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MEKI RESEARCH REPORT

ME ASUR ING I S K E Y T O IMPR OV EMENT Interventions that Work in Dealing with Aggression in Youth Welfare Settings

Measuring is Key to Improvement – Interventions that Work in Dealing with Youth Aggression 2015-2-HU02-KA205-000984

MEKI RESEARCH REPORT Measuring is Key to Improvement - Interventions that Work in Dealing with Aggression in youth welfare settings

2015-2-HU02-KA205-000984 Erasmus+ Key Action 2: Cooperation for Innovation and the Exchange of Good Practices – Strategic Partnership in the Field of Youth August 2018 Author Stijn Custers, Researcher Empowering People ACHT & APART UC Leuven-Limburg

UC Leuven-Limburg Belgium Expertisecel Empowering People Tel: +32 11 180 700

Groep Gezondheid en Welzijn, Campus Diepenbeek Agoralaan gebouw B bus 7 3590 Diepenbeek Programmalijn ACHT & APART stijn.custers@ucll.be

Measuring is Key to Improvement – Interventions that Work in Dealing with Youth Aggression 2015-2-HU02-KA205-000984 Colophon: Published in 2018 by: Stijn Custers University Colleges Leuven-Limburg, UC Limburg vzw.

QUADRI, Empowering People, ACHT & APART Agoralaan gebouw B bus 7 3590 Diepenbeek Belgium ©UC Limburg vzw, all rights reserved This project was financed by The European Union, Erasmus+ Key Action 2: Cooperation for Innovation and the Exchange of Good Practices – Strategic Partnership in the Field of Youth, 2015-2HU02-KA205-000984.

Special thanks goes out to project partners Karin Blankespoor (Jeugdwijs), Noemi Laszlo, Andrea Gruber and Monika Rozsa (Pressley Ridge Hungary, NoBadKid) and Gabriella Komoly and Dora Gerencser for their cooperation in this research project, as well as to all participating organizations and professionals.

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Measuring is Key to Improvement – Interventions that Work in Dealing with Youth Aggression 2015-2-HU02-KA205-000984

Content 1.

Introduction and rationale .............................................................................................................. 5 1.1

Aggression ............................................................................................................................... 6

1.2

Methods used to prevent or manage aggressive behavior in youth care .............................. 8

1.2.1 1.2.2 2.

General effective elements in child or youth welfare ..................................................... 9 Trajectories in child and youth welfare and disruptions in care ....................................... 10

Methodology ................................................................................................................................. 10 2.1

Research questions................................................................................................................ 10

2.2

Research Design .................................................................................................................... 11

2.3 Data-collection I: Survey for organizations on the most common and effective methods for aggression management and preventing disruptions in care ........................................................... 12 2.3.1

Population and sampling ............................................................................................... 12

2.3.2

Content of the questionnaire ........................................................................................ 19

2.3.3

Data-collection .............................................................................................................. 21

2.3.4

Data-analysis ................................................................................................................. 21

2.4 Data-collection II: Survey on aggression incidents and trajectories of youth in child- and youth welfare services....................................................................................................................... 25 2.4.1

Population and sampling ............................................................................................... 25

2.4.2

Content of the questionnaire ........................................................................................ 26

2.4.3

Data-collection .............................................................................................................. 27

2.4.4

Data-analysis ................................................................................................................. 27

2.5 Data-collection III: Survey on youth’s experiences and opinions on helpful methods in preventing and managing aggressive behavior and disruptions in care in youth welfare services.. 28

3.

2.5.1

Population and sampling ............................................................................................... 28

2.5.2

Content of the questionnaire ........................................................................................ 29

2.5.3

Data-collection .............................................................................................................. 29

2.5.4

Data-analysis ................................................................................................................. 30

Results ........................................................................................................................................... 30 3.1 Research question 1: What are the most commonly used methods in preventing or managing aggressive behavior in child and youth welfare services? ............................................... 30 3.2Research question 2: How do professionals and youth evaluate the effectiveness of the most commonly used methods in preventing or managing aggressive behavior in child and youth welfare? ............................................................................................................................................. 37 3.3 Research question 3: How does aggressive behavior influence the trajectories of youth in child and youth welfare? ................................................................................................................... 51

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Measuring is Key to Improvement – Interventions that Work in Dealing with Youth Aggression 2015-2-HU02-KA205-000984 3.4 Research question 4: Which methods for the prevention or management of aggressive behavior are helpful in preventing disruptions in care in child and youth welfare? ........................ 53 4.

Conclusion ..................................................................................................................................... 56

5.

Discussion ...................................................................................................................................... 63

6.

References ..................................................................................................................................... 67

7.

Appendices .................................................................................................................................... 69

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Measuring is Key to Improvement – Interventions that Work in Dealing with Youth Aggression 2015-2-HU02-KA205-000984

1. Introduction and rationale Throughout the EU it is estimated that today 1 out of every 5 children are confronted with some kind of emotional or behavioral issues. Due to deficiencies in the normal development, i.e. lack of proper development of the proprioceptive sense, a lot of behavior observed can be interpreted as aggressive or violent. Though the phenomena of aggressive or violent behavior can vary, this behavior is the biggest threat to a healthy future for children captured in the vicious cycle of their behavior and decisions. Professionals sometimes react to the observed behavior instead of answering the underlying needs or causes.

According to demografia.hu1, there are 1,620,000 children in Hungary between the age of 5-19. 2025% of them are confronted with emotional or behavioral issues.

The state care system of Hungary is overloaded (on average only 8 child psychiatrists finish their professional training in the country in a year; 1 family worker handles about 50 cases at the same time; waiting lists for specialized services are 4-6 weeks long). Professionals working at those services are not always prepared for treating behavioral issues.

The Belgian and Dutch system is more developed in specialized services to help kids with troubled and troubling behavior. Yet, the Dutch numbers (Van den Bossche et al., 2013) indicate that in 2011, 48% of the employees in welfare and care settings for youth were confronted with aggressive behavior.

Opdenacker (2012) provides a clear view of what methods Flemish youth care centers use to prevent and/or manage aggression. However her results also show that, youth welfare services in Flanders do not always use certain methods correctly (e.g. some preventive methods are used in a curative way) and sometimes methods are used without knowing if these methods are effective.

As for the longer term outcomes, Van der Ploeg (2009) states that aggressive youngsters have less chances in society. The high percentage of occurrences of aggression in care and the ambiguity in effects of methods suggest a need for more effective interventions. In line with this, according to the Eurydice report (2012), a number of EU countries still face the challenge of developing key competences among kids.

Behavioral problems, are for instance not always recognized. Violence, aggression and juvenile delinquency can sometimes be viewed as character flows and not as circumstantial responses of the child. A common reaction to serious behavioral issues is retaliation and punishment, even though this might further exacerbate the problem. Another risk of aggressive behavior is that youth experience rough pathways or trajectories in youth welfare settings characterized by disruptions in care, numerous displacements and a series of encounters with more (restrictive) settings.

In this research project, we want to enhance the opportunities for professionals in child and youth welfare services in a European context to consciously, adequately and effectively use methods to prevent or manage aggressive behavior. To increase the quality of care for youth, provide youth with better life chances, prevent risks such as disruptions in care and provide professionals with tools to better manage and prevent aggressive behavior, it is therefore imperative to provide an overview of the most common and effective methods for the prevention or management of aggressive behavior in child and youth welfare and look for general elements and shared outcomes. To this end, this Erasmus+ project will build upon the research of Opdenacker (2012) on common and effective methods for the prevention and management of aggressive behavior in youth welfare settings in

1

http://www.demografia.hu/hu/

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Measuring is Key to Improvement – Interventions that Work in Dealing with Youth Aggression 2015-2-HU02-KA205-000984 Belgium and expands the scope to a broader range of European countries, namely the Netherlands and Hungary.

1.1 Aggression In order to better understand the outcomes of different methods for aggression management or prevention and the effects that aggression has on a future trajectory in child welfare, it is important to clearly define the concept of aggression used in this research report.

A commonly used definition of aggression is: “aggression is behavior that is intended to harm another individual who does not wish to be harmed” (Anderson & Bushman, 2002, p. 373; see also Baron & Richardson, 1994). A characteristic of this definition is that (a) aggressive behavior ought to be intentional, (b) goes against someone else’s will and (c) is aimed at other individuals. ‘Violence’ on the other hand is defined as an extreme form of aggression with extreme proportions in performing physical or emotional harm (Krahé, 2013). A broader definition of aggression is: “aggression is behavior that, whether or not intentional, causes material or immaterial harm and which violates certain formal and or informal rules” (van der Ploeg, 2014, p. 2). This latter definition broadens aggressive behavior towards material objects, living organisms which are capable of experiencing pain and/or emotions, is not necessarily intentional (aggressive behavior can also be caused by subconscious processes or sudden impulses) but does cause harm and usually violates (in)formal rules (as these rules can be cross-culturally diverse). This is also congruent with the definition given

by Morrison (1990) in which he sees aggressive behavior as every verbal, non-verbal or physical behavior that is threatening (towards oneself, others or objects), or any behavior that does inflict observable damage towards oneself, others or objects.

We’d like to take an in between view, where aggressive behavior is verbal, non-verbal or physical behavior that is either threatening or causes observable (im-)material damage or harm as an “act whose goal-response is injury” (Geen & Donnerstein, 1998, p. 2) towards one’s self, other people or belongings, breaks cross-culturally variable general (in)formal rules, but is intentional in a way that it’s not accidental. This is mainly because including the concept of intent seems to be unavoidable, however and despite certain further empirical problems it raises. As illustrated in an example given

by Geen & Donnerstein (1998): “… a team of firefighters attempting to rescue someone trapped in a burning building may cause the person pain, but the harm done is hardly deliberate and may even be necessary to save the person’s life. The firefighters’ behaviour would therefore not be considered aggressive by most observers”.

(Geen & Donnerstein, 1998, p. 2)

In addition, we would like to further elaborate on this using the description given by Krahé (2013, p.

9) that aggressive behavior “is characterized by its underlying motivation (to harm or to injure), not by its consequences (whether or not harm or injury actually occurs)”. While the intention to harm is interlinked to the actor’s understanding that the behavior in question has the “potential to cause harm or injury to the target” (Krahé, 2013, p. 9) and while the target has not given consent for such behavior to occur (for instance a painful medical treatment with consent of a patient does not represent aggressive behavior). We would also like to add that aggression is expressed in a responsive manner to the interaction of inward and outward stimuli as for example frustration, fear, dissatisfaction, disrespect, stress, anger, neglect, harm, ... in an environmental context (this is also touched upon in the General Aggression Model, e.g. Berg, 2012, see also Leers, 2008).

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Measuring is Key to Improvement – Interventions that Work in Dealing with Youth Aggression 2015-2-HU02-KA205-000984 Furthermore, it is important to distinguish different types of aggression or forms under which aggression can manifest itself. Frequent distinctions are made between physical, verbal and relational forms of aggression and pro-active and reactive aggression (e.g. Geen, & Donnerstein, 1998; Warburton & Anderson, 2015). Nevertheless, these are not exhaustive categories and could overlap like in any given typology, as they are ideal-types based on certain characteristics or aspects linked to aggressive behavior. Krahé (2013) as shown in table 1 gives a broader general typology of aggressive behaviour.

Table 1. Typology of aggressive behavior (Krahé, 2013, p. 10)

Most of these different types of aggression are self-explanatory; nonetheless, some of them might require some further explanation. For example, indirect aggression does not occur in a face-to-face confrontation but is aimed at hurting other people behind their backs. The term relational aggression refers to causing harm or hurting someone’s social relationships by aggressive behavior. Both indirect and relational aggression can take place covertly and it represents an alternative strategy for causing harm to someone when the cost of engaging in direct forms of aggression would be too high or are not desirable. These covert, indirect and relational forms of aggression are more often deployed by female than male individuals and are often harder to observe than direct forms of aggression (Krahé, 2013). Instrumental aggression on the other hand is marked by a goal-rational approach of aggression whereas aggressive behavior is a mean to reach a certain goal, whilst hostile aggression is characterized by a more emotional hostility towards a target.

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Measuring is Key to Improvement – Interventions that Work in Dealing with Youth Aggression 2015-2-HU02-KA205-000984

1.2 Methods used to prevent or manage aggressive behavior in youth care While there are plenty of different aggression management ‘methods’ aiming to address different types of aggression, it is imperative to concentrate on a meaningful categorization of different methods, programs, interventions, techniques and to differentiate specific methods applied in reducing aggression from general youth care methods and practices that aim to promote the general wellbeing of youth and children on a physical, social, cognitive and psychological level. This way, cross-cultural and national differences in terminology could also be mitigated.

Based on a review of the existing literature (e.g. Boendermaker & Ince, 2010; Knox & Spivak, 2005; Mihalic & Elliot, 2015; Opdenacker, 2012; Walsh, Rolls Reutz & Williams, 2015; van Yperen, 2010), following classification has been used. In this report, we differentiate a) methods, b) programs (by some also referred to as interventions or intervention programs), c) practices, d) attitudes and e) principles.

1. Methods refer to the aggregated overarching concept encompassing all different practicebased components used for aggression management and prevention. These can encompass certain programs, practices, attitudes and principles and often integrate a certain praxis and conceptual model.

2. Programs (or interventions) used for the prevention and management of aggressive behavior contain a set of different techniques, modules or activities that specifically address aggressive behavior in a preventative or curative manner, are applied systematically and the actions, target group, planning and goals of the program are clearly defined. Some programs also mention which attitudes or principles are of importance in carrying out different activities in the program. Programs used for aggression prevention or aggression management are usually based on different theories, models or perspectives and are goaloriented, clearly defined, systematic and directly refer to preventing or managing aggressive behavior (either in the theoretical framework or in the execution/implementation of the program). In this study the categorization of aggression management (intervention) programs will be based on the goal and target group of the program instead of making a distinction based on primary prevention, secondary prevention and intervention. This approach has also been used in Opdenacker (2012) and Boendermaker & Ince (2010).

Following this approach, following categories are to be distinguished: These programs can focus on:  Children / youth;  Children / youth and their parents, family or context;  Parents;  Restoration between offender(s) and victim(s);  Employees and teams;  Procedures and policy.

This classification in categories can also be motivated by the fact that the distinction between primary prevention, secondary prevention and intervention methods is not as clear and different approaches often intercede, as for example, primary prevention methods can be

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Measuring is Key to Improvement – Interventions that Work in Dealing with Youth Aggression 2015-2-HU02-KA205-000984 used as intervention methods in managing aggressive behavior. We do not claim that this is not the case with the classification in our research, however we believe that these categories provide a more informative indexation of the most common methods used for aggression management to be used by welfare workers and in youth welfare organizations.

3. By practices, we mean those practice-based delineated activities that are carried out in the context of child welfare. Certain practices, such as techniques used for preventing or addressing aggressive behavior, can also make up the body of certain programs.

4. Attitudes or abilities refer to more general attributes or ways of conduct that are of importance for staff in youth care organizations working with youth.

5. Principles refer to guidelines, rules of thumb, or standards in the context of working with youth, often integrated in an organization’s policy or certain methods.

1.2.1 General effective elements in child or youth welfare Next to specific methods used for the management or prevention of aggressive behavior in youth, there are also some general effective elements which are important in improving the wellbeing of youth and children on different life domains (e.g. on a physical, social, cognitive and psychological level). These general effective elements might for example reduce the occurrence of aggressive behavior by mediating effects and provide a general quality framework for providing care. Therefore, we would like to provide an overview of some general effective elements in youth care, regardless of which specific methods are applied. General effective elements contain those aspects of care that contribute to attaining positive results independent of the type of care or target group (van Yperen, 2003). van Yperen, van der Steege, Addinck & Boendermaker (2010) provide an overview of these general effective elements:       

A good and qualitative care relation between client and professional; Finding a match between provided care and the motivation of the client; A clear structuring of methods (clear goals, planning and actions); A good ‘fit’ between the provided care and the specific background, issues and demands for help of the client(-context); Execution of a method in correspondence with its procedures and its intended purposes; Professionalism (the right and profound training and education) of a staff member; Decent working conditions in the organization (such as manageable workload, safety, a decent supportive organizational framework).

Although there is some discussion about the effect sizes2 of these general elements (e.g. Lambert, 1992; Barley, 2001), they clearly underline the importance of investing in both these general effective elements as in specific effective methods. According to van Yperen et al (2010), especially

2

According to Lambert (1992) and Lambert & Barley (2001) these general aspects would account for 30% of total results, while specific effective aspects account for 15%, 40% for client- and setting-related aspects and 15% can be attributed to placebo-effects. However, van Yperen et al (2010) think these numbers are partially outdated and find divergent results in other studies.

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Measuring is Key to Improvement – Interventions that Work in Dealing with Youth Aggression 2015-2-HU02-KA205-000984 the relationship (or therapeutic alliance) between a client and welfare worker is the most import in this context.

1.2.2 Trajectories in child and youth welfare and disruptions in care Disruptions in care trajectories can occur due to practical reasons external to the type of treatment or care (e.g. a facility has to close down, a child and his family move to another place, ‌) or they can be directly related to elements in the care-relationship of a youngster. In the latter case, various authors (e.g. James, Landsverk & Slymen, 2004; Strijker, Knorth & Knot-Dickscheit, 2008) point out the influence of unmanageable behavioral or emotional problems such as externalizing issues as aggression on the occurrence of disruptions in care or on the instability of child- and youth welfare trajectories. However, placement instability, disruptions in care and early entry or long-term trajectories in child- and youth welfare in their turn have also been found to negatively affect physical and behavioral wellbeing, increased behavioral or emotional problems and attachment stability (Aarons et al., 2010; Newton, Litrownik & Landsverk, 2000; Rubin, O’Reilly, Luan & Localio, 2007; Takayama, Wolfe & Coulter, 1998; Villodas, Litrownik, Newton & Davis, 2015).

A disruption because of the problem behavior of a youngster can than take place within the same organization (this can be a placement in another facility or division within the same organization, or a change in personnel due to unmanageable problem behavior) or between different organizations. A care-relation or welfare service program can be terminated according to the case plan but also unplanned. In this case, the termination of the placement or treatment/counseling or disruption in care is not part of the care program, but due to unforeseen reasons, provided care has to be stopped or the child has to be referred to another organization.

Although different authors have already investigated the factors influencing disruptions in care, there is still room to further look into the influences caused by different types of aggressive behavior and to look for methods that allow a better handling or prevention of disruptions in care in order to improve the treatment and care for youngsters and prevent them from experiencing negative outcomes related to disruptions in care and instable trajectories in child- and youth welfare (e.g.

Leathers, 2006; Opdenacker, 2012).

2. Methodology 2.1 Research questions This project aims to clarify methods in youth care organizations with a special focus on preventing and managing aggressive behavior and identify those methods that are perceived as effective by professionals. Based on the partner organizations' existing practices we aim to synthesize experiences in managing and preventing aggression. We are currently not aware of universal methods nor system of interventions to deal with aggressive, troubled and troubling behavior. In an innovative way the project will attempt to distil those elements of the methodology that seem to have an impact regardless of the context it is being implemented.

