Mechanisms Linking Violence Exposure to Health Risk Behavior in Adolescence: Motivation to Cope and Sensation Seeking

Mechanisms Linking Violence Exposure to Health Risk Behavior in Adolescence: Motivation to Cope and Sensation Seeking SONYA S. BRADY, PH.D.,

AND

GERI R. DONENBERG, PH.D.

ABSTRACT Objective: This study examined two potential mechanisms linking violence exposure and health risk behavior among adolescents in psychiatric care: sensation seeking and coping with stress through escape behavior. Method: Male (59%) and female adolescents (N = 251), ages 12 to 19 years, from diverse ethnic backgrounds (61% African American, 19% white, 12% Latino, 8% biracial or other ethnicity) completed a computer-administered survey assessing study variables from 1999Y2004. Overall clinic consent rate was 41%. Age and gender were included in all analyses. Results: Consistent with the literature on nonpsychiatric samples, violence exposure was associated with both increased substance use and sexual risk taking. Violence exposure was not associated with motivation to engage in risk behavior as a means of escape, although motivation to cope through escape was associated with a greater likelihood of substance use. Sensation seeking was related to substance use and sexual risk taking among all adolescents and with violence exposure primarily within male adolescents. Conclusions: Clinical interventions should promote adaptive coping strategies that emphasize maintaining healthy behavior, effective problem solving skills, and stress management techniques. J. Am. Acad. Child Adolesc. Psychiatry, 2006;45(6):673Y680. Key Words: violence, substance use, sexual risk, sensation seeking, coping.

During adolescence, a variety of potentially healthcompromising behaviors (e.g., experimentation with substances, sexual activity) are tried (Bachman et al., 1996; Rodgers, 1996), driven by several developmental factors. As youths become more independent of parents, parental monitoring decreases and access to potentially health-compromising materials (e.g., alcohol,

Accepted January 9, 2006. Dr. Brady is with the Health Psychology Program, University of California, San Francisco, and Dr. Donenberg is with the Institute for Juvenile Research, University of Illinois at Chicago. This research was supported by R01 MH58545, T32 MH019391, the Warren Wright Adolescent Center at Northwestern Memorial Hospital, Northwestern Memorial Hospital_s Intramural Grants Program, and the University of Pittsburgh Provost_s Office. The authors gratefully acknowledge the Healthy Youths Program staff and the families who participated. They also thank the administrators and staff at Northwestern Memorial Hospital, Children_s Memorial Hospital, the Cook County Bureau of Health, and the Institute for Juvenile Research. Reprint requests to Dr. Geri R. Donenberg, 1747 W. Roosevelt Road, Chicago, IL 60608; e-mail: [email protected]. 0890-8657/06/4506-0673Ó 2006 by the American Academy of Child and Adolescent Psychiatry. DOI: 10.1097/01.chi.0000215328.35928.a9

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cigarettes, marijuana) and opportunities to use them increase. Peer norms regarding risk taking loosen, and the prevalence of peer modeling increases. Risk behaviors are purposeful, goal directed, and capable of fulfilling multiple goals central to adolescent life, such as expressing opposition to authority and identifying with the youth subculture (Jessor, 1984). Health-compromising behaviors may also provide a way of coping with personal and social changes that cause stress (Jessor, 1984; Wills et al., 2001). Youths in mental health care are particularly vulnerable to risk behavior and are more likely to demonstrate maladaptive coping (Brown et al., 1997; Donenberg et al., 2001). Compared with their schoolage peers, youths in psychiatric care are more likely to be sexually active, less likely to use condoms, and more likely to use drugs and alcohol (Donenberg and Pao, 2005). Violence is a specific stressor that may influence teens_ level of involvement in health risk behavior. Violence exposure is associated with increased aggression, substance use, and sexual behavior (see Margolin and Gordis, 2000 for a review), yet little is known about potential mechanisms linking violence and risk behavior.

