Intimate Partner Violence in Adolescent Romantic ... - Springer Link

Intimate Partner Violence in Adolescent Romantic Relationships Ann T. Chu, Jane M. Sundermann, and Anne P. DePrince

Intimate partner violence (IPV) in adolescent romantic relationships is a serious public health problem. First, such violence is all too common, affecting a significant number of youth. In grades 9–12, approximately 10 % of male and female students report being physically hurt by a dating partner in the past 12 months (Centers for Disease Control and Prevention, 2011). Rates of exposure are even higher among certain populations: for example, an estimated 25–50 % of adolescent females in foster care report violence in dating relationships (Jonson-Reid & Bivens, 1999). Second, IPV in adolescent romantic relationships is linked to a range of serious negative health consequences, particularly maladaptive mental health outcomes (e.g., Banyard & Cross, 2008; Teten, Ball, Valle, Noonan, & Rosenbluth, 2009). Compared to male victims of adolescent IPV, some of these adverse health outcomes are uniquely elevated for female victims, including the physical and mental stress associated with higher rates of unwanted pregnancies among female IPV victims (versus non-victims; Silverman, Raj, Mucci, Lorelei, & Hathaway, 2001). Serious physical injury is also more likely to occur for female (versus male) victims of adolescent IPV (Coker et al., 2000).

A.T. Chu, Ph.D. (*) • J.M. Sundermann A.P. DePrince, Ph.D. Department of Psychology, University of Denver, 2155 South Race Street, Denver, CO 80208, USA e-mail: [email protected]; [email protected]; [email protected]

In addition to effects on health broadly, IPV victimization during adolescence contributes to IPV risk in adulthood, particularly for females. Both prospective and retrospective studies point to the critical role that IPV in adolescence plays in understanding lifetime risk for IPV among girls and women (Arata, 2002; Gidycz, Hanson, & Layman, 1995; Smith, White, & Holland, 2003). For instance, females who experienced childhood abuse were found to be at risk for dating violence as adults only when they experienced dating violence during adolescence (Smith et al., 2003). Humphrey and White (2000) documented that college women who had been sexually assaulted during adolescence were 4.6 times more likely than their peers to report sexual victimization in young adulthood. Women’s revictimization in adolescence and adulthood, in turn, is linked to greater physical and psychological health costs than single victimizations (DePrince, 2005; Kimerling, Alvarez, Pavao, Kaminski, & Baumrind, 2007; Polusny, Rosenthal, Aban, & Follette, 2004). While some studies suggest that adolescent girls and boys do engage in mutually aggressive relationships (Foshee, Reyes, & Ennett, 2010; Teten et al., 2009), the safety and health trajectories for girls and women exposed to IPV in dating relationships differ significantly than those for boys. This current chapter focuses on understanding the risks and consequences of IPV victimization for girls and women. Because one of the potential consequences of adolescent IPV is adult IPV, we distinguish adolescent IPV through use of the term teen dating

W.T. O’Donohue et al. (eds.), Handbook of Adolescent Health Psychology, DOI 10.1007/978-1-4614-6633-8_14, © Springer Science+Business Media New York 2013

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violence (TDV). TDV definitions have historically focused on physical violence, such as “the use or threat of physical force or restraint carried out with the intent of causing pain or injury to another” (Sugarman & Hotaling, 1989, p. 5). In more recent years, though, definitions of TDV have expanded to recognize a range of behaviors exerted in romantic relationships to “control or dominate another person physically, sexually, or psychologically causing some level of harm” (Wekerle & Wolfe, 1999, p. 436; italics ours). Unless otherwise noted, we use the term TDV to refer broadly to all three forms of aggression (physical, sexual, and psychological) that cause harm to either partner within adolescent romantic relationships. Research on TDV has advanced rapidly in recent decades to include more sophisticated analyses and rigorous study designs. These advances, though, have revealed how complex studying TDV can be. While earlier epidemiological studies focused on establishing prevalence rates of TDV, recent studies take a more nuanced look at differences in prevalence rates among subgroups of adolescents (e.g., Jonson-Reid, Scott, McMillen, & Edmond, 2007). Advocates of ecological models (e.g., Connolly, Friedlander, Pepler, Craig, & Laporte, 2010; White, 2009) also recognize that violence and subsequent sequelae do not exist in a vacuum; rather, many factors at multiple levels interact to influence exposure and response to violence, including TDV. Each level of risk must be well understood in order to develop a valid ecological model that can be used to inform prevention/intervention efforts. Along with a review of TDV prevalence and health consequences, the current chapter uses an ecological model framework to organize existing research on risk factors for TDV victimization. We rely on an ecological model comprised of three levels of risk: individual, relationship, and societal. At each level we identify risk factors that have garnered consistent support across studies. We then review the empirical evidence for efficacious prevention programs. Throughout the chapter, we highlight unanswered questions and suggest areas for continued investigation.

