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Exposure to violence among inner-city youth
JOURNAL OF ADOLESCENT HEALTH 1993;143214-219
Exposure to Violence Among Inner-City Yout HOWARD
SCHUBINBR,
AND ANGELA TZBLBPIS,
M.D.,
RICHARD
SCOTT,
Ph.D.
violence is a majorcause of morbidityand mortalityamong adolescents and young adults. In thie study, 246 her city, predominantly black youth (ages
Interpersonal
14-23 years) were surveyed regarding their exposure to, and participationin, violent acts. An in-depth psycho-
lo@l interview was also completed. A total of 44%reportedthey could access a gun within one day, 42% have seen someone shot or knifed, and 22%have seen someone killed. In the preceding3 months, 18% reportedcarrying a gun, and 32%had been in a physical fight; 34 subjects were rated by the psychologists as at high risk for involvement in violent acta. Those subjects were more likely to be of lower socioeconomic status (p c 0.01) and to have been physically abused (p < 0.001) but no more likely to be a witness to violent events. Inneecity youth are frequently exposed to violence. Those at risk for per petration of violence were more likely to be at high risk for most other health-risk behaviors. RRY WORDS:
Interpersonal injury
Adolescents Firearms Blackyouth Injuries are the leading cause of death for children in the United States (1). Among African-American males between the ages of 14 and 44 years, homicide is the leading cause of death (2). Nationally, most
Fmm the Departmentsof InternalMedicine nnd Pedintrics,Wayne State University and Children’sHospitalof Michigan (U.S., A.T.), and
the kpartment of Community Medicine, Wayne State UniversiQ fR.SJ, Detroit, Michigan. Addwss mprint re&&s to: HounwdSckbiner, M.D., 5C University H&h Center, 4201 St. Antoine, Detroit, Ml 48201. Presented at the Societyfor AdolescentMedicine NationalMeeting, Atlanta, GA, Man%23.1990. Manuscriptaccepted Nwember 3,1992. 214 1054439xt93ls6.00
M.A.,
P&&shed by EIsevieaS+zs
homicides result from assaults with a firearm (3), and high rates of owning and carrying firearms have been documented among adolescents (4,5). Presently, it is known that the prevalence of violence in the United States is greatest in large central cities in which poor, minority populations are over represented (6). Few studies provide empirically identified factors that are known to increase individual risk of violent behavior. Even in communities that have the highest rates of violence, perpetrators and victims represent only a small percentage of the population. In addition to the need to identify factors that are predictive of individual involvement in violence, there is a need to assess the effects of frequent exposure to violence on the quality of life of non-violent residents of violent communities. In this study, a sample of inner-city youth completed a comprehensive survey and psychological interview to assess their overall exposure to various types of violence and to identify specific conditions, which were related to a psychologist’s assessment of individual risk of violent behavior.
Methods Sampling The data for the paper were collected as part of a larger study. The purpose of the study was to develop a brief questionnaire to identify adolescents and young adults at risk for psychosocial health problems (7). Therefore, each subject completed a self-report screening instrument developed by the authors (available upon request) and an in-depth psychological evaluation. The sample consisted of 246 adolescents and young adults, who were recruited to create a sample 8 Society for Adolescent Medicine, 1993 %Xshing Co., Inc., 655 Avenue of the Americas, New York, NY 10010
May1993
of equal proportions of males, females, those aged 14-18 years, and those aged 19-23 years. Recruitment was done through an inner-citypublic health department of Detroit, Michigan. Subjectswere recruited in four ways to attempt to create a sample representativ? of the youth living near the public health department. 1) and 2) Clientsin two different health departmentclinicswere invitedto participate. One was a general medicalclinicfor adolescentsand young adults [andthe other, for sexuallytransmitted diseases for patients of all ages. 3) Youth in nearby summer youth job programs were also recruited. 4) Additional subjects were recruited by way of advertisements in a local newspaper. Subjects were recruited by a research assistant who had worked a number of years in the local community. Subjects 18 years and older signed a consent form at recruitment, and completed the pencil-and-paper questionnaire and psychologicalinterview on the same day. Subjects under 18 years of age were given a parental consent form, and completedthe questionnaire and interview at the clinic upon presentation of the signed parental consent form. Each subject was paid $15.00 for participation. The study was approved by the Human SubjectsCommittee of the Children’s Hospital of Michigan. Subjects Of the 246 subjects, 91% were African-American, and 57% were female. The subjects’ ages ranged between 14 and 23 years. The mean age was 18 years; 128 were between 14 and 18 years old, and 125 were between 19 and 23 years old. A majoritywere from poor families;52% percent were from familieswhich fell into the fifth and lowest category of Hollingshead’s socioeconomic status scale, and 27% were from families in the fourth of Hollingshead’scategories (8). The socioeconomic status of this population is similar to that of Detroit, as 23% of adolescents and young adults (ages 16-24 years) in Detroit have familyincomes belowthe poverty level (1990 census figures).Sixty-sevenpercentof the subjects were in school, and 35% were employed at the tune of the interview. Fifteen percent were heads of their own households, 50% lived in familiesheaded by their mothers, 27% lived in familiesheoded by their fathers, and 8% lived in the home of a relative, usually grandparents. These data are also comparable to 1990 census data for Detroit which reports 47%, 36%, and 15% of adolescents livingin families headed by their mother, their father, and another relative, respectively.
