Key Points Made by Individual Speakers
- Most community-based programs are not evidence-based, and evidence about programs that do work tends not be effectively communicated to practitioners. (Goldweber)
- Effective community-based programs in areas other than bullying demonstrate the potential for bullying prevention programs to exert an influence on the lives of youth. (Goldweber)
- Pediatricians and other health care professionals who work with children can advocate for bullying awareness by teachers, educational administrators, parents, and children and make the case for new laws and policies that affect bullying. (Wright)
- Pediatricians can also make valuable contributions of data to existing surveillance systems and can participate in practice-based research networks that are studying bullying and other problem behaviors. (Wright)
Because youths function as members of communities, community-based interventions can be a particularly effective means of reducing bullying. Yet community settings can be extremely diverse. Two presenters looked at several examples of community-based interventions, including those grounded
in health care, as examples of the potential for such programs to change the norms that exist and to influence youths’ experience of their communities.
EFFECTIVE COMMUNITY-BASED PROGRAMS
Youth have a four times greater chance of being the victim of violent crime during after-school hours to when they are in school, and juvenile crime triples outside of the school setting and hours (Snyder and Sickmund, 2006). Because the after-school hours are so relatively dangerous, it is particularly important that interventions targeted at this period—i.e., community-based interventions—be effective and evidence-based, but most are not (Glasgow et al., 2003; Ringwalt et al., 2009; Saul et al., 2008; Woolf, 2008), observed Asha Goldweber, a behavioral health researcher in SRI International’s Center for Education and Human Services. And, she added, information about programs that do work tend to not be effectively communicated to practitioners (Kerner and Hall, 2009; Saul et al., 2008).
A notable exception to this observation is the work of Swearer et al. (2006) on the importance of neighborhood- or community-level collective efficacy, which Goldweber defined as a neighborhood’s connectedness and willingness to intervene with regard to youth problem behaviors (Odgers et al., 2009). Essentially, she said, this makes the entire community a bystander to bullying. An informal application of this principle, Goldweber said, is a program in Baltimore called Safe Passages, in which garbage collectors act as informal monitors as students make their way through neighborhoods. Another example is a program in California called Homeboy Industries, which was developed by a pastor for severely at-risk youth caught in a cycle of recidivism. The idea, captured in the slogan “Jobs, not jails,” is to provide young adults with skills and training so that they can break the cycle of crime and delinquency, she explained.
Goldweber described a number of community-based interventions that are being evaluated using criteria evaluation developed by Blueprints for Healthy Youth Development, which is one of several sets of criteria for the evaluation of interventions. According to these criteria, for a program to be deemed “promising” it must meet a minimum standard for the specificity, quality, impact, and readiness for dissemination of an intervention. “Model programs” must meet a set of higher standards, including having been validated by a minimum of two high-quality randomized controlled trials or one high-quality randomized controlled trial and one high-quality quasi-experimental evaluation. In addition, the impact of a model program must be sustained for a minimum of 1 year after the intervention ends, Goldweber said.
Because no community-based programs that focus specifically on bullying prevention are in the evaluation phase, Goldweber discussed three other
programs for which evaluations are available and which may be applicable to the development of bullying prevention programs: the Big Brothers and Big Sisters of America, the Communities That Care, and the Multidimensional Treatment Foster Care programs.
The Big Brothers and Big Sisters of America program matches adult volunteer mentors with at-risk children with the expectation that a caring and supportive relationship will develop, Goldweber explained. Multiple evaluations of the Big Brothers and Big Sisters of America program have been conducted at various locations and among a variety of demographic groups, she said, although most of these studies have been small and have lacked methodological rigor. The best study, Goldweber said, which still does meet quality standards, was conducted by Public/Private Ventures beginning in 1991 (Tierney et al., 1995). Outcomes that have been examined include a wide range of effects, including delaying initiation of substance use, academic performance, relationships with family and peers, self-concept, and social and cultural enrichment. The program has been shown to cut illicit drug initiation by 46 percent and to reduce alcohol initiation by 27 percent, although that decrease is only marginally significant. Also notable, youth reported that they were less likely to hit someone at the 1-year follow-up. There were significant reductions in truancy and cutting class and significant effects on risk and protective factors, including improvements in the quality of relationships with parents, marginally significant improvements for peer emotional support, and positive effects on schoolwork competency, Goldweber said.
