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A serious game-based solution to prevent bullying

Cátia Raminhos Ana Paula Cláudio Maria Beatriz Carmo


BioISI - Biosystems & Integrative BioISI - Biosystems & Integrative BioISI - Biosystems & Integrative
Sciences Institute, Faculty of Sciences, Sciences Institute, Faculty of Sciences, Sciences Institute, Faculty of Sciences,
University of Lisbon University of Lisbon University of Lisbon
Campo Grande, Lisbon, Portugal Campo Grande, Lisbon, Portugal Campo Grande, Lisbon, Portugal
catia.s.raminhos@gmail.com apc@di.fc.ul.pt bc@di.fc.ul.pt

Susana Carvalhosa Maria de Jesus Candeias Augusta Gaspar


CIS-IUL, ISCTE – Lisbon University CIS-IUL, ISCTE – Lisbon University CIS-IUL, ISCTE – Lisbon University
Institute Institute Institute & Faculty of Human Sciences,
Lisbon, Portugal Lisbon, Portugal Catholic University of Portugal
Susana.Carvalhosa@iscte.pt jesuscandeias@gmail.com Lisbon, Portugal
Augusta.Gaspar@iscte.pt

ABSTRACT 1. INTRODUCTION
This paper presents a Serious Game with the main purpose of
Bullying is a phenomenon that increasingly concerns civil society
inducing attitude changes as a way to prevent bullying. The target
and school communities, having significant prominence in the
audience are young people between 10 and 12 years old. The
media. Bullying between peers is a type of aggressive behavior
rationale for prevention is: first, to help victims of these aggressive
that involves intentionality from the aggressor, repetition over time
episodes to improve behavioral competence to avoid or to deal with
and abuse of power [20].
future real bullying situations; and, second, to promote in the
bystanders empathy towards the victims. All over the world, and despite the differences between countries,
the prevalence of bullying is high and shows a tendency to grow,
The user studies we have performed lead us to the conclusion that especially among girls and boys aged from 10 to 12 years old [5,
the current solution has potential in bullying prevention while being 18, 27]. Victims (the targets of bullying) and bullies (the agents of
a therapy auxiliary tool. The Serious Game was appreciated by bullying) are the minority, while the bystanders (the witnesses of
young people who, after playing the game in a continuous time these situations) are the majority but, in most cases, a non-
span, reportedly acquired bullying prevention strategies. intervening audience.
The BackOffice application, a distinctive feature of our solution It must be emphasized that this type of behavior has severe short-
when compared to other similar solutions, was also evaluated, and term consequences for those involved (in the worst scenario the
was positively assessed by the psychologists who tried it. suicide), and long-term consequences, in health, financial and
social outcomes [6].
Categories and Subject Descriptors Additionally, the existing interventions have not proved to be
J.4 [Computer Applications]: Social and Behavioral Sciences – effective [7], and traditional therapy usually involves a time gap
economics, psychology, sociology. between sessions and resort to clinical models that are not adapted
to the specificities of bullying participants.
General Terms All these factors highlight the need to find appropriate solutions to
Design, Experimentation, Human Factors. prevent bullying. To effectively put an end to bullying, specific
skills should be taught to victims while bystanders should be
Keywords encouraged to intervene toward helping the victim [6, 12, 19].
Bullying, serious game, bystanders, victims, platform game, Unity The use of Interactive Technologies (IT) has produced fruitful
3D. results in cognitive and self-efficiency development and in the
Permission to make digital or hard copies of all or part of this work for
promotion of specific behaviors [8, 13], with promising results in
personal or classroom use is granted without fee provided that copies are the training of problem-solving skills [7]. More specifically,
not made or distributed for profit or commercial advantage and that Serious Games (SG), which are interactive applications that use
copies bear this notice and the full citation on the first page. Copyrights videogames’ technology with purposes beyond mere entertainment
for components of this work owned by others than the author(s) must be [26], in addition to being widely used, have several advantages that
honored. Abstracting with credit is permitted. To copy otherwise, or make them an exceptional tool for teaching and influence people’s
republish, to post on servers or to redistribute to lists, requires prior behavior [17, 21]. In particular, Persuasive Technologies (PT), that
specific permission and/or a fee. Request permissions from
are more focused on behavior changes, when used properly and
Permissions@acm.org.
MoMM 2015, December 11 - 13, 2015, Brussels, Belgium
ethically, allow the user to reach more rapidly the desired type of
Copyright is held by the owner/author(s). Publication rights licensed to behavior [11].
ACM.
ACM 978-1-4503-3493-8/15/12…$15.00
DOI: http://dx.doi.org/10.1145/2837126.2837135
This paper describes a work tool that we develop for psychologists, suggestion (intervene at the right time, when there is motivation
named “StopBully”, to support young people (in the age group of and ease in acting); v) surveillance (user behavior is monitored and
10 to 12 years old) with different levels of involvement in bullying. observed by others); vi) tailoring (use relevant personal
The tool has, as main component, a SG to prevent bullying and information as part of the intervention); and vii) tunneling
promote empathy, using the PTs, encouraging the potential users to (sequence tasks to achieve, more easily, the great ultimate goal,
change their behavior when they are forced to deal with this type of reducing cognitive load).
situations. The tool also includes a BackOffice Application (BOA) We were concerned with bridging gaps and using the best
which supports the therapy or research work of psychologists. approaches found in these works in the design and development of
The team designing this solution is multidisciplinary and includes our solution.
