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Exposure to Violence
Psychological and Academic Correlates in Child Witnesses
Hallam Hurt, MD;
Elsa Malmud, PhD;
Nancy L. Brodsky, PhD;
Joan Giannetta, BA
Arch Pediatr Adolesc Med. 2001;155:1351-1356.
ABSTRACT
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Background Inner-city children are frequently exposed to violence; however, there
are few data regarding the psychological and academic correlates of such exposure
in young children at school entry.
Objectives To document exposure to violence in inner-city children aged 7 years;
assess their feelings of distress; and evaluate the relationships of exposure
to violence with school performance, behavior, and self-esteem.
Setting A study center in an inner-city hospital.
Participants One hundred nineteen inner-city children evaluated at age 7 years; 119
caregivers (biological and foster).
Design As part of a longitudinal study, children were administered the following
by a masked examiner: Things I Have Seen and Heard (TISH) to assess exposure
to violence; Levonn, a cartoon-based interview for assessing children's distress
symptoms; and the Culture-Free Self-Esteem Inventory, Second Edition. School
performance was assessed by school reports and child behavior by the Child
Behavior Checklist (CBCL), the Parent Report Form, and the Teacher Report
Form. Caregivers for children were administered the parent report version
of the Checklist of Children's Distress Symptoms (CCDS-PRV) as well as the
CBCL Parent Report Form.
Main Outcome Measures Exposure to violence (TISH); feelings of distress (Levonn); school performance;
behavior (CBCL Parent Report Form and CBCL Teacher Report Form); and self-esteem
(Culture-Free Self-Esteem Inventory).
Results We found that these children were frequently exposed to violence. For
example, 75% had heard gun shots, 60% had seen drug deals, 18% had seen a
dead body outside, and 10% had seen a shooting or stabbing in the home (TISH).
Many showed signs of depression and anxiety; eg, 61% worried some or a lot
of the time that they might get killed or die and 19% sometimes wished they
were dead (Levonn). Higher exposure to violence (TISH Total Violence score)
was correlated with higher Levonn composite scores for depression and anxiety
and with lower self-esteem (P .04), and was also associated
with lower grade point average and more days of school absence (P.02). Caregiver assessment of child anxiety correlated poorly
with child report of anxiety (P = .58).
Conclusions Young inner-city children have a high exposure to violence by age 7
years; many show signs of distress that frequently are not recognized by caregivers.
Further, higher exposure to violence in children correlates with poorer performance
in school, symptoms of anxiety and depression, and lower self-esteem.
INTRODUCTION
THAT CHILDREN are witness to or victims of violence is not a novel finding;
it is particularly common among children living in the inner city. A growing
number of reports describe such exposure. Campbell and Schwartz1
reported that 88% of preadolescents in an urban middle school had witnessed
a robbery, beating, stabbing, shooting, or murder. Taylor et al2
reported that 10% of 1- to 5-year-old children in an inner-city clinic had
witnessed a knifing or shooting. Richters and Martinez3
found that 47% of 6- and 7-year-old children had witnessed shootings. With
an estimated 5 million children living in America's inner cities, the number
of children who witness violence is formidable.4
Although exposure to violence is beginning to be documented in young
children, few data are available regarding the association of such exposure
with emotional distress and academic performance. In the studies by Richters
and Martinez,3, 5 young children
witnessing violence in the community had high ratings of overall distress
but they were not assessed for self-esteem or academic outcome.
In our ongoing study, we, too, have been impressed with the frequency
with which young children report to us that they have witnessed violence.
We hypothesized that such exposure could be associated with adverse social-emotional
and academic outcomes, with increasing exposure correlating with worse outcomes.
To explore such associations, we evaluated exposure to violence in 7-year-old
inner-city children to document the degree of exposure in children of school
age, to correlate exposure with social-emotional status and academic performance,
and to expand the literature regarding environmental influences on young inner-city
children.
