The Process of Adapting a Universal Dating Abuse Prevention Program to Adolescents Exposed to Domestic Violence

Abstract

Adolescents exposed to domestic violence are at increased risk of dating abuse, yet no evaluated dating abuse prevention programs have been designed specifically for this high-risk population. This article describes the process of adapting Families for Safe Dates (FSD), an evidenced-based universal dating abuse prevention program, to this high-risk population, including conducting 12 focus groups and 107 interviews with the target audience. FSD includes six booklets of dating abuse prevention information, and activities for parents and adolescents to do together at home. We adapted FSD for mothers who were victims of domestic violence, but who no longer lived with the abuser, to do with their adolescents who had been exposed to the violence. Through the adaptation process, we learned that families liked the program structure and valued being offered the program and that some of our initial assumptions about this population were incorrect. We identified practices and beliefs of mother victims and attributes of these adolescents that might increase their risk of dating abuse that we had not previously considered. In addition, we learned that some of the content of the original program generated negative family interactions for some. The findings demonstrate the utility of using a careful process to adapt evidence-based interventions (EBIs) to cultural sub-groups, particularly the importance of obtaining feedback on the program from the target audience. Others can follow this process to adapt EBIs to groups other than the ones for which the original EBI was designed.

Keywords

dating abuse prevention program adaptation exposure to domestic violence

Introduction

Children who have been exposed to domestic violence are at increased risk of becoming a victim or perpetrator of dating abuse during adolescence and intimate partner violence in adulthood (Ehrensaft et al., 2003; Foshee, Bauman, & Linder, 1999; Magdol, Moffitt, Caspi, & Silva, 1998; O’Donnell et al., 2006). Yet, despite the fact that approximately 15 million children are exposed to domestic violence yearly (McDonald, Jouriles, Ramisetty-Mikler, Caetano, & Green, 2006), no evaluated dating abuse prevention programs have been designed specifically for adolescents exposed to domestic violence.

This article reports formative research conducted to create a dating abuse prevention program targeting adolescents exposed to domestic violence. To create the program, we used a cultural adaptation process to modify an existing evidence-based dating abuse prevention program to this high-risk population. This article is intended to aid others interested in adapting evidenced-based interventions (EBIs) for vulnerable groups and those interested in dating abuse prevention among adolescents who have been exposed to domestic violence.

Cultural Adaptation

Developing interventions de novo is time-consuming and resource-intensive. One way of accelerating the development of programs is to adapt EBIs to new target groups (McKleroy et al., 2006; Wingood & DiClemente, 2008). The goal is to modify the EBI to accommodate the unique cultural beliefs, risk factors, and circumstances of the target group while maintaining the core elements or internal logic of the original program (Castro, Barrera, & Martinez, 2004; Falicov, 2009). Cultural adaptation can increase the relevance of an EBI to a particular sub-group. Increased relevance can result in a higher likelihood of program participation and engagement among that group (Castro et al., 2004; Kumpfer, Alvarado, Smith, & Bellamy, 2002).

We chose to adapt an evidence-based family program, Families for Safe Dates (FSD), to this high-risk population (Foshee et al., 2012). FSD is a universal program in that it was designed for use with the general population. It includes six booklets mailed to the home with dating abuse prevention information and activities (e.g., role-plays, puzzles, games, scenario analyses, guided discussions) for parents and adolescents to do together at home. Families typically take from 3 to 5 months to complete the booklets. A national randomized trial of the program, that recruited families through random digit dialing and listed telephone numbers, demonstrated positive effects on several of the mediating constructs targeted for change in the program, with effect sizes ranging from .25 to .44. The program also demonstrated positive effects on dating abuse victimization, with those not receiving the program reporting substantially higher odds of being victimized by dates than those who received the program (odds ratio [OR] = 3.84; Foshee et al., 2012). FSD is disseminated by Hazelden Publishing and Educational Services (http://www.hazelden.org/web/public/storeeducation.page).