Opdenacker (2012) already did a thorough screening of methods youth welfare services used when dealing with aggressive behavior in Flanders. This project is complementary because it will research which methods are used in other European countries. It is innovative because we would like to explore the link between youngster aggression and the trajectories these youngsters follow in youth care and whether or not there is a link with disruptions in care. This is leaving the care system too soon and by doing so diminishing youth chances for a good integration in society. In addition, we also

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Measuring is Key to Improvement – Interventions that Work in Dealing with Youth Aggression 2015-2-HU02-KA205-000984 want to evaluate the usability and perceived effectiveness of the used methods by professionals as well as by youth themselves. This will help organizations to choose the right methods so youngsters will have a better chance to become successful members of society.

Specifically, we aim to answer following four research questions: 1. What are the most commonly used methods in preventing or managing aggressive behavior in child and youth welfare?

2. How do professionals and youth evaluate the effectiveness of the most commonly used methods in preventing or managing aggressive behavior in child and youth welfare?

3. How does aggressive behavior influence the trajectories of youth in child and youth welfare?

4. Which methods for the prevention or management of aggressive behavior are helpful in preventing disruptions in care in child and youth welfare?

2.2 Research Design To provide an answer to the four main research questions in this project, we will carry out 3 main data-collection activities: 1. Nationwide survey to map the most common methods used for the management and prevention of aggressive behavior in youth welfare and disruptions in care and to evaluate their (perceived) effectiveness. Supplemented by a literature review. (Research questions 1, 2 and 4).

2. A survey for welfare workers in youth welfare services on trajectories of youth and their aggressive behavior. (Research question 3) 3. A survey for youth receiving care in youth welfare services to collect their experiences and opinions on helpful methods in preventing and managing aggressive behavior and disruptions in care in youth welfare services. (Research questions 1, 2 and 4).

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Measuring is Key to Improvement – Interventions that Work in Dealing with Youth Aggression 2015-2-HU02-KA205-000984

Data-collection I

Data-collection II

(Nationwide Survey of organizations in youth welfare & Literature Review)

(Survey on aggression incidents in youth welfare by welfare workers)

•Research questions: 1, 2 and 4

•Research question: 3

Data-collection III (Survey with youth in youth welfare services)

•Research questions: 1, 2 and 4

Figure 1. Overview of different data-collection activities.

2.3 Data-collection I: Survey for organizations on the most common and effective methods for aggression management and preventing disruptions in care 2.3.1 Population and sampling Population The questionnaire in the first survey is based on the questionnaire of Opdenacker (2012) where she already collected data for this questionnaire in Belgium. The modified questionnaire has then been sent out by project partners to youth care organizations in mental health, social, alternative and judicial or juvenile justice services clusters in Hungary and in the Netherlands. The classification of the organizational structure for youth care organizations in the survey is adapted using the care system typology of Stroul & Friedman (1986) as shown in figure 1 and table 2.

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Measuring is Key to Improvement – Interventions that Work in Dealing with Youth Aggression 2015-2-HU02-KA205-000984

Figure 2. Typology of the child and youth welfare system (Stroul & Friedman, 1986, p. 16)

Table 2. Typology of the child and youth welfare system (Stroul & Friedman, 1986, p. 17)

The original youth care system typology of Stroul & Friedman (1986) with seven organizational clusters is supplemented with an additional eight cluster including judicial services which includes the subtype ‘youth detention center or closed juvenile center’ and a ninth cluster including an ‘other or alternative child- or youth welfare service’ category. In addition, an open-ended category for each response category was added next to the pre-defined list. Furthermore, a selection in these subtypes has been made based on the situation in each partners’ participating country as to improve comparability.

In the Netherlands however, due to the latest policy changes, the child and youth care structure is organized quite different from Hungary. Previously, as is still the case in Hungary, care was organized by smaller organizations, carrying out a smaller amount of different service activities, whereas now due to reforms, the landscape has shifted towards a smaller amount of bigger organizations comprised of numerous fusions of different (sub-)departments each carrying out different services and activities, in so called ‘multifunctial organizations’. Therefore, data will also be collected for these smaller (sub-)departments by a professional if they indicate they have their own specific set of activities, operational framework and apply their own particular set of methods.

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Measuring is Key to Improvement – Interventions that Work in Dealing with Youth Aggression 2015-2-HU02-KA205-000984 Summing up, youth care organizations and departments in the following (sub-)categories will be included in this research project: A. Mental Health - Non-residential or semi-residential services o Assessment (diagnostic and evaluation services) o Home Aid Services (services who work on an outreach basis with children and families in their homes and offer an array of therapeutic aid) o Day Treatment (this is a service that provides an integrated set of educational, counseling and family interventions where youngsters stay for at least five hours a day and frequently involve collaboration between mental health and education agencies). o Emergency Services (services that focus specifically on crisis prevention, identification and management for children and their families) o Another organization in the non-residential or semi-residential mental health services category -

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(Semi-)Residential Services o Therapeutic/Treatment Foster Care (specialized foster care services in which trained foster parents are semi-professionals providing care in smaller foster Family homes.

For example, ‘Gezinshuis’ (the Netherlands) / SOS children villages, …) o Therapeutic Group Care (therapeutic group care is provided in organizations which serve a number of youngsters in semi-small groups in a therapeutic environment, and provide an array of therapeutic care) o Therapeutic Family Care (therapeutic environment and service where youngsters and their families stay and that provide an array of therapeutic care) o Therapeutic Camp Services (in therapeutic camp services, youngsters and staff live together in a wilderness situation. This can be can be considered as a special category of therapeutic group care) o Independent Living Services (specific services to help adolescents make the transition to independent living. They typically involve therapy, preparation to live more independently and preparation for paid employment)

Measuring is Key to Improvement – Interventions that Work in Dealing with Youth Aggression 2015-2-HU02-KA205-000984 o

o

o

Residential Treatment Services (residential treatment centers are a somewhat heterogeneous group of mental health facilities which have one characteristic in common: the provision of round-the-clock treatment and care to minors who are diagnosed as having an emotional or mental disorder, but they are less medically oriented than psychiatric hospitals/inpatient hospitalization and more restrictive and normally bigger than therapeutic group care centers) Crisis Residential Services (crisis services are non-hospital, residential services which provide the level of support and intervention needed to resolve the crisis for families and children) Another organization in the (semi-)residential mental health services category

B. Social Services o Foster Care Services (including ’regular’ foster families, or foster homes and supporting services) o Another organization in the social services category C. Judicial/Juvenile Correctional Services o Youth Detention Centers / Closed Juvenile Centers (a type of detention center or prison for minors under the age of 18, often termed juvenile delinquents) o Another organization in the judicial/juvenile correctional services category D. Alternative child- or youth welfare Services o Another/alternative service (e.g. a care farm, …)

The survey is filled out by a coordinator, team leader, manager or care worker who is (most) up to date about the programs and practices used for aggression management or prevention in his or her organization or department(s).

Sample Because of practical considerations (time and budget restraints) and due to improving comparability between samples and countries, data has been collected from a selection of organizations in the mental health, social services, judicial services and alternative services categories. To create the sampling frame, a screening of popular search engines and websites of government services and umbrella organizations has been carried out.

In the Netherlands, out of a total of 70 organizations that were included in the sample, 21 responded (N = 21) resulting in a response rate of 30%. Of the 21 responding staff members, 19% were male and 81% female. The mean years of experience of respondents in their organization was 9,12 (range 0 – 35 years, SD = 8,57) and 15,55 in their field of work (range 3,5 – 38,5 years, SD = 9,87). Most respondents’ highest educational level corresponds to that of ISCED3 level 7 ‘Master’s or equivalent level’ (47,6%) or ISCED level 6 ‘Bachelors’ or equivalent level’ (23,8%). The remaining respondents attained an ISCED level of 5 ‘Short-cycle tertiary education’ (19,0%) or 3 ‘Upper secondary education’ 3

International Standard Classification of Education (ISCED), UNESCO (2012).

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Measuring is Key to Improvement – Interventions that Work in Dealing with Youth Aggression 2015-2-HU02-KA205-000984 (9,5%). 33,3% of respondents had a managing position in their organization (such as director, executive, or head of a department, …) 38,1% a middle-management or medium-range coordinating position (such as team-leader, psychologist leading a team, head of a sub-department, …) and 28,6% an (executive) staff position (e.g. child welfare worker, caseworker, …). In total, 12 respondents (57,1%) filled out the questionnaire for the whole of their organization, 9 (42,9%) respondents for one (23,8% n = 5), two (9,5% n = 2) or three (9,5% n = 2) of their organization’s departments.

In Hungary, out of a total of 104 organizations 30 responded (N = 30), resulting in a response rate of 28,85%. Of the 30 responding staff members, 23,3% were male and 66,7% female (10% missing). The mean years of experience of respondents in their organization was 13,69 (range 1 – 37 years, SD = 9,39) and 17,97 in their field of work (range 1 – 42 years, SD = 9,70). Most respondents’ highest educational level corresponds to that of ISCED4 level 7 ‘Master’s or equivalent level’ (53,3%) or ISCED level 6 ‘Bachelors’ or equivalent level’ (43,3%). 50% of respondents had a managing position in their organization (such as director, executive, or head of a department, …) 30% a middle-management or medium-range coordinating position (such as team-leader, psychologist leading a team, head of a sub-department, …) and 16,7% an (executive) staff position (e.g. child welfare worker, caseworker, …). In total, 21 respondents (70,0%) filled out the questionnaire for the whole of their organization and 9 (30%) respondents for one (16,7% n = 5), four (6,7% n = 2), five (3,3% n = 1) of six (3,3%, n = 1) their organization’s departments.

Of 21 respondents in the Netherlands and 30 respondents in Hungary, following child or youth care services were offered by (departments of) their organization: A.1.

Mental Frequency (N = Health: Non- 21) residential or the Netherlands semi-residential services

Percentage the Netherlands

Frequency (N = 30) Hungary

Percentage Hungary

1) Assessment

33,3

0

0

2) Home Aid 10 Services 3) Day Treatment 11

47,6

0

0

52,4

1

3,3

4) Emergency 9 Services 5) Another type 7 in A.1. (such as counseling for educational, vocational or daytime activities) Total A.1 44

42,9

0

0

33,3

1

3,3

/

2

/

7

Table 3. Overview of collected responses in the first survey for the Mental Health (non-residential or semiresidential) services category in both countries 4

International Standard Classification of Education (ISCED), UNESCO (2012).

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Measuring is Key to Improvement – Interventions that Work in Dealing with Youth Aggression 2015-2-HU02-KA205-000984 A.2. Mental Health: Frequency (N = Semi-residential 21) services or residential the Netherlands services

Percentage the Netherlands

Frequency (N = 30) Hungary

Percentage Hungary

6) Therapeutic/Treatment Foster Care

7

66,7

0

0

9

42,9

1

3,3

4

19,0

0

0

3

14,3

0

0

10

47,6

1

3,3

7

33,3

1

3,3

9

42,9

0

0

3

14,3

3

10,0

52

/

6

/

7) Therapeutic Group Care 8) Therapeutic Family Care 9) Therapeutic Camp Services 10) Independent Living Services 11) Residential Treatment Services 12) Crisis Residential Services 13) Another type in A.2. (not specified) Total

Table 4. Overview of collected responses in the first survey for the Mental Health (semi-residential or residential) services category in both countries

B. Social Services

Frequency (N = 21) the Netherlands

Percentage the Netherlands

Frequency (N = 30) Hungary

Percentage Hungary

14) Foster Care Services 15) Protective services 16) Another type in B. Total

2

9,5

9

30,0

5

23,8

12

40,0

0

0,0

5

16,7

7

/

26

/

Table 5. Overview of collected responses in the first survey for the Social Services category in both countries

17

Measuring is Key to Improvement – Interventions that Work in Dealing with Youth Aggression 2015-2-HU02-KA205-000984 C. Judicial/Juvenile Correctional Services

Frequency (N = 21) the Netherlands

17) Youth Detention 1 Centers / Closed Juvenile Centers 18) Another type in C. 2 such as another juvenile restrictive closed setting, however noncorrectional Total 3

Percentage the Netherlands

Frequency (N = 30) Hungary

Percentage Hungary

4,8

3

10,0

9,5

1

3,3

/

4

/

Table 6. Overview of collected responses in the first survey for the Judicial/Juvenile Correctional services category in both countries

D. Alternative child- or Frequency (N = youth welfare Services 21) the Netherlands

Percentage the Netherlands

Frequency (N = 30) Hungary

Percentage Hungary

Another/alternative 5 service (e.g. a care farm, or another service not included in the list above …)

Total 5

23,8

1

3,3

/

1

/

Table 7. Overview of collected responses in the first survey for the Alternative services category in both countries

The mean number of different services offered by the 21 participating organizations (departments) in the Netherlands was 5,33 (range 1 – 13, median 4, SD = 4,36), with 33,3% (n = 7) of them offering only 1 type of services, 23,8% (n = 5) of them offering between 2 to 5 different services, 19,05% (n = 4) between 6 to 10 different services and 23,8% (n = 5) more than 10 different services).

The mean number of different services offered by the 30 participating organizations or departments in Hungary was 1,30 (range 1 – 3, median 1, SD = 0,53), with 73,3% (n = 22) of them offering only 1 type of services, 23,3% (n = 7) of them offering 2 different services and only 1 of them (3,3%) offering 3 different types of services.

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Measuring is Key to Improvement – Interventions that Work in Dealing with Youth Aggression 2015-2-HU02-KA205-000984

2.3.2 Content of the questionnaire The first questionnaire has been based on the research of Opdenacker (2012) and a literature review (e.g. Swinnen, 2009; Leers, 2011; Oudhof & van der Steege, 2007; FCB, 2010). In order to answer research question 1, organizations are asked to answer questions on which aggression management or prevention programs they use. They can also add a program they use in their organization but is not included in a pre-defined list of programs (of national- and international commonly used, established and/or accredited programs). Next to that, following concepts are included in the first questionnaire:     

19

Organizational characteristics (type of services) Respondent characteristics (position in organization, gender, years of experience) Applied aggression management and prevention programs Helpful practices, techniques, attitudes, principles and organizational policies in managing and/or preventing aggressive behavior Number of disruptions in care, reasons and ways to prevent or manage disruptions in care

Measuring is Key to Improvement – Interventions that Work in Dealing with Youth Aggression 2015-2-HU02-KA205-000984 In a pre-defined list of (intervention) programs (of national- and international commonly used, established and/or accredited programs), following programs were included: Programs for the prevention The Netherlands or management of aggressive behavior in child- or youth welfare Aggression Replacement x Training (ART) Anger Coping Program / x Coping Power Program (Lochman) Defiant children: a clinician’s x manual for assessment and parent training Families First Program x Functional Family Therapy x (FFT) Life Space Crisis Intervention x (LSCI) Multidimensional Treatment x Foster Care (MTFC) (previously Treatment Foster Care Oregon (TFCO)) Multisystemic therapy (MST) x Non Violent Resistance (NVR) x Parenting with Love and Limits x (PLL) Parent Management Training x Oregon (PMTO) Parent-Child Interaction x Therapy (PCIT) Peacemaking Circles x Positive Peer Culture (PPC) x Problem Solving Skills Training x (PSST) Promoting Alternative Thinking x Strategies (PATHS) The Incredible Years (IY) x Triple P - Positive Parenting x Program Tuning in to Kids (TIK) x

Hungary

x x

x

x x x x

x x x x x x x x x x x x

Table 8. Overview of the evidence-based programs for the prevention and management of aggressive behavior included in the first survey in both countries

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Measuring is Key to Improvement – Interventions that Work in Dealing with Youth Aggression 2015-2-HU02-KA205-000984

Programs for the prevention The Netherlands or management of aggressive behavior in child- or youth welfare Agressie Regulatie Training op x Maat Drie-gesprekkenmodel EQUIP x Herstelgericht groepsoverleg x (Hergo) Intervisiemethoden Incidenten x Leren van Delict x Minder Boos en Opstandig x Multidimensionele x familietherapie (MDFT) Relationele Gezinstherapie x Rots en Water x Sociale Vaardigheidstraining x op Maat STOP 4-7 x Teamgericht Zorgoverleg x Agressie en Schokkende gebeurtenissen (TZAS) Training Agressie Controle x (TACt) Video-feedback Intervention to x Promote Positive Parenting and Sensitive Discipline Video-hometraining (VHT) x

Hungary

Table 9. Overview of the evidence-based programs for the prevention and management of aggressive behavior included in the first survey in the Netherlands

2.3.3 Data-collection All youth care organizations included received an invitation to fill out the questionnaire online. We made use of the online survey software ‘Research Suite’ by ‘Qualtrics’ (Qualtrics, Provo, UT, http://www.qualtrics.com). In the invitation information on the goal and outline of the project and the questionnaire is provided. If the questionnaire hasn’t been filled out by an organization, a reminder was sent biweekly by e-mail. Data has been collected from July 2017 until the end of January 2018.

2.3.4 Data-analysis Standardized questions in the questionnaire are analyzed using descriptive statistics with the statistical software package IBM SPSS 22.0, whilst open-ended questions in the analysis will be

21

Measuring is Key to Improvement – Interventions that Work in Dealing with Youth Aggression 2015-2-HU02-KA205-000984 subjected to qualitative analysis. The open-ended questions will first be openly coded, then axially coded and finally selectively coded (Denzin & Lincoln, 2011).

In order to provide an answer to the second research question “How effective are the most common methods for aggression management?”, a framework for evaluating the effectiveness of methods will be used. As a result of these approaches the most common used methods will be indexed based on the existing evaluation framework we use in the literature review scheme, supplemented with the results of open and closed questions in the questionnaire. A screening of the scientific literature of different scientific search engines (e.g. Google Scholar, Librisource, Web of Science) resulted in a first overview of the most common used good- and evidence based practices and aggression management methods.

Evaluation Framework: Effect Ladder The scheme addressed here will build upon the previous research of Opdenacker (2012) and will make use of the effectiveness frame of van Yperen & Veerman (2008). van Yperen & Veerman (2008) have developed a framework (which they call the ‘effect ladder’) in which different methods of intervention are to be divided in different levels of their proven effectiveness. They also propose to relate the concept of ‘effectiveness’ to the stage of development in which a method situates itself.

Following levels of effectiveness are distinguished their evaluation framework: Level 0: operational with implicit knowledge Step or level 0 on the effect ladder refers to methods of intervention which exist only in the minds of the practitioners itself. Therefore, the goals, features, procedure or mechanisms of deployment may not appear to be clear for others and are not (thoroughly) documented. Although methods on this level could possibly be effective, the reasons why and how these methods are effective remain unclear for others. This also hinders the transferability between different practitioners in different organizations as there is no provided standardized consensus on the intervention or prevention method on which they can make an appeal to.

Level 1: well documented interventions On level 1 of the effect ladder, the range of features and characteristics of methods of intervention are well documented and specified. Attention especially goes out to the goal of the intervention, the target audience, the procedure or approach and the performance conditions. By means of the written documentation and explication, the method itself is comprehendible, the chance of its effectiveness can in some way be evaluated and the approach can be examined and performed by other care workers (or others).

Level 2: interventions with theoretical explanatory power that are promising On this level, not only the features of a method of intervention are well documented, but also its ‘program theory’. In this case the method of intervention or theory behind it can fall back on some evidence that the method can work or is possibly effective in its design. The more the theory behind the method is generally accepted or the more the method can be linked to by research supported theories the firmer its place on level 2 of the effect ladder.

