Effects of a Primary Care-Based Intervention on Violent Behavior andInjury in Children

Iris Wagman Borowsky, MD, PhD; Sara Mozayeny, BA; Kristen Stuenkel, MEd; and Marjorie Ireland, PhD

ABSTRACT. Objective. Although many major healthcare organizations have made recommendations regard-ing physicians’ roles in preventing youth violence, theefficacy of violence prevention strategies in primary caresettings remains to be empirically tested.

Methods. We conducted a randomized, controlledtrial to evaluate the effects of an office-based interven-tion on children’s violent behaviors and violence-relatedinjuries. Children 7 to 15 years of age who presented at 8pediatric practices and scored positive on a brief psycho-social screening test (n � 224) were randomly assigned toan intervention group (clinicians saw the screening testresults during the visit and a telephone-based parentingeducation program was made available to clinicians as areferral resource for parents) or a control group (clini-cians did not see the screening test results).

Results. Compared with control subjects, at 9 monthsafter study enrollment, children in the interventiongroup exhibited decreases in aggressive behavior (ad-justed mean difference: �1.71; 95% confidence interval[CI]: �2.89 to �0.53), delinquent behavior (adjustedmean difference: �0.71; 95% CI: �1.28 to �0.13), andattention problems (adjusted mean difference: �1.02;95% CI, �1.77 to �0.26) on the Child Behavior Checklist.Children in the intervention group had lower rates ofparent-reported bullying (adjusted odds ratio: 4.43; 95%CI: 1.87-10.52), physical fighting (adjusted odds ratio:1.79; 95% CI: 1.11-2.87), and fight-related injuries requir-ing medical care (adjusted odds ratio: 4.70; 95% CI: 1.33-16.59) and of child-reported victimization by bullying(adjusted odds ratio: 3.23; 95% CI: 1.96-5.31).

Conclusions. A primary care-based intervention thatincludes psychosocial screening and the availability of aparenting education resource can decrease violent behav-ior and injury among youths. Pediatrics 2004;114:e392–e399. URL: www.pediatrics.org/cgi/doi/10.1542/peds.2004-0693; violence, youth, prevention, primary care,psychosocial intervention, parenting education.

ABBREVIATIONS. PSC, Pediatric Symptom Checklist; CBCL,Child Behavior Checklist; CI, confidence interval.

Violence is one of the leading causes of deathamong adolescents in the United States andaround the world. In America, young people

are disproportionately represented among both vic-tims and perpetrators of violence. Homicide is thefifth leading cause of death for youths 10 to 14 yearsof age and the second leading cause of death foryouths 15 to 19 years of age.1 In 2001, there were 2088homicides among youths 10 to 19 years of age in thiscountry.2 Nonfatal injuries resulting from violenceare also a critical dimension of the public healthproblem. Nonfatal interpersonal violence often pre-cedes fatal violence among youths3 and results indisabilities and high costs of medical care and reha-bilitation. National estimates based on emergencydepartment visits indicated that, in 2002, there were438 391 assault-related nonfatal injuries amongyouths 10 to 19 years of age.4

Risk factors associated with violent behavior andinjuries among youths include exposure to violenceas a witness or direct victim, childhood aggressionand antisocial behavior, substance use, depressedmood, and hyperactivity.5–8 Protective factors in-clude high academic achievement and parent-familyconnectedness.5,8 In addition to supportive parent-child relationships, positive and consistent disciplineand parental monitoring and supervision are criticalfamily-level protective factors in promoting resis-tance to involvement in violence among youths.7,9

Recommendations defining the role of clinicians inyouth violence prevention and management havebeen issued by a number of groups, including theAmerican Medical Association,10 American Acad-emy of Pediatrics,11 American Academy of FamilyPhysicians,12 American College of Physicians,13 So-ciety for Adolescent Medicine,14 and US PublicHealth Service.15 Recommendations include incorpo-rating preventive education, risk screening, and link-ages to necessary intervention and follow-up ser-vices into clinical practice. However, few residentsand practicing physicians in pediatrics and familymedicine routinely provide screening and anticipa-tory guidance for patients and parents regardingyouth violence.16 Furthermore, the effectiveness ofprimary care-based youth violence prevention inter-ventions is unknown.

The purpose of this study was to determine theeffectiveness of a primary care-based intervention,directed at youths and their parents, in reducingviolence involvement and violence-related injuriesamong the youths. We hypothesized that youths ex-

From the Division of General Pediatrics and Adolescent Health, Universityof Minnesota, Minneapolis, Minnesota.Accepted for publication May 7, 2004.doi:10.1542/peds.2004-0693Ms Mozayeny’s current affiliation is the California School of ProfessionalPsychology, Alliant International University, San Francisco, California.Address correspondence to Iris Wagman Borowsky, MD, PhD, Divisionof General Pediatrics and Adolescent Health, University of MinnesotaGateway, 200 Oak St SE, Suite 160, Minneapolis, MN 55455. E-mail:borow004@umn.eduPEDIATRICS (ISSN 0031 4005). Copyright © 2004 by the American Acad-emy of Pediatrics.

e392 PEDIATRICS Vol. 114 No. 4 October 2004 www.pediatrics.org/cgi/doi/10.1542/peds.2004-0693 by guest on August 6, 2018www.aappublications.org/newsDownloaded from

posed to a primary care-based intervention directednot only at reducing risk but also at promoting fam-ily-level protective factors would exhibit significantdecreases in violence participation and fight-relatedinjuries, compared with control subjects.

