rt Violence Exposure, Trauma, and 1Q and/or Reading Deficits Among Urban Children Virginia Delaney-Black, MD, MPH; Chandice Covington, PRD, RN, CPNP; Steven J. Ondersma, PhD; Beth Nordstrom-Klee, PhD; Thomas Templin, PhD: Joel Ager, PhD; James Janisse, PhD; Robert J. Sokol, MD Background: Exposure to violence in childhood has been associated with lower school grades. However, the association between violence exposure and perfor mance on standardized tests (such as 1Q oF academic achievement) in children is unknown. Itisalso not known whether violence exposure itself or subsequent symp- toms of trauma are primarily responsible for negative out- Objectives To examine the relationship beween vio- lence exposure and trauma-related distress and stan- dardized test performance among early school-aged urban children, controlling for important potential ‘confounders Design: A total of 209 urban first-grade children and their earegivers were evaluated using self-report, inter- View, and standardized tests Main Outcome Measures: The child's 1Q (Wechsler Preschool and Primary Scale of Intelligence-Revised) and reading ability (Test of Early Reading Ability, second edi tion) were the outcomes of interest Results: After controlling for confounders (child’s gen- der, caregiver's IQ, home environment, socioeconomic sta- tus, and prenatal exposure to substance abuse) violence ex- posure was related to the child's 1Q (P=.01) and reading, ability (P=.045). Trauma-related distress accounted for additional variance in reading ability (P2.01). Using the derived regression equation to estimate elfect sizes, a child experiencing both violence exposure and trauma-related distress at or above the 90th percentile would be expected to have a 7.5-point (SD, 0.5) decrement in IQ and a 0.8- point (SD, 0.66) decrement in reading achievement, Conelusion: In this study, exposure to violence and trauma-related distress in young children were associ- ated with substantial decrements in 1Q and reading achievement Arch Pediatr Adolesc Med. 2002;156:280-285 LURPRISINGLY HIGH levels ofself- reported violence, both via wit nessing ofand victimization by violent events, are consis- tently found in young urban From the Division of Such research, however, has exelud- ced young children at an early school age. In addition, reports have focused only on relations between violence exposure and grade suppression, which could result from ‘NeonatalPerinatal Medicine, Department of Pediatrics, childrens Hospital of Michigan (Drs Delaney-Black and [Nordstrom-Klee), the ‘Merril Palmer Institute (Br Ondersma), the Center {for Healthcare Effectiveness Research (Ds Ager and Janise), the Collegeof Nursing (Dr Templi), andthe C.S. Mott Center for Human ‘Growth and Development and Department of Obstetrics and Gynecology (Dr Soka), Wayne State University, Detroit Mick; an the School of Nursing, University ‘9f California, Los Angeles (Dr Covington. Downloaded From: https: children."? children reporting high levels of violence exposure have demonstrated higher levels of both internalizing and externalizing behaviors. In addition, evi dence of poor school outcomes among older children affected by violence is also ‘mounting. For example, community vio- lence exposure (such as witnessing oF experiencing a robbery, or being threat- ened with a Weapon) was associated with a decrease in school attendance and grades in a large (N=2009) sample of middle- and high-school students.” Adolescent girls (aged, 12-21 years) in a primary care setting and meeting criteria for posttraumatic stress disorder (PTSD) were more likely to have failed a school grade.” associated behavioral problems, emo- tional problems, or decreased attendance. Evidence that school difficulties are asso- ciated with deficits on standardized tests of academic achievement or intelligence would have additional implications. For example, concern regarding violence ex- posure would he further heightened sf it alfected the children’s actual ability wo dem- onstrate oF to acquire academic skills. Al ternately, our understanding of and ability to prevent violence exposure and associ- ated outcomes could be enhanced if chil- dren with limited intellectual ability were shown to be more at risk. Research findings from related areas suggest that children exposed to high lev- els of violence are likely to show deficits (©2002 American Medical Association, All rights reserved. jamanetvrork.com/ on 01/19/2022.PARTICIPANTS AND METHODS PARTICIPANTS, Participants in the current single-group within-subjects study Were part ofa larger subject