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The impact of violence exposure on adolescents’ ratings of posttraumatic stress, depression and suicidal… Misic, Diana 1999

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T H E I M P A C T OF V I O L E N C E E X P O S U R E O N A D O L E S C E N T S ' RATINGS OF P O S T T R A U M A T I C STRESS, D E P R E S S I O N A N D SUICIDAL IDEATION by Diana M i s i c B.Ed., The University of Alberta, 1993  A T H E S I S S U B M I T T E D IN P A R T I A L F U L F I L L M E N T O F THE REQUIREMENTS FOR THE D E G R E E OF M A S T E R OF A R T S in T H E F A C U L T Y OF G R A D U A T E STUDIES (Department of Educational & Counselling Psychology & Special Education; School Psychology Program)  We accept this thesis as conforming to the required standard.  T H E U N I V E R S I T Y OF BRITISH C O L U M B I A June 1999 © D i a n a M i s i c , 1999  In presenting this thesis in partial fulfilment  of the  requirements for an advanced  degree at the University of British Columbia, I agree that the Library shall make it freely available for reference and study. I further agree that permission for extensive copying of this thesis for scholarly purposes may be granted by the head of my department  or by  his  or her  representatives.  It  is  understood  that  copying or  publication of this thesis for financial gain shall not be allowed without my written permission.  Department The University of British Columbia Vancouver, Canada  DE-6 (2/88)  Abstract The purpose of this study was to examine the relationship between violence exposure and internalizing symptomatology ( P T S D , depression, suicidal ideation). This study also examined the role of gender and social support within this relationship. There are several reasons for examining the impact of exposure to violence on P T S D , depression and suicidal ideation symptomatology. Perhaps the most prominent of theses is the recent publicity regarding the extent of violence in schools and communities. For this study, violence exposure was defined as being physically near, and/or observing a violent event. Past studies have shown that violence exposure is pervasive for adults, children and adolescents (O'Keefe, 1997; Singer et al., 1995). A s the limited literature on gender differences in violence exposure has revealed differing results, further investigation of gender differences in violence exposure is warranted. Studies have shown a positive relationship between different types of internalizing symptomatology (depression, traumatic stress, suicidal ideation) and violence exposure; the greater the violence exposure, the higher the symptoms exhibited by the individual. A n important facet of the relation between violence exposure and internalizing symptomatology often neglected is the issue of social support. In this study negative life events was entered as a controlling variable. The present study examined the following hypotheses and questions: (1) There w i l l be significant differences between levels of social support and violence exposure for internalizing symptomatology, controlling for negative life events; (2) What are the differences in levels of internalizing symptomatology between males and females with high  ii  violence exposure and high social support?, and, What are the differences in levels of internalizing symptomatology between males and females with high violence exposure and low social support?; and (3) D o the proportions of females and males with the low. Moderate and high violence exposure levels significantly differ from one another? Respondents included 431 high school students attending four schools in the Lower Mainland of British Columbia. Students ranged in age from 13 to 20 years, attending grades 8 through 12. O f the total sample, 38% were males and 6 2 % were females. Respondents were asked to complete self-report measures including the Exposure to Violence Questionnaire ( E V Q ) , the Reynolds Adolescent Depression Scale ( R A D S ) , the P T S scale of the Adolescent Psychopathology Scale ( A P S ) , the Suicidal Ideation Questionnaire-Jr. (SIQJr), the Adolescent Support Inventory (ASI) and the Negative Life Events Scale ( N L E ) . O f the total sample, 57% and 44% of females reported moderate or high levels of violence exposure/ Eighty-nine percent of students reported and incidence of violence at their school, and over half reported knowing someone who had been attacked. Upon examining levels of internalizing symptomatology between males with high or moderate levels of violence exposure and high social support and males with high or moderate levels of violence exposure and low social support, results revealed no significant differences between the groups on measures of internalizing symptomatology. N o significant differences between females with high or moderate levels of violence exposure and high social support and females with high or moderate levels of violence exposure and low social support were evident on measures of P T S D or suicidal ideation. Results revealed a significant main effect for social support on a measure of depression.  iii  Upon examining the levels of internalizing symptomatology between males and females with high or moderate levels of violence exposure and high and low social support, no significant differences were present between the groups on all measures of internalizing symptomatology. A greater proportion of females than males were within the low group. However, there was a greater proportion of males within the medium and high violence exposure groups. The high levels of violence exposure of adolescents in their communities and schools suggest the need for developing school and community intervention programs to treat violence and its impact on adolescent mental health. A s well, the results of this study suggest that social support may not have the previously believed buffering effect once violence exposure is high.  iv  Table of Contents Abstract ii List of Tables  viii  List of Figures  ix  Acknowledgements  x  CHAPTER 1 Introduction Community Violence Adolescence Exposure to Violence Internalizing Symptomatology Gender Differences Summary Purpose of Study  1 1 1 1 2 3 5 6 6  CHAPTER 2 Literature Review Overview Adolescence Prevalence of Violence Summary Definitions of Violence Summary Exposure to Violence Prevalence Rates Summary The Effects of Violence Exposure PTSD P T S D and Exposure to Violence P T S D and Wartime Violence Exposure P T S D and Natural Disasters P T S D and Community Violence Summary Depression Depression and Violence Exposure  v  8 8 8 8 10 12 13 14 14 14 21 24 26 29 29 32 33 37 38 39  Suicidal Ideation Suicidal Ideation and Violence Exposure Gender Differences In Internalizing Symptomatology Social Support and Negative Life Events Social Support Social Support and Violence Exposure Social Support and Internalizing Symptomatology Negative Life Events Summary Summary  40 42 42 46 46 46 49 50 51 52  CHAPTER 3 55 Statement of the Problem and Research Questions 55 Purpose of the Study 55 Research Questions and Hypotheses 56 Internalizing Symptomatology as Related to Violence Exposure: . . 56 Rationale 56 Gender Differences 59 Prevalence Rates 59 Rationale 59 CHAPTER 4 Methodology Participants Procedure Instrumentation Demographic Information Assessment of Violence Exposure Assessment o f Posttraumatic Stress Disorder Assessment of Depression Assessment of Suicidal Ideation Assessment of Social Support Assessment of Negative Life Events Data Analysis Violence Exposure and Symptomatology (Hypotheses la-d) Gender Differences (Questions 2a-b) Descriptive Statistics (Question 3)  61 61 61 61 64 64 64 65 65 66 67 67 67 67 69 70  CHAPTER 5 Results  71 71 71 73 80  Descriptive Characteristics Internalizing Symptomatology as Related to Violence Exposure Secondary Analysis  vi  Gender Differences Secondary Analysis Secondary Analysis Supplementary Analysis  82 83 84 84  CHAPTER 6 Discussion Purpose of Study Prevalence of Violence Exposure Internalizing Symptomatology as Related to Violence Exposure Gender Differences Gender Differences in Violence Exposure Limitations of Study Implications for Further Research Summary  90 90 90 90 92 99 102 103 104 107  References  109  APPENDIX A  123  APPENDIX B  124  APPENDIX C  125  APPENDIX D  126  APPENDIX E  127  APPENDIX F  128  APPENDIX G  129  APPENDIX H  130  vii  List of Tables Table 1. Incidence Studies of Violence Exposure  16  Table 2. Descriptive Characteristics of Participants  62  Table 3. Means and Standard Deviations for Male-Female Differences o f Measures for Males, Females, and the Total Sample  72  Table 4. Analysis of Covariance for Males with High and M e d i u m Levels of Violence Exposure: High vs. L o w Social Support Table 5.  75  Analysis o f Covariance for Females with High and M e d i u m Levels o f Violence  Exposure: High vs. L o w Social Support  78  Table 6. Analysis of Covariance for Females and Males with L o w Violence Exposure: H i g h vs. L o w Social Support  81  Table 7. Number and Proportion of Males and Females in Violence Exposure Groups  85  Table 8. Exposure to Violence Item Endorsements  86  Table 9. Internalizing Symptomatology Adjusted Means for Males and Females with L o w , Medium and High Levels of Violence Exposure  vin  88  List of Figures Figure 1. The Iceberg Model  22  Figure 2. Symptom Groupings of P T S D  25  Figure 3. Violence Exposure and Internalizing Symptomatology - Males  57  Figure 4. Violence Exposure and Internalizing Symptomatology - Females  58  Figure 5. Analysis of Covariance for Males with Levels of Violence Exposure: High vs. L o w Social Support  76  Figure 6. Analysis of Covariance for Females with Levels of Violence Exposure: High vs. L o w Social Support  79  Figure 7. Analysis of Covariance for Females and Males with Levels of Violence Exposure on Measures of Internalizing Symptomatology  89  ix  Acknowledgements With a project such as this, there are many people to whom I must give heartfelt thanks. It seems appropriate to begin with my thesis advisor, Dr. W i l l i a m Reynolds, who accepted nothing less than perfection. I would also like to thanks Dr.'s K i m Schonert-Reichl and Marion Porath, my committee members, for their time and supportive comments. Without the help of my colleague and good friend, Erin Moors, I feel that this thesis would never have been completed. I would like to extent heartfelt thanks for her encouragement and support of its accomplishment. A s well, I must thank my mother, father, sister Tamara and cousin Angela for their encouragement, support and affection. Finally, I must thank my husband Robert, for his love, help and patience with everything that I do.  CHAPTER 1 Introduction Community Violence Children and adolescents are faced with enormous pressures in today's society, and are subject to many stresses. The past 30 years have seen a dramatic increase in crime rates across Canada. The general crime rate increased 14% between 1983 and 1993; violent crime increased as well from 8% in 1983 to 11% in 1993 (Statistics Canada, 1996). In British Columbia, newspapers have covered the alarming rise of violence in the schools (Bellett, 1993). These statistics consist of reported crimes - researchers believe the actual crime rate could be substantially higher. A s violence in neighborhoods increase, a logical consequence is the likelihood of children and adolescents either witnessing or becoming victims of violence. When children feel safe in their neighborhood, they are ready to play, explore and make new relationships with other children. When danger and violence replace safety in the neighborhood, there are bound to be serious ramifications in children's social and emotional development. Exposure to violence may affect the intellectual, physical and/or social-emotional development of a child or adolescent (Garbarino, Dubrow, Kostelny, & Pardo, 1992). Outcomes may include traumatic symptomatology, such as posttraumatic stress disorder (PTSD), depression and/or suicidal ideation. Adolescence Adolescence is a time of great change, both physiologically and psychologically (Offer & Schonert-Reichl, 1995). However, a myth exists that adolescence is a period of turmoil and that all adolescents experience mental instability. In fact, adolescence is not a  2  time of severe disturbance for all adolescents (Schonert-Reichl & Offer, 1992).  Many  clinicians have overlooked adolescent symptomatology for this reason (Schonert-Reichl & Offer, 1992). There are researchers who believe that differences exist in psychological reactions to violence exposure with regards to the developmental level of an individual (Osofsky, 1995). Because youngsters have a more limited range of coping skills than adults (Garbarino et al., 1992), one would expect youngsters exposed to violence to be more susceptible to internalizing symptomatology than adults. However, adolescents are in an age group often overlooked by researchers examining violence exposure and/or internalizing symptomatology.  Therefore, adolescence is an important age group to examine when  investigating violence exposure and internalizing symptomatology. Exposure to Violence The definition of violence is vague and inconclusive. Researchers seem to use the term "violence" to mean many different constructs. The most popular definitions have divided violence into two separate constructs: violence exposure and victimization. Many studies examining violence have not differentiated between these forms of violence; rather, they have collapsed exposure to violence and victimization into one entity. Victimization has been defined as being "personally exposed to a situation or event that constituted a direct threat to his or her life or physical well-being" (Saigh, 1991, p. 214). Exposure to violence differs from victimization, in that "although the person was not personally exposed to danger, he or she saw others who were" (p. 214). Research has shown that children and adolescents w i l l have a greater tendency to be exposed to violence than victimized. Richters and Martinez (1993a) examined the extent to which young children living in a violent inner-city  3  community had been exposed to and victimized by various forms of violence. Parents' reports as well as child-completed measures indicated that children were significantly more likely to report having witnessed violence than be victimized themselves. Gladstein and Slater (1988), in examining inner city teenagers' exposure to violence, found that teenagers had witnessed violence far more than they were victimized. There have been few studies examining community violence exposure with adolescents. The largest study examining community violence exposure was conducted with over 3000 participants. Researchers found that between 3 3 % and 4 4 % of adolescents had been victimized, and between 32% and 82% had witnessed violence, depending on the school (Singer, A n g l i n , Song, & Lunghofer, 1995). A study investigating the extent of community violence exposure within an inner-city community found that 39% of the sample were exposed to violence (Breslau, Davis, Andreski, & Peterson, 1991). Another study examining victimization and violence exposure in a group of African-American adolescents found that between 5.5% and 42.3% of the sample were exposed to violence, and between 1.2% and 22.9% were victimized (depending on the school) (Gladstein & Slater, 1988). Internalizing Symptomatology With the increasing prevalence of violence, there has been a growing abundance of literature focusing on the effects of exposure to violence in children and adolescents. The majority of this literature has focused on violence exposure through war and natural disasters. This body of literature suggests that there is a significant relationship between exposure to violence and internalizing symptomatology or diagnoses ( Martinez & Richters, 1993; M a z z a & Reynolds, 1999; Schwarz & K o w a l s k i , 1991).  4  The literature on violence exposure and internalizing symptomatology indicates that individuals exposed to wartime violence or natural disasters are more likely to experience increasing levels of internalizing symptomatology.  Saigh (1991) studied the development of  P T S D following four types of traumatization: direct exposure (being victimized), observation (violence exposure), verbal mediation (hearing or learning about a violent event), and a combination of two types. Although each of these groups had significantly greater P T S D , anxiety and depression scores than the non-clinical controls, Saigh found no differences between the types of exposure and anxiety or depression scores. In examining children's distress symptoms associated with community violence exposure, Martinez and Richters (1993) found that children's reports of witnessing violence and victimization in the community were associated with higher self-reports of overall distress. A study conducted by Fitzpatrick and Boldizar (1993) examining the extent and effect of violence exposure with a sample of over 200 youth living in housing communities found that greater exposure, either as a victim or a witness, was significantly positively related to increased reporting of traumatic symptomatology. Breslau et al. (1991) found that in an urban population of 1,007 young adults, 39.1% reported exposure to one or more stressors that lead to P T S D . O f those who were exposed to these stressors, 23.6% were diagnosed with P T S D . The implications of violence exposure on adolescents may include increasing levels of internalizing symptomatology. Most studies have either examined the extent or the effect of exposure to violence; few have combined the two in one study. The trend in the literature examining the effects of violence on youth suggests that there is a positive relationship  5  between exposure to violence and internalizing symptomatology. Gender Differences There seems to be some disagreement in the literature with respect to the extent and the effect of violence exposure in males and females. For the purposes of this study, the literature on gender differences w i l l be examined within violence exposure and internalizing symptomatology. Research investigating gender differences within violence exposure has revealed differing results as to whether males are more likely to be exposed to violence than females, or whether there are no gender differences in violence exposure. Breslau et al. (1991) found when sampling a population of urban young adults that out of the 394 respondents who reported violence exposure to one or more traumatic events, most were males. Fitzpatrick and Boldizar (1993) in examining exposure to violence found that males were victims of and witnesses to violence more than were females. However, in a study of 6 , 7 and 8 grade t h  th  th  adolescents examining violence exposure and depression and suicidal ideation (Mazza, Reynolds, & Grover, 1995), males and females were found to have similar scores on the violence exposure scales. While males are more likely to be exposed to violence, females, when exposed, are more likely to manifest higher levels of internalizing symptomatology than their male counterparts. Schwarz and Kowalski (1991) reported that girls experienced more distressing dreams and avoided certain games which reminded them of the traumatic event than boys. In a study examining depression occurrence in adolescents, females were more likely to be diagnosed with unipolar depression and anxiety disorders, while males were more likely to be diagnosed  6  with disruptive disorders (Lewinsohn, Hops, Roberts, Seeley & Andrews, 1993). Summary Within the last 10 years, there has been a growing amount of literature regarding violence exposure and internalizing symptomatology in children and adolescents. The trends in the current literature suggest several issues. Studies examining violence exposure and victimization have found that more adolescents are likely to be exposed to violence than victimized. A n adolescent who has experienced violence exposure may exhibit increased levels of internalizing symptomatology, such as posttraumatic stress, depression, and/or suicidal ideation. Gender differences within violence exposure and internalizing symptomatology suggest that males and females may experience varying levels of violence exposure and internalizing symptomatology. These issues w i l l be discussed in the following chapter. Purpose of Study The purpose of this study was to examine the relations between violence exposure and internalizing symptomatology ( P T S D , depression, suicidal ideation). This study also examined the role of gender and social support within this relationship.. There are several reasons for examining the impact of exposure to violence on P T S D , depression and suicidal ideation symptomatology. Perhaps the most prominent of these is the recent publicity that violence exposure has received in the newspapers and other media. A majority of the research that w i l l be examined in the following chapter took place in the United States, a country often in the media for its high crime rates. Nevertheless, violence occurs often in Canada. Canadian teens are not immune to the type of violence seen in the United States.  There is no research in Canada examining the effects of violence exposure on adolescents. Statistics have shown that crime rates in Vancouver are among the highest in Canada (Statistics Canada, 1996). Statistics have established that violence occurs in the lower Mainland. It is therefore logical to assume that adolescents are exposed to this violence. The effects of this exposure have yet to be studied. The following chapter w i l l , in addition to expanding on several of the studies mentioned in this chapter as well as discussing other research, provide a rationale for the importance of conducting this study.  