Risk Factors for Community Violence Exposure in Adolescence

Community violence is recognized a significant public health problem. However, only a paucity of research has examined risk factors for community violence exposure across domains relevant to adolescents or using longitudinal data. This study examined youth aggressive behavior in relation to community violence exposure among a community epidemiologically defined sample of 582 (45% female) urban adolescents. Internalizing behaviors, deviant peer affiliation, and parental monitoring were examined as moderators of the association between aggressive behavior and exposure to community violence. For males with aggressive behavior problems and deviant peer affiliation or low parental monitoring, co-occurring anxiety symptoms protected against subsequent witnessing community violence. In contrast, males with aggressive behavior problems and co-occurring depressive symptoms were at increased risk for witnessing community violence. Implications of the findings for preventive interventions and future research are discussed.     

Exposure Therapy for Posttraumatic Stress Disorder: A Meta-Analysis

This meta-analysis compares the findings of empirical studies that employ either a traditional form of cognitive–behavioral-based exposure therapy or virtual reality exposure therapy (VRET) for the treatment of posttraumatic stress disorder (PTSD) to determine which is more viable and effective. Statistical analyses were performed on 26 studies to determine pre- to posttreatment effect sizes and interactions. Results demonstrated a trend toward significance in favor of traditional exposure therapy showing lower posttreatment PTSD. Limitations included a restricted number of relevant studies; future research on VRET for PTSD should orient more to experimental designs, larger samples, and increased use of control groups.     

Childhood Exposure to Community and Domestic Violence: Prevalence,Risk Factors and Posttraumatic Outcomes in a South African Student Sample

The effects of exposure to direct and vicarious community and domestic violence on the posttraumatic adjustment of 323 South African students were examined. Data were collected using self-administered questionnaires, with the relationship between exposure to violence and posttraumatic outcomes being explored using binomial logistic regression analyses. Two hundred and sixty-two participants (81 %) reported that they had been exposed to some form of interpersonal violence during childhood. An analysis of risk factors for exposure to violence indicated that males were more than twice as likely as females to have experienced victimization by a community member. Direct exposure to domestic violence was the only form of violence which was found to be associated with Posttraumatic Stress Disorder (PTSD). Among participants who had experienced direct domestic violence, clinically significant levels of PTSD were significantly predicted by both gender (being female) and by abuse chronicity.     

Assessment and Intervention for PTSD in Children Exposed to Violence

Summary

Recent research has established that exposure to domestic violence is a major risk factor for posttraumatic stress disorder (PTSD) in children. However, one issue that has been relatively neglected in research conducted to date concerns developmental differences: both in the expression of PTSD symptoms across childhood and adolescence, and in the techniques appropriate for assessing and intervening with PTSD in children at different ages. The available literature is reviewed concerning the conceptualization, measurement, and treatment of PTSD in children, with special attention to the case of children of battered women. Guidelines are provided for developmentally sensitive approaches to assessment and treatment.     

The Role of Maternal Acceptance in the Relation Between Community Violence Exposure and Child Functioning

Children in the United States are exposed to considerable community violence that has been linked to child functioning. However, not all those exposed, experience negative outcomes. Recent research has focused on factors that “buffer” or protect children from negative consequences of violence exposure. The purpose of this investigation was to examine the potential buffering or moderating role of maternal acceptance in the relationship between community violence exposure and internalizing and externalizing problems. Subjects were 268 urban African American first graders. Community violence exposure was significantly related to symptoms of post-traumatic stress, but did not correlate with either internalizing or externalizing problems for all children, after control for demographics, maternal mental health, and general life stress. However, children's perceptions of maternal acceptance moderated the relationship between violence exposure and internalizing and externalizing problems which included being withdrawn, anxious-depressed, and demonstrating delinquent behavior. Children with the lowest levels of self-reported maternal acceptance were most impacted by community violence. In this sample of urban first graders, low levels of maternal acceptance placed children at greater risk for adverse outcomes associated with community violence exposure compared to moderate and high levels of maternal acceptance.     