Level 3: interventions with provisional explanatory power A good description (level 1) or theoretical foundation (level 2) show why and how a method of intervention can be effective. However, if it can be proven that the goals of a method are reached 22

Measuring is Key to Improvement – Interventions that Work in Dealing with Youth Aggression 2015-2-HU02-KA205-000984 while the application followed a well-defined procedure and the intervention has been aimed at the target audience, then its explanatory power also improves. To examine this, there has to be some proven scientific evidence. This is the core of level 3 of the effect ladder as there are numbers available which show: that the target audience has been reached, that the goals of the intervention have been realized, that a minimal amount of clients opted or dropped out throughout the application or shortly after and that the well-being of the clients has been provided for. These data provide the first indication of effectiveness of a method of intervention. However, although if it has been shown that through application of a certain method of intervention, in a maximum number of cases, the expected goals have been reached, it still remains uncertain that this is not related to other effects (e.g. situational or organizational features, competencies of personnel, spontaneous recovery).

Level 4: interventions with causal explanatory power that are proven to be effective Methods of intervention which have sufficient proven causal explanatory power are proven to be effective: the measured results are to be addressed at the used method of intervention. Level 4 is the highest level on the effect ladder, which also means that methods of intervention on this level score well on all other levels of the effect ladder. On this level the intervention method is: well documented / defined, theoretically grounded and scientifically proven to be operatively effective, and moreover it has been shown that the method of intervention is better than ‘no intervention method’ or ‘another intervention method’. In this case, a comparison with a control group that didn’t receive the intervention and a control group that did receive another intervention is necessary.

The different levels and their description are summarized in the table below.

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Measuring is Key to Improvement – Interventions that Work in Dealing with Youth Aggression 2015-2-HU02-KA205-000984

Effect ladder of van Yperen en Veerman (2008) Level on the effect ladder Research type 4.

Is the intervention  Experimentally designed research effective? (As in 1 to 3 (RCT) but now there is clear  Quasi-experimental research evidence that positive  Case-studies (N= 1 studies) outcomes are caused by  Norm-related research (‘Benchmark the intervention and/or studies’) clear evidence showing which elements of the intervention are inducing outcomes) 3.

Is the intervention  Norm-related research without operative and benchmarks functional? (As in 1 and  Goal-attainment research 2, but it has now been  Client satisfaction research demonstrated that goals have been reached, problems have decreased, clients are satisfied and competences have increased).

2.

Is the intervention  Meta-analyses effective in theory? (As  Literature review in 1, but the  Studies on implicit knowledge intervention now has a plausible rationale or program theory to explain why it should work with whom).

1.

Is the intervention well  Descriptive research documented? This  Observational research means that the essential  Document analysis elements of the  Conduct of interviews intervention (e.g. goals, target group, methods and activities, requirements) have been made explicit.

0.

Is the intervention implicit (black box)?

Explanatory power Efficacious (Causal inference) -------------------------------Based on: Quality of research Follow-up Performed in practice Number of studies

Functional (indicative)

Plausible (theoretical)

Potential (descriptive)

Table 10. Effect ladder effectiveness evaluation framework of van Yperen en Veerman (2008) (own adjustments)

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Measuring is Key to Improvement – Interventions that Work in Dealing with Youth Aggression 2015-2-HU02-KA205-000984

2.4 Data-collection II: Survey on aggression incidents and trajectories of youth in child- and youth welfare services To answer the third research question: “What effects has aggression on a future trajectory in child and youth welfare?”, we will make use of a second survey which is to be filled out by welfare workers based on file data and observations.

2.4.1 Population and sampling Population The population for this survey has been delineated to mental health services, judicial services and alternative services in the youth welfare services categories. The target group in this survey will be youth aged 12 – 21 years old receiving care in the categories of youth welfare services above.

Welfare workers will fill out the questionnaire retrospectively based on file data, supplemented by their observations.

Sample Because of practical considerations, sampling will be based on purposive selection criteria. More precisely, we will make use of a theoretical sampling of different organizations or cases (with variation in the youth welfare service type) and a random sampling of units within the cases.

Organizations involved will be addressed according to these criteria. More specifically, organizations in the alternative services category, judicial services category and (semi-) residential mental health categories will be included. In the mental health category, the subcategories ‘Therapeutic/Treatment Foster Care’ and ‘Therapeutic Group Care’ are included. These categories have been selected based on the level of restrictiveness and problem severity and on their place in the youth welfare landscape. Originally, ‘Therapeutic Group Care’ is the regular form of (semi-)residential youth care in different countries, whereas ‘Therapeutic/Treatment Foster Care’ is its closest alternative.

Organizations in the judicial/juvenile youth welfare category on the contrary are organizations which are the most restrictive and they provide care for youth with more severe problems that have been into contact with law enforcement because of criminal offences. In addition, organizations in the alternative youth welfare category often provide care for youth with a broad scope of emotional and behavioral issues, for youth who otherwise fall out of the system of care, or organizations which try to involve new orthopedagogical and social work methods and/or are not (yet) officially subsidized by the state’s legal body of welfare service providers.

Exclusion criteria are applied to children or youth that were in care less than 30 days at the moment of registration, as the second questionnaire is developed in a retrospective way, or for whom case file data are missing.

In the Netherlands, data has been collected by staff members for a total of 21 youngsters (N = 21). Of these 21 respondents, 14 were male (66,7%) and 7 were female (33,3%). The mean age in years of these youngsters was 16,48 (range 12 - 24, SD = 3,89). The mean period of being in care at the current organization in months was 10,21 (range 1 – 33, SD = 8,90). A total of 10 staff members collected the data, 8 of them had an executive function and 2 of them had a middle-management

25

Measuring is Key to Improvement – Interventions that Work in Dealing with Youth Aggression 2015-2-HU02-KA205-000984 function. The mean years of experience of staff in their organizations was 6,25 (range 0,5 – 16,5, SD = 5,26), and 11,15 in their field of work (range 1 – 23, SD = 7,23).

In Hungary, data has been collected by staff members for a total of 41 youngsters (N = 41). Of these 41 respondents, 11 were male (26,8%) and 27 were female (65,9%) (missing = 3, 7,3%). The mean age in years of respondents was 17 (range 12 - 21, SD = 1,82). The mean period of being in care at the current organization in months was 23,88 (range 1 – 100, SD = 26,48). A total of 17 staff members collected the data, 11 had an executive function and 6 had a middle-management function.

The mean years of experience of staff in their organizations was 7,75 (range 1 – 20, SD = 4,88), and 11,56 in their field of work (range 3 – 21, SD = 4,97).

Data from these youngsters in the Netherlands and Hungary for the second survey have been collected in following organizational service types: Organizational services included in the sample Alternative care Juvenile Justice Mental Health Residential care: Therapeutic Group Care Mental Health: Therapeutic Treatment Foster Care Mental Health: Crisis Care Missing Total

The Netherlands: Number of respondents 3 6 7

The Netherlands: Percentage of respondents 14,3 28,6 33,3

Hungary: Number of respondents 8 16 8

Hungary: Percentage of respondents 19,5 39,0 19,5

1

4,8

0

0

4

12,5

7

17,1

/ 21

/ 100

2 41

4,9 100

Table 11. Overview of collected responses for the second survey in different welfare services in both countries

2.4.2 Content of the questionnaire To register aggressive behavior of youth in the second questionnaire, we did a screening of the available scientific instruments and assessment tools commonly used in academic research.

However, we found that most instruments only partly overlap with the definition of aggression applied in this research (see supra). Therefore, we edited, extended and supplemented the instrument developed by Rotenberg (1985) to be able to measure a broader array of components of the concept of aggression. Furthermore, and next to file data, observations of professionals will be collected instead of using a self-registration instrument for youth to provide more external validity and to prevent for socially desirable responses (van Loon, van der Meulen & Minnaert, 2015).

26

Measuring is Key to Improvement – Interventions that Work in Dealing with Youth Aggression 2015-2-HU02-KA205-000984 Following concepts are included in the second questionnaire:         

Sociodemographic characteristics of the child and his/her biological or caregivers (age, sex, country of birth, educational level parents).

History with alcohol and/or drug (ab)use Aggressive behavior (physical, verbal, relational, sexual and auto-aggression, aggression overall and irritability or hostility) during the last 2 months and overall in general up until now.

Number of encounters with child- or youth welfare organizations Duration of care provided in each child-or youth welfare organization Changes in personal welfare workers or caregivers within an organization for each child Reported or known incidents referring to aggressive behavior (towards other clients and/or staff members) Disruptions in care and reasons for disruptions in care Victimization and exposure to aggression/violence in a domestic home environment or in a welfare/care setting

2.4.3 Data-collection Before the co-operation was obtained from organizations, participants were personally contacted and informed about the research outline. Organizations were also asked to provide information about the total number of youngsters they provide care for.

The second questionnaire has been developed to retrospectively investigate the trajectories children in child and youth welfare followed based on file data, supplemented by observations of staff members. The second questionnaire will be filled out by professionals, or care workers for all children (between the ages of 12 – 21 years old) they provide care for, and for who informed consents have been obtained.

All youth care organizations included received an invitation to fill out the questionnaire online. We made use of the online survey software ‘Research Suite’ by ‘Qualtrics’ (Qualtrics, Provo, UT, http://www.qualtrics.com). In the invitation, information on the goal and outline of the project and questionnaire was provided. If the questionnaire is not filled out by an organization, a reminder will be sent by e-mail. Data has been collected from July 2017 until the end of January 2018.

2.4.4 Data-analysis To measure the effects of the intensity or frequency of aggression on the trajectories of youngsters in child and youth welfare, we will make use the of the statistical software package IBM SPSS 22.0. At first, descriptive results would have been complemented by a series of multiple regression analyses in order to provide an answer to the third research question. However due to a smaller response, multiple regression analyses could not be executed. Therefore, a series of bivariate correlations and non-parametric tests have been executed to investigate relations between different variables instead.

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Measuring is Key to Improvement – Interventions that Work in Dealing with Youth Aggression 2015-2-HU02-KA205-000984

2.5 Data-collection III: Survey on youth’s experiences and opinions on helpful methods in preventing and managing aggressive behavior and disruptions in care in youth welfare services 2.5.1 Population and sampling Population The population for the third survey has (parallel to the second survey) been delineated to mental health services, judicial services and alternative services in the youth welfare services. Participants in the survey will be youth aged 12 – 21 years old who receive care in youth welfare service categories as described above.

Sample The sampling procedures and included organizations for the third survey are the same as those for the second survey. Exclusion criteria are applied to children or youth that were in care less than 30 days at the moment of data-collection or in a crisis-situation, the inability to participate in the applied mode of data-collection or a severe mental disability.

In the Netherlands, a total of 40 youngsters responded (N = 40). Of these 40 respondents, 52,5% were male and 47,5% female. The mean age of respondents was 15,25 (range 12 - 23, SD = 2,85). The mean period of being in care at the current organization in months was 28,70 (range 2 – 84, SD = 28,01). The mean for the longest period of care that youngster subsequently received from the same organization in months was 42,31 (range 2 – 120, SD = 34,35). The mean age in years at first contact with a child- or youth welfare organization was 10,58 (range 2 – 21, median = 10, SD = 4,28). The mean total number of encounters with different child- or youth welfare organizations was 3,71 (range 1 – 12, median 3,0, SD = 2,42).

In Hungary, a total of 100 youngsters responded (N = 100). Of these 100 respondents, 59,0% were male and 41,0% female. The mean age of respondents was 16,08 in years (range 12 - 23, SD = 2,196).

The mean period of being in care at the current organization in months was 34,26 (range 0 – 180, SD = 39,50). The mean for the longest period of care that youngster subsequently received from the same organization in months was 47,08 (range 3 – 177, SD = 41,03). The mean age in years at first contact with a child- or youth welfare organization was 10,37 (range 0 – 17, median = 10,75, SD = 4,80). The mean total number of encounters with different child- or youth welfare organizations was 2,75 (range 1 - 11, median 2,0, SD = 1,88).

28

Measuring is Key to Improvement – Interventions that Work in Dealing with Youth Aggression 2015-2-HU02-KA205-000984 Data from these youngsters in the Netherlands and Hungary has been collected in following organizational services: Organizational services included in the sample Alternative care Juvenile Justice Mental Health Residential Care: Therapeutic Group Care Mental Health Therapeutic Treatment Foster Care Mental Health Crisis Care Missing Total

the Netherlands: Number of respondents 11 5 12

the Netherlands: Percentage of respondents 27,5 12,5 30,0

Hungary: Number of respondents 11 41 14

Hungary: Percentage of respondents 11,0 41,0 14,0

6

15,0

23

23,0

5

12,5

9

9,0

1 40

2,5 100

2 100

2,0 100

Table 12. Overview of collected responses for the third survey in different welfare services in both countries.

2.5.2 Content of the questionnaire The content of the third questionnaire has been based on the two previous questionnaires.

Questions have been adjusted and simplified in order to keep the questionnaire as age-adequate as possible.

Following concepts are included in the third questionnaire:      

Sociodemographic characteristics (age, sex) Number of encounters with child or- youth welfare organizations Duration of care provided in each child-or youth welfare organization Helpful elements in organizations and in ways welfare workers behave (when feeling angry, being aggressive, or when being the victim of aggression), specifically in relation to the prevention and management of aggressive behavior Disruptions in care and reasons for disruptions in care Encounters and experiences with aggression management/prevention programs

2.5.3 Data-collection Before questionnaires for youth were distributed, active informed consent forms (translated to native languages) were obtained from parents or legal guardians of youth, who they are sent out to by the cooperation between the participating organizations and project partners. Parents and legal guardians will have the opportunity to respond or ask questions, after which all children whose parents have given consent will be asked to participate. Also, active consent forms will always and 29

Measuring is Key to Improvement – Interventions that Work in Dealing with Youth Aggression 2015-2-HU02-KA205-000984 also be collected from youth themselves and from a welfare worker or staff member in their youth welfare institution who will also assess the possibilities of clients to participate in this research. The informed consent and data-collection procedures have all been approved by the societal ethics committee of the university of KU Leuven.

After the collection of informed consents, a trained interviewer will interview participants by applying a paper-and-pencil or computer-assisted personal interview in Hungary of the questionnaire. The collected responses were then processed in the online tool for data-collection. In the Netherlands however, the project partners did not have the capacity to make use of trained interviewers, nor is the budget available to do so in this project. Therefore, the standard mode of data-collection for the third questionnaire in the Netherlands was an a paper-and-pencil or computer-assisted self-interviewing or self-administered questionnaires. The questionnaires are filled out by youth individually in a quiet place in the organization providing care in proximity of a care worker and research partner which they could ask questions if anything was unclear.

Furthermore, immediately after the questionnaire has been filled out by the children, or the interviews have been conducted, a debriefing is held by project partners and welfare workers who will remind the children how their answers will be processed (anonymously). Also the children will have the possibility to talk to a welfare worker or project partner in private as to dissolve any discomfort which they might have due to completing the questionnaire. The project partners will also be available afterwards and throughout the whole project to address any further questions or concerns.

Data has been collected from July 2017 until the end of January 2018.

2.5.4 Data-analysis Standardized questions in the questionnaire are analyzed using descriptive statistics with the statistical software package IBM SPSS 22.0, whilst open-ended questions in the analysis will be subjected to qualitative analysis. The open-ended questions will first be openly coded, then axially coded and finally selectively coded (Denzin & Lincoln, 2011).

3. Results 3.1 Research question 1: What are the most commonly used methods in preventing or managing aggressive behavior in child and youth welfare services?

Evidence-based (intervention-)programs used in preventing and managing aggressive behavior In the first questionnaire, experts of youth care organizations or departments were asked which (intervention-)programs for the management or prevention of aggressive behavior in youth were used.

30

Measuring is Key to Improvement – Interventions that Work in Dealing with Youth Aggression 2015-2-HU02-KA205-000984 the Netherlands (N = 21) Hungary (N = 20)

The program is used in it’s entirety

Aggression Replacement Training (ART)

3/21 (14,29%)

2/21 (9,52%)

1/20 (5%)

Anger Coping Program / Coping Power Program (Lochman) Defiant children: a clinician’s manual for assessment and parent training Families First Program

1/21 (4,76%)

1/21 (4,76%)

0/20 (0%)

1/20 (5%)

1/21 (4,46%)

1/21 (4,76%)

0/20 (0%)

0/20 (0%)

1/21 (4,76%) 2/21 (9,52%) 4/21 (19,05%) 3/21 (14,29%) 2/21 (9,52%) 1/21 (4,76%) 1/21 (4,76%)

2/21 (9,52%) 2/21 (9,52%) 2/21 (9,52%) 0/21 (0%) 4/21 (19,05%) 1/21 (4,76%) 0/21 (0%)

0/20 (0%) 0/20 (0%) 1/20 (5%) 0/20 (0%) 1/20 (5%) 0/20 (0%) 0/20 (0%)

0/20 (0%) 0/20 (0%) 0/20 (0%) 0/20 (0%) 0/20 (0%) 0/20 (0%) 1/20 (5%)

Parent-Child Interaction Therapy (PCIT)

0/21 (0%)

0/21 (0%)

0/20 (0%)

1/20 (5%)

Peacemaking Circles

0/21 (0%)

0/21 (0%)

0/20 (0%)

1/20 (5%)

Positive Peer Culture (PPC)

0/21 (0%)

0/21 (0%)

1/20 (5%)

1/20 (5%)

0/21 (0%) 2/21 (9,52%) 4/21 (19,05%) 2/21 (9,52%) 3/21 (14,29%)

0/21 (0%) 1/21 (4,76%) 2/21 (9,52%) 0/21 (0%) 1/21 (4,76%)

1/20 (5%)

1/20 (5%)

Functional Family Therapy (FFT) Life Space Crisis Intervention (LSCI) Multisystemic therapy (MST) Non Violent Resistance (NVR) Parent Management Training Oregon (PMTO) Promoting Alternative Thinking Strategies (PATHS)

Problem Solving Skills training (PSST) Triple P - Positive Parenting Program Agressie Regulatie Training op Maat Drie-gesprekkenmodel EQUIP

31

Only some parts or elements of this program are used

The program is used in it’s entirety (count)

Only some parts or elements of this program are used (count) 1/20 (5%)

Measuring is Key to Improvement – Interventions that Work in Dealing with Youth Aggression 2015-2-HU02-KA205-000984 Intervisiemethoden Incidenten Leren van Delict Minder Boos en Opstandig Multidimensionele familietherapie (MDFT) Relationele Gezinstherapie Rots en Water Sociale Vaardigheidstraining op Maat STOP 4-7 Teamgericht Zorgoverleg Agressie en Schokkende gebeurtenissen (TZAS) Training Agressie (TACt Groep)

Controle

Video-feedback Intervention to Promote Positive Parenting and Sensitive Discipline Video-hometraining (VHT) None of the above

2/21 (9,52%) 2/21 (9,52%) 3/21 (14,29%) 1/21 (4,76%)

0/21 (0%) 0/21 (0%) 0/21 (0%) 1/21 (4,76%)

2/21 (9,52%) 3/21 (14,29%) 6/21 (28,57%)

2/21 (9,52%) 4/21 (19,05%) 4/21 (19,05%)

2/21 (9,52%) 0/21 (0%)

0/21 (0%) 1/21 (4,76%)

1/21 (4,76%)

0/21 (0%)

0/21 (0%)

1/21 (4,76%)

3/21 (14,29%) 3/21 (14,29%)

4/21 (19,05%) /

12/20 (60%)

/

Table 13. Overview of evidence-based programs applied by youth welfare services in both countries for the prevention or management of aggressive behavior.

