Exposure to Violence

John D. and Catherine T. MacArthur
Research Network on Socioeconomic Status and Health

Exposure to Violence

Summary prepared by Rosalind J. Wright in collaboration with the Psychosocial Working Group. Last revised October, 1998.

Chapter Contents:
a. Background
b. Measurement of ETV
c. Child Self-Report Versions
d. Measurement of Domestic Violence
e. Violence Exposure and SES
f. Violence Exposure and Health Impact
g. Violence and Social Connectedness
h. Violence and Health Beliefs and Health Promotion Behaviors
i. Violence, Quality of Life, and Healthcare Utilization
j. Bibliography

Background

Stress impacts both psychological and physical well being (^1,2). The preponderance of evidence linking stress and disease is based on the study of major NLEs (^3,4) utilizing checklist measures of commonly occurring major life experiences which potentially have negative impact (i.e., death of someone close, separation or divorce, financial loss, etc.). However, the association between NLE frequency and health outcomes has been relatively modest, with life events accounting for less than IO% of the variance. It has been suggested that, in part, this modest explanatory power reflects the omission from existing NLE measures of both socially controversial events (e.g., sexual abuse, abortion ) (⁵) and the underrepresentation of life experiences more common to particular ethnic groups or a particular social class (⁶). At the same time it has been long recognized that such sociodemographic factors (i.e., belonging to an ethnic minority, living in poverty) predispose individuals to particular pervasive forms of life stress (⁷).

One such obvious omission is the measurement of exposure to violence. The degree of chronic life stress is significantly influenced by the characteristics of the communities in which we live (⁸). Police-documented high crime rates (⁹) and/or the perceived threat of crime and violence (¹⁰) are among unique environmental factors purported to contribute significantly to the chronic stress of low SES communities. Violent victimization is a major cause of morbidity in the United States (US). True estimates are crude, but one national study estimated 6.2 million youth aged 10-16 years experience some form of completed assault or abuse per year; one of eight (2.8 million) experience an injury as a result; and one per one hundred (almost 250,000) require medical attention (¹¹). Crude statistics - such as arrest records and murder rates - document the increase in the incidence of violence in American urban communities (^12,13). It is estimated for every lethality there are 100 assaults (¹¹). Rates of witnessing serious and lethal violence among inner-city youth are also high. Studies in Detroit, Chicago, Boston, and New Orleans estimate that approximately one-quarter of youth surveyed have witnessed someone shot and/or killed during their lifetime (^14,15) (^16,17). One survey in an inner-city public housing development in Chicago (mean age 11 years) found that 42% had seen someone shot, 37% had seen someone stabbed, 21% lived with someone who had been shot and 16% lived with someone who had been stabbed (¹⁷). Others indicate high frequency of exposure at even younger ages. A study of children being evaluated at a pediatric clinic at Boston City Hospital reported that one in ten children witnessed a shooting or stabbing before the age of six (¹⁷).

In addition, national estimates of domestic violence against women and children indicate widespread exposure to violence in the home (^18,19). In 1995, child protective services agencies investigated reports alleging maltreatment of an estimated 3 million children (²⁰). It is currently estimated that between 2-4 million women are physically battered annually in the US (¹⁸); 25-30% of all American women are at risk for domestic violence during their lifetime (²¹). In the US, from 3.3 million (²²) to 10 million (²³) children are estimated to witness parental violence annually. Witnessing violence (^24,25) may be as traumatic as direct victimization.

The operationalization of violence exposure introduces many challenges currently facing investigators in the field. While most instruments include questions regarding more severe events, such as shootings, being attacked with a weapon, or seeing someone killed, few include questions regarding pervasive indicators of neighborhood violence (i.e., drug sales, police arrests), sexual violence, psychological abuse, domestic violence or stalking. Some measures include violence that is observed in the media or ask about violent events that happen to both the subject and to others close to the subject. Measures need to tap into both the nature and severity of traumatic exposures as they are heterogeneous with potentially unique impacts on symptomatology (^26,27). This challenges the investigator to decide on the appropriate item content in exposure to violence (ETV) instruments which may depend on both the population being studied and the health outcomes of particular interest to the investigators. This lack of standardization of the item content for ETV instruments also makes comparisons across studies difficult

Other contextual factors identified as potential mediators of the impact of violence include an individuals' proximity to violence exposure (²⁸), timing of exposure to violent events (e.g., interplay of exposure on child development) (^29,30), chronicity of exposure, and the relationship of the subject to the perpetrator/victim (³¹). Furthermore, children who are both direct victims and witnesses of violence may suffer significant, yet distinct, emotional and developmental consequences (^25,32,33). Also, some evidence suggests that abused children may respond differently to witnessed violence compared with children who are not abused (^25,34). Although these data suggest that it is important to distinguish whether violence exposure occurs in the home or in the community and between violence that is witnessed and violence that is directly experienced (victimization), many studies do not separate such events (³⁵).

