NC-PTSD Clinical Quarterly Volume 8 (4) Fall 1999

56

Fall 1999, Volume 8, Issue 4, ISSN-1052-7168

Treatment of Children and Adolescents 56

Prevention with Youth Exposed to Violence 61

New Directions 63

Women and Trauma: A Clinical Forum 64

INSIDE THIS ISSUE

Many American children and

adolescents are exposed to multiple

acts of community violence before

reaching adulthood. The purposes

of this article are: a) to alert the

clinician to the phenomenon of

community violence exposure in

youth; b) to present the symptom

response picture for children and

adolescents who have been exposed;

and c) to highlight critical

components of treatment for

victimized youth, paying particular

 attention to developmental concerns

 of this patient population.

Scope of the Problem

The study of community violence exposure in children and

adolescents is a relatively recent venture. Some of what we know

was guided by evidence from research in combat veterans, abuse

survivors, and children exposed to political violence. Thus, some

of the skills and strategies used in the treatment of these groups

may serve as a helpful foundation for expansion to treatment of

youth exposed to community violence.

Community violence refers to crime or violence that occur

against humans by humans through intentional and volitional acts.

Examples of community violence include murder, sexual assault,

physical assault, arson, suicide, and threatening behavior. Over the

past decade community violence rates continued to increase steadily,

reaching such intense levels as to qualify as a major national public

health concern. Recently the overall crime rate appears to be

dropping; however, the rate of adolescent crime remains

disturbingly high. The American Psychological Association predicts

that juvenile crime rate will continue to rise. Their report contends

that even if the arrest rate remains constant, violent arrests for

adolescents could still increase by about 22% until 2010 because the

children of the baby boomers will reach adolescence (1). A report

by the Childrens Defense Fund (2) estimated that each day

approximately 5000 teenagers are victims of violent crimes. Of

particular concern is the finding that firearm homicides are the second

leading cause of death for adolescents (15-19 years old), with rates

four to six times higher in the inner-city regions (3). These rates

refer to fatalities; however, Rosenberg and Mercy (4) estimate the

ratio of nonfatal to fatal victimization to be 100 to 1.

Official crime statistics are informative; however, they

significantly underestimate the actual rates of victimization. Surveys

conducted by the government demonstrate that over half of violent

crimes are not reported to the police (5). Moreover, adolescent

victimization is least likely to be reported to the police and detailed

statistics are not usually available for children under 12. In addition,

whereas crime statistics report only the main target of the crime, there

may be other victims of the crime, including those who witnessed the

incident or who suffer a direct loss as a result of the violence.

Therefore, we must assume that vicarious (hearing about the

crime) or witnessing violence is even higher than statistics

demonstrate. For these reasons, clinicians and medical staff would

be wise to routinely screen for community violence exposure and

concomitant stress reactions as part of a routine intake assessment (6).

Rates of exposure to community violence vary according to race,

socioeconomic strata (SES), sex, and geographic location. Exposure is

higher for those who are nonwhite; for example, African American

adolescents are six times more likely to be murdered than White

adolescents. Similarly, victimization is substantially higher for those who

are poor and live in large urban communities (7). Males have higher overall

rates of direct victimization but findings are mixed with respect to indirect

victimization (i.e., witnessing and hearing about anothers victimization).

TREATMENT OF CHILDREN AND ADOLESCENTS

EXPOSED TO COMMUNITY VIOLENCE

 JACQUELINE A. RAIA, PH.D.

Jacqueline A. Raia, Ph.D. ...each day approximately

 5000 teenagers are

 victims of violent crimes

 Continued on page 58

Justice, Education, & Mental Health Partnerships 65

Adolescents At Risk for Perpetrating Violence 67

Screening Trauma & PTSD in a Primary Care Clinic 68

NC-PTSD Education & Support Services 71
Volume 8 (4) Fall 1999

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NC-PTSD Clinical Quarterly

NATIONAL CENTER FOR PTSD

Executive Director

Matthew J. Friedman, M.D., Ph.D.

VAMC/ROC White River Junction

Vermont 05009

Education and Clinical Laboratory Division

Fred Gusman, M.S.W., Director

VAMC, Palo Alto, California 94304

Pacific Islands Division

Sarah Miyahira, Ph.D., Acting Director

Honolulu, Hawaii 96813

Behavioral Science Division

Terence Keane, Ph.D., Director

VAMC, Boston, Massachusetts 02130

Womens Health Science Division

Jessica Wolfe, Ph.D., Director

VAMC, Boston, Massachusetts 02130

Editor

Managing Editor

Executive Editor

Associate Editors

Assistant Editor

Graphic Layout

Clinical Quarterly Staff

Please feel free to contact us at the Education Division: FTS 463-2673/2494; commercial number 650-493-5000 ext. 22673/22494; or E-mail: bhh @ icon.palo-alto.med.va.gov

Please address all correspondence to : Editor, National Center for PTSD Clinical Quarterly, VA Palo Alto Health Care System, 795 Willow Rd (352E117), Menlo Park, CA 94025

FROM THE EDITOR...

Neuroscience Division

Dennis Charney, M.D., Director

VAMC, West Haven, Connecticut 06516

Northeast Program Evaluation Center

Robert Rosenheck, M.D., Director

VAMC, West Haven, Connecticut 06516

Bruce H. Young, L.C.S.W.

Josef I. Ruzek, Ph.D.

Fred D. Gusman, M.S.W.

Eve B. Carlson, Ph.D.

Gregory A. Leskin, Ph.D.

John Aboytes, B.A.

Bruce H. Young & Gregory A. Leskin

Violence in our communities continues to shock but no longer surprise us. Crime rates are dropping, but violent crimes, especially those involving adolescents, remain at historically high levels. While rapid response critical incident debriefing interventions may be

useful, it is clear that comprehensive treatment models caring for children and adolescents exposed to violence are needed, and that

intervention be broadly defined to include the need for more detailed assessment of affected individuals and their families. Instruments

validated for this purpose are being developed (see p. 59), as well as methods of interviewing children (e.g., 1-3).

Innovative program planners are beginning to integrate the services of police, medical and mental health professionals, and the

support of parents, family members, peers, teachers,and religious leaders. As programs develop for children of different age groups and

specific settings (e.g., school, clinic, and home), they must take into account the issues related to the cultural diversity of our communities

and to treatment matching considerations. A one size fits all approach will fail to maximize treatment outcomes.

This issue of the Clinical Quarterly highlights current thinking related to prevention, assessment, and treatment for children

exposed to community violence. Though each of the articles is brief, collectively, Jacqueline Raia, Lisa Jaycox, Bradley Stein, and Greg

Leskin provide an informative digest of the effects of violence, the factors associated with stress reactions to violence, selected validated

inventories, and brief secondary intervention programs. In addition, Jenifer Wood and Winifred Reed describe the recent federal efforts

to create partnerships among common interest groups. From a mental health perspective, such partnerships can help restore childrens

sense of place in the community, mitigate feelings of shame and isolation, and promote a renewed sense of faith in others. Recently, the

Departments of Education and Justice began working together to develop a guide to help school personnel, parents, community members and others identify early indicators of troubling and potentially dangerous student behavior. Similarly, David Foy has been developing a conceptual model for identifying adolescents at risk for perpetrating violence. In his article, he describes the advantages of analyzing

the risk factors associated with community violence from a multi-factorial perspective. By taking into account multiple determinants,

more case-sensitive profiles can be developed to sharpen the focus of prevention with individuals who present a high-risk for violent

behavior. Together, the articles in this issue underscore the fact that violence is complex, and that its prevention, as well as the treatment of

its effects, require that all interested community members, professional and nonprofessional, work together.

Bruce H. Young, Editor

References

Cohen, J.A. (1998). Summary of the practice parameters for the assessment and treatment of children and

adolescents with posttraumatic stress disorder. American Academy of Child and Adolescent Psychiatry Work

Group on Quality Issues. Journal of the American Academy of Child and Adolescent Psychiatry, 37, 997-

1001.

Goodman, G.S., & Schaaf, J. M. (1997). Over a decade of research on childrens eyewitness testimony: What have

we learned? Where do we go from here? Applied Cognitive Psychology, 11, S5-20.

Peterson, C., & Biggs, M. (1997). Interviewing children about trauma: Problems with specificquestions.

