.), The
case for prosocial education: Developing caring,
capable citizens (Vol. 1, pp. 311–345). Lanham, MD:
Rowman & Littlefield.
Sklad, M., Diekstra, R., De Ritter, M., & Ben, J. (2012).
Effectiveness of school-based universal social, emotional, and behavioural programs: Do they enhance
students’ development in the area of skill, behaviour,
and adjustment? Psychology in the Schools, 49,
892–909.

Social and Emotional Learning: Children
Thapa, A., Cohen, J., Guffey, S., & HigginsD’Alessandro, A. (2013). A review of school climate
research. Review of Educational Research, 83,
357–385. doi:10.3102/0034654313483907.
Tobler, N. S., Roona, M. R., Ochshorn, P., Marshall, D. G.,
Streke, A. V., & Stackpole, K. M. (2000). Schoolbased adolescent prevention programs: 1998 metaanalysis. Journal of Primary Prevention, 20, 275–336.
Weare, K., & Nind, M. (2011). Mental health promotion and
problem prevention in schools: What does the evidence
say? Health Promotion International, 26, i29–i69.
Weissberg, R. P., & Cascarino, J. (2013) Academic learning + social-emotional learning = national priority. Phi
Delta Kappan, 95(2), 8–13.

949
Weissberg, R. P., Payton, J. W., O’Brien, M. U., &
Munro, S. (2007). Social and emotional learning. In
F. C. Power, R. J. Nuzzi, D. Narvaez, D. K. Lapsley,
& T. C. Hunt (Eds.), Moral education: A handbook:
Vol. 2. M–Z (pp. 417–418). Westport, CT: Greenwood
Press.
Zins, J. E., & Elias, M. J. (2006). Social and emotional
learning. In G. G. Bear & K. M. Minke (Eds.), Children’s needs III (pp. 1–13). Bethesda, MD: National
Association of School Psychologists.
Zins, J. E., Weissberg, R. P., Wang, M. C., &
Walberg, H. J. (2004). Building academic success on
social and emotional learning: What does the research
say? New York: Teachers College Press.

950

Substance: Misuse During Childhood

events in the course of development. Precocious

Substance: Misuse During Childhood puberty is the onset of puberty that is earlier than
Frank J. Snyder
Department of Health and Kinesiology,
College of Health and Human Sciences, Purdue
University, West Lafayette, IN, USA

the population average. For girls this tends to be
around 9–10 years of age and for boys 11–12
years of age.

Scope
Introduction
Research increasingly shows that childhood substance use is a substantial public health concern
(Donovan, 2007; Hibell et al., 2012; Johnston,
O’Malley, Bachman, & Schulenberg, 2012).
Early initiation of substance use in childhood is
associated with substance use problems later during the life course (Clark, Cornelius, Kirisci, &
Tarter, 2005; Fergusson, Lynskey, & Horwood,
1994). Many risks are related across the life
course, and having one risk during childhood
increases the likelihood that another will develop
(Catalano et al., 2012). Thus, these issues indicate
a need for early substance use intervention and
prevention approaches. The majority of research
and prevention efforts, however, target middleschool and high-school students, simply because
a larger proportion of adolescents are likely to
engage in substance-using behaviors compared to
younger children. Focusing so much attention on
adolescents may be disadvantageous, because the
problem likely takes root much earlier during
childhood development and even before birth
(Zucker, Donovan, Masten, Mattson, & Moss,
2008). In the ensuing entry, an update to a prior
version written by Partridge and Flay (2003) is
provided. We describe recent epidemiological
data and several theories for developing and evaluating programs designed to prevent childhood
substance use. Additionally, we provide a literature
review to highlight prevention strategies that have
succeeded and some important research needs.

Definitions
Biosocial heterochrony refers to differences in
the rate of timing of both biological and social

US Population. Relative to the large amount of
research on adolescents, there is little research
and epidemiological data on childhood substance
use in the United States. Some estimates are
available, however, regarding the extent of childhood substance use. By and large, childhood substance use is restricted to alcohol, tobacco,
inhalants, and marijuana. Alcohol and tobacco
are the most widely used substances in this age
group. The Monitoring the Future Survey
(Johnston et al., 2012), an ongoing study of
adolescents since 1975, reported 2011 data from
a survey of eighth graders that asked about substance use as far back as the fourth grade.
According to these most recent results, nearly
5 % of eighth graders reported using alcohol
during fourth grade or earlier; nearly 16 %
reported use by the sixth grade. Because these
data are available over the last two decades,
trends can be observed across time. During the
last two decades, there has been a gradual decline
for lifetime prevalence of alcohol use, although
the decline is less pronounced in earlier grades,
particularly in grades four and five. A similar
trend is also true about self-reported drunkenness.
Results for 2011 self-reported tobacco use
followed a similar pattern; over 3 % of 2011
eighth graders reported using cigarettes during
fourth grade or earlier, with over one in ten students reporting use by the sixth grade. Again,
during the last two decades, there has been
a decline in cigarette use – a decline more dramatic than alcohol use – although this decline has
occurred most prominently among seventh- and
eighth-grade students. The percent of eighthgrade students who reported using cigarettes in
the fourth and fifth grades has been relatively
stable around 3–5 % during the last two decades.
During 2011, relative to alcohol and tobacco,

T.P. Gullotta, M. Bloom (eds.), Encyclopedia of Primary Prevention and Health Promotion,
DOI 10.1007/978-1-4614-5999-6, # Springer Science+Business Media New York 2014

Substance: Misuse During Childhood

fewer eighth graders reported the use of inhalants
(nearly 3 %) and marijuana (1 %) in the fourth
grade or earlier. These rates increased, however,
to over 7 % using inhalants and over 5 % using
marijuana by the sixth grade. The trends in inhalant and marijuana use have varied over the last
few decades, particularly among grade six
students and above.
Overall, alcohol and tobacco use can begin at
an early age, with inhalant and marijuana use
occurring later. Trends in the Monitoring the
Future data across time have indicated an overall
reduction in the lifetime prevalence of early substance use, and fewer eighth graders are reporting
first use at earlier grades. Substance use is more
common as students approach seventh and eighth
grades. Some students, however, use substances
at a very young age (Faden, 2006), with alcohol
use being a substantial concern at earlier grades
(Donovan, 2007). These findings are important
because children who use substances for the first
time at an earlier age may be more likely to
become long-term users and exhibit other risk
behaviors (Clark et al., 2005; Donovan & Molina,
2011; Fergusson et al., 1994).
International Populations. Relative to the
United States, even less research is available on
childhood substance use from other countries.
There is, however, some information that can be
gleaned from data collected as part of the Health
Behavior in School-Aged Children survey
(HBSC; Settertobulte, Jensen & Hurrelmann,
2001) and the European School Survey Project
on Alcohol and Other Drugs (ESPAD; Hibell
et al., 2012). The HBSC survey began in the
1980s and is a cross-national survey of 11-, 13-,
and 15-year-old students that now includes
43 countries throughout Europe and North America. One detailed HBSC report (Settertobulte
et al., 2001) focuses specifically on alcohol use
among young Europeans. Results from the HBSC
survey show that most youth first use alcohol at
age 15 or before. Among 11-year-olds, more than
50 % reported using alcohol at least once.
Generally, nearly all countries participating in
the HBSC survey show that the initiation of alcohol use takes place early in life. Another recent
HBSC report (Currie et al., 2012) demonstrated

951

similar results and indicated that alcohol use
among 11-year-olds was typically more common
for boys than girls. A similar gender effect
typically occurred for tobacco initiation across
countries. Research has also shown that locations
spanning the globe have a rather uniform age
of initiation of substance use, but lifetime
prevalence rates have differed across these sites
(Vega et al., 2002).
Similar data are available from the ESPAD
project, initiated in 1995 to survey European students aged 15–16 years (World Health Organization, 2011). The survey also includes data on the
self-reported age of initiation for students aged
13 or younger (Hibell et al., 2012). Results show
that in three-quarters of countries, the majority of
students used alcohol by age 13, with the highest
proportions found in Latvia (79 %), Estonia
(76 %), Bulgaria (73 %), Slovenia (71 %), and
the Czech Republic (70 %). With regard to
cigarette use, 31 % of students had smoked by
the age of 13 or younger, with 7 % of students
reporting smoking cigarettes on a daily basis.
Fewer younger students reported using other substances such as inhalants and marijuana, with
averages around 4 % and 3 %, respectively.
Thus, in the United States and internationally,
alcohol and tobacco are used most commonly
among younger students. Compared to alcohol,
cigarette use is generally less common, followed
by the use of inhalants and marijuana. Notably,
similar to the United States, there is a relative
lack of international research on substance use in
populations aged 12 and younger.

Theories
Traditionally, substance use prevention programs
have used concepts based on either social learning theory or health beliefs models (Orlandi,
1996). Social learning theory (Bandura, 1977)
recognizes the influence of role models (e.g.,
parents, peers, siblings, teachers, athletes, celebrities) with whom a child identifies. Expectancyvalue models (e.g., the Theory of Reasoned
Action; Fishbein & Ajzen, 1975) suggest that
adolescent substance use is influenced by

952
Levels of
Causation
Ultimate
Causes

Substance: Misuse During Childhood
Personal Stream

Social Stream

Biological/Nature

Environmental Stream

Nurture/Cultural

BIOLOGY/

SOCIAL

CULTURAL

PERSONALITY

SITUATION

ENVIRONMENT

Senseof
Self/Control

Social
Competence

Self
Determination

Skills:
Social+General

Interpersonal
Bonding

Others’
Beh & Atts

Interactions w/
Social Instit’s

Information/
Opportunities

Distal
Influences

Motivation
to Comply

SELF-EFFICACY
BEHAVIORAL
CONTROL

Perceived
Norms

SOCIAL
NORMATIVE
BELIEFS

Values/
Evaluations

Knowledge/
Expectancies

ATTITUDES
TOWARD THE
BEHAVIOR

Proximal
Predictors
DECISIONS/INTENTIONS

Trial Behavior
EXPERIENCES: Psychological/Physiological -- Social Reinforcements -- Expectancies

Related Behaviors

Substance: Misuse During Childhood, Fig. 1 The theory of triadic influence (Adapted from Flay et al. 2009)

perceived normative attitudes toward substance
use and expectations about the consequences of
substance use involvement. These two theoretical
perspectives are not mutually exclusive, however, and are likely complementary, such that
more recent prevention-oriented theoretical
frameworks have synthesized them. Indeed, the
growing trend in prevention theory is a move
toward integration of microtheories (Orlandi,
1996). Although social learning theory and health
beliefs models form the core of these integrated
theoretical perspectives, the most promising theories are also incorporating theoretical notions
related to biological and personality factors, emotional and cognitive factors, interpersonal and
social skills, and contexts such as families, school
environments, and community organization.
The theory of triadic influence (TTI) is one
integrative model of health behavior based on
both
ecological
and
expectancy-value

frameworks (Flay & Petraitis, 1994; Flay, Snyder
& Petraitis, 2009). This model is useful for etiology research and in developing and evaluating
programs. The TTI includes two primary dimensions that are aligned to form a detailed outline of
human behavior. One dimension – from left to
right in Fig. 1 – refers to three streams of influence on behavior: biology/personality influences,
social situation influences, and cultural/
environmental influences. These influences correspond to Urie Bronfenbrenner’s well-known
bioecological model (Bronfenbrenner & Morris,
2006). The second dimension – from top to bottom in Fig. 1 – refers to levels of causation within
each of the three streams of influence. Thus,
causes can be thought of as flowing down each
stream through the levels of causation. That is,
each stream of influence flows from more
upstream, ultimate causes of behavior (e.g.,
genetics, parental warmth, neighborhood

Substance: Misuse During Childhood

violence, and sociocultural influences like religion, politics, mass media) that influence a wide
array of health outcomes to more downstream,
proximal predictors (e.g., intentions to drink
alcohol or smoke tobacco) that are more behavior
specific and thought to directly influence childhood substance use. Further, the interdependencies among the three streams of influence
are captured in cross-stream influences. For
example, biology/personality influences the
social situation and vice versa. Finally, the TTI
allows for iterative influences whereby experiences such as initial experimentation with
tobacco, alcohol, or other substances provide
feedback – shown as dotted lines in Fig. 1 – that
can change the state of more upstream variables
in each of the three streams of influence. Thus,
the TTI is more explicit than most other ecological frameworks, given that it includes detailed
hypotheses about causal pathways (i.e., mediation and moderation). Overall, the TTI is
a theoretical framework that addresses not only
substance use but also broader health behavior,
including healthy outcomes (e.g., academic
achievement) that relate to positive youth development (Snyder & Flay, 2012). The TTI also
applies across the life course to a broad age
range, including younger children, adolescents,
and adults. In addressing substance use among
children, however, at least two special considerations need to be made more explicit.
First, individual differences in rates of biological and social development (biosocial
heterochrony) play an important role in childhood substance use. Precocious puberty is likely
a prominent type of heterochrony that influences
substance use (Brooks-Gunn & Graber, 1994;
Graber, Nichols, & Brooks-Gunn, 2010). Two
traditional hypotheses attempt to explain the
role of precocious puberty (Tschann et al.,
1994). The early maturation hypothesis suggests
that precocious puberty increases the risk of using
substances through increased social pressure and
exposure to substance use before the child has
developed the social skills to deal with these
situations. The maturation deviance hypothesis
suggests that nonstandard timing of development
increases social and emotional stress, thereby

953

increasing the likelihood of substance use as
a coping mechanism. The effects of precocious
puberty on substance use can also be interpreted
from a developmental contextual framework
whereby individual- and contextual-level factors
influence the likelihood of substance use
(Holmbeck & Shapera, 1999 as cited in
Holmbeck, 2002). For example, precocious
puberty may lead to early substance use only
when family members react to early pubertal
maturity in particular ways, such as strict,
unsupportive parental rules. Indeed, pubertal status, personal characteristics, context, and learned
alcohol experiences can all play a role in childhood alcohol use (Gunn & Smith, 2010).
Second, special consideration should be given
to the distinction between prevention efforts that
target children who begin to experiment with
substances prior to adolescence and prevention
efforts that target experimental and regular substance use in adolescence. Alcohol and tobacco
use is often thought of as somewhat normative
during adolescence, whereas use of these substances earlier in childhood is more indicative
of familial and behavioral problems (Clark
et al., 2005). Further, an important concept is
that peer behavior is a key influence during
adolescence, and it is less important during childhood (Bush, Weinfurt, & Iannotti, 1994).
The majority of successful adolescent prevention
programs incorporate social skills training
designed to build peer communication skills,
with particular emphasis on refusal skills. When
directed at younger children, especially those in
primary grades, such training needs to take into
account the fact that children have less mature
cognitive skills. Social skills of younger children
tend to be more rote and less flexible, and the
social rules that apply to them tend to be
parochial.
Developmental timing issues are also important to theories that inform childhood substance
use programs (Cicchetti, 2006). Multiple sources
of influence and the timing of developmental
processes predict that earlier use and/or regular
use orients the child’s developmental context
toward a state that supports an escalation to
long-term regular substance use and, in some

954

cases, illicit polydrug use, as well as a host of
other negative behaviors. Conversely, the later
the initiation of trial substance use, the more
likely the larger developmental context may be
oriented such that trial behavior will be experimental and of short duration, substantially reducing the risk of chronic use and subsequent
addiction.

