Prevention Science

, Volume 13, Issue 4, pp 402–409 | Cite as

The Development of Dating Violence: What Doesn’t Develop, What Does Develop, How Does it Develop, and What Can We Do About It?


Before starting this commentary, I need to put my biases on the table: I believe that healthy development depends on healthy relationships. This is the central tenet of our national network – Promoting Relationships and Eliminating Violence Network (PREVNet). In considering intimate partner violence (IPV), therefore, I am predisposed to look at how these maladaptive relationship styles develop, what role relationships play in guiding youths onto troubled pathways and, conversely, what role relationships can play in diverting youths onto healthy development and relationship pathways. This set of papers provides a strong foundation for considering the development of dating aggression, as well as the mechanisms that might underlie the development and maintenance of aggression in intimate relationships. With this developmental perspective, we can also consider potential strategies to prevent and intervene to move youths off this troubled pathway and onto a healthy relationship pathway.

What Doesn’t Develop?

The collection of papers in this Special Section provides important pieces in the puzzle of how youths come to a point where they use aggression in their intimate relationships. Langhinrichsen-Rohling and Turner (2012), who report on an intervention for teen mothers, provide a good starting point in our consideration of what critical relationship capacities do not develop by reviewing six characteristics of respectful nonviolent relationships as identified by the Centers for Disease Control and Prevention (CDC 2008). These are: (a) belief in nonviolent conflict resolution; (b) effective communication skills; (c) ability to negotiate and adjust to stress; (d) belief in partner’s right to autonomy; (e) shared decision-making; and (f) trust. We can hypothesize that youths who engage in intimate partner violence fail to develop an understanding of, and capacity for, these elements of healthy relationships. Langhinrichsen-Rohling and Turner note that a reduced understanding of what constitutes a healthy intimate relationship has been associated with experiencing IPV. Consistent with this perspective of IPV as a problem with development, Chiodo et al. (2012) found that delinquency and sexual harassment perpetration predicted membership in a group characterized by mutual intimate partner violence. Although delinquency is different than IPV, youths who are delinquent may fail to consider the consequences of their behaviors on others and fall short in non-violent conflict resolution.

Ehrensaft and Cohen (2012) point to the lack of development in self-regulation for youths who are both antisocial and engage in IPV. Within the brain, a lack of development of self-regulation implies less capacity for executive functioning, cold cognition, and effective social problem solving. This lack of neural regulation is reflected in impulsive, uninhibited and difficult social behavior. In our observations, we found that aggressive youths’ behaviors were unpredictable: They were more likely to engage in “mixed” behaviors – one moment they were prosocial, followed immediately with an aggressive behavior, with no opportunity for the peer to respond (Pepler et al. 1998). These youths had not learned the essential skills for positive exchanges in social relationships. Consistent with this, Reyes et al. (2012) note that youths exposed to family or peer violence have fewer opportunities to learn constructive conflict resolution strategies than peers who are not exposed to relationship violence.

Youths who are undercontrolled may also be those who engage in sexually harassing their peers, because they have failed to develop the self-regulation and perspective-taking skills for empathy, the appropriate levels of respect and concern for the other, and/or effective ways of acquiring power positively, rather than negatively. In our research, we found that sexual harassment was strongly associated with bullying, which is the combined use of power and aggression (Pepler et al. 2006). We consider sexual harassment as a form of bullying because it involves targeting a vulnerability that is especially salient during adolescence when sexuality is emerging.

When we consider IPV, it may be important to envision a continuum of aggression from playful and minimally destructive to violent and debilitating. O’Leary and Slep (2012) cite their own and others’ research indicating that 10–20% of IPV incidents may be playful, non-aggressive and not based on an angry exchange. On this continuum, there is most likely to be a point at which the use of aggression (even playful aggression) is not positive, constructive, and respectful. What does not develop for youths who engage in playful IPV? Youths with poor social-cognitive skills may fail to develop a sensitivity to the point at which playful aggression turns into destructive aggression. In our observational research on bullying, we found this extremely difficult to code and recognized that we could only code the shift from rough-and-tumble aggression to bullying by observing at what point the receiving child indicated emotional distress (Pepler and Craig 1995). We also found that victimized children masked their discomfort – they showed primarily neutral and positive affect while being bullied (Mahady-Wilton et al. 2000).

