Social Psychiatry and Psychiatric Epidemiology (2018) 53:1361–1370

https://doi.org/10.1007/s00127-018-1607-x

ORIGINAL PAPER

Violent interpersonal trauma predicts aggressive thoughts

and behaviors towards self and others: findings from the National
Comorbidity Survey-Adolescent Supplement
Teah‑Marie Bynion1 · Renee Cloutier2 · Heidemarie Blumenthal2 · Emily R. Mischel1 · Sasha M. Rojas1 ·
Ellen W. Leen‑Feldner1

Received: 28 November 2017 / Accepted: 18 September 2018 / Published online: 25 September 2018
© Springer-Verlag GmbH Germany, part of Springer Nature 2018

Abstract
Purpose The purpose of the current study is to examine the relation between adolescent traumatic event exposure and aggres-
sion directed towards the self and others. Theoretical perspectives underscore the particularly pernicious effects of violent
traumas intentionally perpetrated by others in terms of negative posttraumatic outcomes. However, a careful comparison
of trauma type in relation to aggression has not been done with youth. The current project, therefore, examined differences
between youth with a history of violent interpersonal trauma (VIT) compared to those with a non-violent trauma type his-
tory in terms of aggressive behavior directed towards others as well as aggressive self-directed thoughts (suicidal ideation).
Method The sample was drawn from the National Comorbidity Survey-Replication and consisted of 1928 adolescents
(M = 15.4; SD = 1.47 years), each assigned to one of four age- and gender-matched trauma history groups.
Results Consistent with hypotheses, among trauma-exposed youth, those who had experienced or witnessed a VIT (com-
pared to those reporting a non-VIT only) evidenced elevated aggression, even after controlling for a number of theoretically
relevant covariates (e.g., gender, age, household income, demographic factors).
Conclusion Results indicate that youth with a history of VIT may be at unique risk for experiencing aggression directed
towards others and the self compared to those without this specific trauma history. This is important because trauma type
is an easily assessed indicator of potentially elevated risk for these types of deleterious outcomes. Findings are situated in a
research agenda aimed at continuing to refine our understanding of the link between interpersonal trauma and aggression.

Keywords Adolescents · Violent interpersonal trauma · Aggression · Suicidal ideation

Introduction mental health treatment) and indirect (e.g., law enforcement

Aggression perpetrated by youth, whether in the context of
events such as school shootings (other-directed aggression)
or suicidal behavior (self-directed aggression), remains a
pressing public health matter. In addition to human suf-
fering, billions are spent annually in direct (e.g., medical/
* Teah‑Marie Bynion
trbynion@uark.edu
* Ellen W. Leen‑Feldner
eleenfe@uark.edu
1
Department of Psychological Science, University
of Arkansas, 216 Memorial Hall, Fayetteville, AR 72701,
USA
2
University of North Texas, Denton, USA
expenditures) costs related to aggression. Such costs do not
always include intangible costs related to pain and suffering
or death-related losses [1]. Indeed, recent estimates indicate
that both self-harm and interpersonal violence remain one of
the leading causes of death among adolescents [2]. One fac-
tor that may be linked to both types of aggression is a history
of violent interpersonal trauma (VIT) [3]. Given the unique
opportunities and challenges that characterize adolescence,
including high rates of traumatic event exposure [4], the
current study examined whether the experience of a violent
interpersonal traumatic event would relate to elevated self
and other aggression among youth.