Biweekly Delivery of a Group-Based Adaptation of Written Exposure Therapy (WET) for PTSD in Residential Substance Treatment

Written exposure therapy (WET) is a brief intervention for posttraumatic stress disorder (PTSD) with promising and continually emerging research support. Given its efficiency in reducing symptom severity and resolving diagnoses, there is great interest in application to novel populations and settings. The current case series focuses on application of an adaptation of WET to three individuals participating in a residential substance use disorder treatment program in a group setting. The individuals had varying substance problems and trauma histories and all showed a favorable response. The series highlights the promise of an adaptation of WET as a concurrent treatment for PTSD in residential substance use treatment. Moreover, the case series suggests that an adaptation of WET has the potential to be successfully adapted to deliver services in a group environment and delivered in 2.5 weeks, thereby demonstrating the possibility of using an adaptation of WET as a means of maximizing the utilization of scarce resources to successfully treat a large number of individuals with PTSD in a time-limited residential treatment context.     

Epidemiological Measurement of Children's and Adolescents' Exposure to Community Violence: Working with the Current State of the Science

A number of measures have been used in epidemiological studies of children's exposure to community violence, yet the quality of these instruments is not uniformly good. This paper undertakes a systematic review of the most commonly used (or most promising) self-report or interview-administered instruments, with regard to their conceptual bases and psychometric properties. Based on the review, recommendations are made for working with the current state of the science in order to move the field forward. A key recommendation is for sounder conceptualization of work in the field and greater transparency in the reporting of research, in order to facilitate the comparability of studies.     

A Preliminary Investigation of the Relationship Between Emotion Dysregulation and Partner Violence Perpetration Among Individuals with PTSD and Alcohol Dependence

This study examines the link between emotion dysregulation and intimate partner violence (IPV) among 77 individuals with posttraumatic stress disorder (PTSD) and alcohol dependence. Participants were recruited from a residential substance abuse treatment program as part of the eligibility screening for an institutional review board approved clinical trial examining the efficacy of an exposure-based intervention in individuals dually diagnosed with alcohol dependence and PTSD. Participants reported on PTSD symptoms, alcohol use disorder symptoms, emotion dysregulation, and physical and verbal aggression in their intimate relationships during the past year. Findings demonstrated that difficulties with emotion regulation are associated with physical and verbal IPV perpetration in a clinical sample. Although facets of emotion regulation emerged as significant predictors of IPV in the models, alcohol and PTSD symptom severity did not emerge as predictors of IPV. These findings suggest targeted emotion regulation skills training could benefit substance abusers who engage in IPV and that emotion dysregulation might be an important target for future research aimed at understanding elevated rates of IPV perpetration in mental health samples.     

Posttraumatic Stress Disorder and Chronic Pain Arising from Motor Vehicle Accidents: Efficacy of Interoceptive Exposure Plus Trauma-Related Exposure Therapy

Preliminary data are presented on the pattern of treatment response of combining interoceptive exposure (IE) with trauma-related exposure therapy (TRE) in five female patients with posttraumatic stress disorder (PTSD) and comorbid chronic musculoskeletal pain originating from motor vehicle accidents. Treatment consisted of four sessions of IE followed by eight sessions of TRE. Four participants reported a reduction in PTSD symptoms after completing treatment, and three no longer met diagnostic criteria for PTSD. Although both interventions were associated with reductions in PTSD symptoms, TRE was associated with greater reductions in PTSD symptoms than IE and was particularly effective at reducing avoidance. IE was associated with larger reductions in anxiety sensitivity than TRE. Pain symptoms lessened slightly during IE and then worsened following TRE. Anxiety decreased after completing treatment, whereas panic and depressive symptoms responded less so. Three individuals completed a 3-month follow-up assessment. There was no change in their PTSD diagnostic status, and all experienced a slight loss of pre–post gains, particularly involving the return of pain. Clinical and research implications are discussed.     

Comparison of Prolonged Exposure (PE) Coach to Treatment as Usual: A Case Series With Two Active Duty Soldiers

PE Coach is a mobile application (app) designed as a treatment companion to support patient and provider work during prolonged exposure (PE), a first-line treatment for posttraumatic stress disorder. Little research exists about patients’ and providers’ reactions to mobile apps in the context of psychotherapy. The present study examined PE Coach with 2 soldiers to assess usability and satisfaction with the app. Soldiers completed 8 sessions of PE and used PE Coach during 4 of those sessions. Soldiers rated the PE Coach positively and reported higher levels of satisfaction during PE with PE Coach as compared with PE alone. Authors discuss their clinical observations from using PE Coach. The soldier and provider experiences demonstrate the potential value of PE Coach in enhancing treatment engagement and support the value of future research exploring mobile computing platforms to support evidence-based treatments, in general.     