psychologists with experience and knowledge in bullying, and
specialists in computer graphics. 3. THE SOLUTION
To address the problem of bullying and the lack of effectiveness of
We conducted user tests to validate the characters to include in the
the existing solutions, we have developed a solution, named
game, to evaluate a preliminary prototype, adjusting it to the target
“StopBully”, composed of a SG, with cartoon stylish characters
audience’s needs, to evaluate usability, playability and
and environment, based on platform games, and a BOA, to support
effectiveness of the final prototype, and to evaluate the BOA.
the psychologist in the management and monitoring of the players
This paper has the following structure: section 2 describes the most that he/she follows [22]. The characters of the SG were designed
relevant work on SGs applied to bullying and some considerations by Arts students, based on requirements outlined by the team
about PTs; section 3 presents the developed solution; section 4 psychologists and that took into account the roles that would be
presents the evaluations results and the respective discussion; and required in the game.
section 5 draws conclusions and lines for future work. The SG has, as target audience, children from 10 to 12 years old,
specifically victims and bystanders, roles that have been mapped in
2. RELATED WORK profiles. For ethical reasons we did not enable a bully profile (there
Previous studies reveal that SGs players, in general, prefer single would be a risk of victims and bystanders playing the game as
player mode, 2D environments and cartoon stylish characters [28]. bullies and we do not know the consequences this could bring) and
Children prefer to play on laptops, videogames consoles and tablets for requiring, in the opinion of the whole team, different strategies
[4]. Platform games are among the most popular; these are 2D from that used on the other roles.
games, allowing players to move left or right to overcome obstacles Our intention with this game is to help bystanders and victims to
and collect items, tasks that make them earn points and higher change their behavior towards this type of school violence, by
game levels. simulating their environments and stories.
There are currently some SG solutions targeting bullying: “School The SG was conceived for tablets and PCs, using the Unity 3D1
Bullying” [24] provides a limited set of situations and stories, runs and some free sounds libraries. Although mobile devices are the
only on PCs (not tablets) and has a weak performance possibly due preferred platforms of our target audience, not all children have
to the 3D graphics with too much detail. In another SG [23], the them at their disposal; for this reason, the computer remains an
player can’t explicitly choose the victim or bystander role, a option, and even adds the advantage of a larger screen.
discouraging motivation for players. “FearNot!” [14], a widely
tested European project, has too a profile restriction, forcing the The developed SG can be used in therapy sessions, i.e., in the
player to always be a bystander. presence of the therapist, but also outside this environment. Each
game session generates an information record that offers to the
Moreover, “KiVa” [16] is an antibullying program for schools that therapist counselling an individual, the possibility to follow his/her
was created in Finland. It has two components: universal actions, progress up close and timely. Thus, a patient can be effectively
for all students, and indicated actions, used when a bullying case monitored, even outside the in-person therapy sessions. This
has emerged. The universal component includes online games, not information is provided through a BOA (Figure 1). On the other
open to the general public. One of them was developed in cartoon hand, researchers may use this solution in studies in the area of
stylish 2D, with different situations, where the player has to make bullying, using the BOA to assist in data analysis of a particular
the right decision. The data generated by these videogames are not sample. Currently, this BOA is stored on a server to which only the
saved. Still, the data collection is achieved through questionnaires Psychology team has access. We also implemented some
administered at the end of each school year. The program has mechanisms in the BOA and in the SG to ensure data security.
already been implemented in countries such as Finland, New
Zealand, Estonia and the United Kingdom, with positive results, 3.1 The Serious Game
such as a reduction in bullying events. After logging in with credentials, previously provided by the
psychologist who accompanies the young player, he/she can see
In order to change the victims’ and bystanders’ behavior, we have
his/her score and the level he/she is in each profile, or can start the
to look for the best PTs design approaches. King et. al [15] advise
game.
the use of portable or environment integrated solutions with
simulated experiences or surveillance-based solutions. Fogg [11] At the beginning of the game, the player chooses one of two
also suggests the following design principles: i) reinforcement profiles and one of the characters within the chosen profile. With
(reinforce positively when the desired behavior occurs and the character chosen, he/she indicates the level he/she wants to
negatively when it doesn’t occur); ii) reduction (simplify more
complicated tasks, removing unnecessary steps); iii) self-
monitoring (allow the user to monitor his/her behavior); iv) 1 http://unity3d.com/
start, within the available ones. These levels represent locals from a qualitative study conducted with some youth from the target
school (see Figure 2) and, if the player successfully finish all levels, audience of the game [3]. Some levels may also have different
he/she can freely choose one of the other places where the other degrees of difficulty, depending on the score obtained previously by
levels are held. the player: easy, medium and hard. These degrees of difficulty can
be mapped in more intimidating scenarios or in the degree of
difficulty of winning points, and ensure variability and a more
challenging game.

