cycle of abuse research paper

Domestic Violence and Abuse: Theoretical Explanation and Perspectives

First Online: 17 November 2019

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Parveen Ali 3 ,
Julie McGarry 4 &
Caroline Bradbury-Jones 5

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Domestic violence and abuse (DVA) is a complex issue and it is important to understand how and why this happens. Such understanding can help find strategies to minimise DVA. Over past decades, many explanations have been proposed to explain DVA from various perspectives. This chapter aims to present an aggregated overview of that information to help healthcare professionals understand the phenomenon from a theoretical perspective. The chapter provides information about various perspectives including biological, psychological, sociological, and ecological frameworks.

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Women’s Experiences with Domestic Violence in the Commonwealth Caribbean

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Ali, P., McGarry, J., Bradbury-Jones, C. (2020). Domestic Violence and Abuse: Theoretical Explanation and Perspectives. In: Ali, P., McGarry, J. (eds) Domestic Violence in Health Contexts: A Guide for Healthcare Professions. Springer, Cham. https://doi.org/10.1007/978-3-030-29361-1_2

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1 University of Louisville
2 University of Tennessee
PMID: 29763066
Bookshelf ID: NBK499891

Family and domestic violence including child abuse, intimate partner abuse, and elder abuse is a common problem in the United States. Family and domestic health violence are estimated to affect 10 million people in the United States every year. It is a national public health problem, and virtually all healthcare professionals will at some point evaluate or treat a patient who is a victim of some form of domestic or family violence.

Unfortunately, each form of family violence begets interrelated forms of violence. The "cycle of abuse" is often continued from exposed children into their adult relationships and finally to the care of the elderly.

Domestic and family violence includes a range of abuse, including economic, physical, sexual, emotional, and psychological, toward children, adults, and elders.

Intimate partner violence includes stalking, sexual and physical violence, and psychological aggression by a current or former partner. In the United States, as many as one in four women and one in nine men are victims of domestic violence. Domestic violence is thought to be underreported. Domestic violence affects the victim, families, co-workers, and community. It causes diminished psychological and physical health, decreases the quality of life, and results in decreased productivity.

The national economic cost of domestic and family violence is estimated to be over 12 billion dollars per year. The number of individuals affected is expected to rise over the next 20 years, increasing the elderly population.

Domestic and family violence is difficult to identify, and many cases go unreported to health professionals or legal authorities. Due to the prevalence in our society, all healthcare professionals, including psychologists, nurses, pharmacists, dentists, physician assistants, nurse practitioners, and physicians, will evaluate and possibly treat a victim or perpetrator of domestic or family violence.

Definitions

Family and domestic violence are abusive behaviors in which one individual gains power over another individual.

Intimate partner violence typically includes sexual or physical violence, psychological aggression, and stalking. This may include former or current intimate partners.

Child abuse involves the emotional, sexual, physical, or neglect of a child under 18 by a parent, custodian, or caregiver that results in potential harm, harm, or a threat of harm.

Elder abuse is a failure to act or an intentional act by a caregiver that causes or creates a risk of harm to an elder.

Center for Disease Control and Prevention (CDC)

Domestic violence, spousal abuse, battering, or intimate partner violence, is typically the victimization of an individual with whom the abuser has an intimate or romantic relationship. The CDC defines domestic violence as "physical violence, sexual violence, stalking, and psychological aggression (including coercive acts) by a current or former intimate partner."

Domestic and family violence has no boundaries. This violence occurs in intimate relationships regardless of culture, race, religion, or socioeconomic status. All healthcare professionals must understand that domestic violence, whether in the form of emotional, psychological, sexual, or physical violence, is common in our society and should develop the ability to recognize it and make the appropriate referral.

Violence Abuse Types

The types of violence include stalking, economic, emotional or psychological, sexual, neglect, Munchausen by proxy, and physical. Domestic and family violence occurs in all races, ages, and sexes. It knows no cultural, socioeconomic, education, religious, or geographic limitation. It may occur in individuals with different sexual orientations.

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Disclosure: Martin Huecker declares no relevant financial relationships with ineligible companies.

Disclosure: Kevin King declares no relevant financial relationships with ineligible companies.

Disclosure: Gary Jordan declares no relevant financial relationships with ineligible companies.

Disclosure: William Smock declares no relevant financial relationships with ineligible companies.

Continuing Education Activity
Introduction
Epidemiology
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History and Physical
Treatment / Management
Differential Diagnosis
Pearls and Other Issues
Enhancing Healthcare Team Outcomes
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Research Article

A systematic review of intimate partner violence interventions focused on improving social support and/ mental health outcomes of survivors

Roles Conceptualization, Data curation, Formal analysis, Funding acquisition, Investigation, Methodology, Resources, Software, Writing – original draft, Writing – review & editing

* E-mail: [email protected]

Affiliation International Centre for Reproductive Health, Ghent University, Ghent, Belgium

Roles Data curation, Formal analysis, Methodology, Writing – review & editing

Affiliation Georgia State University Alumna, Atlanta, Georgia, United States of America

Roles Validation, Writing – review & editing

Affiliation Médecins Sans Frontières-Operational Centre Brussels, Brussels, Belgium

Roles Methodology, Supervision, Writing – review & editing

Emilomo Ogbe,
Stacy Harmon,
Rafael Van den Bergh,
Olivier Degomme

Published: June 25, 2020
https://doi.org/10.1371/journal.pone.0235177
Reader Comments

Intimate partner violence (IPV) is a key public health issue, with a myriad of physical, sexual and emotional consequences for the survivors of violence. Social support has been found to be an important factor in mitigating and moderating the consequences of IPV and improving health outcomes. This study’s objective was to identify and assess network oriented and support mediated IPV interventions, focused on improving mental health outcomes among IPV survivors.

A systematic scoping review of the literature was done adhering to PRISMA guidelines. The search covered a period of 1980 to 2017 with no language restrictions across the following databases, Medline, Embase, Web of Science, PROQUEST, and Cochrane. Studies were included if they were primary studies of IPV interventions targeted at survivors focused on improving access to social support, mental health outcomes and access to resources for survivors.

337 articles were subjected to full text screening, of which 27 articles met screening criteria. The review included both quantitative and qualitative articles. As the focus of the review was on social support, we identified interventions that were i) focused on individual IPV survivors and improving their access to resources and coping strategies, and ii) interventions focused on both individual IPV survivors as well as their communities and networks. We categorized social support interventions identified by the review as Survivor focused , advocate/case management interventions (15 studies) , survivor focused, advocate/case management interventions with a psychotherapy component (3 studies), community-focused , social support interventions (6 studies) , community-focused , social support interventions with a psychotherapy component (3 studies) . Most of the studies, resulted in improvements in social support and/or mental health outcomes of survivors, with little evidence of their effect on IPV reduction or increase in healthcare utilization.

There is good evidence of the effect of IPV interventions focused on improving access to social support through the use of advocates with strong linkages with community based structures and networks, on better mental health outcomes of survivors, there is a need for more robust/ high quality research to assess in what contexts and for whom, these interventions work better compared to other forms of IPV interventions.

Citation: Ogbe E, Harmon S, Van den Bergh R, Degomme O (2020) A systematic review of intimate partner violence interventions focused on improving social support and/ mental health outcomes of survivors. PLoS ONE 15(6): e0235177. https://doi.org/10.1371/journal.pone.0235177

Editor: Nihaya Daoud, Ben-Gurion University of the Negev Faculty of Health Sciences, ISRAEL

Received: March 7, 2019; Accepted: June 9, 2020; Published: June 25, 2020

Copyright: © 2020 Ogbe et al. This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Data Availability: All relevant data are within the paper and its Supporting Information files.

Funding: E.O- University of Gent BOF startkrediet (BOF.STA.2016.0031.01) The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

Competing interests: The authors have declared that no competing interests exist.

Introduction

The global prevalence of intimate partner violence (IPV) has been estimated at about 30% for women aged 15 and over [ 1 ]. We define IPV within this paper as ‘any acts of physical violence, sexual violence, stalking and psychological aggression (including coercive tactics) by a current or former intimate partner’ [ 2 ]. IPV affects men and women, and men or women can be perpetrators or survivors of violence. However, women are the most affected by IPV, and men tend to perpetrate violence more than women [ 3 ]. Survivors of violence are likely to first disclose experiences of intimate partner violence and expect informal support from a friend, family member, neighbour or other members of their social network, prior to seeking support from formal sources like health institutions and legal officers, however, the extent of disclosure differed with age, nature, ethnicity and gender [ 4 ].

IPV has been found to be associated with an increased risk of poor health, depressive symptoms, substance use, chronic disease, chronic mental illness and injury for both men and women [ 5 ]. Social support has been found to be an important factor for mediating, buffering and improving the outcomes of survivors of violence and improving mental health outcomes[ 6 ]. Conversely, social isolation and lack of social support have been found to be linked with poor health outcomes for survivors of violence. Liang et al [ 6 ] discussed the importance, perception of the abuse by the IPV survivor plays on their decision to ask for help and support. They mentioned how cultural factors including stigma and shame around disclosing IPV, perception of the incident as a personal problem and awareness of resources available, play a determining factor on types of resources accessed, especially for IPV survivors with a migrant background or of a low socioeconomic status. IPV survivors who perceive the abuse to be a personal problem were more likely to use placating and avoidant strategies before seeking external support [ 6 ].

In this study, we make use of Shumaker and Brownell’s definition of social support, and define it as any provision of assistance, which may be financial or emotional, that is recognized by both the beneficiary and provider as advantageous to the beneficiary’s welfare. ‘[ 7 ]. IPV interventions that involve the use of social support, have the potential to improve the health seeking behaviour, access to resources and mental health outcomes of IPV survivors. Commonly cited types of social support interventions include but are not limited to the use of peer support, family support and the use of ‘remote interventions like the use of internet or telephones as sources of social support from trained counsellors, as well as information about resources’ [ 8 ]. Goodman and Smyth [ 9 ] discussed the importance of using a ‘network oriented’ approach to provision of domestic violence services that takes into account the value of informal support, from social network members of IPV survivors, as this would promote the well-being of the survivor and sustain some of the benefits of the intervention over time. Given the existing gap in evidence on the effect of different IPV interventions on social support and/ mental health outcomes of IPV survivors, this study aimed to address the evidence gap, by assessing the effects of these different IPV interventions, and network oriented approaches on improving access to social support and improved mental health outcomes for IPV survivors. This is of added benefit, as access to social support improves the mental health outcome of survivors of violence. More evidence of different types of social support interventions targeted at different groups of people, that are effective in addressing mental health outcomes of survivors, are needed.

The systematic review was developed according to the PRISMA (Preferred Reporting Items for Systematic reviews and Meta-analyses) guidelines. The methods used to screen the studies and define eligibility are described below:

Eligibility criteria

Studies meeting the following criteria were included: Primary research (original articles excluding systematic reviews), targeted at IPV survivors, describing interventions focused on improving access to resources and mental health outcomes for IPV survivors. The interventions had to use a social support or network-oriented approach. There were no restrictions on gender, but most of the studies identified focused on female survivors of violence (See Table 1 ). We defined ‘IPV as physical, sexual and psychological abuse directed against a person, by a current or ex-partner’ [ 10 ].

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https://doi.org/10.1371/journal.pone.0235177.t001

Studies had to address the following outcomes: intimate partner violence, social support, mental health outcomes and quality of life. Other outcomes that were also included were those associated with access to resources, utilisation of health services, and safety-promoting behaviours, if they were assessed in addition to the outcomes mentioned earlier. No restrictions were placed on study design or language, to allow for inclusion of all relevant studies.

Information sources

Between May and July 2017, we conducted a search across 5 databases: Medline, Embase, Web of Science, Cochrane and PROQUEST, for studies published between 1980 and 2017. We decided to include studies from the 1980’s because some of the pioneering publications on the use of advocacy and social support, for example, Sullivan et al’s work were published in the late 80’s and early 1990’s and we wanted our review to include some of these publications. Even though the review eventually included only primary studies, we included studies from COCHRANE to allow us to identify additional articles. We did not conduct a separate search for grey literature, as the PROQUEST database also included scholarly journals, newspapers, reports, working papers, and datasets along with e-books. Retrieved references were imported to Endnote and Mendeley and were then transferred to a systematic review software called Co-evidence [ 11 ]. In January 2019, another search was done to update and ensure new articles or information could be included in the review. Table 1 provides an overview and summary of the studies selected, as well as the evidence ranking of the studies.

Search strategy

The search strategy was developed in collaboration with a librarian, as well as a review of other existing systematic reviews on IPV or social support interventions. Search terms combined MeSH terms, and specific terms related to IPV and were adapted to each of the databases searched. This is presented in Table 2 .

https://doi.org/10.1371/journal.pone.0235177.t002

Study selection

Inclusion of retrieved studies and their eligibility were independently assessed by two reviewers, EO and SH, in a two-step process. First, the authors independently screened all study titles and abstracts using Co-evidence (the systematic review software), which notified each author of conflicts. When a conflict was identified, articles were again independently reviewed, and discordance was resolved through discussion, using the systematic review protocol as a guide. The same process was also used for the full text-screening phase of the study. While this process lengthened the screening process, it allowed for transparency and made it possible for both reviewers to continually reference the study protocol and ensure that the study objectives were adhered to, through the review process.

Data extraction

A standardized data collection form was developed by EO and SH, adapted from the Cochrane data collection grid. EO extracted all the data from the studies, SH and RB reviewed the data and it was agreed that OD would provide input if there was any disagreement about the data extracted.

Risk of bias

The quality and risk of bias in the studies were independently assessed by EO and SH, using the appropriate quality assessment tool. As the studies selected included quantitative and qualitative studies, there was an agreement to assess quantitative and qualitative studies separately. Quantitative studies were assessed using the Quality Assessment Tool for quantitative studies developed by the Effective Public Health Practice Project, see Table 3 for an overview of the components of this tool [ 12 ]. This tool had been used in another systematic review focused on interventions [ 13 ]. Qualitative studies were assessed, using the Critical Appraisal Skills Programme (CASP) Qualitative Research Checklist [ 14 ], the main components focused on assessing the methodological limitations, coherence, adequacy of data and relevance of research. See Table 4 for an overview.

https://doi.org/10.1371/journal.pone.0235177.t003

https://doi.org/10.1371/journal.pone.0235177.t004

Information about studies selected

The initial search across the different databases retrieved 3712 articles, of which 3364 articles were irrelevant based on the screening criteria. 337 articles were assessed at the full text screening stage, and 27 articles selected to be part of the systematic review, the overview is presented in Fig 1

From : Moher D, Liberati A, Tetzlaff J, Altman DG, The PRISMA Group (2009). P referred R eporting I tems for S ystematic Reviews and M eta- A nalyses: The PRISMA Statement. PLoS Med 6(7): e1000097. doi: 10.1371/journal.pmed1000097 For more information, visit www.prisma-statement.org .

https://doi.org/10.1371/journal.pone.0235177.g001

Results/Key findings from the systematic review

The interventions were classified based on the methodology or type of social support provided to the survivors of violence. Most of the studies identified involved the use of an ‘advocate/ case manager’ or ‘interventionist’ (which referred to a nurse, psychologist or volunteer trained to administer the IPV intervention). The advocate was often responsible for offering the survivor information on resources and helping them identify safety strategies. The interventions usually consisted of weekly sessions or phone calls for a certain period of time. These interventions were mostly in the United States and from other countries like China, Canada, Denmark, Netherlands, Uganda and the United Kingdom. Other interventions involved the use of advocacy with an added psychotherapy component, and interventions that focused on community education, as well as empowerment of the IPV survivors. One of such community focused interventions used an empowerment model and encouraged survivors of violence to take photos of their safety strategies. These photos were used to educate the community about the consequences of intimate partner violence and advocate for community support to prevent intimate partner violence and encourage access to services. In our paper, the term ‘community focused’ included interventions targeted at the community which used participatory and non-participatory methods in the design and implementation of the programmes. The interventions identified in this systematic review had different target groups, pregnant women, survivors of violence resident in shelters, community members and IPV survivors, substance abusing women, and women with small children.

Types of social support interventions for intimate partner violence survivor

Survivor- focused social support interventions..

The interventions described below were all focused on providing social support and improving mental health outcomes for the survivors of violence, all of them involved the use of advocacy/case management approaches, through remote or ‘face to face’ methods. We also identified advocacy interventions with a strong therapeutic component, which we have discussed separately.

Advocacy/ Case management interventions

These interventions involved the use of community-based advocacy interventions focused on individuals that were survivors of violence, these interventions were focused on assisting the survivors identify and access resources, supportive relationships and cope with the effects of intimate partner violence. Fifteen of the studies reviewed (11 RCTs, 2 pre-post evaluation, 1 retrospective study, 1 quasi-experimental study with randomization) described experiences with social support interventions that provided some sort of advocacy service in combination with community support for survivors of violence, on an individual level [ 15 – 29 ].

Advocacy interventions may include ‘helping abused women to access services, guiding them through the process of safety planning, and improving abused women’s physical or psychological health’ [ 30 ]. For the review, interventions grouped under this category included mentor-mother interventions (these interventions involved the training of IPV survivors who were mothers as counsellors and mentors, for other IPV survivors), and use of home-based or in-clinic advocates. Most of the studies reported a decrease in depression, fear, post-traumatic stress disorder, and increased access to social support for the IPV survivors included in the study.

