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Violence Exposure, Trauma, and IQ and/or Reading Deficits Among Urban Children
Virginia Delaney-Black, MD, MPH;
Chandice Covington, PhD, RN, CPNP;
Steven J. Ondersma, PhD;
Beth Nordstrom-Klee, PhD;
Thomas Templin, PhD;
Joel Ager, PhD;
James Janisse, PhD;
Robert J. Sokol, MD
Arch Pediatr Adolesc Med. 2002;156:280-285.
ABSTRACT
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Background Exposure to violence in childhood has been associated with lower school
grades. However, the association between violence exposure and performance
on standardized tests (such as IQ or academic achievement) in children is
unknown. It is also not known whether violence exposure itself or subsequent
symptoms of trauma are primarily responsible for negative outcomes.
Objective To examine the relationship between violence exposure and trauma-related
distress and standardized test performance among early school-aged urban children,
controlling for important potential confounders.
Design A total of 299 urban first-grade children and their caregivers were
evaluated using self-report, interview, and standardized tests.
Main Outcome Measures The child's IQ (Wechsler Preschool and Primary Scale of Intelligence–Revised)
and reading ability (Test of Early Reading Ability,
second edition) were the outcomes of interest.
Results After controlling for confounders (child's gender, caregiver's IQ, home
environment, socioeconomic status, and prenatal exposure to substance abuse)
violence exposure was related to the child's IQ (P
= .01) and reading ability (P = .045). Trauma-related
distress accounted for additional variance in reading ability (P = .01). Using the derived regression equation to estimate effect
sizes, a child experiencing both violence exposure and trauma-related distress
at or above the 90th percentile would be expected to have a 7.5-point (SD,
0.5) decrement in IQ and a 9.8-point (SD, 0.66) decrement in reading achievement.
Conclusion In this study, exposure to violence and trauma-related distress in young
children were associated with substantial decrements in IQ and reading achievement.
INTRODUCTION
SURPRISINGLY HIGH levels of self-reported violence, both via witnessing
of and victimization by violent events, are consistently found in young urban
children.1-2 Children reporting
high levels of violence exposure have demonstrated higher levels of both internalizing
and externalizing behaviors.3-4
In addition, evidence of poor school outcomes among older children affected
by violence is also mounting. For example, community violence exposure (such
as witnessing or experiencing a robbery, or being threatened with a weapon)
was associated with a decrease in school attendance and grades in a large
(N = 2099) sample of middle- and high-school students.5
Adolescent girls (aged, 12-21 years) in a primary care setting and meeting
criteria for posttraumatic stress disorder (PTSD) were more likely to have
failed a school grade.6
Such research, however, has excluded young children at an early school
age. In addition, reports have focused only on relations between violence
exposure and grade suppression, which could result from associated behavioral
problems, emotional problems, or decreased attendance. Evidence that school
difficulties are associated with deficits on standardized tests of academic
achievement or intelligence would have additional implications. For example,
concern regarding violence exposure would be further heightened if it affected
the children's actual ability to demonstrate or to acquire academic skills.
Alternately, our understanding of and ability to prevent violence exposure
and associated outcomes could be enhanced if children with limited intellectual
ability were shown to be more at risk.
Research findings from related areas suggest that children exposed to
high levels of violence are likely to show deficits in standardized test scores
in addition to lower school grades. For example, child maltreatment has been
associated with lower scores on standardized tests of academic achievement.7-9 Similar results were
found in a study of Lebanese adolescent schoolchildren, in whom PTSD was associated
with lower scores on standardized achievement tests.10
Moderate correlations between IQ and PTSD in male combat veterans have also
been reported.11
While reports of the relation between community violence exposure and
school grades have been published, virtually no studies specifically evaluate
the influence of community exposure to violence on actual academic or cognitive
ability. In the current investigation, relations between violence exposure
and academic outcomes were examined in a group of 6- to 7-year-old children,
accounting for several methodological considerations: (1) socioeconomic status,
prenatal drug or alcohol exposure, quality of the home environment, sex of
the child, and primary caregiver IQ were all measured to control for confounding
variance from these sources; (2) data were obtained from child self-report
and trained interviewers-psychometrists using validated instruments; and (3)
trauma-related symptoms were also measured to explore the relative contributions
of violence exposure and trauma-related symptoms in explaining the variance
in academic functioning. Given previous findings from studies of maltreated
children and male combat veterans, it was hypothesized that a child's report
of exposure to violence would be associated with deficits in IQ and reading
ability, even after controlling for the aforementioned confounding factors.
