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Triple threat: Community violence as a predictor for post traumatic stress disorder and the associated features of drug use and depressive symptoms among Latino youth

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Triple threat: Community violence as a predictor for post traumatic stress disorder and the associated features of drug use and depressive symptoms among Latino youth

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Content TRIPLE THREAT: COMMUNITY VIOLENCE AS A PREDICTOR FOR
POST TRAUMATIC STRESS DISORDER AND THE ASSOCIATED
FEATURES OF DRUG USE AND DEPRESSIVE SYMPTOMS
AMONG LATINO YOUTH
by
Mona Devich-Navarro
A Thesis is Presented to the
FACULTY OF THE GRADUATE SCHOOL
UNIVERSITY OF SOUTHERN CALIFORNIA
in Partial Fulfillment of the
Requirements for the Degree
MASTER OF ARTS
(PSYCHOLOGY)
MAY 1999
Copyright 1999 Mona Devich-Navarro
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UMI Number: 1417209
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UNIVERSITY O F SO UTHERN CALIFORNIA
TH E GRADUATE SC H O O L
U N IV ERSITY PARK
LOS A N G ELES. C A LIFO R N IA 8 0 0 0 7
This thesis, written by
Mona Deyich-Navarro_____________
under the direction of h hsX.Thesis Com m ittee,
and a p p ro ved by all its m em bers, has been p re
sented to and accepted by the D ean of The
G raduate School, in partial fulfillm ent of the
requirem ents fo r the degree of
Mayt' ery f Arts Psychology
D a te —
THESIS COMMITTEE
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3
Triple Threat: Community Violence as a Predictor for Post Traumatic Stress Disorder
and the associated features of Drug Use/Abuse and Depressive Symptoms
Among Latino Youth
This was an exploratory study investigating violence exposure as a predictor of
Post Traumatic Stress Disorder (PTSD), and the associated features of drug use/abuse and
depressive symptoms among Latino adolescents. The literature addressing the co
occurrence of PTSD and depressive symptoms (e.g., Hubbard, Rualmuto, Northwood, &
Masten, 1995), or PTSD and drug use (e.g., Hyer, Leach, Boudewyns & Davis, 1991) is
extensive. However, research specifically addressing the co-occurrence of PTSD, drug
use and depressive symptoms among adolescents has been sparse and mainly theoretical
(Falsetti & Resnick, 1995; Hanson, Kilpatrick, Falsetti & Resnick, 1995; Riggs, Baker,
Mikulich & Young, 1995; Terr, 1991). In addition, this constellation of symptoms has not
been directly examined among high risk Latino adolescents.
The primary aim of the study was to examine the association between violence
exposure (several events or extremely distressing events) with PTSD, and explore if
depressive symptoms and drug use mediated the relationship. In addition, this study
focused on within group differences versus between group differences. Specifically, this
study explored the relationship across two groups of Latino adolescents: 1) those
currently enrolled in high school; and 2) those who were unable to stay in high school
because they are involved with gangs or some type of criminal activity which placed them
on probation and enrolled in an alternative school program. The analysis examined group
differences in rates of violence exposure and whether these different rates were associated
with PTSD and the associated features of drug use and depressive symptoms. Therefore,
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the study’s goals were as follows: 1) differences in prevalence rates for violence exposure
and drug use between students in a high school and those in an alternative program; 2) the
association between violence exposure and PTSD and the associated features of drug use
and depressive symptoms; and 3) whether drug use and depressive symptoms mediated
the relationship between violence exposure and PTSD.
Background and Significance
This section will briefly review four topics that address the relationship between
violence exposure and PTSD among Latino adolescents. First, research will be presented
discussing the prevalence of chronic exposure to violence among children /adolescents.
Second, the evolving definition of PTSD as it relates to developmental factors and
ethnicity among children/adolescents will be addressed. Third, how youth express their
emotional distress by engaging in aggressive or gang behavior is discussed. Finally, drug
use and depressive symptoms will be considered as co-occurring factors related to PTSD.
Prevalence of Violence Exposure for Children and Adolescents.
Chronic violence characterizes the day to day reality of urban youth. Children are
victimized more often than adults (Bureau of Justice Statistics, 1991). For adolescents
between the ages of 12-19, rates of assault, rape and robbery are two to three times higher
than for adults (Bureau of Justice Statistics, 1991). The National Center for Health
Statistics (NCHS) (1993) identified homicides as the second leading cause of death among
children and adolescents. The National Center for Juvenile Justice (NCJJ) projects an
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increase in the prevalence rates for violent crime among adolescents (as cited in American
Psychological Association, 1998).
Community and domestic violence have transformed urban settings into war zones
(Garbarino, 1991) and its children into traumatized victims (Berman, Kurtines, Silverman,
& Serafini, 1996; Hill & Madhere, 1995; Martinez & Richters, 1993; Pynoos & Nader,
1991; Shakoor & Chalmers, 1991; Schubiner, Scott, & Tzelepis, 1993). For example,
Schubiner et al. (1993) surveyed 246 predominantly urban adolescents and reported 42%
of their sample had seen someone shot or knifed, 22% had seen someone killed, and 18%
reported carrying a gun in their community. In addition, Shakoor (1991) found that, of
433 adolescents between that ages of 13 to 16, 75% of the boys and 70% of girls
indicated that they had seen someone shot, stabbed, robbed, or killed. The prevalence of
urban violence has lead researchers to view it as a “public health epidemic” (Hammond &
Yung, 1993; Spivak, Hausman & Pro throw, 1989) and exposure to violence early in life
can lead to severe psychopathology in adulthood (Schwarz & Perry, 1994).
Being exposed to violence at an early age can be psychologically and emotionally
debilitating for children, especially if they are exposed to several violent acts (Fitzpatrick
& Boldizar, 1993; Garbarino, 1995; Jenkins & Bell, 1994; Osofsky, 1995; Richters &
Martinez, 1993; Weaver & Clum, 1995). Researchers have found that being exposed to
multiple stressors, versus only one stressor, was related to the development of emotional
and behavioral problems among children (Rutter, 1989; Seifer & Sameroff, 1987).
Therefore, being exposed to domestic/community violence, gang involvement, chronic
fear of one’s personal safety, as well as the other urban stressors may collectively render
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children psychologically vulnerable to psychological problems. Furthermore, some of
these stressors may alter family functioning, as well as, affect the child (Fitzpatrick &
Boldizar, 1993; Gorman-Smith & Tolan, 1998; Richters & Martinez, 1993; Osofsky,
Wewers, Hann, & Flick, 1993). For example, Osofsky et al. (1993) found a significant
association between family conflict and being exposed to community violence. Gorman-
Smith & Tolan (1998) found that violence exposure was related to parenting practices and
the use of discipline.
Another reason for children’s psychological vulnerability to violence exposure is
that their threshold for experiencing traumatic stress is lower than adults (Doyle, 1989;
Pynoos, 1990). Levels of distress needed to produce Post-Traumatic Stress Disorder
(PTSD) can be less severe for children. Fletcher (1994) conducted a meta-analysis of
2,695 children exposed to traumatic events (as cited in Fletcher, 1996) and found 36% of
the sample diagnosed with PTSD, and in another meta-analysis focused on adults
(Fletcher, 1996), on average 24% of the adults traumatized later in life were found to be
suffering from PTSD.
Inner-city youth diagnosed with PTSD have been exposed to several types of
extreme violence such as a sibling or parental murder, street homicides due to drug
activity, drive-by shootings and other gunfire, chronic sexual and physical abuse, domestic
violence, rapes, stabbings, robberies, beatings, suicidal behaviors (Bell & Jenkins, 1993;
Berton & Stabb, 1996; Breslau, Davis, Andreski, & Peterson, 1991; Cuffe, Addy,
Garrison, Aller, Jackson, McKeown, & Chilappagari, 1998; Fitzpatrick & Boldizar, 1993;
Giaconia, Reinherz, Silverman, Pakiz, Frost, & Cohen, 1995; Lehmann, 1997; Singer,
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Anglin, Song, & Lunghofer, 1995). For example, Breslau et al. (1991) investigated
violence exposure 1007 urban youth and found prevalence rates of violence exposure
being 39.1%, with 23.6% diagnosed with PTSD. In a comparative analysis between 3735
urban and suburban adolescents, Singer et al. (1995) found urban youth had higher levels
of violence exposure with urban females experiencing more home violence.
Investigators have suggested the need for research that examines the effects of
several interrelated violent experiences rather than focusing on the effects of a single
violent event ( Finkelhor & Dziuba-Leatherman, 1994; Takanishi, 1993). For example, in
the area of child trauma, Finkelhor and Dziuba-Leatherman (1994) have addressed the
notion that researchers tend to target specific areas of victimization such as child abuse,
molestation, or rape. This micro approach tends to fragment information and may not