Two criteria to consider in identifying an EBI that seems appropriate for adaptation include (a) a mode of delivery that is compatible with the lifestyle and circumstances of the target recipients, and (b) content that matches the etiology of the behavior of the targeted recipients. FSD met these criteria. Many of the risk factors for dating abuse in the targeted population stem from family dynamics, making a family-based program appealing. We chose not to adapt a school-based dating abuse prevention program because of the potential for stigmatizing adolescents who have been exposed to domestic violence. Also, we did not adapt a program for use in domestic violence shelters because women in shelters usually have younger children, not adolescents, and the stay at shelters is often too short for delivering a dating abuse prevention program. The booklet format of FSD is convenient for busy families as evidenced by high family program participation in the randomized trial of FSD (Foshee et al., 2012). In addition, Haggerty, MacKenzie, Skinner, Harachi, and Catalano (2006, Haggerty, Skinner, MacKenzie, & Catalano, 2007) found that in a high-risk sample, a family-based program for preventing adolescent problem behaviors that was administered via self-administered booklets had higher family participation and effectiveness than the same content delivered via group-administration. Finally, as described in more detail below, the conceptual framework and the program content of FSD were relevant for the target population. We designed the program for mothers who were victims of domestic violence, but who no longer lived with the abuser, to do with their adolescents who had been exposed to the violence. Women who have survived domestic violence are likely to want their adolescents to avoid becoming ensnared in abusive relationships, and thus might be willing to engage in dating abuse prevention and may even feel empowered by doing so. Not living with the abuser allows for safe delivery of the program to the adolescent. We called the adapted program Moms and Teens for Safe Dates.

The first step in the cultural adaptation was to review the conceptual underpinnings of FSD and make adjustments if necessary for the target population. Next, we revised the booklet content to reflect any changes made to the conceptual model. Castro et al. (2004) suggest that for a program to have high cultural relevance, (a) the content has to match the linguistic, educational, and developmental needs of the group and thus be understandable; (b) the program should include content that is applicable to participants’ everyday lives; and (c) the content should be interesting and important to the group. These precepts guided our next step which was to obtain feedback on the revised booklets and the program mode of delivery from the target population. Eligible mothers and adolescents completed booklets in their homes and provided feedback on the program through a series of focus groups or in-depth interviews. Finally, we revised the program based on that feedback.

Method

Review of the Conceptual Underpinnings of FSD and Initial Revisions to Program Content

In a cultural adaptation process, deletion of content is justified when the content is intended to change a risk factor that is not a risk or is not relevant for the target group (Yu & Seligman, 2002). Also, content addressing unique risk factors can be added if this can be done while maintaining the core components and logic of the original program (Lau, 2006). The top panel of Figure 1 is the conceptual model guiding FSD. Drawing from extant research and our familiarity with the target population, we evaluated each construct in this conceptual model for appropriateness in guiding a dating abuse prevention program for the targeted population. Our review resulted in some changes, including eliminating some constructs that we felt were irrelevant for this population (those in dotted line boxes in Figure 1), emphasizing other constructs (those in bolded line boxes), and adding a new construct that we felt was important to address in this population (in a double bolded line box). The justifications for the changes are described in detail below. These decisions guided our initial booklet revision.

Figure 1.

Conceptual model adaptations.

Panel B.

The final Moms and Teens for Safe Dates conceptual model with emphasized content noted by single bolded line boxes.

The primary goals of FSD were to motivate and facilitate parental engagement with their adolescents in dating abuse prevention activities (i.e., doing the booklets) that decrease risk factors for adolescent dating abuse, and ultimately lead to decreases in dating abuse victimization and perpetration. Thus, the program was intended to change (a) factors that motivate and facilitate parents’ engagement in dating abuse prevention activities with their adolescents, and (b) theoretically and empirically based risk factors for adolescent dating abuse. We deemed these same primary goals to be appropriate for the adapted program. However, we felt that specific constructs targeted for change in these two categories needed to be modified for families in which adolescents were exposed to domestic violence.

FSD was designed to motivate parental engagement in the program by (a) decreasing their acceptance of dating abuse, (b) increasing their belief in the importance of being involved in their adolescent’s dating, (c) increasing their perceptions that dating abuse is a serious problem, (d) increasing their perceptions that their adolescent is susceptible to dating abuse, and (e) increasing their response efficacy, or belief that they have the potential to influence their adolescent’s dating abuse behavior. The program was designed to facilitate parental engagement in the program by (a) increasing their knowledge of dating abuse, (b) improving their skills for communicating with their adolescent, and (c) increasing their self-efficacy, or confidence that they can do dating abuse prevention activities with their adolescent. Many of these constructs derive from Protection Motivation Theory (PMT; Rogers, 1983), which specifies the beliefs and skills that are needed to take a preventive action, in this case, for parents to do dating abuse prevention activities with their adolescents. These constructs were targeted for change in Booklet 1 of FSD, Getting Started, which is for parents only.

