and Adolescents' Exposure
Children's and Adolescents' Exposure to
Post-Traumatic Stress Reactions,
and Treatment Implications
Steven L. Berman, Wendy K. Silverman, and William M. Kurtines, Child and Family Psychosocial Research Center, Department of Psychology, Florida International University, Miami, FL 33199, USA . Email: email@example.com or firstname.lastname@example.org
The rate of community violence in the United States has increased dramatically over the past two decades (Osofsky, 1998; Parson, 1997). Although the numbers have begun to show a decline in recent years [e.g., in 1998 FBI crime statistics indicate that violent acts and property offenses dropped seven percent nationwide (Morales & Reisner, 1999)], the rates remain high, nevertheless. For example, Saint Louis, Missouri, the city with the highest crime rate in 1998, had 14,952 crimes per 100,000 people. Miami, Florida, U.S., where we are from, was ranked sixth in the nation in terms of crime, with 12,054 crimes per 100,000 people. The high rate of crime and violence in the country has had a profound impact on youth: It is the nation's young people, particularly those from low socioeconomic, multi-ethnic and urban communities, who are increasingly exposed to extreme acts of crime or violence, either as a witness or victim (Warner & Weist, 1996). As a consequence of this exposure, young people are at increased risk of experiencing a myriad of disturbing psychological symptoms.
One main set of problems that results in the aftermath of exposure to crime and violence is the development of distress symptoms, particularly those associate with posttraumatic stress reactions. Because of the high levels of distress experienced by youth who suffer from posttraumatic stress, it is important that interventions be developed that will help alleviate this distress. This article first reviews the research literature on the relation between exposure to crime and violence and the development of posttraumatic stress reactions. The article next discusses intervention strategies to help reduce these reactions.
Children's and Adolescents' Exposure to
Post-Traumatic Stress Reactions,
and Treatment Implications
Youth's Exposure to Crime and Violence and Developing Posttraumatic Stress Reactions
Individuals' reactions to exposure to crime and violence are complex and multifaceted. Although exposure to extreme acts of crime and violence places youth at risk for a variety of adverse psychological consequences, distress symptoms of the type associated with posttraumatic stress have emerged as a focal point of recent research (e.g., Davies & Flannery, 1998; Ensink et al., 1997; Glodich, 1998).
The main symptoms associated with posttraumatic stress reactions include: reexperiencing the trauma (e.g., nightmares, flashbacks), avoidance of stimuli associated with the trauma (e.g., thoughts, feelings, conversations, people, places, or things), and increased arousal (e.g., irritability, hypervigilence, easily startled, sleep and/or concentration difficulties). These symptoms became a part of psychiatric nomenclature in the third edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-III; American Psychiatric Association, 1980), and more specifically, in the diagnostic category, Posttraumatic Stress Disorder (PTSD). We note though that in the research that we summarize in this article, some studies focused on assessing the symptoms of PTSD among participants while other studies have focused not only on the symptoms but also on assessing whether full diagnostic criteria have been met to warrant a clinical diagnosis of PTSD among participants.
Studies conducted by Richters and Martinez (Martinez & Richters, 1993; Richters & Martinez, 1993) represent the first systematic attempts to document the linkage between exposure to crime and violence and symptoms in children. In presenting the rationale for conducting their research, Martinez and Richters (1993) pointed out that although some symptoms (e.g., fear, anxiety, intrusive thoughts) may be viewed as normal reactions to abnormal events and may serve adaptive functions in an objectively dangerous environment, such symptoms also can be signals for maladaptive reactions with possible long term negative consequences for normal social, emotional, and cognitive development. This can even happen when initially adaptive responses become entrenched, resistant to change, and overgeneralized to situations. Such responses "in the extreme, have come to be associated with posttraumatic stress" (Martinez & Richters, 1993; p. 23).
