Published in the Fall 2009 issue of SSA Magazine

Studies show that adolescents' exposure to community violence can cause trauma and lead to destructive behaviors.

-By Carl Vogel

CHICAGOANS FOLLOWED IN DISMAY last year as the Chicago Tribune kept a careful tally of each homicide of a Chicago Public School student—by the end of 2008, the number stood at 34. For students at Gage Park High School on the city's Southwest Side, each death was more than a story in the newspaper.

"Every time a CPS student was killed, our students were affected," says Marion Fletcher, the CPS social worker assigned to the high school. "Our students might have been friends or cousins, or they attended school with the student before coming here."

Fletcher, an SSA graduate who has been a school social worker for 20 years and at Gage Park for more than a decade, has seen the impact of violence in the community again and again. "Right up front, there's crying and signs of trauma. Later on, the reactions may vary, depending on the student. But for every child I've worked with, the violence has had an effect on their school work. It's not human to just become used to it," she says.

Fletcher helps students through a wide variety of issues every day that stem from troubles in the community, from a lack of economic opportunities to eviction and homelessness to parental stress, and she understands the role these kind of factors play in creating violence in the neighborhood. But she also sees the toll it takes on students when they witness community violence— loosely defined as an act of violence outside the home, including robberies, muggings, gang-related fights or homicides. Exposure can include being an eyewitness to the incident, seeing the victim afterward and even hearing about it from a neighbor or friend.

"I hear about it so often," she says. "Students are absent because, while many feel safe here in the school, they are anxious about traveling the route from home to school. Some become withdrawn and can't concentrate when they're here. Or they become angry with the situation, make comments like, "I think I'm going to go off ' and become aggressive themselves."

In the early 1990s, a growing number of researchers began looking at the prevalence of community violence. Then, as the scope of the problem became better documented, there were more studies on its effects on mental health, especially to youth, finding that exposure brings greater risk for aggression, depression, anxiety and posttraumatic stress symptoms or disorders. What is only now becoming more apparent, however, is the wider effects that extend into areas such as delinquency and risky sexual behaviors.

"Violence has an impact beyond the victim and the family. There's a ripple effect in the lives of young people who are exposed as witnesses and live in those communities, and we're just beginning to figure how the multiple negative problems associated with such exposure are interrelated," says Dexter Voisin, an associate professor at SSA. "Many clinicians, teachers and service providers working with these youths understand such connections. Research is now making the empirical links."

Neil Guterman, the School's Mose and Sylvia Firestone Professor, argues that we are dramatically underestimating the impact of exposure to community violence on young people, and that social workers and social welfare institutions should be much more aware of the problem. "In comparison to the problem of violence inside the home—child abuse and domestic violence, for example—we're decades behind in what we know, agreed upon service strategies, dedicated service systems and resources to address the problem," he says.

MURDER MAKES THE HEADLINES—and is a shocking, tragic event—but gauging how much violence young people encounter by keeping an eye only on the murder rate is vastly underestimating the problem. One study in 1997 estimated that for every homicide, there are 100 nonfatal assaults, and the National Crime Survey has counted more than a million crimes of violence against adolescents that go unreported each year.

For minorities and those living in low-income communities, the statistics are more grim. African- American youth are eight times more likely to be victims of homicides compared to white youth, according to the Centers for Disease Control, and a 1993 study of African-American children at three elementary schools in Chicago found that one in four had witnessed a shooting, and one-third had seen a stabbing.

In a study by Voisin and other researchers of more than 500 youth in detention centers in Georgia published in Social Work Research last year, more than three-quarters of those surveyed had witnessed one or more types of violence in the past 12 months. Of that group, 20 percent had a family member robbed or attacked and more than half had seen someone beaten, shot or seriously hurt by someone.

Yet community violence is not only a problem in distressed communities. "There are a growing number of studies that find community violence is a problem that transcends geographic, ethnic and class lines, and even national borders. The problem is often portrayed in the media as solely an urban or African-American one, but it's not," Guterman says.

The National Child Traumatic Stress Network cites exposure to community violence incidents such as gang-related violence in the community and school shootings as acute traumatic events. In an article last year in the journal Residential Treatment for Children & Youth, the researchers cite a strong linear relationship between more traumatic experiences and an increased level of high-risk behaviors of children in foster care.

"Exposure to community violence can be one type of these traumatic experiences," says one of the study's authors, Gene Griffin, the clinical director of the Illinois Childhood Trauma Coalition and an assistant professor at Northwestern University's Department of Psychiatry and Behavioral Sciences. "We found that the more categories a child fell under, the more likely they would have disrupted development." Another study co-authored by Voisin found that of multi-ethnic youth who had witnessed community violence in the past 12 months, 76 percent reported more than one type of exposure.

