Workshop on\
Children Exposed to Violence:\
Current Status, Gaps, and Research Priorities

Washington, D.C.

July 24-26, 2002

Workshop sponsors:

National Institute of Child Health and Human Development (NICHD)

National Institute on Drug Abuse (NIDA)

National Institute of Mental Health (NIMH)

Fogarty International Center (FIC)

Office of Behavioral and Social Sciences Research (OBSSR)

Office of the Assistant Secretary for Planning and Evaluation (ASPE)

Centers for Disease Control and Prevention (CDC)

Substance Abuse and Mental Health Services Administration (SAMHSA)

*Department of Health and Human Services (DHHS)*

National Institute of Justice (NIJ)

*Department of Justice*

Office of Special Education Programs (OSEP)

*Department of Education*

Workshop Summary

Prepared by:

Analytical Sciences, Inc.

Table of Contents

[I. Introduction 1](#__RefHeading___Toc18291227)

[II. Setting the Context: Definitional and Measurement Issues
2](#__RefHeading___Toc18291228)

[III. Domestic Violence 6](#__RefHeading___Toc18291229)

[IV. Community and School Violence 11](#__RefHeading___Toc18291230)

[V. Terrorism and War 16](#__RefHeading___Toc18291231)

[VI. Services and Interventions for Children Exposed to Violence
21](#__RefHeading___Toc18291232)

[VII. Legal and Policy Issues 27](#__RefHeading___Toc18291233)

[VIII. Summary and Next Steps 30](#__RefHeading___Toc18291234)

[IX. References 30](#__RefHeading___Toc18291235)

APPENDICES

[Appendix A. Domestic Violence 32](#__RefHeading___Toc18291834)

[Appendix B. Community and School Violence.
37](#__RefHeading___Toc18291835)

[Appendix C. Terrorism/War 39](#__RefHeading___Toc18291836)

[Appendix D. Services and Interventions/Legal and Policy Issues
44](#__RefHeading___Toc18291837)

[Appendix E. Final Agenda 46](#__RefHeading___Toc18291838)

[Appendix F. Biographical Sketches of Presenters
53](#__RefHeading___Toc18291839)

[Appendix G. Workshop Participants 63](#__RefHeading___Toc18291840)

Children Exposed to Violence:

Current Status, Gaps, and Research Priorities

Washington, D.C.

July 24--26, 2002

[]{#__RefHeading___Toc18291227 .anchor}I. Introduction

This workshop brought together researchers, practitioners, and
policymakers to provide perspectives on the current state of knowledge
regarding children exposed to violence, and to identify research gaps
and promising avenues for future research. Three main areas of violence
were addressed:

1.  Children exposed to domestic violence;

2.  Children exposed to community violence, including school violence;
    and

3.  Children exposed to war and terrorism.

There were also additional, overarching presentations addressing
definitional and measurement issues, services and interventions, as well
as legal and policy issues.

The workshop was jointly sponsored by the National Institute of Child
Health and Human Development (NICHD), the National Institute on Drug
Abuse (NIDA), the National Institute of Mental Health (NIMH), the
Fogarty International Center (FIC), and the Office of Behavioral and
Social Sciences Research (OBSSR) at the National Institutes of Health
(NIH); the Office of the Assistant Secretary for Planning and Evaluation
(ASPE); the Centers for Disease Control and Prevention (CDC) and the
Substance Abuse and Mental Health Services Administration (SAMHSA) in
the Department of Health and Human Services (DHHS); the National
Institute of Justice (NIJ) in the Department of Justice; and the Office
of Special Education Programs (OSEP) in the Department of Education. The
involvement and commitment of such a multitude and diversity of Federal
agencies attests to the rising public interest in children exposed to
violence. In her opening remarks, Dr. Margaret Feerick described the
pivotal influence of September 11 on the workshop agenda, transforming
the initial focus on children exposed to domestic and community violence
to a broader focus encompassing the effects on children of exposure to
war and terrorism. While the many components of NIH have supported some
research in this area, there is a need for more targeted attention on
the topic, particularly with regard to measurement, sampling, and
intervention/services.

The workshop planners were most interested in obtaining focused
recommendations to guide the development of a national research agenda.
The first part of the workshop consisted of formal sessions that
attempted to document what is known for each of the three main topic
areas in terms of prevalence, consequences, protective factors,
mediators/moderators, and social and cultural factors, and the current
state of definitions and measurement, services, and interventions. Each
session was followed by a discussion period that allowed participants to
ask questions and exchange ideas. The second part of the workshop
consisted of four breakout groups that sought to identify critical
research gaps and future research directions in their respective topic
areas: Domestic violence; community and school violence; terrorism/war;
and services and interventions/policy issues. The closing session was
devoted to key research needs and next steps in building a research
agenda.

[]{#__RefHeading___Toc18291228 .anchor}II. Setting the Context:
Definitional and Measurement Issues

*Moderator: Ileana Arias, Centers for Disease Control and Prevention*

A. Defining and Conceptualizing Children's Exposure to Violence

*Penelope K. Trickett, Ph.D., University of Southern California*

Drawing upon 20 years of experience examining definitional issues in the
field of child abuse and neglect research, Dr. Trickett summarized the
critical issues for studying children exposed to violence. First, better
definitions are needed to facilitate communication in this complex
research area. At the same time, better definitions will enable
scientific progress through better understanding of the independent
variables, as well as the components of treatment that "make the
difference." It is also important to sort out the contextual factors
that may affect children such as poverty, the family environment,
neighborhood violence, and whether these children experience other forms
of victimization. Children in child abuse and neglect studies frequently
experience more than one form of abuse, with 90 percent of the subjects
in one study experiencing more than one form of abuse and neglect
(McGee, et al. 1995). In addition, community violence may affect rates
of child abuse since violent neighborhoods tend to have higher rates of
physical child abuse. These factors should be considered when conducting
a study.

Dr. Trickett presented data on the characteristics of sexual abuse
trauma and their impact on girls' development to demonstrate the use of
a conceptual model for understanding the possible independent variables.
For the sample of victims studied, a number of factors must be
considered as independent variables, including severity of abuse, age of
onset, duration, relationship to perpetrator, and whether there were
multiple perpetrators. These factors are interrelated and can make a
"difference" in how one child reacts to abuse compared to another. Data
on the onset and duration of abuse for different perpetrator categories
also illustrate the variability of experiences of abuse that must be
considered.

There is also a need to better assess the reliability and validity of
reporters. In comparing the reliability of parents and children as
reporters of abuse, children are more consistent. Studies on domestic
violence have shown a lack of concurrence between parents and children
about the child's exposure to violence, often because the parent is
involved in the violence and may underreport it. Therefore, it is
important to consider other sources of information such as police
records or neighbors. Finally, researchers need to look at children's
exposure to violence from a multidimensional perspective that considers
variables such as the severity of violence (e.g., watching a drug deal
versus watching a neighbor get shot and killed), its dangerousness and
proximity, the frequency, duration, and timing of the violence, the
relationship of the child to the perpetrator or victim, and the context
in which the violence occurs.

B. Differentiating Exposure to Violence and Child Abuse

*George W. Holden, Ph.D., University of Texas at Austin*

Despite the increasing frequency of publications on children exposed to
violence, the literature suffers from a lack of common terminology and
definitions. For example, when researchers talk about children exposed
to domestic violence, many studies have lumped together children across
too large an age range, which may obfuscate some of the effects. There
have also been inconsistencies in defining the term "domestic violence,"
which has been used interchangeably with such terms as "partner
violence," "marital violence," and "interpersonal violence." The problem
is in adequately conceptualizing the violence in terms of type of
violence (physical, psychological), specific acts, severity, type of
perpetrator, frequency and timing. Another issue is how to best assess
how a child exposed to violence perceives it. Current definitions of
violence are mostly centered on adult perceptions. Another issue that
has not been examined is how the perpetrator's resolution to the
violence (i.e., whether they accept blame or deny it) impacts the
child's reaction to the violence.

Defining children's *exposure* to domestic violence is also problematic.
There are many types of exposure that have not been systematically
examined, including the child as an eyewitness, the child who has been
coerced to be involved in the violence, the child who overhears the
violence, or the child who hears about it from someone else. A child may
experience one or more of these types of exposure for each violent
incident, but researchers may not differentiate between these
distinctions and probe deeper to find out how they might affect child
outcomes. One also needs to recognize key timing variables, such as the
child's age when exposure began, the frequency with which it occurs, and
the child's age when it last occurred. A small number of studies have
asked about mothers' perceptions about their children's awareness of
violence, with a wide range of awareness reported. However, this
valuable information has been used only for descriptive purposes and not
as a covariate. It is possible that the mother's reports are not
accurate. Therefore, a fundamental problem is that the independent
variable we are studying---exposure to domestic violence---is a complex
set of experiences that have not been adequately assessed. Creating neat
factorial groups of children who share the same quantity and type of
exposure is difficult, if not impossible.

While not all exposures lead to negative outcomes, children's exposure
to violence has been associated with a range of behavior problems. Even
though it is currently not included as a form of child maltreatment, Dr.
Holden provided two reasons why one might categorize exposure to
domestic violence as abuse: (1) Children exposed to domestic violence
are psychologically abused by living in that situation; and (2) Children
exposed to domestic violence are often physically or sexually abused
themselves, indicating a pattern of co-occurring abuse. Exposure to a
parent being verbally or physically assaulted is physiologically
arousing, emotionally distressing, and often trauma-inducing. Children
exposed to domestic violence may also experience other types of
psychological maltreatment such as rejection, isolation, lack of
emotional responsiveness from the caregiver, and neglect. In a
literature review of over 30 studies, Dr. Holden reported that the
co-occurrence of domestic violence and child abuse/neglect in a majority
of studies ranged from 30 to 60 percent of families (Appel and Holden,
1998; Edleson, 1999). In addition to co-occurring violence, these
children may also face other serious adversities, including community
violence, substance abuse, nutritional neglect, high stress levels, and
mental health problems in parents.

How do we disentangle the problem of co-occurring violence? First, we
need to comprehensively assess the characteristics of domestic violence,
children's exposure to it, and comorbidity. Given the difficulty in
collecting data from these complex samples, it is important to seek out
data from multiple locations and sources, including fathers, and then
pool those data. Second, instead of searching for pure cases of children
exposed to violence, which is unrealistic, researchers need to use
statistical strategies to understand how differing experiences are
impacting children. Finally, there should be more focus on family
dynamics, the context, and the mechanisms, not simply correlations and
associations.

C. Measuring Violence Exposure

*Lewis Leavitt, M.D., University of Wisconsin*

Since multiple perspectives are often involved in defining violence, Dr.
Leavitt emphasized that the research community needs to find a
reasonably small number of variables that explain *a lot* of the
variance. It is also important to *talk to children* and to find the
best ways to interact with them. Children may be the best informants
regarding their own experiences and parents may be unaware of children's
exposure to violence. Parents may not be motivated to report their
children's experiences accurately and may also have different ideas
compared to their children about what constitutes violence.

When developing scales to measure children's exposure to violence,
researchers should have a conceptual model in mind. The research
community needs to address the type of exposure in context, in terms of
community, home, school, or media, and then choose instruments that can
best measure this. Within that framework, it is essential to look at the
proximity of the violence, its intensity and frequency, and the
relationship between the perpetrator and victim. Generally, exposure to
violence is measured in yearly or lifetime increments. For instance,
most questionnaires look at a child's yearly exposure to violence but it
is important to look at exposure to violence in context: 2 years to a
5-year old is different from 2 years to a 16-year old in terms of
lifetime exposure. Tools such as interviews or questionnaires to measure
exposure should be developmentally sensitive, and take into account the
child's cognitive, memory, and reading levels. Researchers should also
consider the reliability (test-retest) and validity of the survey
instruments, develop consistent questions, and validate the child's
responses from other sources.

In terms of surveys, there is a need for a national snapshot of
children's exposure to violence, and for researchers to replicate
previous surveys for reliability and validity. While studies of
children's exposure to violence have become more prevalent in the last 5
years, a great deal of research is needed on younger children, who can
not read and express themselves as easily as older children. Dr. Leavitt
discussed his work with the use of cartoon questionnaires as an
effective tool for interacting with young children in a developmentally
appropriate way. It is also important to measure peer victimization (or
"bullying") since children have reported that they see this as a real
danger in their lives. Finally, researchers must recognize that
institutional review board (IRB) approval and education as well as
informed consent for parents and children are critical to the success of
these studies.

D. Responses

*Barbara L. Bonner, Ph.D., University of Oklahoma*

Dr. Bonner's perspective of children exposed to violence stems from her
experience working with children after the Oklahoma City bombing,
victims of terrorism and natural disasters, and adolescent sex offenders
who had prolonged exposure to domestic violence. She stated that in
1962, a seminal article emerged on child maltreatment (Kempe et al.,
1962), and yet in 2002 we still do not have a standard set of
definitions. Definitions, however, "drive the field" and enable
researchers to conceptualize the problem, as well as incidence,
prevalence, and prevention strategies. Meanwhile, researchers have
jumped ahead with treatment interventions without the benefit of
adequate definitions.

It is also important to accurately understand the complexity of the
child's experience, the child's perceptions and attributions, and those
factors that foster resilience. In terms of children exposed to domestic
violence, researchers need to employ standard definitions in order to
know what it means to be exposed and how children define the
perpetrator. For instance, what does "father figure" mean? It could be
the biological father or a man who has lived in the home for 3 years.
Echoing previous speakers, Dr. Bonner agreed that it is necessary to
focus on a small number of variables and to work from a conceptual
model. There is also a need to develop treatment protocols that can be
replicated and to assess the efficacy and impact of different
interventions. Child protective service agencies should also be included
as a key component of intervention research studies.

*Lourdes Oriana Linares, Ph.D., New York University*

Dr. Linares emphasized that researchers must be precise in identifying
and defining independent variables but at the same time, must think
broadly because of the overlap in categories of violence. She encouraged
the cross-fertilization of ideas among researchers, particularly with
respect to child maltreatment research informing community violence
studies. There is also a need to better define "community" and the
perpetrator for community studies. In one study in Boston, residents
defined community differently from the researchers, and some did not
know what the neighborhood boundaries were. In community violence, it is
difficult to define the perpetrator. The majority of perpetrators of
community violence are not always strangers so a broad range of
witnesses and social networks must be examined. In summary, standard
measurements are critical for community violence studies, especially
since many investigators tend to develop their own scales.

E. Discussion

There was a great deal of discussion on the issue of whether all
children show harm from physical or sexual abuse. Dr. Holden noted that
the issue of harm refers to a legal issue, but we must be careful not to
make blanket statements about the harmful effects of domestic violence
on children, particularly if it occurs outside the home or if the child
is not aware of it. Many participants felt that the focus should be on
the act of violence rather than the consequences since research shows
these acts overwhelmingly affect children. Others contended that it was
important to focus on effects. For instance, Dr. Fantuzzo pointed out
that having a resilient child subjected to violence does not nullify the
act and the impact of the act on the child. Others noted that there are
also delayed effects that are not immediately observable. For instance,
sexual abuse as a child might affect adult sexual life. The effects of
domestic abuse may also be indirect, for example, affecting a parent's
ability to positively care for the child. Dr. Trickett emphasized that
having a specific focus is important. In other words, one should not be
focused on whether exposure to violence affects children, but rather,
what types of violence affect what kind of children in what manner?
Better definitions will allow the field to examine these subtle effects.

There was also significant discussion on the question of whether
exposure to violence is a form of child maltreatment. Some contended
that not all child maltreatment rises to the level of needing
protection, while others suggested that we must consider the child's
subjective assessment, particularly over the long term. One participant
noted that we must also consider how parents explain the abuse to
children and how it subsequently affects them.

Other questions were raised about the utility of current measures. One
participant pointed out that most studies are done with children who
receive services after a violent act, yet the majority of parents and
children experiencing violence do not receive services. Thus, we have
only a very narrow basic understanding of child witnesses to violence,
and this understanding does not adequately capture what is actually
happening. Referring back to his presentation on measurement, Dr.
Leavitt noted that while there are many problems with current
instruments and their ability to measure the variables of interest, we
should not be paralyzed by this fact. Regardless of the form of violence
we are studying, it needs to be looked at in context so that researchers
can identify the "sentinel act" that makes the difference.

F. Definitional and Measurement Issues: Summary of Recommendations

The lack of common terminology, definitions, and conceptual models has
been a major stumbling block to scientific progress in the area of
children's exposure to violence. It is important to sort out the
contextual factors that may affect children such as poverty, the family
environment, neighborhood violence, and whether these children
experience other forms of victimization. It is essential to examine the
proximity of the violence, its intensity and frequency, and the
relationship between perpetrator and victim.

Another issue that deserves examination is how the perpetrator's
resolution to the violence (i.e., whether they accept blame or deny it)
impacts the child's reaction to the violence. Disentangling the problem
of co-occurring violence requires that we comprehensively assess the
characteristics of violence, children's exposure to it, and comorbidity.

There is a need to better assess the reliability and validity of
reporters of violence and abuse, and incorporate information from
disinterested informants in addition to the child or parent. When
children are questioned, the instruments used to measure exposure to
violence should be developmentally sensitive, and take into account the
child's cognitive ability, memory, and reading level. There is a
particular dearth of information about younger children.

It is important to utilize data from multiple sources, including
fathers, and consider pooling of data to increase sample size or
coverage. In terms of surveys, there is a need for a national snapshot
of children's exposure to violence, and for researchers to replicate
previous surveys for reliability and validity.

[]{#__RefHeading___Toc18291229 .anchor}III. Domestic Violence

*Moderator: Susan Solomon, Office of Behavioral and Social Sciences
Research, NIH*

A. Prevalence

*John Fantuzzo, Ph.D., University of Pennsylvania*

Dr. Fantuzzo discussed research on the prevalence of children exposed to
domestic violence, opening his presentation with the following question:
"We see through the glass dimly and is the glass half empty or half
full?" In doing so, he was referring to the substantial amount of
information lacking in the field, particularly regarding violence
prevention and intervention. He cautioned, however, that we should not
try to obtain data too quickly, explaining that this can lead to
tensions among researchers, advocates, and practitioners, and ultimately
leave the field with no standard definitions, no systematic way of
substantiating violence or exposure, no organized network of sentinels,
and no national prevalence data.

Despite the challenges of conducting population-based inquiry, several
national reports and databases are attempting to address the data
inadequacy problem. These resources include National Crime Reports
(uniform crime reports and national incidents-based reporting system),
population-based surveys (e.g., National Family Violence Survey and
National Crime Victimization Survey, both telephone based), and
secondary analyses of cross-city experiments. Each of these sources has
their strengths and weaknesses, and point to areas where there is room
for improvement. For instance, police departments nationally use the
uniform crime reports on investigated and substantiated crime. However,
there is no standard code for domestic violence and no information on
the persons exposed to the violent incident. The Spouse Abuse
Replication Project, a data collection partnership between police and
researchers, reported important information about children in the
domestic violence setting and associated risk factors. Unfortunately, it
was not a national study and was limited to misdemeanor assaults. In
addition, there were missing data on child characteristics and no
details confirming the types of sensory exposure to the violence.
Considering the limitations of past surveys, direct investigation offers
the best hope for defining and substantiating children's exposure to
domestic violence and assessing risks and impacts over time. However, it
must begin with standard definitions and data collection, and then
assess additional risks and history, short and long-term impacts, and
connections to services and follow-up. Population-based surveillance
systems that have standard protocols and take a developmental and
cultural approach are critical. Future research directions should
involve building a rigorous scientific capacity in partnership with
strategic sentinels across municipalities. Researchers cannot adequately
assess the impact of violence, obtain quality information, or develop
research-based interventions without building capacity through
partnerships.

B. Consequences

*David Wolfe, Ph.D., The University of Western Ontario*

Dr. Wolfe began his discussion on the consequences of domestic violence
by discussing the "children's paradox." Children are often torn between
a sense of loyalty to their parents and a sense of fear and apprehension
in the face of domestic violence. They want to stop the violence but
they also want to belong to a family; affection and attention may
coexist with violence and abuse. Ironically, children often perceive
abuse as a short-term act but the intensity of violence tends to
increase over time.

