L Oriana Linares Nicole A Morin

INTRODUCTION

Exposure to community violence was first identified in the early 1990s as a problem of epidemic proportion in the United States affecting the lives of a substantial number of children and youth (USDHHS/PHS, 1992). Although serious violent crime against youth has decreased in major U.S. cities during the past decade (Brener, Simon, Krug, & Lowry, 1999), a substantial number of families with limited resources continue to live in inner city neighborhoods characterized by high levels of violence, crime, and drug activity (Hill & Jones, 1997). In particular, children from ethnic minority backgrounds, such as African American and Latino, are disproportionately represented in neighborhoods with high levels of poverty, substance use, and local crime. They are at a considerably higher risk of developmental harm related to their socially toxic environment than children from nonethnic minority backgrounds, particularly those of higher socio-economic status (SES; Randolph, Koblinsky, & Roberts, 1996). Due to this tremendous public health burden, it is crucial to understand the impact of community violence, early in development, on ethnic minority children of low SES background. Such knowledge is necessary to inform effective and ecologically sound prevention and treatment interventions for this vulnerable population.

In this chapter we describe results from our Boston Community Violence Project (BCVP) which targeted African American and Latino mothers and their preschool children residing in high-crime neighborhoods and examine the contribution of exposure to community violence, a relatively less known psychosocial risk factor, on the problematic internalizing and externalizing behavior of 3-5-year-old children. We report results of the Parenting Study, which uses the sample in the BCVP, to test a multidimensional psychosocial model of the impact of community violence with special attention to the role of parenting behavior as observed during a mother-child interaction compliance task. To end, we discuss findings of the effects of community violence on preschool development from a prevention-intervention perspective.

PREVALENCE AND PSYCHOLOGICAL CONSEQUENCES OF EXPOSURE TO COMMUNITY VIOLENCE

Based on the community violence studies of the early 1990s, between 44-82% of school-aged children and youth are exposed to community violence, depending on definitional criteria, methodology, and sample characteristics (Overstreet, 2000; Stein, Jaycox, Kataoka, Rhodes, & Vestal, 2003). According to the early studies, by the end of elementary school, almost all children residing in high crime innercity areas of Washington and New Orleans had heard (98%) or witnessed (90%) moderate to severe levels of violent occurrences (Richters & Martinez, 1993; Osofsky, Wewers, Hann, & Fick, 1993). School-aged children exposed to community violence are at risk for an array of problematic behavior including: lower self-competence (Farver, Ghosh, & Garcia, 2000), high levels of distress (Martinez & Richters, 1993), depression (Durant, Getts, Cadenhead, Emans, & Woods, 1995), post-traumatic stress disorder (Fitzpatrick & Boldizar, 1993; Jaycox, Stein, Kataoka, Wong, Fink, Escudero, & Zaragoza, 2002), increased aggression (Gorman-Smith & Tolan, 1998), anxiety/depression (Cooley-Quille, Boyd, Frantz, & Walsh, 2001), and antisocial behavior (Miller, Wasserman, Neugebauer, GormanSmith, & Kamboukos, 1999). Exposure to acts of community violence is highly predictive of aggressive cognitions and behavior among younger (Grade 1-3) and older (Grade 4-5) children (Guerra, Huesmann, & Spindler, 2003). In addition, exposure to neighborhood and school danger contribute between 5-16% of the variance in the prediction of school attendance, behavior, and grades (Bowen & Bowen, 1999). Lynch and Cicchetti (1998; 2002) found that exposure to acts of community violence, via witnessing or direct victimization, was related to lowered self-esteem, higher levels of separation anxiety, and less secured feelings of relatedness with their caregivers. Researchers have also identified mediating and moderating influences in the linkage between exposure to community violence and child development involving child-, and family-level factors. For example, Colder and associates (Colder, Mott, Levy, & Flay, 2000), found that a child's positive beliefs about aggression mediated, in part, the relationship between perceived neighborhood danger and childhood aggression. Using a structural modeling methodology, in a study of 732 predominantly African American fifth graders, Colder found direct and indirect effects in that perceived neighborhood danger was associated with positive beliefs about aggression, which in turn was associated with child aggression. There are also moderating familial influences of the impact of community violence on child behavior. For example, Miller and colleagues (Miller et al., 1999) found that family conflict moderated the effect of witnessed community violence on changes in antisocial behavior among 6-10-year-old boys. She found that in families with low levels of parent-child conflict, higher levels of witnessing community violence predicted increases in antisocial behavior over time. Family cohesion is another important moderator in the linkage between exposure to community violence and child outcome. Plybon & Kliewer (2001) showed that high levels of family support ameliorated the effects of living in a violent neighborhood, and resulted in fewer externalizing behavior problems among 8-12-year-old children. Taken together, these findings suggest that the consequences of exposure to community violence among school-aged children are far-reaching and involve an array of psychological, social, and academic problems, but can be mediated or attenuated by factors such as child positive social cognitions about violence, low level of family conflict, and high family support.