Communities That Care (also described in Chapter 10) is a prevention system that gives communities the tools to address adolescent health and behavior problems through a focus on empirically identified risk and protective factors. It encompasses the five steps of getting started, getting organized, developing a community profile, creating a plan, and implementing and evaluating that plan, Goldweber said.
An evaluation of the program found reductions in self-reported violent behaviors at the 1-year follow-up (Hawkins et al., 2012), Goldweber reported. Compared with youth in the comparison group, youth under the Communities That Care program were 25 percent less likely to have initiated delinquent behavior and 32 and 33 percent less likely to have initiated alcohol and cigarette use, respectively.
Finally, the Multidimensional Treatment Foster Care program finds out-of-home placements for youth from the juvenile justice, foster care, and mental health systems, Goldweber said. According to Kerr et al. (2009), 12 months after baseline, boys in the program were incarcerated for 60 percent fewer days, had fewer subsequent arrests, and exhibited less drug use. At the same point, girls in the program had fewer days in locked settings,
fewer criminal referrals, lower caregiver-reported delinquency, and more time spent on homework, Goldweber said.
Goldweber also described community-based participatory research, which brings community members to the table shoulder-to-shoulder with interventionists and researchers. Among the many factors that affect this research, she said, are buy-in through relationship building, engaging gatekeepers, trust, communication, return on investment, capacity, sustainability, and cultural response.
An excellent example of such research, Goldweber said, is the PARTNERS youth violence prevention program (Leff et al., 2010). In this program, Leff and his colleagues meet community members in the community instead of in an academic setting, thereby reducing the perception of a power imbalance. They have informal meetings over a meal so that they can talk about what both parties’ perceptions are for the goals to be achieved, and they agree to remain at the table even when disagreements arise, Goldweber said.
Another example, she said, is the Holistic Life Foundation, which is a nonprofit organization based in Baltimore, Maryland, that provides mindfulness-based interventions in an after-school setting. It trains young adults in the community to become the interventionists. “The kids who are receiving the intervention are seeing someone who looks like them and that they may already know from their community,” she said. “This is changing the cultural or the community climate. It is also invoking that construct of neighborhood collective efficacy.”
Goldweber said that the most important step is to get all of the stakeholders together at the table. She also emphasized the importance of meeting people where they are. Instead of having meetings at a university, practitioners and researchers can have meetings in the community or provide bus fare and meals for meeting participants.
Community-based participatory research needs to meet certain standards of effectiveness, such as the Blueprint guidelines, Goldweber said, but such programs can also balance the demands for systematic implementation of community-based interventions with being responsive to the immediate needs of the community. In addition, issues of generalizability can arise across contexts, because programs developed in one country or region may not generalize to other countries or regions. Strict monitoring of the integrity of the intervention’s implementation is necessary to arrive at a scientifically successful and generalizable program, Goldweber said.
Measures of success can vary across communities. For example, Leff and his colleagues met with community stakeholders and either worked to
adapt existing measures or to develop new measures that would more accurately represent the community’s experience, Goldweber said. “Researchers can work with the community to develop new measures that still meet scientific standards but that are culturally responsive,” she said.
Finally, Goldweber briefly described her work in California on teacher credentialing initiatives and voluntary accreditation processes for community-based organizations that are intended to ensure understanding of student mental health issues. “It is not that the teachers become student mental health providers,” she said, “but that they are aware of the signs and then can appropriately refer students to the necessary stakeholders.” The idea of voluntary accreditation processes for community-based organizations might start a conversation about the importance of community-based research that is also evidence based, she suggested.
ROLES OF HEALTH CARE PROFESSIONALS
For health care professionals, the issue of bullying has largely been subsumed into the broader issue of violence, said Joseph Wright, a professor and vice chair in the Department of Pediatrics and a professor of emergency medicine and health policy at the George Washington University Schools of Medicine and Public Health. Injury due to violence is a substantial problem facing pediatricians, pediatricians feel they have an important role to play in prevention, and parents believe that pediatricians have a central role to play in prevention, according to surveys conducted by the American Academy of Pediatrics (AAP). This interest in violence prevention led the AAP in 2009 to issue a policy statement on the role of the pediatrician in youth violence prevention (Wright et al., 2009). According to Wright, this statement was focused largely on bullying as an emerging topic and one that pediatricians need to be prepared to address no matter in which setting they practice.
The question, Wright said, is, “What is a pediatrician to do?” In his answer, he focused on two kinds of approaches for pediatricians: awareness and advocacy at the community level, and anticipatory guidance at the level of clinical practice.
