Aggression and Violent Behavior 19 (2014) 616–624

Contents lists available at ScienceDirect

Aggression and Violent Behavior

The influence of family skills programmes on violence indicators:Experience from a multi-site project of the United Nations Office onDrugs and Crime in low and middle income countries☆

Wadih Maalouf ⁎, Giovanna CampelloUnited Nations Office on Drugs and Crime (UNODC), Drug Prevention and Health Branch, Prevention Treatment and Rehabilitation Section, Vienna, Austria

☆ Remark: The opinions expressed in this article are tho⁎ Corresponding author at: Prevention, Treatment and R

A-1400 Vienna, Austria. Tel.: +43 1 26060 5182.E-mail addresses: wadih.maalouf@unodc.org (W. Maa

http://dx.doi.org/10.1016/j.avb.2014.09.0121359-1789/© 2014 Elsevier Ltd. All rights reserved.

a b s t r a c t

a r t i c l e i n f o

Article history:Received 22 August 2014Accepted 27 September 2014Available online 5 October 2014

Keywords:Family skillsParentingAdaptationChild developmentPreventionViolence

Families can be one of the most protective forces in the lives of children and youth. Family skills interventionshave been found to be effective in encouraging safe and nurturing relationships between parents (or caregivers)and children in their early years and as suchpreventingmanyproblembehaviours including violence.Most of theevidence in this regards is generated from high income countries. In this article UNODC reports on variablesassociatedwith violence (including conduct problems, stressmanagement, pro-social behaviours, family aggres-sion and conflict) generated from a multisite project aimed at piloting family skills programmes in low andmiddle income countries. The countries of concern are Panama, Honduras, Guatemala, Serbia, Kazakhstan,Kyrgyzstan, Turkmenistan, Tajikistan and Uzbekistan. The family skills piloted were Strengthening the FamiliesProgramme 10-14 (SFP 10-14) and Families And Schools Together (FAST). The data generated indicates highlevel of replicability with fidelity, affinity and need for such programmes in low and middle income countrieswith very encouraging in preventing violence. Significant changes at the post-test level, assessed throughmulti-sources, were recorded across most of the violence indicators assessed related to youth violence andchild maltreatment at least on a comparable level to high-income countries.

© 2014 Elsevier Ltd. All rights reserved.

Contents

1. Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6172. Methodology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 618

2.1. Cultural adaptation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6182.2. Working with the facilitators . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6182.3. Working with the families . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6182.4. Quality assurance and fidelity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6182.5. Evaluation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 618

3. Results . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6193.1. Demographics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6193.2. Change in violence indicators . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 620

3.2.1. SFP 10-14 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6203.2.2. FAST . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 620

4. Discussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6225. Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 623Acknowledgements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 623References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 623

se of the authors and not necessarily those of the United Nations Office on Drugs and Crime.ehabilitation Section,DrugPrevention andHealth Branch, UnitedNationsOffice onDrugs and Crime, RoomD1419, P.O. Box 500,

louf), giovanna.campello@unodc.org (G. Campello).

617W. Maalouf, G. Campello / Aggression and Violent Behavior 19 (2014) 616–624

1. Introduction

Violence is among the leading causes of death worldwide for peopleaged 15–44 (World Health Organization:WHOCollaborating Centre forViolence Prevention, 2010), representing a widespread public healthproblem. Systems and programmes which help to prevent violenceand reduce its impact are therefore urgently required. There are awide range of interventions which work to both reduce and preventviolence. One type of violence prevention strategy with scientific evi-dence is to develop safe, stable relationships between children andtheir parents and caregivers (World Health Organization: WHO Collab-orating Centre for Violence Prevention, 2010). A supportive family envi-ronment is essential for the healthy development of children (Krug,Dahlberg, Mercy, Zwi, & Lozano, 2002), making them more resilient tolife's challenges (Rutter, 1999; Stephenson & Helme, 2006) and thusacting as a powerful protective factor in the lives of children andyouth (Dishion, Andrews, & Crosby, 1995; Forgatch & Knutson, 2001).Conversely, research provides clear evidence that certain family charac-teristics can act as strong risk factors which are associatedwith a varietyof youth problem behavior (United Nations Office on Drugs & Crime,2009). Thus, an insufficient family support system can increase thechances of children developing behaviour problems, whichmay includeviolence and risk factors of violence.

Family skills trainingprogrammeswork on the aforementioned fam-ily relationships characteristics. There are a wide range of programmes,some of which are also designed to reflect the unique, culturally appro-priate norms, age and risks of specific groups, many of which have beenstrongly evaluated scientifically (United Nations Office on Drugs &Crime, 2010). These programmes can be implemented from infancythrough to adolescence and have been shown to have a positive impacton healthy parenting practice and family functioning in sustainableways, resulting in more supportive environments in which childrencan grow and develop (Cooper et al., 2009; Knerr, Gardner, & Culver,2013; Rahman, Iqbal, Roberts, & Husain, 2009). Some of theseprogrammes are modelled to operate on different levels. The first is atthe individual level, promoting positive family attitude, beliefs and be-haviours through employing different activities including observingother families to improve life skills. The second is at the family unitlevel, fostering problem solving skills and promoting healthy relation-ships. The third is at the social relationship level, improving relation-ships and bringing communities closer together to support each otherin different aspect in their life. And the fourth level, is at the broadersocial level, changing social and cultural norms and attitudes.