take into account the whole experience of being a child victim. They argue for a
“victimology of childhood” to be developed in order to assess the cumulative experience
of being victimized. Finkelhor & Kendall-Tackett (1997) has proposed a multidimensional
model of victimization from which to examine the impact of being exposed to violence and
the subsequent development of PTSD.
The Evolving Definition of PTSD as it Relates to Developmental Factors. Ethnicity and
Gender.
The definition of PTSD has been in evolution. An earlier definition of a traumatic
event was limited to an occurrence that was “outside the range of usual human experience
(Diagnostic and Statistical Manual o f Mental Disorders, Third Edition (DSM III)
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(p.236),” thus requiring events to be catastrophic in nature such as a natural disaster or a
war. However, the definition has evolved to include an “actual or threatened” event that
will cause serious injury to the “physical integrity of self or others (Diagnostic and
Statistical Manual o f Mental Disorders, Third Edition (DSM 7F)(p.427).” This revision
of what constituted a traumatic event allowed for the inclusion of more common forms of
community/domestic violence, as well as recognizing that witnessing an event could be a
possible risk factor for developing the disorder. Another development in the definition of
PTSD is the recognition that repeated exposure to violence over time can add to the
impact of the initial trauma (i.e., cumulative trauma; Doyle, 1989).
DSM IV also expanded the nosology to included a specific section addressing
diagnostic issues and symptomology specific to children and adolescents based on
developmental factors influencing the expression of the disorder (Frederick, 1985; Galante
& Foa, 1986; Newman, 1976; Payton & Krocker-Tushman, 1988; Pynoos et al, 1987;
Terr, 1979). These include symptoms such as: children plagued by fears of an unexpected
or reoccurring violent event; ongoing concerns about the security of family/self; flashbacks
and/or nightmares’ re-experiencing the trauma; depressive symptoms; lessened interest in
play; displays of avoidant or extreme attachment behavior toward family and friends;
anger; poor impulse control; preoccupation with revenge; hypervigilance and hyper
alertness. Others have noted that children react to trauma with either internalizing or
externalizing behaviors. Internalizing behaviors are apparent in excessive clinging to
adults, complaining of being lonely, feeling unloved, unhappiness, and worry (Hyman,
1998). Externalizing behaviors include problems of disobedience can occur such as lying,
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cheating, destroying things belonging to themselves or others, being cruel, associating
with disturbed youths, fighting, and the possibility of criminal behavior (Hyman, 1988;
Giaconia, Reinherz, Silverman, Pakiz, Frost, & Cohen, 1995). These symptoms illustrate
how cognitive, emotional, and spiritual growth of a child can be dramatically influenced by
exposure to chronic violence possibly leading to permanent changes in a child’s ability to
learn and to relate with others.
However, the expression of the disorder may differ depending on the ethnicity or
gender of the adolescent (Bruns & Geist, 1984; Foy, Madvig, Pynoos & Camileri, 1996;
Parson, 1988; Parson, 1994; Pynoos, Steinberg & Goenjian, 1996; Scheeringa & Zeanah,
1993; Weisman, 1993). In his writings on veterans of color, Parson (1988) suggested that
ethnicity and traumatic stress could have a “synergistic impact” due to the “ethnocultural
context” of the individual. According to Parson, “a generalized climate of institutional
neglect, discrimination, and systematic exclusion” will affect how stress will be interpreted
by veterans of color. Hough, Canino, Abueg, and Gusman (1996) indicate that Hispanic
Vietnam veterans were at higher risk for PTSD due to their minority status prior to and
during the war which cause them to “construe the world from a victim stance.”
Ethnocultural factors such as ethnic patterns of appraisal and the normalizing of stress
influence the expression of the disorder (Marsella, Matthew, Friedman, Gerity, &
Scurfield, 1996). Hough et al. (1996) report two types of “pathological adaptations” to
traumatic stress: 1) a passive, introspective, and severely depressed response; and 2) a
highly reactive, angry, and potentially explosive response.
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With respect to gender, several researchers have observed higher rates for violence
exposure among men, however higher PTSD levels were observed among women (Berton
& Stabb, 1996; Breslau, Davis, Andreski, & Peterson, 1991; Cufife, Addy, Garrison, Aller,
Jackson, McKeown, & Chilappagari, 1998; Fitzpatrick & Boldizar, 1993). In addition,
among war stressed youth, pre-adolescent boys were found to suffer more from PTSD
than pre-adolescent girls (Dawes et al., 1989; Punancki, 1989; Allodi & Cowgill, 1989).
However, this tendency reversed after post-adolescent development. It is possible that the
symptomology may express itself more among girls because post-adolescent boys begin
taking-up arms during that developmental stage. This proactive behavior may become a
type of psychological buffer to their traumatic experience. Girls may not have access to
similar roles from which to seek empowerment.
PTSD. Aggression, and Gangs.
Some have speculated that adolescents become involved in “gangs” because of
urban violence. Garbarino (1991) has presented several similarities between the effects of
urban communities that are violent and a combative war zone. Developmental growth can
be seriously altered by urban violence (Pynoos & Eth, 1985), and the aggressive behavior
observed among gang youth may be psychological response to these factors. If a
significant amount of men exposed to combat in Vietnam were found to be suffering from
PTSD (Frye, 1982; Engendorf, 1981), then it is possible that urban gang youth are also
suffering from PTSD after having been exposed to a significant amount of community
violence. In an examination of homicidal and aggressive young children, Lewis et al.
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(1983) concluded that witnessing and being a victim of irrational violence engenders a
kind of rage and frustration that, when directed inward, expresses itself as suicidal
behavior; when directed outward and displaced from the perpetrator, it manifests itself as
homicidal aggression. In order for inner-city youths to survive in an environment of
chronic stress, they may develop adaptive strategies that mirror the stressors themselves.
Therefore, the violent behavior demonstrated by these adolescents may be a direct
symptom of PTSD.
The research regarding violent behavior among Vietnam veterans clearly illustrates
this connection between PTSD and aggression. In studies of criminal behavior among
Vietnam veterans suffering from PTSD, investigations have identified a relationship
between high combat exposure and antisocial or maladaptive behaviors such as substance
abuse, suicide, homicide and other criminal behavior (Shaw, 1987; Resnick, 1989). So
convincing is this link between combat related PTSD and violent criminal behavior that the
relationship has been presented in the courtroom to support veterans claims of not guilty
by reason of insanity due to the Vietnam veteran’s “proclivity to explosive aggressive
reaction (Shaw, 1987; pg. 403).” The DSM IV also recognizes such a proclivity:
“increased irritability may be associated with sporadic and unpredictable explosions of
aggressive behavior, upon even minimal or no provocation.” Since the relationship
between PTSD and aggression is supported in the research and is recognized as a
characteristic of PTSD, then it is possible that the antisocial or violent behavior exhibited
by gangs may be a result of a combative environment producing PTSD in youths. In other
words, aggressive behavior may be a marker of PTSD in inner-city youth or youth who
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are unable to stay in school. Several investigators have found a significant relationship
between high levels of PTSD and low academic or delinquent behavior among adolescents
(Breslau, Davis, Andreski, & Peterson, 1991; Giaconia, Reinherz, Silverman, Pakiz,
Frost, & Cohen, 1995; Shakoor & Chalmers, 1991). Giaconia et al. (1995) observed
significantly lower GPA scores among youth diagnosed with PTSD.
PTSD. Drug use, and Depressive Symptoms
Urban youth may also express their distress related to their experience of violence
by using drugs. Among adolescents, Reichler, Clement, and Dunner (1983) found that in
17% of emergency room admissions, elevated blood alcohol levels coincided with
diagnoses of depressive symptoms. In an adolescent counseling center, 16% were
diagnosed with substance abuse and depressive symptoms superimposed on dysthymia
(Kashani, Keller, & Solomon, 1985). Excessive alcohol use and drug use among
adolescents is also associated with suicidal plans or an attempt, an anxiety disorder, and
conduct disorder (Ryan, Puig-Antich, and Ambrosini, 1987). Comorbidity of drug abuse
and psychological illness is associated with an increased rate of hospitalization, poor
medication compliance, homelessness, criminality and suicidal behavior (Weiss, 1992).
PTSD is recognized as a potential risk factor for drug use and abuse, and as a
potential consequence of drug use and abuse, or both. Stressful life change events that are
uncontrollable are associated with increased drug use (Newcomb, Huba, & Bentler, 1986;
Bruns & Geist, 1984). Adolescents who undergo severe and unresolved crises as they