Because of their experience, we reasoned that mother victims of domestic violence are likely to already have strong beliefs about the unacceptability of dating abuse, high recognition of the severity of dating abuse, high perceived susceptibility of their adolescent to dating abuse, and high knowledge of dating abuse. As a result of our beliefs about this population, we deleted these constructs from the conceptual model of the adapted program and deleted program content targeted at changing those constructs. However, we also reasoned that the constructs of mother self-efficacy and response efficacy deserved special emphasis in the adapted program because it is likely that victims of domestic violence are low on these motivating and facilitating constructs. Mothers who have been victims of domestic violence may fear that their credibility for promoting non-abusive relationships with their child is compromised because of their own experience in an abusive relationship, dampening their belief that they can influence their child’s involvement in dating abuse (low response efficacy). Also, they may lack self-efficacy for doing the program with their adolescent because of the stresses associated with leaving an abusive partner and a lack of self-confidence which may have resulted from the abuse (low self-efficacy). Additional content addressing these constructs was added to the revised booklets.

The risk factors for adolescent dating abuse targeted for change in FSD include (a) adolescent acceptance of dating abuse, (b) lack of perceived negative consequences of dating abuse, (c) poor conflict resolution skills, and (d) lack of parental rule-setting and monitoring. Evidence suggests that these four risk factors are all relevant for adolescents exposed to domestic violence. These adolescents have been found to be more accepting of dating abuse, perceive fewer negative consequences from dating abuse, and demonstrate poorer skills in response to conflict than those who have not been exposed to domestic violence. These variables, in turn, have been found to predict both victimization and perpetration of dating abuse among adolescents exposed to domestic violence (Foshee et al., 1999; Jaffe, Wolfe, & Wilson, 1990; Lichter & McCloskey, 2004; Reitzel-Jaffe & Wolfe, 2001). Parental rule-setting and monitoring were also considered appropriate to target in the adapted program because of the strong evidence from longitudinal studies that lack of parental monitoring and rule-setting is among the most consistent predictor of adolescent dating abuse (Brendgen, Vitaro, Tremblay, & Lavoie, 2001; Capaldi & Clark, 1998; Lavoie et al., 2002).

In addition to targeting change in these risk factors, we added gender stereotyping to the conceptual model of the adapted program. There is some evidence that traditional gender stereotyping is reinforced from witnessing domestic violence (Graham-Bermann & Brescoll, 2000; Reitzel-Jaffe & Wolfe, 2001). According to cognitive-developmental theories, attitudes about gender roles provide a framework for future behaviors because they serve as scripts for social interactions, including interactions with romantic partners (Bem, 1981; Eaton & Rose, 2011). Numerous studies have found that gender-based expectations are associated with dating abuse perpetration (Check & Malamuth, 1983; Durán, Moya, Megías, & Viki, 2010; Finn, 1986; Vandiver & Dupalo, 2013) and victimization (Finn, 1986; Reidy, Shirk, Sloan, & Zeichner, 2009), and it have been found that decreasing gender stereotyping by adolescents results in decreased dating abuse victimization and perpetration (Foshee et al., 2005). Thus, new booklet content was developed to decrease adolescent acceptance of traditional gender stereotypes.

In addition to making changes to all of the booklets based on these conceptual considerations, we further edited Getting Started, the booklet for only the mothers to (a) explain that the focus of the program was on preventing dating abuse among adolescents exposed to domestic violence, (b) address challenges that mothers might have in doing the program because they had been a victim of domestic violence, (c) congratulate mothers in their efforts to leave an abusive partner, and (d) provide some tips for healing and staying safe. However, while Getting Started acknowledged the focus on adolescents exposed to domestic violence, the five activity booklets for mothers and adolescents to do together never mentioned that focus. We took this approach so that mothers would have control over how much, if any, of their own abuse they discussed with their adolescents.

