Prev Sci (2016) 17:357–366
DOI 10.1007/s11121-015-0617-0
The Effects of the Moms and Teens for Safe Dates
Program on Dating Abuse: a Conditional Process Analysis
Vangie A. Foshee 1 & Thad Benefield 2 & May S. Chen 1 & Luz McNaughton Reyes 1 &
Kimberly S. Dixon 3 & Susan T. Ennett 1 & Kathryn E. Moracco 1 & J. Michael Bowling 1
Published online: 22 October 2015
# Society for Prevention Research 2015
Abstract Moms and Teens for Safe Dates (MTSD) is a dating
abuse (DA) prevention program for teens exposed to domestic
violence. In a randomized controlled trial (RCT), MTSD
prevented certain types of DA victimization (psychological
and physical) and perpetration (psychological and cyber)
among teens with higher, but not lower, exposure to domestic
violence. We built on these findings by using moderated me-
diation analysis to examine whether level of teen exposure to
domestic violence conditioned the indirect effects of MTSD
on these types of DA through targeted mediators. MTSD
consisted of six mailed activity booklets. Mothers who had
been former victims of domestic violence delivered the pro-
gram to their teens. Mother and teen pairs were recruited into
the RCT through community advertising and completed base-
line and 6-month follow-up interviews (N=277 pairs). As ex-
pected, MTSD had significant favorable effects for teens with
higher but not lower exposure to domestic violence on several
mediators that guided program content, including teen conflict
management skills and mother-perceived severity of DA, self-
efficacy for enacting DA prevention efforts, and comfort in
communicating with her teen. MTSD had significant main
* Vangie A. Foshee
foshee@email.unc.edu
1
Department of Health Behavior, Gillings School of Global Public
Health, The University of North Carolina at Chapel Hill, Rosenau
Hall, Chapel Hill, NC 27599-7400, USA
2
Carolina Mammography Registry, Department of Radiology, The
University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
3
Equal Opportunity and Compliance Office, The University of North
Carolina at Chapel Hill, CB# 9196, 137 E. Franklin St., Suite 404,
Chapel Hill, NC 27599, USA
effects on other mediators including teen feeling of family
closeness and cohesion and mother-perceived susceptibility
of her teen to DA. As expected, all significant indirect effects
of MTSD on DA outcomes through mediators were for teens
with higher exposure to domestic violence. Findings have
implications for developing DA victimization and perpetration
prevention programs for teens with high exposure to domestic
violence.
Keywords DA prevention . Teens exposed to domestic
violence . Teen dating violence . Conditional indirect effects
Although children who have been exposed to domestic vio-
lence are at increased risk of being involved in dating abuse
(DA) as teens and young adults (Ehrensaft et al. 2003; Exner-
Cortens et al. 2013; Foshee et al. 1999; Magdol et al. 1998;
O'Donnell et al. 2006), few DA prevention programs target
this high-risk group. One exception is the Moms and Teens for
Safe Dates (MTSD) program. MTSD is designed for mothers
who are former victims of domestic violence to deliver to their
teens who were exposed to the violence. The effects of MTSD
on eight DA outcomes (psychological, physical, sexual, and
cyber victimization and perpetration), and four a priori speci-
fied moderators of program effects (sex and race/ethnicity of
the teen, mothers’ psychological health, and the amount of
teen exposure to domestic violence) were tested in a random-
ized controlled trial (RCT) (Foshee et al. 2015a). MTSD had
significant effects in preventing psychological and physical
DA victimization, and psychological and cyber DA perpetra-
tion among the teens who had higher, but not lower, exposure
to domestic violence. There were no other main or condi-
tioned effects of MTSD on DA outcomes.
The purpose of the current study was to examine why
MTSD was effective at preventing DA among teens who
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had higher but not lower exposure to domestic violence.
Program content may have had greater salience for those at
higher levels of domestic violence exposure, which may have
resulted in greater program engagement. Evidence supporting
this possibility would be findings of greater impact of the
program on the theoretically and empirically based mediators
that guided program content for those with higher levels of
domestic violence exposure. Thus, the current study examined
whether and how levels of teen exposure to domestic violence
conditioned the indirect effects of MTSD on DA outcomes
through targeted mediators, including both mother- and teen-
targeted mediators.
Beyond the specific purpose of examining evidence that
might explain the moderated effects of MTSD on DA out-
comes, examining the process through which the program
had effects on intended outcomes is crucial for program de-
velopment. Constructs found to be mediators of program ef-
fects can be targeted for change in future programs, and those
found to not mediate effects can be discarded from further
consideration, resulting in more efficacious and efficient pro-
graming (Kraemer et al. 2002). Additionally, identifying the
mediators of program effects contributes to greater under-
standing of the development of problematic behaviors and
can thus inform future etiological research and interventions
for primary prevention of DA (Kraemer et al. 2002;
MacKinnon and Dwyer 1993). Yet, despite the importance
of assessing mediators of program effects, only one evaluation
of a DA prevention program has examined mediation process-
es (Foshee et al. 2005).
The MTSD Program and Targeted Mediators
MTSD consisted of six booklets of DA prevention informa-
tion and interactive activities (role plays, puzzles, games, sce-
nario analyses, guided discussions). The first booklet, Getting
Started, was for mothers only, and the other five provided
activities for mothers to do with their teens in their homes at
times convenient for the family. Based on characterizations of
teen abusive dating relationships (Mulford and Giordano
2008), the activities depict both boys and girls as perpetrators
and victims of DA and provide examples of both mutually and
unilaterally abusive relationships. The program was devel-
oped by adapting an evidence-based DA prevention program
for the general population, Families for Safe Dates (Foshee et al.
2012), for teens exposed to domestic violence. The adaptation
process is described in detail in Foshee et al. (2015b).
The overall goals of MTSD were to motivate and facilitate
the mother’s engagement with her teen in DA prevention ac-
tivities (i.e., completing the MTSD booklets) that decrease
risk factors and enhance protective factors for DA, ultimately
leading to decreases in DA victimization and perpetration.