Prevalence Estimates of TDV prevalence vary greatly, likely due to methodological differences across studies. Research drawing on nationally representative samples tends to report lower prevalence rates of IPV victimization, ranging from 3 to 32 % (Halpern, Oslak, Young, Martin, & Kupper, 2001; Wolitzky-Taylor et al., 2008), while research using more extensive and indepth questionnaires documents higher rates with studies reporting up to 80 % in schoolbased and inpatient samples (e.g., Hickman, Jaycox, & Aronoff, 2004; Rizzo, EspositoSmythers, Spirito, & Thompson, 2010; Smith et al., 2003). The epidemiological surveys may provide more conservative estimates of TDV prevalence because questions regarding violence are typically limited to a few concrete and specific behaviors. For example, the Youth Risk Behavior Survey (YRBS), a biannual school-based survey by the Centers for Disease Control and Prevention (CDC), asks only one “Yes or No” question regarding dating violence (i.e., “During the past 12 months, did your boyfriend or girlfriend ever hit, slap, or physically hurt you on purpose?”) and one “Yes or No” question regarding forced sexual intercourse (i.e., “Have you ever been physically forced to have sexual intercourse when you did not want to?”; CDC, 2011). Prevalence estimates are also affected by varying operationalization and measurement of adolescent romantic relationships and TDV across studies. Despite the observation that teens have multiple dating partners across adolescence (e.g., Halpern et al., 2001), many TDV studies rely on cross-sectional approaches focused on a specific relationship, thereby precluding researchers’ ability to examine individual differences in and across romantic relationships (e.g., Banyard & Cross, 2008; Coker et al., 2000; Noonan & Charles, 2009; Rizzo et al., 2010). Studies also include a range of TDV experiences, from victimization in the context of casual one-time dating to serious long-term relationships. Further, studies vary

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in the time frames used to assess violence in relationships; some questionnaires ask about relationships in a specific time frame (e.g., Conflict in Adolescent Dating Relationships Inventory (CADRI; Wolfe et al., 2001), across the lifespan (e.g., Youth Risk Behavior Survey; CDC, 2011), or violent experiences within the last relationship (e.g., Revised Conflict Tactics Scales (CTS-2); Straus, Hamby, BoneyMcCoy, & Sugarman, 1996). Violence can vary from relatively benign (e.g., “He insulted me with put downs” from the CADRI; Wolfe et al., 2001) to serious abuse that affects psychological and physical health (e.g., “He threw something at me,” “I touched him/her sexually when he/she didn’t want me to” from the CADRI; Wolfe et al., 2001; Rizzo et al., 2010). In general, the field lacks systematic assessment for different types of romantic involvements and dating violence; methodological differences also present challenges to making comparisons across studies. To date, knowledge on TDV from epidemiological and empirical studies primarily comes from school settings with adolescents who are or had been involved in heterosexual romantic relationships. To our knowledge, there have been no studies on TDV in same-sex romantic relationships in adolescence specifically; and few studies have recruited from nonschool settings. Additionally, most empirical studies have traditionally utilized samples that comprise primarily Caucasian adolescents. Although findings from school-based samples of primarily Caucasian adolescents in heterosexual relationships have established an important foundation from which to expand, focusing solely on such sampling methods ignores a large portion of US youth and likely limits our understanding of the heterogeneity of TDV experiences. Demonstrating the importance of expanding sampling methods, one study of TDV with an urban sample of homeless youth found higher prevalence rates among those youth involved with the child welfare system as compared to their peers without child welfare involvement (Goldstein, Leslie, Wekerle, Leung, & Erickson, 2010).