enter into their adult roles may turn to alcohol and drug use. For example, survivors of
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cMdhood sexual abuse initiate drug use earlier than their peers and abuse elicit drugs,
typically uppers and downers (Harrison, Hoffinan, & Edwall, 1989; Singer & Petchers,
1989). Khantzian (1985) proposed a theory that outlines how drug use is used to relieve
negative emotions through the “specific anti-aggression action of narcotics (p.32)”
implying a self-medicating function for drug use.
The association between drug use and depressive symptoms for the purpose of
self-medicating for emotional distress was observed among delinquent boys (Riggs et al,
1995). Depressed subjects, who were found to be diagnosed with substance dependence,
tended to maintain their depressive symptoms despite achieving four weeks of abstinence.
In addition, women diagnosed with PTSD and depressive symptoms were found to relapse
more quickly and often than non-comorbid women (Brown, Stout & Mueller, 1996).
There is evidence that individuals who abuse cocaine and have a history of depression tend
to experience more severe withdrawal symptoms (Gawin & Kleber, 1986; Hall, Munoz, &
Reus, 1991). As Weiss (1992) argues, certain illnesses (e.g., depression, antisocial
personality disorder and drug use) impair an individual’s capacity to plan ahead and attend
to their personal safety. Lee, Mendes de Leon, and Markides (1988) discovered smoking
and alcohol use predicted hostility in young Latino males. This hostility, they
hypothesized, either made these young men more sensitive to environmental stress or
intensified their reactions to stress. Also, emotional distress can be both precipitant and
consequence of drug use. Kaplan and Johnson (1992) describe a cycle in which the
individual initiates drug use to reduce negative affect. The reduction of negative affect
reinforces drug use. Drug use escalates which: 1) interferes with the development of
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effective coping and, 2) allows the individual to neglect the problem, thus allowing it to
intensify. The Los Angeles Epidemiologic Catchment Area studies and several studies
conducted among Hispanic veterans at the Brentwood VA (as cited in Hough, Canino,
Abueg, and Gusman, 1996) both found significant levels of Comorbidity between PTSD,
drug use, and depressive symptoms. Unfortunately, much of the research has focused on
adults and research investigating these factors collectively among Latino adolescents is
still needed.
Methods
Participants.
Location. Adolescents were recruited from two mainstream high schools and an
alternative school in which the student population was predominately Latino. The three
schools were located in low income Latino communities of Los Angeles. Participants
were both gang affiliated and non-gang affiliated.
The alternative school students were part of a community agency established by
the U.S. Justice Department to assist youth who have been placed on probation, or are
returning to the mainstream after being incarcerated. The community agency allowed us
access to youth who had dropped out of high school and may be at higher risk for violence
exposure, gang involvement, drugs, or living on the street. This area has the highest
prevalence rates of violent crimes in the city of Los Angeles (JJDP SVJO Program Area).
The poverty rate for the area 52.18% (JJDP SVJO Program Area). Eighty-six percent of
the population is of Latino origin with the three largest group being immigrants from
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Mexico (53%), El Salvador (23.7%), and Guatemala (14%). The average income was
$20,653 per year (JJDP SVJO Program Area).
Overall, this sample is at risk for behavioral problems. School psychologists at the
two high schools estimate a large percentage (40%) of students had been exposed to
violence both in and out of the home (personal communication, October 16, 1998). The
numbers of students seeking emotional assistance have recently increased and school
administrators report that the number of students arrested on campus for drug use have
also increased significantly (personal communication, October 16, 1998). The majority of
students at each high school are female. Unfortunately, the school district was not able to
provide data to support their observations. In addition, teachers and case managers at the
alternative school indicated that the majority of their students were involved in gangs and
have been exposed to violence and drugs. These para-professionals report that their
students experience severe levels of emotional distress and are unable to stay in high
school (personal communication, June 1998). Alternative school students tend to be
under-represented in research because access to them is difficult.
Our sample is somewhat representative of the school populations surveyed.
However, the sample may be biased due to self-selection of the participants. The more
distressed students may have either: 1) avoided volunteering in order to not discussing
their experiences of violence exposure and/or drug use, or 2) over volunteered due to
needing to discuss their experiences of violence exposure and/or drug use. Another factor
possibly biasing the sample is that students may have felt compelled to give the socially
desirable answer by indorsing high levels of violence exposure or drug use.
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Procedures.
Recruitment procedures. Procedures for gathering data differed at each school
site. At the high school, participants were recruited from 3-4 co-ed P.E. classes per class
period. A 20 minute class presentation explaining the project to students was given by the
principal investigator. Parental consent forms along with an information sheet describing
the study were distributed to all students and asked to be return to their P.E. teacher. At
the alternative school, each student was contacted by either their teacher or case manager,
the study was described to them, and then they were asked if they wanted to participate.
Because parental or guardian consent for treatment and research is collected as the youth
enter the agency, no additional parental consent was required.
However, there were situations where parental consent was unavailable. The
Institutional Review Board (IRB) at USC granted the opportunity to waive parental
consent if the adolescent did not live with their parent or guardian due to: a) being
abandoned by parents; b) running away from home; or c) living on the street. Several of
our participants met this criteria with 34% returning forms with parental consent waived.
While this may seem highly unusual, the federal regulations state that if “a research
protocol is designed for conditions or for a subject population for which parental or
guardian permission is not a reasonable requirement to protect the subjects (for example,
neglected or abused children), it may waive the consent requirements . . . provided an
appropriate mechanism for protecting children who will participate as subjects in the
research is substituted, and provided further that the waiver is not inconsistent with
federal, state or local law. The choice of an appropriate mechanism would depend on the
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nature and purpose of the activities described in the protocol, the risk and anticipated
benefit to the research subjects, their age, maturity, status, and condition. ” ( 45 CFR
46.408(c)). This study’s protocol provided appropriate mechanisms for protecting
adolescents (i.e., safeguards for confidentiality, trained interviewers, protocols for
responding to a subject’s psychological distress).
At both school sites, details of the project were given before students were asked
to participate. They were told the study was an attempt to find about the stressors of
being a Latino adolescent. It was explained that participation would entail a 1 1 4 - 2 1 4
hour interview consisting of questions dealing with issues of violence, drug use, and their
emotions associated with these experiences. Participants were informed that: 1) their
participation was completely voluntary; 2) they could stop the interview at any time; 3)
their compensation (two movie tickets) would not be withheld as a result of stopping or
declining to answer any question. They were also informed about the limits of
confidentiality (i.e., harm to selfiothers, child/elder abuse). In addition, participant’s
assent was obtained immediately before the interview.
Because some items in the interview could have legal implications (i.e., reporting
abuse, gang involvement), safeguards for confidentiality were taken by assigning each
subject a numerical code which was not cross-referenced with the participant's name, nor
did their name appear on their interview data. The data was accessible only to research
staff and not to their parents or legal authorities. Date and consent forms were stored in a
locked file cabinet in the office of the principal investigator. Participants’ welfare was
protected through careful training of interviewer and providing referrals.
Training o f the Interviewers. Six interviewers underwent an extensive series of
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training sessions for four months which covered several topics: 1) interviewing,
developing rapport, and communication skills; 2) instruction regarding the diagnostic
categories of PTSD, Drug Use, and Depressive symptoms; 3) instrument completion
procedures; 4) identification of possible emotional and psychological distress during the
interview; 5) limits of confidentiality and reporting procedures; 6) crisis intervention and