Specifically, MTSD included information and activities
Prev Sci (2016) 17:357–366
intended to change (1) factors that motivate mother’s engage-
ment in DA prevention activities, (2) factors that facilitate
mothers’ engagement in DA prevention activities, and (3) the-
oretically and empirically based risk and protective factors for
teen DA.
Mothers are the change agents in MTSD; therefore, moti-
vating them to deliver intervention content to their teen and
facilitating their delivery of the program are imperative.
MTSD was designed to motivate mothers to engage in DA
prevention activities with their teen by increasing mothers’
beliefs that their teen could become involved in DA (per-
ceived teen susceptibility to DA), that specific negative con-
sequences could accrue to them and their teen if the teen
became involved in DA (perceived severity of DA), and that
they could potentially influence their teen’s DA behavior (re-
sponse efficacy for preventing DA). Protection motivation
theory (PMT) (Rogers 1983), which explicates conditions
needed to motivate a prevention action, informed selection
of the three motivation factors to target for change.
The program was designed to facilitate mother engagement
in DA prevention by increasing mothers’ self-efficacy, or con-
fidence, in participating in DA prevention activities with their
teen, improving their communication with their teen, and in-
creasing their knowledge of DA. Self-efficacy for performing
a preventive action is a key factor of PMT and is described as
important for enabling enactment of prevention behaviors
(Rogers 1983). Poor parent communication skills and lack
of knowledge are commonly noted barriers to parent–teen
communication about sensitive topics (Jackard et al. 2002).
Thus, improving mother communication skills with the teen
and her knowledge of DA were expected to facilitate delivery
of the program and optimize the magnitude and duration of the
program impact.
The risk and protective factors for teen DA targeted for
change included teen acceptance of DA, teen conflict manage-
ment skills, mother monitoring of the teen, and family close-
ness and cohesion. Theory and empirical findings suggest that
these are particularly salient constructs to target in DA preven-
tion programs targeted at teens exposed to domestic violence.
Social learning theory (SLT) posits that aggression is learned
from observing the positive consequences of aggression by
others (Bandura 1977). Because violence is a powerful means
of coercion and control, children who observe domestic vio-
lence may witness positive consequences from aggression,
which promotes learning of aggression and development of
an accepting attitude toward or even preference for aggression
as a means of interacting. Also, children exposed to domestic
violence often do not have the opportunity to observe the
positive consequences of constructive conflict management
skills, and thus they lack opportunities to learn skills that could
help them avoid aggression in situations of conflict.
Adolescents who have been exposed to domestic violence
have been found to be more accepting of DA and demonstrate
Prev Sci (2016) 17:357–366
poorer skills in response to conflict than those who have not
been exposed to domestic violence (Jouriles et al. 2012), and
these variables, in turn, have been found to predict both vic-
timization and perpetration of DA (Foshee et al. 1999; Lichter
and McCloskey 2004; Reitzel-Jaffe and Wolfe 2001).
Spillover theory suggests that Bemotions, affect, and
mood generated in the marital realm transfer to the par-
ent–child relationship^ (Krishnakumar and Buehler 2000;
p.26). According to this theory, parent preoccupation with
relationship problems can deplete their emotional resources
for engaging with their children, leading to inadequate
monitoring of the child’s activities and friends, lack of in-
volvement in the child’s activities, and emotional unavail-
ability for the child (Gerard et al. 2006; Krishnakumar and
Buehler 2000). Parental monitoring has been found to be
protective against DA in longitudinal studies (Capaldi and
Clark 1998; Lavoie et al. 2002). Lack of family cohesion
and closeness has also been found to predict DA perpetra-
tion (Gorman-Smith et al. 2001; Magdol et al. 1998) and
victimization (Magdol et al. 1998; Pflieger and Vazsonyi
2006), and mother–child closeness has been found to buffer
the negative effects of domestic violence on children
(Wekerle and Wolfe 1998). Thus, promoting parental mon-
itoring of the teen and family closeness and cohesion are
particularly important goals for a program targeting teens
exposed to domestic violence.
Study Hypotheses
Because MTSD had stronger effects on DA outcomes
for teens with higher than lower levels of domestic vi-
olence exposure, we posited that the proposed mediation
process described above may have occurred only for
those teens with the highest amount of exposure, pro-
ducing conditional indirect effects or moderated
mediation. Moderated mediation arises when the associ-
ation between an independent variable and a mediator
variable (the a path) varies by a moderator, or the effect
of a mediator variable on an outcome (b path) varies by
a moderator, or both (Hayes 2013). We posited that the
effect of MTSD on the mediators (i.e., the a paths)
would be moderated by teen exposure to domestic vio-
lence, producing conditional indirect effects of the pro-
gram on DA outcomes through the mediators (Fig. 1).
Specifically, we hypothesized that (1) MTSD would be
associated with changes in the proposed mediators
among teens with higher, but not lower, exposure to
domestic violence and, as a result, (2) the indirect ef-
fects of MTSD on DA outcomes through the proposed
mediators would be significant for those with higher,
but not lower, exposure to domestic violence.
359
Methods
Design
Data were drawn from a randomized controlled trial (RCT)
that assessed MTSD program effects 6 months after program
exposure. Mothers who had been in an abusive relationship
but were currently living apart from the abusive partner were
recruited into the study, along with their 12- to 15-year-old
teen who had been exposed to the domestic violence. Details
on the variety of community-based recruitment strategies used
can be found in Foshee et al. (2015b). Eligible mothers pro-
vided consent for their teen’s and assent for their own partic-
ipation; eligible teens provided assent for their own participa-
tion. Mothers and teens who consented and assented to par-
ticipate then completed a 25-min baseline telephone interview
and were subsequently randomly allocated to the treatment or
control condition. Families in the treatment group were mailed
a program booklet every 2 weeks. Families in the control
group were not sent any program materials. Nine months after
baseline (6 months post-intervention completion), the mothers
and teens were interviewed again by telephone. Study proce-
dures were approved by the University of North Carolina
Institutional Review Board.