group participating ina National Institute on Drug Abuse-funded project study= {ng the outcomes of 6- to 7-year-old African American chi ddren prenatally exposed to cocaine and alcohol and their tunexposed (control) peers° The sample for the current {investigation was selected from the contro group who had. no history of prenatal exposure 1 har illicit drugs (eg, co- caine, heroin, methadone, amphetamines [uppers], arbi- trates [downers] and any other drugs). The contra group, did include children of mothers who used alcohol and/or ‘marijuana during pregnancy. Prenatal marijuana expo- sure was reported by 21% ofthis sample; some level of pre~ natal alcohol expostre was reported by 60% ‘OF 376 Arian American caregiver-child dyads who were contacted, 97% (n=360) agreed to participate. How- ever, multiple missed appointments (n=49) or incom- plete data (n=21) reduced the final sample to 209 partici- pants (80% of the original sample). The 299 participants, id not differ from those who refused to participate, who provided incompletedata, or who missed multiple appoint- ‘ments, when compared using prenatal and neonatal char- acteristics infant birth weight, engi, gestational age, Ap- garscores, prenatal alcohol or nicotine exposure, maternal ge, educational level, parity, or gravity). PROCEDURE ‘The Wayne State University insutional review board, De trot Mich, approve all data collection procedurem all are jverssigned informed consent forms befor participating fn this study Selbrepor, interview, and standardized test dain were collected from children and thelr caregivers during half-day evaluation sessions at our laboratory. Separate research aistants interviewed children and eae takers independently. all research assistants were blind to prenatal exposure status, which was matched to labora {ory collected subject information bya database manager al- {er contact with all subjects was completed, licensed psy chologist trsined and closely supervised the research assistants fn the administration ofall test instruments, MEASURES. Independent Variables Previous rescarch findings have suggested that parents un- derrepor a child's exposure Yo violence when compared withthe childs self-report consequently, a child report Ineasure was sed inthis std. The Things | Have Seen did Heard scale consists of 20 ems and assesses the r= Gqency of childrens self-reported exposure to velence and ‘olenc-related themes. lems are rated ona 5point scale Indleating the frequency of exposure to each even. The Things Have Seen and Heard eae hasbeen shown o have adequate estretestrelality 081), good internal con- sstency (a= 80-83)" and hasbeen used in many com- munity violence studies" Children's rauma-related distress was evaluated us- ing the Levonn scale” This measure of taumati distress =ymploms was modified frm ts orginal version for use ‘with urban children, The Levonn sale consists of 29 car toon picture items where children rate on a Spolnt scale how often they fee ike the child inthe carton, total score aswell as subscales representing depression, ana tty andor intrusive thoughts, and sleep problems can be derived, and have reported reliability coelficens ranging from 0.71 0084." One-week test-retest reliability forthe {otal score good (081), and he Levon sae hasbeen ‘sed with suecss in muliple research projets” outcomes Children’s reading bility was assessed with the Test of Early Reading Ability, second edition. a brief measure of the Continued of next page in standardized test scores in addition to lower school ‘grades. For example, child maltreatment has been asso- ciated with lower scores on standardized tests of aca- demicachievement." Similar results were found in study ‘of Lebanese adolescent schoolchildren, in whom PTSD ‘was associated with lower scores on standardized achie rent tests!” Moderate correlations between IQand PTSD in male combat veterans have also been reported." While reports ofthe relation between community vio lence exposure and schoo! grades have been published, vir tually no studies specifically evaluate the influence of com- ‘munity exposure to violence on actual academic oF cognitive ability. In the current investigation, relations between vio- lence exposure and academic outcomes were examined in 48 group of 6- to T-year-old children, accounting for sev ‘eral methodological considerations: (1) socioeconomic sta- tus, prenatal drug or alcohol exposure, quality of the home ‘environment, sex of the child, and primary caregiver 1Q ‘wereall measured to control for confounding variance from, these sources; (2) data