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COMMUNITY VIOLENCE-RELATED
PTSD IN
CHILDREN AND ADOLESCENTS
David W. Foy, PhD1
Graduate School of
Education and Psychology
Pepperdine University
and
Carole A. Goguen, PsyD2
National Center for PTSD
Dartmouth Medical School
Homicide has become the leading cause of death among minority adolescent males
in some inner city areas. Recent media attention has been focused on the plight
of inadvertent victims of violent street crime, and the issue of community violence
is now recognized as a major public health issue‹more than a criminal justice
problem‹especially among youths. Early studies of youths¹ experiences with community
violence focused primarily upon the issue of recidivism anong adolescent perpetrators.
More recently, studies have begun to examine a spectrum of community violence
and its traumatic consequences to youth victims.
This article is intended to provide an up-to-date overview of this relatively
new area of trauma study. To narrow the definition of community violence for
the purposes of this article, distinction is made between studies of crime-related
trauma, which are most often conducted with adult samples, and stud-ies of community
violence exposure in children and adolescents. (See Resnick & Kilpatrick, 1994,
for an overview of crime-related PTSD among adults.) Several types of possible
violent interpersonal events among youths are examined. In the context of the
ongoing national epidemic of inner city violence, key risk factors are identified
for victimization of children and adolescents. Findings from recent stud-ies
examining violence-related PTSD symptomatol-ogy in adolescent survivors are
then presented. Methodologic issues in operationally defining and assessing
key variables in the study of community violence-related PTSD are discussed,
and selected instruments that have proven useful are described. Finally, the
article raises two critical clinical issues for future direction: treatment
of community vio-lence- related distress in adolescents; and violence pre-vention
efforts.
Critical Issues in Research on Community Violence and its Mental Health Consequences.
One of the pri-mary limitations in existing research on community violence is
the use of convenient, non-representa-tive samples. Studies primarily focus
on inner-city, minority youths. To date, only one study (Boney-McCoy & Finkelhor,
1995) that used a national sample has been reported. Although the definition
of community violence used in most studies reflects its chronic nature (Garbarino,
1993) and includes the assessment of exposure to multiple community violence
events, different operational definitions are used and exposure to other types
of trauma (e.g. childhood physical or sexual abuse) is frequently not assessed
(McLain et al., 1998). In most studies of community violence, a lifetime approach
to assess-ing trauma is taken in which questions about expo-sure are posed in
the ³have you ever experienced...² format. Unfortunately, few studies have incorpo-rated
recency or frequency of exposure as critical vari-ables in the conceptualization
of community vio-lence exposure, thereby limiting the representation of exposure
severity to a basic screening level. In most present studies, use of control
groups or other appropriate methods to isolate community violence exposure as
the salient independent variable have been lacking. Finally, most existing studies
do not feature longitudinal designs that would permit ex-amination of temporality
between community violence exposure and psychological distress manifestations.
Prevalence, Descriptive Characteristics, and Risk Fac-tors for Exposure to
Community Violence. The phe-nomenon of community violence exposure is con-ceptually
complex. The kinds of experiences cov-ered under the community violence concept
include both predatory violence and violence arising from non-family interpersonal
conflicts (Bell, 1997). In the case of predatory violent incidents, the perpetrator¹s
objective is to take something of value from the victim (usually a stranger),
and physical threats or direct violence to the victim are means to achieve that
goal. Conversely, participants in violent inter-personal conflicts are usually
acquaintances involved in an altercation in which the distinction between perpetrator
and victim is not clearly defined. Bell (1997) points out that gang-related
and drug-related violence can represent either predatory or conflictual types,
and that an additional form of community violence occurs (through negligence)
when ³inno-cent victims² are caught incidentally in the line of fire.
The community violence concept applies not only to direct personal exposure
(happened to you), it also includes exposure through witnessing (saw it happen
to someone else) and vicarious (know someone it hap-pened to) routes. Instruments
that are used to mea-
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sure community violence exposure take these different
forms of exposure into account, providing separate items
and summary scores for each type. Available instruments
with established psychometrics include the Survey of
Children's Exposure to Community Violence (SCECV;
Richters and Saltzman, 1990) and the Screen for Adoles-
cent Violence Exposure (SAVE; Hastings & Kelley, 1997).
Risk for victimization has been found to be dispropor-
tionately distributed across demographic categories, in-
cluding gender, socioeconomic status (SES), race, level of
community urbanization, and age (e.g. Fitzpatrick &
Boldizar, 1993). Risk for community violence exposure is
higher among the poor, the non-white, and those who live
in densely populated urban areas. Studies found that late
adolescence, ages 15-19, represents the period of highest
risk for community violence exposure.
Although high rates of community exposure are re-
ported among urban minority youths, this problem may
not be unique to the inner city. In the only study using a
national sample of adolescents, over one third of the youths
reported having directly experienced community violence
in the form of assault (Boney-McCoy & Finkelhor, 1995).