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Understanding these mechanisms may be key in distinguishing normative risk taking from excessive risk behavior and inform clinical and health promotion interventions. The present study examines two potential processes that may explain the association between violence exposure and health risk behavior: sensation seeking and coping with stress through escape behavior. These processes may be especially relevant for youths in mental health care, given their greater vulnerability to risk behavior and stress. Alarmingly high percentages of youths are exposed to violence in their homes, schools, and communities (Boney-McCoy and Finkelhor, 1995; Singer et al., 1995). Roughly half of high school youths report being threatened, slapped, hit, or punched in their home, school, or neighborhood (Singer et al., 1995). As many as one third of high school youths indicate being beaten or mugged in their school or neighborhood, attacked with a knife or stabbed, or shot at by another person. The percentage of youths witnessing specific acts of violence is higher, and adolescents from low-income urban settings typically report the most violence overall. Rates of violence exposure among youths in psychiatric care are less clear but may be substantial given established linkages between violence exposure and mental health problems. The present study examined reports of violence exposure among teens receiving mental health care. A small but consistent body of literature suggests that victimization by and witnessing and knowledge of violence are associated with increased likelihood of adolescent alcohol, cigarette, and marijuana use (Albus et al., 2004; Berenson et al., 2001). Violence exposure has been linked to earlier initiation of substance use, greater frequency of use, and greater likelihood of being substance dependent (Schwab-Stone et al., 1995; Sullivan et al., 2004). In a nationally representative sample, witnessed violence and physical assault predicted both current cigarette use (Acierno et al., 2000) and alcohol or marijuana abuse or dependence (Kilpatrick et al., 2000). Violence exposure is also related to sexual risk taking during adolescence, including earlier age at first intercourse, greater number of sexual partners, decreased condom use, contracting a sexually transmitted infection (STI), and becoming pregnant (Berenson et al., 2001; Silverman et al., 2001). Among female youths seeking contraceptive care at a family planning clinic, those who had witnessed violence were two to three

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times more likely than their nonexposed peers to report alcohol and drug use before sex and having intercourse with a partner who had multiple partners (Berenson et al., 2001). Females directly victimized by violence were also more likely than their nonexposed peers to report early initiation of intercourse, intercourse with strangers, multiple partners, and having an STI. In summary, violence exposure is associated with substance use and sexual risk behavior, regardless of the mode of exposure (e.g., witnessed violence, victimization). Adolescents experiencing multiple types of violence appear to engage in the highest level of risk taking (Berenson et al., 2001). These patterns may not generalize to youths in psychiatric care, however, because these teens often lack effective coping resources and may be more vulnerable to any type of violence exposure. Two mechanisms linking violence exposure and risk behavior were investigated in this study. One reflects an attempt to cope with stress through escape, consistent with goal-directed motivations for coping (Jessor, 1984). Avoidant coping (i.e., attempting to remove, ignore, or distract oneself from distress) is associated with greater frequency of alcohol and marijuana use and negative consequences among adolescents (Eftekhari et al., 2004; Wagner et al., 1999). Coping through avoidance and escape may be particularly harmful if it interferes with the ability to assert oneself and resist pressure to behave in risky ways. A second possible mechanism linking violence exposure and health risk behavior is the presence of an underlying personality characteristic that systematically co-occurs as part of a general problem behavior syndrome (Jessor et al., 1996). Sensation seeking often co-occurs with substance use and sexual risk behavior among youths (Donohew et al., 2000; Wagner, 2001) and may underlie constellations of problem behaviors. Indeed, evidence suggests that sensation seeking is part of a larger pattern of poor coping ability (e.g., low ability to decline offers to engage in substance use [Unger et al., 2003]). Both of the proposed mechanisms linking violence exposure to health risk behavior (i.e., motivation to cope, sensation seeking) may be relevant for teens in psychiatric care. For example, the poor judgment, cognitive impairment, and impulsivity that are characteristic of many adolescents in psychiatric care may predispose them toward coping with stress (e.g., violence exposure)