Youths who engage in playful IPV may fail to recognize when it is no longer fun for their partners, and even playful aggression may have a negative impact on the victimized individual if this ambivalent interaction is not embedded in the context of an intimate, trusting relationship. Youths who exclusively engage in playful aggression may be more likely than their less skillful peers to desist in dating aggression, when they come to recognize the value of engaging non-aggressively with their intimate partners. O’Leary and Slep (2012) note that some youths are stable in their use of IPV, whereas others manage to move away from using aggression with their dating partners. In contrast to those who desist, the youths who persist in being aggressive may experience a critical lag in the development of relationship capacity. They may fail to develop important relationship skills during the critical period of adolescence, when the lessons for life-long intimate relationships are being learned. There is a need for further research to explore whether these youths experience a developmental lag or a developmental difference (i.e., they have developed an advanced set of skills, just not those necessary for healthy relationships). Nevertheless, it is clear that something has gone awry in these youths’ development of the capacity to relate positively and not aggressively in the early stages of intimate relationships in adolescence.

The papers in this Special Section suggest that many capacities that are essential for healthy relationships are not developing for youths who engage in IPV. These include: self regulation, constructive and non- violent conflict resolution strategies, an understanding of the consequences of one’s behavior on others, sensitivity to the point at which playful aggression is harmful, and an understanding of what constitutes a healthy relationship.

What Develops?

If positive relationships skills are not developing, what are youths learning that leads them into patterns of aggression in romantic relationships? Consistent with a developmental perspective that bullying may transform into other forms of interpersonal aggression, O’Leary and Slep (2012) raise the concern that IPV may be learned as a form of problem solving or as an adaptive strategy for status, dominance, or control. From a developmental-systemic perspective, we can consider what youths are developing at an individual and relationship level.

At an individual level, Ehrensaft and Cohen (2012) point to research on early stress, such as child maltreatment, and the association of stress with neurobiological processing. With elevated stress responses, children who have experienced violence in their homes may become increasingly vigilant to hostile interactions, have difficulty regulating their arousal, and develop an understanding of relationships based in anxiety, unpredictability, reactivity, and distrust. These neurological and social-cognitive processes may curtail the development of positive internal working models of relationships and underlie the development of hostile attributional biases characteristic of aggressive children and youths (Crick and Dodge 1994). Reyes et al. (2012) provide a learning perspective on social-cognitive development. They argue that when youths are exposed to violence in the family and dating violence in the peer group, they may develop norms that are more accepting of IPV and more positive and fewer negative perceptions of the consequences of using physical aggression in dating relationships. Reyes and colleagues (2012) discuss the implications of substance use on IPV. These authors suggest a mechanism linking poor self-regulation, hostile social cognitions, deviant norms, substance use, and IPV: Aggressive youths may be more susceptible to the disinhibiting effects of intoxication on being aggressive with a dating partner. We contend that the style of using aggression in relationships develops prior to substance use because we found that children who bully at a high level develop substance use behaviors earlier than their non-bullying peers (Pepler et al. 2002).

When we consider what youths might be learning in the context of relationships, the family provides the primary socialization context. In developing their intervention, Langhinrichsen-Rohling and Turner (2012) considered how different attachment styles might be reflected in response to their treatment. They note that insecure attachment dimensions have been associated with the perpetration of IPV. They hypothesize that individuals who are high on avoidant attachment may learn to use violence to maintain psychological distance in the relationship. In contrast, individuals who are high on anxious attachment may learn to use violence in response to jealousy, emotional dysregulation, or fear of abandonment. In keeping with this line of reasoning, it may be helpful to think of power dynamics and how youths are learning to use violence to control their intimate relationships. In social bullying, youths often use power and aggression to exclude a peer and maintain distance in a relationship (Underwood 2003).

Alternatively, there is often increased arousal in bullying and that might continue to engage the other, particularly if the intimate partner is eager to be in the relationship. These attachment styles may be maintained by interactional patterns within intimate relationships. Shortt et al. (2012) use longitudinal data to unravel the reciprocity of IPV and how the stability of IPV depends on men’s dating partners’ levels of IPV. Several other authors also point to the reciprocity of IPV in relationships – if one partner is aggressive there is a high probability that the other will also be aggressive.