METHODS

Study DesignWe conducted a randomized, controlled trial to evaluate the

primary care-based intervention. The study was conducted in 8outpatient pediatric practices in the Minneapolis-St. Paul metro-politan area and included 36 primary care clinicians. The practicesincluded 2 urban community clinics, 2 urban private practices,and 4 suburban private practices. Randomization occurred at theindividual patient level. During defined data collection periodsfrom June 2001 through November 2001, all consecutive English-speaking parents of children 7 to 15 years of age who wereundergoing a medical visit were invited to complete the 17-itemPediatric Symptom Checklist (PSC-17) before their visit with theprimary care clinician. The PSC-17 is a brief, validated, psycho-social screening instrument developed to facilitate recognition andreferral of child psychosocial problems by primary care pediatri-cians.17,18 The checklist consists of subscales for internalizing,externalizing, and attentional symptoms. A positive screeningscore was defined as at least 1 positive subscale score or a positivePSC-17 total score (Table 1).18 Youths who scored positive on thescreening test and had not yet seen the clinician by the time thescreening test was scored were eligible to participate in the studywith their parents or guardians. Eligible youth-parent pairs wererandomly assigned, by research staff members in the clinic wait-ing room, to receive a primary care-based intervention to reduceviolence participation or to be control subjects. For those in thecontrol group, the primary care provider did not see the psycho-social screening test. Procedures and consent and assent formswere approved by the institutional review board of the Universityof Minnesota.

InterventionThe intervention focused on 2 strategies to reduce violence

involvement among youths, ie, 1) to identify, prevent, and treatmental health problems among youths through psychosocialscreening and appropriate mental health referral and follow-upmonitoring; and 2) to promote healthy child-parent relationshipsthrough a telephone-based positive parenting program. For thosein the intervention group, the patient’s scored PSC-17 was at-tached to the medical chart, so that the provider would see thepsychosocial screening test during the visit. Clinicians were in-structed to respond to the positive screening test results as they

thought appropriate. In addition, a telephone-based parentingeducation program, Positive Parenting, was made available to cli-nicians as a referral resource for parents in the intervention group.Providers were asked to indicate on a form whether they madereferrals to mental health services, Positive Parenting, or otherresources and whether they recommended follow-up visits withthemselves for each patient in the intervention group.

The parent training curriculum was adapted for telephonedelivery from the Positive Parenting curriculum, a research-based,family-strengthening program developed by the University ofMinnesota Extension Service, in cooperation with the Universityof Wisconsin Extension Service.19 The program emphasizes 3 coredimensions of authoritative parenting, namely, nurturance, disci-pline, and respect or granting of psychologic autonomy.20 Parentsreferred to Positive Parenting by their child’s provider were con-tacted by a parent educator via telephone, and a series of 15- to30-minute weekly telephone sessions with the parent educatorwere scheduled at the parents’ convenience. Parents received 2videotapes and a manual for the parenting course. Video seg-ments included role-playing and a group of parents discussing theparenting topic. Sessions and curricular materials were organizedaround 13 lessons, ie, parenting tools, attention, respect, respon-sibility, monitoring, perception, development, communication,conflict, discipline, parenting styles, decision-making, and friend-ships/peer influence. From these lessons, parents were asked tochoose the topics and number of sessions that they wanted. Threeparent educators provided training; all had a parent educationlicense.

Outcome MeasurementsControl and intervention participants were contacted by

trained interviewers, via telephone, for a baseline assessment im-mediately after the medical visit at which they were enrolled inthe study and for a follow-up assessment 9 months later. Inter-viewers conducting follow-up assessments were blinded with re-spect to participant allocation and indicated on the questionnaireafter each interview whether they became aware of the parent’s orchild’s group assignment during the interview. Study allocationwas ascertained by the interviewer in 7% of all follow-up inter-views (23 of 324 interviews) conducted with youths and parents.Interviews were conducted with all parents and with youths �10years of age at the time of study enrollment.

Parents were asked questions about their children’s behaviorwith the Child Behavior Checklist (CBCL).21 Questions aboutproblem behaviors produced subscales including aggressive be-havior, delinquent behavior, attention problems, and anxiety/depression. Youths completed the Achenbach Youth Self-Report,producing similar subscales.

Parents and youths independently completed questions mea-suring the frequency of bullying and being bullied during the past

TABLE 1. PSC-17 Subscales and Scoring13

Please Mark Under the Heading That BestDescribes Your Child

Never(0)

Sometimes(1)

Often(2)

PositiveScreen

Internalizing problems �51. Feels sad, unhappy � � �2. Feels hopeless � � �3. Is down on self � � �4. Worries a lot � � �5. Seems to be having less fun � � �

Attention problems �76. Fidgety, unable to sit still � � �7. Daydreams too much � � �8. Distracted easily � � �9. Has trouble concentrating � � �

10. Acts as if driven by a motor � � �Externalizing problems �7

11. Fights with other children � � �12. Does not listen to rules � � �13. Does not understand other people’s feelings � � �14. Teases others � � �15. Blames others for his/her troubles � � �16. Refuses to share � � �17. Takes things that do not belong to him/her � � �

Total of �15

www.pediatrics.org/cgi/doi/10.1542/peds.2004-0693 e393 by guest on August 6, 2018www.aappublications.org/newsDownloaded from

school term among the youths.22 Parents reported how manytimes during the past year their child was “in a physical fight” andwas “in a physical fight in which he or she was injured and had tobe treated by a doctor or nurse.” Youths also reported on physicalfighting during the past year. Youth attitudes toward interper-sonal peer violence, as well as knowledge and skill in resolvingconflicts nonviolently, were evaluated with 14 items assessing thelevel of agreement with statements such as “If I walked away froma fight, I’d be a coward (”chicken“)” and “I don’t need to fightbecause there are other ways to deal with being mad.”23 Cron-bach’s �, which is used to assess the internal consistency of multi-item scales, was .65 for this measure.