were obtained [rom child self- report and trained interviewers-psychometzsis using vali (©2002 American Med dated instruments; and (3) trauma-related symptoms were also measured to explore the relative contributions of vio- lence exposure and trauma-related symptoms in explain- {ng the variance in academic functioning, Given previous findings from studies of maltreated children and male com- bat veterans, twas hypothesized that achild's report of ex- posure to violence would be associated with defieits in 1Q and reading ability, even after controlling for the afore- mentioned confounding factors. —_—_ ii ml! The final sample consisted of 157 boys (52%) and 142 girls (48%), with a mean age of 6.9 years (age range, 5.0- 7.9 years). The sample was primarily of moderately low socioeconomic status, with 48% ofthe caregivers report- {nga total annual family income of less than $1500; 60% of the primary caregivers have a high school or General Educational Development diploma. Exposure to com- munity violence and trauma-related distress were both prevalent in this sample (Table 1) 1 Association, All rights reserved.children's reading ability with a mean (SD) of 100 (15) points. It has been validated with a representative sample ‘ofmore than 1400 children, hasan internal consistency co- efficient of 0.93, and (inthe standardization sample) dem- fonstrated a 2-week test-retest reliability of r=0.89." The ‘Test of Early Reading Abily, second edition, has success fully discriminated between learning disabled and healthy children, has been associated with age and school expeti~ ence, and correlated signlicantly with alternate measures, of early academic achievement (eg, Basic School Skills Inventory: Diagnostic"; r=0.61, P= 01)" Child 1Q was evaluated using the Wechsler Primary and Preschool Sale of Intelligence-Revised,” an extensively standardized and validated measure ofthe child's ability to complete verbal find nonverbal intellectual tasks, Control Variables Socioeconomic status was estimated using the Hollings head 2fctor index Information regarding maternal pre taal alcohol use was collected during each prenatal ist tnd converted to average absolute ounces of alcohol pet dy dng praganey formation reguding aca prensa ct drug use was also collected at exch prenatal Fst Any indication of prenatal use of cacaine, heron, of other lit drugs (euch a serie sci diethylamide or ‘mphetamine) excep for prenatal marijuana use, resuled in exclusion from the current sample, To control for tnateral or caregiver intellectual ability (a possible con- founding biological inflence on cil academic outcomes, a well a possible confounding environmental inf nce), caregiver 1Q was measured with the performance subscale of the Wechsler Adult Intelligence Scale-Re- vised” The performance subscale of the Wechsler Adult Intelligence Scale-Revised was chosen because of is tne ‘vantages over full-scale Wechsler Adult Ineligence Scale-Revised administration, its excellent reliability (Gplichal relislitycocficient=0.93;test-retest=0.99), anit high correlation with fullscale IQ (7=0.91 across allage groups) Home cavironment was evaluated using an interview, conducted in the laboratory, based on the Home Observa- tion for Measurement of the Environment (HOME)." This scale used observations of caregiver-cild interactions dar- ing the laboratory vist (eg, caregiver responds to the child's questions, caregiver's voice conveys positive feel- Ings when speaking to the child, caregiver introduces examiner tothe child), and asked for caregiver report for other items taken from the HOME (eg, “Child is encour- aged to read on his own.”). As with the HOME, multiple- fem scores on this interview were summed to create a continuous scale representing the quality of the home environment. Higher scores denoted better quality of hhome environment. Thus, while the laboratory-based Interview used for this study was not previously validated, it bore significant similarities to the HOME scale and Incorporated opportunites for observation. Further, this ‘measire demonstrated a promising pattern of external cor- relates in the current study, similar to that found for the HOME in previous research. Scores from the current ‘measure of the quality of the home environment were positively associated with socioeconomic status (r=0.36, P<001), caregiver's performance 1Q (r=0.33, P=001 and child's 1Q (r=0.52, P=.001), and were negatively fssociated with a chiles report of truma-related distress (using the Levonn scale, deseribed below; r=-0.11, P<.05). While these findings do not constitute