The effectiveness of family skills training programmes in preventingsubstance abuse and other risky behaviour is supported by extensiveresearch (United Nations Office on Drugs & Crime, 2013). Althoughmany of these programmes do not explicitly aim at reducing violentbehaviour by parents or children, there is evidence of their ability toimprove relationships which helps to both reduce and prevent violence(Banyard, 2013), with long term effect (Hawkins, Catalano, Kosterman,Abbott, & Hill, 2009; Spoth, Redmond, & Shin, 2000), including in ethnicminorities (Rodney, Johnson, & Srivastava, 2005). More studies showthat these programmes have an impact specifically on two types of in-terpersonal violence: child maltreatment (MacLeod & Nelson, 2000;MacMillan et al., 2008; Olds, Sadler, & Kitzman, 2007; Prinz, Sanders,Shapiro, Whitaker, & Lutzker, 2009) and, more indirectly, youth vio-lence, by reducing child aggression (Dumas, Arriaga, & Begle, 2011)and preventing child aggression (Love et al., 2005; Miller et al., 2009).Numerous studies have also indicated that family skills programmescan effectively reduce or prevent a number of other risk factors foryouth violence and other types of violence later in life such as conductdisorder and problem behaviour with positive short-term and long-term effects (Bagner, Sheinkopf, Vohr, & Lester, 2010; Bodenmann,Cina, Ledermann, & Sanders, 2008; Bywater et al., 2009; Eckenrodeet al., 2010; Hutchings et al., 2007; Matos, Bauermeister, & Bernal,2009; Reid, Webster-Stratton, & Beauchaine, 2001; Sanders, Bor, &

Morawska, 2007; Santisteban et al., 2003). Research has also demon-strated the ability of these programmes to reduce and prevent delin-quency (Reynolds, Chang, & Temple, 1998; Reynolds, Ou, & Topitzes,2004); lower anti-social behaviour (Braet et al., 2012; Stormshaket al., 2005; Van Ryzin, Stormshak, & Dishion, 2012); reduce bullyingand anger (Nickel et al., 2005, 2006); prevent recidivism (Quinn &Van Dyke, 2004; Woolfenden, Williams, & Peat, 2001) and arrests(Reynolds et al., 2004; Reynolds et al., 2007). Programmes that preventor reduce these factors and promote positive parenting skills target riskfactors for later violence and are therefore likely to prevent it(Farrington, 2007).

It is important to note that the evidence of parenting programmes'effectiveness in preventing different social and health outcomes, includ-ing violence, is predominantly from high-income countries. However,the scientific evidence suggests that family skills training programmescan improve parenting in low and middle income countries despitethe likelihood that these parents are also facing many other challengessuch as poverty and difficult living environments (Knerr et al., 2013).Nevertheless, very few of these evaluation reports emanate from lowandmiddle income countries and, if any, rarely do theymeasured actualviolence as an outcome.

As of November 2009, the United Nations Office on Drugs and Crime(UNODC) launched a global project that aims at advocating for adoptionof evidence based prevention interventions, including family skills, withthe main aim of preventing substance use in low and middle incomecountries. This project operates at the normative level, encouragingpolicy makers beneficiary member states to design and adopt evidencebased policies and strategies as recommended by the UNODC Interna-tional Standards on Drug Use Prevention. The project also operates onthe technical capacity level, bridging national prevention service pro-viders at different level with the developers of evidence based preven-tion programmes to adapt and nationally pilot and evaluate evidencebased prevention programmes. One of these programmes piloted arefamily skills programmes. The evidence based family skills programmesselected to date to be piloted are: Strengthening the Family 10-14 (SFP10-14 programme) and Family and Schools Together (FAST) (UnitedNations Office on Drugs & Crime, 2010).

Both FAST and SFP 10-14 use a number of evidence-based familyskills strategies which aim to increase parental empowerment, familycommunication, cohesion, support and trust, build family unity andbonds, increase self-esteem, as well as create a supportive network forparents and build peer relations for children.

Since the project's launch inNovember 2009, to the date of submittingthis article, 16 countries have been included in these pilot schemes. A totalof five countries in Central Asia (Turkmenistan, Kyrgyzstan, Tajikistan,Kazakhstan andUzbekistan) are piloting FAST; and another five countriesin Central America (Panama, Honduras, El Salvador, Guatemala andNicaragua) and five in South East Europe (Albania, Serbia, Montenegro,Macedonia and Bosnia Herzegovina) are piloting SFP 10-14 programme.In addition to Brazil where both FAST and SFP 10-14 were piloted.Currently, the project has reached close to 7000 parents and children.

It is important to note that the main purpose of UNODC at this stageof the project was to advocate member states participating in the pro-ject to adopt such programmes and to scale them up. Hence the focuswas on building the capacity and infrastructure for the government tobe able to do so. The main outcomes of concern were ensuring thattools are adapted and culturally acceptable, local facilitators are properlytrained on implementing the family sessions of concern, some facilita-tors are trained as trainers to ensure scale up and the governmentalcounterpart is provided by a full report focusing on the national pilotfocusing primarily on the process (feasibility, quality and cost) as wellas on some element of the outcomes (including changes within thefamily as well as affinity of families, schools and facilitators to furtherencourage other parents to participate).

Hence, most of the tools used at this level focused on the processlevel. Nevertheless, pre–post measurement instruments were also

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applied to assess changes at the family level. These tools included mea-sures of violence or violent risk factors assessed before and after thepro-gramme being implemented to get some insight on the programme'seffect. Accordingly this article attempts to summarize the indicatorsof violence or violence risk factors generated from assessed familiesusing a quasi-experimental basis, using a single group design.

Despite the fact that the report relies on a quasi-experimentaldesign, the scarcity of data on family skills programme from developingcountries, particularly when implementing evidence based programmessuch as FAST and SFP 10-14 with quality supervision presented an op-portunity to centralize the generated data in this article for the purposeof benefiting the scientific community.