To assess positive parenting skills, items were taken from aparent self-check questionnaire.24 Questions comprising the posi-tive parenting skills scale asked parents to assess their strengthsand needs regarding 4 parenting practices, such as “calmly setlimits with defiant and disrespectful behavior.” For these items,parents responded with a number on a scale from 1 to 10, where1 indicated “not at all; major change needed,” 5 indicated “somechanges needed,” and 10 indicated “okay as is; area of strength.”Cronbach’s � for this measure was .71. Youths were asked similarquestions regarding parenting practices of the parent enrolled inthe study with them. Parental monitoring was assessed with 4items that were completed independently by parents and youthsand were adapted from a parental monitoring scale.25 Cronbach’s� was .73 for the youth version and .72 for the parent version. Twoquestions that were completed independently by parents andyouths assessed the use of corporal punishment, ie, “I use physicalpunishment as a way of disciplining my child” and “I spank mychild when he or she is disobedient.” Response options were“never,” “sometimes,” and “always.” Youths also responded to 13items assessing parent-family connectedness, including perceivedcloseness to and caring by mother and/or father and feeling lovedand wanted by family members.5 Cronbach’s � for this scale was.85. Parental depression was assessed with a 3-item version of theRand Corporation Screening Instrument for Depressive Disor-ders.26

Statistical AnalysesBaseline comparability of the intervention and control groups

was assessed with �2 tests for categorical variables and t tests forcontinuous variables. Intervention effects for continuous and di-chotomous measures were tested with Proc Mixed and Proc Gen-mod, respectively. These generalized linear models procedures,based on generalized estimating equations, allowed us to controlfor clustering of participants according to pediatric practices. Foreach multivariate analysis, the posttest measure was the depen-dent variable, group assignment (intervention versus control) wasthe independent variable, and the baseline measure of the depen-dent variable, age, and gender were covariates. Each outcomemeasure was also tested for intervention-age and intervention-gender interactions. All analyses were conducted on an intention-to-treat basis, and all tests of statistical significance were 2-tailed,with � � .05.

An anticipated sample size of �100 youth-parent pairs pergroup gave the study 80% power to detect an effect size of 0.40,with a 2-tailed test of statistical significance with � � .05 and acorrelation of 0.50 between baseline and follow-up measures.27

Parent-reported measures were the primary outcomes of thestudy, potentially available for all eligible youth-parent pairs.Child-reported measures were secondary outcomes, availableonly for the subset of youths who were �10 years of age at thetime of study enrollment.

RESULTS

Sample CharacteristicsThe study design and participation are presented

in Fig 1. Overall, 22% of youths (455 of 2032 youths)scored positive on the psychosocial screening test. Ofthose with a positive score, 164 parent-youth pairs(36%) saw the clinician before they could be invitedto participate in the study, 67 (15%) declined to par-ticipate, and 224 (49%) were enrolled in the study.Study participants were significantly less likely to

live with their biological father (60% vs 72%, P �.011) and were more likely to receive welfare (13% vs4%, P � .002) than were youths who were ineligibleto be in the study because they had seen the clinicianby the time their screening tests were scored. Thisfinding likely reflects longer average waiting times inthe waiting room before seeing the clinician in theurban clinics serving more low-income patients thanin the suburban clinics. Eligible participants whodeclined to be in the study did not differ from studyparticipants in key demographic variables, includingage, gender, race/ethnicity, family structure, and re-ceipt of welfare.

Baseline and postintervention telephone inter-views were completed by 95 parents (85%) in theintervention group and 97 parents (87%) in the con-trol group. Among the youths, baseline and post-intervention telephone interviews were completedby 65 of the 79 youths (82%) in the interventiongroup who were �10 years of age and 66 of the 77youths (86%) in the control group who were �10years of age at the time of study enrollment. Inter-vention and control participants were comparable inage (mean � SD: 11.2 � 2.3 years vs 10.9 � 2.3 years,P � .43), gender (44.6% vs 40.0% girls, P � .53),race/ethnicity (78.3% vs 78.9% white, P � .92), fam-ily structure (64.1% vs 60.0% living with both biolog-ical parents, P � .57), and receipt of welfare (12.1% vs12.6%, P � .91).

Exposure to Intervention ComponentsFor all intervention participants, the clinician saw

the psychosocial screening test results during thevisit. Clinicians indicated that they referred 30 of the112 youths (27%) in the intervention group to mentalhealth services and scheduled follow-up visits for 38of the youths (34%). Referral to mental health ser-vices was significantly more likely for youths with apositive versus a negative score on the internalizingsubscale (38% vs 15%, P � .05) and for youths with apositive versus a negative PSC-17 total score (40% vs18%, P � .05). Recommendation of a clinician fol-low-up visit was more likely for youths with a pos-itive versus a negative score on the attention subscale(50% vs 26%, P � .05).

Clinicians referred 78 of the 112 parents (70%) inthe intervention group of the study to Positive Par-enting. Of the referred parents, 6 (8%) declined par-ticipation at the clinician visit and the remaining 72(92%) received an introductory call from a parenteducator. Overall, 60 of the 78 parents (77%) referredfor the parenting education program received a man-ual and videotapes for the program by mail, 52 (67%)completed an initial assessment telephone session,and 41 (53%) completed at least 1 educational tele-phone session. These 41 participants completed amean of 6.7 telephone sessions (SD: 3.9), with a rangeof 1 to 15.