Journal of Traumatic Stress, 10, 279-290.
NC-PTSD Clinical Quarterly Volume 8 (4) Fall 1999

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TREATMENT OF CHILDREN & ADOLESCENTS

 Age appears to be related to the number of incidents of

violence one experiences rather than the overall number of types of

incidents to which the youth are exposed. There are, however, a few

findings regarding types of violent events. Young children are more

likely to be exposed to violence within the family, such as the murder

of a parent (8, 9), whereas older adolescents are more likely to be

victims of violence in the community (10).

Surveys of community violence better estimate the complete

range of victimization. A survey of elementary school children in

New Orleans indicated that 90% of children had witnessed severe

violence with 70% having seen a weapon used (11). Similarly, Shakoor

and Chalmers (12) surveyed 1000 Chicago-area students aged 10-

19. An astonishing 75% of students reported witnessing either a

shooting or a stabbing, and 23% had witnessed a homicide. Studies

of inner-city youth indicate that as many as 90 percent of urban

children witness violence, such as murders, shootings, and stabbings,

whereas nearly one of two inner-city adolescents has directly

experienced (i.e., as a victim) a violent crime.

Both gang members and those living in areas with high levels

of gang activity are at higher risk of exposure to community violence

(13). Between 75% and 85% of students interviewed at continuation

high schools reported that they had been victimized in a gang-related

incident (e.g., witnessing anothers death, being stabbed, being shot).

Reactions to Community Violence Exposure

Posttraumatic stress disorder in children and adolescents

presents in a manner similar to that in adults (14). The symptom

constellation follows DSM-IV criteria (15). The DSM-IV indicates

that a persons reactions may include intense fear, helplessness, or

horror. However, this may manifest itself in children as disorganized

or agitated behavior. Similarly, reexperiencing symptoms may

appear as repetitive traumatic themes in childrens play (16). Likewise,

several factors including the intensity of the violence (17), physical

proximity to the violence, and relationship of the youth to the target

victim (18) influence the severity of the symptom response to

violence exposure. For a detailed review of the etiology of PTSD

in children and adolescents as well as which factors appear to be

most traumagenic, readers are referred to Foy, Madvig, Pynoos, and

Camilleri (19). Despite the remarkable similarities, there are some

developmental considerations that differentiate PTSD in children

and adolescents from that in adults. Developmental capabilities must

be examined for each client. The clinician is encouraged to ask the

following questions: 1) What level of cognitive development has

the youth achieved and, given that level, how is he or she processing

the violent event(s)? 2) What normal developmental tasks are the

youth facing at the time of exposure that may be affected by the

trauma? For example, is the youth in the process of forming a selfidentity, establishing intimate relationships, or separating emotionally

from parents. This type of assessment will help determine in what

ways the trauma may interfere with social and cognitive development.

Children and adolescents exposed to community violence may

also manifest other symptomatology besides PTSD. They may

exhibit anxiety, depression, and acting out behaviors. In the

investigators study of inner-city junior-high-school students

experiences with community violence, exposure was associated with

symptoms of anxiety, depression, PTSD, anger, and dissociation (20).

Our recent data from 75 inner-city middle-school students

indicated that witness and vicarious (i.e., knowing of anothers

victimization) exposure were both significantly related to anxiety

levels [r = .48 and .44 respectively, p < .001; (21)]. Specifically,

community violence exposure was significantly related to separation

anxiety (r = .43, p < .001), overanxious disorder (r = .44, p < .001),

and marginally related to social phobia (r = .25, p = .06). Findings

are mixed regarding depression and school functioning. Some studies

find links among community violence exposure and depression and

academic functioning whereas others do not. In the middle-school

study described above, direct exposure was marginally related to

school functioning (e.g., suspensions, expulsions) (r = .25, p < .10),

but not to academic functioning. One explanation of these

inconsistencies is that there may be many pathways to depression

and to academic difficulties; traumatic violence exposure may be

one of many, thus, the associations are weakened.

Community violence exposure also can be associated with

acting out or aggressive behaviors and with a general decrease in

the ability to modulate emotions. Considering that emotional

regulation is a task of development for both younger children and

adolescents, traumatic victimization may greatly interfere with this

growth process and the impact of community violence exposure on

this area of functioning can be immense. Coupled with emotion

modulation problems is behavior dysregulation. Children, and

adolescents in particular, may engage in reckless and risky behavior

subsequent to violence victimization. Two other areas of functioning

are quite difficult to measure yet they may be significantly disrupted

in mid-development. The first is the youths sense of self and world

view. The second can be called, generally, the youths maturity level.

Adolescence, and particularly early adolescence, represents a

time in the developmental process during which youth form identity

and establish their sense of place in the world. When an intentional

violent event occurs during this world view formation, it can

dramatically alter the individuals perception of the world and

subsequently, the adolescents attitudes and behaviors. For example,

our middle school research participants commonly state that after

an incident of victimization, they changed their overall life

perspective. Following the trauma, they believe that the world is an

uncontrollable, dangerous place--they will probably get killed so

there is no point in trying to achieve in school or stay out of trouble.

They believe they will not live long enough to reap the benefits of

efforts that delay gratification; therefore, what is wrong with living

in the present and reacting to all immediate urges? Another

commonly reported belief is that relationships and connections with

other people are either hopeless or risky because they are likely to

be killed, yielding yet another traumatic experience. These youth

may disconnect from others emotionally in a seemingly protective

effort. General maturity level refers to the level of emotional and

behavioral functioning at which the child operates. Frequently when

children and adolescents are victims of community violence they regress

to less mature levels of behavior or emotions. This phenomenon is

quite difficult to measure empirically as the manifestation of it is fairly it
Volume 8 (4) Fall 1999

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NC-PTSD Clinical Quarterly

RAIA

may be more subtle) than it does for younger children.

Assessment of PTSD following Community Violence

Even more than adults, children and adolescents frequently

may not connect their cognitive, emotional, and behavioral responses

to the trauma. For example, a teen may not realize his agitated state

is a result of his witnessing a shooting. A young child may not connect

her recent bad dreams to her being robbed at gunpoint, because the

content of the dreams does not always reenact the robbery.

Moreover, most youth do not link their difficulty concentrating with

their exposure to community violence. It seems both unfeasible and

fairly irrelevant for youth victims to determine which symptom

reaction results from one violent event versus another violent event.

One needs to conceptualize community violence exposure as a

cumulative and ongoing traumatic stressor rather than as unique

events.

Several assessment measures and screening instruments are

quite useful for clinical intake purposes (e.g., school nursing clinic,

hospital pediatric care clinic). Also, we use self-report symptom

checklists that can be administered in interview format. The

following are some suggested instruments validated with both clinical

and community samples:

l Community Violence Exposure - Adolescent Version

(CVE-A)[22]. This new 20-item instrument based on

the Survey of Childrens Exposure to Community

Violence (23) and the Survey of Childrens Exposure

to Community Violence - Revised (24). The CVE-A

obtains information on adolescents experiences with

violence in the community, including frequency, severity,

and modality of exposure.

l The Los Angeles Symptom Checklist - Adolescent

Version (LASC-A,[25}). This adolescent version of the

LASC assesses DSM criteria for PTSD.

l Posttraumatic Stress Inventory - Adolescent Version

(PSI-A, [22]). This newly developed scale is based on

experience with the PSI. The measure assesses Criterion

A exposure and DSM-IV posttraumatic stress

symptomatology related to traumatic events.

If time constraints do not allow the use of these brief

screening questionnaires, then simply adding two questions to the

intake interview can provide helpful information: (a) Have you ever

been in a situation when you thought that you might die or be seriously injured

(hurt very badly? and (b) Have you ever seen something terrible happen to

someone else and you thought that the person might die or be seriously injured

(hurt very badly)? If the answer to either question is yes, then the

clinician can follow up with questions obtaining a brief description

.of the event(s) and then probe for trauma symptoms.

Treatment of Traumatized Children and Adolescents

An important component of treatment for acute stress reactions to

community violence is to educate the trauma victim. One integral

message for trauma patients is that the stress reactions (i.e., bodily

responses, ruminations, sleep problems) are normal difficulties

following exposure to violence (26). Normalizing responses is

particularly important for children and adolescents. This can be

done individually or in a group setting.

Interventions for PTSD in children and adolescents should

include components aimed at reducing PTSD symptoms and

bolstering coping resources (27). The symptom reduction segment

should include an exposure-based therapy and follow the segment

in which adaptive coping is strengthened (26). Individual treatment

allows the child or adolescent to proceed at his or her own pace

and provides a controlled setting in which to conduct exposure

therapy that is customized for that child.