In Tiwari et al’s study, where an advocacy intervention was compared to the usual community services, the reduction in depression and other mental outcomes, was not significant but the reduction in ‘partner aggression’ and increase in access to social support in the intervention arm was significant [ 15 ]. Two of the studies, an in-clinic advocacy intervention by Coker et al [ 23 ] and a home-based advocate intervention by Sharps et al [ 20 ] resulted in a significant reduction in the experience of intimate partner violence by the survivors (decrease in experience of IPV in the intervention arm compared to the control group). The two mentor mothers’ studies included in this review, showed an increase in uptake of support services and mental health services. Prosman et al’s study [ 18 ] specifically showed evidence that the mentor mother intervention led to a decrease of in experience of IPV (decreased Composite Abuse Scale (CAS) mean score by 37.7 (SD 25.7) after 16 weeks), as well as in depression scores. This study had a component that focused on uptake of therapy, which may have influenced the outcomes. Four of these studies compared ‘face to face’ case management/ advocacy services to remote modes of care and assessed the impact on social support and IPV. Gilbert et al’s study [ 24 ] compared online and case manager implemented screening, assessment, and referral to treatment intervention for IPV survivors who were substance abusing, the intervention was guided by social cognitive theory, and focused on short screening, an intervention and referral to treatment (SBIRT) model. There were no significant differences between both groups in terms of impact of the interventions, the study found both groups has an increase in access to social support, IPV self-efficacy (ability to protect themselves from IPV) and abstinence from substance use, irrespective of the type of intervention they received. McFarlane et al [ 26 ] assessed the differences between nurse case management and a referral card on reduction of violence and use of community resources among IPV survivors, and found no differences in outcome between both groups, but found compared to baseline, participants who received either intervention (nurse case management or referral card) had a significant reduction in experiences of violence (threats of abuse, assaults, risks of homicide and work harassment) between baseline and 24 months post-intervention. There were no significant differences in outcome for participants who were in the referral card or case management intervention arm. Other outcomes like improved safety behaviors and a reduction in the utilization of community resources were also found across both groups. Stevens et al’s [ 27 ] study focused on using telephone based support/referral services for IPV survivors compared to enhanced usual care (, the intervention was based on a social support and empowerment model. The study found no significant difference in outcomes between the intervention arm (telephone-based arm) and the control arm (enhanced usual care- community services provided by the community center including health, social, educational, and recreational services). Research participants reported a decrease in experiences of IPV across both groups, associated with ‘higher levels of social support’ at baseline and at 3 months post-intervention. However, the reduced levels of violence did not influence the capacity to obtain or utilize community resources among the research participants. Constantino et al’s [ 29 ] study compared an advocacy based intervention across different methods (online and face to face) and found the intervention reduced depression, anxiety and increased personal and social support among the online group compared to the control group. The intervention included a module that addressed interpersonal relationships, thoughts and emotions as well as access to referral services like legal aid. Another study by Constantino [ 28 ] involved a nurse led intervention focused on providing information on resources and services for IPV survivors living in a domestic violence shelter. The intervention was compared to usual care in the shelter. The intervention group had reduced psychological distress, increased levels of social support and reduced reporting of health care issues. Most of the studies we found in this category showed moderate levels of quality of evidence.

Advocacy/Case management interventions with a psychotherapy component

3 of the studies (3 RCTs) [ 31 – 33 ] were focused on interventions that included specific types of psychotherapy, sometimes delivered remotely or through individual or group sessions. Zlotnick et al [ 31 ] described the use of interpersonal psychotherapy among pregnant women focused at improving social support among the survivors of violence during individual psychotherapy sessions. Though there was a moderate change in depression and PTSD scores (reduction) between the control and intervention groups at post-intake (5–6 weeks), this difference was not sustained at the post-partum period. Hansen et al [ 33 ] describes the use of psychotherapy using either the ‘Trauma Recovery Group’ (TRG) method developed by ‘a private Danish organization called ‘‘The Mothers’ Aid”‘ or regular trauma therapy for individual or groups of women who were survivors of IPV. The study reported significant changes in PTSD, depression and anxiety symptoms and increased levels of social support (high effect sizes); however, our assessment with the EPHPP grading revealed that the study design was weak. Miller et al’s [ 32 ] study shows the effect of a ‘mom empowerment programme’ focused on improving mental health outcomes and ability to access resources among IPV survivors participating in the programme, with resulting improvement in PTSD, depression and anxiety symptoms.

Community-focused/ network social support interventions

These group of studies, distinct from the ones described above focused on community education and change, so the focus of the studies was not just the individual survivor of violence, but the community as a whole. 9 (3 RCTs, 3 pre-post evaluations, 3 qualitative research) of the studies we reviewed consisted of interventions described as being community-based [ 34 – 42 ]. The definitions of community-focused interventions used for classifying the studies followed the typology by McLeroy et al [ 43 ], which refers to interventions where:

The setting of the intervention is the community
The target population of the intervention is the community
The intervention uses community members as a resource
The community serves as an agent for the intervention (i.e. interventions working with already existing structures within the community)

We have focused on interventions in this category where the focus of the intervention is the community. The interventions described include community participatory research, like those described by Ragavan et al’s systematic review on community participatory research on domestic violence [ 44 ], as well as interventions that are ‘community placed’, where the community is a target of the intervention, and might not have been involved in the design of the intervention, in a participatory way.

All the interventions were focused on IPV reduction and improving social support and mental health outcomes for survivors of violence. Interventions like SASA [ 34 , 39 ], used community members as a resource for the intervention. In the SASA intervention, community activists in the intervention sites were trained on GBV prevention, power inequalities and gender norms. After training, they carried out advocacy activities, engaging different stakeholders and members of their social networks to address harmful social norms around GBV. At the end of the intervention, there were reported lower rates of IPV among the intervention community. Other interventions like the ‘Framing Safety project’ [ 35 ], which focused on promoting agency and self-empowerment among survivors of violence, found that by providing means through which survivors of violence could tell their own stories and take ownership of this process, there was a resulting feeling of empowerment among the women. Other interventions used group therapy sessions that were community-based and culturally tailored to the specific target population. Wuest et al [ 41 ] described a collaborative partnership with different stakeholders (academic, NGOs and community members) to develop a comprehensive intervention to IPV, ‘Intervention for Health Enhancement After Leaving (iHEAL), a primary health care intervention for women recently separated from violent/abusive partners’. The post evaluation revealed significant reduction in depression and PTSD from baseline to 6 months post-intervention, these improvements in mental health outcomes, were present at 12 months post-intervention. Other outcomes, like social support, showed some initial improvement from baseline to 6 months post-intervention but these changes were not sustained till 12 months post-intervention.

Community focused/ network interventions with a psychotherapy component

Three of the nine studies (1 RCT and 2 pre-post study) by Kelly et al [ 36 ], McWhirter et al [ 37 ], and Nicolaidis et al [ 38 ] described group therapy interventions that were designed in collaboration with the target population in a participatory way. These studies reported significant reductions in severity of mental health conditions like depression and PTSD, as well as an increase in social support and self-efficacy for the women who were involved in the study.

The focus of this systematic review was to assess the existing evidence available on IPV interventions focused on improving social support and/or mental health outcomes. To ensure that we included all relevant studies, we included both quantitative and qualitative articles. 27 articles were included in the systematic review out of 337 full text articles assessed. The following interventions were identified via the review: Survivor focused interventions (18 studies: 15 of these studies were focused on advocacy/case management services; 3 of these on advocacy/case management services with a psychotherapy component), community-based social support interventions (9 studies:4 out of these were community coordinated interventions with a psychotherapy component). The heterogeneity of the studies made it difficult to conduct a meta-analysis because of the variability in outcome measures, study design and processes and duration of interventions implemented. Survivor focused advocacy/case management IPV interventions made up most of the interventions identified (18 out of 27). The studies showed good to moderate evidence of the positive impact of these interventions on mental health outcomes and also access to social support for the IPV survivors included in the study, and in a few studies, a reduction in partner aggression or experience of IPV (IPV scores) [ 15 – 23 ]. In one study, by De Prince et al [ 42 ], where a community-based advocacy intervention was compared to an advocacy intervention that was focused on referral, both groups showed improvement in mental health outcomes, but the community-based advocacy intervention group (outreach) had slightly better mental health outcomes. A specific approach of the intervention was that it was community-led/ coordinated, the community based organisation reached out directly to the survivors of violence based on information from the systems based advocate, hence removing the need for survivors to seek out services themselves based on the referrals received from the system based advocate. This study might have important lessons for future advocacy interventions, as just provision of referrals might not ensure uptake of services, and a community coordinated follow up of IPV survivors might be more effective in ensuring uptake. However, it must be noted that only few of the advocate-based studies and 1 of the community-focused interventions reported an impact on IPV, with good level of evidence [ 15 , 20 – 23 , 34 ], similar to what has been found in other reviews of advocate-based interventions on intimate partner violence [ 45 ]. Tiwari et al’s study, which focused on the use of an empowerment, social support and advocacy-focused telephone intervention, found improved mental health outcomes among the intervention group. In comparison, Cripe et al’s [ 46 ] study also compared the effect of an empowerment-based intervention in comparison to usual care among abused pregnant women and found higher scores of improved safety behaviours among the intervention group compared to the control group but ‘no statistically significant difference in health-related quality of life, adoption of safety behaviours, and use of community resources between women in the intervention and control groups’. These differences we attribute to the study design, context and characteristics of the study participant. Goodman et al has described the importance of integrating a ‘social network’ approach into IPV interventions, and linking interventions with social networks of IPV survivors to ensure sustained access to social support for the survivors [ 9 , 47 ]. Many of the advocacy/case management interventions described above have created these linkages by assisting IPV survivors identify sources of support within their existing networks and also engage in forming new social relationships [ 16 , 18 , 48 ]. However, more IPV interventions should integrate this approach in a coordinated systemic manner, as engaging with social network members of the IPV survivors ensures sustainability of the programme’s effects over time [ 9 ].

Several of the studies focused on psychotherapy interventions, which were individual, or group based. We classified these interventions separately as these interventions combined community-based advocacy with a therapeutic component, as opposed to advocacy/case management alone or community focused interventions. These interventions either used interpersonal therapy [ 31 ], traumatic treatment therapy [ 33 ], empowerment based group therapy [ 32 ], and a multicomponent intervention that combined therapeutic education sessions with information on resources and legal help remotely or ‘face to face’ [ 29 ]. All the interventions showed some impact on mental health outcomes and social support, with a weaker level of evidence of an impact on IPV. Although Zlotnick et al’s study[ 31 ] on a therapeutic intervention for pregnant IPV survivors, described an improvement of mental health outcomes (moderate effect on PTSD and depression), this finding was not sustained in the postpartum period, drawing attention to the need to assess the efficacy of interventions in this particular group, taking into account time dependent factors and participant attributes. A review done by Trabold et al [ 49 ], found that clinically focused interventions and group-based cognitive or cognitive behavioural interventions had a significant effect on depression and PTSD, as well as the uses of Interpersonal therapy (time dependent). However, as our review focused on therapies focused on improving social support and mental health outcomes, we included fewer studies. Although we found a similar trend as described by Trabold et al, among community-based interventions (including those that were psychotherapy focused), we could not assign the effect specifically to the type of psychotherapy method, but rather to the length, associated support services and context of the intervention. Sullivan et al [ 50 ] discussed the positive effect of trauma informed practice on mental health outcomes of IPV survivors in Shelters, showing evidence of the importance of IPV interventions to include a comprehensive ‘therapeutic or mental health component’. They also discussed the six components of what ‘trauma informed practice’ which includes: (a) reflecting and understanding of trauma and its many impacts on health and behaviour, (b) addressing both physical and psychological safety concerns, (c) using a culturally informed strengths-based approach, (d) helping to illuminate the nature and impact of trauma on survivors’ everyday experience, and (e) providing opportunities for clients to regain control over their lives’. These components were useful for advocacy/case management interventions for IPV survivors, to ensure a focus on improving mental health outcomes, intersectional collaboration between stakeholders, and that the intervention is survivor-centred and addresses cultural factors.

Interventions that compared remote and ‘face to face’ methods of support and advocacy mostly resulted in a reduction in IPV victimization and increased access to social support. In cases where different modes of intervention delivery were tested, for example a comparison between remotely delivered interventions (telephone or online) and ‘face to face’ interventions, no difference was noted between both modes of intervention. Krasnoff and Moscati’s study [ 51 ] discussed a multi-component referral, support and case management intervention that reported similar reduction in perceived IPV victimization as seen in studies included in our review. There were some differences in the telephone support interventions included, Stevens et al’s study [ 27 ] reported no difference in mental health outcomes compared to Tiwari et al’s study[ 15 ] which found an improvement in mental health outcomes among the intervention group. We postulate differences in outcome could be attributable to the fact that Tiwari’s intervention was more advocacy, empowerment and support focused than the intervention described in Stevens et al study, which was more information and referral focused.

Summary of key findings and recommendations

Most of the interventions that used advocacy with strong community linkages and a focus on community networks showed significant effects on mental health outcomes and access to social support, we assume a reason for this could be that because these interventions were rooted in the community, there were more sources of support that allowed the survivors of violence to develop better coping strategies, for example in the SASA study that included a strong community engagement component, community responses to cases of IPV were supportive of the survivor, and this had an effect on incidence of IPV. Future research and interventions on IPV should focus on ensuring stronger community linkages and outreach programmes to enhance the impact of the interventions on IPV survivors.
This review found that when remote modes of intervention delivery were compared to ‘in person’ delivery of an intervention, there were no significant differences in outcome. This finding is of specific importance to hard-to-reach and vulnerable populations whom might be unwilling to access care at hospitals and registered clinics. More research focused on the use of remote support interventions among vulnerable populations (specifically IPV survivors), should be encouraged.
There was a lot of heterogeneity in outcome measurements, especially measures of social support, drawing attention to the need for research and discussions around standardization and synthesis of evidence-based research on social support and IPV.
In some of the studies, the ‘dosage of the intervention’, as well as some participant characteristics like age or ethnicity are often cited as potential moderators of some of the outcomes, more research on IPV intervention should examine the time dependent nature of interventions and their effect on outcomes similar to what was done by Bybee et al[ 16 ].

Limitations

Although there were no language restrictions included in our search strategy, most of the studies retrieved and subsequently reviewed were in English, which could have influenced some of our conclusions.

Conclusions

This systematic review presented the findings from IPV interventions focused on social support and mental health outcomes for IPV survivors. Advocacy/case management interventions that had strong linkages with communities, and were community focused seemed to have significant effects on mental health outcomes and access to resources for IPV survivors. However, all IPV survivors are not the same, and culture, socioeconomic background and the perception of abuse by the IPV survivor, have a mediating effect on their decision to access social support and utilize referral services. ‘An intersectional trauma informed practice’[ 50 ] [ 52 ] that addresses psychological and physical effects of IPV, is culturally appropriate and is empowering for the survivor, in addition to a ‘social network oriented approach’ might provide a way to ensure that IPV interventions are responsive to the needs of the IPV survivor[ 47 ]. This will ensure the interventions are targeted at ensuring survivors are able to access social support from their existing networks or new social relationships, and might also promote community education about IPV and promote community support for IPV prevention and mitigation. Future studies on IPV interventions should assess how these approaches impact the incidence of IPV, social and mental health outcomes across different populations’ of IPV survivors.

Supporting information

S1 checklist. prisma 2009 checklist..

https://doi.org/10.1371/journal.pone.0235177.s001

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Violence in Families: Assessing Prevention and Treatment Programs (1998)

Chapter: 9 conclusions and recommendations, 9 conclusions and recommendations.

The problems of child maltreatment, domestic violence, and elder abuse have generated hundreds of separate interventions in social service, health, and law enforcement settings. This array of interventions has been driven by the urgency of the different types of family violence, client needs, and the responses of service providers, advocates, and communities. The interventions now constitute a broad range of institutional services that focus on the identification, treatment, prevention, and deterrence of family violence.

The array of interventions that is currently in place and the dozens of different types of programs and services associated with each intervention represent a valuable body of expertise and experience that is in need of systematic scientific study to inform and guide service design, treatment, prevention, and deterrence. The challenge for the research community, service providers, program sponsors, and policy makers is to develop frameworks to enhance critical analyses of current strategies, interventions, and programs and identify next steps in addressing emerging questions and cross-cutting issues. Many complexities now characterize family violence interventions and challenge the development of rigorous scientific evaluations. These complexities require careful consideration in the development of future research, service improvements, and collaborative efforts between researchers and service providers. Examples of these complexities are illustrative:

The interventions now in place in communities across the nation focus services on discrete and isolated aspects of family violence. They address different aspects of child maltreatment, domestic violence, and elder abuse. Some
interventions have an extensive history of experience, and others are at a very early stage of development.
Many interventions have not been fully implemented because of limited funding or organizational barriers. Thus in many cases it is too early to expect that research can determine whether a particular intervention or strategy (such as deterrence or prevention) is effective because the intervention may not yet have sufficient strength to achieve its intended impact.
The social and institutional settings of many interventions present important challenges to the design of systematic scientific evaluations. The actual strength or dosage of a particular program can be directly influenced by local or national events that stimulate changes in resources, budgets, and personnel factors that influence its operation in different service settings. Variations in service scope or intensity caused by local service practices and social settings are important sources of "noise" in cross-site research studies; they can directly affect evaluation studies in such key areas as definitions, eligibility criteria, and outcome measures.
Emerging research on the experiences of family violence victims and offenders suggests that this is a complex population composed of different types of individuals and patterns of behavior. Evaluation studies thus need to consider the types of clients served by particular services, the characteristics of those who benefited from them, and the attributes of those who were resistant to change.

In this chapter the committee summarizes its overall conclusions and proposes policy and research recommendations. A key question for the committee was whether and when the research evidence is sufficient to guide a critical examination of particular interventions. In some areas, the body of research is sufficient to inform policy choices, program development, evaluation research, data collection, and theory-building; the committee makes recommendations for current policies and practices in these areas below. In other areas, although the research base is not yet mature enough to guide policy and program development, some interventions are ready for rigorous evaluation studies. For this second tier of interventions, the committee makes recommendations for the next generation of evaluation studies. The committee then identifies a set of four topics for basic research that reflect current insights into the nature of family violence and trends in family violence interventions. A final section makes some suggestions to increase the effectiveness of collaborations between researchers and service providers.

Conclusions

The committee's conclusions are derived from our analysis of the research literature and discussions with service providers in the workshops and site visits, rather than from specific research studies. This analysis takes a client-oriented

approach to family violence interventions, which means that we focus on how existing services in health, social services, and law enforcement settings affect the individuals who come in contact with them.