PARTICIPANTS AND METHODS
PARTICIPANTS
Participants in the current single-group within-subjects study were
part of a larger subject group participating in a National Institute on Drug
Abuse–funded project studying the outcomes of 6- to 7-year-old African
American children prenatally exposed to cocaine and alcohol and their unexposed
(control) peers.12 The sample for the current
investigation was selected from the control group who had no history of prenatal
exposure to hard illicit drugs (eg, cocaine, heroin, methadone, amphetamines
[uppers], barbiturates [downers], and any other drugs). The control group
did include children of mothers who used alcohol and/or marijuana during pregnancy.
Prenatal marijuana exposure was reported by 21% of this sample; some level
of prenatal alcohol exposure was reported by 60%.
Of 376 African American caregiver–child dyads who were contacted,
97% (n = 366) agreed to participate. However, multiple missed appointments
(n = 46) or incomplete data (n = 21) reduced the final sample to 299 participants
(80% of the original sample). The 299 participants did not differ from those
who refused to participate, who provided incomplete data, or who missed multiple
appointments, when compared using prenatal and neonatal characteristics (infant
birth weight, length, gestational age, Apgar scores, prenatal alcohol or nicotine
exposure, maternal age, educational level, parity, or gravidity).
PROCEDURE
The Wayne State University institutional review board, Detroit, Mich,
approved all data collection procedures; all caregivers signed informed consent
forms before participating in this study. Self-report, interview, and standardized
test data were collected from children and their caregivers during half-day
evaluation sessions at our laboratory. Separate research assistants interviewed
children and caretakers independently. All research assistants were blind
to prenatal exposure status, which was matched to laboratory collected subject
information by a database manager after contact with all subjects was completed.
A licensed psychologist trained and closely supervised the research assistants
in the administration of all test instruments.
MEASURES
Independent Variables
Previous research findings have suggested that parents underreport a
child's exposure to violence when compared with the child's self-report13; consequently, a child report measure was used in
this study. The Things I Have Seen and Heard scale consists of 20 items and
assesses the frequency of children's self-reported exposure to violence and
violence-related themes.14 Items are rated
on a 5-point scale indicating the frequency of exposure to each event. The
Things I Have Seen and Heard scale has been shown to have adequate test-retest
reliability (r = 0.81),15
good internal consistency ( = .80-.83),16-17
and has been used in many community violence studies.3, 16-19
Children's trauma-related distress was evaluated using the Levonn scale.13 This measure of traumatic distress symptoms was modified
from its original version20 for use with urban
children. The Levonn scale consists of 29 cartoon picture items where children
rate on a 3-point scale how often they feel like the child in the cartoon.
A total score as well as subscales representing depression, anxiety and/or
intrusive thoughts, and sleep problems can be derived, and have reported reliability
coefficients ranging from 0.71 to 0.84.13 One-week
test-retest reliability for the total score is good (r
= 0.81),13 and the Levonn scale has been used
with success in multiple research projects.13, 21-22
Outcomes
Children's reading ability was assessed with the Test of Early Reading Ability, second edition,23
a brief measure of the children's reading ability with a mean (SD) of 100
(15) points. It has been validated with a representative sample of more than
1400 children, has an internal consistency coefficient of 0.93, and (in the
standardization sample) demonstrated a 2-week test-retest reliability of r = 0.89.23 The Test of Early Reading Ability, second edition, has successfully discriminated
between learning disabled and healthy children, has been associated with age
and school experience, and correlated significantly with alternate measures
of early academic achievement (eg, Basic School Skills Inventory:
Diagnostic24; r
= 0.61, P<.01)23
Child IQ was evaluated using the Wechsler Primary and Preschool Scale of Intelligence–Revised,25 an extensively standardized and validated measure
of the child's ability to complete verbal and nonverbal intellectual tasks.