Patterns of interacting in the family and with peers may carry over to interactions with intimate partners. For example, Chiodo et al. (2012) note that children who use coercive behaviors in friendships are likely to continue using these strategies in other relationship contexts. They suggest that sexual harassment may be a key behavior in the developmental pathway from peer to dating aggression. This raises an important question about what develops. Some youths who engage in IPV may not be using aggression to cause destructive distress, but to gain attention, status, and power in their relationships. Even if they are engaging in playful aggression, there is a concern that youths are learning how effective it is to use aggression in their intimate relationships as an attention seeking, arousal, and engagement strategy.

On the school playground, we were able to observe the power dynamics of bullying unfolding and to recognize that youths who bullied were learning how to use their power aggressively to control and distress others (Craig and Pepler 1997). As indicated above, a feature of respectful and healthy relationships is the belief in a partner’s right to autonomy. Using aggression to control or distress an intimate partner violates the right to autonomy, which leads us to consider what an equal power balance in a relationship means. Issues of power are important to understand at dyadic, group, and broader social context levels.

There is emerging research showing a strong association between the level of bullying and other forms of interpersonal aggression among children and youth with the level of income inequity for a municipality (Chaux et al. 2009) and for a country (Elgar et al. 2009). In their research on national levels of income inequity, Wilkinson and Pickett (2009) illustrate the strong association between national levels of income inequities and indices of IPV. They argue that a substantial gap in advantages leaves those who are disadvantaged eager to achieve power and status, which they may try to acquire in proximal relationships, leading to higher levels of all forms of IPV in countries with high inequity.

This collection of papers points to many aspects of youths’ understanding of and behavior in relationships that may underlie the emergence of violence with intimate partners. These youths may develop an understanding of aggression as an effective strategy for problem solving, gaining control, attention, and status, as well as a means of increasing arousal and engagement in interactions with their partners. Given their exposure to violence in the family context, youths may develop insecure attachments and working models of relationships as distrustful and hostile. In deviant peer groups, youths may develop norms that are accepting of IPV and its consequences. Finally, youths who are aggressive may be more susceptible to the effects of substances in disinhibiting the use of aggression in relationships.

How Does Intimate Partner Violence Develop?

As we gather pieces of the puzzle of IPV to consider what lessons these youths have not and have learned, we can now turn to how youths might be learning that aggression is an acceptable and adaptive strategy to use in relating to intimate partners. Here again, the developmental-systemic framework provides an effective way to consider the diverse research presented in this Special Section and the mechanisms that may be related to the development of IPV at individual and relationship levels.

Individual Development

Children’s predispositions and behaviors contribute significantly not only to their own development, but also to the way in which others interact with them. As Ehrensaft and Cohen (2012) point out, when children are aggressive early in life, they are challenging to manage and their parents may find it increasingly difficult and stressful to parent effectively. We conducted research on the reciprocal relationship between maternal negativity and children’s externalizing behavior over three time points, starting when the children were 10 and 11 years old until they were 14 and 15 years old. As expected, we found that mothers and children influenced each other over time; however, children’s influences on the development of maternal negativity increased over time (Zadeh et al. 2010). In other words, as children become more antisocial, their mothers become less and less effective in their parenting role. These dynamics are reciprocal and may carry over into other intimate relationships. In another study, we found that the extent of youths’ aggression toward their parents was a significant predictor of whether or not they were aggressive toward their dating partners, particularly for girls (Laporte et al. 2011).

Ehrensaft and Cohen (2012) highlight two potential mechanisms underlying the problems that arise in the lives of troubled children: Parenting practices become increasingly ineffective and parents are not able to support the child’s development of self-regulation. A lack of self-regulation may compound the problems of these youth, because antisocial youth, as in our study of bullying, are the earliest onto a substance use pathway (Pepler et al. 2002). As Reyes et al. (2012) point out, being intoxicated increases the risk of partner aggression because it decreases cognitive functioning and the ability to self-regulate and respond to stress, which for aggressive youths is already low.

Another mechanism to consider in the development of interpersonal aggression is that when youths lack the capacity to regulate themselves, they can quickly become emotionally aroused in stressful situations, which in turn decreases their cognitive capacities for executive functioning. In research on neurological changes for aggressive children who participated in a treatment program, Lewis et al. (2008) found that those who had improved had lower activation of the ventral prefrontal systems which are associated with emotional arousal compared to those children who did not improve through the program.