The urgency of the need to respond to the problem of family violence and the paucity of research to guide service interventions have created an environment in which insights from small-scale studies are often adopted into policy and professional practice without sufficient independent replication or reflection on their possible shortcomings. Rigorous evaluations of family violence interventions are confined, for the most part, to small or innovative programs that provide an opportunity to develop a comparison or control study, rather than focusing on the major existing family violence interventions.
This situation has fostered a series of trial-and-error experiences in which a promising intervention is later found to be problematic when employed with a broader and more varied population. Major treatment and prevention interventions, such as child maltreatment reporting systems, casework, protective orders, and health care for victims of domestic violence, battered women's shelters, and elder abuse interventions of all types, have not been the subjects of rigorous evaluation studies. The programmatic and policy emphasis on single interventions as panaceas to the complex problems of family violence, and the lack of sufficient opportunity for learning more about the service interactions, client characteristics, and contextual factors that could affect the impact of different approaches, constitute formidable challenges to the improvement of the knowledge base and prevention and treatment interventions in this filed.
In all areas of family violence, after-the-fact services predominate over preventive interventions. For child maltreatment and elder abuse, case identification and investigative services are the primary form of intervention; services designed to prevent, treat, or deter family violence are relatively rare in social service, health, and criminal justice settings (with the notable exceptions of foster care and family preservation services). For domestic violence, interventions designed to treat victims and offenders and deter future incidents of violence are more common, but preventive services remain relatively underdeveloped.
The current array of family violence interventions (especially in the areas of child maltreatment and elder abuse) is a loosely coupled network of individual programs and services that are highly reactive in nature, focused primarily on the detection of specific cases. It is a system largely driven by events, rather than one that is built on theory, research, and data collection. Interventions are oriented toward the identification of victims and the substantiation and documentation of their experiences, rather than the delivery of recommended services to reduce the incidence and consequences of family violence in the community overall. As a result, enormous resources are invested to develop evidence that certain victims or offenders need treatment, legal action, or other interventions, and comparatively limited funds are available for the treatment and support services themselves—a
situation that results in lengthy waiting lists, discretionary decisionmaking processes in determining which cases are referred for further action, and extensive variation in a service system's ability to match clients with appropriate interventions.
The duration and intensity of the mental health and social support services needed to influence behaviors that result from or contribute to family violence may be greater than initially estimated. Family violence treatment and preventive interventions that focus on single incidents and short periods of support services, especially in such areas as parenting skills, mental health, and batterer treatment, may be inadequate to deal with problems that are pervasive, multiple, and chronic. Many programs for victims involve short-term treatment services—less than 6 weeks. Services for offenders are also typically of short duration. Yet research suggests that short-term programs designed to alter violent behavior are often the least likely to succeed, because of the difficulties of changing behavior that has persisted for a period of years and has become part of an established pattern in relationships. Efforts to address fundamental sources of conflict, stress, and violence that occur repeatedly over time within the family environment may require extensive periods of support services to sustain the positive effects achieved in short-term interventions.
The interactive nature of family violence interventions constitutes a major challenge to the evaluation of interventions because the presence or absence of policies and programs in one domain may directly affect the implementation and outcomes of interventions in another. Research suggests that the risk and protective factors for child maltreatment, domestic violence, and elder abuse interact across multiple levels. The uncoordinated but interactive system of services requires further attention and consideration in future evaluation studies. Such evaluations need to document the presence and absence of services that affect members of the same family unit but offer treatment for specific problems in separate institutions characterized by different service philosophies and resources.
For example, factors such as court oversight or mandatory referrals may influence individual participation in treatment services and the outcomes associated with such participation. The culture and resources of one agency can influence the quality and timing of services offered by another. Yet little information is available regarding the extent or quality of interventions in a community. Clients who receive multiple interventions (especially children) are often not followed through different service settings. Limited information is available to distinguish key features of innovative interventions from those usually offered in a community; to describe the stages of implementation of specific family violence programs, interventions, or strategies; to explain rates of attrition in the client base; or to capture case characteristics that influence the ways in which clients are selected for specific treatment programs.
The emergence of secondary prevention interventions specifically targeted to serve children, adults, and communities with characteristics that are
thought to place them at greater risk of family violence than the general population, along with the increasing emphasis on the need for integration and coordination of services, has the potential to achieve significant benefits. However, the potential of these newer interventions to reduce the need for treatment or other support services over the lifetime of the client has not yet been proven for large populations.
Secondary preventive interventions, such as those serving children exposed to domestic violence, have the potential to reduce future incidents of family violence and to reduce the existing need for services in such areas as recovery from trauma, substance abuse, juvenile crime, mental health and health care. However, evaluation studies are not yet available to determine the value of preventive interventions for large populations in terms of reduction of the need for treatment or other support services over a client's lifetime.
The shortage of service resources and the emphasis on reactive, short-term treatment have directed comparatively little attention to interventions for people who have experienced or perpetrated violent behavior but who have not yet been reported or identified as offenders or victims. Efforts to achieve broader systemic collaboration, comprehensive service integration, and proactive interventions require attention to the appropriate balance among enforcement, treatment, and prevention interventions in addressing family violence at both state and national levels. Such efforts also need to be responsive to the particular requirements of diverse ethnic communities with special needs or unique resources that can be mobilized in the development of preventive interventions. Because they extend to a larger population than those currently served by treatment centers, secondary prevention efforts can be expensive; their benefits may not become apparent until many years after the intervention occurs.
Policy leadership is needed to help integrate family violence treatment, enforcement and support actions, and preventive interventions and also to foster the development of evaluations of comprehensive and cross-problem interventions that have the capacity to consider outcomes beyond reports of future violent behavior.
Creative research methodologies are also needed to examine the separate and combined effects of cross-problem service strategies (such as the treatment of substance abuse and family violence), follow individuals and families through multiple service interventions and agency settings, and examine factors that may play important mediating roles in determining whether violence will occur or continue (such as the use of social networks and support services and the threat of legal sanctions).
Most evaluations seek to document whether violent behavior decreased as a result of the intervention, an approach that often inhibits attention to other factors that may play important mediating roles in determining whether violence will occur. The individual victim or offender is the focus of most interventions and
the unit of analysis in evaluation studies, rather than the family or the community in which the violence occurred.

Integrated approaches have the potential to illuminate the sequences and ways in which different experiences with violence in the family do and do not overlap with each other and with other kinds of violence. This research approach requires time to mature; at present, it is not strong enough to determine the strengths or limitations of strategies that integrate different forms of family violence compared with approaches that focus on specific forms of family violence. Service integration efforts focused on single forms of family violence may have the potential to achieve greater impact than services that disregard the interactive nature of this complex behavior, but this hypothesis also remains unproven.

Recommendations For Current Policies And Practices

It is premature to offer policy recommendations for most family violence interventions in the absence of a research base that consists of well-designed evaluations. However, the committee has identified two areas (home visitation and family preservation services) in which a rigorous set of studies offers important guidance to policy makers and service providers. In four other areas (reporting practices, batterer treatment programs, record keeping, and collaborative law enforcement approaches) the committee has drawn on its judgment and deliberations to encourage policy makers and service providers to take actions that are consistent with the state of the current research base.

These six interventions were selected for particular attention because (1) they are the focus of current policy attention, service evaluation, and program design; (2) a sufficient length of time has elapsed since the introduction of the intervention to allow for appropriate experience with key program components and measurement of outcomes; (3) the intervention has been widely adopted or is under consideration by a large number of communities to warrant its careful analysis; and (4) the intervention has been described and characterized in the research literature (through program summaries or case studies).

Reporting Practices

All 50 states have adopted laws requiring health professionals and other service providers to report suspected child abuse and neglect. Although state laws vary in terms of the types of endangerment and evidentiary standards that warrant a report to child protection authorities, each state has adopted a procedure that requires designated professionals—or, in some states, all adults—to file a report if they believe that a child is a victim of abuse or neglect. Mandatory reporting is thought to enhance early case detection and to increase the likelihood that services will be provided to children in need.

For domestic violence, mandatory reporting requirements for professional groups like health care providers have been adopted by the state of California and are under consideration in several other states. Mandatory reports are seen as a method by which offenders who abuse multiple partners can be identified through the health care community for law enforcement purposes. Early detection is assumed to lead to remedies and interventions that will prevent further abuse by holding the abuser accountable and helping to mitigate the consequences of family violence.

Critics have argued that mandatory reporting requirements may damage the confidentiality of the therapeutic relationship between health professionals and their clients, disregard the knowledge and preferences of the victim regarding appropriate action, potentially increase the danger to victims when sufficient protection and support are not available, and ultimately discourage individuals who wish to seek physical or psychological treatment from contacting and disclosing abuse to health professionals. In many regions, victim support services are not available or the case requires extensive legal documentation to justify treatment for victims, offenders, and families.

For elder abuse, 42 states have mandatory reporting systems. Several states have opted for voluntary systems after conducting studies that considered the advantages and disadvantages of voluntary and mandatory reporting systems, on the grounds that mandatory reports do not achieve significant increases in the detection of elder abuse cases.

In reviewing the research base associated with the relationship between reporting systems and the treatment and prevention of family violence, the committee has observed that no existing evaluation studies can demonstrate the value of mandatory reporting systems compared with voluntary reporting procedures in addressing child maltreatment or domestic violence. For elder abuse, studies suggest that a high level of public and professional awareness and the availability of comprehensive services to identify, treat, and prevent violence is preferable to reporting requirements in improving rates of case detection.

The absence of a research base to support mandatory reporting systems raises questions as to whether they should be recommended for all areas of family violence. The impact of mandatory reporting systems in the area of child maltreatment and elder abuse remains unexamined. The committee therefore suggests that it is important for the states to proceed cautiously at this time and to delay adopting a mandatory reporting system in the area of domestic violence, until the positive and negative impacts of such a system have been rigorously examined in states in which domestic violence reports are now required by law.

Recommendation 1: The committee recommends that states initiate evaluations of their current reporting laws addressing family violence to examine whether and how early case detection leads to improved outcomes for the victims or families and promote changes based on sound research. In

particular, the committee recommends that states refrain from enacting mandatory reporting laws for domestic violence until such systems have been tested and evaluated by research.

In dealing with family violence that involves adults, federal and state government agencies should reconsider the nature and role of compulsory reporting policies. In the committee's view, mandatory reporting systems have some disadvantages in cases involving domestic violence, especially if the victim objects to such reports, if comprehensive community protections and services are not available, and if the victim is able to gain access to therapeutic treatment or support services in the absence of a reporting system.

The dependent status of young children and some elders provides a stronger argument in favor of retaining mandatory reporting requirements where they do exist. However, the effectiveness of reporting requirements depends on the availability of resources and service personnel who can investigate reports and refer cases for appropriate treatment, as well as clear guidelines for processing reports and determining which cases qualify for services. Greater discretion may be advised when the child and family are able to receive therapeutic treatment from health care or other service providers and when community resources are not available to respond appropriately to their cases. The treatment of adolescents especially requires major consideration of the pros and cons of mandatory reporting requirements. Adolescent victims are still in a vulnerable stage of development: they may or may not have the capacity to make informed decisions regarding the extent to which they wish to invoke legal protections in dealing with incidents of family violence in their homes.

Batterer Treatment Programs

Four key questions characterize current policy and research discussions about the efficacy of batterer treatment, one of the most challenging problems in the design of family violence interventions: Is treatment preferable to incarceration, supervised probation, or other forms of court oversight for batterers? Does participation in treatment change offenders' attitudes and behavior and reduce recidivism? Does the effectiveness of treatment depend on its intensity, duration, or the voluntary or compulsory nature of the program? Is treatment what creates change, or is change in behavior reduced by multiple interventions, such as arrest, court monitoring of client participation in treatment services, and victim support services?

Descriptive research studies suggest that there are multiple profiles of batterers, and therefore one generic approach is not appropriate for all offenders. Treatment programs may be helpful in changing abusive behavior when they are part of an overall strategy designed to recognize and reduce violence in a relationship, when the batterer is prepared to learn how to control aggressive impulses, and

when the treatment plan emphasizes victim safety and provides for frequent interactions with treatment staff.

Research on the effectiveness of treatment programs suggests that the majority of subjects who complete court-ordered treatment programs do learn basic cognitive and behavioral principles taught in their course. However, such learning requires appropriate program content and client participation in the program for a sufficient time to complete the necessary training. Very few studies have examined matched groups of violent offenders who are assigned to treatment and control groups or comparison groups (such as incarceration or work-release). As a result, the comparative efficacy of treatment is unknown in reducing future violence. Differing client populations and differing forms of court oversight are particularly problematic factors that inhibit the design of rigorous evaluation studies in this field.

The absence of strong theory and common measures to guide the development of family violence treatment regimens, the heterogeneity of offenders (including patterns of offending and readiness to change) who are the subjects of protective orders or treatment, and low rates of attendance, completion, and enforcement are persistent problems that affect both the evaluation of the interventions and efforts to reduce the violence. A few studies suggest that court oversight does appear to increase completion rates, which have been linked to enhanced victim safety in the area of domestic violence, but increased completion rates have not yet led to a discernible effect on recidivism rates in general.

Further evaluations are needed to examine the outcomes associated with different approaches and programmatic themes (such as cognitive-behavioral principles: issues of power, control, and gender; personal accountability). Completion rates have been used as an interim outcome to measure the success of batterer treatment programs; further studies are needed to determine if completers can be identified readily, if program completion by itself is a critical factor in reducing recidivism, and if participation in a treatment program changes the nature, timing, and severity of future violent behavior.

The current research base is inadequate to identify the conditions under which mandated referrals to batterer treatment programs offer a clear advantage over incarceration or untreated probation supervision in reducing recidivism for the general population of male offenders. Court officials should monitor closely the attendance, participation, and completion rates of offenders who are referred to batterer treatment programs in lieu of more punitive sentences. Treatment staff should inform law enforcement officials of any significant behavior by the offender that might represent a threat to the victim. Mandated treatment referrals may be effective for certain types of batterers, especially if they increase completion rates. The research is inconclusive, however, as to which types of individuals should be referred for treatment rather than more punitive sanctions. In selecting individuals for treatment, attention should be given to client history

(first-time offenders are more likely to benefit), motivation for treatment, and likelihood of completion.

Mandated treatment referrals for batterers do appear to provide benefits to victims, such as intensive surveillance of offenders, an interlude to allow planning for safety and victim support, and greater community awareness of the batterer's behavior. These outcomes may interact to deter and reduce domestic violence in the community, even if a treatment program does not alter the behavior of a particular batterer. Treatment programs that include frequent interactions between staff and victims also provide a means by which staff can help educate victims about danger signals and support them in efforts to obtain greater protection and legal safeguards, if necessary.

Recommendation 2: In the absence of research that demonstrates that a specific model of treatment can reduce violent behavior for many domestic violence offenders, courts need to put in place early warning systems to detect failure to comply with or complete treatment and signs of new abuse or retaliation against victims, as well as to address unintended or inadvertent results that may arise from the referral to or experience with treatment.

Further research evaluation studies are needed to review the outcomes for both offenders and victims associated with program content and levels of intensity in different treatment models. This research will help indicate whether treatment really helps and what mix of services are more helpful than others. Improved research may also help distinguish those victims and offenders for whom particular treatments are most beneficial.

Record Keeping

Since experience with family violence appears to be associated with a wide range of health problems and social service needs, service providers are recognizing the importance of documenting abuse histories in their client case records. The documentation in health and social service records of abuse histories that are self-reported by victims and offenders can help service providers and researchers to determine if appropriate referrals and services have been made and the outcomes associated with their use. The exchange of case records among service providers is essential to the development of comprehensive treatment programs, continuity of care, and appropriate follow-up for individuals and families who appear in a variety of service settings. Such exchanges can help establish greater accountability by service systems for responding to the needs of identifiable victims and offenders; health and social service records can also provide appropriate evidence for legal actions, in both civil and criminal courts and child custody cases.

Research evaluations of service interventions often require the use of anonymous case records. The documentation of family violence in such records will

enhance efforts to improve the quality of evaluations and to understand more about patterns of behavior associated with violent behaviors and victimization experiences. Although documentation of abuse histories can improve evaluations and lead to integrated service responses, such procedures require safeguards so that individuals are not stigmatized or denied therapeutic services on the basis of their case histories. Insurance discrimination, in particular, which may preclude health care coverage if abuse is judged to be a preexisting condition, requires attention to ensure that professional services are not diminished as a result of voluntary disclosures. Creative strategies are needed to support integrated service system reviews of medical, legal, and social service case records in order to enhance the quality and accountability of service responses. Such reviews will need to meet the expectations of privacy and confidentiality of both individual victims and the community, especially in cases in which maltreatment reports are subsequently regarded as unfounded.

Documentation of abuse histories that are voluntarily disclosed by victims or offenders to health care professionals and social service providers must be distinguished from screening efforts designed to trigger such disclosures. The committee recommends screening as a strong candidate for future evaluation studies (see discussion in the next section).

Recommendation 3: The committee recommends that health and social service providers develop safeguards to strengthen their documentation of abuse and histories of family violence in both individual and group records, regardless of whether the abuse is reported to authorities.

The documentation of histories of family violence in health records should be designed to record voluntary disclosures by both victims and offenders and to enhance early and coordinated interventions that can provide a therapeutic response to experiences with abuse or neglect. Safeguards are required, however, to ensure that such documentation does not lead to stigmatization, encourage discriminatory practices, or violate assurances of privacy and confidentiality, especially when individual histories become part of patient group records for health care providers and employers.

Collaborative Law Enforcement Strategies

In the committee's view, collaborative law enforcement strategies that create a web of social control for offenders are an idea worth testing to determine if such efforts can achieve a significant deterrent effect in addressing domestic violence. Collaborative strategies include such efforts as victim support and offender tracking systems designed to increase the likelihood that domestic violence cases will be prosecuted when an arrest has been made, that sanctions and treatment services will be imposed when evidence exists to confirm the charges brought against the offender, and that penalties will be invoked for failure to comply with treatment

conditions. The attraction of collaborative strategies is based on their potential ability to establish multiple interactions with offenders across a large domain of interactions that reinforce social standards in the community and establish penalties for violations of those standards. Creating the deterrent effect, however, requires extensive coordination and reciprocity between victim support and offender monitoring efforts involving diverse sectors of the law enforcement community. These efforts may be difficult to implement and evaluate. Further studies are needed to determine the extent to which improved collaboration among police officers, prosecutors, and judges will lead to improved coordination and stronger sanctions for offenders and a reduction in domestic violence.

The absence of empirical research findings of the results of a collaborative law enforcement approach in addressing domestic violence makes it difficult to compare the costs and benefits of increased agency coordination with those achieved by a single law enforcement strategy (such as arrest) in dealing with different populations of offenders and victims. Even though relatively few cases of arrest are made for any form of family violence, arrest is the most common and most studied form of law enforcement intervention in this area. Research studies conducted in the 1980s on arrest policies in domestic violence cases are the strongest experimental evaluations to date of the role of deterrence in family violence interventions. These experiments indicate that arrest may be effective for some, but not most, batterers in reducing subsequent violence by the offender. Some research studies suggest that arrest may be a deterrent for employed and married individuals (those who have a stake in social conformity) and may lead to an escalation of violence among those who do not, but this observation has not been tested in studies that could specifically examine the impact of arrest in groups that differ in social and economic status. The differing effects (in terms of a reduction of future violence) of arrest for employed/unemployed and married/unmarried individuals raise difficult questions about the reliance of law enforcement officers on arrest as the sole or central component of their response to domestic violence incidents in communities where domestic violence cases are not routinely prosecuted, where sanctions are not imposed by the courts, or where victim support programs are not readily available.

The implementation of proarrest policies and practices that would discriminate according to the risk status of specific groups is challenged by requirements for equal protection under the law. Law enforcement officials cannot tailor arrest policies to the marital or employment status of the suspect or other characteristics that may interact with deterrence efforts. Specialized training efforts may help alleviate the tendency of police officers to arrest both suspect and victim, however, and may alert law enforcement personnel to the need to review both criminal and civil records in determining whether an arrest is advisable in response to a domestic violence case.

