The Hand that Rocks the Cradle (2005) Thursday, July 28, 2022 This article was originally published on on 1st January 2003 by former WAVE Trust CEO George Hosking OBE. WAVE (Worldwide Alternatives to Violence) was formed in 1996 to develop an understanding of the causes of violence - especially child abuse - and to research effective measures to reduce it. Seven years of research have produced the following conclusions: Violence is on the increase. It has two interactive components: propensity to violence (personal factors) and triggers (social factors). Social factors reflect long-term cultural shifts and are unlikely to be reversed. The prime time when humans develop the propensity to violence is as infants aged 0-3 years. Effective measures to reduce significantly the propensity for violence already exist. These measures are a sound economic investment. Devoting resources to improving infant care is our best hope of producing peaceable citizens - "The hand that rocks the cradle" really does shape the world. Violence is on the increase Recorded violence in the UK rose 34-fold between 1950 and 1997(1) While some of this increase reflects more accurate reporting, the actual increase was still huge. Similar trends are found in the United States, Canada, Australia and Western Europe. The statistics are horrifying, and I will not catalogue them here (see WAVE's web site, wavetrust.org). Instead, I will focus on what can be done to alter the patterns that produce the problem. Violence has two interactive components There are two necessary elements for violence: the potential and the circumstances causing the violence to be acted out. Using the analogy of an exploding bomb for violence, we can make the distinction between the propensity (the bomb) and the triggering of violence (the fuse to set off a bomb). Both the propensity and the trigger must be present for a violent act to take place. Social factors reflect long-term shifts in society and are unlikely to be reversed There are arguments that violence is encouraged by social factors such as economic inequality, deprivation of justice, extreme poverty, low wages, social isolation, overcrowding and poor housing. A culture of violence, absence of moral or spiritual teaching and ready availability of firearms are also plausible contributors. There is growing evidence that diet may play a role. Yet while all are credible contributors, violence in western nations rose sharply in the second half of the 20th Century while many of these factors actually improved.(2) Most violence is carried out by adolescents, and part of the huge rise in violence in recent years related to a change in triggering factors affecting them. Research on this topic is scant(3) but, based on what has been seen, WAVE finds the most likely contributory causes to include: longer gestation period between adolescent males achieving puberty and beginning work; sharp rise in teenage alcohol consumption; growth of television viewing, modelling violent behaviour, and the huge expansion in the territory young males can cover, far beyond areas where they are known, accompanied by much reduced supervision of their leisure behaviour. These "fuses" are social issues, and this article does not address them because the research underpinning our conclusions about the triggers to violence is, as yet, too incomplete. Besides, solutions for society are challenging, to put it mildly. We may change diet, but its impact is unlikely to be major. It is unlikely that as a society we will successfully prevent alcohol consumption by under-18s, remove violence from television, send adolescents to work at puberty, restrict their movements to areas where they are known, or return parental supervision to that more typical of the 1930s. Removing poverty is a challenge society could meet, but has so far been unwilling to pay for. In view of these difficult realities, the approach recommended by WAVE gives priority to stopping the creation of the bombs, rather than reducing the number of fuses. Many people get drunk, watch violent television, eat fast food and own a car, but do not turn to violence. Our question has been "What is it that causes those who do so to become violent?" In the absence of a bomb, a fuse is not dangerous. If it is unrealistic to ban the production of fuses, let us at least do what we can to minimise the number of bombs running around our streets and running our families. The cycle of violence Genetic influences may play a part in the propensity to violence, but are typically activated by early-life experience.(4) WAVE has concluded that the prime causes of violence lie in experience of family life, and begin very early. Within this overall pattern we found child abuse has a central role. Despite decades of attention to this issue, child protection agencies report that abuse today is at least as serious a problem as it was 50 years ago. A key factor in this persistence, demonstrated in numerous studies, is the transmission of patterns of violence and abuse from one generation to another - the cycle of violence.(5) 30-40% of children who suffer abuse or neglect go on to abuse or neglect their own children.(6), (7), (8) These same child victims are the most likely to grow up and perpetrate domestic violence, to commit violent crimes and to suffer mental health problems, both as children and as adults. Many of you will be familiar with the famous remark of Cambridge University professor of psychological criminology David Farrington, following a study of South London children between ages 8 and 32: "Anti-social children grow up to become anti-social adults who go on to raise anti-social children".