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1362
Traumatic event exposure
Traumatic event exposure, defined by witnessing or expe-
riencing a life-threatening event or sexual violation [5], is
common among adolescents. Nationally representative find-
ings suggest 60–70% of youth report experiencing at least
one traumatic event [5, 6]. Although most people recover
from traumatic event exposure without developing problems,
there is a great deal of heterogeneity in outcomes among
those who do develop problems [7]. That is, traumatic event
exposure is linked to an array of negative outcomes, includ-
ing mood disorders, posttraumatic stress disorder (PTSD),
and substance use problems [8–10]. Further, traumatic event
exposure is linked with increased risk for both suicidal
behavior [11] and aggression towards others [12]. Thus,
trauma type is an important factor to consider in relation to
traumatic event exposure and aggression towards the self
and others.
Trauma type
Extant data indicate traumatic events of a violent, interper-
sonal nature (e.g., abuse, sexual assault), compared to events
such as car accidents or natural disasters are associated with
elevated rates of PTSD among adults [13, 14] and youth [4].
Indeed, traumatic events perpetrated by others, particularly
when they occur in childhood [15], are linked with anxiety,
substance use, and other stress-related problems [16, 17].
From a theoretical perspective, traumatic events involving
intentional violence by others runs counter to the impetus
to form and maintain social bonds as a means of ensuring
survival [18]. Accordingly, traumatic experiences in which
another person violates accepted behavioral norms may be
more insidious than traumatic experiences involving inter-
personal loss, natural disasters, or accidents, and by virtue
of disrupting social bonding systems, facilitate aggression
towards others and the self. In line with this view, Kisiel and
colleagues [19], in a large sample of children entering the
state child welfare custody system (M = 5.2 years), found
repeated exposure to physical or sexual abuse or family vio-
lence was linked with a twofold increase in anger control
problems, poor self-regulation, and danger to others com-
pared to “other” traumatic events (e.g., single incident, non-
violent trauma). Such findings are consistent with studies
that link sexual assault [20], childhood abuse [21], family
violence [22], and peer victimization [23] with self and other
aggression among youth. To the best of our knowledge, how-
ever, no studies have specifically compared VIT exposure,
defined as traumatic events characterized by intentional vio-
lence perpetrated by others, to other types of trauma in terms
of associations with forms of aggression among adolescents.
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Social Psychiatry and Psychiatric Epidemiology (2018) 53:1361–1370
Current study
The current study aimed to address this gap in the litera-
ture by examining the relation between traumatic event
type and aggression towards the self and others within a
large sample of adolescents. It was predicted that youth who
experienced a VIT, relative to those who experienced a non-
violent interpersonal trauma (non-VIT) and those with no
history of trauma (No Trauma), would evidence elevated
aggressive behavior towards others (e.g., hitting others) and
self-directed aggressive thoughts (i.e., suicidal ideation).
Because both gender [24, 25] and age [25, 26] relate posi-
tively to these outcomes, case control matching procedures
were utilized to equate groups on these factors.
Method
Design overview
Data were drawn from the National Comorbidity Survey-
Adolescent Supplement (NCS-A), a nationally representa-
tive cross-sectional survey designed to assess the prevalence
and psychosocial correlates of the Diagnostic and Statisti-
cal Manual of Mental Disorders (DSM-IV) [5] diagnoses
among adolescents 13–18 years of age. Study background,
methods, and sampling procedures for the complete sample
(N = 10,148) is comprehensively described elsewhere [27,
28]. Briefly, the survey was based on a dual-frame design
that recruited adolescents from households who had par-
ticipated in the National Comorbidity Survey-Replication
(NCS-R; n = 879), and from a representative sample of
schools in the same communities as the NCS-R households
(n = 9,244). Adolescents completed face-to-face, computer-
assisted interviews [including a modified Composite Inter-
national Diagnostic Interview (CIDI)] [28, 29] in their home
with professional interviewers.
Participants
Given the large sample size differences across trauma his-
tory, we age- and gender-matched adolescents who experi-
enced a VIT with those who experienced a non-VIT, Both,
and No Trauma to create four groups of participants with
482 cases each. Participants endorsing “Other” or “Private
Events” were excluded (n = 982). Private events were meas-
ured by asking, “… did you ever have an extremely upset-
ting or life-threatening event that you did not tell me about
because you did not want to talk about it?”. After match-
ing, the final sample included 1,928 adolescents (M = 15.4,
SD = 1.47; 51.9% girls). Please see Tables 1 and 2 for
Social Psychiatry and Psychiatric Epidemiology (2018) 53:1361–1370 1363

Table 1  Sample descriptive No trauma IPV only Non-IPV only Both Total
statistics n (%) n (%) n (%) n (%) N (%)

