The authors have declared that no competing interests exist.
Available literature identifies the need for a deeper understanding of the role of gender, age and socioeconomic status in children’s exposure to violence and associations with mental health (MH) outcomes. The 1548 participants for this study were enrolled from 28 public charter schools and 9 community-based settings; youth were administered a screener that assessed exposure to traumatic events and symptoms of post-traumatic stress disorder (PTSD) and depression. Respondents reported extremely high levels of exposure to indirect violence: 41.7% witnessed shooting/stabbing/beating; 18.3% witnessed murder; and 53.8% experienced the murder of someone close. Frequency of adverse MH outcomes was high: 21.2% screened positive for depression; 45.7% for lifetime PTSD; and 26.9% for current PTSD. More males than females reported witnessing shooting/stabbing/beating (
Large proportions of children in the United States (US) are subject to violence within their homes, schools, and communities [
Urban-residing African-American youth in particular are at very high risk of exposure to violence. In a study of African American adolescents from economically disadvantaged communities, 95% of youth endorsed exposures to more than one violent event, 30% reported hearing gunshots in the community, 65% had seen someone being threatened by a weapon, and 54% reported that someone close to them was shot or attacked [
The study of indirect violence exposures among youth–as distinct from all types of violence exposures—is important for a number of reasons. Prior research has suggested that viewed violence is an independent risk factor for adverse psychological sequelae [
Recent reviews of published evidence have found a moderate relationship between hearing about, witnessing and victimization of community violence. In these studies authors found hearing about and witnessing violence predicted PTSD symptoms to the same extent as victimization, leading to the consideration of the theory of “collective traumatization” to interpret this finding—a feeling that violence pervades the neighborhood and no one is safe [
The association between violence exposure and depression alone (non-comorbid) is less straightforward, based on available data. Some researchers suggest that youth chronically exposed to community violence may become desensitized and suppress feelings of sadness or anxiety [
The literature points to a clear relationship between childhood exposures to violence and a variety of health and social challenges that can be predicted by these experiences throughout the life course, particularly during the childhood years [
Understanding disparities in witnessed violence and MH outcomes across key demographic correlates is essential for tailoring prevention and intervention programs aimed at specific subgroups [
A large review of data on gender differences in urban youth indicated that males were more likely than females to be victims and witnesses to violent acts [
Recent reviews of the moderating effect of gender on the relationship of violence exposure to MH symptoms decry the scarcity of studies and lack of consensus in available data [
Among a sample of predominantly African-American youth aged 7–18 years, Fitzpatrick and Boldizar [
Large national surveys have found that the frequency of witnessed community violence increases with age; family violence exposure showed no age gradient [
US studies seeking to elucidate the separate effects of SES (as distinct from race) as modifiers of the impact of violence on MH have been few and challenging due to the overrepresentation of African-American youth living in impoverished, higher-violence areas. Earlier research indicated children and adolescents of lower SES from larger urban areas are at greater risk for victimization than those with larger family incomes [
Numerous gaps remain in our understanding of the correlates of violence exposure as well as MH sequelae of these exposures on youth. Youth responses have often been provided via proxy reporting, possibly resulting in an underestimate of violence exposures [
We report on the prevalence and correlates of indirect violence exposures, and on associations between indirect violence and adverse MH symptomatology among a large, public school population of mostly African-American youth, with a focus on addressing these gaps. In particular, by restricting our attention to indirect violence, our study aimed to: (1) describe the frequency of these outcomes as distinct from direct victimization; (2) describe associations of indirect violence with symptoms of depression and PTSD; (3) explore how key demographic variables were associated with violence exposure and as possible moderators of any observed associations between indirect violence and adverse MH symptoms. We were particularly interested in the role of gender and the interplay of gender with age and SES on apparent trauma-related symptoms, given an insufficient understanding of these dynamics to date [
Believe in Youth–Louisiana (BY-LA) is a trauma-informed adolescent reproductive health intervention intended for Southeast Louisiana youth ages 11–19 years. Youth are enrolled from a variety of settings including middle and high schools, community-based organizations, after-school programs, and juvenile justice programs. BY-LA is a 12-module intervention delivered in one-hour group sessions by trained health educators. Program content is comprised of the eight modules of the evidence-based reproductive health curriculum
The 1548 BY-LA participants for this study were enrolled from a convenience/volunteer sample of 28 public charter schools and 9 community-based settings. An Emotional Wellness Screener (EWS) developed by IWES was administered during the program supported by an IWES licensed social worker (LMSW). A parent/guardian was required to indicate active consent for all youth participants prior to enrollment in the program including the EWS. Before the emotional wellness modules were implemented to students, health educators proctored the EWS, a 31-item questionnaire adapted from the Diagnostic Statistical Manual of Mental Disorders, Fourth Edition, (DSM-IV) clinical diagnostic criteria [
IWES utilizes a community-based institutional review board (IRB) registered with the Office for Human Research Protections of the U.S. Department of Health & Human Services. The BY-LA intervention, including the EWS, was reviewed and approved by the IRB in October 2015. At the time of review and approval, the IRB was comprised of professionals of varying backgrounds and expertise—sociology, social work, public health, and nursing—and also included a recent high school graduate from the community to represent the perspective of intervention participants.