The papers in this Special Section point to youths’ inabilities to regulate their emotions and behaviors as a potential mechanism underlying their movement into patterns of IPV. Their lack of self-regulation may relate to their own reactions to stress, as well as to increased risk for substance use and increased difficulties that their parents, and presumably teachers, experience in socializing them.

Development in the Context of Relationships

How important are relationships for children and youths’ development? The National Scientific Council on the Developing Child stated that “relationships are the ‘active ingredients’ of the environment’s influence on healthy human development” (2004, p. 1). In other words, healthy development depends on healthy relationships. In considering the potential mechanisms underlying the development of IPV, we can focus on the three relationship domains that are most important in youths’ lives: the family, peer group, and romantic relationships.


Children and youths who grow up in a family environment characterized by inter-parental and parent–child violence experience problems with both aggression and victimization (Bowes et al. 2009). Several papers in this Special Section provide insights as to the potential mechanisms that promote the development of dating violence. These mechanisms can be generally categorized as: modeling, reinforcement and lack of positive social learning, as well as problems in developing a healthy understanding of relationships and one’s worth in relationships.

Children are embedded in experiences that shape their learning in the family context. Children who grow up in families in which there is violence have daily behavioral lessons on the use of aggression in relationships. As Reyes et al. (2012) point out, there is an imbalance in these children’s learning opportunities: They have many opportunities to learn about how to use aggression in close relationships and few opportunities for how to resolve conflicts in positive ways. Parents provide the most salient models of using harsh and aggressive behaviors as a means of problem solving. With parents who are themselves stressed and over-reactive, children may also experience an imbalance in the reinforcements that they receive for their own behaviors. When they act out aggressively and cause a disturbance, their parents may consistently pay attention and respond, albeit harshly. Conversely, when these youths are prosocial, compliant, and compassionate, their parents may fail to respond because of the psychological and/or social stresses that they are experiencing. Therefore, youths who grow up in violent families have many opportunities to learn about the use of aggression within close relationships and few opportunities to learn the critical capacities that underlie the development of healthy relationships.

The second potential mechanism within the family relates to the first; however, it involves youths’ development of understanding of relationships and of their worth in relationships. Against the backdrop of the strained and negative relationships they experience, troubled youths learn that relationships are not reliable. As Ehrensaft and Cohen (2012) found, parents who themselves had experienced IPV reported low satisfaction with their children. The children, in turn, may experience their parents’ dissatisfaction as rejection by those who are still most important in their lives. To understand this mechanism, we perhaps need to consider parents’ own development. They may take a low interest in their children because of an unwanted or precocious pregnancy (as with the young mothers in Langhinrichsen-Rohling and Turner’s (2012) intervention), strained resources for personal survival, a lack of social support and few positive relationships to enable them to overcome their experiences of abuse in relationships.

Chiodo et al. (2012) found that youths who reported parental rejection were more likely to be in the group characterized by mutual IPV. These youths are aggressive to their partners and appear to have chosen partners who are aggressive to them. Their behaviors and partner choices may reflect an insecure attachment style and sensitivity to rejection in their dating relationships because of their rejection experiences with their parents.

Peer Group

The mechanisms within the peer group that potentially influence the development of aggression in dating relationships are, not surprisingly, similar to the social learning and social-cognitive processes described above in the family context. Youths who are antisocial tend to associate in deviant groups and reinforce each other for antisocial behaviors (Dishion et al. 1999). Therefore, youths who are already at risk for using interpersonal aggression are exposed to learning about the use of aggression in intimate relationships through processes of modeling and reinforcement. Given the composition of their peer groups, there are perhaps few peer models of positive romantic relationships.

Reyes et al. (2012) found that associating with friends who engaged in dating violence was significantly positively related to youths’ own levels of dating violence. The learning mechanism appears to be specific to the type of relationship: Associating with friends who were violent to their peers was not associated with an increased risk for dating aggression. Being embedded in a peer group with members who engage in dating aggression may also shape youths’ understanding and norms for relationships.

Romantic Partners

There is a high degree of reciprocity of aggression within dating relationships, which may be a function of youths’ choice of partner, as highlighted in the three papers by Chiodo et al. (2012), O’Leary and Slep (2012), and Shortt et al. (2012). Youths tend to choose partners who have similar personality profiles (O’Leary and Smith 1991). It is particularly concerning that aggressive boys and aggressive girls tend seek out one another, as Capaldi and her colleagues (Kim and Capaldi 2004) have shown.