Shifting the Focus to the Preschool Years

In the preschool years, between the ages of 3-5, young children venture into the public spheres of their neighborhoods by becoming engaged in various social activities outside of their homes. Preschool children may attend a playgroup or a preschool program, play in public playgrounds, stay outdoors for longer periods of time, and visit community areas often accompanied by their mother or an older sibling. As compared to toddlers, increased mobility and higher levels of cognitive competence (Cicchetti, 1989) may afford young children a greater exposure to social events in the neighborhood, and a greater ability to explore the outside world. It is through this normative socialization process that preschool children develop a capacity to form and maintain cognitive "social maps," a concept described by Garbarino (1999) as "representations of the world" which emerge to give meaning to the social and interpersonal environment of the child, e.g., what or who is dangerous, who to turn to for protection, or who to trust in unsafe circumstances. The types of social constructions (e.g., whether maps are benign or hostile) are shaped by the child's immediate social experiences.

Consistent with their experiential world, preschool children who witness or experience routine acts of violence in chronically dangerous neighborhoods (Taylor, Zuckerman, Harik, & Groves, 1994; Farver, Natera, & Frosch, 1999) are likely to form distorted social maps, reflecting an unpredictable, unsafe, or dangerous world. Although there is no empirical research on the emergence of social maps during the preschool years, the concept is consistent with a social cognitive perspective for the emergence of aggressive behavior. According to social information processing (SIP) theory (Dodge, Pettit, Bates, & Valente, 1995), children who are exposed to aggressive models learn to anticipate a hostile world around them because they have developed 'social maps' consistent with their experiences. When trauma-exposed children encounter an interpersonal transgression (i.e., a child bumping into somebody else in the hallway; a child taking the chair of another child in the lunchroom), in which the intent of the perpetrator is unclear (intentional vs. unintentional harm), victimized children are more likely to retaliate because they read in others an intention to harm, as compared to their non-victimized counterparts. The findings from SIP theory are consistent with Garbarino's notion that victimized children are at risk of creating a hostile cognitive social map of interpersonal relationships based on their prior violence-related experiences; these hostile social maps lead to distorted attributions under conditions of uncertainty; which eventually result in child's aggressive behavior. Most recently Guerra and colleagues (Guerra, Huesmann, & Spindler, 2003), provided support for the mediational role of aggressive social cognitions, over time, on the relation between community violence and subsequent aggression.

Although exposure to community violence has been known to have serious psychological and behavioral consequences for school-age children (Garbarino, Dubrow, Kostelny, & Pardo, 1992), only recently has attention shifted downward to the preschool years (Lynch, 2003). This historical omission has jeopardized our understanding of the conditions under which trauma-related exposure may first appear; the processes by which exposure produces developmental harm in some preschool children but not in others; and how the presence of individual, family, and contextual factors mediate exposure on the developing child. The handful of existing studies focusing on preschool children suggest that community violence exposure rates are close in proportion to that of school-age children, dissipating the notion that young children are protected from exposure due to their age. In one of the first studies with preschoolers, Taylor and colleagues (Taylor et al., 1994) interviewed 115 parents of 1- to 5-year-old children receiving pediatric care at Boston Medical Center. Mothers of these preschool children reported that 1 out of10 children had witnessed, by the time they were 6 years old, a knifing or a shooting; 18% had witnessed shoving, kicking, or punching; and 47% had heard gunshots. In this study, however, the distinction between types of child exposure, i.e., community versus family violence, was not made so that above exposure rates may reflect exposure to one or both types.