Methods for Obtaining Feedback From the Target Audience

Our next step in the adaptation was to obtain feedback on the revised program from the target population. Mothers who had been in an abusive relationship but were currently living apart from the abusive partner, and their 12- to 15-year-old adolescents were recruited to complete the revised booklets together and provide feedback on program structure and content. The targeted age group was 12- to 15 years old because this is an appropriate developmental period for efforts aimed at the primary prevention of dating abuse (Foshee & Reyes, 2009). Feedback was provided through focus groups or in-depth interviews. Initially, mothers and adolescents completed two booklets together in their homes, then participated in a 1½ hr-long focus group to provide feedback. This process was repeated until the family had completed all six booklets and participated in three focus groups that were held separately for the mothers and adolescents. Childcare was provided on site during the focus groups and the women coming to focus groups received an extra US$3 to help cover transportation costs. Because of the difficulties women had in coming to focus group meetings, however, 3 months after we began recruitment, we revised the data collection method to conduct separate individual telephone interviews with the mother and the adolescent. All focus groups and interviews were audio-taped and mothers and adolescents each received US$10 for each focus group or interview completed. Parental consent and adolescent assent were obtained at the beginning of the focus group or telephone interview. All procedures were approved by the Institutional Review Board at the sponsoring university.

The focus group and interview guides were designed to assess program comprehension, relevance to the target population and motivation for doing the activities. The guides included open-ended questions about each section and activity in the booklets and solicited feedback on (a) the organization, layout, and formatting of the program; clarity of activity instructions; likeability of each activity; and overall impressions of the program; (b) barriers to completing the program; (c) content that was not appropriate for mothers and adolescents who had been exposed to domestic violence; (d) time demands on the family; and (e) content that should be added.

Recruitment Strategies

Our first recruitment strategy was to identify women filing for a Domestic Violence Protective Order (DVPO), who had appropriately aged adolescents, through two North Carolina judicial districts. A DVPO is a civil procedure that legally restrains a domestic violence perpetrator from further abuse against a partner. Adolescents of mothers seeking DVPOs have had significant exposure to domestic abuse (Moracco, Clark, Buchanan, Espersen, & Bowling, 2010). Also, women filing for a DVPO have made a strong commitment to leave the abusing partner, and if the DVPO is granted, the mother is legally protected from the abusive partner for a year. Thus, the mother could deliver a dating abuse prevention program to her adolescent without the abuser being present.

Informational study fliers inviting women to participate in the study were attached to the ex parte paperwork in the Clerk of Court offices. The ex parte is a temporary protection order which is in effect until the mandatory hearing, usually held 12 to 14 days after the paperwork has been filed and the defendant has been served. For 4 months, recruiters attended the domestic violence court sessions each day they were held. After the hearing, a recruiter approached each woman with an adolescent of eligible age, as determined by either the Victim Information Sheet completed before the hearing or from information heard during the hearing. Women whose children’s ages could not be determined from either source were also approached. When a woman was approached, eligibility was determined, information about the study was presented, and permission was requested for study staff to call the woman to discuss the study in more detail and to enroll families. Participating mothers were mailed the first two program booklets, and the first focus groups (or interviews) with mothers and adolescents were scheduled approximately 2 weeks from that date.

Although 1,200 women sought DVPOs during the recruitment period, only 26 of them were determined to be eligible for the study; the primary limiting factor was having a 12- to15-year-old adolescent. Of the 26 eligible women, 19 (73%) agreed to be called about the study and 15 (79%) of those women enrolled in the study. Of these 15 women, only 7 (47%) attended the focus groups or completed the telephone interviews, even though all indicated on a reminder call the previous day that they would be at the focus group or would be available for the telephone interview. After 4 months, the in-person courtroom recruitment approach was discontinued because the recruitment efforts were too costly for the number of eligible women identified.

Recruitment efforts were then expanded to two additional counties and included dissemination of pamphlets and fliers about the study at victim service agencies, departments of social services, health departments, mental health agencies, and other public locations, and fliers were posted on courthouse bulletin boards and in bathroom stalls throughout the courthouses. The eligibility criteria remained the same. Twenty-one additional eligible women and their adolescents were recruited through these procedures.

Results

In all, 12 focus groups and 107 telephone interviews were conducted with the 28 mothers (7 seeking DVPOs and 21 recruited through community efforts) and their 35 adolescents. Mothers were between 28 and 56 years old. Sixty-four percent were African American, 25% were White, and 11% were of another race/ethnicity; 25% had a high-school degree or less, 29% had some college, and 46% graduated from college; and 32% were never married, 32% were divorced, and 36% were re-married. Of the adolescents, 71% were girls and 29% were boys.

Feedback on Program Structure

Overall, the families indicated that they liked the mailed booklet approach and found it convenient. The many positive comments made about the program structure, coupled with the barriers we encountered in getting mothers and adolescents to show up to focus groups, suggest that mailed delivery of booklets is preferable to asking families to go to a central location to participate in the program. Mothers also liked having control over how much, if any, of their own domestic violence experiences they discussed with the adolescent.