To examine the relation between children's exposure to crime and violence and distress symptoms, Richters and Martinez (Martinez & Richters, 1993; Richters & Martinez, 1993) used the Survey of Exposure to Community Violence (SECV; Richters & Saltzman, 1990) to assess exposure to crime and violence and parents' ratings of their children's distress using the Checklist of Child Distress Symptoms (Richters & Martinez 1990) and the Child Behavior Checklist (Achenbach, 1978). Children's self-ratings of distress also were obtained via a cartoon-based interview (Richters, Martinez, & Valla, 1990). Participants were 165 children (111 first and second graders and 54 fifth and sixth graders) in a low-income moderately violent neighborhood in Washington, DC.
Results indicated that among the first and second graders, parents reported that 21% of the children had been victims of at least one violent act. Considerably more children were reported as having been witnesses, with 84% having witnessed at least one violent act. Among the fifth and sixth graders, generally higher rates of exposure were reported by parents, with parents reporting that 35% of the children were victims of at least one violent act and 90% were witnesses to a violent act. The parents also reported that 3% of the younger children and 4% of the older children had witnessed a murder. For both age groups, parents tended to report lower levels of distress in their children than the children reported themselves. There were no gender differences in terms of exposure to violence or distress symptoms. In terms of the specific symptoms of distress reported by children and parents, symptoms of anxiety and depression were most pronounced; more specific PTSD symptoms were not assessed.
Another study that documented a relation between exposure to crime and violence and distress symptoms was Fitzpatrick and Boldizar (1993). This study however involved a sample of not only children but also adolescents. Specifically, participants were low-income African-American youth (ages = 7 to 18 years; N = 221) who were involved in a federally funded summer camp program within a large, southern central city. An adaptation of the SECV was used as well as a revised group administered version of the Purdue Posttraumatic Stress Scale (Figley, 1989).
In this sample, more than 70% of the children and adolescents reported being victims of at least one violent act. Similar to Richters and Martinez (1993), participants were more likely to have witnessed violence than to have been victimized, with close to 85% having witnessed at least one violent act and 43.4% having witnessed a murder. In addition, of those who had been exposed either as witness or victim, 89% met at least one of the DSM III-R criteria for PTSD (American Psychiatric Association, 1987), with the average number of symptoms being five. Boys reported significantly more exposure to violence than girls, but girls reported more PTSD symptoms than boys.
In another study (Jenkins & Bell, 1994), 203 African American students (ages = 13 to 18 years) from a public high school on Chicago's south side in a high violent crime district were surveyed using the SECV to assess exposure to crime and violence, and the Checklist of Child Distress Symptoms to assess the effects of the exposure. Almost two-thirds of the youth indicated that they had seen a shooting and almost one-half had been shot at themselves. Forty-five percent reported that they had seen someone killed. Of those who had witnessed severe violence, 36% reported that the victim was a friend and 34% reported that the victim was a family member. Although being personally victimized was similarly correlated with psychological distress symptoms for boys (r=.25) and girls (r=.22), witnessing violence was more highly correlated with psychological distress symptoms for girls (r=.33) than boys (r=-.07). Overall, girls reported more distress symptoms than boys, and boys reported more high risk behaviors (e.g., weapon carrying, substance use, and fighting) than girls. As Jenkins and Bell pointed out, however, the correlational nature of the data precludes one from concluding whether the boys' high risk behaviors represent either reactions to violence exposure or contributors that lead to exposure.
A large sample of youth (N=2,248; sixth, eight, and tenth graders) in New Haven, Connecticut was surveyed by Schwab-Stone et al. (1995) using a measure devised by the investigators. The survey, referred to as the Social and Health Assessment, was designed to assess positive school and community involvement as well as high risk behaviors. Of particular relevance to this article are the students' responses to the question on the survey that pertained to exposure to violence (i.e., During the past year, how many times have you seen someone get shot or stabbed?), and the four questions about feelings of personal safety. To the question about exposure to violence, more than 40% of the youth reported exposure to a shooting or stabbing in the past year. To the questions about feelings of personal safety, 74% reported feeling unsafe in one or more common settings (e.g., home, neighborhood, school). Exposure to violence was found to be associated with increased willingness to use physical aggression, diminished perception of risk, lowered personal expectations for the future, dysphoric mood, antisocial activity, alcohol use, and diminished academic achievement. This study too was correlational in nature, however.
