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Relationship Between Type of Trauma Exposure and Posttraumatic Stress Disorder Among Urban Children and Adolescents
Rohini Luthra, Robert Abramovitz, Rick Greenberg, Alan Schoor, Jeffrey Newcorn, James Schmeidler, Paul Levine, Yoko Nomura and Claude M. Chemtob J Interpers Violence 2009 24: 1919 originally published online 22 October 2008 DOI: 10.1177/0886260508325494 The online version of this article can be found at: http://jiv.sagepub.com/content/24/11/1919

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physical abuse. gender. New York Paul Levine Jewish Board of Family and Children’s Services. New York Journal of Interpersonal Violence Volume 24 Number 11 November 2009 1919-1927 © 2009 SAGE Publications 10. fire. Structured clinical interviews are carried out. New York Alan Schoor Jewish Board of Family and Children’s Services. witnessing domestic violence.com Robert Abramovitz Jewish Board of Family and Children’s Services. Keywords: interpersonal violence. and ethnicity. New York Rick Greenberg Episcopal Social Services. and exposure to accidents. and sexual abuse are each significantly associated with PTSD. PTSD 1919 Downloaded from jiv. Chemtob Mount Sinai School of Medicine.1177/0886260508325494 http://jiv.com at USC Norris Medical Library on October 25. New York James Schmeidler Mount Sinai School of Medicine. Witnessing a crime.sagepub. and linear and logistic regression analyses are conducted to examine the relationship between PTSD and type of trauma exposure controlling for age.sagepub. being the victim of a crime. These findings underscore the association between interpersonal violence and childhood PTSD.Brief Note Relationship Between Type of Trauma Exposure and Posttraumatic Stress Disorder Among Urban Children and Adolescents Rohini Luthra Mount Sinai School of Medicine.com hosted at http://online. New York This study examines the association between trauma exposure and posttraumatic stress disorder (PTSD) among 157 help-seeking children (aged 8-17).sagepub. or disaster are not associated with PTSD. trauma exposure. Confrontation with traumatic news. 2011 . New York Jeffrey Newcorn Mount Sinai School of Medicine. New York Claude M. New York Yoko Nomura Mount Sinai School of Medicine.

In addition. PI: Claude M. Riedesser. Linear and logistic regression analyses were conducted to examine the association between PTSD and type of trauma exposure. 2007). Mount Sinai School of Medicine. being in a fire.to 17-year-old youth recruited from three large urban community mental health clinics in the New York City metropolitan Authors’ Note: This study was supported by NIMH (R24 MH063910-04.1920 Journal of Interpersonal Violence R esearchers have identified a range of risk factors associated with the development of PTSD among adults. Ribi. 2011 . Child and Family Resilience Program. Room 419-A. education. gender. and pretrauma psychopathology (Tolin & Foa. 1995. Please address correspondence to Rohini Luthra. Barkmann.edu. Lee. The Funder had no role in the design or conduct of the study. Schafer. & Andreskie. Christopher. Method Participants Participants were 8. while controlling for the effects of age.sagepub. & Hadar.com at USC Norris Medical Library on October 25. & Delahanty. the only study that looked at the relative associations of multiple traumas to PTSD examined physical abuse. Schulte-Markwort. Shalev. Department of Psychiatry.. Ostrowski. usually drawn from university clinic populations (Landolt.. New York. Pynoos et al. sexual abuse. and witnessing a serious accident or death of a parent or loved one). such as a natural disaster or motor vehicle accident (McDermott.luthra@mssm. being robbed or mugged. and subsequent symptoms. Studies examining risk for PTSD among children have focused on the impact of exposure to a particular type of traumatic exposure. 2000). gender. most studies that have examined the risk of developing child PTSD have studied highly restricted samples. and domestic violence and then lumped together all other traumas into one category (Silva et al. NY 10029. being seriously wounded. To our knowledge. Davis. 2004). Tuval-Mashiach. Downloaded from jiv. Judd. The vast majority of studies on risk factors for PTSD have exclusively sampled adult populations. The current study addressed the limitations of past research by sampling children and adolescents from three large urban community mental health clinics. & Sennhauser. One set of factors includes the frequency and severity of trauma exposure (Breslau. and ethnicity. Vollrath. 249 5th Avenue. Gnehm. & Gibbon. A second set of factors involves the individual’s personal attributes such as age. witnessing acts of violence. e-mail: rohini. Chemtob). 2005. 2003. 2006). This study was conducted as part of a larger research study in which we gathered data on the association of diverse types of trauma exposure and psychosocial functioning using self-report measures and a structured clinical interview. 2006). 1993. (The “other” category in this study included the following events: family home being broken into.