METHODS
DESIGN
This prospective study of inner-city children is part of an ongoing
longitudinal study of the effects of gestational cocaine exposure on infant
and child outcomes. The children were enrolled at birth, half of whom had
in utero cocaine exposure (COC) and half of whom did not (CON). We evaluate
children on an annual basis for growth, development, and behavior. As the
children reach school age, we perform additional evaluations to include social-emotional
outcome, neurocognitive status, and academic performance.
At the time of enrollment of mothers and infants, all mothers were of
low socioeconomic status in that they were receiving state medical assistance
at the time of parturition. Mothers who did not speak English, who had a major
psychiatric disorder, or who used drugs other than cocaine, marijuana, cigarettes,
and alcohol were excluded. Infants were excluded if they were less than or
equal to 34 weeks of gestational age at birth, had a 5-minute Apgar score
of 5 or less, or had a syndrome known to be associated with adverse neurodevelopmental
outcome. Mothers were classified as COC if they had a positive history of
cocaine use. Mothers and infants were categorized as CON if there was a negative
history for drug use and a negative result of enzyme-linked immunoassay urinalysis
for cocaine metabolites in both the mother and infant.
Two hundred twenty-four (105 COCs and 119 CONs) participants were enrolled
during a 3-year period (1989-1991). Five (1 CON and 4 COCs) have since died.
There was approximately 30% attrition by 36 months; subsequently the attrition
rate has declined, with cohort numbers remaining stable for the past several
years.
A large database exists for this cohort. Briefly, COC and CON children,
while differing on some natal variables (COCs had lower growth percentiles
and increased admission to the NICU),6 have
showed similar outcomes on the Bayley Scales of Infant Development,7 play,8 language,9 Full-Scale IQ (intelligence quotient),10
development at age 5 years,11 and neurological
examination at age 6 years.12 Annual assessments
of this cohort continue; the data presented here were obtained from 7-year-old
children during one of their ongoing assessments.
These children were administered Things I Have Seen and Heard (TISH),
an interview for young children about exposure to violence3;
the Levonn, a cartoon-based interview for assessing children's distress symptoms5; and the Culture-Free Self-Esteem Inventories, Second
Edition (CFSEI-2).13, 14 The TISH
is a 20-item questionnaire that assesses the child's perception of the frequency
with which he or she has been exposed to violence (to self or others) in both
the home and community. Prior to administering the TISH, the examiner (E.M.)
(a school psychologist) explains to the child that the child is to report
only events that have happened to the child or that the child has witnessed;
the child is told not to report events experienced by siblings or friends
or events seen on television. Children rate answers on a 5-point pictogram
scale ranging from never (0 times) to many times (>3) in regard to specific
situations. On a one-on-one basis, the child is asked questions by the examiner
and in response, the child points to the scale that in the child's estimation
most accurately reflects his or her experience. When the examiner receives
a response that elicits concern, such as a child having seen someone shot
or stabbed in the home, the examiner asks for additional details. Referrals
are made when appropriate. The TISH, used in a study of inner-city children
in Washington, DC,3 has good test-retest reliability.
Test-retest reliability for a composite score of the sum of all instances
of child-reported exposure to violence was 0.81 for a random sample of 21
children in the cohort of Richters and Martinez.3
Validity has not been established, although developers of the TISH found no
significant difference between reports of exposure to violence among young
children and their older schoolmates in the fifth and sixth grades.
The Levonn, created by Martinez and Richters,5
evaluates children's symptoms of distress, such as anxiety and depression.
It is a 40-item questionnaire assessing the similarity of the child's experience
to that of a cartoon character named Levonn, who is shown in a variety of
situations accompanied by verbal descriptions. The examiner reads the description
to the child; for example, the description of the cartoon in Figure 1 states, "Here's Levonn at a birthday
party. All of his friends are laughing and having a good time, but Levonn
feels very sad about something. How many times have you felt like Levonn?"