2. Methodology

Despite the difference in the age group targeted by each of thepiloted family skills programme, the process of implementation wasrelatively similar across. A governmental endorsement was sought forthe purpose of the national piloting from the concerned ministries.Depending on the country, the governmental counterpart was eitherthe ministry of health or education or both, in addition to the nationaldrug coordination body (if available). Such approval was sought to en-sure national ownership of the process from the early stages, facilitatingas such future prospects of national scale up by the government oncethe UNODC piloting phases out and feedback reports were provided.

At the time of the writing of this article, the data available wascollected from 9 countries. The first five were in Central Asian countries(implementing FAST): Tajikistan (Dushanbe), Turkmenistan (Ashgabat),Kyrgyzstan (Bishkek), Kazakhstan (Pavlodar and Shymkent) andUzbekistan (Tashkent). Furthermore, three countries from CentralAmerica (implementing SFP 10-14) also provided data: Panama(Panama City, Colon, Chiriqui), Honduras (Tegucigalpa), Guatemala(Guatemala City). Additionally, data was available from Serbia,implementing SFP 10-14 in Novi Beograd and Zvezdara, Belgrade.

2.1. Cultural adaptation

Upon receipt of governmental approval, the national counterpartassigned a cultural adaptation team to review and assess appropriate-ness of the translated material to local cultures and norms. Any recom-mendations of this team are accounted post-discussion with thedevelopers of each of the programmes of concern to ensure adherenceto the theories upon which the programmes are designed. In the vastmajority of cases the adaptation was mostly cosmetic, changing onlynames and examples. There were no changes affecting the structure,content or the order of the sessions of either of the two programmes,as confirmed by the developers.

2.2. Working with the facilitators

The governmental counterpart assigned local facilitators in each ofthe cities concerned, with qualifications meeting the recommendationsof the developers of each of the programmes. Facilitators of bothprogrammes were trained over 5 days through qualified trainers,assigned and supervised by the developers and/or experienced trainers.Each training session entertained between 20 and 40 facilitators.

The facilitators were assigned in teams of two to three, each teamserving a group ofmaximum10 to 15 families. Each teamwas requestedto implement all sessions of the programmes packages. The sessionswere held in classroom settings of schools serving the neighbourhoodswhere the families were recruited. The timing of the sessions wasnationally discussed and agreed by the cultural adaptation team. Inmost instances, they were weekday evenings at a rate of one sessionper week. A level of flexibility of the sessions timing was allowed toensure suitability for participating families. Facilitators were paidminor retributions for their time and efforts.

2.3. Working with the families

Participating schools were selected and approached by the govern-mental counterparts for consent. Minor incentives (not exceeding theequivalent of 3000US$)were allotted to participating schools to encour-age them to participate in the pilots. These incentives were in the formof investing in the infrastructure of the schools, either refurbishing itsclassrooms or providing Audio–Visual equipment necessary for theundertaking of the sessions and beyond. The programmeswere intendedto be implemented on a universal basis. In an effort to encourage familiesto participate, the programmes were advised to be promoted by theschool and facilitators as family improvement packages, and not drugprevention ones.

In most instances, during the first cycle of implementation, schoolpersonnel invited families to attend sessions, the participation acrossprogrammes was strictly voluntary. Those interested received per-sonal contact from the facilitator to further explain the programme.Parents were invited to come and try it once and complete a pre-programme questionnaire. Informed consent was also sought fromparents on child's participation. During further implementationcycles, families benefiting from the programme also invited otherfamilies.

In the case of FAST, parents also consented on provision of furtherinfo on the student by the teacher. Confidentiality of data was explainedto participating families. The sessions were undertaken as per the in-structions of each of the concerned programmes, and under the super-vision of the lead consultants/developers. No direct incentives werepaid for the participating families.

2.4. Quality assurance and fidelity

First off facilitators were selected to be culturally representativefrom the communitieswhere the familieswere to be served. These facil-itators were directly trained by the developers or senior certified trainerof each of the programme. These trained facilitators to work with fami-lies were supervised nationally by a senior qualified assigned persontrained by the developers or other senior trainer. Furthermore, Skype-based conference callswere also undertakenwith the developers/seniorpersonnel for trouble shooting purposes during the implementation. Allfacilitators were provided the complete manuals of each programme.For FAST, a programme integrity checklist was also utilized by thefacilitators in each session. For SFP 10-14 a process evaluation toolwas administered during the 2nd and 5th sessions of interaction withfamilies. Customer satisfaction and family retention rate were furthermeasures reflecting quality and fidelity. Furthermore qualitativeevaluations through expert opinion, provided by the developers of theprogrammes were also utilized as feedback to troubleshoot where andif necessary.

2.5. Evaluation

For SFP 10-14, a retrospective pre-test and post-test modality hasbeen implemented immediately after the 7th (last) session of the pro-gramme, a process referred to as “thentest”. The pre-test and post-testtools have been modified from original version focusing on indicatorsof immediate concern and of importance to the national counterparts.The modification was carried out by the national cultural adaptationteams and in consultation with the developers and lead consultants(Virginia and LelandMoolgard). These tools came in two complimenta-ry versions, one filled by parents and the other by the participatingyouth. The questions were not part of a formal scale of assessment butwere rather individual indicators of concern. The questions responseoptions were on a Likert scale ranging from 1 (rarely), 2 (sometimes),3 (often) to 4 (most of the time). The aggregate mean score of responsewas calculated for pre-test and post-test results. The statistical signifi-cance change in mean values recorded was assessed using a paired

619W. Maalouf, G. Campello / Aggression and Violent Behavior 19 (2014) 616–624

t-test analysis. This article reports on the changes in indicators deemed todirectly assess violence and common to all the 9 countries providing data.