There are a number of consequences for children exposed to domestic
violence. Unfortunately, most of what is known comes from children in
shelters, thus limiting our ability to generalize. Reactions to domestic
violence vary and change over the developmental life course. For
instance, infants and toddlers may experience listlessness, failure to
thrive, and problems with trust while preschool children may react
through behaviors such as aggression, cruelty to animals, or clinging.
For elementary school-aged children, it is a critical time for learning
how to relate to women. Thus, witnessing abuse during this time can
foster disrespect for females and reinforce sex role stereotypes.
Experiencing domestic violence in adolescence may not only influence
school achievement and self-esteem, but also provide the example for
dating violence.

The effect of domestic violence on children can differ by gender. A
man's history of violence is a more powerful predictor of a violent
relationship than is a woman's childhood history of witnessing violence.
Girls appear to be more able to avoid the domestic violence experienced
by their mothers, but if they do end up in such a relationship, they are
more likely to tolerate it. Factors contributing to resilience include a
strong relationship with a positive, caring adult, community safe
havens, and certain characteristics of the child including intelligence,
self-esteem, and access to resources.

C. Responses

*Laura McCloskey, Ph.D., Harvard University*

Dr. McCloskey commended Dr. Fantuzzo's five-city study for its
usefulness in understanding epidemiological problems that need to be
investigated further and for setting future priorities. She then
discussed a number of research gaps, noting that not enough research has
focused on preschool children. Despite the challenges of working with
this age group, this is an important area to develop. Referring to the
work of her colleagues, Dr. McCloskey also talked about the impact of
domestic violence on mothers. Many studies have shown that abuse over
time causes maternal depression leading to child and parenting problems.
In addition, if the perpetrator is the father, and he is chronically
violent, children miss out on child support and paternal investment.
Thus, it is important to assess the long-term economic and psychological
impact on the father-child relationship and the child's perception of
the father.

Conceptual models appropriate for different development stages are also
needed. Children under 5 require particular attention and we need to
know more about emotional regulation at this stage. Children who have
been exposed to domestic violence may undergo extreme stress that can
have potentially serious impacts on brain development. In one study
where women were asked about their long-term history of having violent
partners, it was possible to identify periods in the child's life when
they were exposed to domestic violence. Researchers found that children
exposed to violence before age six were more aggressive than those
exposed in middle childhood. This suggests that there is a critical
period in terms of developmental psychopathology. Clinical symptoms in
middle childhood could serve as potential entry points for adolescent
and young adult risk for domestic violence, beginning a potential "cycle
of violence."

In adolescence, behaviors such as peer aggression and dating violence
may surface in response to violence. This is another critical time to
intervene, considering that aggressive behavior can deteriorate into
long-term intimate partner violence in adults. Referring to Dr. Wolfe's
presentation, Dr. McCloskey agreed that domestic violence affects boys
and girls differently. Boys tend to exhibit aggression while girls tend
to respond more with psychopathology and depression. If girls respond
with low self-esteem and depression, which many do in childhood, they
are more likely to enter abusive relationships. Girls have more
opportunities to enter more serious, sexually intense relationships with
older men. Finally, Dr. McCloskey pointed out that there is an inequity
in access to services for troubled boys and girls that must be
addressed.

*Jacquelyn Campbell, Ph.D., R.N., Johns Hopkins University*

Dr. Campbell began her presentation by noting that little attention has
been given to the physical effects of children exposed to intimate
partner violence. There have been some hints in previous clinical
studies that show exacerbation of asthma, eating disorders, and other
stress-related problems (Kerouac et al., 1986). There have been a few
studies on the long-term adult effects of witnessing violence and child
physical and sexual abuse on physical health, including mortality as
well as morbidity (Felitti et al. 1998; McCauley et al.1997; and Feerick
and Haguaard 2002). However, in general, there has been limited research
on the physical health effects of domestic violence, such as immune
system effects, stress, and depression. For instance, are colds and flu
in children in shelters due to immune system suppression? Do sleep
disorders in children result from being kept awake by fighting or
waiting for fighting?

There are other consequences of intimate partner violence that merit
further research. There is little information on how children respond to
the severest forms of violence such as homicide and suicide. We also
need to know about the physiological effects of abuse during pregnancy,
as well as how domestic violence affects parenting behavior. Another
important question to address is how intimate partner violence affects
family coping styles and seeking of mental health resources. In terms of
policies, we need to determine what are the unintended consequences of
legally defining exposure to violence as child abuse and how that
ultimately affects the child in terms of protective services. It is also
important to consider cultural issues, such as the individual effects of
neighborhoods, ethnicity, culture, immigration status, and poverty on
exposure to violence, and to what extent witnessing violence contributes
to known health disparities.

Research in this area presents a number of challenges including
ascertaining the effects of violence on very young children, developing
measurement instruments that are ethnically and culturally appropriate,
identifying appropriate comparison groups, and separating out other
traumatic influences such as marital dissolution, community violence,
and other stressors. Suggestions for future research include adding
intimate partner violence to parent measures in existing research
programs and to other studies involving children, using school health
records as a source of data, and combining the resources of
researcher/practitioner teams.

D. Discussion

There were a number of varied comments raised in response to the
domestic violence presentations. For instance, Dr. Groves commented on
the limitations of police data, noting that in some communities people
do not see police as helpful. Dr. Fantuzzo commented that community
partnerships are important for changing how cultures view police and
pointed out that in Philadelphia, African Americans are more likely to
call 911.

Other comments focused on the need for good measures of parenting
styles, particularly in families with low incomes. Others emphasized the
need to consider the developmental perspective of children exposed to
violence. Dr. Margolin noted that children who have problems in
childhood might not have problems later, while others who are showing no
effects now may have problems later. Participants also pointed to the
need for strategies to intervene in the stress response in childhood.

Discussions during the breakout session focused on major research gaps
and what needs to be done to address them, based on what participants
believe most needs to be funded. (See Appendix A for the summary and
recommendations presented by the breakout group chairpersons). A wide
range of specific study topics formed the base of discussion.

Participants believed that the taxonomy of domestic violence experiences
should be broader and reflect a more inclusive definition of violence.
The timing and patterns of domestic violence exposure, the effects of
other forms of violence, and the effects of other forms of adversity
(e.g., poverty, parental mental illness, parental substance abuse,
displacement from home, unhealthy peer relations, natural disasters) are
components of the taxonomy.

It is crucial that all effects on children be assessed across age groups
ranging from early childhood through the teenage years. There is a basic
need to first understand children\'s perspectives, attributions, and the
meanings they ascribe to domestic violence before looking at effects or
attempting to measure outcomes. Also of importance is the need to
measure a child\'s degree of involvement in domestic violence, the type
and intensity of exposure, and the type of sensory input (e.g., directly
see, hear from another room, hear about it from someone else, see
evidence of domestic violence). Other measurement issues involve how the
meaning of domestic violence changes across childhood development, and
children's reactions to domestic violence, particularly when they
witness or hear an incident (e.g., they may try to physically intervene,
call police or contact another adult, leave home, protect siblings, or
hide in a closet). Of special interest are outcomes such as homicide or
suicide that derive from domestic violence.

In assessing the affects of domestic violence on children, participants
noted two essential areas of study: The effects of domestic violence on
children and the effects of domestic violence on family functioning as
it relates to the well-being of children.

Discussion of the effects of domestic violence on children addressed
several behavioral and developmental outcomes. The cumulative effects of
combined multiple, co-occurring, or sequential types of violence (e.g.,
school, community, and domestic violence; terrorism, etc.) are
important. Examination of children's resilience factors is a research
issue. Short-term and long-term mental and physical health effects are
critical issues for study, including issues such as overall physical
health disparities (as measured by recognized health/medical standards),
neuro-physiological effects of and reactions to domestic violence, and
the impact of substance abuse. Any research on substance abuse effects
should include effects relating to parental substance abuse (e.g., care
or protection of children, as an adjunct to increased incidence of
domestic violence, and as a factor in parenting overall) and those
effects leading to a child's substance abuse. The effects of children
witnessing domestic violence on teen relationships, pregnancies, and
subsequent marriages also are of interest, along with research on the
parenting abilities of children who have witnessed domestic violence.

The group's discussion of the effects of domestic violence on family
functioning looked at family as a system and at parenting practices of
victims and perpetrators. Some of the family functioning sub-issues
included:

-   The effects on family organization and structure (e.g., roles,
    sibling relationships, overall stability, and the ability to handle
    ongoing basic needs \[regular meals, clean clothes, school supplies,
    medication, etc.\]);

-   The effects on family interaction, such as a child's perception of
    hostility vs. warmth and whether or not the family is thought of as
    a safe place;

-   The effects on relationships with extended family members (involved
    vs. isolated);

-   The impact on a teen\'s decision to leave home and/or cut-off
    relations with the family;

-   The impact of family violence on poverty and on other life stresses.

Parenting issues/problems stemming from the effects of domestic violence
on parenting were of great concern to the participants. Parenting should
be addressed as a global issue and expanded to include the exploration
of a variety of related/intervening issues. Numerous issues are a part
of this broad category, so there is a need to look at the following
aspects of parenting practices involving both the victims and the
perpetrators of domestic violence:

-   How does domestic violence change male and female parents? Are there
    patterns of competent and compromised parenting styles among victims
    and perpetrators?

-   How does domestic violence affect/influence the protective role and
    other aspects of parenting?

-   How does domestic violence affect parenting children of different
    ages (prenatal care and protection of the fetus; parenting the
    preschool child \-- meeting the child\'s high need for engagement
    and supervision; parenting the school-age child \-- parents as the
    link to the outside world; monitoring activities and friendships;
    facilitating a child's emerging competencies; parenting the
    adolescent \-- continuing to keep open communication channels while
    tolerating adolescent\'s separation from family)

-   What are the effects of domestic violence on behavioral correction
    and the creation of behavioral change in children?

-   How do parental coping styles affect parenting practices?

-   How do we work with and/or enhance the parenting skills of domestic
    violence victims?

-   How does parenting of female vs. male children differ in families
    experiencing domestic violence?

-   How does domestic violence affect the perception of parents as role
    models for male and female behavior?

Another important research issue is the impact of community/societal
systems (relatives, neighbors, schools, child protective and other
social services, criminal justice, healthcare, etc.) on domestic
violence issues. Of equal importance are the intended and unintended
effects of domestic violence on those community/societal systems. Areas
of interest include staff training needs, giving greater attention to
referral diversity and referral follow-up, increasing inter-agency
collaboration, and the development of domestic violence education and
intervention programs.

Participants proposed that future research focus on some of the topics
suggested and that more detail related to the use of qualitative and
quantitative measures and uniform instrumentation should be included. Of
particular concern is the need for projects to include multiple
competencies, address multiple problems, serve to move the field
forward, and address what other work needs to be done. As with other
fields of study, cultural/ethnic practices and beliefs are known to have
an immense effect on what is considered as the norm. The group believed
that all projects should examine culture/ethnicity as a critical
variable, an integral part of each study, and a factor that affects
measurement. The group also emphasized that research in the area of
children exposed to domestic violence will require expertise from a wide
range of subject areas; linkages between and across disciplines will
enhance study outcomes.

E. Domestic Violence: Summary of Recommendations

Considering the limitations of existing surveys, direct investigation
offers the best hope for defining, substantiating, and understanding
children's exposure to domestic violence and assessing risks and impacts
over time. However, as echoed elsewhere, future progress is predicated
on standard definitions and data collection, with broader and more
inclusive definitions of violence, assessments of risks and history,
short- and long-term impacts, and connections to services and follow-up.
Population-based surveillance systems that have standard protocols and
take a developmental and cultural approach are critical. Too much of
what is known comes from children in shelters, thus limiting our ability
to generalize. Future research directions should include building a
rigorous scientific capacity in partnership with strategic sentinels
across municipalities. Researchers cannot adequately assess the impact
of violence, including domestic violence, obtain quality information, or
develop research-based interventions without building capacity through
partnerships.

Conceptual models are needed that are appropriate for different
developmental stages and that consider differences in effects by gender
and culture. Much more attention needs to be given to preschool
children. Another critical time to intervene is during adolescence, when
behaviors such as peer aggression and dating violence may surface in
response to domestic violence, and when aggressive behavior can develop
into a pattern of violent behavior as adults. The inequity in access to
services for troubled boys and girls must also be addressed. More
research is also needed on neuro-physiological effects of domestic
violence, such as immune system effects, stress, and depression.

In addition to studying the effects of domestic violence on children,
research needs to focus on the effects of domestic violence on family
functioning, particularly as it relates to the well-being of children.
Family organization and structure, family interaction, parenting
behaviors, coping styles, and practices, involving both the victims and
the perpetrators of domestic violence, need to be considered. It is also
important to assess the long-term economic and psychological impact on
the father-child relationship and the child's perception of the father.

Another important research issue is the interface of domestic violence
with other systems, such as the healthcare system, mental health system,
educational system, justice system, and community and societal systems.

A systematic program of research could help accelerate progress in this
field by calling attention to the need for more research to better
understand, respond more effectively, and ultimately to prevent
children's exposure to domestic violence. Such research should include
multiple competencies and address multiple problems, should examine the
implications of culture/ethnicity on measurement, and should be
multidisciplinary.

[]{#__RefHeading___Toc18291230 .anchor}IV. Community and School Violence

*Moderator: Tom V. Hanley, Ed.D., Office of Special Education Programs,
DOE*

Dr. Hanley began this segment of the conference by discussing the waxing
and waning of the public and political attention spans. For instance,
over the past few years, there has been increased attention on shooting
in schools, yet schools are still overwhelmingly safe. He also referred
to and circulated two documents produced as a result of the shootings
that he hoped would switch the focus away from violence to public
health.

A. Prevalence

*Bradley D. Stein, M.D., MPH, RAND and University of Southern
California*

Dr. Stein's presentation focused on four main themes underlying
community violence prevalence: (1) Types of exposure to violence; (2)
predictors of exposure; (3) exposure in different contexts; and
(4) relative gaps in our knowledge. Community violence can be described
in terms of direct and indirect exposure as well as the nature of the
violence (weapon-related, criminal, and physical). There are substantial
variations in estimates of weapon-related, criminal, and physical
violence in the literature, and very little data, except for the
National Longitudinal Study of Adolescent Health (AddHealth), on
children's exposure to violence in the general population. Most data
reports come from children in high-risk areas. Despite these
inconsistencies, the general predictors of violence exposure include
being male, being an older child, being an ethnic minority, living in
urban areas, low socioeconomic status (SES), and early conduct problems.

There is also a lot of misinformation about violence exposure in
schools. For instance, single victim homicides are declining while
multivictim homicides are increasing. Overall, the numbers are small but
draw a lot of attention. Witnessing and being a victim of threats and
physical violence are quite common in schools. However, this must be
placed in context. Children spend more time in school and thus may be
more likely to experience violence in school. However, little is known
about violence exposure in schools, particularly for U.S. communities
and compared to other countries.

Some of the key knowledge gaps in community violence include variations
in prevalence estimates due to differences in sample characteristics,
measures of what constitutes violence, and reporting methods. We also
need to know how often violence is occurring, whether exposure to
violence is changing over time, and longitudinal studies to measure the
chronicity of violence exposure. Characteristics of violence are seldom
reported in the literature in terms of the relationship to the
perpetrator and the social context. In addition, most reports are of
at-risk populations.

Finally, it is important to distinguish between bullying and other types
of violence. Children think about bullying more than other types of
violence. We also need to look at the relationship between community
violence exposure and other health risk behaviors.

B. Consequences

*Michael Lynch, Ph.D, State University of New York at Geneseo*

Dr. Lynch began his discussion by presenting the challenges of community
violence research, which include dealing with co-occurring risk factors
and clarifying how community violence is operationalized. He then
outlined the direct effects, mediating variables, moderating factors,
and resilience issues involved in children's exposure to community
violence.

One direct effect is post-traumatic stress disorder (PTSD), which has
been reported in a number of studies. There are also psychobiological
effects that manifest through alterations in physiological arousal. This
can result in lower baseline heart rates (hypoarousal) or high blood
pressure, epinephrine secretion, and cortisol production (hyperarousal).
Previous studies have shown that children exposed to violence may also
externalize their pain through antisocial behavior, violence,
aggression, substance abuse, and other behavior problems. Recent studies
have indicated that there are developmental differences in this
externalizing behavior, and that there may be a "feedback loop"
predicting subsequent exposure. Children exposed to violence may also
internalize their pain. Internalizing problems can result in anxiety and
depression, lower self-esteem, separation anxiety, and feelings of
insecurity. A number of studies have also reported that children exposed
to violence may experience problems in peer relations, educational
achievement, and with the juvenile justice system.

The effects of community violence can vary, however, based on certain
mediating variables. One category of mediating variables can be
described as "factors within the child," such as emotional regulation,
social information processing, and perceptions of exposure. Other
mediating variables occur in the social environment, including family
systems. This underscores the need to assess the potentially protective
nature of family systems. Factors that may moderate (or lessen) the
impact of community violence have also been reported in the last decade.
They include characteristics of the child (temperament, gender, and
ethnicity); characteristics of exposure (chronicity, proximity, and
familiarity); and characteristics of the social environment (supportive
relationships, parental monitoring, extent of family conflict). Support
from parents, the school environment, and peers all play a role in
helping children overcome adversity in their world.

C. Responses

*Kathy Sanders-Phillips, Ph.D., Howard University*

Dr. Phillips came to the discussion of community violence from the
perspective of a drug abuse researcher, and as a public health
researcher in general. She is interested in the impact of exposure to
community violence on risk behaviors such as substance abuse,
particularly among minority adolescent populations. She discussed her
work examining the impact of community violence on HIV infection and
other risk behaviors linked to health disparities in South African
adolescent girls.

Dr. Phillips then discussed theoretical models and the importance of
modifying those models as research yields new information. The first
critical theoretical model to consider is that children and families are
embedded in social and cultural systems. We cannot understand the
development of behaviors or responses without reference to the social
system in which children live and grow. Therefore, we must examine these
systems, as well as race and ethnicity, and incorporate them into our
theoretical models. Referring to Dr. McCloskey's presentation, Dr.
Phillips mentioned the disparate identification of males for
intervention services to illustrate the plight of African-American boys.
The literature suggests that adolescent male victims, if African
American, are more likely to be identified by the juvenile justice
system and incarcerated. By contrast, white adolescent males are more
likely to be identified by the mental health system. There are
cumulative effects from multiple experiences of poverty, violence,
racism, and oppression, and other forms of abuse. These experiences
reinforce alienation from society, and feelings of helplessness and
powerlessness. Therefore, it is important to examine how the experiences
of children of color impact their responses to violence.

It is also critical to understand the mechanisms by which exposure to
violence impacts psychological dysfunction. More research is needed on
the psychological, physical, and social mechanisms in children, as well
as the impacts on parental behaviors, social norms, cultural norms, and
how these multiple levels of experiences interact to foster dysfunction.
We need to incorporate our theoretical findings into interventions and
consider the multiple avenues where intervention can take place. It is
also important to train health care personnel on how to assess and treat
exposure to violence, and to develop strategies to help schools protect
children.

*Gregory A. Thomas, M.S., New York City Board of Education*

Mr. Thomas prefaced his remarks by describing the New York City school
system, which has over one million children in over one thousand
schools. Schools are generally safe but what happens on weekends carries
over into the schools. His goal is trying to reduce violence in New York
City schools and the surrounding community. He emphasized that we must
be careful about how we define violence, because perceptions vary for
urban and suburban areas. What is normal for one community may seem
violent to another community. In addition, tolerance of violence in
urban communities may lead to lower incidence of reporting in these
areas. The more children see violence and get used to it, the less
likely they are to report it.

Mr. Thomas also discussed the "No Child Left Behind Law," which allows
parents to transfer children from persistently dangerous schools (those
schools deemed dangerous for 2 concurrent years). One measure of how
dangerous schools are is the number of weapons identified in the
schools. However, while weapon scanning can identify weapons in schools
that have these devices, not all schools have scanning systems. Mr.
Thomas also referred to an article on the World Trade Center attacks and
the impact on schools. A number of schools were in the proximity of the
World Trade Center attacks, and a number of students lost parents or
knew people killed in the attacks. This attack was seen as a violent
episode in the minds of children, and had a devastating impact. Thus,
researchers should consider the long-term effects of this act in future
studies.

