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Caretaker-Child Concordance for Child's Exposure to Violence in a Preadolescent Inner-City Population
Carey Conley Thomson, MD, MPH;
Kevin Roberts, MS;
Andrew Curran, BA;
Louise Ryan, PhD;
Rosalind J. Wright, MD, MPH
Arch Pediatr Adolesc Med. 2002;156:818-823.
ABSTRACT
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Background Effective screening for exposure to violence (ETV) in the pediatric
setting depends on informant reliability and recognition of patients at increased
risk. Pediatricians screening for children's ETV often rely on parent reporting.
Hypothesis That there would be poor caretaker-child concordance given that children
would report events occurring outside the home not witnessed by the caretaker
and that ETV would be higher among immigrant families.
Objectives To examine concordance between caretaker and child self-report of the
child's ETV in a preadolescent population and to explore factors related to
increased risk.
Design Community-based survey.
Setting Urban community health center.
Participants One hundred sixty-five caretaker-child pairs.
Methods The ETV was assessed by means of a standardized interview questionnaire
on location and frequency of ETV. A Rasch model was used to develop summary
scores of ETV (frequency and severity).
Results Caretaker-child concordance on reports of child's ETV was poor. The 
statistics ranged from –0.04 for seeing someone knifed to 0.39 for witnessing
a shooting. Children reported ETV more often in their neighborhood or at school,
whereas caretakers reported more events near or at home. Univariate predictors
of child's self-reported ETV were female sex (ß ± SE, –10.1
± 4.6; P = .03) and caretaker being divorced
(ß ± SE, 12.6 ± 6.0; P = .04).
In multivariate analyses, country of origin predicted child's ETV, adjusting
for child's age and sex, and caretaker educational status and marital status.
Conclusions Caretakers and their children have poor agreement on reports of the
child's ETV. Intervention strategies around ETV should include assessment
of the child independent of caretaker report for preadolescents. Screening
may be more effective if pediatricians are aware of factors related to increased
risk, including immigration status and caretaker marital status.
INTRODUCTION
VIOLENCE IS A MAJOR cause of childhood morbidity in urban America. Finkelhor
and Dziuba-Leatherman1 interviewed 2000 children
aged 10 to 16 years and found that more than half were victims of violence
at some time in their lives. These investigators estimate that 6.2 million
youth aged 10 to 16 years experience some form of completed assault or abuse
per year; 1 in 8 (2.8 million) experience an injury; and 1 in 100 (almost
250 000) require medical attention.1
High rates of witnessing violence among inner-city youth have been reported.2-4 A prevalence study in
an urban pediatric primary care clinic found that 10% of children had witnessed
a knifing or shooting before the age of 6 years; 18% had witnessed shoving,
kicking, or punching; and 47% reported hearing gunshots in their neighborhood.5 Sheehan and colleagues6
surveyed 146 African-American children aged 6 to 13 years and found that 42%
had seen someone shot, 37% had seen someone stabbed, 21% lived with someone
who had been shot, 16% lived with someone who had been stabbed, and 47% of
girls and 55% of boys had witnessed violence.6
In addition, children experience violence in the home,7
with an estimated 3.3 million8 to 10 million9 children witnessing parental violence annually. Taken
together, these data suggest that our urban youth are experiencing violence
of epidemic proportions.
Another body of research demonstrates potential adverse psychological
consequences among children growing up with chronic violence.10-11
Adverse behavioral sequelae have been documented, including increased risk
for smoking, substance abuse,12-14
and violent behavior.15-17
In this context, the pediatrician's role in screening for violence exposure
and potential early identification of children with emotional or behavioral
sequelae has been increasingly recognized.18-19
Given time limitations and privacy issues, it may not always be practical
to screen both the parent(s) and child regarding the child's exposure to violence
(ETV). Practitioners may therefore rely solely on parental reports. Caretakers
may not be the most accurate reporters, particularly among older children
who spend time away from home unsupervised by the parent(s), although little
empirical data are available to support this assumption.20
To intervene effectively, pediatricians need to not only be aware of
which respondent gives the most reliable information but also understand potential
factors that may be associated with increased risk. Violence exposure may
have important correlates in ethnically diverse urban populations that pediatricians
need to consider. Inner-city primary care settings often include a significant
proportion of immigrants to the United States. Recent studies among a community-based
sample of ethnically diverse primary care patients21
and countries outside the United States that had recently experienced political
violence or war22 raise awareness of the need
to consider immigration status or country of origin when identifying patients
at increased risk for violence exposure.
