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Adverse Behavioral and Emotional

Outcomes from Child Abuse and
Witnessed Violence
L. Amaya-jackson, Wanda Hunter

Child Maltreatment

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JohnsonMALTREATMENT
CHILD et al. / ADVERSE OUTCOMES
/ AUGUST 2002

Adverse Behavioral and Emotional Outcomes

From Child Abuse and Witnessed Violence

Renee M. Johnson
Jonathan B. Kotch
Diane J. Catellier
University of North Carolina School of Public Health
Jane R. Winsor
Rho, Inc.
Vincent Dufort
Northeast Health Care Quality Foundation
Wanda Hunter
University of North Carolina Injury Prevention Research Center
Lisa Amaya-Jackson
Duke University Medical Center

This article examines mental health outcomes of children who
have witnessed violence in their social environment and/or
have been physically abused. Participants (n = 167) come
from a longitudinal study on child maltreatment. Out-
comes—including depression, anger, and anxiety—are mea-
sured by the Child Behavior Checklist and the Trauma
Symptom Checklist for Children. The authors used adjusted
multivariate analyses to test the statistical significance of as-
sociations. The majority of children were female (57%) and
non-White (64%). One third had been physically victimized;
46% had witnessed moderate-high levels of violence. Results
confirm that children are negatively affected by victimization
and violence they witness in their homes and neighborhoods.
Victimization was a significant predictor of child aggression
and depression; witnessed violence was found to be a signifi-
cant predictor of aggression, depression, anger, and anxiety.
Implications will be discussed.
A lthough child abuse and children’s witnessing of
violence are highly comorbid (Edelson, 1999;
Shipman, Rossman, & West, 1999), they are generally
investigated separately. Studies have shown child
CHILD MALTREATMENT, Vol. 7, No. 3, August 2002 179-186
© 2002 Sage Publications
abuse to be associated with adverse behavioral and
emotional outcomes in children, including internal-
izing problems such as withdrawal, anxiety, and de-
pression, and externalizing problems such as con-
duct disorders, aggression, and delinquency (Boney-
McCoy & Finkelhor, 1995; Malinosky-Rummell &
Hansen, 1993; Panel on Research on Child Abuse and
Neglect, 1993). Witnessing violence in the home
and/or neighborhood is also associated with height-
ened levels of adverse behavioral and emotional prob-
lems (Carter, Weithhorn, & Behrman, 1999; Hughes,
1988; Osofsky, 1995; Socolar, 2000). Children’s pro-
longed exposure to chronic neighborhood violence is
associated with post-traumatic stress disorder, emo-
Authors’ Note: This study is based on a poster presented by Vincent
Dufort, Ph.D., at the 125th annual meeting of the American Public
Health Association in Indianapolis, IN, November 12, 1997. This
research was supported in part by Grant 1 RO1 HD39689, “Neglect
and Adolescents: A Multi-Site Longitudinal Study,” from the
USDHHS’s National Institute of Child Health and Human Devel-
opment, and Grant 90CA1677/01, “Longitudinal Studies of Child
Abuse and Neglect,” USDHHS/ACF/ACYF/CB/Office on Child
Abuse and Neglect. Requests for reprints should be sent to Dr.
Jonathan B. Kotch, Department of Maternal and Child Health,
Rosenau Hall, CB# 7445, University of North Carolina at Chapel
Hill, Chapel Hill, NC 27599-7445.