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Prevalence and Gender Some adolescent research suggests that females engage in as much psychological and/or physical aggression as males (e.g., Halpern et al., 2001), while other studies suggest that females engage in greater physical and/or psychological aggression than males (see Foshee & Matthew, 2007; Wolfe et al., 2003). Despite the fact that females may engage in physical and psychological aggression at approximately equal (or greater) rates to males, feminist theorists point to important characteristics of TDV to demonstrate that TDV remains a gendered phenomenon influenced by principles of social learning theory and sociocultural values (White, 2009). A review by Saunders (2002) indicated that female victims of male-perpetrated TDV suffer more serious negative consequences, particularly health outcomes, compared to male victims of female-perpetrated TDV. Straus’ (1995) landmark finding that women needed medical attention seven times as often as husbands after a physically violent conflict in the relationship is echoed in studies with youth. For instance, Muñoz-Rivas, Graña, O’Leary, and González (2007) found that female TDV victims were more likely to receive injuries and need medical attention/hospitalization for injuries than male TDV victims. This disparity in consequences may be due to the fact that males engage in violence that is more severe and more often involves lethal weapons compared to females who engage in lower level violence such as kicking, slapping, or shoving (Schwartz, Magee, Griffin, & Dupuis, 2004). Unlike psychological and physical aggression, researchers have documented that males are more likely to perpetrate sexual violence than females (Basile, Chen, Lynberg, & Saltzman, 2007; USDJ, 2008, National Crime Victimization Survey). Interestingly, Spitzberg (1999) conducted a review of 120 studies of sexual violence, 90 of which used adolescent or college samples. This review demonstrated that, when sexual violence was assessed at a broad level, males and females did not report significantly different perpetration rates; however, when more specific forms of

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sexual violence were assessed, such as rape, males were four times more likely than females to identify as perpetrators while females were four times more likely than males to identify as victims. Sexual violence in adolescence is particularly important to consider because statistics from nationally representative samples demonstrate that adolescents and young adults are disproportionately victims of sexual assault: the 2008 National Crime Victimization Survey found that half of all rape/sexual assault victims were aged 12–24 (USDJ, 2008). Emerging qualitative studies examining motivations or reasons for perpetrating aggressive behaviors may be important to understanding gender differences in prevalence rates. Adolescent females appear to use physical violence as a means of self-defense or due to other situational factors whereas male teens use physical violence as a means to control their partners (Foshee, Bauman, Linder, Rice, & Wilcher, 2007; O’Keeffe, 1997). Further, rigid gender roles may result in inequities in power between male and female partners as well as expectancies that relationships involve harm to women (Wolfe et al., 2003). Supporting the latter argument, DePrince, Combs, and Shanahan (2009) documented expectances that relationships involve harm among college women who had been revictimized, compared to women who had not.

Prevalence and Race/Ethnicity Several studies, including the CDC national survey, have found that adolescents from racial and ethnic minority groups report higher rates of dating violence compared to non-Hispanic Caucasian adolescents (e.g., CDC, 2011; Chapple, 2003; Connolly et al., 2010; Foshee et al., 2010). Specifically, the highest prevalence rates were found among Black adolescents, followed by Hispanic and Caucasian adolescents, and then Asian adolescents, even after controlling for socioeconomic status (SES). However, two separate reviews on risk factors for TDV also identified a number of studies that found either lower rates of dating violence in teens from racial/ethnic minority

groups or no link at all between race/ethnicity and TDV (Lewis & Fremouw, 2001; Vézina & Hébert, 2007). The authors of the reviews suggest methodological variation and potential third variables as explanations for this discrepancy. For example, many studies do not distinguish between immigrants versus US-born racial/ethnic minority teens. This distinction may be important because racial/ ethnic identity, involvement with culture of origin, and lower levels of acculturation have been found to be buffers against TDV for some racial/ethnic groups (for a review, see Smokowski, DavidFerdon, & Stroupe, 2009). Additionally, many general racial categories (e.g., Latino, Asian) are differentiated by specific subgroups (e.g., Cuban versus Mexican, Chinese versus Japanese), with great heterogeneity across the subgroups. Yet the variability between ethnic groups often gets washed out by comparisons of only the larger racial categories.

Recommendations The differences in prevalence rates between genders and racial/ethnic groups highlight the importance of moving beyond documenting broad group differences (e.g., victimized youth versus non-victimized youth) to identifying the mechanisms and processes that lead to these disparities (e.g., relationship dynamics, acculturation). To date, however, TDV research has largely involved single informants in the context of heterosexual romantic relationships. Research involving both partners as well as same-gendered romantic relationships may help to clarify the impact of gender role expectations and gender differences in relationship dynamics on TDV. While studies are starting to pay more attention to cross-cultural and gender issues, these areas remain important topics for future research to fully examine.

