The Relationships Among Exposure to Violence, Psychological Distress, and Gun Carrying Among Male Adolescents Found Guilty of Serious Legal Offenses

Gun carrying among youths is a significant public health concern in the United States (1). Those who carry weapons are at increased risk for fighting, being injured and hospitalized, or injuring others (24). Firearm-associated homicide and suicide are leading causes of death among American youths (aged 10 to 24 years); rates observed among African American and Hispanic youths are disproportionately high (5). Weapon carrying and exposure to violence have been repeatedly linked in research using samples of minority, inner-city youths (6, 7). Weapon carrying is viewed primarily as a protection-driven behavior resulting from a combination of 3 factors: fear of crime, risk perception of crime victimization, and prior victimization (8, 9). Some suggest that gun violence and psychological distress may be related, with psychological distress increasing gun carrying (10, 11). However, prior empirical examinations of this relationship among adults (12) and youths (12, 13) are limited and have relied on cross-sectional designs (12). Even less is known about the effect of exposure to violence on the association between psychological distress and gun carrying. What is understood is that victims of crime, especially violent crime, can experience enduring deterioration in their emotional health, with symptoms of anxiety, depression, hostility, and fear (14, 15). For example, youths who are repeatedly bullied may become aggressive and hypersensitive to threats and may misinterpret even minor slights as deliberate cruelty (16, 17). The schema of an aggressive-reactive victim has been supported by findings that link victims of bullying to violent and antisocial behaviors, including frequent fighting, carrying a weapon, and perpetrating school-related homicides (1820). Certain psychological symptomsspecifically paranoia, delusions, and depressionhave been retrospectively linked to 60% of mass shootings in the United States (21, 22). In light of the continuing prevalence of gun violence among vulnerable adolescents and the pressing need for greater understanding of the mechanisms driving gun carrying, our study examined 3 research hypotheses clarifying the associations among gun carrying, psychological distress, and exposure to violence. First, we expected gun carrying to be linked to higher levels of psychological distress (21). Second, we expected that exposure to violence (both experienced and witnessed) would predict gun carrying (14, 15). Finally, we hypothesized that the association between psychological distress and gun carrying would become less prominent when we considered the effect of exposure to violence, as either a victim or a witness (23, 24). Understanding mechanisms, such as psychological distress and exposure to violence, that drive gun carrying among adolescents has important implications for effective delivery of services aimed at averting risk and maximizing protection from gun violence for vulnerable adolescents, their families, and their communities. Methods Sample and Data Collection Procedures Data used in this study were collected as part of the Pathways to Desistance study, a longitudinal investigation of the transition of justice-involved adolescents into adulthood (25, 26). Adolescents participating in the Pathways to Desistance study had been found guilty of a serious offense (almost exclusively felony-level violent crime, property offense, or drug offense) in juvenile or adult court in Philadelphia County, Pennsylvania (Philadelphia), or Maricopa County, Arizona (Phoenix), between November 2000 and January 2003. To avoid overrepresentation of drug offenders in the study, the proportion of males found guilty of a drug charge who were invited to participate was capped at 15%. The participation rate (the percentage of those invited to participate who enrolled) was 67%, and the refusal rate (the percentage of those invited to participate who did not) was 20%. These figures are favorable compared with other studies in high-risk populations (27). Data collected from male youths (n= 1170) at the baseline assessment and 4 follow-up assessments conducted at 6-month intervals were used to study the temporal associations among gun carrying, psychological distress, and exposure to violence during adolescence. The retention rates of study participants were 94% at the 6-month follow-up, 93% at the 12-month follow-up, and 91% at the 18- and 24-month follow-ups. Further information on institutional review board approvals, recruitment, descriptions of the total sample, and data collection procedures are available in other published work (27) and at the study Web site (www.pathwaysstudy.pitt.edu). Measures Gun carrying was based on responses to the question, Have you carried a gun? gathered at the baseline and follow-up assessments. This item was taken from the Self-Reported Offending survey (28). At each assessment, participants reported