During this time. / Trauma Exposure and Posttraumatic Stress Disorder 1921 area. For this study. and (10) experiencing sexual abuse.sagepub. The K-SADS PTSD module includes a structured trauma exposure checklist that lists the following events: (1) being involved in a car accident. in this interview. (8) witnessing domestic violence. between December 2005 and November 2006. 1997). 1994). To ensure that assessors were consistent in the administration of the KSADS. (2) being involved in other accident. Thus. Data collection occurred over an 11-month period. we used the child as the primary informant and only administered the PTSD module of the K-SADS. we conducted a reliability analysis on a subset of KSADS interviews.) (American Psychiatric Association. Approximately 15% (n = 23) of the KSADS Downloaded from jiv. Respondents were then asked to identify which (if any) of these 10 events they had been exposed to and then to select which event was most distressing to them at the time of the intake. Seventeen of these families declined to have the data used for research purposes. Respondents were then queried about PTSD symptoms specific to the event they identified as currently most distressing. The K-SADS has good interrater reliability (Ambrosini. 2011 . Kaufman et al.com at USC Norris Medical Library on October 25. (7) receiving traumatic news. 174 completed the research interview. (3) being involved in a fire. 197 eligible families were approached for consent.Luthra et al. (4) witnessing a disaster. The K-SADS is a semistructured. Measures Exposure to trauma events and PTSD symptoms were assessed using the Kiddie Schedule for Affective Disorders and Schizophrenia (K-SADS.. clinician-administered diagnostic interview that is based on the Diagnostic and Statistical Manual of Mental Disorders (4th ed. Assessors and K-SADS Reliability The K-SADS was administered by 13 research clinicians who were master’s-level social workers or psychologists. with the exception of two PhD clinical psychologists.. 1997) for current and lifetime PTSD. parent and child act as dual informants in the assessment of the child’s current and lifetime psychopathology. (9) experiencing physical abuse. it would have been imprecise to generate a combined symptom score. These clinicians received extensive training in the administration of the K-SADS. (6) being victim of a violent crime. we decided to use the child as the primary informant. Because the parent and child generally identified disparate trauma exposures. Of these. 2000) and concurrent validity (Kaufman et al. (5) witnessing a violent crime. which yielded a final sample of 157 families.

and 38% reported that their exposure met diagnostic conditions for full Criterion A.9%). and obtained parent informed consent and child assent. Among exposed children. explained its voluntary nature. Ninety-one (58%) of the participants were boys. helplessness. The kappa statistic indicated good reliability across raters (0. 45% reported that their exposure met Criterion A1 (i.9%)..e.4%). A kappa statistic was conducted to measure pairwise agreement between the raters.com at USC Norris Medical Library on October 25. Procedure The study was reviewed and approved by the Mount Sinai School of Medicine Institutional Review Board.e. 2011 . or threat to physical integrity). all participants were approached by a research clinician who described the study. 47% reported that their exposure met Criterion A2 (i.7). Results Participants A total of 157 children provided informed consent and assent to participate in the research assessment.2 (SD = 2. serious injury..1 (SD = 1.) Of the children who reported exposure to a traumatic event. the average lifetime exposure rate was 3. mixed (8. A total of 38% (n = 60) participants indicated that trauma exposure was part of the reason they presented at the mental health clinics.9%).sagepub.74). The research clinician then administered the K-SADS as part of a larger study being conducted at the three clinics. (See Table 1 for the frequency of exposure to each type of traumatic event. The interviews were independently scored by a second rater. The mean age of the sample was 12. African American/Black (17. Trauma Exposure The majority of children (88%) reported exposure to at least one traumatic event. Roughly one third of the participants were Hispanic (36. or other/unknown (8. life threat. with the remainder being Caucasian/White (27. to assess interrater reliability.8). using audiotaped recordings of the interviews. intense fear. or horror).8).1922 Journal of Interpersonal Violence interview tapes were randomly chosen for this analysis. After completing the standard community clinic intake. Downloaded from jiv.

