The Impact of Adverse Childhood Experiences and Community Violence Exposure on a Sample of Anxious, Treatment-Seeking Children.

Screening for adverse childhood experiences (ACEs) can help prevent and reduce adverse outcomes on child development, including increased risk for anxiety disorders. Emerging studies strongly support the inclusion of community-level adversities in ACE screeners to consider diverse contexts and populations. Recent studies suggest that community violence exposure (CVE) may have a distinct impact on youth mental health. Although recent studies have examined the association between ACEs, CVE, and mental health in primary care settings, this association has not been examined on treatment-seeking children in urban mental health settings. The present study employs a mediation model using the PROCESS macro to examine community violence exposure mediating the effect on the association between ACEs and somatic symptoms (SS) on a sample of anxious treatment-seeking children. A total of 98 participants (Mage = 11.7, SD = 3.79, 51.6% males, 54.1% ethnic minority children) who sought services at a specialized anxiety clinic completed self-report measures. Results indicated that exposure to ACEs is associated with endorsement of somatic symptoms as a result of reporting hearing, witnessing, or experiencing CVE. Evidence of mediation was found in a statistically significant indirect effect of ACEs on SS through CREV (Effect = .17, 95% CI = .069-.294). These findings support recent evidence that CVE is a distinct ACE as it contributes to toxic stress similar to individual-level ACEs. The use of a comprehensive ACE screening that includes CVE is warranted, particularly when working with culturally and socioeconomically diverse populations, as it would better capture a broader range of adversities across demographic groups.

The Urban Youth Trauma Center: A Trauma-Informed Continuum for Addressing Community Violence Among Youth.

Contemporary community violence has escalated into a national public health crisis with urban youth, particularly ethnic minorities, suffering disproportionate negative impacts. The Urban Youth Trauma Center (UYTC) promotes a trauma-informed continuum of prevention-to-intervention services that combines community-based and clinic-based manualized protocols designed to reduce and prevent community violence for youth and families. Based on a socio-ecological model, UYTC has the main goals of addressing community violence and related traumatic stress as well as co-occurring conditions of substance abuse and disruptive behavior problems in urban youth by: (1) raising public awareness; (2) disseminating specialized trauma-informed training; and (3) mobilizing service system coalitions. UYTC employs this evidence-based yet flexible structure for disseminating, implementing, and evaluating trauma-informed training as a means of contributing to the reduction and prevention of community violence for low-income urban minority youth and families who bear the biggest burden of this current crisis.

Identifying Bereavement-Related Markers of Mental and Behavioral Health Problems Among Clinic-Referred Adolescents.

Objective: This study examined bereavement-related risk markers (number of deaths, cause of death, and relationship to deceased) of mental and behavioral health problems (suicidal thoughts or behaviors, self-injury, depression, posttraumatic stress, and substance use) in a national sample of clinic-referred bereaved adolescents. Method: Participants included 1281 bereaved youth aged 12-21 years (M=15, SD=1.8; 62.1% female), from the National Child Traumatic Stress Network Core Data Set. Results: Generalized linear mixed-effects regression models controlling for demographics and other traumas revealed that youth bereaved by multiple deaths had higher posttraumatic stress scores than youth bereaved by a single death (Estimated difference ±SE=3.36 ± 1.11, p=0.003). Youth bereaved by suicide were more likely to report experiencing suicidal thoughts or behaviors (AOR=1.68, p=0.049) and alcohol use (AOR=2.33, p<0.001) than youth bereaved by natural causes. Youth bereaved by homicide were at greater risk for substance use than youth bereaved by natural death (AOR=1.76, p=0.02). Compared to parentally bereaved youth, youth who lost a peer were more likely to use alcohol (AOR=2.32, p=0.02) or other substances (AOR=2.41, p=0.01); in contrast, parentally bereaved youth were more likely to experience depression compared to those who experienced the death of an adult relative or unrelated adult (range of AOR: 0.40 to 0.64, p-values<0.05). Conclusion: These bereavement-related contextual factors can serve as early markers of mental and behavioral health problems among bereaved youth.