D. Discussion

There was a significant discussion about how gang violence is
conceptualized, which has not been consistently addressed in the
literature. Dr. Lynch noted that gang violence is often subsumed under
school violence, while Dr. Phillips noted that in some areas, community
violence is defined by gang violence. In addition, many gang members see
the gang as part of their family system, which can further complicate
outsiders' perspectives of the issue. Dr. Stein cautioned, however, that
we are creating somewhat artificial categories to group sexual,
community, domestic, and school violence. We must consider the
complexity of these issues and the relationships between these forms of
violence.

There was also some discussion about the use of high-risk samples to
inform community violence research. For instance, Dr. Fantuzzo suggested
that high-risk samples may compromise the content validity of surveys.
Dr. Stein agreed that this is a problem, and that there are few studies
of the general population to give us a broader perspective on the
prevalence of violence. Dr. Hill added that we need to look beyond paper
and pencil instruments and ask the community to help interpret answers
in their social context. This will allow researchers to construct
studies that can yield more relevant data.

Other participants urged the research community to consider the
neurological pathways resulting from exposure to violence, particularly
how they affect impulse control and aggressive behavior. There was also
discussion about the need to separate out pre-existing mental health
conditions and behavior tendencies when considering the effects of
violence. Dr. Lynch suggested that a possible solution to this is to
start early identifying impacts and precursors of violence. In real life
there are millions of things that account for all the variances.

Dr. Leavitt concluded the discussion by reminding the group to look at
its ultimate goals: Fostering resilience, determining the underlying
pathways that lead to problems in children exposed to violence, and
developing interventions. Dr. Stein agreed that the goal is
interventions that will have a greater likelihood of actually being used
in communities. We have to understand the different communities to help
different children.

During the breakout group discussion, the group posed the concept that
the community is not just the location of the violence or a set of
people, houses, and apartments. (See Appendix B for the summary and
recommendations presented by the breakout group chairpersons). The
community is a set of interconnecting relationships. The group also made
the assumption that violence in schools often stems from the community,
and that the school can be viewed as an integral part of the community;
therefore, it does not make sense to distinguish between school violence
and community violence, except in unique issues such as bullying. We
also need to understand school violence in terms of chronic conditions,
not just acute events like Columbine. Participants discussed research
needed to inform policymakers about best practices, including on the
relationship between witnessing violence and violent behavior, the
psychological and physiological mechanisms linking the two, whether and
how violence may exacerbate health disparities between racial and ethnic
groups, and the physical effects of living in a violent community.

Additional research on how schools influence occurrence and consequences
of neighborhood or school-related violence is also needed. Specifically,
how does violence within a school setting impede educational achievement
and ultimate escape from the community? What are the educational
outcomes associated with community violence? What is the role of schools
in mediating violence? If you reduce family and community violence, does
it change how children behave in schools? How do you link government and
education to improve the community? What are the effects of bullying,
particularly at younger ages?

Participants also discussed the importance of developing interventions
directed not just at the individual child, but at the community as well
to help foster resilience. As part of this discussion, participants
raised a number of research questions, including:

-   How does violence affect the social contract within the community?

-   How do different groups define community, family, and neighborhood?

-   How is the community affected by violence?

-   What is the role of the community as a potential buffer for violence
    and for how its people react to that violence?

-   How does community reaction to violence affect children, their
    reactions, and their development?

-   How does violence in the community affect the overall area, not just
    individuals?

-   Is there a relationship between community violence and a violent
    community?

-   What are the effects of *direct* and *indirect* exposure to
    community violence? How do the two compare?

Further discussion focused on identifying the mechanism that occurs
between witnessing violence and violent behavior to understand the
biological and psychological pathways. In particular, researchers should
examine:

-   How violence affects children at different developmental stages;

-   The underlying mechanisms leading to violence that can inform
    interventions;

-   The impact of direct or indirect exposure to violence on outcomes
    such as behaviors and feelings;

-   Younger children's constructions of community;

-   How poverty, culture, and ethnicity mediate exposure to violence and
    outcomes, including the causes for feelings of alienation and
    hopelessness within groups;

-   Protective factors, assets, etc. in a community that foster
    resilience to violence;

-   Specific outcomes of children exposed to dual violence (e.g.,
    domestic and community);

-   Gun control policies internationally and their effects on community
    violence.

E. Community and School Violence: Summary of Recommendations

Some of the key issues in community violence research include variations
in prevalence estimates due to differences in sample characteristics,
measures of what constitutes violence, and reporting methods. We need to
know how often violence is occurring, whether exposure to violence is
changing over time, and we need longitudinal studies to measure the
chronicity of violence exposure. As community violence research relies
primarily on high-risk samples, general population studies of violence
are sorely needed to provide a broader perspective on the prevalence of
violence.

It is important to examine how community violence affects risk
behaviors, and, in turn, health disparities. It is also important to
look at the cumulative experiences of children of color, including
multiple experiences of poverty, violence, racism, and oppression, and
other forms of abuse, and how these experiences reinforce alienation
from society and feelings of helplessness and powerlessness, and how
they impact their behaviors and responses to violence. Also important
are the neurological pathways resulting from violence, particularly how
violence affects impulse control and aggressive behavior.

There is a need for theoretical models concerning how community violence
impacts development. It is critical to understand the psychological,
physical, and social mechanisms by which exposure to violence impacts
psychological dysfunction, as well the impacts on parental behaviors,
social norms, cultural norms, and how these multiple levels of
experiences interact to foster dysfunction. We need to incorporate our
theoretical findings into interventions and consider the multiple
avenues where intervention can take place. It is also important to train
health care personnel on how to assess and treat exposure to violence,
and to develop strategies to help schools protect children.

The attack on the World Trade Center was seen as a violent episode in
the minds of children, and had a devastating impact. However, the
episode provides an opportunity to study the long-term effects of an
attack of such far-reaching proportions.

Participants also recommended that future research examine the
relationship between witnessing violence and violent behavior, the
psychological and physiological mechanisms linking the two, whether and
how violence may exacerbate health disparities between racial and ethnic
groups, and the physical effects of living in a violent community.
Research on how schools influence occurrence and consequences of
neighborhood or school-related violence is also needed. Interventions
should be directed not just at the individual child, but at the
community as well to help foster resilience.

[]{#__RefHeading___Toc18291231 .anchor}V. Terrorism and War

*Moderator: Farris Tuma, NIMH*

A. Prevalence

*Robert Pynoos, M.D., M.P.H., University of California at Los Angeles*

Dr. Pynoos presented an ecological model on the determinants of
long-term postwar adjustment in Bosnian youths and discussed the prewar,
wartime, and postwar factors that impact adjustment. He presented a
postwar adversities scale that illustrated how the family may be
traumatized by the effects of war. This scale illustrates that traumatic
events may also occur *after* the war, while some traumatic events, such
as the disappearance of a loved one or the confirmed death of a loved
one, may be caused *by* the war. There are also postwar traumas such as
accidents or crime that are not war-related that may affect the family.
Together, these events comprise a "postwar trauma variable."

PTSD, depression, and grief can often co-occur after a traumatic event.
Dr. Pynoos used these findings to create a general psychological
distress factor in his structural model. Postwar trauma reminders,
including sudden loud noises, destroyed or damaged buildings, and
hearing news of political instability, can have an ongoing impact on a
person's psyche and strongly predict long-term adjustment in
adolescents, more so than family environment and refugee experiences.
These results suggest that assessment and treatment efforts should
address reminders. Studies have found that exposure to traumatic events
is also mediated by parenting practices. Lessons from developmental
psychopathology suggest that therapeutic approaches should target prewar
trauma, trauma exposure, postwar trauma reminders, postwar family
adversities, psychological distress, and developmental impact.

Turning to terrorism, Dr. Pynoos discussed the impacts of several high
profile events on children. One study of Oklahoma and Nairobi showed
that the repercussions of loss were much more devastating than PTSD. In
the Three Mile Island incident, pregnant women and their offspring
associated with a government zone of evacuation showed higher anxiety
levels even though the zone had no correlation to radiation. Eleven
percent of children in New York City had a family member or friend
exposed to the World Trade Center terrorist attacks. Two-thirds of these
children had been exposed to a traumatic event prior to the attack. A
high incidence of agoraphobia was reported after the attacks.

Dr. Pynoos concluded with a brief discussion of the National Child
Traumatic Stress Network, funded by SAMHSA. The mission of the network
is to raise the standard of care and improve access to services for
traumatized children, their families, and communities throughout the
United States. The Intervention Development and Evaluation Program of
the network is primarily responsible for developing, delivering, and
evaluating improved treatment approaches and service delivery models,
which are then implemented through the Community Treatment and Service
Programs.

B. Consequences

*Jon A. Shaw, M.D., University of Miami*

It is estimated over the last decade that two million children have been
killed due to war related injuries, four million have been disabled, one
million orphaned, and twelve million dislocated from their homes. Yet
there are relatively few studies of the effects of war and terrorism on
children. There are a number of generally accepted but perhaps
questionable truths about the effects of war and terrorism on children.
For example, some say children's responses to stressful conditions are
often less intense than might be anticipated.

Unlike other forms of violence, there are specific situations associated
with war such as torture, bioterrorism, refugee status, pupils of war
(children socialized to violence), and distant trauma (experiencing a
horrifying event from a relatively remote and safe distance). There have
been some studies of children captured and tortured in Mozambique that
found that while some children identified with the caretaker, some
identified with the soldier. There have also been studies in Bosnia and
Cambodia on the impact of refugee status on the child.

War can produce a variety of consequences in the child. Biological
effects can include malnutrition, starvation, disease, and war-related
injuries. There can also be emotional, behavioral, or mental effects,
ranging from little or no reaction, to immediate effects such as PTSD,
mood disorders, and externalizing behavior. Long-term effects can also
result. Developmental effects can appear in the form of decreased
academic performance, difficulty concentrating, cognitive impairment,
structural changes in the central nervous system, and changes in
personality structure.

These effects can be heightened or lessened by a variety of mediating
variables, which can be categorized by: (1) Levels of exposure, (2)
disruption in the family system, (3) disruptions in the social support
system, (4) child-specific variables, such as developmental age and
gender, and (5) cultural factors, including religion. Known protective
factors include family and social supports, cultural and religious
values, strengths intrinsic in the child, leadership, and anticipatory
preparation.

There are a number of research gaps in this area of study including
determining the most effective treatments for war-exposed children,
developing empirically based interventions for children and families
experiencing grief, and designing training modules to help non-mental
health providers intervene in psychological crises. There is also a need
for studies of resilience, determining which acute physiological
responses predict long-term consequences, assessing the impact of early
parent death on children, examining the role of culture and values as
protective factors, and assessing the use of pharmacological treatments
in children with PTSD.

C. Respondent

*Paramjit T. Joshi, M.D., Children's National Medical Center*

War and terrorism are abnormal events that occur in usually normal
populations, causing acute stress reactions. Irrational fear leads to
group compulsion to eliminate neighbors or potential enemies, setting up
a cascade of events across the world. This pattern is repeated over and
over again in different parts of the world through different
generations.

In terms of the children affected by these acts, Dr. Joshi agreed with
Dr. Shaw's assertion that we need to know more about "pupils of war."
How do young children get recruited to be soldiers? Dr. Joshi suggested
that the developmental trajectory goes off track seeing the death of
loved ones. When support mechanisms such as family, community, and
religion are gradually taken away, children are increasingly vulnerable
to outside influences.

Children can be affected by repeated acts of war or terrorism.
Retraumatization has cumulative effects, enhancing the intensity and
duration of response, and lengthening the recovery period. There are
also social effects. For instance, family role reversal may occur.
Demoralized fathers may return from war only to find their wives,
formerly submissive, assuming the more dominant role. Terrifying
experiences can also cause defects in gene regulation. In addition,
functional magnetic resonance imaging of people's brains when they are
observing violent scenes may also help us understand whether stress
contributes to a constant state of brain activation. We need research to
answer this question. On the subject of desensitization, rates of
aggression, violence, truancy, and substance use in Israeli youth have
implications for inner city youth here. In the United States, the need
for appreciation, to be wanted, and to have a purpose in life can often
draw children into violent groups. This theory can also apply to
motivations of suicide bombers. Tragically, there are lost generations
due to the effects of war. Our challenge in the event of war or a
terrorist act is how to prioritize and go about developing large-scale
interventions that can provide support, outreach, and education, and
identify those at greatest risk.

D. Discussion

There was significant discussion on the subject of ideology. One
participant suggested considering the role of ideology, religion, and
related forms of thought to distinguish between war and community
violence. For example, whereas war typically develops results from
differences in ideology, community violence is often the result of
multiple more proximal causes such as poverty and housing conditions.
There was also discussion about whether having a group ideology was
positive or negative for children. Dr. Levy noted that children from
refugee camps sometimes fared better if they had a strong ideological
orientation. Dr. Pynoos noted that the study of ideology is not so
straightforward and that it is hard to know what this means in terms of
long-term pyschological and physiological effects. Dr. Phillips noted
that ideology and ethnicity often may serve as protective factors for
minority children. She also suggested that war and terrorism may not be
so different from community violence as one might think and that
considering them as having common causes and consequences will move us
forward in the research in these areas. Dr. McCloskey agreed with this
point, and added that the effect of community violence on black men in
the United States could be compared to war considering that one in four
black men are in prison by age 25.

The breakout group framed their discussion and recommendations by first
defining war and terrorism. (See Appendix C for the summary and
recommendations presented by the breakout group chairperson). The group
used existing Department of Defense (DOD) and Federal Bureau of
Investigation (FBI) definitions and then added their own thoughts.
Terrorism is the "Unlawful use of threat or force against an
individual/government for political or other end with the intent/purpose
of imposing one's will (DOD)." It can also be construed as the
"Illegitimate use of force to achieve political, social, or religious
objectives, when innocent people are targeted (FBI)." Terrorism is
usually played out before a larger audience, is marked by unexpected,
recurrent attacks, and is carried out by groups who do not have other
means to get their message across. Civilians are often a major target of
these attacks. By contrast, war is planned and executed, usually by
governments against governments perhaps in self-defense or revenge, and
has a defined beginning and end. Civilians are usually secondary
targets.

The main research gap in the area of children exposed to war/terrorism
is in understanding the different consequences of exposure to war versus
terrorism. This issue entails differences in acute, unexpected (terror)
versus chronic, expected (war) exposure. A related issue is that the
effects from exposure to terrorism may be different than those from
other forms of violence in many ways. For example, geographically,
people who are distant from a terrorist incident still suffer
psychological trauma. Can anticipatory preparedness reduce the level of
anxiety? What are the effects of anticipating incidents without being
prepared?

There is a need to contrast the prevalence of problems associated with
war versus terrorism. A comprehensive, three-dimensional matrix is
needed, comparing war and terrorism across variables such as
interventions and type of phenomena and across various individual risk
factors. The cells of such a matrix need to be filled in with research
from many studies. One large, all-encompassing study is not recommended.

A number of characteristics (besides type of trauma) are important to
consider in terms of the research on mechanisms and consequences of
exposure to war/terrorism. Consequences need to be considered more
broadly, and secondary consequences need to be considered. Terror can
influence other behaviors (e.g., if adolescents stop going to malls, the
economy can be affected). Studies are needed on the psychological
effects of bioterrorism on children and families and on the
psychological effects of activities aimed at disaster preparedness on
children (e.g., some private schools now do mock school shootings). We
need to consider effects from the biological (genetics) to the
existential, from neurons to neighborhoods. Another intriguing area for
future research is the impact of chronic stress, especially the impact
on children, including prenatal effects.

There is a need to consider research and models from other fields. A
public health (not just mental health) model is needed. Ideally, a
modular model would be developed to give to communities. Modular
intervention is needed in schools since immediate responses can take
place in schools. Various responses need to be tried to see which work
better. Medical outcomes such as immune disorders, somatic disorders,
and disease need to be examined, as well as the influence of ethnicity
and culture.

To inform intervention strategies, participants discussed the need to
understand the longitudinal course of the evolution of psychological
morbidity, and the developmental stages and development of psychological
neuropsychiatric symptoms. For example, is depression related to
maternal response to trauma? What are the effects of early parent death,
considering variables such as age and gender?

Research on measuring and examining resilience first demands answers to
the following questions: How can we define resilience? How do we build
resilience? What are the coping and adapting strategies that contribute
to resilience? There is a need for long-term studies and
intergenerational studies (e.g., the effects of loss of fathers on
families). Empowerment issues also need to be studied (e.g., confidence
that one will prevail and a feeling of control over a situation).

Researchers' challenges need to be considered, such as the ethical
dilemmas of doing research on the battlefield (international sphere).
How does one remain neutral but empathetic?

To prevent or treat long-term negative emotional consequences of
witnessing war and/or terrorism, research is needed on:

-   Crisis intervention, including the best types;

-   The potential harm and benefit from traumatic reminders of past
    violence, such as memorials;

-   Social communication, for example, addressing what to say to
    children on TV about attacks;

-   Individual reactions and helping to reprogram through possible
    training;

-   Identification of our target audience---should we be training the
    helpers, such as teachers, religious figures, parents, social
    workers, etc.? What do the children think would be helpful?

-   Types of therapy that might be effective and their possible
    outcomes;

-   First responders and their families;

-   Effects of parental factors on children's symptoms, including
    intervention strategies for single parents and remaining survivors'
    strategies.

In discussing the type of research needed in the area of preventive
interventions models targeted toward at-risk individuals or families,
participants believed that analogues for intervention models already
exist in other fields (i.e., infectious disease, natural disasters).
Rather than reinventing the wheel, attention should focus on
effectiveness studies of models for individuals, families, and
groups---we especially need to focus on children. Studies are needed on
how children respond in relation to their own aggression, including the
risk factors for becoming future terrorists. For example, what effect
does the parental political belief system have on a child? What are the
psychological and other effects of quarantine on children and families?
What type of anticipatory preparedness is best?

E. Terrorism and War: Summary of Recommendations

The main research gaps in the area of children exposed to war and
terrorism is in determining the most effective treatments for these
children, and in understanding the different consequences of exposure to
war versus terrorism. A number of characteristics (besides type of
trauma) are important to consider in terms of the research on mechanisms
and consequences of exposure to war/terrorism. Consequences need to be
considered more broadly, and secondary behavioral consequences need to
be considered. Studies are needed on the psychological effects of
bioterrorism on children and families and on the psychological effects
of activities aimed at disaster preparedness on children. Additionally,
we need to consider effects from the biological (genetics) to the
existential, from neurons to neighborhoods. Another intriguing area for
future research is the impact of chronic stress, especially the impact
on children, including prenatal effects.

It is important to develop empirically-based interventions for children
and families experiencing grief and training modules to help non-mental
health providers intervene in psychological crises. Research and models
from other fields should be considered. A public health (not just mental
health) model is needed that includes medical outcomes such as immune
disorders, somatic disorders, and disease, as well as the influence of
ethnicity and culture. Long-term and intergenerational studies (e.g.,
the effects of loss of fathers on families) should be considered.

There is also a need for studies of resilience, determining which acute
physiological responses predict long-term consequences, assessing the
impact of early parent death on children, examining the role of culture
and values as protective factors, and assessing the use of
pharmacological treatments in children with PTSD. Research on measuring
and examining resilience first requires attention to definitional
issues, and then the factors that contribute to resilience, including
empowerment issues.

Studies are needed on how children respond in relation to their own
aggression, including the risk factors for becoming future terrorists.
To prevent or treat long-term negative emotional consequences of
witnessing war and/or terrorism, research is needed on crisis
intervention, the impact of traumatic reminders of past violence, types
of therapy that might be more effective and their possible outcomes,
first responders and their families, and the effects of parental factors
on children's symptoms, including intervention strategies for single
parents and remaining survivors' strategies.