The group setting can be especially powerful when youth see

and hear that others had similar reactions and provides a forum for

sharing feelings, working on modulating emotions and behaviors,

and exploring interpersonal relationship issues.

 Two models for group interventions can be conducted in

clinic or school settings. The CUES Psychoeducational Counseling

Groups coordinated by Dr. Jill Waterman (28) at UCLA are schoolbased groups for at-risk middle-school and high-school students.

The empirically-tested program features a curriculum comprised of

separate modules addressing community violence exposure, anger

management, educational aspirations, ethnic identity, countering or

preventing gang and peer pressure, and enhancing family

relationships. The modules represents areas of functioning that

appear to be especially vulnerable to the effects of community

violence exposure.

The Group Cognitive-Behavioral Treatment Program (29) is

a school-based intervention designed for fifth grade children exhibiting

clinical levels of PTSD symptoms as a consequence of community violence exposure. The GCBT uses exposure-based exercises and cognitive-behavioral procedures to reduce posttraumatic stress symptoms,

enhance adaptive coping strategies, and improve utilization of social

support. Art-projects, modeling, role playing, contingency contracting

and feedback are some of the behavioral techniques employed in the

program. Participants were the direct victims of or witnesses to

shootings, stabbings, muggings, physical assaults, murders, or suicides.

Empirical evidence from the pilot groups indicated that participants

PTSD symptom levels as measured by the Childrens Post Traumatic

Stress Reaction Index (30) decreased from the severe range (M = 45,

SD = 10.51) to the moderate range (M = 25, SD = 15.63) after the sixweek/12-session program. In addition, functioning was greatly improved as indicated by the increase in the mean Columbia Global Assessment Scale scores (57.33 [SD = 8.98] to 83.71 [SD = 5.35]). Presumably, the therapeutic gains would be significantly increased with parent

involvement in therapy. Both of the above group interventions have

collateral parent programs available but data are only available for

the youth groups. The success of these empirically-tested group

unique to each individual and takes different forms for adolescents (e.g.,
NC-PTSD Clinical Quarterly Volume 8 (4) Fall 1999

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TREATMENT OF CHILDREN & ADOLESCENTS

15. Saigh, P. A., (1989). The validity of the DSM-III posttraumatic stress

disorder classification as applied to children. Journal of Abnormal

Psychology, 98, 189-192.

16. American Psychiatric Association (1994). Diagnostic and statistical manual

of mental disorders (4th ed.). Washington, DC: Author.

17. Richters, J.E., & Martinez, P. (1993). The NIMH community violence

project: I. Children as witnesses to violence. Psychiatry, 56, 7-21.

18. Pynoos, R.S. & Nader, K. (1988). Psychological first aid and treatment

approaches to children exposed to community violence: Research

implications. Journal of Traumatic Stress, 1, 445-473.

19. Foy, D.W., Madvig, B.T., Pynoos, R.S., Camilleri, A.J. (1996). Etiologic

factors in the development of posttraumatic stress disorder in

children. Journal of School Psychology, 34, 133-145.

20. Raia, J.A. (1995). Perceived social support and coping as moderators of

effects of childrens exposure to community violence. Unpublished

doctoral dissertation, University of California, Los Angeles.

21 Raia, J.A. (1998, November). Community violence in early adolescence: PTSD,

anxiety and depression. In A. Goebel-Fabbri (Chair), The impact of

community violence on child and adolescent development. Symposium

conducted at the Annual Meeting of the International Society for

Traumatic Stress Studies, Washington, DC.

22. Raia, J.A., & Waterman, J. (1996). Exposure to community violence and

post-traumatic stress in inner-city young adolescents. Manuscript

in preparation.

23. Richters, J.E., & Saltzman, W. (1990). Survey of childrens exposure to

community violence. National Institute of Mental Health.

24 Raia, J.A. (1998, November). Community violence, school functioning

and anxiety symptomatology in young inner-city adolescents. In G.

Leskin (Chair), The impact of community violence from childhood

to adulthood. Symposium conducted at the Annual Meeting of

the Association for the Advancement of Behavior Therapy,

Washington, DC.

25. Foy, D.W., Wood, J.L., King, D.W., King, L.A., & Resnick, H. S. (1997).

The LASC: Psychometric evidence with an adolescent sample.

Assessment, 4, 377-384.

26. Keane, T. M. (1995). The role of exposure therapy in the psychological

treatment of PTSD. National Center for Posttraumatic Stress

Disorder Clinical Quarterly, 5(4), 1-6.

27 Amaya-Jackson, L. & March, J. (In press). Post-traumatic stress disorder

in children and adolescents. In H.L. Leonard (Ed.). Child psychiatric

clinics of North America: Anxiety disorders. New York: Saunders.

28 Waterman, J. (Chair) (1994, August). Psychoeducational counseling groups

for inner-city youth: Curriculum development and evaluation.

Symposium conducted at the Annual Meeting of the American

Psychological Association, Los Angeles, CA.

29. Freeman, L. N., Raia, J. A., Mufson, L., Silverman, W. K., & Wasserman,

G. (1997, August). School-based group cognitive-behavioral

treatment of posttraumatic stress for violence-exposed children.

Poster presented to the American Academy of Child and Adolescent

Psychiatry, Toronto, Canada.

30. Frederick, C. J., & Pynoos, R. S. (1988). The child post-traumatic stress

reaction index. Unpublished manuscript, University of California,

Los Angeles.

interventions as well as numerous individual case studies provide a blueprint for clinicians faced with youth experiencing the effects of community violence exposure.

Whereas medication is often used in the treatment of adult

clients, it is a less viable option for children for three reasons. First,

fewer investigations of medications have been conducted to determine both the efficacy and the safety of the relevant drugs in developing children. Second, parents are often reluctant to place children on medication when there is a suitable psychotherapeutic intervention available. Third, medication provides temporary symptom relieve but does not cure the trauma response and does not

affect all of the reactions to violent victimization.

 In summary, there is an alarmingly high number of youth

exposed to violence who, in turn, suffer from post-traumatic stress.

Standardized assessment measures are available and empirical studies

of treatment interventions are beginning to appear in the literature. It

would behoove all clinicians to be alert to this significant problem and

the issues involved in treatment of young victims.

References

1. American Psychological Association, Policy Report.

2. Childrens defense fund, Washington, DC. An opinion makers guide to

children in election year 1992: Leave no child behind.

3. Fingerhut, A., Ingram, D.D., & Feldman, J. (1992). Firearm and nonfirearm homicide among persons 15 through 19 years of age. Journal

of the American Medical Association, 267, 3048-3053.

4 Rosenberg, M.L., & Mercy, J.A. (1986). Homicide: Epidemiologic analysis

at the national level. Bulletin of the New York Academy of Medicine,

62, 376-399.

5. Bureau of Justice Statistics. (1992). Criminal victimization in the United

States: 1973-90 Trends. Bureau of Justice Statistics. A National Crime

Victimization Survey Report, December, NCJ-139564. US

Department of Justice. Office of Justice Programs.

6. Leskin, G.A., Ruzek, J.I., Friedman, M.J., & Gusman, F.D. (1999). Effective

clinical management of PTSD in primary care settings: screening

and assessment options. Primary Care Psychiatry, 5, 3-12.

7. Centers for Disease Control. (1992). Health objectives for the nation:

behaviors related to unintentional and intentional injuries among

high school studentsUnited States1991. MMWR, 41, 760-772.

8. Pynoos R.S. & Eth S. (1985). Developmental perspectives on psychic

trauma on childhood. In C.R. Figley (Ed.) Trauma and its wake.

New York: Brunner/Mazel.

 9. Black, D., & Kaplan, T. (1988). Father kills mother: Issues and problems

encountered by a child psychiatric team. British Journal of Psychiatry,

153, 624-630.

10. Christoffel, K.K. (1990). Violent death and injury in US children and

adolescents. American Journal of Disease Control, 144, 697-706.

11. Osofsky, J.O., Wewers, S., Hann, D.M., & Fick, A.C. (1993). Chronic

community violence: What is happening to our children? Psychiatry,

56, 36-45.

12. Shakoor, B.H., & Chalmers, D. (1990). Co-victimization of AfricanAmerican children who witness violence: Effects on cognitive,

emotional, and behavioral development. Journal of the National

Medical Association, 83, 233-238.