Current Research
The current trend in substance use prevention
theory toward integrative, ecological frameworks
relates to earlier work in developmental systems
theory (Ford & Lerner, 1992; Lerner, 2006).
Developmental systems theories incorporate
components that highlight the importance of
both biological and environmental factors and
the interactions between them (Lerner). At least
one noteworthy point should be highlighted
regarding the implications for developmental
systems approaches to childhood substance use
etiology: There are various etiological pathways
due to the multiple domains of influence and the
contextual nature of any given risk or protective
factor (Cicchetti, 2006). Simply put, there are
many interacting influences that cause human
behavior. This suggests that empirical findings
can be inconsistent across studies and at times
contradictory, but nevertheless useful in different
contexts. There are, however, findings that are
consistent with regard to childhood factors that
predict increased risk for early alcohol use. These
factors include but are not limited to a family
history of alcohol abuse, parents’ antisocial
behavior, prenatal exposure to alcohol, maltreatment, and children’s challenges with regulating
their attention and emotion (Masten, Faden,
Zucker, & Spear, 2008). While many of these
issues are beyond the scope of the current entry,
we will address three issues that are of special
consideration for childhood substance use.
First, the issue of precocious puberty is often
under-addressed in prevention programs. There is
evidence, however, that it plays an important
role. For instance, Stattin and Magnusson
(1990) report extensive findings indicating that

Substance: Misuse During Childhood

precocious pubescent girls are more likely than
their normative pubescent peers to engage in
a wide range of risk behaviors, prominent
among them substance use. More recent research
also reports this effect of early menarche on substance use (Posner, 2006) and indicates a need to
better understand the experiences of adolescent
females. Further, as theory suggests, there is evidence showing that the effects of precocious
puberty on substance use are not purely biological in nature, but rather represent the convergence
of multiple sources of influence, including
biological and psychosocial events (BrooksGunn, & Graber, 1994; Mendle, Turkheimer, &
Emery, 2007). For example, precocious pubescent girls may get caught in a complex cycle of
mutually reinforcing influences that stabilizes
early smoking behavior. The confluence of
distorted body image, early weight gain associated with early pubescence, and the perceived
weight reduction properties of cigarettes have
been shown to lead to early initiation of smoking
in preadolescent girls (Crisp, Sedgwick, Halek,
Joughin, & Humphrey, 1999). Boys are a more
difficult population in which to study maturation,
but there is also evidence that early maturation
among boys is related to internalizing and externalizing challenges (Graber et al., 2010).
The second area of special consideration for
the prevention of childhood substance use is the
role of the family versus peers as the predominant
influence on substance use behavior. Research
shows that both family and peers can play a role
in substance use among elementary-aged children
(Donovan et al., 2006). For instance, parental
beliefs that allowing children to sip alcohol can
have protective consequences are related to childreported alcohol use (Jackson, Ennett, Dickinson,
& Bowling, 2012). Other variables related to alcohol use in this group include conflict with parents,
parents’ approval of children drinking, and peers’
approval of drinking and drug use (Donovan &
Molina, 2011). Perceived family use has been
shown to be a stronger influence relative to perceived peer use on substance use behaviors
among fourth- and fifth-grade students. However,
this relationship was reversed by the seventh
grade (Bush et al., 1994). Furthermore, a deviant

Substance: Misuse During Childhood

peer group is a major predictor of adolescent
substance use, but parent–child conflict, impaired
quality of mother–child interactions, and several
other parental factors have been shown to predict
belonging to a deviant peer group (Arnett, 2007;
Fergusson & Horwood, 1999).
Third, in addition to the identification of multiple etiologies derived from the adoption of developmental systems theoretical perspectives, the
timing of initiation is critical (Cicchetti, 2006).
As reported by Fergusson et al. (1994) in a New
Zealand sample, exposure to alcohol before age
6 increased the likelihood of becoming a regular
alcohol user during adolescence by 1.9 to 2.4
times. Further, in a US sample, recent research
shows that sipping or tasting alcohol by the age
of 10 nearly doubled the likelihood of alcohol use
later in adolescence (Donovan & Molina, 2011).

Overview of Strategies
Much as in the case of childhood substance use
epidemiological data, there is a relative dearth of
research on prevention programs for elementaryaged children. In contrast to mental health
outcomes, too little research has been done on
childhood substance use prevention and treatment to draw many empirically based conclusions (Chorpita et al., 2011). There has been,
however, an escalation and improvement in
research on childhood substance use prevention
programs over the last decade. Some of these
programs were adapted from programs originally
designed for adolescents. Although there has
been progress, there is often a need for replication
and long-term follow-up research, and we
encourage readers to examine whether programs
meet criteria for effectiveness (see Flay et al.,
2005). The term “evidence-based” is frequently
used broadly to suggest that a program evinced
some effectiveness without regard to the scientific rigor of the research.
Generally speaking, successful and promising
programs include components that are developmentally focused, seek to enhance skills, are
easily integrated into the curriculum, incorporate
interactive approaches (e.g., modeling, role play,

955

practice), and involve a collaborative process
between children, parents, teachers, school
administrators, and communities (WebsterStratton & Taylor, 2001). These program features
are similar to those included in effective programs designed for middle-school and highschool students. This suggests that there are
some general components that should be common among childhood and adolescent programs.
First and foremost, as suggested by integrative
theories, these programs should address multiple
domains of influence – ranging from the biological to the immediate psychosocial context to the
larger family, school, and community contexts
(Catalano, Berglund, Ryan, Lonczak, & Hawkins, 2004). Second, similar to adolescent prevention programs and social and emotional
learning programs, curricula that use an interactive teaching format tend to be of more benefit
(Durlak, Weissberg, Dymnicki, Taylor, &
Schellinger, 2011). Lecture alone does not
tend to work. Moreover, Durlak and colleagues
(2011) suggest a sequenced step-by-step training
approach, including active forms of learning, a
focus on social and personal skill development,
and explicit learning goals (i.e., SAFE practices).
Third, school-based programs must take into
account teacher acceptance of the program and
provide teacher training on implementation.
Lastly, elementary school prevention programs
must be incorporated into a systematic prevention
regime that extends from middle school to high
school and beyond (Snyder & Flay, 2012).
As suggested above, there are some special
considerations regarding the elements of an
elementary-aged prevention program. First,
there should be greater emphasis on family relations and support and less emphasis on peer factors (Bush et al., 1994). However, this should
gradually shift during the transition from primary
grades to fourth and fifth grades. Second, a strong
focus on children’s strengths tends to be advantageous (Webster-Stratton & Taylor, 2001). Third,
social refusal skills may be less effective in younger children as a result of the time lag between
learning the skill and the situations in which those
skills are used (Herrmann & McWhirter, 1997;
Wynn, Schulenberg, Maggs, & Zucker, 2000).

956

Again, this relative shift in focus should gradually
transition during the fourth- and fifth-grade years.
Refusal skills should be used in combination
with other program components (Herrmann &
McWhirter, 1997). Finally, more emphasis should
be given to aiding children who have started to
either experiment or regularly use substances in
finding effective treatment resources. Given that
childhood substance use is often indicative of one
or more challenges (Clark et al., 2005), special
efforts should be made to address the needs of
these children.
Overall, the above considerations do not represent a fundamental deviation from what is
known about effective prevention programs
with adolescents, young adults, and adults – the
most effective programs often address people’s
needs and their context. Programs should take an
integrative approach that includes family, school,
and community settings. As presented herein,
programs can fit into at least four categories:
family systems-based programs, preschool programs, school-based programs, and integrative
programs that may include a combination of family, school, and community features. The following review of programs is not meant to be
exhaustive, but rather highlights general successes and challenges in efforts to prevent childhood substance use and to sustain program
effects.

Strategies That Work
Family Systems-Based Programs
As noted above, research shows that parents are
an important influence on children’s substance
use. Therefore, programs that enhance parent–
child relationships and functioning can be of considerable value. One such strategy that seeks to
achieve this involves prenatal and early childhood home-visitation services. The most thoroughly investigated home-visitation program
utilized nurses as home visitors (Olds et al.,
1997, 1998). The program is designed to provide
parent education and support as well as increase
positive parent–child interactions. Results from
a 15-year follow-up to a randomized control trial

Substance: Misuse During Childhood

of this program showed less child abuse and
neglect among mothers participating in the
intervention as compared to the control group
(Olds et al., 1997). Also at long-term follow-up,
children from unmarried, low-income mothers
who enrolled in the intervention reported
smoking fewer cigarettes and less alcohol use as
compared to the control group (Olds et al., 1998).
More recent research shows home-visitation services can significantly improve outcomes related
to children’s mental health (Olds, Kitzman, et al.,
2004; Olds, Robinson, et al., 2004).
Another family-based program, Guiding
Good Choices (formerly Preparing for the Drug
Free Years), is a training program for parents of
children aged 8–14. The program includes components to increase parent–child bonding that is
hypothesized to occur through children’s proactive involvement in the family, children’s participation skills, child–family interaction, and
rewards and punishments from parents (Mason
et al., 2007). This program has been shown to be
effective at improving parent–child relations
(Kosterman, Hawkins, Spoth, Haggerty, &
Zhu, 1997). Research also showed program
effects on reducing the increase of substance
use (Mason, Kosterman, Hawkins, Haggerty, &
Spoth, 2003; Mason et al., 2007; Park et al.,
2000) among older children who began the
program in grade six and were followed
into adolescence. Overall, more research is
needed on family-based approaches, although
empirical evidence suggests such programs can
play a key role in preventing substance use
(Velleman, Templeton, & Copello, 2005).

Preschool Programs
Two preschool programs, the Abecedarian program and the Perry Preschool program, are important prevention efforts involving preschool-aged
children and their families. Both programs were
evaluated using randomized designs and have
shown impressive effects on a number of indicators including substance use outcomes. The Abecedarian program (Duncan, Ludwig, &
Magnuson, 2007) was an intensive program,

Substance: Misuse During Childhood

providing year-round, full-time care for 5 years to
a mostly African-American sample of mothers
and children. The program began during
children’s first year of life and included several
components: access to transportation; low
child-to-teacher ratios (i.e., 3:1 for younger
children); a curriculum that emphasized language
development and cognitive skills, with educational games; health care; and social services.
Results indicated that the program had long-term
effects on participants’ mental health and quality
of life (Duncan et al., 2007), along with
a reduction in substance use (Campbell, Ramey,
Pungello, Sparling, & Miller-Johnson, 2002).
Overall, the economic value of the program’s benefits has been shown to greatly exceed the costs.
The Perry Preschool intervention (Duncan
et al., 2007) afforded one or 2 years of part-day
educational services and home visits to AfricanAmerican children aged three to four from
low-income families. The program included several key components: highly educated teachers,
with at least a bachelor’s degree; low child-toteacher ratio (i.e., 6:1); and active learning. Results
demonstrated that children participating in the program had significant long-term improvements in
a number of quality-of-life indicators, along with
lower rates of substance use (Schweinhart &
Weikart, 1993). Similar to the relatively intensive
Abecedarian and Perry Preschool programs,
appropriately designed school-based and integrative programs are more likely to be effective.

School-Based Programs
The Good Behavior Game is a classroom behavior management program (Kellam et al., 2011).
Early in the first-grade year, the program involves
teachers displaying classroom rules of behavior
and organizing groups of students that are
rewarded for the group’s collective good behavior. The aim of this program is to reduce disruptive and aggressive behavior. Researchers
hypothesized that the Good Behavior Game
could prevent substance use as well as related
risk behaviors by targeting disruptive and aggressive behavior. In a test of this hypothesis, Kellam

957

and Anthony (1998) reported on an epidemiological randomized field trial involving over
2,000 first graders from Baltimore area schools.
This study showed a significantly reduced risk of
smoking by age 14 for children who participated
in the Good Behavior Game versus controls. This
effect was significantly stronger for boys than for
girls, but this finding is consistent with gender
differences in the etiological role of aggression
in smoking. In another randomized trial (Storr,
Ialongo, Kellam, & Anthony, 2002), elementaryaged students who participated in the program
were less likely to have started smoking compared to control students. More recently, in
a long-term follow-up when first-grade participants were aged 19–21, Kellam and colleagues
(2008) found significant program effects. As
young adults, male participants had significantly
less substance abuse disorders and regular
smoking.
Researchers at the American Health Foundation developed the Know Your Body program in
the 1980s for students in grades ranging from
kindergarten to the end of high school (Resnicow,
Cross, & Wynder, 1993). This program takes
a general health-oriented approach but emphasizes substance use knowledge and addresses
variables such as self-esteem, social skills, coping skills, and explicit refusal skills. Walter,
Hofman, Vaughan, and Wynder (1988; Walter,
Vaugh, & Wynder, 1989; Walter & Wynder,
1989)
evaluated
the
program
using
a randomized design involving 15 New York
State elementary schools. The researchers found
that intervention school students had significantly
lower biomarkers of tobacco use compared to
control students. Another randomized trial with
African-American students from Washington
D.C. found similar results (Bush, Zuckerman,
Taggart et al., 1989; Bush, Zuckerman, Theiss
et al., 1989).
Growing Healthy is a comprehensive health
education curriculum developed by the National
Center for Health Education that is designed for
children in kindergarten through sixth grade
(Connell, Turner, & Mason, 1985). The program
involves nearly 50 sessions per year, with each
year’s lessons focusing on a single health topic.

958

Substance use education and social/refusal skills
are incorporated into the overall curriculum
design. There has been an independent evaluation
involving a sample of about 30,000 students in
grades 4–7 (Connell et al., 1985). Results demonstrated the program group had lower rates of
smoking in ninth grade than controls. Further,
program participants had higher scores on variables including general health information and
attitudes regarding health risk behavior.

Integrative Programs
Some programs include features that extend to
other contexts and include a combination of family, school, and community components. For
instance, the Fast Track PATHS (Promoting
Alternative Thinking Strategies) program is an
approach that draws on the strengths of traditional school-based programming and integrates
universal and selective interventions (Conduct
Problems Prevention Research Group, 2010).
The core program involves a curriculum that
includes features addressing self-control, emotional awareness, social skills, and problem solving. Results of a randomized trial involving
nearly 3,300 students demonstrate that the program can improve aggression and prosocial
behavior among boys (Conduct Problems Prevention Research Group). Previous research
(Bierman et al., 2004) has shown that an earlier
version of the Fast Track program resulted in less
self-reported substance use among fourth- and
fifth-grade students involved in the program as
compared to control students.
Another integrative approach is the Positive
Action program (Flay & Allred, 2010; Flay,
Allred, & Ordway, 2001). The Positive Action
program is a comprehensive, school-wide program shown to affect youth development (e.g.,
academic achievement; Snyder et al., 2010) and
create whole-school contextual change (Snyder,
Vuchinich, Acock, Washburn, & Flay, 2012) in
order to reduce risk behaviors, such as substance
use. The full program includes K–12 classroom
curricula (consisting of almost daily 15–20-min
lessons), a school-wide climate development

Substance: Misuse During Childhood

component, and family- and communityinvolvement components. The sequenced curricula include an interactive approach and cover six
major units on topics related to self-concept,
physical and intellectual actions, social/emotional actions for managing oneself responsibly,
getting along with others, being honest with yourself and others, and continuous selfimprovement. The first randomized trial of the
program involved 20 schools in Hawaii and
showed that elementary-aged students receiving
the program evinced significantly less substance
use compared to control students (Beets et al.,
2009). As theory suggests, whereby a link exists
between positive and negative behaviors, less
substance use was related to positive academic
behaviors (Snyder et al., 2013). Another randomized trial of Positive Action included 14 schools
in Chicago and demonstrated that students
receiving the program self-reported less substance use in grade five (Li et al., 2011) compared
to control students, with program effects
sustained through grade eight (Lewis et al.,
2012). These program effects were mediated by
students’ change in social–emotional and character development. Overall, research has shown
that the program’s focus on children’s assets
and positive actions can lead to improvements
in a variety of health domains, including
substance use.
The Aban Aya Project was designed to
improve several risk behaviors among urban students, including violence, substance use, school
delinquency, and risky sexual practices
(Flay, Graumlich, Segawa, Burns, & Holliday,
2004). The project was a randomized control
trial of three programs (two experimental interventions and one “attention-placebo” control)
that were implemented in grades 5–8 in 12 Chicago schools from 1994 to 1998. One of the
experimental conditions was a social development curriculum – a classroom-based program
that included lessons to teach skills related to
decision making, problem solving, conflict resolution, and goal setting. The other experimental
condition was a school and community intervention that included the social development curriculum and added parental support plus school

Substance: Misuse During Childhood

climate and community components. Results
showed that both experimental interventions
reduced the rate of increase in negative behaviors
among boys, including substance use. As hypothesized, the school and community intervention
demonstrated stronger effects (Flay et al., 2004).
The Seattle Social Development Project is
another integrative program that includes family
and school components designed to enhance
students’ social, emotional, and refusal skills,
along with improved parent and teacher skills
(Hawkins, Kosterman, Catalano, Hill, & Abbott,
2005). The project began in 1981 with first
graders from eight Seattle public schools. After
students reached grade five, the program was
expanded to involve a total of 18 schools that
were nonrandomly assigned to several conditions. Overall, results have demonstrated
a positive impact of this integrative program on
multiple health domains, including substance use
(O’Donnell, Hawkins, Catalano, Abbott, & Day,
1995). Long-term follow-up studies have shown
that the intervention did not improve substance
use, but improved other important outcomes
including crime, sexual activity, and school success among adolescents (Hawkins, Catalano,
Kosterman, Abbott, & Hill, 1999) and similar
outcomes into young adulthood (Hawkins et al.,
2005; Hawkins, Kosterman, Catalano, Hill, &
Abbott, 2008).
More recently, Hawkins, Catalano, and colleagues (2008) have evaluated Communities
That Care (CTC) – a system to help guide communities in choosing, installing, and monitoring
programs intended to improve youth outcomes.
The Community Youth Development Study is
a randomized trial of CTC involving 24 communities in the United States. Student self-reports of
substance use from grade 5 to 10 showed that by
the tenth grade students from CTC communities
had significantly less alcohol and cigarette
use compared to control students (Hawkins
et al., 2011).
We note that some of the aforementioned
programs do not focus specifically or solely on
substance use, but rather emphasize changes in
variables thought to influence substance use. This
approach is also true for other programs such as

959

LifeSkills Training, a program discussed in the
next section that was originally designed for
and rigorously evaluated with adolescents.
Approaches that do not focus on substance use
may lend programs a greater potential for the
prevention of childhood substance use and other
related risk behaviors. This is because these
developmentally appropriate programs can be
implemented early in childhood where many
problems likely take root (Zucker et al., 2008).