p < .05).007). Neither community violence Downloaded from jiv.006). p < . p < .01).16.01). witnessing domestic violence (p = .69. witnessing domestic violence (B = 4. / Trauma Exposure and Posttraumatic Stress Disorder 1923 Table 1 Frequency of Exposure to Each Type of Traumatic Event Type of Exposure Witnessing a disaster Being involved in a fire Being involved in a car accident Experiencing sexual abuse Being victim of a violent crime Experiencing physical abuse Being involved in other accident Witnessing a violent crime Witnessing domestic violence Being confronted with traumatic news n 11 12 19 19 27 38 50 50 61 105 % 7 8 12 12 17 24 32 32 39 67 Type of Traumatic Exposure and PTSD A linear regression was conducted to examine the relationship between type of trauma exposure selected as currently most distressing and total number of PTSD symptoms. hearing traumatic news (p = . These events largely included exposures to interpersonally traumatic events. and experiencing sexual abuse (p = . such as the death of a loved one). An omnibus test of the model indicated that type of exposure was significantly related to PTSD diagnosis (χ2 = 25. A total of 19% (n = 30) of the sample met full diagnostic criteria for PTSD.sagepub.58.005). being exposed to traumatic news (B = 4. (Note: A variety of events constituted the “confrontation with traumatic news” category.90. Being in a car accident or other accident and witnessing a violent crime were not significantly associated with total number of PTSD symptoms.01). Being the victim of a violent crime (B = 3. and experiencing sexual abuse (B = 5.035) were all significantly associated with a diagnosis of PTSD.Luthra et al. p < .64. An omnibus test of the model indicated that type of exposure was significantly related to number of PTSD symptoms (F = 6.06. p < . experiencing physical abuse (B = 5.01). p < .01) were all significantly related to total number of trauma symptoms.001).com at USC Norris Medical Library on October 25.7. p = . A binary logistic regression was then conducted to examine the relationship between type of trauma exposure selected as currently most distressing and diagnosis of PTSD. Experiencing physical abuse (p = . 2011 .

23 .3 9. Kilpatrick. *p < .55 Ethnicity –0.e.35 Note: CI = confidence interval. 2006).08 0.15 .7 0.8-224.48-34.e. witnessing community violence or being the victim of community violence) was significantly associated with PTSD.001 .4 0. (i.0 0.3 0.6 Witnessing a violent crime 1. witnessing violence or being the victim of violence) nor noninterpersonal trauma (i. our results corroborate research with adults suggesting that exposure to interpersonal trauma has greater psychosocial consequences than exposure to noninterpersonal trauma (Ford. and Best (1993) found that lifetime rates of PTSD associated with interpersonal Downloaded from jiv.006 . neither exposure to noninterpersonal events.sagepub.0 29.e.3 0.7 0.81 0.5 4.42-1.07 .e. Saunders.5 Experiencing physical abuse** 3.46 0.11 Gender 0.1 8.005 ..5 3.1 2.001.26 Significance Exp(B) .8 2.3 Witnessing domestic violence** 2.0-71.95-1.91 1. and domestic violence) were significantly associated with PTSD.70 95% CI 0. and disaster) nor community violence (i.20 . Stockton.4 Being victim of a violent crime 2.70-4.0-48. fire. accidents.7 1. Discussion Results of the present study indicate that type of trauma exposure is significantly associated with a diagnosis of child PTSD.20 . Although this has not been previously studied directly among child populations.0 Being confronted with traumatic news** 2.com at USC Norris Medical Library on October 25.7 1.e.7 0.2-65. accidents. Dansky.1 1.8 12.80-227.2 (i. **p ≤ .1924 Journal of Interpersonal Violence Table 2 Type of Trauma Exposure by Posttraumatic Stress Disorder B Being involved in a car accident 2... only interpersonally traumatic events (i. Resnick..4 Experiencing sexual abuse* 2..2 Age 0. & Green.1 7.0 1. hearing traumatic news or experiencing physical abuse. sexual abuse. In contrast. SE 1.3 0. 2011 . or disaster) was significantly associated with PTSD (see Table 2). Kaltman.4 1.05. In our study.50-106.035 .18 13.1 1. The finding that interpersonal trauma is more distressing than either community violence or noninterpersonal trauma is very much in line with research on adult populations. fire.