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VIOLENCE EXPOSURE AND HEALTH RISK

through substance use and sexual behavior because they lack the resources to engage in more adaptive coping strategies (Donenberg and Pao, 2005). Alternatively, health risk behavior among youths in psychiatric care may reflect a general tendency toward problem behavior, especially externalizing problems. For example, teenagers with conduct disorder and attention-deficit/hyperactivity disorder tend to be more impulsive across different behaviors (Brown et al., 1997), and high novelty seeking and low harm avoidance are associated with varied externalizing problems among adolescents (Schmeck and Poustka, 2001). Gender may influence the proposed mechanisms in important ways. Witnessed violence and victimization by violence are associated with internalizing symptoms indicative of posttraumatic stress disorder (PTSD) among adolescent girls, and with externalizing problems (e.g., delinquency) among adolescent boys (McGee et al., 2001). Coping through escape behaviors may be more characteristic of girls than boys. For example, Wills et al. (2001) found that girls are more likely than boys to engage in substance use as life stressors increases. Avoidant coping has also been associated with depressive symptoms among girls but not boys (Seiffge-Krenke and Stemmler, 2002). In contrast, boys may be more likely than girls to engage in health risk behavior as part of a larger pattern of externalizing behavior, with sensation seeking underlying a constellation of different risk behaviors. Correlations between sexual risk taking and substance use are stronger among men than women (Bell et al., 1999), and sensation seeking is related to men_s but not women_s sexual risk behavior. Sensation seeking is also more prevalent among men than among women (Scourfield et al., 1996). We tested two alternative models to explain the association between violence exposure and health risk behavior in the present study: a stress-coping model, in which the desire to escape from stress mediates an association between violence exposure and health risk behavior, and a problem behavior syndrome model, in which violence exposure and health risk behavior cooccur because they represent different means of sensation seeking. We compared the proposed models among males and females receiving mental health services. We hypothesized that females would be more likely to engage in health risk behavior as a means of coping with violence exposure, whereas sensation

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seeking would better explain associations between violence exposure and health risk behavior among male adolescents.

METHOD Overview of Procedures The data from the present study are part of a larger longitudinal study to understand human immunodeficiency virus risk behavior among youth in psychiatric care. Adolescents and caregivers were recruited from four outpatient clinics in Chicago between 1999 and 2004. At three sites, a clinic staff member telephoned eligible families and requested permission to release their names and contact information to research staff. At the fourth site, data were collected as part of the clinic_s routine intake procedure and families were asked permission to use their clinical data for research. Parents and youths were reassured that participation was voluntary and their decision whether to participate would not affect their treatment. Forty-three percent (267 of 620) of the families contacted agreed to participate. Consent rates differed for the clinic where data were collected as part of the intake procedure (27/45 or 60%) versus the clinics where a staff member invited eligible families to participate (240/575 or 42%). Consenting adolescents/parents and those who refused participation did not differ significantly by teen gender (p = .11) or age (p = .71). Restrictions in access to private health information prevented examination of other differences. The University Institutional Review Board approved the study. Parents and youths separately completed self-report measures and interviews. They were compensated for their participation and received informational pamphlets about acquired immunodeficiency syndrome transmission and prevention. Total testing time was approximately 3 hours.

Participants Participants were 251 adolescents (59% male) enrolled in the larger study for whom data were available on all of the study variables. Youths were excluded if they (1) were identified as mentally retarded or had a cognitive impairment that would limit their ability to understand the questions or the assent process (n = 58); (2) were wards of the Department of Children and Family Services, whose institutional review board denied approval for the study (n = 46); (3) did not speak English because measures and consent/assent forms were norm-based for English speakers (n = 37); (4) did not live with a guardian or caretaker (n = 3). Participants ranged in age from 12 to 19 years (mean = 14.6; SD = 1.8) and were ethnically diverse: 61% African American, 19% white, 12% Latino, and 8% who reported being biracial or Bother[ for ethnicity. Fiftyfive percent of families scored in the first three levels of the Hollingshead (1975) index, indicating low to middle incomes. Adolescents met criteria for a variety of psychiatric disorders according to the Computerized Diagnostic Interview Schedule for Children (Shaffer et al., 1991). According to youth reports, 11%, 18%, 13%, and 30% met criteria for a mood disorder, anxiety disorder, conduct disorder, and at least one disorder, respectively. The rate of adolescent-reported PTSD was low (2%). According to parental reports, 18%, 21%, 46%, and 61% of the teens met criteria

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for a mood disorder, anxiety disorder, disruptive behavior disorder, and at least one disorder, respectively.