Strategies That Are Promising
School-Based Program
LifeSkills Training is one of the most researched
prevention programs designed for adolescents. It
has demonstrated effectiveness in preventing
substance use and other risk behaviors among
this population. The program emphasizes teaching personal and social skills, norms, and drug
resistance skills. Relatively little evaluation
research is available involving elementary-aged
students. However, the program was revised to be
developmentally appropriate and evaluated
in one randomized trial involving over 1,000
students in grades 3–6 from 20 schools
(Botvin, Griffin, Paul, & Macaulay, 2003).
Results indicated that intervention students
reported less smoking, but did not differ on selfreported drinking frequency compared to control
students. We are unaware of any long-term
follow-up research on the effects of LifeSkills
Training among children.

Strategies That Do Not Work
Here again we must mention a lack of research.
Moreover, it is often and unfortunately the case
that research is not published about strategies that
do not work. Such information is useful in understanding what not to do. As noted above, lecture
alone does not tend to work and relatively few
prevention programs targeted at elementary
school students have been evaluated. Among
those that have, long-term effectiveness was
mixed. While a few elementary school programs

960

have demonstrated short-term successes, by
twelfth grade these effects may erode unless
there have been follow-up programs (Resnicow
& Botvin, 1993). As such, it appears that isolated,
“single-shot” interventions are ineffective –
much like math or science education for a single
year in elementary school will unlikely result in
high academic achievement in high school and
beyond.
We would be remiss not to mention programs
such as Drug and Alcohol Resistance Education
(DARE), an ineffective, albeit well-intentioned
program. DARE uses a school-based approach
that attempts to develop resistance skills among
students, and it is one of the more widespread
substance use prevention programs in the United
States. However, multiple studies have shown
DARE to be ineffective at achieving even shortterm reduction of substance use (e.g., Ennett,
Tobler, Ringwalt, & Flewelling, 1994).

Synthesis
Researchers, practitioners, and policies generally
pay too little attention to substance use in preadolescents, and relatively little epidemiological
data exists around the world. Because early adolescence is where the majority of substance use
occurs, that developmental period has been the
focus of both research and intervention. But there
is a growing recognition that substance use prevention should occur as early as grades k–3 and
that more can be done to assure that children
develop in healthy, supportive contexts. This recognition derives from not only evidence that children are using substances earlier but also an
empirical understanding of the importance of
children’s context and putting children on a path
that discourages long-term use of harmful
substances.
The foremost theoretical underpinnings of
current prevention thinking are drawn from integrative, ecological theories such as the TTI. Prevention thinking includes two key concepts:
(1) Childhood substance use is multifaceted in
nature and results from multiple etiological pathways, and (2) preventive intervention is highly

Substance: Misuse During Childhood

sensitive to developmental timing. As such, both
individual factors (such as emotional/cognitive
traits and personality/temperament profiles) and
contextual factors (including caregivers, siblings,
peers, community institutions, media, and
national funding and policy mandates) play
a vital role in the development of childhood substance use. Further, the importance of any single
factor depends upon all the other factors listed
above and the timing of a child’s experiences
across development.
Substantial advances have been made over the
last several decades in child development
research and in our understanding that investing
in early childhood can have major economic
returns on investment (Shonkoff, 2010). Despite
advances in developmental and prevention theory
in more recent years, relatively few new techniques have been adopted to change behavior.
Most preventive interventions are still targeted
at early adolescents and largely administered at
school. There are, however, several pioneering
programs that recognize the multidimensional
influences on substance use. These programs
have begun to involve parents, schools, and communities and are showing results. A number of
programs have been set up for younger children
and target variables that are linked to later substance use behaviors. Noteworthy programs
include those that focus on families by featuring
home-visitation designs. Other programs of particular note are integrative programs that seek to
involve families, change school environments,
and include community components. Given current empirical findings and available prevention
approaches, we believe that a viable childhood
substance use program must, at a minimum, recognize local contextual influences such as peer
and family influences. It should also address
broader contextual influences, such as the school
setting, community infrastructure, policies, and
media influences. Thus, prevention approaches
need to extend beyond classroom walls to the
family and community to address circumstances
that support or deter substance use.
There is a need for programs to develop
with and follow youth from early childhood to
adolescence. Single exposure programs are

Substance: Misuse During Childhood

often insufficient and ultimately ineffective,
wasting valuable resources. Prevention programs should be sensitive to the fact that childhood substance use arises out of a complex set of
interactions within a variety of contexts and
among children who develop at different rates.
Given this complexity and variability, programs
need to be flexible or tailored in order to address
the many different pathways through which children come to use substances. We emphasize that
a need still exists for basic substance use
research and intervention trials with early childhood cohorts. This includes more research
involving understudied populations, longitudinal research, genetically informed research, economic analyses, and replication. Such efforts
hold tremendous potential to advance our understanding of substance use etiology and intervention research that can improve health outcomes
throughout the life course.

References
Arnett, J. J. (2007). The myth of peer influence in adolescent smoking initiation. Health Education & Behavior,
34(4), 594–607.
Bandura, A. (1977). Social learning theory. Englewood
Cliffs, NJ: Prentice Hall.
Beets, M. W., Flay, B. R., Vuchinich, S., Snyder, F. J.,
Acock, A., Li, K.-K., et al. (2009). Use of a social and
character development program to prevent substance
use, violent behaviors, and sexual activity among
elementary-school students in Hawaii. American Journal of Public Health, 99(8), 1438–1445.
Bierman, K. L., Coie, J. D., Dodge, K. A., Foster, E. M.,
Greenberg, M. T., Lochman, J. E., et al. (2004). The
effects of the Fast Track program on serious problem
outcomes at the end of elementary school. Journal of
Clinical Child and Adolescent Psychology, 33(4),
650–661.
Botvin, G. J., Griffin, K. W., Paul, E., & Macaulay, A. P.
(2003). Preventing tobacco and alcohol use among
elementary school students through life skills training.
Journal of Child & Adolescent Substance Abuse,
12(4), 1–17.
Bronfenbrenner, U., & Morris, P. A. (2006). The
bioecological model of human development. In
W. Damon & R. M. Lerner (Eds.), Handbook of child
psychology (pp. 793–828). Hoboken, NJ: Wiley.
Brooks-Gunn, J., & Graber, J. A. (1994). Puberty as
a biological and social event: Implications for research
on pharmacology. Journal of Adolescent Health,
15(8), 663–671.

961
Bush, P. J., Weinfurt, K. P., & Iannotti, R. J. (1994).
Families versus peers: Developmental influences
on drug use from grade 4-5 to grade 7-8. Journal
of Applied Developmental Psychology, 15(3),
437–456.
Bush, P. J., Zuckerman, A. E., Taggart, V. S., Theiss,
P. K., Peleg, E. O., & Smith, S. A. (1989). Cardiovascular risk factor prevention in black school children:
The “Know Your Body” evaluation project. Health
Education Quarterly, 16(2), 215–227.
Bush, P. J., Zuckerman, A. E., Theiss, P. K., Taggart,
V. S., Horowitz, C., Sheridan, M. J., et al. (1989).
Cardiovascular risk factor prevention in black
schoolchildren: Two-year results of the “Know Your
Body” program. American Journal of Epidemiology,
129(3), 466–482.
Campbell, F. A., Ramey, C. T., Pungello, E., Sparling, J.,
& Miller-Johnson, S. (2002). Early childhood
education: Young adult outcomes from the Abecedarian Project. Applied Developmental Science, 6(1),
42–57.
Catalano, R. F., Berglund, M. L., Ryan, J. A. M., Lonczak,
H. S., & Hawkins, J. D. (2004). Positive youth development in the United States: Research findings on
evaluations of positive youth development programs.
Annals of the American Academy of Political and
Social Science, 591, 98–124.
Catalano, R. F., Fagan, A. A., Gavin, L. E., Greenberg,
M. T., Irwin, C. E., Ross, D. A., et al. (2012). Worldwide application of prevention science in adolescent
health. Lancet, 379, 1653–1664.
Chorpita, B. F., Daleiden, E. L., Ebesutani, C., Young, J.,
Becker, K. D., Nakamura, B. J., et al. (2011).
Evidence-based treatments for children and adolescents: An updated review of indicators of efficacy
and effectiveness. Clinical Psychology: Science and
Practice, 18(2), 154–172.
Cicchetti, D. (2006). Development and psychopathology.
In D. Cicchetti & D. J. Cohen (Eds.), Developmental
psychopathology (Theory and method 2nd ed., Vol. 1,
pp. 1–23). Hoboken, NJ: Wiley.
Clark, D. B., Cornelius, J. R., Kirisci, L., & Tarter, R. E.
(2005). Childhood risk categories for adolescent substance involvement: A general liability typology. Drug
and Alcohol Dependence, 77(1), 13–21.
Conduct Problems Prevention Research Group. (2010).
The effects of a multiyear universal social-emotional
learning program: The role of student and school characteristics. Journal of Consulting and Clinical Psychology, 78(2), 156–168.
Connell, D. B., Turner, R. R., & Mason, E. F. (1985).
Summary of findings of the school health education
evaluation: Health promotion effectiveness, implementation, and costs. Journal of School Health,
55(8), 316–321.
Crisp, A., Sedgwick, P., Halek, C., Joughin, N., &
Humphrey, H. (1999). Why may teenage girls
persist in smoking? Journal of Adolescence, 22(5),
657–672.

962
Currie, C., Zanotti, C., Morgan, A., Currie, D., de Looze,
M., Roberts, C.,.et al. (Eds.). (2012). Social determinants of health and well-being among young people.
Health behaviour in school-aged children (HBSC)
study: International report from the 2009/2010 survey
(Health policy for children and adolescents, No. 6).
Copenhagen, Denmark: WHO Regional Office for
Europe.
Donovan, J. E. (2007). Really underage drinkers: The
epidemiology of children’s alcohol use in the United
States. Prevention Science, 8(3), 192–205.
Donovan, J. E., Leech, S. L., Zucker, R. A., LovelandCherry, C. J., Jester, J. M., Fitzgerald, H. E.,
et al. (2006). Really underage drinkers: Alcohol use
among elementary students. Alcoholism, Clinical and
Experimental Research, 28(2), 341–349.
Donovan, J. E., & Molina, B. S. G. (2011). Childhood risk
factors for early-onset drinking. Journal of studies on
alcohol and drugs, 72(5), 741–751.
Duncan, G. J., Ludwig, J., & Magnuson, K. A. (2007).
Reducing poverty through preschool interventions.
The Future of Children, 17(2), 143–160.
Durlak, J. A., Weissberg, R. P., Dymnicki, A. B., Taylor,
R. D., & Schellinger, K. B. (2011). The impact of
enhancing students’ social and emotional learning:
A meta-analysis of school-based universal interventions. Child Development, 82(1), 405–432.
Ennett, S. T., Tobler, N. S., Ringwalt, C. L., & Flewelling,
R. L. (1994). How effective is drug abuse resistance
education? A meta-analysis of Project DARE outcome
evaluations. American Journal of Public Health,
84(9), 1394–1401.
Faden, V. B. (2006). Trends in initiation of alcohol use in
the United States 1975 to 2003. Alcoholism, Clinical
and Experimental Research, 30(6), 1011–1022.
Fergusson, D. M., & Horwood, L. J. (1999). Prospective
childhood predictors of deviant peer affiliations in
adolescence. Journal of Child Psychology and Psychiatry, 40(4), 581–592.
Fergusson, D. M., Lynskey, M. T., & Horwood, L. (1994).
Childhood exposure to alcohol and adolescent drinking patterns. Addiction, 89(8), 1007–1016.
Fishbein, M., & Ajzen, I. (1975). Belief, attitude, intention
and behavior: An introduction to theory and research.
Reading, MA: Addison-Wesley.
Flay, B. R., & Allred, C. G. (2010). The positive
action program: Improving academics, behavior and character by teaching comprehensive skills for successful
learning and living. In T. Lovat & R. Toomey (Eds.),
International handbook on values education and student
well-being (pp. 471–501). Dordrecht: Springer.
Flay, B. R., Allred, C. G., & Ordway, N. (2001). Effects of
the positive action program on achievement and discipline: Two matched-control comparisons. Prevention
Science, 2(2), 71–89.
Flay, B. R., Biglan, A., Boruch, R. F., Castro, F. G.,
Gottfredson, D., Kellam, S., et al. (2005). Standards
of evidence: Criteria for efficacy, effectiveness and
dissemination. Prevention Science, 6(3), 151–175.

Substance: Misuse During Childhood
Flay, B. R., Graumlich, S., Segawa, E., Burns, J. L., &
Holliday, M. Y. (2004). Effects of 2 prevention programs on high-risk behaviors among African American youth: A randomized trial. Archives of Pediatrics
& Adolescent Medicine, 158(4), 377–384.
Flay, B. R., & Petraitis, J. (1994). The theory of triadic
influence: A new theory of health behavior with implications for preventive interventions. Advances in Medical Sociology, 4, 19–44.
Flay, B. R., Snyder, F. J., & Petraitis, J. (2009). The theory
of triadic influence. In R. J. DiClemente, R. A. Crosby,
& M. C. Kegler (Eds.), Emerging theories in health
promotion practice and research (2nd ed.,
pp. 451–510). San Francisco: Jossey-Bass.
Ford, D. H., & Lerner, R. M. (1992). Developmental
systems theory: An integrative approach. Newbury
Park, CA: Sage.
Graber, J. A., Nichols, T. R., & Brooks-Gunn, J. (2010).
Putting pubertal timing in developmental context:
Implications for prevention. Developmental Psychobiology, 52(3), 254–262.
Gunn, R. L., & Smith, G. T. (2010). Risk factors for
elementary school drinking: Pubertal status, personality, and alcohol expectancies concurrently predict fifth
grade alcohol consumption. Psychology of Addictive
Behaviors, 24(4), 617–627.
Hawkins, J. D., Catalano, R. F., Arthur, M. W., Egan, E.,
Brown, E. C., Abbott, R. D., et al. (2008). Testing
communities that care: The rationale, design and
behavioral baseline equivalence of the Community
Youth Development Study. Prevention Science, 9(3),
178–190.
Hawkins, J. D., Catalano, R. F., Kosterman, R., Abbott, R.,
& Hill, K. G. (1999). Preventing adolescent health-risk
behaviors by strengthening protection during childhood. Archives of Pediatrics & Adolescent Medicine,
153(3), 226–234.
Hawkins, J. D., Kosterman, R., Catalano, R. F., Hill, K. G.,
& Abbott, R. D. (2005). Promoting positive adult
functioning through social development intervention
in childhood: Long-term effects from the Seattle
Social Development Project. Archives of Pediatrics
& Adolescent Medicine, 159(1), 25–31.
Hawkins, J. D., Kosterman, R., Catalano, R. F., Hill, K. G.,
& Abbott, R. D. (2008). Effects of social development
intervention in childhood 15 years later. Archives of
Pediatrics & Adolescent Medicine, 162(12),
1133–1141.
Hawkins, J. D., Oesterle, S., Brown, E. C., Monahan,
K. C., Abbott, R. D., Arthur, M. W., et al. (2011).
Sustained decreases in risk exposure and youth problem behaviors after installation of the communities
that care prevention system in a randomized trial.
Archives of Pediatrics & Adolescent Medicine,
166(2), 141–148.
Herrmann, D. S., & McWhirter, J. J. (1997). Refusal and
resistance skills for children and adolescents:
A selected review. Journal of Counseling and Development, 75(3), 177–187.