Control Variables
Socioeconomic status was estimated using the Hollingshead 2-factor index.26 Information regarding maternal prenatal alcohol use
was collected during each prenatal visit and converted to average absolute
ounces of alcohol per day during pregnancy. Information regarding maternal
prenatal illicit drug use was also collected at each prenatal visit. Any indication
of prenatal use of cocaine, heroin, or other illicit drugs (such as lysergic
acid diethylamide or amphetamines) except for prenatal marijuana use, resulted
in exclusion from the current sample. To control for maternal or caregiver
intellectual ability (a possible confounding biological influence on child
academic outcomes, as well as a possible confounding environmental influence),
caregiver IQ was measured with the performance subscale of the Wechsler Adult
Intelligence Scale–Revised.27 The performance
subscale of the Wechsler Adult Intelligence Scale–Revised was chosen
because of its time advantages over full-scale Wechsler Adult Intelligence
Scale–Revised administration, its excellent reliability (split-half
reliability coefficient = 0.93; test-retest = 0.89), and its high correlation
with full-scale IQ (r = 0.91 across all age groups).27
Home environment was evaluated using an interview, conducted in the
laboratory, based on the Home Observation for Measurement of the Environment
(HOME).28 This scale used observations of caregiver-child
interactions during the laboratory visit (eg, caregiver responds to the child's
questions, caregiver's voice conveys positive feelings when speaking to the
child, caregiver introduces examiner to the child), and asked for caregiver
report for other items taken from the HOME (eg, "Child is encouraged to read
on his own."). As with the HOME, multiple-item scores on this interview were
summed to create a continuous scale representing the quality of the home environment.
Higher scores denoted better quality of home environment. Thus, while the
laboratory-based interview used for this study was not previously validated,
it bore significant similarities to the HOME scale and incorporated opportunities
for observation. Further, this measure demonstrated a promising pattern of
external correlates in the current study, similar to that found for the HOME
in previous research.28 Scores from the current
measure of the quality of the home environment were positively associated
with socioeconomic status (r = 0.36, P<.001), caregiver's performance IQ (r
= 0.33, P<.001), and child's IQ (r = 0.32, P<.001), and were negatively
associated with a child's report of trauma-related distress (using the Levonn
scale, described below; r = -0.11, P<.05). While these findings do not constitute a thorough validation
of this measure, they (along with the face validity of the interview) do suggest
that variance related to the quality of the home environment was being tapped.
DATA ANALYSIS
The current research hypothesis was tested using multiple regression,
with stepwise selection of confounders and subsequent simultaneous entry of
independent variables (community violence exposure and distress). Two analyses
using this variable set were conducted, one each for reading ability and child's
IQ, using the Statistical Package for the Social Sciences, Version 10.07.29
RESULTS
The final sample consisted of 157 boys (52%) and 142 girls (48%), with
a mean age of 6.9 years (age range, 5.9-7.9 years). The sample was primarily
of moderately low socioeconomic status, with 48% of the caregivers reporting
a total annual family income of less than $15 000; 69% of the primary
caregivers have a high school or General Educational Development diploma.
Exposure to community violence and trauma-related distress were both prevalent
in this sample (Table 1).
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Table 1. Report of Exposure to Violence and Trauma Symptoms by 299
Urban Children*
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The 2 independent variables, community violence exposure and trauma-related
distress, were significantly related (r = 0.25, P<.001). However, collinearity statistics were well
within the acceptable range (tolerance, 0.96-0.99). Many other potentially
confounding variables were correlated with the outcome measures, including
the home environment, the caretaker's verbal ability, the child's gender,
socioeconomic status, and amount of prenatal alcohol exposure. These variables
were considered as confounders in all further analyses. The first regression
equation examined community violence exposure and trauma-related distress
as predictors of a child's IQ. After controlling for confounders, community
violence exposure accounted for significant variance in a child's IQ (P<.05), with higher violence exposure associated with
lower IQ scores. However, trauma-related distress was not significantly related
to a child's IQ (Table 2). The
total equation accounted for 23% of the variance in the child's IQ. Using
the derived regression equation (entering scores, multiplying them by derived ß
weights, and summing to yield a predicted score on the dependent variable),
a child scoring at or above the 90th percentile on both community violence
exposure and trauma-related distress would be expected to have a decrement
of 7.5 IQ points when compared with a child at the lowest (first) percentile
on both variables (Figure 1). This
difference of half an SD represents a medium effect size.30
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Table 2. Multiple Regression of a Child's Exposure to Violence and
Distress on the Child's IQ*
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Graph shows the predicted violence-related IQ and reading achievement
decrements of an urban cohort of children (N = 299) between the ages of 6
and 7 years. Bars indicate expected standard scores for children scoring above
the 90th percentile on one or both major independent variables (Things I Have
Seen and Heard14 and the Levonn20
scales), using ß weights from the derived regression equations (Table 2 and Table 3). The predicted score indicates the IQ scores of 6- and
7-year-old children using the Wechsler Preschool and Primary Scale of Intelligence–Revised;
reading scores using the Test of Early Reading Ability, second
edition. All scores represent standard scores with a mean (SD) of 100 (15)
points that are adjusted for the influence of confounders (Table 2 and Table 3).