Figure 1. Solution vision with the Serious Game and the


BackOffice Application.
Before and after the level execution, the player must assess his/her
emotional state, indicating the values of each dimension of the Self-
Assessment Manikin (SAM), an instrument comprising pictorial Figure 3. Serious Game’s interface of the self-assessment of the
scales for assessing the emotional states perceived by the individual pleasure component of SAM.
[2]. One dimension of this instrument, Pleasure, ranging from
We ensured the design principles for PTs [11] in our SG, as
“Displeased” to “Pleased”, can be observed in Figure 3. We
follows:
integrated this instrument in the SG, because it is easy to use, easy
to understand and is commonly used to measure affective 1. Reinforcement: by assigning the score depending on the
responses. chosen option in every interaction and by authorizing the
access to the next level when the made choices were the
most appropriate;
2. Reduction: we simplified more complicated tasks,
removing unnecessary steps in the simulation of bullying
situations;
3. Self-monitoring: monitoring of the performance of the
player through the summary of the scores and the
wins/losses notifications in the end of the level,
indicating a good behavior/misbehavior;
4. Suggestion: the intervention is performed during the
game through the options available in each interaction
and the return of those choices, with the attribution of the
score, and after the game, when the player is faced with
Figure 2. Map of the school, where the player can choose the its performance relative to the number of won friends,
level. how brave he/she is and his/her popularity, symbolized
In the course of a level, the player is faced with challenges and by the number of invitations;
bullying situations, as a bystander or a victim, depending on the 5. Surveillance: the choices made by the player and his/her
profile he/she chose, integrated in familiar stories and scenarios emotional evolution are monitored by the player’s
and accompanied by environment sounds, thus altogether counselling psychologist;
attempting to create an experience as closer to the reality of the
young person as possible. When faced with a challenge, the player 6. Tailoring: the player chooses, after choosing the profile
must make a decision, which will have consequences on the score he/she wants to play, the character with which he/she
that is built up by number of friends, amount of courage and count most identify with. In addition to the gender, there was a
of invitations, and will impact the course of the story. The player concern to provide characters with the most prevalent
only pass the level, if he/she gets at least the minimum score ethnic groups in Portugal: Caucasian and African.
required. 7. Tunneling: to achieve the goals of the game, the player
Currently, SG has 3 levels in the bystander profile and 3 in the has to pass each level. To pass each level, the player
victim profile, which take place in the school entrance, on the must complete small tasks (making a decision in a given
football field and in the school hallway, according to the interaction) successfully.
storyboards provided by the Psychology team, based on the
The values of the SAM and the choices made by the player are sent group is thoughtful and looks to the player with admiration, and the
to the BOA and can be queried by the psychologist who victim is relieved.
accompanies the player.
In the next section, we describe a complex level of the SG, to make
easier the understanding of the game dynamics.