179
180 Johnson et al. / ADVERSE OUTCOMES
tional distress, depression, fear, somatic complaints,
memory problems, aggression, and social withdrawal
(Fitzpatrick & Boldizar, 1993; Osofsky, Wewers,
Hann, & Fick, 1993; Richters & Martinez, 1993).
Children who have witnessed domestic violence ex-
hibit symptoms similar to those of children who have
been abused or exposed to neighborhood violence
(Carter et al., 1999; Martinez & Richters, 1993;
Socolar, 2000).
Research exploring child outcomes resulting from
witnessing violence or being abused tends to have
cross-sectional study designs and methodological
weaknesses including small sample sizes and biased
sampling procedures, all of which preclude determin-
ing whether the relationship is causal. Particularly
problematic, however, is the lack of statistical control
for confounding variables. For example, although it
has been theorized that child psychological outcomes
attributable to witnessing neighborhood violence
depend partly on levels of parental well-being and
family functioning, these variables generally have not
been accounted for in analyses. These limitations are
understandable given the ethical considerations that
arise in the process of conducting family violence
research. Nevertheless, the findings that witnessing
violence and being abused are associated with varying
degrees of child psychopathology need to be con-
firmed by more rigorous scientific investigation.
The present study examines the extent to which
children respond negatively to witnessing violence in
their social environments and to victimization at the
hands of caregivers. In particular, this investigation
seeks to predict mental health status at age 8 from
exposure variables related to reports of physical
abuse, witnessing domestic violence, or observing vio-
lence in children’s neighborhoods prior to age 8.
Internalizing and externalizing behaviors will be
examined as consequences of exposure to neighbor-
hood and domestic violence on one hand and physi-
cal child abuse on the other. We expect both victim-
ization and witnessing of violence to be associated
with internalizing and externalizing problems, even
when controlling for confounding variables.
METHOD
Sample
The participants for this analysis were drawn from
a sample of participants in the Stress, Social Support
and Abuse & Neglect in High Risk Infants Study
(SSS), which is focused on determining the anteced-
ents of child maltreatment reports. Seven hundred
and eighty-eight mother-infant dyads were recruited
in 1985-1987 from North Carolina hospitals and
health departments. Four out of every 5 infants
recruited had at least one risk factor qualifying them
for North Carolina’s High Priority Infant Program,
such as low birth weight (< 2,500 grams), young
maternal age (younger than 18 years), congenital
abnormalities, birth defects, maternal impoverish-
ment, substance abuse, or other significant medical
or social problems. The remaining 20% of the infants
had none of the above risk factors.
When the participants were 4 years of age, a subset
of the original group of 788 was selected for contin-
ued follow-up as the Southern site of the Longitudinal
Studies of Child Abuse & Neglect (LONGSCAN) con-
sortium, which is a collaborative of five longitudinal
studies of child maltreatment (Runyan et al., 1998).
Of those SSS children who, by their fourth birthday,
had come to the attention of the State Division of
Social Services for suspicion of being maltreated, 70
were randomly selected and then matched with two
nonreported controls (also randomly selected) based
on age, socioeconomic status, race, and sex. Maltreat-
ment status was determined by a regular review of the
state’s Central Registry of Child Abuse and Neglect,
which contains all state documentation on child mal-
treatment reports. As part of LONGSCAN, partici-
pant children and/or their primary caregivers were
interviewed in person at child ages 4, 6, and 8 years.
The interview contained items about the caregiver,
family, and social domains of the participant child’s
environment, as well as about the child’s own experi-
ences, behaviors, and socioemotional well-being. The
data for this study came from the age 6 and age 8 inter-
views and the Central Registry review. The Southern
site of LONGSCAN has been approved by the Insti-
tutional Review Board for the Protection of Human
Research Subjects at the University of North
Carolina at Chapel Hill School of Public Health.
The research activities of the Southern site of
LONGSCAN have been approved by the Institutional
Review Board at the University of North Carolina at
Chapel Hill School of Public Health. Ethical issues
concerning the investigations are described in detail
elsewhere (Knight et al., 2000; Kotch, 2000; Runyan,
2000).
Mental Health Outcome Variables
Outcome variables can be conceptualized as
externalizing and internalizing problems. The only
externalizing behavior—aggression—was assessed
using the Aggressive Behavior construct of the Child
Behavior Checklist (CBCL). The CBCL is designed to
obtain reports of children’s competencies and behav-
ior problems, as reported by caregivers, teachers, or
CHILD MALTREATMENT / AUGUST 2002