Psychometric properties of the Community Violence-Prevention Activation Measure (CV-PAM): Evaluating provider activation toward community violence prevention.

This study reports on the conceptualization of activation, and the development and psychometrics of the Community Violence-Prevention Activation Measure (CV-PAM). The CV-PAM was adapted from the Patient Activation Measure (PAM; Hibbard et al., 2004, Health Serv Res, 39, 1005-1026; Hibbard et al., 2005, Health Serv Res, 40, 1918-1930) for use among a workforce servicing youth exposed to community violence. Activation toward community violence prevention is defined as a process in which community members are activated to prevent violence, believe they have important roles to play in violence prevention and supporting the well-being of community members. Activated community members have a good understanding of the factors that contribute to violence and they apply skills and strategies that are consistent with prevention efforts. Six hundred and ninety-four youth providers completed the 18-item CV-PAM to describe their level of activation toward community violence. Exploratory and confirmatory factor analyses were performed and demonstrated that a three factor versus a four factor structure of activation (modeled after PAM) held together. The three factors included (a) belief that an active role is important to address community violence; (b) having the confidence and knowledge to take action around community violence prevention; (c) taking action: frequency of participation and responsiveness to community needs. The proposed fourth factor, staying the course under stress, did not have any qualifying loadings, and thus, could not be interpreted. CV-PAM performed well in tests of reliability and validity. The CV-PAM appears to be a precise, valid, reliable, and useful measure. Implications suggest that using this tool is potentially the first step toward understanding activation among engaged providers and a stepping stone toward increased involvement in community violence prevention through implementation and dissemination efforts.

The Association between Caregiver Substance Abuse and Mental Health Problems and Outcomes for Trauma-Exposed Youth.

Trauma-exposed youth with impaired caregivers (i.e., due to substance use and/or mental health problems) may be at particular risk for negative outcomes. This study utilized data from the National Child Traumatic Stress Network Core Data Set to examine the impact of caregiver impairment on youth outcomes. Trauma-exposed youth with an impaired caregiver due to either: substance use (n = 498), mental health problems (n = 231), or both substance use and mental health problems (n = 305) were compared to youth without a reported impaired caregiver (n = 2282) to determine if impaired caregiver status is independently associated with increased likelihood of negative behavioral and mental health outcomes and service utilization after accounting for demographics and exposure to traumatic events. Youth with impaired caregivers compared to those without were more likely to display PTSD, emotional and behavioral problems, suicidality, self-injury, and substance abuse and had higher rates of service utilization (p < 0.05). Differential patterns were observed based on the type of caregiver impairment. Findings support the importance of family-centered assessment and intervention approaches for youth affected by trauma.

Community violence and posttraumatic stress disorder symptoms in urban youth: The moderating influence of friend and parent support.

Separate lines of research have demonstrated that community violence predicts posttraumatic stress disorder (PTSD) symptoms in youth and that social support is one protective factor against the development of PTSD symptoms. The current study sought to examine the associations between primary and secondary exposure to community violence and the moderating role of parent and friend support on these relations. Participants were 96 urban youths (aged 6-17 years; 58.4% racial/ethnic minority; 51% female) and a caregiver recruited from a university mental health clinic. Results indicated that both primary and secondary exposure to community violence predicted PTSD symptoms. Friend support, but not parent support, moderated the association between primary, but not secondary, exposure to community violence and PTSD symptoms. The findings suggest that friend support is a salient protective factor for urban youth who may be at risk of PTSD symptoms due to exposure to community violence.

Substance Abuse and Trauma.

There is a strong, bidirectional link between substance abuse and traumatic experiences. Teens with cooccurring substance use disorders (SUDs) and posttraumatic stress disorder (PTSD) have significant functional and psychosocial impairment. Common neurobiological foundations point to the reinforcing cycle of trauma symptoms, substance withdrawal, and substance use. Treatment of teens with these issues should include a systemic and integrated approach to both the SUD and the PTSD.

Gender differences in the effects of community violence on mental health outcomes in a sample of low-income youth receiving psychiatric care.