a thorough validation of this measure, they (along with the face valid ity of the interview) do suggest that variance related to the ality ofthe home environment was being tapped DATA ANALYSIS. ‘The current research hypothesis was tested using mul tiple regression, wth stepwise selection of confounders and stibsequent simllaneots entry of independent variables (community violence exposure and distress). Two analy ses using this variable set were conducted, one each fr read {ng ability and child's 1Q, using the Statistical Package for the Social Sciences, Version 10.07." The 2 independent variables, community violence exposure and trauma-related distress, were signifi- cantly related (7=0.25, P<.001). However, collinearity statistics were well within the acceptable range (toler~ ance, 0.96-0.99). Many other potentially confounding vari- ables were correlated with the outcome measures, in- cluding the home environment, the caretaker's verbal ability, the child's gender, socioeconomic status, and amount of prenatal alcohol exposure. These variables were considered as confounders in all further analyses The first regression equation examined community violence exposure and trauma-related distress as pre- dictors of a child's 1Q. Alter controlling for confound- ces, community violence exposure accounted for sig- nificant variance in a child's 1Q (P<.05), with higher violence exposure associated with lower IQ scores. However, trauma-related distress was not significantly related to a child's 1Q (Table 2). The total equation accounted for 23% of the variance in the child's 1Q. Using the derived regression equation (entering scores, multiplying them by derived B weights, and summing to (aepnnyrep) ARCH FEDIATRABOUSC MEDTOL TSS OT (©2002 American Med yield a predicted score on the dependent variable), a child scoring at or above the 90th percentile on both community violence exposure and trauma-related dis- tress would be expected to have a decrement of 7.5 1Q points when compared with a child at the lowest (lrst) percentile on both variables (Figure). This difference of half an SD represents & medium ellect size." The second regression equation examined commu nity violence exposure and trauma-related distress as predictors of reading ability (fable 3). After control for confounding, both community violence exposure and Uuauma-related distress explained significant variance in reading achievement (P<.05), with higher scores on each independent variable associated with decreased reading achievement. The total equation accounted for 28% of the variance in reading ability. Using the derived regression equation, a child scoring at or above the 90th percentile on both community violence exposure and Uuauma-related distress would be expected to have a dec- rement of 9.8 points on the Test of Early Reading Ability second edition, when compared with a child at the low- 1 Association, All rights reserved.‘Table 1. Report of Exposure to Violence and Trauma Symptoms by 289 Urban Children ‘Selecta Volnce Exposure Hams never ‘time ztimes eines >a Timer Tha ead guns being shot Teac) ra) «eT Ca) «8B ha een somebody ting bat up. 187(56) 10.468) tA0(az) 8455) 8) hav seen somebody get stabbed Tso = 140) a(t) 20) 33/10) hav seen somebody get set. rz) = 15145) Sat6) ©4012) 3310) Grown-ps ny home hit each othe @2@) = s0@7) = ai) S05) 10.41) Grovn-ips in my home threstentostaborshooteach the. 62.0(275) 2016) 2018) 2018) 206) ‘Seteted Trauma Symplom tems Never ‘Sone ofthe Tine ‘Alek ot the Time Saw something scary, ca stop tiskng about 52168) 184 (5) a5) Har tie going to sep: remembers something sea. 639,10) 187 (47) 2461) Inclass weris about peopl bang shat. 61.9 (185), 19.4 (68) 187 (68) ages of hd Things Have Seen and Hear cal making this epr, The numbers in parentheses eer tothe [Stet an fom the Levon measure ef ehlren ievess symptoms scala” cuore seated wih the nted parentage ‘Table 2. Multiple Regression ofa Chil’s Exposure to Violence and Distress on the Child's 10° [Bwoight——_sigaeance ‘sigtteance tert Measure (Unigde) offs weit weight EAB cnange ot Acnange 1 ually of he home enirnment 036 one 7 oo 001 2 Gatetaar pertermance a oa 01 19 1 0.05 <0 3 Sacascanomie statue o19 one 18 08 003 03 4 Chids sex 216 13 13020 aoe 7 5 Vilece exposure 0 ore 13 ozs 003 ne Trauma dsvest “008 413 <0 “Te ol samples was 299 urban & to Tyearad chide: na cst (Hirst) percentile on both measures (Figure). This two thirds of an SD difference represents a moderate- large-elfect siz ——_ iimld€~ ‘Our study examined the association between reported: ‘community violence