the child. We used the parent report version. The
CBCL is the most commonly used measure of child
psychopathology. Evidence for content, construct,
and criterion-related validity is well documented
(Achenbach, 1991; Achenbach, Edelbrock, & Howell,
1987).
Two internalizing behavior problems—anger and
anxiety—were assessed using the Anger and Anxiety
subscales of the Trauma Symptom Checklist for
Children (TSCC). The TSCC is a widely used and rep-
utable measure of psychological symptomatology
intended for use in the evaluation of children who
have experienced traumatic events (Briere, 1996). It
assesses the effect of trauma through the child’s self-
report. The internal consistency of the TSCC has
been reported as high; Cronbach’s alpha =.95 (Evans,
Briere, Boggiano, & Barrett, 1994). Results of TSCC
are congruent with those derived from similar mea-
sures, including the CBCL, indicating good concur-
rent validity (Lanktree & Briere, 1990, 1995).
A third internalizing behavior, depression, was
measured using the Depression subscales of both the
CBCL and the TSCC. We followed the instrument
developer’s recommendation for nonclinical samples
and thus used raw scores, rather than T scores, in ana-
lyzing the CBCL (Achenbach, 1991). All outcome
variables were kept continuous and were measured at
the age 8 interview.
Victimization
Child victimization status was determined using
both Central Registry data prior to the age 8 interview
and caregiver responses to the Conflict Tactics Scales
(CTS) at the age 6 interview (Straus, 1979). The CTS
measures the extent to which caregivers use reason-
ing and nonviolent discipline, verbal aggression, or
physical aggression in response to their child’s behav-
ior. Validity for the CTS has been demonstrated in a
number of studies (Straus & Hamby, 1997). If a care-
giver’s report on the CTS did not imply physical
aggression, and if there had not been a report of child
abuse, victimization was considered not present. The
child was considered to have experienced a moderate
level of victimization if the caregiver reported throw-
ing, smashing, hitting, or kicking an object, or push-
ing, grabbing, shoving, or slapping the child as means
of discipline and punishment. If there was a report of
physical abuse (either with or without parental
endorsement of physical aggression), the child was
considered to have experienced a high level of
victimization.
CHILD MALTREATMENT / AUGUST 2002
Johnson et al. / ADVERSE OUTCOMES 181
Exposure to Violence
We determined the level of violence witnessed by
the child through both child and caregiver reports.
The child’s report of witnessed violence was mea-
sured by the “Things I’ve Seen and Heard” survey,
administered at the age 8 interview (Richters & Marti-
nez, 1990). Things I’ve Seen and Heard assesses expo-
sure to violence throughout a child’s lifetime. A child
was considered to have witnessed minimal levels of
violence if she or he did not endorse any of the follow-
ing items: (a) seeing a person arrested more than
once, (b) seeing someone beaten up more than once,
(c) ever having heard grownups in the home yell at
one another, (d) ever having seen grownups in the
home hit each other, (e) ever having seen someone
get stabbed, (f) ever having seen someone get shot,
(g) ever having seen a dead body (not in the context
of a funeral or wake), (h) ever having seen someone
pull a gun on someone, (i) ever having seen someone
shot in the child’s own home, and ( j) ever having seen
someone pull a knife on someone. If the child
endorsed any of the first four items but none of the
items (e) through ( j), she or he was considered to
have witnessed a moderate level of violence. If the
child endorsed any of the last six items, she or he was
considered to have witnessed a high level of violence.
Caregiver report measures of violence witnessed by
the child were assessed using items from the age 8
administration of the Child Life Events survey. This
project-developed survey is based on an existing sur-
vey (Sarason, Johnson, & Siegel, 1978) and was
designed to track events that occurred in the past year
that may have had an impact on the child’s psycholog-
ical well-being. A child was considered to have wit-
nessed a high level of violence if the caregiver
reported that the child observed any of the following
events in the home or neighborhood environment:
someone getting threatened with a weapon, someone
being stabbed, someone being killed or murdered, or
someone getting kicked, hit, or otherwise physically
harmed. If the parent reported that the child was
exposed to loud arguments but not to any of the other
indicators, the child was considered to have been wit-
ness to a moderate level of violence. For cases in which
parents did not endorse any of the above-listed indica-
tors of violence, the child was considered to have been
exposed to a minimal level of violence.
Control Variables
To reduce the chances of finding a spurious associ-
ation, as well as to show the adjusted effects of victim-
ization and violence exposure on adverse outcomes,
we controlled for the following variables in our study:
182 Johnson et al. / ADVERSE OUTCOMES
race of caregiver (non-White, White), sex of child,
number of siblings (0, 1, 2+), caregiver level of depres-
sion (continuous), age of caregiver (continuous),
whether caregiver has a high school education,
whether caregiver is the child’s biological mother,
presence of father figure in the home (no, yes: biolog-
ical father, yes: caregiver’s boyfriend, partner, or hus-
band), child’s health status as reported by the care-
giver (fair/poor, good, or excellent), caregiver
perception of social support (continuous), socioeco-
nomic status (continuous), and the number of signifi-
cant life events experienced by the child in the past
year (continuous). Maternal depression and social
support were included as control variables because
they have emerged as strong predictors of child mal-
treatment in previous analyses involving this popula-
tion (Kotch et al., 1995). Maternal depression was
measured by the Depression subscale of the Brief
Symptom Inventory (Derogaitis & Spencer, 1982), in
which respondents rate statements about their nega-
tive feelings on a 5-point Likert-type scale. Scores for
the subscale can fall within a range of 0 (not at all
depressed) to 30 (extremely depressed). The Social Provi-
sions Scale was used to examine the degree to which
respondents’ social relationships provide various
dimensions of social support (Cutrona & Russell,
1987). Possible scores range from 4 to 96; a higher
score indicates a greater perception of social support.
To capture family socioeconomic status, we com-
puted the family’s percentage of the poverty level by
dividing the total household income by the federal
poverty level, taking family size into account. The
number of child life events was assessed using the
Child Life Events survey. This 31-item survey covers
events relating to changes in the participant child’s
household composition, serious illness or injury
among the child’s household members, child’s wit-
nessing of violence, and involvement of family mem-
bers with the legal system. Social support and care-
giver depression were measured at the age 8
interview. All other control variables were measured
at the age 6 interview.
Analysis
Initially, we conducted a descriptive analysis, gen-
erating frequencies, means, and standard deviations
as appropriate. Then, to test the global effect of each
predictor variable on all outcome variables (internal-
izing and externalizing behavior problems), we fit
multivariate analyses of variance (MANOVA) models.
MANOVA models compare the mean values of multi-
ple outcome variables across different levels of the
predictor variable while maintaining a Type I error
rate below the prespecified alpha level (.05) (Hand &
Taylor, 1987). Further analyses were to be conducted
with each predictor variable that is significantly associ-
ated with all five outcome variables.
We also conducted MANOVA tests to identify
potentially confounding variables. Using a signifi-
cance level of .10, we first assessed the interaction
effect of caregiver level of depression with each pre-
dictor variable on the outcomes. These sets of interac-
tions were hypothesized because caregiver depression
has been found to be a strong effect modifier in previ-
ous analyses involving this study population (Kotch
et al., 1999). Next, we fit successively reduced
MANOVA models by discarding the least significant
control variables at each step until the remaining con-
trol variables met the criterion of p = .10.
If the overall multivariate test of the effect of the
victimization or witnessed violence variable was statis-
tically significant, we went on to perform analysis of
variance (ANOVA) tests of the predictor variable on
each individual outcome variable, adjusting for con-
trol variables. This approach allowed us to interpret
the findings by identifying the specific dependent
variables that contributed to the significant overall
effect. Analyses were performed using SAS software
(SAS Institute, 1990).
RESULTS
The sample for this investigation is limited to the
167 caregiver-child pairs who completed both age 6
and age 8 interviews. A comparison of the study sam-
ple with those pairs who only completed the age 6 (n =
222) or age 8 (n = 180) interview showed that there
were no significant differences across groups in terms
of the predictor variables or with regard to levels of
victimization and witnessed violence.
Forty-four percent of the children in the sample
were male, and 64% were non-White. Only 7% were
reported by their caregivers to be in fair or poor
health; all others were reported to be in good or excel-
lent health. Fewer than a quarter of the participants
(22%) were the only children living in their house-
holds; 38% had one sibling, and 40% had two or more
siblings. Children had an average of 1½ significant life
events in the past year according to the Child Life
Events survey (SD = 1.4). The mean score for care-
givers on the Social Provisions Scale was 76, indicating
that parents in the sample perceived themselves as
having above-average levels of social support. The
mean score for caregivers on the Brief Symptom
Inventory was 2.1, indicating that respondents were
not experiencing high levels of depressive symptom-
atology. Sixty-one of the caregivers reported that they
had finished high school, and 80% reported that they
CHILD MALTREATMENT / AUGUST 2002
 Johnson et al. / ADVERSE OUTCOMES 183