VIOLENCE AMONGINNER-CITY YOUTH
215
ments
The 30 violence-relateditems (of the total 175 health behavior questionnaire)in the questionnairewere written by the authors to assess individual risk of being involved in interpersonalviolence. These included witnessing violence, violence victimization, behaviorswhich increase the risk of involvementin violence, and past involvement in violence. The questionnairewas pilot tested with similar patients in a medical clinic to assess relevance and comprehension, prompting minor changes. The psychological interview was based on the Childhood Assessment Schedule (CAS) (9). The CAS is a semistructured diagnostic interview consisting of several content areas, including school, friends, activities and hobbies, family, fears, worries, self-image, mood (especiallysadness), somatic concerns, expressions of anger, and thought disorder symptomatology which parallelsthe DSM-IIIR (10). The CAS has been reviewed for cultural sensitivityby a panel of African-Americanscholarsand has been utilizedwith African-Americanyouth (11). Informationwas also obtainedon risk for unwanted pregnancy, sexually transmitted disease, risk for motor vehicle accidents, weapon carrying, access to guns, and exposure to violent acts. Trained psychologists, blinded to the results of the s&report screeningquestions, rated each subject on a 5-point scale (from 1 = no problem/treatment not indicated to 5 = extreme problem/ treatment absolutelynecessary) for the following:1) need for school or academic counseling due to academic failure; 2) need for vocational/employment counselingdue to vocationalfailure;3) need for family counseling due to parent-teen conflict;4) need for treatment of depression; 5) need for treatment of conduct disorder or antisocialbehavior; 6) need for alcohol abuse treatment; 7) need for drug abuse treatment; 8) need for birth control counseling; 9) need for counseling on sexually transmitted diseases; 10) involvementin significantacts of violence as a perpetrator; 11) risk of involvement in motor vehicle accidents; and 12) anxiety disorders. The criteria used to determine an individual’srisk as a perpetrator of violent acts were the following: involvement in physical fights, access to weapons, prior arrests or convictions, assessment Of iI?iplsiveness and volatile temper, and involvement in criminalactivity. Data
alysis
The data were analyzed in two phases. In the first
zl6
WHUBINER ET AL.
phase, frequency distributions were obtained for exposure to various categories of violence. Additionally, bivariate analyses were conducted to assess the relationships between exposure and gender, age, and living status. In the second phase of analysis, the sample was divided into two categories defined by the psychologist’s rating of individual risk of future involvement in violence, i.e., severity rating of 1, 2, or 3 (low risk) compared to a rating of 4 or 5 (high risk). Bivariate analyses were then conducted to identify demographic and experiential factors, which discriminate between individuals at low and high risk of future involvement in violence.
Red ts Exposure to Violence The prevalence of exposure to violence was high among the survey respondents. During the 3 months prior to the study, 81% of the subjects had witnessed at least one loud argument, 58% had seen at least one physical fight, 34% had seen someone shooting a gun, and 19% had seen at least one fight involving knives. At some time in their lives, 42% of the respondents had seen someone shot or knifed, and 22% had seen someone killed. Nine percent had seen more than one person killed. In the 3 months prior to the interview, 73% of the respondents had been involved in a loud argument, 32% had been in a physical fight, 30% had carried a knife, and 18% had carried a gun. Also, 30% of the respondents said that they could acquire a gun witlua an hour, and another 31% indicated that they could get one within a few days. Forty-four percent reported that there were guns in their homes. There were no sign&ant differences between males and females in witnessing arguments or fights, or in being involved in arguments. For the remainder of the above items, males reported significantly higher exposure to violence than did females (p < 0.001). Age was significantly related to several of the violence items in the questionnaire. Comparison of three age groups (U-16,17-19, and 20-24) revealed that the youngest group was significantly more likely to have seen and been involved in a physical fight (p < 0.01). Subjects living with families headed by their fathers or their grandmothers were significantly more likely to have seen a physical fight in the 3 months prior to the interview than were those living in homes headed by their mothers or by themselves (JJ < 0.05). Those living in homes headed by their fa-
JOURNAL OF ADOLESCENT HEALTH Vol. 14, No. 3
thers were also more likely to report the presence of guns in their homes (p < 0.01). In response to a question about personal safety, 50% reported concern about being attacked in the street. As part of the psychological interview, respondents were asked to state their general concerns and fears. Thirty-eight percent reported concerns about violence, including “getting shot” and ‘guns, ” etc. There was no difference in such concerns between males and females. In the psychological interview, 9% of the respondents reported that they had been the victims of physical abuse. An additional 9% of the respondents reported that they had been sexually abused. There were no gender differences in rates of physical abuse, but females were significantly more likely to have been sexually abused than were males (15% and 3%, respectively; x2 = 8.4, p < 0.01).