exposure and school outcomes, AE. ter ruling out oF controlling for many potential con- founders, using multiple sources of data and standard- sd measurement of cognitive and reading abilities, sell- reported violence exposure in children was negatively correlated with 1Q scores and standardized reading, achievement test performance. Community violence ex- posure in urban children appears to be similar to child ‘maltreatment and other trauma in its association with cog- This finding has clear implications, although the nature of these depends on the directionality of the observed relationship. For example, children of lim- ited intellectual ability may be more likely to witness for experience violence, perhaps because they are un- able to verbally mediate dangerous situations, or per haps because of an inability to accurately predict and avoid violent situations. Preventive efforts might profit. ably focus on problem-solving skills in children who have a low 1Q if later research confirms that intellectual limitations are a risk factor for community violence exposure, (©2002 American Medi jamanetwork.comy on O1/19/2022 i Epes deat not ppb 48t95 Tough dare the resto stepwise slcton rom the ange of possi confounding arabes (onl raat alcool exposure dnt et eps the forced simultaneous erry ofthe 2 indepndent vals (cence exposure ad postaumatc ss dsrder sympa). We Tipe Pecai oh, Buia iaecs 0) [ism cen no 5 2 w. n, ® 0 Faeg Graph shows he predicted volone elated 0 and reading achievement crament ofan urban cohort of cadre (N= 290) bree ha ages ot Bad yeas a ra andard eres freien cong shove he th prenteon ane a Both major ngspenden! variables anc Heard ante Lavan eal). sing weghte sion equabions (ales 2 and 3). Th prectdseore inlets te I cores of and 7-jear-lé chlran using ha Wechsler Preschel and Pinay Sele af nligance-Reviad rating scores sig the Tost of ny Reading Abi, econ dion. Allscoras repose tana esores wha man (60) of 100 (5) pl tat ar assed to confounders Tables 23), PTSD indetae pastaumate ses disorder Alternately, exposure to violence may actually in- hibit intellectual and academic functioning. If eomrmu- nity violence exposure does in fact cause such deficits, the estimated number of urban children experiencing vio- 1 Association, All rights reserved.‘Table 3. Multiple Regression ofa Child's Exposure to Violence and Distress on Reading Ability (TERA-RO)* ‘Bweigit—_sigaeance ‘Signtteance stent Measure (Uaigas) off. weight fo weigt__—*_—cnange ot A change 1 Garataker performance 0 035 <0 B ats =o 2 Quality ofthe hme erionment ose <1001 2 a1 6 =o 3 Childe 500 = 001 2 023 ons <0 1 ——Prastalalcahl posure as? “086 10 025 oor 05 5 Vinee exgoeue “010 ‘nas 10-078 03 oot Truma-reteddtass “016 a 4 Te ol saps was 20 urban & to Tyearod chee: a Elias inate na appleable #595 {ough dae th 79, TERA RO detest st Ely Paacing Abi, Revised Ouestomnate tt sepuse secon rom th ange of possible confounding arable (ol socosconami status didnt ant sop 3 the forced ssmutaneeus entry ofthe 2 indepandent arable (ven exposure and pstraumate sss asrde yma). lence at this level would make this an issue of major concern, For example, Lester and colleagues” have previously demonstrated that even very small 1Q dec- Fements (only 3.26 points, <0.25 SD) can have a major practical impact if large numbers of children are affected. Levels of community violence exposure were high in the current study, even though the sample was in-no way selected for ils exposure to violence (Table 1). The inclusion of many parents with high school or General Educational Development diplomas (69%) and the exclusion of children prenatally exposed 10 any illicit drug other than marijuana makes this group ‘of children potentially less likely to experience vio- lence than other urban samples." If community violence exposure does in fact, impair academic ability, efforts to identify factors pre- dicting which urban children are or will be exposed to high levels of violence are needed. Despite the high levels of self-reported violence exposure in this and other studies,"* many children in the current ‘sample—in spite of the homogeneity of socioeconomic status and city of residence in this study—reported very low levels of exposure. If preventable factors contribute to this variability in community violence exposure, ‘could lead to interventions that reduce the number of children who witness violence, regardless of the levels of violence present in the community. Second, if vie lence exposure itself leads to cognitive deficits, inter- ventions targeted at children demonstrating