PTSD indicates posttraumatic stress disorder.
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Table 3. Multiple Regression of a Child's Exposure to Violence and
Distress on Reading Ability (TERA-RQ)*
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The second regression equation examined community violence exposure
and trauma-related distress as predictors of reading ability (Table 3). After control for confounding, both community violence
exposure and trauma-related distress explained significant variance in reading
achievement (P<.05), with higher scores on each
independent variable associated with decreased reading achievement. The total
equation accounted for 28% of the variance in reading ability. Using the derived
regression equation, a child scoring at or above the 90th percentile on both
community violence exposure and trauma-related distress would be expected
to have a decrement of 9.8 points on the Test of Early Reading
Ability, second edition, when compared with a child at the lowest (first)
percentile on both measures (Figure 1).
This two thirds of an SD difference represents a moderate- to large-effect
size.30
COMMENT
Our study examined the association between reported community violence
exposure and school outcomes. After ruling out or controlling for many potential
confounders, using multiple sources of data and standardized measurement of
cognitive and reading abilities, self-reported violence exposure in children
was negatively correlated with IQ scores and standardized reading achievement
test performance. Community violence exposure in urban children appears to
be similar to child maltreatment and other trauma in its association with
cognitive outcomes.
This finding has clear implications, although the nature of these depends
on the directionality of the observed relationship. For example, children
of limited intellectual ability may be more likely to witness or experience
violence, perhaps because they are unable to verbally mediate dangerous situations,
or perhaps because of an inability to accurately predict and avoid violent
situations. Preventive efforts might profitably focus on problem-solving skills
in children who have a low IQ if later research confirms that intellectual
limitations are a risk factor for community violence exposure.
Alternately, exposure to violence may actually inhibit intellectual
and academic functioning. If community violence exposure does in fact cause
such deficits, the estimated number of urban children experiencing violence
at this level would make this an issue of major concern. For example, Lester
and colleagues31 have previously demonstrated
that even very small IQ decrements (only 3.26 points, <0.25 SD) can have
a major practical impact if large numbers of children are affected. Levels
of community violence exposure were high in the current study, even though
the sample was in no way selected for its exposure to violence (Table 1). The inclusion of many parents with high school or General
Educational Development diplomas (69%) and the exclusion of children prenatally
exposed to any illicit drug other than marijuana makes this group of children
potentially less likely to experience violence than other urban samples.1-2
If community violence exposure does in fact impair academic ability,
efforts to identify factors predicting which urban children are or will be
exposed to high levels of violence are needed. Despite the high levels of
self-reported violence exposure in this and other studies,32
many children in the current sample—in spite of the homogeneity of socioeconomic
status and city of residence in this study—reported very low levels
of exposure. If preventable factors contribute to this variability in community
violence exposure, it could lead to interventions that reduce the number of
children who witness violence, regardless of the levels of violence present
in the community. Second, if violence exposure itself leads to cognitive deficits,
interventions targeted at children demonstrating symptoms of trauma may miss
children who, although not showing clear PTSD or related symptoms, may be
compromised in their ability to function scholastically. The results of our
study suggest that interventions would need to be targeted at children who
either demonstrate trauma-related symptoms or at those who report high levels
of exposure to violence.
It is unclear which causal direction is more likely, or even whether
a third variable might cause both violence exposure and intellectual deficits.
The possible mechanism underlying the relation is also unknown. Some evidence
has suggested that early trauma can lead to autonomic nervous system or hormonal
hyperreactivity,32 affecting a child's ability
to remain focused while attempting to learn or to perform complex cognitive
tasks. Perhaps more parsimoniously, long-term exposure to violence results
in an anxious preoccupation with personal safety or other concentration difficulties
that are incompatible with learning and performing such tasks.33
Our finding that PTSD-related symptoms accounted for significant variance
in reading ability, even when entered along with exposure to community violence,
provides some support for this latter suggestion. Alternately, as noted earlier,
children with intellectual limitations may somehow be at risk for violence
in ways not yet fully understood.