We examined the concordance between caretaker report and child's self-report
of child's ETV in an inner-city preadolescent population. We hypothesized
that there would be poor caretaker-child concordance for ETV given that children
would report events occurring outside the home not witnessed by the caretaker.
We further hypothesized that violence exposure would be higher among immigrant
families than US-born participants.
SUBJECTS AND METHODS
PARTICIPANTS
Participants included mother-child pairs drawn from a larger sample
voluntarily recruited for a longitudinal study of the effects of prenatal
maternal smoking on childhood respiratory illnesses. The design of the parent
study has been detailed previously.23 The study
is based at an inner-city neighborhood health center. The study protocol was
approved by the human subjects committees of the Brigham and Women's Hospital
and the Beth Israel Deaconess Medical Center, Boston, Mass.
The initial study population consisted of 1000 mother-child pairs enrolled
in early pregnancy between March 1986 and October 1992. The majority of participants
were urban poor or working class, with 75% of participants coming from households
with an annual family income of less than $30 000. Fifty percent were
white, 48% Hispanic, 2% black, and 5% of other or mixed racial or ethnic backgrounds.
Of this initial group, approximately 500 families continued under active follow-up.
Beginning in November 1996, participants were recruited from the original
cohort. Voluntary written consent was obtained from 412 adult caretaker participants
who agreed to participate in the violence assessment. Subjects were interviewed
face-to-face in their preferred language (English or Spanish) in a private
setting located in the clinic. The subjects who did not participate did not
differ significantly from those who underwent the assessment in terms of education,
but they did differ by ethnic composition (54.6% white, non-Hispanic and 45.4%
Hispanic).Reasons for nonparticipation included being unavailable for follow-up
(53 participants), refusal (22 participants), and failure to keep scheduled
visits for interview on more than 2 occasions (12 participants).
DEMOGRAPHIC VARIABLES
A series of demographic variables was assessed for potential interrelationships
with violence exposure. These included race, caretaker's education (as a proxy
for socioeconomic status), caretaker's marital status, child's sex, child's
age, and country of origin. For the last of these, 3 main groups were considered:
US-born, Central or South American and Caribbean immigrants (El Salvador,
Colombia, Guatemala, Peru, Honduras, Dominican Republic, Nicaragua, Costa
Rica, Panama, Haiti, and Cuba), and other immigrants (Mexico, Puerto Rico,
Cape Verde, Portugal, and Italy). These categories were chosen on the basis
of previous research showing increased violence exposure among Central American,
South American, and Caribbean immigrants (ie, related to political violence,
drug trafficking, and socioeconomic conditions) relative to others.21, 24
CARETAKER MEASURES
A modified version of the violence exposure survey developed by Richters
and Saltzman25 was administered to 412 caretakers.
Caretakers reported on their children's ETV (caretaker report of child's ETV).
This questionnaire was structured to gather data on ETV (both direct victimization
and witnessing violence). The scale was designed to measure specific acts
of violence, including hearing gunshots and witnessing slapping, hitting,
or punching, beatings, knife attacks, and shootings. Details were obtained,
including (1) frequency of exposure and (2) where the violence occurred (eg,
at home, at school, or in the neighborhood). Lifetime ETV was considered in
these analyses.
CHILD SELF-REPORT MEASURES
Children who were 8 years or older (n = 171) answered the questionnaire
on violence exposure that was parallel to that answered by the adult caretaker.26 Six children responded to the self-report version
when their primary caretaker did not keep the appointment for the parent-report
version after 3 or more attempts; thus, 165 caretaker-child pairs were included
in these analyses. Two-week test-retest reliability in a random sample of
11 children was 0.64; test-retest reliability was 0.97 with removal of 1 outlier.
Children younger than 8 years were administered the more age-appropriate "Things
I Have Seen and Heard"27 and will be reported
on elsewhere.
ANALYSES
Responses to the violence exposure questionnaire were summarized into
a continuous ETV score by means of Rasch modeling techniques.28
Rasch analysis is a method for obtaining a continuous objective measure of
ETV from ordered category responses obtained on the questionnaire. Violent
events were ordered on the basis of their level of severity (lowest to highest).