Youth at High Risk of Being Involved in Future Violence Based upon the psychological evaluation, 34 of the 246 respondents (14%) were rated at high risk (i.e., 4 or 5 on the 5-point violence severity scale) of being a perpetrator of violence in the future. Males were more likely to be at high risk than were females (23% and 82, respectively; p < 0.01). A summary of selected variables for which the high-risk group was significantly different from the low-risk group is given in Table 1. When compared to the remainder of the subjects, the high-risk group was more likely to have low socioeconomic status, to have been victims of physical abuse, and to have had problems in school. In addition, individuals in the high-risk group were significantly more likely to have been at increased risk (psychological severity rating of 4 or 5) for motor vehicle injuries, sexually transmitted diseases, becoming an adolescent parent, alcohol and substance abuse, difficulties in school and employment, family conflict, depression, and conduct disorder (all relationships sign&ant at p < 0.01). Therefore, the group at high risk for violence was also more likely to be at high risk for every other category rated by the psychologists with one exception, anxiety disorder (12% versus 5%, p = 0.29). They were also more likely to be involved in a physical fight and to have carried a gun (p c 0.0001). There were no differences between the high-risk group and the remainder of the sample in reported levels of concern about violence or in the frequency of witnessing violence.
May 1993
VIOLENCEAMONG INNER-CITYYOUTH
Table 1.
Characteristics Which Discriminate Between Youth at High”and Low Risk of Being Involved in Violence
Discriminating characteristis Low SES’ Physical abuse Failed a grade Been expelled Physical fights Canied a gun Motor vehicle injury risk Sexually transmitted disease risk Pregnancy risk Alcohol abuse risk Drug abuse risk School failure risk Vocational failure risk Family conflict Depression Conduct disorder.
High-risk Low-risk group group (%) (%) p valueb 77
49
32 47 55 68 56 47 27 41 18 15 32 41 27 29 50
6 28 27 26 13 9 8 17 3 2 11 19 9 9 3
0.01 0.0001 0.04 0.002 0.0001 0.0001 0.0001 0.004 0.002 0.003 0.004 0.002 0.007 0.009 0.001 0.0001
“Youth at high risk of being involved in violence are those who were rated as 4 or 5 by the psychologist. bBy Chi-Square analysis. ‘Low socioeconomic status (SES)is defined as categories 4 and 5 of Hotigshead’s scale.
Discussion Rates of expos:lre f3 ~AOkilCt?in this sample were striking. A majority of the subjects reported that they had seen at least one loud argument and at least one physical fight in the 3 months prior to the interview. Furthermore, surprisingly large percentages of the subjects had seen the use of deadly weapons at least once, and more than one in five of the respondents had seen someone killed in their lifetime. This level of community violence is likely to impact the quality of life of all inner-city adolescents, affecting their decisions about the clothes they wear, the routes they travel, school activities, and their choice of friends. Many of the subjects reported that they were concerned or worried about violence, their safety, and the safety of family members and friendIs. The violence also contributes to the further deterioration of the community by encouraging families with the necessary resource to move away, increasing the social isolation of the poor. Thirty-four (14%) of the respondents were rated by the psychologist to be at high risk for future violence. When compared to the remainder of the sample, indl#lduals in this high-risk group were not more likely to have witnessed a violent incident.
217
highlights the level of exposure to violence by the entire population studied. There are two caveats to be considered when interpreting these data. First, the sample was a convenience sample drawn from a variety of sources. Nevertheless, we attempted to sample a diverse group of inner-city adolescents and young adults, and the census da we obtained suggests that our sample is similar to a cross section of adolescents in Detroit. Second, all of the data are self-reported. The rating of the respondents’ risk of violence exposure was based on an in-depth psychological interview. We were unable to obtain objective, external indicators of behavior, such as criminal or driving records. Bell (12) reported rates of exposure to violence similar to the rates reported here. In a survey of 538 school-age children (grades 2-8) in Chicago, Bell found that 31% had seen someone shot, 34% had seen someone stabbed, and 84% had seen someone “beaten up.” Gladstein and Slater (13) reported that a population of inner-city teenagers in Baltimore also had striking rates of witnessing violent activity. In addition, the mean number of times this population was victimized by a violent act was 1.42 (13). This frequent exposure to violence and the media coverage of violence results in high rates of concerns and worries about violence. Public opinion polls note that 40% of inner-city adults report being concerned about street violence and half express concerns about going out at night (14). In a comparative study of concerns and worries among adolescents in the United States and the Union of Soviet Socialist Republics, “being a victim of violent crime” was found to be the eighth (of 19) most common cause of worly in both countries (15). Social and contextual factors have been shown to be associated with violent behavior. saultive behavior has frequently been reported to be associated with individual risk of violence (16-19). Gelles (20) reported that rates of child abuse are strongly associated with family structure and poverty. Importantly, he found that there is an interaction between these two factors such that poor families with a male in the household are at increased risk of child abuse. Hawkins et al. (21) have argued that failure to connect with prosocial in&viduals, especially family and school representatives, increases the likelihood that adolescents will bond with delinquent peers and engage in a variep] of antisocial and self-destructive behaviors. Similar implications can be drawn from a recent study in
This
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JOURNAL OF ADOLESCENT HEALTH Vol. 14, No. 3
SCHUBINER ET AL.