Event centrality and posttraumatic outcomes in the context of pervasive violence: a study of teachers in El Salvador

It is well established that the importance assigned to a trauma can affect one's recovery and psychological health in numerous ways. Event centrality is an increasingly popular construct that captures the tendency among survivors to reevaluate and possibly accommodate their worldviews posttrauma. The centrality given to trauma appears to serve as a “double-edged sword” in that this construct might factor prominently in both posttraumatic stress disorder (PTSD) and posttraumatic growth (PTG). Focusing on 257 violence-exposed teachers from educational departments throughout El Salvador, we examined whether the centrality assigned by the teachers to stressful life events uniquely predicted both PTSD symptomatology and PTG. Results revealed that event centrality was positively related to both PTSD and PTG, even when controlling for demographic factors, violence exposure, and depression. In addition, PTSD symptomatology and PTG were not associated with one another in this sample. In summary, these findings support the role of event centrality as a contributing factor for PTSD and PTG among persons exposed to pervasive trauma.     

Exposure Therapy Beliefs and Utilization for Treatment of PTSD: A Survey of Licensed Mental Health Providers

Exposure-based therapies for posttraumatic stress disorder (PTSD) and anxiety disorders remain underutilized, despite their effectiveness and widescale dissemination efforts. This study surveyed a broad range of licensed providers (N = 155) to examine rates at which prolonged exposure (PE) and other interventions are used to treat PTSD and to investigate provider characteristics linked to exposure beliefs and utilization. While 92.3% of clinicians reported understanding of or training in exposure, only 55.5% of providers reported use of PE to treat PTSD. Clinicians with current cognitive behavioral therapy (CBT) orientation, CBT training orientation, a doctoral degree, and training in PE endorsed greater likelihood of exposure utilization for PTSD (ps < .001, ds = 0.82–1.98) and less negative beliefs about exposure (ps < .01, ds = 0.55–2.00). Exposure beliefs also differed based on healthcare setting (p < .001). Among providers trained in exposure (n = 106), master’s degree and non-CBT current theoretical orientation were associated with high utilization yet also negative beliefs. Results suggest exposure training, accurate beliefs, and utilization still lag among some groups of providers. Additionally, negative beliefs and misunderstanding of the exposure rationale may persist even among providers who are trained and report high utilization.     

Prevalence of Child and Adolescent Exposure to Community Violence

Emerging as one of the most significant health issues facing American youth today, child and adolescent exposure to community violence has generated much interest across multiple disciplines. Most research to date has focused on documenting the prevalence of community violence and the emotional and behavioral ramifications. This paper provides an overview of the current literature regarding prevalence of youth exposure to community violence, and identifies those areas where further research is warranted. In addition to examining overall rates of community violence exposure, this paper reviews the prevalence of different types of community violence, such as weapon use, physical aggression, and crime-related events. Predictors of community violence exposure, including gender, age, race, socioeconomic status, behavior patterns, and geography, are discussed.     

Conducting Prolonged Exposure for PTSD During the COVID-19 Pandemic: Considerations for Treatment

The unprecedented effects and duration of the COVID-19 crisis are likely to elevate the population’s level of anxiety due to psychological stress, economic hardship, and social isolation. This effect may be especially potent for individuals with preexisting mental health conditions, such as posttraumatic stress disorder (PTSD). Prolonged Exposure (PE) therapy is a highly effective treatment for PTSD across trauma-exposed populations, and has been implemented effectively via telehealth. Nevertheless, PE implementation via telehealth may require specific adaptations during the COVID-19 crisis due to public health mandates calling for sheltering in place and physical distancing. This paper discusses strategies for implementing PE for PTSD during the COVID-19 pandemic, which may also be applied to other situations in which physical distancing must be considered.     