In the table above, only the programs that were used in at least one country are shown, following programs weren’t applied in either one of the countries and are therefore excluded from the results: Multidimensional Treatment Foster Care (MTFC) (previously Treatment Foster Care Oregon (TFCO)), Parenting with Love and Limits (PLL), The Incredible Years (IY), Tuning in to Kids (TIK), Herstelgericht groepsoverleg (Hergo).

Based on these results, in the Netherlands it appears that most of the included programs are in use in different welfare services, implying that most of the respondents are familiar with one or more of these (inter-)nationally accredited evidence-based programs. Out of a total of 21 respondents, 85,7% (n = 18) responded to use at least one of these programs (either partly or completely), while 14,3% of respondents (n = 3) didn’t use any of these programs at all. Of these 18 respondents who apply at least one program, 33,3% of respondents (n = 6) only used parts or elements of these programs

32

Measuring is Key to Improvement – Interventions that Work in Dealing with Youth Aggression 2015-2-HU02-KA205-000984 instead of a program in it’s entirety, 16,7% (n = 3) used one program in its entirety, 38,89% (n = 7) used between 2 to up to 4 programs in their entirety, and 27,78% (n = 5) used 5 or more programs in their entirety within their organization (‘s departments). In addition, of those 18 respondents who apply at least one program, 22,22% (n = 4) used certain parts or elements of one program, 38,89% (n = 7) used certain parts or elements of 2 to up to 4 programs and 1 respondent (n = 5,56%) even mentioned to use certain parts or elements of up to 13 programs resulting in a total of 12 respondents (66,67%) out of 18 that use only certain parts or elements of one program.

In Hungary, the situation is a little bit different from the Netherlands. Out of 30 respondents in Hungary, 40% didn’t use any of the (intervention) programs included in the pre-structured list (n = 12), 33,3% didn’t answer this question (n = 10) and only 26,7% responded to (either partly or completely) use at least one of these programs in their organization (n = 8). Out of the 8 respondents who answered to apply at least one program, 2 respondents (25%) used one of these programs in its entirety and 2 other respondents (25%) used a total of two of these programs in its entirety. Another 3 respondents (37,5%) mentioned to use certain parts or elements of one program while one respondent (12,5%) mentioned to use elements or parts of up to 7 of these programs.

In the Netherlands, the most prevalent applied programs seem to be (based on at least 5 responses referring to using a program either partly or entirely): ‘Sociale Vaardigheidstraining op Maat’ (n = 10), ‘Video-hometraining (VHT)’ (n = 7), ‘Rots en Water’ (n = 7), ‘Agressie Regulatie Training op Maat’ (n = 6), ‘Life Space Crisis Intervention (LSCI)’ (n = 6), ‘Non Violent Resistance (NVR)’ (n = 6) and ‘Aggression Replacement Training (ART)’ (n = 5). In Hungary, only the following programs are being used by respondents: ‘Positive Peer Culture (PPC)’ (n = 2), ‘Problem Solving Skills training (PSST)’ (n = 2), ‘Aggression Replacement Training (ART)’ (n = 2), ‘Life Space Crisis Intervention (LSCI)’ (n = 1), ‘Non Violent Resistance (NVR)’ (n = 1), ‘Promoting Alternative Thinking Strategies (PATHS)’ (n = 1), ‘ParentChild Interaction Therapy (PCIT)’ (n = 1) and ‘Peacemaking Circles’ (n = 1).

Comparing the results between countries it seems that the use of evidence-based, systematically and specifically oriented of (intervention)-programs in the Netherlands in dealing with aggressive behavior in youth is more prevalent than in Hungary. Therefore, there might be still some room for improvement (i.e. research, implementation and exchange of good practices) on this level in Hungary.

The results to this question also show that (in either country) not every program that is used is being applied in its entirety in the sense that only certain elements or aspects of programs are being applied. This implies that organizations pick and apply only some parts or elements of programs, although usually programs ought to be applied in their entirety as implied by their designers in order to attain effectiveness. Reasons given by respondents to only use certain parts or elements of programs are that only some elements of a program are used that are applicable, fit with, or are supplementary to the provided services, not all personnel are fully trained, and programs haven’t been fully implemented in the organization yet.

Other evidence-based programs When respondents were asked if, they used any other aggression management or prevention programs in their organization, 9 out of 21 respondents (42,86%) in the Netherlands and 7 out of 29 respondents (24,14%) in Hungary replied to use another program that hasn’t been included in the list 33

Measuring is Key to Improvement – Interventions that Work in Dealing with Youth Aggression 2015-2-HU02-KA205-000984 of (inter)nationally accredited evidence-based programs above. The other programs that respondents answered to use are included in the table below: The Netherlands 1. ABC-methode 2. PAC. 3. Radar methode 4. In Control!

5. Tops 6. Doen Wat Werkt 7. Dreigend en destructief gedrag (DDG) 8. AVA (angst voor agressie) 9. EMDR Woede, 10. Wraak en Wrok protocol

Hungary 1. Szabadidős tevékenységek, sport, és logikai gondolkodást fejlesztő programok 2. Élménypedagógiai programok 3. AVP tréning (Alternatives to Violence Project) 4. Tematikus kiscsoport 5. Környezeti és egészségnevelési program 6. Erőszekmentes kommunikáció 7. szenvedély függő gyermekek csoportjában pszichodráma

Table 14. Overview of other evidence-based programs applied by youth welfare services in both countries for the prevention or management of aggressive behavior.

Commonly used practices or actions for the prevention or management of aggressive behavior Next to specific programs, there are also some practices (actions or techniques) that are being applied by staff members in child and youth welfare settings in dealing with aggressive behavior.

Youth staying in (semi-)residential care were asked which of these practices they already experienced once. The results are provided in the table below: When you felt or were angry in child- or youth welfare … … they separated or isolated you (1) … they gave you medication “to calm down” (2) … they gave you a time-out5 (3) … they gave you a sanction or 5

Country

Total (N)

I have never experienced this

I have ever experienced this

the Netherlands Hungary Both countries the Netherlands Hungary Both countries the Netherlands Hungary Both countries the Netherlands Hungary

32 91 123 32 90 122 32 89 121 32 89

21 (65,6%) 54 (59,3%) 75 (61,0%) 25 (78,1%) 66 (73,3%) 91 (74,6%) 13 (40,6%) 41 (46,1%) 54 (44,6%) 16 (50,0%) 32 (36,0%)

11 (34,4%) 37 (40,7%) 48 (39,0%) 7 (21,9%) 24 (26,7%) 31 (25,4%) 19 (59,4%) 48 (53,9%) 67 (55,4%) 16 (50,0%) 57 (64,0%)

A time-out means that contact with other youngsters and/or staff members is temporarily paused for a youngster and he/she should stay in a ‘calm’ location for a while until he ‘cools down’.

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Measuring is Key to Improvement – Interventions that Work in Dealing with Youth Aggression 2015-2-HU02-KA205-000984 punishment (4) … they held you down or restrained you (5) ... somebody of the staff talked to you about the situation (6) … they let you talk to the person you were angry with, to help sort things out (7) ... the incident got reported to the police (8) … somebody of the staff was available and accessible for you to talk to or listen to you (9) … somebody of the staff was nearby to intervene (10) … there were clear rules and boundaries regarding what kind of behavior was or wasn’t allowed (11) … there was the possibility to have some time on your own (12)

Both countries the Netherlands Hungary Both countries the Netherlands Hungary Both countries

121 32 89 121 32 88 120

48 (39,7%) 16 (50,0%) 51 (57,3%) 67 (55,4%) 7 (21,9%) * 6 (6,8%) * 13 (10,8%)

73 (60,3%) 16 (50,0%) 38 (42,7%) 54 (44,6%) 25 (78,1%) * 82 (93,2%) * 107 (89,2%)

the Netherlands Hungary Both countries

32 88 120

13 (40,6%) * 19 (21,6%) * 32 (26,7%)

19 (59,4%) * 69 (78,4%) * 88 (73,7%)

the Netherlands Hungary Both countries the Netherlands Hungary Both countries

32 88 120 32 88 120

26 (81,2%) 64 (72,7%) 90 (75,0%) 3 (9,4%) 8 (9,1%) 11 (9,2%)

6 (18,8%) 24 (27,3%) 30 (25,0%) 29 (90,6%) 80 (90,9%) 109 (90,8%)

the Netherlands Hungary Both countries

32 85 117

14 (43,8%) 22 (25,9%) 36 (30,8%)

18 (56,2%) 63 (74,1%) 81 (69,2%)

the Netherlands Hungary Both countries

32 87 119

6 (18,8%) 10 (11,5%) 16 (13,4%)

26 (81,2%) 77 (88,5%) 103 (86,6%)

the Netherlands Hungary Both countries

32 87 119

3 (9,4%) 4 (4,6%) 7 (5,9%)

29 (90,6%) 89 (95,4%) 112 (94,1%)

Table 15. Most commonly experienced practices for the prevention or management of aggressive behavior by youth in both countries.

Most practices are experienced as prevalent by youth in both countries, except for two answer categories. A chi-square test of independence was performed to examine the relation between countries and youth’s experiences of a staff member that talked to them about the situation. The relation between these variables was significant, X2 (1, N = 120) = 5,507, p <.05. Dutch youth were less likely to report someone of the staff to talk to them about the situation than Hungarian youth.

Another chi-square test of independence was performed to examine the relation between countries

35

Measuring is Key to Improvement – Interventions that Work in Dealing with Youth Aggression 2015-2-HU02-KA205-000984 and youth’s experiences to be able to talk to the person they were angry with to sort things out. The relation between these variables was significant, X2 (1, N = 120) = 4,348, p <.05. Dutch youth were less likely to report to be able to talk to the person they were angry with than Hungarian youth.

The most common practices in both countries applied by staff members in youth care organizations as reported by youth when they were angry are: 1. … there was the possibility to have some time on your own (94,1%) 2. … somebody of the staff was available and accessible for you to talk to or listen to you (90,8%) 3. … somebody of the staff talked to you about the situation (89,2%) 4. … there were clear rules and boundaries regarding what kind of behavior was or wasn’t allowed (86,6%) 5. … they let you talk to the person you were angry with, to help sort things out (73,7%) Some other remarkable results are that already 39% of youth in both countries experienced to be separated or isolated, 25,4% of youth in both countries have already received medication after they were angry in order to calm them down, 55,4% of youth in both countries have already received a time-out when they were angry, 60,3% of youth already received a sanction or punishment, 44,6% of youth were already held down or restrained when angry and 25% of youth already experienced that an aggression incident has been reported to the police by staff in a youth care organization.

Other commonly used practices applied by staff members in youth welfare organizations after an aggression incident takes place Next to the list above, respondents were also asked if their organization/department(s) applied any other practices after an aggression incident took place. In the Netherlands, 9 out of 21 respondents provided other practices such as: evaluating and reconsidering the provided care and agreements (n = 2), provide a sanction, but reframe this as a ‘logical consequence’ of the actions of youth (n = 1), register the incident (n = 1), let youth de-compress or de-escalate (n = 1), provide sufficient aftercare (n = 1), provide intervision and supervision for staff (n = 1), setting up or adapting (possibly together with youth) an individually tailored safety and aggression plan (with possible actions for staff and youth when tensions rise or only for staff) (n = 2), setting up and adapting a tiered and individually tailored sanction plan (depending on the frequency and intensity of aggressive behavior, n =1). Next to that, one respondent also mentioned that police were sometimes also contacted in the context of prevention rather than for sanctioning.

In Hungary, out of a total of 30 respondents, only 11 respondents answered to this question, with 6 respondents mentioning they don’t use any other practices, while the other respondents summed up some practices such as: displacing the youngster to another setting (n = 2), providing a time-out (n = 1) or carry out meditative actions or other restorative processes (n = 2).

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Measuring is Key to Improvement â&#x20AC;&#x201C; Interventions that Work in Dealing with Youth Aggression 2015-2-HU02-KA205-000984

3.2 Research question 2: How do professionals and youth evaluate the effectiveness of the most commonly used methods in preventing or managing aggressive behavior in child and youth welfare?

Conditions to implementing and executing specific (intervention) programs for managing or preventing aggressive behavior When respondents in the first questionnaire were asked if there are any conditions or prerequisites which must be seen to, or that have to be in place before it is possible to effectively carry out specific aggression management or -prevention programs, in Hungary a total of 12 out of 22 respondents (54,5%) that responded to this question agreed, whereas 10 respondents disagreed (45,5%). In the Netherlands a majority of respondents also agreed (13 out of a total of 17 respondents, 76,5%) rather than disagreed (n = 4, 23,5%). However, based on a Chi-square test of independency, results were not significantly different between countries: X2 (1, N = 39) = 2,003, p = .157. This results in a total of 25 out of 39 respondents (64,1%) for both countries agreeing that there are conditions requiring attention before being able to carry out specific aggression management or â&#x20AC;&#x201C;prevention programs for youth.

When respondents agreed, they were asked to elaborate on their answer. 12 respondents in the Netherlands and 12 respondents in Hungary that agreed to this question clarified their answer. No substantial differences in answers were found between countries. The conditions and prerequisites that were mentioned in both countries were related to support in the organization and structural capacity, co-operation between staff, training of personnel, fit with the organization and target group and effectiveness of a program. Related to support was the willingness to apply a program in all layers of the organization (n = 3) but also the conviction to prevent and handle aggressive behavior in an organization (n = 1), facilitation of staff (e.g. by management) in using programs (n = 3) and a level of co-operation between staff (n = 2). In addition, itâ&#x20AC;&#x2122;s necessary to understand the paradigms of a program and make sure that a program has a good fit with the approach in an organization (n = 3), that they are evidence-based, effective (n = 2) and broadly applicable towards a heterogeneous target group when the profiles of clients of an organization are diverse (n = 2), and the necessary attitudes for staff are well thought through in the program description. Next to that however, organizational capacity (finances and time) is also needed to implement certain programs (n = 3) and staff have to be trained prior in more general methods and possess the adequate level of competences (e.g. stay calm and patient, ability to self-reflect) for working in the sector and in handling aggressive behavior (n = 4). Related to that, (the majority of) staff in an organization have to be rightly trained in applying a program (n = 4). Furthermore, respondents also mention that the safety of staff and youth must be looked after and that a possible treatment climate has to be in place at first (n = 2, e.g. staff capacity and aggression policy, aggression can be openly discussed, adjusted infrastructure). Also, the needs and problems of youth and conflicts have to be examined and analyzed thoroughly before applying any programs (n = 5), a decent confidential bond and trust have to be in place between youngsters and staff (n = 1) and youth have to be willing to participate (n = 2).

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Measuring is Key to Improvement â&#x20AC;&#x201C; Interventions that Work in Dealing with Youth Aggression 2015-2-HU02-KA205-000984

Effective programs for the prevention or management of aggressive behavior Programs applied in both the Netherlands or Hungary Aggression Replacement Training (ART) Anger Coping Program / Coping Power Program (Lochman) Defiant children: parent training

Level of effectiveness ***

Families First Program Functional Family Therapy (FFT)

** ****

Life Space Crisis Intervention (LSCI) Multisystemic therapy (MST) Non Violent Resistance (NVR)

***

*** *

**** ***

Parent Management Training Oregon (PMTO) Promoting Alternative Thinking Strategies (PATHS) Parent-Child Interaction Therapy (PCIT) Peacemaking Circles Positive Peer Culture (PPC)

****

Problem Solving Skills training (PSST)

****

**** *** * ***

Programs only applied in the Netherlands Triple P - Positive Parenting Program Agressie Regulatie op Maat

Level of effectiveness * ***

Drie-gesprekkenmodel

*

EQUIP Intervisiemethoden Incidenten (IMI) Leren van Delict

** *

Minder Boos en Opstandig Multidimensionele familietherapie (MDFT) Relationele Gezinstherapie (RGT) Rots en Water Sociale Vaardigheidstraining op Maat STOP 4-7 Teamgericht Zorgoverleg Agressie en Schokkende gebeurtenissen (TZAS) Training Agressie Controle (TACt) Video-feedback Intervention to Promote Positive Parenting and Sensitive Discipline Video-hometraining (VHT)

* *** **** * * ** ** *

* ****

*

Table 16. Overview of the level of effectiveness of evidence-based programs for the prevention or management of aggressive behavior applied in youth welfare services in both countries.

In the table above, an evaluation of the most commonly used programs is provided based on their effectiveness in line with other evaluation procedures applied by actors such as Blueprints Programs6, The California Evidence-Based Clearinghouse for Child Welfare (CEBC)7â&#x20AC;Ś and the the Netherlands Youth Institute (NJi, Nederlands Jeugdinstituut)8 The scores for the levels of 6

https://www.blueprintsprograms.org/programs http://www.cebc4cw.org/ 8 http://www.youthpolicy.nl/ 7

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Measuring is Key to Improvement – Interventions that Work in Dealing with Youth Aggression 2015-2-HU02-KA205-000984 effectiveness are based on the effect-ladder evaluation framework of van Yperen & Veerman (2008), see supra. Level 1 (*) indicates a potentially effective program, level 2 (**) indicates a plausible effective program, level 3 (***) indicates a functional (indicative) effectiveness of the program and level 4 (****) indicates that the program is effective on a causal level.

Effective practices for the prevention of aggressive behavior according to professionals When respondents were asked which practices they experience to be the most effective or helpful in preventing aggressive behavior in youth (regardless of their profile), a total of 14 respondents in the Netherlands and 17 respondents in Hungary responded to this question. Answers are related to following answer-categories: ‘specific types of (psycho)therapy’, ‘specific actions by staff’, ‘training and learning of youth’, ‘types of care-approach by staff’, ‘therapeutic alliance and co-operative relation with youth (and their context)’, ‘fit of care and bespoke care’, ‘detecting and signaling aggression’, ‘rules and agreements’ and ‘actions regarding time and space’.

Out of a total of 31 respondents in both countries, most answers (n = 14) were related to practices related to training and learning of youth, for example by training alternative coping strategies of youth (n = 5), developing self-knowledge of youth (n = 4), by applying experiential learning (n = 3) and by providing insights in incidents (n = 2). An almost equal number of answers (n = 13) were related to investing in a therapeutic alliance and co-operative relation with youth (and their context), such as staff investing in a real commitment and in making a qualitative and genuine contact with youth (n = 4), investing in a therapeutic alliance in general (not specified, n = 2) or in a trusting relation (n = 2), by cooperating together with youth (n = 2 and their context, n = 1), or by improving the sense of safety in youth (n = 1) and providing open and transparent communication (n = 1). In addition, some respondents (n = 7) answered to apply a number of specific miscellaneous actions such as listening carefully to youth (n = 3), looking and asking for causes behind symptoms and behavior (n = 2), providing a time out (n = 1) or by checking observations of behavior and emotions together with youth (n = 1). Next to that, some respondents (n = 6) mentioned specific kinds of (psycho)therapy such as solution focused therapy (n = 3), cognitive-behavioral therapy (n = 2) and systemic therapy (n = 1). Similarly, a number of respondents (n = 6) also referred to different care approaches by staff to be applied such as: a positive approach by providing positive feedback and reinforcement on current behavior of youth (n = 3), a proactive preventive approach (n = 1) or a more active ‘hands on’ approach (n = 1), and a balanced approach between talking, listening and doing (n = 1). Some respondents (n = 6) also answered that they found actions related to the detection and signaling of aggressive behavior to be helpful, like carrying out an early detection of (re-)occurring aggression, by setting up policy guidelines and a plan about reporting an signaling of aggressive incidents (n = 2), or by providing youth with certain tools to better help them signal their feelings (e.g. emotion thermometers, n = 1). Another group of respondents’ (n = 4) answers were related to rules and agreements like providing clear rules and agreements on what is (not) allowed (n = 2) and by providing clear agreements on possible actions of youth in case of a crisis or when they experience stress (n = 2). Next to that, some respondents (n = 3) also found the fit of care and a form of bespoke care efficient in preventing aggressive behavior, by providing a good fit with the type of care for youth (n = 1), by providing a good fit with the applied care approach of staff and their analyses of the needs and behavior of youth (n = 1), and by providing a flexible type of bespoke care on fluctuating different needs of individual youth (no one-size fits all, n = 1). Finally, some respondents also mentioned actions related to providing time and space for youth (n = 3), such as

39

Measuring is Key to Improvement – Interventions that Work in Dealing with Youth Aggression 2015-2-HU02-KA205-000984 providing enough time and space for youth to calm down in a build-up phase by staff taking distance (n = 2) or by providing a clear day-schedule for youth (n = 1).