8  CHAPTER 2 Literature Review Overview Research examining exposure to violence and the effects of exposure to violence has taken many different perspectives. The intent of this study is to examine the prevalence rates of violence exposure as well as the effects of this exposure on a sample of adolescents. A s of yet, research examining these two domains has not often been integrative. Many studies that have examined violence exposure have not examined the effects of this exposure. Others who have looked at both of these domains have not integrated factors important in examining the extent and effect o f violence exposure, such as those o f gender or social support. The issue of adolescence as a developmental stage w i l l be examined in this review. This chapter w i l l also include research on the extent of violence exposure as well as three possible psychologically deleterious effects of violence exposure: posttraumatic stress disorder (PTSD), depression, and suicidal ideation. Social support and gender issues w i l l be put forth as important issues to examine in the relationship between violence exposure and these internalizing symptomatologies. These issues are important facets of the research to examine in order to better understand the relationship between violence exposure and symptomatology. Adolescence Most would agree that adolescence is a time of great change in human biological, psychological and social development. Adolescence boasts may different changes at many levels (Eccles et al., 1993). Optimal adolescent development has been hypothesized to occur  9  when there is a good "stage-environment fit" between adolescents and their social environment (Eccles et al. 1993). When an individual's social environment has been faced with violence exposure, it is logical to assume that the individual's development w i l l be affected in a negative way. Garbarino et al. (1992) describe the adolescent response to community violence as being "characterized by a premature entrance into adulthood or a premature closure on identity formation" (p. 52). The authors also describe behaviors such as aggression, truncated moral development or identification with the aggressor (joining a gang) as possible outcomes of adolescent violence exposure. In most studies examining the relations between violence exposure and associated symptomatology, researchers do not treat adolescence as a separate developmental group. However, there are researchers who believe that differences exist in psychological reactions to violence exposure with regards to the developmental level of an individual (Osofsky, 1995). A myth exists that adolescence is a period of turmoil and that all adolescents experience mental instability. In fact, adolescence is not a time of severe disturbance for all adolescents (Offer & Schonert-Reichl, 1995). Many clinicians have overlooked adolescent symptomatology for this reason (Offer & Schonert-Reichl, 1995). The Diagnostic and Statistical Manual of Mental Disorders - IV ( D S M I V ; American Psychiatric Association, 1994), while it acknowledges children as a separate developmental group, still makes the assumption that adolescents w i l l have similar symptomatology to adults or to children. In a study examining the relationship between negative life events and depression symptoms, adolescents were found to experience more negative life events than preadolescents (Larson & Ham, 1993). A s well, negative events were found to be a stronger predictor of negative  10  affect for adolescents than preadolescents. In a study examining childhood and adolescent depression in a large sample of youths aged 6 to 16, a significant age effect was revealed, with more adolescents displaying higher rates of depression than children (Fleming, Offord, & Boyle, 1989). The overall prevalence of depression increased three fold from pre-adolescence to adolescence. Gjerde and colleagues (Gjerde, Block, & Block, 1988) posit that although there are some similarities between depression in adults and adolescents, "adolescents sometimes seem to express their underlying depression through behaviors differing from the traditional manifestations of adult depression" (p. 475). These studies seem to refute the idea that adolescents can be collapsed with children or adults; rather, they should be treated as a separate developmental entity. M a n y o f the studies reviewed in this chapter w i l l focus on adults or children. A s many of the study samples do include individuals in their teenage years, the adolescent extent and effect of violence exposure w i l l have to be generalized from these studies. Prevalence of Violence In the media, it is not uncommon to be barraged with statistics of criminal activity perpetrated by adults as well as youths. Many of the statistics reported in the media are from the United States, and often are disregarded as not comparable to less populated countries such as Canada. However, many Canadian statistics on crime and violence are remarkably similar to their American counterparts. Vancouver has the highest violent/property crime rate compared with other metropolitan centers in Canada (1,300 per 100,000 population) (Statistics Canada, 1996). Although the past year has seen a decline in Canadian crime rates (general crime and violent crime), the rates of youths, aged 12 to 17 years, charged with  11  violent crime has increased by 2.4% (from 9,275 to 22,375), more than twice the rate from 1986 (Statistics Canada, 1996). In 1993, Statistics Canada conducted a telephone survey aimed at people 15 years and older of over 10,000 Canadians. Within this sample, 24% reported that they were victims of at least one crime or one attempted crime (Statistics Canada, 1993). Younger Canadians (ages 15-24) were found to have higher rates of criminal victimization than older Canadians (225 per 1000 population); two times higher than people between the ages of 25 to 44 (96 per 1000 population) and four times higher than those between the ages of 45 and 64 (45 per 1000 population). In the same year, the McCreary Centre Society conducted a province-wide survey examining the health status and risk behaviors of adolescents. Over 170 schools participated in the survey, with 15,549 students from grades 7 through 12 participating in the study. O f this sample, 4 5 % of males and 2 1 % of females reported having one or more physical fights in the past year. A s well, 2 7 % of males and 5% of females reported carrying a weapon on one or more days in the preceding months (McCreary Centre Society, 1993). Perhaps as important as prevalence statistics of crime is the perception of crime by individuals. Canadians are becoming increasingly fearful of crime and of being victimized. Many Canadians believe that crime in general is increasing, and are particularly concerned with violent crime (Statistics Canada, 1993). In the General Social Survey conducted in 1993, 2 7 % of the sample surveyed felt "very unsafe" in their homes and communities (Statistics Canada, 1993). A s well, 4 2 % of the sample were most concerned about violent crime. A study examined how different facets of social-emotional adjustment are affected by  12 violence exposure with a group of 150 African-American 4 , 5 and 6 graders (Hill & th  th  th  Madhere, 1996). The authors examined social support, violence perception (such as apprehension, a sense of retaliation) and violence exposure (witnessing violence) as well as variables associated with social-emotional adjustment (such as state anxiety and competence). Results revealed that "children's perceptions of their exposure to community violence proved more powerful.. .than the composite of actual numbers of incidents of violence" (Hill & Madhere, 1996, p.39). This seems to suggest that i f children perceive that they have witnessed a certain level of violence within their community, regardless of how accurate these findings are, their perceptions w i l l structure how they w i l l be affected by violence. Summary It is important to note that the above statistics have included only reported crimes; it can be assumed that as many or even more crimes go unreported. Adolescents especially may be fearful to report that they have been victimized due to fear of repercussions, and may be especially afraid to report i f the crime occurs at school or in the surrounding community. The British Columbia Task Force on schools, in their review of school and community violence, concluded, " There is currently no provincial tabulation of violent incidences reported in schools" (British Columbia Teachers' Federation, 1994). It is reasonable to assume that although there is no statistical evidence as to the presence of school violence, it is widely viewed as a pervasive problem. If indeed youths are being exposed to violence at school and in their community, the assumption can be made that children who have been exposed may not show some type of deleterious effects. Therefore, it is important to examine the extent as  13  well as the possible effects of violence exposure. Definitions of Violence Upon examining the research on violence exposure, an important issue arises almost immediately: the definition of violence. Two terms that are most often mentioned in the violence exposure literature are victimization and violence exposure. Victimization suggests that the person has been directly affected by violence, that is, personally assaulted or attacked (Boney-McCoy & Finklehor, 1995; Durant, Pendergrast & Cadenhead, 1994). Violence exposure, often called observation or witnessing (Fick & Thomas, 1995; Hurley & Jaffe, 1990), suggests that a violent "situation...did not pose an immediate threat of physical harm but did have the potential for psychological trauma" (Fick & Thomas, 1995, p. 139). For the purposes of this study, "victimization" w i l l be used to indicate personal assaults or attacks. Violence exposure w i l l be used to indicate both observation and verbal mediation, or hearing about a violent event. The D S M IV gives a definition of victimization and violence exposure as a predecessor to the development of P T S D . The first criterion or diagnostic feature of P T S D is "exposure to an extreme traumatic stressor involving direct personal experience of an event that involves actual or threatened death or serious injury, or threat to one's physical integrity (victimization); or witnessing an event that involves death, injury or a threat to the physical integrity of another person; or learning about unexpected or violent death, serious harm, or threat of death or injury experienced by a family member or other close associate (exposure to violence)" (American Psychiatric Association, p.424, 1994). Many studies collapse these two definitions into one definition of violence exposure. Others use either victimization or violence exposure as a general definition of violence  14  exposure. However, in doing so, many studies may be overlooking important discrepancies and similarities between victimization and violence exposure. Many victims of violence exposure are ignored even though studies have shown that violence exposure victims constitute the majority of those touched by violence (Richters & Martinez, 1993a; Singer et al., 1995). Summary. There has been some discrepancy in the literature with regard to the definition of violence exposure. For the purposes of this study, victimization w i l l be defined as being directly affected by a violent event, that is, personally assaulted or attacked. Violence exposure w i l l be defined as being physically near, observing a violent event. The following studies w i l l be interpreted with these definitions in mind. Exposure to Violence Prevalence Rates Researchers who have examined prevalence rates of violence exposure have found alarmingly high rates with adolescents. Many studies have compared the extent of inner-city violence in the United States to that type of violence experienced in war zones around the world (Garbarino et al., 1992; Sautter, 1995). The 1970s saw an explosion of violence in the United States. It is not surprising that much of this violence occurs in schools (Sautter, 1995). A s the years go by, there seems to be an increasing risk for young people to be affected by violence. A s communities begin to experience more violence, the people within that community stand a greater chance of being affected by that violence. The violence on television, as well as growing violence in the community makes it easy to become  15  desensitized to violence. In order to realize that violence is a real and pervasive problem, it is important to become sensitized to this violence. A summary of prevalence studies is shown in Table 1. B o n e y - M c C o y and Finklehor (1995) examined the psychological affects of violence exposure in a sample of 2,000 youths between the ages of 10 and 16 selected through telephone interviews. The sample was geographically stratified by region and contacted through random digit dialing. The term "victimization" was used to mean all direct forms of violence exposure; that is, the victim was directly affected (e.g., assaulted, kidnapped). They found that 40.5% of the sample were victims of some type of violence. It is interesting to note that only 5.7% of these victimizations were reported to the police. In this study, it would be remiss to conclude that only 4 0 % were exposed to violence, or even victimized by violence. The authors of this study were examining only one small domain of violence exposure by examining only direct victimization. Breslau et al. (1991) examined the relation between traumatic events and P T S D symptomatology in a sample of over 1000 adults. The sample was drawn from all members of a health maintenance organization, and the authors found the sample to be representative of the surrounding metropolitan area. The participants were interviewed with an adaptation of the Mental Health Diagnostic Interview. Traumatic events were taken from the D S M III-R to include such events as sudden injury or serious accident, seeing someone seriously hurt or killed, robbery, threat to one's life, rape, and news of sudden death or injury of close relative or friend.  The authors found that 39.1% reported exposure to one or more of these events.  A study by Durant et al. (1994) examined violence exposure and victimization in a  so  w  oo EL oo c»  o-  a.  2 3'  W  •n 03  03 3  oo »  v>  3,  CO C  re  5' > u  s  (t  *> 3 2. §  3  1,1  I2.I  2 . ^ 5/  3 <T>  £0  3  "•I 3  5?  o  re a.  5'  re fii « g. "§-§ §  a>  a 3-  3 3 • =• 2 > 3 2  3  i5  so so  3  <—. re  - n  co  co ft  3- o- 2.  03 —  = 2.  •2.  3  3  3  "2.  -o  I Si  m  n  re 3 te  OS  O O o  © O  u<  00  OS  ho  ?2! to o  o  SO  •o. Ul  OS  00  a a. res = _§ 3 3  <1  so u> SO  sO  as OS O  0_  =• re  3  3  CL < D  13  O 3 vi C  3  2  re  II 2,  <  1  o  3  re  3. re  i  UJ  >— Ul to Ui  KJ to  ce  X  re  to  -a  if  3  so  -i  s s,  Q  2 2- P 3  re  ce  00  s?  re O  2.r ae  •O  -• TO  UJ 00 U>  UJ  -4  c  a >  OS s< ~ i OS  SO  ^  I  to tO  SO -  3 1  '  <•  re 3  re re re x •o o  re x •a o  re" 3  re 3  00 & oo  3"  00  f?  3.  o re  2  2  ce  o  ©  re p —  Ui  SO  Ul < re'  o <  i" 3  UJ  -J  re o.  Ul O  oo  <  1  re N  S  23 cn re  re re re CL re  on  x re •a o g. a.  o re  3 a.  no  PP  O 73 oo  SO  F5'  ro  21 a-  11"  pp  2  so so  O  VO  C  -t o- f> o  CO  3. N  V-  CO  §• * S "° o — ca-  3 3  PP<5'  O  o  3  sr ro S 3  00  ON  oo  &• S" OS CO  VO  .  OS  00  w  Ui to v?  U\ to  tO  (  V> 7*  4^.  o ^  L« — NO  00 vO  O op 3* C  3 £."o 0 ro o 1 3 <£ co = C  —  ro  <  3  =  a  O  Cfl  O  is ^ cn ro 3 O co Ui  s«>  As ^ ^ t o oo -  ro ro  3  a. re a. 3 c 3 00  ua  3' 00  §  3  iy> u> u> t o U) v o NP  Is.  3  5'  v—'  3  to VO  w  3  ro  •o o  xO  O  °- n 2 o  <m 2. If s 2 3" «ro SS co 3  -U V«  —  I  I  to  Os  Os  VO tro ~— oo « \? o ^ x  Jv  3  v  O  N  \  I3 * a  co Q.  O 00 o  SO  I  5;  ri  3.  -»> re  "*> ro X 13 O  C-s  | 3 rs  x •o o CA  ro  a.  I.  -J Ui  c fto a.  18 sample of 225 African-American adolescents. The study sample was drawn from housing projects in an urban area of the United States. Questionnaires were group administered. The authors examined the relation between fighting behaviors and violence exposure and victimization. Unfortunately, the authors did not list any prevalence statistics for violence exposure or victimization. However, they found that 6 0 % of participants reported being in a fight and that 6 5 % of males and 4 4 % of females had engaged in at least one gang fight. It is unclear in the study as to whether "being" (actually being kicked and punched, or doing the kicking and punching) and "engaging" (witnessing, shouting encouragements) constitute direct action or playing a small role in the fighting. Frequency of gang fighting was significantly correlated with frequency of violence exposure and victimization. Exposure to violence and victimization accounted for 11.5% of the variation in gang fighting. Gladstein and Slater (1988) examined victimization and exposure to violence in a sample of 168 predominantly black inner-city population of adolescents. The sample was drawn from an adolescent walk-in clinic. The authors found no relation between the reasons for coming into the clinic and violence exposure. The questionnaire included a number of events relating to victimization (e.g., robbed with/without a weapon, shot with a gun, assaulted with/without a weapon) as well as violence exposure (e.g., knowing or witnessing someone being robbed, raped, assaulted, shot). The authors also asked if individuals who were victimized received counseling. Results revealed that between 1.2% and 22.9% (depending on the type o f event) o f the teenagers had been directly victimized. Between 5.5% and 4 2 . 3 % (depending on the type of event) of the teenagers had been exposed to violence. In this study,  19 the authors only examined counseling with regard to direct victims and found that although it varied depending on the violent act, it was low; half of the adolescents who had been sexually assaulted sought psychological care. Richters and Martinez (1993a) sought to assess the extent to which a group o f inner-city children were either victimized or exposed to violence. The sample included 165 children from the 1 and 2 st  nd  grade as well as children from the 5 and 6 grade. Children and their th  th  parents were asked to complete the Survey of Children's Exposure to Community Violence, which evaluates both victimization and violence exposure. Both age groups and both parent and child reports indicated greater exposure to violence than victimization. In grades 1 and 2, 19% of parents reported their child being victimized and 6 1 % reported being exposed to violence; in grades 5 and 6, 32% of parents reported their child being victimized and 72% reported being exposed to violence. Consistent with their parent's reports, more older children reported being exposed (97%) than being victimized (59%). Younger children (grades 1 and 2) were not asked any questions relating to victimization. A study investigating exposure to violence within a group of inner-city children and adolescents (Bell & Jenkins, 1993) found similar prevalence rates to the Richters and Martinez study. In a study by B e l l and Jenkins (1993) examining community violence and children and adolescents, they found that 3/4 of children aged 10 to 19 years had witnessed a robbery, stabbing, shooting or killing; 4 7 % had been personally victimized. The authors state that those who have experienced violence exposure are "covictims" and should not be ignored. Due to the fact that individuals who have been victimized are most often examined, the prevalence of victims of violence exposure is important in developing interventions for  20  those living in high violence environments. A study investigated the levels of violence exposure in adolescents from two different socio-economic backgrounds (inner-city and middle-class) (Gladstein, Rusonis, & Heald, 1992). The groups were drawn from two medical clinics, one serving a predominantly African-American inner-city population, and one serving mostly college students working in a resort town for the summer.  Over 800 adolescents were given a self-report exposure to  violence questionnaire designed by the authors. Victimization and exposure to violence included such events as robbery with/without a weapon, assault with/without a weapon, and shooting. In total, 9 5 % of males and 7 5 % of females in the inner-city group had been either exposed to violence or victimized; 8 3 % males and 74% females in the resort group had either been exposed to violence or victimized. A s well, significantly more of the inner-city adolescents were witnesses and victims than middle-class adolescents were. Perhaps one of the more comprehensive studies examining the extent and effect of violence exposure is one done by Singer and his colleagues (Singer et al., 1995). This study used a sample of 3,735 adolescents between the ages of 14 to 19 from six public schools. The sample was representative of the general school population and there was a relatively equal number of males and females. The authors found that rate of violence exposure was high. The prevalence rates for males who experienced violence exposure varied by school site as well as by violent acts: 9% to 21.3% saw someone else abused or assaulted; 32.3% to 81.7% saw someone else beaten up or mugged at school; 25.4% to 82.3% saw someone beaten up or mugged in the neighborhood; 14.3% to 46.3% saw someone else attacked or stabbed with a knife. The prevalence rates for females were: 15.3% to 2 0 % saw someone  4  21 else beaten up or assaulted; 23.7% to 82.1% saw someone else beaten up or mugged at school; 6.8%o to 43.7% saw someone else attacked or stabbed with a knife. Although the authors do not elaborate on the socio-economic characteristics of the school sites, the differences in results among the school sites are most likely due to socio-economic factors; the adolescents reporting the highest victimization/violence exposure rates were from urban central city schools, while those reporting the least were from small city or suburban schools. A model for violence exposure can be easily adapted from a suicidal ideation/attempts model brought forth by Ladame and Jeanneret (1982) (see Figure 1). In this model, victimization constitutes the tip of the iceberg while below the surface of the water is the majority: those exposed to violence. Summary The above studies have shown that violence exposure is pervasive for adults, children and adolescents. The majority of researchers have examined violence exposure within an innercity community; this seems logical as children are more likely to be exposed to violence when living in a violent environment. A l l of the above studies show that violence exposure in adolescents occurs more frequently than victimization. Gender Differences in Violence Exposure A prominent issue that arises in the literature on the extent of violence exposure is the difference between the male and the female experience. There have been some different findings in the literature as to whether males and females differ with respect to violence exposure, or whether this difference is significant. The literature on victimization and violence exposure has revealed varying results with  23  regard to gender differences. Some studies have found differences in gender with regard to victimization but not violence exposure. A study conducted by Bell and Jenkins (1993) examined gender differences in violence exposure and victimization in a group of 7 to 15 year olds and a group of 10 to 19 year olds. Results revealed that for both groups, gender and age were unrelated to witnessing violence; girls were as likely as boys to witness violence. For the older group, boys reported more victimization than girls. Boys also reported more fighting behavior than girls. In a study examining violence exposure and depression and suicidal ideation of 6 , 7 and 8 grade adolescents (Mazza et al., 1995) males and females t h  th  th  were found to have identical scores on the violence exposure scales. However, other studies have found a preponderance of males who are exposed to violence. A study examining the difference between inner-city and middle-class adolescents' exposure to violence (Gladstein et al., 1992) revealed that for both inner-city and middle-class youths, males were more likely to be victimized and exposed to violence than females. O f the total sample, 9 5 % of males and 7 5 % of females reported that they had been exposed to violence. A study examining the extent of violence exposure in youth (Fitzpatrick & Boldizar, 1993) revealed that males were victims of and witnesses to more violence than females. Richters and Martinez's (1993a)project in Washington, D . C . revealed that boys reported higher rates of victimization and violence exposure than girls. Yet, a study has found females to be more exposed to violence than males. In examining the extent and effect of violence exposure in a large group of adolescents (Singer et al., 1995), females were found to witness more violence, while males were more likely to be victimized. Due to the fact that the limited literature on gender differences in violence exposure has revealed differing results, further investigation of gender  24  differences in violence exposure is warranted. The Effects of Violence Exposure Most of the above studies discuss violent events as acts occurring within the community, such as assaults or muggings. The focus of this study w i l l be on community violence and its effect on adolescents in terms of levels of internalizing symptomatology. More specifically, this study w i l l be focusing on posttraumatic stress disorder (PTSD), depression, and suicidal ideation symptomatology as effects of violence exposure. However, the majority of research examining the outcomes or effects of violence exposure have not come from the examination of community violence. Most have come from a wide array of violence exposure, including natural disasters (McFarlane, Policansky, & Irwin, 1987; Vernberg, LaGreca, Silverman, & Prinstein, 1996), violence in war torn countries (Garbarino et al.,1992 ; Saigh, 1989; Straker, Mendelsohn, Moosa, & Tudin, 1996), and domestic violence (Wolfe, Zak, Wilson, & Jaffe, 1986). Research has shown the effects that experiencing a violent event may have on youngsters. Figure 2 shows the extent of symptomatology (see Figure 2) that may occur after experiencing a violent event (Pynoos & Nader, 1990). The authors explain that the catalyst for these P T S D symptoms may be either victimization or violence exposure. These symptomatic reactions may result from not only being victimized by violence, but by witnessing a violent event. The preceding studies have focused on the extent of violence. These studies w i l l focus on the effects of violence exposure, namely traumatic or P T S D , depression, and suicidal ideation symptomatology. It is important to note that in this study, diagnoses w i l l not be examined. Most research  CTQ  n  to • •  3  T3  o  o i  i—»•  Co ^ H  O 0)  7)  1 3  3  CD  "O  i—i-  o  Q5_ o  —h  m  £  3 i I S' 8 8-  O  o .