Participants’ demographics were collected at the time of enrollment with the parental consent form for participation in the BY-LA program. Age, race, ethnicity, gender, grade, and enrollment site (i.e. school, community-based organization, or program) were among demographic measures collected. For this study both continuous and categorical scaling for age (age group defined as ≤14 years or >14 years) and grade (grade group defined as <9th grade or ≥9th grade) were used.
Extracts of the Emotional Wellness Screener were analyzed in this study to assess participant symptomatology for PTSD and depression as well as experiences of indirect violence exposure (
The first two sections, Items 1–17, of the Emotional Wellness Screener assess symptomatology of PTSD and depression, respectively. Items 1–8 of the EWS screen for symptoms of PTSD due to one or more unspecified traumatic events experienced at any point during the participant’s lifetime. The assessed symptoms align with the DSM-IV diagnostic criteria for PTSD—re-experiencing the trauma(s), persistent avoidance of stimuli associated with the trauma(s) and numbing of general responsiveness, and increased arousal due to the traumas. For this study, individuals answering “Yes” to experiencing four or more items for as long as one month or more after the event(s) are considered to endorse symptomology of PTSD. Item 9 assesses whether or not four or more symptoms of PTSD were experienced within the 30 days preceding the survey date. Items 10–17 of the EWS assess symptoms of depression within the 14 days preceding the survey date and follow DSM-IV scoring criteria. After summing the total number of “Yes” responses for this section, a score of five or more with one of the following patterns indicates symptomatology of depression: 1) “Yes” to Item 10 (feeling sad or blue)
Items 18–21 query participants for violence witnessed personally, including violence against a parent perpetrated by another parent or a parent’s significant other; against a sibling perpetrated by a parent; witnessing a shooting, stabbing, or beating (excluding games or other media entertainment); and murder (excluding games or other media entertainment). Item 22 assesses whether or not the participant has experienced the murder of someone close, such as a friend, neighbor, classmate, or relative.
Data from this survey were first entered into Social Solutions Efforts to Outcomes™ software, exported to Microsoft Excel, and converted to SAS® data files for analysis. All analyses were conducted using SAS® Studio of SAS® University Edition. Univariate analyses were conducted to describe the demographic characteristics of the sample as well as the prevalence of indirect violence exposures and adverse MH symptomatology. Chi-squared tests were conducted to test for gender differences across all variables of interest; differences between age groups and across levels of free/reduced lunch participation (dichotomized as <90% and ≥90%) were also explored with the same approach. We generated Cramer’s V statistics and used conventional thresholds to determine statistical significance (p< 0.05). The results of the univariate analyses were used to guide multivariate regression analyses which explored associations of indirect violence exposures with the presence of adverse MH symptomatology; assessed associations of age, gender, and FRLP with adverse MH symptomatology and indirect violence exposure, respectively; and assessed any interaction between FRLP and gender in the presence of adverse MH symptomatology. The generated odds ratios (ORs) and corresponding confidence intervals (CIs) were evaluated.