Two additional observations merit consideration in examining the deterrent effects of arrest. First, in the research studies conducted thus far, the implementation

of legal sanctions was minimal. Most offenders in the replication studies were not prosecuted once arrested, and limited legal sanctions were imposed on those cases that did receive a hearing. Some researchers concluded that stronger evidence of effectiveness might be obtained from proarrest policies if they are implemented as part of a law enforcement strategy that expands the use of punitive sanctions for offenders—including conviction, sentencing, and intensive supervised probation.

Second is the issue of reciprocity between formal sanctions against the offender and informal support actions for the victims of domestic violence. The effects of proarrest policies may depend on the extent to which victims have access to shelter services and other forms of support, demonstrating the interactive dimensions of community interventions. A mandatory arrest policy, by itself, may be an insufficient deterrent strategy for domestic violence, but its effectiveness may be enhanced by other interventions that represent coordinated law enforcement efforts to deter domestic violence—including the use of protective orders, victim advocates, and special prosecution units. Coordinated efforts may help reduce or prevent domestic violence if they represent a collaborative strategy among police, prosecutors, and judges that improves the certainty of the use of sanctions against batterers.

Recommendation 4: Collaborative strategies among caseworkers, police, prosecutors, and judges are recommended as law enforcement interventions that have the potential to improve the batterer's compliance with treatment as well as the certainty of the use of sanctions in addressing domestic violence.

The impact of single interventions (such as mandatory arrest policies) is difficult to discern in the research literature. Such practices by themselves can neither be recommended nor rejected as effective measures in addressing domestic violence on the basis of existing research studies.

Home Visitation and Family Support Services

Home visitation and family support programs constitute one of the most promising areas of child maltreatment prevention. Studies in this area have experimented with different levels of treatment intensity, duration, and staff expertise. For home visitation, the findings generally support the principle that early intervention with mothers who are at risk of child maltreatment makes a difference in child outcomes. Such interventions may be difficult to implement and maintain over time, however, and their effectiveness depends on the willingness of the parents to participate. Selection criteria for home visitation should be based on a combination of social setting and individual risk factors.

In their current form, home visitation programs have multiple goals, only one of which is the prevention of child abuse and neglect. Home visitation and family

support programs have traditionally been designed to improve parent-child relations with regard to family functioning, child health and safety, nutrition and hygiene, and parenting practices. American home visiting programs are derived from the British system, which relies on public health nurses and is offered on a universal basis to all parents with young children. Resource constraints, however, have produced a broad array of variations in this model; most programs in the United States are now directed toward at-risk families who have been reported to social services or health agencies because of prenatal health risks or risks for child maltreatment. Comprehensive programs provide a variety of services, including in-home parent education and prenatal and early infant health care, screening, referral to and, in some cases, transportation to social and health services. Positive effects include improved childrearing practices, increased social supports, utilization of community services, higher birthweights, and longer gestation periods.

Researchers have identified improvements in cognitive and parenting skills and knowledge as evidence of reduced risk for child maltreatment; they have also documented lower rates of reported child maltreatment and number of visits to emergency services for home-visited families. The benefits of home visitation appear most promising for young, first-time mothers who delay additional pregnancies and thus reduce the social and financial stresses that burden households with large numbers of young children. Other benefits include improved child care for infants and toddlers and an increase in knowledge about the availability of community services for older children. The intervention has not been demonstrated to have benefits for children whose parents abuse drugs or alcohol or those who are not prepared to engage in help-seeking behaviors. The extent to which home visitation benefits families with older children, or families who are already involved in abusive or neglectful behaviors, remains uncertain.

Recommendation 5: As part of a comprehensive prevention strategy for child maltreatment, the committee recommends that home visitation programs should be particularly encouraged for first-time parents living in social settings with high rates of child maltreatment reports.

The positive impact of well-designed home visitation interventions has been demonstrated in several evaluation studies that focus on the role of mothers in child health, development, and discipline. The committee recommends their use in a strategy designed to prevent child maltreatment. Home visitation programs do require additional evaluation research, however, to determine the factors that may influence their effectiveness. Such factors include (1) the conditions under which home visitation should be provided as part of a continuum of family support programs, (2) the types of parenting behaviors that are most and least amenable to change as a result of home visitation, (3) the duration and intensity of services (including amounts and types of training for home visitors) that are necessary to achieve positive outcomes for high-risk families, (4) the experience

of fathers in general and of families in diverse ethnic communities in particular with home visitation interventions, and (5) the need for follow-up services once the period of home visitation has ended.

Intensive Family Preservation Services

Intensive family preservation services represent crisis-oriented, short-term, intensive case management and family support programs that have been introduced in various communities to improve family functioning and to prevent the removal of children from the home. The overall goal of the intervention is to provide flexible forms of family support to assist with the resolution of circumstances that stimulated the child placement proposal, thus keeping the family intact and reducing foster care placements.

Eight of ten evaluation studies of selected intensive family preservation service programs (including five randomized trials and five quasi-experimental studies) suggest that, although these services may delay child placement for families in the short term, they do not show an ability to resolve the underlying family dysfunction that precipitated the crisis or to improve child well-being or family functioning in most families. However, the evaluations have shortcomings, such as poorly defined assessment of child placement risk, inadequate descriptions of the interventions provided, and nonblinded determination of the assignment of clients to treatment and control groups.

Intensive family preservation services may provide important benefits to the child, family, and community in the form of emergency assistance, improved family functioning, better housing and environmental conditions, and increased collaboration among discrete service systems. Intensive family preservation services may also result in child endangerment, however, when a child remains in a family environment that threatens the health or physical safety of the child or other family members.

Recommendation 6: Intensive family preservation services represent an important part of the continuum of family support services, but they should not be required in every situation in which a child is recommended for out-of-home placement.

Measures of health, safety, and well-being should be included in evaluations of intensive family preservation services to determine their impact on children's outcomes as well as placement rates and levels of family functioning, including evidence of recurrence of abuse of the child or other family members. There is a need for enhanced screening instruments that can identify the families who are most likely to benefit from intensive short-term services focused on the resolution of crises that affect family stability and functioning.

The value of appropriate post-reunification (or placement) services to the child and family to enhance coping and the ability to make a successful transition

toward long-term adjustment also remains uncertain. The impact of post-reunification or post-placement services needs to be considered in terms of their relative effects on child and family functioning compared with the use of intensive family preservation services prior to child removal. In some situations, one or the other type of services might be recommended; in other cases, they might be used in some combination to achieve positive outcomes.

Recommendations For The Next Generation Of Evaluations

Determining which interventions should be selected for rigorous and in-depth evaluations in the future will acquire increased importance as the array of family violence interventions expands in social services, law, and health care settings. For this reason, clear criteria and guiding principles are necessary to guide sponsoring agencies in their efforts to determine which types of interventions are suitable for evaluation research. Recognizing that all promising interventions cannot be evaluated, public and private agencies need to consider how to invest research resources in areas that show programmatic potential as well as an adequate research foundation. Future allocations of research investments may require agencies to reorganize or to develop new programmatic and research units that can inform the process of selecting interventions for future evaluation efforts, determine the scope of adequate funding levels, and identify areas in which program integration or diversity may contribute to a knowledge base that can inform policy, practice, and research. Such agencies may also consider how to sustain an ongoing dialogue among research sponsors, research scientists, and service providers to inform these selection efforts and to disseminate evaluation results once they are available.

In the interim, the committee offers several guiding principles to help inform the evaluation selection process.

. Evidence is needed, based on descriptive studies, that an existing intervention has been or has the capacity to be fully implemented and that it can attract and retain clients over an extended period. Prior to the conduct of a rigorous evaluation, preliminary research studies are necessary to provide an understanding of the flow and selection effects of participants and to identify variations that may exist in the intervention process as a result of time, client or contextual characteristics, or other factors.

Program maturity does not imply that evaluations of effectiveness should be restricted to areas with a clear track record in the research literature; such a conservative tactic would unnecessarily slow the pace of service innovation and evaluation research. What is more important is that the intervention is able to

meet the preconditions for experimentation that are described in the other principles outlined below.

. Prior to the evaluation study, key aspects of usual care must be described so that the effects of the intervention can be measured. An appropriate comparison or control group should be similar in character to those who will receive the intervention but it should receive services that are measurably different.

. Sufficient support for a sound evaluation effort from relevant service providers is essential to the execution of a rigorous evaluation. If service providers are unwilling to cooperate, or do not understand or support the importance of maintaining an independent study, they can seriously compromise the subject selection and assignment process and create sources of bias within the study. If appropriate data are not accessible in the service records, service providers who wish to cooperate may not be able to provide the basic information necessary for the conduct of the study.

. The rationale for change embedded in the intervention should be clearly understood so that researchers can identify and observe the relevant domains in which results are likely to occur. Research measures that can assess these changes over time also need to be in place prior to the initiation of an evaluation, so that appropriate data can be collected and critical pathways can be explored in areas in which long-term results may not be easily obtained.

. A funding source should be in place, prior to the initiation of an in-depth evaluation, that can provide stability and consistency for the study over the period of data collection and analysis. The analysis of long-term outcomes, in particular, requires extensive time, resources, and creative research management to examine whether the intervention has achieved enduring effects for a significant proportion of the client population.

With these principles in mind, the committee has identified a set of interventions that are the focus of current policy attention and service innovation efforts but have not received significant attention from research. In the committee's judgment, each of these nine interventions has reached a level of maturation and preliminary description in the research literature to justify their selection as strong candidates for future evaluation studies.

Training for Service Providers and Law Enforcement Officials

Training in basic educational programs and continuing education on all aspects

of family violence has expanded for professionals in the health care, legal, and social service systems. Such efforts can be expected to enhance skills in identifying individual experiences with family violence, but improvements in training may improve other outcomes as well, including the patterns and timing of service interventions, the nature of interactions with victims of family violence, linkage of service referrals, the quality of investigation and documentation for reported cases, and, ultimately, improved health and safety outcomes for victims and communities.

Training programs alone may be insufficient to change professional behavior and service interventions unless they are accompanied by financial and human resources that emphasize the role of psychosocial issues and support the delivery of appropriate treatment, prevention, and referral services in different institutional and community settings. Evaluations of their effectiveness therefore need to consider the institutional culture and resource base that influence the implementation of the training program and the abilities of service providers to apply their knowledge and skills in meeting the needs of their clients.

Evaluation research is needed to assess the impact of training programs on counseling and referral practices and service delivery in health care, social service, and law enforcement settings. This research should include examination of the effects of training on the health and mental health status of those who receive services, including short- and long-term outcomes such as empowerment, freedom from violence, recovery from trauma, and rebuilding of life. Evaluations should also examine the role of training programs as catalysts for innovative and collaborative services. They should consider the extent to which training programs influence the behavior of agency personnel, including the interaction of service providers with professionals from other institutional settings, their participation in comprehensive community service programs, and the exposure of personal experiences in institutions charged with providing interventions for abuse.

Universal Screening in Health Care Settings

The significant role of health care and social service professionals in screening for victimization by all forms of family violence deserves critical analysis and rigorous evaluation. Early detection of child maltreatment, spousal violence, and elder abuse is believed to lead to an infusion of treatment and preventive services that can reduce exposure to harm, mitigate the negative consequences of abuse and neglect, improve health outcomes, and reduce the need for future health services. Screening programs can also enhance primary prevention efforts by providing information, education, and awareness of resources in the community. The benefits associated with early detection need to be balanced against risks presented by false positives and false negatives associated with large-scale screening efforts and programs characterized by inadequate staff training and responses.

Such efforts also need to consider whether appropriate treatment, protection, and support services are available for victims or offenders once they have been detected.

The use of enhanced screening instruments also requires attention to the need for services that can respond effectively to the large caseloads generated by expanded detection activities. The child protective services literature suggests that increased reporting can diminish the capacity of agencies to respond effectively if additional resources are not available to support enhanced services as well as screening.

The use of screening instruments in health care and social service settings for batterer identification and treatment is more problematic, given the lack of knowledge about factors that enhance or discourage their violent behavior. Screening only victims may be insufficient to provide a full picture of family violence; however, screening batterers may increase the danger for their victims, especially if batterer treatment interventions are not available or are not reliable in providing effective treatment and if support services are not available for victims once a perpetrator is identified. Screening adults for histories of childhood abuse, which may help prevent future victimization of the patient or others, may also be problematic without adequate training or mental health services to deal with the possible resurgence of trauma.

Evaluation studies of family violence screening efforts could build on the lessons derived from screening research in other health care areas (such as HIV detection, lead exposure, sickle cell, and others). This research could provide data that would support or contradict the theory that early identification is a useful secondary prevention intervention, especially in areas in which appropriate services may not be available or reliable. The cost issues associated with universal screening need to be considered in terms of their implications for savings in possible cost reductions from consequent conditions (such as the health consequences of HIV infection, sexually transmitted diseases, unplanned pregnancy, substance abuse, post-traumatic stress disorder, depression, and the exacerbation of other medical conditions) that may occur in other health care areas. Finally, the risks associated with screening (such as the establishment of a preexisting condition that may influence insurance eligibility) require consideration; such issues are already being addressed by some advocacy groups, insurance corporations, and regulatory bodies in the health care area.

Mental Health and Counseling Services

Little is known at present regarding the comparative effectiveness of different forms of therapeutic services for victims of family violence. Findings from recent studies of child physical and sexual abuse suggest that certain approaches (specifically cognitive-behavioral programs) are associated with more positive outcomes for parents, such as reducing aggressive/coercive behavior, compared

with family therapy and routine community mental health services. No treatment outcome studies have been conducted in the area of child neglect. Interventions in this field generally draw on approaches for dealing with other childhood and adolescent problems with similar symptom profiles.

For domestic violence, research evaluations are in the early stages of design and empirical data are not yet available to guide analyses of the effectiveness of different approaches. Major challenges include the absence of agreement regarding key psychosocial outcomes of interest in assessing the effectiveness of interventions, variations in the use of treatment protocols designed for post-traumatic stress for individuals who may still be experiencing traumatic situations, tensions between protocol-driven models of treatment (which are easier to evaluate) and those that are driven by the needs of the client or the context in which the violence occurred, the co-occurrence of trauma and other problems (such as prior victimization, depression, substance abuse, and anxiety disorders) that may have preceded the violence but require mental health services, and the difficulty of involving victims in follow-up studies after the completion of treatment. Variations in the context in which mental health services are provided for victims of domestic violence (such as isolated services, managed care programs, and services that are incorporated into an array of social support programs, including housing and job counseling) also require attention. Topics of special interest include contextual issues, such as the general lack of access to quality mental health services for women without sufficient independent income, and the danger of psychiatric diagnoses being used against battered women in child custody cases.

Collaborative efforts are needed to provide opportunities for the exchange of methodology, research measures, and designs to foster the development of controlled studies that can compare the results of innovative treatment approaches with routine counseling programs in community services.

Comprehensive Community Initiatives

Evaluations of batterer treatment programs, protective orders, and arrest policies suggest that the role of these individual interventions may be enhanced if they are part of a broad-based strategy to address family violence. The development of comprehensive, community-based interventions has become extremely widespread in the 1990s; examples include domestic violence coordinating councils, child advocacy centers, and elder abuse task forces. A few communities (most notably Duluth, Minnesota, and Quincy, Massachusetts) have developed systemwide strategies to coordinate their law enforcement and other service responses to domestic violence.

Comprehensive community-based interventions must confront difficult challenges, both in the design and implementation of such services, and in the selection of appropriate measures to assess their effectiveness. Many evaluations of comprehensive community-based interventions have focused primarily on the

design and implementation process, to determine whether an individual program had incorporated sufficient range and diversity among formal and informal networks so that it can achieve a significant impact in the community. This type of process evaluation does not necessarily require new methods of assessment or analysis, although it can benefit from recent developments in the evaluation literature, such as the empowerment evaluations discussed in Chapter 3 .

In contrast, the evaluation challenges that emerge from large-scale community-based efforts are formidable. First, it may be difficult to determine when an intervention has reached an appropriate stage of implementation to warrant a rigorous assessment of its effects. Second, the implementation of a community-wide intervention may be accompanied by a widespread social movement against family violence, so that it becomes difficult to distinguish the effects of the intervention itself from the impact of changing cultural and social norms that influence behavior. In some cases, the effects attributed to the intervention may appear weak, because they are overwhelmed by the impact of the social movement itself. Third, the selection of an appropriate comparison or control group for community-wide interventions presents formidable problems in terms of matching social and structural characteristics and compensating for community-to-community variation in record keeping.

These challenges require close attention to the emerging knowledge associated with the evaluation of comprehensive community-wide interventions in areas unrelated to family violence, so that important design, theory, and measurement insights can be applied to the special needs of programs focused on child maltreatment, domestic violence, and elder abuse. Although no single model of service integration, comprehensive services, or community change can be endorsed at this time, a range of interesting community service designs has emerged that have achieved widespread popularity and support at the local level. Because their primary focus is often on prevention, rather than treatment, comprehensive community interventions have the potential to achieve change across multiple levels of interactions affecting individuals, families, communities, and social norms and thus reduce the scope and severity of family violence as well as contribute to remedies to other important social problems.

A growing research literature has appeared in other fields, particularly in the area of substance abuse and community development, that identifies the conceptual frameworks, data collection, and methodological issues that need to be considered in designing evaluation studies for community-based and systemwide interventions. As an example, the Center for Substance Abuse Prevention in the federal Substance Abuse and Mental Health Services Administration has funded a series of studies designed to improve methodologies for the evaluation of community-based substance abuse prevention programs that offer important building blocks for the field of family violence interventions.

Developing effective evaluation strategies for comprehensive and systemwide programs is one of the most challenging issues for the research community

in this field. No evaluations have been conducted to date to examine the relative advantages of comprehensive and systemwide community initiatives compared with traditional services. Evaluations need to consider the mix of components in comprehensive interventions that determine their effectiveness and successful implementation; the comparative strengths and limitations of inter- and intra-agency interventions; community factors, such as political leadership, historical tensions, diversity of ethnic/cultural composition, and resource allocation strategies; and the impact of comprehensive interventions on the capacity of service agencies to provide traditional care and effective responses to reports of family violence.

Shelter Programs and Other Domestic Violence Services

Over time, most battered women's shelters have expanded their services to encompass far more than the provision of refuge. Today, many shelters have support groups for women residents, support groups for child residents, emergency and transitional housing, and legal and welfare advocacy. Nonresidential services also have expanded, so that any battered woman in the community is able to attend a support group or request advocacy services. Many agencies now offer educational groups for men who batter, as well as programs dealing with dating violence. Some communities have never opened a shelter yet are able to offer support groups, advocacy, crisis intervention, and safe homes (neighbors sheltering a neighbor, for example) to help battered women and their families in times of crisis. In addition to providing services for victims, the battered women service organizations also define their goal as transforming the conditions and norms that support violence against women. Thus these organizations work as agents of social change in their communities to improve the community-wide response to battered women and their children.