13. Garbarino, J., Kostelny, K., & Dubrow, N. (1991). No place to be a

child: Growing up in a war zone. Lexington, MA: Lexington Books.

14. McNally, R.J. (1991). Assessment of posttraumatic stress disorder in

children. Psychological Assessment: A Journal of Consulting and

Clinical Psychology, 3, 531-537.

Jacqueline Raia, Ph.D. is currently Assistant Professor and Graduate

Director at William Paterson University in Wayne, NJ. Her primary

areas of research are community violence, post-traumatic stress, child and

adolescent mental health.
Volume 8 (4) Fall 1999

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NC-PTSD Clinical Quarterly

Todays youth are commonly

exposed to violence in their homes,

schools, and communities, affecting

between 20 and 50% of American

youth (1). Violence now touches the

lives of more young people than ever

before (2-4), both as victims, but even

more commonly as witnesses (5-7).

The emotional impact of

such experiences on youth may be

profound. In children and

adolescents, exposure to community

violence has been associated with the

 development of PTSD at alarming

rates (8-11). Many others develop substantial posttraumatic stress

symptoms without the disorder itself, or develop related

disorders such as depression, substance abuse, or other anxiety

disorders.

Given the range of deleterious outcomes associated with

trauma exposure, it is not unexpected that children receiving

mental health treatment have higher rates of traumatic violence

exposure than do the general population (12). One recent study

found that 40.3% of children receiving mental health services

had been previously exposed to a traumatic event, and of these,

42.9% had significant PTSD symptoms (13). Our own study

examined rates of violence exposure and related distress among

youth referred to school district mental health services. In a

consecutive sample of 124 newly referred 4th - 8th graders, we

found that 69% reported the personal experience of violence

(ranging from being slapped/hit/punched to life-threatening

events) in the past year, and that 93% reported witnessing these

same types of violence. Children reported that physical violence

and threats of violence happened more often at school than at

home or in their neighborhoods. Eighty-nine (72%) of the

children identified a specific serious trauma, and of these, 46%

reported at least moderate PTSD symptoms related to that

trauma.

Interventions for violence exposed children range from

those designed to prevent problems to treatment for those with

an identified disorders. Increasingly, there is evidence that

children with PTSD can be effectively treated (14,15). Two

controlled studies evaluated the efficacy of a cognitive behavioral

therapy (CBT) program for child sexual abuse victims, and found

reductions in PTSD symptoms and fewer inappropriate sexual

behaviors than in control groups (16,17). A program for older

children testing a school-based group treatment following a

single-incident stressor found robust reductions in PTSD that

improved even more at follow-up

(14), as well as reduced depression,

anxiety, and anger. This recent

progress is promising, as is the fact

that a general consensus has been

reached by many experts on the

important components of PTSD

treatment. These include providing

the traumatized child with an

opportunity to evaluate and

reconsider the cognitive assumptions

made with regard to the traumatic

event, as well as including parents and

/or supportive others in the treatment

process (18). Psycho-education of the parents about their childs

PTSD symptoms and suggestions concerning management of

these symptoms is one common approach to involving the

parents in the childs treatment (19-21).

Children reported that

physical violence and threats

of violence happened more

often at school than at home

or in their neighborhoods.

Although treatment advances are promising, such

treatments are rarely used in community settings, and frequently

are limited to the relatively small number of individuals who have

a diagnosable disorder. The opportunity to decrease rates of

PTSD in children through prevention programs has been largely

unexplored, although work with adults shows that prevention

programs using CBT techniques are effective. A study of 20 female

assault victims compared those who received a brief prevention

program (4 individual therapy sessions) to those who underwent

an assessment procedure only. Participants in the brief prevention

program showed symptom reduction of 74%, as compared to a

mean reduction of 33% in the control group (22). The prevention

included education and brief practice with relaxation, imaginal

exposure to the trauma, real-life exposure to trauma reminders,

and cognitive restructuring for trauma-related cognitive

disto rtions. Although p relimina r y, these findings are

encouraging, and Foa and colleagues are continuing to study this

program in a larger sample of traumatized women.

How can we prevent emotional disturbances inyouth exposed to violence in schools?

LISA JAYCOX, PH.D. & BRADLEY STEIN, M.D., M.P.H.

Lisa Jaycox, Ph.D. Bradley Stein, M.D.
NC-PTSD Clinical Quarterly Volume 8 (4) Fall 1999

62

The high degree of overlap between symptoms of PTSD

and depression suggests that programs developed to target

depression may provide a roadmap for efforts to prevent

emotional disturbance after violence. For instance, programs

have been developed and proven effective in preventing

depression among adolescents (23) and depressive symptoms

among elementary school children (24). Both programs used

cognitive-behavioral therapy techniques such as cognitive

restructuring, social problem-solving, and social skills training.

Emotional disturbances related to violence exposure

during critical developmental periods can alter life trajectories

and create problems that last into adulthood. Research on the

ways in which interventions can target trauma-related symptoms

early, before they interfere with the important developmental

processes during the transition to adulthood, is lacking. Given

the research summarized above, a program that combines traumafocused exposure and CBT skills to prevent depression and

anxiety might be quite effective in reducing a wide array of

trauma-related symptoms and associated dysfunction.

References

1. Finkelhor, D., & Dziuba-Leatherman, J. (1994). Children as victims of

violence: A national survey. Pediatrics, 94, 413-420.

2. Federal Bureau of Investigation. (1992). Uniform crime reports (1991) .

Washington DC: Department of Justice.

3. Fitzpatrick, K. M., & Boldizar, J. P. (1993). The prevalence and

consequences of exposure to violence among African-American

youth. Journal of the American Academy of Child and Adolescent

Psychiatry, 32, 424-430.

4. Jenkins, E. J., & Bell, C. C. (1994). Post-traumatic stress disorder and

violence among inner city high school students. In S. Friedman (Ed.),

Anxiety disorders in African Americans. New York: Springer.

5. American School Health Association. (1989). The national adolescent

student health survey: A report on the health of Americas youth.

Oakland CA: Third Party Publishing.

6. Martinez, P., & Richters, J. E. (1993). The NIMH Community Violence

Project: II. Childrens distress symptoms associated with violence

exposure. Special Issue: Children and violence. Psychiatry

Interpersonal and Biological Processes, 56, 22-35.

7. Richters, J. E., & Martinez, P. (1993). The NIMH Community Violence

Project: I. Children as victims of and witnesses to violence. Special

Issue: Children and violence. Psychiatry Interpersonal and Biological

Processes, 56, 7-21.

8. Berman, S. L., Kurtines, W. M., Silverman, W. K., & Serafini, L. T. (1996).

The impact of exposure to crime and violence on urban youth.

American Journal of Orthopsychiatry, 66, 329-336.

9. Berton, M. W., & Stabb, S. D. (1996). Exposure to violence and posttraumatic stress disorder in urban adolescents. Adolescence, 31,

489-498.

10. Breslau, N., Davis, G. C., Andreski, P., & Peterson, E. (1991). Traumatic

events and posttraumatic stress disorder in an urban population of

young adults. Archives of General Psychiatry, 48, 216-222.

11. Horowitz, K., Weine, S., & Jekel, J. (1995). PTSD symptoms in urban

adolescent girls: Compounded community trauma. Journal of the

American Academy of Child & Adolescent Psychiatry, 34, 1353-

1361.

12. Bell, C. C., & Jenkins, E. J. (1993). Community violence and children on

Chicagos southside. Special Issue: Children and violence. Psychiatry

Interpersonal and Biological Processes, 56, 46-54.

13. Kelley, S. D., & Bickman, L. (1998). Childrens posttraumatic stress

reactions: Issues related to assessment, outcomes, and service

utilization. Nashville, TN: Vanderbilt Institute for Public Policy

Studies Center for Mental Health Policy.

14. March, J. S., Amaya-Jackson, L., Murray, M. C., & Schulte, A. (1998).

Cognitive-behavioral psychotherapy for children and adolescents

with posttraumatic stress disorder after a single-incident stressor.

Journal of the American Academy of Child & Adolescent

Psychiatry, 37, 585-593.

15. Pfefferbaum, B. (1997). Posttraumatic stress disorder in children - A

review of the past 10 years. Journal of the American Academy

of Child & Adolescent Psychiatry, 36, 1503-1511.

 16. Cohen, J. A., & Mannarino, A. P. (1996). A treatment outcome study for

sexually abused preschool children. Journal of the American Academy

of Child and Adolescent Psychiatry, 35, 42-50.