Also in New Haven, Connecticut, Horowitz, Weine, and Jekel (1995) assessed 79 adolescent females (ages = 12 to 21 years), recruited from a clinic that provided medical and gynecological care to a predominantly urban female adolescent population. Participants completed the Adolescent Self-Report Trauma Questionnaire, which included questions drawn from a number of other inventories as well as several additional items written by the authors. The PTSD Symptom Scale (Foa, Riggs, Dancu, & Rothbaum, 1993) was used to assess the adolescents' reactions. The lowest number of violent events experienced by one person was eight and the highest number was 55, with a mean of 28 violent events across the participants. Approximately 45% of the sample had witnessed a shooting. The mean number of PTSD symptoms for the total sample was ten, and 67% of the participants met full DSM-III-R diagnostic criteria for PTSD.
Berman, Kurtines, Silverman, and Serafini (1996) also examined the relation between exposure and posttraumatic stress symptoms in a sample of students (N=96; ages = 14 to 18 years) enrolled in an alternative high school aimed at dropout prevention in Miami, Florida. Most of the students enrolled in this school came from low income inner-city neighborhoods where crime and violence are most prevalent. An adaptation of the SECV was once again used to assess exposure to crime and violence, and the Posttraumatic Stress Disorder Reaction Index (Frederick, 1985) was used to assess symptoms of PTSD resulting from the exposure.
Results indicated that more than 93% of the respondents had witnessed one or more act of community violence, and 44% reported having been a victim of a violent crime. Similar to the rate reported by Fitzpatrick and Boldizar (1993), 41.6% had witnessed a murder. The results further indicated that 83% of those who had been exposed, either as witness or victim, met at least one DSM-III-R criteria for PTSD, with the average number of symptoms being ten. Using the categorization of level of severity of PTSD of Fredrick (1985), 34% of the participants' symptoms were categorized as mild, 44% were moderate, and 18% were severe. Social support and coping style also were assessed: Higher scores on the Reaction Index were found to be related to increased usage of negative coping and the perception of less social support.
In a study conducted in South Africa (Ensink, Robertson, Zissis, & Leger, 1997), 60 Xhosa speaking black children, ages 10 to 16 years were recruited from a children's home (n=30) and a school (n=30), both located in a township known for high levels of community violence, on the outskirts of Cape Town. Participants were administered the SECV and various sections (PTSD, major depression, dysthymia, conduct disorder, and panic disorder) of a structured clinical interview. All participants had been exposed to community violence with 56% reporting having been a victim, and 45% reporting having been a witness to at least one killing. In terms of the effects of exposure, the most common DSM-III-R diagnosis assigned to the children was dysthymia (31.6%), followed by PTSD (21.6%), major depression (6.6%), and conduct disorder (1.6%). Overall, of the 60 participants, 40% were diagnosed with one or more psychiatric disorders, 42% reported psychiatric symptoms but did not meet criteria for a specific psychiatric disorder, and 18% reported no symptoms.
Kliewer, Lepore, Oskin, and Johnson (1998) recently reported that among 99 children (ages = 8 to 12 years; 96% African-American) who lived in high crime and violence areas in Richmond, Virginia, SECV results showed that 88% of the children had heard gunfire near home, 25% had seen someone shot, and 17% had seen someone killed. Based on children's and parents' ratings on several questionnaires, exposure to community violence was found to be significantly associated with internalizing symptoms of depression and anxiety. Social support also was assessed in this study and was found to be inversely related to levels of internalizing symptoms of depression and anxiety, and to moderate the relation between violence exposure and intrusive thoughts.
