Early Prevention of Aggression in Children in Developing Countries

Introduction

Expressions of violence are significantly more common in developing countries than in developed countries. Africa and Latin America have the highest rates of violent deaths in the world.¹Problems with aggression and behaviour are also seen beginning in childhood in poor countries such as Brazil,² Egypt³ and Colombia.^4-6 We can therefore see the importance of offering violence prevention programs in developing countries. In order to prevent violence, such programs must be effective and sustainable using the resources of these countries, and must be culturally accepted in them.

Importance of the issue

Both in developed^7-9 and developing countries,¹⁰ it has been documented that early aggression is predictive of crime and violence in youth and adulthood. It is also predictive of other behaviours that threaten social and personal life, such as drug abuse, alcoholism, poor academic achievement, smoking, unsafe sex, teen pregnancy, family violence and problems at work.^7-9

These risky behaviours tend to occur as a cluster and can be considered to be comorbidities¹¹ with common causes.¹² This provides a basis to infer that it would be possible to develop successful programs for early prevention of violence that would also have effects on other risky behaviours: that is, multipurpose programs. This approach is of particular importance for developing countries, since it avoids the need to maintain a series of parallel programs aimed at preventing specific risky behaviours, such as drug abuse, alcoholism, gang membership, etc., and reduces duplicate overhead and administration and their associated costs. In developed^13-15 and underdeveloped countries,^16-21 it has been documented that this is possible, but we need to have more and better evidence in this regard.

The behaviours mentioned previously present risks for personal and social life and are, in turn, associated with several of the leading causes of illness, disability and death in developing countries. These include violent deaths, injuries, interpersonal assault, traffic accidents, several types of cancer, lung disease, sexually transmitted diseases and HIV/AIDS.^22-25 Another important association is the link between aggression early in life and learning problems²⁶ and school dropout rates,²⁷ which hinder personal and social development and can lead to failure to achieve the Millennium Development Goal that children complete at least primary education.

We thus have common causes that account for children’s behaviour in their early years, their learning ability, and the state of their health later in life. These root causes include, very significantly, social inequity,²⁸ which paradoxically is much more prevalent in poor countries than rich ones;¹ patterns of education and parenting and children’s relationship with theirparents,^29,30 and the physical, social and economic environment of the neighbourhood or environment where the child lives.^31,32 Children subjected to social and family stress have a high probability of serious consequences throughout their lives, such as problems with learning and economic productivity, poor health and shorter life expectancy.¹²

Despite the fact that in developing countries we find a high prevalence of behavioural problems in children and multiple risk factors, we also have very few studies in such countries that assess the effectiveness of early prevention programs addressing risky behaviours.³³

Problems

1. There is little scientific evidence of the effectiveness of early prevention programs targeting aggression and risky behaviour in developing countries.
2. Assessments that have been carried out have problems in terms of measurements and evaluation methodology.
3. When existing programs from developed countries are implemented in developing countries, they are often inadequatelly adapted to the cultural context of these countries.

Research Context

Evaluations of the effectiveness of early prevention programs that target aggression in developing countries are limited, and little is known about strategies to carry out such assessments. There are also few resources and minimal interest from decision-makers in funding this type of initiative. However, it is important to note that in a study on research and priorities of decision-makers in low-and moderate-income countries, mental health problems were the fourth highest research priority.³⁴

Key Research Questions

What is the effect of early aggression prevention programs in developing countries?

Should the same risk and protective factors be addressed in developing countries as in developed countries? What risk factors should be addressed?

Is it possible to take interventions conducted in developed countries and implement them in developing countries?

Recent Research Results

Of 30 successful interventions conducted in developing countries, 27 were assessed using experimental or quasi-experimental methods, including 18 carried out after 2000. We found interventions targeting parents,^{17,20,21,35-46} interventions involving school teachers^47,48 and four studies that mixed these types of interventions.^16,18,49,50 Two involved clinical interventions with parents,^51,52 and four interventions integrated health care services, nutrition and psycho-social development.^19,20,53-55 The majority of the programs focused on small groups of children with conduct disorders or risk factors, and a few worked with broader sectors of the childhood population.^19,41,44

Most of the assessments reported positive impacts on children’s conduct, including fewer involvements in fights and fewer aggressive behaviours,^{16,18,21,47,50} improvement in pro-social behaviour,^16,18 better management of emotions^17,47,55 and better psycho-social development.^17,47,55 With respect to parents, some interventions noted reductions in physical punishments,^16,17 better parent-child interaction^{36,38,44-46,52} and improved understanding of the child and his or her needs.^37,43,48,55 It was found that teachers improved their ability to respond to the various needs of children.^47,56

The program evaluations were carried out using a large variety of instruments and measurements of outcome variables. In many cases these instruments were not properly validated. Most sample sizes were very small, limiting the analysis of potential confounding and interacting variables and decreasing the power of their estimates. Some measured the direct effect on children, while others looked at intermediate achievements in the behaviours and practices of teachers and parents. Most did not report on possible biases and limitations of the study. Positive effects on the behaviour of children, teachers and parents were reported for most of the studies. Harmful effects were found in two interventions; in both it appears that this may be due to difficulties in implementing the program.^41,49

Research Gaps

We recommend the following steps to overcome the major research gaps identified above:

1. Increase research on the effectiveness of early risky behaviour prevention programs in developing countries, taking the socio-cultural context into account. It is important to draw attention to the inclusion of local researchers in studies conducted in developing countries, as authors or coauthors of major importance; if local researchers are limited to being mere “collaborators” or data collectors, it will weaken the research.
2. Conduct rigorous validation of instruments used to assess behavioural problems and practices, beliefs, and attitudes of parents and teachers, so that they can be used to assess the effectiveness of early interventions to prevent aggression, and in clinical practice.

Conclusions

It is possible to carry out successful early prevention programs addressing risky behaviours in developing countries, which is home to the majority of the world’s children who are coping with economic, social, and family stress.

However there are few studies in developing countries that assess the effectiveness of early prevention programs addressing risky behaviours, and these studies share certain limitations, such as sample size and the methodology and measurement instruments used.

Of the evaluations found, most show an improvement in parents’ knowledge and practices and in children’s behaviour. We must encourage the evaluation of these programs, with a strong emphasis on the socio-cultural context of developing countries.

Implications for Parents, Services and Policy

Decision-makers must have solid, scientific bases for policies and programs to promote early prevention of risky behaviours. They should develop programs that are multipurpose and should promote studies of their effectiveness in developing countries. To do so requires an alliance between politicians, academia and the broader community.

If parents were to prefer that they and their children participate early prevention programs that address various risky behaviours and that are based on solid local scientific evidence, this would be very significant and would serve to legitimize public policies and programs. For parents in developing countries, implementing such culturally-sensitive multipurpose interventions represents an opportunity to improve educational practices and promote the development of children.

Academic institutions should increase their competence in the field of methodologies for assessing the effectiveness of early prevention programs that address risky behaviour in developing countries.

The implementation of early prevention interventions addressing risky behaviors could help break the cycle of violence in many countries that have experienced generations of armed conflict and criminal groups, where initiatives aimed at control have not been effective. It should be stressed that in order to effect change in society, we must implement long-term programs grounded in broadly conceived public policies and that cover the most vulnerable groups.

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