At this time the child points to a thermometer that best reflects his or her
feelings: never (thermometer on zero), some of the time (thermometer half-filled),
or most of the time (thermometer filled). Higher scores indicate greater stress
(depression, anxiety). Test-retest reliability for a composite score of distress
ratings was 0.81 for a random subsample of 22 first- and second-graders in
the study by Martinez and Richters.5 Validity
was 0.30 with the Child Behavior Checklist Parent Report Form (CBCL-PRF) and
0.32 with the Parent Report Version of Children's Distress Symptoms (CCDS-PRV).
Authors of the Levonn explain this low correlation as reflecting lack of caregiver
recognition of child's feelings.5
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Example of illustration and thermometer shown to child during administration
of Levonn, a cartoon-based interview for assessing children's distress.
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The CFSEI-2 has 30 yes/no items and yields 4 self-esteem subscales (General
[child's overall perception of self-worth], Social [child's perceptions of
the quality of his or her relationship with peers], Academic [child's perceptions
of ability to succeed academically], and Parent-Related [child's perception
of relationships with parents]), and a Total Self-Esteem score (based on the
4 subscales). Higher scores on the CFSEI-2 indicate higher self-esteem. At
the same session at which the child is being evaluated, the child's caregiver
is administered the CCDS-PRV,3, 5
a 28-item instrument designed as a companion to the Levonn that asks caregivers
to rate signs of distress in their children on a 5-point Likert Scale ranging
from 1 = never to 5 = most of the time. This instrument has high interrater
reliability and concurrent validity.15 Internal
consistency reliabilities are also reported by Richters and Martinez3, 5 for the CCDS-PRV, which reveal 2 correlated
scales (r = 0.80) of moderately high reliability:
depression ( = .75) and anxiety ( = .70).
In addition to these evaluations, child IQ (Wechsler Preschool and Primary
Scale of Intelligence–Revised)16 was
obtained at age 6 years and the CBCL-PRF17
was completed by the caregiver at the 6 -year visit. At age 8 years,
the child's home environment was evaluated using the elementary school version
of the Home Observation for Measurement of the Environment (HOME).18 Caregiver IQ (Wechsler Adult Intelligence Scale),19 self-esteem (CFSEI-2 adult version),14
and yearly urine drug screen results were also obtained as part of the longitudinal
study. With permission from and cooperation with the School District of Philadelphia
(Pa), school performance (grades, days absent, and CBCL Teacher Report Form
[TRF20]) was also documented. Informed consent
was obtained from the parent or guardian. The institutional review boards
of the Albert Einstein Medical Center (Philadelphia) and the School District
of Philadelphia approved this study.
DATA ANALYSIS
Data analysis included a tabulation of children's exposure to violence
and feelings of distress. Based on question content, composite scores for
the TISH (Total Violence [T-VIOL]), Levonn (Depression, Anxiety), and CCDS-PRV
(Depression, Anxiety) were calculated.3, 5
Correlations between T-VIOL score (higher scores indicate more exposure to
violence) and depression, anxiety, self-esteem, behavior, and school outcome
were assessed using the Pearson r for parametric
or the Spearman  for nonparametric data as appropriate. Children's anxiety
and depression composite scores, derived from the Levonn, were correlated
with the corresponding anxiety and depression scores from caregiver responses
on the CCDS-PRV. Regression analyses were performed with SPSS 9.0 for Windows
95 (SPSS, Chicago, Ill). All P values are 2-tailed
and P.05 was considered statistically significant.
RESULTS
One hundred nineteen children were evaluated at age 7 years with the
TISH, Levonn, and CFSEI-2. The mean ± SD age at testing was 7.6 ±
0.2 years, 57% of subjects were girls, 82% were in the care of their biological
mothers, and 98% were African American. Selected results of the TISH show
that the cohort was frequently exposed to violence (Table 1). Selected results of the Levonn are presented in Table 2.