gun carrying within the previous 6 months. Scores on the Global Severity Index (GSI), computed from the Brief Symptom Inventory (BSI) scales, were used to measure general psychological distress at the baseline and follow-up assessments. The BSI is a 53-item self-reported inventory in which participants rate the extent to which they have been bothered (0 [not at all] to 4 [extremely]) in the past week by various symptoms (29). Nine BSI subscales are designed to assess various symptom groups, including somatization (for example, Faintness or dizziness), obsessive-compulsive (for example, Having to check and double-check what you do), interpersonal sensitivity (for example, Feeling inferior to others), depression (for example, Feelings of worthlessness), anxiety (for example, Feeling tense or keyed up), hostility (for example, Having urges to beat, injure or harm someone), phobic anxiety (for example, Feeling uneasy in crowds, such as shopping or at a movie), paranoid ideation (for example, Feeling that most people cannot be trusted), and psychoticism (for example, Never feeling close to another person). The reliability and validity of the BSI have been examined in many studies, and the inventory is generally considered an adequate measure of psychological symptoms and distress (30). The GSI score was computed by using the mean of scores across the 9 subscales and had good internal consistency, with the Cronbach ranging from 0.95 to 0.96 across all stages of data collection. Exposure to violence was based on responses gathered at the baseline and follow-up assessments using a modified version of the Exposure to Violence Inventory (31). The exposure-to-violence measure contained 2 subscales. One subscale included 6 items documenting experienced violence (for example, Have you ever been shot? ), and the second contained 7 items documenting witnessed or observed violence (for example, Have you ever seen someone else being shot? ). The exposure-to-violence measures collected information on witnessed and experienced violence during the participants' lifetime at the baseline assessment and during the recall period (the previous 6 months) at the follow-up assessments. To assess the internal consistency of the exposure-to-violence items, confirmatory factor analyses were conducted for each of the subscales. Based on the model fit indices for the confirmatory factor analyses, the factor structures of the subscales for experiencing and witnessing violence were found to be acceptable. Study site, age, and race/ethnicity (white, African American, Hispanic, or other), all of which potentially influence gun carrying, were included as control variables in the multivariate models. To control for the effect of youths being out of the community in a controlled environment on the associations among carrying, GSI score, and exposure to violence, the proportion of time participants spent on the streets was included in each of the multivariate analyses. Statistical Analysis First, descriptive and bivariate analyses were conducted to provide an understanding of the study sample and the associations among gun carrying, GSI score, and exposure to violence. Concurrent bivariate associations among these 3 variables were examined at each time point. For each period, participants were grouped by whether they reported carrying a gun during that period (active carrying vs. no carrying). Next, average GSI score, witnessing violence, and experiencing violence were compared separately across the 2 gun-carrying groups at each follow-up. Next, a series of binary logistic regression models predicting gun carrying during each follow-up period were fit at each time point. With each model, GSI score, experiencing violence, and witnessing violence were entered in successive stages to allow for a comparison of model fit and to determine changes in coefficients as predictors were added. A likelihood ratio test was used to assess the degree to which the addition of experiencing violence and witnessing violence improved model fit at each time point. In addition, the stability of the relationship between gun carrying and GSI score over time was examined by documenting the predictive probability of carrying based on low versus high scores on the GSI, stratified by exposure to violence across all stages of data collection. The multiple imputation procedure in SPSS Statistics 23 (IBM) was used to impute missing data and assess whether they influenced the multivariate analyses. Multiple imputation replicates the incomplete data set multiple times by replacing the missing data in each replicate with plausible values drawn from an imputation model. The linear regression method was automatically selected by SPSS as the best imputation method for handling the missing data. Age, race/ethnicity, study site, GSI score, experiencing violence, and witnessing violence were included as independent variables in the imputation models. Ten imputed data sets were created. The binary logistic regression models were performed on each complete data set