In a more recent study of 64 preschoolers attending a Head Start program in California, Farver et al. (1999) reported that at least 50% of mothers reported hearing gunshots in their homes, and more than 60% reported witnessing drug deals, and arrests. In this study though, the children's exposure to community violence was not assessed. Additionally, in a small sample of 31 Latina mothers and their children (ages 4-5) attending a Head Start program in Los Angeles, Aisenberg (2001) reported that 26% of children were direct victims of violence and 45% witnessed violence, in their lifetime. Based on maternal reports of children's exposure to community violence, 71% heard gunshots near the home and 32% witnessed a beating. Finally, Shahinfar and colleagues (Shahinfar, Fox & Leavitt, 2000) studied 155 parents and their preschool children attending a Head Start program near Washington, DC. Using a cartoon-based self-report assessment of exposure to violence (VEX scale; Fox & Leavitt, 1995), they found that 78% of children and 67% of parents reported children's exposure (witnessing or experiencing) to at least one incident of violence during the summer when the evaluation took place. In this study, once again, there was no distinction between type of exposure, with rates reflecting exposure to either community or family violence. Furthermore, results may be questionable given that 53% of the children did not complete the self-report VEX scale due to test comprehension problems or an unwillingness to respond. The difficulty in obtaining self-reports from the preschoolers themselves underscores the challenge of gathering reliable exposure ratings at this developmental period.

EXPOSURE AND PRESCHOOL DEVELOPMENT

Mirroring the broad psychological consequences on the development of school-aged children exposed to acts of community violence, mothers of preschoolers report child distress-related problems in various functioning domains including internalizing behavior problems (i.e., anxiety and depression), externalizing behavior problems (i.e., aggression), and trauma-specific PTSD symptoms. In the Shahinfar et al., study (2000) of Head Start preschoolers exposed to interpersonal violence, CBCL internalizing (mean = 5.3 vs. 3.5) and externalizing (mean = 13.2 vs. 9.6) behavior symptoms were more likely in children who witnessed violence than in those who did not. These results are difficult to interpret, however, once again because of the lack of distinction between types of violence exposure (i.e., community violence and family violence). Finally, the Aisenberg study (2001) of a small sample of 31 Latina mothers and their children found that children exposed to acts of community violence obtained significantly higher T-scores for both CBCL internalizing (m = 54) and externalizing (m = 55) behavior problems, as compared with children in the normative sample (m = 50). Boys scored consistently higher than girls on both scales as well, suggesting male gender vulnerability for preschoolers following exposure to acts of community violence.

Preschool children are also at risk for developing symptoms related to Posttraumatic Stress Disorder (PTSD). According to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV, 1995), cardinal trauma-related PTSD symptoms include re-experiencing of the traumatic event, persistent avoidance of stimuli associated with the trauma, and symptoms of increased arousal (APA, 2000). In the Boston Community Violence Project, mothers of preschool children reported PTSD cardinal symptoms at a high frequency (Linares & Cloitre, 2004). For example, we found high rates of maternal endorsement of child PTSD symptoms for: re-experiencing (54%) new fears (82%), avoidance (53%), and hyper arousal (92%). Only re-experiencing symptoms during disregulated play, however, were related to exposure to community violence. Mothers with partial PTSD reported more re-experiencing symptoms as well as disregulated free play in their children than mothers with no PTSD (p < .05). These results supported the clinical use of observational methods using an alternative set of criteria for PTSD for preschool children as proposed by Scheeringa and colleagues (Scheeringa, Peebles, Cook, & Zeanah, 2001; Scheeringa, Zeanah, Myers, & Putnam, 2003). Our findings warned us against imposing a strict definition of PTSD based on DSM criteria developed for adults and older children to the diagnosis of preschool PTSD, without considering the unique developmental characteristics of this age period. For example, given that hyper arousal and transitional fears are very common during early childhood, caution is needed in interpreting symptom elevation in these domains as clinically important. Findings from our PTSD study underscore the need to attend to developmental level to differentiate clinically significant trauma-related PTSD symptoms from normative behaviors commonly seen during the preschool period.