Individuals process trauma differently, and an event or series of events that causes post-traumatic stress disorder (PTSD) in one teen can be responded to differently by another. "About 8 percent of men and 20 percent of women exposed to a traumatic event develop PTSD, however, the rates can be higher for various types of traumas," says SSA Assistant Professor Malitta Engstrom. In the wake of community violence exposure, studies have found that girls are more likely to isolate themselves and be depressed, while boys are more likely to act out or be aggressive.

Voisin's research is part of a movement that is exploring how community violence's influence goes even deeper. For example, in his study of multi-ethnic youth, Voisin found that those exposed to community violence were almost four times more likely to have had sex without condoms, engaged in sex while using drugs or alcohol, or engaged in group sex. Another study of urban African-American adolescents in middle and high school found that exposure to community violence is associated with increased rates of alcohol and marijuana use, and other findings have linked exposure to poorer academic outcomes.

In a paper published in African-American Research Perspectives, Voisin and Vincent Guilamo-Ramos, an associate professor at the Columbia University School of Social Work, begin to tease out the indirect factors that may be causing these behaviors. Seeing violence in the community may lead to expectations for a shorter life expectancy, for instance, which makes careful decisions about behavior seem less important. Risk desensitization may mean that adolescents are less able to discern the potential harm of risky behavior. And social control theory would argue that common violence weakens the authority of institutions and conventional values against these activities.

"I think there is a web of connections that we really haven't fully explored yet around community violence and negative outcomes," Voisin says. "When kids are afraid to go to school, it means they're probably unsupervised at home, which is one of the greatest risk factors for sexual risk taking. And of course, being out of school affects academic performance. If a male adolescent is being aggressive, studies have shown that he's less likely to be positively evaluated by teachers—and that affects academics too. What is unfortunate is that many of these males are manifesting untreated symptoms of trauma exposure."

IN THE AFTERMATH OF THE SHOOTINGS at Columbine High School, the student witnesses were provided with mental health counseling, as is typically done in these kinds of horrific situations. And for youth who experience or are exposed to violence inside the home, there are service systems in place to protect them, both physically and mentally— along with professional journals, conferences, funding streams and organizations dedicated to the cause.

"The equivalent does not exist for violence when it occurs outside the home," Guterman notes. "For example, social workers don't face a specific mandate like child abuse reporting when they know that someone has experienced or eyewitnessed violence outside the home. Yet we know the psychosocial consequences are parallel to violence exposure inside the home, and there are more reported deaths every year from violence outside the home."

Absent a system to provide support to those exposed to community violence, most adolescents do not get mental health services after experiencing it. In fact, Guterman has found in research of a nationwide sample that, after accounting for common behavioral difficulties, adolescents who are victimized hold a significantly lower likelihood of receiving mental health services than those who are not. "Some of this problem lies at the clinical level—you can't do something about a problem if you don't know it's there. But social workers and health care professionals don't routinely screen for violence exposure outside the home," he says.

In a study at residential treatment centers outside New York City, published in the American Journal of Orthopsychiatry, Guterman and his colleagues found that 23 percent of the children reported witnessing a murder— but not a single social worker at the facilities knew that fact about their clients. Similarly, more than 40 percent of the youth had seen someone shot, yet only 5 percent of the therapists knew that their clients had that experience. And, as Guterman notes, "these were kids who had been at a long-term treatment facility for weeks and weeks."

Guterman labels the condition a "don't ask, don't tell" situation, where social workers and clients both remain mum about the reality of community violence with a lack of training, policy mandates and clinical procedures abetting the silence. "Clinicians generally don't know what to do with the problem when they find it, and that appears to be one of the reasons they overlook it," Guterman notes (for more, see "Behind the Numbers" on page 44).

Although the systemic changes that Guterman envisions are not on the horizon at this time, there are promising signs that key institutions are beginning to take the issues of exposure to community violence seriously. For example, last year the Chicago Public Schools instituted a program, "Cognitive Behavioral Intervention for Trauma in Schools" (CBITS), that was developed for the Los Angeles Unified School District in conjunction with the University of California, Los Angeles and the RAND Corp.

A skills-based, group intervention, CBITS consists of 12 weekly group sessions during the school day, where students learn skills in relaxation, challenging upsetting thoughts and processing traumatic memories and grief. During this school year, CPS will institute the program at approximately 90 schools. Two other programs, "Second Step" and "Lion's Quest," are being implemented at another set of schools, determined by a metric of academic achievement, attendance and disruptive behavior.

"We're highly invested in a multi-tiered strategy that works to prevent violence by building coping and problem-solving skills. But we know, as much as we're working to prevent violence, kids are going to encounter it at times in the community, and we're very interested in reducing the impact of that exposure on their success in school," says Jennifer Loudon, the CPS manager of coordinated school health and an alumna of SSA.

For Dexter Voisin, the next step in his work is clear: He wants to begin working in schools to bring more clinical interventions to the students who have been exposed to community violence. "We have to move beyond assessing this problem," he says. "That is important, but we know this is affecting our children. We have to talk about how to help them cope and help them relieve these pressures and ensure that such efforts are routinely incorporated into the programmatic efforts of schools in high violence communities."