&>  o t/> "2 CD  O  l-t  26  to date has looked for elevated levels of symptomatology that could be intrusive in how people live their day to day life. Because the prevalence rates for diagnoses for P T S D (3.7 %) (Last, Perrin, Herzen, & Kazdin, 1992) and depression (4%) (Whitaker et al., 1990) are low, it is highly unlikely that a diagnosis could be made with the measures used as well as the small amount of the students that w i l l be sampled in this study. PTSD In examining the effects of violence, the symptomatology most often examined as a result of violence exposure has been posttraumatic stress disorder, or P T S D . Most research has found P T S D to be an outcome of exposure to violence. However, most research done with P T S D and adolescents has used clinical samples. This may be due to the fact that the literature on P T S D is predominantly theoretical and clinical in nature (Cameron, 1994). P T S D is a distinct diagnostic entity (Yehuda & McFarlane, 1995). The Diagnostic and Statistical Manual of Mental Disorders IV ( D S M I V ; American Psychiatric Association, 1994) lists P T S D as an outcome of military combat, violent assault, natural or manmade disasters, or witnessing a killing or violent death (American Psychiatric Association, p. 424). The traumatic event is reexperienced in recurrent, distressing recollections of a traumatic event (such as images or thoughts). Other symptoms include recurrent dreams of the event, flashback episodes, intense psychological distress or physiological reactivity at exposure to cues, both internal or external.  Many people experiencing P T S D w i l l experience such  symptoms as avoidance of stimuli associated with the event, a numbing of response, and a sense of foreshortened future, and more commonly in the cases of domestic violence, forced silence, or the command that the victim remain silent about the episode (Lister, 1982). The  27  D S M IV states that children w i l l display increased irritability, repetitive play and frightening dreams not directly about but related to the event. The repetitive play that children exhibit after trauma seems to be an unconscious link between play and the traumatic event (Terr, 1981). Children also experience clinging behavior, fear of the dark and, most commonly, sleep disturbances (Udwin, 1993; Csapo, 1991). One study has postulated that, with individuals experiencing P T S D , R E M sleep mechanisms are either dysfunctional or inappropriate. While normal participants were found to have an average of less than one nightmare a year, participants with P T S D were experiencing one or more nightmares per month. Most commonly, the nightmare was of the actual events, in fact a replica of the event being replayed over and over again (Ross, B a l l , Sullivan, & Caroff, 1989). Although researchers list the symptoms of children and adults, they do not list symptoms for adolescents. It is often assumed that adolescents w i l l exhibit symptomatology similar to that of adults. Terr (1981) discusses that adolescents may relive the trauma by exhibiting risk taking behavior and more dangerous play. Adolescents being adventurous is normal, but when an adolescent begins to seek extreme danger it becomes abnormal (Garbarino, Kostelny, & Dubrow, 1991). Trauma is a "psychic organizer" that alters one's world (Eth & Pynoos, 1985). It is an intense and distressing experience (Lazarus, 1966). The witness to a violent event has no schemata to assimilate or accommodate the event, which results in psychological distress (Lyons, 1987), and the individual's stimulus barrier becomes overwhelmed. When faced with a violent situation, witnesses to violence experience no disavowal (Eth  28  & Pynoos, 1985). That is, they believe the violent situation to be reality. A s a witness, they are able to imagine all perspectives; therefore their fear and horror has to do more with the personal meaning of the threat. Witnesses may be horrified by the assailant's loss of control, and the question of safety of all interpersonal relationships arises in the observer (Eth & Pynoos, 1985). This seems to be especially the case in adolescents, where they have just begun to question their reality. Harmful events provide cues about future consequences (Lazarus, 1966). Youngsters assume a sense of safety and benevolence of the world and of people (Janoff-Bulman, 1987); when that is destroyed, their sense of personal safety becomes jeopardized. Witnessing a violent experience shatters certain basic beliefs that people assume about themselves and the world (Fletcher, 1996). Research on P T S D and children has lagged far behind that of adults (Motta, 1990). Children have always been thought to have been little affected by traumatic experiences, and i f affected, then not for very long (Motta, 1990). Most of the research on adults and P T S D has been done with Vietnam veterans (Fletcher, 1996). A study conducted by K o l b (1989) estimated that as many as 15% of all Vietnam veterans are diagnosed with P T S D . Another study examining the mental health of over 200 Vietnam vets found that 2 9 % met the criteria for a P T S D diagnosis (Green, Lindy, Grace, & Gleser, 1989). Research examining war zone stressors in Vietnam veterans (King, K i n g , Gudanowski, & Vreven, 1995) looked at 4 stressor indexes: (1) traditional combat (2) atrocities (3) perceived threat and (4) malevolent environment. They found that being in a malevolent environment was the most potent factor of P T S D for both men and women. Thus, the environment or community can be the source of traumatic symptomatology in adults; it may be this way for adolescents living in a violent  community. There have been a number of studies that have examined rates of P T S D in adolescents. In a clinical sample of 188 children and adolescents, Last et al. (1992) found that the prevalence of P T S D was "very rare", only 7 of the 188 examined being diagnosed with the disorder. In a larger study examining the P T S D in over 2000 young adult men and women from the general population (Helzer, Robins, & M c E v o y , 1987) they found that 15% of men and 16% of women were diagnosed with P T S D after being subjected to attacks or seeing someone hurt or die. People with P T S D were twice as likely to have some other disorder as were persons without it. Depressive disorders were among the most common disorders. P T S D and Exposure to Violence A s previously mentioned, there have been many negative life events examined which have been construed as potentially traumatic. These traumatic events all have an element of violence exposure. Most research examining the nature of P T S D in adolescents has been conducted during wartime or after the occurrence of natural disasters. There have only been a limited number of studies examining the effects of community violence exposure. The following studies have examined the relationship between P T S D symptomatology/diagnosis and these different types of violence exposure. P T S D and Wartime Violence Exposure M u c h of the research examining P T S D in adolescents has been conducted abroad in wartorn countries. Studies have shown that this type of violence exposure has a profound effect on adolescent psychological development. In November 1987, eleven people were killed and 60 seriously injured when a bomb  30  exploded in Enniskillen, Northern Ireland. Many witnessed the bombing, and most had been within 30 metres of the exploding bomb. Curran and his colleagues set out to research the psychological effects of witnessing this bombing in a group of 30 survivors, aged 14 to 57. Participants were assessed six months and 12 months after the bombing. A t the six month assessment researchers found that 13 of the 30 sampled, soem of whom were adolsescents, met criteria for P T S D diagnosis. A t the second assessment, out of the original group only one had recovered, and two patients developed P T S D between the two assessments (Curran et al., 1990). It should be noted that these researchers examined P T S D diagnosis and therefore participants who examined high levels o f symptomatology but were not diagnosed were considered not to have P T S D . Mghir, Freed, Raskin, and Katon (1995) examined P T S D symptomatology among 38 adolescent and young adult (12 to 24 years) Afghan refugees. The participants and their families were interviewed through a series of home visits. O f the sample, 5 5 % were males and 4 5 % were female. Results revealed that 5 participants met the criteria for P T S D diagnosis. The authors found that the total number of traumatic events experienced (e.g., witnessing the murder of strangers, forced separation from family members) was significantly correlated with P T S D scores. Macksoud and Aber (1996) in investigating the P T S D reactions of 224 children and adolescents aged 10 to 16 years in Lebanon found that children who had experienced more trauma were more likely to exhibit more P T S D symptoms. Children who were either victims or were exposed to violent acts were more likely to report symptoms of P T S D . While the children who were victims of violent acts were significantly more likely to report symptoms  31  of P T S D , the children who witnessed or were exposed to violence had a trend toward reporting more symptoms o f P T S D . The effects o f violence exposure during wartime has been extensively studied by Philip Saigh. Saigh has investigated the similarities in symptomatology between victimization and violence exposure. In one study, Saigh examined the development o f traumatic, depressive and anxiety symptomatology in over 200 cases o f children in Lebanon. These children were split into 5 groups: those who had been traumatized through (1) direct experience (2) observation (3) verbal mediation (4) a combination o f two and (5) a control group. Saigh found that although there were no differences between the groups on scores o f P T S D , anxiety and depression scales, the first four groups were all significantly higher than the control group (Saigh, 1991). In order to stress the fact that violence exposure has the same deleterious effects that is experienced through victimization, Saigh conducted a case study examining the effects o f verbal mediation on an 11 year old girl. The girl had learned, in graphic detail, about the death o f her favorite uncle, by overhearing her parents speak about the incident. Her P T S D , anxiety, and depression scores, relative to four cohorts (those who had experienced either direct victimization, observation or verbal mediation, and a control group) were comparable to the scores o f the other cohorts (Saigh, 1992). P T S D and Natural Disasters The occurrence o f natural disasters and accidents has been the basis for a number o f studies examining the relation between disasters and internalizing symptomatology. Research examining this relationship has found strong links between experiencing a disaster  32  and levels of internalizing symptomatology. Vernberg et al. (1996) investigated the P T S D symptomatology in 568 children in grades three, four and five after hurricane Andrew. Exposure to the hurricane was measured by counting the number of events to which the child has been exposed (e.g., " D i d you get hurt during the hurricane", " D i d you see anyone else get hurt badly during the hurricane", " W a s your home badly damaged or destroyed by the hurricane"). O f the sample, 56% reported being exposed to 1 to 2 events, and 12% reported 3 to 4 events. The authors also found that 86% of the children sampled reported some P T S D symptomatology.  There were four factors  included in the study: Exposure to traumatic events, child characteristics, access to social support, and children's coping. Results revealed 62% of the variance in the children's symptoms was accounted for by these factors. The exposure variables accounted for 35%, the most of the variance in symptomatology. Yule and U d w i n (1991) screened 24 girls, aged 14 to 16 years, for P T S D symptoms after the sinking of the Jupiter, a ship on which over 400 school children were taking an educational cruise. The girls were asked to complete measures of anxiety, depression and two aspects of P T S D symptomatology (the presence of intrusive thoughts, and blocking out these thoughts). Their scores were compared with the scores of children who survived a similar shipwreck. They found that these survivors had scores on intrusive thoughts that were indistinguishable from the other child survivors of a shipwreck who were all diagnosed with P T S D . Pynoos et al. (1993) examined P T S D reactions in children after an earthquake in Armenia.  The sample, consisting of 321 children aged 8 to 16, was asked to complete a 20  33  item self-report scale designed by the authors to assess PTSD symptomatology. A subgroup of 111 children were interviewed with a diagnostic measure based on D S M III-R criteria for PTSD diagnosis. Of the 111 children and adolescents interviewed, 78 were given the PTSD diagnosis. Children's and adolescents' PTSD reactions were significantly associated with the proximity to the epicenter of the earthquake. The authors conclude that after a natural disaster, PTSD in children "may well reach endemic proportions" (Pynoos et al., 1993, p.245). PTSD and Community Violence There have been a limited number of studies examining the relation between community violence exposure and internalizing symptomatology. Most research focusing on community violence exposure has examined the extent, rather than the effect, of violence exposure. Studies that have examined the relationship between community violence exposure and internalizing symptomatology (PTSD, depression) have yielded similar results. Schwarz and Kowalski (1991) examined PTSD reactions in children after a school shooting. The sample included 64 children and adults screened using an interview procedure 8 to 14 months after the shooting. Participants were asked to described their type of violence exposure. For adults, some examples were "saw media coverage of the event", "smell or touch experience with the injured" or "heard the shooting". For the children, the examples were "saw blood", "heard gunshot", "saw someone get shot", and "saw the gun". The authors also examined emotional states as a type of violence exposure. The most common emotional states for the adults were "worried about the families of the injured", "thought it could happen to me or loved ones" and "feared alleged perpetrator still loose". The most  34  common emotional reactions for children were "worried about someone during or after the event" and " thought I was in danger" and " thought I would be shot". These emotional states were found to be significantly correlated with traumatic symptomatology. The authors conclude that as these emotional reactions were sufficient to lead to symptomatology the "concept of violence might be broadened to include not only physical nearness but emotional states as w e l l " (p. 942). A study conducted by Pynoos (Pynoos et al., 1987) examined the P T S D symptomatology in 159 school children after a sniper attack occurred at their school. The sniper killed one child and one passerby and injured 13 children. Each child was interviewed using a P T S D screening measure developed by the authors. The researchers found that as the level of proximity to the shooting increased, so did the level of traumatic symptomatology. Nader et al. (1990), in examining 100 children one year after a sniper attack at school, found that the children that had experienced the highest level of violence exposure had significantly higher P T S D reaction scores compared to all other groups. One of the largest and most comprehensive studies done on violence exposure and traumatic symptomatology was conducted by Singer et al. (1995) who sampled over 3700 adolescents. Details on the nature of the sample as well as the violence exposure measure have been mentioned in the preceding section on the prevalence of violence exposure. Trauma symptoms were measured using the Trauma Symptom Checklist for Children ( T S C C ; Briere, 1997). This measure was judged to have acceptable reliability and validity by the authors. Five variable clusters examining recent violence exposure were extracted from the violence exposure scale: items that (1) measured being a witness of neighborhood violence  35  (2) measured being a victim or a witness of violence at home (3) measured being a witness of violence at school (4) measured being a witness of a shooting or knife attack and (5) measured being a victim of neighborhood or school violence. Approximately 57% of the total variance on the violence exposure scale was explained by these clusters. Three variable clusters examining past violence exposure included those items that (1) measured being a witness of past violence (2) measured past exposure to very serious violence (being a witness or victim of a shooting or knife attack) and (3) measured being a victim of past violence. These clusters accounted for approximately 64% of the variance in the total violence exposure scale. Hierarchical regression analyses were conducted on the T S C - C in order to examine the effects of student violence exposure rates on their levels of internalizing symptomatology. Violence exposure variables explained 2 9 % of the variance in the total trauma score, and ranged from 19% to 2 7 % across the symptom subscales. The greater the violence exposure, the higher the scores for total trauma symptoms and for each symptom subscale (Singer et a l , 1995). Osofsky and her colleagues (Osofsky, Wewers, Harm, & Fick, 1993) examined the relation between community violence exposure and P T S D symptomatology in N e w Orleans with a sample of 53 children aged 9 to 12 years. The authors examined the prevalence of exposure to different levels of violence (severe, less severe, moderate). They found that there was a significant relation ( r = .67) between hearing about and witnessing community violence and reports of stress symptoms in children. Three variables (family conflict, witnessing, hearing about violence) accounted for 5 3 % of the variance in reports of child stress symptoms.  36  A study conducted by Fitzpatrick and Boldizar (1993) examining the extent and effect of violence exposure with a sample of 221 low-income youth living in eight housing communities found that more than 70% of the sample were exposed to violence or victimized. The frequency of witnessing was higher, over 85% being exposed to at least one type of violence. In this study exposure to violence was divided into 2 scales: the victim scale and the witness scale. The authors investigated P T S D symptomatology as a possible outcome of violence exposure, using multiple regression analysis. The authors found that greater exposure, either as a victim or as a witness was significantly positively related ( r =.283 for the witness scale; r =.570 for the victim scale) to increased reporting of traumatic symptomatology. However, it should be noted that this study examined a nonrandom sample of youth and therefore generalization of these results to more random populations is not recommended. M a z z a and Reynolds (1999) examined the relationship between community violence exposure and levels of P T S D in a sample of 94 adolescents aged 11 to 15 years in Brooklyn, N e w York. The sample was predominantly Hispanic or African-American. A series of hierarchical regression analyses were conducted in order to determine the relation of each type of internalizing symptomatology to violence exposure. Results revealed that the relation between P T S D and violence exposure was significant, even after controlling for depression and suicidal ideation. Another series of regression analyses suggested that P T S D may mediate the relationship between violence exposure and depression. The authors suggest that P T S D may be the initial type of internalizing symptomatology experienced after witnessing a violent event and posit that P T S D "may occur sequentially and prior to other negative mental  37  health outcomes" (p. 211). Breslau et al. (1991) examined exposure to traumatic events and P T S D in an urban population of 1007 young adults. Exposure to traumatic events included such events as sudden injury, seeing someone seriously hurt or killed, rape, or a threat to one's life, among others. P T S D diagnosis was done through diagnostic interview. Results revealed that 39.1% reported exposure to one or more stressors that lead to P T S D . O f those who were exposed to these stressors, 23.6% were diagnosed with P T S D . It should be noted that the authors examined diagnoses rather than symptomatology levels of P T S D , and that the authors' definition of violence exposure included victimization. Summary Exposure to traumatic events such as political warfare and natural disasters are types of violence exposure, and their effects have been examined most commonly with P T S D symptomatology. A l l of the above studies have shown a positive relationship between a traumatic event being experienced and increased levels of traumatic symptomatology; the greater the violence exposure, the higher the scores for trauma victims. When research on P T S D and community violence exposure is compared with research on P T S D and wartime violence exposure or natural disasters, there seems to be a lack of research examining community violence exposure and P T S D symptomatology. The limited research examining this relationship has found that as adolescents are exposed to violence, the likelihood increases that they w i l l experience higher levels of P T S D symptomatology. Depression Next to traumatic symptomatology, depression has been the most common outcome  38 studied in the violence exposure literature. In the past decade, there has been increasing research on depression with both children and adolescents (Reynolds & Johnston, 1994). There is an overlap between the symptoms or characteristics of depression and P T S D , such as sleep problems and a sense of foreshortened future. D S M IV lists depression symptoms as poor appetite, overeating, insomnia, low energy, feelings of hopelessness, poor concentration and loss of interest (American Psychiatric Association, 1994). Fleming et al. (1989) examined the prevalence of childhood and adolescent depression in a sample of over 2800 participants. They found a significant age effect; adolescents had higher rates of depression than children. In fact, the overall prevalence of depression increased threefold from preadolescence to adolescence. The prevalence rates of children who were in the 12-16 age range were 1.8% for high rates of depression, 7.8% for medium levels of depression and 43.9% for low levels of depression. In a sample of over 1700 high school adolescents Lewinsohn et al. (1993) found that 22.3% of females and 11.4% of males reported one episode of unipolar depression; 4.9% of females and 1.6% of males reported 2 or more episodes. Whitaker et al. (1990) in a sample of over 5000 adolescents found the lifetime prevalence estimate for major depression to be 4%, the second most common disorder (dysthymia being 4.9%). There has been research to show that depression rates may be increasing in children and adolescents. A study examining siblings of preadolescent depressed and nondepressed children found significantly higher rates of depression in siblings born more recently for the depressed and the control groups (Ryan et al., 1987). The authors postulate that some of the causes may be due to social changes that increase vulnerability to depression.  