Shelter services and battered women's support organizations are ready for evaluations that can identify program outcomes and compare the effectiveness of different service interventions. Research studies are also needed that can describe the multiple goals and theories that shape the program objectives of these interventions, provide detailed histories of the ways in which different service systems have been implemented, and examine the characteristics of the women who do or do not use or benefit from them.

Protective Orders

Protective orders can be an important part of the prevention strategy for domestic violence and help document the record of assaults and threatening actions. The low priority traditionally assigned to the handling of protective orders, which are usually treated as civil matters in police agencies, requires attention, as do the procedural requirements of the legal system. Courts have

accepted alternative forms of due process, including public notice, notice by mail, and other forms of notification that do not require personal contact. Efforts are needed now to compare the effectiveness of short-term (30-day) restraining orders with a longer (1-year) protective order in reducing violent behavior by offenders and securing access to legal and support services for the complainants.

In-depth case studies and interviews with victims who have had police and court contacts because of domestic violence are needed to highlight individual, social, and institutional factors that facilitate or inhibit victim use of and perpetrator compliance with protective orders in different community settings. Such studies could (1) reveal patterns of help-seeking contacts and services that affect the use of protective orders and compliance with their requirements, (2) highlight the forms of sanctions that are appropriate to ensure compliance and to deter future violent behavior, (3) explore the extent to which the effects of protective orders are enhanced in reducing violence if victim advocates, shelter services, or other social support resources are available and are used by the victim in redefining the terms of her relationship with her partner, and (4) examine the extent to which protective orders can mitigate the consequences of violence for children who may have been assaulted or who may have witnessed an assault against their mother.

Child Fatality Review Panels

The emergence of child fatality review teams in 21 states since 1978 represents an innovative effort in many communities to address systemwide implications of severe violence against children and infants. Child fatality review teams involve a multiagency effort to compile and integrate information about child deaths and to review and evaluate the record of caseworkers and agencies in providing services to these children when a report of abuse or neglect had been made prior to a child's death. These review teams can provide an opportunity to examine the quality of a community's total approach to child abuse and neglect prevention and treatment.

The experience of child fatality review teams in identifying systemic features that enhance or weaken agency efforts to protect children needs to be evaluated and made accessible to individual service providers in health, legal, and social service agencies. Key research issues include: the effect of review team actions on the protection of family members of children who have died as a result of child maltreatment; the impact of child fatality review reports on the prosecution of offenders; the influence of review team efforts on the routine investigation, treatment, and prevention activities of participating agencies; the impact of review teams on other community child protection and domestic violence prevention efforts; and the identification of early warning signals that emerge in child homicide investigations that represent opportunities for preventive interventions.

Child Witness to Violence Programs

Child witness programs represent an important development in the evolution of comprehensive approaches to family violence, but they have not yet been evaluated. Evaluation studies of these programs should examine the experience with symptomatology among children who witness family violence, to determine whether and for whom early intervention influences the course of development of social and mental health consequences, such as depression, anxiety, emotional detachment, aggression and violence, and post-traumatic stress symptoms. Such studies could also compare variations in the developmental histories of children who witness violence with those of children who are injured or otherwise are directly victimized by their parents or who witness violence in their communities. Evaluation studies should consider the recommended forms of treatment for these children, the standards of eligibility that determine their placement in treatment programs, and the impact of institutional setting (hospital, shelter, or social service agency) and reimbursement plans on the quality of the treatment.

Elder Abuse Services

Only seven program evaluation studies have been published on elder abuse interventions, none of which includes random groups and most of which involve small sample sizes. Three major issues challenge effective interventions in this area: the degree of dependence between perpetrators and victims, restricted social services budgets, general public distrust of social welfare programs, and the relationship between judgments about competence and the application of the principles of self-determination and privacy to the problem of elder abuse.

Evaluation studies should consider the different types and multiple dimensions of elder abuse in the development of effective interventions. The benefits of specific programs need to be compared with integrated service systems that are designed to foster the well-being of the elderly population without regard to special circumstances. Evaluation research should be integrated into community service programs and agency efforts on behalf of elderly persons to foster studies that involve the use of comparison and control groups, common measures, and the assessment of outcomes associated with different forms of service interventions.

Topics For Basic Research

The committee identified four basic research topics that require further development to inform policy and practice. These topics raise fundamental questions about the approaches that should be used in designing treatment, prevention, and enforcement strategies. As such, they highlight important dimensions of family violence that should be addressed in a research agenda for the field.

. Richer knowledge of the complex origins and ramifications of family violence has called attention to the need for research that can examine ways in which family violence contributes to, and is influenced by, health and other social problems. Substance abuse and alcoholism are prime candidates for initiating cross-issue research in family violence studies. The co-occurrence of family violence and substance abuse or alcoholism has been documented in public health and social work research, and some communities have taken steps to integrate components of substance abuse treatment and domestic violence prevention programs.

Other candidates are the links between family violence and community violence, which warrant study given growing interest in community-based approaches to injury control and prevention, and pressing questions regarding the interactive effects on children and adults of exposure to violence both inside and outside the home. Research on mental disorders is another opportunity for cross-problem studies that could integrate research on family violence with studies of depression, stress disorders, suicide, antisocial conduct, and related problems.

This research needs to explore critical issues such as the forms and sequence of overlap between family violence and associated problems and disorders; the existence of common pathways that lead to the occurrence of multiple problems and the implications of this research for prevention and treatment; the processes by which the existence of co-occurring problems influence the outcomes and consequences of family violence; and the impact of cultural and social settings that mediate the experience and impact of abuse, service utilization, and outcomes of interventions.

. Children who are victimized by witnessing family violence have only recently been the subject of research. Although this literature has identified a range of consequences, it has also revealed that many children exposed to violence do not develop marked problems. This relatively young area of research has the potential to take the family as the unit of analysis and integrate the largely separate strands of research on child maltreatment, domestic violence, and elder abuse. For this reason, the committee strongly urges that this line of research be continued in a fashion that cuts across these areas of study.

One productive next step would be to broaden theoretical frameworks for studying how children are brought into violent adult interactions in families and how they cope with and interpret violence in their homes. From the adult perspective, for example, how often are children the ''reason why" parents fight and in what ways does this situation exacerbate the effects on children who are exposed to violence? How often do children perceive themselves to be the cause of marital conflict and violence?

Another useful approach would be an examination of the links between family formation and development and the onset and intensification of family violence, looking specifically at stressful stages of family life, such as pregnancy,

birth, infancy, and adolescence. Other issues linked to family formation include the use of corporal punishment in child discipline, gender roles, privacy, and strategies for resolving conflict among adults or siblings.

A third approach would be studies to discern the protective factors inside and outside families that enable some children who are exposed to violence to not only survive but also to develop coping mechanisms that serve them well later in life. This analysis would have widespread implications for assessing the impact of biological and experiential factors in specific domains, such as fear, anxiety, self-blame, identity formation, helplessness, and help-seeking behaviors. Such research could also identify abuse-related coping strategies (such as excessive distrust of or overdependence on others) that may contribute to other problems that emerge in the course of adolescent and adult development.

. The economic and social costs of family violence remain virtually undocumented. Cost analysis studies are needed that can distinguish between direct and indirect service costs; the impact of family violence on its victims and offenders; cost implications for health, social service, and law enforcement agencies and community programs; the costs and benefits associated with integrated service records and more comprehensive record management, especially in managed care settings; the extent to which episodes and histories of violence can be tracked within families or across generations; and the relationships between the need or demand for services and the available supply in specific communities. These economic and social indicators will become increasingly important with the enhanced use of performance measures by health care, public health, and social service agencies.

Programmatic research is needed that can identify whether certain characteristics of selected family violence treatment and prevention interventions (such as the mixture, scope, and intensity of services; the philosophy and training of service providers; and levels of institutional support) are related to improved outcomes for particular groups of clients. The effectiveness of family support services (including intensive family preservation and home visitation services) for reducing child and elder maltreatment needs to be studied through the development and critical assessment of models (1) to determine program goals that can be converted to interim and long-term operational measures (especially in the domains of family cooperation and receptivity to services), (2) to examine multiple program outcomes, such as attitudinal changes, improvements in family functioning, environmental issues related to housing and safety, child well-being, and consumer satisfaction, rather than focusing solely on program-specific goals, such as rates of placement or maltreatment, and (3) to clarify program components that appear to contribute directly to positive outcomes and require attention in future certification standards. The advantages and limitations of targeted interventions need to be compared with integrated service systems, especially in dealing with specific age groups and populations (such as the elderly, adolescents,

first-time parents, victims and offenders who have substance abuse histories, etc.)

. In numerous family violence interventions, key social setting issues arise that warrant study because of their implications for the design of treatment, support, prevention, and law enforcement strategies. These issues include ways in which the mandatory or voluntary character of reporting and treatment systems influences service provider behavior and institutional practices; conditions and factors in the criminal justice system that foster deterrence, especially among individuals who have a history of violent behavior and who have little stake in social conformity; psychological, social, and institutional factors that facilitate or inhibit victim use of and perpetrator compliance with protective orders, treatment programs, mental health services, and other interventions in different community settings; classification of groups of offenders that can distinguish offenders who use violence only against certain family members from those who pose a general threat to others inside and outside their family; and behavioral or cognitive processes associated with "natural improvements" or "spontaneous change" (without intervention) in comparison populations of offenders and victims in the different areas of family violence.

Forging Partnerships Between Research And Practice

Although it is premature to expect research to offer definitive answers about the relative effectiveness of the array of current service and enforcement strategies, the committee sees valuable opportunities that now exist to accelerate the rate by which service providers can identify the types of individuals, families, and communities that may benefit from certain types or combinations of service and enforcement interventions. Major challenges must be addressed, however, to improve the overall quality of the evaluations of family violence interventions and to provide a research base that can inform policy and practice. These challenges include issues of study design and methodology as well as logistical concerns that must be resolved in order to conduct research in open service systems where the research investigator is not able to control factors that may weaken the study design and influence its outcome. The resolution of these challenges will require collaborative partnerships between researchers, service providers, and policy makers to generate common approaches and data sources.

The integration of research and practice in the field of family violence, as in many other areas of human services, has occurred on a haphazard basis. As a result, program sponsors, service providers, clients, victims, researchers, and community representatives have not been able to learn in a systematic manner from the diverse experiences of both large and small programs. Mayors, judges, police officers, caseworkers, child and victim advocates, health professionals, and others must make life-or-death decisions each day in the face of tremendous

uncertainty, often relying on conflicting reports, anecdotal data, and inconsistent information in judging the effectiveness of specific interventions.

The development of creative partnerships between the research and practice communities would greatly improve the targeting of limited resources to specific clients who can benefit most from a particular type of intervention. Yet significant barriers inhibit the development of such partnerships, including disagreements about the nature and origins of family violence, broad variations in the conceptual frameworks that guide service delivery, differences over the relative merits of service and research, a lack of faith in the ability of research to inform and improve services, a lack of trust in the ability of service providers to inform the design of research experiments and the formation of theoretical frameworks, and concerns about fairness and safety in including victims and offenders in experimental treatment groups. These fundamental differences obscure identification of outcomes of interest in the development of evaluation studies, which are further complicated by limitations in study design and access to appropriate subjects that are necessary for the conduct of research.

Even if greater levels of trust fostered more interaction between the research community and service providers, collaborative efforts would be challenged by factors such as the lack of funding for empirical studies, the availability of limited resources to support studies over appropriate time frames, and the social and economic characteristics of some of the populations served by family violence interventions that make them difficult to follow over extended periods of time (chaotic households, high mobility of the client population, concerns for safety, lack of telephones and permanent residences, etc.).

Service providers and program sponsors have often been skeptical of efforts to evaluate the impact of a selected intervention, knowing that critical or premature assessments could jeopardize the program's future and restrict future opportunities for service delivery. Service providers have also been less than enthusiastic in seeking program evaluations, knowing that the programs to be evaluated have been underfunded and are understaffed and present a less than ideal situation; in their view, the assessment may diminish future resources and affect the development of a particular strategy or programmatic approach. The tremendous demand for services and the limited availability of staff resources create a pressured environment in which the staff time involved in filling out forms for research purposes is seen as being sacrificed from time that might be used to serve people in need. In some cases, research funds support demonstration programs that are highly valued by a community, yet few resources are available to support them once the research phase has been completed.

Researchers and service providers need to resolve the programmatic tensions that have sometimes surfaced in contentious debates over the type of services that should be put into place in addressing problems of family violence. The mistrust and skepticism present major challenges that need to resolved before the technical challenges to effective evaluations can be addressed. A reformulation of the

research process is needed so that, while building a long-term capacity to focus on complex issues and conduct rigorous studies, researchers can also provide useful information to service providers.

The committee has identified three major principles to help integrate research and practice in the field of family violence interventions:

Evaluation should be an integral part of any major intervention, particularly those that are designed to be replicated in multiple communities. Interventions have often been put into place without a research base to support them or rigorous evaluation efforts to guide their development. Evaluation research based on theoretical models is needed to link program goals and operational objectives with multiple program components and outcomes. Intensive marketing and praise for a particular intervention or program should no longer be a substitute for empirical data in determining the effectiveness of programs that are intended to be replicated in multiple sites.
Coordinating policy, program, and research agendas will improve family violence interventions. Evaluation research will help program sponsors and managers clarify program goals and experience and identify areas in need of attention because of the difficulties of implementation, the use of resources, and changes in the client base. Research and data-based analysis can guide ongoing program and policy efforts if evaluation studies are integrated into the design and development of interventions. The knowledge base can be improved by (1) framing key hypotheses that can be tested by existing or new services, (2) building statistical models to explore the system-wide effects of selected interventions and compare these effects with the consequences of collaborative and comprehensive approaches, (3) using common definitions and measures to facilitate comparisons across individual studies, (4) using appropriate comparison and control groups in evaluation studies, including random assignment, when possible, (5) developing culturally sensitive research designs and measures, (6) identifying relevant outcomes in the assessment of selected interventions, and (7) developing alternative designs when traditional design methodology cannot be used for legal, ethical, or practical reasons.
Surmounting existing barriers to collaboration between research and practice communities requires policy incentives and leadership to foster partnership efforts. Many interventions are not evaluated because of limited funds, because the individuals involved in service delivery consider research to be peripheral to the needs of their clients, because the researchers are disinterested in studying the complexity of service delivery systems and the impact of violence in clients' lives, or because research methods are not yet available to assess outcomes that result from the complex interaction of multiple systems. This situation will continue until program sponsors and policy officials exercise leadership to build partnerships between the research and practice communities and to provide funds for rigorous evaluations in the development of service and law enforcement
interventions. Additional steps are required to foster a more constructive dialogue and partnership between the research and practice communities.

Partnership efforts are also needed to focus research attention on the particular implementation of an individual program rather than the strategy behind the program design. Promising intervention strategies may be discarded prematurely because of special circumstances that obstructed full implementation of the program. Conversely, programs that offer only limited effectiveness may appear to be successful on the basis of evaluation studies that did not consider the significant points of vulnerability and limitations in the service design or offer a comparative analysis with the benefits to be derived from routine services.

The establishment and documentation of a series of consensus conferences on relevant outcomes, and appropriate measurement tools, will strengthen and enhance evaluations of family violence interventions and lead to improvements in the design of programs, interventions, and strategies. May opportunities currently exist for research to inform the design and assessment of treatment and prevention interventions. In addition, service providers can help guide researchers in the identification of appropriate domains in which program effects may occur but are currently not being examined. Ongoing dialogues can guide the identification and development of instruments and methods that can capture the density and distribution of relevant effects that are not well understood. The organization of a series of consensus conferences by sponsors in public and private agencies that are concerned with the future quality of family violence interventions would be an important contribution to the development of this field.

Reports of mistreated children, domestic violence, and abuse of elderly persons continue to strain the capacity of police, courts, social services agencies, and medical centers. At the same time, myriad treatment and prevention programs are providing services to victims and offenders. Although limited research knowledge exists regarding the effectiveness of these programs, such information is often scattered, inaccessible, and difficult to obtain.

Violence in Families takes the first hard look at the successes and failures of family violence interventions. It offers recommendations to guide services, programs, policy, and research on victim support and assistance, treatments and penalties for offenders, and law enforcement. Included is an analysis of more than 100 evaluation studies on the outcomes of different kinds of programs and services.

Violence in Families provides the most comprehensive review on the topic to date. It explores the scope and complexity of family violence, including identification of the multiple types of victims and offenders, who require different approaches to intervention. The book outlines new strategies that offer promising approaches for service providers and researchers and for improving the evaluation of prevention and treatment services. Violence in Families discusses issues that underlie all types of family violence, such as the tension between family support and the protection of children, risk factors that contribute to violent behavior in families, and the balance between family privacy and community interventions.

The core of the book is a research-based review of interventions used in three institutional sectors—social services, health, and law enforcement settings—and how to measure their effectiveness in combating maltreatment of children, domestic violence, and abuse of the elderly. Among the questions explored by the committee: Does the child protective services system work? Does the threat of arrest deter batterers? The volume discusses the strength of the evidence and highlights emerging links among interventions in different institutional settings.

Thorough, readable, and well organized, Violence in Families synthesizes what is known and outlines what needs to be discovered. This volume will be of great interest to policymakers, social services providers, health care professionals, police and court officials, victim advocates, researchers, and concerned individuals.

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DOI: 10.1111/J.1467-8624.1988.TB03260.X
Corpus ID: 9181943

Breaking the cycle of abuse.

Claudio Consuegra
Published in Child Development 1 August 1988

639 Citations

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Front Psychol

The Vicious Cycle: Problematic Family Relations, Substance Abuse, and Crime in Adolescence: A Narrative Review

Valeria saladino.

1 Department of Human, Social and Health Sciences, University of Cassino and Southern Lazio, Cassino, Italy

Oriana Mosca

2 Department of Education, Psychology, Philosophy, University of Cagliari, Cagliari, Italy

Filippo Petruccelli

Lilli hoelzlhammer.

3 Department of Philology and Literature, LMU Munich, Ludwig-Maximilians-Universität, Munich, Germany

Marco Lauriola

4 Department of Developmental and Social Psychology, University of Rome “Sapienza,”, Rome, Italy

Valeria Verrastro

5 Department of Medical and Surgical Sciences, University of Catanzaro “Magna Graecia,”, Catanzaro, Italy

Cristina Cabras

Despite the copiousness of studies on the risky behaviors of adolescents, we cannot establish with certainty the leading aspects involved in teens’ substance abuse and criminal actions. This review aims to explore the interplay among the family system, substance abuse, and criminal behavior. An analysis of the main results of the 61 articles published between 2010 and 2020 shows that adolescents whose parents are justice-involved and often absent from home are more likely to perceive lower cohesion, support, and poor family communication. These factors can involve them in criminal acts and substance abuse. Moreover, these conducts are often linked to a form of uneasiness and a search of autonomy. Indeed, risky behaviors could have more than one meaning. Our findings also suggest that the most diffused drug-related crimes in adolescence are economic crimes, weapon carrying, robberies, dealing, and drug possession. Considering these results, future clinical implications might be based on multidimensional approaches, focusing more on the family context to promote interventions for at-risk adolescents.