A secondary goal of this study was to explore whether the impact of
community violence exposure is primarily limited to children who also demonstrate
trauma-related symptoms, or whether violence exposure itself is related to
poor academic outcomes even in the absence of high levels of anxiety and distress.
When both variables were considered simultaneously, violence exposure had
an independent effect on both IQ and reading ability. This finding suggests
that reported violence exposure might be associated with negative academic
outcomes, whether or not children are subjectively distressed from the exposure.
However, trauma-related distress did account for additional variance in reading
ability, suggesting that subjectively distressed child victims who experience
community violence may be at additional risk for deficits in reading ability.
A major obstacle for our current study and other similar investigations
is the lack of well-validated measures of community violence exposure and
related trauma. Although the Levonn and Things I Have Seen and Heard scales
may be the best available options for measuring young children's reports of
community violence exposure and trauma-related distress, they have not yet
been subjected to rigorous validation and may have important unknown weaknesses.
For example, the low internal consistency of the Things I Have Seen and Heard
scale in our sample (r = 0.68) suggests that multiple
and minimally related constructs are being tapped by this scale in its current
form.
A final important consideration in interpreting these data is the strong
observed relation between other factors and the academic outcomes studied.
As already established by previous research,34-35
the quality of the home environment and prenatal alcohol exposure both accounted
for significant variance in academic outcomes in our study. Further, standardized ßs
for these variables were of greater absolute value than those for violence
exposure or trauma-related symptoms. These findings suggest that the importance
of considering the range of biopsychosocial insults faced by urban children,
including violence exposure, cannot be overestimated.
| What This Study Adds
Research findings have increasingly documented high self-reported levels
of exposure to violence by even very young urban children. Research findings
have also documented a range of troubling correlates of self-reported violence
exposure, including elevated levels of externalizing and internalizing behaviors.
Evidence that broad and prevalent violence exposure is negatively associated
with school outcomes also exists, but such research has relied primarily on
grades in school and not more objective measures such as scores on standardized
tests (eg, academic achievement and IQ tests).
The current study extends previous findings by demonstrating an association
between child self-reported violence exposure and school outcomes when defined
as scores on standardized achievement and IQ tests. This research also explored
whether violence exposure alone or whether only violence exposure that concurrently
occurs with symptoms of trauma-related distress is associated with decrements
on measures of school outcomes. The findings suggest that violence exposure
may be associated with actual impairments in academic ability and learning
potential, even in the absence of distress.
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AUTHOR INFORMATION
Accepted for publication November 30, 2001.
This research was funded in part by grants DA 08524 (Dr Delaney-Black)
and DA 00516 (Dr Ondersma) from the National Institute on Drug Abuse, Rockville,
Md; grant 12-FY97-0047 (Dr Delaney-Black) from The National Foundation March
of Dimes, White Plains, NY; and the Helppie Institute for Urban Pediatric
Health Research, Children's Research Center of Michigan, Children's Hospital
of Michigan, Detroit.
Corresponding author and reprints: Virginia Delaney-Black, MD, MPH,
Division of Neonatal/Perinatal Medicine, Department of Pediatrics, Children's
Hospital of Michigan, 3901 Beaubien, Detroit, MI 48201-1498 (e-mail: vdelaney{at}med.wayne.edu).
From the Division of Neonatal/Perinatal Medicine, Department of Pediatrics,
Children's Hospital of Michigan (Drs Delaney-Black and Nordstrom-Klee), the
Merrill-Palmer Institute (Dr Ondersma), the Center for Healthcare Effectiveness
Research (Drs Ager and Janisse), the College of Nursing (Dr Templin), and
the C. S. Mott Center for Human Growth and Development and Department of Obstetrics
and Gynecology (Dr Sokol), Wayne State University, Detroit, Mich; and the
School of Nursing, University of California, Los Angeles (Dr Covington).
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A Mental Health Intervention for Schoolchildren Exposed to Violence: A Randomized Controlled Trial
Stein et al.
JAMA 2003;290:603-611.
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OTHER ARTICLES NOTED (Nov 01 to 18 Oct 02)
Evid. Based Nurs. 2003;6:e1-1.
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