Substance: Misuse During Childhood
Hibell, B., Guttormsson, U., Ahlström, S., Balakireva, O.,
Bjarnason, T., Kokkevi, A., et al. (2012). The 2011
European school survey project on alcohol and
other drugs (ESPAD) report: Substance use among
students in 36 European countries. Stockholm: The
Swedish Council for Information of Alcohol and
Other Drugs.
Holmbeck, G. N., & Shapera, W. (1999). Research
methods with adolescents. In P. C. Kendall, J. N.
Butcher, & G. N. Holmbeck (Eds.), Handbook of
research methods in clinical psychology (2nd ed., pp.
634–661). New York: Wiley.
Holmbeck, G. N. (2002). A developmental perspective on
adolescent health and illness: An introduction to the
special issues. Journal of Pediatric Psychology, 27(5),
409–416.
Jackson, C., Ennett, S. T., Dickinson, D. M., & Bowling,
J. M. (2012). Letting children sip: Understanding why
parents allow alcohol use by elementary school-aged
children. Archives of Pediatrics & Adolescent Medicine, 166(11), 1053–1057.
Johnston, L. D., O’Malley, P. M., Bachman, J. G., &
Schulenberg, J. E. (2012). Monitoring the future
national survey results on drug use, 1975–2011:
Volume I, Secondary school students. Ann Arbor,
MI: Institute for Social Research, The University of
Michigan.
Kellam, S. G., & Anthony, J. C. (1998). Targeting early
antecedents to prevent tobacco smoking: Findings from
an epidemiologically based randomized field trial.
American Journal of Public Health, 88(10), 1490–1495.
Kellam, S. G., Brown, C. H., Poduska, J., Ialongo, N.,
Wang, W., Toyinbo, P., et al. (2008). Effects of
a universal classroom behavior management program
in first and second grades on young adult behavioral,
psychiatric, and social outcomes. Drug and Alcohol
Dependence, 95(Suppl. 1), S5–S28.
Kellam, S. G., Mackenzie, A. C. L., Brown, C. H.,
Poduska, J. M., Wang, W., Petras, H., et al. (2011).
The good behavior game and the future of prevention
and treatment. Addiction Science & Clinical Practice,
6(1), 73–84.
Kosterman, R., Hawkins, J. D., Spoth, R., Haggerty, K. P.,
& Zhu, K. (1997). Effects of a preventive parenttraining intervention on observed family interactions:
Proximal outcomes from preparing for the drug free
years. Journal of Community Psychology, 25(4),
337–352.
Lerner, R. M. (2006). Developmental science, developmental systems, and contemporary theories of human
development. In R. M. Lerner & W. Damon (Eds.),
Theoretical models of human development (Handbook
of child psychology 6th ed., Vol. 1, pp. 1–17). Hoboken,
NJ: Wiley.
Lewis, K. M., Bavarian, N., Snyder, F. J., Acock, A., Day,
J., DuBois, D. L., et al. (2012). Direct and mediated
effects of a social-emotional and character development program on adolescent substance use. The International Journal of Emotional Education, 4(1), 56–78.

963
Li, K.-K., Washburn, I., Dubois, D. L., Vuchinich, S.,
Brechling, V., Day, J., et al. (2011). Effects of the
positive action programme on problem behaviors in
elementary school students: A matched-pair randomised
control trial in Chicago. Psychology & Health, 26(2),
179–204. doi:10.1080/08870446.2011.531574.
Mason, W. A., Kosterman, R., Hawkins, J. D., Haggerty,
K. P., & Spoth, R. L. (2003). Reducing adolescents’
growth in substance use and delinquency: Randomized
trial effects of a parent-training prevention intervention. Prevention Science, 4(3), 203–212.
Mason, W. A., Kosterman, R., Hawkins, J. D., Haggerty,
K. P., Spoth, R. L., & Redmond, C. (2007). Influence
of a family-focused substance use preventive intervention on growth in adolescent depressive symptoms.
Journal of Research on Adolescence, 17(3), 541–564.
Masten, A. S., Faden, V. B., Zucker, R. A., & Spear, L. P.
(2008). Underage drinking: A developmental framework. Pediatrics, 121(Suppl. 4), S235–S251.
Mendle, J., Turkheimer, E., & Emery, R. E. (2007).
Detrimental psychological outcomes associated with
early pubertal timing in adolescent girls. Developmental Review, 27(2), 151–171.
O’Donnell, J., Hawkins, J. D., Catalano, R. F., Abbott,
R. D., & Day, L. E. (1995). Preventing school failure,
drug use, and delinquency among low-income children: Long-term intervention in elementary schools.
American Journal of Orthopsychiatry, 65(1), 87–100.
Olds, D. L., Eckenrode, J., Henderson, C. R., Kitzman, H.,
Powers, J., Cole, R., et al. (1997). Long-term effects of
home visitation on maternal life course and child abuse
and neglect. Journal of the American Medical Association, 278(8), 637–643.
Olds, D. L., Henderson, C. R., Jr., Cole, R., Eckenrode, J.,
Kitzman, H., Luckey, D., et al. (1998). Long-term
effects of nurse home visitation on children’s criminal
and antisocial behavior. Journal of the American Medical Association, 280(14), 1238–1244.
Olds, D. L., Kitzman, H., Cole, R., Robinson, J. A., Sidora,
K., Luckey, D. W., et al. (2004). Effects of nurse
home-visiting on maternal life course and child development: Age 6 follow-up results of a randomized trial.
Pediatrics, 114(6), 1550–1559.
Olds, D. L., Robinson, J. A., Pettitt, L., Luckey, D. W.,
Holmberg, J., Ng, R. K., et al. (2004). Effects of home
visits by paraprofessionals and by nurses: Age 4 follow-up results of a randomized trial. Pediatrics,
114(6), 1560–1568.
Orlandi, M. A. (1996). Prevention technologies for drug
involved youth. In C. B. McCoy, L. R. Metsch, & J. A.
Inciardi (Eds.), Intervening with drug-involved youth
(pp. 81–100). Thousand Oaks, CA: Sage.
Park, J., Kosterman, R., Hawkins, J. D., Haggerty, K. P.,
Duncan, T. E., Duncan, S. C., et al. (2000). Effects of the
“Preparing for the Drug Free Years” curriculum
on growth in alcohol use and risk for alcohol use
in early adolescence. Prevention Science, 1(3), 125–138.
Partridge, T., & Flay, B. (2003). Substance use in childhood. In T. P. Gullotta & M. Bloom (Eds.),

964
Encyclopedia of primary prevention and health promotion (pp. 1052–1059). New York: Kluwer Academic/Plenum.
Posner, R. B. (2006). Early menarche: A review of
research on trends in timing, racial differences, etiology and psychosocial consequences. Sex Roles, 54(5),
315–322.
Resnicow, K., & Botvin, G. (1993). School-based substance use prevention programs: Why do effects
decay? Preventive Medicine, 22, 484–484.
Resnicow, K., Cross, D., & Wynder, E. (1993). The know
your body program: A review of evaluation studies.
Bulletin of the New York Academy of Medicine, 70(3),
188–207.
Schweinhart, L. J., & Weikart, D. P. (1993). Success by
empowerment: The high/scope Perry Preschool Study
through age 27. Young Children, 49(1), 54–58.
Settertobulte, W., Jensen, B. B., & Hurrelmann, K. (2001).
Drinking among young Europeans. Copenhagen,
Denmark: World Health Organization.
Shonkoff, J. P. (2010). Building a new biodevelopmental
framework to guide the future of early childhood
policy. Child Development, 81(1), 357–367.
Snyder, F. J., Acock, A. C., Vuchinich, S., Beets, M. W.,
Washburn, I. J., & Flay, B. R. (2013). Preventing
negative behaviors among elementary-school students
through enhancing students’ social-emotional and
character development. American Journal of Health
Promotion, 28(1), 50–58. doi:10.4278/ajhp.120419QUAN-207.
Snyder, F. J., & Flay, B. R. (2012). Positive youth
development. In P. Brown, M. W. Corrigan, &
A. Higgins-D’Alessandro (Eds.), Handbook of
prosocial education (pp. 415–443). Lanham, MD:
Rowman & Littlefield Publishing Group.
Snyder, F. J., Flay, B., Vuchinich, S., Acock, A.,
Washburn, I., Beets, M., et al. (2010). Impact
of a social-emotional and character development
program on school-level indicators of academic
achievement, absenteeism, and disciplinary outcomes:
A matched-pair, cluster-randomized, controlled trial.
Journal of Research on Educational Effectiveness,
3(1), 26–55.
Snyder, F. J., Vuchinich, S., Acock, A., Washburn, I. J., &
Flay, B. R. (2012). Improving elementary school quality through the use of a social-emotional and character
development program: A matched-pair, clusterrandomized, controlled trial in Hawai’i. Journal of
School Health, 82(1), 11–20. doi:10.1111/j.17461561.2011.00662.x.
Stattin, H., & Magnusson, D. (1990). Pubertal maturation
in female development: Paths through life (Vol. 2).
Hillsdale, NJ: Lawrence Erlbaum Associates.

Substance: Misuse During Childhood
Storr, C. L., Ialongo, N. S., Kellam, S. G., & Anthony, J. C.
(2002). A randomized controlled trial of two primary
school intervention strategies to prevent early onset
tobacco smoking. Drug and Alcohol Dependence,
66(1), 51–60.
Tschann, J. M., Adler, N. E., Irwin, C. E., Millstein, S. G.,
Turner, R. A., & Kegeles, S. M. (1994). Initiation of
substance use in early adolescence: The roles of pubertal timing and emotional distress. Health Psychology,
13(4), 326–333.
Vega, W. A., Aguilar-Gaxiola, S., Andrade, L., Bijl, R.,
Borges, G., Caraveo-Anduaga, J. J., et al. (2002). Prevalence and age of onset for drug use in seven international sites: Results from the international consortium
of psychiatric epidemiology. Drug and Alcohol
Dependence, 68(3), 285–297.
Velleman, R. D. B., Templeton, L. J., & Copello, A. G.
(2005). The role of the family in preventing and intervening with substance use and misuse:
A comprehensive review of family interventions,
with a focus on young people. Drug and Alcohol
Review, 24(2), 93–109.
Walter, H. J., Hofman, A., Vaughan, R. D., & Wynder,
E. L. (1988). Modification of risk factors for coronary
heart disease. New England Journal of Medicine,
318(17), 1093–1100.
Walter, H. J., Vaugh, R. D., & Wynder, E. L. (1989).
Primary prevention of cancer among children:
Changes in cigarette smoking and diet after six years
of intervention. Journal of the National Cancer Institute, 81(13), 995–997.
Walter, H. J., & Wynder, E. L. (1989). The development,
implementation, evaluation, and future directions of
a chronic disease prevention program for children: The
“Know Your Body” studies. Preventive Medicine,
18(1), 59–71.
Webster-Stratton, C., & Taylor, T. (2001). Nipping early
risk factors in the bud: Preventing substance abuse,
delinquency, and violence in adolescence through
interventions targeted at young children (0-8 years).
Prevention Science, 2(3), 165–192.
World Health Organization. (2011). Global status report
on alcohol and health. Geneva, Switzerland: WHO
Press.
Wynn, S. R., Schulenberg, J., Maggs, J. L., & Zucker,
R. A. (2000). Preventing alcohol misuse: The impact
of refusal skills and norms. Psychology of Addictive
Behaviors, 14(1), 36–47.
Zucker, R. A., Donovan, J. E., Masten, A. S., Mattson,
M. E., & Moss, H. B. (2008). Early developmental
processes and the continuity of risk for underage drinking and problem drinking. Pediatrics, 121(Suppl. 4),
S252–S272.

Violence by Children in Schools and the Community

Violence by Children in Schools and
the Community
Courtney Swisher Banks1, Emily M. Lund1,
Ryne Pulido1, Jessica E. Vaughan-Jensen1 and
Jamilia J. Blake2
1
Texas A&M University, College Station,
TX, USA
2
Department of Educational Psychology, Texas
A&M University, College Station, TX, USA

Introduction
Youth violence is a highly publicized issue and
has received national attention within the last
15 years due to school shootings that questioned
the safety of public schools. In 1998, the media
coverage of the Columbine shootings and the
school shootings in Jonesboro, Arkansas,
gripped the country and brought school safety
into national awareness (Muschert, 2009). In
response to these events, public demand for
greater school safety prompted the implementation of a number of school violence prevention
programs in order to curtail youth violence.
More recently, cases of suicides related to bullying have moved school districts and
policymakers to develop anti-bullying laws
(Smith, 2011). Youth homicides occurring at
school, however, are less than 2 % of all youth
homicides, and youth suicides occurring at
school are less than 1 % of all youth suicides
(Robers, Zhang, & Truman, 2010). It would
appear that schools are indeed safe environments for children and adolescents.
On the other hand, aggression and violence
occur in many forms, at different levels of severity, and with varying degrees of overtness in
schools and the larger community. Additionally,
any incidence of youth violence can disrupt the
physical and psychological development of
a child, negatively impact a child’s academic
achievement, and have far reaching societal ripple effects. Thus, research has focused on examining theories of human behavior, specific factors
that relate to and promote different forms of

965

youth violence, and prevention programs that
aim to reduce specific forms of youth violence.

Definitions and Scope
Youth Violence
The Centers for Disease Control and Prevention
(CDC) defines violence as a threatened or actual
physical force or power initiated by an individual
which results in physical or psychological injury
or death. Youth violence can be defined as harmful
behaviors that occur in early childhood and can
continue into young adulthood that cause physical
and/or emotional harm (Centers for Disease Control and Prevention [CDC], n.d.). Youth violence
is different from accidental injury or death and can
be either verbal (e.g., threats) or physical. Specific
forms of youth violence are aggression, bullying,
gang involvement, and violence with weapons.
Aggression and Bullying. Aggression is any
volitional behavior that is intended to harm or
injure another person. Aggression may take
many forms, but is most commonly manifested
in youth as physical (e.g., kicks, punches, and
pushing), verbal (e.g., name calling), relational
(e.g., verbal and nonverbal social exclusion or
malicious gossip; Blake, Lease, Olejnik, &
Turner, 2010), or cyber aggression (e.g., using
technology to ostracize or destroy one’s reputation; Wolak, Mitchell, & Finkelhor, 2007). Similarly, bullying is a form of aggression that is
characterized by an intention to harm but differs
from aggression in that it involves repeated
aggressive acts of aggression and an imbalance
of power between the bully or bullies and their
victims (Merrell, Gueldner, Ross, & Isava, 2008).
Rates of aggression, specifically physical aggression, have demonstrated declines in the past
15, whereas incidents of bullying appear to be
stable. For example, acts of physical aggression
declined from 42 % in 1993 to 31 % in 2009 for
children aged 9–12. Yet, in 2009, 19.9 % of
youths in grades 9–12 reported being bullied in
the past year (CDC, 2010).
Gangs and Violence with Weapons. Gang
involvement can be thought of as the extreme
end of deviant peer involvement (Dishion,

T.P. Gullotta, M. Bloom (eds.), Encyclopedia of Primary Prevention and Health Promotion,
DOI 10.1007/978-1-4614-5999-6, # Springer Science+Business Media New York 2014

966

Nelson, & Yasui, 2005). Gangs are defined as
a group of individuals that have allegiance with
each other and seek to increase their status within
the community through involvement in criminal
activities (Esbensen, Winfree, He, & Taylor,
2001). During the 2007–2008 school year, 20 %
of public schools reported incidences of gang
activities (Robers et al., 2010). According to the
Youth Risk Behavior Survey (Robers et al.),
between 1 % and 8 % of students in grades
9–12 reported being threatened or injured with
a weapon on school property.
Measurement. The most common assessment
method of youth and school violence is selfreport surveys administered to students and staff
to identify the frequency and severity of violent
events. However, concerns surrounding privacy
and confidentiality, response bias, and faulty
memory retrieval of events can compromise the
psychometric adequacy of self-report measures.
Therefore, multiple informants (e.g., students and
staff) in addition to alternate measures of youth
and school violence such as school discipline
records and criminal justice records are used to
assess the incidence of youth violence in schools
and community settings.