Next, a generalization of the Rasch model was used to account for greater
frequency of ETV. For example, instead of answering yes or no to the question
of whether the child has seen someone knifed, the response can be summarized
as "no," "yes, just once," or "yes, more than once." A higher score on the
Rasch violence scale thus indicates both greater severity of violence exposure
(witnessing a knifing or shooting compared with pushing or shoving) and more
frequent exposure, which can be an indicator of more chronic violence exposure.
Rasch models were fit by means of statistical software WINSTEPS.29
Goodness of fit was demonstrated on the basis of 2 fit statistics (ie, mean-square
infit statistic = 1.09 and the mean-square outlier statistic = 10.5) indicating
good fit.
All other analyses used SAS statistical software (SAS Institute Inc,
Cary, NC; version 6.12). Caretaker-child agreement was quantified with the
statistic. This statistic, introduced by Cohen,30
indicates perfect agreement if equal to 1.0. If equal to 0, then agreement
shown occurs by chance. The higher the value is, the stronger the agreement.
Values less than 0 occur, although they are rare, if agreement is weaker than
that expected by chance. The statistic ranges from values of 1.0 (perfect
agreement) to –1.0 (complete disagreement). Values of greater
than 0.75 are considered to indicate high agreement, 0.40 to 0.75 represent
moderate agreement, and less than 0.40 indicate poor agreement.30-31
The statistic compares caretaker-child response to "ever" or "never"
exposure to the violent event. The Rasch summary score (continuous measure
of severity and frequency) of caretaker report of child's ETV and child's
self-reported ETV were examined by means of the Spearman correlation. More
detailed analyses of the interrelationships among the sociodemographic factors
and ETV were approached with a series of linear regression models, which allowed
for the control of multiple factors at once.
RESULTS
Table 1 outlines the demographic
characteristics of the study population. More than half (56%) reported the
United States as their country of origin. The majority of caretaker respondents
(95%) were the biological mothers, and 35% had less than a high school education.
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Table 1. Sample Characteristics of 165 Caretaker-Child Pairs
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AGREEMENT BETWEEN CARETAKER REPORT AND CHILD SELF-REPORT OF CHILD'S
ETV
Table 2 compares caretaker
and child reports of the child's ETV. There was poor agreement between the
caretaker's report and children's self-report, with caretakers consistently
underestimating the violence exposure reported by their child. Although
statistics for caretaker-child agreement were higher for more severe events
(eg, hearing gunshots [ = 0.22] and seeing someone shot [ =
0.39]), these were still poor. Notably, 4 children reported witnessing a knifing
that was unknown to the caretaker reporter, with 3 of these children reporting
more than 1 witnessed knifing.
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Table 2. Comparison of Caretaker's Report and Child's Self-report of
Child's Violence Exposure
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COMPARISON OF CARETAKER-CHILD AGREEMENT BASED ON LOCATION
Figure 1 compares the caretaker's
report and child's self-report of the frequency of the child's exposure to
selected violent events based on where the event had occurred. Lack of agreement
appears to be related to the location of the child's ETV, with caretakers
reporting more violence exposure at home or closer to home, and children reporting
more exposure at school, in the park, or in the neighborhood. Similar trends
were seen related to rare events, including witnessing a stabbing or seeing
someone shot (ie, children reported witnessing these events away from home,
in the neighborhood, or at school, while the caretakers reported these events
only when they had occurred near home). Notably, some events were experienced
in the participant's country of origin. In an open-ended response category
for where the event(s) occurred, these participants reported experiencing
violence both before immigration to the United States and when traveling back
to their country of origin after migration. It was not an unusual practice
for caretakers to send their children to their native countries for an extended
visit with relatives or a noncustodial parent.
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Comparison of caretaker's report and child's self-report of child's
exposure to violence (frequency and location). In the "Other" category, the
majority were outside of the child's neighborhood, and 5 gunshots were heard
when in Central or South America.
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CORRELATION OF CARETAKER'S AND CHILD'S REPORT OF CHILD'S ETV
Not surprisingly, the overall Rasch model summary scores (severity and
frequency) for caretaker report and child self-report of the child's ETV were
not significantly correlated (r = 0.12).