Overall, the research summarized in this section document that children and adolescents are significantly exposed to community crime and violence and the majority of these youth experience symptoms associated with posttraumatic stress as a result of this exposure. Many of these children experience the full clinical disorder of PTSD as well. It is worth noting however that most of the research conducted thus far has been conducted on children who reside in generally medium to large urban regions and mainly in the United States . Although it is reasonable to suspect that similar reactions would be displayed among children and adolescents from other countries as well as other types of regions (e.g., rural, etc.) this is an issue that requires further research attention.
Interventions for Youths' Post-Traumatic Stress Reactions Following Exposure to Crime and Violence
In light of the high rates of youth exposure to crime and violence and its psychological sequelae, it is important that interventions be developed that can help alleviate the distress and suffering that is likely to ensue. In addition, although children's reactions following exposure to crime and violence have not been followed over extended time periods, research in other areas have shown that a considerable proportion of children continue to display significant posttraumatic stress reactions for as long as 18 months following exposure to traumatic events (e.g., hurricanes; La Greca, Silverman, Vernberg, & Prinstein, 1996).
Despite the need for effective interventions that can be used in the aftermath of children's exposure to crime and violence, the research in this area is sparse. For example, we are not aware of any randomized controlled trials that have been conducted in this area. The literature mainly consists of a small number of studies that have investigated the efficacy of treating PTSD in young people who have been exposed to a variety of traumatic events, not necessarily community violence (e.g., Albano, Miller, Zarate, Cote, & Barlow, 1997; Farrell, Hains, & Davies, 1998; March, Amaya-Jackson, Murray, & Schulte, 1998). March et al. (1998), for example, used a school based group cognitive behavioral intervention with seventeen youth (ages 10 to 15 years) who had been exposed to a single event stressor (type of traumatic stressor varied across participants, though some of the events involved exposure to community violence) and who met DSM-IV criteria for PTSD. The treatment took place over eighteen weekly sessions. The study used a single case design to control for extraneous variables rather than a comparison control group. More specifically, intervention start dates were staggered by four weeks in two of four schools, thereby generating a multiple baseline across setting and time design. Results indicated that 57% of the participants no longer met DSM-IV criteria for PTSD at post-treatment; 86% were free of PTSD at 6-month follow-up. Significant improvements also were observed in symptoms of depression, anxiety, and anger at post-treatment and follow-up.
In light of the sparse treatment research conducted in this area, there is a clear need for clinical trials to confirm that psychosocial interventions particularly cognitive behavioral treatments, are safe, acceptable and effective for children and adolescents who suffer from symptoms of posttraumatic stress and/or PTSD as a result of exposure to community violence (e.g., March et al., 1998). With this need in mind, in the section below we describe what we believe would be the main elements of an effective intervention. The intervention that we describe draws, in part, on the research findings that have been summarized in this article as well as on research findings obtained in other areas of children's reactions to trauma (e.g., hurricanes; La Greca et al., 1996; Vernberg, La Greca, Silverman, & Prinstein,1996). The intervention also draws on research findings obtained from clinical trials on anxiety disorders in youth with anxiety disorders (e.g., Kendall, 1994; Kendall et al., 1997; Silverman et al., 1999a; 1999b). We stress however that the intervention described represents, at this point, a general prototype. Refinement will likely occur, as the intervention undergoes empirical scrutiny.
The basic intervention would be group cognitive behavioral treatment (GCBT). Using exposure-based exercises as well as cognitive and behavioral procedures in a group format, GCBT, as used in the clinic (Silverman et al., 1999a), would be adapted as a school based intervention to be implemented by school personnel (e.g., school counselors). As others have pointed out (Duncan, 1996; Goenjian et al., 1997; Osofsky, 1998; Pynoos & Nader, 1988; Warner & Weist, 1996)) it makes particular sense to work with youth who have been exposed to crime and violence in the school setting and who experience distressing symptoms. This is because such youths are not likely to seek help for their distress through traditional modes of interventions, such as mental health clinics or private practice.