Demographics
Age (M, SD) 15.4 (1.47) 15.4 (1.47) 15.4 (1.47) 15.4 (1.47) 15.4 (1.47)
Gender (female) 250 (51.9) 250 (51.9) 250 (51.9) 250 (51.9) 250 (51.9)
Race/ethnicity
Hispanic 82 (17.0) 116 (24.1) 67 (13.9) 112 (23.2) 377 (19.6)
Black 63 (13.1) 89 (18.5) 116 (24.1) 120 (24.9) 388 (20.1)
Other 25 (5.2) 33 (6.8) 30 (6.2) 29 (6.0) 117 (6.1)
White 312 (64.7) 244 (50.6) 269 (55.8) 221 (45.9) 1046 (54.3)
Household Income
Median $40–44,999 $25–29,999 $40–44,999 $30–34,999 $35–39,999
Below poverty ratio 83 (17.2) 96 (19.9) 91 (18.9) 99 (20.5) 369 (19.1)
DSM-IV diagnoses
PTSD – 30 (6.2) 12 (2.5) 54 (11.2) 96 (5.0)
Major depressive episode 40 (8.3) 98 (20.3) 46 (9.5) 115 (23.9) 299 (15.5)
Externalizing disorders 36 (7.5) 97 (20.1) 46 (9.5) 161 (33.4) 340 (17.6)
CD 9 (1.9) 44 (9.1) 12 (2.5) 85 (17.6) 150 (7.8)
ODD 28 (5.8) 71 (14.7) 38 (7.9) 110 (22.8) 247 (12.8)
Substance use disorder 32 (6.6) 90 (18.7) 41 (8.5) 115 (23.9) 278 (14.4)
Alcohol abuse 16 (3.3) 36 (7.5) 27 (5.6) 61 (12.7) 140 (7.3)
Alcohol dependence 3 (0.6) 7 (1.5) 1 (0.2) 12 (2.5) 23 (1.2)
Drug abuse 20 (4.1) 55 (11.4) 27 (5.6) 61 (12.7) 163 (8.5)
Drug dependence 2 (0.4) 10 (2.1) 3 (0.6) 29 (6.0) 44 (2.3)

n = 482 in each group; N = 1928 total. Poverty ratio was defined using household family income for the
past-year relative to the federally defined poverty line based on family size. Adolescents with a household
family income of three or more times the poverty level were considered ‘above’ (reference) and adolescents
with a household family income less than three times the poverty line were considered ‘below’
IPV interpersonal violence, PTSD post-traumatic stress disorder, DSM-IV diagnostic criteria, CD/ODD
meeting criteria for either conduct or oppositional defiance disorder

descriptive statistics and specific traumatic events observed
in the current sample.
Measures
Traumatic events
Participants were administered a modified version of the
World Health Organization Composite International Diag-
nostic Interview (CIDI) [28, 29], a structured diagnostic
interview with excellent psychometric properties [30]. For
the purpose of the NCS-A study, the CIDI was modified to
include multiple indicators of emotional functioning (e.g.,
suicidality) and for use with youth (e.g., language, compre-
hension) [31]. Lifetime exposure to traumatic events was
assessed via the PTSD module of the CIDI. The PTSD mod-
ule has demonstrated good test–retest and inner-rater reli-
ability in previous samples [30, 32] and is consistent with
DSM-IV criteria. Following McLaughlin and colleagues
[4], nine items corresponding to nine VIT event types were
identified (e.g., robbery, physical abuse, rape). Consistent
with theoretical models discussed in the introduction, these
events reflect the perpetration of intentional violence by oth-
ers. Eight items corresponding to non-VIT events were also
identified (e.g., serious illness, major disaster). Here, the
non-VIT category combines categories from McLaughlin
and colleagues [4], who distinguished between “accidents”
(e.g., car accidents, accidentally hurting another person)
and “network/witnessing” events (e.g., unexpected death of
a loved one). Because “other” and “private” events were
not defined and could conceivably include VIT or non-VIT
events, these events were excluded from analyses.
Suicidal ideation
Self-directed aggressive thoughts were assessed with a sin-
gle yes/no item from the suicidality module of the CIDI that
was administered to all adolescents (i.e., have you ever seri-
ously thought about killing yourself?). Skip logic employed
in the interview required participants to first endorse suicidal
ideation before being asked about plans or attempts. Due
to the low number of participants endorsing suicidal plans

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1364 Social Psychiatry and Psychiatric Epidemiology (2018) 53:1361–1370

Table 2  Prevalence of exposure Traumatic event VIT Only Non-VIT Only Both Total
to trauma by group n = 482 n = 482 n = 482 N = 1446
n (%) n (%) n (%) n (%)