 17. Deblinger, E., & Heflin, A. H. (1996). Treating sexually abused children

and their nonoffending parents: A cognitive behavioral approach.

Thousand Oaks, CA: Sage Publications, Inc.

18. Cohen, J. A., & et al. (1998). Practice Parameters for the Assessment and

Treatment of Children and Adolescents With Posttraumatic Stress

Disorder. Washington, DC: American Academy of Child and

Adolescent Psychiatry.

19. Deblinger, E., McLeer, S. V., Atkins, M. S., Ralphe, D., & et al. (1989).

Post-traumatic stress in sexually abused, physically abused, and

nonabused children. 21st Annual Convention of the Association

for Advancement of Behavior Therapy (1987, Boston,

Massachusetts).

20. Parson, E. (1997). Posttraumatic child therapy (P-TCT). Journal of

Interpersonal Violence, 12, 192-194.

21. Rigamer, E. F. (1986). Psychological management of children in a national

crisis. Journal of the American Academy of Child and Adolescent

Psychiatry, 25, 364-369.

22. Foa, E. B., Hearst-Ikeda, D., & Perry, K. J. (1995). Evaluation of a brief

cognitive-behavioral program for the prevention of chronic PTSD

in recent assault victims. Journal of Consulting & Clinical

Psychology, 63, 948-955.

23. Clarke, G. N., Hawkins, W., Murphy, M., Sheeber, L. B., Lewinsohn, P.

M., & Seeley, J. R. (1995). Targeted prevention of unipolar depressive

disorder in an at-risk. Journal of American Academy of Child

Adolescent Psychiatry, 34, 312-21.

24. Jaycox, L. H., Reivich, K. J., Gillham, J., & Seligman, M. E. P. (1994).

Prevention of depressive symptoms in school children. Behaviour

Research & Therapy, 32, 801-816.

Lisa Jaycox, Ph.D. is an Associate Behavioral Scientist at RAND

(Santa Monica, CA) and a Clinical Psychologist (University of

Pennsylvania, 1993). Dr. Jaycox is working on projects related to the

treatment of adolescent depression in primary care settings, mental health

consequences of community violence among young adults, evaluation of

adolescent substance-abuse treatment programs, trauma-related distress among

adolescent help-seekers in school mental health and substance abuse

treatment settings, and the use of trauma-focused therapy to improve

school-based mental health services for children.

Bradley Stein M.D, M.P.H. is Visiting Assistant Professor of Psychiatry

at the University of Southern California, and a Faculty Scholar at the

UCLA/RAND Research Center on Managed Care for Psychiatric

Disorders. His current research focuses on the provision of school mental

health services to children exposed to violence, in addition to studying the

effects of managed behavioral health care on behavioral health service

utilization among vulnerable populations.
Volume 8 (4) Fall 1999

63

NC-PTSD Clinical Quarterly

 NEW DIRECTIONS Matthew J. Friedman, M.D., Ph.D.

 Executive Director, NC-PTSD

PTSD as a Severe Mental Illness

At the annual meeting of the National Alliance for the Mentally Ill (NAMI), held in Chicago last July, Dennis Charney, Bob Rosenheck,

Jackie Garrick (from the American Legion), and I had the opportunity to present a symposium entitled PTSD: A Brain Disorder and

Chronic Mental Illness.

In my opinion, this presentation reflects an important evolution for both NAMI and the PTSD field. NAMI is the most powerful

American organization dedicated to mental health support, education, advocacy and research. Having begun 20 years ago, primarily as a

group of parents of children with severe mental illness, NAMI now describes itself as the nations leading grassroots, self-help organization. It has played a major role in fostering legislative, public policy, professional and consumer initiatives on behalf of people with

mental illnesses due to brain disorders such as schizophrenia and affective disorders. It has paid little official attention to PTSD in the past.

Similarly, the PTSD field has generally looked to affective and anxiety disorders as its frame of reference rather than to severe mental

illness (SMI). In recent years, however, there has been a progressive convergence between the PTSD and SMI fields. That is why I think our

NAMI symposium is noteworthy. It represents the mutual recognition that both NAMI and PTSD professionals must begin to work

together to understand and assist SMI patients who have been previously or currently exposed to traumatic events.

Our NAMI symposium emphasized that: a) PTSD is associated with significant alterations in brain structure and function; b) people

with severe, chronic incapacitating PTSD are often superficially indistinguishable from other SMI patients; and c) within the SMI population, trauma is ubiquitous and PTSD quite prevalent.

During the past few years brain imaging research has shown that people with PTSD exhibit abnormal blood flow when confronted

with trauma-related stimuli or after they have received a drug (e.g., yohimbine) that activates adrenergic neurotransmission. Furthermore,

the hippocampus, a key brain structure involved in learning and memory, has been shown to have reduced volume among adults whose

PTSD is due to military trauma or childhood sexual abuse (1). These findings suggest that fundamental brain mechanisms that mediate

perception, learning, and memory are significantly altered in PTSD.

Five years ago, Bob Rosenheck and I suggested that PTSD may sometimes become a persistent mental illness. We pointed out that

although PTSD is not inherently a persistent mental disorder, some people with PTSD are severely and chronically incapacitated. They

suffer from severe and intolerable symptoms, marital, social, and vocational disability, and extensive use of psychiatric and clinical

services(They) can often be found on the fringes of society, in homeless shelters or enrolled in programs designed for patients with

chronic mental illnesses such as schizophrenia (2). We also showed that the intensity and pattern of clinical utilization, resembled that of

SMI patients within the VA system of healthcare. We went on to recommend that social rehabilitation treatment approaches, such as case

management, that have been developed for SMI patients, also be utilized for severe and incapacitating PTSD.

Finally, Kim Mueser and associates (3) assessed trauma exposure and PTSD prevalence among SMI patients in New Hampshire and

Baltimore. They found that almost all (98%) of the 275 patients interviewed reported lifetime exposure to at least one traumatic event.

Furthermore, almost half (43%) met diagnostic criteria for PTSD although only 2% had been so diagnosed in their clinical record. The

most common traumatic experiences were: adult or childhood sexual assault, attack with a weapon, automobile or work accidents, physical

attack without a weapon, and witnessing killing or serious injury of another. In short, both the lifetime prevalence of trauma exposure and

PTSD is higher among SMI patients than among the general population.

Taken together, these findings indicate that we must expand the neurobiological, clinical, and conceptual context in which we seek to

assist patients with PTSD. Advanced neuroimaging and other techniques have only begun to help us appreciate the disruption in brain

function associated with this disorder. Case management, work therapy, and other psychosocial rehabilitation therapies may be the treatments of choice for severe, incapacitating PTSD with or without adjunctive cognitive-behavioral and pharmacotherapeutic approaches.

Therefore, through collaborative initiatives, we must share our expertise with colleagues in the SMI field and let them teach us, in return,

what they have learned about treatment of SMI patients so that we may provide better care for people with severe, incapacitating PTSD as

well as for SMI patients with comorbid PTSD.

References

1. Bremner J.D. (in press). Alterations in brain structure and function associated with posttraumatic stress disorder. Seminars in Clinical

Neuropsychiatry, 4, (October, 1999).

2. Friedman M.J. & Rosenheck R.A. (1996). PTSD as a persistent mental illness. In S. Soreff (Ed.), The seriously and persistently mentally

ill: The state-of-the-art treatment handbook (pp. 369-389). Seattle: Hogrefe & Huber.

3. Mueser K.T., Goodman L.B., Trumbetta, S.L., Rosenberg, S.D., Osher, F.C., Vidaver, R., Auciello, P. & Foy, D.W. (1998). Trauma and

posttraumatic stress disorder in severe mental illness. Journal of Consulting and Clinical Psychology, 66, 493-499.
NC-PTSD Clinical Quarterly Volume 8 (4) Fall 1999

64

 WOMEN AND TRAUMA: A CLINICAL FORUM

Marie B. Caulfield, Ph.D., & Annabel Prins, Ph.D.

Finding Strength: Understanding the Function of Symptoms

Marie B. Caulfield, Ph.D.

Mental health care providers working with trauma survivors are often faced with an extensive array of presenting

problems. Trauma survivors frequently have a wide range of psychopathology including depression, posttraumatic stress disorder, and substance abuse. In addition, they may present with practical problems such as unemployment, legal problems, and

homelessness as well as serious safety issues such as self-mutilation, suicidality, and dangerous lifestyles. Finally, the provider

may also be helping the client deal with a wide range of problems in relationships.