[]{#__RefHeading___Toc18291232 .anchor}VI. Services and Interventions
for Children Exposed to Violence

*Moderator: Jerry Silverman, ASPE*

A. Domestic Violence

*Honore M. Hughes, Ph.D., Saint Louis University*

Dr. Hughes began her presentation with an overview of the literature on
the scope and variety of domestic violence interventions. The early
eighties were marked by the beginning of published studies in this area
while the nineties were marked by more studies on pre-post designs and
follow-up studies. She also presented an overview of the variety of
programs targeting children exposed to domestic violence. These programs
can vary based on their approach, setting, target populations, outcomes,
funding sources, and intensity of services.

She then posed the question about whether domestic violence can serve as
a gateway to services. Overall, many children are not identified and few
mothers seek services, but much depends on the training of workers. The
current knowledge base on the needs and services for this population is
very limited and it likely that needs are not being met by current
services. A few exemplary studies on this topic do exist. For instance,
the Kids' Club is a low-intensity intervention that compared a
children-only intervention to one involving both mothers and children.
The study found that the mother-child group was more effective. Another
program, the Learning Club, reduced child abuse and exposure to domestic
violence, and increased child self-competence through pyschoeducational
groups for children and home interventions.

These studies show that children's attitudes, distress levels, and
behavior can be changed along with their mother's skills. They also
emphasize the importance of mother involvement. However, while there is
high quality research out there in the field, we need to do more.
Different types of problems require different types of intensity, and
research is needed to inform interventions.

B. Community Violence and Terrorism/War

*Steven J. Berkowitz, M.D., Yale University*

Dr. Berkowitz began his presentation by stressing that while war tends
to be episodic, terrorism and community violence can be continual.
Therefore, we need different responses for different events. In war and
terrorism, which involve larger numbers, the government has an important
role in coordinating services and restoring social order. With regard to
community violence, there is a need for increased focus on developmental
perspectives and including primary caretakers in interventions. When
parents receive support, the effects on children diminish.

There is no empirical data on the best time to intervene although the
general belief is that earlier is better. The advantages of early
intervention include the potential to decrease immediate suffering, to
recognize and respond to environmental issues, to assess the ongoing
threat, and to track the trajectory of traumatic response from the
baseline. There are also disadvantages such as use of limited clinical
resources prior to demonstrated need and unclear treatment parameters.
We must also consider when the family is likely to take advantage of the
intervention, and how cases are referred to professionals. Cases are
found through both traditional (parents, schools, courts) and
nontraditional (outreach, police, emergency medical systems, community
organizations) sources.

We also know that interventions can occur in a variety of settings with
a wide range and level of expertise in the provision of interventions.
Interventions can be defined in multiple ways. They can be either
collaborative or individual, can be led by different providers, and have
more or less emphasis on diagnosis and developmental issues. In terms of
what interventions provide, however, there are few studies on children
and fewer still on immediate and early interventions. The best empirical
evidence available involves sexually abused children. We also know that
psychoeducation for parents and older children is very useful.

To move the field forward, we need studies addressing the best time to
intervene, which interventions work best, studies of early markers for
high-risk behaviors, and studies of the best techniques for intervening
with children exposed to violence. The challenge for researchers is the
difficulty in following up subjects, characterizing the intervention,
and the complex number and definition of variables that must be
analyzed.

C. Desired Outcomes and Evaluation of Programs

*Hope M. Hill, Ph.D., Howard University*

Dr. Hill discussed the lessons she had learned from intervening in the
lives of children exposed to domestic and community violence, both in
the United States and internationally. It is important to have experts
from the participant community construct the intervention. At the same
time, researchers need to take seriously the study of the social and
cultural context to insure the integrity of the work; they should make
no assumptions. They should intervene simultaneously in all levels of
the child's ecology, and appreciate the grinding effects of poverty on
all aspects of the intervention and act accordingly. Once highly
stressed, low resource families trust the intervention, they will still
need support after the intervention is "officially" over.

She discussed previous evaluations of interventions for children exposed
to domestic and community violence, and their relative strengths and
weaknesses. Overall, programs have been successful in reaching goals
such as reducing children's anxiety, reducing aggression, and improving
social skills. However, most programs do not specify the extent to which
the child has been abused in addition to witnessing abuse. Furthermore,
few evaluation studies incorporate existing theory in their design, and
most are small samples of convenience.

We can also learn from analyses of which programs work and which do not.
Examples of effective primary prevention strategies are programs aimed
to prevent the onset of youth violence through skills training, behavior
monitoring and reinforcement, as well as building school capacity and
youth development programs. There are a number of effective secondary
prevention strategies including parent training, home visitation, and
social problem solving. Exemplary tertiary prevention strategies include
those involving social role taking, clinical marital and family therapy,
and wraparound services. Overall, the Blueprints model for Violence
Prevention was lauded as a model approach. Ineffective strategies
include peer counseling (when used alone), gun buyback programs, boot
camps, waivers to adult court, and residential programs. Dr. Hill also
emphasized the importance of cost-benefit estimates. Previous studies by
Greenwood (1996, 1998) suggest interventions targeting problem youth are
more cost effective than those targeting the general population.

Suggested next steps include long-term intervention studies, inclusion
of strong resilience paradigms, studies of culture as a protective
process, model interventions that mimic real world situations, and
prospective, community-wide interventions that blend key areas of the
child and family ecology, including school, law enforcement, church, and
businesses.

Dr. Hill also added a final note about working with South African
youngsters to see how they have coped during apartheid. She is working
with over one thousand secondary school students in South Africa, and
comparing them to students in Washington D.C. schools. Students in D.C.
are more concerned about serious injury in school than those in South
Africa. Protective factors such as prayer and family seem to work for
both sets of students. However, African-American men tend to isolate
themselves to insulate themselves from a violent community, while South
African men tend to rely on friends. Likewise, African-American women
use prayer first and then isolation as coping mechanisms, while South
African women rely on relatives.

D. Responses

*Judith A. Cohen, M.D., M.C.P., Hahnemann University*

Dr. Cohen discussed the need for randomized, controlled studies of
community interventions and outlined some of the key elements those
studies should include. First, it is important to document treatment
protocols. If researchers are unable to accurately describe the
treatment, clinicians will not be able to implement it. In addition, if
therapists help develop treatment models, they will be more likely to
buy into them. Involving consumers in treatment design and getting
feedback is also critical. People do not want to be guinea pigs so it is
important to inform them that a systematically evaluated treatment may
be better than what they are currently receiving. Dr. Cohen also
emphasized the importance of integrating developmental and cultural
perspectives in treatment models.

In terms of what to measure and how to measure it, it is important to
ask children about their symptoms and their ability to function.
Research is also needed to understand more about functional impairments
and parent functioning. It is important to look beyond just what works
and examine the target audience for specific interventions, the proper
dosage, intensity, etc. Finally, it is important to ensure that care is
rendered by trained professionals, and to make an effort to provide care
for patients who may not fit the study criteria. This fosters trust and
allows patients to return for support and follow-up.

*Betsy McAllister-Groves, M.S.W., L.I.C.S.W., Boston University*

Dr. Groves reinforced the sentiment of previous speakers that we need to
think of cultural and geographic context when designing interventions.
The definition of violence differs in rural versus urban areas. In
addition, we need to think about how to deliver interventions to
geographically dispersed populations. When examining culture, it is
important that interventions match the beliefs of the target population.
It is also important to look at what interventions work for young
children---group interventions are not developmentally appropriate so it
is often necessary to look at individual and family interventions. From
the policy perspective, we need to reexamine how we identify children
who need services. We need to consider the feasibility of conducting
universal screening in a pediatric environment, including whether we ask
children for information and how that may involve protective services.
Finally, we need to consider how to translate research findings into
information useful for a broad range of caregivers, particularly for
preschool teachers and day care providers, as well as children.

E. Discussion

Participants raised a number of issues dealing with research in health
care settings including the importance of using the collaborative
approach with underserved communities, and ensuring that medical and
community "systems" that control resources are involved. It was also
noted that school-based interventions are powerful, and that school
nurses are important first counselors for children.

Debate on early intervention centered on whether this approach is
effective or not. Participants felt that there were not enough good
studies on the subject, but noted that even if you do not intervene
early, it is important to let people know support is available as soon
as possible.

There was discussion about the extraordinary impact of media, radio, and
Internet penetration on child perception. It was noted that we have a
lot to learn from research on media exposure. While television exposure
correlates with exposure to violence, media can also be a positive
mechanism, particularly when parents serve as a mediating factor.

Participants in the breakout group sought to answer the question: What
are the research needs and the gaps in scientific knowledge related to
services and interventions? (See Appendix D for the summary and
recommendations presented by the breakout group chairperson). The group
encouraged more exploration of nontraditional/indigenous protective
processes (e.g., spirituality, and early introduction to cultural norms
and values) to understand factors that contribute to resilience in
children. We need to cast our net wider than the "big three" protective
factors, one participant said.

Discussion also focused on specific aspects of interventions, for
example,

-   The effect of the timing of interventions---is there a best time to
    intervene?

-   The mode of delivery---can we dispense therapy other than through a
    therapist?

-   The dosage of therapy---are children receiving too much therapy? Is
    it effective? Is too much harmful?

-   The timing of interventions---when are people most receptive (i.e.,
    available psychologically and physically) to intervention,
    immediately after the violent/traumatic event, or at onset of
    symptoms? What motivates people to change?

The types of intervention studies that are needed should apply a
home-based model (versus bringing people to clinics, schools, or other
institutions), should focus more on evaluating shelter programs, and
should favor multisite studies. The latter are difficult but feasible
with the use of modern technology.

Participants suggested a number of avenues for research on intervention
approaches for different types of trauma and for children of different
ages. Among those mentioned:

-   Studies of effective domestic violence prevention programs. For
    instance, programs teaching at-risk youth about healthy
    relationships;

-   Identification of the needs of children who have been exposed to
    violence but who are not symptomatic---i.e., they have no
    psychiatric symptoms. Current research focuses on symptomatic
    children;

-   Research on the differential impact of various types of
    violence/trauma. It is important to control for the different types
    of violence for which therapy is being provided;

-   Research on and programs for very young children and older children
    (ages 16-21). While studies on the very young are difficult, they
    are feasible. And while we talk a lot about *early* intervention, we
    do not do enough work with older children who may have been victims,
    witnesses, or perpetrators. One participant observed that there are
    exposure data on older children, but not much research on effective
    interventions;

-   Studies on the effects of stress inoculation. Does providing a plan
    of action in anticipation of a traumatic event (e.g., terrorist
    attack) decrease anxiety? One participant suggested providing
    schools with a modular toolkit that would help them get the children
    through the first 1 to 2 hours following such an event;

-   Approaches to terrorism. For instance, how do you best serve the
    individuals who were not at the site of the terrorist attack but who
    nonetheless suffer psychological symptoms?

In terms of preventive intervention models targeted toward at-risk
individuals or families, participants recognized the needs of the
nation's fast-growing Hispanic communities---including this community's
language needs. Intervention development should involve the subjects or
target community, and should be ethnically and culturally appropriate
for minority populations.

Additional discussion focused on the need to evaluate the cost
effectiveness of different intervention approaches. More research in
this area would help in the formulation of powerful policy arguments
about the relative importance of certain types of projects. Research on
workforce issues (e.g., who is delivering the services and what training
they need) also impact on cost effectiveness. Even when we know what
works, we cannot rely on the workforce to deliver the "gold standard."
Replication, said one participant, needs to be practical given the
system realities.

A number of suggestions were proposed for research directions to
elucidate how interventions for parents may affect the development of
their children. Among them:

-   Research on the psychoeducational impact of parenting
    interventions/training;

-   Research on teaching parenting skills to divorced parents with a
    history of domestic violence, and research on custody management. We
    often think of parenting as the mother's responsibility, but we need
    to encourage discussion about the positive role that the father can
    play in cases of divorce;

-   Identification (screening and assessment) of domestic violence by
    health care practitioners---tools, safety issues;

-   Research on the impact of substance abuse treatment and mental
    health treatment on children's outcomes. To what extent and for what
    aged children does treating parents help children?

-   Research on how to involve parents in middle and high school
    interventions with children. Most community violence prevention is
    school-based and does not involve the parent, possibly because this
    requires another level of coordination. How can we get parents to
    the schools? Is the school the best venue for the intervention?

-   Research on parenting approaches across the developmental
    spectrum---especially with older children (16 and older);

-   Research on how to teach parenting using alternative tools---e.g.,
    video, CD-ROM, written self-study.

The group also discussed needed research on outcomes for children and
parents, including studies capturing:

-   Functional outcomes, such as school attendance, performance, health,
    use of emergency room services, days lost at work, productivity,
    sense of future;

-   Court costs, police, service utilization, substance abuse;

-   Social-interpersonal relations; and

-   Quality of life for both parents and children.

An underlying theme throughout the discussion was the need to better
understand the limitations of existing data sources and to improve
research designs. Research is too reliant on multidata sources,
especially given the variability of what is accessible. It is difficult
to obtain and make sense of case records, which are not always well
coordinated and not always computerized. Further, self-reports are not
always consistent with earlier records. Partnerships between researchers
and health insurers, which have large data sources, should be
considered, as should greater support for prospective studies.
Longitudinal studies that follow the family over time are needed to
prevent or treat long-term emotional consequences of witnessing violence
in the family or community. Longitudinal studies would help us
understand what happens to parents and children long after exposure to
violence/trauma. At the same time, we need to better understand how to
study families with whom we have only short-term access. Participants
agreed that IRBs need to be educated on the conduct of research on
violence, child abuse, range of risk, and related topics to allow the
science to move forward.

F. Services and Interventions: Summary of Recommendations

Future research needs to focus particularly on improving our
understanding of factors that contribute to resilience in children, and
the effect of timing, dosage, and receptivity of interventions on short-
and long-term outcomes. The types of intervention studies that are
needed should apply a home-based model (versus bringing people to
clinics, schools, or other institutions) should focus more on evaluating
shelter programs, and should favor multisite studies.

Study design issues are paramount. We need to better understand the
limitations of existing data sources and improve research designs.
Longitudinal studies are needed to help us understand what happens to
parents and children long after exposure to violence and trauma. The
subjects or target community should collaborate in the construction of
intervention programs, which would make those programs more culturally
grounded and appropriate. Partnerships between researchers and health
insurers, which have large data sources, can also prove advantageous, as
would greater support for prospective studies. Studies need to capture
data on functional outcomes, such as school attendance, performance,
health, use of emergency room services, days lost at work, productivity,
sense of future; court costs, policy, service utilization, and substance
abuse; social-interpersonal relations; and quality of life for both
parents and children. At the same time, we need to better understand how
to study families with whom we have only short-term access. Participants
expected DHHS to take a leadership role in looking at possible IRB
barriers to research.

A number of avenues for research on intervention approaches exist for
different types of trauma and for children of different ages. These
include studies of effective domestic violence prevention programs,
children exposed to violence but who display no psychiatric symptoms,
differential impact of various types of violence/trauma, programs for
very young and older children, the effects of stress inoculation, and
peripheral effects of terrorism.

Intervention development should involve the subjects or target
community, and interventions should be ethnically and culturally
appropriate for the population studied.

More research should focus on evaluating the cost-effectiveness of
different intervention approaches. A side benefit of this would be in
facilitating the formulation of powerful policy arguments in support of
specific interventions.

More research is needed on how interventions for parents affect the
development of their children. Specifically, future research foci should
include the psycho-educational impact of parenting
interventions/training, the role of the father, the impact of parental
substance abuse treatment and mental health treatment, parenting
approaches across the developmental spectrum, especially with older
children (aged 16+), involvement of parents in different settings
(including home and school) and alternative tools to reach parents.

[]{#__RefHeading___Toc18291233 .anchor}VII. Legal and Policy Issues

*Moderator: Shelly Jackson, Ph.D., National Institute of Justice*

A. Intended Goals, Outcomes, and Effectiveness

*Peter Jaffe, Ph.D., University of Western Ontario*

Dr. Jaffe prefaced his talk by noting that the response to domestic
violence is becoming integrated at all levels in Canada---through
legislation, training, community collaboration, and though public and
school-based prevention programs. He then reviewed some of the
state-level legislative penalties throughout the U.S. for adults who
expose children to domestic violence, noting that legislation can often
be seen as a quick fix. Some of the benefits of new criminal laws
include access to victim compensation funds, education for law
enforcement, and referrals to Child Protective Services where
appropriate. Legislation also makes a public statement about the issue.
Some of the unintended, negative effects are that "victims" end up being
charged, children have to testify in court, and laws may prevent victims
and their children from disclosing their situation.

Another legislative issue is whether children exposed to domestic
violence should be deemed in need of protection by the law. On the one
hand, it provides help for vulnerable children and sends a clear message
to the public about the government's position on this issue. It also
promotes consistency in the handling of cases. On the other hand, Child
Protective Services may not be able to handle the increased workload.
Moreover, not all children exposed to domestic violence have problems,
and mothers are placed in the position of losing their children if they
disclose their abusive situation to the authorities.

Domestic violence is often a critical factor in deciding child custody
disputes. It is important for judges to consider the effects of domestic
violence, because abuse does not end with separation, and in extreme
cases homicide and abductions can result. In addition, domestic violence
often coexists with child abuse. Judges need to also consider that
children living with an abusive parent are exposed to an inappropriate
role model, and that new relationships formed by that parent are also
potentially violent. Unfortunately, recent child custody legislation has
fostered greater skepticism in judges and lawyers about domestic
violence allegations, delayed court proceedings, and increased pressure
to settle cases without regard to child safety.

Future research priorities should include collection of baseline data on
victims, perpetrators and their children, and their court experiences.
There is also a need to comprehensively evaluate the positive and
negative impact of legislation and policy on these persons. We need to
understand the interplay of all involved sectors, including courts,
police, and community services.

B. Gaps, Unintended Consequences, and International Issues

*Sheldon Levy, Ph.D., M.P.H., Brown University*

Children living in high crime areas are at increased risk for behavior
problems. There is considerable research on how such factors as the
characteristics of the child, frequency, severity, and chronicity of
violence, and how the quality of the family and social relationships
moderate the impact of domestic violence and abuse on the child.
However, there is a paucity of research on whether these factors also
moderate children's response to community violence. One study found that
the level of maternal distress and her socioeconomic status mediated how
community violence impacted her child's behavior. This suggests that
programs and resources that support mothers and alleviate their distress
can have positive effects on their child's coping.

Often adults, however, minimize or deny the presence of children at
crime scenes. Because of this, both the National Institute of Justice
and the International Association of Chiefs of Police have recommended
specific training for police and other first responders such as firemen,
emergency medical technicians, teachers, religious leaders, and health
care providers. It may also be worth considering Victims of Crime
legislation to cover child witnesses as potential victims of crime.
Current laws generally only address adults. Extending victim services to
children who experience violent events may help many children obtain
immediate help.

Since September 11, one study found that children's perceptions of death
risk were dramatically higher compared to one year before. While
agencies like the CDC are reviewing their policies about how to deal
with bioterrorist attacks, such as anthrax, no decisions have been made
about how to handle unaccompanied children in potential quarantine
situations, and there are no specific laws about responding to the
psychological needs of these children or how to insure contact with
family. We do not know how prolonged family separation due to quarantine
will affect children, or how to best design such facilities to minimize
stressful effects. While one follow-up study has been published on the
impact of children exposed to the Oklahoma City bombing, it would be
useful to conduct follow-up research on children who were in the
geographic region of the World Trade Tower attacks of 1993 and 2001, or
the sarin gas attack in Tokyo. We could also look at syntheses of
existing research on children separated from parents due to isolation in
infectious disease units.

In terms of war and terrorism in other countries, the Convention on the
Rights of the Child, adopted by the United Nations in General Assembly
in 1989, provides clear standards on the protection of children from
violence. However, as of July 2002, the United States had not ratified
it, making it one of only two countries not to have done so. In
addition, current U.S. refugee policy requires that children who are
refugees, adoptees, or immigrants have medical screenings prior to
coming to the United States; however, the required mental status
component is not consistently done. This is true even for children known
to have been exposed to armed conflict or terrorism. Given the known
impact of war and terrorism on children who eventually are referred for
services, it would seem reasonable to identify these children early to
address the short- and long-term impact of the trauma. There are also a
number of epidemiological and health services research studies that can
help inform policies on refugee children exposed to armed conflict.