39  Depression and Violence Exposure Research examining the relation between violence exposure and depression in adolescents attending high school has been limited. M a z z a et al. (1995) examined violence exposure, suicidal ideation and depression in a sample of 6th, 7th, and 8th grade adolescents living in an inner-city metropolitan center. Groups of adolescents were formed based on their level of exposure (none/low, moderate, severe). They found that adolescents who were in the high exposure group had significantly higher levels of depression than those in the moderate/low group. Philip Saigh has also examined the depression rate of children, adolescents and adults and exposure to wartime violence. In examining 12 female undergraduate and graduate students before and after a war stressor, he found that the students exhibited a significantly higher depression rate after the war stressor than before the stressor occurred (Saigh, 1988). Saigh (1989) also investigated the relationship between various internalizing and externalizing disorders in a sample of 80 children. The measures used included the Children's P T S D Inventory, the Revised Children's Manifest Anxiety Scale, and the Children's Depression Inventory. Based on their results, these children were put in three groups: (1) those with chronic P T S D , (2) those with test phobia, and (3) nonclinical controls. Saigh found that the children who were diagnosed with P T S D had significantly higher depression scores (F(2,73) = 18.06, p<.001) than those who were in the test phobia or the control groups. In a similar study, he also investigated the relationship between types of traumatization (violence exposure versus victimization) and found that there were no differences in depression scores among the groups, but they were significantly higher than the group who had not been  40  exposed to violence at all (Saigh, 1991). A case study examining the same relationship yielded equal results (Saigh, 1992). The case study focused on an 11 year old Lebanese girl who exhibited behavioral and academic problems at school and was referred for psychological testing. It was revealed through parent and child interviews that the child had learned in graphic detail how her favorite uncle had died. Saigh compared her scores on depression, anxiety, and P T S D measures with cohorts who had developed P T S D after direct exposure, observation, verbal mediation as well as a control group. Her scores were found to be comparable to the first three cohort groups and significantly higher than the control group. Suicidal Ideation Another possible outcome of violence exposure is suicidal ideation. Most research examining violence exposure and associated symptomatology has not examined this construct. Suicidal ideation may be defined as "thoughts and cognitions about taking one's life as well as thoughts specific to the act of suicide"(Reynolds & M a z z a , 1994, p.533). Ideation is a critical aspect in suicidal behavior; it may be construed as the earliest and the most neglected warning of a child crying for help. Children and adolescents differ from adults in their ability to successfully cope with stressors and their ability to have a healthy perspective on others and the future (Reynolds & M a z z a , 1994). This can lead to feelings of worthlessness and wanting to take their own life. Durkeim's theory of suicide has postulated several categories of suicide, one of them being anomic suicide, which is defined as where the individual's relationship to society is suddenly shattered (Blumenthal, 1990). A m o n g risk factors for suicide, psychosocial milieu or life events have also been listed (Blumenthal,  41  1990). There have been a number of prevalence studies investigating suicidal ideation in preadolescence and adolescence. A study examining ideation, threats and attempts in preadolescent school children found that 8.9% of school children expressed suicidal ideation (Pfeffer, Zuckerman, Plutchik, & Mizruchi, 1984). In a longitudinal study of over 1000 young adolescents spanning three years, between 15 and 20 % reported moderate suicidal ideation, while approximately 5% reported high suicidal ideation (Garrison, Addy, Jackson, M c K e o w n , & Waller, 1991a). Another study investigated the frequency of suicidal behavior in young adolescents. In this study of over 1500 7th and 8th grade children, the authors found prevalence estimates for mild suicidal ideation to be 2 1 % and moderate to severe suicidal ideation to be 10% (Garrison, Addy, Jackson, M c K o e w n , & Waller, 1991b). The authors also found that adolescent self-reports were more accurate than parents' reports; many times parents were underestimating their child's level of suicidal ideation. A l l of these prevalence estimates are consistent with each other. The McCreary Centre Society conducted a B . C . province-wide survey of over 15,000 adolescents, asking questions about the mental health status of adolescents. They found that of the sample, 16% considered suicide in the past year. Suicidal ideation was experienced by more females than males. Between 13% and 26% of females (depending on grade level) had thought about suicide in the past year; between 9% and 13%) of males (depending on grade level) had thought about suicide in the past year (McCreary Centre Society, 1993). Suicidal Ideation and Violence Exposure There have been very few studies which have examined suicidal ideation as an outcome  42  of violence exposure. Mazza. and Reynolds (1999) examined the relation between community violence exposure and levels of suicidal ideation in a sample of 94 inner city adolescents aged 11 to 15 years. The sample has been described in a preceding section on exposure to violence. The Suicidal Ideation Questionnnaire-Jr (SIQ-JR; Reynolds, 1987) was used to determine the levels of suicidal ideation in the sample. A hierarchical regression analysis was conducted in order to determine the relationship between suicidal ideation and violence exposure. Results revealed that while a significant relationship existed between violence exposure and suicidal ideation, suicidal ideation did not significantly contribute to the regression model after other mental health variables and demographic factors were controlled for. Clearly, the lack of studies incorporating this important dimension of mental health is grounds for a study examining suicidal ideation as a possible outcome of violence exposure. Gender Differences In Internalizing Symptomatology Research on gender differences in both traumatic and depressive symptomatology, while revealing stronger trends than in violence exposure, still raises a multitude of questions. A review paper examining the relation between gender differences and adolescence discusses three models of depression (Nolen-Hoeksema, & Girgus, 1994). The authors present a model that, although discusses depression, is easily generalizable to other forms of symptomatology already discussed. The authors posit that there are certain gender differences in personality present before early adolescence which prove to be catalysts when combined with the increased challenges of adolescence to make females more prone to depression and P T S D symptomatology than males. In combination with the greater number of biological and social  43  challenges that girls must face, these "risk factors" prove to result in greater levels of internalizing symptomatology. The changes during puberty evoke more negative feelings for girls than for boys (Peterson, Sarigiani, & Kennedy, 1991), and seem to play a large role in the manifestation of symptomatology (Hayward et al., 1997). Gender differences are prominent in the P T S D literature. A trend in this literature shows that females are more likely to exhibit P T S D symptomatology than males. In a study examining the general stress reactions of the Iraqi invasion for a group of Kuwaiti children (Al-Shatti, 1996), girls displayed more stress reactions than boys did. A study examining the effects of violence in South A f r i c a on children, adolescents and adults revealed that while young males reported more P T S D symptomatology than young females did, this reversed in adolescence with more adolescent girls reporting P T S D symptoms than boys. This trend continued into adulthood (Dawes, Tredoux, & Feinstein, 1989). In a study examining the effects of violence exposure in youth (Fitzpatrick & Boldizar, 1993), females reported more P T S D symptomatology than males. In a study examining the symptomatology of children exposed to wartime stress in Lebanon (Macksoud & Aber, 1996), while boys were more likely to be exposed to war traumas, girls were more likely to exhibit P T S D symptomatology. In a study examining the effects on adolescent violence exposure (Singer et al., 1995), females were found to exhibit higher levels of P T S D symptomatology than males. In a study examining P T S D symptomatology after hurricane Andrew, female children reported more symptomatology than did their male counterparts (Vernberg et al., 1996). Although there seems to be a trend toward females exhibiting more P T S D symptomatology, there has been research done that refutes this trend. In a study examining  44 depression and P T S D in a sample of Afghan refugee adolescents and young adults, no gender-specific effects were found (Mghir et al., 1995). However, these results may be due to other culture-specific issues. Perhaps nowhere is the issue of gender difference more prominent than in depression. Most research reports a preponderance of female adolescents with depression (Dean & Ensel, 1982). A study examining children's distress symptoms after being exposed to violence (Martinez & Richters, 1993) revealed that girls reported significantly higher levels of depression anxiety and sleep problems than boys. In a study examining the prevalence of adolescent and childhood depression in a sample of over 2800 students (Fleming et al., 1989), the prevalence rates were estimated to be 1.8% for severe, 7.8% for moderate and 43.9% for low depression rates for young adolescents aged 12 to 16 years. A study investigating sex differences and depression found that adolescent girls reported significantly more depressive symptomatology than boys (Allgood-Merten, Lewinsohn, & Hops, 1990). A study examining depression in adults diagnosed with anxiety disorders (Dealy et al., 1981) revealed that while 2 5 % of men had secondary depression, 48.5% of women were diagnosed with depression, a significant difference. In a longitudinal study examining adolescent depression in a group of 6th grade through 12th grade youths, the scores for girls showed a decline in the 8th grade, while boys' scores remained constant (Peterson et al., 1991). A study examining gender, depression and family involvement puts forth the hypothesis that in stress situations, boys are protected from negative emotional effects while girls are more subject to experience distress (Gore, Aseltine, & Colten, 1993). Another study has shown that girls display greater reactivity to stressful events and greater depressive vulnerability than  45  their male counterparts (Leadbeater, Blatt, & Quinlan, 1995). While a trend seems to show that males are affected by witnessing or being victimized by violence, this may not be the case. In fact, it is more likely that they are experiencing as much of an effect as females do, but the outcome of the exposure is manifesting itself in a different way. In a study examining depressive symptoms in late adolescence (Gjerde et al., 1988), males who were diagnosed with dysthymia were found to exhibit characteristics consistent with an externalizing pattern of symptom expression (e.g., disagreeable, aggressive, antagonistic), while dysthymic females were found to exhibit those characteristics associated with an internalizing pattern of symptom expression (e.g., unconventional, ego-brittle, ruminating). A subsequent study examining the antecedents of depressive tendencies in males and females yielded similar results (Block, Gjerde, & Block, 1991). In a study examining depression occurrence in adolescents, females were more likely to be diagnosed with unipolar depression and anxiety disorders, while males were more likely to be diagnosed with disruptive disorders (Lewinsohn et al., 1993). A similar study revealed that adolescent girls were found to be more prone to report inwardly directed symptomatology (depression, anxiety) than adolescent boys, who were more prone to report acting out behaviors (Ostrov, Offer & Howard, 1988).  However, in a study done by H i l l and Madhere  (1996), girls who were exposed to violence were found to be more confrontational than boys. This difference may be due to the methodology of the studies. H i l l and Madhere's study was conducted through parents' reports, while the rest were done through self-reports. W i d o m (1989), in a study examining adults who were victimized, found that males had higher rates of delinquency, adult criminality and violent criminal behavior than their female  46  counterparts. Social Support and Negative Life Events Social Support A n important facet of the relationship between violence exposure and internalizing symptomatology often neglected is the issue of social support. Even though many developmental psychologists would agree that social-emotional environment plays an integral part in the lives of adolescents, much research on violence exposure and its relationship to levels of internalizing symptomatology has failed to include social support as a possible mediating variable. The definition of social support is at best an ambiguous one. The majority of research conducted on the extent and effects of violence exposure which have included social support as a variable have defined it as emotional support from family and friends. Essentially, it has been defined as the adolescent having the belief that he or she is cared for and feels to be an esteemed member of a social network with open communication as well as a sense of caring for each other within this network. Social Support and Violence Exposure Studies that have examined the relationship between violence exposure and internalizing symptomatology have found that social support has a tempering, or buffering effect upon levels of internalizing symptomatology (Boney-McCoy & Finklehor, 1995; Macksoud & Aber, 1996). Macksoud and Aber (1996), in their study examining the effects of war experiences on children, made the observation that children who have experienced trauma due to war and have the opportunity to process this trauma in the presence of parents and  47 other family members have a higher likelihood of their symptoms disappearing after a short period of time. Strong social bonds have also been identified as a protective factor that may stand in the way of the effects of violence exposure. Children without social bonds have not known secure dependence (Brendttro & Long, 1995). The prediction which has been found to be true in these studies has been that individuals with high violence exposure and high social support levels w i l l develop less severe symptomatology than those with high violence exposure and low levels of social support. Studies which have examined either the relationship between violence exposure and social support or different types of internalizing symptomatology and social support have yielded similar protective, or buffering, results. These studies are discussed below. B o n e y - M c C o y and Finklehor (1995) examined the extent as well as the effect of violent victimizations in a large number of adolescents. In their study, they included several covariates, one being family dynamics defined as the parent-child relationship. This parent-child relationship index, when entered as a covariate, was found to be significantly related to symptomatology; the better the child parent relations, the fewer the symptoms exhibited by the adolescent. A study examining the effects of political violence over time in a sample of youth in South A f r i c a found an increase in negative effects such as mistrust and hostility as well as an increasing social disintegration within the community causing intra-community violence (Straker et al., 1996). Participants were asked to list five things that made living in their township difficult. Results revealed that between 1987 (when the first study was run) and  48  1992 (when the last study was run), there was a significant increase in mistrust and hostility within the community. The authors comment on how the level of social disintegration within the community has increased with the level of violence exposure within their community. This study shows how violence exposure can weaken social bonds and threaten social support for youth and community. A similar study investigated how different facets of social and emotional adjustment are affected by chronic violence exposure within a community sample of African-American children ( H i l l & Madhere, 1996). The sample included 150 African-American 4 , 5 , and 6 th  th  th  graders from 6 inner-city schools. Children, mothers and teachers were interviewed. A particular question raised by this research was "to what extent does social support from family, teachers, and peers have multiple or unique effects on particular aspects of children's psychological adjustment?" (Hill & Madhere, 1996, p. 27). Results revealed that social support has specific effects on social-emotional adjustment after violence exposure. Family support was significantly associated with lower levels of anxiety, while parent and peer support was associated with school-related competence. The findings suggest that the impact of social support has a modifying effect on stressful, anxious behavior in the face of risk factors (e.g., violence exposure). Richters and Martinez (1993b) investigated possible predictors of early success and failure in a group of 72 elementary school children living in an inner-city community. The authors examined two domains of adaptational success: social-emotional functioning and academic functioning. Results revealed that 2 0 % of the sample were failing in both domains. The authors explored several possible predictors of adaptational failure, namely, mothers'  49 and children's reports of violence exposure, a teacher rating of stability within the children's homes, and children's reports of witnessing guns and/or drugs in the home. Results revealed that home instability as well as seeing drugs and/or guns in the home were significant predictors of adaptational failure. Together, these variables accounted for 2 1 % of the variance in children's adaptational failure scores. A s well, upon classifying and grouping the families as unstable or unsafe, the authors found that the odds of failing in social domains rose systematically as a function of whether or not children were living in unstable unsafe homes (Richters & Martinez, 1993b). Social Support and Internalizing Symptomatology Social support has also been found in a number of studies to have a modifying effect on internalizing symptomatology. In a study examining 94 adolescents with depression, high family social support was associated with lower depression scores (Barrera & Garrison-Jones, 1992). Another study examining social support and depressive symptomatology in a sample of young to older adults revealed that among other factors (life events, personal competence), social support was found to be the most significant predictor of depression in all age and sex groups (Dean & Ensel, 1982). A study investigating traumatic stress symptomatology after Hurricane Andrew (Vernberg et al., 1996) found that social support was a significant predictor of traumatic symptomatology; lower levels of social support were related to greater P T S D symptomatology. Support from teachers and classmates was found to be particularly significant. These findings indicated that access to supportive relationships within the classroom were important in a child's life after being exposed to a traumatic event.  50  Negative Life Events Stressful life events have been defined as stimuli which exert either chronic or acute demands on an individual and "requires an adaptational response by that individual" (Compas, 1987, p. 276). However, not all stressful life events result in deleterious psychological dysfunction. Negative life events are the more probable source of distress in individuals. Negative life events are based on a model where events are implicated as possible causal factors in some types of psychological distress (Compas, 1987). It is important to distinguish between negative life events, such as a divorce in the family, to violence exposure. However, there are some studies which have shown that both violence exposure and negative life events have similar psychological effects. There have been a number of studies that show a positive relation between negative life events and internalizing symptomatology. A study examining the social adjustment of 86 pregnant adolescent females found that their ratings of negative life events were significantly correlated with their levels of depression (r =.39), anxiety (r = .20), and total symptom level (r = .40) (Barrera, 1981). Johnson and McCutcheon (1980) examined the relationship between negative life events and depression and anxiety in 97 male and female adolescents and found that negative life events were significantly related to levels of depression (r = .22) and anxiety (r = .33). Another study investigated the relationship between negative life events and suicidal symptomatology in a sample of children and adolescents and found that children who were suicidal (that is, had more suicide attempts) were found to have experienced more negative life events (Cohen-Sandier, Berman, & K i n g , 1982). It should be noted that a criticism of research examining negative life events and internalizing  51  symptomatology has been that the reliability of measures used to examine negative life events has been questionable. A s well, more comprehensive studies are needed in order to clarify the paths of association between negative life events and distress (Compas, 1987). These studies show a relationship between negative life events and internalizing symptomatology. Specifically, as the individual experiences more negative life events, the more likely it is that the individual w i l l exhibit higher levels of internalizing symptomatology. Due to the fact that negative life events and violence exposure are related, and that there is a relationship between negative life events and internalizing symptomatology, negative life events may be viewed as a possible confounding variable for this study. Therefore, in this study, negative life events were controlled for. Summary The previous studies demonstrate the importance of socially supportive relationships in the lives of adolescents, particularly when adolescents are faced with a hardship. Social support, that is, emotional support from friends, family and teachers, has been found to have a modifying effect on depression and posttraumatic stress symptomatology. The strength of social supports has also been shown to be an important factor in suicidal ideation (Blumenthal, 1990). Research has shown that those individuals with high social support experience lower levels of internalizing symptomatology. This study w i l l attempt to confirm the modifying hypotheses proven by these other studies. Negative life events have been shown to have a positive relationship with levels of internalizing symptomatology, namely, the more negative life events experienced, the higher the levels of internalizing symptomatology exhibited. Due to this relationship, negative life  52  events may be a confounding variable for this study, and w i l l be controlled for. Summary This chapter has explained several issues important in examining the extent and effects of violence exposure in adolescents. Violence exposure has been found to have a profound effect on adolescents. These effects may include internalizing symptomatology such as posttraumatic stress, depression and/or suicidal ideation. Adolescence is a time of turmoil for many individuals. Many researchers recognize adolescence as a time of change on many levels, yet in the case of violence exposure, little research is conducted with adolescents. Most of the studies examined have included adolescents in the adult or child samples thereby not recognizing adolescence as a separate developmental group. This study w i l l focus on adolescents and their experiences with violence exposure. Violence exposure among adolescents is not uncommon. The rate of youths charged with violent crime is now more than twice the rate from 10 years ago (Statistics Canada, 1996). Over 2 0 % of youngsters have reported that they have been victims of at least one crime or one attempted crime (Statistics Canada, 1993). Many of these crimes go unreported. Most studies have reported that youths are exposed to violent events. However, there has been some discrepancy with regard to the definitions of violence exposure. For the purposes of this study, violence exposure w i l l be defined as a violent "situation...did not pose an immediate threat of physical harm but did have the potential for psychological trauma " (Fick & Thomas, 1995, p. 139). There have been few studies examining the relationship between either victimization or violence exposure and levels of internalizing symptomatology.  