Large gender differences were found, with 35% of males
reporting victimization, compared to 13% of females. Con-
versely, 15% of females reported having been sexually
assaulted, compared to 6% of the males. Because the study
did not differentiate between familial and non-familial
types of sexual assault, the proportion of sexual assault
cases representing community violence could not be deter-
mined. In addition, the study did not include rates of victim-
ization through witnessing or vicarious routes of exposure.
Other studies on prevalence of community violence
have examined rates of victimization related to direct,
witnessing, and vicarious types of exposure. These studies
have consistently identified higher levels of indirect (wit-
nessing and vicarious) than direct exposure to community
violence among urban youths (e.g. Fitzpatrick & Boldizar,
1993). Males reported significantly higher direct and
witnessing exposure, but not more vicarious exposure
than females. Most community violence studies with ado-
lescents use the youths' self-report as the basis for deter-
mining community violence exposure. Youths' self-report
may be preferred because studies comparing parents' re-
ports of their child's community violence exposure and
trauma-related psychological distress to the child's report
found that parents reported significantly less exposure
(Hill & Jones, 1997) and distress (Martinez & Richters, 1993).
Gang affiliation has also emerged as a key risk factor for
victimization. Gang-related violence has become one of
the most pervasive, brutal, and multifaceted forms of
community violence, frequently taking the form of being
"jumped in" or "jumped out" of the gang, or fighting
members of a rival gang. Armed robberies, high-speed car
chases with rival gangs or police, beatings, muggings,
Prevalence and Risk Factors for Community Violence-related
PTSD. Validated self-report instruments for assessing
PTSD symptoms in youth samples are now available (e.g.
Foy et al., 1997). Consistent with findings from studies on
other types of trauma, studies of community violence
among urban youth have also revealed positive correla-
tions between the degree of exposure and reported levels
of psychological distress (e.g. Burton et al., 1994; Fitzpatrick
& Boldizar, 1993; Lynch & Cicchetti, 1998). High rates of
PTSD (25-30%) among highly exposed adolescents have
been reported. Among studies that measured rates of
exposure by modality, direct victimization correlated more
strongly with measures of distress than exposure via
witnessing or vicarious victimization, although each mo-
dality has been demonstrated to induce PTSD in children
(Saigh, 1991).
A recent review of 55 studies on youth PTSD found 8
studies that examined etiologic factors in community vio-
lence-related PTSD (McLain et al., 1998). Prior trauma
exposure was significantly related to community violence-
related PTSD severity in all three of the studies in which it
was assessed. Studies examining age, gender, and ethnicity
as potential risk factors produced mixed findings. To date,
there are more studies reporting insignificant results for
these demographic variables, although definitive patterns
are not yet evident. The possible mediating role of social
support was examined in another recent study of children's
psychological adjustment following community violence
exposure. Results showed that community violence expo-
sure was most highly related (inverse correlation) to well-
being in those children with low social support or high
levels of social strain (Kliewer et al., 1998).
Future Directions in Treatment and Prevention. In view of
the high rates of community violence exposure and risk for
PTSD among inner city minority youth, increased efforts to
provide appropriate clinical services are needed (Osofsky,
1995, 1997). Hospital emergency departments where com-
munity violence-related physical injuries are treated rep-
resent a realistic starting place for crisis intervention and
short-term treatment for residual PTSD symptoms in youth
who have recently survived a life-threatening episode (e.g.
Pynoos & Nader, 1988). School-based clinics are another
site where services can be provided, especially for youths
victimized through witnessing or vicarious trauma. Con-
sidering options in form, individual treatment provides a
controlled, supportive therapeutic environment; group
methods offer validation and normalization of traumatic
reactions through sharing with other members. While
empirical validation of specific treatments for community
violence-related PTSD is lacking, an empirically based
form of cognitive-behavioral group therapy that has been
used with another youth trauma population is available
(March et al., 1998).
Relatively more progress has been made in developing
violence prevention programs. Gang prevention and con-
flict resolution skill-building programs for high-risk youth
currently dominate the focus in these programs (Hausman
et al., 1994). However, a recent review of the community
gang or individual rapes, stabbings, drive-by or walk-by
shootings, shootouts, and kidnappings represent other
violent activities in which gang members may be involved
(Burton et al., 1994).
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violence prevention literature found that prevention ef-
forts appear to be more effective if children are engaged
early (beginning before age 6), and the program includes
intervention in children's social environments at home
and at school (Kellerman et al., 1998). Additionally, pro-
grams should continue to make specific efforts to reduce
obvious high-risk behaviors such as gang involvement,
heavy drinking, and carrying handguns among adoles-
cents.
RICHTERS, J.E., & SALTZMAN, W. (1990). Survey of
Children's Exposure to Community Violence. National Insti-
tute of Mental Health. To obtain a copy of the SCECV, contact
Child and Adolescent Disorders Research Branch, The Na-
tional Institute of Mental Health, 5600 Fishers Lane, Room 18-
C17, Rockville, Maryland, 20857, (301) 443-5944.