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Table 1. Selected Results of TISH*: Percentage of Children Exposed
to an Event 1 or More Times
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Table 2. Selected Results of Levonn*: Percentage of Children With These
Feelings Some or a Lot of the Time
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Correlations between the T-VIOL score and measures of psychologic status,
academic performance, and behavior are presented in Table 3. Exposure to violence was associated with increased anxiety
(r = 0.37; P<.001) and
depression (r = 0.31; P<.001)
as measured by the Levonn. Higher exposure to violence was also associated
with lower self-esteem as indicated by the General Self-Esteem subscale (r = –0.24; P = .01) and
the Total Self-Esteem score (r = –0.19; P = .04). There was no correlation with the Social, Academic,
or Parent-Related subscales of the child's version of the CFSEI-2 (r–0.13; P .18) or with any caregiver
self-esteem scale (r0.10; P.06) (data not shown). In addition, higher exposure to violence
was associated with lower grade point average (r
= –0.29; P = .01) and more days of absence
from school (r = 0.25; P
= .02). There were no significant associations between T-VIOL and any CBCL-PRF
or CBCL-TRF summary scores (r0.24; P.08) (Table 3). In
subscores, however, higher T-VIOL was associated with lower School Competency
(PRF) (r = 0.35; P = .002)
and more Delinquent Behavior (TRF) (r = 0.32; P = .02).
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Table 3. Correlations With TISH Total Violence Score*
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Although detailed multivariate analyses are desirable to define whether
higher exposure to violence is associated with psychological, behavioral,
and academic outcomes or is causal, such analyses are hampered by the modest
correlation coefficients in univariate analyses, the relatively small sample
size, and the multiple factors that affect child outcome. However, to explore
factors that could confound the associations found between violence exposure
and psychological, behavioral, and academic outcomes, we first evaluated several
child, caregiver, and home characteristics that might be related to violence
exposure (Table 3). There was
no correlation between child sex or IQ and T-VIOL. Likewise, child T-VIOL
was not correlated with caregiver IQ, caregiver self-esteem, or with the Total
HOME score. Interestingly, given the original study design, caregiver cocaine
use, either current or during pregnancy, was not correlated with child T-VIOL
or any other study outcome. Since there was no relationship between any of
these factors and T-VIOL, these factors do not seem to confound our findings.
Second, we examined the relationship between anxiety and violence exposure
using regression analysis with the Levonn anxiety score as the outcome; we
entered factors associated with anxiety as independent variables at P.10. Results (Table
4) show that Total Violence exposure (P
= <.03) and Total Self-Esteem (P = .003) were
the only factors that predicted the Levonn anxiety score (R2 = 0.37; F5,56 = 6.7; P<.001).
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Table 4. Factors Associated With Child Anxiety: Linear Regression Analysis*
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Finally, caregiver perception of child anxiety as determined by the
CCDS (the Levonn companion instrument) had poor correlation with anxiety reported
by children (r = 0.05; P
= .58).
COMMENT
Our study, conducted on very young inner-city African American children
and their caregivers, supports and extends the literature describing the relationship
of children's exposure to violence and psychological distress. Using TISH,
the instrument developed by Richters and Martinez,3
we find data similar to what these investigators have reported from their
cohort in Washington. While they found the prevalence of exposure to violent
events to be high, they reported that the data from the young children did
not differ significantly from rates reported by the fifth and sixth grade
schoolmates of these children. In our evaluations, performed on a one-on-one
basis (in contrast to the small groups used by Richters and Martinez3), children were repeatedly reminded to report only
what they had seen and heard, not events reported to them by others or seen
on television. Further, if a child reported a particularly upsetting event,
such as a stabbing or shooting seen in the home, the examiner asked for specific
details to verify the report and refer for counseling, if appropriate. Thus,
while we cannot absolutely verify the data reported to us by these young children,
we feel the information given is a reasonable reflection of their exposure
to violence.
