Dating Violence Prevention in Middle School and

ORIGINAL
Sharron
Dating
Blackwell
Oxford,
Journal
JCAP
©
1073-6077
if ARTICLE
2004Violence
know M.Publishing,
of
by
2004
UK Close
Child Prevention
Nursecom, Inc. in Middle
and Adolescent
Ltd. SchoolNursing
Psychiatric and High School Youth

High School Youth

Sharron M. Close, MS, RN, CPNP

TOPIC: Dating violence and interpersonal abuse
among middle school and high school students.
PURPOSE:
evaluate the need of conducting further study in
order to create early interventions for the
prevention of relationship abuse.
SOURCES USED:
literature.
CONCLUSIONS:
school and high school youth must be addressed
by screening risk and offering anticipatory
guidance during each health maintenance visit in
order to prevent victimization of youth in dating
and attraction relationships.
To review the current literature and
Case report and review of the
Dating violence among middle
Sharron M. Close, M.S., R.N., C.P.N.P. is a Pediatric
Nurse Practitioner in the NYU/Bellevue Department of
Pediatrics, New York, NY.
When young adolescents hurt each other within
the contexts of attraction and dating, questions emerge
concerning the etiology and prevention of such actions.
The subject of dating violence among teens has been
studied in the literature since 1981 (Makepeace, 1981).
The purpose of this work is to present a case report
regarding relationship abuse and to review the litera-
ture on the subject of dating violence prevention in
middle school and high school youth. The case report
was generated from a health care maintenance visit
conducted at a hospital-based middle school clinic
located in the Bronx, New York. The review will examine
the problem of relational abuse among young dating
adolescents, risk factors, gender differences, and current
program strategies for intervention. This paper will
also discuss additional strategies to assist teens in the
acquisition and carry-over of newly-learned relation-
ship skills as they apply to the development of inti-
mate relationships.

Case Study

A.M. is a 12-year-old female in a large urban mid-

dle school in Bronx, New York. She is currently dating
a-14-year-old boy. They have been sexually active for
the past 3 months. She reports that she engages in
unprotected vaginal intercourse with her boyfriend
more than three times per week. This is her first sexual
relationship. She is his third partner. A.M. has many
risk behaviors including poor choice of nutrition,
alcohol use, and avoidance of birth control and safe
sex precautions. She recently terminated her first
pregnancy and resumed sexual activity 2 days
following the procedure. A.M. considers herself a
jealous and possessive person. If she senses that her
Journal of Child and Adolescent Psychiatric Nursing, Volume 18, boyfriend is inattentive, or that he is speaking to a
Number 1, pp. 2–9 person she dislikes, she acts out physically against