were the biological parents of the participant child. TABLE 1: Prevalence of Victimization and Exposure to Vio-
lence Among Participants (N = 167)
The average age of caregivers was 32 years (SD = 8.7,
range = 21-63). There were biological fathers residing N %
in 28% of the participant children’s homes, and care-
givers’ partners resided in 19% of the children’s Level of victimization
homes. The average income for families in this sam- None 117 70.9
Moderate 24 14.5
ple was 98% of the poverty level (SD = 74.1, range =
High 24 14.5
11%-417%). Child self-report of witnessing violence
More than one quarter (29%) of the children were Minimal 38 22.8
categorized as having been victimized (Table 1). Moderate 77 46.1
According to the child self-report of exposure to vio- High 52 31.1
Caregiver report of child’s witnessing violence
lence, more than three quarters of the participants
Minimal 90 53.9
had witnessed violent events. Caregivers tended to Moderate 52 31.1
underreport children’s exposure to violence when High 25 15.0
compared to the child self-report measure. According NOTE: The total N for some variables does not add to 167 due to
to caregiver report of exposure to violence, slightly missing data.
fewer than half of the children had witnessed moderate-
high levels of violence in their home or community.
In the first series of MANOVA analyses, all three
predictor variables (victimization, witnessed 7
6.65
violence–child report, and witnessed violence– 6
caregiver report) emerged as significant predictors of