REFERENCES
MARCH, J.S., AMAYA-JACKSON, L., MURRAY, M.C., &
SCHULTE, A. (1998). Cognitive-behavioral psychotherapy for
children and adolescents with posttraumatic stress disorder
after a single-incident stressor. Journal of the American Academy of
Child and Adolescent Psychiatry, 37, 585-593.
SAIGH, P.A. (1991). The development of posttraumatic stress
disorder following four different types of traumatization.
Behaviour Research and Therapy, 29, 213-216.
SELECTED ABSTRACTS
BELL, C.C. (1997). Community violence: causes, prevention,
and intervention. Journal of the National Medical Association, 89,
657-662. Presents pragmatic schemata for understanding various
types and motivations for community violence. This under-
standing is essential to frame prevention, intervention, and
postvention strategies designed to reduce the phenomena of
violence in society. Each category of violence (collective, indi-
vidual, drug-related, gang-related, etc.) lists examples of preven-
tion, intervention, and postvention strategies. This article is in-
tended to broaden the understanding of violence so that strate-
gies to address violence will become more specific and measurable.
BONEY-MCCOY, S. & FINKELHOR, D. (1995). Psychosocial
sequelae of violent victimization in a national youth sample.
Journal of Consulting and Clinical Psychology 63, 726-736. In a
national telephone sample of youths aged 10-16 years, over one
third reported having been the victims of an assault. Victimized
respondents displayed significantly more psychological and be-
havioral symptomatology than did nonvictimized respondents
(more symptomatology related to PTSD, more sadness, and more
school difficulties), even after controlling for some other possible
sources of distress. Sexual assault was associated with particu-
larly high levels of symptomatology. However, victims of other
forms of assault-nonfamily assaults involving weapons or physi-
cal injury (aggravated assaults), assaults by parents, violence to
genitals, and attempted kidnappings-also evidenced levels of
distress that were not statistically lower than those suffered by
victims of sexual assault. The findings suggest that substantial
mental health morbidity in the general child and adolescent
population is associated with victimization.
BURTON, D., FOY, D.W., BWANAUSI, C., JOHNSON, J., &
MOORE, L. (1994). The relationship between traumatic expo-
sure, family dysfunction, and post-traumatic stress symptoms
in male juvenile offenders. Journal of Traumatic Stress, 7, 83-93.
This study examined some chronic, stressful conditions and some
acute, traumatic events which may place youths at risk for
specific types of psychopathology. 91 delinquent adolescents
with histories of serious and repeated crimes were assessed for
their exposure to 11 different types of trauma. The subjects were
also tested using measures which assess family functioning, and
frequency and intensity of PTSD symptoms. Results indicated
that 24 percent of the subjects tested met full DSM III-R criteria for
PTSD. Both exposure to violence and family dysfunction were
significantly associated with PTSD symptomatology. These find-
ings suggest that juvenile offenders may constitute a high risk
group for exposure to multiple types of trauma and the develop-
ment of PTSD symptoms related to such exposure. This study
provides a rationale for future cross-trauma research both within
the juvenile offender population and between it and other iden-
tified trauma groups.
FITZPATRICK, K.M. & BOLDIZAR, J.P. (1993). The preva-
lence and consequences of exposure to violence among Afri-
can-American youth. Journal of the American Academy of Child and
Adolescent Psychiatry, 32, 424-430. The objective of this study was
to examine the relationship between chronic exposure to commu-
nity violence and PTSD symptoms in a nonrandom sample (N =
221) of low-income African-American youth between 7 and 18
years old. Results showed males were more likely than females to
be victims of and witnesses to violent acts; there were no other
significant sociodemographic differences in the degree of expo-
sure to violence. PTSD symptoms reporting was moderately high
for this sample of youth; 54 youth (27.1 percent) met all three of
the diagnostic criteria considered. Regression analyses revealed
that being victimized and witnessing violence were significantly
related to the reporting of PTSD symptoms. These symptoms
were more extreme among victimized females and victimized
youth who had no primary males living with them in the house-
hold (i.e., fathers and/or brothers). Exposure to violence among
youth is clearly significant to their reporting of PTSD symptoma-
tology, yet the clinical implications of this relationship remain
largely unexplored.
FOY, D.W., WOOD, J.L., KING, D.W., KING, L.A., RESNICK,
H.S. (1997). Los Angeles Symptom Checklist: psychometric
evidence with an adolescent sample. Assessment, 4, 377-384. The
Los Angeles Symptom Checklist (LASC) is a self-report measure
of PTSD and general distress that has been used with a variety of
adult trauma populations. This study provided psychometric
support for the instrument's use with adolescents. Internal con-
sistency estimates were .90 and .95 for the 17-item PTSD index
and the 43-item full-scale index, respectively. When mean scores
were compared across trauma exposure groups, results were
supportive of the LASC's ability to detect symptoms of posttrauma
sequelae. Confirmatory factor analysis findings supported 3 highly
correlated factors representing the DSM-IV symptom categories
of reexperiencing, avoidance and numbing, and arousal.