Health Consequences of TDV TDV is associated with a diverse array of maladaptive health-related outcomes measured proximally in adolescence as well as more distally in


adulthood. Examples of maladaptive outcomes for health among victims include significantly higher levels of mental health symptomatology such as depression (Banyard & Cross, 2008; Yen et al., 2010). In a longitudinal survey of approximately 2,000 female high school students, Silverman et al. (2001) found that female teens reporting physical or sexual dating violence victimization also reported higher levels of substance use, unhealthy weight control behaviors, sexual risk behaviors, pregnancy, and suicidality as compared to their non-victimized peers. These associations held above and beyond the effects of potentially confounding demographics and other risk behaviors. Few studies have examined differential health outcomes based on the distinctions between pure perpetrators, pure victims, or teens who are both perpetrators and victims. One of the few studies that examined these subtypes found a higher percentage of teens reporting as being both the offender and victim versus offender or victim only (Gray & Foshee, 1997). Furthermore, teens who identified as being both perpetrator and victim endorsed perpetrating more severe levels of violence and sustaining more injuries as compared to individuals who were victims only. Yen et al. (2010) also conducted a study that asked teens to make the distinction between being a perpetrator only, victim only, or both. Teens across all three groups had higher rates of depression, insomnia, suicidality, and alcohol abuse compared to teens with no experience of TDV as perpetrator or victim. However, teens reporting both victimization and perpetration experiences had significantly higher levels of alcohol abuse than pure victims and significantly higher rates of externalizing behaviors (i.e., truancy and theft) than pure perpetrators. These two studies point to important characteristic differences in teens who engage in mutually aggressive relationship as compared to teens who are perpetrators or victims only, though research to date has not focused a great deal of attention to this subgroup of teens. Some studies have also suggested that rape has unique and severe health consequences relative to other types of violence. A study by Coker et al. (2000) revealed that forced-sex victimization was

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associated with suicidal ideation and attempts among both female and male high school students. Because suicidal ideation and attempts are clearly one of the most severe (i.e., by definition, lifethreatening) mental health symptoms and female teens suffer much more from rape victimization than male teens, these findings provide yet further evidence for gender differences in the severity of TDV’s consequences for victims, namely, that female teen victims, on average, suffer more severe consequences than male teen victims.

Recommendations Existing research demonstrates a robust relationship between TDV and maladaptive health outcomes. However, identifying potential moderators and mediators linking TDV and deleterious consequences are sorely needed. For example, studies are starting to examine race and/or ethnicity as a moderator of health consequences in adult IPV; existing data suggest that racial/ethnic minority IPV victims suffer more severe consequences relative to Caucasian victims (Stark, 1990). However, researchers in the adult IPV field have yet to identify the mechanisms that drive these group differences. Importantly, researchers have also yet to examine race/ethnicity and/or associated variables as moderators of outcomes in the TDV literature. Understanding moderators could provide policy makers and practitioners insight into how to direct services in the context of limited resources. Despite the heterogeneous nature of TDV, most studies examine broad-level differences (e.g., TDV versus no TDV) rather than identifying specific subgroup profiles of adolescents with different experiences of TDV (e.g., victim only versus perpetrator-victim; subtypes of violence); therefore, studies may inadvertently overlook important individual differences that lead to varied outcomes. Recently, researchers in the adult IPV literature have called for and started to adopt person-centered analyses to better understand the full variability of victimization experiences and responses that may be lost in group comparisons (see Macy, 2008). Given that not all adolescents

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who experience TDV report similar health problems as sequelae, adopting a person-centered approach in the field of TDV may help target subpopulations to more effectively ameliorate specific deleterious outcomes.

Risk Factors for TDV Victimization: Applying an Ecological Model The ecological model, first proposed by Bronfenbrenner (1979), comprises multiple embedded levels (e.g., individual, family, societal) that work together to influence individual experiences. Ecological models have been applied to different aspects of violence exposure (for a discussion on the application to childhood maltreatment, see Chu, Pineda, DePrince, & Freyd, 2011). Using an ecological model to organize our review, we turn now to identifying risk factors for TDV at individual (e.g., internalizing/externalizing problems, age), relationship (e.g., peer, family), and societal (e.g., attitudes, affiliations, acculturation, neighborhood) levels. We focus on risk factors that have been replicated across studies.