Thus a primary challenge in the field has been to develop an instrument that contains items which cover a broad range of events in terms of context, severity, and chronicity, and that separately address victimization and witnessed violence. Another methodological limitation that has been raised is how the measures are scored to reflect the level of ETV between subjects (³⁶). At the same time, until recently information on the psychometric properties of existing ETV instruments was sparse (^37,38) (^39,40). This overview focuses on the more commonly used measure, those instruments for which validity and reliability data are available, and measures which try to address some of the methodological issues raised.

Measurement of ETV

One of the most widely used measure of ETV is the diagnostic criteria for Post Traumatic Stress Disorder (PTSD) (⁴¹). This measure asks the subject whether they have ever had ‘a terrible experience that most people never go through like being attacked....’. A total of nine classes of events are included (e.g., military combat, rape, and seeing someone hurt or killed). The measure is scored on a 0, 1 binary scale whereby if the respondent indicates that they have experienced any one or more of the events, they receive a score of 1, if they have experienced none of the events they receive a score of 0.

Another widely used measure, the Survey of Exposure to Community Violence-Self Report Version (SECV-SR) (⁴²) has minimal available psychometric data on internal consistency (⁴³). Kindlon et al. (³⁶) have pointed out that the SECV-SR, similar to most other ETV measures used, sum ordinal item responses which are treated as falling on an interval scale. The SECV-SR uses a frequency scale ranging from 0 (no exposure) to 8 (exposed every day). This approach assumes an interval scale which necessarily requires that the increase in ETV impact between 0 (no exposure) and 1 (exposed once) is the same as the increase in ETV impact between 7 (exposed once a week) and 8 (exposed every day). These authors argue that no justification exists of equal intervals between these ordinal scale points (³⁶). They go on to point out an additional scoring problem which lies in the equal weighting of items despite extensive qualitative differences in item content. They provide the example that being the victim of a knife attack would meet criteria for a traumatic event in diagnosing PTSD, whereas witnessing illegal drug use or hearing gunshots would not. They underscore the issue that with current methods, an individual reporting only a knife attack item would be indistinguishable from one who had only heard gunshots - both would be scored as having the same 'level' of ETV.

Existing ETV instruments that simply sum the total number of exposures to a range of violent events lose information regarding the differential impact of experiencing acute as opposed to chronic exposures as well. In response to these recognized limitations, these investigators have applied existing mathematical modeling techniques utilizing ETV ordinal response data to take into account frequency of exposure and severity of events and have recently reported on the development of a structured interview, My Exposure to Violence (My ETV) (a parent/caregiver-report version) (⁴⁰). This is a highly structured interviewer-administered instrument designed to cover a subject's lifetime and past year exposure to 18 different violent events that have either been witnessed or personally experienced by the subject. This also ascertains location of violence (e.g., school, home, neighborhood), identifies both perpetrators and victims of violence (e.g., family member, stranger), and whether the exposure has been gang-related. The instrument measures lifetime exposure ('ever') and annual prevalence ('in the past year'). Frequency of exposure is measured on a 6-point scale (never, once, 2 or 3 times, 4 to 10 times, 11 to 50 times, and more than 50 times). Six subscales are defined: 1) Witnessing violent events, 2) Victimization, and 3) Total exposure (witnessing and victimization) obtaining scores for both lifetime and past year exposure. These scales had high internal consistency (r=0.68 to 0.93) and test-retest reliability (r=0.75 to 0.94). These authors also provide evidence of construct validity.

This instrument is currently being used in the Program on Human Development in Chicago Neighborhoods (PHDCN) (Felton Earls, PI). The PHDCN is sponsored by the John D. and Catherine T. MacArthur Foundation, the National Institute of Justice, the National Institute of Mental Health and the Department of Education. This study is the largest prospective study (tracking 6000 children in 80 Chicago neighborhoods until 2003) aimed at examining interrelationships of multiple social factors on mental health (PTSD) and behavior.