INFLUENCE OF SOCIODEMOGRAPHIC FACTORS ON ETV REPORTS
One potential reason for poor concordance or lack of correlation may
be that there are different factors determining caretaker and child accuracy
on the ETV standardized survey. To assess internal validity of the measure,
we examined the relationship between the sociodemographic factors and report
of the child's ETV for each informant. In univariate analyses, the sociodemographic
factors were related in the expected directions, corroborating previous research.32 Girls reported significantly (ß ± SD, -10.1
± 4.6; P = .03) less violence exposure than
boys. Children were likely to report higher violence exposure as they got
older (ß ± SD, 3.1 ± 2.4; P =
.2 calculated for a 1-year increase in age)—a relationship that was
not significant, which may be due to the relatively narrow age range in our
sample (8-13 years). Caretaker's report of being divorced or widowed was significantly
(ß ± SE, 12.6 ± 6.0; P = .04)
associated with increased violence exposure among the children compared with
married caretaker status. There was a trend for lower caretaker educational
level to predict higher violence in the children, although this was not significant.
Notably, these associations were qualitatively similar, but not significant,
for caretaker report of child's ETV (data not shown for simplicity). Discordance
did not seem to be related to validity across informants.
MULTIVARIATE PREDICTORS OF CHILD'S SELF-REPORTED ETV
Predictors of the level and frequency of the child's self-reported ETV
are shown in Table 3. Country
of origin was the strongest predictor of child's self-reported ETV after adjusting
for all other covariates (ie, child's age and sex and caretaker educational
status and marital status). Subjects who had immigrated had higher violence
exposure scores than those born in the United States. Divorced and widowed
caretaker status also remained a significant predictor of child's ETV.
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Table 3. Predictors of Child's Self-report of Exposure to Violence
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COMMENT
These data demonstrate poor caretaker-child concordance on reports of
the child's witnessed violence or victimization in this preadolescent inner-city
primary care population. From a clinical perspective, pediatricians need to
be aware of such discordance when incorporating screening protocols for assessing
risk of ETV among children and youth in their practices. These data suggest
that, although parents may be ready sources of clinical information, they
may significantly underestimate ETV among older children. Child self-report
of ETV should be obtained in the preadolescent age group.
These data corroborate other studies demonstrating that assessment of
children's ETV may result in differing results depending on the informant.32 Indeed, a consistent finding in the epidemiology
of childhood ETV is the relative discordance between parent-child report of
violence exposure.5, 32-35
Richters and Martinez33 investigated violence
reports in 111 parent-child dyads from the first and second grades and 54
from the fifth and sixth grades of the same school. Child reports were similar
to their parents', with more children reporting witnessed violence (97%) than
victimization (59%); however, more children reported victimization than their
parents did (69% vs 44%; P<.05).10, 25-26
Similarly, Howard and colleagues34 concluded
that caretakers underestimated child victimization 58% of the time overall
and 75% among children older than 12 years. It has been postulated that such
discordance is, in part, related to children experiencing events outside of
the supervision of their caretakers; however, to our knowledge, this has scarcely
been formally examined.
In this sample, many events witnessed by children but not reported by
caretakers occurred outside of the child's home environment. This may be related
to lack of direct caretaker supervision away from home. Moreover, caretakers'
knowledge of events that occur outside the home requires communication from
their children. Reasons for lack of communication around ETV between caretakers
and their children were not directly assessed in this study. It has been postulated
that the child may not report events to their parents for fear of social restrictions
or because of desensitization to community violence.20
Lack of agreement in caretaker-child report of ETV has been associated
with increased youth perpetration of violence, increased alcohol and other
drug use, and decreased psychosocial functioning. Other research has linked
low parent-child agreement with higher levels of childhood ETV,34-37 behavioral
problems,15-16,36, 38
and childhood distress symptoms.10-11,17, 20, 35-36
Conversely, Ceballo and colleagues35 found
that higher caregiver-child agreement regarding a child's ETV was related
to improved psychological functioning in the child. Less attention has been
paid to factors that might help explain the discordance and mediate the relationship
between poor agreement and behavioral and psychological sequelae in youth.
Further research to evaluate such factors may inform more effective interventions
in the clinical setting.