Individual At the individual level, researchers have identified both internalizing and externalizing problems as risk factors for TDV. For example, internalizing problems such as depressive symptoms have been consistently linked to TDV, according to a review of 61 studies conducted by Vézina and Hébert (2007). Though depression is a common consequence of violence, several longitudinal studies found that depression may also be an antecedent to TDV (see Vézina & Hébert, 2007). Depression might increase risk for TDV by decreasing female adolescents’ perceptions of self-efficacy in relationships and potentially violent situations, by increasing tolerance of abusive behaviors from dating partners in order to maintain intimacy and to avoid feelings of isolation, or by increasing high-risk behaviors as a coping strategy against feelings of depression (see Vézina & Hébert, 2007). However, these

explanations have yet to be supported consistently by empirical data. A few studies have also documented the finding that suicidal attempts increase risk for TDV in addition to being a consequence of violence (Vézina & Hébert, 2007). Again, the pathway by which suicidal attempts increase risk for TDV remains unexplored. Externalizing problems such as substance abuse as well as risky/disruptive behaviors also appear to put teens at higher risk for experiencing TDV (Vézina & Hébert, 2007). Researchers have assumed that substance use makes youth vulnerable to high-risk situations that they would otherwise avoid or be able to protect themselves; however, we are aware of no empirical data that exist to support that link. Thus, the process by which substance use leads to dating violence remains unclear. As mentioned previously, substance use as well as other internalizing and externalizing problems could be either risk factors for and/or consequences of TDV. Only with more longitudinal research will researchers be able to tease out important causal/transactional processes related to TDV. Age also appears to be linked to TDV risk. In the handful of TDV longitudinal studies available, researchers have documented a curvilinear relationship such that aggressive behaviors increase from early adolescence to a peak point around mid-adolescence, and then decline by the end of adolescence, though the exact age at which aggressive behaviors peaked differed across studies (see Foshee et al., 2009). Additionally, Wolfe and colleagues (2003) found that though girls reported engaging in higher rates of physical dating aggression than boys, this difference decreased over time such that by ages 16–18 there were no significant gender differences in aggression rates. Thus, the gender difference between rates of aggression may also vary as a function of age.

Relationships Adolescents are embedded in multiple, complex relational systems that are linked to risk for TDV. For example, adolescents are just starting to form


and explore their self-identities and sexuality (Erikson, 1968) while also experiencing considerable need to conform and be accepted in peer relationships. Though positive peer norms may provide a buffer against many negative experiences, negative peer influences may represent a risk factor. Drawing on the social learning framework, one well-established finding is that violent behavior appears in part to be learned through associations with peer reference groups (see Elliot & Menard, 1996). Indeed, Arriaga and Foshee (2004) found that having friends who experienced violence in their romantic relationships predicted teen girls’ victimization 6 months later. Having peers who experience dating violence predicted victimization above the contribution of inter-parental violence. This pattern has been replicated in several other studies (for a review, see Vézina & Hébert, 2007). Theories and emerging empirical findings suggest that gender differences in peer interactions may also impact romantic relationships and the experience of dating violence. For example, gender socialization in childhood of girls and boys may lead to different expectations for how males and females “should” behave in adolescence (see Maccoby, 1998). Male and female adolescents then come together in heterosexual romantic relationships within two different “cultures.” The female culture emphasizes intimate relationships, self-disclosure, and emotional expression while the male culture focuses on activities, multiple superficial relationships, minimal disclosure, and anger expression. Data from one longitudinal study provide some preliminary evidence to support this theory (Underwood & Rosen, 2009). The authors found that girls’ relational interactions and boy’s aggression in same-gender peer relationships may relate to having emotionally intense arguments when they come together in romantic relationships in early adolescence. Adolescent relationships within families can also increase TDV risk. For example, teens who live in single-parent households and/or who have inadequate parental supervision are at elevated risk of experiencing TDV (Vézina & Hébert, 2007). Findings also consistently show that

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childhood abuse and witnessing violence in the home increases risk for being a victim of TDV (see Vézina & Hébert, 2007). Reitzel-Jaffe and Wolfe (2001) postulate that living with aggressive parents leads to the development of aggressive social-cognitive information processing, which is then carried over to teens’ abilities to form healthy relationships as well as their interpersonal interactions within romantic relationships. While these findings are starting to provide more comprehensive knowledge on the impact of relationships on the risk for TDV, the underlying mechanisms again remain theoretical. Empirical support is sorely needed to better understand the processes that drive these associations.