Means of Child Depression

High Caregiver Depression
5
all five outcome variables (p < .05). The following con- 4.69
4
trol variables survived the covariate selection proce-
3
dure: sex of child, caregiver education, age of care- 3

Low Caregiver Depression

giver, presence of father figure in home, health of 2
2.22

child, caregiver level of social support, and number of 1

major life events for the child. Tests of the product 0

terms of caregiver depression by each of the victimiza- Minimal/Moderate High

tion and witnessing variables showed that caregiver Caregiver's Report of Witnessed Violence

depression interacted with caregiver report of child’s
witnessed violence to affect child depression (p < .01),
indicating caregiver depression to be an effect modi-
fier. As no other interaction terms were significant,
their product terms were subsequently dropped from
further analyses. Surviving covariates were adjusted
for in ANOVA models.
The effect of the Caregiver Depression × Witnessed
Violence interaction term was apparent when wit-
nessed violence was a three-level variable. We then
collapsed the two lower levels of exposure to ease
interpretation. When caregivers exhibited high levels
of depression, the children’s depression scores on the
CBCL were linearly related to their exposure to wit-
nessed violence. In contrast, when caregivers exhib-
ited lower levels of depression, the child’s depression
scores were higher when they witnessed minimal or
moderate levels of violence than when they were wit-
ness to severe violence (Figure 1).
The results of the final multivariable regression
analyses (ANOVA) are shown in Table 2. Child victim-
ization had significant effects on caregiver report of
both aggression and depression (p < .05). The corre-
sponding patterns of least-square means of the
FIGURE 1: Effect of Caregiver Depression × Witnessed Violence
Interaction on Child Depression
adjusted scores showed that levels of aggression and
depression jumped sharply from no victimization to
any victimization, with only a slight difference
between moderate and severe levels of victimization.
Child report of witnessed violence was significantly
associated with all five outcome variables (p < .05).
The least-square means for the child-reported vari-
ables (depression, anger, and anxiety) increased lin-
early as the amount/severity of violence increased.
Caregiver report of witnessed violence was a signifi-
cant predictor of caregiver report of depression and
child reported anxiety, but not of anger or aggression
or child’s report of depression. Levels of child depres-
sion, as measured by caregiver report, increased sig-
nificantly from minimal to moderate levels of wit-
nessed violence, declining somewhat from moderate
to severe. However, more severe anxiety was reported
at the lowest level of witnessed violence and the least
severe anxiety was reported at moderate levels of wit-
nessed violence.

CHILD MALTREATMENT / AUGUST 2002

184 Johnson et al. / ADVERSE OUTCOMES

TABLE 2: Least-Square Means for Predictors From Multivariable Regression Analyses for Each Outcome (N = 167)

Outcomes
Caregiver Report: Caregiver Report: Child Report: Child Report: Child Report:
a a b b b
Predictor Aggression Depression Depression Anger Anxiety

Victimization
None 8.56 3.49 6.28 5.56 7.54
Moderate 11.83 6.32 7.90 8.01 8.11
Severe 12.10 5.23 5.45 4.09 6.56
p .0189 .0014 .1921 .0910 .6367
Caregiver report of witnessed violence
Minimal 9.12 4.51 7.08 6.00 8.74
Moderate 12.23 5.50 5.90 5.88 5.75
Severe 11.14 5.02 6.65 5.78 7.71
p .1686 .0041 .3057 .4483 .0451
Child report of witnessed violence
Minimal 12.84 5.98 4.52 3.67 4.67
Moderate 9.59 3.79 6.50 6.01 7.23
Severe 10.09 5.26 8.61 7.98 10.29
p .0443 .0372 < .001 .0029 < .001
NOTE: Least square means estimates are Type III sum of squares and control for caregiver depression, child sex, maternal education, care-
giver age, father figure in home, child health status, caregiver social support, and significant life events.
a. Measured by the Child Behavior Checklist.
b. Measured by the Trauma Symptom Checklist for Children.