A group format, in particular, also makes a great deal of sense for use in school settings because group treatment is more cost and time efficient than an individual treatment format. A group format also may be especially useful for working with youth who have been a witness or victim of crime and violence (Alessi & Hearn, 1984; Frederick, 1985) because group processes can facilitate the discussion of content related to the traumatic event. For example, within the group, discussions of children's reactions can be normalized and universalized (Frederick, 1985). A group format also is consistent with the fact that symptoms associated with posttraumatic stress often result from traumatic events that expose groups of individuals to crime or violence in public places (e.g., shootings in schools, stores, or restaurants; snipers; hostage taking). Thus, even when individuals do not co-experience exactly the same traumatic event, in cases such as exposure to crime and violence, individuals experience very similar events. The group format thus provides a natural setting for individuals to address their shared experience. Other group processes available in GCBT include peer modeling, peer reinforcement, feedback, and social comparison. The main foci of GCBT would be the reduction of posttraumatic stress reactions through exposure-based exercises, the enhancement of the use of adaptive coping responses, and the enhancement of social support availability and utilization.
There is general consensus that systematic exposure to the traumatic cues is essential in reducing symptoms associated with posttraumatic stress symptoms in youth and adults (e.g., Eth & Pynoos, 1985; Fairbanks et al., 1993; Foa & Kozak, 1986; Keane & Kaloupek, 1982; Lyons, 1987). Although exposure is merely a description of what occurs in treatment, and is not an explanation of the process of change, the various theoretical accounts that have been suggested (but not sufficiently empirically confirmed) involve the modification of behavioral, cognitive, or affective processes, or a combination thereof (see Barlow, 1988). For example, a cognitive explanation of exposure procedures would be that through direct experience with the traumatic event, children's mastery expectations are raised (Bandura, 1977). Once strong expectations have been developed through repeated success, children can tolerate the negative impact of the occasional failure. Behavioral explanations involve the processes of habituation and extinction (Rachman, 1978). Habituation refers to the decline of the unlearned responses after repeated presentations of the traumatic stimulus. Extinction refers to the repeated presentation of the traumatic stimulus (conditioned stimulus) in the absence of the aversive stimulus (unconditioned stimulus) with a decrement in the strength of the conditioned response. Rachman (1978) has discussed the varying roles of habituation and extinction in decreasing anxious responses. Briefly, Rachman suggested that the former is most important for reducing the physiological component; the latter is most important for reducing the behavioral component, i.e., avoidance, and both are important for reducing the subjective component.
In their discussion of emotional processing theory, Foa and Kozak (1986) recommended the use of some type of exposure-based procedure to (1) activate the fear memory and (2) provide new information that is incompatible with the current fear structure to allow for a new memory to be formed (also see Litz & Keane, 1989). In this frame, Foa and Kozak (1986) proposed that the use of systematic exposure-based procedures in a safe environment serves to modify the feared memory such that threat cues are reevaluated and habituated. Further, because most children who have experienced events as upsetting as crime and violence-- either as a witness or a victim--tend to have oppressive and overpowering emotions, they usually attempt to suppress or avoid these emotions. When successful in avoiding these oppressive emotions, individuals have described a complete numbing of affect (Resick & Schnicke, 1992). The use of exposure-based exercises is thereby also designed to encourage individuals' expressions of affect. Indeed, in the absence of such exposure, there is no guarantee that all of these emotions and their related beliefs will be sufficiently elicited (Resick & Schnicke, 1992).
There has been insufficient research attention paid to the length of a therapeutic exposure experience. What appears important however is that elevated levels of arousal or discomfort are experienced during the exposure task. Also important is that the child then face arousal and discomfort, and not leave the situation until these feelings are reduced. Whether this is five minutes, twenty-five minutes, or five hours will likely vary from case to case.