(9) Some of the evidence Our research showed overwhelming evidence for the following conclusions, which represent only a fraction of the material reviewed and evaluated. Harsh Parental discipline trains violence Parents justify abusive punishment as being "for the child's own good" (see Alice Miller(10)). A great deal of severe child abuse is described as a "slap" or a "tap" by abusing parents. I am familiar with the phrase "just gave him a slap" from my work with violent offenders, when they describe incidents in which they have broken the jaws and ribs of people who crossed them as "just gave him a slap". Analysis of parents' thought patterns when committing abuse shows they often have unrealistic expectations, requiring children to show understanding at a level 12 months or more beyond what is appropriate for their age. They also make wrong interpretations - for example, that the child deliberately seeks to annoy.(11) The sad fact is that parental behaviour unwittingly "trains" children to be violent.(12) Parents model abusive behaviour by using violence to control the child and the child learns that violence pays. There is overwhelming research evidence tracing violent behaviour to parental competence and methods of family discipline(13), poor child rearing(14), "unskilled parenting"(15) and lack of parenting skills.(16), (17), (18) Amongst these factors the one predictor of future violence that stands out most strongly is harsh family discipline. A plethora of studies indicate that harsh or explosive discipline leads to violence and criminality in children(19) and that discipline styles typically run in families over many generations(20) as people tend, consciously or unconsciously, to copy the parenting styles of their own parents. The harmful effects of receiving harsh discipline are not limited to future criminal behaviour. Harsh parenting has been associated with mental illness(21) (and parental mental illness is also a potent factor in the development of antisocial behaviour in children).(22) Years 0-3 are the prime time for development of violent behaviour Abuse often begins very early in life. Three quarters of babies are hit before they are one year old, and the first year of life is the peak age for suffering child abuse.(23) In the United States infant homicide rates for under 1s doubled between 1970 and 2000, from 4.3 to 8.6 per 100,000 children, falling back to 7.7 in 2001.(24) Negative early experience is particularly unfortunate because the early years are critically important to the child's later social development. Pathways to crime are often laid down by the age of 2 or 3.(25), (26) The result can be aggressive personalities for life (studies consistently show that aggression and violence are stable character traits).(27) The earlier aggression is established, the worse the long-term outcome tends to be.(28), (29) Male aggressive behaviour is highly stable as early as age 2.(30) After age 3, the habit of violence is increasingly difficult to shift. Three quarters of aggressive 2-year-olds are still aggressive at 5; thereafter it is an even more stable trait.(31) Serious antisocial behaviour is highly resistant to change in school-age children.(32), (33) If we want to discourage aggression in schoolchildren, we need to begin corrective action long before they come to school. Dunedin Convincing evidence of how root causes occur at an early age comes from the Dunedin Study in New Zealand, in which it was found that nurses could predict future criminal tendencies 18 years in advance.(34) Every child born in Dunedin in 1972 has been followed from birth, and assessed every two to three years on a variety of health, social, behavioural and environmental measures. Nurses identified an "at risk" group of 3-year-olds on the basis of 90 minutes' observation; they were restless and negative, and lacked persistence and attention. At age 21, males in the "at risk" group were compared with other 21 year olds: 47% abused their partners (compared with 9.5% of others); three times as many had antisocial personality; two and a half times as many had two or more criminal convictions. 55% of "at risk" offences were violent (compared with 18% of others). The "at risk" group not only committed many more violent offences, but also much more severe ones, such as robbery, rape and homicide. Fewer of the females became conduct-disordered but where they did, 30% of the "at risk" group had teenage births (the others had none) and 43% were in violent, abusive relationships.(35) The authors conclude: "Immature mothers with no strong parenting skills, and violent partners, have already borne the next generation of "at risk" children." Professor Farrington's famous remark is as true in South Island New Zealand as in South London. The Infant Brain What could explain the fact that children's future lives may already be being shaped in infancy? Understanding the infant brain reveals the reason. At birth there are 100 billion neurons (brain cells) and 50 trillion synapses (connections). By age 3, remarkably, the number of synapses has increased twenty-fold to 1,000 trillion. Because this is too large a number to be specified by genes alone, it is thought that the new synapses are formed by experience.(36) Certainly, infants are very sensitive to environmental experience. They have an innate drive to learn and they actively seek out human faces within half an hour of birth. Associations in early life help choose which synapses live or die, experience acting to strengthen synapses. Synapses are "hard-wired" or protected by repeated use. This implies very rapid learning via early life experience. It also makes the learned behaviour resistant to change. Synaptogenesis begins in the motor cortex at about 2 months. Around then, infants lose their "startle" reflexes and begin to master purposeful movements. In the second half of the first year, the prefrontal cortex, the seat of forethought and logic, forms synapses at such a rate that it consumes twice as much energy as an adult brain.