Rates of crime and violence (or the lack of it) have been considered
as indicators of collective well-being, social relations, or social cohesion
within a community and society.39-40
Therefore, it is often the case that both caretakers and children living in
the same environment (eg, neighborhood or community) are likely to be at risk
for increased ETV. In the context of shared exposure to chronic violence,
children may choose not to report events to their caretaker to protect their
families from further emotional pain (or vice versa). That is, children and
their caretakers may avoid talking to each other about exposures for fear
of reminding or upsetting each other.22 Future
studies need to consider such shared exposures as a potential mediating factor
for poor caretaker-child concordance in violence reporting. Correlates of
the caretaker's own violence exposure such as psychological comorbidity (eg,
depression or anxiety) may influence their reaction to their child's ETV and
child's distress.22
These data also suggest interethnic differences in frequency of ETV
when country of origin was considered. This might be anticipated given that
immigration to the United States is often related to socioeconomic and political
forces linked to violence exposure in other countries. More recent immigrants
may also be at greater socioeconomic disadvantage relative to their US-born
counterparts and consequently be more likely to live in communities burdened
by greater poverty and higher crime rates. Immigrant children may visit their
native country after migration, where they may be more likely to encounter
violence. As continued waves of immigrants change the face of urban America,
pediatricians must be aware of these potential ethnic and cultural influences
on violence exposure.41-42
Caretakers' marital status may also be an indicator of increased risk
of ETV for youth. In the current study, children from households where caretakers
reported being divorced or widowed experienced higher rates of violence. This
finding has been demonstrated in earlier studies as well.21
An important limitation in this study is the relatively small sample
size. This did not allow us, for example, to examine whether occurrence of
violence near home or away from home statistically predicted worse caretaker-child
agreement. Small numbers in migration status (country of origin or ethnicity)
required collapse into broad categories, which limits meaningful comment on
sociocultural explanations for the observed associations. Future studies with
larger sample sizes that also include other ethnic backgrounds (Southeast
Asians, Middle Easterners, etc) may further this line of research.
Clinically, these data suggest that intervention strategies around youth
ETV in the pediatric primary care setting should include assessment of the
child independent of caretaker report. In addition, future studies of potential
mediating factors to explain the poor concordance may help us develop more
effective interventions. Potential important mediating factors might include
caretakers' own experience with violence and psychological distress symptoms,
child psychological distress, family dynamics, poverty, and other social supports
in the community.
| What This Study Adds
Violence exposure and violent injuries are a serious threat to the health
of children and youth in the United States. Our research has demonstrated
poor caretaker-child agreement on the child's exposure to violence (ETV) in
this preadolescent urban sample. Children frequently experience violence away
from home and outside the supervision of their caretakers. These data support
the observation that multiple informants will provide the most information
regarding a child's ETV and should include child self-reports. In addition,
we need to recognize important correlates such as migration status (country
of origin or ethnicity), which may be related to increased frequency of ETV.
Often, immigrants have experienced trauma related to political violence before
migration or when they travel back to their native country. Caretakers' marital
status (ie, being divorced or widowed) may also be an indicator of increased
risk of ETV for youth.
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AUTHOR INFORMATION
Accepted for publication April 9, 2002.
During preparation of the manuscript, Dr Wright was supported by the
National Institutes of Health (NIH)(Bethesda, Md) grant HL07427 and the Medical
Foundation Deborah Munroe Noonan Memorial Fund (Boston); Dr Thomson was supported
by NIH grant HL07427-22; and Mr Roberts was supported by NIH grant GM553353.
Corresponding author and reprints: Rosalind J. Wright, MD, MPH, Channing
Laboratory, 181 Longwood Ave, Boston, MA 02115 (e-mail: rosalind.wright{at}channing.harvard.edu).
From the Channing Laboratory, Department of Medicine, Brigham and Women's
Hospital (Drs Thomson and Wright and Mr Curran), and Pulmonary and Critical
Care Unit, Massachusetts General Hospital, Department of Medicine (Dr Thomson),
Harvard Medical School, Department of Biostatistics, Harvard School of Public
Health (Mr Roberts and Dr Ryan), and Pulmonary and Critical Care Division,
Beth Israel Deaconess Medical Center (Dr Wright), Boston, Mass.