In working with children and adolescents who have been exposed to community violence, the use of drawing/writing and reading exercises is also likely to serve as a useful exposure experience. The participants, for example, might be asked to draw pictures or write stories about their experiences. These might then be shared with the other members of the group and similarities and differences in experiences might be elaborated upon through group discussion.
Coping is critical in competency/vulnerability models of child and adolescent psychopathology (Rutter, 1979; 1990). In these models, coping is viewed as a process that may serve as a protective factor that helps to buffer individuals' responses to stressful life events. Thus, exposure to crime and violence challenges the victim/witness' capacity to generate adaptive coping responses, and promotes the use of maladaptive coping responses. These might include self-blame, anger, withdrawal, blaming others, etc., (Schepple & Bart, 1983). These maladaptive coping responses, moreover, if sufficiently intense, may facilitate the intrusive memories and avoidance reactions associated with posttraumatic stress (Resick & Schnicke, 1992), and interfere with successful emotional processing during the exposure-based exercise. In GCBT, coping skills enhancement would provide the youth with corrective information as it relates to a particular maladaptive coping response. Thus, coping skills enhancement would serve not only to improve the coping responses of the youth but also potentially moderate the reduction of posttraumatic stress symptoms.
Coping skills training can take a variety of forms. As noted above, the process of exposure in and of itself may serve to enhance children's coping as children's mastery expectations are raised via successful exposure experiences (Bandura, 1977). Similarly, the drawing/writing and reading exercises also can be a medium by which coping skills can be enhanced as children might be asked to draw pictures or write stories not only about their experiences (i.e., an exposure) but they also might be asked to draw pictures or write stories about various ways (both adaptive and maladaptive) to handle the situations, followed by discussion about the advantages and disadvantages of these various ways.
Peers serve as a major source of social support for youth (Levitt, 1991), and traumatic events deplete social support (Kaniasty & Norris, 1993). Existing evidence suggests that the broader and deeper the network of social support, the greater the chance of ameliorating the negative effects of stressful life events (Cohen & Wills, 1985; Kaniasty & Norris, 1992). In GCBT, a main focus of the social support enhancement component would be on the group itself as a source of social support. In addition, an active effort would be made to enhance external sources of social support. In this effort, it would be important to enhance both perceived and received support (Kaniasty & Norris, 1992). Thus, for example, in helping youth to identify support agents it could be pointed out that they have "more support than they think they have" (perceived support), and the youth can be taught how to engage outside sources (e.g., parents, siblings, friends) as support agents (received support). To help accomplish this, behavioral strategies such as contingency contracting, modeling, role-playing, and feedback can be used.
Although reactions to exposure to crime and violence are complex and multifaceted, distress symptoms associated with posttraumatic stress constitute a central feature of the distress reaction that youth exhibit when exposed to crime and violence. In addition to the adverse psychological consequences, exposure to crime and violence challenges the victim/witness's capacity to generate adaptive coping responses and to access and utilize social support. Unfortunately, the population most at-risk - low socioeconomic, multi- ethnic urban youth - is not likely to seek help for distress symptoms associated with exposure to crime and violence through traditional modes of intervention (e.g., mental health clinics, private practice, etc.). In addition, crime and violence have become so much a part of the culture of modern American life that exposure to such traumatic events among many youth has become the norm. Consequently, the effects of exposure to community violence are frequently not recognized by youth as "problems" in need of mental health services. Thus, the need for development and implementation of community and school based interventions is considerable. Although the exact nature and content of intervention programs will evolve as empirical research findings in this area become available, basic elements that we outlined in this paper for such programs include the following: First, it would be a school based group cognitive behavioral intervention; second, it would use exposure based exercises; third, it would enhance individuals' use of adaptive coping skills, and fourth, it would enhance the availability and utilization of individuals' social support (both perceived and received).
Apparent from this article, there is great need for additional research in this understudied area. We hope this article will serve to stimulate such research that will help to reduce the distress experienced by the large numbers of youth who have been witnesses to or victims of community crime and violence.
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Massey University, New Zealand
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