symptoms fof trauma may miss children who, although not show- ing clear PTSD or related symptoms, may be compro- mised in their ability to function scholastically. The results of our study suggest that interventions would need to be targeted at children who either demonstrate tuauma-related symptoms or at those who report high levels of exposure to violence. I is unclear which causal direction is more likely, ‘or even whether a thitd variable might cause both vio- lence exposure and intellectual deficits. The possible mechanism underlying the relation isalso unknown, Some evidence has suggested that early trauma can lead to au- tonomic nervous system or hormonal hyperreactivity, allecting child’ ability to remain focused while at- {empting to learn or to perform complex cognitive tasks. Perhaps more parsimoniously, long-term exposure to vio- lence results nan anxious preoccupation with personal (©2002 American Med safety or other concentration difficulties that are incom- pauble with learning and performing such tasks.” Our finding that PTSD-related symptoms accounted for sig- nificant variance in reading ability, even when entered along with exposure to community violence, provides some support for this latter suggestion. Alternately, as noted earlier, children with intellectual limitations may somehow be at risk for violence in ways not yet fully un- derstood. A secondary goal ofthis study was to explore whether the impact of community violence exposure is primar- lly limited to children who also demonstrate tratma- related symptoms, or whether violence exposure itself fs related to poor academic outcomes even in the ab- sence of high levels of anxiety and distress, When both variables were considered simultaneously, violence ex- posure had an independent effect on both 1Q and read- ing ability. This finding suggests that reported violence exposure might be associated with negative academic ou- comes, whether or not children are subjectively dis- tressed from the exposure. However, trauma-related dis- tress did account for additional variance in reading ability suggesting that subjectively distressed child victims who experience community violence may be at additional risk for deficits in reading ability ‘A major obstacle for our current study and other similar investigations is the lack of well-validated mea- sures of community violence exposure and related trauma, Although the Levonn and Things I Have Seen and Heatd scales may be the best available options for measuring, young children’s reports of community violence expo- sure and trauma-related distress, they have not yet been subjected to rigorous validation and may have impor- tant unknown weaknesses. For example, the low inter nal consistency of the Things I Have Seen and Heard scale in oursample (7=0.68) suggests that multiple and mini- mally related constructs are being tapped by this scale fm its current form, ‘final important consideration in interpreting these data isthe strong observed relation between other fac- tors and the academic outcomes studied. As already es- Lablished by previous research,” the quality of the home cavironment and prenatal alcohol expostre both ac- counted for significant variance in academic outcomes tn our study. Further, standardized Bs for these vari ables were of greater absolute value than those for vio- 1 Association, All rights reserved.Downloaded From: https:/ Soeur a Research findings have increasingly documented high self-reported levels of exposute to violence by even ‘ery young urban children Research ndings have also Aocumented a range of woubling correlates of sell Teported violence exposure, including elevated levels of externalizing and internalizing behavior. Evidence that broad and prevalent violence exposure is negativel scsciated with school outcomes sla exists, but suck research has relied primarily on grades in school and tot more objective measures such as scores on sa- dardized tests eg, academic achievement and 1Q tess). “The current study extends previous findings by demonstrating an association between child sell teported violence expostre and school outcomes when Alefined as scores on siandardized achievement and 1Q tests This research also explored whether violence exposure alone or whether only violence expose that oncurently occurs with symptoms of atma-telated Altres i ascocnted with decrements on measures of School outcomes The findings suggest that violence exposure may be associated with actual mpalrments in Scademic ability and lesrning potential, even in the absence of dre lence exposure of