The proportion of missing data was low (< 10%) for the main variables to be analyzed. We elected to use imputation for missing data to reduce magnifying their effect in our planned analyses which involved bivariate modeling and various levels of stratification. Values for age group were imputed by reviewing the range of ages within each grade level represented among the sample and assigning the majority age group to the subjects with missing values (e.g. only one of 154 subjects in sixth grade was older than 14 years therefore sixth grade students with missing age group values were imputed as ≤14 years). Missing values for age group were not imputed for those in grade levels in which age variability was high. Fifty-nine of the 175 cases of missing age were imputed, bringing missing age data from 6.8% to 4.5%. Gender was not reported for 149 cases, 5.8% of the total sample. To impute values, two raters independently assigned gender based on participant name, and a third rater rated subjects for which there was disagreement between the first two raters. Grade level data was missing for 221 cases, 8.6% of the total sample. Discrete grade level (6 through 12) could be determined in cases in which implementation of particular cohorts was known to be conducted with a single grade level (i.e., missing values for grade were imputed based on the grade level of participants in the same cohort). Imputation reduced the proportion missing to 4.5%. Values for grade group were imputed where possible from school type attended (ie. high school vs. middle school).
As a proxy for economic disadvantage, a measure of the proportion of students eligible for free and reduced lunch (“free and reduced lunch participation” or FRLP) across schools attended by BY-LA participants was constructed using information provided by
From January 2016 to May 2017, 2572 youth were eligible to complete the EWS; 629 (24.4%) were absent on the day the survey was administered, and 395 (15% of those eligible) were not offered the survey (
DEMOGRAPHICS | ||
---|---|---|
Measure | % | |
Gender | 1547 | |
Female | 877 | 56.7 |
Male | 670 | 43.3 |
Race | 1426 | |
Black/African American | 1326 | 93.0 |
White | 44 | 3.1 |
More than one race | 38 | 2.7 |
Asian | 12 | 0.8 |
American Indian/Alaska Native | 6 | 0.4 |
Ethnicity | 903 | |
Hispanic/Latino | 830 | 91.9 |
Not Hispanic/Latino | 73 | 8.1 |
Age (years) | 1478 | |
≤14 | 1136 | 76.9 |
>14 | 342 | 23.1 |
Grade | 1533 | |
<9th | 976 | 63.7 |
≥9th | 557 | 36.3 |
% Students eligible for free/reduced lunch of attended school (Mean 88,2, SD 8.9; Range: 66.8–96.3) | 1149 | |
<90 | 792 | 68.9 |
≥90 | 357 | 31.1 |
Witnessed violence against parent | 1519 | |
Yes | 462 | 29.8 |
No | 1057 | 68.3 |
Witnessed violence against sibling | 1523 | |
Yes | 252 | 16.3 |
No | 1271 | 82.1 |
Witnessed shooting/stabbing/beating | 1531 | |
Yes | 645 | 41.7 |
No | 886 | 57.2 |
Witnessed murder | 1523 | |
Yes | 283 | 18.3 |
No | 1240 | 80.1 |
Experienced murder of someone close | 1525 | |
Yes | 832 | 53.8 |
No | 693 | 44.8 |
Positive screen for depression | 1546 | |
Yes | 328 | 21.2 |
No | 1218 | 78.7 |
Positive screening for lifetime PTSD | 1544 | |
Yes | 708 | 45.7 |
No | 836 | 54.0 |
Positive screening for current PTSD | 1544 | |
Yes | 416 | 26.9 |
No | 1128 | 72.9 |
EWS respondents reported extremely high levels of lifetime exposure to violence: 29.8% witnessed violence against a parent; 41.7% witnessed a shooting/stabbing/beating; 18.3% witnessed a murder; and 53.8% experienced the murder of someone close (
There were a number of gender differences in exposure to violence and reported MH symptomatology. More males (45.2%) than females (39.9%) reported witnessing a shooting/stabbing/beating (
Measure | Males |
Females |
Cramer’s V | |
---|---|---|---|---|
Witnessed parent get pushed, slapped, hit, punched, or beaten by another parent or parent’s partner | 191 (29.16) | 271 (31.40) | -0.0241 | 0.3471 |
Witnessed sibling get pushed, slapped, hit, punched, or beaten by parent (not including spanking) | 114 (17.19) | 138 (16.07) | 0.0151 | 0.5567 |
Witnessed shooting/stabbing/beating | 299 (45.17) | 346 (39.86) | 0.0532 | 0.0374 |
Witnessed murder | 134 (20.24) | 149 (17.33) | 0.0372 | 0.1472 |
Experienced the murder of someone close | 326 (49.77) | 506 (58.23) | -0.0841 | 0.0010 |