Violence Exposure and Early Adolescent Alcohol Use: An Exploratory Study of Family Risk and Protective Factors

In this short-term longitudinal exploratory interview study, the relations between exposure to community violence and subsequent alcohol use were examined, with a focus on caregiver and family variables as moderators. Maternal caregivers and their children (N =101 families; 98% African American; M child age = 11.2 yrs) were interviewed separately and completed measures of violence exposure, caregiver and child adjustment, including substance use, and family functioning. Family interaction was also videotaped and coded. Child alcohol use at Time 2 was positively associated with all forms of violence exposure, and was negatively related to felt acceptance from caregiver, but was not associated with caregiver-rated family competence, observer-rated family interaction, maternal problems with alcohol, or maternal psychopathology. Logistic regression analyses predicting child alcohol use at Time 2 indicated that exposure to community violence increased risk of alcohol use, and felt acceptance from the caregiver decreased the likelihood of alcohol use, but did not buffer the effects of violence exposure on alcohol use. Implications and future directions are discussed.     

Feasibility and Acceptability of Group-Facilitated Prolonged Exposure Therapy for PTSD in VA Residential Rehabilitation Treatment Programs

Prolonged Exposure therapy (PE) is a first-line treatment for posttraumatic stress disorder (PTSD); however, few VA patients receive this treatment. One of the barriers to PE receipt is that it is only available in an individual (one-on-one) format, whereas many VA mental health clinics provide the majority of their psychotherapy services in group format. In particular, PTSD residential rehabilitation treatment programs (RRTPs) offer most programming in group format. Consequently, strategies are needed to improve the scalability of PE by adapting it to fit the delivery setting. The current study was designed to pilot test a group-facilitated format of PE in RRTPs. Thirty-nine Veterans who were engaged in care in the PTSD RRTP at a Midwestern VA were recruited to participate in a Group-facilitated PE protocol. Participants engaged in twelve 90-minute sessions of Group PE over the course of 6 weeks, plus six 60-minute individual sessions for imaginal exposure. Group treatment followed the PE model and consisted of psychoeducation, treatment rationale, and in vivo exposure to reduce trauma-related avoidance and thereby improve PTSD symptoms. PTSD symptoms were measured via the PTSD Checklist for DSM-5 (PCL-5) and depression symptoms were measured via the Patient Health Questionnaire (PHQ-9) at baseline, endpoint (6 weeks), and at 2-month follow-up. Thirty-nine individuals initiated Group-facilitated PE and 34 completed treatment. The average number of group sessions attended was 11 out of 12. Acceptability ratings were high. Mean change (improvement) in the intent-to-treat sample at 2-month follow-up was 20.0 points on the PCL-5 (CI 18.1, 21.9; Cohen’s d = 1.1) and 4.8 points on the PHQ-9 (CI 4.1, 5.5, d = .8). These results suggest that adapted evidence-based interventions for PTSD can improve treatment access and efficiency for the RRTP setting. A group-based approach has the potential to improve the scalability of PTSD treatment by reducing required resources. A fully powered trial is now needed to test the effectiveness of Group-facilitated PE in the RRTP setting.     

Patterns of Community Violence Exposure During Adolescence

This study examined cross-sectional and longitudinal patterns of community violence exposure and malleable predictors of these exposure patterns among a community sample of 543 urban African American early adolescents (45.3% female; mean age: 11.76). In each of grades 6, 7, and 8, latent class analyses revealed two patterns of community violence exposure: high exposure and low exposure. For the majority of participants, experiences with community violence were similar at each grade. Impulsive behavior and depressive symptoms distinguished adolescents in the high and low exposure classes in grade 6. Implications for interventions to prevent community violence exposure are discussed.     

Posttraumatic Stress Disorder and Associated Functional Impairments During Pregnancy: Some Consequences of Violence Against Women

Despite the high prevalence of violence in the lives of women of reproductive age, and the adverse consequences posed to pregnant women suffering from PTSD, few studies have examined violence-related trauma and PTSD among pregnant women. A structured research interview was administered to a convenience sample of 85 prenatal care women to collect information regarding their experiences of violence victimization, PTSD symptoms related to violence-related traumatic events, and whether these symptoms impaired various aspects of the women's daily functioning. Results indicated that 69% of the women experienced a violent traumatic event, with the majority of events occurring before the current pregnancy and being perpetrated by the women's intimate partners. The traumatized women evidenced high levels of PTSD symptoms during pregnancy, with 58% of the women meeting criteria for a PTSD diagnosis. Moreover, many of the women with PTSD symptoms reported that the symptoms adversely affected aspects of their daily functioning.