Theories
Researchers and mental health professionals have
attempted to determine the etiology of violence,
aggression, delinquency, and antisocial behaviors, which include a wide range of behaviors
that violate societal norms (Rutter, Giller, &
Hagell, 1998). Whereas a number of theories
have been proposed to explain the development
of violence, some perspectives have received
more empirical support in the literature than
others, specifically genetic explanations for violence, developmental perspectives, social learning, and attachment theories.
Many researchers have theorized that violence
is transmitted genetically. Aggressive behavior
appears to be moderately heritable. For example,
a meta-analysis of twin and adoption studies
concluded that genes explain about 40 % of the
variance in antisocial behavior, while

Violence by Children in Schools and the Community

environmental factors explain the rest of the variance in antisocial behavior (Rhee & Waldman,
2002). If parents exhibit violent behavior, there is
a chance they will transmit genetic factors to their
child that make their child more likely to engage
in aggressive behavior (Rhee & Waldman).
When considering violence from a developmental psychology perspective, children’s early
stages of development impact their behavior at
later stages and could be associated with violence. If children do not develop appropriate
social skills, emotional control, and behavioral
control during their first years of life, it can be
difficult for them to function well in later
developmental stages of life. Poor functioning
then places them at risk for developing
aggression (Cicchetti & Toth, 1995).
Terrie Moffitt (1993) proposed a dual pathway
developmental theory of violent behavior.
Their theory categorizes violent, delinquent adolescents according to their age at the time of onset
of problem behavior. Some of these adolescents
are categorized as life course persistent
offenders, who begin exhibiting violent or
delinquent behaviors early in life and continue
to engage in this problem behavior throughout
adolescence. The other adolescents are categorized as adolescent limited offenders, who begin
behaving violently or delinquently later in life
and cease to engage in these problematic behaviors after some time (Moffitt).
Similar to Moffitt’s theory, David Farrington’s
(2005) integrated cognitive antisocial potential
theory categorizes individuals according to longterm antisocial potential and short-term antisocial
potential. People’s antisocial potential is their
likelihood of engaging in antisocial behaviors
based on the presence of risk factors and cognitive
thought processes that predispose people to
become violent (Farrington). Short-term risk factors increase an individual’s likelihood of behaving violently in a specific situation. Short-term
risk factors include not having a guardian present,
being with other violent individuals, or being
under the influence of drugs or alcohol. However,
only people with long-term risk factors (e.g.,
impulsivity, poor academic performance, or poor
social skills), which predispose them towards

Violence by Children in Schools and the Community

antisocial behavior, are persuaded by short-term
risk factors and consequently behave violently in
a specific situation (Van der Laan, Blom, &
Kleemans, 2009).
According to social learning theory (Bandura,
1977), people learn behavior through a process of
vicarious learning, which occurs through symbolic processes, rather than direct experience.
When vicarious learning occurs, an observer
witnesses a person (e.g., model) behaving in
a particular way and learns from the consequences the person receives for that behavior,
rather than experiencing the behavior and
consequences themselves. In line with this theory, individuals learn to behave violently by seeing other people in their lives behave violently.
Seeing violence modeled by parents, friends, and
other significant people in a child’s life teaches
the child that aggression is an acceptable form of
expression and an efficient strategy for meeting
their needs.
Attachment theory focuses on the relationships between children and their caregivers. The
quality of the bonds between children and caregivers can lead to secure attachment or insecure
attachment. When a parent provides support and
comfort to a child but also displays harm and
aggression towards the child, the child forms an
insecure attachment, and the child consistently
feels confused and anxious. This constant state
of confusion and anxiety can bring about violent
behavior and aggression in the child (Bowlby,
1969, 1988).

Research
Exposure to violence has many dimensions
because children can engage in, witness, or be
victims of violent events within their family,
community, school, and through media
(Schechter & Willheim, 2009). The association
between adverse social and emotional outcomes
and exposure to violence, even at a young age, is
well documented (Schechter & Willheim). For
example, cruelty to animals during childhood is
associated with future violence towards humans
in adulthood (Merz-Perez & Heide, 2003).

967

In order to understand the development of violence in children, researchers often assess the contexts in which children may be exposed to violence
in the family, community, school, and through
the media as a predictor of future violent behaviors
later in life. However, in many instances, it is
the combination of contexts that gives rise to the
development of later violent behavior.
Family violence occurs when a child experiences or witnesses violent acts such as neglect,
sexual or physical abuse (i.e., leaving bruises or
marks on the skin), or intimate partner violence
involving family members or caretakers
(Schechter & Willheim, 2009). Briggs-Gowan
and colleagues (2010) found that clinically
referred children as young as 24 months who
witnessed family violence and their parents’
distress as a result (i.e., witnessing someone hit,
push, or kick a family member or seen someone
use a weapon to threaten or hurt a family
member) displayed more symptoms of separation
anxiety disorder and conduct problems characterized by aggressive and delinquent behavior.
Gover, Kaukinen and Fox (2008) found that
girls who witnessed paternal abuse as a child
were more likely to be victims of physical violence in dating relationships.
Exposure to violence in the community or
community violence can include a child
witnessing violent victimization of neighbors,
friends, or family or being violently victimized
themselves (Shahinfar, Fox, & Leavitt, 2000).
Kia-Keating (2006) found that common community characteristics that contribute to the development of violent behaviors due to higher
violence exposure are communities with high
concentrations of poverty, high ethnic heterogeneity, and high residential mobility, and elevated
neighborhood violence can contribute to the
development of future violent behaviors. Further,
Stein, Jaycox, Kataoka, Rhodes, and Vestal
(2003) found in their longitudinal study that
urban, low-income, and predominately minority
communities had a higher likelihood of
presenting higher rates of community violence.
Some research has shown that the higher rates of
community violence within such neighborhoods
can be attributed to the number of individuals in

968

the neighborhood who live in poverty which in
turn can result in a lack of social organization
within the community (APA Task Force on
Urban Psychology, n.d.). A specific type of community violence which contributes to community
violence exposure is gang involvement. Gangs
may use severe violence to intimidate rival
gangs and to create territories to establish the
necessary status for engaging in criminal activities (Struyk, 2006). Research suggests that there
may be a correlation between exposure to gangs
and delinquent and violent behaviors among
youth. Dishion et al. (2005) found that youth
who engage in antisocial behavior also had
deviant peer relationships and were reported to
affiliate with gangs.
Research has shown that exposure to violence
in media (i.e., video games, television, and
movies) is associated with involvement in reallife violent events. Schechter (2006) found
a relationship between family preferences for
viewing media with violence and the likelihood
that the caregiver of the young child experienced
real traumatization. However, Boxer, Huesmann,
Bushman, O’Brien, and Moceri (2009) discussed
that although there has been research to indicate
that exposure to media violence has the potential
to increase violent behaviors, limited research is
available to support the direct association
between media violence exposure and child and
adolescent engagement in violent acts. Boxer
et al. attribute the lack of research on the causal
effects of media violence exposure on child and
adolescent outcomes to the inherent difficulty in
measuring violent behaviors and to limited
longitudinal studies examining media violence
exposure in children. Despite current limitations
in the media violence exposure literature, Boxer
and colleagues (2009) found some evidence for
the role of media violence exposure in explaining
youth violence. In their study of incarcerated
juveniles, they found that adjudicated youth
who recalled watching violent television shows
at ages 7 or 8 were at greater risk for engaging in
violent behavior and aggression at ages 15 and
16 years old. Additionally, media violence exposure significantly contributed to the prediction of
violence and aggression in these youth after

Violence by Children in Schools and the Community

controlling for other risk factors for violence
such as community violence exposure and
presenting traits of psychopathology (i.e., callousness and psychoticism).
Although schools seek to provide a positive
and safe climate for all students, schools unfortunately are not immune to violence especially if
the community around the school reinforces violence. School violence can include any acts of
violence on school grounds such as bullying,
fighting, school shootings, and involvement in
gang activity. High levels of violence within the
school setting contribute to lower levels of perceived school climate by students. School climate is defined as the perception from students
that they are supported by teachers and peers and
the perceived level of safety of that they experience in their school (Hoy, Smith, & Sweetland,
2002). Research has shown that a perceived positive school climate is associated with
a reduction of violent behaviors at school.
Eliot, Cornell, Gregory, and Fan (2010) found
that a positive perception of school climate was
associated with students’ willingness to seek
assistance from school staff related to interpersonal issues surrounding bullying and threats of
violence. Conversely, school climates that reinforce delinquency by giving unclear rules and
inconsistent consequences are related to students exhibiting higher levels of antisocial
behaviors at a school (Welsh, Stokes, & Greene,
2000).

Strategies
Because violence is a complex and multifaceted
problem, interventions that successfully address
and prevent it must be wide reaching. Thus, the
most promising research-supported interventions
for violence in children and youth address the
problem on multiple levels by simultaneously
targeting individual, social, and/or environmental
risk factors. Conversely, programs that take
a “one size fits all” approach to addressing
violence, such as zero tolerance policies, have
generally been shown to be ineffective or even
detrimental.

Violence by Children in Schools and the Community

Strategies That Work
Community and Gang Violence. The “pulling
levers” approach has shown preliminary promise
for reducing rates of youth homicide communities. The pulling levers approach involves careful
identification and targeting of specific individuals, gangs, and situations responsible for
a disproportionately high number of youth homicides, specifically homicides due to gun violence
(Braga, Kennedy, Waring, & Piehl, 2001). Once
these individuals and situations have been
targeted, they become the focus of
a “workgroup” comprised of police officers,
street workers (i.e., social workers, clergy members, and other volunteers who work to help gang
members and prevent gang violence), and community groups, including churches that attempt to
target gang involvement as a community. Police
officers, probation officers, and others in the
criminal justice system convey to gang members
that gang-related youth homicides will be swiftly
and severely addressed by the police and legal
system, and steps are taken to see that youth
homicides are indeed addressed in a swift, meaningful, and serious manner. Simultaneously,
access to community and social service resources
is heavily facilitated by both the criminal justice
system and community partners involved in the
workgroup in hopes of addressing the social,
economic, and community issues that may underlie gang violence. Cooperation and coordination
among police, legal, and community partners and
intensive targeting are key elements of these
programs.
Braga and colleagues (2001) evaluated the
impact of the pulling levers strategy as part of
Boston’s Operation Ceasefire initiative in the
mid- to late 1990s. Not only did youth homicides
in Boston decrease in a pre-post comparison of
monthly youth homicides, but youth homicide
rates also decreased at a greater rate than that of
other large cities during the same period,
suggesting the possibility of a casual intervention
effect. The evaluation of a similar pulling levers
gun violence intervention program in Stockton,
California, yielded similar results in both simple
pre-post comparisons and comparisons to the
homicide rate trends of other cities within the

969

same timeframe (Braga, 2008). Furthermore,
Corsaro and McGarrell (2009) found that not
only did a pulling levers intervention
implemented in Indianapolis decrease gun
violence homicide significantly compared to
pre-intervention rates, but the decrease was significantly more pronounced for gang-related versus non-gang-related violence. Because pulling
levers programs specifically target gang-related
gun violence, these results give further support to
the possibility of an intervention effect, in spite
of the inability to conduct a “true” randomized
controlled trial of this type of intervention.
Multisystemic therapy (MST) is a therapy
targeted towards youth who are serious violent
and/or chronic offenders. MST is designed to
address the multitude of family, peer, contextual,
and individual factors that lead to recidivism
rates among criminal offenders (Schaeffer &
Borduin, 2005). A series of research studies by
the creators of MST in the 1990s found that the
intervention significantly reduced recidivism
rates in arrested or previously incarcerated
youth with histories of chronic, violent offending
and that it generally produced superior outcomes
compared to individual therapy (for a review, see
Schaeffer and Borduin). Additionally, Schaeffer
and Borduin conducted a 10-year follow-up of
176 adults who had participated in a randomized
clinical trial of MST versus individual therapy as
adolescents; at the time of the original study, just
under half of the participants had at least one
violent offense on record. At the 10-year
follow-up, participants who had been randomized
to the MST condition had significantly fewer
violent and nonviolent adult offenses than those
who had been randomized into the individual
therapy condition, suggesting that MST may
have significant long-term effects on violent
behavior as well. While MST is not a preventive
intervention, it could be an effective treatment.
Strategies That Might Work
Community and Gang Violence. The Gang
Resistance Education and Training II (GREAT
II) program is a middle school gang-involvement
prevention program that trains police officers to
deliver a gang-involvement resistance curriculum

970

to middle school students (Esbensen et al., 2011).
The original GREAT program was similar to the
Drug Abuse Resistance Education (DARE) program and was similarly ineffective in achieving
its target outcome (i.e., reducing gang involvement). Following the disappointing results of the
evaluation of the original GREAT program, the
curriculum, training, and evaluation methods
were significantly revised. Esbensen and colleagues conducted a longitudinal randomized
controlled trial across 195 classrooms in 31 middle schools in several cities determined to have
high rates of gang activity. A 1-year follow-up
suggests students who participated in the GREAT
II program have significantly lower rates of gang
involvement compared to the control group and
were more likely to resist peer pressure and use
refusal skills, although no significant group
differences for delinquency were found. More
research is needed to establish the efficacy, effectiveness, and long-term impact of the program.
Bullying. In general, bullying prevention programs have shown low-to-minimal efficacy in
decreasing actual bullying behavior among students (Merrell et al., 2008). However, there are
some packaged bullying intervention programs
that have promising – although not conclusive –
empirical support. The Olweus Bullying Prevention Program (OBPP) was developed in the
mid-1980s in response, in part, to bullyingrelated suicides in Norway (Limber, 2011).
OBPP is a multi-tier, multifaceted program that
involves school-wide, classroom-level, and individual intervention strategies as well as involvement from the community in order to address,
intervene in, and prevent bullying in schools.
The program involves a bullying prevention
coordination committee of administrators,
teachers, school-based mental health professionals (e.g., school counselors and school psychologists), parents, and others who make
school-wide decisions and oversee the implementation of the program. Although the program
has produced significant reductions in bullying in
many Norwegian and other European schools
(Limber), studies of OBPP in US schools have
produced mixed results – in some US studies, the
program did not produce significant or notable