We (RJ Wright) have developed an ETV instrument modified from two sources including Richters' Survey of Exposure to Community Violence instrument (⁴²) and the Adult Witness to Violence Questionnaire developed by the group at Boston Medical Center (Betsy Groves, personal communication). This instrument is the Witness to Violence (WTV) questionnaire (unpublished). The adult/caregiver version gathers information on experience of violence for both the adult and the child. The child version (for ages 8 years or older) asks the child directly. This has been administered in a face-to-face interview setting. This questionnaire was structured to gather data on exposure to violence (both direct victimization and witnessing violence), and like the My ETV instrument (⁴³), it ascertains location of violence (e.g., school, home, neighborhood) and identifies both perpetrators and victims of violence (e.g., family member, stranger). In addition, we obtain information on the seriousness of any injury related to the violent event (e.g., broken bones, bleeding, death) and whether emergency medical care was required. The 31-item scale was designed to broadly measure acts of violence including hearing gunshots, witnessing slapping/hitting/punching, knife attacks, and shootings. Adult/parent responders reported on these exposures for themselves as well as for their children. Age of the child at the time of each recorded event is also obtained. The instrument measures both lifetime exposure and within the past year. This is currently being used in a longitudinal study of asthma morbidity in an inner-city cohort (^44,45).

Cooley-Quille et al. (⁴⁶) have recently reported the reliability and validity of the Children's Report of Exposure to Violence (CREV) in an inner-city population. The CREV is a self-report questionnaire composed of 32 items (29 rated on a 5-point Likert scale and 3 open-ended questions to indicate other violent experiences not specifically asked about) assessing the frequency of lifetime exposure to a variety of types of community violence (i.e., media, hearsay, direct witness, and direct victimization for self, familiar persons or strangers). A score is derived by summing the responses on the 29 scored items. These authors report good 2-week test-retest reliability (r=0.75), internal consistency (Cronbach's a =0.78), and construct validity supporting this as a sound brief self-report instrument for use in community violence research.

Hastings and Kelley (⁴⁷) provide empirical evidence on the utility of the Screen for Adolescent Violence Exposure (SAVE) in assessing adolescent exposure to school, home, and community violence. This instrument was developed on 1,250 inner-city adolescents and obtained excellent reliability and validity. These authors identified three subscales including Traumatic Violence, Indirect Violence, and Physical/Verbal Abuse. The SAVE correlated significantly with both objective crime data and theoretically relevant constructs (anger, posttraumatic stress symptoms, and internalizing/externalizing problems). The SAVE does allow quantification of severity of violence exposure by setting.

When assessing level of exposure to violence among children it may be important to get both parental as well as self- (child-) reports. Studies of the impact of ETV on the child primarily have relied on mother's report to document both the violence and the child's response to it. Yet the mothers have oftentimes recently experienced violence themselves, may be depressed/anxious, and may not be the most reliable reporters of the events/sequelae (⁴⁸). Parent-child agreement on exposure to violence in the community may be moderate at best (⁴⁰). In the instance of domestic violence, many parents minimize or deny the presence of children during incidents of violence by suggesting that the children were asleep or playing outdoors. Studies have shown that despite mothers' efforts to shield their children from violence, 68 to 87% of incidents of partner abuse are, in fact, witnessed by children (⁴⁹). Parental underestimation of children's distress symptom's has been clearly documented in the child psychology literature (^50,51). These parent-child discrepancies underscore the need for investigators to interview children directly to accurately measure both the frequency of exposure to violent events and assess their subsequent psychological response. This presents another challenge in the field, as instruments to measure ETV among young children (i.e., less than 8-9 years old) are even less well developed and yet ETV during critical developmental stages may make younger subjects the most vulnerable (^17,52).

Child Self-Report Versions

Richters and Martinez (⁵³) have developed an instrument called 'Things I Have Seen and Heard' which is a 15-question structured interview that probes young children's ETV and violence-related themes in an age-appropriate format (i.e., grades 1 and 2). The interview consists of 15 pages, each describing a different form of violence. Response categories are depicted as five stacks of balls, each with a different number of balls, ranging from none to four; the columns are labeled sequentially from 'never' to 'many times'. Prior to administration, children are taught how to circle the stacks to indicate the frequency of their exposure to each event. These authors report good 1-week test-retest reliability (r=0.8 1) (⁴⁰).

Fox and Leavitt (⁵⁴) have developed an instrument utilizing cartoon pictures which depict violent events and response categories are depicted as a thermometer which the child uses to report frequency of exposure. This is the VEX-R� , the Violence Exposure Scale for Children - Revised (Full Scale Version) which was revised in 1995. However, validity and reliability data are not yet available.

A modified version of the My ETV instrument is being developed and piloted among children ages 6-8 years (FJ Earls, personal communication) however reliability and validity data are not yet available.

Measurement of Domestic Violence

Historically, exposure to conflict and violence in the home has been most widely assessed through the Conflicts Tactic Scale (CTS) which has been recently revised (⁵⁵).