Mothers and adolescents liked the booklet format because it provided a structure for communicating with each other. Mothers indicated desiring to talk to their adolescents about sensitive topics, like dating abuse, but said that they did not always know how to do that. Adolescents expressed the same desire and barriers to communicating with their mothers. Both mothers and adolescents made comments indicating that the booklets gave them a structure for initiating and guiding their conversation about dating abuse. For example one mother said, “I don’t know how to get out a lot of my words, so reading this—it build up my vocabulary—to express to her better.” Another said, “The booklets made it easier for me to talk to my adolescent about abusive relationships” and another said, “I think I got closer to my daughter and it opened up communication with her in a very nice way.” An adolescent girl said, “I really liked this program and I would definitely encourage my family or other people who don’t have good communication with their mom to do this program.”

In addition, both mothers and adolescents indicated that they liked the fact that the program provided a structure for them to spend time each week doing something together and learning more about each other. As stated by one adolescent boy,

I got to spend time with my mom where it was just like a one on one thing and we learned a little bit about each other. I don’t know, I just felt like I could open up to her about stuff.

One mother said, “We got to know each other all over again” and another said,

What I really did enjoy is doing something together with my daughter. It kind of gave us, you know, a time together to discuss something that was really serious. You know, because see I couldn’t do this with my mother.

In addition to comments on the structure of Moms and Teens for Safe Dates, mothers’ comments indicated that they appreciated being offered the program because they felt there was very little information available to them and their adolescent about dating abuse prevention. For example one mother said,

I was talking to one of my friends who is a psychologist and was like “I don’t understand why nobody’s doing anything. You know, sexual assault is so rampant in our society. And I just don’t understand why there are no public service announcements and I haven’t seen any.” You know, it’s just like a big void. And it’s such a huge issue. And so I am really, really happy to see somebody is at least trying to develop something, you know.

Another said,

I thank you for doing this study. I really think it’s a wonderful thing that you all are doing and a nice humanitarian effort for people who have been through a lot of painful things. It’s really nice that you’re trying to prevent that from happening for other people. I appreciate it.

Feedback on Program Content

In addition to getting detailed feedback from mothers and adolescents on how to improve each specific program activity, we learned important information that led to additional revisions to the conceptual model of the adapted program and thus to program content. First, we found that our assumptions were erroneous that because of their experiences, these women would be knowledgeable about adolescent dating abuse, believe that dating abuse is a serious concern for adolescents, and believe that their adolescents were at high risk of dating abuse. We found that some of the mothers were surprised that abuse could begin as early as adolescence; they perceived it as an adult issue. As one mother noted, “Well to be honest, I didn’t really think about the next generation as far as our kids going through you know the abuse.” Another said “I didn’t think about kids my daughter’s age been getting raped.” Another mother said “Is dating abuse really an issue for teens as young as mine? I hadn’t realized it.” And another said “What it did was made me more aware . . . you know . . . you don’t really think of dating abuse and violence in such young kids.” It is possible that these women had been focused on what they were dealing with and on trying to get out of their own abusive relationship, and were not aware of the potential impact of the abuse on their adolescent’s dating experiences. As a result, we added mothers’ acceptance of dating abuse, knowledge of dating abuse, perceived severity of dating abuse, and perceived susceptibility of the adolescent to dating abuse back into the conceptual model and included booklet content intended to change those constructs.

Second, mothers had a strong desire for a focus on psychological abuse. The booklets that the mothers and adolescents reviewed included many references to psychological abuse, but the mothers wanted even more. They were adamant about ensuring that their adolescents recognized psychological abuse and saw it as a warning sign of or precursor to physical violence. Many said that their abuse had started with psychological abuse and they were naive about it and did not realize what was happening to them. In addition, the women noted that psychological abuse was devastating in and of itself. As one mother said “Yes . . . I believe that’s where it starts. I mean, when you get psychologically abused for long enough, it can easily turn into physical and then go even deeper. I suggest that there be even more examples.” Another said,

I thought the definition of psychological abuse was excellent. I think you could even expand more on that because I think that’s where it starts. I experienced some of those things and that should have been a red flag to turn the other way.