VIT
Kidnapped 4 (0.09) – 17 (3.5) 21(1.1)
Physical abuse by caregiver 10 (2.1) – 37 (7.7) 73 (5.0)
Beaten up by partner 9 (1.8) – 19 (3.9) 28 (1.9)
Beaten up by anyone else 84 (17.4) – 93 (19.3) 177 (12.2)
Mugged 108 (22.4) – 170 (35.4) 278 (19.2)
Raped 50 (10.4) – 56 (11.6) 106 (7.3)
Other sexual molestation 72 (14.9) – 84 (17.4) 156 (10.8)
Stalked 95 (19.7) – 94 (19.5) 189 (13.1)
Witnessed domestic violence 176 (36.5) – 169 (35.1) 345 (23.9)
Non-VIT
Car accident – 80 (16.6) 69 (14.3) 149 (10.3)
Other serious accident – 50 (10.4) 98 (20.3) 148 (10.2)
Major disaster – 116 (24.1) 94 (19.5) 210 (14.5)
Serious illness – 48 (9.9) 65 (13.5) 113 (7.8)
Unexpected death of loved one – 262 (54.4) 280 (58.1) 542 (37.5)
Someone else stressful experience – 57 (11.8) 103 (21.5) 160 (11.1)
Saw bad injury/death – 74 (15.4) 151 (31.3) 225 (15.6)
Accidentally hurt another person – 5 (1.0) 16 (3.3) 21 (1.5)

The total (N = 1446) represents the percentage of traumatic event type endorsed given event in the VIT or
non-VIT only plus the number who endorsed the event in the “Both” group; non-VIT, reported at least one
non violent interpersonal trauma only; VIT, reported at least one violent interpersonal trauma only; Both,
reported at least one non-VIT and one VIT

(n = 69) and attempts (n = 64), the current study focused
exclusively on aggressive thoughts related to killing oneself.
Other‑focused aggression
Aggression towards others was assessed with three yes/no
items of the CIDI that addressed attacks of anger which led
to breaking items of value (have you ever in your life had
attacks of anger when all of a sudden you lost control and
broke or smashed something worth more than a few hun-
dred dollars?), attacking another person (have you ever had
attacks of anger when all of a sudden you lost control and
hit or tried to hurt someone?), or, if responding ‘no’ to any
actual attacks, threats towards another person (have you ever
had attacks of anger when all of a sudden you lost control
and threatened to hit or hurt someone?).
Covariates
To compute adjusted odds ratios (OR), several factors
were considered as covariates due to their association
with aggression. Specifically, race/ethnicity [33], house-
hold income [34], and relevant lifetime DSM-IV diagno-
ses [35, 36] were considered as additional predictors to
include in the final conditional logistic regression models.
Household income was based on the ratio of income to
poverty line and was used as a proxy for socioeconomic
status (SES). Poverty ratio was defined using household
family income for the past year relative to the federally
defined poverty line based on family size. To evaluate the
incremental predictive validity of trauma type on self/other
aggression, lifetime history of theoretically-relevant dis-
orders was selected as indices of psychiatric risk. These
included any substance use disorders, externalizing disor-
ders (oppositional defiant disorder or conduct disorder),
major depressive episode, and PTSD [37]. To provide
stable parameter estimates and avoid ‘overfitting’ [38],
we elected to merge conceptually similar diagnoses with
low sample prevalence rates (< 15%) thereby reducing the
total number of additional predictors in the model. Specifi-
cally, alcohol abuse, alcohol dependence, drug abuse, and
drug dependence were consolidated to represent ‘any life-
time substance use disorder’. Conduct disorder and ODD
were consolidated to represent ‘any lifetime externalizing
disorder’. Finally, lifetime MDE (15.5% in sample) and
PTSD (5%) were retained as individual predictors given
their conceptual relationship to the outcomes (e.g., suici-
dality) and primary predictors. Although age and gender
are also related to aggression [22, 39, 40], these variables
were already methodologically addressed by the age- and