53  Research that has examined these relationships has found a positive relationship between violence exposure and internalizing symptomatology. Many different types of violence exposure have been studied and were found to have profound psychological effects on children, adolescents, and adults. Perhaps the most common is P T S D . Most research has found P T S D symptomatology to be an outcome of exposure to violence, both direct and indirect. Many studies have shown a significant positive correlation between experiencing a violent event and traumatic symptomatology (Boney-McCoy & Finklehor, 1995; Hyman, Zelikoff, & Clarke, 1988; Nader et al., 1990). Depression has also been found to be a possible outcome of violence exposure. Depression is a pervasive problem in adolescence; as high as 22.3% of females and 11.4% of males have experienced depression (Lewinsohn et al., 1993). There have been studies confirming a positive relationship between violence exposure and depression. Another possible, yet less studied outcome of violence exposure is that of suicidal ideation, or thinking about suicide. This has also been found to be a problem in today's society. The lack of studies incorporating this important dimension of mental health is grounds for a study examining suicidal ideation as a possible outcome of violence exposure. Studies examining the relationship between gender and violence exposure have found varying results. While some studies show that gender is not related to violence exposure (Bell & Jenkins, 1993; M a z z a et al., 1995) other studies have found that males are more likely to be exposed to violence than females (Gladstein et al., 1992). Research on gender differences in symptomatology reveal stronger trends than in violence exposure. Most studies report that in adolescence females significantly report more P T S D and depression  54  than males (Dawes, Tredoux, & Feinstein, 1989; Fitzpatrick & Boldizar, 1993; Peterson et al., 1991). Research has shown adolescent girls to be more prone to symptomatology (depression, anxiety) than adolescent boys, who were more prone to report acting out behaviors (Ostrov et al., 1988). Another important issue to be examined in this study is that of social support. Social support plays a large part in the life of adolescents; yet, most research on violence exposure does not include it as a possible mediating variable. Research that has been conducted with children and adolescents has found social support to have a moderating effect on internalizing symptomatology (Barrera & Garrison-Jones, 1992; Dean & Ensel, 1982). This study examined the differences in levels between violence exposure and three different types of internalizing symptomatology ( P T S D , depression, suicidal ideation) in a sample of adolescents. Social support was examined as a possible moderating factor between violence exposure and internalizing symptomatology. Other questions answered included gender differences in levels of violence exposure and internalizing symptomatology as well as prevalence estimates for violence exposure in males and females. B y conducting this study, greater insight can be gained into adolescents' experience with violence within the community and its effect on their day to day lives.  55  CHAPTER 3 Statement of the Problem and Research Questions Purpose of the Study The purpose of this study was to examine the relationship between violence exposure and internalizing symptomatology ( P T S D , depression, suicidal ideation). Gender and social support were also examined within the context of this relationship. There are several reasons for examining the impact of exposure to violence on internalizing symptomatology. The recent publicity that violence exposure has received in the newspapers and other media has focused much attention on the epidemic of violence. Statistics have shown that, in Canada, the rates of violent crime have increased within the last decade (Statistics Canada, 1996). Research has shown that a large number of adolescents have been exposed to community violence (Richters & Martinez, 1993; Singer et al., 1995; B e l l & Jenkins, 1993). A large majority of the research that has been examined in the preceding chapter took place in the United States, a country known in the media for its high crime rates. Nevertheless, violence occurs often in Canada; Canadian teens are not immune to the type of violence seen in United States (Statistics Canada, 1996). A s well, there is a lack of research in Canada examining the effects of violence exposure. Statistics have established that violence occurs in the lower Mainland. It is therefore logical to assume that adolescents are exposed to this violence. The limited research examining the effects of violence exposure has found violence exposure to have a detrimental effect on adolescents' mental health (Fitzpatrick & Boldizar, 1993; Reynolds & M a z z a , 1999). This study set out to show the extent of community violence exposure in the lower Mainland, and shed some light on the effects of  56 violence exposure, an increasing factor in adolescent mental health. Research Questions and Hypotheses Internalizing Symptomatology as Related to Violence Exposure: There w i l l be significant differences between levels of social support and violence exposure for internalizing symptomatology, controlling for life events, la). Males with high levels of violence exposure and high levels of social support w i l l have significantly lower scores on measures of internalizing symptomatology than males with high levels of violence exposure and low levels of social support. lb). Males with medium levels of violence exposure and high levels of social support w i l l have significantly lower scores on measures of internalizing symptomatology than males with medium levels of violence exposure and low levels of social support. l c ) . Females with high levels of violence exposure and high levels of social support w i l l have significantly lower scores on measures of internalizing symptomatology than females with high levels of violence exposure and low levels of social support. Id). Females with medium levels of violence exposure and high levels of social support w i l l have significantly lower scores on measures of internalizing symptomatology than females with medium levels of violence exposure and low levels of social support. These hypotheses are depicted in Figures 3 and 4. Rationale. Research has shown that as the level of adolescent exposure to violence increases, the individual is more likely to experience traumatic and depressive symptomatology (Singer et  57  Figure 3. Violence Exposure and Internalizing Symptomatology - Males  Figure 4 Violence Exposure and Internalizing Symptomatology - Females  59 al., 1995; Vernberg et al., 1996). One study has shown a link between high ratings of violence exposure and suicidal ideation (Mazza et al., 1995). Research has also shown that i f an individual, when faced with violence exposure has access to socially supportive relationships, these relationships w i l l have a positive effect on both the duration as well as the level of symptomatology experienced (Barrera & Garrison-Jones, 1992; Dean & Ensel, 1982; Vernberg et al., 1996). Gender Differences 2a) What are the differences in levels of internalizing symptomatology between females and males with high violence exposure and high social support? 2b) What are the differences in levels of internalizing symptomatology between females and males with high violence exposure and low social support? Prevalence Rates 3) D o the proportions of females and males in the low, medium and high violence exposure groups significantly differ from each other? Rationale. There has been some conflict in the literature whether there are gender differences in rates of violence exposure and internalizing symptomatology. Studies examining gender differences within violence exposure have found varying results. While some studies show that gender differences are not present when examining rates of violence exposure (Bell & Jenkins, 1993; M a z z a et al., 1995) other studies have found that males are more likely to be exposed to violence than females (Gladstein et al., 1992). Research on gender differences in symptomatology reveal stronger trends than in violence exposure. Most studies report that  60  symptomatology reveal stronger trends than in violence exposure. Most studies report that females significantly report more P T S D and depression than males (Dawes et a l , 1989; Fitzpatrick & Boldizar, 1993; Peterson et al., 1991).  61  CHAPTER 4 Methodology Participants The study sample included 431 high school students attending four schools in the Lower Mainland of British Columbia. Students ranged in age from 13 to 20 years, with a mean age of 16.9 years ( S D = 1.41). Approximately 6 5 % of the total sample were between 15 and 17 years of age. Students attended grades 8 through 12, with the mean grade being 10.50 ( S D = 1.15). O f the total sample, 38% were males and 6 2 % were females. Prior to participation, all youths had parental consent to be involved in the study (see Appendix A ) . A l l completed parental consent forms were entered in a drawing to win two gift certificates to a music store. A total of approximately 1200 parental consent forms were handed out, and 582 were returned, resulting in a 4 9 % return rate. Four hundred fifty three participants (78% of the total return) consented to partake in the study; 42 chose not to participate and 87 did not indicate whether or not they consented. Those individuals with intellectual or learning disabilities were not included in the study. Demographics on the participant sample are listed in Table 2. The participants agreed to act as volunteers for this research project by completing self-report questionnaires, described in the subsequent section. Procedure The Directors of Research for eight Lower Mainland school districts were approached for their participation in this research study. Three school districts agreed to participate. A total of four high schools participated in the study. The principals of these schools were contacted and asked for a list of teachers who would be interested in participating in the study. The  62  Table 2 Descriptive Characteristics of Participants Gender Characteristic  Total  Male  Female  N  431  164  265  M  15.91  15.92  15.91  SD  1.42  1.49  1.37  Range  13-20  13-20  13-20  M  10.50  10.45  10.53  SD  1.16  1.21  1.12  Range  8-12  8-12  8-12  Caucasian  51.7  53.0  50.9  East Indian  22.0  22.6  21.9  African American  0.7  0.0  1.1  Hispanic  2.3  3.0  1.9  Asian  8.6  7.9  8.7  Pacific Islands  2.1  1.2  2.6  Other  5.1  3.0  6.4  Analysis*  2 X  ( l ) = 23.78, p < . 0 1  Age (years) t(427) = 0.05, p_ = ns.  Grade t(422)= 1.68, p = ns.  Ethnicity (%)  * Between males and females  X (6) =5.79, p=ns. 2  63  researcher then met with the teachers to outline the procedure of the study and what their participation would require. Teachers agreeing to participate were given packets of consent forms to give students. Parents were provided with a description of the research project outlining the study and requesting their participation. Packets including the questionnaires and an outline of the data collection procedure were dropped off to the participating teachers two to three days before the study was to be run. O n the day the study was conducted, the teachers were given a class list on which was highlighted students participating in the study. Only those students with signed consent forms participated in the study. Students who did not participate read quietly or finished homework. Prior to test administration, students were assured that their participation in the study is voluntary, that choosing not to participate would not affect their academic standing, and that they could decline to participate in this research study at any time. Students were provided with verbal and written instructions and told to work through the package of materials at their own pace. The administration of all measures took approximately 45 minutes. Each package had a top sheet with the student's name and an identification number which was torn off by the teacher and kept as a master list at the school. The first page of the questionnaire was designed to collect demographic information. After thequestionnaires were completed, the researcher collected the completed forms and examined them for high depression and/or suicidal ideation scores. Scores of 77 or above on the depression measure and 31 or above on the suicidal ideation measure are indicative of clinical levels of depression and suicidal ideation and warrant further mental health assessment. These identification numbers were then given to the school counselor in order to  64  target those students in need of further assessment and treatment. Questionnaires are described in detail in the proceeding section. Instrumentation A l l of the constructs in this study were assessed through self-report measures. These included measures of violence exposure, posttraumatic stress disorder, depression, suicidal ideation, social support and major life events. These instruments are described below and copies of each measure are included in the Appendices. It should be noted that other data were included in the package as part of a larger study. These other data were not examined within this study. Demographic Information. A n information form was administered in order to collect information regarding age, gender, and family background (see Appendix B). Assessment of Violence Exposure. Assessment of violence exposure was conducted with the Exposure to Violence Questionnaire ( E V Q ; Reynolds & Mazza, 1995). This scale is a self-report measure designed to assess the degree of indirect violence exposure experienced by adolescents. The measure consists of 21 dichotomously scored items (see Appendix C ) . Participants are asked to answer dichotomously (no-yes) to questions such as: "Have you seen someone get shot?" and "Have you seen someone use another weapon in a fight?" Reynolds and M a z z a (1999) conducted a study examining the reliability of the E V Q with inner-city youth. The sample consisted of 98 adolescents from inner-city Brooklyn. Participants were tested and retested after an average of three weeks. Internal consistency reliability of the E V Q was found to be  65 .85; the average inter-item correlation was .265 and a median item total correlation was .49. These results suggest that the E V Q is a reliable measure for assessing violence exposure with adolescents. Assessment of Posttraumatic Stress Disorder. P T S D symptomatology was evaluated with the Posttraumatic Stress Disorder Scale (PTS), a scale from the Adolescent Psychopathology Scale ( A P S ; Reynolds, 1998). There are 12 items on the P T S that asses the symptomatology that arises upon experiencing a negative event (see Appendix D). The P T S items are based upon the core criteria listed in the D S M IV. Construct validity of the scale has been evidenced by results of an item factor analysis, which corresponded to negative events and insomnia. A reliability estimate of .84 with the total standardization sample of approximately 1800 participants was found. Questions are presented in both a dichotomous (true-false) and a Likert type format (from "almost never" to "nearly all the time"). Questions include: "I kept thinking about the bad thing that happened", and "I had trouble concentrating". Assessment of Depression. The Reynolds Adolescent Depression Scale ( R A D S ; Reynolds, 1986) developed for use with adolescent populations consists of 30 items and uses a 4 point Likert format, from "almost never" to "most of the time" (see Appendix E). The R A D S items reflect symptomatology consistent with that specified by the Diagnostic and Statistical Manual of Mental Disorders - Third Edition ( D S M III; American Psychiatric Association, 1980) for major and minor depression, as well as the adult version of the Schedule for Affective Disorders and Schizophrenia ( S A D S ) . In a study with over 3000 adolescents (Reynolds,  66 1984), the P v A D S has been shown to be reliable (internal consistency o f .93 to .96 and test-retest reliability of .84 with a six week interval) and valid (.72 to .83) with self-report and clinical interview scales o f depression. Examples o f R A D S items are: "I feel sad", and "I feel like crying". There are also items which are reverse-scored, such as "I feel like talking to other students". Assessment of Suicidal Ideation. The Suicide Ideation Questionnaire - Junior (SIQ- J R ; Reynolds, 1987) was developed to assess the extent o f suicidal ideation being experienced. The SIQ-JR is a 15 item self-report questionnaire which presents a series of thoughts concerned with death and suicide (see Appendix F). The items are drawn from categories reflecting the seriousness of thoughts, beginning with general, mild thoughts (e.g., "I thought about death") to more serious specific thoughts ("I thought about how I would k i l l m y s e l f ) . A n adolescent who scores above 31 should be referred for further mental health assessment. There are a number of critical items to be aware of when scoring the measure. The standardization sample size consisted o f over 2180 adolescents in junior and senior high schools, 1283 taking part in the junior high version of the SIQ. The sample was found to be representative of the general population. Participants make a rating of how frequently they experienced the thoughts in the past month, ranging from "not at a l l " to "almost every day". Responses are scored on a seven point Likert format scale with most frequently occurring thoughts receiving a six and thoughts never experienced receiving a zero. A study using the SIQ-JR found the reliability to be high (r =.90) as well (Mazza et al., 1995). The SIQ-JR, although designed for use with junior high school populations, has been found to be effective with adolescents of all ages (Reynolds &  67 M a z z a , 1999). Therefore, due to the number of measures that w i l l be used in the study, the SIQ-JR was used to minimize the time needed to complete the measures. Assessment of Social Support The Adolescent Support Inventory (Reynolds & Waltz, 1984) was developed to assess social support experienced by adolescents. The scale consists of 16 dichotomously scored (yes/no) items (see Appendix G). The scale assesses the extent, nature and quality of an adolescent's perceived social network including family, peers and teachers. The authors of this scale have found it to have an internal consistency reliability of .81 (Reynolds & Waltz, 1986). Assessment of Negative Life Events The Life Events List (Reynolds, 1982) is a revision of the Life Events List by Gersten, Langner, Eisenberg, and Orzeck (1974). This revision consists of 16 items assessing major negative life events that have occurred over varying periods of time (within the past six months, between six months and one year, between one and three years, between three and five years, over five years, or never) (see Appendix H). Negative life events include severe accident or illness of a parent, divorce or separation, and death of a family member. Internal consistency reliability of this scale was found to be .71 (Reynolds & Waltz, 1986). Data Analysis Violence Exposure and Symptomatology (Hypotheses la-d) 1). There w i l l be significant differences between levels of social support and violence exposure for internalizing symptomatology, controlling for negative life events. In order to examine group differences based on violence exposure, three categorizations  68  were made based upon the level of violence exposure experienced. Based on their scores of violence exposure, students were placed in one of three groups: those with a score less than six on the E V Q were placed in the " l o w " group; those with a score of six to ten on the E V Q were placed in the "moderate" group; those with a score above ten on the E V Q were placed in the " h i g h " group. Based on their scores, students were also put into two categories of social support: low or high (median split). The outcome variables were adolescents' scores on the P T S D , depression and suicidal ideation measures. A multivariate analysis of covariance ( M A N C O V A ) was conducted because these three outcome variables are expected to be correlated. A covariate of negative life events was included in order to control for potential differences among groups. la). Males with high levels of violence exposure and high levels of social support w i l l have significantly lower scores on measures of internalizing symptomatology than males with high levels of violence exposure and low levels of social support. Cases were selected based on high scores of violence exposure and male gender. Three A N C O V A ' s were conducted with P T S D , depression, and suicidal ideation as the outcome variables and social support as the independent variable. Negative life events were entered as the covariate. lb). Males with medium levels of violence exposure and high levels of social support w i l l have significantly lower scores on measures of internalizing symptomatology than males with medium levels of violence exposure and low levels of social support. Cases were selected based on medium scores of violence exposure and male gender. Three A N C O V A ' s were conducted with P T S D , depression, and suicidal ideation as the  69  outcome variables and social support as the independent variable. Negative life events were entered as the covariate. lc). Females with high levels of violence exposure and high levels of social support w i l l have significantly lower scores on measures of internalizing symptomatology than females with high levels of violence exposure and low levels of social support. Cases were selected based on high scores of violence exposure and female gender. Three A N C O V A ' s were conducted with P T S D , depression, and suicidal ideation as the outcome variables and social support as the independent variable. Negative life events were entered as the covariate. Id). Females with medium levels of violence exposure and high levels of social support w i l l have significantly lower scores on measures of internalizing symptomatology than females with medium levels of violence exposure and low levels of social support. Cases were selected based on medium scores of violence exposure and female gender. Three A N C O V A ' s were conducted with P T S D , depression, and suicidal ideation as the outcome variables and social support as the independent variable. Negative life events were entered as the covariate. Gender Differences (Questions 2a-b) 2a) What are the differences in levels of internalizing symptomatology between females and males with high violence exposure and high social support? Cases were selected based on high violence exposure and high social support. T-tests were then conducted in order to determine the presence of any gender differences. 2b) What are the differences in levels of internalizing symptomatology between females and  70  males with high violence exposure and low social support? Cases were selected based on high violence exposure and low social support. T-tests were then conducted in order to determine the presence of any gender differences. Descriptive Statistics (Question 3) 3) D o the proportions of females and males in the low, medium and high violence exposure groups significantly differ from each other? The proportion of the total sample exposed to violence was reported in percentages of the total sample. Chi-square analyses were conducted in order to examine the proportion of males and females in the sample. Means, standard deviations, and reliabilities were reported for the E V Q , A P S , R A D S , SIQ, A S I and L E L .  