Introduction

Adolescence and risky behaviors.

Adolescence is characterized by high psychosocial vulnerability ( Hatano et al., 2018 ). It is a specific moment of the development of young people engaging in a great deal of personal and interpersonal exploration to understand themselves, their significant others, and their social world. Concomitantly, many physical, behavioral, and cognitive changes occur in the teenage years. Moreover, risk-taking behavior is common and is often associated with the engagement in unlawful acts and conducts ( Gonzales et al., 2017 ).

Aggressive criminal behaviors in adolescence often aim to achieve autonomy ( Piquero et al., 2013 ) and to build one’s identity, simultaneously modified by the family system and environment ( Willoughby et al., 2014 ). The primary theoretical frameworks in criminology and developmental psychology suggest a multifactorial approach in the study of the topic. Indeed, risk-taking behavior in adolescence needs to consider individual, family, and environmental factors ( Lösel and Farrington, 2012 ). According to these theories, risky behaviors can contribute to building adolescent’s self-image; therefore, if adolescents receive positive reinforcements about delinquency, antisocial behavior, or drug abuse, they are more likely to maintain these attitudes in adulthood ( Jolliffe et al., 2017 ). These behaviors, in most cases, describe a form of uneasiness; in fact, an adolescent can communicate the feelings of rage, fear, and solitude and may show internalizing conducts, such as substance abuse, or externalizing conducts, such as illicit and aggressive actions against people or property ( Moylan et al., 2010 ).

In this perspective, the family system assumes the role of protective or risk factors, especially referred to the family climate, communication, and parental support. According to this perspective, it is important to consider the meaning that risky behaviors could have for adolescents, especially in the study of delinquency and substance abuse conduct, which often involve young people ( Johnston et al., 2017 , 2018 ). This aspect is important to evaluate adolescents’ risky trajectories, incorporating the developmental perspective.

Substance Abuse: Some Definitions

Juvenile involvement in risky behaviors continues to be a sensitive issue. Substance abuse is among the most common risky behaviors widespread in adolescence. For this reason, a definition of the term is needed.

Substance abuse could be described “as a maladaptive pattern of drug use leading to clinically significant impairment or distress” ( Kpae, 2019 ). According to some authors ( Mamman et al., 2014 ), the term usually refers to illegal drugs. However, substance abuse is also related to the degree of social acceptance of substances, such as alcohol, prescription medicine, and other legal substances, which are viewed as illicit and less harmful. Indeed, it may also be defined as the use of psychotherapeutic and medical drugs in the presence or in the absence of a specific diagnosis ( Fareo, 2012 ). According to the Diagnostic and Statistical Manual of Mental Disorders DSM-III-R ( American Psychiatric Association [APA], 1987 ), “psychoactive substance abuse” is defined as “a maladaptive pattern of use indicated by. continued use despite the knowledge of having a persistent or recurrent social, occupational, psychological, or physical problem that is caused or exacerbated by the use (or by) recurrent use in situations in which it is physically hazardous.” The definition of “substance abuse,” instead, is not included in the fifth version of DSM ( American Psychiatric Association [APA], 2013 ). DSM 5 identifies the “Substance-related and addictive disorders” section, including “Substance use disorders,” “Substance-related disorders,” and “Substance/medication-induced mental disorders.” Moreover, due to the ambiguity in its definition, ICD-10 use the term “abuse” only in the case of non-dependence-producing substances. The WHO ( WHO Expert Committee on Drug Dependence and World Health Organization, 1969 ) also highlights the same as the hazardous and harmful use of illicit drugs could result in the dependence syndrome that is derived from the repeated use of substances and leads to a “strong desire to take the drug, difficulty in controlling its use, (and) persisting in its use despite harmful consequences” ( Kpae, 2019 ). In fact, both legal and illegal drugs have chemicals, which can influence the behavior and cognition of individuals.

There is consensus among researchers about the consistent and overdose intake of illicit drugs affects the brain and causes biological changes to the body. It creates the craving and excitement for things such as food and sex ( Koob and Volkow, 2010 ) and can make, especially adolescents, not to weigh the consequences of their actions, affecting their development ( Volkow et al., 2019 ).

Theories of Drug Abuse

Mamman et al. (2014) proposed different theories explaining the origin of drug abuse: (1) sociocultural theory, (2) personality theory, (3) biological theory, and (4) learning theory. These theories describe the abuse of drug as influenced by several factors, emphasizing the personal motivation in using a specific substance. The key role of these theories is derived from the evaluation of the peculiarity of the relationship between the subject and the drug. This evaluation avoids any form of simplification and generalization in explaining drug abuse behaviors and might be useful for intervention and prevention programs based on drug abuse at different levels of influence.

The authors (Ibid) specified these theories in detail as follows:

(1) Sociocultural theory of drug abuse postulates that substance abuse is derived from the values shared by a specific society and context, which are culturally determined. For instance, in some cultures, adolescents are permitted to consume alcohol and smoke marijuana, and in other cultures they are not permitted to do so. Moreover, in such cultures, alcohol and tobacco are considered as a normal product, and used by youth and adults in everyday life and as a social activity or a way to spend time and have fun within the peer group, considering drug use as a life experience. Among some tribes in Nigeria, alcohol is also used in cultural activities ( Mamman et al., 2014 ), whereas it is forbidden by the law in the north of Nigeria. Cultural norms and social attitude toward such drugs influence the personal and community perception of a specific substance. Foley et al. (2004) , in a cross-sectional telephone survey among white, black and Latino youth, found that adults’ approval of alcohol use can increase or decrease adolescents’ drinking behavior according to the cultural and social perception of the context. As the social and cultural context promote the use of certain substances, the perception of risk decreases, especially among young people who tend to imitate the behavior of adults and to adapt to their context. This is also true for an illicit substance. Indeed, the data from an epidemiological study conducted in Australia indicates that the consumption of illicit substances by young people has recently increased as in United Kingdom. According to Howard Parker’s “normalization thesis” ( Parker et al., 1998 ), youth no longer use drugs as a form of transgressive conduct but perceive this as a habit, which enriches their leisure time.” Today is no longer possible to attribute the use of drugs to a subcultural world described as bad or dysfunctional because drug abuse is more culturally normalized and ordinary. According to this theory, the inclusion of a concept introduced in the social cognitive theory by Bandura (1986) is needed. In fact, the etiology of the substance abuse can be described as the triadic reciprocity influence of the behavioral, environmental and personal factors.

(2) Personality theory of drug abuse considers specific personality characteristics more related to drug abuse. These personalities are characterized by elements, which could increase the possibility to use substances, such as low self-esteem, poor coping skills, low tolerance to frustration and in delay gratification, high sensitivity and impulsiveness, and a tendency of being emotionally dependent on others ( Calamai, 2021 ). A few literature studies have shown that the onset of substance dependence tends to be earlier, especially in the presence of Cluster B Personality Disorder as reported by DSM 5 ( American Psychiatric Association [APA], 2013 ). Antisocial, borderline, histrionic, and narcissistic personality disorder increase the likelihood of developing drug addiction ( Lingiardi and Gazzillo, 2014 ) with a prevalence estimate of 75% for the borderline patients and of 95% for those with antisocial personality disorder ( Hatzitaskos et al., 1999 ). Each personality disorder influences the motivations behind the use of a substance: each type of drug, in fact, produces different effects. According to a few literature studies, patients with narcissistic personality use cocaine as a “self-medication” to regulate dysphoric or depressed mood states, whereas people with antisocial personality and impulsivity traits, also defined as sensation seekers, use it to produce pleasant and positive emotional states ( Rigliano and Bignamini, 2009 ). According to Khantzian (1997) , cocaine and, in general, psychostimulants are used to regulate mood (mania, hypomania, and depression), whereas opiates are used to reduce the psychological suffering associated with negative emotions such as anger or sadness. Adolescents have some characteristics and traits common to the DSM cluster B personality disorders that increase the likelihood of consuming drugs, for example, impulsiveness, tendency to transgress, dependence in relationships, difficulty in delaying gratification, insecurity, difficulty in managing emotions and sudden changes in mood.

(3) Biological theory of drug abuse is based on the vulnerability link between potential genetic risk factors and the development of drug abuse. According to this theory, individuals diverge in taking drugs and in developing an addiction. For most people, drug use consists of single experience or a few experiences. Substance use among people who persist in taking drugs can be associated with specific situations, such as weekends or leisure time spend with friends, but remains an occasional behavior. People who use drugs more than occasionally can develop a drug addiction. In these subjects, the use of drugs is associated with a compulsive behavior directed to satisfy the physical and psychological need of the substance ( O’Brien et al., 1986 ). Biological theory of drug abuse is divided from two points of view. The first one is a drug-centered approach, according to which drug addiction is derived from a repeated drug intake, which causes brain modifications and leads to tolerance, sensitization, and craving. Therefore, according to this point of view, the most vulnerable people are those who are most exposed to drug use due to a specific background (environments, neighborhoods, and peer groups). The second approach is individual-centered and describes substance abuse as a consequence of the pathological reaction to drug. Vulnerable people are those who have a specific biological substrate, which provokes this effect ( Piazza et al., 1998 ). Specifically, research on the biological origins of individual vulnerability to addiction describes the key role of the mesencephalic dopaminergic neurons, stress, and glucocorticoids, as identified by Piazza et al. (1990) . Also, all substances of abuse induce an effect on the neuronal system of the drug-reward circuit. The neurotransmission system that has been most clearly identified with the developmental actions of drug abuse is the mesolimbic dopamine system, with its efferent targets in the nucleus accumbens. The actions relevant to the reward of amphetamine and cocaine are in the dopaminergic synapses of the nucleus accumbens and possibly also in the medial prefrontal cortex. For instance, rats learn to press the lever for cocaine injections into the medial prefrontal cortex, which works by increasing dopamine turnover in the nucleus accumbens ( Goeders and Smith, 1983 , 1993 ). Understanding how our brain reacts to drugs is fundamental to establish the goals of addiction therapies and to better evaluate the physical addiction to drugs.

(4) Learning theory of drug abuse posits that drug abuse is derived from different types of learning (social, conditional, and instrumental). As mentioned in the sociocultural theory of drug abuse, Bandura (1986) explained the theory of social learning according to which people can learn by observing others. It is possible to apply this construct also to drug abuse ( Niaura, 2000 ). Indeed, most people, especially youth, start in taking drugs due to the social conditioning or the peer pressure, learning this behavior through social interactions (family members, peer group, neighbor, and teacher). For instance, youth who frequently observe their parent relaxing in gambling or their peers who socialize and have fun after drinking alcohol, smoking marijuana, or after using other drugs could learn that these behaviors lead to positive results ( Eiser, 2011 ). This perception is derived from a social learning. In addition, social interactions and the sense of acceptance are important factors for individuals who often see drug use as a way to develop or maintain social bonds. Moreover, people who only interact with addicted persons have fewer opportunities to learn healthy habits ( Wilson, 1988 ). This aspect leads them to disengage from developing positive habitudes but progressively to occupy their time in using drugs. The learning associated with drug abuse influences the choice of social interactions. In fact, as the persons are encouraged to use drugs, they will look for like-minded people or groups and gradually move away from those who do not use drugs ( Smith, 2021 ). This involves a psychological closure which risks becoming the future personality of the addicted subject. Learning theory of drug abuse could be useful in promoting the treatment based on a social learning perspective, with support groups and with an opportunity to interact with healthier people.

Social Stigma and Poverty: Negative Identity and Crime

In adolescence, teens develop their identity, a coherent, homogeneous, and continuous image of the essence of their future personality ( Erikson and Erikson, 2018 ). This process is derived from an interiorization and symbolization of models and the roles assumed during life experiences. A criminal or poor environment, offense involvement, justice-involved or drug abuser parents, relatives, or friends, and living in a poverty condition are some of the main social factors that can impact an adolescent development. Teens who suffered from one or more of these risk factors could receive negative expectations from others and interiorize a self-image based on the proposed perception of self. This is called “prophecy that is self-fulfilling” and derived from the labeling theory ( McIntosh and Rock, 2018 ), which investigates the complexity and multidimensionality of individuals and their social interactions ( Lemert, 1974 ). These concepts are linked to the stigma and the criminal stereotype ( Ciampi, 2017 ).

According to this theory, juveniles labeled as “criminal” or “drug addicted” are more likely to suffer from marginalization, isolation, stigmatization, and imprisonment. They are confirmed of their negative identity by society, peer group, and family, creating a social stigma ( Goffman, 1961 ; Chapman, 1968 ). In several cases, teens with justice-involved or drug abuser parents or adolescents who live in a disadvantaged neighborhood develop a sense of stigmatization, which leads them to assume criminal and antisocial conduct and to maintain it in adulthood ( Adlaf et al., 2009 ; Luther, 2016 ; Massarwi and Khoury-Kassabri, 2017 ). Stigmatization is one of the most adverse consequences of parental incarceration ( Phillips and Gates, 2011 ). Youth who have justice-involved parents are adversely affected and can develop emotional and behavioral issues ( Al Gharaibeh, 2008 ). Similarly, drug abuse within the family negatively influences the perception of the adolescent on the substance and increment the others’ prejudice ( Mehta and Farina, 2011 ). Goffman (1963) referred to this attitude with the term “stigma of courtesy,” which was also defined as secondary or associative stigma ( Furst and Evans, 2015 ). Courtesy stigma indicates that the label affects the safety and well-being of family members, significant others, roommates, and others who are associated with a stigmatized individual, passing for association from the stigmatized people to the members of their social network ( Goffman, 1963 ; Mehta and Farina, 2011 ).

Another theory explaining delinquency through the multifactorial interaction of factors is Wikstrom’ situational action theory (SAT) ( Wikstrom, 2009 ). According to this model, it is important to evaluate the criminal actions by considering the individual, environmental, situational, and behavioral elements. Wikstrom analyzes an individual’s reactions to a given situation, asserting that the commission of a crime is derived from the interaction between the mentioned elements. Thus, criminality could be derived from desensitization, resulting in a natural tendency to act on the learned behavior (Ibid). Wikstrom conducted a longitudinal study on youth belonging to disadvantaged contexts, highlighting that the criminal context does not imply a tendency to commit a crime per se but rather stems from youth with prolonged exposure to it, thus, mostly influencing a deviant behavior ( Wikstrom and Sampson, 2003 ). Similarly, Shaw and McKay (1942) developed the social disorganization theory to define the study of areas with a higher rate of crime and poverty as criminal areas. According to these studies, criminal areas consist of neighborhoods with a high need for economic assistance, unemployment, and general discomfort. Mostly, families decide to live in such conditions because they have no choice ( Leventhal and Brooks-Gunn, 2000 ). These areas, therefore, become an attractive center for those who are looking for a permissive and an adequate environment for delinquent status ( Krohn et al., 2009 ).

Despite these findings, we know that not all those who live in criminal and disadvantaged areas develop a deviant career, as shown by Oreopoulos’ study ( Oreopoulos, 2003 ). The author studied two groups. In one group, the author analyzed the experiences of adults who were involved as children to a housing project in the Toronto metropolitan area. This area comprises a wide neighborhood location and services. The second group was composed of adults living in public houses with a higher exposure to crime and poverty. In comparing these two groups, Oreopoulos found that different living conditions did not play a significant role in determining the youth behavior and that the family factors were more powerful in influencing their behavior. Similarly, Jacob (2005) explored the experiences of youth relocated by the Chicago Housing Authority from public housing to private-market housing. The author found no evidence of the adverse effects of public housing poverty and disadvantage conditions, comparing the group of youths who moved in other places with the group of youths lodged in a public house. These results show the importance of considering other factors, such as individual and family elements, which may play a moderating role in the adulthood outcomes, especially during development.

Another factor influencing criminality is the socio-economic status (SES) ( Hollingshead, 1975 ). In childhood and adolescence, low-SES neighborhoods could have an adverse influence on children’s and adolescents’ mental health and on externalized behaviors, such as acting out, aggression, drug use, and delinquent behaviors ( Saladino et al., 2020b ). According to the evaluation of the Yonkers Project, adolescents who remained in low-SES neighborhoods were more likely to become substance users, especially alcohol and marijuana users ( Briggs, 1997 ).

Another evidence shows a strong connection between low-SES, drug use, and criminality in youth. Tobler et al. (2011) found a positive association between environment deprivation and the alcohol use. Tucker et al. (2013) examined the correlation between neighborhoods’ disorganization and the onset of drug use; based on the hypothesis that the onset for both alcohol and marijuana may be more likely among adolescents who come from a poor neighborhood, with greater residential instability and a poor perception of cohesion and safety. The first important result shows that residing in a neighborhood characterized by a high rate of unemployment is the most influential factor on adolescent’s onset marijuana use, whereas the environmental perception of disapproval in marijuana use is related to lower rates of adolescent cannabis use ( Keyes et al., 2011 ).

Social stigma derived from justice-involved or drug abuser parent and a neighborhood with a high rate of crime and poverty could lead to delinquent behaviors to become a channel of transmission of criminal values, especially in childhood and early adolescence. Moreover, the criminal history of a neighborhood or of a family increases the social stigma and affects the probability of obtaining a higher education and employment, developing into the only possible career, criminality.

Aim of This Study

This narrative review (NR) aims to: (a) document the reciprocal interaction among family relations, substance abuse, and criminal conduct and (b) evaluate the connection between substance abuse and criminality, focusing on the different types of offenses and drug-related conducts.

Materials and Methods

To capture the complexity of the dynamic processes of family relations and adolescents’ behaviors, the following electronic databases were used in conducting this narrative review: Google Scholar, PsycINFO Database Record, and PubMed. Using the similar methods in previous reviews, we searched the databases using the following specific keywords to collect the studies dealing with the connection among family system, substance abuse, and criminal conduct: “family communication,” “drugs in adolescence,” “drug abuse,” “alcohol abuse,” “substance abuse,” “family and drugs,” “drugs and crime in adolescence,” “family influence,” “behavior and drugs,” “impulsive acts and family,” “family background,” “family support,” “parental support,” “family climate and substance abuse,” “juvenile delinquency,” “family climate and crime,” and “parent drug talk and substance abuse.” The search was conducted between March 2019 and December 2020. It is well known that narrative reviews do not include databases and inclusion criteria (e.g., Cipriani and Geddes, 2003 ; Collins and Fauser, 2005 ). However, to allow the readers to better evaluate the transparency of the work, we provided some key elements about the search strategy ( Campo et al., 2019 ). The quality of a narrative review may be improved by borrowing from the systematic review methodological elements aimed at reducing bias in the selection of articles for a review and employing an effective bibliographic research method. Due to the existence of no consensus on the standard structure of an NR, we used the common format Introduction, Methods, Results, and Discussion (IMRAD) ( Ferrari, 2015 ). Moreover, due to the absence of specific standard in the selection of the range of time for the research query and using similar methods of previous reviews ( Weinberg et al., 1998 ; Putnam, 2003 ) the authors decided to focus their work on the past 10 years in writing the current review and also to avoid obsolete contributions.