For FAST, the pre-test questionnaires were filled by parents at thetime of their contact with the FAST facilitator inviting them to the ses-sions. Another set of pre-programme questionnaires were also filledby the teachers, upon receipt of parental consent, and prior to the un-dertaking of the sessions. Within two weeks of the programme ending,facilitators distributed the post-test questionnaires to participating par-ents and teachers. In order to protect confidentiality, each family mem-ber was assigned an identification number assigned by the FAST teammember collecting the data. The families were identified by the num-bers across questionnaires. Details on the data collection instrumentscan be found in (McDonald & Doostgharin, 2013). This report only fo-cuses on changes in violence related indicators which are part of: the“conflict” subscale of the Family Relationship Index of the Family Envi-ronment Scale (FES used (Moos &Moos, 1981)) and the “conduct prob-lems” subscale of the Strength and Difficulties Questionnaire (SDQ)(Goodman, 1997) as assessed by both parents and teachers. The scoresfor the conflict subscale ranged from 0 to 9, with higher scores indicat-ing poorer family functioning. The SDQ conduct problems subscaleranged between 0 and 10. Within the conduct problem subscale rating,when the score ranged: between 0 and 2 it was considered normal, be-tween 3 and 4 was borderline and 4 and above was considered abnor-mal. The statistical significance change in mean values recorded wasassessed using a paired t-test analysis (the same was applied for com-paring proportions when the prevalence of response to a specificvalue of the item scale was reported).

3. Results

3.1. Demographics

The demographics of families attending the FAST sessions wererecorded as part of the instruments used in the pilots (Table 1). Themothers were in the majority of cases the parents represented, thefathers usually attended after the 3rd or 4th session and rarely as ofthe first one. The age group of the children attending the sessions was

Table 1Demographic characteristics of families benefiting from piloting Families And School Together

Tajikistan Turkmenistan

Number of parents 120 100% mothers 81.7% 93%

Number of children 120 110% boys 61.3% 61.8%

Average family size (range) 4.8 (2–10 kids) 4.46 (2–10kids)Average age children (range) 7 (7–8) years 7.20 (7–10) yearsAverage age parents (range) 39.6 (28–67) yrs 34.78 (27–61) yrParental education

Less than high school 16.5% 51.1%High school 41.0% 8.1%Junior/vocational college 0 14.0%Graduate professional school 34.3% 1.2%Some college 1.8% 1.2%College graduate 6.4% 24.4%

Family Incomeb10,000 US$/year 100% 19%10,000–24,999 US$/year 8%25,000–49,999 US$/year 11%50,000–75,000 US$/year 8%N75,000 US$/year 28%

EmploymentFull time 53.2% 68.0%Part time 12.1% 17.2%Not employed/never employed 34.5% 14.8%

Marital status of parentsMarried 88.9% 93.5%Never married/divorced 11.1% 6.5%

a 50% or more of the responses are missing.

consistent with the recruitment requirement. The remaining demo-graphics were consistent with the Central Asian communities throughwhich the families were recruited.

For the SFP 10-14 pilots, the family demographicswere not collectedas part of the testing tools. Nevertheless, given similitude of the recruit-ment to the one of FAST, it was expected that families would be fullyrepresentative of the communities. Two qualitative studies on therelevance (including cultural relevance) of the SFP 10-14 pilots are cur-rently being analyzed for communities in Panama and Serbia. The de-mographics of the families reached and available to provide data forsuch study were recorded. These are described below to provide thereaders with an impression of what sort of families attended as wellas to validate their representativeness of the communities.

In Serbia, the qualitative study covered parents only (almost allparents participating in the first 2 cycles), 84% of those participating inthis study were mothers. The average family size was between 1 and2 children per family (76% of the families with 2 children or less). Thesocio-economic class of the families was estimated to vary betweenlow to middle high, with an average leaning to middle low. TheSerbian coordinator of the programme overseeing the entire pilot re-ported that these demographics are fully representative of the commu-nity as well as the families benefiting from the programme.

In Panama, a total of 30 parents attending the UNODC SFP 10-14 ses-sions participated in the qualitative study. The sample average age ofthe children participating in the programme was 13.35 years (74% ofthem were boys). Only mothers' participated in the qualitative study,48% of them were married, 29% were cohabiting, 3% were widowed,and the other 23%were single mothers. An average of 13% had only pri-mary level education, 29% had some high school, 36% completed HighSchool, 16% had some college education and 6% had a post graduate de-gree. The reported monthly income of these families was as follow: 7%less than what is equivalent to 100 US Dollars per month, 17% between100 and 249 USD/month, 45% reported 250 to 599 USD/month, 10% be-tween 600 and 999USD and 21% over 1000USD. The assessment of thecoordinator of the programme in Panama is that these rates could begeneralizable to the entire Panamanian participating families. More-over, and per the same coordinator, it was safe to assume that the afore-

(FAST) in Central Asia.

Kazakhstan Kyrgyzstan Uzbekistan

110 110 10087.3% 77% 94.7%110 140 9050.5% 49.5% 50%4.10 (2–6 kids) 4.31 (2–10 kids) 4.6 (1–10) kids7.31 (6–8) years 7.14 (4–10) years 7.6 (2–11) years

s 36.5 (25–67) yrs 34.2 (22–62) yrs 35 (24–61) yrs

22.2% 38.3% 28.3%35.5% 43% 29.7%8.9% 3.2% 4%7.8% 12.8% 12.2%3.3% 1% 1.3%22.3% 1.7% 24.5%

57.6%a 76.1%a 7.9%30.5% 22.6% 19%3.3% 0% 25.4%3.3% 0% 7.9%5.3% 1.3% 39.8%

50.5% 50% 28.2%12.9% 19.8% 11.5%36.6% 30.2% 60.3%

70.2% 91.2% 92.5%29.8% 8.8% 7.5%

620 W. Maalouf, G. Campello / Aggression and Violent Behavior 19 (2014) 616–624

mentioned demographics also apply to the Guatemalan and Honduranfamilies in Guatemala City and Tegucigalpa City respectively.