Effects of the Intervention on Mental Health ServiceUse and Parenting Practices

At baseline, 24.7% of parents in the interventiongroup and 23.9% of parents in the control groupreported that their child was currently receiving

e394 INTERVENTION TO REDUCE VIOLENT BEHAVIOR AND INJURY by guest on August 6, 2018www.aappublications.org/newsDownloaded from

mental health treatment (P � .89). During the9-month follow-up period, there were no statisticallysignificant differences between youths in the inter-vention and control groups with respect to parent-reported primary care clinic visits (mean � SD: 2.9 �4.2 visits vs 4.1 � 7.3 visits, P � .16), mental healthtreatment (36.8% vs 41.2%, P � .53), or medicationuse for a mental health problem (26.3% vs 32.0%, P �.39). There was no difference in the percentages ofintervention and control parents who reported thatthe clinician recommended any referral for theirchild at the visit in which they were enrolled in thestudy (15.8% vs 16.5%, P � .89). However, interven-tion parents reported that 80.0% of these referralswere to mental health professionals, whereas controlparents reported that 37.5% of the referrals were tomental health professionals (P � .01). Of parentswho reported a mental health referral for their childat the visit in which they were enrolled in the study,66.7% of intervention parents and 33.3% of controlparents reported that their child saw the professionalto whom they were referred at least once during thestudy period (P � .18).

In baseline assessments, the intervention and con-trol groups did not show significant differences inparental characteristics (Table 2). In follow-up as-sessments, there were no significant intervention ef-fects on parents’ reports of their positive parenting

skills or parental monitoring. Parents in the interven-tion group reported significant decreases in the useof corporal punishment, compared with control sub-jects. The intervention also significantly decreasedreported parental depression on a 3-item screeningtest. Differences in child-reported parenting practicesand parent-family connectedness between the inter-vention and control groups in follow-up assessmentswere not statistically significant.

Effects of the Intervention on Behavior Problems andViolence

Behavioral problems noted on the CBCL are pre-sented in Table 3, and other violence-related mea-sures are presented in Table 4. In baseline assess-ments, the intervention and control groups werecomparable with respect to all measures. In fol-low-up assessments, youths in the interventiongroup exhibited significant decreases in aggressivebehavior, delinquent behavior, and attention prob-lems on the CBCL, compared with control subjects.Differences in anxiety/depression were not statisti-cally significant but favored the intervention group.The intervention also significantly reduced parent-reported bullying, fighting, and fight-related injuriesrequiring medical care among youths in the interven-tion group. Similarly, youth reports of being thevictim of bullying were much lower in follow-up

Fig 1. Profile of the randomized controlled study.

www.pediatrics.org/cgi/doi/10.1542/peds.2004-0693 e395 by guest on August 6, 2018www.aappublications.org/newsDownloaded from

assessments among intervention children, comparedwith control subjects. There were no significant dif-ferences in other child-reported measures of violentbehaviors. Although the differences were not statis-tically significant, youths in the control group had amore violent attitude orientation and less knowledge

and skill in nonviolent conflict resolution than didyouths in the intervention group in follow-up assess-ments.

The results did not change when family structureand welfare status were added as additional covari-ates in the analysis for any of the behavioral or

TABLE 2. Parental Characteristics

Baseline Follow-Up Adjusted Difference(95% CI)*

P Value

Intervention Control Intervention Control

Parent reportPositive parenting skills, 1–10 scale 7.50 (1.40) 7.45 (1.51) 7.54 (1.24) 7.50 (1.34) �0.02 (�0.35 to 0.31) .91Parental monitoring, 1–3 scale 2.81 (0.30) 2.83 (0.27) 2.81 (0.28) 2.84 (0.24) �0.01 (�0.08 to 0.05) .69Use of corporal punishment,

1–3 scale1.26 (0.43) 1.31 (0.45) 1.15 (0.33) 1.27 (0.40) �0.19 (�0.36 to �0.01) .04

Parental depression, no. (%) 36 (40.0) 43 (45.3) 23 (24.2) 38 (39.2) 2.03 (1.08 to 3.81) .03Child report†

Positive parenting skills, 1–10 scale 7.50 (1.33) 7.75 (1.55) 7.59 (1.48) 7.52 (1.93) 0.28 (�0.20 to 0.76) .25Parental monitoring, 1–3 scale 2.59 (0.38) 2.61 (0.40) 2.62 (0.36) 2.63 (0.42) 0.01 (�0.11 to 0.13) .88Use of corporal punishment,

1–3 scale1.37 (0.52) 1.28 (0.40) 1.28 (0.48) 1.22 (0.43) 0.05 (�0.10 to 0.19) .52

Family caring/connectedness,1–3 scale

2.64 (0.38) 2.71 (0.34) 2.66 (0.33) 2.65 (0.40) 0.05 (�0.05 to 0.15) .32

Data are presented as mean (SD) unless otherwise stated.* Difference between intervention and control groups at follow-up assessments, adjusted for baseline score, age, and gender, except forparental depression, which is reported as an odds ratio adjusted for baseline parental depression, age, and gender.† Youths �10 years of age at the time of study enrollment.

TABLE 3. Children’s Behavioral and Emotional Problems

Baseline, Mean (SD) Follow-Up, Mean (SD) Adjusted Difference(95% CI)*

P Value

Intervention Control Intervention Control

Parent report†Aggressive behavior, 0–40 scale 13.92 (7.65) 14.40 (7.35) 12.02 (6.35) 14.30 (6.64) �1.71 (�2.89 to �0.53) .005Delinquent behavior, 0–26 scale 3.65 (3.58) 3.29 (2.50) 2.98 (2.87) 3.48 (3.01) �0.71 (�1.28 to �0.13) .02Attention problems, 0–22 scale 7.45 (4.21) 8.15 (4.38) 6.09 (3.89) 7.61 (4.12) �1.02 (�1.77 to �0.26) .009Anxiety/depression, 0–28 scale 9.15 (5.50) 9.58 (5.07) 8.05 (5.04) 9.09 (4.96) �0.65 (�1.64 to 0.33) .20