Previous research suggests that community violence impacts mental health outcomes, but much of this research has not (a) distinguished between different types of community violence, (b) examined gender differences, and (c) focused on youth living in urban poverty. The current study addresses these questions. Participants were 306 youth (23 % girls) and one parent/guardian receiving outpatient psychiatric services for disruptive behavior disorders in a large urban city. Youth and parents reported on youth's experience of different types of community violence (being a direct victim, hearing reports, and witnessing violence), and whether violence was directed toward a stranger or familiar. Outcomes included youth externalizing, internalizing, and posttraumatic stress symptoms assessed via parent and youth reports. Being a direct victim of violence accords risk for all mental health outcomes similarly for both boys and girls. However, gender differences emerged with respect to indirect violence, such that girls who hear reports of violence against people they know are at increased risk for all assessed mental health outcomes, and girls who witness violence against familiars are at increased risk for externalizing mental health symptoms in particular. There are gender differences in violence-related mental health etiology, with implications for intervention assessment and design.

Comparison of behavioral profiles for anxiety-related comorbidities including ADHD and selective mutism in children.

BACKGROUND: Elucidating differences in social-behavioral profiles of children with comorbid presentations, utilizing caregiver as well as teacher reports, will refine our understanding of how contextual symptoms vary across anxiety-related disorders. METHODS: In our pediatric anxiety clinic, the most frequent diagnoses and comorbidities were mixed anxiety (MA; ≥ 1 anxiety disorder; N = 155), anxiety with comorbid attention-deficit hyperactivity disorder (MA/ADHD, N = 47) and selective mutism (SM, N = 48). Behavioral measures (CPRS, CTRS) were analyzed using multiple one-way multivariate analyses of covariance tests. Differences between the three diagnostic groups were examined using completed parent and teacher reports (N = 135, 46, and 48 for MA, MA/ADHD, and SM groups, respectively). RESULTS: Comparisons across the MA, MA/ADHD, and SM groups indicate a significant multivariate main effect of group for caregiver and teacher responses (P < 0.01). Caregivers reported that children with SM are similar in profile to those with MA, and both groups were significantly different from the MA/ADHD group. Teachers reported that children with SM had more problems with social behaviors than with the MA or MA/ADHD groups. Further comparison indicates a significant main effect of group (P < 0.001), such that children with SM have the greatest differences in behavior observed by teachers versus caregivers. CONCLUSIONS: Clinical profiles between MA/ADHD, MA, and SM groups varied, illustrating the importance of multi-rater assessment scales to capture subtle distinctions and to inform treatment planning given that comorbidities occur frequently in children who present with anxiety.

Contextual factors and anxiety in minority and European American youth presenting for treatment across two urban university clinics.

The current study compared ethnic minority and European American clinically-referred anxious youth (N=686; 2-19 years) on internalizing symptoms (i.e., primary anxiety and comorbid depression) and neighborhood context. Data were provided from multiple informants including youth, parents, and teachers. Internalizing symptoms were measured by the Multidimensional Anxiety Scale for Children, Child Depression Inventory, Child Behavior Checklist and Teacher Report Form. Diagnoses were based on the Anxiety Disorders Interview Schedule for Children. Neighborhood context was measured using Census tract data (i.e., owner-occupied housing, education level, poverty level, and median home value). Ethnic minority and European American youth showed differential patterns of diagnosis and severity of anxiety disorders. Further, ethnic minority youth lived in more disadvantaged neighborhoods. Ethnicity and neighborhood context appear to have an additive influence on internalizing symptoms in clinically-referred anxious youth. Implications for evidence-based treatments are discussed.

Treatment and outcomes for anxiety disorders among children and adolescents: a review of coping strategies and parental behaviors.

This article reviews the current literature on the treatment of anxiety disorders in children and adolescents and describes the factors that are essential to address in treatment. Coping deficits and parental behaviors are highlighted as factors that contribute to anxiety in youth. Interventions for anxious youth are described, with particular emphasis on cognitive-behavioral therapy for anxiety disorders. Finally, a review of the longitudinal course of anxiety and suggestions for future directions in treatment and research are provided.