emergency procedures; and 7) referral and closure procedures. Weekly supervision
meetings were held for interviewers to discuss issues that might have occurred during the
interview, or answer any questions that may have arisen. Interviewers were instructed to
solicit feedback from participants throughout the interview to ensure that the participant
would not experience any psychological distress. As part of the referral process,
interviewers referred subjects to individual therapy with: 1) the school psychologist, or 2)
a counselor from the community agency. Finally, a list of community mental health
referrals were also provided. If participants distress was severe, interviewers were
instructed to terminate the interview.
Data collection. The data were gathered in a two-stage process: 1) focus group
and preliminary interviews were conducted with a small pilot sample to refine our
instruments and research definitions; and 2) a larger sample was interviewed to measure
PTSD, drug use, depressive symptoms and violence exposure. The length of the
structured interview was between two to two and half hours. Given the time needed to
complete the interview, some subjects required two separate sessions. Participants
completed a pen and paper questionnaire while the interviewer read each question out
loud with the subject circling the appropriate responses on their answer sheet.
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Measures.
The structured interview included four instruments. The outcome measure for
PTSD, and the associated features of drug use and depressive symptoms were: 1) Trauma
Symptom Checklist for Children (TSC-C) (Briere, 1995); 2)Center for Epidemiological
Studies: Depression Scale-20 item form (CES-D) (Radloff, 1977); 3) Personal Experience
Inventory (PEI) (Winters & Henly, 1989); and 4) Michigan Alcohol and Other Drugs
School Survey (MAOD Survey)(Van Valey & Johnston, 1997). Violence exposure was
assessed with the Violence Exposure Scale (VES).
The TSC-C assessed the traumatic symptoms of PTSD and dissociation. The two
subscales provide differential interpretations of the symptom complex. The measure
includes 54 items rated on a four-point Likert scale ranging from (0) "Never” to (3)
“Almost all of the time.” The reliability for the overall measure was .96 and for the
subscales: PTSD (« =.86) and dissociation (< * =.83). Sample responses for the lead
question of “How often does each of these things happen to you”are: l)“Bad dreams or
nightmares”; 2)“Feeling sad or unhappy”; and 3)“Feeling afraid somebody will kill me.”
The CES-D is a 20-item measure that assesses adolescent depressive symptoms.
The scale has been used in studies measuring depressive symptoms among Latino youth
(Roberts, Rhoades, & Vernon, 1990; Roberts, 1992; Roberts & Sobhan, 1992; Roberts,
1980). The reported reliabilities for the instrument have ranged between .70 to .87.
Among Spanish-speaking participants, reported alpha coefficient was .87 (Roberts, 1980).
Scale responses are from (0) “Rarely or none of the time: less than 1 day” to (3) “Most or
all of the time: 5-7 days.” Depressive symptoms are evaluated for the one-week period
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preceding the interview. Sample items are “For the past week my sleep was restless,” and
“For the past week I felt that everything I did was an effort.” Scores ranged from zero to
60, with high scores indicating a higher frequency of symptoms.
The PEI is a inventory that assesses the multidimensional nature of alcohol and
drug involvement among adolescents. It identifies personal risk factors that may
precipitate or maintain substance abuse. This scale has been developed on several clinical
and high school samples (Henly & Winters, 1988; Henly & Winters, 1989; Winters,
Stinchfield & Henly, 1992). For the purposes of this project, two subscales from
Chemical Involvement Problem Severity: Personal Involvement (PI) with drugs (29 items;
=.97) and Psychological Benefits (PB) Drug Use (7 items;o c = .94). The PI subscale
assesses the adolescent’s degree of psychological involvement with alcohol and drugs.
The PB taps into the adolescents need to use alcohol and drugs for the purpose of self-
medication. Sample items for each subscale are: 1) PI - How often have you used alcohol
and other drugs to get high; and 2) PB - How often have you used alcohol and other drugs
when you were mad or irritated? Items were rated with a four-point Likert scale ranging
from (0) - “Never” to (3) - “A lot.”
The MAOD survey (Van Valey & Johnston, 1997) assessed the prevalence of
alcohol and drug use among high school students. Questions from the MAOD study were
based on a larger national survey of alcohol/drug use developed and administered by the
Institute for Social Research (ISR) at the University of Michigan. For this project, a
subset of 47 questions were selected from MAOD survey to assess alcohol and drug use
prevalence among this sample of Latino youth. These items allowed us to compare our
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21
results to the national results for Hispanics from the 1998 ISR report. Both frequency and
quantity of use was assessed across several different types of drugs (Alcohol,
Marijuana/Hashish, LSD, Other Psychedelics (Mescaline, PCP, Hallucinogens, Mushrooms),
Cocaine (Crack, Crystal Meth.), Amphetamines (Speed, Uppers, Bennies), Quaaludes,
Barbiturates, Tranquilizers, Heroin, Opium, Methadone, Morphine, Inhalants (Sniffed Glue,
Aerosol Spray Can), Drugs by Injection, Steroids, Herbal Drugs). Frequency of drug use
was assessed for the past 30 days, the last 12 months and for their lifetime with a seven-
point Likert format ranging from (0) “Never” to (6) “40 or more times.”
The VES is a 37-item scale that was developed for this study to examine
participants’ exposure to violence in two domains: 1) the number of events they have been
exposed to; and 2) the degree of exposure to each event. For each of the 10 types of
urban violence, the participants degree of exposure was evaluated across three levels: 1)
having personally experienced the event; 2) witnessed the event happening to another
person; and 3) having knowledge of someone else experiencing the event. The events
were: 1) fistfights/beaten-up; 2) assault/robbery/jacked-up; 3) threatened with a weapon;
4) carrying a weapon; 5) suicides; 6) rape/sexual assault; 7) stabbings; 8) gunfire; 9)
attempt on the subject’s life; and 10) murder. The environmental domain in which the
exposure occurred was also assessed: 1) at home, 2) at school, or 3) in the community.
Based on the NIMH Community Violence Project (Richters & Martinez, 1993), a five-
point Likert scale was selected to examine the frequency of exposure for each violent
event. Scale responses were: (0) “Never,” (1) 1 “time,” (2) “2-3 times,” (3) “4-5 times,”
(4) “6 or more times.”
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22
Results
Sample Characteristics (Tables 1-2).
Table 1 presents the sample characteristics by gender. Overall, the distribution for
gender was somewhat evenly divided with boys slightly over represented (55%) as
compared to girls (45%). Significant gender differences were found for location, age, and
gang affiliation. There were more older girls in the sample than older boys (79% of the
girls were 16-17 years old versus 47% of the boys being 16-17), and there were
significantly more younger boys than younger girls (38% of the boys were 14-15 years old
versus 8% of the girls being 14-15) (F(l,38)=5.80, p<.05). In addition, significantly more
boys than girls endorsed gang affiliation (% 2 (1)=4.11; p< .05).
Gender was unevenly distributed across the three school sites. Students from High
School #1 were predominantly female, while High School #2 students and the alternative
school students were predominantly male. This sampling problem precludes making any
conclusions regarding the effect of gender apart from the effects of location. In addition,
because additional analysis (ANOVAS) revealed few significant differences for gender,
this variable was dropped from subsequent analyzes (See appendix A). However,
significant differences did emerge consistently between the two high school samples and
the alternative school. Therefore, the high school samples were collapsed into one group
and the remainder of the analyses focused on group differences between high school
students and alternative school youth.
Table 2 presents sample characteristics for high school students (72%) and the
alternative school students (28%). There were significantly more girls than boys within
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23
Table 1:
Sample Characteristics of Latino/Latina Adolescents bv Gender
Variable
Total
n % n
Male
%
Female
n %
Test
Statistic
Total 85 100.0 47 55.3 38 44.7
Location
High School #1 33 38.8 9 19.1 23 63.2 x2 (2)=
High School #2 28 32.9 19 40.4 9 23.7 17.803***
Alternative High School 24 28.2 19 40.4 5 13.2
Age
14 6 7.1 5 10.6 1 2.6 F(l,83)=
15 15 17.6 13 27.7 2 5.3 5.795*
16 31 36.5 15 31.9 16 42.1
17 21 24.7 7 14.9 14 36.8
18 12 14.1 7 14.9 5 13.2
Generational status
Immigrant 17 20.0 8 17.0 9 23.7
1s t Generation 49 57.6 28 59.6 21 55.3
2n d Generation 19 22.4 11 23.4 8 21.1
Ethnicity
Mexican American 50 58.8 27 57.4 23 60.5
Mexican 15 17.6 4 8.5 11 28.9
Central American 17 20.0 13 27.7 4 10.5
Other Latino 3 3.5 3 6.4 0 0.0
Gang Affiliation
Yes 20 23.5 15 31.9 5 13.2 x2 (1)=
No 65 76.5 32 68.1 33 86.8 4.109*
* <.05;
* * < . 0 1 ;
*** <.000.
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24
the high school sample and fewer girls participated among the alternative school (x2