71  CHAPTER 5 Results The results of this study w i l l be presented according to the previously stated research questions and hypotheses. Each of the research hypotheses and questions w i l l be presented followed by the relevant statistical procedures and results. The first section w i l l present the descriptive characteristics of the study sample as well as the means and standard deviations of the measures used in the study. The second section of this chapter w i l l address hypotheses examining the relation between violence exposure and types of internalizing symptomatology. The third section w i l l address research questions examining gender differences in violence exposure and internalizing symptomatology ( P T S D , depression, suicidal ideation). Finally, the fourth section w i l l address the extent of violence exposure across the sample of secondary school students surveyed. Descriptive Characteristics The means and standard deviations for the study measures for males, females, and the total sample are presented in Table 3. T-tests for male-female differences were conducted and the results listed in Table 3. For the total sample, the scores on the E V Q ranged from 0 to 19. Participants were placed into one of three groups based on their scores on the E V Q : the low, the medium, or the high violence exposure group.  Within the total sample, 50.9%  of the participants fell within the low violence exposure group, 35.0% fell within the medium violence exposure group, and 14.1 % fell within the high violence exposure group. The reliability for this measure was found to be r - .82. a  Table 3 Means and Standard Deviations and Male-Female Differences of Measures for Males, Females, and the Total Sample  Measures  Males  Females  Total  Analysis  EVQ  N M SD  164 7.19 4.27  265 5.49 3.49  431 6.14 3.89  t(427) = 4.48, p < .01  APS - PTS  N  157 18.02 4.83  259 18.83 4.41  418 18.51 4.58  t(414) = -1.74,E = ns.  265 61.59 13.12  431 59.45 13.55  t(427) = -4.21,E<-01  SD  164 56.04 13.54  SIQ- J R  N M SD  164 10.20 12.67  265 12.31 12.48  431 11.46 12.57  t(427) = -1.69,E = ns.  ASI  N  154 28.40 2.97  261 28.96 2.44  417 28.74 2.66  t(413) = -2.10,E<-05  163 16.64 12.42  264 18.41 11.88  429 17.70 12.11  t(425) = -1.47,E = ns.  M SD RADS  N  M  M SD LEL  N  M SD  Note: E V Q = Exposure to Violence Questionnaire A P S - P T S = A P S Posttraumatic Stress Disorder Scale R A D S = Reynolds Adolescent Depression Scale SIQ - J R = Suicidal Ideation Questionnaire Junior A S I = Adolescent Support Inventory L E L = Life Events Scale  73 For the total sample, the scores on the Posttraumatic Stress Scale (PTS), from the Adolescent Psychopathology Scale, ranged from 12 to 31. The reliability for this measure was found to be r = .85. For the total sample, the scores on the R A D S ranged from 31 to a  102. The reliability for this measure was found to be r = .92. a  The mean score was found to  be similar to that in the standardization sample (Reynolds, 1986). For the total sample, the scores on the SIQ ranged from 1 to 83. The reliability for this measure was found to be r = a  .92. For the total sample, the scores on the A S I ranged from 16 to 32. Participants were placed into low or high social support groups, determined by a median split score of 30. O f the total sample, 50.9% fell within the low social support group; 49.1% fell within the high social support group. The reliability for this measure was found to be r = .72. For the total a  sample, the scores on the L E L ranged from 0 to 57. The reliability for this measure was found to be r = .75. This variable was used as a covariate in this study. a  Internalizing Symptomatology as Related to Violence Exposure Hypothesis 1. There will be significant differences between levels of social support and violence exposure for internalizing symptomatology, controlling for negative life events. A multivariate analysis of variance was performed in order to determine whether significant differences exist between the groups when negative life events are controlled for. The M A N C O V A revealed that there were significant differences between groups controlling for the relation among P T S D , depression, and suicidal ideation (F(3, 398) = 34.32, p_ < .01). la) Males with high levels of violence exposure and high levels of social support will have significantly lower scores on measures of internalizing symptomatology than males with high levels of violence exposure and low levels of social support.  74 Cases were selected based on male gender and high levels of violence exposure. A n analyses of covariance ( A N C O V A ) was then performed in order to test the hypothesis o f whether any significant differences exist between males with high levels of violence exposure and high levels of social support and males with high levels of violence exposure and low levels of social support. Negative life events was used as the covariate. Results are listed i n Table 4, and are graphed in Figure 5. Results revealed no significant differences between the groups on measures of P T S D ( F ( l , 25) = .416, p = ns.), depression ( F ( l , 26) = 2.28, p_ <.15), and suicidal ideation ( F ( l , 26) = .176, p. = ns.). Therefore, this hypothesis was not supported, lb) Males with medium levels of violence exposure and high levels of social support will have significantly lower scores on measures of internalizing symptomatology than males with medium levels of violence exposure and low levels of social support. Cases were selected based on male gender and medium levels of violence exposure. A n analyses of covariance ( A N C O V A ) was performed to investigate whether significant differences existed between males with medium levels of violence exposure and high levels of social support and males with medium levels of violence exposure and low levels of social support. Results are listed in Table 4, and are graphed in Figure 5. Results revealed no significant differences between the groups on measures of P T S D ( F ( l , 53) = .004, p. = ns.), depression ( F ( l , 53) = .001, p_ = ns.), and suicidal ideation ( F ( l , 53) = .431, p = ns.). Therefore, this hypotheses was not supported. lc) Females with high levels of violence exposure and high levels of social support will have significantly lower scores on measures of internalizing symptomatology than females with high levels of violence exposure and low levels of social support.  >  CD  •73  ^ O  cr  3  Cn «-+  x  CTQ  >  H  »  j3  p  Co  <f °> cn° O  o C/3  Cn  o  oo  H  H  Cn  OO O  OO  o  cr  o < 3  o 3  r  m O  tO  ON  KJ  ON  KJ  ON  MD  •<>  OJ OJ  NO  9.76  3.27  11.79  o  OO  6.16  tO  19.68  OJ  oo o oo  o CTQ  on  o  g O  on  s  TO*  16.00  o  o SO  B.  cr oo o o_ 5] oo  t3 O  55.18  19.82  13.90  57.11  9.74  18.08  3  >  cr cr o.  8" 3 3  o  CD  m x  T3 O  OJ  o  OJ  o  OJ  o  cn  NO  NO  C  NO  CD  r 00  o  OJ  NO  ON  ON  ON  o  4^ OO  to OJ  OJ  14.15  ^1  OJ  ON  5.41  on  KJ ON  15.13  00  -J © OJ  11.24  o  *  4.16  11.05 '  on  ON K> NO  CD  OO a  o oo o o oo c  >  cn  t-  1  O  OO  T3 O  2  cr <  a  o oo  § o  Figure 5 Analysis o f Covariance for Males with Levels o f Violence Exposure: H i g h V s . L o w Social Support  65  60  CO  Hi Social Support  50  Lo Social Support  45  Violence Exposure  25  20 Q CO Hi Social Support  15 Lo Social Support  10  2  3  Violence Exposure  20  15  1 '» Hi Social Support  Lo Social Support  Violence Exposure  77 Cases were selected based on female gender and high levels o f violence exposure. A n analyses o f covariance ( A N C O V A ) was performed to investigate whether significant differences existed between females with high levels o f violence exposure and high levels o f social support and females with high levels o f violence exposure and low levels o f social support. Results are listed in Table 5, and are graphed in Figure 6. Results revealed a significant main effect for social support on depression ( F ( l , 24) = 8.79, p_<.01). Results revealed no significant differences between the groups on measures o f P T S D ( F ( l , 23) = 3.19, p_ < .09) and suicidal ideation ( F ( l , 24) = .000, p. = ns.). Therefore, this hypothesis was partially supported.  Id) Females with medium levels of violence exposure and high levels of social support will have significantly lower scores on measures of internalizing symptomatology than females with medium levels of violence exposure and low levels of social support. Cases were selected based on female gender and medium levels o f violence exposure. A n analyses o f covariance ( A N C O V A ) was performed to investigate whether significant differences existed between females with medium levels o f violence exposure and high levels of social support and females with medium levels o f violence exposure and l o w levels o f social support. Negative life events were used as a covariate. Results are listed in Table 5, and are graphed in Figure 6. Results revealed a significant main effect for social support on a measure o f depression ( F ( l , 83) - 7.56, p_<.01). Results revealed no significant differences between the groups on measures o f P T S D ( F ( l , 82) = 2.51, p = ns.) and suicidal ideation ( F ( l , 83) = 3.00, p. < .09). Therefore, this hypothesis was partially supported.  X  >  ft)  c  f  cr  Cu  &  c/1  •a o  era'  6 °  r-tCD  RADS  o  PTSD  oo  SIQ  c/i  RADS  §  PTSD  re  CD P  cn  c  3-  re  rt>  CTQ  8CO  <  -J  -J  NJ  SO UJ  Ui  oo  UJ  bo  SO '-J -J  Ul  Ui  Os © 00  SO NJ  UJ  NJ  UJ Ul  oo UJ  ao , cr  00  10.88  SO UJ Ul  UJ  3.54  NJ  UJ  16.68  CD  4.49  i-t  8.50  o O <  i—*  OS  12.57  on  4*.  -J  Ul  bo o  GfJ  o  I  o  5'  2  ro  g  a  ft)  ro o  > UJ  so  Os i—»  s©  UJ 00  NJ  OS  o  bs  Os  4^-  Os Os 4>-  UJ  NJ  Os  UJ 00  UJ  o > SO 11.92  5.16  20.07  10.46  4.50  14.18  70.47  21.84  17.23  67.71  20.81  16.43  8Z.  UJ  ro  rT  1  g" GO  O  SI 3  >  p'  i  1  ro ro o  3-  79 Figure 6 Analysis o f Covariance for Females with Levels o f Violence Exposure: High vs. L o w Social Support 80 75 70 65  CO Q  60  < or  55 50  Hi Social Support  45  Lo Social Support  40  Violence Exposure  25  15  a  Hi Social Support  CO Lo Social Support  10  5  1  2  Violence Exposure  3  80  Secondary Analysis Although the relationship between levels of social support and low levels of violence exposure was not examined within this study, secondary analyses were performed to investigate whether any significant differences existed between males with low levels of violence exposure and high levels of social support and males with low levels of violence exposure and low levels of social support. Cases were selected based on male gender and low levels of violence exposure. A n analyses of covariance ( A N C O V A ) was performed to investigate whether any significant differences existed between males with low levels of violence exposure and high levels of social support and males with low levels of violence exposure and low levels of social support. Negative life events were used as a covariate. Results are listed in Table 6, and are graphed in Figure 5. Results revealed no significant differences between the groups on measures of depression ( F ( l , 66) = .945, p. = ns.), P T S D ( F ( l , 63) = 0.08, p. = ns.) and suicidal ideation ( F ( l , 66) = 1.17, p = ns.). Secondary analyses were performed in order to investigate whether any significant differences existed between females with low levels of violence exposure and high levels of social support and females with low levels of violence exposure and low levels of social support. Cases were selected based on female gender and low levels of violence exposure. A n analyses of covariance ( A N C O V A ) was then performed to investigate i f any significant differences existed between females with low levels of violence exposure and high levels of social support and females with low levels of violence exposure and low levels of social support. Negative life events were used as a covariate. Results are listed in Table 6, and are graphed in Figure 6. Results revealed significant differences between the groups on  o  3 >£-  2L  of  <T>  3 C  to  C/3  o  TJ H oo O  O oo  to  oo /O  -J  to  to  on  on  ON  o  oo  ©  ©  OJ  4^-  to  ©  ©  ON  o  OJ  on  OJ  ON  4^.  to  NO ON 00  oo  ON ON  i—'  on  i—»  to  bo  to on  to  ON  so oo ©  oo  SO  OJ  4^  ON  1 — > ON  on  on  on  OJ  OJ ON  o  ON ON -J OJ OJ on  -0. 4^  H-*  on  ON  ©  g  ©  oo O  on  —J  oo  4^  4^-  OJ  ON KJ  to 1— to  oo ON O  oo o o i T3 O  1  a  o  ON  so  >—»  tfq" ,  -4  4^  •—*  g >  00 'on  OJ  n  -J  to  OJ  P  O oo  56.08  —i  4*.  —i  16.67  50.46 OJ  4^  8.33  16.21 to  5.32 OJ  id H oo O  to  g oo  a  f TS O  3-  ON KJ on  o p'  g  >  82 measures o f depression ( F ( l , 145) = 8.64, p < .01), P T S D ( F ( l , 141) = 10.67, p < .01) and suicidal ideation ( F ( l , 145) = 4.38, p. < .05). Gender Differences Question 2a. What are the differences in levels of internalizing symptomatology between females and males with high violence exposure and high social support? Cases were selected based on high violence exposure and high social support. A series o f A N C O V A s were then performed to test the differences in levels o f internalizing symptomatology ( P T S D , depression, suicidal ideation) between females and males with high violence exposure and high social support, controlling for negative life events. Results are presented in Table 4 for males and Table 5 for females. Results revealed no differences between the groups on measures o f P T S D , (F (1, 19) = .123, p. = ns.), depression, (F (1, 20) = .056, p_ = ns.), or suicidal ideation, (F (1, 20) = .180, p_ = ns.). Question 2b. What are the differences in levels of internalizing symptomatology between females and males with high violence exposure and low social support? Cases were selected based on high violence exposure and low social support. A series o f A N C O V A s were then performed to test the differences in levels o f internalizing symptomatology ( P T S D , depression, suicidal ideation) between females and males with high violence exposure and low social support. Results are presented in Table 4 for males and Table 5 for females. Results revealed no differences between the groups on measures o f P T S D , (F (1, 29) = .069, p = ns.), depression, (F (1, 30) = 2.59, p < .12), or suicidal ideation, (F (1,30) = .000, rj = ns.).  83 Secondary Analysis The above questions have examined the gender differences in the effect of social support among groups with high or moderate levels of violence exposure. Although the relation between levels of social support and low levels of violence exposure was not examined within this study, secondary analyses were performed in order to investigate whether any significant differences existed between females and males with low levels of violence exposure and high levels of social support.  A series of A N C O V A s were then performed to  test the differences in levels of internalizing symptomatology ( P T S D , depression, suicidal ideation) between females and males with low violence exposure and high social support. Results are presented in Table 6. Results revealed significant differences between males and females on measures of depression, (F (1, 94) = 3.85, p_ = .05). Results revealed no differences between the groups on measures of P T S D , (F (1, 91) = .001, p. = ns.), or suicidal ideation, (F (1, 94) = 2.27, p < .14). Secondary analyses were also performed in order to investigate whether any significant differences existed between females and males with low levels of violence exposure and low levels of social support.  Cases were selected based on low violence exposure and low social  support. A series of A N C O V A s were then performed to test the differences in levels of internalizing symptomatology ( P T S D , depression, suicidal ideation) between females and males with low violence exposure and low social support. Results are presented in Table 6. Results revealed significant differences between the males and females on measures of depression, (F (1, 117) = 6.94, p_ = .01), with females reporting greater levels of depressive symptomatology than males. Results revealed no differences between males and females on  84 measures o f P T S D , (F (1, 113) = 3.59, p < .07), or suicidal ideation, (F (1, 117)= 1.40, p = ns.).  Question 3. Do the proportions of females and males in the low, medium and high violence exposure groups significantly differ from each other? A chi-square analysis was conducted in order to examine the proportion o f females and males in the sample. Table 7 presents a summary o f the proportions o f males and females in the low, medium and high violence exposure groups. A greater proportion o f females than males (x (2) = 10.05, p < .01) were within the low (males: 42.7%; females: 56.2%) group, 2  with a somewhat similar proportion o f males and females within the medium (males: 37.8%; females: 33.2%) and a higher proportion o f males in the high (males: 19.5%; females: 10.6%) violence exposure groups. Secondary Analysis In order to have a more in-depth understanding o f the extent and type o f violence exposure experienced, a number o f items on the Exposure T o Violence Questionnaire were examined. These items were selected based on the fact that they examined violence exposure and not victimization.  Frequencies were run in order to examine the total percentage, as well  as the proportion o f females and males that positively endorsed these items. The results are listed in Table 8. Males were significantly more likely to endorse items pertaining to the use of guns and weapons, while females and males equally endorsed the occurrence o f violence in their schools and neighbourhoods. Supplementary Analysis A supplementary analysis was conducted in order to examine the impact o f violence  Table 7 Number and Proportion of Males and Females in Violence Exposure Groups  Violence Exposure Group  Low  Males  Females  Moderate  High  n  70  62  32  %  42.7  37.8  19.5  n  149  88  28  %  56.2  33.2  10.6  85  Table 8  86  Internalizing Symptomatology Means and Standard Deviations for Females and Males with High Violence Exposure and H i g h Social Support  Measure  Males  Females  Mean  Mean dj*  Mean  Mean jj  RADS  56.70  56.02  56.70  57.22  PTSD  19.77  20.16  19.77  19.50  SIQ  15.87  13.99  15.87  17.31  Adjusted Means  A  A(  87  exposure on levels of internalizing symptomatology, controlling for negative life events. The adjusted means of females and males are listed in Table 9 and graphed in Figure 7.  No  significant main effects for violence exposure were found on measures of depression (F (2, 428) = .032, p = ns.), P T S D (F (2, 415) = 1.75, JJ = ns.) or suicidal ideation, (F ( 2, 428) = 1.80, p_ = ns.). A s well, no significant main effects for violence exposure were found for males on measures of depression (F (2, 162) = .024, g = ns.), P T S D (F (2, 152) = 2.26, p. = ns.) or suicidal ideation, (F ( 2, 15) = 1.04, p = ns.) or females on measures of depression (F (2, 260) = .52, p = ns.), P T S D (F (2, 254) = .89, p. = ns.) or suicidal ideation, (F ( 2, 260) = 1.55, p = ns.).  88  Table 9 Internalizing Symptomatology Adjusted Means for Males and Females with L o w , Medium and High Levels of Violence Exposure  Violence Exposure  Measure  Males  Females  N  Mean dj*  N  RADS  70  55.42  149  60.79  PTSD  66  17.52  145  18.49  SIQ  70  9.16  149  11.33  RADS  62  56.17  87  62.53  PTSD  60  17.76  86  19.17  SIQ  62  9.96  87  12.79  RADS  31  57.48  28  62.80  PTSD  30  19.54  27  19.40  SIQ  31  13.04  28  16.03  A  Mean  A d j  Low  Medium  High  89  Figure 7 Analysis o f Covariance for Females and Males with Levels o f Violence Exposure on Measures o f Internalizing Symptomatology  65  60 CO Q Female  55  50  1  2  Violence Exposure  3  17 15  o  13  co  11  Female  1  2  Violence Exposure  3  21  20  Q CO  19  Female  17 16  1  2  Violence Exposure  90  CHAPTER 6 Discussion Purpose o f Study The purpose o f this study was to examine the relation between violence exposure and internalizing symptomatology ( P T S D , depression, suicidal ideation). This study also examined the role o f gender and social support within this relationship. There are several reasons for examining the impact o f exposure to violence on P T S D , depression and suicidal ideation symptomatology. Research has shown that a large number o f adolescents have been exposed to community violence (Bell & Jenkins, 1993; Richters & Martinez, 1993; Singer et al., 1995). The limited research examining the effects o f violence exposure has found violence exposure to have a detrimental effect on adolescents' mental health (Fitzpatrick & Boldizar, 1993; Reynolds & Mazza, 1999). This study has focused on the impact o f community violence exposure on levels o f internalizing symptomatology, and has also examined the role o f social support and gender differences within this relationship. Prevalence o f Violence Exposure The present study investigated whether the proportions o f females and males in the low, medium and high violence exposure groups significantly differed from each other. Results revealed that there were significant differences in the proportions o f females and males within the low, medium and high violence exposure groups. A greater proportion o f females than males were within the low violence exposure group, with a greater proportion o f males within the medium and high violence exposure groups. Males had significantly higher scores on the Exposure to Violence Questionnaire than females. O f the total sample, 57% o f males  91  and 4 4 % of females have been exposed to moderate or high levels of violence.  These  figures are comparable to previous studies examining prevalence rates of violence exposure, and revealed that high rates of violence exposure exist among adolescents. O f the total sample, 89% of students reported an occurrence of violence in their school; over one half of students reported knowing someone who had been attacked; 19% had seen someone use a gun or a knife in a fight. These results indicate that adolescents are experiencing high rates of general violence exposure as well as high rates of being exposed to particularly violent crime. These figures are comparable to American studies examining the prevalence of youth exposure to community violence. In a study examining the role of exposure to community violence and its relationship to developmental problems in a group of adolescent boys, results revealed that 54% saw someone beaten up, and 15% had seen someone shot or killed (Gorman-Smith & Tolan, 1998). One of the more comprehensive studies examining the extent and effect of violence exposure was done by Singer and his colleagues (Singer et al., 1995). The prevalence rates for students who experienced violence exposure varied by school site as well as by violent acts: 9% to 21.3% saw someone else abused or assaulted; 32.3% to 81.7% saw someone else beaten up or mugged at school. Breslau et al. (1991) examined the relationship between traumatic events and P T S D symptomatology in a sample of over 1000 adults. Traumatic events were taken from the D S M III-R to include such events as sudden injury or serious accident, seeing someone seriously hurt or killed, robbery, threat to one's life, rape, and news of sudden death or injury of close relative or friend.  