Positive screening for depression | 85 (12.72) | 243 (27.71) | -0.1815 | <0.0001 |
Positive screening for lifetime PTSD | 234 (34.14) | 473 (53.93) | -0.1891 | <0.0001 |
Positive screening for current PTSD | 131 (19.67) | 285 (32.50) | -0.1447 | <0.0001 |
The proportion of youth indicating any history of indirect violence exposure generally increased with age (and grade level, see
Measure | ≤14 years |
>14 years |
Cramer’s V | |
---|---|---|---|---|
Witnessed parent get pushed, slapped, hit, punched, or beaten by another parent or parent’s partner | 328 (29.42) | 117 (34.82) | -0.0494 | 0.0597 |
Witnessed sibling get pushed, slapped, hit, punched, or beaten by parent (not including spanking) | 175 (15.68) | 60 (17.70) | -0.0232 | 0.3765 |
Witnessed shooting/stabbing/beating | 449 (39.95) | 158 (46.64) | -0.0570 | 0.0291 |
Witnessed murder | 179 (16.04) | 88 (26.04) | -0.1091 | <0.0001 |
Experienced the murder of someone close | 611 (54.60) | 186 (55.03) | -0.0036 | 0.8900 |
Positive screening for depression | 231 (20.35) | 80 (23.46) | -0.0321 | 0.2172 |
Positive screening for lifetime PTSD | 534 (47.09) | 142 (41.76) | 0.0464 | 0.0839 |
Positive screening for current PTSD | 310 (27.34) | 86 (25.29) | 0.0204 | 0.4561 |
Increasing level of FRLP (categorized as ≥90% highest vs. <90% lower) of schools was associated with a consistent rise across all indirect violence exposures, as well as with adverse MH symptomatology in the frequency of youth reporting these outcomes; most of these differences were statistically significant. When stratifying by gender, it was apparent that statistically significant increases in violence exposures with increased FRLP were seen considerably more often in males than in females; but significant changes in MH symptom frequency with increased FRLP occurred more often in females than in males (
Measure | Males | Cramer’s V | Females | Cramer’s V | ||||
---|---|---|---|---|---|---|---|---|
≥90% FRLP n (%) | <90% FRLP n (%) | ≥90% FRLP n (%) | <90% FRLP n (%) | |||||
Witnessed parent get pushed, slapped, hit, punched, or beaten by another parent or parent’s partner | 103 (34.22) | 29 (17.58) | 0.1766 | 0.0001 | 154 (32.35) | 54 (30.17) | 0.0209 | 0.5924 |
Witnessed sibling get pushed, slapped, hit, punched, or beaten by parent (not including spanking) | 58 (19.27) | 19 (11.05) | 0.1071 | 0.0198 | 87 (18.24) | 25 (13.97) | 0.0506 | 0.1952 |
Witnessed shooting/stabbing/beating | 134 (44.37) | 55 (31.98) | 0.0085 | 0.0081 | 201 (41.88) | 66 (36.46) | 0.2065 | 0.2061 |
Witnessed murder | 67 (22.19) | 24 (13.95) | 0.0295 | 0.0287 | 83 (17.44) | 30 (16.57) | 0.0102 | 0.7936 |
Experienced the murder of someone close | 161 (54.21) | 69 (40.59) | 0.1311 | 0.0046 | 289 (60.21) | 92 (50.83) | 0.0846 | 0.0295 |
Positive screening for depression | 41 (13.49) | 14 (8.05) | 0.0820 | 0.0729 | 145 (29.77) | 39 (21.55) | 0.0819 | 0.0344 |
Positive screening for lifetime PTSD | 107 (35.31) | 53 (30.64) | 0.0490 | 0.2987 | 286 (58.73) | 89 (49.17) | 0.0856 | 0.0270 |
Positive screening for current PTSD | 59 (19.47) | 29 (16.76) | 0.0345 | 0.4640 | 60 (33.15) | 169 (34.70) | 0.0145 | 0.7070 |
In stratified analyses by age category (≤14 years vs. >14 years), additional gender differences emerged; moving from younger to older ages, more boys than girls witnessed a shooting/stabbing/beating (
Measure | ≤14 years | Cramer’s V | >14 years | Cramer’s V | ||||
---|---|---|---|---|---|---|---|---|
Males n (%) | Females n (%) | Males n (%) | Females n (%) | |||||
Witnessed parent get pushed, slapped, hit, punched, or beaten by another parent or parent’s partner | 131 (28.67) | 197 (29.98) | -0.0142 | 0.6346 | 54 (33.33) | 63 (36.21) | -0.0301 | 0.5806 |
Witnessed sibling get pushed, slapped, hit, punched, or beaten by parent (not including spanking) | 75 (16.30) | 100 (15.27) | 0.0140 | 0.6393 | 29 (17.47) | 31 (17.92) | -0.0059 | 0.9137 |
Witnessed shooting/stabbing/beating | 194 (42.08) | 255 (38.52) | 0.0358 | 0.2305 | 86 (52.12) | 72 (41.38) | 0.1076 | 0.0475 |
Witnessed murder | 76 (16.49) | 103 (15.75) | 0.0099 | 0.7414 | 52 (31.71) | 36 (20.69) | 0.1255 | 0.0211 |
Experienced the murder of someone close | 224 (49.23) | 387 (58.37) | -0.0902 | 0.0026 | 85 (51.83) | 101 (58.05) | -0.0625 | 0.2509 |