in which it was found that one of the strongest predictors of antisocial behavior (e.g., drug abuse and poor school performance) among adolescents was a feeling that no adult cared about their well-being (22). Firearms are readily accessible to a large number of adolescents. In this study, 62% of respondents reported that they could obtain a gun within a few days, and 18%reported having carried a gun at some time. These rates, although alarming, are actually lower than other reports (4, 23). This issue is yartitularly significant when one considers that those most likely to carry weapons are also likely to be depressed and to use alcohol or other drugs. Brent and colleagues (24, 25) have reported on this association and the increased risk of suicide in adolescents with ready access to firearms. Our data are the first to document the lack of difference in witnessing violent acts between adolescents who are at low versus high risk for committing violence. They are also the first to describe the risk for violence as being the single risk factor which predicts high risk in virtually all other psychosocial risk areas. It has been suggested that clinicians in office settings can counsel youth to reduce their risk of violence (26). Given the complex nature of the causes of interpersonal injury and the association of other risk behaviors, however it seems unlikely that briefoffice-based interventions will be effective. Referral to community or school programs tha: offer intensive individual or small group counseling, if available, might be preferable. Several studies have documented high rates of exposure to violence; however, little attention has been paid to the effects of this exposure on adolescents and young adults. Street violence is undoubtedly a realistic fear for many inner-city youth. As mentioned, the subgroup rated at lower risk for violence was just as likely to witness violence as the high-risk group. One can only speculate as to the effects of this exposure to violence on overall indices d stress, which may cause a variety of physical and emotional problems (27). Many inner-city youth are at risk for educational and employment failure, substance abuse, unwanted pregnancy, and sexually transmitted diseases, including HIV. The additional risk from endemic interpersonal injury only adds to the burden. It appears likely that only strategies that affect the overall health (i.e., economic, educational, medical, and social) of inner-city communities have the Potential to solve this complex problem (28). Minneapolis
Rtferences
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11. 12. 13. 14. 15.
16.
17.
18. 19.
20.
21.
22. 23.
Rivara FP. Traumatic deaths of children in the US: Currently available prevention strategies. Pediatrics 1985;75:456-62. Runyan CW, Gerken EA. Epidemiology and prevention of adolescent injury. JAMA 1989;262:2273-9. Centers for Disease Control. Homicide Surveillance, 19701983: High Risk Racia! and Ethnic Minorities-Blacks and Hispanics. Atlanta, GA: Centers for Disease Control, 1985. Grand Jury of Baltimore City. Grand Jury Report of Juveniles and Firearms. Baltimore, MD: 1987. Sadowski LS, Cairns RB, Earp JA. Firearm ownership among non-urban adolescents. Am J Dis Child 1989;143:1410-3. Federal Bureau of Investigation. Crime in the United States: Uniform Crime Reports for the United States. Washington, DC Federal Bureau of Investigation, Annual. Schubiner H, Tzelepis A, Podany E. Development of the Safe Times Questionnaire. J Adolesc Health Care 1989;10:249. Hollingshead AB, Redlich FC. Social class and mental illness: A community study. New York, Wiley, 1958. Hodges K, Gordon Y, Lennon MP. Parent-child agreement on symptoms assessed via a clinical research interview for children: The Childhood Assessment Schedule (CAS). J Child Psycho1 Psychiatry 1990;31:427-36. Diagnostic and statistical manual of mental disorders, Third edition, (DSM-III-R). American Psychiatric Association, Washington, DC; revised 1987. Hodger K. Personal communication. Bell CC. Preventive strategies for dealing with violence among blacks. Community Ment Health J 1987;23:217-28. Gladstein J, Slater EJ. Inner city teenagers’ exposure to violence: A prevalence study. MD Med J 1988;37:951-4. Silberman CE. Criminal violence, criminal justice. New York, Random House, 1978:3. Chivian E, Robinson JP, Tndge JR, et al. American and Soviet teenagers’ concerns about nuclear war and the future. N Engl J Med 1988;319:407-13. Pfeffer CR, Plutchik R, Mizruchi MS. Predictors of assaultiveness in latency age children. Am J Psychiatry 1983;140: 31-5. Tarter RE, Hegedus AM, Winsten NE, Alterman AL Neuropsychological, peisonality, and familial characteristics oof physically abused delinquents. J Am Acad Child Psychiatry 1984;23%8-74. McCord J. Some child rearing antecedents of criminal behavior in adult men. J Pers Sot Psycho1 1979;9:1477-86. Loeber R, Weissman W, Reid J. Family interactions of assaultive adolescents, stealers, and non-delinquents. J Abnorm Child Psycho1 1983;11:1-14. Gelles RJ. Child abuse and violence in single parent families: Parent absence and economic deprivation. Am J Orthopsychiatry 1989;59:492-501. Hawkins JD, Lishner DM, Catalan0 RF. Childhoood predictors and the prevention of adolescen, substance abuse. In: Jones CL, Battjes RJ, eds. Etiology of Drug Abuse: Implications for Prevention. National Institute on Drug Abuse, ggc;graph 56. Washington, DC: U.S. Government Printing . . Blum RW. Personal communication, 1990. Wolf MS, Bishop V, Guagliardo M, D’Angelo LJ. Weapons and urban adolescents: Are other risk behaviors associated with their possession? J Adolesc Health 1992;13:41.