Measures Family Demographics. Parents indicated their adolescent_s age, gender, ethnicity, and family socioeconomic status (Hollingshead, 1975). Violence Exposure. We assessed lifetime exposure to five potentially traumatic events taken from the PTSD module of the Computerized Diagnostic Interview Schedule for Children: ever thought you or someone close to you were going to be killed or hurt very badly; ever been attacked or badly beaten; ever been threatened with a weapon; ever been in a bad accident; other than on television and in movies, ever seen or heard someone getting killed, hurt very badly, or die. Items were summed to create a composite of overall violence exposure. Two potentially traumatic events assessed as part of the PTSD module were excluded from analyses because they did not constitute interpersonal violence (i.e., natural disaster and ever becoming upset over a dead body, which could have been seen at a funeral). Forced sexual behavior, which occurred among 8% of adolescents (15 females and 5 males), was not included in main analyses because of low reported frequency. Forced sexual behavior was examined in supplemental analyses involving females. Risky Sexual Behavior and Substance Use. The AIDS Risk Behavior Assessment (Donenberg et al., 2001) is a self-administered interview designed for use with adolescents to assess their self-reported sexual behavior and drug/alcohol use. The AIDS Risk Behavior Assessment uses a skip structure so that more detailed items do not follow screening questions answered negatively. Youths self-administered the AIDS Risk Behavior Assessment using a voice-directed computer. An interviewer remained in the room to answer any questions and to ensure item comprehension. Consistent with previous research (Donenberg et al., 2001, 2002), we created a sexual risk-taking composite score by summing across five indices: (1) ever having vaginal sex; (2) having sex with two or more partners in the past 6 months; (3) having sex while using drugs or alcohol; (4) having vaginal sex at age 14 or younger; (5) inconsistent condom use. For the latter variable, adolescents indicated how frequently they used condoms on a scale. Any response other than Bevery time[ was coded as inconsistent condom use. We conducted a square root transformation of the composite variable because of slight positive skew. A substance use composite score was created by summing across adolescents_ report of ever using (yes/no) alcohol, marijuana, and cigarettes. Motivation to Cope Through Escape. Coping through escape is one subscale of a measure assessing adolescent-reported reasons for engaging in risk behavior. (This measure may be obtained by contacting the second author.) Four items assessed coping through escape: Risk behavior (a) takes my mind off the rest of my life, (b) gives me an escape, (c) helps me get away from things, and (d) distracts me from my problems. Youths rated items on a 5-point scale, with higher scores indicating greater motivation to cope through escape. Ratings were averaged across items. The measure exhibited adequate internal consistency within males (0.86) and females (0.84). Motivation to cope through escape was significantly correlated with parent-reported adolescent withdrawn and delinquent behavior and anxiety/depression on the Child Behavior Checklist (Achenbach, 1991), providing evidence of convergent validity. Sensation Seeking. We created a 19-item composite measure of sensation seeking from established measures based on Zuckerman_s