While this is a widely used, reliable, and validated measure of domestic conflict, several limitations have more recently been pointed out in the literature regarding this developed a 10-item Women's instrument (^56,57,58). The CTS details a hierarchy of potential responses to family conflict ranging from reasoning to verbal and/or physical aggression. Interpersonal conflict can be scored on three scales: Reasoning Scale (RS), Verbal Aggression Scale (VAS) and the Physical Aggression Scale (PAS). An Overall Violence Index (OVI) which sums all the component items from the PAS will be obtained. The CTS will measure lifetime prevalence and prevalence over the last year.

Qualitative research in women battering has revealed battering to be an enduring traumatic, and multidimensional experience conceptually distinct from episodic physical assault and more appropriately characterized as a chronic epidemiology (⁵⁹). Battering is not only associated with the pain and injury from physical assault, but ongoing psychological degradation, sustained fear, diminished power and control, and loss of identity and self-esteem. Measuring only discrete physical events fails to ascertain the chronic vulnerability of the battering experience (⁶⁰). Smith and colleagues have Experiences with Battering (WEB) Scale which focuses on the chronic psychological nature of battering which shapes women's behaviors, views of self, and beliefs in the controllability of their lives (⁶⁰). Domains include the "perceived threat" or constant fear and danger women experience in their relationships with abusive partners; they live in fear of future harm. "Managing" represents a pattern of chronic behavior used in trying to prevent the abusive partner from being violent and abusive; this is accompanied by the feeling of "walking on eggshells". The third domain, "altered identity" reflects battered women's changing self concept and loss of self that follows from the negative images of themselves batterers reflect back to them. "Disconnection", the fourth domain, represents battered women's largely futile efforts to establish intimacy with their partners. "Entrapment" represents the disempowerment which reflects the women's loss of power. These authors demonstrated high internal consistency and reliability and good construct validity.

Violence Exposure and SES

Exposure to community-level violence impacts all racial and ethnic groups although poor minority youths are disproportionately affected (^59,60). Nationally, violent crime rates are associated with economic inequality and racial residential segregation (i.e., racial inequality) (⁶¹). Child maltreatment also is highly correlated with lower-SES (⁶²). Although violence crosses all social boundaries, it is not uniformly distributed in all classes. Violence in the home is more prevalent in poor, minority, undereducated populations (⁶³). Thus, chronic ETV may be considered as a pervasive environmental stressor imposed on an already vulnerable population of children and families (⁶⁴).

Violence Exposure and Health Impact

The prevalence and mental and physical health consequences of ETV are a topic of a growing number of research initiatives. Historically, research on the health effects of social and political violence has typically centered on direct exposure of individuals to violent acts (^65,66,67) which were often discrete catastrophic events (i.e., sniper attacks) (⁶⁸). More recently, investigators have focused on large population studies to explore the effect of living in a violent environment, with a chronic pervasive atmosphere of fear and the perceived threat of violence, on health outcomes (^69,70,71). A growing body of research explores potential adverse psychological consequences on children growing up in chronically violent neighborhoods and homes (^72,73). What are notably missing, are studies that examine the possible adverse implications growing up in a violent environment may have on physical health, and specifically chronic disease expression, morbidity, and management in children.

Earlier research and theory on posttraumatic stress disorder (PTSD) (⁷⁴), children exposed to discrete catastrophic events (i.e., sniper attacks) (⁷⁵), children exposed to political violence and war (⁷⁶), and children exposed to domestic violence (^77,78) suggest that a number of domains of cognitive, social, emotional and psychophysiological functioning are significantly affected by exposure to violence (e.g., depression, withdrawal, fear, anxiety, affect disregulation, dissociative reactions, and intrusive thoughts). Studies of school-age children in domestic violence shelters have described clinical levels of trauma-related stress consistent with posttraumatic stress symptomatology including repetitive nightmares, exaggerated startle response, inability to focus attention, and intrusive thoughts and memories related to the violence (^79,80). Descriptive studies of children following a sniper attack on a playground (⁸¹) and children who were kidnapped from their school bus and buried alive (⁸²) reported maladaptive behavior including reduced involvement with the external world, constricted affects, fewer interests, and estrangement. Investigators have consistently documented problematic development in school-age children exposed to domestic violence (⁸³). Specifically, such at-risk children are found to have increased rates of both internalizing and externalizing behavior problems, lower self-esteem, and more difficulties related to school relationships and academics (^25,48). Only recently, researchers are beginning to document similar adverse developmental sequelae among preschool-age children of battered mothers (⁸⁴).