Societal In studying interpersonal violence, it is difficult to measure environmental factors separate from the individual; however, the environmental context, with its affiliated attitudes, beliefs, and practices, may increase risk for or protect youth from TDV. For example, beliefs that violence is acceptable are linked to increases in TDV risk (Vézina & Hébert, 2007) while cultural affiliation appears to buffer against TDV risk (see Smokowski et al., 2009). Importantly, though, societal factors such as cultural affiliation may interact with individual- and relationship-level factors to influence risk for TDV in complex ways. For example, family violence exposure predicted the initiation of dating violence among Black, but not White, adolescents for reasons that are yet unclear (Foshee, Ennett, Bauman, Benefield, & Suchindran, 2005). The processes by which particular attitudes or cultural affiliations translate into TDV risk remain unclear across studies. Perhaps highly culturally affiliated teens with high values of collectivism tend to report dating violence less than their peers, or strong cultural affiliation may contribute to better social support as well as more prosocial peer and/or partner involvement. For example, being less involved in religious activities has been shown to be a risk factor (for a review, see Vézina & Hébert, 2007).

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Other factors in adolescents’ living contexts may also affect TDV risk. For example, the few available studies that involve youth from rural settings suggest that those teens are at higher risk for TDV relative to teens in more urban environments (see Spencer & Bryant, 2000; Vézina & Hébert, 2007). Unfortunately, researchers have been unable to identify the mechanisms by which living in a rural environment increases risk for TDV. It may be that the driving force behind the difference between rural and urban environments is the level of involvement in prosocial and supportive networks (Vézina & Hébert, 2007). The mechanisms for these contextual societal risk factors need to be further examined.

Recommendations Research in the TDV field began by documenting broad group differences (e.g., gender, culture/ ethnicity) and correlations (e.g., previous violence exposure, substance use) associated with TDV. As many researchers (e.g., Coulton, Crampton, Irwin, Spilsbury, & Korbin, 2007; White, 2009) have suggested, we must now employ an ecological perspective that includes all levels of analysis in order to fully understand the context within which TDV happens. Such studies may clarify nonlinear processes of risk and protective factors of TDV, which in turn can further inform risk for further victimization. Increasingly, studies have started to examine interactions between and across levels of analyses. For example, Foshee et al. (2010) found that depression, marijuana use, and aggression against peers predicted perpetration of dating violence by girls but not by boys. Anxiety predicted dating violence perpetration by Caucasian adolescents, while anger predicted perpetration by AfricanAmerican adolescents (Foshee et al., 2005). Reyes, Foshee, Bauer, and Ennett (2011) also found that the positive association between heavy alcohol use and dating violence perpetration increased as family violence severity and level of friend involvement in dating violence increased. This pattern was present in teens from grades 8 through 12. These research examining interactions

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across multiple ecological levels while using more complex analyses and multiple methods is sorely needed. Such research will have important implications for clinical practice with teens experiencing TDV (both as perpetrators and as victims) as it helps build an empirical base of knowledge to identify resources for preventions and interventions. There also needs to be further systematic research on whether specific risk factors in certain subgroups of teens are particularly influential in predicting dating violence. For example, Wekerle and colleagues (2001) recruited two samples of female adolescents: one school-based group and one comprised of teens involved with the child welfare system. They found that different risk factors predicted victimization in romantic relationships. In the high school group, post-traumatic stress disorder (PTSD) symptoms completely mediated the relationship between childhood abuse and TDV. In the child welfare group, PTSD symptoms only partially mediated this relationship. Smokowski et al. (2009) also found that the buffer effects of low levels of acculturation, ethnic identity, and culture-of-origin involvement were particularly strong for female minority teens compared to male minority teens. Whether risk factors vary according to the type of violence remains another question to be answered. In Vézina and Hébert’s review (2007), only 5 out of 61 studies examined risk factors by specific types of dating violence. Findings from those five studies provide initial evidence that some risk factors may differentially impact TDV depending on type. However, additional studies need to be conducted to confirm these patterns. Notably, the way that variables affect adolescents’ risk for TDV may be different from the effects of variables on adult IPV. For example, SES is a risk factor for adult IPV (Field & Caetano, 2004; Riggs, Caulfield, & Street, 2000); however, two separate reviews failed to find consistent links between SES and TDV (Foshee & Matthew, 2007; Vézina & Hébert, 2007). Vézina and Hébert (2007) postulated that parents with higher SES may hold more prestigious occupations that lead to more hours of work; in turn, more time away from home may lead to lower


levels of parental involvement and monitoring, which increases risk for TDV. This example illustrates the importance of testing (and not assuming) whether risk factors identified in the adult literature translate to youth.