May 1993
24. Brent DA, Perper JA, Allman CJ. Alcohol, firearms, and suicide among youth: Temporal trends in Allegheny County, Pennsylvania, 1960-1983. JAMA 1987;257:3369-72. 25. Brent DA, Perper
JA, Allman CJ, et al. The presence and accessibility of firearms in the homes of ado&ctirri suicides: A case-control study. JAMA 1991;266:2989-95.
26. Stringham P, Neitzman M. Violence counseling in the routine health care of adolescents. J Adolesc Health Care. 1988;9:38993.
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219
27. Shakoor BH, Chalmers D. Covictimizatton of AfricanAmerican children who witness violence: Effects on cognitive, emotional, and Behavioral development. J Nat1 Med ASsot 1991;83:233-8. 28. Cohall AT, Mayer R, Cohall K, Walter H. Teen violence: The search for solutions. Contemporary Pediatr 1991;11:71-93.
Exposure to Violence Among Inner-City Yout HOWARD
SCHUBINBR,
AND ANGELA TZBLBPIS,
M.D.,
RICHARD
SCOTT,
Ph.D.
violence is a majorcause of morbidityand mortalityamong adolescents and young adults. In thie study, 246 her city, predominantly black youth (ages
Interpersonal
14-23 years) were surveyed regarding their exposure to, and participationin, violent acts. An in-depth psycho-
lo@l interview was also completed. A total of 44%reportedthey could access a gun within one day, 42% have seen someone shot or knifed, and 22%have seen someone killed. In the preceding3 months, 18% reportedcarrying a gun, and 32%had been in a physical fight; 34 subjects were rated by the psychologists as at high risk for involvement in violent acta. Those subjects were more likely to be of lower socioeconomic status (p c 0.01) and to have been physically abused (p < 0.001) but no more likely to be a witness to violent events. Inneecity youth are frequently exposed to violence. Those at risk for per petration of violence were more likely to be at high risk for most other health-risk behaviors. RRY WORDS:
Interpersonal injury
Adolescents Firearms Blackyouth Injuries are the leading cause of death for children in the United States (1). Among African-American males between the ages of 14 and 44 years, homicide is the leading cause of death (2). Nationally, most
Fmm the Departmentsof InternalMedicine nnd Pedintrics,Wayne State University and Children’sHospitalof Michigan (U.S., A.T.), and
the kpartment of Community Medicine, Wayne State UniversiQ fR.SJ, Detroit, Michigan. Addwss mprint re&&s to: HounwdSckbiner, M.D., 5C University H&h Center, 4201 St. Antoine, Detroit, Ml 48201. Presented at the Societyfor AdolescentMedicine NationalMeeting, Atlanta, GA, Man%23.1990. Manuscriptaccepted Nwember 3,1992. 214 1054439xt93ls6.00
M.A.,
P&&shed by EIsevieaS+zs
homicides result from assaults with a firearm (3), and high rates of owning and carrying firearms have been documented among adolescents (4,5). Presently, it is known that the prevalence of violence in the United States is greatest in large central cities in which poor, minority populations are over represented (6). Few studies provide empirically identified factors that are known to increase individual risk of violent behavior. Even in communities that have the highest rates of violence, perpetrators and victims represent only a small percentage of the population. In addition to the need to identify factors that are predictive of individual involvement in violence, there is a need to assess the effects of frequent exposure to violence on the quality of life of non-violent residents of violent communities. In this study, a sample of inner-city youth completed a comprehensive survey and psychological interview to assess their overall exposure to various types of violence and to identify specific conditions, which were related to a psychologist’s assessment of individual risk of violent behavior.