DISCUSSION moderate-high levels of violence, whereas the care-

Although there has been previous research on neg-
ative mental health effects subsequent to child abuse,
children’s exposure to household violence, and chil-
dren’s exposure to neighborhood violence, few stud-
ies have used longitudinal data and adjusted for
potentially confounding variables. The purpose of
this investigation was to examine the association of
experiencing physical abuse and/or witnessing vio-
lence in the household or neighborhood environ-
ment with mental health outcomes among children.
We build on prior research by adjusting for a strict set
of control variables and using data collected at multi-
ple time points.
The children in our sample experienced high lev-
els of violence at a young age. More than one fourth
(29%) had either come to the attention of the State
Division of Social Services as being possible victims of
child abuse or had experienced physical aggression at
the hands of caregivers, that is, they were shoved,
slapped, pushed, or grabbed. (Physical aggression to
children by caregivers was assessed through caregiver
report.) Violence witnessed by children in the home
and neighborhood was assessed through both care-
giver and child report. Nearly half (46%) of the chil-
dren reported seeing an arrest, an assault, or loud
arguments. According to the child self-report mea-
sure of witnessed violence, more than three quarters
(77.2%) of the children had been exposed to
giver report indicated that 46% of children had been
exposed to moderate-high levels of violence. This dis-
crepancy may be due to several factors. First, the Child
Life Events survey, which was administered to care-
givers, inquires about events in the past year. In con-
trast, the child self-report Things I’ve Seen and Heard
survey inquires about the child’s entire lifetime. Sec-
ond, the highly personal nature of the questions may
have resulted in underreporting by caregivers. How-
ever, even the findings from the more conservative
assessment reflect an above-average level of witnessed
violence. According to caregivers’ reports, 15% of
children had seen someone severely assaulted or
threatened with a weapon, and 31% were exposed to
loud arguments.
Our findings confirm that children are negatively
affected by exposure to violence, both personal vic-
timization and what they see around them. When we
ran multivariate statistical models that tested the
effect of each predictor variable (victimization, child
self-report of witnessed violence, caregiver report of
witnessed violence) on all five mental health outcome
variables (child self-report of depression, anger, and
anxiety; caregiver report of child’s depression and
aggression), all three were significantly associated
with negative mental health outcomes. The series of
multivariable statistical tests, which were adjusted for
potentially confounding variables, examined the
effects of victimization and witnessing violence on