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GARBARINO, J. (1993). Children's response to community
violence: What do we know? Infant Mental Health Journal, 14, 103-
115. Presents a framework for understanding the developmental
significance of violence-related trauma in the lives of young
children. Acute trauma is more readily dealt with through psy-
chological first aid and a therapy of reassurance. Chronic trauma
requires a more systematic reconstruction of the child's social
map of the world. Situations of chronic danger can stimulate the
process of moral development if they are matched by an interac-
tive climate crated by adults and if the child is free of debilitating
psychopathology. Socioeconomic and demographic correlates of
violent trauma predict an accumulation of risk factors in the
child's life that compounds the problem of developmental dis-
ability. The problem community violence poses for the child must
be understood in the larger context of greater risk for family
disruption, domestic violence, poverty, and minority group status.
HAUSMAN, A.J., SPIVAK, H., PROTHROW-SMITH, D. (1994).
Adolescents' knowledge and attitudes about and experience
with violence. Journal of Adolescent Health, 15, 400-406. PURPOSE:
Educational interventions directed to the prevention of youth
inter-personal violence make assumptions about the educational
needs of adolescents for violence-prevention despite little avail-
able data. This paper provides new information on background
levels of adolescents' knowledge of, attitudes about and experi-
ence with violence. METHODS: Over 400 teens across Boston's
neighborhoods were surveyed by random-digit dialed telephone
techniques. RESULTS: Results show that while boys are more
often involved in violence, almost one quarter of girls report
fighting. Black teens witness more violence and are threatened
more often than whites, but they do not fight more. Knowledge
scores indicate a need for improvement in adolescents' under-
standing of risk factors. Attitude scores indicate that adolescents
believe fighting can and should be avoided, but they lack knowl-
edge of behavioral options. Regression analyses sow a positive
relationship between violence experience and knowledge and
attitudes. CONCLUSION: These data suggest that preventive
interventions should be directed to both improving adolescents'
knowledge and understanding of personal risk and increasing
their repertoire of conflict-resolution skills.
HILL, H.M. & JONES, L.P. (1997). Children's and parents'
perceptions of children's exposure to violence in urban neigh-
borhoods. Journal of the National Medical Association, 89, 270-276.
Examined child and parent perceptions of children's exposure to
community violence among 50 male and 46 female 4th-6th grad-
ers (aged 9-12 yrs.), 51 from high- and 45 from low-violence
neighborhoods in 6 elementary schools in Washington, D.C.
More than 75% of the African-American elementary school chil-
dren sampled indicated that they had witnessed incidents of
community violence ranging from homicides to nonfatal
shootings, physical assaults, gang violence, robbery with as-
saults, and rape in their neighborhoods. Yet almost half of the Ss'
mothers in the study denied that their children had been exposed
to any community violence. When these discrepancies were
examined, results reveal that Ss' whose mothers were in disagree-
ment regarding their exposure to community violence were less
likely to experience social support from their peers. Mothers'
possible lack of awareness as to the experience of their children
may place them at further risk by eliminating the possibility for
adult-child interaction and guidance regarding their experience
with violence in their neighborhoods.
KELLERMAN, A.L., FUQUA-WHITLEY, D.S., & MERCY, J.
(1998). Preventing youth violence: What works? Annual Review
of Public Health, 19, 271-292. Between 1985 and 1992, serious youth
violence in the United States surged to unprecedented levels. The
growing use of firearms to settle disputes has contributed to this
phenomenon. Youth are most often victimized by one of their
peers. In response to this problem, a wide variety of programs
have been implemented in an attempt to prevent youth violence
or reduce its severity. Few have been adequately evaluated. In
general, interventions applied between the prenatal period and
age 6 appear to be more effective than interventions initiated in
later childhood or adolescence. Community-based programs
that target certain high-risk behaviors may be beneficial as well.
A sustained commitment to evaluation research is needed to identify
the most effective approaches to youth violence prevention.
KLIEWER, W., LEPORE, S.J., OSKIN, D., & JOHNSON, P.D.
(1998). The role of social and cognitive processes in children's
adjustment to community violence. Journal of Consulting and
Clinical Psychology, 66, 199-209. This study examined associations
of community violence exposure and psychological well-being
among 99 8-12-year-old children (M = 10.7 years) using home
interviews with mothers and children. Both moderators and
mediators of the links between violence exposure and well-being
were tested. After demographics and concurrent life stressors
were controlled for, violence exposure was significantly associ-
ated with intrusive thinking, anxiety, and depression. Regression
analyses indicated that intrusive thinking partially mediated
associations between violence exposure and internalizing symp-
toms. Planned comparisons revealed that violence exposure had
the strongest effect on well-being among children with low social
support or high levels of social strains. Furthermore, children with
high levels of intrusive thinking were most likely to show heightened
internalizing symptoms when they had inadequate social support.