Therefore, we gave psychological abuse even more prominence in the booklets to increase the relevance of the program for these mothers. We provided more definitions of psychological abuse, stressed the negative consequences of this type of abuse, and incorporated it into more of the scenarios and activities done with the adolescents.

Third, we detected more anger from these adolescents than we detected from the general population of adolescents who participated in the focus groups that informed the development of FSD. We perceived this anger through the adolescents’ body language during the focus groups and by the way they described their interactions with others including peers and parents, which often included descriptions of heated interactions. Many studies have found that children who witness violence between their parents often grow into adolescents and young adults with higher levels of internalized and/or externalized anger than children who have not witnessed domestic violence, both toward parents (Adams, 2006) and overall (Adams, 2006; Turcotte-Seabury, 2010; Wolfe et al., 2003). Wolfe and colleagues (2003), for example, found that maltreated youth, many of whom had witnessed domestic violence, scored very high on interpersonal hostility. More activities to teach adolescents how to manage their anger and prevent anger from leading to dating abuse were therefore added to the booklets.

We also observed two diametrically opposed types of mother–adolescent relationships that needed to be considered in programming. One type was a very close relationship between the mother and adolescent with exceptionally good communication, which was often attributed by the mother to the closeness that formed between her and her adolescent as a result of the domestic violence experience. In the other type, communication between the mother and adolescent was extremely poor and sometimes involved explosive conversations. Especially problematic for the adolescents and mothers with poor communication were activities in which the adolescent was asked to indicate his or her preferences of some type (e.g., in characteristics of their dream date) or their typical behavioral response (e.g., in their ways of responding to anger), the mother was asked to indicate what she thought her adolescent’s answers would be, and then the mother and adolescent were asked to discuss the similarities and differences in their responses. During these types of activities, these mothers would often criticize or judge the adolescent’s choices and preferences, make fun of the adolescent, or use sarcasm, each of which would infuriate the adolescent and put him or her on the defensive. Therefore, we modified activities that triggered explosive reactions, and we included other activities that promoted communication while diffusing potentially contentious issues and we added more information to Getting Started on how mothers can communicate so that adolescents do not shut down or get defensive.

Finally, we found that many of the mothers were overly strict and dogmatic when it came to their adolescent’s dating, with many saying that they would not allow their adolescent to date at all until very late ages. This strictness was evidently related to the bad experiences the women had had with partners. As one woman said in justifying her strictness, “I don’t want my kids to go through what I went through.” However, many adolescents indicated that they were dating anyway and sneaking around. Thus, they were dating without parental guidance or monitoring. Although these mothers were extremely strict and expected their children to “act right,” many also revealed that they had never actually talked to their adolescents about their expectations. For example, one mother said “I don’t allow my [15-year-old] daughter to date.” But later in the interview, she said that she had never had a conversation with her daughter about dating expectations. Therefore, we added content in Getting Started on the tendency of mothers who have been victims of domestic violence to be protective of their adolescents, while pointing out the potential negative consequences of being overly strict and inflexible about dating. We also stressed the importance of setting reasonable rules and expectations and discussing them with the adolescent.

The final Moms and Teens for Safe Dates conceptual model, based on participant feedback, is in the bottom panel of Figure 1. As can be noted, this model is the same as the FSD conceptual mode with the exceptions that the Moms and Teens for Safe Dates conceptual model includes gender stereotyping. The feedback from the families confirmed the appropriateness of the constructs in the figure for the targeted population, informed additional modification of the content addressing some of the constructs, revealed other constructs that needed to be emphasized through additional content and activities (those in bolded line boxes), and confirmed the appropriateness of many of the content changes we made during the initial revisions. Table 1 summarizes the content of each of the final Moms and Teens for Safe Dates booklets.

Table 1.

A Description of the Final Moms and Teens for Safe Dates Booklets.