Methods Sampling The data for the paper were collected as part of a larger study. The purpose of the study was to develop a brief questionnaire to identify adolescents and young adults at risk for psychosocial health problems (7). Therefore, each subject completed a self-report screening instrument developed by the authors (available upon request) and an in-depth psychological evaluation. The sample consisted of 246 adolescents and young adults, who were recruited to create a sample 8 Society for Adolescent Medicine, 1993 %Xshing Co., Inc., 655 Avenue of the Americas, New York, NY 10010
May1993
of equal proportions of males, females, those aged 14-18 years, and those aged 19-23 years. Recruitment was done through an inner-citypublic health department of Detroit, Michigan. Subjectswere recruited in four ways to attempt to create a sample representativ? of the youth living near the public health department. 1) and 2) Clientsin two different health departmentclinicswere invitedto participate. One was a general medicalclinicfor adolescentsand young adults [andthe other, for sexuallytransmitted diseases for patients of all ages. 3) Youth in nearby summer youth job programs were also recruited. 4) Additional subjects were recruited by way of advertisements in a local newspaper. Subjects were recruited by a research assistant who had worked a number of years in the local community. Subjects 18 years and older signed a consent form at recruitment, and completed the pencil-and-paper questionnaire and psychologicalinterview on the same day. Subjects under 18 years of age were given a parental consent form, and completedthe questionnaire and interview at the clinic upon presentation of the signed parental consent form. Each subject was paid $15.00 for participation. The study was approved by the Human SubjectsCommittee of the Children’s Hospital of Michigan. Subjects Of the 246 subjects, 91% were African-American, and 57% were female. The subjects’ ages ranged between 14 and 23 years. The mean age was 18 years; 128 were between 14 and 18 years old, and 125 were between 19 and 23 years old. A majoritywere from poor families;52% percent were from familieswhich fell into the fifth and lowest category of Hollingshead’s socioeconomic status scale, and 27% were from families in the fourth of Hollingshead’scategories (8). The socioeconomic status of this population is similar to that of Detroit, as 23% of adolescents and young adults (ages 16-24 years) in Detroit have familyincomes belowthe poverty level (1990 census figures).Sixty-sevenpercentof the subjects were in school, and 35% were employed at the tune of the interview. Fifteen percent were heads of their own households, 50% lived in familiesheaded by their mothers, 27% lived in familiesheoded by their fathers, and 8% lived in the home of a relative, usually grandparents. These data are also comparable to 1990 census data for Detroit which reports 47%, 36%, and 15% of adolescents livingin families headed by their mother, their father, and another relative, respectively.
VIOLENCE AMONGINNER-CITY YOUTH
215
ments
The 30 violence-relateditems (of the total 175 health behavior questionnaire)in the questionnairewere written by the authors to assess individual risk of being involved in interpersonalviolence. These included witnessing violence, violence victimization, behaviorswhich increase the risk of involvementin violence, and past involvement in violence. The questionnairewas pilot tested with similar patients in a medical clinic to assess relevance and comprehension, prompting minor changes. The psychological interview was based on the Childhood Assessment Schedule (CAS) (9). The CAS is a semistructured diagnostic interview consisting of several content areas, including school, friends, activities and hobbies, family, fears, worries, self-image, mood (especiallysadness), somatic concerns, expressions of anger, and thought disorder symptomatology which parallelsthe DSM-IIIR (10). The CAS has been reviewed for cultural sensitivityby a panel of African-Americanscholarsand has been utilizedwith African-Americanyouth (11). Informationwas also obtainedon risk for unwanted pregnancy, sexually transmitted disease, risk for motor vehicle accidents, weapon carrying, access to guns, and exposure to violent acts. Trained psychologists, blinded to the results of the s&report screeningquestions, rated each subject on a 5-point scale (from 1 = no problem/treatment not indicated to 5 = extreme problem/ treatment absolutelynecessary) for the following:1) need for school or academic counseling due to academic failure; 2) need for vocational/employment counselingdue to vocationalfailure;3) need for family counseling due to parent-teen conflict;4) need for treatment of depression; 5) need for treatment of conduct disorder or antisocialbehavior; 6) need for alcohol abuse treatment; 7) need for drug abuse treatment; 8) need for birth control counseling; 9) need for counseling on sexually transmitted diseases; 10) involvementin significantacts of violence as a perpetrator; 11) risk of involvement in motor vehicle accidents; and 12) anxiety disorders. The criteria used to determine an individual’srisk as a perpetrator of violent acts were the following: involvement in physical fights, access to weapons, prior arrests or convictions, assessment Of iI?iplsiveness and volatile temper, and involvement in criminalactivity. Data
alysis
The data were analyzed in two phases. In the first
zl6
WHUBINER ET AL.
phase, frequency distributions were obtained for exposure to various categories of violence. Additionally, bivariate analyses were conducted to assess the relationships between exposure and gender, age, and living status. In the second phase of analysis, the sample was divided into two categories defined by the psychologist’s rating of individual risk of future involvement in violence, i.e., severity rating of 1, 2, or 3 (low risk) compared to a rating of 4 or 5 (high risk). Bivariate analyses were then conducted to identify demographic and experiential factors, which discriminate between individuals at low and high risk of future involvement in violence.