(1)=7.710; p<.01). Significant differences were observed for generational status with
most of the students for both schools (53% - high school; 71% - alternative school) being
first generation (subject is U.S. bom with both parents bom outside of the U.S.) (x2
(2)=6.38; p<.05). Proportionally, more immigrant students attended the alternative school
(25%), and more second generation students attended the high school (30%). Significant
differences were observed for ethnicity with more Mexican American/Chicanos (69%) at
the high school and more Central American subjects (54%) being at the alternative school
(X2 (3)=28.844; p<.000). The majority of gang affiliated youth (58%) (subjects who are
currently or in the past have been gang members) were at the alternative school. The
majority of high school youth (90%) did not endorse any type of gang affiliation (x2
(1)=22.51; p<.000).
Scale Reliabilities (Tables 31.
Table 3 presents reliability coefficients for all the summed scales to be used in
subsequent analysis. Overall, coefficient scores ranged from .76 to .96. The largest
coefficients were found for depressive symptoms (.94), personal involvement with drug
use (.96), and Total Score for Exposure to Violence (.96). Reliability coefficients were
not computed for the specific type of violence exposure and for each type of drug use due
to these variables being based on a single question.
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25
Table 2:
Sample Characteristics of Latino/Latina Adolescents Across Schools.
Variable
Total
n %
High
School
n %
Alternative
School
n %
Test
Statistic
Total 85 100.0 61 71.8 24 28.2
Gender
Male 47 55.3 28 45.9 19 79.2
x2(1)=
Female 38 44.7 33 54.1 5 20.8 7.710**
Age
14 6 7.1 3 4.9 3 12.5
15 15 17.6 8 13.1 7 29.2
16 31 36.5 25 41.0 6 25.0
17 21 24.7 16 26.2 5 20.8
18 12 14.1 9 14.8 3 12.5
Generational status
Immigrant 17 20.0 11 18.0 6 25.0 x2 (2)=
1s t Generation 49 57.6 32 52.5 17 70.8 6.375*
2n d Generation 19 22.4 18 29.5 1 4.2
Ethnicity
Mexican American 50 58.8 42 68.9 8 33.3 x2(3)=
Mexican 15 17.6 14 23.0 1 4.2 28.844***
Central American 17 20.0 13 6.6 13 54.2
Other Latino 3 3.5 3 1.6 2 8.3
Gang Affiliation
Yes 20 23.5 6 9.8 14 58.3 x2(1)=
No 65 76.5 55 90.2 10 41.7 22.514***
* <.05;
** <.01;
*** <.000.
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Table 3:
Reliability Coefficients for the Dependent and Independent Measures.
26
Measures Alpha Coefficients
Depressive Symptoms (CESD) .94
Post Traumatic Stress Disorder (TSCC) .85
Dissociation (TSCC) .85
VES Subscales:
- Exposure to Home Violence .87
- Exposure to School Violence .91
- Exposure to Community Violence .76
- Total Score for Exposure to Violence .96
PEI Subscales:
- Personal Involvement with Drug Use .96
- Social Benefits of Drug Use .83
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27
Mean Comparisons for Depressive Symptoms. PTSD. and Dissociation (Table 4).
Table 4 presents group differences for Depressive Symptoms, PTSD, and
dissociation1 between high school and alternative school students. No significant
differences between the high school and alternative school students were observed for
these outcome variables. However, mean scores for the alternative school students were
consistently higher for all three measures.
Evaluation of Violence Exposure (Tables 5-7).
Violence exposure was measured in two ways. First, prevalence of violence
exposure was calculated for the overall sample, each school site (see Table 5), and for
each school by their three degrees of exposure and three domains of exposure for each
violent event (see Table 6). Next, an intensity score for each violent event was calculated
by weighting the raw scores for each event by their degree of exposure (heard about,
witnessed, experienced). The weighting procedure was guided by previous research
which suggested that events witnessed were far more distressing to adolescents than
events that were described to them (Pynoos & Nadar, 1988). In addition, violent events
experienced by children were far more distressing than events that were witnessed. They
concluded that the subject’s proximity to an event would influence the amount of
emotional distress the subject would experience. Based on these findings, researchers
i
Due to the exploratory nature of the study, the TSC-C dissociation subscale became an
important variable in examining the relationship between violence exposure and PTSD.
Therefore, this subscale will be included in the remainder of the analyses.
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28
decided to weight each event by their degree of exposure. A higher weight of 3 was
assigned to events personally experienced, a score of 2 was given to events witnessed, and
an event heard about remained the same. These violence intensity scores were then used
to calculate intensity of exposure scores for each event and each domain of exposure
(home, school, and community) (See Table 7). In addition, scores generated for each
event were added together to compute a Total Violence Intensity Score.
Overall Prevalence Rates of Violence Exposure (Table 51.
Table 5 presents overall prevalence rates of violence exposure for the total sample,
and by school. Rates of violence exposure were high for the entire sample and ranged
from 12.16% for rape/sexual assault to 60.51% for fistfights. In comparing prevalence
rates between high school and alternative school students, rates of exposure for each event
tended to be higher for alternative school students with scores ranging between 12% to
65% versus high school scores which ranged from 13% to 56%. Rates of exposure
almost doubled for the alternative school students for threatened with a weapon, stabbing,
and gunfire. However, prevalence rapes for rape/sexual assault (12.73%) and suicide
(19.67%) tended to be higher for high school students in comparison to the alternative
school students exposure to rape/sexual assault (11.58%) and suicide (18.06%).
Prevalence Rates for Violence Exposure bv Degree and Domain of Exposure (Table 6).
Generally, higher prevalence rates were observed for “hearing about” an event,
and the lowest rates of exposure were observed for experiencing an event. Most exposure
to violence occurred in the community.
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29
Table 4:
Analysis of Variance for Dependent Variables Among Latino Adolescents Across Schools.
High Alternative
School School
n=61 n=24
Variable M SD M SD F Statistic
Depressive Symptoms (CESD) 15.89 (11.84) 19.63 (15.28) .23
Post Traumatic Stress Disorder (TSCC) 8.51 ( 5.77) 10.50 (7.16) .19
Dissociation (TSCC) 8.21 ( 5.63) 9.50 (5.80) .35
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30
Table 5:
Overall Prevalence Rates of Violence Exposure Across Schools.
Violent Event
Total Sample
%
High
School
%
Alternative
School
%
Fist Fights/Beaten up 60.51% 55.73% 65.29%
Robbed, Mugged, Jacked-Up 45.40% 41.71% 49.09%
Threatened with a Weapon 37.31% 29.70% 44.91%
Carrying a Weapon 39.94% 34.97% 44.91%
Stabbing 22.65% 16.58% 28.72%
Rape/Sexual Assault 12.16% 12.73% 11.58%
Suicide 18.87% 19.67% 18.06%
Gun Violence 33.89% 26.67% 41.11%
Murder/Death 26.59% 20.19% 32.99%
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31
Degree o f Exposure. Degree of violence exposure varied across both schools.
High school students most often reported “hearing about” fistfights (69.93%),
robbery/mugged (70.50%), threats with a weapon (50.83%), carrying a weapon (44.27%),
stabbings (37.70%), rape/sexual assaults (32.23%), suicides (35.50%), and gunfire
(49.17%). However, most high school students reported witnessing murders/deaths
(24.05%) rather than hearing about or experiencing these events. Across both groups of
students, prevalence rates for “hearing about” each types of violence were similar. High
school students also reported witnessing fistfights (61.73%), robbery/muggings (33.33%),
threats with a weapon (25.67%), and carrying a weapon (39.87%). However, high
school students reported witnessing fewer stabbings (9.30%), rape/sexual assaults
(2.70%), suicides (13.67%), and gunfire (13.13%) than the alternative school students. In
addition, personal experiences of violence were also low with scores ranging between
2.73% for stabbings to 35.53% for fistfights.
Among alternative school students, prevalence rates for degree of exposure tended
to be higher than high school students for all types of violence exposure. This was evident
in higher percentages for “hearing about” fistfights (69.47%), robbery/muggings
(63.90%), threatened with a weapon (54.17%), stabbing (41.67%), rape/sexual assault
(25.03%), suicide (33.33%), and gunfire (57.65%); and personal exposure to violence was
higher for carrying a weapon (70.83%) and personal attempts on their lives (41.67%).
Domain o f Exposure. Exposure to violence also varied across domains. High
school students reported higher exposure rates for robbery/mugging (56.30%), threatened
with a weapon (41.53%), stabbing (26.77%), rape/sexual assault (15.83%), gunfire
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(44.28%), and murder/death (29.84%) in the community. Reports of fistfights (80.90%),
carrying a weapon (44.27%), and suicide (22.93%) occurred more at school. Rates of
home exposure were much lower than the other two domains of exposure with scores
ranging from 5.47% for stabbing to 31.13% for fistfights. Across each domain of
exposure, prevalence rates for the alternative school students tended to be higher than
high school students. Alternative school students reported higher rates of violence in the
community except for fistfights (84.73%) in the domain of school.
Mean Comparisons of Violence Exposure (Table 7).