Child report‡Aggressive behavior, 0–40 scale 11.11 (5.78) 10.91 (5.45) 10.64 (5.55) 10.85 (6.31) �0.13 (�1.83 to 1.57) .88Delinquent behavior, 0–26 scale 3.73 (2.52) 3.55 (2.42) 3.26 (2.43) 3.40 (2.80) �0.14 (�0.89 to 0.60) .70Attention problems, 0–22 scale 7.41 (3.35) 7.05 (3.49) 6.83 (2.93) 6.89 (3.37) 0.11 (�0.84 to 1.06) .82Anxiety/depression, 0–28 scale 9.97 (5.63) 9.23 (5.52) 8.38 (4.86) 8.17 (4.67) 0.33 (�0.98 to 1.65) .62

* Difference between intervention and control groups at follow-up assessments, adjusted for baseline score, age, and gender.† Parent reports on problem scales of the CBCL.‡ Child reports on problem scales of the Youth Self-Report, from youths �10 years of age at the time of study enrollment.

TABLE 4. Children’s Bullying Behaviors, Fighting, and Injury

Baseline Follow-Up Adjusted Odds Ratio(95% CI)*

P Value

Intervention Control Intervention Control

Parent reportBullying 21 (22.6) 17 (17.5) 10 (10.5) 22 (22.7) 4.43 (1.87 to 10.52) �.001Being bullied 31 (33.3) 43 (44.3) 22 (23.2) 32 (33.0) 1.58 (0.93 to 2.66) .09Bullying/being bullied 14 (15.1) 14 (14.4) 6 (6.3) 14 (14.4) 4.28 (1.23 to 14.86) .02Physical fighting 44 (47.3) 51 (52.6) 30 (31.6) 43 (44.3) 1.79 (1.11 to 2.87) .02Fight-related injury 7 (7.4) 6 (6.2) 1 (1.1) 7 (7.2) 4.70 (1.33 to 16.59) .02

Child report†Bullying 3 (4.8) 8 (12.1) 9 (13.8) 10 (15.2) 1.02 (0.29 to 3.57) .97Being bullied 23 (36.5) 24 (36.4) 14 (21.5) 28 (42.4) 3.23 (1.96 to 5.31) �.001Bullying/being bullied 2 (3.2) 4 (6.1) 3 (4.6) 7 (10.6) 2.35 (0.90 to 6.14) .08Physical fighting 32 (50.0) 38 (57.6) 22 (33.9) 28 (42.4) 1.46 (0.61 to 3.49) .40Attitude toward violence, mean

(SD) on 0–14 scale11.59 (1.96) 11.32 (2.35) 11.64 (2.35) 10.94 (2.77) 0.05 (�0.01 to 0.10) .096

Data are presented as number (percent) reporting each behavior unless otherwise stated.* Odds ratio adjusted for baseline value, age, and gender, except for fight-related injury, for which gender was excluded from the model.Because there were no fight-related injuries among girls at follow-up assessments, the model would not converge when gender wasincluded. In addition, attitude toward violence is reported as an adjusted difference, which is the difference between intervention andcontrol groups at follow-up assessments adjusted for baseline score, age, and gender.† Youths �10 years of age at the time of study enrollment.

e396 INTERVENTION TO REDUCE VIOLENT BEHAVIOR AND INJURY by guest on August 6, 2018www.aappublications.org/newsDownloaded from

violence-related outcomes. There were no significantintervention-age interactions for any of these out-comes, and the only significant intervention-genderinteraction was for aggressive behavior. Separateanalyses of intervention effects on aggressive behav-ior for boys and girls showed that the interventionhad a significant effect on parent-reported aggressivebehavior for boys (adjusted difference: �2.75; 95%confidence interval [CI]: �1.21 to �4.29; P � .001)but not for girls (adjusted difference: �0.23; 95% CI:�2.08 to 1.62; P � .80).

DISCUSSIONTo our knowledge, this is the first randomized,

controlled evaluation of a primary care-based inter-vention designed to reduce youth involvement inviolent behavior and fight-related injury. We foundthat the intervention significantly decreased aggres-sive and delinquent behavior, bullying, physicalfighting, and fight-related injuries for which medicalcare was sought among the youths. In addition, theintervention significantly reduced the use of corporalpunishment by parents and parental depression.

Use of the PSC-17 to screen for psychosocial prob-lems at acute-care or well-care visits in this office-based intervention resulted in identification and in-tervention for a high-risk group of youths. Atbaseline, one-half of the youths in this study hadbeen in a physical fight in the past year and 44%were involved in moderate or frequent bullying (as abully, a target of bullying, or both). These behaviorsare markers for more serious violent behaviors.3,28

In addition, we found that the subscale scores onthe PSC-17 seemed to play a role in clinician deci-sion-making regarding referral and follow-up moni-toring of patients. This conclusion is based on thefinding that clinicians were more likely to reportmaking referrals or scheduling follow-up visits forpatients with a positive versus a negative score onspecific subscales of the screening test. Therefore, ascreening tool such as the PSC-17 can be useful inguiding clinicians in their assessment and treatmentof patients. Clinicians infrequently use standardizedtools to assess child psychosocial problems.29 Epi-demiologic research has documented the under-recognition of mental health problems, and resultingunmet needs, of children in primary care.30 Approx-imately 1 of 5 children attending pediatric practiceshas significant mental health problems. It is esti-mated that 60% of those children do not receive theservices they need.31 Untreated emotional and be-havioral problems contribute to poor overall func-tioning, school failure, substance use, violence, andsuicide among adolescents and adults.32–34 Guide-lines for the assessment and treatment of childrenand adolescents with depressive, attention, and con-duct disorders have been published,35–37 and theeffectiveness of some treatments has been docu-mented.38–41