(37) Conversely, just as a memory will fade if it is not accessed from time to time, so unused synapses will wither away in a process called pruning. The experiences that develop, hard-wire or prune different combinations of the trillions of synapses mean each baby's brain develops differently in response to its particular environment. Extreme examples can be seen in children such as the Romanian orphans, Red Indians with acute hearing and balance skills and modern children who cannot function without TV background noise. Flexibility in sculpting the infant brain has enormous survival value and enables the infant to adapt to its environment.(38) Sensitive Windows Significantly, during this three-year period there are sensitive windows of time during which specific learnings take place and the brain hones particular skills or functions. Certain elements of human capability, such as vision, language and emotional development, tend to occur in spurts during these sensitive times. The size of the window is different depending on the skill. Synapse formation in the visual cortex peaks at 3 months, the brain fine-tuning connections allowing eyes to focus on an object; visual synapse formation is finished at age 2. An infant's auditory map is formed by 12 months. If the chance to practise a skill is missed during the window, a child may either never learn it, or its learning may be impaired.(39) Japanese children who do not learn to distinguish "l" and "r" by 12 months have great difficulty in doing so ever afterwards. Emotional sensitivity and empathy apparently develop in the first 18 months and are shaped by a mother's (or prime carer's) interaction style. The wrong style can have disastrous results. Attunement An important concept is that of "attunement" between infant and carer. Parents who empathise with their infants and sensitively read and respond to their signals are less likely to abuse or neglect their children and are more likely to read babies' developmental capabilities accurately, leading to fewer non-accidental injuries.(40) Studies with primates have shown that neuro-endocrine systems are "tuned" by caregiver-infant interaction.(41) Such systems emerge as a result of "give and take" between mother and child. Like the Romanian orphans, primate babies become socially dysfunctional if mothers are unresponsive to their needs.(42) Dr Myron Hofer, a psychiatrist at the New York State Psychiatric Institute in New York, has found numerous "hidden modulators" in the mother/infant relationship. For example, the licking of a mother rat influences the setting of her pup's heart rate, temperature, circadian rhythms, growth, immune system and other physiological states. If baby rats are deprived of maternal licking when they are between 7 and 14 days old, they develop fewer hormone receptors in their brains.(43) Human mothers provide similar modulators. Premature babies who are touched and held on a regular basis gain weight more quickly, make greater gains in head circumference and show greater overall improvement.(44) Human babies thrive from parenting which is warm and responsive to their rhythms, preferences and moods, in which the parents use rocking, holding, touching, feeding and gazing to create "attunement" between themselves and the baby, reinforcing positive emotional responses and developing empathy in the child.(45) Attunement is where the parent and child are emotionally functioning in tune with each other and where the child learns from the parent that its emotional needs for love, acceptance and security are met and reciprocated. Alan Schore is a scientist with the remarkable ability to remember everything he reads. Following a 10-year immersion in thousands of scientific papers in neurobiology, psychology and infant development, he concluded: "The child's first relationship, the one with the mother, acts as a template. [it] permanently moulds the individual's capacity to enter into all later emotional relationships."(46) Sadly, for many parents attunement either does not come naturally, or is disrupted by post-natal depression, domestic violence or other severe stresses. If the child does not experience attunement, its emotional development is retarded, and it may lack empathy altogether.(47) A baby knows when a mother is cold or distant, despite her ministrations to physical needs. Daily neglect conditions a baby to expect isolation - a model for depression has been acquired from experience, handed down from one generation to the next, and studies show maternal depression is a prime factor in the pathway to behaviour problems for many children.(48) Maternal depression impedes brain development.(49) Infants of severely depressed mothers show reduced left lobe activity (associated with being happy, joyful or interested) and increased right lobe activity (associated with negative feelings).(50) These emotional deficits become harder to overcome once the sensitive "window" has passed. The presence or absence of healthy emotional development has significant implications for the level of violent crime in society. A baby who is healthily attached to its carer can regulate its emotions as it grows older because the cortex, which exercises rational thought and control, has developed properly. But in the case of the child whose life has been badly impacted, the cortex is underdeveloped. The damaged child lacks an "emotional guardian". The result can be unlocked violence that emerges as domestic violence and child abuse in later life. Studies have found a pathway from low maternal responsiveness at 10-12 months through aggression, non-compliance and temper tantrums at 18 months, lower compliance, attention getting and hitting at 2 years; problems with other children at 3 years; coercive behaviour at age 4 and fighting and stealing at 6 years.