For this reason, the current review includes the articles, reviews, and reports published in English between 2010 and 2020. The Articles that used the definitions of substance abuse as discussed in Section “Substance Abuse: Some Definitions” and the articles that conceptualized drug use as a risk factor in developing substance abuse conduct were included in our analysis, whereas the studies discussing drug misuse or drug addiction were excluded from the review.

Of the 150 articles returned from the search, 61 were retained for the current review after screening their titles and abstracts.

Family Relationships, Substance Abuse, and Delinquency in Adolescence

Adolescents are more likely to be involved in behaviors such as drug abuse and criminal acts. These behaviors impact not only the individuals but also their family, schools, and social context. In adolescence, risky behaviors are common among individuals who have a problematic family system and difficulties in relationships with parents ( Kam and Middleton, 2013 ), aggressive and risky acts among adolescents can be used as habitual ways to communicate. Such perpetual patterns of behavior need to be understood by going beyond the apparent meaning of risky actions ( Saladino et al., 2020a ).

Several studies emphasized the importance of family relationships and family climate—considering parental support and communication, parental drug abuse, and parental incarceration—on illicit and at-risk behaviors, such as crime and substance abuse of youth ( World Health Organization, 2010 ; Piko and Balaìzs, 2012 ; Thomas et al., 2013 ; Buelga et al., 2017 ). Indeed, negative parent–children relationship could lead to a sense of lack support and to use violence as a strategy to survive ( Kann et al., 2016 ). Adolescents who perceive their parents absent and unable to protect them from a risky context also experience a sense of un-confidence and discomfort ( Garrido et al., 2018 ).

Along the same lines, the data from a brief review on the topic ( Saladino et al., 2020b ) confirmed these results, reporting that participants whose parents are involved in illegal activities and are often absent from home are more likely to experience a lack of family cohesion and support and are more at risk in developing binge drinking and smoking marijuana habits. On the contrary, the presence of parents increments the perceived support of the participants and, therefore, decreases risky conducts ( Brown and Shillington, 2017 ). According to Tucker et al. (2013) , in addition to the lack of closeness to parents, the availability of drugs at home and parents’ perception of alcohol and illegal drugs also are two variables within family risk factors, which can influence substance abuse conduct among youth.

The influence of these factors is associated with the family context change according to the substance. For instance, the abuse of marijuana seems to be more linked to the relationships with parents, as shown by a comparison between frequent marijuana users and never or less frequent lifetime marijuana users, where the first category of users is more likely to perceive a lack of parental support ( De Looze et al., 2015 ). Binge drinking, instead, seems to be associated with less parental supervision and the absence of parent, the availability of alcohol at home, and parents who drink alcohol ( Martínez-Montilla et al., 2020 ). The Canadian Institute of Health Research and the Heart and Stroke Foundation of Canada ( De Looze et al., 2015 ) confirmed these results, showing an association between the frequency of alcohol consumption and parental drinking. Adolescents whose parents drink alcohol are more at risk in becoming alcohol and polysubstance users. This survey shows that the parent–children relationship assumes a mediator role in risky behaviors connected to substance abusive conduct among youth. Indeed, a positive relationship with parents might decrease the odd to develop an addiction in adulthood, and not depend on contextual variables, such as where adolescents attend schools in high- or low-at-risk neighborhoods ( De Looze et al., 2015 ).

Regarding parent involvement in crime and its connection with an increased risk of substance abuse and delinquency, this factor is often related to a history of physical abuse, maltreatment, parental neglect, a negative family climate, which, as mentioned above, is strongly associated with criminality and substance abuse ( Lee et al., 2012 ; LoBraico et al., 2020 ; Saladino et al., 2020b ). The data from the 2016 Minnesota Student Survey on 126,868 youth in public schools found that parental incarceration could determine an increased occurrence of externalizing behaviors among teens ( Ruhland et al., 2020 ). NeMoyer et al. (2020) confirmed these results, linking parental incarceration with self-reported delinquent acts of youth. Parental incarceration is also associated with an increased risk of developing substance abuse as the Baltimore Prevention Project discovered ( Furr-Holden et al., 2011 ). According to this study, adolescents who have incarcerated fathers (13% of the sample) are more at risk of drug abuse and delinquency, compared with adolescents without justice-involved fathers ( Furr-Holden et al., 2011 ). Kjellstrand et al. (2019) confirmed that parents formally incarcerated can lead to problematic developmental trajectories, such as suicide ideation, suicide attempt, adolescent delinquency, and substance abuse ( Kjellstrand et al., 2019 ).

Good family communication and disclosure are also important in preventing risky behaviors among youth ( Savage, 2014 ; Pettigrew et al., 2017 ). A strong sense of openness within the family context increases social and emotional skills among teens ( Haverfield and Theiss, 2017 ), and decreases risky behavior ( Harris et al., 2017 ; Massarwi and Khoury-Kassabri, 2017 ). Positive communication with parents is an antidrug socialization agent ( Shin and Miller-Day, 2017 ). In this regard, parental drug-talk styles, especially in early adolescence, assume a key role in preventing substance abuse ( Choi et al., 2017 ; Pettigrew et al., 2018 ). Shin et al. (2019) identified four types of parent’s drug-talk styles, considering Miller-Day and Kam (2010) parent–offspring drug-talk model (PODT): situated direct, ongoing direct, situated indirect, and ongoing indirect style. In the situated direct style of PODT, parents talk one time with explicit comments about substance use and abuse; in the ongoing direct style, parents express their opinion on drugs systematically; in the situated indirect style, they hint at the drug talk, showing their disappointment through non-verbal communication, and in the ongoing indirect style, they communicate repeatedly the opinions and feelings on drugs using verbal and non-verbal messages. Parents change their drug-talk style according to the specific age of their children and to the situation. According to the authors, parent drug-talk styles are influenced by family environments, which could be characterized by expressiveness, structural traditionalism, and conflict avoidance. The first dimension is characterized by openness and closeness, the second instead by a sense of control and power by parents and of obedience by children; and the third one tends to suppress conflicts to maintain family harmony. Shin et al. (2019) examined the relationships among parent–adolescent drug-talk styles, family communication environments, and substance use and abuse (alcohol, cigarette, marijuana, and chewing tobacco), and the main results of the study showed that the ongoing direct style has a more positive outcome than other drug-talk styles on substance abuse behaviors of youth. Regarding the family environment, compared to other dimensions, expressiveness can predict more positive family outcomes and interactions ( Burns and Pearson, 2011 ), can influence more the personal anti-substance-use perception of youth ( Shin and Miller-Day, 2017 ), and is significantly related to lower levels of use while conflict avoidance is related to higher levels of drug abuse.

Similarly, Reimuller et al. (2011) found that alcohol-specific communication characterized by permissive messages leads adolescents to a higher risk of alcohol abuse than alcohol-negative messages. Communication, in general, and parent drug-talk influence the personal perception of adolescents and their future choices in adulthood as well.

As suggested by the data, parental support, communication, and family climate can protect teens from risky behaviors ( Haverfield and Theiss, 2017 ; Pereyra and Bean, 2017 ; Saladino et al., 2020b ). It is important to consider the complexity of the relationship between parents and adolescents and their bidirectional influence on the developmental trajectories. An example of this perspective derived from the family-based therapy approaches that are focused on family in a multidimensional level. This approach is composed of three frameworks that help therapists and health professionals to think in terms of mutual interaction between different factors, including the influence on adolescents’ behavior. The first one is the protective factor framework, which includes family, social, and individual domains. Clinicians must know the interaction between these factors to facilitate positive adaptation during the main critical phases of the development. A framework of protective factors is based on interpreting each situation according to the current life circumstances of the adolescent’s family. The second one is a developmental perspective framework, which focuses on developmental psychology distinguishing the typical development from the dysfunctional development in terms of psychopathology and maladaptive behaviors. The last one is an ecological framework based on an ecological approach as it studies the human behavior in a specific context. The most used and effective family-based therapy considers and integrates these frameworks by taking care of the individual and his/her family system. One of the family-based models that have considerable effectiveness among teens involved in drug abuse and criminality is the multidimensional family therapy (MDFT). According to this model, the family is the principal arena and shapes the individual in both intrapersonal and intrafamilial dynamics through a modeling process, playing a role in reinforcing behaviors, both negative and positive ( Liddle, 2010 ). For this reason, the family is considered as a starting point to improve the living quality of adolescents who present any form of behavioral problems. MDFT is based on indirectly helping family members to implement new ways of interacting with one another and supporting their family member’s drug-free lifestyle and facilitating a change of perspective. Furthermore, MDFT also involves other influencing systems, which maintain drug abuse, through the “extrafamilial” work. As reported by Liddle et al. (2011) , MDFT engaged 97% of youth drug users as compared with 55% in services as usual (SAU) and retained 87% of these teens in at least 3 months after release compared with 23% in SAU. Compared to other approaches, MDFT has a higher long-term effect on both adolescent drug use and family functioning ( Rowe, 2012 ). Another approach based on multilevel domains and focusing on the family system is the brief strategic family therapy (BSFT), which has an evidence base of effectiveness for drug abuse and related behavioral problems in adolescence. This approach, based on the work of Minuchin and Haley ( Robbins et al., 2011 ), has a common perspective and the goals of MDFT, which aims at reducing adolescent behavioral problems by promoting good relationships among individual, family, and other systems, such as school and peers; supporting personal skills; and improving the new coping capacity in both adolescents and parents. Robbins et al. (2011) have conducted a study to compare BSFT with treatment as usual (TAU) including a sample of 480 adolescents and their family members using a specific and practical approach. The results showed that the group treated with BSFT reported higher levels of attendance and reduced probability to drop out than that treated with TAU. Moreover, participants treated with BSFT have shown a greater improvement in family functioning, also reported for adolescents, than that with TAU.

Finally, another model based on the behavioral and systemic approach is the functional family therapy (FFT). This model aims to identify and modify the maladaptive family patterns that maintain the problem. FFT changes the family interactions through positive reinforcements by introducing new problem-solving strategies. This therapy reduces recidivism among criminal teens and decreases antisocial behavior, as shown by a study on adolescent inmates with callous-unemotional (CU) traits who have committed violent and propriety crimes ( White et al., 2013 ). The participants and their families were involved in FFT, and according to the evaluation pre–post treatment, the association between CU traits and recidivism was lower after the treatment as well as the aggressive and violent behaviors reported by parents ( White et al., 2013 ). The same results were obtained by analyzing 917 families from both rural and urban settings in 14 different counties ( Sexton and Turner, 2010 ). Most of the participants committed weapon crimes, had some gang involvement and a history of running away from home, were school dropouts, and used alcohol and marijuana. Criminal onset was in early adolescence between 12 and 17 years old. The participants were divided into two groups; one received FFT and the other TAU in traditional probation services in their local county. When the therapist was adherent to FFT, the results showed a reduction in serious crimes 1 year after treatment, and when the therapist was not adherent to FFT, the recidivism rates were significantly higher compared to the TAU group ( Sexton and Turner, 2010 ).

The effectiveness of family-based models for adolescence drug abuse and other related problems has been demonstrated. The strength of these treatments is their focus on the interaction of several factors that trigger the vicious circle of crime and addiction in adolescence, and the results appear to have a broader outcome compared to the traditional family therapy approaches. Family-based therapy clients are less likely to be arrested, to relapse after a treatment, and to experiment internalizing and externalizing symptoms and in other co-occurring problems ( Liddle et al., 2011 ). These data explained the reciprocal influence between parents and adolescents and highlighted the important implications for future clinical practice.

Substance Abuse and Criminal Conduct

Drug abuse could influence criminal acts, including violent and non-violent offenses, such as threatening a person with a weapon, throwing objects, stealing money, physical aggression, sexual violence, and others ( Coretta, 2012 ). Karofi (2012) confirmed the association between drug abuse and a high crime rate. Indeed, drug abuse could make individuals, especially adolescents, to commit crimes for acquiring drugs. Green et al. (2016) highlighted the link between substance abuse and economic crimes, weapon carrying, robberies (particularly among the users of heroin), illegal import, manufacturing, dealing, and drug possession.

Drug dealing is almost the most common crimes spread in adolescence. It could have different interpretations and motivations. The small drug dealing is often an extension of consumption and is understood as a sharing between friends who get the substance acquires prestige. Thus, the illegal act is specific to a certain phase of adolescence and does not continue into adulthood. Additionally, when drug dealing is associated with the youth culture and combined with personal and social problems, it may be used to have fun during a party with friends or to face feelings of sadness or insecurity. Adolescents who sell drugs in a specific context and situation are more likely to develop a drug addiction in adulthood rather than to become professional drug dealers. In other situations, the drug dealing may take place in non-disadvantaged social contexts, where the parents’ expectations lead the adolescent to look for alternative routes that become a sort of escape from family rules. Drug dealing can become dangerous for the development of an addiction rather than a criminal career because it is linked to a specific need for autonomy and recognition of one’s identity. On the contrary, when drug dealing is considered as a form of work and survival for those who come from contexts in which they do not perceive alternatives or when adolescents are hired by an organized crime group to carry out drug dealing activities, they are more likely to become professional drug dealers and to perpetuate this criminal behavior during adulthood ( Johnston et al., 2018 ). Shook et al. (2013) documented that young drug dealers are also more likely to be engaged in other risky and delinquent behaviors. These results have been replicated in other studies with community and population samples ( Vaughn et al., 2011a , b ) and in research using the samples of justice-involved youth ( Gunter et al., 2011 ; Magyar et al., 2011 ; Jeffrey et al., 2013 ).

The data suggest that the relationship between individuals and their context is fundamental for studying drug selling behaviors. Specifically, psychological, family, peer, and economic context are associated with differences among groups of young drug dealers. The literature studies converge in considering the drug-related conduct associated to antisocial behavior, delinquency, and criminality, including violent offending ( Coretta, 2012 ). The choice of an individual to engage in such offenses, mostly exposing youth to incur in criminal sanctions, such as arrest. However, as the types and frequency of drug-related behaviors influence the link between drug-related behaviors and criminal offending, the explanatory mechanisms are complex to identify ( Shook et al., 2013 ).

Additionally, to analyze the involvement of adolescents in drug-related behaviors, Phillips (2017) created a classification of these behaviors, considering the level of adolescents’ involvement measured on a continuum. Thus, it is possible to study the relationship between drug dealing and criminal conduct according to a categorical approach.

The link between drug abuse and criminal behavior was recently studied in an undergraduate student sample in Nigeria ( Patrick and Okwukwe, 2019 ). Respondents of the survey affirmed that (the percentage of respondents is indicated in brackets): people who use drugs behaves aggressive (44.1%), use violent and bad language (9.5%), are school dropouts (9.2%), and are more likely to lose control (29.5%). Mostly, the respondents agree that substance abuse involves an organized crime (95%) and an armed robbery (97%), especially among youth, whereas 92% of the respondents think that substance abuse, among female students, leads to prostitution. Another study conducted in Nigeria ( Mamman et al., 2014 ) confirmed these results, showing that adolescents who are drug abuser are more likely to be involved in gang formation and armed robbery.

The results of a few studies ( Mamman et al., 2014 ; Patrick and Okwukwe, 2019 ) also showed some risk factors toward the development of drug abuse among students: peer group influence, curiosity, stress, family problem management, and high availability of the substance. Authors discussed the types and effects of this unhealthy practice among students, highlighting the need for the government, parents, teachers, counselors, and other members of the society to actively get involved in the fight against drug abuse not only by condemning it but also by living an exemplary lifestyle. The need for the proper education of parents on adolescent behavior was stressed out. The adolescent themselves should also be educated early enough about the dangers of addiction and parents on their side should try to watch their children very closely. By doing so, they can easily detect early issues in their own or other’s behaviors.

Principal Findings

To summarize the key findings of this review, one needs to conclude that there has been an increased number of studies on the multifactorial interaction among the family system, substance abuse, and juvenile delinquency in adolescence. We also considered the associated factors of the family system such as family communication, feelings of disclosure, and family climate. The interaction among family, individual, and behavioral factors is not a linear but a circular process, which is defined by a reciprocal and an interactive influence. According to our findings, family relationships and climate (in particular, parental support and communication, parental drug abuse, and parental incarceration) have a strong impact on illicit and at-risk behaviors of youth, especially on delinquency and substance abuse ( World Health Organization, 2010 ; Piko and Balaìzs, 2012 ; Thomas et al., 2013 ; Buelga et al., 2017 ). The family system represents the first space of communication and should give its members a feeling of belonging. When children live in disrupted or negligent families, they are more likely to be involved in risky conducts. However, these findings are not a norm but just the more common results. There may be cases, instead, where teens get involved in crime and drug abuse while not coming from dysfunctional families ( Kann et al., 2016 ). In these cases, it is important to evaluate the individual and environmental factors that can influence, along with the family system, the adolescents’ behavior. Indeed, we focused on the interaction among influence factors according to a circular process, avoiding a linear and causal interpretation of behavior prediction ( Lösel and Farrington, 2012 ).

Resorting to violence could be a strategy to survive at specific situations in which adolescents perceive parents as not supportive and absent in their lives ( Lee et al., 2012 ; Kann et al., 2016 ; LoBraico et al., 2020 ; Saladino et al., 2020b ). These negative feelings also contribute to developing poor confidence in others, negatively impacting the adolescents’ capacity to manage negative emotions ( Garrido et al., 2018 ). Risky conducts become the only strategy to communicate their feelings and oversee their emotions ( Myers et al., 2018 ). Another important finding is in regard to parent justice involvement, which is often associated with a lower perception of support and cohesion among family members, the absence of parents, and the lack of family communication. All these factors impact adolescent’s life, who might become a drug experimenter or emulate parents’ behaviors, being involved in criminal conducts ( Saladino et al., 2020b ). Furthermore, parents in prison negatively influence behaviors of youth, leading to more externalizing acts ( Ruhland et al., 2020 ). This result shows a strong tendency of children to imitate parents’ behaviors, evaluating those conducts correct or justified. In this way, adolescents learn to react to frustration and to solve problems using violence and crime ( Furr-Holden et al., 2011 ; Kjellstrand et al., 2019 ; NeMoyer et al., 2020 ).