LYNCH, M. & CICCHETTI, D. (1998). An ecological-transac-
tional analysis of children and contents: The longitudinal inter-
play among child maltreatment, community violence, and
children's symptomatology. Development and Psychopathology,
10, 235-257. Cicchetti and Lynch have conceptualized ecological
contexts as consisting of nested levels with varying degrees of
proximity to the individual. These levels of the environment
interact and transact with each other over time in shaping indi-
vidual development and adaptation. With a sample of maltreated
(n = 188) and nonmaltreated (n = 134) children between the ages
of 7 and 12 years, this investigation employed a 1-year longitudi-
nal design to conduct an ecological-transactional analysis of the
mutual relationships among community violence, child mal-
treatment, and children's functioning over time. Indicators of
children's functioning were externalizing and internalizing be-
havior problems and self-rated traumatic stress reactions, de-
pressive symptomatology, and self-esteem. Either full or partial
support was obtained for the study's primary hypotheses. Rates
of maltreatment, particularly physical abuse, were related to
levels of child-reported violence in the community. In addition,
child maltreatment and exposure to community violence were
related to different aspects of children's functioning. Specific
effects were observed for neglect and sexual abuse and for
witnessing and being victimized by violence in the community.
Finally, there was evidence that children and their contexts
mutually influence each other over time. Results were discussed within
the framework of an ecological-transactional model of development.
MARTINEZ, P. & RICHTERS, J.E. (1993). The NIMH Commu-
nity Violence Project: II. Children's distress symptoms associ-
ated with violence exposure. Psychiatry, 56, 22-35. The rising tide
of violence in American cities has placed the causes and conse-
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quences of violence squarely on the public health agenda. The
U.S. Government's Year 2000 National Health Promotion and
Disease Prevention Objectives includes a full chapter devoted to
violence issues and delineates a number of goals and programs
aimed at reducing the number of deaths and injuries associated
with violence. Notably absent from these objectives, however, is
attention to the possible adverse psychological consequences of
exposure to acute or chronic violence. Nonetheless, in light of
numerous media reports of children's exposure to community
violence and recent reports documenting high levels of exposure
even among very young children, it is reasonable to question
whether the risks of exposure extend beyond death and physical
injury to psychological well-being.
MCLAIN, S.L., MORLAND, L.A., SHAPIRO, J.A., & FOY,
D.W. (1998). Etiologic factors in posttraumatic stress disorder in
children: Comparing child abuse to other trauma types. Family
Violence and Sexual Assault Bulletin, 14 (1-2), 27-30. Research on the
incidence of childhood trauma and its psychological consequences
has grown rapidly in the last 10 years. To help professionals stay
abreast of key findings from these studies, we present results
from a comprehensive review of 55 articles on (community
violence-N-8) on the etiology of child and adolescent PTSD. 85
percent of those 31 studies that examined linkages between
trauma exposure severity and PTSD symptomatology demon-
strated significant relationships. Prior trauma exposure was also
consistently associated with increased PTSD symptomatology.
This pattern of findings is highly consistent with 2 decades of
research in other trauma-exposed populations (e.g., combat vet-
erans), where robust dose-response associations between trauma
severity and PTSD symptomatology have been established. Find-
ings regarding the role of demographic variables as possible
moderators of exposure-distress relationships were more equivo-
cal. Age, gender, and ethnicity were significantly related to PTSD
in some studies, but more studies are needed before definitive
patterns are discernible.
OSOFSKY, J.D. (1995). The effects of exposure to violence on
young children. American Psychologist, 50, 782-788. Violence has
been characterized as a "public health epidemic" in the United
States. At the same time, children's witnessing of violence is
frequently overlooked by law enforcement officers, families, and
others at the time of a violent incident. Although mothers de-
scribe the panic and fear in their children and themselves when
violence occurs, little research or clinical attention has focused on
the potential impact on children of living under conditions of
chronic community violence. The purpose of this article is to
present an overview of available research and clinical under-
standing of the effects of exposure to violence on school-age and
younger children. Suggestions for future research and public
policy initiatives are offered.
OSOFSKY, J.D. (1997). Commentary: community-based ap-
proaches to violence prevention. Developmental and Behavioral
Pediatrics, 18, 405-407. Briefly describes the Violence Intervention
Project for Children and Families, which was developed in New
Orleans in 1993 to address youth violence. The project combines
early intervention, counseling, and treatment, as well as a com-
munication hotline and the education of people officers to en-
hance their skills in dealing with violent incidents.
ADDITIONAL CITATIONS
Annotated by the Editors
COOLEY-QUILLE, M.R., TURNER, S.M., & BEIDEL, D.C.
(1995). Emotional impact of children's exposure to commu-
nity violence: a preliminary study. Journal of the American
Academy of Child and Adolescent Psychiatry, 34, 1362-1368.
Examined the impact of exposure to community violence in 36
children who ranged in age from 7-12 years. Amount of violence
exposure was unrelated to DSM-III-R diagnoses and internaliz-
ing behavior, but high exposure was related to increased likeli-
hood of externalizing behavior.