Family-level interventions have repeatedly shownefficacy in reducing violent and delinquent behavioramong youths and are among the most promisinginterventions known to date.42,43 Effective family-level interventions include parent training, home vis-

iting, and family therapy. Although each approachworks, parent training is often the most cost-effectivefamily-level intervention. The present interventionused the telephone to deliver the parenting educa-tion resource. Telephone-based parent training mayreduce barriers to participation in parent training,such as difficulty getting time off work, lack of trans-portation, and difficulty finding or affording childcare.44 Telephone-based counseling programs for be-havior changes in multiple areas, including weightmanagement, smoking cessation, and stress manage-ment, have been offered by a large health mainte-nance organization and have been found to be con-venient and easily accessible for patients and toallow long-term follow-up monitoring.45 Telephonecounseling services for smoking cessation have pro-liferated in the United States and many other coun-tries in recent years, supported by strong evidencethat such counseling is effective and has the potentialto reach large numbers of smokers.46,47

Although parenting interventions are among themost effective strategies known for preventing youthviolence, parenting programs have not been widelyimplemented. Challenges include locating resourcesto start a program and replicating a program imple-mented in another community. Telephone-based de-livery of the parenting program has the potential toovercome dissemination challenges by permittingaccess to parents throughout a state or region andbeyond. Implementation of the program in the set-ting of a health maintenance organization could offera source of funding and support.

This study has a number of limitations. The in-tervention included complementary strategies ofidentifying, preventing, and treating mental healthproblems among youths and promoting healthychild-parent relationships. All participants in theintervention group received the intervention, ie, amedical visit with a clinician who 1) saw a parent-completed, positive, psychosocial screening test forthe child and 2) had a telephone-based, parentingeducation program available to him or her as a re-ferral resource for the parent. However, exposure ofintervention participants to potential elements of theintervention varied widely, contingent on assess-ment and treatment by the clinician and on patientand parent factors. This study design did not permitus to disaggregate intervention components todetermine which were most effective. Measures ofintervention effectiveness were based on parent andchild reports. These results are constructed from theframes of reference of the parent and child, ie, per-ceived reality rather than objective reality is beingreflected in the reporting of behavior. To minimizesocially desirable responses, follow-up assessmentswere conducted by a different interviewer than theinterviewer who conducted the baseline interviews.We used previously validated measures of violence-related outcomes, such as the CBCL.21 Although re-ported outcomes may be subject to bias and thus notas reliable as directly observed outcomes, manystudies have found that self-reported behavioralchanges are correlated with objective measures.48 Inaddition, studies have shown adequate correlation

www.pediatrics.org/cgi/doi/10.1542/peds.2004-0693 e397 by guest on August 6, 2018www.aappublications.org/newsDownloaded from

between the results of parent reports of child behav-ior and independent observations.49,50 Finally, thestudy was conducted in a single geographic area andmay not be generalizable to other parts of the coun-try.

Most children with psychosocial problems aretreated in general medical settings, rather than men-tal health settings, and most psychotropic drug pre-scriptions for children and adolescents are pre-scribed by primary care physicians.31,51 Despite thekey role of primary care clinicians in identifying andtreating mental health disorders among children andadolescents, research on primary care-based mentalhealth services for children and adolescents is under-developed.52 Studies in adult primary care settingshave demonstrated promising educational and orga-nizational interventions with strong potential to im-prove the management of depression in primary caresettings. Effective strategies include components ofcollaborative care, such as nurse care management,consultations of primary care providers with mentalhealth specialists that do not involve face-to-facecontact with patients, and follow-up monitoring ofpatients that includes telephone medication counsel-ing by practice nurses.53 Future research should as-sess the effectiveness of these strategies in primarymedical care settings for children. In addition, par-enting education may be a critical component ofaddressing the mental health of children and adoles-cents. This study indicates that psychosocial screen-ing and the availability of a telephone-based, parent-ing education referral resource may represent apromising, primary care-based approach to help pre-vent violent behavior and injury among children andadolescents.

ACKNOWLEDGMENTSThis study was supported by a Robert Wood Johnson Founda-

tion Generalist Physician Faculty Scholar Award.We thank Tiffany Austad, Becky Beucher, Jamie Blum, Jessica

Boyer, Sarah Brand, Rachel Friedlieb, Tony Nadler, Deborah Nis-tler, Sandra Olson, Stephanie Pempe, Melissa Schmidt, Jackie Si-monson, Sopheak Srun, and Bridgett Erlanson Tangney for theirefforts in collecting the study data and Zora Chrislock and Mela-nie Faulhaber for their parent education work. We also expressdeep appreciation to the patients, clinicians, and office staff mem-bers at Central Pediatrics-Midway, Community University HealthCare Center, Fairview Oxboro Clinic, Fairview Ridges Clinic,North End Medical Center, Partners in Pediatrics-Robinsdale,Southdale Pediatric Associates-Burnsville, and Staub PediatricClinic for their participation in the study.