Legal and policy responses to help children better cope with community
violence, war, and terrorism require thoughtful research. Ultimately,
political consensus will be necessary to make decisions about the
allocation of resources regardless of what scientific research may
reveal. In the final analysis, however, what will be in the best
interest of children will be to reduce the factors that contribute to
community violence and find less violent ways to resolve the social,
political, cultural, and economic conflicts that lead to war and
terrorism.

C. Response

*Patricia M. Sullivan, Ph.D., Creighton University*

Dr. Sullivan commented on the issue of violence in all segments of U.S.
society. In terms of school violence, she noted that corporal punishment
still exists in some schools, reinforcing the culture of violence. We
need to look at the rising occurrence of relational aggression among
girls. Violence also exists in the media, and we need to examine the
increasing sensitization of youth to violence, as well as violence
outcomes stemming from the early sexualization of girls. Violence is
also a component of religion. For instance, many wars are predicated on
the debate over whose god is better. Systemic violence also occurs in
institutions, for instance residential schools for the disabled. We need
to take a closer look at restraints, seclusion, and medications used as
punishment. Overall, however, it is important to consider whether taking
children out of the home is improving or worsening lives.

There is much pending legislation that has implications for children
exposed to violence. Congress has a strong interest in this area,
although no consensus exists at the federal level about best approaches.
There is also legislation aimed at addressing violence against persons
with disabilities. Researchers and policymakers need to look at the
unintended consequences of already enacted legislation such as Megan's
Law, and the Health Insurance Portability and Accountability Act, which
have implications for children exposed to violence.

Future research efforts should focus on including child disability
status in violence research, epidemiologic research on disability and
violence, and surveillance research related to violence and disability.
We also need to take a public health approach, integrate evolutionary
biology, educate IRBs regarding violence and disabilities, have
disability review teams, and evaluate legislative and workshop outcomes.

D. Discussion

The legal and policy issues discussion yielded brief but important
points on recognizing the impact of institutionalization on violence,
the need for culturally sensitive studies of violence, and reporting
problems for researchers conducting domestic violence research.

It was also noted that, in general, policymakers do not wait for
performance research to implement legislation. Researchers need to be
aware of pending policies and legislation, and respond accordingly.
Participants advocated rapid funding mechanisms, like those implemented
in response to the terrorism initiative, as possible solutions.

E. Summary of Recommendations

Future research priorities should include collection of baseline data on
victims, perpetrators and their children, and their court experiences.
There is also a need to comprehensively evaluate the positive and
negative impact of legislation and policy on these persons. We need to
understand the interplay of all involved sectors, including courts,
police, and community services.

It is also important to explore whether factors such as characteristics
of the child, frequency, severity, and chronicity of violence, and
quality of the family and social relationships moderate or mediate
children's response to violence.

[]{#__RefHeading___Toc18291234 .anchor}VIII. Summary and Next Steps

A wealth of recommendations for future research directions emerged from
the Workshop on Children Exposed to Violence. One of the key themes was
a call for more attention to definitional and measurement issues, to
help us understand how different people define violence, community,
exposure, abuse, and other key terms. Consistent definitions enable
researchers to conceptualize and systematically study the problem.
Another key theme was the need for better data and more attention to
improving study designs, including longitudinal and intergenerational
studies. Common themes included the need to consider unique social,
cultural, and developmental perspectives of different children, to
improve our understanding of the factors that foster resilience, and to
focus on empirically based interventions.

In her concluding remarks, Dr. Feerick suggested that the next step is
to figure out the best way to implement the recommendations arising from
this meeting. She indicated that there would be follow-up work to these
presentations and a possible special journal issue on this topic.

Participants noted that poverty is a complex issue that is difficult to
change given the political and legislative issues, but many felt that we
must continue to keep it on the nation's research agenda, particularly
when assessing its relationship to violence and human capital. There
were also suggestions concerning looking at other micro- and
macro-system variables that may contribute to violence, particularly for
some sub-groups that are at particularly high-risk for domestic and
community violence (e.g., poor communities). We also need to look at how
terrorism incites aggression and racial prejudice. Some suggested that
community be viewed in terms of social relationships rather than
geographic area, and to look to findings from sociology, urban
anthropology, and urban planning to understand how historical isolation
contributes to violence. In terms of final thoughts regarding services
and interventions, participants endorsed approaches that involved
children with disabilities, and parent education and interventions for
"resistant families." Another suggestion was to consider the extent to
which cultural variables such as "family friendliness" in societies help
to promote policies likely to mitigate children's exposure to violence.
Researchers strive to remain neutral but empathetic. Researchers'
challenges need to be considered, such as the ethical dilemmas of doing
research in the field, both in domestic and international venues.

[]{#__RefHeading___Toc18291235 .anchor}IX. References

Appel AE and Holden GW, 1998. "The co-occurrence of spouse and physical
child abuse: A review and appraisal." *Journal of Family Psychology* 12
(4): 578-599.

Edleson JL, 1999. "The overlap between child maltreatment and woman
battering." *Violence Against Women, 5*(2), 134-154.

Feerick MM and Haguaard JJ, 1999. "Long-term effects of witnessing
marital violence for women: The contribution of childhood physical and
sexual abuse." Journal of Family Violence, 14(4), 377-98.

Felitti VJ, Anda RF, Nordenberg D, Williamson DF, Spitz AM, Edwards V,
Koss MP, Marks JS, 1998. "Relationship of childhood abuse and household
dysfunction to many of the leading causes of death in adults." The
Adverse Childhood Experiences (ACE) Study. *Am J Prev Med* 14 (4):
245-58(May).

Greenwood PW, 1996. "Responding to juvenile crime: lessons learned."
Future Child 6 (3): 75-85 (Winter).

Greenwood PW, Model KE, Rydell CP, and Chiesa JR, 1998. "Diverting
Children from a Life of Crime: Measuring Costs and Benefits." RAND
publication,
[MR-699-1-UCB/RC/IF](http://www.rand.org/cgi-bin/Abstracts/ordi/getabbydoc.pl?doc=MR-699-1-UCB/RC/IF)
available online at:
<http://www.rand.org/pubs/monograph_reports/MR699-1/index.html>.

Kempe CH, Silverman FN, Steele BF, Droegemuller W, and Silver HK, 1962.
"The battered child syndrome." *Journal of the American Medical
Association* 181:17 - 24.

Kerouac S, Taggart ME, Lescop J, and Fortin MF, 1986. "Dimensions of
health in violent families." Health Care Women Int, 7(6), 413-26.

McCauley J, Kern DE, Kolodner K, Dill L, Schroeder AF, DeChant HK, Ryden
J, Derogatis LR, and Bass EB, 1997. "Clinical characteristics of women
with a history of childhood abuse: unhealed wounds." *JAMA* 277 (17):
1400-1 (May 7).

McGee R, Wolfe DA, Yuen SA, Wilson SK, and Carnochan, J, 1995. "The
measurement of maltreatment: A comparison of approaches." *Child Abuse
and Neglect* 19 (2): 233-249.

[]{#__RefHeading___Toc18291834 .anchor}Appendix A.

Domestic Violence:

Summary and Recommendations of Breakout Group

Chairs: Gayla Margolin and Martin Teicher

Children's Exposure to Marital Violence

***Basic Question:*** What scientific developments are needed for us to
understand better, to respond more effectively, and ultimately to
prevent children's exposure to domestic violence (DV)?

-   Strategies

-   Topics

-   Repeating themes

Strategies

-   Broaden the scope of independent and dependent variables

-   Enhance the depth and precision of processes and mechanisms through
    both descriptive and theory-driven designs

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-   examine pathways; examine iterative cycles;

-   examine protective factors as well as risk factors

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-   Measure stability vs. change over time/longitudinal designs

-   Monitor outcomes of naturally occurring and experimental
    interventions

Topics for Further Study

-   The nature of exposure to domestic violence

-   The impact of domestic violence on family functioning

-   The impact of domestic violence on child functioning

-   The interface with other systems

Repeating Themes

Research needs to be. . .

-   Culturally sensitive

-   Developmentally sensitive

-   Gender sensitive

Understanding the Nature of Exposure

1.  Broader/more inclusive definitions of violence

-   Range of intensity (e.g., verbal aggression through homicide)

-   Range of behaviors (e.g., psychological control, threat of violence,
    coercion, etc.)

-   Develop a common language/common measurement across researchers

2.  Timing and patterning of exposure (e.g., age of onset, frequency of
    exposure, single episode vs. multiple episode vs. chronic,
    coincidence with important developmental transitions)

3.  Multiple reporters (moms, dads, children, other family members,
    first line responders such as police, health care workers)

-   For purposes of corroboration

-   For purposes of different perspectives

4.  Understand children's perspectives, attributions and meanings
    ascribed to DV

-   How does the meaning of DV (understanding of danger) change across
    development?

-   What explanations have the parents given to the child regarding the
    DV?

5.  Measure child's degree of involvement in DV

-   Type of sensory input (e.g., directly see, hear from another room,
    hear about DV from someone else, see evidence of DV such as mother's
    bruise)

-   Child's reaction, particularly when directly see or hear (try to
    physically intervene, call police or contact another adult, leave
    home, protect sibling, hide in closet)

6.  Measure DV within an Overall Context

-   Place in context of other forms of violence (e.g., direct
    victimization through child abuse, sibling abuse, community
    violence, terrorism)

-   Place in context of other adversities (e.g., poverty, parental
    mental illness, parental substance abuse, displacement from home,
    unhealthy peer relations, natural disasters)

-   Whether co-occurring or sequential, consider cumulative effects\--To
    what extent does DV lead to unique variance in child outcomes?

7.  Cultural Definitions and Understanding of Violence

-   Sample populations that differ on SES, cultural background,
    ethnicity, immigrant status, etc.

-   Understand the meaning of DV from different cultural perspectives

-   Apply theoretically driven approaches to cultural questions (e.g.,
    cultural views on male-female roles, on hierarchies in family, on
    permeability of family boundaries to outside influences; cultural
    identity as a strength)

Impact of Domestic Violence on Family Functioning

1.  Impact of DV on family as a system

-   Effect on family organization and structure (e.g., role reversal vis
    a vis parents and siblings; chaos and unpredictability vs. overly
    rigid; providing for child's needs in terms of regular meals, clean
    clothes, school supplies, medication, etc.)

-   Effect on family interaction\--hostility vs. warmth; family as a
    safe place

-   Relations with extended family\--involved vs. isolated

-   Impact on teen's decision to leave home and/or cut-off relations
    with family

-   Impact of family violence on poverty and life stress

8.  Impact of DV on Parenting

-   Need focus on competent parenting as well as compromised parenting

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-   What do mothers do to protect their children?

-   How does a mother's style of coping with trauma affect her
    parenting?

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-   Need focus on fathers as well as on mothers

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-   What is the father's commitment/involvement with child?

-   Is contact with the father helpful vs. harmful?

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-   How DV affects parenting children of different ages

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-   Prenatal care and protection of the fetus

-   Parenting the preschool child\--meeting the child's high need for
    engagement and supervision

-   Parenting the school-age child\--parent as link to the outside world
    such as school system; monitoring activities and friendships;
    facilitating child's emerging competencies

-   Parenting the adolescent; continuing to keep open communication
    channels while tolerating adolescent's separation from family

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-   Ethnic differences in parenting and how they relate to DV

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-   Authoritarian vs. authoritative parenting

-   Closeness vs. distance\--exaggerated with DV?

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-   Parenting of female vs. male children in families with DV (and with
    respect to ethnicity)

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-   Parents as role models for male and female behavior

Consequences for the Child

There is a pressing need for research that broadens and expands our
understanding of the effects of exposure to DV on children.

Research has largely focused on outcome in terms of psychiatric symptoms
or psychopathology in school age children.

Much more research is needed to better understand outcomes or
consequences from a comprehensive perspective (biopsychosocial,
developmental).

What are the neurobiological consequences of exposure to DV? What brain
regions/systems are vulnerable? How is vulnerability affected by age and
duration of exposure? How is vulnerability affected by gender? How
enduring are the consequences, and how are they affected by treatment?
How does plasticity and recuperative ability change with age and
duration of exposure?

What are the neurophysiological consequences of exposure to DV? What are
the short-term and long-term consequences on measures of arousal,
sympathetic and parasympathetic function, functional brain activity? Are
there enduring effects of exposure to domestic violence on
neuroendocrine regulation? What are the mediating effects of sleep
impairments?

What are the neuromaturational consequences of exposure to DV? Are their
alterations in the time course and development of startle inhibition,
attentional capacity, regulation of affect, stress reactivity, control
of motor activity, executive functions, linguistic and cognitive
capabilities?

What are the medical / health consequences of exposure to DV? Are there
alterations in immune system function that affect vulnerability to
infections or increase risk for autoimmune disorders? Are there
particular medical / health problems that occur with unusual frequency
in children exposed to DV? How is this affected by gender, age and
duration of exposure?

What are the functional consequences of exposure to DV? How does
exposure to DV impact school readiness, school performance, degree of
educational achievement, work abilities, job performance?

What are the consequences of exposure to DV on the ability to form and
maintain relationships? How does exposure to DV affect peer
interactions, dating behaviors, attitudes toward the opposite gender,
intimate relationships? What factors explain why some males exposed to
DV engage in violence as adults while others do not?

What are the consequences of exposure to DV on moral development and
social responsibility? What is the relationship between exposure to DV
and juvenile crime?

What are the consequences of exposure to DV on risk for substance or
alcohol abuse? How is this affected by age and duration of exposure,
gender? How does exposure to DV interact with genetic/familial risk
factors?

Research is needed that identifies outcome at each developmental stage.
There is a particular need for research that identifies consequences of
exposure to DV on very young children (preschool children).

Careful methodological research is needed that specifically identifies
the effects of exposure to DV, recognizing that children exposed to DV
are often exposed to other forms of violence, and multiple forms of
stress and adversity. What are the additive, synergistic or cumulative
effects of exposure to multiple forms of violence?

What are the consequences of chronic exposure to relatively low levels
of DV (e.g., verbal abuse of a partner)?

What are the consequences of exposure to the most extreme forms of DV
(homicide, homicide - suicide)?

There is a need for theory-guided research on gender differences in the
consequences of exposure to DV that provides a meaningful understanding
of gender differences in response.

There is a need for theory-guided research on factors that help to
protect children from the consequences of exposure to DV. It is
important to distinguish protective factors from the absence of risk
factors.

There is a need for theory-guided research on the mediating or
moderating effects that culture and socioeconomic status exert on the
consequences of exposure to DV.

There is a need for further research on resilience to understand
intrinsic factors that lead to healthier outcomes in children exposed to
DV.

There is a need for better instruments that provide a broader degree of
assessment and measurement of the consequences of exposure to DV.

There is a need for qualitative research studies in all domains to
provide more detailed and meaningful characterization of the
consequences of exposure to DV, and which also guides and informs
quantitative research on protective factors and aspects of resilience.

Systems Interface

Children exposed to DV often come into contact with many different
systems, such as the healthcare system, mental health system,
educational system, and justice system. They can come into contact with
police officers, child protective services, shelters, foster care
placements, Department of Youth Services facilities, and even
*researchers*.

Children exposed to DV often interact with a variety of informal systems
that include: relatives, neighbors, friends, religious groups, community
groups.

There is a need for research that delineates the natural course of
contact that children exposed to DV have with these formal and informal
systems. There is a need for research to understand the pipeline of
system services.

There is a need for research that identifies for children exposed to DV
the consequence of their interaction with these different formal
systems. How is a child's outcome affected by the pipeline of services
that the child is exposed to?

There is a need for research that delineates for children and parents
the effects of contact with various informal systems. How does exposure
to these informal systems affect outcome?

There is a need for research that rapidly identifies the consequences of
new legislation designed to better protect or to help victims of DV and
their children. What is the impact of the legislation? Are there
unintended consequences of the legislation?

There is a need for research that examines the impact and consequences
of media campaigns or educational efforts that are designed to increase
awareness about DV. What types of campaigns are successful, and how can
success be measured in creative and meaningful ways?

There is a need for research that evaluates the impact and success of
educational programs designed to increase awareness and understanding of
DV of key sentinels (e.g., police, ER personnel, teachers, school
nurses, guidance counselors, judges).

There is a need for research that enhances the ability of agencies or
sentinels to identify children in need of services, and which guide them
to making effective decisions for referral or services.

[]{#__RefHeading___Toc18291835 .anchor}APPENDIX B.

Community and School Violence:

Summary and Recommendations of Breakout Group

Chairs: John Bolland and Gregory Thomas

The group posed the concept that the community is not just the location
of the violence or a set of people, houses, and apartments. The
community is a set of interconnecting relationships. Since violence in
schools often stems from the community, the school can be viewed as an
integral part of the community; therefore, it does not make sense to
distinguish between school violence and community violence, except in
unique issues such as bullying. We also need to understand school
violence in terms of a chronic condition, not just acute incidents like
Columbine. Research is needed to inform policymakers about best
practices. Given this we need to know more about the following.

Definitional and Measurement Issues

-   Is exposure to violence the same as witnessing violence?

-   How does being a victim differ from being in a violent environment?

-   How do we define the term "violent" and what it means to individual
    students and individual communities? How children perceive violence
    whether they see it or not?

-   How do different racial, ethnic, cultural groups define "community,"
    "family," and "neighborhood?"

-   How do you define who is the "perpetrator" and who is the "victim?"
    Is that perceived differently in different communities? For
    instance, police may be considered the savior in one community and
    the bad guy in another.

Effects of Violence on the Community

-   We know less about how violence exerts its influence on communities
    and families.

-   How does violence affect the community? How does the community
    buffer violence in its response to it?

-   What does the community reaction to violence do to children? Their
    reactions? Their development?

-   What are the specific outcomes of children exposed to dual violence
    (for example, domestic and community violence)? Do the effects
    differ for domestic violence compared to community violence? What
    are the implications for interventions?

-   What are the physical outcomes (health, trauma, disease) of
    community violence?

Theoretical Studies

-   How do children develop values in terms of whom to trust and whom
    not to trust?

-   What are the key underlying pathways/mechanisms between being
    exposed to violence and the outcome of violence? This can be
    examined through longitudinal studies on the mediators of violence

Developmental Perspectives

-   How does exposure to violence affect each stage of a child's
    development? How does violence affect the child at different stages
    of cognitive development?

-   There is very little known about how younger children (3-5) perceive
    and define their community. We need instruments that can better
    measure young children's perception of their communities and
    neighborhoods.

Ethnic/Cultural Perspectives

-   What is the impact of exposure to violence on other risk behaviors
    and ultimately health disparities?

-   Currently, much of the community violence research is being
    conducted in communities of color. How is exposure to violence
    impacted by ethnicity?

-   What causes feelings of alienation and hopelessness across
    ethnicity?

-   How do you disentangle the specific and individual effects of SES,
    ethnicity, and culture on community violence? Studies are needed
    that can provide that information.

School Violence

Participants noted that school violence should not be equated to
Columbine, and that concentrating on school violence as an "island,"
separate from community violence, is wrong.

-   What are the effects of chronic exposure to school violence on
    children in terms of normal development and educational outcomes?

-   What role can schools play in mediating school violence?

-   Some social problems are solvable. If you reduce family and
    community violence, does it change how children behave in schools?

-   How can you link government and education systems to improve the
    community?

-   Studies are needed to examine the effects of bullying in schools,
    particularly at younger ages.

-   Better instruments need to be developed to capture the qualities
    that describe the culture of a school.

Moderators and Mediators

-   What are the protective factors, assets, etc. in a community that
    foster resilience to violence?

-   Does faith/religion modify an individual, family, and community
    response to violence?

-   How do substance abuse and the juvenile justice system contribute to
    community violence?

Interventions

We need more interventions directed at the community level compared to
just individual only interventions.

Policy and Legislation

Studies of international gun control policies and their effects on
community violence would be particularly useful.

[]{#__RefHeading___Toc18291836 .anchor}APPENDIX C.