Sample Description
A total of 409 families (mother and teen pairs) were recruited
into the study. Families were recruited from 17 states with the
majority (51 %) from North Carolina. The average age of the
teens was 13.6 years. Approximately 36 % were males;
54.8 % were black, 26.9 % were white, and the rest were of
another race. The average age of the mothers was 38.1 years.
Approximately 20 % had less than a high school education,
59.7 % were unemployed, 64.1 % were single, and 84 %
received public assistance. Approximately 66 % of the teens
had been exposed to domestic violence perpetrated by their
biological father. At baseline, 35.7 and 23.2 % of the teens had
ever been a victim of psychological and physical DA, respec-
tively. These percentages are higher than the 24.5 % (in the
past 18 months) and 10 % (in the past year) for psychological
and physical DA victimization, respectively, found in repre-
sentative samples of the general population (Centers for
Disease Control and Prevention 2008; Halpern et al. 2001,
2004). At baseline, 27.4 and 26.2 % reported ever having
perpetrated psychological and cyber DA; national estimates
from general population samples are not available for these
types of DA perpetration.
Of the 409 recruited families, 305 mothers (75 %) and 295
teens (72 %) completed follow-up interviews. There was no
significant difference between the treatment and control
groups in the amount of attrition between baseline and fol-
low-up. Also, there were no significant interactions between
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Fig. 1 Conceptual model of
study hypotheses
MTSD
Amount of Teen
Exposure to
Domestic Violence
Note. DA = Dating abuse
treatment condition and study variables on loss to follow-up,
and no main effects of these variables on loss to follow-up.
Program Exposure
Each of the five MTSD activity booklets included a card
that asked a series of questions that could be answered only
if the family had done that booklet’s activities. The card also
included a space for filling in a Bsecret code^ that was re-
vealed throughout the booklet as families carried out activ-
ities and thus served as an indicator of booklet completion.
After finishing a booklet, families answered the questions,
filled in the code, and then mailed the card to the study
office. The teens were then sent a $15 visa gift card for
completion of the booklet. Booklet completion in the treat-
ment group ranged from 80 % for the first to 62 % for the
last booklet. The amount of teen exposure to domestic vio-
lence (measure described below) was not associated with the
number of booklets completed.
Measures
Dating Abuse Outcomes
Prior to answering the questions about DA, the teens were
asked if they had ever been on a date, defined as informal
activities like going out in a group and then pairing up with
someone in whom they were interested; meeting someone
they were interested in at a mall, park, or sporting event; or
more formal activities like going out to eat or to a movie
together. If teens responded Byes,^ then they completed the
DA questions. If they responded Bno,^ they were assigned a
value of 0 on the DA outcomes. The reference period for DA
questions was lifetime at baseline and past 3 months at follow-
Prev Sci (2016) 17:357–366
Motivate Program Engagement
Mother perceived susceptibility of teen to DA
Mother perceived severity of DA
Mother response-efficacy for preventing DA
Facilitate Program Engagement
Mother self-efficacy for enacting DA prevention efforts
Mother communication skills DA Victimization
Mother comfort in communicating with teen and Perpetration
Mother knowledge of DA
Teen Risk and Protective Factors
Teen acceptance of DA
Teen conflict management skills
Mother monitoring of teen
Teen feeling of family closeness and cohesion
up. Response options to all of the DA questions ranged from
Bnever^ to Bmore than 4 times.^
Psychological DA Victimization and Perpetration
Victimization from and perpetration of psychological DA
were assessed with items from the Safe Dates Psychological
Dating Abuse Scales (Foshee 1996). To assess victimization,
teens were asked how many times a date had done the follow-
ing to them: (1) insulted them in front of others, (2) not let
them do things with other people, (3) threatened to hurt them,
(4) hurt their feelings on purpose, and (5) said mean things to
them. Parallel questions were asked to assess perpetration by
asking teens how many times they had done these things to a
date. Responses were summed to create psychological DA
victimization and perpetration composite variables.
Physical DA Victimization Victimization from physical DA
was assessed with items from the Safe Dates Physical Dating
Abuse Scale (Foshee 1996). Teens were asked how many
times the following had been done to them that was not done
in self-defense: (1) been slapped or scratched by a date, (2)
had their arm physically twisted or their fingers bent back by a
date, (3) been pushed, grabbed, shoved, or kicked by a date,
(4) been hit by a date with a fist or something hard, and/or (5)
been assaulted by a date with a knife or gun. Teens were
instructed not to count acts perpetrated against them that were
done in self-defense. Responses were summed to create the
physical DA victimization composite variable.
Cyber DA Perpetration The perpetration of cyber DA was
measured using a modified version of the Tech Abuse in Teen
Relationships Scale (Picard 2007). To assess perpetration,
teens were asked how many times they had done the following
things to a person they were dating using a cell phone, e-mail,
Prev Sci (2016) 17:357–366
IM, text messaging, Web chat, a blog, or a networking site like
MySpace or Facebook: (1) spread rumors about someone they
were dating, (2) called the person bad names, put him/her
down, or said really mean things to the person, (3) showed
private or embarrassing pictures/videos of the person to
others, and/or (4) repeatedly checked up on the person to see
where he or she was. Responses were summed to create a
cyber DA perpetration composite variable.
Moderator Variable
Amount of Teen Exposure to Domestic Violence To mea-
sure the amount of teen exposure to domestic violence,
mothers were first asked to think about the abusive partner
that the teen was around for the longest period of time. The
mothers indicated how many times this partner had used the
following abusive acts against them, Bused a knife or gun on
you,^ Bbeat you up,^ Bhit you with a fist or with something
else hard,^ Bpushed, grabbed, or shoved you,^ Bslapped or
scratched you,^ Bthreatened you with physical harm,^
Binsulted you,^ and Bdid something to humiliate you,^ and
then were asked the percentage of these times the teen had
heard or witnessed the abusive act. The number of times the
teen had witnessed or heard each of these acts was then cal-
culated and summed. As in the earlier paper (Foshee et al.