The majority of respondents’ answers were similar in the Netherlands and Hungary. The only small differences in answers were related to slightly more respondents in Hungary referring to certain forms of training such as experiential learning or by focusing on self-knowledge of youth, whereas in the Netherlands more respondents mentioned the importance of solution-focused therapy and the detection of signals by staff and possibility to signal emotions by youth.

Effective practices for the management of aggressive behavior according to professionals When professionals in the first survey were asked which practices they experience to be the most effective or helpful in directly handling aggressive behavior in youth (regardless of their profile), a total of 17 respondents in the Netherlands and 17 respondents in Hungary responded to this question. Answers are related to following answer-categories: ‘specific kinds of (psycho-)therapy’, ‘specific programs’, ‘activities related to calming down, de-escalation and decompressing’, ‘specific intervening actions by staff’, ‘activities related to training and learning’, ‘types of care approach by staff’, ‘therapeutic alliance between staff and youth’, ‘fit of care’, ‘rules and agreements’ and ‘sanctions and consequences’.

The answers of a total of 34 respondents in both countries referred to similar answers categories, but were mostly divergent between countries.

In the Netherlands, most answers (n = 15) were related to activities related to letting youth calm down, decompress or to de-escalate the situation, by calming down youth (n = 1), by referring to a time-out or calm-down/safe space (n = 4) or either not specified (n = 7) as this is a condition for some personnel (n = 2) to only afterwards be able to talk or reconnect with youth exposing aggressive behavior. A second group of respondents referred to the effectiveness of specific care-approaches (n =7), such as by not counter-reacting aggressively towards youth (n = 1), by providing youth with a series of options to give them a sense of ownership and control over the situation and by installing a positive care-approach by providing positive feedback and reinforcement on the current behavior of youth (n = 2), by disarming aggressive behavior by giving compliments (n = 1), or by being neutral (non-judgmental), forgiving and accepting the possibility that youth make mistakes (n =2). Some other respondents specifically mentioned certain programs (n = 3), like for example Life Space Crisis Intervention (n = 2), while others referred to specific forms of (psycho-)therapy such as cognitive behavioral therapy (n = 1) or solution focused therapy (n = 1). Another series of answers was related to specific intervening actions by staff (n = 2) such as being perseverant in carrying out the interventions as planned (n = 1), or by providing safety for all actors during and after an incident took place, and to activities related to training and learning for youth such as by providing insights and perspective in youngsters own behavior and during incidents (n = 3). Some answers were also related to providing a good treatment fit or fit of care for youth (n = 3) and by providing clear rules and agreements on which behavior is (not) allowed or tolerated (n = 3). Finally, the last two respondents in the Netherlands also referred to the importance of a therapeutic alliance between staff and youth (not specified, n = 1; or by investing in having a positive and genuine relation with youth, n = 1).

In Hungary answers were mostly different than from those in the Netherlands, most answers (n = 4) to investing in a therapeutic alliance between staff and youth (by investing in a positive and genuine relation with youth) and equally (n = 4) to activities related to letting youth calm down, decompress 40

Measuring is Key to Improvement – Interventions that Work in Dealing with Youth Aggression 2015-2-HU02-KA205-000984 and de-escalate the situation by letting youth have some free time and sport activities (n = 3) or by letting youth get out of the situation (n = 1). Next to that, some answers were related to training or learning activities for youth such as teaching social skills (e.g. assertive communication, aggression management, etc. n = 2) or by carrying out peer-counseling activities for youth (n = 1). Furthermore, some respondents also mentioned some specific intervening actions of staff (n = 3), such as applying a method of crisis intervention (n = 1), by letting staff systematically provide feedback on youngsters’ behavior (n = 1), or by handling aggressive incidents of youth (not specific, n = 1). A last series of answers was related to the need for therapy (not specified) when youth are dangerous to their selves or others (n = 1), by applying a specific and positive care-approach by staff (by providing positive feedback and reinforcement on the current behavior of youth, n = 1), and to sanction youth when exposing aggressive behavior (n = 1).

Differences in the effectiveness of practices for the prevention or management of aggressive behavior because of different aggression phases and fluctuating intensity of aggression When professionals in the first survey were asked whether the applied practices differ in effectiveness during different phases and intensities of aggressive behavior of youth, a total of 15 respondents in the Netherlands and 15 respondents in Hungary responded to this question.

In the Netherlands, 14 out of 15 respondents agreed that the applied practices differ in effectiveness, while only one respondent declined. In Hungary 12 out of 15 respondents agreed, while 3 respondents declined that these practices differ in effectiveness during different phases of aggression intensity.

Respondents that answered no mostly illustrated their answers by saying that a generalization in the approach by staff should be necessary, without substantial differences between countries.

Respondents that approved explained there answers slightly different in Hungary than in the Netherlands.

In Hungary, out of 12 respondents that agreed, 8 didn’t explain their answer, while one respondent mentioned that during a peak period of increased aggression intensity, crisis intervention steps should be applied, while another respondent answered that during a build-up phase of aggression, breathing exercises should be done by the youngster in order to further prevent aggressive behavior.

One remaining respondent mentioned that the effectiveness of applied practices is also dependent upon group dynamics (not specified).

In the Netherlands, out of 14 respondents that agreed, most answers (n = 9) were related to the necessity of applying different practices during a peak period when tension and aggression intensity increases and there is more need for focusing on safety of everyone involved (n = 2), staff have less possibilities in making contact with youth (n = 1), or applying more verbal practices (n = 1), there’s a lesser possibility that interventions are receptive or admissible (n = 1), more comforting practices are needed (n = 1), or there’s rather more need for a time-out (n = 1) or other crisis intervention methods (n = 1). Some respondents (n = 3) also mentioned that a different approach is necessary during the build-up phase, explaining that staff should try to prevent escalation and stop aggression by focusing on the youngster’s self-regulation and emotion-regulation (n = 1), that staff should prevent escalation and stop aggression by applying methods for early-detection of signals (n = 1), and that staff should pay more attention to the needs of youth and on reducing tensions (n = 1). Finally, 41

Measuring is Key to Improvement – Interventions that Work in Dealing with Youth Aggression 2015-2-HU02-KA205-000984 some respondents also answered that a certain amount of motivation and willingness to change of youth is necessary as a condition to react to aggressive behavior by staff (n = 1), and that the level of calmness of staff (n = 1) and sense of safety of youth (n = 1) can also be of influence on the effectiveness of applied practices.

Effective methods according to youth when feeling angry or frustrated When youth were asked what they found helpful in dealing with feelings of angriness whilst receiving care in a youth care setting, following main response categories were identified: ‘Someone to talk to’, ‘Comforting others’ and ‘Activities related to self-control, calming down, ways of decompressing and expressing feelings’.

Out of a total of 94 respondents in Hungary and 35 respondents in the Netherlands who responded to this question, most answers (n = 51) were related to the wish for some space, time alone, or peaceful and tranquil surroundings (e.g. to get away from a stimulus or to calm down). Youth especially expressed their need for some solitude or some time alone when they were angry (n = 27) and the need to for a space to be on their own, away from a stressful situation or to find some diversion or peace (e.g. in my room, go outside, go home or away from, … n = 22). Second to that, another frequent answer related to more general activities for calming down, ways of decompressing and expressing feelings (n = 45) such as listening to music (n = 19), sports (n = 9), drawing (e.g. the situation, n = 5) and walking (n = 4). Other answers referring to activities related to self-control, calming down, ways of decompressing and expressing feelings included substance use (n = 15) such as smoking a cigarette (n = 11), drinking alcohol (n = 2) and taking drugs (n = 2), outing anger and aggressive behavior (n = 15) by damaging physical objects (n = 8), shouting (n = 4) physically attacking the person their angry with (n = 3) or self-harm (n = 3). Others applied specific self-control activities (n = 11) such as counting to 10 in their head (n = 6), and experienced the need to express emotions by crying (n = 5) or reflecting on the situation (n = 4) by their selves in order to look for a solution (e.g. find a better care setting). Youth also expressed the need to talk to someone about their angriness (n = 44) by referring to certain people (n = 23) such as staff members with whom they have a good relationship (n = 9), other youngsters or good friends (n = 6), by discussing it with the person that made them angry (n = 5) and by either not specifying their answers (n = 11) or by referring to ways of conduct of a person to talk to (n = 7) such as someone who listens and stays calm, who explains the situation, who’s understanding and honest and who hears them out without arguing with them. Lastly, youth also expressed their need for comforting or calming others to help them deal with their angriness (n = 26) by either not specifying their answer (n = 5) or by referring to care workers (n = 6), family members (n = 6) or friends (n = 3) who calm them down or someone that calms them down by holding them down when their angry (n = 2). Two answers explicitly referred to the need for being comforted (n = 2) (e.g. either not specified or by hugging). However, some youth also mentioned that nothing seemed to help them (n = 7).

In Hungary more youngsters mentioned certain people (e.g. a staff member, or friends and family) they wish to talk to whereas in the Netherlands respondents more generally referred to certain ways of conduct or attitudes they would like a person to have. Next to that, in Hungary there were also more youngsters that gave answers related to externalizing coping behaviors such as expressing angry behavior in an aggressive way or by substance use. The other responses were similar between both countries.

42

Measuring is Key to Improvement – Interventions that Work in Dealing with Youth Aggression 2015-2-HU02-KA205-000984 Ineffective methods according to youth when feeling angry or frustrated When youth were asked what they didn’t find helpful in dealing with their angriness whilst receiving care, following main response categories were identified: ‘Negative conversational attitudes of staff / others’, ‘Negative intervention strategies’, ‘Negative appliance of rules and sanctions’ and ‘Personal reasons of youngsters’.

Out of a total of 79 respondents in Hungary and 35 in the Netherlands who responded to this question, most answers (n = 33) were related to negative comments/thoughts and aggressive or provoking behavior of others or staff, such as staff getting verbally angry at the youngster (e.g. yelling, or shouting n = 11), others provoked or insulted the youngster (n = 11) or a family member (n = 3), others annoy the youngster (n = 4), or staff give the youngster a telling of or only think or talk negatively to him or her (n = 5). In addition, some youth didn’t find it helpful when staff got too worked up about the situation (n = 1) or addressed the youngster too strictly (n = 2). Next to that, the second least helpful aspect was when youth weren’t allowed the space and time they needed to either calm down or handle their emotions (n = 24), by for example not letting the youngster calm down first before talking to him or her when angry (n = 10) or staff just don’t leave the youngster alone when he wants to be left alone (n = 8) or they keep following the youngster around (n = 6). This is in line with some answers that illustrated the perseverance of staff that youngster didn’t find helpful when angry (n = 7) such as staff members that keep asking the youngster what’s wrong (n = 5), ask too many questions or don’t stop talking when the youngster wants to stop (n = 2). This is also related to the series of answers in which youth referred to either others or staff that tried to comfort them or calm them down (e.g. telling me to calm down or telling me not to be anxious or angry, n = 22). Furthermore, youth explicitly didn’t find some interventions strategies that staff applied helpful when angry (n = 18) of which the most important were telling the youngster what to do or by giving orders (e.g. forcing me to do something I don’t want) (n = 9), by intervening in the conflict and physically holding down the youngster (n = 5), or by sending the youngster away without talking about his or her feelings or actions (n = 2). Another series of answer was related to staff who didn’t listen to the youngster (for example by talking too much him / herself) (n = 3), not being involved or engaged at all (e.g. staff is not interested, doesn’t take the youngster into account or doesn’t put in any effort) (n = 7) or by arguing with youth or deciding in favors of others while youth think they’re right (n =6).

Lastly, some youngsters mentioned inefficient personal coping styles while angry or referred to their own part in remaining angry (n = 9), for example if they became too aggressive their selves or if they kept thinking about what made them angry. One youngster specifically mentioned the fact that no one ever taught him how to handle his anger. However, some youth also mentioned that nothing (n = 3) or no-one can help them (n = 7).

The only substantial difference in responses between both countries was that in the Netherlands slightly more youth gave answers related to not being able to receive the time or space that they needed to be able to calm down or handle their emotions first before anything else and that youth in Hungary gave more responses related to others annoying, provoking or insulting them (or their family). The other responses were similar in both countries.

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Measuring is Key to Improvement – Interventions that Work in Dealing with Youth Aggression 2015-2-HU02-KA205-000984 Effective practices of staff members according to youth when feeling angry or frustrated In the questionnaire for youth, respondents were also asked what they find staff members should do to better help them when they were or felt angry. The responses can mainly be clustered in the following categories: ‘Attitudes of staff’, ‘Intervening actions of welfare workers’, ‘Actions related to calming down and time and space’ and ‘Youth’s activities to calm down, express feelings, decompress or self-reflect’.

Out of a total of 78 respondents in Hungary and 32 in the Netherlands for this question, most answers (n = 41) were related to letting the youngster calm down first when he or she felt angry and the need for time and space. Youngsters especially expressed their need to have some time alone to calm down while staff don’t talk to them (n = 22), after which some youth found it okay that staff members came and talked to them when they were already calmer (n = 2). Others expressed their need to be able to get some space, go outside or to somewhere else (n = 10) (e.g. where they could find some repose or tranquility n = 1) or to be calmed down (n = 1) or calm down their selves (not specified, n = 4). One youngster additionally said he would like staff to be more near or close by at times he felt angry, so they could step in if necessary or prevent any further build-ups. Other prevalent answers related to intervening actions of staff members (n = 33) such as: talking about it with the individual youngster (n = 23) (e.g. in a calm and collaborative way, by letting the youngster explain him- or herself, by asking what’s wrong, by providing good advice, by someone he or she thrusts or prefers at that moment), addressing another party that annoyed him or made him angry (n =2), by having a group conversation together with the individual youngster and the one that made him angry (n = 2), by comforting the youngster (e.g. laying an arm around me, but only if I’m ok with it, or like me mother would do, n = 4) or by stopping him from breaking things or preventing him from any misbehavior (n = 2). Furthermore, some youth also referred to attitudes of staff members (n = 28), like for example: that staff listen more closely to them (e.g. about what they want, feelings or needs and by letting the youngster finish what he wants to say, n = 8), staff keep calm (n = 5), don’t get angry (n = 1), are professional (e.g. do the work as they should, n = 3), strive for fairness or justice (n = 4), are understanding or empathic (n = 3), or are (more) attentive to youth (n = 2) and supportive (n = 1). Lastly, some youth (n = 23) also expressed the wish that staff members allowed them to do certain activities that helped them calm down, decompress, express feelings or selfreflect when angry, such as: smoking a cigarette (n = 5), expressing anger (n = 4), sports (n = 4), drawing or writing (n = 4), listening to music (n = 3) or walking (n = 1). However, some youth also mentioned that they felt like nothing helps (n = 8) or no staff member could help them (n = 11), they didn’t need their help (n = 1) or it depended on the situation (n = 1).

Some differences in answers between countries were identified for this question. In the Netherlands, slightly more youngsters wish that staff keep calm or listen more closely to youth, whereas youngsters in Hungary rather have staff act professional (e.g. do the work as they should) and strive for justice. In addition, in Hungary more youngsters expressed the need that staff let respondents talk with the other youngster(s) they are angry with or that annoys them or for staff to calm them down. Lastly, up to 17 youngsters in Hungary responded that staff cannot help them or they didn’t know while in the Netherlands no-one of the respondents answered this.

Next to the open-ended question on helpful methods according to youth when feeling angry, a prestructured list or different practices has also been evaluated by youth that have already experienced one of these practices applied by staff members already. Results are shown in the table below.

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Measuring is Key to Improvement – Interventions that Work in Dealing with Youth Aggression 2015-2-HU02-KA205-000984

When you felt or were angry in child- or youth welfare … … they separated or isolated you (1) … they gave you medication “to calm down” (2) … they gave you a time-out9 (3) … they gave you a sanction or punishment (4) … they held you down or restrained you (5) ... somebody of the staff talked to you about the situation (6) … they let you talk to the person you were angry with, to help sort things out (7) ... the incident got reported to the police (8) … somebody of the staff was available and accessible for you to talk to or listen to you (9) … somebody of the staff was nearby to intervene (10) … there were 9

Country

Total (N)

I found this helpful

I didn’t find this helpful

the Netherlands Hungary Both countries the Netherlands Hungary Both countries the Netherlands Hungary Both countries the Netherlands Hungary Both countries the Netherlands Hungary Both countries the Netherlands Hungary Both countries

11 36 47 7 24 31 19 48 67 16 57 73 16 38 54 25 82 107

1 (9,1%) *** 25 (69,4%) *** 26 (55,3%) 2 (28,6%) 15 (62,5%) 17 (54,8%) 10 (52,6%) ** 40 (83,3%) ** 50 (74,6%) 2 (12,5%) 19 (33,3%) 21 (28,8%) 5 (31,2%) 11 (28,9%) 16 (29,6%) 17 (68,0%) * 73 (89,0%) * 90 (84,1%)

10 (90,9%) *** 11 (30,6%) *** 21 (44,7%) 5 (71,4%) 9 (37,5%) 14 (45,2%) 9 (47,7%) ** 8 (16,7%) ** 17 (25,4%) 14 (87,5%) 38 (66,7%) 52 (71,2%) 11 (68,8%) 27 (71,1%) 38 (70,4%) 8 (32,0%) * 9 (11,0%) * 17 (15,9%)

the Netherlands Hungary Both countries

19 69 88

10 (52,6%) 52 (75,4%) 62 (70,5%)

9 (47,4%) 17 (24,6%) 26 (29,5%)

the Netherlands Hungary Both countries the Netherlands Hungary Both countries

6 24 30 29 80 109

1 (16,7%) 2 (8,3%) 3 (10,0%) 22 (75,9%) ** 76 (95,0%) ** 98 (89,9%)

5 (83,3%) 22 (91,7%) 27 (90,0%) 7 (24,1%) ** 4 (5,0%) ** 11 (10,1%)

the Netherlands Hungary Both countries

18 63 81

13 (72,2%) 38 (60,3%) 51 (63,0%)

5 (27,8%) 25 (39,7%) 30 (37,0%)

the Netherlands

26

15 (57,7%)

11 (42,3%)

A time-out means that contact with other youngsters and/or staff members is temporarily paused for a youngster and he/she should stay in a ‘calm’ location for a while until he ‘cools down’.