Positive screening for depression | 49 (10.54) | 182 (27.20) | -0.1761 | <0.0001 | 30 (18.07) | 50 (28.57) | -0.1154 | 0.0222 |
Positive screening for lifetime PTSD | 165 (35.56) | 368 (55.01) | -0.1932 | <0.0001 | 55 (33.33) | 87 (49.71) | -0.1702 | 0.0022 |
Positive screening for current PTSD | 90 (19.40) | 220 (32.88) | -0.1498 | <0.0001 | 33 (20.00) | 53 (30.29) | -0.1213 | 0.0292 |
When restricting attention to middle school aged youth (11–14 years), in continuous analyses of yearly age, endorsement of PTSD (lifetime and/or current) symptoms among boys exhibited a marked linear decline with increasing age, compared with a much slower decline among girls. At age 11 years, for example, 43.5% of boys and 36.8% of girls endorsed PTSD symptoms (without depression); by age 14 years, the ratio reversed to 18.9% and 28.9%, respectively. Data on depression only were too sparse for meaningful gender comparisons. At age 11 years, high proportions—56.5% of boys and 54.4% of girls—endorsed depression and/or PTSD symptomatology; by age 14 years, the striking and conventional gender-based imbalance had emerged, with these proportions at 25.7% and 64.9%, respectively (
The number of distinct types of indirect violence exposures was directly proportional to the percentage of youth endorsing symptoms of any MH outcome; percentages ranged from 44.0%-100% in girls and 21.5%-62.5% in boys for 0 to 5 distinct exposures (
Measure | Positive symptomatology for depression and/or PTSD | |
---|---|---|
Males |
Females |
|
Sum of reported indirect violence exposure types | ||
0 | 29 (21.48) | 62 (43.97) |
1 | 34 (28.10) | 100 (51.55) |
2 | 41 (48.81) | 93 (64.58) |
3 | 36 (52.17) | 70 (72.16) |
4 | 19 (54.29) | 45 (86.54) |
5 | 5 (62.50) | 10 (100.00) |
We compared two distinct sets of indirect violence exposures as independent variables: “community violence” (comprising ever witnessing shooting/stabbing/beating or murder, not specified as parent or sibling) and “family violence” (comprising ever witnessing a sibling or a parent get pushed, slapped, hit, punched, or beaten). Family violence demonstrated moderately strong and significant associations with endorsed symptoms of any MH outcome (OR = 2.6;
Multivariable regression analyses of exposure to violence (any/none) revealed significant associations with gender and FRLP. Females had 1.4 times the odds of indirect violence exposure as males. Students at schools with higher FRLP (≥90%) had 1.8 times the odds of indirect violence exposure compared with students at schools with lower FRLP (
Characteristic (referent) | OR (95% CI) |
---|---|
Age (standardized) | 1.28 (1.02–1.61) |
Gender (Male) | |
Female | 1.43 (1.08–1.90) |
Free/Reduced Lunch Participation (<90%) | |
≥90% | 1.86 (1.40–2.48) |
When analyzing results for our combined MH variable, any MH outcome, we found significant associations for female gender (aOR = 2.60), FRLP (aOR = 1.35), and number of different indirect violence exposure types (aORs from 1.34 to 10.43; p for trend < 0.0001;
Characteristic (referent) | Positive symptomatology for depression and/or PTSD |
---|---|
OR (95% CI) | |
Gender (Male) | |
Female | 2.60 (2.00–3.83) |
Age (≤14) | |
>14 | 0.93 (0.67–1.31) |
Free/Reduced lunch participation of attended school (<90%) | |
≥90% | 1.35 (1.03–1.79) |
Sum of reported indirect violence exposure types (0) | |
1 | 1.34 (0.95–1.90) |
2 | 2.62 (1.80–3.82) |
3 | 3.45 (2.27–5.24) |
4 | 5.46 (3.14–9.50) |
5 | 10.43 (2.86–38.03) |
Characteristic (referent) | Males | Females |
---|---|---|
Positive screening for depression and/or PTSD |
Positive screening for depression and/or PTSD |
|
OR (95% CI) | OR (95% CI) | |
Age (≤14) | ||
>14 | 0.93 (0.55–1.57) | 0.99 (0.64–1.55) |
Free/Reduced lunch participation of attended school (<90%) | ||
≥90% | 1.11 (0.72–1.70) | 1.63 (1.13–2.35) |
Sum of reported indirect violence exposure types (0) | ||
1 | 1.40 (0.79–2.50) | 1.32 (0.85–2.05) |
2 | 3.42 (1.88–6.21) | 2.21 (1.37–3.58) |
3 | 3.91 (2.08–7.38) | 3.18 (1.82–5.56) |
4+ | 4.52 (2.15–9.51) | 9.91 (4.42–23.36) |
Results for the two regression analyses remained significant after applying a Bonferroni correction for multiple tests [