2015a), this score was coded into even quartiles, with the
highest score (3) indicating the greatest amount of exposure
to domestic violence and the lowest score (0) indicating the
least amount of exposure.
Targeted Mediating Variables Measurement of the targeted
mediating variables is described in Table 1. All of the media-
tors, except for teen acceptance of DA, teen conflict manage-
ment skills, and teen feeling of family closeness and cohesion,
which were measured with established scales, were created
specifically for the MTSD RCT as needed to match program
content.
Analytical Strategy
An intent-to-treat approach was used in all analyses; that is,
analyses were based on the treatment condition families were
assigned to, not on the amount of treatment received (Wright
and Sim 2003). Linear regression was performed using PROC
GLM in SAS 9.3. (SAS Institute Inc. 2012) to test the first set
of hypotheses, that the effects of MTSD on each of the
targeted mediators would be conditioned by teen exposure to
domestic violence. Each proposed mediator was regressed on
treatment condition (0=control and treatment=1), teen level
of exposure to domestic violence, the control variables (teen
sex, race/ethnicity, age in years, and follow-up dating status,
and mother’s education level), the baseline value of the pro-
posed mediator, and the interaction between treatment
361
condition and teen exposure to domestic violence. Post hoc
analyses of significant interactions were conducted to deter-
mine the significance of the association between treatment
condition and the proposed mediator at high (1 standard devi-
ation above the mean), medium (the mean), and low (1 stan-
dard deviation below the mean) levels of teen exposure to
domestic violence (simple slopes). If the interaction was not
significant, it was dropped from the model and the main effect
of MTSD on the mediator was examined.
Next, analyses were conducted to test the second set of
hypotheses, that the indirect effects of the program on DA
outcomes through the mediators would be conditioned by
the amount of exposure the teen had to domestic violence.
For these analyses we used the SAS PROCESS computational
macro which was developed specifically to test for conditional
indirect effects (Hayes 2013). Separate models for each DA
outcome were specified to examine conditional indirect ef-
fects of MTSD on the DA outcome through the proposed
mediators, controlling for the baseline measures of the medi-
ators, the baseline measure of the specific DA outcome
(referencing a lifetime time period), and the control variables.
Each model was specified to accommodate our expectations
that the associations between treatment condition and the pro-
posed mediators would be moderated by teen exposure to
domestic violence (conditional a paths). The models also in-
corporated our previous findings that the associations between
treatment condition and DA outcomes were conditioned by
teen exposure to domestic violence. The indirect effects of
MTSD on each DA outcome through each mediator at the
three previously defined levels of teen exposure to domestic
violence (high, medium, low) were estimated using
bootstrapping, a non-parametric method that provides greater
power for detecting indirect effects than other methods (Hayes
2013; Preacher and Hayes 2008). PROCESS addresses miss-
ing data through listwise deletion. Therefore, all analyses, in-
cluding the regression analyses, were conducted with a sample
of 277 teens and mothers who completed baseline and follow-
up data collection and were not missing data on any of the
study variables.
Results
Main and Conditioned Effects of MTSD on Proposed
Mediators
Table 2 presents the findings from the regression analyses
testing the first set of hypotheses that the effects of MTSD
on the proposed mediators would be conditioned by teen ex-
posure to domestic violence. As expected, the effects of
MTSD on several of the proposed mediators were conditioned
by teen exposure to domestic violence in the hypothesized
direction. Specifically, MTSD was significantly associated

Table 1 Measurement of mediating variables
Variable
Factors motivating mother engagement in DA prevention activities
Mother perceived susceptibility of
teen to DA
Mother perceived severity of DA
Mother response efficacy for
preventing DA
Factors facilitating mother engagement in DA prevention activities
Mother self-efficacy for enacting
teen DA prevention
Mother communication skills
with teen
Mother comfort in communicating
with her teen
Mother knowledge of DA
Risk and protective factors
Teen acceptance of DA
(Foshee et al. 2005)
Teen conflict management skills
(Foshee et al. 2005)
Maternal monitoring of teen
Teen feeling of family closeness and
cohesion (Office of Applied Studies 2000;
Simpson and McBride 1992)
DA dating abuse, N/A not applicable
362
No. of items Response categories Item or example item
(follow-up alpha)
4 (.85) 1=very unlikely to 4=very likely BCompared to other teens [TEEN’S NAME] age, how likely or unlikely is it
that [HE/SHE] will become a victim of psychological or emotional DA
in the future?^
3 (.60) 1=strongly agree to 4=strongly disagree BIf a teen is frequently insulted by a date it is not that big a deal as long as there
is no physical violence.^
5 (.68) 1=strongly disagree to 4=strongly agree BTalking to [TEEN’S NAME] about DA will decrease [HIS/HER] chances of
abusing dates^
5 (.70) 1=not confident at all to 4=very confident BHow confident do you feel in your ability to talk to [TEEN’S NAME] about
teen DA?^
5 (.65) 1=never to 4=very often BDuring the last 3 months when you and [TEEN’S NAME] had a disagreement,
how often did you suggest a possible solution?^
2 1=very hard to 4=very easy BIn general, how hard or easy is it for you to talk to [TEEN’S NAME] about
things that are personal to [HIM/HER]?^
5 (N/A) 1=true, 2=false Coded to be proportion correct BAbout 5 % of teens have been physically abused by a date.^
11 (.84) 0=strongly disagree to 4=strongly agree BIt is OK for a girl to hit her boyfriend if he insulted her in front of friends.^
BA girl who makes her boyfriend jealous on purpose deserves to be hit.^