Richters and Martinez,3 who developed
the Levonn instrument,5 reported that children
witnessing violence in the community had high ratings of overall distress.
The specific elements of psychological distress in children exposed to violence
include depression,21, 22, 23
anxiety,24 dissociation,25
and posttraumatic stress.22, 26, 27, 28, 29, 30
Lai31 reported higher levels of depression
and lower self-esteem in adolescents with high exposure to violence, either
as a witness or victim. Likewise, Schwab-Stone et al32
found that violence exposure was closely associated with both externalizing
and internalizing symptoms in adolescence. Internalizing symptoms (anxiety,
depression, and somatization) were seen more frequently in younger adolescents
(sixth grade) than in older adolescents (10th grade). Similar to these reports,
children in our cohort with higher exposure to violence had significantly
higher composite scores for both depression and anxiety than children with
lower exposure. We further explored the association of exposure to violence
with psychological status by extending our evaluations to include a self-esteem
measure, the CFSEI, administered to the children and their caregivers. Results
showed that by age 7 years, children with the highest exposure to violence
are beginning to demonstrate lower self-esteem on some measures when compared
with children with lower exposure to violence. In our review of the literature,
the correlation of high exposure to violence with low self-esteem in children
aged 7 years is novel. Moreover, low self-esteem was also suggested in caregivers
of children with high exposure to violence (data not shown), with Total Self-Esteem
of the child and caregiver correlating (r = 0.25; P = .01). Given this correlation, the low self-esteem in
children with higher exposure to violence may be multifactorial in origin.
Regardless, the lower self-esteem of both caregivers and children with high
exposure to violence suggests potential for future maladaptive behavior in
the children, since low self-esteem has been cited as a precursor to participating
in risk behaviors.13, 33, 34, 35
Children in our cohort with higher exposure to violence had lower grade
point averages—suggestive of poorer academic performance—than
did the children with less exposure. Further, higher violence exposure was
correlated with more days of school absence than was lower exposure. To our
knowledge, this association of exposure to violence and poorer academic performance
has not been previously reported to our knowledge in children at this young
age. Poor academic performance, however, has been associated with low self-esteem.13, 33 In this regard, our cohort's school
performance was documented at the end of the first grade, with the CFSEI-2
being administered during the school year; thus, it is not clear whether the
low self-esteem found in children with high exposure preceded or was concomitant
with the less favorable school experience. Regardless, the coexistence of
low self-esteem, poor academic performance, and exposure to violence renders
these children particularly vulnerable to risk behaviors, including violent
behavior.31, 33, 36, 37, 38
This study has several limitations. First, it is possible that our outcome
variables, such as low self-esteem and increased anxiety and depression, antedated
the exposure to violence. Since we did not measure these characteristics prior
to our assessment of exposure to violence, these outcomes or characteristics
may have been preexisting and not a result of exposure to violence. Earlier
and repeated assessments in larger cohorts should provide important information.
Second, our sample size is not large enough to determine whether exposure
to violence is causal or merely an associative factor with cohort outcomes.
We have described the correlation of higher exposure to violence with more
emotional distress, lower self-esteem, and poorer academic performance but
we cannot assign causality from a sample size of 119 children. While multivariate
analyses would help differentiate factors causing distress and poor academic
performance, as previously noted, we are limited by the numerous factors (home
environment, maternal and child IQ, preschool experience, etc) that affect
these outcomes, and by the cohort size. The suggestion, however, that high
exposure to violence may lead to adverse outcomes, needs to be explored with
larger cohorts. Third, relying on self-report in young children has inherent
problems that cannot be completely resolved.