DURANT, R.H., GETTS, A., CADENHEAD, C., EMANS, S.J.,
& WOODS, E.R. (1995). Exposure to violence and victimiza-
tion and depression, hopelessness, and purpose in life among
adolescents living in and around public housing. Journal of
Developmental and Behavioral Pediatrics, 16, 233-237.
Administered a questionnaire to 225 black adolescents (44%
male) to study violence exposure, family factors, and psychologi-
cal outcomes. Corporal punishment was significantly associated
with depression, hopelessness, and lack of purpose in life even
when a number of other factors were accounted for in multiple
regression.
FREEMAN, L.N., MOKROS, H., & POZNANSKI, E.O. (1993).
Violent events reported by normal urban school-aged chil-
dren: characteristics and depression correlates. Journal of the
American Academy of Child and Adolescent Psychiatry, 32, 419-
423.
Studied 223 inner-city children who ranged in age from 6-12
years. Just over one-quarter of the sample had experienced vio-
lence. These children were at increased risk of depressive symp-
toms, low self-esteem, weeping, and worries about death or
injury. The authors suggest that history of violence exposure be
included in psychiatric assessment of inner-city youth.
GABA, R.J. (1996). Psychometric properties of the survey of
children's exposure to community violence: screening ver-
sion. Unpublished doctoral dissertation, Fuller Theological Semi-
nary.
Describes the psychometric properties of a 50-item self-report
instrument designed to identify and measure the degree of expo-
sure to violent events commonly experienced by children and
adolescents. Confirms the ability of the SCECV to provide a
quantifiable measure of community violence exposure.
GLADSTEIN, J., RUSONIS, E.J.S., & HEALD, F.P. (1992). A
comparison of inner-city and upper-middle-class youths'
exposure to violence. Journal of Adolescent Health, 13, 275-280.
Studied exposure to violence among male and female 18-24-year-
olds from two medical clinics: 403 inner-city youths and 435
middle- and upper-class youths. Inner-city youths were rela-
tively morel likely to have witnessed and experienced violence.
Males from both groups had more violence exposure than fe-
males. Few victims from either group sought help after being
victimized.
HASTINGS, T.L. & KELLEY, M.L. (1997). Development and
validation of the Screen for Adolescent Violence Exposure
(SAVE). Journal of Abnormal Child Psychology, 25, 511-520.
Describes the development and validation of a screening ques-
tionnaire for assessing exposure to school, home, and community
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violence in adolescents. Exploratory and confirmatory factor
analysis identified 3 factors: traumatic violence, indirect violence,
and physical/verbal abuse. Data are presented to demonstrate
the validity of the measure.
HILL, H.M., HAWKINS, S.R., RAPOSO, M., & CARR, P. (1995).
Relationship between multiple exposures to violence and
coping strategies among African-American mothers. Violence
and Victims, 1, 55-71.
Assessed relationships among coping strategies, exposure to
community violence, and interpersonal victimization in 136 Af-
rican-American mothers. Use of coping strategies varied as a
function of amount of violence within a social context and of
socioeconomic factors. Coping strategies also differed based on
violence exposure.
LORION, R.P. & SALTZMAN, W. (1993). Children's exposure
to community violence: Following a path from concern to
research to action. Psychiatry, 56, 55-65.
Describes several large studies conducted by the authors to study
the effects of direct and indirect exposure to urban violence on
children. After reviewing their findings, the authors raise ethical
questions in the conduct of research on urban violence and pose
questions for future investigation.
PYNOOS, R.S. & NADER, K. (1988). Psychological first aid
and treatment approach to children exposed to community
violence: research implications. Journal of Traumatic Stress, 1,
445-473.
Reviews theory and data regarding the effects of violence on
children. Early intervention strategies and treatment approaches
are discussed in terms of posttraumatic stress, grief, worry, and
prior trauma. Interventions are discussed at the level of the child,
the family, the classroom, and the group.
RESNICK, H.S. & KILPATRICK, D.G. (1994). Crime-related
PTSD: emphasis on adult general population samples. PTSD
Research Quarterly, 5(3), 1-7.
Highlights general population studies of crime-related PTSD
that provide descriptive characteristics of crime events and
information relevant to the study of PTSD etiology. Includes
abstracts of selected articles and addditional citations with annotations.
SCHUBINER, H., SCOTT, R., & TZELEPIS, A. (1993). Expo-
sure to violence among inner-city youth. Journal of Adoles-
cent Health, 14, 214-219.
Surveyed 246 predominantly black, inner-city youth, age 14-23,
regarding exposure to and participation in violence. Based on
psychological interview, 14% were judged to be at high risk for
involvement in violent acts. Predictors of being in this high risk
category were low socioeconomic status and childhood physical
abuse, but not witnessing violence.
TAYLOR, L., ZUCKERMAN, B., HARIK, V., & GROVES, B.M.
(1994). Witnessing violence by young children and their
mothers. Journal of Developmental and Behavioral Pediatrics, 15,
120-123.
Recruited 115 mothers with children 1-5 years of age from a
pediatric primary care clinic in a large urban metropolitan area.