Data gathered in the Emotional Wellness Screener, administered to a sample of 6th to 12th grade students enrolled in New Orleans public schools, demonstrated extremely high levels of indirect violence that agreed with findings from other urban samples of youth [
We uncovered clear associations of both gender and economic hardship with violence exposure as well as with MH symptoms; additionally, gender worked as a seeming moderator of the association between economic hardship and MH symptoms. Prior reviews of the relationship of violence with adolescent MH [
In our data, gender was associated with different types of violent exposures—in particular, girls’ “vicarious exposure” (i.e., knowing someone who was murdered) was considerably higher than that of boys, across both age and school-based SES categories. In univariate analyses, boys more frequently witnessed shootings, stabbings and beatings, and, to a lesser extent, murders, with considerable variation by school-based SES. The findings support a generally held view that boys experience the worst/most severe direct witnessing of violence [
We also found that the progression of MH symptoms over the middle school years worked differently for boys and girls. Endorsement of any measured MH symptoms demonstrated opposite trends for boys and girls; symptom reporting in boys decreased markedly over age 11–14 years, by more than half; girls’ endorsed symptoms over these same ages rose by more than 10 percentage points. The results for PTSD-only seem to substantiate the idea of desensitization over adolescence, proposed by several prior reports [
Finally, the data suggest a remarkably consistent association of our socio-economic status indicator with indirect violence exposure and with depressive and PTSD-associated symptoms, even among this sample of youth all of whom were attending New Orleans public schools. Indeed, the free/reduced school lunch variable was the single variable associated with uniform increases across all types of indirect violence exposure and all types of adverse MH symptomatology—in contradistinction to our other main covariates, age and gender, which showed heterogeneous effects across these outcomes. These findings agree with some prior studies, most notably with a longitudinal study on 5th graders indicating that children from lower income families witnessed more school and community violence [
Too, our analyses suggested important interactions of gender with age and socioeconomic disparity that require future study and elaboration. Specifically, although increased levels of our school-based economic hardship indicator were associated in adjusted analyses with greater likelihood of any MH symptom reporting overall, upon gender stratification, this effect appeared to be most pronounced among girls; economic hardship did not significantly affect the odds of adverse MH symptom reporting in boys. These results are not easily understood and there are few corresponding analyses of these variables in existing research. A recent review by Richards et al. [
Our study had numerous limitations. The data were cross sectional, thus limiting causal inferences between violence exposure and MH symptoms. Much existing literature on these associations is also based on cross sectional data; nevertheless, there is considerable agreement with results of available longitudinal studies. Because we did not systematically survey all age eligible students, our sample may not be representative of all students in the target population; participating students may have been different in key variables measured as compared to those not surveyed. Witnessed violence and symptom reporting prevalence estimates for the sample as a whole (i.e. external validity) would have been the most vulnerable to such a bias, with the internal comparisons across covariates to be less at risk of distortion. Our sample had slightly greater female participation (56%) in comparing the overall New Orleans public school population (51% female), as well as a somewhat higher FRLP (weighted average FRLP, 88.7%) than the New Orleans schools’ overall average (84%). Our sample included proportionately greater numbers of African-American youth (93% vs. 81%, New Orleans overall), fewer whites (3.1% vs. 9%), and a comparable proportion of Hispanics (8.1% vs. 7%). If our results overestimate the overall prevalence of the main outcomes, the magnitude of the bias is small, and does not change our main conclusion that these youth experience alarming levels of witnessed violence and serious MH symptoms. Finally, our violence prevalence estimates largely agree with those from other similar samples [