3.1.1 Example of a level of the Serious Game


The level taking place in the school hallway, in bystander profile,
starts with a group of bystanders and bullies talking, to which the
player joins, and an isolated victim, slightly away from the group,
viewing the messages in the mobile phone. One of the bullies
suggests that they steal the mobile phone and the whole group
agrees, laughing (Figure 4). The avatar’s player, although
thoughtful, follows the group.

Figure 6. Level in the school hallway, where the player must


make a decision after facing the group and the intimidation of
the bully.
The player can only pass this level (Figure 7), if he/she chooses to
tell what happened to a janitor or to face the group.

Figure 4. Level in the school hallway, where the bully proposes


to steal the victim’s mobile phone.
When they are with the victim, the bully, who suggested to
intimidate her, asks her to give the mobile phone and everyone
laugh (except the character player). The victim refuses herself,
saying that she needs it. The other bully threatens her and the group
keeps laughing. At this point, the player has to make a decision:
joins them (loses points), moves away and says nothing (loses
Figure 7. Serious Game’s interface of the level end, stating that
points) or bids the group to stop (Figure 5).
the player passes it, with 4 friends, level of 8 in courage and 8
invitations.

4. SOLUTION EVALUATION
In an early stage of prototype assessment, we carried out a
preliminary evaluation, which consisted in: i) a validation of the
characters; ii) a preliminary evaluation of the prototype, with the
target audience, to ensure that any emerging problems in this
assessment would be solved in the prototype to be assessed in
schools; iii) an evaluation of the SG prototype, with the target
audience at a school; and iv) an evaluation of the BOA, with
psychologists.

4.1 Characters Validation


In order to confirm the roles that had been defined for each
Figure 5. Level in the school hallway, where the player must character to be included in the game, we conducted a role validation
make a decision, after having witnessed a bullying situation. study with a larger audience than the target audience. Voluntary
If he/she choose the last option, the player is faced by the bully and participants (N=82; F=51; M=31) were recruited in schools and
by the mockery of the remaining individuals of the group. To universities in the Lisbon area and invited to fill an online
escape from this situation, he/she will have to choose one of three questionnaire with the game characters. The characters were
paths: laughs (loses points), moves away and reports the situation presented randomly in one of 3 different sequences. One of the 3
to a janitor or faces the group, making it clear that their attitudes sequences is presented in Figure 8.
are wrong (Figure 6). If the player chooses the last one, the whole
a Likert-scale varied from 1 (Strongly Disagree) to 5 (Strongly
Agree). To determine the participants’ type of bullying
involvement and to measure empathy, a paper questionnaire was
provided, comprising the following instruments: Olweus Bully
/Victim Questionnaire [25]; Davis Interpersonal Reactivity Index
Perspective Taking and Empathic Concern scales [9]; Reading the
Mind in the Eyes Test (RMIEt) [1]; and the Portuguese version of
the Animal Empathy Scale (AES) [10].