(51) Interestingly, low maternal responsiveness at 18 months did not seem to have this effect.(52) This is consistent with the hypothesis that there are "windows" for emotional development and that the timing of the deprivation is important. Infant Trauma The downside of the brain's great plasticity is that it is acutely vulnerable to trauma. If the early experience of an infant is fear and stress, especially if these are overwhelming and occur repeatedly, then the neurochemical responses to fear and stress become primary architects of the brain. Trauma elevates stress hormones, such as cortisol, that wash over the tender brain like acid.(53), (54), (55) One result is significantly fewer synapses. Specialists viewing CAT scans of the key emotional areas in the brains of abused or neglected children have likened it to looking at a black hole. The brains of abused children are significantly smaller than those of non-abused. The limbic system (governing emotions) is 20-30% smaller and tends to have fewer synapses. The hippocampus (responsible for memory) is also smaller. Both are thought to be due to the toxic effects of the cortisol.(56),(57), (58) High cortisol levels during the vulnerability years of zero to 3 increase activity in the brain structure involved in vigilance and arousal (the locus coeruleus, responsible for hair-trigger alert), as one might expect in a child under the permanent threat of sudden violence.(59), (60) For such a child the slightest stress unleashes a new surge of stress hormones. This causes hyperactivity, anxiety and impulsive behaviour. Trauma also scrambles the neurotransmitter signals that play key roles in telling growing neurons where to go and what to connect to. Children exposed to chronic and unpredictable stress - a parent who lashes out in fury, an alcoholic who is kind one day and abusive the next - will suffer deficits in their ability to learn. IQ will be lower - another risk factor for conduct problems. Babies brought up in violent families are incubated in terror and their brains can be permanently damaged. Small wonder so many of the mentally ill - infants, children and adults - are found amongst those who suffered the wrong kind of early care-giving.(61) Effective measures which greatly reduce propensity for violence already exist Prevention or Cure? Given the potentially positive role of sensitive parenting, and the damaging impact of early abuse and neglect, what is the optimum strategy for addressing this growing tide of violence and abuse? Some valuable pointers are given by MacLeod and Nelson, who studied and analysed 56 separate programmes designed to promote family wellness and prevent child maltreatment.(62) They describe three approaches to preventing child abuse: Proactive and universal Proactive and selective (high-risk families) Reactive to prevent recurrence Proactive programmes begin pre-natally, at birth or in infancy and include: home visiting, social support (often based on mutual aid and building networks), media interventions (e.g. newsletters focussing on developmental stages and parenting strategies) and "multi-components". Reactive programmes tend to begin at school age and focus on teaching parenting strategies, and help parents improve their management skills. They are usually taught in groups, based on a model such as social learning or Adlerian. MacLeod and Nelson based their assessment on two outcome measures: reduced child maltreatment (e.g. injury, sexual abuse, severe punishment, neglect) increased family wellness (e.g. supportive, affectionate parent-child relationships and a stimulating home environment conducive to positive child development) Their conclusions were: Most interventions to promote family wellness, and prevent child maltreatment, are successful The overall effect size compares favourably with effect sizes in many other intervention programmes The earlier the intervention the better Proactive interventions had greater effect sizes at follow-up (i.e. they are sustained and even grow in effect) Reactive interventions tend to fade in effect, and relapse is a common problem. They speculate that proactive interventions initiate a positive chain of events and break the downward spiral that can end in child abuse for those exposed to adverse conditions. The Key Implications for policy makers are: Emphasis should be placed on proactive rather than reactive programmes The earlier the intervention the better WAVE's conclusions Following in-depth study of the root causes of violent behaviour, WAVE concluded that no child should leave school without receiving fundamental training in how to parent in a non-violent manner and, crucially, how to "attune" with babies. We also concluded that before the birth of the first child is an ideal time to provide support, so that new enriching habits can be established before bad habits have begun and become embedded. For those families with the greatest risk of abuse we think it crucial they receive extra support and that their children's progress should be monitored until 3 years of age. Search for highly effective and practicable international programmes WAVE conducted a review of the global literature to identify effective methods of intervention and prevention, searching for highly effective and practicable international programmes. This work is ongoing, and we are always pleased to have new programmes