Our study included relatively few demographic/predictor variables to work with and we did not measure other potentially moderating exposures, such as victimization or exposure to other types of violence that might have an association with the outcome variables we measured and thus impact the results and conclusions. Substantial proportions of youth, especially girls, reported adverse symptoms even in the absence of any indirect violence, likely indicating other exposures that were not captured in this study. We could not distinguish between certain grouped variables (e.g. stabbings and shootings), and we did not have precise data on the site where exposure occurred (e.g. school vs. community). Some prior work [
Our study also has numerous strengths, as noted throughout. Our large sample of non–referred, public school students provides the basis for community and school-based intervention efforts that would have a large impact. Violence exposures and MH symptoms were self-reported, reducing error and bias compared with proxy reporting. Our MH symptom measures were validated and piloted. We included key covariates—including a (school-based) SES variable, still infrequent in existing research—and our large sample allowed for finer analyses to more fully explore gender, SES, and moderation effects. We included two types of indirect exposure: witnessing and vicarious, generating certain rich gender specific findings for further elaboration. Finally, we analyzed both student age and school grade, and validated similar findings across the two variables, thus providing substantial confidence in the results presented.
Our results elaborate on prior research in important ways. Adverse MH symptom prevalence in our population of youth increased proportionately with frequency of different exposures to violence; adjusted analyses confirmed an association with these symptoms. There is no current consensus on the relative importance of frequency or intensity of violence exposure in MH consequences [
These data contribute important evidence of the urgent need for trauma informed school-based and other community-based awareness, training, intervention, and policy initiatives that recognize the high level of indirect violence exposures of students and development of associated adverse serious MH symptoms [
These findings have implications for research and practice. As a matter of practice, young people should be screened for pre-existing trauma exposure and associated symptoms before receiving a mental health diagnosis. Trauma science now shows that trauma-based conditions are disorders of affect or ‘emotion’ (anxiety, irritability, depression) and regulation. Youth of the age in our sample are often subject to harsh school disciplinary practices if they display behavioral regulation challenges in the classroom. ‘Dysregulated’ students (a common diagnosis is, for example, Attention Deficit Hyperactivity Disorder, or ADHD) are typically treated with cognitive behavioral therapy and/or medications, rather than trauma-focused treatment activities. As more schools and youth-serving institutions aspire to be trauma-informed and trauma-responsive, interventions must address the needs of youth who display both internalizing and externalizing behaviors, and who have experiences of acute and chronic exposures to traumatic events. Young people with chronic stressors such as poverty, discrimination and ongoing exposures to violence should have access to a variety of treatment activities and be a part of longitudinal studies. In communities where lower SES is associated with increased exposures to indirect violence and all types of adverse MH symptomatology, effective interventions must go beyond individualized treatment and take more collective and small group approaches to trauma response.
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The authors are grateful to Christina Ventura-DiPersia, MPH for her assistance with statistical issues and in manuscript formatting.