With all of these problems, mental health care providers often feel as if they have their hands full and may sometimes

feel at a loss as to where to begin to intervene. For the benefit of both survivors and providers, it may be helpful for mental

health care providers to systematically examine the clients strengths. Finding and highlighting a clients strengths may sound

obvious, however, trauma survivors strengths may be reflected in their symptoms. A therapist may highlight this by making

explicit to clients that their reactions during the trauma were logical, beneficial, and perhaps even wise. For example, statements

such as you did whatever you needed to do to get through the beatings; you did whatever you could to make life bearable until you could come home

from a war you didnt understand anyway, can help to reframe the clients appraisal of their reactions. Moreover, in this supportive

context, observations may lead to a discussion of how strategies that were functional at the time of the trauma may now be

related to some of the clients current presenting problems.

Brattons (1), work on recovery from child abuse takes this idea one step further. She describes part of the healing

process as understanding the brilliance of childhood defenses. She highlights the important process of discovering with the

survivor that, not only were the childhood responses to trauma sensible, they were in fact creative, even brilliant solutions to

an impossible and horrible situation. For example, a client may be stuck on the fact that they did not do anything to stop their

abuse as a child. It may be critical to her recovery to help this client understand that she tolerated the abuse because the other

choice was being abandoned or being hurt worse, and that she made a strategic decision to survive by not fighting back. Her

ability to tolerate pain to prevent further suffering reflects a strength on which she can build. Similarly, for many clients who

dissociate, dissociating during the abuse was not just avoidance but a brilliant way of maintaining some control over their world.

Gondolf and Browne (2) emphasize the need to recognize and highlight the strengths of domestic violence survivors

because others, including the batterers, often negate these womens strengths. They describe how symptomatology or behaviors

that might be described as pathological can also can be considered coping strategies to endure abuse, escape abuse, or protect

children from abuse. Gondolf and Browne (2) provide a model for working with a client to assess her strengths, how she has

used these in the past, and any barriers to her using her strengths to achieve her goals. Although targeted for work with domestic

violence, their model may be useful for work with any trauma survivors.

It is important for therapists not only to encourage clients to look at past behaviors as unique and creative coping

strategies to intolerable situations, but also for therapists to work to understand these behaviors in this way themselves. Linehans (3)

successful treatment for clients with borderline personality disorder stresses the need for the therapist to believe that, at any

point in time, the client is doing the best she can. Empathy and understanding of the client is enhanced when the care provider

can understand the function of behavior in both past and current contexts as strategies to survive.

References

1. Bratton, M. (1999). From Surviving to Thriving: A Therapists Guide to Stage II Recovery for Survivors of Childhood Abuse.

New York: Hawthorn Press, Inc.

2. Gondolf, E.W. & Browne, A. (1998). Recognizing the strengths of battered women. In E.W. Gondolf, Assessing woman

battering in mental health services. Thousand Oaks, CA: Sage.

3. Linehan, M.M. (1993). Cognitive-behavioral treatment of borderline personality disorder. New York: Guilford.
Volume 8 (4) Fall 1999

65

NC-PTSD Clinical Quarterly

   

At a time of intense public concern

surrounding incidents of school violence, mental

health professionals should be mindful that, just as

they cannot bear the entire responsibility for

predicting and preventing such incidents, they do

not possess all the tools necessary to respond to and

repair the social and emotional damage that has been

done. The Columbine High School tragedy comes

at a time of unprecedented awareness-on the Federal,

State, and local levels-of the importance of

community-wide, collaborative approaches to the

issue of school safety, in particular, and preventing

and responding to incidents of youth violence in

general. This article summarizes some of the current

thinking on the Federal level related to the promotion

of school safety and highlights the role of mental

health professionals within this integrated,

collaborative framework.

In the recently announced combined federal

grant program, Safe Schools / Healthy Students,

the U.S. Departments of Justice, Education, and

Health and Human Services have emphasized the

importance of collaborative efforts which bring

together justice system actors (including law

enforcement), education personnel, and mental health

professionals to enhance school safety and promote

healthy child development. Another joint venture,

Early Warning, Timely Response: A Guide to Safe

Schools, was produced in response to a Presidential

directive to help all adults reach out to children at

risk for violence. This guide encourages the

formation of local Prevention and Response Teams

that include parents, mental health professionals, child

welfare representatives, physicians, business leaders,

members of the faith community, and juvenile justice

Justice, Education, and Mental Health Partnerships:

 Creating a Safety Net for Children

JENIFER WOOD, PH.D. & WINIFRED REED, M.A.

system representatives, among others.

These Federal initiatives reflect a growing

consensus that law enforcement, educators, and mental

health professionals all have meaningful roles to play

in both prevention and intervention related to incidents

of violence in schools and communities. The

development of partnerships between stakeholders as

diverse as police departments, early childhood program

staff, school administrators, community-based mental

health providers, and youth advocates creates a safety

net for children that independent, poorly integrated

efforts cannot. The complementary roles of these

partners in school safety promotion can be viewed

within a risk and protective framework. That is, to the

extent that children are securely embedded within a

nested sequence of protective environments-the family,

school, and larger community-their risk for negative

outcomes, including school violence, is diminished.

By working together, through the developmentof a

Prevention and Response Team, for example, mental

health professionals and other adults within the

community create this protective layering or safety net

for children.

Each partner in such collaborative efforts brings

a different type of expertise, and their involvement in

childrens lives connotes a different meaning. Although

the explicitly therapeutic contributionsof teachers, police

officers, and others may be limited, these individuals

serve as important sources of social support, identifiers

...parents, teachers, and police officers

can provide a context for childrens

recovery from traumatic experiences

that enhances the specialized work of

trained mental health professionals.
NC-PTSD Clinical Quarterly Volume 8 (4) Fall 1999

66

of warning signs, and potential conduits to more

specialized mental health services, as appropriate.

Moreover, parents, teachers, and police officers can

provide a context for childrens recovery from

traumatic experiences that enhances the specialized

work of trained mental health professionals. Law

enforcement officers, in particular, may play an

important, symbolic role in restoring childrens

sense of safety and connectedness to social

institutions after devastating events occur (1).

An example of a successful collaborative

effort is the Child Development - Community

Policing (CD-CP) Program, implemented by the

Yale Child Study Center in partnership with the

New Haven Police Department. The program

provides police officers with training in child

development and how to identify children at risk

for adverse outcomes following exposure to

community violence (2). Law enforcement officers

responding to crime scenes in which children are

victims, witnesses, or perpetrators are responsive

to those children and proactive in getting them

connected with appropriate mental health services.

In addition, CD-CP has expanded their work to

include intervention in the schools with children,

parents, and school administrators. As part of the

Community Outreach Police in Schools (COPS)

Intervention, neighborhood police officers and

clinicians co-lead therapeutic groups for

elementary-school students who have been victims

of or witnesses to crime. Work of this kind closes

the gaps between law enforcement, mental health

professionals, and schools to reduce the incidence

and negative consequences of childrens exposure

to potentially traumatic violence.

Although the terrain of these collaborative

initiatives may be unfamiliar to many clinicians,

mental health professionals have a key role to play.

To summarize, clinicians interested in prevention

and intervention around school and community

violence might consider the following

recommendations:

 Play an active role in building local partnerships between

mental health, law enforcement, the schools, and other key

stakeholders interested in childrens well being.

 Acknowledge the important functions that parents, teachers,

law enforcement, and others fulfill in childrens lives. At the same

time, assist these partners to recognize their limitations and feel

comfortable about knowing when a referral for specialized

mental health services is indicated.

 Work with these partners to incorporate targeted, clinical

interventions within broader, universal interventions, such as

violence prevention curricula and safe school policies. Too often,

school-wide efforts that reach large numbers of children are

not complemented by the availability of specialized mental health

services for those students who need them.

  Create opportunities to educate others about child

development and mental health. Clinicians may be more aware,

for example, of internalizing problems and could play a

valuable role in sensitizing educators and law enforcement to

childhood depression, post-traumatic stress, etc. Mental health

professionals bring a sophisticated understanding of risk factorsand particularly the risk imparted by being a victim of violencethat should inform the responses of other adults in the

community as well.