brought to our attention. The numerous intervention projects we reviewed include 18 separate parent-training programmes. Many have much to commend them. We are particularly drawn to programmes aimed directly at fostering the development of attunement in parents and empathy in children - it is the absence of empathy which so often explains horrendous acts of violence and cruelty by both children and adults. Among programmes to catch our eye have been the Sunderland Infant Programme(63) and Family Links. However we have not yet seen research evidence to demonstrate their impact. It is fundamental to WAVE's "evidence-based" approach to require research underpinning to support claims made. There are 4 specific recommendations WAVE is making at this time: Specific Recommendation 1: Roots of Empathy We recommend piloting Roots of Empathy (ROE), a proven Canadian parenting program for school children aged 3 to 14, currently being delivered with great success to over 12,000 children in Canada, and now also in Japan. The ROE organisation's website iswww.rootsofempathy.org. ROE fosters the development of empathy. Students learn emotional literacy, human development, infant safety and how to identify with another person's feelings. Children prone to developing violent behaviour patterns are connected with emotionally satisfying parenting, through interaction with visiting parents and their babies. In a classroom setting, children share in 9 monthly visits with a neighbourhood parent, infant, and a trained ROE Instructor. ROE Instructors conduct 18 further visits without the family. Babies are 2-4 months old at the beginning of the ROE program and about 1 year old at conclusion, a period of enormous growth and development. Over this time, the children can learn how to see and feel things as others see and feel them, and understand how babies develop. As the program progresses, the students become attached to "their" baby as they observe the continuum of the infant's development, celebrate milestones, interact with the baby, learn about an infant's needs and witness the baby's development. The program also has links to the school curriculum. Students use maths skills to measure, weigh and chart the development of their baby. They write poems for the baby, and read stories that tap emotions, such as fear, sadness, anger, shyness. Children learn to relate to their own feelings, as well as recognize these same emotions in others. Research evaluation has shown reduced bullying and violence, and more responsible attitudes to pregnancy and marriage, in children who have been through the ROE programme.(64) When children understand how others feel, they are less likely to victimise them through bullying. Ultimately, they become more competent parents who will be less likely to abuse their children. Specific Recommendation 2: First Steps in Parenting (formerly PIPPIN) Focusing on ante-natal preparation for parenting, First Steps in Parenting is a programme, developed by Dr Mel Parr, founder of the charity PIPPIN, which trains professionals and voluntary sector workers to help prospective fathers and mothers build strong, nurturing relationships with their infants. In a 4-stage preventative model of preparation and support for early parenting, delivered to groups of 4-6 couples, First Steps in Parenting coaches on how to optimise emotions and relationships in early parenting, fostering secure attachment and resilience. Their approach also helps cement the father-mother bond during this sensitive, and often stressful, period. First Steps in Parenting is operating in a number of NHS trusts in the UK. Further details can be obtained from Mel Parr via e-mailing WAVE. This programme is described in some WAVE documents as PIPPIN, but whereas the charity PIPPIN no longer exists, the programme is still available. Specific Recommendation 3: Nurse Family Partnership We recommend the adoption in Britain of the key elements of the "Nurse Family Partnership" Home Visiting programme (www.nccfc.org), set up by Professor David Olds at the University of Colorado to replicate the programmes for low-income mothers having first babies in Elmira, NY and Memphis. Among its striking successes have been reductions in child abuse and neglect by 50% in the Elmira study(65) and reduced hospitalisations due to non-accidental injuries by 75% in Memphis.(66) In Elmira, where 15-year follow-up data on children is available, the nurse-visited children had 50% lower arrests, 80% fewer convictions, significantly lower substance abuse with drugs, alcohol and tobacco, and less promiscuous sexual activity, than the control group.(67) Mothers on the programmes had fewer subsequent pregnancies, greater employment and less use of public assistance. The key elements include: targeting of the programme to support "at risk" families specific training aimed at supporting parental behaviour which fosters emotional attunement, and confident non-violent parenting an average 33 visits per family from onset of pregnancy to age 2 visits which last, on average, 75-90 minutes per family a case load of about 25 families per nurse UK health visitors, sometimes with case loads of 240 families, and unable to afford more than 20-30 minutes per visit, will recognise the difference. In addition to helping parents to attune emotionally with their children, and to use consistent and more appropriate discipline regimes, the nurses help women envision a future consistent with women's own values and aspirations; help them evaluate contraceptive methods, child care options, and career choices; and help the women develop concrete plans for achieving their goals. This programme is not cheap - it costs about $8,000 per family for 2.5 years support - but economic evaluation by the Rand Corporation shows a payback to the public purse of 4 times its cost.