Booklet	Overall Goals	Sample Activities	Constructs Targeted for Change
Getting Started: Introducing Moms to the Moms and Teens for Safe Dates Program (This booklet is for mothers only)	To explain to mothers how to do the program; address specific challenges that she may have in doing the program based on having been a victim of domestic violence; congratulate her on leaving an abusive partner; provide her with tips for healing and staying safe; describe ways of interacting with her adolescent that facilitate and block communication; offer suggestions for how she can encourage adolescent program participation; and address constructs related to motivating and facilitating her engagement in the program.	Mothers complete a true/false assessment that taps into DA myths and realities.	Mother perceived severity of DA Mother perceived susceptibility of her adolescent to DA Mother response efficacy for preventing DA Mother self-efficacy for talking to her adolescent about DA Mother knowledge of DA Mother acceptance of DA
Booklet 1: Talking About Dating	To improve communication between the mother and adolescent so that they can more comfortably talk about DA and date rape in later booklets.	A card game that helps mothers understand current adolescent dating practices and helps adolescents realize what dating was like for the mother. A communication checklist is completed after each activity to indicate which Tips for Successful Communication and Communication Blockers mothers and adolescents used in activity discussions.	Mother skills for communicating with her adolescent Adolescent conflict resolution skills
Booklet 2: How You Feel & How You Deal: Skills for Handling conflict	To increase mother and adolescent skills for diffusing and dealing with anger and settling disagreements.	Families are taught skills for settling disagreements through the acronym SAFE (stay calm, ask questions, find out feelings, and exchange ideas for possible solutions). Families identify the SAFE skills used in a scripted role-play of an adolescent dating couple settling a disagreement.	Mother skills for communicating with her adolescent. Mother communication skills with adolescent Adolescent conflict resolution skills
Booklet 3: Now I See: Recognizing Dating Abuse	To increase mother and adolescent awareness of the various types of DA; harmful consequences of DA; and manipulation tactics used by abusers so as to “inoculate” the adolescent from those controlling tactics; and to introduce the adolescent to healthy dating characteristics.	Mothers and adolescents discuss how holding traditional stereotypes of men and women led to dating abuse depicted in various scenarios. Adolescents complete a comic strip replacing an abusive reaction to conflict with a date from earlier scenarios with non-abusive and respectful ways of responding to the conflict.	Mother knowledge of DA Adolescent acceptance of DA Adolescent perceived negative consequences of DA Adolescent conflict resolution skills. Adolescent gender stereotyping
Booklet 4: Preventing Dating Sexual Abuse and Rape	To challenge certain date rape myths and beliefs; increase mother and adolescent awareness of sexual dating abuse and its harmful consequences; learn strategies to prevent being a perpetrator or victim of sexual DA; and learn about date rape drugs (including alcohol).	Mothers and adolescents read scenarios of sexual dating abuse situations and discuss questions about the manipulation tactics used by the perpetrators, signs that the victims did not want to have sex, and potential negative consequences of the rape for the perpetrators and victims.	Mother knowledge of sexual DA Adolescent acceptance of sexual DA Adolescent perceived negative consequences of sexual DA
Booklet 5: Ready, Set, Date! Planning for the Future	To help adolescents think about their goals for treating and being treated by dates; identify warning signs of DA; develop a plan with the mother for what to do if they are being treated disrespectfully by a date or if they are treating a date disrespectfully; and help families develop guidelines and rules about dating.	Adolescents and mothers work together to develop a plan for what to do if the adolescent is being abused or is abusing dates. Families work together to develop guidelines for dating which are posted on the refrigerator.	Mother date rule-setting and monitoring Mother belief in the importance of being involved in her adolescent’s dating Adolescent conflict resolution skills

Note. DA = dating abuse.

Discussion

Given the large number of adolescents exposed to domestic violence and the high-risk status of those adolescents, effective dating abuse prevention programs designed specifically for adolescents exposed to domestic violence are needed, but are currently unavailable. We created a dating abuse prevention program for this high-risk population through adaptation of an existing evidence-based dating abuse prevention program. Our findings suggest that using the original program with this population could be problematic, potentially resulting in low program participation and perhaps even iatrogenic effects for some. The findings demonstrate the utility of using a careful process to adapt evidence-based programs to cultural sub-groups, particularly the importance of obtaining feedback on the program from the target audience. The process we followed can be followed by others to adapt EBIs to groups other than the ones for which the original EBI was designed.

Each step that we followed was valuable for the adaptation process. Although we learned through participant feedback that some of the initial changes we made based on extant research, familiarity with the target population, and our reasoning were unfounded, many of the initial revisions were viewed favorably by the participants. Thus, these initial steps expedited the adaptation. As is apparent from the findings, participant feedback on program materials is an essential feature of an adaptation. Through feedback from the targeted population, we learned that these families valued the program. We also learned that the program structure of mail home booklets of information and activities was received well by mothers exposed to domestic violence and their adolescents. Very importantly, we learned that some of our assumptions about this population’s beliefs and behaviors, which had influenced our initial changes to the conceptual model and program revisions, were not accurate. From talking directly with the target audience, we also identified practices and beliefs of mothers and attributes of the adolescent that might influence adolescent risk of dating abuse that we had not previously considered. And finally, we learned that some of the content of the original program generated negative family interactions for some. From this information, we were able to modify program content to make it more relevant, understandable, and interesting to the target population while maintaining the core elements and internal logic of the original program; these are primary goals of a cultural adaptation (McKleroy et al., 2006).