REFERENCES1. Arias E, MacDorman MF, Strobino DM, Guyer B. Annual summary of

vital statistics: 2002. Pediatrics. 2003;112:1215–12302. National Center for Injury Prevention and Control, Centers for Disease

Control and Prevention. WISQARS Injury Mortality Reports, 2000–2001.March 4, 2004. Available at: http://webappa.cdc.gov/sasweb/ncipc/mortrate10_sy.html. Accessed March 15, 2004

3. Luckenbill DF. Criminal homicide as a situated transaction. Soc Probl.1977;25:176–86

4. National Center for Injury Prevention and Control, Centers for DiseaseControl and Prevention. WISQARS Nonfatal Injury Reports. February 3,2004. Available at: http://webapp.cdc.gov/sasweb/ncipc/nfirates2001.html. Accessed March 15, 2004

5. Resnick MD, Bearman PS, Blum RW, et al. Protecting adolescents fromharm: findings from the National Longitudinal Study on AdolescentHealth. JAMA. 1997;278:823–832

6. Loeber R, Farrington DP, Stouthamer-Loeber M, Moffitt TE, Caspi A.The development of male offending: key findings from the first decadeof the Pittsburgh youth study. Stud Crime Crime Prev. 1998;7:141–171

7. Herrenkohl TI, Maguin E, Hill KG, Hawkins JD, Abbott RD, CatalanoRF. Developmental risk factors for youth violence. J Adolesc Health.2000;26:176–186

8. Borowsky IW, Ireland M. Predictors of future fight-related injuryamong adolescents. Pediatrics. 2004;113:530–536

9. DiClemente RJ, Wingood GM, Crosby R, et al. Parental monitoring:association with adolescents’ risk behaviors. Pediatrics. 2001;107:1363–1368

10. Elster A, Kuznets N. AMA Guidelines for Adolescent Preventive Services(GAPS). Baltimore, MD: Williams & Wilkins; 1994

11. American Academy of Pediatrics, Task Force on Violence. The role ofthe pediatrician in youth violence prevention in clinical practice and atthe community level. Pediatrics. 1999;103:173–181

12. American Academy of Family Physicians. Age Charts for Periodic HealthExamination. Kansas City, MO: American Academy of FamilyPhysicians; 1994. Reprint no. 510

13. American College of Physicians. Preventing firearm violence: a publichealth imperative. Ann Intern Med. 1995;122:311–313

14. Borowsky IW, Resnick MD. Adolescents and firearms: position paper ofthe Society for Adolescent Medicine. J Adolesc Health. 1998;23:117–118

15. Mason J. Reducing youth violence: the physician’s role. JAMA. 1992;267:3003

16. Borowsky IW, Ireland M. National survey of pediatricians’ violenceprevention counseling. Arch Pediatr Adolesc Med. 1999;153:1170–1176

17. Jellinek MS, Murphy JM, Burns B. Brief psychosocial screening in out-patient pediatric practice. J Pediatr. 1986;109:371–378

18. Gardner W, Murphy M, Childs G, et al. The PSC-17: a brief pediatricsymptom checklist including psychosocial problem subscales: a reportfrom PROS and ASPN. Ambul Child Health. 1999;5:225–236

19. Pitzer R. Positive Parenting: Project Overview. University of MinnesotaExtension Service. 2001. Available at: www.extension.umn.edu/projects/positiveparenting/po.html. Accessed November 19, 2003

20. Gray MR, Steinberg L. Unpacking authoritative parenting: reassessing amultidimensional construct. J Marriage Fam. 1999;61:574–587

21. Achenbach TM. Manual for the Child Behavior Checklist/4–18 and 1991Profile. Burlington, VT: University of Vermont, Department ofPsychiatry; 1991

22. Nansel TR, Overpeck M, Pilla RS, Ruan WJ, Simons-Morton B, ScheidtP. Bullying behaviors among US youth. JAMA. 2001;285:2094–2100

23. Slaby RG, Guerra NG. Cognitive mediators of aggression in adolescentoffenders: part I: assessment. Dev Psychol. 1988;24:580–588

24. Dishion T, Kavanagh K. Intervening in Adolescent Problem Behavior: AFamily-Centered Approach. New York, NY: Guilford Press; 2003

25. Stanton BF, Li X, Galbraith J, et al. Parental underestimates of adoles-cent risk behavior: a randomized, controlled trial of a parental moni-toring intervention. J Adolesc Health. 2000;26:18–26

26. Kemper KJ, Babonis TR. Screening for maternal depression in pediatricclinics. Am J Dis Child. 1992;146:876–888

27. Kraemer HC, Thiemann S. How Many Subjects? Statistical Power Analysisin Research. Newbury Park, CA: Sage Publications; 1987

28. Nansel TR, Overpeck MD, Haynie DL, Ruan WJ, Scheidt PC. Relation-ships between bullying and violence among US youth. Arch PediatrAdolesc Med. 2003;157:348–353

29. Gardner W, Kelleher KJ, Pajer KA, Campo JV. Primary care clinicians’use of standardized tools to assess child psychosocial problems. AmbulPediatr. 2003;3:191–195

30. Costello EJ, Edelbrock C, Costello AJ. Psychopathology in pediatricprimary care: the new hidden morbidity. Pediatrics. 1988;82:415–424

31. Burns J, Costello J, Angold A, et al. Children’s mental health service useacross service sectors. Health Aff (Millwood). 1995;14:147–159

32. Wells KB, Stewart A, Hays RD, et al. The functioning and well-being ofdepressed patients: results from the Medical Outcomes Study. JAMA.1989;262:914–919

33. Farrington DP. Childhood aggression and adult violence: early precur-sors and later-life outcomes. In: Pepler DJ, Rubin KH, eds. The Develop-ment and Treatment of Childhood Aggression. Hillsdale, NJ: LawrenceErlbaum Associates; 1991:5–29

34. Farrington DP. Childhood origins of teenage antisocial behavior andadult social dysfunction. J R Soc Med. 1993;86:13–17

35. American Academy of Child and Adolescent Psychiatry. Practice pa-rameters for the assessment and treatment of children and adolescentswith conduct disorder. J Am Acad Child Adolesc Psychiatry. 1997;36(suppl):122S–139S

e398 INTERVENTION TO REDUCE VIOLENT BEHAVIOR AND INJURY by guest on August 6, 2018www.aappublications.org/newsDownloaded from