A continuation of this longitudinal research, reported by Shortt et al. (2012), shows that IPV remains relatively stable if men stay with the same partners; however, when they changed partners, there was a change in men’s levels of aggression to their intimate partners. Shortt and colleagues note that these findings are consistent with a developmental-systemic perspective suggesting that although IPV may be related to many individual predispositions, it may be maintained by both partner behavior and established interactional patterns in relationships. The dynamics within the romantic dyad may influence the probability of IPV. As O’Leary and Slep (2012) note, romantic partners shape each other – if one partner engages in IPV, it adds to the risk that the other partner will engage in IPV. The strong influence of the partner on IPV was illustrated by Shortt et al. (2012) with their longitudinal research: If a man partnered with a woman who was less aggressive than his previous partner, the man’s levels of IPV decreased; conversely, if a man partnered with a woman who was more aggressive than his previous partner, the man’s levels of IPV increased. Given these findings, Shortt and colleagues argue that to prevent and treat IPV, we need to focus on the behaviors of both partners and on the dyadic interactions.

There is a need for more research to reveal what mechanisms are operating in mutually violent relationships. Partners may reinforce the other’s behavior by complying to aggressive outbursts. Social-cognitive processes may also be at play. With insecure attachments or internal working models of relationships as hostile and potentially rejecting, youths may have expectations of relationships as volatile and not recognize the need to avoid relationships that mirror the aggression within their family dynamics. In addition, youths who choose partners similar to themselves may find themselves with partners who are similarly dysregulated, which sets the stage for impulsive, unskilled problem solving when conflicts inevitably arise. It is important to consider the nature of romantic relationships that may lay the fertile soil for IPV. In adolescence, romantic interactions are characterized by heightened arousal and emotions. With familiarity and longevity in the relationship, there may be more opportunities for conflicts and fewer inhibitions against using aggression to resolve these conflicts, especially when a partner is similarly uninhibited.

Although some youths may be predisposed to engage in aggression across a wide range of relationships, their development of the capacity for healthy relationships emerges within the context of their relationships within the family and peer group, as well as in the proximal interactions within the romantic relationship itself. Social learning and social-cognitive processes are potential mechanisms in the development of IPV; therefore, these may also be processes that can be altered through prevention and intervention efforts to curtail the development of IPV. The longitudinal research described by Shortt et al. (2012) provides clear evidence that prevention and intervention efforts should focus not only on the challenges faced by individuals in intimate relationships, but also on the nature of their dyadic interactional patterns.

What Can We Do to Prevent and Intervene?

Taken together, this set of papers provides strong direction for prevention and intervention strategies to address the development of IPV. The six characteristics of respectful relationships identified by the CDC (2008) can be considered from a developmental-systemic framework. At the individual level, both boys and girls need to develop belief in nonviolent conflict resolution, effective communication skills, and the ability to negotiate and adjust to stress. Within relationships, they need to develop a belief in their partners’ right to autonomy, the capacity for shared decision-making, and trust not only in their partners, but in other relationships as well. As Langhinrichsen-Rohling and Turner (2012) note, these characteristics of respectful relationships provide direction for developing prevention and intervention efforts.

Developing the Capacity for Relationships

Youths who perpetrate violence with their intimate partners may fail to develop many of the skills required for healthy relationships. These skills are first developed in the context of the family and later within the peer group and school. Programs are needed that highlight the importance of developing the capacity for getting along with others and support parents in their efforts to develop children’s relationship skills. Because learning to get along with others is so complex, with challenges that change with development, this type of programming for parents and youths needs to be ongoing and adapted to the developmental needs of children and parents. Although much more complex, this process is similar to developing capacities in literacy and numeracy – it doesn’t end in the early school years. In addition, similar to the development of academic skills, we need to recognize that children learn through trial and error. Therefore, when children make mistakes in relationship skills, the logical solution is not to punish them but to help them understand and develop perspective taking, self-regulation, and problem-solving skills throughout childhood and adolescence. It is important to remember that children, even those with common difficulties, are diverse and require different forms and levels of support tailored to their needs and capacities.

