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James J. Mazza, Ph.D., Department
of Psychology This research was conducted in collaboration with Dr. William M. Reynolds from the University of British Columbia and was assisted by the voluntary efforts of Jennifer Grover, Jeaninne DeVito, Carmela Gencorelli and Alan Becker during their graduate studies at St. John's University. The study examines the relationship of exposure to violence with suicidal ideation, depression, and posttraumatic stress disorder for 94 inner city adolescents in New York City. Adolescents were assessed using self-report measures and clinical interviews. The results suggest that inner-city adolescents who are exposed to a high number of violent events are at greater risk for mental health problems in the areas of depression, suicidal behavior, and posttraumatic stress disorder than those who have had minimal exposure. Specific results and their implications for psychologists and mental health professionals working with adolescents are discussed. Suicide and violence are two prominent issues facing young adults today. Suicide is the second leading cause of death in adolescents age 15 through 19 at a rate of 12.1/100,000 (Blumenthal, 1990; Berman and Jobes, 1991). Violence, specifically homicide, is the third leading cause of death overall for the same age group at a rate of 11.1/100,000 (Furlong and Morrison, 1994). However for inner-city youths the problem is much worse, with homicide being the leading cause of death for African-American and Hispanic males under the age of 25. Moreover, gun-related homicides for African-American males living in core urban areas is at an alarming rate of 143.9/100,000 (Furlong and Morrison, 1994). The increased rate of violence in young adults over the past decade coincides with the increased rate of suicidal behavior in adolescents, especially in minority populations. Although the overall adolescent suicide rate (aged 15-19) is highest in the non-minority population, over the past decade the largest rate of increase has been in minority populations, according to the Center of Disease Control (1995). This increase corresponds to the large increased rate of homicides for adolescents since 1987 (Furlong and Morrison, 1994). According to Guyer (1992), African American males aged 15-19 have a homicide rate nine times higher than Caucasian males in the same age group (Guyer cited by DuRant, Pendergrast, and Cadenhead, 1994). Similarly, the homicide rate among young African-American females is 3.5 times higher than Caucasian females (Mercy and Fenley, 1991). Although studies have examined the increased rate of crime or violence in schools and surrounding areas (Hechinger, 1992; Martinez and Richters, 1993; Richters and Martinez, 1993; Schubiner, Scott, and Tzelepis, 1993; Soriano cited by Soriano, Soriano, and Jimenez, 1994), there has been minimal research investigating the impact of exposure to violence on young adolescents, especially in the area of mental health, and particularly in depression, suicidal behavior, and post-traumatic stress disorder. Depression has been recently identified as one of the key variables that plays an important role in violent behavior for inner-city youth (DuRant et al., 1994) as well as one of the psychological consequences of exposure to violence (Fitzpatrick, 1993; Richters and Martinez, 1993; Schubiner et al., 1994). In a systematic study of exposure to violence and depression in 223 inner-city elementary students, Freeman, Mokros, and Poznanski (1993) found that children who had reported violent events were judged as showing more symptoms related to depression than those who did not report violent events. Similar adverse effects of exposure to violence have been reported in the area of posttraumatic stress disorder (PTSD) (Bell and Jenkins, 1991; Martinez and Richters, 1993; Pynoos et al., 1987). Research examining the relationship between PTSD and exposure to violence in children and adolescents has mainly focused on acute violent events such as, sniper attack (Pynoos et al., 1987) and kidnappings (Terr, 1979, 1983). These studies have reported that children who were either victims or witnesses of violence were more likely to be diagnosed or had more symptoms associated with PTSD than nonvictims or nonwitnesses. Recently, Richters and Martinez (1993) examined the effects of chronic community violence in relation to PTSD symptomatology in elementary children, and found the results were similar to those examining acute violent events. The current investigation was conducted to examine the relationship between exposure to violence and severity levels of suicidal ideation, depression, and PTSD in young inner-city adolescents. Exposure to violence was examined using the 14-item Exposure to Violence Questionnaire (EVQ; Reynolds and Mazza, 1995) that assessed different types of violence exposure, such as drive-by shootings, seeing someone murdered, and being attacked. Adolescents were placed in one of three groups based on the EVQ, none/low exposure, moderate exposure, and high exposure. Suicidal ideation, depression, and PTSD severity levels were compared among the three groups.