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Measuring is Key to Improvement – Interventions that Work in Dealing with Youth Aggression 2015-2-HU02-KA205-000984 clear rules and boundaries regarding what kind of behavior was or wasn’t allowed (11) … there was the possibility to have some time on your own (12)

Hungary Both countries

77 103

55 (71,4%) 70 (68,0%)

22 (28,6%) 33 (32,0%)

the Netherlands Hungary Both countries

29 83 112

26 (89,7%) 77 (92,8%) 103 (92,0%)

3 (10,3%) 6 (7,2%) 9 (8,0%)

Table 17. Most helpful practices for the prevention or management of aggressive behavior according to youth in both countries.

Most practices are experienced as (un)helpful by youth in both countries, except for four answer categories. A chi-square test of independence was performed to examine the relation between countries and youth’s perception of the helpfulness of being separated or isolated. The relation between these variables was significant, X2 (1, N = 47) = 12,417, p <.001. Dutch youth were less likely than Hungarian youth to report that they found being separated or isolated helpful. Another chisquare test of independence was performed to examine the relation between countries and youth’s perception of the helpfulness of having a time-out. The relation between these variables was significant, X2 (1, N = 67) = 6,776, p <.01. Dutch youth were less likely than Hungarian youth to report that having a time-out was helpful for them. A third chi-square test of independence was performed to examine the relation between countries and youth’s perception of the helpfulness of having someone of the staff talk to them about the situation. The relation between these variables was significant, X2 (1, N = 107) = 6,337, p <.05. Dutch youth were less likely than Hungarian youth to report that having someone of the staff to talk to about the situation was helpful. Lastly, a chi-square test of independence was performed to examine the relation between countries and youth’s perception of the helpfulness of having someone of the staff available and accessible for them to talk to or listen to them. The relation between these variables was significant, X2 (1, N = 109) = 8,592, p <.01. Dutch youth were less likely than Hungarian youth to report that having someone of the staff available and accessible for them to talk to or listen to them was helpful.

The most helpful practices in both countries applied by staff members in youth care organizations as reported by youth when they were angry are: 1. … there was the possibility to have some time on your own (92,0% found this helpful) 2. … somebody of the staff was available and accessible for you to talk to or listen to you (89,9% found this helpful) 3. … somebody of the staff talked to you about the situation (84,1% found this helpful) 4. … they gave you a time-out (74,6% found this helpful) 5. … they let you talk to the person you were angry with, to help sort things out (70,5% found this helpful) Some other remarkable results are that more youngsters in Hungary found being isolated or separated helpful rather than not helpful for them (69,4% vs. 30,6%), as was also the case for receiving medication to calm down (62,5% vs. 37,5%).

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Measuring is Key to Improvement – Interventions that Work in Dealing with Youth Aggression 2015-2-HU02-KA205-000984 The least helpful practices in both countries applied by staff members in youth care organizations as reported by youth when they were angry are: 1.

2.

3.

4.

5.

… the incident got reported to the police (90,0% didn’t find this helpful) … they gave you a sanction or punishment (71,2% didn’t find this helpful) … they held you down or restrained you (70,4% didn’t find this helpful) … they gave you medication to calm down (45,2% didn’t find this helpful) … they separated or isolated you (44,7% didn’t find this helpful)

Effective methods applied by staff according to youth when youth expose aggressive behavior (verbal, proactive, or reactive aggression) In the questionnaire for youth, respondents were asked how staff could help them the best if they yelled at, hurt, threatened or bullied someone while receiving care in child- our youth welfare. The responses are divided into the following main response categories: ‘Intervening actions of staff members’, ‘Actions related to letting the youngster calm down and time and space’, ‘Appliance of rules and sanctions by staff members’, ‘Preventive actions of staff members’, ‘Education and skills training’, ‘Wishes of youngsters regarding attitudes or opinions of staff members’, ‘Individual actions of youngsters’ and a ‘Miscellaneous category’.

Out of a total of 76 respondents in Hungary and 20 respondents in the Netherlands, most responses were related to ‘intervening actions of staff members’ (n = 49) such as providing aftercare or reconciliation and problem exploration after a conflict took place (n = 37), by talking to the individual youngster separately (n = 30) (e.g. and keeping calm n = 3, about how to handle things differently next time n = 1, talking things through n = 5, or exploring underlying reasons of behavior n = 4, by cheering up the youngster, n = 1, or not specified n = 16), by talking to different youngsters involved in the conflict together (n = 3), separately (n = 3) or applying other forms of reconciliation and mediation (n = 1). Next to that, youth also asked staff members to apply direct intervention strategies during the conflict (n = 12) such as separating the youngster (n = 7), by not intervening at all (n = 3), by stopping another youngster who’s the cause of this behavior (n = 1), or not specified (n = 1). The second most prevalent response category refers to actions related to letting the youngster calm down and time and space (n = 22), such as the need for some time alone (and after a while talk to the youngster by a staff member n = 7, or by just leaving the youngster alone for some time without talking to him or by not coming hear him, n =5), by letting the youngster go to some other space to calm down (and afterwards talk to the youngster by a staff member, n = 2 or not specified, n = 4), the need for some time to calm down (not specified, n = 1), or a staff member that calms the youngster down (n = 3). Furthermore, some answers were related to the appliance of rules and/or sanctions (n = 19), in the sense that some youngsters expressed the need that a staff member addresses their behavior and calls them to account (and afterwards leave the youngster alone n = 1, by telling this behavior isn’t appropriate n = 4, by telling to reconsider their actions n = 2, or not specified n = 5), or that staff members provide a sanction (n = 1), a time-out (n = 1), or by letting the youngster choose out of a list of different consequences and by involving him in this (n = 1). Next to that, some responses were related to the wish for preventive actions of welfare workers (staff are present and prevent conflicts, n = 1), education and skills training such as conflict resolution (n = 2), that staff members tell the youngster he’s right (n = 2) or to some personal actions of youngster’s to deal with the conflict such as talking to a family member (n = 1) or carrying out activities to calm down or decompress (listen to music n =2, smoke a cigarette n =1). Lastly however, an important 47

Measuring is Key to Improvement – Interventions that Work in Dealing with Youth Aggression 2015-2-HU02-KA205-000984 share of respondents in the miscellaneous response category mentioned that nothing or no-one of the staff members could help them (n = 17) or that it depends on the person of the staff if they’re able to help (not specified, n = 2).

Some minor differences in answers between countries were found for this question. In Hungary, slightly more youngsters expressed their wish for staff to talk to them without specifying in what way or about which topic this would be, whereas in the Netherlands more youngster referred to the way they would like staff to talk to them (e.g. calmly) or about a certain topic. Another minor difference between countries was that slightly more youngsters in Hungary than in the Netherlands expressed that they found it helpful when staff directly intervened by separating youngsters involved in a conflict.

Lastly, a bigger difference was found between countries where a bigger share of youngsters mentioned that nothing or no-one could help them in Hungary (n = 16) than in the Netherlands (n = 1).

Least effective methods applied by staff according to youth when youth expose aggressive behavior (verbal, proactive, or reactive aggression) In the questionnaire for youth, respondents were asked what they found the least helpful staff could do to manage aggressive behavior (yelling, hurting, threatening or bullying) while receiving care in child- our youth welfare. The responses are grouped into the following main response categories: ‘Negative conversational attitudes of staff’, ‘Negative intervention strategies of staff’, ‘Absent attitudes of staff’, ‘Activities of staff regarding rules and sanctions’, ‘Activities or attitudes related to justice and fairness’, ‘Activities of staff related to time and space and calming down’ and ‘Aggressive behavior of staff’.

Out of a total of 76 respondents in Hungary and 22 respondents in the Netherlands, most responses were related to negative conversational attitudes of staff (n = 29), in the sense that staff don’t listen or talk too much themselves (n = 6), staff addresses or messes with the youngster in a way that makes him even more angry (n = 5), staff keep talking to a youngster when he’s angry (not specified, n = 4), staff give wrong advice (n = 3), staff give youngsters a telling-of (n = 3) or get too worked up or uptight about the situation their selves (n = 2), staff try to silence the youngster (e.g. by saying ‘shhh’, n = 1), are ironic (n = 1), look down on a youngster (n = 1), talk in a disrespectful way (n = 1), or address the youngster too strictly (n = 1) or by giving too many orders (n = 1). The second least helpful that staff can do according to youth is becoming aggressive their selves (n = 27) when trying to handle the situation, by for example yelling at the youngster (n = 20), becoming physically aggressive (e.g. pushing or hitting, n = 3), getting (too) angry with the youngster (not specified, n = 3) or threating the youngster (n = 1). Next to that, youngsters don’t like certain intervention strategies that staff members carry out (n = 16), like intervening in a conflict (and holding the youngster down, n = 7; without knowing anything about the situation, n = 2; or not specified, n = 3), sending the youngster away (without talking about it) (n = 3) or separating the youngster (n = 1). In addition, youth didn’t find specific activities of staff regarding rules and sanctions helpful (n = 13), such as: punishing the youngster (not specified, n = 4), giving the youngster a warning without any reason (n = 4), by calling the police (n = 1), locking up the youngster (n =1) and referring the youngster to a more restricted setting (n = 1) or a psychologist (n = 1). One youngster also didn’t find it helpful when he’s sent away for a time-out or to his room at the moment he’s very angry as this will only work when he’s already calmer (n = 1). Furthermore, some ineffective activities of staff were related to time and 48

Measuring is Key to Improvement – Interventions that Work in Dealing with Youth Aggression 2015-2-HU02-KA205-000984 space and letting the youngster calm down (n = 11), by for example not letting the youngster calm down before addressing him (n = 7), by touching or coming near the youngster when he’s angry (n = 2), by not calming the youngster down (n = 1) or by keep telling the youngster to calm down (n = 1).

Another group of respondents didn’t like absent attitudes of staff (n = 9), in the sense that staff aren’t interested in the conflict or don’t handle the conflict (e.g. by not asking what’s wrong, n = 8), or by ignoring the youngster (n = 1). Lastly, some youth mentioned some ineffective actions of staff members related to justice and fairness (n =8), such as not believing any youngster in the conflict or agreeing with everybody (n = 2), by protecting the other party and saying that he’s right (n = 2), or by not agreeing with the youngster or blaming only him (n =4).

Some minor differences in answers between countries were found for this question. In Hungary, slightly more youngsters mentioned they didn’t find it helpful when staff made them more angry by for example messing with them and by providing more responses related to negative attitudes or actions by staff regarding justice and fairness (e.g. protecting the other party or only listening to them) than in the Netherlands. Other answers were similar between both countries.

Effective methods when youth experience victimization of aggressive behavior (verbal, proactive or reactive aggression) In the questionnaire for youth, respondents were asked what they found the most helpful staff could do when they were ever the victim of aggressive behavior (yelling at, hurting, threatening or bullying) while receiving care in child- our youth welfare. The responses are grouped into the following main response categories: ‘Aftercare after a conflict took place’, ‘Direct intervention strategies in the conflict’, ‘Supportive actions towards the individual youngster’, ‘Actions related to time and space and letting the youngster calm down’, ‘Wishful conversational attitudes of staff according to the youngster’ and a ‘Miscellaneous’ category.

Out of a total of 70 respondents in Hungary and 22 respondents in the Netherlands, most responses were related to the need of youth for staff to provide a form of aftercare after the conflict took place (n = 47), either towards individual youngsters (n = 24) by comforting and calming the ‘victim’ (n 12), providing medical help (n = 1) or give advice (n = 1), or by calming the ‘offender’ down (n =5), or by providing aftercare towards the group (n = 21) by talking to both youngsters that were involved together about the conflict (n = 12), having a group conversation with the whole group (n = 6) or by talking to different youngsters involved separately (n = 3). Another form of aftercare that youth found helpful was if staff let youth contact their family (n = 1), if they explored the problem (e.g. and ask what happened, n = 1) or if they provided support to the victim (n = 2) by encouraging him or by providing some distractive activities. Second to that, most responses were related to actions of staff regarding rules and sanctions (n = 20), in the sense that youth wished staff gave a warning to the offender (n = 11) or both youngsters (n = 1), that staff addressed the offender and called him to account (n = 5) and by giving a sanction (n = 2), letting the youngster report to the police (n = 1) or not specified (n = 3), or by reminding the offender of the consequences and rules (n = 2). In addition, some youth explicitly mentioned the need for staff to directly intervene during a conflict (n = 16), by separating the youngsters (e.g. by sending the offender away, n = 6), by stopping the other youngster (n = 3), by providing safety (n = 2), by just intervening directly (not specified, n = 3) or by not intervening in the conflict at all (n = 2). Some youth, also mentioned the need for some time and space to calm down after the conflict (n = 12), by having some time alone or for their self (n = 5), by telling them go somewhere else to calm down (e.g. go outside, having a walk, to their room, … n = 5), 49

Measuring is Key to Improvement – Interventions that Work in Dealing with Youth Aggression 2015-2-HU02-KA205-000984 or by letting the youngster calm down first (not specified) and afterwards talk about it together with a staff member (n = 1). One youngster also mentioned the need to express himself and decompress (e.g. by releasing tension by yelling), before he wanted to talk to a staff member. Next to that, some youngsters responses were related to wishful or helpful conversational attitudes of staff (n = 11), in the sense that they wanted staff to stay calm (e.g. don’t yell at me, n = 5), that staff agree with the victim (n = 2), listen carefully (n = 1), know how to react personally to an individual youngster (n = 1) or are solution focused (n = 1). Lastly, some youth responded however that staff couldn’t help them (n = 10), that they stood up for their selves (n = 1) or that staff their selves were the ones that were aggressive towards the youngster (n = 1).

Some minor differences in answers between countries were found for this question. In Hungary, more youngsters than In the Netherlands mentioned they found forms of group conversations helpful, as well as when staff calmed them down and another youngster got a warning for his/her behavior. Also, more youngsters in Hungary than in the Netherlands mentioned no-one or nothing could help them. In the Netherlands however, more youth expressed their wish for certain conversational attitudes of staff. Other answers were similar between both countries.

Least effective methods when youth experience victimization of aggressive behavior (verbal, proactive or reactive aggression) In the questionnaire for youth, respondents were asked what they found the least helpful staff could do when they were ever the victim of aggressive behavior (yelling, hurting, threatening or bullying) while receiving care in child- our youth welfare. The responses are grouped into the following main response categories: ‘Negative conversational attitudes of staff’, ‘Absent attitudes of staff’, ‘Negative intervention strategies of staff’, ‘Activities of staff regarding rules and sanctions’, ‘Activities of staff regarding justice and fairness’, ‘Aggressive behavior of staff’ and a ‘Miscellaneous’ category.

Out of a total of 64 respondents in Hungary and 18 respondents in the Netherlands, most responses were related to absent attitudes of staff in handling the conflict (n = 17) in the sense they don’t intervene or handle the conflict at all (n = 14) even if the victim tells them someone else did something to them or by letting the aggressive behavior continue (n = 2), or by just not talking about it with the youngster (n =2) or ignoring him (n = 1). A same amount of responses were related to other negative conversational attitudes of staff (n = 17) for example if they minimize the conflict (e.g. by telling me it will all be okay, without them knowing how I feel, n = 3), give wrong advice (not specified, n = 3), pretend to know everything better (n = 2), they incite the conflict (n =2), violate trust (e.g. by spreading private information to others, n = 2), don’t ask for reasons behind youth’s actions (n = 1), get too worked up or uptight about the situation their selves (n = 1), look down on the youngster (n = 1), are ironic/sarcastic (n = 1) or give the youngster a telling off (n = 1).Furthermore, some youngster also mentioned some intervention strategies applied by staff members they didn’t find helpful (n = 14), like when they send the victim or (wrong) youngster away (without talking about it) (n = 4) (e.g. that they tell you to go to your room or send you to your room, because it feels like I’m the one who did something wrong) or by separating the youngsters (not specified, n = 1). However, some youth also mentioned that they didn’t like it when staff members intervened in the conflict (n = 8) or more staff members intervene in the conflict (n = 1). Next to that, another group of respondents said they didn’t find certain actions of staff members regarding justice and fairness helpful (n = 15), such as when staff think the other party is right and protect them (n = 10) or even blame the victim of the conflict (n = 5). In addition, youth also didn’t find it helpful when 50

Measuring is Key to Improvement â&#x20AC;&#x201C; Interventions that Work in Dealing with Youth Aggression 2015-2-HU02-KA205-000984 staff became aggressive their selves (n = 13) like when they yell at the youngster (e.g. I donâ&#x20AC;&#x2122;t like it when they yell at me, because then I feel even more angry, insecure and sad, n = 8), get angry with youngster (n = 1) or in general (n = 1), or by threatening a youngster (not specified who, n = 2) or becoming physically aggressive (not specified against who, n = 1). Lastly, one youngster also mentioned that this depends on the personality of the staff member.

Some minor differences in answers between countries were found for this question. In Hungary, more youngsters than In the Netherlands mentioned they didnâ&#x20AC;&#x2122;t find certain actions of staff related to justice and fairness helpful like when staff think the other party is right or protect them or they blame the victim instead. Other answers were similar between both countries.

3.3 Research question 3: How does aggressive behavior influence the trajectories of youth in child and youth welfare?

In the second survey the trajectories of youth in child and youth welfare services were mapped, as well as their past and present aggressive outbursts or incidents.

When looking at correlations between general aggressive behavior of youth during the last 2 months and on average throughout their stay at their current organization (when receiving care there for longer than 2 months) and their total amount of encounters with child or youth welfare services, a positive correlation was found between the total number of encounters youngsters had with child or youth welfare services and the general average aggressive behavior of youth throughout their stay in their current organization in both countries, r (51) = 0.310, p = .027. In addition, a positive correlation between the number of reported aggression incidents towards other youth in an organization based on file data and the total number of encounters with child or youth welfare services can also be found in both countries, r (51) = .521, p = .000. Although the correlation in both countries between the number of reported aggression incidents towards staff members in an organization based on file data and the total number of encounters with child or youth welfare services was not significant, r (48) = .234, p = .109.

These correlations signify a possible relation between aggressive behavior of youth and complex pathways in care with numerous displacements. Youth with more aggression incidents namely, had more encounters with different services in child and youth welfare services, but they also had more encounters with different organizations within these different services in child and youth welfare services.

Regarding the different types of youth services, we also notice that there is a positive correlation between the number of encounters in more restricted settings in the (semi-)residential mental health care category in both countries and the number of registered aggression incidents towards other youth, r (52) = .483, p = 000, the number of disruptions in care due to aggressive behavior, r (51) = .423, p = .002, and the general average aggressive behavior of youth throughout their stay at their current organization, r (54) = .276, p = .043. This is also true for the number of encounters in more restricted settings in the juvenile justice care category in both countries and the number of registered aggression incidents towards other youth, r (52) = .538, p = .000, the number of registered aggression incidents towards staff members, r (51) = .303, p = .031 and the general aggressive behavior of youth throughout their stay at their current organization, r (54) = .275, p = .044. This

51

Measuring is Key to Improvement â&#x20AC;&#x201C; Interventions that Work in Dealing with Youth Aggression 2015-2-HU02-KA205-000984 indicates that youth that expose more aggressive behavior in general experience more encounters with more restricted settings in the child- and youth welfare structure.