Prevention Whitaker and colleagues (2006) conducted a systematic review of 11 studies examining the efficacy of TDV prevention programs designed for middle- and high-school students. Though the reviewed efficacy studies were mostly randomized control trials (RCT), Whitaker et al. (2006) noted a lack of evidence for the efficacy of prevention programs in general. However, evidence did converge in support of two specific prevention programs: Safe Dates (Foshee et al., 1998, 2004) and Youth Relationships Project (Wolfe et al., 2003; Wolfe, Crooks, Chiodo, & Jaffe, 2009). Safe Dates has both a school and community component and includes activities aimed at changing norms of dating violence and improving prosocial skills. Foshee et al. (1998, 2004) evaluated the efficacy of Safe Dates via a RCT design where the control group received exposure to general community activities. At a 1-year follow-up, Safe Dates students reported lower perceived acceptability of dating violence compared to control group students. At a 4-year follow-up, students who received Safe Dates (versus control) reported less physical and sexual TDV perpetration and victimization. Whereas Safe Dates is a school-based prevention program that targets a broad group of adolescents, the Youth Relationships Project took place at community agencies and targeted high-risk adolescents who were identified through the child protective service (CPS) system. Wolfe et al. (2009, 2003) evaluated the Youth Relationships Project via a RCT design where the control group received standard CPS services. At a 16-month follow-up, adolescents who received the Youth Relationships Project intervention (versus control) reported less physical abuse perpetration and victimization.

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Recommendations With the exceptions of Safe Dates and the Youth Relationships Project, most prevention programs of TDV have not yet demonstrated a sufficient level of evidence for their efficacy. In order to increase the efficacy of TDV prevention programs, we make several recommendations. RCTs that compare adolescents who receive intervention versus an active control treatment should be the gold standard for evidence of efficacy. Whenever possible, studies should employ additional research methodologies to complement the RCT design. For instance, studies should utilize a multi-rater (i.e., parents, teachers, etc.) and multimethod (i.e., self-report, behavioral) approach to examining program efficacy. Behavioral measures of change and long-term follow-up assessments are crucial to sufficiently document the impact of the intervention. As risk factors for TDV become more wellknown, programs should specifically target teens with those specific risk factors. Such targeted interventions could provide more specific information regarding mediating variables between early risk factors like maltreatment and outcomes like TDV, as well as highlight the nuanced “active ingredients” of prevention programs. Programs should also continue to explore ways to enhance cultural-sensitivity to targeted populations of adolescents and to recruit adolescents from more diverse settings beyond schools. Though program recruitment through school-settings is an efficient way to reach large numbers of adolescents, adolescents who are at the highest risk for TDV may be the adolescents who are truant or simply not very engaged in school-related activities. Thus, the combination of school- and community-based approaches, as demonstrated by Safe Dates, appears critical for reaching both large numbers of teens as well as high-risk teens. More targeted prevention programs for high-risk youth certainly come with additional challenges. Rizzo et al. (2010) noted that at-risk teens may also have significant difficulties with affect regulation which in turn prevents them from responding appropriately when overwhelmed in various social situations. When working with such a

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population on reducing TDV, then, prevention/ intervention components would also need to address broader affect regulation skills prior to addressing knowledge and attitudes about dating violence. With the preponderance of universal prevention programs implemented in schools, Wolfe and colleagues (2009) argue for addressing wellbeing and enhancing resilience as a way to reduce TDV as well as to help adolescents develop adaptive skills more generally. In fact, Foshee and colleagues (1998) found that after completing an educational program teaching appropriate positive behaviors and adaptive socioemotional skills, adolescent participants reported perpetrating 25 % fewer psychological abuse, 60 % fewer physical abuse, and 60 % fewer sexual abuse at the 1-year follow-up. However, notably throughout this current chapter and the larger literature, information on protective factors and resilience is absent (with the exception of acculturation as buffer). All too often, studies that examine violence view protective factors as simply the flip side of vulnerability. That is, if female gender is a risk factor, then male gender is protective. Therefore, we know little about protective factors independent of risk. In order for prevention programs to enhance resilience, more research is needed to identify protective factors.

Future Directions In addition to the specific recommendations we provided at the close of the major sections in this chapter, we turn now to highlighting additional recommendations for future research directions that are critical to improving TDV-related policy and practice.