2 JCAPN Volume 18, Number 1, January-March, 2005

him. She reports that her anger causes her to hit,
scratch or pummel him with her fists. He refuses to
retaliate. She reports that she does not like it when he
refuses to defend himself. She sees it as a sign of weak-
ness, and is therefore casting her attention toward
another potential partner. When asked why she phys-
ically strikes out at him, she replies that her anger is
relieved when she hits him. She states, “I can’t stand it
when he doesn’t hit me back. I don’t respect that. I
can’t be with a guy I don’t respect. The first guy who
hits me back, that’s the man I’ll marry.”
Description of the Problem
The case of A.M. illustrates many problems associ-
ated with young adolescence including early sexual
activity, pregnancy, poor conflict resolution, and dis-
ordered thinking relative to planning future intimate
relationships. Young adolescents are at risk for many
harmful behaviors owing to their sense of increasing
independence and peer pressure (Wekerle, 1999).
Social immaturity and impulsive behavior set a back-
ground against which caustic interpersonal transactions
can escalate into abuse or violence. Relational abuse
may be described as verbal/emotional or physical
aggression that results in psychological or physical
harm of the intended victim (Cohall, Cohall, Bannis-
ter, & Northridge, 1999).
Verbal/emotional abuse is comprised of the use of
words or gestures intended to denigrate, humiliate, or
threaten the safety of an individual. Examples of
victimization resulting from this psychological aggres-
sion include a partner doing the following: making the
victim feel jealous, damaging possessions, hurting
their feelings, insulting them in front of others, blam-
ing them for the aggression, and bringing something
up from the past to hurt them. Physical aggression
may involve pushing, shoving, slapping, punching,
scratching, biting, hair-pulling, choking, physical
restraint, forced sex or the use of a weapon intended to
cause bodily harm to another person. (James, West,
Deters, & Armijo, 2000). The common thread that
JCAPN Volume 18, Number 1, January-March, 2005
underlies the relationship between perpetrator and
victim in this regard is fear. Fear is assigned signi-
ficance within the context of the relationship with
the intended function of exerting control over the
other person. (Wekerle, 1999; Wolfe & Feiring, 2000).
When a person establishes dominance over another,
the balance of power is shifted. The dominant partner
maintains power by subjugating the other using tactics
that intimidate or threaten them. The nondominant
partner begins to behave in response to the fear cre-
ated as he or she tries to avoid unpleasant or harmful
outcomes.
Incidence
The literature reports the incidence of dating vio-
lence among adolescents to range from 10% to 35%
(Bergman, 1992; Henton, Cate, Koval, Lloyd & Christo-
pher, 1983; Avery-Leaf, Cascardi, O’Leary, & Cano,
1997; Foshee, Linder, Bauman, Langwick, & Arriaga,
1996; O’Keefe, 1997; Rybarik, Dosch, Gilmore, & Kra-
jewski, 1995). One report states that verbal aggression
and violence have been reduced over a 20-year period
from 1976–1996 (Billingham, Bland, & Leary, 1999).
Prevalence of perpetration and victimization is equal
between the genders (Henton et al., 1983; Symons,
Groer, Kepler-Youngblood, & Slater, 1994). Gender
differences are found when victimization, perpetra-
tion, nonsexual attacks, sexual aggression and degrees
of physical violence are taken into account (Foshee,
Linder, MacDougall, & Bangdiwala, 2001; Foshee, Bau-
man, Arriaga, Helms, Koch, & Linder, 1998; Foshee
et al., 1996). Most dating violence research has focused
on young people of high school through college age
(Avery-Leaf et al., 1997; Lavoie, Vezina, Piche & Boivin,
1995; Lonsway, Klaw, Berg, Waldo, Kothari, Mazurek,
& Hegeman, 1998; Frazier, Valtinson, & Candel, 1995);
and Jaffe, Suderman, Reitzal, & Killip 1992). Contem-
porary American culture, however has witnessed ear-
lier physical maturation of adolescents, earlier dating
behaviors, and earlier romantic/sexual liaisons. The
pool of individuals who are engaged in “dating”
3
Dating Violence Prevention in Middle School and High School Youth
relationships has not only grown, also, the age of these
dating adolescents has shown a steady downward trend
(McFee, Turano, & Roberts, 2001).
Background
Domestic violence historically has been studied rel-
ative to spousal abuse. Abusive behaviors between
unmarried courting couples were first reported in a
study by Makepeace in 1981. Since then, studies in the
literature have defined behaviors, populations, gender
differences, ethnic impact and intervention programs.
While the body of literature is growing, the general age
range of the experimental or observed group continues
to be adolescents of high school age (grades 9–12)
(Henton et al., 1983; Bergman, 1992; Avery-Leaf et al., 1997;
O’Keefe, 1997; Symons et al., 1994). Early pubarche and
coupling in very young adolescents lend focus on the
need for the study of and the design of interventions
for the younger set of middle school age children in
grades 6–8 (Foshee et al., 2001; Krajewski, Rybarik,
Dosch, & Gilmore, 1996; Macgowan, 1997; Weisz &
Black, 2001).
Etiology of Abusive Relational Behavior
Many variables emerge when interpersonal aggres-
sion is examined closely. A theoretical model