REFERENCES
| |
1. Finkelhor D, Dziuba-Leatherman J. Children as victims of violence: a national survey. Pediatrics. 1994;94:413-420.
FREE FULL TEXT
2. Schubiner H, Scott R, Tzelepis A. Exposure to violence among inner-city youth. J Adolesc Health. 1993;14:214-219.
FULL TEXT
|
ISI
| PUBMED
3. Osofsky JD, Wewers S, Hann DM, Fick AC. Chronic community violence: what is happening to our children? Psychiatry. 1993;56:36-45.
ISI
| PUBMED
4. Shakoor BH, Chalmers D. Co-victimization of African-American children who witness violence. J Natl Med Assoc. 1991;83:233-238.
PUBMED
5. Taylor L, Zuckerman B, Harik V, Groves BM. Witnessing violence by young children and their mothers. J Dev Behav Pediatr. 1994;15:120-123.
ISI
| PUBMED
6. Sheehan K, DiCara JA, LeBailly S, Christoffel KK. Children's exposure to violence in an urban setting. Arch Pediatr Adolesc Med. 1997;151:502-504.
ABSTRACT
7. Straus M, Gelles R. How violent are American families? estimates from the National Family
Violence Resurvey and other studies. In: Gelles R, ed. Physical Violence in American
Families: Risk Factors and Adaptation to Violence in 8,145 Families.
New Brunswick, NJ: Transaction Publishers; 1990:113-127.
8. Carlson B. Children's observations of interparental violence. In: Roberts A, ed. Battered Women and Their Families. New York, NY: Springer Publishing Co Inc; 1984:147-167.
9. Straus M. Children as Witness to Marital Violence: A Risk Factor
for Lifelong Problems Among a Nationally Representative Sample of American
Men and Women. Washington, DC: Ross Roundtable on Children and Violence; 1991.
10. Martinez P, Richters JE. The NIMH community violence project, II: children's distress symptoms
associated with violence exposure. Psychiatry. 1993;56:22-35.
ISI
| PUBMED
11. Boney-McCoy S, Finkelhor D. Psychosocial sequelae of violent victimization in a national youth
sample. J Consult Clin Psychol. 1995;63:726-736.
FULL TEXT
|
ISI
| PUBMED
12. Acierno R, Kilpatrick DG, Resnick H, Saunders B, De Arellano M, Best C. Assault, PTSD, family substance use, and depression as risk factors
for cigarette use in youth. J Trauma Stress. 2000;13:381-396.
FULL TEXT
|
ISI
| PUBMED
13. Berenson AB, San Miguel VV, Wilkinson GS. Violence and its relationship to substance use in adolescent pregnancy. J Adolesc Health. 1992;13:470-474.
FULL TEXT
|
ISI
| PUBMED
14. Kilpatrick DG, Acierno R, Saunders B, Resnick HS, Best CL, Schnurr PP. Risk factors for adolescent substance abuse and dependence: data from
a national sample. J Consult Clin Psychol. 2000;68:19-30.
FULL TEXT
|
ISI
| PUBMED
15. Eiden R. Exposure to violence and behavior problems during early childhood. J Interpersonal Violence. 1999;14:1299-1313.
FREE FULL TEXT
16. Miller LS, Wasserman GA, Neugebauer R, Gorman-Smith D, Kamboukos D. Witnessed community violence and antisocial behavior in high-risk,
urban boys. J Clin Child Psychol. 1999;28:2-11.
FULL TEXT
|
ISI
| PUBMED
17. Singer MI, Anglin TM, Song LY, Lunghofer L. Adolescents' exposure to violence and associated symptoms of psychological
trauma. JAMA. 1995;273:477-482.
ABSTRACT
18. American Academy of Pediatrics Task Force on Violence. The role of the pediatrician in youth violence prevention in clinical
practice and at the community level [guideline]. Pediatrics. 1999;103:173-181.
FREE FULL TEXT
19. Stringham P. Violence anticipatory guidance. Pediatr Clin North Am. 1998;45:439-448.
FULL TEXT
|
ISI
| PUBMED
20. Hurt H, Malmud E, Brodsky NL, Giannetta J. Exposure to violence. Arch Pediatr Adolesc Med. 2001;155:1351-1356.
FREE FULL TEXT
21. Holman A, Silver R, Waitzkin H. Traumatic life events in primary care patients: a study in an ethnically
diverse sample. Arch Fam Med. 2000;9:802-810.