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original sensation-seeking scale (Kalichman et al., 2002; Zuckerman et al., 1993). Items have been shown to be a valid indicator of thrill and novelty seeking (e.g., BI sometimes do Fcrazy_ things just for fun[). The resulting scale had adequate internal consistency within males (0.77) and females (0.78). Overview of Data Analyses Preliminary analyses examined associations between participant age and study variables and the percentage of males and females reporting each type of violence exposure and health risk behavior. Main analyses addressed three research questions: Is violence exposure associated with health risk behavior? Does motivation to cope through escape mediate associations between violence exposure and health risk behavior? Does sensation seeking account for the clustering of violence exposure and health risk behavior? To test whether violence exposure was associated with health risk behavior, we conducted linear regression analyses for the substance use and sexual risk taking composite outcomes and logistic regression analyses for individual health risk behaviors. We used the same analytic approach to test whether motivation to cope through escape was associated with individual and composite health risk behaviors. A linear regression analysis tested whether violence exposure was related to motivation to cope through escape. Tests of mediation were consistent with the approach of Baron and Kenny (1986). To assess whether sensation seeking accounted for the clustering of violence exposure and health risk behavior, we initially examined whether violence exposure, substance use, and sexual risk taking together constituted an individual risk factor through principal components analysis with Varimax rotation. A single factor emerged, explaining 67% and 61% of variance in scores within males and females, respectively. Item loadings ranged between 0.64 and 0.88 within females and between 0.70 and 0.88 within males. A total risk composite score was computed by standardizing and summing across the violence exposure, substance use, and sexual risk-taking composite scores. We conducted linear regression analyses of the total risk and individual risk composites on sensation seeking. Age and gender were included as covariates in all regression analyses. Potential interactions between predictor variables and gender were examined. RESULTS Preliminary Analyses

Age was significantly associated with all study variables (all p values G.01). Older adolescents were more likely to report a greater number of violent events (r = 0.18), ever using a greater number of substances (r = 0.61), and engaging in more risky sex (r = 0.60). Older adolescents were also more likely to engage in risk behaviors as a means of escaping from stress (r = 0.24) and to endorse items consistent with a sensation-seeking personality (r = 0.18). The correlation between sensation seeking and motivation to engage in risk behavior as a means of escape was 0.37 (0.34 when controlling for age and gender), suggesting that escape coping and sensation seeking were not redundant measures.

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TABLE 1 Percentage of Males and Females Endorsing Violent Events Males Females (n = 148) (n = 103) Thought you or someone close to you were going to be killed or hurt very badly Attacked/badly beatena Threatened with weapona Bad accident Seen or heard someone get killed, very badly hurt, or die (excluding television and movies) a

34%

40%

32% 30% 24% 53%

10% 13% 18% 53%

Significant gender difference at p G .05.

Table 1 presents the percentage of urban males and females receiving psychiatric care who endorsed different types of violent events within their lifetime. Roughly half of the youths endorsed seeing or hearing someone get killed, very badly hurt, or die (excluding television or movies), and more than one third of youths thought that they or someone close to them would be killed or hurt very badly. Males were more likely than females to be directly victimized by violence; roughly one third of males endorsed being attacked or badly beaten, and being threatened with a weapon. Males reported a greater number of total violent events in comparison with females (mean = 1.7 versus 0.3, respectively, p G .05). Table 2 presents the percentage of males and females in psychiatric care who endorsed past or present health risk behaviors. Roughly one third of males and females TABLE 2 Percentage of Males and Females Reporting Health Risk Behaviorsa Males Females (n = 148) (n = 103) Vaginal sex, ever Early vaginal sex debut (age e14 yr)b Sex with Q2 partners in past 6 mob Inconsistent use of condoms during vaginal sex Sex while using drugs/alcohol Alcohol useb Cigarette use Marijuana use

28% 22% (80%)

34% 15% (44%)

22% (71%) 11% (43%)

13% (37%) 16% (55%)

16% (55%) 30% 30% 30%

15% (43%) 46% 39% 26%

a

Percentages in parentheses refer to adolescents who have had vaginal sex. b Significant gender difference at p G .05.