trauma-related symptoms. These find- ings suggest that the importance of considering the range of biopsychosocial insults faced by urban children, in- cluding violence exposure, cannot be overestimated. Accepted for publication November 30, 2001 This research was funded in part by grants DA 08524 (Dr Delaney-Black) and DA 00516 (Dr Ondersma) from the National Institute on Drug Abuse, Rockville, Md; grant 412-FY97-0047 (Dr Delaney: Black ) from The National Foun- dation March of Dimes, White Plains, NY; and the Helppie Institute for Urban Pediatric Health Research, Children’s Rescarch Center of Michigan, Children’s Hospital of Michi- gan, Detroit Corresponding author and reprints: Virginia Delaney Black, MD, MPH, Division of Neonatal/Perinatal Medi- cine, Department of Pediatrics, Children’s Hospital of Michigan, 3901 Beaubien, Detroit, MI #8201-1498 (e-mail: vdelaney@med wayne.edw) —_ I lam Gros 8, Zuclrnan &, Masa S, Cohan. Sie vine chien who wt sevice. AMA 006260.262 264 el ek Community vk Panay. OBSS64E58 4. Mir 5 Wasserman A, augebauer, Gomar Sith Kanbouts DW ‘seed cara valence and ano behav Wri aan bays. cin chi Pet 0082821 Freaman i Makes, ornansli ED. Von wens rego by normal un staged hres nd depression crete. Am cad Onid Adols Pah. 6829042, 5 Bows donen GE tine and vos innghboronts andes an th schoo bear and perlomanoe of aoesces J Adolesc es 199 tao, psc DS,Rasmsson AM, Ayan W, Crom P Southwick SM. Ccal 1 chtien on Chicas oui (aepnnyrep) ARCH FEDATRABOUSC MEDTOT TSS OT 0 2 2 Es 4 8 6 a 28 0 . a 2 2 Ps 2 nd functonacoreltes of postaunati sss corer in urban adeescet tsar chm ea Cn Ales sch 200030104 in Later Jomsen MC. Cid malts an shel prtrmanc. Am J Ea sane 519. Fela Lad M, Otis. eho! pafermaneané cin probs mang abused ad nected chiran Dev Pye 1902-2042 62. are, Gasn MJ, Weds, Hong PT Matstone eho hl school peromaneeconsquencrs. Chg Abuse gl 1085 1781- oa Sigh PR Mouth M, rene. Shoastimpsimants mong taumatind dolce, Stay as hr 157 25420-496, uel T, Blanchard, Nil Tron pacesing and PTSD: View tempi erat, in Psy Re 200020 T0185 Daa lk Congr C, Temple Teacherasesed eka of hlen pena exposed cosine. Pes 200 0872-791 aria Rica J The conuny oles poet I: cles - tes symp assoc wih veo posure Peeh) T3362 35 Firs, MarinerP. Things ave Sean and Heart A Stuer oy Asesing Young Chia’ Valece Ease. Masher DC: Neral Inet Menta Hes 990, crs JE MarinzP. Th HIM cormutiy vec pj, chien as Vic of ard waresses lence. Pay 8657-21 Wate, Brace Se, Fare AD, Kier Was of xposue a community vine on nit aleogiutnal sy oan soca suport a apratecive factor matan cen J hg Fam Sud. WOBT187-208, versa Darpsey M, raha, Mes 8, ala amily spp as ‘otra of xposure to comeniy vies. J ln Ci Psycho 108828: ‘sit. Fae AD, Bruce SE. pat of xpsure community vlan on vit b= havior and ematonal ates among uan otc CCl Psa 7262-14, Schon Sone M Chan, Grestrgr Sher, Lhan oye: Nese hae, Ite eet af lnee exposure urban you Jn esd hi Ao ese Pye. 100038350367 chr artis P Vala P- Levon: Cartoon Based Src nr vw for Assess Yur esses Symons Washi, OC Mon nett Mena Het; 1090 aviv Eel, Foxe Indu mesurmant of exposure to eryeay Vibes among sein shuel cide across various etigs-J Comme iy jel 2002811710. aviv Shimoni FoxNA Lett LA. chide’ slepr at expoeuetvio- lance an its elo we email svess. 4 pov Pehl 190820357 = Fig Hao WR, HariOD ast fay Rening Ability 2nd. Asin, Te Pro-E Pabishre 189. Hari 0, Ligh asi eh Shits Ineo: Dagrastic Astin, Te Prod Pubihere 198. Wet, Mona fre tl Paschal andar Sae ot iene ened Sin Atari, To soll Cory 1380 Hoingsba AB Conenertay ont indsermite tae of social ass mea- fremont” So Fores 17053 $87 Wechsler , Mana for he Wechsler At nligsce Sel Roied, San Atari, Tex Psyop Cry, 181 Caldwell 8M, Bracey RH. Aamnistation Mana Raised Eatin: Home ‘sera for Mssurent ofthe Enronmant Lie Rok Unity ot asa; 084 ‘Sustial Paclage othe Soci Scenes, eso 10.07 Chiao: PSS: 200 Chen. Suita Power Aas rte Bava Sceces Hl, Lance AEronur coi 088, Lester BM, LaGasse LL, Sailer Coc exposure an chin: the nearing ‘fsubte wc, Sense 198 26069-64 Hai Neo 0, Ht, Puta eral ané autonome rspensesto sss in women at sna physical abuse in chidheo JANA 200084: 0-6. ashow A. Motion and Psat New Yor WY Harper & Row, 158 DeGarmo 0, Frgath MS, Marina OR J Param ot erasers 2 Tinkbewee oc stan ard boy academic outcomes: urging teats ft seccsonomi tts, hid ev 100 70129-1265, asa 8, Rey EP Graming L Des DC ones KL. Newropsychlgjel pase flab gosad chien wih or whut gyal leas lf tlaena sda, Mewapsyehoy 100512146188, (©2002 American Medical Association, All rights reserved. /jjamanetwork.comy on 01/19/2022