13 (.69) 1=never to 4=very often BDuring the last 3 months, when you were angry with someone, how often
would you say that you explained to the person why you were angry?^
7 (.78) 1=not like you to 4=very like you BYou find out where [TEEN’S NAME] is going when [HE/SHE] goes out.^
BYou try to meet [TEEN’S NAME] friends.^
11 (.90) 1=never to 4=very often BHow often does your mother cheer you up when you are sad?^
1=not close at all to 5=extremely close BIn the past 3 months, how often was there a feeling of togetherness in
your family?^
BHow close do you feel towards your mother?^
Prev Sci (2016) 17:357–366
Prev Sci (2016) 17:357–366 363

Table 2 Effects of MTSD on the proposed mediating variables (N=277)

Targeted outcome Main effect coef (se) Interactiona coefficient if significant

Factors motivating mother engagement in DA prevention activities

Mother perceived susceptibility of teen to DA −0.191 (0.09)*
Mother perceived severity of DA −0.055 (0.058) 0.071 (0.031)*
Mother response efficacy for preventing DA 0.088 (0.077) –
Factors facilitating mother engagement in DA prevention activities
Mother self-efficacy for enacting DA prevention efforts −0.139 (.089) 0.150 (0.048)**
Mother communication skills with teen 0.047 (0.044) –
Mother comfort in communicating with teen −0.154 (0.147) 0.162 (0.079)*
Mother knowledge of DA 0.005 (0.019) –
Risk and protective factors for DA
Teen acceptance of DA −0.117 (0.068) ‡ –
Mother monitoring of teen 0.061 (0.065) 0.108 (0.557) ‡
Teen conflict management skills −0.047 (.087) 0.133 (.047) **
Teen feeling of family closeness and cohesion 0.177 (.085)* –

All analyses control for teen age in years, sex (0=female; 1=male), race/ethnicity (white and other with the reference for both being black) and dating
status (ever dated or not), mother’s education level (exactly high school and more than high school with the reference for both being not graduating from
high school), and baseline levels of the outcome. Bold indicates significance at p<.05
DA dating abuse
‡
p<.10; *p<.05;**p<.01;***p<.001
a
Significant interaction between treatment condition and level of teen exposure to domestic violence

with greater mother perceived severity of DA when teen ex-
posure to domestic violence was high (b=.1576; p=.0107),
but not when teen exposure was medium (b=.0514; p=.1638)
or low (b=−.0548; p=.3482). MTSD exposure was signifi-
cantly related to greater mother self-efficacy when teen expo-
sure was high (b=.3103; p=.0011), but not when it was me-
dium (b=.0856; p=.1299) or low (b=−.1392; p=.1200). The
program was also significantly related to greater mother com-
fort in communicating with her teen when teen exposure to
domestic violence was high (b=.3322; p=.0319), but not
when it was medium (b = .0889; p = .3373) or low (b =
−.1544; p=.2929). Additionally, MTSD exposure was signif-
icantly associated with improved teen conflict management
skills among teens with high (b=.3506; p=.0002) and medi-
um (b=.1517; p=.0064), but not low (b=−.0473; p=.5895),
exposure to domestic violence. Finally, there was a marginal
conditional effect of MTSD on mother monitoring (b=.1080;
p=.053) and the trend was in the direction hypothesized;
MTSD was associated with more monitoring among teens of
high (b = .2300; p = .0350), but not medium (b = .0680;
p=.2979) or low (b=−.0941; p=.3629), exposure.
Contrary to expectations, the effects of MTSD on
other proposed mediators were not conditioned by teen
exposure to domestic violence. There was a main effect
of MTSD on mother perceived susceptibility of teen to
DA, but the association was opposite that expected;
MTSD was associated with lower rather than higher
mother perceived susceptibility of her teen to DA.
MTSD had a significant main effect on teen feeling of
family closeness and cohesion such that teens exposed
to the program reported feeling more family closeness
and cohesion at follow-up than those not receiving the
program. Additionally, there was a marginally signifi-
cant negative effect of MTSD on teen acceptance of
DA (b = −0.117; p = .07); teens receiving the program
had less acceptance of DA at follow-up than those not
receiving the program.
Conditioned Indirect Effects
The mediators that were included in the four PROCESS
models testing conditional indirect effects were those
that were found in the regression analyses to be affected
by MTSD (at p<.10) as either main or conditioned ef-
fects (mother perceived susceptibility of teen to DA,
perceived severity of DA, self-efficacy, comfort in com-
municating with her teen, and monitoring, and teen ac-
ceptance of DA, conflict management skills, and feeling
of family closeness and cohesion).
As expected, all of the indirect effects (IE) that were signifi-
cant were significant only for teens with higher exposure to
domestic violence. The indirect effects of MTSD on psycho-
logical DA victimization through teen conflict management
skills and teen feeling of family closeness and cohesion were
significant at higher but not lower levels of teen exposure.
Specifically, the indirect effect of MTSD on psychological
364
DA victimization through teen conflict management skills was
significant when teen exposure was high (IE = −0.180,
CI = −0.4484, −0.0350) and medium (IE = −0.0792, CI =
−0.2143, −0.0141), but not when it was low (IE=0.0211,
CI=−0.0678, 0.2013). The indirect effect of MTSD on psy-
chological DA victimization through teen feeling of family
closeness and cohesion was significant when teen exposure
was high (IE = −0.0885, CI= −0.2457, −0.0041), but not
when it was medium (IE=−0.0382, CI=−0.1365, 0.0150)
or low (IE=0.0122, CI=−0.0660, 0.1077).
As with psychological DA victimization, the indirect effect
of MTSD on physical DA victimization through teen conflict
management skills was significant when teen exposure was
high (IE=−0.1192, CI=−0.2831, −0.0297) and medium (IE=
−0.0531, CI=−0.1504, −0.0110), but not when it was low
(IE=0.0131, CI=−0.0429, 0.1267). Unlike with psychologi-
cal DA victimization, the indirect effect of MTSD on physical
DA victimization through teen feeling of family closeness and
cohesion was not significant at any level of teen exposure.