Violence by Children in Schools and the Community

declines in bullying behavior among students –
suggesting that the program may not translate
well or be as feasible in the American school
system (Merrell et al., 2008).
Aggression. Similar to bullying prevention
programs, the research on school-based aggression prevention programs have yielded mixed
findings, with many studies demonstrating effectiveness in reducing correlates of aggression and
emotional behavioral regulation (e.g., prosocial
skills, increased academic achievement), but
inconsistent evidence for reducing aggression
per se. However, the Second Step program has
been identified as a promising program in
reducing youth aggression. The Second Step is
a classroom-based prevention program developed by the Committee for Children as an intervention to decrease aggression and increase
prosocial behavior in children and adolescents.
Grossman and colleagues (1997) conducted
a year-long evaluation of Second Step with
790 second and third-grade children. Teacher
reports and observations indicated a marked
decrease in aggressive behavior and increase in
prosocial behavior in children in the program,
and researchers reported that these results were
maintained at a 6-month follow-up. Cooke and
colleagues (2007) evaluated the effects of the
program on a sample of 741 third and fourth
graders who were among 986 elementary
school-age children in the Second Step program
as part of a citywide implementation. Again, they
found significant decreases in aggressive behavior and significant increases in prosocial behavior
among the students studied. In a randomized
controlled trial of the Second Step program in
seven intervention and eight control schools,
students in the program showed significantly
lower aggression and significantly greater
prosocial behavior than those not receiving the
program (Frey, Nolen, Edstrom, & Hirschstein,
2005).
Although the results of studies of Second Step
have been generally positive, several studies have
found that the program is not consistently effective across gender and grade. For example,
a controlled evaluation of the Second Step
program with Norwegian fifth and sixth graders

Violence by Children in Schools and the Community

showed some promising pre-post and group
intervention effects for social competence and
externalizing behavior, although results varied
by both grade and gender (Holsen, Smith, &
Frey, 2008). Similarly, a study of Second Step
in 109 low-income preschool and kindergarten
students found that decreases in problem and
disruptive behavior varied both by grade and
how the outcome was measured, providing
inconsistent results in this domain (McMahon,
Washburn, Felix, Yakin, & Childrey, 2000).
Further research is needed to better understand
the efficacy and limits of this program.
School Violence. The Virginia Student Threat
Assessment Guidelines were developed in order
to provide a uniform, systematic way for school
personnel to address and evaluate violent threats
made by students in order to prevent fatal school
violence (Cornell & Allen, 2011). These guidelines can be used for threats ranging from threats
of bullying (e.g., “I’m going to beat him up!”) to
threatened school bombings or shootings. By
allowing for a systematic and thorough understanding of each threat, these guidelines allow
schools to address threats and the students who
make them in an individualized, effective, and
fair manner. They also provide guidance on how
threats may be appropriately remediated; this
sharply differentiates them from ineffective zero
tolerance policies, which focus solely on severe
punishment and fail to address core issues.
The guidelines provide a means by which
school administrators and other relevant psychological staff can address the nature of the threat
(transient, substantive, or unclear) and the seriousness (“very serious” versus “serious”) of the
threatened actions, with “very serious” actions
including rape, murder, or violence with weapons
(Cornell & Allen, 2011). In contrast, “serious”
threats include threats unlikely to cause fatal or
critical harm, such as threatening to beat another
student up. The guidelines also include suggestions for addressing threats depending on their
nature and severity, including notifying parents,
conducting a mental health evaluation, notifying
authorities, creating a written safety plan, and
engaging in school-based discipline. Preliminary
evaluation studies summarized by Cornell and

971

Allen suggest that use of the Virginia guidelines
may decrease post-threat assessment disciplinary
referrals, decrease long-term suspensions, and
improve school climate and student willingness
to report bullying, while still preventing or reducing the likelihood that threats are carried out.
Cornell and Allen report that a randomized controlled trial of the Virginia assessment guidelines
versus treatment as usual is currently underway.
Strategies That Do Not Work
Because youth violence, aggression, and bullying
are generally considered to be serious social and
public health issues, schools and policymakers
may feel pressure to respond with “solutions”
that sound good but are not supported by research.
One of the most prominent examples of this is
“zero-tolerance” policies for violence in schools,
which have been shown to be both ineffective in
preventing violence and detrimental to students
and the general school climate (Skiba, 2000). Due
to the popularity and serious implications of the
ineffectiveness of zero tolerance policies, they
will be the primary focus of this section. However, school security measures and profiling will
also be discussed as examples of nonempirically
supported treatments.
Zero Tolerance Policies. In contrast to the
highly individualized, systematic assessments of
threats and appropriate consequences in the
Virginia Student Threat Assessment guidelines,
zero tolerance policies proscribe a “one size fits
all” approach to addressing threats and violent or
aggressive acts. In practice, this can lead to
punishments that are grossly incongruent with
the severity of the “crime” or infraction committed, such as involving law enforcement and
suspending students for accidently hitting
a school bus driver with a peanut (National Summit on Zero Tolerance [NSZT], 2000). Because
these severe, almost automatic punishments
frequently involve suspension, students miss
substantial portions of coursework and classroom discussion, creating the possibility of serious academic deficiencies and loss of
opportunity as a result (NSZT). Additionally,
out-of-school suspensions may place high levels
of stress and burden on families, particularly

972

those who are unable to supervise the student
during his or her suspension (NSZT).
Furthermore, zero tolerance policies and their
focus on severe punishment may negatively
impact school climate. Students may react to
seemingly draconian disciplinary policies by
acting out or becoming resentful of school officials, thus creating a negative school climate
characterized by hostility and resistance (Skiba,
2000). Because these policies are purely reactive
in nature, they leave little or no room to actually
try to remediate problems among students or support the development of a positive and mutually
supportive school climate (NSZT, 2000). Additionally, zero tolerance policies have been shown
to disproportionately affect students who are
racial and ethnic minorities, particularly African
American students, and students with disabilities,
indicating that these policies may, in practice,
infringe on some students’ civil rights.
School Security Measures. Similarly, in their
review of the literature, Borum, Cornell,
Modzeleski, and Jimerson (2010) also note that
little to no evidence supports the effectiveness of
mental detectors, video cameras, identification
badges, and other such “security measures” in
reducing school violence, despite their popularity
as highly visible ways of responding to public
concerns about school violence. Skiba (2000)
also notes the lack of evidence for the effectiveness
of such security measures and notes that some
research suggests that well-understood and
enforced school rules are more effective than security measures at decreasing student fighting and
aggression. Additionally, such measures have the
potential to negatively impact school climate by
creating an atmosphere of fear and suspension.
Profiling of Potential School Shooters.
Borum and colleagues (2010) also note that “profiling” potential school shooters – as contrasted
with a systematic threat assessment program – is
ineffective and impractical at the individual
level. Although statistical modeling suggests
some predictor variables correlate significantly
with school shooter profiles retrospectively,
these variables are unlikely to reliably identify
potentially violent students in a way that helps
prevent violence (Borum et al.).

Violence by Children in Schools and the Community

Summary
The prevention of youth violence is a national
public health concern due to the negative impact
of violence on the physical and mental health and
educational and the economic trajectories of
youth. It is important to note that while there are
unique risk factors that predict youth violence,
individual differences such as child temperament
and psychiatric history, as well as risk presence
and risk for mental health disorders, can also play
a part in the developmental trajectory of violence
(Bardick & Bernes, 2008). Whereas the combination to violence exposure in a number of
settings plays a central role in children’s engagement in violent behavior, not all children exposed
to violence will engage in violent behaviors in the
future. Thus, it is recommended that personcentered approach to understanding risk for violence be adopted. In general, research suggests
that proactive, not reactive, interventions are the
key to effectively addressing and decreasing violence in schools and among youth. Given the
multifaceted and systemic causes and consequences of violence, it is imperative that violence
prevention programs adopt a multi-tier approach
with primary, secondary, and tertiary prevention
components implemented simultaneously across
settings. Currently, violence prevention programs are isolated to a single context, schools,
or community mental health centers, with little
integration of the implementation of violence
prevention programs across contexts in which
children spend most of their time, schools,
out-of-school time programs, churches, or
religious centers. In order to effectively reduce
violence for youths most at risk for experiencing
violence, a multisystemic approach to violence
prevention is critical.

References
APA Task Force on Urban Psychology. (n.d.). Toward an
urban psychology: Research, action, and policy.
Retrieved August 11, 2011, from www.apa.org/pi/
ses/resources/publications/urban-taskforce.pdf
Bandura, A. (1977). Social learning theory. New York:
General Learning Press.

Violence by Children in Schools and the Community
Bardick, A. D., & Bernes, K. D. (2008). A framework for
assessing violent behaviors in elementary school-age
children. Children & Schools, 30(2), 83–91.
Blake, J. J., Lease, A. M., Olejnik, S., & Turner, T. L.
(2010). Ethnic differences in parents’ attitudes toward
girls’ use of aggression. Journal of Aggression,
Maltreatment & Trauma, 19, 393–413.
Borum, R., Cornell, D. G., Modzeleski, W., & Jimerson,
S. R. (2010). What can be done about school shootings?:
A review of the evidence. Educational Researcher, 39,
27–37. doi:10.3102/0013189X09357620.
Bowlby, J. (1969). Attachment and loss: Vol. 1.
Attachment. London: The Hogarth Press and The
Institute of Psycho-Analysis.
Bowlby, J. (1988). A secure base: Clinical applications of
attachment theory. London: Routledge.
Boxer, P., Huesmann, L. R., Bushman, B. J., O’Brien, M.,
& Moceri, D. (2009). The role of violent media
preference in cumulative developmental risk for violence and general aggression. Journal of Youth and
Adolescence, 38, 417–428.
Braga, A. A. (2008). Pulling levers focused deterrence
strategies and the prevention of gun homicide. Journal
of Criminal Justice, 36, 332–343. doi:10.1016/j.
jcrimjus.2008.06.009.
Braga, A. A., Kennedy, D. M., Waring, E. J., &
Piehl, A. M. (2001). Problem-oriented policing, deterrence, and youth violence: An evaluation of Boston’s
operation ceasefire. Journal of Research in Crime
and Delinquency, 38(3), 195–225. doi:10.1177/
0022427801038003001.
Briggs-Gowan, M. J., et al. (2010). Exposure to potentially
traumatic events in early childhood: Differential links
to emergent psychopathology. Journal of Child
Psychology and Psychiatry, 51(10), 1132–1140.
Centers for Disease Control and Prevention. (2010).
Youth risk behavioral surveillance–United States,
2009. Morbidity and Mortality Weekly Report, 59
(SS-5). Retrieved August 11, 2011, from http://www.
cdc.gov/mmwr/pdf/ss/ss5905.pdf
Centers for Disease Control and Prevention. (n.d.). Youth
violence: Definitions. Retrieved August 11, 2011, from
http://www.cdc.gov/violenceprevention/youthviolence/
definitions.html
Cicchetti, D., & Toth, S. L. (1995). A developmental
psychopathology perspective on child abuse and
neglect. Journal of the American Academy of Child
and Adolescent Psychiatry, 34, 541–565.
Cooke, M. B., et al. (2007). The effects of city-wide
implementation of “SECOND STEP” on elementary
school students’ prosocial and aggressive behaviors.
The Journal of Primary Prevention, 28(2), 93–115.
Cornell, D., & Allen, K. (2011). Development, evaluation,
and future directions of the Virginia Student Threat
Assessment guidelines. Journal of School Violence,
10(1), 88–106. doi:10.1080/15388220.2010.519432.
Corsaro, N., & McGarrell, E. F. (2009). Testing
a promising homicide reduction strategy: Reassessing
the impact of the Indianapolis “pulling levers”

973
intervention. Journal of Experimental Criminology,
5(1), 63–82. doi:10.1007/s11292-008-9065-1.
Dishion, J. T., Nelson, E. S., & Yasui, M. (2005).
Predicting early adolescent gang involvement from
middle school adaptation. Journal of Clinical Child
and Adolescent Psychology, 34(1), 62–73.
Eliot, M., Cornell, D., Gregory, A., & Fan, X. (2010).
Supportive school climate and student willingness to
seek help for bullying and threats of violence. Journal
of School Psychology, 48, 533–553.
Esbensen, F., Winfree, L. T., He, N., & Taylor, T. J.
(2001). Youth gangs and definitional issues: When is
gang a gang, and why does it matter? Crime and
Delinquency, 47(1), 105–130.
Esbensen, F.-A., et al. (2011). Evaluation and evolution
of the gang resistance education and training
(G.R.E.A.T.) program. Journal of School Violence,
10(1), 53–70. doi:10.1080/15388220.2010.519374.
Farrington, D. P. (2005). The Integrated Cognitive Antisocial Potential (ICAP) theory. In D. P. Farrington
(Ed.), Integrated developmental and life-course
theories of offending (pp. 73–92). New Brunswick,
NJ: Transaction.
Frey, K. S., Nolen, S. B., Edstrom, L. V., & Hirschstein,
M. K. (2005). Effects of a school based socialemotional competence program: Linking children’s
goals, attributions, and behavior. Journal of Applied
Developmental Psychology, 26, 171–200.
Gover, A. R., Kaukinen, C., & Fox, K. A. (2008). The
relationship between violence in the family of origin
and dating violence among college students. Journal
of Interpersonal Violence, 23(12), 1667–1693.
Grossman, D. C., et al. (1997). Effectiveness of a violence
prevention curriculum among children in elementary
school: A randomized controlled trial. Journal of the
American Medical Association, 277, 1605–1611.
Holsen, I., Smith, B. H., & Frey, K. S. (2008). Outcomes of
the social competence program Second Step in Norwegian elementary schools. School Psychology International, 29(1), 71–88. doi:10.1177/0143034307088504.
Hoy, W. K., Smith, P. A., & Sweetland, S. R. (2002). The
development of the organizational climate index for
high schools: Its measure and relationship to faculty
trust. The High School Journal, 86, 38–49.
Kia-Keating, B. (2006). The relationship between
individual, family, peer, and community factors and
development of violent behavior in children and
adolescents. Unpublished dissertation, Harvard
University, Harvard, MA.
Limber, S. P. (2011). Development, evaluation, and future
directions of the Olweus Bullying Prevention
Program. Journal of School Violence, 10(1), 71–87.
doi:10.1080/15388220.2010.519375.
McMahon, S. D., Washburn, J., Felix, E. D., Yakin, J., &
Childrey, G. (2000). Violence prevention: Program
effects on urban preschool and kindergarten children.
Applied and Preventive Psychology, 9, 271–281.
Merrell, K. W., Gueldner, B. A., Ross, S. W., &
Isava, D. M. (2008). How effective are school bullying

974
intervention programs? A meta-analysis of intervention research. School Psychology Quarterly, 23,
26–42.
Merz-Perez, L., & Heide, K. M. (2003). Animal cruelty:
Pathway to violence against people. Lanham, MD:
Rowman & Littlefield.
Moffitt, T. E. (1993). Adolescence-limited and life-coursepersistent antisocial behavior: A developmental
taxonomy. Psychological Review, 100, 674–701.
Muschert, G. (2009). Frame-changing in the media
coverage of a school shooting: The rise of Columbine
as a national concern. The Social Science Journal,
46(1), 164–170.
National Summit on Zero Tolerance. (2000). Opportunities
suspended: Devastating consequences of zero tolerance
and school disciplinary policies. Washington, DC:
The Civil Rights Project.
Rhee, S. H., & Waldman, I. D. (2002). Genetic and
environmental influences on antisocial behavior:
A meta-analysis of twin and adoption studies.
Psychological Bulletin, 29, 490–529.
Robers, S., Zhang, J., & Truman, J. (2010). Indicators of
school crime and safety: 2010 (NCES 2011 002/NCJ
230812). Washington, DC: National Center for
Education Statistics, U.S. Department of Education,
and Bureau of Justice Statistics, Office of Justice
Programs, U.S. Department of Justice.
Rutter, M., Giller, H., & Hagell, A. (1998). Antisocial
behavior by young people. Cambridge, UK:
Cambridge University Press.
Schaeffer, C. M., & Borduin, C. M. (2005). Long-term
follow-up to a randomized clinical trial of
multisystemic therapy with serious and violent juvenile offenders. Journal of Consulting and Clinical
Psychology, 73(3), 445–453. doi:10.1037/0022006X.73.3.445.
Schechter, D. S. (2006, October). Maternal PTSD and
availably of mutual emotion regulation with toddlers.