described by Riggs and O’Leary (1989) explains that
aggressive behaviors are set into motion by situational
variables such as a history of personal exposure to vio-
lence and use of drugs and/or alcohol. The context of
aggression may come from intimate, parental or peer-
to-peer relations. Personality features such as arousa-
bility and emotionality play a role. Highly arousable
or emotional individuals experience stressors more
intensely causing them to over-respond because of
lack of self-regulation. The aggressor and victim may
interpret aggression as a legitimate response to conflict
(Riggs & O’Leary, 1989; Malik, Sorenson, & Aneshen-
sel, 1997). Increased interpersonal stress may result
from the use of alcohol, drugs, pregnancy, and
4 JCAPN Volume 18, Number 1, January-March, 2005
repeated previous attempts to negotiate disagree-
ments (Riggs & O’Leary, 1989; Koval, 1989; Cohall et
al., 1999). This model demonstrates how intrinsic and
extrinsic factors can potentiate volatile responses to
situations leading to abusive behaviors. Other con-
tributing factors to volatile interpersonal relation-
ships include family history of domestic violence,
prior victimization of violence (Wolfe, Scott, Wekerle,
& Pittman, 2000), relationship dissatisfaction, and
expectation of a positive outcome to violence (Riggs &
O’Leary, 1989). Children who are witnesses to interpa-
rental violence combined with direct physical abuse
within the family are at risk for the development of
psychiatric disturbances such as post-traumatic stress
disorder, oppositional defiant disorder, and separation
anxiety disorder (Pelcovitz, Kaplan, DeRosa, Mandel,
& Salzinger, 2000). Many adolescents come from fam-
ily backgrounds in which abusive behavior is not
regarded as aberrant (Koval, 1989). These experiences
are carried along as adolescents move through the
developmental milestones of forming identity. Con-
flict resolution and intimate relationship strategies
are created based on innate personality characteristics
combined with life experiences. These patterns of
behavior may carry over into adult relationships
(Hamberger & Ambuel, 1998).
Risk Factors and Sequelae
Child maltreatment has been identified as a signifi-
cant risk factor for adolescent maladjustment and sub-
sequent dating violence. (Wolfe, et al., 2000; Roscoe &
Callahan, 1985; O’Keefe, 1997). Children who experi-
ence maltreatment at home are at risk for developing
mental health disorders such as depression, anxiety,
suicidal ideation, and post-traumatic stress disorder.
(Toth, Manly, & Cicchetti, 1992; McCloskey & Walker,
2000).
The combination of maltreatment at home, mental
health factors and early sexual behavior, and tobacco,
alcohol and drug use cause children to inaccurately
infer emotional reactions in others, thereby setting up
interpersonal difficulties with peers and dating partners
(Shields, Cicchetti, & Ryan, 1994; Rogosch, Cicchetti &
Aber, 1995).
Adolescent girls who have experienced dating
violence may also demonstrate sequelae such as
unhealthy weight-control behaviors, sexually trans-
mitted diseases, and suicidal ideation (Silverman,
Raj, Mucci, & Hathaway, 2001). In addition to a
negative impact on mental health, dating violence
experience may result in a poor health-related
quality of life and reduced life-satisfaction imposing
significant psychological and economic costs (Coker,
McKeown, Sanderson, Davis, Valois, & Huebner,
2000).
Gender Differences
Studies have demonstrated that perpetration and
victimization of dating violence are prevalent in both
genders. Both sexes are commonly victimized by less
severe acts, such as pushing, grabbing or shoving
(Henton et al., 1983). Girls are more likely to perpetrate
dating violence (Malik et al., 1997; Morse, 1995; Foshee
et al., 2001). Younger adolescent females of middle
school age have been found to perpetrate more mild,
moderate and severe violence than boys when controlled
for self-defense (Foshee et al., 2001). Variables identi-
fying cross-sectional correlates of female-initiated dat-
ing violence include having friends who are victims of
dating violence, and belonging to a race other than
Caucasian (Foshee et al., 1996). These variables may be
associated with the influence of peer relationships
during the adolescent stage of social development.
When males perpetrate violence, they are more likely
to force sex or cause injury when compared to females.
Females sustain more psychological, sexual, and
physical injury (Foshee, 1996). Females may initiate
less severe acts of interpersonal aggression, but when
males respond, they demonstrate more forceful physi-
cal and psychological impacts, perhaps owing to their
larger stature, and concomittent use of drugs and/or
alcohol. (Malik et al., 1997).
JCAPN Volume 18, Number 1, January-March, 2005
Prevention/Intervention Programs
Strategies for the prevention of domestic violence
are changing to anticipate the needs of people at all
stages of life (Wolfe & Jaffe, 1999). Wolfe and Jaffe
describe a three-pronged approach to identify oppor-
tunities for prevention along “a continuum of harm”:
• Primary prevention: to reduce the incidence before
it occurs.
• Secondary prevention: to decrease the prevalence
after early signs of the problem have been identified.
• Tertiary prevention: intervention after the problem
has already caused harm.