References

1. Murphy, L., Pynoos, R., & James, C.B. (1997). The trauma / grieffocused group psychotherapy module of an elementary schoolbased violence prevention - intervention program. In J. Osofsky

(Ed.), Children in a violent society (pp. 223-255). New York:

Guilford Press.

2. Marans, S., & Schaefer, M. (1998). Community policing, schools, and

mental health: The challenge of collaboration. In D. Elliot, B.

Hamburg, & K.Williams (Eds.), Violence in American schools:

A new perspective (pp. 312-347). New York: Cambridge

University Press.

Jenifer Wood, Ph.D. received her doctorate in clinical psychology from UCLA

and is currently the Director of Juvenile Justice and Mental Health at the National

Mental Health Association. Formerly, Dr. Wood served as a social science analyst at the

National Institute of Justice, focusing on issues related to mental health, substance abuse,

and prevention.

Winifred L. Reed, M.A. is a Social Science Analyst in the Crime Control

and Prevention Division, Office of Research and Evaluation at the National Institute

of Justice. She has worked in a wide range of substantive areas during her 25 plus

years of criminal justice experience including law enforcement, gangs, school-based

programs, criminal careers, criminal behavior, and crime prevention.

For further information about U.S. Dept. of Justice initiatives, contact: Winifred

Reed, Program Manager, National Institute of Justice, 810 Seventh Street NW,

Washington DC 20531; phone: (202) 307-2952; fax: (202) 616-0275; email:

winnie@ojp.usdoj.gov

Points of view are those of the authors and do not necessarily represent the views of the

National Institute of Justice or the U.S. Department of Justice.
Volume 8 (4) Fall 1999

67

NC-PTSD Clinical Quarterly

Among the poor in inner-city areas across the country, living

day by day with the fear of life-threatening violence erupting within

their neighborhoods has long been a fact of life. For others of us

living in middle class suburban communities, the problem may have

seemed remote. However, in the wake of the recent rash of actual

and threatened school shootings and bombings, it seems timely to

consider several key issues related to community violence (CV) that

have been identified by recent research conducted with high risk

inner city adolescents. School and mental health professionals now

must be prepared for providing crisis services when community

disasters occur, as well as taking necessary steps to prevent

predictable human perpetrated acts of violence.

Since the problem has taken on epidemic proportions in

recent years, adopting a public health model to conceptualize the

factors involved has been useful. In this approach, CV-related

variables are organized into three domains: agent, host and

environmental. Agent factors refer to the types of weapons and

their lethality, along with their cost and availability through legal

and illegal sources. Host factors include relevant personal

characteristics of those individuals who threaten or commit violence

against others (e.g., male adolescent, disaffected, uninvolved in

mainstream activities).

Environmental factors include the obvious family, school,

peer group, and neighborhood factors, as well as information inputs

such as advertising, movies, TV, internet, and video games. A

primary advantage of using this multifactoral approach is that it

requires simultaneous consideration of several risk factors, as well

as situational variables, in our attempts to understand complex acts

of violence and those who commit them, rather than using our

personally held, single-factor theories (e.g., poor parenting, guns,

or gangs are responsible).

Given the foregoing, risk screening to identify troubled

youth can proceed along the lines of a public health approach. For

example, by using the model, at-risk adolescents could be defined

as those who: are members of known high risk groups; engage in

high risk behaviors; and function in higher risk environments. In

Table 1 lets consider several variables from each public health

model domain that research has found to be associated with

increased risk for being victimized or perpetrating violence.

While the list of risk factors is not meant to be exhaustive, it

does illustrate how a confluence of factors, taken from the three

public health domains, can present a formidable set of

predispositions for an adolescent to carry into risk situations. On

the positive side, many of the risk factors are modifiable behaviors,

subject to prosocial change through active prevention efforts.

Immediate crisis intervention and short term treatment for

residual PTSD symptoms are indicated for adolescents who have

recently experienced a life-threatening episode of community violence.

Individual treatment provides a controlled, supportive therapeutic

environment, while group methods offer validation and normalization

of traumatic experiences through sharing with other members.

 GUNS, GANGS AND GIN

 Our violence prevention programs need to include

intervention in childrens social environments at home and at

school, as well as specific efforts to reduce risk behaviors such

as gang involvement, heavy drinking, and carrying handguns.

David Foy, Ph.D. is a professor of psychology at Pepperdine University,

Graduate School of Education. He has served as a research consultant to

the National Center for PTSD since 1991.

Table 1. Community violence risk domains & factors for adolescents

DAVID W. FOY, PH.D.

DOMAIN FACTORS DESCRIPTION

1. Male gender.

3. Prior violence/pro-

 aggression attitudes

3. Scapegoat or

 blacksheep in family

 system.

A

G

E

N

T

1. Lethal weapons. 1. Personal possession

 or access; carrying a

 weapon; threatening

 to get or use a lethal

 weapon in a dispute.

2. Substance abuse. 2. Alcohol in high doses;

 cocaine or other

 stimulants; sustained

 use or use in combin-

 ation with other drugs.

H

O

S

T

1. Females far less risk

 for direct community

 violence exposure.

4. History of traumatic

 victimization by

 community violence,

 domestic violence,

 or childhood

 physical/sexual abuse.

2. Impaired judgment

 and problem-solving.

3. & 4. Justifies use of

 violence for revenge

 when disrespected;

 uses dehumanizing

 language to describe

 opponents.

E

N

V

I

R

O

N

M

E

N

T

A

L

1. Association with

 antisocial peer

 group.

2. Parental communica-

 tion or monitoring

 lacking.

4. Absence of

 supportive others in

 extended family.

5. Marginal investment

 in academics or

 extra-curricular

 activities.

1. Affiliated with a clique,

 gang, or set with

 deviant rules.

2. & 3. Family

 dysfuntional and

 inappropriate blaming

 of adolescent.

4. Parent surrogates

 lacking.

5. Prosocial contract

 with society missing.

2. Recent loss or

 betrayal or depres-

 sion/other psycho-

 logical disorder.

RECOGNIZING ADOLESCENTS

AT RISK FOR PERPETRATING

COMMUNITY VIOLENCE
NC-PTSD Clinical Quarterly Volume 8 (4) Fall 1999

68

For many inner city young adults, violence

commonly occurs in the family, on the streets and in

schools. Recent high profile school shootings have

brought a renewed interest to closely examine the

developmental impact of community violence and

identify points for intervention. This article looks at

trauma histories and symptoms of PTSD in ethnic

minority, adult male medical patients interviewed in an

inner-city primary care clinic.

The term community violence is defined here

as intentional human acts that involve physical force or

injury and may occur anywhere, including at home or

in the community. Examples of community violence

include physical and sexual assault at home, being shot

at by a passing car or witnessing a homicide. Community

violence is an overly inclusive term, but useful when

working with traumatized individuals representing atrisk groups, such as young African-American males.

When working with minority groups from lower social

economic status with high rates of violence, a

community violence model can provide mental health

professionals a full perspective of the intensity and

frequency of violence that permeates these young mens

lives. The primary care clinic may serve as an important

gateway for identifying victims of crime who could

benefit from psychological services and treatment.

Background

Even though violent crime rates appear to be

decreasing, urban and suburban Americans still

experience criminal violence at very high rates. Within

the African-American communities, the violent crime

rate is even higher. The Massachusetts Department of

Public Health (1) reported that one in every 38 black

male teenager (age 15-19) was shot or stabbed in 1994.

The Massachusetts rate of nonfatal firearm assault

injuries among African-Americans was 159.3 per 100,000

in 1994; for whites, the rate was 2.9 per 100,000; and for

Hispanics, the rate was 75.3 per 100,000. This high level

of violence continues to represent a major challenge,

GREGORY A. LESKIN, PH.D.

not only for law enforcement, but also for the medical and

mental health communities who treat the bodily injuries

and human suffering caused by criminal violence.

The interviews were conducted at Boston Medical

Centers Young Mens Health Clinic. Boston Medical

Center (BMC) is a 350 bed, urban hospital in eastern

Massachusetts. BMC is the regional trauma center for

the sur rounding neighborhoods of Roxbur y,

Dorchester, and Mattapan. Together, these three areas

comprise 90% of the citys minority population. In

1995, these three districts together accounted for over

33% of all crime in the City of Boston; furthermore,

70% of all homicides in Boston involved AfricanAmerican victims. The Young Mens Health Clinic at

BMC is a clinic focusing on providing primary care

services to many adult males who live in these

communities, which made it an ideal location for

studying the emotional impact of urban crime and

violence.