Violence by Children in Schools and the Community
Paper presented at 53rd annual meeting of the
American Academy of Child and Adolescent
Psychiatry, Washington, DC.
Schechter, D. S., & Willheim, E. (2009). The effects
of violent experiences of infants and young children.
In C. H. Zeanah Jr. (Ed.), Handbook of infant
mental health (pp. 197–213). New York: The Guilford
Press.
Shahinfar, A., Fox, N. A., & Leavitt, L. A. (2000).
Preschool children’s exposure to violence: Relation
of behavior problems to parent and child reports.
American Journal of Orthopsychiatry, 70(1), 115–125.
Skiba, R. J. (2000). Zero tolerance, zero evidence: An
analysis of school disciplinary practice. Bloomington,
IN: Indiana Policy Education Center.
Smith, M. (2011, March 3). Legislature spotlights bullying
in schools. The New York Times. Retrieved August
11, 2011, from http://www.nytimes.com/2011/03/04/
us/04ttbullying.html
Stein, B. D., Jaycox, L. H., Kataoka, S., Rhodes, H. J., &
Vestal, K. D. (2003). Prevalence of child and
adolescent exposure to community violence. Clinical
Child and Family Psychology Review, 6(4), 247–264.
Struyk, R. (2006). Gangs in our schools: Identifying gang
indicators in our school population. The Clearing
House, 80(1), 11–13.
Van der Laan, A. M., Blom, M., & Kleemans, E. R.
(2009). Exploring long-term and short term risk factors
for serious delinquency. European Journal of
Criminology, 6, 1477–3708.
Welsh, W., Stokes, R., & Greene, J. (2000). A macro-level
model of school disorder. Journal of Research in
Crime and Delinquency, 37, 243–283.
Wolak, J., Mitchell, K. J., & Finkelhor, D. (2007).
Does online harassment constitute bullying? An exploration of online harassment by known peers and online
only contacts. Journal of Adolescent Health, 41,
851–858.

Violence Prevention During Early Childhood

Violence Prevention During Early
Childhood
Jannette Rey Todaro
Providence Behavioral Health Associates,
Providence, RI, USA

975

prevention, whether applied during pregnancy
to address maternal-fetal pathways or in the preschool period of early childhood, continues to
outweigh the cost in terms of improved mental
health and productivity across the lifespan
(SAMHSA, 2007). This entry is designed to provide a review of youth violence during this
unique period of development as well as to summarize key research and intervention outcomes.

Introduction
Youth violence, childhood psychopathology, and
its behavioral sequelae in the early childhood
period (up to age 5) have been well documented
in the last decade (Angold & Egger, 2007;
Wakschlag, Tolan, & Leventhal, 2010). Early
antisocial behavior and, indeed, a behavior disorder diagnosis early in life (i.e., prior to age 10)
have been found to increase the risk of violence
later in adulthood (Loeber et al., 2005).
Relatedly, the explosion of research in the field
of epigenetics, neurodevelopmental processes,
and maternal-fetal pathways has provided a rich
evidence base in this third millennium for consideration of the strength of epigenetic factors in
affecting gene transcription and, subsequently,
predicting behavioral outcomes (Liu, 2010;
National Alliance for Research Progress, 2008).
Psychosocial interventions in the last decade
have been characterized by a steady effort toward
emphasizing adoption and implementation of primary prevention and early intervention programs
to address youth violence (Tremblay, 2006). In
the field of youth violence, it is well accepted that
preventive interventions are best when they
account for the transactional nature of childspecific characteristics and the context within
which the child develops (Brotman et al., 2008)
and are developmentally based (Cicchetti &
Toth, 2009). Clinical research in youth violence
now not only involves assessing the efficacy and
effectiveness of preventive interventions for
treating early childhood psychopathology but
also for subclinical populations where health
risk factors (biological and psychosocial environments combined) are at play. What remains clear
in clinical research outcomes over the past
decade is that the benefit of youth violence

Definitions and Scope
The study of the development of and reliance on
violent behavior in childhood has led to a wealth
of scholarly research regarding precursors, mediators and moderators, as well as developmental
trajectories across various subpopulations. Youth
violence as a discrete behavioral target, however,
is not easily linked to current clinical research
literature and, therefore, can affect accurate
extrapolations from study findings. Indeed,
experts in the fields of human development,
childhood conduct/externalizing behaviors and
disorders, youth violence intervention and
prevention, juvenile justice, and externalizing
behaviors point to the persistent struggle when
characterizing youth violence different from
normative misbehaviors of childhood (Kumpfer
& Alvarado, 2003; Loeber et al., 2005;
Wakschlag et al., 2010). Given the multifaceted
(e.g., severity, course) and developmentally
linked nature of the construct of youth violence
as well as the inherent variations, the term “youth
violence” will be utilized in this entry to refer to
those relevant externalizing behaviors most commonly identified in explanatory and intervention
models for the early childhood period: physical
aggression and conduct problem behaviors
(e.g., bullying, antisocial behavior) (Tremblay,
2006) rather than temperamental variables
(e.g., irritability, hostility, negativistic attitude)
associated with defiance or oppositionality
(Rowe, Costello, Angold, Copeland, & Maughan,
2010).
The scope of impact of youth violence extends
globally and can yield a significant burden across
all levels of global functioning in terms of

T.P. Gullotta, M. Bloom (eds.), Encyclopedia of Primary Prevention and Health Promotion,
DOI 10.1007/978-1-4614-5999-6, # Springer Science+Business Media New York 2014

976

financial, psychological, and societal functioning
(Weaver, Borkowski, & Whitman, 2008). Homicide, for example, continues to be one of the
leading causes of death in youth ages 15–24
years and remarkably accounts for 41 % of the
global incidence of homicide for youth aged
10–29 years (Centers for Disease Control
[CDC], 2012; Krug, Dahlberg, & Mercy, 2002).
Global nonfatal violence also continues to be
high, with exposure rates to bullying or physical
aggression ranging from 5 % to 35 % for girls
and 8–45 % for boys (CDC, 2009; Krug et al.).
The prevalence of externalizing behaviors in
youth where intensity and frequency meet thresholds for a behavior disorder continues to be relatively large, with study estimates ranging from
2 % to 16 % of youth (SAMHSA, 2007). Notably, prevalence of conduct problems in early
childhood has been found to be similar across
diverse global populations (Rescorla et al.,
2011). The alarming pattern of aggression
amongst youth has catapulted the issue of
violence, particularly bullying, to the forefront
of school and community agendas across the
United States and other countries worldwide
(Olweus, 2004).

Theories
Current theories of youth violence have largely
examined biopsychosocial and ecological processes and point to the need for considering
transactional-developmental contexts. For example, studies designed to test theories of developmental trajectories continue to provide support
for a pathway model of violence whereby factors
early in a child’s life (e.g., childhood conduct
problems, neurocognitive problems, parental
conflict, low self-esteem) predict delinquency
later in life (Fergusson, Horwood, & Ridder,
2005). More recently, neurodevelopment, epigenetics, and phenotype expression have greatly
contributed to expanding the depth and breadth
of explanatory models of violence.
Robust risk factors and correlates continue to
be identified in the research on the development
of early childhood violence. Approximately

Violence Prevention During Early Childhood

one-half of all children entering kindergarten
have been found to be exposed to at least one
risk factor. In terms of early health risk factors
present during the prenatal stage, for example,
research has identified key factors such as
smoking during pregnancy, lead exposure, child
abuse, and maternal stress as potent factors in
predicting later aggressive behavior (Liu, 2010).
The recent decade of studies in youth violence
continue to highlight the role of previously
identified child-based risk factors such as
hyperactivity and history of aggressive behavior
(Rowe et al., 2010). During the toddler and
preschool period, variables such as young childhood age of onset of violence or antisocial
cognitive patterns also have been found to be
strong predictors of later youth violence
(Farrington, 2005). In fact, research regarding
the longitudinal stability of conduct problems
has also highlighted that conduct problems first
identified in the preschool years are as strong
a predictor for later deviance as conduct problems beginning in the elementary school-age
years (Bilancia & Rescorla, 2010). Risk factors
related to family and peers include such variables
as low parental involvement, low family income,
and parental substance abuse or criminality (Wilson, 2004). Finally, communities lacking adequate social cohesion or stability as well as high
rates of conflict and/or violent crime increase the
probability of youth violence and the development of conduct problems (Commission on Children at Risk, 2003).

Current Research
The research literature on physical aggression in
childhood has produced a large knowledge base
about effective preventive strategies for
addressing youth violence. In the last decade,
programs at the local, regional, and federal level
(e.g., National Academic Centers of Excellence
on Youth Violence, NIMH Prevention Research
Program) have produced substantial evidence
pointing to several stable trajectory patterns
(SAMHSA, 2011). Data for birth cohorts studied
longitudinally suggest a common onset of

Violence Prevention During Early Childhood

aggression during the midpoint of toddlerhood
(Rowe et al., 2010). By the age of 6, for example,
behavioral rehearsal in social interactions typically has been found to be characterized by the
young child’s use of physical contact as a way to
initiate or terminate interaction. For those children who continue to demonstrate defiance into
early childhood, researchers have found that the
probability for later emotional maladjustment
was more likely than serious conduct problems.
However, early onset of serious conduct behavior
problems is more likely to result in serious delinquency later in life (Campbell, Spieker,
Burchinal, Poe, & The NICHD Early Child Care
Research Network, 2006; Webster-Stratton &
Reid, 2010). In terms of sex differences, recent
studies indicate this pattern is especially true for
boys (Rowe et al., 2010). Epigenetics research
has underscored the contribution protective factors have on the maternal-fetal pathway. Specifically, adverse neurodevelopment of the fetus
compromises the child’s resilience while also
increasing vulnerability to risk factors (Liu,
2010). Interventions that target risk factors such
as aggression in early childhood, then, continue
to be most useful in achieving outcomes that
impact later behavioral patterns in adolescence
and beyond (Greenberg, Domitrovich, &
Bumbarger, 2000; Loeber et al., 2005).
Theories of human ecology (Bronfenbrenner,
1992) and attachment (Bowlby, 1969) are common theoretical underpinnings for preventive
intervention models. More recently, the contribution of individual factors and process (e.g., executive functioning, self-efficacy) has become
integral in many program frameworks and the
resulting focus on building resiliency in the
child as well as enhancing the child’s context
for development.

Strategies
The goal of altering the presence or impact of risk
factors in early childhood has been one of the
driving goals in violence prevention clinical
research, particularly due to their cumulative
negative influence
on individual
and

977

community-wide health both short and long
term. Since the 1990s when studies on youth
violence prevention began to flourish, the knowledge base has broadened and deepened to go
beyond addressing the impact of risk factors
alone. Rather, empirical support has been most
robust where programs have been culturally
appropriate, implemented with adequate fidelity,
and targeted the enhancement of protective factors as well (Webster-Stratton & Reid, 2010). As
such, a critical trend in this past decade has been
toward early childhood intervention programs
that focus on both the individual child and additional multiple ecological systems (e.g., family,
early
childhood learning environments)
(Forehand et al., 2011). These comprehensive
preventive interventions have been found to
impact individual short-term and long-term adaptive outcomes as well as producing multisystem
advantages (e.g., economic costs to society,
enhanced quality of life at the community level).
The public health approach evident in current
strategies in violence prevention interventions
relies on a process whereby data is used to identify problem targets and relevant risk and protective factors. Then, via monitoring and evaluation,
dissemination involves providing education for
widespread adoption of the components found
to promote health and prevent illness. In this
context, all members of a target community are
affected by the well-being of the individuals
within that community. Since 2000, following
recommendations by the Institute of Medicine,
the prevention model was expanded to include
not only those interventions that occur after the
onset of a disorder (primary, secondary, tertiary
prevention) but also those that target prevention
of the onset (universal, selective, indicated
prevention) based on the degree of risk of onset
(Institute of Medicine [IOM], 2000, 2009). Interventions describe herein will largely fit into one
of the latter classification categories. Therefore,
universal preventive interventions will include
programming that is applied to everyone within
the population, while selective preventive interventions are designed for individuals with risk of
developing the target mental health problem.
Finally, indicated preventive interventions are

978

targeted at individuals who demonstrate some
aspects of the mental health problem but fall
below diagnostically significant levels. The sections that follow outline notable programs within
these classifications and are grouped according to
outcomes based on effectiveness trials where
available. “What Works” refers to interventions
with at least three successful trials, whereas
“What Is Promising” will describe those interventions with fewer than three successful trials
or mixed trial results.

What Works
Enhancing prosocial skills of the individual child,
enriching the quality of the parent-child interaction, and improving the contextual aspects of the
child’s learning environment (caregiver behavior
management practices, generalization of skills)
reflect primary components across the group of
most effective violence prevention interventions
for young children (Reyno & McGrath, 2006).
A model prevention intervention during the
early childhood period is The Nurse-Family
Partnership (Olds, Hill, Mihalic, & O’Brien,
1998). The NFP, a selective intervention, is
a home visitation service delivered by nurses
that focuses on improving maternal prenatal
health and mother-child healthy bonding and
well-being through the first 2 years of the child’s
life for at-risk expectant mothers. The five target
mother-child outcome domains include physical
and mental health, home/neighborhood environment, family/friend support, parental roles, and
major life events (e.g., education, employment).
Follow-up studies of program participants found
that, when compared to a control group, the treatment group demonstrated significant reductions
in child abuse or neglect, maternal substance
abuse-related problems, maternal arrest rates,
and high-risk behaviors.
Similarly, violence prevention in the early
childhood preschool population has been consistently demonstrated in clinical research of The
Incredible Years Program (IYP; WebsterStratton & Reid, 2010) and in Parent-child
Interaction Therapy (Boggs et al., 2004). These

Violence Prevention During Early Childhood

interventions target enhancement of the ecology
of the caregiver-child relationship to prevent the
development of conduct problems in later youth
for young children at risk for violence. In the IYP
intervention, children between the ages of 2–10
years and their parents, teachers, and caregivers
participate in a multifaceted and developmentally
based curricula designed to prevent and reduce
the occurrence of aggressive and oppositional
behavior in children. Treatment outcome studies
point to robust outcomes whereby children in the
intervention group demonstrated more effective
problem-solving skills, greater use of prosocial
play skills, and reduced oppositional and conduct
problems both at home and school as compared to
control group counterparts (Webster-Stratton,
Reid, & Beauchaine, 2011). For young children
below the age of 8 with externalizing behavior
disorders, PCIT also helps parents build specific
skills to establish or strengthen a nurturing and
secure relationship with their child while encouraging prosocial behavior and discouraging negative behavior (Borden, Schultz, Herman, &
Brooks, 2010). Significant treatment effects
have been found for treatment families as well
as for those families with a history of physical
abuse, children with prenatal substance exposure,
and children with developmental disabilities.
Recent promising data for an abbreviated version
of PCIT (i.e., four-session version for primary
care PC-PCIT) highlights the utility of preventive
interventions for preschool-aged children with
subclinical behavior problems (Berkovits,
O’Brien, Carter, & Eyberg, 2010). The Perry
Preschool Program (Schweinhart et al., 2005)
incorporates both a home visit modality of treatment delivery as well as targeting individual and
context variables. Designed in particular for
young children living in poverty, the intervention
also aims to enhance the child’s active engagement and confidence in their cognitive and
readiness skills for social and school success.
When compared to control groups, longitudinal
studies of children from the intervention
groups indicate lower rates of criminality and
reliance on social welfare as well as higher rates
of home ownership and greater employment
earning.

Violence Prevention During Early Childhood

For young children beginning their school career
(4–5 years of age), the preschool version of Promoting Alternative Thinking Strategies (Preschool
PATHS) (Greenberg et al., 2000) is a groupwide
social-emotional learning curriculum with direct
instruction for key areas related to positive mental
health outcomes (i.e., self-control, emotional
awareness, peer relations, and problem solving).
In studies examining program effectiveness, significant positive effects on behavior and the general
mood of the classroom was demonstrated (Conduct
Problems Prevention Research Group, 1999).