Procedures
For a month, 2 weekly sessions (8 sessions in total) of 45 minutes
each took place in the school facilities, monitored by a member of
the psychology team. All the participants in these sessions had an
informed consent signed by their respective guardians. Among the
Figure 8. Final characters, with bystanders (y, o, x and s), 25 individuals monitored in this school, 22 were enrolled in these
victims (v, t, u and k), bullies (z, m, p and w) and adults (i and sessions, and 4 only played the SG.
j). In the 1st session, a questionnaire was given out to participants, in
There were no critical problems, as most characters receiving order to determine their type of bullying involvement and to
highly convergent role attributions (i.e. matching our expectation). measure empathy. In the 2nd session participants began to play the
There were no significant differences between age groups (less than desktop version of the SG, which communicated with our server,
12, inclusive, and more than 12) in most role attribution (d.f.=1; p and, 15 minutes before finishing the session, participants filled an
<.05; Character z, X2= .059; Character y, X2= .364; Character v, online questionnaire about the game. In the remaining sessions,
X2= 1.11; Character m, X2= 2.78; Character i, X2= 5.76; Character they continued to play the SG. In the last three sessions, and after
o, X2= .0004; Character t, X2= 1.61; Character p, X2= .531; 15 minutes of playing the SG, we discussed with the students the
Character x, X2= .061; Character j, X2= .0882; Character s, X2= bullying situations, favorite profiles and levels in the SG, and
.0079; Character u, X2= 5.75; Character w, X2= .001; Character k, strategies at the level of bystanders and the school. In the last
X2= .631, ). Although respondents reported the lack of a social session, empathy was measured again, to determine if and how
context, as the characters were displayed individually, this is of much it might have changed as a result of playing the SG; the
course a problem that is overcome when they are integrated into the results of these empathy measurements are not available yet and
SG. are reported elsewhere (Carvalhosa et al. in preparation). We report
and discuss here the results of the SG questionnaire.
4.2 Serious game preliminary evaluation The individuals who did not participate in these sessions (4 of the
After the validation of the characters, we made a preliminary
total number of participants), played all SG levels and
evaluation of the prototype, with only two levels available, to fit the
subsequently completed the online questionnaire.
target audience’s needs. We evaluated the usability and playability
with 7 individuals of the target audience, who used an online 4.3.2 Results and Discussion
version of the prototype and who answered to an online Almost all participants played videogames (93%), where the Grand
questionnaire. The feedback we obtained was very positive. The Theft Auto, friv, transformice, imvu, girls videogames, cars
small problems, such as the map icons and how the characters videogames and football videogames were the most popular.
appeared in the level, were immediately corrected.
Based on a previous questionnaire instrument [25], team
4.3 Serious game evaluation psychologists were able to identify the role of 22 of the 25
To validate the integrated levels, the corrections relative to the participants in real bullying situations from school: 1 was a bully
preliminary prototype and the impact of the final prototype of this (4%), 5 were victims (23%) and the others were bystanders (73%).
project on the prevention of bullying, we evaluated the SG with the For most of the menus of the game, with improvements from the
target audience. previous version of the prototype, there were no doubts. The
screens with the three pictorial subscales of SAM raised more
4.3.1 Methods doubts. Some of the individuals were careful when choosing the
Participants values of SAM, but others indicated them randomly.
Twenty-seven students (9-14 years old; M=11.37; SD=1.11) from To assess each level of the SG, we integrated questions about the
4th to 6th grades, participated in the SG assessment [Girls=10 perception of the scenario, the perception of sound and immersion,
(37%); Boys=17 (63%)]. Most participants were from the same the perception of the story and the grade to give to the level.
school and were monitored for 4.5 weeks.
In the perception of the scenario (Figure 9), all levels had positive
Instruments and similar results, with the backdrop of the football field getting
An online questionnaire was made available in order to validate the the best result (by having the grass and the ball and therefore being
integrated levels and the respective stories, the decisions taken and a more obvious scenario than the others).
the changes on the preliminary prototype, at interface level and With regard to perception of sound and immersion, there were
interaction with user level. The questionnaire link was given to the some differences between the levels, more significant in the levels
school participants and 60 questions were answered (e.g., at school entry (see Figure 10). This significant difference may be
perception of scenarios at each level of the Serious Game), 45 with related to the fact that the school entrance is not usually a playful
place (perhaps more convivial, before entering in the classrooms). other characters (Median = 5), there was general satisfaction.
The levels in the football field were the ones who had better results However, the participants missed more characters, to select and in
because the football field usually have children playing. the course of the level. As for the narration, some judges did not
Furthermore, the levels that take place in the school hallway have like the associated sound. In general, participants succeeded in
results below the levels that occur on the football field, perhaps identifying the three types of score, but it was not clear to everyone
because the nature of the environment sound and the volume (low that courage was included. A large number of participants enjoyed
volume and very quiet sound, with steps and distant voices). the game (Median = 5) and provided suggestions for its
As for the perception of the story, we obtained positive and similar instructions (e.g., with an animation) and more difficult levels.
results in all levels (Figure 11). The simplest levels were those who Regarding the grade given to the game, a Wilcoxon-Mann Witney
performed better (school entrance in both profiles and school test revealed no differences between boys and girls (U=62,5;
hallway in the victim profile). In the grade given to each level, the N=22; p<.05 two tailed) , nor between participants who usually
results, concerning the perception of the story, are reversed (see play violent and complex games and those who not play this kind
Figure 12), with the simplest levels being the least favorite for the of games (U=76; N=22; p<.05 two tailed). A Kruskal-Wallis test
participants and the most complex and challenging being the showed that there was not either an effect of roles in bullying over
favorites. this grade (X2= 0,228; N=21; p < 0.05). We also noted, through the
Regarding the preferences of the victim's profile levels, there were discussion sessions, an assimilation of the strategies passed by the
no effects of the different roles in bullying, as shown by a Kruskal- game. In addition, most individuals involved in these discussions,
Wallis test (X2= 0,375; N=21; p < .05). With regard to characters said that they preferred the bystander profile because it was the
(Median = 5), speech bubbles (Median = 5) and interaction with most useful for them (most of them were bystanders).