The indirect effects of MTSD on psychological DA perpe-
tration through teen conflict management skills, teen feeling
of family closeness and cohesion, and teen acceptance of DA
were significant at higher, but not lower, levels of teen expo-
sure. More specifically, the indirect effect of MTSD on psy-
chological DA perpetration through conflict management
skills was significant when teen exposure was high (IE=
−0.1395, CI=−0.3572, −0.0352), and medium (IE=−0.0633,
CI=−0.1644, −0.0133), but not when low (IE=0.0128, CI=
−0.0560, 0.1326). The indirect effect of MTSD on psycholog-
ical DA perpetration through teen feeling of family closeness
and cohesion was significant when teen exposure was high
(IE=−0.0652, CI=−0.1876, −0.0002), but not when exposure
was medium (IE=−0.281, CI=−0.1112, 0.0086) or low (IE=
0.0089, CI=−0.0475, 0.847). Likewise, the indirect effect of
MTSD on psychological DA perpetration through teen accep-
tance of DA was significant when teen exposure was high
(IE=−0.1174, CI=−0.3426, −0.0052), but not when exposure
was medium (IE=−0.0720, CI=−0.2314, 0.0009) or low (IE=
−0.0266, CI=−0.2127, 0.0738).
The indirect effect of MTSD on cyber DA perpetration
through teen acceptance of DA was significant at higher, but
not lower, levels of teen exposure. More specifically, the in-
direct effect of MTSD on cyber DA perpetration through teen
acceptance of DA was significant when teen exposure was
high (IE = −0.0732, CI =−0.2331, −0.0088), and medium
(IE=−0.0452, CI= −0.1449, −0.0010), but not when low
(IE=−0.0172, CI=−0.1255, 0.0490).
Finally, contrary to expectations, we found no indi-
rect effects (conditional or unconditional) of the pro-
gram on DA outcomes through mother-perceived sus-
ceptibility of teen to DA, perceived severity of DA,
self-efficacy, comfort in communicating with her teen,
or monitoring.
Prev Sci (2016) 17:357–366
Discussion
In earlier analyses, MTSD was found to be effective in
preventing psychological and physical DA victimization and
psychological and cyber DA perpetration among teens with
higher but not lower levels of exposure to domestic violence
(Foshee et al. 2015a). The current study examined a possible
explanation for those findings: that MTSD may have been
more effective among teens with higher domestic violence
exposure in changing the theoretically and empirically based
mediators that guided program content, which led to stronger
program effects on DA for high exposure teens. In general, we
found support for this explanation in that MTSD had signifi-
cant effects on several of the proposed mediators for teens
with higher but not lower exposure to domestic violence,
and all of the significant indirect effects of MTSD on DA
outcomes through mediators were for teens with higher expo-
sure to domestic violence.
MTSD was effective among teens with higher, but not
lower, exposure to domestic violence at increasing the
mothers’ perceptions of the severity of DA, self-efficacy
for enacting DA prevention efforts, and comfort in commu-
nicating with the teen and at improving the teens’ conflict
management skills. However, MTSD had significant effects
on mother-perceived susceptibility of her teen to DA and
teen feeling of family closeness and cohesion, and margin-
ally significant effects on teen acceptance of DA regardless
of the level of exposure to domestic violence. The effects of
MTSD on all of the mediators were in the expected direc-
tion, except for the effects on mother perceived susceptibil-
ity of the teen to DA; mothers who received MTSD per-
ceived their teen to be less rather than more susceptible to
DA than those who did not receive MTSD. Perhaps these
mothers believed that the program Binoculated^ their teen
against future involvement in DA.
Teen acceptance of DA, teen conflict management skills,
and teen feeling of family closeness and cohesion significantly
mediated the effects of MTSD on DA outcomes among teens
with higher exposure to domestic violence; the specific medi-
ator(s) varied depending on the DA outcome. There were no
significant indirect effects of the program on DA outcomes
through the mediators for teens with lower exposure to do-
mestic violence. Although there were significant main or con-
ditioned effects of MTSD on several mother motivation and
facilitating variables, none of these variables were significant
mediators of the MTSD and DA relationships for teens at any
level of exposure to domestic violence. However, changes in
these constructs due to the program may have indirectly af-
fected DA by enhancing delivery of program content that
targeted changes in teen risk and protective factors, which
did mediate program effects.
The findings have implications for practice and future re-
search. Key constructs were identified (teen acceptance of
Prev Sci (2016) 17:357–366
DA, teen conflict management skills, and family closeness
and cohesion) that can be targeted for change in DA preven-
tion programs designed for teens with high levels of exposure
to domestic violence. Our findings demonstrated that those
constructs can be changed through intervention, even in this
very high risk group, and result in the prevention of DA.
These constructs link to theoretical explanations, specifically
social learning theory (Bandura 1977) and spillover theory
(Krishnakumar and Buehler 2000) for why exposure to do-
mestic violence may increase risk for DA. Tenants of the the-
ories could be drawn on in developing future DA prevention
programs targeting teens with high exposure to domestic vio-
lence. These constructs should also inform areas to focus on in
future theory-based etiological research on the development
of DA among high-exposure teens. Study findings also poten-
tially inform more efficient programing in that they inform
how to limit the scope of what is targeted for change in pro-
grams so that unnecessary program content (targeting ineffec-
tual constructs) is not developed and delivered. Other RCTs of
MTSD are needed to determine if the findings can be replicat-
ed; such trials need to include process data, beyond simply the
number of booklets completed, that would allow for examin-
ing why MTSD was more effective at changing the proposed
mediators for teens with higher than lower domestic violence
exposure, if that finding should be replicated, and also why the
changes that occurred in some mediators (teen acceptance of
DA and family closeness and cohesion) for all teens resulted
in prevention of DA for only those at the highest exposure.