Fewer systematic studies of the impact of community violence on child development are available. Richters and Martinez have found significant associations between childrens' (aged 6 to 10 years) reports of witnessing acts of violence in communities around Washington DC and psychological distress, depression, and maladaptive behavior (⁴⁰). Osofsky and colleagues (^85,86) found similar increased likelihood of psychopathology and maladaptive behaviors among exposed school-aged children living in a high crime urban environment around New Orleans, Louisiana. One community study of urban adolescents found an increased rate of posttraumatic stress disorder among the exposed youth (⁸⁷). These studies support an association between community violence exposure and negative impact on childhood psychological well-being.

Violence and Social Connectedness

Social support has repeatedly been shown to buffer the association between psychosocial stress and both physical and psychological morbidity (⁸⁸). Parents who are worried about their child's safety in the neighborhood due to drugs and crime may keep their children indoors and otherwise restrict their social behavior, and thus their ability to develop or use support networks may be compromised (⁸⁹). Psychopathology (e.g., PTSD, depression) may prevent the child from forming relationships that are necessary to promote normal social development. Isolation from social networks, support groups, and extended family is also associated with violence in the home (i.e., child abuse, domestic violence) (^90,91). Social isolation in general has been linked to an array of adverse health outcomes (⁹²) and physiologic effects such as altered immunologic functioning (⁹³). The instability and social isolation documented in abusive families may influence health outcomes as well. Fear of crime in the community fosters a distrust of others and can contribute to social isolation (⁹⁴). In turn, social mistrust has been linked to mortality. Kawachi and others (⁹⁵) have utilized per capita social trust as a marker of social cohesion and disinvestment in social capital within communities across the United States. These investigators found that level of social trust was inversely associated with total mortality, as well as rates of death from coronary heart disease, malignant neoplasms, and infant mortality.

It is clear that violence is related to factors that limit formation of social networks. These additional supports may be especially important to health and well-being in inner-city populations faced with cumulative effects of many ecological risk factors (i.e., poverty, low education, poor housing, etc.). It may be that violence impacts health and well-being in through impact on social networks and social capital. This warrants further study.

Violence and Health Beliefs and Health Promotion Behaviors

Health beliefs, in particular the belief that one is susceptible, that the consequences of disease could be serious, and that taking the recommended action results in greater benefit than cost, have consistently been associated with health behavior (⁹⁶). Given the above discussion, it seems reasonable to speculate that those living with the pervasive threat of violence in their lives may develop a distorted view of the world, including the priorities given to their chronic illness. There is increasing evidence that health behaviors are adversely influenced by environments that include high levels of violence and by daily life experiences in unpredictable environments. Children exposed to high levels of violence in the community and in the home (^97,98,99) are more likely to develop a foreshortened sense of the future, with a fatalistic outlook that may undermine their ability to invest in the future by complying with a prescribed treatment regimen for chronic medical conditions for example. Exposure to community violence may affect impulse control and risk-taking behavior (^100,101). Current theory holds that people repeatedly exposed to aversive events they cannot predict or control may learn to become helpless (¹⁰²). DuRant and colleagues (¹⁰³) examined the relationships between exposure to community or intrafamilial violence and depression, hopelessness, and purpose in life among black adolescents living in or around public housing developments. These authors found that higher current depression and hopelessness and lower purpose in life were significantly associated with the reported higher frequency of exposure to, or victimization by, violence in their lifetime. The relationship among violence exposure, feelings of hopelessness or lack of control, and adherence with medical therapy, to date remains unexplored.

Violence, Quality of Life, and Healthcare Utilization

Studies of the association between violence exposure and quality of life are scarce. In one community study of elderly Americans, fear of victimization and concern for personal safety accounted for the greatest percent of variance in quality of life between low-income black adults and whites (¹⁰⁴). We could not find studies that examined this question in children. Mechanisms that mediate this association have not been characterized.

Many studies have found psychosocial correlates of increased healthcare utilization among adults and children. Examining the 1988 child health supplement to the NHIS, Angel and Angel (¹⁰⁵) found that poverty was associated with greater risk of emotional/behavioral problems, which in turn was a highly significant predictor of frequency of medical care visits unrelated to mental health complaints. Others have found that parental mental health, family conflict and determinants of life stress contribute to healthcare use among children (^106,107). Here, too, few studies have directly examined the association between violence exposure and healthcare utilization. Koss et al. (¹⁰⁸) found that women who were victims of domestic or stranger violence, compared with nonvictims, made physicians visits twice as frequently and had outpatient costs that were 2.5 times greater during the index year following documented victimization.

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