Figure 9. Level of agreement of participants with the perception of scenarios at each level of the Serious Game.
Figure 10. Level of agreement of participants with the perception of sound and immersion at each level of the Serious Game.

Figure 11. Level of agreement of participants with the perception of the story at each level of the Serious Game.
Figure 12. Grade given to each level of the Serious Game by the participants.

By and large, the roles attributed to the characters to be included in


4.4 BackOffice Application Evaluation the SG were matched by participants’ role attributions, even when
Finally, we evaluated the BOA interfaces and features with clinical
participants were from outside the realm of the target audience.
psychologists and psychology researchers, providing an online
This suggests that there is a consistent representation of roles
questionnaire.
between young people and professionals in this area. However, a
Despite the small sample (5 subjects), we received many possible shortcoming is the dissemination of stereotypes. The SG
suggestions (e.g., more explicit errors; to improve the aesthetics of was appreciated by young people and it allowed, according to
some interfaces and tables; to improve the action icons, to provide discussion sessions, the “intake” of bullying prevention strategies.
fields for the school status of the player; the possibility of In addition, the BOA was widely accepted and appreciated by
searching archived players by birthdate; stronger and different psychologists who participated in the assessment. The problems
colors in the SAM evolution chart and manual setting of the encountered and the small tips should be used to improve both
sessions plan; to map the SAM and the levels through immediate tools in the future.
captions or a separate page; more editable fields of the
The results of empathy questionnaires will be examined in order to
psychologist and player accounts; integration of a password
understand the impact of the SG on it. The appearance of the
recovery mechanism and to enable a preview of the excel file with
characters should also be further explored, enabling identification
the data of the players. All individuals were interested in the
whilst avoiding stereotypy (e.g., a girl with a friendly look, who is
solution that combines the BOA with the SG and they would use it
in fact a bully). Future developments are to include more
as an auxiliary tool in their real work contexts.
storyboards, and adjust current ones, in order to develop a fluid
story and more challenging levels. Since collaboration/competition
5. CONCLUSIONS AND FUTURE WORK increases players’ motivation to engage in the game, we plan to
This paper describes a serious game to prevent episodes of school address whether it is appropriate and feasible to include some
bullying. This phenomenon, highly prevalent in several countries, mechanisms of collaboration/competition.
leaves indelible marks on its victims and bystanders and has an
impact on their future lives. This tool holds potential as a bullying preventive intervention in
schools, and thus studying ways to improve it are a current priority.
The presented solution stands out by: offering a BOA to therapists Another promising step in this research will be to explore the
with data management features, including the choice of profiles impact of 3D on motivation, immersion and effectiveness of the
adjusted to the individuals; generating a targeted intervention, by SG, and to study the best approach to deal with cyberbullying.
allowing the player to play the SG whenever she/he wants, even
outside a therapy session (e.g. at home); by providing portability;
by having strong social features, such as friends and invitations, to 6. ACKNOWLEDGMENTS
which young people give much importance; and by offering a We appreciate the support material of BioISI R&D unit,
variability of scenarios and consequences of actions, taking into UID/MULTI/04046/2013 funded by FCT/MCTES/PIDDAC,
account the user's performance in the game. Portugal. We also thank Joana Branquinho and Catarina Dantas,
students of FBAUL, their invaluable collaboration in the game’s
characters design, and Avelar Brotero Primary School, for its 105. DOI=
support during the evaluation of the serious game. http://dx.doi.org/10.1016/j.adolescence.2007.05.002.
[13] Gold, W. R., Manning, T., and Street, R. L. 1997. Health
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