Thirty African-American males (age 18-32) were

interviewed following their regularly scheduled medical

visit. Each individual was asked about his history of

criminal victimization, psychological problems related

to urban violence, and functional health. We found

Research points to the possible

advantages of actively

identifying trauma patients for

clinical education and

treatment to reduce symptoms

associated with PTSD

SCREENING FOR TRAUMA AND PTSD

IN A PRIMARY CARE CLINIC

very high rates of criminal victimization and related

psychopathology in this population. Using the Survey
Volume 8 (4) Fall 1999

69

NC-PTSD Clinical Quarterly

References

1. Massachusetts Department of Public Health (1996).

Weapon injury update. Bureau of Health Statistics,

Research and Evaluation: Massachusetts

Department of Public Health.

2. Raia, J.A. (1998, November). Community violence,

school functioning and anxiety symptomatology in

young inner-city adolescents. In G. Leskin (Chair),

The impact of community violence from childhood

to adulthood. Symposium conducted at the Annual

Meeting of the Association for the Advancement

of Behavior Therapy, Washington, DC.

3. Foa, E.B., Riggs, D.S., Dancu, C.V., & Rothbaum, B.O.

(1993). Reliability and validity of a brief instrument

for assessing post-traumatic stress disorder. Journal

of Traumatic Stress, 6, 459-473.

4. Leskin, G.A., Ruzek, J.I., Friedman, M.J. & Gusman,

F.D. (1999). Effective clinical management of PTSD

in primary care settings: Screening and treatment

options. Primary Care Psychiatry, 5, pp. 3-11.

Using the PTSD Symptom Scale (3), more than

half of this group met diagnostic criteria for PTSD. In

fact, the PTSD scores for this group were also high,

making this group comparable to other studied trauma

populations, such as an acute rape sample.

We also found a strong correlation between the level

of violence exposure and psychopathology. The correlation

coefficient between direct victimization and PTSD was

.50 (p < .001). The study also examined the relationship

between functional health (SF-12), and PTSD. The

correlation between PTSD and overall mental health

functioning was -.80, suggesting the presence of PTSD is

related to decreased general mental abilities. The correlation

between PTSD and physical health functioning was -.35.

This correlation may indicate that individuals with PTSD

may also suffer from physical health problems. These

findings support a growing literature that draw a connection

between PTSD and physical health problems (4).

Primary Care Models for Treating PTSD

The findings make it clear that many of the patients

being treated for medical problems would also be well

served if asked about their histories of abuse and trauma.

The model used for the study was a collaborative model

of behavioral healthcare. The primary care physician

referred patients directly to a psychologist in the clinic for

trauma screening and psychological evaluation. The

primary care physician has a vested interest to treat both

the medical and psychological problems of the patients in

the Young Mens Health Clinic. Because of the physicians

knowledge of the impact of trauma on development, he

collaborated with a Ph.D. level clinician to measure the

impact of trauma and PTSD. This close collaboration

between primary and specialty care physicians with mental

health professionals can be advantageous for overall patient

care. Many trauma patients do not seek mental health

services, but will request medical services for their bodily

pains. The advantages of this integrated, multidisciplinary

research points to the possible advantages of actively

identifying trauma patients for possible clinical education

for Exposure to Community Violence Revised (2), the

mean number of direct victimization experiences (e.g.,

being injured or having life threatened) was 21.2

(SD=15.0). The number of violent experiences ranged

between 6 and 189 lifetime events.

and treatment to reduce symptoms associated with PTSD.

Such an approach might help to reduce an individuals risk

for future victimization or violent acting out.

Summary

This article presented findings from a study that

examined the rate of traumatic life events and PTSD in a

primary care setting. The Young Mens Health Clinic was

an ideal place to position mental health staff to interview

medical patients and screen for trauma and PTSD. Many

individuals visiting this setting were found to have high

rates of previous community violence trauma, PTSD and

related physical health problems. Hopefully, by educating

patients and physicians in medical settings about the

potential impact of traumatic stress, trauma professionals

and mental health staff can help reduce health related

consequences of violence.

Greg A. Leskin, Ph.D. completed his NIMH post-doctoral

fellowship at the National Center for PTSD Behavioral

Science Division in 1998 and then joined the staff at the

Education and Clinical Laboratory Division. His primary

area of interest is behavioral integration in primary care.

PTSD IN A PRIMARY CARE CLINIC
NC-PTSD Clinical Quarterly Volume 8 (4) Fall 1999

70

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NC-PTSD Clinical Quarterly

PTSD Assessment Library

Available upon request are selected instruments from our library of

assessment and program evaluation tools (with accompanying articles),

together with templates describing over 100 trauma-related measures

courtesy of Beth Stamm, Ph.D., and Sidran Press. Telephone (650) 493-

5000 ext. 22477.

PTSD Article Library

A helpful set of key articles on aspects of PTSD is available to VA

or Vet Center clinicians free of charge. Telephone (650) 493-5000 ext.

22673.

PTSD Video Library

The Menlo Park Education Team maintains a small videotape

lending library exploring topics related to PTSD diagnosis,

evaluation, and treatment. Videotapes may be borrowed free of

charge. Telephone (650) 493-5000 ext. 22673.

PTSD Program Liaison and Consultation

The Menlo Park Education Team can help VA health care professionals

locate needed resources. Services may include assistance in locating relevant

articles, locating resource persons, or problem-solving. Staff are available to

consult in the areas of PTSD Diagnosis and Treatment, Program

Development and Design, Women and Trauma, Relapse Prevention, and

with other PTSD-related concerns. Telephone (650) 493-5000 ext. 22977.

National Center for PTSD Web Page

The NC-PTSD Home Page provides a description of activities of the

National Center for PTSD and other trauma related information. The

world wide web address is: http://www.dartmouth.edu/dms/ptsd/

PILOTS Database

PILOTS, the only electronic index focused exclusively on the worlds

literature on PTSD and other mental health consequences of exposure

to traumatic events, provides clinicians and researchers with the ability

to conduct literature searches on all topics relevant to PTSD. http://

www.dartmouth.edu/dms/ptsd/PILOTS.html

NC-PTSD Research Quarterly

The Research Quarterly reviews recent scientific PTSD literature.

Telephone (802) 296-5132 for subscription information.

Disaster Mental Health Training and Consultation

Education staff provide training in disaster mental health services,

including team development, interfacing with other agencies, on-site

and off-site interventions, debriefing, and psychoeducational and

treatment interventions with disaster survivors and workers.

Telephone (650) 493-5000 ext. 22494 or email: bhh@icon.paloalto.med.va.gov

The Education and Clinical Laboratory Education

Division for the National Center for Post Traumatic

Stress Disorder at the Palo Alto CA VAMC, in

collaboration with the VA Employee Education

System offers a Clinical Training Program (CTP).

The training program is approved for 35 Category 1

CEUs for physicians, psychologists, social workers,

and nurses.

Each year we welcome many mental health

professionals from across the United States and from

around the world. Most clinicians who enroll in the

program have a working knowledge about treating

the effects of trauma and PTSD and are looking to

upgrade their clinical skills. The CTP offers a broad

range of educational activities including:

* Lectures

* Clinical consultation

* Clinical observation of group treatment

* Group discussions facilitated by staff

Specific training topics include warzone trauma group

treatment, treatment of women veterans, treatment

of sexual assault related PTSD, relapse prevention,

cross cultural treatment issues, assessment and

treatment of families, disaster mental health services,

cognition and PTSD, assessment of PTSD, and

psychiatric assessment.

Training programs are scheduled for a minimum of

one week, though longer programs are available if

the applicant can justify an extended stay. Programs

are scheduled nine times per year, generally on the

third week of the month.

At present time, funding for attendance is not

available from the National Center. There is no fee

for the training program itself, but participants are

responsible for providing their own transportation,

lodging, and meals. Interested applicants are encouraged

to explore funding options through their local medical

centers or VA Employee Education System. For more

information, or to request an application, please email:

jir@icon.palo-alto.med.va.gov, or call FTS 700-463-2673, or

commercial number 650-493-5000, ext. 22673.

NC-PTSD EDUCATION & SUPPORT SERVICES

Clinical Training Program

Conferences and Training Events

The Menlo Park Education Team provides consultative support for

the development of training in PTSD. Services include assistance in

finding faculty and designing program content. Telephone (650) 493-5000

ext. 22673.