Ninety-three percent of the sample had been exposed to at least one violent event or were familiar with someone involved in violence. No gender differences were found. A significant age difference was found among the three exposure groups, with moderate and high exposure adolescents being older than those with none or low exposure. Thirteen adolescents (13.8%) had previously attempted suicide, with 11 (85%) of the suicide attempts in the moderate or high exposure groups, and 8 (62%) in the high exposure group. Adolescents in the moderate and high exposure groups had significantly higher levels of suicidal ideation than those in the none/low group. The comparison between the moderate and high exposure group showed a trend, with high exposure adolescents having higher SIQ-JR scores. The RADS mean scores for the total sample and for each violence exposure group are presented in Table 2. Adolescents in the high exposure group had higher levels of depression than those in the none/low exposed group. The RADS for the total sample was similar to the mean score reported in the standardization sample (Reynolds, 1986). In examining gender difference, a trend was found with females reporting higher depression scores than males. The results on the HDRS were similar to the RADS; adolescents in the high exposure group had significantly higher scores on the HDRS than those in the none/low group and the moderate group. The comparison between the none/low group and the moderate group showed a trend, with moderately exposed adolescents showing higher levels of depression severity. The mean scores on the APS-PTSD scale for the total sample and for each violence exposure group are also presented in Table 2. Adolescents in the high exposure group showed more symptoms associated with PTSD than those in the none/low groups. Similarly, moderately exposed adolescents had higher severity levels than those in the none/low group. The comparison between those in the high and those in the moderate group showed a trend, with high exposure adolescents showing more symptomatology. There was no gender difference on the APS-PTSD scores. The results of this study showed that over 90% of the young adolescents in this sample had been exposed to violence. Unfortunately, these numbers are consistent with other researchers who have examined chronic violence for inner-city adolescents (DuRant et al., 1994; Gladstein, Slater Rusonis, and Heald, 1992; Richters and Martinez, 1993; Schubiner et al., 1993). Gladstein and colleagues (1992) reported from their study that only 12% of adolescents denied being victims, knowing victims, or witnessing violence. Given that the age of adolescents in this study was approximately four years younger than those in the Gladstein et al. study, and yet, they had similar rates of exposure to violence, highlights that exposure to violence in young adolescents is even more widespread and problematic than previously reported (Gladstein et al., 1992). The results of the study showed that approximately one out of eight adolescents in this sample had made a previous suicide attempt. This finding is consistent with those suicide attempt rates found with older adolescents (Harkavy-Friedman, Asnis, Boeck, and DiFiore, 1987; Reynolds and Mazza, 1992; Riggs and Cheng, 1988). Riggs and Cheng (1988) reported an attempt rate of 11.8% with an ethnically diverse sample of 635 adolescents. Reynolds and Mazza (1992), who conducted a study examining suicidal behavior with 3,437 adolescents (M = 15.46 years) drawn from eight states, reported a suicide attempt rate of 13.65%. Given that the adolescents in this study were approximately three years younger than those in the Reynolds and Mazza (1992) study, yet the suicide attempt rates were similar, suggests that younger adolescents may be equally at-risk for suicidal behavior as older adolescents. Results examining the dependent measures of depression, suicidal ideation and APS-PTSD scores showed that adolescents who are exposed to many violent events are experiencing higher levels of depression, are currently thinking about suicide more frequently, and have more symptomatology associated with PTSD than those with minimal exposure. Moderate levels of exposure to violence were also related to increased levels of suicidal ideation and increased severity of PTSD but not depression when compared to none/low peers. These results suggest that even moderate levels of exposure to violence may result in higher levels of suicidal ideation and PTSD symptomatology. These findings highlight that the mental health of young adolescents is adversely affected by exposure to violence, even at moderate levels, emphasizing the need to develop intervention programs that reduce violence. Intervention and prevention programs designed at reducing violence and the impact of exposure to violence may in turn also reduce the number of mental health problems experienced by young adolescents. Gladstein and colleagues reported that only 32% of the adolescent victims in their study sought help or counseling after being physically assaulted. This finding emphasizes the need for schools and school-based professionals to proactively assess exposure to violence, particularly victimization, especially with males. Our research, as well as others (Bell and Jenkins, 1991; Jacobson, Koehler, and Jones-Brown, 1986), has found that most adolescents will respond honestly to questions regarding exposure to violence. Thus, school-wide screening procedures that ask direct questions regarding exposure to violence, including victimization, is a viable method for identifying these youth who are at-risk. There are several limitations of this study. First, the sample consisted of inner-city adolescents attending a parochial school. In general, students attending a parochial school are less likely to be exposed to school related violence than those attending a public school. Also, students attending parochial school may not be representative of those attending public schools in the same area. Second, adolescents who have been exposed to family violence (physical or sexual) are not as likely to receive parental permission to participate in a study examining exposure to violence compared to those who have not been exposed. Thus, students exposed to family violence were probably underrepresented in this sample. Taking into account these two limitations, the results of this study showing 93% of the adolescents having been exposed to violence is probably an underestimate of the true percentage. A third limitation is that the exposure to violence score is a summation score across the different items, and thus not taking into account the frequency of that event. Therefore, an adolescent who is exposed to five murders would receive the same score on that particular item as someone who was exposed to one murder. The results from this study show that a majority of inner city youth have been exposed to violence. Adolescents who have been exposed to moderate or high levels of violence are showing adverse psychological consequences in the areas of suicidal ideation, depression and symptoms associated with PTSD. Intervention programs designed at reducing violence may also assist in reducing the number of mental health problems experienced by students. Although efforts are being made to provide a safer environment for these youngsters (i.e., more police, gun control, etc.), it may be more pertinent in the immediate future for clinical and school psychologists and mental health professionals to identify these young adolescents who have been exposed to violence and focus on helping them understand, cope and alleviate the adverse psychological effects that appear to be related to exposure to violence. Unless
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Exposure
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