Red ts Exposure to Violence The prevalence of exposure to violence was high among the survey respondents. During the 3 months prior to the study, 81% of the subjects had witnessed at least one loud argument, 58% had seen at least one physical fight, 34% had seen someone shooting a gun, and 19% had seen at least one fight involving knives. At some time in their lives, 42% of the respondents had seen someone shot or knifed, and 22% had seen someone killed. Nine percent had seen more than one person killed. In the 3 months prior to the interview, 73% of the respondents had been involved in a loud argument, 32% had been in a physical fight, 30% had carried a knife, and 18% had carried a gun. Also, 30% of the respondents said that they could acquire a gun witlua an hour, and another 31% indicated that they could get one within a few days. Forty-four percent reported that there were guns in their homes. There were no sign&ant differences between males and females in witnessing arguments or fights, or in being involved in arguments. For the remainder of the above items, males reported significantly higher exposure to violence than did females (p < 0.001). Age was significantly related to several of the violence items in the questionnaire. Comparison of three age groups (U-16,17-19, and 20-24) revealed that the youngest group was significantly more likely to have seen and been involved in a physical fight (p < 0.01). Subjects living with families headed by their fathers or their grandmothers were significantly more likely to have seen a physical fight in the 3 months prior to the interview than were those living in homes headed by their mothers or by themselves (JJ < 0.05). Those living in homes headed by their fa-
JOURNAL OF ADOLESCENT HEALTH Vol. 14, No. 3
thers were also more likely to report the presence of guns in their homes (p < 0.01). In response to a question about personal safety, 50% reported concern about being attacked in the street. As part of the psychological interview, respondents were asked to state their general concerns and fears. Thirty-eight percent reported concerns about violence, including “getting shot” and ‘guns, ” etc. There was no difference in such concerns between males and females. In the psychological interview, 9% of the respondents reported that they had been the victims of physical abuse. An additional 9% of the respondents reported that they had been sexually abused. There were no gender differences in rates of physical abuse, but females were significantly more likely to have been sexually abused than were males (15% and 3%, respectively; x2 = 8.4, p < 0.01).
Youth at High Risk of Being Involved in Future Violence Based upon the psychological evaluation, 34 of the 246 respondents (14%) were rated at high risk (i.e., 4 or 5 on the 5-point violence severity scale) of being a perpetrator of violence in the future. Males were more likely to be at high risk than were females (23% and 82, respectively; p < 0.01). A summary of selected variables for which the high-risk group was significantly different from the low-risk group is given in Table 1. When compared to the remainder of the subjects, the high-risk group was more likely to have low socioeconomic status, to have been victims of physical abuse, and to have had problems in school. In addition, individuals in the high-risk group were significantly more likely to have been at increased risk (psychological severity rating of 4 or 5) for motor vehicle injuries, sexually transmitted diseases, becoming an adolescent parent, alcohol and substance abuse, difficulties in school and employment, family conflict, depression, and conduct disorder (all relationships sign&ant at p < 0.01). Therefore, the group at high risk for violence was also more likely to be at high risk for every other category rated by the psychologists with one exception, anxiety disorder (12% versus 5%, p = 0.29). They were also more likely to be involved in a physical fight and to have carried a gun (p c 0.0001). There were no differences between the high-risk group and the remainder of the sample in reported levels of concern about violence or in the frequency of witnessing violence.
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VIOLENCEAMONG INNER-CITYYOUTH
Table 1.
Characteristics Which Discriminate Between Youth at High”and Low Risk of Being Involved in Violence
Discriminating characteristis Low SES’ Physical abuse Failed a grade Been expelled Physical fights Canied a gun Motor vehicle injury risk Sexually transmitted disease risk Pregnancy risk Alcohol abuse risk Drug abuse risk School failure risk Vocational failure risk Family conflict Depression Conduct disorder.
High-risk Low-risk group group (%) (%) p valueb 77
49
32 47 55 68 56 47 27 41 18 15 32 41 27 29 50
6 28 27 26 13 9 8 17 3 2 11 19 9 9 3
0.01 0.0001 0.04 0.002 0.0001 0.0001 0.0001 0.004 0.002 0.003 0.004 0.002 0.007 0.009 0.001 0.0001
“Youth at high risk of being involved in violence are those who were rated as 4 or 5 by the psychologist. bBy Chi-Square analysis. ‘Low socioeconomic status (SES)is defined as categories 4 and 5 of Hotigshead’s scale.