Further research is now needed to examine the ways in which various types of traumas affect a child’s functioning. Hughes. 1993). Similarly. and Nelson (1995) found that PTSD rates associated with rape. Taken together. 1994. or witnessing a traumatic event ranged from 4% to 6% in men and from 5% to 9% in women. Kessler. domestic violence. these findings suggest that exposure to interpersonal trauma warrants careful assessment and treatment because these events appear to have worse psychosocial consequences compared with exposure to community or noninterpersonal trauma. physical abuse. a handful of studies have shown that repeated exposure to community violence does not always yield psychological distress (Farrell & Bruce. Bromet. & Linder. This research should look closely at the type of trauma exposure as well as the frequency and severity of each exposure. and therefore report low levels of distress because of it. Farrell and Bruce (1997).Luthra et al. Sonnega. 1997. / Trauma Exposure and Posttraumatic Stress Disorder 1925 trauma ranged from 31% to 39%. natural disaster. 2011 . In contrast to this. Slavens.sagepub. Pendergrast. Future research should also identify protective factors that may help buffer the impact of a child’s exposure to various types of trauma events. 1993). Interestingly. posited that in some cases. that children in our sample (largely from urban neighborhoods) may have been exposed to various types of community violence on a regular basis and may therefore have become desensitized and less distressed because of this type of trauma exposure. molestation. become desensitized to it.. then. children who experience repeated exposure to community violence are more likely to normalize this type of abuse. the relationship between community violence and PTSD warrants closer examination to more fully understand the consequences of repeated exposure to this type of violence. Martinez & Richters. for instance.e. and sexual abuse). the majority of literature on community violence suggests that exposure to this type of aggression is strongly associated with posttraumatic symptoms (DuRant. Our findings support the idea that different types of trauma exposure have different associations with PTSD. and physical attack ranged from 2% to 65% in men and from 21% to 49% in women. Osofsky. hearing traumatic news and experiencing physical abuse. Werers. whereas the lifetime rate of PTSD associated with noninterpersonal trauma was only 9%. Hann. An interesting finding of our study was that neither witnessing a violent crime nor being the victim of one was associated with PTSD. Our study highlighted that childhood PTSD was only associated with exposure to interpersonal trauma events (i. Downloaded from jiv. Cadenhead. whereas rates of PTSD attributable to accident. & Fick. It stands to reason.com at USC Norris Medical Library on October 25. Clearly.

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Her research interests include the consequences of interpersonal violence and the prevention of secondary trauma. PhD. Tuval-Mashiach. & Hadar. (2006). Jeffrey Newcorn. is assistant professor of psychiatry at the Mount Sinai School of Medicine. (2004). Yoko Nomura. D.. Tolin. Matzner. S. I. R.. He also serves as an adjunct associate professor at the New York University School of Social Work.. 159-164. (2000). is assistant executive director at Episcopal Social Services. Rohini Luthra. F. MBA. Journal of Clinical Psychiatry. & Foa. Chemtob. C. Munoz.sagepub. American Journal of Psychiatry. Alan Schoor. is chief psychiatrist at the Jewish Board of Family and Children’s Services. Sex differences in trauma and posttraumatic stress disorder: A quantitative review of 25 years of research. Posttraumatic stress disorder as a result of mass trauma. P. MPH. James Schmeidler. F. Posttraumatic syndromes in children and adolescents after road traffic accidents: A prospective cohort study. is clinical professor of psychiatry and pediatrics at the Mount Sinai School of Medicine. 157. 65(Suppl. MD. He served as a statistical consultant for this article. He also serves as director for Trauma Program Innovation. Paul Levine. D. S. & Dummit.. He is also president of the New York State Coalition of Children’s Mental Health Services. is associate professor of psychiatry and pediatrics.com at USC Norris Medical Library on October 25. is assistant professor of psychiatry at the Mount Sinai School of Medicine. Shalev. Psychopathology. Barkmann. 2011 . B. H. Singh. is a licensed clinical psychologist in the department of psychiatry at the Mount Sinai School of Medicine. 39.. Stress and vulnerability to posttraumatic stress disorder in children and adolescents.. Mount Sinai School of Medicine.. Riedesser. Psychological Bulletin. is deputy executive director at Jewish Board of Family and Children’s Services. 132. & Schulte-Markwort. PhD. E. PhD.. is executive vice president and CEO designate at the Jewish Board of Family and Children’s Services. Rick Greenberg. R.. M.. LCSW. R.Luthra et al. MD. PhD. 4-10. He is also director of the Division of Child and Adolescent Psychiatry at the Mount Sinai Hospital. director of the Child and Family Resilience Program. M. Y. PhD. Her primary research is on developmental psychopathology in the life course. 1229-1235. A National Traumatic Stress Network Treatment Services Adaptation Center. and codirector of ACS-MSSM Children’s Trauma Institute. A. LCSW. Silva. 1). (2006). Downloaded from jiv.. / Trauma Exposure and Posttraumatic Stress Disorder 1927 Schafer. Alpert. Claude M. M. 959-992. Robert Abramovitz.