Developing Positive Relationship Perspectives

Youths who perpetrate IPV tend to have distorted perspectives about what constitutes a healthy relationship, how to build trust and respect in relationships, and how to determine whether a relationship is healthy or not. Because these understandings about relationships develop first in the family context – where these youths often feel unappreciated and unwanted, it is necessary to include parents in prevention or intervention efforts. In her work with seriously antisocial children, Moretti and her colleagues (Moretti and Obsuth 2009) have developed the Connect program – an intervention for parents and caregivers based on attachment theory with a focus on parental sensitivity, cooperation, reflective capacity, and effective dyadic affect regulation. Initial evaluations for this program, which focuses solely on parents, show increases in parenting satisfaction and perceived efficacy and reductions in caregiver burden (Moretti and Obsuth 2009). Consistent with the transactional processes in parent–child relationships, it is encouraging to note that there was a parallel increase in youths’ social functioning and a decrease in their problem behaviors following the program. This program has not been extended to consider the impact on youths’ romantic relationships, but that may be a fruitful avenue for future development, given the relationship framework for the intervention. If relationship dynamics between parents and their children improve, it may carry over to youths’ relationships with their partners.

Promote Positive Mechanism and Mitigate Negative Mechanisms

As we learn more about how IPV develops, we may be able to promote positive mechanisms in youths’ lives and mitigate the effects of negative mechanisms through prevention and intervention efforts. As with the previous recommendations, this strategy has as much to do with others’ behaviors as with the youths’ own problem behaviors. Therefore, a developmental-systemic perspective is essential to change not only the way the youths relate to others, but also the way others relate to the youths. It is a challenge to change well- established interaction patterns for both youths and those with whom they relate. If youths are dysregulated and unskilled, it takes strong self-awareness among socializing adults to build and maintain a positive relationship with these troubled youths. In our work within PREVNet, we are learning that training for those working with children and youths frequently omits critical lessons in how to build healthy relationships with youths and among youths. Parents, in particular, need support in understanding the importance of supporting their children’s social-emotional development and in recognizing their children’s strengths and enjoying them, rather than being dissatisfied, as Ehrensaft and Cohen (2012) point out. As far back as the early parenting programs developed by Patterson (1975), research has pointed to the importance of helping parents build positive relationships before helping them to be effective in monitoring and controlling their children. Within PREVNet, we recognize that all those involved with children and youths require the essential knowledge and strategies to create healthy relationships with them, support their learning, and create social contexts that promote healthy and reduce the possibilities for unhealthy relationships (Pepler and Craig 2011).

When Should We Intervene?

A final developmental consideration is at what point should we introduce prevention and intervention programming to prevent IPV? The brief answer to that question is: Start early and keep providing learning opportunities. Some authors point to the need for early identification and intervention to prevent the development of coercive interaction patterns. Consistent with our view of bullying as a relationship problem that requires relationship solutions, our data indicate a strong link between developmental pathways of bullying and dating aggression (Pepler et al. 2004). Boys and girls who enter school already using their power aggressively to control and distress others have missed critical lessons in caring about others and interacting in respectful ways. They need support and will benefit from a classroom and school climate that promotes positive relationships and does not reinforce bullying. As Reyes et al. (2012) note, physical aggression with a dating partner peaks in late adolescence, suggesting that the time when youths are learning about intimate relationships in early adolescence may be an appropriate time for additional focus on developing the skills and perspectives for respectful relationships.

Promoting Relationships to Prevent Violence

A consideration of the development of IPV highlights the importance of providing children and youths with relationship skills and understanding and ensuring that all the relationship contexts they live in are positive and supportive of their social-emotional development. The consequences of failing to protect children from violence and support them in developing healthy relationships are costly and life long (CDC 2011). Bullying, dating aggression, violence, mental and physical health problems, substance abuse, school drop out, and unemployment are all outcomes rooted in experiences within violent relationships (CDC 2011). A recent meta-analysis indicated that poor social relationships are as big a contributor to early death as smoking, drinking, and obesity (Holt-Lunstead et al. 2010). By preventing violence and promoting healthy relationships, we can optimize children and youths’ healthy physical, social, emotional, and cognitive development – all of which underlie well-being, healthy family life, productivity, and citizenship.


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Copyright information

© Society for Prevention Research 2012

Authors and Affiliations

  1. 1.York University and The Hospital for Sick ChildrenTorontoCanada

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