Comparisons of mean intensity scores for each event are presented in Table 7.
Alternative school students had significantly higher intensity scores for every type of
violence event except rape/sexual assault and suicide. For both groups, the violent event
with the highest mean intensity score was fistfights or situations where someone was
beaten-up. In addition, group differences for mean scores of violence exposure were
examined across domains and the total violence subscales. The alternative school students
had significantly higher mean intensity scores for school (p<.01), community (p<.000),
and total violence exposure subscale (p<.000).
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Table 6:
Prevalence Rates for Violence Exposure bv Degree and Domain of Exposure Across Schools.
Degree of Exposure Domain of Exposure
Violent Event Heard Witnessed Experienced Home School Community
Fist Fights/Beaten up 69.93% 61.73%
High School Students
35.53% 31.13% 80.90% 55.17%
Robbed, Mugged, Jacked-Up 70.50% 33.33% 21.30% 16.40% 52.43% 56.30%
Threatened with a Weapon 50.83% 25.67% 12.60% 14.23% 33.33% 41.53%
Carrying a Weapon 44.27% 39.87% 20.77% 18.03% 44.27% 42.60%
Stabbing 37.70% 9.30% 2.73% 5.47% 17.50% 26.77%
Rape/Sexual Assault 32.23% 2.70% 3.27% 7.63% 14.73% 15.83%
Suicide 35.50% 13.67% 9.83% 13.67% 22.93% 22.40%
Gun Violence 49.17% 13.13% 10.93% 20.32% 15.40% 44.28%
Murder/Death 25.67% 24.05% 6.98% 2 0 .8 8 % 9.85% 29.84%
Fist Fights/Beaten up 69.47% 66.67%
Alternative School Students
59.73% 31.97% 84.73% 79.17%
Robbed, Mugged, Jacked-Up 63.90% 48.63% 34.73% 23.63% 51.40% 72.23%
Threatened with a Weapon 54.17% 43.07% 37.50% 12.50% 54.17% 68.07%
Carrying a Weapon 47.23% 45.83% 70.83% 12.50% 51.40% 70.83%
Stabbing 41.67% 31.97% 12.53% 5.57% 27.80% 52.80%
Rape/Sexual Assault 25.03% 4.17% 5.53% 1.40% 13.90% 19.43%
Suicide 33.33% 16.67% 4.17% 9.70% 15.30% 29.17%
Gun Violence 57.65% 27.77% 31.25% 19.98% 37.52% 65.84%
Murder/Death 31.97% 29.17% 41.67% 12.50% 23.95% 62.53%
u >
O J
34
Table 7:
Analysis of Variance for Mean Intensity Scores of Violence Exposure Across Schools.
Variable
High School
n=61
M SD
Alternative School
n=24
M SD F - Statistic
Types of Violence:
Fist Fights/Beaten up 22.98 (15.43) 33.91 (18.84) 7.405**
Robbed/Mugged 11.02 (9.21) 19.83 (14.15) 11.200**
Threatened with a Weapon 8.59 (10.84) 19.65 (17.26) 12.318**
Carrying a Weapon 11.39 (12.18) 21.26 (16.42) 8.989**
Stabbing 3.38 (4.64) 9.26 (9.18) 15.058***
Raped/Sexual Assault 2.31 (3.00) 3.30 (5.76) 1.063
Suicide 4.15 (6.13) 4.35 (6.44) .017
Gun Violence 12.20 (14.01) 26.87 (20.23)
14.184***
Murder/Death 9.61 (10.11) 18.78 (15.84) 9.895**
Violence Exposure Subscales:
Home Intensity 14.64 (15.18) 16.96 (23.89) .279
School Intensity 29.08 (18.58) 47.52 (37.29) 9.077**
Community Intensity 41.90 (41.39) 92.74 (59.39) 19.623***
Total Intensity Score 85.62 (67.96) 157.22 (105.78) 13.415***
* <.05;
** <.01;
*** <.000.
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35
Prevalence Rates and Mean Comparisons for Drug Use (Tables 8-9 ).
Table 8 presents lifetime prevalence rates for drug use among the high school and
alternative school students. Overall, more alternative school students reported higher
rates of use for all substances ranging from 21.7% to 95.7%, relative to the high school
students with drug use rates ranging between 9.8% to 82.0%. Alcohol was the most
widely used drug for both groups. Significant differences were observed for lifetime use
of marijuana/hashish (p<.01), with the majority of the alternative school students having
used it during their lifetime. The groups differed significantly in the use of psychedelic
drugs (p< .01) with over a third of the alternative school students using them in their
lifetime in comparison to 10% of the high school students. One of the most dramatic
differences observed was in the lifetime prevalence of cocaine use (p< .000). Over half
(60.9%) of the alternative school students had used cocaine or a derivative during their
lifetime, in contrast to less than a quarter of high school students.
Table 9 presents the analyzes of variance for frequency of drug use and PEI
subscale scores (Personal Involvement, Psychological Benefits). Overall, mean
frequencies for drug use among the high school students were low ranging from .34 (crack
use) to .74 (Drugs with depressive/Numbing effects). These low mean scores indicate
“never” having used the drug or having uses “once or twice” in a lifetime. An exception
to this finding was observed for Alcohol (3.10) and Marijuana/Hashish (2.02) use. These
mean scores are equivalent to “three to five times” to “10-19 times” for lifetime use.
Overall mean scores among the alternative school students varied tremendously from .26
(Amphetamines) to 4.83 (Alcohol) for lifetime drug use and these scores tended to be
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36
Table 8:
Prevalence Rates for Types of Drug Use Across Schools.
High
School
Alternative
School
x2
Variable n % n % Statistic
Types of Drug Use:
Alcohol 50 82.0% 22 95.7% 2.55
Marijuana/Hashish 35 57.4% 21 91.3% 8.65**
LSD 9 14.8% 7 30.4% 2.66
Other Psychedelics
(Mescaline, PCP, Mushrooms)
6 9.8% 9 39.1%
9 77**
Cocaine
(Crack, Crystal Meth.)
11 18.0% 14 60.9% 14.66***
Amphetamines
(Speed, Uppers, Bennies)
12 19.7% 5 21.7% .044
Drug with Depressive/Numbing Effects
(Quaaludes, Tranquilizers, Heroin, Opium, Morphine)
12 19.7% 7 30.4% .948
Inhalants
(Sniffed Glue, Aerosol Spray Can)
16 26.2% 14 60.9% 8.729
Herbal Drugs 13 21.3% 7 30.4% .381
* <.05;
** <.01;
*** <.000.
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37
Table 9:
Analysis of Variance for Various Measures of Drug Use Across Schools.
Variable
High School
n=61
M SD
Alternative School
n=24
M SD F-Statistic
Type of Drug Use:
Alcohol 3.10 (2.27) 4.83 (1.75) 10.85**
Marijuana/Hashish 2.02 (2.31) 4.22 (2.17) 15.61***
LSD .30 ( -82) 1.13 (2.05) 7.17**
Other Psychedelics
(Mescaline, PCP, Mushrooms)
.16
( -69) .78 (1.28) 8.16**
Cocaine
(Crack, Crystal Meth.)
.34 (1.00) 2.22 (2.21) 28.66***
Amphetamines
(Speed, Uppers, Bennies)
.66 (1.59) .26 ( -54) 1.35
Drugs with Depressive/Numbing Effects .74 (2.17)
(Quaaludes, Tranquilizers, Heroin, Opium, Methadone, Morphine)
.83 (1.58) .03
Inhalants
(Sniffed Glue, Aerosol Spray Can)
.51 (1.09) 1.04 (1.15) 3.92
Herbal Drugs .57 (1.47) .87 (1.74) .61
PEI Subscales:
Personal Involvement with Drug Use. 14.54 (17.17) 28.30 (17.48) 10.63**
Psychological Benefits of Drug Use. 3.43 ( 4.23) 6.87 (3.91) 11.52**
* s.05;
** <.01;
*** <.000.
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38
higher than observed means for high school students. Significant differences emerged with
the alternative school youth using some drugs more frequently than high school students:
Alcohol (p<.01), Marijuana/Hashish (p<.000), LSD (p<.01), Other Psychedelics (p<.01),
and Cocaine use (p<.000). The most dramatic difference was observed for cocaine
lifetime use which the alternative school students indicted using three to four times in their
lifetime, while high school students reported never using or using it once or twice.
Mean scores were significantly higher for the alternative school students on both
P.E.I. subscale scores: Personal Involvement with Drug Use (p< .01) and Psychological
Benefits of Drug Use (p<.01).
Correlations (Table 101.
Bivariate correlations began to examine the relationship between violence
exposure2 and drug use, depressive symptoms, PTSD, and dissociation. Differences
between high school and the alternative school students were examined. Among high
school students, violence exposure correlated more with drug use, depressive symptoms,
PTSD, and dissociation with scores ranging from .22 to .54. The Total Violence Intensity
Score was most strongly related to Personal Involvement with drug use. The violence
subscales tended to be most strongly related to both of the drug use scales with scores
ranging from .30 to .54. All of the violence subscales correlated positively with the
dissociative subscale. However, violence exposure correlated mostly with PTSD and
2
References to violence exposure in this section include both the Total Violence Intensity
Score and all the violence exposure subscales.
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Table 10:
Correlations Between the Violence Exposure Scales and PTSD. Depressive Symptoms. Drug Use, and Dissociation.
PTSD Depressive Personal Involvement Psychological Benefits Dissociation
Symptoms with Drug Use of Drug Use
High School Students
Total Violence Intensity score .386** .288* .537** .371** .442***
Fistfights .267* .189 .532***
441***
.356**
Robbed/Mugged
342**
.321*
504***
.380** .421**
Threaten with a Weapon
4 0 9 **
.2 0 1
491***
.393** .350**
Carrying a Weapon .242 .140 446*** .304* .303*
Stabbings .225 .185 .489*** .330** .284*
Rape/Sexual Assault
502***
3 7 9 **
.198 .068 .407**
Suicides
464***
3 9 7 **
.303** .161 .458***
Gunfire .184 .165 .348** .167 .270*
Murder/Death .357** .304* .327*
Alternative School Students
.188 .403*
Total Violence Intensity score
7 08***
.388 .188 .119 .445*
Fistfights .570** .191 .376 .358 .378
Robbed/Mugged .618** .328 .171 .049 .371
Threaten with a Weapon 734*** .419 .068 .057 .500*
Carrying a Weapon .528** .341 .320 .242 .274
Stabbings .712*** .470* -.065 -.060 .394
Rape/Sexual Assault .500** -.093 .293 .131 .287
Suicides .421* .170 -.128 -.157 .041
Gunfire
624**
.367 .096 -.014 .494
Murder/Death .590** .483* .1 1 0 .082 .383
* <.05;
** s.01;
* * * £ . 0 0 0 .
o j
vo
40
dissociation among alternative school students with scores ranging from .42 to .71. The
strongest relationships were observed between violence exposure and PTSD among the
students in the alternative school.
Mediators of the Relationship between Violence Exposure and PTSD (Table 111.