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Social Psychiatry and Psychiatric Epidemiology (2018) 53:1361–1370
gender- matching procedure and, therefore, were not
included as additional predictors.
Data analytic approach
Case control matching
Adolescents exposed to VIT events only (n = 482) were
exact matched with adolescents in three different compari-
son groups on relevant demographics (i.e., age and gender).
The larger NCS-A dataset includes a substantially larger pro-
portion of adolescents outside of the VIT group with com-
plete gender and age data making this an ideal application
of a 1:1 exact matching procedure [41]. Exact matches were
selected at random, without replacement using the ‘Case-
Control Matching’ Python extension command in SPSS 22
[42, 43]. Sampling weights were not applied.1
Preliminary and primary analyses
Descriptive data for the final sample of 1928 participants
were examined (see Table 1). The sample consisted of four
equal groups: those who experienced a VIT, those who
experienced a non-VIT, Both, or No trauma. A series of
cross-tabulations and Chi-square tests were conducted to
examine the relation between these four groups and aggres-
sion-related outcomes. Unadjusted ORs were then calculated
to determine the extent to which the two groups exposed to
VIT or Both were associated with increased odds of each
outcome occurring in comparison to No Trauma and non-
VIT exposure. Cross-tabulations and Chi-square analyses
testing the associations of potential covariates with each out-
come also were conducted. To ensure that the overall model
explains more variance in our outcomes than the null, we
examined whether there was a statistically significant change
in variance accounted for by the overall model than what
would be expected by chance. Variables related to at least
one of the outcomes were included in the final conditional
logistic regression analyses [44].
Finally, adjusted ORs and associated 95% confidence
intervals (CIs) were calculated using logistic regression to
determine the extent to which VIT exposure was associated
with increased odds of each outcome in comparison to No
Trauma and non-VIT exposure, after adjusting for identified
covariates. To examine the extent to which trauma expo-
sure type is associated with increased risk for experiencing
1
Sampling weights for the NCS-A dataset are often used to ensure
analyses are conducted on a nationally representative sample [28].
However, because we selected a sub-sample of adolescents based on
history of exposure to a traumatic event, our sample is not nationally
representative of the US adolescent population thus sampling weights
were not applied.
1365
negative outcomes, two sets of analyses were conducted—
the first included No Trauma as the reference group and
excluded PTSD as a predictor, the second included non-VIT
event as the reference group while excluding the No Trauma
group and included PTSD as a predictor. These analyses pro-
vide comparison groups which include a relevant ‘baseline’
for what a low-risk (i.e., non-trauma exposed) population is
likely to experience.
Results
Descriptive/preliminary analyses
Following the coding scheme for classifying potentially
traumatic events outlined by McLaughlin and colleagues
[4], prevalence of trauma exposure by group was examined
(Table 2). Unadjusted odds ratios indicated a significant
difference in the proportion of cases from the four groups
endorsing serious thoughts of suicidality, having attacks of
anger where they broke something, having attacks of anger
where they hit/attempted to hit someone, or an anger attack
where they threatened to hit another person. Specifically,
adolescents in the VIT and Both groups endorsed signifi-
cantly more (a) serious thoughts of suicidality, (b) anger
attacks where valuables were broken, and (c) anger attacks
where someone else was hit compared to those in the No
Trauma group and non-VIT groups.2 Please see Fig. 1 for
the percentage of each outcome by trauma group.
Among the subsample of youth responding to the ques-
tion of anger attacks including the threat of hitting someone,
threats were endorsed by a significantly smaller proportion
of adolescents in the No Trauma group than the VIT only
and Both group, but not the non-VIT only group. Accord-
ingly, we did not include threatening aggression as an out-
come in primary analyses; we return to this issue in the
discussion.
Of the six covariates tested, only household income
was unrelated to any outcomes. Therefore, the final set of
analyses include race/ethnicity, substance use disorder,
2
Chi square tests of independence indicated a significant difference
in the proportion of cases from the four groups endorsing serious
thoughts of suicidality [χ2 (3, N = 1876) = 59.469, p < .001], hav-
ing attacks of anger where they broke something [χ2 (3, N = 1928)
= 102.618, p < .001], having attacks of anger where they hit/
attempted to hit someone [χ2 (3, N = 1927) = 117.242, p < .001], or
an anger attack where they threatened to hit another person [χ2 (3,
N = 1090) = 13.381, p = .004]. Specifically, (a) serious thoughts of
suicidality, (b) anger attacks where valuables were broken, and (c)
anger attacks where someone else was hit each were endorsed by
fewer adolescents in the No Trauma and non-VIT groups, and signifi-
cantly more adolescents in the VIT and Both groups, than expected
by chance.
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1366
Fig. 1  Percentage of reported
Percent Endorsed by Youth
self and other aggression by
trauma group
externalizing disorders, major depressive episode, and PTSD
(for trauma exposed sample only) as covariates.
Primary analyses/logistic regression/adjusted odds
ratios
In the total sample with No Trauma used as the reference
group, the conditional logistic regression models fit the
data significantly better than the null model for: suicidal
ideation, anger where objects are broken, and anger involv-
ing hitting others. Overall, VIT and Both group member-
ship was associated with greater endorsements of suicidal
ideation (OR = 2.28, 95% CI = 1.50–3.46; OR = 2.08;
95% CI = 1.36–3.20), breaking items (OR = 2.21, 95%
CI = 1.65–2.96; OR = 2.30; 95% CI = 1.71–3.11), and hit-
ting others (OR = 2.08; 95% CI = 1.57–2.75; OR = 2.42; 95%
CI = 1.82–3.23) compared to membership in the No Trauma
group. In contrast, there were no differences on any of these
outcomes between the non-VIT and No Trauma groups. Sim-
ilarly, in the trauma exposed sample with non-VIT trauma
as the reference group, the conditional logistic regression
models fit the data significantly better than the null model for
each outcome and the VIT only and Both groups were asso-
ciated with greater endorsements on each of the outcomes.
Please see Table 3 for predictor-specific adjusted odds ratios.
Discussion
The current study is the first to compare violent interper-
sonal traumatic events and other trauma types in relation to
both aggressive self-directed thoughts, as well as aggres-
sive behaviors towards others within a large sample of ado-
lescents. Although previous empirical research indicates
aggression is elevated following traumatic event exposure
generally [19, 21], less is known about the role of trauma
type and its link to various forms of aggression in this rela-
tion, particularly among adolescents. This is important
because of the relative ease with which traumatic event
type can be assessed, thereby identifying youth at elevated
13
Social Psychiatry and Psychiatric Epidemiology (2018) 53:1361–1370
40
35
30
25
20
15
10
5
0
Suicidal Ideation (n=473) Breaking Items (n=700) Hitting Others (n=838)
Types of Aggression by Trauma Group
No Trauma non-VIT VIT Both
risk for aggression-related outcomes. As expected, results
suggest that exposure to events that involve the intentional
perpetration of violence by others is uniquely associated
with endorsement of both self-directed aggression (suicidal
ideation) and aggression towards others.
Self‑directed aggression
First, with regard to suicidal ideation, analyses from the
total sample indicated that, compared to adolescents who
had not been exposed to trauma, those with a history of
VIT were more than twice as likely to endorse having
seriously thought about killing themselves. This was not
the case for those who were exposed to events such as a
car accident or serious illness—there was no difference
between youth with non-VIT history and those with no
trauma in terms of suicidal ideation. A similar pattern was
observed within the trauma-exposed groups; those with
a history of VIT were significantly more likely to report
suicidal ideation compared to those whose trauma his-
tory was not characterized by violent events intentionally
perpetrated by others (i.e., non-VIT history). Importantly,
groups were matched on age and gender, and observed
findings held after controlling for a number of theoreti-
cally relevant covariates. These results accord with previ-
ous work linking trauma generally [11] and interpersonal
events such as sexual assault specifically [20] to suicide
risk behavior among youth. The current findings extend
the literature by comparing specific types of trauma as
they relate to both suicidal ideation as well as aggression
towards others among youth, and underscore the particu-
larly destructive effects of traumatic event exposure that
involves the intentional perpetration of violence by oth-
ers. Specifically, such experiences are correlated with an
increased likelihood of seriously considering taking one’s
life. An important next step will be to extend these findings
to other indicators of suicidal behavior. Although suicidal
ideation is predictive of other suicidal behaviors [45], the
manner in which self-directed aggression was operational-
ized here (i.e., suicidal ideation) does not include active
Social Psychiatry and Psychiatric Epidemiology (2018) 53:1361–1370 1367