In all pilots undertaken, the retention rates of families attending thefirst session of either SFP 10-14 or FAST ranged between 80 and 100%.

3.2. Change in violence indicators

3.2.1. SFP 10-14The violence indicators reported by parents attending SFP 10-14

sessions were mainly focused on controlling and managing parents'own anger while dealing with their child (1 — I wait to calm down be-fore dealing with my child and 2 — I tell my child when I am irritatedwithout blaming or criticising) as well as attempting to manage theirchild's anger (3— I listen tomy childwhen he is angry or disappointed).

A statistically significant change in these anger management indica-torswas noted pre–post-test almost across all parental groups assessed.In the few cases where the change in mean score comparing pre-test topost-test resultswas not statistically significant, the change remained inthe appropriate direction (Table 2).

Further to the violence indicators collected from theparents, compli-mentary indicators were also collected from the children attending thesessions. These indicators were at different levels. The first was relatedto attitude and reaction to external influences from families, friendsand teachers (three indicators: 1 — expressing gratitude towards par-ents for what they do and 2 — using the steps taught to manage theinfluence of friends when the child is pressured to be put in troubleand 3 — feeling that parents and tutors really love and respect me).The second level was a direct child assessment of indicators of violencefrom parents and tutors towards them (two indicators: 1— sitting withparents and teachers to solve problems together without shouting orgetting angry at each other and 2 — feeling that the tutors and parentsare calm when they discipline the child).

A statistically significant change on these indicators was noted pre–post-test almost across all parental groups assessed in Honduras,Guatemala, Panama and Serbia. In the few cases where the change inmean score comparing pre-test to post-test results was not statisticallysignificant, the change remained in the appropriate direction.

While these changes are generally important it was particularly ofinterest to see that they also work in communities where the level ofviolence is higher than average such as inHonduras. Themean difference

Table 2Change on violence indicators in parents noted per group per country piloting SFP 10-14 pre–

I wait to calm down before dealingwith my child problems.

Pre-testMean ± SD

Post-testMean ± SD

HondurasGroup 1 (16 parents) 1.125 ± 0.341 2.063⁎⁎ ± 1.082Group 2 (12 parents) 2.167 ± 0.937 3.417⁎⁎ ± 0.669Group 3 (14 parents) 1.357 ± 0.518 3.000⁎⁎ ± 0.707Group 4 (16 parents) 1.563 ± 0.629 2.938⁎⁎ ± 0.854

GuatemalaGroup 1 (13 parents) 2.800 ± 0.837 3.333⁎ ± 0.516Group 2 (16 parents) 1.750 ± 0.463 2.600⁎ ± 1.265Group 3 (13 parents) 1.111 ± 0.333 3.222⁎⁎ ± 0.441

PanamaGroup 1 (8 parents) — Colon 2.250 ± 1.165 3.250⁎⁎ ± 0.887Group 2 (17 parents) — Chiriqui 2.000 ± 1.061 3.529⁎⁎ ± 0.624Group 3 (53 parents)¤ — Panama City 1.766 ± 0.865 3.362⁎⁎ ± 0.806

SerbiaGroup 1 (40 parents)¤ 2.710 ± 0.940 3.312⁎⁎ ± 0.752

————— Not assessed.Cluster of 4 groups.⁎ p b 0.05.⁎⁎ p b 0.005.

at pre-test between assessment of Honduras and those of Guatemala,Panama and Serbia, were important proxy of the difference at the com-munity level characteristics (Table 3).

3.2.2. FASTFor the purposes of evaluating the impact on violence across families

benefiting from FAST, the indicators selected were all the items of the“conflict” subscale recorded on the Family Relationship Index of theFamily Environmental Scale (FES). Additionally, the items of theconduct problems on the Child and Difficulties Scale (SDQ) were alsoaccounted for. Both items from the FES and SDQ were reported by theparents. The mean overall score across the aforementioned selectedsubscales as assessed by parents was also evaluated pre–post imple-mentation. Furthermore the Conduct problem subscale of the SDQ asassessed by the teacher was also used to contrast the changes notedon the parental evaluation (Tables 4, 5 and 6).

When assessing the conflict subscale of the FES, and despite thesimilarity in the family recruitment process in all the Central Asiancountries participating in the pilots, a noted variabilitywas recorded be-tween countries. Tajikistan families reported the highest mean score onthe conflict subscale (over 4), the remaining countries had a relativelysimilar pre-test mean score orbiting around 2. Nevertheless, post testresults indicated a significant reduction on the conflict subscales in allcountries assessed, with post level results being very similar (Table 6).The same trend was noted across the individual items of the conflictsubscale of the FES (Table 4).

As for the conduct problem subscale, with the exception ofUzbekistan, a noted congruence and correspondence was noted acrossthe scores assessed by teachers as well as the parents, within country(Table 6). In Uzbekistan, parents seem to have over-rated the conductproblems in their children as compared to the teachers. Nevertheless,both parental and teachers rating was within the borders of a normalscore of the conduct problem subscale of the SDQ (Table 6).

When comparing the conflict subscale of the SDQ between coun-tries, only the Kazakh participating children had a mean SDQ scorerated in the mid upper range of the “borderline” score on the pre-test.Nevertheless, at the pre-test the parental assessment seemed to havesignificantly shifted downwards in the direction of the normal score(Table 6), this was also noted across the individual items of the scale(Table 4). While moving in a similar direction per the teachers' rating,

post evaluation.