CHILD MALTREATMENT / AUGUST 2002


each mental health outcome separately. Victimiza-
tion was significantly associated with increased depres-
sion and aggression among children. Although the
caregivers’ report of witnessed violence was related to
significant increases in depression and anxiety, the
child self-report of witnessed violence was related to
significant increases in all five mental health
outcomes.
As compared to children who had not experienced
any victimization, those who had been physically
abused exhibited more severe adverse behavioral and
emotional outcomes. The mean scores for aggression,
depression, anxiety, and anger among nonvictimized
children were comparable to the scores of children in
the general population. In contrast, the scores of
those children who had been victimized were higher
than average (Achenbach, 1991; Briere, 1996). Simi-
larly, those children who reported witnessing severe
violence also had high anxiety and depression scores
relative to the general population and to those who
reported witnessing a minimal or moderate amount
of violence. Strangely, systematic linear increases in
the magnitude of negative mental health outcomes
were not apparent for additional models. This is
partly due to the fact that in some cases, even those
children who experienced the lowest degree of vio-
lence had above-average levels of negative mental
health outcomes.
LIMITATIONS
This analysis depends in part on maltreatment data
provided by a state central registry that includes all
maltreatment reports. It is likely that these reports
underestimate the prevalence of maltreatment. Even
though a truncated form of the CTS, without the most
severe forms of physical violence, was used as well to
increase the likelihood of capturing all maltreated
participants, our main predictor remains reported mal-
treatment rather than maltreatment itself.
Neither is this a study of a representative popula-
tion. Because participants were initially recruited
based on risk of maltreatment, the results are not
generalizable to all children.
Finally, not all of the hypothesized relationships
were significant or in the predicted direction. Per-
haps, for example, witnessing violence has an inhibit-
ing effect on aggression in young children who report
high levels of anxiety. It is possible that the parents’
reports in these cases simply do not reflect reality, or
the instruments and our attempts to create cut-points
along scales that are continuous may not adequately
capture the emotional and behavioral phenomena we
are studying. Nevertheless, the preponderance of our
CHILD MALTREATMENT / AUGUST 2002
Johnson et al. / ADVERSE OUTCOMES 185
observations supports our hypotheses that witnessing
and experiencing violence each contribute to adverse
psychological outcomes for young children.
CONCLUSION
This study of the impact of exposure to violence
among young children is unusual in three ways. First,
the study is based on a sample selected from a commu-
nity, not a clinic. Second, the study is longitudinal,
examining the consequences of victimization and of
witnessing violence at a point in time after the expo-
sures. Finally, the analyses are well controlled, taking
multiple potential confounders and interactions into
account. The conclusion, that witnessing violence
and being a victim of physical violence each is associ-
ated with adverse behavioral and emotional outcomes
for children, is not surprising. The implications of the
findings, however, are not so obvious. Parents, care-
givers, and human service providers need to consider
the context of maltreatment, especially any exposure
of children to family and neighborhood violence, to
prevent aggression, anxiety, and depression in victim-
ized young children.
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Renee M. Johnson worked as a graduate research assistant with
Dr. Desmond Runyan’s Longitudinal Studies of Child Abuse and
Neglect project (LONGSCAN) and with Dr. Jonathan Kotch’s
Southern local site of LONGSCAN. She is also an advanced gradu-
ate student in the Department of Health Behavior and Health Edu-
cation at the University of North Carolina at Chapel Hill.
Jonathan B. Kotch, a board-certified specialist in both pediatrics
and preventive medicine, is a professor and associate chair for grad-
uate studies in the Department of Maternal and Child Health,
School of Public Health, University of North Carolina at Chapel
Hill. He is the principal investigator of the Southern local site for the
Longitudinal Studies of Child Abuse and Neglect project
(LONGSCAN) project. In addition to child maltreatment, his spe-
cific areas of research and practice relate to child health policy,
injury prevention, and health and safety of children in out-of-home
child care.
Diane J. Catellier, a research assistant professor of biostatistics at
the University of North Carolina at Chapel Hill, provides statistical
data management, quality assurance, and studies management ser-
vices for a number of multicenter public health and medical studies.
She has statistical expertise in the areas of missing data, mixed mod-
els, categorical data analysis, and generalized estimating equations
procedures. Currently, she is a statistician for three NIH-sponsored
multicenter studies: the Atherosclerosis in Communities Study, the
Enhancing Recovery in Coronary Heart Disease Study, and the
Trial of Activity for Adolescent Girls.
Jane R. Winsor worked as a data manager and statistical pro-
grammer for Dr. Kotch’s Southern local site for the Longitudinal
Studies of Child Abuse and Neglect project (LONGSCAN) project
and the Stress and Social Support project for 11 years. She has an
additional 10 years of programming experience in a variety of appli-
cation areas. She is currently a project manager for a clinical
research organization, Rho, Inc., in Chapel Hill, North Carolina.
Vincent Dufort is an epidemiologist who has worked in maternal
and child health as a research associate, focusing on child maltreat-
ment and child injuries. He is currently working as an epidemiolo-
gist for a nonprofit organization whose primary goal is to help
improve the quality of health care for Medicare beneficiaries
throughout Maine, New Hampshire, and Vermont. He continues
his collaboration with researchers at the Department of Maternal
and Child Health at the University of North Carolina and is
involved in studies addressing prenatal care among Medicaid bene-
ficiaries and assessments of blood lead levels among their children in
New Hampshire.
Wanda Hunter is a research associate professor in the Depart-
ment of Social Medicine and assistant director for teaching and ser-
vice at the University of North Carolina Injury Prevention Research
Center. She has been engaged in research involving at-risk children
for 18 years. At the time this article was written, she was co–principal
investigator for the LONGSCAN Coordinating Center.
Lisa Amaya-Jackson is an assistant professor in psychiatry and
behavioral sciences at Duke University Medical Center and director
of trauma, evaluation, treatment, research, and preventive mental
health services at the Center for Child and Family Health North
Carolina, which is a consortium among Duke University, the Uni-
versity of North Carolina at Chapel Hill, and North Carolina Cen-
tral University.
CHILD MALTREATMENT / AUGUST 2002