Table 3  Odds ratios of group Variables Suicidal ideation Breaking items Hitting others
on outcomes adjusting for
sociodemographics and relevant AOR 95% CI AOR 95% CI AOR (95% CI)
DSM-IV diagnoses (No Trauma
and non-VIT as reference) No Trauma as reference (N = 1928)
Race/ethnicity
NH White (ref) 1.0 (ref) [0.52–1.05] 1.0 (ref) 1.0 (ref)
Hispanic 0.739 0.907 [0.69–1.18] 0.85 [0.66–1.10]
NH Black 0.510* [0.34–0.765] 1.07 [0.82–1.39] 1.35* [1.05–1.74]
Other 0.531 [0.28–1.00] 1.34 [0.89–2.02] 1.15 [0.76–1.74]
Lifetime diagnosis
Any SUD 2.19* [1.57–3.06] 1.67* [1.26–2.23] 1.61* [1.20–2.16]
CD/ODD 1.48* [1.07–2.06] 2.28* [1.75–2.98] 3.00* [2.28–3.96]
MDE 3.98* [2.95–5.37] 2.03* [1.56–2.65] 1.77 [1.34–2.33]
Group
No Trauma 1.0 (ref) 1.0 (ref) 1.0 (ref)
Non-VIT 1.137 [0.71–1.82] 1.28 [0.95–1.73] 1.24 [0.94–1.65]
VIT 2.28* [1.50–3.46] 2.21* [1.65–2.96] 2.08* [1.57–2.75]
Both 2.08* [1.36–3.20] 2.30* [1.71–3.11] 2.42* [1.82–3.23]
Non-VIT as reference (n = 1446)
Race/ethnicity
NH White (ref) 1.0 (ref) 1.0 (ref) 1.0 (ref)
Hispanic 0.75 [0.51–1.09] 0.995 [0.74–1.33] 0.98 [0.73–1.31]
NH Black 0.53* [0.35–0.81] 1.04 [0.78–1.38] 1.42* [1.08–1.87]
Other 0.57 [0.29–1.11] 1.39 [0.88–2.21] 1.36 [0.85–2.15]
Lifetime diagnosis
Any SUD 2.07* [1.45–2.95] 1.80* [1.32–2.45] 1.78* [1.30–2.45]
CD/ODD 1.40 [0.99–1.99] 2.09* [1.57–2.78] 2.56* [1.90–3.45]
MDE 3.51* [2.53–4.88] 2.05* [1.52–2.75] 1.71* [1.26–2.31]
PTSD 1.55 [0.94–2.57] 0.811 [0.51–1.29] 0.80 [0.50–1.27]
Group
Non-VIT 1.0 (ref) 1.0 (ref) 1.0 (ref)
VIT 2.00* [1.34–3.00] 1.72* [1.30–2.28] 1.68* [1.28–2.20]
Both 1.82* [1.20–2.75] 1.83* [1.37–2.44] 1.99* [1.51–2.63]