36. American Academy of Pediatrics. Clinical practice guideline: treatmentof the school-aged child with attention-deficit/hyperactivity disorder.Pediatrics. 2001;108:1033–1044

37. American Academy of Child and Adolescent Psychiatry. Practice pa-rameters for the assessment and treatment of children and adolescentswith depressive disorders. J Am Acad Child Adolesc Psychiatry. 1998;37(suppl):63S–83S

38. Wagne KD, Ambrosinis P, Rynn M, et al. Efficacy of sertraline in thetreatment of children and adolescents with major depressive disorder:two randomized controlled trials. JAMA. 2003;290:1033–1041

39. Kaslow NJ, Thompson MP. Applying the criteria for empirically sup-ported treatments to studies of psychosocial interventions for child andadolescent depression. J Clin Child Psychol. 1998;27:146–155

40. Brestan EV, Eyberg SM. Effective psychosocial treatments of conduct-disordered children and adolescents: 29 years, 82 studies, and 5,272kids. J Clin Child Psychol. 1998;27:180–189

41. Greenhill L, Abikoff H, Arnold L, et al. Psychopharmacological TreatmentManual, NIMH Multimodal Treatment Study of Children With AttentionDeficit Hyperactivity Disorder (MTA Study). New York, NY: Psychophar-macology Subcommittee of the MTA Steering Committee; 1998

42. Tolan P, Guerra N. What Works in Reducing Adolescent Violence: AnEmpirical Review of the Field. Boulder, CO: Center for the Study andPrevention of Violence; 1998

43. Thornton TN, Craft CA, Dahlberg LL, Lynch BS, Baer K. Best Practices ofYouth Violence Prevention: A Sourcebook for Community Action. Atlanta,GA: Centers for Disease Control and Prevention, National Center forInjury Prevention and Control; 2000

44. Wood WD III, Baker JA. Preference for parental education programsamong low socioeconomic status, culturally diverse parents. PsycholSchools. 1999;36:239–247

45. Boucher J, Pronk NP, Gehling EM. Telephone-based lifestyle counsel-ing. Diabetes Spectrum. 2000;13:190–192

46. Stead LF, Lancaster T. Telephone counseling for smoking cessation(Cochrane review). In: The Cochrane Library, 1. Oxford, England: UpdateSoftware; 2002

47. Zhu S, Anderson CM, Tedeschi GJ, et al. Evidence of real-world effec-tiveness of a telephone quitline for smokers. N Engl J Med. 2002;347:1087–1093

48. Bien TH, Miller WR, Tonigan JS. Brief intervention for alcoholproblems: a review. Addiction. 1993;88:315–336

49. Robinson TN, Wilde ML, Navracruz LC, Haydel KF, Varady A. Effectsof reducing children’s television and video game use on aggressivebehavior: a randomized controlled trial. Arch Pediatr Adolesc Med. 2001;155:17–23

50. Scott S, Spender Q, Doolan M, et al. Multicentre controlled trial ofparenting groups for childhood antisocial behavior in clinical practice.BMJ. 2001;323:194–197

51. Kelleher KJ, Hohmann A, Lareson D. Prescription of psychotropicdrugs in office-based practice. Am J Dis Child. 1989;143:855–859

52. Horwitz SM, Kelleher K, Boyce T, et al. Barriers to health care researchfor children and youth with psychosocial problems. JAMA. 2002;288:1508–1512

53. Gilbody S, Whitty P, Grimshaw J, Thomas R. Educational and organi-zational interventions to improve the management of depression inprimary care: a systematic review. JAMA. 2003;289:3145–3151

www.pediatrics.org/cgi/doi/10.1542/peds.2004-0693 e399 by guest on August 6, 2018www.aappublications.org/newsDownloaded from

DOI: 10.1542/peds.2004-06932004;114;e392Pediatrics 

Iris Wagman Borowsky, Sara Mozayeny, Kristen Stuenkel and Marjorie IrelandChildren

Effects of a Primary Care-Based Intervention on Violent Behavior and Injury in

ServicesUpdated Information &

http://pediatrics.aappublications.org/content/114/4/e392including high resolution figures, can be found at:

Referenceshttp://pediatrics.aappublications.org/content/114/4/e392#BIBLThis article cites 40 articles, 8 of which you can access for free at:

Subspecialty Collections

son_prevention_subhttp://www.aappublications.org/cgi/collection/injury_violence_-_poiInjury, Violence & Poison Prevention_management_subhttp://www.aappublications.org/cgi/collection/administration:practiceAdministration/Practice Managementfollowing collection(s): This article, along with others on similar topics, appears in the

Permissions & Licensing

http://www.aappublications.org/site/misc/Permissions.xhtmlin its entirety can be found online at: Information about reproducing this article in parts (figures, tables) or

Reprintshttp://www.aappublications.org/site/misc/reprints.xhtmlInformation about ordering reprints can be found online:

by guest on August 6, 2018www.aappublications.org/newsDownloaded from

DOI: 10.1542/peds.2004-06932004;114;e392Pediatrics 

Iris Wagman Borowsky, Sara Mozayeny, Kristen Stuenkel and Marjorie IrelandChildren

Effects of a Primary Care-Based Intervention on Violent Behavior and Injury in

http://pediatrics.aappublications.org/content/114/4/e392located on the World Wide Web at:

The online version of this article, along with updated information and services, is

1073-0397. ISSN:60007. Copyright © 2004 by the American Academy of Pediatrics. All rights reserved. Print

the American Academy of Pediatrics, 141 Northwest Point Boulevard, Elk Grove Village, Illinois,has been published continuously since 1948. Pediatrics is owned, published, and trademarked by Pediatrics is the official journal of the American Academy of Pediatrics. A monthly publication, it

by guest on August 6, 2018www.aappublications.org/newsDownloaded from