FREE FULL TEXT
22. Smith P, Perrin S, Yule W, Rabe-Hesketh S. War exposure and maternal reactions in the psychological adjustment
of children from Bosnia-Hercegovina. J Child Psychol Psychiatry. 2001;42:395-404.
FULL TEXT
|
ISI
| PUBMED
23. Hanrahan JP, Tager IB, Castile RG, Segal MR, Weiss ST, Speizer FE. Pulmonary function measures in healthy infants. Am Rev Respir Dis. 1990;141:1127-1135.
ISI
| PUBMED
24. Kliewer W, Murrele L, Mejia R, Torres de Y, Angold A. Exposure to violence against a family member and internalizing symptoms
in Colombian adolescents: the protective effects of family support. J Consult Clin Psychol. 2001;69:971-982.
FULL TEXT
|
ISI
| PUBMED
25. Richters JE, Saltzman W. Survey of Exposure to Community Violence—Parent
Report Version. Bethesda, Md: Child and Adolescent Disorders Research Branch, National
Institute of Mental Health; 1990.
26. Richters JE, Saltzman W. Survey of Exposure to Community Violence—Child
Report Version. Bethesda, Md: Child and Adolescent Disorders Research Branch, National
Institute of Mental Health; 1990.
27. Richters J, Martinez P. Things I Have Seen and Heard: An Interview for Young
Children About Exposure to Violence. Bethesda, Md: Child and Adolescent Disorders Research Branch, National
Institute of Mental Health; 1990.
28. Kindlon D, Wright B, Raudenbush S, Earls F. The measurement of children's exposure to violence: a Rasch analysis. Int J Methods Psychiatr Res. 1996;6:187-194.
FULL TEXT
29. Linacre J, Wright B. WINSTEPS: Rasch Model Computer Program. Chicago, Ill: MESA Press; 2000.
30. Cohen J. A coefficient of agreement of nominal scales. Educ Psychol Meas. 1960;20:37-46.
FULL TEXT
|
ISI
31. Fleiss J. Statistical Methods for Rates and Proportions. 2nd ed. New York, NY: John Wiley & Sons Inc; 1981.
32. Kuo M, Mohler B, Raudenbush SL, Earls FJ. Assessing exposure to violence using multiple informants. J Child Psychol Psychiatry. 2000;41:1049-1056.
FULL TEXT
|
ISI
| PUBMED
33. Richters JE, Martinez P. The NIMH community violence project, I: children as victims of and
witnesses to violence. Psychiatry. 1993;56:7-21.
ISI
| PUBMED
34. Howard DE, Cross SI, Li X, Huang W. Parent-youth concordance regarding violence exposure. J Adolesc Health. 1999;25:396-406.
FULL TEXT
|
ISI
| PUBMED
35. Ceballo R, Dahl T, Aretakis M, Ramirez C. Inner-city children's exposure to community violence: how much do parents
know? J Marriage Fam. 2001;63:927-940.
FULL TEXT
36. Linares LO, Heeren T, Bronfman E, Zuckerman B, Augustyn M, Tronick E. A mediational model for the impact of exposure to community violence
on early child behavior problems. Child Dev. 2001;72:639-652.
FULL TEXT
|
ISI
| PUBMED
37. Durant RH, Pendergrast RA, Cadenhead C. Exposure to violence and victimization and fighting behavior by urban
black adolescents. J Adolesc Health. 1994;15:311-318.
FULL TEXT
|
ISI
| PUBMED
38. Shahinfar A, Fox NA, Leavitt LA. Preschool children's exposure to violence. Am J Orthopsychiatry. 2000;70:115-125.
ISI
| PUBMED
39. Sampson RJ, Raudenbush SW, Earls F. Neighborhoods and violent crime: a multilevel study of collective efficacy. Science. 1997;277:918-924.
FREE FULL TEXT
40. Kawachi I, Kennedy BP, Wilkinson RG. Crime. Soc Sci Med. 1999;48:719-731.
41. Fallon J. The impact of immigration on US demographics. J Soc Polit Econ Stud. 1996;21:141-167.
PUBMED
42. Gracey M. The pediatrician's role in the twenty-first century. Acta Paediatr Jpn. 1998;40:393-399.
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