The Boston Community Violence Project

Despite extensive research on the influence of multiple psychosocial risk factors on problem behavior (Forehand, Biggar, & Kotchick, 1998; Atzaba-Poria, Pike, & Deater-Deckard, 2004), community violence has been treated generally as an isolated risk variable, and seldom has been examined within a multidimensional, additive, fashion. It is likely that the preschooler's experience of community violence is not only determined by the levels and the characteristics of the exposure, and the child's understanding of the events, but also by contextual factors surrounding the child such as family relationships, maternal functioning, and parenting. The Boston Community Violence Project was designed to examine community violence within a larger psychosocial web of contextual influences. Little is known about whether exposure to community violence has a unique effect on child behavior problems, separately and beyond and above related risk factors. It is likely that multiple psychosocial stressors have an equal or higher detrimental impact on preschool internalizing and externalizing behavior problems among multiply disadvantaged preschoolers. The Boston Community Violence Project is a research project informed by ecological theory (Bronfenbrenner, 1979) that considers the child as a part of a larger ecological system of psychosocial influences (i.e., the mother-child system, the family, the neighborhood), and by an ecological-transactional perspective, which states that levels of the ecology interact on each other (Cicchetti & Lynch, 1993; 1995). In our multidimensional risk model of preschool problems we examined the influence of exposure to community violence after considering three sets of factors: demographic characteristics (maternal education, maternal immigrant status, and child age), exposure to family violence (partner violence to mother and to child), and maternal functioning (physical health, global distress, and the quality of parenting) In addition to focusing on the impact of exposure to community violence (e.g., frequency, type, and relationship to perpetrator) on preschool problems, by either witnessing or experiencing, we examined whether these effects were independent of other known risk factors affecting young children living in high crime neighborhoods, namely low maternal education, immigrant status, child older age, exposure to family violence, maternal distress, and quality of parenting.

Researchers who construct models of risk for child problems have stressed the need to attend to social class and ethnic background when studying minority children residing in the inner city (Gorman-Smith, Tolan, Zelli, & Huesmann, 1996). Lower maternal education, immigrant status, and older child age are selected because they may negatively impact on preschool outcomes. Lower maternal education increases the risk for child behavior problems among African American school children (Horn, Cheng, & Joseph, 2004). Immigration may be a source of stress for children and parents alike; older preschoolers are likely to have more behavior problems than younger preschoolers (even in a restricted range of ages 3-5). Earlier studies of community violence with school-aged children suggest that trauma-related symptoms vary by demographic and family characteristics. For example, Richters and Martinez (1993) found children of less educated mothers, living in unstable homes, experienced higher levels of distress than those of higher SES and more stable homes.

The Sample

Beginning in 1996, with funds from the National Institutes of Health (R01DA/MH11157), we began a series of maternal interviews with residents of selected inner city neighborhoods in Boston. We selected five urban contiguous residential zip codes with the highest crime police district rates (twice the citywide rate) for seven serious crimes (homicide, rape, robbery, simple assault, aggravated assault, burglary, and larceny) for the 5 years prior to the outset of the study (1991-1995) from which to draw a high-risk community sample of preschool children and their mothers. Residential zip codes corresponded to geographically contiguous census tracts with high concentration of ethnic minority residents, female-headed households, adolescent pregnancy, and school dropout rates, according to U.S. census data for 1990. The sampling strategy was aimed at over sampling dyads exposed to high levels of community violence; however, reported neighborhood crime varied widely due to the large geographic areas contained in zip codes demarcations (about 32,000 residents).

The original sample included 160 dyads and children were selected using a two step screening process described in detail elsewhere (Linares et al., 1999; Linares et al., 2001). Briefly, in level 1 screening, a consecutive sample of 689 children was identified from all current pediatric patients in a teaching city hospital who: (a) were between the ages of 3.0 and 5.11 years; and (b) resided in the preselected target neighborhoods. In level 2 screening, 89% of level 1 subjects were approached (via the telephone or an announced home visit) to determine willingness to participate and further assess study eligibility criteria. Due to the focus on the effects of community violence, stringent entry criteria were imposed to screen out mothers or children at high risk for adverse psychological outcomes due to other environmental or psychosocial stressors such as teenage parenting; children living in foster homes or shelters; residential instability; or medical disability. Level 2 screening resulted in a subject inclusion rate of 23%. Excluded mothers included those: (a) who were 18 years old or younger; (b) who resided in target address less than past 9/12 months; (c) who resided in shelters or other residential housing arrangement; (d) who were recipients of Social Supplement Income (SSI) due to a medical disability, such as a mental illness, mental retardation, or a chronic physical illness; and (e) who were not the child's primary caregiver. In addition, due to the linguistic limitations of the research team, mothers who did not speak English or Spanish were excluded. We excluded preschoolers with chronic medical problems, who were hospitalized for over two weeks in the last year, who had an identified developmental delay, genetic disability, prematurity (below 32 gestational weeks), serious birth complications, or who were SSI recipients. Refusal rate was 20%.