Discussion Rates of expos:lre f3 ~AOkilCt?in this sample were striking. A majority of the subjects reported that they had seen at least one loud argument and at least one physical fight in the 3 months prior to the interview. Furthermore, surprisingly large percentages of the subjects had seen the use of deadly weapons at least once, and more than one in five of the respondents had seen someone killed in their lifetime. This level of community violence is likely to impact the quality of life of all inner-city adolescents, affecting their decisions about the clothes they wear, the routes they travel, school activities, and their choice of friends. Many of the subjects reported that they were concerned or worried about violence, their safety, and the safety of family members and friendIs. The violence also contributes to the further deterioration of the community by encouraging families with the necessary resource to move away, increasing the social isolation of the poor. Thirty-four (14%) of the respondents were rated by the psychologist to be at high risk for future violence. When compared to the remainder of the sample, indl#lduals in this high-risk group were not more likely to have witnessed a violent incident.
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highlights the level of exposure to violence by the entire population studied. There are two caveats to be considered when interpreting these data. First, the sample was a convenience sample drawn from a variety of sources. Nevertheless, we attempted to sample a diverse group of inner-city adolescents and young adults, and the census da we obtained suggests that our sample is similar to a cross section of adolescents in Detroit. Second, all of the data are self-reported. The rating of the respondents’ risk of violence exposure was based on an in-depth psychological interview. We were unable to obtain objective, external indicators of behavior, such as criminal or driving records. Bell (12) reported rates of exposure to violence similar to the rates reported here. In a survey of 538 school-age children (grades 2-8) in Chicago, Bell found that 31% had seen someone shot, 34% had seen someone stabbed, and 84% had seen someone “beaten up.” Gladstein and Slater (13) reported that a population of inner-city teenagers in Baltimore also had striking rates of witnessing violent activity. In addition, the mean number of times this population was victimized by a violent act was 1.42 (13). This frequent exposure to violence and the media coverage of violence results in high rates of concerns and worries about violence. Public opinion polls note that 40% of inner-city adults report being concerned about street violence and half express concerns about going out at night (14). In a comparative study of concerns and worries among adolescents in the United States and the Union of Soviet Socialist Republics, “being a victim of violent crime” was found to be the eighth (of 19) most common cause of worly in both countries (15). Social and contextual factors have been shown to be associated with violent behavior. saultive behavior has frequently been reported to be associated with individual risk of violence (16-19). Gelles (20) reported that rates of child abuse are strongly associated with family structure and poverty. Importantly, he found that there is an interaction between these two factors such that poor families with a male in the household are at increased risk of child abuse. Hawkins et al. (21) have argued that failure to connect with prosocial in&viduals, especially family and school representatives, increases the likelihood that adolescents will bond with delinquent peers and engage in a variep] of antisocial and self-destructive behaviors. Similar implications can be drawn from a recent study in
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SCHUBINER ET AL.
in which it was found that one of the strongest predictors of antisocial behavior (e.g., drug abuse and poor school performance) among adolescents was a feeling that no adult cared about their well-being (22). Firearms are readily accessible to a large number of adolescents. In this study, 62% of respondents reported that they could obtain a gun within a few days, and 18%reported having carried a gun at some time. These rates, although alarming, are actually lower than other reports (4, 23). This issue is yartitularly significant when one considers that those most likely to carry weapons are also likely to be depressed and to use alcohol or other drugs. Brent and colleagues (24, 25) have reported on this association and the increased risk of suicide in adolescents with ready access to firearms. Our data are the first to document the lack of difference in witnessing violent acts between adolescents who are at low versus high risk for committing violence. They are also the first to describe the risk for violence as being the single risk factor which predicts high risk in virtually all other psychosocial risk areas. It has been suggested that clinicians in office settings can counsel youth to reduce their risk of violence (26). Given the complex nature of the causes of interpersonal injury and the association of other risk behaviors, however it seems unlikely that briefoffice-based interventions will be effective. Referral to community or school programs tha: offer intensive individual or small group counseling, if available, might be preferable. Several studies have documented high rates of exposure to violence; however, little attention has been paid to the effects of this exposure on adolescents and young adults. Street violence is undoubtedly a realistic fear for many inner-city youth. As mentioned, the subgroup rated at lower risk for violence was just as likely to witness violence as the high-risk group. One can only speculate as to the effects of this exposure to violence on overall indices d stress, which may cause a variety of physical and emotional problems (27). Many inner-city youth are at risk for educational and employment failure, substance abuse, unwanted pregnancy, and sexually transmitted diseases, including HIV. The additional risk from endemic interpersonal injury only adds to the burden. It appears likely that only strategies that affect the overall health (i.e., economic, educational, medical, and social) of inner-city communities have the Potential to solve this complex problem (28). Minneapolis
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