Non-VIT as Reference group excludes No Trauma; AOR, adjusted odds ratio; NH, non-Hispanic; any SUD,
meeting DSM-IV criteria for either alcohol or other substance use disorder (excluding nicotine); any CD/
ODD, meeting criteria for either conduct or oppositional defiance disorder; any MDE, meeting criteria for
major depressive episodes
*OR values are statistically different from reference group at p < .05

suicidal ideation or suicide attempts. Future studies should
consider assessing the link between trauma type and fac-
tors further along the continuum from ideation to action
[46]. Additionally, the current cross-sectional study design
precludes temporal conclusions. Notably, empirical work
which includes longitudinal studies suggests interpersonal
trauma (e.g., victimization, abuse) typically precedes sui-
cidal ideation [47, 48]. Indeed, suicidal ideation has not
been examined as a precipitant risk factor for experienc-
ing a violent interpersonal trauma. Nonetheless, an impor-
tant next step will be to disentangle temporal patterning
between traumatic event exposure and suicidal ideation
[49] as well as deliberate self-harm [50] via longitudinal
designs. Further, theoretical and empirical work suggests
that intrapersonal and interpersonal distress in response
to a traumatic event is also linked to an increased risk for
intentional self-harm [51, 52] and mediates the association
between psychopathology (e.g., depression) and suicidal
behaviors [53]. Therefore, potential mediators of the rela-
tion between specific types of traumatic event exposure
and aggression towards self and others will be important
to consider in future research. Examples of such media-
tors include subjective levels of distress, emotion regula-
tion difficulties, quality and quantity of social support, and
negative belief systems [54–56].