I tell my child when I am irritated,without blaming or criticizing.

I listen to my child when he/she isdisappointed or angry

Pre-testMean ± SD

Post-testMean ± SD

Pre-testMean ± SD

Post-testMean ± SD

1.438 ± 0.629 2.125⁎ ± 0.957 1.188 ± 0.403 2.000⁎⁎ ± 0.9661.417 ± 0.515 3.083⁎⁎ ± 0.669 2.000 ± 0.853 3.167⁎⁎ ± 0.8351.357 ± 0.518 2.786⁎⁎ ± 0.802 1.357 ± 0.518 2.643 ± 0.7451.300 ± 0.483 3.063⁎⁎ ± 0.573 1.800 ± 0.632 2.875 ± 0.619

2.600 ± 0.547 3.200⁎ ± 0.836 3.000 ± 0.707 3.231 ± 0.5572.100 ± 1.370 2.385 ± 1.325 3.222 ± 0.833 3.728⁎ ± 0.4671.875 ± 0.641 2.667⁎ ± 1.000 1.556 ± 1.013 3.333⁎⁎ ± 0.707

2.125 ± 0.835 3.375⁎⁎ ± 0.7442.294 ± 1.105 3.176⁎⁎ ± 0.635

2.255 ± 0.913 3.019⁎⁎ ± 0.960 2.735 ± 1.056 3.400⁎⁎ ± 0.881

3.411 ± 0.711 3.663 ± 0.552

Table 3Change on violence indicators reported by children noted per group per country piloting SFP 10-14 pre–post evaluation.

I express gratitude to my parents forwhat they do for me.

I use steps taught to manageinfluence of friends whenpressured and pushed to beput in troubles.

My parents/tutors and I can sit andsolve the problem together withoutshouting or get angry at each other.

My parents/tutors are calm whenthey discipline me.

I feel my parents/tutors really loveand respect me.

Pre-testMean ± SD

Post-testMean ± SD

Pre-testMean ± SD

Post-testMean ± SD

Pre-testMean ± SD

Post-testMean ± SD

Pre-testMean ± SD

Post-testMean ± SD

Pre-testMean ± SD

Post-testMean ± SD

HondurasGroup 1(15 children)

2.267 ± 1.163 1.533 ± 0.640 2.067 ± 1.163 2.467 ± 0.834 1.733 ± 0.961 1.867 ± 1.125 1.600 ± 0.737 2.400 ± 0.910 1.400 ± 0.632 1.467 ± 0.516

Group 2(16 children)

1.750 ± 0.683 3.313⁎⁎ ± 0.602 1.625 ± 0.719 2.750⁎⁎ ± 0.856 1.688 ± 0.602 3.063⁎⁎ ± 0.772 2.125 ± 0.806 3.250⁎⁎ ± 0.775 1.563 ± 0.512 2.813⁎⁎ ± 0.655

Group 3(16 children)

1.250 ± 0.447 3.438⁎⁎ ± 0.512 1.250 ± 0.447 3.188⁎⁎ ± 0.655 1.188 ± 0.403 3.378⁎⁎ ± 0.500 2.188 ± 0.655 3.623⁎⁎ ± 0.500 2.375 ± 0.885 3.500⁎⁎ ± 0.516

Group 4(26 children)

2.115 ± 0.952 3.346⁎⁎ ± 0.797 1.333 ± 0.480 3.037⁎⁎ ± 0.759 1.423 ± 0.503 2.846⁎⁎ ± 0.732 1.667 ± 0.620 3.346⁎⁎ ± 0.577 1.846 ± 0.675 3.231⁎⁎ ± 0.847

GuatemalaGroup 1(11 children)

3.428 ± 0.756 3.533 ± 0.639 2.467 ± 0.915 3.267⁎ ± 0.961 2.938 ± 0.854 3.133 ± 0.834 2.867 ± 0.640 3.333 ± 0.976 3.933 ± 0.258 3.933 ± 0.258

Group 2(16 children)

3.000 ± 0.943 3.000 ± 0.953 1.778 ± 0.972 3.222⁎⁎ ± 0.972 2.778 ± 1.202 3.222 ± 0.972 3.111 ± 1.269 3.333 ± 1.118 3.333 ± 1.000 3.667 ± 0.707

Group 3(17 children)

2.800 ± 1.082 3.000 ± 1.095 2.067 ± 1.163 2.235 ± 1.200 2.077 ± 0.954 2.058 ± 1.088 2.430 ± 1.016 2.118 ± 1.111 3.143 ± 1.099 3.059 ± 0.899

PanamaGroup 1(9 children) — Colon

1.778 ± 1.093 3.333⁎⁎ ± 0.707 2.000 ± 0.707 3.111⁎⁎ ± 0.600 1.778 ± 0.833 3.444⁎⁎ ± 0.726

Group 2(18 children) — Chiriqui

1.778 ± 1.060 3.111⁎⁎ ± 0.758 2.222 ± 1.215 3.278⁎⁎ ± 0.894 2.722 ± 1.074 3.611⁎⁎ ± 0.608

Group 3(56 children) — Panama City¤

2.535 ± 0.977 3.175⁎⁎ ± 0.782 2.018 ± 1.001 2.589⁎⁎ ± 1.053 2.053 ± 0.982 2.714⁎⁎ ± 0.988 2.667 ± 0.893 3.107⁎ ± 0.888 2.877 ± 1.119 3.518⁎⁎ ± 0.763

SerbiaGroup 1(40 children) ¤

3.132 ± 1.021 3.477 ± 0.722 2.968 ± 0.868 3.379⁎ ± 0.750 2.907 ± 0.982 3.133 ± 0.973 3.565 ± 0.766 3.634 ± 0.713

————— Not assessed.Cluster of 4 groups.⁎ p b 0.05.⁎⁎ p b 0.005.