These limitations aside, of great concern to us is the lack of caregiver
recognition of child distress. In our cohort, there was poor correlation between
child anxiety and caregiver recognition of child anxiety (r = 0.05; P = .58). Similarly, Richters and
Martinez,3 in their cohort of fifth- and sixth-grade
children, found the children to report significantly higher levels of distress
than their parents reported them to have. For example, 49% of the parents
reported that their children never worried about being safe, whereas none
of the children said they never worried. In our study, 58% of the parents
reported that their children never worried about being safe, whereas none
of the children said they never worried.
This caregiver lack of recognition of child distress, using the Children's
Checklist of Distress Symptoms, was corroborated by findings from the CBCL,
both the PRF and TRF: neither parents nor teachers perceived high anxiety
levels in children with high exposure to violence. Thus, 3 instruments suggest
that child anxiety is not recognized by individuals close to the child who
could offer counsel or seek support for the child. Reasons for lack of recognition
include: caregivers may be "immune" to exposure and the effects of exposure
through chronic exposure to violence themselves; caregivers may not be aware
of the amount of violence to which the child is exposed because the child
underreports for fear of curtailment of activities3, 5;
caregivers may be preoccupied with social-emotional issues of their own.
The lack of recognition of distress in young children exposed to violence
is critical to rectify. In high-profile events, such as the Jonesboro (Jonesboro,
Ark, 1998) and Columbine (Littleton, Colo, 1999) school shootings, the nation
was shocked and grieved; schools closed and counseling was offered. In stark
contrast, many young inner-city children enter school each day with a heavy
burden of exposure to violence. The distress associated with exposure to violence
is not being recognized.
Pediatricians have become actively involved in violence prevention.38, 39, 40 The American Academy
of Pediatrics Task Force on Violence, in a recent strong statement,40 issued policies for pediatricians in youth violence
prevention and management. Early nurturing, limit-setting, safety screening,
and treatment and referral guidelines are given in detail for age ranges from
infancy to later adolescence. The importance of parent support, encouragement,
and education is emphasized repeatedly. Given the results of our study, however,
we would encourage direct assessments of young children. For example, questions
regarding exposure to violence should be directed not only at parents, but
also at children to assess their reported feelings of distress.
Despite this recent emphasis on violence prevention and management,
according to one survey,41 few pediatricians
are routinely screening for exposure to family and community violence. Reasons
cited include lack of training in violence prevention and reluctance to provide
anticipatory guidance when the pediatrician perceives that the advice will
not be followed. Regardless of reasons, not addressing this issue comes at
a time when it is increasingly important to direct attention to the young
inner-city child at the time of school entry. Neglecting to assess exposure
to violence and to screen for signs of distress may not only fail the individual
child but may also contribute to the cycle of violence experienced by inner-city
children.
AUTHOR INFORMATION
Accepted for publication August 2, 2001.
This research was supported by grant DAO4965 from the National Institute
on Drug Abuse, Bethesda, Md, and an Einstein Society Grant from Albert Einstein
Healthcare Network, Philadelphia.
What This Study Adds
It is common for children living in the inner city to witness violence.
Few data are available regarding the emotional and academic effects of witnessing
violence at a young age. Our study explores associations between exposure
to violence by age 7 years and emotional distress and poor academic performance.
We found that young inner-city children have a high exposure to violence by
age 7, with many children showing signs of anxiety, depression, and low self-esteem
that frequently are not recognized by caregivers. Further, higher exposure
to violence correlated with poorer performance in school. These findings underscore
pediatricians' responsibility to not only assess young children for exposure
to violence but to screen for signs of distress as well.
From the Division of Neonatology, Albert Einstein Medical Center (Drs
Hurt, Brodsky, and Malmud and Ms Giannetta), and the Jefferson Medical College
of Thomas Jefferson University (Drs Hurt and Brodsky), Philadelphia, Pa.
Corresponding author: Hallam Hurt, MD, Division of Neonatology, Albert
Einstein Medical Center, 5501 Old York Rd, Philadelphia, PA 19141 (e-mail: hurth{at}aehn2.einstein.edu).
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ABSTRACT
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