13
1368
Aggression towards others
Similarly, with regard to aggression towards others, analyses
of the total sample indicated that those with a history of VIT
were more than twice as likely to endorse breaking items or
hitting others compared to those who had not been exposed
to trauma. Further, there was no difference between youth
with non-VIT history and those with no trauma in terms
of other-focused aggression. Within the trauma exposed
groups, those who endorsed VIT were more than twice as
likely to endorse breaking things and hitting others when
compared to those with a non-VIT history. These results are
consistent with work linking traumatic event exposure gener-
ally [12], and intentional harm inflicted by another person
specifically (e.g., bullying) [23], with displays of aggression.
The current study extends this body of work by providing
evidence that youth exposed to a VIT, even compared to
youth with other types of traumatic event exposure, report
elevated aggressive behavior towards others. From a theo-
retical perspective, surviving an act of violence intentionally
perpetuated by another person may disrupt the formation
of normal social bonds and predict aggression [18]. This
study lays the foundation for future research examining why
traumatic experiences involving intentional perpetration of
violence correlate with aggression. For instance, perhaps
violent interpersonal trauma results in greater distress during
the trauma itself, which contributes to increased aggressive
behavior. Another possibility is the negative effects on one’s
beliefs about the world secondary to such experiences [57].
Future work could examine the role of theoretically-rele-
vant mechanisms, including peri-traumatic stress levels and
posttraumatic cognitions, in driving the current observed
differences.
A different pattern was observed for threatening aggres-
sion among the trauma-exposed groups. Here, preliminary
analyses indicated VIT and Both groups did not differ from
the non-VIT group. Methodological factors may be at play
here, as subjects had to say “no” to the question related to
hitting someone before the threat question was posed. Fur-
ther, developmental scholars contend that youth typically
hold relatively accepting beliefs around mild aggression
such as verbal threat, suggesting it may not be a sensitive
outcome indicator in terms of the effects of experiencing a
VIT trauma [58, 59]. This represents an important area for
future work.
Limitations
Although the current findings extend the literature by
underscoring the importance of comparing specific types
of trauma as they relate to aggression towards self and oth-
ers, there are a number of important limitations. First, this
study cannot speak to causality. Additional factors may be
13
Social Psychiatry and Psychiatric Epidemiology (2018) 53:1361–1370
at play, such as a dispositional tendency toward impulsiv-
ity, which may elevate risk for both traumatic event expo-
sure and aggression [60]. Laboratory-based experimental
work (e.g., manipulation of imaginal exposure to various
trauma types) would increase confidence in the role of spe-
cific trauma types as they relate to aggression towards self
and others. Second, it will be important to examine study
hypotheses using approaches other than exclusively self-
report. Future work may usefully incorporate multi-modal
assessments such as a death/suicide implicit association
test [44] or multi-informant report to bolster confidence
that findings are not unduly influenced by memory or
mood-related biases. Third, an exact-case matching pro-
cedure was employed to reduce bias [61]. As suggested,
the current sample was matched without replacement [42]
and sample weights were not applied [27, 62]. Two poten-
tial drawbacks of the matching approach include loss of
statistical power from excluding available cases and the
inability to directly test the estimates on which cases are
matched (here, age and gender). Because the findings are
consistent when the analyses are conducted in the entire
sample with age/gender included as covariates, the con-
cerns with the matching approach are minimized. Finally,
the current study separately examined self- and other-
directed aggression. However, research points toward a
third category of “combined” aggression [63–65]. This
co-morbidity is less common than either form of aggres-
sion alone. For example, data from a large national sam-
ple indicates about 3% of adolescents reported both being
in a physical fight and attempting suicide during the past
year. Substance use, particularly binge drinking, along
with depressive symptoms were elevated in this combined
group. It is not currently clear what drives the target of
aggression (e.g., self versus other), although theorists have
suggested specific endogenous factors such as depres-
sion or resentment may be implicated [66]. Future work
comparing different forms of aggression as a function of
trauma history should consider including the comorbidity
between self-and-other aggression as an additional form
of aggression.
Conclusion
These limitations notwithstanding, the findings link expe-
riences of violent interpersonal trauma with elevated dis-
plays of aggression towards others as well as aggressive
self-directed thoughts among a large sample of youth.
Important next steps will be to better clarify the nature of
this relation, as such data can usefully inform interventions
targeting youth at risk for aggression by virtue of traumatic
event history.
Social Psychiatry and Psychiatric Epidemiology (2018) 53:1361–1370
Compliance with ethical standards
Conflict of interest On behalf of all authors, the corresponding author
states that there is no conflict of interest.
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