Terrorism/War:

Summary and Recommendations of Breakout Group

Chair: Paramjit Joshi

Gaps in Research

Definitions:

Terrorism:

-   Unlawful use of threat or force against an individual/government for
    political or other end with the intent/purpose of imposing ones will
    (DOD).

-   Illegitimate use of force to achieve political, social or religious
    objectives, when innocent people are targeted (FBI).

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-   Played out before a larger audience

-   Non-war atmosphere, unexpected, occurs in a safe place

-   Asymmetrical warfare, recurrent attacks

-   Groups who don't have other means to get their message across

-   Usually many more civilians involved

War:

-   Planned and executed usually by governments against other
    governments or countries in self defense or revenge

-   Usually have a beginning and an end

-   Civilians affected secondarily (collateral damage, not primary
    target)

QUESTIONS:

-   Is there a difference in the psychological consequences in a war
    situation versus a terrorist attack?

-   Is there a difference in emotional consequences if attack occurs
    when children are in a safe place

War & Terrorism

Peace interrupted by war, or war interrupted by peace (e.g., Middle
East)

QUESTIONS:

-   Chronic vs Acute: are the consequences different?

-   What is the role of anticipatory preparedness? Does it help or harm?

-   What are the effects of "chronic preparedness," whether violent acts
    happen or not?

Prevalence and Nature of Emotional Consequences

QUESTIONS:

-   What does the prevalence of harmful consequences depend on?

-   What are the risk and protective factors?

-   Should we develop a "Risk Model" or "Vulnerability Scale?

-   What does the phenotype look like?

-   What are the various variables that affect the phenotype

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-   Culture

-   Religious belief systems

-   Developmental stages of the child

-   Societal status of the victims

3 - D MATRIX: Cells need to be completed

+----------+----------+----------+------------+-----------+----------+
|          | **Pr     | **Risk** | **Pheno    | **Risk**  | *        |
|          | evalence |          | menology** |           | *Interve |
|          | of       | **F      |            | **Commun  | ntions** |
|          | Pat      | actors** |            | ication** |          |
|          | hology** |          |            |           |          |
+----------+----------+----------+------------+-----------+----------+
| Terror   |          |          |            |           |          |
+----------+----------+----------+------------+-----------+----------+
| War      |          |          |            |           |          |
+----------+----------+----------+------------+-----------+----------+

Third dimension: Proximity/Loss/Poverty

Secondary Effects of Terrorism

Teenagers not going to mall

Ripple effect

Cyber-terrorism

Effect on the economy

Parents losing their jobs

QUESTION: Need to think about it as a public health crisis and respond
accordingly?

In What Domains Do We Need To Examine The Effects?

Neurons to neighborhoods

Effects to be Examined in a Socio-Cultural Context?

When does adaptation to a stress become maladaptive? Allostatic load?

-   Physiological

-   Neurobiological

-   Psychosomatic (immune system, diseases etc.)

-   Psychological

-   Impairment of functioning in the absence of a Diagnostic and
    Statistical Manual (DSM) diagnosis

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-   Changes in behavior

-   Family interactions and structure

-   Societal interactions

-   Effects on learning

-   Neonatal and peri-natal impact on the child

Developmental Approach to Understanding?

Need to take a developmental approach - neuro-cognitive changes at
different ages and the relationship on the development of
neuro-psychiatric symptoms

Are their gender differences?

Effects of bereavement - early parent death and the effects depending on
age (e.g., Stolz has shown that bonding of the father with a child born
while the father is away at war is different than the bonding he has
with his other children)

Cultural Differences

"It is meant to be"

"It is Karma"

"God wanted it this way"

QUESTION: When does this type of coping become unhelpful and
maladpative? Does it work in the short run?

Longitudinal Course of the Evolution of Psychiatric Morbidity and
Co-Morbidity?

Is depression always preceded by anxiety?

If intervention is done in a timely fashion, can one postpone or even
prevent the development of depression?

Is depression related to the maternal response to trauma?

Other Factors to Consider

Refugee or not?

Leaves the situation or not?

Split families?

Immigration?

Public Health Model

Large majority need reassurance

Interventions get more specific and intense as one moves up to the tip

How does one identify those at greatest risk when an entire population
is affected?

Interventions - What Works?

Available models of interventions following disasters generally don't
focus on children

What are the effects of activities aimed at disaster preparedness in
children?

-   Psychological/behavioral

-   Learning

-   Phsysiological/neurobiological

Understanding coping and adaptation skills and strategies

How does one define resilience and how do we promote it?

What should the content of intervention modules be?

Do we want to think about the modules that have already been developed
to help youngsters after a natural disaster?

Do Modular Interventions in School Work?

Immediate response that can take place in the schools

Should schools be closed?

Prepositioned supplies or resources for the first 24 to 48 hrs. in
school (Level of preparedness).

The National Education Association (NEA) has developed intervention
models for the immediate response

SHOULD RESEARCH INITIATIVES BE DEVELOPED THAT FORCE COLLABORATION
BETWEEN THE SCHOOLS, MENTAL HEALTH & OTHER FIRST RESPONDERS?

Value of a Demonstration Project?

What Works?

Family interventions?

Extended family involvement?

Parenting techniques?

Single interventions strategies vs. ongoing?

School interventions?

Traumatic Reminders?

Do we need to have anniversaries?

What helps? What hurts even more?

Should there be memorials?

Challenges Faced by Researchers

Need empathy but neutrality at the same time

Expectations of the "subject"

International research during war or an act of terrorism presents other
ethical dilemmas

Helping the Helpers

Effect on children of helpers

Effect of "helpers" on their own children. Are they at more risk?

Evidence of increased levels of substance abuse, domestic violence and
suicide

Intergenerational Violence

How do we study it and are there prevention strategies?

Preventive Preparedenss

Gives people a sense of control vs. worrying them without giving them a
way to prepare and react

What effect does this have on society, parents, and children?

Quarantine?

What are the effects of quarantine on children and their families in a
situation of bioterrorism?

What are the psychological risks and benefits of such an approach?

[]{#__RefHeading___Toc18291837 .anchor}APPENDIX D.

Services and Interventions/Legal & Policy:

Summary and Recommendations of Breakout Group

Chair: Barbara Bonner

Principles

-   Learn from past mistakes in research -- lumping effect

-   John Fantuzzo approach -- fewer variables that account for more of
    the variance

-   Ecological/developmental approach

Immediate Research Recommendation

-   Evaluate current shelter programs for batterers, spouses, and
    children (process and outcome program evaluation)

-   Replicate promising programs

Recommend Intervention Research

Longitudinal\
Prospective\
Multi-site\
Multi agency

Culturally specific\
Adjusted for specific disabilities (hearing impaired)

Incorporates current research findings\
Includes young children and older adolescents

Involves community participants in designing intervention

Broad referral base

Methods to reduce attrition (e.g., provide transportation, use of
incentives)

Multiple data sources

Evaluate timing of interventions

-   Immediate

-   Onset of symptoms

-   Onset of disorders

Differential effects of forms of violence

Effects of substance use

> Effects of service site (e.g., clinic, in-home)
>
> Dosage effects
>
> Needs of children who do not present with symptoms
>
> Factors contributing to resilience for children and parents
>
> Father/child relationships
>
> Functional outcomes of children

-   Biological factors contributing to violence

-   Degree of collaboration among agencies

Problems

Availability of personnel to serve minority populations

IRB approval

-   Need education on violence, child abuse and neglect

-   DHHS needs to take leadership role on IRB barriers to research

Work force

-   Who is delivering services?

-   What training do they need?

Sustaining financing for services

Effects of HIPPA

-   Replicate current promising programs

Other Testable Ideas

Parenting for divorced parents with DV history regarding custody,
parenting

Parenting approach for parents with teens

Teach parenting using alternative tools (e.g., video, CD Rom, written
self-study)

Involve health insurance companies to decrease medical costs

[]{#__RefHeading___Toc18291838 .anchor}Appendix E. Final Agenda

**[Children Exposed To Violence:]{.smallcaps}**

# Current Status, Gaps, and Research Priorities

## July 24-26, 2002

#### Georgetown Holiday Inn

##### 2101 Wisconsin Avenue, NW

Washington, DC 20007

##### Day One 

8:00am -- 8:30am **CONTINENTAL BREAKFAST**

8:30am \-- 8:45am **Welcome/Overview-Purpose of the Workshop**

-   Margaret Feerick, NICHD

8:45am -- 9:45am **Setting the Context: Definitional and Measurement
Issues**

### Moderator\-- Ileana Arias, CDC

-   Penny Trickett *\[8:45am-- 9:05am\]*

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-   Defining and conceptualizing children's exposure to violence
    (domestic and community violence and war/terrorism)

-   Reliable and valid definitions

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```
-   George Holden *\[9:05am -- 9:25am\]*

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-   Exposure to violence (domestic) as constituting child abuse

-   What we know/where we are now?

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-   Disentangling incidence and effects of witnessing violence from
    actual abuse or victimization

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-   Lewis Leavitt *\[9:25am -- 9:45am\]*

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-   Measuring Violence Exposure: State-of-the-art measurement tools

9:45am -- 10:05am Panel of Respondents

-   Oriana Linares

-   Barbara Bonner

10:05am -- 10:35am Open Discussion

10:35am -- 10:50am **BREAK**

10:50am -- 11:30am **Domestic Violence**

Moderator\--Susan Solomon, OBSSR

-   John Fantuzzo

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-   *Prevalence \[10:50am -- 11:10am\]*

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-   What do we know about the prevalence of exposure to domestic
    violence?

-   Social contexts: How does exposure to violence differ in different
    social contexts?

-   Chronic exposure to violence

-   Cross-culturally and around the world

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-   David Wolfe

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-   *Consequences \[11:10am -- 11:30am\]*

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-   Emotional, behavioral, and mental health effects

-   Developmental differences (in the effects of exposure)

-   Child resilience: protective or buffering factors

-   Juvenile justice and education outcomes

11:30am -- 11:50am **Panel of Respondents**

-   Laura McCloskey

-   Jacquelyn Campbell

11:50am -- 12:20pm Open Discussion

12:20pm \-- 1:30pm **LUNCH**

1:30pm \-- 2:10pm **Community and School Violence**

Moderator\--Tom Hanley, OSEP

-   Bradley Stein

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```
-   *Prevalence \[1:30pm -- 1:50pm\]*

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```
-   What do we know about the prevalence of exposure to community and
    school violence?

-   Social contexts: how does exposure to violence differ in different
    social contexts (including schools)?

-   Chronic exposure to violence

-   Cross-culturally and around the world

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-   Michael Lynch

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```
-   *Consequences \[1:50pm -- 2:10pm\]*

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```
-   Emotional, behavioral, and mental health effects

-   Developmental differences (in the effects of exposure)

-   Child resilience: protective or buffering factors

-   Juvenile justice and education outcomes

2:10pm \-- 2:30pm **Panel of Respondents**

-   Kathy Sanders-Phillips

-   Gregory Thomas

2:30pm \-- 3:00pm Open Discussion

3:00pm \-- 3:15pm **BREAK**

3:15pm -- 3:55pm **Terrorism/War**

Moderator\--Farris Tuma, NIMH

-   Robert Pynoos

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```
-   *Prevalence \[3:15pm -- 3:35pm\]*

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```
-   What do we know about the prevalence of exposure to war/terrorism?

-   Social contexts: how does exposure to war/terrorism differ in
    different social contexts?

-   Chronic exposure to violence

-   Cross-culturally and around the world

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```
-   Jon Shaw

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```
-   *Consequences \[3:35pm -- 3:55pm\]*

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```
-   Emotional, behavioral, and mental health effects

-   Developmental differences (in the effects of exposure)

-   Child resilience: protective or buffering factors

-   Juvenile justice and education outcomes

3:55pm \-- 4:15pm **Respondent**

-   Paramjit Joshi

4:15pm \-- 4:45pm Open Discussion

4:45pm \-- 5:15pm **Q & A and Open Discussion of the Day's Topics**

5:15pm **ADJOURN**

**[Children Exposed To Violence:]{.smallcaps}**

# Current Status, Gaps, and Research Priorities

## July 24-26, 2002

#### Georgetown Holiday Inn

##### 2101 Wisconsin Avenue, NW

Washington, DC 20007

[Day Two]{.smallcaps}

8:30am -- 9:00am **CONTINENTAL BREAKFAST**

9:00am -- 10:00am **Services and Interventions for Children Exposed to
Violence**

> Moderator -- Jerry Silverman, ASPE

-   Honore Hughes *\[9:00am-9:20am\]*

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-   Overview of the scope and variety of interventions for children
    exposed to domestic violence

-   Exposure to domestic violence as a gateway to service

-   Services and the needs of children exposed to domestic violence

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```
-   Steven Marans and Steven Berkowitz *\[9:20am-9:40am\]*

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```
-   Overview of the scope and variety of interventions for children
    exposed to community violence and war/terrorism

-   Exposure to community violence as a gateway to service

-   Services and the needs of children exposed to community violence and
    war/terrorism

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```
-   Hope Hill *\[9:40am-10:00am\]*

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-   The desired outcomes of intervention programs

-   Evaluation of the success of programs

-   Domestic and international issues; developing countries

10:00am -- 10:20am **Panel of Respondents**

-   Judith Cohen

-   Betsy McAlister Groves

10:20am -- 10:50am Open Discussion

10:50am -- 11:05am **BREAK**

11:05am -- 11:45am **Legal and Policy Issues**

Moderator -- Shelly Jackson, NIJ

-   Peter Jaffe *\[11:05am -- 11:25am\]*

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-   Laws and policies addressing the needs of children exposed to
    violence

-   Intended goals and outcomes of policies and programs

-   Effectiveness of programs

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```
-   Sheldon Levy *\[11:25am -- 11:45am\]*

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-   Gaps and research needed to inform the development of laws and
    policies

-   The unintended consequences of laws and policies

-   Domestic and international issues; developing countries

11:45am -- 12:05pm **Respondent**

-   Patricia Sullivan

12:05pm -- 12:35pm Open Discussion

12:35pm -- 1:45pm **LUNCH**

1:45pm -- 2:00pm **Charge to Break-out Groups**

Margaret Feerick, NICHD

2:00pm - 4:30pm Breakout Groups: Research Gaps in Each of the Areas
(Focus on Child

health outcomes, mechanisms, research needed for interventions)

Domestic Violence Group\--Moderator: Coryl Jones, NIDA

*Chairs: Gayla Margolin and Martin Teicher*

Questions to be addressed:

-   What are the main research gaps/needs in the area of children
    exposed to domestic violence?

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-   What research is needed in terms of prevalence, consequences, causal
    risk factors, and mechanisms?

-   How should research take into account developmental stages of
    children and youth exposed to domestic violence?

-   What research is needed on how different ways of coping (both
    positive and negative) by battered women affect their children?

-   What characteristics (besides type of trauma) are important to
    consider in terms of the research on mechanisms and consequences of
    exposure to domestic violence?

-   How should the research on outcomes be expanded (e.g., should
    medical outcomes be examined)?

-   What basic research is needed in terms of time phase of symptoms and
    behavioral reactions in order to inform intervention strategies?

-   What research is needed in the area of interventions to prevent or
    treat long-term negative emotional consequences of witnessing family
    violence?

-   What research is needed in the area of preventive intervention
    models targeted toward at-risk individuals or families?

-   What research is needed in the area of definitions/measurement?

-   What research is needed regarding measuring and examining
    resilience?

-   What research is needed in order to inform services and policies in
    this area?

Community and School Violence Group\--Moderator: Susan Martin, NIDA

> *Chairs: John Bolland and Gregory Thomas*
>
> Questions to be addressed:

-   What are the main research gaps/needs in the area of children
    exposed to community and school violence?

-   What research is needed in terms of prevalence, consequences, causal
    risk factors, and mechanisms?

-   What characteristics (besides type of trauma) are important to
    consider in terms of the research on mechanisms and consequences of
    exposure to community and school violence?

-   How should the research on outcomes be expanded (e.g., should
    medical outcomes be examined)?

-   What research is needed to address how schools or neighborhoods
    influence occurrence and consequences of neighborhood or
    school-related violence?

-   What research is needed in terms of time phase of symptoms and
    behavioral reactions in order to inform intervention strategies?

-   What research is needed in the area of definitions/measurement?

-   What research is needed regarding measuring and examining
    resilience?

-   What research is needed in order to inform services and policies in
    this area?

-   What research is needed in the area of interventions to prevent or
    treat long-term negative emotional consequences of witnessing
    community or school violence?

-   What research is needed in the area of preventive intervention
    models targeted toward at-risk individuals or families?

Terrorism/ War Group\--Moderator: LeShawndra Price, NIMH

*Chair: Paramjit Joshi*

Questions to be addressed:

-   What are the main research gaps/needs in the area of children
    exposed to terrorism/war violence?

-   What research is needed in terms of prevalence, consequences, causal
    risk factors, and mechanisms?

-   What characteristics (besides type of trauma) are important to
    consider in terms of the research on mechanisms and consequences of
    exposure to war/terrorism?

-   How should the research on outcomes be expanded (e.g., should
    medical outcomes be examined?)

-   What research is needed in terms of time phase of symptoms and
    behavioral reactions in order to inform intervention strategies?

-   What research is needed in the area of definitions/measurement?

-   What research is needed regarding measuring and examining
    resilience?

-   What research is needed in order to inform services and policies in
    this area?

-   What research is needed in the area of interventions to prevent or
    treat long-term negative emotional consequences of witnessing family
    violence?

-   What research is needed in the area of preventive interventios
    models targeted toward at-risk individuals or families?

Services and Interventions/Legal & Policy Issues Group-Moderator: Sharon
Amatteti, SAMHSA

*Chair : Barbara Bonner*

Questions to be addressed*:*

###### What are the limitations of current research and the scientific knowledge base on services and interventions? What gaps exist and what new research is needed?

###### What are the intended and desired outcomes of interventions and what are the strengths and limitations of existing indicators and data sources commonly used to evaluate and monitor the success of these programs?

###### What are the limitations of methods typically used to evaluate these programs?

-   What research is needed in order to develop and evaluate effective
    interventions (including research on content, duration, number of
    sessions, timing, inclusion criteria, and symptom threshold for
    interventions)?

-   What research is needed on how services/interventions impact on
    children and families?

-   What research is needed on intervention approaches for different
    types of trauma and for children of different ages?

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-   What research is needed in the area of interventions to prevent or
    treat long-term emotional consequences of witnessing violence in the
    family or community?

-   What research is needed in the area of preventive intervention
    models targeted toward at-risk individuals or families?

-   What research is needed on how services/policies impact children and

> families?

-   What research is needed to evaluate the cost-effectiveness of
    different intervention approaches?

-   What research is needed to assess the effectiveness of various
    collaborative approaches to addressing issues of exposure?

-   What research is needed on how interventions for parents affect the
    development of their children?

4:30pm **ADJOURN**

**[Children Exposed To Violence:]{.smallcaps}**

# Current Status, Gaps, and Research Priorities

## July 24-26, 2002

#### Georgetown Holiday Inn

##### 2101 Wisconsin Avenue, NW

Washington, DC 20007

[Day Three]{.smallcaps}

8:30am -- 9:00am **CONTINENTAL BREAKFAST**

9:00am -- 9:15am **Definitions and Overview of Discussion of Summary and
Recommendations**

-   *Margaret Feerick, NICHD*

9:15am -- 9:45am **Domestic Violence: Summary and Recommendations**

-   *Gayla Margolin and Martin Teicher*

9:45am -- 10:15am **Community and School Violence: Summary and
Recommendations**

-   *John Bolland and Gregory Thomas*

10:15am -- 10:45am **Terrorism/War: Summary and Recommendations**

-   *Paramjit Joshi*

10:45am -- 11:15am **Services and Interventions/Legal & Policy Issues:
Summary and Recommendations**

-   *Barbara Bonner*

11:15am -- 12:00pm **Discussion: Summary and Next Steps**

12:00pm **ADJOURN**

[]{#__RefHeading___Toc18291839 .anchor}Appendix F. Biographical Sketches
of Presenters

**Steven J. Berkowitz, M.D.** is the Medical Director of the National
Center for Children Exposed to Violence (NCCEV) and an Assistant
Professor of Child and Adolescent Psychiatry at the Yale University
School of Medicine's Child Study Center. Dr. Berkowitz has been one of
the primary developers and proponents of the Child Development-Community
Policing Program, a nationally replicated program between law
enforcement and child mental health professionals. This program is the
core intervention project of the NCCE and provides immediate and follow
up collaborative mental health and law enforcement intervention for
children who witness and are victimized by violence in their homes,
schools and communities. Dr. Berkowitz has helped develop several other
community based initiatives for children and families that are at high
risk for poor developmental and psychiatric outcomes. He is a founder
and Medical Director of the Intensive In-home Child and Adolescent
Psychiatry Service (IICAPS). A model of intensive home and community
based treatment that has recently become a core service for
disadvantaged children and their families in the State of Connecticut.
The majority of children served by the IICAPS have histories of violence
exposure.