621W.M

aalouf,G.Cam

pello/A

ggressionand

ViolentBehavior

19(2014)

616–624

Table4

Percen

tof

parentsan

swering“true”

onindividu

alconfl

ictsubscale

item

son

theFamily

Relation

ship

Inde

xof

theFamily

Environm

entScaleby

CentralA

sian

Coun

tryan

dAgg

rega

te.

Tajik

istan

Turkmen

istan

Kazak

hstan

Kyrgy

zstan

Uzb

ekistan

Agg

rega

tefor5

coun

tries

N=

114

N=

92N

=95

N=

102

N=

79N

=18

8

Pre

Post

Pre

Post

Pre

Post

Pre

Post

Pre

Post

Pre

Post

Wefigh

talotin

ourfamily

75%

15%⁎⁎

8%4%

10%

14%

19%

14%

22%

25%

31%

9%⁎⁎

Family

mem

bers

rarely

beco

meop

enly

angry

30%

95%⁎⁎

60%

72%

55%

52%

53%

59%

68%

63%

49%

60%

Family

mem

bers

sometim

ege

tso

angrythey

throw

things

40%

5%⁎⁎

23%

5%⁎⁎

16%

20%

32%

18%⁎

9%10

%30

%12

%⁎⁎

Family

mem

bers

hardly

ever

lose

theirtempe

rs10

%95

%⁎⁎

91%

96%

76%

77%

73%

83%

79%

86%

64%

85%⁎⁎

Family

mem

bers

oftencriticizeea

chothe

r95

%10

%⁎⁎

18%

4%⁎⁎

29%

33%

43%

43%

41%

32%

47%

25%⁎⁎

Family

mem

bers

sometim

ehitea

chothe

r70

%5%

⁎⁎

7%4%

12%

9%14

%6%

⁎41

%33

%20

%5%

⁎⁎

Ifthere'sadisagree

men

tin

our

family

,wetryha

rdto

smoo

ththings

over

and

keep

thepe

ace

80%

95%⁎⁎

63%

57%

97%

93%

90%

93%

96%

96%

87%

97%

Family

mem

bers

oftentryto

one-up

orou

t-do

each

othe

r30

%5%

⁎⁎

35%

21%⁎

20%

27%

36%

31%

26%

28%

37%

19%⁎⁎

Inou

rfamily

webe

lieve

youdo

n'tev

erge

tan

ywhe

reby

raisingou

rvo

ice

40%

95%⁎⁎

76%

40%⁎⁎

73%

79%

65%

77%

75%

83%

69%

80%

⁎pb0.05

.⁎⁎

pb0.00

5.

622 W. Maalouf, G. Campello / Aggression and Violent Behavior 19 (2014) 616–624

the degree of shift was not to the same extent in comparison with theparents' assessment. All other countries mean scores were within thenormal scores range at the pre-test stages and the overall mean signifi-cantly shifted downwards post test, both from the teachers and parentsperspectives (Table 6). This significant shifting to lower scorewas notedacross many of the individual items of the scale (Table 5).

4. Discussion

Adolescence is a critical and challenging age of development for fam-ilies, anger management control both from the parents and the childrenperspective is a key ingredient in defusing many violence problems.

Despite the fact that the evaluation was undertaken in a quasi-experimental way, both programmes (FAST and SFP 10-14) showedsignificant effect on violence all indicators assessed on the families re-cruited on a universal basis. More importantly, it is also worth notingthat all results were cross validated via more than one source (parents,child and teacher's assessments) to further strengthen conclusions onchanges noted across indicators.

What is further encouraging was the fact that both programmescarried an effect on other family factors that might indirectly alleviateviolence, such as family cohesion, family expressiveness and communi-cation, pro-social behaviour attitude, alleviation of child emotionalproblems, etc… (McDonald & Doostgharin, 2013).

It is also worth noting that the process through which bothprogrammes were implemented was designed in a way to carry an im-pact on the social relationship level, improving relationships and bring-ing communities closer together to support each other in differentaspect in their life as well as on the broader social level, changing socialand cultural norms and attitudes. Though, the last two levels have notbeen formally evaluated, it is hypothesized that changes on the individuallevel will carry changes on the social and community level. The extentand degree of such a change would be interesting to assess and anychange on such levels would further add credit to the value of changesnoted on the direct indicators of violence.

Admittedly, the programme was offered universally to a relativelysmall number of self-selected families per school/ community and re-sults cannot be fully generalizable. Nevertheless these programmeswere implemented with a good level of fidelity. All necessary measuresof fidelity assurance were carried over as recommended. Moreover theimplementation was under the developer's purview and their assess-ment of quality was positive. The fact that the retention rate amongfamilies that participated in the programmes was very high (80–100%) is further encouraging and heartening.

In keeping with scientific evidence collected by other researchers,the experience of this project was also positive with regard to the feasi-bility of successfully implementing family skills training programmes inlow- andmiddle-income countries. Results from other UNODC support-ed pilots, including an SFP 6-11 adaptation implemented in the city ofNuevo Leon in Monterrey (Mexico) as well as FAST and SFP 10-14 infavelas in the outskirts of Brasilia, Brazil. While the data sets are notfully analysed yet, nevertheless preliminary findings reported seem tofurther support the results noted in other countries.