Although the feedback we obtained from these families was invaluable, the study would have been strengthened by having a more diverse sample. Our sample of mothers was primarily single African American women, a high percentage of whom only had a high-school education. Thus, it is not representative of the total population of mothers of adolescents in the United States who have been victims of domestic violence who are of all races/ethnicities and socioeconomic levels. Also, our sample of adolescents was primarily girls. We may have garnered additional themes that would influence the program adaptation with other types of samples. Also, it would have been desirable to get another round of feedback from additional families on the booklets that were revised based on the initial participant feedback. However, the funds were not available for doing so.

This formative research laid the groundwork for the first randomized controlled trial (RCT) of a program for preventing dating abuse designed specifically for adolescents exposed to domestic violence. The RCT is currently underway. In addition to informing the development of the Moms and Teens for Safe Dates program, this formative research informed recruitment procedures for the RCT. We learned that the DVPO courtroom recruitment approach would not be feasible for recruiting mothers and adolescents into the RCT because of the high cost of recruitment. But it is important to note that, despite the high level of stress that these women were likely experiencing, a high percentage of them (73%) agreed to be contacted about the study, reflecting their interests in preventing dating abuse in their adolescents. We learned that the community-based recruitment methods used in the formative research would be feasible for the RCT; using these methods we have been able to recruit 409 mothers and adolescents thus far into the RCT.

In the RCT, in addition to determining if Moms and Teens for Safe Dates is effective in changing the targeted factors of the conceptual model and in preventing and reducing dating abuse victimization and perpetration, we will be able to determine if this adapted program has program participation and outcome efficacy comparable with that of the original program. Although the RCT is still in progress, program participation thus far is high; 80% of families in the treatment group have completed at least one booklet and 62% have completed all 6 booklets. At this point, these percentages are comparable with family participation rates of 88% and 69% respectably in the FSD RCT, despite the higher risk sample. These participation rates are much higher than those for programs requiring caregivers to go to central locations for the program, where it is not atypical to have 40% or lower program participation (Dusenbury, 2000).

Footnotes

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) declared receipt of the following financial support for the research, authorship, and/or publication of this article: This project was supported by Grant No. 2008-WG-BX-0003 awarded by the National Institute of Justice, Office of Justice Programs, U.S. Department of Justice. Opinions, findings and conclusions or recommendations expressed in this publication/program/exhibition are those of the author(s) and do not necessarily reflect those of the Department of Justice.

Author Biographies

Vangie A. Foshee’s research focus is on adolescent problem behaviors, with a special focus on adolescent dating abuse, and includes both etiological and evaluation research.

Kimberly S. Dixon has for more than 20 years managed violence-related research projects and has worked with community-based and governmental organizations to build system-level capacity to improve services for victims and prevention of violence against women.

Susan T. Ennett’s research focuses on the development and etiology of adolescent health risk behaviors.

Kathryn E. Moracco conducts applied research on the primary and secondary prevention of violence, primarily gender-based violence in global and domestic settings. Her work is focused on evaluating violence prevention programs and policies while simultaneously building the capacity of stakeholders to design and evaluate their own interventions.

J. Michael Bowling is a research associate professor in the UNC Department of Health Behavior, and an adjunct associate professor in the Department of Biostatistics. He is a senior biostatistician with the Department of Biostatistics Carolina Survey Research Laboratory and the Lineberger Comprehensive Cancer Center and the associate director for Research of the UNC Injury Prevention Research Center. His primary doctoral training is in sociology with a concentration in demography and survey sampling methodology.

Ling-Yin Chang is a doctoral candidate in the Department of Health Behavior at University of North Carolina at Chapel Hill. She received her MS in health policy and management from National Taiwan University. Her research interests are on the etiology, including genetic contributions of adolescent antisocial behaviors, particularly adolescent dating abuse.

Jennifer L. Moss is a doctoral student in the Department of Health Behavior at the University of North Carolina, Chapel Hill. Her research interests include adolescent sexual and reproductive health.

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