Table 11 presents three regression models evaluating drug use, depressive
symptoms, and dissociation as mediating variables for the relationship between violence
exposure and PTSD. There are four steps to test for mediation as indicated in the table.
The first, second, and third steps are simple linear regressions, and the fourth step is a
stepwise regression testing each model of mediation. In the first three steps, drug use,
depressive symptoms, and dissociation are dependent variables with violence exposure at
the independent variable. In the forth step, PTSD is the dependent variable (DV) and
violence exposure, drug use, depressive symptoms, and dissociation as the independent
variable. Violence exposure is the first independent variable (IV-1) to be used in the
stepwise regression equation with drug use, depressive symptoms, and dissociation as the
second independent variables (IV-2) to be entered into the regression equation.
Step one tests for the direct predictive relationship between violence exposure and
PTSD. For both groups, violence exposure did predict PTSD with the relationship being
strongest for students in the alternative school. Step two tests the relationships between
IV-1 (violence exposure) and the three IV-2s (depressive symptoms, dissociation, and
drug use). Among high school students, violence exposure predicted depressive
symptoms, dissociation, and drug use. For students in the alternative program,
dissociation was the only IV-2 predicted by being exposed to violence. Step three
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Table 11:
Regression Analysis to Test for Mediators Of Violence Exposure and PTSD Across Schools f Steps I - IV).
Simple Linear Beta
Hieh School
R2 F
Alternative School
Beta R2 F
Step I: Violence Predicting PTSD.
IV I: Total Score for Violence Exposure .37 .13 10.32** .71 .48 21.14***
Step IP. Violence Predicting Mediators.
IVII: Drug Use - Psychological Benefits .37 .14
9 4 4 **
.1 2 .1 2 .30
IVII: Depressive Symptoms .29 .08 5.33** .39 .15 3.72
IVII: Dissociation .44 .2 0 14.36*** .45 .2 0 5.19**
Step IIP. Mediators Predicting PTSD.
IVII: Drug Use - Psychological Benefits .41 .17 11.71** .2 1 .04 .95
IVII: Depressive Symptoms .73 .53 67.22** .54 .29 8.85**
IVII: Dissociation .80 .64 103.73*** .75 .56
27 4 4 ***
Step IV: Mediation Models (Stepwise). Beta R2 R2 Change F Beta R2 R2 Change F
Model I:
IVI - Total Score for Violence Exposure .31 .17 .17 8.64** N/S
IVII - Drug Use - Psychological Benefits .27 .23 .06
Model II:
IVI - Total Score for Violence Exposure .6 8 .53 .53 37.85*** N/S
IVII - Depressive Symptoms .19 .57 .03
Model III:
IVI - Total Score for Violence Exposure N/S .47 .57 .57 28.78***
IVII - Dissociation .55 .74 .17
* s . 0 5 ;
** 5.01;
* * * 5 . 000.
42
examines the three IV-2s as predictors for PTSD. All three IV-2s predicted PTSD among
the high school students, however for youth in the alternative program, only depressive
symptoms and dissociation predicted PTSD.
The forth step tests is the final step to test for mediation. Violence exposure is
regressed with each IV-2 using stepwise regression equations. Among high school
students, Psychological Benefits of drug use and Depressive symptoms were found to be
significant mediators in reducing the amount of variance accounted for by violence
exposure in predicting PTSD. Among these mediators, depressive symptoms appeared to
have the strongest effect in reducing the effect of violence exposure in developing PTSD
symptoms among high school students. It should be noted that a mediation trend for
depressive symptoms did emerge for students in the alternative program. However,
dissociation was the only variable found to mediate the effect of violence exposure on
PTSD among students in the alternative school. The effect of violence exposure on PTSD
was reduced dramatically when dissociation was entered into the model and was the
strongest effect observed among the three mediation models.
Discussion
Research Questions.
This study explored the relationship between violence exposure and PTSD among
Latino adolescents. As expected, adolescents in the alternative school reported higher
rates of violence exposure than high school students. This difference was consistent
regardless of whether they were witnessirig or experiencing the event; and were also higher
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43
in the domains of school and community. In comparison to other studies (Bell and Jenkins,
1993; Fitzpatrick & Boldizar, 1993; Richters and Martinez, 1993; Shakoor & Chalmers,
1991), prevalence rates measured in this study tended to be higher. For example, Bell and
Jenkins (1993) presented results from four studies investigating violence prevalence rates
among older children for witnessing robberies (55.1%), stabbings (34.6%), shootings
(39.4%) and killings (23.5%) and these were lower than the rates observed among youth in
the alternative program. However, Fitzpatrick and Boldizar (1993) investigating violence
prevalence rates among African American adolescents found slightly higher rates for
fistfights (78%), stabbings (55%), shootings (69%) and killings (44%) than those observed
among students in the alternative school. Unfortunately, epidemiological research
establishing national rates for violence exposure are unavailable, therefore comparisons of
prevalence are limited to smaller studies.
Even though prevalence rates were much higher among youth in the alternative
school, violence exposure was still high among high school students. For example, nearly a
quarter had experienced gunfire, carried a weapon, and robbed/mugged. Both groups of
students may be at risk for high levels of emotional distress, evidenced by the fact that no
significant group differences for PTSD, Depressive Symptoms, or Dissociation were
observed. However, there may be a certain level of violence exposure at which a students’
ability to stay in school is impaired. This may support research establishing an association
between high levels of PTSD and low academic or delinquent behavior among adolescents
(Breslau, Davis, Andreski, & Peterson, 1991; Giaconia, Reinherz, Silverman, Pakiz, Frost,
& Cohen, 1995; Shakoor & Chalmers, 1991). PTSD. Giaconia et al. (1995) observed
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44
significantly lower GPA scores among youth diagnosed with PTSD. Violence exposure
may be moderating the relationship between academic performance and PTSD.
Overall, students placed in the alternative program were significantly higher in drug
use than high school students. More alternative school students had used alcohol,
marijuana, psychedelics, and cocaine than rates reported among high school students. The
same trend was observed for the personal involvement and psychological benefits
subscales. Fortunately, national prevalence rates for drug use are available for comparison.
Contrasting our data to the 1997 national averages for lifetime drug use (See Table 12),
prevalence rates for drug use were higher for both groups of students. Dramatic
differences were observed in the percentage of students who have used marijuana, LSD and
other psychedelics, and cocaine during their lifetime, with the greatest difference being
between the national rates and alternative school students. Adolescents’ drug use may be
precipitated by exposure to violence or be it may be an outcome of severe exposure to
violence. Further research is needed in order to understand how these two variables
interact among Latino youth.
The next goal was to see if violence exposure would predict depressive symptoms,
drug use/abuse, dissociation, and PTSD, and if so, did these relationships vary between the
two groups of students. Among high school students, the hypothesis that violence
exposure would predict depressive symptoms, drug use, and PTSD was supported.
However, for students in the alternative program, being exposed to violence only predicted
dissociation and PTSD; and did not predict depressive symptoms or drug use. These
results do support previous research indicating violence exposure as a risk factor
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45
Table 12:
Comparison of National Prevalence Rates for Drug Use to Both Schools.
Variable
National
Rates
%
High
School
%
Alternative
School
%
Types of Drug Use:
Alcohol 69.2 82.0 95.7%
Marijuana/Hashish 38.2 57.4% 91.3%
LSD 8.2 14.8% 30.4%
Other Psychedelics (Mescaline, PCP, Mushrooms) 2.7 9.8% 39.1%
Cocaine (Crack, Crystal Meth.) 5.4 18.0% 60.9%
Amphetamines (Speed, Uppers, Bennies) 12.6 19.7% 21.7%
Drug with Depressive/Numbing Effects Unavailable 19.7% 30.4%
(Quaaludes, Tranquilizers, Heroin, Opium, Morphine)
Inhalants (Sniffed Glue, Aerosol Spray Can) Unavailable 26.2% 60.9%
Herbal Drugs Unavailable 21.3% 30.4%
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for PTSD (Bell & Jenkins, 1993; Berton & Stabb, 1996; Breslau, Davis, Andreski, &
Peterson, 1991; CufFe, Addy, Garrison, Aller, Jackson, McKeown, & Chilappagari, 1998;
Fit2patrick & Boldizar, 1993; Lehmann, 1997; Singer, Anglin, Song, & Lunghofer, 1995).
However, these studies do not investigate factors that can mediate or moderate the
association between violence exposure and PTSD. It is possible that lower rates of
violence exposure produce lower levels of distress which are not severe enough to
undermine an adolescents’ ability to stay in school. In addition, drugs may be more
effective in medicating the emotional distress at these lower levels of exposure. In
comparison, students with higher rates of violence exposure, regardless of their high rates
of drug use, are unable to stay in high school and out of criminal activity. Possibly, drug