Dating violence prevention studies have primarily
focused on primary prevention in high school or
college student populations (Frazier et al., 1995; Jaffee
at al., 1992; Lavoie, et al., 1995; Lonsway et al., 1998;
and Avery-Leaf et al., 1997). Primary prevention pro-
grams generally focus on dating violence awareness,
conflict management skills, and addressing issues of
gender stereotyping. Participants of these programs
who are of high school and college age bring life
experience into the class regarding personal dating
experience or peers involved in relationships. Studies
involving middle school youth also appear in the
literature (Foshee et al., 2001; Krajewski et al., 1996;
Macgowan, 1997; and Weisz & Black, 2001). Compari-
son of these studies is complicated, however, by dis-
parate study variables such as age and ethnicity of
subjects, demographic sampling differences, type and
length of treatment, as well as lack of follow up.
All of the interventional studies conducted between
1992 and 2001 employed quasi-experimental design
using pretest and post-test questionnaires that meas-
ured acquisition of knowledge and attitudes regarding
dating violence. Six studies (Jaffee et al., 1992; Frazier
et al., 1995; Lavoie et al., 1995; Lonsway et al., 1998;
Avery-Leaf et al., 1997; Foshee et al., 1998) worked
on samples of eighth and ninth grade students who
were primarily of European-American descent. Three
5
Dating Violence Prevention in Middle School and High School Youth
studies (Krajewski et al., 1996; Macgowan, 1997; Weisz
& Black, 2001) focused on middle school youth. Two
studies worked with primarily African-American
students in urban settings (Macgowan, 1997; Weisz &
Black, 2001). The others worked with students of
European-American descent from suburban settings.
All studies except for one were cross-sectional. Foshee
et al., 1998 conducted a longitudinal study, following
up their results at 6 months and 1 year after interven-
tion. Interventions among groups were similar as far
as utilization of dating violence prevention curricula.
Interventions varied, however, from as brief as half to
one full day (Jaffe et al., 1992), 2 1/2 to 5 hours (Lavoie
et al., 1995) to much longer treatments. The longest
courses were five one-hour sessions (Avery-Leaf et al.,
1997; Macgowan, 1997), 10 1-hour sessions (Foshee
et al., 1998) and 12 one-and-a-half-hour sessions (Weisz
& Black, 2001).
While all studies reported that program partici-
pants improved knowledge-base and attitudes against
dating violence immediately following the programs,
only four of the studies (Foshee et al., 2000; Jaffee et
al., 1992; Krajewski et al., 1996; Weisz & Black, 2001)
conducted follow-up evaluations to examine whether
improvements were lasting. Of the four studies meas-
uring follow-up results, one reported that differences
were not stable at 5-month follow-up (Krajewski et al.,
1996). Three studies conducting follow-up demon-
strated carry over of knowledge from 6 weeks, up to 6
months and up to 1 year, respectively ( Foshee et al.,
1998; Jaffe et al., 1992; Weisz & Black, 2001). Although
the studies cited here have demonstrated significant
limitations, they collectively offer strategies for further
investigation that might be incorporated into larger,
and more effective experimental designs.
The main limitation of cross-sectional studies is that
the measurement parameters relate only to the time,
place, and population at the time the study was con-
ducted. Longitudinal design offers follow-up at suffi-
cient time intervals to enable the researcher to see if
the effects of the intervention continue over time.
Other important limitations in these studies include
6 JCAPN Volume 18, Number 1, January-March, 2005
small sampling sizes, populations with predominant
ethnicity representation, and sampling from limited
demographic regions. These factors limit generaliza-
bility. Generalizabilty is desirable in order to plan
intervention on a larger scale from a public health per-
spective.
Prospective longitudinal design is one method of
studying this problem that may offer the opportunity
to assess whether intervention is worthwhile and
applicable to public health on a large scale. A potential
strategy could be to select a study group (intervention)
from one school district, using a control (noninterven-
tion) group matched by age, sex, race, and demo-
graphics from the same district. Intervention of study
subjects would begin on the fifth grade or at age 10 and
would continue until the 12th grade. The study group
would undergo primary prevention via classes, projects,
and interactive programs while the control group
would receive no intervention. Outcomes would be
measured at yearly intervals by a questionnaire assess-
ing the participants’ knowledge and experiences of
dating abuse behaviors. This design could be expanded
to include school districts from urban, suburban, and
rural areas from several regions of the country. The
results of this multiple cohort study could be used to
design meaningful interventions leading to reduced
dating violence.
Discussion
Domestic violence is a threat to the psycho-emo-
tional and physical well-being of victims, perpetrators,
and all those who witness it. It is a complicated and
multi-faceted problem in which family background,
peer/family environment, demographic region, eth-