The primary study limitation relates to the external validity,
or generalizability, of study findings. MTSD is designed for
administration by mothers who no longer live with an abuser
because of the potential dangers inherent in delivering a teen
DA prevention program in homes where domestic violence is
currently occurring. Whether the findings are applicable for
teens whose mothers still live with the abuser is not known.
Also, the sample for the RCT was a convenience sample that
was primarily of low socio-economic status (SES) families.
Thus, the study findings may not generalize to teens at higher
SES levels who are exposed to domestic violence. However,
there are few sampling options other than convenience sam-
pling for identifying teens exposed to domestic violence.
Also, attrition in the RCT was fairly high, which may influ-
ence the generalizability of study results. However, none of
the study variables were associated with attrition, suggesting
that the analytic sample represented the sample of families
recruited into the trial.
Another limitation is that most of the measures of the
mediators were created for the study and therefore had
not been subjected to prior validity and reliability test-
ing. However, creating measures was necessary when
standardized measures for constructs were not available.
Also, creating measures allowed for tailoring them to
the content of the program. The exposure to domestic
365
violence variable was limited by the possibility that
mothers may have under- or over-reported teen expo-
sure. Teen reports were not collected but there are lim-
itations to assessing exposure to domestic violence from
children/teens as well, and there is no consistency in
recommendations about whether exposure reports are
more accurate from the parent or the child (Edleson
et al. 2007).
The study had many strengths. The RCT design eliminated
many potential threats to the internal validity of the findings.
Contamination between the treatment and control groups was
minimal because the families in the trial were spread out over
a large geographic area; thus, the integrity of the design was
maintained. Participation in the program was relatively high,
especially given the high-risk sample. The mediators guiding
program content were based on theory and empirical findings
and were specified a priori. The study statistically tested for
mediation, which has rarely been done in evaluations of DA
prevention programs.
In conclusion, our findings suggest that the greater effects
of MTSD on certain types of DA victimization and perpetra-
tion for teens with higher exposure to domestic violence that
were found in earlier analyses (Foshee et al. 2015a) may have
been attained because the program was also more effective at
changing targeted mediator variables that guided program
content for those teens. Aiming to improve teen conflict man-
agement skills, increase teen feeling of family closeness and
cohesion, and decrease teen acceptance of DA in future DA
prevention programs for teens with high domestic violence
exposure offers promise because we demonstrated that these
constructs are modifiable through intervention and that mod-
ification of them led to the prevention of certain types of DA
among the high exposure teens. Although limitations of the
MTSD program are that it was not effective at preventing DA
for teens at all levels of exposure, and it was not effective at
preventing certain types of DA for any teens, a strength of the
program is that it was effective at preventing DA among the
highest-risk teens because there have been noted challenges to
preventing problem behaviors among very high risk teens
(Dutton et al. 2003).
Acknowledgements This research was supported by a grant from the
National Institute of Justice [NIJ 2008-WG-BX-1003; PI Vangie A.
Foshee] which was administered through the Injury Prevention Research
Center at the University of North Carolina at Chapel Hill (UNC-CH) and
by a grant from the Centers for Disease Control and Prevention [CDC
R01CE001867-01; PI Vangie A. Foshee] which was administered
through the Department of Health Behavior at UNC-CH. The study
was reviewed and approved by the Public Health-Nursing Institutional
Review Board for the Protection of Human Subjects at UNC-CH.
Compliance with Ethical Standards
Conflict of Interest None of the authors have any conflicts of interest
associated with this study.
366
References
Bandura, A. (1977). Social learning theory. Englewood Cliffs: Prentice-
Hall.
Capaldi, D. M., & Clark, S. (1998). Prospective family predictors of
aggression toward female partners for at-risk young men.
Developmental Psychology, 34, 1175–1188.
Centers for Disease Control and Prevention. (2008). Surveillance
Summaries. MMWR. Morbidity and Mortality Weekly Report, 57,
1–131.
Dutton, M. A., Holtzworth-Monroe, A., Jouriles, E., McDonald, R.,
Krishnan, S., McFarlane, J., & Sullivan, C. (2003). Recruitment
and retention in intimate partner violence research. Washington
DC: National Institute of Justice.
Edleson, J. L., Ellerton, A. L., Seagren, E. A., Kirchberg, S. L., Schmidt,
S. O., & Ambrose, A. T. (2007). Assessing child exposure to adult
domestic violence. Children and Youth Services Review, 29, 961–
971.
Ehrensaft, M. K., Cohen, P., Brown, J., Smailes, E., Chen, H., & Johnson,
J. G. (2003). Intergenerational transmission of partner violence: A
20-year prospective study. Journal of Consulting and Clinical
Psychology, 71, 741–753.
Exner-Cortens, D., Eckenrode, J., & Rothman, E. (2013). Longitudinal
associations between teen dating violence victimization and adverse
health outcomes. Pediatrics, 71, 71–78.
Foshee, V. (1996). Gender differences in adolescent dating abuse
prevalence, types, and injuries. Health Education Research,
11, 275–286.
Foshee, V. A., Bauman, K. E., & Linder, G. F. (1999). Family violence
and the perpetration of adolescent dating violence: Examining social
learning and social control processes. Journal of Marriage and the
Family, 61, 331–342.
Foshee, V. A., Bauman, K. E., Ennett, S. T., Suchindran, C., Benefield, T.,
& Linder, G. F. (2005). Assessing the effects of the dating violence
prevention program BSafe Dates^ using random coefficient regres-
sion modeling. Prevention Science, 6, 245–258.
Foshee, V. A., Reyes, H. L. M., Ennett, S. T., Cance, J. D., Bauman, K. E.,
& Bowling, J. M. (2012). Assessing the effects of Families for Safe
Dates, a family-based teen DA prevention program. Journal of
Adolescent Health, 51, 349–356.