According to the mothers' reports, 10% of the children had
witnessed a killing or shooting, and 47% had heard gunshots.
Mothers of children who had witnessed violence were more
likely than mothers whose children had not witnessed violence to
worry about safety and limit their movements in their neighbor-
hoods.
WALLEN, J. & RUBIN, R.H. (1997). The role of the family in
mediating the effects of community violence on children.
Aggression and Violent Behavior, 2, 33-41.
Reviews the epidemiological and clinical data on exposure to
violence among children. Parenting issues are discussed, and a
research agenda for the area is presented. The author also in-
cludes policy recommendations for parents and communities.
PILOTS UPDATE
(Continued from Page 8)
ternment of Japanese Americans and the response of Ger-
man psychiatrists to war neuroses after the First World
War; analyses of writing about PTSD in novels and autobi-
ographies; and psychometric studies of the Personality
Assessment Inventory, Everstine Trauma Response Index,
and several other instruments. These are all subjects poorly
represented in the existing corpus of journal articles and
book chapters indexed in the PILOTS database.
While it is true that the most significant findings of the
best dissertations and theses will probably find their way
into peer-reviewed journal articles, this may take several
years to happen. And there are many studies whose results
are never published elsewhere, but which may still contain
precisely the information needed to help solve a research
or clinical problem. We believe that theses and disserta-
tions represent a potentially valuable part of the traumatic
stress literature, and we hope that the inclusion of this
material in the PILOTS database will increase its availabil-
ity to scholars, students, and practitioners.
Theses and dissertations make up one category of what
information scientists call "grey literature." This term is
used to describe "literature which is not readily available
through normal book selling channels, and therefore diffi-
cult to identify and obtain." Since this definition was first
written, nearly twenty years ago, there has been much
progress in making grey literature bibliographically acces-
sible. There are databases that index technical reports in
many disciplines and the government publications of many
nations. Bibliographic coverage of conference proceedings
and unpublished translations has also improved.
The PILOTS database was established to provide a single
access point to an international interdisciplinary literature.
We intend to expand its coverage to provide users with the
same ability to identify relevant materials in the grey
literature that we provide for more conventional publica-
tions. We welcome suggestions from the traumatic stress
community as to which classes of grey-literature materials
should receive our highest priority.
Prev Page 7 Next
THE MATSUNAGA VIETNAM VETERANS PROJECT
Matthew J. Friedman, MD, PhD
The Matsunaga Vietnam Veterans Project (MVVP) was
mandated by Public Law 101-507, which directed the Na-
tional Center for PTSD to conduct an epidemiologic study
among American Indian and Asian-Pacific Islander Viet-
nam veterans because they had not been sampled in the
National Vietnam Veterans Readjustment Study (NVVRS).
NVVRS had focused on White, Black, and Hispanic Viet-
nam veterans but not on other minority veteran samples.
Because the legislation stipulated that MVVP should be an
"NVVRS-like" study, the MVVP focused primarily on
findings pertinent to the most important results in the
NVVRS Final Report. These included prevalence of PTSD,
comorbid psychiatric diagnoses, readjustment problems,
physical health problems, and clinical utilization.
MVVP had two components. The American Indian Viet-
nam Veterans Project (AIVVP) was conducted by the Na-
tional Center for American Indian and Alaska Native
Mental Health Research, University of Colorado Health
Sciences Center, Denver, CO. It surveyed Southwest (SW)
and Northern Plains (NP) American Indian veterans living
on or near their respective reservations. The Hawaii Viet-
nam Veterans Project (HVVP) surveyed Native Hawaiian
(NH) and Americans of Japanese Ancestry (AJA) veterans
living in Hawaii. It was conducted by VA's Northwest
Center for Cooperative Studies in Health Service in Seattle,
WA. I was responsible for overall supervision of the entire
project and chaired the MVVP Executive Committee, which
included Drs. Marie Ashcraft, Janette Beals, Terence Keane,
Spero Manson, and Anthony Marsella.
Current PTSD prevalence was highest among American
Indian (NP, 31.0% and SW, 26.8%) and lowest for AJA
(2.9%) veterans. Current PTSD prevalence for NH veterans
(12.0%) was in between and not significantly different
from current prevalence for Hispanic (27.0%), Black (20.6%),
or White (13.7%) veterans.
Within MVVP and NVVRS cohorts, between one-third
and two-thirds of all veterans who ever suffered from
PTSD still met full DSM-III-R diagnostic criteria at the time
of the survey. Lifetime PTSD prevalence was highest among
all minority veteran samples except for AJA veterans: NP
(57.2%), SW (45.3%), NH (38.1%), Black (35.4%), and His-
panic (33.7%). There were no significant differences among these
groups. The lowest lifetime prevalence for PTSD was found
among White (19.9%) and AJA (8.7%) veterans; the difference
between these two samples was not statistically significant.
War-zone exposure was the best predictor of PTSD preva-
lence, explaining between 26% and 39% of the variance.