It is also interesting to note that McDonald et al, also contrasted thepre–post changes across items of the FES in the UNODC Central Asiantrials to those assessed across 7000US FAST Families. The level of familyfunctioning at the outset between Central Asian families aswell as thoseof the US was quite similar. However, post scores showed substantiallymore significant positive changes in the Central Asian Families com-pared to those of the US (McDonald & Doostgharin, 2013). Such indica-tion of possible relative stronger impact of the interventions in low andmiddle income countries might be explained by the relative generalpaucity of services for parents. The high affinity indicators for suchprogrammes in all countries, as assessed by the level of demand forsuch programmes to UNODC in countries were piloting is on its way

Table 5Percent of parents answering “certainly true” on individual conduct problem Items on the Child andDifficulties Scale (SDQ) as reported by parents by Central Asian Country and Aggregate.

Tajikistan Turkmenistan Kazakhstan Kyrgyzstan Uzbekistan Aggregate for 5countries

N = 68 N = 69 N = 58 N = 57 N = 68 N = 115

Pre Post Pre Post Pre Post Pre Post Pre Post Pre Post

Often has temper tantrums or hot tempers 50% 10%⁎⁎ 8% 11% 16% 11% 14% 4%⁎ 25% 19% 27% 5%⁎⁎

Generally obedient, usually does what adult requests 25% 75%⁎⁎ 79% 61% 38% 49% 47% 75%⁎ 56% 53% 44% 68%⁎⁎

Often fights with other children or bullies them 25% 10%⁎ 3% 7% 5% 6% 6% 2% 7% 6% 10% 1%⁎⁎

Often lies or cheats 15% 5%⁎ 9% 0%⁎⁎ 7% 2% 7% 3% 2% 2% 7% 1%⁎

Steals from home, school or elsewhere 15% 5%⁎ 5% 0%⁎ 3% 4% 6% 1% 2% 1% 6% 0%⁎⁎

⁎ p b 0.05.⁎⁎ p b 0.005.

623W. Maalouf, G. Campello / Aggression and Violent Behavior 19 (2014) 616–624

and beyond is also encouraging and might potentially further supportthe aforementioned conclusion.

Both FAST and SFP10-14 comewith assuring evidence of effectivenessfrom the scientific trials historically undertaken for both programmes.Despite the limitations of the current trials, the indication is very posi-tive of the replicability and success of such programmes in low andmiddle income countries. Nevertheless, further research is still neededto formally assess the impact of such family skills programmes, includ-ing the differential effect by gender of the children, the size effect andthe long term retention of such changes. Such long term RandomisedClinical Trials assessing impact would undoubtedly further strength-ened the results.

Nevertheless, the UNODC pilots have provided a fertile infrastruc-ture to carry out more in-depth research in this regard and the lessonslearned from the process so far are very encouraging and would be ofbenefit for further replication of such trials in other countries.

5. Conclusion

The UNODC experience of implementing family skills programmesin low and middle income countries is very encouraging in preventingviolence. Moreover, the programmes seem to be easily adaptable andexecutable with very high level of affinity by all communities werethe pilots were undertaken. This is particularly relevant given theneeds of the families in countries concerned. Significant results were re-corded in terms of outcomes linked to lower levels of youth violenceand child maltreatment at least on a comparable level to high-incomecountries. Further studies from these countries, particularly in theform of randomised clinical trials, could further substantiate such find-ings, while also assessing the effect size and impact of the interventions.Additional studies could also assess how these interventions couldaffect violence noted at the community and social level.

Table 6Change in mean score on subscales related to violence related indicators recorded by parents a

Tajikistan Turkmenistan

PreMean(SD)

PostMean(SD)

PreMean(SD)

PostMean(SD)

Conflict subscale of Family EnvironmentScale (FES) of Family Relationship Indexreported by parents

4.49(2.28)

1.09⁎⁎⁎

(1.48)1.98(1.35)

1.66⁎⁎

(1.12)N = 114 N = 92

Conduct Problems of Strength and Difficultiesof Children (SDQ) scale reported by parents

2.73(1.14)

2.05⁎⁎

(1.06)1.98(1.76)

1.85 (1.9

N = 68 N = 69Conduct Problems of Strength and Difficultiesof Children (SDQ) scale reported by teachers

2.69(0.75)

2.01⁎⁎

(1.04)1.47(2.52)

1.26⁎

(2.31)N = 55 N = 70

Acknowledgements

The authors would like to acknowledge the following UNODC stafffor their contribution to realise the pilots of reference in this article:UNODC Office in Vienna (Dr. Gilberto Gerra, Ms. Nina Fabiola MonteroSalas, Ms. Katri Tala and Ms. Hanna Heikkila), UNODC Regional Officefor Central America and the Caribbean (Ms. Melva Ramirez and Ms.Noemi Gomez), UNODC Office in Serbia (Mr. Milos Stojanovic andMr. Bojan Milosavljevic) and UNODC Regional Office for CentralAsia (Mr. Borikhan Shaumarov, Ms. Sevara Karimova and Ms. MalikaDjabbarkhodjaeva). The following UNODC interns for their support inthis article (Ms. Jessica Brettschneider and Ms. Andrea Kazan).

As well as the following researchers who were instrumental inavailing some of this data: Dr. Anilena Meja, Dr. Taghi Doostgharin,and Dr. Zehra Kacapor Dzihic.

Moreover a special word of gratitude goes to Dr. LynnMcDonald forher leadership role in guiding the pilots of the Family And SchoolTogether Programme (FAST) as well as Drs. Virginia and LelandMolgaard for their leadership role in guiding the pilots of the Strength-ening the Families Programme 10-14 (SFP 10-14).

The authors would like to acknowledge the governments of France,Japan, Spain and Sweden whose generous contribution to the projectmade all the pilots mentioned possible.

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