In the community, Wright said, pediatricians need to advocate for bullying awareness by teachers, educational administrators, parents, and children as well as for the role of health care professionals as appropriate public health messengers through print, electronic, or online media. Pediatricians see children and families repeatedly over time, so they have repeated opportunities to provide information and increase awareness. Furthermore, Wright said, pediatricians and others who see the effects of bullying behavior have many opportunities to make the case for new laws and policies.
The majority of states still do not require anti-bullying education as part of the professional development for educators, Wright said. However, the AAP policy statement recommends that pediatricians have a working familiarity with Connected Kids, which is the AAP’s primary care violence prevention protocol. Connected Kids includes provisions for screening, counseling, appropriate and timely treatment, and referral for violence-related problems, including bullying (AAP, 2014).
When parents take their children to a pediatrician, they should expect the children to receive anticipatory guidance from the doctor, Wright said. The kinds of questions a pediatrician might ask of a child are:
- Have you been in any pushing or shoving fights?
- What happens when you and your friends argue or disagree?
- What do you do for fun?
- What do you like best about school?
- If you see someone being bullied, what do you do?
Such questions are child centered and parent centered, are connected to the community in which a family lives, and have a primary focus on the physical safety of children, Wright said. The questions are designed to be open ended rather than leading to a close-ended response. The emphasis is not on risk, he explained, but rather on helping the children become strong, resilient, and healthy and socially oriented.
Research has demonstrated the value of anticipatory guidance, Wright said. For example, an analysis conducted at the Harborview Injury Prevention Center at the University of Washington with preschool children found that parental cognitive stimulation and emotional support, which are provided by reading with children or having meals together, are independently and significantly protective against bullying (Zimmerman et al., 2005). This study also found that each additional hour of daily television viewing is significantly associated with the development of subsequent bullying behavior. These results are “a promising outcome for the anticipatory guidance approach,” Wright said.
For middle childhood, brochures are available to both pediatricians and parents—as part of the Connected Kids curriculum—on independence, drug abuse, friends, anger, and bullying, Wright said. These brochures provide pediatricians with a way to address the issue of bullying in the most common health care setting that children will encounter, which is the office-based setting, he said.
Finally, Wright pointed out another valuable contribution that pediatricians can make to anti-bullying efforts: They can contribute data to existing surveillance systems. They can also participate in practice-based research networks that are studying bullying and other problem behaviors.
Wright also noted, in response to a question about opportunities presented by the Patient Protection and Affordable Care Act, that the health care profession, in the context of Medicaid expansion, is working on a uniform tool for behavioral health screening in the clinical setting. Such a tool could produce broader compliance with recommendations for early and periodic screening, diagnosis, and treatment, he said.
In response to another question, Wright observed that the universal definition of bullying enables the collection of information that could be kept in an electronic health record. More uniform reporting and responses to bullying could help school systems, health care practitioners, and other groups that interact with children, such as parks and recreation departments, speak the same language and be on the same page, he said.
THE FOCUS OF PREVENTION
One issue that arose during the discussion session was whether prevention should be issue-specific or general. The moderator of the session, Angela Diaz of the Icahn School of Medicine at Mount Sinai, said, “The way that we do prevention tends to be very distinct and issue specific—pregnancy prevention, sexually transmitted disease prevention, HIV prevention, bullying prevention, and the funding tends to be like that also, very separate and categorical.” We should consider the benefits of a more integrated prevention approach, Diaz said, because often the same youth may get involved in multiple of these behaviors or be at risk for multiple of these outcomes. In addition, having a more integrated prevention approach is likely to be more cost effective, she said.
Wright said that a universal approach to prevention has many positive aspects. For example, the project at the University of Washington, which encouraged parental cognitive stimulation and emotional support of children to deal with various potential issues, stressed primary prevention, not secondary prevention after an issue is present. Goldweber agreed that early and universal prevention approaches, such as focusing on kindness or compassion, are needed, along with funding that cuts across outcomes.
Wright agreed with a questioner that pediatricians have limited time with children and parents. But if anti-bullying interventions were incorporated as part of a longitudinal approach to prevention, he said, the time pressures would be less difficult. This approach needs to begin when children are young, he said, and then continue as they age.
Diaz also emphasized the “sacred space” of the clinic. “Young people are willing, if you ask them directly, to share their entire life with you, but it does not have to be the physician doing this questioning,” she said. “We have many different members of the team—the nurses, the health educators, the social workers, and others.…We will know the life of the kids,