Supporting the need for an integrated system of care for youth with co-occurring traumatic stress and substance abuse problems.

Adolescents are at high risk for violence exposure and initiation of drug use. Co-occurring substance use and trauma exposure are associated with increased risk of mental health disorders, school underachievement, and involvement with multiple systems of care. Coordination and integration of systems of care are of utmost importance for these vulnerable youth. This study delineates the negative sequelae and increased service utilization patterns of adolescents with a history of trauma, substance abuse, and co-occurring trauma and substance abuse to support the need for integrated mental health and substance abuse services for youth. Data from two national sources, the National Child Traumatic Stress Network and Center for Substance Abuse Treatment demonstrate the increased clinical severity (measured by reports of emotional and behavioral problems), dysfunction, and service utilization patterns for youth with co-occurring trauma exposure and substance abuse. We conclude with recommendations for an integrated system of care that includes trauma-informed mental health treatment and substance abuse services aimed at reducing the morbidity and relapse probability of this high-risk group.

"It Depends on What You Mean by 'Disagree'": Differences between Parent and Child Perceptions of Parent-Child Conflict.

We examined a new structured interview of parent-child conflict that assesses parent and child perceptions of behavioral conflict about daily life topics (e.g., doing chores, homework), and whether discrepancies exist on beliefs about these topics. In a sample of 100 parents and children ages 10 to 17 years (M=13.5 years, 52 males, 57 % African-American), informants could reliably distinguish between perceived behavioral conflicts and perceived discrepant beliefs about topics. These scores were also significantly related to questionnaire reports of parent-child conflict. Parent and child questionnaire reports did not significantly differ, yet on the structured interview, parents reported significantly greater levels of perceived conflict and discrepant beliefs relative to child reports. Additionally, structured interview reports of conflict demonstrated incremental validity by relating to child self-reports of delinquent behaviors, when accounting for questionnaire conflict reports. The findings have implications for increasing understanding of the links between parent-child conflict and psychosocial outcomes.

Assessment and treatment of anxiety disorders in children and adolescents.

This article reviews the current screening and assessment tools for anxiety disorders in children and adolescents, as well as evidence-based treatment interventions for these disorders. The following anxiety disorders are discussed: separation anxiety disorder, generalized anxiety disorder, specific phobia, panic disorder, social anxiety disorder (social phobia), and selective mutism. There are several well-studied screening and assessment tools to identify childhood anxiety disorders early and differentiate the various anxiety disorders. Evaluations of baseline somatic symptoms, severity, and impairment ratings of the anxiety disorders, and collecting ratings from several sources is clinically helpful in assessment and treatment follow-up. Cognitive-behavioral therapy (CBT) has been extensively studied and has shown good efficacy in treatment of childhood anxiety disorders. A combination of CBT and medication may be required for moderate to severely impairing anxiety disorders and may improve functioning better than either intervention alone. Selective serotonin reuptake inhibitors are currently the only medications that have consistently shown efficacy in treatment of anxiety disorders in children and adolescents. Despite proven efficacy, the availability of CBT in the community is limited. Current research is focusing on early identification of anxiety disorders in community settings, increasing the availability of evidence-based interventions, and modification of interventions for specific populations.

Prevalence and correlates of childhood-onset anxiety disorders among Latinos and non-Latino whites in the United States / /Prevalencia y correlación del inicio de los trastornos de ansiedad en la infancia entre blancos latinos y no latinos en los Estados Unidos