When focusing on disruptions in care that youth experienced in child or youth welfare services in both the Netherlands and Hungary, it appears that out of a total of 18 respondents in the Netherlands, 8 youngsters (44,4%) already experienced a disruption or breach in care at a welfare service, making it necessary to stop care and/or be displaced to another organization. In Hungary, out of a total of 38 respondents, 21 youngsters (51,2%) already experienced a disruption in care at least once in a youth care organization. The total count for both countries is 29 (51,8%) out of 56 youngsters that already experienced a disruption in care at least once. There are no significant differences between both countries.

However, out of the 8 respondents in the Netherlands that already experienced a disruption in care once, for 4 (50,0%) of them this has been already due to incidents related to aggressive behavior of the youngster. In Hungary, this was the case for 13 (72,22%) out of 18 youngsters. The total count for both countries is 17 (65,38%) out of 26 youngsters that already experienced a disruption in care at least once due to aggressive behavior of the youngster. This implies a relation between aggressive behavior of youth and the disruptions in care they experience. Results were not significantly different between countries.

Also, for respondents of both countries a positive correlation can be found between internal shifts in the organization of responsible staff members or client groups for the youngster and his/her general aggressive behavior (during the last 2 months), r (48) = .506, p = .000, and on average throughout their stay in the current organization, r (49) = .489, p = .000. Another positive correlation can be found between the number of reported aggression incidents towards other youth in an organization based on file data and internal shifts in the organization of responsible staff members or client groups for the youngster, r (49) = .462, p = .001. An even bigger positive correlation can be found between the number of reported aggression incidents towards staff members in an organization based on file data and internal shifts in the organization of responsible staff members or client groups for the youngster, r (48) = .600, p = .000.

Furthermore, for respondents of both countries, a positive correlation can be found between the total amount of disruptions in care they experienced and their general aggressive behavior (during the last 2 months), r (46) = .453, p = .002, and on average throughout their stay in the current organization, r (44) = .557, p = .000. Another positive correlation can be found between the number of reported aggression incidents towards other youth in an organization based on file data and the total amount of disruptions in care youth experienced, r (44) = .457, p = .002. A bigger correlation can also be found between the number of reported aggression incidents towards staff members in an organization based on file data and the total amount of disruptions in care youth experienced, r (44) = .556, p = .000.

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3.4 Research question 4: Which methods for the prevention or management of aggressive behavior are helpful in preventing disruptions in care in child and youth welfare?

The relation between disruptions in care and aggressive behavior of youth Respondents in the first questionnaire were asked how many disruptions in care they had experienced in their organization due to aggressive behavior of youth during the last 12 months. In the Netherlands and in Hungary a majority of respondentsâ&#x20AC;&#x2122; organizations or departments were confronted with one or more possible disruptions or breaches in care due to aggressive behavior of youth during the last 12 months (8 out of 9 respondents or 88,9% in the Netherlands, and 9 out of 12 respondents or 75,0% in Hungary) implying the linkage between unmanageable aggressive behavior of youth and the risk for disruptions or breaches in care.

Methods to prevent disruptions in care due to aggressive behavior of youth according to staff members Respondents in the first questionnaire were also asked how possible disruptions in care due to aggression could be successfully prevented. Out of a total of 12 respondents in the Netherlands and 11 in Hungary, most answers were related to modifying the type of care provided, care approach and intensifying care such as by providing more counseling conversations (n = 2), or more individual rather than group counseling conversations (n = 2), by intensifying the attention and care for this youngster or the intensity of contacts (not specified, n = 5), or by modifying the type of care in the sense that certain practices were applied (e.g. a time-out, narrative therapy or mapping of personal competences, n = 3). However, some answers were more closely related to a change in the care approach or care relationship towards the youngster or by investing in certain relevant attitudes of staff members (n = 7) such as by taking a more positive and supportive approach, by achieving more co-operation and mutual understand together with the youngster, by showing faith, by accepting some symptomatic behavior and focusing more on causes rather than symptoms, or by either maintaining more explicit expectations and agreements for youth or rather less (especially in other domains), or by investing in the care relationship or therapeutic alliance in general (not specified, n = 2). In addition, some respondents also found the implementation, adaptation and evaluation of a more clearly defined care and aggression plan useful in order to prevent a disruption in care (n = 4), by for example executing the care plan as agreed, by setting up a clear defined aggression plan in order to prevent further aggression incidents, or by evaluating and adapting the care plan. Next to that, another group of respondents mentioned the need for more support for the (resilience of a) team (e.g. by providing training and group-learning experiences in dealing with aggression) and an increased level of co-operation and discussions or meetings (e.g. about the incident and possibilities in care) in teams (n = 3). Furthermore, some respondents mentioned the involvement of external partners as mutually successful (n = 6), such as involving a neutral conciliator (e.g. during conversation about the evaluation or implementation of an aggression plan, n =1) or by looking for some external coaching and expertise (e.g. an expert in relevant topics, n = 4), or by even involving the police (n = 1). Also, respondents found involving, and more closely co-operating together with the (family-)context of the youngster helpful (e.g. by having a dialogue with the family and the youngster about the care plan or by investing in parent-counseling, n = 4). Lastly, some respondents

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Measuring is Key to Improvement – Interventions that Work in Dealing with Youth Aggression 2015-2-HU02-KA205-000984 also mentioned the necessity for a displacement of the individual youngster to another (less stressful) group in the same organization (n = 2).

Some minor differences between countries were found for this question. In the Netherlands, more answer were given related to increasing the intensity and type of care (e.g. by providing more individual counseling conversations) and investing more time and energy in the co-operation between staff, youth and their context (e.g. investing in co-operation between youngster and staff and having family counseling conversations). In the Netherlands, more answers were also related to changing the expectations and agreements such as having more, or rather, less explicit expectations for the individual youngster regarding his behavior and making more explicit agreements in a tailored care or aggression plan. Other answers were mostly convergent between both countries.

Reasons why some disruptions in care due to aggression couldn’t be prevented according to staff members When respondents in the first survey were asked why in some cases disruptions in care due to aggression could not be prevented, out of a total of 11 respondents in the Netherlands most responses were related to unmanageable problematic and aggressive behavior of youth (n = 6) such as continuous and persistent aggressive behavior (n = 2), unmanageable aggressive behavior (not specified, n = 2) and persistent aggressive behavioral patterns of both youth and their parents (n = 1), all resulting in the fact that the safety of staff and other youth was in danger (n = 1). Next to that, respondents also mention that sometimes teams are internally divided too much (n = 1) and their resiliency is depleted (n = 1), or there are too little resources to be able to adequately handle aggressive behavior (n = 2). However, in some cases there were also some issues with the type of care provided in the sense that treatment wasn’t effective for a youngster (n = 1), the organization had numerous departments and a more intense type of care was necessary (n = 1), and there are some issues with the care trajectory of a youngster (n = 2), such as when there are too many changes in care settings for a youngster and he distrusts staff or staff shift the responsibility to other youth care organizations (n = 1), or a wrong intake assessment for the youngster took place (n = 1).

In Hungary most answers were, as in the Netherlands, related to unmanageable problem or aggressive behavior of youth or uncooperative attitudes (n = 8) such as youth who don’t want to cooperate or lack the motivation for behavioral change (n = 4), persistent aggressive behavior (n = 3) and drug abuse (n = 1). Some other answers were also related to problematic external influences such as a bad relationship with peers (n = 1) and parental refusal (n = 1), or to a heavy work- and caseload of staff (n = 1).

Effective practices according to staff members in preventing disruptions in care due to aggressive behavior in youth When respondents in the first survey were asked which practices they think are the most effective to specifically prevent disruptions in care due to aggressive behavior responses were mostly divergent between countries. Out of a total of 13 respondents in the Netherlands, most answers were related to to investing in or modifying the general care approach in an organization or team (n = 8) by for example applying a pro-active (n = 1) or positive (n = 1) approach, by constantly evaluating and adapting the provided care and by learning from mistakes (n = 1), by being solution-focused (n = 1), by being available for youth (n = 1) and provide them with enough space to express emotions (n = 1) 54

Measuring is Key to Improvement â&#x20AC;&#x201C; Interventions that Work in Dealing with Youth Aggression 2015-2-HU02-KA205-000984 and by communicating open and transparent (n = 2), or to carrying out specific activities (n = 9) like looking for possibilities and opportunities for youth (not specified, n = 2), carrying out a risk-analysis (n = 1), setting goals about aggression in the care plan (n = 1), monitoring of symptoms and signals (n = 2), providing a time-out (n = 1) and supporting youth (not specified, n = 2). Another group of respondents specifically mentioned the importance of cooperating closely together with youth (n = 6, either not specified or by setting up the care plan and making agreements together, n = 1; and trying to achieve a mutual understanding, n = 1). Next to that, some respondents (n = 5) answers were related to specific actions related to aggression incidents, in the sense that they found it helpful when shortly after an aggression incident occurred, a crisis-meeting with everyone involved in the incident takes place (n = 1), a team meeting about the incident is held (not specified, n = 1; or about intensifying care or adapting care, n = 1) and by directly providing safety for those involved (n = 1) or by accurately managing aggression (not specified, n = 1). Also, according to some respondents some actions related to setting rules and boundaries were helpful (n = 5) by either trying to not be too strict or repressive (n = 1) or otherwise installing more norms and boundaries (n = 2) and providing more clearly formulated agreements, rules and expectations (n = 2). In addition, respondents also found it helpful when staff and teams were able to support and cooperate together (n = 5), by cooperating more closely together (n = 1), by receiving support and acknowledgement (e.g. from management, n = 1), by providing that everyone in the team (and if possible, the whole organization) is on the same page and acts accordingly (n = 2) and teams are not afraid to handle the situation (n = 1). In accordance to this was also the need to invest in training and education of staff members in order to deal professionally with aggression and disruptions in care (n = 2). Lastly, some answers were related to intensifying care (n = 4) by providing a more intensive coaching and counseling and providing more attention for youth (n = 3) and their context (e.g. parents, n = 1), otherwise to the need for more means and capacity (n = 1) in order to be able to provide more intensive care for youth and to provide safety, and to certain attitudes of welfare workers (n = 3) which are helpful such as a neutral, non-judgmental (n = 1) or engaged (n = 1) attitude or by showing perseverance (n = 1).

In Hungary however, out of 15 respondents most answers were related to providing training and education for youth in specific topics (n = 8), such as by focusing on self-awareness and sensitivity training (n = 3), mentalization (n = 1), aggression management (n = 1), group cohesion (n = 1), patterns of positive behavior (n = 1) and assertiveness (n = 1), or to specific activities and forms of therapy and training (n = 5) such as narrative therapy (n = 1), role playing (n = 1), conflict resolution (n = 1), outdoor education (n = 1) and a time-out activity (n = 1). Some other respondents mentioned certain attitudes of staff members that would be important such as by setting a good example for youth (n = 1) and by persuading youth to stay (n = 1). The other answers of respondents in Hungary overlapped with results in the Netherlands in the way that they were related to the need for more intensive counseling and attention for youth (n = 2), the wish for more means and capacity in order to be able to provide more intensive care and provide safety (n = 1), and by carrying out a riskanalysis (n = 1).

Other practices or actions applied by organizations when care is being threatened by a disruption in care due to aggressive behavior Respondents were also asked which other practices or actions are applied when care is being threatened by a disruption because of aggression. A total of 7 respondents in the Netherlands and 4 respondents in Hungary added some additional practices. In the Netherlands most answers referred 55

Measuring is Key to Improvement â&#x20AC;&#x201C; Interventions that Work in Dealing with Youth Aggression 2015-2-HU02-KA205-000984 to adapting the type of care or intensity of care (n = 4), by intensifying care or counseling (n = 2), by setting up multidisciplinary care by different actors (n = 1), or the need for more means to intensify care or counseling (n = 1), or to including external partners (n = 4), such as by looking for external expertise and advice (n = 2), looking for supervision (n = 1) and by talking to the referrer (n = 1).

Some other responses were related to more team support and co-operation (n = 3), such as team coaching (n = 1), or having a team-meeting on either intensifying or adapting care (n = 1) or on looking for other possibilities of care (n = 1), and the need for certain sanctions such as (temporarily) separating or isolating a youngster (n = 1), or to cooperating more closely together with a youngster in setting up a care plan for aggression and improving the resilience of all parties involved (n = 1). In Hungary the extra practices were also related to involving external partners (n = 2), by calling for help of an external expert or installing supervision in teams, or to carrying out a specific form of therapy (e.i. Narrative therapy, n = 1) and by creating support and involvement from all staff members in the organization in managing aggression accordingly (n = 1).

4. Conclusion 1. What are the most commonly used methods in preventing or managing aggressive behavior in child and youth welfare?

Evidence based programs for the prevention or management of aggressive behavior in child and youth welfare We see that most organizations that responded to the first questionnaire in the Netherlands use a number of various (inter)national evidence-based programs for the management and prevention of aggressive behavior in child and youth welfare services. 85,7% responding organizations in the Netherlands use at least one of these programs (either partly or completely) while most of them use more than one of the included programs. In Hungary only 26,7% of responding organization apply mostly (elements) of one program. This indicates that evidence-based programs in the Netherlands are being applied more broadly than in Hungary.

A difference between the Netherlands and Hungary might be due to the fact that the culture and policy in the field of investing in more evidence-based programs are divergent between both nations.

In the Netherlands, the Netherlands Youth Institute actively spreads knowledge and collects evidence on the effectiveness of programs in youth welfare, as well as promotes these programs in the working field whereas a similar organization doesnâ&#x20AC;&#x2122;t exist in Hungary. Also, the culture of doing evidence-based research and applying evidence based programs might be more widespread and endorsed in the working field in the Netherlands than in Hungary. Besides, in the Netherlands, it is common policy of government actors to expect from organizations in child and youth welfare organizations to apply evidence-based programs as a condition for their funding. This is not yet the case in Hungary.

The programs that are being applied most prevalently in the Netherlands are: 1. Sociale Vaardigheidstraining op Maat 2. Video-hometraining (VHT)

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Measuring is Key to Improvement – Interventions that Work in Dealing with Youth Aggression 2015-2-HU02-KA205-000984 3.

4.

5.

6.

7.

Rots en Water Agressie Regulatie Training op Maat Life Space Crisis Intervention (LSCI) Non-Violent Resistance (NVR) Aggression Replacement Training (ART)

In Hungary, only the following programs are being used by respondents: 1.

2.

3.

4.

5.

6.

7.

8.

Positive Peer Culture (PPC) Problem Solving Skills training (PSST) Aggression Replacement Training (ART) Life Space Crisis Intervention (LSCI) Non-Violent Resistance (NVR) Promoting Alternative Thinking Strategies (PATHS) Parent-Child Interaction Therapy (PCIT) Peacemaking Circles

Another result was that (in either country) not every program that is used is being applied in its entirety in the sense that only certain elements or aspects of programs are being applied. This implies that organizations pick and apply only some parts or elements of programs, although usually programs ought to be applied in their entirety as implied by their designers in order to attain effectiveness Commonly used practices for the prevention or management of aggressive behavior in child and youth welfare Next to specific programs, there are also some practices (actions or techniques) that are being applied by staff members in child and youth welfare settings in dealing with aggressive behavior.

The most common practices in both countries applied by staff members in youth care organizations as reported by youth when they were angry are: 1. … there was the possibility to have some time on your own (94,1%) 2. … somebody of the staff was available and accessible for you to talk to or listen to you (90,8%) 3. … somebody of the staff talked to you about the situation (89,2%) 4. … there were clear rules and boundaries regarding what kind of behavior was or wasn’t allowed (86,6%) 5. … they let you talk to the person you were angry with, to help sort things out (73,7%) While most practices were experienced as prevalent by youth in both countries, there were two exceptions. Dutch youth reported less than Hungarian youth, namely, that someone of the staff talked to them about the situation and also that a staff member let them to the person they were angry with to sort things out.

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Measuring is Key to Improvement – Interventions that Work in Dealing with Youth Aggression 2015-2-HU02-KA205-000984 2. How do professionals and youth evaluate the effectiveness of the most commonly used methods in preventing or managing aggressive behavior in child and youth welfare?

Evidence based programs for the prevention or management of aggressive behavior in child and youth welfare Based on an evaluation of the effectiveness of the most commonly used programs by applying the effect-ladder of van Yperen & Veerman (2008) and a literature review, results show that a number of different evidence-based programs are available for the prevention and management of aggressive behavior in child and youth welfare services which are evaluated as being effective.

The most effective programs for the prevention and management of aggressive behavior on a causal level are found to the be following evidence-based programs:     

Functional Family Therapy (FFT) Multisystemic therapy (MST) Parent Management Training Oregon (PMTO) Promoting Alternative Thinking Strategies (PATHS) Problem Solving Skills training (PSST)

These have all been repeatedly proven to be causally effective for the prevention and management of aggressive behavior in youth. However, a broad range of other potentially effective programs have also been developed (see the full list in the results section) and organizations in child and youth welfare services are applying a different set of either new developing programs or (elements) of these evidence-based programs. Although future initiatives for doing more research on new developing programs and on existing ones that haven’t been fully researched yet, and focusing on using the most effective programs in child- and youth welfare should be further promoted.

Effective practices for the prevention of aggressive behavior in child and youth welfare according to staff members Most professionals of youth welfare organizations in both countries found practices related to training and learning for youth in preventing aggressive behavior to be the most effective. Answers that were given related to training alternative coping strategies, emotion-regulation, developing selfknowledge and self-management abilities of youth and by providing them with insights in aggression related incidents. Applying experiential learning practices has also been found to be helpful according to some professionals.

Nevertheless, investing in a therapeutic alliance and co-operative relationship with youth (and their) context remained an important topic to invest in according to staff members, in order to prevent aggressive behavior of youth. Staff members for example did this by being committed and by trying to build a qualitative, trusting and genuine relation together with a youngster. As already mentioned in the part on general effective elements, investing in the therapeutic alliance is one of the main core effective elements of a care-relation in youth welfare services. Although preventative practices shouldn’t stop there, investing in a therapeutic alliance might work as a pre-condition in order to work on insights in behavior and to build on alternative coping strategies together with youth and to provide a main sense of belonging, acceptance and safety.

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Next to that, some professionals also mentioned certain kinds of (psycho)therapy to be helpful such as solution focused therapy, cognitive behavioral therapy and systemic therapy, while some professionals also referred to the importance of the way the care approach is applied by staff, in the sense that a positive, re-enforcing, proactive and balanced approach is helpful. Other helpful activities were related to the (early) detection and signaling of aggressive behavior, developing an aggression policy and guidelines for staff and youth, providing clear rules and agreements (also on possible actions for youth in case of stressful events or crisis) and providing time and space for youth in order to let them decompress.

Effective practices for the management of aggressive behavior in child and youth welfare according to staff members When professionals in youth care organizations were asked which practices they found the most effective in directly managing aggressive behavior of youth, results were mostly divergent between countries however answers related to similar answer categories.

In the Netherlands, most professionals found activities for letting youth calm down, decompress or de-escalate the situation the most helpful, by for example giving the youngster a time-out or referring him to a place to calm down. To some professionals this is an absolute pre-condition before being able to talk or reconnect with youngsters exposing aggressive behavior. Furthermore, some professionals found certain care-approaches and attitudes of staff members of importance in handling aggressive behavior of youth, by for example not counter-reacting aggressively, by providing youth with a series of options to give them a sense of ownership and control over the situation and by installing a positive care-approach by providing positive feedback and reinforcement on the current positive intentions of youth, and by being neutral (non-judgmental), forgiving and tolerant of the possibility of a certain level of mistakes. Next to that, providing safety in aggression incidents for all actors during and after an incident takes place is also of importance to staff, as well as applying a method for crisis-intervention and practices related to training and learning activities for youth such as social skills training, assertiveness, aggression management skills etc.