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reported ever having vaginal sex. Among sexually active adolescents, close to half reported inconsistent condom use and having sex while using drugs or alcohol. Sexually active males were almost twice as likely as sexually active females to have initiated vaginal sex at age 14 or younger and to have had two or more sexual partners within the past 6 months. More than 50% of females and 40% of males reported ever using any kind of substance (alcohol, cigarettes, or marijuana; not shown in table). When use of individual substances was examined, roughly one third of adolescents reported ever using cigarettes or marijuana. Females were more likely than males to report alcohol use. Is Violence Exposure Associated With Health Risk Behavior? Table 3 presents regressions of health risk behaviors on violence exposure. Greater violence exposure was associated with greater overall substance use and sexual risk taking. Analyses of individual risk behaviors showed that for every violent event that youths reported, they were almost twice as likely to have engaged in vaginal sex (odds ratio or exp B was 1.9). Violence exposure was also associated with a greater likelihood that males and females initiated vaginal sex at or before age 14 and had ever had sex while using drugs or alcohol. Violence exposure was associated with a greater likelihood of ever using alcohol, marijuana, and

TABLE 3 Regressions of Health Risk Behaviors on Violence Exposure Risk-Taking Standardized $ Exp B Variable (Linear Regression) (Logistic Regression) Substance use composite Alcohol use Marijuana use Cigarette use Sexual risk-taking composite Vaginal sex, ever Early vaginal sex debut (age e14 yr) Sex with Q2 partners in past 6 mo Inconsistent use of condoms during vaginal sex Sex while using drugs/alcohol

0.20** 1.30* 1.63** 1.28* 0.31** 1.90** 1.60** 1.18 1.30

2.09**

* p G .05. ** p G .001.

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cigarettes. Gender did not modify associations between violence exposure and overall substance use and sexual risk taking. However, the association between greater violence exposure and alcohol use was limited to males (exp B = 1.59, p G .01). Supplemental analyses revealed that forced sex did not mediate the association between (nonsexual) violence exposure and sexual risk taking among females. Violence exposure (F = 7.6, p = .007) and forced sex (F = 4.3, p G .05) were independently associated with sexual risk taking when included in the same regression analysis. Does Motivation to Cope Through Escape Mediate Associations Between Violence Exposure and Health Risk Behavior. Violence exposure was not associated with motivation to engage in risk behavior as a means of escaping from stress, within or across gender. Thus, we could not test whether motivation to cope through escape mediated associations between violence exposure and health risk behavior. Motivation to cope through escape was not associated with overall sexual risk taking, but it was associated with higher scores on the overall substance use measure (t = 2.7, p G .01). When health risk behaviors were examined individually, motivation to cope through escape was associated with a greater likelihood of ever using alcohol (exp B = 1.3, p G .05) and cigarettes (exp B = 1.3, p G .05), a lower likelihood of having two or more partners within the past 6 months (exp B = 0.7, p G .10), and greater likelihood of inconsistent condom use during vaginal sex (exp B = 1.5, p G .10). Gender did not modify associations between motivation to cope through escape and overall substance use and sexual risk taking. However, the association between motivation to cope through escape and inconsistent condom use was limited to males (exp B = 2.0, p G .05). TABLE 4 Regressions of Violence Exposure, Substance Use, and Sexual Risk-Taking Composite Scores on Sensation Seeking Standardized $ for Outcome Sensation Seeking Total risk composite Individual risk composites Violence exposure Substance use composite Sexual risk-taking composite * p G .001.

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0.21* 0.23* 0.19* 0.10

Does Sensation Seeking Account for the Clustering of Violence Exposure and Health Risk Behavior. Table 4 presents linear regressions of the total risk and individual risk composites on sensation seeking. Greater scores on sensation seeking were significantly associated with greater total risk, violence exposure, and likelihood of ever engaging in substance use. The association between sensation seeking and sexual risk taking was marginally significant (p = .07). Gender did not modify associations between sensation seeking and total risk, substance use, or sexual risk taking. However, the association between sensation seeking and violence exposure was limited to males ($ = .30, p G .001). DISCUSSION