Single Victimization Versus Repeat Victimization Many studies on current adult symptomatology or level of functioning ask participants to retrospectively recount their experiences of childhood victimization, often defined as before age 18 (e.g.,

Masho & Ahmed, 2007). Studies also often define revictimization as at least one incident of childhood abuse (before age 18) and at least one incident of victimization in adulthood (after age 18; e.g., Kimerling et al., 2007). Both of these approaches completely exclude adolescence as a distinct category. This perspective continues even as recent findings suggest that victimization in adolescence is the crucial link between childhood victimization and increased risk for adulthood victimization (Arata, 2002; Gidycz et al., 1995; Smith et al., 2003). Victimization in early adolescence has also been shown to place individuals at increased risk for additional victimizations at a later time (e.g., Humphrey & White, 2000; Smith et al., 2003). To date, we know little about specific aspects of revictimization in adolescence. Similarly, much of the past research has focused on identifying risk factors for experiencing victimization broadly defined. Many researchers on TDV do not measure or distinguish between singly victimization and multiple victimization. One of the few exceptions is a study conducted by Young and Furman (2008). They found that more sexual experience and higher levels of demonstrated sensitivity to rejection were risk factors for both single and repeat victimizations. To date, we are aware of no studies that have identified risk factors for single versus multiple victimizations in adolescence. Part of the reason for the paucity of research on this topic may be due to the fact that we do not clearly understand whether revictimization represents a distinct phenomenon. In other words, are there different characteristics or risk factors for individuals who experience a single victimization versus individuals who experience multiple victimizations? Understanding the trajectory of dating violence throughout childhood and adolescence as well as any distinctions between single versus multiple victimizations may be crucial steps in preventing additional victimizations.

TDV Versus IPV in Adulthood Given the persistence of dating violence exposure from adolescence to adulthood, more efforts


should be made to design studies that are methodologically similar in adolescent and adulthood samples so that findings within these age groups can be more readily compared. This is especially important in the absence of longitudinal studies that can follow individuals over long periods of time, such as from adolescence to adulthood. Currently, several differences in the research design and methodologies stand out when comparing adolescent studies of dating violence and adulthood studies of dating violence. One difference is that adolescent studies often utilize schools as a source of recruitment while this source of recruitment is clearly not utilized in adult samples. Thus, adolescents who are assessed may not fully represent the population, but rather encompass a much narrower portion of the population that might not readily translate to findings on IPV in adulthood. Another important difference between studies in adolescence versus adulthood is that studies with adolescents have rarely included data from both partners in the relationship but have instead relied on the report of individuals. Thus, within the adolescent literature, important information related to the prevalence of mutual aggression or reporting biases from one partner versus another (i.e., victims versus perpetrators) are sometimes very difficult, if not impossible, to estimate. Such estimates in adolescence should be viewed as critical given that some level of mutual aggression often characterizes relationships and has important outcomes for both victims and perpetrators as demonstrated in adulthood. Even within a given adolescent community like a school, rates of perpetration and victimization do not as easily “match up” as they might in adulthood studies where relationships might be defined by households, living arrangements, or other indicators, like marriage or engagement, that are more present in adult relationships. Health-related consequences of TDV may also differ in important ways from health-related consequences of adult IPV. A large scale study by Masho and Ahmed (2007) found that victimization by TDV was associated with worse mental health outcomes than adult IPV. Specifically, women who reported sexual assault in their

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adolescent years also reported higher levels of PTSD than women who reported sexual assault only in their adulthood years. Masho and Ahmed (2007) did not control for subsequent victimizations in adulthood, so the individuals who reported sexual assault in adolescence may be at higher risk for PTSD because that earlier victimization led to many other subsequent victimizations, not necessarily because it occurred in the context of adolescence. Given the paucity of longitudinal research or research that specifically compares adolescent versus adult victims, these findings need to be interpreted with caution until further replicated. Masho and Ahmed’s (2007) study does demonstrate, though, that researchers should systematically present what the results may look like when controlling for earlier or subsequent victimizations.

Summary and Conclusion Based on the research to date, TDV poses a serious public health issue. TDV affects a large number of adolescents. Though males and females endorse similar rates of TDV when defined broadly, female victims report more severe levels of TDV and suffer more serious consequences. The existing body of research on TDV clearly illustrates that TDV cannot be reduced to a single-risk model. Instead, risk factors need to be viewed through an ecological model at the individual, relationship, and societal levels; factors across and within levels influence each other in additive and interactive ways to increase or ameliorate risk for TDV. Importantly, even while we continue to gain a better understanding of the interaction between risk factors, many of the mechanisms that underlie these interactions remain poorly understood (see DePrince et al., 2009 for related discussions). With the important advances in research design and statistical tools, we need to continue asking more nuanced research questions. A better understanding of gender and racial/ethnic differences along with identifying subgroups of adolescents who may be particularly vulnerable to TDV will help to address some of the unanswered questions. In turn,

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researchers, clinicians, and policy makers must work together to provide comprehensive and collaborative services in both the prevention and treatment of TDV.

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