Los trastornos de ansiedad son los trastornos psiquiátricos más comunes (Kessler et al., 2005) y su comienzo a temprana edad pone a las personas en riesgo de una gran variedad de problemas posteriores (Weissman et al., 1999). Se utilizaron los datos del Estudio Nacional de Latinos y Asiáticos Americanos (National Latino and Asian American Study, NLAAS) y de la Replicación de la Encuesta Nacional de Comorbilidad (National Comorbidity Survey-Replication, NCS-R) para investigar la prevalencia y los factores asociados con el inicio de la ansiedad en la infancia entre los blancos nacidos en Estados Unidos, Latinos nacidos en Estados Unidos y Latinos nacidos en el extranjero. Se encontraron diferencias significativas en las tasas del trastorno por ansiedad con inicio en la infancia, con las tasas más bajas en los Latinos nacidos en el extranjero. En los tres grupos de etnia/lugar de nacimiento, los individuos con trastornos de ansiedad con inicio en la infancia mostraron niveles similares o más elevados de deterioro en el año anterior que los individuos con trastornos de ansiedad con inicio en la adultez. También se mostró el curso crónico asociado con los trastornos de ansiedad de comienzo en la infancia, pues estuvo presente sin importar la etnia o el lugar de nacimiento, indicado por las semejanzas a través de los grupos en el número promedio de trastornos a lo largo de la vida y las tasas de comorbilidad. Se discuten recomendaciones para la evaluación y el tratamiento con respecto a los hallazgos del estudio (AU)

Anxiety disorders are the most prevalent class of psychiatric disorders (Kessler et al., 2005) and their early onset places individuals at risk for a wide range of subsequent problems (Weissman et al., 1999). Data from the National Latino and Asian American Study (NLAAS) and the National Comorbidity Survey-Replication (NCS-R) were used to investigate the prevalence and correlates of childhood-onset anxiety disorders among U.S.-born whites, U.S.-born Latinos, and foreign-born Latinos. Significant differences in rates of childhood-onset anxiety disorders were found, with foreign-born Latinos reporting the lowest rates. Across all three ethnicity/nativity groups, individuals with childhood-onset anxiety disorders had equal or higher levels of past-year impairment, relative to individuals with adult-onset anxiety disorders. The chronic course associated with childhood-onset anxiety disorders was also revealed to be present regardless of ethnicity and nativity, as indicated by the similarities across groups in the mean number of lifetime disorders and comorbidity rates. Treatment and assessment recommendations are discussed with respect to the findings

Prevalence and Correlates of Childhood-Onset Anxiety Disorders among Latinos and Non-Latino Whites in the United States.

Anxiety disorders are the most prevalent class of psychiatric disorders (Kessler, et al., 2005) and their early onset places individuals at risk for a wide range of subsequent problems (Weissman, et al., 1999). Data from the National Latino and Asian American Study (NLAAS) and the National Comorbidity Survey-Replication (NCS-R) were used to investigate the prevalence and correlates of childhood-onset anxiety disorders among U.S.-born whites, U.S.-born Latinos, and foreign-born Latinos. Significant differences in rates of childhood-onset anxiety disorders were found, with foreign-born Latinos reporting the lowest rates. Across all three ethnicity/nativity groups, individuals with childhood-onset anxiety disorders had equal or higher levels of past-year impairment, relative to individuals with adult-onset anxiety disorders. The chronic course associated with childhood-onset anxiety disorders was also revealed to be present regardless of ethnicity and nativity, as indicated by the similarities across groups in the mean number of lifetime disorders and comorbidity rates. Treatment and assessment recommendations are discussed with respect to the findings.

Identification of high-risk behaviors among victimized adolescents and implications for empirically supported psychosocial treatment.

An adolescent's possible response to being the victim of interpersonal violence is not limited to posttraumatic stress disorder and depression but may also involve a host of developmental effects, including the occurrence of high-risk behaviors that may have a significant and negative impact on the adolescent's psychological and physical health. Identifying such high-risk behaviors, understanding their possible link to a previous victimization incident, and implementing interventions that have been demonstrated to reduce such behaviors may help decrease potential reciprocal interactions between these areas. Clinicians in psychiatric practice may be in a unique position to make these connections, since parents of adolescents may perceive a greater need for mental health services for youth engaging in problematic externalizing behaviors than for those displaying internalizing symptoms. In this article, the authors first describe high-risk behaviors, including substance use, delinquent behavior, risky sexual behaviors, and self-injurious behaviors, that have been linked with experiencing interpersonal violence. They then review empirically based treatments that have been indicated to treat these deleterious behaviors in order to help clinicians select appropriate psychosocial interventions for this population. Recommendations for future research on the treatment of high-risk behaviors in adolescents are also presented.