nicity, and risk factors come into play. The incidence
of dating violence among young adolescents is sub-
stantial and predicts future interpersonal risk for
unhealthy and dangerous relationships. Prevention of
domestic violence will require coordinated efforts of
local communities, schools, health care providers, and
all levels of government.
 In order to create a meaningful change in the inci-
dence of dating violence and interpersonal abuse among
adolescents, a strategic plan must be implemented that
incorporates identification, intervention, and means to
measure the outcome. The process of identifying ado-
lescents at risk must be systematic. General screening
may be undertaken at school, in the community, and
in the office of the primary health care provider. This
could realistically be accomplished by using a concise
standardized screening questionnaire. “Red flag” markers
suggesting possible dating abuse include recurrent
sexually transmitted diseases, complaints with no
etiology, depressed mood, unexplained bruising, and
decline in academic performance. There are many
obstacles, however, to identification including denial
of the problem, withholding history, peer acceptance
of violence, misinterpretation of “love”, and fear of the
aggressive partner. Adolescents are also reluctant to
disclose relational abuse because of the fear of confi-
dentiality breach or of being blamed for the abuse.
Many adolescents withhold information for fear of
being judged as “immature”, “wrong”, or not normal.
Adolescents in contemporary society are exposed to
various forms of violence in all kinds of media. Expo-
sure to violence in real life and in various media
desensitizes them to the point of their acceptance of it
in real life. In intimate relationships, partners may
interpret “love” as submission or domination relative
to what they have seen in their own families or what
they have learned from more experienced peers. Ado-
lescents are intensely private about their personal
affairs. They require a great deal of trust with another
in order to discuss something as personal as being
hurt by a loved one. Breach of confidentiality may
carry as much fear as fearing an abusive partner. Part
of the fear instilled by an abusive partner is helping
the victim believe that he or she is the actual cause of
the abuse. Adolescents may become confused about
their difficult situation, and do not have the trust or
wisdom to help them find their way out.
Intervention programs for middle school adoles-
cents are ways to pre-emptively manage relationship
JCAPN Volume 18, Number 1, January-March, 2005
problems before dangerous interpersonal habits
become established. Programs at the middle school
level need to utilize curricula that are age-appropriate,
incorporating features that are culturally sensitive and
regionally pertinent. Programs need to be of sufficient
length to enable teaching of a full curriculum. Several
teaching strategies include didactic, performance, role-
playing, interactive games, and art-related projects that
engage various interest levels of this age group while
delivering important information. Finally, each inter-
vention group needs to be followed at designated
intervals in order to determine if the program affected
their attitudes and behaviors as they mature toward
the high school years. Ideally, these intervals would
remeasure attitudes and behaviors at 6 months, 1
year, and 2 years following the initial intervention.
Most health classes at public schools focus on physical
health issues. These are perfect forums, however, to
address mental, emotional and psychological health
issues. Teaching young people how to interact in
healthy ways on a regular basis as part of health edu-
cation is a way of giving them skills that may promote
nonviolent conflict resolution, and send them toward
healthy partnering behaviors.
Future studies need to be designed so that results
may be interpreted as representative of larger popula-
tions. Prospective longitudinal design using randomly
chosen large samples would lend the important feature
of generalizability. Results from such a design could
lead to program implementation on a large scale with
the intent to reduce the incidence of adolescent dating
violence.
Reducing adolescent dating violence may conse-
quently reduce the incidence of domestic violence in
the future. Comparing interventions at middle school
versus high school may offer evidence for the optimum
timing for intervention.
Conclusion
Dating and domestic violence is a public health
concern. Accurate definition and scope of the problem
7
Dating Violence Prevention in Middle School and High School Youth
must be determined in order to plan future inter-
ventions that can be administered on a large scale. In
the meantime, there is no substitute for individual
intervention that can be accomplished in privacy
during a visit to the health care provider. Health care
providers must act to identify the problem by offering
appropriate screening for risk as well as for actual
events. Anticipatory guidance during health mainte-
nance visits for young adolescents increases awareness
and provides teaching that may protect these young
people from victimization or from perpetrative behav-
iors in the future.
Author contact: smc184@columbiu.edu, with a copy to the
Editor: Poster@uta.edu
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