**John M. Bolland, Ph.D**. is a Senior Research Scientist at the
University of Alabama and Director of its Institute for Social Science
Research. His Ph.D. is in Political Science from The Ohio State
University, and he taught for six years at the University of Kansas
before moving to the University of Alabama. Dr. Bolland's long-term
research interests have addressed urban issues, and he has published a
book (with Lawrence J.R. Herson) on urban politics, policy, and theory.
During the past ten years, his research has concentrated on inner-city
poverty and its impact on children and families. Specific research
studies conducted during this period include assessments of homelessness
in two Alabama cities; the design, implementation, and evaluation of a
community development program to reduce risk behaviors among adolescents
living in public housing developments in Huntsville, AL; an ongoing
longitudinal survey of adolescents living in low-income neighborhoods in
Mobile, AL; and an evaluation of a maternal and child health program for
low-income adolescents and their babies in Mobile, AL.

**Barbara L. Bonner, Ph.D.,** a Clinical Child Psychologist, is a
Professor and the CMRI/Jean Gumerson Endowed Chair, Director of the
Center on Child Abuse and Neglect, and Associate Director of the Child
Study Center in the Department of Pediatrics at the University of
Oklahoma Health Sciences Center. Her clinical and research interests
include the assessment and treatment of abused children, treatment
outcome and program effectiveness, prevention of child fatalities, and
treatment of children and adolescents with inappropriate or illegal
sexual behavior. Dr. Bonner established a treatment program for
adolescent sex offenders in 1986 and has presented seminars on the
program throughout the United States and in several foreign countries.
She has completed a five-year research project funded by the National
Center on Child Abuse and Neglect to compare two approaches to treatment
for children with sexual behavior problems. Dr. Bonner is
President-Elect of the Board of Councilors of the International Society
to Prevent Child Abuse and is Past President of the American
Professional Society on the Abuse of Children (APSAC). She has also
served on the Executive Committee of Division 37, Children, Youth and
Families, of the American Psychological Association.

**Jacquelyn C. Campbell, Ph.D., R.N.** is the Anna D. Wolf Endowed
Professor and Associate Dean of the Ph.D. Program and Research in the
Johns Hopkins University School of Nursing with a joint appointment in
the Bloomberg School of Public Health. Her B.S.N., M.S.N. and Ph.D. are
from Duke University, Wright State University and the University of
Rochester Schools of Nursing. She has been conducting advocacy policy
work and research in the area of domestic violence since 1980. Dr.
Campbell has been the Principal Investigator on nine major NIH, NIJ or
CDC research grants and published more than 100 articles and five books
on this subject. She is an elected member of the Institute of Medicine
and the American Academy of Nursing, a member of the Congressionally
appointed US Department of Defense Task Force on Domestic Violence, and
on the Board of Directors of the Family Violence Defense Fund and the
House of Ruth Battered Women's Shelter.

**Judith A. Cohen, M.D.** is a Board Certified Child and Adolescent
Psychiatrist, Professor of Psychiatry at MCP Hahnemann University School
of Medicine, and Medical Director of the Center for Traumatic Stress in
Children and Adolescents at Allegheny General Hospital in Pittsburgh.
She and her colleagues have developed treatment models for children
exposed to traumatic life events including sexual abuse and traumatic
loss, and has conducted several randomized controlled treatment trials
for these children. Dr. Cohen is the Principal Author of the Practice
parameters for Childhood PTSD published by the American Academy of Child
and Adolescent Psychiatry, and has published extensively with regard to
the assessment and treatment of traumatized children. Dr. Cohen is also
Director of the Center for Child Abuse and Traumatic Loss, which is part
of the SAMHSA-funded National Child Traumatic Stress Network.

**John Fantuzzo, Ph.D.** is the Diana Riklis Professor of Education in
the School, Community, and Clinical Child Psychology Program at the
University of Pennsylvania. Dr. Fantuzzo is a clinical child
psychologist whose research has focused primarily on the design,
implementation, and evaluation of school- and community-based assessment
and prevention strategies for vulnerable, low-income children and
families in high-risk urban environments. His applied research is the
result of numerous partnerships with parents, teachers, school
administrators, community-based organizations, and city government.
Currently, Dr. Fantuzzo\'s funded research projects involve working with
large urban municipalities to build capacity through integrated
databases to study incidence and prevalence of risk and protective
factors that influence the development and learning of young children.
This also includes a grant to develop and test a scientifically valid
system in partnership with law enforcement and other relevant municipal
agencies to investigate the prevalence and impact of child exposure to
domestic violence.

**Margaret Feerick, Ph.D.** is a developmental psychologist with a
research background in child maltreatment and family violence. Dr.
Feerick received her doctorate from Cornell University in Developmental
Psychology, with concentrations in social and personality development
and developmental psychopathology. Prior to joining the NICHD, Dr.
Feerick held research positions on several federally-funded grants,
including two projects funded by the NIH, and the National Data Archive
on Child Abuse and Neglect, funded by the National Center for Child
Abuse and Neglect. Dr. Feerick has also been the recipient of several
national fellowships and awards, including an NIH Individual National
Service Award, and a Society for Research in Child Development Executive
Branch Policy Fellowship. Dr. Feerick has worked as director of
development and contributions for an independent school in New York City
and has taught at both the elementary and junior high school levels. As
part of the Child Development and Behavior Branch of the NICHD, Dr.
Feerick is responsible for managing a large research and training
program in cognitive, social, and affective development, and child
maltreatment and violence.

**Betsy McAlister Groves, MSW, LICSW** is the founding Director of the
Child Witness to Violence Project at Boston Medical Center, and
Assistant Professor of Pediatrics at Boston University School of
Medicine. She is the past recipient of a fellowship from the Open
Society Institute and has been a fellow at the Malcolm Weiner Center of
Social Policy at Harvard University. She has lectured widely, providing
training to police, social workers, health providers, judges and court
personnel, and teachers on a range of topics associated with children's
exposure to violence. Her publications include a book, Children Who See
Too Much: Lessons from the Child Witness to Violence Project, published
by Beacon Press and articles in the Journal of the American Medical
Association, Pediatrics, Harvard Mental Health Letter, and Topics in
Early Childhood Special Education. She is a member of the Massachusetts
Governor\'s Commission on Domestic Violence and has served as consultant
to the Massachusetts Department of Social Services, the Massachusetts
Judicial Institute, Family Communications, Inc, producer of Mister
Roger\'s Neighborhood, the Family Violence Prevention Fund, and the
National Center for Children Exposed to Violence. Ms. Groves received
her Master\'s degree from Boston University School of Social Work and
her undergraduate degree from the College of William and Mary.

**Hope M. Hill, Ph.D.** is a Professor of Psychology and Director of
Howard University's Center for Violence Prevention and Youth
Development. She is a graduate of Wesleyan University and Columbia
University where she received a Ph.D. in psychology. She completed a
post-doctoral fellowship at Yale in child development and social policy.
Dr. Hill is responsible for the development of a number of school-based
and community-based interventions designed to prevent youth involvement
in violence. She has developed several interventions throughout the
United States designed to promote the well being of families living
under stressful conditions. She has conducted parenting and adult
development groups for the past 25 years. At Howard she conducts basic
research on the impact of witnessing violence on young children and
effective protective processes for children living in high-risk
situations. She is currently the Principal Investigator for a unique
program in Washington, DC. for children who have been exposed to family
violence. Both her advocacy work and research have been devoted to
maximizing human potential among individuals exposed to major life
stresses such as violence and poverty. Dr. Hill recently completed a
project in South Africa examining the coping capacities of high school
students who have been exposed to serious community and societal
violence, and developed an HIV prevention intervention for two locales
in South Africa. Dr. Hill has authored several publications on youth
violence, mental health and child development and how women cope with
stressors. She speaks French and some KiSwahili.

**George W. Holden, Ph.D.** is Professor and Associate Chair of the
Psychology Department at the University of Texas at Austin. He received
his B.A. from Yale University and his M.A. and Ph.D. in developmental
psychology with a minor in social psychology from the University of
North Carolina at Chapel Hill. He served as head of the developmental
area in the Psychology Department from 1990 to 1996. From 1995 to 1997
he was the director of the Institute of Human Development and Family
Studies. He is a fellow of the American Psychological Society and a
member of the Society for Research in Child Development and the American
Professional Society on the Abuse of Children. He has been or is
currently on the editorial boards of *Child Development*, *Developmental
Psychology*, and the *Journal of Emotional Abuse*. Dr. Holden's research
interests are in the area of social development, with a focus on
parent-child relationships. He is especially interested in understanding
the determinants of parental behavior, parental social cognition, and
the causes and effects of family violence. One of the topics of several
of his studies has been why parents use corporal punishment. He has also
studied how parenting is affected and children are impacted by marital
violence. His research has been supported by grants from the NICHD, the
Guggenheim Foundation, and the Hogg Foundation for Mental Health. He is
author of numerous scientific articles and chapters, and the book
Parents and the Dynamics of Child Rearing (1997). In addition he is a
co-editor of Children Exposed to Marital Violence (1998) and the
Handbook of Family Measurement Techniques, Vol. 2 & 3 (2001).

**Honore M. Hughes, Ph.D.** is a Professor of Psychology at Saint Louis
University and a Clinical Child Psychologist whose research and clinical
interests are in the area of family violence broadly defined, including
child sexual abuse, and child physical abuse, as well as children who
have been exposed to interparental violence. She has written numerous
research and practice articles and book chapters, and has been working
clinically with children of battered women and conducting research in
this area for over two decades. One of her most recent publications is
the book Children and Interparental Violence: The Impact of Exposure,
co-authored with Robbie Rossman and Mindy Rosenberg. She received
funding from NCCAN in the early- and mid-1980's for one of the first
demonstration projects regarding services provided to children of
battered women and their mothers. After obtaining her Ph.D. from the
University of South Carolina, she completed an internship at the
Vanderbilt-Peabody Internship in Professional Psychology in Nashville,
TN. She went on to a post-doctoral fellowship in Portland, OR, with the
Crippled Children's Division of the University of Oregon Health Sciences
Center. While at the University of Arkansas, she began consulting with
the staff of the local battered women's shelter, and in 1979 initiated
the program of research she continues to pursue in her present position.
Currently at Saint Louis University, she maintains her research and
consulting with several local battered women's shelters, supervises
graduate students providing clinical services to community residents,
and teaches students in the graduate training program in Clinical
Psychology.

**Janice Humphreys R.N., C.S., Ph.D., P.N.P.** is an Associate Professor
in the Dept. of Family Health Care Nursing at the University of
California, San Francisco. Over the last 13 years Dr. Humphreys has been
involved in a program of research that addresses the strengths and
experiences of battered women and their children. Her initial research
explored the life histories of adult daughters of battered women who
have successfully overcome the experience of growing up in a violent
home. More recently she has researched sleep patterns of sheltered
battered women and their children and the role of resilience and
spirituality in mediating these symptoms. She has twice been
acknowledged as an outstanding woman faculty member at UCSF and was
selected by the American Nurses Foundation Virginia Kelley, CRNA Scholar
for 2000-2001. In addition to her many graduate teaching
responsibilities, Dr. Humphreys continues to provide advanced practice
nursing to women and children at the Riley Center, one of three battered
women's shelters in San Francisco. She is President-Elect of the Nursing
Network on Violence Against Women International and a member of the
Nursing Research Consortium on Violence and Abuse, an invited panel of
expert nurse-scientists. Along with co-editor Jacquelyn Campbell, FAAN,
R.N., Ph.D., she is currently revising their book Nursing Care of
Survivors of Family Violence.

**Peter Jaffe, Ph.D.** is the Founding Director for the Centre for
Children and Families in the Justice System (1975-2001) and currently a
Special Advisor on Violence Prevention for the Centre, which is a
children's mental health center specializing in issues which bring
children and families into the justice system in London, Ontario. He is
a member of the Clinical Adjunct Faculty for the Department of
Psychology and Professor (part-time) for the Department of Psychiatry at
the University of Western Ontario. Dr. Jaffe received his undergraduate
training from McGill University in Montreal (1970) and his Ph.D. in
Clinical Psychology from the University of Western Ontario (1974). Most
of his clinical work and research has focused on children and
adolescents involved with police or the courts, either as offenders or
victims of family violence or custody disputes as well as individuals
traumatized by violence in childhood or adult relationships. He has
co-authored eight books, 24 chapters and over 70 articles related to
children, families and the justice system including Children of Battered
Women and Working Together to End Domestic Violence. His current
research involves the impact of family violence on children. Among his
many activities, he was a member of the Canadian Panel on Violence
Against Women between 1991 and 1993, and was appointed to the Joint
Committee on Domestic Violence to provide advice to the Attorney General
on the implementation of the jury's recommendations. Dr. Jaffe has been
honoured by receiving several awards for his work including the
Commemorative Medal for the 125th Anniversary of the Confederation of
Canada for his dedication and contributions to the community and to all
fellow Canadians, and the distinguished Colonel Watson Award, presented
annually by the Ontario Association for Curriculum Development, for his
significant contribution to education in Ontario, and the Award of Merit
from the Ontario Psychological Foundation for his contribution to
research and clinical practice in the prevention of family violence.

**Paramjit T. Joshi, M.D.** is Chair of the Department of Psychiatry and
Behavioral Sciences, at the Children's National Medical Center (CNMC)
and Professor of Psychiatry, Behavioral Sciences & Pediatrics, at the
George Washington University School of Medicine in Washington D.C. Over
the past 20 years, Dr. Joshi has developed an expertise in the study of
psychological effects of violence, crisis and trauma in children. She
has received numerous grants to direct research and provide outreach
services, including programs in Croatia, Bosnia-Hercegovina and
Macedonia. She recently returned from Israel where she was able to get a
closer look at the psychological impact of armed conflict on children in
the Middle East. Dr. Joshi's focus over the last decade has been to
chart local and international efforts to identify and treat children
traumatized by violence -- in wars abroad and closer to home in America:
on its streets, in its schools, and through the media. Dr. Joshi joined
CNMC in 1999, after serving as Director of Clinical Services at Johns
Hopkins Hospital in the Division of Child & Adolescent Psychiatry. She
obtained her medical degree from the Christian Medical College and Brown
Memorial Hospital, Punjab University in India, where she first trained
as a Pediatrician. She completed her training in general and child and
adolescent psychiatry at Johns Hopkins Hospital, where she remained for
22 years before coming to CNMC. Dr. Joshi is a fellow of the American
Psychiatric Association (APA) and a recipient of the APA's Bruno Lima
award for outstanding contributions in the care and understanding of
disaster psychiatry. In addition the National Alliance for the Mentally
Ill (NAMI) recently honored her with the Annual Exemplary Psychiatrist
Award for her contributions to a greater understanding of brain
disorders and mental illness. She has taught and published extensively
on the issues of depression and childhood trauma, and in 1999
co-authored the book, Empowering Children: Psychological Assistance,
Under Difficult Circumstances

**Lewis Leavitt, M.D.** is a Professor of Pediatrics at the University
of Wisconsin School of Medicine. He is coordinator of the Social and
Affective Processes Research Unit and Medical Director of the Waisman
Center on Human Development and Mental Retardation. His research
interests include early language development in typical and atypically
developing children and the development of parent-infant communication.
His publications include work on infant speech perception, children's
language play, language development in children with Down Syndrome and
the role of parental expectations in determining parent-child
interaction. His research has used physiologic responses such as heart
rate, skin contracture and eye-blink to study neuro-developmental and
behavioral phenomena. In recent years he has also done research on the
psychological effects of violence on children and studied media
interactions to enhance mutual respect in children of different ethnic
groups. He has co-edited books on children's exposure to violence and
communication development in people with Down Syndrome. As a clinician
involved in evaluating young children with developmental disabilities,
Dr. Leavitt has been active in efforts to translate research into
clinical practice. He has worked extensively with parent groups on
public education about developmental disabilities. He directs an
interdisciplinary training program at the Waisman Center for pre- and
post-doctoral physicians, nurses and allied health workers in the field
of Child Development and Developmental Disabilities. His work on
parent-child interaction includes a current project on how parents cope
with adolescent and adult children with autism. Dr. Leavitt received his
B.S. in Mathematics and M.D. degree from the University of Chicago. He
did post-doctoral fellowships in neonatology and psychophysiology at the
University of Wisconsin.

**Sheldon Levy, Ph.D., M.P.H.** is a child clinical psychologist and is
currently the Staff Executive for the Rhode Island Governor's Advisory
Council on Health and a Consultant to the Center for Child and Family
Health at the Rhode Island Department of Human Services. In addition, he
is Clinical Associate Professor of Family Medicine and Adjunct Associate
Professor of Community Health at Brown University Medical School. His
work for the state involves developing programs for children with
special health care needs under the State Medicaid Program. His
research, teaching and clinical work at Brown has focused on the
psychological and mental health aspects of primary care including the
role of gender in clinical decision-making, substance abuse and child
abuse screening by primary care physicians and self-esteem and
preventive medicine practices of women. In addition, he has been
involved in research and program development related to child abuse and
neglect and street children in Central and Eastern Europe and the Former
Soviet Union. This international work began in 1991 when he was awarded
an Individual Health Scientist Exchange to the Former Soviet Union by
the Fogarty International Center, NIH. Between 1995 and 1997 he served
as a member of an advisory committee which provided consultation on
primary care to Health Resources and Services Administration, DHHS, for
the Summits between Vice-President Gore and the then Prime Minister of
Russia, Victor Chernomyrdin. Between 1985 and 1987 he was on the faculty
of the National College of District Attorney's and trained prosecutors
around the United States in the behavioral indicators of child abuse and
neglect. In 1985 he was also invited to participate in the Surgeon
Generals Policy Workshop to develop public health policy guidelines for
the States in the area of Family Violence. Prior to this, he served as
the psychologist on the Child Abuse Team at Cook County Hospital in
Chicago. During the late 1970's he worked at the Office of Child Abuse
Prevention in the California State Department of Health and Social
Services where he contributed to the policy development for statewide
programs for the Prevention of Child Abuse and Neglect.

**Michael Lynch, Ph.D.** is an Assistant Professor in the Department of
Psychology at the State University of New York, College at Geneseo. He
received his doctoral degree from the University of Rochester working
with his advisor Dante Cicchetti. Prior to joining the faculty at
Geneseo, Dr. Lynch worked for nearly 15 years at the Mt. Hope Family
Center in Rochester with Dr. Cicchetti. While at Mt. Hope, Dr. Lynch
supervised intervention programs for multi-risk urban children, and he
coordinated a major longitudinal investigation of child abuse and
neglect. Throughout his career, Dr. Lynch has been interested in the
development of psychopathology, and his research has focused on the
effects of child maltreatment and exposure to community violence. He has
written extensively with Dr. Cicchetti about an ecological-transactional
model of violence. He also has looked at the impact of community
violence on children from a family systems perspective. Currently, he is
expanding his research to investigate links between family adversity and
the timing of pubertal maturation. Dr. Lynch is a former Graduate
Student Research Fellow for the National Center on Child Abuse and
Neglect. He is a current member of the Federal Child Neglect Research
Consortium, where he is a co-principal investigator on a five-year study
of child neglect entitled "Processes Linking Child Neglect and
Adaptation to School." He also is a founding board member for the
Charter School of Science and Technology in Rochester where he is
working to integrate his knowledge about the effects of ecological
adversity into school-based approaches for supporting children and
families.