The  authors found that 39.1%> reported exposure to one or more of these events. There are other studies which have shown even higher rates of violence exposure. In a  92  study by Bell and Jenkins (1993) examining community violence among children and adolescents, they found that 3/4 of children aged 10 to 19 years had witnessed a robbery, stabbing, shooting or killing; 47% had been personally victimized. While some of these studies have shown higher rates of violence exposure among adolescents, it is important to remember that these studies had focused on adolescents from inner-city schools. The elevated rate of violent crime within these communities may be the reason for the discrepancy between these data and the results found in the present study. Therefore it is important to note that the prevalence rates found within the present study are based on local samples and are sensitive to community differences. A high proportion of adolescents are living in environments where they have been exposed to serious violence in their schools and communities. These findings underscore the importance of understanding and examining the impact that violence has on adolescent mental health. Internalizing Symptomatology as Related to Violence Exposure In the present study, it was hypothesized that there would be significant differences in internalizing symptomatology between levels of social support and violence exposure. More specifically, it was hypothesized that males with high or medium levels of violence exposure and high levels of social support would have significantly lower scores on measures of internalizing symptomatology than males with high or medium levels of violence exposure and low levels of social support. Results indicated that males with high levels of social support did not have significantly lower scores on any of the measures of internalizing symptomatology than males with low levels of social support. A trend was evident between  93  males with high violence exposure on a measure of depression, and had the sample size been greater, this trend may have approached significance. Secondary analyses were conducted in order to determine whether males with low violence exposure and low social support had significantly higher scores than males with low violence exposure and high social support. Results revealed that, similar to males with moderate and high levels of violence exposure, no significant differences were present in the levels of internalizing symptomatology between males with high and low levels of social support. It was hypothesized that females with high or medium levels of violence exposure and high levels of social support would have significantly lower scores on measures of internalizing symptomatology than females with high or medium levels of violence exposure and low levels of social support. Results revealed that females with high social support did not have significantly lower scores on measures of traumatic stress and suicidal ideation than females with low levels of social support, although a trend was evident for the level of traumatic symptomatology. Females with high social support did have significantly lower scores on measures of depression than females with low levels of social support. A secondary analysis was conducted in order to determine whether the females with low violence exposure and high social support had significantly lower scores on measures of internalizing symptomatology than females with low violence exposure and low social support. Results revealed that significant differences existed on measures of depression, traumatic stress, and suicidal ideation; females with high levels of social support had significantly lower scores on all three measures of internalizing symptomatology than  94  females with low levels of social support. It appears as though for males, social support may not have the desired buffering or moderating effect on the impact of violence exposure. Other factors, such as social status within a group, desensitization due to media and television, and resiliency factors may act as possible mediating factors for males. This finding is consistent with the literature that suggests that children exposed to high levels of violence experience a "desensitization process" such that these stressors do not have an impact on their overall well-being (Fitzpatrick & Boldizar, 1993; Osofsky et al., 1993). The findings of the present study may be related to the results of a study examining the role of exposure to violence and developmental problems in a sample of 245 teenage boys (Gorman-Smith & Tolan, 1998). The researchers found that violence exposure could not be predicted from family relationship and parenting characteristics. The authors in turn suggested that family factors did not relate to who is exposed to violence, and believed that other factors such as community level influences may be more important in influencing the risk for violence exposure. Another study examining the extent and impact of violence exposure found that violence exposure was related only to family living arrangements (e.g., living in a house or an apartment) and not to other family factors (Richters & Martinez, 1993a). Contrary to the findings regarding the role of social support and males, social support appears to make a difference in females with low levels of violence exposure (see Figure 6). This is consistent with previous findings, which have found that especially for females, social support plays an important part in adolescent life (Boney-McCoy & Finklehor, 1995; H i l l &  95  Madhere, 1996). However, as the level of violence exposure increases, it appears as though, although a trend is present, social support loses its significant mediating effect on levels of P T S D and suicidal ideation. This may be due to the fact that as the level of violence exposure and subsequent trauma increases, social support is not enough to mediate the effects of violence exposure. Female adolescents may feel that they are unable to discuss their feelings or relate to their support systems any longer. These support systems in turn may be unable to provide the type of support they need. Whereas once they were able to provide comfort, stability and strength, they may be unable to deal with the trauma that the high levels of violence exposure have incurred in the adolescent. This may be due to the fact that the support systems are unable to cope with the situation themselves. These findings suggest that for adolescents that have experienced high levels of violence exposure, interventions that focus primarily on social support without considering other important aspects of community context may have limited impact. It is important to note that when the relationship between social support and internalizing symptomatology is examined, results revealed significant differences between students with high levels of social support and those with low levels of social support. Students with high levels of social support had significantly lower levels of P T S D , depression and suicidal ideation than students with low levels of social support. These results suggest that social support is a mediating variable for students with high levels of internalizing symptomatology, and also suggest that as violence exposure increases, it affects social support's mediating effect. Although there has been research to suggest that social support has a moderating effect on  96  psychological sequelae after violence exposure, there have been studies to suggest otherwise. A study examined the relationship between exposure to violence and anxiety as well as the extent to which social support moderated this relationship with a sample of 385 preadolescents (White, Bruce, Farrell, Kliewer, 1998). Results revealed that social support did not effectively moderate youths' anxiety after being exposed to violence. Another study investigating the health impact of four stressors (sexual abuse, lifetime losses, turmoil in childhood family, recent stressful life events) in a group of adult females found that social support did not buffer the effects of stress (Lesserman, Zhiming, Y u m i n g , & Drossman, 1998). In a study examining social support and psychological distress in Kuwaiti children after the G u l f War, results revealed that while children exposed to high levels of trauma have higher P T S D scores and depression scores, social support did not mediate the relation between trauma and distress (Llabre & Hadi, 1997). For females, results revealed a significant difference in levels of depression between females with low and high levels of social support. Studies that have examined the relationship between social support and violence exposure have found that social support has a buffering effect upon internalizing symptomatology; the higher the level of social support, the fewer the internalizing symptoms exhibited by the adolescent (Boney-McCoy & Finklehor, 1995; H i l l & Madhere, 1996). In a study examining adolescents with depression, high family social support was associated with lower depression scores (Barrera & GarrisonJones, 1992). Several reasons may be attributed as to the reason why females' depression scores were found to be affected by social support while males were not. The sample sizes were greater  97 for females; had the sample sizes for males been greater, the trends exhibited in the study may have approached significance. A s well, the strength of the parent-child and peer relationships may have a greater influence on adolescent girls' well-being than on the wellbeing of adolescent boys. A study examining children's distress symptoms after being exposed to violence revealed that girls reported significantly higher levels of depression than boys (Martinez & Richters, 1993). Another study has shown that girls display greater depressive vulnerability than their male counterparts (Leadbeater, Blatt, & Quinlan, 1995). It is important to note, however that research has shown males to exhibit more externalizing patterns of symptom expression, such as being aggressive or antagonistic (Block, Gjerde & Block, 1991; Gjerde et al., 1988). A similar study revealed that adolescent girls were found to be more prone to report inwardly directed symptomatology (depression, anxiety) than adolescent boys, who were more prone to report acting out behaviors (Ostrov, Offer & Howard, 1988). It is important to note that while social support had some mediating effect on levels of internalizing symptomatology for females, it did not have that effect with males. This may be due to the fact that males do not experience the levels of internalizing symptomatology that females do. The question arises as to why depression scores were found to be significantly affected by levels of social support and P T S D and suicidal ideation symptomatology were not. Research examining P T S D and community violence exposure has found that the greater the violence exposure, the higher the levels of trauma symptoms (Pynoos et a l , 1987; Singer at al., 1995). A study conducted by M a z z a and Reynolds (1999) found that adolescents experiencing high levels of violence exposure were found to have significantly higher scores on a measure of  98 P T S D symptomatology. It is important to note that specific groups or levels of social support were not sampled within these studies. For females, the P T S D symptomatology scores approached significance; traumatic stress may have been significantly affected by levels of social support had the sample sizes been larger (19 males sampled, 13 females sampled). The results of the present study suggest that for males and females with high levels of violence exposure, the level of social support does not have an effect on levels of suicidal ideation. Research examining the effect of violence exposure on suicidal ideation is very limited. M a z z a and Reynolds (1999) examined the relationship between community violence exposure and levels of suicidal ideation. Results revealed that those who had higher levels of violence exposure were more likely to experience higher levels of suicidal ideation. A g a i n it is important to note that specific groups, such as those targeted in this study were not examined within the M a z z a and Reynolds study. A possible reason for the fact that the level of social support did not have an effect on suicidal ideation may be that once the level of suicidal ideation reaches moderate to high levels, peer and family factors are not having a great enough influence in deterring suicidal thoughts. Adolescents may feel that their family and peers have no idea what they have been through, and have a difficult time relating to their peers and family members. In turn, family members may not understand how to cope with the situation at hand. A supplementary analysis, which examined the impact of violence exposure on levels of internalizing symptomatology, found that when negative life events were controlled for, there were no differences in levels of depressive, traumatic stress, or suicidal ideation symptomatology among groups with low, moderate or high violence exposure. This suggests  99  that other factors such as negative life events, or other social factors such as peer pressure, bullying or teasing may play an important part in adolescent mental health. A study examining the social adjustment of 86 pregnant adolescent females found that their ratings of negative life events were significantly correlated with their levels of depression (r =.39), anxiety (r = .20), and total symptom level (r = .40) (Barrera, 1981). Johnson and McCutcheon (1980) examined the relationship between negative life events and depression and anxiety in 97 male and female adolescents and found that negative life events were significantly related to levels of depression (r= .22) and anxiety (r = .33). Another study investigated the relationship between negative life events and suicidal symptomatology in a sample of children and adolescents and found that children who were suicidal (that is, had more suicide attempts) were found to have experienced more negative life events (CohenSandier, Berman & K i n g , 1982). These results suggest that negative life events are correlated with increased levels of internalizing symptomatology. It is important to note that when negative life events are excluded, significant differences are present in levels of internalizing symptomatology among violence exposure groups. Results revealed that adolescents in the high and moderate violence exposure groups had higher levels of internalizing symptomatology than adolescents in the low group. This may suggest that there may be some overlap in negative incidents between violence exposure and negative life events, and that in removing negative life events, some incidents of violence exposure may be removed as well. Gender Differences A question was asked as to whether there were significant differences in levels of  100  internalizing symptomatology between females and males with high violence exposure and high social support. Results indicated that no significant differences existed between females and males with high violence exposure and high social support. A similar question was asked as to whether there were significant differences in levels of internalizing symptomatology between females and males with high violence exposure and low social support. Results indicated that no significant differences existed between females and males with high violence exposure and low social support. Both females and males were equally affected by high violence exposure. Secondary analyses were conducted in order to examine whether males and females with low violence exposure and high levels of social support significantly differed from each other in terms of their internalizing symptomatology scores. Results revealed that males and females did not differ on measures of traumatic stress and suicidal ideation. However, the difference in depression scores between males and females was significant, with females reporting a greater level of depressive symptomatology than males. A secondary analysis was conducted in order to determine whether females with low levels of violence exposure and low levels of social support significantly differed from each other with regards to their symptomatology levels. Results revealed that males and females did significantly differ on measures of depression, females having higher depression scores than males. The difference between males and females on measures of traumatic stress approached significance, with females reporting slightly higher levels of traumatic stress than males. Females and males were found not to significantly differ on measures of suicidal ideation. It appears as though when the level of violence exposure is high, females and males react  101  the same. This may suggest that both males and females feel equally vulnerable to violence exposure. Upon comparing females' and males' mean scores for the total sample, females were found to have higher depression scores than males. Research on gender differences in depressive symptomatology has found a preponderance of female adolescents with depression (Dean & Ensel, 1982). A study examining distress symptoms after being exposed to violence (Martinez & Richters, 1993) revealed that girls reported significantly higher levels of depression than boys. When means are compared between females and males with high levels of violence exposure and low levels of social support, a trend can be seen on measures of depression. Females have greater mean scores on measures of depression than males. Had the sample sizes been greater, this trend may have approached significance. Some research has shown no gender differences present in the levels of depression and P T S D symptomatology (Mghir et al., 1995). N o gender differences were found on measures of P T S D . This may be due to differences in symptomatology between P T S D and depression. Although these types of internalizing symptomatology are highly correlated, P T S D has several unique symptoms. The D S M IV lists three primary criteria: avoidance/numbness, overarousal, and reexperiencing events. While the avoidance/numbness and overarousal criteria have symptoms which are similar to depression, the reexperiencing factor, which include intrusive memories, reliving the event and trauma-specific fears is unique to P T S D . Therefore, while the former two criteria may be more likely to be gender-specific, the latter criteria may not be. Therefore, both males and females when exposed to high levels of community violence, may be experiencing equal amounts of intrusive memories or trauma specific fears.  102 Gender Differences in Violence Exposure This study has revealed a preponderance of males witnessing moderate to high levels of violence; 57% of males and 44% of females have been exposed to moderate or high levels of community violence. While there was no differences between males and females in their endorsement of general violence, males are more likely to witness and be a part of more violent crimes. These results suggest that both males and females are exposed to large amounts of violence and have been a part of very violent situations, and agree with the majority of studies that have examined gender differences in violence exposure. A study examining the difference between inner-city and middle-class adolescents' exposure to violence (Gladstein et al., 1992) revealed that for both inner-city and middle-class youths, males were more likely to be victimized and exposed to violence. O f the total sample, 9 5 % of males and 7 5 % of females reported that they had been exposed to violence. A study examining the extent of violence exposure in youth (Fitzpatrick & Boldizar, 1993) revealed that males were victims of and witnesses to more violence than females. Richters and Martinez's project in Washington, D . C . (Richters & Martinez, 1993a) revealed that boys reported higher rates of victimization and violence exposure than girls. Males may be witnessing more violence than females due to the fact that males commonly perpetuate more violence and are more likely to be present when the violence occurs. Males are taught that it is socially acceptable to fight and are more prone than females to view aggression as a viable conflict resolution method. Male adolescents may also be allowed to stay out later than females and therefore are more prone to viewing acts of violence, which most often occurs late in the evening.  103  Limitations of Study To date, this study is the first of its kind to examine the relationship between violence exposure and internalizing symptomatology , taking into account social support, negative life events and gender differences. The measures used in the study have been found to have very good reliability and validity. A s well, compared to other studies examining the community violence exposure and internalizing symptomatology, the sample size was large. However it is important to acknowledge the limitations of this study. In conducting this study, there were several limitations which surfaced. Due to the restrictions by which the researcher was allowed to collect data, the participants in the research study as well as the teachers and schools had to be volunteers. This resulted in irregular sample sizes across schools; some schools were more willing and able to provide classes in which to conduct the study. Further, since parental permission was required, the sample may have excluded adolescents with high violence exposure and/or high symptomatology rates. Another limitation revealed while conducting this study concerns the sample sizes within specific groups. Due to the specificity of the questions selected, the data sample was diminished to include only certain cases, based upon the question or hypothesis. This resulted in using very small groups, usually between 9 and 28 participants. Had the initial sample size been larger, the groups may have in turn been greater in number, and the trends that were observed may have approached significance. It is important to note that the consent rate for the present study was moderate, at 49%. Due to the low consent rate as well as the small sample size, it is difficult to make comparisons across groups. A s well, small sample sizes are a concern in terms of statistical power; had the sample sizes been larger, the power  104  of the analyses conducted would have increased. The present study relied solely on self-reports of violence exposure, internalizing symptomatology and social support. The use of self-reports have been criticized in the past with regards to accuracy and recall of events (Martinez & Richters, 1993). Some researchers believe that the use of only self-reports when measuring types of internalizing symptomatology compromises the accuracy with which internalizing symptomatology can be diagnosed and increases the subjectivity of the response. However, research examining the effects of violence exposure have primarily employed self-report methods in order to gather information (Berton & Stabb, 1996; Shapiro et al., 1998; Singer et al., 1995). Implications for Further Research Although a start has been made in understanding the impact of violence exposure on adolescent mental health, numerous challenges remain. The results of this study have made several contributions to the emerging knowledge base on the impact of violence exposure as well as on gender differences specific to violence exposure and internalizing symptomatology, and at the same time point to several unanswered questions. One aspect of this study focused on the effects of social support on the levels of internalizing symptomatology of adolescents with moderate to high violence exposure. It would be interesting to further examine the relationship between social support, violence exposure and internalizing symptomatology with a greater number of participants, with a larger initial sample from which to draw sample groups. Due to the fact that the sample of the present study was obtained through schools and classes who volunteered to participate, a comparison was not able to be made between the  105  levels of violence exposure in inner-city schools as compared to middle or upper-class schools. Future research may want to examine the differences in the extent and impact of violence exposure taking into account the socio-economic status of the community and participants. It may be interesting to examine the role that resiliency plays within the relationship between violence exposure and internalizing symptomatology. Resiliency issues may be a factor that has yet to be examined within the relationship between violence exposure and internalizing symptomatology, and may play an important role in the impact of violence exposure. Research has shown that resiliency plays an important part in how adolescents deal with negative stresses and influences in their life (Freitas & Downey, 1998; Jew & Green, 1998). A study that examined the effectiveness of an early intervention program for at-risk youth found that training staff in risk and resiliency strategies had positive effects on risk level (Richards-Colocino, M c K e n z i e , & Newton, 1996). The present study did not include aggression and externalizing behavior as a possible outcome of violence exposure. This may have been useful, particularly for males. Research has shown that, when exposed to violence, males are prone to react with externalizing symptoms, while females are more prone to react with internalizing behaviors. Future research may want to include a measure of aggression and examine the relationship between levels of violence exposure and aggressive symptomatology for males. Future research may want to examine the extent and impact of multiple exposures to violence over time. Little research has been done examining the psychological sequelae