use is ineffective at the higher levels of violence exposure. Unfortunately, these questions
can not be answered in this data and further research is needed.
The analysis revealed that as violence exposure rates increased, the severity of
PTSD symptoms increase proportionally. This finding supports Doyle’s (1989) construct
of "cumulative trauma" or "layered trauma" referring to increased levels of violence
exposure producing more intense symptomology. Nevertheless, teasing apart the influence
each violent event has in developing symptoms for PTSD is extremely difficult. It is
possible that being exposed to more severe events such as gunfire, stabbings, and murder
may increase the distress levels of the less severe events of fistfights or robberies. For
example, results indicate that the less severe events (i.e. fistfights, robbery) significantly
predicted PTSD across both groups. The probability that only being exposed to fistfights
would produce PTSD symptoms is highly unlikely. However, the results of fistfights
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47
significantly predicting PTSD maybe more a function of participants having also been
exposed to more severe events such as gunfire, stabbings, and murder.
However, violence exposure did not predict depressive symptoms among students
in the alternative school and these findings contradict results found by other researchers
(Breslau, Davis, Andreski, & Peterson, 1991; Fitzpatrick & Boldizar, 1993; Giaconia,
Reinherz, Silverman, Pakiz, Frost, & Cohen, 1995; Singer, Anglin, Song, & Lunghofer,
1995). For example, Singer et al. (1995) reported violence exposure as a significant
predictor for depressive symptoms. However, both studies exhibited lower prevalence
rates for violence exposure and this may indicate different mental processes at high and low
levels of exposure. It is possible that at lower levels of violence exposure, depressive
symptoms may co-occur with PTSD, and then at higher levels of violence exposure
adolescents may need to engage in more dissociative processes in order to cope with the
increased intensity of violence. This may have been evidenced by the fact that violence
exposure predicted dissociation among students in the alternative program and they did
report significantly higher levels of violence exposure.
Results indicating that violence exposure predicted drug use among high school
students supports the findings of Giaconia et al. (1995). As part of an ongoing longitudinal
study investigating the co-occurrence of PTSD and other among 385 adolescents, Giaconia
et al. (1995) reported an association between serious substance dependence and PTSD for
more than two thirds of the sample. Despite the fact that prevalence rates for violence
exposure and drug use were highest among students in the alternative school, and the fact
that these rates seem to be high in comparison to other indicators, violence exposure did
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48
not predict drug use among students in the alternative program. It is possible that drug use
may medicate the effects of being exposed to violence at lower levels and that for youth
experiencing the higher levels drug use may stop being effective as a coping strategy. As
previously stated, students in the alternative program may have needed to cognitively
dissociate as a method of coping with their emotional distress due to experiencing higher
levels of violence exposure.
The final goal of the study was to investigate drug use, depressive symptoms, and
dissociation as mediators between violence exposure and PTSD. Among high school
students, drug use and depressive symptoms significantly mediated the relationship between
violence exposure and PTSD, and dissociation was found to be a significant mediator only
for students in the alternative program. This is an important finding because it begins to
clarify how these variables are interrelated. The relationship between violence exposure
and PTSD is not a direct one and factors that mediate the relationship should be
considered.
Limitations.
The results presented in this paper must be viewed in light of methodological
limitations of the study. First, sample size was not large enough to be able to make more
conclusive statements about the relationships among the variables. There was not sufficient
power to detect significant effects that might be small in magnitude. It is possible that drug
use did mediate the effect of violence exposure among youth in the alternative program.
However, with a small sample, it is difficult to make any definitive statement. Next, a few
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49
outliers emerged in the sample. This may been the reason why no differences were
detected between the groups for depressive symptoms, dissociation, and PTSD. For this
preliminary analysis, a decision was made to include these subjects in the analysis because it
was unclear whether or not the outliers represented a specific phenomenon or if these were
an artifact of sampling error. Third, the uneven gender sampling at each of the location
sites did not allow for an accurate assessment of gender differences among the variables.
Forth, volunteer bias may have occurred as a result of students avoiding participation, or it
is possible that only the most distressed students volunteered because they needed to share
their experiences. Unfortunately, a social desirability measure was not included in order to
control these factors in the analysis. Finally, participants completed self report
questionnaires while interviewers read the questions out loud with subjects circling
response on an answer sheet. This format might have discouraged participants from
reporting violence in the home, sexual abuse, drug use, or gang affiliation. For example,
regardless of repeated assurances that confidentiality regarding drug use would be
maintained, high school students at the high schools may not have felt comfortable
disclosing this information due to the recent prosecutions of students who have used drugs
on campus. In addition for participants at the alternative school, because drug use and
gang involvement are conditions that violate their probation, they may have under-reported
their drug use or gang affiliation.
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50
Future Implications.
These results have a number of important prevention and treatment implications.
First, the high prevalence rates of violence exposure and drug use among both groups of
students are disturbing. These rates are above the national averages and may be indicators
of emerging trends among urban youth which demonstrate the need for prevention
programs directed at assisting youth in developing strategies for coping with these risk
factors for emotional distress. In addition, the extremely high prevalence rates for students
in the alternative program underscore the need for an intervention program directly
targeting this population. These students are clearly at risk for chronic later life problems.
Urban youth are having to cope with significantly higher levels of stress and these
experiences may be undermining students’ ability to stay in school.
The majority of the gang affiliated participants were enrolled in the alternative
program, and the behavior that might have placed them on probation, may also have been a
psychological response to their increased levels violence exposure. It is difficult to
determine which came first, increased levels of violence exposure or whether being in a
gang increased the participant’s risk for being exposed to violence. Longitudinal research
in this area is needed in order to fully understand the psychological processes that a child
undergoes while on the road to becoming involved in a gang. If a significant amount of
men exposed to combat in Vietnam were found to be suffering from PTSD (Frye, 1982;
Engendorf, 1981), then it can be hypothesized that urban gang youth might be suffering
from PTSD having been exposed to a significant amount of community violence at a young
age.
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51
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An investigation of a new diagnostic sub-type: Post traumatic stress disorder with psychotic features

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Creator Devich-Navarro, Mona (author)

Core Title Triple threat: Community violence as a predictor for post traumatic stress disorder and the associated features of drug use and depressive symptoms among Latino youth

Contributor Digitized by ProQuest (provenance)

Degree Master of Arts

Degree Program Psychology

Publisher University of Southern California (original), University of Southern California. Libraries (digital)

Tag OAI-PMH Harvest,Psychology, clinical,psychology, developmental

Language English

Permanent Link (DOI) https://doi.org/10.25549/usctheses-c16-310288

Unique identifier UC11336739

Identifier 1417209.pdf (filename),usctheses-c16-310288 (legacy record id)

Legacy Identifier 1417209.pdf

Dmrecord 310288

Document Type Thesis

Rights Devich-Navarro, Mona

Type texts

Source University of Southern California (contributing entity), University of Southern California Dissertations and Theses (collection)

Access Conditions The author retains rights to his/her dissertation, thesis or other graduate work according to U.S. copyright law. Electronic access is being provided by the USC Libraries in agreement with the au...

Repository Name University of Southern California Digital Library

Repository Location USC Digital Library, University of Southern California, University Park Campus, Los Angeles, California 90089, USA