What Is Promising
While enhancing social adjustment and promoting prosocial development during early childhood have been fruitful targets of interest for
violence prevention programming, achieving
long-lasting positive individual and systemic
change has been elusive for numerous evidencebased interventions. To this point, researchers in
the areas of implementation science have
described the marked reduction in treatment
effects accounted for by factors solely related to
inadequate planning for fidelity and sustainability
(Fixsen et al., 2005). The evidence-based programs listed here, while falling short of criteria
utilized for this encyclopedia for effectiveness,
are promising in their effects on both proximal
and distal risk factors for violence.
The school-based intervention “I Can Problem
Solve” (ICPS; Shure, 1997) teaches young children how to effectively generate, evaluate, and
utilize solutions to interpersonal problems, as
well as factors that help prevent conflict.
In small group formats, the interventionists
teach problem-solving techniques, utilizing
visual graphics, puppets, and behavioral
rehearsal incorporating personal examples. Children also build skills in identifying emotions,
empathy building, and adapting responses to
increase the likelihood of positive outcomes.
Treatment outcome studies have revealed significant benefits for children who participated in
ICPS as compared to control students. While the
studies with robust findings are limited, a large

979

study of inner city children in the program
revealed improved problem-solving skills,
greater frequency of prosocial behaviors, and
less impulsiveness. These results were
maintained at follow-up 3 and 4 years post
intervention.
A promising violence prevention program
targeting family risk factors for child maltreatment as well as child risk factors for violence
(behavioral and emotional problems) is the
community-wide version of Triple P (Positive
Parenting Program) (Prinz, Sanders, Shapiro,
Whitaker, & Lutzker, 2009). This comprehensive, five-level system specifically targets
parental competence and modification of
dysfunctional parenting practices. Communitybased organizations working with the family
serve as the program deliverers, moving through
five intervention levels beginning with level 1
(informational dissemination to facilitate and
destigmatize help seeking) to level 5 (additional
practice sessions with individual families toward
improving child targets and parental communication). Compared to control communities,
treatment outcome studies suggest significant
reductions in substantiated child maltreatment,
child out-of-home placements, and urgent
medical care for child maltreatment injuries
(Prinz et al., 2009).
Other promising programs in early childhood
violence prevention follow the “early starter”
model, intervening with at-risk children who
demonstrate early conduct problems. First Steps
to Success (Walker et al., 1998) in an early intervention program involves both school-based
intervention component and parent training.
Children are taught replacement skills and
receive immediate feedback through the school
day via visual real-time cues if meeting behavioral goals for the situation. A follow-up homebased positive reinforcement system is added to
promote generalization of the skills across
settings. Results of a treatment outcome study
conducted with early elementary-aged children
suggest significant improvements for those
cohorts who received full implementation as
compared to controls (Greenberg et al., 2000).
A promising empirically validated violence

980

prevention intervention that can be applied at the
whole school level as well as with selective
populations is Positive Behavioral Intervention
and Supports (PBiS; Horner et al., 2009). The
universally applied model of PBiS is characterized by implementation of a whole school,
function-based behavior support system whereby
all school personnel are the interventionists and
key targets are selected based on conduct problems within the given student population.
Randomized controlled trials have been
conducted in the recent years yielding positive
and socially meaningful outcomes related to
efficacy; however, further study, replication,
and evaluation of implementation variables are
necessary to confirm its effectiveness and
long-term sustainability.

What Does Not Work
In the past decade, it has become more evident
that the veracity of conclusions regarding treatment outcome results for violence prevention
programs must be interpreted through the lens
of the degree and fidelity of program adoption
and implementation. Thus, much research in violence prevention interventions that have utilized
rigorous study designs but have failed to plan to
an adequate extent for fidelity and broad adoption
and implementation over time has led to long lists
of what began as promising models but ended as
not empirically supported. Character education
programs that target the development of core
values linked to corresponding cognitive and
behavioral patterns is one such intervention
group whose research has yielded mixed results
(Sanchez, 2005) or too few studies evaluating
their effectiveness for youth in early childhood.
Similarly, despite a model program for bullying
prevention at the elementary and secondary
levels for students, community entities such as
school teams commonly deconstruct these interventions and opt for only a portion of the
intervention (e.g., signing a anti-bullying statement) and erroneously consider their systems
enhanced (Ryan & Smith, 2009). Similarly, full
implementation of interventions that are not

Violence Prevention During Early Childhood

evidence-based or based on poor research design
unfortunately become disseminated and lead to
unintended or, worse yet, negative results.
A review conducted by Ryan and Smith of
violence prevention studies for older youth points
to the all too common problematic designs and
evaluation practices that comprise this area of
research, with over one-third of the evaluations
examined falling short of fully utilizing an RCT
design, evaluating the impact on bullying before
adequate spacing from the point of initial full
launch, and relying on a single information for
the key outcome measure despite empirical evidence regarding its potential for biased data.
Finally, violence prevention programs that rely
solely on any one aspect of intervention implementation (e.g., training, system reorganization,
dissemination of information) continue to yield
poor or inconclusive results with estimates of
5–20 % of the interventions achieving their
intended results (Fixsen et al., 2005).

Summary
Advancing the adoption and quality implementation of violence prevention programming for
young children requires multiple system involvement, if just for improving the nature of
long-term sustainability and fidelity of implementation by the interventionists. Such systems
restructuring is possible and probable when
stakeholders, and particularly the program
practitioners, collaborate with program developers and implementation support persons
around the key targets and goals of interest.
Further, outcomes of the collaboration should
inform specific planning around efficient implementation (e.g., build on existing programming)
as well as systematic information dissemination
despite changing personnel.
Incidents of school-based violence have
persisted at problematic levels into this millennium. As such, efforts have grown exponentially
toward pushing the limits of ethical boundaries
for earlier detection (e.g., prenatal) and identification of violence-prone “markers” in early
stages of development. This wave of

Violence Prevention During Early Childhood

methodology relatively new to the field of violence prevention includes standardizing the
inclusion of biological data collection as a study
variable for pinpointing mediators and moderators of violence both in nonclinical and clinical
populations. The ethical challenges therein points
to the need more than ever for ongoing rigorous
RCTs that must incorporate greater planning for
and evaluation of implementation integrity as
a rule so as to accurately inform predictive
models. Burgeoning data sets from the world of
neuroscience research underscores the need for
the science and practice of prevention to continue
to move boldly in all directions that support
multilevel, multisystem, and sustainability planning collaboration and results. The need for fervent activity in the area of early childhood
violence prevention and, more broadly, promotion of positive mental health outcomes for all
youth via legislative, programmatic, and research
progress is vital.

References
Angold, A., & Egger, H. (2007). Preschool psychopathology: Lessons for the lifespan. Journal of Child Psychology and Psychiatry, 48(10), 961–966.
Berkovits, M. D., O’Brien, K. A., Carter, C. G., & Eyberg,
S. M. (2010). Early identification and intervention for
behavior problems in primary care: A comparison of
two abbreviated versions of parent-child interaction
therapy. Behavior Therapy, 41(3), 375–387.
Bilancia, S. D., & Rescorla, L. (2010). Stability of behavioral and emotional problems over 6 years in children
ages 4 to 5 or 6 to 7 at time 1. Journal of Emotional and
Behavioral Disorders, 18, 149–161.
Boggs, S. R., Eyberg, S. M., Edwards, D. L., Rayfield, A.,
Jacobs, J., Bagner, D., et al. (2004). Outcomes of Parentchild Interaction Therapy: A comparison of treatment
completers and study dropouts one to three years later.
Child and Family Behavior Therapy, 26(4), 1–22.
Borden, L. A., Schultz, T. R., Herman, K. C., & Brooks,
C. M. (2010). The Incredible Years parent training
program: Promoting resilience through evidencebased prevention groups. Group Dynamics: Theory,
Research, and Practice, 14(3), 230–241.
Bowlby, J. (1969). Attachment and loss: Vol. i: Attachment. London: The Hogarth Press and the Institute of
Psycho-Analysis.
Bronfenbrenner, U. (1992). Ecological systems theory.
In R. Vasta (Ed.), Six theories of child development
(pp. 187–250). Philadelphia: Jessica Kingsley.

981
Brotman, L. M., Gouley, K. K., Huang, K., Rosenfelt, A.,
O’Neal, C., & Klein, R. G. (2008). Preventive intervention for preschoolers at high risk for antisocial
behavior: Long-term effects on child physical aggression and parenting practices. Journal of Clinical Child
& Adolescent Psychology, 37(2), 386–396.
Campbell, S. B., Spieker, S., Burchinal, M., Poe, M. D., &
The NICHD Early Child Care Research Network.
(2006). Trajectories of aggression from toddlerhood
to age 9 predict academic and social functioning
through age 12. Journal of Child Psychology and
Psychiatry, 47(8), 791–800.
Centers for Disease Control and Prevention.(2012).
Web-based Injury Statistics Query and Reporting
System (WISQARS). Atlanta, GA: National Center for
Injury Prevention and Control. Retrieved March 15, 2012,
from http://www.cdc.gov/injury/wisqars/index.html
Cicchetti, D., & Toth, S. L. (2009). The past achievements
and future promises of developmental psychopathology: The coming of age of a discipline. Journal of
Child Psychology and Psychiatry, 50, 16–25.
Commission on Children at Risk. (2003). Hardwired to
connect: The new scientific case for authoritative communities. New York: Institute for American Values.
Conduct Problems Prevention Research Group. (1999).
Initial impact of the fast track prevention trial for
conduct problems: II. Classroom effects. Journal of
Consulting and Clinical Psychology, 67, 648–657.
Farrington, D. P. (2005). Childhood origins of antisocial
behavior. Clinical Psychology & Psychotherapy,
12(3), 177–190.
Fergusson, D. M., Horwood, L. J., & Ridder, E. M. (2005).
Show me the child at seven: The consequences of
conduct problems in childhood for psychosocial functioning in adulthood. Journal of Child Psychology and
Psychiatry, 46(8), 837–849.
Fixsen, D. L., Naoom, S. F., Blase, K. A., Friedman, R. M.,
Wallace, F., & Wallace, F. (2005). Implementation
research: A synthesis of the literature. Tampa, FL:
University of South Florida, Louis de la Parte Florida
Mental Health Institute, The National Implementation
Research Network (FMHI Publication #231).
Forehand, R. L., Merchant, M. J., Parent, J., Long, N., Linnea,
K., & Baer, J. (2011). An examination of a group
curriculum for parents of young children with disruptive
behavior. Behavior Modification, 35(3), 235–251.
Greenberg, M. T., Domitrovich, C., & Bumbarger, B.
(2000). Preventing mental disorders in school-age
children: A review of the effectiveness of prevention
programs. State College, PA: Prevention Research
Center for the Promotion of Human Development College of Health and Human Development, Pennsylvania
State University.
Horner, R. H., Sugai, G., Smolkowski, K., Eber, L.,
Nakasato, J., Todd, A. W., et al. (2009). A randomized,
wait-list controlled effectiveness trial assessing
school-wide positive behavior support in elementary
schools. Journal of Positive Behavior Interventions,
11(3), 133–144.

982
Institute of Medicine. (2000). Neurons to neighborhoods:
The science of early childhood development. Washington, DC: National Academy Press.
Institute of Medicine. (2009). Preventing mental, emotional, and behavioral disorders among young people.
Washington, DC: National Academy Press.
Krug, E. G., Dahlberg, L. L., & Mercy, J. A. (2002). World
report on violence and health. Geneva, Switzerland:
World Health Organization.
Kumpfer, K. L., & Alvarado, R. (2003). Family-strengthening approaches for the prevention of youth problem
behaviors. American Psychologist, 58, 457–465.
Liu, J. (2010). Early health risk factors for violence: Conceptualization, evidence, and implications. Aggression
and Violent Behavior, 16(1), 63–73.
Loeber, R., Pardini, D., Homish, D. L., Wei, E. H.,
Farrington, D. P., Creemers, J., et al. (2005). The
prediction of violence and homicide in young men.
Journal of Consulting and Clinical Psychology,
73(6), 1074–1088.
National Alliance for Research Progress. Meeting Held on
July 21, 2008 in Bethesda, MD. (2008). Washington,
DC: National Institute of Mental Health.
Olds, D., Hill, P., Mihalic, S., & O’Brien, R. (1998). Blueprints for violence prevention, book seven: Prenatal and
infancy home visitation by nurses. Boulder, CO: Center
for the Study and Prevention of Violence, Institute of
Behavioral Science, University of Colorado, USA.
Olweus, D. (2004). The Olweus Bullying Prevention
Programme: Design and implementation issues and
a new national initiative in Norway. In P. K. Smith,
D. Pepler, & K. Rigby (Eds.), Bullying in schools: How
successful can interventions be? (pp. 13–36). Cambridge, UK: Cambridge University Press.
Prinz, R. J., Sanders, M. R., Shapiro, C. J., Whitaker, D. J.,
& Lutzker, J. R. (2009). Population-based prevention
of child maltreatment: The U.S. Triple P system population trial. Prevention Science, 10, 1–12.
Rescorla, L. A., Achenbach, T. M., Ivanova, M. Y.,
Harder, V. S., Otten, L., Bilenberg, N., et al. (2011).
International comparisons of behavioral and emotional
problems in preschool children: Parents’ reports from
24 societies. Journal of Clinical Child & Adolescent
Psychology, 40(3), 456–467.
Reyno, S. M., & McGrath, P. J. (2006). Predictors of
parent training efficacy for child externalizing behavior problems – A meta-analytic review. Journal of
Child Psychology and Psychiatry, and Allied Disciplines, 47(1), 99–111.
Rowe, R., Costello, E. J., Angold, A., Copeland, W. E., &
Maughan, B. (2010). Developmental pathways in
oppositional defiant disorder and conduct disorder.
Journal of Abnormal Psychology, 119(4), 726–738.
Ryan, W., & Smith, J. D. (2009). Antibullying programs in
schools: How effective are evaluation practices?
Prevention Science, 10(3), 248–259.

Violence Prevention During Early Childhood
Sanchez, T. R. (2005). Facing the challenge of character
education. International Journal of Social Education,
19(2), 106–111.
Schweinhart, L. J., Montie, J., Xiang, Z., Barnett, W. S.,
Belfield, C. R., & Nores, M. (2005). Lifetime effects:
The high/scope perry preschool study through age 40.
Ypsilanti, MI: The High/Scope Press.
Shure, M. B. (1997). Interpersonal cognitive
problem solving: Primary prevention of early high-risk
behaviors in the preschool and primary years. In
G. Albee & T. P. Gullotta (Eds.), Primary prevention
works (pp. 167–188). Thousand Oaks, CA: Sage.
Substance Abuse and Mental Health Services Administration, Center for Mental Health Services. (2007).
Promotion and prevention in mental health: Strengthening parenting and enhancing child resilience
(pp. 17–28). Rockville, MD: Substance Abuse and
Mental Health Services Administration.
Substance Abuse and Mental Health Services Administration, Center for Mental Health Services. (2011).
Results from the 2011 national survey on drug use
and health: Summary of national findings, section 6.
Rockville, MD: Substance Abuse and Mental Health
Services Administration.
Tremblay, R. E. (2006). Prevention of youth violence:
Why not start at the beginning? Journal of Abnormal
Child Psychology, 34, 481–487.
Wakschlag, L., Tolan, P., & Leventhal, B. (2010).
Research Review: ‘Ain’t misbehavin’: Towards a
developmentally-sensitive nosology for preschool disruptive behavior. Journal of Child Psychology and
Psychiatry, 51, 3–22.
Walker, H. M., Kavanagh, K. A., Stiller, B., Golly, A.,
Severson, H. H., & Feil, E. G. (1998). First step to
success: An early intervention approach for preventing
school antisocial behavior. Journal of Emotional and
Behavioral Disorders, 6, 66–80.
Weaver, C. M., Borkowski, J. G., & Whitman, T. L.
(2008). Violence breeds violence: Childhood exposure
and adolescent conduct problems. Journal of Community Psychology, 36(1), 96–112.
Webster-Stratton, C., & Reid, M. J. (2010). The incredible
years parents, teachers, and children training series:
A multifaceted treatment approach for young children
with conduct disorders. In J. R. Weisz & A. E. Kazdin
(Eds.),
Evidence-based
psychotherapies
for
children and adolescents (pp. 194–210). New York:
Guilford Press.
Webster-Stratton, C. H., Reid, M. J., & Beauchaine, T.
(2011). Combining parent and child training for young
children with ADHD. Journal of Clinical Child and
Adolescent Psychology, 40(2), 191–203.
Wilson, D. (2004). The interface of school climate and
school connectedness and relationships with aggression and victimization. Journal of School Health,
74(7), 293–299.