In Hungary, most answers were related to investing in the therapeutic alliance between youth and staff (e.g. investing in a positive and genuine relation with youth) and to activities related to letting youth calm down or decompress or by de-escalating the situation by letting youth have some free time or do some sport activities. Some answers were also related to training and learning activities for youth such as social skills, assertive communication and anger management. Furthermore, staff also found crisis intervention methods and handling the aggressive incident helpful (both not specified), next to specific forms of therapy, applying a positive care approach (positive feedback and reinforcement on current behavior) and to sanction youth when exposing aggressive behavior.

Effective methods for the prevention and management of angriness and frustrations in child and youth welfare according to youth When youth were asked what they found helpful in dealing with feelings of angriness whilst receiving care in a youth care setting in general, the most important thing for them was the wish to have some space, time alone, or peaceful and tranquil surroundings (e.g. to get away from a stimulus or to calm down). Second to that, another frequent answer that was given by youngsters was related to more 59

Measuring is Key to Improvement – Interventions that Work in Dealing with Youth Aggression 2015-2-HU02-KA205-000984 general activities for calming down, ways of decompressing and expressing feelings (e.g. listening to music, walking, drawing, sports, outing emotions, …) or by performing specific self-control activities (e.g. “counting to 10 in my head”). Another helpful activity according to youngsters was talking to someone about their angriness such as staff members with whom they had a good relationship, other youngster or good friends, or with the person that made them angry. Sometimes, important ways of conduct during a conversation were also expressed by youth, in the sense that they found it important that the person they talk to about their frustrations and anger listens and stays calm, explains the situation, is understanding, honest and hears them out without arguing. Lastly youth also expressed their need for comforting or calming others to help them deal with their angriness.

Youngsters were also asked about what they found staff members should do to better help them when they felt angry or frustrated. Again, most answers were related to the need to calm down first and the need for some time and space. Youngsters especially expressed their need to have some time alone to calm down, after which some youth found it okay that staff members came and talked to them when they were already calmer. Others expressed their need to be able to get some space, go outside or to someplace else, be calmed down or calm themselves down (e.g. by drawing, listen to music, walking, …). Other prevalent answers related to intervening actions of staff members such as: talking about it with the individual youngster (e.g. in a calm and collaborative way, by letting the youngster explain him- or herself, by asking what’s wrong, by providing good advice, …), by having a group conversation or by comforting the youngster.

Furthermore, some youth also referred to attitudes of staff members, like for example: that staff listen more closely to them, don’t get angry, are professional, strive for fairness or justice, are understanding or empathic, or are (more) attentive and supportive to youth.

Next to these results on open-ended questions, a series of common practices was given to be evaluated on their experienced helpfulness by youngsters. The most helpful practices in both countries applied by staff members in youth care organizations as reported by youth when they were angry are: 1. … there was the possibility to have some time on your own (92,0% found this helpful) 2. … somebody of the staff was available and accessible for you to talk to or listen to you (89,9% found this helpful) 3. … somebody of the staff talked to you about the situation (84,1% found this helpful) 4. … they gave you a time-out (74,6% found this helpful) 5. … they let you talk to the person you were angry with, to help sort things out (70,5% found this helpful) Some other remarkable results are that more youngsters in Hungary found being isolated or separated helpful rather than not helpful for them (69,4% vs. 30,6%), as was also the case for receiving medication to calm down (62,5% vs. 37,5%).

The least helpful practices in both countries applied by staff members in youth care organizations as reported by youth when they were angry are: 1. … the incident got reported to the police (90,0% didn’t find this helpful) 2. … they gave you a sanction or punishment (71,2% didn’t find this helpful) 3. … they held you down or restrained you (70,4% didn’t find this helpful) 4. … they gave you medication to calm down (45,2% didn’t find this helpful) 5. … they separated or isolated you (44,7% didn’t find this helpful)

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Effective practices for the prevention and management of aggressive behavior in child and youth welfare according to youth when youth expose aggressive behavior or are the victim of aggressive behavior In the questionnaire for youth, respondents were asked how staff could help them the best if they yelled at, hurt, threatened or bullied someone else while receiving care in child- our youth welfare.

Most answers were related to intervening actions of staff members related to: aftercare, reconciliation, or problem exploration, by especially talking to the individual youngsters involved in a conflict separately (while staff keep calm, about how to do things differently next time, exploring causes behind behavior, cheering up the individual youngster), while a lesser proportion of youth also expressed their need for staff to talk with all parties involved in the conflict together or apply reconciliation/mediation techniques. Next to that, direct intervening strategies during the conflict were also found helpful by some youngsters, such as when staff separate youth during the conflict.

Another prevalent series of answers was related to letting youth calm down and have some time and space to do so (e.g. the need for some time alone and only afterwards talk about it, or a staff member calms the youngster down). Furthermore, some youth also referred to the appliance of rules and/or sanctions, in the sense they would like to have staff members call them to account, or tell them their behavior Isn’t appropriate (and afterwards leave me alone), or by giving a sanction or let youth choose out of list of possible consequences and involving him/her in this. Lastly, some responses were related to the wish for preventive actions of welfare workers (staff are present and prevent conflicts), education and skills training such as conflict resolution, that staff members tell the youngster he’s right or to some personal actions of youngster’s to deal with the conflict such as talking to a family member or carrying out activities to calm down or decompress.

In the questionnaire for youth, respondents were also asked what they found the most helpful staff could do when they were ever the victim of aggressive behavior (yelling at, hurting, threatening or bullying) while receiving care in child- our youth welfare.

Most responses were related to the need of youth for staff to provide a form of aftercare after the conflict took place, either towards individual youngsters by comforting and calming the ‘victim’, providing medical help, give advice or by calming the ‘offender’ down, providing aftercare towards the group, by talking to both youngsters that were involved in the conflict together, having a group conversation with the whole group or by talking to different youngsters involved separately. Some youth, also mentioned the need for some time and space to calm down after the conflict by having some time on their own or to go somewhere else to calm down, and when they’re calmer have a staff member talk to them about it. Next to that, some youngsters responses were related to wishful or helpful conversational attitudes of staff, in the sense that they wanted staff to stay calm (e.g. don’t yell at me), that staff agree with the victim, listen carefully, know how to react personally to an individual youngster or are positive and solution focused.

3. How does aggressive behavior influence the trajectories of youth in child and youth welfare?

In a survey for staff we investigated possible correlations between aggression incidents of youth or the level of aggressive behavior they exposed (in the past and present) with disruptions in care, 61

Measuring is Key to Improvement â&#x20AC;&#x201C; Interventions that Work in Dealing with Youth Aggression 2015-2-HU02-KA205-000984 displacements, internal shifts in responsible staff members or living groups and the total number of encounters with different (more and less restrictive) services and settings.

Numerous correlations were found between the number of registered aggression incidents and aggressive behavior of youth and rougher pathways in care with in general, more numerous displacements (in more restrictive settings) that youth experienced. Youth who were involved in more aggression incidents namely, had more encounters with different services in child and youth welfare services, but they also had more encounters with different organizations within these different services in child and youth welfare services. Furthermore, we also noticed that aggression incidents and aggressive behavior of youth positively correlated with the number of encounters in more restricted settings in the (semi-)residential mental health care category, juvenile justice care category. A positive correlation has also been found for aggression incidents and aggressive behavior of youth and internal shifts in the organization of responsible staff members or client groups for the youngster and for the disruptions in care youth already experienced. Furthermore, for respectively 50% and 72,22% of respondents in the Netherlands and in Hungary, disruptions in care already occurred due to the aggressive behavior of a youngster.

4. Which methods for the prevention or management of aggressive behavior are helpful in preventing disruptions in care in child and youth welfare?

As already discussed above, a relation between disruptions and instable trajectories that youth experience while being in care at youth welfare services and aggressive behavior can be found.

Implying the importance of the usage of both effective methods for the prevention and management of aggressive behavior of youth in general, but also more specifically in order to prevent a breach in care when care is being seriously threatened by a disruption in care due to aggressive behavior of youth. To this extent, in a survey for professionals, respondents were asked how these possible disruptions in care due to aggression could be successfully prevented.

Most answers were related to modifying the type of care, care approach or intensifying care such as by providing more counseling conversations, or more individual rather than group counseling conversations, by intensifying the attention and care for this youngster or the intensity of contacts, and by modifying the type of care in the sense that certain practices were applied more often (e.g. a time-out or narrative therapy). Some respondents found a change in the care relationship towards the youngster important, by for example by focusing on certain relevant attitudes of staff members such as by taking a more positive and supportive approach, by achieving more co-operation and mutual understand together with the youngster, by communicating open and transparent, by showing faith, by accepting some symptomatic behavior and focusing more on causes rather than symptoms, or by either maintaining more explicit expectations and agreements for youth or rather less (especially in other domains), or by investing in the care relationship or therapeutic alliance in general. In addition, some respondents also found the implementation, adaptation and evaluation of a more clearly defined care and aggression plan useful in order to prevent a disruption in care.

Furthermore, another group of respondents mentioned the need for more support for (the resilience of) a team (e.g. by providing training and group-learning experiences in dealing with aggression) and an increased level of co-operation and discussions or meetings in teams (e.g. about the incident and possibilities in care). Equally important was that everyone in the team (and if possible, the whole organization) is on the same page and acts accordingly and teams are not afraid to handle the situation. In accordance to this was also the need to invest in training and education of staff members in order to deal professionally with aggression and disruptions in care. Some staff members also found it imperative to provide more training and education for youth in specific topics, such as 62

Measuring is Key to Improvement â&#x20AC;&#x201C; Interventions that Work in Dealing with Youth Aggression 2015-2-HU02-KA205-000984 by focusing on self-awareness and sensitivity training, mentalization, aggression management, group cohesion, patterns of positive behavior and assertiveness. Furthermore, some respondents mentioned the involvement of external partners as mutually successful, such as involving a neutral conciliator (e.g. during conversations about the evaluation or implementation of an aggression plan) or by looking for some external coaching and expertise (e.g. an expert in relevant topics). Also, respondents found involving, and more closely co-operating together with the (family-)context of the youngster helpful (e.g. by having a dialogue with the family and the youngster about the care plan or by investing in parent-counseling). Some respondents also mentioned the necessity for a displacement of the individual youngster to another (less stressful) group in the same organization.

Additionally, some other answers of professionals were related to practices such as carrying out a risk-analysis, setting goals about aggression in a care plan, monitoring of symptoms and signals and providing a time-out.

5. Discussion Research limitations and recommendations The first survey of this research aimed to collect the most prevalent or commonly used methods applied by youth welfare setting on a national level. However, due to a smaller response rate of 30% in the Netherlands and 28,85% in Hungary some caution is necessary in generalizing results as there might be some bias on the representativeness or external validity of results. We recommend future research projects to improve the number of respondents and also to carry out research in even more European countries to improve the comparability of results on an international level. Furthermore, because of the national differences in policy and structure of the youth welfare system in the Netherlands and Hungary, cross-country comparisons should be interpreted with caution.

In the second survey, due to a smaller number of respondents than expected, multivariate analyses such as a series of (logistic) regression analyses could not be carried out as planned. Therefore, analyses on the relation between aggression incidents and disruptions and trajectories of care could not be controlled for any confounding variables. This also meant the comparison between different service types was not possible at this moment. Also, because of time and budget restraints, data has been collected retrospectively for the second survey although an experimental or longitudinal research design might make more causal findings possible. Therefore, the results of the second survey should not be interpreted as causal in any way, although they provide a clear indication on the correlation between the mentioned variables.

Furthermore, in the third survey for youth, due to the differences in the mode of data-collection in each country, some bias in the results might arise due to the possibility of social desirable answers.

Also, the results collected in this survey provide an overview of the prevalence of the most common practices but not of the frequency in which these most common practices are being applied. Future research might want to investigate the frequency of applied practices and methods as well.

In general, due to time, budget and sampling restraints an in-depth comparative analysis between different service types, this is a limitation which might cause some sampling bias in the results.

Furthermore, as the focus of this research was mainly on child and youth welfare services future research might also want to duplicate findings in other settings such as (regular) educational or family settings. Another recommendation would be to investigate the relation between what youth experience as effective or helpful and how this corresponds with what methods are being applied in

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Measuring is Key to Improvement â&#x20AC;&#x201C; Interventions that Work in Dealing with Youth Aggression 2015-2-HU02-KA205-000984 an organization. Lastly, the second research question about the effectiveness of commonly used methods for the prevention and management of aggressive behavior was basically descriptive, while more research on why certain methods or elements of methods are effective is desirable on an explanatory level.

Other recommendations As aggressive behavior of youth in child and youth welfare services is such a potentially negative phenomenon for all actors involved and is proven to be related to rougher pathways and disruptions in care that youth experience in youth welfare settings, it is important that organizations find methods in order to prevent and accurately manage aggressive behavior and mitigate these negative outcomes.

To that end, we see that most organizations that responded in the first survey in the Netherlands use a number of various (inter)national evidence-based programs for the management and prevention of aggressive behavior in child and youth welfare services. 85,7% of responding organizations in the Netherlands used at least one of these programs (either partly or completely) while most of them use more than one of the included programs. In Hungary only 26,7% of responding organization apply mostly (elements) of one program. This indicates that evidence-based programs in the Netherlands are being applied more broadly than in Hungary.

A difference between the Netherlands and Hungary might be due to the fact that the culture and policy in the field on investing on more evidence-based programs are divergent between both nations. In the Netherlands, the Netherlands Youth Institute actively spreads knowledge and collects evidence on the effectiveness of programs in youth welfare, as well as promotes these programs in the working field whereas a similar organization doesnâ&#x20AC;&#x2122;t exist in Hungary. Also, the culture of doing evidence-based research and applying evidence based programs might be more widespread and endorsed in the working field in the Netherlands than in Hungary. Besides, in the Netherlands, it is common policy of government actors to expect from organizations in child and youth welfare organizations to apply evidence-based programs as a condition for their funding. This is not yet the case in Hungary.

However, we belief that applying evidence-based programs for the prevention and management of aggressive behavior (without losing focus on other general effective elements and aspects of care) is imperative in order to achieve the most effective results and highest quality for youth receiving care.

If aggressive behavior of youth is such a big influence on their care trajectories in youth welfare services, this is of an even greater importance in order to prevent unnecessary disruptions in care, displacements or other negative outcomes for youth. In European countries such as Hungary, where the usage of evidence-based programs compared to in this instance the Netherlands is still relatively small, the installment of a nationally centralized governmental or sectoral body such as the Netherlands Youth Institute, that collects evidence about effective programs and practices, does research on effective methods and validates external research, and promotes the usage of effective methods in the working field might be a facilitator for this. This is also the case on a European or international level, as we are not aware of the existence of a European organization or network collecting and disseminating information about effective methods (programs and practices) related to this subject. A recommendation for future research would also be to collect more information on this subject in more European countries. During this research project, it became also clear that due 64

Measuring is Key to Improvement – Interventions that Work in Dealing with Youth Aggression 2015-2-HU02-KA205-000984 to language and cross-cultural differences, the meaning of concepts such as ‘methods’, ‘programs’, ‘interventions’, ‘practices’, ‘models’ etc., was sometimes unclear and misinterpreted. A European organization or network setting up a standardized framework for this might also prove meaningful.

On an organizational and individual level, the focus of focusing on reaching organizational goals efficiently and effectively, while striving for social impact and implementing an organizational impact culture to support this is equally important. To openness for change and innovation should also be supported in organizations to that end.

While already an important share of organizations apply evidence-based programs and other methods, it sometimes remains a challenge of capacity (financial and structural) for organizations to a) collect the right information about programs and b) get some of their staff members trained in desired programs. Some information is restricted and some trainings seem to follow a for-profit business scheme. We do not want to undermine copy right procedures, quality control and standards of use and implementation of information and training, however, a form of more open-sourced nonfor-profit use and dissemination network (which is still monitored and peer-reviewed) for the dissemination and validation of existing methods (such as evidence-based programs) might be a solution in order to scale up the level of organizations applying effective methods for the best attainable impact for youth and children.

However, we might want to stress that although the focus on evidence-based working is desirable, it shouldn’t become the only goal, imperative and one-size-fits-all model for organizations as room for innovation, identity, preventing risks of too rigid bureaucratic structures and promoting practice based evidence might be equally important.

Another result of the research was that (in either country) evidence-based programs that are being used, are not always being applied in their entirety in the sense that only certain elements or aspects of programs are being applied. This implies that organizations pick and apply only some parts or elements of programs, although usually programs ought to be applied in their entirety as implied by their designers in order to attain effectiveness. On one hand, it should be desirable that organizations use at least elements of evidence based-programs (rather than none), while using those elements that fit well with their organizational needs and different target groups. On the other hand, this might not stand in the way of carrying out those elements of programs that are proven to be effective. However, the current research on the effectiveness of programs is most often carried out using randomized controlled trials, which says something about the effectiveness of a program in its entirety, but most often not about the effectivity of its underlying components individually or on the similarities between programs in search of shared effective components and elements. More research focusing on the effectiveness of components of programs or shared effective elements between programs might therefore be useful. One possibility for this might be increasing the use of factorial experimental designs.

Furthermore, we found that the appliance of freedom-restricting measures are still being carried out quite commonly after an aggression incident took place (e.g. restraining or isolation), although these practices are arguably beneficial for youth and are under discussion in order to prevent youth with emotional and behavioral disorders to experience new forms of complex trauma while receiving care in youth welfare services. Therefore, organizations and professionals might want to focus on alternative ways in order to better prevent and manage aggressive behavior in their organization, especially in a build-up phase in order to prevent resorting to these extreme measures.

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As a condition to implement or execute programs, professionals also mentioned that youth should be motivated in receiving care in an organization and in attending a program. However we belief that the focus should not be on the motivation of youth influencing the experience a program or the provided care is helpful or not. The focus should rather be on making it work by professionals as staff members should have the right skills and attitudes to be able to invest in the therapeutic alliance with youth. Youth normally did not voluntarily choose to receive professional care. Therefore, it might be imperative professionals rather show youth a way to change and success, instead of expecting them to be motivated. This requires a paradigm-shift. Another suggestion for a condition might be that the organizational mission, vision and goals are articulated and to implement an monitoring and evaluating system in an organization in order to monitor the results of the provided care and methods Next to that, when youth where asked how staff members could better help them if they were angry or frustrated, exposed aggressive behavior their selves, or were the victim of aggressive behavior, a relatively large proportion of youth mentioned no-one or nothing they already experienced while receiving care in youth welfare services could help them. This implies the need for youth welfare services to keep focusing on finding ways and effectively implementing methods in both attaining results related to general effective elements of care (such as the fit of care or therapeutic alliance) and appliance of specific effective methods related to the prevention and management of aggressive behavior.

Lastly, as aggressive behavior is related to disruptions and rougher pathways youth experience in child and youth welfare services, it is imperative that organizations focus on applying methods that could mitigate these risks and set up guidelines and procedures in case a crisis or possible disruption due to aggressive behavior might occur. However, developers of methods and programs should also add practices focusing on preventing these possible disruptions due to aggressive behavior in their operational framework and procedures as well.

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7. Appendices

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