This study tested whether violence exposure was related to health risk behaviors among adolescents receiving psychiatric care. We examined two alternative models to explain associations: a stress-coping model, in which the desire to escape from stress mediates an association between violence exposure and risk behavior, and a problem behavior syndrome model, in which violence exposure and risk behavior co-occur because they represent different means of sensation seeking. Consistent with previous literature, violence exposure was associated with increased substance use and sexual risk taking among males and females. To our knowledge, this is the first study to replicate these associations among young people in psychiatric care. Although violence exposure was not related to motivation to engage in risk behavior as a means of escape, motivation to cope through escape was associated with increased likelihood of substance use among males and females. Linkages between coping through escape and substance use underscore the potential long-term negative consequences of relying on avoidance and escape as a coping strategy (e.g., Wills et al., 2001). Our findings also suggest that motivation to cope through escape is related to inconsistent condom use among males. The goal of using sexual activity as a distraction from problems may de-emphasize concerns about preventing pregnancy and STIs. This highlights the importance of addressing stress and coping as part of effective health promotion interventions. Although we hypothesized that females would be more likely than males to engage in health risk behavior as a means of coping, results suggest that coping through escape is an

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important mechanism leading to risk behavior among both genders. As hypothesized, sensation seeking accounted for overall violence exposure, substance use, and sexual risk taking among males and females, extending observed associations among general population youths to this vulnerable population. The pattern of findings suggests that similar processes link sensation seeking to health risk behavior among both genders, despite other evidence that sensation seeking may be more strongly linked to risk behavior among men than among women (Bell et al., 1999). Clinical and health promotion interventions targeting adolescent risk behaviors may benefit from targeting sensation seeking, particularly among youths in mental health care. Rates of adolescent self-reported substance use were lower than the general population within the same city and time frame (Youth Online: Comprehensive Results, 2006). Lower rates may be explained by the younger age of our sample and the greater proportion of African Americans, who typically have lower rates of alcohol and cigarette use than whites (Youth Online: Comprehensive Results, 2006). For adolescents who are older or of white ethnicity, the frequency of substance use may be of greater value in identifying at-risk youths. Limitations

We assessed violence exposure through a small number of items and used cross-sectional data. Although rates of violence exposure were high, rates of clinically significant PTSD were low. This prevents conclusions about causality and generalizations to diagnoses of PTSD. Because youths in custody of the Department of Children and Family Services could not participate in our study, some adolescents exposed to high amounts of violence may have been excluded. Findings may not generalize to nonpsychiatric samples. Data on adolescent risk taking were obtained through self-report and were not corroborated through drug testing or screening for STIs. However, evidence suggests that self-reported risk behavior closely approximates actual behavior (Harrison, 1995), especially when questions are administered using computer technology (Romer et al., 1997), as in the present study. Mechanisms linking violence exposure to health risk behavior have been largely unexplored among adolescents, with the exception of observing comorbid negative affect and posttraumatic stress (e.g., Kilpatrick

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et al., 2003; Singer et al., 1995); mechanisms have not been explored among adolescents receiving psychiatric care. A key strength of this study is the development and testing of two conceptual models explaining how violence exposure and health risk behavior may be linked for these youths, either through a goal-driven behavior (motivation to escape) or a specific personality characteristic (sensation seeking). Clinical Implications

Violence prevention and health promotion programs may be most effective by addressing the broader context in which risk occurs, including exposure to violence and engagement in multiple forms of risk behavior (Albus et al., 2004; Sullivan et al., 2004). Our results suggest that clinical and health promotion interventions would benefit from tailoring messages to reflect the processes linking violence exposure and health risk behavior among youths. For teens in psychiatric care, males may be particularly prone to violence as part of a general pattern of sensation seeking. Sensation seeking may account for substance use and sexual risk taking among both males and females. Interventions that promote adaptive outlets for sensation seeking and emphasize the importance of maintaining health may be more likely to reduce risk behavior. Youths in psychiatric care also appear to engage in risk behavior as a means of escaping from stress. This may be unique to troubled teens lacking appropriate and effective coping strategies. Youths should be encouraged to develop alternative coping approaches, including the application of problem-solving skills and appropriate distraction techniques (e.g., reading, artwork). Additional research on mechanisms linking violence exposure and health risk behaviors will be critical to uniquely tailoring interventions. Disclosure: The authors have no financial relationships to disclose.

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