Likewise, the availability of drugs at home and the perception of parents about drugs can influence substance abuse conduct among youth ( Saladino et al., 2020a ). Specially, binge drinking, more than marijuana use, seems to be related to low parental supervision and the absence of parent. This finding is interesting and may be related to the common use of alcohol among parents at home and with their low perception of risks in using it ( Martínez-Montilla et al., 2020 ). Indeed, parental drinking is associated with more probability to become a drinker in adolescence and adulthood ( De Looze et al., 2015 ). The use of drugs among youth is also related to parental drug-talk styles. Indeed, general good family communication and disclosure can prevent risky behaviors among youth ( Savage, 2014 ; Pettigrew et al., 2017 ; Shin and Miller-Day, 2017 ), specifically, if parents are confident in talking about drugs ( Choi et al., 2017 ; Pettigrew et al., 2018 ). According to the PODT ( Miller-Day and Kam, 2010 ), the most favorable drug-talk style in preventing drug abuse is an ongoing direct style, in which parents express their opinion on drugs systematically ( Shin et al., 2019 ). In the same way, a family environment characterized by expressiveness (openness and closeness among family members) could predict more positive family outcomes ( Burns and Pearson, 2011 ), decreasing the risk of substance abuse and criminal acts more than other environments, such as structural traditionalism, and conflict avoidance, based on parents’ control and power, and a tendency to avoid conflicts ( Shin and Miller-Day, 2017 ).

Regarding the connection between substance abuse and criminal conducts, our findings suggest that drug abuse and crime are associated, especially in the case of economic crimes, weapons usage, robberies, illegal import, manufacturing, dealing, and drug possession ( Green et al., 2016 ). Drug dealing is a risk factor for the development of an addiction and for a criminal career and is often linked to a specific need for autonomy and recognition of one’s identity. Small traffics are transients and often an extension of consumption ( Johnston et al., 2018 ). The evaluation of different contexts, situations, and family backgrounds is essential to give the correct interpretation of drug-related behaviors (e.g., escaping from family rules, parental negligence, survival, and involvement in peer groups). Families and schools are the primary prevention environments where the future of adolescents with drug abuse and criminal problems is shaped ( Patrick and Okwukwe, 2019 ).

According to the main findings discussed above, drug abuse in adolescence is a complex problem, which involves the individual and social and environmental levels as revealed in developmental psychology and psychopathology research studies. Studies in this field have the common aim to identify the critical “markers” to prevent and treat the abuse of drugs as well as the illicit conduct diffused among both categories of teens: the convict and the student. Consistent research findings support the reciprocal interaction between positive family functioning and positive outcomes in desistance from crime and drug abuse in adolescents and adults ( Hochstetler et al., 2010 ; Robertson et al., 2010 ).

Limitations

This review presents some limitations. As noted, gender differences and social environment were not considered in criminal behavior and the abuse of substances. Moreover, even though the studies presented are European, the majority are conducted in the United States, probably because of the high rates of criminality and risky behaviors compared with other countries. Our review did not consider the influence of the culture in the main findings of research. Family relationships, the quality of communication, and support are also culturally determined.

This review did not consider recent changes in the illicit/licit drug definition, an important issue especially in the United States, in which most of the studies on crime and deviance are published. For example, recently, a change in the consideration of marijuana occurred: in reviewing a series of WHO recommendations on cannabis and its derivatives, the Commission on Narcotic Drugs (CND) removed cannabis from Schedule IV of the 1961 Single Convention on Narcotic Drugs—where it was listed alongside specific deadly, addictive opioids, including heroin, recognized as having little to no therapeutic purposes.

Another limit that emerged from our review is that different studies belong to the gray literature, therefore potential “spuriousness” problems could arise. For example, recently, the Marijuana Gateway Hypotheses were challenged ( Jorgensen and Wells, 2021 ). MGH postulates that marijuana use serve as a “gateway” that increases the likelihood of engagement of users in subsequent use of harder and more harmful substances. Jorgensen and Wells (2021) make a call for improvements in the salience of findings regarding the MGH to better understand the complex relationship between marijuana and hard drug use and to discover if that relationship is causal. We consider this focus important not only for the MGH but also for deviance prevention: the circular approach adopted in this study allows to draw such connections. Jorgensen and Wells (2021) advanced the body of research on the MGH by applying propensity score matching (PSM) to a longitudinal, nationally representative sample. The authors appealed to the spuriousness problems applied to the whole body of research analysis: “In practice, control for all relevant confounding factors is an ideal that cannot be achieved, because the critic can always invoke the lack of control for important non-measured factors” ( Kandel, 2003 , p. 470). To solve this issue, they applied the PSM approach to provide an alternative to traditional approaches (e.g., regression analysis using unbalanced data) in testing the MGH when true experimental methods are not possible to be devised. PSM is a selection on observables method based on the counterfactual approach to hypothesis testing that allows researchers to estimate causal effects ( Apel and Sweeten, 2010 ). This recent literature is very important to consider because our narrative review showed that one of the most used substances is marijuana.

We believe that future research linking family relations with drug abuse and deviance should be based on a solid experimental design to avoid spuriousness and to incorporate the recent advancements in drug classification.

Lastly, consistent with most narrative reviews, we did not appraise the quality of the included studies because our primary goal was to provide a broad perspective on the association of the family system, substance abuse, and crime in adolescence.

Future Implications: A Multidimensional Approach

According to the main findings discussed above, drug abuse in adolescence is a complex issue, which involves individuals, the society, and families, as shown by research studies conducted in the developmental psychology and psychopathology field. As well as from the previous literature, our study has an aim at identifying the critical “markers” for juvenile risky and deviant behaviors, to prevent and treat the abuse of drugs as well as the diffusion of illicit conducts among teens. Consistent research findings support the reciprocal interaction between positive family climate and communication, and positive outcomes in desistance from crime and drug abuse in adolescents and adults ( Hochstetler et al., 2010 ; Robertson et al., 2010 ; Okoiye and Adebisi, 2015 ). The family system plays a key role in the prevention of risky behaviors and social rehabilitation after being released from prison or after a drug addiction treatment.

These results could be useful in structuring programs on substance abuse and criminality prevention for the whole family system, both parents and youth. For instance, measures and programs focusing on adolescents are needed, based on the following indications and according to a perspective that considers the familial, educational, and social level and can be applied to both parents and youth:

(1) Familial interventions should be based on the direct involvement of parents, developing programs of support and parent training for families to improve their relationship with their children, and on decreasing the risk factors for youth associated with the dysfunctional family system. Familial interventions can help parents to establish positive communication, reduce conflicts within the family, promote a parenting style based on active listening, affection, and rules, lead parents to understand the effects of neglection, physical and psychological violence, and systematic exposure to a criminogenic context on the child’s development. These interventions could have a double aim: the treatment for families with drug-addicted and justice-involved parents or relatives and the prevention for conflictual families with dysfunctional communication and negative climate.

(2) Educational interventions for youth aim to develop more awareness among juveniles on the consequences of drug abuse and crime. These interventions could promote a joint and coordinated effort of family and school, which collaborate to reduce the spread of drug abuse and crime among youth. Educational projects can be the target considering gender and age differences. Teachers could organize lectures, seminars, rallies, and films, which teach alternative behaviors than the risky ones. Moreover, it could be useful to include a psychological support service at school for youth with family issues or who have parents involved in crime or drug addicted, to give a space in which they can disclose with a professional, reducing the risk to violent or self-harming acting out.

(3) Community interventions aim to promote social awareness through antidrug and anti-crime campaigns, especially on new drugs, drug selling websites on the dark web, legal consequences, and life in prisons. These interventions can use social media and social networks to diffuse a good policy on the topic and prevent from drug-addiction and juvenile justice involvement. It could be useful to establish a national and an international policy of intervention based on scientific divulgation of the main research findings to create best practices for schools and families in high-risk areas.

(4) Future researches are needed, especially focusing on longitudinal monitoring of the effect of long-term exposure to the risk factors mentioned in our and in the previous research. Also, psychologists, sociologists, and researchers in this field should be focused on identifying criminal areas in which young people are more likely to be exposed to violence, poverty, substances, and dissatisfaction with familial relationships to enrich the knowledge of the factors that can affect young people. Finally, it could be useful to stimulate a scientific debate with European and non-European countries to evaluate the topic according to a different cultural point of view and to enrich the discussion about possible interventions.

(5) Future studies are needed for addressing the cross-cultural dimension of the relationship of parents–children. Indeed, the development of theoretical models on parent–adolescent relationships reflect limited cultural considerations, in part due to the majority of previous works being carried out in western, educated, industrialized, rich, and democratic (WEIRD) countries ( Dishion and McMahon, 1998 ; Stattin and Kerr, 2000 ). Nowadays, more and more research on parenting is conducted in different cultures as well as cross-culturally, calling for more nuanced tests of the degree of similarity/difference of parenting dimensions across cultures ( Hadiwijaya et al., 2017 ). For example, recently, Vazsonyi et al. (2021) , to address some research gaps, focused on maternal parenting excluding the role of father involvement, employed Steinberg and Silk’s (2002) conceptual framework to inform the operationalization of parenting, and tested its cross-cultural applicability by examining the links between both perceived maternal and paternal parenting processes and measures of adolescent internalizing and externalizing problems, which are risk factors for the development of deviant behaviors. This framework can be described by the interplay of three overarching dimensions, namely autonomy, harmony, and conflict. Three primary parenting domains, namely harmony, autonomy, and conflict, were mapped: harmony is operationalized as the affective dimension of parents–children relationship and includes constructs such as closeness, intimate communication, and warmth ( Vazsonyi et al., 2021 ). Autonomy describes balancing growth and independence through connectedness and boundary-setting and includes monitoring, restrictiveness, and parents’ approval of the adolescent’s friends.

The main findings of this review suggest that adolescents whose parents are involved in illegal behavior and the use of drugs are more likely to be involved in delinquency and substance abuse conduct. Furthermore, the perception of lacking family support, negative climate, and communication and of having justice-involved parents might contribute to the development of risky trajectories among young people. Moreover, there is a connection between criminal activities and substance abuse, which can lead to a future criminal career and addiction in later adolescence and adulthood.

The parent–children relationship seems to have a key role in risky behaviors among youth. Therefore, positive and supportive relationships with parents may reduce these risks. For this reason, we consider it useful for future research and interventions to place the focus on family in a multidimensional level. For instance, the so-called family-based approach therapy in treating and preventing drug abuse and criminal behavior among youth provides such possibilities.

Moreover, according to an overview of a systematic review about interventions for adolescent substance abuse ( Das et al., 2016 ), school programs based on the promotion of social competence and the antidrug information were effective. However, there was poor empirical evidence in the evaluation of the long-term efficacy and the sustainability of substance abuse programs for adolescents.

Future research should focus on evaluating the effectiveness of specific intervention components with standardized intervention and outcome measures. Furthermore, the inclusion of gender differences in the family system influencing substance abuse and criminal conducts and of higher quality evidence, especially from low- and middle-income countries on effective interventions, to prevent and manage substance abuse among adolescents will be useful.

Author Contributions

All the authors equally contributed to developing the project of present research, and to writing the manuscript. VS: conceptualization. VS, OM, and CC: methodology. VS and OM: investigation and writing—original draft preparation. LH, CC, ML, FP, and VV: writing—review and editing. VV, CC, ML, and FP: supervision. All authors have read and agreed to the published version of the manuscript.

Conflict of Interest

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Publisher’s Note

All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.

Funding. The publication of this article was funded by the Department of Education, Psychology, Philosophy, University of Cagliari (Italy). The research was funded by the Department of Human, Social and Health Sciences, University of Cassino and Southern Lazio (Italy), and the Institute for the Study of Psychotherapy of Rome (Italy).

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Strategic analysis of intimate partner violence (IPV) and cycle of violence in the autobiographical text -When I Hit You
1. Introduction. Intimate Partner Violence (IPV) is a grave social issue that violates women's rights, and it is recognized as a significant global health concern that infringes on women's well-being across all countries and cultures (Ellsberg et al., 2015).It is widely recognized as a kind of gender-based violence, with women being victims of physical, sexual, and psychological abuse at a ...
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Domestic Violence and Abuse in Intimate Relationship ...
Domestic Violence and Abuse: Theoretical Explanation and ...
Domestic violence and abuse (DVA) is a complex issue and it is important to understand how and why this happens. Such understanding can help find strategies to minimise DVA. Over past decades, many explanations have been proposed to explain DVA from various perspectives. This chapter aims to present an aggregated overview of that information to ...
Exploring factors influencing domestic violence: a comprehensive study
Exploring factors influencing domestic violence
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Domestic Violence
Sociological Theories to Explain Intimate Partner Violence: A
Intimate partner violence (IPV) is the most common form of violence against women globally, with recent estimates indicating that nearly one in four women globally experience physical and/or sexual IPV in their lifetime (Sardinha et al., 2022).IPV is defined as acts perpetrated by a current or previous partner that cause physical, sexual, or psychological harm (WHO & PAHO, 2012).
A systematic review of intimate partner violence interventions focused
Background Intimate partner violence (IPV) is a key public health issue, with a myriad of physical, sexual and emotional consequences for the survivors of violence. Social support has been found to be an important factor in mitigating and moderating the consequences of IPV and improving health outcomes. This study's objective was to identify and assess network oriented and support mediated ...
The Cycle of Violence: Abused and Neglected Girls to Adult Female
Cathy Spatz Widom, PhD, is a distinguished professor in the Psychology Department at John Jay College of Criminal Justice and a member of the Graduate Center faculty, City University of New York.Widom and her colleagues have been studying the long-term consequences of childhood abuse (physical and sexual) and neglect, the cycle of violence, and the intergenerational transmission of child abuse ...
Breaking the Cycle of Family Violence: A Critique of Family Violence
Of the 14 papers included in this narrative review, only 3 explicitly stated that they aimed to break the cycle of family violence; 12 papers came from high-income countries, and 10 focused on individuals, with half focusing on mothers.
PDF Social-cognitive mechanisms in the cycle of violence: Cognitive and
Exposure to emotional abuse (on the CECA, or above the validated CTQ threshold) and domestic violence (on the VEX-R interview or PTSD-RI trauma screen) was determined based on child report only. A total of 76 children (30.9%) reported experiencing emotional abuse, and 94 (38.2%) reported witnessing domestic violence.
Cycle of Violence
The phrase "cycle of violence" initially described the relationship between physical abuse in childhood and the perpetration of violence in adolescence or adulthood. Researchers largely attribute the concept of a cycle of violence to Cathy Widom ( 1989 ). The methodological rigor of Widom's ( 1989) research provided considerable support for ...
Understanding cycles of abuse: A multimotive approach.
Fundamental to the definition of abusive supervision is the notion that subordinates are often victims of a pattern of mistreatment (Tepper, 2000). However, little research has examined the processes through which such destructive relational patterns emerge. In this study, we draw from and extend the multimotive model of reactions to interpersonal threat (Smart Richman & Leary, 2009) to ...
Cycle of Violence
Instead of seeing domestic violence as a set of randomly occurring episodes of violence, Walker demonstrated how the violence followed a predictable cycle or pattern that repeated itself. With each cycle, the length of time required to complete it becomes shorter and the violence within it increases. To explain why women stay in the abusive ...
Intimate partner violence: A loop of abuse, depression and
Intimate partner violence: A loop of abuse, depression and ...
Breaking the Cycle of Abuse
rental abuse. Egeland, Jacobvitz, and Sroufe 1081 The aim of the present study was to examine this notion by contrasting the in-cidence of supportive relationships experi-enced by mothers who continued the cycle by abusing their own child versus those who broke the cycle and provided the child with adequate care. To permit a richer description
PDF breaking the cycle: a life course framework for preventing domestic
ors in early childhood are largely the same for both young boys and girls. The life course framework points to experiences of child-hood abuse and witnessing domestic. violence as critical predictors of future perpetration of domestic violence.It also signals how the cycle of violence can emerge— i.e., when domestic.
Breaking the Cycle of Abuse: How to Move Beyond Your Past to Create an
This chapter discusses how to identify and manage your emotions and develop long-term strategies to help you break the Cycle of abuse. Acknowledgments. Introduction. Part One: Understanding the Legacy of Abuse. 1. What Will Be Your Legacy? 2. Assessing Your Risk Factors. 3. Why We Do to Others (and Ourselves) What Was Done to Us. Part Two: Facing the Truth and Facing Your Feelings. 4. Coming ...
9 CONCLUSIONS AND RECOMMENDATIONS
Recommendation 2: In the absence of research that demonstrates that a specific model of treatment can reduce violent behavior for many domestic violence offenders, courts need to put in place early warning systems to detect failure to comply with or complete treatment and signs of new abuse or retaliation against victims, as well as to address ...
[PDF] Breaking the cycle of abuse.
Breaking the cycle of abuse. Claudio Consuegra. Published in Child Development 1 August 1988. Psychology. TLDR. Abused mothers who were able to break the abusive cycle were significantly more likely to have received emotional support from a nonabusive adult during childhood, participated in therapy during any period of their lives, and to have ...
Domestic Violence
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Intergenerational effects of childhood maltreatment
The Vicious Cycle: Problematic Family Relations, Substance Abuse, and
Problematic Family Relations, Substance Abuse, and ...

Domestic Violence and Abuse: Theoretical Explanation and Perspectives

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A systematic review of intimate partner violence interventions focused on improving social support and/ mental health outcomes of survivors

Introduction

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Types of social support interventions for intimate partner violence survivor

Advocacy/ Case management interventions

Advocacy/Case management interventions with a psychotherapy component

Community-focused/ network social support interventions

Community focused/ network interventions with a psychotherapy component

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Violence in Families: Assessing Prevention and Treatment Programs (1998)

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Reporting Practices

Batterer Treatment Programs

Record Keeping

Collaborative Law Enforcement Strategies

Home Visitation and Family Support Services

Intensive Family Preservation Services

Recommendations For The Next Generation Of Evaluations

Training for Service Providers and Law Enforcement Officials

Universal Screening in Health Care Settings

Mental Health and Counseling Services

Comprehensive Community Initiatives

Shelter Programs and Other Domestic Violence Services

Protective Orders

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Breaking the cycle of abuse.

639 Citations

The Vicious Cycle: Problematic Family Relations, Substance Abuse, and Crime in Adolescence: A Narrative Review

Oriana Mosca

Filippo Petruccelli

Marco Lauriola

Valeria Verrastro

Cristina Cabras

Introduction

Substance Abuse: Some Definitions

Theories of Drug Abuse

Social Stigma and Poverty: Negative Identity and Crime

Aim of This Study

Materials and Methods

Family Relationships, Substance Abuse, and Delinquency in Adolescence

Substance Abuse and Criminal Conduct

Principal Findings

Limitations