This is an unusually powerful finding in social science
research. Risk factors that affected one's likelihood of
developing war-zone-related PTSD were: a family history
of substance abuse, physical abuse as a child, a negative
relationship with one's parents, deviant behavior as a
child, lower educational attainment, non-officer status in
Vietnam, and service in I-Corps (where the heaviest fighting
took place) during the war.
Most results in this report are presented in two ways, as
unadjusted and adjusted findings. Many significant differ-
ences between groups obtained from analyses of the raw
data appeared to be due to PTSD symptoms and war-zone
exposure after the data were adjusted. For example, SW,
NP, and NH cohorts reported greater distress than did AJA
or NVVRS cohorts. The high unadjusted prevalence of
alcohol abuse/dependence among American Indian vet-
erans appeared to be explained by comorbidity with PTSD
symptoms. In contrast, the adjusted prevalence data for
comorbid disorders indicate that both the NH and AJA
samples were more likely than the American Indian samples
to meet diagnostic criteria for at least one psychiatric
disorder that was not positively associated with PTSD or
war-zone exposure.
Postwar readjustment problems tended to be highest
among both American Indian cohorts, followed by Black
and Hispanic cohorts. AJA and White veterans reported
the lowest levels, and NH veterans were in between. Such
problems included educational attainment, vocational sta-
tus, drug and alcohol use, legal difficulties, family prob-
lems, social isolation, and a history of homelessness or
vagrancy. Following adjustment of the data, most ethnic
differences appeared to be due to PTSD symptoms and
war-zone exposure. American Indian veterans reported
the poorest perceived health status and the greatest num-
ber of chronic health problems. Some, but not all, of these
differences disappeared after data adjustment for PTSD
symptoms and war-zone exposure.
American Indian veterans reported the highest amount
of clinical service utilization while AJA veterans reported
the lowest. Treatment-seeking behavior was predicted by
perceived health status and by the number of chronic
health problems reported by all ethnic groups except for
AJA veterans. AJA veterans appeared to utilize fewer
clinical services than would have been predicted by re-
ported symptomology. With few exceptions, PTSD symp-
toms were highly correlated with clinical utilization by all
ethnic groups. This was true for all VA utilization (medical,
psychiatric, inpatient, outpatient, and Vet Center). It was
also true for non-VA mental but not physical health-care
utilization. Over half of SW American Indian veterans had
participated in culture-specific traditional healing ceremo-
nies for physical and mental health problems, followed by
NP (13-16%), NH (7%), and AJA (1-5%) veterans. Further-
more, two-thirds of all American Indian veterans who had
ever made use of such services had done so during the
previous six months.
We believe that MVVP represents a major step forward
in psychiatric epidemiologic research among minority vet-
erans (and non-veterans). We hope that these results will
be deemed useful by the United States Congress and by the
VA. We also hope that MVVP findings will result in im-
proved sensitivity towards and treatment for all veterans
suffering from war-zone-related PTSD.
Prev Page 8 Next
PILOTS UPDATE
With the Fall update we added citations and abstracts for
266 recent English-language doctoral dissertations and
master's theses to the PILOTS database. We hope in the
near future to add several hundred earlier dissertations
and theses, and to add new ones on a regular basis. (We
would also like to include foreign-language academic pub-
lications to the database, though this is unlikely to happen
in the immediate future.)
Over one million doctoral dissertations have been ac-
cepted by North American universities since 1861. While
there already exists an apparatus for searching this litera-
ture, only one in a thousand of these documents deals with
PTSD or some other topic related to traumatic stress stud-
ies. By including references to relevant dissertations and
theses in the PILOTS database, we hope to make it easier
for researchers and clinicians to find those that might
contain information useful to their work.
Most modern American and Canadian dissertations, as
well as an increasing number from other countries, are
listed in bibliographies compiled by UMI (formerly Uni-
versity Microfilms International) of Ann Arbor, Michigan.
Because UMI serves as a clearinghouse for the distribution
of most of these publications, PILOTS database entries for
dissertations and theses include the UMI order number in
the "Availability" field
(visible in "long format" displays).
In addition to UMI's database, we are searching other
bibliographies to identify dissertations that we might
otherwise miss.
While many researchers are skeptical about the value of
dissertations and theses, it is worth noting that these
documents often provide the only detailed information on
a particular subject. The requirement that a doctoral disser-
tation present original research means that candidates are
careful to select topics that are not fully covered in the
published literature. Whatever methodological shortcom-
ings there might be to dissertation research, it often antici-
pates by several years the availability of more authorita-
tive studies.
Dissertations and theses may be of special interest to
clinicians or researchers interested in a particular popula-
tion. Among the narrow groups studied in the disserta-
tions just added to the PILOTS database are athletic train-
ers, North Dakota peace officers, wives of fire fighters, and
sexual assault nurse examiners. The treatment of Haitian
immigrants, Cuban rafter refugee children, and Latvian
expatriates are among the topics covered. There are also
historical studies of the consequences of the wartime in-
(Continues on Page 6)
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