Foshee, V. A., Benefield, T., Dixon, K. S., Chang, L, Senkomago, V.,
Ennett, S. T., … Bowling, J. M. (2015). The effects of Moms and
Teens for Safe Dates, a dating abuse prevention program for adoles-
cents exposed to domestic violence. Journal of Youth and
Adolescence, 44, 995–1010.
Foshee, V. A., Dixon, K. S., Ennett, S. T., Moracco, K. E., Bowling, J. M.,
Chang, L., & Moss, J. L. (2015b). The process of adapting a uni-
versal DA prevention program to adolescents exposed to domestic
violence. Journal of Interpersonal Violence, 30, 2151–2173.
Gerard, J. M., Krishnakumar, A., & Buehler, C. (2006). Marital conflict,
parent–child relations, and youth maladjustment: A longitudinal in-
vestigation of spillover effects. Journal of Family Issues, 27, 951–
975.
Gorman-Smith, D., Tolan, P. H., Shiedow, A. J., & Henry, D. B. (2001).
Partner violence and street violence among urban adolescents: Do
the same family factors relate? Journal of Research on Adolescence,
11, 273–295.
Halpern, C. T., Oslak, S. G., Young, M. L., Martin, S. L., & Kupper, L. L.
(2001). Partner violence among adolescents in opposite-sex roman-
tic relationships: Findings from the National Longitudinal Study of
Adolescent Health. American Journal of Public Health, 91, 1679–
1685.
Halpern, C. T., Young, M. L., Waller, M., Martin, S. L., & Kupper, L.
(2004). Prevalence of partner violence in same-sex romantic and
Prev Sci (2016) 17:357–366
sexual relationships in a national sample of adolescents. Journal of
Adolescent Health, 35, 124–131.
Hayes, A. F. (2013). Introduction to mediation, moderation, and condi-
tional process analysis: a regression-based approach. New York:
Guilford Press.
Jackard, J., Dodge, T., & Dittus, P. (2002). Parent teen communication
about sex and birth control: A conceptual framework. In S. Feldman
& D. A. Rosenthal (Eds.), Talking sexuality: parent-teen
communication (pp. 9–41). San Francisco: Jossey-Bass.
Jouriles, E. N., McDonald, R., Mueller, V., & Grych, J. H. (2012). Youth
experiences of family violence and teen dating violence perpetra-
tion: Cognitive and emotional mediators. Clinical Child and Family
Psychology Review, 15, 58–68.
Kraemer, H. C., Wilson, G. T., Fairburn, C. G., & Agras, W. S. (2002).
Mediators and moderators of treatment effects in randomized clini-
cal trials. Archives of General Psychiatry, 59, 877–883.
Krishnakumar, A., & Buehler, C. (2000). Interparental conflict and par-
enting behaviors: A meta-analytic review. Family Relations, 49, 25–
44.
Lavoie, F., Hebert, M., Tremblay, R., Vitaro, F., Vezina, L., & McDuff, P.
(2002). History of family dysfunction and perpetration of dating
violence by adolescent boys: A longitudinal study. The Journal of
Adolescent Health, 30, 375–383.
Lichter, E. L., & McCloskey, L. A. (2004). The effects of childhood
exposure to marital violence on adolescent gender-role beliefs and
dating violence. Psychology of Women Quarterly, 28, 344–357.
MacKinnon, D. P., & Dwyer, J. H. (1993). Estimating mediated effects in
prevention studies. Evaluation Review, 17, 144–158.
Magdol, L., Moffitt, T. E., Caspi, A., & Silva, P. A. (1998).
Developmental antecedents of partner abuse: A prospective-
longitudinal study. Journal of Abnormal Psychology, 107, 375–389.
Mulford, C., & Giordano, P. C. (2008). Teen dating violence: A closer
look at adolescent romantic relationships. NIJ Journal, 261, 34–40.
O'Donnell, L., Stueve, A., Myint-U, A., Duran, R., Agronick, G., &
Wilson-Simmons, R. (2006). Middle school aggression and subse-
quent intimate partner physical violence. Journal of Youth and
Adolescence, 25, 693–703.
Office of Applied Studies. (2000). National household survey on drug
abuse: CAI specs for programming. Rockville: Substance Abuse
and Mental Health Services Administration.
Pflieger, J. C., & Vazsonyi, A. T. (2006). Parenting processes and dating
violence: The mediating role of self-esteem in low-and high-SES
adolescents. Journal of Adolescence, 29, 495–512.
Picard, P. (2007). Tech abuse in teen relationships study: a report pre-
pared for Liz Clairborne Inc. Northbrook: Teenage Research
Unlimited (TRU).
Preacher, K. J., & Hayes, A. F. (2008). Asymptotic and resampling strat-
egies for assessing and comparing indirect effects in multiple medi-
ator models. Behavior Research Methods, 40, 879–891.
Reitzel-Jaffe, D., & Wolfe, D. A. (2001). Predictors of relationship abuse
among young men. Journal of Interpersonal Violence, 16, 99–115.
Rogers, R. (1983). Cognitive and physiological processes in fear based
attitude change: A revised theory of protection motivation. In J.
Cacioppo & R. Petty (Eds.), Social psycho-physiology: a
sourcebook (pp. 153–176). New York: Guilford Press.
SAS Institute Inc. (2012). SAS Software, Version 9.3. Cary: SAS Institute
Inc.
Simpson, D. D., & McBride, A. A. (1992). Family, Friends, and Self
(FFS) assessment scales for Mexican American Youth. Hispanic
Journal of Behavioral Sciences, 14, 327–340.
Wekerle, C., & Wolfe, D. A. (1998). The role of child maltreatment and
attachment style in adolescent relationship violence. Development
and Psychopathology, 10, 571–586.
Wright, C. C., & Sim, J. (2003). Intention-to-treat approach to data from
randomized controlled trials: A sensitivity analysis. Journal of
Clinical Epidemiology, 56, 833–842.
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