THE MULTIDIMENSIONAL ASSESSMENT OF EXPOSURE TO COMMUNITY VIOLENCE

We used a multidimensional perspective to the assessment of community violence involving exposure to particular (episodic) violent events by mother and her preschool child together (co-witnessing), as well as exposure to enduring (chronic) violence-related features that dyads routinely experience in their neighborhood. Our episodic co-witnessing measure, adapted from the work of Richters & Martinez (1993) refers to the frequency of the child co-witnessing events in the neighborhood, such as a police arrest, a serious violence-related accident, weapon possession, a threat of physical harm, physical assault, murder, or a dead body. We found that 81% of mothers and 42% of children witnessed at least one violent event in the past year; 21% of children saw three or more events, and 12% saw eight or more events. Events witnessed included a police arrest (31%), a serious accident (12%), a threat (11%), a beating (7%), or a gang chase (7%). Less than 5% of cases involved witnessing a weapon possession, a shooting, a mugging, a dead body, or a murder.

In addition to exposure to episodic co-witnessing of violent events in the neighborhood, we measured physical and structural aspects of the neighborhood that impact on the quality of life of residents. According to social disorganization theory (Shaw & McKay, 1972; Taylor, 1996; Perkins & Taylor, 1996), perceptions of social decay and disorder in the neighborhood (such as dilapidated or vacant housing, broken glass, or uncollected trash), although not violent criminal acts per se, erode the social fabric of neighborhood life. These negative characteristics decrease social order, increase fear of crime, and threaten the safety of local residents as much as violent crime events do (Taylor, 1996; Skogan, 1990; Bursik & Grasmick 1993; LaGrange, Ferraro, & Supancic, 1992, Perkins & Taylor, 1996). Maternal reports of perceived local crime, social disorder and decay, and fear of crime are a proxy of the level of fear and violence that families routinely experience in their neighborhoods. This measure, referred to as chronic community violence is used in the Parenting Study, the focus of this chapter. We found that the proportion of mothers who reported perceived local crime often or some of the time was 26%, ranging from hearing sounds of gunshots (39%) to witnessing a sexual assault (9%). The proportion of mothers who perceived social disorder as a big problem or somewhat of a problem was 47%, ranging from seeing broken glass or trash (70%) to seeing excessive use of police force (33%). The proportion of mothers who experienced fear of crime often or some of the time was 23%, ranging from feeling afraid for their child's safety (57%) to hiding away from others (9%).

The Contribution of Family Violence

There is also ample evidence that exposure to family violence (partner violence directed against the mother or the child) is associated with child internalizing behavior problems such as depression, post-traumatic stress symptomatology, and increased externalizing behavior problems, such as aggression and noncompliance (Fantuzzo, DePaola, Lambert, Martino, Anderson, & Sutton, 1991; Holden &

Ritchie, 1991; Osofsky et al., 1993; Jaffe, Wolfe, Wilson, & Zak, 1986; McCloskey, Figueredo, & Koss, 1995; Jouriles, Murphy, & O'Leary, 1989; Crockenberg & Covey, 1991). For example, in nonclinical samples, preschool children exposed to marital discord showed more externalizing behavior problems, including aggression and noncompliance (Crockenberg & Covey, 1991). A recent meta analysis examining 118 studies of children exposed to interparental violence indicate a low-to-moderate effect size (d = -.29) on child problems (Kitzmann, Gaylord, Holt, & Kenny, 2003), with greater exposure risk shown among preschoolers.

A critical methodological issue in the study of community violence is to distinguish types of violence exposure in multiply exposed dyads. Different types of victimization are often present in the same families (Margolin & Gordis, 2000). For example, 40% of mothers in our original sample reported lifetime exposure to family violence (i.e., intimate partner violence) in which the perpetrator in 80% of the cases was the partner or ex-partner (Linares, Groves, Greenberg, Bronfman, Augustyn, & Zuckerman, 1999), as measured by the Conflict Tactics Scale. In studies of community violence it is important to distinguish the effects of community violence from that of exposure to family violence because the psychological effects for children and mediating/moderating influences are similar across types of interpersonal violence. For example, family variables such as parental stress (Plybon & Kliewer, 2001) and parental attachment and monitoring (Formoso, Gonzales, & Aiken, 2000) moderate the relationship between family conflict and conduct problems. These same factors are important in community violence studies. Taking into account overlapping violence exposure, we considered exposure to family violence when examining the impact of exposure to community violence, so that we do not erroneously attribute to community violence effects that are related to family violence.

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