(68) Specific Recommendation 4: Recognition and Treatment of PTSD Post Traumatic Stress Disorder (PTSD) has come into the public eye since the Vietnam war, when it became apparent that many veterans were suffering trauma arising from combat shock.(69), (70) Often, previously non-aggressive men became violent after contracting PTSD in combat.(71) There is research evidence that (a) a significant proportion of people who have suffered violent or sexual abuse in childhood become traumatised, frequently leading to PTSD(72), (73), (74) and violent behaviour;(75), (76), (77), (78) (b) a significant proportion of violent offenders in prisons and young offenders' institutes suffer from PTSD.(79), (80), (81), (82), (83), (84), (85) The correlation between PTSD and violent behaviour has major implications for treatment of offenders and ex-offenders. If PTSD is not treated, the likelihood of a recurrence of violent behaviour is much higher. Current child, prison and probation treatment programmes largely ignore PTSD. There are proven Cognitive-Behavioural techniques for treatment of PTSD, whose success with combat veterans and rape victims has been demonstrated.(86), (87), (88), (89) With the combat veterans, where aggression and violence, often leading to incarceration, have been a major problem, treatment of PTSD has significantly reduced violent behaviour.(90) One of these Cognitive-Behavioural treatment methods (Prolonged Exposure Therapy) has been used by me within WAVE's "An End to Violence" Programme for violent prison inmates and ex-prisoners. Our approach is showing very positive results. Levels of violence and aggression dropped from an average 42% of maximum on the Buss-Durkee, Novaco and Spielberger scales to a "normal" 10% of maximum, 11% at follow-up.(91) There was also a sharp improvement in acceptance of responsibility; and improvements, sometimes very striking, in Fear of Negative Evaluation and Social Avoidance, which can impede re-integration into the community. We recommend that PTSD caused by early abuse or neglect should be detected (e.g. via screening at school entry) and steps taken to heal it in children, and when such persons enter the legal and prison systems. Early interventions are a cost effective use of society resources There have been many studies demonstrating that early intervention is cost effective. A recent report by the Institute of Psychiatry(92) contrasted the £70,000 per head direct cost to the public of children with severe conduct disorder with the £600 per child cost of parent training programmes. The £70,000 does not include the costs of crimes or victims - only direct expenditure on the child. The RAND Corporation in the US studied(93) the comparative cost effectiveness of five approaches to reducing crime, including prison and parent training (parents of 5-7 year olds). Though the study took a narrow view of the benefits of parent training, putting no value on the prevention of child abuse and ignoring benefits other than crime reduction (e.g. better educational achievements), it found parent training was a highly cost effective approach for preventing serious crime, costing only £4,000 per serious crime prevented compared with £9,000 for prison. Earlier parent training would be even more cost effective. A RAND Corporation economic evaluation of the Nurse Home Visiting programme for at risk mothers showed savings (reduced welfare and criminal justice expenditures and increased tax revenues) exceeded programme costs by a factor of four over the life of the child. The return on investment was realized well before the child's fourth birthday.(94) Professor Steven Barnett of Rutgers University evaluated the benefits of 36 early childhood programmes. While his focus was educational rather than emotional benefits (the best programmes deliver both), he concluded ". the nation needs to move ahead with public support for Early Childhood Care and Education. Current policies are penny wise and pound foolish, inexcusably costly in human and financial terms."(95) Devoting resources to improve the quality of infant care is our best hope of producing peaceable citizens These conclusions, together with WAVE's findings that violence and aggression are often established before 3 years of age, underscore the case for public policy priority to be given to proactive intervention programmes beginning pre-natally or at birth. Sadly, at the 1999 Royal Society of Medicine Conference on Children and Violence, a government spokesman said the government spends 300 times more on the consequences of crime than on its prevention.(96) Although there has been a shift of some resources towards prevention since then, this is heavily skewed towards later, less effective interventions - e.g. reactive programmes aimed at teenage offenders, rather than at proactive interventions with babies. While Sure Start exists as a channel for Government "prevention" spending, in our experience few Sure Starts tackle the root causes of violence - perhaps because their programmes are generated locally where there is little understanding of these root causes. Time and again we have found priority in allocation of both government and charitable foundation money being given to reactive intervention, justified because "this can be more clearly seen to help those in need". We agree that helping those in need is important, but until we devote sufficient resources to prevention, the need will continue at levels far beyond those of 50 years ago. Download the references here George Hosking OBE is Scottish, Operations and Research Manager - and former CEO - at WAVE Trust.