**Steven Marans Ph.D.** is the Harris Associate Professor of Child
Psychoanalysis at the Yale Child Study Center (CSC) where he is the
Director of the National Center for Children Exposed to Violence (NCCEV)
and the Center for Childhood Violent Trauma. Dr. Marans is also the
founder of the Child Development-Community Policing Program (upon which
the National Center for Children Exposed to Violence is founded). The
primary goals of the NCCEV are to raise public awareness of the effects
of violence on children and families; to serve as a national resource
center for information about the effects of violence on children and
families; and to provide training and technical assistance to
communities throughout the country that respond to children and families
exposed to violence. The Center for Childhood Violent Trauma is part of
the National Childhood Traumatic Stress Network and is involved in
program evaluation and research regarding acute response to violent
trauma. The CSC programs provide direct services for children, families
and communities with the aftermath of violent events and traumatic
reactions. In addition, Dr. Marans has consulted and worked closely with
ranking members of the U. S. Department of Justice, members of Congress,
and the White House, on issues related to trauma, youth violence, and
law enforcement. Dr. Marans has led the NCCEV in responding to September
11th, with the 3rd Congressional District, the State of Connecticut,
nationally and within New York City.

**Gayla Margolin, Ph.D.**, Professor of Psychology, has been at the
University of Southern California since 1978, where she also served as
Director of Clinical Training from 1995-2000. She is a clinical
psychologist with research specialties in marital conflict/violence, and
children's exposure to multiple forms of violence. She received her
Ph.D. from the University of Oregon in 1976. She was the recipient of
the Harry Frank Guggenheim Career Development Award (1985-1989) for a
project titled "Interpersonal Factors in the Intergenerational
Transmission of Family Violence." She received the 1993 Award for
Distinguished Contribution to Family System Research from the American
Family Therapy Association. She has received four competitive NIMH
grants studying the treatment of multi-problem families and the effects
of family violence. Dr. Margolin has presented to the California
Assembly Select Committee on Domestic Violence and provided Domestic
Violence Training for Child Custody Evaluators and Mediators for the
State of California. She has served as Associate Editor for the *Journal
of Family Psychology and Behavioral Assessment* and also has served on
the editorial/advisory boards of 10 additional journals.

**Laura McCloskey, Ph.D.** is an Associate Professor in the Department
of Maternal and Child Health at the Harvard University School of Public
Health. She received her doctorate in Psychology from the University of
Michigan (1986) and was a postdoctoral scholar at the University of
Rochester working with Dante Cicchetti. Dr. McCloskey was on the faculty
in Psychology at the University of Arizona for eleven years, where she
launched her landmark longitudinal study of children exposed to marital
violence. Her research has received funding from the National Center on
Child Abuse and Neglect, the NIMH and, most recently, the Agency for
Healthcare Research and Quality. The Arizona study was conducted over a
decade-long series of large data collection waves. Children who were
exposed to marital violence and control group children were followed up
and studied to examine outcomes in aggressive behavior and crime, dating
and sexual relationships, academic achievement, and mental health.
Findings reveal a long shadow of early domestic violence on later
adjustment, but there is also remarkable evidence of resilience. Dr.
McCloskey is presently engaged in a new research effort to evaluate
community-based interventions for abused women and their children to
identify the parameters of an effective public health approach to the
problem of domestic violence. She is also a founding member of the new
Women, Gender and Health Program at Harvard University.

**Robert S. Pynoos, M.D., M.P.H.** is Professor of Psychiatry in the
UCLA Department of Psychiatry and Biobehavioral Sciences. He is
Co-Director of the National Center for Child Traumatic Stress, Director
of the UCLA Trauma Psychiatry Service and Executive Director of the UCLA
Anxiety Disorders Section. Dr. Pynoos is a graduate of Harvard
University and Columbia University Schools of Physicians & Surgeons and
Public Health. Over the past two decades, he has written extensively on
child development and child traumatic stress, the neurobiology of child
and adolescent trauma, and public mental health approaches for children
and families after disaster, war and community violence, and has
elevated the standards of mental health care for child victims and
witnesses. He is past President of the International Society for
Traumatic Stress Studies and the 2001 recipient of the Lifetime
Achievement Award. Dr. Pynoos has served as Chair for the William T.
Grant Consortium on Adolescent Bereavement and for the MacArthur
Foundation Network Study Group on Children's Responses to Traumatic
Stress. He served as a consultant to the United States Department of
Education after the Oklahoma City bombing, to the Springfield Oregon
Public School District after the Thurston High School shooting, to
Jefferson County Mental Health after the Columbine High School tragedy
and to Santana High School, Santee, California. He has been a consultant
to UNICEF for Kuwait after the Gulf War, has a long-standing
collaborative relationship with UNICEF to conduct a long-term post-war
recovery program for adolescents in Bosnia-Herzegovina, and worked for
years with the Armenian Relief Society in their decade-long
post-earthquake recovery efforts. Dr. Pynoos was an invited participant
to the 1999 White House Strategy Session on Children, Violence and
Responsibility. He has received the American Psychiatric Association
Bruno Lima Award for excellence in disaster psychiatry. Dr. Pynoos has
extensive experience in work with the Institute of Medicine, serving as
committee member, reviewer, and speaker on a range of topics, including
issues related to chemical and biological terrorism R&D needs and
civilian readiness, clinical evaluation protocols, and public mental
health planning and readiness, response and recovery to catastrophic
acts of terrorism. In response to September 11, he has served as a
consultant to the New York State Office of Mental Health and to the New
York City Department of Health, as well providing assistance to the New
York City Board of Education and U.S. Department of Education outreach
to the private school community. By recommendation of the NIMH, Dr.
Pynoos provided consultation to the First Lady, Laura Bush, in regard to
publicly addressing children and families in the aftermath of September
11.

**Kathy Sanders-Phillips, Ph.D.** is currently the Director of the
Research Program in the Epidemiology and Prevention of Drug Abuse and
Professor in the Department of Human Development and Psychoeducational
Studies at Howard University in Washington, DC. She also holds an
appointment as Clinical Associate Professor in the School of Public
Health at the University of California at Berkeley and serves on several
national advisory boards. She has a Ph.D. in developmental psychology
and is an expert on the topics of children\'s exposure to community
violence and the relationship between exposure to community violence and
risky behaviors. Dr. Sanders-Phillips has authored numerous articles,
which have been published in a variety of sources, such as *Advances in
Medical Sociology*, *Journal of Adolescent Health*, and the *Journal of
Health Care*. Raised in St. Louis, MO, Kathy is married with two
children. Having had a long-term research career at UCLA and King Drew
Medical Center, she recently began working at Howard University. She
will continue multidisciplinary research, facilitating the careers of
research scientists and establishing collaborative external
institutional research activities.

**Jon A. Shaw, M.D., Ret. Col. USA** is Professor and Director, Division
of Child and Adolescent Psychiatry, University of Miami School of
Medicine. He is certified in General Psychiatry, Child and Adolescent
Psychiatry, Adult and Child Psychoanalysis. Dr. Shaw graduated from the
University of Oregon Medical School obtaining his M.D. degree and a M.S.
in Physiological Psychology. He completed his residency training in
General Psychiatry, Child Psychiatry and a Clinical Research Fellowship
at the Walter Reed Army Medical Center. While on active duty with the U.
S. Army, Dr. Shaw held such positions as Chief, Child and Adolescent
Psychiatry, Walter Reed Army Medical Center; Chairman, Department of
Psychiatry at the Walter Reed Army Medical Center; and Consultant in
Psychiatry and Neurology to the Army Surgeon General. After serving on
the National Advisory Council to the NIMH, he became Director of the
Child and Adolescent Disorders Research Branch at the NIMH, 1987-1989.
Dr. Shaw's areas of scientific publications and research interests have
focused on the psychological effects of trauma both on adults and
children with publications on the transcultural aspects of sexual abuse,
child on child sexual abuse, sexual aggression, psychological effects of
Hurricane Andrew and a number of papers on combat stress reactions, the
psychological effects of war on children, and grief and mourning. He
served as a consultant to Mozambique and was instrumental in developing
the prevention-intervention program for child victims of war in that
country. He edited a book on Sexual Aggression, (1999). More recently he
has served on a task force with the Uniform Services University of the
Health Sciences focusing on bioterrorism and has written a paper about
the psychological effects of a community-wide disaster on children and
planning for bioterrorism.

**Bradley D. Stein** is a Health Services Researcher at RAND and
Assistant Professor of Psychiatry at the University of Southern
California. He has worked closely with the Los Angeles Unified School
District Mental Health Services Unit over the last 4 years on the
development, implementation, and evaluation of the Mental Health
Intervention Program, which identifies and intervenes with students
traumatized by community violence. Recent activities also include
working with RAND colleagues in examining the psychological effects of
terrorism and examining "best practices" for school mental health
response after school violence.

**Patricia M. Sullivan, Ph.D.** is currently affiliated with Creighton
University in Omaha, Nebraska where she is a Professor of Neurology in
the School of Medicine and Professor of Psychology in the College of
Arts and Sciences. She is also the Director of the Center for the Study
of Children's Issues, a university-wide center dedicated to conducting
research on issues impacting children and their families. Dr. Sullivan
previously directed the Center for Abused Children with Disabilities at
the Boys Town National Research Hospital, a division of Father
Flanagan's Boys Town. Dr. Sullivan's research has focused on children
and youth with disabilities as victims and perpetrators of physical and
sexual violence, including child maltreatment and domestic violence. Her
research has addressed institutional abuse, the prevalence of
maltreatment among children and youth with disabilities, and
co-occurring factors of that maltreatment including domestic violence
and runaway behavior as they relate to disability status. She is
currently investigating violence linkages among children and youth with
and without disabilities, including both perpetrator and victim outcomes
in adulthood.

**Martin H. Teicher, M.D., Ph.D.** is an Associate Professor of
Psychiatry at Harvard Medical School and Director of the
internationally-recognized Developmental Biopsychiatry Research Program
at McLean Hospital. His research studies range from the molecular
mechanisms of brain development, cellular neuroanatomy, regional
neuropharmacology, and up through studies of human behavior and brain
imaging. Currently, the major focus of his clinical research program has
been on the possible enduring effects of childhood maltreatment on brain
development. Among his pioneering work, Dr. Teicher has been at the
forefront of studies of actigraphy and motion analysis as tools for
research in psychiatry and developed a new approach and software for
non-linear modeling of biological rhythms that can delineate and define
the different forms of rest-activity disturbance observed in many of the
major psychiatric disorders including depression in children, adults and
geriatric patients, ADHD, Post-traumatic stress disorder, and
Alzheimer's disease. In collaboration with Perry Renshaw, M.D., Ph.D. in
the Brain Imaging Center at McLean Hospital, Dr. Teicher devised,
validated and patented a new method for functional MRI imaging
(T2-relaxometry) that provides indirect information about basal blood
volume that is not only safer for developing brains, but also has higher
resolution. Using this technique, this collaborative research team
provided the first evidence that there is an abnormality in the
paramagnetic properties of the striatum (specifically the putamen) and
cerebellar vermis in children with ADHD that stems from alterations in
brain activity and cerebral blood volume. Furthermore, these changes
correlate strongly with the child's basal level of activity and
inattention and change significantly with drug treatment. In addition,
Dr. Teicher has done seminal work on dopamine-receptor pruning, a
developmental phenomenon that occurs between adolescence and adulthood,
that may have relevance to the emergence of schizophrenia in late
adolescence or early adulthood, and to the waxing and waning of symptoms
of ADHD and Tourette's disorder during development. He is currently
investigating the molecular mechanisms that regulate the overproduction
and pruning of these dopamine receptors, along with the effects of
exposure to early stress on the process. Dr. Martin Teicher has served
on the Editorial Board of the *Journal of Child and Adolescent
Psychopharmacology* since its inception, has been a Committee Member of
the NIMH Neurochemistry and Neuropharmocology Study Section, is a member
of the Scientific Advisory Board of the Juvenile Bipolar Research
Foundation, and is the author of over 150 articles in the scientific
literature.

**Gregory A. Thomas, M.S.** was born and raised in Brooklyn, New York,
completed public school in New York City, and attended the University of
Maryland, Eastern Shore where he received his Bachelor of Arts Degree in
Sociology in1982. He returned to New York City to continue his education
at the Brooklyn Campus of Long Island University (L.I.U.) where he
received his Master of Science Degree in Criminal Justice in 1984. As a
result of his exemplary graduate work at L.I.U., in 1984, Mr. Thomas was
inducted into Alpha Phi Sigma, the National Criminal Justice Honor
Society. Mr. Thomas is currently employed with the New York City Board
of Education as the Executive Director of the Division of Student Safety
and Prevention Services. In this capacity, he is responsible for
developing school safety programs and conducting research on the best
practices to keep the over one million students that attend the one
thousand New York City schools safe. Prior to his current position, Mr.
Thomas served as the Acting Executive Director of the Board of
Education's Division of School Safety where he was responsible for
managing the daily operations of the country's largest school based
security force ( 3,500 sworn New York State Peace Officers). During his
eighteen years of public service, Mr. Thomas has held various executive
positions in the fields of criminal justice and public safety, including
as Assistant Commissioner with the New York City Fire Department;
Associate Director of the City University of New York/New York City
Police Department Cadet Program at John Jay College of Criminal Justice;
Senior Investigator and member of the executive staff with the Mollen
Commission, the mayoral commission that investigated corruption in the
New York City Police Department; and as First Deputy Inspector General
with the New York City Department of Investigation. In recognition of
his professional and civic accomplishments, Mr. Thomas has received the
Thurgood Marshall Scholarship Fund Award for Outstanding Community
Service and the United Parents Associations Award for Distinguished
Service. He was also the first recipient of the Outstanding Young
Alumnus Award from his undergraduate alma mater, The University of
Maryland-Eastern Shore in 1993 and was honored in 1994 with a
distinguished alumni citation from the National Association for Equal
Opportunity in Higher Education.

**Penelope K. Trickett, M.A., Ph.D.** is a Professor of Social Work and
Psychology at the University of Southern California. Dr. Trickett earned
her Ph.D. from the New School for Social Research, New York. She is a
developmental psychologist whose research, for the last 20 years, has
focused on the developmental consequences of child abuse and/or neglect
on children and adolescents and on the characteristics of families in
which such abuse occurs. She has an Independent Scientist Award from the
NIMH titled, "The Developmental Consequences of Child Abuse and
Violence." In addition, Dr. Trickett is conducting two longitudinal
studies. One, now in its 15th year, concerns the psychobiological impact
of familial sexual abuse on female adolescents and young adults. The
second is a study of the impact of neglect, alone or in combination with
other forms of maltreatment, on young adolescent development. Dr.
Trickett also directs a university-wide interdisciplinary violence
research initiative at the University of Southern California.

**David A. Wolfe, Ph.D.** is Professor of Psychology and Psychiatry and
Academic Director of the Center for Research on Violence Against Women
and Children at the University of Western Ontario. He is a fellow of the
American Psychological Association and past President of Division 37
(Child, Youth, and Family Services). Dr. Wolfe has broad research and
clinical interests in abnormal child and adolescent psychology, with a
special focus on child abuse, domestic violence, and developmental
psychopathology. He has authored numerous articles on these topics,
especially in relation to the impact of early childhood trauma on later
development in childhood, adolescence, and early adulthood. He is
currently studying ways to prevent violence in relationships with
adolescents. He recently received the Outstanding Career Award from the
American Professional Society on the Abuse of Children, and the John
Dewan Prize for Outstanding Contribution to Psychology from the Ontario
Mental Health Foundation. His recent books include Children of Battered
Women (with P. Jaffe and S. Wilson; Sage, 1990), Preventing Physical and
Emotional Abuse of Children (Guilford, 1991), Alternatives to Violence:
Empowering Youth to Develop Healthy Relationships (with C. Wekerle & K.
Scott; Sage, 1996), the Youth Relationships Manual (Sage, 1996), and
Abnormal Child Psychology (with E. Mash; Wadsworth, 2002).

[]{#__RefHeading___Toc18291840 .anchor}Appendix G. Workshop Participants

**Sharon Amatetti, M.P.H.,** Substance Abuse and Mental Health Services
Administration

**Ileana Arias, Ph.D.**, Centers for Disease Control and Prevention

**Bernard Auchter,** National Institute of Justice

## Laila P. Baradaran, National Institute of Child Health and Human Development, NIH

**Evvie Becker, Ph.D.,** Office of the Assistant Secretary for Planning
and Evaluation, DHHS

## Steven Berkowitz, M.D., Yale University

## John M. Bolland, Ph.D., University of Alabama

**Barbara L. Bonner, Ph.D.,** University of Oklahoma Health Science
Center

**Cheryl A. Boyce, Ph.D.,** National Institute of Mental Health, NIH

**Jacquelyn C. Campbell, Ph.D.,** Johns Hopkins University

**Judith A. Cohen, M.D.,** Allegheny General Hospital Center for
Traumatic Stress in Children & Adolescents

**Robin Delany-Shabazz,** Office of Juvenile Justice and Delinquency
Prevention, Department of Justice

**John W. Fantuzzo, Ph.D.,** University of Pennsylvania

**Margaret Feerick, Ph.D.,** National Institute of Child Health and
Human Development, NIH

**Betsy McAlister Groves, LICSW,** Boston University School of Medicine

**Tom V. Hanley, Ed.D.,** Office of Special Education Programs,
Department of Education

**Hope M. Hill, Ph.D.,** Howard University

**George W. Holden, Ph.D.**, University of Texas at Austin

**Honore M. Hughes, Ph.D.**, Saint Louis University

**Janice Humphreys, Ph.D.**, University of California, San Francisco

**Shelly Jackson, Ph.D.,** National Institute of Justice

**Peter G. Jaffe, Ph.D.**, Centre for Children & Families in the Justice
System of the London Family Court Clinic, Inc.

**Coryl Jones, Ph.D.** (retired), formerly with the National Institute
on Drug Abuse, NIH

**Anna Jordan,** National Institute of Justice

**Paramjit T. Joshi, M.D.,** George Washington University School of
Medicine

**Lewis A. Leavitt, M.D.,** University of Wisconsin-Madison

**Sheldon Levy, Ph.D., M.P.H.,** Brown University Medical School

**Oriana Linares, Ph.D.,** New York University

**Michael D. Lynch, Ph.D.,** SUNY Geneseo

**Steven Marans, Ph.D.,** Yale University School of Medicine

**Gayla Margolin, Ph.D.**, University of Southern California

**Susan E. Martin, Ph.D.,** National Institute on Drug Abuse

**Laura Ann McCloskey, Ph.D.,** Harvard University School of Public
Health

**Kathleen Michels, Ph.D.,** Fogarty International Center, NIH

**Catherine M. Nolan, M.S.W.,** Administration on Children, Youth and
Families

**LeShawndra N. Price, Ph.D.,** National Institute of Mental Health

**Aron Primack, Ph.D.,** Fogarty International Center, NIH

**Robert S. Pynoos, M.D., M.P.H.,** UCLA School of Medicine

**Kathy Sanders-Phillips, Ph.D.**, Howard University

**Sandra Scarbrough, M.A.**, National Institute of Child Health and
Human Development, NIH

**Jon A. Shaw, M.D.,** University of Miami School of Medicine

**Jerry Silverman,** Office of the Assistant Secretary for Planning and
Evaluation, DHHS

**Susan D. Solomon, Ph.D.,** Office of Behavioral and Social Sciences
Research, NIH

## Bradley D. Stein, M.D., M.P.H., RAND

**Patricia M. Sullivan, Ph.D.,** Creighton University

**Martin H. Teicher, M.D., Ph.D.**, Harvard Medical School

**Gregory A. Thomas, M.S.**, New York City Board of Education

**Penelope K. Trickett, Ph.D.**, University of Southern California

**Farris Tuma, Sc.D.,** National Institute of Mental Health

**Linda Anne Valle, Ph.D.,** Centers for Disease Control and Prevention

**David A. Wolfe, Ph.D.,** The University of Western Ontario

##