of adolescents who have been exposed to multiple incidences of violence over a period of time.  106  It may be interesting to examine in a longitudinal study the effect of possible multiple exposures over time. Often in examining violence exposure, the focus has been on the violence itself, such as the number of assaults and weapons within the community (Shapiro et al., 1998). This "crime focused" perspective tends to dominate the view of violence, leaving the victims of violence exposure in the background. Researchers examining the phenomenon of school violence have concluded that mental health professionals, including school psychologists, have not taken a leadership role in this area (Morrison & Morrison, 1994). The stressors to which adolescents find themselves exposed are serious, which indicates a need for further research to examine the causative and predisposing factors of stress symptoms in adolescents (Berton & Stabb, 1996). The objective of the mental health professional can be two-fold: prevention and crisis intervention. B y becoming aware of the impact of violence exposure on adolescents, as well as the possible factors that may affect their response to violence exposure, mental health professionals can be better prepared to deal with school and community violence. After a crisis has occurred, an appropriate crisis intervention model based on research can be implemented so as to minimize the effect of violence exposure. The present study, along with previous research has underscored the need for the model to focus on a wider range of community influences and not solely on social support systems. This highlights the need for appropriate service delivery models to take care of both of these objectives. Results of this study support and extend the findings of previous studies demonstrating a relationship between violence exposure and internalizing symptomatology. These results give evidence of the need to identify and provide trauma-related services for  107  adolescents who have been exposed to violence. A n opportunity exists to gain further information about youth violence. A s the knowledge base regarding the impact of violence exposure expands, the opportunity exists to further increase the effectiveness of support services to adolescents and their families. Summary The present study sought to examine the extent and effect of community violence exposure in a sample of adolescents. Violence exposure was defined as witnessing acts of violence in the community. The effects of violence exposure that were measured included depressive symptomatology, traumatic stress and suicidal ideation. A l s o taken into account were social support, negative life events and gender differences. Results revealed that a larger number of adolescent females and males are exposed to violence. O f the total sample, 57% of males and 44% of females were exposed to moderate or high levels of violence. A s well, 89%) reported an occurrence of violence in their school, and over one half of the students witnessed someone being violently attacked. The present study examined the role of social support within the relationship between violence exposure and internalizing symptomatology. Specifically, males with high or moderate levels of violence exposure and high social support were hypothesized to have lower levels of internalizing symptomatology than males with high or moderate levels of violence exposure and low social support. Similarly, females with high or moderate levels of violence exposure and high social support were hypothesized to have lower levels of internalizing symptomatology than females with high or moderate levels of violence exposure and low social support. Results revealed that for males, social support did not  108 significantly affect the level of internalizing symptomatology experienced. For females, while the level of social support did not affect the levels of traumatic stress or suicidal ideation experienced, it did affect the level of depressive symptomatology. Gender differences were also examined within the relationship between social support, violence exposure and internalizing symptomatology. U p o n examining the levels of internalizing symptomatology between males and females with high or moderate levels of violence exposure and high and low social support, no significant differences were present between the groups on all measures of internalizing symptomatology. The high levels of violence exposure of adolescents in their communities and schools suggest the need for developing school and community intervention programs to treat violence and its impact on adolescent mental health. A s well, the results of this study suggest that social support may not have the previously believed buffering effect once violence exposure is high, and that the trauma of violence exposure may be so severe as to supersede the mediating effect of social support.  109 References Al-Shatti, A . (1996). 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British Journal of Clinical Psychology. 30. 131-138.  123  APPENDIX A  The University of British Columbia Department of Educational Psychology and Special Education 2125 Main Mall, Vancouver, BC V6T 1Z4 Phone: (604) 822-5263 Fax: (604) 822-3302  Informed Consent Form Exposure to Violence in Adolescents: Relationship to Psychological Distress and Social Problem-Solving  Dear Parent or Guardian: We are writing to ask permission for your youngster to take part in a research project that is being conducted at your child's school. The general focus of this study is to examine the potential negative effects that community exposure to violence may have on young people. This project is directed by Dr. William Reynolds, who is Professor of Educational Psychology and Special Education at the University of British Columbia, with Ms. Diana Misic and Ms. Erin Moors, graduate students at UBC also collaborating on this study as part of their masters thesis projects. Purpose:  The purpose of this study is to examine: (a) the extent and nature of violence exposure among adolescents in the Lower Mainland of BC and (b) the relationship between exposure to violence and psychological distress and social problem-solving ability in adolescents. Violence has become a major concern in many communities and the potential impact of exposure to violence has been shown to be a factor in the mental health of adolescents. Few studies of exposure to violence have been conducted in Canada, and there is limited information on the scope of the problem in the Lower Mainland. The current study will report on the extent to which youth are exposed to violence at school and in the community and the potential effects that this exposure may have on their mental health. In addition, we will be studying the degree to which distress in some youngsters may interfere with their social problem solving ability. What is involved?  W e plan on assessing the majority of students in the school. Youngsters who are participating in the study will be asked to fill out a set of questionnaires that will take about 45 minutes to complete and will be done in the classroom during class time. All of the questionnaires have previously been used in research or general use with adolescents in school settings and there have been no ill effects from answering the questions. The questionnaires will assess the extent to which your youngster has been exposed to violence at school and in the community, as well as what type of hassles and events are going on in your youngster's life. In addition, several questionnaires will inquire as to mental health outcomes including posttraumatic stress and anxiety, suicidal thoughts, and depression. Most youngsters find the questionnaires interesting. A group of students will be asked to complete several of the original set of questionnaires and measures of social problem solving approximately one week later. The second session will be conducted in small groups of about 5 or 6 students and take about 30 minutes. Students who do not wish to participate will be doing class work. Page 1 of 3  125 c Please complete the section below the dotted line and return the form to school with your child. Keep the top section for your records. Thank you.  Consent:  I understand that my child's participation in this study is entirely voluntary and that I as well as my youngster may refuse to participate or withdraw from the study at any time without jeopardy. I have received a copy of this consent form for my own records I give consent / I do not give consent (please circle one) for my son or daughter to participate in this study. I would like more information before giving my permission for my child to participate in this study. Please call me at . Parent or Guardian's Name  (please print)  Parent or Guardian's signature  Date  Son or Daughter's name  (please print)  Please send this form back to school With your son or daughter within the next three days. Thank you!  Consent:  I understand that my child's participation in this study is entirely voluntary and that I as well as my youngster may refuse to participate or withdraw from the study at any time without jeopardy. I have received a copy of this consent form for my own records I give consent / I do not give consent (please circle one) for my son or daughter to participate in this study. I would like more information before giving my permission for my child to participate in this study. Please call me at . Parent or Guardian's Name  (please print)  Parent or Guardian's signature Son or Daughter's name  '  Date  _ _ _ _ (please print)  Please send this form back to school with your son or daughter within the next three days. Thank you! Page 3 of 3  124  APPENDIX B  12<t A DoNotMark •  •  •  •  •  •  •  •  •  •  •  •  •  •  •  •  •  •  •  O  i  2  3  M  (r  S  7  V  •  c  l  Student Information Form This packet of questionnaires is to find out how students are feeling a n d any problems that may b e going on in their lives. You will also b e asked some questions about how you have been feeling lately. There are no right or wrong answers. Please complete the questions below a n d then answer the questions on the a t t a c h e d sheets. Answer all the questions the best that you c a n . Do Not Put Your Name Anywhere On These Pages. Sex:  •Male  Age: •  12 • •  •  Female  13 •  14  Grade: •  •  15 •  16 •  8• 17 •  9 • 18  10 •  • 19 •  11 •  12  20  Race/ Ethnicity: Who do you live with (check • Mother a n d Father • • Mother only • • Father only •  one)? Mother a n d Stepfather Father a n d Stepmother Other: (please specify): |  • •  Foster Family Other Relatives  Mother's Occupation (Job):|  Father's Occupation (Job): Do you think you are (check one): Very popular with other kids  •  Somewhat popular with other kids  •  Not very popular with other kids  •  V e r y unpopular with other kids  •  During the week, how often do you hang out with friends after school (check one)? More than 4 times a week  •  Between 2 and 4 times a week  •  About once a week  Almost never  •  Has anything bad happened to you in the past year (check one)? • If yes, please explain:  • Yes •  No  125  APPENDIX C  Office Use-Do not mark 2. a. • • • • • • • • • 1. • • • • • • • 2. b. • • • • • • • • • . C I 2 2> M S O i 2 3 *i •S t ?  • •  3. 1  • • • • • • • • • • • • • • • • • • • • C i 2 3 H ' S 6 V » - 9 veq 1.3 12/94-9/97  EVENTS QUESTIONNAIRE Please answer the following questions as best as you can. There are no right or wrong answers. If an event has not happened in the PAST YEAR check or mark NO, if it has happened check or mark Y E S .  NO  IN T H E PAST 12 MONTHS:  1. 2. 3. 4.  5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20.  Have you been in a fight? Have you been hurt in a fight? Have you been attacked? Has anyone shot at you?  Have you seen someone get shot? Have you been shot? Have you seen someone killed? Did you know someone who was killed? Do you know someone in a gang? Did you talk on the telephone? Did you belong to a gang? Have you been arrested? Did you ever see a student attacked? Has anyone in your family been attacked? Has anyone in your family been hurt and had to go to the hospital? Has anyone else you know been attacked? Have you seen a stranger being attacked? Has there been any violence in your home? Has there been any violence in your school? Has there been any violence in your neighborhood? :  21. Have there been any drive-by shootings near your home? 22. Has your home or apartment been hit by bullets? 23. Has someone said they would hurt you?  24. Has somebody said they would hurt someone in your family?  25. 27. 28. 29.  Did your parents tell you to do something you did not want to do? Have you carried a knife to school? Have you seen someone with a knife in school? Have you taken a gun to school?  30. Have you taken another weapon to school? 31. Have you seen someone use a knife in a fight?  32. Have you seen someone with a gun in school? 33. Have you seen someone use a gun?  34. Have you seen somebody shoot a gun at someone? 35. Did your parents get upset with you?  36. Have you seen someone use another weapon in a fight?  • •  •  •  • • • ma m mm  m  • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • •  YES  • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • •  co*V>™*u o*\f\e*Vpo^....  2  126  APPENDIX D  APS/REYNOLDS  ABOUT M Y S E L F QUESTIONNAIRE  Please answer the following questions as best as you can. There are no right or wrong answers. The statements ask about your behaviour or feelings in the past 6 months. Mark ( S or X) True or False as it relates to you and mark the box next to the statement that best describes you. IN THE PAST 6 MONTHS: 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14.  15. 16. 17. 18. 19. 20. 21. 22. 23. 24. 25. 26. 27. 28. 29. 30.  I argued with my teachers or parents. I lost my temper. I felt very angry. I got so mad that I threw things at home or at school. I felt mad or angry with nearly everyone. I had a hard time concentrating on what was going on around me. It was hard for me to be with people. I kept thinking about the bad thing(s) that happened. I felt depressed or sad. I felt that something bad would happen to me or people I know. I had trouble concentrating. I feel out of touch with things. It was hard for me to get to sleep at night. Once I got to sleep, I seemed to wake up a lot at night. People make me mad real easily. I get so angry that I can't control it.  FALSE  • • • • • • • •  • • • • • • • •  • • • • • •  I picked on other kids. I started fights with others. I broke or destroyed things belonging to others. I used a weapon in a fight. I physically hurt someone. I often broke the rules at home or at school. On purpose, I damaged a car, or broke windows or things in a building. I felt mad enough to hurt people. I didn't care if I hurt people. I have taken a gun or weapon to school. I set something on fire that I shouldn't have. I did something bad to someone who got me mad. Someone did something to hurt me. Something very bad happened to me or my family.  IN T H E P A S T 6 MONTHS:  TRUE  NEVER OR SOMETIMES ALMOST NEVER  • • • • • • • • • • • • • • • •  • • • • • • • • • • • • • • • •  • • • • • •  NEARLY ALL THE TIME  • • • • • • • • • • • • • • • •  Copyright © 1988, 1997 by William M . Reynolds and Psychological Assessment Resources A l l rights reserved. This form may not be reproduced In any form without permission of the author. Ptds-aps.997  5  127  APPENDIX E  37. Did someone break in or try to break into your house? 38. Did someone destroy or try to destroy something of yours? 39. Did someone steal or try to steal something or yours?  40. Did you call the police because of a problem at home or elsewhere?  • • •  • • •  •  •  Copyright © 1994,1997 by William M . Reynolds and James J. Mazza All rights reserved. This (orm may not be reproduced in any form without permission ot the authors.  Directions Listed below are some sentences about how you feel. Read each sentence and decide how often you feel this way. Decide if you feel this way: .almost never, hardly ever, sometimes, or most of the time. Check the box under the answer that best describes how you really feel. Remember, there are no right or wrong answers. Just choose the answer that tells how you usually feel. ALMOST HARDLY NEVER EVER  1. 2. 3. 4. 5. 6. 7. 8.  I feel h a p p y  I worry about s c h o o l  I feel lonely  I feel my parents don't like me I feel important  I feel like hiding from p e o p l e I feel s a d  I feel like crying 9. I feel that no o n e c a r e s about m e 10. I feel like h a v i n g fun with other s t u d e n t s  11. 12. 13. 14. 15. 16. 17. 18. 19. 20. 21. 22. 23. 24. 25. 26. 27. 28. 29. 30.  • •  I feel sick  I feel loved I feel like running a w a y  ;  I feel like hurting myself I feel that other students don't like m e I feel upset I feel life is unfair I feel tired  I feel I a m b a d I feel I a m no g o o d I feel sorry for myself I feel m a d about things I feel like talking to other students. I h a v e trouble s l e e p i n g I feel like having fun I feel worried I get s t o m a c h a c h e s . . . . I feel bored I like eating meals... I feel like nothing I do h e l p s a n y m o r e  •  •  mmm  mam mm • mmm  •  • • • • • • • • • • • • • • • • • • • • • • • • • • • • • •  • • • • • • • • • • • • • • • • • • • • • • • • •  • • • •  SOMETIMES  • • • • • • • • • • • • • • • • • • • • • • • • • . •  a  • • •  MOST OF THE TIME  • • • • • • • • • • • • • • • • • • • • • • • • • • • • • •  3  128  APPENDIX  F  mA A d a p t e d a n d reproduced by special permission of the Publisher. Psychological Assessment Resources. Inc. 16204 North Florida Avenue. Lutz. Florida. 33549. from the RADS by William M. Reynolds. Ph.D. Copyright. 1981. 1986 by Psychological Assessment Resources. Inc. Further reproduction is prohibited without permission from PAR. Inc.  Directions  Listed below are a number of sentences about thoughts that people sometimes have. Please indicate which of these thoughts you have had in the past month. Check the box under the answer that best describes your own thoughts. Be sure to fill in a square for each sentence. Remember, there are no n'ght or wrong answers.  Almost every day This thought was in my mind: 1.1 thought it would be better if I was not alive... 2.1 thought about killing myself 3.1 thought about how I would kill myself 4.1 thought about when I would kill myself 5.1 thought about people dying.... 6.1 thought about death 7.1 thought about what to write in a suicide 8.1 thought about writing a will 9.1 thought about telling people I plan to kill myself 10.1 thought about how people would feel if I killed myself 11.1 wished 1 were dead 12.1 thought that killing myself would solve my problems 13.1 thought that others would be happier if I was dead 14.1 wished that I had never been born 15.1 thought that no one cared if I lived or died.  Couple of times a week  About once a week  Couple of times a month  • • • • • • • •  • • • • • • • •  • • • • • • • •  • • • • • • • •  • • • • • • • •  • • •  • • •  • • •  • • •  •  •  •  • • •  • • •  • • •  16. Have you ever tried to kill yourself  • Yes • No  17. If yes, how many times  O 1  18. If yes, when was the last time you tried  About once a month  .. • • • •  • 2  I had this thought before but not in the past month  1 never had this thought  • • • • • • • •  • • • • • • • •  • • •  • • •  • • •  •  •  •  •  • • •  • • •  • • •  • • •  • 3  • 4 O 5 or more  less than 1 month ago  1 to 5 months ago 6 to 12 months ago More than a year ago  Adapted and reproduced by special permission of the Publisher, Psychological Assessment Resources. Inc. 16204 North Florida Avenue, Lutz, Florida, 33549. from the SIQ-JR by William M. Reynolds, Ph.D. Copyright 1987 by Psychological Assessment Resources, Inc. Further reproduction is prohibited without permission from PAR, Inc.  4  129  A P P E N D I X  G  ASI/HS Questionnaire  The following statements describe some good and some not so good things that may have HAPPENED TO YOU IN THE PAST MONTH OR TWO. Read EACH statement carefully and decide IF THE STATEMENT is TRUE or MOSTLY TRUE about you, or if it is FALSE or MOSTLY FALSE about you. BE SURE TO ANSWER EVERY ITEM. Check or mark true or false as it relates to you. REMEMBER, there are no right or wrong answers. Answer each item as things were in the past month or two, not as you wish they were. TRUE FALSE 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. 21. 22. 23. 24. 25. 26. 27. 28. 29. 30. 31. 32. 33. 34.  • 1 had friends who would be there if 1 needed them. • My grades in school got worse. • People talked about me behind my back. • My parents helped me with problems when they could. • 1 argued with a good friend. • My family cared about me. • My family had money problems. • 1 didn't have many friends. • My parents expected too much of me. • 1 had friends with whom 1 did things. • 1 missed my girlfriend or boyfriend. 1 was hassled by my parents because of things 1 wanted to •do. • 1 was bothered by how 1 looked. • 1 spent time in extracurricular activities at school. 1 didn't have enough money to buy things 1 really wanted. • • People at school excluded me in activities. • 1 had problems with my health that bothered me. • 1 wished 1 had more or different clothes. • 1 looked but could not find a good job. • A friend treated me badly. • There were people who counted on me for help. • 1 had hassles with my girlfriend or boyfriend. • My parents bothered me about my grades. 1 was pressured by others my age to do things 1 didn't • want to. • 1 did not get along with people at work. • 1 knew my parents would be there if 1 needed them. 1 didn't make a team or group 1 wanted to. • A teacher did not like me. • 1 did not do as well in school as 1 could have. • My parents made me do too much work at home. • My parents did not get along with each other. • 1 was part of a group at school. • Teachers in school cared about how 1 was doing. 1 couldn't do things 1 wanted because 1 did not have a car.•  • • • • • • • • • • • • • • • • • • • • • • •  • • • • • • • • • • • 6  35.1 did not get along with my parents. 36.1 had a good friend who 1 could spend time with. 37. My parents did not like my friends. 38.1 had friends 1 could talk to about my problems 39.1 got into hassles at school. 40. My parents treated me like a child. 41. People teased or made fun of me. 42.1 had a group of friends with whom 1 did things. 43.1 didn't get along with my brother(s) and/or sister(s). 44. People that 1 know cared about me. 45.1 felt that 1 had something to give to others. 46.1 did things at church or after school that 1 enjoyed. 47.1 got into hassles'at home.  C o p y r i g h t 1984, rights r e s e r v e d .  • • • • • • • • • • • • •  1988 b y W i l l i a m M . R e y n o l d s a n d J e n n i f e r W a l t z .  This f o r m m a y  • • • • • • • • • • • • • All  n o t b e r e p r o d u c e d in w h o l e or in p a r t w i t h o u t  written permission of the  authors.  130  A P P E N D I X  H  130 MLE/Reynolds 1982  A  eventsl  E V E N T S LIST  For each of the events listed below please check when the event occurred, or if it has not occurred. Be sure to place a (v'or X) for each event. Do not leave any items blank. If you feel an event had an especially powerful effect on you circle the number of the event(s). OCCURRED  Event  1. Mother had a severe illness or accident 2. Father had a severe illness or accident 3. Family had serious financial troubles 4. Parents were divorced 5. Parents were separated. 6. Mother was remarried 7. Father was remarried 8. Death(s) occurred in your family 9. Y o u had a severe illness or accident. 10. Y o u lost a close friend 11. You didn't get along with a new teacher 12. Y o u had a serious problem at school or with the law.... 13. You broke up with your boyfriend or girlfriend 14. A n event occurred that affected you badly 15. An event occurred that made you sad or angry and unable to study or work 16. A n event or events occurred that interfered with your life  Within past 6 months  6 mo1 yr ago  1-3 yrs ago  3-5 yrs ago  Over 5 yrs ago  Has not occurred  Do not mar  •  •  •  •  •  •  •  •  •  •  •  •  •  •  • • • • •  • • • • •  • • • • •  • • • • •  • • • • •  • • • • •  • • • • •  •  •  •  •  •  •  •  • •  • •  • •  • •  • •  • •  • •  •  •  •  •  •  •  •  •  •  •  •  •  •  •  •  •  •  •  •  •  •  •  •  •  •  •  •  •  •  •  •  •  •  •  •  •  •  •  •  •  •  • 8  

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